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115th Congress   }                                        {     Report
                        HOUSE OF REPRESENTATIVES
 2d Session      }                                        {    115-585

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



 
                      VA CARE IN THE COMMUNITY ACT

                                _______
                                

 March 5, 2018.--Committed to the Committee of the Whole House on the 
              State of the Union and ordered to be printed

                                _______
                                

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

                              R E P O R T

                             together with

                            DISSENTING VIEWS

                        [To accompany H.R. 4242]

      [Including cost estimate of the Congressional Budget Office]

    The Committee on Veterans' Affairs, to whom was referred 
the bill (H.R. 4242) to amend title 38, United States Code, to 
establish a permanent VA Care in the Community Program, and for 
other purposes, having considered the same, report favorably 
thereon with an amendment and recommend that the bill as 
amended do pass.

                                CONTENTS

                                                                   Page
Purpose and Summary..............................................    28
Background and Need for Legislation..............................    28
Hearings.........................................................    43
Subcommittee Consideration.......................................    44
Committee Consideration..........................................    44
Committee Votes..................................................    46
Committee Oversight Findings.....................................    54
Statement of General Performance Goals and Objectives............    54
New Budget Authority, Entitlement Authority, and Tax Expenditures    54
Earmarks and Tax and Tariff Benefits.............................    54
Committee Cost Estimate..........................................    54
Congressional Budget Office Estimate.............................    54
Federal Mandates Statement.......................................    61
Advisory Committee Statement.....................................    61
Constitutional Authority Statement...............................    61
Applicability to Legislative Branch..............................    61
Statement on Duplication of Federal Programs.....................    62
Disclosure of Directed Rulemaking................................    62
Section-by-Section Analysis of the Legislation...................    62
Changes in Existing Law Made by the Bill as Reported.............    71
Dissenting Views.................................................   161

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

SECTION 1. SHORT TITLE; TABLE OF CONTENTS.

  (a) Short Title.--This Act may be cited as the ``VA Care in the 
Community Act''.
  (b) Table of Contents.--The table of contents for this Act is as 
follows:

Sec. 1. Short title; table of contents.

  TITLE I--IMPROVED ACCESS FOR VETERANS TO NON-DEPARTMENT OF VETERANS 
                          AFFAIRS MEDICAL CARE

Sec. 101. Assignment of veterans to primary care providers.
Sec. 102. Establishment of VA Care in the Community Program.
Sec. 103. Veterans Care Agreements.
Sec. 104. Modification of authority to enter into agreements with State 
homes to provide nursing home care.
Sec. 105. Department of Veterans Affairs electronic interface for 
processing of medical claims.
Sec. 106. Funding for VA Care in the Community Program.
Sec. 107. Termination of certain provisions authorizing medical care to 
veterans through non-Department of Veterans Affairs providers.
Sec. 108. Implementation and transition.
Sec. 109. Transplant procedures with live donors and related services.

                 TITLE II--OTHER ADMINISTRATIVE MATTERS

Sec. 201. Reimbursement for emergency ambulance services.
Sec. 202. Improvement of care coordination for veterans through 
exchange of certain medical records.
Sec. 203. Elimination of copayment offset.
Sec. 204. Use of Department of Veterans Affairs Medical Care 
Collections Fund for certain improvements in collections.
Sec. 205. Department of Veterans Affairs health care productivity 
improvement.
Sec. 206. Licensure of health care professionals of the Department of 
Veterans Affairs providing treatment via telemedicine.
Sec. 207. Establishment of processes to ensure safe opioid prescribing 
practices by non-Department of Veterans Affairs health care providers.
Sec. 208. Assessment of health care furnished by the Department to 
veterans who live in the territories.
Sec. 209. Oversight and accountability of financial processes of 
Department of Veterans Affairs.
Sec. 210. Authority for Department of Veterans Affairs Center for 
Innovation for Care and Payment.

          TITLE III--IMPROVEMENTS TO RECRUITMENT OF PHYSICIANS

Sec. 301. Designated scholarships for physicians and dentists under 
Department of Veterans Affairs Health Professional Scholarship Program.
Sec. 302. Establishment of Department of Veterans Affairs Specialty 
Education Loan Repayment Program.
Sec. 303. Veterans healing veterans medical access and scholarship 
program.

  TITLE I--IMPROVED ACCESS FOR VETERANS TO NON-DEPARTMENT OF VETERANS 
                          AFFAIRS MEDICAL CARE

SEC. 101. ASSIGNMENT OF VETERANS TO PRIMARY CARE PROVIDERS.

  Section 1706 of title 38, United States Code, is amended by adding at 
the end the following new subsection:
  ``(d)(1) Except as provided in section 1703A of this title, in 
furnishing primary care under this chapter, the Secretary shall assign 
each eligible veteran to--
          ``(A) a patient-aligned care team of the Department; or
          ``(B) a dedicated primary care provider of the Department as 
        a part of any other model of providing consistent primary care 
        determined appropriate by the Secretary.
  ``(2) Each patient-aligned care team of the Department shall consist 
of a team of health care professionals of the Department who--
          ``(A) provide to each eligible veteran comprehensive primary 
        care in partnership with the veteran; and
          ``(B) manage and coordinate comprehensive hospital care and 
        medical services consistent with the goals of care agreed upon 
        by the veteran and team.
  ``(3) The Secretary shall ensure that an eligible veteran is not 
simultaneously assigned to more than one patient-aligned care team or 
dedicated primary care provider under this subsection at a single 
location, including by establishing procedures in the event a primary 
care provider retires or is otherwise no longer able to treat the 
veteran. In the case of an eligible veteran who resides in more than 
one location, the Secretary may assign such veteran to a patient-
aligned care team or dedicated primary care provider at each such 
location.
  ``(4) The term `eligible veteran' means a veteran who--
          ``(A) is enrolled in the patient enrollment system of the 
        Department established and operated under section 1705(a) of 
        this title; and
          ``(B) has--
                  ``(i) been furnished hospital care or medical 
                services at or through a Department facility on at 
                least one occasion during the two-year period preceding 
                the date of the determination of eligibility; or
                  ``(ii) requested a first-time appointment for 
                hospital care or medical services at a Department 
                facility.''.

SEC. 102. ESTABLISHMENT OF VA CARE IN THE COMMUNITY PROGRAM.

  (a) Establishment of Program.--
          (1) In general.--Chapter 17 of title 38, United States Code, 
        is amended by inserting after section 1703 the following new 
        section:

``Sec. 1703A. VA Care in the Community Program

  ``(a) Program.--(1) Subject to the availability of appropriations for 
such purpose, hospital care, medical services, and extended care 
services under this chapter shall be furnished to an eligible veteran 
through contracts or agreements authorized under subsection (d), or 
contracts or agreements, including national contracts or agreements, 
authorized under section 8153 of this title or any other provision of 
law administered by the Secretary, with network providers for the 
furnishing of such care and services to veterans.
  ``(2) Subject to subsection (b), an eligible veteran may select a 
provider of such care or services from among network providers.
  ``(3) The Secretary shall coordinate the furnishing of care and 
services under this section to eligible veterans.
  ``(4)(A) In carrying out this section, the Secretary shall establish 
regional networks of network providers. The Secretary shall determine, 
and may modify, such regions based on the capacity and market 
assessments of Veterans Integrated Service Networks conducted under 
subsection (k) or upon recognized need.
  ``(B) The Secretary may enter into one or more contracts for the 
purposes of managing the operations of the regional networks and for 
the delivery of care pursuant to this section.
  ``(C) The Secretary shall--
          ``(i) verify upon enrollment, and annually thereafter, that 
        network providers have not been excluded from participation in 
        other federally funded health care programs; and
          ``(ii) submit to the Committees on Veterans' Affairs of the 
        House of Representatives and the Senate an annual report on the 
        results of such verifications.
  ``(b) Primary and Specialty Care.--(1)(A) If the Secretary is unable 
to assign an eligible veteran to a patient-aligned care team or 
dedicated primary care provider under section 1706(d) of this title 
because the Secretary determines such a care team or provider at a 
Department facility is not available--
          ``(i) the Secretary shall consult with the veteran regarding 
        available primary care providers from among network providers 
        that are located in the regional network in which the veteran 
        resides or a regional network that is adjacent to the regional 
        network in which the veteran resides; and
          ``(ii) the veteran may select one of the available primary 
        care providers to serve as the dedicated primary care provider 
        of the veteran.
  ``(B) In determining whether a patient-aligned care team or dedicated 
provider under section 1706(d) of this title is available for 
assignment to a veteran, the Secretary shall take into consideration 
each of the following:
          ``(i) Whether the veteran faces an unusual or excessive 
        burden in accessing such patient-aligned care team or dedicated 
        provider at a medical facility of the Department including with 
        respect to--
                  ``(I) geographical challenges;
                  ``(II) environmental factors, including roads that 
                are not accessible to the general public, traffic, or 
                hazardous weather;
                  ``(III) a medical condition of the veteran; or
                  ``(IV) such other factors as determined by the 
                Secretary.
          ``(ii) Whether the veteran reasonably believes that the 
        assignment of a particular care team or provider to the veteran 
        would detrimentally affect the patient-provider relationship 
        and result in sub-optimal care to the veteran.
          ``(iii) Whether the panel size of the care team or provider 
        is at such a number that it would result in difficulty for the 
        veteran in accessing timely care or in sub-optimal care to the 
        veteran.
          ``(iv) Whether the veteran resides in a State where the 
        Department does not operated a full-service medical facility.
  ``(C) If the Secretary determines that a patient-aligned care team or 
dedicated primary care provider at a Department facility has become 
available for assignment to an eligible veteran who had been assigned 
to a network provider under subparagraph (A), the Secretary shall 
provide the veteran with the option of reassignment to the team or 
provider at the Department facility.
  ``(D) In the case of an eligible veteran who is assigned to a network 
provider under subparagraph (A), the Secretary shall reevaluate such 
assignment not earlier than one year after a veteran makes a selection 
under subparagraph (A)(ii), and on an annual basis thereafter, to--
          ``(i) determine whether the Secretary is able to assign to 
        the veteran a patient-aligned care team or dedicated primary 
        care provider under section 1706(d) of this title; and
          ``(ii) in consultation with and upon approval of the veteran, 
        make such assignment if able.
  ``(2)(A)(i) Except as provided in clause (ii), the Secretary may only 
furnish specialty hospital care, medical services, or extended care 
services to an eligible veteran under this section pursuant to a 
referral for such specialty care or services made by the primary care 
provider of the veteran.
  ``(ii) The Secretary may designate specialties which shall be exempt 
from the requirement under clause (i).
  ``(B) The Secretary shall determine whether to furnish specialty 
hospital care, medical services, or extended care services to an 
eligible veteran pursuant to subparagraph (A)--
          ``(i) at a medical facility of the Department that is within 
        a reasonable distance of the residence of the veteran, as 
        determined by the Secretary;
          ``(ii) by a network provider that, to the greatest extent 
        practicable, is located in the regional network in which the 
        veteran resides or a regional network that is adjacent to the 
        regional network in which the veteran resides; or
          ``(iii) pursuant to an agreement described in subparagraph 
        (C).
  ``(C) An agreement described in this subparagraph is an agreement 
entered into by the Secretary with a network provider under which--
          ``(i) specialty hospital care, medical services, or extended 
        care services are furnished to an eligible veteran pursuant to 
        subparagraph (A)--
                  ``(I) at a medical facility of the Department by a 
                network provider possessing the appropriate 
                credentials, as determined by the Secretary; or
                  ``(II) at a facility of a network provider by a 
                health care provider of the Department; and
          ``(ii) such specialty care or services are so furnished 
        either--
                  ``(I) in accordance with this section with respect to 
                fees and payments for care and services furnished under 
                subsection (a); or
                  ``(II) at no cost to the United States.
  ``(D) In making the determination under subparagraph (B), the 
Secretary shall give priority to medical facilities and health care 
providers of the Department but shall take into account--
          ``(i) whether the veteran faces an unusual or excessive 
        burden in accessing such specialty hospital care, medical 
        services, or extended care services at a medical facility of 
        the Department, including with respect to--
                  ``(I) geographical challenges;
                  ``(II) environmental factors, such as roads that are 
                not accessible to the general public, traffic, or 
                hazardous weather;
                  ``(III) a medical condition of the veteran; or
                  ``(IV) such other factors as determined by the 
                Secretary;
          ``(ii) whether the primary care provider of the veteran 
        recommends that such specialty hospital care, medical services, 
        or extended care services should be furnished by a network 
        provider;
          ``(iii) whether the veteran resides in a State where the 
        Department does not operate a full-service medical facility; 
        and
          ``(iv) in the case of a veteran who requires an organ or bone 
        marrow transplant, whether the veteran has, in the opinion of 
        the primary care provider of the veteran, a medically 
        compelling reason to travel outside the region of the Organ 
        Procurement and Transplantation Network, established under 
        section 372 of the National Organ Transplantation Act (Public 
        Law 98-507; 42 U.S.C. 274), in which the veteran resides, to 
        receive such transplant.
  ``(E) The Secretary shall ensure that each medical facility of the 
Department processes referrals for specialty hospital care, medical 
services, or extended care services in a standardized manner, including 
with respect to the organization of the program office responsible for 
such referrals.
  ``(F) In carrying out this section, the Secretary shall establish a 
process to review any disagreement between an eligible veteran and the 
Department, or between an eligible veteran and a health care provider 
of the Department, regarding the eligibility of the veteran to receive 
care or services from a network provider under this section or the 
assignment of a primary care provider of the Department to the veteran. 
In reviewing a disagreement under such process with respect to the 
availability of and assignment to a patient aligned care team or 
dedicated primary care provider, the Secretary may give deference to 
the veteran with respect to any determination under subsection 
(b)(1)(B)(ii).
  ``(G)(i) The Secretary shall develop procedures to ensure that 
assigning a veteran to a patient-aligned care team or dedicated primary 
care provider under subparagraph (A), (C), or (D) does not adversely 
affect the continuity or quality of care for the veteran during the 
transition.
  ``(ii) Procedures under clause (i) shall provide for--
          ``(I) the appointment of a contact in the Department for the 
        veteran who shall provide information to the veteran and 
        resolve issues regarding the transition;
          ``(II) the transfer of relevant medical records;
          ``(III) coordination of care between providers;
          ``(IV) the continued treatment of chronic or current episodes 
        of care (by means including medication, subspecialty care, and 
        ancillary services); and
          ``(V) any other action the Secretary determines is necessary.
  ``(c) Episodes of Care.--(1) The Secretary shall ensure that, at the 
election of an eligible veteran who receives hospital care, medical 
services, or extended care services from a network provider in an 
episode of care under this section, the veteran receives such care or 
services from that network provider, another network provider selected 
by the veteran, or a health care provider of the Department, through 
the completion of the episode of care, including all specialty and 
ancillary services determined necessary by the provider as part of the 
treatment recommended in the course of such care or services. In making 
such determination with respect to necessary specialty and ancillary 
services provided by a network provider, the network provider shall 
consult with the Secretary, acting through the program office of the 
appropriate medical facility.
  ``(2) In cases of episodes of care that the Secretary determines case 
management to be appropriate, the Secretary shall provide case 
management to an eligible veteran who receives hospital care, medical 
services, or extended care services from a network provider for such 
episodes of care. The Secretary may provide such case management 
through the Veterans Health Administration or through an entity that 
manages the operations of the regional networks pursuant to subsection 
(a)(4)(B).
  ``(d) Care and Services Through Contracts and Agreements.--(1) The 
Secretary shall enter into contracts or agreements, including national 
contracts or agreements for, but not limited to, dialysis, for 
furnishing care and services to eligible veterans under this section 
with network providers.
  ``(2)(A) In entering into a contract or agreement under paragraph (1) 
with a network provider, the Secretary shall--
          ``(i) negotiate rates for the furnishing of care and services 
        under this section; and
          ``(ii) reimburse the provider for such care and services at 
        the rates negotiated pursuant to clause (i) as provided in such 
        contract or agreement.
  ``(B)(i) Except as provided in paragraph (3), rates negotiated under 
subparagraph (A)(i) 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.
  ``(ii) In determining the rates under the Medicare Program under 
title XVIII of the Social Security Act (42 U.S.C. 1395 et seq.) for 
purposes of clause (i), in the case of care or services furnished by a 
provider of services with respect to which such rates are determined 
under a fee schedule to which the area wage index under section 
1886(d)(3)(E) of the Social Security Act (42 U.S.C. 1395ww(d)(3)(E)) 
applies, such area wage index so applied to such provider of services 
may not be less than 1.00.
  ``(C) In carrying out paragraph (2), the Secretary may incorporate 
the use of value-based reimbursement models to promote the provision of 
high-quality care.
  ``(3)(A) With respect to the furnishing of care or services under 
this section to an eligible veteran who resides in a highly rural area 
(as defined under the rural-urban commuting area codes developed by the 
Secretary of Agriculture and the Secretary of Health and Human 
Services), the Secretary of Veterans Affairs may negotiate a rate that 
is more than the rate paid by the United States as described in 
paragraph (2)(B).
  ``(B) With respect to furnishing care or services under this section 
in Alaska, the Alaska Fee Schedule of the Department of Veterans 
Affairs will be followed, except for when another payment agreement, 
including a contract or provider agreement, is in place.
  ``(C) With respect to furnishing care or services under this section 
in a State with an All-Payer Model Agreement under the Social Security 
Act that became effective on or after January 1, 2014, the Medicare 
payment rates under paragraph (2)(B) shall be calculated based on the 
payment rates under such agreement, or any such successor agreement.
  ``(D) With respect to furnishing care or services under this section 
in a location in which the Secretary determines that adjusting the rate 
paid by the United States as described in paragraph (2)(B) is 
appropriate, the Secretary may negotiate such an adjusted rate.
  ``(E) With respect to furnishing care or services under this section 
in a location or in a situation in which an exception to the rates paid 
by the United States 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 applies, the Secretary may follow such exception.
  ``(F) With respect to furnishing care or services under this section 
for care or services not covered under the Medicare Program under title 
XVIII of the Social Security Act (42 U.S.C. 1395 et seq.), the 
Secretary shall establish a schedule of fees for such care or services.
  ``(G) With respect to furnishing care or services under this section 
pursuant to an agreement with a tribal or Federal entity, the Secretary 
may negotiate a rate that is more than the rate paid by the United 
States as described in paragraph (2)(B).
  ``(4) For the furnishing of care or services pursuant to a contract 
or agreement under paragraph (1), a network provider may not collect 
any amount that is greater than the rate negotiated pursuant to 
paragraph (2)(A).
  ``(5)(A) If, in the course of an episode of care under this section, 
any part of care or services is furnished by a medical provider who is 
not a network provider, the Secretary may compensate such provider for 
furnishing such care or services.
  ``(B) The Secretary shall make reasonable efforts to enter into a 
contract or agreement under this section with any provider who is 
compensated pursuant to subparagraph (A).
  ``(e) Prompt Payment Standard.--(1) The Secretary shall ensure that 
claims for payments for hospital care, medical services, or extended 
care services furnished under this section are processed in accordance 
with this subsection, regardless of whether such claims are--
          ``(A) made by a network provider to the Secretary;
          ``(B) made by a network provider to a regional network 
        operated by a contractor pursuant to subsection (a)(4)(B); or
          ``(C) made by such a regional network to the Secretary.
  ``(2) A covered claimant that seeks payment for hospital care, 
medical services, or extended care services furnished under this 
section shall submit to the covered payer a claim for payment not later 
than--
          ``(A) with respect to a claim by a network provider, 180 days 
        after the date on which the network provider furnishes such 
        care or services; or
          ``(B) with respect to a claim by a regional network operated 
        by a contractor, 180 days after the date on which the 
        contractor pays the network provider for furnishing such care 
        or services.
  ``(3) Notwithstanding chapter 39 of title 31 or any other provision 
of law, the covered payer shall pay a covered claimant for hospital 
care, medical services, or extended care services furnished under this 
section--
          ``(A) in the case of a clean claim submitted to the covered 
        payer on paper, not later than 45 calendar days after receiving 
        the claim; or
          ``(B) in the case of a clean claim submitted to the covered 
        payer electronically, not later than 30 calendar days after 
        receiving the claim.
  ``(4)(A) If the covered payer denies a claim submitted by a covered 
claimant under paragraph (1), the covered payer shall notify the 
covered claimant of the reason for denying the claim and the additional 
information, if any, that may be required to process the claim--
          ``(i) in the case of a clean claim submitted to the covered 
        payer on paper, not later than 45 calendar days after receiving 
        the claim; or
          ``(ii) in the case of a clean claim submitted to the covered 
        payer electronically, not later than 30 calendar days after 
        receiving the claim.
  ``(B) Upon receipt by the covered payer of additional information 
specified under subparagraph (A) relating to a claim, the covered payer 
shall pay, deny, or otherwise adjudicate the claim, as appropriate, not 
later than 30 calendar days after receiving such information.
  ``(5)(A) If the covered payer has not paid a covered claimant or 
denied a clean claim for payment by the covered claimant under this 
subsection during the appropriate period specified in this subsection, 
such clean claim shall be considered overdue.
  ``(B) If a clean claim for payment by a covered claimant is 
considered overdue under subparagraph (A), in addition to the amount 
the covered payer owes the covered claimant under the claim, the 
covered payer shall owe the covered claimant an interest penalty amount 
that shall--
          ``(i) be prorated daily;
          ``(ii) accrue from the date the payment was overdue;
          ``(iii) be payable at the time the claim is paid; and
          ``(iv) be computed at the rate of interest established by the 
        Secretary of the Treasury, and published in the Federal 
        Register, for interest payments under subsections (a)(1) and 
        (b) of section 7109 of title 41 that is in effect at the time 
        the covered payer accrues the obligation to pay the interest 
        penalty amount.
  ``(6)(A) If the covered payer overpays a covered claimant for 
hospital care, medical services, or extended care services furnished 
under this section--
          ``(i) the covered payer shall deduct the amount of any 
        overpayment from payments due to the covered claimant after the 
        date of such overpayment; or
          ``(ii) if the covered payer determines that there are no such 
        payments due after the date of the overpayment, the covered 
        claimant shall refund the amount of such overpayment not later 
        than 30 days after such determination.
  ``(B)(i) Before deducting any amount from a payment to a covered 
claimant under subparagraph (A), the covered payer shall ensure that 
the covered claimant is provided an opportunity--
          ``(I) to dispute the existence or amount of any overpayment 
        owed to the covered payer; and
          ``(II) to request a compromise with respect to any such 
        overpayment.
  ``(ii) The covered payer may not make any deduction from a payment to 
a covered claimant under subparagraph (A) unless the covered payer has 
made reasonable efforts to notify the covered claimant of the rights of 
the covered claimant under subclauses (I) and (II) of clause (i).
  ``(iii) Upon receiving a dispute under subclause (I) of clause (i) or 
a request under subclause (II) of such clause, the covered payer shall 
make a determination with respect to such dispute or request before 
making any deduction under subparagraph (A) unless the time required to 
make such a determination would jeopardize the ability of the covered 
payer to recover the full amount owed to the covered payer.
  ``(7) Notwithstanding any other provision of law, the Secretary may, 
except in the case of a fraudulent claim, false claim, or 
misrepresented claim, compromise any claim of an amount owed to the 
United States under this section.
  ``(8) This subsection shall apply only to payments made on a claims 
basis and not to capitation or other forms of periodic payments to 
network providers.
  ``(9) A network provider that provides hospital care, medical 
services, or extended care services to an eligible veteran under this 
section may not seek any payment for such care or services from the 
eligible veteran.
  ``(10) With respect to making a payment for hospital care or medical 
services furnished to an eligible veteran by a network provider under 
this section--
          ``(A) the Secretary may not require receipt by the veteran or 
        the Department of a medical record under subsection (g) 
        detailing such care or services before a covered payer makes a 
        payment for such care or services; and
          ``(B) the Secretary may require that the network provider 
        attests to such care or services so provided before a covered 
        payer makes a payment for such care or services.
  ``(f) Cost-Sharing.--(1) The Secretary shall require an eligible 
veteran to pay a copayment for the receipt of care or services under 
this section only if such eligible veteran would be required to pay a 
copayment for the receipt of such care or services at a medical 
facility of the Department or from a health care provider of the 
Department under this chapter.
  ``(2) The amount of a copayment charged under paragraph (1) may not 
exceed the amount of the copayment that would be payable by such 
eligible veteran for the receipt of such care or services at a medical 
facility of the Department or from a health care provider of the 
Department under this chapter.
  ``(3) In any case in which an eligible veteran is furnished hospital 
care or medical services under this section for a non-service-connected 
disability described in subsection (a)(2) of section 1729 of this 
title, the Secretary shall recover or collect reasonable charges for 
such care or services from a health-plan contract described in section 
1705A in accordance with such section 1729.
  ``(g) Medical Records.--(1) The Secretary shall ensure that any 
network provider that furnishes care or services under this section to 
an eligible veteran--
          ``(A) upon the request of the veteran, provides to the 
        veteran the medical records related to such care or services; 
        and
          ``(B) upon the completion of the provision of such care or 
        services to such veteran, provides to the Department the 
        medical records for the veteran furnished care or services 
        under this section in a timeframe and format specified by the 
        Secretary for purposes of this section, except the Secretary 
        may not require that any payment by the Secretary to the 
        eligible provider be contingent on such provision of medical 
        records.
  ``(2) To the extent practicable, the Secretary shall submit to a 
network provider that furnishes care or services under this section to 
an eligible veteran the medical records of such eligible veteran that 
are maintained by the Department and are relevant to such care or 
services.
  ``(3) To the extent practicable, the Secretary shall--
          ``(A) ensure that the medical records shared under paragraphs 
        (1) and (2) are shared in an electronic format accessible by 
        network providers and the Department through an Internet 
        website; and
          ``(B) provide to network providers access to the electronic 
        patient health record system of the Department, or successor 
        system, for the purpose of furnishing care or services under 
        this section.
  ``(h) Use of Card.--The Secretary shall ensure that the veteran 
health identification card, or such successor identification card, 
includes sufficient information to act as an identification card for an 
eligible entity or other non-Department facility. The Secretary may not 
use any amounts made available to the Secretary to issue separate 
identification cards solely for the purpose of carrying out this 
section.
  ``(i) Prescription Medications.--(1) With respect to requirements 
relating to the licensing or credentialing of a network provider, the 
Secretary shall ensure that the network provider is able to submit 
prescriptions for pharmaceutical agents on the formulary of the 
Department to pharmacies of the Department in a manner that is 
substantially similar to the manner in which the network provider 
submits prescriptions to retail pharmacies.
  ``(2) Nothing in this section shall be construed to affect the 
process of the Department for filling and paying for prescription 
medications.
  ``(j) Quality of Care.--In carrying out this section, the Secretary 
shall use the quality of care standards set forth or used by the 
Centers for Medicare & Medicaid Services or other quality of care 
standards, as determined by the Secretary.
  ``(k) Capacity and Commercial Market Assessments.--(1) On a periodic 
basis, but not less often than once every three years, the Secretary 
shall conduct an assessment of the capacity of each Veterans Integrated 
Service Network and medical facility of the Department to furnish care 
or services under this chapter. Each such assessment shall--
          ``(A) identify gaps in furnishing such care or services at 
        such Veterans Integrated Service Network or medical facility;
          ``(B) identify how such gaps can be filled by--
                  ``(i) entering into contracts or agreements with 
                network providers under this section or with entities 
                under other provisions of law;
                  ``(ii) making changes in the way such care and 
                services are furnished at such Veterans Integrated 
                Service Network or medical facility, including but not 
                limited to--
                          ``(I) extending hours of operation;
                          ``(II) adding personnel; or
                          ``(III) expanding space through construction, 
                        leasing, or sharing of health care facilities; 
                        and
                  ``(iii) the building or realignment of Department 
                resources or personnel;
          ``(C) forecast, based on future projections and historical 
        trends, both the short- and long-term demand in furnishing care 
        or services at such Veterans Integrated Service Network or 
        medical facility and assess how such demand affects the needs 
        to use such network providers;
          ``(D) include a commercial health care market assessment of 
        designated catchment areas in the United States conducted by a 
        nongovernmental entity; and
          ``(E) consider the unique ability of the Federal Government 
        to retain a presence in an area otherwise devoid of commercial 
        health care providers or from which such providers are at a 
        risk of leaving.
  ``(2) The Secretary shall submit each assessment under paragraph (1) 
to the Committees on Veterans' Affairs of the House of Representatives 
and the Senate and shall make each such assessment publicly available.
  ``(l) Allocation of Funds.--The Secretary shall develop a plan for 
the allocation of funds in the Medical Community Care account.
  ``(m) Reports on Rates.--Not later than December 31, 2019, and 
annually thereafter during each of the subsequent three years, the 
Secretary shall submit to the Committees on Veterans' Affairs of the 
House of Representatives and the Senate a report detailing, for the 
fiscal year preceding the fiscal year during which the report is 
submitted, the rates paid by the Secretary for hospital care, medical 
services, or extended care services under this section that, pursuant 
to subsection (d)(3), are more than the rates described in subsection 
(d)(2)(B) for the same care or services.
  ``(n) Definitions.--In this section:
          ``(1) The term `clean claim' means a claim submitted--
                  ``(A) to the covered payer by a covered claimant for 
                purposes of payment by the covered payer of expenses 
                for hospital care or medical services furnished under 
                this section;
                  ``(B) that contains substantially all of the required 
                elements necessary for accurate adjudication, without 
                requiring additional information from the network 
                provider; and
                  ``(C) in such a nationally recognized format as may 
                be prescribed by the Secretary for purposes of paying 
                claims for hospital care or medical services furnished 
                under this section.
          ``(2) The term `covered claimant' means--
                  ``(A) a network provider that submits a claim to the 
                Secretary for purposes of payment by the Secretary of 
                expenses for hospital care or medical services 
                furnished under this section; or
                  ``(B) a regional network operated by a contractor 
                pursuant to subsection (a)(4)(B) that submits a claim 
                to the Secretary for purposes of reimbursement for a 
                payment made by the contractor to a network provider 
                for hospital care or medical services furnished under 
                this section.
          ``(3) The term `covered payer' means--
                  ``(A) a regional network operated by a contractor 
                pursuant to subsection (a)(4)(B) with respect to a 
                claim made by a network provider to the contractor for 
                purposes of payment by the contractor of expenses for 
                hospital care or medical services furnished under this 
                section; or
                  ``(B) the Secretary with respect to--
                          ``(i) a claim made by a network provider to 
                        the Secretary for purposes of payment by the 
                        Secretary of expenses for hospital care or 
                        medical services furnished under this section; 
                        and
                          ``(ii) a claim made by a regional network 
                        operated by a contractor pursuant to subsection 
                        (a)(4)(B) for purposes of reimbursement for a 
                        payment described by subparagraph (A).
          ``(4) The term `eligible veteran' means a veteran who--
                  ``(A) is enrolled in the patient enrollment system of 
                the Department established and operated under section 
                1705(a) of this title; and
                  ``(B) has--
                          ``(i) been furnished hospital care or medical 
                        services at or through a Department facility on 
                        at least one occasion during the two-year 
                        period preceding the date of the determination 
                        of eligibility; or
                          ``(ii) requested a first-time appointment for 
                        hospital care or medical services at a 
                        Department facility.
          ``(5) The term `fraudulent claim' means a claim by a network 
        provider for reimbursement under this section that includes an 
        intentional and deliberate misrepresentation of a material fact 
        or facts that is intended to induce the Secretary to pay an 
        amount that was not legally owed to the provider.''.
          (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. VA Care in the Community Program.''.

  (b) Conforming Amendments.--The Veterans Access, Choice, and 
Accountability Act of 2014 (Public Law 113-146) is amended--
          (1) in section 101(p)(1) (38 U.S.C. 1701 note), by inserting 
        before the period at the end the following: ``or the date on 
        which the Secretary certifies to the Committees on Veterans' 
        Affairs of the House of Representatives and the Senate that the 
        Secretary is fully implementing section 1703A of title 38, 
        United States Code, whichever occurs first''; and
          (2) in section 208(1), by striking ``section 101'' and 
        inserting ``section 1703A of title 38, United States Code''.
  (c) Definitions.--Section 1701 of title 38, United States Code, is 
amended by adding at the end the following new paragraphs:
          ``(11) The term `network provider' means any of the following 
        health care providers that have entered into a contract or 
        agreement under which the provider agrees to furnish care and 
        services to eligible veterans under section 1703A of this 
        title:
                  ``(A) Any health care provider or supplier that is 
                participating in the Medicare Program under title XVIII 
                of the Social Security Act (42 U.S.C. 1395 et seq.), 
                including any physician furnishing services under such 
                program.
                  ``(B) Any provider of items and services receiving 
                payment under a State plan under title XIX of such Act 
                (42 U.S.C. 1396 et seq.) or a waiver of such a plan.
                  ``(C) Any Federally-qualified health center (as 
                defined in section 1905(l)(2)(B) of the Social Security 
                Act (42 U.S.C. 1396d(l)(2)(B))).
                  ``(D) The Department of Defense.
                  ``(E) The Indian Health Service.
                  ``(F) Any health care provider that is an academic 
                affiliate of the Department.
                  ``(G) Any health care provider not otherwise covered 
                under any of subparagraphs (A) through (F) that meets 
                criteria established by the Secretary for purposes of 
                such section.
          ``(12) The term `VA Care in the Community Program' means the 
        program under which the Secretary furnishes hospital care or 
        medical services to veterans through network providers pursuant 
        to section 1703A of this title.''.
  (d) Transition of Provision of Care.--This Act, and the amendments 
made by this Act, may not be construed to affect the obligations of the 
Secretary of Veterans Affairs under contracts and agreements for the 
provision of hospital care, medical services, and extended care 
services entered into before the date of the enactment of this Act at 
the terms and rates contained in such contracts and agreements.

SEC. 103. VETERANS CARE AGREEMENTS.

  (a) In General.--Subchapter I of chapter 17 of title 38, United 
States Code, is further amended by inserting after section 1703A, as 
added by section 102, the following new section:

``Sec. 1703B. Veterans Care Agreements with non-network providers

  ``(a) Veterans Care Agreements.--(1) In addition to furnishing 
hospital care, medical services, or extended care services under this 
chapter at facilities of the Department or under contracts or 
agreements entered into pursuant to section 1703A of this title or any 
other provision of law other than this section, the Secretary may 
furnish such care and services to eligible veterans through the use of 
agreements, to be known as `Veterans Care Agreements', entered into 
under this section by the Secretary with eligible non-network 
providers.
  ``(2) The Secretary may enter into a Veterans Care Agreement under 
this section with an eligible non-network provider if the Secretary 
determines that--
          ``(A) the provision of the hospital care, medical services, 
        or extended care services at a Department facility is 
        impracticable or inadvisable because of the medical condition 
        of the veteran, the travel involved, or the nature of the care 
        or services required, or a combination of such factors; and
          ``(B) such care or services are not available to be furnished 
        by a non-Department health care provider under a contract or 
        agreement entered into pursuant to a provision of law other 
        than this section.
  ``(3)(A) In accordance with subparagraphs (C) and (D), the Secretary 
shall review each Veterans Care Agreement with a non-network provider 
to determine whether it is practical or advisable to, instead of 
carrying out such agreement--
          ``(i) provide at a Department facility the hospital care, 
        medical services, or extended care services covered by such 
        agreement; or
          ``(ii) enter into an agreement with the provider under 
        section 1703A of this title to provide such care or services.
  ``(B) If the Secretary determines pursuant to a review of a Veterans 
Care Agreement under subparagraph (A) that it is practical or advisable 
to provide hospital care, medical services, or extended care services 
at a Department facility, or enter into an agreement under section 
1703A of this title to provide such care or services, as the case may 
be, the Secretary--
          ``(i) may not renew the Veterans Care Agreement; and
          ``(ii) shall take such actions as are necessary to implement 
        such determination.
  ``(C) This paragraph shall apply with respect to Veterans Care 
Agreements entered into with a non-network provider whose gross annual 
revenue, as determined under subsection (b)(1), exceeds--
          ``(i) $3,000,000, in the case of a provider that furnishes 
        homemaker or home health aide services; or
          ``(ii) $1,000,000, in the case of any other provider.
  ``(D) The Secretary shall conduct each review of a Veterans Care 
Agreement under subparagraph (A) as follows:
          ``(i) Once during the 18-month period beginning on the date 
        that is six months after date on which the agreement is entered 
        into.
          ``(ii) Not less than once during each four-year period 
        beginning on the date on which the review under subparagraph 
        (A) is conducted.
  ``(b) Eligible Non-Network Providers.--A provider of hospital care, 
medical services, or extended care services is eligible to enter into a 
Veterans Care Agreement under this section if the Secretary determines 
that the provider meets the following criteria:
          ``(1) The gross annual revenue of the provider under 
        contracts or agreements entered into with the Secretary in the 
        year preceding the year in which the provider enters into the 
        Veterans Care Agreement does not exceed--
                  ``(A) $5,000,000 (as adjusted in a manner similar to 
                amounts adjusted pursuant to section 5312 of this 
                title), in the case of a provider that furnishes 
                homemaker or home health aide services; or
                  ``(B) $2,000,000 (as so adjusted), in the case of any 
                other provider.
          ``(2) The provider is not a network provider and does not 
        otherwise provide hospital care, medical services, or extended 
        care services to patients pursuant to a contract entered into 
        with the Department.
          ``(3) The provider is--
                  ``(A) a provider of services that has enrolled and 
                entered into a provider agreement under section 1866(a) 
                of the Social Security Act (42 U.S.C. 1395cc(a));
                  ``(B) a physician or supplier that has enrolled and 
                entered into a participation agreement under section 
                1842(h) of such Act (42 U.S.C. 1395u(h));
                  ``(C) a provider of items and services receiving 
                payment under a State plan under title XIX of such Act 
                (42 U.S.C. 1396 et seq.) or a waiver of such a plan;
                  ``(D) an Aging and Disability Resource Center, an 
                area agency on aging, or a State agency (as defined in 
                section 102 of the Older Americans Act of 1965 (42 
                U.S.C. 3002)); or
                  ``(E) a center for independent living (as defined in 
                section 702 of the Rehabilitation Act of 1973 (29 
                U.S.C. 796a)).
          ``(4) The provider is certified pursuant to the process 
        established under subsection (c)(1).
          ``(5) Any additional criteria determined appropriate by the 
        Secretary.
  ``(c) Provider Certification.--(1) The Secretary shall establish a 
process for the certification of eligible providers to enter into 
Veterans Care Agreements under this section that shall, at a minimum, 
set forth the following:
          ``(A) Procedures for the submission of applications for 
        certification and deadlines for actions taken by the Secretary 
        with respect to such applications.
          ``(B) Standards and procedures for the approval and denial of 
        certifications and the revocation of certifications.
          ``(C) Procedures for assessing eligible providers based on 
        the risk of fraud, waste, and abuse of such providers similar 
        to the level of screening under section 1866(j)(2)(B) of the 
        Social Security Act (42 U.S.C. 1395(j)(2)(B)) and the standards 
        set forth under section 9.104 of title 48, Code of Federal 
        Regulations, or any successor regulation.
          ``(D) Requirement for denial or revocation of certification 
        if the Secretary determines that the otherwise eligible 
        provider is--
                  ``(i) excluded from participation in a Federal health 
                care program (as defined in section 1128B(f) of the 
                Social Security Act (42 U.S.C. 1320a-7b(f))) under 
                section 1128 or 1128A of the Social Security Act (42 
                U.S.C. 1320a-7 and 1320a-7a); or
                  ``(ii) identified as an excluded source on the list 
                maintained in the System for Award Management, or any 
                successor system.
          ``(E) Procedures by which a provider whose certification is 
        denied or revoked under the procedures established under this 
        subsection will be identified as an excluded source on the list 
        maintained in the System for Award Management, or successor 
        system, if the Secretary determines that such exclusion is 
        appropriate.
  ``(2) To the extent practicable, the Secretary shall establish the 
procedures under paragraph (1) in a manner that takes into account any 
certification process administered by another department or agency of 
the Federal Government that an eligible provider has completed by 
reason of being a provider described in any of subparagraphs (A) 
through (E) of subsection (b)(4).
  ``(3) The Secretary shall--
          ``(A) verify upon enrollment, and annually thereafter, that 
        eligible providers have not been excluded from participation in 
        other federally funded health care programs; and
          ``(B) submit to the Committees on Veterans' Affairs of the 
        House of Representatives and the Senate an annual report on the 
        results of such verifications.
  ``(d) Terms of Agreements.--Subsections (d), (e), (f), and (g) of 
section 1703A of this title shall apply with respect to a Veterans Care 
Agreement in the same manner such subsections apply to contracts and 
agreements entered into under such section.
  ``(e) Exclusion of Certain Federal Contracting Provisions.--(1) 
Notwithstanding any other provision of law, the Secretary may enter 
into a Veterans Care Agreement using procedures other than competitive 
procedures.
  ``(2)(A) Except as provided in subparagraph (B) and unless otherwise 
provided in this section, an eligible non-network provider that enters 
into a Veterans Care Agreement under this section is not subject to, in 
the carrying out of the agreement, any provision of law that providers 
of services and suppliers under the original Medicare fee-for-service 
program under parts A and B of 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.) are not subject to.
  ``(B) In addition to the provisions of laws covered by subparagraph 
(A), an eligible non-network provider shall be subject to the following 
provisions of law:
          ``(i) Any applicable law regarding integrity, ethics, or 
        fraud, or that subject a person to civil or criminal penalties.
          ``(ii) Section 1352 of title 31, except for the filing 
        requirements under subsection (b) of such section.
          ``(iii) Section 4705 or 4712 of title 41, and any other 
        applicable law regarding the protection of whistleblowers.
          ``(iv) Section 4706(d) of title 41.
          ``(v) Title VII of the Civil Rights Act of 1964 (42 U.S.C. 
        2000e et seq.) to the same extent as such title applies with 
        respect to the eligible non-network provider in providing care 
        or services through an agreement or arrangement other than 
        under a Veterans Care Agreement.
  ``(f) Termination of a Veterans Care Agreement.--(1) An eligible non-
network provider may terminate a Veterans Care Agreement with the 
Secretary under this section at such time and upon such notice to the 
Secretary as the Secretary may specify for purposes of this section.
  ``(2) The Secretary may terminate a Veterans Care Agreement with an 
eligible non-network provider under this section at such time and upon 
such notice to the provider as the Secretary may specify for the 
purposes of this section, if the Secretary determines necessary.
  ``(g) Disputes.--(1) The Secretary shall establish administrative 
procedures for providers with which the Secretary has entered into a 
Veterans Care Agreement to present any dispute arising under or related 
to the agreement.
  ``(2) Before using any dispute resolution mechanism under chapter 71 
of title 41 with respect to a dispute arising under a Veterans Care 
Agreement under this section, a provider must first exhaust the 
administrative procedures established by the Secretary under paragraph 
(1).
  ``(h) Authority To Pay for Other Authorized Services.--(1) If, in the 
course of an episode of care for which hospital care, medical services, 
or extended care services are furnished to an eligible veteran pursuant 
to a Veterans Care Agreement, any part of such care or services is 
furnished by a medical provider who is not an eligible non-network 
provider or a network provider, the Secretary may compensate such 
provider for furnishing such care or services.
  ``(2) The Secretary shall make reasonable efforts to enter into a 
Veterans Care Agreement with any provider who is compensated pursuant 
to paragraph (1).
  ``(i) Annual Reports.--(1) Not later than December 31 of the year 
following the fiscal year in which the Secretary first enters into a 
Veterans Care Agreement under this section, and each year thereafter, 
the Secretary shall submit to the appropriate congressional committees 
an annual report that includes a list of all Veterans Care Agreements 
entered into as of the date of the report.
  ``(2) The requirement to submit a report under paragraph (1) shall 
terminate on the date that is five years after the date of the 
enactment of this section.
  ``(j) Quality of Care.--In carrying out this section, the Secretary 
shall use the quality of care standards set forth or used by the 
Centers for Medicare & Medicaid Services or other quality of care 
standards, as determined by the Secretary.
  ``(k) Delegation.--The Secretary may delegate the authority to enter 
into or terminate a Veterans Care Agreement to an official of the 
Department at a level not below the Director of a Veterans Integrated 
Service Network or the Director of a Network Contracting Office.
  ``(l) Definitions.--In this section:
          ``(1) The term `appropriate congressional committees' means--
                  ``(A) the Committees on Veterans' Affairs of the 
                House of Representatives and the Senate; and
                  ``(B) the Committees on Appropriations of the House 
                of Representatives and the Senate.
          ``(2) The term `eligible veteran' has the meaning given such 
        term in section 1703A(m) of this title.''.
  (b) Clerical Amendment.--The table of sections at the beginning of 
such chapter is amended by inserting after the item relating to section 
1703A, as added by section 102, the following new item:

``1703B. Veterans Care Agreements with non-network providers.''.

SEC. 104. MODIFICATION OF AUTHORITY TO ENTER INTO AGREEMENTS WITH STATE 
                    HOMES TO PROVIDE NURSING HOME CARE.

  (a) Use of Agreements.--
          (1) In general.--Paragraph (1) of section 1745(a) of title 
        38, United States Code, is amended, in the matter preceding 
        subparagraph (A), by striking ``a contract (or agreement under 
        section 1720(c)(1) of this title)'' and inserting ``an 
        agreement''.
          (2) Payment.--Paragraph (2) of such section is amended by 
        striking ``contract (or agreement)'' each place it appears and 
        inserting ``agreement''.
  (b) Treatment of Certain Laws.--Such section is amended by adding at 
the end the following new paragraph:
  ``(4)(A) An agreement under this section may be entered into without 
regard to any law that would require the Secretary to use competitive 
procedures in selecting the party with which to enter into the 
agreement.
  ``(B)(i) Except as provided in clause (ii) and unless otherwise 
provided in this section or in regulations prescribed pursuant to this 
section, a State home that enters into an agreement under this section 
is not subject to, in the carrying out of the agreement, any law to 
which providers of services and suppliers are not subject under the 
original Medicare fee-for-service program under parts A and B of 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.).
  ``(ii) The exclusion under clause (i) does not apply to laws 
regarding integrity, ethics, fraud, or that subject a person to civil 
or criminal penalties.
  ``(C) Title VII of the Civil Rights Act of 1964 (42 U.S.C. 2000e et 
seq.) shall apply with respect to a State home that enters into an 
agreement under this section to the same extent as such title applies 
with respect to the State home in providing care or services through an 
agreement or arrangement other than under this section.''.
  (c) Effective Date.--
          (1) In general.--The amendments made by this section shall 
        apply to agreements entered into under section 1745 of such 
        title on and after the date on which the regulations prescribed 
        by the Secretary of Veterans Affairs to implement such 
        amendments take effect.
          (2) Publication.--The Secretary shall publish the date 
        described in paragraph (1) in the Federal Register not later 
        than 30 days before such date.

SEC. 105. DEPARTMENT OF VETERANS AFFAIRS ELECTRONIC INTERFACE FOR 
                    PROCESSING OF MEDICAL CLAIMS.

  (a) Electronic Interface.--Not later than the implementation date 
specified in section 108(a), the Chief Information Officer of the 
Department of Veterans Affairs shall ensure that the information 
technology system used by the Department to receive, process, and pay 
claims under the VA Care in the Community Program established in 
section 1703A of title 38, United States Code, as added by section 102, 
and under Veterans Care Agreements established in section 1703B of such 
title, as added by section 103, includes the following:
          (1) A function through which a covered non-Department health 
        care provider may submit all required data and supporting 
        information required for claims reimbursement through 
        electronic data interchanges.
          (2) An ability to automatically adjudicate claims.
          (3) A centralized claims database that is accessible 
        nationwide.
          (4) Integration with the relevant eligibility and 
        authorization information technology systems of the Department.
          (5) Ability for a covered non-Department health care provider 
        to ascertain the status of a pending claim submitted by the 
        provider, receive information regarding missing documentation 
        or discrepancies that may impede claim processing timelines or 
        result in rejection, and receive notification when such claim 
        is accepted for reimbursement or rejected.
          (6) A claim review system similar to that used by the Centers 
        for Medicare & Medicaid Services, as of the date of the 
        enactment of this Act, including the use of contractors to 
        perform audits through data analytics, to determine the 
        appropriateness and accuracy of claims of providers and to 
        ensure program integrity and oversight.
  (b) Security and Privacy.--The Chief Information Officer shall also 
ensure that the information technology system covered under subsection 
(a) meets the following criteria:
          (1) Such system shall be developed and implemented in 
        compliance with all applicable laws, regulations and Federal 
        Government standards regarding information security, privacy, 
        and accessibility.
          (2) Such system shall provide for the elicitation, analysis, 
        and prioritization of functional and nonfunctional information 
        security and privacy requirements for such system, including 
        security and privacy services and architectural requirements 
        relating to security and privacy based on a thorough risk 
        assessment of all reasonably anticipated cyber and noncyber 
        threats to the security and privacy of electronic protected 
        health information made available through such interface.
          (3) Such system shall provide for the elicitation, analysis, 
        and prioritization of secure development requirements relating 
        to such system.
          (4) Such system shall provide assurance that the prioritized 
        information security and privacy requirements of such system--
                  (A) are correctly implemented in the design and 
                implementation of such system through the systems 
                development lifecycle; and
                  (B) satisfy the information objectives of such system 
                relating to security and privacy throughout the systems 
                development lifecycle.
  (c) Contract Authority.--The Chief Information Officer may enter into 
a contract for purposes of carrying out this section.
  (d) Definitions.--In this section:
          (1) The term ``electronic protected health information'' has 
        the meaning given that term in section 160.103 of title 45, 
        Code of Federal Regulations, as in effect on the date of the 
        enactment of this Act.
          (2) The term ``covered non-Department health care provider'' 
        means--
                  (A) a network provider (as defined by section 
                1701(11) of title 38, United States Code, as added by 
                section 102);
                  (B) a non-network provider with which the Secretary 
                has entered into a Veterans Care Agreement under 
                section 1703B of such title, as added by section 103; 
                or
                  (C) any other non-Department eligible provider or 
                non-Department health care provider that furnishes 
                hospital care or medical services pursuant to chapter 
                17 of such title.
          (3) The term ``secure development requirements'' means, with 
        respect to the information technology system established under 
        subsection (a), activities that are required to be completed 
        during the system development lifecycle of such interface, such 
        as secure coding principles and test methodologies.
          (4) The term ``VA Care in the Community Program'' has the 
        meaning given that term in section 1701(12) of title 38, United 
        States Code, as added by section 102.

SEC. 106. FUNDING FOR VA CARE IN THE COMMUNITY PROGRAM.

  (a) In General.--All amounts required to carry out the VA Care in the 
Community Program and Veterans Care Agreements under section 1703B of 
title 38, United States Code, shall be derived from the Veterans Health 
Administration, Medical Community Care account.
  (b) Transfer of Amounts.--
          (1) In general.--Any unobligated amounts in 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) shall be transferred to the Veterans Health 
        Administration, Medical Community Care account on the later of 
        the following dates:
                  (A) The date that is one year after the date of the 
                enactment of this Act.
                  (B) The date on which the Secretary of Veterans 
                Affairs submits to the Committees on Veterans' Affairs 
                of the Senate and the House of Representatives the 
                certification required by section 107(c).
          (2) Conforming repeal.--
                  (A) In general.--Effective immediately following the 
                transfer of amounts under paragraph (1), section 802 of 
                the Veterans Access, Choice, and Accountability Act of 
                2014 (Public Law 113-146; 38 U.S.C. 1701 note) is 
                repealed.
                  (B) Conforming amendment.--Section 4003 of the 
                Surface Transportation and Veterans Health Care Choice 
                Improvement Act of 2015 (Public Law 114-41; 38 U.S.C. 
                1701 note) is amended by striking ``for non-Department 
                provider programs (as defined in section 2(d))'' and 
                all that follows through ``1802)'' and inserting the 
                following: ``for the VA Care in the Community Program 
                (as defined in section 1701(12) of title 38, United 
                States Code) and Veterans Care Agreements under section 
                1703B of title 38, United States Code''.
  (c) VA Care in the Community Program Defined.--In this section, the 
term ``VA Care in the Community Program'' has the meaning given that 
term in section 1701(12) of title 38, United States Code, as added by 
section 102.

SEC. 107. TERMINATION OF CERTAIN PROVISIONS AUTHORIZING MEDICAL CARE TO 
                    VETERANS THROUGH NON-DEPARTMENT OF VETERANS AFFAIRS 
                    PROVIDERS.

  (a) Termination of Authority To Contract for Care in Non-Department 
Facilities.--
          (1) In general.--Section 603of title 38, United States Code, 
        is amended by adding at the end the following new subsection:
  ``(e) The authority of the Secretary to carry out this section 
terminates on the date on which the Secretary certifies to the 
Committees on Veterans' Affairs of the House of Representatives and the 
Senate that the Secretary is fully implementing section 1703A of this 
title.''.
          (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 the VA Care 
                        in the Community Program''; and
                          (ii) in paragraph (4)(A), in the first 
                        sentence--
                                  (I) by striking ``and section 1703 of 
                                this title'' and inserting ``and the VA 
                                Care in the Community Program (with 
                                respect to such a year beginning on or 
                                after the date on which the Secretary 
                                commences implementation of the VA Care 
                                in the Community Program)''; and
                                  (II) by striking ``in section 1703 of 
                                this title'' and inserting ``under the 
                                VA Care in the Community Program''.
                  (B) Readjustment counseling.--Section 1712A(e)(1) of 
                such title is amended by striking ``(under sections 
                1703(a)(2) and 1710(a)(1)(B) of this title)'' and 
                inserting ``(under the VA Care in the Community 
                Program)''.
                  (C) Death in department facility.--Section 
                2303(a)(2)(B)(i) of such title is amended by striking 
                ``in accordance with section 1703 of this title'' and 
                inserting ``under the VA Care in the Community 
                Program''.
                  (D) Medicare provider agreements.--Section 
                1866(a)(1)(L) of the Social Security Act (42 U.S.C. 
                1395cc(a)(1)(L)) is amended--
                          (i) by striking ``under section 1703 of title 
                        38'' and inserting ``under the VA Care in the 
                        Community Program (as defined in section 
                        1701(12) of title 38, United States Code)''; 
                        and
                          (ii) by striking ``such section'' and 
                        inserting ``such program''.
  (b) Repeal of Authority To Contract for Scarce Medical Specialists.--
          (1) In general.--Section 7409 of title 38, United States 
        Code, is repealed.
          (2) Clerical amendment.--The table of sections at the 
        beginning of chapter 74 of such title is amended by striking 
        the item relating to section 7409.
  (c) Effective Date.--The amendments made by subsections (a) and (b) 
shall take effect on the date on which the Secretary certifies to the 
Committees on Veterans' Affairs of the House of Representatives and the 
Senate that the Secretary is fully implementing section 1703A of title 
38, United States Code, as added by section 102.

SEC. 108. IMPLEMENTATION AND TRANSITION.

  (a) Implementation.--The Secretary of Veterans Affairs shall commence 
the implementation of section 1703A of title 38, United States Code, as 
added by section 102, and section 1703B of such title, as added by 
section 103, and shall make the transfer under section 106(b), by not 
later than one year after the date of the enactment of this Act. The 
Secretary shall prescribe interim final regulations to implement such 
sections and publish such regulations in the Federal Register.
  (b) Training.--Before commencing the implementation of sections 1703A 
and 1703B of title 38, United States Code, as added by sections 102 and 
103, respectively, the Secretary of Veterans Affairs shall--
          (1) certify to the Committees on Veterans' Affairs of the 
        House of Representatives and the Senate that--
                  (A) each network provider (as defined by section 
                1701(11) of title 38, United States Code) and eligible 
                non-network provider that furnishes care or services 
                under such section 1703A or section 1703B is trained to 
                furnish such care or services under such sections; and
                  (B) each employee of the Department that refers, 
                authorizes, or coordinates such care or services is 
                trained to carry out such sections; and
          (2) establish standard, written guidance for network 
        providers, non-Department health care providers, and any non-
        Department administrative entities acting on behalf of such 
        providers, with respect to the policies and procedures for 
        furnishing care or services under such sections.

SEC. 109. TRANSPLANT PROCEDURES WITH LIVE DONORS AND RELATED SERVICES.

  (a) In General.--Subchapter I of chapter 17 of title 38, United 
States Code, is further amended by inserting after section 1703B, as 
added by section 103, the following new section:

``Sec. 1703C. Transplant procedures with live donors and related 
                    services

  ``(a) In General.--Subject to subsections (b) and (c), in a case in 
which a veteran is eligible for a transplant procedure from the 
Department, the Secretary may provide for an operation on a live donor 
to carry out such procedure for such veteran, notwithstanding that the 
live donor may not be eligible for health care from the Department.
  ``(b) Other Services.--Subject to the availability of appropriations 
for such purpose, the Secretary shall furnish to a live donor any care 
or services before and after conducting the transplant procedure under 
subsection (a) that may be required in connection with such procedure.
  ``(c) Use of Non-Department Facilities.--(1) In carrying out this 
subsection, the Secretary may provide for the operation described in 
subsection (a) on a live donor and furnish to the live donor the care 
and services described in subsection (b) at a non-Department facility 
pursuant to an agreement entered into by the Secretary under this 
section. The live donor shall be deemed to be an individual eligible 
for hospital care and medical services at a non-Department facility 
pursuant to such an agreement solely for the purposes of receiving such 
operation, care, and services at the non-Department facility.
  ``(2) The Secretary may only provide for an operation at a non-
Department of Veterans Affairs transplant center pursuant to paragraph 
(1) if the center is in compliance with regulations prescribed by the 
Centers for Medicare & Medicaid Services applicable to transplant 
centers.''.
  (b) Clerical Amendment.--The table of section at the beginning of 
such chapter is further amended by inserting after the item relating to 
section 1703B, as added by section 103, the following new item:

``1703C. Transplant procedures with live donors and related 
services.''.

                 TITLE II--OTHER ADMINISTRATIVE MATTERS

SEC. 201. REIMBURSEMENT FOR EMERGENCY AMBULANCE SERVICES.

  (a) In General.--Section 1725(c) of title 38, United States Code, is 
amended by adding at the end the following new paragraph:
  ``(5) In delineating the circumstances under which reimbursement may 
be made under this section for ambulance services for an individual, 
the Secretary shall treat such services as emergency services for which 
reimbursement may be made under this section if the Secretary 
determines that--
          ``(A) the request for ambulance services was made as a result 
        of the sudden onset of a medical condition of such a nature 
        that a prudent layperson who possesses an average knowledge of 
        health and medicine--
                  ``(i) would have reasonably expected that a delay in 
                seeking immediate medical attention would have been 
                hazardous to the life or health of the individual; or
                  ``(ii) could reasonably expect the absence of 
                immediate medical attention to result in placing the 
                health of the individual in serious jeopardy, the 
                serious impairment of bodily functions, or the serious 
                dysfunction of any bodily organ or part; and
          ``(B) the individual is transported to the most appropriate 
        medical facility capable of treating such medical condition.''.
  (b) Effective Date.--The amendment made by subsection (a) shall take 
effect on the date of the enactment of this Act and shall apply with 
respect to ambulance services provided on or after January 1, 2019.

SEC. 202. IMPROVEMENT OF CARE COORDINATION FOR VETERANS THROUGH 
                    EXCHANGE OF CERTAIN MEDICAL RECORDS.

  Section 7332(b) of title 38, United States Code, is amended--
          (1) in paragraph (2), by adding at the end the following new 
        subparagraphs:
                  ``(I) To a public or private health care provider in 
                order to provide treatment or health care to a shared 
                patient.
                  ``(J) To a third party in order to recover or collect 
                reasonable charges for care furnished to a veteran for 
                a non-service-connected disability pursuant to section 
                1729 of this title or section 1 of Public Law 87-693 
                (42 U.S.C. 2651).''; and
          (2) by adding at the end the following new paragraph:
  ``(4) Nothing in this section shall be construed to authorize any 
provision of records in violation of relevant health record privacy 
laws, including the Health Insurance Portability and Accountability Act 
of 1996 (Public Law 104-191).''.

SEC. 203. ELIMINATION OF COPAYMENT OFFSET.

  (a) In General.--Section 1729(a) of title 38, United States Code, is 
amended by adding at the end the following new paragraph:
          ``(4) Notwithstanding any other provision of law, any amount 
        that the United States may collect or recover under this 
        section shall not affect any copayment amount a veteran is 
        otherwise obligated to pay under this chapter.''.
  (b) Effective Date.--The amendment made by subsection (a) shall take 
effect on the date of the enactment of this Act and apply with respect 
to a copayment obligation that arises on or after the date of the 
enactment of this Act.

SEC. 204. USE OF DEPARTMENT OF VETERANS AFFAIRS MEDICAL CARE 
                    COLLECTIONS FUND FOR CERTAIN IMPROVEMENTS IN 
                    COLLECTIONS.

  Section 1729A(c)(1)(B) of title 38, United States Code, is amended by 
inserting ``(including with respect to automatic data processing or 
information technology improvements)'' after ``collection''.

SEC. 205. DEPARTMENT OF VETERANS AFFAIRS HEALTH CARE PRODUCTIVITY 
                    IMPROVEMENT.

  (a) In General.--Subchapter I of chapter 17 of title 38, United 
States Code, is further amended by inserting after section 1705A the 
following new section:

``Sec. 1705B. Management of health care: productivity

  ``(a) Relative Value Unit Tracking.--The Secretary shall track 
relative value units for all Department providers.
  ``(b) Clinical Procedure Coding Training.--The Secretary shall 
require all Department providers to attend training on clinical 
procedure coding.
  ``(c) Performance Standards.--(1) The Secretary shall establish for 
each Department facility--
          ``(A) in accordance with paragraph (2), standardized 
        performance standards based on nationally recognized relative 
        value unit production standards applicable to each specific 
        profession in order to evaluate clinical productivity at the 
        provider and facility level;
          ``(B) remediation plans to address low clinical productivity 
        and clinical inefficiency; and
          ``(C) an ongoing process to systematically review the 
        content, implementation, and outcome of the plans developed 
        under subparagraph (B).
  ``(2) In establishing the performance standards under paragraph 
(1)(A), the Secretary may--
          ``(A) incorporate values-based productivity models; and
          ``(B) take into account non-clinical duties, including with 
        respect to training and research.
  ``(d) Definitions.--In this section:
          ``(1) The term `Department provider' means an employee of the 
        Department whose primary responsibilities include furnishing 
        hospital care or medical services, including a physician, a 
        dentist, an optometrist, a podiatrist, a chiropractor, an 
        advanced practice registered nurse, and a physician's assistant 
        acting as an independent provider.
          ``(2) The term `relative value unit' means a unit for 
        measuring workload by determining the time, mental effort and 
        judgment, technical skill, physical effort, and stress involved 
        in delivering a procedure.''.
  (b) Clerical Amendment.--The table of sections at the beginning of 
such chapter is further amended by inserting after the item relating to 
section 1705A the following new item:

``1705B. Management of health care: productivity.''.

  (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 
implementation of section 1705B of title 38, United States Code, as 
added by subsection (a). Such report shall include, for each 
professional category of Department providers, the relative value unit 
of such category of providers at the national, Veterans Integrated 
Service Network, and facility levels.

SEC. 206. LICENSURE OF HEALTH CARE PROFESSIONALS OF THE DEPARTMENT OF 
                    VETERANS AFFAIRS PROVIDING TREATMENT VIA 
                    TELEMEDICINE.

  (a) In General.--Chapter 17 of title 38, United States Code, is 
further amended by inserting after section 1730A the following new 
section:

``Sec. 1730B. Licensure of health care professionals providing 
                    treatment via telemedicine

  ``(a) In General.--Notwithstanding any provision of law regarding the 
licensure of health care professionals, a covered health care 
professional may practice the health care profession of the health care 
professional at any location in any State, regardless of where the 
covered health care professional or the patient is located, if the 
covered health care professional is using telemedicine to provide 
treatment to an individual under this chapter.
  ``(b) Property of Federal Government.--Subsection (a) shall apply to 
a covered health care professional providing treatment to a patient 
regardless of whether the covered health care professional or patient 
is located in a facility owned by the Federal Government during such 
treatment.
  ``(c) Construction.--Nothing in this section may be construed to 
remove, limit, or otherwise affect any obligation of a covered health 
care professional under the Controlled Substances Act (21 U.S.C. 801 et 
seq.).
  ``(d) Covered Health Care Professional Defined.--In this section, the 
term `covered health care professional' means a health care 
professional who--
          ``(1) is an employee of the Department appointed under the 
        authority under section 7306, 7401, 7405, 7406, or 7408 of this 
        title, or title 5;
          ``(2) is authorized by the Secretary to provide health care 
        under this chapter;
          ``(3) is required to adhere to all quality standards relating 
        to the provision of telemedicine in accordance with applicable 
        policies of the Department; and
          ``(4) has an active, current, full, and unrestricted license, 
        registration, or certification in a State to practice the 
        health care profession of the health care professional.''.
  (b) Clerical Amendment.--The table of sections at the beginning of 
chapter 17 of such title is further amended by inserting after the item 
relating to section 1730A the following new item:

``1730B. Licensure of health care professionals providing treatment via 
telemedicine.''.

  (c) Report on Telemedicine.--
          (1) In general.--Not later than one year after the date of 
        the enactment of this Act, the Secretary of Veterans Affairs 
        shall submit to the Committee on Veterans' Affairs of the 
        Senate and the Committee on Veterans' Affairs of the House of 
        Representatives a report on the effectiveness of the use of 
        telemedicine by the Department of Veterans Affairs.
          (2) Elements.--The report required by paragraph (1) shall 
        include an assessment of the following:
                  (A) The satisfaction of veterans with telemedicine 
                furnished by the Department.
                  (B) The satisfaction of health care providers in 
                providing telemedicine furnished by the Department.
                  (C) The effect of telemedicine furnished by the 
                Department on the following:
                          (i) The ability of veterans to access health 
                        care, whether from the Department or from non-
                        Department health care providers.
                          (ii) The frequency of use by veterans of 
                        telemedicine.
                          (iii) The productivity of health care 
                        providers.
                          (iv) Wait times for an appointment for the 
                        receipt of health care from the Department.
                          (v) The reduction, if any, in the use by 
                        veterans of in-person services at Department 
                        facilities and non-Department facilities.
                  (D) The types of appointments for the receipt of 
                telemedicine furnished by the Department that were 
                provided during the one-year period preceding the 
                submittal of the report.
                  (E) The number of appointments for the receipt of 
                telemedicine furnished by the Department that were 
                requested during such period, disaggregated by Veterans 
                Integrated Service Network.
                  (F) Savings by the Department, if any, including 
                travel costs, of furnishing health care through the use 
                of telemedicine during such period.

SEC. 207. ESTABLISHMENT OF PROCESSES TO ENSURE SAFE OPIOID PRESCRIBING 
                    PRACTICES BY NON-DEPARTMENT OF VETERANS AFFAIRS 
                    HEALTH CARE PROVIDERS.

  (a) Receipt and Review of Guidelines.--The Secretary of Veterans 
Affairs shall ensure that all covered health care providers are 
provided a copy of and certify that they have reviewed the evidence-
based guidelines for prescribing opioids set forth by the Opioid Safety 
Initiative of the Department of Veterans Affairs under sections 
911(a)(2) and 912(c) of the Jason Simcakoski Memorial and Promise Act 
(Public Law 114-198; 38 U.S.C. 1701 note) before first providing care 
under the laws administered by the Secretary and at any time when those 
guidelines are modified thereafter.
  (b) Inclusion of Medical History and Current Medications.--The 
Secretary shall implement a process to ensure that, if care of a 
veteran by a covered health care provider is authorized under the laws 
administered by the Secretary, the document authorizing such care 
includes the relevant medical history of the veteran and a list of all 
medications prescribed to the veteran.
  (c) Submittal of Prescriptions.--
          (1) In general.--Except as provided in paragraph (3), the 
        Secretary shall require, to the maximum extent practicable, 
        each covered health care provider to submit prescriptions for 
        opioids--
                  (A) to the Department for prior authorization for the 
                prescribing of a limited amount of opioids under 
                contracts the Department has with retail pharmacies; or
                  (B) directly to a pharmacy of the Department for the 
                dispensing of such prescription.
          (2) Department responsibility.--In carrying out paragraph 
        (1), upon receipt by the Department of a prescription for 
        opioids for a veteran under the laws administered by the 
        Secretary, the Secretary shall--
                  (A) record such prescription in the electronic health 
                record of the veteran; and
                  (B) monitor such prescription as outlined in the 
                Opioid Safety Initiative of the Department.
          (3) Exception.--
                  (A) In general.--A covered health care provider is 
                not required under paragraph (1)(B) to submit an opioid 
                prescription directly to a pharmacy of the Department 
                if--
                          (i) the health care provider determines that 
                        there is an immediate medical need for the 
                        prescription, including an urgent or emergent 
                        prescription or a prescription dispensed as 
                        part of an opioid treatment program that 
                        provides office-based medications; and
                          (ii)(I) following an inquiry into the matter, 
                        a pharmacy of the Department notifies the 
                        health care provider that it cannot fill the 
                        prescription in a timely manner; or
                          (II) the health care provider determines that 
                        the requirement under paragraph (1)(B) would 
                        impose an undue hardship on the veteran, 
                        including with respect to travel distances, as 
                        determined by the Secretary.
                  (B) Notification to department.--If a covered health 
                care provider uses an exception under subparagraph (A) 
                with respect to an opioid prescription for a veteran, 
                the health care provider shall, on the same day the 
                prescription is written, submit to the Secretary for 
                inclusion in the electronic health record of the 
                veteran a notice, in such form as the Secretary may 
                establish, providing information about the prescription 
                and describing the reason for the exception.
                  (C) Report.--
                          (i) In general.--Not less frequently than 
                        quarterly, the Secretary shall submit to the 
                        Committee on Veterans' Affairs of the Senate 
                        and the Committee on Veterans' Affairs of the 
                        House of Representatives a report evaluating 
                        the compliance of covered health care providers 
                        with the requirements under this paragraph and 
                        setting forth data on the use by health care 
                        providers of exceptions under subparagraph (A) 
                        and notices under subparagraph (B).
                          (ii) Elements.--Each report required by 
                        clause (i) shall include the following with 
                        respect to the quarter covered by the report:
                                  (I) The number of exceptions used 
                                under subparagraph (A) and notices 
                                received under subparagraph (B).
                                  (II) The rate of compliance by the 
                                Department with the requirement under 
                                subparagraph (B) to include such 
                                notices in the health records of 
                                veterans.
                                  (III) The identification of any 
                                covered health care providers that, 
                                based on criteria prescribed the 
                                Secretary, are determined by the 
                                Secretary to be statistical outliers 
                                regarding the use of exceptions under 
                                subparagraph (A).
  (d) Use of Opioid Safety Initiative Guidelines.--
          (1) In general.--If a director of a medical center of the 
        Department or a Veterans Integrated Service Network determines 
        that the opioid prescribing practices of a covered health care 
        provider conflicts with or is otherwise inconsistent with the 
        standards of appropriate and safe care, as that term is used in 
        section 913(d) of the Jason Simcakoski Memorial and Promise Act 
        (Public Law 114-198; 38 U.S.C. 1701 note), the director shall 
        take such action as the director considers appropriate to 
        ensure the safety of all veterans receiving care from that 
        health care provider, including removing or directing the 
        removal of any such health care provider from provider networks 
        or otherwise refusing to authorize care of veterans by such 
        health care provider in any program authorized under the laws 
        administered by the Secretary.
          (2) Inclusion in contracts.--The Secretary shall ensure that 
        any contracts entered into by the Secretary with third parties 
        involved in administering programs that provide care in the 
        community to veterans under the laws administered by the 
        Secretary specifically grant the authority set forth in 
        paragraph (1) to such third parties and to the directors 
        described in that paragraph, as the case may be.
  (e) Denial or Revocation of Eligibility of Non-Department 
Providers.--The Secretary shall deny or revoke the eligibility of a 
non-Department health care provider to provide health care to veterans 
under the laws administered by the Secretary if the Secretary 
determines that the opioid prescribing practices of the provider--
          (1) violate the requirements of a medical license of the 
        health care provider; or
          (2) detract from the ability of the health care provider to 
        deliver safe and appropriate health care.
  (f) Covered Health Care Provider Defined.--In this section, the term 
``covered health care provider'' means a non-Department of Veterans 
Affairs health care provider who provides health care to veterans under 
the laws administered by the Secretary of Veterans Affairs.

SEC. 208. ASSESSMENT OF HEALTH CARE FURNISHED BY THE DEPARTMENT TO 
                    VETERANS WHO LIVE IN THE TERRITORIES.

  (a) In General.--Not later than 180 days after the date of the 
enactment of this Act, the Secretary of Veterans Affairs shall submit 
to the Committees on Veterans' Affairs of the Senate and the House of 
Representatives a report regarding health care furnished by the 
Department of Veterans Affairs to veterans who live in the territories.
  (b) Elements.--The report under subsection (a) shall include 
assessments of the following:
          (1) The ability of the Department to furnish to veterans who 
        live in the territories the following:
                  (A) Hospital care.
                  (B) Medical services.
                  (C) Mental health services.
                  (D) Geriatric services.
          (2) The feasibility of establishing a medical facility of the 
        Department in any territory that does not contain such a 
        facility.
  (c) Definition.--In this section, the term ``territories'' means the 
Northern Mariana Islands, Puerto Rico, American Samoa, Guam, and the 
Virgin Islands.

SEC. 209. OVERSIGHT AND ACCOUNTABILITY OF FINANCIAL PROCESSES OF 
                    DEPARTMENT OF VETERANS AFFAIRS.

  (a) Sense of Congress.--It is the sense of Congress that--
          (1) the normal budget process for the Department of Veterans 
        Affairs should be grounded in sound actuarial analysis based on 
        accurate demand forecasting;
          (2) the regular budget process for the Department should be 
        the norm;
          (3) supplemental requests for appropriations should be used 
        sparingly and for unforeseen demand or natural occurrences; and
          (4) upon receipt of the financial audit of the Office of 
        Inspector General of the Department, the Committee on Veterans' 
        Affairs of the Senate and the Committee on Veterans' Affairs of 
        the House of Representatives shall give due consideration to 
        the report, including by holding hearings as appropriate
  (b) Plans for Use of Supplemental Appropriations Required.--Whenever 
the Secretary submits to address a budgetary issue affecting the 
Department of Veterans Affairs to Congress a request for supplemental 
appropriations or any other appropriation when the request is submitted 
outside the standard budget process, the Secretary shall, not later 
than 45 days before the date on which such budgetary issue would start 
affecting a program or service, submit to Congress a justification for 
the request, including a plan that details how the Secretary intends to 
use the requested appropriation and how long the requested 
appropriation is expected to meet the needs of the Department and 
certification that the request was made using an updated and sound 
actuarial analysis.
  (c) Annual Attestation Regarding Financial Projections.--Concurrent 
with the President's annual budget request submitted to Congress under 
section 1105 of title 31, United States Code, for fiscal year 2019 and 
each fiscal year thereafter, the Chief Financial Officer of the 
Department of Veterans Affairs shall submit to the Committee on 
Veterans' Affairs of the Senate and the Committee on Veterans' Affairs 
of the House of Representatives the following:
          (1) A statement of assurance that financial projections 
        included in such budget or the supporting materials submitted 
        along with such budget for the Department of Veterans Affairs 
        are sufficient to provide benefits and services under laws 
        administered by the Secretary of Veterans Affairs.
          (2) A certification of the Chief Financial Officer's 
        responsibility for internal financial controls of the 
        Department.
          (3) An attestation that the Chief Financial Officer has 
        collaborated sufficiently with the financial officers of the 
        facilities and components of the Department to be confident in 
        such financial projections.

SEC. 210. AUTHORITY FOR DEPARTMENT OF VETERANS AFFAIRS CENTER FOR 
                    INNOVATION FOR CARE AND PAYMENT.

  (a) In General.--Subchapter I of chapter 17, as amended by section 
103, is further amended by inserting after section 1703C, as added by 
section 109, the following new section:

``Sec. 1703D. Center for Innovation for Care and Payment

  ``(a) In General.--(1) There is established within the Department a 
Center for Innovation for Care and Payment (in this section referred to 
as the `Center').
  ``(2) The Secretary, acting through the Center, may carry out such 
pilot programs the Secretary determines to be appropriate to develop 
innovative approaches to testing payment and service delivery models in 
order to reduce expenditures while preserving or enhancing the quality 
of care furnished by the Department.
  ``(3) The Secretary, acting through the Center, shall test payment 
and service delivery models to determine whether such models--
          ``(A) improve access to, and quality, timeliness, and patient 
        satisfaction of care and services; and
          ``(B) create cost savings for the Department.
  ``(4)(A) The Secretary shall test a model in a location where the 
Secretary determines that the model will addresses deficits in care 
(including poor clinical outcomes or potentially avoidable 
expenditures) for a defined population.
  ``(B) The Secretary shall focus on models the Secretary expects to 
reduce program costs while preserving or enhancing the quality of care 
received by individuals receiving benefits under this chapter.
  ``(C) The models selected may include those described in section 
1115A(b)(2)(B) of the Social Security Act (42 U.S.C. 1315a(b)(2)(B)).
  ``(5) In selecting a model for testing, the Secretary may consider, 
in addition to other factors identified in this subsection, the 
following factors:
          ``(A) Whether the model includes a regular process for 
        monitoring and updating patient care plans in a manner that is 
        consistent with the needs and preferences of individuals 
        receiving benefits under this chapter.
          ``(B) Whether the model places the individual receiving 
        benefits under this chapter at the center of the care team 
        (including family members and other caregivers) of such 
        individual.
          ``(C) Whether the model uses technology or new systems to 
        coordinate care over time and across settings.
          ``(D) Whether the model demonstrates effective linkage with 
        other public sector payers, private sector payers, or statewide 
        payment models.
  ``(6)(A) Models tested under this section may not be designed in such 
a way that would allow the United States to recover or collect 
reasonable charges from a Federal health care program for care or 
services furnished by the Secretary to a veteran under pilot programs 
carried out under this section.
  ``(B) In this paragraph, the term `Federal health care program' 
means--
          ``(i) an insurance program described in section 1811 of the 
        Social Security Act (42 U.S.C. 1395c) or established by section 
        1831 of such Act (42 U.S.C. 1395j); or
          ``(ii) a State plan for medical assistance approved under 
        title XIX of such Act (42 U.S.C. 1396 et seq.); or
          ``(iii) a TRICARE program operated under sections 1075, 
        1075a, 1076, 1076a, 1076c, 1076d, 1076e, or 1076f of title 10.
  ``(b) Duration.--Each pilot program carried out by the Secretary 
under this section shall terminate no later than five years after the 
date of the commencement of the pilot program.
  ``(c) Location.--The Secretary shall ensure that each pilot program 
carried out under this section occurs in an area or areas appropriate 
for the intended purposes of the pilot program.
  ``(d) Budget.--Funding for each pilot program carried out by the 
Secretary under this section shall come from appropriations--
          ``(1) provided in advance in appropriations acts for the 
        Veterans Health Administration; and
          ``(2) provided for information technology systems.
  ``(e) Notice.--The Secretary shall--
          ``(1) publish information about each pilot program under this 
        section in the Federal Register; and
          ``(2) take reasonable actions to provide direct notice to 
        veterans eligible to participate in such pilot programs.
  ``(f) Waiver of Authorities.--(1) Subject to reporting under 
paragraph (2) and approval under paragraph (3), in implementing a pilot 
program under this section, the Secretary may waive such requirements 
in subchapters I, II, and III of this chapter as the Secretary 
determines necessary solely for the purposes of carrying out this 
section with respect to testing models described in subsection (a).
  ``(2) Before waiving any authority under paragraph (1), the Secretary 
shall submit a report to the Speaker of the House of Representatives, 
the minority leader of the House of Representatives, the majority 
leader of the Senate, the minority leader of the Senate, and each 
standing committee with jurisdiction under the rules of the Senate and 
of the House of Representatives to report a bill to amend the provision 
or provisions of law that would be waived by the Department describing 
in detail the following:
          ``(A) The specific authorities to be waived under the pilot 
        program.
          ``(B) The standard or standards to be used in the pilot 
        program in lieu of the waived authorities.
          ``(C) The reasons for such waiver or waivers.
          ``(D) A description of the metric or metrics the Secretary 
        will use to determine the effect of the waiver or waivers upon 
        the access to and quality, timeliness, or patient satisfaction 
        of care and services furnished through the pilot program.
          ``(E) The anticipated cost savings, if any, of the pilot 
        program.
          ``(F) The schedule for interim reports on the pilot program 
        describing the results of the pilot program so far and the 
        feasibility and advisability of continuing the pilot program.
          ``(G) The schedule for the termination of the pilot program 
        and the submission of a final report on the pilot program 
        describing the result of the pilot program and the feasibility 
        and advisability of making the pilot program permanent.
          ``(H) The estimated budget of the pilot program.
  ``(3)(A) Upon receipt of a report submitted under paragraph (2), each 
House of Congress shall provide copies of the report to the chairman 
and ranking member of each standing committee with jurisdiction under 
the rules of the House of Representatives or the Senate to report a 
bill to amend the provision or provisions of law that would be waived 
by the Department under this subsection.
  ``(B)(i) The waiver requested by the Secretary under paragraph (2) 
shall be considered approved under this paragraph if there is enacted 
into law a bill or joint resolution approving such request in its 
entirety. Such bill or joint resolution shall be passed by recorded 
vote to reflect the vote of each member of Congress thereon.
  ``(ii) The provisions of this paragraph are enacted by Congress--
          ``(I) as an exercise of the rulemaking power of the Senate 
        and the House of Representatives and as such shall be 
        considered as part of the rules of each House of Congress, and 
        shall supersede other rules only to the extent that they are 
        inconsistent therewith; and
          ``(II) with full recognition of the constitutional right of 
        either House of Congress to change the rules (so far as they 
        relate to the procedures of that House) at any time, in the 
        same manner, and to the same extent as in the case of any other 
        rule of that House.
  ``(C) During the 60-calendar-day period beginning on the date on 
which the Secretary submits the report described in paragraph (2) to 
Congress, it shall be in order as a matter of highest privilege in each 
House of Congress to consider a bill or joint resolution, if offered by 
the majority leader of such House (or a designee), approving such 
request in its entirety.
  ``(g) Limitations.--(1) The waiver provisions in subsection (f) shall 
not apply unless the Secretary, in accordance with the requirements in 
subsection (f), submits the first proposal for a pilot program not 
later than 18 months after the date of the enactment of the VA Care in 
the Community Act.
  ``(2) Notwithstanding section 502 of this title, decisions by the 
Secretary under this section shall, consistent with section 511 of this 
title, be final and conclusive and may not be reviewed by any other 
official or by any court, whether by an action in the nature of 
mandamus or otherwise.
  ``(3)(A) If the Secretary determines that the pilot program is not 
improving the quality of care or producing cost savings, the Secretary 
shall--
          ``(i) propose a modification to the pilot program in the 
        interim report that shall also be considered a report under 
        subsection (f)(2)(A) and shall be subject to the terms and 
        conditions of subsection (f)(2); or
          ``(ii) terminate such pilot program not later than 30 days 
        after submitting the interim report to Congress.
  ``(B) If the Secretary terminates the pilot program under 
subparagraph (A)(ii), for purposes of clauses (vi) and (vii) of 
subsection (f)(2)(A), such interim report will also serve as the final 
report for that pilot program.
  ``(h) Evaluation and Reporting Requirements.--(1) The Secretary shall 
conduct an evaluation of each model tested, which shall include, at a 
minimum, an analysis of--
          ``(A) the quality of care furnished under the model, 
        including the measurement of patient-level outcomes and 
        patient-centeredness criteria determined appropriate by the 
        Secretary; and
          ``(B) the changes in spending by reason of that model.
  ``(2) The Secretary shall make the results of each evaluation under 
this subsection available to the public in a timely fashion and may 
establish requirements for other entities participating in the testing 
of models under this section to collect and report information that the 
Secretary determines is necessary to monitor and evaluate such models.
  ``(i) Coordination and Consultation.--(1) The Secretary shall consult 
with the Under Secretary for Health and the Special Medical Advisory 
Group established pursuant to section 7312 of this title in the 
development and implementation of any pilot program operated under this 
section.
  ``(2) In carrying out the duties under this section, the Secretary 
shall consult representatives of relevant Federal agencies, and 
clinical and analytical experts with expertise in medicine and health 
care management. The Secretary shall use appropriate mechanisms to seek 
input from interested parties.
  ``(j) Expansion of Successful Pilot Programs.--Taking into account 
the evaluation under subsection (f), the Secretary may, through 
rulemaking, expand (including implementation on a nationwide basis) the 
duration and the scope of a model that is being tested under subsection 
(a) to the extent determined appropriate by the Secretary, if--
          ``(1) the Secretary determines that such expansion is 
        expected to--
                  ``(A) reduce spending without reducing the quality of 
                care; or
                  ``(B) improve the quality of patient care without 
                increasing spending; and
          ``(2) the Secretary determines that such expansion would not 
        deny or limit the coverage or provision of benefits for 
        individuals receiving benefits under this chapter.''.
  (b) Conforming Amendment.--The table of sections at the beginning of 
such chapter, as amended by section 109, is further amended by 
inserting after the item relating to section 1703C the following new 
item:

``1703D. Center for Innovation for Care and Payment.''.

          TITLE III--IMPROVEMENTS TO RECRUITMENT OF PHYSICIANS

SEC. 301. DESIGNATED SCHOLARSHIPS FOR PHYSICIANS AND DENTISTS UNDER 
                    DEPARTMENT OF VETERANS AFFAIRS HEALTH PROFESSIONAL 
                    SCHOLARSHIP PROGRAM.

  (a) Scholarships for Physicians and Dentists.--Section 7612(b) of 
title 38, United States Code, is amended by adding at the end the 
following new paragraph:
  ``(6)(A) Of the scholarships awarded under this subchapter, the 
Secretary shall ensure that not less than 50 scholarships are awarded 
each year to individuals who are accepted for enrollment or enrolled 
(as described in section 7602 of this title) in a program of education 
or training leading to employment as a physician or dentist until such 
date as the Secretary determines that the staffing shortage of 
physicians and dentists in the Department is less than 500.
  ``(B) After such date, the Secretary shall ensure that of the 
scholarships awarded under this subchapter, a number of scholarships is 
awarded each year to individuals referred to in subparagraph (A) in an 
amount equal to not less than ten percent of the staffing shortage of 
physicians and dentists in the Department, as determined by the 
Secretary.
  ``(C) Notwithstanding subsection (c)(1), the agreement between the 
Secretary and a participant in the Scholarship Program who receives a 
scholarship pursuant to this paragraph shall provide the following:
          ``(i) The Secretary's agreement to provide the participant 
        with a scholarship under this subchapter for a specified number 
        (from two to four) of school years during which the participant 
        is pursuing a course of education or training leading to 
        employment as a physician or dentist.
          ``(ii) The participant's agreement to serve as a full-time 
        employee in the Veterans Health Administration for a period of 
        time (hereinafter in this subchapter referred to as the `period 
        of obligated service') of 18 months for each school year or 
        part thereof for which the participant was provided a 
        scholarship under the Scholarship Program.
  ``(D) In providing scholarships pursuant to this paragraph, the 
Secretary may provide a preference for applicants who are veterans.
  ``(E) On an annual basis, the Secretary shall provide to appropriate 
educational institutions informational material about the availability 
of scholarships under this paragraph.''.
  (b) Breach of Agreement.--Section 7617(b) of such title is amended--
          (1) by redesignating paragraphs (4) and (5) as paragraphs (5) 
        and (6), respectively; and
          (2) by inserting after paragraph (3) the following new 
        paragraph (4):
          ``(4) In the case of a participant who is enrolled in a 
        program or education or training leading to employment as a 
        physician, the participant fails to successfully complete post-
        graduate training leading to eligibility for board 
        certification in a specialty.''.
  (c) Extension of Program.--Section 7619 of such title is amended by 
striking ``December 31, 2019'' and inserting ``December 31, 2033''.

SEC. 302. ESTABLISHMENT OF DEPARTMENT OF VETERANS AFFAIRS SPECIALTY 
                    EDUCATION LOAN REPAYMENT PROGRAM.

  (a) In General.--Chapter 76 of title 38, United States Code, is 
amended by inserting after subchapter VII the following new subchapter:

     ``SUBCHAPTER VIII--SPECIALTY EDUCATION LOAN REPAYMENT PROGRAM

``Sec. 7691. Establishment

  ``As part of the Educational Assistance Program, the Secretary may 
carry out a student loan repayment program under section 5379 of title 
5. The program shall be known as the Department of Veterans Affairs 
Specialty Education Loan Repayment Program (in this chapter referred to 
as the `Specialty Education Loan Repayment Program').

``Sec. 7692. Purpose

  ``The purpose of the Specialty Education Loan Repayment Program is to 
assist, through the establishment of an incentive program for certain 
individuals employed in the Veterans Health Administration, in meeting 
the staffing needs of the Veterans Health Administration for physicians 
in medical specialties for which the Secretary determines recruitment 
or retention of qualified personnel is difficult.

``Sec. 7693. Eligibility; preference; covered costs

  ``(a) Eligibility.--An individual is eligible to participate in the 
Specialty Education Loan Repayment Program if the individual--
          ``(1) is hired under section 7401 of this title to work in an 
        occupation described in section 7692 of this title;
          ``(2) owes any amount of principal or interest under a loan, 
        the proceeds of which were used by or on behalf of that 
        individual to pay costs relating to a course of education or 
        training which led to a degree that qualified the individual 
        for the position referred to in paragraph (1); and
          ``(3) is--
                  ``(A) recently graduated from an accredited medical 
                or osteopathic school and matched to an accredited 
                residency program in a medical specialty described in 
                section 7692 of this title; or
                  ``(B) a physician in training in a medical specialty 
                described in section 7692 of this title with more than 
                two years remaining in such training.
  ``(b) Preference for Veterans.--In selecting individuals for 
participation in the Specialty Education Loan Repayment Program under 
this subchapter, the Secretary may give preference to veterans.
  ``(c) Covered Costs.--For purposes of subsection (a)(2), costs 
relating to a course of education or training include--
          ``(1) tuition expenses;
          ``(2) all other reasonable educational expenses, including 
        expenses for fees, books, equipment, and laboratory expenses; 
        and
          ``(3) reasonable living expenses.

``Sec. 7694. Specialty education loan repayment

  ``(a) In General.--Payments under the Specialty Education Loan 
Repayment Program shall consist of payments for the principal and 
interest on loans described in section 7682(a)(2) of this title for 
individuals selected to participate in the Program to the holders of 
such loans.
  ``(b) Frequency of Payment.--The Secretary shall make payments for 
any given participant in the Specialty Education Loan Repayment Program 
on a schedule determined appropriate by the Secretary.
  ``(c) Maximum Amount; Waiver.--(1) The amount of payments made for a 
participant under the Specialty Education Loan Repayment Program may 
not exceed $160,000 over a total of four years of participation in the 
Program, of which not more than $40,000 of such payments may be made in 
each year of participation in the Program.
  ``(2)(A) The Secretary may waive the limitations under paragraph (1) 
in the case of a participant described in subparagraph (B). In the case 
of such a waiver, the total amount of payments payable to or for that 
participant is the total amount of the principal and the interest on 
the participant's loans referred to in subsection (a).
  ``(B) A participant described in this subparagraph is a participant 
in the Program who the Secretary determines serves in a position for 
which there is a shortage of qualified employees by reason of either 
the location or the requirements of the position.

``Sec. 7695. Choice of location

  ``Each participant in the Specialty Education Loan Repayment Program 
who completes residency may select, from a list of medical facilities 
of the Veterans Health Administration provided by the Secretary, at 
which such facility the participant will work in a medical specialty 
described in section 7692 of this title.

``Sec. 7696. Term of obligated service

  ``(a) In General.--In addition to any requirements under section 
5379(c) of title 5, a participant in the Specialty Education Loan 
Repayment Program must agree, in writing and before the Secretary may 
make any payment to or for the participant, to--
          ``(1) obtain a license to practice medicine in a State;
          ``(2) successfully complete post-graduate training leading to 
        eligibility for board certification in a specialty;
          ``(3) serve as a full-time clinical practice employee of the 
        Veterans Health Administration for 12 months for every $40,000 
        in such benefits that the employee receives, but in no case for 
        fewer than 24 months; and
          ``(4) except as provided in subsection (b), to begin such 
        service as a full-time practice employee by not later than 60 
        days after completing a residency.
  ``(b) Fellowship.--In the case of a participant who receives an 
accredited fellowship in a medical specialty other than a medical 
specialty described in section 7692 of this title, the Secretary, on 
written request of the participant, may delay the term of obligated 
service under subsection (a) for the participant until after the 
participant completes the fellowship, but in no case later than 60 days 
after completion of such fellowship.
  ``(c) Penalty.--(1) An employee who does not complete a period of 
obligated service under this section shall owe the Federal Government 
an amount determined in accordance with the following formula: 
A=B((T-S)T)) .
  ``(2) In the formula in paragraph (1):
          ``(A) `A' is the amount the employee owes the Federal 
        Government.
          ``(B) `B' is the sum of all payments to or for the 
        participant under the Specialty Education Loan Repayment 
        Program.
          ``(C) `T' is the number of months in the period of obligated 
        service of the employee.
          ``(D) `S' is the number of whole months of such period of 
        obligated service served by the employee.

``Sec. 7697. Relationship to Educational Assistance Program

  ``Assistance under the Specialty Education Loan Repayment Program may 
be in addition to other assistance available to individuals under the 
Educational Assistance Program.''.
  (b) Conforming and Technical Amendments.--
          (1) Conforming amendments.--
                  (A) Section 7601(a) of title 38, United States Code, 
                is amended--
                          (i) in paragraph (4), by striking ``and'';
                          (ii) in paragraph (5), by striking the period 
                        and inserting ``; and''; and
                          (iii) by adding at the end the following new 
                        paragraph:
          ``(6) the specialty education loan repayment program provided 
        for in subchapter VIII of this chapter.''.
                  (B) Section 7603(a)(1) of title 38, United States 
                Code, is amended by striking ``or VI'' and inserting 
                ``VI, or VIII''.
                  (C) Section 7604 of title 38, United States Code, is 
                amended by striking ``or VI'' each place it appears and 
                inserting ``VI, or VIII''.
                  (D) Section 7631 of title 38, United States Code, is 
                amended--
                          (i) in subsection (a)(1)--
                                  (I) by striking ``and'' after 
                                ``scholarship amount,''; and
                                  (II) by inserting ``, and the maximum 
                                specialty education loan repayment 
                                amount'' after ``reduction payments 
                                amount''; and
                          (ii) in subsection (b) by adding at the end 
                        the following new paragraph:
  ``(7) The term `specialty education loan repayment amount' means the 
maximum amount of specialty education loan repayment payments payable 
to or for a participant in the Department of Veterans Affairs Specialty 
Education Loan Repayment Program under subchapter VIII of this chapter, 
as specified in section 7694(c)(1) of this title and as previously 
adjusted (if at all) in accordance with this section.''.
                  (E) Section 7632 of title 38, United States Code, is 
                amended--
                          (i) in paragraph (1), by striking ``and the 
                        Education Debt Reduction Program'' and 
                        inserting ``the Education Debt Reduction 
                        Program, and the Specialty Education Loan 
                        Repayment Program''; and
                          (ii) in paragraph (4), by striking ``and per 
                        participant in the Education Debt Reduction 
                        Program'' and inserting ``per participant in 
                        the Education Debt Reduction Program, and per 
                        participant in the Specialty Education Loan 
                        Repayment Program''.
          (2) Table of sections.--The table of sections at the 
        beginning of chapter 76 of such title is amended by inserting 
        after the items relating to subchapter VII the following:

      ``subchapter viii--specialty education loan repayment program

``7691. Establishment.
``7692. Purpose.
``7693. Eligibility; preference; covered costs.
``7694. Specialty education loan repayment.
``7695. Choice of location.
``7696. Term of obligated service.
``7697. Relationship to Educational Assistance Program.''.

  (c) Needs of the VHA.--In making determinations each year under 
section 7692 of title 38, United States Code, as enacted by subsection 
(a), the Secretary of Veterans Affairs shall consider the anticipated 
needs of the Veterans Health Administration during the period two to 
six years in the future.
  (d) Offer Deadline.--In the case of an applicant who applies before 
receiving a residency match and whom the Secretary of Veterans Affairs 
selects for participation in the Specialty Education Loan Repayment 
Program established by subsection (a), the Secretary shall offer 
participation to the applicant not later than 28 days after--
          (1) the applicant matches with a residency in a medical 
        specialty described in section 7692 of title 38, United States 
        Code, as enacted by subsection (a); and
          (2) such match is published.
  (e) Publicity.--The Secretary of Veterans Affairs shall take such 
steps as the Secretary determines are appropriate to publicize the 
Specialty Education Loan Repayment Program established under subchapter 
VIII of chapter 76 of title 38, United States Code, as enacted by 
subsection (a).

SEC. 303. VETERANS HEALING VETERANS MEDICAL ACCESS AND SCHOLARSHIP 
                    PROGRAM.

  (a) Establishment.--The Secretary of Veterans Affairs, acting through 
the Office of Academic Affiliations of the Department of Veterans 
Affairs, shall carry out a pilot program under which the Secretary 
shall provide funding for the medical education of a total of 18 
eligible veterans. Such funding shall be provided for two veterans 
enrolled in each covered medical schools in accordance with this 
section.
  (b) Eligible Veterans.--To be eligible to receive funding for medical 
education under this section, a veteran shall--
          (1) have been discharged from the Armed Forces not more than 
        ten years before the date of application for admission to a 
        covered medical school;
          (2) not be entitled to educational assistance under chapter 
        30, 31, 32, 33, 34, or 35 of title 38, United States Code, or 
        chapter 1606 or 1607 of title 10, United States Code;
          (3) apply for admission to a covered medical school for the 
        entering class of 2019;
          (4) indicate on such application for admission that the 
        veteran would like to be considered for an award of funding 
        under this section;
          (5) meet the minimum admissions criteria for the covered 
        medical school to which the veteran applies; and
          (6) enter into an agreement described in subsection (e).
  (c) Award of Funding.--
          (1) In general.--Each covered medical school that opts to 
        participate in the program under this section shall reserve two 
        seats in the entering class of 2019 for eligible veterans who 
        receive funding under such program. Such funding shall be 
        awarded to the two eligible veterans with the highest 
        admissions rankings for such class at such school.
          (2) Amount of funding.--Each eligible veteran who receives 
        funding under this section shall receive an amount equal to the 
        actual cost of--
                  (A) tuition at the covered medical school at which 
                the veteran enrolls for four years;
                  (B) books, fees, and technical equipment;
                  (C) fees associated with the National Residency Match 
                Program;
                  (D) two away rotations performed during the fourth 
                year at a Department of Veterans Affairs medical 
                facility; and
                  (E) a monthly stipend for the four-year period during 
                which the veteran is enrolled in medical school in an 
                amount to be determined by the Secretary.
          (3) Distribution of funding.--In the event that two or more 
        eligible veterans do not apply for admission at one of the 
        covered medical schools for the entering class of 2019, the 
        Secretary shall distribute the available funding to eligible 
        veterans who applied for admission at other covered medical 
        schools.
  (d) Agreement.--
          (1) Terms of agreement.--Each eligible veteran who accepts 
        funding for medical education under this section shall enter 
        into an agreement with the Secretary that provides that the 
        veteran agrees--
                  (A) to maintain enrollment and attendance in the 
                medical school;
                  (B) while enrolled in such medical school, to 
                maintain an acceptable level of academic standing (as 
                determined by the medical school under regulations 
                prescribed by the Secretary);
                  (C) to complete post-graduate training leading to 
                eligibility for board certification in a speciality 
                applicable to the Department of Veterans Affairs, as 
                determined by the Secretary;
                  (D) after completion of medical school, to obtain a 
                license to practice medicine in a State; and
                  (E) after completion of medical school and post-
                graduate training, to serve as a full-time clinical 
                practice employee in the Veterans Health Administration 
                for a period of four years.
          (2) Breach of agreement.--If an eligible veteran who accepts 
        funding under this section breaches the terms of the agreement 
        described in paragraph (1), the United States shall be entitled 
        to recover damages in an amount equal to the total amount of 
        such funding received by the veteran.
  (e) Rule of Construction.--Nothing in this section shall be construed 
to prevent any covered medical school from accepting more than two 
eligible veterans for the entering class of 2019.
  (f) Report to Congress.--Not later than December 31, 2020, and 
annually thereafter for the subsequent three years, the Secretary shall 
submit to Congress a report on the pilot program under this section. 
Such report shall include the evaluation of the Secretary of the 
success of the pilot program, including the number of veterans who 
received funding under the program who matriculated and an evaluation 
of the academic progress of such veterans.
  (g) Covered Medical Schools.--In this section, the term ``covered 
medical school'' means any of the following.
          (1) The Teague-Cranston medical schools, consisting of--
                  (A) Texas A&M College of Medicine;
                  (B) Quillen College of Medicine at East Tennessee 
                State University;
                  (C) Boonshoft School of Medicine at Wright State 
                University;
                  (D) Joan C. Edwards School of Medicine at Marshall 
                University; and
                  (E) University of South Carolina School of Medicine.
          (2) Charles R Drew University of Medicine and Science.
          (3) Howard University College of Medicine.
          (4) Meharry Medical College.
          (5) Morehouse School of Medicine.

                          Purpose and Summary

    H.R. 4242, as amended, the ``VA Care in the Community 
Act,'' would improve the provision of care and services to 
veterans through Department of Veterans Affairs (VA) medical 
facilities and through VA providers in the community. 
Representative David P. Roe of Tennessee, the Chairman of the 
Committee on Veterans' Affairs, introduced H.R. 4242 on 
November 3, 2017.

                  Background and Need for Legislation


  TITLE I--IMPROVED ACCESS FOR VETERANS TO NON-DEPARTMENT OF VETERANS 
                          AFFAIRS MEDICAL CARE

    VA operates the largest integrated health care system in 
the country and provides care to approximately nine million 
veteran patients.\1\ The majority of the health care that 
veterans receive through VA is provided by VA-employed medical 
professionals and support staff at VA medical facilities, which 
are managed by the Veterans Health Administration (VHA).\2\ 
However, since 1945, VA has also collaborated with medical 
professionals and support staff in the community who are not VA 
employees to provide veterans with timely, accessible, high-
quality care.\3\ This is generally referred to as ``community 
care'' though has previously been referred to as ``non-VA 
care,'' ``fee basis care,'' or ``purchased care.'' Over time, 
Congress has authorized VA to use community care when a needed 
clinical service cannot be provided by a VA facility and the 
veteran cannot be transferred to another VA facility, when VA 
cannot recruit a needed clinician, when a veteran cannot access 
a VA facility due to geographic inaccessibility, when there is 
an emergent situation in which a delay in care in order to 
travel to a VA facility could be considered life-threatening, 
and in order to meet patient wait time standards.
---------------------------------------------------------------------------
    \1\About VHA. Veterans Health Administration. https://www.va.gov/
health/aboutVHA.asp. Accessed November 14, 2017.
    \2\United States Cong. House Committee on Veterans' Affairs. ``The 
State of VA's Fiscal Year 2015 Budget'' June 25, 2015. 114th Cong. 1st 
sess. Washington: GPO, 2015 (statement of the Honorable Sloan Gibson, 
Deputy Secretary of Veterans Affairs).
    \3\January 11, 2017, MyVA Advisory Committee Meeting, Georgetown 
University, Washington, D.C.
---------------------------------------------------------------------------
    The most recent VA community care authority is the Choice 
program (Choice). Choice was established by the Veterans 
Access, Choice, and Accountability Act of 2014 (Public Law 113-
146; 128 STAT. 1754). Choice expanded the availability of 
community care to veteran patients by setting specific triggers 
that would require VA to give veterans the option of receiving 
care in the community rather than in a VA medical facility. In 
general, veterans are eligible to receive care through Choice 
if they are unable to secure an appointment at a VA medical 
facility within 30 days or if they reside more than 40 miles 
from the nearest VA medical facility. Through Choice, veteran 
patients are referred to regional networks of community 
providers who are managed by Third Party Administrators. 
However, under other community care programs, VA refers veteran 
patients to community providers through agreements with the 
Indian Health Service, the Department of Defense, or academic 
affiliates; through the Patient Centered Community Care 
program; or through national or local contracts or sharing 
agreements.\4\
---------------------------------------------------------------------------
    \4\United States Cong. House Committee on Veterans' Affairs. ``The 
State of VA's Fiscal Year 2015 Budget'' June 25, 2015. 114th Cong. 1st 
sess. Washington: GPO, 2015 (statement of the Honorable Sloan Gibson, 
Deputy Secretary of Veterans Affairs).
---------------------------------------------------------------------------
    Each of VA's current community care programs and 
authorities contain different eligibility criteria, 
reimbursement rates, payment structures, referral and 
authorization requirements, and contracting approaches.\5\ 
According to VA, ``this has resulted in a complex and confusing 
landscape for veterans, community providers, and [the] VA 
employees that serve and support them.''\6\ As a result, 
``veterans face excessive bureaucracy, access based on 
administrative eligibility, and minimal care coordination 
[which] inhibits the delivery of high-quality personalized 
care.''\7\ This led VA and the Committee to conclude that, ``it 
is imperative for VA to modernize how care is provided through 
a high performing integrated network which includes care 
provided both in VA and in the community.''\8\
---------------------------------------------------------------------------
    \5\January 11, 2017, MyVA Advisory Committee Meeting, Georgetown 
University, Washington, D.C.
    \6\May 24, 2017. U.S. Department of Veterans Affairs Fact Sheet. 
``A Consolidated and Modernized VA Community Care Program.''
    \7\Ibid.
    \8\Ibid.
---------------------------------------------------------------------------
    That imperative has been exacerbated by a significant 
increase in veteran demand for community care in recent years. 
Since the establishment of Choice in fiscal year 2014, 
community care appointments have increased by 61 percent 
overall and by 41 percent as a percentage of total VA 
appointments.\9\ In fiscal year 2016, 31 percent of all 
completed appointments across the VA health care system were 
held in the community.\10\ However, Choice represents a 
relatively small portion of the overall community care 
landscape, accounting for just 23 percent of all community care 
appointments in fiscal year 2016.\11\
---------------------------------------------------------------------------
    \9\January 11, 2017, MyVA Advisory Committee Meeting, Georgetown 
University, Washington, D.C.
    \10\United States Cong. House Committee on Veterans' Affairs. ``The 
State of VA's Fiscal Year 2015 Budget'' June 25, 2015. 114th Cong. 1st 
sess. Washington: GPO, 2015 (statement of the Honorable Sloan Gibson, 
Deputy Secretary of Veterans Affairs).
    \11\January 11, 2017, MyVA Advisory Committee Meeting, Georgetown 
University, Washington, D.C.
---------------------------------------------------------------------------
    Despite the increased demand for and utilization of 
community care, VA has struggled to effectively administer 
community care programs and veterans do not always receive 
timely care when utilizing community care. For many years, the 
VA Inspector General has documented substantial problems with 
VA's management of community care programs, including issues 
authorizing and scheduling appointments, managing consults, 
ensuring network adequacy, and promptly paying community 
providers.\12\ The IG concluded that, ``our audits, reviews, 
and inspections have highlighted that VA has had a history of 
challenges in administering its purchased care programs. 
Veteran's access to care, proper expenditure of funds, timely 
payment of providers, and continuity of care are at risk to the 
extent that VA lacked adequate processes to manage funds and 
oversee program execution.''\13\ The Government Accountability 
Office (GAO) has found similar problems with community care 
programs. Most recently, in March 2017, GAO found that veterans 
who were referred to Choice for routine care because such care 
was not available through a VA medical facility in a timely 
manner could potentially wait up to 81 calendar days to obtain 
Choice care.\14\ GAO also found that VA had failed to establish 
standardized processes and procedures for Choice, to issue 
program guidance, and to track or monitor how long it took VA 
medical centers to refer a veteran to Choice (a process which 
GAO found was duplicative and could take as long as 21 
days).\15\
---------------------------------------------------------------------------
    \12\United States Cong. House Committee on Veterans' Affairs. 
``Shaping the Future: Consolidating and Improving VA Community Care'' 
March 7, 2017. 115th Cong. 1st sess. Washington: GPO, 2017 (statement 
of the Honorable Michael Missal, Inspector General, U.S. Department of 
Veterans Affairs).
    \13\Ibid.
    \14\United States Cong. House Committee on Veterans' Affairs. 
``Shaping the Future: Consolidating and Improving VA Community Care'' 
March 7, 2017. 115th Cong. 1st sess. Washington: GPO, 2017 (statement 
of Randall B. Williamson, Director, Health Care, Government 
Accountability Office).
    \15\Ibid.
---------------------------------------------------------------------------
    The Committee concurs with the IG and GAO regarding the 
long history of challenges with regard to VA community care 
programs. The Committee also concurs with VA's assessment about 
the need to consolidate VA's multiple community care programs 
and authorities in order to create a more seamless network of 
care in VA medical facilities and in the community to better 
serve veterans and achieve improved health outcomes, patient 
satisfaction, care coordination, and efficiency.\16\ 
Accordingly, Title I of the bill would establish a permanent VA 
Care in the Community Program (the Program) to provide hospital 
care, medical services, and extended care to veteran patients 
through contracts or agreements with network providers. In this 
program, VA would be required to establish regional networks of 
community providers and to coordinate the care veterans receive 
through network providers as well as provide case management, 
where appropriate. A veteran would be eligible to receive 
primary care through the Program if VA is unable to assign that 
veteran to a primary care provider in a VA medical facility and 
would be eligible to receive specialty care through the Program 
if that veteran is referred by his/her primary care provider. 
In determining whether or not to provide specialty care to a 
veteran in a VA medical facility rather than through the 
Program, VA would be required to consider whether the VA 
medical facility is within a reasonable distance of the 
veteran's residence and to take into account any unusual or 
excessive travel burdens and geographical or environmental 
challenges the veteran may face, the veteran's medical 
condition, and the recommendation of the veteran's primary care 
provider. Once a veteran is referred to a community provider 
through the Program, VA would be required to ensure that the 
veteran receives care through the completion of an episode of 
care including specialty and ancillary services and to ensure 
appropriate medical documentation of such care is returned to 
VA. VA would be required to establish a process to review 
disagreements regarding the eligibility of a veteran to receive 
care or services from a community provider using the Program. 
Under the Program, community providers would be reimbursed in 
accordance with Medicare rates with certain exceptions allowed 
for, for example, highly rural areas, Alaska, states with all-
payer models, and federal or tribal entities. In addition, VA 
would be authorized to enter into value-based reimbursement 
models. To ensure the care veterans receive through the Program 
is high quality, VA would be required to develop quality 
standards to track the quality of network providers.
---------------------------------------------------------------------------
    \16\May 24, 2017. U.S. Department of Veterans Affairs Fact Sheet. 
``A Consolidated and Modernized VA Community Care Program.''
---------------------------------------------------------------------------
    Title I of the bill would require the Program to be funded 
out of the Community Care account established by the Surface 
Transportation and Veterans Health Care Choice Improvement Act 
of 2015 (Public Law 114-41; 129 STAT. 443) and stipulate that 
remaining funds, if any, in the Veterans Choice Fund 
established by the Veterans Access, Choice, and Accountability 
Act of 2014 (Public Law 113-146; 128 STAT. 1754) to be 
transferred to the Community Care account one year after 
enactment. Importantly, it would also terminate VA's existing 
care in the community programs and authorities upon 
commencement of the Program, which would occur no later than 
one year after enactment via interim final regulations after VA 
has certified to Congress that each community care provider and 
VA employee is trained to furnish care under the Program and 
has established standard, written guidance with respect to the 
policies and procedures of the Program.
    The Committee strongly believes that VA's ability to 
accurately process timely payments to community provider 
providers in compliance with the prompt payment rule is 
critical to the Program's success and to ensuring access to 
community care for the increasing number of veterans who rely 
on it. However, in 2014, GAO issued a report which found that 
community providers experienced ``lengthy delays'' in the 
processing of their claims that, in some cases, took years to 
resolve.\17\ According to GAO, this resulted in an environment 
where community providers are hesitant to provide care to 
veterans due to fears they will not be paid for services 
provided on VA's behalf.\18\ These findings were echoed in 
testimony GAO provided in 2016, which stated that ``the 
substantial increase in utilization of VA care in the community 
programs poses challenges for VHA, which has had ongoing 
difficulty processing claims from community providers in a 
timely manner.''\19\ As such, Title I of the bill would also 
establish a prompt payment standard in which claims are 
required to be submitted 180 days after care is provided (or a 
network provider is paid by a contractor) and clean paper 
claims are either paid or denied within 45 days of receipt and 
clean electronic claims are either paid or denied within 30 
days of receipt. If a claim is denied and additional 
information has been submitted, adjudication would be required 
within 30 days of receipt. Pursuant to this authority, VA would 
be required to pay interest payments for overdue claims, allow 
for the recovery of overpayments through deductions of future 
payments or refunds from the claimant, and prohibited from 
requiring receipt of medical records as a requisite for 
payment. Title I of the bill would also require VA to establish 
a Center for Innovation to test and develop innovative pilot 
models for payment and service delivery for community care. The 
Committee believes this could potentially reduce expenditures 
while preserving or enhancing the quality of care furnished by 
VA.
---------------------------------------------------------------------------
    \17\GAO-14-175, Actions Needed to Improve Administration and 
Oversight of Veterans' Millennium Act Emergency Care Benefit. http://
www.gao.gov/assets/670/661404.pdf.
    \18\Ibid.
    \19\United States Cong. House Committee on Veterans' Affairs, 
Subcommittee on Health. ``Choice Consolidation: Improving VA Community 
Care Billing and Reimbursement'' February 11, 2016. 114th Cong. 2nd 
sess. Washington: GPO, 2016 (statement of Randall B. Williamson, 
Director, Health Care, U.S. Government Accountability Office).
---------------------------------------------------------------------------
    The Committee recognizes that, in certain cases, veterans 
may require community care outside of the Program. In general, 
VA's community care authorities utilize traditional Federal 
Acquisition Regulation (FAR)-based contracts to do business 
with private providers. However, the Veterans Access, Choice, 
and Accountability Act of 2014 (Public Law 113-146; 128 STAT. 
1754) granted VA the authority to purchase community care 
through non-FAR based provider agreements. This was in 
recognition of the difficult and sometimes burdensome processes 
and requirements that the FAR imposes on community providers 
who are small or unaccustomed to federal contracting. VA has 
requested legislative authority to enter into non FAR-based 
provider agreements since 2015.\20\ In particular, some 
community providers have cited their classification as federal 
contractors subject to the audit and reporting requirements of 
the Department of Labor's Office of Federal Contract Compliance 
Programs (OFCCP) as especially onerous. VA has claimed that 
provider agreement authority would ``. . . ensure that veterans 
receive the necessary care they earned through the fullest 
complement of non-VA providers'' and, the absence of such 
authority, ``has resulted in complications with extended care 
providers and other [non-Choice providers as] some small, long-
term care facilities have already withdrawn their support of 
veterans due to the overwhelming administrative requirements of 
the FAR.''\21\ The American Health Care Association concurs and 
has testified about the ``onerous reporting requirements and 
regulations'' that have ``dissuaded nursing care centers from 
admitting VA patients'' which ``limits the care available to 
veterans needing long term care in their local 
communities.''\22\ This has created an acute need in some 
areas, particularly for those veterans who live in rural areas 
where VA facilities are far away and community providers are 
scarce. Title I of the bill would authorize VA to enter into 
provider agreements to deliver care to veteran patients when 
furnishing such care at VA facilities is impractical or 
inadvisable for a particular veteran and such care is not 
available from a community provider under a traditional FAR-
based contract or sharing agreement. This provider agreement 
authority would be limited to not more than $5 million for 
community providers furnishing homemaker or home health aide 
services and to not more than $2 million for other community 
providers. VA would be required to establish a process to 
certify eligible providers and ensure they meet certain terms, 
conditions, and quality standards. Importantly, Title I of the 
bill would stipulate that provider agreements under this 
authority are not subject to competitive procedures and are 
exempted from any provision of law that Medicare providers are 
exempted from but are subject to the Civil Rights Act of 1964. 
Title I of the bill would also modify VA's authority to enter 
into agreements with State Veterans Homes by stipulating that 
such agreements are not subject to competitive procedures or 
laws that Medicare providers are exempt from but are subject to 
all laws regarding integrity, ethics, fraud, and that would 
protect against employment discrimination.
---------------------------------------------------------------------------
    \20\January 2, 2017. U.S. Department of Veterans Affairs, The 
Honorable Secretary Robert McDonald. ``Caring for Those Who Have Borne 
the Battle: Cabinet Exit Memo.'' https://www.va.gov/opa/publications/
docs/VA-Exit-Memo.pdf.
    \21\Ibid.
    \22\United States Cong. House Committee on Veterans' Affairs. 
Legislative Hearing. October 24, 2017. 115th Cong. 1st sess. 
Washington: GPO, 2017 (statement for the record from the American 
Health Care Association).
---------------------------------------------------------------------------
    The Committee is committed to ensuring that the care 
provided through the Program supplements but does not supplant 
the care provided in VA medical facilities and that VA 
continues to provide timely, high quality care to veterans both 
in the community and in VA. To that end, Title I of the bill 
would also require VA to conduct periodic (defined as not less 
often than once every three years) capacity and commercial 
market assessments in each Veterans Integrated Service Network 
and VA medical facility to identify gaps in care and recommend 
how such gaps could be filled via changing how care is 
furnished and/or building or realigning VA resources or 
personnel.

Section 109. Transplant procedures with live donors and related 
        services

    VA has offered solid organ transplant services for eligible 
veteran patients since 1962 and bone marrow transplant services 
for eligible veteran patients since 1982.\23\ Through VA's 
National Transplant Program, VA provides transplants primarily 
through 13 VA transplant centers located in: Palo Alto, 
California; Portland, Oregon; Seattle, Washington; Houston, 
Texas; San Antonio, Texas; Salt Lake City, Utah; Iowa City, 
Iowa; Madison, Wisconsin; Birmingham, Alabama; Nashville, 
Tennessee; West Roxbury, Massachusetts; Bronx, New York; 
Pittsburgh, Pennsylvania; and Richmond, Virginia.\24\
---------------------------------------------------------------------------
    \23\VA National Transplant Program. https://www.va.gov/health/
services/transplant/ Accessed October 30, 2017.
    \24\Ibid.
---------------------------------------------------------------------------
    The Veterans Access, Choice, and Accountability Act of 2014 
(Public Law 113-146; 128 STAT. 1754) created the Choice program 
to increase access to care in the community for veteran 
patients unable to receive care at VA medical facilities due to 
long waiting times for VA appointments or lengthy travel 
distances to VA medical facilities. Since the implementation of 
the Choice program, the Committee has heard an increasing 
number of complaints about the VA transplant program from 
veterans who are concerned about the lengthy travel required 
for many veterans to reach a VA transplant center and barriers 
to receiving transplant care in the community. For example, in 
2016, Charles Nelson--a 100 percent service-connected veteran 
from Leander, Texas--attempted to receive a kidney transplant 
through the VA health care system.\25\ Mr. Nelson's non-veteran 
son, Austin, was willing and able to serve as Mr. Nelson's live 
donor.\26\ Rather than travel to VA transplant centers in 
Nashville, Tennessee, or Portland, Oregon, to receive his 
kidney transplant, Mr. Nelson asked VA to authorize him to 
receive his transplant at the University Hospital in San 
Antonio via the Choice program.\27\\28\ Though his request was 
approved by local VA officials in Texas, VA Central Office in 
Washington, D.C. denied Mr. Nelson's request to receive his 
transplant through the Choice program, arguing that because 
Austin was not a veteran VA would be unable to use Choice funds 
to cover the costs of his care.\29\ Though Choice is just one 
of several care in the community programs that VA could have 
used to cover the costs of Mr. Nelson's transplant at the 
University Hospital in San Antonio, Mr. Nelson eventually 
received his transplant at that facility using his Medicare 
benefits, private donations, and personal savings to cover the 
cost of his care.\30\
---------------------------------------------------------------------------
    \25\United States Cong. House Committee on Veterans' Affairs. 
Legislative Hearing. October 24, 2017. 115th Cong. 1st sess. 
Washington: GPO, 2017 (statement for the record Representative John 
Carter).
    \26\Ibid.
    \27\Ibid.
    \28\Fox 7, ``Leander Veteran Fighting for VA to Pay for Kidney 
Transplant,'' May 24, 2016, http://www.fox7austin.com/news/local-news/
disabled-leander-veteran-fighting-to-get-va-to-pay-for-kidney-
transplant.
    \29\United States Cong. House Committee on Veterans' Affairs. 
Legislative Hearing. October 24, 2017. 115th Cong. 1st sess. 
Washington: GPO, 2017 (statement for the record Representative John 
Carter).
    \30\Ibid.
---------------------------------------------------------------------------
    On June 29, 2016, the Journal of the American Medical 
Association published an article which found that greater 
distance from a VA Transplant Center was associated with a 
lower likelihood of receiving a transplant and a greater 
likelihood of death among certain veteran transplant 
patients.\31\ Given the article's findings the Committee 
believes that veterans residing far from VA transplant centers 
should be given the option of receiving their transplant from 
transplant centers in the community closer to the veteran's 
place of residence. The Committee also believes that, wherever 
possible, VA should remove barriers to transplant care in the 
community for veteran patients. Consistent with those goals, 
section 109 of the bill would authorize veterans to obtain a 
transplant outside of the region of the Organ Procurement and 
Transplantation Network if veteran's primary care provider 
opines that there is a medically compelling reason and also 
authorize VA to support the cost of a donor transplant 
operation, including perioperative care and care performed in a 
non-VA facility, for a live donor who is not a veteran but who 
is donating an organ for a veteran.
---------------------------------------------------------------------------
    \31\Journal of the American Medical Association, ``Association of 
Distance from a Transplant Center with Access to Waitlist Placement, 
Receipt of Liver Transplantation, and Survival Among U.S. Veterans, 
June 29, 2016, https://www.ncbi.nlm.nih.gov/pubmed/24668105.
---------------------------------------------------------------------------

                 TITLE II--OTHER ADMINISTRATIVE MATTERS

Section 201. Reimbursement for emergency ambulance services

    While VA has experienced long-standing difficulties 
complying with prompt pay rules in general, VA has had 
particular challenges issuing timely reimbursement for 
ambulance providers. In June 2015, American Medical Response, 
the nation's largest single ambulance provider, testified 
before the Subcommittee on Health that they have had 
``consistent difficulty'' receiving reimbursement from VA and, 
despite working with VA for a year, had a payment backlog 
totaling approximately $12 million.\32\ Section 201 of the bill 
would require VA to reimburse an ambulance provider or other 
emergency transport service for providing transportation to a 
veteran for purposes of receiving emergency medical care at a 
community facility if the request for transportation was made 
as a result of the sudden onset of a medical condition of such 
a nature that it meets the prudent layperson standard and the 
veteran is transported to the most appropriate medical 
facility.
---------------------------------------------------------------------------
    \32\United States Cong. House Committee on Veterans' Affairs. 
``Assessing VA's Ability to Promptly Pay Non-VA Providers.'' June 3, 
2015. 114th Cong. 1st sess. Washington: GPO, 2017 (statement for the 
record from American Medical Response).
---------------------------------------------------------------------------

Section 202. Improvement of care coordination for veterans through 
        exchange of certain medical records

    Since fiscal year 2014, VA community care appointments have 
increased by 61 percent overall and by 41 percent as a 
percentage of total VA appointments.\33\ In FY 2016 alone, 25.5 
million appointments--or 30 percent of all VA appointments--
occurred in the community rather than in VA medical 
facilities.\34\ Given the dramatic increase in VA community 
care demand in recent years and the need to ensure that the 
care veterans receive both in VA medical facilities and in the 
community is effectively coordinated to ensure quality, the 
Committee believes that it is critically important for VA and 
community providers to be able to share pertinent medical 
record information about the veteran patients they are jointly 
treating while also ensuring appropriate protections are in 
place to secure patient privacy.
---------------------------------------------------------------------------
    \33\January 11, 2017, MyVA Advisory Committee Meeting, Georgetown 
University, Washington, D.C.
    \34\Ibid.
---------------------------------------------------------------------------
    Accordingly, section 202 of the bill would amend section 
7332 of title 38 U.S.C. to permit VA to share confidential 
medical information with a public or private health care 
provider in order to provide care or treatment to a shared 
patient and to a third party in order to recover (or collect) 
reasonable charges for care furnished to a veteran for a non-
service connected disability with the stipulation that such 
sharing must be in accordance with relevant health record 
privacy laws (including HIPPA). The Committee believes this 
would improve the provision of care to veteran patients from 
both VA providers and community providers while also ensuring 
that personal patient information is safeguarded from 
inappropriate disclosure.

Section 203. Elimination of copayment offset

    As a condition for receiving VA health care services, 
veterans with income greater than VA income thresholds must 
agree to pay a copayment for care VA provides that is not 
related to a service-connected condition.\35\ Section 1729 of 
title 38 United States Code authorizes VA to bill a veteran's 
private (third party) health insurance reasonable charges for 
treatment of a veteran's non service-connected conditions and 
to reduce any copayment amounts such veteran would otherwise 
owe to VA dollar for dollar based on the collection from the 
private insurer.\36\ Funds collected by VA from private 
insurers are deposited in the VA Medical Care Collections Fund 
(MCCF) and used to augment VA's medical care accounts and cover 
expenses incurred by VA as a result of first and third-party 
collections. VA estimates that approximately twenty-three 
percent of veterans enrolled in the VA health care system pay 
copayments to VA for treatment in connection with a non-service 
connected condition have billable private insurance plans.\37\ 
According to VA, the practice of reducing a veteran's copayment 
amounts using money from such veteran's private insurer ``. . . 
reduces the total collections received by VA that is available 
for use in providing direct medical care and does not align 
with standard health care industry practice.''\38\ The 
Committee concurs with VA's assessment.
---------------------------------------------------------------------------
    \35\VA Fiscal Year 2018 Budget Submission, Volume 2, VHA-347.
    \36\Ibid.
    \37\Ibid.
    \38\Ibid.
---------------------------------------------------------------------------
    As such, section 203 of the bill would eliminate the 
current requirement for VA to offset a veteran's copayment with 
amounts recovered from the veteran's third party insurance. VA 
estimates that this will result in improved collections 
totaling approximately $62 million.\39\ While the Committee 
does not believe that eliminating the requirement for VA to 
offset a veterans copayment amount with collections from 
private insurance companies is, on its own, sufficient to 
incentive a veteran to abandon his/her other health insurance, 
the Committee intends to closely monitor how the number of 
veteran patients with other health insurance and MCCF 
collection rates are impacted by enactment of this section of 
the bill.
---------------------------------------------------------------------------
    \39\Ibid.
---------------------------------------------------------------------------

Section 204. Use of Department of Veterans Affairs Medical Care 
        Collections Fund for certain improvements in collections

    The Balanced Budget Act of 1997 (Public Law 105-33; 111 
STAT. 251) established the VA MCCF and required that amounts 
collected or recovered after June 30, 1997, be deposited into 
the MCCF and used to furnish medical care and services to 
eligible veterans and to cover expenses incurred to collect 
amounts owed by first or third parties for the medical care and 
services furnished by VA.\40\ VA's fiscal year 2018 budget 
submission notes that the Department has re-estimated 
collections in 2017 and 2018 downward due to broader healthcare 
payer changes that have resulted in third-party payers 
proposing reductions to their reimbursement levels.\41\ The 
Committee is increasingly concerned that VA is not sufficiently 
collecting revenue from first and third party payers. As a 
result, section 204 of the bill would include automatic data 
processing and information technology improvements as an MCCF 
expense allowed in the billing, auditing, and collecting of 
such revenues.
---------------------------------------------------------------------------
    \40\VA Fiscal Year 2018 Budget Submission, Volume 2, VHA-173.
    \41\VA Fiscal Year 2018 Budget Submission, Volume 2, VHA-174.
---------------------------------------------------------------------------

Section 205. Department of Veterans Affairs health care productivity 
        improvement

    The Committee believes it is important that VA achieves and 
maintains a high level of productivity among VA clinicians in 
order to maximize veteran access to care and ensure a prudent 
use of taxpayer dollars. However, recent analyses have called 
into question how well VA tracks provider productivity and how 
productive they are compared to their non-VA counterparts. For 
example, the 2015 Independent Assessment of the Health Care 
Delivery Systems and Management Processes of the Department of 
Veterans Affairs found that VA specialty providers are less 
productive than their private sector counterparts on two 
industry measures--encounters and relative value units 
(RVUs).\42\ RVUs are a commonly used measure of a provider's 
productivity that take into account the time, technical skill, 
mental effort, and stress that are needed for a clinician to 
provide a given clinical service.\43\ More recently, the 
Government Accountability Office released a report in 2017, 
which found that VA lacks complete and accurate information on 
clinical productivity and efficiency because VA's existing 
productivity metrics and efficiency models do not account for 
all providers and clinical services, may not accurately reflect 
the intensity of clinical workloads or staffing levels, and may 
be adversely impacted by inaccurate data.\44\ GAO also found 
that VA Central Office does not systematically oversee 
productivity and efficiency and, thus, cannot ensure that low 
productivity and clinical inefficiencies are addressed at 
individual VA medical facilities or identify and correct 
patterns that could increase productivity and efficiency across 
the VA health care system. Accordingly, section 205 of the bill 
would require VA to track RVUs for all VA providers, to ensure 
that all VA providers attending training on clinical procedure 
coding, and to establish RVU-based performance standards as 
well as remediation plans to address low clinical productivity 
and inefficiency.
---------------------------------------------------------------------------
    \42\CMS Alliance to Modernize Healthcare Federally Funded Research 
and Development Center, September 1, 2015, ``Independent Assessment of 
the Health Care Delivery Systems and Management Processes of the 
Department of Veterans Affairs,'' https://www.va.gov/opa/choiceact/
documents/assessments/Integrated_Report.pdf.
    \43\January 12, 2015, National Health Policy Forum, ``The Basics: 
Relative Value Units,'' https://www.nhpf.org/library/the-basics/
Basics_RVUs_01-12-15.pdf.
    \44\GAO-17-480, May 2017, ``Improvements Needed in Data and 
Monitoring of Clinical Productivity and Efficiency,'' https://
www.gao.gov/assets/690/684869.pdf.
---------------------------------------------------------------------------

Section 206. Licensure of health care professionals of the Department 
        of Veterans Affairs providing treatment via telemedicine

    As a national, integrated health care system, the Veterans 
Health Administration (VHA) has a responsibility to ensure that 
veteran patients receive access to care no matter where the 
veteran patient is located.\45\ This is a particular challenge 
for veteran patients residing in remote, rural, or medically 
underserved areas far from VA medical facilities and for 
veteran patients with mobility or other issues that impact 
their ability to travel to VA medical facilities to receive 
care.\46\
---------------------------------------------------------------------------
    \45\Authority of Health Care Providers to Practice Telehealth. 
https://www.federalregister.gov/documents/2017/10/02/2017-20951/
authority-of-health-care-providers-to-practice-telehealth. Accessed 
October 31, 2017.
    \46\Ibid.
---------------------------------------------------------------------------
    Telemedicine refers to ``the use of telehealth technologies 
to provide clinical care in circumstances where distance 
separates those receiving services and those providing 
services.''\47\ By allowing VA clinicians to provide ``the 
right care in the right place at the right time,'' telemedicine 
is critical to VA's ability to deliver health care to veteran 
patients who could not otherwise access such care.\48\\49\ 
According to VA, ``[telemedicine] increases the accessibility 
of VA health care, bringing VA medical services to locations 
convenient for beneficiaries, including clinics in remote 
communities and beneficiaries'' homes.''\50\ In fiscal year 
2016, VA health care providers provided more than 2 million 
episodes of care via telemedicine to more than 700,000 veteran 
patients, approximately 12 percent of VA's total patient 
population.\51\ Veteran patients who have had experience with 
VA telemedicine programs have demonstrated improved health 
outcomes, including decreases in hospital admissions.\52\
---------------------------------------------------------------------------
    \47\VA Telehealth Services. https://www.telehealth.va.gov/ Accessed 
October 30, 2017.
    \48\Ibid.
    \49\Authority of Health Care Providers to Practice Telehealth. 
https://www.federalregister.gov/documents/2017/10/02/2017-20951/
authority-of-health-care-providers-to-practice-telehealth. Accessed 
October 31, 2017.
    \50\Ibid.
    \51\Ibid.
    \52\Ibid.
---------------------------------------------------------------------------
    However, the continued expansion of telemedicine across the 
VA health care system is constrained by restrictions on the 
ability of VA providers to practice telemedicine across state 
lines without jeopardizing their state licensure and facing 
potential penalties for the unauthorized practice of 
medicine.\53\ VA claims that this disparity--between VA health 
care practice and state medical licensure laws--has severely 
inhibited the provision of telemedicine in VA and, therefore, 
reduced the availability and accessibility of care for veteran 
patients.\54\
---------------------------------------------------------------------------
    \53\Ibid.
    \54\Ibid.
---------------------------------------------------------------------------
    In response to this, VA announced on August 3, 2017, that 
VA would be amending regulations to allow VA health care 
providers who are licensed, registered, or certified in ``a 
state'' to practice in any state when they are acting within 
the scope of their VA employment--regardless of individual 
state licensure, registration, or certification restrictions 
except for applicable state restrictions on the authority to 
prescribe and administer controlled substances.\55\ VA claims 
that this action would serve to ``authorize VA health care 
providers to furnish care, consistent with their employment 
obligations, through [telemedicine], without fear of adverse 
action by any state.''\56\ Despite this rulemaking, VA 
testified during a Committee hearing that legislation was 
needed to ``[provide] statutory protection and [codify] VA's 
longstanding practice of allowing VA providers to practice in 
any state as long as they are licensed in a state.''\57\
---------------------------------------------------------------------------
    \55\Ibid.
    \56\Ibid.
    \57\United States Cong. House Committee on Veterans' Affairs. 
Legislative Hearing. October 24, 2017. 115th Cong. 1st sess. 
Washington: GPO, 2017 (statement from the Honorable David Shulkin M.D., 
Secretary of Veterans Affairs).
---------------------------------------------------------------------------
    Therefore, section 206 of the bill would exercise 
preemption of state licensure, registration, and certification 
laws, rules, and regulations or requirements to the extent such 
state laws conflict with the ability of VA providers to engage 
in the practice of telehealth while acting within the state of 
their VA employment and authorize a VA licensed health care 
provider to practice telemedicine at any location in any state, 
regardless of where the provider or patient is located and 
whether or not the patient or provider is on federal government 
property. The Committee believes that the continued expansion 
of telemedicine across the VA healthcare system will aid 
veterans in receiving timely, quality care from VA and in 
achieving improved health outcomes. Further, the Committee 
concurs with the American Medical Association that providing VA 
healthcare providers the authority to practice telemedicine 
across state lines would ``address the significant and unique 
need to expand access to health care services for veterans 
being treated within the VA system while also ensuring that 
important patient protections remain in place, including the 
direct oversight, accountability, training, and quality control 
specific to VA-employed physicians and other health care 
professionals.''\58\ Section 206 of the bill would also require 
VA to submit a report to Congress on the Department's 
telemedicine programs, which would allow the effectiveness of 
VA telemedicine to be better understood.
---------------------------------------------------------------------------
    \58\United States Cong. House Committee on Veterans' Affairs. 
Legislative Hearing. October 24, 2017. 115th Cong. 1st sess. 
Washington: GPO, 2017 (statement for the record from the American 
Medical Association).
---------------------------------------------------------------------------

Section 207. Establishment of processes to ensure safe opioid 
        prescribing practices by non-Department of Veterans Affairs 
        health care providers

    Overdose deaths involving prescriptions have quintupled 
since 1999. Between 1999 and 2016 more than 200,000 deaths were 
attributed to overdoses from prescription drugs.\59\ The opioid 
epidemic has impacted veterans and overdose deaths among 
veterans remain elevated when compared to the civilian 
population. Due to the prevalence of chronic pain in the 
veteran population, many being treated with opioids, VA 
instituted the Opioid Safety Initiative (OSI), a program using 
evidence-based management guidelines, including dosing and 
monitoring guidelines, to treat pain and to mitigate the risks 
of prescription opioids.\60\
---------------------------------------------------------------------------
    \59\Prescription Opioid Overdose Data, Centers for Disease Control 
and Prevention; https://www.cdc.gov/drugoverdose/data/overdose.html. 
    \60\Department of Veterans Affairs, Office of Inspector General 
report no. 17-01846-316, Healthcare Inspection: Opioid Prescribing to 
high-Risk Veterans Receiving VA Purchased Care, July 3, 2017.
---------------------------------------------------------------------------
    Over the past several years, VA has implemented purchased 
care programs to enable veterans to access care by non-
department providers in the community. This care includes the 
management of chronic pain conditions for which veterans are 
prescribed opioids.\61\ This raises the potential for 
inconsistencies in management between the community provider 
and guidelines promulgated by VA increasing risk to the 
veteran. Moreover, medical information may not be shared 
between the community provider and VA further exacerbating such 
risks.\62\ GAO recommended that community providers receive and 
review the guidelines in the OSI, that VA implement a process 
to share up to date veterans' medication records with community 
providers, require community providers to submit opioid 
prescriptions to a VA pharmacy with recordation of the 
prescription in the VA electronic health record, and to ensure 
that if a community provider's provider prescribing practices 
are in conflict OSI guidelines, that actions are taken to 
ensure the safety of the veteran.\63\
---------------------------------------------------------------------------
    \61\Ibid.
    \62\Ibid.
    \63\Ibid.
---------------------------------------------------------------------------
    The Committee believes that VA must take steps to ensure 
safe opioid prescribing practices are adhered to when a veteran 
is sent to the community for care. Accordingly, section 207 of 
the bill would require VA to provide OSI guidelines to 
community providers and certify that the community providers 
have reviewed the guidelines and to implement a process to 
ensure that community providers receive a veteran's relevant 
history including all medications. It would further require 
that opioid prescriptions be filled at a VA pharmacy, or at a 
community pharmacy only if prior authorization has been 
received (with an exception for certain urgent or emergent 
circumstances). Section 2017 would also require that opioid 
prescriptions be recorded in the electronic health record and 
that community providers whose prescribing practices are 
inconsistent with OSI requirements or violate licensing 
guidelines are removed from VA community care networks.

Section 208. Assessment of health care furnished by the Department to 
        veterans who live in territories

    Veterans in Puerto Rico, the U.S. Virgin Islands, the 
American Samoa, Guam, and the Northern Mariana Islands face a 
number of barriers to timely, accessible VA care and benefits. 
The principle barrier these veterans face is the lack of VA 
care at home, which often necessitates lengthy travel to VA 
medical centers and clinics in other areas. In light of the 
unique challenges that veterans residing in these territories 
face accessing VA services, section 208 of the bill would 
require VA to report on the care provided to veterans in Puerto 
Rico, the U.S. Virgin Islands, the American Samoa, Guam, and 
the Northern Mariana Islands and include whether it would be 
feasible for VA to establish a medical facility in any 
territory that does not contain such a facility.

Section 209. Oversight and accountability of financial processes of 
        Department of Veterans Affairs

    Since Choice was established in 2014, VA has returned to 
Congress several times seeking additional, ``emergency'' 
appropriations to keep the program operational in the face of 
funding shortfalls. Most recently, on December 12, 2017, 
Secretary Shulkin predicted without additional funding by the 
end of the year, veterans would see a ``dramatic impact'' on 
their overall healthcare.\64\ The Committee contends that these 
repeated requests for additional appropriations are outside the 
scope what would typically constitute an ``emergency'' 
designation and believe VA must improve its community care 
accounting, bringing all projections for care purchased from 
the community back into the standard budget request process. 
Section 209 of the bill would require VA to submit a 
justification to any request for supplemental appropriations, 
based upon sound actuarial analysis. It would require VA's 
Chief Financial Officer to certify the sufficiency, to the 
extent possible, of VA's annual budget submission to provide 
benefits and health services to veterans, as required by law.
---------------------------------------------------------------------------
    \64\December 12, 2017. Letter from the Honorable David J. Shulkin 
M.D., Secretary of the U.S. Department of Veterans Affairs to the 
Honorable David P. Roe, Chairman of the Committee on Veterans' Affairs 
of the U.S. House of Representatives. https://veterans.house.gov/
uploadedfiles/roe.pdf.
---------------------------------------------------------------------------

Sec. 210. Authority for Department of Veterans Affairs Center for 
        Innovation for Care and Payment

    As a nationwide system, VA has struggled to maximize 
efficiency of payment and care in its clinics and hospitals. 
Some areas have seen improvement, while others have fallen 
behind. Section 210 of the bill would address this by amending 
subchapter I of chapter 17, as amended by section 122, by 
authorizing a ``Center for Innovation for Care and Payment.'' 
Through this center, the Secretary could carry out pilot 
programs to develop innovative approaches to testing payment 
and service delivery models to reduce expenditures while 
preserving or improving the quality of care. The programs could 
be carried out in locations appropriate for the intended 
purpose of the programs, and no pilot shall last longer than 
five years. The Secretary would be required to obtain advice 
from the VA special Medical Advisory Group in the development 
and implementation of any pilot. In implementing the pilot 
programs, the Secretary would be authorized to waive any 
requirements under Title 38 only after submitting a report to 
Congress explaining the authorities to be waived and the 
reasons for such requirement. The Secretary would only be 
allowed to act upon any such waiver after Congress enacts a 
bill or joint resolution approving the action. The Secretary 
would be required to conduct an evaluation of each model tested 
and make such information public.

          TITLE III--IMPROVEMENTS TO RECRUITMENT OF PHYSICIANS

Section 301--Designated scholarships for physicians and dentists under 
        Department of Veterans Affairs Health Professional Scholarship 
        Program

    VA currently has several programs to address recruiting in 
its professional ranks. These programs include the Education 
Debt Repayment Program (EDRP) and the Health Professions 
Scholarship Program (HPSP). Physician remains the top position 
in VA's mission critical positions shortage despite these 
programs, with VA indicating a need to hire more than one 
thousand additional physicians in fiscal year 2017.\65\ VA's 
considerable recruitment and retention issues are worsened by 
an aging workforce that is becoming increasingly retirement-
eligible.\66\
---------------------------------------------------------------------------
    \65\United States Cong. House Committee on Veterans' Affairs. 
Oversight Hearing. March 22, 2017. 115th Cong. 1st sess. Washington: 
GPO, 2017 (Question for the Record response from the U.S. Department of 
Veterans Affairs.)
    \66\United States Cong. House Committee on Veterans' Affairs. 
Legislative Hearing. March 16, 2016. 114th Cong. 2nd sess. Washingtoon: 
GPO, 2016. (Testimony from the Partnership for Public Service.)
---------------------------------------------------------------------------
    To help alleviate the shortage of physicians and increases 
the number of young physicians working at VA, section 301 would 
provide scholarships to medical students in exchange for 
service to VA. A minimum of two to four year scholarships for 
medical and dental students would be required so long as the 
shortage of those positions exceed 500. Once the number falls 
below 500, the minimum number of scholarships provided annually 
would be at least ten percent of the number of positions deemed 
in shortage. The obligation requirement for the scholarship is 
successful completion of residency training leading to board 
eligibility in a specialty and 18 months of clinical service at 
a VA facility for each year of scholarship support. Section 301 
would also authorize VA to provide preference to veterans and 
require VA to conduct annual advertising to educational 
institutions.

Section 302--Establishment of Department of Veterans Affairs Specialty 
        Education Loan Re-payment Program

    The average medical education debt is approximately 
$192,000 for a 2017 graduate.\67\ VA's current loan repayment 
program is offered just before a resident completes training or 
has completed training in exchange for service at a VA 
facility. The Veterans Integrated Service Network (VISN) 
determines how much EDRP funds are allotted to each facility 
and each facility director is authorized to offer up to $24,000 
annually in exchange for service. The timing of the offer 
presents potential obstacles as VA is competing with other 
professional and financial opportunities for physicians. The 
salaries offered by other practices are competitive with VA, 
and the anticipated salary is high enough so that the burden of 
a loan payment may not appear onerous.\68\ Moreover, because of 
VHA human resource policies for hiring physicians, for example, 
firm offers cannot be made until physical examinations and 
credentialing are completed, the earliest of which are 120 days 
prior to starting a position, many senior resident physicians 
are offered positions earlier than VA\69\ thus obviating the 
ability to present the EDRP to potential hires. Lastly, the 
EDRP program is effectuated at the local level based on local 
needs, therefore does not have a mechanism for VA to direct 
funds to recognized needed specialties on a national level.
---------------------------------------------------------------------------
    \67\AAMC Medical School Graduation Questionnaire. https://
www.aamc.org/download/481784/data/2017gqallschoolssummaryreport.pdf.
    \68\Medscape Physician Compensation Report 2917. https://
www.medscape.com/slideshow/compensation-2017-overview-6008547#4.
    \69\Darves, B, Physician Job-Search Timeline: Delayed Approach Not 
Advised; The New England Journal of Medicine, October 8, 2014.
---------------------------------------------------------------------------
    Section 302 would establish a new loan repayment program 
for medical or osteopathic student educational loans for newly 
graduated medical students, or residents with at least 2 years 
of training remaining, who are training in specialties deemed 
by VA to be experiencing a shortage. The loan repayment would 
be $40,000 per year for a maximum of $160,000. In exchange for 
the loan repayment, the recipient would agree to obtain a 
license to practice medicine, complete training leading to 
board eligibility in a specialty, and to serve in clinical 
practice at a VA facility for a period of 12 months for each 
$40,000 of loan repayment with a minimum of 24 months of 
obligated service. Because resident salaries are much lower 
than salaries for fully trained clinicians, this would make the 
loan repayment is more economically meaningful and allow VA to 
fund specialty positions in shortage areas, develop a 
predictable future physician workforce, and ensure a cadre of 
young physicians are able to join VA's physician workforce.

Section 303--Veterans Healing Veterans Medical Access and Scholarship 
        Program

    In order to assist VA in recruiting veteran physicians, 
section 303 would establish a pilot program for supporting four 
years of medical school education costs for two veterans at 
each of the five Teague-Cranston Schools and the four 
traditional black medical schools. The covered medical schools 
would include Texas A&M College of Medicine, Quillen College of 
Medicine at East Tennessee State University, Boonshoft School 
of Medicine at Wright State University, Edwards School Medicine 
at Marshall University, the University of South Carolina School 
of Medicine, Drew University of Medicine and Science, Howard 
University of Medicine, Meharry Medical College, and Morehouse 
School of Medicine. The medical schools that opt to participate 
in the program would be required to reserve two seats each in 
the class of 2019. Eligible veteran scholarship recipients 
would be those within ten years of military discharge who are 
not eligible for GI Bill benefits but who meet the minimum 
admission requirement for medical school and apply for the 
entering class of 2019. The scholarship recipients would agree 
to successfully complete medical school, obtain a license to 
practice medicine, complete post-graduate training leading to 
board eligibility in a specialty applicable to VA, and after 
training, serve in clinical practice at a VA facility for four 
years.

                                Hearings

    There were no Subcommittee hearings held on H.R. 4242, as 
amended.
    On October 24, 2017, the full Committee conducted a 
legislative hearing on a number of bills including a draft bill 
that was later introduced as H.R. 4242.
    The following witnesses testified:

          The Honorable Jim Banks, U.S. House of 
        Representatives, 3rd District, Indiana; The Honorable 
        Mike Gallagher, U.S. House of Representatives, 8th 
        District, Wisconsin; The Honorable John R. Carter, U.S. 
        House of Representatives, 31st District, Texas; The 
        Honorable Glenn Thompson, U.S. House of 
        Representatives, 5th District, Pennsylvania; The 
        Honorable Neal P. Dunn, U.S. House of Representatives, 
        2nd District, Florida; The Honorable Andy Barr, U.S. 
        House of Representatives, 6th District, Kentucky; The 
        Honorable David J. Shulkin, M.D., Secretary, U.S. 
        Department of Veterans Affairs, who was accompanied by 
        Carolyn Clancy M.D, the Executive in Charge of the 
        Veterans Health Administration, and Laurie Zephyrin 
        M.D., MPH, MBA, the Acting Deputy Under Secretary for 
        Health for Community Care for the Veterans Health 
        Administration; Adrian M. Atizado, Deputy National 
        Legislative Director, Disabled American Veterans; 
        Roscoe G. Butler, Deputy Director for Health Care, 
        Veterans Affairs and Rehabilitation Division, The 
        American Legion; and, Kayda Keleher, Associate 
        Director, National Legislative Service, Veterans of 
        Foreign Wars of the United States.

    Statements for the record were submitted by:

          American Federation of Government Employees, AFL-CIO; 
        American Health Care Association; American Medical 
        Association; AMVETS; Concerned Veterans of America; 
        Fleet Reserve Association; Got Your 6; Health IT Now; 
        Iraq and Afghanistan Veterans of America; Military 
        Officers Association of America; Military Order of the 
        Purple Heart; National Alliance on Mental Illness; 
        National Guard Association of the United States; Nurses 
        Organization of Veterans Affairs/Association of VA 
        Psychologist Leaders/Association of VA Social Workers/
        Veterans Healthcare Action Campaign; Paralyzed Veterans 
        of America; Reserve Officers Association; University of 
        Pittsburgh; Vietnam Veterans of America; and, the 
        Wounded Warrior Project.

                       Subcommittee Consideration

    There was no Subcommittee consideration of H.R. 4242, as 
amended.

                        Committee Consideration

    On December 19, 2017, the full Committee met in open markup 
session, a quorum being present, and ordered H.R. 4242, as 
amended, to be reported favorably to the House of 
Representatives by roll call vote.
    During consideration of the bill, the following amendments 
were considered en bloc and agreed to via voice:

          An amendment offered by Representative John 
        Rutherford of Florida to improve VA's ability to 
        recruit physicians and dentists through scholarship and 
        educational loan repayment programs.
          An amendment offered by Representative Neal Dunn of 
        Florida to authorize veterans to obtain a transplant 
        outside such veteran's Organ Procurement and 
        Transplantation Network region if veteran's primary 
        care provider opines that there is a medically 
        compelling reason and authorize VA to support the cost 
        of a donor transplant operation for a live donor who is 
        not a veteran but who is donating an organ to a 
        veteran.
          An amendment offered by Representative Mike Coffman 
        of Colorado to require community care providers to be 
        aware of and comply with VA's Opioid Safety Initiative.
          An amendment offered by Representative Jenniffer 
        Gonzalez-Colon of Puerto Rico to require VA to report 
        on health services provided veterans in the Northern 
        Mariana Islands, Puerto Rico, American Samoa, Guam, and 
        the Virgin Islands.
          An amendment offered by Representative Julia Brownley 
        of California to require VA to use actuarial analysis 
        based on accurate demand forecasting, to certify 
        financial projections, to limit supplemental budget 
        requests unless absolutely necessary, and--when 
        requesting supplemental appropriations or any other 
        request outside the standard budget process--to provide 
        justification for such request.
          An amendment offered by Representative Gus Bilirakis 
        of Florida to require VA to certify that community care 
        providers have not been excluded from participating in 
        federally funded health programs.

    During consideration of the bill, the following amendments 
were considered:

          An amendment offered and then withdrawn by 
        Representative Elizabeth Esty of Connecticut to require 
        VA to establish a center of excellence for the 
        prevention, diagnosis, mitigation, treatment, and 
        rehabilitation of health conditions related to exposure 
        to burn pits and other environmental exposures.
          An amendment offered and then withdrawn by 
        Representative Elizabeth Esty of Connecticut to expand 
        the Comprehensive Assistance for Family Caregivers 
        program to caregivers of pre-9/11 veterans.
          An amendment offered by Representative David P. Roe 
        of Tennessee, the Chairman of the full Committee, to: 
        (1) authorize, rather than require, VA to provide 
        deference to a veteran when resolving disputes 
        regarding primary care provider designations; (2) 
        establish a process to transition veterans between VA 
        and community primary care providers; and (3) authorize 
        VA to incorporate values-based productivity models and 
        take non-clinical duties like training and research 
        into account when establishing performance standards. 
        The amendment was agreed to by voice vote.
          An amendment offered and then withdrawn by 
        Representative David P. Roe of Tennessee, the Chairman 
        of the full Committee, to set a community care 
        authorization level for fiscal years 2019 through 2022.
          An amendment offered by Representative David P. Roe 
        of Tennessee, the Chairman of the full Committee, to 
        create a Center for Innovation for Care and Payment. 
        The amendment was agreed to by voice vote.
          An amendment offered by Representative Mark Takano of 
        California to require Veteran Care Agreements to be 
        subject to Federal Acquisition Regulations. The 
        amendment was not agreed to by voice vote.
          An amendment offered by Representative Mark Takano of 
        California to set the minimum level of VA employees at 
        405,386 as of September 30, 2019. The amendment was not 
        agreed to by a recorded vote of 9 yeas to 14 noes.
          An amendment offered by Representative Mark Takano of 
        California to establish an Office of Non-VA Delivered 
        Medical Care Accountability. The amendment was not 
        agreed to by voice vote.
          An amendment offered by Representative Ann Kuster of 
        New Hampshire to require VA to consider whether a 
        veteran resides in a state with no VA medical center 
        when establishing eligibility criteria for any program 
        that furnishes primary or specialty care through a 
        community provider. The amendment was agreed to by 
        voice vote.
          An amendment offered by Representative Julia Brownley 
        of California to amend the authorization of 
        appropriations for VA major medical facility leases by 
        requiring the Committees on Veterans' Affairs of the 
        Senate and House of Representatives to adopt 
        resolutions approving the leases. The amendment was not 
        agreed to by a recorded vote of 9 yeas to 14 noes.
          An amendment in the nature of a substitute offered by 
        Representative Tim Walz of Minnesota, the Ranking 
        Member of full Committee. The amendment in the nature 
        of a substitute was not agreed to by a recorded vote of 
        9 yeas to 14 noes.

                            Committee Votes

    Clause 3(b) of rule XIII of the Rules of the House of 
Representatives require the Committee to list the recorded 
votes on motions to report legislation and amendments thereto. 
During the full Committee markup of H.R. 4242, as amended, on 
December 19, 2017, four recorded votes were taken and are 
described below.
    An amendment offered by Representative Mark Takano of 
California to set the minimum level of VA employees at 405,386 
as of September 30, 2019, was not agreed to by a recorded vote 
of 9 yeas to 14 noes. The names of the Members who voted for 
and against are as follows:


    An amendment offered by Representative Julia Brownley of 
California to amend the authorization of appropriations for VA 
major medical facility leases by requiring the Committees on 
Veterans' Affairs of the Senate and House of Representatives to 
adopt resolutions approving the leases was not agreed to by a 
recorded vote of 9 yeas to 14 noes. The names of the Members 
who voted for and against are as follows:


    An amendment in the nature of a substitute offered by 
Representative Tim Walz of Minnesota, the Ranking Member of 
full Committee, was not agreed to by a recorded vote of 9 yeas 
to 14 noes. The names of the Members who voted for and against 
are as follows:


    A motion by Representative Gus Bilirakis of Florida, the 
Vice Chairman of the Committee on Veterans' Affairs, to report 
H.R. 4242, as amended, favorably to the House of 
Representatives was agreed to by a recorded vote of 14 yeas and 
9 noes. The names of the Members who voted for and against the 
motion are as follows:


                      Committee Oversight Findings

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

         Statement of General Performance Goals and Objectives

    In accordance with clause 3(c)(4) of rule XIII of the Rules 
of the House of Representatives, the Committee's performance 
goals and objectives are to improve the provision of timely, 
quality care to veteran patients through both VA medical 
facilities and VA community care providers.

   New Budget Authority, Entitlement Authority, and Tax Expenditures

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

                  Earmarks and Tax and Tariff Benefits

    H.R. 4242, as amended, does not contain any Congressional 
earmarks, limited tax benefits, or limited tariff benefits as 
defined in clause 9 of rule XXI of the Rules of the House of 
Representatives.

                        Committee Cost Estimate

    The Committee adopts as its own the cost estimate on H.R. 
4242, as amended, prepared by the Director of the Congressional 
Budget Office pursuant to section 402 of the Congressional 
Budget Act of 1974.

               Congressional Budget Office Cost Estimate

    Pursuant to clause 3(c)(3) of rule XIII of the Rules of the 
House of Representatives, the following is the cost estimate 
for H.R. 4242, as amended, provided by the Congressional Budget 
Office pursuant to section 402 of the Congressional Budget Act 
of 1974:

                                     U.S. Congress,
                               Congressional Budget Office,
                                 Washington, DC, February 15, 2018.
Hon. Phil Roe, M.D.,
Chairman, Committee on Veterans' Affairs,
House of Representatives, Washington, DC.
    Dear Mr. Chairman: The Congressional Budget Office has 
prepared the enclosed cost estimate for H.R. 4242, the VA Care 
in the Community Act.
    If you wish further details on this estimate, we will be 
pleased to provide them. The CBO staff contact is Ann E. 
Futrell.
            Sincerely,
                                                Keith Hall,
                                                          Director.
    Enclosure.

H.R. 4242--VA Care in the Community Act

    Summary: H.R. 4242 would increase the use of community 
health care and long-term care by the Department of Veterans 
Affairs (VA) by broadening eligibility for such care and 
allowing VA to enter into agreements with health care providers 
in the private sector without complying with the Federal 
Acquisition Regulation (FAR). The bill also would change VA's 
coverage of ambulance services and transplant operations at 
nondepartment facilities. In addition, H.R. 4242 would allow VA 
to repay loans for and provide scholarships to its medical 
staff. In total, CBO estimates that implementing the bill would 
cost $38.8 billion over the 2018-2022 period, assuming 
appropriation of the necessary amounts.
    Enacting the bill would not affect direct spending or 
revenues; therefore, pay-as-you-go procedures do not apply.
    CBO estimates that enacting H.R. 4242 would not increase 
net direct spending or on-budget deficits in any of the four 
consecutive 10-year periods beginning in 2028.
    H.R. 4242 would impose an intergovernmental mandate as 
defined in the Unfunded Mandates Reform Act (UMRA) by 
preempting state laws that prohibit VA physicians from 
practicing telemedicine to treat veterans across state lines. 
Although it would limit the application of state regulations, 
that mandate would impose no duty on state governments that 
would result in additional spending or any significant loss of 
revenues.
    The bill contains no private-sector mandates as defined in 
UMRA.
    Estimated cost to the Federal Government: The estimated 
budgetary effects of H.R. 4242 are shown in the following 
table. The costs of this legislation fall within budget 
function 700 (veterans benefits and services).

----------------------------------------------------------------------------------------------------------------
                                                            By fiscal year, in millions of dollars--
                                               -----------------------------------------------------------------
                                                   2018       2019       2020       2021       2022    2018-2022
----------------------------------------------------------------------------------------------------------------
                                 INCREASES IN SPENDING SUBJECT TO APPROPRIATION
 
VA Care in the Community Program:
    Estimated Authorization Level.............        200      2,000      4,200      6,700      8,800     21,900
    Estimated Outlays.........................        200      1,700      3,900      6,200      8,300     20,300
Veterans Care Agreements:
    Estimated Authorization Level.............          *      4,400      4,500      4,700      4,800     18,400
    Estimated Outlays.........................          *      3,800      4,300      4,500      4,700     17,300
Agreements for State Veterans Homes:
    Estimated Authorization Level.............          0         80        110        130        160        480
    Estimated Outlays.........................          0         70        100        130        150        450
Center for Innovation for Care and Payment:
    Estimated Authorization Level.............          2          3         86        131        128        350
    Estimated Outlays.........................          2          3         75        122        124        326
Ambulance Services:
    Estimated Authorization Level.............          0         57         78         80         83        298
    Estimated Outlays.........................          0         50         73         77         81        281
Transplant Donors:
    Estimated Authorization Level.............          2         17         35         47         49        150
    Estimated Outlays.........................          2         15         32         44         47        140
Health Professional Scholarship Program:
    Estimated Authorization Level.............          0          0          4          6          6         16
    Estimated Outlays.........................          0          0          3          6          6         15
Loan Repayment for Medical Specialists:
    Estimated Authorization Level.............          1          3          3          3          3         13
    Estimated Outlays.........................          1          3          3          3          3         13
Health Care Productivity:
    Estimated Authorization Level.............          1          2          2          2          2          9
    Estimated Outlays.........................          1          2          2          2          2          9
Scholarship Program:
    Estimated Authorization Level.............          0          2          2          2          2          8
    Estimated Outlays.........................          0          2          2          2          2          8
    Total Changes in Spending Subject to
     Appropriation:
        Estimated Authorization Level.........        206      6,564      9,020     11,801     14,033     41,624
        Estimated Outlays.....................        206      5,645      8,490     11,086     13,415     38,842
----------------------------------------------------------------------------------------------------------------
* = between zero and $500,000; VA = Department of Veterans Affairs.

    Basis of estimate: For this estimate, CBO assumes that the 
bill will be enacted early in calendar year 2018 and that the 
estimated amounts will be appropriated each year. Estimated 
outlays are based on historical spending patterns for the 
affected programs.
    VA Care in the Community Program. Section 102 would 
establish the VA Care in the Community Program. Through that 
program, the department would establish networks of health care 
providers outside of VA to furnish hospital care, medical 
services, and extended-care services to veterans enrolled in 
the VA health care system. Under the program, subject to 
appropriations, VA would be required to pay for care through 
those networks if VA cannot assign the veteran to a suitable 
primary care physician or a Patient Aligned Care Team (PACT) at 
a VA medical facility. Assignment may be unsuitable in the 
following situations:
           The veteran would face excessive challenges 
        in receiving care at a VA medical facility because of 
        geographic, environmental, or medical factors;
           The veteran believes that the assignment to 
        a particular primary care physician or PACT at a VA 
        medical facility would result in unsatisfactory health 
        care;
           The veteran would face long wait times for 
        care at a VA medical facility; or
           The veteran resides in a state without a 
        full-service medical facility (such as Alaska, Hawaii, 
        or New Hampshire).
    Veterans may later choose to receive care at a VA medical 
facility if VA notifies them that a primary care provider or a 
PACT has become available.
    The bill would require VA to promulgate regulations to 
implement the program within one year.
    The VA Care in the Community Program is similar to the 
Veterans Choice Program (VCP), which CBO expects will end in 
2018. The VCP provides community care to veterans who face 
excessive wait times or live 40 miles or more from a VA medical 
facility. CBO estimated the costs for the VA Care in the 
Community Program based on information about the VCP.
    CBO expects that the VA Care in the Community Program would 
cost more than the VCP for the following reasons:
     Veterans would make more visits for community 
health care because once they are referred for community care 
they could see network providers for primary care for at least 
one year without additional authorization from VA.
     Veterans would be eligible for community care 
under the new program in more circumstances.
    However, there are several factors that CBO expects would 
constrain that cost growth:
     Diverting more veterans to community care could 
shorten wait times at VA facilities and thus reduce the number 
of veterans who would need to be referred to community care 
because VA care was not available in a timely fashion.
     Regulations that need to be written to implement 
the program could curtail use.
     Veterans would need approval from VA to receive 
certain specialty services.
     The size and scope of community care networks 
could be limited, particularly in rural areas, reducing the 
accessibility of such care.
     VA might implement the program slowly, as it did 
the VCP.
    CBO expects that the new program would be implemented 
gradually and by 2022, usage of the new program would be 30 
percent greater than for the VCP. CBO estimates that eventually 
usage of the new program would be about 75 percent greater than 
that of the VCP.
    In 2017, VA processed 8.7 million claims at a total cost of 
$5 billion for community health care under the VCP. After 
accounting for the increase in usage, inflation, and underlying 
growth in enrollment in the VA health system, CBO estimates 
that the new program would cost $8.3 billion by 2022. In total, 
implementing section 102 would cost $20.3 billion over the 
2018-2022 period, CBO estimates.
    Veterans Care Agreements. Section 103 would allow VA to 
enter into Veterans Care Agreements with health care providers 
in the community to provide hospital care, medical services, or 
extended care to eligible veterans. The authorization for such 
agreements would exempt VA from using the competitive bidding 
procedures as required under the FAR. The FAR is an extensive 
and complex set of rules governing the federal government's 
purchasing processes.
    Under current law, VA must comply with the FAR for 
agreements and contracts with community health care and 
extended-care providers.
    According to VA, the FAR's requirements are appropriate for 
large and long-term agreements for contracted health care 
services but may not be practical for case-by-case arrangements 
in all regions of the United States. H.R. 4242 would allow VA 
to use other agreements for certain health care services and 
extended care provided outside the VA system.
    For 2018, the Congress has provided roughly $10 billion for 
community health care at VA (excluding the VCP). Using 
information from VA, CBO estimates that implementing section 
103 would give VA the legal authority to continue to provide 
about 40 percent (or roughly $4 billion annually) of that 
community health care. After adjusting for inflation and 
accounting for existing appropriations, CBO estimates that 
implementing this section would cost $17.3 billion over the 
2018-2022 period.
    Agreements for State Veterans Homes. Section 104 would 
waive the requirements of the FAR for contracts and agreements 
that VA enters into with state-run nursing homes for veterans. 
Under current law, the state veterans' homes (SVHs) must fill 
75 percent of their beds with veterans. Under a contract or 
agreement, VA pays SVHs the full cost of care for veterans with 
a service-connected disability (SCD) rating of 70 percent or 
more. For all other veterans, VA pays SVHs a fixed daily 
allowance.
    According to VA, in 2015 the department used such 
agreements to reimburse state-run nursing homes at a daily rate 
of $380 for each veteran with an SCD of 70 percent or more--at 
an annual cost of roughly $350 million (or 37 percent of the 
total reimbursed to SVHs). However, those agreements do not 
comply with the FAR, and VA does not expect to be able to enter 
into new FAR-compliant agreements with any of the SVHs. In the 
absence of this legislation, CBO expects that VA would 
gradually phase out the use of such agreements as veterans who 
are currently under that payment structure die or leave the 
SVHs. Those veterans would probably be replaced by veterans 
under the lower daily allowance rate of roughly $100 per 
patient. By allowing VA to enter into agreements outside of the 
FAR framework, CBO estimates, this proposal would more than 
triple VA's reimbursements to SVHs for veterans with SCDs of 70 
percent or more.
    As a result, after factoring in a gradual phaseout of 
existing non-FAR agreements, CBO estimates that enacting this 
provision would cost $450 million over the 2018-2022 period. 
The additional costs from waiving the FAR requirements would 
begin in 2019. Because appropriations already have been 
provided for such agreements in 2018, no additional funding 
would be necessary in that year.
    Center for Innovation for Care and Payment. Section 210 
would require VA to establish the Center for Innovation for 
Care and Payment, which would evaluate ways to reduce costs and 
increase efficiency at VA medical facilities. CBO expects that 
the center would pursue programs similar to those that were 
tested by the Center for Medicare and Medicaid Innovation 
(CMMI) operated by the Centers for Medicare & Medicaid 
Services. CBO estimates that costs for the center would be 
similar to those for CMMI. CBO expects any savings that 
resulted from the center's efforts would not occur in the next 
five years.
    In 2010, CMMI received $5 million to develop models for 
reducing health care costs and increasing efficiency for 
Medicare. CBO expects that VA would need similar resources to 
establish its program. On the basis of information from the 
department regarding the availability of necessary staff, CBO 
expects that it would take VA two years to establish the center 
at an estimated cost of $5 million over the 2018-2019 period.
    CMMI received $10 billion over the 2011-2019 period to test 
its models. CBO expects that VA's costs would be proportional. 
VA Health Administration costs are approximately one-tenth 
those of Medicare. After factoring in a gradual implementation 
period similar to that of CMMI, CBO estimates that the costs 
for the center would be $321 million over the 2020-2022 period.
    In total, CBO estimates that implementing section 210 would 
cost $326 million over the 2018-2022 period.
    Ambulance Services. Section 201 would require VA to 
reimburse veterans for ambulance services under certain 
conditions. Currently, VA can choose to reimburse veterans for 
ambulance services when they receive emergency care at 
nondepartment medical facilities. H.R. 4242 would require VA to 
cover the cost of ambulance services if a delay in providing 
immediate medical attention could result in death or harm to 
the veteran.
    Using data from the National Institutes of Health and VA, 
CBO estimates that VA would reimburse veterans for about 
165,000 ambulance trips each year, at an average cost of $480 
per trip. The bill would require VA to pay for ambulance trips 
after January 1, 2019. Thus, CBO estimates that implementing 
section 201 would cost $281 million over the 2018-2022 period.
    Transplant Donors. Section 109 would allow VA to cover 
costs related to organ transplant procedures incurred by 
veterans and their living donors for procedures at 
nondepartment facilities. Currently, VA covers the medical and 
service expenses (such as transportation and lodging) for 
veterans and their living donors only for procedures performed 
at the Department of Veterans Affairs Transplant Centers 
(VATCs). Otherwise, VA reimburses donors only for 
transportation and lodging. In 2017, VA provided 560 organ 
transplants, most at VATCs. Of those operations, about 200 were 
kidney transplants and about 20 involved living donors.
    Section 109 would authorize VA to pay for transplant 
procedures at various locations nationwide with minimal out-of-
pocket expenses for veterans and their living donors. As a 
result, CBO expects more veterans would use VA for such 
procedures and more people would be willing to donate organs. 
In determining the additional number of transplant procedures, 
CBO considered the other sources of health care coverage 
carried by enrolled veterans and the likelihood, under this 
proposal, that those veterans would instead use VA for their 
transplant procedures.
    Using information from the Census Bureau, VA, and the 
Department of Health and Human Services, CBO estimates that 
under section 109, roughly 60 additional veterans would undergo 
transplants at nondepartment facilities each year, at an 
average cost of $750,000 per patient. CBO estimates that VA 
would cover the medical expenses of an additional 50 living 
donors (some for procedures that will occur under current law 
but for which VA would not pay medical expenses) each year, at 
an average cost of $80,000 per donor. In addition, CBO believes 
that implementing this section would allow veterans to undergo 
transplants closer to home. As a result, CBO estimates a 
reduction in transportation reimbursements of about $4 million 
each year. Based on the expectation that VA would implement the 
bill gradually, CBO estimates that implementing section 109 
would have a net cost of $140 million over the 2018-2022 
period.
    Health Professional Scholarship Program. Section 301 would 
extend the Health Professional Scholarship Program, currently 
set to expire on December 31, 2019, through December 31, 2033. 
At an annual cost of $5 million, the program subsidizes tuition 
and educational fees and provides monthly stipends to medical 
students who pursue careers at VA. After accounting for rising 
tuition costs, CBO estimates that implementing section 301 
would cost $15 million over the 2019-2022 period.
    Loan Repayment for Medical Specialists. Section 302 would 
authorize VA to repay the education loans of practitioners in 
medical specialties for which the department has difficulty 
recruiting. In exchange, those specialists would commit to work 
for VA for two to four years. The payments could not exceed 
$40,000 for each year worked or a total of $160,000 over four 
years. Those limits could be waived for medical positions for 
which a shortage exists because of the location or requirements 
of the position.
    Under a similar loan repayment program, VA can reimburse up 
to $120,000 for tuition and educational fees for medical 
personnel at the department. In 2016, roughly 2,000 employees 
(or less than 1 percent of total employees) received an average 
award of about $15,000. On the basis of participation rates and 
costs of that program, CBO estimates that roughly 120 medical 
practitioners in specialty areas would participate in the new 
program each year and would receive an average annual award of 
$23,000. After factoring in a gradual implementation period and 
growth in tuition, CBO estimates that implementing section 302 
would cost $13 million over the 2018-2022 period.
    Health Care Productivity. Section 205 would require that VA 
develop standards for using relative-value units (RVUs) to 
evaluate medical services. It also would require VA to train 
its health care providers to use and adhere to those standards. 
RVUs are tools used by physicians participating in Medicare to 
rank on a common scale the resources (such as medical supplies) 
used to provide health care.
    On the basis of information from VA regarding its ability 
to train personnel to use RVUs in all department facilities, 
CBO estimates that VA would need to hire the equivalent of 10 
full-time clinicians at an average annual compensation of 
$150,000 to develop standards and provide ongoing training and 
support. CBO expects that VA would develop an internal website 
to train its medical providers to use RVUs. CBO estimates that 
development of the website would cost less than $500,000.
    As a result, CBO estimates that implementing section 205 
would cost $9 million over the 2018-2022 period.
    Scholarship Program. Section 303 would require VA to fully 
cover the costs of medical school for 18 eligible veterans. 
Under this scholarship program, VA would pay for tuition, 
books, fees, technical equipment, rotations, and reasonable 
living expenses for newly separated veterans who enter medical 
school in 2019. Veterans who are entitled to other education 
benefits provided by VA would not be eligible. Participating 
veterans would be required to agree to work full time at a VA 
medical facility for four years after completing medical 
school.
    On the basis of the average costs to attend a private 
medical school, which includes tuition, books, fees, and 
technical equipment, CBO estimates that annual costs would 
average $69,000 per awardee. After adjusting for growth in the 
costs of medical school, CBO estimates that such education 
expenses would cost $5 million over the 2019-2022 period.
    The Department of Defense pays monthly stipends for living 
expenses to recipients of similar scholarships that currently 
average $2,229 a month. On that basis, CBO estimates that 
individual stipends would total roughly $25,000 over a 10.5-
month school year. After adjusting for inflation, CBO estimates 
that such stipends would cost a total of $2 million over the 
2019-2022 period. In addition, CBO estimates that the costs of 
residency fees, off-site rotations, and reports would cost $1 
million over 2020-2022 period.
    In total, CBO estimates that implementing section 303 would 
cost $8 million over the 2019-2022 period.
    Pay-As-You-Go considerations: None.
    Increase in long-term direct spending and deficits: CBO 
estimates that enacting H.R. 4242 would not increase net direct 
spending or on-budget deficits in any of the four consecutive 
10-year periods beginning in 2028.
    Mandates: H.R. 4242 would impose an intergovernmental 
mandate as defined in UMRA by preempting state laws that 
prohibit VA physicians from practicing telemedicine to treat 
veterans across state lines. Although it would limit the 
application of state regulations, that mandate would impose no 
duty on state governments that would result in additional 
spending or any significant loss of revenues.
    The bill contains no private-sector mandates as defined in 
UMRA.
    Previous CBO estimates: On January 17, 2018, CBO 
transmitted a cost estimate for S. 2193, the Caring for Our 
Veterans Act of 2017, as ordered reported by the Senate 
Committee on Veterans' Affairs on December 5, 2017. Sections 
102, 103, and 242 in S. 2193 are similar to sections 103, 104, 
and 109 of H.R. 4242 and the estimated costs for those sections 
are the same for each bill.
    Estimate prepared by: Federal costs: Ann E. Futrell; 
Mandates: Andrew Laughlin.
    Estimate approved by: Leo Lex; Deputy Assistant Director 
for Budget Analysis.

                       Federal Mandates Statement

    The Committee adopts as its own the estimate of Federal 
mandates regarding H.R. 4242, as amended, prepared by the 
Director of the Congressional Budget Office pursuant to section 
423 of the Unfunded Mandates Reform Act.

                      Advisory Committee Statement

    No advisory committees within the meaning of section 5(b) 
of the Federal Advisory Committee Act would be created by H.R. 
4242, as amended.

                 Statement of Constitutional Authority

    Pursuant to Article I, section 8 of the United States 
Constitution, H.R. 4242, as amended is authorized by Congress' 
power to ``provide for the common Defense and general Welfare 
of the United States.''

                  Applicability to Legislative Branch

    The Committee finds that H.R. 4242, as amended, does not 
relate to the terms and conditions of employment or access to 
public services or accommodations within the meaning of section 
102(b)(3) of the Congressional Accountability Act.

              Statement on Duplication of Federal Programs

    Pursuant to section 3(g) of H. Res. 5, 115th Cong. (2017), 
the Committee finds that no provision of H.R. 4242, as amended, 
establishes or reauthorizes a program of the Federal Government 
known to be duplicative of another Federal program, a program 
that was included in any report from the Government 
Accountability Office to Congress pursuant to section 21 of 
Public Law 111-139, or a program related to a program 
identified in the most recent Catalog of Federal Domestic 
Assistance.

                   Disclosure of Directed Rulemaking

    Pursuant to section 3(i) of H. Res. 5, 115th Cong. (2017), 
the Committee estimates that H.R. 4242, as amended, contains no 
directed rulemaking that would require the Secretary to 
prescribe regulations.

             Section-by-Section Analysis of the Legislation


  TITLE I--IMPROVED ACCESS FOR VETERANS TO NONDEPARTMENT OF VETERANS 
                          AFFAIRS MEDICAL CARE

Sec 101. Assignment of veterans to primary care providers

    Section 101 of the bill would amend Section 1706 of Title 
38, U.S.C., by adding a new subsection (d).
    Section 1706(d) requires VA to assign each eligible veteran 
to a PACT team of the Department, or a dedicated primary care 
provider of the department. This section also defines the term 
``eligible veteran''.

Section 102. Establishment of VA Care in the Community Program

    Section 102(a) of the bill would amend section 1703 of 
title 38, U.S.C., by inserting after section 1703 a new section 
1703A:
    Section 1703A(a) of the bill would establish a permanent 
authority for the VA Care in the Community program to provide 
hospital care, medical services and extended care to eligible 
veterans through contracts and agreements. Under this section, 
VA would coordinate the care provided to eligible veterans 
through regional networks of community providers, which are to 
be periodically assessed for capacity.
    Section 1703A(b) allows for a veteran to choose a provider 
from among network providers located in a regional network (or 
adjacent network, if closer) if VA does not have an available 
or accessible primary care provider for the veteran. Upon this 
election, a veteran may utilize this primary care provider for 
a period of one year and shall not be counted twice against a 
VA primary care provider's panel size. Should a VA primary care 
provider become available, the veteran will be given an option 
to be reassigned. This section requires VA to consider the 
following when determining if a VA provider is available for 
assignment: if the veteran faces unusual excessive burden such 
as geographical challenges, environmental factors, or medical 
conditions; if the veteran reasonably believes the assigned 
care team is detrimental to the patient-provider relationship 
and/or could result in suboptimal care; if the panel size of 
the team is such a number that it would prevent timely access 
to care or lead to sub-optimal results; or the veteran resides 
in a State where the Department does not operate a full medical 
facility. In an appeal of VA's assignment under this section, 
VA may give deference to the veteran if the veteran reasonably 
believes that their assignment would result in suboptimal care. 
Under this section, specialty care requires a referral from the 
veteran's primary care provider, with the ability for the 
Secretary to make exceptions. VA shall determine whether 
specialty care is to be sourced from a nearby VA facility, 
through a network provider, or pursuant to other agreements--
with preference given to VA facilities subject to various 
factors of veteran accommodation. This section requires 
referrals to be processed in a standardized manner to include 
the organization of a pF1rogram office at each facility. The 
Secretary shall establish a process to review any disagreements 
between the veteran, the Department, or provider as to 
eligibility for care or services under this section. This 
section also requires VA to establish procedures for 
transitioning a veteran to a different primary care provider so 
as to not adversely impact continuity of care, to include the 
appointment of a contact to resolve issues, transfer of 
relevant records, continued and coordinated treatment for 
chronic or current episodes of care.
    Section 1703A(c) establishes that care shall be authorized 
through the completion of an episode of care to include all 
specialty and ancillary services deemed necessary. This section 
requires VA to provide case management for the veteran, when 
appropriate, and allows for case management to be provided 
through the network. Under this section, VA is authorized to 
pay non-network providers who provide care as part of an 
episode of care and VA shall take reasonable efforts to enter 
into contracts or agreements with them.
    Section 1703A(d) establishes that the rates for non-VA care 
shall not exceed Medicare rates, with exceptions for highly 
rural states that require adjusted rates. This section allows 
for VA to incorporate value-based reimbursement models and for 
VA to establish a schedule of fees for care not covered under 
Medicare. VA may also negotiate higher rates pursuant to an 
agreement with a tribal or federal entity.
    Section 1703A(e) establishes a 180 day requirement for 
claim submissions and states that all parties shall pay or 
notify of denial of a claim no later than 45 days for ``clean'' 
claims and 30 days for electronic claims with an additional 30 
days to respond. If a claim is overdue, the penalty will be 
prorated daily, accrue from overdue date, computed at U.S. 
Treasury interest rate, and shall be resolved in subsequent 
billing or no later than 30 days of determination. This section 
states that the receipt of medical records is not required for 
payment, but the provider must attest to the provision of care 
or services.
    Section 1703A(f) establishes that veterans who would pay a 
copay within the VA system would pay the same amount if 
receiving care from the community network. This section also 
requires VA to seek reimbursement from other non-government 
health care plans for non-service-connected condition care.
    Section 1703A(g) requires network providers to provide 
medical records to veterans upon request and to the VA upon 
completion of care. Likewise, VA shall provide medical records 
as needed to network providers. VA shall also ensure medical 
records can be shared in an electronic format and community 
providers can have access to them.
    Section 1703A(h) requires VA to ensure that existing VA 
identification cards are sufficient for receiving community 
care and specifically prohibits VA from creating a separate 
card for the program.
    Section 1703A(i) states that formulary prescriptions can be 
submitted by community providers to the VA in the same manner, 
utilizing the same credentials, as community providers would 
submit to any retail pharmacy.
    Section 1703A(j) requires the Secretary to use the quality 
of care standards as set by the Centers for Medicare & Medicaid 
Services (CMS) or other standards as determined by the 
Secretary.
    Section 1703A(k) requires VA to assess, no less than once 
every three years, the capacity of each department medical 
center, identify gaps and how they will be filled, and forecast 
short and long term demands and how they impact network 
composition. VA shall also include commercial health care 
market assessment for services available within designated 
catchment areas.
    Section 1703A(l) requires VA to plan for the allocation of 
funds within the Medical Community Care accounts.
    Section 1703A(m) requires VA to provide an annual report 
for the next three years detailing rates paid as an exception 
to the Medicare rates.
    Section 1703A(n) establishes definitions for the terms: 
clean claim, covered claimant, covered payer, eligible veteran, 
and fraudulent claim.
    Section 102(b) provides conforming amendments to the bill.
    Section 102(c) provides definitions for the following 
terms: Network Provider, VA Care in the Community.
    Section 102(d) requires that the bill may not be construed 
to affect obligations entered into via prior agreements or 
contracts.

Sec. 103. Veterans Care Agreements

    Section 103 of the bill would amend Section 1706 of Title 
38, U.S.C., by inserting after section 1703A, added by section 
102, a new section 1703B--Veterans Care Agreements with non-
network providers:
    Section 1703B(a) authorizes the use of provider agreements 
in addition to contracts for care and services when contracts 
are impractical or inadvisable. This section requires VA to 
review each agreement once during the 18-month period beginning 
six months after entering an agreement and each four-year 
period after any agreement that exceeds $3 million for a 
provider that furnishes homemaker or home health aide services, 
or $1 million for any other provider.
    Section 1703B(b) establishes the requirements for network 
provider participation under the program.
    Section 1703B(c) requires VA to establish a process for 
certification of network providers under the program or to 
adopt a process already administered by another Federal 
department or agency.
    Section 1703B(d) requires that agreements be applied in the 
same manner as Section 1703A of Title 38, U.S.C.
    Section 1703B(e) stipulates that network providers are not 
subject to any provision that providers of Medicare and 
Medicaid are not subject to, as well as other provisions of law 
regarding integrity, ethics, fraud, protection of 
whistleblowers, and Title VII of the Civil Rights Act of 1964.
    Section 1703B(f) states that agreements can be terminated 
by VA or the provider at such time and upon such notice as 
required by the Secretary.
    Section 1703B(g) requires VA to establish administrative 
procedures to handle disputes, and states that entities must 
exhaust administrative procedures before pursuing judicial 
review.
    Section 1703B(h) states that, in the course of an episode 
of care, VA may compensate a non-network provider who provides 
care as part of that treatment.
    Section 1703B(i) requires VA to submit a report at the 
beginning of each fiscal year on all provider agreements 
entered into the prior year. The reporting requirement sunsets 
five years after the date of enactment.
    Section 1703B(j) requires VA to utilize quality of care 
standards set forth by CMS or as determined by the Secretary.
    Section 1703B(k) states that the authority to enter into 
and terminate agreements shall not be delegated to below the 
VISN Director or Director of a Network Contracting Office.
    Section 1703B(l) provides definitions for the following 
terms: Appropriate Congressional Committees, Eligible Veteran.
    Section 103(b) provides a clerical amendment to this 
section.

Sec. 104. Modification of authority to enter into agreements with state 
        homes to provide nursing home care

    Section 104(a) allows for the use of agreements under the 
program.
    Section 104(b) exempts VA from certain competitive 
procedures and states that providers are not subject to any 
provision that providers of Medicare or Medicaid are not 
subject to. This section also states that other provisions of 
law regarding integrity, ethics, or fraud apply.
    Section 104(c) requires VA to establish, through 
regulations, an effective date to be published in the Federal 
Register no later than 30 days prior to such date.

Sec. 105. Electronic interface for processing of claims

    Section 105(a) establishes requirements for VA's Chief 
Information Officer to put in place an IT system to receive, 
process, and pay claims and outlines the capabilities required 
of such an IT system.
    Section 105(b) ensures that all federal information 
protection requirements are met.
    Section 105(c) allows for VA to enter into a contract for 
the purposes of this section.
    Section 105(d) sets definitions for the following terms: 
electronic protected health information, covered non-department 
health care providers, secure development requirements, VA Care 
in the Community Program.

Sec. 106. Funding for VA Care in the Community Program

    Section 106(a) requires all funds for Section 1703B to be 
derived from the Medical Community Care Account.
    Section 106(b) requires that all unobligated amounts from 
Sec. 802 of PL 113-146 shall be transferred to the Medical 
Community Care Account on the later of the following: one year 
after enactment; or, the date on which the Secretary certifies 
implementation of Section 1703A to Congress.
    Section 106(c) defines the VA Care in the Community 
Program.

Sec. 107. Termination of certain provisions authorizing care to 
        veterans through non-Department of Veterans Affairs providers

    Section 107(a)(1) of the bill would amend Section 1703 of 
Title 38, U.S.C., adding a new subsection (e):
    Section 1703(e) of title 38, U.S.C., terminates Section 
1703 of Title 38, U.S.C., upon VA's certification that 1703A is 
fully implemented. This section also includes conforming 
amendments regarding dental care, readjustment counseling, 
death in a department facility and Medicare provider 
agreements.
    Section 107(b) repeals an authority for VA to contract for 
scarce medical specialists.
    Section 107(c) sets an effective date for amendments under 
this section of the date on which the Secretary certifies that 
Section 1073A of Title 38 is fully implemented.

Sec. 108. Implementation and transitions

    Section 108(a) states that implementation of Sections 1703A 
and 1703B of title 38, U.S.C., shall commence no later than one 
year after enactment and that VA shall prescribe interim final 
rules. The same date applies to the transfer of funds, as 
required by section 106(b).
    Section 108(b) requires the Secretary to certify that 
providers and employees are trained to furnish care and 
services under this program. This section requires VA to 
establish written guidance on policies and procedures for the 
program.

Sec. 109. Transplant procedures with live donors and related services

    Section 109(a) of the bill would amend subchapter I of 
chapter 17 of title 38, U.S.C. by inserting after Section 1703B 
of title 38, U.S.C., Section 1703C--``Transplant Procedures 
with Live Donors and Related Services.''
    Section 1703C(a) of subchapter I, if a veteran is eligible 
for a transplant procedure from the Department, the Secretary 
may provide for a transplant operation on a live donor 
notwithstanding the live donor's eligibility for health care 
from the VA.
    Section 1703C(b) of subchapter I authorizes VA to support 
the cost of a donor transplant operation, including 
perioperative care for a live donor who is not a veteran but 
who is donating an organ for a veteran.
    Section1703C(c) of subchapter I would allow for non-VA 
facilities to be used for transplant operations on living 
donors as long as the transplant center is in compliance with 
regulations prescribed by the Centers for Medicare and Medicaid 
Services.

                 TITLE II--OTHER ADMINISTRATIVE MATTERS

Sec. 201. Reimbursement for emergency ambulance services

    Section 201(a) of the bill amends Section 1725(c) of title 
38, U.S.C., by adding at the end a new paragraph:
    Section 1725(c)(5) of title 38, U.S.C., delineates 
circumstances for reimbursement of ambulance services and sets 
a prudent layperson determination of the need for ambulance 
services.
    Section 201(b) sets an effective date of January 1, 2019.

Sec. 202. Improvement of care coordination for veterans through 
        exchange of certain medical records

    Section 202 amends Section 7332(b) of title 38, U.S.C. to 
allow for the provision of medical health information to non-
Department entities to provide treatment and to any third party 
in order to recover or collect charges for non-service 
connected care.

Sec. 203. Elimination of copay offset

    Section 203(a) amends Section 7329(a) of title 38, U.S.C., 
to eliminate the offset of a veteran copay from amounts covered 
from a third party.
    Section 203(b) sets an effective date on the date of 
enactment.

Sec. 204. Use of Department of Veterans Affairs Medical Care 
        Collections Fund for certain improvements in collections

    Section 204 amends Section 1729A(c)(1)(B) of title 38, 
U.S.C., to allow funds to be utilized for automatic data 
processing or IT improvements.

Sec. 205. Department of Veterans Affairs health care productivity 
        improvement

    Section 205(a) amends Subchapter I of chapter 17 of title 
38, U.S.C., by inserting after Section 1705A a new section, 
Section 1705B-- ``Management of health care'':
    Section 1705B(a) requires VA to track relative value units 
for all VA providers.
    Section 1705B(b) requires VA providers to attend coding 
training.
    Section 1705B(c) requires VA to establish performance 
standards based on nationally recognized relative value unit 
standards.
    Section 1705B(d) defines the following terms: department 
provider, relative value unit.
    Section 205(b) provides a clerical amendment for this 
section.
    Section 205(c) requires VA to submit a report regarding 
implementation of this section by no later than one year after 
enactment.

Sec. 206. Licensure of Health Care Professionals of the Department of 
        Veterans Affairs Providing Treatment via Telemedicine

    Section 206(a) amends Chapter 17 of title 38, U.S.C., by 
inserting after section 1730A a new section, Section 1730B--
``Licensure of Health Care Professionals Providing Treatment 
via Telemedicine.''
    Section 1730B(a) provides that any licensed covered 
professional may provide telemedicine services in any state 
regardless of where the provider or patient is located.
    Section 17030B(b) states that the authorities under this 
section applies regardless of whether the covered provider or 
patient is located in a Federal facility.
    Section 1730B(c) states that all provisions of the 
Controlled Substances Act apply.
    Section 1730B(d) defines the term ``covered health care 
professional.''
    Section 206(b) provides a clerical amendment for this 
section.
    Section 206(c) requires VA, by no later than one year after 
enactment, to submit a report to Congress on the effectiveness 
of telemedicine within VA. This report shall include an 
assessment of patient and provider satisfaction, the effect on 
access, patient utilization, productivity, wait times, and 
utilization of facilities. This report shall include amount of 
and types of appointments, as well as any savings achieved.

Sec. 207 Establishment of processes to ensure safe opioid prescribing 
        practices by non-Department of Veterans Affairs health care 
        providers

    Section 207(a) of the bill would require VA to provide 
Opioid Safety Initiative (OSI) guidelines to community 
providers and certify that the community providers have 
reviewed the guidelines.
    Section 207(b) would implement a process to ensure that 
community providers receive a veteran's relevant history 
including all medications.
    Section 207(c) would further require that opioid 
prescriptions be filled at a VA pharmacy or a community 
pharmacy only if prior authorization has been received (with an 
exception for certain urgent or emergent circumstances), that 
opioid prescriptions be recorded in the electronic health 
record and monitored.
    Section 207(d) requires that community providers whose 
prescribing practices are inconsistent with OSI requirements or 
violate licensing guidelines are removed from VA community care 
networks.
    Section 207(e) authorizes VA to revoke or deny eligibility 
under this bill for providers who violate do not comply with 
the Opioid Safety Initiative.
    Section 207(f) defines the term ``Covered Health Care 
Provider.''

Sec. 208 Assessment of health care furnished by the Department to 
        Veterans who live in the territories

    Section 208 requires VA to submit a report, by no later 
than 180 days after enactment of this bill, on the health 
services provided to veterans in the US territories: Northern 
Mariana Islands, Puerto Rico, American Samoa, Guam, and the 
Virgin Islands. The report will also address the feasibility of 
constructing any medical facilities in any of the above 
territories that do not have such a facility.

Sec. 209 Oversight and accountability of financial processes of 
        Department of Veterans Affairs

    Section 209(a) of the bill would require VA to submit a 
justification to any request for supplemental appropriations, 
based upon sound actuarial analysis.
    Section 209(b) requires that whenever the Secretary submits 
a supplemental funding request, the Secretary shall, not later 
than 45 days before the date on which such budgetary issue 
would start affecting a program or service, submit to Congress 
a justification for the request and how long the requested 
appropriations are expected to meet the needs of VA.
    Section 209(c) would require VA's Chief Financial Officer 
to certify the sufficiency, to the extent possible, of VA's 
annual budget submission to provide benefits and health 
services to veterans, as required by law.

Sec. 210 Authority for Department of Veterans Affairs Center for 
        Innovation for Care and Payment

    Section 210(a) amends subchapter I of chapter 17, as 
amended by section 122, by inserting after section 1703B of 
title 38, U.S.C., as added by section 103, Section 1703C of 
title 38, U.S.C.,--``Center for Innovation for Care and 
Payment.''
    Section 1703C(a) authorizes the Secretary to carry out 
pilot programs to develop innovative approaches to testing 
payment and service delivery models to reduce expenditures 
while preserving or improving the quality of care.
    Section 1703C(b) requires that no pilot under this section 
shall last longer than five years.
    Section 1703C(c) requires that the programs be carried out 
in locations appropriate for the intended purpose of the 
programs.
    Section 1703C(d) states that the funding for the pilot 
programs shall come from appropriations provided in advance for 
VHA and IT systems.
    Section 1703C(e) requires the Secretary to publish 
information and take all reasonable action to give notice to 
veterans eligible to participate in the pilot programs.
    Section 1703C(f) authorizes the Secretary to waive any 
requirements under Title 38 only after submitting a report to 
Congress explaining the authorities to be waived and the 
reasons for such requirement. The Secretary would only be 
allowed to act upon any such waiver after Congress enacts a 
bill or joint resolution approving the action.
    Section 1703C(g) states that if the Secretary fails to 
follow the waiver provisions, the waiver shall not apply.
    Section 1703C(h) requires the Secretary to conduct an 
evaluation of each model tested, and Section 1703C(i) requires 
the Secretary to coordinate and consult with the Under 
Secretary for Health and the VA Special Medical Advisory Group 
regarding the pilot programs.
    Section 1703C(j) states that should the program be 
positively evaluated according to subsection (f) the Secretary 
may, through rulemaking, expand the duration and scope of the 
model being tested.

          TITLE III--IMPROVEMENTS TO RECRUITMENT OF PHYSICIANS

Sec. 301 Designated scholarships for physicians and dentists under 
        Department of Veterans Affairs Health Professional Scholarship 
        Program

    Section 301(a) of this bill will amend section 7612(b) of 
title 38, U.S.C., by inserting at the end new paragraph (6).
    Section 7612(b)(6)(A) would require the Secretary to award 
no fewer than 50 scholarships a year to individuals who are 
enrolled or have accepted enrollment in a physician or dentist 
program. The number of awarded scholarships must be at least 50 
a year until the Secretary determines that staffing shortage of 
dentists and physicians is lower than 500.
    Section 7612(b)(6)(B) requires the Secretary to award 
scholarships in an amount equal to not less than 10 percent of 
the staffing shortage.
    Section 7612(b)(6)(C) States that the Secretary's agreement 
to provide scholarship will be provided for a designated number 
of school years (two to four years). The agreement will mandate 
the participant's service for 18 months for every school year 
of scholarship funding.
    Section 7612(b)(6)(D) The Secretary may give preference to 
applicants who are veterans.
    Section 7612(b)(6)(E) On an annual basis, the Secretary 
shall provide to appropriate educational institutions 
information material about the availability of scholarships.
    Section 301(b) amends Section 7617 of title 38, U.S.C., to 
authorize VA to recoup a debt owed from scholarship recipients 
who fail to successfully complete post-graduate training 
leading to eligibility for board certification in a specialty.
    Section 301(c) extends the effective date from December 21, 
2019, to December 31, 2033.

Sec. 302 Establishment of Department of Veterans Affairs Specialty 
        Education Loan Repayment Program

    Section 302(a) would amend Chapter 76 of title 38, U.S.C., 
by inserting after subchapter VII the following new subchapter: 
``Subchapter VIII--Specialty Education Loan Repayment 
Program.''
    Section 7691 of subchapter VIII establishes a loan 
repayment program to incentivize individuals employed in the 
Veterans Health Administration to pursue education and training 
in medical specialties for which the Secretary determines there 
is a shortage.
    Section7692 of subchapter VIII outlines the purpose of the 
Specialty Education Loan Repayment Program.
    Section 7693(a) of subchapter VIII outlines eligibility for 
the participation in the Specialty Education Loan Repayment 
Program.
    Section 7693(b) of subchapter VIII states that the 
Secretary may give preference to veterans in this program.
    Section 7693(c) of subchapter VIII outlines which expenses 
are allowed to be covered under this section.
    Section 7694 of subchapter VIII outlines the manner in 
which the Specialty Education Loan Repayment Program are to be 
made.
    Section 7695 of subchapter VIII allows each participant who 
completes their residency to select their location of 
employment from a list of medical facilities of the VHA.
    Section 7696(a) of subchapter VIII outlines the terms of 
the service obligation for the Specialty Education Loan 
Repayment Program.
    Section 7696(b) of subchapter VIII states that in the case 
of a participant who receives an accredited fellowship in a 
medical specialty other than a medical specialty described in 
section 7692 of this title, the Secretary, on written request 
of the participant, may delay the terms of obligated service 
under subsection (a) for the participant until after the 
participant completes the fellowship, but in no case later than 
60 days after completion of such fellowship.
    Section 7696(c) of subchapter VIII defines the formula by 
which VA may seek monetary collections from an employee who 
violates the terms of obligated service under this section.
    Section 7697 of subchapter VIII allows for participants of 
the Specialty Education Loan Repayment Program to concurrently 
participate in the Educational Assistance Program. This section 
also includes conforming and technical amendments, as well as 
requires VA to match participants with the projected needs of 
the VA and to publicize the availability of the program.

Sec. 303 Veterans Healing Veterans Medical Access and Scholarship 
        Program

    Section 303(a) establishes that the Secretary shall carry 
out a pilot program under which the Secretary shall provide 
funding for the medical education of a total of 18 eligible 
veterans. Such funding shall be provided for two veterans 
enrolled in each covered medical schools in accordance with 
this section.
    Section 303(b) outlines the eligibility requirements for 
the Veterans Healing Veterans Medical Access and Scholarship 
Program.
    Section 303(c) requires that each covered medical school, 
if it opts to join the program, shall reserve two seats in the 
entering class of 2019 for eligible veterans with the highest 
admissions rankings for said class. Each eligible veteran shall 
receive funding at an amount equal to the cost of (A) tuition 
for four years; (B) books, fees, and technical equipment; (C) 
fees associated with the National Residency Match Program; (D) 
two away rotations performed during the fourth year at a VA 
medical facility; and (E) a monthly stipend for the four-year 
period. Funds shall be distributed to eligible veterans at 
other covered medical schools should one covered school not 
have two eligible veteran applicants.
    Section 303(d)(1) outlines the terms of the agreement for 
eligible veterans who accept funding for medical education 
under this section.
    Section 303(d)(2) states that, if the eligible veteran 
breaches the above agreement, the U.S. shall be entitled to 
recover an amount equal to the total amount of funding received 
by the veteran.
    Section 303(e) allows covered schools to accept more than 
two eligible veterans for the entering class of 2019.
    Section 303(f) states that no later than December 31, 2020, 
and annually thereafter for three years, the Secretary shall 
submit to Congress a full report on the pilot program.
    Section 303(g) defines ``covered medical schools'' as 
Teague-Cranston medical schools and the medical schools of 
Historically Black Colleges and Universities.

         Changes in Existing Law Made by the Bill, as Reported

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

                      TITLE 38, UNITED STATES CODE




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

           *       *       *       *       *       *       *


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


                          SUBCHAPTER I--GENERAL

Sec.
1701. Definitions.
1702. Presumptions: psychosis after service in World War II and 
          following periods of war; mental illness following service in 
          the Persian Gulf War.
1703. Contracts for hospital care and medical services in non-Department 
          facilities.
1703A. VA Care in the Community Program.
1703B. Veterans Care Agreements with non-network providers.
1703C. Center for Innovation for Care and Payment.
1703C. Transplant procedures with live donors and related services.
1704. Preventive health services: annual report.
1705. Management of health care: patient enrollment system.
1705A. Management of health care: information regarding health-plan 
          contracts.
1705B. Management of health care: productivity.
1706. Management of health care: other requirements.
1707. Limitations.
1708. Temporary lodging.
1709. Comprehensive policy on reporting and tracking sexual assault 
          incidents and other safety incidents.
1709A. Teleconsultation.
1709B. Evaluations of mental health care and suicide prevention 
          programs.

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

1710. Eligibility for hospital, nursing home, and domiciliary care.
1710A. Required nursing home care.
1710B. Extended care services.
1710C. Traumatic brain injury: plans for rehabilitation and 
          reintegration into the community.
1710D. Traumatic brain injury: comprehensive program for long-term 
          rehabilitation.
1710E. Traumatic brain injury: use of non-Department facilities for 
          rehabilitation.
1711. Care during examinations and in emergencies.
1712. Dental care; drugs and medicines for certain disabled veterans; 
          vaccines.
1712A. Eligibility for readjustment counseling and related mental health 
          services.
1712C. Dental insurance plan for veterans and survivors and dependents 
          of veterans.
1712B. Counseling for former prisoners of war.
[1713. Renumbered.]
1714. Fitting and training in use of prosthetic appliances; guide dogs; 
          service dogs.
1715. Tobacco for hospitalized veterans.
1716. Hospital care by other agencies of the United States.
1717. Home health services; invalid lifts and other devices.
1718. Therapeutic and rehabilitative activities.
1719. Repair or replacement of certain prosthetic and other appliances.
1720. Transfers for nursing home care; adult day health care.
1720A. Treatment and rehabilitative services for persons with drug or 
          alcohol dependency.
1720B. Respite care.
1720C. Noninstitutional alternatives to nursing home care.
1720D. Counseling and treatment for sexual trauma.
1720E. Nasopharyngeal radium irradiation.
1720F. Comprehensive program for suicide prevention among veterans.
1720G. Assistance and support services for caregivers.
1720H. Mental health treatment for veterans who served in classified 
          missions.

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

1721. Power to make rules and regulations.
1722. Determination of inability to defray necessary expenses; income 
          thresholds.
1722A. Copayment for medications.
1722B. Copayments: waiver of collection of copayments for telehealth and 
          telemedicine visits of veterans.
1723. Furnishing of clothing.
1724. Hospital care, medical services, and nursing home care abroad.
1725. Reimbursement for emergency treatment.
1726. Reimbursement for loss of personal effects by natural disaster.
1727. Persons eligible under prior law.
1728. Reimbursement of certain medical expenses.
1729. Recovery by the United States of the cost of certain care and 
          services.
1729A. Department of Veterans Affairs Medical Care Collections Fund.
1729B. Consolidated patient accounting centers.
1730. Community residential care.
1730A. Prohibition on collection of copayments from catastrophically 
          disabled veterans.
1730B. Licensure of health care professionals providing treatment via 
          telemedicine.

 SUBCHAPTER IV--HOSPITAL CARE AND MEDICAL TREATMENT FOR VETERANS IN THE 
                       REPUBLIC OF THE PHILIPPINES

1731. Assistance to the Republic of the Philippines.
1732. Contracts and grants to provide for the care and treatment of 
          United States veterans by the Veterans Memorial Medical 
          Center.
1733. Supervision of program by the President.
1734. Hospital and nursing home care and medical services in the United 
          States.
1735. Definitions.

                  SUBCHAPTER V--PAYMENTS TO STATE HOMES

1741. Criteria for payment.
1742. Inspections of such homes; restrictions on beneficiaries.
1743. Applications.
1744. Hiring and retention of nurses: payments to assist States.
1745. Nursing home care and medications for veterans with service-
          connected disabilities.

                    SUBCHAPTER VI--SICKLE CELL ANEMIA

1751. Screening, counseling, and medical treatment.
1752. Research.
1753. Voluntary participation; confidentiality.
1754. Reports.

                      SUBCHAPTER VII--TRANSFERRED]

[1771 to 1774. Renumbered.]

       SUBCHAPTER VIII--HEALTH CARE OF PERSONS OTHER THAN VETERANS

1781. Medical care for survivors and dependents of certain veterans.
1782. Counseling, training, and mental health services for immediate 
          family members and caregivers.
1783. Bereavement counseling.
1784. Humanitarian care.
1784A. Examination and treatment for emergency medical conditions and 
          women in labor.
1785. Care and services during certain disasters and emergencies.
1786. Care for newborn children of women veterans receiving maternity 
          care.
1787. Health care of family members of veterans stationed at Camp 
          Lejeune, North Carolina.

SUBCHAPTER I--GENERAL

           *       *       *       *       *       *       *


Sec. 1701. Definitions

   For the purposes of this chapter--
  (1) The term ``disability'' means a disease, injury, or other 
physical or mental defect.
  (2) The term ``veteran of any war'' includes any veteran 
awarded the Medal of Honor.
  (3) The term ``facilities of the Department'' means--
          (A) facilities over which the Secretary has direct 
        jurisdiction;
          (B) Government facilities for which the Secretary 
        contracts; and
          (C) public or private facilities at which the 
        Secretary provides recreational activities for patients 
        receiving care under section 1710 of this title.
  (4) The term ``non-Department facilities'' means facilities 
other than Department facilities.
  (5) The term ``hospital care'' includes--
          (A)(i) medical services rendered in the course of the 
        hospitalization of any veteran, and (ii) travel and 
        incidental expenses pursuant to the provisions of 
        section 111 of this title;
          (B) such mental health services, consultation, 
        professional counseling, marriage and family 
        counseling, and training for the members of the 
        immediate family or legal guardian of a veteran, or the 
        individual in whose household such veteran certifies an 
        intention to live, as the Secretary considers 
        appropriate for the effective treatment and 
        rehabilitation of a veteran or dependent or survivor of 
        a veteran receiving care under the last sentence of 
        section 1781(b) of this title; and
          (C)(i) medical services rendered in the course of the 
        hospitalization of a dependent or survivor of a veteran 
        receiving care under the last sentence of section 
        1781(b) of this title, and (ii) travel and incidental 
        expenses for such dependent or survivor under the terms 
        and conditions set forth in section 111 of this title.
  (6) The term ``medical services'' includes, in addition to 
medical examination, treatment, and rehabilitative services, 
the following:
          (A) Surgical services.
          (B) Dental services and appliances as described in 
        sections 1710 and 1712 of this title.
          (C) Optometric and podiatric services.
          (D) Preventive health services.
          (E) Noninstitutional extended care services, 
        including alternatives to institutional extended care 
        that the Secretary may furnish directly, by contract, 
        or through provision of case management by another 
        provider or payer.
          (F) In the case of a person otherwise receiving care 
        or services under this chapter--
                  (i) wheelchairs, artificial limbs, trusses, 
                and similar appliances;
                  (ii) special clothing made necessary by the 
                wearing of prosthetic appliances; and
                  (iii) such other supplies or services as the 
                Secretary determines to be reasonable and 
                necessary.
          (G) Travel and incidental expenses pursuant to 
        section 111 of this title.
  (7) The term ``domiciliary care'' includes necessary medical 
services and travel and incidental expenses pursuant to the 
provisions of section 111 of this title.
  (8) The term ``rehabilitative services'' means such 
professional, counseling, and guidance services and treatment 
programs as are necessary to restore, to the maximum extent 
possible, the physical, mental, and psychological functioning 
of an ill or disabled person.
  (9) The term ``preventive health services'' means--
          (A) periodic medical and dental examinations;
          (B) patient health education (including nutrition 
        education);
          (C) maintenance of drug use profiles, patient drug 
        monitoring, and drug utilization education;
          (D) mental health preventive services;
          (E) substance abuse prevention measures;
          (F) immunizations against infectious diseases, 
        including each immunization on the recommended adult 
        immunization schedule at the time such immunization is 
        indicated on that schedule;
          (G) prevention of musculoskeletal deformity or other 
        gradually developing disabilities of a metabolic or 
        degenerative nature;
          (H) genetic counseling concerning inheritance of 
        genetically determined diseases;
          (I) routine vision testing and eye care services;
          (J) periodic reexamination of members of likely 
        target populations (high-risk groups) for selected 
        diseases and for functional decline of sensory organs, 
        together with attendant appropriate remedial 
        intervention; and
          (K) such other health-care services as the Secretary 
        may determine to be necessary to provide effective and 
        economical preventive health care.
  (10) The term ``recommended adult immunization schedule'' 
means the schedule established (and periodically reviewed and, 
as appropriate, revised) by the Advisory Committee on 
Immunization Practices established by the Secretary of Health 
and Human Services and delegated to the Centers for Disease 
Control and Prevention.
  (11) The term ``network provider'' means any of the following 
health care providers that have entered into a contract or 
agreement under which the provider agrees to furnish care and 
services to eligible veterans under section 1703A of this 
title:
          (A) Any health care provider or supplier that is 
        participating in the Medicare Program under title XVIII 
        of the Social Security Act (42 U.S.C. 1395 et seq.), 
        including any physician furnishing services under such 
        program.
          (B) Any provider of items and services receiving 
        payment under a State plan under title XIX of such Act 
        (42 U.S.C. 1396 et seq.) or a waiver of such a plan.
          (C) Any Federally-qualified health center (as defined 
        in section 1905(l)(2)(B) of the Social Security Act (42 
        U.S.C. 1396d(l)(2)(B))).
          (D) The Department of Defense.
          (E) The Indian Health Service.
          (F) Any health care provider that is an academic 
        affiliate of the Department.
          (G) Any health care provider not otherwise covered 
        under any of subparagraphs (A) through (F) that meets 
        criteria established by the Secretary for purposes of 
        such section.
  (12) The term ``VA Care in the Community Program'' means the 
program under which the Secretary furnishes hospital care or 
medical services to veterans through network providers pursuant 
to section 1703A of this title.

           *       *       *       *       *       *       *


Sec. 1703. Contracts for hospital care and medical services in non-
                    Department facilities

  (a) When Department facilities are not capable of furnishing 
economical hospital care or medical services because of 
geographical inaccessibility or are not capable of furnishing 
the care or services required, the Secretary, as authorized in 
section 1710 of this title, may contract with non-Department 
facilities in order to furnish any of the following:
          (1) Hospital care or medical services 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 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 out-patient 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.
  (b) In the case of any veteran for whom the Secretary 
contracts to furnish care or services in a non-Department 
facility pursuant to a provision of subsection (a) of this 
section, the Secretary shall periodically review the necessity 
for continuing such contractual arrangement pursuant to such 
provision.
  (c) The Secretary shall include in the budget documents which 
the Secretary submits to Congress for any fiscal year a 
detailed report on the furnishing of contract care and services 
during the most recently completed fiscal year under this 
section, sections 1712A, 1720, 1720A, 1724, and 1732 of this 
title, and section 115 of the Veterans' Benefits and Services 
Act of 1988 (Public Law 100-322; 102 Stat. 501).
  (d)(1) The Secretary shall conduct a program of recovery 
audits for fee basis contracts and other medical services 
contracts for the care of veterans under this section, and for 
beneficiaries under sections 1781, 1782, and 1783 of this 
title, with respect to overpayments resulting from processing 
or billing errors or fraudulent charges in payments for non-
Department care and services. The program shall be conducted by 
contract.
  (2) Amounts collected, by setoff or otherwise, as the result 
of an audit under the program conducted under this subsection 
shall be available, without fiscal year limitation, for the 
purposes for which funds are currently available to the 
Secretary for medical care and for payment to a contractor of a 
percentage of the amount collected as a result of an audit 
carried out by the contractor.
  (3) The Secretary shall allocate all amounts collected under 
this subsection with respect to a designated geographic service 
area of the Veterans Health Administration, net of payments to 
the contractor, to that region.
  (4) The authority of the Secretary under this subsection 
terminates on September 30, 2020.
  (e) The authority of the Secretary to carry out this section 
terminates on the date on which the Secretary certifies to the 
Committees on Veterans' Affairs of the House of Representatives 
and the Senate that the Secretary is fully implementing section 
1703A of this title.

Sec. 1703A. VA Care in the Community Program

  (a) Program.--(1) Subject to the availability of 
appropriations for such purpose, hospital care, medical 
services, and extended care services under this chapter shall 
be furnished to an eligible veteran through contracts or 
agreements authorized under subsection (d), or contracts or 
agreements, including national contracts or agreements, 
authorized under section 8153 of this title or any other 
provision of law administered by the Secretary, with network 
providers for the furnishing of such care and services to 
veterans.
  (2) Subject to subsection (b), an eligible veteran may select 
a provider of such care or services from among network 
providers.
  (3) The Secretary shall coordinate the furnishing of care and 
services under this section to eligible veterans.
  (4)(A) In carrying out this section, the Secretary shall 
establish regional networks of network providers. The Secretary 
shall determine, and may modify, such regions based on the 
capacity and market assessments of Veterans Integrated Service 
Networks conducted under subsection (k) or upon recognized 
need.
  (B) The Secretary may enter into one or more contracts for 
the purposes of managing the operations of the regional 
networks and for the delivery of care pursuant to this section.
  (C) The Secretary shall--
          (i) verify upon enrollment, and annually thereafter, 
        that network providers have not been excluded from 
        participation in other federally funded health care 
        programs; and
          (ii) submit to the Committees on Veterans' Affairs of 
        the House of Representatives and the Senate an annual 
        report on the results of such verifications.
  (b) Primary and Specialty Care.--(1)(A) If the Secretary is 
unable to assign an eligible veteran to a patient-aligned care 
team or dedicated primary care provider under section 1706(d) 
of this title because the Secretary determines such a care team 
or provider at a Department facility is not available--
          (i) the Secretary shall consult with the veteran 
        regarding available primary care providers from among 
        network providers that are located in the regional 
        network in which the veteran resides or a regional 
        network that is adjacent to the regional network in 
        which the veteran resides; and
          (ii) the veteran may select one of the available 
        primary care providers to serve as the dedicated 
        primary care provider of the veteran.
  (B) In determining whether a patient-aligned care team or 
dedicated provider under section 1706(d) of this title is 
available for assignment to a veteran, the Secretary shall take 
into consideration each of the following:
          (i) Whether the veteran faces an unusual or excessive 
        burden in accessing such patient-aligned care team or 
        dedicated provider at a medical facility of the 
        Department including with respect to--
                  (I) geographical challenges;
                  (II) environmental factors, including roads 
                that are not accessible to the general public, 
                traffic, or hazardous weather;
                  (III) a medical condition of the veteran; or
                  (IV) such other factors as determined by the 
                Secretary.
          (ii) Whether the veteran reasonably believes that the 
        assignment of a particular care team or provider to the 
        veteran would detrimentally affect the patient-provider 
        relationship and result in sub-optimal care to the 
        veteran.
          (iii) Whether the panel size of the care team or 
        provider is at such a number that it would result in 
        difficulty for the veteran in accessing timely care or 
        in sub-optimal care to the veteran.
          (iv) Whether the veteran resides in a State where the 
        Department does not operated a full-service medical 
        facility.
  (C) If the Secretary determines that a patient-aligned care 
team or dedicated primary care provider at a Department 
facility has become available for assignment to an eligible 
veteran who had been assigned to a network provider under 
subparagraph (A), the Secretary shall provide the veteran with 
the option of reassignment to the team or provider at the 
Department facility.
  (D) In the case of an eligible veteran who is assigned to a 
network provider under subparagraph (A), the Secretary shall 
reevaluate such assignment not earlier than one year after a 
veteran makes a selection under subparagraph (A)(ii), and on an 
annual basis thereafter, to--
          (i) determine whether the Secretary is able to assign 
        to the veteran a patient-aligned care team or dedicated 
        primary care provider under section 1706(d) of this 
        title; and
          (ii) in consultation with and upon approval of the 
        veteran, make such assignment if able.
  (2)(A)(i) Except as provided in clause (ii), the Secretary 
may only furnish specialty hospital care, medical services, or 
extended care services to an eligible veteran under this 
section pursuant to a referral for such specialty care or 
services made by the primary care provider of the veteran.
  (ii) The Secretary may designate specialties which shall be 
exempt from the requirement under clause (i).
  (B) The Secretary shall determine whether to furnish 
specialty hospital care, medical services, or extended care 
services to an eligible veteran pursuant to subparagraph (A)--
          (i) at a medical facility of the Department that is 
        within a reasonable distance of the residence of the 
        veteran, as determined by the Secretary;
          (ii) by a network provider that, to the greatest 
        extent practicable, is located in the regional network 
        in which the veteran resides or a regional network that 
        is adjacent to the regional network in which the 
        veteran resides; or
          (iii) pursuant to an agreement described in 
        subparagraph (C).
  (C) An agreement described in this subparagraph is an 
agreement entered into by the Secretary with a network provider 
under which--
          (i) specialty hospital care, medical services, or 
        extended care services are furnished to an eligible 
        veteran pursuant to subparagraph (A)--
                  (I) at a medical facility of the Department 
                by a network provider possessing the 
                appropriate credentials, as determined by the 
                Secretary; or
                  (II) at a facility of a network provider by a 
                health care provider of the Department; and
          (ii) such specialty care or services are so furnished 
        either--
                  (I) in accordance with this section with 
                respect to fees and payments for care and 
                services furnished under subsection (a); or
                  (II) at no cost to the United States.
  (D) In making the determination under subparagraph (B), the 
Secretary shall give priority to medical facilities and health 
care providers of the Department but shall take into account--
          (i) whether the veteran faces an unusual or excessive 
        burden in accessing such specialty hospital care, 
        medical services, or extended care services at a 
        medical facility of the Department, including with 
        respect to--
                  (I) geographical challenges;
                  (II) environmental factors, such as roads 
                that are not accessible to the general public, 
                traffic, or hazardous weather;
                  (III) a medical condition of the veteran; or
                  (IV) such other factors as determined by the 
                Secretary;
          (ii) whether the primary care provider of the veteran 
        recommends that such specialty hospital care, medical 
        services, or extended care services should be furnished 
        by a network provider;
          (iii) whether the veteran resides in a State where 
        the Department does not operate a full-service medical 
        facility; and
          (iv) in the case of a veteran who requires an organ 
        or bone marrow transplant, whether the veteran has, in 
        the opinion of the primary care provider of the 
        veteran, a medically compelling reason to travel 
        outside the region of the Organ Procurement and 
        Transplantation Network, established under section 372 
        of the National Organ Transplantation Act (Public Law 
        98-507; 42 U.S.C. 274), in which the veteran resides, 
        to receive such transplant.
  (E) The Secretary shall ensure that each medical facility of 
the Department processes referrals for specialty hospital care, 
medical services, or extended care services in a standardized 
manner, including with respect to the organization of the 
program office responsible for such referrals.
  (F) In carrying out this section, the Secretary shall 
establish a process to review any disagreement between an 
eligible veteran and the Department, or between an eligible 
veteran and a health care provider of the Department, regarding 
the eligibility of the veteran to receive care or services from 
a network provider under this section or the assignment of a 
primary care provider of the Department to the veteran. In 
reviewing a disagreement under such process with respect to the 
availability of and assignment to a patient aligned care team 
or dedicated primary care provider, the Secretary may give 
deference to the veteran with respect to any determination 
under subsection (b)(1)(B)(ii).
  (G)(i) The Secretary shall develop procedures to ensure that 
assigning a veteran to a patient-aligned care team or dedicated 
primary care provider under subparagraph (A), (C), or (D) does 
not adversely affect the continuity or quality of care for the 
veteran during the transition.
  (ii) Procedures under clause (i) shall provide for--
          (I) the appointment of a contact in the Department 
        for the veteran who shall provide information to the 
        veteran and resolve issues regarding the transition;
          (II) the transfer of relevant medical records;
          (III) coordination of care between providers;
          (IV) the continued treatment of chronic or current 
        episodes of care (by means including medication, 
        subspecialty care, and ancillary services); and
          (V) any other action the Secretary determines is 
        necessary.
  (c) Episodes of Care.--(1) The Secretary shall ensure that, 
at the election of an eligible veteran who receives hospital 
care, medical services, or extended care services from a 
network provider in an episode of care under this section, the 
veteran receives such care or services from that network 
provider, another network provider selected by the veteran, or 
a health care provider of the Department, through the 
completion of the episode of care, including all specialty and 
ancillary services determined necessary by the provider as part 
of the treatment recommended in the course of such care or 
services. In making such determination with respect to 
necessary specialty and ancillary services provided by a 
network provider, the network provider shall consult with the 
Secretary, acting through the program office of the appropriate 
medical facility.
  (2) In cases of episodes of care that the Secretary 
determines case management to be appropriate, the Secretary 
shall provide case management to an eligible veteran who 
receives hospital care, medical services, or extended care 
services from a network provider for such episodes of care. The 
Secretary may provide such case management through the Veterans 
Health Administration or through an entity that manages the 
operations of the regional networks pursuant to subsection 
(a)(4)(B).
  (d) Care and Services Through Contracts and Agreements.--(1) 
The Secretary shall enter into contracts or agreements, 
including national contracts or agreements for, but not limited 
to, dialysis, for furnishing care and services to eligible 
veterans under this section with network providers.
  (2)(A) In entering into a contract or agreement under 
paragraph (1) with a network provider, the Secretary shall--
          (i) negotiate rates for the furnishing of care and 
        services under this section; and
          (ii) reimburse the provider for such care and 
        services at the rates negotiated pursuant to clause (i) 
        as provided in such contract or agreement.
  (B)(i) Except as provided in paragraph (3), rates negotiated 
under subparagraph (A)(i) 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.
  (ii) In determining the rates under the Medicare Program 
under title XVIII of the Social Security Act (42 U.S.C. 1395 et 
seq.) for purposes of clause (i), in the case of care or 
services furnished by a provider of services with respect to 
which such rates are determined under a fee schedule to which 
the area wage index under section 1886(d)(3)(E) of the Social 
Security Act (42 U.S.C. 1395ww(d)(3)(E)) applies, such area 
wage index so applied to such provider of services may not be 
less than 1.00.
  (C) In carrying out paragraph (2), the Secretary may 
incorporate the use of value-based reimbursement models to 
promote the provision of high-quality care.
  (3)(A) With respect to the furnishing of care or services 
under this section to an eligible veteran who resides in a 
highly rural area (as defined under the rural-urban commuting 
area codes developed by the Secretary of Agriculture and the 
Secretary of Health and Human Services), the Secretary of 
Veterans Affairs may negotiate a rate that is more than the 
rate paid by the United States as described in paragraph 
(2)(B).
  (B) With respect to furnishing care or services under this 
section in Alaska, the Alaska Fee Schedule of the Department of 
Veterans Affairs will be followed, except for when another 
payment agreement, including a contract or provider agreement, 
is in place.
  (C) With respect to furnishing care or services under this 
section in a State with an All-Payer Model Agreement under the 
Social Security Act that became effective on or after January 
1, 2014, the Medicare payment rates under paragraph (2)(B) 
shall be calculated based on the payment rates under such 
agreement, or any such successor agreement.
  (D) With respect to furnishing care or services under this 
section in a location in which the Secretary determines that 
adjusting the rate paid by the United States as described in 
paragraph (2)(B) is appropriate, the Secretary may negotiate 
such an adjusted rate.
  (E) With respect to furnishing care or services under this 
section in a location or in a situation in which an exception 
to the rates paid by the United States 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 applies, the 
Secretary may follow such exception.
  (F) With respect to furnishing care or services under this 
section for care or services not covered under the Medicare 
Program under title XVIII of the Social Security Act (42 U.S.C. 
1395 et seq.), the Secretary shall establish a schedule of fees 
for such care or services.
  (G) With respect to furnishing care or services under this 
section pursuant to an agreement with a tribal or Federal 
entity, the Secretary may negotiate a rate that is more than 
the rate paid by the United States as described in paragraph 
(2)(B).
  (4) For the furnishing of care or services pursuant to a 
contract or agreement under paragraph (1), a network provider 
may not collect any amount that is greater than the rate 
negotiated pursuant to paragraph (2)(A).
  (5)(A) If, in the course of an episode of care under this 
section, any part of care or services is furnished by a medical 
provider who is not a network provider, the Secretary may 
compensate such provider for furnishing such care or services.
  (B) The Secretary shall make reasonable efforts to enter into 
a contract or agreement under this section with any provider 
who is compensated pursuant to subparagraph (A).
  (e) Prompt Payment Standard.--(1) The Secretary shall ensure 
that claims for payments for hospital care, medical services, 
or extended care services furnished under this section are 
processed in accordance with this subsection, regardless of 
whether such claims are--
          (A) made by a network provider to the Secretary;
          (B) made by a network provider to a regional network 
        operated by a contractor pursuant to subsection 
        (a)(4)(B); or
          (C) made by such a regional network to the Secretary.
  (2) A covered claimant that seeks payment for hospital care, 
medical services, or extended care services furnished under 
this section shall submit to the covered payer a claim for 
payment not later than--
          (A) with respect to a claim by a network provider, 
        180 days after the date on which the network provider 
        furnishes such care or services; or
          (B) with respect to a claim by a regional network 
        operated by a contractor, 180 days after the date on 
        which the contractor pays the network provider for 
        furnishing such care or services.
  (3) Notwithstanding chapter 39 of title 31 or any other 
provision of law, the covered payer shall pay a covered 
claimant for hospital care, medical services, or extended care 
services furnished under this section--
          (A) in the case of a clean claim submitted to the 
        covered payer on paper, not later than 45 calendar days 
        after receiving the claim; or
          (B) in the case of a clean claim submitted to the 
        covered payer electronically, not later than 30 
        calendar days after receiving the claim.
  (4)(A) If the covered payer denies a claim submitted by a 
covered claimant under paragraph (1), the covered payer shall 
notify the covered claimant of the reason for denying the claim 
and the additional information, if any, that may be required to 
process the claim--
          (i) in the case of a clean claim submitted to the 
        covered payer on paper, not later than 45 calendar days 
        after receiving the claim; or
          (ii) in the case of a clean claim submitted to the 
        covered payer electronically, not later than 30 
        calendar days after receiving the claim.
  (B) Upon receipt by the covered payer of additional 
information specified under subparagraph (A) relating to a 
claim, the covered payer shall pay, deny, or otherwise 
adjudicate the claim, as appropriate, not later than 30 
calendar days after receiving such information.
  (5)(A) If the covered payer has not paid a covered claimant 
or denied a clean claim for payment by the covered claimant 
under this subsection during the appropriate period specified 
in this subsection, such clean claim shall be considered 
overdue.
  (B) If a clean claim for payment by a covered claimant is 
considered overdue under subparagraph (A), in addition to the 
amount the covered payer owes the covered claimant under the 
claim, the covered payer shall owe the covered claimant an 
interest penalty amount that shall--
          (i) be prorated daily;
          (ii) accrue from the date the payment was overdue;
          (iii) be payable at the time the claim is paid; and
          (iv) be computed at the rate of interest established 
        by the Secretary of the Treasury, and published in the 
        Federal Register, for interest payments under 
        subsections (a)(1) and (b) of section 7109 of title 41 
        that is in effect at the time the covered payer accrues 
        the obligation to pay the interest penalty amount.
  (6)(A) If the covered payer overpays a covered claimant for 
hospital care, medical services, or extended care services 
furnished under this section--
          (i) the covered payer shall deduct the amount of any 
        overpayment from payments due to the covered claimant 
        after the date of such overpayment; or
          (ii) if the covered payer determines that there are 
        no such payments due after the date of the overpayment, 
        the covered claimant shall refund the amount of such 
        overpayment not later than 30 days after such 
        determination.
  (B)(i) Before deducting any amount from a payment to a 
covered claimant under subparagraph (A), the covered payer 
shall ensure that the covered claimant is provided an 
opportunity--
          (I) to dispute the existence or amount of any 
        overpayment owed to the covered payer; and
          (II) to request a compromise with respect to any such 
        overpayment.
  (ii) The covered payer may not make any deduction from a 
payment to a covered claimant under subparagraph (A) unless the 
covered payer has made reasonable efforts to notify the covered 
claimant of the rights of the covered claimant under subclauses 
(I) and (II) of clause (i).
  (iii) Upon receiving a dispute under subclause (I) of clause 
(i) or a request under subclause (II) of such clause, the 
covered payer shall make a determination with respect to such 
dispute or request before making any deduction under 
subparagraph (A) unless the time required to make such a 
determination would jeopardize the ability of the covered payer 
to recover the full amount owed to the covered payer.
  (7) Notwithstanding any other provision of law, the Secretary 
may, except in the case of a fraudulent claim, false claim, or 
misrepresented claim, compromise any claim of an amount owed to 
the United States under this section.
  (8) This subsection shall apply only to payments made on a 
claims basis and not to capitation or other forms of periodic 
payments to network providers.
  (9) A network provider that provides hospital care, medical 
services, or extended care services to an eligible veteran 
under this section may not seek any payment for such care or 
services from the eligible veteran.
  (10) With respect to making a payment for hospital care or 
medical services furnished to an eligible veteran by a network 
provider under this section--
          (A) the Secretary may not require receipt by the 
        veteran or the Department of a medical record under 
        subsection (g) detailing such care or services before a 
        covered payer makes a payment for such care or 
        services; and
          (B) the Secretary may require that the network 
        provider attests to such care or services so provided 
        before a covered payer makes a payment for such care or 
        services.
  (f) Cost-sharing.--(1) The Secretary shall require an 
eligible veteran to pay a copayment for the receipt of care or 
services under this section only if such eligible veteran would 
be required to pay a copayment for the receipt of such care or 
services at a medical facility of the Department or from a 
health care provider of the Department under this chapter.
  (2) The amount of a copayment charged under paragraph (1) may 
not exceed the amount of the copayment that would be payable by 
such eligible veteran for the receipt of such care or services 
at a medical facility of the Department or from a health care 
provider of the Department under this chapter.
  (3) In any case in which an eligible veteran is furnished 
hospital care or medical services under this section for a non-
service-connected disability described in subsection (a)(2) of 
section 1729 of this title, the Secretary shall recover or 
collect reasonable charges for such care or services from a 
health-plan contract described in section 1705A in accordance 
with such section 1729.
  (g) Medical Records.--(1) The Secretary shall ensure that any 
network provider that furnishes care or services under this 
section to an eligible veteran--
          (A) upon the request of the veteran, provides to the 
        veteran the medical records related to such care or 
        services; and
          (B) upon the completion of the provision of such care 
        or services to such veteran, provides to the Department 
        the medical records for the veteran furnished care or 
        services under this section in a timeframe and format 
        specified by the Secretary for purposes of this 
        section, except the Secretary may not require that any 
        payment by the Secretary to the eligible provider be 
        contingent on such provision of medical records.
  (2) To the extent practicable, the Secretary shall submit to 
a network provider that furnishes care or services under this 
section to an eligible veteran the medical records of such 
eligible veteran that are maintained by the Department and are 
relevant to such care or services.
  (3) To the extent practicable, the Secretary shall--
          (A) ensure that the medical records shared under 
        paragraphs (1) and (2) are shared in an electronic 
        format accessible by network providers and the 
        Department through an Internet website; and
          (B) provide to network providers access to the 
        electronic patient health record system of the 
        Department, or successor system, for the purpose of 
        furnishing care or services under this section.
  (h) Use of Card.--The Secretary shall ensure that the veteran 
health identification card, or such successor identification 
card, includes sufficient information to act as an 
identification card for an eligible entity or other non-
Department facility. The Secretary may not use any amounts made 
available to the Secretary to issue separate identification 
cards solely for the purpose of carrying out this section.
  (i) Prescription Medications.--(1) With respect to 
requirements relating to the licensing or credentialing of a 
network provider, the Secretary shall ensure that the network 
provider is able to submit prescriptions for pharmaceutical 
agents on the formulary of the Department to pharmacies of the 
Department in a manner that is substantially similar to the 
manner in which the network provider submits prescriptions to 
retail pharmacies.
  (2) Nothing in this section shall be construed to affect the 
process of the Department for filling and paying for 
prescription medications.
  (j) Quality of Care.--In carrying out this section, the 
Secretary shall use the quality of care standards set forth or 
used by the Centers for Medicare & Medicaid Services or other 
quality of care standards, as determined by the Secretary.
  (k) Capacity and Commercial Market Assessments.--(1) On a 
periodic basis, but not less often than once every three years, 
the Secretary shall conduct an assessment of the capacity of 
each Veterans Integrated Service Network and medical facility 
of the Department to furnish care or services under this 
chapter. Each such assessment shall--
          (A) identify gaps in furnishing such care or services 
        at such Veterans Integrated Service Network or medical 
        facility;
          (B) identify how such gaps can be filled by--
                  (i) entering into contracts or agreements 
                with network providers under this section or 
                with entities under other provisions of law;
                  (ii) making changes in the way such care and 
                services are furnished at such Veterans 
                Integrated Service Network or medical facility, 
                including but not limited to--
                          (I) extending hours of operation;
                          (II) adding personnel; or
                          (III) expanding space through 
                        construction, leasing, or sharing of 
                        health care facilities; and
                  (iii) the building or realignment of 
                Department resources or personnel;
          (C) forecast, based on future projections and 
        historical trends, both the short- and long-term demand 
        in furnishing care or services at such Veterans 
        Integrated Service Network or medical facility and 
        assess how such demand affects the needs to use such 
        network providers;
          (D) include a commercial health care market 
        assessment of designated catchment areas in the United 
        States conducted by a nongovernmental entity; and
          (E) consider the unique ability of the Federal 
        Government to retain a presence in an area otherwise 
        devoid of commercial health care providers or from 
        which such providers are at a risk of leaving.
  (2) The Secretary shall submit each assessment under 
paragraph (1) to the Committees on Veterans' Affairs of the 
House of Representatives and the Senate and shall make each 
such assessment publicly available.
  (l) Allocation of Funds.--The Secretary shall develop a plan 
for the allocation of funds in the Medical Community Care 
account.
  (m) Reports on Rates.--Not later than December 31, 2019, and 
annually thereafter during each of the subsequent three years, 
the Secretary shall submit to the Committees on Veterans' 
Affairs of the House of Representatives and the Senate a report 
detailing, for the fiscal year preceding the fiscal year during 
which the report is submitted, the rates paid by the Secretary 
for hospital care, medical services, or extended care services 
under this section that, pursuant to subsection (d)(3), are 
more than the rates described in subsection (d)(2)(B) for the 
same care or services.
  (n) Definitions.--In this section:
          (1) The term ``clean claim'' means a claim 
        submitted--
                  (A) to the covered payer by a covered 
                claimant for purposes of payment by the covered 
                payer of expenses for hospital care or medical 
                services furnished under this section;
                  (B) that contains substantially all of the 
                required elements necessary for accurate 
                adjudication, without requiring additional 
                information from the network provider; and
                  (C) in such a nationally recognized format as 
                may be prescribed by the Secretary for purposes 
                of paying claims for hospital care or medical 
                services furnished under this section.
          (2) The term ``covered claimant'' means--
                  (A) a network provider that submits a claim 
                to the Secretary for purposes of payment by the 
                Secretary of expenses for hospital care or 
                medical services furnished under this section; 
                or
                  (B) a regional network operated by a 
                contractor pursuant to subsection (a)(4)(B) 
                that submits a claim to the Secretary for 
                purposes of reimbursement for a payment made by 
                the contractor to a network provider for 
                hospital care or medical services furnished 
                under this section.
          (3) The term ``covered payer'' means--
                  (A) a regional network operated by a 
                contractor pursuant to subsection (a)(4)(B) 
                with respect to a claim made by a network 
                provider to the contractor for purposes of 
                payment by the contractor of expenses for 
                hospital care or medical services furnished 
                under this section; or
                  (B) the Secretary with respect to--
                          (i) a claim made by a network 
                        provider to the Secretary for purposes 
                        of payment by the Secretary of expenses 
                        for hospital care or medical services 
                        furnished under this section; and
                          (ii) a claim made by a regional 
                        network operated by a contractor 
                        pursuant to subsection (a)(4)(B) for 
                        purposes of reimbursement for a payment 
                        described by subparagraph (A).
          (4) The term ``eligible veteran'' means a veteran 
        who--
                  (A) is enrolled in the patient enrollment 
                system of the Department established and 
                operated under section 1705(a) of this title; 
                and
                  (B) has--
                          (i) been furnished hospital care or 
                        medical services at or through a 
                        Department facility on at least one 
                        occasion during the two-year period 
                        preceding the date of the determination 
                        of eligibility; or
                          (ii) requested a first-time 
                        appointment for hospital care or 
                        medical services at a Department 
                        facility.
          (5) The term ``fraudulent claim'' means a claim by a 
        network provider for reimbursement under this section 
        that includes an intentional and deliberate 
        misrepresentation of a material fact or facts that is 
        intended to induce the Secretary to pay an amount that 
        was not legally owed to the provider.

Sec. 1703B. Veterans Care Agreements with non-network providers

  (a) Veterans Care Agreements.--(1) In addition to furnishing 
hospital care, medical services, or extended care services 
under this chapter at facilities of the Department or under 
contracts or agreements entered into pursuant to section 1703A 
of this title or any other provision of law other than this 
section, the Secretary may furnish such care and services to 
eligible veterans through the use of agreements, to be known as 
``Veterans Care Agreements'', entered into under this section 
by the Secretary with eligible non-network providers.
  (2) The Secretary may enter into a Veterans Care Agreement 
under this section with an eligible non-network provider if the 
Secretary determines that--
          (A) the provision of the hospital care, medical 
        services, or extended care services at a Department 
        facility is impracticable or inadvisable because of the 
        medical condition of the veteran, the travel involved, 
        or the nature of the care or services required, or a 
        combination of such factors; and
          (B) such care or services are not available to be 
        furnished by a non-Department health care provider 
        under a contract or agreement entered into pursuant to 
        a provision of law other than this section.
  (3)(A) In accordance with subparagraphs (C) and (D), the 
Secretary shall review each Veterans Care Agreement with a non-
network provider to determine whether it is practical or 
advisable to, instead of carrying out such agreement--
          (i) provide at a Department facility the hospital 
        care, medical services, or extended care services 
        covered by such agreement; or
          (ii) enter into an agreement with the provider under 
        section 1703A of this title to provide such care or 
        services.
  (B) If the Secretary determines pursuant to a review of a 
Veterans Care Agreement under subparagraph (A) that it is 
practical or advisable to provide hospital care, medical 
services, or extended care services at a Department facility, 
or enter into an agreement under section 1703A of this title to 
provide such care or services, as the case may be, the 
Secretary--
          (i) may not renew the Veterans Care Agreement; and
          (ii) shall take such actions as are necessary to 
        implement such determination.
  (C) This paragraph shall apply with respect to Veterans Care 
Agreements entered into with a non-network provider whose gross 
annual revenue, as determined under subsection (b)(1), 
exceeds--
          (i) $3,000,000, in the case of a provider that 
        furnishes homemaker or home health aide services; or
          (ii) $1,000,000, in the case of any other provider.
  (D) The Secretary shall conduct each review of a Veterans 
Care Agreement under subparagraph (A) as follows:
          (i) Once during the 18-month period beginning on the 
        date that is six months after date on which the 
        agreement is entered into.
          (ii) Not less than once during each four-year period 
        beginning on the date on which the review under 
        subparagraph (A) is conducted.
  (b) Eligible Non-network Providers.--A provider of hospital 
care, medical services, or extended care services is eligible 
to enter into a Veterans Care Agreement under this section if 
the Secretary determines that the provider meets the following 
criteria:
          (1) The gross annual revenue of the provider under 
        contracts or agreements entered into with the Secretary 
        in the year preceding the year in which the provider 
        enters into the Veterans Care Agreement does not 
        exceed--
                  (A) $5,000,000 (as adjusted in a manner 
                similar to amounts adjusted pursuant to section 
                5312 of this title), in the case of a provider 
                that furnishes homemaker or home health aide 
                services; or
                  (B) $2,000,000 (as so adjusted), in the case 
                of any other provider.
          (2) The provider is not a network provider and does 
        not otherwise provide hospital care, medical services, 
        or extended care services to patients pursuant to a 
        contract entered into with the Department.
          (3) The provider is--
                  (A) a provider of services that has enrolled 
                and entered into a provider agreement under 
                section 1866(a) of the Social Security Act (42 
                U.S.C. 1395cc(a));
                  (B) a physician or supplier that has enrolled 
                and entered into a participation agreement 
                under section 1842(h) of such Act (42 U.S.C. 
                1395u(h));
                  (C) a provider of items and services 
                receiving payment under a State plan under 
                title XIX of such Act (42 U.S.C. 1396 et seq.) 
                or a waiver of such a plan;
                  (D) an Aging and Disability Resource Center, 
                an area agency on aging, or a State agency (as 
                defined in section 102 of the Older Americans 
                Act of 1965 (42 U.S.C. 3002)); or
                  (E) a center for independent living (as 
                defined in section 702 of the Rehabilitation 
                Act of 1973 (29 U.S.C. 796a)).
          (4) The provider is certified pursuant to the process 
        established under subsection (c)(1).
          (5) Any additional criteria determined appropriate by 
        the Secretary.
  (c) Provider Certification.--(1) The Secretary shall 
establish a process for the certification of eligible providers 
to enter into Veterans Care Agreements under this section that 
shall, at a minimum, set forth the following:
          (A) Procedures for the submission of applications for 
        certification and deadlines for actions taken by the 
        Secretary with respect to such applications.
          (B) Standards and procedures for the approval and 
        denial of certifications and the revocation of 
        certifications.
          (C) Procedures for assessing eligible providers based 
        on the risk of fraud, waste, and abuse of such 
        providers similar to the level of screening under 
        section 1866(j)(2)(B) of the Social Security Act (42 
        U.S.C. 1395(j)(2)(B)) and the standards set forth under 
        section 9.104 of title 48, Code of Federal Regulations, 
        or any successor regulation.
          (D) Requirement for denial or revocation of 
        certification if the Secretary determines that the 
        otherwise eligible provider is--
                  (i) excluded from participation in a Federal 
                health care program (as defined in section 
                1128B(f) of the Social Security Act (42 U.S.C. 
                1320a-7b(f))) under section 1128 or 1128A of 
                the Social Security Act (42 U.S.C. 1320a-7 and 
                1320a-7a); or
                  (ii) identified as an excluded source on the 
                list maintained in the System for Award 
                Management, or any successor system.
          (E) Procedures by which a provider whose 
        certification is denied or revoked under the procedures 
        established under this subsection will be identified as 
        an excluded source on the list maintained in the System 
        for Award Management, or successor system, if the 
        Secretary determines that such exclusion is 
        appropriate.
  (2) To the extent practicable, the Secretary shall establish 
the procedures under paragraph (1) in a manner that takes into 
account any certification process administered by another 
department or agency of the Federal Government that an eligible 
provider has completed by reason of being a provider described 
in any of subparagraphs (A) through (E) of subsection (b)(4).
  (3) The Secretary shall--
          (A) verify upon enrollment, and annually thereafter, 
        that eligible providers have not been excluded from 
        participation in other federally funded health care 
        programs; and
          (B) submit to the Committees on Veterans' Affairs of 
        the House of Representatives and the Senate an annual 
        report on the results of such verifications.
  (d) Terms of Agreements.--Subsections (d), (e), (f), and (g) 
of section 1703A of this title shall apply with respect to a 
Veterans Care Agreement in the same manner such subsections 
apply to contracts and agreements entered into under such 
section.
  (e) Exclusion of Certain Federal Contracting Provisions.--(1) 
Notwithstanding any other provision of law, the Secretary may 
enter into a Veterans Care Agreement using procedures other 
than competitive procedures.
  (2)(A) Except as provided in subparagraph (B) and unless 
otherwise provided in this section, an eligible non-network 
provider that enters into a Veterans Care Agreement under this 
section is not subject to, in the carrying out of the 
agreement, any provision of law that providers of services and 
suppliers under the original Medicare fee-for-service program 
under parts A and B of 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.) are not subject to.
  (B) In addition to the provisions of laws covered by 
subparagraph (A), an eligible non-network provider shall be 
subject to the following provisions of law:
          (i) Any applicable law regarding integrity, ethics, 
        or fraud, or that subject a person to civil or criminal 
        penalties.
          (ii) Section 1352 of title 31, except for the filing 
        requirements under subsection (b) of such section.
          (iii) Section 4705 or 4712 of title 41, and any other 
        applicable law regarding the protection of 
        whistleblowers.
          (iv) Section 4706(d) of title 41.
          (v) Title VII of the Civil Rights Act of 1964 (42 
        U.S.C. 2000e et seq.) to the same extent as such title 
        applies with respect to the eligible non-network 
        provider in providing care or services through an 
        agreement or arrangement other than under a Veterans 
        Care Agreement.
  (f) Termination of a Veterans Care Agreement.--(1) An 
eligible non-network provider may terminate a Veterans Care 
Agreement with the Secretary under this section at such time 
and upon such notice to the Secretary as the Secretary may 
specify for purposes of this section.
  (2) The Secretary may terminate a Veterans Care Agreement 
with an eligible non-network provider under this section at 
such time and upon such notice to the provider as the Secretary 
may specify for the purposes of this section, if the Secretary 
determines necessary.
  (g) Disputes.--(1) The Secretary shall establish 
administrative procedures for providers with which the 
Secretary has entered into a Veterans Care Agreement to present 
any dispute arising under or related to the agreement.
  (2) Before using any dispute resolution mechanism under 
chapter 71 of title 41 with respect to a dispute arising under 
a Veterans Care Agreement under this section, a provider must 
first exhaust the administrative procedures established by the 
Secretary under paragraph (1).
  (h) Authority to Pay for Other Authorized Services.--(1) If, 
in the course of an episode of care for which hospital care, 
medical services, or extended care services are furnished to an 
eligible veteran pursuant to a Veterans Care Agreement, any 
part of such care or services is furnished by a medical 
provider who is not an eligible non-network provider or a 
network provider, the Secretary may compensate such provider 
for furnishing such care or services.
  (2) The Secretary shall make reasonable efforts to enter into 
a Veterans Care Agreement with any provider who is compensated 
pursuant to paragraph (1).
  (i) Annual Reports.--(1) Not later than December 31 of the 
year following the fiscal year in which the Secretary first 
enters into a Veterans Care Agreement under this section, and 
each year thereafter, the Secretary shall submit to the 
appropriate congressional committees an annual report that 
includes a list of all Veterans Care Agreements entered into as 
of the date of the report.
  (2) The requirement to submit a report under paragraph (1) 
shall terminate on the date that is five years after the date 
of the enactment of this section.
  (j) Quality of Care.--In carrying out this section, the 
Secretary shall use the quality of care standards set forth or 
used by the Centers for Medicare & Medicaid Services or other 
quality of care standards, as determined by the Secretary.
  (k) Delegation.--The Secretary may delegate the authority to 
enter into or terminate a Veterans Care Agreement to an 
official of the Department at a level not below the Director of 
a Veterans Integrated Service Network or the Director of a 
Network Contracting Office.
  (l) Definitions.--In this section:
          (1) The term ``appropriate congressional committees'' 
        means--
                  (A) the Committees on Veterans' Affairs of 
                the House of Representatives and the Senate; 
                and
                  (B) the Committees on Appropriations of the 
                House of Representatives and the Senate.
          (2) The term ``eligible veteran'' has the meaning 
        given such term in section 1703A(m) of this title.

Sec. 1703C. Transplant procedures with live donors and related services

  (a) In General.--Subject to subsections (b) and (c), in a 
case in which a veteran is eligible for a transplant procedure 
from the Department, the Secretary may provide for an operation 
on a live donor to carry out such procedure for such veteran, 
notwithstanding that the live donor may not be eligible for 
health care from the Department.
  (b) Other Services.--Subject to the availability of 
appropriations for such purpose, the Secretary shall furnish to 
a live donor any care or services before and after conducting 
the transplant procedure under subsection (a) that may be 
required in connection with such procedure.
  (c) Use of Non-Department Facilities.--(1) In carrying out 
this subsection, the Secretary may provide for the operation 
described in subsection (a) on a live donor and furnish to the 
live donor the care and services described in subsection (b) at 
a non-Department facility pursuant to an agreement entered into 
by the Secretary under this section. The live donor shall be 
deemed to be an individual eligible for hospital care and 
medical services at a non-Department facility pursuant to such 
an agreement solely for the purposes of receiving such 
operation, care, and services at the non-Department facility.
  (2) The Secretary may only provide for an operation at a non-
Department of Veterans Affairs transplant center pursuant to 
paragraph (1) if the center is in compliance with regulations 
prescribed by the Centers for Medicare & Medicaid Services 
applicable to transplant centers.

Sec. 1703D. Center for Innovation for Care and Payment

  (a) In General.--(1) There is established within the 
Department a Center for Innovation for Care and Payment (in 
this section referred to as the ``Center'').
  (2) The Secretary, acting through the Center, may carry out 
such pilot programs the Secretary determines to be appropriate 
to develop innovative approaches to testing payment and service 
delivery models in order to reduce expenditures while 
preserving or enhancing the quality of care furnished by the 
Department.
  (3) The Secretary, acting through the Center, shall test 
payment and service delivery models to determine whether such 
models--
          (A) improve access to, and quality, timeliness, and 
        patient satisfaction of care and services; and
          (B) create cost savings for the Department.
  (4)(A) The Secretary shall test a model in a location where 
the Secretary determines that the model will addresses deficits 
in care (including poor clinical outcomes or potentially 
avoidable expenditures) for a defined population.
  (B) The Secretary shall focus on models the Secretary expects 
to reduce program costs while preserving or enhancing the 
quality of care received by individuals receiving benefits 
under this chapter.
  (C) The models selected may include those described in 
section 1115A(b)(2)(B) of the Social Security Act (42 U.S.C. 
1315a(b)(2)(B)).
  (5) In selecting a model for testing, the Secretary may 
consider, in addition to other factors identified in this 
subsection, the following factors:
          (A) Whether the model includes a regular process for 
        monitoring and updating patient care plans in a manner 
        that is consistent with the needs and preferences of 
        individuals receiving benefits under this chapter.
          (B) Whether the model places the individual receiving 
        benefits under this chapter at the center of the care 
        team (including family members and other caregivers) of 
        such individual.
          (C) Whether the model uses technology or new systems 
        to coordinate care over time and across settings.
          (D) Whether the model demonstrates effective linkage 
        with other public sector payers, private sector payers, 
        or statewide payment models.
  (6)(A) Models tested under this section may not be designed 
in such a way that would allow the United States to recover or 
collect reasonable charges from a Federal health care program 
for care or services furnished by the Secretary to a veteran 
under pilot programs carried out under this section.
  (B) In this paragraph, the term ``Federal health care 
program'' means--
          (i) an insurance program described in section 1811 of 
        the Social Security Act (42 U.S.C. 1395c) or 
        established by section 1831 of such Act (42 U.S.C. 
        1395j); or
          (ii) a State plan for medical assistance approved 
        under title XIX of such Act (42 U.S.C. 1396 et seq.); 
        or
          (iii) a TRICARE program operated under sections 1075, 
        1075a, 1076, 1076a, 1076c, 1076d, 1076e, or 1076f of 
        title 10.
  (b) Duration.--Each pilot program carried out by the 
Secretary under this section shall terminate no later than five 
years after the date of the commencement of the pilot program.
  (c) Location.--The Secretary shall ensure that each pilot 
program carried out under this section occurs in an area or 
areas appropriate for the intended purposes of the pilot 
program.
  (d) Budget.--Funding for each pilot program carried out by 
the Secretary under this section shall come from 
appropriations--
          (1) provided in advance in appropriations acts for 
        the Veterans Health Administration; and
          (2) provided for information technology systems.
  (e) Notice.--The Secretary shall--
          (1) publish information about each pilot program 
        under this section in the Federal Register; and
          (2) take reasonable actions to provide direct notice 
        to veterans eligible to participate in such pilot 
        programs.
  (f) Waiver of Authorities.--(1) Subject to reporting under 
paragraph (2) and approval under paragraph (3), in implementing 
a pilot program under this section, the Secretary may waive 
such requirements in subchapters I, II, and III of this chapter 
as the Secretary determines necessary solely for the purposes 
of carrying out this section with respect to testing models 
described in subsection (a).
  (2) Before waiving any authority under paragraph (1), the 
Secretary shall submit a report to the Speaker of the House of 
Representatives, the minority leader of the House of 
Representatives, the majority leader of the Senate, the 
minority leader of the Senate, and each standing committee with 
jurisdiction under the rules of the Senate and of the House of 
Representatives to report a bill to amend the provision or 
provisions of law that would be waived by the Department 
describing in detail the following:
          (A) The specific authorities to be waived under the 
        pilot program.
          (B) The standard or standards to be used in the pilot 
        program in lieu of the waived authorities.
          (C) The reasons for such waiver or waivers.
          (D) A description of the metric or metrics the 
        Secretary will use to determine the effect of the 
        waiver or waivers upon the access to and quality, 
        timeliness, or patient satisfaction of care and 
        services furnished through the pilot program.
          (E) The anticipated cost savings, if any, of the 
        pilot program.
          (F) The schedule for interim reports on the pilot 
        program describing the results of the pilot program so 
        far and the feasibility and advisability of continuing 
        the pilot program.
          (G) The schedule for the termination of the pilot 
        program and the submission of a final report on the 
        pilot program describing the result of the pilot 
        program and the feasibility and advisability of making 
        the pilot program permanent.
          (H) The estimated budget of the pilot program.
  (3)(A) Upon receipt of a report submitted under paragraph 
(2), each House of Congress shall provide copies of the report 
to the chairman and ranking member of each standing committee 
with jurisdiction under the rules of the House of 
Representatives or the Senate to report a bill to amend the 
provision or provisions of law that would be waived by the 
Department under this subsection.
  (B)(i) The waiver requested by the Secretary under paragraph 
(2) shall be considered approved under this paragraph if there 
is enacted into law a bill or joint resolution approving such 
request in its entirety. Such bill or joint resolution shall be 
passed by recorded vote to reflect the vote of each member of 
Congress thereon.
  (ii) The provisions of this paragraph are enacted by 
Congress--
          (I) as an exercise of the rulemaking power of the 
        Senate and the House of Representatives and as such 
        shall be considered as part of the rules of each House 
        of Congress, and shall supersede other rules only to 
        the extent that they are inconsistent therewith; and
          (II) with full recognition of the constitutional 
        right of either House of Congress to change the rules 
        (so far as they relate to the procedures of that House) 
        at any time, in the same manner, and to the same extent 
        as in the case of any other rule of that House.
  (C) During the 60-calendar-day period beginning on the date 
on which the Secretary submits the report described in 
paragraph (2) to Congress, it shall be in order as a matter of 
highest privilege in each House of Congress to consider a bill 
or joint resolution, if offered by the majority leader of such 
House (or a designee), approving such request in its entirety.
  (g) Limitations.--(1) The waiver provisions in subsection (f) 
shall not apply unless the Secretary, in accordance with the 
requirements in subsection (f), submits the first proposal for 
a pilot program not later than 18 months after the date of the 
enactment of the VA Care in the Community Act.
  (2) Notwithstanding section 502 of this title, decisions by 
the Secretary under this section shall, consistent with section 
511 of this title, be final and conclusive and may not be 
reviewed by any other official or by any court, whether by an 
action in the nature of mandamus or otherwise.
  (3)(A) If the Secretary determines that the pilot program is 
not improving the quality of care or producing cost savings, 
the Secretary shall--
          (i) propose a modification to the pilot program in 
        the interim report that shall also be considered a 
        report under subsection (f)(2)(A) and shall be subject 
        to the terms and conditions of subsection (f)(2); or
          (ii) terminate such pilot program not later than 30 
        days after submitting the interim report to Congress.
  (B) If the Secretary terminates the pilot program under 
subparagraph (A)(ii), for purposes of clauses (vi) and (vii) of 
subsection (f)(2)(A), such interim report will also serve as 
the final report for that pilot program.
  (h) Evaluation and Reporting Requirements.--(1) The Secretary 
shall conduct an evaluation of each model tested, which shall 
include, at a minimum, an analysis of--
          (A) the quality of care furnished under the model, 
        including the measurement of patient-level outcomes and 
        patient-centeredness criteria determined appropriate by 
        the Secretary; and
          (B) the changes in spending by reason of that model.
  (2) The Secretary shall make the results of each evaluation 
under this subsection available to the public in a timely 
fashion and may establish requirements for other entities 
participating in the testing of models under this section to 
collect and report information that the Secretary determines is 
necessary to monitor and evaluate such models.
  (i) Coordination and Consultation.--(1) The Secretary shall 
consult with the Under Secretary for Health and the Special 
Medical Advisory Group established pursuant to section 7312 of 
this title in the development and implementation of any pilot 
program operated under this section.
  (2) In carrying out the duties under this section, the 
Secretary shall consult representatives of relevant Federal 
agencies, and clinical and analytical experts with expertise in 
medicine and health care management. The Secretary shall use 
appropriate mechanisms to seek input from interested parties.
  (j) Expansion of Successful Pilot Programs.--Taking into 
account the evaluation under subsection (f), the Secretary may, 
through rulemaking, expand (including implementation on a 
nationwide basis) the duration and the scope of a model that is 
being tested under subsection (a) to the extent determined 
appropriate by the Secretary, if--
          (1) the Secretary determines that such expansion is 
        expected to--
                  (A) reduce spending without reducing the 
                quality of care; or
                  (B) improve the quality of patient care 
                without increasing spending; and
          (2) the Secretary determines that such expansion 
        would not deny or limit the coverage or provision of 
        benefits for individuals receiving benefits under this 
        chapter.

           *       *       *       *       *       *       *


Sec. 1705B. Management of health care: productivity

  (a) Relative Value Unit Tracking.--The Secretary shall track 
relative value units for all Department providers.
  (b) Clinical Procedure Coding Training.--The Secretary shall 
require all Department providers to attend training on clinical 
procedure coding.
  (c) Performance Standards.--(1) The Secretary shall establish 
for each Department facility--
          (A) in accordance with paragraph (2), standardized 
        performance standards based on nationally recognized 
        relative value unit production standards applicable to 
        each specific profession in order to evaluate clinical 
        productivity at the provider and facility level;
          (B) remediation plans to address low clinical 
        productivity and clinical inefficiency; and
          (C) an ongoing process to systematically review the 
        content, implementation, and outcome of the plans 
        developed under subparagraph (B).
  (2) In establishing the performance standards under paragraph 
(1)(A), the Secretary may--
          (A) incorporate values-based productivity models; and
          (B) take into account non-clinical duties, including 
        with respect to training and research.
  (d) Definitions.--In this section:
          (1) The term ``Department provider'' means an 
        employee of the Department whose primary 
        responsibilities include furnishing hospital care or 
        medical services, including a physician, a dentist, an 
        optometrist, a podiatrist, a chiropractor, an advanced 
        practice registered nurse, and a physician's assistant 
        acting as an independent provider.
          (2) The term ``relative value unit'' means a unit for 
        measuring workload by determining the time, mental 
        effort and judgment, technical skill, physical effort, 
        and stress involved in delivering a procedure.

Sec. 1706. Management of health care: other requirements

  (a) In managing the provision of hospital care and medical 
services under section 1710(a) of this title, the Secretary 
shall, to the extent feasible, design, establish and manage 
health care programs in such a manner as to promote cost-
effective delivery of health care services in the most 
clinically appropriate setting.
  (b)(1) In managing the provision of hospital care and medical 
services under such section, the Secretary shall ensure that 
the Department (and each geographic service area of the 
Veterans Health Administration) maintains its capacity to 
provide for the specialized treatment and rehabilitative needs 
of disabled veterans (including veterans with spinal cord 
dysfunction, blindness, amputations, and mental illness) within 
distinct programs or facilities of the Department that are 
dedicated to the specialized needs of those veterans in a 
manner that (A) affords those veterans reasonable access to 
care and services for those specialized needs, and (B) ensures 
that overall capacity of the Department to provide such 
services is not reduced below the capacity of the Department 
(and each geographic service area of the Veterans Health 
Administration), nationwide, to provide those services, as of 
October 9, 1996. The Secretary shall carry out this paragraph 
in consultation with the Advisory Committee on Prosthetics and 
Special Disabilities Programs and the Committee on Care of 
Severely Chronically Mentally Ill Veterans.
  (2) For purposes of paragraph (1), the capacity of the 
Department (and each geographic service area of the Veterans 
Health Administration) to provide for the specialized treatment 
and rehabilitative needs of disabled veterans (including 
veterans with spinal cord dysfunction, traumatic brain injury, 
blindness, prosthetics and sensory aids, and mental illness) 
within distinct programs or facilities shall be measured for 
seriously mentally ill veterans as follows (with all such data 
to be provided by geographic service area and totaled 
nationally):
          (A) For mental health intensive community-based care, 
        the number of discrete intensive care teams constituted 
        to provide such intensive services to seriously 
        mentally ill veterans and the number of veterans 
        provided such care.
          (B) For opioid substitution programs, the number of 
        patients treated annually and the amounts expended.
          (C) For dual-diagnosis patients, the number treated 
        annually and the amounts expended.
          (D) For substance-use disorder programs--
                  (i) the number of beds (whether hospital, 
                nursing home, or other designated beds) 
                employed and the average bed occupancy of such 
                beds;
                  (ii) the percentage of unique patients 
                admitted directly to outpatient care during the 
                fiscal year who had two or more additional 
                visits to specialized outpatient care within 30 
                days of their first visit, with a comparison 
                from 1996 until the date of the report;
                  (iii) the percentage of unique inpatients 
                with substance-use disorder diagnoses treated 
                during the fiscal year who had one or more 
                specialized clinic visits within three days of 
                their index discharge, with a comparison from 
                1996 until the date of the report;
                  (iv) the percentage of unique outpatients 
                seen in a facility or geographic service area 
                during the fiscal year who had one or more 
                specialized clinic visits, with a comparison 
                from 1996 until the date of the report; and
                  (v) the rate of recidivism of patients at 
                each specialized clinic in each geographic 
                service area of the Veterans Health 
                Administration.
          (E) For mental health programs, the number and type 
        of staff that are available at each facility to provide 
        specialized mental health treatment, including 
        satellite clinics, outpatient programs, and community-
        based outpatient clinics, with a comparison from 1996 
        to the date of the report.
          (F) The number of such clinics providing mental 
        health care, the number and type of mental health staff 
        at each such clinic, and the type of mental health 
        programs at each such clinic.
          (G) The total amounts expended for mental health 
        during the fiscal year.
  (3) For purposes of paragraph (1), the capacity of the 
Department (and each geographic service area of the Veterans 
Health Administration) to provide for the specialized treatment 
and rehabilitative needs of disabled veterans within distinct 
programs or facilities shall be measured for veterans with 
spinal cord dysfunction, traumatic brain injury, blindness, or 
prosthetics and sensory aids as follows (with all such data to 
be provided by geographic service area and totaled nationally):
          (A) For spinal cord injury and dysfunction 
        specialized centers and for blind rehabilitation 
        specialized centers, the number of staffed beds and the 
        number of full-time equivalent employees assigned to 
        provide care at such centers.
          (B) For prosthetics and sensory aids, the annual 
        amount expended.
          (C) For traumatic brain injury, the number of 
        patients treated annually and the amounts expended.
  (4) In carrying out paragraph (1), the Secretary may not use 
patient outcome data as a substitute for, or the equivalent of, 
compliance with the requirement under that paragraph for 
maintenance of capacity.
  (5)(A) Not later than April 1 of each year, the Secretary 
shall submit to the Committees on Veterans' Affairs of the 
Senate and House of Representatives a report on the Secretary's 
compliance, by facility and by service-network, with the 
requirements of this subsection. Each such report shall include 
information on recidivism rates associated with substance- use 
disorder treatment.
  (B) In preparing each report under subparagraph (A), the 
Secretary shall use standardized data and data definitions.
  (C) Each report under subparagraph (A) shall be audited by 
the Inspector General of the Department, who shall submit to 
Congress a certification as to the accuracy of each such 
report.
  (6)(A) To ensure compliance with paragraph (1), the Under 
Secretary for Health shall prescribe objective standards of job 
performance for employees in positions described in 
subparagraph (B) with respect to the job performance of those 
employees in carrying out the requirements of paragraph (1). 
Those job performance standards shall include measures of 
workload, allocation of resources, and quality-of-care 
indicators.
  (B) Positions described in this subparagraph are positions in 
the Veterans Health Administration that have responsibility for 
allocating and managing resources applicable to the 
requirements of paragraph (1).
  (C) The Under Secretary shall develop the job performance 
standards under subparagraph (A) in consultation with the 
Advisory Committee on Prosthetics and Special Disabilities 
Programs and the Committee on Care of Severely Chronically 
Mentally Ill Veterans.
  (c) The Secretary shall ensure that each primary care health 
care facility of the Department develops and carries out a plan 
to provide mental health services, either through referral or 
direct provision of services, to veterans who require such 
services.
  (d)(1) Except as provided in section 1703A of this title, in 
furnishing primary care under this chapter, the Secretary shall 
assign each eligible veteran to--
          (A) a patient-aligned care team of the Department; or
          (B) a dedicated primary care provider of the 
        Department as a part of any other model of providing 
        consistent primary care determined appropriate by the 
        Secretary.
  (2) Each patient-aligned care team of the Department shall 
consist of a team of health care professionals of the 
Department who--
          (A) provide to each eligible veteran comprehensive 
        primary care in partnership with the veteran; and
          (B) manage and coordinate comprehensive hospital care 
        and medical services consistent with the goals of care 
        agreed upon by the veteran and team.
  (3) The Secretary shall ensure that an eligible veteran is 
not simultaneously assigned to more than one patient-aligned 
care team or dedicated primary care provider under this 
subsection at a single location, including by establishing 
procedures in the event a primary care provider retires or is 
otherwise no longer able to treat the veteran. In the case of 
an eligible veteran who resides in more than one location, the 
Secretary may assign such veteran to a patient-aligned care 
team or dedicated primary care provider at each such location.
  (4) The term ``eligible veteran'' means a veteran who--
          (A) is enrolled in the patient enrollment system of 
        the Department established and operated under section 
        1705(a) of this title; and
          (B) has--
                  (i) been furnished hospital care or medical 
                services at or through a Department facility on 
                at least one occasion during the two-year 
                period preceding the date of the determination 
                of eligibility; or
                  (ii) requested a first-time appointment for 
                hospital care or medical services at a 
                Department facility.

           *       *       *       *       *       *       *


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

           *       *       *       *       *       *       *


Sec. 1712. Dental care; drugs and medicines for certain disabled 
                    veterans; vaccines

  (a)(1) Outpatient dental services and treatment, and related 
dental appliances, shall be furnished under this section only 
for a dental condition or disability--
          (A) which is service-connected and compensable in 
        degree;
          (B) which is service-connected, but not compensable 
        in degree, but only if--
                  (i) the dental condition or disability is 
                shown to have been in existence at the time of 
                the veteran's discharge or release from active 
                military, naval, or air service;
                  (ii) the veteran had served on active duty 
                for a period of not less than 180 days or, in 
                the case of a veteran who served on active duty 
                during the Persian Gulf War, 90 days 
                immediately before such discharge or release;
                  (iii) application for treatment is made 
                within 180 days after such discharge or 
                release, except that (I) in the case of a 
                veteran who reentered active military, naval, 
                or air service within 90 days after the date of 
                such veteran's prior discharge or release from 
                such service, application may be made within 
                180 days from the date of such veteran's 
                subsequent discharge or release from such 
                service, and (II) if a disqualifying discharge 
                or release has been corrected by competent 
                authority, application may be made within 180 
                days after the date of correction; and
                  (iv) the veteran's certificate of discharge 
                or release from active duty does not bear a 
                certification that the veteran was provided, 
                within the 90-day period immediately before the 
                date of such discharge or release, a complete 
                dental examination (including dental X-rays) 
                and all appropriate dental services and 
                treatment indicated by the examination to be 
                needed;
          (C) which is a service-connected dental condition or 
        disability due to combat wounds or other service 
        trauma, or of a former prisoner of war;
          (D) which is associated with and is aggravating a 
        disability resulting from some other disease or injury 
        which was incurred in or aggravated by active military, 
        naval, or air service;
          (E) which is a non-service-connected condition or 
        disability of a veteran for which treatment was begun 
        while such veteran was receiving hospital care under 
        this chapter and such services and treatment are 
        reasonably necessary to complete such treatment;
          (F) from which a veteran who is a former prisoner of 
        war is suffering;
          (G) from which a veteran who has a service-connected 
        disability rated as total is suffering; or
          (H) the treatment of which is medically necessary (i) 
        in preparation for hospital admission, or (ii) for a 
        veteran otherwise receiving care or services under this 
        chapter.
  (2) The Secretary concerned shall at the time a member of the 
Armed Forces is discharged or released from a period of active 
military, naval, or air service of not less than 180 days or, 
in the case of a veteran who served on active duty during the 
Persian Gulf War, 90 days provide to such member a written 
explanation of the provisions of clause (B) of paragraph (1) of 
this subsection and enter in the service records of the member 
a statement signed by the member acknowledging receipt of such 
explanation (or, if the member refuses to sign such statement, 
a certification from an officer designated for such purpose by 
the Secretary concerned that the member was provided such 
explanation).
  (3) The total amount which the Secretary may expend for 
furnishing, during any twelve-month period, outpatient dental 
services, treatment, or related dental appliances to a veteran 
under this section through private facilities for which the 
Secretary has contracted [under clause (1), (2), or (5) of 
section 1703(a) of this title] under the VA Care in the 
Community Program may not exceed $1,000 unless the Secretary 
determines, prior to the furnishing of such services, 
treatment, or appliances and based on an examination of the 
veteran by a dentist employed by the Department (or, in an area 
where no such dentist is available, by a dentist conducting 
such examination under a contract or fee arrangement), that the 
furnishing of such services, treatment, or appliances at such 
cost is reasonably necessary.
  (4)(A) Except as provided in subparagraph (B) of this 
paragraph, in any year in which the President's Budget for the 
fiscal year beginning October 1 of such year includes an amount 
for expenditures for contract dental care under the provisions 
of this subsection [and section 1703 of this title] and the VA 
Care in the Community Program (with respect to such a year 
beginning on or after the date on which the Secretary commences 
implementation of the VA Care in the Community Program) during 
such fiscal year in excess of the level of expenditures made 
for such purpose during fiscal year 1978, the Secretary shall, 
not later than February 15 of such year, submit a report to the 
appropriate committees of the Congress justifying the requested 
level of expenditures for contract dental care and explaining 
why the application of the criteria prescribed [in section 1703 
of this title] under the VA Care in the Community Program for 
contracting with private facilities and in the second sentence 
of section 1710(c) of this title for furnishing incidental 
dental care to hospitalized veterans will not preclude the need 
for expenditures for contract dental care in excess of the 
fiscal year 1978 level of expenditures for such purpose. In any 
case in which the amount included in the President's Budget for 
any fiscal year for expenditures for contract dental care under 
such provisions is not in excess of the level of expenditures 
made for such purpose during fiscal year 1978 and the Secretary 
determines after the date of submission of such budget and 
before the end of such fiscal year that the level of 
expenditures for such contract dental care during such fiscal 
year will exceed the fiscal year 1978 level of expenditures, 
the Secretary shall submit a report to the appropriate 
committees of the Congress containing both a justification 
(with respect to the projected level of expenditures for such 
fiscal year) and an explanation as required in the preceding 
sentence in the case of a report submitted pursuant to such 
sentence. Any report submitted pursuant to this paragraph shall 
include a comment by the Secretary on the effect of the 
application of the criteria prescribed in the second sentence 
of section 1710(c) of this title for furnishing incidental 
dental care to hospitalized veterans.
  (B) A report under subparagraph (A) of this paragraph with 
respect to a fiscal year is not required if, in the documents 
submitted by the Secretary to the Congress in justification for 
the amounts included for Department programs in the President's 
Budget, the Secretary specifies with respect to contract dental 
care described in such subparagraph--
          (i) the actual level of expenditures for such care in 
        the fiscal year preceding the fiscal year in which such 
        Budget is submitted;
          (ii) a current estimate of the level of expenditures 
        for such care in the fiscal year in which such Budget 
        is submitted; and
          (iii) the amount included in such Budget for such 
        care.
  (b) Dental services and related appliances for a dental 
condition or disability described in paragraph (1)(B) of 
subsection (a) shall be furnished on a one-time completion 
basis, unless the services rendered on a one-time completion 
basis are found unacceptable within the limitations of good 
professional standards, in which event such additional services 
may be afforded as are required to complete professionally 
acceptable treatment.
  (c) Dental appliances, wheelchairs, artificial limbs, 
trusses, special clothing, and similar appliances to be 
furnished by the Secretary under this section may be procured 
by the Secretary either by purchase or by manufacture, 
whichever the Secretary determines may be advantageous and 
reasonably necessary.
  (d) The Secretary shall furnish to each veteran who is 
receiving additional compensation or allowance under chapter 11 
of this title, or increased pension as a veteran of a period of 
war, by reason of being permanently housebound or in need of 
regular aid and attendance, such drugs and medicines as may be 
ordered on prescription of a duly licensed physician as 
specific therapy in the treatment of any illness or injury 
suffered by such veteran. The Secretary shall continue to 
furnish such drugs and medicines so ordered to any such veteran 
in need of regular aid and attendance whose pension payments 
have been discontinued solely because such veteran's annual 
income is greater than the applicable maximum annual income 
limitation, but only so long as such veteran's annual income 
does not exceed such maximum annual income limitation by more 
than $1,000.
  (e) In order to assist the Secretary of Health and Human 
Services in carrying out national immunization programs under 
other provisions of law, the Secretary may authorize the 
administration of immunizations to eligible veterans who 
voluntarily request such immunizations in connection with the 
provision of care for a disability under this chapter in any 
Department health care facility. Any such immunization shall be 
made using vaccine furnished by the Secretary of Health and 
Human Services at no cost to the Department. For such purpose, 
notwithstanding any other provision of law, the Secretary of 
Health and Human Services may provide such vaccine to the 
Department at no cost. Section 7316 of this title shall apply 
to claims alleging negligence or malpractice on the part of 
Department personnel granted immunity under such section.

Sec. 1712A. Eligibility for readjustment counseling and related mental 
                    health services

  (a)(1)(A) Upon the request of any individual referred to in 
subparagraph (C), the Secretary shall furnish counseling, 
including by furnishing counseling through a Vet Center, to the 
individual--
          (i) in the case of an individual referred to in 
        clauses (i) through (iv) of subparagraph (C), to assist 
        the individual in readjusting to civilian life; and
          (ii) in the case of an individual referred to in 
        clause (v) of such subparagraph who is a family member 
        of a veteran or member described in such clause--
                  (I) in the case of a member who is deployed 
                in a theater of combat operations or an area at 
                a time during which hostilities are occurring 
                in that area, during such deployment to assist 
                such individual in coping with such deployment; 
                and
                  (II) in the case of a veteran or member who 
                is readjusting to civilian life, to the degree 
                that counseling furnished to such individual is 
                found to aid in the readjustment of such 
                veteran or member to civilian life.
  (B) Counseling furnished to an individual under subparagraph 
(A) may include a comprehensive individual assessment of the 
individual's psychological, social, and other characteristics 
to ascertain whether--
          (i) in the case of an individual referred to in 
        clauses (i) through (iv) of subparagraph (C), such 
        individual has difficulties associated with readjusting 
        to civilian life; and
          (ii) in the case of an individual referred to in 
        clause (v) of such subparagraph, such individual has 
        difficulties associated with--
                  (I) coping with the deployment of a member 
                described in subclause (I) of such clause; or
                  (II) readjustment to civilian life of a 
                veteran or member described in subclause (II) 
                of such clause.
  (C) Subparagraph (A) applies to the following individuals:
          (i) Any individual who is a veteran or member of the 
        Armed Forces, including a member of a reserve component 
        of the Armed Forces, who served on active duty in a 
        theater of combat operations or an area at a time 
        during which hostilities occurred in that area.
          (ii) Any individual who is a veteran or member of the 
        Armed Forces, including a member of a reserve component 
        of the Armed Forces, who provided direct emergency 
        medical or mental health care, or mortuary services to 
        the causalities of combat operations or hostilities, 
        but who at the time was located outside the theater of 
        combat operations or area of hostilities.
          (iii) Any individual who is a veteran or member of 
        the Armed Forces, including a member of a reserve 
        component of the Armed Forces, who engaged in combat 
        with an enemy of the United States or against an 
        opposing military force in a theater of combat 
        operations or an area at a time during which 
        hostilities occurred in that area by remotely 
        controlling an unmanned aerial vehicle, notwithstanding 
        whether the physical location of such veteran or member 
        during such combat was within such theater of combat 
        operations or area.
          (iv) Any individual who received counseling under 
        this section before the date of the enactment of the 
        National Defense Authorization Act for Fiscal Year 
        2013.
          (v) Any individual who is a family member of any--
                  (I) member of the Armed Forces, including a 
                member of a reserve component of the Armed 
                Forces, who is serving on active duty in a 
                theater of combat operations or in an area at a 
                time during which hostilities are occurring in 
                that area; or
                  (II) veteran or member of the Armed Forces 
                described in this subparagraph.
  (2) Upon request of an individual described in paragraph 
(1)(C), the Secretary shall provide the individual a 
comprehensive individual assessment as described in paragraph 
(1)(B) as soon as practicable after receiving the request, but 
not later than 30 days after receiving the request.
  (b)(1) If, on the basis of the assessment furnished under 
subsection (a) of this section, a licensed or certified mental 
health care provider employed by the Department (or, in areas 
where no such licensed or certified mental health care provider 
is available, a licensed or certified mental health care 
provider carrying out such function under a contract or fee 
arrangement with the Secretary) determines that the provision 
of mental health services to such veteran is necessary to 
facilitate the successful readjustment of the veteran to 
civilian life, such veteran shall, within the limits of 
Department facilities, be furnished such services on an 
outpatient basis. For the purposes of furnishing such mental 
health services, the counseling furnished under subsection (a) 
of this section shall be considered to have been furnished by 
the Department as a part of hospital care. Any hospital care 
and other medical services considered necessary on the basis of 
the assessment furnished under subsection (a) of this section 
shall be furnished only in accordance with the eligibility 
criteria otherwise set forth in this chapter (including the 
eligibility criteria set forth in section 1784 of this title).
  (2) Mental health services furnished under paragraph (1) of 
this subsection may, if determined to be essential to the 
effective treatment and readjustment of the veteran, include 
such consultation, counseling, training, services, and expenses 
as are described in sections 1782 and 1783 of this title.
  (c) Upon receipt of a request for counseling under this 
section from any individual who has been discharged or released 
from active military, naval, or air service but who is not 
otherwise eligible for such counseling, the Secretary shall--
          (1) provide referral services to assist such 
        individual, to the maximum extent practicable, in 
        obtaining mental health care and services from sources 
        outside the Department; and
          (2) if pertinent, advise such individual of such 
        individual's rights to apply to the appropriate 
        military, naval, or air service, and to the Department, 
        for review of such individual's discharge or release 
        from such service.
  (d) The Under Secretary for Health may provide for such 
training of professional, paraprofessional, and lay personnel 
as is necessary to carry out this section effectively, and, in 
carrying out this section, may utilize the services of 
paraprofessionals, individuals who are volunteers working 
without compensation, and individuals who are veteran-students 
(as described in section 3485 of this title) in initial intake 
and screening activities.
  (e)(1) In furnishing counseling and related mental health 
services under subsections (a) and (b) of this section, the 
Secretary shall have available the same authority to enter into 
contracts with private facilities that is available to the 
Secretary [(under sections 1703(a)(2) and 1710(a)(1)(B) of this 
title)] (under the VA Care in the Community Program) in 
furnishing medical services to veterans suffering from total 
service-connected disabilities.
  (2) Before furnishing counseling or related mental health 
services described in subsections (a) and (b) of this section 
through a contract facility, as authorized by this subsection, 
the Secretary shall approve (in accordance with criteria which 
the Secretary shall prescribe by regulation) the quality and 
effectiveness of the program operated by such facility for the 
purpose for which the counseling or services are to be 
furnished.
  (3) The authority of the Secretary to enter into contracts 
under this subsection shall be effective for any fiscal year 
only to such extent or in such amounts as are provided in 
appropriation Acts.
  (f) The Secretary, in cooperation with the Secretary of 
Defense, shall take such action as the Secretary considers 
appropriate to notify veterans who may be eligible for 
assistance under this section of such potential eligibility.
  (g) In carrying out this section and in furtherance of the 
Secretary's responsibility to carry out outreach activities 
under chapter 63 of this title, the Secretary may provide for 
and facilitate the participation of personnel employed by the 
Secretary to provide services under this section in 
recreational programs that are--
          (1) designed to encourage the readjustment of 
        veterans described in subsection (a)(1)(C); and
          (2) operated by any organization named in or approved 
        under section 5902 of this title.
  (h) For the purposes of this section:
          (1) The term ``Vet Center'' means a facility which is 
        operated by the Department for the provision of 
        services under this section and which is situated apart 
        from Department general health care facilities.
          (2) The term ``Department general health-care 
        facility'' means a health-care facility which is 
        operated by the Department for the furnishing of 
        health-care services under this chapter, not limited to 
        services provided through the program established under 
        this section.
          (3) The term ``family member'', with respect to a 
        veteran or member of the Armed Forces, means an 
        individual who--
                  (A) is a member of the family of the veteran 
                or member, including--
                          (i) a parent;
                          (ii) a spouse;
                          (iii) a child;
                          (iv) a step-family member; and
                          (v) an extended family member; or
                  (B) lives with the veteran or member but is 
                not a member of the family of the veteran or 
                member.

           *       *       *       *       *       *       *


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

           *       *       *       *       *       *       *


Sec. 1725. Reimbursement for emergency treatment

  (a) General Authority.--(1) Subject to subsections (c) and 
(d), the Secretary shall reimburse a veteran described in 
subsection (b) for the reasonable value of emergency treatment 
furnished the veteran in a non-Department facility.
  (2) In any case in which reimbursement is authorized under 
subsection (a)(1), the Secretary, in the Secretary's 
discretion, may, in lieu of reimbursing the veteran, make 
payment of the reasonable value of the furnished emergency 
treatment directly--
          (A) to a hospital or other health care provider that 
        furnished the treatment; or
          (B) to the person or organization that paid for such 
        treatment on behalf of the veteran.
  (b) Eligibility.--(1) A veteran referred to in subsection 
(a)(1) is an individual who is an active Department health-care 
participant who is personally liable for emergency treatment 
furnished the veteran in a non-Department facility.
  (2) A veteran is an active Department health-care participant 
if--
          (A) the veteran is enrolled in the health care system 
        established under section 1705(a) of this title; and
          (B) the veteran received care under this chapter 
        within the 24-month period preceding the furnishing of 
        such emergency treatment.
  (3) A veteran is personally liable for emergency treatment 
furnished the veteran in a non-Department facility if the 
veteran--
          (A) is financially liable to the provider of 
        emergency treatment for that treatment;
          (B) 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 (f)(2)(B) 
        or (f)(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);
          (C) has no other contractual or legal recourse 
        against a third party that would, in whole, extinguish 
        such liability to the provider; and
          (D) is not eligible for reimbursement for medical 
        care or services under section 1728 of this title.
  (c) Limitations on Reimbursement.--(1) The Secretary, in 
accordance with regulations prescribed by the Secretary, 
shall--
          (A) establish the maximum amount payable under 
        subsection (a);
          (B) delineate the circumstances under which such 
        payments may be made, to include such requirements on 
        requesting reimbursement as the Secretary shall 
        establish; and
          (C) provide that in no event may a payment under that 
        subsection include any amount for which the veteran is 
        not personally liable.
  (2) Subject to paragraph (1), the Secretary may provide 
reimbursement under this section only after the veteran or the 
provider of emergency treatment has exhausted without success 
all claims and remedies reasonably available to the veteran or 
provider against a third party for payment of such treatment.
  (3) Payment by the Secretary under this section on behalf of 
a veteran to a provider of emergency treatment shall, unless 
rejected and refunded by the provider within 30 days of 
receipt, extinguish any liability on the part of the veteran 
for that treatment. Neither the absence of a contract or 
agreement between the Secretary and the provider nor any 
provision of a contract, agreement, or assignment to the 
contrary shall operate to modify, limit, or negate the 
requirement in the preceding sentence.
  (4)(A) If the veteran has contractual or legal recourse 
against a third party that would only, in part, extinguish the 
veteran's liability to the provider of the emergency treatment, 
and payment for the treatment may be made both under subsection 
(a) and by the third party, the amount payable for such 
treatment under such subsection shall be the amount by which 
the costs for the emergency treatment exceed the amount payable 
or paid by the third party, except that the amount payable may 
not exceed the maximum amount payable established under 
paragraph (1)(A).
  (B) In any case in which a third party is financially 
responsible for part of the veteran's emergency treatment 
expenses, the Secretary shall be the secondary payer.
  (C) A payment in the amount payable under subparagraph (A) 
shall be considered payment in full and shall extinguish the 
veteran's liability to the provider.
  (D) The Secretary may not reimburse a veteran under this 
section for any copayment or similar payment that the veteran 
owes the third party or for which the veteran is responsible 
under a health-plan contract.
  (5) In delineating the circumstances under which 
reimbursement may be made under this section for ambulance 
services for an individual, the Secretary shall treat such 
services as emergency services for which reimbursement may be 
made under this section if the Secretary determines that--
          (A) the request for ambulance services was made as a 
        result of the sudden onset of a medical condition of 
        such a nature that a prudent layperson who possesses an 
        average knowledge of health and medicine--
                  (i) would have reasonably expected that a 
                delay in seeking immediate medical attention 
                would have been hazardous to the life or health 
                of the individual; or
                  (ii) could reasonably expect the absence of 
                immediate medical attention to result in 
                placing the health of the individual in serious 
                jeopardy, the serious impairment of bodily 
                functions, or the serious dysfunction of any 
                bodily organ or part; and
          (B) the individual is transported to the most 
        appropriate medical facility capable of treating such 
        medical condition.
  (d) Independent Right of Recovery.--(1) In accordance with 
regulations prescribed by the Secretary, the United States 
shall have the independent right to recover any amount paid 
under this section when, and to the extent that, a third party 
subsequently makes a payment for the same emergency treatment.
  (2) Any amount paid by the United States to the veteran (or 
the veteran's personal representative, successor, dependents, 
or survivors) or to any other person or organization paying for 
such treatment shall constitute a lien in favor of the United 
States against any recovery the payee subsequently receives 
from a third party for the same treatment.
  (3) Any amount paid by the United States to the provider that 
furnished the veteran's emergency treatment shall constitute a 
lien against any subsequent amount the provider receives from a 
third party for the same emergency treatment for which the 
United States made payment.
  (4) The veteran (or the veteran's personal representative, 
successor, dependents, or survivors) shall ensure that the 
Secretary is promptly notified of any payment received from any 
third party for emergency treatment furnished to the veteran. 
The veteran (or the veteran's personal representative, 
successor, dependents, or survivors) shall immediately forward 
all documents relating to such payment, cooperate with the 
Secretary in the investigation of such payment, and assist the 
Secretary in enforcing the United States right to recover any 
payment made under subsection (c)(3).
  (e) Waiver.--The Secretary, in the Secretary's discretion, 
may waive recovery of a payment made to a veteran under this 
section that is otherwise required by subsection (d)(1) when 
the Secretary determines that such waiver would be in the best 
interest of the United States, as defined by regulations 
prescribed by the Secretary.
  (f) Definitions.--For purposes of 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.

           *       *       *       *       *       *       *


Sec. 1729. Recovery by the United States of the cost of certain care 
                    and services

  (a)(1) Subject to the provisions of this section, in any case 
in which a veteran is furnished care or services under this 
chapter for a non-service-connected disability described in 
paragraph (2) of this subsection, the United States has the 
right to recover or collect reasonable charges for such care or 
services (as determined by the Secretary) from a third party to 
the extent that the veteran (or the provider of the care or 
services) would be eligible to receive payment for such care or 
services from such third party if the care or services had not 
been furnished by a department or agency of the United States.
  (2) Paragraph (1) of this subsection applies to a non-
service-connected disability--
          (A) that is incurred incident to the veteran's 
        employment and that is covered under a workers' 
        compensation law or plan that provides for payment for 
        the cost of health care and services provided to the 
        veteran by reason of the disability;
          (B) that is incurred as the result of a motor vehicle 
        accident to which applies a State law that requires the 
        owners or operators of motor vehicles registered in 
        that State to have in force automobile accident 
        reparations insurance;
          (C) that is incurred as the result of a crime of 
        personal violence that occurred in a State, or a 
        political subdivision of a State, in which a person 
        injured as the result of such a crime is entitled to 
        receive health care and services at such State's or 
        subdivision's expense for personal injuries suffered as 
        the result of such crime;
          (D) that is incurred by a veteran--
                  (i) who does not have a service-connected 
                disability; and
                  (ii) who is entitled to care (or payment of 
                the expenses of care) under a health-plan 
                contract; or
          (E) for which care and services are furnished before 
        September 30, 2019, under this chapter to a veteran 
        who--
                  (i) has a service-connected disability; and
                  (ii) is entitled to care (or payment of the 
                expenses of care) under a health-plan contract.
  (3) In the case of a health-plan contract that contains a 
requirement for payment of a deductible or copayment by the 
veteran--
          (A) the veteran's not having paid such deductible or 
        copayment with respect to care or services furnished 
        under this chapter shall not preclude recovery or 
        collection under this section; and
          (B) the amount that the United States may collect or 
        recover under this section shall be reduced by the 
        appropriate deductible or copayment amount, or both.
  (4) Notwithstanding any other provision of law, any amount 
that the United States may collect or recover under this 
section shall not affect any copayment amount a veteran is 
otherwise obligated to pay under this chapter.
  (b)(1) As to the right provided in subsection (a) of this 
section, the United States shall be subrogated to any right or 
claim that the veteran (or the veteran's personal 
representative, successor, dependents, or survivors) may have 
against a third party.
  (2)(A) In order to enforce any right or claim to which the 
United States is subrogated under paragraph (1) of this 
subsection, the United States may intervene or join in any 
action or proceeding brought by the veteran (or the veteran's 
personal representative, successor, dependents, or survivors) 
against a third party.
  (B) The United States may institute and prosecute legal 
proceedings against the third party if--
          (i) an action or proceeding described in subparagraph 
        (A) of this paragraph is not begun within 180 days 
        after the first day on which care or services for which 
        recovery is sought are furnished to the veteran by the 
        Secretary under this chapter;
          (ii) the United States has sent written notice by 
        certified mail to the veteran at the veteran's last-
        known address (or to the veteran's personal 
        representative or successor) of the intention of the 
        United States to institute such legal proceedings; and
          (iii) a period of 60 days has passed following the 
        mailing of such notice.
  (C) A proceeding under subparagraph (B) of this paragraph may 
not be brought after the end of the six-year period beginning 
on the last day on which the care or services for which 
recovery is sought are furnished.
  (c)(1) The Secretary may compromise, settle, or waive any 
claim which the United States has under this section.
  (2)(A) The Secretary, after consultation with the Comptroller 
General of the United States, shall prescribe regulations for 
the purpose of determining reasonable charges for care or 
services under subsection (a)(1) of this section. Any 
determination of such charges shall be made in accordance with 
such regulations.
  (B) Such regulations shall provide that the reasonable 
charges for care or services sought to be recovered or 
collected from a third-party liable under a health-plan 
contract may not exceed the amount that such third party 
demonstrates to the satisfaction of the Secretary it would pay 
for the care or services if provided by facilities (other than 
facilities of departments or agencies of the United States) in 
the same geographic area.
  (C) Not later than 45 days after the date on which the 
Secretary prescribes such regulations (or any amendment to such 
regulations), the Comptroller General shall submit to the 
Committees on Veterans' Affairs of the Senate and the House of 
Representatives the Comptroller General's comments on and 
recommendations regarding such regulations (or amendment).
  (d) Any contract or agreement into which the Secretary enters 
with a person under section 3718 of title 31 for collection 
services to recover indebtedness owed the United States under 
this section shall provide, with respect to such services, that 
such person is subject to sections 5701 and 7332 of this title.
  (e) A veteran eligible for care or services under this 
chapter--
          (1) may not be denied such care or services by reason 
        of this section; and
          (2) may not be required by reason of this section to 
        make any copayment or deductible payment in order to 
        receive such care.
  (f) No law of any State or of any political subdivision of a 
State, and no provision of any contract or other agreement, 
shall operate to prevent recovery or collection by the United 
States under this section or with respect to care or services 
furnished under section 1784 of this title.
  (h)(1) Subject to paragraph (3) of this subsection, the 
Secretary shall make available medical records of a veteran 
described in paragraph (2) of this subsection for inspection 
and review by representatives of the third party concerned for 
the sole purposes of permitting the third party to verify--
          (A) that the care or services for which recovery or 
        collection is sought were furnished to the veteran; and
          (B) that the provision of such care or services to 
        the veteran meets criteria generally applicable under 
        the health-plan contract involved.
  (2) A veteran described in this paragraph is a veteran who is 
a beneficiary of a health-plan contract under which recovery or 
collection is sought under this section from the third party 
concerned for the cost of the care or services furnished to the 
veteran.
  (3) Records shall be made available under this subsection 
under such conditions to protect the confidentiality of such 
records as the Secretary shall prescribe in regulations.
  (i) For purposes of this section--
          (1)(A) The term ``health-plan contract'' means 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) Such term does not include--
                  (i) an insurance program described in section 
                1811 of the Social Security Act (42 U.S.C. 
                1395c) or established by section 1831 of such 
                Act (42 U.S.C. 1395j);
                  (ii) a State plan for medical assistance 
                approved under title XIX of such Act (42 U.S.C. 
                1396 et seq.);
                  (iii) a workers' compensation law or plan 
                described in subparagraph (A) of subsection 
                (a)(2) of this section; or
                  (iv) a program, plan, or policy under a law 
                described in subparagraph (B) or (C) of such 
                subsection.
          (2) The term ``payment'' includes reimbursement and 
        indemnification.
          (3) The term ``third party'' means--
                  (A) a State or political subdivision of a 
                State;
                  (B) an employer or an employer's insurance 
                carrier;
                  (C) an automobile accident reparations 
                insurance carrier; or
                  (D) a person obligated to provide, or to pay 
                the expenses of, health services under a 
                health-plan contract.

Sec. 1729A. Department of Veterans Affairs Medical Care Collections 
                    Fund

  (a) There is in the Treasury a fund to be known as the 
Department of Veterans Affairs Medical Care Collections Fund.
  (b) Amounts recovered or collected under any of the following 
provisions of law shall be deposited in the fund:
          (1) Section 1710(f) of this title.
          (2) Section 1710(g) of this title.
          (3) Section 1711 of this title.
          (4) Section 1722A of this title.
          (5) Section 1725 of this title.
          (6) Section 1729 of this title.
          (7) Section 1784 of this title.
          (8) Section 8165(a) of this title.
          (9) Section 113 of the Veterans Millennium Health 
        Care and Benefits Act (Public Law 106-117; 38 U.S.C. 
        8111 note).
          (10) Public Law 87-693, popularly known as the 
        ``Federal Medical Care Recovery Act'' (42 U.S.C. 2651 
        et seq.), to the extent that a recovery or collection 
        under that law is based on medical care or services 
        furnished under this chapter.
  (c)(1) Subject to the provisions of appropriations Acts, 
amounts in the fund shall be available, without fiscal year 
limitation, to the Secretary for the following purposes:
          (A) Furnishing medical care and services under this 
        chapter, to be available during any fiscal year for the 
        same purposes and subject to the same limitations 
        (other than with respect to the period of availability 
        for obligation) as apply to amounts appropriated from 
        the general fund of the Treasury for that fiscal year 
        for medical care.
          (B) Expenses of the Department for the 
        identification, billing, auditing, and collection 
        (including with respect to automatic data processing or 
        information technology improvements) of amounts owed 
        the United States by reason of medical care and 
        services furnished under this chapter.
  (2) Amounts available under paragraph (1) may not be used for 
any purpose other than a purpose set forth in subparagraph (A) 
or (B) of that paragraph.
  (d) Of the total amount recovered or collected by the 
Department during a fiscal year under the provisions of law 
referred to in subsection (b) and made available from the fund, 
the Secretary shall make available to each Department health 
care facility of the Department an amount that bears the same 
ratio to the total amount so made available as the amount 
recovered or collected by such facility during that fiscal year 
under such provisions of law bears to such total amount 
recovered or collected during that fiscal year. The Secretary 
shall make available to each facility the entirety of the 
amount specified to be made available to such facility by the 
preceding sentence.
  (e) Amounts recovered or collected under the provisions of 
law referred to in subsection (b) shall be treated for the 
purposes of sections 251 and 252 of the Balanced Budget and 
Emergency Deficit Control Act of 1985 (2 U.S.C. 901, 902) as 
offsets to discretionary appropriations (rather than as offsets 
to direct spending) to the extent that such amounts are made 
available for expenditure in appropriations Acts for the 
purposes specified in subsection (c).

           *       *       *       *       *       *       *


Sec. 1730B. Licensure of health care professionals providing treatment 
                    via telemedicine

  (a) In General.--Notwithstanding any provision of law 
regarding the licensure of health care professionals, a covered 
health care professional may practice the health care 
profession of the health care professional at any location in 
any State, regardless of where the covered health care 
professional or the patient is located, if the covered health 
care professional is using telemedicine to provide treatment to 
an individual under this chapter.
  (b) Property of Federal Government.--Subsection (a) shall 
apply to a covered health care professional providing treatment 
to a patient regardless of whether the covered health care 
professional or patient is located in a facility owned by the 
Federal Government during such treatment.
  (c) Construction.--Nothing in this section may be construed 
to remove, limit, or otherwise affect any obligation of a 
covered health care professional under the Controlled 
Substances Act (21 U.S.C. 801 et seq.).
  (d) Covered Health Care Professional Defined.--In this 
section, the term ``covered health care professional'' means a 
health care professional who--
          (1) is an employee of the Department appointed under 
        the authority under section 7306, 7401, 7405, 7406, or 
        7408 of this title, or title 5;
          (2) is authorized by the Secretary to provide health 
        care under this chapter;
          (3) is required to adhere to all quality standards 
        relating to the provision of telemedicine in accordance 
        with applicable policies of the Department; and
          (4) has an active, current, full, and unrestricted 
        license, registration, or certification in a State to 
        practice the health care profession of the health care 
        professional.

           *       *       *       *       *       *       *


SUBCHAPTER V--PAYMENTS TO STATE HOMES

           *       *       *       *       *       *       *


Sec. 1745. Nursing home care and medications for veterans with service-
                    connected disabilities

  (a)(1) The Secretary shall enter into [a contract (or 
agreement under section 1720(c)(1) of this title)] an agreement 
with each State home for payment by the Secretary for nursing 
home care provided in the home, in any case in which such care 
is provided to any veteran as follows:
          (A) Any veteran in need of such care for a service-
        connected disability.
          (B) Any veteran who--
                  (i) has a service-connected disability rated 
                at 70 percent or more; and
                  (ii) is in need of such care.
  (2) Payment under each [contract (or agreement)] agreement 
between the Secretary and a State home under paragraph (1) 
shall be based on a methodology, developed by the Secretary in 
consultation with the State home, to adequately reimburse the 
State home for the care provided by the State home under the 
[contract (or agreement)] agreement.
  (3) Payment by the Secretary under paragraph (1) to a State 
home for nursing home care provided to a veteran described in 
that paragraph constitutes payment in full to the State home 
for such care furnished to that veteran.
  (4)(A) An agreement under this section may be entered into 
without regard to any law that would require the Secretary to 
use competitive procedures in selecting the party with which to 
enter into the agreement.
  (B)(i) Except as provided in clause (ii) and unless otherwise 
provided in this section or in regulations prescribed pursuant 
to this section, a State home that enters into an agreement 
under this section is not subject to, in the carrying out of 
the agreement, any law to which providers of services and 
suppliers are not subject under the original Medicare fee-for-
service program under parts A and B of 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.).
  (ii) The exclusion under clause (i) does not apply to laws 
regarding integrity, ethics, fraud, or that subject a person to 
civil or criminal penalties.
  (C) Title VII of the Civil Rights Act of 1964 (42 U.S.C. 
2000e et seq.) shall apply with respect to a State home that 
enters into an agreement under this section to the same extent 
as such title applies with respect to the State home in 
providing care or services through an agreement or arrangement 
other than under this section.
  (b) The Secretary shall furnish such drugs and medicines as 
may be ordered on prescription of a duly licensed physician as 
specific therapy in the treatment of illness or injury to any 
veteran as follows:
          (1) Any veteran who--
                  (A) is not being provided nursing home care 
                for which payment is payable under subsection 
                (a); and
                  (B) is in need of such drugs and medicines 
                for a service-connected disability.
          (2) Any veteran who--
                  (A) has a service-connected disability rated 
                at 50 percent or more;
                  (B) is not being provided nursing home care 
                for which payment is payable under subsection 
                (a); and
                  (C) is in need of such drugs and medicines.
  (c) Any State home that requests payment or reimbursement for 
services provided to a veteran under this section shall provide 
to the Secretary such information as the Secretary considers 
necessary to identify each individual veteran eligible for 
payment under such section.

           *       *       *       *       *       *       *


CHAPTER 23--BURIAL BENEFITS

           *       *       *       *       *       *       *


Sec. 2303. Death in Department facility; plot allowance

  (a)(1) When a veteran dies in a facility described in 
paragraph (2), the Secretary shall--
          (A) pay the actual cost (not to exceed $700 (as 
        increased from time to time under subsection (c))) of 
        the burial and funeral or, within such limits, may make 
        contracts for such services without regard to the laws 
        requiring advertisement for proposals for supplies and 
        services for the Department; and
          (B) when such a death occurs in a State, transport 
        the body to the place of burial in the same or any 
        other State.
  (2) A facility described in this paragraph is--
          (A) a facility of the Department (as defined in 
        section 1 701(3) of this title) to which the deceased 
        was properly admitted for hospital, nursing home, or 
        domiciliary care under section 1710 or 1711(a) of this 
        title; or
          (B) an institution at which the deceased veteran was, 
        at the time of death, receiving--
                  (i) hospital care [in accordance with section 
                1703 of this title] under the VA Care in the 
                Community Program;
                  (ii) nursing home care under section 1720 of 
                this title; or
                  (iii) nursing home care for which payments 
                are made under section 1741 of this title.
  (b) In addition to the benefits provided for under section 
2302 of this title and subsection (a) of this section, in the 
case of a veteran who is eligible for burial in a national 
cemetery under section 2402 of this title and who is not buried 
in a national cemetery or other cemetery under the jurisdiction 
of the United States--
          (1) if such veteran is buried (without charge for the 
        cost of a plot or interment) in a cemetery, or a 
        section of a cemetery, that (A) is used solely for the 
        interment of persons who are (i) eligible for burial in 
        a national cemetery, and (ii) members of a reserve 
        component of the Armed Forces not otherwise eligible 
        for such burial or former members of such a reserve 
        component not otherwise eligible for such burial who 
        are discharged or released from service under 
        conditions other than dishonorable, and(B) is owned by 
        a State or by an agency or political subdivision of a 
        State, the Secretary shall pay to such State, agency, 
        or political subdivision the sum of $700 (as increased 
        from time to time under subsection (c)) as a plot or 
        interment allowance for such veteran; and
          (2) if such veteran is eligible for a burial 
        allowance under section 2302 of this title or under 
        subsection (a) of this section, or was discharged from 
        the active military, naval, or air service for a 
        disability incurred or aggravated in line of duty, and 
        such veteran is buried in a cemetery, or a section of a 
        cemetery, other than as described in clause (1) of this 
        subsection, the Secretary shall pay a sum not exceeding 
        $700 (as increased from time to time under subsection 
        (c)) as a plot or interment allowance to such person as 
        the Secretary prescribes, except that if any part of 
        the plot or interment costs of a burial to which this 
        clause applies has been paid or assumed by a State, an 
        agency or political subdivision of a State, or a former 
        employer of the deceased veteran, no claim for such 
        allowance shall be allowed for more than the difference 
        between the entire amount of the expenses incurred and 
        the amount paid or assumed by any or all of the 
        foregoing entities.
  (c) With respect to any fiscal year, the Secretary shall 
provide a percentage increase (rounded to the nearest dollar) 
in the maximum amount of burial and funeral expenses payable 
under subsection (a) and in the maximum amount of the plot or 
interment allowance payable under subsection (b), equal to the 
percentage by which--
          (1) the Consumer Price Index (all items, United 
        States city average) for the 12-month period ending on 
        the June 30 preceding the beginning of the fiscal year 
        for which the increase is made, exceeds
          (2) the Consumer Price Index for the 12-month period 
        preceding the 12-month period described in paragraph 
        (1).

           *       *       *       *       *       *       *


PART V--BOARDS, ADMINISTRATIONS, AND SERVICES

           *       *       *       *       *       *       *


CHAPTER 73--VETERANS HEALTH ADMINISTRATION - ORGANIZATION AND FUNCTIONS

           *       *       *       *       *       *       *


SUBCHAPTER III--PROTECTION OF PATIENT RIGHTS

           *       *       *       *       *       *       *


Sec. 7332. Confidentiality of certain medical records

  (a)(1) Records of the identity, diagnosis, prognosis, or 
treatment of any patient or subject which are maintained in 
connection with the performance of any program or activity 
(including education, training, treatment, rehabilitation, or 
research) relating to drug abuse, alcoholism or alcohol abuse, 
infection with the human immunodeficiency virus, or sickle cell 
anemia which is carried out by or for the Department under this 
title shall, except as provided in subsections (e) and (f), be 
confidential, and (section 5701 of this title to the contrary 
notwithstanding) such records may be disclosed only for the 
purposes and under the circumstances expressly authorized under 
subsection (b).
  (2) Paragraph (1) prohibits the disclosure to any person or 
entity other than the patient or subject concerned of the fact 
that a special written consent is required in order for such 
records to be disclosed.
  (b)(1) The content of any record referred to in subsection 
(a) may be disclosed by the Secretary in accordance with the 
prior written consent of the patient or subject with respect to 
whom such record is maintained, but only to such extent, under 
such circumstances, and for such purposes as may be allowed in 
regulations prescribed by the Secretary.
  (2) Whether or not any patient or subject, with respect to 
whom any given record referred to in subsection (a) is 
maintained, gives written consent, the content of such record 
may be disclosed by the Secretary as follows:
          (A) To medical personnel to the extent necessary to 
        meet a bona fide medical emergency.
          (B) To qualified personnel for the purpose of 
        conducting scientific research, management audits, 
        financial audits, or program evaluation, but such 
        personnel may not identify, directly or indirectly, any 
        individual patient or subject in any report of such 
        research, audit, or evaluation, or otherwise disclose 
        patient or subject identities in any manner.
          (C)(i) In the case of any record which is maintained 
        in connection with the performance of any program or 
        activity relating to infection with the human 
        immunodeficiency virus, to a Federal, State, or local 
        public-health authority charged under Federal or State 
        law with the protection of the public health, and to 
        which Federal or State law requires disclosure of such 
        record, if a qualified representative of such authority 
        has made a written request that such record be provided 
        as required pursuant to such law for a purpose 
        authorized by such law.
          (ii) A person to whom a record is disclosed under 
        this paragraph may not redisclose or use such record 
        for a purpose other than that for which the disclosure 
        was made.
          (D) If authorized by an appropriate order of a court 
        of competent jurisdiction granted after application 
        showing good cause therefor. In assessing good cause 
        the court shall weigh the public interest and the need 
        for disclosure against the injury to the patient or 
        subject, to the physician-patient relationship, and to 
        the treatment services. Upon the granting of such 
        order, the court, in determining the extent to which 
        any disclosure of all or any part of any record is 
        necessary, shall impose appropriate safeguards against 
        unauthorized disclosure.
          (E) To an entity described in paragraph (1)(B) of 
        section 5701(k) of this title, but only to the extent 
        authorized by such section.
          (F)(i) To a representative of a patient who lacks 
        decision-making capacity, when a practitioner deems the 
        content of the given record necessary for that 
        representative to make an informed decision regarding 
        the patient's treatment.
          (ii) In this subparagraph, the term 
        ``representative'' means an individual, organization, 
        or other body authorized under section 7331 of this 
        title and its implementing regulations to give informed 
        consent on behalf of a patient who lacks decision-
        making capacity.
          (G) To a State controlled substance monitoring 
        program, including a program approved by the Secretary 
        of Health and Human Services under section 399O of the 
        Public Health Service Act (42 U.S.C. 280g-3), to the 
        extent necessary to prevent misuse and diversion of 
        prescription medicines.
          (H)(i) To a non-Department entity (including private 
        entities and other Federal agencies) that provides 
        hospital care or medical services to veterans as 
        authorized by the Secretary.
          (ii) An entity to which a record is disclosed under 
        this subparagraph may not redisclose or use such record 
        for a purpose other than that for which the disclosure 
        was made.
          (I) To a public or private health care provider in 
        order to provide treatment or health care to a shared 
        patient.
          (J) To a third party in order to recover or collect 
        reasonable charges for care furnished to a veteran for 
        a non-service-connected disability pursuant to section 
        1729 of this title or section 1 of Public Law 87-693 
        (42 U.S.C. 2651).
  (3) In the event that the patient or subject who is the 
subject of any record referred to in subsection (a) is 
deceased, the content of any such record may be disclosed by 
the Secretary only upon the prior written request of the next 
of kin, executor, administrator, or other personal 
representative of such patient or subject and only if the 
Secretary determines that such disclosure is necessary for such 
survivor to obtain benefits to which such survivor may be 
entitled, including the pursuit of legal action, but then only 
to the extent, under such circumstances, and for such purposes 
as may be allowed in regulations prescribed pursuant to section 
7334 of this title.
  (4) Nothing in this section shall be construed to authorize 
any provision of records in violation of relevant health record 
privacy laws, including the Health Insurance Portability and 
Accountability Act of 1996 (Public Law 104-191).
  (c) Except as authorized by a court order granted under 
subsection (b)(2)(D), no record referred to in subsection (a) 
may be used to initiate or substantiate any criminal charges 
against, or to conduct any investigation of, a patient or 
subject.
  (d) The prohibitions of this section shall continue to apply 
to records concerning any person who has been a patient or 
subject, irrespective of whether or when such person ceases to 
be a patient.
  (e) The prohibitions of this section shall not prevent any 
interchange of records--
          (1) within and among those components of the 
        Department furnishing health care to veterans, or 
        determining eligibility for benefits under this title; 
        or
          (2) between such components furnishing health care to 
        veterans and the Armed Forces.
  (f)(1) Notwithstanding subsection (a) but subject to 
paragraph (2), a physician or a professional counselor may 
disclose information or records indicating that a patient or 
subject is infected with the human immunodeficiency virus if 
the disclosure is made to (A) the spouse of the patient or 
subject, or (B) to an individual whom the patient or subject 
has, during the process of professional counseling or of 
testing to determine whether the patient or subject is infected 
with such virus, identified as being a sexual partner of such 
patient or subject.
  (2)(A) A disclosure under paragraph (1) may be made only if 
the physician or counselor, after making reasonable efforts to 
counsel and encourage the patient or subject to provide the 
information to the spouse or sexual partner, reasonably 
believes that the patient or subject will not provide the 
information to the spouse or sexual partner and that the 
disclosure is necessary to protect the health of the spouse or 
sexual partner.
  (B) A disclosure under such paragraph may be made by a 
physician or counselor other than the physician or counselor 
referred to in subparagraph (A) if such physician or counselor 
is unavailable by reason of absence or termination of 
employment to make the disclosure.
  (g) Any person who violates any provision of this section or 
any regulation issued pursuant to this section shall be fined, 
in the case of a first offense, up to the maximum amount 
provided under section 5701(f) of this title for a first 
offense under that section and, in the case of a subsequent 
offense, up to the maximum amount provided under section 
5701(f) of this title for a subsequent offense under that 
section.

           *       *       *       *       *       *       *


         CHAPTER 74--VETERANS HEALTH ADMINISTRATION - PERSONNEL

                       SUBCHAPTER I--APPOINTMENTS

Sec.
     * * * * * * *
[7409. Contracts for scarce medical specialist services.]
     * * * * * * *

SUBCHAPTER I--APPOINTMENTS

           *       *       *       *       *       *       *


[Sec. 7409. Contracts for scarce medical specialist services

  [(a) The Secretary may enter into contracts with institutions 
and persons described in subsection (b) to provide scarce 
medical specialist services at Department facilities. Such 
services may include the services of physicians, dentists, 
podiatrists, optometrists, chiropractors, nurses, physician 
assistants, expanded-function dental auxiliaries, technicians, 
and other medical support personnel.
  [(b) Institutions and persons with whom the Secretary may 
enter into contracts under subsection (a) are the following:
          [(1) Schools and colleges of medicine, osteopathy, 
        dentistry, podiatry, optometry, and nursing.
          [(2) Clinics.
          [(3) Any other group or individual capable of 
        furnishing such scarce medical specialist services.]

           *       *       *       *       *       *       *


CHAPTER 76--HEALTH PROFESSIONALS EDUCATIONAL ASSISTANCE PROGRAM

           *       *       *       *       *       *       *


                         SUBCHAPTER I--GENERAL

Sec. 7601. Establishment of program; purpose

  (a) There is hereby established a program to be known as the 
Department of Veterans Affairs Health Professionals Educational 
Assistance Program (hereinafter in this chapter referred to as 
the ``Educational Assistance Program''). The program consists 
of--
          (1) the scholarship program provided for in 
        subchapter II of this chapter;
          (2) the tuition reimbursement program provided for in 
        subchapter III of this chapter;
          (3) the Selected Reserve member stipend program 
        provided for under subchapter V of this chapter;
          (4) the employee incentive scholarship program 
        provided for in subchapter VI of this chapter; [and]
          (5) the education debt reduction program provided for 
        in subchapter VII of this chapter[.]; and
          (6) the specialty education loan repayment program 
        provided for in subchapter VIII of this chapter.
  (b) The purpose of the Educational Assistance Program is to 
assist in providing an adequate supply of trained health-care 
personnel for the Department and the Nation.

           *       *       *       *       *       *       *


Sec. 7603. Application and acceptance

  (a)(1) To apply to participate in the Educational Assistance 
Program under subchapter II, III, V, [or VI] VI, or VIII of 
this chapter, an individual shall submit to the Secretary an 
application for such participation together with an agreement 
described in section 7604 of this title under which the 
participant agrees to serve a period of obligated service in 
the Veterans Health Administration as provided in the agreement 
in return for payment of educational assistance as provided in 
the agreement.
  (2) To apply to participate in the Educational Assistance 
Program under subchapter VII of this chapter, an individual 
shall submit to the Secretary an application for such 
participation.
  (b)(1) An individual becomes a participant in the Educational 
Assistance Program upon the Secretary's approval of the 
individual's application and the Secretary's acceptance of the 
agreement (if required).
  (2) Upon the Secretary's approval of an individual's 
participation in the program, the Secretary shall promptly 
notify the individual of that approval. Such notice shall be in 
writing.
  (c)(1) In distributing application forms and agreement forms 
to individuals desiring to participate in the Educational 
Assistance Program, the Secretary shall include with such forms 
the following:
          (A) A fair summary of the rights and liabilities of 
        an individual whose application is approved (and whose 
        agreement is accepted) by the Secretary, including a 
        clear explanation of the damages to which the United 
        States is entitled if the individual breaches the 
        agreement.
          (B) A full description of the terms and conditions 
        that apply to participation in the Educational 
        Assistance Program and service in the Veterans Health 
        Administration.
  (2) The Secretary shall make such application forms and other 
information available to individuals desiring to participate in 
the Educational Assistance Program on a date sufficiently early 
to allow such individuals adequate time to prepare and submit 
such forms.
  (d) In selecting applicants for acceptance in the Educational 
Assistance Program, the Secretary shall give priority to the 
applications of individuals who have previously received 
educational assistance under the program and have not completed 
the course of education or training undertaken under such 
program.

Sec. 7604. Terms of agreement

   An agreement between the Secretary and a participant in the 
Educational Assistance Program shall be in writing, shall be 
signed by the participant, and shall include the following 
provisions:
          (1) The Secretary's agreement--
                  (A) to provide the participant with 
                educational assistance as authorized in 
                subchapter II, III, V, [or VI] VI, or VIII of 
                this chapter and specified in the agreement; 
                and
                  (B) to afford the participant the opportunity 
                for employment in the Veterans Health 
                Administration (subject to the availability of 
                appropriated funds for such purpose and other 
                qualifications established in accordance with 
                section 7402 of this title).
          (2) The participant's agreement--
                  (A) to accept such educational assistance;
                  (B) to maintain enrollment and attendance in 
                the course of training until completed;
                  (C) while enrolled in such course, to 
                maintain an acceptable level of academic 
                standing (as determined by the educational 
                institution offering such course of training 
                under regulations prescribed by the Secretary); 
                and
                  (D) after completion of the course of 
                training, to serve as a full-time employee in 
                the Veterans Health Administration as specified 
                in the agreement in accordance with subchapter 
                II, III, V, [or VI] VI, or VIII of this 
                chapter.
          (3) A provision that any financial obligation of the 
        United States arising out of an agreement entered into 
        under this chapter, and any obligation of the 
        participant which is conditioned on such agreement, is 
        contingent upon funds being appropriated for 
        educational assistance under this chapter.
          (4) A statement of the damages to which the United 
        States is entitled under this chapter for the 
        participant's breach of the agreement.
          (5) Such other terms as are required to be included 
        in the agreement under subchapter II, III, V, [or VI] 
        VI, or VIII of this chapter or as the Secretary may 
        require consistent with the provisions of this chapter.

SUBCHAPTER II--SCHOLARSHIP PROGRAM

           *       *       *       *       *       *       *


Sec. 7612. Eligibility; application; agreement

  (a)(1) Except as provided in paragraph (2) of this 
subsection, an individual must be accepted for enrollment or be 
enrolled (as described in section 7602 of this title) as a 
full-time student to be eligible to participate in the 
Scholarship Program.
  (2) An individual who is an eligible Department employee may 
be accepted as a participant if accepted for enrollment or 
enrolled (as described in section 7602 of this title) for study 
on less than a full-time but not less than a half-time basis. 
(Such a participant is hereinafter in this subchapter referred 
to as a ``part-time student''.)
  (3) For the purposes of paragraph (2) of this subsection, an 
eligible Department employee is a full-time Department employee 
who is permanently assigned to a Department health-care 
facility on the date on which the individual submits the 
application referred to in section 7603 of this title and on 
the date on which the individual becomes a participant in the 
Scholarship Program.
  (b)(1) A scholarship may be awarded under this subchapter 
only in a qualifying field of education or training.
  (2) A qualifying field of education or training for purposes 
of this subchapter is education or training leading to 
employment as an appointee under paragraph (1) or (3) of 
section 7401 of this title.
  (3) The Secretary may designate additional fields of 
education or training as qualifying fields of education or 
training if the education or training leads to employment in a 
position which would qualify the individual for increased basic 
pay under subsection (a)(1) of section 7455 of this title for 
personnel described in subsection (a)(2)(B) of such section.
  (4) Before awarding the initial scholarship in a course of 
education or training other than medicine or nursing, the 
Secretary shall notify the Committees on Veterans' Affairs of 
the Senate and House of Representatives of the Secretary's 
intent to award a scholarship in such course of education or 
training. The notice shall include a statement of the reasons 
why the award of scholarships in that course of education or 
training is necessary to assist in providing the Department 
with an adequate supply of personnel in the health profession 
concerned. Any such notice shall be given not less than 60 days 
before the first such scholarship is awarded.
  (5) In selecting applicants for the Scholarship Program, the 
Secretary--
          (A) shall give priority to applicants who will be 
        entering their final year in a course of training;
          (B) shall give priority to applicants pursuing a 
        course of education or training toward a career in an 
        occupation for which the Inspector General of the 
        Department has, in the most current determination 
        published in the Federal Register pursuant to section 
        7412(a) of this title, determined that there is one of 
        the largest staffing shortages throughout the 
        Department with respect to such occupation; and
          (C) shall ensure an equitable allocation of 
        scholarships to persons enrolled in the second year of 
        a program leading to an associate degree in nursing.
  (6)(A) Of the scholarships awarded under this subchapter, the 
Secretary shall ensure that not less than 50 scholarships are 
awarded each year to individuals who are accepted for 
enrollment or enrolled (as described in section 7602 of this 
title) in a program of education or training leading to 
employment as a physician or dentist until such date as the 
Secretary determines that the staffing shortage of physicians 
and dentists in the Department is less than 500.
  (B) After such date, the Secretary shall ensure that of the 
scholarships awarded under this subchapter, a number of 
scholarships is awarded each year to individuals referred to in 
subparagraph (A) in an amount equal to not less than ten 
percent of the staffing shortage of physicians and dentists in 
the Department, as determined by the Secretary.
  (C) Notwithstanding subsection (c)(1), the agreement between 
the Secretary and a participant in the Scholarship Program who 
receives a scholarship pursuant to this paragraph shall provide 
the following:
          (i) The Secretary's agreement to provide the 
        participant with a scholarship under this subchapter 
        for a specified number (from two to four) of school 
        years during which the participant is pursuing a course 
        of education or training leading to employment as a 
        physician or dentist.
          (ii) The participant's agreement to serve as a full-
        time employee in the Veterans Health Administration for 
        a period of time (hereinafter in this subchapter 
        referred to as the ``period of obligated service'') of 
        18 months for each school year or part thereof for 
        which the participant was provided a scholarship under 
        the Scholarship Program.
  (D) In providing scholarships pursuant to this paragraph, the 
Secretary may provide a preference for applicants who are 
veterans.
  (E) On an annual basis, the Secretary shall provide to 
appropriate educational institutions informational material 
about the availability of scholarships under this paragraph.
  (c)(1) An agreement between the Secretary and a participant 
in the Scholarship Program shall (in addition to the 
requirements set forth in section 7604 of this title) include 
the following:
          (A) The Secretary's agreement to provide the 
        participant with a scholarship under this subchapter 
        for a specified number (from one to four) of school 
        years during which the participant is pursuing a course 
        of education or training described in section 7602 of 
        this title.
          (B) The participant's agreement to serve as a full-
        time employee in the Veterans Health Administration for 
        a period of time (hereinafter in this subchapter 
        referred to as the ``period of obligated service'') of 
        one calendar year for each school year or part thereof 
        for which the participant was provided a scholarship 
        under the Scholarship Program, but for not less than 
        two years.
  (2) In a case in which an extension is granted under section 
7614(3) of this title, the number of years for which a 
scholarship may be provided under this subchapter shall be the 
number of school years provided for as a result of the 
extension.
  (3) In the case of a participant who is a part-time student--
          (A) the period of obligated service shall be reduced 
        in accordance with the proportion that the number of 
        credit hours carried by such participant in any such 
        school year bears to the number of credit hours 
        required to be carried by a full-time student in the 
        course of training being pursued by the participant, 
        but in no event to less than one year; and
          (B) the agreement shall include the participant's 
        agreement to maintain employment, while enrolled in 
        such course of education or training, as a Department 
        employee permanently assigned to a Department health-
        care facility.
  (4) If a participant's period of obligated service is 
deferred under section 7616(b)(3)(A)(i) of this title, the 
agreement terms under paragraph (1) of this subsection shall 
provide for the participant to serve any additional period of 
obligated service that is prescribed by the Secretary under 
section 7616(b)(4)(B) of this title.

           *       *       *       *       *       *       *


Sec. 7617. Breach of agreement: liability

  (a) A participant in the Scholarship Program (other than a 
participant described in subsection (b) of this section) who 
fails to accept payment, or instructs the educational 
institution in which the participant is enrolled not to accept 
payment, in whole or in part, of a scholarship under the 
agreement entered into under section 7603 of this title shall 
be liable to the United States for liquidated damages in the 
amount of $1,500. Such liability is in addition to any period 
of obligated service or other obligation or liability under the 
agreement.
  (b) A participant in the Scholarship Program shall be liable 
to the United States for the amount which has been paid to or 
on behalf of the participant under the agreement if any of the 
following occurs:
          (1) The participant fails to maintain an acceptable 
        level of academic standing in the educational 
        institution in which the participant is enrolled (as 
        determined by the educational institution under 
        regulations prescribed by the Secretary).
          (2) The participant is dismissed from such 
        educational institution for disciplinary reasons.
          (3) The participant voluntarily terminates the course 
        of training in such educational institution before the 
        completion of such course of training.
          (4) In the case of a participant who is enrolled in a 
        program or education or training leading to employment 
        as a physician, the participant fails to successfully 
        complete post-graduate training leading to eligibility 
        for board certification in a specialty.
          [(4)] (5) The participant fails to become licensed to 
        practice medicine, osteopathy, dentistry, podiatry, or 
        optometry in a State, fails to become licensed as a 
        registered nurse in a State, or fails to meet any 
        applicable licensure requirement in the case of any 
        other health-care personnel who provide either direct 
        patient-care services or services incident to direct 
        patient-care services, during a period of time 
        determined under regulations prescribed by the 
        Secretary.
          [(5)] (6) In the case of a participant who is a part-
        time student, the participant fails to maintain 
        employment, while enrolled in the course of training 
        being pursued by such participant, as a Department 
        employee permanently assigned to a Department health-
        care facility.
Liability under this subsection is in lieu of any service 
obligation arising under the participant's agreement.
  (c)(1) If a participant in the Scholarship Program breaches 
the agreement by failing (for any reason) to complete such 
participant's period of obligated service, the United States 
shall be entitled to recover from the participant an amount 
determined in accordance with the following formula: 
A=3(t-s/t)
   In such formula:
          (A) ``A'' is the amount the United States is entitled 
        to recover.
          (B) ``'' is the sum of (i) the amounts paid 
        under this subchapter to or on behalf of the 
        participant, and (ii) the interest on such amounts 
        which would be payable if at the time the amounts were 
        paid they were loans bearing interest at the maximum 
        legal prevailing rate, as determined by the Treasurer 
        of the United States.
          (C) ``t'' is the total number of months in the 
        participant's period of obligated service, including 
        any additional period of obligated service in 
        accordance with section 7616(b)(4) of this title.
          (D) ``s'' is the number of months of such period 
        served by the participant in accordance with section 
        7613 of this title.
  (2) Any amount of damages which the United States is entitled 
to recover under this section shall be paid to the United 
States within the one-year period beginning on the date of the 
breach of the agreement.

           *       *       *       *       *       *       *


Sec. 7619. Expiration of program

  The Secretary may not furnish scholarships to new 
participants in the Scholarship Program after [December 31, 
2019] December 31, 2033.

           *       *       *       *       *       *       *


                 SUBCHAPTER IV--ADMINISTRATIVE MATTERS

Sec. 7631. Periodic adjustments in amount of assistance

  (a)(1) Whenever there is a general Federal pay increase, the 
Secretary shall increase the maximum monthly stipend amount, 
the maximum tuition reimbursement amount, the maximum Selected 
Reserve member stipend amount, the maximum employee incentive 
scholarship amount, [and] the maximum education debt reduction 
payments amount, and the maximum specialty education loan 
repayment amount. Any such increase shall take effect with 
respect to any school year that ends in the fiscal year in 
which the pay increase takes effect.
  (2) The amount of any increase under paragraph (1) of this 
subsection is the previous maximum amount under that paragraph 
multiplied by the overall percentage of the adjustment in the 
rates of pay under the General Schedule made under the general 
Federal pay increase. Such amount shall be rounded to the next 
lower multiple of $1.
  (b) For purposes of this section:
          (1) The term ``maximum monthly stipend amount'' means 
        the maximum monthly stipend that may be paid to a 
        participant in the Scholarship Program specified in 
        section 7613(b) of this title and as previously 
        adjusted (if at all) in accordance with this section.
          (2) The term ``maximum tuition reimbursement amount'' 
        means the maximum amount of tuition reimbursement 
        provided to a participant in the Tuition Reimbursement 
        Program specified in section 7622(e) of this title and 
        as previously adjusted (if at all) in accordance with 
        this section.
          (3) The term ``maximum Selected Reserve member 
        stipend amount'' means the maximum amount of assistance 
        provided to a person receiving assistance under 
        subchapter V of this chapter, as specified in section 
        7653 of this title and as previously adjusted (if at 
        all) in accordance with this section.
          (4) The term ``maximum employee incentive scholarship 
        amount'' means the maximum amount of the scholarship 
        payable to a participant in the Department of Veterans 
        Affairs Employee Incentive Scholarship Program under 
        subchapter VI of this chapter, as specified in section 
        7673(b)(1) of this title and as previously adjusted (if 
        at all) in accordance with this section.
          (5) The term ``maximum education debt reduction 
        payments amount'' means the maximum amount of education 
        debt reduction payments payable to a participant in the 
        Department of Veterans Affairs Education Debt Reduction 
        Program under subchapter VII of this chapter, as 
        specified in section 7683(d)(1) of this title and as 
        previously adjusted (if at all) in accordance with this 
        section.
          (6) The term ``general Federal pay increase'' means 
        an adjustment (if an increase) in the rates of pay 
        under the General Schedule under subchapter III of 
        chapter 53 of title 5.
          (7) The term ``specialty education loan repayment 
        amount'' means the maximum amount of specialty 
        education loan repayment payments payable to or for a 
        participant in the Department of Veterans Affairs 
        Specialty Education Loan Repayment Program under 
        subchapter VIII of this chapter, as specified in 
        section 7694(c)(1) of this title and as previously 
        adjusted (if at all) in accordance with this section.

Sec. 7632. Annual report

   Not later than March 1 of each year, the Secretary shall 
submit to Congress a report on the Educational Assistance 
Program. Each such report shall include the following 
information:
          (1) The number of students receiving educational 
        assistance under the Educational Assistance Program, 
        showing the numbers of students receiving assistance 
        under the Scholarship Program, the Tuition 
        Reimbursement Program, the Employee Incentive 
        Scholarship Program, [and the Education Debt Reduction 
        Program] the Education Debt Reduction Program, and the 
        Specialty Education Loan Repayment Program separately, 
        and the number of students (if any) enrolled in each 
        type of health profession training under each program.
          (2) The education institutions (if any) providing 
        such training to students in each program.
          (3) The number of applications filed under each 
        program, by health profession category, during the 
        school year beginning in such year and the total number 
        of such applications so filed for all years in which 
        the Educational Assistance Program (or predecessor 
        program) has been in existence.
          (4) The average amounts of educational assistance 
        provided per participant in the Scholarship Program, 
        per participant in the Tuition Reimbursement Program, 
        per participant in the Employee Incentive Scholarship 
        Program, [and per participant in the Education Debt 
        Reduction Program] per participant in the Education 
        Debt Reduction Program, and per participant in the 
        Specialty Education Loan Repayment Program.
          (5) The amount of tuition and other expenses paid, by 
        health profession category, in the aggregate and at 
        each educational institution for the school year 
        beginning in such year and for prior school years.
          (6) The number of scholarships accepted, by health 
        profession category, during the school year beginning 
        in such year and the number, by health profession 
        category, which were offered and not accepted.
          (7) The number of participants who complete a course 
        or course of training in each program each year and for 
        all years that such program (or predecessor program) 
        has been in existence.

           *       *       *       *       *       *       *


      SUBCHAPTER VIII--SPECIALTY EDUCATION LOAN REPAYMENT PROGRAM

Sec. 7691. Establishment

  As part of the Educational Assistance Program, the Secretary 
may carry out a student loan repayment program under section 
5379 of title 5. The program shall be known as the Department 
of Veterans Affairs Specialty Education Loan Repayment Program 
(in this chapter referred to as the ``Specialty Education Loan 
Repayment Program'').

Sec. 7692. Purpose

  The purpose of the Specialty Education Loan Repayment Program 
is to assist, through the establishment of an incentive program 
for certain individuals employed in the Veterans Health 
Administration, in meeting the staffing needs of the Veterans 
Health Administration for physicians in medical specialties for 
which the Secretary determines recruitment or retention of 
qualified personnel is difficult.

Sec. 7693. Eligibility; preference; covered costs

  (a) Eligibility.--An individual is eligible to participate in 
the Specialty Education Loan Repayment Program if the 
individual--
          (1) is hired under section 7401 of this title to work 
        in an occupation described in section 7692 of this 
        title;
          (2) owes any amount of principal or interest under a 
        loan, the proceeds of which were used by or on behalf 
        of that individual to pay costs relating to a course of 
        education or training which led to a degree that 
        qualified the individual for the position referred to 
        in paragraph (1); and
          (3) is--
                  (A) recently graduated from an accredited 
                medical or osteopathic school and matched to an 
                accredited residency program in a medical 
                specialty described in section 7692 of this 
                title; or
                  (B) a physician in training in a medical 
                specialty described in section 7692 of this 
                title with more than two years remaining in 
                such training.
  (b) Preference for Veterans.--In selecting individuals for 
participation in the Specialty Education Loan Repayment Program 
under this subchapter, the Secretary may give preference to 
veterans.
  (c) Covered Costs.--For purposes of subsection (a)(2), costs 
relating to a course of education or training include--
          (1) tuition expenses;
          (2) all other reasonable educational expenses, 
        including expenses for fees, books, equipment, and 
        laboratory expenses; and
          (3) reasonable living expenses.

Sec. 7694. Specialty education loan repayment

  (a) In General.--Payments under the Specialty Education Loan 
Repayment Program shall consist of payments for the principal 
and interest on loans described in section 7682(a)(2) of this 
title for individuals selected to participate in the Program to 
the holders of such loans.
  (b) Frequency of Payment.--The Secretary shall make payments 
for any given participant in the Specialty Education Loan 
Repayment Program on a schedule determined appropriate by the 
Secretary.
  (c) Maximum Amount; Waiver.--(1) The amount of payments made 
for a participant under the Specialty Education Loan Repayment 
Program may not exceed $160,000 over a total of four years of 
participation in the Program, of which not more than $40,000 of 
such payments may be made in each year of participation in the 
Program.
  (2)(A) The Secretary may waive the limitations under 
paragraph (1) in the case of a participant described in 
subparagraph (B). In the case of such a waiver, the total 
amount of payments payable to or for that participant is the 
total amount of the principal and the interest on the 
participant's loans referred to in subsection (a).
  (B) A participant described in this subparagraph is a 
participant in the Program who the Secretary determines serves 
in a position for which there is a shortage of qualified 
employees by reason of either the location or the requirements 
of the position.

Sec. 7695. Choice of location

  Each participant in the Specialty Education Loan Repayment 
Program who completes residency may select, from a list of 
medical facilities of the Veterans Health Administration 
provided by the Secretary, at which such facility the 
participant will work in a medical specialty described in 
section 7692 of this title.

Sec. 7696. Term of obligated service

  (a) In General.--In addition to any requirements under 
section 5379(c) of title 5, a participant in the Specialty 
Education Loan Repayment Program must agree, in writing and 
before the Secretary may make any payment to or for the 
participant, to--
          (1) obtain a license to practice medicine in a State;
          (2) successfully complete post-graduate training 
        leading to eligibility for board certification in a 
        specialty;
          (3) serve as a full-time clinical practice employee 
        of the Veterans Health Administration for 12 months for 
        every $40,000 in such benefits that the employee 
        receives, but in no case for fewer than 24 months; and
          (4) except as provided in subsection (b), to begin 
        such service as a full-time practice employee by not 
        later than 60 days after completing a residency.
  (b) Fellowship.--In the case of a participant who receives an 
accredited fellowship in a medical specialty other than a 
medical specialty described in section 7692 of this title, the 
Secretary, on written request of the participant, may delay the 
term of obligated service under subsection (a) for the 
participant until after the participant completes the 
fellowship, but in no case later than 60 days after completion 
of such fellowship.
  (c) Penalty.--(1) An employee who does not complete a period 
of obligated service under this section shall owe the Federal 
Government an amount determined in accordance with the 
following formula: A=B((T-S) T)).
  (2) In the formula in paragraph (1):
          (A) `` A'' is the amount the employee owes the 
        Federal Government.
          (B) `` B'' is the sum of all payments to or for the 
        participant under the Specialty Education Loan 
        Repayment Program.
          (C) `` T'' is the number of months in the period of 
        obligated service of the employee.
          (D) `` S'' is the number of whole months of such 
        period of obligated service served by the employee.

Sec. 7697. Relationship to Educational Assistance Program

  Assistance under the Specialty Education Loan Repayment 
Program may be in addition to other assistance available to 
individuals under the Educational Assistance Program.

           *       *       *       *       *       *       *

                              ----------                              


        VETERANS ACCESS, CHOICE, AND ACCOUNTABILITY ACT OF 2014



           *       *       *       *       *       *       *
TITLE I--IMPROVEMENT OF ACCESS TO CARE FROM NON-DEPARTMENT OF VETERANS 
                           AFFAIRS PROVIDERS

SEC. 101. EXPANDED AVAILABILITY OF HOSPITAL CARE AND MEDICAL SERVICES 
                    FOR VETERANS THROUGH THE USE OF AGREEMENTS WITH 
                    NON-DEPARTMENT OF VETERANS AFFAIRS ENTITIES.

  (a) Expansion of Available Care and Services.--
          (1) Furnishing of care.--
                  (A) In General.--Hospital care and medical 
                services under chapter 17 of title 38, United 
                States Code, shall be furnished to an eligible 
                veteran described in subsection (b), at the 
                election of such veteran, through agreements 
                authorized under subsection (d), or any other 
                law administered by the Secretary of Veterans 
                Affairs, with entities specified in 
                subparagraph (B) for the furnishing of such 
                care and services to veterans.
                  (B) Entities specified.--The entities 
                specified in this subparagraph are the 
                following:
                          (i) 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.), 
                        including any physician furnishing 
                        services under such program.
                          (ii) Any Federally-qualified health 
                        center (as defined in section 
                        1905(l)(2)(B) of the Social Security 
                        Act (42 U.S.C. 1396d(l)(2)(B))).
                          (iii) The Department of Defense.
                          (iv) The Indian Health Service.
                          (v) Subject to subsection (d)(5), a 
                        health care provider not otherwise 
                        covered under any of clauses (i) 
                        through (iv).
          (2) Choice of provider.--An eligible veteran who 
        makes an election under subsection (c) to receive 
        hospital care or medical services under this section 
        may select a provider of such care or services from 
        among the entities specified in paragraph (1)(B) that 
        are accessible to the veteran.
          (3) Coordination of care and services.--The Secretary 
        shall coordinate, through the Non-VA Care Coordination 
        Program of the Department of Veterans Affairs, the 
        furnishing of care and services under this section to 
        eligible veterans, including by ensuring that an 
        eligible veteran receives an appointment for such care 
        and services within the wait-time goals of the Veterans 
        Health Administration for the furnishing of hospital 
        care and medical services.
  (b) Eligible Veterans.--A veteran is an eligible veteran for 
purposes of this section if--
          (1) the veteran is enrolled in the patient enrollment 
        system of the Department of Veterans Affairs 
        established and operated under section 1705 of title 
        38, United States Code, including any such veteran who 
        has not received hospital care or medical services from 
        the Department and has contacted the Department seeking 
        an initial appointment from the Department for the 
        receipt of such care or services; and
          (2) the veteran--
                  (A) attempts, or has attempted, to schedule 
                an appointment for the receipt of hospital care 
                or medical services under chapter 17 of title 
                38, United States Code, but is unable to 
                schedule an appointment within--
                          (i) the wait-time goals of the 
                        Veterans Health Administration for the 
                        furnishing of such care or services; or
                          (ii) with respect to such care or 
                        services that are clinically necessary, 
                        the period determined necessary for 
                        such care or services if such period is 
                        shorter than such wait-time goals;
                  (B) resides more than 40 miles (as calculated 
                based on distance traveled) from--
                          (i) with respect to a veteran who is 
                        seeking primary care, a medical 
                        facility of the Department, including a 
                        community-based outpatient clinic, that 
                        is able to provide such primary care by 
                        a full-time primary care physician; or
                          (ii) with respect to a veteran not 
                        covered under clause (i), the medical 
                        facility of the Department, including a 
                        community-based outpatient clinic, that 
                        is closest to the residence of the 
                        veteran;
                  (C) resides--
                          (i) in a State without a medical 
                        facility of the Department that 
                        provides--
                                  (I) hospital care;
                                  (II) emergency medical 
                                services; and
                                  (III) 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 clause (i); or
                  (D)(i) resides in a location, other than a 
                location in Guam, American Samoa, or the 
                Republic of the Philippines, that is 40 miles 
                or less from a medical facility of the 
                Department, including a community-based 
                outpatient clinic; and
                          (ii)(I) is required to travel by air, 
                        boat, or ferry to reach each medical 
                        facility described in clause (i) that 
                        is 40 miles or less from the residence 
                        of the veteran; or
                                  (II) 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.
  (c) Election and Authorization.--
          (1) In general.--In the case of an eligible veteran 
        described in subsection (b)(2)(A), the Secretary shall, 
        at the election of the eligible veteran--
                  (A) provide the veteran an appointment that 
                exceeds the wait-time goals described in such 
                subsection or place such eligible veteran on an 
                electronic waiting list described in paragraph 
                (2) for an appointment for hospital care or 
                medical services the veteran has elected to 
                receive under this section; or
                  (B)(i) authorize that such care or services 
                be furnished to the eligible veteran under this 
                section for a period of time specified by the 
                Secretary; and
                          (ii) notify the eligible veteran by 
                        the most effective means available, 
                        including electronic communication or 
                        notification in writing, describing the 
                        care or services the eligible veteran 
                        is eligible to receive under this 
                        section.
          (2) Electronic waiting list.--The electronic waiting 
        list described in this paragraph shall be maintained by 
        the Department and allow access by each eligible 
        veteran via www.myhealth.va.gov or any successor 
        website (or other digital channel) for the following 
        purposes:
                  (A) To determine the place of such eligible 
                veteran on the waiting list.
                  (B) To determine the average length of time 
                an individual spends on the waiting list, 
                disaggregated by medical facility of the 
                Department and type of care or service needed, 
                for purposes of allowing such eligible veteran 
                to make an informed election under paragraph 
                (1).
  (d) Care and Services Through Agreements.--
          (1) Agreements.--
                  (A) In general.--The Secretary shall enter 
                into agreements for furnishing care and 
                services to eligible veterans under this 
                section with entities specified in subsection 
                (a)(1)(B). An agreement entered into pursuant 
                to this subparagraph may not be treated as a 
                Federal contract for the acquisition of goods 
                or services and is not subject to any provision 
                of law governing Federal contracts for the 
                acquisition of goods or services. Before 
                entering into an agreement pursuant to this 
                subparagraph, the Secretary shall, to the 
                maximum extent practicable and consistent with 
                the requirements of this section, furnish such 
                care and services to such veterans under this 
                section with such entities pursuant to sharing 
                agreements, existing contracts entered into by 
                the Secretary, or other processes available at 
                medical facilities of the Department.
                  (B) Agreement defined.--In this paragraph, 
                the term ``agreement'' includes contracts, 
                intergovernmental agreements, and provider 
                agreements, as appropriate.
          (2) Rates and reimbursement.--
                  (A) In general.--In entering into an 
                agreement under paragraph (1) with an entity 
                specified in subsection (a)(1)(B), the 
                Secretary shall--
                          (i) negotiate rates for the 
                        furnishing of care and services under 
                        this section; and
                          (ii) reimburse the entity for such 
                        care and services at the rates 
                        negotiated pursuant to clause (i) as 
                        provided in such agreement.
                  (B) Limit on rates.--
                          (i) In general.--Except as provided 
                        in clause (ii), rates negotiated under 
                        subparagraph (A)(i) 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.
                          (ii) Exception.--
                                  (I) In general.--The 
                                Secretary may negotiate a rate 
                                that is more than the rate paid 
                                by the United States as 
                                described in clause (i) with 
                                respect to the furnishing of 
                                care or services under this 
                                section to an eligible veteran 
                                who resides in a highly rural 
                                area.
                                  (II) Highly rural area 
                                defined.--In this clause, 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.
                                  (III) Other exceptions.--With 
                                respect to furnishing care or 
                                services under this section in 
                                Alaska, the Alaska Fee Schedule 
                                of the Department of Veterans 
                                Affairs will be followed, 
                                except for when another payment 
                                agreement, including a contract 
                                or provider agreement, is in 
                                place. With respect to care or 
                                services furnished under this 
                                section in a State with an All-
                                Payer Model Agreement under the 
                                Social Security Act that became 
                                effective on January 1, 2014, 
                                the Medicare payment rates 
                                under clause (i) shall be 
                                calculated based on the payment 
                                rates under such agreement.
                  (C) Limit on collection.--For the furnishing 
                of care or services pursuant to an agreement 
                under paragraph (1), an entity specified in 
                subsection (a)(1)(B) may not collect any amount 
                that is greater than the rate negotiated 
                pursuant to subparagraph (A)(i).
          (3) Certain procedures.--
                  (A) In general.--In entering into an 
                agreement under paragraph (1) with an entity 
                described in subparagraph (B), the Secretary 
                may use the procedures, including those 
                procedures relating to reimbursement, available 
                for entering into provider agreements under 
                section 1866(a) of the Social Security Act (42 
                U.S.C. 1395cc(a)) and participation agreements 
                under section 1842(h) of such Act (42 U.S.C. 
                1395u(h)). During the period in which such 
                entity furnishes care or services pursuant to 
                this section, such entity may not be treated as 
                a Federal contractor or subcontractor by the 
                Office of Federal Contract Compliance Programs 
                of the Department of Labor by virtue of 
                furnishing such care or services.
                  (B) Entities described.--The entities 
                described in this subparagraph are the 
                following:
                          (i) In the case of the Medicare 
                        program, any provider of services that 
                        has entered into a provider agreement 
                        under section 1866(a) of the Social 
                        Security Act (42 U.S.C. 1395cc(a)) and 
                        any physician or other supplier who has 
                        entered into a participation agreement 
                        under section 1842(h) of such Act (42 
                        U.S.C. 1395u(h)); and
                          (ii) In the case of the Medicaid 
                        program, any provider participating 
                        under a State plan under title XIX of 
                        such Act (42 U.S.C. 1396 et seq.).
          (4) Information on policies and procedures.--The 
        Secretary shall provide to any entity with which the 
        Secretary has entered into an agreement under paragraph 
        (1) the following:
                  (A) Information on applicable policies and 
                procedures for submitting bills or claims for 
                authorized care or services furnished to 
                eligible veterans under this section.
                  (B) Access to a telephone hotline maintained 
                by the Department that such entity may call for 
                information on the following:
                          (i) Procedures for furnishing care 
                        and services under this section.
                          (ii) Procedures for submitting bills 
                        or claims for authorized care and 
                        services furnished to eligible veterans 
                        under this section and being reimbursed 
                        for furnishing such care and services.
                          (iii) Whether particular care or 
                        services under this section are 
                        authorized, and the procedures for 
                        authorization of such care or services.
          (5) Agreements with other providers.--In accordance 
        with the rates determined pursuant to paragraph (2), 
        the Secretary may enter into agreements under paragraph 
        (1) for furnishing care and services to eligible 
        veterans under this section with an entity specified in 
        subsection (a)(1)(B)(v) if the entity meets criteria 
        established by the Secretary for purposes of this 
        section.
  (e) Responsibility for Costs of Certain Care.--
          (1) Submittal of information on health-care plans.--
        Before receiving hospital care or medical services 
        under this section, an eligible veteran shall provide 
        to the Secretary information on any health-care plan 
        described in paragraph (2) under which the eligible 
        veteran is covered.
          (2) Health-care plan.--A health-care plan described 
        in this paragraph--
                  (A) is an insurance policy or contract, 
                medical or hospital service agreement, 
                membership or subscription contract, or similar 
                arrangement not administered by the Secretary 
                of Veterans Affairs, under which health 
                services for individuals are provided or the 
                expenses of such services are paid; and
                  (B) does not include any such policy, 
                contract, agreement, or similar arrangement 
                pursuant to title XVIII or XIX of the Social 
                Security Act (42 U.S.C. 1395 et seq.) or 
                chapter 55 of title 10, United States Code.
          (3) Recovery of costs for certain care.--
                  (A) In general.--In any case in which an 
                eligible veteran is furnished hospital care or 
                medical services under this section for a non-
                service-connected disability described in 
                subsection (a)(2) of section 1729 of title 38, 
                United States Code, or for a condition for 
                which recovery is authorized or with respect to 
                which the United States is deemed to be a third 
                party beneficiary under Public Law 87-693, 
                commonly known as the ``Federal Medical Care 
                Recovery Act'' (42 U.S.C. 2651 et seq.), the 
                Secretary shall recover or collect from a third 
                party (as defined in subsection (i) of such 
                section 1729) reasonable charges for such care 
                or services to the extent that the veteran (or 
                the provider of the care or services) would be 
                eligible to receive payment for such care or 
                services from such third party if the care or 
                services had not been furnished by a department 
                or agency of the United States.
                  (B) Use of amounts.--Amounts collected by the 
                Secretary under subparagraph (A) shall be 
                deposited in the Medical Community Care account 
                of the Department. Amounts so deposited shall 
                remain available until expended.
  (f) Veterans Choice Card.--
          (1) In general.--For purposes of receiving care and 
        services under this section, the Secretary shall, not 
        later than 90 days after the date of the enactment of 
        this Act, issue to each veteran described in subsection 
        (b)(1) a card that may be presented to a health care 
        provider to facilitate the receipt of care or services 
        under this section.
          (2) Name of card.--Each card issued under paragraph 
        (1) shall be known as a ``Veterans Choice Card''.
          (3) Details of card.--Each Veterans Choice Card 
        issued to a veteran under paragraph (1) shall include 
        the following:
                  (A) The name of the veteran.
                  (B) An identification number for the veteran 
                that is not the social security number of the 
                veteran.
                  (C) The contact information of an appropriate 
                office of the Department for health care 
                providers to confirm that care or services 
                under this section are authorized for the 
                veteran.
                  (D) Contact information and other relevant 
                information for the submittal of claims or 
                bills for the furnishing of care or services 
                under this section.
                  (E) The following statement: ``This card is 
                for qualifying medical care outside the 
                Department of Veterans Affairs. Please call the 
                Department of Veterans Affairs phone number 
                specified on this card to ensure that treatment 
                has been authorized.''.
          (4) Information on use of card.--Upon issuing a 
        Veterans Choice Card to a veteran, the Secretary shall 
        provide the veteran with information clearly stating 
        the circumstances under which the veteran may be 
        eligible for care or services under this section.
  (g) Information on Availability of Care.--The Secretary shall 
provide information to a veteran about the availability of care 
and services under this section in the following circumstances:
          (1) When the veteran enrolls in the patient 
        enrollment system of the Department under section 1705 
        of title 38, United States Code.
          (2) When the veteran attempts to schedule an 
        appointment for the receipt of hospital care or medical 
        services from the Department but is unable to schedule 
        an appointment within the wait-time goals of the 
        Veterans Health Administration for the furnishing of 
        such care or services.
          (3) When the veteran becomes eligible for hospital 
        care or medical services under this section under 
        subparagraph (B), (C), or (D) of subsection (b)(2).
  (h) Follow-Up Care.--In carrying out this section, the 
Secretary shall ensure that, at the election of an eligible 
veteran who receives hospital care or medical services from a 
health care provider in an episode of care under this section, 
the veteran receives such hospital care and medical services 
from such health care provider through the completion of the 
episode of care, including all specialty and ancillary services 
deemed necessary as part of the treatment recommended in the 
course of such hospital care or medical services.
  (i) Providers.--To be eligible to furnish care or services 
under this section, a health care provider must--
          (1) maintain at least the same or similar credentials 
        and licenses as those credentials and licenses that are 
        required of health care providers of the Department, as 
        determined by the Secretary for purposes of this 
        section; and
          (2) submit, not less frequently than once each year 
        during the period in which the Secretary is authorized 
        to carry out this section pursuant to subsection (p), 
        verification of such licenses and credentials 
        maintained by such health care provider.
  (j) Cost-Sharing.--
          (1) In general.--The Secretary shall require an 
        eligible veteran to pay a copayment for the receipt of 
        care or services under this section only if such 
        eligible veteran would be required to pay a copayment 
        for the receipt of such care or services at a medical 
        facility of the Department or from a health care 
        provider of the Department pursuant to chapter 17 of 
        title 38, United States Code.
          (2) Limitation.--The amount of a copayment charged 
        under paragraph (1) may not exceed the amount of the 
        copayment that would be payable by such eligible 
        veteran for the receipt of such care or services at a 
        medical facility of the Department or from a health 
        care provider of the Department pursuant to chapter 17 
        of title 38, United States Code.
          (3) Collection of copayment.--A health care provider 
        that furnishes care or services to an eligible veteran 
        under this section shall collect the copayment required 
        under paragraph (1) from such eligible veteran at the 
        time of furnishing such care or services.
  (k) Claims processing system.--
          (1) In general.--The Secretary shall provide for an 
        efficient nationwide system for processing and paying 
        bills or claims for authorized care and services 
        furnished to eligible veterans under this section.
          (2) Regulations.--Not later than 90 days after the 
        date of the enactment of this Act, the Secretary of 
        Veterans Affairs shall prescribe regulations for the 
        implementation of such system.
          (3) Oversight.--The Chief Business Office of the 
        Veterans Health Administration shall oversee the 
        implementation and maintenance of such system.
          (4) Accuracy of payment.--
                  (A) In general.--The Secretary shall ensure 
                that such system meets such goals for accuracy 
                of payment as the Secretary shall specify for 
                purposes of this section.
                  (B) Quarterly report.--
                          (i) In general.--The Secretary shall 
                        submit to the Committee on Veterans' 
                        Affairs of the Senate and the Committee 
                        on Veterans' Affairs of the House of 
                        Representatives a quarterly report on 
                        the accuracy of such system.
                          (ii) Elements.--Each report required 
                        by clause (i) shall include the 
                        following:
                                  (I) A description of the 
                                goals for accuracy for such 
                                system specified by the 
                                Secretary under subparagraph 
                                (A).
                                  (II) An assessment of the 
                                success of the Department in 
                                meeting such goals during the 
                                quarter covered by the report.
                          (iii) Deadline.--The Secretary shall 
                        submit each report required by clause 
                        (i) not later than 20 days after the 
                        end of the quarter covered by the 
                        report.
  (l) Medical Records.--
          (1) In general.--The Secretary shall ensure that any 
        health care provider that furnishes care or services 
        under this section to an eligible veteran submits to 
        the Department a copy of any medical record related to 
        the care or services provided to such eligible veteran 
        by such health care provider for inclusion in the 
        electronic medical record of such eligible veteran 
        maintained by the Department upon the completion of the 
        provision of such care or services to such eligible 
        veteran.
          (2) Electronic format.--Any medical record submitted 
        to the Department under paragraph (1) shall, to the 
        extent possible, be in an electronic format.
  (m) Tracking of Missed Appointments.--The Secretary shall 
implement a mechanism to track any missed appointments for care 
or services under this section by eligible veterans to ensure 
that the Department does not pay for such care or services that 
were not furnished to an eligible veteran.
  (n) Implementation.--Not later than 90 days after the date of 
the enactment of this Act, the Secretary shall prescribe 
interim final regulations on the implementation of this section 
and publish such regulations in the Federal Register.
  (o) Inspector General Report.--Not later than 30 days after 
the date on which the Secretary determines that 75 percent of 
the amounts deposited in the Veterans Choice Fund established 
by section 802 have been exhausted, the Inspector General of 
the Department shall submit to the Secretary a report on the 
results of an audit of the care and services furnished under 
this section to ensure the accuracy and timeliness of payments 
by the Department for the cost of such care and services, 
including any findings and recommendations of the Inspector 
General.
  (p) Authority To Furnish Care and Services.--
          (1) In general.--The Secretary may not use the 
        authority under this section to furnish care and 
        services after the date specified in paragraph (2) or 
        the date on which the Secretary certifies to the 
        Committees on Veterans' Affairs of the House of 
        Representatives and the Senate that the Secretary is 
        fully implementing section 1703A of title 38, United 
        States Code, whichever occurs first.
          (2) Date specified.--The date specified in this 
        paragraph is the date on which the Secretary has 
        exhausted all amounts deposited in the Veterans Choice 
        Fund established by section 802.
          (3) Publication.--The Secretary shall publish such 
        date in the Federal Register and on an Internet website 
        of the Department available to the public not later 
        than 30 days before such date.
  (q) Reports.--
          (1) Initial report.--Not later than 90 days after the 
        publication of the interim final regulations under 
        subsection (n), the Secretary shall submit to the 
        Committee on Veterans' Affairs of the Senate and the 
        Committee on Veterans' Affairs of the House of 
        Representatives a report on the furnishing of care and 
        services under this section that includes the 
        following:
                  (A) The number of eligible veterans who have 
                received care or services under this section.
                  (B) A description of the types of care and 
                services furnished to eligible veterans under 
                this section.
          (2) Final report.--Not later than 30 days after the 
        date on which the Secretary determines that 75 percent 
        of the amounts deposited in the Veterans Choice Fund 
        established by section 802 have been exhausted, the 
        Secretary shall submit to the Committee on Veterans' 
        Affairs of the Senate and the Committee on Veterans' 
        Affairs of the House of Representatives a report on the 
        furnishing of care and services under this section that 
        includes the following:
                  (A) The total number of eligible veterans who 
                have received care or services under this 
                section, disaggregated by--
                          (i) eligible veterans described in 
                        subsection (b)(2)(A);
                          (ii) eligible veterans described in 
                        subsection (b)(2)(B);
                          (iii) eligible veterans described in 
                        subsection (b)(2)(C); and
                          (iv) eligible veterans described in 
                        subsection (b)(2)(D).
                  (B) A description of the types of care and 
                services furnished to eligible veterans under 
                this section.
                  (C) An accounting of the total cost of 
                furnishing care and services to eligible 
                veterans under this section.
                  (D) The results of a survey of eligible 
                veterans who have received care or services 
                under this section on the satisfaction of such 
                eligible veterans with the care or services 
                received by such eligible veterans under this 
                section.
                  (E) An assessment of the effect of furnishing 
                care and services under this section on wait 
                times for appointments for the receipt of 
                hospital care and medical services from the 
                Department.
                  (F) An assessment of the feasibility and 
                advisability of continuing furnishing care and 
                services under this section after the 
                termination date specified in subsection (p).
  (r) Rule of Construction.--Nothing in this section shall be 
construed to alter the process of the Department for filling 
and paying for prescription medications.
  (s) Wait-Time Goals of the Veterans Health Administration.--
          (1) In general.--Except as provided in paragraph (2), 
        in this section, the term ``wait-time goals of the 
        Veterans Health Administration'' means not more than 30 
        days from the date on which a veteran requests an 
        appointment for hospital care or medical services from 
        the Department.
          (2) Alternate goals.--If the Secretary submits to 
        Congress, not later than 60 days after the date of the 
        enactment of this Act, a report stating that the actual 
        wait-time goals of the Veterans Health Administration 
        are different from the wait-time goals specified in 
        paragraph (1)--
                  (A) for purposes of this section, the wait-
                time goals of the Veterans Health 
                Administration shall be the wait-time goals 
                submitted by the Secretary under this 
                paragraph; and
                  (B) the Secretary shall publish such wait-
                time goals in the Federal Register and on an 
                Internet website of the Department available to 
                the public.
  (t) Waiver of Certain Printing Requirements.--Section 501 of 
title 44, United States Code, shall not apply in carrying out 
this section.

           *       *       *       *       *       *       *


TITLE II--HEALTH CARE ADMINISTRATIVE MATTERS

           *       *       *       *       *       *       *


SEC. 208. INFORMATION IN ANNUAL BUDGET OF THE PRESIDENT ON HOSPITAL 
                    CARE AND MEDICAL SERVICES FURNISHED THROUGH 
                    EXPANDED USE OF CONTRACTS FOR SUCH CARE.

  The materials on the Department of Veterans Affairs in the 
budget of the President for a fiscal year, as submitted to 
Congress pursuant to section 1105(a) of title 31, United States 
Code, shall set forth the following:
          (1) The number of veterans who received hospital care 
        and medical services under [section 101] section 1703A 
        of title 38, United States Code during the fiscal year 
        preceding the fiscal year in which such budget is 
        submitted.
          (2) The amount expended by the Department on 
        furnishing care and services under such section during 
        the fiscal year preceding the fiscal year in which such 
        budget is submitted.
          (3) The amount requested in such budget for the costs 
        of furnishing care and services under such section 
        during the fiscal year covered by such budget, set 
        forth in aggregate and by amounts for each account for 
        which amounts are so requested.
          (4) The number of veterans that the Department 
        estimates will receive hospital care and medical 
        services under such section during the fiscal years 
        covered by the budget submission.
          (5) The number of employees of the Department on paid 
        administrative leave at any point during the fiscal 
        year preceding the fiscal year in which such budget is 
        submitted.

           *       *       *       *       *       *       *


TITLE VIII--OTHER MATTERS

           *       *       *       *       *       *       *


[SEC. 802. VETERANS CHOICE FUND.

  [(a) In general.--There is established in the Treasury of the 
United States a fund to be known as the Veterans Choice Fund.
  [(b) Administration of Fund.--The Secretary of Veterans 
Affairs shall administer the Veterans Choice Fund established 
by subsection (a).
  [(c) Use of Amounts.--
          [(1) In general.--Except as provided by paragraph 
        (3), any amounts deposited in the Veteran Choice Fund 
        shall be used by the Secretary of Veterans Affairs to 
        carry out section 101, including, subject to paragraph 
        (2), any administrative requirements of such section.
          [(2) Amount for administrative requirements.--
                  [(A) Limitation.--Except as provided by 
                subparagraph (B), of the amounts deposited in 
                the Veterans Choice Fund, not more than 
                $300,000,000 may be used for administrative 
                requirements to carry out section 101.
                  [(B) Increase.--The Secretary may increase 
                the amount set forth in subparagraph (A) with 
                respect to the amounts used for administrative 
                requirements if--
                          [(i) the Secretary determines that 
                        the amount of such increase is 
                        necessary to carry out section 101;
                          [(ii) the Secretary submits to the 
                        Committees on Veterans' Affairs and 
                        Appropriations of the House of 
                        Representatives and the Committees on 
                        Veterans' Affairs and Appropriations of 
                        the Senate a report described in 
                        subparagraph (C); and
                          [(iii) a period of 60 days has 
                        elapsed following the date on which the 
                        Secretary submits the report under 
                        clause (ii).
                  [(C) Report.--A report described in this 
                subparagraph is a report that contains the 
                following:
                          [(i) A notification of the amount of 
                        the increase that the Secretary 
                        determines necessary under subparagraph 
                        (B)(i).
                          [(ii) The justifications for such 
                        increased amount.
                          [(iii) The administrative 
                        requirements that the Secretary will 
                        carry out using such increased amount.
          [(3) Temporary authority for other uses.--
                  [(A) Other non-department care.--In addition 
                to the use of amounts described in paragraph 
                (1), of the amounts deposited in the Veterans 
                Choice Fund, not more than $3,348,500,000 may 
                be used by the Secretary during the period 
                described in subparagraph (C) for amounts 
                obligated by the Secretary on or after May 1, 
                2015, to furnish health care to individuals 
                pursuant to chapter 17 of title 38, United 
                States Code, at non-Department facilities, 
                including pursuant to non-Department provider 
                programs other than the program established by 
                section 101.
                  [(B) Hepatitis c.--Of the amount specified in 
                subparagraph (A), not more than $500,000,000 
                may be used by the Secretary during the period 
                described in subparagraph (C) for 
                pharmaceutical expenses relating to the 
                treatment of Hepatitis C.
                  [(C) Period described.--The period described 
                in this subparagraph is the period beginning on 
                the date of the enactment of the VA Budget and 
                Choice Improvement Act and ending on October 1, 
                2015.
                  [(D) Reports.--Not later than 14 days after 
                the date of the enactment of the VA Budget and 
                Choice Improvement Act, and not less frequently 
                than once every 14-day period thereafter during 
                the period described in subparagraph (C), the 
                Secretary shall submit to the appropriate 
                congressional committees a report detailing--
                          [(i) the amounts used by the 
                        Secretary pursuant to subparagraphs (A) 
                        and (B); and
                          [(ii) an identification of such 
                        amounts listed by the non-Department 
                        provider program for which the amounts 
                        were used.
                  [(E) Definitions.--In this paragraph:
                          [(i) The term ``appropriate 
                        congressional committees'' means--
                                  [(I) the Committee on 
                                Veterans' Affairs and the 
                                Committee on Appropriations of 
                                the House of Representatives; 
                                and
                                  [(II) the Committee on 
                                Veterans' Affairs and the 
                                Committee on Appropriations of 
                                the Senate.
                          [(ii) The term ``non-Department 
                        facilities'' has the meaning given that 
                        term in section 1701 of title 38, 
                        United States Code.
                          [(iii) The term ``non-Department 
                        provider program'' has the meaning 
                        given that term in section 4002(d) of 
                        the VA Budget and Choice Improvement 
                        Act.
  [(d) Appropriation and Deposit of Amounts.--
          [(1) In general.--There is authorized to be 
        appropriated, and is appropriated, to the Secretary of 
        Veterans Affairs, out of any funds in the Treasury not 
        otherwise appropriated $10,000,000,000 to be deposited 
        in the Veterans Choice Fund established by subsection 
        (a). Such funds shall be available for obligation or 
        expenditure without fiscal year limitation, and only 
        for the program created under section 101(or for 
        hospital care and medical services pursuant to 
        subsection (c)(3) of this section).
          [(2) Availability.--The amount appropriated under 
        paragraph (1) shall remain available until expended.
  [(e) Sense of Congress.--It is the sense of Congress that the 
Veterans Choice Fund is a supplement to but distinct from the 
Department of Veterans Affairs' current and expected level of 
non-Department care currently part of Department's medical care 
budget. Congress expects that the Department will maintain at 
least its existing obligations of non-Department care programs 
in addition to but distinct from the Veterans Choice Fund for 
each of fiscal years 2015 through 2017.]

           *       *       *       *       *       *       *

                              ----------                              


SURFACE TRANSPORTATION AND VETERANS HEALTH CARE CHOICE IMPROVEMENT ACT 
                                OF 2015



           *       *       *       *       *       *       *
TITLE IV--VETERANS PROVISIONS

           *       *       *       *       *       *       *


SEC. 4003. FUNDING ACCOUNT FOR NON-DEPARTMENT CARE.

  Each budget of the President submitted to Congress under 
section 1105 of title 31, United States Code, for fiscal year 
2017 and each fiscal year thereafter shall include an 
appropriations account [for non-Department provider programs 
(as defined in section 2(d)) to be comprised of--]
          [(1) discretionary medical services funding that is 
        designated for hospital care and medical services 
        furnished at non-Department facilities; and]
          [(2) any funds transferred for such purpose from the 
        Veterans Choice Fund established by section 802 of the 
        Veterans Access, Choice, and Accountability Act of 2014 
        (Public Law 113-146; 128 Stat. 1802)] for the VA Care 
        in the Community Program (as defined in section 
        1701(12) of title 38, United States Code) and Veterans 
        Care Agreements under section 1703B of title 38, United 
        States Code.

           *       *       *       *       *       *       *

                              ----------                              


                          SOCIAL SECURITY ACT

TITLE XVIII--HEALTH INSURANCE FOR THE AGED AND DISABLED

           *       *       *       *       *       *       *


Part E--Miscellaneous Provisions

           *       *       *       *       *       *       *


      agreements with providers of services; enrollment processes

  Sec. 1866. (a)(1) Any provider of services (except a fund 
designated for purposes of section 1814(g) and section 1835(e)) 
shall be qualified to participate under this title and shall be 
eligible for payments under this title if it files with the 
Secretary an agreement--
          (A)(i) not to charge, except as provided in paragraph 
        (2), any individual or any other person for items or 
        services for which such individual is entitled to have 
        payment made under this title (or for which he would be 
        so entitled if such provider of services had complied 
        with the procedural and other requirements under or 
        pursuant to this title or for which such provider is 
        paid pursuant to the provisions of section 1814(e)), 
        and (ii) not to impose any charge that is prohibited 
        under section 1902(n)(3),
          (B) not to charge any individual or any other person 
        for items or services for which such individual is not 
        entitled to have payment made under this title because 
        payment for expenses incurred for such items or 
        services may not be made by reason of the provisions of 
        paragraph (1) or (9) of section 1862(a), but only if 
        (i) such individual was without fault in incurring such 
        expenses and (ii) the Secretary's determination that 
        such payment may not be made for such items and 
        services was made after the third year following the 
        year in which notice of such payment was sent to such 
        individual; except that the Secretary may reduce such 
        three-year period to not less than one year if he finds 
        such reduction is consistent with the objectives of 
        this title,
          (C) to make adequate provision for return (or other 
        disposition, in accordance with regulations) of any 
        moneys incorrectly collected from such individual or 
        other person,
          (D) to promptly notify the Secretary of its 
        employment of an individual who, at any time during the 
        year preceding such employment, was employed in a 
        managerial, accounting, auditing, or similar capacity 
        (as determined by the Secretary by regulation) by an 
        agency or organization which serves as a fiscal 
        intermediary or carrier (for purposes of part A or part 
        B, or both, of this title) with respect to the 
        provider,
          (E) to release data with respect to patients of such 
        provider upon request to an organization having a 
        contract with the Secretary under part B of title XI as 
        may be necessary (i) to allow such organization to 
        carry out its functions under such contract, or (ii) to 
        allow such organization to carry out similar review 
        functions under any contract the organization may have 
        with a private or public agency paying for health care 
        in the same area with respect to patients who authorize 
        release of such data for such purposes,
          (F)(i) in the case of hospitals which provide 
        inpatient hospital services for which payment may be 
        made under subsection (b), (c), or (d) of section 1886, 
        to maintain an agreement with a professional standards 
        review organization (if there is such an organization 
        in existence in the area in which the hospital is 
        located) or with a quality improvement organization 
        which has a contract with the Secretary under part B of 
        title XI for the area in which the hospital is located, 
        under which the organization will perform functions 
        under that part with respect to the review of the 
        validity of diagnostic information provided by such 
        hospital, the completeness, adequacy, and quality of 
        care provided, the appropriateness of admissions and 
        discharges, and the appropriateness of care provided 
        for which additional payments are sought under section 
        1886(d)(5), with respect to inpatient hospital services 
        for which payment may be made under part A of this 
        title (and for purposes of payment under this title, 
        the cost of such agreement to the hospital shall be 
        considered a cost incurred by such hospital in 
        providing inpatient services under part A, and (I) 
        shall be paid directly by the Secretary to such 
        organization on behalf of such hospital in accordance 
        with a rate per review established by the Secretary, 
        (II) shall be transferred from the Federal Hospital 
        Insurance Trust Fund, without regard to amounts 
        appropriated in advance in appropriation Acts, in the 
        same manner as transfers are made for payment for 
        services provided directly to beneficiaries, and (III) 
        shall not be less in the aggregate for a fiscal year 
        than the aggregate amount expended in fiscal year 1988 
        for direct and administrative costs (adjusted for 
        inflation and for any direct or administrative costs 
        incurred as a result of review functions added with 
        respect to a subsequent fiscal year) of such reviews),
          (ii) in the case of hospitals, critical access 
        hospitals, skilled nursing facilities, and home health 
        agencies, to maintain an agreement with a quality 
        improvement organization (which has a contract with the 
        Secretary under part B of title XI for the area in 
        which the hospital, facility, or agency is located) to 
        perform the functions described in paragraph (3)(A),
          (G) in the case of hospitals which provide inpatient 
        hospital services for which payment may be made under 
        subsection (b) or (d) of section 1886, not to charge 
        any individual or any other person for inpatient 
        hospital services for which such individual would be 
        entitled to have payment made under part A but for a 
        denial or reduction of payments under section 
        1886(f)(2),
          (H)(i) in the case of hospitals which provide 
        services for which payment may be made under this title 
        and in the case of critical access hospitals which 
        provide critical access hospital services, to have all 
        items and services (other than physicians' services as 
        defined in regulations for purposes of section 
        1862(a)(14), and other than services described by 
        section 1861(s)(2)(K), certified nurse-midwife 
        services, qualified psychologist services, and services 
        of a certified registered nurse anesthetist) (I) that 
        are furnished to an individual who is a patient of the 
        hospital, and (II) for which the individual is entitled 
        to have payment made under this title, furnished by the 
        hospital or otherwise under arrangements (as defined in 
        section 1861(w)(1)) made by the hospital,
          (ii) in the case of skilled nursing facilities which 
        provide covered skilled nursing facility services--
                  (I) that are furnished to an individual who 
                is a resident of the skilled nursing facility 
                during a period in which the resident is 
                provided covered post-hospital extended care 
                services (or, for services described in section 
                1861(s)(2)(D), that are furnished to such an 
                individual without regard to such period), and
                  (II) for which the individual is entitled to 
                have payment made under this title,
        to have items and services (other than services 
        described in section 1888(e)(2)(A)(ii)) furnished by 
        the skilled nursing facility or otherwise under 
        arrangements (as defined in section 1861(w)(1)) made by 
        the skilled nursing facility,
          (I) in the case of a hospital or critical access 
        hospital--
                  (i) to adopt and enforce a policy to ensure 
                compliance with the requirements of section 
                1867 and to meet the requirements of such 
                section,
                  (ii) to maintain medical and other records 
                related to individuals transferred to or from 
                the hospital for a period of five years from 
                the date of the transfer, and
                  (iii) to maintain a list of physicians who 
                are on call for duty after the initial 
                examination to provide treatment necessary to 
                stabilize an individual with an emergency 
                medical condition,
          (J) in the case of hospitals which provide inpatient 
        hospital services for which payment may be made under 
        this title, to be a participating provider of medical 
        care under any health plan contracted for under section 
        1079 or 1086 of title 10, or under section 613 of title 
        38, United States Code, in accordance with admission 
        practices, payment methodology, and amounts as 
        prescribed under joint regulations issued by the 
        Secretary and by the Secretaries of Defense and 
        Transportation, in implementation of sections 1079 and 
        1086 of title 10, United States Code,
          (K) not to charge any individual or any other person 
        for items or services for which payment under this 
        title is denied under section 1154(a)(2) by reason of a 
        determination under section 1154(a)(1)(B),
          (L) in the case of hospitals which provide inpatient 
        hospital services for which payment may be made under 
        this title, to be a participating provider of medical 
        care under section 603 of title 38, United States Code, 
        in accordance with such admission practices, and such 
        payment methodology and amounts, as are prescribed 
        under joint regulations issued by the Secretary and by 
        the Secretary of Veterans Affairs in implementation of 
        [such section] such program,
          (M) in the case of hospitals, to provide to each 
        individual who is entitled to benefits under part A (or 
        to a person acting on the individual's behalf), at or 
        about the time of the individual's admission as an 
        inpatient to the hospital, a written statement 
        (containing such language as the Secretary prescribes 
        consistent with this paragraph) which explains--
                  (i) the individual's rights to benefits for 
                inpatient hospital services and for post-
                hospital services under this title,
                  (ii) the circumstances under which such an 
                individual will and will not be liable for 
                charges for continued stay in the hospital,
                  (iii) the individual's right to appeal 
                denials of benefits for continued inpatient 
                hospital services, including the practical 
                steps to initiate such an appeal, and
                  (iv) the individual's liability for payment 
                for services if such a denial of benefits is 
                upheld on appeal,--and which provides such 
                additional information as the Secretary may 
                specify,
          (N) in the case of hospitals and critical access 
        hospitals--
                  (i) to make available to its patients the 
                directory or directories of participating 
                physicians (published under section 1842(h)(4)) 
                for the area served by the hospital or critical 
                access hospital,
                  (ii) if hospital personnel (including staff 
                of any emergency or outpatient department) 
                refer a patient to a nonparticipating physician 
                for further medical care on an outpatient 
                basis, the personnel must inform the patient 
                that the physician is a nonparticipating 
                physician and, whenever practicable, must 
                identify at least one qualified participating 
                physician who is listed in such a directory and 
                from whom the patient may receive the necessary 
                services,
                  (iii) to post conspicuously in any emergency 
                department a sign (in a form specified by the 
                Secretary) specifying rights of individuals 
                under section 1867 with respect to examination 
                and treatment for emergency medical conditions 
                and women in labor, and
                  (iv) to post conspicuously (in a form 
                specified by the Secretary) information 
                indicating whether or not the hospital 
                participates in the medicaid program under a 
                State plan approved under title XIX,
          (O) to accept as payment in full for services that 
        are covered under this title and are furnished to any 
        individual enrolled with a Medicare+Choice organization 
        under part C, with a PACE provider under section 1894 
        or 1934, or with an eligible organization with a risk-
        sharing contract under section 1876, under section 
        1876(i)(2)(A) (as in effect before February 1, 1985), 
        under section 402(a) of the Social Security Amendments 
        of 1967, or under section 222(a) of the Social Security 
        Amendments of 1972, which does not have a contract (or, 
        in the case of a PACE provider, contract or other 
        agreement) establishing payment amounts for services 
        furnished to members of the organization or PACE 
        program eligible individuals enrolled with the PACE 
        provider, the amounts that would be made as a payment 
        in full under this title (less any payments under 
        sections 1886(d)(11) and 1886(h)(3)(D)) if the 
        individuals were not so enrolled,
          (P) in the case of home health agencies which provide 
        home health services to individuals entitled to 
        benefits under this title who require catheters, 
        catheter supplies, ostomy bags, and supplies related to 
        ostomy car (described in section 1861(m)(5)), to offer 
        to furnish such supplies to such an individual as part 
        of their furnishing of home health services,
          (Q) in the case of hospitals, skilled nursing 
        facilities, home health agencies, and hospice programs, 
        to comply with the requirement of subsection (f) 
        (relating to maintaining written policies and 
        procedures respecting advance directives),
          (R) to contract only with a health care clearinghouse 
        (as defined in section 1171) that meets each standard 
        and implementation specification adopted or established 
        under part C of title XI on or after the date on which 
        the health care clearinghouse is required to comply 
        with the standard or specification,
          (S) in the case of a hospital that has a financial 
        interest (as specified by the Secretary in regulations) 
        in an entity to which individuals are referred as 
        described in section 1861(ee)(2)(H)(ii), or in which 
        such an entity has such a financial interest, or in 
        which another entity has such a financial interest 
        (directly or indirectly) with such hospital and such an 
        entity, to maintain and disclose to the Secretary (in a 
        form and manner specified by the Secretary) information 
        on--
                  (i) the nature of such financial interest,
                  (ii) the number of individuals who were 
                discharged from the hospital and who were 
                identified as requiring home health services, 
                and
                  (iii) the percentage of such individuals who 
                received such services from such provider (or 
                another such provider),
          (T) in the case of hospitals and critical access 
        hospitals, to furnish to the Secretary such data as the 
        Secretary determines appropriate pursuant to 
        subparagraph (E) of section 1886(d)(12) to carry out 
        such section,
          (U) in the case of hospitals which furnish inpatient 
        hospital services for which payment may be made under 
        this title, to be a participating provider of medical 
        care both--
                  (i) under the contract health services 
                program funded by the Indian Health Service and 
                operated by the Indian Health Service, an 
                Indian tribe, or tribal organization (as those 
                terms are defined in section 4 of the Indian 
                Health Care Improvement Act), with respect to 
                items and services that are covered under such 
                program and furnished to an individual eligible 
                for such items and services under such program; 
                and
                  (ii) under any program funded by the Indian 
                Health Service and operated by an urban Indian 
                organization with respect to the purchase of 
                items and services for an eligible urban Indian 
                (as those terms are defined in such section 4),
        in accordance with regulations promulgated by the 
        Secretary regarding admission practices, payment 
        methodology, and rates of payment (including the 
        acceptance of no more than such payment rate as payment 
        in full for such items and services,
          (V) in the case of hospitals that are not otherwise 
        subject to the Occupational Safety and Health Act of 
        1970 (or a State occupational safety and health plan 
        that is approved under 18(b) of such Act), to comply 
        with the Bloodborne Pathogens standard under section 
        1910.1030 of title 29 of the Code of Federal 
        Regulations (or as subsequently redesignated),
                  (W) in the case of a hospital described in 
                section 1886(d)(1)(B)(v), to report quality 
                data to the Secretary in accordance with 
                subsection (k),
                  (X) maintain and, upon request of the 
                Secretary, provide access to documentation 
                relating to written orders or requests for 
                payment for durable medical equipment, 
                certifications for home health services, or 
                referrals for other items or services written 
                or ordered by the provider under this title, as 
                specified by the Secretary, and
          (Y) beginning 12 months after the date of the 
        enactment of this subparagraph, in the case of a 
        hospital or critical access hospital, with respect to 
        each individual who receives observation services as an 
        outpatient at such hospital or critical access hospital 
        for more than 24 hours, to provide to such individual 
        not later than 36 hours after the time such individual 
        begins receiving such services (or, if sooner, upon 
        release)--
                  (i) such oral explanation of the written 
                notification described in clause (ii), and such 
                documentation of the provision of such 
                explanation, as the Secretary determines to be 
                appropriate;
                  (ii) a written notification (as specified by 
                the Secretary pursuant to rulemaking and 
                containing such language as the Secretary 
                prescribes consistent with this paragraph) 
                which--
                          (I) explains the status of the 
                        individual as an outpatient receiving 
                        observation services and not as an 
                        inpatient of the hospital or critical 
                        access hospital and the reasons for 
                        such status of such individual;
                          (II) explains the implications of 
                        such status on services furnished by 
                        the hospital or critical access 
                        hospital (including services furnished 
                        on an inpatient basis), such as 
                        implications for cost-sharing 
                        requirements under this title and for 
                        subsequent eligibility for coverage 
                        under this title for services furnished 
                        by a skilled nursing facility;
                          (III) includes such additional 
                        information as the Secretary determines 
                        appropriate;
                          (IV) either--
                                  (aa) is signed by such 
                                individual or a person acting 
                                on such individual's behalf to 
                                acknowledge receipt of such 
                                notification; or
                                  (bb) if such individual or 
                                person refuses to provide the 
                                signature described in item 
                                (aa), is signed by the staff 
                                member of the hospital or 
                                critical access hospital who 
                                presented the written 
                                notification and includes the 
                                name and title of such staff 
                                member, a certification that 
                                the notification was presented, 
                                and the date and time the 
                                notification was presented; and
                          (V) is written and formatted using 
                        plain language and is made available in 
                        appropriate languages as determined by 
                        the Secretary.
In the case of a hospital which has an agreement in effect with 
an organization described in subparagraph (F), which 
organization's contract with the Secretary under part B of 
title XI is terminated on or after October 1, 1984, the 
hospital shall not be determined to be out of compliance with 
the requirement of such subparagraph during the six month 
period beginning on the date of the termination of that 
contract.
  (2)(A) A provider of services may charge such individual or 
other person (i) the amount of any deduction or coinsurance 
amount imposed pursuant to section 1813(a)(1), (a)(3), or 
(a)(4), section 1833(b), or section 1861(y)(3) with respect to 
such items and services (not in excess of the amount 
customarily charged for such items and services by such 
provider), and (ii) an amount equal to 20 per centum of the 
reasonable charges for such items and services (not in excess 
of 20 per centum of the amount customarily charged for such 
items and services by such provider) for which payment is made 
under part B or which are durable medical equipment furnished 
as home health services (but in the case of items and services 
furnished to individuals with end-stage renal disease, an 
amount equal to 20 percent of the estimated amounts for such 
items and services calculated on the basis established by the 
Secretary). In the case of items and services described in 
section 1833(c), clause (ii) of the preceding sentence shall be 
applied by substituting for 20 percent the proportion which is 
appropriate under such section. A provider of services may not 
impose a charge under clause (ii) of the first sentence of this 
subparagraph with respect to items and services described in 
section 1861(s)(10)(A) and with respect to clinical diagnostic 
laboratory tests for which payment is made under part B. 
Notwithstanding the first sentence of this subparagraph, a home 
health agency may charge such an individual or person, with 
respect to covered items subject to payment under section 
1834(a), the amount of any deduction imposed under section 
1833(b) and 20 percent of the payment basis described in 
section 1834(a)(1)(B). In the case of items and services for 
which payment is made under part B under the prospective 
payment system established under section 1833(t), clause (ii) 
of the first sentence shall be applied by substituting for 20 
percent of the reasonable charge, the applicable copayment 
amount established under section 1833(t)(5). In the case of 
services described in section 1833(a)(8) or section 1833(a)(9) 
for which payment is made under part B under section 1834(k), 
clause (ii) of the first sentence shall be applied by 
substituting for 20 percent of the reasonable charge for such 
services 20 percent of the lesser of the actual charge or the 
applicable fee schedule amount (as defined in such section) for 
such services.
  (B) Where a provider of services has furnished, at the 
request of such individual, items or services which are in 
excess of or more expensive than the items or services with 
respect to which payment may be made under this title, such 
provider of services may also charge such individual or other 
person for such more expensive items or services to the extent 
that the amount customarily charged by it for the items or 
services furnished at such request exceeds the amount 
customarily charged by it for the items or services with 
respect to which payment may be made under this title.
  (C) A provider of services may in accordance with its 
customary practice also appropriately charge any such 
individual for any whole blood (or equivalent quantities of 
packed red blood cells, as defined under regulations) furnished 
him with respect to which a deductible is imposed under section 
1813(a)(2), except that (i) any excess of such charge over the 
cost to such provider for the blood (or equivalent quantities 
of packed red blood cells, as so defined) shall be deducted 
from any payment to such provider under this title, (ii) no 
such charge may be imposed for the cost of administration of 
such blood (or equivalent quantities of packed red blood cells, 
as so defined), and (iii) such charge may not be made to the 
extent such blood (or equivalent quantities of packed red blood 
cells, as so defined) has been replaced on behalf of such 
individual or arrangements have been made for its replacement 
on his behalf. For purposes of subparagraph (C), whole blood 
(or equivalent quantities of packed red blood cells, as so 
defined) furnished an individual shall be deemed replaced when 
the provider of services is given one pint of blood for each 
pint of blood (or equivalent quantities of packed red blood 
cells, as so defined) furnished such individual with respect to 
which a deduction is imposed under section 1813(a)(2).
  (D) Where a provider of services customarily furnishes items 
or services which are in excess of or more expensive than the 
items or services with respect to which payment may be made 
under this title, such provider, notwithstanding the preceding 
provisions of this paragraph, may not, under the authority of 
section 1866(a)(2)(B)(ii), charge any individual or other 
person any amount for such items or services in excess of the 
amount of the payment which may otherwise be made for such 
items or services under this title if the admitting physician 
has a direct or indirect financial interest in such provider.
  (3)(A) Under the agreement required under paragraph 
(1)(F)(ii), the quality improvement organization must perform 
functions (other than those covered under an agreement under 
paragraph (1)(F)(i)) under the third sentence of section 
1154(a)(4)(A) and under section 1154(a)(14) with respect to 
services, furnished by the hospital, critical access hospital, 
facility, or agency involved, for which payment may be made 
under this title.
  (B) For purposes of payment under this title, the cost of 
such an agreement to the hospital, critical access hospital, 
facility, or agency shall be considered a cost incurred by such 
hospital, critical access hospital, facility, or agency in 
providing covered services under this title and shall be paid 
directly by the Secretary to the quality improvement 
organization on behalf of such hospital, critical access 
hospital, facility, or agency in accordance with a schedule 
established by the Secretary.
  (C) Such payments--
          (i) shall be transferred in appropriate proportions 
        from the Federal Hospital Insurance Trust Fund and from 
        the Federal Supplementary Medical Insurance Trust Fund, 
        without regard to amounts appropriated in advance in 
        appropriation Acts, in the same manner as transfers are 
        made for payment for services provided directly to 
        beneficiaries, and
          (ii) shall not be less in the aggregate for a fiscal 
        year--
                  (I) in the case of hospitals, than the amount 
                specified in paragraph (1)(F)(i)(III), and
                  (II) in the case of facilities, critical 
                access hospitals, and agencies, than the 
                amounts the Secretary determines to be 
                sufficient to cover the costs of such 
                organizations' conducting the activities 
                described in subparagraph (A) with respect to 
                such facilities, critical access hospitals, or 
                agencies under part B of title XI.
  (b)(1) A provider of services may terminate an agreement with 
the Secretary under this section at such time and upon such 
notice to the Secretary and the public as may be provided in 
regulations, except that notice of more than six months shall 
not be required.
  (2) The Secretary may refuse to enter into an agreement under 
this section or, upon such reasonable notice to the provider 
and the public as may be specified in regulations, may refuse 
to renew or may terminate such an agreement after the 
Secretary--
          (A) has determined that the provider fails to comply 
        substantially with the provisions of the agreement, 
        with the provisions of this title and regulations 
        thereunder, or with a corrective action required under 
        section 1886(f)(2)(B),
          (B) has determined that the provider fails 
        substantially to meet the applicable provisions of 
        section 1861,
          (C) has excluded the provider from participation in a 
        program under this title pursuant to section 1128 or 
        section 1128A, or
          (D) has ascertained that the provider has been 
        convicted of a felony under Federal or State law for an 
        offense which the Secretary determines is detrimental 
        to the best interests of the program or program 
        beneficiaries.
  (3) A termination of an agreement or a refusal to renew an 
agreement under this subsection shall become effective on the 
same date and in the same manner as an exclusion from 
participation under the programs under this title becomes 
effective under section 1128(c).
  (4)(A) A hospital that fails to comply with the requirement 
of subsection (a)(1)(V) (relating to the Bloodborne Pathogens 
standard) is subject to a civil money penalty in an amount 
described in subparagraph (B), but is not subject to 
termination of an agreement under this section.
  (B) The amount referred to in subparagraph (A) is an amount 
that is similar to the amount of civil penalties that may be 
imposed under section 17 of the Occupational Safety and Health 
Act of 1970 for a violation of the Bloodborne Pathogens 
standard referred to in subsection (a)(1)(U) by a hospital that 
is subject to the provisions of such Act.
  (C) A civil money penalty under this paragraph shall be 
imposed and collected in the same manner as civil money 
penalties under subsection (a) of section 1128A are imposed and 
collected under that section.
  (c)(1) Where the Secretary has terminated or has refused to 
renew an agreement under this title with a provider of 
services, such provider may not file another agreement under 
this title unless the Secretary finds that the reason for the 
termination or nonrenewal has been removed and that there is 
reasonable assurance that it will not recur.
  (2) Where the Secretary has terminated or has refused to 
renew an agreement under this title with a provider of 
services, the Secretary shall promptly notify each State agency 
which administers or supervises the administration of a State 
plan approved under title XIX of such termination or 
nonrenewal.
  (d) If the Secretary finds that there is a substantial 
failure to make timely review in accordance with section 
1861(k) of long-stay cases in a hospital, he may, in lieu of 
terminating his agreement with such hospital, decide that, with 
respect to any individual admitted to such hospital after a 
subsequent date specified by him, no payment shall be made 
under this title for inpatient hospital services (including 
inpatient psychiatric hospital services) after the 20th day of 
a continuous period of such services. Such decision may be made 
effective only after such notice to the hospital and to the 
public, as may be prescribed by regulations, and its 
effectiveness shall terminate when the Secretary finds that the 
reason therefor has been removed and that there is reasonable 
assurance that it will not recur. The Secretary shall not make 
any such decision except after reasonable notice and 
opportunity for hearing to the institution or agency affected 
thereby.
  (e) For purposes of this section, the term ``provider of 
services'' shall include--
          (1) a clinic, rehabilitation agency, or public health 
        agency if, in the case of a clinic or rehabilitation 
        agency, such clinic or agency meets the requirements of 
        section 1861(p)(4)(A) (or meets the requirements of 
        such section through the operation of subsection (g) or 
        (ll)(2) of section 1861), or if, in the case of a 
        public health agency, such agency meets the 
        requirements of section 1861(p)(4)(B) (or meets the 
        requirements of such section through the operation of 
        subsection (g) or (ll)(2) of section 1861), but only 
        with respect to the furnishing of outpatient physical 
        therapy services (as therein defined), (through the 
        operation of section 1861(g)) with respect to the 
        furnishing of outpatient occupational therapy services, 
        or (through the operation of section 1861(ll)(2)) with 
        respect to the furnishing of outpatient speech-language 
        pathology; and
          (2) a community mental health center (as defined in 
        section 1861(ff)(3)(B)), but only with respect to the 
        furnishing of partial hospitalization services (as 
        described in section 1861(ff)(1)).
  (f)(1) For purposes of subsection (a)(1)(Q) and sections 
1819(c)(2)(E), 1833(s), 1855(i), 1876(c)(8), and 1891(a)(6), 
the requirement of this subsection is that a provider of 
services, Medicare+Choice organization, or prepaid or eligible 
organization (as the case may be) maintain written policies and 
procedures with respect to all adult individuals receiving 
medical care by or through the provider or organization--
          (A) to provide written information to each such 
        individual concerning--
                  (i) an individual's rights under State law 
                (whether statutory or as recognized by the 
                courts of the State) to make decisions 
                concerning such medical care, including the 
                right to accept or refuse medical or surgical 
                treatment and the right to formulate advance 
                directives (as defined in paragraph (3)), and
                  (ii) the written policies of the provider or 
                organization respecting the implementation of 
                such rights;
          (B) to document in a prominent part of the 
        individual's current medical record whether or not the 
        individual has executed an advance directive;
          (C) not to condition the provision of care or 
        otherwise discriminate against an individual based on 
        whether or not the individual has executed an advance 
        directive;
          (D) to ensure compliance with requirements of State 
        law (whether statutory or as recognized by the courts 
        of the State) respecting advance directives at 
        facilities of the provider or organization; and
          (E) to provide (individually or with others) for 
        education for staff and the community on issues 
        concerning advance directives.
Subparagraph (C) shall not be construed as requiring the 
provision of care which conflicts with an advance directive.
  (2) The written information described in paragraph (1)(A) 
shall be provided to an adult individual--
          (A) in the case of a hospital, at the time of the 
        individual's admission as an inpatient,
          (B) in the case of a skilled nursing facility, at the 
        time of the individual's admission as a resident,
          (C) in the case of a home health agency, in advance 
        of the individual coming under the care of the agency,
          (D) in the case of a hospice program, at the time of 
        initial receipt of hospice care by the individual from 
        the program, and
          (E) in the case of an eligible organization (as 
        defined in section 1876(b)) or an organization provided 
        payments under section 1833(a)(1)(A) or a 
        Medicare+Choice organization, at the time of enrollment 
        of the individual with the organization.
  (3) In this subsection, the term ``advance directive'' means 
a written instruction, such as a living will or durable power 
of attorney for health care, recognized under State law 
(whether statutory or as recognized by the courts of the State) 
and relating to the provision of such care when the individual 
is incapacitated.
  (4) For construction relating to this subsection, see section 
7 of the Assisted Suicide Funding Restriction Act of 1997 
(relating to clarification respecting assisted suicide, 
euthanasia, and mercy killing).
  (g) Except as permitted under subsection (a)(2), any person 
who knowingly and willfully presents, or causes to be 
presented, a bill or request for payment inconsistent with an 
arrangement under subsection (a)(1)(H) or in violation of the 
requirement for such an arrangement, is subject to a civil 
money penalty of not to exceed $2,000. The provisions of 
section 1128A (other than subsections (a) and (b)) shall apply 
to a civil money penalty under the previous sentence in the 
same manner as such provisions apply to a penalty or proceeding 
under section 1128A(a).
  (h)(1)(A) Except as provided in paragraph (2), an institution 
or agency dissatisfied with a determination by the Secretary 
that it is not a provider of services or with a determination 
described in subsection (b)(2) shall be entitled to a hearing 
thereon by the Secretary (after reasonable notice) to the same 
extent as is provided in section 205(b), and to judicial review 
of the Secretary's final decision after such hearing as is 
provided in section 205(g), except that, in so applying such 
sections and in applying section 205(l) thereto, any reference 
therein to the Commissioner of Social Security or the Social 
Security Administration shall be considered a reference to the 
Secretary or the Department of Health and Human Services, 
respectively.
  (B) An institution or agency described in subparagraph (A) 
that has filed for a hearing under subparagraph (A) shall have 
expedited access to judicial review under this subparagraph in 
the same manner as providers of services, suppliers, and 
individuals entitled to benefits under part A or enrolled under 
part B, or both, may obtain expedited access to judicial review 
under the process established under section 1869(b)(2). Nothing 
in this subparagraph shall be construed to affect the 
application of any remedy imposed under section 1819 during the 
pendency of an appeal under this subparagraph.
  (C)(i) The Secretary shall develop and implement a process to 
expedite proceedings under this subsection in which--
          (I) the remedy of termination of participation has 
        been imposed;
          (II) a remedy described in clause (i) or (iii) of 
        section 1819(h)(2)(B) has been imposed, but only if 
        such remedy has been imposed on an immediate basis; or
          (III) a determination has been made as to a finding 
        of substandard quality of care that results in the loss 
        of approval of a skilled nursing facility's nurse aide 
        training program.
  (ii) Under such process under clause (i), priority shall be 
provided in cases of termination described in clause (i)(I).
  (iii) Nothing in this subparagraph shall be construed to 
affect the application of any remedy imposed under section 1819 
during the pendency of an appeal under this subparagraph.
  (2) An institution or agency is not entitled to separate 
notice and opportunity for a hearing under both section 1128 
and this section with respect to a determination or 
determinations based on the same underlying facts and issues.
  (i)(1) If the Secretary determines that a psychiatric 
hospital which has an agreement in effect under this section no 
longer meets the requirements for a psychiatric hospital under 
this title and further finds that the hospital's deficiencies--
          (A) immediately jeopardize the health and safety of 
        its patients, the Secretary shall terminate such 
        agreement; or
          (B) do not immediately jeopardize the health and 
        safety of its patients, the Secretary may terminate 
        such agreement, or provide that no payment will be made 
        under this title with respect to any individual 
        admitted to such hospital after the effective date of 
        the finding, or both.
  (2) If a psychiatric hospital, found to have deficiencies 
described in paragraph (1)(B), has not complied with the 
requirements of this title--
          (A) within 3 months after the date the hospital is 
        found to be out of compliance with such requirements, 
        the Secretary shall provide that no payment will be 
        made under this title with respect to any individual 
        admitted to such hospital after the end of such 3-month 
        period, or
          (B) within 6 months after the date the hospital is 
        found to be out of compliance with such requirements, 
        no payment may be made under this title with respect to 
        any individual in the hospital until the Secretary 
        finds that the hospital is in compliance with the 
        requirements of this title.
  (j) Enrollment Process for Providers of Services and 
Suppliers.--
          (1) Enrollment process.--
                  (A) In general.--The Secretary shall 
                establish by regulation a process for the 
                enrollment of providers of services and 
                suppliers under this title. Such process shall 
                include screening of providers and suppliers in 
                accordance with paragraph (2), a provisional 
                period of enhanced oversight in accordance with 
                paragraph (3), disclosure requirements in 
                accordance with paragraph (5), the imposition 
                of temporary enrollment moratoria in accordance 
                with paragraph (7), and the establishment of 
                compliance programs in accordance with 
                paragraph (9).
                  (B) Deadlines.--The Secretary shall establish 
                by regulation procedures under which there are 
                deadlines for actions on applications for 
                enrollment (and, if applicable, renewal of 
                enrollment). The Secretary shall monitor the 
                performance of medicare administrative 
                contractors in meeting the deadlines 
                established under this subparagraph.
                  (C) Consultation before changing provider 
                enrollment forms.--The Secretary shall consult 
                with providers of services and suppliers before 
                making changes in the provider enrollment forms 
                required of such providers and suppliers to be 
                eligible to submit claims for which payment may 
                be made under this title.
          (2) Provider screening.--
                  (A) Procedures.--Not later than 180 days 
                after the date of enactment of this paragraph, 
                the Secretary, in consultation with the 
                Inspector General of the Department of Health 
                and Human Services, shall establish procedures 
                under which screening is conducted with respect 
                to providers of medical or other items or 
                services and suppliers under the program under 
                this title, the Medicaid program under title 
                XIX, and the CHIP program under title XXI.
                  (B) Level of screening.--The Secretary shall 
                determine the level of screening conducted 
                under this paragraph according to the risk of 
                fraud, waste, and abuse, as determined by the 
                Secretary, with respect to the category of 
                provider of medical or other items or services 
                or supplier. Such screening--
                          (i) shall include a licensure check, 
                        which may include such checks across 
                        States; and
                          (ii) may, as the Secretary determines 
                        appropriate based on the risk of fraud, 
                        waste, and abuse described in the 
                        preceding sentence, include--
                                  (I) a criminal background 
                                check;
                                  (II) fingerprinting;
                                  (III) unscheduled and 
                                unannounced site visits, 
                                including preenrollment site 
                                visits;
                                  (IV) database checks 
                                (including such checks across 
                                States); and
                                  (V) such other screening as 
                                the Secretary determines 
                                appropriate.
                  (C) Application fees.--
                          (i) Institutional providers.--Except 
                        as provided in clause (ii), the 
                        Secretary shall impose a fee on each 
                        institutional provider of medical or 
                        other items or services or supplier 
                        (such as a hospital or skilled nursing 
                        facility) with respect to which 
                        screening is conducted under this 
                        paragraph in an amount equal to--
                                  (I) for 2010, $500; and
                                  (II) for 2011 and each 
                                subsequent year, the amount 
                                determined under this clause 
                                for the preceding year, 
                                adjusted by the percentage 
                                change in the consumer price 
                                index for all urban consumers 
                                (all items; United States city 
                                average) for the 12-month 
                                period ending with June of the 
                                previous year.
                          (ii) Hardship exception; waiver for 
                        certain medicaid providers.--The 
                        Secretary may, on a case-by-case basis, 
                        exempt a provider of medical or other 
                        items or services or supplier from the 
                        imposition of an application fee under 
                        this subparagraph if the Secretary 
                        determines that the imposition of the 
                        application fee would result in a 
                        hardship. The Secretary may waive the 
                        application fee under this subparagraph 
                        for providers enrolled in a State 
                        Medicaid program for whom the State 
                        demonstrates that imposition of the fee 
                        would impede beneficiary access to 
                        care.
                          (iii) Use of funds.--Amounts 
                        collected as a result of the imposition 
                        of a fee under this subparagraph shall 
                        be used by the Secretary for program 
                        integrity efforts, including to cover 
                        the costs of conducting screening under 
                        this paragraph and to carry out this 
                        subsection and section 1128J.
                  (D) Application and enforcement.--
                          (i) New providers of services and 
                        suppliers.--The screening under this 
                        paragraph shall apply, in the case of a 
                        provider of medical or other items or 
                        services or supplier who is not 
                        enrolled in the program under this 
                        title, title XIX, or title XXI as of 
                        the date of enactment of this 
                        paragraph, on or after the date that is 
                        1 year after such date of enactment.
                          (ii) Current providers of services 
                        and suppliers.--The screening under 
                        this paragraph shall apply, in the case 
                        of a provider of medical or other items 
                        or services or supplier who is enrolled 
                        in the program under this title, title 
                        XIX, or title XXI as of such date of 
                        enactment, on or after the date that is 
                        2 years after such date of enactment.
                          (iii) Revalidation of enrollment.--
                        Effective beginning on the date that is 
                        180 days after such date of enactment, 
                        the screening under this paragraph 
                        shall apply with respect to the 
                        revalidation of enrollment of a 
                        provider of medical or other items or 
                        services or supplier in the program 
                        under this title, title XIX, or title 
                        XXI.
                          (iv) Limitation on enrollment and 
                        revalidation of enrollment.--In no case 
                        may a provider of medical or other 
                        items or services or supplier who has 
                        not been screened under this paragraph 
                        be initially enrolled or reenrolled in 
                        the program under this title, title 
                        XIX, or title XXI on or after the date 
                        that is 3 years after such date of 
                        enactment.
                  (E) Use of information from the department of 
                treasury concerning tax debts.--In reviewing 
                the application of a provider of services or 
                supplier to enroll or reenroll under the 
                program under this title, the Secretary shall 
                take into account the information supplied by 
                the Secretary of the Treasury pursuant to 
                section 6103(l)(22) of the Internal Revenue 
                Code of 1986, in determining whether to deny 
                such application or to apply enhanced oversight 
                to such provider of services or supplier 
                pursuant to paragraph (3) if the Secretary 
                determines such provider of services or 
                supplier owes such a debt.
                  (F) Expedited rulemaking.--The Secretary may 
                promulgate an interim final rule to carry out 
                this paragraph.
          (3) Provisional period of enhanced oversight for new 
        providers of services and suppliers.--
                  (A) In general.--The Secretary shall 
                establish procedures to provide for a 
                provisional period of not less than 30 days and 
                not more than 1 year during which new providers 
                of medical or other items or services and 
                suppliers, as the Secretary determines 
                appropriate, including categories of providers 
                or suppliers, would be subject to enhanced 
                oversight, such as prepayment review and 
                payment caps, under the program under this 
                title, the Medicaid program under title XIX. 
                and the CHIP program under title XXI.
                  (B) Implementation.--The Secretary may 
                establish by program instruction or otherwise 
                the procedures under this paragraph.
          (4) 90-day period of enhanced oversight for initial 
        claims of dme suppliers.--For periods beginning after 
        January 1, 2011, if the Secretary determines that there 
        is a significant risk of fraudulent activity among 
        suppliers of durable medical equipment, in the case of 
        a supplier of durable medical equipment who is within a 
        category or geographic area under title XVIII 
        identified pursuant to such determination and who is 
        initially enrolling under such title, the Secretary 
        shall, notwithstanding sections 1816(c), 1842(c), and 
        1869(a)(2), withhold payment under such title with 
        respect to durable medical equipment furnished by such 
        supplier during the 90-day period beginning on the date 
        of the first submission of a claim under such title for 
        durable medical equipment furnished by such supplier.
          (5) Increased disclosure requirements.--
                  (A) Disclosure.--A provider of medical or 
                other items or services or supplier who submits 
                an application for enrollment or revalidation 
                of enrollment in the program under this title, 
                title XIX, or title XXI on or after the date 
                that is 1 year after the date of enactment of 
                this paragraph shall disclose (in a form and 
                manner and at such time as determined by the 
                Secretary) any current or previous affiliation 
                (directly or indirectly) with a provider of 
                medical or other items or services or supplier 
                that has uncollected debt, has been or is 
                subject to a payment suspension under a Federal 
                health care program (as defined in section 
                1128B(f)), has been excluded from participation 
                under the program under this title, the 
                Medicaid program under title XIX, or the CHIP 
                program under title XXI, or has had its billing 
                privileges denied or revoked.
                  (B) Authority to deny enrollment.--If the 
                Secretary determines that such previous 
                affiliation poses an undue risk of fraud, 
                waste, or abuse, the Secretary may deny such 
                application. Such a denial shall be subject to 
                appeal in accordance with paragraph (7).
          (6) Authority to adjust payments of providers of 
        services and suppliers with the same tax identification 
        number for medicare obligations.--
                  (A) In general.--Notwithstanding any other 
                provision of this title, in the case of an 
                applicable provider of services or supplier, 
                the Secretary may make any necessary 
                adjustments to payments to the applicable 
                provider of services or supplier under the 
                program under this title in order to satisfy 
                any amount described in subparagraph (B)(ii) 
                due from such obligated provider of services or 
                supplier.
                  (B) Definitions.--In this paragraph:
                          (i) In general.--The term 
                        ``applicable provider of services or 
                        supplier'' means a provider of services 
                        or supplier that has the same taxpayer 
                        identification number assigned under 
                        section 6109 of the Internal Revenue 
                        Code of 1986 as is assigned to the 
                        obligated provider of services or 
                        supplier under such section, regardless 
                        of whether the applicable provider of 
                        services or supplier is assigned a 
                        different billing number or national 
                        provider identification number under 
                        the program under this title than is 
                        assigned to the obligated provider of 
                        services or supplier.
                          (ii) Obligated provider of services 
                        or supplier.--The term ``obligated 
                        provider of services or supplier'' 
                        means a provider of services or 
                        supplier that owes an amount that is 
                        more than the amount required to be 
                        paid under the program under this title 
                        (as determined by the Secretary).
          (7) Temporary moratorium on enrollment of new 
        providers; nonpayment.--
                  (A) In general.--The Secretary may impose a 
                temporary moratorium on the enrollment of new 
                providers of services and suppliers, including 
                categories of providers of services and 
                suppliers, in the program under this title, 
                under the Medicaid program under title XIX, or 
                under the CHIP program under title XXI if the 
                Secretary determines such moratorium is 
                necessary to prevent or combat fraud, waste, or 
                abuse under either such program.
                  (B) Limitation on review.--There shall be no 
                judicial review under section 1869, section 
                1878, or otherwise, of a temporary moratorium 
                imposed under subparagraph (A).
                  (C) Nonpayment.--
                          (i) In general.--No payment may be 
                        made under this title or under a 
                        program described in subparagraph (A) 
                        with respect to an item or service 
                        described in clause (ii) furnished on 
                        or after October 1, 2017.
                          (ii) Item or service described.--An 
                        item or service described in this 
                        clause is an item or service 
                        furnished--
                                  (I) within a geographic area 
                                with respect to which a 
                                temporary moratorium imposed 
                                under subparagraph (A) is in 
                                effect; and
                                  (II) by a provider of 
                                services or supplier that meets 
                                the requirements of clause 
                                (iii).
                          (iii) Requirements.--For purposes of 
                        clause (ii), the requirements of this 
                        clause are that a provider of services 
                        or supplier--
                                  (I) enrolls under this title 
                                on or after the effective date 
                                of such temporary moratorium; 
                                and
                                  (II) is within a category of 
                                providers of services and 
                                suppliers (as described in 
                                subparagraph (A)) subject to 
                                such temporary moratorium.
                          (iv) Prohibition on charges for 
                        specified items or services.--In no 
                        case shall a provider of services or 
                        supplier described in clause (ii)(II) 
                        charge an individual or other person 
                        for an item or service described in 
                        clause (ii) furnished on or after 
                        October 1, 2017, to an individual 
                        entitled to benefits under part A or 
                        enrolled under part B or an individual 
                        under a program specified in 
                        subparagraph (A).
          (8) Compliance programs.--
                  (A) In general.--On or after the date of 
                implementation determined by the Secretary 
                under subparagraph (C), a provider of medical 
                or other items or services or supplier within a 
                particular industry sector or category shall, 
                as a condition of enrollment in the program 
                under this title, title XIX, or title XXI, 
                establish a compliance program that contains 
                the core elements established under 
                subparagraph (B) with respect to that provider 
                or supplier and industry or category.
                  (B) Establishment of core elements.--The 
                Secretary, in consultation with the Inspector 
                General of the Department of Health and Human 
                Services, shall establish core elements for a 
                compliance program under subparagraph (A) for 
                providers or suppliers within a particular 
                industry or category.
                  (C) Timeline for implementation.--The 
                Secretary shall determine the timeline for the 
                establishment of the core elements under 
                subparagraph (B) and the date of the 
                implementation of subparagraph (A) for 
                providers or suppliers within a particular 
                industry or category. The Secretary shall, in 
                determining such date of implementation, 
                consider the extent to which the adoption of 
                compliance programs by a provider of medical or 
                other items or services or supplier is 
                widespread in a particular industry sector or 
                with respect to a particular provider or 
                supplier category.
          (9) Hearing rights in cases of denial or non-
        renewal.--A provider of services or supplier whose 
        application to enroll (or, if applicable, to renew 
        enrollment) under this title is denied may have a 
        hearing and judicial review of such denial under the 
        procedures that apply under subsection (h)(1)(A) to a 
        provider of services that is dissatisfied with a 
        determination by the Secretary.
  (k) Quality Reporting by Cancer Hospitals.--
          (1) In general.--For purposes of fiscal year 2014 and 
        each subsequent fiscal year, a hospital described in 
        section 1886(d)(1)(B)(v) shall submit data to the 
        Secretary in accordance with paragraph (2) with respect 
        to such a fiscal year.
          (2) Submission of quality data.--For fiscal year 2014 
        and each subsequent fiscal year, each hospital 
        described in such section shall submit to the Secretary 
        data on quality measures specified under paragraph (3). 
        Such data shall be submitted in a form and manner, and 
        at a time, specified by the Secretary for purposes of 
        this subparagraph.
          (3) Quality measures.--
                  (A) In general.--Subject to subparagraph (B), 
                any measure specified by the Secretary under 
                this paragraph must have been endorsed by the 
                entity with a contract under section 1890(a).
                  (B) Exception.--In the case of a specified 
                area or medical topic determined appropriate by 
                the Secretary for which a feasible and 
                practical measure has not been endorsed by the 
                entity with a contract under section 1890(a), 
                the Secretary may specify a measure that is not 
                so endorsed as long as due consideration is 
                given to measures that have been endorsed or 
                adopted by a consensus organization identified 
                by the Secretary.
                  (C) Time frame.--Not later than October 1, 
                2012, the Secretary shall publish the measures 
                selected under this paragraph that will be 
                applicable with respect to fiscal year 2014.
          (4) Public availability of data submitted.--The 
        Secretary shall establish procedures for making data 
        submitted under paragraph (4) available to the public. 
        Such procedures shall ensure that a hospital described 
        in section 1886(d)(1)(B)(v) has the opportunity to 
        review the data that is to be made public with respect 
        to the hospital prior to such data being made public. 
        The Secretary shall report quality measures of process, 
        structure, outcome, patients' perspective on care, 
        efficiency, and costs of care that relate to services 
        furnished in such hospitals on the Internet website of 
        the Centers for Medicare & Medicaid Services.

           *       *       *       *       *       *       *


                            DISSENTING VIEWS

                                   I

    Earlier this year, the House Committee on Veterans' Affairs 
(HVAC) began the arduous task of outlining what the future of 
community care at the Department of Veterans Affairs (VA) would 
look like. Community care, also sometimes referred to as non-VA 
care or fee-basis care, has long been the subject of numerous 
critical reports from bodies such as VA's Office of Inspector 
General (VAOIG), Government Accountability Office (GAO), the 
Independent Assessment,\1\ and the Commission on Care.\2\ These 
reports emphasized the challenges of maintaining six separate 
pathways, all with different eligibility criteria and payment 
rates, to send veterans into the community for care. Not only 
is this confusing to veterans, VA staff and community 
providers, it is also highly inefficient. H.R. 4242 would 
streamline eligibility and payment rates, among other things, 
into one easy to use and administer program that would allow VA 
to take advantage of economies of scale. While the Minority 
generally agrees with the broad policy that is outlined in H.R. 
4242, we do have several concerns.
---------------------------------------------------------------------------
    \1\A congressional mandate outlined in Section 201 of Public Law 
P.L. 113-146.
    \2\A congressional mandate outlined in Section 202 of P.L. 113-146.
---------------------------------------------------------------------------
    The most significant of these concerns is funding. The 
Congressional Budget Office (CBO) issued a preliminary score 
for H.R. 4242 on November 7, 2017, of nearly $40 billion over 
five years. In recent years, leadership of both HVAC and the 
Senate Committee on Veterans' Affairs (SVAC) have required 
discretionary spending to be off-set before a bill can be voted 
out of committee. As written, H.R. 4242 provides no pay-for and 
was the main reason the bill was pulled from the November 8, 
2017, markup agenda. A pay-for was not identified ahead of the 
December 19, 2017 markup either.
    In an effort to address the score, during the December 19, 
2017, markup Chairman Roe offered an amendment which would 
place caps on VA's Medical Community Care account. In effect, 
growth of the program would be restricted to just 3 percent a 
year. We believe that will not be sufficient and could lead to 
rationing of community care or diversion of funds from VA's 
Medical Care account. This belief is based on several factors, 
including the overall growth in community care spending 
(between Fiscal Year (FY) 2017 and FY 2018, obligation 
authorities are expected to grow by 8.3 percent);\3\ the steady 
increase in the number of authorizations for the Veterans 
Choice Program (VCP) (between March and May 2017, VA issued 
nearly 800,000 authorizations for VCP, which represented a 32% 
increase over the same time-period in 2016);\4\ and the 
projected demand for Long-Term Support and Service (LTSS), 
which include high-cost services such as nursing home care and 
adult day care that will continue to steadily increase as the 
number of 85-year-old enrollees in VA will almost double over 
the next 20 years.\5\
---------------------------------------------------------------------------
    \3\Briefing from Department of Veterans Affairs' Office of 
Management, June 22, 2017.
    \4\United States Cong. House Committee on Veterans' Affairs, 
Subcommittee on Health Hearing--``Health Programs Budget Request for 
Fiscal Year 2018'' June 22, 2017. 115th Cong. 1st sess. Washington. 
GPO, 2017 (Statement by Poonam Alaigh, Acting Under Secretary for 
Health, Veterans Health Administration, US Department of Veterans 
Affairs).
    \5\VA FY 2018 Budget Submission--Vol. 2, Pg. 369 https://
www.va.gov/budget/docs/summary/
fy2018VAbudgetVolumeIImedicalProgramsAndInformationTechnology.pdf.
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    Additional factors that would significantly impact VA's 
ability to deliver care in the community on an artificially 
constrained budget that would include financial constraints on 
VA just as demand for care is likely to expand in response to 
the Republican tax plan, which not only undermines the 
Affordable Care Act but triggers Medicaid funding cuts. In 
fact, one in 10 veterans are on Medicaid, which is 1.75 million 
veterans.\6\ Furthermore, earlier this year, documents leaked 
by administration officials revealed a plan to merge the VCP 
with TRICARE, a health insurance program that service members 
and their families pay to use.\7\
---------------------------------------------------------------------------
    \6\Callow, Andrea. Cutting Medicaid Would Hurt Veterans. Families 
USA. May 2017. http://familiesusa.org/product/cutting-medicaid-would-
hurt-veterans.
    \7\Yen, Hope. VA exploring idea of merging health system with 
Pentagon. Federal News Radio. November 17, 2017. https://
federalnewsradio.com/veterans-affairs/2017/11/vas-quiet-plan-to-widen-
private-care-with-tricare-stirs-ire/.
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    Although we appreciate the Chairman's removal of his 
amendment, this legislation continues to lack a sustainable 
path to fund this permanent program. Playing tricks with 
authorizing caps, either in the hearing or when this bill is 
brought to the floor for final passage sends the wrong message 
to VA, community providers and the veterans we are supposed to 
serve. Moreover, without a plan to appropriately fund any 
future community care program, we are equally concerned that 
Congress will continue to kick the proverbial can down the road 
and will opt instead to carry on appropriating more funding for 
the flawed VCP that was only ever intended to be a temporary 
measure to address VA's access to care crisis.
    In addition, we are concerned the changes made to H.R. 4242 
by an amendment offered by Chairman Roe does not fully address 
the anxieties expressed by the Veteran Service Organizations 
(VSOs) and will ultimately lead to an uneven policy application 
across VA medical facilities. In mid-November, a number of VSOs 
raised their concerns with Majority and Minority staff about 
certain portions of the language in Section 102, Establishment 
of VA Care in the Community Program of H.R. 4242. In particular 
they were worried about language that from their perspective 
gave veterans access to ``unfettered choice''. VSOs have been 
highly critical of any attempt, or perceived attempt, to 
privatize VA care.
    The amendment in question sought to change language related 
to veteran eligibility and the appeals process among other 
things. In particular, language in the underlying bill 
expressed that the Secretary ``SHALL'' give deference to the 
veteran with respect to reviewing a disagreement regarding the 
availability of and assignment to a patient aligned care team 
or dedicated primary care provider. The Roe amendment changed 
that to a ``MAY''.
    Given the language now reflects an option rather than an 
imperative, we are concerned that this could lead to an uneven 
administrative application of the provision. Within the 
veterans community there is a well-known saying to describe the 
Veterans Health Administration (VHA): ``If you've been to one 
VA, you've been to one VA.'' Despite the prolific use of 
directives and memos across VHA, countless stakeholders have 
observed the lack of standardized implementation and oversight 
of policy and procedures. In fact, it is one of the reasons VA 
was added to GAO's high-risk list in 2015.\8\ Had the suggested 
language of the VSOs been adopted, ``SHALL give the benefit of 
the doubt to the veteran when there is an approximate balance 
of positive and negative evidence,'' additional opportunities 
for unclear policy application could have been avoided.
---------------------------------------------------------------------------
    \8\https.//www.gao.gov/assets/670/668415.pdf.
---------------------------------------------------------------------------
    In addition, another amendment adopted during markup would 
create a new Center for Innovation for Care and Payment. 
Although we generally support looking at new methods of paying 
non-VA providers and new methods for delivering health care 
services to veterans to reduce expenditures and improve care 
quality, we remain concerned the process for developing the 
pilot program in the legislation gives the VA Secretary overly-
broad authority to waive federal law. We are also concerned 
that resources intended for delivery of health care to veterans 
will be diverted to pay for the pilot program without a 
specific funding source designated.
    The Roe amendment would not prohibit enrolled veterans with 
service-connected disabilities to be billed or charged for 
health care services related to service-connection under the 
pilot program. It also gives the VA Secretary broad authority 
to waive certain requirements under Chapter 17 of title 38 to 
implement the pilot program. This includes the authority to 
waive VA healthcare eligibility requirements, contracting 
requirements, and standard of care requirements for community 
care providers. Once granted, the waiver would not be subject 
to judicial review. This waiver could easily be granted via a 
privileged resolution or bill that would circumvent the House 
and Senate Veterans' Affairs Committees and require only a 
majority vote in each Chamber to be granted. With this special 
procedure to grant a waiver, an identical procedure should at 
least exist for termination of the waiver.
    No specific funding was authorized for the Center, which 
would be funded out of VHA's Medical Services Accounts. Since 
the Center would be piloting new care delivery and billing 
models, the pilot program could yield higher costs for the 
delivery of care, which would take precious resources away from 
the direct delivery of care by VA. Any pilot in which new care 
delivery models are tested with community providers should be 
funded specifically for that purpose so that funds for direct 
delivery of care are not diverted to pay for pilot programs 
that pay non-VA providers for care.
    If this amendment had been subject to Committee process, we 
would have requested views from VA and experts on the need for 
granting the VA Secretary such broad authority. We would have 
worked with Veteran Service Organizations to ensure the pilot 
programs grant preference to delivery models that also improve 
the coordination, quality, and efficiency of health care 
services furnished to veterans enrolled in the VA's patient 
enrollment system. We also would have had the opportunity to 
determine the levels of specific purpose funding that would be 
appropriate to test care delivery models under the Center's 
pilot programs.

                                   II

    The continued near-flat line request for the Medical 
Services account will continue the trend of VA being unable to 
provide the needed services internally and forcing veterans 
into the community for care. Failure to adequately fund VA so 
that it is able to hire staff to fill over 45,000 provider 
vacancies and address its significant infrastructure needs will 
cause veterans to wait longer for appointments. Sending more 
veterans for care in the community is not the panacea for all 
of VA's access challenges. Community care is only intended to 
fill gaps in care that VA is unable to provide due to lack of 
capacity, and only accounts for approximately 30 percent of the 
care delivered by VA.\9\ Provider shortages exist throughout 
the U.S., and in many cases, community providers lack the 
expertise or cultural competency to provide quality care to 
veterans. A holistic, systems-based approach, not a narrow 
focus on sending veterans for care in the community is needed 
to address VHA's access-to-care challenges.
---------------------------------------------------------------------------
    \9\The MITRE Corporation, Independent Assessment of the Health Care 
Delivery Systems and Management Processes of the Department of Veterans 
Affairs Integrated Report, xii (2015), ``VHA must adopt systems 
thinking to address its most challenging problems, including access, 
quality, cost, and patient experience.''
---------------------------------------------------------------------------
    Democrats offered 7 amendments during markup that would 
have addressed VA's internal capacity. Unfortunately, only 2 of 
these 7 amendments were adopted. The 5 amendments not agreed to 
addressed VA's significant staffing and provider shortages, 
infrastructure needs, accountability measures for non-VA 
providers, expansion of the VA Family Caregiver Program to all 
generations of veterans, and authorized $1 billion for 
educational assistance for providers, additional graduate 
medical education residency positions, and recruitment, 
relocation, and retention incentives for providers.
    On November 29, 2017, the Senate Committee on Veterans' 
Affairs favorably reported to the Senate legislation to reform 
VA's community care program and address VA's access-to-care-
challenges. This bipartisan legislation was favorably reported 
14-1. The Senate legislation addresses VA's capacity and access 
challenges holistically by addressing infrastructure, provider 
shortages, expanding the Comprehensive Assistance for Family 
Caregiver Program, and reforming VA's community care programs. 
We agree with this approach. For this reason, the Senate's 
legislation and Title I of H.R. 4242 (with amendments requested 
by Veteran Service Organizations) formed the basis of Ranking 
Member Walz's amendment in the nature of a substitute to H.R. 
4242 that was supported by Committee Democrats, but voted down 
by all Committee Republicans.
    The A.N.S. offered by Ranking Member Walz would expand the 
Comprehensive Assistance for Family Caregiver Program to all 
generations of veterans. It would authorize $1 billion to pay 
for up to $240,000 per VA provider over 5 years in education 
debt reduction under the Education Debt Reduction Program,\10\ 
lift the limit on annual awards for recruitment, relocation, or 
retention incentives, establish a higher maximum amount of 
basic pay for nurses, authorize a tuition reimbursement and 
loan repayment pilot program for providers at underserved 
facilities, and create an additional 1,500 graduate medical 
residency positions. It authorizes an additional $4 billion for 
the Veterans Choice Fund to pay for community care. It would 
also give VA more flexibility over its construction programs by 
permitting VA to perform construction on projects costing under 
$20 million without congressional approval, grants VA more 
flexibility to issue enhanced use leases, facilitates sharing 
of medical facilities with other agencies such as the 
Department of Defense, and authorizes construction on a medical 
facility realignment project in Livermore, California.
---------------------------------------------------------------------------
    \10\Clinical staff employed at Vet Centers would also be eligible 
for EDRP.
---------------------------------------------------------------------------
    An amendment to H.R. 4242 offered by Representative 
Brownley would have streamlined approval for major construction 
of medical facilities by permitting approval via adoption of 
resolutions by the House and Senate Veterans' Affairs 
Committees. Amendments offered by Rep. Takano would have set 
firm hiring levels for VA so that it would be required to 
immediately address the provider shortage, required non-VA 
providers to follow the same contracting laws and regulations 
as other government contractors, and would have established an 
Office of Non-VA Delivered Medical Care Accountability in 
charge of overseeing, auditing, analyzing, and investigating 
non-VA delivered care. The majority did not support these 
amendments.
    All amendments offered by Democrats did not seek to 
fundamentally alter the bipartisan community care eligibility 
language. Instead, these amendments sought to holistically 
address VA's access and capacity challenges by strengthening 
VA's internal capacity to deliver health care to veterans, and 
by reforming the community care programs--including the Choice 
Program--intended to supplement VA-delivered care. Without 
taking a systems approach, as recommended in the Independent 
Assessment, we cannot expect to address VHA's challenges by 
narrowly focusing only on offering veterans community care.
                                                  Tim Walz,
                                                    Ranking Member.

                                  [all]