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115th Congress     }                                {    Rept. 115-671
                        HOUSE OF REPRESENTATIVES
 2d Session        }                                {          Part 1

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



 
 VA MAINTAINING INTERNAL SYSTEMS AND STRENGTHENING INTEGRATED OUTSIDE 
                          NETWORKS ACT OF 2018

                                _______
                                

  May 11, 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. 5674]

    The Committee on Veterans' Affairs, to whom was referred 
the bill (H.R. 5674) to establish a permanent community care 
program for veterans, to establish a commission for the purpose 
of making recommendations regarding the modernization or 
realignment of facilities of the Veterans Health 
Administration, to improve construction of the Department of 
Veterans Affairs, to make certain improvements in the laws 
administered by the Secretary of Veterans Affairs relating to 
the home loan program of the Department of Veterans Affairs, 
and for other purposes, having considered the same, report 
favorably thereon without amendment and recommend that the bill 
do pass.

                                CONTENTS

                                                                   Page
Purpose and Summary..............................................     2
Background and Need for Legislation..............................     2
Hearings.........................................................    34
Subcommittee Consideration.......................................    34
Committee Consideration..........................................    34
Committee Votes..................................................    35
Committee Correspondence.........................................    43
Committee Oversight Findings.....................................    45
Statement of General Performance Goals and Objectives............    45
New Budget Authority, Entitlement Authority, and Tax Expenditures    45
Earmarks and Tax and Tariff Benefits.............................    45
Committee Cost Estimate..........................................    45
Congressional Budget Office Estimate.............................    45
Federal Mandates Statement.......................................    45
Advisory Committee Statement.....................................    46
Constitutional Authority Statement...............................    46
Applicability to Legislative Branch..............................    46
Statement on Duplication of Federal Programs.....................    46
Disclosure of Directed Rulemaking................................    46
Section-by-Section Analysis of the Legislation...................    46
Changes in Existing Law Made by the Bill as Reported.............    85
Dissenting Views.................................................   205

                          Purpose and Summary

    H.R. 5674, the ``VA Maintaining Internal Systems and 
Strengthening Integrated Outside Networks Act of 2018'' or the 
``VA MISSION Act of 2018'' would strengthen and improve the 
Department of Veterans Affairs (VA) healthcare system for the 
benefit of the nation's veterans. The bill would consolidate 
VA's multiple community care programs and authorities and 
provide further funding for the Choice Program. It would 
establish an Asset and Infrastructure Review (AIR) process to 
recommend actions to modernize and realign VA's massive medical 
infrastructure. It would also expand VA's Family Caregiver 
Program to pre-9/11 veterans and increase VA's internal 
capacity to care for veteran patients in VA medical facilities 
through improvements to various recruitment and retention 
programs. The bill represents a negotiated agreement between 
the Committee on Veterans' Affairs of the U.S. House of 
Representatives and the Committee on Veterans' Affairs of the 
U.S. Senate and combines various elements of H.R. 4242, as 
amended, H.R. 4243, as amended, and S. 2193, as amended. 
Representative David P. Roe of Tennessee, the Chairman of the 
full Committee, introduced H.R. 5674 on May 3, 2018.

                  Background and Need for Legislation


                    TITLE I--CARING FOR OUR VETERANS

      Subtitle A--Developing an Integrated High-Performing Network

    VA operates the nation's largest integrated healthcare 
system and provides care to approximately nine million veteran 
patients.\1\ The majority of the health care that veterans 
receive through the VA health care system is provided through 
medical professionals and support staff employed by VA and 
working in VA facilities that are managed and overseen by the 
Veterans Health Administration (VHA). However, since 1945, VA 
has also collaborated with medical professionals and support 
staff in the community--who are not VA employees and who do not 
work in VA facilities--to provide veterans with timely, 
accessible, high-quality care.\2\ 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 various community 
care programs to care for veteran patients when a needed 
clinical service cannot be provided by a given 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\January 11, 2017, MyVA Advisory Committee Meeting, Georgetown 
University, Washington, D.C.
---------------------------------------------------------------------------
    The most recent VA community care program 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) (the Choice Act). Choice expanded the 
availability of community care to veteran patients by setting 
specific triggers upon which VA would be required 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 facility within 30 days or if 
they reside more than 40 miles from the nearest VA facility. 
Through Choice, veteran patients are referred to regional 
networks of community providers who are managed by Third Party 
Administrators (TPAs). However, under other community care 
programs, VA refers veteran patients to community providers 
through agreements with the Indian Health Service, the 
Department of Defense, academic affiliates, or other entities; 
through the Patient Centered Community Care program; or through 
national or local contracts or sharing agreements.\3\
---------------------------------------------------------------------------
    \3\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, different 
reimbursement rates, different payment structures, different 
referral and authorization requirements, and different 
contracting approaches.\4\ 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.''\5\ 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.''\6\ 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.''\7\
---------------------------------------------------------------------------
    \4\January 11, 2017, MyVA Advisory Committee Meeting, Georgetown 
University, Washington, D.C.
    \5\May 24, 2017. U.S. Department of Veterans Affairs Fact Sheet. 
``A Consolidated and Modernized VA Community Care Program.''
    \6\Ibid.
    \7\Ibid.
---------------------------------------------------------------------------
    That imperative has been exacerbated by a significant 
increase in veteran demand for community care in recent years. 
Since Choice was established in fiscal year 2014, community 
care appointments increased by 61 percent overall and by 41 
percent as a percentage of total VA appointments through fiscal 
year 2016.\8\ That upward trend continued in fiscal year 2017, 
with the number of completed appointments across the VA 
healthcare system that occur in the community rising from 31 
percent in fiscal year 2016 to 36 percent in fiscal year 
2017.\9\
---------------------------------------------------------------------------
    \8\January 11, 2017, MyVA Advisory Committee Meeting, Georgetown 
University, Washington, D.C.
    \9\United States Cong. House Committee on Veterans' Affairs. ``U.S. 
Department of Veterans Affairs Budget Request for Fiscal Year 2019'' 
February 15, 2018. 115th Cong. 2nd sess. Washington: GPO, 2018 
(Testimony of the the Honorable David Shulkin M.D., Secretary, U.S. 
Department of Veterans Affairs).
---------------------------------------------------------------------------
    Despite the increased demand for and utilization of 
community care, VA has struggled to effectively administer 
community care programs and, consequently, veterans have not 
always received timely care in the community. For many years, 
the VA Inspector General (IG) 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.\10\ This led the IG to conclude in 
2017 that, ``our audits, reviews, and inspections have 
highlighted that VA has had a history of challenges in 
administering its purchased care programs [and] 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 lack[s] adequate processes to manage funds and oversee 
program execution.''\11\ The Government Accountability Office 
(GAO) has found similar problems with VA's management of 
community care programs. For example, in March 2017, GAO found 
that veterans who were referred to Choice for routine care 
because such care was not available through a VA facility in a 
timely manner could potentially wait up to 81 calendar days to 
obtain Choice care.\12\ GAO also found that VA had failed to 
establish standardized processes and procedures for Choice, to 
issue program guidance regarding Choice, and to track or 
monitor how long it took VA medical centers to refer veterans 
to Choice (a process which GAO found was duplicative and could 
take up to 21 days).\13\
---------------------------------------------------------------------------
    \10\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).
    \11\Ibid.
    \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 Randall B. Williamson, Director, Health Care, Government 
Accountability Office).
    \13\Ibid.
---------------------------------------------------------------------------
    The Committee is aware of the concerns expressed by VA, the 
IG, and GAO regarding the challenging nature of many current VA 
community care programs and the potential adverse consequences 
veteran patients could face if those concerns are not 
expeditiously addressed. The Committee believes that a robust, 
consolidated VA community care program is vital to the long-
term stability and success of the VA healthcare system in at 
least two significant ways. First, an effective VA community 
care program augments the care provided in VA medical 
facilities and, therefore, increases VA's capacity to serve the 
nation's veterans. Second and most importantly, an effective VA 
community care program helps to ensure that veterans have 
access to timely, quality care and--as such--provides them with 
improved health outcomes, patient satisfaction, care 
coordination, and efficiency.\14\
---------------------------------------------------------------------------
    \14\May 24, 2017. U.S. Department of Veterans Affairs Fact Sheet. 
``A Consolidated and Modernized VA Community Care Program.''
---------------------------------------------------------------------------
    Accordingly, title I of the bill would establish a robust, 
consolidated VA community care program, the Veterans Community 
Care Program (the Program). Through the Program, veterans who 
are enrolled in the VA healthcare system or otherwise entitled 
to VA care would be granted access to care in the community 
under certain circumstances, which are detailed below. VA would 
be responsible for managing and overseeing the Program as well 
as coordinating the care that veterans receive through the 
Program, including ensuring that appointments are scheduled in 
a timely manner and that continuity of care is preserved.
    Access to community care would be required under the 
Program if VA does not offer the care or services the veteran 
requires, if VA does not operate a full-service medical 
facility in the state in which a given veteran resides, if a 
given veteran was eligible for care in the community under the 
Choice 40-mile rule and meets certain other criteria, or if a 
given veteran and the referring clinician agree that furnishing 
care in the community is in the best medical interest of the 
veteran after considering certain criteria. Access to community 
care would also be required if VA is not able to furnish care 
within designated access standards developed by VA after 
consultation with certain other entities and published in the 
Federal Register and on VA's website. Such designated access 
standards would be reviewed at a minimum of every three years 
and veterans would be able to request a determination at any 
time regarding whether they are eligible to receive community 
care as a result of such access standards.
    Access to community care would be authorized under the 
Program if a given medical service line within a VA facility 
fails to meet certain VA quality standards developed by VA 
after consultation with certain other entities and published on 
the Center for Medicare and Medicaid's Hospital Compare 
website. VA would be required to provide a plan to Congress 
detailing how VA intends to remediate medical service lines 
that fall below such quality standards and VA's authority to 
refer veterans to the Program due to a failure to meet such 
quality standards would be limited to no more than 36 service 
lines nationally and three service lines per facility.
    Access to community care would also be authorized under 
this title to veterans in need of an organ or bone marrow 
transplant if, in the opinion of the veteran's primary care 
provider, the veteran has 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; 98 STAT. 
2339). This provision is in accordance with the Committee's 
belief that veterans in need of an organ or bone marrow 
transplant have highly complex needs that may impede their 
ability to travel for care more than other veterans and 
necessitate care in the community using a lower eligibility 
threshold than otherwise provided for through the Program. The 
Committee's further thoughts regarding the provision of 
transplant care through VA are explained in the descriptive 
portion of section 153 below. However, the Committee believes 
that veterans with amputations have similar needs to veterans 
in need of transplants and are deserving of a similarly lower 
threshold for community care. In particular, the Committee 
remains supportive of VA's long-standing practice to allow 
veterans with amputations to access prosthetic and orthotic 
care through community providers and encourages VA to continue 
that practice unabated.
    Access to community care would also be authorized through 
the Program for veterans in need of walk-in care. Veterans who 
have used VA health care services in the 24-month period prior 
would be eligible pursuant to this authority to seek walk-in 
care through community providers and Federally-qualified health 
centers who have entered into a contract or agreement with VA 
to provide such care. Veterans who are not required to make a 
copayment at a VA facility would be entitled to two walk-in 
care visits without a copayment though VA would be authorized 
to charge such veterans an adjustable copayment for subsequent 
walk-in care visits. Veterans who are required to make a 
copayment at a VA facility would pay such copayment for the 
first two walk-in care visits though VA would be authorized to 
charge an adjusted copayment for subsequent walk-in care 
visits.
    To resolve disputes regarding eligibility for care in the 
community under the Program, title I of the bill would require 
VA to provide veterans with a clinical appeal process to review 
community care eligibility determinations but prohibit such 
appeals from being appealed to the Board of Veterans Appeals. 
Title 1 of the bill would also require VA to develop and 
administer a number of training programs to ensure that 
veterans, VA employees, and community providers are fully aware 
of and educated on the Program, the VA healthcare system, and 
mental and physical health conditions that are common among 
veterans.
    To carry out the Program, VA would be required to enter 
into a contract or contracts to establish a network of 
community care providers and authorized to establish tiered 
networks pursuant to such contract or contracts but would be 
prohibited from prioritizing providers in one tier over another 
in a manner that limits a veteran's choice of providers. In 
order to ensure quality of the community care provider 
networks, VA would be authorized to deny, suspend, or revoke 
the eligibility of a community provider to participate in the 
community care program if the provider was previously removed 
from VA employment or had their medical license revoked.
    In recognition of the fact that veterans may sometimes 
require services from community providers who have not entered 
into a contract or agreement with VA, title I of the bill would 
authorize VA to pay for services not subject to a contract or 
agreement but deemed necessary by VA nevertheless. In such 
cases, VA would be required to take reasonable efforts to enter 
into a formal agreement, contract, or other legal arrangement 
to ensure that future care and services provided by the 
provider in question are covered.
    Title I of the bill would also allow for the continuity of 
existing memorandums of understanding and memorandums of 
agreement that were in effect on the day before enactment of 
the bill between VA and the American Indian and Alaska Native 
healthcare systems as established under the terms of the VA and 
Indian Health Service Memorandum of Understanding, signed 
October 1, 2010, the National Reimbursement Agreement, signed 
December 5, 2012, arrangements under section 405 of the Indian 
Health Care Improvement Act, and agreements entered into under 
sections 102 and 103 of the Choice Act to enhance the 
collaboration between VA and the Native Hawaiian health care 
system.
    Title I of the bill would require VA, to the extent 
practicable, to reimburse community care providers under the 
Program at Medicare rates. However, the Committee recognizes 
that such rates may not always be sufficient to yield an 
adequate provider network that is available to treat veteran 
patients, particularly in rural areas. As such, title I of the 
bill would authorize VA to pay higher rates in highly rural 
areas, to pay in accordance with the Alaska Fee Schedule for 
providers in Alaska, and to pay in accordance with applicable 
All-Payer Model Agreements in relevant states. What's more, 
title 1 would also authorize VA to incorporate value-based 
reimbursement models to the extent practicable to promote high-
quality care. The Committee encourages VA to utilize such 
models to provide dialysis care in the community to veterans 
pursuant to the national dialysis contracts that have been in 
place for the last several years and of which the Committee 
continues to strongly support.
    The Committee strongly believes that VA's ability to timely 
and accurately process payments to community providers is 
critical to the Program's success and to ensuring access to 
community care for the increasing number of veterans who rely 
on it. The Committee also recognizes that VA's ability to 
promptly reimburse community providers for the services they 
provide to veteran patients has significantly fallen short of 
expectations in recent years, which has hampered the viability 
of VA's community care provider networks. 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.\15\ 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.\16\ These 
findings were echoed in GAO testimony 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.''\17\ As such, title I of the bill would 
establish a prompt payment process that would require VA to pay 
for, or deny payment for, services within 30 calendar days of 
receipt of a clean electronic claim or within 45 calendar days 
of receipt of a clean paper claim. In the case of a denial, VA 
would have to notify the provider of the reason for denying the 
claim and what, if any, additional information would be 
required to process the claim. Upon the receipt of the 
additional information, VA would have to pay, deny, or 
otherwise adjudicate the claim within 30 calendar days. Any 
claim that has not been denied, made pending, or paid within 
the specified time periods would be considered overdue and 
subject to interest payment penalties. Community care entities 
or providers would be required to submit a claim to VA within 
180 days of providing care or services.
---------------------------------------------------------------------------
    \15\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.
    \16\Ibid.
    \17\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 VA may be best served by 
delegating claims processing to a thirty party entity. As such, 
title I would authorize VA to enter into an agreement with a 
third party entity to electronically process claims from 
community providers and would require an independent review of 
VA's capacity to process claims in a timely manner and a cost 
benefit analysis comparing VA's performance with a third party 
claims processing entity. It would also require that VA conduct 
a study on whether to establish a funding mechanism for a VA 
contractor to act as a fiscal intermediary for the Federal 
Government to pay claims.
    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 Choice Act 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 some community providers. 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.''\18\ 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.''\19\ 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. VA has requested legislative authority to enter into 
non FAR-based provider agreements since 2015.\20\ Accordingly, 
title I of the bill would authorize VA to enter into provider 
agreements called Veterans Care Agreements (VCAs). VCAs would 
not be subject to competition or other requirements associated 
with federal contracts and the same affirmative action 
moratorium that applies to TRICARE contractors and 
subcontractors pursuant to OFCCP Directive 2014-01 would apply 
to VCA contractors and subcontractors. Veteran eligibility for 
care under VCAs would be subject to the same terms as VA care 
itself and the rates paid under VCAs would, to the extent 
practicable, be in accordance with rates specified for the 
Program above.
---------------------------------------------------------------------------
    \18\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
    \19\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).
    \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
---------------------------------------------------------------------------
    Title I of the bill would also authorize VA to enter into 
VCAs with State Veterans Homes and eliminate competitive 
contracting actions and other requirements associated with 
federal contracts for State Veterans Homes. While not 
considered federal contactors for the purposes of this section, 
State Veterans Homes would still be required to follow federal 
laws related to employment, fraud, waste, and abuse.
    Finally, title I of the bill would require VA to perform 
market area assessments on a number of key factors at least 
once every four years. VA would be required to submit the 
assessments to Congress and to use them to determine the 
capacity of the Program's provider networks and access and 
quality standards. VA would also be required to submit a 
strategic plan to Congress, no later than one year after the 
date of enactment and at least every four years thereafter. The 
strategic plan would be required to specify the demand for care 
and the capacity to meet such demand both at each VA medical 
center and in the community. VA would be required to take a 
number of elements into consideration when developing the 
strategic plan and to identify emerging issues, challenges, and 
opportunities and recommendations to address them. The 
Committee believes the market area assessments and strategic 
plan will assist VA in successfully implementing the Program 
and in ensuring appropriate ongoing administration, management, 
and oversight of the Program by VA.

Chapter 4--Other Matters Relating to Non-Department of Veterans Affairs 
                               Providers


Section 131. Establishment of processes to ensure safe opioid 
        prescribing practices by non-Department of Veterans Affairs 
        health care providers

    Between 1999 and 2016 more than 200,000 deaths were 
attributed to overdoses from prescription drugs.\21\ Overdose 
deaths remain elevated within the civilian population and 
veterans have certainly not immune to that crisis or to the 
opioid epidemic. 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.\22\ However, as demand for community 
care among veterans continues to grow, the Committee is 
concerned about the potential for inconsistencies in the 
management of opioid prescriptions between VA and community 
providers. 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 
131 of the bill would require VA to provide OSI guidelines to 
community providers participating in the Program, certify that 
such providers have reviewed the guidelines, and implement a 
process to ensure that such providers receive a veteran's 
relevant history including all prescribed medications. It would 
further require that prescriptions for opioids be filled at a 
VA pharmacy (or at a community pharmacy only if prior 
authorization has been received with exceptions for certain 
urgent or emergent circumstances). It would also require opioid 
prescriptions to be recorded in the electronic health record 
and VA to remove from the Program provider networks any 
community provider whose prescribing practices are inconsistent 
with OSI or who violate licensing guidelines. The Committee 
believes this would ensure an equitable provision of care in VA 
and in the community and ensure safe and appropriate opioid 
prescriptions are provided to veteran patients regardless of 
where they receive VA care.
---------------------------------------------------------------------------
    \21\Prescription Opioid Overdose Data, Centers for Disease Control 
and Prevention; https://www.cdc.gov/drugoverdose/data/overdose.html.
    \22\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.
---------------------------------------------------------------------------

Section 132. Improving information sharing with community providers

    The Committee believes that it is vital for VA and 
community providers to be able to share pertinent medical 
record information about the veteran patients they are jointly 
treating in order to ensure that the care veterans receive in 
the community is safe, effective, coordinated and of the 
highest quality. This is particularly important given the 
dramatic and growing increase in community care appointments in 
the last several years, a trend the Committee expects to 
continue under the Program. Section 132 of the bill would 
clarify that VA could share medical record information with 
community providers for the purpose of providing health care to 
patients or performing other health care related activities and 
remove certain restrictions on VA's ability to recover funds 
from third parties for the cost of non-service-connected care. 
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 133. Competency standard for non-Department of Veterans Affairs 
        health care providers

    While noting the growing importance of an effective 
community care network on the overall strength and success of 
the VA healthcare system, the Committee nevertheless 
acknowledges that community providers are likely not as 
familiar with or competent in military- and veteran-specific 
conditions and concerns as VA providers are. To ensure that 
veterans are able to access culturally competent care from care 
through the Program, section 133 of the bill would require VA 
to establish competency standards for community providers. Such 
standards would include information regarding injuries and 
illnesses that VA has a special expertise in, such as post-
traumatic stress disorder, traumatic brain injury, and military 
sexual trauma. All community providers, to the extent 
practicable as determined by VA, would be required to meet 
these standards before furnishing care to veterans under the 
Program.

Section 134. Department of Veterans Affairs participation in national 
        network of State-based prescription drug monitoring programs

    The Centers for Disease Control and Prevention (CDC) 
defines a PDMP as an electronic database that tracks controlled 
substance prescriptions in a state and provides information 
about prescribing and patient patterns and behaviors.\23\ PDMPs 
have been shown to improve prescribing, inform clinical 
practice, protect at-risk patients, and decrease substance 
abuse treatment admissions.\24\ In 2011, the National 
Association of Boards of Pharmacy (NABP) developed and launched 
the Prescription Monitoring Program (PMP) InterConnect to 
facilitate the secure exchange of information across state 
lines by PDMPs.\25\ According to NABP, PDMPs are, ``. . . are 
enhanced by PMP InterConnect because [it] provides the means 
for physicians and pharmacists to more easily identify patients 
with prescription drug abuse and misuse problems, especially if 
those patients are crossing state lines to obtain drugs.''\26\ 
Currently 44 states and Washington, D.C. participate in PMP 
InterConnect with several additional states intending to begin 
sharing data using PMP InterConnect.\27\,\28\
---------------------------------------------------------------------------
    \23\What States Need to Know about PDMPs. Centers for Disease 
Control and Prevention. https://www.cdc.gov/drugoverdose/pdmp/
states.html. Accessed April 30, 2018.
    \24\Ibid
    \25\NABP PMP InterConnect: The Only National Network of State-Based 
PMPs. National Association of Boards of Pharmacy. https://
nabp.pharmacy/initiatives/pmp-interconnect/. Accessed April 30, 2018.
    \26\Ibid.
    \27\United States Cong. House Committee on Veterans' Affairs. 
Legislative Hearing. April 17, 2018. 115th Cong. 2nd sess. Washington: 
GPO, 2018 (statement from the Honorable Neal Dunn, U.S. House of 
Representatives, 2nd District, Florida).
    \28\NABP PMP InterConnect: The Only National Network of State-Based 
PMPs. National Association of Boards of Pharmacy. https://
nabp.pharmacy/initiatives/pmp-interconnect/. Accessed April 30, 2018.
---------------------------------------------------------------------------
    Section 5701(l) of title 38 United States Code (U.S.C.) 
requires VA to disclose information to PDMPs for either a 
veteran or the dependent of a veteran who is prescribed a 
controlled substance through VA ``to the extent necessary to 
prevent misuse or diversion of prescription medications.'' 
Veterans Health Administration (VHA) Directive 1306 provides VA 
national policy for querying PDMPs.\29\ It requires PDMPs to be 
queried prior to initiating therapy with a controlled 
substance, annually at a minimum, and more often when 
clinically indicated unless the patient is enrolled in hospice 
care or receives a controlled substance prescription for five 
days or less without refills.\30\ The results of such query are 
required to be documented in the patient's medical record and 
are subject to limitations imposed by state law, in which case 
providers and prescribers are required to conform to the 
policies and recommendations of their state licensure.\31\ 
According to VA, this policy allows providers to identify 
patients receiving controlled substances from multiple 
providers which may assist in preventing accidental or 
intentional misuse or diversion and in the detection, 
prevention, and early treatment of substance use disorders.\32\ 
However, the policy does not allow VA to track controlled 
substance prescriptions across multiple states since VA lacks 
the authority to use a system like PMP InterConnect.
---------------------------------------------------------------------------
    \29\VHA Directive 1306. Query State Prescription Drug Monitoring 
Programs. October 19, 2016.
    \30\Ibid.
    \31\Ibid.
    \32\Ibid.
---------------------------------------------------------------------------
    Section 134 of the bill would require VA to enter into an 
agreement with a national network of PDMPs to allow for the 
monitoring of controlled substance prescriptions written in 
participating states. It would also require VA health care 
providers practicing in states that do not have a PDMP to join 
the network of the closest state that does have a PDMP.

          Chapter 5--Other Non-Department Health Care Matters


Section 141. Plans for use of supplemental appropriations required

    Since the passage of the Choice Act in 2014, Congress has 
acted numerous times to address unexpected shortfalls in the 
Choice Fund and in VA's other medical care accounts as a result 
of higher than expected demand for care in the community and 
cost overruns as a result of the Denver replacement medical 
center project in Aurora, Colorado. Some of those instances are 
detailed in the descriptive portion of section 510 below. The 
Committee is concerned about VA's seeming inability to 
anticipate funding requirements and utilization timelines and 
the impact such inability may have on the provision of care to 
veteran patients and the appropriate use of taxpayer dollars. 
Section 141 of the bill would require VA to submit a 
justification to Congress for any new supplemental 
appropriations request submitted outside of the standard budget 
process. Such justification would be required no later than 45 
days before the date on which a budgetary issue would start 
affecting a program or service. It would be required to contain 
a detailed strategic plan for how VA intends to use the 
requested appropriation and for how long the requested funds 
are expected to meet the need.

Section 142. Veterans Choice Fund flexibility

    The Committee expects, based on numerous conversations with 
VA senior leaders and rank-and-file employees alike, that it 
will take one year from enactment for VA to implement the 
Program. As described in the descriptive portion of section 510 
below, the Committee intends to provide sufficient funding in 
this bill to fund Choice and ensure access to timely, quality 
care in the community to veteran patients until that time. 
However, the Committee understands that, as the Program 
approaches the implementation date, VA may require funding 
flexibility to enable the Department of sufficiently balance 
community care accounts. As such, section 142 of the bill would 
authorize VA, beginning on March 1, 2019, to use funds 
remaining in the Choice Fund to pay for community care provided 
to veteran patients pursuant to Chapter 17 of title 38 U.S.C. 
at community facilities or through community providers 
furnishing care in VA facilities.

Section 143. Sunset of Veterans Choice Program

    The Choice Act created and deposited $10 billion into the 
Veterans Choice Fund to fund the Choice program. It also 
stipulated that Choice would sunset either when the money in 
the Choice Fund was fully expended or three years after 
enactment of the Act. Since the law was enacted on August 7, 
2014, three years after enactment of the Act would have been 
August 7, 2017. However, the VA Choice and Quality Employment 
Act of 2017 (Public Law 115-26; 131 STAT. 129) amended the 
Choice Act to modify the termination date for Choice in April 
2017 following testimony that VA expected to have money left in 
the Choice Fund on August 7, 2017.\33\ Section 143 of the bill 
would provide a sunset date for the Veterans Choice Program one 
year after the date of enactment of this Act, upon which time 
the Committee expects the Program to be fully implemented.
---------------------------------------------------------------------------
    \33\United States Cong. House Committee on Veterans' Affairs 
Oversight Hearing--``Care Where it Count: Assessing VA's Capital Asset 
Needs.'' March 7 2017. 115th Cong. 1st sess. Washington: GPO, 2017 
(statement from the Honorable David Shulkin M.D, Secretary of Veterans 
Affairs).
---------------------------------------------------------------------------

   Subtitle B--Improving Department of Veterans Affairs Health Care 
                                Delivery


Section 151. Licensure of health care professionals of the Department 
        of Veterans Affairs providing treatment via telemedicine

    As a national, integrated health care system, VHA has a 
responsibility to ensure that veteran patients receive the same 
level of and access to care no matter where the veteran patient 
is located.\34\ 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.\35\
---------------------------------------------------------------------------
    \34\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.
    \35\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.''\36\ 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.\37\,\38\ 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.''\39\ 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.\40\ Veteran patients who have 
had experience with VA telemedicine programs have demonstrated 
improved health outcomes, including decreases in hospital 
admissions.\41\
---------------------------------------------------------------------------
    \36\VA Telehealth Services. https://www.telehealth.va.gov/ Accessed 
October 30, 2017.
    \37\Ibid.
    \38\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.
    \39\Ibid.
    \40\Ibid.
    \41\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.\42\ 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.\43\
---------------------------------------------------------------------------
    \42\Ibid.
    \43\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.\44\ 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.''\45\ Despite this rulemaking, VA 
testified during an October 24, 2017 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.''\46\
---------------------------------------------------------------------------
    \44\Ibid.
    \45\Ibid.
    \46\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).
---------------------------------------------------------------------------
    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.''\47\ As such, section 151 of the bill would 
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, and 
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. Section 151 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.
---------------------------------------------------------------------------
    \47\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 152. Authority for Department of Veterans Affairs Center for 
        Innovation for Care and Payment

    As the nation's largest integrated healthcare system, the 
Committee believes that VA has a unique ability to be a leader 
in the healthcare industry. However, all too often, VA has 
struggled to embrace innovation and private sector best 
practices that would allow VA facilities to maximize 
productivity, efficiency, and--most importantly--the provision 
of modern, high quality care. Section 152 of the bill would aid 
VA in this endeavor by authorizing a Center for Innovation for 
Care and Payment (the Center). Through the Center, VA would 
develop and test innovative approaches to testing payment and 
service delivery models to reduce expenditures while preserving 
or improving the quality of care. In doing so, VA would be 
authorize to waive any current statutory requirements but would 
first be required to submit a report to Congress explaining the 
authorities to be waived and the reasons for such a waiver and 
receive a bill or joint resolution approving such a waiver. VA 
would also be required to conduct an evaluation of each model 
tested and make such evaluation available to the public.

Section 153. Authorization to provide for operations on live donors for 
        purposes of conducting transplant procedures for veterans

    VA has offered solid organ transplant services for eligible 
veteran patients since 1962 and bone marrow transplant services 
for eligible veteran patients since 1982.\48\ 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.\49\
---------------------------------------------------------------------------
    \48\VA National Transplant Program. https://www.va.gov/health/
services/transplant/.Accessed October 30, 2017.
    \49\Ibid.
---------------------------------------------------------------------------
    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.\50\ Mr. Nelson's non-veteran son, Austin, was 
willing and able to serve as Mr. Nelson's live donor.\51\ 
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.\52\ \53\ 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.\54\ 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.\55\
---------------------------------------------------------------------------
    \50\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).
    \51\Ibid.
    \52\Ibid.
    \53\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
    \54\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).
    \55\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.\56\ 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 and that, for veterans receiving 
a transplant from a live donor, any associated care for the 
live donor, should be covered by VA. Consistent with those 
goals, section 153 of the bill would authorize VA to provide 
for any care or services a live donor may require to carry out 
a transplant procedure in either a VA transplant center or 
medical facility or VA community care facility for an eligible 
veteran notwithstanding that the live donor may not be eligible 
for VA health care.
---------------------------------------------------------------------------
    \56\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.
---------------------------------------------------------------------------

                     Subtitle C--Family Caregivers

    Improvements in battlefield medicine and follow-up 
treatment have significantly improved survival rates for 
severely wounded servicemembers. However, servicemembers 
returning from battle with severe wounds that would have 
previously proved fatal may require lifelong medical 
intervention and supportive care and, as a result, family 
members and friends are increasingly being called upon to act 
as caregivers. The Committee acknowledges how integral 
caregivers are to the rehabilitation and recovery process for 
severely injured veterans as well as the significant physical, 
mental, and financial toll that caregiving can take.
    In recognition of that, Congress passed the Caregivers and 
Veterans Omnibus Health Services Act (Public Law 111-163; 124 
STAT. 1130), which established two programs to provide support 
to veteran caregivers. The first program is the General 
Caregiver Support Services Program. Under the General Caregiver 
Support Services Program, caregivers of veterans from all eras 
are eligible to receive peer support mentoring, caregiving 
training, and support through VA's National Caregiver Support 
line and website as well as through VA Caregiver Support 
Coordinators located at every VA medical center. The second 
program is the Program of Comprehensive Assistance for Family 
Caregivers (Family Caregiver Program), which is available to 
post-9/11 veterans only.
    Under the Family Caregiver Program, approved family 
caregivers of post-9/11 veterans are eligible to receive a 
monthly, tax-free stipend paid directly to the caregiver; 
enrollment in VA's Civilian Health and Medical Program 
(CHAMPVA) if the caregiver is not already covered under an 
existing insurance plan; up to 30 days of respite care; and 
travel expenses when receiving initial caregiver training and 
during the veterans' medical appointments. Veterans (or 
servicemembers who are undergoing a medical discharge from the 
Armed Forces) are eligible for the Family Caregiver Program if 
they meet certain eligibility criteria, including: the presence 
of a serious injury incurred or aggravated in the line of duty 
on or after 9/11; a need for personal care services for at 
least six continuous months as a result of such serious injury; 
a clinical determination that participation in the Family 
Caregiver Program is in the veteran's best interest; the lack 
of simultaneous, regular provision of personal care services by 
or through another entity or program; and an agreement to 
receive ongoing care from a VA primary care team.
    Veteran demand for the Family Caregiver Program has 
outpaced expectations by 550 percent leading to delays, 
workload concerns, and other issues.\57\ Many of those concerns 
were detailed in a 2014 GAO report which found that staffing to 
support the Family Caregiver Program was insufficient to meet 
higher-than-expected demand at certain VA medical centers, with 
some Caregiver Support Coordinators managing a workload of up 
to 251 approved caregivers at a time.\58\ These staffing 
shortages impeded the timeliness of key functions and 
negatively affected services to caregivers.\59\ GAO also found 
that oversight of the Family Caregiver Program is impeded by 
information technology (IT) system limitations that prevented 
access to key workload and other data.\60\ This led GAO to 
conclude that, ``[a]fter 3 years of operation, it is clear that 
VHA needs to formally reassess and restructure key aspects of 
the Family Caregiver Program.''\61\ More than three years 
later, many of the recommendations that GAO made to address 
these findings remain open.
---------------------------------------------------------------------------
    \57\United States Cong. House Committee on Veterans' Affairs. ``VA 
Caregiver Support Program: Correcting Course for Veteran Caregivers.'' 
February 6, 2018. 115th Cong. 2nd sess. Washington: GPO, 2018 
(Statement of the Honorable David P. Roe M.D., Chairman, Committee on 
Veterans' Affairs, U.S. House of Representatives).
    \58\GAO-14-675, Actions Needed to Address Higher-Than-Expected 
Demand for the Family Caregiver Program. https://www.gao.gov/assets/
670/665928.pdf.
    \59\Ibid.
    \60\Ibid.
    \61\Ibid.
---------------------------------------------------------------------------
    Given that, the Committee has concerns about the management 
and administration of the Family Caregiver Program. However, 
the Committee also acknowledges the inequity that currently 
exists between pre- and post-9/11 veterans and their caregivers 
regarding the Family Caregiver Program. To address this 
inequity and recognize the service and sacrifice of veteran 
caregivers of all ages and eras, subtitle C of the bill would 
expand eligibility for the Family Caregiver Program to pre-9/11 
veterans. It would also require VA to implement an IT system 
that fully supports the Family Caregiver Program and allows for 
data assessment and comprehensive monitoring. Subtitle C would 
further amend requirements for VA's annual report on the Family 
Caregiver Program to include a description of any barriers to 
accessing and receiving care and services through the Family 
Caregiver Program and an evaluation of the sufficiency and 
consistency of the training provided to family caregivers.

              TITLE II--VA ASSET AND INFRASTRUCTURE REVIEW

              Subtitle A--Asset and Infrastructure Review

    VA is one of the federal government's largest property-
holding entities with a capital asset portfolio that includes 
approximately 155 million square feet across more than 35,000 
acres of land.\62\ Unlike many other federal agencies, the 
majority--86 percent--of VA's capital asset portfolio is 
owned.\63\ VA also controls approximately 24.6 million square 
feet of leased space.\64\ In July 2017, VA testified before the 
Committee that ``most of VA's infrastructure portfolio is 
dated, in need of repair/replacement, and requires considerable 
investment.''\65\ VA further testified that ``the majority of 
VA facilities have out-lived their useful life-cycle,'' raising 
serious questions about VA's continued ability to meet the 
needs of veteran patients and beneficiaries.\66\
---------------------------------------------------------------------------
    \62\United States Cong. House Committee on Veterans' Affairs 
Oversight Hearing--``Care Where it Count: Assessing VA's Capital Asset 
Needs.'' July 12, 2017. 115th Cong. 1st sess. Washington: GPO, 2017 
(statement from James M. Sullivan, Director of the Office of Asset 
Enterprise Management, U.S. Department of Veterans Affairs).
    \63\Ibid.
    \64\Ibid.
    \65\Ibid.
    \66\Ibid.
---------------------------------------------------------------------------
    Most VA facilities are medical facilities that are operated 
by VHA. Nationally, VHA's portfolio includes 168 VA medical 
centers, 135 community living centers, 48 domiciliary centers, 
737 community-based outpatient clinics, 22 health care centers, 
and 305 other outpatient facilities such as mobile treatment 
spaces.\67\ The average VHA building is approaching 60 years 
old, more than five times older than the average building age 
of a not-for-profit hospital system in the United States.\68\ 
These buildings were designed to meet an older, primarily 
inpatient, model of care.\69\ Thus, they are not well suited to 
provide care in accordance with modern, primarily outpatient, 
care models or to meet the contemporary ambulatory care needs 
of veteran patients.\70\
---------------------------------------------------------------------------
    \67\GAO-17-349, April 2017, ``VA Real Property: VA Should Improve 
Its Efforts to Align Facilities with Veterans' Needs,'' https://
www.gao.gov/assets/690/683938.pdf.
    \68\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.
    \69\Commission on Care, June 30, 2016, ``Commission on Care Final 
Report,'' https://s3.amazonaws.com/sitesusa/wp-content/uploads/sites/
912/2016/07/Commission-on-Care_Final-Report_063016_FOR-WEB.pdf
    \70\Ibid.
---------------------------------------------------------------------------
    VHA's capital asset portfolio also includes a significant 
number of vacant properties, which led the bipartisan 
Commission on Care to note in 2016 that ``VHA's principal 
mission is to provide health care to veterans, yet over time it 
has acquired an ancillary mission: caretaker of an extensive 
portfolio of vacant buildings.''\71\ The bipartisan Commission 
on Care also found that ``maintaining outdated, vacant, and 
unused buildings, which require millions of dollars in 
maintenance even in mothball status, diminishes operating funds 
needed for patient care and yields no benefit to veteran 
patients.''\72\ VA announced in June 2017 that the Department 
would initiate reuse or disposal of approximately 430 vacant 
buildings totaling 5.9 million gross square feet over the next 
two years.\73\ VA expects to save approximately $7 million 
annually as a result of this effort.\74\ VA also intends to 
review approximately 784 underutilized buildings to determine 
if they can be reused or disposed of to yield additional 
savings.\75\
---------------------------------------------------------------------------
    \71\Ibid.
    \72\Ibid.
    \73\United States Cong. House Committee on Veterans' Affairs 
Oversight Hearing--``Care Where it Count: Assessing VA's Capital Asset 
Needs.'' July 12, 2017. 115th Cong. 1st sess. Washington: GPO, 2017 
(statement from James M. Sullivan, Director of the Office of Asset 
Enterprise Management, U.S. Department of Veterans Affairs).
    \74\Ibid.
    \75\Ibid.
---------------------------------------------------------------------------
    The amount of empty or underutilized spaces across the VA 
health care system has been exacerbated by VHA's struggle to 
align VA medical facilities with the veteran patient 
population. In 2015, the Independent Assessment of the Health 
Care Delivery Systems and Management Processes of VA 
(Independent Assessment) found that VA struggles to 
consistently allocate capital to projects that represent the 
greatest areas of veteran need in the most cost effective and 
timely manner.\76\ The Independent Assessment argued that the 
misalignment of VA's properties with VA's patients was due, in 
part, to lengthy approval and funding timelines that hinder 
VA's ability to meet the identified space requirements to keep 
up with veteran demand and invest in facility updates that 
align with changing models for care.\77\ GAO made a similar 
judgment in a 2017 report that found significant geographic 
shifts in the veteran patient population coupled with changes 
in the delivery of care, ``antiquated'' infrastructure, and 
serious limitations with VA's capital planning processes 
created, ``an imperative for VA to better align its medical 
facilities and services.''\78\
---------------------------------------------------------------------------
    \76\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.
    \77\Ibid.
    \78\GAO-17-349, April 2017, ``VA Real Property: VA Should Improve 
Its Efforts to Align Facilities with Veterans' Needs,'' https://
www.gao.gov/assets/690/683938.pdf.
---------------------------------------------------------------------------
    Even absent a serious realignment effort, VA has identified 
more than $50 billion in capital needs over the next decade to 
modernize and maintain the Department's infrastructure.\79\ 
However, the capital requirement for VHA to maintain facilities 
and meet projected growth needs over the next decade is two to 
three times higher than anticipated funding levels, a gap which 
is expected to could continue to widen.\80\ Furthermore, the 
Independent Assessment also found that VA's construction costs 
are double private industry best practice, that VA time-to-
complete construction projects exceeds both public and private 
sector peers, and that VA's facility management costs are two 
to three times higher than comparable private medical 
facilities, on average.\81\
---------------------------------------------------------------------------
    \79\United States Cong. House Committee on Veterans' Affairs 
Oversight Hearing--``Care Where it Count: Assessing VA's Capital Asset 
Needs.'' July 12, 2017. 115th Cong. 1st sess. Washington: GPO, 2017 
(statement from James M. Sullivan, Director of the Office of Asset 
Enterprise Management, U.S. Department of Veterans Affairs).
    \80\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.
    \81\Ibid.
---------------------------------------------------------------------------
    VA has attempted to address the Department's capital asset 
challenges previously. In 2003, Secretary Principi initiated 
the VA Capital Asset Realignment for Enhanced Services (CARES) 
process.\82\ As part of CARES, an independent commission was 
formed to provide recommendations for the realignment and 
allocation of capital assets to meet veteran health care demand 
over the next 20 years.\83\ The CARES Commission conducted 38 
public hearings and 10 public meetings around the country, 
heard from 770 witnesses--including 135 members of Congress and 
seven governors--and received written comments from more than 
212,000 people.\84\ In February 2004, the CARES Commission 
released a report recommending substantial changes to existing 
VA facilities and a limited number of facility closures. Yet, 
thirteen years after the CARES report was released, its 
recommendations have yet to be fully implemented.\85\ Secretary 
Prinicipi testified before the Committee in July 2017 that, 
while CARES offered ``sound recommendations for realignment and 
allocation of the Department's capital assets to meet demand 
for VA's services over the next twenty years,'' it did not 
require Congress to adopt or reject the final CARES 
recommendations as a package and, thus, failed.\86\ The 
bipartisan Commission on Care similarly noted that ``political 
resistance doomed previous attempts to better align VHA's 
capital assets and veterans' needs.''\87\ In light of this, the 
Commission also recommended that Congress establish a VHA 
facility and capital asset realignment process based on the 
process established by the Department of Defense Base 
Realignment and Closure Commission process to be implemented as 
soon as practicable.\88\
---------------------------------------------------------------------------
    \82\February 12, 2004, VA Office of Public and Intergovernmental 
Affairs, ``CARES Commission Announces Recommendations,'' https://
www.va.gov/opa/pressrel/pressrelease.cfm?id=729.
    \83\Ibid.
    \84\Ibid.
    \85\United States Cong. House Committee on Veterans' Affairs 
Oversight Hearing--``Care Where it Count: Assessing VA's Capital Asset 
Needs.'' July 12, 2017. 115th Cong. 1st sess. Washington: GPO, 2017 
(statement from the Honorable Anthony J.Principi).
    \86\Ibid.
    \87\Commission on Care, June 30, 2016, ``Commission on Care Final 
Report,'' https://s3.amazonaws.com/sitesusa/wp-content/uploads/sites/
912/2016/07/Commission-on-Care_Final-Report_063016_FOR-WEB.pdf
    \88\Ibid.
---------------------------------------------------------------------------
    The Committee applauds VA's recent efforts to initiate 
reuse or disposal of vacant and underutilized properties across 
the country and encourages their continuation. However, the 
Committee also believes that bold steps are needed to fully 
address VHA's significant and increasing capital asset 
challenges, to ensure VHA uses taxpayer dollars wisely in 
caring for the nation's veterans, and--most importantly--to 
ensure a strong VA health care system is available to meet the 
needs veteran patients both today and for generations to come. 
Accordingly, the Committee concurs with the bipartisan 
Commission on Care's recommendation to establish a robust VHA 
capital asset realignment process freed, to the greatest extent 
possible, from political constraints.
    As such, title II of the bill would require VA to establish 
a nine member AIR Commission. The AIR Commissioners would be 
appointed by the President, with the advice and consent of the 
Senate and in consultation with Congressional leaders and 
congressionally chartered, membership-based veterans service 
organizations (VSOs). The Commission as a whole would be 
required to reflect current demographics of veterans enrolled 
in the VA health care system and to have expertise in health 
care system and federal capital asset planning and management. 
In addition, at least three Commissioners would be required to 
represent the VSO community. The Commission would be tasked 
with considering recommendations made by VA and submitting a 
report to the President on VHA facility modernization and 
realignment. The Commission would only be able to change a 
recommendation made by VA for the modernization or realignment 
of a VHA facility if: the Commission determines that VA 
deviated substantially from VA's criteria in making a given 
recommendation and a change would be consistent with the final 
criteria; the Commission publishes a notice of the proposed 
change in the Federal Register not less than 45 days before 
transmitting the Commission's report including the change to 
the President; and the Commission conducts public hearings on 
the proposed change. Upon the President's approval of the 
Commission's report, the report would be transmitted to 
Congress. Congress would be required to act under expedited 
legislative procedures to issue a resolution of disapproval of 
the Commission's report and the full list of recommendations it 
contains. Absent such a resolution, VA would be required to 
take any such action as may be necessary to carry out the 
actions recommended by the Commission.
    The Committee recognizes that the implementation of the 
Commission's recommended actions would be a substantial task 
for VA as it is likely that VA will need to carry out a level 
of construction, leasing, environmental compliance, and 
property disposition activity that exceeds typical levels. As 
VA's existing legal authority to initiate property actions may 
be inadequate to accommodate the Commission's recommendations, 
title II of the bill would include additional authorities to 
allow VA to take such action as may be necessary to modernize 
or realign any VHA facility and to transfer or lease properties 
to historic preservation organizations. To ensure that VA's 
maintenance needs continue to be met while the Commission's 
work is ongoing, title II of the bill would prohibit VA from 
pausing major or minor construction activities while the 
Commission process is ongoing.
    The Committee intends for the AIR Commission process to be 
data-driven and to incorporate feedback from veterans, 
employees, stakeholders, and communities who would be most 
impacted by VHA modernization or realignment. As such, title II 
of the bill would require VA to consult with VSOs to establish 
criteria to use to assess and recommend the modernization or 
realignment of VHA facilities and to take certain factors--
including local veteran and stakeholder input--into account to 
ensure such recommendations are robust and fair. Title II of 
the bill would also require VA to consult with local veterans 
and VSOs to conduct periodic assessments of the capacity of 
each Veterans Integrated Service Network (VISN) and VA medical 
facility to furnish hospital care or medical services to 
veterans. Each assessment would be required to: (1) identify 
existing deficiencies in the furnishing of care and services to 
veterans and how such deficiencies may be filled by entering 
into contracts or agreements with community health care 
providers or other entities under other provisions of law and 
changing the way care and services are furnished at such VISNs 
or VA medical facilities (including through extending hours of 
operation, adding personnel, and expanding treatment space 
through construction, leasing, or sharing of health care 
facilities); (2) forecast both the short-term and long-term 
demand in furnishing care and services at such VISN or VA 
medical facility; (3) consider how demand affects the need to 
enter into contracts or agreements; (4) consider the commercial 
health care market of designated catchment areas conducted by a 
non-governmental entity; and (5) consider the unique ability of 
the Federal government to retain a presence in a rural area 
otherwise devoid of commercial health care providers or from 
which such providers are at risk of leaving.
    The Committee also intends the AIR Commission process to be 
transparent and veteran-centric. Accordingly, title II of the 
bill would: require that each meeting of the Commission be open 
to and all proceedings, information, and deliberations of the 
Commission to be available for review by the public; to require 
the online publication within 24 hours of any information 
transmitted or received by VA, the Commission, or the President 
regarding the Commission (or related activities) to be 
published online within 24 hours; prohibit the restriction of 
lawful communication from a VA employee to the Commission; 
require VA to make the local capacity and commercial market 
assessments publically available; and require the Commission to 
conduct public hearings and include local veterans and VSOs as 
witnesses in those hearings.
    The Committee is aware that the ultimate success of the 
Commission may be contingent upon ensuring VA has sufficient 
time before the Commission begins its work to gather needed 
data, establish appropriate criteria, and make initial 
recommendations regarding facility actions. Accordingly, title 
II of the bill would allow VA until January 31, 2022, before 
transmitting recommendations to the Commission for review. The 
Commission would then have a year to conduct their work before 
transmitting the Commission's report to the President on 
January 31, 2023. The Commission would terminate on December 
31, 2023.
    The Committee is aware of the sensitive political 
considerations inherent in the AIR Commission process and, as 
such, title II of the bill includes provisions stipulating 
expedited legislative consideration of the Commission's report 
by Congress. The Committee believes expedited consideration is 
appropriate and necessary given the Committee's full 
concurrence with Secretary Principi's testimony that:
          [VA] will fail to honor our nation's commitment to 
        its veterans if VA's medical system does not evolve 
        with the times. . . While the practice of VA medicine 
        has evolved, VA's medical infrastructure has not kept 
        pace. VA facilities are out of step with changes in the 
        practice of medicine, with demographic changes in the 
        veteran population, and with statutory changes in VA's 
        health care benefits packages. If VA does not realign 
        itself, and close its unneeded facilities, the current 
        decline in the veteran population will make many VA 
        medical centers museums of the past--not the guideposts 
        for the future they should be.\89\
---------------------------------------------------------------------------
    \89\United States Cong. House Committee on Veterans' Affairs 
Oversight Hearing--``Care Where it Count: Assessing VA's Capital Asset 
Needs.'' July 12, 2017. 115th Cong. 1st sess. Washington: GPO, 2017 
(statement from the Honorable Anthony J.Principi).
---------------------------------------------------------------------------
    However, it is important to note that the Committee in no 
way intends title II of the bill to supersede the prohibition 
on the sale of the VA Greater Los Angeles Healthcare System 
West LA (WLA) campus in Los Angeles, California, in current 
law. The 387-acre property that the WLA campus resides on was 
deeded to the United States in 1888 to be used as the Pacific 
Branch of the National Home for Disabled Volunteer 
Soldiers.\90\ The property was maintained in accordance with 
this purpose until the 1970s when the WLA campus was placed 
there. Today, the WLA campus is one of the busiest and largest 
medical and research campuses in the entire VA healthcare 
system. The Homeless Veterans Comprehensive Service Programs 
Act of 1992 (Public Law 102-590, 106 STAT. 5136) authorized VA 
to lease property on the WLA campus. However, in 2011, the 
American Civil Liberties Union (ACLU) of Southern California 
filed a class action lawsuit on behalf of homeless veterans 
with disabilities alleging that VA was misusing the WLA campus 
and discriminating against homeless veterans, ``because they 
cannot access the medical, mental health and other services to 
which they are entitled'' in part due to VA's use of the WLA 
campus leasing authority.\91\ In January 2015, VA and attorneys 
for the plaintiffs announced that they had reached an agreement 
in that lawsuit in which VA agreed to develop a master plan for 
the WLA campus to prioritize bridge and permanent supportive 
housing for homeless veterans. The West Los Angeles Leasing Act 
of 2016 (Public Law 114-226; 130 STAT. 926) authorized VA to 
carry out certain leases on the WLA campus in accordance with 
the master plan and prohibited the sale of any property located 
on the WLA campus. Similar prohibitions can be found in both 
the Veterans' Benefits and Services Act of 1988 (Public Law 
100-322; 102 STAT. 487) and the Consolidated Appropriations 
Act, 2008 (Public Law 110-161; 121 STAT. 1844). Given the 
unique history and importance of the property the WLA campus is 
located on, the Committee is strongly supportive of maintaining 
and improving the WLA campus and increasing the services 
provided to veterans on and through it.
---------------------------------------------------------------------------
    \90\VA Greater Los Angeles Campus Draft Master Plan, January 28, 
2016, http://www.losangeles.va.gov/masterplan/.
    \91\Valentini v. Shinseki. https://www.aclusocal.org/valentini/.
---------------------------------------------------------------------------

                Subtitle B--Other Infrastructure Matters


Section 211. Improvement to training of construction personnel

    VA's construction management capability has come under 
intense scrutiny for inadequacy in recent years. For example, 
in 2013, GAO found that were substantially increased costs and 
schedules were delayed for the largest VA major medical 
facility construction projects in Denver, Colorado; Las Vegas, 
Nevada; New Orleans, Louisiana; and Orlando, Florida.\92\ In 
2015 GAO testified before the Committee that these projects 
ranged from 66 percent to 427 percent over budget and 14 months 
to 86 months behind schedule.\93\ Given these findings, 
Congress enacted the Department of Veterans Affairs Expiring 
Authorities Act of 2015 (Public Law 114-58; 129 STAT. 530), 
which required that all VA medical facility construction 
projects exceeding $100 million be managed by another federal 
agency. Congress also enacted the Jeff Miller and Richard 
Blumenthal Veterans Health Care and Benefits Improvement Act of 
2016 (Public Law 114-315; 130 STAT. 1536), which required that 
each VA employee with construction responsibilities undergoes a 
program of ongoing professional training and development 
including instruction on industry standards and acquisition 
best practices. However, the Committee remains concerned about 
the level of training that VA construction personnel receive 
and about VA's interpretation of current law give that it 
appears that VA has interpreted and implemented the law to 
cover training courses that are not significantly more numerous 
or wide ranging than the courses being offered before the law's 
enactment. The Committee also believes that it is necessary to 
broaden training in construction disciplines beyond architects, 
engineers, real property specialists, and other such 
professionals located in programmatic offices that are 
specifically devoted to construction. There is a much wider 
universe of personnel involved in construction acquisition, 
notably including contracting officers, contract specialists, 
and contracting officers' representatives. Relatedly, since the 
passage of the Defense Workforce Improvement Act of 1991 
(Public Law 101-510; 104 STAT. 1485), the accepted way to 
deliver such interdisciplinary acquisition training is through 
formal certification programs. All civilian agencies have 
subsequently been mandated to adopt certification programs for 
the fields of contracting and program management. The 
Department of Defense continues to offer a wider range of 
certification programs to its employees, notably including 
certification in facilities engineering. The Committee asserts 
that it would be advantageous for VA to adopt a similar, formal 
certification program for construction and facilities 
management.
---------------------------------------------------------------------------
    \92\GAO 13-302, GAO Report, ``VA Construction: Actions Needed to 
Decrease Delays and Lower Costs of Major Medical Facility Projects,'' 
April 4, 2013.
    \93\GAO-15-332T, GAO Testimony ``VA Construction: VA Actions to 
Address Cost Increases and Schedule Delays at Major Medical-Facility 
Projects,'' January 21, 2015; GAO-15-564T, GAO Testimony, ``VA 
Construction: Actions to Address Cost Increases and Schedule Delays at 
Denver and Other VA Major Medical-Facility Projects,'' April 24, 2015.
---------------------------------------------------------------------------
    In accordance with this belief, section 211 of the bill 
would require VA to implement a training and certification 
program for construction and facilities management personnel. 
All VA employees who are members of occupational series 
relating to construction or facilities management or VA 
employees who award or administer contracts for major 
construction, minor construction, or non-recurring maintenance 
(including contract specialists or contracting officers' 
representatives) would be included in such a program. VA would 
be required to create the training and certification program 
within one year of enactment, to ensure a majority of covered 
employees are certified within two years of enactment, and to 
ensure that all covered employees are certified as quickly as 
possible thereafter. VA would be required to model the training 
and certification program on existing curricula and 
certification programs in title 10 U.S.C. (namely, the existing 
Defense Acquisition Workforce Improvement Act program).

Section 212. Review of enhanced use leases

    Section 8162 of title 38 U.S.C. authorizes VA to enter into 
enhanced use leases (EULs) with respect to VA property. Through 
this authority, VA out-leases underutilized real estate to 
private sector entities for the purpose of developing 
supportive housing for homeless and at-risk veterans and their 
families.\94\ VA asserts that EUL authority affords the 
Department the ability to provide veterans with an expanded 
range of services that would not otherwise be available on 
medical center campuses and is both an important component of 
VA's program to end homelessness among veterans and a critical 
tool to assist VA in the effective management of physical 
assets. The Committee concurs with that though also believes 
that oversight of VA's use of its EUL authority is critical to 
ensure the appropriate use of VA property. As such, section 212 
would require the Office of Management and Budget to review 
each EUL before it goes into effect to determine whether it is 
in compliance with relevant statutes.
---------------------------------------------------------------------------
    \94\Enhanced Use Lease (EUL). Department of Veterans Affairs. 
https://www.va.gov/assetmanagement/. Accessed May 9, 2018.
---------------------------------------------------------------------------

Section 213. Assessment of health care furnished by the Department to 
        veterans who live in the Pacific territories

    Veterans in 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 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 213 of the bill would 
require VA to report on the care provided to veterans in these 
areas. Such a report would be required to include whether VA 
believes it would be feasible and appropriate to establish a VA 
facility in any territory that does not already contain such a 
facility.

  TITLE III--IMPROVEMENTS TO RECRUITMENT OF HEALTH CARE PROFESSIONALS

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, including the Education Debt Repayment 
Program and the Health Professions Scholarship Program (HPSP). 
Despite these programs, VA maintains a significant number of 
physician vacancies across the VA healthcare system. VA's 
considerable recruitment and retention issues are worsened by 
an aging workforce that is becoming increasingly retirement-
eligible.\95\
---------------------------------------------------------------------------
    \95\United States Cong. House Committee on Veterans' Affairs. 
Legislative Hearing. March 16, 2016. 114th Cong. 2nd sess. Washington: 
GPO, 2016. (Testimony from the Partnership for Public Service.)
---------------------------------------------------------------------------
    To help alleviate the shortage of physicians, section 301 
of the bill 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. Increase in maximum amount of debt that may be reduced 
        under Education Debt Reduction Program of Department of 
        Veterans Affairs

    The Education Debt Repayment Program (EDRP) was authorized 
by the Veterans Programs Enhancement Act of 1998 (Public Law 
105-368; 112 STAT. 3315). EDRP is intended to provide veteran 
patients with specialized care by increasing the supply of 
qualified health care professionals in VA facilities and 
assisting VA in meeting the need for qualified health care 
professionals in occupations where recruitment or retention is 
difficult.\96\ VA recently testified that EDRP is among VA's 
most effective recruitment and retention programs.\97\ The 
Committee strongly supports EDRP and recognizes the value it 
has provided to VA facilities across the country. In an effort 
to strengthen the effectiveness of EDRP, section 302 of the 
bill would increase the amount of education debt reduction 
available through EDRP from $120,000 to $200,000 over five 
years and from $24,000 to $40,000 annually.
---------------------------------------------------------------------------
    \96\Education Debt Reduction Program (EDRP). https://
www.vacareers.va.gov/assets/common/print/EDRP_VA_Careers_Page.pdf. 
Accessed May 8, 2018.
    \97\United States Cong. House Committee on Veterans' Affairs. ``FY 
2019 Department of Veterans Affairs Budget Request for the Veterans 
Health Administration.'' March 15, 2018. 115th Cong. 2nd sess. 
Washington: GPO, 2018. (Testimony from Carolyn M. Clancy M.D., 
Executive in Charge of the Veterans Health Administration for the U.S. 
Department of Veterans Affairs.)
---------------------------------------------------------------------------

Section 303. Establishing the Department of Veterans Affairs specialty 
        education loan repayment program

    Given the recruitment and retention challenges that VA 
faces and the need for VA to hire more high quality providers 
to treat veteran patients, section 303 of the bill would 
establish a new loan repayment program for medical or 
osteopathic student loans for newly graduated medical students 
or residents with at least 2 years of training remaining and 
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, the 
Committee believes this would make the loan repayment more 
economically meaningful and allow VA to fund specialty 
positions in shortage areas, develop a predictable future 
physician workforce, and ensure a cadre of physicians who are 
incentivized to join VA's physician workforce and treat the 
nation's veterans.

Section 304. Veterans healing veterans medical access and scholarship 
        program

    In order to assist VA in recruiting veteran physicians, 
section 304 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 at four 
historically black colleges and universities. 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 their last military discharge who are not eligible 
for GI Bill benefits and who meet the minimum admission 
requirement for medical school. 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.

Section 305. Bonuses for recruitment, relocation, and retention

    Chapter 45 and Chapter 53 of title 5 U.S.C. authorizes VA 
to provide awards and bonuses to employees. The Choice Act 
limited the amount of awards and bonuses payable to VA 
employees to no more than $360 million from fiscal year 2014 
through fiscal year 2024. The Comprehensive Addiction and 
Recovery Act of 2016 (Public Law 114-198; 130 STAT 695) further 
limited the amount of awards and bonuses payable to VA 
employees to $230 million for fiscal year 2017 through fiscal 
year 2018, $225 million for fiscal year 2019 through fiscal 
year 2021, and $360 million for fiscal year 2022 through fiscal 
year 2024. The limitations imposed on awards and bonuses to VA 
employees included recruitment, relocation, and retention 
incentive payments. This has raised concerns from VA, VSOs, and 
other stakeholders that such limitations could have unintended 
negative consequences on VA's ability to hire high-quality 
clinicians and support staff to effectively serve veteran 
patients. As such, section 305 of the bill roll back the 
limitation on amounts available for award and would prioritize 
recruitment, relocation, and retention incentives within the 
total limitations on awards and bonuses.

Section 306. Inclusion of Vet Center employees in education debt 
        reduction program of Department of Veterans Affairs

    As referenced in the analysis portion of section 302 of the 
bill above, the Committee strongly supports EDRP and believes 
it to be an effective tool to increase recruitment and 
retention of highly-qualified clinicians. Through the 
Readjustment Counseling Service, VA operates 300 Vet 
Centers.\98\ Vet Centers provide readjustment counseling 
services to eligible veterans, servicemembers, and their 
families in an effort to assist them in making a successful 
transition from the military to civilian life.\99\ Such 
services include individual, group, and family counseling; 
bereavement counseling; military sexual trauma counseling; peer 
support; recreational opportunities; substance abuse 
assessment; and employment assessment.\100\ The Committee 
strongly supports the Vet Center program and commends the VA 
clinicians working there for the services they provide to 
veterans and their families. In an effort to aid those 
clinicians in their work and to recruit more clinicians to join 
their ranks, section 306 of the bill would require VA to ensure 
that clinical staff working in Vet Centers are eligible to 
compete for and participate in EDRP.
---------------------------------------------------------------------------
    \98\Vet Center Program. https://www.vetcenter.va.gov/
Vet_Center_Services.asp. Accessed May 8, 2018.
    \99\Ibid.
    \100\Ibid.
---------------------------------------------------------------------------

               TITLE IV--HEALTH CARE IN UNDERSERVED AREAS

    The Department of Health and Human Services' Health 
Resources and Services Administration (HRSA) defines a 
medically underserved area as an area designated by HRSA as 
having too few primary care providers, a high infant mortality, 
a high poverty or a high elderly population.\101\ The Committee 
acknowledges that some VA facilities may meet this criterion or 
may otherwise face unique challenges to providing timely, 
quality care for veteran patients. As such, those facilities 
may require a higher level of support and resources and should 
be identified and supported by VA leaders. Accordingly, title 
IV of the bill would require VA to: (1) develop criteria to 
designate VA medical facilities as underserved facilities; (2) 
consider a number of factors with respect to such facilities, 
including the ratio of veterans to providers; the range of 
specialties covered; whether the local community is medically 
underserved; the type, number, and age of open consults; and 
whether the facility is meeting VA's wait time goals; (3) 
perform an analysis annually (if not more often) to determine 
which facilities qualify as underserved; and (4) submit a plan 
to Congress, within one year of enactment and not less 
frequently than annually thereafter, to address underserved 
facilities. Title IV of the bill would also require VA to carry 
out a three-year pilot program to furnish mobile deployment 
teams of medical personnel to underserved facilities and to 
consider the medical positions of greatest need at such 
facilities and the size and composition of teams to be 
deployed. It would also require VA to establish a pilot program 
to establish medical residency programs at covered facilities, 
including VA facilities, a facility operated by an Indian tribe 
or tribal organization, an Indian Health Service facility, a 
Federally-qualified health center, or a DOD facility.
---------------------------------------------------------------------------
    \101\AMUA Find. Health Resources and Services Administration. 
https://datawarehouse.hrsa.gov/tools/analyzers/muafind.aspx. Accessed 
May 9, 2018.
---------------------------------------------------------------------------

                         TITLE V--OTHER MATTERS

Section 501. Annual report on performance awards and bonuses awarded to 
        certain high-level employees of the Department

    As referenced in the analysis portion of section 305 of the 
bill above, current law authorizes VA to provide performance 
awards and bonuses to certain employees. The Committee 
recognizes that this authority represents an important 
recruitment and retention tool and can be a powerful incentive 
to hard-working employees at all levels of the Department. The 
Committee supports a judicious use of this authority to reward 
top performers but desires transparency for Congress and the 
American people regarding the performance awards and bonuses 
that are paid to senior leaders across the country. As such, 
section 501 of the bill would require VA to submit an annual 
report to Congress on performance awards and bonuses paid to 
the Veterans Integrated Service Network Directors, VA medical 
center Directors, Regional Office Directors, and senior 
executives. Each such report would be required to include the 
amount of each award or bonus, the job title of each individual 
who received an award or bonus, and the location where each 
individual who received an award or bonus works.

Section 502. Role of Podiatrists in Department of Veterans Affairs

    Approximately 61 percent of veterans newly separated from 
service in the Armed Forces have used VA health care since 
October 1, 2001.\102\ The most common diagnosis for these 
veterans is for a musculoskeletal ailment.\103\ Some of these 
musculoskeletal ailments are the result of lower extremity 
injuries inflicted by improvised explosive devices on the 
battlefield. Musculoskeletal ailments and lower extremity 
injuries are also an increasingly prevalent concern among 
previous generations of veterans who may be struggling with 
issues exacerbated by aging, chronic conditions like diabetes, 
and complications resulting from military service. A February 
2017 VA white paper states that, in fiscal year 2016, 
approximately 1.8 million veteran users of the VA healthcare 
system were at risk for major foot wounds, infection, and 
amputations.\104\ That number represents a 21 percent increase 
from fiscal year 2015.\105\ This led VA to conclude that, 
``[t]here is a growing health care demand for primary and 
specialty podiatric services, especially among veterans 
suffering from polytraumatic injuries, spinal cord injury, and 
limb amputation.''\106\
---------------------------------------------------------------------------
    \102\VA Health Care Utilization by Recent Veterans. Public Health, 
Epidemiology. https://www.publichealth.va.gov/epidemiology/reports/
oefoifond/health-care-utilization/. Accessed July 20, 2017.
    \103\Ibid.
    \104\Department of Veterans Affairs White Paper on Podiatry Pay. 
February 2017.
    \105\Ibid.
    \106\Ibid.
---------------------------------------------------------------------------
    However, VA's ability to effectively and efficiently 
recruit and retain podiatrists to treat foot and ankle issues 
among veteran patients are hampered by outdated statutory 
requirements governing the treatment of podiatrists within the 
VA healthcare system. VA's qualifications for podiatrists were 
developed in 1976 and have not kept pace with modern podiatric 
education and training.\107\ The American Podiatric Medical 
Association (APMA) testified in 2017 that ``unlike 41 years 
ago, the current podiatric medical school curriculum is vastly 
expanded in medicine, surgery and patient experiences and 
encounters, including whole body history and physical 
examinations.''\108\ Because VA's standards do not align with 
current podiatry practice, VA podiatrists experience 
disparities in recognition and pay when compared to their non-
VA peers, which results in serious podiatry recruitment and 
retention issues within VA. The average compensation for a 
podiatrist in the private sector is $30,000 higher than the 
highest compensation available to a podiatrist practicing in 
VA.\109\ As a result, VA struggles to recruit the most 
experienced, qualified podiatrists and to retain the 
podiatrists already practicing within the VA healthcare system. 
For example, in fiscal years 2015 and 2016, almost 62 percent 
of VA medical centers had to replace podiatrists, disrupting 
patient care and continuity.\110\ What's more, 66 percent of 
the new podiatrists hired in 2016 had less than 10 years of 
experience and only 30 percent were board certified.\111\ 
Further, when there is a podiatry vacancy within a VA medical 
facility, it takes an average of 14 months, for that vacancy to 
be filled.\112\
---------------------------------------------------------------------------
    \107\Ibid.
    \108\United States Cong. House Committee on Veterans' Affairs 
Subcommittee on Health. ``VA Specialized Services: Lower Extremity 
Conditions'' May 2, 2017. 115th Cong. 1st sess. Washington: GPO, 2017 
(statement from Seth Rubenstein DPM, Treasurer, Board of Trustees/
Immediate Past Chairman, Legislative Committee, American Podiatric 
Medical Association).
    \109\United States Cong. House Committee on Veterans' Affairs 
Subcommittee on Health. ``VA Specialized Services: Lower Extremity 
Conditions'' May 2, 2017. 115th Cong. 1st sess. Washington: GPO, 2017 
(statement from Jeffrey Robbins, DPM, Chief of Podiatry, Veterans 
Health Administration, U.S. Department of Veterans Affairs).
    \110\Ibid.
    \111\Ibid.
    \112\VA White Paper on Podiatry Pay. February 2017.
---------------------------------------------------------------------------
    To address the growing need for podiatry care within the VA 
healthcare system, section 502 of the bill would stipulate that 
a VA podiatrist is eligible to be appointed to a supervisory 
position to the same degree that a VA physician is eligible to 
be appointed to such a position. To ensure appropriate 
supervision of specialty providers within the VA healthcare 
system, section 502 of the bill would also require VA to work 
with appropriate stakeholders to establish standards to ensure 
that specialists appointed to supervisory positions do not 
provide direct clinical oversight for purposes of peer review 
or practice evaluation for providers of other clinical 
specialties. Further, section 502 of the bill would make 
Doctors of Podiatric Medicine (DPMs) equal to Doctors of 
Osteopathy (DOs) and Medical Doctors (MDs) in terms of pay 
within the VA healthcare system. The Committee believes that 
this will correct long-standing inequities between the 
treatment of podiatrists in VA medical facilities and in the 
private sector, significantly improve VA's ability to recruit 
and retain high-quality podiatrists to treat veteran patients 
with foot and ankle issues and result in better care and higher 
cost savings than would otherwise be expected.

Section 503. Definition of major medical facility project

    Section 8104(a)(2) of title 38, U.S.C. requires 
Congressional authorization for VA major medical facility 
projects. A ``major medical facility project'' is defined as a 
project for the construction, alteration, or acquisition of a 
medical facility involving a total expenditure of more than $10 
million. That $10 million threshold was set by the Veterans 
Benefits, Health Care, and Information Technology Act of 2006 
(Public Law 109-461, 120 STAT. 3403), which raised such 
threshold from $7 million to $10 million. The bipartisan 
Commission on Care noted that this $10 million threshold--which 
has not been revisited since 2006--has made it difficult for VA 
to modernize and renovate aging facilities in recent 
years.\113\ The Committee concurs. Section 503 of the bill 
would modify the definition of a VA major medical facility 
project by raising the threshold for Congressional 
authorization from $10 million to $20 million.
---------------------------------------------------------------------------
    \113\Commission on Care, June 30, 2016, ``Commission on Care Final 
Report,'' https://s3.amazonaws.com/sitesusa/wp-content/uploads/sites/
912/2016/07/Commission-on-Care_Final-Report_063016_FOR-WEB.pdf
---------------------------------------------------------------------------

Section 504. Authorization of certain major medical facility projects 
        of Department of Veterans Affairs

    As referenced in the analysis portion of section 503 of the 
bill above, section 8104(a)(2) of title 38, U.S.C. requires 
Congressional authorization for VA major medical facility 
projects. Section 504 of the bill would authorize a VA major 
medical facility project in Livermore, California, in an amount 
not to exceed $117.3 million.

Section 505. Department of Veterans Affairs personnel transparency

    Committee oversight as well as GAO and IG reports have 
found inadequate staffing and gaps in hiring at VA facilities 
nationwide for the last several years. This can adversely 
impact care to veteran patients by creating or contributing to 
access issues and scheduling delays. In December 2016, GAO 
released a report, which found that VHA fell short of Federal 
standards for effective internal controls to support Human 
Resources (HR) functions, compromising VHA's ability to deliver 
sufficient support to effectively recruit and retain the high-
quality employees VA needs to effectively serve veteran 
patients.\114\ This finding is consistent with the Committee's 
findings that VA HR employees in the field and in leadership 
often lack information regarding key measures that could 
indicate weaknesses in HR practices. This is particularly 
concerning given that testimony before the Committee has found 
that VA's considerable recruitment and retention issues are 
worsened by an aging workforce that is becoming increasingly 
retirement-eligible.\115\ In order to increase transparency 
with respect to staffing for VA facilities and aid in 
Congressional and stakeholder oversight of the generous hiring 
authorities that VA has been granted, section 505 of the bill 
would require VA to make information regarding vacancies, 
accessions and separation actions, new hires, and personnel 
encumbering positions publically
---------------------------------------------------------------------------
    \114\GAO-17-30, December 2016, ``Management Attention is Needed to 
Address Systemic, Long-standing Human Capital Challenges,'' http://
www.gao.gov/assets/690/681805.pdf
    \115\United States Cong. House Committee on Veterans' Affairs 
Subcommittee on Health. ``Legislative Hearing on draft legislation to 
improve the authority of the Secretary of Veterans Affairs to hire and 
retain physicians and other employees of the Department of Veterans 
Affairs.'' March 16, 2016. 114th Cong. 2nd sess. Washington: GPO, 2016 
(Testimony of Max Stier, President and Chief Executive Officer, 
Partnership for Public Service.) available on a VA website. It would 
also require the IG to conduct a review of the website on a semi-annual 
basis and VA to report to Congress annually on the steps VA is taking 
to achieve full staffing capacity, including the amount of additional 
funds necessary to enable VA to reach full staffing capacity.
---------------------------------------------------------------------------

Section 506. Program on establishment of peer specialists in patient 
        aligned care team settings within medical centers of Department 
        of Veterans Affairs

    VA operates a number of programs in which veteran patients 
are assisted by fellow veterans who are employed by VA (or 
serve as volunteers) and work alongside the veteran patient's 
care team to promote a successful recovery and reintegration 
and adherence to the veteran patient's plan of care. The 
Committee strongly supports peer support programs, particularly 
for those veteran patients who are struggling with mental 
health or substance abuse issues. The Committee believes that 
further integrating peer support into VA primary care settings 
could help engage more veterans into these programs and assist 
in reducing stigma and other barriers to care among at-risk 
veterans. Accordingly, section 506 of the bill would require VA 
to carry out a program to place at least two peer specialists 
within patient aligned care teams to promote the use and 
integration of mental health, substance use disorder, and 
behavioral health services in a primary care setting.

Section 507. Department of Veterans Affairs medical scribe pilot 
        program

    The use of electronic health records (EHRs) has become 
standard practice for the vast majority of healthcare delivery 
systems in United States. While evidence shows that EHRs do 
improve patient safety and outcomes, many clinicians find using 
EHRs to be burdensome and feel that taking time to enter data 
into a computer detracts from the quality of their interaction 
with patients and limits the amount of patients they are able 
to see daily. To address this disconnect between providers, 
patients, and productivity, private practices have begun 
employing non-clinical staff whose sole purpose is entering 
dictations from the physician into a patient's EHR and helping 
the physician to navigate the patient's existing medical 
record.
    Medical scribes have proven to be particularly useful for 
increasing physician productivity and satisfaction in fast-
paced clinical environments such as emergency departments (EDs) 
and specialty care settings.\116\ Medical scribes are trained 
on privacy considerations and on how to swiftly and accurately 
navigate and enter data into a patient's medical record before 
being assigned to a physician. Once appropriately trained, the 
scribe then follows the physician during patient interactions 
and documents each encounter as appropriate.
---------------------------------------------------------------------------
    \116\Rajiv Arya MD, Danielle M. Salovich, Pamela Ohman-Strickland 
PhD, Mark A. Merlin DO. ``Impact of Scribes on Performance Indicators 
in the Emergency Department'' Academic Emergency Medicine: Official 
Journal of the Society for Academic Emergency Medicine. April 23, 2010. 
http://onlinelibrary.wiley.com/doi/10.1111/j.1553_2712.2010.00718.x/
full
---------------------------------------------------------------------------
    Section 507 of the bill would create a two-year pilot 
program under which VA will increase the use of medical scribes 
in emergency department and specialty care settings at 10 VA 
medical centers. To provide transparency on staffing 
methodology for medical scribes in VA facilities, such pilot 
would require half of the scribes in such pilot to be employed 
by VA and half to be contract employees. VA would be required 
to regularly report to Congress on the effects the pilot on 
provider efficiency, patient satisfaction, average wait times, 
the number of patients seen per day and the amount of time 
required to train an employee to perform medical scribe 
functions under the pilot program. GAO would also be required 
to issue a report on the pilot after its conclusion.

Section 508. Loans guaranteed under home loan program of Department of 
        Veterans Affairs

    Section 3729 of title 38, U.S.C., requires individuals who 
utilize their VA home loan guaranty benefit to pay a funding 
fee. The amount of the funding fee varies based on an 
individual's status; the amount of down payment brought 
forward; and the date of the loan origination. The rates of 
funding fees (expressed as a percentage of the loan) have 
remained the same since 2004. The funding fee can be rolled 
into the life of the loan and is waived if the servicemember 
has a service-connected disability. These fees reduce the 
subsidy cost associated with VA's guaranty of mortgage loans, 
and have typically been viewed as a reasonable cost to the 
benefit gained by having VA guarantee a mortgage loan. Section 
508 of the bill would extend the current funding fee rates for 
mortgages closed on or after September 30, 2027, through 
September 30, 2028. The Committee believes that this is a 
reasonable extension of the current rates.

Section 509. Extension of reduction in amount of pension furnished by 
        Department of Veterans Affairs for certain veterans covered by 
        Medicaid plans for services furnished by nursing facilities

    Section 5503 of title 38 U.S.C. sets forth the criteria 
under which eligibility for income-based pension payments and 
aid and attendance allowances are affected by domiciliary or 
nursing home residence. In instances where a veteran, or 
surviving spouse, has neither a spouse nor a child and is 
receiving Medicaid-covered nursing home care, the veteran or 
surviving spouse is eligible to receive no more than $90 per 
month in VA pension or death pension payments for any period 
after the end of the third full calendar month following the 
month of admission. Under current law, this authority shall 
expire on September 30, 2027. Section 509 of the bill would 
extend such authority through September 30, 2028.

Section 510. Appropriation of amounts

    To fund the Choice program, the Choice Act also created and 
deposited $10 billion into the Veterans Choice Fund and 
stipulated that Choice would sunset either when the money in 
the Choice fund was fully expended or three years after 
enactment of the Act. Since the law was enacted on August 7, 
2014, three years after enactment of the Act would have been 
August 7, 2017. However, Congress passed an Act to amend the 
Veterans Access, Choice, and Accountability Act of 2014 to 
modify the termination date for the Veterans Choice Program, 
and for other purposes (Public Law 115-26; 131 STAT. 129) in 
April 2017 following testimony that VA expected to have money 
left in the Choice Fund on August 7, 2017.\117\ However, in 
June 2017, VA testified that Choice funds would be fully 
obligated sooner than previously expected and, as a result, VA 
was requesting additional funds be deposited into the Choice 
Fund.\118\ VA also testified that, without such action, waiting 
times for veteran patients would increase and access to care in 
the community would decrease.\119\ In response, Congress 
enacted the VA Choice and Quality Employment Act of 2017 
(Public Law 115-46; 131 STAT. 958) to appropriate $2.1 billion 
into the Choice Fund to preserve the availability of Choice 
care for veterans patients through the end of calendar year 
2017 and the Third Continuing Appropriations for Fiscal Year 
2018, Missile Defense, Health Provisions, Other Matters, and 
Budgetary Effects Act (Public Law 115-96; 131 STAT. 2044) to 
appropriate an additional $2.1 billion into the Choice Fund to 
preserve the availability of Choice care for veterans patients 
through May 2018.
---------------------------------------------------------------------------
    \117\United States Cong. House Committee on Veterans' Affairs 
Oversight Hearing--``Care Where it Count: Assessing VA's Capital Asset 
Needs.'' March 7 2017. 115th Cong. 1st sess. Washington: GPO, 2017 
(statement from the Honorable David Shulkin M.D, Secretary of Veterans 
Affairs).
    \118\United States Cong. House Committee on Veterans' Affairs 
Oversight Hearing--``FY 2018 Department of Veterans Affairs Budget 
Request for the Veterans Health Administration.'' June 22, 2017. 115th 
Cong. 1st sess. Washington: GPO, 2017 (statement from Poonam Alaigh 
M.D., Acting Under Secretary for Health, U.S. Department of Veterans 
Affairs).
    \119\Ibid.
---------------------------------------------------------------------------
    Section 510 of the law would authorize and appropriate $5.2 
billion to the Choice Fund. It is the Committee's intent that 
this amount will be sufficient to ensure veteran access to care 
until one year after enactment of the bill when the Program is 
fully implemented.

                                Hearings

    There were no full Committee or Subcommittee hearings held 
on H.R. 5674. The bill represents a negotiated agreement 
between the Committee on Veterans' Affairs of the U.S. House of 
Representatives and the Committee on Veterans' Affairs of the 
U.S. Senate and combines various elements of H.R. 4242, as 
amended, H.R. 4243, as amended, and S. 2193, as amended.

                       Subcommittee Consideration

    There was no Subcommittee consideration of H.R. 5674.

                        Committee Consideration

    On May 8, 2018, the full Committee met in open markup 
session, a quorum being present, and ordered H.R. 5674 to be 
reported favorably to the House of Representatives by a 
recorded vote of 20 yeas and 2 noes. During consideration of 
the bill, the following amendments were considered:
          An amendment offered by Representative Tim Walz of 
        Minnesota, the Ranking Member of the full Committee, 
        that would require discretionary budget caps to be 
        raised in accordance with the authorization of 
        appropriations and regulations made by or pursuant to 
        the bill. The amendment was not agreed to by a recorded 
        vote of 8 yeas to 13 noes.
          An amendment offered by Representative Tim Walz of 
        Minnesota, the Ranking Member of the full Committee, 
        that would: (1) require VA to review a determination to 
        provide care to an eligible veteran in the community 
        six months after the date of such determination for 
        veterans referred to the community due to a VA medical 
        facility's failure to comply with quality standards and 
        one year after the date of such determination for 
        veterans referred to the community for other reasons; 
        and (2) cap at two the number of walk-in care visits a 
        veteran could make in a year. The amendment was not 
        agreed to by a recorded vote of 8 yeas to 13 noes.
          An amendment offered by Representative Beto O'Rourke 
        of Texas that would allow a recipient of EDRP funds to 
        elect to receive payments on a monthly or annual basis. 
        The amendment was not agreed to by voice vote.
          An amendment offered and then withdrawn by 
        Representative Julia Brownley of California that would 
        include roads that are not accessible to the general 
        public, traffic, or hazardous weather as 
        ``environmental factors.''
          An amendment offered and then withdrawn by 
        Representative Julia Brownley of California that would 
        require VA to provide child care assistance to eligible 
        veterans.
          An amendment offered and then withdrawn by 
        Representative Julia Brownley of California that would 
        make the pilot program on counseling in retreat 
        settings for women veterans permanent.
          An amendment in the nature of a substitute offered by 
        Representative Tim Walz of Minnesota, the Ranking 
        Member of full Committee, that would replace the bill 
        with a combination of elements from H.R. 4242, as 
        amended, and S. 2193, as amended. The amendment in the 
        nature of a substitute was not agreed to by a recorded 
        vote of 8 yeas to 14 noes.

                            Committee Votes

    In compliance with clause 3(b) of rule XIII of the Rules of 
the House of Representatives four recorded votes were taken on 
amendments or in connection with ordering H.R. 5674 reported to 
the House. Their disposition was as follows:
          An amendment offered by Representative Tim Walz of 
        Minnesota, the Ranking Member of the full Committee, 
        that would require discretionary budget caps to be 
        raised in accordance with the authorization of 
        appropriations and regulations made by or pursuant to 
        the bill. The amendment was not agreed to by a recorded 
        vote of 8 yeas to 13 noes. The names of the Members who 
        voted for and against are as follows:
        [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
        
    An amendment offered by Representative Tim Walz of 
Minnesota, the Ranking Member of the full Committee, that 
would: (1) require VA to review a determination to provide care 
to an eligible veteran in the community six months after the 
date of such determination for veterans referred to the 
community due to a VA medical facility's failure to comply with 
quality standards and one year after the date of such 
determination for veterans referred to the community for other 
reasons; and (2) cap at two the number of walk-in care visits a 
veteran could make in a year. The amendment was not agreed to 
by a recorded vote of 8 yeas to 13 noes. The names of the 
Members who voted for and against are as follows:
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

    An amendment in the nature of a substitute offered by 
Representative Tim Walz of Minnesota, the Ranking Member of 
full Committee, that would replace the bill with a combination 
of elements from H.R. 4242, as amended, and S. 2193, as 
amended. The amendment in the nature of a substitute was not 
agreed to by a recorded vote of 8 yeas to 14 noes. The names of 
the Members who voted for and against are as follows:
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

    A motion by Representative Gus Bilirakis of Florida, the 
Vice Chairman of the full Committee, to report H.R. 5674 
favorably to the House of Representatives was adopted by a 
recorded vote of 20 yeas and 2 noes. The names of the Members 
who voted for and against the motion are as follows:
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

                      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 strengthen and improve the VA 
healthcare system's ability to provide timely, quality care to 
the nation's veterans and their caregivers.

   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 has requested 
but not received from the Director of the Congressional Budget 
Office an estimate of new budget authority, entitlement 
authority, or tax expenditures or revenues.

                  Earmarks and Tax and Tariff Benefits

    H.R. 5674 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 has requested but not received from the 
Director of the Congressional Budget Office an estimate of new 
budget authority, entitlement authority, or tax expenditures or 
revenues. The Committee believes, according to a preliminary 
score from the Congressional Budget Office, that enactment of 
H.R. 5674 would result in approximately $48 billion in 
discretionary costs over 5 years and approximately $5.2 billion 
in mandatory costs for the Choice fund.

               Congressional Budget Office Cost Estimate

    Pursuant to clause 3(c)(3) of rule XIII of the Rules of the 
House of Representatives, the Committee has requested but not 
received from the Director of the Congressional Budget Office 
an estimate of the costs of the reported bill.

                       Federal Mandates Statement

    The Committee has requested but not received from the 
Director of the Congressional Budget Office an estimate of new 
budget authority, entitlement authority, or tax expenditures or 
revenues. The Committee intends to adopt as its own estimate of 
Federal Mandates regarding H.R. 5674 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. 
5674.

                 Statement of Constitutional Authority

    Pursuant to Article I, section 8 of the United States 
Constitution, H.R. 5674 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. 5674 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 clause 3(c)(5) of rule XIII of the Rules of the 
House of Representatives, the Committee finds that no provision 
of H.R. 5674 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. 5674 contains directed 
rulemaking provisions that would require the Secretary to 
prescribe regulations.

             Section-by-Section Analysis of the Legislation


Section 1. Short title; Table of contents

    Section 1(a) of the bill would provide a short title of 
H.R. 5674, the ``VA Maintaining Internal Systems and 
Strengthening Integrated Outside Networks Act of 2018'' or ``VA 
MISSION Act of 2018.''
    Section 1(b) of the bill would provide the table of 
contents:

                    TITLE I--CARING FOR OUR VETERANS

    Sec. 100. Short title; references to title 38, United 
States Code.

      Subtitle A--Developing an Integrated High-Performing Network


            CHAPTER 1--ESTABLISHING COMMUNITY CARE PROGRAMS

    Sec. 101. Establishment of Veterans Community Care Program.
    Sec. 102. Authorization of agreements between Department of 
Veterans Affairs and non-Department providers.
    Sec. 103. Conforming amendments for State veterans homes.
    Sec. 104. Access standards and standards for quality.
    Sec. 105. Access to walk-in care.
    Sec. 106. Strategy regarding the Department of Veterans 
Affairs High-Performing Integrated Health Care Network.
    Sec. 107. Applicability of Directive of Office of Federal 
Contract Compliance Programs.
    Sec. 108. Prevention of certain health care providers from 
providing non-Department health care services to veterans.
    Sec. 109. Remediation of medical service lines.

         CHAPTER 2--PAYING PROVIDERS AND IMPROVING COLLECTIONS

    Sec. 111. Prompt payment to providers.
    Sec. 112. Authority to pay for authorized care not subject 
to an agreement.
    Sec. 113. Improvement of authority to recover the cost of 
services furnished for non-service-connected disabilities.
    Sec. 114. Processing of claims for reimbursement through 
electronic interface.

               CHAPTER 3--EDUCATION AND TRAINING PROGRAMS

    Sec. 121. Education program on health care options.
    Sec. 122. Training program for administration of non-
Department of Veterans Affairs health care.
    Sec. 131. Establishment of processes to ensure safe opioid 
prescribing practices by non-Department of Veterans Affairs 
health care providers.
    Sec. 132. Improving information sharing with community 
providers.
    Sec. 133. Competency standards for non-Department of 
Veterans Affairs health care providers.
    Sec. 134. Department of Veterans Affairs participation in 
national network of State-based prescription drug monitoring 
programs.

          CHAPTER 5--OTHER NON-DEPARTMENT HEALTH CARE MATTERS

    Sec. 141. Plans for Use of Supplemental Appropriations 
Required.
    Sec. 142. Veterans Choice Fund flexibility.
    Sec. 143. Sunset of Veterans Choice Program.
    Sec. 144. Conforming amendments.

   Subtitle B--Improving Department of Veterans Affairs Health Care 
                                Delivery

    Sec. 151. Licensure of health care professionals of the 
Department of Veterans Affairs providing treatment via 
telemedicine.
    Sec. 152. Authority for Department of Veterans Affairs 
Center for Innovation for Care and Payment.
    Sec. 153. Authorization to provide for operations on live 
donors for purposes of conducting transplant procedures for 
veterans.

                     Subtitle C--Family Caregivers

    Sec. 161. Expansion of family caregiver program of 
Department of Veterans Affairs.
    Sec. 162. Implementation of information technology system 
of Department of Veterans Affairs to assess and improve the 
family caregiver program.
    Sec. 163. Modifications to annual evaluation report on 
caregiver program of Department of Veterans Affairs.

              TITLE II--VA ASSET AND INFRASTRUCTURE REVIEW

              Subtitle A--Asset and Infrastructure Review

    Sec. 201. Short title.
    Sec. 202. The Commission.
    Sec. 203. Procedure for making recommendations.
    Sec. 204. Actions regarding infrastructure and facilities 
of the Veterans Health Administration.
    Sec. 205. Implementation.
    Sec. 206. Department of Veterans Affairs Asset and 
Infrastructure Review Account.
    Sec. 207. Congressional consideration of Commission report.
    Sec. 208. Other matters.
    Sec. 209. Definitions.

                Subtitle B--Other Infrastructure Matters

    Sec. 211. Improvement to training of construction 
personnel.
    Sec. 212. Review of enhanced use leases.
    Sec. 213. Assessment of health care furnished by the 
Department to veterans who live in the Pacific territories.

  TITLE III--IMPROVEMENTS TO RECRUITMENT OF HEALTH CARE PROFESSIONALS

    Sec. 301. Designated scholarships for physicians and 
dentists under Department of Veterans Affairs Health 
Professional Scholarship Program.
    Sec. 302. Increase in maximum amount of debt that may be 
reduced under Education Debt Reduction Program of Department of 
Veterans Affairs.
    Sec. 303. Establishing the Department of Veterans Affairs 
Specialty Education Loan Repayment Program.
    Sec. 304. Veterans healing veterans medical access and 
scholarship program.
    Sec. 305. Bonuses for recruitment, relocation, and 
retention.
    Sec. 306. Inclusion of Vet Center employees in education 
debt reduction program of Department of Veterans Affairs.

               TITLE IV--HEALTH CARE IN UNDERSERVED AREAS

    Sec. 401. Development of criteria for designation of 
certain medical facilities of the Department of Veterans 
Affairs as underserved facilities and plan to address problem 
of underserved facilities.
    Sec. 402. Pilot program to furnish mobile deployment teams 
to underserved facilities.
    Sec. 403. Pilot program on graduate medical education and 
residency.

                         TITLE V--OTHER MATTERS

    Sec. 501. Annual report on performance awards and bonuses 
awarded to certain high-level employees of the department.
    Sec. 502. Role of podiatrists in Department of Veterans 
Affairs.
    Sec. 503. Definition of major medical Sec. 1. Short title; 
table of contents.
    Sec. 504. Authorization of certain major medical facility 
projects of the Department of Veterans Affairs.
    Sec. 505. Department of Veterans Affairs personnel 
transparency.
    Sec. 506. Program on establishment of peer specialists in 
patient aligned care team settings within medical centers of 
Department of Veterans Affairs.
    Sec. 507. Department of Veterans Affairs medical scribe 
pilot program.
    Sec. 508. Loans guaranteed under home loan program of 
Department of Veterans Affairs.
    Sec. 509. Extension of reduction in amount of pension 
furnished by Department of Veterans Affairs for certain 
veterans covered by Medicaid plans for services furnished by 
nursing facilities.
    Sec. 510. Appropriation of amounts.
    Sec. 511. Technical correction.

                    TITLE I--CARING FOR OUR VETERANS

Section 100. Short title; Reference to Title 38, United States Code

    Section 100(a) of this bill would provide a short title to 
be cited as the ``Caring for our Veterans Act of 2018.''
    Section 100(b) of the bill would specify that any title 
that is amended or repeal that is expressed in terms of an 
amendment, is in reference to a section or provision in Title 
38, U.S.C, unless otherwise expressed.

      Subtitle A--Developing an Integrated High-Performing Network


            Chapter 1--Establishing Community Care Programs


Section 101. Establishment of veterans community care program

    Section 101(a) of this bill would amend section 1703 of 
title 38 U.S.C. to read as follows: ``1703. Veterans Community 
Care Program.''
    The amended section 1703(a) would establish a program to 
furnish hospital care, medical services, and extend care 
services to covered veterans through health care providers 
specified in subsection (c) of the amended section 1703. VA 
would be required to coordinate the furnishing of hospital 
care, medical services, and extended care services to covered 
veterans, including coordination of, at a minimum, the 
following: ensuring the scheduling of medical appointments in a 
timely manner and the establishment of a mechanism to receive 
medical records from non-Department providers; ensuring 
continuity of care and services; ensuring coordination among 
regional networks if the covered veteran accesses care and 
services in a different network than the regional network in 
which a covered veteran resides; and ensuring that covered 
veterans do not experience a lapse in care resulting from 
errors or delays by VA or its contractors or an unusual or 
excessive burden in accessing hospital care, medical services, 
or extended care services. The amended section 1703 would also 
establish that a covered veteran is only authorized to receive 
care or services under this section upon the authorization of 
such care or services by VA.
    The amended section 1703(b) would define the term ``covered 
veteran'' as any veteran who is enrolled under section 1705 of 
this title or, if not enrolled, is otherwise entitled to 
hospital care, medical services, or extended care services.
    The amended section 1703(c) would define ``health care 
providers'' as providers participating in the Medicare program, 
the Department of Defense, Indian Health Service, any 
Federally-qualified health center, or any other provider that 
meets criteria established by the Secretary.
    The amended section 1703(d) would establish the conditions 
under which care is required to be furnished through non-VA 
providers. Subject to the availability of appropriations, 
hospital care, medical services, and extended care services 
shall be provided to a covered veteran through health care 
providers specified in subsection (c) if: VA does not offer the 
care or services the veteran requires; VA does not operate a 
full service medical facility in the State in which the covered 
veteran resides; the covered veteran was an eligible veteran 
under the Veterans Access, Choice, and Accountability Act of 
2014 as of the day before the date of enactment of this bill 
who continues to reside in a location that would qualify the 
veteran for eligibility under such section and either resides 
in one of the five States with the lowest population density as 
determined by data from the 2010 decennial census or does not 
reside in such a State but received care or services under this 
title in the year preceding the enactment of this bill and is 
seeking care or services within two years of the date of the 
enactment of this bill; the covered veteran has contacted VA to 
request care or services and the Department is not able to 
furnish such care and service in a manner that complies with 
designated access standards developed by VA under section 1703B 
of this title; or the covered veteran and the covered veteran's 
referring clinician agree that furnishing care and services 
through a non-Department entity or provider would be in the 
best medical interest of the covered veteran based on criteria 
created by VA. Such criteria shall include consideration of the 
following: the distance between the covered veteran and the 
facility that provides the care or services the veteran 
requires; the nature of the care or services required; the 
frequency that the care or services needs to be furnished; the 
timeliness of available appointments for the care or services 
the veteran needs; and whether the covered veteran faces an 
unusual or excessive burden to access care or services, and 
should include the following considerations: whether the 
covered veteran faces an excessive driving distance, 
geographical challenge, or environmental factor that impedes 
the access of the covered veteran; whether the care or service 
sought by the veteran is provided by a VA medical facility that 
is reasonably accessible to a covered veteran; whether a 
medical condition of the covered veteran affects the ability of 
said veteran to travel; whether there is a compelling reason as 
determined by VA that the veteran needs to receive care or 
service from a medical facility other than a VA medical 
facility; and such other consideration as VA considers 
appropriate. The decision to receive hospital care, medical 
services, or extended care services under such subparagraphs 
from a non-department health care provider shall be at the 
election of the veteran.
    The amended section 1703(e) would establish conditions 
under which care is authorized to be furnished through non-
Department providers. VA shall measure timeliness of a VA 
medical service line in comparison with the same medical 
service lines at different VA facilities and measure quality at 
a VA medical service line of a facility by comparing it with 
two or more distinct and appropriate non-Department service 
lines. VA may not concurrently furnish care or services through 
non-department providers with respect to more than three 
medical service lines at any one VA facility and may not 
concurrently furnish care or services through non-department 
providers under this authority with respect to more than 36 
medical service lines nationally. VA may limit the types of 
care veterans receive in terms of the length of time such care 
and services will be available, the location at which such care 
and services will be available, and the clinical care and 
services that will be available. Care authorized under this 
subsection with respect to a medical service line shall cease 
when the remediation described in section 1706A with respect to 
such medical service line is complete. VA shall ensure 
continuity and coordination of care for any veteran who elects 
to receive care or services under this subsection from a non-
department health care provider through the completion of an 
episode of care. VA would be required to publish in the Federal 
Register, and shall take all reasonable steps to provide direct 
notice to covered veterans affected, at least once a year 
starting the time period during which such care and services 
will be available, the location or locations where such care 
and services will be available, and the clinical services 
available at each location in accordance with regulations that 
VA shall proscribe. The veteran shall elect whether to receive 
the care or service.
    The amended section 1703(f) would require the review of 
decisions made under subsection (d) or (e) to be subject to 
VA's clinical appeals process and may not be appealed to the 
Board of Veterans' Appeals.
    The amended section 1703(g) would authorize VA to develop a 
tiered provider network based on criteria established by VA but 
prohibit VA from prioritizing providers in a tier over 
providers in any other tier in a manner that limits the choice 
of a veteran in selecting a health care provider.
    The amended section 1703(h) would require VA to enter into 
consolidated, competitively bid contracts to establish networks 
of health care providers to provide sufficient access to care. 
VA must ensure that covered veterans are able to make their own 
appointments using advanced technology, to the extent 
practicable, and require VA, to the extent practicable, to 
schedule appointments for care and service. VA may terminate a 
contract with an entity at such time and upon such notice to 
the entity as VA may specify for purposes of this section, if 
VA notifies the appropriate committees of Congress that, at a 
minimum the entity: failed to comply substantially with the 
provisions of the contract or this section and the regulations 
prescribed under this section; failed to comply with the access 
standards or the standards for quality established by VA; is 
excluded from participating in a Federal health care program; 
is identified as an excluded source on the list maintained in 
the System for Award Management, or any successor system; or 
has been convicted of felony or other serious offense under 
Federal or state law and the continued participation of the 
entity would be detrimental to the best interests of veterans 
or the Department. It is reasonable to terminate the contract 
based on the health care needs of veterans or to terminate the 
contract based on coverage provided by contract or sharing 
agreements entered into under authorities other than this 
section. Whenever an entity is failing to meet contractual 
obligations, VA shall submit to the House and Senate Committees 
on Veterans' Affairs a report on such failings. The report 
shall include: an explanation of the reasons for providing such 
notice; a description of the effect of such failure, including 
with respect to cost, schedule, and requirements; a description 
of the actions taken by VA to mitigate such failure; a 
description of the actions taken by the contractor to address 
such failure; and a description of any effect on the community 
provider market for veterans in the affected area. VA would be 
required to instruct each entity awarded a contract to 
recognize and accept, on an interim basis, the credentials and 
qualifications of health care providers who are authorized to 
furnish care to veterans under a community care program of the 
Department in effect as of the day before the date of enactment 
of the Caring for our Veterans Act of 2018, including under the 
Patient-Centered Community Care Program and the Veterans Choice 
Program. The interim acceptance period shall be determined by 
VA based on the following criteria: when the current 
certification agreement for a health care provider expires and 
whether the Department has enacted certification and 
eligibility criteria and regulatory procedures by which non-
department providers will be authorized under this section. VA 
would be required to create a system or systems for monitoring 
and assessing the quality of care provided to veterans through 
a network under this subsection.
    The amended section 1703(i) would establish payment rates 
for care and services. Except as provided in paragraph (2), and 
to the extent practicable, the rate paid for care and services 
under any provision in this title may not exceed the rate paid 
by the United States to a provider of services or a supplier 
under the Medicare program under title XI or title XVIII of the 
Social Security Act, including but not limited to section 1834 
of such Act, for the same care or services. A higher rate than 
the rate established in paragraph (1) may be negotiated with 
respect to furnishing care to a veteran who resides in a highly 
rural area. A ``highly rural area'' is defined as an area 
located in a county that has fewer than seven individuals 
residing in that county per square mile. With respect to 
furnishing care or services under this section in Alaska, the 
Alaska Fee Schedule of the Department shall be followed, except 
for when another payment agreement, including a contract or 
provider agreement, is in effect. With respect to care or 
services under this section in a state with an All-Payer Model 
Agreement under section 1814(b)(3) of the Social Security Act, 
the Medicare payment rates under paragraph (2)(A) shall be 
calculated based on the payment rates under such agreement. VA 
may incorporate, to the extent practicable, the use of value-
based reimbursement models to promote the provision of high-
quality care, and with respect to care for which there is not a 
rate paid under Medicare, the rate paid for such care shall be 
determined by VA.
    The amended section 1703(j) would establish the standards 
for the treatment of other health plan contracts. In any case 
where a veteran is furnishing care under this section for a 
non-service connected disability, as described in subsection 
(a)(2) of section 1729 of this title, VA shall recover or 
collect reasonable charges for such care from a health plan 
contract described in section 1729.
    The amended section 1703(k) would establish the standard 
for payment made by the veteran. A covered veteran shall not 
pay a greater amount for receiving care or services under this 
section than the amount the veteran would pay for receiving the 
same or comparable care at a medical facility of the Department 
or health care provider of the Department.
    The amended section 1703(l) would require the Secretary to 
determine whether to authorize an organ or bone marrow 
transplant for a covered veteran at a non-Department facility 
when such transplant is required and, in the opinion of the 
primary care provider, the covered veteran has a medically 
compelling reason to travel outside the region of the Organ 
Procurement and Transplantation Network.
    The amended section 1703(m) would establish the system to 
monitor the care provided. Not later than 540 days after the 
date of enactment, and annually thereafter, VA shall submit to 
the appropriate committees of Congress a review of the types 
and frequency of care furnished trough non-Department 
providers. The review submitted shall include an assessment of 
the following: the top 25 percent of types of care and services 
most frequently provided due to the Department not offering 
such care and services; the frequency such care and services 
were sought by covered veterans; an analysis of the reasons VA 
was unable to provide such care; any steps the Department took 
to provide such care and services at a medical facility of the 
Department; and the cost of such care and services. In 
monitoring the care furnished under this section, VA would be 
required to do the following: with respect to the care 
furnished through provider networks VA shall compile data on 
the types of care furnished through such network and how many 
patient used each type of care and service; identify gaps in 
care furnished through such networks; identify how such gaps 
may be fixed through new contracts with such networks or 
changes in the manner in which care is provided through such 
networks; assess the total amount spent by VA to furnish care 
through such network; assess the timelines of the Department in 
referring care and services to such networks; and assess the 
timelines of such networks in accepting referrals and 
scheduling and completing appointments. VA shall report the 
number of medical service lines not to be providing care or 
services that comply with the standards for quality that VA 
established. Additionally, VA would assess the use of academic 
affiliates and centers of excellence of the Department to 
furnish care and services to veterans under this section. 
Lastly, VA would assess the care and services furnished to 
veterans under this section by medical facilities operated by 
Federal agencies other than the Department.
    The amended section 1703(n) would establish a prohibition 
on certain limitations. VA shall not limit the types of care or 
services veterans may receive under this section if it is in 
the best medical interest of the veteran as determined by the 
veteran and the veteran's health care provider. Additionally, 
no provision in this section may be construed to alter or 
modify any other provision of law establishing specific 
eligibility criteria for certain care services.
    The amended section 1703(o) would define the term 
``appropriate committees of Congress'' to mean the Committee on 
Veterans' Affairs and the Committee on Appropriations of the 
Senate and the House of Representatives and the term ``medical 
service line'' to mean a clinic within a VA medical center.
    Section 101(b) of this bill would establish an effective 
date. Section 1703 of title 38 U.S.C., as amended by subsection 
(a), shall take effect on the later of the date that is 30 days 
after the date on which VA submits the report required under 
section 101(q)(2) of the Veterans Access, Choice, and 
Accountability Act of 2014, or the date on which VA promulgates 
regulations pursuant to subsection (c).
    Section 101(c) of this bill would require VA to promulgate 
regulations to carry out section 1703 of title 38 U.S.C. Before 
promulgating the regulations required, VA shall provide to the 
appropriate committees of Congress periodic updates to confirm 
the progress of VA toward developing such regulations. The 
first update shall occur no later than 120 days from the date 
of the enactment of this Act.
    Section 101(d) of this bill would require VA, 
notwithstanding section 1703 of title 38 U.S.C., as amended by 
subsection (a), to continue all contracts, memorandums of 
understanding, memorandums of agreements, and other 
arrangements that were in effect on the day before the date of 
the enactment of this Act between VA and the Department of 
American Indian and Alaska Native health care systems as 
established under the terms of VA and the Department of 
American Indian and Alaska Native Health Service Memorandum of 
Understanding, signed October 1, 2010, the National 
Reimbursement Agreement, signed December 5, 2012, arrangements 
under section 405 of the Indian Health Care Improvement Act, 
and agreements entered into under sections 102 and 103 of the 
Veterans Access, Choice, and Accountability Act of 2014. In 
addition, the above shall not be construed to prohibit VA and 
the parties to the contracts, memorandums of understanding, 
memorandums or agreements, and other arrangements described 
from making lawful changes.

Sec. 102. Authorization of agreements between Department of Veterans 
        Affairs and non-Department providers

    Section 102(a) of this bill would amend subchapter I of 
chapter 17 by inserting after section 1703 the following new 
section: Sec. 1703A. Agreements with eligible entities or 
providers; certification processes''
    The new section 1703A(a) would stipulate that when care or 
service is required by a veteran who is entitled to such care 
or service under this chapter is not feasibly available to the 
veteran from a facility of the Department or through a contract 
or sharing agreement entered into pursuant to another provision 
of law, VA may furnish such care or services to such veteran 
through an agreement under this section with an eligible entity 
or provider to provide such care or services. An agreement 
entered into under this section to provide care and service 
shall be known as a ``Veterans Care Agreement.'' Care or 
services provided to a veteran from a facility of VA or through 
a contract or sharing agreement may be considered not feasibly 
available when VA determines the veteran's medical condition, 
the travel involved, the nature of the care or services 
required, or a combination of these factors make the use of a 
VA facility or sharing agreement impracticable or inadvisable. 
The Secretary or any official authorized by the Secretary may 
enter into a Veterans Care Agreement. Each agreement of 
material size, as determined by VA, shall be reviewed by VA to 
determine whether it is feasible and advisable to provide such 
care or service within a VA facility or by sharing agreement, 
and if so, act to do so. VA shall review each Veterans Care 
Agreement of material size that has been in effect for at least 
six months within the first two years of its taking effect, and 
not less frequently than once every four years thereafter. If a 
Veterans Care Agreement has not been in effect for at least six 
months by the date of the required review, the agreement shall 
be reviewed during the next cycle of required reviews. In 
fiscal year 2019 and in each fiscal year thereafter, in 
addition to the standards of material size established by VA, 
any agreement for the purchase of extended care services that 
exceeds $5,000,000 annually shall be considered of material 
size. From time to time, VA may publish a notice in the Federal 
Register to adjust the dollar amount specified above to account 
for changes in the cost of health care based upon market 
surveys and other available data.
    The new section 1703A(b) would define eligible entities and 
providers as: any provider of services that has enrolled and 
enter into provider agreement under section 1866(a) of the 
Social Security Act and any physician or supplier who has 
enrolled and entered into a participation agreement under 
section 1842(h) of such act; any provider participating under a 
State plan under title XIX of such act; 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); a center 
for independent living (as defined in section 702 of the 
Rehabilitation Act); or any entity or provider not described 
above that VA determines to be eligible pursuant to the 
certification process described above.
    The new section 1703A(c) would require VA to establish a 
process for certification of eligible providers or 
recertification of current providers. The process shall, at a 
minimum, establish deadlines for actions on applications for 
certification; create standards for approval or denial of 
certification, duration of certification, revocation of 
certification, and recertification; require the denial of 
certification if the provider is excluded from participating in 
a Federal health care program under section 1128 or section 
1128A of the Social Security Act; establish procedures for 
screening eligible providers according to the risk of fraud, 
waste, and abuse that are similar to the standards under 
section 1866 of Social Security Act and title 48, Code of 
Federal Regulations, or successor program; and apply the 
restrictions and penalties set forth in chapter 21 of title 41 
and treat this section as a procurement program only for the 
purposes of applying such provisions.
    The new section 1703A(d) would establish the rates paid by 
VA to health care providers under a Veterans Care agreement at 
the rates paid by the U.S. under section 1703(i) of this title.
    The new section 1703A(e) would establish the terms of 
Veterans Care Agreements. VA may define the requirements for 
providers and entities entering into agreements under this 
section based upon such factors as the number of patients 
receiving care, the number of employees employed by said 
entity, the amount paid by VA to the provider or entity, or 
other factors as determined by VA. To furnish care under this 
section, an eligible entity or provider shall agree: to accept 
payment at the rates established in regulations prescribed 
under this section; that payment by VA under this section on 
behalf of a veteran to a provider of services or care shall, 
unless rejected and refunded by the provider within 30 days of 
receipt, constitute payment in full and extinguish any 
liability on the part of the veteran for the treatment or care 
provided, and no provision of a contract, agreement, or 
assignment to the contrary shall operate to modify, limit, or 
negate this requirement; to provide only the care and services 
authorized by VA under this section and to obtain prior written 
consent from VA for any care outside the scope of such 
authorization; to bill VA in accordance with the regulations 
under this section; to not seek to recover or collect from a 
health plan contract or third party for any care or service 
that is furnished or paid for by VA; to provide medical records 
to VA in the time frame and format specified by VA; and to meet 
such other terms and conditions, including quality of care 
assurance standards as specified in regulation.
    The new section 1703A(f) would establish the 
discontinuation or nonrenewal of a Veterans Care Agreement. An 
eligible entity or provider may discontinue a Veterans Care 
Agreement upon notice to VA as may be provided in regulations 
prescribed under this section. VA may discontinue a Veterans 
Care Agreement upon such reasonable notice to the eligible 
entity or provider as may be specified in regulations under 
this section. VA may terminate the contract if an official 
designated by VA: has determined that the provider failed to 
comply substantially with the provisions of the agreement or 
with provision of this section; has determined the provider is 
excluded from participation in a Federal health care program 
under the Social Security Act or is identified on the System 
for Award Management Exclusions list as provided in part 9 of 
title 48, Code of Federal Regulations, and part 180 of title 2 
of such Code, or successor regulations; has ascertained that 
the eligible entity or provider has been convicted of a felony 
or other serious offense under Federal or State law and 
determines the provider's continued participation would be 
detrimental the best interest of veterans or VA; or has 
determined that it is reasonable to terminate the agreement 
based on health care needs of a veteran.
    The new section 1703A(g) would require VA to establish a 
system(s) for monitoring the quality of care provided to 
veterans through Veterans Care Agreements and for assessing the 
quality of care furnished by providers before the renewal of 
their agreement.
    The new section 1703A(h) would require VA to create 
procedures for providers to present all disputes arising under 
or related to Veterans Care Agreements. Such procedures 
constitute the providers exhaustive and exclusive 
administrative remedies. Providers must first exhaust such 
administrative procedures before seeking any judicial review 
under section 1346 of title 28. Any disputes under this section 
must pertain to either the scope of authorization under the 
agreement or claims for payment subject to the agreement and 
are not claims that would otherwise require application of 
sections 7101 through 7109 of title 41 U.S.C.
    The new section 1703A(i) would establish the applicability 
of other provisions of law under this section. A Veterans Care 
Agreement may be authorized by VA and such action shall not be 
treated as: an award for the purposes of such laws that would 
otherwise require the use of competitive procedures for the 
furnishing of care and services; or a Federal contract for the 
acquisition of goods or services for purposes of any provision 
of Federal law governing Federal contracts for the acquisition 
of goods or services except section 4706(d) of title 41 U.S.C. 
Unless otherwise specified in this section, any provider that 
enters into an agreement is not subject to, in the carrying out 
of the agreement, any law to which providers of services under 
the Medicare program are not subject. An eligible provider is 
subject to: all laws regarding integrity, ethics, or fraud, or 
that subject a person to civil or criminal penalties; and all 
laws that protect against employment discrimination or that 
otherwise ensure equal employment opportunities. A provider 
under this section shall not be treated as a Federal contractor 
or subcontractor for purposes of chapter 67 of title 41, U.S.C.
    The new section 1703A(j) would establish that care 
furnished to a veteran under a Veterans Care Agreement shall be 
subject to the same terms and provisions as they would be if 
receiving care in VA.
    The new section 1703A(k) would require VA to promulgate 
regulations to carry out this section.
    Section 102(b) of this bill provides for a clerical 
amendment of the table of sections.

Sec. 103. Conforming amendments for State Veterans Homes

    Section 103(a) of this bill would amend section 1745(a) of 
title 38, U.S.C. to authorize VA to enter into Veteran Care 
Agreements with State Veterans Homes and eliminate competitive 
contracting actions and other requirements associated with 
federal contracts. State Veterans Homes, while not considered 
federal contactors for the purposes of this section, would 
still be required to follow federal laws related to fraud, 
waste, and abuse as well as employment law.
    Section 103(b) of this bill would establish the effective 
date as on or after the effective date of regulations issued by 
VA.

Sec. 104. Access standards and standards for quality

    Section 104(a) of this bill would further amend Subchapter 
I of chapter 17 by inserting after section 1703A the following 
new sections: ``Sec. 1703B. Access standards'' and 
``Sec. 1703C. Standards for quality.''
    The new section 1703B(a) would require VA to establish 
access standards for furnishing care and services to covered 
veterans and shall define such categories to cover all care and 
services within the medical benefits package.
    The new section 1703B(b) would ensure that the access 
standards provide to covered veterans, VA employees, and health 
care providers in the establish network, relevant comparative 
information that is clear, useful, and timely so that covered 
veterans can make informed decisions regarding their care.
    The new section 1703B(c) would require VA to consult with 
all pertinent Federal entities, private sector entities, and 
other nongovernmental entities to create the access standards.
    The new section 1703B(d) would require VA to submit to the 
appropriate committees of Congress a report detailing the 
access standards not later than 270 days after enactment. 
Before submitting the report, VA shall provide periodic updates 
to confirm progress toward developing the access standards. The 
first update shall occur no later than 120 days after 
enactment. Following the creation of access standards, VA shall 
submit to the appropriate committees of Congress a report 
detailing implementation of and compliance with the access 
standards. This report shall be submitted no later than 540 
days after implementation of the access standards.
    The new section 1703B(e) would establish that every three 
years after implementation, and no less frequently than once 
every three years thereafter, VA must review the access 
standards and submit a report to Congress on the findings and 
any necessary modifications.
    The new section 1703B(f) would require VA to ensure that 
health care providers in the network are able to comply with 
the access standards.
    The new section 1703B(g) would have VA publish in the 
Federal Register and on its website the access standards.
    The new section 1703B(h) would allow for covered veterans 
to contact VA at any time to request a determination of their 
eligibility to receive care and services from a non-Department 
entity or provider as it pertains to the access standards. VA 
shall establish a process to review any requests from covered 
veterans to determine clinical necessity for requested care and 
if VA is able to provide such care in a manner that complies 
with the designated access standards.
    The new section 1703B(i) would define terms: ``appropriate 
committees of Congress'' and ``covered veteran.''
    The new section 1703C(a) would require VA to establish 
standards for quality regarding care and services furnished by 
VA and non-VA providers. In establishing standards for quality, 
VA shall consider existing health quality measures in public 
and private health care systems and shall consider data such 
as: veteran satisfaction with care and service quality at VA 
medical facilities within the past two years; the timeliness of 
care; the effectiveness of care; the safety, including 
complications, readmissions, and deaths; and efficiency of 
care. VA shall consult with all pertinent Federal entities, 
entities in the private sector, and other nongovernmental 
entities in establishing standards of quality. VA shall submit 
to the appropriate committees of Congress a report detailing 
the standards for quality not later than 270 days after 
enactment. Before submitting the report, VA shall provide 
periodic updates to confirm progress toward developing the 
standards for quality. The first update shall occur no later 
than 120 days after enactment.
    The new section 1703C(b) would require VA to publish data 
on these quality measures on the Hospital Compare website 
through the Centers for Medicare and Medicaid to give veterans 
the information necessary to compare performance measures 
between VA and community health care providers not later than 
one year after implementation of the standards. VA shall 
consider and solicit public comment on potential changes not 
later than two years after implementation of the standards.
    The new section 1703C(c) would define the terms: 
``appropriate committees of Congress'' and ``covered veteran.''
    Section 104(b) of this bill provides for a clerical 
amendment of the table of sections.

Sec. 105. Access to Walk-In Care.

    Section 105 of this bill would amend Subchapter I of 
chapter 17 by inserting after section 1725 the following new 
section: ``Sec. 1725A. Access to walk-in care.''
    The new section 1725A(a) would require VA to develop 
procedures to ensure eligible veterans can access walk-in care 
from non-Department providers.
    The new section 1725(b) defines an eligible veteran under 
this section as one who is enrolled in the VA health system and 
has received care within the last two years.
    The new section 1725(c) defines qualifying non-department 
entities or providers as a non-department provider or entity 
with an agreement or contract with the VA to furnish services 
provided under this section.
    The new section 1725(d) authorizes VA to utilize Federally 
Qualified Health Centers (FQHC), when practicable.
    The new section 1725(e) requires VA to ensure continuity of 
care for veterans who receive walk-in care, including the 
sharing of medical records.
    The new section 1725(f) requires VA to establish a 
copayment structure for eligible veterans. For the first two 
visits in a calendar year, a veteran who would not be required 
to pay a copay if not otherwise required to pay such a copay 
under this title. Similarly, for the first two visits in a 
calendar year, a veteran who would be required to pay a copay 
if otherwise required to pay such a copay under this title. The 
Secretary shall prescribe by rule any adjusted copayment 
requirements for visits furnished after the first two episodes 
of care.
    The new section 1725(g) requires VA to promulgate 
regulations no later than one year after enactment to carry out 
this section.
    The new section 1725(h) defines ``walk-in care'' as non-
emergent care provided by a qualifying non-Department entity or 
provider that furnishes episodic care and not longitudinal 
management of conditions.
    Section 105(b) of this bill establishes an effective date 
upon the implementation of final regulations.
    Section 105(c) of this bill provides for a clerical 
amendment of the table of sections.

Sec. 106. Strategy regarding the Department of Veterans Affairs high-
        performing integrated health care network

    Section 106(a) of this bill would amend Subchapter II of 
chapter 73 by inserting after section 7330B the following new 
section: ``Sec. 7330C. Quadrennial Veterans Health 
Administration Review.''
    The new section 7330C(a) would require VA to conduct 
quadrennial market area assessments, including: demand for VA 
healthcare; an inventory of VA's capacity to provide 
healthcare; an assessment of community contract capacity; an 
assessment obtained from other Federal direct delivery systems 
of their capacity to provide health care to veterans; an 
assessment of the health care capacity of non-contracted 
providers where there is insufficient network supply; an 
assessment of the health care capacity of academic affiliates 
and other VA collaborations as it relates to providing health 
care to veterans; an assessment of the effects on VA health 
care capacity by the access and quality standards established 
under this bill; and the number of appointments for health care 
services, disaggregated by VA medical facilities and non-
Department health care providers. VA shall submit to the 
appropriate committees of Congress the market area assessments 
and shall ensure that the Department budget for any fiscal year 
reflects the findings of the most recent market assessments.
    The new section 7330C(b) of the bill would require VA to 
submit one year after the date of enactment and not less 
frequently than once every four years thereafter to the 
appropriate committees a strategic plan that specifies a four-
year forecast of demand for care from the Department, capacity 
provided by each medical center of the Department, and capacity 
provided through community care providers. In developing the 
strategic plan, the Secretary shall assess access and quality 
standards, assess market assessments, assess the needs of the 
Department to provide for service connected conditions, consult 
with key stakeholders, identify emerging issues, trends and 
opportunities, develop recommendations, consider surveys, 
examine existing programs and policies, assess remediation of 
medical service lines, and consider other matters as 
appropriate.
    The new section 7330C(c) outlines responsibilities of VA 
for overseeing transformation and organizational changes across 
the Department, developing capital infrastructure planning and 
procurement, and developing a multi-year budget process.
    The new section 7330C(d) defines ``Appropriate Committees 
of Jurisdiction.''
    Section 106(b) of this bill provides for a clerical 
amendment of the table of sections.

Sec. 107. Applicability of directive of Office of Federal Contract 
        Compliance programs

    Section 107(a) of this bill would require the same 
affirmative action moratorium on Veterans Care Agreement 
contractors and subcontractors as is applied to TRICARE 
contractors and subcontractors in Directive 2014-01 of the 
Office of Federal Contract Compliance Programs of the 
Department of Labor.
    Section 107(b) of this bill would direct the above 
moratorium to not be altered or rescinded until May 19, 2019.
    Section 107(c) of this bill defines the term ``TRICARE 
program.''

Sec. 108. Prevention of certain health care providers from providing 
        non-Department health care services to veterans

    Section 108(a) of this bill would allow VA to deny or 
revoke the eligibility of a provider to provide non-Department 
care if VA deems that provider was removed from employment with 
the Department due to conduct relating to the delivery of safe 
and appropriate care or violated the requirements of a medical 
license that resulted in the loss of such license.
    Section 108(b) of this bill would allow VA permissive 
action to deny, revoke, or suspend the eligibility of a health 
care provider to provide non-Department care on and after the 
date that is one year after enactment.
    Section 108(c) of this bill would require VA to suspend the 
eligibility of a non-VA provider if the provider is suspended 
from serving as a VA provider.
    Section 108(d) of this bill would require the Comptroller 
General of the United States to submit to Congress a report on 
the implementation of this section, including: the aggregate 
number of health care providers denied or suspended; an 
evaluation of any impact on access to care for patients or 
staffing shortages; an explanation of the coordination of VA 
with medical licensing boards of States and the efforts of VA 
to address any concerns from these boards; and any 
recommendations the Comptroller General finds appropriate.
    Section 108(e) of this bill would define the term: ``non-
Department health care services.''

Sec. 109. Remediation of medical services lines

    Section 109(a) of this bill would amend subchapter I of 
chapter 17 by inserting after section 1706 the following new 
section: ``Sec. 1706A. Remediation of medical service lines.''
    The new section 1706A(a) would require VA to submit to 
Congress a plan to remediate medical service lines not later 
than 30 days after determining that the service line does not 
comply with standards for quality. The specific actions shall 
include, but are not limited to: increasing personnel or 
temporary personnel assistance, including mobile deployment 
teams; utilizing special hiring incentives, including the 
Education Debt Reduction Program (EDRP) and recruitment, 
relocation, and retention incentives; utilizing direct hiring 
authority; providing improved training opportunities for staff; 
acquiring improved equipment; making structural modifications 
to the facility used by the medical service line; and such 
other actions as VA considers appropriate.
    The new section 1706A(b) would require each report to 
include the individuals at the Central Office of the Veterans 
Health Administration, the facility used by the medical service 
line, and the central office of relevant Veterans Integrated 
Service Network who are responsible for overseeing the progress 
of the service line.
    The new section 1706A(c) would require VA to submit interim 
reports to Congress on the remediation actions and costs taken 
for each medical service line submitted for assessment. This 
analysis shall be published on the VA's website.
    The new section 1706A(d) would require VA to submit annual 
reports to Congress on the remediation actions and costs taken 
for each medical service line submitted for assessment. This 
analysis shall be published on the VA's website.
    Section 109(b) of this bill provides for a clerical 
amendment of the table of sections.

         Chapter 2--Paying Providers and Improving Collections


Sec. 111. Prompt payment to providers

    Section 111(a) of this bill would amend subchapter I of 
chapter 17 by inserting after section 1703C, the following new 
section: ``Sec. 1703D. Prompt payment standards.''
    The new section 1703D(a) would establish a prompt payment 
process that requires VA to pay for, or deny payment for, 
services within 30 calendar days of receipt of a clean 
electronic claim or within 45 calendar days of receipt of a 
clean paper claim. In the case of a denial, VA would have to 
notify the provider of the reason for denying the claim and 
what, if any, additional information would be required to 
process the claim. Upon the receipt of the additional 
information, VA would have to pay, deny, or otherwise 
adjudicate the claim within 30 calendar days. These 
requirements would only apply to payments made on an invoice 
basis and would not apply to capitation or other forms of 
periodic payments to entities or providers.
    The new section 1703D(b) would establish that Non-VA 
entities or providers would be required to submit a claim to VA 
within 180 days of providing care or services.
    The new section 1703D(c) would establish the application of 
title 31 to fraudulent claims. The Secretary shall prescribe 
regulations barring a health care entity or provide from 
furnishing care or services if it is determined that such 
entity or provider submitted fraudulent claims.
    The new section 1703D(d) would establish that any claim 
that has not been denied, made pending, or paid within the 
specified time periods would be considered overdue and subject 
to interest payment penalties. VA to report annually on the 
number of and the amount paid in overdue claims.
    The new section 1703D(e) would authorize VA to deduct the 
amount of any overpayment from payments due to an entity or 
provider under certain conditions.
    The new section 1703D(f) would require VA to provide to all 
health care entities and providers in the program a list of 
information and documentation that is required to establish a 
clean claim under this section.
    The new section 1703D(g) would allow VA to have claims 
processing performed by either a contracted third-party 
administrator or other entity to conduct these administrative 
functions. This section would require an independent review of 
claims that includes the capacity of VA to process such claims 
in a timely manner and a cost benefit analysis comparing the 
capacity of VA to a third-party entity capable of processing 
such claims.
    The new section 1703D(h) would require VA to submit to the 
appropriate committees of Congress a report on the feasibility 
and advisability of adopting a funding mechanism similar to 
what is utilized by other Federal agencies.
    The new section 1703D(i) would define the terms: 
``appropriate committees of Congress'', ``clean electronic 
claim'', ``clean paper claim'', ``fraudulent claims'', and 
``health care entity or provider.''
    Section 111(b) of this bill provides for a clerical 
amendment of the table of sections

Sec. 112. Authority to pay for authorized care not subject to an 
        agreement.

    Section 112(a) of this bill would amend subchapter IV of 
chapter 81 by adding the following new section: ``Sec. 8159. 
Authority to pay for services authorized but not subject to an 
agreement.''
    The new section 8159(a) would authorize VA to pay for 
services not subject to a contract or agreement.
    The new section 8159(b) would require VA to take reasonable 
efforts to enter into a contract or agreement with a provider 
to ensure that future care and services authorized by VA are 
subject to the contract.
    Section 112(b) of this bill provides for a clerical 
amendment of the table of sections.

Sec. 113. Improvement of authority to recover the cost of services 
        furnished for non-service-connected disabilities

    Section 113(a) of this bill would allow for VA to collect 
from a third-party for care provided to non-veterans by 
amending section 1729.
    Section 113(b) of this bill would authorize VA to seek 
collections when VA pays for care rather than furnishing it. 
This section also removes duplicative language.
    Section 113(c) of this bill would amend the statute on 
eligible individuals.

Sec. 114. Processing of claims for reimbursement through electronic 
        interface

    Section 114 of this bill would allow VA to enter into an 
agreement with a third-party entity to electronically process 
health care claims from community providers.

               Chapter 3--Education and Training Programs


Sec. 121. Education program on health care options

    Section 121(a) of this bill would require VA to develop and 
administer an education program that teaches veterans about 
their health care options.
    Section 121(b) of this bill would establish the elements of 
the program. It shall teach veterans about: eligibility 
criteria for care from VA; priority groups for enrollment; the 
copayments and other financial obligations, if any apply; how 
to utilize the access standards and standards for quality; 
teach veterans about the interaction between health insurance 
and VA; and provide information on what to do when filing a 
complaint about health care received.
    Section 121(c) of this bill would require VA to ensure that 
such programs are accessible to all veterans, regardless of 
internet access or disabilities.
    Section 121(d) of this bill would require VA to develop a 
method to evaluate the effectiveness of the education program 
and once a year, submit a report to Congress on the evaluations 
of the education program.
    Section 121(e) of this bill would define the terms: 
``Medicaid'', ``Medicare'', and ``TRICARE program.''

Sec. 122. Training program for administration of non-Department of 
        Veterans Affairs health care

    Section 122(a) of this bill would require VA to develop and 
implement a training program to train employees and contractors 
of VA on how to administer non-VA health care programs, 
particularly the management of prescription opioids.
    Section 122(b) of this bill would require VA to develop a 
method to evaluate the effectiveness of the training program 
and shall submit to Congress an annual report on the findings 
of the evaluation.

Sec. 123. Continuing medical education for non-Department medical 
        professionals

    Section 123(a) of this bill would establish a program to 
provide continuing medical education material to non-VA medical 
professionals at no cost to them.
    Section 123(b) of this bill would establish that the 
material provided to non-VA professionals be the same material 
provided to VA professionals.
    Section 123(c) of this bill would require VA to administer 
the program, determine the curriculum of the program, ensure 
the accreditation of the program in as many States as possible, 
ensure the consistence of the program with rules and 
regulations of medical licensing agency in each State, that the 
program is no cost to the participant, and that VA monitor, 
evaluate, and report to Congress on the utilization and 
effectiveness once a year.
    Section 123(d) of this bill would define ``non-Department 
medical professional.''

Chapter 4--Other Matters Relating to Non-Department of Veterans Affairs 
                               Providers


Sec. 131. Establishment of processes to ensure safe opioid prescribing 
        practices by non-Department of Veterans Affairs health care 
        providers

    Section 131(a) of this bill would require VA to 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 VA.
    Section 131(b) of this bill would require VA to implement a 
process to ensure that, if a veteran is provided care by a 
covered provider under the laws administered by VA, the 
provider submit medical history of the veteran to VA.
    Section 131(c) of this bill would require all covered 
providers to submit medical record of any care furnished, 
including prescriptions of opioids, to VA for each veteran 
seen. Upon receiving these records, VA is responsible for 
entering the prescriptions into the electronic health record of 
the veteran, and VA is responsible for monitoring the 
prescription as outlined in the Opioid Safety Initiative. VA 
must submit an annual report to Congress evaluating the 
compliance of cover providers with the requirements of this 
section.
    Section 131(d) of this bill would require VA to take 
appropriate action with a covered provider determined to not be 
adhering to or complying with the Opioid Safety Initiative. VA 
may refuse authorization of care by such provider and direct 
their removal from the network.
    Section 131(e) of this bill would define ``covered health 
care provider.''

Sec. 132. Improving information sharing with community providers

    Section 132 of this bill would amend section 7332(b)(2) to 
clarify that VA could share medical record information with 
non-Department entities for the purpose of providing health 
care to patients or performing other health care related 
activities and remove certain restrictions on VA's ability to 
recover funds from third parties for the cost of non-service-
connected care.

Sec. 133. Competency standards for non-Department of Veterans Affairs 
        health care providers

    Section 133(a) of this bill would require VA to establish 
standards and requirements for the provision of care by non-VA 
health care providers in clinical areas for which VA has 
special expertise, including post-traumatic stress disorder, 
military sexual trauma-related conditions, and traumatic brain 
injuries.
    Section 133(b) of this bill would, to the extent possible, 
require covered health care providers who are in a clinical 
area of expertise for VA to fulfill training requirements 
determined by VA, before furnishing care.
    Section 133(c) of this bill would establish an effective 
date at one year after the date of enactment.

Sec. 134. Department of Veterans Affairs participation in national 
        network of State-based prescription drug monitoring program

    Section 134(a) of this bill would amend chapter 17 by 
inserting after section 1730A the following new section: 
``Sec. 1730B. Access to State prescription drug monitoring 
programs.''
    The new section 1730B(a) would allow any licensed health 
care provider or delegate to be considered an authorized 
recipient or user of data from the national network of State-
based prescription drug monitoring programs. Under this 
authority, licensed health care providers or delegates would be 
required to query the network in accordance with applicable VA 
regulations and policies and no State would be authorized to 
restrict the access of licensed health care providers or 
delegates from accessing that State's prescription drug 
monitoring programs.
    The new section 1730B(b) would define ``covered patients.''
    The new section 1730B(c) would define terms: ``controlled 
substance'', ``delegate'', ``licensed health care provider'', 
``national network of State-based prescription monitoring 
programs'', and ``State''.
    Section 134(b) of this bill provides for a clerical 
amendment of the table of sections.

          Chapter 5--Other Non-Department Health Care Matters


Sec. 141. Plans for use of supplemental appropriations required

    Section 141 of this bill would require VA to submit to 
Congress a justification for any new supplemental 
appropriations request submitted outside of the standard budget 
process no later than 45 days before the date on which a 
budgetary issue would start affecting a program or service. It 
would also require a detailed strategic plan on how VA intends 
to use the requested appropriation and for how long the 
requested funds are expected to meet the need.

Sec. 142. Veterans Choice fund flexibility

    Section 142 of this bill would amend section 802 of the 
Choice Act to authorize VA, beginning March 1, 2019, to use the 
remaining Veterans Choice Fund to pay for any health care 
services under Chapter 17 of Title 38 at non-Department 
facilities or through non-Department providers furnishing care 
in VA facilities.

Sec. 143. Sunset of Veterans Choice Program

    Section 143 of this bill would provide a sunset date for 
the Veterans Choice Program one year after the date of 
enactment of this Act.

Sec. 144. Conforming amendments

    Section 144 of this bill would repeal and replace existing 
authorities to account for changes made by section 101 of the 
bill to consolidate and create the Veterans Community Care 
program.

   Subtitle B--Improving Department of Veterans Affairs Health Care 
                                Delivery


Sec. 151. Licensure of health care professionals of the Department of 
        Veterans Affairs providing treatment via telemedicine

    Section 151(a) of this bill would amend Chapter 17 by 
inserting after section 1730B, as added by section 134, the 
following new section: ``Sec. 1730C. Licensure of health care 
professionals providing treatment via telemedicine.''
    The new section 1730C(a) would allow covered health care 
professionals to practice at any location in any State if using 
telemedicine under this chapter.
    The new section 1730C(b) would define a ``covered health 
care professional.''
    The new section 1730C(c) would enforce that subsection (a) 
of this section shall apply to a covered health care 
professional regardless of whether they are located in a 
Federally owned facility during the treatment.
    The new section 1730C(d) would establish that this 
provision shall supersede any provisions of State law if those 
provisions are inconsistent with this section.
    The new section 1730C(e) would establish that nothing may 
be construed to remove, limit, or otherwise affect any 
obligation of a covered health care professional under the 
Controlled Substance Act.
    The new section 1730C(f) would define ``State.''
    Section 151(b) of this bill provides for a clerical 
amendment of the table of sections.
    Section 151(c) of this bill would require VA to submit a 
report to Congress on the effectiveness of telemedicine within 
one year of enactment, providing data on provider and patient 
satisfaction, the effect of telemedicine on patient wait-times, 
health care utilization, and other measures.

Sec. 152. Authority for Department of Veterans Affairs Center for 
        Innovation for Care and Payment

    Section 152(a) of this bill would amend subchapter I of 
chapter 17 by inserting after section 1703D, as added by 
section 11, the following new section: ``Sec. 1703E. Center for 
Innovation for Care and Payment.''
    The new section 1703E(a) would authorize VA 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. VA would be 
required to test models where VA determines that there is 
evidence that the model addresses a defined population for 
which there are deficits in care leading to poor clinical 
outcomes or potentially avoidable expenditures. VA would be 
required to focus on models expected to reduce program costs 
while preserving or enhancing the quality of or access to care 
VA provides. VA would be authorized to consider a number of 
different factors in selecting models to test. The models 
tested under this program could not be designed in such a way 
as to allow the United States to recover or collect reasonable 
charges from a Federal health care program (including Medicare, 
Medicaid, and TRICARE) for care or services furnished by VA to 
veterans.
    The new section 1703E(b) would authorize the pilot programs 
to last no longer than five years.
    The new section 1703E(c) would require VA ensure that each 
pilot program occurs in an area or areas appropriate for the 
intended purpose of the program. To the extent possible, the 
programs shall be located in geographically diverse areas.
    The new section 1703E(d) would establish that the funding 
for the pilot programs shall come from appropriations provided 
in advance for VHA and information technology systems.
    The new section 1703E(e) would require VA to publish 
information and take all reasonable action to give notice to 
veterans eligible to participate in the pilot programs.
    The new section 1703E(f) would authorize VA 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. VA would only be allowed to act 
upon any such waiver after Congress enacts a joint resolution 
approving the action.
    The new section 1703E(g) would limit VA to carrying out no 
more than ten pilot programs concurrently and would prohibit VA 
from spending more than $50 million per fiscal year on the 
programs. This limit may be increased only if VA receives 
written consent from the Chairmen of the Committees on 
Veterans' Affairs in the House and the Senate, respectively.
    The new section 1703E(h) would require VA to conduct an 
evaluation of each model tested, which shall include an 
analysis of the quality of care furnished under the model, 
including the measurement of patient-level outcomes and 
patient-centeredness criteria determined by VA and the changes 
in spending by reason of that model. VA shall make the results 
of each evaluation public in the Federal Registry.
    The new section 1703E(i) would establish that VA shall 
obtain advice from the Under Secretary for Health and the 
Special Medical Advisory Group to develop and implement any of 
the pilot programs, as well as consult relevant Federal 
agencies and interested parties.
    The new section 1703E(j) would authorize VA to expand, 
through rulemaking, the duration and scope of successful pilot 
programs to the extent VA determines that such expansion is 
expected to reduce spending without reducing the quality of or 
access to care or improve the quality of or access to care 
without increasing spending; VA would also have to determine 
that such expansion would not deny or limit the coverage or 
provision of benefits for applicable individuals.
    Section 152(b) of this bill provides for a conforming 
amendment of the table of sections.

Sec. 153. Authorization to provide for operations on live donors for 
        purposes of conducting transplant procedures for veterans

    Section 153(a) of this bill would amend subchapter VIII of 
chapter 17 by adding the following new section: ``Sec. 1788. 
Transplant procedures with live donors and related services.''
    The new section 1788(a) would authorize VA to provide for 
an operation on a live donor, regardless of the donor's 
eligibility for VA health care, if the procedure is for an 
eligible veteran.
    The new section 1788(b) would require VA to provide any 
care or services before and after conducting the transplant 
procedure.
    The new section 1788(c) would allow VA to, in carrying out 
this section, provide the care and services from subsection (a) 
and (b) of this section in a non-VA facility, provided VA has 
an agreement with the facility.
    Section 153(b) of this bill provides for a clerical 
amendment of the table of sections.

                     Subtitle C--Family Caregivers


Sec. 161. Expansion of Family Caregiver Program of Department of 
        Veterans Affairs

    Section 161(a) of this bill would amend Subparagraph (B) of 
subsection (a)(2) of section 1720G to expand eligibility for 
VA's Program of Comprehensive Assistance for Family Caregivers 
to veterans with a serious injury incurred or aggravated in the 
line of duty in the active military, naval, or air service on 
or before May 7, 1975. After the date that is two years after 
the date on which the certification is submitted, eligibility 
would be expanded to also include veterans with a serious 
injury incurred or aggravated in the line of duty in the active 
military, naval, or air service after May 7, 1975, and before 
September 11, 2001. Not later than 30 days after the date on 
which VA submits to Congress the certification of this title, 
VA shall publish the date specified in such subsection in the 
Federal Register. The stipend calculation is also modified, and 
VA shall take into account: the assessment by the family 
caregiver of the needs of the veteran; the extent to which the 
veteran can function safely and independently; and the amount 
of time required for the family caregiver to provide assistance 
to the veteran. VA shall provide instruction, preparation, and 
training, as well as technical support, to each family 
caregiver who is approved as a provider of personal care for an 
eligible veteran. VA shall periodically evaluate the needs of 
the eligible veteran to determine if additional instruction, 
training, or technical support is needed. VA may enter into 
agreements with Federal agencies, States, and private entities 
to provide assistance to family caregivers, and VA may provider 
fair compensation to these entities for assistance rendered.
    Section 161(b) of this bill would modify the definition of 
``personal care services'' under Subsection (d)(4).

Sec. 162. Implementation of information technology system of Department 
        of Veterans Affairs to assess and improve the Family Caregiver 
        Program

    Section 162(a) of this bill would require VA to implement 
an information technology system that fully supports the Family 
Caregiver Program and allows for data assessment and 
comprehensive monitoring by not later than October 1, 2018.
    Section 162(b) of this bill would require VA to use data 
from the system to conduct an assessment of key aspects of the 
program and how they are carried out. The assessment shall 
occur no later than 180 days after implementation of the 
system.
    Section 162(c) of this bill would establish that VA shall 
use the system to monitor and assess the workload of the 
Program and the use of support services by the caregivers. 
Based on the monitoring and assessment, VA shall identify and 
implement modifications to ensure the program is functioning as 
intended.
    Section 162(d) of this bill would require VA to submit a 
report to Congress and the Comptroller General of the United 
States not later than 90 days after the date of enactment of 
this bill. The Comptroller General shall review the report and 
notify Congress on the progress and assessment of the system.
    Section 162(e) of this bill would define the terms: 
``active military, naval, or air service'' and ``Program.''

Sec. 163. Modifications to annual evaluation report on Caregiver 
        Program of Department of Veterans Affairs

    Section 163(a) of this bill would amend subparagraph 
(A)(iv) of section 101(c)(2) of the Caregivers and Veterans 
Omnibus Health Services Act by inserting ``including a 
description of any barriers to accessing and receiving care and 
services und such programs.''
    Section 163(b) of this bill would amend Subparagraph (b) of 
such section by inserting a requirement for an evaluation of 
the sufficiency and consistency of caregiver training.

              TITLE II--VA ASSET AND INFRASTRUCTURE REVIEW

              Subtitle A--Asset and Infrastructure Review


Section 201. Short title

    Section 201 of this bill would establish the short title of 
the subtitle as the ``VA Asset and Infrastructure Review Act of 
2018.''

Section 202. The Commission

    Section 202(a) of this bill would establish an independent 
``Asset and Infrastructure Review Commission.''
    Section 202(b) of this bill would require the Commission to 
carry out the duties described in this title.
    Section 202(c) of this bill would require the President, 
with the advice and consent of the Senate, to appoint nine AIR 
Commissioners and to transmit nominations to the Senate by May 
31, 2021. Additionally, it would require the President to 
consult with the Speaker and minority leader of the House of 
Representatives and the majority and minority leader of the 
Senate in selecting individuals for Commission nomination and 
congressionally chartered, membership-based veterans service 
organizations (VSOs) specifically concerning the appointment of 
three members. The President would be required to nominate one 
person to serve as the Chair of the Commission and one person 
to serve as the Vice Chair of the Commission, and in nominating 
individuals for appointment to the Commission, to ensure: that 
veterans (reflecting current demographics of veterans enrolled 
in the VA health care system) are adequately represented in the 
membership of the Commission; that at least one member of the 
Commission has experience with a private integrated health care 
system that has annual gross revenue of more than $50 million; 
that at least one member has experience as a senior manager for 
a Federally-qualified health center, the Department of Defense, 
or the Indian Health Service; that at least one member has 
experience with capital asset management for the Federal 
government and is familiar with trades related to building and 
real property (including construction, engineering, 
architecture, leasing, and strategic partnerships); and, that 
at least three members represent congressionally-chartered, 
membership-based VSOs.
    Section 202(d) of this bill would require the Commission to 
meet only during calendar years 2022 and 2023, and requires 
that each meeting of the Commission be open and all 
proceedings, information, and deliberations of the Commission 
to be available for review by the public.
    Section 202(e) of this bill would require a vacancy in the 
Commission to be filled in the same manner as the original 
appointment, but the individual appointed to fill the vacancy 
to serve only for the unexpired portion of the term for which 
the individual's predecessor was appointed.
    Section 202(f) of this bill would require Commissioners to 
serve without pay, requires each member of the Commission who 
is an officer/employee of the United States to only receive 
compensation for their services as an officer/employee of the 
U.S, and allows Commissioners to receive travel expenses, 
including per diem.
    Section 202(g) of this bill would require the Commission to 
appoint a staff director who has not served as a VA employee 
during the one-year period preceding the date of appointment 
and who is not otherwise barred or prohibited from serving as a 
Director under Federal ethics law and regulations by reason of 
post-employment conflict of interest and requires the Director 
to be paid at the rate of basic pay payable for level IV of the 
Executive Schedule.
    Section 202(h) of this bill would require the Director, 
with the approval of the Commission, to appoint and fix the pay 
of additional personnel, to make such appointments without 
regard to the provisions of title 5 U.S.C. governing 
appointments in the competitive service, and any personnel so 
appointed to be paid without regard to provisions relating to 
the classification and General Schedule pay rates except that 
an individual so appointed may not receive pay in excess of the 
annual rate of basic pay payable for GS-15. This bill would 
allow not more than two-thirds of the personnel employed by or 
detailed to the Commission to be on detail from VA and not more 
half of the professional analysts to be detailed from VA. This 
section also prohibits a person from being detailed to the 
Commission from VA if, within six months before the detail is 
set to begin, the person participated personally or 
substantially in any matter concerning the preparation of 
recommendations regarding Veterans Health Administration (VHA) 
facilities. Additionally, it would allow any Federal department 
or agency to detail personnel to the Commission upon request. 
Lastly, this bill would allow the Commission to secure 
necessary information from Federal agencies and Federal 
agencies to furnish such information upon request.
    Section 202(i) of this bill would allow the Commission to 
procure, by contract to the extent funds are available, the 
temporary or intermittent services or experts of consultants 
and to lease real property and acquire personal property either 
of its own accord or in consultation with the General Services 
Administration (GSA).
    Section 202(j) of this bill would terminate the Commission 
on December 31, 2023.
    Section 202(k) of this bill would prohibit the restriction 
of lawful communication from a VA employee to the Commission.

Section 203. Procedure for making recommendations

    Section 203(a) of this bill would require VA, not later 
than February 1, 2021, and after consulting with VSOs, to 
publish in the Federal Register and transmit to the Committees 
on Veterans' Affairs of the House of Representatives and the 
Senate the criteria proposed by VA to be used in assessment and 
making recommendations regarding the modernization or 
realignment of VHA facilities and require such criteria to 
include the veteran's preference regarding access to VA health 
care. VA would be required to hold a 90-day public comment 
period for VA's proposed criteria, and, not later than May 31, 
2021, to publish in the Federal Register and transmit to HVAC/
SVAC, the final criteria to be used in making recommendations 
regarding the modernization or realignment of VHA facilities.
    Section 203(b) of this bill would require VA, not later 
than January 31, 2022, and after consulting with VSOs, to 
publish in the Federal Register and transmit to Committees on 
Veterans' Affairs of the House of Representatives and the 
Senate a report detailing recommendations regarding the 
modernization or realignment of VHA facilities. VA would be 
required to consider the following factors in making 
recommendations regarding the modernization or realignment of 
VHA facilities: the degree to which health care delivery or 
other site for providing services to veterans reflect VA's 
metrics regarding market area health system planning; the 
provision of effective and efficient access to high-quality 
health care and services to veterans; the extent to which real 
property that no longer meets the needs of the Federal 
Government could be reconfigured, repurposed, consolidated, 
realigned, exchanged, outleased, repurposed, replaced, sold, or 
disposed; VHA's need to acquire infrastructure or facilities 
that will be used for the provision of health care and service 
to veterans; the extent to which operation and maintenance 
costs are reduced through consolidating, collocating, and 
reconfiguring space and through realizing other operational 
efficiencies; the extent and timing of potential costs and 
savings, including the number of years such costs and savings 
will be incurred, beginning with the date of completion of the 
proposed recommendation; the extent to which the real property 
aligns with VA's mission; the extent to which any action would 
impact other VA missions including education, research, or 
emergency preparedness; local stakeholder inputs and any 
factors identified through public field hearings; capacity and 
commercial market assessments; and, any other factors VA 
determines appropriate. VA would be required to assess the 
capacity of each Veterans Integrated Service Network (VISN) and 
VA medical facility to furnish hospital care or medical 
services to veterans and require each assessment to: identify 
existing deficiencies in the furnishing of care and services to 
veterans and how such deficiencies may be filled by entering 
into contracts or agreements with community health care 
providers or other entities under other provisions of law and 
changing the way care and services are furnished at such VISNs 
or VA medical facilities (including through extending hours of 
operation, adding personnel, and expanding treatment space 
through construction, leasing, or sharing of health care 
facilities); forecast, based on future projections and 
historical trends, both the short-term and long-term demand in 
furnishing care and services at such VISN or VA medical 
facility; consider how demand affects the need to enter into 
contracts or agreements; consider the commercial health care 
market of designated catchment areas conducted by a non-
governmental entity; and, consider the unique ability of the 
Federal government to retain a presence in a rural area 
otherwise devoid of commercial health care providers or from 
which such providers are at risk of leaving. VA would be 
required to consult with VSOs and veterans served by each VISN 
and medical facility affected by the assessments. VA would be 
required to submit the local capacity and commercial market 
assessments to Committees on Veterans' Affairs of the House of 
Representatives and the Senate with the recommendations 
regarding the modernization or realignment of VHA facilities 
and to make the assessments publicly available. VA would be 
required to include with the recommendations regarding the 
modernization or realignment of VHA facilities a summary of the 
selection process that resulted in the recommendation for each 
VHA facility and a justification for each recommendation and to 
transmit the summaries and justifications not later than 7 days 
after the date of transmittal to HVAC/SVAC. VA shall consider 
all facilities equally without regard to whether the facility 
has been previously considered or proposed for reuse, 
modernization, or realignment. VA shall make all information 
used by VA to prepare a recommendation available to Congress, 
the Commission and the Comptroller General. Each VA Under 
Secretary, VISN director, VA medical center director, VA 
program office director, and each person who is in a position 
of duties which includes personal and substantial involvement 
in the preparation and submission of information and 
recommendations concerning the modernization or realignment of 
VHA facilities would certify that information submitted to VA 
or to the Commission concerning the modernization or 
realignment of VHA facilities is accurate and complete to the 
best of that person's knowledge and belief. The Commission is 
required to conduct public hearings on VA's recommendations 
regarding the modernization or realignment of VHA facilities, 
to include required public hearings in regions affected by a VA 
recommendation for the closure of a facility and, to the 
greatest extent practicable, public hearings in regions 
affected by a recommendation for other (non-closure) action by 
VA. Each Commission public hearing shall include, at a minimum, 
a local veteran who is enrolled in the VA healthcare system and 
identified by a local VSO and a local elected official. The 
Commission shall, not later than January 31, 2023, to transmit 
to the President a report and analysis of the recommendations 
made by VA together with the Commission's recommendations for 
the modernization or realignment of VHA facilities. The 
Commission is authorized to change a recommendation made by VA 
for the modernization or realignment of a VHA facility only if 
the Commission: determines that VA deviated substantially from 
VA's final criteria in making such recommendation; determines 
that the change is consistent with the final criteria; 
publishes a notice of the proposed change in the Federal 
Register not less than 45 days before transmitting the 
Commission's recommendations to the President; and, conducts 
public hearings on the proposed change. The Commission must 
explain and justify any recommendation made by the Commission 
that is different from the recommendations made by VA in the 
Commission's report that is transmitted to the President and to 
transmit the copy of such report to Committees on Veterans' 
Affairs of the House of Representatives and the Senate on the 
same day that it is transmitted to the President. The 
Commission, after transmitting its report to the President, 
shall promptly provide information used by the Commission in 
making its recommendations to any Member of Congress upon 
request.
    Section 203(d) of this bill would require the President, 
not later than February 15, 2023, to transmit to the Commission 
and to Congress a report containing the President's approval or 
disapproval of the Commission's recommendations. If the 
President approves of the Commission's recommendations, the 
President is required to transmit a copy of the Commission's 
recommendations to the Congress together with a certification 
of approval. If the President disapproves of the Commission's 
recommendations in whole or in part, the President is required 
to transmit to the Commission and the Congress the reasons for 
that disapproval and require the Commission, not later than 
March 15, 2023, to transmit a report containing the 
Commission's findings and conclusions based on the review and 
analysis of the reasons for disapproval and a list of 
recommendations that the commission determines are appropriate 
to the President. If the President approves of the Commission's 
resubmitted recommendations, the President is required to 
transmit a copy of the recommendations to Congress together 
with a certification of such approval. This bill would require 
the process for modernization or realignment of VHA facilities 
to be terminated, if the President does not transmit a 
certification of approval to Congress, by March 30, 2023.

Section 204. Actions regarding infrastructure and facilities of the 
        Veterans Health Administration

    Section 204(a) of this bill would require VA, in the 
absence of a resolution of Congressional disapproval having 
been enacted within 45 days of Presidential transmission of the 
report to Congress or the adjournment of the 117th Congress, to 
begin implementing the recommendations made in the report under 
Section 103(d) within 3 years the President having transmitted 
the report to Congress.
    Section 204(b) of this bill would allow VA not to carry out 
any modernization or realignment recommendations by the 
Commission in a report transmitted from the President if a 
joint resolution is enacted disapproving such recommendations 
of the Commission before the earlier of: the end of the 45-day 
period beginning on the date on which the President transmits 
such report; or the adjournment of Congress sine die for the 
session during which a report is transmitted. Implementation 
includes the planning of modernizations or realignments. Days 
on which either House is not in session because of adjournment 
of more than three days shall be excluded from the computation 
of the period.

Section 205. Implementation

    Section 205(a) of this bill would allow VA to take such 
actions as necessary to implement the modernization or 
realignment of any VHA facility, perform environmental 
mitigation, abatement or restoration of facilities being closed 
or realigned to include compliance with historical preservation 
requirements, provide outplacement assistance to employees of 
the Department, reimburse Federal agencies for services, and 
enter into Enhanced Use Lease contracts.
    Section 205(b) of this bill would outline how VA may 
dispose or transfer surplus properties slated for disposal or 
realignment under this Act, including consultation with state 
and local governments for proper disposal of real property and 
roads. VA may transfer title to a redevelopment authority for a 
facility for the purposes of a federal lease for a term not to 
exceed 50 years. Such lease may not require rental payments by 
the government. If the lease involves a substantial portion of 
the facility, the department or agency may obtain facility 
services from the redevelopment authority as a provision of the 
lease. Such services shall not include municipal services, 
firefighting or security guard functions. Provisions of the 
Comprehensive Environmental Response, Compensation, and 
Liability Act of 1980 apply. Nothing in this title shall limit 
or otherwise affect application of McKinney-Vento Homeless 
Assistance Act provisions.
    Section 205(c) of this bill would exempt the actions of the 
President, Commission, and the VA, except during the process of 
disposal and relocation, from the National Environmental Policy 
Act of 1969. The Secretary shall not have to consider the need 
for closing, realigning, transferring function, or alternative 
facilities in carrying out the this subtitle.
    Section 205(d) of this bill would exempt VA from any legal 
prohibition of closing or realigning VHA facilities included in 
any appropriation or authorization Act.
    Section 205(e) of this bill would provide the authority for 
VA to transfer a deed of a VHA facility to a party who agrees 
to perform the environmental compliance activities that are 
required under Federal and State laws. Such transfer may occur 
if VA certifies to Congress that all costs to be paid by the 
Department are equal to or greater than market value or if such 
cost are lower than the recipient of the transfer agrees to pay 
the difference, and authorizes VA to pay the recipient an 
amount equal to the lesser of the two such amounts. VA would be 
required to disclose information regarding environmental 
restoration, waste management, and environmental compliance 
activities before entering into a deed transfer.

Section 206. Department of Veterans Affairs Asset and Infrastructure 
        Review Account

    Section 206(a) of this bill would establish a single 
account in the ledgers of the US Treasury with which VA shall 
administer as a single account. The account shall be known as 
``Department of Veterans Affairs Asset and Infrastructure 
Review Account.''
    Section 206(b) of this bill would allow for the credit to 
the account any funds authorized and appropriated and any 
proceeds from a lease, transfer, or disposal of property.
    Section 206(c) of this bill would allow VA to use the 
account for the purposes of carrying out this subtitle, to 
cover property management and disposal costs, to cover costs of 
supervision, inspection, overhead, engineering, and design, or 
for any other purposes in support of the Department's mission 
and operations.
    Section 206(d) of this bill would require VA to establish a 
consolidated budget display detailing the amount and nature of 
the credits to and expenditures from, separately details 
environmental remediation costs, specifies and details any 
transfers, and details any intra-budget activity transfers with 
the account that does or will exceed one million dollars during 
a fiscal year. This information shall be submitted to Congress 
as part of the Presidential budget submission.
    Section 206(e) of this bill would require that upon closure 
of the account any unobligated funds, upon submission of an 
accounting report to the appropriate committees of Congress, 
shall be transferred from the Treasury to VA. No later than 60 
days after the closure of the Account, VA shall submit a report 
to the appropriate committees of Congress detailing all the 
funds credited to and expended from the Account and any 
remaining funds.

Section 207. Congressional consideration of Commission report

    Section 207(a) of this bill would describe the term ``joint 
resolution'' as a resolution introduced within the 45-day 
period beginning on the date on which the President transmits 
the report to congress which does not include a preamble and 
contains specific language as to the resolving clause and 
title.
    Section 207(b) of this bill would outline the means by 
which the House of Representatives shall consider such 
resolution to include reporting and discharge, proceeding to 
consideration, and consideration.
    Section 207(c) of this bill outlines the means by which the 
Senate shall consider such resolution to include referral, 
reporting and discharge, and floor consideration to include 
consideration, vote on passage, and ruling of the chair on 
procedure.
    Section 207(d) of this bill would prohibit any amendment to 
a joint resolution of disapproval.
    Section 207(e) of the bill would define the coordination 
between either House upon receipt of companion measures.
    Section 207(f) of the bill would state that this section is 
applicable only with respect to the procedure followed in that 
House in the case of a joint resolution and supersedes other 
rules only to the extent that it is inconsistent with such 
rules, with the recognition of the constitutional right of 
either House to change the rules.

Section 208. Other matters

    Section 208(a) of the bill would require the online 
publication of all communications, within 24 hours, between VA, 
the Commission and the President with regards to this title.
    Section 208(b) of this bill would prohibit the VA from 
pausing or stopping any scheduled construction, leasing, long-
term planning project activities, or budgetary processes with 
regards to the construction during the activities of the 
Commission, President, or Congress in carrying out this title.
    Section 208(c) of this bill authorizes the Secretary to 
recommend, via budget submissions, any recommendations for 
future commissions or other capital realignment and management 
processes.

Section 209. Definitions

    Section 209 of this bill would define the terms: 
``Account'', ``Commission'', ``date of approval'', ``VHA 
facility'', ``infrastructure'', ``modernization'', 
``realignment'', ``Secretary'', ``redevelopment authority'', 
and ``redevelopment plan.''

                Subtitle B--Other Infrastructure Matters


Section 211. Improvement to training of construction personnel

    Section 211 of this bill would amend subsection (g) of 
section 8103 of title 38, U.S.C., requiring VA to implement a 
training and certification program for construction and 
facilities management personnel. VA would be required to create 
the training and certification program within one year of 
enactment, to ensure a majority of covered employees are 
certified within two years of enactment, and to ensure that all 
covered employees are certified as quickly as possible 
thereafter. VA would be required to model the training and 
certification program on existing curricula and certification 
programs in title 10 U.S.C. (namely, the existing Defense 
Acquisition Workforce Improvement Act program). VA would be 
authorized to provide the training in-person, online, provided 
by another Federal department or agency, or a combination of 
the above. VA would be authorized to offer one or more than one 
level of certification and to enter into a contract with an 
appropriate entity to provide the training curriculum and 
certification. All VA employees who are members of occupational 
series relating to construction or facilities management or VA 
employees who award or administer contracts for major 
construction, minor construction, or non-recurring maintenance 
(including contract specialists or contracting officers' 
representatives) would be included.

Sec. 212. Review of enhanced use lease

    Section 212 of this bill would amend section 8162(b)(6) to 
require the Office of Management and Budget review each 
enhanced use lease before the lease goes into effect.

Section 213. Assessment of health care furnished by the Department to 
        Veterans who live in the Pacific territories

    Section 213(a) of this bill would require VA to submit to 
the House and Senate Committees on Veterans' Affairs a report 
regarding the health care furnished by VA to veterans who live 
in the Pacific territories.
    Section 213(b) of this bill would establish that the report 
shall assess the ability of the Department to provide hospital 
care, medical, mental health, and geriatric services, as well 
as assess the feasibility of establishing a medical facility in 
any territory that does not contain such a facility.
    Section 213(c) of this bill would define the term: 
``Pacific territories'' as American Samoa, Guam, and the 
Northern Mariana Islands.

  TITLE III--IMPROVEMENTS TO RECRUITMENT OF HEALTH CARE PROFESSIONALS

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 requiring VA 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 
VA determines that staffing shortage of dentists and physicians 
is lower than 500. VA would award scholarships in an amount 
equal to not less than 10 percent of the staffing shortage. 
VA's agreement to provide a 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. VA may give 
preference to applicants who are veterans. On an annual basis, 
VA will provide to appropriate educational institutions 
information material about the availability of scholarships.
    Section 301(b) of this bill 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 of Section 7619 
of title 38, U.S.C. from December 21, 2019, to December 31, 
2033.

Sec. 302. Increase in maximum amount of debt that may be reduced under 
        Education Debt Reduction Program of Department of Veterans 
        Affairs

    Section 302(a) of this bill would amend Section 7683(d)(1) 
of Title 38, U.S.C., to increase the amount of debt which may 
be reimbursed under VA's Education Debt Reduction Program 
(EDRP) to $200,000 total over five years for the Specialty 
Education Loan Reduction Program, and $40,000 annually.
    Section 302(b) of this bill requires VA to conduct and 
submit to Congress a study on the demand for VA's EDRP, to 
include: (1) the total number of vacancies within VHA whose 
applicants are eligible for EDRP, (2) the types of medical 
professionals in greatest demand in the US, and (3) projections 
of the numbers and types of medical professions that meet the 
needs of veterans.

Sec. 303. Establishing the Department of Veterans Affairs specialty 
        education loan repayment program

    Section 303(a) of this bill 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.''
    The new section, ``Sec. 7691. Establishment'' would 
establish a loan repayment program to incentivize individuals 
employed in the Veterans Health Administration to pursue 
education and training in medical specialties for which VA 
determines there is a shortage.
    The new section, ``Sec. 7692. Purpose'' would outline the 
purpose of the Specialty Education Loan Repayment Program.
    The new section, ``Sec. 7693. Eligibility; preferences; 
covered costs'' would outline eligibility for the participation 
in the Specialty Education Loan Repayment Program, give 
preference to veterans in this program, and outline which 
expenses are allowed to be covered under this section.
    The new section, ``Sec. 7694. Specialty education loan 
repayment'' would outline the manner in which the Specialty 
Education Loan Repayment Program are to be made.
    The new section, ``Sec. 7695. Choice of location'' would 
allow each participant who completes their residency to select 
their location of employment from a list of medical facilities 
of the VHA.
    The new section, ``Sec. 7696. Term of Obligation'' would 
outline the terms of the service obligation for the Specialty 
Education Loan Repayment Program and would state 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, VA, 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. A formula is established 
by which VA may seek monetary collections from an employee who 
violates the terms of obligated service under this section.
    The new section, ``Sec. 7697. Relationship to Educational 
Assistance Program'' would allow 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.
    Section 303(b) of this bill would provide conforming and 
technical corrections.
    Section 303(c) of this bill would require VA to consider 
the needs of VHA and anticipate the needs during the next two 
to six years.
    Section 303(d) of this bill would require VA to determine 
whether a facility of the Department is underserved.
    Section 303(e) of this bill would require VA to offer 
participation to the applicant not later than 28 days after the 
applicant matches with a residency in a medical specialty and 
such match is published.

Sec. 304. Veterans Healing Veterans Medical Access and Scholarship 
        Program

    Section 304(a) of this bill would establish that VA shall 
carry out a pilot program under which VA 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 304(b) of this bill would establish the eligibility 
requirements for the Veterans Healing Veterans Medical Access 
and Scholarship Program.
    Section 304(c) of this bill would require 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 tuition for four years; books, fees, and technical 
equipment; fees associated with the National Residency Match 
Program; two away rotations performed during the fourth year at 
a VA medical facility; and 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 304(d) of this bill would outline the terms of the 
agreement for eligible veterans who accept funding for medical 
education under this section. Additionally, this section 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 304(e) of this bill would allow covered schools to 
accept more than two eligible veterans for the entering class 
of 2019.
    Section 304(f) of this bill would require that no later 
than December 31, 2020, and annually thereafter for three 
years, VA shall submit to Congress a full report on the pilot 
program.
    Section 304(g) of this bill would define ``covered medical 
schools'' as Teague-Cranston medical schools and the medical 
schools of Historically Black Colleges and Universities.

Sec. 305. Bonuses for recruitment, relocation, and retention

    Section 302 of this bill amends Section 705(a) of PL113-146 
to increase the amount authorized for the provision of bonuses 
to improve recruitment, relocation, and retention of employees. 
The section sets the limitations on bonus awards from 
$230,000,000 to $250,000,000 for fiscal years 2019 through 
2022, and from $225,000,000 to $290,000,000 for fiscal years 
2022 through 2024, with a minimum of $20,000,000 for 
recruitment, relocation, and retention bonuses for both time 
periods

Sec. 306. Inclusion of Vet Center employees in Education Debt Reduction 
        Program of Department of Veterans Affairs

    Section 306(a) of this bill extends eligibility for VA's 
Education Debt Reduction Program (EDRP) to clinical staff 
working at Vet Centers.
    Section 306(b) of this bill directs VA to submit to 
Congress a report on the number of participants in the EDRP who 
work at Vet Centers.
    Section 306(c) of this bill defines the term, ``Vet 
Center.''

               TITLE IV--HEALTH CARE IN UNDERSERVED AREAS

Sec. 401. Development of criteria for designation of certain medical 
        facilities of the Department of Veterans Affairs as underserved 
        facilities and plan to address problem of underserved 
        facilities

    Section 401(a) of this bill would establish that VA shall, 
not later than 180 days after enactment, develop criteria to 
designate medical facilities as underserved.
    Section 401(b) of this bill would require the developed 
criteria to consider: the ratio of veterans to health care 
providers of VA, including a separate ratio for general 
practitioners and specialist; the range of clinical specialties 
covered by such providers; whether the local community is 
underserved; the type, number, and age of open consults; 
whether the facility is meeting the wait-time goals of VA; and 
such other criteria developed by VA.
    Section 401(c) of this bill would require Veterans 
Integrated Service Networks, not less than annually, perform an 
analysis to determine which facilities qualify as underserved.
    Section 401(d) of this bill would establish that not later 
than one year after enactment and annually thereafter, VA shall 
submit to congress a plan to address the problem of underserved 
facilities.

Sec. 402. Pilot program to furnish mobile deployment teams to 
        underserved facilities

    Section 402(a) of this bill would require VA to carry out a 
pilot program to furnish mobile deployment teams to underserved 
facilities.
    Section 402(b) of this bill would establish that VA shall 
consider the medical positions of greatest need at the 
underserved facilities, the size and composition of the team 
deployed, and other elements established by VA for oversight of 
the program.
    Section 402(c) of this bill would require that VA use the 
results from the annual analysis from the above section 401(c) 
of this bill to send mobile deployment teams to the underserved 
areas with the most needed medical personnel.
    Section 402(d) of this bill would require VA to report, not 
later than one year after the date of enactment, to Congress on 
the implementation of the program. Not later than the 
termination date of the pilot program, VA shall also submit a 
final report on the feasibility of extending and expanding the 
pilot program and making the pilot program permanent.
    Section 402(e) of this bill would establish the duration of 
the pilot at three years after the date of enactment.
    Section 402(f) of this bill would define the term 
``underserved facility.''

Sec. 403. Pilot program on graduate medical education and residency

    Section 403(a) of this bill would establish a pilot program 
to create medical residency positions authorized under section 
301(b)(2) of the Veterans Access, Choice, and Accountability 
Act at covered facilities, including: VA facilities, a facility 
operated by an Indian Tribe or tribal organization, an Indian 
Health Service facility, a Federally-qualified health center, a 
DOD facility, or any other health care facility considered 
appropriate. To carry out the pilot program, VA may enter into 
agreements with entities that operate covered facilities. When 
establishing the parameters for location, affiliate sponsor, 
and duration, VA shall consider: the ratio of veterans to 
providers, including separate ratio for general practitioners 
and specialists; the range of clinical specialties of providers 
in the area; whether the specialty of a provider is included in 
the most recent staffing shortage assessment; whether the local 
community designated by VA as underserved; whether HHS has 
designated the region as a health professional shortage area; 
whether the facility is located in a rural or remote area; and 
other criteria determined to be important to VA. VA may pay 
stipends and provide benefits for residents regardless of 
whether they have been assigned to a VA facility.
    Section 403(b) of this bill would establish that VA shall 
reimburse a covered facility for cost of: curriculum 
development; recruitment and retention of faculty; 
accreditation of the program by the Accreditation Council for 
Graduate Medical Education; faculty salaries attributable to 
duties under an agreement under this section; and expenses 
relating to educating a resident under this program.
    Section 403(c) of this bill would require VA to report not 
less frequently than annually until the termination of the 
project on the implementation of the pilot program.
    Section 403(d) of this bill would establish the termination 
date of the program of August 7, 2024.

                         TITLE V--OTHER MATTERS

Sec. 501. Annual report on performance awards and bonuses awarded to 
        certain high-level employees of the department

    Section 501(a) of this bill would amend Chapter 7 of title 
38, U.S.C. by adding the following new section ``Sec. 726. 
Annual report on performance awards and bonuses awarded to 
certain high-level employees.''
    The new section 726(a) would require VA to submit a report 
no later than 100 days after the end of each fiscal year to the 
appropriate committees of Congress. The report shall contain a 
description of all performance awards or bonuses awarded to 
each of the following: Regional Office Director of the VA; 
Director of a Medical Center of the VA; Director of a Veterans 
Integrated Service Network; and Senior executive of VA.
    The new section 726(b) would establish that each report 
included the following: the amount rewarded; the job title of 
the individual awarded the bonus; and the location where the 
individual works.
    The new section 726(c) would establish definitions.
    Section 501(b) of this bill provides for a clerical 
amendment of the table of sections.

Sec. 502. Role of podiatrists in Department of Veterans Affairs

    Section 502(a) of this bill would amend Subchapter I of 
chapter 74 by adding the following new section ``Sec. 7413. 
Treatment of podiatrists; clinical oversight standards.''
    The new section 7413(a) would establish that, except as 
provided under subsection (b), a podiatric doctor appointed 
under section 7401(1) of this title is eligible for any 
supervisory position in the Veterans Health Administration to 
the same decree as any other physician.
    The new section 7413(b) would require VA to create 
standards to ensure that specialists appointed to supervisory 
positions do not provide direct clinical oversight for purposes 
of peer review or practical evaluation for providers.
    Section 502(a) of this bill provides for a clerical 
amendment of the table of sections.
    Section 502(b) of this bill would amend section 7404(b) of 
such title to ensure that Doctors of Podiatric Medicine, 
Doctors of Osteopathy, and VA Medical Doctors are equal in 
terms of pay within the VA healthcare system. The effective 
date of no later than 30 days after enactment of this bill.

Sec. 503. Definition of major medical facility project

    Section 503(a) of this bill would amend section 8101(3) by 
striking ``Secretary'' and all that follows through ``nursing 
home'' and inserting ``Secretary, or as otherwise authorized by 
law, for the provision of health-care services (including 
hospital, outpatient clinic, nursing home).''
    Section 503(b) of this bill would amend 8104(a) to modify 
the definition of a VA major medical facility project from a 
$10 million to $20 million project cost, excluding the 
construction, alteration, or acquisition of shared medical 
facility or acquisitions by exchange, non-recurring 
maintenance, and shared facilities, which VA's estimated costs 
do not exceed $20 million.

Sec. 504. Authorization of certain major medical facility projects of 
        the Department of Veterans Affairs

    Section 504(a) of this bill would authorize VA to carry out 
construction on the major medical facility projects in 
Livermore, California. The project includes: the new East Bay 
Community Based Outpatient Clinic and all associated site work; 
construction of the central Valley Engineering and Logistics 
support facility; and enhancing flood plain mitigation at the 
Central Valley and East Bay Community Based Outpatient Clinics. 
The construction shall not exceed $117.3 million.
    Section 504(b) of this bill would authorize appropriations 
for construction at $117.3 million.
    Section 504(c) of this bill would require VA to submit a 
report to the House and Senate Veterans Affairs Committees no 
later than 90 days after enactment of this bill. The report 
shall include the following: a line item accounting of 
expenditures relating to construction management carried out by 
VA for the project; the future amounts that are budgeted to be 
obligated for construction management; a justification for the 
expenditures above; and any agreement entered into by VA 
regarding a non-VA Federal entity providing management services 
relating to this project.

Sec. 505. Department of Veterans Affairs personnel transparency

    Section 505(a) of this bill would require VA to make 
publicly available on their website the following information 
no later than 90 days after the enactment of this bill. VA will 
post by medical facility: the number of personnel encumbering 
positions; the number of accessions and separation actions 
processed during the quarter preceding the date of the 
publication of this information; the number of vacancies, by 
occupation; and the percentage of new hires for VA who were 
hired within the time-to-hire target of the Office of Personnel 
Management. VA may withhold from publication information 
relating to law enforcement, information security, or other 
positions VA has determined to be sensitive. VA shall update 
the information on a quarterly basis, and any VA position 
filled by a contractor may not be published. The VA Office of 
the Inspector General shall conduct a review of the website 
semi-annually.
    Section 505(b) of this bill would require VA to submit to 
Congress an annual report on the steps VA is taking to achieve 
full staffing capacity. The report shall include the amount of 
additional funds necessary to enable VA to reach full staffing 
capacity.

Section 506. Program on establishment of peer specialists in patient 
        aligned care team settings within medical centers of Department 
        of Veterans Affairs

    Section 506(a) of this bill would require VA to carry out a 
program to place at least two peer specialists in patient 
aligned care teams at VA medical centers.
    Section 506(b) of this bill would establish the timeframe 
for creating the program as follows: not later than May 31, 
2019, there shall be at least two peer specialists at 15 
medical centers and not later than May 31, 2020, at 30 medical 
centers.
    Section 506(c) of this bill would require VA to select 
medical centers for the program as follows: not fewer than five 
shall be medical centers designated as polytrauma centers by 
VA, and not fewer than ten shall be medical centers not 
designated as polytrauma centers. Additionally, VA shall 
consider the feasibility of selecting medical centers in the 
following areas: rural areas and underserved areas; areas not 
close to active military bases, and areas representing 
different geographic locations.
    Section 506(d) of this bill would require VA to ensure 
that: the needs of female veterans are specifically considered 
and addressed and female peer specialists are made available to 
female veterans.
    Section 506(e) of this bill would require VA to consider 
ways in which peer specialists can conduct outreach to health 
care providers serving veterans.
    Section 506(f) of this bill would require VA to submit to 
Congress a report not later than 180 days after enactment, and 
every 180 days thereafter, on the effectiveness of the program. 
Not later than 180 days after VA has determined the program has 
been carried out at the last facility.

Sec. 507. Department of Veterans Affairs medical scribe pilot program

    Section 507(a) of this bill would require VA to carry out a 
pilot program to increase the use of medical scribes at VA 
medical centers.
    Section 507(b) of this bill would require the pilot program 
be carried out at ten VA medical centers with at least four 
being in rural areas, at least four being in urban areas, and 
at least two being in areas with a need for increased access or 
efficiency, as determined by VA.
    Section 507(c) of this bill would require VA to hire 20 
medical scribes as VA employees and seek to enter into 
contracts with appropriate entities to employ 20 medical 
scribes. It would also require VA to assign four medical 
scribes to each of the identified medical centers with two 
scribes assigned to each of two physicians, thirty percent of 
the scribes assigned to an emergency care settings, and seventy 
percent of the scribes assigned in specialty care settings in 
specialties with the longest wait times or lowest efficiency 
ratings, as determined by VA.
    Section 507(d) of this bill would require VA to submit a 
report to the Committees on Veterans' Affairs of the Senate and 
the House of Representatives on the pilot program by not later 
than 180 days after the date of the commencement of the pilot 
and every 180 days thereafter for the duration of the pilot. 
Each such report would be required to include a separate 
analysis with respect to medical scribes employed by VA and 
those performing VA functions under contract regarding provider 
efficiency, patient satisfaction, average wait times, the 
number of patients seen per day by each physician or 
practitioner as well as metrics and data for analyzing the 
effectiveness of the pilot including an evaluation of each of 
the above elements at VA medical centers who employed scribes 
for an appropriate period preceding the hiring of such scribes. 
GAO is required to submit a report to Congress no more than 90 
days after the termination of the pilot and such report is 
required to include a comparison of the pilot program with 
similar programs carried out in the private sector.
    Section 507(e) of this bill would define the term: 
``medical scribe'' as a licensed individual hired to enter 
information into the electronic health record or chart at the 
direction of a physician or licensed independent practitioner 
whose responsibilities include assisting the physician or 
practitioner in navigating the electronic health record, 
responding to various messages as direct by the physician or 
practitioner, and entering information into the electronic 
health record as directed by the physician or practitioner; and 
``urban'' and ``rural'' as having the meanings given such terms 
under the rural-urban commuting codes developed by the 
Secretary of Agriculture and the Secretary of Health and Human 
Services.
    Section 507(f) of this bill would stipulate that the pilot 
program is to be carried out using amounts otherwise authorized 
to be appropriated for VA and that no additional amounts are 
authorized to be appropriated to carry out the requirements of 
Section 507 of the bill.

Sec. 508. Extension of requirement to collect fees for housing loans 
        guaranteed by Secretary of Veterans Affairs

    Section 508 of this bill would amend Section 3729(b)(2) of 
title 38, U.S.C., by striking ``2027'' and inserting ``2028.''

Sec. 509. Extension of reduction in amount of pension furnished by 
        Department of Veteran Affairs for certain veterans covered by 
        Medicaid plans for services furnished by nursing facilities

    Section 509 of this bill would amend Section 5503(d)(7) of 
title 38, U.S.C., by striking ``September 30, 2027,'' and 
inserting ``September 30, 2028.''

Sec. 510. Appropriations of amounts

    Section 510 of this bill would authorize and appropriate 
$5.2 billion to the Veterans Choice Fund.

Sec. 511. Technical correction

    Section 511 of this bill would redesignate section 1712I of 
title 38 U.S.C. as section 1720I of title 38 U.S.C.

         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, existing law in which no change is 
proposed is shown in roman):

         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 I--GENERAL PROVISIONS

           *       *       *       *       *       *       *


                          CHAPTER 7--EMPLOYEES


                 SUBCHAPTER I --GENERAL EMPLOYEE MATTERS

Sec.
701. Placement of employees in military installations.
     * * * * * * *
726. Annual report on performance awards and bonuses awarded to certain 
          high-level employees.
     * * * * * * *

SUBCHAPTER I--GENERAL EMPLOYEE MATTERS

           *       *       *       *       *       *       *



Sec. 726. Annual report on performance awards and bonuses awarded to 
                    certain high-level employees

  (a) In General.--Not later than 100 days after the end of 
each fiscal year, the Secretary shall submit to the appropriate 
committees of Congress a report that contains, for the most 
recent fiscal year ending before the submittal of the report, a 
description of all performance awards or bonuses awarded to 
each of the following:
          (1) Regional Office Director of the Department.
          (2) Director of a Medical Center of the Department.
          (3) Director of a Veterans Integrated Service 
        Network.
          (4) Senior executive of the Department.
  (b) Elements.--Each report submitted under subsection (a) 
shall include the following with respect to each performance 
award or bonus awarded to an individual described in such 
subsection:
          (1) The amount of each award or bonus.
          (2) The job title of the individual awarded the award 
        or bonus.
          (3) The location where the individual awarded the 
        award or bonus works.
  (c) Definitions.--In this section:
          (1) The term ``appropriate committees of Congress'' 
        means the Committees on Veterans' Affairs and 
        Appropriations of the Senate and House of 
        Representatives.
          (2) The term ``senior executive'' means--
                  (A) a career appointee; or
                  (B) an individual--
                          (i) in an administrative or executive 
                        position; and
                          (ii) appointed under section 7306(a) 
                        or section 7401(1) of this title.
          (3) The term ``career appointee'' has the meaning 
        given that term in section 3132(a) of title 5, United 
        States Code.

           *       *       *       *       *       *       *


PART II--GENERAL BENEFITS

           *       *       *       *       *       *       *


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


                          SUBCHAPTER I--GENERAL

Sec.
1701. Definitions.
     * * * * * * *
[1703. Contracts for hospital care and medical services in non-
          Department facilities.]
1703. Veterans Community Care Program.
1703A. Agreements with eligible entities or providers; certification 
          processes.
1703B. Access standards.
1703C. Standards for quality.
1703D. Prompt payment standard.
1703E. Center for Innovation for Care and Payment.
     * * * * * * *
1706A. Remediation of medical service lines.
     * * * * * * *

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

     * * * * * * *
Sec. 1725A. Access to walk-in care.
     * * * * * * *
1730B. Access to State prescription drug monitoring programs.
1730C. Licensure of health care professionals providing treatment via 
          telemedicine.
     * * * * * * *

       SUBCHAPTER VIII--HEALTH CARE OF PERSONS OTHER THAN VETERANS

     * * * * * * *
1788. Transplant procedures with live donors and related services.

SUBCHAPTER I--GENERAL

           *       *       *       *       *       *       *



[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.]

Sec. 1703. Veterans Community Care Program

  (a) In General.--(1) There is established a program to 
furnish hospital care, medical services, and extended care 
services to covered veterans through health care providers 
specified in subsection (c).
  (2) The Secretary shall coordinate the furnishing of hospital 
care, medical services, and extended care services under this 
section to covered veterans, including coordination of, at a 
minimum, the following:
          (A) Ensuring the scheduling of medical appointments 
        in a timely manner and the establishment of a mechanism 
        to receive medical records from non-Department 
        providers.
          (B) Ensuring continuity of care and services.
          (C) Ensuring coordination among regional networks if 
        the covered veteran accesses care and services in a 
        different network than the regional network in which 
        the covered veteran resides.
          (D) Ensuring that covered veterans do not experience 
        a lapse in care resulting from errors or delays by the 
        Department or its contractors or an unusual or 
        excessive burden in accessing hospital care, medical 
        services, or extended care services.
  (3) A covered veteran may only receive care or services under 
this section upon the authorization of such care or services by 
the Secretary.
  (b) Covered Veterans.--For purposes of this section, a 
covered veteran is any veteran who--
          (1) is enrolled in the system of annual patient 
        enrollment established and operated under section 1705 
        of this title; or
          (2) is not enrolled in such system but is otherwise 
        entitled to hospital care, medical services, or 
        extended care services under subsection (c)(2) of such 
        section.
  (c) Health Care Providers Specified.--Health care providers 
specified in this subsection are the following:
          (1) Any health care provider that is participating in 
        the Medicare program under title XVIII of the Social 
        Security Act (42 U.S.C. 1395 et seq.), including any 
        physician furnishing services under such a program.
          (2) The Department of Defense.
          (3) The Indian Health Service.
          (4) 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))).
          (5) Any health care provider not otherwise covered 
        under any of paragraphs (1) through (4) that meets 
        criteria established by the Secretary for purposes of 
        this section.
  (d) Conditions Under Which Care is Required to Be Furnished 
Through Non-department Providers.--(1) The Secretary shall, 
subject to the availability of appropriations, furnish hospital 
care, medical services, and extended care services to a covered 
veteran through health care providers specified in subsection 
(c) if--
          (A) the Department does not offer the care or 
        services the veteran requires;
          (B) the Department does not operate a full-service 
        medical facility in the State in which the covered 
        veteran resides;
          (C)(i) the covered veteran was an eligible veteran 
        under section 101(b)(2)(B) of the Veterans Access, 
        Choice, and Accountability Act of 2014 (Public Law 113-
        146; 38 U.S.C. 1701 note) as of the day before the date 
        of the enactment of the Caring for Our Veterans Act of 
        2018;
          (ii) continues to reside in a location that would 
        qualify the veteran for eligibility under such section; 
        and
          (iii) either--
                  (I) resides in one of the five States with 
                the lowest population density as determined by 
                data from the 2010 decennial census; or
                  (II) resides in a State not described in 
                subclause (I) and--
                          (aa) received care or services under 
                        this title in the year preceding the 
                        enactment of the Caring for Our 
                        Veterans Act of 2018; and
                          (bb) is seeking care or services 
                        within two years of the date of the 
                        enactment of the Caring for Our 
                        Veterans Act of 2018;
          (D) the covered veteran has contacted the Department 
        to request care or services and the Department is not 
        able to furnish such care or services in a manner that 
        complies with designated access standards developed by 
        the Secretary under section 1703B of this title; or
          (E) the covered veteran and the covered veteran's 
        referring clinician agree that furnishing care and 
        services through a non-Department entity or provider 
        would be in the best medical interest of the covered 
        veteran based upon criteria developed by the Secretary.
  (2) The Secretary shall ensure that the criteria developed 
under paragraph (1)(E) include consideration of the following:
          (A) The distance between the covered veteran and the 
        facility that provides the hospital care, medical 
        services, or extended care services the veteran needs.
          (B) The nature of the hospital care, medical 
        services, or extended care services required.
          (C) The frequency that the hospital care, medical 
        services, or extended care services needs to be 
        furnished.
          (D) The timeliness of available appointments for the 
        hospital care, medical services, or extended care 
        services the veteran needs.
          (E) Whether the covered veteran faces an unusual or 
        excessive burden to access hospital care, medical 
        services, or extended care services from the Department 
        medical facility where a covered veteran seeks hospital 
        care, medical services, or extended care services, 
        which shall include consideration of the following:
                  (i) Whether the covered veteran faces an 
                excessive driving distance, geographical 
                challenge, or environmental factor that impedes 
                the access of the covered veteran.
                  (ii) Whether the hospital care, medical 
                services, or extended care services sought by 
                the veteran is provided by a medical facility 
                of the Department that is reasonably accessible 
                to a covered veteran.
                  (iii) Whether a medical condition of the 
                covered veteran affects the ability of the 
                covered veteran to travel.
                  (iv) Whether there is compelling reason, as 
                determined by the Secretary, that the veteran 
                needs to receive hospital care, medical 
                services, or extended care services from a 
                medical facility other than a medical facility 
                of the Department.
                  (v) Such other considerations as the 
                Secretary considers appropriate.
  (3) If the Secretary has determined that the Department does 
not offer the care or services the covered veteran requires 
under subparagraph (A) of paragraph (1), that the Department 
does not operate a full-service medical facility in the State 
in which the covered veteran resides under subparagraph (B) of 
such paragraph, that the covered veteran is described under 
subparagraph (C) of such paragraph, or that the Department is 
not able to furnish care or services in a manner that complies 
with designated access standards developed by the Secretary 
under section 1703B of this title under subparagraph (D) of 
such paragraph, the decision to receive hospital care, medical 
services, or extended care services under such subparagraphs 
from a health care provider specified in subsection (c) shall 
be at the election of the veteran.
  (e) Conditions Under Which Care is Authorized to Be Furnished 
Through Non-department Providers.--(1)(A) The Secretary may 
furnish hospital care, medical services, or extended care 
services through a health care provider specified in subsection 
(c) to a covered veteran served by a medical service line of 
the Department that the Secretary has determined is not 
providing care that complies with the standards for quality the 
Secretary shall establish under section 1703C.
  (B) In carrying out subparagraph (A), the Secretary shall--
          (i) measure timeliness of the medical service line at 
        a facility of the Department when compared with the 
        same medical service line at different Department 
        facilities; and
          (ii) measure quality at a medical service line of a 
        facility of the Department by comparing it with two or 
        more distinct and appropriate quality measures at non-
        Department medical service lines.
  (C)(i) The Secretary may not concurrently furnish hospital 
care, medical services, or extended care services under 
subparagraph (A) with respect to more than three medical 
service lines described in such subparagraph at any one health 
care facility of the Department.
  (ii) The Secretary may not concurrently furnish hospital 
care, medical services, or extended care services under 
subparagraph (A) with respect to more than 36 medical service 
lines nationally described in such subparagraph.
  (2) The Secretary may limit the types of hospital care, 
medical services, or extended care services covered veterans 
may receive under paragraph (1) in terms of the length of time 
such care and services will be available, the location at which 
such care and services will be available, and the clinical care 
and services that will be available.
  (3)(A) Except as provided for in subparagraph (B), the 
hospital care, medical services, and extended care services 
authorized under paragraph (1) with respect to a medical 
service line shall cease when the remediation described in 
section 1706A with respect to such medical service line is 
complete.
  (B) The Secretary shall ensure continuity and coordination of 
care for any veteran who elects to receive care or services 
under paragraph (1) from a health care provider specified in 
subsection (c) through the completion of an episode of care.
  (4) The Secretary shall publish in the Federal Register, and 
shall take all reasonable steps to provide direct notice to 
covered veterans affected under this subsection, at least once 
each year stating the time period during which such care and 
services will be available, the location or locations where 
such care and services will be available, and the clinical 
services available at each location under this subsection in 
accordance with regulations the Secretary shall prescribe.
  (5) When the Secretary exercises the authority under 
paragraph (1), the decision to receive care or services under 
such paragraph from a health care provider specified in 
subsection (c) shall be at the election of the covered veteran.
  (f) Review of Decisions.--The review of any decision under 
subsection (d) or (e) shall be subject to the Department's 
clinical appeals process, and such decisions may not be 
appealed to the Board of Veterans' Appeals.
  (g) Tiered Network.--(1) To promote the provision of high-
quality and high-value hospital care, medical services, and 
extended care services under this section, the Secretary may 
develop a tiered provider network of eligible providers based 
on criteria established by the Secretary for purposes of this 
section.
  (2) In developing a tiered provider network of eligible 
providers under paragraph (1), the Secretary shall not 
prioritize providers in a tier over providers in any other tier 
in a manner that limits the choice of a covered veteran in 
selecting a health care provider specified in subsection (c) 
for receipt of hospital care, medical services, or extended 
care services under this section.
  (h) Contracts to Establish Networks of Health Care 
Providers.--(1) The Secretary shall enter into consolidated, 
competitively bid contracts to establish networks of health 
care providers specified in paragraphs (1) and (5) of 
subsection (c) for purposes of providing sufficient access to 
hospital care, medical services, or extended care services 
under this section.
  (2)(A) The Secretary shall, to the extent practicable, ensure 
that covered veterans are able to make their own appointments 
using advanced technology.
  (B) To the extent practicable, the Secretary shall be 
responsible for the scheduling of appointments for hospital 
care, medical services, and extended care services under this 
section.
  (3)(A) The Secretary may terminate a contract with an entity 
entered into under paragraph (1) at such time and upon such 
notice to the entity as the Secretary may specify for purposes 
of this section, if the Secretary notifies the appropriate 
committees of Congress that, at a minimum--
          (i) the entity--
                  (I) failed to comply substantially with the 
                provisions of the contract or with the 
                provisions of this section and the regulations 
                prescribed under this section;
                  (II) failed to comply with the access 
                standards or the standards for quality 
                established by the Secretary;
                  (III) is 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);
                  (IV) is identified as an excluded source on 
                the list maintained in the System for Award 
                Management, or any successor system; or
                  (V) has been convicted of a felony or other 
                serious offense under Federal or State law and 
                the continued participation of the entity would 
                be detrimental to the best interests of 
                veterans or the Department;
          (ii) it is reasonable to terminate the contract based 
        on the health care needs of veterans; or
          (iii) it is reasonable to terminate the contract 
        based on coverage provided by contracts or sharing 
        agreements entered into under authorities other than 
        this section.
  (B) Nothing in subparagraph (A) may be construed to restrict 
the authority of the Secretary to terminate a contract entered 
into under paragraph (1) under any other provision of law.
  (4) Whenever the Secretary provides notice to an entity that 
the entity is failing to meet contractual obligations entered 
into under paragraph (1), 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 such failure. Such report shall include the following:
          (A) An explanation of the reasons for providing such 
        notice.
          (B) A description of the effect of such failure, 
        including with respect to cost, schedule, and 
        requirements.
          (C) A description of the actions taken by the 
        Secretary to mitigate such failure.
          (D) A description of the actions taken by the 
        contractor to address such failure.
          (E) A description of any effect on the community 
        provider market for veterans in the affected area.
  (5)(A) The Secretary shall instruct each entity awarded a 
contract under paragraph (1) to recognize and accept, on an 
interim basis, the credentials and qualifications of health 
care providers who are authorized to furnish hospital care and 
medical services to veterans under a community care program of 
the Department in effect as of the day before the date of the 
enactment of the Caring for Our Veterans Act of 2018, including 
under the Patient-Centered Community Care Program and the 
Veterans Choice Program under section 101 of the Veterans 
Access, Choice, and Accountability Act of 2014 (Public Law 113-
146; 38 U.S.C. 1701 note), as qualified providers under the 
program established under this section.
  (B) The interim acceptance period under subparagraph (A) 
shall be determined by the Secretary based on the following 
criteria:
          (i) With respect to a health care provider, when the 
        current certification agreement for the health care 
        provider expires.
          (ii) Whether the Department has enacted certification 
        and eligibility criteria and regulatory procedures by 
        which non-Department providers will be authorized under 
        this section.
  (6) The Secretary shall establish a system or systems for 
monitoring the quality of care provided to covered veterans 
through a network under this subsection and for assessing the 
quality of hospital care, medical services, and extended care 
services furnished through such network before the renewal of 
the contract for such network.
  (i) Payment Rates for Care and Services.--(1) Except as 
provided in paragraph (2), and to the extent practicable, the 
rate paid for hospital care, medical services, or extended care 
services under any provision in this title may not exceed the 
rate 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 XI or title XVIII of the Social Security Act (42 
U.S.C. 1301 et seq.), including section 1834 of such Act (42 
U.S.C. 1395m), for the same care or services.
  (2)(A) A higher rate than the rate paid by the United States 
as described in paragraph (1) may be negotiated with respect to 
the furnishing of care or services to a covered veteran who 
resides in a highly rural area.
  (B) In this paragraph, 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.
  (3) With respect to furnishing care or services under this 
section in Alaska, the Alaska Fee Schedule of the Department of 
Veterans Affairs shall be followed, except for when another 
payment agreement, including a contract or provider agreement, 
is in effect.
  (4) With respect to furnishing hospital care, medical 
services, or extended care services under this section in a 
State with an All-Payer Model Agreement under section 
1814(b)(3) of the Social Security Act (42 U.S.C. 1395f(b)(3)) 
that became effective on or after January 1, 2014, the Medicare 
payment rates under paragraph (2)(A) shall be calculated based 
on the payment rates under such agreement.
  (5) Notwithstanding paragraph (1), the Secretary may 
incorporate, to the extent practicable, the use of value-based 
reimbursement models to promote the provision of high-quality 
care.
  (6) With respect to hospital care, medical services, or 
extended care services for which there is not a rate paid under 
the Medicare program as described in paragraph (1), the rate 
paid for such care or services shall be determined by the 
Secretary.
  (j) Treatment of Other Health Plan Contracts.--In any case in 
which a covered veteran is furnished hospital care, medical 
services, or extended care 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 1729 in accordance 
with such section.
  (k) Payment by Veteran.--A covered veteran shall not pay a 
greater amount for receiving care or services under this 
section than the amount the veteran would pay for receiving the 
same or comparable care or services at a medical facility of 
the Department or from a health care provider of the 
Department.
  (l) Transplant Authority for Improved Access.--(1) In the 
case of a covered veteran described in paragraph (2), the 
Secretary shall determine whether to authorize an organ or bone 
marrow transplant for that covered veteran at a non-Department 
facility.
  (2) A covered veteran described in this paragraph--
          (A) requires an organ or bone marrow transplant; and
          (B) 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.
  (m) Monitoring of Care Provided.--(1)(A) Not later than 540 
days after the date of the enactment of the Caring for Our 
Veterans Act of 2018, and not less frequently than annually 
thereafter, the Secretary shall submit to appropriate 
committees of Congress a review of the types and frequency of 
care sought under subsection (d).
  (B) The review submitted under subparagraph (A) shall include 
an assessment of the following:
          (i) The top 25 percent of types of care and services 
        most frequently provided under subsection (d) due to 
        the Department not offering such care and services.
          (ii) The frequency such care and services were sought 
        by covered veterans under this section.
          (iii) An analysis of the reasons the Department was 
        unable to provide such care and services.
          (iv) Any steps the Department took to provide such 
        care and services at a medical facility of the 
        Department.
          (v) The cost of such care and services.
  (2) In monitoring the hospital care, medical services, and 
extended care services furnished under this section, the 
Secretary shall do the following:
          (A) With respect to hospital care, medical services, 
        and extended care services furnished through provider 
        networks established under subsection (i)--
                  (i) compile data on the types of hospital 
                care, medical services, and extended care 
                services furnished through such networks and 
                how many patients used each type of care and 
                service;
                  (ii) identify gaps in hospital care, medical 
                services, or extended care services furnished 
                through such networks;
                  (iii) identify how such gaps may be fixed 
                through new contracts within such networks or 
                changes in the manner in which hospital care, 
                medical services, or extended care services are 
                furnished through such networks;
                  (iv) assess the total amounts spent by the 
                Department on hospital care, medical services, 
                and extended care services furnished through 
                such networks;
                  (v) assess the timeliness of the Department 
                in referring hospital care, medical services, 
                and extended care services to such networks; 
                and
                  (vi) assess the timeliness of such networks 
                in--
                          (I) accepting referrals; and
                          (II) scheduling and completing 
                        appointments.
          (B) Report the number of medical service lines the 
        Secretary has determined under subsection (e)(1) not to 
        be providing hospital care, medical services, or 
        extended care services that comply with the standards 
        for quality established by the Secretary.
          (C) Assess the use of academic affiliates and centers 
        of excellence of the Department to furnish hospital 
        care, medical services, and extended care services to 
        covered veterans under this section.
          (D) Assess the hospital care, medical services, and 
        extended care services furnished to covered veterans 
        under this section by medical facilities operated by 
        Federal agencies other than the Department.
  (3) Not later than 540 days after the date of the enactment 
of the Caring for Our Veterans Act of 2018 and not less 
frequently than once each year thereafter, 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 information gathered under 
paragraph (2).
  (n) Prohibition on Certain Limitations.--(1) The Secretary 
shall not limit the types of hospital care, medical services, 
or extended care services covered veterans may receive under 
this section if it is in the best medical interest of the 
veteran to receive such hospital care, medical services, or 
extended care services, as determined by the veteran and the 
veteran's health care provider.
  (2) No provision in this section may be construed to alter or 
modify any other provision of law establishing specific 
eligibility criteria for certain hospital care, medical 
services, or extended care services.
  (o) Definitions.--In this section:
          (1) The term ``appropriate committees of Congress'' 
        means--
                  (A) the Committee on Veterans' Affairs and 
                the Committee on Appropriations of the Senate; 
                and
                  (B) the Committee on Veterans' Affairs and 
                the Committee on Appropriations of the House of 
                Representatives.
          (2) The term ``medical service line'' means a clinic 
        within a Department medical center.

Sec. 1703A. Agreements with eligible entities or providers; 
                    certification processes

  (a) Agreements Authorized.--(1)(A) When hospital care, a 
medical service, or an extended care service required by a 
veteran who is entitled to such care or service under this 
chapter is not feasibly available to the veteran from a 
facility of the Department or through a contract or sharing 
agreement entered into pursuant to another provision of law, 
the Secretary may furnish such care or service to such veteran 
through an agreement under this section with an eligible entity 
or provider to provide such hospital care, medical service, or 
extended care service.
  (B) An agreement entered into under this section to provide 
hospital care, a medical service, or an extended care service 
shall be known as a ``Veterans Care Agreement''.
  (C) For purposes of subparagraph (A), hospital care, a 
medical service, or an extended care service may be considered 
not feasibly available to a veteran from a facility of the 
Department or through a contract or sharing agreement described 
in such subparagraph when the Secretary determines the 
veteran's medical condition, the travel involved, the nature of 
the care or services required, or a combination of these 
factors make the use of a facility of the Department or a 
contract or sharing agreement described in such subparagraph 
impracticable or inadvisable.
  (D) A Veterans Care Agreement may be entered into by the 
Secretary or any Department official authorized by the 
Secretary.
  (2)(A) Subject to subparagraph (B), the Secretary shall 
review each Veterans Care Agreement of material size, as 
determined by the Secretary or set forth in paragraph (3), for 
hospital care, a medical service, or an extended care service 
to determine whether it is feasible and advisable to provide 
such care or service within a facility of the Department or by 
contract or sharing agreement entered into pursuant to another 
provision of law and, if so, take action to do so.
  (B)(i) The Secretary shall review each Veterans Care 
Agreement of material size that has been in effect for at least 
six months within the first two years of its taking effect, and 
not less frequently than once every four years thereafter.
  (ii) If a Veterans Care Agreement has not been in effect for 
at least six months by the date of the review required by 
subparagraph (A), the agreement shall be reviewed during the 
next cycle required by subparagraph (A), and such review shall 
serve as its review within the first two years of its taking 
effect for purposes of clause (i).
  (3)(A) In fiscal year 2019 and in each fiscal year 
thereafter, in addition to such other Veterans Care Agreements 
as the Secretary may determine are of material size, a Veterans 
Care Agreement for the purchase of extended care services that 
exceeds $5,000,000 annually shall be considered of material 
size.
  (B) From time to time, the Secretary may publish a notice in 
the Federal Register to adjust the dollar amount specified in 
subparagraph (A) to account for changes in the cost of health 
care based upon recognized health care market surveys and other 
available data.
  (b) Eligible Entities and Providers.--For purposes of this 
section, an eligible entity or provider is--
          (1) any 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)) and 
        any physician or other supplier who has enrolled and 
        entered into a participation agreement under section 
        1842(h) of such Act (42 U.S.C. 1395u(h));
          (2) any provider participating under a State plan 
        under title XIX of such Act (42 U.S.C. 1396 et seq.);
          (3) 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));
          (4) a center for independent living (as defined in 
        section 702 of the Rehabilitation Act of 1973 (29 
        U.S.C. 796a)); or
          (5) any entity or provider not described in paragraph 
        (1) or (2) of this subsection that the Secretary 
        determines to be eligible pursuant to the certification 
        process described in subsection (c).
  (c) Eligible Entity or Provider Certification Process.--The 
Secretary shall establish by regulation a process for the 
certification of eligible entities or providers or 
recertification of eligible entities or providers under this 
section. Such a process shall, at a minimum--
          (1) establish deadlines for actions on applications 
        for certification;
          (2) set forth standards for an approval or denial of 
        certification, duration of certification, revocation of 
        an eligible entity or provider's certification, and 
        recertification of eligible entities or providers;
          (3) require the denial of certification if the 
        Secretary determines the eligible entity or provider is 
        excluded from participation in a Federal health care 
        program under section 1128 or section 1128A of the 
        Social Security Act (42 U.S.C. 1320a-7 or 1320a-7a) or 
        is currently identified as an excluded source on the 
        System for Award Management Exclusions list described 
        in part 9 of title 48, Code of Federal Regulations, and 
        part 180 of title 2 of such Code, or successor 
        regulations;
          (4) establish procedures for screening eligible 
        entities or providers according to the risk of fraud, 
        waste, and abuse that are similar to the standards 
        under section 1866(j)(2)(B) of the Social Security Act 
        (42 U.S.C. 1395cc(j)(2)(B)) and section 9.104 of title 
        48, Code of Federal Regulations, or successor 
        regulations; and
          (5) incorporate and apply the restrictions and 
        penalties set forth in chapter 21 of title 41 and treat 
        this section as a procurement program only for purposes 
        of applying such provisions.
  (d) Rates.--To the extent practicable, the rates paid by the 
Secretary for hospital care, medical services, and extended 
care services provided under a Veterans Care Agreement shall be 
in accordance with the rates paid by the United States under 
section 1703(i) of this title.
  (e) Terms of Veterans Care Agreements.--(1) Pursuant to 
regulations promulgated under subsection (k), the Secretary may 
define the requirements for providers and entities entering 
into agreements under this section based upon such factors as 
the number of patients receiving care or services, the number 
of employees employed by the entity or provider furnishing such 
care or services, the amount paid by the Secretary to the 
provider or entity, or other factors as determined by the 
Secretary.
  (2) To furnish hospital care, medical services, or extended 
care services under this section, an eligible entity or 
provider shall agree--
          (A) to accept payment at the rates established in 
        regulations prescribed under this section;
          (B) that payment by the Secretary under this section 
        on behalf of a veteran to a provider of services or 
        care shall, unless rejected and refunded by the 
        provider within 30 days of receipt, constitute payment 
        in full and extinguish any liability on the part of the 
        veteran for the treatment or care provided, and no 
        provision of a contract, agreement, or assignment to 
        the contrary shall operate to modify, limit, or negate 
        this requirement;
          (C) to provide only the care and services authorized 
        by the Department under this section and to obtain the 
        prior written consent of the Department to furnish care 
        or services outside the scope of such authorization;
          (D) to bill the Department in accordance with the 
        methodology outlined in regulations prescribed under 
        this section;
          (E) to not seek to recover or collect from a health 
        plan contract or third party, as those terms are 
        defined in section 1729 of this title, for any care or 
        service that is furnished or paid for by the 
        Department;
          (F) to provide medical records to the Department in 
        the time frame and format specified by the Department; 
        and
          (G) to meet such other terms and conditions, 
        including quality of care assurance standards, as the 
        Secretary may specify in regulation.
  (f) Discontinuation or Nonrenewal of a Veterans Care 
Agreement.--(1) An eligible entity or provider may discontinue 
a Veterans Care Agreement at such time and upon such notice to 
the Secretary as may be provided in regulations prescribed 
under this section.
  (2) The Secretary may discontinue a Veterans Care Agreement 
with an eligible entity or provider at such time and upon such 
reasonable notice to the eligible entity or provider as may be 
specified in regulations prescribed under this section, if an 
official designated by the Secretary--
          (A) has determined that the eligible entity or 
        provider failed to comply substantially with the 
        provisions of the Veterans Care Agreement, or with the 
        provisions of this section or regulations prescribed 
        under this section;
          (B) has determined the eligible entity or provider is 
        excluded from participation in a Federal health care 
        program under section 1128 or section 1128A of the 
        Social Security Act (42 U.S.C. 1320a-7 or 1320a-7a) or 
        is identified on the System for Award Management 
        Exclusions list as provided in part 9 of title 48, Code 
        of Federal Regulations, and part 180 of title 2 of such 
        Code, or successor regulations;
          (C) has ascertained that the eligible entity or 
        provider has been convicted of a felony or other 
        serious offense under Federal or State law and 
        determines the eligible entity or provider's continued 
        participation would be detrimental to the best 
        interests of veterans or the Department; or
          (D) has determined that it is reasonable to terminate 
        the agreement based on the health care needs of a 
        veteran.
  (g) Quality of Care.--The Secretary shall establish a system 
or systems for monitoring the quality of care provided to 
veterans through Veterans Care Agreements and for assessing the 
quality of hospital care, medical services, and extended care 
services furnished by eligible entities and providers before 
the renewal of Veterans Care Agreements.
  (h) Disputes.--(1) The Secretary shall promulgate 
administrative procedures for eligible entities and providers 
to present all disputes arising under or related to Veterans 
Care Agreements.
  (2) Such procedures constitute the eligible entities' and 
providers' exhaustive and exclusive administrative remedies.
  (3) Eligible entities or providers must first exhaust such 
administrative procedures before seeking any judicial review 
under section 1346 of title 28 (known as the ``Tucker Act'').
  (4) Disputes under this section must pertain to either the 
scope of authorization under the Veterans Care Agreement or 
claims for payment subject to the Veterans Care Agreement and 
are not claims for the purposes of such laws that would 
otherwise require application of sections 7101 through 7109 of 
title 41, United States Code.
  (i) Applicability of Other Provisions of Law.--(1) A Veterans 
Care Agreement may be authorized by the Secretary or any 
Department official authorized by the Secretary, and such 
action shall not be treated as--
          (A) an award for the purposes of such laws that would 
        otherwise require the use of competitive procedures for 
        the furnishing of care and services; or
          (B) a Federal contract for the acquisition of goods 
        or services for purposes of any provision of Federal 
        law governing Federal contracts for the acquisition of 
        goods or services except section 4706(d) of title 41.
  (2)(A) Except as provided in the agreement itself, in 
subparagraph (B), and unless otherwise provided in this section 
or regulations prescribed pursuant to this section, an eligible 
entity or provider 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 
under the Medicare program under title XVIII of the Social 
Security Act (42 U.S.C. 1395 et seq.) are not subject.
  (B) An eligible entity or provider that enters into an 
agreement under this section is subject to--
          (i) all laws regarding integrity, ethics, or fraud, 
        or that subject a person to civil or criminal 
        penalties; and
          (ii) all laws that protect against employment 
        discrimination or that otherwise ensure equal 
        employment opportunities.
  (3) Notwithstanding paragraph (2)(B)(i), an eligible entity 
or provider that enters into an agreement under this section 
shall not be treated as a Federal contractor or subcontractor 
for purposes of chapter 67 of title 41 (commonly known as the 
``McNamara-O'Hara Service Contract Act of 1965'').
  (j) Parity of Treatment.--Eligibility for hospital care, 
medical services, and extended care services furnished to any 
veteran pursuant to a Veterans Care Agreement shall be subject 
to the same terms as though provided in a facility of the 
Department, and provisions of this chapter applicable to 
veterans receiving such care and services in a facility of the 
Department shall apply to veterans treated under this section.
  (k) Rulemaking.--The Secretary shall promulgate regulations 
to carry out this section.

Sec. 1703B. Access standards

  (a)(1) The Secretary shall establish access standards for 
furnishing hospital care, medical services, or extended care 
services to covered veterans for the purposes of section 
1703(d).
  (2) The Secretary shall ensure that the access standards 
established under paragraph (1) define such categories of care 
to cover all care and services within the medical benefits 
package of the Department of Veterans Affairs.
  (b) The Secretary shall ensure that the access standards 
provide covered veterans, employees of the Department, and 
health care providers in the network established under section 
1703(h) with relevant comparative information that is clear, 
useful, and timely, so that covered veterans can make informed 
decisions regarding their health care.
  (c) The Secretary shall consult with all pertinent Federal 
entities (including the Department of Defense, the Department 
of Health and Human Services, and the Centers for Medicare & 
Medicaid Services), entities in the private sector, and other 
nongovernmental entities in establishing access standards.
  (d)(1) Not later than 270 days after the date of the 
enactment of the Caring for Our Veterans Act of 2018, the 
Secretary shall submit to the appropriate committees of 
Congress a report detailing the access standards.
  (2)(A) Before submitting the report required under paragraph 
(1), the Secretary shall provide periodic updates to the 
appropriate committees of Congress to confirm the Department's 
progress towards developing the access standards required by 
this section.
  (B) The first update under subparagraph (A) shall occur no 
later than 120 days from the date of the enactment of the 
Caring for Our Veterans Act of 2018.
  (3) Not later than 540 days after the date on which the 
Secretary implements the access standards established under 
subsection (a), the Secretary shall submit to the appropriate 
committees of Congress a report detailing the implementation of 
and compliance with such access standards by Department and 
non-Department entities or providers.
  (e) Not later than three years after the date on which the 
Secretary establishes access standards under subsection (a) and 
not less frequently than once every three years thereafter, the 
Secretary shall--
          (1) conduct a review of such standards; and
          (2) submit to the appropriate committees of Congress 
        a report on the findings and any modification to the 
        access standards with respect to the review conducted 
        under paragraph (1).
  (f) The Secretary shall ensure health care providers 
specified under section 1703(c) are able to comply with the 
applicable access standards established by the Secretary.
  (g) The Secretary shall publish in the Federal Register and 
on an internet website of the Department the designated access 
standards established under this section for purposes of 
section 1703(d)(1)(D).
  (h)(1) Consistent with paragraphs (1)(D) and (3) of section 
1703(d), covered veterans may contact the Department at any 
time to request a determination regarding whether they are 
eligible to receive care and services from a non-Department 
entity or provider based on the Department being unable to 
furnish such care and services in a manner that complies with 
the designated access standards established under this section.
  (2) The Secretary shall establish a process to review such 
requests from covered veterans to determine whether--
          (A) the requested care is clinically necessary; and
          (B) the Department is able to provide such care in a 
        manner that complies with designated access standards 
        established under this section.
  (3) The Secretary shall promptly respond to any such request 
by a covered veteran.
  (i)(1) The term ``appropriate committees of Congress'' 
means--
          (A) the Committee on Veterans' Affairs and the 
        Committee on Appropriations of the Senate; and
          (B) the Committee on Veterans' Affairs and the 
        Committee on Appropriations of the House of 
        Representatives.
  (2) The term ``covered veterans'' refers to veterans 
described in section 1703(b) of this title.

Sec. 1703C. Standards for quality

  (a) In General.--(1) The Secretary shall establish standards 
for quality regarding hospital care, medical services, and 
extended care services furnished by the Department pursuant to 
this title, including through non-Department health care 
providers pursuant to section 1703 of this title.
  (2) In establishing standards for quality under paragraph 
(1), the Secretary shall consider existing health quality 
measures that are applied to public and privately sponsored 
health care systems with the purpose of providing covered 
veterans relevant comparative information to make informed 
decisions regarding their health care.
  (3) The Secretary shall collect and consider data for 
purposes of establishing the standards under paragraph (1). 
Such data collection shall include--
          (A) after consultation with veterans service 
        organizations and other key stakeholders on survey 
        development or modification of an existing survey, a 
        survey of veterans who have used hospital care, medical 
        services, or extended care services furnished by the 
        Veterans Health Administration during the most recent 
        two-year period to assess the satisfaction of the 
        veterans with service and quality of care; and
          (B) datasets that include, at a minimum, elements 
        relating to the following:
                  (i) Timely care.
                  (ii) Effective care.
                  (iii) Safety, including, at a minimum, 
                complications, readmissions, and deaths.
                  (iv) Efficiency.
  (4) The Secretary shall consult with all pertinent Federal 
entities (including the Department of Defense, the Department 
of Health and Human Services, and the Centers for Medicare & 
Medicaid Services), entities in the private sector, and other 
nongovernmental entities in establishing standards for quality.
  (5)(A) Not later than 270 days after the date of the 
enactment of the Caring for Our Veterans Act of 2018, the 
Secretary shall submit to the appropriate committees of 
Congress a report detailing the standards for quality.
  (B)(i) Before submitting the report required under 
subparagraph (A), the Secretary shall provide periodic updates 
to the appropriate committees of Congress to confirm the 
Department's progress towards developing the standards for 
quality required by this section.
  (ii) The first update under clause (i) shall occur no later 
than 120 days from the date of the enactment of the Caring for 
Our Veterans Act of 2018.
  (b) Publication and Consideration of Public Comments.--(1) 
Not later than one year after the date on which the Secretary 
establishes standards for quality under subsection (a), the 
Secretary shall publish the quality rating of medical 
facilities of the Department in the publicly available Hospital 
Compare website through the Centers for Medicare & Medicaid 
Services for the purpose of providing veterans with information 
that allows them to compare performance measure information 
among Department and non-Department health care providers.
  (2) Not later than two years after the date on which the 
Secretary establishes standards for quality under subsection 
(a), the Secretary shall consider and solicit public comment on 
potential changes to the measures used in such standards to 
ensure that they include the most up-to-date and applicable 
industry measures for veterans.
  (c)(1) The term ``appropriate committees of Congress'' 
means--
          (A) the Committee on Veterans' Affairs and the 
        Committee on Appropriations of the Senate; and
          (B) the Committee on Veterans' Affairs and the 
        Committee on Appropriations of the House of 
        Representatives.
  (2) The term ``covered veterans'' refers to veterans 
described in section 1703(b) of this title.

Sec. 1703D. Prompt payment standard

  (a) In General.--(1) Notwithstanding any other provision of 
this title or of any other provision of law, the Secretary 
shall pay for hospital care, medical services, or extended care 
services furnished by health care entities or providers under 
this chapter within 45 calendar days upon receipt of a clean 
paper claim or 30 calendar days upon receipt of a clean 
electronic claim.
  (2) If a claim is denied, the Secretary shall, within 45 
calendar days of denial for a paper claim and 30 calendar days 
of denial for an electronic claim, notify the health care 
entity or provider of the reason for denying the claim and 
what, if any, additional information is required to process the 
claim.
  (3) Upon the receipt of the additional information, the 
Secretary shall ensure that the claim is paid, denied, or 
otherwise adjudicated within 30 calendar days from the receipt 
of the requested information.
  (4) This section shall only apply to payments made on an 
invoice basis and shall not apply to capitation or other forms 
of periodic payment to entities or providers.
  (b) Submittal of Claims by Health Care Entities and 
Providers.--A health care entity or provider that furnishes 
hospital care, a medical service, or an extended care service 
under this chapter shall submit to the Secretary a claim for 
payment for furnishing the hospital care, medical service, or 
extended care service not later than 180 days after the date on 
which the entity or provider furnished the hospital care, 
medical service, or extended care service.
  (c) Fraudulent Claims.--(1) Sections 3729 through 3733 of 
title 31 shall apply to fraudulent claims for payment submitted 
to the Secretary by a health care entity or provider under this 
chapter.
  (2) Pursuant to regulations prescribed by the Secretary, the 
Secretary shall bar a health care entity or provider from 
furnishing hospital care, medical services, and extended care 
services under this chapter when the Secretary determines the 
entity or provider has submitted to the Secretary fraudulent 
health care claims for payment by the Secretary.
  (d) Overdue Claims.--(1) Any claim that has not been denied 
with notice, made pending with notice, or paid to the health 
care entity or provider by the Secretary shall be overdue if 
the notice or payment is not received by the entity provider 
within the time periods specified in subsection (a).
  (2)(A) If a claim is overdue under this subsection, the 
Secretary may, under the requirements established by subsection 
(a) and consistent with the provisions of chapter 39 of title 
31 (commonly referred to as the ``Prompt Payment Act''), 
require that interest be paid on clean claims.
  (B) Interest paid under subparagraph (A) shall be computed at 
the rate of interest established by the Secretary of the 
Treasury under section 3902 of title 31 and published in the 
Federal Register.
  (3) Not less frequently than annually, the Secretary shall 
submit to Congress a report on payment of overdue claims under 
this subsection, disaggregated by paper and electronic claims, 
that includes the following:
          (A) The amount paid in overdue claims described in 
        this subsection, disaggregated by the amount of the 
        overdue claim and the amount of interest paid on such 
        overdue claim.
          (B) The number of such overdue claims and the average 
        number of days late each claim was paid, disaggregated 
        by facility of the Department and Veterans Integrated 
        Service Network region.
  (e) Overpayment.--(1) The Secretary shall deduct the amount 
of any overpayment from payments due a health care entity or 
provider under this chapter.
  (2) Deductions may not be made under this subsection unless 
the Secretary has made reasonable efforts to notify a health 
care entity or provider of the right to dispute the existence 
or amount of such indebtedness and the right to request a 
compromise of such indebtedness.
  (3) The Secretary shall make a determination with respect to 
any such dispute or request prior to deducting any overpayment 
unless the time required to make such a determination before 
making any deductions would jeopardize the Secretary's ability 
to recover the full amount of such indebtedness.
  (f) Information and Documentation Required.--(1) The 
Secretary shall provide to all health care entities and 
providers participating in a program to furnish hospital care, 
medical services, or extended care services under this chapter 
a list of information and documentation that is required to 
establish a clean claim under this section.
  (2) The Secretary shall consult with entities in the health 
care industry, in the public and private sector, to determine 
the information and documentation to include in the list under 
paragraph (1).
  (3) If the Secretary modifies the information and 
documentation included in the list under paragraph (1), the 
Secretary shall notify all health care entities and providers 
described in paragraph (1) not later than 30 days before such 
modifications take effect.
  (g) Processing of Claims.--(1) In processing a claim for 
compensation for hospital care, medical services, or extended 
care services furnished by a non-Department health care entity 
or provider under this chapter, the Secretary may act through--
          (A) a non-Department entity that is under contract or 
        agreement for the program established under section 
        1703(a) of this title; or
          (B) a non-Department entity that specializes in such 
        processing for other Federal agency health care 
        systems.
  (2) The Secretary shall seek to contract with a third party 
to conduct a review of claims described in paragraph (3) that 
includes--
          (A) a feasibility assessment to determine the 
        capacity of the Department to process such claims in a 
        timely manner; and
          (B) a cost benefit analysis comparing the capacity of 
        the Department to a third party entity capable of 
        processing such claims.
  (3) The review required under paragraph (2) shall apply to 
claims for hospital care, medical services, or extended care 
services furnished under section 1703 of this Act, as amended 
by the Caring for Our Veterans Act of 2018, that are processed 
by the Department.
  (h) Report on Encounter Data System.--(1) Not later than 90 
days after the date of the enactment of the Caring for Our 
Veterans Act of 2018, the Secretary shall submit to the 
appropriate committees of Congress a report on the feasibility 
and advisability of adopting a funding mechanism similar to 
what is utilized by other Federal agencies to allow a 
contracted entity to act as a fiscal intermediary for the 
Federal Government to distribute, or pass through, Federal 
Government funds for certain non-underwritten hospital care, 
medical services, or extended care services.
  (2) The Secretary may coordinate with the Department of 
Defense, the Department of Health and Human Services, and the 
Department of the Treasury in developing the report required by 
paragraph (1).
  (i) Definitions.--In this section:
          (1) The term ``appropriate committees of Congress'' 
        means--
                  (A) the Committee on Veterans' Affairs and 
                the Committee on Appropriations of the Senate; 
                and
                  (B) the Committee on Veterans' Affairs and 
                the Committee on Appropriations of the House of 
                Representatives.
          (2) The term ``clean electronic claim'' means the 
        transmission of data for purposes of payment of covered 
        health care expenses that is submitted to the Secretary 
        which contains substantially all of the required data 
        elements necessary for accurate adjudication, without 
        obtaining additional information from the entity or 
        provider that furnished the care or service, submitted 
        in such format as prescribed by the Secretary in 
        regulations for the purpose of paying claims for care 
        or services.
          (3) The term ``clean paper claim'' means a paper 
        claim for payment of covered health care expenses that 
        is submitted to the Secretary which contains 
        substantially all of the required data elements 
        necessary for accurate adjudication, without obtaining 
        additional information from the entity or provider that 
        furnished the care or service, submitted in such format 
        as prescribed by the Secretary in regulations for the 
        purpose of paying claims for care or services.
          (4) The term ``fraudulent claims'' means the knowing 
        misrepresentation of a material fact or facts by a 
        health care entity or provider made to induce the 
        Secretary to pay a claim that was not legally payable 
        to that provider.
          (5) The term ``health care entity or provider'' 
        includes any non-Department health care entity or 
        provider, but does not include any Federal health care 
        entity or provider.

Sec. 1703E. 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 (including family members 
        and other caregivers of such individual) at the center 
        of the care team 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. To the extent practicable, the Secretary shall ensure 
that the pilot programs are located in geographically diverse 
areas of the United States.
  (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 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, a 
report 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 Secretary may not carry out more 
than 10 pilot programs concurrently.
          (2)(A) Subject to subparagraph (B), the Secretary may 
        not expend more than $50,000,000 in any fiscal year 
        from amounts under subsection (d).
          (B) The Secretary may expend more than the amount in 
        subparagraph (A) if--
                  (i) the Secretary determines that the 
                additional expenditure is necessary to carry 
                out pilot programs under this section;
                  (ii) the Secretary submits to the Committees 
                on Veterans' Affairs of the Senate and the 
                House of Representatives a report setting forth 
                the amount of the additional expenditure and a 
                justification for the additional expenditure; 
                and
                  (iii) the Chairmen of the Committees on 
                Veterans' Affairs of the Senate and the House 
                of Representatives transmit to the Secretary a 
                letter approving of the additional expenditure.
          (3) 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 Caring for Our 
        Veterans Act of 2018.
  (4) 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.
  (5)(A) If the Secretary determines that a 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) 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 a pilot program under 
subparagraph (A)(ii), for purposes of subparagraphs (F) and (G) 
of subsection (f)(2), 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 Advice.--(1) The Secretary shall obtain 
advice from 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. 1706A. Remediation of medical service lines

  (a) In General.--Not later than 30 days after determining 
under section 1703(e)(1) that a medical service line of the 
Department is providing hospital care, medical services, or 
extended care services that does not comply with the standards 
for quality established by the Secretary, the Secretary shall 
submit to Congress an assessment of the factors that led the 
Secretary to make such determination and a plan with specific 
actions, and the time to complete them, to be taken to comply 
with such standards for quality, including the following:
          (1) Increasing personnel or temporary personnel 
        assistance, including mobile deployment teams.
          (2) Special hiring incentives, including the 
        Education Debt Reduction Program under subchapter VII 
        of chapter 76 of this title and recruitment, 
        relocation, and retention incentives.
          (3) Utilizing direct hiring authority.
          (4) Providing improved training opportunities for 
        staff.
          (5) Acquiring improved equipment.
          (6) Making structural modifications to the facility 
        used by the medical service line.
          (7) Such other actions as the Secretary considers 
        appropriate.
  (b) Responsible Parties.--In each assessment submitted under 
subsection (a) with respect to a medical service line, the 
Secretary shall identify the individuals at the Central Office 
of the Veterans Health Administration, the facility used by the 
medical service line, and the central office of the relevant 
Veterans Integrated Service Network who are responsible for 
overseeing the progress of that medical service line in 
complying with the standards for quality established by the 
Secretary.
  (c) Interim Reports.--Not later than 180 days after 
submitting an assessment under subsection (a) with respect to a 
medical service line, the Secretary shall submit to Congress a 
report on the progress of that medical service line in 
complying with the standards for quality established by the 
Secretary and any other measures the Secretary will take to 
assist the medical service line in complying with such 
standards for quality.
  (d) Annual Reports.--Not less frequently than once each year, 
the Secretary shall--
          (1) submit to Congress an analysis of the remediation 
        actions and costs of such actions taken with respect to 
        each medical service line with respect to which the 
        Secretary submitted an assessment and plan under 
        paragraph (1) in the preceding year, including an 
        update on the progress of each such medical service 
        line in complying with the standards for quality and 
        timeliness established by the Secretary and any other 
        actions the Secretary is undertaking to assist the 
        medical service line in complying with standards for 
        quality as established by the Secretary; and
          (2) publish such analysis on the internet website of 
        the Department.

           *       *       *       *       *       *       *


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] or entered an agreement 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] 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 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 or agreements with private facilities that is 
available to the Secretary [(under sections 1703(a)(2) and 
1710(a)(1)(B) of this title)] 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.

           *       *       *       *       *       *       *


Sec. 1720G. Assistance and support services for caregivers

  (a) Program of Comprehensive Assistance for Family 
Caregivers.--(1)(A) The Secretary shall establish a program of 
comprehensive assistance for family caregivers of eligible 
veterans.
  (B) The Secretary shall only provide support under the 
program required by subparagraph (A) to a family caregiver of 
an eligible veteran if the Secretary determines it is in the 
best interest of the eligible veteran to do so.
  (2) For purposes of this subsection, an eligible veteran is 
any individual who--
          (A) is a veteran or member of the Armed Forces 
        undergoing medical discharge from the Armed Forces;
          [(B) has a serious injury (including traumatic brain 
        injury, psychological trauma, or other mental disorder) 
        incurred or aggravated in the line of duty in the 
        active military, naval, or air service on or after 
        September 11, 2001; and]
          (B) for assistance provided under this subsection--
                  (i) before the date on which the Secretary 
                submits to Congress a certification that the 
                Department has fully implemented the 
                information technology system required by 
                section 162(a) of the Caring for Our Veterans 
                Act of 2018, has a serious injury (including 
                traumatic brain injury, psychological trauma, 
                or other mental disorder) incurred or 
                aggravated in the line of duty in the active 
                military, naval, or air service on or after 
                September 11, 2001;
                  (ii) during the two-year period beginning on 
                the date on which the Secretary submitted to 
                Congress the certification described in clause 
                (i), has a serious injury (including traumatic 
                brain injury, psychological trauma, or other 
                mental disorder) incurred or aggravated in the 
                line of duty in the active military, naval, or 
                air service--
                          (I) on or before May 7, 1975; or
                          (II) on or after September 11, 2001; 
                        or
                  (iii) after the date that is two years after 
                the date on which the Secretary submits to 
                Congress the certification described in clause 
                (i), has a serious injury (including traumatic 
                brain injury, psychological trauma, or other 
                mental disorder) incurred or aggravated in the 
                line of duty in the active military, naval, or 
                air service; and
          (C) is in need of personal care services because of--
                  (i) an inability to perform one or more 
                activities of daily living;
                  (ii) a need for supervision or protection 
                based on symptoms or residuals of neurological 
                or other impairment or injury[; or];
                  (iii) a need for regular or extensive 
                instruction or supervision without which the 
                ability of the veteran to function in daily 
                life would be seriously impaired; or
                  [(iii)] (iv) such other matters as the 
                Secretary considers appropriate.
  (3)(A) As part of the program required by paragraph (1), the 
Secretary shall provide to family caregivers of eligible 
veterans the following assistance:
          (i) To each family caregiver who is approved as a 
        provider of personal care services for an eligible 
        veteran under paragraph (6)--
                  (I) such instruction, preparation, and 
                training as the Secretary considers appropriate 
                for the family caregiver to provide personal 
                care services to the eligible veteran;
                  (II) ongoing technical support consisting of 
                information and assistance to address, in a 
                timely manner, the routine, emergency, and 
                specialized caregiving needs of the family 
                caregiver in providing personal care services 
                to the eligible veteran;
                  (III) counseling; and
                  (IV) lodging and subsistence under section 
                111(e) of this title.
          (ii) To each family caregiver who is designated as 
        the primary provider of personal care services for an 
        eligible veteran under paragraph (7)--
                  (I) the assistance described in clause (i);
                  (II) such mental health services as the 
                Secretary determines appropriate;
                  (III) respite care of not less than 30 days 
                annually, including 24-hour per day care of the 
                veteran commensurate with the care provided by 
                the family caregiver to permit extended 
                respite;
                  (IV) medical care under section 1781 of this 
                title[; and];
                  (V) a monthly personal caregiver stipend[.]; 
                and
                  (VI) through the use of contracts with, or 
                the provision of grants to, public or private 
                entities--
                          (aa) financial planning services 
                        relating to the needs of injured 
                        veterans and their caregivers; and
                          (bb) legal services, including legal 
                        advice and consultation, relating to 
                        the needs of injured veterans and their 
                        caregivers.
  (B) Respite care provided under subparagraph (A)(ii)(III) 
shall be medically and age-appropriate and include in-home 
care.
  (C)(i) The amount of the monthly personal caregiver stipend 
provided under subparagraph (A)(ii)(V) shall be determined in 
accordance with a schedule established by the Secretary that 
specifies stipends based upon the amount and degree of personal 
care services provided.
  (ii) The Secretary shall ensure, to the extent practicable, 
that the schedule required by clause (i) specifies that the 
amount of the monthly personal caregiver stipend provided to a 
primary provider of personal care services for the provision of 
personal care services to an eligible veteran is not less than 
the monthly amount a commercial home health care entity would 
pay an individual in the geographic area of the eligible 
veteran to provide equivalent personal care services to the 
eligible veteran.
  (iii) In determining the amount and degree of personal care 
services provided under clause (i) with respect to an eligible 
veteran whose need for personal care services is based in whole 
or in part on a need for supervision or protection under 
paragraph (2)(C)(ii) or regular instruction or supervision 
under paragraph (2)(C)(iii), the Secretary shall take into 
account the following:
          (I) The assessment by the family caregiver of the 
        needs and limitations of the veteran.
          (II) The extent to which the veteran can function 
        safely and independently in the absence of such 
        supervision, protection, or instruction.
          (III) The amount of time required for the family 
        caregiver to provide such supervision, protection, or 
        instruction to the veteran.
  [(iii)] (iv) If personal care services are not available from 
a commercial home health entity in the geographic area of an 
eligible veteran, the amount of the monthly personal caregiver 
stipend payable under the schedule required by clause (i) with 
respect to the eligible veteran shall be determined by taking 
into consideration the costs of commercial providers of 
personal care services in providing personal care services in 
geographic areas other than the geographic area of the eligible 
veteran with similar costs of living.
  (D) In providing instruction, preparation, and training under 
subparagraph (A)(i)(I) and technical support under subparagraph 
(A)(i)(II) to each family caregiver who is approved as a 
provider of personal care services for an eligible veteran 
under paragraph (6), the Secretary shall periodically evaluate 
the needs of the eligible veteran and the skills of the family 
caregiver of such veteran to determine if additional 
instruction, preparation, training, or technical support under 
those subparagraphs is necessary.
  (4) An eligible veteran and a family member of the eligible 
veteran seeking to participate in the program required by 
paragraph (1) shall jointly submit to the Secretary an 
application therefor in such form and in such manner as the 
Secretary considers appropriate.
  (5) For each application submitted jointly by an eligible 
veteran and family member, the Secretary shall evaluate (in 
collaboration with the primary care team for the eligible 
veteran to the maximum extent practicable)--
          (A) the eligible veteran--
                  (i) to identify the personal care services 
                required by the eligible veteran; and
                  (ii) to determine whether such requirements 
                could be significantly or substantially 
                satisfied through the provision of personal 
                care services from a family member; and
          (B) the family member to determine the amount of 
        instruction, preparation, and training, if any, the 
        family member requires to provide the personal care 
        services required by the eligible veteran--
                  (i) as a provider of personal care services 
                for the eligible veteran; and
                  (ii) as the primary provider of personal care 
                services for the eligible veteran.
  (6)(A) The Secretary shall provide each family member of an 
eligible veteran who makes a joint application under paragraph 
(4) the instruction, preparation, and training determined to be 
required by such family member under paragraph (5)(B).
  (B) Upon the successful completion by a family member of an 
eligible veteran of instruction, preparation, and training 
under subparagraph (A), the Secretary shall approve the family 
member as a provider of personal care services for the eligible 
veteran.
  (C) The Secretary shall, subject to regulations the Secretary 
shall prescribe, provide for necessary travel, lodging, and per 
diem expenses incurred by a family member of an eligible 
veteran in undergoing instruction, preparation, and training 
under subparagraph (A).
  (D) If the participation of a family member of an eligible 
veteran in instruction, preparation, and training under 
subparagraph (A) would interfere with the provision of personal 
care services to the eligible veteran, the Secretary shall, 
subject to regulations as the Secretary shall prescribe and in 
consultation with the veteran, provide respite care to the 
eligible veteran during the provision of such instruction, 
preparation, and training to the family member so that the 
family member can participate in such instruction, preparation, 
and training without interfering with the provision of such 
services to the eligible veteran.
  (7)(A) For each eligible veteran with at least one family 
member who is described by subparagraph (B), the Secretary 
shall designate one family member of such eligible veteran as 
the primary provider of personal care services for such 
eligible veteran.
  (B) A primary provider of personal care services designated 
for an eligible veteran under subparagraph (A) shall be 
selected from among family members of the eligible veteran 
who--
          (i) are approved under paragraph (6) as a provider of 
        personal care services for the eligible veteran;
          (ii) elect to provide the personal care services to 
        the eligible veteran that the Secretary determines the 
        eligible veteran requires under paragraph (5)(A)(i);
          (iii) have the consent of the eligible veteran to be 
        the primary provider of personal care services for the 
        eligible veteran; and
          (iv) are considered by the Secretary as competent to 
        be the primary provider of personal care services for 
        the eligible veteran.
  (C) An eligible veteran receiving personal care services from 
a family member designated as the primary provider of personal 
care services for the eligible veteran under subparagraph (A) 
may, in accordance with procedures the Secretary shall 
establish for such purposes, revoke consent with respect to 
such family member under subparagraph (B)(iii).
  (D) If a family member designated as the primary provider of 
personal care services for an eligible veteran under 
subparagraph (A) subsequently fails to meet any requirement set 
forth in subparagraph (B), the Secretary--
          (i) shall immediately revoke the family member's 
        designation under subparagraph (A); and
          (ii) may designate, in consultation with the eligible 
        veteran, a new primary provider of personal care 
        services for the eligible veteran under such 
        subparagraph.
  (E) The Secretary shall take such actions as may be necessary 
to ensure that the revocation of a designation under 
subparagraph (A) with respect to an eligible veteran does not 
interfere with the provision of personal care services required 
by the eligible veteran.
  (8) If an eligible veteran lacks the capacity to make a 
decision under this subsection, the Secretary may, in 
accordance with regulations and policies of the Department 
regarding appointment of guardians or the use of powers of 
attorney, appoint a surrogate for the eligible veteran who may 
make decisions and take action under this subsection on behalf 
of the eligible veteran.
  (9)(A) The Secretary shall monitor the well-being of each 
eligible veteran receiving personal care services under the 
program required by paragraph (1).
  (B) The Secretary shall document each finding the Secretary 
considers pertinent to the appropriate delivery of personal 
care services to an eligible veteran under the program.
  (C) The Secretary shall establish procedures to ensure 
appropriate follow-up regarding findings described in 
subparagraph (B). Such procedures may include the following:
          (i) Visiting an eligible veteran in the eligible 
        veteran's home to review directly the quality of 
        personal care services provided to the eligible 
        veteran.
          (ii) Taking such corrective action with respect to 
        the findings of any review of the quality of personal 
        care services provided an eligible veteran as the 
        Secretary considers appropriate, which may include--
                  (I) providing additional training to a family 
                caregiver; and
                  (II) suspending or revoking the approval of a 
                family caregiver under paragraph (6) or the 
                designation of a family caregiver under 
                paragraph (7).
  (10) The Secretary shall carry out outreach to inform 
eligible veterans and family members of eligible veterans of 
the program required by paragraph (1) and the benefits of 
participating in the program.
  (11)(A) In providing assistance under this subsection to 
family caregivers of eligible veterans, the Secretary may enter 
into contracts, provider agreements, and memoranda of 
understanding with Federal agencies, States, and private, 
nonprofit, and other entities to provide such assistance to 
such family caregivers.
  (B) The Secretary may provide assistance under this paragraph 
only if such assistance is reasonably accessible to the family 
caregiver and is substantially equivalent or better in quality 
to similar services provided by the Department.
  (C) The Secretary may provide fair compensation to Federal 
agencies, States, and other entities that provide assistance 
under this paragraph.
  (b) Program of General Caregiver Support Services.--(1) The 
Secretary shall establish a program of support services for 
caregivers of covered veterans who are enrolled in the health 
care system established under section 1705(a) of this title 
(including caregivers who do not reside with such veterans).
  (2) For purposes of this subsection, a covered veteran is any 
individual who needs personal care services because of--
          (A) an inability to perform one or more activities of 
        daily living;
          (B) a need for supervision or protection based on 
        symptoms or residuals of neurological or other 
        impairment or injury; or
          (C) such other matters as the Secretary shall 
        specify.
  (3)(A) The support services furnished to caregivers of 
covered veterans under the program required by paragraph (1) 
shall include the following:
          (i) Services regarding the administering of personal 
        care services, which, subject to subparagraph (B), 
        shall include--
                  (I) educational sessions made available both 
                in person and on an Internet website;
                  (II) use of telehealth and other available 
                technologies; and
                  (III) teaching techniques, strategies, and 
                skills for caring for a disabled veteran;
          (ii) Counseling and other services under section 1782 
        of this title.
          (iii) Respite care under section 1720B of this title 
        that is medically and age appropriate for the veteran 
        (including 24-hour per day in-home care).
          (iv) Information concerning the supportive services 
        available to caregivers under this subsection and other 
        public, private, and nonprofit agencies that offer 
        support to caregivers.
  (B) If the Secretary certifies to the Committees on Veterans' 
Affairs of the Senate and the House of Representatives that 
funding available for a fiscal year is insufficient to fund the 
provision of services specified in one or more subclauses of 
subparagraph (A)(i), the Secretary shall not be required under 
subparagraph (A) to provide the services so specified in the 
certification during the period beginning on the date that is 
180 days after the date the certification is received by the 
Committees and ending on the last day of the fiscal year.
  (4) In providing information under paragraph (3)(A)(iv), the 
Secretary shall collaborate with the Assistant Secretary for 
Aging of the Department of Health and Human Services in order 
to provide caregivers access to aging and disability resource 
centers under the Administration on Aging of the Department of 
Health and Human Services.
  (5) In carrying out the program required by paragraph (1), 
the Secretary shall conduct outreach to inform covered veterans 
and caregivers of covered veterans about the program. The 
outreach shall include an emphasis on covered veterans and 
caregivers of covered veterans living in rural areas.
  (c) Construction.--(1) A decision by the Secretary under this 
section affecting the furnishing of assistance or support shall 
be considered a medical determination.
  (2) Nothing in this section shall be construed to create--
          (A) an employment relationship between the Secretary 
        and an individual in receipt of assistance or support 
        under this section; or
          (B) any entitlement to any assistance or support 
        provided under this section.
  (d) Definitions.--In this section:
          (1) The term ``caregiver'', with respect to an 
        eligible veteran under subsection (a) or a covered 
        veteran under subsection (b), means an individual who 
        provides personal care services to the veteran.
          (2) The term ``family caregiver'', with respect to an 
        eligible veteran under subsection (a), means a family 
        member who is a caregiver of the veteran.
          (3) The term ``family member'', with respect to an 
        eligible veteran under subsection (a), means an 
        individual who--
                  (A) is a member of the family of the veteran, 
                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 but is not a 
                member of the family of the veteran.
          (4) The term ``personal care services'', with respect 
        to an eligible veteran under subsection (a) or a 
        covered veteran under subsection (b), means services 
        that provide the veteran the following:
                  (A) Assistance with one or more [independent] 
                activities of daily living.
                  (B) Supervision or protection based on 
                symptoms or residuals of neurological or other 
                impairment or injury.
                  (C) Regular or extensive instruction or 
                supervision without which the ability of the 
                veteran to function in daily life would be 
                seriously impaired.
                  [(B)] (D) Any other non-institutional 
                extended care (as such term is used in section 
                1701(6)(E) of this title).
  (e) Authorization of Appropriations.--There are authorized to 
be appropriated to carry out the programs required by 
subsections (a) and (b)--
          (1) $60,000,000 for fiscal year 2010;
          (2) $1,542,000,000 for the period of fiscal years 
        2011 through 2015;
          (3) $625,000,000 for fiscal year 2016;
          (4) $734,628,000 for fiscal year 2017; and
          (5) $839,828,000 for each of fiscal years 2018 and 
        2019.

           *       *       *       *       *       *       *


Sec. [1712I]  1720I. Mental and behavioral health care for certain 
                    former members of the Armed Forces

  (a) In General The Secretary shall furnish to former members 
of the Armed Forces described in subsection (b)--
          (1) an initial mental health assessment; and
          (2) the mental healthcare or behavioral healthcare 
        services authorized under this chapter that are 
        required to treat the mental or behavioral health care 
        needs of the former service members, including risk of 
        suicide or harming others.
  (b) Eligible Individuals A former member of the Armed Forces 
described in this subsection is an individual who--
          (1) is a former member of the Armed Forces, including 
        the reserve components;
          (2) while serving in the active military, naval, or 
        air service, was discharged or released therefrom under 
        a condition that is not honorable but not--
                  (A) a dishonorable discharge; or
                  (B) a discharge by court-martial;
          (3) is not otherwise eligible to enroll in the health 
        care system established by section 1705 of this title; 
        and
          (4)(A)(i) served in the Armed Forces for a period of 
        more than 100 cumulative days; and
          (ii) was deployed in a theater of combat operations, 
        in support of a contingency operation, or in an area at 
        a time during which hostilities are occurring in that 
        area during such service, including by controlling an 
        unmanned aerial vehicle from a location other than such 
        theater or area; or
          (B) while serving in the Armed Forces, was the victim 
        of a physical assault of a sexual nature, a battery of 
        a sexual nature, or sexual harassment (as defined in 
        section 1720D(f) of this title).
  (c) Non-Department Care(1) In furnishing mental or behavioral 
health care services to an individual under this section, the 
Secretary may provide such mental or behavioral health care 
services at a non- Department facility if--
          (A) in the judgment of a mental health professional 
        employed by the Department, the receipt of mental or 
        behavioral health care services by that individual in 
        facilities of the Department would be clinically 
        inadvisable; or
          (B) facilities of the Department are not capable of 
        furnishing such mental or behavioral health care 
        services to that individual economically because of 
        geographical inaccessibility.
  (2) The Secretary shall carry out paragraph (1) pursuant to 
section 1703 of this title or any other provision of law 
authorizing the Secretary to enter into contracts or agreements 
to furnish hospital care and medical services to veterans at 
non-Department facilities.
  (d) Setting and Referrals In furnishing mental and behavioral 
health care services to individuals under this section, the 
Secretary shall--
          (1) seek to ensure that such services are furnished 
        in settings that are therapeutically appropriate, 
        taking into account the circumstances that resulted in 
        the need for such services; and
          (2) provide referral services to assist former 
        members who are not eligible for services under this 
        chapter to obtain services from sources outside the 
        Department.
  (e) Information The Secretary shall provide information on 
the mental and behavioral health care services available under 
this section. Efforts by the Secretary to provide such 
information--
          (1) shall include notification of each eligible 
        individual described in subsection (b) about the 
        eligibility of the individual for covered mental and 
        behavioral health care under this section not later 
        than the later of--
                  (A) 180 days after the date of the enactment 
                of the Military Construction, Veterans Affairs, 
                and Related Agencies Appropriations Act, 2018; 
                or
                  (B) 180 days after the date on which the 
                individual was discharged or released from the 
                active military, naval, or air service;
          (2) shall include availability of a toll-free 
        telephone number (commonly referred to as an 800 
        number);
          (3) shall ensure that information about the mental 
        health care services available under this section--
                  (A) is revised and updated as appropriate;
                  (B) is made available and visibly posted at 
                appropriate facilities of the Department; and
                  (C) is made available to State veteran 
                agencies and through appropriate public 
                information services; and
          (4) shall include coordination with the Secretary of 
        Defense seeking to ensure that members of the Armed 
        Forces and individuals who are being separated from 
        active military, naval, or air service are provided 
        appropriate information about programs, requirements, 
        and procedures for applying for mental health care 
        services under this section.
  (f) Annual Reports(1) Not less frequently than once each 
year, 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 mental and 
behavioral health care services provided under this section.
  (2) Each report submitted under paragraph (1) shall include, 
with respect to the year preceding the submittal of the report, 
the following:
          (A) The number of eligible individuals who were 
        furnished mental or behavioral health care services 
        under this section, disaggregated by the number of men 
        who received such services and the number of women who 
        received such services.
          (B) The number of individuals who requested an 
        initial mental health assessment under subsection 
        (a)(1).
          (C) Such other information as the Secretary considers 
        appropriate.

           *       *       *       *       *       *       *


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

           *       *       *       *       *       *       *



Sec. 1725A. Access to walk-in care

  (a) Procedures to Ensure Access to Walk-in Care.--The 
Secretary shall develop procedures to ensure that eligible 
veterans are able to access walk-in care from qualifying non-
Department entities or providers.
  (b) Eligible Veterans.--For purposes of this section, an 
eligible veteran is any individual who--
          (1) is enrolled in the health care system established 
        under section 1705(a) of this title; and
          (2) has received care under this chapter within the 
        24-month period preceding the furnishing of walk-in 
        care under this section.
  (c) Qualifying Non-Department Entities or Providers.--For 
purposes of this section, a qualifying non-Department entity or 
provider is a non-Department entity or provider that has 
entered into a contract or other agreement with the Secretary 
to furnish services under this section.
  (d) Federally-qualified Health Centers.--Whenever 
practicable, the Secretary may use a 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))) to carry out this 
section.
  (e) Continuity of Care.--The Secretary shall ensure 
continuity of care for those eligible veterans who receive 
walk-in care services under this section, including through the 
establishment of a mechanism to receive medical records from 
walk-in care providers and provide pertinent patient medical 
records to providers of walk-in care.
  (f) Copayments.--(1)(A) The Secretary may require an eligible 
veteran to pay the United States a copayment for each episode 
of hospital care or medical services provided under this 
section if the eligible veteran would be required to pay a 
copayment under this title.
  (B) An eligible veteran not required to pay a copayment under 
this title may access walk-in care without a copayment for the 
first two visits in a calendar year. For any additional visits, 
a copayment at an amount determined by the Secretary may be 
required.
  (C) An eligible veteran required to pay a copayment under 
this title may be required to pay a regular copayment for the 
first two walk-in care visits in a calendar year. For any 
additional visits, a higher copayment at an amount determined 
by the Secretary may be required.
  (2) After the first two episodes of care furnished to an 
eligible veteran under this section, the Secretary may adjust 
the copayment required of the veteran under this subsection 
based upon the priority group of enrollment of the eligible 
veteran, the number of episodes of care furnished to the 
eligible veteran during a year, and other factors the Secretary 
considers appropriate under this section.
  (3) The amount or amounts of the copayments required under 
this subsection shall be prescribed by the Secretary by rule.
  (4) Section 8153(c) of this title shall not apply to this 
subsection.
  (g) Regulations.--Not later than one year after the date of 
the enactment of the Caring for Our Veterans Act of 2018, the 
Secretary shall promulgate regulations to carry out this 
section.
  (h) Walk-in Care Defined.--In this section, the term ``walk-
in care'' means non-emergent care provided by a qualifying non-
Department entity or provider that furnishes episodic care and 
not longitudinal management of conditions and is otherwise 
defined through regulations the Secretary shall promulgate.

           *       *       *       *       *       *       *


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.] 
(1) Subject to the provisions of this section, in any case in 
which the United States is required by law to furnish or pay 
for 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 from a third party the reasonable charges of care or 
services so furnished or paid for to the extent that the 
recipient or 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 or paid 
for 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] the 
        individual'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] the individual 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]
          (D) that is incurred by an individual who is entitled 
        to care (or payment of the expenses of care) under a 
        health-plan contract.
          (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] the individual--
          (A) [the veteran's] the individual'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.
  (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] the individual (or [the veteran's] the 
individual'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] the individual 
(or [the veteran's] the individual'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] the 
        individual by the Secretary under this chapter;
          (ii) the United States has sent written notice by 
        certified mail to [the veteran] the individual at [the 
        veteran's] the individual's last-known address (or to 
        [the veteran's] the individual'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] An individual 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] 
an individual 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] 
        the individual; and
          (B) that the provision of such care or services to 
        [the veteran] the individual meets criteria generally 
        applicable under the health-plan contract involved.
  (2) [A veteran] An individual described in this paragraph is 
[a veteran] an individual 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] the individual.
  (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. 1730B. Access to State prescription drug monitoring programs

  (a) Access to Programs.--(1) Any licensed health care 
provider or delegate of such a provider shall be considered an 
authorized recipient or user for the purpose of querying and 
receiving data from the national network of State-based 
prescription drug monitoring programs to support the safe and 
effective prescribing of controlled substances to covered 
patients.
  (2) Under the authority granted by paragraph (1)--
          (A) licensed health care providers or delegates of 
        such providers shall query such network in accordance 
        with applicable regulations and policies of the 
        Veterans Health Administration; and
          (B) notwithstanding any general or specific provision 
        of law, rule, or regulation of a State, no State may 
        restrict the access of licensed health care providers 
        or delegates of such providers from accessing that 
        State's prescription drug monitoring programs.
  (3) No State shall deny or revoke the license, registration, 
or certification of a licensed health care provider or delegate 
who otherwise meets that State's qualifications for holding the 
license, registration, or certification on the basis that the 
licensed health care provider or delegate queried or received 
data, or attempted to query or receive data, from the national 
network of State-based prescription drug monitoring programs 
under this section.
  (b) Covered Patients.--For purposes of this section, a 
covered patient is a patient who--
          (1) receives a prescription for a controlled 
        substance; and
          (2) is not receiving palliative care or enrolled in 
        hospice care.
  (c) Definitions.--In this section:
          (1) The term ``controlled substance'' has the meaning 
        given such term in section 102(6) of the Controlled 
        Substances Act (21 U.S.C. 802(6)).
          (2) The term ``delegate'' means a person or automated 
        system accessing the national network of State-based 
        prescription monitoring programs at the direction or 
        under the supervision of a licensed health care 
        provider.
          (3) The term ``licensed health care provider'' means 
        a health care provider employed by the Department who 
        is licensed, certified, or registered within any State 
        to fill or prescribe medications within the scope of 
        his or her practice as a Department employee.
          (4) The term ``national network of State-based 
        prescription monitoring programs'' means an 
        interconnected nation-wide system that facilitates the 
        transfer to State prescription drug monitoring program 
        data across State lines.
          (5) The term ``State'' means a State, as defined in 
        section 101(20) of this title, or a political 
        subdivision of a State.

Sec. 1730C. 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) Covered Health Care Professionals.--For purposes of this 
section, a covered health care professional is any 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 standards for 
        quality relating to the provision of medicine 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.
  (c) 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.
  (d) Relation to State Law.--(1) The provisions of this 
section shall supersede any provisions of the law of any State 
to the extent that such provision of State law are inconsistent 
with this section.
  (2) No State shall deny or revoke the license, registration, 
or certification of a covered health care professional who 
otherwise meets the qualifications of the State for holding the 
license, registration, or certification on the basis that the 
covered health care professional has engaged or intends to 
engage in activity covered by subsection (a).
  (e) Rule of 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.).
  (f) State Defined.--In this section, the term ``State'' means 
a State, as defined in section 101(20) of this title, or a 
political subdivision of a State.

           *       *       *       *       *       *       *


SUBCHAPTER V--PAYMENTS TO STATE HOMES

           *       *       *       *       *       *       *



Sec. 1745. Nursing home care, adult day health 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)] (or 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) 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).
  (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 authorized by 
the Secretary or any Department official authorized by the 
Secretary, and any such action is not an award for purposes of 
such laws that would otherwise require the use of competitive 
procedures for the furnishing of hospital care, medical 
services, and extended care services.
  (B)(i) Except as provided in the agreement itself, in clause 
(ii), and unless otherwise provided in this section or 
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 provision of law 
to which providers of services and suppliers under the Medicare 
program under title XVIII of the Social Security Act (42 U.S.C. 
1395 et seq.) are not subject.
  (ii) A State home that enters into an agreement under this 
section is subject to--
          (I) all provisions of law regarding integrity, 
        ethics, or fraud, or that subject a person to civil or 
        criminal penalties;
          (II) all provisions of law that protect against 
        employment discrimination or that otherwise ensure 
        equal employment opportunities; and
          (III) all provisions in subchapter V of chapter 17 of 
        this title.
  (iii) Notwithstanding subparagraph (B)(ii)(I), a State home 
that enters into an agreement under this section may not be 
treated as a Federal contractor or subcontractor for purposes 
of chapter 67 of title 41 (known as the ``McNamara-O'Hara 
Service Contract Act of 1965'').
  (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.
  (d)(1) The Secretary shall enter into an agreement with each 
State home for payment by the Secretary for medical supervision 
model adult day health care provided to a veteran described in 
subsection (a)(1) on whose behalf the State home is not in 
receipt of payment for nursing home care from the Secretary.
  (2)(A) Payment under each agreement between the Secretary and 
a State home under paragraph (1) for each veteran who receives 
medical supervision model adult day health care under such 
agreement shall be made at a rate established through 
regulations prescribed by the Secretary to adequately reimburse 
the State home for the care provided by the State home, 
including necessary transportation expenses.
  (B) The Secretary shall consult with the State homes in 
prescribing regulations under subparagraph (A).
  (C) The rate established through regulations under 
subparagraph (A) shall not take effect until the date that is 
30 days after the date on which those regulations are published 
in the Federal Register.
  (3) Payment by the Secretary under paragraph (1) to a State 
home for medical supervision model adult day health 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) In this subsection, the term ``medical supervision model 
adult day health care'' means adult day health care that 
includes the coordination of physician services, dental 
services, nursing services, the administration of drugs, and 
such other requirements as determined appropriate by the 
Secretary.

           *       *       *       *       *       *       *


SUBCHAPTER VIII--HEALTH CARE OF PERSONS OTHER THAN VETERANS

           *       *       *       *       *       *       *



Sec. 1788. 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.--In carrying out this 
section, 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 chapter. 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.

           *       *       *       *       *       *       *


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] with sections 1703A, 8111, and 8153 of 
                this title;
                  (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 III--READJUSTMENT AND RELATED BENEFITS

           *       *       *       *       *       *       *


CHAPTER 37--HOUSING AND SMALL BUSINESS LOANS

           *       *       *       *       *       *       *



SUBCHAPTER III--ADMINISTRATIVE PROVISIONS

           *       *       *       *       *       *       *



Sec. 3729. Loan fee

  (a) Requirement of Fee.--(1) Except as provided in subsection 
(c), a fee shall be collected from each person obtaining a 
housing loan guaranteed, insured, or made under this chapter, 
and each person assuming a loan to which section 3714 of this 
title applies. No such loan may be guaranteed, insured, made, 
or assumed until the fee payable under this section has been 
remitted to the Secretary.
  (2) The fee may be included in the loan and paid from the 
proceeds thereof.
  (b) Determination of Fee.--(1) The amount of the fee shall be 
determined from the loan fee table in paragraph (2). The fee is 
expressed as a percentage of the total amount of the loan 
guaranteed, insured, or made, or, in the case of a loan 
assumption, the unpaid principal balance of the loan on the 
date of the transfer of the property.
  (2) The loan fee table referred to in paragraph (1) is as 
follows:


                             LOAN FEE TABLE
------------------------------------------------------------------------
                   Active duty
 Type of loan        veteran            Reservist         Other obligor
------------------------------------------------------------------------
(A)(i) Initial  2.00               2.75                 NA
 loan
 described in
 section 3710
 (a) to
 purchase or
 construct a
 dwelling with
 0-down, or
 any other
 initial loan
 described in
 section 3710
 (a) other
 than with 5-
 down or 10-
 down (closed
 before
 January 1,
 2004)
(A)(ii)         2.20               2.40                 NA
 Initial loan
 described in
 section 3710
 (a) to
 purchase or
 construct a
 dwelling with
 0-down, or
 any other
 initial loan
 described in
 section 3710
 (a) other
 than with 5-
 down or 10-
 down (closed
 on or after
 January 1,
 2004, and
 before
 October 1,
 2004)
(A)(iii)        2.15               2.40                 NA
 Initial loan
 described in
 section 3710
 (a) to
 purchase or
 construct a
 dwelling with
 0-down, or
 any other
 initial loan
 described in
 section 3710
 (a) other
 than with 5-
 down or 10-
 down (closed
 on or after
 October 1,
 2004, and
 before
 September 30,
 [2027] 2028)
(A)(iv)         1.40               1.65                 NA
 Initial loan
 described in
 section 3710
 (a) to
 purchase or
 construct a
 dwelling with
 0-down, or
 any other
 initial loan
 described in
 section 3710
 (a) other
 than with 5-
 down or 10-
 down (closed
 on or after
 September 30,
 [2027] 2028)
(B)(i)          3.30               3.30                 NA
 Subsequent
 loan
 described in
 section 3710
 (a) to
 purchase or
 construct a
 dwelling with
 0-down, or
 any other
 subsequent
 loan
 described in
 section 3710
 (a) (closed
 before
 September 30,
 [2027] 2028)
(B)(ii)         1.25               1.25                 NA
 Subsequent
 loan
 described in
 section 3710
 (a) to
 purchase or
 construct a
 dwelling with
 0-down, or
 any other
 subsequent
 loan
 described in
 section 3710
 (a) (closed
 on or after
 September 30,
 [2027] 2028)
(C)(i) Loan     1.50               1.75                 NA
 described in
 section 3710
 (a) to
 purchase or
 construct a
 dwelling with
 5-down
 (closed
 before
 September 30,
 [2027] 2028)
(C)(ii) Loan    0.75               1.00                 NA
 described in
 section 3710
 (a) to
 purchase or
 construct a
 dwelling with
 5-down
 (closed on or
 after
 September 30,
 [2027] 2028)
(D)(i) Initial  1.25               1.50                 NA
 loan
 described in
 section 3710
 (a) to
 purchase or
 construct a
 dwelling with
 10-down
 (closed
 before
 September 30,
 [2027] 2028)
(D)(ii)         0.50               0.75                 NA
 Initial loan
 described in
 section 3710
 (a) to
 purchase or
 construct a
 dwelling with
 10-down
 (closed on or
 after
 September 30,
 [2027] 2028)
(E) Interest    0.50               0.50                 NA
 rate
 reduction
 refinancing
 loan
(F) Direct      1.00               1.00                 NA
 loan under
 section 3711
(G)             1.00               1.00                 NA
 Manufactured
 home loan
 under section
 3712 (other
 than an
 interest rate
 reduction
 refinancing
 loan)
(H) Loan to     1.25               1.25                 NA
 Native
 American
 veteran under
 section 3762
 (other than
 an interest
 rate
 reduction
 refinancing
 loan)
(I) Loan        0.50               0.50                 0.50
 assumption
 under section
 3714
(J) Loan under  2.25               2.25                 2.25
 section 3733
 (a)
------------------------------------------------------------------------

  (3) Any reference to a section in the ``Type of loan'' column 
in the loan fee table in paragraph (2) refers to a section of 
this title.
  (4) For the purposes of paragraph (2):
          (A) The term ``active duty veteran'' means any 
        veteran eligible for the benefits of this chapter other 
        than a Reservist.
          (B) The term ``Reservist'' means a veteran described 
        in section 3701 (b)(5)(A) of this title who is eligible 
        under section 3702(a)(2)(E) of this title.
          (C) The term ``other obligor'' means a person who is 
        not a veteran, as defined in section 101 of this title 
        or other provision of this chapter.
          (D) The term ``initial loan'' means a loan to a 
        veteran guaranteed under section 3710 or made under 
        section 3711 of this title if the veteran has never 
        obtained a loan guaranteed under section 3710 or made 
        under section 3711 of this title.
          (E) The term ``subsequent loan'' means a loan to a 
        veteran, other than an interest rate reduction 
        refinancing loan, guaranteed under section 3710 or made 
        under section 3711 of this title if the veteran has 
        previously obtained a loan guaranteed under section 
        3710 or made under section 3711 of this title.
          (F) The term ``interest rate reduction refinancing 
        loan'' means a loan described in section 3710(a)(8), 
        3710(a)(9)(B)(i), 3710(a)(11), 3712(a)(1)(F), or 
        3762(h) of this title.
          (G) The term ``0-down'' means a downpayment, if any, 
        of less than 5 percent of the total purchase price or 
        construction cost of the dwelling.
          (H) The term ``5-down'' means a downpayment of at 
        least 5 percent or more, but less than 10 percent, of 
        the total purchase price or construction cost of the 
        dwelling.
          (I) The term ``10-down'' means a downpayment of 10 
        percent or more of the total purchase price or 
        construction cost of the dwelling.
  (c) Waiver of Fee.--(1) A fee may not be collected under this 
section from a veteran who is receiving compensation (or who, 
but for the receipt of retirement pay or active service pay, 
would be entitled to receive compensation) or from a surviving 
spouse of any veteran (including a person who died in the 
active military, naval, or air service) who died from a 
service-connected disability.
  (2)(A) A veteran described in subparagraph (B) shall be 
treated as receiving compensation for purposes of this 
subsection as of the date of the rating described in such 
subparagraph without regard to whether an effective date of the 
award of compensation is established as of that date.
  (B) A veteran described in this subparagraph is a veteran who 
is rated eligible to receive compensation--
          (i) as the result of a pre-discharge disability 
        examination and rating; or
          (ii) based on a pre-discharge review of existing 
        medical evidence (including service medical and 
        treatment records) that results in the issuance of a 
        memorandum rating.

           *       *       *       *       *       *       *


PART IV--GENERAL ADMINISTRATIVE PROVISIONS

           *       *       *       *       *       *       *


CHAPTER 55--MINORS, INCOMPETENTS, AND OTHER WARDS

           *       *       *       *       *       *       *



Sec. 5503. Hospitalized veterans and estates of incompetent 
                    institutionalized veterans

  (a)(1)(A) Where any veteran having neither spouse nor child 
is being furnished domiciliary care by the Department, no 
pension in excess of $90 per month shall be paid to or for the 
veteran for any period after the end of the third full calendar 
month following the month of admission for such care.
  (B) Except as provided in subparagraph (D) of this paragraph, 
where any veteran having neither spouse nor child is being 
furnished nursing home care by the Department, no pension in 
excess of $90 per month shall be paid to or for the veteran for 
any period after the end of the third full calendar month 
following the month of admission for such care. Any amount in 
excess of $90 per month to which the veteran would be entitled 
but for the application of the preceding sentence shall be 
deposited in a revolving fund at the Department medical 
facility which furnished the veteran nursing care, and such 
amount shall be available for obligation without fiscal year 
limitation to help defray operating expenses of that facility.
  (C) No pension in excess of $90 per month shall be paid to or 
for a veteran having neither spouse nor child for any period 
after the month in which such veteran is readmitted for care 
described in subparagraph (A) or (B) of this paragraph and 
furnished by the Department if such veteran is readmitted 
within six months of a period of care in connection with which 
pension was reduced pursuant to subparagraph (A) or (B) of this 
paragraph.
  (D) In the case of a veteran being furnished nursing home 
care by the Department and with respect to whom subparagraph 
(B) of this paragraph requires a reduction in pension, such 
reduction shall not be made for a period of up to three 
additional calendar months after the last day of the third 
month referred to in such subparagraph if the Secretary 
determines that the primary purpose for the furnishing of such 
care during such additional period is for the Department to 
provide such veteran with a prescribed program of 
rehabilitation services, under chapter 17 of this title, 
designed to restore such veteran's ability to function within 
such veteran's family and community. If the Secretary 
determines that it is necessary, after such period, for the 
veteran to continue such program of rehabilitation services in 
order to achieve the purposes of such program and that the 
primary purpose of furnishing nursing home care to the veteran 
continues to be the provision of such program to the veteran, 
the reduction in pension required by subparagraph (B) of this 
paragraph shall not be made for the number of calendar months 
that the Secretary determines is necessary for the veteran to 
achieve the purposes of such program.
  (2) The provisions of paragraph (1) shall also apply to a 
veteran being furnished such care who has a spouse but whose 
pension is payable under section 1521(b) of this title. In such 
a case, the Secretary may apportion and pay to the spouse, upon 
an affirmative showing of hardship, all or any part of the 
amounts in excess of the amount payable to the veteran while 
being furnished such care which would be payable to the veteran 
if pension were payable under section 1521(c) of this title.
  (b) Notwithstanding any other provision of this section or 
any other provision of law, no reduction shall be made in the 
pension of any veteran for any part of the period during which 
the veteran is furnished hospital treatment, or institutional 
or domiciliary care, for Hansen's disease, by the United States 
or any political subdivision thereof.
  (c) Where any veteran in receipt of an aid and attendance 
allowance described in subsection (r) or (t) of section 1114 of 
this title is hospitalized at Government expense, such 
allowance shall be discontinued from the first day of the 
second calendar month which begins after the date of the 
veteran's admission for such hospitalization for so long as 
such hospitalization continues. Any discontinuance required by 
administrative regulation, during hospitalization of a veteran 
by the Department, of increased pension based on need of 
regular aid and attendance or additional compensation based on 
need of regular aid and attendance as described in subsection 
(l) or (m) of section 1114 of this title, shall not be 
effective earlier than the first day of the second calendar 
month which begins after the date of the veteran's admission 
for hospitalization. In case a veteran affected by this 
subsection leaves a hospital against medical advice and is 
thereafter admitted to hospitalization within six months from 
the date of such departure, such allowance, increased pension, 
or additional compensation, as the case may be, shall be 
discontinued from the date of such readmission for so long as 
such hospitalization continues.
  (d)(1) For the purposes of this subsection--
          (A) the term ``Medicaid plan'' means a State plan for 
        medical assistance referred to in section 1902(a) of 
        the Social Security Act (42 U.S.C. 1396a(a)); and
          (B) the term ``nursing facility'' means a nursing 
        facility described in section 1919 of such Act (42 
        U.S.C. 1396r), other than a facility that is a State 
        home with respect to which the Secretary makes per diem 
        payments for nursing home care pursuant to section 
        1741(a) of this title.
  (2) If a veteran having neither spouse nor child is covered 
by a Medicaid plan for services furnished such veteran by a 
nursing facility, no pension in excess of $90 per month shall 
be paid to or for the veteran for any period after the month of 
admission to such nursing facility.
  (3) Notwithstanding any provision of title XIX of the Social 
Security Act, the amount of the payment paid a nursing facility 
pursuant to a Medicaid plan for services furnished a veteran 
may not be reduced by any amount of pension permitted to be 
paid such veteran under paragraph (2) of this subsection.
  (4) A veteran is not liable to the United States for any 
payment of pension in excess of the amount permitted under this 
subsection that is paid to or for the veteran by reason of the 
inability or failure of the Secretary to reduce the veteran's 
pension under this subsection unless such inability or failure 
is the result of a willful concealment by the veteran of 
information necessary to make a reduction in pension under this 
subsection.
  (5)(A) The provisions of this subsection shall apply with 
respect to a surviving spouse having no child in the same 
manner as they apply to a veteran having neither spouse nor 
child.
  (B) The provisions of this subsection shall apply with 
respect to a child entitled to pension under section 1542 of 
this title in the same manner as they apply to a veteran having 
neither spouse nor child.
  (6) The costs of administering this subsection shall be paid 
for from amounts available to the Department of Veterans 
Affairs for the payment of compensation and pension.
  (7) This subsection expires on [September 30, 2027] September 
30, 2028.

           *       *       *       *       *       *       *


PART V--BOARDS, ADMINISTRATIONS, AND SERVICES

           *       *       *       *       *       *       *


CHAPTER 73--VETERANS HEALTH ADMINISTRATION - ORGANIZATION AND FUNCTIONS


                       SUBCHAPTER I--ORGANIZATION

Sec.
7301. Functions of Veterans Health Administration: in general.
     * * * * * * *

           SUBCHAPTER II--GENERAL AUTHORITY AND ADMINISTRATION

     * * * * * * *
7330C. Quadrennial Veterans Health Administration review.
     * * * * * * *

SUBCHAPTER II--GENERAL AUTHORITY AND ADMINISTRATION

           *       *       *       *       *       *       *



Sec. 7330C. Quadrennial Veterans Health Administration review

  (a) Market Area Assessments.--(1) Not less frequently than 
every four years, the Secretary of Veterans Affairs shall 
perform market area assessments regarding the health care 
services furnished under the laws administered by the 
Secretary.
  (2) Each market area assessment established under paragraph 
(1) shall include the following:
          (A) An assessment of the demand for health care from 
        the Department, disaggregated by geographic market 
        areas as determined by the Secretary, including the 
        number of requests for health care services under the 
        laws administered by the Secretary.
          (B) An inventory of the health care capacity of the 
        Department of Veterans Affairs across the Department's 
        system of facilities.
          (C) An assessment of the health care capacity to be 
        provided through contracted community care providers 
        and providers who entered into a provider agreement 
        with the Department under section 1703A of title 38, as 
        added by section 102, including the number of 
        providers, the geographic location of the providers, 
        and categories or types of health care services 
        provided by the providers.
          (D) An assessment obtained from other Federal direct 
        delivery systems of their capacity to provide health 
        care to veterans.
          (E) An assessment of the health care capacity of non-
        contracted providers where there is insufficient 
        network supply.
          (F) An assessment of the health care capacity of 
        academic affiliates and other collaborations of the 
        Department as it relates to providing health care to 
        veterans.
          (G) An assessment of the effects on health care 
        capacity of the access standards and standards for 
        quality established under sections 1703B and 1703C of 
        this title.
          (H) The number of appointments for health care 
        services under the laws administered by the Secretary, 
        disaggregated by--
                  (i) appointments at facilities of the 
                Department of Veterans Affairs; and
                  (ii) appointments with non-Department health 
                care providers.
  (3)(A) The Secretary shall submit to the appropriate 
committees of Congress the market area assessments established 
in paragraph (1).
  (B) The Secretary also shall submit to the appropriate 
committees of Congress the market area assessments completed by 
or being performed on the day before the date of the enactment 
of the Caring for Our Veterans Act of 2018.
  (4)(A) The Secretary shall use the market area assessments 
established under paragraph (1) to--
          (i) determine the capacity of the health care 
        provider networks established under section 1703(h) of 
        this title;
          (ii) inform the Department budget, in accordance with 
        subparagraph (B); and
          (iii) inform and assess the appropriateness of the 
        access standards established under section 1703B of 
        this title and standards for quality under section 
        1703C and to make recommendations for any changes to 
        such standards.
  (B) The Secretary shall ensure that the Department budget for 
any fiscal year (as submitted with the budget of the President 
under section 1105(a) of title 31) reflects the findings of the 
Secretary with respect to the most recent market area 
assessments under paragraph (1) and health care utilization 
data from the Department and non-Department entities or 
providers furnishing care and services to covered veterans as 
described in section 1703(b).
  (b) Strategic Plan to Meet Health Care Demand.--(1) Not later 
than one year after the date of the enactment of the Caring for 
Our Veterans Act of 2018 and not less frequently than once 
every four years thereafter, the Secretary shall submit to the 
appropriate committees of Congress a strategic plan that 
specifies a four-year forecast of--
          (A) the demand for health care from the Department, 
        disaggregated by geographic area as determined by the 
        Secretary;
          (B) the health care capacity to be provided at each 
        medical center of the Department; and
          (C) the health care capacity to be provided through 
        community care providers.
  (2) In preparing the strategic plan under paragraph (1), the 
Secretary shall--
          (A) assess the access standards and standards for 
        quality established under sections 1703B and 1703C of 
        this title;
          (B) assess the market area assessments established 
        under subsection (a);
          (C) assess the needs of the Department based on 
        identified services that provide management of 
        conditions or disorders related to military service for 
        which there is limited experience or access in the 
        national market, the overall health of veterans 
        throughout their lifespan, or other services as the 
        Secretary determines appropriate;
          (D) consult with key stakeholders within the 
        Department, the heads of other Federal agencies, and 
        other relevant governmental and nongovernmental 
        entities, including State, local, and tribal government 
        officials, members of Congress, veterans service 
        organizations, private sector representatives, 
        academics, and other policy experts;
          (E) identify emerging issues, trends, problems, and 
        opportunities that could affect health care services 
        furnished under the laws administered by the Secretary;
          (F) develop recommendations regarding both short- and 
        long-term priorities for health care services furnished 
        under the laws administered by the Secretary;
          (G) after consultation with veterans service 
        organizations and other key stakeholders on survey 
        development or modification of an existing survey, 
        consider a survey of veterans who have used hospital 
        care, medical services, or extended care services 
        furnished by the Veterans Health Administration during 
        the most recent two-year period to assess the 
        satisfaction of the veterans with service and quality 
        of care;
          (H) conduct a comprehensive examination of programs 
        and policies of the Department regarding the delivery 
        of health care services and the demand of health care 
        services for veterans in future years;
          (I) assess the remediation of medical service lines 
        of the Department as described in section 1706A in 
        conjunction with the utilization of non-Department 
        entities or providers to offset remediation; and
          (J) consider such other matters as the Secretary 
        considers appropriate.
  (c) Responsibilities.--The Secretary shall be responsible 
for--
          (1) overseeing the transformation and organizational 
        change across the Department to achieve such high 
        performing integrated health care network;
          (2) developing the capital infrastructure planning 
        and procurement processes, whether minor or major 
        construction projects or leases; and
          (3) developing a multi-year budget process that is 
        capable of forecasting future year budget requirements 
        and projecting the cost of delivering health care 
        services under a high-performing integrated health care 
        network.
  (d) Appropriate Committees of Congress Defined.--In this 
section, the term ``appropriate committees of Congress'' 
means--
          (1) the Committee on Veterans' Affairs and the 
        Committee on Appropriations of the Senate; and
          (2) the Committee on Veterans' Affairs and the 
        Committee on Appropriations of the House of 
        Representatives.

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.]
          (H)(i) To a non-Department entity (including private 
        entities and other Federal agencies) for purposes of 
        providing health care, including hospital care, medical 
        services, and extended care services, to patients or 
        performing other health care-related activities or 
        functions.
          (ii) An entity to which a record is disclosed under 
        this subparagraph may not disclose or use such record 
        for a purpose other than that for which the disclosure 
        was made or as permitted by law.
          (I) To a third party in order to recover or collect 
        reasonable charges for care furnished to, or paid on 
        behalf of, a patient in connection with a non-service 
        connected disability as permitted by section 1729 of 
        this title 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 the Act 
        entitled ``An Act to provide for the recovery from 
        tortiously liable third persons of the cost of hospital 
        and medical care and treatment furnished by the United 
        States'' (Public Law 87-693; 42 U.S.C. 2651 et seq.; 
        commonly known as the ``Federal Medical Care Recovery 
        Act'').
  (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.
  (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.
7401. Appointments in Veterans Health Administration.
     * * * * * * *
7413. Treatment of podiatrists; clinical oversight standards.

           *       *       *       *       *       *       *


SUBCHAPTER I--APPOINTMENTS

           *       *       *       *       *       *       *



Sec. 7404. Grades and pay scales

  (a)(1)(A) The annual rates or ranges of rates of basic pay 
for positions provided in section 7306 and 7401(4) of this 
title shall be prescribed from time to time by Executive order 
as authorized by chapter 53 of title 5 or as otherwise 
authorized by law.
  (B) Section 5377 of title 5 shall apply to a position under 
section 7401(4) of this title as if such position were included 
in the definition of ``position'' in section 5377(a) of title 
5.
  (2) The pay of physicians and dentists serving in positions 
to which an Executive order applies under paragraph (1) shall 
be determined under subchapter III of this chapter instead of 
such Executive order.
  (3)(A) The rate of basic pay for a position to which an 
Executive order applies under paragraph (1) and is not 
described by paragraph (2) shall be set in accordance with 
section 5382 of title 5 as if such position were a Senior 
Executive Service position (as such term is defined in section 
3132(a) of title 5).
  (B) A rate of basic pay for a position may not be set under 
subparagraph (A) in excess of--
          (i) in the case the position is not described in 
        clause (ii), the rate of basic pay payable for level 
        III of the Executive Schedule; or
          (ii) in the case that the position is covered by a 
        performance appraisal system that meets the 
        certification criteria established by regulation under 
        section 5307(d) of title 5, the rate of basic pay 
        payable for level II of the Executive Schedule.
  (C) Notwithstanding the provisions of subsection (d) of 
section 5307 of title 5, the Secretary may make any 
certification under that subsection instead of the Office of 
Personnel Management and without concurrence of the Office of 
Management and Budget.
  (b) The grades for positions provided for in paragraph (1) of 
section 7401 of this title shall be as follows. The annual 
ranges of rates of basic pay for those grades shall be 
prescribed from time to time by Executive order as authorized 
by chapter 53 of title 5 or as otherwise authorized by law:
          [PHYSICIAN AND DENTIST SCHEDULE] PHYSICIAN AND 
        SURGEON (MD/DO), PODIATRIC SURGEON (DPM), AND DENTIST 
        AND ORAL SURGEON (DDS, DMD) SCHEDULE
          [Physician grade] Physician and surgeon grade.
          Dentist grade.
          NURSE SCHEDULE
          Nurse V.
          Nurse IV.
          Nurse III.
          Nurse II.
          Nurse I.
          CLINICAL [PODIATRIST, CHIROPRACTOR, AND] CHIROPRACTOR 
        AND OPTOMETRIST SCHEDULE
          Chief grade.
          Senior grade.
          Intermediate grade.
          Full grade.
          Associate grade.
  (c) Notwithstanding the provisions of section 7425(a) of this 
title, a person appointed under section 7306 of this title who 
is not eligible for pay under subchapter III shall be deemed to 
be a career appointee for the purposes of sections 4507 and 
5384 of title 5.
  (d) Except as provided under subsection (e), subchapter III, 
and section 7457 of this title, pay for positions for which 
basic pay is paid under this section may not be paid at a rate 
in excess of the rate of basic pay authorized by section 5316 
of title 5 for positions in Level V of the Executive Schedule.
  (e) The position of Chief Nursing Officer, Office of Nursing 
Services, shall be exempt from the provisions of section 7451 
of this title and shall be paid at a rate determined by the 
Secretary, not to exceed the maximum rate established for the 
Senior Executive Service under section 5382 of title 5.

           *       *       *       *       *       *       *


Sec. 7413. Treatment of podiatrists; clinical oversight standards

  (a) Podiatrists.--Except as provided by subsection (b), a 
doctor of podiatric medicine who is appointed as a podiatrist 
under section 7401(1) of this title is eligible for any 
supervisory position in the Veterans Health Administration to 
the same degree that a physician appointed under such section 
is eligible for the position.
  (b) Establishment of Clinical Oversight Standards.--The 
Secretary, in consultation with appropriate stakeholders, shall 
establish standards to ensure that specialists appointed in the 
Veterans Health Administration to supervisory positions do not 
provide direct clinical oversight for purposes of peer review 
or practice evaluation for providers of other clinical 
specialties.

           *       *       *       *       *       *       *


    CHAPTER 76--HEALTH PROFESSIONALS EDUCATIONAL ASSISTANCE PROGRAM


                          SUBCHAPTER I--GENERAL

Sec.
7601. Establishment of program; purpose.
     * * * * * * *

       Subchapter VIII--Specialty Education Loan Repayment Program

Sec.
7691. Establishment.
7692. Purpose.
7693. Eligibility; preferences; covered costs.
7694. Specialty education loan repayment.
7695. Choice of location.
7696. Term of obligated service.
7697. Relationship to 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 VII--EDUCATION DEBT REDUCTION PROGRAM

           *       *       *       *       *       *       *



Sec. 7683. Education debt reduction

  (a) In General.--Education debt reduction payments under the 
Education Debt Reduction Program shall consist of--
          (1) payments to individuals selected to participate 
        in the program of principal and interest on loans 
        described in section 7682(a)(2) of this title; or
          (2) payments for the principal and interest on such 
        loans of such individuals to the holders of such loans.
  (b) Frequency of Payment.--(1) The Secretary may make 
education debt reduction payments to or for any given 
participant in the Education Debt Reduction Program on a 
monthly or annual basis, as determined by the Secretary.
  (2) The Secretary shall make such payments at the end of the 
period determined by the Secretary under paragraph (1).
  (c) Performance Requirement.--The Secretary may make 
education debt reduction payments to or for a participant in 
the Education Debt Reduction Program for a period only if the 
Secretary determines that the individual maintained an 
acceptable level of performance in the position or positions 
served by the participant during the period.
  (d) Maximum Annual Amount.--(1) The amount of education debt 
reduction payments made to or for a participant under the 
Education Debt Reduction Program may not exceed [$120,000] 
$200,000 over a total of five years of participation in the 
Program, of which not more than [$24,000] $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 education debt repayments 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.

           *       *       *       *       *       *       *


      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; preferences; 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) Preferences.--In selecting individuals for participation 
in the Specialty Education Loan Repayment Program under this 
subchapter, the Secretary may give preference to the following:
          (1) Individuals who are, or will be, participating in 
        residency programs in health care facilities--
                  (A) located in rural areas;
                  (B) operated by Indian tribes, tribal 
                organizations, or the Indian Health Service; or
                  (C) affiliated with underserved health care 
                facilities of the Department.
          (2) 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.

           *       *       *       *       *       *       *


PART VI--ACQUISITION AND DISPOSITION OF PROPERTY

           *       *       *       *       *       *       *


   CHAPTER 81--ACQUISITION AND OPERATION OF HOSPITAL AND DOMICILIARY 
    FACILITIES; PROCUREMENT AND SUPPLY; ENHANCED-USE LEASES OF REAL 
                                PROPERTY


      SUBCHAPTER I--ACQUISITION AND OPERATION OF MEDICAL FACILITIES

Sec.
8101. Definitions.
     * * * * * * *

SUBCHAPTER IV--SHARING OF MEDICAL FACILITIES, EQUIPMENT, AND INFORMATION

     * * * * * * *
8159. Authority to pay for services authorized but not subject to an 
          agreement.
     * * * * * * *

     SUBCHAPTER I--ACQUISITION AND OPERATION OF MEDICAL FACILITIES


Sec. 8101. Definitions

   For the purposes of this subchapter:
  (1) The term ``alter'', with respect to a medical facility, 
means to repair, remodel, improve, or extend such medical 
facility.
  (2) The terms ``construct'' and ``alter'', with respect to a 
medical facility, include such engineering, architectural, 
legal, fiscal, and economic investigations and studies and such 
surveys, designs, plans, construction documents, 
specifications, procedures, and other similar actions as are 
necessary for the construction or alteration, as the case may 
be, of such medical facility and as are carried out after the 
completion of the advanced planning (including the development 
of project requirements and design development) for such 
facility.
  (3) The term ``medical facility'' means any facility or part 
thereof which is, or will be, under the jurisdiction of the 
[Secretary for the provision of health-care services (including 
hospital, nursing home,] Secretary, or as otherwise authorized 
by law, for the provision of health-care services (including 
hospital, outpatient clinic, nursing home, or domiciliary care 
or medical services), including any necessary building and 
auxiliary structure, garage, parking facility, mechanical 
equipment, trackage facilities leading thereto, abutting 
sidewalks, accommodations for attending personnel, and 
recreation facilities associated therewith.
  (4) The term ``committee'' means the Committee on Veterans' 
Affairs of the House of Representatives or the Committee on 
Veterans' Affairs of the Senate, and the term ``committees'' 
means both such committees.

           *       *       *       *       *       *       *


Sec. 8103. Authority to construct and alter, and to acquire sites for, 
                    medical facilities

  (a) Subject to section 8104 of this title, the Secretary--
          (1) may construct or alter any medical facility and 
        may acquire, by purchase, lease, condemnation, 
        donation, exchange, or otherwise, such land or 
        interests in land as the Secretary considers necessary 
        for use as the site for such construction or 
        alteration;
          (2) may acquire, by purchase, lease, condemnation, 
        donation, exchange, or otherwise, any facility 
        (including the site of such facility) that the 
        Secretary considers necessary for use as a medical 
        facility; and
          (3) in order to assure compliance with section 
        8110(a)(2) of this title, in the case of any outpatient 
        medical facility for which it is proposed to lease 
        space and for which a qualified lessor and an 
        appropriate leasing arrangement are available, shall 
        execute a lease for such facility within 12 months 
        after funds are made available for such purpose.
  (b) Whenever the Secretary considers it to be in the interest 
of the United States to construct a new medical facility to 
replace an existing medical facility, the Secretary (1) may 
demolish the existing facility and use the site on which it is 
located for the site of the new medical facility, or (2) if in 
the judgment of the Secretary it is more advantageous to 
construct such medical facility on a different site in the same 
locality, may exchange such existing facility and the site of 
such existing facility for the different site.
  (c) Whenever the Secretary determines that any site acquired 
for the construction of a medical facility is not suitable for 
that purpose, the Secretary may exchange such site for another 
site to be used for that purpose or may sell such site.
  (d)(1) The Secretary may provide for the acquisition of not 
more than three facilities for the provision of outpatient 
services or nursing home care through lease-purchase 
arrangements on real property under the jurisdiction of the 
Department of Veterans Affairs.
  (2)(A) In carrying out this subsection and notwithstanding 
any other provision of law, the Secretary may lease, with or 
without compensation and for a period of not to exceed 35 
years, to another party any of the real property described in 
paragraph (1) of this subsection.
  (B) Such real property shall be used as the site of a 
facility referred to in paragraph (1) of this subsection--
          (i) constructed and owned by the lessee of such real 
        property; and
          (ii) leased under paragraph (3)(A) of this subsection 
        to the Department for such use and for such other 
        activities as the Secretary determines are appropriate.
  (3)(A) The Secretary may enter into a lease for the use of 
any facility described in paragraph (2)(B) of this subsection 
for not more than 35 years under such terms and conditions as 
may be in the best interests of the Department.
  (B) Each agreement to lease a facility under subparagraph (A) 
of this paragraph shall include a provision that--
          (i) the obligation of the United States to make 
        payments under the agreement is subject to the 
        availability of appropriations for that purpose; and
          (ii) the ownership of such facility shall vest in the 
        United States at the end of such lease.
  (4)(A) The Secretary may sublease any space in such a 
facility to another party at a rate not less than--
          (i) the rental rate paid by the Secretary for such 
        space under paragraph (3) of this subsection; plus
          (ii) the amount the Secretary pays for the costs of 
        administering such facility (including operation, 
        maintenance, utility, and rehabilitation costs) which 
        are attributable to such space.
  (B) In any such sublease, the Secretary shall include such 
terms relating to default and nonperformance as the Secretary 
considers appropriate to protect the interests of the United 
States.
  (5) The Secretary shall use the receipts of any payment for 
the lease of real property under paragraph (2) for the payment 
of the lease of a facility under paragraph (3).
  (6) The authority to enter into an agreement under this 
subsection--
          (A) shall not take effect until the Secretary has 
        entered into agreements under section 316 of this title 
        to carry out at least three collocations; and
          (B) shall expire on October 1, 1993.
  (e)(1) In the case of any super construction project, the 
Secretary shall enter into an agreement with an appropriate 
non-Department Federal entity to provide full project 
management services for the super construction project, 
including management over the project design, acquisition, 
construction, and contract changes.
  (2) An agreement entered into under paragraph (1) with a 
Federal entity shall provide that the Secretary shall reimburse 
the Federal entity for all costs associated with the provision 
of project management services under the agreement.
  (3) In this subsection, the term ``super construction 
project'' means a project for the construction, alteration, or 
acquisition of a medical facility involving a total expenditure 
of more than $100,000,000.
  (f) To the maximum extent practicable, the Secretary shall 
use industry standards, standard designs, and best practices in 
carrying out the construction of medical facilities.
  [(g) The Secretary shall ensure that each employee of the 
Department with responsibilities, as determined by the 
Secretary, relating to the infrastructure construction or 
alteration of medical facilities, including such construction 
or alteration carried out pursuant to contracts or agreements, 
undergoes a program of ongoing professional training and 
development. Such program shall be designed to ensure that 
employees maintain adequate expertise relating to industry 
standards and best practices for the acquisition of design and 
construction services. The Secretary may provide the program 
under this subsection directly or through a contract or 
agreement with a non-Federal entity or with a non-Department 
Federal entity.]
  (g)(1)(A) Not later than September 30 of the fiscal year 
following the fiscal year during which the VA Asset and 
Infrastructure Review Act of 2018 is enacted, the Secretary 
shall implement the covered training curriculum and the covered 
certification program.
  (B) In designing and implementing the covered training 
curriculum and the covered certification program under 
paragraph (1), the Secretary shall use as models existing 
training curricula and certification programs that have been 
established under chapter 87 of title 10, United States Code, 
as determined relevant by the Secretary.
  (2) The Secretary may develop the training curriculum under 
paragraph (1)(A) in a manner that provides such training in any 
combination of--
          (A) training provided in person;
          (B) training provided over an internet website; or
          (C) training provided by another department or agency 
        of the Federal Government.
  (3) The Secretary may develop the certification program under 
paragraph (1)(A) in a manner that uses--
          (A) one level of certification; or
          (B) more than one level of certification, as 
        determined appropriate by the Secretary with respect to 
        the level of certification for different grades of the 
        General Schedule.
  (4) The Secretary may enter into a contract with an 
appropriate entity to provide the covered training curriculum 
and the covered certification program under paragraph (1)(A).
  (5)(A) Not later than September 30 of the second fiscal year 
following the fiscal year during which the VA Asset and 
Infrastructure Review Act of 2018 is enacted, the Secretary 
shall ensure that the majority of employees subject to the 
covered certification program achieve the certification or the 
appropriate level of certification pursuant to paragraph (3), 
as the case may be.
  (B) After carrying out subparagraph (A), the Secretary shall 
ensure that each employee subject to the covered certification 
program achieves the certification or the appropriate level of 
certification pursuant to paragraph (3), as the case may be, as 
quickly as practicable.
  (6) In this subsection:
          (A) The term ``covered certification program'' means, 
        with respect to employees of the Department of Veterans 
        Affairs who are members of occupational series relating 
        to construction or facilities management, or employees 
        of the Department who award or administer contracts for 
        major construction, minor construction, or nonrecurring 
        maintenance, including as contract specialists or 
        contracting officers' representatives, a program to 
        certify knowledge and skills relating to construction 
        or facilities management and to ensure that such 
        employees maintain adequate expertise relating to 
        industry standards and best practices for the 
        acquisition of design and construction services.
          (B) The term ``covered training curriculum'' means, 
        with respect to employees specified in subparagraph 
        (A), a training curriculum relating to construction or 
        facilities management.

Sec. 8104. Congressional approval of certain medical facility 
                    acquisitions

  (a)(1) The purpose of this subsection is to enable Congress 
to ensure the equitable distribution of medical facilities 
throughout the United States, taking into consideration the 
comparative urgency of the need for the services to be provided 
in the case of each particular facility.
  (2) No funds may be appropriated for any fiscal year, and the 
Secretary may not obligate or expend funds (other than for 
advance planning and design), for any major medical facility 
project or any major medical facility lease unless funds for 
that project or lease have been specifically authorized by law.
  [(3) For the purpose of this subsection:
          [(A) The term ``major medical facility project'' 
        means a project for the construction, alteration, or 
        acquisition of a medical facility involving a total 
        expenditure of more than $10,000,000, but such term 
        does not include an acquisition by exchange.
          [(B) The term ``major medical facility lease'' means 
        a lease for space for use as a new medical facility at 
        an average annual rental of more than $1,000,000.]
  (3) For purposes of this subsection, the term ``major medical 
facility project'' means a project for the construction, 
alteration, or acquisition of a medical facility involving a 
total expenditure of more than $20,000,000, but such term does 
not include an acquisition by exchange, non-recurring 
maintenance projects of the Department, or the construction, 
alteration, or acquisition of a shared Federal medical facility 
for which the Department's estimated share of the project costs 
does not exceed $20,000,000.
  (b) Whenever the President or the Secretary submit to the 
Congress a request for the funding of a major medical facility 
project (as defined in subsection (a)(3)(A)) or a major medical 
facility lease (as defined in subsection (a)(3)(B)), the 
Secretary shall submit to each committee, on the same day, a 
prospectus of the proposed medical facility. Any such 
prospectus shall include the following:
          (1) A detailed estimate of the total costs of the 
        medical facility to be constructed, altered, leased, or 
        otherwise acquired under this subchapter, including a 
        description of the location of such facility and, in 
        the case of a prospectus proposing the construction of 
        a new or replacement medical facility, a detailed 
        report of the consideration that was given to acquiring 
        an existing facility by lease or purchase and to the 
        sharing of health-care resources with the Department of 
        Defense under section 8111 of this title. Such detailed 
        estimate shall include an identification of each of the 
        following:
                  (A) Total construction costs.
                  (B) Activation costs.
                  (C) Special purpose alterations (lump-sum 
                payment) costs.
                  (D) Number of personnel.
                  (E) Total costs of ancillary services, 
                equipment, and all other items.
          (2) Demographic data applicable to such facility, 
        including information on projected changes in the 
        population of veterans to be served by the facility 
        over a five-year period, a ten-year period, and a 
        twenty-year period.
          (3) Current and projected workload and utilization 
        data regarding the facility, including information on 
        projected changes in workload and utilization over a 
        five-year period, a ten-year period, and a twenty-year 
        period.
          (4) Projected operating costs of the facility, 
        including both recurring and non-recurring costs 
        (including and identifying both recurring and non-
        recurring costs (including activation costs and total 
        costs of ancillary services, equipment and all other 
        items)) over a five-year period, a ten-year period, and 
        a twenty-year period.
          (5) The priority score assigned to the project or 
        lease under the Department's prioritization methodology 
        and, if the project or lease is being proposed for 
        funding before a project or lease with a higher score, 
        a specific explanation of the factors other than the 
        priority score that were considered and the basis on 
        which the project or lease is proposed for funding 
        ahead of projects or leases with higher priority 
        scores.
          (6) In the case of a prospectus proposing the 
        construction of a new or replacement medical facility, 
        each of the following:
                  (A) A detailed estimate of the total costs 
                (including total construction costs, activation 
                costs, special purpose alterations (lump-sum 
                payment) costs, number of personnel and total 
                costs of ancillary services, equipment and all 
                other items) for each alternative to 
                construction of the facility that was 
                considered.
                  (B) A comparison of total costs to total 
                benefits for each such alternative.
                  (C) An explanation of why the preferred 
                alternative is the most effective means to 
                achieve the stated project goals and the most 
                cost-effective alternative.
          (7) In the case of a prospectus proposing funding for 
        a major medical facility lease, a detailed analysis of 
        how the lease is expected to comply with Office of 
        Management and Budget Circular A-11 and section 1341 of 
        title 31 (commonly referred to as the ``Anti-Deficiency 
        Act''). Any such analysis shall include--
                  (A) an analysis of the classification of the 
                lease as a ``lease-purchase'', ``capital 
                lease'', or ``operating lease'' as those terms 
                are defined in Office of Management and Budget 
                Circular A-11;
                  (B) an analysis of the obligation of 
                budgetary resources associated with the lease; 
                and
                  (C) an analysis of the methodology used in 
                determining the asset cost, fair market value, 
                and cancellation costs of the lease.
  (c)(1) Not less than 30 days before obligating funds for a 
major medical facility project approved by a law described in 
subsection (a)(2) of this section in an amount that would cause 
the total amount obligated for that project to exceed the 
amount specified in the law for that project (or would add to 
total obligations exceeding such specified amount) by more than 
10 percent, the Secretary shall provide the committees with 
notice of the Secretary's intention to do so and the reasons 
for the specified amount being exceeded.
  (2) The Secretary shall--
          (A) enter into a contract or agreement with an 
        appropriate non-department Federal entity with the 
        ability to conduct forensic audits on medical facility 
        projects for the conduct of an external forensic audit 
        of the expenditures relating to any major medical 
        facility or super construction project for which the 
        total expenditures exceed the amount requested in the 
        initial budget request for the project submitted to 
        Congress under section 1105 of title 31 by more than 25 
        percent; and
          (B) enter into a contract or agreement with an 
        appropriate non-department Federal entity with the 
        ability to conduct forensic audits on medical facility 
        projects for the conduct of an external audit of the 
        medical center construction project in Aurora, 
        Colorado.
  (d)(1) Except as provided in paragraph (2), in any case in 
which the Secretary proposes that funds be used for a purpose 
other than the purpose for which such funds were appropriated, 
the Secretary shall promptly notify each committee, in writing, 
of the particulars involved and the reasons why such funds were 
not used for the purpose for which appropriated.
  (2)(A) In any fiscal year, unobligated amounts in the 
Construction, Major Projects account that are a direct result 
of bid savings from a major construction project may only be 
obligated for major construction projects authorized for that 
fiscal year or a previous fiscal year.
  (B) Whenever the Secretary obligates amounts for a major 
construction project under subparagraph (A), the Secretary 
shall submit to the Committee on Veterans' Affairs and the 
Committee on Appropriations of the Senate and the Committee on 
Veterans' Affairs and the Committee on Appropriations of the 
House of Representatives notice of the following:
          (i) The major construction project that is the source 
        of the bid savings.
          (ii) If the major construction project that is the 
        source of the bid savings is not complete--
                  (I) the amount already obligated by the 
                Department or available in the project reserve 
                for such project;
                  (II) the percentage of such project that has 
                been completed; and
                  (III) the amount available to the Department 
                to complete such project.
          (iii) The other major construction project for which 
        the bid savings amounts are being obligated.
          (iv) The bid savings amounts being obligated for such 
        other major construction project.
  (C) The Secretary may not obligate an amount under 
subparagraph (A) to expand the purpose of a major construction 
project except pursuant to a provision of law enacted after the 
date on which the Secretary submits to the committees described 
in subparagraph (B) notice of the following:
          (i) The major construction project that is the source 
        of the bid savings.
          (ii) The major construction project for which the 
        Secretary intends to expand the purpose.
          (iii) A description of such expansion of purpose.
          (iv) The amounts the Secretary intends to obligate to 
        expand the purpose.
  (e) The Secretary may accept gifts or donations for any of 
the purposes of this subchapter.
  (f) The Secretary may not obligate funds in an amount in 
excess of $500,000 from the Advance Planning Fund of the 
Department toward design or development of a major medical 
facility project (as defined in subsection (a)(3)(A)) until--
          (1) the Secretary submits to the committees a report 
        on the proposed obligation; and
          (2) a period of 30 days has passed after the date on 
        which the report is received by the committees.
  (g) The limitation in subsection (f) does not apply to a 
project for which funds have been authorized by law in 
accordance with subsection (a)(2).
  (h)(1) Not less than 30 days before entering into a major 
medical facility lease, the Secretary shall submit to the 
Committees on Veterans' Affairs of the Senate and the House of 
Representatives--
          (A) notice of the Secretary's intention to enter into 
        the lease;
          (B) a detailed summary of the proposed lease;
          (C) a description and analysis of any differences 
        between the prospectus submitted pursuant to subsection 
        (b) and the proposed lease; and
          (D) a scoring analysis demonstrating that the 
        proposed lease fully complies with Office of Management 
        and Budget Circular A-11.
  (2) Each committee described in paragraph (1) shall ensure 
that any information submitted to the committee under such 
paragraph is treated by the committee with the same level of 
confidentiality as is required by law of the Secretary and 
subject to the same statutory penalties for unauthorized 
disclosure or use as the Secretary.
  (3) Not more than 30 days after entering into a major medical 
facility lease, the Secretary shall submit to each committee 
described in paragraph (1) a report on any material differences 
between the lease that was entered into and the proposed lease 
described under such paragraph, including how the lease that 
was entered into changes the previously submitted scoring 
analysis described in subparagraph (D) of such paragraph.

           *       *       *       *       *       *       *


     SUBCHAPTER IV--SHARING OF MEDICAL FACILITIES, EQUIPMENT, AND 
INFORMATION

           *       *       *       *       *       *       *



Sec. 8159. Authority to pay for services authorized but not subject to 
                    an agreement

  (a) In General.--If, in the course of furnishing hospital 
care, a medical service, or an extended care service authorized 
by the Secretary and pursuant to a contract, agreement, or 
other arrangement with the Secretary, a provider who is not a 
party to the contract, agreement, or other arrangement 
furnishes hospital care, a medical service, or an extended care 
service that the Secretary considers necessary, the Secretary 
may compensate the provider for the cost of such care or 
service.
  (b) New Contracts and Agreements.--The Secretary shall take 
reasonable efforts to enter into a contract, agreement, or 
other arrangement with a provider described in subsection (a) 
to ensure that future care and services authorized by the 
Secretary and furnished by the provider are subject to such a 
contract, agreement, or other arrangement.

SUBCHAPTER V--ENHANCED-USE LEASES OF REAL PROPERTY

           *       *       *       *       *       *       *



Sec. 8162. Enhanced-use leases

  (a)(1) The Secretary may in accordance with this subchapter 
enter into leases with respect to real property that is under 
the jurisdiction or control of the Secretary. Any such lease 
under this subchapter may be referred to as an ``enhanced-use 
lease''. The Secretary may dispose of any such property that is 
leased to another party under this subchapter in accordance 
with section 8164 of this title. The Secretary may exercise the 
authority provided by this subchapter notwithstanding section 
8122 of this title, subchapter II of chapter 5 of title 40, 
sections 541-555 and 1302 of title 40, or any other provision 
of law (other than Federal laws relating to environmental and 
historic preservation) inconsistent with this section. The 
applicability of this subchapter to section 421(b) of the 
Veterans' Benefits and Services Act of 1988 (Public Law 100-
322; 102 Stat. 553) is covered by subsection (c).
  (2) The Secretary may enter into an enhanced-use lease only 
for the provision of supportive housing and if the lease is not 
inconsistent with and will not adversely affect the mission of 
the Department.
  (3) The provisions of sections 3141-3144, 3146, and 3147 of 
title 40 shall not, by reason of this section, become 
inapplicable to property that is leased to another party under 
an enhanced-use lease.
  (4) A property that is leased to another party under an 
enhanced-use lease may not be considered to be unutilized or 
underutilized for purposes of section 501 of the McKinney-Vento 
Homeless Assistance Act (42 U.S.C. 11411).
  (b)(1) If the Secretary has determined that a property should 
be leased to another party through an enhanced-use lease, the 
Secretary shall, at the Secretary's discretion, select the 
party with whom the lease will be entered into using such 
selection procedures as the Secretary considers appropriate.
  (2) The term of an enhanced-use lease may not exceed 75 
years.
  (3)(A) For any enhanced-use lease entered into by the 
Secretary, the lease consideration provided to the Secretary 
shall consist solely of cash at fair value as determined by the 
Secretary.
  (B) The Secretary shall receive no other type of 
consideration for an enhanced-use lease besides cash.
  (C) The Secretary may enter into an enhanced-use lease 
without receiving consideration.
  (D) The Secretary may not waive or postpone the obligation of 
a lessee to pay any consideration under an enhanced-use lease, 
including monthly rent.
  (4) The terms of an enhanced-use lease may provide for the 
Secretary to use minor construction funds for capital 
contribution payments.
  (5) The terms of an enhanced-use lease may not provide for 
any acquisition, contract, demonstration, exchange, grant, 
incentive, procurement, sale, other transaction authority, 
service agreement, use agreement, lease, or lease-back by the 
Secretary or Federal Government.
  [(6) The Secretary may not enter into an enhanced-use lease 
without certification in advance in writing by the Director of 
the Office of Management and Budget that such lease complies 
with the requirements of this subchapter.]
  (6) The Office of Management and Budget shall review each 
enhanced-use lease before the lease goes into effect to 
determine whether the lease is in compliance with paragraph 
(5).
  (c) The entering into an enhanced-use lease covering any land 
or improvement described in section 421(b)(2) of the Veterans' 
Benefits and Services Act of 1988 (Public Law 100-322; 102 
Stat. 553) or section 224(a) of the Military Construction and 
Veterans Affairs and Related Agencies Appropriations Act, 2008, 
other than an enhanced-use lease under the Los Angeles Homeless 
Veterans Leasing Act of 2016, shall be considered to be 
prohibited by such sections unless specifically authorized by 
law.
  (d)(1) Nothing in this subchapter authorizes the Secretary to 
enter into an enhanced-use lease that provides for, is 
contingent upon, or otherwise authorizes the Federal Government 
to guarantee a loan made by a third party to a lessee for 
purposes of the enhanced-use lease.
  (2) Nothing in this subchapter shall be construed to abrogate 
or constitute a waiver of the sovereign immunity of the United 
States with respect to any loan, financing, or other financial 
agreement entered into by the lessee and a third party relating 
to an enhanced-use lease.

           *       *       *       *       *       *       *

                              ----------                              


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).
          [(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.]
  (p) Authority To Furnish Care and Services.--The Secretary 
may not use the authority under this section to furnish care 
and services after the date that is one year after the date of 
the enactment of the Caring for Our Veterans Act of 2018.
  (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 VII--OTHER VETERANS MATTERS

           *       *       *       *       *       *       *


SEC. 705. LIMITATION ON AWARDS AND BONUSES PAID TO EMPLOYEES OF 
                    DEPARTMENT OF VETERANS AFFAIRS.

  (a) Limitation.--The Secretary of Veterans Affairs shall 
ensure that the aggregate amount of awards and bonuses paid by 
the Secretary in a fiscal year under chapter 45 or 53 of title 
5, United States Code, or any other awards or bonuses 
authorized under such title or title 38, United States Code, 
does not exceed the following amounts:
          (1) With respect to each of fiscal years 2017 through 
        2018, [$230,000,000] $250,000,000, of which not less 
        than $20,000,000 shall be for recruitment, relocation, 
        and retention bonuses.
          (2) With respect to each of fiscal years 2019 through 
        2021, [$225,000,000] $290,000,000, of which not less 
        than $20,000,000 shall be for recruitment, relocation, 
        and retention bonuses.
          (3) With respect to each of fiscal years 2022 through 
        2024, $360,000,000.
  (b) Sense of Congress.--It is the sense of Congress that the 
limitation under subsection (a) should not disproportionately 
impact lower-wage employees and that the Department of Veterans 
Affairs is encouraged to use bonuses to incentivize high-
performing employees in areas in which retention is 
challenging.

           *       *       *       *       *       *       *


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)] in paragraphs (3) and (4), 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.
          (4) Permanent authority for other uses.--Beginning on 
        March 1, 2019, amounts remaining in the Veterans Choice 
        Fund may be used to furnish hospital care, medical 
        services, and extended care services 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. Such amounts shall be 
        available in addition to amounts available in other 
        appropriations accounts for such purposes.
  (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)] to paragraphs (3) and (4) of 
        subsection (c) 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.

           *       *       *       *       *       *       *

                              ----------                              


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,
          (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.

           *       *       *       *       *       *       *

                              ----------                              


     SECTION 104 OF THE VETERANS' BENEFITS IMPROVEMENTS ACT OF 1994


SEC. 104. DEVELOPMENT OF MEDICAL EVALUATION PROTOCOL.

  (a) Uniform Medical Evaluation Protocol.--(1) The Secretary 
of Veterans Affairs shall develop and implement a uniform and 
comprehensive medical evaluation protocol that will ensure 
appropriate medical assessment, diagnosis, and treatment of 
Persian Gulf War veterans who are suffering from illnesses the 
origins of which are (as of the date of the enactment of this 
Act) unknown and that may be attributable to service in the 
Southwest Asia theater of operations during the Persian Gulf 
War. The protocol shall include an evaluation of complaints 
relating to illnesses involving the reproductive system.
  (2) If such a protocol is not implemented before the end of 
the 120-day period beginning on the date of the enactment of 
this Act, the Secretary shall, before the end of such period, 
submit to the Committees on Veterans' Affairs of the Senate and 
House of Representatives a report as to why such a protocol has 
not yet been developed.
  (3)(A) The Secretary shall ensure that the evaluation under 
the protocol developed under this section is available at all 
Department medical centers that have the capability of 
providing the medical assessment, diagnosis, and treatment 
required under the protocol.
  (B) The Secretary may enter into contracts with non-
Department medical facilities for the provision of the 
evaluation under the protocol.
  (C) In the case of a veteran whose residence is distant from 
a medical center described in subparagraph (A), the Secretary 
may provide the evaluation through a Department medical center 
described in that subparagraph and, in such a case, may provide 
the veteran the travel and incidental expenses therefor 
pursuant to the provisions of section 111 of title 38, United 
States Code.
  (4)(A) If the Secretary is unable to diagnose the symptoms or 
illness of a veteran provided an evaluation, or if the symptoms 
or illness of a veteran do not respond to treatment provided by 
the Secretary, the Secretary may use the authority [in section 
1703] in sections 1703A, 8111, and 8153 of title 38, United 
States Code, in order to provide for the veteran to receive 
diagnostic tests or treatment at a non-Department medical 
facility that may have the capability of diagnosing or treating 
the symptoms or illness of the veteran. The Secretary may 
provide the veteran the travel and incidental expenses therefor 
pursuant to the provisions of section 111 of title 38, United 
States Code.
  (B) The Secretary shall request from each non-Department 
medical facility that examines or treats a veteran under this 
paragraph such information relating to the diagnosis or 
treatment as the Secretary considers appropriate.
  (5) In each year after the implementation of the protocol, 
the Secretary shall enter into an agreement with the National 
Academy of Sciences under which agreement appropriate experts 
shall review the adequacy of the protocol and its 
implementation by the Department of Veterans Affairs.
  (b) Relationship to Other Comprehensive Clinical Evaluation 
Protocols.--The Secretary, in consultation with the Secretary 
of Defense, shall ensure that the information collected through 
the protocol described in this section is collected and 
maintained in a manner that permits the effective and efficient 
cross-reference of that information with information collected 
and maintained through the comprehensive clinical protocols of 
the Department of Defense for Persian Gulf War veterans.
  (c) Case Definitions and Diagnoses.--The Secretary shall 
develop case definitions or diagnoses for illnesses associated 
with the service described in subsection (a)(1). The Secretary 
shall develop such definitions or diagnoses at the earliest 
possible date.
                              ----------                              


CAREGIVERS AND VETERANS OMNIBUS HEALTH SERVICES ACT OF 2010

           *       *       *       *       *       *       *



                       TITLE I--CAREGIVER SUPPORT

SEC. 101. ASSISTANCE AND SUPPORT SERVICES FOR CAREGIVERS.

  (a) Assistance and Support Services.--
          (1) (Amendatory-Omitted)
          (2) (Amendatory-Omitted)
          (3) Effective date.--
                  (A) In General.--The amendments made by this 
                subsection shall take effect on the date that 
                is 270 days after the date of the enactment of 
                this Act.
                  (B) Implementation.--The Secretary of 
                Veterans Affairs shall commence the programs 
                required by subsections (a) and (b) of section 
                1720G of title 38, United States Code, as added 
                by paragraph (1) of this subsection, on the 
                date on which the amendments made by this 
                subsection take effect.
  (b) Implementation Plan and Report.--
          (1) In General.--Not later than 180 days after the 
        date of the enactment of this Act, the Secretary of 
        Veterans Affairs shall--
                  (A) develop a plan for the implementation of 
                the program of comprehensive assistance for 
                family caregivers required by section 
                1720G(a)(1) of title 38, United States Code, as 
                added by subsection (a)(1) of this section; and
                  (B) submit to the Committee on Veterans' 
                Affairs of the Senate and the Committee on 
                Veterans' Affairs of the House of 
                Representatives a report on such plan.
          (2) Consultation.--In developing the plan required by 
        paragraph (1)(A), the Secretary shall consult with the 
        following:
                  (A) Individuals described in section 
                1720G(a)(2) of title 38, United States Code, as 
                added by subsection (a)(1) of this section.
                  (B) Family members of such individuals who 
                provide personal care services to such 
                individuals.
                  (C) The Secretary of Defense with respect to 
                matters concerning personal care services for 
                members of the Armed Forces undergoing medical 
                discharge from the Armed Forces who are 
                eligible to benefit from personal care services 
                furnished under the program of comprehensive 
                assistance required by section 1720G(a)(1) of 
                such title, as so added.
                  (D) Veterans service organizations, as 
                recognized by the Secretary for the 
                representation of veterans under section 5902 
                of such title.
                  (E) National organizations that specialize in 
                the provision of assistance to individuals with 
                the types of disabilities that family 
                caregivers will encounter while providing 
                personal care services under the program of 
                comprehensive assistance required by section 
                1720G(a)(1) of such title, as so added.
                  (F) National organizations that specialize in 
                provision of assistance to family members of 
                veterans who provide personal care services to 
                such veterans.
                  (G) Such other organizations with an interest 
                in the provision of care to veterans and 
                assistance to family caregivers as the 
                Secretary considers appropriate.
          (3) Report contents.--The report required by 
        paragraph (1)(B) shall contain the following:
                  (A) The plan required by paragraph (1)(A).
                  (B) A description of the individuals, 
                caregivers, and organizations consulted by the 
                Secretary of Veterans Affairs under paragraph 
                (2).
                  (C) A description of such consultations.
                  (D) The recommendations of such individuals, 
                caregivers, and organizations, if any, that 
                were not adopted and incorporated into the plan 
                required by paragraph (1)(A), and the reasons 
                the Secretary did not adopt such 
                recommendations.
  (c) Annual Evaluation Report.--
          (1) In General.--Not later than 2 years after the 
        date described in subsection (a)(3)(A) and annually 
        thereafter, 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 
        comprehensive report on the implementation of section 
        1720G of title 38, United States Code, as added by 
        subsection (a)(1).
          (2) Contents.--The report required by paragraph (1) 
        shall include the following:
                  (A) With respect to the program of 
                comprehensive assistance for family caregivers 
                required by subsection (a)(1) of such section 
                1720G and the program of general caregiver 
                support services required by subsection (b)(1) 
                of such section--
                          (i) the number of caregivers that 
                        received assistance under such 
                        programs;
                          (ii) the cost to the Department of 
                        providing assistance under such 
                        programs;
                          (iii) a description of the outcomes 
                        achieved by, and any measurable 
                        benefits of, carrying out such 
                        programs;
                          (iv) an assessment of the 
                        effectiveness and the efficiency of the 
                        implementation of such programs, 
                        including a description of any barriers 
                        to accessing and receiving care and 
                        services under such programs; and
                          (v) such recommendations, including 
                        recommendations for legislative or 
                        administrative action, as the Secretary 
                        considers appropriate in light of 
                        carrying out such programs.
                  (B) With respect to the program of 
                comprehensive assistance for family caregivers 
                required by such subsection (a)(1)--
                          (i) a description of the outreach 
                        activities carried out by the Secretary 
                        under such program[; and];
                          (ii) an assessment of the manner in 
                        which resources are expended by the 
                        Secretary under such program, 
                        particularly with respect to the 
                        provision of monthly personal caregiver 
                        stipends under paragraph (3)(A)(ii)(v) 
                        of such subsection (a)[.]; and
                          (iii) an evaluation of the 
                        sufficiency and consistency of the 
                        training provided to family caregivers 
                        under such program in preparing family 
                        caregivers to provide care to veterans 
                        under such program.
                  (C) With respect to the provision of general 
                caregiver support services required by such 
                subsection (b)(1)--
                          (i) a summary of the support services 
                        made available under the program;
                          (ii) the number of caregivers who 
                        received support services under the 
                        program;
                          (iii) the cost to the Department of 
                        providing each support service provided 
                        under the program; and
                          (iv) such other information as the 
                        Secretary considers appropriate.
  (d) Report on Expansion of Family Caregiver Assistance.--
          (1) In general.--Not later than 2 years after the 
        date described in subsection (a)(3)(A), 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 
        feasibility and advisability of expanding the provision 
        of assistance under section 1720G(a) of title 38, 
        United States Code, as added by subsection (a)(1), to 
        family caregivers of veterans who have a serious injury 
        incurred or aggravated in the line of duty in the 
        active military, naval, or air service before September 
        11, 2001.
          (2) Recommendations.--The report required by 
        paragraph (1) shall include such recommendations as the 
        Secretary considers appropriate with respect to the 
        expansion described in such paragraph.

           *       *       *       *       *       *       *


                            DISSENTING VIEWS

    The Minority offers the following dissenting views for H.R. 
5674, VA Maintaining Internal Systems and Strengthening Outside 
Networks (MISSION) Act of 2018:
    This Committee, along with our Senate counterparts, have 
spent the better part of this Congress outlining how to 
consolidate the Department of Veterans Affairs' (VA) seven 
community care programs, all with different eligibility 
criteria and payment rates, into a single, consolidated, easy 
to use and administer program. The policy outlined in H.R. 5674 
is the result of that hard work. While the Minority largely 
agrees with said policy, we do have concerns.
    Overall, the Minority is pleased that moving forward all 
community care will be funded using discretionary dollars. 
However, we are concerned the coming fiscal cliff could 
catastrophically jeopardize VA's ability to continue providing 
care and services to our nation's veterans.
    Ranking Member Walz offered an amendment that would 
consider the authorization of appropriations in H.R. 5674 as a 
change in the concepts and definitions in section 251(b)(1) of 
the Balanced Budget and Emergency Deficit Control Act of 1985 
(2 U.S.C. Sec. 901(b)(1)). This Change in Concepts and 
Definitions, opposed by the Majority, is vital to ensuring the 
mandatory costs in H.R. 5674 that are shifted to discretionary 
costs will be covered with an adjustment to discretionary 
appropriations levels that are specified for those 
authorizations of appropriations. Without this language 
covering the costs within the current caps established by the 
Bipartisan Budget Act (P.L. 115-123) will be difficult if not 
impossible. Without the inclusion of this language this bill is 
setting up a situation where the cost of the Community Care 
program will exhaust its funds in the middle of FY 2019 and 
force VA to cannibalize itself to meet the needs of this 
program.
    President Trump's VA budget already proposed spending half 
of the $4 billion increase in VA's budget caps under the 
Bipartisan Budget Act deal on community care instead of VA's 
infrastructure--a violation of the deal. The $4 billion cap 
increase for VA under the Bipartisan Budget Act deal was for 
addressing VA's significant infrastructure needs. Without a 
change in concepts and definitions, this bill will renege on 
that deal as VA would be forced to find the funds under the 
caps (to prevent triggering across the board cuts under 
sequestration) to pay for community care.
    Passing this bill without the change in the concepts and 
definitions would amount to an unfunded mandate that would 
force cuts to VA programs, including medical services provided 
by VA providers, VA research, and maintenance and construction 
for VA medical facilities. The significant costs associated 
with sending veterans to the private sector for care under this 
program could also require significant cuts to other non-
defense discretionary programs such as veterans homelessness 
programs like HUD-VASH, veteran treatment courts, and veteran 
job training and employment assistance programs administered by 
other federal agencies. Without the change in concepts and 
definitions language, veterans and their families would be 
affected by these cuts, while more and more health care is 
administered by private providers.
    Furthermore, given the budgetary concerns outlined above 
and the substantial preliminary score that accompanied HR 5674, 
nearly $51 billion over five years, the minority is concerned 
that certain provisions in this bill will become unfunded 
mandates giving veterans a false promise. In some instances, 
these veterans have been waiting for nearly a decade to receive 
parity in services. It would be unconscionable to not deliver 
on those pledges following implementation of this legislation. 
Restricting eligibility should not be used as a pay for in the 
future. Time and again the Minority has opposed robbing Peter 
to pay Paul and in this instance the Administration would seek 
to rob Paul to pay Paul. That is simply unacceptable.
    At the time of writing these views, VA does not have a 
permanent Secretary, Undersecretary for Health or a Deputy 
Undersecretary for Health for Community Care. The Minority is 
troubled the lack of permanent leadership at VA will have a 
detrimental effect on the Department's ability to implement 
such a large piece of complex legislation. Without permanent 
leadership in place, Congress will not have anyone to hold 
accountable as VA undertakes the monumental task of 
consolidating multiple community care programs into a single 
multi-billion dollar a year program funded with taxpayer money. 
If history at this agency has taught us anything, interim and 
acting officials generally do not own the issue or problem. 
Instead they simply seek to maintain the status quo until a 
successor can be named. Given the task at hand, that would be a 
disaster. The Minority implores the administration to name 
permanent leadership in these roles as quickly as possible. The 
task ahead is too important.
    In addition, the eligibility criteria laid out in HR 5674 
for the new Veterans Community Care Program are complex, 
arguably more so then the current Veterans Choice Program, and 
in some instances nuanced, which will require careful oversight 
by this Committee to ensure accurate interpretation as 
regulations are written and policies and procedures are 
implemented. For example, while the Committee failed to adopt 
an amendment by Representative Brownley at the May 8, 2018 
markup that sought to explicitly indicate traffic should be 
considered an ``environmental factor'' providers and veterans 
should consider as they determine whether a veteran would be 
best placed to receive care at a VA facility or in the 
community, the Minority expects as VA writes regulations 
related to this topic that they would allow traffic to be a 
consideration under ``environmental factor''. During the 
markup, Chairman Roe indicated he agreed with the premise but 
had been limited in his ability to support the amendment due to 
a preexisting deal he had with Ranking Member Walz regarding 
the broader legislation.
    Finally, while the Commission on Care recommended a Base 
Realignment and Closure (BRAC)-like review was needed for VA, 
declaring it would, ``offer a level of rigor far beyond what 
currently exists for repurposing and selling capital 
assets''\1\, we are not convinced such a model is entirely 
appropriate in the case of VA. That being said, the Minority is 
not opposed to the concept of realigning VA's capital assets to 
right-size the agency. To the contrary. We believe that process 
is long overdue.
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    \1\Commission on Care, page 60, June 30, 2016, ``Commission on Care 
Final Report,'' https://s3.amazonlaws.com/sitesusa/wp-content/uploads/
sites/912/2016/07/Commission-on-Care_Final-Report_0630_16_FOR-WEB.pdf.
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    The Minority would like to express their appreciation to 
the Majority for working with us to remedy some of the specific 
concerns we had related to the Commission and its process. 
However, we remain concerned that Title II does not provide the 
Secretary enough tools and authorities on the front end of the 
process as he or she makes their recommendations to the 
Commission. For example, Minority staff had advocated for 
inclusion of provisions that would have provided the Secretary 
the authority to enter into more public-private partnerships 
and the ability to enter into agreements or contracts with the 
Secretary of Health and Human Services for mutually beneficial 
coordination, use or exchange of health care resources between 
VA and the Public Health Service which would give the Secretary 
additional options to consider as they drafted recommendations 
to the Commission.
                                                   Timothy J. Walz.

                                 [all]