Ҥ 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 2 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.”
“1703. Veterans Community Care Program.”.
Ҥ 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 6 months within the first 2 years of its taking effect, and not less frequently than once every 4 years thereafter.
“(ii) If a Veterans Care Agreement has not been in effect for at least 6 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 2 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.”
“1703A. Agreements with eligible entities or providers; certification processes.”.
“(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’).”
Ҥ 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 3 years after the date on which the Secretary establishes access standards under subsection (a) and not less frequently than once every 3 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.
Ҥ 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 2-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 1 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 2 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.”
“1703B. Access standards.
“1703C. Standards for quality.”.
Ҥ 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 1 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.”
“1725A. Access to walk-in care.”.
Ҥ 7330C. Quadrennial Veterans Health Administration review
“(a) Market Area Assessments.—
(1) Not less frequently than every 4 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 1 year after the date of the enactment of the Caring for Our Veterans Act of 2018 and not less frequently than once every 4 years thereafter, the Secretary shall submit to the appropriate committees of Congress a strategic plan that specifies a 4-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 2-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.”
“7330C. Quadrennial Veterans Health Administration review.”.
Ҥ 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.”
“1706A. Remediation of medical service lines.”.
Ҥ 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.”
“1703D. Prompt payment standard.”.
Ҥ 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.”
“8159. Authority to pay for services authorized but not subject to an agreement.”.
“(D) that is incurred by an individual who is entitled to care (or payment of the expenses of care) under a health-plan contract.”
“(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’).”
Ҥ 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.”
“1730B. Access to State prescription drug monitoring programs.”.
“(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.”
; and
“(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 1 year after the date of the enactment of the Caring for Our Veterans Act of 2018.”
Ҥ 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.”
“1730C. Licensure of health care professionals providing treatment via telemedicine.”.
Ҥ 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);
“(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 5 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 on a request for waiver that describes 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) The waiver requested by the Secretary under paragraph (2) shall be considered approved under this paragraph if there is enacted into law a joint resolution approving such request in its entirety.
“(C) For purposes of this paragraph, the term ‘joint resolution’ means only a joint resolution which is introduced within the period of five legislative days beginning on the date on which the Secretary transmits the report to the Congress under such paragraph (2), and—
“(i) which does not have a preamble; and
“(ii) the matter after the resolving clause of which is as follows: ‘that Congress approves the request for a waiver under section 1703E(f) of title 38, United States Code, as submitted by the Secretary on ＿＿＿’, the blank space being filled with the appropriate date.
“(D)
(i) Any committee of the House of Representatives to which a joint resolution is referred shall report it to the House without amendment not later than 15 legislative days after the date of introduction thereof. If a committee fails to report the joint resolution within that period, the committee shall be discharged from further consideration of the joint resolution.
“(ii) It shall be in order at any time after the third legislative day after each committee authorized to consider a joint resolution has reported or has been discharged from consideration of a joint resolution, to move to proceed to consider the joint resolution in the House. All points of order against the motion are waived. Such a motion shall not be in order after the House has disposed of a motion to proceed on a joint resolution addressing a particular submission. The previous question shall be considered as ordered on the motion to its adoption without intervening motion. The motion shall not be debatable. A motion to reconsider the vote by which the motion is disposed of shall not be in order.
“(iii) The joint resolution shall be considered as read. All points of order against the joint resolution and against its consideration are waived. The previous question shall be considered as ordered on the joint resolution to its passage without intervening motion except two hours of debate equally divided and controlled by the proponent and an opponent. A motion to reconsider the vote on passage of the joint resolution shall not be in order.
“(E)
(i) A joint resolution introduced in the Senate shall be referred to the Committee on Veterans’ Affairs.
“(ii) Any committee of the Senate to which a joint resolution is referred shall report it to the Senate without amendment not later than 15 session days after the date of introduction of a joint resolution described in paragraph (C). If a committee fails to report the joint resolution within that period, the committee shall be discharged from further consideration of the joint resolution and the joint resolution shall be placed on the calendar.
“(iii)
(I) Notwithstanding Rule XXII of the Standing Rules of the Senate, it is in order at any time after the third session day on which the Committee on Veterans’ Affairs has reported or has been discharged from consideration of a joint resolution described in paragraph (C) (even though a previous motion to the same effect has been disagreed to) to move to proceed to the consideration of the joint resolution, and all points of order against the joint resolution (and against consideration of the joint resolution) are waived. The motion to proceed is not debatable. The motion is not subject to a motion to postpone. A motion to reconsider the vote by which the motion is agreed to or disagreed to shall not be in order. If a motion to proceed to the consideration of the resolution is agreed to, the joint resolution shall remain the unfinished business until disposed of.
“(II) Consideration of the joint resolution, and on all debatable motions and appeals in connection therewith, shall be limited to not more than two hours, which shall be divided equally between the majority and minority leaders or their designees. A motion further to limit debate is in order and not debatable. An amendment to, or a motion to postpone, or a motion to proceed to the consideration of other business, or a motion to recommit the joint resolution is not in order.
“(III) If the Senate has voted to proceed to a joint resolution, the vote on passage of the joint resolution shall occur immediately following the conclusion of consideration of the joint resolution, and a single quorum call at the conclusion of the debate if requested in accordance with the rules of the Senate.
“(IV) Appeals from the decisions of the Chair relating to the application of the rules of the Senate, as the case may be, to the procedure relating to a joint resolution shall be decided without debate.
“(F) A joint resolution considered pursuant to this paragraph shall not be subject to amendment in either the House of Representatives or the Senate.
“(G)
(i) If, before the passage by one House of the joint resolution of that House, that House receives the joint resolution from the other House, then the following procedures shall apply:
“(I) The joint resolution of the other House shall not be referred to a committee.
“(II) With respect to the joint resolution of the House receiving the joint resolution—
“(aa) the procedure in that House shall be the same as if no joint resolution had been received from the other House; but
“(bb) the vote on passage shall be on the joint resolution of the other House.
“(ii) If the Senate fails to introduce or consider a joint resolution under this paragraph, the joint resolution of the House shall be entitled to expedited floor procedures under this subparagraph.
“(iii) If, following passage of the joint resolution in the Senate, the Senate then receives the companion measure from the House of Representatives, the companion measure shall not be debatable.
“(H) This subparagraph is enacted by Congress—
“(i) as an exercise of the rulemaking power of the Senate and House of Representatives, respectively, and as such it is deemed a part of the rules of each House, respectively, but applicable only with respect to the procedure to be followed in that House in the case of a joint resolution, and it supersedes other rules only to the extent that it is inconsistent with such rules; and
“(ii) with full recognition of the constitutional right of either House to change the rules (so far as relating to the procedure 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.
“(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.”
“1703E. Center for Innovation for Care and Payment.”.
Ҥ 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.”
“1788. Transplant procedures with live donors and related services.”.
“(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 2-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 2 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”
“(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”
“(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.”
“(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.”
“(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.”
“(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) 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.”
“(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.”