# VA Maintaining Internal Systems and Strengthening Integrated Outside Networks Act of 2018 (VA MISSION Act; P.L.115-182)

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URL: https://www.frixlaw.com/law-library/documents/crs%3AR45390

## Record

- **Collection:** Congressional research report
- **Document type:** CRS Report
- **Published:** November 1, 2018
- **Citation:** R45390

## Text

VA Maintaining Internal Systems and
Strengthening Integrated Outside Networks
Act of 2018 (VA MISSION Act; P.L.115-182)
(name redacted), Coordinator
Specialist in Veterans Policy
(name redacted)
Specialist in Health and Aging Policy
(name redacted)
Analyst in Health Policy
(name redacted)
Specialist in American National Government
(name redacted)
Specialist in Health Services
Updated November 1, 2018

Congressional Research Service
7-....
www.crs.gov
R45390

SUMMARY

VA Maintaining Internal Systems and
Strengthening Integrated Outside Networks
Act of 2018 (VA MISSION Act; P.L.115-182)
On June 6, 2018, the John S. McCain III, Daniel K. Akaka, and Samuel R. Johnson VA
Maintaining Internal Systems and Strengthening Integrated Outside Networks Act of 2018, or the
VA MISSION Act of 2018 (S. 2372; P.L. 115-182; H.Rept. 115-671), was signed into law. The
Department of Veterans Affairs Expiring Authorities Act of 2018 (S. 3479; P.L. 115-251),
enacted on September 29, 2018, made some changes and technical amendments to the VA
MISSION Act. This act, as amended, broadly addresses four major areas.
First, it establishes a new permanent Veterans Community Care Program (VCCP), replacing the
current Veterans Choice Program (VCP). The VA MISSION Act stipulates that the new program
must be operational when regulations are published by the Department of Veterans Affairs (VA)
no later than one year after the date of enactment (June 6, 2018), or when the VA determines that
75% of the amounts deposited in the Veterans Choice Fund (VCF) have been exhausted.
Second, it expands the current Program of Comprehensive Assistance for Family Caregivers, in
two phases, to all eligible veterans who served prior to September 11, 2001.
Third, it establishes an asset and infrastructure review process by establishing an Asset and
Infrastructure Review Commission. The purpose of the commission is to examine the VA’s
assets and to make recommendations for modernizing and realigning medical facilities.
Fourth, it provides various statutory authorities to the Veterans Health Administration (VHA) of
the VA to recruit and retain health care providers.

R45390
November 1, 2018
(name redacted),
Coordinator
Specialist in Veterans
Policy
-redacted-@crs.loc.gov
(name redacted)
Specialist in Health and
Aging Policy
-redacted-@crs.loc.gov
(name redacted)
Analyst in Health Policy
-redacted-@crs.loc.gov
(name redacted)
Specialist in American
National Government
-redacted-@crs.loc.gov
(name redacted)
Specialist in Health
Services
-redacted-@crs.loc.gov
For a copy of the full report,
please call 7-. ... or visit
www.crs.gov.

Veterans Community Care Program (VCCP)
The VA MISSION Act establishes a new permanent discretionary community care program known as VCCP. The act
provides conditions under which the VA is required to provide care in the community once the program is established.
Generally, all veterans enrolled in the VA health care system would be able to qualify when (1) the VA does not offer the
care or service required by the veteran; or (2) the veteran resides in a state without a full-service VA medical facility; or (3)
the veteran previously qualified under the 40-mile criterion of the VCP; or (4) the VA cannot provide the veteran with care
and services that comply with designated access and quality standards; or (5) the veteran and the veteran’s primary care
provider agree that it is in the best interest of the veteran to receive care in the community. In addition, the VA is required to
enter into contracts to build a network of private community providers.
Expansion of Comprehensive Assistance for Family Caregivers
The VA MISSION Act expands the Program of Comprehensive Assistance for Family Caregivers to pre-9/11 veterans in two
phases. Under the first phase, veterans with serious service-connected injuries incurred on or before May 7, 1975, would
qualify for benefits over a two-year period beginning on the date when the VA certifies to Congress that it has fully
implemented the information technology system required for this program. Under the second phase, those with serious
service-connected injuries incurred between May 7, 1975, and September 11, 2001, would qualify for the Comprehensive
Assistance for Family Caregivers program two years after implementation of the first phase.
Capital Asset Review
The VA MISSION Act establishes a process for realigning and modernizing facilities of the VHA. Under this process, the
VA will develop criteria for selecting VHA facilities to dispose of, modernize, or acquire, so as to better meet the health care
needs of veterans. VA must then create a list of recommendations based on those criteria and submit it to a newly created
Asset Infrastructure Review (AIR) Commission. The AIR Commission shall review the VA’s recommendations but may not
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alter them, unless it determines that one or more recommendations are inconsistent with the criteria. The commission shall
submit the list of recommendations to the President, who shall either approve the list in its entirety or send it back to the AIR
Commission. The AIR Commission may change the recommendations and resubmit a revised list to the President for
reconsideration. The President may approve or disapprove of the revised list. If the President approves of the original or
revised list, then VA must begin implementation of the recommendations within three years, unless Congress passes a joint
resolution of disapproval, in which case the asset review process terminates.
Recruiting and Retaining Health Care Providers in the VHA
The VA MISSION Act authorizes or expands several programs, with the intention of recruiting and retaining health care
providers in the VHA. Among other things, the act



increases the maximum amount of student loan debt that may be reduced under VA’s Education Debt
Reduction Program (EDRP);



authorizes designated scholarships for physicians and dentists under the VA Health Professional
Scholarship Program (HPSP);



establishes the VA specialty education loan repayment program to incentivize VHA employees to pursue
education and training in medical specialties for which VA determines there is a shortage;




establishes a pilot Veterans Healing Veterans Medical Access and Scholarship Program; and
extends eligibility for VA’s EDRP to clinical staff working at Vet Centers.

The act also requires the VHA to establish a program to deploy mobile health teams to serve in underserved VA medical
facilities.
Lastly, the VA MISSION Act authorizes and appropriates $5.2 billion in mandatory funding for the VCP until the VCCP is
operational.

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Contents
Introduction ..................................................................................................................................... 1
Brief Legislative History of Community Care ................................................................................ 2
Background and Legislative History of the VA MISSION Act ....................................................... 3
Budgetary Impact ............................................................................................................................ 6
Provisions in the VA MISSION Act of 2018 ................................................................................... 6
Title I: Caring for Our Veterans ....................................................................................................... 7
Subtitle A: Developing an Integrated High-Performing Network............................................. 9
Section 100. Short Title....................................................................................................... 9
Section 101. Establishment of the Veterans Community Care Program (VCCP) ............... 9
Section 102. Authorization of Agreements Between Department of Veterans
Affairs and Nondepartment Providers ........................................................................... 19
Section 103. Authorizing State Veterans Homes to Enter into VCAs ............................... 21
Section 104. Access Standards and Standards for Quality ................................................ 21
Section 105. Access to Walk-In Care ................................................................................ 22
Section 106. Strategy Regarding the VA High-Performing Integrated Health Care
Network. ........................................................................................................................ 22
Section 107. Applicability of Directive of Office of Federal Contract Compliance
Programs ........................................................................................................................ 23
Section 108. Prevention of Certain Health Care Providers from Providing NonVA Health Care Services to Veterans ............................................................................. 23
Section 109. Remediation of Medical Service Lines ........................................................ 23
Section 111. Prompt Payment to Providers ....................................................................... 23
Section 112. Authority to Pay for Authorized Care Not Subject to an Agreement ........... 25
Section 113. Improvement of Authority to Recover the Cost of Services
Furnished for Nonservice-Connected Disabilities ......................................................... 25
Section 114. Processing of Claims for Reimbursement Through Electronic
Interface ......................................................................................................................... 25
Section 121. Education Program on Health Care Options ................................................ 25
Section 122. Training Program for Administration of Non-VA Health Care .................... 25
Section 123. Continuing Medical Education for Non-VA Medical Professionals ............ 25
Section 131. Establishment of Processes to Ensure Safe Opioid Prescribing
Practices by Non-VA Health Care Providers ................................................................. 26
Section 132. Improving Information Sharing with Community Providers ....................... 26
Section 133. Competency Standards for Non-VA Health Care Providers ........................ 26
Section 134. VA Participation in National Network of State-Based Prescription
Drug-Monitoring Programs ........................................................................................... 27
Section 141. Plans for Use of Supplemental Appropriations ............................................ 27
Section 142. Veterans Choice Fund Flexibility ................................................................. 27
Section 143. Sunset of Veterans Choice Program ............................................................. 27
Subtitle B: Improving VA Health Care Delivery ..................................................................... 27
Section 151. Licensure of Health Care Professionals of the VA Providing
Treatment Via Telemedicine .......................................................................................... 28
Section 152. Authority for the VA Center for Innovation for Care and Payment ............. 28
Section 153. Authority for Operations on Live Donors for the Purposes of
Conducting Transplant Procedures for Veterans ............................................................ 28
Subtitle C: Family Caregivers ................................................................................................. 28

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Section 161. Expansion of Family Caregiver Program of the VA .................................... 29
Section 162. Implementation of Information Technology System of the VA to
Assess and Improve the Family Caregiver Program...................................................... 30
Section 163. Modification to Annual Evaluation Report on Caregiver Program of
the VA ............................................................................................................................ 30
Title II: VA Asset and Infrastructure Review................................................................................. 31
Subtitle A: Asset and Infrastructure Review ........................................................................... 32
Section 201. Short Title..................................................................................................... 33
Section 202. The Commission .......................................................................................... 33
Section 203. Procedure for Making Recommendations.................................................... 34
Section 204. Actions Regarding Infrastructure and Facilities of the VHA ....................... 37
Section 205. Implementation ............................................................................................ 37
Section 206. Department of Veterans Affairs Asset and Infrastructure
Review Account............................................................................................................. 38
Section 207. Congressional Consideration of Commission Report .................................. 38
Section 208. Other Matters ............................................................................................... 42
Section 209. Definitions.................................................................................................... 43
Subtitle B: Other Infrastructure Matters.................................................................................. 43
Section 211. Improvement to Training of Construction Personnel ................................... 43
Section 212. Review of Enhanced Use Leases ................................................................. 43
Section 213. Assessment of Health Care Furnished by the VA to Veterans Who
Live in U.S. territories ................................................................................................... 44
Title III: Improvements to Recruitment of Health Care Professionals .......................................... 44
Section 301. Designated Scholarships for Physicians and Dentists Under the VA
Health Professional Scholarship Program ............................................................................ 44
Section 302. Increase in Maximum Amount of Debt That May Be Reduced Under
Education Debt Reduction Program (EDRP) of the VA ...................................................... 45
Section 303. Establishing the VA Specialty Education Loan Repayment Program ................ 45
Section 304. Veterans Healing Veterans Medical Access and Scholarship Program .............. 45
Section 305. Bonuses for Recruitment, Relocation, and Retention ........................................ 46
Section 306. Inclusion of Vet Center Employees in Education Debt Reduction
Program (EDRP) of the VA.................................................................................................. 46
Title IV: Heath Care in Underserved Areas ................................................................................... 46
Section 401. Development of Criteria for Designation of Certain Medical Facilities of
the VA as Underserved Facilities and Plan to Address Problem of Underserved
Facilities. .............................................................................................................................. 48
Section 402. Pilot Program to Furnished Mobile Deployment Teams to Underserved
Facilities ............................................................................................................................... 48
Section 403. Pilot Program on Graduate Medical Education and Residency ......................... 48
Title V: Other Matters.................................................................................................................... 49
Section 501. Annual Report on Performance Awards and Bonuses Awarded to Certain
High-Level Employees ........................................................................................................ 49
Section 502. Role of Podiatrists in the VA .............................................................................. 50
Section 503. Definition of Major Medical Facility Project ..................................................... 50
Section 504. Authorization of Certain Major Medical Facility Projects ................................. 50
Section 505. VA Personnel Transparency................................................................................ 50
Section 506. Program on Establishment of Peer Specialists in Patient-Aligned Care
Team Settings Within VAMCs ............................................................................................. 51
Section 507. VA Medical Scribe Program ............................................................................... 51

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Section 508. Extension of VA Home Loan Guarantee Fees .................................................... 52
Section 509. Extension of Reduction in VA Pensions for Certain Medicaid-Covered
Veterans in Nursing Facilities .............................................................................................. 52
Section 510. Appropriation of Funds ...................................................................................... 52
Section 512. Budgetary Effects ............................................................................................... 52

Figures
Figure 1. Conditions Under Which Care Is Required to Be Provided Through the Veterans
Community Care Program (VCCP) ........................................................................................... 12
Figure 2. Conditions Under Which the VA May Authorize Care to be Provided Through
the Veterans Community Care Program (VCCP) ....................................................................... 14

Tables
Table A-1. The VA MISSION Act of 2018 (P.L. 115-182; as amended by P.L. 115-251):
Major Provisions Pertaining to Implementation, Reporting Requirements, and
Deadlines .................................................................................................................................... 54

Appendixes
Appendix. The VA MISSION Act of 2018: Implementation, Reporting Requirements, and
Deadlines .................................................................................................................................... 54

Contacts
Author Contact Information .......................................................................................................... 68

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Introduction
Policymakers and other stakeholders may hold a variety of views regarding the appropriate role
of the private sector in meeting the health care needs of eligible veterans. Some believe that the
best course for veterans is to provide all needed care in facilities under the direct jurisdiction of
the Department of Veterans Affairs (VA), Veterans Health Administration (VHA), health care
system. On the other hand, some see the use of private sector providers as important in ensuring
veterans’ access to a comprehensive slate of services (in particular, to specialty services that are
needed infrequently), or in addressing geographic or other access barriers, such as long wait times
for an appointment. In addition, those who believe that all needed care should be provided by VA
providers in VA-owned facilities express concern that private sector options for providing care to
veterans may dilute the quality of care in the VA health care system, and could fail to leverage
key strengths of the VA health care network.
Furthermore, studies have shown that private sector community providers may not have the
necessary training and skills to provide “complex and specialized multidisciplinary care including
integrated behavioral health services that many veterans require.”1 Some are concerned that if
veterans leave the VA health care system for the private sector, some VHA sites and specialized
medical services may be eliminated from the VA health care system, if comparable care is
provided in the private sector.2 However, some propose that over the long term, having private
sector options could improve the quality of services within the VA health care system through
competition. Reaching the correct balance between providing care through VHA’s health care
system and through non-VA community providers has been an issue for policymakers, as well as
for the VA and other stakeholders, for many years. On June 6, 2018, President Donald Trump
signed into law the John S. McCain III, Daniel K. Akaka, and Samuel R. Johnson VA Maintaining
Internal Systems and Strengthening Integrated Outside Networks Act of 2018, or the VA
MISSION Act of 2018 (S. 2372; P.L. 115-182; H.Rept. 115-671). The Department of Veterans
Affairs Expiring Authorities Act of 2018 (S. 3479; P.L. 115-251), enacted on September 29, 2018,
made some changes and technical amendments to the VA MISSION Act. Section 101 of this act,
establishing the Veterans Community Care Program, or VCCP, is a legislative outcome of this
long-standing policy debate on the role of the private sector in the delivery of health care to the
nation’s veterans.
To understand the key amendments made by the VA MISSION Act with respect to care provided
through private sector community providers, this report begins with a brief history of key
legislative changes to community care passed by Congress from the 1920s onwards. It should be
noted that over the years, care provided through private sector providers has been known by many
names, including “Hometown Medical Program,” “Non-VA Fee Care,” “Fee-Basis Care,”
“Purchased Care,” “Preauthorized Care,” and the “Fee-Care Program,” among others.3 In this
report, such care is referred to as the Veterans Community Care Program, or VCCP, as established
by the VA MISSION Act. Following the brief legislative history of VA provided community care,
1 Jennifer Daley, “Ensuring Timely Access to Quality Care for US Veterans,” The Journal of the American Medical

Association, vol. 319, no. 5 (February 6, 2018), p. 440. Also see Terri Tanielian et al., Ready or Not? Assessing the
Capacity of New York State Health Care Providers to Meet the Needs of Veterans, RAND Corporation, Santa Monica,
CA, 2018, https://www.rand.org/pubs/research_reports/RR2298.html.
2 Jennifer Daley, “Ensuring Timely Access to Quality Care for US Veterans,” The Journal of the American Medical
Association, vol. 319, no. 5 (February 6, 2018), p. 440.
3 RAND Corporation, Assessment C (Care Authorities), The MITRE Corporation. A Product of the CMS Alliance to
Modernize Healthcare Federally Funded Research and Development Center Centers for Medicare & Medicaid Services
(CMS) Prepared For the U.S. Department of Veterans Affairs, September 1, 2015, p. 22.

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the report describes the background and legislative history leading up to the enactment of the VA
MISSION Act. This is followed by summaries of the major provisions in the VA MISSION Act
by title. The report concludes with an appendix providing implementation and reporting deadlines
contained in the VA MISSION Act.

Brief Legislative History of Community Care
Since the early 1920s, Congress has authorized the VA to contract for care in the community. For
instance, the World War Veterans Act of 1924 (P.L. 68-242), enacted on June 7, 1924, included
language that authorized the Director of the then Veterans Bureau to contract with private
facilities in exceptional cases:
In the event Government hospital facilities are insufficient or inadequate the director may
contract with State, municipal, or in exceptional cases, with private hospitals for such
medical, surgical, and hospital services and supplies as may be required, and such contracts
may be made for a period of not exceeding three years and may be for the use of a ward or
other hospital unit or on such other basis as may be in the best interest of the beneficiaries
under this Act.4

VA’s Hometown Medical Care Program, which was also known as the fee-basis care program,
was established by the VA in FY1946, and under this program the VA entered into contracts with
state medical societies, or with designated agencies for authorized services, and was reimbursed
based on a VA fee schedule.5 Generally, the Hometown Medical Program was used to provide
out-patient care—including dental care for veterans who were in need of treatment for a serviceconnected disability—because at that time outpatient care was generally authorized for treatment
of service-connected disabilities.6 According to VA’s annual report from FY1950:
This program has saved veterans many hours they would otherwise have been required to
use in traveling to and from VA clinics, some of which would have been lost from their
work. The convenience of treatment in their own hometown, together with the privilege of
being treated by a doctor of their own choice, has made this [program] highly acceptable
to veteran-patients.7

In June 1957, Congress passed the Veterans’ Benefit Act of 1957 (P.L. 85-56), which provided the
VA the authority to contract with private facilities “in order to provide hospital care (i) in
emergency cases for persons suffering from service-connected disabilities or from disabilities for
which such persons were discharged or released from the active military, naval, or air service; (ii)
for women veterans of any war; or (iii) for veterans of any war in a Territory, Commonwealth, or
possession of the United States.”8
The Veterans Health Care Expansion Act of 1973 (P.L. 93-82) broadly expanded out-patient care
to nonservice-connected veterans, and by 1976, to address the “patient and staff complaints
generated by the overcrowded conditions in outpatient programs and ambulatory care services at

4 World War Veterans Act of 1924 (S. 2257; P.L. 68-242; 43 Stat. 610, c. 320).
5 Veterans Administration, Annual Report of the Administrator of Veterans Affairs, Annual Report for Fiscal Year

Ending June 30, 1946, Washington, DC, January 6, 1947, p. 3.
6 Veterans Administration, Annual Report of the Administrator of Veterans Affairs, Annual Report for Fiscal Year
Ending June 30, 1950, Washington, DC, January 4, 1951, p. 30.
7 Ibid., p. 33.
8 Veterans’ Benefits Act of 1957 (H.R. 53, P.L. 85-56; 71 Stat. 110).

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VA health care facilities across the Nation.”9 Congress passed the Veterans Omnibus Health Care
Act of 1976 (P.L. 94-581). This law made several changes to the fee-basis program. It added
current (38 U.S.C. §1703) statutory language stating that “when facilities [Departmental] are not
capable of furnishing economical care because of geographical inaccessibility or of furnishing the
care or services required” and further limited fee-basis or contract care to specific categories of
veterans. These included veterans receiving hospital care or medical services for the treatment of
a service-connected disability or a disability for which a veteran was discharged or released from
the active military, naval, or air service, among other categories.
Further changes made by the Veterans’ Health Care Amendments of 1979 (P.L. 96-22) provided
authority for fee-basis care for veterans with nonservice-connected disabilities and in receipt of
increased pension or other additional compensation who are in need of regular aid and attendance
or who are housebound. The Consolidated Omnibus Budget Reconciliation Act of 1985
(Veterans’ Health-Care Amendments of 1986; P.L. 99-272) clarified the definition of the term
“Veterans’ Administration facilities” and authorized the VA to contract for medical care in private
facilities. These and other legislative changes in subsequent Congresses eventually became
codified at Title 38 United State Code (U.S.C.) section 1703. This section was completely
amended by the VA MISSION Act (S. 2372; P.L. 115-182; H.Rept. 115-671; and P.L. 115-251).
Over time, Congress has authorized additional programs to provide care through non-VA
community providers or entities, each with their own unique requirements. In general, the VA
MISSION Act amends the legal framework around several existing veterans care programs: the
Veterans Choice Program (38 U.S.C. §1701 note), Traditional VA Care in the Community (38
U.S.C. §1703), Project ARCH (Access Received Closer to Home) (38 U.S.C. §1703 note),
community nursing home and adult health day care, home health care services, respite care, and
hospice care (38 U.S.C. §§1720; 1720B and 1720C). It also creates a new program for walk-in
care (38 U.S.C. §1725A). However, it leaves intact other statutory provisions for emergency care
for nonservice-connected conditions to certain veterans (38 U.S.C. §1725), authority to provide
reimbursement for emergency care for service-connected veterans (38 U.S.C. §1728), authority to
share health care resources with the Department of Defense (38 U.S.C. §8111), health care
sharing and contracting authority (38 U.S.C. §8153), and agreements with Indian Health Service
and tribal health program providers (25 U.S.C. §1645).

Background and Legislative History of the
VA MISSION Act
In response to the allegations of wait time manipulation and access issues at many VHA hospitals
and clinics across the country, which were brought to the attention of congressional committees in
the spring and summer of 2014,10 the Veterans Access, Choice and Accountability Act of 2014
(VACAA; P.L. 113-146, as amended) was enacted. This act, among other things, established the
temporary Veterans Choice Program (VCP), which authorized veterans meeting certain criteria,
9 U.S. Congress, Senate Committee on Veterans’ Affairs, Veterans Omnibus Health Care Act of 1976, Hearings on S.

2908 and Related Bills, 94th Cong., February 18 and 19, 1976 (Washington: GPO, 1977), p. 104.
10 Department of Veterans Affairs, Office of Inspector General (OIG), Administrative Summaries of Investigation
Regarding Wait Time, available at https://www.va.gov/oig/publications/administrative-summaries-of-investigation.asp,
accessed on July 20, 2018; and U.S. Congress, House Committee on Veterans’ Affairs, Scheduling Manipulation and
Veteran Deaths in Phoenix: Examination of the OIG’S Final Report, 113th Cong., 2nd sess., September 17, 2014,
H.Hrg. 113–87 (Washington: GPO, 2015).

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such as wait times for appointments and distance from the nearest VA medical facility, to access
care in the community.11 In addition, Section 802 of VACAA established the Veterans Choice
Fund (VCF) and provided $10 billion in mandatory appropriations.
Significant challenges surrounding the implementation of the VCP are documented in several VA
Office of Inspector General (OIG) and Government Accountability Office (GAO) reports, as well
as congressional hearings.12
Acknowledging these implementation challenges associated with VCP, as well as the confusing
and complex community care landscape created by the various statutory authorities, coupled with
pilot programs such as Project Access Received Closer to Home (ARCH)13 and Patient-Centered
Community Care (PC3),14 Congress passed the Surface Transportation and Veterans Health Care
Choice Improvement Act of 2015 (P.L. 114-41) and mandated the VA to provide a plan to
consolidate existing community care programs. This plan was submitted to Congress on October
30, 2015.15 Numerous hearings were held during the 114th Congress, and several measures were
introduced to incorporate many of the concepts addressed in the VA’s Plan to Consolidate
Programs of Department of Veterans Affairs to Improve Access to Care, such as the Improving
Veterans Access to Care in the Community Act (S. 2633) and the Veterans Choice Improvement
Act of 2016 (S. 2646). However, at the end of the 114th Congress, no major legislative action
occurred to revamp and consolidate veterans community care programs.
At the beginning of the 115th Congress, once again Congress faced implementation issues
regarding the VCP, including its expiration in August 2017 and funding shortfalls. In response to
this, Congress passed P.L. 115-26 (unofficially referred to as the Veterans Choice Program
Improvement Act), eliminated the August 7, 2017, sunset date, and allowed the VCP to continue
11 For more information on the implementation of the Veterans Choice Program (VCP), see CRS Report R44562, The

Veterans Choice Program (VCP): Program Implementation.
12 Department of Veterans Affairs, Office of the Inspector General, Veterans Health Administration Review of the
Implementation of the Veterans Choice Program, 15-04673-333, January 30, 2017; Department of Veterans Affairs,
Office of the Inspector General, Accuracy and Timeliness of Payments Made Under the Choice Program Authorized by
the Veterans Access, Choice, and Accountability Act, Memorandum to the Secretary of Veterans Affairs, September 12,
2017; U.S. Government Accountability Office, Veterans Choice Program: Improvements Needed to Address AccessRelated Challenges as VA Plans Consolidation of its Community Care Programs, GAO-18-281, June 2018; U.S.
Congress, House Committee on Veterans’ Affairs, Shaping The Future: Consolidating And Improving VA Community
Care, 115th Cong., 1st sess., March 7, 2017 (Washington: GPO, 2018).
13 Section 403 the Veterans’ Mental Health and Other Care Improvements Act of 2008 (P.L. 110-387) required the VA
to conduct pilot programs during a three-year period to provide non-VA health care services through contractual
arrangements to eligible veterans in in rural areas. The Caregiver and Veterans Omnibus Health Services Act of 2010
(P.L. 111-163) made technical corrections regarding hardship exception and the mileage standard. The program was
established in 2011 and was extended by the Veterans Access, Choice, and Accountability Act (VACAA) of 2014 (P.L.
113-46, as amended) and expired on August 7, 2016. Veterans under the ARCH program were then provided care
under the VCP using the unusual or excessive burden provision contained VACAA of 2014 (P.L. 113-46, as amended).
14 The PC3 program traces its roots to the pilot program known as the Project HERO (Healthcare Effectiveness
Through Resource Optimization). The five-year pilot was established in 2007 in response to the conference committee
report issued to accompany the FY2006 Military Quality of Life and Veterans Affairs Appropriations Act (P.L. 109114). Congress intended Project HERO to be implemented in similar manner to private health care and managed carecontracted services models. When the Project HERO pilot ended, the VA awarded a new contract called PatientCentered Community Care, known as PCCC or PC3, as a regional contracting vehicle to partner with private health
care providers. When the VCP was established in 2014 by the by the Veterans Access, Choice, and Accountability Act
(VACAA) of 2014 (P.L. 113-46, as amended), VA modified the PC3 contracts, and the two commercial vendors
became the third-party administrators of the VCP.
15 Department of Veterans Affairs, Plan to Consolidate Programs Department of Veterans Affairs to Improve Access to
Care, October 30, 2015, https://www.va.gov/opa/publications/va_community_care_report_11_03_2015.pdf (accessed
August 8, 2018).

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until all funds in the VCF were expended. Later in 2017, as VCF funding was diminishing,
Congress passed the VA Choice and Quality Employment Act of 2017 (P.L. 115-46), and P.L.
115-96, and provided additional funding of $4.2 billion to continue VCP.
In the meantime, on October 6, 2017, the VA submitted to the House and Senate Veterans’ Affairs
Committees another plan to consolidate and streamline community care programs to replace the
VCP. This plan, known as the Veterans Coordinated Access & Rewarding Experiences (CARE)
plan, made additional enhancements to the initial plan that was provided in October 2015. More
specifically, it focused on eligibility criteria for veterans to access care in the community, with
criteria based on clinical need, quality of care, and convenience—which had not been specifically
addressed in the October 2015 plan.16 The House Veterans’ Affairs Committee (HVAC) held a
hearing on the CARE plan and other legislative proposals on October 24, 2017.17 Based on major
concepts in this plan and other legislative proposals,18 the Senate and House Veterans’ Affairs
Committees began drafting legislation. On November 3, 2017, the VA Care in the Community Act
(H.R. 4242) was introduced, and the measure was marked up by the HVAC and ordered reported
as amended on December 19, 2017. It was subsequently reported with an amendment by the
HVAC (H.Rept. 115-585) on March 5, 2018. On November 29, 2017, the Senate Veterans’ Affairs
Committee (SVAC) marked up a draft measure, and it was reported to the Senate on December 5,
2017, entitled the Caring for Our Veterans Act of 2017 (S. 2193; S.Rept. 115-212). However, no
further action occurred at the close of the first session of the 115th Congress.
At the beginning of the second session of the 115th Congress, combining various provisions of the
VA Care in the Community Act (H.R. 4242; H.Rept. 115-585), the VA Asset and Infrastructure
Review Act of 2017 (H.R. 4243), and the Caring for Our Veterans Act of 2017 (S. 2193; S.Rept.
115-212), HVAC Chairman Dr. Phil Roe introduced the VA Maintaining Internal Systems and
Strengthening Integrated Outside Networks Act of 2018, or the VA MISSION Act of 2018 (H.R.
5674), on May 3, 2018. The HVAC marked up the legislation on May 8. The measure was
reported by the HVAC on May 11 (H.Rept. 115-671, Part 1). The text of H.R. 5674 was then
substituted as an amendment to S. 2372 and modified to include a new short title known as the
John S. McCain III, Daniel K. Akaka, and Samuel R. Johnson VA Maintaining Internal Systems
and Strengthening Integrated Outside Networks Act of 2018. The House passed S. 2372 on May
16. The Senate began consideration of the House amendment to S. 2372 on May 17, and it passed
the measure by concurring to the House amendment to S. 2372 on May 23. President Donald
Trump signed the VA MISSION Act to law (S. 2372; P.L. 115-182) on June 6, 2018.19 The
16 Department of Veterans Affairs, “VA Announces Veterans Coordinated Access & Rewarding Experiences (‘CARE’)

Act: Replaces Current ‘30-day/40-mile’ System with Patient/Provider-centric Decision-making,” press release, October
16, 2017, https://www.va.gov/opa/pressrel/pressrelease.cfm?id=2963(accessed August 8, 2018).
17 U.S. Congress, House Committee on Veterans’ Affairs, Legislative Hearing on: Draft legislation to establish a
permanent Veterans Choice Program; Draft legislation to modify VA’s authority to enter into agreements with State
homes to provide nursing home care to veterans, to direct the Secretary to carry out a program to increase the number
of graduate medical education residency positions, and for other purposes; Draft legislation, to direct VA to conduct a
study of the Veterans Crisis Line; Draft legislation, to direct VA to furnish mental health care to veterans at community
or non-profit mental health providers participating in the Veterans Choice Program; the Department of Veterans
Affairs’ (VA’s) legislative proposal, the Veteran Coordinated Access and Rewarding Experiences (CARE) Act; H.R.
1133; H.R. 2123; H.R. 2601; and, H.R. 3642,” 115th Cong., 2nd sess., October 24, 2017.
18 For an in-depth discussion on the measures introduced and considered by the Senate Veterans Affairs Committee, see
U.S. Congress, Senate Committee on Veterans’ Affairs, Caring for Our Veterans Act of 2017, Report to Accompany S.
2193, 114th Cong., 2nd sess., March 7, 2018, S.Rept. 115-212 (Washington: GPO, 2018), pp. 1-4.
19 Donald J. Trump, Statement by the President on the John S. McCain III, Daniel K. Akaka, and Samuel R. Johnson
VA Maintaining Internal Systems and Strengthening Integrated Outside Networks Act of 2018, or the “VA MISSION
Act of 2018,” https://www.whitehouse.gov/briefings-statements/statement-by-the-president-3/ (accessed August 8,

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Department of Veterans Affairs Expiring Authorities Act of 2018 (S. 3479; P.L. 115-251) made
amendments and technical corrections to the VA MISSION Act.

Budgetary Impact20
The VA MISSION Act of 2018 (P.L. 115-182) provides $5.2 billion in direct or mandatory
appropriations for the VCF established by Section 802 of the VACAA (P.L. 113-146, as
amended). The Congressional Budget Office (CBO) estimates that this amount would continue to
provide funding for the current VCP until about the first half of calendar year 2019.21 Excluding
this direct appropriation, the CBO estimates that implementing all the provisions of the VA
MISSION Act would cost approximately $46.5 billion over the FY2019-FY2023 time frame,
subject to discretionary appropriations from Congress. This estimate includes a cost of $21.4
billion for the new Veterans Community Care Program (VCCP) and $6.7 billion for the
provisions related to expansion of the Program of Comprehensive Assistance for Family
Caregivers to those veterans injured or disabled during military service on or before September
11, 2001. The $6.7 billion estimate excludes any long-term implementation costs of this
expansion, since the expansion would happen in two stages.22 The CBO estimates that the VA
MISSION Act would increase the deficit by $5.2 billion over six years (FY2018-FY2023) and
almost $4.5 billion over 11 years (FY2018-FY2028).23

Provisions in the VA MISSION Act of 2018
This report summarizes the major provisions of the John S. McCain III, Daniel K. Akaka, and
Samuel R. Johnson VA Maintaining Internal Systems and Strengthening Integrated Outside
Networks Act of 2018 (VA MISSION Act; P.L. 115-182, H.Rept. 115-671), including
amendments made by the Department of Veterans Affairs Expiring Authorities Act of 2018 (S.
3479; P.L. 115-251). It does not analyze every provision in the act, but instead provides brief
outlines of the matters addressed.
Subsequent sections of the report are organized as follows: a summary is provided for each title
of the act, followed by a summary of the provisions under that respective title. Relevant
background is provided for context, where applicable, at the title level or subtitle level.
Throughout this report, unless otherwise stated, the Secretary means the Secretary of Veterans
Affairs, and the VA means the U.S. Department of Veterans Affairs. In addition, this section refers
to matters addressed under that specific section of the act. This report uses a number of acronyms,
Acronyms
CBO

Congressional Budget Office

CBOC

Community Based Outpatient Clinic

C.F.R.

Code of Federal Regulations

2018).
20 Congressional Budget Office (CBO), Cost Estimate, H.R. 5674, VA Maintaining Internal Systems and Strengthening
Integrated Outside, May 14, 2018, https://www.cbo.gov/publication/53871. The House amended S. 2372 to include the
text of H.R. 5674, as reported, with “technical and procedural corrections.”
21 Ibid., p. 18.
22 Ibid., p. 8.
23 Ibid., p. 21.

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CMS

Centers for Medicare & Medicaid Services

DOD

Department of Defense

DME

Durable Medical Equipment

EDRP

Education Debt Reduction Program

FQHC

Federally Qualified Health Center

GAO

Government Accountability Office

GME

Graduate Medical Education

GSA

General Services Administration

HAC

House Appropriations Committee

HHS

Department of Health and Human Services

HPSP

Health Professional Scholarship Program

HPSA

Health Professional Shortage Areas

HVAC

House Committee on Veterans’ Affairs

IHS

Indian Health Service

OIG

VA Office of Inspector General

PDMP

State Prescription Drug Monitoring Program

SAC

Senate Appropriations Committee

SVAC

Senate Committee on Veterans’ Affairs

U.S.C.

United States Code

VA

Department of Veterans Affairs

VACAA

Veterans Access, Choice, and Accountability Act of 2014 (P.L. 113-146, as amended; 38 U.S.C. §1701 note)

VAMC

VA Medical Center

VCA

Veterans Community Care Agreements

VCCP

Veterans Community Care Program

VCF

Veterans Choice Fund

VCP

Veterans Choice Program

VHA

Veterans Health Administration

VISN

Veterans Integrated Services Networks

VSO

Veterans Service Organization

Title I: Caring for Our Veterans
This title amends current law (codified at 38 U.S.C. §1703) that provided the Secretary the
authority—whether under a contract or an individual authorization—to provide care under certain
circumstances




care of a service-connected disability;
care for a disability for which a veteran was discharged or released from the
active military, naval, or air service;
care of a disability of a veteran who has a total disability permanent in nature
from a service-connected disability;

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





care of a disability associated with and held to be aggravating a serviceconnected disability;
care of a disability of a veteran participating in a rehabilitation program under 38
U.S.C. Chapter 31;
hospital care for women veterans;
outpatient dental care for certain veterans; and
when there is a need for hospital care for reasons set forth in VA regulations (38
C.F.R. §17.52).

Title I liberalizes the VA’s current community care program by establishing a new Veterans
Community Care Program (VCCP), which amends the above-mentioned statutory hierarchy and
provides greater flexibility to all enrolled veterans in accessing care in the community, for
hospital care, medical services, and extended care services, at their election. Under the new
VCCP, eligibility will apply more broadly to all enrolled veterans and service-connected
disability will not be a major factor for eligibility for care in the community. In addition, this title
would eventually sunset the current Veterans Choice Program (VCP) one year after the date of
enactment of the VA MISSION Act (i.e., on June 6, 2019).
This title requires the Secretary to establish access and quality standards for medical care and
extended care services. It authorizes the VA to enter into Veteran Care Agreements (VCAs) that
are not subject to the contracting requirements generally required under federal contracting
regulations. In addition, the VA is authorized to enter into VCAs with State Veterans Homes,
thereby eliminating the need for contractual agreements with the VA. These VCAs will not be
considered federal contracts with the United States; however, State Veterans Homes will still have
to comply with all other applicable federal laws concerning employment and hiring practices.
Title I also requires the Secretary to conduct a quadrennial market area assessment of VA health
services, and to develop a broad-ranging quadrennial review of the VHA. It also expands
eligibility for veterans to access walk-in care from private community providers. Moreover, this
title amends VA’s prompt payment standards for all community care providers. It also requires
the Secretary to develop and administer a program to educate veterans about the interaction
between health insurance programs such as Medicare, Medicaid, and TRICARE and the services
provided by the VA health care system. Title I also requires the Secretary to improve information
sharing with community providers and to ensure the competency of private community providers.
It also provides VA clinicians access to State Prescription Drug Monitoring Programs (PDMPs).
This title also provides authority for VA providers to provide a telemedicine episode of care
without regard to where the veteran patient and VA provider are located within the United States
and U.S. territories. Furthermore, it establishes a VA Innovation for Care and Payment Center,
and provides the Secretary with authority to conduct pilot programs to develop innovative
payment and health care delivery models.
Lastly, Title I liberalizes eligibility for the Program of Comprehensive Assistance for Family
Caregivers to pre-9/11 veterans under two phases. Under the first phase, veterans with serious
service-connected injuries incurred on or before May 7, 1975, will qualify for benefits over a
two-year period beginning on the date when the VA certifies to Congress that it has fully
implemented the information technology system required for this program. Under the second
phase, those with serious service-connected injuries incurred between May 7, 1975, and
September 11, 2001, will qualify for the Comprehensive Assistance for Family Caregivers
program two years after the implementation of the first phase.

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Subtitle A: Developing an Integrated High-Performing Network
Section 100. Short Title
This section provides the title as the “Caring for Our Veterans Act of 2018.”

Section 101. Establishment of the Veterans Community Care Program (VCCP)
This section amends current law (38 U.S.C. §1703) and establishes a new Veterans Community
Care Program (VCCP) to provide hospital care, medical services, and extended care services to
eligible veterans through specified non-VA health care providers. Once VCCP is implemented by
the Secretary, it would entirely replace current provisions in Section 1703 that provide authority
for hospital care and medical services in non-VA facilities. In the following paragraphs, this
section means the newly amended Section 1703 and its subdivisions.

Care Coordination
This section requires the Secretary to coordinate care provided through the VCCP to eligible
veterans. This care coordination must include at least the following: (1) timely scheduling of
medical appointments, including the establishment of a mechanism to receive medical records
from non-VA providers; (2) ensuring the continuity of care and services; (3) coordinating among
regional networks if the eligible veteran accesses care and services in a different network than the
regional network in which the veteran resides; and (4) ensuring that eligible veterans do not
experience a lapse in care or an unusual or excessive burden in accessing care because of errors
or delays by the VA or its contractors.

Eligible Veterans
This section stipulates that any veteran enrolled in the VA health care system,24 or any veteran
who is not enrolled in the VA health care system but is entitled to hospital care, medical services,
and extended care services, is eligible for care through the VCCP.25

Specified Community Health Care Providers
This section requires that eligible veterans be provided care through the following non-VA health
care providers: (1) any physician or practitioner or health care provider participating in the

24 38 U.S.C. §1705 requires the VA to establish a patient enrollment system. A veteran must be enrolled in the VA

health care system as a condition for receiving care. Once a veteran is enrolled, the veteran remains in the system and
does not have to reapply for enrollment annually. Enrolled veterans do not pay any premiums, deductibles, or
coinsurance for their care. Some veterans are required to pay copayments.
25 Even if not enrolled in the VA health care system, some veterans are eligible to receive care through the VA health
care system. See 38 C.F.R §17.37 for conditions under which enrollment is not required for hospital and outpatient
care.

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Medicare program,26 (2) DOD medical facilities,27 (3) IHS medical facilities,28 (4) any FQHCs,29
or (5) any other health care provider that meets criteria established by the Secretary.

Eligibility for Community Care
This section stipulates two major provisions under which the Secretary



is required to authorize care, subject to the availability of annual
appropriations, to eligible veterans through VCCP; or
may authorize care through VCCP to eligible veterans.

These provisions are further delineated below (see Figure 1 and Figure 2).
Conditions under which care is required to be provided by the VA through VCCP:
An eligible veteran can elect to receive care if he or she meets one of the five major conditions:
1. the VA does not offer the care or services the veteran requires; or
2. the VA does not operate a full-service VA medical facility in the state the
veteran resides; or
3. the veteran was eligible for care under the 40-mile distance eligibility criteria
under the previous Veterans Choice Program (VCP)30 on the day before the
date of enactment of the Caring for Our Veterans Act of 2018 (i.e., the
veteran was eligible on June 5, 2018); and continues to reside in the same
location that qualifies the veteran under the 40-mile distance eligibility
criteria; and
(a) resides in one of the five states with the lowest population density based on data
from the 2010 decennial census or
(b) resides in a state other than the five states with the lowest population density and


received care or services through the VA within one year before the
enactment of the Caring for Our Veterans Act of 2018 (i.e., June 6,
2018) and
 is seeking care or services within two years of the date of the
enactment of the Caring for Our Veterans Act of 2018 (i.e., June 6,
2018); or
4. the VA is unable to provide care or services that is requested by the veteran in
a manner that meets designated access standards for care or services as
developed by the Secretary; or

26 Title 42 U.S.C.§§1395 et seq. Providers, under Medicare, include patient care institutions such as hospitals, critical

access hospitals, hospices, nursing homes, and home health agencies. See https://www.cms.gov/Medicare/ProviderEnrollment-and-Certification/CertificationandComplianc/index.html.
27 For more information on military treatment facilities, see CRS In Focus IF10530, Defense Primer: Military Health
System.
28 For more information on the IHS health care system, see CRS Report R43330, The Indian Health Service (IHS): An
Overview.
29 As defined in Section 1905(l)(2)(B) of the Social Security Act (42 U.S.C. §1396d(l)(2)(B)). For more information on
FQHCs, see CRS Report R43937, Federal Health Centers: An Overview.
30 For more information on the 40-mile distance eligibility criteria under VCP, see CRS Report R44562, The Veterans
Choice Program (VCP): Program Implementation.

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5. the veteran’s referring clinician agrees, after consultations with the eligible
veteran, that care and services through VCCP would be in the best medical
interest of the veteran based on criteria established by the Secretary (see text
box below).
Factors to Be Considered by the VA Secretary when Developing Criteria to Be
Used by a Referring Clinician
The Secretary is required to consider the following factors when developing criteria to be used by an eligible
veteran’s clinician to refer the veteran for care through VCCP:


the distance between the veteran’s residence and the VA facility that provides care or services the veteran
needs;



the type of care or service required by the veteran;



the frequency of care or services needed by the veteran;



the timeliness of available appointments for care or services the veteran needs;



whether the veteran faces an unusual or excessive burden to access care or services from the VA medical
facility where an eligible veteran seeks care or services. In determining unusual or excessive burden, the
Secretary is required to consider the following:


whether the veteran faces an excessive driving distance, geographical challenge, or environmental factor
that impedes the access to care;



whether care or services sought by the veteran are provided by a VA facility that is reasonably accessible
to the veteran;



whether the veteran’s medical condition affects his or her ability to travel;



whether there is a compelling reason, as determined by the Secretary, that would require the veteran to
receive care or services from a non-VA medical facility; and



other considerations as the Secretary considers appropriate.

Election of the Veteran
This section stipulates that the decision to receive care or services authorized by the Secretary
through VCCP by an eligible veteran will be at the election of that veteran.

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Figure 1. Conditions Under Which Care Is Required to Be Provided Through the
Veterans Community Care Program (VCCP)
(38 U.S.C. §1703(d))

Source: Figure developed by CRS based on statutory language in Section 101(a) of P.L. 115-182.
Notes: This pathway may be subject to changes based on regulations to be published by the Department of
Veterans Affairs.

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Conditions under which care may be authorized by VA to be provided through
VCCP:
This section authorizes the Secretary to provide care through the VCCP to an eligible veteran if a
VA medical service line (defined as a clinic within a VAMC) required by the veteran fails to
comply with access and quality standards. The Secretary is required to develop access and quality
standards, and is required to consider the following factors when developing those quality
standards:



compare the timeliness of a VA medical service line at two VA facilities, and
compare the quality of care of a VA medical service line at one VA facility
with two or more distinct and appropriate quality measures at non-VA
medical service lines in the community.

This section limits the number of medical service lines that the Secretary could compare at any
one VA facility to no more than three; it limits the total number of medical service lines
nationwide to no more than 36. The care provided under this authorization would end when the
deficient medical service line has been remedied. A veteran is eligible to receive care through
VCCP under this provision until the completion of an episode of care, and the Secretary is
required to ensure the coordination of such care through VCCP.

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Figure 2. Conditions Under Which the VA May Authorize Care to be Provided
Through the Veterans Community Care Program (VCCP)
(38 U.S.C. §1703(e))

Source: Figure developed by CRS based on statutory language in Section 101 (a) of P.L. 115-182.
Notes: This pathway may be subject to changes based on regulations to be published by the Department of
Veterans Affairs.

Federal Register Publication
This section requires the Secretary to publish a notice in the Federal Register, at least once a year,
stating (1) the time period during which such care and services will be available, (2) the location

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or locations where such care and services will be available, and (3) the clinical services available
at each location.

Review of VCCP Authorization Decisions
This section states that eligible veterans who disagree with authorization of care decisions
determined through VCCP may appeal such decisions through VHA’s internal clinical decision
appeals process and cannot file an appeal with the Board of Veterans’ Appeals (BVA).

Tiered Network
This section authorizes the Secretary to develop a tiered network of eligible providers based on
criteria established by the Secretary. However, the Secretary is prohibited from prioritizing
providers in one tier over those in another tier in a manner that limits the choice of an eligible
veteran to select an eligible VCCP health care provider.

Contracts to Establish Networks of Health Care Providers31
This section requires the Secretary to enter into consolidated, competitively bid contracts to
establish networks of health care providers, including any physician or practitioner or health care
entity participating in the Medicare program32 and any other health care provider that meets
criteria established by the Secretary. The section stipulates that it does not restrict the Secretary’s
authority to modify a contract after entering into such a contract.

Appointments Using Advanced Technology
This section requires the Secretary to ensure that eligible veterans are able to make their own
appointments using advanced technology.

Responsibility for the Scheduling of Appointments
This section requires the Secretary to be responsible for the scheduling of appointments for
eligible veterans.

Termination of Contracts
This section authorizes the Secretary to terminate contracts intended to establish networks of
health care providers. When the Secretary notifies an entity of his or her intention to terminate the
contract, the Secretary is required to notify the SVAC and HVAC that the entity failed to meet, at
a minimum, at least one of the following provisions:


comply substantially with the provisions of the contract or with VCCP
regulations established by the Secretary; or



comply with the access standards or the standards for quality established by
the Secretary; or
be excluded from participation in a federal health care program; or



31 Amended by the Department of Veterans Affairs Expiring Authorities Act of 2018 (S. 3479; P.L. 115-251).
32 Title 42 U.S.C. §§1395 et seq. Providers under Medicare include patient care institutions such as hospitals, critical

access hospitals, hospices, nursing homes, and home health agencies. See, https://www.cms.gov/Medicare/ProviderEnrollment-and-Certification/CertificationandComplianc/index.html.

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


be identified as an excluded source on the list maintained in the System for
Award Management, or any successor system; or
have been convicted of a felony or other serious offense under federal or
state law, and the continued participation of the entity would not be in the
best interests of veterans or the VA.

The Secretary may also terminate a contract if it is no longer needed based on the health care
needs of veterans, or if there are other contracts or sharing agreements. This section also requires
the Secretary to submit a report to SVAC and HVAC regarding contract terminations.
Whenever the Secretary notifies a contractor that it is failing to meet contractual obligations
required by the Secretary in the respective contract, the Secretary shall submit to SVAC and
HVAC a report on such failure. The report must include the following:






an explanation of the reasons for providing a notice to a contractor for
terminating a contract;
a description of the effect of the contractor’s failure to meet contractual
obligations, including with respect to cost, schedule, and requirements;
a description of the actions taken by the Secretary to mitigate failures by the
contractor to meet its contractual obligations;
a description of the actions taken by the contractor to address failures in
meeting its contractual obligations; and
a description of any effect on the community provider market for veterans in
the affected area.

Interim Recognition of Credentials and Qualifications33
This section requires the Secretary to instruct an entity that was awarded a contract to establish
networks of health care providers to recognize and accept, on an interim basis, the credentials and
qualifications of health care providers who are authorized to furnish care to veterans under a
community care program prior to the establishment of the VCCP. These include providers under
the Patient-Centered Community Care Program (PCCC)34 and the Veterans Choice Program
(VCP).

Systems for Monitoring the Quality of Care
This section requires the Secretary to establish a system to monitor the quality of care provided
through a network, or networks, of providers prior to contract renewal for such a network.

Payment Rates for Care and Services
This section stipulates that, with some exceptions, the rate paid for care or services through
VCCP may not exceed the rate paid to providers under the Medicare program under Title XVIII
of the Social Security Act, set by the Centers for Medicare & Medicaid Services (CMS),
33 Amended by the Department of Veterans Affairs Expiring Authorities Act of 2018 (S. 3479; P.L. 115-251).
34 The PCCC (PC3) contracts were awarded in September 2013 to provide inpatient and outpatient specialty care and

mental health care for eligible veterans when the local VA Medical Center (VAMC) cannot readily provide the
services, such as when there is a lack of available specialists, there are long wait times, or there is an extraordinary
distance from a veteran’s home.

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including rates paid under Medicare for Durable Medical Equipment (DME). However, the
Secretary may negotiate and pay a higher rate than the established Medicare rate for eligible
veterans in highly rural areas. Furthermore, in the state of Alaska, the VA will be able to
reimburse providers under the VA Alaska Fee Schedule; in states with an All-Payer Model
agreement, the VA will calculate Medicare payments based on payment rates under such
agreements.35 When a given type of care or service is not payable under Medicare rates, or is
payable under Medicare but does not have established pricing at the national or local level, those
services are required to be paid based on rates established by the Secretary. The Secretary may
also use alternative value-based reimbursement models to promote high-quality care through
VCCP.

Treatment of Veterans Other Health Insurance
This section requires the Secretary to collect or recover reasonable charges for the cost of medical
care or services furnished to an eligible veteran under VCCP for a nonservice-connected
disability if the veteran has third-party health insurance coverage. The VA’s right to recovery and
collections is limited to the same extent as when the veteran or community care provider would
otherwise be eligible to receive payment for such medical care or services from a third-party
payer, such as a private medical insurer, if the care or services had not been furnished by the VA.

Veterans Out-of-Pocket Expenses
This section stipulates that an eligible veteran’s copayments under VCCP will be the same as the
copayments paid for the same nonservice-connected care or services provided at a VA medical
facility.

Authority for Organ Transplant Coverage
This section requires the Secretary to authorize organ or bone marrow transplants to eligible
veterans at non-VA facilities. An eligible veteran under this section is a (1) veteran who requires
an organ or bone marrow transplant, and (2) based on the veteran’s primary care provider’s
opinion, has a medical necessity to travel outside the Organ Procurement and Transplantation
Network (OPTN)36 region in which the veteran resides.

Monitoring and Assessing of Care Provided Through VCCP
This section requires the Secretary to submit a report to the SVAC, HVAC, SAC, and HAC on the
types and frequency of care provided under VCCP. The first report is due no later than 540 days
after the enactment of the Caring for Our Veterans Act of 2018, and annually thereafter. The
report must include the following data elements, among others: (1) the top 25% of types of care
and services most frequently provided under VCCP because the VA is not providing such care and
35 As amended by the Consolidated and Further Continuing Appropriations Act, 2015 (P.L. 113-235). Maryland

operates the nation’s only all-payer hospital rate regulation system. Under Section 1814(b)(3) of the Social Security
Act, the Centers for Medicare & Medicaid Services (CMS) has exempted certain hospitals in Maryland from
reimbursement under the national payment system and has allowed the state to set reimbursement rates payable by
Medicare for applicable services that otherwise would be reimbursed under Medicare’s Inpatient Prospective Payment
System (IPPS) and Outpatient Prospective Payment System (OPPS). On January 10, 2014, CMS and the State of
Maryland jointly announced a new initiative to modernize Maryland’s unique all-payer rate-setting system for hospital
services. In the state of Maryland, the VA will follow this reimbursement system (also see https://innovation.cms.gov/
initiatives/Maryland-All-Payer-Model/).
36 https://optn.transplant.hrsa.gov/ (accessed August 14, 2018).

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services; (2) the frequency of care and services that were sought by eligible veterans under
VCCP; (3) an analysis of why the VA was not able to provide care and services sought by eligible
veterans; (4) steps the VA took to provide care and services at a VA medical facility; and (5) the
cost of care and services provided under VCCP.
This section also requires the Secretary to compile various data elements, gap analysis, and
assessments of care provided under VCCP. These include, among others, (1) data on the types of
care and services and the number of veteran patients using each type of care; (2) gaps in care and
services provided through VCCP community care networks; (3) identification of ways in which
those gaps can be fixed; (4) assessment of the total amounts spent by the VA to provide care to
eligible veterans through VCCP community care networks; (5) assessment of the timeliness of VA
referrals to VCCP community care networks; and (6) assessment of the timeliness of VCCP
community care networks in accepting referrals and scheduling appointments. Furthermore, the
Secretary is required to report on the number of VA medical service lines not providing care
under standards developed by the Secretary, and to assess the use of academic affiliates and other
federal health care facilities under VCCP. The Secretary is required to provide a report on all the
above information to SVAC and HVAC no later than 540 days after the date of the enactment, and
annually thereafter.

Prohibition on Limiting Medical Care and Services
This section prohibits the Secretary from limiting hospital care, medical services, or extended
care services under VCCP if it is in the best interest of the eligible veteran, as determined by the
veteran and the veteran’s health care provider.

No Changes in Eligibility Criteria
This section states that no changes are made to a veteran’s eligibility criteria for hospital care,
medical services, or extended care services under VCCP (i.e., if a veteran is not eligible under
current law for a specific care or service, he or she is not eligible for that specific care or service
under VCCP).

Effective Date of VCCP and Publication of Regulations to Implement VCCP
This section stipulates that the effective date of VCCP implementation would be the later of (a) a
date that is 30 days after the date the Secretary submits a final report to Congress in which the
Secretary determines that 75% of the amounts deposited in the Veterans Choice Fund, established
under the Veterans Access, Choice, and Accountability Act of 2014 (P.L. 113-146; as amended),
have been exhausted, or (b) on the date when the Secretary is required to promulgate regulations
implementing VCCP, which is one year after the date of the enactment (i.e., June 6, 2019).

Continuity of Existing Community Care Agreements
This section requires the Secretary to continue all existing contracts, memorandums of
understanding, memorandums of agreement, and other arrangements between the VA and the
American Indian and Alaska Native health care systems and Native Hawaiian health care
systems.

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Section 102. Authorization of Agreements Between Department of Veterans
Affairs and Nondepartment Providers
This section amends current law to add a new 38 U.S.C. §1703A, which authorizes the Secretary
to enter into agreements with community providers. In the following paragraphs, “this section”
means the newly amended §1703A and its subdivisions.

Authorization of Community Care Agreements
This section authorizes the Secretary to enter into agreements known as Veterans Care
Agreements (VCAs) if care cannot be feasibly delivered through VA facilities, VCCP community
care networks, or other statutory authorities to provide care in the community. When authorizing
care under VCAs, the Secretary is required to consider factors that would make the use of a VA
facility or a community care network facility impracticable or inadvisable for the eligible veteran,
such as a veteran’s medical condition, the travel involved, the nature of the care or services
required, or a combination of these factors.

The Review of Each VCA
This section requires the Secretary to review each VCA of material size that has been entered into
for at least six months by the date of review. The reviews are required within the first two years
after going into effect, and not less than every four years thereafter. For VCAs used for the
purchase of extended care services in FY2019 and after, the material size will be defined as those
exceeding $5 million annually.

Entities and Providers Eligible to Enter into VCAs
This section stipulates which entities and providers are eligible to enter into VCAs. These include
(1) any provider of services that has enrolled and entered into a provider agreement under
Medicare, and any physician or other supplier who has enrolled and entered into a participation
agreement under Medicare; (2) any provider participating under a State Medicaid program; (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); (4) a center for independent living (as defined
in Section 702 of the Rehabilitation Act of 1973); and (5) any other entity or provider as
determined by the Secretary.

Certification of Eligible VCA Entities and Providers
This section requires the Secretary to develop a certification process through the promulgation of
regulations. The regulations at a minimum must (1) set deadlines for applications for certification;
(2) provide standards for approval or denial of certification; (3) require the denial of certification
if an entity or provider is excluded from participation in a federal health care program such as
Medicare and Medicaid;37 and (4) establish procedures for screening providers or entities for the
risk of fraud, waste, and abuse.

37 42 U.S.C. §1320a-7b(f) defines “federal health care program” as (1) any plan or program that provides health

benefits, whether directly through insurance, or otherwise, that is funded directly, in whole or in part, by the U.S.
government (not including health insurance provided to federal government employees), or (2) any state health care
program, as defined in Section 1128(h) of the Social Security Act (42 U.S.C. §1320a-7(h)).

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Reimbursement Rates Under VCAs
This section requires that rates paid by the VA for hospital care, medical services, and extended
care services provided under VCAs be similar to rates paid under the VCCP. (Rates paid for care
or services through VCCP may not exceed rates paid to providers under the Medicare program,
set by CMS, including rates paid under Medicare for Durable Medical Equipment [DME].)

Requirements for Providers and Entities Entering into VCAs
This section requires the Secretary to promulgate regulations that define the terms under which
providers and entities could enter into to VCAs with the VA. VCAs will be required to accept
payments at the rates established through regulations, to accept payments in full, and to not hold a
veteran liable for any care provided through a VCA authorization. In addition, entities are not
allowed to bill a veteran’s third-party health insurance provider for any care or service that is
furnished or paid for by the VA, and entities are required to meet all other terms and conditions,
including quality of care standards specified in regulations.

Discontinuation or Nonrenewal of a VCA
This section authorizes the Secretary to discontinue a VCA based on the following factors: (1) it
is determined that the eligible entity or provider failed to comply with the requirements of the
VCA; (2) it is determined that the eligible entity or provider is excluded from participation in a
federal health care program; (3) it has been ascertained that the eligible entity or provider has
been convicted of a felony or other serious offense, or the provider’s continued participation
would be detrimental to the best interests of veterans or the VA; or (4) it has been determined that
it is reasonable to terminate the agreement based on the health care needs of the veteran.

Monitoring Quality of Care of VCAs
This section requires the Secretary to establish a system for monitoring the quality of care
provided to veterans through VCAs, and to use such information when determining whether to
renew VCAs.

Exclusion of VCAs from Federal Laws Governing Federal Contracts
This section stipulates that VCAs are not subject to competitive procedures associated with
federal contracts for the acquisition of goods or services, and that VCAs are exempt from any
provisions in law similar to those provisions that exempt Medicare providers. Entities that enter
into VCAs would not be considered federal contractors or subcontractors. However, entities and
providers that enter into VCAs with the VA are subject to all federal laws regarding integrity,
ethics, and fraud, as well as all laws that protect against employment discrimination or that
otherwise ensure equal employment opportunities.

Definition of Covered Individuals under VCAs38
This section defines those eligible to receive care through VCAs as any individual eligible for
hospital care, medical services, or extended care services under any law administered by the VA.

38 Amended by the Department of Veterans Affairs Expiring Authorities Act of 2018 (S. 3479; P.L. 115-251).

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Parity of Treatment
This section requires that care and services provided to veterans through VCAs should be similar
and be subject to the same terms as care provided in a VA facility.

Section 103. Authorizing State Veterans Homes to Enter into VCAs
This section amends current law 38 U.S.C. §1745 to authorize the VA to enter into VCAs with
State Veterans Homes. These VCAs, similar to Medicare providers, are exempt from certain
federal contracting laws and are not subject to competitive procedures associated with federal
contracts for the acquisition of goods or services, including any provisions in law similar to those
provisions that exempt Medicare providers. State Veterans Homes that enter into VCAs are not
considered federal contractors or subcontractors. However, State Veterans Homes that enter into
VCAs with the VA are subject to all federal laws regarding integrity, ethics, and fraud, as well as
laws that protect against employment discrimination or that otherwise ensure equal employment
opportunities.

Section 104. Access Standards and Standards for Quality
This section amends current law to add two new sections (38 U.S.C. §1703B and §1703C) that
require the Secretary to develop access and quality standards for furnishing hospital care, medical
services, or extended care services to eligible veterans under the VCCP. In the following
paragraphs, this section means the newly amended Section 1703B and Section 1703C and their
respective subdivisions.

Access Standards
This section requires the Secretary to establish access standards for hospital care, medical
services, and extended care services furnished by the VA and health care providers under the
VCCP. It also requires the Secretary to ensure that the access standards established by the VA are
clear, useful, and timely so that veterans, employees of the VA, and health providers in the VCCP
have relevant comparative information upon which to make informed and responsible decisions.
It also requires the Secretary to consult DOD, HHS, CMS, private sector entities, and other
nongovernmental entities when establishing access standards. The Secretary is required to submit
a report detailing the access standards to SVAC, HVAC, SAC, and HAC no later than 270 days
after enactment. Prior to this, the Secretary is required to provide the first update no later than 120
days after enactment. No later than 540 days after the Secretary implements access standards, the
Secretary is required to submit a report to SVAC, HVAC, SAC, and HAC detailing the
implementation. The Secretary is also required to review the access standards on a periodic basis.
The first review is required three years after the access standards are first established, and not less
than every three years thereafter. It requires the Secretary to publish the established access
standards in the Federal Register and on the VA website. This section stipulates that an eligible
veteran could contact the VA at any time and request care through the VCCP, provided that a VA
facility is unable to provide care or services based on access standards established by the VA.

Standards for Quality
This section requires the Secretary to establish standards of quality for hospital care, medical
services, and extended care services provided by the VA and the VCCP, and requires the
Secretary, when establishing standards for quality, to consider existing health quality measures in
both the private and public health care systems in order to provide veterans relevant comparative

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information. The Secretary is required to consult with DOD, HHS, CMS, and other entities in
developing these standards. The Secretary is required to submit a report detailing the standards
for quality to SVAC, HVAC, SAC, and HAC no later than 270 days after enactment, and to
provide periodic updates to SVAC, HVAC, SAC, and HAC prior to submitting the quality
standards report. The first update is due 120 days after enactment. Moreover, no later than two
years after the Secretary establishes quality standards, the Secretary is required to seek public
comment and make any changes to quality measures.

Section 105. Access to Walk-In Care
This section amends current law to add a new 38 U.S.C. §1725A, which requires the Secretary to
develop procedures to allow certain veterans to access walk-in care through community
providers. All veterans enrolled in the VA health care system, and who have received VA care or
services within 24 months prior to accessing a walk-in care clinic, are eligible. Both requirements
must be satisfied for eligibility under this provision. Walk-in clinics that have entered into
contracts or other agreements with the VA, including FQHCs, are eligible to participate in the
walk-in care clinic program. Under this section, walk-in care means nonemergent care provided
by qualifying non-VA providers or entities that furnish episodic care and not longitudinal
management of conditions, and as defined by the Secretary in regulations.

Copayments
This section requires veterans to pay certain copayments when receiving care through a walk-in
clinic or facility. If a veteran is required to pay a copayment for care at a VA facility, then the
veteran may be required to pay a copayment when accessing walk-in care. If a veteran is not
required to pay a copayment at a VA facility, then the first two visits in a calendar year will be
free, and any additional visits after the first two visits may require copayments, as determined by
the Secretary in regulations. If a veteran is required to pay a copayment for care at a VA facility,
then the veteran would be required to pay the same regular copayment amount for the first two
walk-in care visits in a calendar year. For any additional visits, a higher copayment amount, as
determined by the Secretary in regulations, may be required.

Effective Date
The Secretary is required to publish regulations no later than one year after the date of enactment,
and the effective date for walk-in care is the date when the final regulations pertaining to walk-in
care take effect.

Section 106. Strategy Regarding the VA High-Performing Integrated Health
Care Network.
This section amends current law to add a new 38 U.S.C. §7330C, which requires the Secretary to
conduct a quadrennial market area assessments regarding VHA health care services. The
assessment must assess the demand for VA health care; the VA’s health care capacity; the
capacity of VCCP providers; and the capacity of academic affiliates and other federal partners
that provide health care to veterans, among other factors. The Secretary is required to use this
assessment data when developing the President’s annual budget request to Congress. This section
requires the VA to submit the quadrennial market area assessments to SVAC, HVAC, SAC, and
HAC.

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Strategic Plan to Meet Health Care Demand
This section requires the Secretary to submit to SVAC, HVAC, SAC, and HAC a strategic plan
that provides a four-year forecast of (1) the demand for VA health care, (2) the health care at each
VAMC, and (3) the health care capacity to be provided through community care providers. The
first plan is required one year after the enactment, and then once every four years.

Section 107. Applicability of Directive of Office of Federal Contract
Compliance Programs
This section stipulates that the Office of Federal Contract Compliance Programs’ (OFCCP)
moratorium, which is currently applicable to all health care entities that participate in the
TRICARE program as subcontractors under a prime contract between DOD and the TRICARE
Management Activity, will be applicable in a similar manner to VCAs throughout the duration of
the moratorium.39

Section 108. Prevention of Certain Health Care Providers from Providing NonVA Health Care Services to Veterans
This section requires the Secretary to deny and revoke the eligibility of certain previous VA health
care providers from providing health care services to veterans in the community. Such providers
include those who have been removed from VA employment due to conduct that violated VA
policies pertaining to the safe delivery of health care to veterans, or those who violated their
medical licensing requirements and lost their medical license to practice. This section stipulates
that no later than two years after enactment, the GAO must submit a report to Congress regarding
the Secretary’s implementation of this provision.

Section 109. Remediation of Medical Service Lines
This section amends current law to add a new 38 U.S.C. §1706A, which requires the Secretary to
take steps to improve a medical service line that fails to meet the quality standards established by
the Secretary. These steps include, among others things, increasing personnel; utilizing special
hiring incentives, such as the Education Debt Reduction Program (EDRP) and recruitment,
relocation, and retention incentives; utilizing direct hiring authority; providing improved training
for staff; purchasing improved equipment; and making structural modifications to the VAMC.
This section requires the Secretary to submit an annual report to Congress analyzing the
remediation actions taken by the Secretary to improve the VA medical service line.

Section 111. Prompt Payment to Providers
This section amends current law to add a new 38 U.S.C. §1703D, which delineates prompt
payment standards that the Secretary is required to follow for care provided to eligible veterans in
the community. This section requires the Secretary to pay health care providers and entities for
39 Office of Federal Contract Compliance Programs (OFCCP) is responsible for enforcing Executive Order (E.O.)

11246, as amended; Section 503 of the Rehabilitation Act of 1973, as amended; and the Vietnam Era Veterans’
Readjustment Assistance Act of 1974 (VEVRAA), as amended. Collectively, these laws prohibit federal contractors
and subcontractors from discriminating on the basis of race, color, religion, sex, national origin, and status as a
qualified individual with a disability or protected veteran. Beginning May 7, 2014, for a period of five years, OFCCP
stopped enforcement activities on TRICARE subcontractors. For more details and background, see Department of
Labor, Office of Federal Contract Compliance Programs, DIRECTIVE (DIR) 2014-01 https://www.dol.gov/ofccp/regs/
compliance/directives/dir2014_01.htm.

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care furnished to veterans within 45 calendar days of receiving a clean paper claim, or within 30
calendar days of receiving a clean electronic claim. In addition, if the Secretary denies a paper
claim, the Secretary must within 45 calendar days notify the entity regarding the reasons for
denial and request additional information to process the claim. If an electronic claim is denied,
the Secretary has 30 days to notify an entity and request additional information.

Submittal of Claims by Health Care Entities and Providers
This section requires a community health care provider or entity to submit a claim for payment to
the VA no later than 180 days after the date in which care or services were provided to an eligible
veteran.

Fraudulent Claims
This section stipulates that penalties and civil action applicable to false or fraudulent claims for
payment or approval as delineated in 31 U.S.C. §§3729-3733 will be applicable in the same
manner to entities and providers submitting false or fraudulent claims to the Secretary.

Overdue Claims
This section stipulates that any claim that has not been denied by the Secretary and for which
payment is pending for more than 45 calendar days following the receipt of a clean paper claim,
or more than 30 calendar days of receiving a clean electronic claim, will be deemed an overdue
claim. Such overdue claims may be subject to the Prompt Payment Act (31 U.S.C. Chapter 39)
requirements.

Overpayment40
This section stipulates that the Secretary may deduct overpayments to a health care provider or
entity after reasonable steps have been taken to resolve the dispute. The Secretary may also use
other means as authorized by federal law to correct or recover overpayments.

Information and Documentation Required
This section requires the Secretary to provide all relevant documentation to community health
care providers and entities in order for them to generate clean claims.

Processing of Claims
The sections authorizes the Secretary to contract with the entity contracted to develop the VCCP
network, or another private medical claims processor, to process community care medical claims.

Report on Encounter Data System
This section requires the Secretary to submit a report to SVAC, SAC, HVAC, and HAC on the
feasibility and advisability of adopting a funding mechanism similar to other federal agencies that
use a fiscal intermediary (a private insurance company) to serve as the federal government’s
agents in the administration of a health care program, including the payment of medical claims.
This report is due no later than 90 days after enactment.

40 Amended by the Department of Veterans Affairs Expiring Authorities Act of 2018 (S. 3479; P.L. 115-251).

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Section 112. Authority to Pay for Authorized Care Not Subject to an Agreement
This section amends current law to add a new U.S.C. §8159, which authorizes the Secretary to
compensate for care provided to a veteran, even if the provider or entity does not have a contract
or agreement with the VA. The Secretary is required take reasonable steps to enter into a contract
or other arrangement with such an entity or provider so that future care provided to a veteran will
be subject to an agreement, contract, or other reimbursable arrangement.

Section 113. Improvement of Authority to Recover the Cost of Services
Furnished for Nonservice-Connected Disabilities
This section amends current law 38 U.S.C. §1729, which authorizes the Secretary to recover the
cost of care for nonservice-connected conditions of veterans, and expands it to include care
furnished by the VA to nonveterans requiring emergency services as well. It also authorizes the
Secretary to seek collections in the event that the VA pays for care, rather than just furnishes it.
This section also authorizes the Secretary to recover the cost of care of a nonservice-connected
disability incurred by an individual who is entitled to care, or payment for the expenses of care,
under a private health insurance plan.

Section 114. Processing of Claims for Reimbursement Through Electronic
Interface
This section authorizes the Secretary to enter into an agreement with a third party to process
medical claims using an electronic method.

Section 121. Education Program on Health Care Options
This section requires the Secretary to develop and conduct an education program to teach
veterans about their health care options through the VA health care system, as well as VCCP
eligibility criteria and any financial obligations they may have for their nonservice-connected
care. It also requires that veterans be taught about the interaction between Medicare, Medicaid,
TRICARE, tribal health programs, and VA health care.

Section 122. Training Program for Administration of Non-VA Health Care
This section requires the Secretary to develop and implement a training program to educate VA
employees and contractors about VCCP, reimbursement for non-VA community emergency room
services, and safe opioid prescription management, and how to administer these programs. This
section also requires the Secretary to develop a method to evaluate the training program, and to
submit a report to Congress each year regarding the findings from the most recent evaluation.

Section 123. Continuing Medical Education for Non-VA Medical Professionals
This section requires the Secretary to establish a continuing medical education program to
provide education material to non-VA medical professionals. These education materials must
include, among other things, information on identifying and treating mental and physical
conditions of veterans, as well as the VA health care system. The materials provided to non-VA
community care providers must be the same as those provided to VA health care providers. The
Secretary is required to determine the curriculum of the program and the credit hour
requirements, to develop a method to evaluate the continuing medical education program, and to
provide a report to Congress about its effectiveness. A non-VA medical professional is defined in

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this section as “any individual who is licensed by an appropriate medical authority in the United
States and is in good standing, is not an employee of the Department of Veterans Affairs, and
provides care to veterans or family members of veterans under the laws administered by the
Secretary of Veterans Affairs.”

Section 131. Establishment of Processes to Ensure Safe Opioid Prescribing
Practices by Non-VA Health Care Providers
This section requires the Secretary to ensure that all non-VA, nonfederal community providers are
knowledgeable about opioid-prescribing practices described in the “Opioid Safety Initiative of the
Department of Veterans Affairs.” It further requires the Secretary to create a process to ensure that
VA, non-VA, and nonfederal community providers share all medication and medical history of an
eligible veteran. The VA is responsible for monitoring an eligible veteran’s prescriptions, as
described in the “Opioid Safety Initiative of the Department of Veterans Affairs.”

Section 132. Improving Information Sharing with Community Providers
This section amends current law 38 U.S.C. §7332 regarding the confidentiality of certain medical
records and adds a new subparagraph. This amended section authorizes the Secretary to share a
veteran’s confidential VA medical records with non-VA entities, including private entities and
other federal agencies, for the purposes of providing health care, as well as with third-party
insurance providers, for the purposes of recovering charges for care provided to a veteran with a
nonservice-connected condition.

Section 133. Competency Standards for Non-VA Health Care Providers
Establishment of Standards and Requirements
This section requires the Secretary to establish standards and requirements for non-VA
community providers to follow when providing care to eligible veterans. Specifically, these
standards and requirements must focus on clinical areas for which the VA has special expertise,
including post-traumatic stress disorder, military sexual trauma-related conditions, and traumatic
brain injuries.

Condition for Eligibility to Furnish Care
Each non-VA community provider must meet the standards and training requirements specified
by the Secretary before providing care to an eligible veteran in the clinical areas for which the VA
has special expertise, including post-traumatic stress disorder, military sexual trauma-related
conditions, and traumatic brain injuries.

Effective Date
This section will take effect one year after the date of the enactment.

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Section 134. VA Participation in National Network of State-Based Prescription
Drug-Monitoring Programs41
This section amends current law to add a new 38 U.S.C. §1730B. It requires the VA to enter into
an agreement with a national network of prescription drug-monitoring programs (PDMPs) or any
state or regional prescription drug-monitoring program, to allow licensed VA health care
providers to query controlled substance prescriptions (21 U.S.C. §802(6)) written in participating
states or regions. It requires VA health care providers practicing in states that do not have a PDMP
to join the nearest state or regional PDMP.

Section 141. Plans for Use of Supplemental Appropriations
Whenever the Secretary requests from Congress supplemental appropriations or any other type of
appropriation outside the annual congressional appropriations process, this section requires the
Secretary to submit to Congress a justification detailing how the Secretary intends to use the
requested appropriation and the expected duration of the supplemental appropriations.

Section 142. Veterans Choice Fund Flexibility
This section authorizes the Secretary, beginning on March 1, 2019, to use the remaining funds in
the VCF for care in the community programs provided at non-VA facilities. However, the
Secretary is prohibited from using the remaining VCF funds for VCCP.

Section 143. Sunset of Veterans Choice Program
This section amends VACAA and stipulates that the Secretary may not authorize care under the
VCP program one year after the date of enactment (i.e., on June 6, 2019).

Subtitle B: Improving VA Health Care Delivery
In general, VA providers are able to practice across state lines in VA health care facilities with
clinical privileging and a single, unrestricted, active state license.42 However, these providers
cannot practice in non-VA health care facilities located in states where they are not licensed. For
that reason, according to the VA, some VA providers were concerned that their state licensing
boards might take action against their licenses if they provided telehealth services in non-VA
health care facilities in states where they were not licensed.43 To address this issue, on May 11,
2018, the VA finalized a rule to exempt its providers that deliver care via telemedicine from
certain state licensing laws and regulations.44 The VA’s final rule became effective on June 11,
2018. The passage of the VA MISSION Act codified the core elements of VA’s final rule in
statute. The rule provides the details of how VA will implement the provisions contained in the
new law.

41 Amended by the Department of Veterans Affairs Expiring Authorities Act of 2018 (S. 3479; P.L. 115-251).
42 VHA, Credentialing and Privileging, VHA Handbook 1100.19, Washington, DC, October 15, 2012.
43 VA, “Authority of Health Care Providers to Practice Telehealth,” 82 Federal Register 45757, October 2, 2017.
44 VA, “Authority of Health Care Providers to Practice Telehealth,” 83 Federal Register 21897-21907, May 11, 2018.

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Section 151. Licensure of Health Care Professionals of the VA Providing
Treatment Via Telemedicine
This section amends current law to add a new 38 U.S.C. §1730B, which removes all geographical
barriers to telemedicine, therefore allowing a telemedicine episode of care to be delivered without
regard to where a veteran patient and VA provider are located within the United States and U.S.
territories, and without regard to whether the veteran patient is located in a non-VA health care
facility.45 It also protects VA providers against possible liability issues stemming from state
licensure laws by prohibiting states from denying or revoking the licenses, registrations, or
certifications of VA providers that practice under this authority.
This section also requires the Secretary, not later than one year after enactment, to submit an
annual report to Congress outlining the effectiveness of the agency’s use of telemedicine. The
report must contain six elements: (1) incurred savings; (2) veteran patients’ satisfaction in
receiving telemedicine; (3) VA providers’ satisfaction in providing telemedicine; (4) the types of
telemedicine services delivered; (5) the number of telemedicine episodes of care delivered, by
medical facility; and (6) outcome measurements, such as accessibility to and the frequency of use
of telemedicine services by veteran patients.

Section 152. Authority for the VA Center for Innovation for Care and Payment
This section amends current law to add a new 38 U.S.C. §1703E, which establishes within the VA
a Center for Innovation for Care and Payment. The Secretary may implement appropriate pilot
programs to develop innovative approaches to testing payment and service delivery models, with
the goal of reducing expenditures and enhancing the quality of care for veterans. However, the
Secretary is prohibited from testing payment and service delivery models that would allow the VA
to bill or recover charges from Medicare, Medicaid, or TRICARE for health care services
provided to veterans eligible under those programs. In implementing this section, the Secretary
may waive certain requirements. However, the Secretary is required to notify Congress before
waiving such requirements.

Section 153. Authority for Operations on Live Donors for the Purposes of
Conducting Transplant Procedures for Veterans
This section amends current law to add a new 38 U.S.C. §1788, which, subject to the availability
of appropriations, requires the Secretary to furnish to any live donor, regardless of whether the
donor is a veteran, any care or services that may be required in connection with such procedure
before and after conducting the transplant procedure for an eligible veteran. The Secretary could
provide for the operation on a live donor and furnish to the live donor the care and services at a
VA or Non-VA facility.

Subtitle C: Family Caregivers
In recognition of the significant role that family caregivers play in providing personal care
services and other supports to veterans, the Caregivers and Veterans Omnibus Health Services Act
45 Telemedicine is the electronic delivery of a clinical health care service via a technological method. See Department

of Health and Human Services (HHS), Report to Congress: E-health and Telemedicine, August 12, 2016, pp. 4-5,
https://aspe.hhs.gov/system/files/pdf/206751/TelemedicineE-HealthReport.pdf. The Department of Veterans Affairs
uses the term “telehealth” in its regulations to mean “the use of electronic information or telecommunications
technologies to support clinical health care, patient and professional health-related education, public health, and health
administration” (38 C.F.R. §17.417).

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of 2010 (P.L. 111-163) was signed into law on May 5, 2010. The law requires the Secretary to
establish the following two programs:



Program of General Caregiver Support Services, which includes caregiver
programs for veterans of all eras.
Program of Comprehensive Assistance for Family Caregivers
(Comprehensive Care Program), which provides additional supports and
services, including financial compensation in the form of a caregiver stipend,
to family caregivers of eligible veterans or servicemembers seriously injured
in the line of duty on or after September 11, 2001 (post-9/11 veterans).

Subtitle C expands the VA’s Comprehensive Care Program over time to include veterans of all
eras (pre-9/11 veterans) and makes certain modifications to the services and assistance to family
caregivers in such program. These provisions also require the VA to implement an information
technology (IT) system that supports the Comprehensive Care Program and to amend the
requirements for VA’s annual evaluation report.

Section 161. Expansion of Family Caregiver Program of the VA
Eligibility
This section amends 38 U.S.C. §1720G(a)(2) to expand eligibility for the Comprehensive
Caregiver Program to pre-9/11 veterans, beginning on the date when the Secretary submits to
Congress the certification that the VA has fully implemented the IT system (described in Section
162), herein referred to as the certification date. Beginning on the certification date, the
Comprehensive Caregiver Program is extended over a two-year period to pre-9/11 veterans who
have a serious injury incurred or aggravated in the line of duty in the active military, naval, or air
service on or before May 7, 1975. Two years after the certification date, the Comprehensive Care
Program is extended to all pre-9/11 veterans, covering veterans of all eras. It requires the
Secretary, no later than 30 days after the date the Secretary submits to Congress the above
certification, to publish the certification date in the Federal Register.
It also amends 38 U.S.C. §1720G(a)(2) to expand the eligibility criteria for the Comprehensive
Caregiver Program to include those veterans in need of personal care services because of 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, among other existing criteria.

Caregiver Assistance
This section amends 38 U.S.C. §1720G(a)(3) to expand the types of assistance available to family
caregivers under the Comprehensive Care Program to include financial planning services and
legal services relating to the needs of injured veterans and their caregivers. It further amends this
subsection regarding the monthly stipend determination to specify that in determining the amount
and degree of personal care services provided to an eligible veteran whose need is based on a
need for supervision or protection, as specified, or regular instruction or supervision, as specified,
the determination must take into account (1) the assessment by the family caregiver; (2) the
extent to which the veteran can function safely and independently without supervision, protection,
or instruction; and (3) the amount of time required for the family caregiver to provide
supervision, protection, or instruction.
It also adds new language under 38 U.S.C. §1720G(a)(3) that in providing instruction,
preparation, and training to each approved family caregiver, the Secretary is required to

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periodically evaluate the needs of the eligible veteran and the skills of the family caregiver to
determine if additional support is necessary. It amends 38 U.S.C. §1720(a)(5) to require the
Secretary to evaluate each application submitted jointly by an eligible veteran in collaboration
with the primary care team for the eligible veteran to the maximum extent practicable.
It further adds a new paragraph under 38 U.S.C. §1720(a) that in providing assistance to family
caregivers of eligible veterans, the Secretary may enter into contracts or agreements with
specified entities to provide family caregivers such assistance. The Secretary is required to
provide such assistance only if it is reasonably accessible to the family caregiver and is
substantially equivalent or better in quality to similar services provided by the VA. It authorizes
the Secretary to provide fair compensation to federal agencies, states, and other entities that
provide such assistance.
It amends the definition of personal care services under 38 U.S.C. §1720(d)(4) to include services
that provide the veteran with (1) supervision or protection based on symptoms or residuals of
neurological or other impairment or injury, and (2) regular or extensive instruction or supervision
without which the ability of the veteran to function in daily life would be seriously impaired.

Section 162. Implementation of Information Technology System of the VA to
Assess and Improve the Family Caregiver Program
This section requires the Secretary to implement an IT system, no later than October 1, 2018,
with certain specified elements that fully supports the Comprehensive Caregiver Program and
allows for data assessment and program monitoring. No later than 180 days after implementing
the IT system, the Secretary is required, through the Under Secretary for Health, to conduct an
assessment of how key aspects of the Comprehensive Caregiver Program are structured and
carried out using data from the IT system and any other relevant data. The Secretary is required to
use the IT system to monitor and assess program workload, and to implement certain
modifications necessary to ensure program functioning and timeliness of services.
It also requires the Secretary, no later than 90 days after enactment, to submit an initial report to
the SVAC, HVAC, and GAO on the status of the planning, development, and deployment of the
IT system. The initial report must include an assessment of the needs of family caregivers of
veterans eligible for the Comprehensive Program solely due to a serious injury incurred or
aggravated in the line of duty in the active military, naval, or air service before September 11,
2001; the resource needs for including such family caregivers; and any changes necessary to
ensure successful program expansion. The GAO is required to review the initial report and notify
SVAC and HVAC with respect to the progress of the Secretary in fully implementing the required
IT system, as well implementation of a process to monitor, assess, and modify the program as
necessary. No later than October 1, 2019, the Secretary is required to submit a final report to
SVAC, HVAC, and the GAO on system implementation, including program monitoring,
assessment, and modification, as specified.

Section 163. Modification to Annual Evaluation Report on Caregiver Program
of the VA
This section amends 38 U.S.C. §1720G note to add certain reporting requirements to VA’s
submission of the annual evaluation report to the SVAC and HVAC regarding program
implementation. With respect to both caregiver programs, it requires the annual evaluation report
to describe any barriers to accessing and receiving care and services under such programs. With
respect to the Comprehensive Caregiver Program, it adds new reporting language to evaluate the
sufficiency and consistency of the training provided to family caregivers under such programs.

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Title II: VA Asset and Infrastructure Review
The VHA operates in approximately 5,670 buildings and another 1,648 leased facilities.46 The last
major comprehensive review of VA real property and medical facilities throughout the country
was done under the Capital Asset Realignment for Enhanced Services (CARES) program. In
October 2000, the VA established the CARES program with the goal of evaluating the projected
health care needs of veterans over the next 20 years and of realigning VA’s infrastructure to better
meet those needs. In August 2003, VA’s then-Undersecretary for Health issued a preliminary
Draft National CARES Plan (DNCP). The DNCP, among other things, recommended that seven
VA health care facilities close and that duplicative clinical and administrative services delivered at
over 30 other VHA facilities be eliminated. The sites slated to be closed were in the following
locations: Canandaigua, NY; Pittsburgh, PA (Highland Drive Division); Lexington, KY
(Leestown Division); Cleveland, OH (Brecksville Unit); Gulfport, MS; Waco, TX; and
Livermore, CA. Patients currently receiving services at these VHA facilities would have been
provided care at other nearby sites. The DNCP recommended that new major medical facilities be
built in Las Vegas, NV, and East Central, FL. Furthermore, the DNCP recommended significant
infrastructure upgrades at numerous sites including, at or near locations where the VA proposed to
close facilities. In addition, the draft plan called for the establishment of 48 new high-priority
Community Based Outpatient Clinics (CBOCs).
Following the release of the DNCP, the then-VA Secretary Anthony Principi appointed a 16member independent commission to study the draft plan. The commission was composed of
individuals from a wide variety of backgrounds outside of the federal government. The CARES
Commission developed and applied six factors in the review of each proposal in the DNCP: (1)
impact on veterans’ access to health care, (2) impact on health care quality, (3) veteran and
stakeholder views, (4) economic impact on the community, (5) impact on VA missions and goals,
and (6) cost to the government. The commission conducted 38 public hearings and 81 site visits
throughout 2003 and submitted its recommendations to the Secretary in February 2004. After
reviewing the recommendations, the then Secretary announced the final details of the CARES
plan in May 2004 (Secretary’s CARES Decision). The final plan called for consolidating several
facilities, as well as building new hospitals in Orlando and Las Vegas; adding 156 new CBOCs,
four new spinal cord injury centers, and two blind rehabilitation centers; and expanding mental
health outpatient services nationwide. However, critics of the CARES plan contended that
closures were considered without assessing what kind of facilities would be needed for long-term
care and mental health care in the future. Also, some believed that the CARES plan did not focus
enough on future nursing home needs, would leave the VA short of beds in a few decades, and, as
a result, would leave the VA with no choice but to privatize some parts of the health care system.
Moreover, some veterans’ groups believed that CARES was only about closing “surplus”
hospitals and did not believe that CARES would result in the building of new and modern
facilities. Finally, the closure of some VA medical facilities raised serious concern among some
Members of Congress who felt that they had little control over the CARES process.47
The Independent Assessment required by Section 201 of VACAA found that
[c]urrent facilities, whether they have been maintained adequately or not, often do not
match current models of care. The overwhelming majority of VHA hospitals were designed
when care was focused more heavily around inpatient hospital treatments. Over the past
46 Department of Veterans Affairs, FY2019 Congressional Budget Submission, Medical Programs and Information

Technology Programs, Volume 2 of 4, February 2018, pp. VHA-251.
47 Honorable Bob Graham, “Statements on Introduced Bill and Joint Resolutions,” remarks in the Senate,
Congressional Record, 108th Congress, vol. 149 (June 18, 2003), p. S8135.

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eight years, Veteran inpatient bed days of care have declined nearly ten percent while
outpatient clinic workload has increased more than 40 percent. Space for outpatient care is
typically housed in converted inpatient spaces or VHA’s growing number of clinics. As a
result, VHA’s capital needs fall into a broad range of categories, including ensuring
adequate facility condition, providing sufficient and appropriate space for Veteran care,
and upgrading infrastructure. As facilities age further and care continues to shift to the
outpatient setting, the size of the capital need could continue to grow. 48

Furthermore, the Commission on Care was established by VACAA “to examine the access of
veterans to health care from the Department of Veterans Affairs and strategically examine how
best to organize the [VHA], locate health resources, and deliver health care to veterans.”49 In its
final report, it recommended that the VA “develop and implement a robust strategy for meeting
and managing VHA ‘s facility and capital asset needs.”50
Within this context, the HVAC began to examine VA’s capital asset program in the summer of
2017. At a hearing held on July 12, 2017, the then-VA Secretary who was involved in the CARES
plan testified that “under CARES there was no requirement for Congress to adopt or reject the
commission’s final recommendations as a package. As a result, recommendations for some
needed new hospitals and outpatient clinics were accepted. Most of those to change, realign, or
maybe close the mission of other facilities were rejected.”51
Based on input and recommendations from various stakeholders, on November 3, 2017, the VA
Asset and Infrastructure Review Act of 2017 (H.R. 4243) was introduced; it was ordered reported
on November 8 (without a written report). Provisions from H.R. 4243 were then incorporated as
Title II of the VA MISSION Act.

Subtitle A: Asset and Infrastructure Review
This title establishes a process for realigning and modernizing facilities of the VHA. Under this
process, the VA will develop criteria for selecting VHA facilities to dispose of, modernize, or
acquire, so as to better meet the health care needs of veterans. The VA must the

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Source: Frix Law Library, https://www.frixlaw.com/law-library/documents/crs%3AR45390. Public record. Not legal advice.