Sec. 102. Establishment of VA Care in the Community Program

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Chapter 17 of title 38, United States Code, is amended by inserting after section 1703 the following new section: Subject to the availability of appropriations for such purpose, hospital care, medical services, and extended care services under this chapter shall be furnished to an eligible veteran through contracts or agreements authorized under subsection (d), or contracts or agreements, including national contracts or agreements, authorized under section 8153 of this title or any other provision of law administered by the Secretary, with network providers for the furnishing of such care and services to veterans.

Subject to subsection (b), an eligible veteran may select a provider of such care or services from among network providers. The Secretary shall coordinate the furnishing of care and services under this section to eligible veterans. In carrying out this section, the Secretary shall establish regional networks of network providers. The Secretary shall determine, and may modify, such regions based on the capacity and market assessments of Veterans Integrated Service Networks conducted under subsection

(k)or upon recognized need. The Secretary may enter into one or more contracts for the purposes of managing the operations of the regional networks and for the delivery of care pursuant to this section. If the Secretary is unable to assign an eligible veteran to a patient-aligned care team or dedicated primary care provider under section 1706(d) of this title because the Secretary determines such a care team or provider at a Department facility is not available— the Secretary shall consult with the veteran regarding available primary care providers from among network providers that are located in the regional network in which the veteran resides or a regional network that is adjacent to the regional network in which the veteran resides; and the veteran may select one of the available primary care providers to serve as the dedicated primary care provider of the veteran. In determining whether a patient-aligned care team or dedicated provider under section 1706(d) of this title is available for assignment to a veteran, the Secretary shall take into consideration each of the following: Whether the veteran faces an unusual or excessive burden in accessing such patient-aligned care team or dedicated provider at a medical facility of the Department including with respect to— geographical challenges; environmental factors, including roads that are not accessible to the general public, traffic, or hazardous weather; a medical condition of the veteran; or such other factors as determined by the Secretary. Whether the veteran reasonably believes that the assignment of a particular care team or provider to the veteran would detrimentally affect the patient-provider relationship and result in sub-optimal care to the veteran. Whether the panel size of the care team or provider is at such a number that it would result in difficulty for the veteran in accessing timely care or in sub-optimal care to the veteran. If the Secretary determines that a patient-aligned care team or dedicated primary care provider at a Department facility has become available for assignment to an eligible veteran who had been assigned to a network provider under subparagraph (A), the Secretary shall provide the veteran with the option of reassignment to the team or provider at the Department facility. In the case of an eligible veteran who is assigned to a network provider under subparagraph (A), the Secretary shall reevaluate such assignment not earlier than one year after a veteran makes a selection under subparagraph (A)(ii), and on an annual basis thereafter, to— determine whether the Secretary is able to assign to the veteran a patient-aligned care team or dedicated primary care provider under section 1706(d) of this title; and in consultation with and upon approval of the veteran, make such assignment if able. Except as provided in clause (ii), the Secretary may only furnish specialty hospital care, medical services, or extended care services to an eligible veteran under this section pursuant to a referral for such specialty care or services made by the primary care provider of the veteran. The Secretary may designate specialties which shall be exempt from the requirement under clause (i). The Secretary shall determine whether to furnish specialty hospital care, medical services, or extended care services to an eligible veteran pursuant to subparagraph (A)— at a medical facility of the Department that is within a reasonable distance of the residence of the veteran, as determined by the Secretary; by a network provider that, to the greatest extent practicable, is located in the regional network in which the veteran resides or a regional network that is adjacent to the regional network in which the veteran resides; or pursuant to an agreement described in subparagraph (C). An agreement described in this subparagraph is an agreement entered into by the Secretary with a network provider under which— specialty hospital care, medical services, or extended care services are furnished to an eligible veteran pursuant to subparagraph (A)— at a medical facility of the Department by a network provider possessing the appropriate credentials, as determined by the Secretary; or at a facility of a network provider by a health care provider of the Department; and such specialty care or services are so furnished either— in accordance with this section with respect to fees and payments for care and services furnished under subsection (a); or at no cost to the United States. In making the determination under subparagraph (B), the Secretary shall give priority to medical facilities and health care providers of the Department but shall take into account— whether the veteran faces an unusual or excessive burden in accessing such specialty hospital care, medical services, or extended care services at a medical facility of the Department, including with respect to— geographical challenges; environmental factors, such as roads that are not accessible to the general public, traffic, or hazardous weather; a medical condition of the veteran; or such other factors as determined by the Secretary; and whether the primary care provider of the veteran recommends that such specialty hospital care, medical services, or extended care services should be furnished by a network provider. The Secretary shall ensure that each medical facility of the Department processes referrals for specialty hospital care, medical services, or extended care services in a standardized manner, including with respect to the organization of the program office responsible for such referrals. In carrying out this section, the Secretary shall establish a process to review any disagreement between an eligible veteran and the Department, or between an eligible veteran and a health care provider of the Department, regarding the eligibility of the veteran to receive care or services from a network provider under this section or the assignment of a primary care provider of the Department to the veteran. In reviewing a disagreement under such process with respect to the availability of and assignment to a patient aligned care team or dedicated primary care provider, the Secretary shall give deference to the veteran with respect to any determination under subsection (b)(1)(B)(ii). The Secretary shall ensure that, at the election of an eligible veteran who receives hospital care, medical services, or extended care services from a network provider in an episode of care under this section, the veteran receives such care or services from that network provider, another network provider selected by the veteran, or a health care provider of the Department, through the completion of the episode of care, including all specialty and ancillary services determined necessary by the provider as part of the treatment recommended in the course of such care or services. In making such determination with respect to necessary specialty and ancillary services provided by a network provider, the network provider shall consult with the Secretary, acting through the program office of the appropriate medical facility. In cases of episodes of care that the Secretary determines case management to be appropriate, the Secretary shall provide case management to an eligible veteran who receives hospital care, medical services, or extended care services from a network provider for such episodes of care. The Secretary may provide such case management through the Veterans Health Administration or through an entity that manages the operations of the regional networks pursuant to subsection (a)(4)(B). The Secretary shall enter into contracts or agreements, including national contracts or agreements for, but not limited to, dialysis, for furnishing care and services to eligible veterans under this section with network providers. In entering into a contract or agreement under paragraph

(1)with a network provider, the Secretary shall— negotiate rates for the furnishing of care and services under this section; and reimburse the provider for such care and services at the rates negotiated pursuant to clause

(i)as provided in such contract or agreement. Except as provided in paragraph (3), rates negotiated under subparagraph (A)(i) shall not be more than the rates paid by the United States to a provider of services (as defined in section 1861(u) of the Social Security Act ( 42 U.S.C. 1395x(u) )) or a supplier (as defined in section 1861(d) of such Act ( 42 U.S.C. 1395x(d) )) under the Medicare Program under title XVIII of the Social Security Act ( 42 U.S.C. 1395 et seq.) for the same care or services. In determining the rates under the Medicare Program under title XVIII of the Social Security Act ( 42 U.S.C. 1395 et seq.) for purposes of clause (i), in the case of care or services furnished by a provider of services with respect to which such rates are determined under a fee schedule to which the area wage index under section 1886(d)(3)(E) of the Social Security Act ( 42 U.S.C. 1395ww(d)(3)(E) ) applies, such area wage index so applied to such provider of services may not be less than 1.00. In carrying out paragraph (2), the Secretary may incorporate the use of value-based reimbursement models to promote the provision of high-quality care. With respect to the furnishing of care or services under this section to an eligible veteran who resides in a highly rural area (as defined under the rural-urban commuting area codes developed by the Secretary of Agriculture and the Secretary of Health and Human Services), the Secretary of Veterans Affairs may negotiate a rate that is more than the rate paid by the United States as described in paragraph (2)(B). With respect to furnishing care or services under this section in Alaska, the Alaska Fee Schedule of the Department of Veterans Affairs will be followed, except for when another payment agreement, including a contract or provider agreement, is in place. With respect to furnishing care or services under this section in a State with an All-Payer Model Agreement under the Social Security Act that became effective on or after January 1, 2014, the Medicare payment rates under paragraph (2)(B) shall be calculated based on the payment rates under such agreement, or any such successor agreement. With respect to furnishing care or services under this section in a location in which the Secretary determines that adjusting the rate paid by the United States as described in paragraph (2)(B) is appropriate, the Secretary may negotiate such an adjusted rate. With respect to furnishing care or services under this section in a location or in a situation in which an exception to the rates paid by the United States under the Medicare Program under title XVIII of the Social Security Act ( 42 U.S.C. 1395 et seq.) for the same care or services applies, the Secretary may follow such exception. With respect to furnishing care or services under this section for care or services not covered under the Medicare Program under title XVIII of the Social Security Act ( 42 U.S.C. 1395 et seq.), the Secretary shall establish a schedule of fees for such care or services. With respect to furnishing care or services under this section pursuant to an agreement with a tribal or Federal entity, the Secretary may negotiate a rate that is more than the rate paid by the United States as described in paragraph (2)(B). For the furnishing of care or services pursuant to a contract or agreement under paragraph (1), a network provider may not collect any amount that is greater than the rate negotiated pursuant to paragraph (2)(A). If, in the course of an episode of care under this section, any part of care or services is furnished by a medical provider who is not a network provider, the Secretary may compensate such provider for furnishing such care or services. The Secretary shall make reasonable efforts to enter into a contract or agreement under this section with any provider who is compensated pursuant to subparagraph (A). The Secretary shall ensure that claims for payments for hospital care, medical services, or extended care services furnished under this section are processed in accordance with this subsection, regardless of whether such claims are— made by a network provider to the Secretary; made by a network provider to a regional network operated by a contractor pursuant to subsection (a)(4)(B); or made by such a regional network to the Secretary. A covered claimant that seeks payment for hospital care, medical services, or extended care services furnished under this section shall submit to the covered payer a claim for payment not later than— with respect to a claim by a network provider, 180 days after the date on which the network provider furnishes such care or services; or with respect to a claim by a regional network operated by a contractor, 180 days after the date on which the contractor pays the network provider for furnishing such care or services. Notwithstanding chapter 39 of title 31 or any other provision of law, the covered payer shall pay a covered claimant for hospital care, medical services, or extended care services furnished under this section— in the case of a clean claim submitted to the covered payer on paper, not later than 45 calendar days after receiving the claim; or in the case of a clean claim submitted to the covered payer electronically, not later than 30 calendar days after receiving the claim. If the covered payer denies a claim submitted by a covered claimant under paragraph (1), the covered payer shall notify the covered claimant of the reason for denying the claim and the additional information, if any, that may be required to process the claim— in the case of a clean claim submitted to the covered payer on paper, not later than 45 calendar days after receiving the claim; or in the case of a clean claim submitted to the covered payer electronically, not later than 30 calendar days after receiving the claim. Upon receipt by the covered payer of additional information specified under subparagraph

(A)relating to a claim, the covered payer shall pay, deny, or otherwise adjudicate the claim, as appropriate, not later than 30 calendar days after receiving such information. If the covered payer has not paid a covered claimant or denied a clean claim for payment by the covered claimant under this subsection during the appropriate period specified in this subsection, such clean claim shall be considered overdue. If a clean claim for payment by a covered claimant is considered overdue under subparagraph (A), in addition to the amount the covered payer owes the covered claimant under the claim, the covered payer shall owe the covered claimant an interest penalty amount that shall— be prorated daily; accrue from the date the payment was overdue; be payable at the time the claim is paid; and be computed at the rate of interest established by the Secretary of the Treasury, and published in the Federal Register, for interest payments under subsections (a)(1) and

(b)of section 7109 of title 41 that is in effect at the time the covered payer accrues the obligation to pay the interest penalty amount. If the covered payer overpays a covered claimant for hospital care, medical services, or extended care services furnished under this section— the covered payer shall deduct the amount of any overpayment from payments due to the covered claimant after the date of such overpayment; or if the covered payer determines that there are no such payments due after the date of the overpayment, the covered claimant shall refund the amount of such overpayment not later than 30 days after such determination. Before deducting any amount from a payment to a covered claimant under subparagraph (A), the covered payer shall ensure that the covered claimant is provided an opportunity— to dispute the existence or amount of any overpayment owed to the covered payer; and to request a compromise with respect to any such overpayment. The covered payer may not make any deduction from a payment to a covered claimant under subparagraph

(A)unless the covered payer has made reasonable efforts to notify the covered claimant of the rights of the covered claimant under subclauses

(I)and

(II)of clause (i). Upon receiving a dispute under subclause

(I)of clause

(i)or a request under subclause

(II)of such clause, the covered payer shall make a determination with respect to such dispute or request before making any deduction under subparagraph

(A)unless the time required to make such a determination would jeopardize the ability of the covered payer to recover the full amount owed to the covered payer. Notwithstanding any other provision of law, the Secretary may, except in the case of a fraudulent claim, false claim, or misrepresented claim, compromise any claim of an amount owed to the United States under this section. This subsection shall apply only to payments made on a claims basis and not to capitation or other forms of periodic payments to network providers. A network provider that provides hospital care, medical services, or extended care services to an eligible veteran under this section may not seek any payment for such care or services from the eligible veteran. With respect to making a payment for hospital care or medical services furnished to an eligible veteran by a network provider under this section— the Secretary may not require receipt by the veteran or the Department of a medical record under subsection

(g)detailing such care or services before a covered payer makes a payment for such care or services; and the Secretary may require that the network provider attests to such care or services so provided before a covered payer makes a payment for such care or services. The Secretary shall require an eligible veteran to pay a copayment for the receipt of care or services under this section only if such eligible veteran would be required to pay a copayment for the receipt of such care or services at a medical facility of the Department or from a health care provider of the Department under this chapter. The amount of a copayment charged under paragraph

(1)may not exceed the amount of the copayment that would be payable by such eligible veteran for the receipt of such care or services at a medical facility of the Department or from a health care provider of the Department under this chapter. In any case in which an eligible veteran is furnished hospital care or medical services under this section for a non-service-connected disability described in subsection (a)(2) of section 1729 of this title, the Secretary shall recover or collect reasonable charges for such care or services from a health-plan contract described in section 1705A in accordance with such section 1729. The Secretary shall ensure that any network provider that furnishes care or services under this section to an eligible veteran— upon the request of the veteran, provides to the veteran the medical records related to such care or services; and upon the completion of the provision of such care or services to such veteran, provides to the Department the medical records for the veteran furnished care or services under this section in a timeframe and format specified by the Secretary for purposes of this section, except the Secretary may not require that any payment by the Secretary to the eligible provider be contingent on such provision of medical records. To the extent practicable, the Secretary shall submit to a network provider that furnishes care or services under this section to an eligible veteran the medical records of such eligible veteran that are maintained by the Department and are relevant to such care or services. To the extent practicable, the Secretary shall— ensure that the medical records shared under paragraphs

(1)and

(2)are shared in an electronic format accessible by network providers and the Department through an Internet website; and provide to network providers access to the electronic patient health record system of the Department, or successor system, for the purpose of furnishing care or services under this section. The Secretary shall ensure that the veteran health identification card, or such successor identification card, includes sufficient information to act as an identification card for an eligible entity or other non-Department facility. The Secretary may not use any amounts made available to the Secretary to issue separate identification cards solely for the purpose of carrying out this section. With respect to requirements relating to the licensing or credentialing of a network provider, the Secretary shall ensure that the network provider is able to submit prescriptions for pharmaceutical agents on the formulary of the Department to pharmacies of the Department in a manner that is substantially similar to the manner in which the network provider submits prescriptions to retail pharmacies. Nothing in this section shall be construed to affect the process of the Department for filling and paying for prescription medications. In carrying out this section, the Secretary shall use the quality of care standards set forth or used by the Centers for Medicare & Medicaid Services or other quality of care standards, as determined by the Secretary. On a periodic basis, but not less often than once every three years, the Secretary shall conduct an assessment of the capacity of each Veterans Integrated Service Network and medical facility of the Department to furnish care or services under this chapter. Each such assessment shall— identify gaps in furnishing such care or services at such Veterans Integrated Service Network or medical facility; identify how such gaps can be filled by— entering into contracts or agreements with network providers under this section or with entities under other provisions of law; making changes in the way such care and services are furnished at such Veterans Integrated Service Network or medical facility, including but not limited to— extending hours of operation; adding personnel; or expanding space through construction, leasing, or sharing of health care facilities; and the building or realignment of Department resources or personnel; forecast, based on future projections and historical trends, both the short- and long-term demand in furnishing care or services at such Veterans Integrated Service Network or medical facility and assess how such demand affects the needs to use such network providers; include a commercial health care market assessment of designated catchment areas in the United States conducted by a nongovernmental entity; and consider the unique ability of the Federal Government to retain a presence in an area otherwise devoid of commercial health care providers or from which such providers are at a risk of leaving. The Secretary shall submit each assessment under paragraph

(1)to the Committees on Veterans’ Affairs of the House of Representatives and the Senate and shall make each such assessment publicly available. The Secretary shall develop a plan for the allocation of funds in the Medical Community Care account. Not later than December 31, 2019, and annually thereafter during each of the subsequent three years, the Secretary shall submit to the Committees on Veterans’ Affairs of the House of Representatives and the Senate a report detailing, for the fiscal year preceding the fiscal year during which the report is submitted, the rates paid by the Secretary for hospital care, medical services, or extended care services under this section that, pursuant to subsection (d)(3), are more than the rates described in subsection (d)(2)(B) for the same care or services. In this section: The term clean claim means a claim submitted— to the covered payer by a covered claimant for purposes of payment by the covered payer of expenses for hospital care or medical services furnished under this section; that contains substantially all of the required elements necessary for accurate adjudication, without requiring additional information from the network provider; and in such a nationally recognized format as may be prescribed by the Secretary for purposes of paying claims for hospital care or medical services furnished under this section. The term covered claimant means— a network provider that submits a claim to the Secretary for purposes of payment by the Secretary of expenses for hospital care or medical services furnished under this section; or a regional network operated by a contractor pursuant to subsection (a)(4)(B) that submits a claim to the Secretary for purposes of reimbursement for a payment made by the contractor to a network provider for hospital care or medical services furnished under this section. The term covered payer means— a regional network operated by a contractor pursuant to subsection (a)(4)(B) with respect to a claim made by a network provider to the contractor for purposes of payment by the contractor of expenses for hospital care or medical services furnished under this section; or the Secretary with respect to— a claim made by a network provider to the Secretary for purposes of payment by the Secretary of expenses for hospital care or medical services furnished under this section; and a claim made by a regional network operated by a contractor pursuant to subsection (a)(4)(B) for purposes of reimbursement for a payment described by subparagraph (A). The term eligible veteran means a veteran who— is enrolled in the patient enrollment system of the Department established and operated under section 1705(a) of this title; and has— been furnished hospital care or medical services at or through a Department facility on at least one occasion during the two-year period preceding the date of the determination of eligibility; or requested a first-time appointment for hospital care or medical services at a Department facility. The term fraudulent claim means a claim by a network provider for reimbursement under this section that includes an intentional and deliberate misrepresentation of a material fact or facts that is intended to induce the Secretary to pay an amount that was not legally owed to the provider. . The table of sections at the beginning of chapter 17 of such title is amended by inserting after the item relating to section 1703 the following new item: 1703A. VA Care in the Community Program. . The Veterans Access, Choice, and Accountability Act of 2014 ( Public Law 113–146 ) is amended— in section 101(p)(1) ( 38 U.S.C. 1701 note), by inserting before the period at the end the following: or the date on which the Secretary certifies to the Committees on Veterans’ Affairs of the House of Representatives and the Senate that the Secretary is fully implementing section 1703A of title 38, United States Code, whichever occurs first ; and in section 208(1), by striking section 101 and inserting section 1703A of title 38, United States Code . Section 1701 of title 38, United States Code, is amended by adding at the end the following new paragraphs: The term network provider means any of the following health care providers that have entered into a contract or agreement under which the provider agrees to furnish care and services to eligible veterans under section 1703A of this title: Any health care provider or supplier that is participating in the Medicare Program under title XVIII of the Social Security Act ( 42 U.S.C. 1395 et seq.), including any physician furnishing services under such program. Any provider of items and services receiving payment under a State plan under title XIX of such Act ( 42 U.S.C. 1396 et seq.) or a waiver of such a plan. Any Federally-qualified health center (as defined in section 1905(l)(2)(B) of the Social Security Act ( 42 U.S.C. 1396d(l)(2)(B) )). The Department of Defense. The Indian Health Service. Any health care provider that is an academic affiliate of the Department. Any health care provider not otherwise covered under any of subparagraphs

(A)through

(F)that meets criteria established by the Secretary for purposes of such section. The term VA Care in the Community Program means the program under which the Secretary furnishes hospital care or medical services to veterans through network providers pursuant to section 1703A of this title. . This Act, and the amendments made by this Act, may not be construed to affect the obligations of the Secretary of Veterans Affairs under contracts and agreements for the provision of hospital care, medical services, and extended care services entered into before the date of the enactment of this Act at the terms and rates contained in such contracts and agreements.

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