[Congressional Bills 107th Congress]
[From the U.S. Government Publishing Office]
[S. 2233 Introduced in Senate (IS)]







107th CONGRESS
  2d Session
                                S. 2233

To amend title XVIII of the Social Security Act to establish a medicare 
             subvention demonstration project for veterans.


_______________________________________________________________________


                   IN THE SENATE OF THE UNITED STATES

                             April 23, 2002

 Mr. Thomas (for himself, Mr. Rockefeller, Mr. Jeffords, Mr. Specter, 
  Mrs. Carnahan, Ms. Snowe, and Mr. Cleland) introduced the following 
  bill; which was read twice and referred to the Committee on Finance

_______________________________________________________________________

                                 A BILL


 
To amend title XVIII of the Social Security Act to establish a medicare 
             subvention demonstration project for veterans.

    Be it enacted by the Senate and House of Representatives of the 
United States of America in Congress assembled,

SECTION 1. SHORT TITLE.

    This Act may be cited as the ``Medicare Equity for Veterans Act of 
2002''.

SEC. 2. ESTABLISHMENT OF MEDICARE SUBVENTION DEMONSTRATION PROJECT FOR 
              VETERANS.

    Title XVIII of the Social Security Act (42 U.S.C. 1395 et seq.) is 
amended by adding at the end the following new section:

        ``medicare subvention demonstration project for veterans

    ``Sec. 1897. (a) Definitions.--In this section:
            ``(1) Administering secretaries.--The term `administering 
        Secretaries' means the Secretary and the Secretary of Veterans 
        Affairs acting jointly.
            ``(2) Demonstration project.--The term `demonstration 
        project' means the demonstration project carried out under this 
        section.
            ``(3) Demonstration site.--
                    ``(A) In general.--Subject to subparagraph (B), the 
                term `demonstration site' means a Veterans Affairs 
                medical facility that provides, alone or in conjunction 
                with other facilities under the jurisdiction of the 
                Secretary of Veterans Affairs and affiliated public or 
                private entities--
                            ``(i) in the case of a coordinated care 
                        health plan, the health care benefits 
                        prescribed in subsection (c)(3) to targeted 
                        medicare-eligible veterans residing within the 
                        service area (as prescribed under regulations 
                        for the Medicare+Choice program under part C); 
                        and
                            ``(ii) in the case of health care benefits 
                        being provided on a preferred provider basis, 
                        the health care benefits described in 
                        subsection (d)(1) to targeted medicare-eligible 
                        veterans.
                    ``(B) Exclusion.--The term `demonstration site' 
                shall not include the entire catchment area of a 
                Veterans Integrated Services Network (VISN).
            ``(4) Medicare health care services.--The term `medicare 
        health care services' means items or services covered under 
        part A or part B.
            ``(5) Targeted medicare-eligible veteran.--The term 
        `targeted medicare-eligible veteran' means an individual who--
                    ``(A) is a veteran (as defined in section 101 of 
                title 38, United States Code) who is enrolled in the 
                annual patient enrollment system under section 
                1705(a)(7) of title 38, United States Code;
                    ``(B) has attained age 65;
                    ``(C) is entitled to, or enrolled for, benefits 
                under part A;
                    ``(D) is enrolled for benefits under part B; and
                    ``(E) did not receive medical care from a Veterans 
                Affairs medical facility based on the individual's 
                eligibility for care and services under section 
                1710(a)(3) of title 38, United States Code, during the 
                period beginning on the date that the individual 
                attained age 65 and ending on September 30, 1998.
            ``(6) Trust funds.--The term `trust funds' means the 
        Federal Hospital Insurance Trust Fund established in section 
        1817 and the Federal Supplementary Medical Insurance Trust Fund 
        established in section 1841.
            ``(7) Veterans affairs medical facility.--The term 
        `Veterans Affairs medical facility' means a medical facility as 
        defined in section 8101 of title 38, United States Code.
    ``(b) Demonstration Project.--
            ``(1) In general.--
                    ``(A) Establishment.--The administering Secretaries 
                are authorized to establish a demonstration project 
                (under agreements entered into by the administering 
                Secretaries) under which the Secretary shall reimburse 
                the Secretary of Veterans Affairs, from the trust 
                funds, for medicare health care services furnished to 
                targeted medicare-eligible veterans.
                    ``(B) Separate agreements for coordinated care and 
                preferred provider models.--The administering 
                Secretaries shall enter into separate agreements with 
                regard to demonstration sites operating under a 
                coordinated care health plan model and a preferred 
                provider model, and shall include in each agreement 
                only such information that is applicable to that model.
            ``(2) Number of demonstration sites.--
                    ``(A) In general.--Subject to the succeeding 
                provisions of this paragraph and subsection (k)(1)(B), 
                the demonstration project shall be conducted in not 
                more than 10 demonstration sites, designated jointly by 
                the administering Secretaries.
                    ``(B) At least 1 coordinated care and 1 preferred 
                provider site.--The administrating Secretaries shall 
                ensure that at least 1 of the demonstration sites is 
                operated under a coordinated care health plan model and 
                at least 1 demonstration site is operated under a 
                preferred provider model.
                    ``(C) Restriction.--A demonstration site may not 
                operate under both a coordinated care health plan model 
                and a preferred provider model.
                    ``(D) Demonstration sites in rural areas.--At least 
                3 demonstration sites shall be sites that are located 
                in geographically diverse rural areas.
            ``(3) Restriction on new or expanded facilities.--No new 
        Veterans Affairs medical facilities may be built or expanded 
        with funds from the demonstration project.
            ``(4) Commencement of project.--The administering 
        Secretaries shall commence the demonstration project not later 
        than 6 months after the date of enactment of the Medicare 
        Equity for Veterans Act of 2002.
            ``(5) Duration.--Subject to subsection (k)(1)(A), the 
        authority of the administering Secretaries to conduct the 
        demonstration project shall terminate on the date that is 3 
        years after the date of the commencement of the demonstration 
        project.
    ``(c) Coordinated Care Health Plan Model.--
            ``(1) In general.--The Secretary of Veterans Affairs shall 
        establish and operate coordinated care health plans in order to 
        provide the health care benefits prescribed in paragraph (3) to 
        targeted medicare-eligible veterans participating in the 
        demonstration project consistent with part C.
            ``(2) Operation by or through a demonstration site.--Any 
        coordinated care health plan established in accordance with 
        paragraph (1) shall be operated by or through a demonstration 
        site.
            ``(3) Health care benefits.--
                    ``(A) In general.--Subject to subparagraph (B), the 
                Secretary of Veterans Affairs shall prescribe the 
                health care benefits to be provided to a targeted 
                medicare-eligible veteran enrolled in a coordinated 
                care health plan under the demonstration project.
                    ``(B) Minimum benefits.--The benefits prescribed by 
                the Secretary of Veterans Affairs pursuant to 
                subparagraph (A) shall include at least all medicare 
                health care services that are required to be provided 
                by a Medicare+Choice organization under part C.
            ``(4) Medicare requirements.--
                    ``(A) In general.--
                            ``(i) Requirements.--Except as provided in 
                        clause (ii), a coordinated care health plan 
                        operating under the demonstration project shall 
                        meet all requirements applicable to a 
                        Medicare+Choice plan under part C and 
                        regulations pertaining thereto, and any other 
                        requirements for receiving payments under this 
                        title, except that the prohibition of payments 
                        to Federal providers of services under sections 
                        1814(c) and 1835(d), and paragraphs (2) and (3) 
                        of section 1862(a), shall not apply.
                            ``(ii) Waiver.--Except with respect to any 
                        requirement described in subparagraph (B), the 
                        Secretary is authorized to waive any 
                        requirement described in clause (i), or approve 
                        equivalent or alternative ways of meeting such 
                        a requirement, but only if such waiver or 
                        approval--
                                    ``(I) reflects the unique status of 
                                the Department of Veterans Affairs as 
                                an agency of the Federal Government; 
                                and
                                    ``(II) is necessary to carry out, 
                                or improve the efficiency of, the 
                                demonstration project.
                    ``(B) Beneficiary protections and other matters.--A 
                coordinated care health plan shall comply with the 
                requirements of part C that relate to beneficiary 
                protections and other related matters, including such 
                requirements relating to the following areas:
                            ``(i) Enrollment and disenrollment.
                            ``(ii) Nondiscrimination.
                            ``(iii) Information provided to 
                        beneficiaries.
                            ``(iv) Cost-sharing limitations.
                            ``(v) Appeal and grievance procedures.
                            ``(vi) Provider participation.
                            ``(vii) Access to services.
                            ``(viii) Quality assurance and external 
                        review.
                            ``(ix) Advance directives.
                            ``(x) Other areas of beneficiary 
                        protections that the Secretary determines are 
                        applicable to a coordinated health care plan 
                        operating under the demonstration project.
    ``(d) Preferred Provider Model.--
            ``(1) In general.--The administering Secretaries shall 
        contract with a private entity to establish a preferred 
        provider model under which--
                    ``(A) targeted medicare-eligible veterans 
                participating in the project shall receive medicare 
                health care services and additional health care 
                services determined appropriate by the administering 
                Secretaries; and
                    ``(B) the Veterans Affairs medical facility 
                participating at the demonstration site is the 
                preferred provider under the plan.
            ``(2) Cost-sharing.--The administering Secretaries shall 
        establish cost-sharing requirements for targeted medicare-
        eligible veterans that receive medicare health care services 
        under a preferred provider model at the Veterans Affairs 
        medical facility at the demonstration site. Such cost-sharing 
        requirements may be different than the cost-sharing 
        requirements required under this title.
            ``(3) Medicare requirements.--
                    ``(A) In general.--Except as provided in 
                subparagraph (B), any entity or health care provider 
                that provides medicare health care services under the 
                demonstration project on a preferred provider basis 
                shall meet all of the requirements under this title, 
                except that the prohibition of payments to Federal 
                providers of services under sections 1814(c) and 
                1835(d), and paragraphs (2) and (3) of section 1862(a), 
                shall not apply.
                    ``(B) Waiver.--The Secretary is authorized to waive 
                any requirement described under subparagraph (A), or 
                approve equivalent or alternative ways of meeting such 
                a requirement, but only if such waiver or approval--
                            ``(i) reflects the unique status of the 
                        Department of Veterans Affairs as an agency of 
                        the Federal Government; and
                            ``(ii) is necessary to carry out, or 
                        improve the efficiency of, the demonstration 
                        project.
            ``(4) Verification of eligibility.--
                    ``(A) In general.--The Secretary of Veterans 
                Affairs shall establish procedures for determining 
                whether an individual is eligible to receive medicare 
                health care services on a preferred provider basis 
                under the demonstration project.
                    ``(B) Restriction.--No payments shall be made under 
                this section for any medicare health care service 
                provided to an individual on a preferred provider basis 
                under the demonstration project unless the individual 
                has been determined to be eligible for the service 
                pursuant to the procedures established under 
                subparagraph (A).
    ``(e) Crediting of Payments.--A payment received by the Secretary 
of Veterans Affairs under the demonstration project shall be credited 
to the appropriation of the Department of Veterans Affairs for Medical 
Care. Amounts credited to that appropriation for services furnished by 
a demonstration site shall be credited to amounts in the appropriation 
that are available for the demonstration site. Amounts so credited 
shall be available without fiscal year limitation.
    ``(f) Waiver of Certain VA Requirements.--Notwithstanding any other 
provision of law, the Secretary of Veterans Affairs shall furnish 
medicare health care services to targeted medicare-eligible veterans 
pursuant to the demonstration project.
    ``(g) Inspector General.--Nothing in any agreement entered into 
under subsection (b)(1) shall limit the Inspector General of the 
Department of Health and Human Services from investigating any matters 
regarding the expenditure of funds under this title for the 
demonstration project, including compliance with the provisions of this 
title and all other relevant laws.
    ``(h) Information Provided to Secretary To Ensure Maintenance of 
Effort.--Prior to the commencement of the demonstration project, the 
Secretary of Veterans Affairs shall provide the Secretary with a list 
of individuals who will not be eligible to receive benefits under the 
demonstration project because of the application of subsection 
(a)(5)(E).
    ``(i) Payments Based on Regular Medicare Payment Rates.--
            ``(1) Amount.--Subject to the succeeding provisions of this 
        subsection, the Secretary shall reimburse the Secretary of 
        Veterans Affairs for health care benefits provided under the 
        demonstration project at the following rates:
                    ``(A) Coordinated care health plans.--In the case 
                of health care benefits provided under the 
                demonstration project to a targeted medicare-eligible 
                veteran enrolled in a coordinated care health plan, at 
                a rate equal to 100 percent of the amount paid to a 
                Medicare+Choice organization under part C for an 
                enrollee in a Medicare+Choice plan offered by such 
                organization (as risk adjusted under section 
                1853(a)(1)(B)).
                    ``(B) Preferred provider model.--In the case of a 
                medicare health care service that is provided at a 
                demonstration site operating under a preferred provider 
                model, at a rate equal to 95 percent of the amounts 
                that otherwise would be payable under this title on a 
                noncapitated basis for such service if the 
                demonstration site was not part of this demonstration 
                project, was participating in the medicare program, and 
                imposed charges for such service.
            ``(2) Exclusion of certain amounts.--In computing the 
        amount of payment under paragraph (1), the following amounts 
        shall be excluded:
                    ``(A) Disproportionate share hospital adjustment.--
                Any amount attributable to an adjustment under section 
                1886(d)(5)(F).
                    ``(B) Direct graduate medical education payments.--
                Any amount attributable to a payment under section 
                1886(h).
                    ``(C) Indirect medical education adjustment.--Any 
                amount attributable to the adjustment under section 
                1886(d)(5)(B).
                    ``(D) Percentage of capital payments.--67 percent 
                of any amounts attributable to payments for capital-
                related costs under medicare payment policies under 
                section 1886(g).
            ``(3) Periodic payments from medicare trust funds.--
        Payments under this subsection shall be made--
                    ``(A) on a periodic basis consistent with the 
                periodicity of payments under this title; and
                    ``(B) in appropriate part, as determined by the 
                Secretary, from the trust funds.
            ``(4) Annual limit on medicare payments.--
                    ``(A) Coordinated care health plan model.--Subject 
                to subparagraph (C), the aggregate amount that may be 
                paid to the Department of Veterans Affairs under this 
                subsection for enrollees in coordinated care health 
                plans for any of the 3 consecutive 12-month periods 
                (the first of which begins on the date of the 
                commencement of the demonstration project) shall be 
                equal to an amount determined appropriate by the 
                administering Secretaries.
                    ``(B) Preferred provider model.--Subject to 
                subparagraph (C), the aggregate amount that may be paid 
                to the Department of Veterans Affairs under this 
                subsection for medicare health care services provided 
                on a preferred provider basis at a demonstration site 
                for any of the 3 consecutive 12-month periods described 
                in subparagraph (A) shall be equal to an amount 
                determined appropriate by the administering 
                Secretaries.
                    ``(C) Cap.--The aggregate amount to be paid to the 
                Department of Veterans Affairs under this section--
                            ``(i) during the first 12-month period 
                        described in subparagraph (A) shall not exceed 
                        $75,000,000;
                            ``(ii) during the second 12-month period so 
                        described shall not exceed $75,000,000; and
                            ``(iii) during the third 12-month period so 
                        described shall not exceed $75,000,000.
    ``(j) GAO Evaluation and Reports.--
            ``(1) Evaluation.--
                    ``(A) In general.--The Comptroller General of the 
                United States shall conduct an evaluation of the 
                demonstration project, including--
                            ``(i) an evaluation of demonstration sites 
                        operating under a coordinated care health plan 
                        model and under a preferred provider model; and
                            ``(ii) where appropriate, a comparison of 
                        such models.
                    ``(B) Contents.--Any evaluation conducted under 
                subparagraph (A) shall include an assessment, based on 
                the agreements entered into under subsection (b)(1), of 
                the following:
                            ``(i) Any savings or costs to the medicare 
                        program under this title resulting from the 
                        demonstration project.
                            ``(ii) Compliance of participating 
                        demonstration sites with applicable measures of 
                        quality of care, compared to such compliance by 
                        other entities that participate in medicare and 
                        are not Veterans Affairs medical facilities.
                            ``(iii) Compliance by the Department of 
                        Veterans Affairs with the requirements under 
                        this title.
                            ``(iv) The number of targeted medicare-
                        eligible veterans opting to receive health care 
                        benefits under the demonstration project 
                        instead of receiving such benefits through 
                        another health insurance plan (including health 
                        care benefits under this title).
                            ``(v) A comparison of the costs of 
                        participation of the demonstration sites in the 
                        project with the reimbursements for health care 
                        services provided by such sites.
                            ``(vi) Any impact the demonstration project 
                        has on the access to health care services, or 
                        the quality of such services, for--
                                    ``(I) targeted medicare-eligible 
                                veterans receiving health care benefits 
                                under the demonstration project; and
                                    ``(II) veterans (including targeted 
                                medicare-eligible veterans) that are 
                                not receiving health care benefits 
                                under the demonstration project.
                            ``(vii) Any impact the demonstration 
                        project has on private health care providers 
                        and on beneficiaries under this title that are 
                        not receiving health care benefits under the 
                        demonstration project.
                            ``(viii) Any effect that the demonstration 
                        project has on the enrollment in 
                        Medicare+Choice plans offered by 
                        Medicare+Choice organizations under part C in 
                        the established demonstration site areas.
                            ``(ix) Any impact that the exclusion of the 
                        amounts described in subsection (i)(2) from the 
                        reimbursement amounts under the demonstration 
                        has on the Department of Veterans Affairs or on 
                        targeted medicare-eligible veterans.
                            ``(x) A description of the difficulties (if 
                        any) experienced by--
                                    ``(I) the Department of Veterans 
                                Affairs in managing the demonstration 
                                project; or
                                    ``(II) the Department of Health and 
                                Human Services in overseeing the 
                                demonstration project.
                            ``(xi) The quality and precision of billing 
                        procedures utilized by demonstration sites.
                            ``(xii) The timeliness of billing at 
                        demonstration sites.
                            ``(xiii) The timeliness of reimbursement by 
                        the Secretary under the demonstration project.
                            ``(xiv) The satisfaction level of targeted 
                        medicare-eligible veterans participating in the 
                        demonstration project.
                            ``(xv) The quality of the care provided at 
                        demonstration sites.
                            ``(xvi) The ability of targeted medicare-
                        eligible veterans participating in the 
                        demonstration project to access care, including 
                        documentation of mean and medium waiting 
                        periods.
                            ``(xvii) Patient safety under the 
                        demonstration project.
                            ``(xviii) The ability of a demonstration 
                        site to deliver totality of care in the local 
                        service area.
                            ``(xix) The percent of targeted medicare-
                        eligible veterans participating in the 
                        demonstration project that required referral 
                        for health care services and the cost of such 
                        referrals relative to the cost of care 
                        delivered locally.
                            ``(xx) The satisfaction of Veterans Affairs 
                        medical facilities participating in the 
                        demonstration project with the operation of the 
                        project.
                            ``(xxi) The average pharmacy cost relative 
                        to matched Veterans Affairs population.
                            ``(xxii) The in-patient care cost compared 
                        to a Veterans Affairs medical facility not 
                        participating in the demonstration project.
                            ``(xxiii) Regional variations in the 
                        operation of the demonstration project.
                            ``(xxiv) Differences in demonstration sites 
                        located in rural areas and demonstration sites 
                        located in urban areas.
                            ``(xxv) The economic profile of targeted 
                        medicare-eligible veterans participating in the 
                        demonstration.
                            ``(xxvi) Any additional elements specified 
                        in the agreements entered into under subsection 
                        (b)(1).
                            ``(xxvii) Any additional elements that the 
                        Comptroller General of the United States 
                        determines are appropriate to assess regarding 
                        the demonstration project.
            ``(2) Initial report.--
                    ``(A) In general.--During the 6-month period that 
                begins on the 2-year anniversary of the commencement of 
                the demonstration project, the Comptroller General of 
                the United States shall submit a report to the 
                administering Secretaries and to the committees of 
                jurisdiction of Congress on the evaluation conducted 
                under paragraph (1), together with the recommendations 
                described in subparagraph (B).
                    ``(B) Recommendations.--The recommendations 
                described in this subparagraph are recommendations 
                regarding--
                            ``(i) how best to replicate the 
                        demonstration sites operating under a 
                        coordinated care health plan model and under 
a preferred provider model in various demographic and geographic 
settings; and
                            ``(ii) whether the administrating 
                        Secretaries should extend and expand the 
                        demonstration project, and if so, the 
                        configuration and timing for the expansion 
                        (broken down by demographic, geographic, and 
                        care delivery model factors).
            ``(3) Subsequent reports if project is extended.--
                    ``(A) In general.--If the administrating 
                Secretaries extend the demonstration project pursuant 
                to subsection (k)(1)(A), the Comptroller General of the 
                United States, on the 4-year, 6-year, and 8-year 
                anniversary of the commencement of the demonstration 
                project, shall submit a report to the administering 
                Secretaries and to the committees of jurisdiction of 
                Congress on the evaluation conducted under paragraph 
                (1), together with the recommendations described in 
                paragraph (2)(B).
                    ``(B) Reports not required if project terminated.--
                No report shall be required under subparagraph (A) if 
                the reporting date is after the date that the 
                demonstration project is terminated by the 
                administrating Secretaries.
    ``(k) Continuing Authority To Extend and Expand the Demonstration 
Project.--
            ``(1) Authority.--If, after review of the operation of the 
        demonstration project and the evaluations and reports submitted 
        by the Comptroller General of the United States under 
        subsection (j), the administrating Secretaries determine 
        appropriate, the administrating Secretaries may modify the 
        agreements entered into under subsection (b)(1) in the 
        following manner:
                    ``(A) Notwithstanding subsection (b)(5), the 
                administering Secretaries may continue to conduct the 
                demonstration project beyond the date described in such 
                subsection.
                    ``(B) Notwithstanding subsection (b)(2)(A), the 
                demonstration project may be conducted at any 
                demonstration site designated jointly by the 
                administering Secretaries.
                    ``(C) Notwithstanding subsection (i)(4)(C), the 
                Administering Secretaries may establish a cap for any 
                12-month period after the period described in clause 
                (iii) of such subsection that is greater than the cap 
                described in such clause.
            ``(2) Annual reports.--
                    ``(A) In general.--If the administrating 
                Secretaries extend the demonstration project pursuant 
                to paragraph (1)(A), the administering Secretaries 
                shall submit, for as long as the demonstration project 
                is being conducted, annual reports to the committees of 
                jurisdiction of Congress on the demonstration project.
                    ``(B) Required elements.--Each report submitted 
                under subparagraph (A) shall include a detailed 
                description of--
                            ``(i) the administrating Secretaries plans 
                        for future expansion and extension of the 
                        demonstration project;
                            ``(ii) justifications for such expansion 
                        and extension; and
                            ``(iii) performance measures under the 
                        demonstration project.''.
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