[Congressional Bills 108th Congress]
[From the U.S. Government Publishing Office]
[S. 176 Introduced in Senate (IS)]







108th CONGRESS
  1st Session
                                 S. 176

To amend title XVIII of the Social Security Act to establish a program 
to provide for medicare reimbursement for health care services provided 
 to certain medicare-eligible veterans in facilities of the Department 
                          of Veterans Affairs.


_______________________________________________________________________


                   IN THE SENATE OF THE UNITED STATES

                            January 16, 2003

  Mr. Dayton 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 program 
to provide for medicare reimbursement for health care services provided 
 to certain medicare-eligible veterans in facilities of the Department 
                          of Veterans Affairs.

    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 ``Veterans Health Care Reimbursement 
Act of 2003''.

SEC. 2. ESTABLISHMENT OF MEDICARE REIMBURSEMENT PROGRAM FOR VETERANS.

    (a) In General.--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 reimbursement program 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) Medicare health care services.--The term `medicare 
        health care services' means items or services covered under 
        part A or part B.
            ``(3) Program.--The term `program' means the program 
        carried out under this section.
            ``(4) Program site.--The term `program 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--
                    ``(A) 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; and
                    ``(B) in the case of health care benefits being 
                provided on a fee-for-service basis, the health care 
                benefits prescribed in subsection (d)(2) to targeted 
                medicare-eligible veterans.
            ``(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 paragraph (4), 
                (5), (6), or (7) of section 1705(a) of title 38, United 
                States Code;
                    ``(B) has attained age 65;
                    ``(C) is entitled to, or enrolled for, benefits 
                under part A; and
                    ``(D) is enrolled for benefits under part B.
            ``(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) Program.--
            ``(1) In general.--
                    ``(A) Establishment.--The administering Secretaries 
                shall establish a program (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) Agreement.--Any agreement entered into under 
                this paragraph shall include at a minimum--
                            ``(i) a detailed description of the health 
                        care benefits to be provided to the 
                        participants of the program;
                            ``(ii) a description of the eligibility 
                        rules for participation in the program, any 
                        premiums established for a coordinated care 
                        health plan, and any cost-sharing arrangements;
                            ``(iii) a description of how the program 
                        will satisfy the requirements under this title;
                            ``(iv) a description of the sites selected 
                        under paragraph (2) and which model such site 
                        will operate under;
                            ``(v) a description of how reimbursement 
                        requirements under subsection (i), maintenance 
                        of effort requirements under subsection (j), 
                        and the annual reconciliation under subsection 
                        (k) will be implemented in the program;
                            ``(vi) a statement that the Secretary shall 
                        have access to all data of the Department of 
                        Veterans Affairs that the Secretary determines 
                        is necessary to conduct independent estimates 
                        and audits of the maintenance of effort 
                        requirement under subsection (j), the annual 
                        reconciliation under subsection (k), and 
                        related matters required under the program;
                            ``(vii) a statement that the Comptroller 
                        General of the United States shall have access 
                        to all data of the Department of Veterans 
                        Affairs that the Comptroller General determines 
                        is necessary to carry out the reporting 
                        requirements under subsections (k) or (l);
                            ``(viii) a description of any requirement 
                        that the Secretary waives pursuant to 
                        subsection (c)(4) or (d)(4); and
                            ``(ix) a certification, provided after 
                        review by the administering Secretaries, that 
                        any facility or entity described in subsection 
                        (a)(4) that is receiving payments by reason of 
                        the program has sufficient--
                                    ``(I) resources and expertise to 
                                provide, consistent with payment 
                                requirements under subsection (i), the 
                                health care benefits required to be 
                                provided to beneficiaries under the 
                                program (as established under 
                                subsections (c)(3) and (d)(2)); and
                                    ``(II) information and billing 
                                systems in place to ensure--
                                            ``(aa) accurate and timely 
                                        submission of claims for health 
                                        care benefits to the Secretary; 
                                        and
                                            ``(bb) that providers of 
                                        health care services that are 
                                        not affiliated with the 
                                        Department of Veterans Affairs 
                                        are reimbursed by the Secretary 
                                        of Veterans Affairs in a timely 
                                        and accurate manner.
                    ``(C) Separate agreements for coordinated care and 
                fee-for-service.--The administering Secretaries shall 
                enter into separate agreements with regard to program 
                sites operating under a coordinated care health plan 
                model and a fee-for-service model, and shall include in 
                each agreement only such information that is applicable 
                to that model.
            ``(2) Location of program sites.--The program shall be 
        conducted at any program site that is designated by the 
        Secretary of Veterans Affairs.
            ``(3) Restrictions.--
                    ``(A) Only 1 model at a site.--A program site may 
                not operate under both a coordinated care health plan 
                model and a fee-for-service model.
                    ``(B) Restriction on new or expanded facilities.--
                No new Veterans Affairs medical facilities may be built 
                or expanded with funds from the program.
            ``(4) Commencement of project.--The administering 
        Secretaries shall commence the demonstration project not later 
        than 6 months after the date of enactment of the Veterans 
        Health Care Reimbursement Act of 2003.
            ``(5) Termination.--If determined appropriate, the 
        Secretary of Veterans Affairs may terminate the program.
            ``(6) Report.--At least 30 days prior to the commencement 
        of the program (for both the coordinated care health plan model 
        and the fee-for-service model), the administering Secretaries 
        shall submit a copy of any agreement entered into under 
        paragraph (1) to the committees of jurisdiction of Congress.
    ``(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 enrolled in the program 
        under this section consistent with the Medicare+Choice program 
        under part C.
            ``(2) Operation by or through a program site.--Any 
        coordinated care health plan established in accordance with 
        paragraph (1) shall be operated by or through a program 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 program.
                    ``(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 
                        under clause (ii), a coordinated care health 
                        plan operating under the program 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 
                                program.
                    ``(B) Beneficiary protections and other matters.--A 
                coordinated care health plan shall comply with the 
                requirements of the Medicare+Choice program under 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 care health plan 
                        operating under the program under this section.
    ``(d) Fee-For-Service Model.--
            ``(1) In general.--The Secretary of Veterans Affairs shall 
        establish and operate a program site in order to provide, on a 
        fee-for-service basis, the medicare health care services 
        prescribed in paragraph (2) to targeted medicare-eligible 
        veterans under the program in a manner consistent with this 
        title.
            ``(2) Health care benefits.--The administering Secretaries 
        shall prescribe the medicare health care services available to 
        a targeted medicare-eligible veteran at a program site 
        operating under a fee-for-service model.
            ``(3) Cost-sharing.--The Secretary of Veterans Affairs 
        shall establish cost-sharing requirements for targeted 
        medicare-eligible veterans that receive medicare health care 
        services under a fee-for-service model at a program site. Such 
        cost-sharing requirements shall be the same as those required 
        under this title.
            ``(4) Medicare requirements.--
                    ``(A) In general.--Except as provided under 
                subparagraph (B), any entity or health care provider 
                that provides medicare health care services under the 
                program on a fee-for-service 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 program.
            ``(5) 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 fee-for-service basis under 
                the program.
                    ``(B) Restriction.--No payments shall be made under 
                this section for any medicare health care service 
                provided to an individual on a fee-for-service basis 
                under the program unless the individual has been 
                determined to be eligible for the service pursuant to 
                the procedures established under subparagraph (A).
    ``(e) Voluntary Participation.--Participation of a targeted 
medicare-eligible veteran in the program shall be voluntary, subject to 
the capacity of participating program sites and any annual limitation 
on medicare payments specified by the administering Secretaries in 
subsection (i)(4), and shall be subject to such terms and conditions as 
the administering Secretaries may establish.
    ``(f) Crediting of Payments.--A payment received by the Secretary 
of Veterans Affairs under the program 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 
program site shall be credited to amounts in the appropriation that are 
available for the Veterans Integrated Services Network (VISN) in which 
the program site is located. Amounts so credited for a Veterans 
Integrated Services Network shall be available for the furnishing of 
health care and services by any Veterans Affairs medical facility in 
the Veterans Integrated Services Network. Amounts so credited shall be 
available in accordance with the preceding sentence without fiscal year 
limitation.
    ``(g) 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 program.
    ``(h) 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 program, 
including compliance with the provisions of this title and all other 
relevant laws.
    ``(i) Payments Based on Regular Medicare Payment Rates.--
            ``(1) Amount.--Subject to the succeeding provisions of this 
        subsection and subsection (k), the Secretary shall reimburse 
        the Secretary of Veterans Affairs for health care benefits 
        provided under the program at the following rates:
                    ``(A) Coordinated care health plans.--In the case 
                of health care benefits provided under the program to a 
                targeted medicare-eligible veteran enrolled in a 
                coordinated care health plan, at a rate equal to 95 
                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) Fee-for-service model.--In the case of a 
                medicare health care service prescribed in subsection 
                (d)(2) that is provided at a program site operating 
                under a fee-for-service 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 program site was not part of the program under this 
section, 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 to be determined by 
        administering secretaries.--The aggregate amount that may be 
        paid to the Department of Veterans Affairs under this 
        subsection for enrollees in coordinated care health plans for a 
        year and for health care benefits provided on a fee-for-service 
        basis at a program site in that year shall be equal to an 
        amount determined appropriate by the administering Secretaries.
    ``(j) Maintenance of Effort.--
            ``(1) In general.--The Secretary may not reimburse the 
        Secretary of Veterans Affairs, from the trust funds, for 
        medicare health care services furnished under the program to 
        targeted medicare-eligible veterans at a program site in a 
        fiscal year until the expenditures during that year by the 
        Department of Veterans Affairs for such services provided at 
        that site to individuals that meet the definition of a targeted 
        medicare-eligible veteran under subsection (a)(5) (without 
        regard to subparagraph (D) of such subsection) exceeds such 
        expenditures at the site for such services provided to 
        applicable veterans during fiscal year 1998.
            ``(2) Applicable veteran defined.--For purposes of 
        paragraph (1), the term `applicable veteran' means an 
        individual who--
                    ``(A) is a veteran (as defined in section 101 of 
                title 38, United States Code) who is eligible for care 
                and services under section 1710(a)(3) of title 38, 
                United States Code;
                    ``(B) has attained age 65; and
                    ``(C) is entitled to, or enrolled for, benefits 
                under part A.
            ``(3) Rule of construction.--The criteria for eligibility 
        for health care benefits furnished to veterans by the Secretary 
        of Veterans Affairs is established under chapter 17 of title 
        38, United States Code, and nothing in this section shall be 
        construed to add additional criteria for such eligibility.
    ``(k) Annual Reconciliation To Assure No Increase in Costs to 
Medicare Program.--
            ``(1) Monitoring effect of program on costs to medicare 
        program.--
                    ``(A) In general.--The administering Secretaries, 
                in consultation with the Comptroller General of the 
                United States, shall closely monitor the expenditures 
                made under the medicare program under this title for 
                targeted medicare-eligible veterans at each program 
                site during a fiscal year compared to the expenditures 
                that would have been made for such veterans during that 
                year if the program had not been conducted.
                    ``(B) Annual reports by the comptroller general.--
                Not later than 6 months after the end of each fiscal 
                year in which the program is operated, the Comptroller 
                General of the United States shall submit to the 
                administering Secretaries and the appropriate 
                committees of Congress a report on the extent, if any, 
                to which the costs of the Secretary under the medicare 
                program under this title for each program site 
                increased as a result of the program under this section 
                during the fiscal year to which the report applies.
            ``(2) Required response in case of increase in costs.--
                    ``(A) In general.--If the administering Secretaries 
                find, based on paragraph (1), that the expenditures 
                under the medicare program under this title for each 
                program site increased (or are expected to increase) 
                during a fiscal year because of the program under this 
                section, the administering Secretaries shall take such 
                steps as may be needed--
                            ``(i) to recoup for the medicare program 
                        the amount of such increase in expenditures; 
                        and
                            ``(ii) to prevent any such increase in any 
                        succeeding fiscal year.
                    ``(B) Steps.--Such steps--
                            ``(i) under subparagraph (A)(i), shall 
                        include payment of an amount equal to the 
                        amount of such increased expenditures by the 
                        Secretary of Veterans Affairs from the current 
                        appropriation for Medical Care of the 
                        Department of Veterans Affairs to the trust 
                        funds; and
                            ``(ii) under subparagraph (A)(ii), shall 
                        include suspending or terminating the program 
                        (in whole or in part) or reducing the amount of 
                        payment under subsection (i).
    ``(l) GAO Evaluation and Additional Reports.--
            ``(1) Evaluation.--
                    ``(A) In general.--The Comptroller General of the 
                United States shall conduct an evaluation of the 
                program, including--
                            ``(i) an evaluation of program sites 
                        operating under a coordinated care health plan 
                        model and under a fee-for-service 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 
                        program.
                            ``(ii) Compliance of participating program 
                        sites with applicable measures of quality of 
                        care, compared to such compliance by other 
                        entities that participate in the medicare 
                        program 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 program 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 program sites in the 
                        program with the reimbursements for health care 
                        services provided by such sites.
                            ``(vi) Any impact the program 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 program; and
                                    ``(II) veterans (including targeted 
                                medicare-eligible veterans) that are 
                                not receiving health care benefits 
                                under the program.
                            ``(vii) Any impact the program has on 
                        private health care providers and on 
                        beneficiaries under this title that are not 
                        receiving health care benefits under the 
                        program.
                            ``(viii) Any effect that the program has on 
                        the enrollment in Medicare+Choice plans offered 
                        by Medicare+Choice organizations under part C 
                        in the established program site areas.
                            ``(ix) Any impact that the exclusion of the 
                        amounts described in subsection (i)(2) from the 
                        reimbursement amounts under the program 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 program; or
                                    ``(II) the Department of Health and 
                                Human Services in overseeing the 
                                program.
                            ``(xi) Any additional elements specified in 
                        the agreements entered into under subsection 
                        (b)(1).
                            ``(xii) Any additional elements that the 
                        Comptroller General of the United States 
                        determines are appropriate to assess regarding 
                        the program.
            ``(2) Biannual reports.--Not later than the date that is 
        the 2-year anniversary of the commencement of the program and 
        biannually thereafter (for as long as the program is being 
        conducted), the Comptroller General of the United States shall 
        submit reports on the evaluation conducted under subparagraph 
        (A) to the administering Secretaries and to the committees of 
        jurisdiction of Congress.
    ``(m) Reports by Administering Secretaries on Program Operation and 
Changes.--
            ``(1) Annual report.--The administering Secretaries shall 
        submit to the committees of jurisdiction of Congress an annual 
        report on the program and its impact on costs and the provision 
        of health services under this title and title 38, United States 
        Code.
            ``(2) Report before making certain program changes.--
                    ``(A) In general.--The administering Secretaries 
                shall submit to the committees of jurisdiction of 
                Congress a report at least 60 days before--
                            ``(i) adding or changing the designation of 
                        a site under subsection (b)(2);
                            ``(ii) waiving any requirement under 
                        subsection (c)(4) or (d)(4) that was not 
                        described in any agreement under subsection 
                        (b)(1) or previous report under this 
                        subsection;
                            ``(iii) making other significant changes in 
                        the operation of the program; or
                            ``(iv) terminating the agreement under 
                        subsection (b)(5).
                    ``(B) Explanation.--Each report under subparagraph 
                (A) shall include justifications for the changes or 
                termination to which the report refers.''.
    (b) Sense of Congress.--It is the sense of Congress that the amount 
of funds appropriated for the Department of Veterans Affairs for 
Medical Care in any fiscal year beginning after the date of enactment 
of this Act should not be reduced because of the implementation of the 
Medicare Reimbursement Program for Veterans under section 1897 of the 
Social Security Act (as added by subsection (a)).
                                 <all>