[House Report 111-55]
[From the U.S. Government Publishing Office]



111th Congress                                                   Report
                        HOUSE OF REPRESENTATIVES
 1st Session                                                     111-55

======================================================================

 
 AMENDING TITLE 38, UNITED STATES CODE, TO EXPAND VETERAN ELIGIBILITY 
 FOR REIMBURSEMENT BY THE SECRETARY OF VETERANS AFFAIRS FOR EMERGENCY 
    TREATMENT FURNISHED IN A NON-DEPARTMENT FACILITY, AND FOR OTHER 
                                PURPOSES

                                _______
                                

 March 26, 2009.--Committed to the Committee of the Whole House on the 
              State of the Union and ordered to be printed

                                _______
                                

  Mr. Filner, from the Committee on Veterans' Affairs, submitted the 
                               following

                              R E P O R T

                        [To accompany H.R. 1377]

      [Including cost estimate of the Congressional Budget Office]

    The Committee on Veterans' Affairs, to whom was referred 
the bill (H.R. 1377) to amend title 38, United States Code, to 
expand veteran eligibility for reimbursement by the Secretary 
of Veterans Affairs for emergency treatment furnished in a non-
Department facility, and for other purposes, having considered 
the same, report favorably thereon with an amendment and 
recommend that the bill as amended do pass.

                                CONTENTS

                                                                   Page
Amendment........................................................     2
Purpose and Summary..............................................     2
Background and Need for Legislation..............................     2
Hearings.........................................................     3
Subcommittee Consideration.......................................     3
Committee Consideration..........................................     4
Committee Votes..................................................     4
Committee Oversight Findings.....................................     4
Statement of General Performance Goals and Objectives............     4
New Budget Authority, Entitlement Authority, and Tax Expenditures     4
Earmarks and Tax and Tariff Benefits.............................     4
Committee Cost Estimate..........................................     4
Congressional Budget Office Estimate.............................     5
Federal Mandates Statement.......................................     6
Advisory Committee Statement.....................................     6
Constitutional Authority Statement...............................     6
Applicability to Legislative Branch..............................     6
Section-by-Section Analysis of the Legislation...................     6
Changes in Existing Law Made by the Bill as Reported.............     7

                               Amendment

    The amendment is as follows:
    Strike all after the enacting clause and insert the 
following:

SECTION 1. EXPANSION OF VETERAN ELIGIBILITY FOR REIMBURSEMENT BY 
                    SECRETARY OF VETERANS AFFAIRS FOR EMERGENCY 
                    TREATMENT FURNISHED IN A NON-DEPARTMENT FACILITY.

  (a) Expansion of Eligibility.--Section 1725 of title 38, United 
States Code, is amended--
        (1) in subsection (b)(3)(C), by striking ``or in part''; and
        (2) in subsection (f)(2), by striking subparagraph (E).
  (b) Limitations on Reimbursement.--Subsection (c) of such section is 
amended by adding at the end the following new paragraph:
          ``(4)(A) If the veteran has contractual or legal recourse 
        against a third party that would only, in part, extinguish the 
        veteran's liability to the provider of the emergency treatment, 
        and payment for the treatment may be made both under subsection 
        (a) and by the third party, the amount payable for such 
        treatment under such subsection shall be the amount by which 
        the costs for the emergency treatment exceed the amount payable 
        or paid by the third party, except that the amount payable may 
        not exceed the maximum amount payable established under 
        paragraph (1)(A).
          ``(B) In any case in which a third party is financially 
        responsible for part of the veteran's emergency treatment 
        expenses, the Secretary shall be the secondary payer.
          ``(C) A payment in the amount payable under subparagraph (A) 
        shall be considered payment in full and shall extinguish the 
        veteran's liability to the provider.
          ``(D) The Secretary may not reimburse a veteran under this 
        section for any copayment or similar payment that the veteran 
        owes the third party or for which the veteran is responsible 
        under a health-plan contract.''.
    (c) Effective Date.--
          (1) In general.--The amendments made by subsections (a) and 
        (b) shall take effect on the date of the enactment of this Act, 
        and shall apply with respect to emergency treatment furnished 
        on or after the date of the enactment of this Act.
          (2) Reimbursement for treatment provided before effective 
        date.--The Secretary may provide reimbursement under section 
        1725 of title 38, United States Code, as amended by subsections 
        (a) and (b), for emergency treatment furnished to a veteran 
        before the date of the enactment of this Act, if the Secretary 
        determines that, under the circumstances applicable with 
        respect to the veteran, it is appropriate to do so.

                          Purpose and Summary

    H.R. 1377 was introduced on March 6, 2009, by 
Representative Bob Filner of California, Chairman of the 
Committee on Veterans' Affairs. This legislation would expand 
veteran eligibility for reimbursement by the Secretary of 
Veterans Affairs (VA) for emergency treatment furnished in a 
non-Department facility. It would also set certain limitations 
on reimbursement.

                  Background and Need for Legislation

    VA is required to reimburse veterans or pay for emergency 
treatment in non-VA facilities. This authority was last revised 
in 2008 with the enactment of the Veterans' Mental Health and 
Other Care Improvements Act of 2008, Public Law 110-387 (122 
Stat. 4110), which made these provisions mandatory.
    The Committee has learned that under current law the VA 
does not pay for emergency treatment for non-service connected 
conditions in non-VA facilities if the veteran has third-party 
insurance that pays any portion of the costs associated with 
such emergency treatment. This situation can inadvertently 
arise if a veteran has minimal health insurance coverage 
through a state-mandated automobile insurance policy. 
Consequently, if an emergency does occur, and the veteran has a 
policy containing such minimal coverage, the veteran may be 
responsible for essentially the full cost of emergency 
treatment. While some veterans are able to negotiate payment 
plans and debt forgiveness of a portion of their medical bills 
with the non-VA hospital where they received the emergency 
treatment, many veterans are without the financial resources to 
shoulder such a cost and are unaware that the VA would not be 
responsible for such emergency care.
    To address this problem, Representative Filner introduced 
H.R. 5888 during the 110th Congress. At a June 5, 2008, 
legislative hearing, the VA supported the intent of H.R. 5888 
but expressed concerns about the reimbursement responsibilities 
of the VA.
    H.R. 1377, as amended, would allow the VA to reimburse 
veterans for treatment in a non-VA facility if they have a 
third-party insurer that would pay a portion of the emergency 
care. In addition, in response to the concerns put forth by the 
VA last Congress, H.R. 1377 would clarify the reimbursement 
responsibilities of the VA.
    H.R. 1377, as amended, provides for an effective date which 
is the date of the enactment of the Act. However, many veterans 
have been adversely affected by the VA's non-reimbursement for 
emergency treatment under the current law. The Committee 
strongly urges the Secretary to use the discretionary authority 
provided by this bill to reimburse veterans for emergency 
treatment provided prior to the date of enactment who have been 
financially harmed under the VA's current non-reimbursement 
policy.

                               Hearings 

    On March 3, 2009, the Subcommittee on Health held a 
legislative hearing on a number of bills introduced during the 
111th Congress, including a discussion draft of the emergency 
care reimbursement bill.
    The following witnesses testified: The Honorable Niki 
Tsongas of Massachusetts; The Honorable Stephanie Herseth 
Sandlin of South Dakota; Ms. Joy Ilem, Assistant National 
Legislative Director, Disabled American Veterans; Mr. Joseph L. 
Wilson, Deputy Director, Veterans Affairs and Rehabilitation 
Commission, The American Legion; Mr. Eric Hilleman, Deputy 
Director, National Legislative Service, Veterans of Foreign 
Wars of the United States; Mr. Todd Bowers, Director of 
Government Affairs, Iraq and Afghanistan Veterans of America; 
Gerald Cross, M.D., FAAFP, Principal Deputy Under Secretary for 
Health, Veterans Health Administration, U.S. Department of 
Veterans Affairs, accompanied by Mr. Walter A. Hall, Assistant 
General Counsel, U.S. Department of Veterans Affairs. Those 
submitting statements for the record included: The Honorable 
Bob Filner of California; the Vietnam Veterans of America; and 
the Paralyzed Veterans of America.

                       Subcommittee Consideration

    On March 19, 2009, the Subcommittee on Health met in open 
markup session and ordered favorably forwarded to the full 
Committee H.R. 1377, as amended, by voice vote. During 
consideration of the bill the following amendment was 
considered:

          An amendment by Mr. Rodriguez of Texas to amend the 
        effective date was agreed to by voice vote.

                        Committee Consideration

    On March 25, 2009, the full Committee met in an open markup 
session, a quorum being present, and ordered H.R. 1377, as 
amended, favorably reported to the House of Representatives, by 
voice vote.

                            Committee Votes

    Clause 3(b) of rule XIII of the Rules of the House of 
Representatives requires the Committee to list the record votes 
on the motion to report the legislation and amendments thereto. 
There were no record votes taken on amendments or in connection 
with ordering H.R. 1377 reported to the House. A motion by Mr. 
Buyer of Indiana to order H.R. 1377, as amended, reported 
favorably to the House of Representatives was agreed to by 
voice vote.

                      Committee Oversight Findings

    In compliance with clause 3(c)(1) of rule XIII and clause 
(2)(b)(1) of rule X of the Rules of the House of 
Representatives, the Committee's oversight findings and 
recommendations are reflected in the descriptive portions of 
this report.

         Statement of General Performance Goals and Objectives

    In accordance with clause 3(c)(4) of rule XIII of the Rules 
of the House of Representatives, the Committee's performance 
goals and objectives are reflected in the descriptive portions 
of this report.

   New Budget Authority, Entitlement Authority, and Tax Expenditures

    In compliance with clause 3(c)(2) of rule XIII of the Rules 
of the House of Representatives, the Committee adopts as its 
own the estimate of new budget authority, entitlement 
authority, or tax expenditures or revenues contained in the 
cost estimate prepared by the Director of the Congressional 
Budget Office pursuant to section 402 of the Congressional 
Budget Act of 1974.

                  Earmarks and Tax and Tariff Benefits

    H.R. 1377 does not contain any congressional earmarks, 
limited tax benefits, or limited tariff benefits as defined in 
clause 9(d), 9(e), or 9(f) of rule XXI of the Rules of the 
House of Representatives.

                        Committee Cost Estimate

    The Committee adopts as its own the cost estimate on H.R. 
1377 prepared by the Director of the Congressional Budget 
Office pursuant to section 402 of the Congressional Budget Act 
of 1974.

               Congressional Budget Office Cost Estimate

    Pursuant to clause 3(c)(3) of rule XIII of the Rules of the 
House of Representatives, the following is the cost estimate 
for H.R. 1377 provided by the Congressional Budget Office 
pursuant to section 402 of the Congressional Budget Act of 
1974:

                                     U.S. Congress,
                               Congressional Budget Office,
                                    Washington, DC, March 25, 2009.
Hon. Bob Filner,
Chairman, Committee on Veterans' Affairs,
House of Representatives, Washington, DC.
    Dear Mr. Chairman: The Congressional Budget Office has 
prepared the enclosed cost estimate for H.R. 1377, a bill to 
amend title 38, United States Code, to expand veteran 
eligibility for reimbursement by the Secretary of Veterans 
Affairs for emergency treatment furnished in a non-Department 
facility, and for other purposes.
    If you wish further details on this estimate, we will be 
pleased to provide them. The CBO staff contact is Sunita 
D'Monte.
            Sincerely,
                                      Douglas W. Elmendorf,
                                                          Director.
    Enclosure.

H.R. 1377--A bill to amend title 38, United States Code, to expand 
        veteran eligibility for reimbursement by the Secretary of 
        Veterans Affairs for emergency treatment furnished in a non-
        Department facility, and for other purposes

    H.R. 1377 would require the Department of Veterans Affairs 
(VA) to pay for the emergency care that certain veterans 
receive at non-VA medical facilities, or to reimburse veterans 
if they have paid for that care. It also would permit VA, 
subject to the Secretary's discretion, to reimburse veterans 
for emergency treatment that was provided prior to the date of 
enactment. CBO estimates that implementing the bill would cost 
$5 million over the 2010-2014 period, assuming appropriation of 
the estimated amounts. Enacting the bill would not affect 
direct spending or revenues.
    Under current law, VA has the authority to reimburse 
certain veterans or pay for emergency treatment of a 
nonservice-connected condition, if VA is the payer of last 
resort. Veterans who have recourse against a third party that 
would partly cover those medical expenses are ineligible for 
reimbursement from VA. H.R. 1377 would remove that requirement 
and make them eligible for such reimbursements.
    Based on information from VA, CBO estimates that under the 
bill VA would approve about 700 new claims a year over the 
2010-2014 period and about 2,000 claims for emergency treatment 
provided over the 2005-2009 period. (CBO assumes that few 
veterans retain records for emergency treatment provided before 
2005.) CBO estimates that VA would pay an average of $730 per 
claim in 2010, rising to about $900 per claim in 2014, for 
total costs of $1 million a year.
    H.R. 1377 contains no intergovernmental or private-sector 
mandates as defined in the Unfunded Mandates Reform Act and 
would not affect the budgets of state, local, or tribal 
governments.
    The CBO staff contact for this estimate is Sunita D'Monte. 
The estimate was approved by Theresa Gullo, Deputy Assistant 
Director for Budget Analysis.

                       Federal Mandates Statement

    The Committee adopts as its own the estimate of Federal 
mandates regarding H.R. 1377 prepared by the Director of the 
Congressional Budget Office pursuant to section 423 of the 
Unfunded Mandates Reform Act.

                      Advisory Committee Statement

    No advisory committees within the meaning of section 5(b) 
of the Federal Advisory Committee Act would be created by H.R. 
1377.

                   Constitutional Authority Statement

    Pursuant to clause 3(d)(1) of rule XIII of the Rules of the 
House of Representatives, the Committee finds that the 
Constitutional authority for H.R. 1377 is provided by Article 
I, section 8 of the Constitution of the United States.

                  Applicability to Legislative Branch

    The Committee finds that the legislation does not relate to 
the terms and conditions of employment or access to public 
services or accommodations within the meaning of section 
102(b)(3) of the Congressional Accountability Act.

             Section-by-Section Analysis of the Legislation


Section 1. Expansion of veteran eligibility for reimbursement by 
        Secretary of Veterans Affairs for emergency treatment furnished 
        in a non-department facility

    This section would amend section 1725 of title 38, United 
States Code, to expand the eligibility for reimbursement by the 
VA for emergency treatment received in a non-Department 
facility.
    It also clearly establishes that the VA is responsible for 
the cost of the emergency treatment which exceeds the amount 
payable or paid by the third-party insurer. However, the 
reimbursement may not exceed the maximum amount payable 
established by the VA. It further defines the VA as a secondary 
payor where a third-party insurer is financially responsible 
for a part of the veteran's emergency treatment expenses. Next, 
it protects veterans by clarifying that they are not liable for 
any remaining balance due to the provider after the third-party 
insurer and the VA have made their payments. Finally, it 
prohibits the Secretary from reimbursing the veteran for 
copayments or similar payments that the veteran owes to the 
third party under a health-plan contract.
    This section, as amended, would provide for an effective 
date of the date of the enactment of the Act. In addition, the 
Secretary of the VA has the authority to reimburse certain 
veterans for emergency treatment provided before the effective 
date of this Act if the Secretary determines that it is 
appropriate to do so.

         Changes in Existing Law Made by the Bill, as Reported

    In compliance with clause 3(e) of rule XIII of the Rules of 
the House of Representatives, changes in existing law made by 
the bill, as reported, are shown as follows (existing law 
proposed to be omitted is enclosed in black brackets, new 
matter is printed in italic, existing law in which no change is 
proposed is shown in roman):

              SECTION 1725 OF TITLE 38, UNITED STATES CODE



Sec. 1725. Reimbursement for emergency treatment

    (a) * * *
    (b) Eligibility.--(1) * * *

           *       *       *       *       *       *       *

    (3) A veteran is personally liable for emergency treatment 
furnished the veteran in a non-Department facility if the 
veteran--
          (A) * * *

           *       *       *       *       *       *       *

          (C) has no other contractual or legal recourse 
        against a third party that would, in whole [or in 
        part], extinguish such liability to the provider; and

           *       *       *       *       *       *       *

    (c) Limitations on Reimbursement.--(1) * * *

           *       *       *       *       *       *       *

    (4)(A) If the veteran has contractual or legal recourse 
against a third party that would only, in part, extinguish the 
veteran's liability to the provider of the emergency treatment, 
and payment for the treatment may be made both under subsection 
(a) and by the third party, the amount payable for such 
treatment under such subsection shall be the amount by which 
the costs for the emergency treatment exceed the amount payable 
or paid by the third party, except that the amount payable may 
not exceed the maximum amount payable established under 
paragraph (1)(A).
    (B) In any case in which a third party is financially 
responsible for part of the veteran's emergency treatment 
expenses, the Secretary shall be the secondary payer.
    (C) A payment in the amount payable under subparagraph (A) 
shall be considered payment in full and shall extinguish the 
veteran's liability to the provider.
    (D) The Secretary may not reimburse a veteran under this 
section for any copayment or similar payment that the veteran 
owes the third party or for which the veteran is responsible 
under a health-plan contract.

           *       *       *       *       *       *       *

    (f) Definitions.--For purposes of this section:
          (1) * * *
          (2) The term ``health-plan contract'' includes any of 
        the following:
                  (A) * * *

           *       *       *       *       *       *       *

                  [(E) A law of a State or political 
                subdivision described in section 1729(a)(2)(B) 
                of this title.]

           *       *       *       *       *       *       *


                                  
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