[House Report 114-35]
[From the U.S. Government Publishing Office]


114th Congress     }                               {   Report
                       HOUSE OF REPRESENTATIVES
 1st Session       }                               {   114-35
======================================================================
 
                   LONG-TERM CARE VETERANS CHOICE ACT

                                _______
                                

 March 2, 2015.--Committed to the Committee of the Whole House on the 
              State of the Union and ordered to be printed

                                _______
                                

   Mr. Miller  of Florida, from the Committee on Veterans' Affairs, 
                        submitted the following

                              R E P O R T

                        [To accompany H.R. 294]

      [Including cost estimate of the Congressional Budget Office]

    The Committee on Veterans' Affairs, to whom was referred 
the bill (H.R. 294) to amend title 38, United States Code, to 
authorize the Secretary of Veterans Affairs to enter into 
contracts and agreements for the transfer of veterans to non-
Department medical foster homes for certain veterans who are 
unable to live independently, having considered the same, 
report favorably thereon with amendments and recommend that the 
bill as amended do pass.

                                CONTENTS

                                                                   Page
Amendment........................................................     2
Purpose and Summary..............................................     2
Background and Need for Legislation..............................     3
Hearings.........................................................     4
Subcommittee Consideration.......................................     5
Committee Consideration..........................................     5
Committee Votes..................................................     5
Committee Oversight Findings.....................................     5
Statement of General Performance Goals and Objectives............     6
New Budget Authority, Entitlement Authority, and Tax Expenditures     6
Earmarks and Tax and Tariff Benefits.............................     6
Committee Cost Estimate..........................................     6
Congressional Budget Office Estimate.............................     6
Federal Mandates Statement.......................................     8
Advisory Committee Statement.....................................     8
Statement of Constitutional Authority............................     8
Applicability to Legislative Branch..............................     9
Statement on Duplication of Federal Programs.....................     9
Disclosure of Directed Rulemaking................................     9
Section-by-Section Analysis of the Legislation...................     9
Changes in Existing Law Made by the Bill as Reported.............    10

                Amendment in the Nature of a Substitute

    The amendments are as follows:
  Strike all after the enacting clause and insert the 
following:

SECTION 1. SHORT TITLE.

  This Act may be cited as the ``Long-Term Care Veterans Choice Act''.

SEC. 2. SECRETARY OF VETERANS AFFAIRS CONTRACT AUTHORITY FOR PLACEMENT 
                    OF VETERANS IN NON-DEPARTMENT MEDICAL FOSTER HOMES.

  (a) Authority.--
          (1) In general.--Section 1720 of title 38, United States 
        Code, is amended by adding at the end the following new 
        subsection:
  ``(h)(1) During the three-year period beginning on October 1, 2015, 
and subject to paragraph (2), at the request of a veteran for whom the 
Secretary is required to provide nursing home care under section 1710A 
of this title, the Secretary may place the veteran in a medical foster 
home that meets Department standards, at the expense of the United 
States, pursuant to a contract or agreement entered into between the 
Secretary and the medical foster home for such purpose. A veteran who 
is placed in a medical foster home under this subsection shall agree, 
as a condition of such placement, to accept home health services 
furnished by the Secretary under section 1717 of this title.
  ``(2) Not more than 900 veterans placed in a medical foster home, 
whether placed before or after the enactment of the Long-Term Care 
Veterans Choice Act, may have their care covered at the expense of the 
United States under subsection (a).
  ``(3) In this subsection, the term `medical foster home' means a home 
designed to provide non-institutional, long-term, supportive care for 
veterans who are unable to live independently and prefer a family 
setting.''.
          (2) Effective date.--Subsection (h) of title 38, United 
        States Code, as added by subsection (a), shall take effect on 
        October 1, 2015.
  (b) Limitations on Awards and Bonuses.--Section 705 of the Veterans 
Access, Choice, and Accountability Act of 2014 (Public Law 113-146; 38 
U.S.C. 703 note) is amended to read as follows:

``SEC. 705. LIMITATION ON AWARDS AND BONUSES PAID TO EMPLOYEES OF 
                    DEPARTMENT OF VETERANS AFFAIRS.

  ``The Secretary of Veterans Affairs shall ensure that the aggregate 
amount of awards and bonuses paid by the Secretary in a fiscal year 
under chapter 45 or 53 of title 5, United States Code, or any other 
awards or bonuses authorized under such title or title 38, United 
States Code, does not exceed the following amounts:
          ``(1) With respect to each of fiscal years 2015 through 2018, 
        $300,000,000.
          ``(2) With respect to each of fiscal years 2019 through 2024, 
        $360,000,000.''.

    Amend the title so as to read:
    A bill to amend title 38, United States Code, to authorize 
the Secretary of Veterans Affairs to enter into contracts and 
agreements for the placement of veterans in non-Department 
medical foster homes for certain veterans who are unable to 
live independently.

                          Purpose and Summary

    H.R. 294, the Long-Term Care Veterans Choice Act, was 
introduced by Representative Jeff Miller of Florida, the 
Chairman of the Committee, on January 13, 2015.
    H.R. 294, as amended would authorize the Department of 
Veterans Affairs (VA), for three years beginning on October 1, 
2015, to enter into a contract or agreement with a certified 
medical foster home to pay for long-term care for not more than 
900 eligible veterans. Eligible veterans are defined as those 
who are eligible for VA-paid nursing home care and agree to 
receive VA home health services. H.R. 294, as amended, would 
also limit the amount of the awards and bonuses paid to VA 
employees to $300 million over each of fiscal years (FYs) 2015-
2018.

                               Background


Section 2--Secretary of Veterans Affairs contract authority for 
        placement of veterans in non-department medical foster homes

    Section 101 of the Veterans Millennium Health Care and 
Benefits Act, Public Law 106-117 (113 Stat. 1545, 1547) 
requires VA to provide nursing home services to all enrolled 
veterans who are: 70 percent or more service-connected; 60 
percent or more service-connected and unemployable and in need 
of such care; or, who are service-connected for a condition 
that makes such care necessary. VA meets the requirements of 
the law by providing short- and long-term nursing home care, 
respite care, and end-of-life care through Community Living 
Centers located on VA medical center (VAMC) campuses; purchased 
care in Community Nursing Homes; and, through the State 
Veterans Nursing Home program.
    Additionally, VA provides a variety of non-institutional 
long-term care services to allow many veterans to remain within 
their homes and delay or avoid nursing home placement. One of 
the many non-institutional long-term care programs VA provides 
is the Community Residential Care (CRC) program.
    The CRC program is authorized under section 1730 of title 
38, United States Code (U.S.C.) and is a form of enriched 
housing which provides health care supervision to eligible 
veterans who do not require hospital or nursing home care but 
are not able to live independently because of medical or 
psychosocial limitations or care needs that exceed the 
capabilities of their families. VA health care personnel may 
assist veterans by referring them for placement in a privately 
or publicly owned community residential care facility if 
certain criteria--codified at 38 C.F.R. Sec.  17.61 through 
Sec.  17.72--are met.
    A relatively new variant of CRC is known as Medical Foster 
Home (MFH) care. VA's MFH program began in 1999 as a pilot 
project for veterans who prefer to live in a family setting but 
have complex medical conditions and/or disabilities due to 
chronic disease, frailty, or traumatic injury and, 
consequently, are unable to live independently. In general, a 
MFH is an adult foster home that, combined with a VA 
interdisciplinary home care team, provides non-institutional 
long-term care for veterans.
    A MFH is distinguished from other CRC homes because, in 
general: the home is owned or rented by the MFH caregiver; the 
MFH caregiver lives in the MFH and provides personal care and 
supervision; there are not more than three residents receiving 
care in the MFH, including both veterans and non-veterans; and, 
veteran MFH residents are enrolled in a VA Home Based Primary 
Care or Spinal Cord Injury Home Care Program.
    However, because a MFH is not considered institutional care 
that is eligible for VA nursing home payments, VA does not have 
the authority under the CRC program to pay for the cost of the 
MFH. A veteran who chooses to live in a MFH must pay out of 
pocket with personal funds, regardless of whether or not such 
veteran is eligible for VA-paid nursing home care.
    The inability of VA to pay for this type of long term care 
has forced service-connected veterans eligible for VA paid 
nursing home care who choose to reside in MFHs to pay for the 
service themselves, or to defer the MFH option in order to 
reside in an institutional setting that may not be the best 
option for the veteran's needs. VA believes many more veterans 
would elect to receive care in a MFH should VA be granted the 
authority to pay for care in such facilities.
    According to VA testimony from January 2015, VA considers 
MFHs to offer safe, highly veteran-centric care that many 
veterans prefer at a lower cost than traditional nursing home 
care while increasing access and promoting veteran choice. More 
than 900 veterans receive care in MFHs--at their own cost--and 
more than two-thirds of VAMCs currently manage a MFH program. 
These programs are managed by local MFH Coordinators who 
oversee the approval, inspection and placement process for MFHs 
in the community.
    VA also provides safeguards to ensure veterans receive 
safe, high-quality care by requiring MFH caregivers to: pass a 
federal background check and VA screening, agree to undergo 
annual training, and allow VA to make both announced and 
unannounced home visits.
    The Committee commends VA for these efforts and for 
focusing on education and training of MFH caregivers to ensure 
they provide safe, quality, and effective specialized care for 
veterans. The Committee recommends VA enter into partnerships 
with ongoing caregiver training initiatives to develop and host 
additional training to ensure incoming MFH caregivers are 
adequately trained and experienced and to help support and 
retain existing MFH caregivers.
    As the veteran population continues to age, the need for 
long-term care services will continue to grow. The Committee 
believes it is important to expand the long term care choices 
offered to veterans beyond traditional services and provide VA 
authority to pay for long term care in qualifying MFHs for 
eligible veterans. Granting VA the authority to pay for 
veterans who are eligible for VA-paid nursing home care to 
receive care in a MFH would allow veterans a choice of a more 
tailored long term care option that may better fit the quality 
of life they seek. Of additional benefit, VA has found that 
this action would ultimately provide a cost saving for the 
Department.
    Section 2 would authorize VA for three years beginning on 
October 1, 2015, to enter into a contract or agreement with a 
certified medical foster home to pay for long-term care for not 
more than 900 eligible veterans. It would also require an 
eligible veteran to receive VA home health services as a 
component of such payment and to be eligible for VA-paid 
nursing home care. To pay for this authority, Section 2 would 
also limit the amount the awards and bonuses paid to VA 
employees at $300 million over fiscal years (FYs) 2015-2018.

                                Hearings

    On May 21, 2013, the Full Committee conducted a legislative 
hearing on various bills introduced during the 114th Congress, 
including H.R. 189, H.R. 216, H.R. 245, H.R. 294, and H.R. 294.
    The following witnesses testified:
    The Honorable Alan Grayson of Florida; David R. McLenachen, 
Acting Deputy Under Secretary for Disability Assistance for the 
Veterans Benefits Administration of the U.S. Department of 
Veterans Affairs, accompanied by Dr. Rajiv Jain, the Assistant 
Deputy Under Secretary for Health for Patient Services for the 
Veterans Health Administration of the U.S. Department of 
Veterans Affairs, Susan Sullivan, the Deputy Assistant 
Secretary for Policy Office of Policy and Planning for the U.S. 
Department of Veterans Affairs, and Kim McLeod, Counsel for the 
Office of General Counsel of the U.S. Department of Veterans 
Affairs; Joseph A. Violante, the National Legislative Director 
for the Disabled American Veterans; Aleks Morosky, the Deputy 
Director of the National Legislative Service of the Veterans of 
Foreign Wars; Zachary Hearn, the Deputy Director of Claims for 
the Veterans Affairs and Rehabilitation Commission of The 
American Legion; and, Blake Ortner, the Deputy Government 
Relations Director for the Paralyzed Veterans of America.
    Statements for the record were submitted by the following:
    Vietnam Veterans of America and the Housing Policy Council.

                       Subcommittee Consideration

    There was no Subcommittee consideration of H.R. 294, as 
amended.

                        Committee Consideration

    On February 12, 2015, the full Committee met in an open 
markup session, a quorum being present, and ordered H.R. 294, 
as amended, reported favorably to the House of Representatives 
by voice vote.
    During consideration of H.R. 294, the following amendment 
was considered and agreed to by voice vote:
    An amendment in the nature of a substitute offered by 
Chairman Miller of Florida which limited the number of veterans 
eligible for VA-paid medical foster home care to 900 and also 
limited the awards and bonuses paid to VA employees at $300 
million for each of FYs 2015-2018.

                            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 recorded votes taken on amendments or in 
connection with ordering H.R. 294, as amended, reported to the 
House. A motion by Ranking Member Corrine Brown of Florida to 
report H.R. 294, as amended, 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. 294, as amended, does not contain any Congressional 
earmarks, limited tax benefits, or limited tariff benefits as 
defined in clause 9 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. 
294, as amended, 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. 294, as amended, 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 2, 2015.
Hon. Jeff Miller,
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. 294, the Long-Term 
Care Veterans Choice Act.
    If you wish further details on this estimate, we will be 
pleased to provide them. The CBO staff contact is Ann E. 
Futrell.
            Sincerely,
                                      Douglas W. Elmendorf,
                                                          Director.
    Enclosure.

H.R. 294--Long-Term Care Veterans Choice Act

    H.R. 294 would authorize the Department of Veterans Affairs 
(VA) to provide long-term care in medical foster homes (MFHs) 
for certain veterans with severe service-connected 
disabilities. The bill also would limit the awards and bonuses 
paid to VA employees. On net, CBO estimates that implementing 
the bill would reduce discretionary costs by $253 million over 
the 2016-2020 period, subject to appropriation action 
consistent with the bill.
    Pay-as-you-go procedures do not apply to this legislation 
because it would not affect direct spending or revenues.
    H.R. 294 contains no intergovernmental or private-sector 
mandates as defined in the Unfunded Mandates Reform Act (UMRA) 
and would not affect the budgets of state, local, or tribal 
governments.
    Estimated cost to the Federal Government: The estimated 
budgetary effect of H.R. 294 is shown in the following table. 
The costs of this legislation fall within budget function 700 
(veterans benefits and services).
    Basis of estimate: For this estimate, CBO assumes that the 
legislation will be enacted near the end of fiscal year 2015, 
that the necessary amounts will be appropriated for each year, 
and that outlays will follow historical spending patterns for 
similar and existing programs.

----------------------------------------------------------------------------------------------------------------
                                                          By fiscal year, in millions of dollars--
                                          ----------------------------------------------------------------------
                                             2015      2016      2017      2018      2019      2020    2015-2020
----------------------------------------------------------------------------------------------------------------
                                  CHANGES IN SPENDING SUBJECT TO APPROPRIATION
 
Medical Foster Care:
    Estimated Authorization Level........         0        27        33        40        39        38        177
    Estimated Outlays....................         0        24        32        39        39        38        172
Limitation on Awards and Bonuses:
    Estimated Authorization Level........         0      -101      -105      -109       -53       -57       -425
    Estimated Outlays....................         0      -101      -105      -109       -53       -57       -425
    Total Changes:
        Estimated Authorization Level....         0       -74       -72       -69       -14       -19       -248
        Estimated Outlays................         0       -77       -73       -70       -14       -19       -253
----------------------------------------------------------------------------------------------------------------

Medical foster care

    For the three-year period beginning on October 1, 2015, the 
bill would authorize VA to place up to 900 veterans with severe 
service-connected disabilities in MFHs and to pay the full cost 
of their stay in those establishments. A MPH is a private home 
in which a trained caregiver provides services to a few 
individuals. VA has an existing program under which it inspects 
and approves MFHs for veterans. Veterans currently living in 
such homes are eligible to receive VA's Home Based Primary Care 
services, which include case management and health care 
provided in the home. VA is not currently authorized to pay for 
the cost of living in MFHs, but under this bill, VA could pay 
that cost. CBO expects that once veterans are placed in medical 
foster care under this new program, VA will pay for their stays 
in those facilities indefinitely.
    CBO estimates that half of the veterans eligible for this 
program (or 450 individuals) would become residents of MFHs as 
a result of the bill's enactment. For those veterans, VA would 
pay for their living expenses, as well as the costs for Home 
Based Primary Care services. We estimate that those veterans 
would receive health care that would cost $9,000 per year more 
than they would receive under current law because providing 
care in the individual homes is costlier than providing health 
care at VA medical facilities Including the costs for living 
expenses at the MFHs of $39,000 per year, we estimate total 
costs per new resident of $48,000 per year. As a result, total 
costs for new MPH residents would be about $22 million a year, 
CBO estimates.
    CBO estimates that the remaining half of the eligible 
population (450 veterans) would be individuals already living 
in MFHs. Because VA already provides those veterans with in-
home health care services, the incremental cost would be 
$39,000 a year per veteran to cover the expense of living in 
the MFHs. Those costs would total about $18 million a year for 
those 450 veterans, CBO estimates.
    After factoring in inflation, appropriate mortality rates, 
and a gradual implementation period to reflect the time for VA 
to transition additional veterans into the MFH program, CBO 
estimates that implementing this bill would cost an additional 
$172 million over the 2016-2020 period, assuming appropriation 
of the necessary amounts.

Limitation on awards and bonuses

    This bill also would limit to $300 million the amount that 
VA could pay in awards and bonuses to VA employees through 2018 
and $360 million from 2019 to 2024. Over the 2010-2013 period, 
VA paid an average of $395 million each year in awards and 
bonus payments to employees. Assuming such payments will grow 
with inflation under current law, CBO estimates that 
implementing this provision would reduce discretionary spending 
for pay and performance by $425 million over the 2016-2020 
period, assuming appropriation actions consistent with the 
bill.
    Pay-As-You-Go considerations: None.
    Intergovernmental and private-sector impact: H.R. 294 
contains no intergovernmental or private-sector mandates as 
defined in UMRA and would not affect the budgets of state, 
local, or tribal governments.
    Estimate prepared by: Federal Costs: Ann E. Futrell and 
Dwayne M. Wright; Impact on State, Local, and Tribal 
Governments: Jon Sperl; Impact on the Private Sector: Paige 
Piper-Bach.
    Estimate 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. 294, as amended, 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. 
294, as amended.

                 Statement of Constitutional Authority

    Pursuant to Article I, section 8 of the United States 
Constitution, the reported bill is authorized by Congress' 
power to ``provide for the common Defense and general Welfare 
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.

              Statement on Duplication of Federal Programs

    Pursuant to section 3(g) of H. Res. 5, 114th Cong. (2015), 
the Committee finds that no provision of H.R. 294, as amended, 
establishes or reauthorizes a program of the Federal Government 
known to be duplicative of another Federal program, a program 
that was included in any report from the Government 
Accountability Office to Congress pursuant to section 21 of 
Public Law 111-139, or a program related to a program 
identified in the most recent Catalog of Federal Domestic 
Assistance.

                   Disclosure of Directed Rulemaking

    Pursuant to section 3(i) of H. Res. 5, 114th Cong. (2015), 
the Committee estimates that H.R. 294, as amended, does not 
require directed rule making.

             Section-by-Section Analysis of the Legislation


Section 1. Short title

    Section 1 of the bill would provide that the short title of 
H.R. 294, as amended, would be the ``Long-Term Care Veterans 
Choice Act.''

Section 2--Secretary of Veterans Affairs contract authority for 
        placement of veterans in non-department medical foster homes

    Section 2(a)(1) of the bill would amend section 1720 of 
title 38, United States Code, by adding a new subsection (h) 
that would authorize VA, during the three year period beginning 
on October 1, 2015, to facilitate the placement of veterans to 
medical foster homes at the request of the veteran for whom VA 
is required to provide nursing home care under 38 U.S.C. Sec.  
1710(A). Under this subsection, the medical foster home would 
be required to meet department standards, and not more than 900 
veterans, whether placed in a MFH before or after enactment, 
would be eligible to have the cost of their MFH care paid for 
by VA. Such care would be pursuant to a contract or agreement 
entered into between the Secretary and the medical foster home. 
A veteran who is placed in a medical foster home under this 
subsection would be required to agree, as a condition of such 
transfer, to accept home health services furnished by the 
Secretary under 38 U.S.C. Sec.  1717.
    Section 2(a)(2) of the bill would set an effective date of 
October 1, 2015, for the (h).
    Section 2(b) of the bill would amend Section 705 of Public 
Law 113-146 to limit the aggregate amount of awards and bonuses 
that can be paid to VA employees to $300 million for each of 
FYs 2015-2018.

         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):

TITLE 38, UNITED STATES CODE

           *       *       *       *       *       *       *



PART II--GENERAL BENEFITS

           *       *       *       *       *       *       *


CHAPTER 17--HOSPITAL, NURSING HOME, DOMICILIARY, AND MEDICAL CARE

           *       *       *       *       *       *       *



SUBCHAPTER II--HOSPITAL, NURSING HOME, OR DOMICILIARY CARE AND MEDICAL 
TREATMENT

           *       *       *       *       *       *       *



Sec. 1720. Transfers for nursing home care; adult day health care

  (a)(1) Subject to subsection (b) of this section, the 
Secretary may transfer to a non-Department nursing home, for 
care at the expense of the United States--
          (A) a veteran--
                  (i) who has been furnished care by the 
                Secretary in a facility under the direct 
                jurisdiction of the Secretary; and
                  (ii) who the Secretary determines--
                          (I) requires a protracted period of 
                        nursing home care which can be 
                        furnished in the non-Department nursing 
                        home; and
                          (II) in the case of a veteran who has 
                        been furnished hospital care in a 
                        facility under the direct jurisdiction 
                        of the Secretary, has received maximum 
                        benefits from such care; and
          (B) a member of the Armed Forces--
                  (i) who has been furnished care in a hospital 
                of the Armed Forces;
                  (ii) who the Secretary concerned determines 
                has received maximum benefits from such care 
                but requires a protracted period of nursing 
                home care; and
                  (iii) who upon discharge from the Armed 
                Forces will become a veteran.
  (2) The Secretary may transfer a person to a nursing home 
under this subsection only if the Secretary determines that the 
cost to the United States of the care of such person in the 
nursing home will not exceed--
          (A) the amount equal to 45 percent of the cost of 
        care furnished by the Department in a general hospital 
        under the direct jurisdiction of the Secretary (as such 
        cost may be determined annually by the Secretary); or
          (B) the amount equal to 50 percent of such cost, if 
        such higher amount is determined to be necessary by the 
        Secretary (upon the recommendation of the Under 
        Secretary for Health) to provide adequate care.
  (3) Nursing home care may not be furnished under this 
subsection at the expense of the United States for more than 
six months in the aggregate in connection with any one transfer 
except--
          (A) in the case of a veteran--
                  (i) who is transferred to a non-Department 
                nursing home from a hospital under the direct 
                jurisdiction of the Secretary; and
                  (ii) whose hospitalization was primarily for 
                a service-connected disability;
          (B) in a case in which the nursing home care is 
        required for a service-connected disability; or
          (C) in a case in which, in the judgment of the 
        Secretary, a longer period of nursing home care is 
        warranted.
  (4) A veteran who is furnished care by the Secretary in a 
hospital or domiciliary facility in Alaska or Hawaii may be 
furnished nursing home care at the expense of the United States 
under this subsection even if such hospital or domiciliary 
facility is not under the direct jurisdiction of the Secretary.
  (b) No veteran may be transferred or admitted to any 
institution for nursing home care under this section, unless 
such institution is determined by the Secretary to meet such 
standards as the Secretary may prescribe. The standards 
prescribed and any report of inspection of institutions 
furnishing care to veterans under this section made by or for 
the Secretary shall, to the extent possible, be made available 
to all Federal, State, and local agencies charged with the 
responsibility of licensing or otherwise regulating or 
inspecting such institutions.
  (c)(1)(A) In furnishing nursing home care, adult day health 
care, or other extended care services under this section, the 
Secretary may enter into agreements for furnishing such care or 
services with--
          (i) in the case of the medicare program, a provider 
        of services that has entered into a provider agreement 
        under section 1866(a) of the Social Security Act (42 
        U.S.C. 1395cc(a));
          (ii) in the case of the medicaid program, a provider 
        participating under a State plan under title XIX of 
        such Act (42 U.S.C. 1396 et seq.); and
          (iii) a provider of services eligible to enter into a 
        contract pursuant to section 1745(a) of this title that 
        is not otherwise described in clause (i) or (ii).
  (B) In entering into an agreement under subparagraph (A) with 
a provider of services described in clause (i) of that 
subparagraph or a provider described in clause (ii) of that 
subparagraph, the Secretary may use the procedures available 
for entering into provider agreements under section 1866(a) of 
the Social Security Act.
  (2) In applying the provisions of section 6704(a) of title 41 
with respect to any contract entered into under this section to 
provide nursing home care of veterans, the payment of wages not 
less than those specified in section 6(b) of the Fair Labor 
Standards Act of 1938 (29 U.S.C. 206(b)) shall be deemed to 
constitute compliance with such provisions.
  (d)(1) Subject to subsection (b) of this section, the 
Secretary may authorize for any veteran requiring nursing home 
care for a service-connected disability direct admission for 
such care at the expense of the United States to any non-
Department nursing home. The Secretary may also authorize a 
direct admission to such a nursing home for nursing home care 
for any veteran who has been discharged from a hospital under 
the direct jurisdiction of the Secretary and who is currently 
receiving medical services as part of home health services from 
the Department.
  (2) Direct admission authorized by paragraph (1) of this 
subsection may be authorized upon determination of need 
therefor--
          (A) by a physician employed by the Department; or
          (B) in areas where no such physician is available, by 
        a physician carrying out such function under contract 
        or fee arrangement,
based on an examination by such physician.
  (3) The amount which may be paid for such care and the length 
of care available under this subsection shall be the same as 
authorized under subsection (a) of this section.
  (e)(1) The cost of intermediate care for purposes of payment 
by the United States pursuant to subsection (a)(2)(B) of this 
section shall be determined by the Secretary except that the 
rate of reimbursement shall be commensurately less than that 
provided for nursing home care.
  (2) For the purposes of this section, the term ``non-
Department nursing home'' means a public or private institution 
not under the direct jurisdiction of the Secretary which 
furnishes nursing home care.
  (f)(1)(A) The Secretary may furnish adult day health care 
services to a veteran enrolled under section 1705(a) of this 
title who would otherwise require nursing home care.
  (B) The Secretary may provide in-kind assistance (through the 
services of Department employees and the sharing of other 
Department resources) to a facility furnishing care to veterans 
under subparagraph (A) of this paragraph. Any such in-kind 
assistance shall be provided under a contract or agreement 
between the Secretary and the facility concerned. The Secretary 
may provide such assistance only for use solely in the 
furnishing of adult day health care and only if, under such 
contract or agreement, the Department receives reimbursement 
for the full cost of such assistance, including the cost of 
services and supplies and normal depreciation and amortization 
of equipment. Such reimbursement may be made by reduction in 
the charges to the United States or by payment to the United 
States. Any funds received through such reimbursement shall be 
credited to funds allotted to the Department facility that 
provided the assistance.
  (2) The Secretary may conduct, at facilities over which the 
Secretary has direct jurisdiction, programs for the furnishing 
of adult day health care to veterans who are eligible for such 
care under paragraph (1) of this subsection, except that 
necessary travel and incidental expenses (or transportation in 
lieu thereof) may be furnished under such a program only under 
the terms and conditions set forth in section 111 of this 
title. The furnishing of care under any such program shall be 
subject to the limitations that are applicable to the duration 
of adult day health care furnished under paragraph (1) of this 
subsection.
  (g) The Secretary may contract with appropriate entities to 
provide specialized residential care and rehabilitation 
services to a veteran of Operation Enduring Freedom or 
Operation Iraqi Freedom who the Secretary determines suffers 
from a traumatic brain injury, has an accumulation of deficits 
in activities of daily living and instrumental activities of 
daily living, and because of these deficits, would otherwise 
require admission to a nursing home even though such care would 
generally exceed the veteran's nursing needs.
  (h)(1) During the three-year period beginning on October 1, 
2015, and subject to paragraph (2), at the request of a veteran 
for whom the Secretary is required to provide nursing home care 
under section 1710A of this title, the Secretary may place the 
veteran in a medical foster home that meets Department 
standards, at the expense of the United States, pursuant to a 
contract or agreement entered into between the Secretary and 
the medical foster home for such purpose. A veteran who is 
placed in a medical foster home under this subsection shall 
agree, as a condition of such placement, to accept home health 
services furnished by the Secretary under section 1717 of this 
title.
  (2) Not more than 900 veterans placed in a medical foster 
home, whether placed before or after the enactment of the Long-
Term Care Veterans Choice Act, may have their care covered at 
the expense of the United States under subsection (a).
  (3) In this subsection, the term ``medical foster home'' 
means a home designed to provide non-institutional, long-term, 
supportive care for veterans who are unable to live 
independently and prefer a family setting.

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VETERANS ACCESS, CHOICE, AND ACCOUNTABILITY ACT OF 2014

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TITLE VII--OTHER VETERANS MATTERS

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[SEC. 705. LIMITATION ON AWARDS AND BONUSES PAID TO EMPLOYEES OF 
                    DEPARTMENT OF VETERANS AFFAIRS.

  [In each of fiscal years 2015 through 2024, the Secretary of 
Veterans Affairs shall ensure that the aggregate amount of 
awards and bonuses paid by the Secretary in a fiscal year under 
chapter 45 or 53 of title 5, United States Code, or any other 
awards or bonuses authorized under such title does not exceed 
$360,000,000.]

SEC. 705. LIMITATION ON AWARDS AND BONUSES PAID TO EMPLOYEES OF 
                    DEPARTMENT OF VETERANS AFFAIRS.

  The Secretary of Veterans Affairs shall ensure that the 
aggregate amount of awards and bonuses paid by the Secretary in 
a fiscal year under chapter 45 or 53 of title 5, United States 
Code, or any other awards or bonuses authorized under such 
title or title 38, United States Code, does not exceed the 
following amounts:
          (1) With respect to each of fiscal years 2015 through 
        2018, $300,000,000.
          (2) With respect to each of fiscal years 2019 through 
        2024, $360,000,000.

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