[House Report 118-284]
[From the U.S. Government Publishing Office]
118th Congress } { Report
HOUSE OF REPRESENTATIVES
1st Session } { 118-284
======================================================================
ELIZABETH DOLE HOME- AND COMMUNITY-BASED SERVICES FOR VETERANS AND
CAREGIVERS ACT OF 2023
_______
November 29, 2023.--Committed to the Committee of the Whole House on
the State of the Union and ordered to be printed
Mr. Bost, from the Committee on Veterans' Affairs, submitted the
following
R E P O R T
[To accompany H.R. 542]
[Including cost estimate of the Congressional Budget Office]
The Committee on Veterans' Affairs, to whom was referred
the bill (H.R. 542) to amend title 38, United States Code, to
improve certain programs of the Department of Veterans Affairs
for home- and community-based services for veterans, and for
other purposes, having considered the same, reports favorably
thereon with an amendment and recommends that the bill as
amended do pass.
CONTENTS
Page
Amendment........................................................ 2
Purpose and Summary.............................................. 8
Background and Need for Legislation.............................. 9
Hearings......................................................... 16
Subcommittee Consideration....................................... 17
Committee Consideration.......................................... 17
Committee Votes.................................................. 17
Committee Correspondence.........................................
Committee Oversight Findings..................................... 18
Statement of General Performance Goals and Objectives............ 18
Earmarks and Tax and Tariff Benefits............................. 18
Committee Cost Estimate.......................................... 18
Budget Authority and Congressional Budget Office Estimate........ 18
Federal Mandates Statement....................................... 24
Advisory Committee Statement..................................... 24
Applicability to Legislative Branch.............................. 24
Statement on Duplication of Federal Programs..................... 24
Section-by-Section Analysis of the Legislation................... 25
Changes in Existing Law Made by the Bill as Reported............. 29
The amendment is as follows:
Strike all after the enacting clause and insert the
following:
SECTION 1. SHORT TITLE; TABLE OF CONTENTS.
(a) Short Title.--This Act may be cited as the ``Elizabeth Dole Home-
and Community-Based Services for Veterans and Caregivers Act of 2023''
or the ``Elizabeth Dole Home Care Act of 2023''.
(b) Table of Contents.--The table of contents for this Act is as
follows:
Sec. 1. Short title; table of contents.
Sec. 2. Increase of expenditure cap for noninstitutional care
alternatives to nursing home care.
Sec. 3. Coordination with Program of All-Inclusive Care for the
Elderly.
Sec. 4. Home- and community-based services: programs.
Sec. 5. Coordination with assistance and support services for
caregivers.
Sec. 6. Development of centralized website for program information.
Sec. 7. Improvements relating to Homemaker and Home Health Aide
program.
Sec. 8. Reviews and other improvements relating to home- and community-
based services.
Sec. 9. Modification of certain housing loan fees.
Sec. 10. Definitions.
SEC. 2. INCREASE OF EXPENDITURE CAP FOR NONINSTITUTIONAL CARE
ALTERNATIVES TO NURSING HOME CARE.
(a) Increase of Expenditure Cap.--Section 1720C(d) of title 38,
United States Code, is amended--
(1) by striking ``The total cost'' and inserting ``(1) Except
as provided in paragraph (2), the total cost'';
(2) by striking ``65 percent'' and inserting ``100 percent'';
and
(3) by adding at the end the following new paragraph:
``(2)(A) The total cost of providing services or in-kind assistance
in the case of any veteran described in subparagraph (B) for any fiscal
year under the program may exceed 100 percent of the cost that would
otherwise have been incurred as specified in paragraph (1) if the
Secretary determines, based on a consideration of clinical need,
geographic market factors, and such other matters as the Secretary may
prescribe through regulation, that such higher total cost is in the
best interest of the veteran.
``(B) A veteran described in this subparagraph is a veteran with
amyotrophic lateral sclerosis, a spinal cord injury, or a condition the
Secretary determines to be similar to such conditions.''.
(b) Applicability.--The amendments made by subsection (a) shall apply
with respect to fiscal years beginning on or after the date of the
enactment of this Act.
SEC. 3. COORDINATION WITH PROGRAM OF ALL-INCLUSIVE CARE FOR THE
ELDERLY.
Section 1720C of title 38, United States Code, as amended by section
2, is further amended by adding at the end the following new
subsection:
``(f) In furnishing services to a veteran under the program conducted
pursuant to subsection (a), if a medical center of the Department
through which such program is administered is located in a geographic
area in which services are available to the veteran under a PACE
program (as such term is defined in sections 1894(a)(2) and 1934(a)(2)
of the Social Security Act (42 U.S.C. 1395eee(a)(2); 1396u-4(a)(2))),
the Secretary shall seek to enter into an agreement with the PACE
program operating in that area for the furnishing of such services.''.
SEC. 4. HOME- AND COMMUNITY-BASED SERVICES: PROGRAMS.
(a) Programs.--Chapter 17 of title 38, United States Code, is amended
by inserting after section 1720J the following new section (and
conforming the table of sections at the beginning of such chapter
accordingly):
``Sec. 1720K. Home- and community-based services: programs
``(a) In General.--In furnishing noninstitutional alternatives to
nursing home care pursuant to the authority of section 1720C of this
title (or any other authority under this chapter or other provision of
law administered by the Secretary of Veterans Affairs), the Secretary
shall carry out each of the programs specified in this section in
accordance with such relevant authorities except as otherwise provided
in this section.
``(b) Veteran-Directed Care Program.--(1) The Secretary of Veterans
Affairs, in collaboration with the Secretary of Health and Human
Services, shall carry out a program to be known as the `Veteran-
Directed Care program'. Under such program, the Secretary of Veterans
Affairs may enter into agreements with the providers described in
paragraph (2) to provide to eligible veterans funds, to the extent
practicable, to obtain such in-home care services and related items as
may be determined appropriate by the Secretary of Veterans Affairs and
selected by the veteran, including through the veteran hiring
individuals to provide such services and items or directly purchasing
such services and items.
``(2) The providers described in this paragraph are the following:
``(A) An Aging and Disability Resource Center, an area agency
on aging, or a State agency.
``(B) A center for independent living.
``(C) An Indian tribe or tribal organization receiving
assistance under title VI of the Older Americans Act of 1965
(42 U.S.C. 3057 et seq.).
``(3) In carrying out the Veteran-Directed Care program, the
Secretary of Veterans Affairs shall--
``(A) administer such program through each medical center of
the Department of Veterans Affairs;
``(B) seek to ensure the availability of such program in
American Samoa, Guam, the Commonwealth of the Northern Mariana
Islands, the Commonwealth of Puerto Rico, the Virgin Islands of
the United States, and any other territory or possession of the
United States, to the extent practicable; and
``(C) seek to ensure the availability of such program for
eligible veterans who are Native American veterans receiving
care and services furnished by the Indian Health Service, a
tribal health program, an Urban Indian organization, or (in the
case of a Native Hawaiian veteran) a Native Hawaiian health
care system, to the extent practicable.
``(4) If a veteran participating in the Veteran-Directed Care program
is catastrophically disabled, the veteran may continue to use funds
under the program during a period of hospitalization in the same manner
that the veteran would be authorized to use such funds under the
program if the veteran were not hospitalized.
``(c) Homemaker and Home Health Aide Program.--(1) The Secretary
shall carry out a program to be known as the `Homemaker and Home Health
Aide program' under which the Secretary may enter into agreements with
home health agencies to provide to eligible veterans such home health
aide services as may be determined appropriate by the Secretary.
``(2) In carrying out the Homemaker and Home Health Aide program, the
Secretary shall, to the extent practicable, ensure the availability of
such program--
``(A) in the locations specified in subparagraph (B) of
subsection (b)(3); and
``(B) for the veteran populations specified in subparagraph
(C) of such subsection.
``(d) Home-Based Primary Care Program.--The Secretary shall carry out
a program to be known as the `Home-Based Primary Care program' under
which the Secretary may furnish to eligible veterans in-home health
care, the provision of which is overseen by a provider of the
Department.
``(e) Purchased Skilled Home Care Program.--The Secretary shall carry
out a program to be known as the `Purchased Skilled Home Care program'
under which the Secretary may furnish to eligible veterans such in-home
care services as may be determined appropriate and selected by the
Secretary for the veteran.
``(f) Caregiver Support.--(1) With respect to a resident eligible
caregiver of a veteran participating in a program under this section,
the Secretary shall--
``(A) if the veteran meets the requirements of a covered
veteran under section 1720G(b) of this title, provide to such
caregiver the option of enrolling in the program of general
caregiver support services under such section;
``(B) provide to such caregiver covered respite care of not
less than 30 days annually; and
``(C) conduct on an annual basis (and, to the extent
practicable, in connection with in-person services provided
under the program in which the veteran is participating), a
wellness contact of such caregiver.
``(2) Covered respite care provided to a resident eligible caregiver
of a veteran under paragraph (1) may exceed 30 days annually if such
extension is requested by the resident eligible caregiver or veteran
and determined medically appropriate by the Secretary.
``(g) Rule of Construction.--Nothing in this section shall be
construed to limit the authority of the Secretary to carry out programs
providing home- and community-based services under any other provision
of law.
``(h) Definitions.--In this section:
``(1) The terms `Aging and Disability Resource Center', `area
agency on aging', and `State agency' have the meanings given
those terms in section 102 of the Older Americans Act of 1965
(42 U.S.C. 3002).
``(2) The terms `caregiver' and `family caregiver', with
respect to a veteran, have the meanings given those terms,
respectively, under subsection (e) of section 1720G of this
title with respect to an eligible veteran under subsection (a)
of such section or a covered veteran under subsection (b) of
such section, as the case may be.
``(3) The term `center for independent living' has the
meaning given that term in section 702 of the Rehabilitation
Act of 1973 (29 U.S.C. 796a).
``(4) The term `covered respite care' has the meaning given
such term in section 1720G(d) of this title.
``(5) The term `eligible veteran' means any veteran--
``(A) for whom the Secretary determines participation
in a specific program under this section is medically
necessary to promote, preserve, or restore the health
of the veteran; and
``(B) who absent such participation would be at
increased risk for hospitalization, placement in a
nursing home, or emergency room care.
``(6) The term `home health aide' means an individual
employed by a home health agency to provide in-home care
services.
``(7) The term `in-home care service' means any service,
including a personal care service, provided to enable the
recipient of such service to live at home.
``(8) The terms `Indian tribe' and `tribal organization' have
the meanings given those terms in section 4 of the Indian Self-
Determination and Education Assistance Act (25 U.S.C. 5304).
``(9) The terms `Native American' and `Native American
veteran' have the meanings given those terms in section 3765 of
this title.
``(10) The terms `Native Hawaiian' and `Native Hawaiian
health care system' have the meanings given those terms in
section 12 of the Native Hawaiian Health Care Improvement Act
(42 U.S.C. 11711).
``(11) The terms `tribal health programs' and `Urban Indian
organizations' have the meanings given those terms in section 4
of the Indian Health Care Improvement Act (25 U.S.C. 1603).
``(12) The term `resident eligible caregiver' means an
individual who--
``(A) is a caregiver, or a family caregiver, of a
veteran and resides with that veteran; and
``(B) has not entered into a contract, agreement, or
other arrangement for such individual to act as a
caregiver for that veteran unless such individual is a
family member of the veteran or is furnishing caregiver
services through a medical foster home.''.
(b) Deadline for Improved Administration.--The Secretary of Veterans
Affairs shall ensure that the Veteran-Directed Care program and the
Homemaker and Home Health Aide program are administered through each
medical center of the Department of Veterans Affairs in accordance with
section 1720K of title 38, United States Code (as added by subsection
(a)), by not later than two years after the date of the enactment of
this Act.
SEC. 5. COORDINATION WITH ASSISTANCE AND SUPPORT SERVICES FOR
CAREGIVERS.
(a) Coordination With Program of Comprehensive Assistance for Family
Caregivers.--
(1) Coordination.--Section 1720G(a) of title 38, United
States Code, is amended by adding at the end the following new
paragraph:
``(14)(A) In the case of a veteran or caregiver who seeks services
under this subsection and is denied such services, or a veteran or the
family caregiver of a veteran who is discharged from the program under
this subsection, the Secretary shall--
``(i) if the veteran meets the requirements of a covered
veteran under subsection (b), provide to such caregiver the
option of enrolling in the program of general caregiver support
services under such subsection;
``(ii) assess the veteran or caregiver for participation in
any other available program of the Department for home- and
community-based services (including the programs specified in
section 1720K of this title) for which the veteran or caregiver
may be eligible and, with respect to the veteran, store (and
make accessible to the veteran) the results of such assessment
in the electronic medical record of the veteran; and
``(iii) provide to the veteran or caregiver written
information on any such program identified pursuant to the
assessment under clause (ii), including information about
facilities, eligibility requirements, and relevant contact
information for each such program.
``(B) For each veteran or family caregiver who is discharged from the
program under this subsection, a caregiver support coordinator shall
provide for a smooth and personalized transition from such program to
an appropriate program of the Department for home- and community-based
services (including the programs specified in section 1720K of this
title), including by integrating caregiver support across programs.''.
(2) Applicability.--The amendments made by paragraph (1)
shall apply with respect to denials and discharges occurring on
or after the date that is 180 days after the date of the
enactment of this Act.
(3) Technical and conforming amendments.--Section 1720G(d) of
such title is amended--
(A) by striking ``or a covered veteran'' each place
it appears and inserting ``, a veteran denied or
discharged as specified in paragraph (14) of such
subsection, or a covered veteran''; and
(B) by striking ``under subsection (a), means'' each
place it appears and inserting ``under subsection (a)
or a veteran denied or discharged as specified in
paragraph (14) of such subsection, means''.
(b) Conformity of Respite Care Across Programs.--Section 1720G of
title 38, United States Code, as amended by subsection (a)(3), is
further amended--
(1) in subsection (a)(3)--
(A) by amending subparagraph (A)(ii)(III) to read as
follows:
``(III) covered respite care of not less than 30 days
annually;''; and
(B) by striking subparagraph (B) and redesignating
subparagraphs (C) and (D) as subparagraphs (B) and (C),
respectively; and
(2) by amending subsection (b)(3)(A)(iii) to read as follows:
``(iii) Covered respite care of not less than 30 days
annually.''; and
(3) in subsection (d)--
(A) by redesignating paragraphs (2) through (4) as
paragraphs (3) through (5), respectively; and
(B) by inserting after paragraph (1) the following
new paragraph:
``(2) The term `covered respite care' means, with respect to
a caregiver of a veteran, respite care under section 1720B of
this title that--
``(A) is medically and age appropriate for the
veteran (including 24-hour per day care of the veteran
commensurate with the care provided by the caregiver);
and
``(B) includes in-home care.''.
(c) Review Relating to Caregiver Contact.--The Secretary shall
conduct a review of the capacity of the Department to establish a
streamlined system for contacting all caregivers enrolled in the
program of general caregiver support services under section 1720G(b) of
title 38, United States Code, to provide to such caregivers program
updates and alerts relating to emerging services for which such
caregivers may be eligible.
SEC. 6. DEVELOPMENT OF CENTRALIZED WEBSITE FOR PROGRAM INFORMATION.
(a) Centralized Website.--The Secretary shall develop and maintain a
centralized and publically accessible internet website of the
Department as a clearinghouse for information and resources relating to
covered programs.
(b) Contents.--The website under subsection (a) shall contain the
following:
(1) A description of each covered program.
(2) An informational assessment tool that--
(A) explains the administrative eligibility, if
applicable, of a veteran, or a caregiver of a veteran,
for any covered program; and
(B) provides information, as a result of such
explanation, on any covered program for which the
veteran or caregiver (as the case may be) may be
eligible.
(3) A list of required procedures for the directors of the
medical facilities of the Department to follow in determining
the eligibility and suitability of veterans for participation
in a covered program, including procedures applicable to
instances in which the resource constraints of a facility (or
of a community in which a facility is located) may result in
the inability to address the health needs of a veteran under a
covered program in a timely manner.
(c) Updates.--The Secretary shall ensure the website under subsection
(a) is updated on a periodic basis.
SEC. 7. IMPROVEMENTS RELATING TO HOMEMAKER AND HOME HEALTH AIDE
PROGRAM.
(a) Pilot Program for Communities With Shortage of Home Health
Aides.--
(1) Program.--Beginning not later than 18 months after the
date of the enactment of this Act, the Secretary shall carry
out a three-year pilot program under which the Secretary shall
provide homemaker and home health aide services to veterans who
reside in communities with a shortage of home health aides.
(2) Locations.--The Secretary shall select not fewer than
five geographic locations in which the Secretary determines
there is a shortage of home health aides at which to carry out
the pilot program under paragraph (1).
(3) Nursing assistants.--
(A) In general.--In carrying out the pilot program
under paragraph (1), the Secretary may hire nursing
assistants as new employees of the Department of
Veterans Affairs, or reassign nursing assistants who
are existing employees of the Department, to provide to
veterans in-home care services (including basic tasks
authorized by the State certification of the nursing
assistant) under the pilot program, in lieu of or in
addition to the provision of such services through non-
Department home health aides.
(B) Relationship to home-based primary care
program.--Nursing assistants hired or reassigned under
subparagraph (A) may provide services to a veteran
under the pilot program under paragraph (1) while
serving as part of a health care team for the veteran
under the Home-Based Primary Care program.
(4) Report to congress.--Not later than one year after the
date on which the Secretary determines the pilot program under
paragraph (1) has terminated, the Secretary shall submit to the
Committees on Veterans' Affairs of the House of Representatives
and the Senate a report on the result of the pilot program.
(b) Report on Use of Funds.--Not later than one year after the date
of the enactment of this Act, the Secretary of Veterans Affairs shall
submit to the Committees on Veterans' Affairs of the House of
Representatives and the Senate a report containing, with respect to the
period beginning in fiscal year 2012 and ending in fiscal year 2023,
the following:
(1) An identification of the amount of funds that were
included in a budget of the Department of Veterans Affairs
during such period for the provision of in-home care to
veterans under the Homemaker and Home Health Aide program but
were not expended for such provision, disaggregated by medical
center of the Department for which such unexpended funds were
budgeted (if such disaggregation is possible).
(2) To the extent practicable, an identification of the
number of veterans for whom, during such period, the hours
during which a home health aide was authorized to provide
services to the veteran under the Homemaker and Home Health
Aide program were reduced for a reason other than a change in
the health care needs of the veteran, and a detailed
description of the reasons why any such reductions may have
occurred.
(c) Updated Guidance on Program.--Not later than one year after the
date of the enactment of this Act, the Secretary shall issue updated
guidance for the Homemaker and Home Health Aide program. Such updated
guidance shall include the following:
(1) A process for the transition of veterans from the
Homemaker and Home Health Aide program to other covered
programs.
(2) A requirement for the directors of the medical facilities
of the Department to complete such process whenever a veteran
with care needs has been denied services from home health
agencies under the Homemaker and Home Health Aide program as a
result of the clinical needs or behavioral issues of the
veteran.
SEC. 8. REVIEWS AND OTHER IMPROVEMENTS RELATING TO HOME- AND COMMUNITY-
BASED SERVICES.
(a) Office of Geriatric and Extended Care.--
(1) Review of programs.--The Under Secretary for Health of
the Department of Veterans Affairs shall conduct a review of
each program administered through the Office of Geriatric and
Extended Care of the Department, or successor office, to--
(A) ensure consistency in program management;
(B) eliminate service gaps at the medical center
level; and
(C) ensure the availability of, and the access by
veterans to, home- and community-based services.
(2) Assessment of staffing needs.--The Secretary of Veterans
Affairs shall conduct an assessment of the staffing needs of
the Office of Geriatric and Extended Care of the Department of
Veterans Affairs, or successor office.
(3) Goals for geographic alignment of care.--
(A) Establishment of goals.--The Director of the
Office of Geriatric and Extended Care, or successor
office, shall establish quantitative goals to enable
aging or disabled veterans who are not located near
medical centers of the Department to access extended
care services (including by improving access to home-
and community-based services for such veterans).
(B) Implementation timeline.--Each goal established
under subparagraph (A) shall include a timeline for the
implementation of the goal at each medical center of
the Department.
(4) Goals for in-home specialty care.--The Director of the
Office of Geriatric and Extended Care, or successor office,
shall establish quantitative goals to address the specialty
care needs of veterans through in-home care, including by
ensuring the education of home health aides and caregivers of
veterans in the following areas:
(A) Dementia care.
(B) Care for spinal cord injuries and diseases.
(C) Ventilator care.
(D) Other speciality care areas as determined by the
Secretary.
(5) Report to congress.--Not later than one year after the
date of the enactment of this Act, the Secretary shall submit
to the Committees on Veterans' Affairs of the House of
Representatives and the Senate a report containing the findings
of the review under paragraph (1), the results of the
assessment under paragraph (2), and the goals established under
paragraphs (3) and (4).
(b) Review of Incentives and Efforts Relating to Home- and Community-
Based Services.--
(1) Review.--The Secretary of Veterans Affairs shall conduct
a review of the following:
(A) The financial and organizational incentives for
the directors of medical centers of the Department to
establish or expand covered programs at such medical
centers.
(B) Any incentives for such directors to provide to
veterans home- and community-based services in lieu of
institutional care.
(C) The efforts taken by the Secretary to enhance
spending of the Department for extended care by
shifting the balance of such spending from
institutional care to home- and community-based
services.
(D) The plan of the Under Secretary for Health of the
Department to accelerate efforts to enhance spending as
specified in subparagraph (C), to match the progress of
similar efforts taken by the Administrator of the
Centers for Medicare & Medicaid Services with respect
to spending of the Centers for Medicare & Medicaid
Services for extended care.
(2) Report to congress.--Not later than one year after the
date of the enactment of this Act, the Secretary shall submit
to the Committees on Veterans' Affairs of the House of
Representatives and the Senate a report on the findings of the
review under paragraph (1).
(c) Review of Respite Care Services.--Not later than two years after
the date of the enactment of this Act, the Secretary of Veterans
Affairs shall conduct a review of the use, availability, and
effectiveness, of the respite care services furnished by the Secretary
under chapter 17 of title 38, United States Code.
(d) Collaboration To Improve Home- and Community-Based Services.--
(1) Report on expansion of certain mental health services.--
(A) Report.--Not later than two years after the date
of the enactment of this Act, the Secretary of Veterans
Affairs, in collaboration with the Secretary of Health
and Human Services, shall submit to the Committees on
Veterans' Affairs of the House of Representatives and
the Senate a report containing recommendations for the
expansion of mental health services and related support
to the caregivers of veterans.
(B) Matters included.--The report under subparagraph
(A) shall include an assessment of the feasibility and
advisability of authorizing access to Vet Centers by--
(i) family caregivers enrolled in a program
under section 1720G of title 38, United States
Code; and
(ii) family caregivers of veterans
participating in a program specified in section
1720K of such title, as added by section 4.
(2) Recommendations.--
(A) Development.--The Secretary of Veterans Affairs
shall develop recommendations as follows:
(i) With respect to home- and community-based
services for veterans, the Secretary of
Veterans Affairs shall develop recommendations
regarding new services (in addition to those
furnished as of the date of the enactment of
this Act) in collaboration with the Secretary
of Health and Human Services.
(ii) With respect to the national shortage of
home health aides, the Secretary of Veterans
Affairs shall develop recommendations regarding
methods to address such shortage in
collaboration with the Secretary of Health and
Human Services and the Secretary of Labor.
(B) Submission to congress.--The Secretary of
Veterans Affairs shall submit to the Committees on
Veterans' Affairs of the House of Representatives and
the Senate a report containing the recommendations
developed under subparagraph (A) and an identification
of any changes in existing law or new statutory
authority necessary to implement the recommendations,
as determined by the Secretary.
(C) Consultation with secretary of labor.--In
carrying out this paragraph, the Secretary of Veterans
Affairs shall consult with the Secretary of Labor.
(3) Feedback and recommendations on caregiver support.--
(A) Feedback and recommendations.--The Secretary of
Veterans Affairs shall solicit from the entities
described in subparagraph (B) feedback and
recommendations regarding opportunities for the
Secretary to enhance home- and community-based services
for veterans and the caregivers of veterans, including
through the potential provision by the entity of care
and respite services to veterans and caregivers who may
not be eligible for any program under section 1720G of
title 38, United States Code, or section 1720K of such
title (as added by section 4), but have a need for
assistance.
(B) Covered entities.--The entities described in this
subparagraph are veterans service organizations and
nonprofit organizations with a focus on caregiver
support (as determined by the Secretary).
(4) Collaboration for native american veterans.--The
Secretary of Veterans Affairs shall collaborate with the
Director of the Indian Health Service and representatives from
tribal health programs and Urban Indian organizations to ensure
the availability of home- and community-based services for
Native American veterans, including Native American veterans
receiving health care and medical services under multiple
health care systems.
SEC. 9. MODIFICATION OF CERTAIN HOUSING LOAN FEES.
The loan fee table in section 3729(b)(2) of title 38, United States
Code, is amended by striking ``November 14, 2031'' each place it
appears and inserting ``January 26, 2032''.
SEC. 10. DEFINITIONS.
In this Act:
(1) The terms ``caregiver'' and ``family caregiver'' have the
meanings given those terms under section 1720K(h) of title 38,
United States Code (as added by section 4).
(2) The term ``covered program''--
(A) means any program of the Department of Veterans
Affairs for home- and community-based services; and
(B) includes the programs specified in section 1720K
of title 38, United States Code (as added by section
4).
(3) The term ``home- and community-based services''--
(A) means the services referred to in section
1701(6)(E) of title 38, United States Code; and
(B) includes services furnished under a program
specified in section 1720K of such title (as added by
section 4).
(4) The terms ``Home-Based Primary Care program'',
``Homemaker and Home Health Aide program'', and ``Veteran-
Directed Care program'' mean the programs of the Department of
Veterans Affairs specified in subsection (d), (c), and (b) of
such section 1720K, respectively.
(5) The terms ``home health aide'', ``Native American'',
``Native American veteran'', ``tribal health programs'', and
``Urban Indian organizations'' have the meanings given those
terms in subsection (h) of such section 1720K.
(6) The term ``Vet Center'' has the meaning given that term
in section 1712A(h) of title 38, United States Code.
(7) The term ``veterans service organization'' means any
organization recognized by the Secretary under section 5902 of
such title.
Purpose and Summary
H.R. 542, the ``Elizabeth Dole Home and Community-Based
Services for Veterans and Caregivers Act of 2023,'' or the
``Elizabeth Dole Home Care Act of 2023,'' was introduced by
Representative Julia Brownley of California on January 26,
2023.
H.R. 542, as amended, would modify the reimbursement for
and the provision of noninstitutional alternatives to nursing
home care for veterans. The bill would require the Department
of Veterans Affairs (VA) to collaborate on specific programs,
expand home and community-based services, support caregivers of
disabled veterans, pilot homemaker services in underserved
areas, and ensure Native American veterans' access to services.
This legislation would also ensure that the Veterans Health
Administration has consistent and accessible geriatric and
extended care programs through reviews and by eliminating
service gaps.
Background and Need for Legislation
While America's healthcare systems continue to recover from
the COVID-19 pandemic, they are also contending with one of the
largest generations in history entering its later years.
Americans now live longer than generations before, but have
more complex needs. For VA, preparation for this influx is
particularly crucial, as VA patients tend to be older, sicker,
poorer, and more likely to live in rural areas than users of
other healthcare systems.\1\ As of fiscal year 2022, about 3.1
million veterans using VA healthcare services--approximately
half of VA's entire active patient population--were 65 years of
age or older. About 80 percent of VA healthcare users in fiscal
year 2022 fell into priority groups one through five, which
means they have service-connected disabilities, other
catastrophically disabling conditions, or are low-income.
Approximately one-third of VA healthcare users resided in rural
areas.\2\
---------------------------------------------------------------------------
\1\https://www.ruralhealth.va.gov/aboutus/ruralvets.asp.
\2\U.S. Department of Veterans Affairs, FY 2024 Budget Submission:
Medical Programs, Volume 2 of 5 (Washington, D.C.: March 2023).
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Roughly 90% of all aging adults would prefer to remain at
home for care rather than be admitted to a long-term care
facility.\3\ Veterans are no different.\4\ Even if
institutional care was preferred, there are not enough beds to
meet the needs of such a population--particularly in the wake
of the COVID-19 pandemic. Since 2020, more than 400,000 staff
of nursing homes and assisted living facilities have left the
industry due to burnout and low wages. This exodus has left
institutional long-term care providers no choice but to limit
admissions, since they lack enough staff to safely serve as
many residents as they did before. This trend has in turn
contributed to longer hospital stays, which places patients at
greater risk of hospital-acquired infections.\5\ H.R. 542, as
amended's expansion of VA's non-institutional long-term care
services would enable aging and disabled veterans to remain in
their homes as long as they can and preserve the availability
of institutional care for those veterans who truly need it.
---------------------------------------------------------------------------
\3\See, for example, Associated Press-NORC Center for Public
Affairs Research, Long-Term Care in America: Americans Want to Age at
Home (Chicago, IL: May 2021); and AARP Public Policy Institute, Beyond
50.05--A Report to the Nation on Livable Communities: Creating
Environments for Successful Aging (Washington, D.C.: May 2005).
\4\See testimony of Dr. Scotte Hartronft, Executive Director,
Office of Geriatrics and Extended Care, Veterans Health Administration,
Department of Veterans Affairs, before the House Committee on Veterans'
Affairs, Subcommittee on Health, Hearing on Aging in Place: Examining
Veterans' Access to Home and Community Based Services, 117th Cong.
(July 27, 2021).
\5\Nursing Home Staff Shortages Are Worsening Problems at
Overwhelmed Hospitals, Washington Post (January 7, 2022).
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VA's Office of Geriatrics and Extended Care (GEC)
administers numerous Long-Term Services & Supports (LTSS),
which include both institutional and non-institutional long-
term care programs. The non-institutional programs are called
Home and Community Based Services (HCBS). Unlike institutional
care, VA has not been statutorily required to provide HCBS to
all veterans who need these services. The availability of such
programs is largely at the discretion of each VA medical
center. As a result, veterans are often referred to
institutional care settings in instances where remaining at
home would have otherwise been clinically appropriate and more
desirable for the veteran and their loved ones.
VA has not been moving as quickly as individual states have
in terms of shifting its investments from institutional long-
term care programs to HCBS. In 2008, VA noted that states found
through their Medicaid expansion programs that they were able
to reduce costly nursing home care by rebalancing their
expenditures for long-term care between institutional or home
and community-based settings. In the four years after that, VA
made rebalancing resources from institutional care to HCBS a
direct performance measure for Veterans Integrated Service
Networks (VISN) Directors and medical center Directors, and
HCBS began to take hold across VA. However, this measure has
not been part of VISN and medical facility leaders' performance
plans since 2012, so there has been less incentive to move
staff and resources to expand programs that could keep veterans
at home.
Since 2012, veterans and veterans service organizations
have urged VA to focus its efforts on expanding veterans'
access to HCBS. For example, in testimony before the House
Veterans Affairs Subcommittee on Health in March of 2020, a
witness from Disabled American Veterans stated:
As younger veterans with acute disabilities and
differing needs began to flood the VA in the wake of
the Gulf Wars, VA's priorities shifted, and long-term
care lost out to responding to post-traumatic care
needs of a younger population. Creating or revitalizing
its programs to respond to these needs shifted
resources from Long Term Services and Supports programs
(Geriatrics and Extended Care). Instituting new
community-care programs has lately also consumed VA's
resources and focus. VA had begun important end of life
care initiatives and important innovations of its non-
institutional long-term care portfolio that now
languish.\6\
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\6\Adrian Atizado, Deputy National Legislative Director, Disabled
American Veterans, before the House Committee on Veterans' Affairs,
Subcommittee on Health, Hearing on The Silver Tsunami: is VA Ready?,
116th Cong. (March 3, 2020).
For seventeen years, the co-authors of the Independent
Budget (IB)--Paralyzed Veterans of America, Disabled American
Veterans, and Veterans of Foreign Wars--have commented on VA's
long-term care programs and challenges. In their 2023
publication, the groups affirmed yet again their three
legislative recommendations for VA Long Term Care.
Specifically, they recommend that:
Congress eliminate the annual cap on
noninstitutional care;
Congress expand the availability of
institutional and non-institutional care, but grow HCBS
at a faster rate than institution-based care; and
Congress mandate that all HCBS, including
Veteran Directed Care, be made available at all VA
medical centers.\7\
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\7\Disabled American Veterans, Paralyzed Veterans of America, and
Veterans of Foreign Wars, The Independent Budget Veterans Agenda for
the 118th Congress: Budget for FY 2024-2025 and Critical Issues
(Washington, D.C.: Feb. 13, 2023).
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Much of VA's focus on home-based care has been on
implementing the Program of Comprehensive Assistance for Family
Caregivers (PCAFC). While a necessary program, it is, by its
design, small, and intended to support the caregivers of
catastrophically disabled veterans. It was not intended to
function as a geriatrics program. Since implementation of
PCAFC, VA's other HCBS programs have received far less
attention from VA GEC and VA medical center officials.
In the absence of statutory mandates, local GEC programs at
the facility level have often prioritized investments in
institutional settings rather than HCBS programs, and VA is
lagging behind state Medicaid programs in terms of the
percentage of its LTSS budget that has been devoted to non-
institutional programs. For example, in 2016, Medicaid
expenditures for home and community-based services for the
population most like VHA users (i.e., older adults and people
with disabilities), accounted for about 45 percent of total
spending for LTSS. In comparison, in fiscal year 2019, VA
spending on comparable personal care services (i.e., for the
Homemaker Home Health Aide, Respite Care, and Adult Day Health
Care programs) accounted for only 31 percent of VA's long-term
services and support obligations. Veterans have endured
unnecessary hardships at home in addition to HCBS waitlists,
and institutionalization as VA has maintained its focus on
institutional care. The current annual per-veteran costs for
nursing home care are 8.6 times the annual costs of home and
community-based services within VA.\8\
---------------------------------------------------------------------------
\8\See Teresa Boyd, Assistant Deputy Under Secretary for Health for
Clinical Operations, Veterans Health Administration, Department of
Veterans Affairs, before the House Committee on Veterans' Affairs,
Subcommittee on Health, Field Hearing on VA Long-term Care: What's
Working, What's Not, and How to Best Serve Our Aging Veterans, 115th
Cong. (July 30, 2018); and Teresa Boyd, Assistant Deputy Under
Secretary for Health for Clinical Operations, Veterans Health
Administration, Department of Veterans Affairs, before the House
Committee on Veterans' Affairs, Subcommittee on Health, Hearing on The
Silver Tsunami: is VA Ready?, 116th Cong. (March 3, 2020).
---------------------------------------------------------------------------
VA GEC provides programmatic oversight for several
successful, highly desired HCBS programs that enable veterans
to remain safely at home while managing the impacts of aging,
disability, or both. It is the Committee's expectation that VA
make every effort to offer these programs to all veterans; in
particular; the Veteran Directed Care and Homemaker Home Health
Aide Programs. It is also Committee's intention that veterans
be eligible for participation in these HCBS programs when such
programs are determined to be clinically necessary to promote,
preserve, or restore the health of a veteran and the veteran is
at risk of hospitalization, nursing home placement, or
emergency room care.
The United States is facing an enormous challenge, and VA
is not immune to it. Caring for the largest and oldest cohort
of Americans in this country's history will stress every part
of the community and healthcare systems currently in place. VA
has the means to enable its patients to remain safely at home.
While the Department has made progress, the Committee believes
it has not expanded HCBS programs fast enough. VA's HCBS
programs and partnerships are world class, in the best clinical
interest of most aging and disabled veterans, and what veterans
want. This legislation would ensure that veterans are able to
remain in their homes, a part of their communities, and
connected to their families.
Section 1: Short title
This Act may be cited as the ``Elizabeth Dole Home- and
Community-Based Services for Veterans and Caregivers Act of
2023,'' or the ``Elizabeth Dole Home Care Act of 2023.''
Section 2: Increase of expenditure cap for noninstitutional care
alternatives to nursing home care
This section would increase the amount VA may spend for a
veteran receiving HCBS from 65 percent of the cost of nursing
home care to 100 percent or more if the Secretary determines it
to be in the best interest of the veteran. This determination
would be based on a consideration of clinical need, geographic
market factors, and other such matters that he Secretary may
prescribe through regulation.
For a relatively small number of veterans, the 65 percent
cap on spending for home-based care has had a devastating
impact on their health and quality of life. The veterans who
reach the cap in a given year have the greatest clinical needs,
such as those with spinal cord injuries and diseases like
amyotrophic lateral sclerosis (ALS), which can still safely be
managed in non-institutional settings. However, when these
veterans hit the 65 percent cap, they are forced into
institutional care for the remainder of the year. This
arbitrary cap has no clinical value and is certainly not a cost
savings measure, as VA must cover short-term institutional
stays for these veterans. The Committee views these unnecessary
transitions in care settings as not only disruptive, but
clinically risky for veterans.
Section 3: Coordination with program of all-inclusive care for the
elderly
This section would require VA medical centers to enter into
agreements with all Program of All-Inclusive Care for the
Elderly (PACE) programs in locations where they do not already
have partnerships. PACE programs cover services such as primary
care, therapy, meals, recreation, and personal care services.
To be eligible for participation, individuals must be 55 or
older, live within the service area of a PACE organization, and
be certified by their state as meeting the criteria for nursing
home level of care, but still be able to live safely in the
community with the help of PACE services. Currently, there are
134 PACE organizations operating in 32 states and the District
of Columbia. Veterans often use both VA and PACE, and the care
goes uncoordinated. This provision would improve coordination
of care across all HCBS programs veterans may be using. The
Committee believes that this coordination is critical for
patient health.
Section 4: Home- and community-based services programs
This section would codify several existing HCBS programs
and expand the availability of these programs to all VA medical
centers. Specifically, VA would be required to offer the
Veteran-Directed Care Program, the Homemaker Home Health Aide
Program, the Home-Based Primary Program, and the Purchased
Skilled Home Care Program at all VA medical centers. VA would
further be required to expand the Veteran-Directed Care program
and the Homemaker and Home Health Aide program to all of its
medical centers within two years of enactment. The section
would also ensure that veterans can continue to use Veteran-
Directed Care program funds during periods of hospitalization,
in the same manner they would use such funds if they were not
hospitalized.
Under this section, VA would collaborate with the U.S.
Department of Health and Human Services to carry out the
Veteran-Directed Care program. VA would be authorized to enter
into agreements with Aging and Disability Resource Centers,
area agencies on aging, state agencies, centers for independent
living, and Indian tribes or tribal organizations. VA would be
required to ensure--to the extent practicable--the availability
of the Veteran-Directed Care Program in the U.S. territories
and for veterans who receive services from the Indian Health
Service, tribal health programs, Urban Indian organizations,
and Native Hawaiian health care systems.
While the Veteran-Directed Care Program is similar to VA's
PCAFC, it provides direct financial assistance to veterans,
rather than their family caregivers. Veterans are empowered to
hire their own caregivers to assist with activities of daily
living, such as eating, getting dressed, bathing, using the
bathroom, and grocery shopping. Veterans who do not meet the
eligibility criteria for PCAFC may benefit from the Veteran-
Directed Care Program, which has been an enormously successful
program, born from thoughtful interagency collaboration, as it
is managed by local and aging disability network providers. The
Veteran-Directed Care program could serve three veterans for
every one veteran residing in a community nursing home at VA's
expense.\9\ According to VA, only 71 of its medical centers
were participating in the Veteran Directed Care program as of
March 2023. All eligible veterans deserve access to this
program, not just those who happen to use a VA medical center
that has opted to offer it.
---------------------------------------------------------------------------
\9\Lori Gerhard, Director, Office of Interagency Innovation and
U.S. Administration for Community Living, at National Prevention
Science Coalition briefing for congressional staff (Oct. 19, 2021).
Archived at https://www.youtube.com/watch?v=k9lyTSuIVjA.
---------------------------------------------------------------------------
VA's Homemaker and Home Health Aide Program was established
about 30 years ago and contracts with licensed and Medicare-
and Medicaid-certified agencies that employ home health aides
to care for veterans in their homes. It provides skilled
services, case management, help with activities of daily
living, and eases caregiver burden. Like the Veteran-Directed
Care Program, VA would be required to ensure--to the extent
practicable--the availability of the Homemaker and Home Health
Aide Program in the U.S. territories and for veterans who
receive services from the Indian Health Service, tribal health
programs, Urban Indian organizations, and Native Hawaiian
health care systems.
The Home-Based Primary Care Program provides in-home
healthcare--supervised by a VA physician--to veterans who are
isolated, have difficultly traveling, or whose caregivers are
burdened. While this program is already available at every VA
medical center, this section would prevent medical facilities
from eliminating its use. Home-Based Primary Care has long been
a popular and effective program and as such, demand for it is
high. In 2020, the U.S. Government Accountability Office
reported persistent wait lists for the program as facilities
have struggled with staffing challenges.\10\ Ensuring the
program remains a fixture of VA's HBCS would urge VA to make
the necessary movements towards addressing their staffing
challenges in HBCS.
---------------------------------------------------------------------------
\10\U.S. Government Accountability Office, VA Health Care:
Veterans' Use of Long-Term Care is Increasing, and VA Faces Challenges
in Meeting the Demand, GAO 20-284 (Washington, D.C.: Feb. 19, 2020).
---------------------------------------------------------------------------
The Purchased Skilled Home Health Care Program is for
veterans who have higher levels of need such as wound care,
catheter management, speech therapy, or skilled nursing. VA
contracts with Medicare- and Medicaid-certified agencies to
provide this care in veterans' homes. Veterans would be
eligible for participation in this program if it is determined
to be medically necessary to promote, preserve or restore the
health of a veteran and the veteran is at risk of
hospitalization, nursing home placement, or emergency room
care.
Finally, this section would require VA to offer caregivers
who live with veterans enrolled in these HCBS programs an
opportunity to participate in the Program of General Caregiver
Support Services. This program includes at least 30 days of
respite care each year and wellness contacts for caregivers at
least once annually. Additional respite care could be covered
if requested by the caregiver and deemed medically appropriate
by VA.
Section 5: Coordination with assistance and support services for
caregivers
This section would improve coordination of care for
veterans and caregivers who are found to be ineligible for
PCAFC. Specifically, in the case of a veteran or caregiver who
has applied and been denied or discharged from PCAFC, VA would
be required to offer the caregiver the option of enrolling in
its program of general caregiver support services and assess
the veteran and caregiver for participation in other available
HCBS programs administered by the Department.
To date, there has been little, if any, coordination
between PCAFC, the program of general caregiver support, and
other HCBS programs; particularly, in matters concerning
veterans' ineligibility for PCAFC. Veterans who are found
ineligible, or who are discharged from PCAFC, are often left
with little guidance on how to access other home-based support
covered by VA. This sense of ``being left behind'' after a
rejected application or removal is an unnecessary experience
and has caused great harm to veterans' satisfaction with, and
the reputation of the PCAFC.\11\ This section would require
that such veterans be assessed for participation in other HCBS
programs, and ensure that if deemed clinically appropriate, a
``warm handoff'' between PCAFC and the other programs occurs.
---------------------------------------------------------------------------
\11\See Caira Benson, Military Caregiver and Dole Caregiver Fellow
with the Elizabeth Dole Foundation, before the Senate Committee on
Veterans' Affairs Hearing on Honoring Our Commitment: Improving VA's
Program of Comprehensive Assistance for Family Caregivers, 117th Cong.
(March 23, 2022); and Steve Schwab, Chief Executive Officer, the
Elizabeth Dole Foundation, before the Senate Committee on Veterans'
Affairs Hearing on Honoring Our Commitment: Improving VA's Program of
Comprehensive Assistance for Family Caregivers, 117th Cong. (March 23,
2022).
---------------------------------------------------------------------------
Section 6: Development of centralized website for program information
This section would further address veterans' and
caregivers' frustration with PCAFC and other VA HCBS programs
by requiring VA to create a centralized and publicly accessible
``one stop shop'' website to serve as a clearinghouse of
information on all HCBS programs covered by VA. The website
would provide a description of each covered program and include
an informational assessment tool that would explain the
eligibility requirements for each program, and help veterans
and caregivers determine the programs for which they may be
eligible. While VA currently provides some high-level
descriptive information about HCBS programs on its public-
facing website, the website lacks sufficient detail about
eligibility criteria and how veterans can go about enrolling in
each program. The current website also includes broken and
outdated links, which contribute to the frustration of veterans
and caregivers who are trying to research available resources.
Section 7: Improvements relating to homemaker and home health aide
program
This section would require VA to carry out a three-year
pilot program in five locations to provide homemaker and home
health aide services to veterans residing in communities with
home health aide shortages. To do this, VA may hire nursing
assistants as new VA employees or reassign nursing assistants
who are existing VA employees to provide veterans with in-home
care, in addition to providing services through home health
agencies. This section would require VA to submit a report to
Congress detailing the results of the pilot program. VA would
also be required to submit a report to Congress on unexpended
funds budgeted for the Homemaker Home Health Aide program, the
number of veterans who experienced a reduction in hours for
home health aide services for reasons other than a change in
clinical need, and reasons why reductions in hours have
occurred.
Home health aide shortages are felt nationwide, and VA must
do what it can to ensure veterans are spared from the impact.
In the aftermath of the pandemic, many home health aides have
left the profession. The Committee believes that while VA may
never be the market leader on salary, it is possible that VA
could attract more employees to deliver homemaker and home
health aide services via the benefits that come with federal
employment--including health insurance, paid leave, and
retirement benefits.
Section 8: Reviews and other improvements relating to home- and
community-based services
This section would require the Under Secretary for Health
to review the structure and goals of GEC, to ensure consistency
in program management, eliminate service gaps at the VA medical
center level, and ensure veterans' access to HCBS. VA would
also be required to conduct an assessment of the staffing needs
of GEC. This office is charged with caring for the largest and
most clinically complex population of veterans in history, and
administering more than a dozen critical programs. Despite
this, it has a relatively small presence at VA Central Office
in terms of the number of full-time employees involved in long-
term care program administration and oversight.
This section would also require the Director of GEC to
establish quantitative goals to measure access to HCBS programs
for veterans who are not located near VA medical centers. The
Director of GEC would also be required to establish
quantitative goals to address specialty care needs of veterans
through home-based care, including by educating home health
aides and veterans' caregivers in areas such as dementia care,
care for spinal cord injuries and disorders, and ventilator
care.
VA would be required to report to Congress, a year after
enactment, the findings of the review, the results of the
assessment of GEC, and the goals established. Additionally, VA
would conduct a review of as to what incentive structures
propelled some medical center directors to stand up HCBS
programs for their veterans while others were slow in providing
such services. The Secretary will conduct a review on the use,
availability, and effectiveness of respite care services. The
Secretary will also collaborate with the Secretary of Health
and Human Services to submit a report to Congress containing
recommendations for the expansion of mental health services to
the caregivers of veterans, including the feasibility and
advisability of providing caregivers access to services from
Vet Centers.
The Secretary would, in collaboration with the Secretary of
Health and Human Services and Secretary of Labor, develop
recommendations regarding any potential new services and
recommendations regarding methods to address the national
shortage of home health aides.
Lastly, the Secretary would collaborate with the Director
of the Indian Health Service, Tribal Health Programs, and Urban
Indian Health Organizations to ensure the availability of HCBS
for native veterans, including and particularly those veterans
who receive their health care from both VA and tribal systems.
VA, to date, has not collaborated with IHS or tribal health
systems to ensure that aging veterans have the support and
services necessary to age safely at home.
Section 9: Modification of certain housing loan fees
This section would provide funding to offset the cost of
implementing the bill, as amended, by extending VA's home loan
fees for about two-and-a-half months.
Section 10: Definitions
This section would define various terms used throughout
H.R. 542, as amended.
Hearings
On March 29, 2023, the Subcommittee on Health held a
legislative hearing on H.R. 542, and other bills pending before
the subcommittee. The following witnesses testified:
The Honorable Mark Takano, U.S. House of
Representatives, 39th Congressional District,
California; The Honorable Frank Mrvan, U.S. House of
Representatives, 1st Congressional District, Indiana;
The Honorable Brian Mast, U.S. House of
Representatives, 21st Congressional District, Florida;
The Honorable Jim Baird, U.S. House of Representatives,
4th Congressional District, Indiana; The Honorable John
Moolenaar, U.S. House of Representatives, 2nd
Congressional District, Michigan; The Honorable Steve
Womack, U.S. House of Representatives, 3rd
Congressional District, Arkansas; The Honorable Debbie
Lesko, U.S. House of Representatives, 8th Congressional
District, Arizona; Mr. Alfred Montoya, Deputy Assistant
Under Secretary for Health for Operations, Veterans
Health Administration, U.S. Department of Veterans
Affairs; Dr. Scotte Hartronft, Executive Director,
Office of Geriatrics and Extended Care, Veterans Health
Administration, U.S. Department of Veterans Affairs;
Mr. David Perry, Chief Officer Workforce Management,
Veterans Health Administration, U.S. Department of
Veterans Affairs; Mr. Jon Retzer, Assistant National
Legislative Director, Disabled American Veterans; Ms.
Tiffany Ellett, Deputy Director of Health Policy, The
American Legion; Mr. Morgan Brown, National Legislative
Director, Paralyzed Veterans of America.
The following individuals and organizations submitted
statements for the record:
Veterans of Foreign Wars of the United States;
Student Veterans of America; Elizabeth Dole Foundation.
Subcommittee Consideration
There was no Subcommittee consideration of H.R. 542, as
amended.
Committee Consideration
On July 26, 2023, the full Committee met in open markup
session, a quorum being present, and ordered H.R. 542, as
amended, be reported favorably to the House of Representatives
by voice vote. During consideration of the bill, the following
amendment was considered:
An amendment in the nature of a substitute was
offered by Representative Brownley of California that
included the text of H.R. 542, and amended the
authorization to spend on Home and Community Based
Services (HCBS) to 100% from 65%, and under discretion
of the Secretary, to go beyond that if needed for
certain high need veterans (ALS, SCI). The amendment
would also extend current rates for VA home loan
funding fees to pay for programs in the bill. The
amendment in the nature of substitute was approved by
voice vote.
A motion by Ranking Member Takano of California to report
H.R. 542, as amended, favorably to the House of Representatives
was agreed to by voice vote.
Committee Votes
In compliance with clause 3(b) of rule XIII of the Rules of
the House of Representatives, no recorded votes were taken on
amendments or in connection with ordering H.R. 542, as amended,
reported to the House.
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 of H.R. 542, as amended, are to provide
improvements to healthcare benefits provided to veterans.
Earmarks and Tax and Tariff Benefits
H.R. 542, 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.
542, as amended, prepared by the Director of the Congressional
Budget Office pursuant to section 402 of the Congressional
Budget Act of 1974.
Budget Authority and 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. 542, as amended, provided by the Congressional Budget
Office pursuant to section 402 of the Congressional Budget Act
of 1974:
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
The bill would
Require the Department of Veterans Affairs
(VA) to expand access to health care teams outside of
the department that would furnish all-inclusive care to
elderly veterans living in the community
Require VA to update information technology
capabilities to assist veterans and caregivers using
long-term health care and support services
Require VA to carry out a pilot program for
homemaker and health aide services to veterans
Increase the limit on amounts that VA would
pay for long-term care provided outside of VA
facilities
Require reports and studies on related
programs
Extend the higher rates for fees that VA
charges borrowers for home loan guarantees
Estimated budgetary effects would mainly stem from
Increasing payments for veterans' health
care
Increasing the number of veterans receiving
care in the community
Updating technological capabilities to
assist veterans and caregivers
Extending the higher rates for fees charged
by VA for home loan guarantees
Areas of significant uncertainty include
Estimating the number of veterans who would
enroll in the Program of All-Inclusive Care for the
Elderly
Bill summary: H.R. 542 would require the Department of
Veterans Affairs (VA) to establish agreements with outside
providers to furnish medical and social services to veterans
who are not in VA nursing homes. The bill also would require VA
to improve in-home assistance and support for caregivers of
veterans and raise the limit on expenses for nursing home care
provided outside of VA facilities. In addition, the bill would
require VA to conduct several studies related to medical and
health services for elderly veterans and report on those
topics. Finally, the bill also would make changes to VA's home
loan guarantee program.
Estimated federal cost: The estimated budgetary effects of
H.R. 542 are shown in Table 1. The costs of the legislation
fall within budget function 700 (veterans benefits and
services).
TABLE 1.--ESTIMATED BUDGETARY EFFECTS OF H.R. 542
--------------------------------------------------------------------------------------------------------------------------------------------------------
By fiscal year, millions of dollars--
----------------------------------------------------------------------------------------------
2023- 2023-
2023 2024 2025 2026 2027 2028 2029 2030 2031 2032 2033 2028 2033
--------------------------------------------------------------------------------------------------------------------------------------------------------
Increases in Spending Subject to Appropriation
Estimated Authorization.................................. 0 6 8 13 12 12 13 13 14 14 15 51 120
Estimated Outlays........................................ 0 6 8 13 12 12 13 13 14 14 15 51 120
Increases or Decreases (-) in Direct Spending
Estimated Budget Authority............................... 0 2 3 7 7 8 9 10 11 -164 13 27 -94
Estimated Outlays........................................ 0 2 3 7 7 8 9 10 11 -164 13 27 -94
--------------------------------------------------------------------------------------------------------------------------------------------------------
Basis of estimate: For this estimate, CBO assumes that the
legislation will be enacted at the beginning of fiscal year
2024 and that the estimated amounts will be appropriated each
year. Estimated outlays are based on historical spending
patterns for the affected programs.
Provisions that affect both spending subject to
appropriation and direct spending: H.R. 542 would increase
costs for health care programs that have typically been paid
from discretionary appropriations. Some of the beneficiaries of
those programs would be veterans who have been exposed to
environmental hazards; thus, CBO expects that some of the costs
of implementing the bill would be paid from the Toxic Exposures
Fund (TEF) established by Public Law 117-168, the Honoring our
PACT Act.\1\ The TEF is a mandatory appropriation that VA uses
to pay for health care, disability claims processing, medical
research, and information technology modernization that benefit
veterans who were exposed to environmental hazards.
---------------------------------------------------------------------------
\1\For additional information about spending from the TEF, see
Congressional Budget Office, ``Statement for the Record Regarding How
CBO Would Estimate the Effects of Future Authorizing Legislation on
Spending From the Toxic Exposures Fund'' (December 2022), www.cbo.gov/
publication/58843.
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Additional spending from the TEF occurs if legislation
increases the costs of similar activities that benefit veterans
with such exposure. Therefore, in addition to increasing
spending subject to appropriation, the bill would increase
amounts paid from the TEF, which are classified as direct
spending.
In CBO's projections, the percentage of costs paid by the
TEF is estimated to grow over time based on the amount of
formerly discretionary appropriations that CBO estimated will
be provided through the mandatory appropriation as specified in
the Honoring our PACT Act. For purposes of this estimate, those
growing percentages are applied to the estimated increase in
costs under H.R. 542. Accordingly, CBO estimates that 24
percent of the costs of the changes from this bill would be
paid from the TEF in 2024, increasing to 47 percent in 2033.
All told, CBO estimates, implementing the health care
provisions of H.R. 542 (all-inclusive care for elderly
veterans, caregiver support, in-home assistance, and
alternative nursing home care, discussed below) would increase
spending subject to appropriation by $119 million and direct
spending by $82 million over the 2023 2033 period.
All-Inclusive Care for Elderly Veterans. Section 3 would
require VA to partner with the Program of All-Inclusive Care
for the Elderly (PACE) to provide care for veterans who are
served by VA medical centers in areas also served by PACE.
Through the Centers for Medicare & Medicaid Services, PACE
provides health care to elderly people who do not live in
nursing homes. In addition to coordinated care from visiting
health care providers, beneficiaries receive transportation,
home care, prescription filling, and hospital visits.
Recipients must be eligible either for Medicare or for
Medicaid, they must require nursing-home-level care, and they
must be able to safely live in the community with the help of
PACE services.
There are 10 regions where PACE organizations operate near
VA medical centers. VA has active agreements with PACE
organizations in 4 of them. Those organizations currently serve
about 70 veterans annually, and VA pays for the long-term-care
portion of the PACE benefit for Medicare-eligible veterans who
are not also eligible for Medicaid. CBO expects that VA would
establish agreements with PACE organizations at the remaining 6
locations, increasing the number of veterans who use PACE.
Using historical information on PACE enrollment and accounting
for the projected growth in the number of Medicare-eligible
veterans who enroll with VA health care, CBO estimates that VA
would pay for an average of 350 veterans to use the PACE
benefit each year at an average annual cost of $48,000.
In total, CBO estimates, implementing section 3 would cost
$189 million over the 2023-2033 period, of which $110 million
would be spending subject to appropriation and $79 million
would be direct spending.
Caregiver Support. Sections 5 and 6 would require VA to
provide information about programs that support caregivers.
Section 5 would require VA to determine whether a caregiver
who is not eligible for the department's support programs is
eligible for other in-home and community-based programs. It
also would require that a VA support coordinator help
caregivers move from one program to another. In addition,
section 5 would require VA to regularly inform caregivers about
new services. Using information from VA, CBO expects that the
department would hire one full-time administrative employee and
would develop a system to provide caregivers with updates about
new services.
Section 6 would require VA to establish and regularly
update a website detailing information and resources related to
all VA programs that benefit caregivers. That website would
include an assessment tool providing extensive information on
eligibility and participation.
Using information on average salaries and costs for similar
information technology efforts, CBO estimates that, in total,
satisfying the requirements of sections 5 and 6 would cost $5
million over the 2023-2033 period, of which $4 million would be
spending subject to appropriation and $1 million would be
direct spending.
In-Home Assistance. Section 7 would require VA to establish
a three-year pilot program for providing homemaker and home
health aide services to veterans who reside in areas with
shortages of home health aides. The program would take place in
at least 10 locations, and VA could hire new nursing assistants
or reassign current assistants to provide care to veterans. In
2022, the department initiated a similar program at 3
locations. CBO expects that the program would partially satisfy
the requirement of section 7.
VA reports that it has had difficulty hiring and recruiting
home health aides. CBO expects that the department would expand
the program to 7 additional locations and offer premium pay to
new nursing aides. CBO estimates that VA would hire five new
nursing assistants for each location at an average cost of
$69,000 for salaries, benefits, and travel expenses.
In total, CBO estimates that implementing the program at
those additional locations would cost $7 million over the 2023-
2033 period, of which $5 million would be spending subject to
appropriation and $2 million direct spending.
Alternative Nursing Home Care. Section 2 would increase the
limit on amounts that VA pays for long-term care provided
outside of its facilities. Under current law, VA may pay
providers for long-term health care and services delivered to
veterans outside of VA nursing homes until those payments reach
65 percent of what the annual cost to the department would be
if it had provided care to the veteran in a VA nursing home
that serves the region where the veteran resides. The average
cost of care for veterans who reached that cap in 2022 was
$840,000. When the cost of a veteran's care exceeds that
amount, that veteran must move to a VA nursing home to have
their care paid for by VA. Section 2 would increase the amount
VA would pay to 100 percent of the cost of providing care at a
VA facility. VA could pay more than 100 percent of its in-house
cost to care for veterans with amyotrophic lateral sclerosis
(ALS), a spinal cord injury, or a similar condition. According
to VA, on average, 40 veterans reach the current limit each
year. Implementing the section could reduce overall costs to VA
in cases where the cost of a veteran's care outside of VA
facilities exceeds the current limit but is less than VA's cost
of providing care directly. Conversely, CBO expects that VA
would pay more for some veterans with ALS, a spinal cord
injury, or a similar condition. Because of the small number of
people affected and the offsetting effects on costs, CBO
estimates that implementing section 2 would have an
insignificant net effect on the budget over the 2023-2033
period.
Spending subject to appropriation: Spending subject to
appropriation would increase by $119 million as a result of
implementing the provisions described above. In addition, H.R.
542 would require VA to conduct five studies and deliver six
reports to the Congress on program management, staffing, and
the availability of services provided in homes and in the
community. Based on the costs of similar studies and reports,
CBO estimates that satisfying those requirements would cost $1
million over the 2023-2033 period.
In total, implementing H.R. 542 would increase costs paid
for by discretionary appropriations by $120 million over the
2023-2033 period, CBO estimates (see Table 2).
TABLE 2.--ESTIMATED INCREASES IN SPENDING SUBJECT TO APPROPRIATION UNDER H.R. 542
--------------------------------------------------------------------------------------------------------------------------------------------------------
By fiscal year, millions of dollars--
--------------------------------------------------------------------------------------------
2023- 2023-
2023 2024 2025 2026 2027 2028 2029 2030 2031 2032 2033 2028 2033
--------------------------------------------------------------------------------------------------------------------------------------------------------
All-Inclusive Care for Elderly Veterans:
Estimated Authorization.................................. 0 2 5 10 12 12 13 13 14 14 15 41 110
Estimated Outlays........................................ 0 2 5 10 12 12 13 13 14 14 15 41 110
Caregiver Support:
Estimated Authorization.................................. 0 2 1 1 * * * * * * * 4 4
Estimated Outlays........................................ 0 2 1 1 * * * * * * * 4 4
In-Home Assistance:
Estimated Authorization.................................. 0 1 2 2 * * * * 0 0 0 5 5
Estimated Outlays........................................ 0 1 2 2 * * * * 0 0 0 5 5
Studies and Reports:
Estimated Authorization.................................. 0 1 * * 0 0 0 0 0 0 0 1 1
Estimated Outlays........................................ 0 1 * * 0 0 0 0 0 0 0 1 1
Total Changes:
Estimated Authorization.................................. 0 6 8 13 12 12 13 13 14 14 15 51 120
Estimated Outlays........................................ 0 6 8 13 12 12 13 13 14 14 15 51 120
--------------------------------------------------------------------------------------------------------------------------------------------------------
* = between zero and $500,000.
Direct spending: The provisions that would change long-term
support and service programs (described above in ``Provisions
Affecting Both Spending Subject to Appropriation and Direct
Spending'') would increase direct spending by $82 million over
the 2023-2033 period. In addition, the bill would increase the
fees paid by borrowers for VA home loan guarantees, which would
be reflected in the budget as negative outlays. CBO estimates
that enacting the bill would decrease net direct spending by
$94 million over the 2023-2033 period (see Table 3).
Loan Fees. The bill would extend--for about two months--the
higher fees that VA charges borrowers for its loan guarantees.
VA provides loan guarantees to lenders that allow eligible
borrowers to obtain better loan terms--such as lower interest
rates or smaller down payments--to purchase, build, improve, or
refinance a home. VA typically pays lenders up to 25 percent of
the outstanding mortgage balance if a borrower's home is
foreclosed upon. Those payments, net of fees paid by borrowers
and recoveries by lenders, constitute the subsidy cost for the
loan guarantees.\2\
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\2\Under the Federal Credit Reform Act of 1990, the subsidy cost of
a loan guarantee is the net present value of estimated payments by the
government to cover defaults and delinquencies, interest subsidies, or
other expenses offset by any payments to the government, including
origination or other fees, penalties, and recoveries on defaulted
loans. Such subsidy costs are calculated by discounting those expected
cash flows using the rate on Treasury securities of comparable
maturity. The resulting estimated subsidy costs are recorded in the
budget when the loans are disbursed or modified. A positive subsidy
indicates that the loan results in net outlays from the Treasury; a
negative subsidy indicates that the loan results in net receipts to the
Treasury.
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Under current law, the rates for most fees that borrowers
pay to VA for loans guaranteed on or after November 14, 2031,
will drop from a weighted average of about 2.4 percent to about
1.2 percent of the loan amount. Section 9 of the bill would
extend the higher rates through January 26, 2032, thereby
reducing the subsidy cost of loans guaranteed during that four-
month period. Using information from VA, CBO estimates that
extending the higher rates would decrease direct spending by
$176 million over the 2023-2033 period.
TABLE 3.--ESTIMATED CHANGES IN DIRECT SPENDING UNDER H.R. 542
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By fiscal year, millions of dollars--
-----------------------------------------------------------------------------------------------
2023- 2023-
2023 2024 2025 2026 2027 2028 2029 2030 2031 2032 2033 2028 2033
--------------------------------------------------------------------------------------------------------------------------------------------------------
Loan Fees:
Estimated Budget Authority............................ 0 0 0 0 0 0 0 0 0 -176 0 0 -176
Estimated Outlays..................................... 0 0 0 0 0 0 0 0 0 -176 0 0 -176
All-Inclusive Care For Elderly Veterans:
Estimated Authorization............................... 0 1 2 6 7 8 9 10 11 12 13 24 79
Estimated Outlays..................................... 0 1 2 6 7 8 9 10 11 12 13 24 79
Caregiver Support:
Estimated Authorization............................... 0 1 * * * * * * * * * 1 1
Estimated Outlays..................................... 0 1 * * * * * * * * * 1 1
In-Home Assistance:
Estimated Authorization............................... 0 * 1 1 0 0 0 0 0 0 0 2 2
Estimated Outlays..................................... 0 * 1 1 0 0 0 0 0 0 0 2 2
Total Changes:
Estimated Authorization............................... 0 2 3 7 7 8 9 10 11 -164 13 27 -94
Estimated Outlays..................................... 0 2 3 7 7 8 9 10 11 -164 13 27 -94
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* = between zero and $500,000.
Uncertainty: CBO's estimate of the costs of implementing
changes to PACE is subject to uncertainty largely because of
the difficulty in projecting the number of veterans who would
enroll in that program. Costs would differ if that factor is
higher or lower than CBO estimates.
Pay-as-you-go considerations: The Statutory Pay-As-You-Go
Act of 2010 establishes budget-reporting and enforcement
procedures for legislation affecting direct spending or
revenues. The net changes in outlays that are subject to those
pay-as-you-go procedures are shown in Table 3.
Increase in long-term net direct spending and deficits: CBO
estimates that enacting H.R. 542 would increase net direct
spending by less than $2.5 billion in any of the four
consecutive 10-year periods beginning in 2034.
CBO estimates that enacting H.R. 542 would increase on-
budget deficits by less than $5 billion in any of the four
consecutive 10-year periods beginning in 2034.
Mandates: None.
Previous CBO estimate: On March 10, 2023, CBO transmitted a
cost estimate for S. 141, the Elizabeth Dole Home Care Act, as
ordered reported by the Senate Committee on Veterans' Affairs
on February 16, 2023. Most of the provisions of the bills
related to health care are similar and the estimated costs are
the same. H.R. 542 includes an additional provision that would
increase the reimbursement cap for veterans using alternative
nursing home options; CBO estimates that the budgetary effects
of that provision would be insignificant. H.R. 542 also would
extend the higher fees that VA charges borrowers for its loan
guarantees, reducing direct spending. S. 141 does not include a
similar provision and the estimated effects on direct spending
of that bill are higher as a result.
Estimate Prepared By: Federal Costs: Etaf Khan (veterans'
health care); Paul B.A. Holland (veterans' education and
housing benefits); Mandates: Grace Watson.
Estimate reviewed by: David Newman, Chief, Defense,
International Affairs, and Veterans' Affairs Cost Estimates
Unit; Kathleen FitzGerald, Chief, Public and Private Mandates
Unit; Christina Hawley Anthony, Deputy Director of Budget
Analysis.
Estimate approved by: Phillip L. Swagel, Director,
Congressional Budget Office.
Federal Mandates Statement
The Committee adopts as its own the estimate of Federal
mandates regarding H.R. 542, 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.
542, as amended.
Applicability to Legislative Branch
The Committee finds that H.R. 542, as amended, 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 clause 3(c)(5) of rule XIII of the Rules of the
House of Representatives, the Committee finds that no provision
of H.R. 542, 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.
Section-by-Section Analysis of the Legislation
Section 1: Short title
Section 1(a) would establish the short title as the
``Elizabeth Dole Home- and Community-Based Services for
Veterans and Caregivers Act of 2023'' or the ``Elizabeth Dole
Home Care Act of 2023.''
Section 1(b) would create the table of contents for this
Act.
Section 2: Increase of expenditure cap for noninstitutional care
alternatives to nursing home care
Section 2(a) would amend Section 1720C(d) of title 38
U.S.C.: by striking ``the total cost'' and inserting ``(1)
Except as provided in paragraph (2), the total cost; by
striking ``65 percent'' and inserting ``100 percent''; and by
adding at the end the following new paragraph:
``(2)(A) The total cost of providing services or in-
kind assistance in the case of any veteran described in
subparagraph (B) for any fiscal year under the program
may exceed 100 percent of the cost that would otherwise
have been incurred as specified in paragraph (1) if the
Secretary determines, based on a consideration of
clinical need, geographic market factors, and such
other matters as the Secretary may prescribe through
regulation, that such higher total cost is in the best
interest of the veteran.
(B) A veteran described in this subparagraph is a
veteran with amyotrophic lateral sclerosis, a spinal
cord injury, or a condition the Secretary determines to
be similar to such conditions.''
Section 2(b) would apply amendments made by subsection (a)
to fiscal years beginning on or after the date of enactment.
Section 3: Coordination with program of all-inclusive care for the
elderly
Section 3 would amend Section 1720C of title 38 U.S.C., as
amended by section 2, and would require the Secretary to enter
into agreements with PACE programs operated in geographic areas
located near medical center.
Section 4: Home and community-based services: programs
Section 4(a) would amend Chapter 17 of title 38 U.S.C., by
inserting after section 1720J the following new section,
``1720K. Home and Community-Based Services: Programs.''
Section (a) would require the Secretary to carry out
each of the programs specified in this section in
accordance with such relevant authorities except as
otherwise provided in this section.
Section (b)(1) would require the Secretary of
Veterans Affairs, in collaboration with the Secretary
of Health and Human Services to carry out a program to
be known as the `Veteran-Directed Care Program.' The
program would allow the Secretary to enter into
agreements with select providers to provide veterans
funds to obtain in-home care and related items, to
include the veterans hiring individuals to provide such
services or being able to directly purchase such care
or items directly. Section (b)(2) would identify select
providers as; an Aging and Disability Resource Center,
an area agency on aging, or a state agency; a center
for independent living; or an Indian tribe or tribal
organization receiving assistance under Title VI of the
Older Americans Act of 1965. Section (b)(3) would
require the Secretary to carry out the Veteran-Directed
Care program through each VA medical center, while
seeking to extend its availability across the U.S.
territories. Additionally, special efforts would be
made to offer the program to eligible Native American
veterans receiving care through Indian Health Service,
tribal health programs, Urban Indian organizations, or
Native Hawaiian health care systems. Section (b)(4)
would allow catastrophically disabled veterans continue
using program funds during hospitalization, as they
would if not hospitalized.
Section (c)(1) would require the Secretary to
implement a `Homemaker and Home Health Aide program,'
where VA may enter into agreements with home health
agencies to provide eligible veterans with appropriate
home health aide services. Section (c)(2) would require
the availability of the program in specified locations
and for specified veteran populations.
Section (d) would require the Secretary to carry out
a program to be known as the `Home-Based Primary Care
program' under which eligible veterans may be furnished
in-home health care, overseen by a Department provider.
Section (e) would require the Secretary to carry out
a program to be known as the `Purchased Skilled Home
Care program' under which eligible veterans may be
furnished in-home healthcare, as determined appropriate
and selected by the Secretary.
Section (f)(1) would require the Secretary to provide
certain resident eligible caregivers the option to
enroll in the program of general caregiver support
services; provide at least 30 days of covered respite
care annually; and conduct annual wellness check on the
caregiver. Section (f)(2) would allow covered respite
care to exceed 30 days per year if the caregiver or
veteran requests an extension and the Secretary
determines it medically appropriate.
Section (g) would require that nothing in this
section should limit the authority of the Secretary to
carry out programs providing home and community-based
services under any provision of law.
Section (h) would define terms in this section.
Section 4(b) would ensure that the Veteran-Directed Care
program and the Homemaker and Home Health Aide Program are
administered through each medical center of VA no later than
two years after date the date of enactment.
Section 5: Coordination with assistance and support services for
caregivers
Section 5(a)(1) would amend Section 1720G(a) of title 38
U.S.C., by adding a new paragraph that would require in the
case of a veteran or caregiver who seeks services under this
subsection and is denied or discharged from the program, that
the Secretary provide the option, if eligible, of enrolling in
the program for general caregiver support services, assess the
possibility of another available program for home- and
community-based services, and provide written information on
any such programs identified. Section 5(a)(2) would make the
amendments made by paragraph (1) apply to denials and
discharges occurring on or after the date that is 180 days
after enactment. Section 5(a)(3) would make technical and
conforming changes.
Section 5(b)(1) would further amend Section 1720G of title
38, to conform the provision of respite care across programs.
Section 5(b)(2) would define `covered respite care' as
medically and age appropriate and to include in-home care.
Section 5(c) would require the Secretary to conduct a review of
the capacity of the VA to establish a streamlined system for
contacting all caregivers enrolled in the program of caregiver
support services, to provide caregivers program updates and
alerts relating to emerging services.
Section 6: Development of centralized website for program information
Section 6(a) would require the Secretary to develop and
maintain a centralized and publicly accessible website to
provide information and resources relating to covered programs.
Section 6(b) would provide the required contents that the
website must contain.
Section 6(c) would require that the website be updated on a
periodic basis.
Section 7: Improvements Relating to homemaker and home health aide
program
Section 7(a)(1) would establish a three-year pilot program
under which the Secretary would provide homemaker and home
health aide services to veterans who reside in communities with
a shortage of home health aides. Section 7(a)(2) would require
the Secretary to select not fewer than five geographic
locations for the pilot. Section 7(a)(3) would authorize the
Secretary to hire nursing assistants as new employees or
reassign existing nursing assistants to provide veteran in-home
care. These nursing assistants would serve as part of the
health care team as part of the Home-Based Primary Care
program. Section 7(a)(4) would require the Secretary to submit
a report no later than one year after the date of enactment to
the Committees on Veterans' Affairs of the House of
Representatives and the Senate on the result of the pilot
program.
Section 7(b) would require the Secretary, not later than
one year after the date of enactment, to submit a report on use
of funds to the Committees on Veterans' Affairs of the House of
Representatives and the Senate.
Section 7(c) would require the Secretary, no later than one
year after enactment, to issue updated guidance for the
Homemaker and Home Health Aide program.
Section 8: Reviews and other improvements relating to home and
community-based services
Section 8(a)(1) would require the Under Secretary for
Health of the VA to conduct a review of each program
administered through the Office of Geriatric and Extended Care
to ensure consistency in program management, eliminate medical
service gaps, and to ensure availability and access to home and
community-based services. Section 8(a)(2) would require the
Secretary to conduct an assessment of staffing needs for the
Office of Geriatric and Extended Care. Section (8)(a)(3) would
require the Director of the Office of Geriatric and Extended
Care to establish quantitative goals, and timelines to
implement such goals, to enable greater access to extended care
services for veterans not located near medical centers. Section
8(a)(4) would require the Director of the Office of Geriatric
and Extended Care to establish quantitative goals to address
specialty care needs through in-home care. Section 8(a)(5)
would require the Secretary to report on the findings,
assessments, and goal of this section.
Section 8(b)(1) would require the Secretary to review the
incentives and efforts relating to home and community-based
services. Section 8(b)(2) would require the Secretary, no later
than one year after the date of enactment, to submit a report
to the Committees on Veterans' Affairs of the House of
Representatives and Senate of the findings of the review.
Section 8(c) would require the Secretary, no later than two
years after enactment, to conduct a review of the use,
availability, and effectiveness, of the respite care services.
Section 8(d)(1) would require the Secretary of Veterans
Affairs in collaboration with the Secretary of Health and Human
Services, no later than two years after enactment, to submit a
report to the Committees on Veterans' Affairs of the House of
Representatives and the Senate on the expansion of certain
mental health services and support to caregivers. The report
would include an assessment of the feasibility and advisability
of authorizing access to Vet Centers by family caregivers.
Section 8(d)(2) would require the Secretary of Veterans Affairs
to develop recommendations in consultation with the Secretary
of Labor with respect to the development of new home- and
community-based services and methods to address the national
shortage of home health aides. The Secretary would be required
to report to Congress on any recommendations. Section 8(d)(3)
would require the Secretary to solicit feedback and
recommendations regarding opportunities to enhance home-and
community-based services for veterans and caregivers. Section
8(d)(4) would require the Secretary to collaborate with the
Director of the Indian Health Service, representatives from
tribal health programs, and Urban Indian programs to ensure the
availability of home-and community-based services.
Section 9: Modification of certain housing loan fees
Section 9 would provide funding for the programs included
in the bill by extending current rates for VA home loan funding
fees as established in section 3729(b)(2) of title 38, from
November 14, 2031, to January 26, 2032.
Section 10: Definitions
Section 10 would define terms used in this Act.
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 italics, existing law in which no change
is proposed is shown in roman):
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 italics, and 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. 1720C. Noninstitutional alternatives to nursing home care
(a) The Secretary may furnish medical, rehabilitative, and
health-related services in noninstitutional settings for
veterans who are eligible under this chapter for, and are in
need of, nursing home care. The Secretary shall give priority
for participation in such program to veterans who--
(1) are in receipt of, or are in need of, nursing
home care primarily for the treatment of a service-
connected disability; or
(2) have a service-connected disability rated at 50
percent or more.
(b)(1) Under the program conducted pursuant to subsection
(a), the Secretary shall (A) furnish appropriate health-related
services solely through contracts with appropriate public and
private agencies that provide such services, and (B) designate
Department health-care employees to furnish case management
services to veteran furnished services under the program.
(2) For the purposes of paragraph (1), the term ``case
management services'' includes the coordination and
facilitation of all services furnished to a veteran by the
Department of Veterans Affairs, either directly or through
contract, including assessment of needs, planning, referral
(including referral for services to be furnished by the
Department, either directly or through a contract, or by an
entity other than the Department), monitoring, reassessment,
and followup.
(c) The Secretary may provide in-kind assistance (through the
services of Department of Veterans Affairs employees and the
sharing of other Department resources) to a facility furnishing
services to veterans under subsection (b)(1)(A). Any such in-
kind assistance shall be provided under a contract between the
Department and the facility concerned. The Secretary may
provide such assistance only for use solely in the furnishing
of appropriate services under this section and only if, under
such contract, 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.
(d) [The total cost] (1) Except as provided in paragraph (2),
the total cost of providing services or in-kind assistance in
the case of any veteran for any fiscal year under the program
may not exceed [65 percent] 100 percent of the cost that would
have been incurred by the Department during that fiscal year if
the veteran had been furnished, instead, nursing home care
under section 1710 of this title during that fiscal year.
(2)(A) The total cost of providing services or in-kind
assistance in the case of any veteran described in subparagraph
(B) for any fiscal year under the program may exceed 100
percent of the cost that would otherwise have been incurred as
specified in paragraph (1) if the Secretary determines, based
on a consideration of clinical need, geographic market factors,
and such other matters as the Secretary may prescribe through
regulation, that such higher total cost is in the best interest
of the veteran.
(B) A veteran described in this subparagraph is a veteran
with amyotrophic lateral sclerosis, a spinal cord injury, or a
condition the Secretary determines to be similar to such
conditions.
(e) The authority of the Secretary to enter into contracts
under this section shall be effective for any fiscal year only
to the extent that appropriations are available.
(f) In furnishing services to a veteran under the program
conducted pursuant to subsection (a), if a medical center of
the Department through which such program is administered is
located in a geographic area in which services are available to
the veteran under a PACE program (as such term is defined in
sections 1894(a)(2) and 1934(a)(2) of the Social Security Act
(42 U.S.C. 1395eee(a)(2); 1396u-4(a)(2))), the Secretary shall
seek to enter into an agreement with the PACE program operating
in that area for the furnishing of such services.
* * * * * * *
Sec. 1720G. Assistance and support services for caregivers
(a) Program of Comprehensive Assistance for Family
Caregivers.--(1)(A) The Secretary shall establish a program of
comprehensive assistance for family caregivers of eligible
veterans.
(B) The Secretary shall only provide support under the
program required by subparagraph (A) to a family caregiver of
an eligible veteran if the Secretary determines it is in the
best interest of the eligible veteran to do so.
(2) For purposes of this subsection, an eligible veteran is
any individual who--
(A) is a veteran or member of the Armed Forces
undergoing medical discharge from the Armed Forces;
(B) for assistance provided under this subsection--
(i) before the date on which the Secretary
submits to Congress a certification that the
Department has fully implemented the
information technology system required by
section 162(a) of the Caring for Our Veterans
Act of 2018, has a serious injury (including
traumatic brain injury, psychological trauma,
or other mental disorder) incurred or
aggravated in the line of duty in the active
military, naval, air, or space service on or
after September 11, 2001;
(ii) during the 2-year period beginning on
the date on which the Secretary submitted to
Congress the certification described in clause
(i), has a serious injury (including traumatic
brain injury, psychological trauma, or other
mental disorder) incurred or aggravated in the
line of duty in the active military, naval,
air, or space service--
(I) on or before May 7, 1975; or
(II) on or after September 11, 2001;
or
(iii) after the date that is 2 years after
the date on which the Secretary submits to
Congress the certification described in clause
(i), has a serious injury (including traumatic
brain injury, psychological trauma, or other
mental disorder) incurred or aggravated in the
line of duty in the active military, naval,
air, or space service; and
(C) is in need of personal care services because of--
(i) an inability to perform one or more
activities of daily living;
(ii) a need for supervision or protection
based on symptoms or residuals of neurological
or other impairment or injury;
(iii) a need for regular or extensive
instruction or supervision without which the
ability of the veteran to function in daily
life would be seriously impaired; or
(iv) such other matters as the Secretary
considers appropriate.
(3)(A) As part of the program required by paragraph (1), the
Secretary shall provide to family caregivers of eligible
veterans the following assistance:
(i) To each family caregiver who is approved as a
provider of personal care services for an eligible
veteran under paragraph (6)--
(I) such instruction, preparation, and
training as the Secretary considers appropriate
for the family caregiver to provide personal
care services to the eligible veteran;
(II) ongoing technical support consisting of
information and assistance to address, in a
timely manner, the routine, emergency, and
specialized caregiving needs of the family
caregiver in providing personal care services
to the eligible veteran;
(III) counseling; and
(IV) lodging and subsistence under section
111(e) of this title.
(ii) To each family caregiver who is designated as
the primary provider of personal care services for an
eligible veteran under paragraph (7)--
(I) the assistance described in clause (i);
(II) such mental health services as the
Secretary determines appropriate;
[(III) respite care of not less than 30 days
annually, including 24-hour per day care of the
veteran commensurate with the care provided by
the family caregiver to permit extended
respite;]
(III) covered respite care of not less than
30 days annually;
(IV) medical care under section 1781 of this
title;
(V) a monthly personal caregiver stipend; and
(VI) through the use of contracts with, or
the provision of grants to, public or private
entities--
(aa) financial planning services
relating to the needs of injured
veterans and their caregivers; and
(bb) legal services, including legal
advice and consultation, relating to
the needs of injured veterans and their
caregivers.
[(B) Respite care provided under subparagraph (A)(ii)(III)
shall be medically and age-appropriate and include in-home
care.]
[(C)] (B)(i) The amount of the monthly personal caregiver
stipend provided under subparagraph (A)(ii)(V) shall be
determined in accordance with a schedule established by the
Secretary that specifies stipends based upon the amount and
degree of personal care services provided.
(ii) The Secretary shall ensure, to the extent practicable,
that the schedule required by clause (i) specifies that the
amount of the monthly personal caregiver stipend provided to a
primary provider of personal care services for the provision of
personal care services to an eligible veteran is not less than
the monthly amount a commercial home health care entity would
pay an individual in the geographic area of the eligible
veteran to provide equivalent personal care services to the
eligible veteran.
(iii) In determining the amount and degree of personal care
services provided under clause (i) with respect to an eligible
veteran whose need for personal care services is based in whole
or in part on a need for supervision or protection under
paragraph (2)(C)(ii) or regular instruction or supervision
under paragraph (2)(C)(iii), the Secretary shall take into
account the following:
(I) The assessment by the family caregiver of the
needs and limitations of the veteran.
(II) The extent to which the veteran can function
safely and independently in the absence of such
supervision, protection, or instruction.
(III) The amount of time required for the family
caregiver to provide such supervision, protection, or
instruction to the veteran.
(iv) If personal care services are not available from a
commercial home health entity in the geographic area of an
eligible veteran, the amount of the monthly personal caregiver
stipend payable under the schedule required by clause (i) with
respect to the eligible veteran shall be determined by taking
into consideration the costs of commercial providers of
personal care services in providing personal care services in
geographic areas other than the geographic area of the eligible
veteran with similar costs of living.
[(D)] (C) In providing instruction, preparation, and training
under subparagraph (A)(i)(I) and technical support under
subparagraph (A)(i)(II) to each family caregiver who is
approved as a provider of personal care services for an
eligible veteran under paragraph (6), the Secretary shall
periodically evaluate the needs of the eligible veteran and the
skills of the family caregiver of such veteran to determine if
additional instruction, preparation, training, or technical
support under those subparagraphs is necessary.
(4) An eligible veteran and a family member of the eligible
veteran seeking to participate in the program required by
paragraph (1) shall jointly submit to the Secretary an
application therefor in such form and in such manner as the
Secretary considers appropriate.
(5) For each application submitted jointly by an eligible
veteran and family member, the Secretary shall evaluate (in
collaboration with the primary care team for the eligible
veteran to the maximum extent practicable)--
(A) the eligible veteran--
(i) to identify the personal care services
required by the eligible veteran; and
(ii) to determine whether such requirements
could be significantly or substantially
satisfied through the provision of personal
care services from a family member; and
(B) the family member to determine the amount of
instruction, preparation, and training, if any, the
family member requires to provide the personal care
services required by the eligible veteran--
(i) as a provider of personal care services
for the eligible veteran; and
(ii) as the primary provider of personal care
services for the eligible veteran.
(6)(A) The Secretary shall provide each family member of an
eligible veteran who makes a joint application under paragraph
(4) the instruction, preparation, and training determined to be
required by such family member under paragraph (5)(B).
(B) Upon the successful completion by a family member of an
eligible veteran of instruction, preparation, and training
under subparagraph (A), the Secretary shall approve the family
member as a provider of personal care services for the eligible
veteran.
(C) The Secretary shall, subject to regulations the Secretary
shall prescribe, provide for necessary travel, lodging, and per
diem expenses incurred by a family member of an eligible
veteran in undergoing instruction, preparation, and training
under subparagraph (A).
(D) If the participation of a family member of an eligible
veteran in instruction, preparation, and training under
subparagraph (A) would interfere with the provision of personal
care services to the eligible veteran, the Secretary shall,
subject to regulations as the Secretary shall prescribe and in
consultation with the veteran, provide respite care to the
eligible veteran during the provision of such instruction,
preparation, and training to the family member so that the
family member can participate in such instruction, preparation,
and training without interfering with the provision of such
services to the eligible veteran.
(7)(A) For each eligible veteran with at least one family
member who is described by subparagraph (B), the Secretary
shall designate one family member of such eligible veteran as
the primary provider of personal care services for such
eligible veteran.
(B) A primary provider of personal care services designated
for an eligible veteran under subparagraph (A) shall be
selected from among family members of the eligible veteran
who--
(i) are approved under paragraph (6) as a provider of
personal care services for the eligible veteran;
(ii) elect to provide the personal care services to
the eligible veteran that the Secretary determines the
eligible veteran requires under paragraph (5)(A)(i);
(iii) have the consent of the eligible veteran to be
the primary provider of personal care services for the
eligible veteran; and
(iv) are considered by the Secretary as competent to
be the primary provider of personal care services for
the eligible veteran.
(C) An eligible veteran receiving personal care services from
a family member designated as the primary provider of personal
care services for the eligible veteran under subparagraph (A)
may, in accordance with procedures the Secretary shall
establish for such purposes, revoke consent with respect to
such family member under subparagraph (B)(iii).
(D) If a family member designated as the primary provider of
personal care services for an eligible veteran under
subparagraph (A) subsequently fails to meet any requirement set
forth in subparagraph (B), the Secretary--
(i) shall immediately revoke the family member's
designation under subparagraph (A); and
(ii) may designate, in consultation with the eligible
veteran, a new primary provider of personal care
services for the eligible veteran under such
subparagraph.
(E) The Secretary shall take such actions as may be necessary
to ensure that the revocation of a designation under
subparagraph (A) with respect to an eligible veteran does not
interfere with the provision of personal care services required
by the eligible veteran.
(8) If an eligible veteran lacks the capacity to make a
decision under this subsection, the Secretary may, in
accordance with regulations and policies of the Department
regarding appointment of guardians or the use of powers of
attorney, appoint a surrogate for the eligible veteran who may
make decisions and take action under this subsection on behalf
of the eligible veteran.
(9)(A) The Secretary shall monitor the well-being of each
eligible veteran receiving personal care services under the
program required by paragraph (1).
(B) The Secretary shall document each finding the Secretary
considers pertinent to the appropriate delivery of personal
care services to an eligible veteran under the program.
(C) The Secretary shall establish procedures to ensure
appropriate follow-up regarding findings described in
subparagraph (B). Such procedures may include the following:
(i) Visiting an eligible veteran in the eligible
veteran's home to review directly the quality of
personal care services provided to the eligible
veteran.
(ii) Taking such corrective action with respect to
the findings of any review of the quality of personal
care services provided an eligible veteran as the
Secretary considers appropriate, which may include--
(I) providing additional training to a family
caregiver; and
(II) suspending or revoking the approval of a
family caregiver under paragraph (6) or the
designation of a family caregiver under
paragraph (7).
(10) The Secretary shall carry out outreach to inform
eligible veterans and family members of eligible veterans of
the program required by paragraph (1) and the benefits of
participating in the program.
(11)(A) In providing assistance under this subsection to
family caregivers of eligible veterans, the Secretary may enter
into contracts, provider agreements, and memoranda of
understanding with Federal agencies, States, and private,
nonprofit, and other entities to provide such assistance to
such family caregivers.
(B) The Secretary may provide assistance under this paragraph
only if such assistance is reasonably accessible to the family
caregiver and is substantially equivalent or better in quality
to similar services provided by the Department.
(C) The Secretary may provide fair compensation to Federal
agencies, States, and other entities that provide assistance
under this paragraph.
(12)(A) The Secretary shall notify the individuals described
in subparagraph (C) regarding decisions affecting the
furnishing of assistance under this subsection using
standardized letters, as the Secretary determines such
notifications and letters to be appropriate.
(B) A notification provided under subparagraph (A) shall
include the elements required for notices of decisions under
section 5104(b) of this title to the extent that those elements
apply to such notification, unless, not later than 60 days
after the date of the enactment of the Transparency and
Effective Accountability Measures for Veteran Caregivers Act,
the Secretary determines that it would not be feasible to
include such elements in such notifications and submits to the
Committee on Veterans' Affairs of the Senate and the Committee
on Veterans' Affairs of the House of Representatives a report
setting forth the reasons for such determination.
(C) The individuals described in this subparagraph shall
include--
(i) an individual who submits an application for the
program established under paragraph (1);
(ii) an individual determined by the Secretary to be
an eligible veteran pursuant to such an application;
and
(iii) a family caregiver of an eligible veteran who
is--
(I) approved as a provider of personal care
services under paragraph (6)(B); or
(II) designated as a primary provider of
personal care services under paragraph (7)(A).
(13)(A) If the Secretary determines that a veteran receiving
services under the program established under paragraph (1) is
no longer eligible for such program solely because of
improvement in the condition of the veteran--
(i) the effective date of discharge of the veteran
from the program shall be not earlier than the date
that is 60 days after the date on which the Secretary
provides notice of such lack of eligibility under
paragraph (12)(A) to the relevant individuals described
in paragraph (12)(C); and
(ii) the Secretary shall extend benefits under the
program established under paragraph (1) for a family
caregiver of the veteran described in paragraph
(12)(C)(iii), including stipends under paragraph
(3)(A)(ii)(V), if such an extension is determined
appropriate by the Secretary, for a 90-day period
following discharge of the veteran from the program.
(B) This paragraph shall not be construed to limit the
authority of the Secretary--
(i) to prescribe regulations addressing other bases
for--
(I) the discharge of a veteran from the
program established under paragraph (1); or
(II) the revocation of the designation of a
family caregiver of a veteran as a primary
provider of personal care services under
paragraph (7)(A); or
(ii) to provide advance notice and extended benefits
under the program, as appropriate, if another basis for
discharge of a veteran described in subclause (I) of
clause (i) or revocation of a designation described in
subclause (II) of such clause applies.
(14)(A) In the case of a veteran or caregiver who seeks
services under this subsection and is denied such services, or
a veteran or the family caregiver of a veteran who is
discharged from the program under this subsection, the
Secretary shall--
(i) if the veteran meets the requirements of a
covered veteran under subsection (b), provide to such
caregiver the option of enrolling in the program of
general caregiver support services under such
subsection;
(ii) assess the veteran or caregiver for
participation in any other available program of the
Department for home- and community-based services
(including the programs specified in section 1720K of
this title) for which the veteran or caregiver may be
eligible and, with respect to the veteran, store (and
make accessible to the veteran) the results of such
assessment in the electronic medical record of the
veteran; and
(iii) provide to the veteran or caregiver written
information on any such program identified pursuant to
the assessment under clause (ii), including information
about facilities, eligibility requirements, and
relevant contact information for each such program.
(B) For each veteran or family caregiver who is discharged
from the program under this subsection, a caregiver support
coordinator shall provide for a smooth and personalized
transition from such program to an appropriate program of the
Department for home- and community-based services (including
the programs specified in section 1720K of this title),
including by integrating caregiver support across programs.
(b) Program of General Caregiver Support Services.--(1) The
Secretary shall establish a program of support services for
caregivers of covered veterans who are enrolled in the health
care system established under section 1705(a) of this title
(including caregivers who do not reside with such veterans).
(2) For purposes of this subsection, a covered veteran is any
individual who needs personal care services because of--
(A) an inability to perform one or more activities of
daily living;
(B) a need for supervision or protection based on
symptoms or residuals of neurological or other
impairment or injury; or
(C) such other matters as the Secretary shall
specify.
(3)(A) The support services furnished to caregivers of
covered veterans under the program required by paragraph (1)
shall include the following:
(i) Services regarding the administering of personal
care services, which, subject to subparagraph (B),
shall include--
(I) educational sessions made available both
in person and on an Internet website;
(II) use of telehealth and other available
technologies; and
(III) teaching techniques, strategies, and
skills for caring for a disabled veteran;
(ii) Counseling and other services under section 1782
of this title.
[(iii) Respite care under section 1720B of this title
that is medically and age appropriate for the veteran
(including 24-hour per day in-home care).]
(iii) Covered respite care of not less than 30 days
annually.
(iv) Information concerning the supportive services
available to caregivers under this subsection and other
public, private, and nonprofit agencies that offer
support to caregivers.
(B) If the Secretary certifies to the Committees on Veterans'
Affairs of the Senate and the House of Representatives that
funding available for a fiscal year is insufficient to fund the
provision of services specified in one or more subclauses of
subparagraph (A)(i), the Secretary shall not be required under
subparagraph (A) to provide the services so specified in the
certification during the period beginning on the date that is
180 days after the date the certification is received by the
Committees and ending on the last day of the fiscal year.
(4) In providing information under paragraph (3)(A)(iv), the
Secretary shall collaborate with the Assistant Secretary for
Aging of the Department of Health and Human Services in order
to provide caregivers access to aging and disability resource
centers under the Administration on Aging of the Department of
Health and Human Services.
(5) In carrying out the program required by paragraph (1),
the Secretary shall conduct outreach to inform covered veterans
and caregivers of covered veterans about the program. The
outreach shall include an emphasis on covered veterans and
caregivers of covered veterans living in rural areas.
(c) Construction.--(1) A decision by the Secretary under this
section affecting the furnishing of assistance or support shall
be considered a medical determination.
(2) Nothing in this section shall be construed to create--
(A) an employment relationship between the Secretary
and an individual in receipt of assistance or support
under this section; or
(B) any entitlement to any assistance or support
provided under this section.
(d) Definitions.--In this section:
(1) The term ``caregiver'', with respect to an
eligible veteran under subsection (a) [or a covered
veteran], a veteran denied or discharged as specified
in paragraph (14) of such subsection, or a covered
veteran under subsection (b), means an individual who
provides personal care services to the veteran.
(2) The term ``covered respite care'' means, with
respect to a caregiver of a veteran, respite care under
section 1720B of this title that--
(A) is medically and age appropriate for the
veteran (including 24-hour per day care of the
veteran commensurate with the care provided by
the caregiver); and
(B) includes in-home care.
[(2)] (3) The term ``family caregiver'', with respect
to an eligible veteran [under subsection (a), means]
under subsection (a) or a veteran denied or discharged
as specified in paragraph (14) of such subsection,
means a family member who is a caregiver of the
veteran.
[(3)] (4) The term ``family member'', with respect to
an eligible veteran [under subsection (a), means] under
subsection (a) or a veteran denied or discharged as
specified in paragraph (14) of such subsection, means
an individual who--
(A) is a member of the family of the veteran,
including--
(i) a parent;
(ii) a spouse;
(iii) a child;
(iv) a step-family member; and
(v) an extended family member; or
(B) lives with the veteran but is not a
member of the family of the veteran.
[(4)] (5) The term ``personal care services'', with
respect to an eligible veteran under subsection (a) [or
a covered veteran], a veteran denied or discharged as
specified in paragraph (14) of such subsection, or a
covered veteran under subsection (b), means services
that provide the veteran the following:
(A) Assistance with one or more activities of
daily living.
(B) Supervision or protection based on
symptoms or residuals of neurological or other
impairment or injury.
(C) Regular or extensive instruction or
supervision without which the ability of the
veteran to function in daily life would be
seriously impaired.
(D) Any other non-institutional extended care
(as such term is used in section 1701(6)(E) of
this title).
* * * * * * *
SEC. 1720K. HOME- AND COMMUNITY-BASED SERVICES: PROGRAMS
(a) In General.--In furnishing noninstitutional alternatives
to nursing home care pursuant to the authority of section 1720C
of this title (or any other authority under this chapter or
other provision of law administered by the Secretary of
Veterans Affairs), the Secretary shall carry out each of the
programs specified in this section in accordance with such
relevant authorities except as otherwise provided in this
section.
(b) Veteran-Directed Care Program.--(1) The Secretary of
Veterans Affairs, in collaboration with the Secretary of Health
and Human Services, shall carry out a program to be known as
the ``Veteran-Directed Care program''. Under such program, the
Secretary of Veterans Affairs may enter into agreements with
the providers described in paragraph (2) to provide to eligible
veterans funds, to the extent practicable, to obtain such in-
home care services and related items as may be determined
appropriate by the Secretary of Veterans Affairs and selected
by the veteran, including through the veteran hiring
individuals to provide such services and items or directly
purchasing such services and items.
(2) The providers described in this paragraph are the
following:
(A) An Aging and Disability Resource Center, an area
agency on aging, or a State agency.
(B) A center for independent living.
(C) An Indian tribe or tribal organization receiving
assistance under title VI of the Older Americans Act of
1965 (42 U.S.C. 3057 et seq.).
(3) In carrying out the Veteran-Directed Care program, the
Secretary of Veterans Affairs shall--
(A) administer such program through each medical
center of the Department of Veterans Affairs;
(B) seek to ensure the availability of such program
in American Samoa, Guam, the Commonwealth of the
Northern Mariana Islands, the Commonwealth of Puerto
Rico, the Virgin Islands of the United States, and any
other territory or possession of the United States, to
the extent practicable; and
(C) seek to ensure the availability of such program
for eligible veterans who are Native American veterans
receiving care and services furnished by the Indian
Health Service, a tribal health program, an Urban
Indian organization, or (in the case of a Native
Hawaiian veteran) a Native Hawaiian health care system,
to the extent practicable.
(4) If a veteran participating in the Veteran-Directed Care
program is catastrophically disabled, the veteran may continue
to use funds under the program during a period of
hospitalization in the same manner that the veteran would be
authorized to use such funds under the program if the veteran
were not hospitalized.
(c) Homemaker and Home Health Aide Program.--(1) The
Secretary shall carry out a program to be known as the
``Homemaker and Home Health Aide program'' under which the
Secretary may enter into agreements with home health agencies
to provide to eligible veterans such home health aide services
as may be determined appropriate by the Secretary.
(2) In carrying out the Homemaker and Home Health Aide
program, the Secretary shall, to the extent practicable, ensure
the availability of such program--
(A) in the locations specified in subparagraph (B) of
subsection (b)(3); and
(B) for the veteran populations specified in
subparagraph (C) of such subsection.
(d) Home-Based Primary Care Program.--The Secretary shall
carry out a program to be known as the ``Home-Based Primary
Care program'' under which the Secretary may furnish to
eligible veterans in-home health care, the provision of which
is overseen by a provider of the Department.
(e) Purchased Skilled Home Care Program.--The Secretary shall
carry out a program to be known as the ``Purchased Skilled Home
Care program'' under which the Secretary may furnish to
eligible veterans such in-home care services as may be
determined appropriate and selected by the Secretary for the
veteran.
(f) Caregiver Support.--(1) With respect to a resident
eligible caregiver of a veteran participating in a program
under this section, the Secretary shall--
(A) if the veteran meets the requirements of a
covered veteran under section 1720G(b) of this title,
provide to such caregiver the option of enrolling in
the program of general caregiver support services under
such section;
(B) provide to such caregiver covered respite care of
not less than 30 days annually; and
(C) conduct on an annual basis (and, to the extent
practicable, in connection with in-person services
provided under the program in which the veteran is
participating), a wellness contact of such caregiver.
(2) Covered respite care provided to a resident eligible
caregiver of a veteran under paragraph (1) may exceed 30 days
annually if such extension is requested by the resident
eligible caregiver or veteran and determined medically
appropriate by the Secretary.
(g) Rule of Construction.--Nothing in this section shall be
construed to limit the authority of the Secretary to carry out
programs providing home- and community-based services under any
other provision of law.
(h) Definitions.--In this section:
(1) The terms ``Aging and Disability Resource
Center'', ``area agency on aging'', and ``State
agency'' have the meanings given those terms in section
102 of the Older Americans Act of 1965 (42 U.S.C.
3002).
(2) The terms ``caregiver'' and ``family caregiver'',
with respect to a veteran, have the meanings given
those terms, respectively, under subsection (e) of
section 1720G of this title with respect to an eligible
veteran under subsection (a) of such section or a
covered veteran under subsection (b) of such section,
as the case may be.
(3) The term ``center for independent living'' has
the meaning given that term in section 702 of the
Rehabilitation Act of 1973 (29 U.S.C. 796a).
(4) The term ``covered respite care'' has the meaning
given such term in section 1720G(d) of this title.
(5) The term ``eligible veteran'' means any veteran--
(A) for whom the Secretary determines
participation in a specific program under this
section is medically necessary to promote,
preserve, or restore the health of the veteran;
and
(B) who absent such participation would be at
increased risk for hospitalization, placement
in a nursing home, or emergency room care.
(6) The term ``home health aide'' means an individual
employed by a home health agency to provide in-home
care services.
(7) The term ``in-home care service'' means any
service, including a personal care service, provided to
enable the recipient of such service to live at home.
(8) The terms ``Indian tribe'' and ``tribal
organization'' have the meanings given those terms in
section 4 of the Indian Self-Determination and
Education Assistance Act (25 U.S.C. 5304).
(9) The terms ``Native American'' and ``Native
American veteran'' have the meanings given those terms
in section 3765 of this title.
(10) The terms ``Native Hawaiian'' and ``Native
Hawaiian health care system'' have the meanings given
those terms in section 12 of the Native Hawaiian Health
Care Improvement Act (42 U.S.C. 11711).
(11) The terms ``tribal health programs'' and ``Urban
Indian organizations'' have the meanings given those
terms in section 4 of the Indian Health Care
Improvement Act (25 U.S.C. 1603).
(12) The term ``resident eligible caregiver'' means
an individual who--
(A) is a caregiver, or a family caregiver, of
a veteran and resides with that veteran; and
(B) has not entered into a contract,
agreement, or other arrangement for such
individual to act as a caregiver for that
veteran unless such individual is a family
member of the veteran or is furnishing
caregiver services through a medical foster
home.
* * * * * * *
PART III--READJUSTMENT AND RELATED BENEFITS
* * * * * * *
CHAPTER 37--HOUSING AND SMALL BUSINESS LOANS
* * * * * * *
SUBCHAPTER III--ADMINISTRATIVE PROVISIONS
* * * * * * *
Sec. 3729. Loan fee
(a) Requirement of Fee.--(1) Except as provided in subsection
(c), a fee shall be collected from each person obtaining a
housing loan guaranteed, insured, or made under this chapter,
and each person assuming a loan to which section 3714 of this
title applies. No such loan may be guaranteed, insured, made,
or assumed until the fee payable under this section has been
remitted to the Secretary.
(2) The fee may be included in the loan and paid from the
proceeds thereof.
(b) Determination of Fee.--(1) The amount of the fee shall be
determined from the loan fee table in paragraph (2). The fee is
expressed as a percentage of the total amount of the loan
guaranteed, insured, or made, or, in the case of a loan
assumption, the unpaid principal balance of the loan on the
date of the transfer of the property.
(2) The loan fee table referred to in paragraph (1) is as
follows:
----------------------------------------------------------------------------------------------------------------
Type of loan Active duty veteran Reservist Other obligor
----------------------------------------------------------------------------------------------------------------
(A)(i) Initial loan described in 2.15 2.40 NA
section 3710(a) to purchase or
construct a dwelling with 0-down, or
any other initial loan described in
section 3710(a) other than with 5-
down or 10-down (closed on or after
October 1, 2004, and before January
1, 2020).
(A)(ii) Initial loan described in 2.30 2.30 NA
section 3710(a) to purchase or
construct a dwelling with 0-down, or
any other initial loan described in
section 3710(a) other than with 5-
down or 10-down (closed on or after
January 1, 2020, and before April 7,
2023).
(A)(iii) Initial loan described in 2.15 2.15 NA
section 3710(a) to purchase or
construct a dwelling with 0-down, or
any other initial loan described in
section 3710(a) other than with 5-
down or 10-down (closed on or after
April 7, 2023, and before [November
14, 2031] January 26, 2032 ).
(A)(iv) Initial loan described in 1.40 1.40 NA
section 3710(a) to purchase or
construct a dwelling with 0-down, or
any other initial loan described in
section 3710(a) other than with 5-
down or 10-down (closed on or after
[November 14, 2031] January 26, 2032
).
(B)(i) Subsequent loan described in 3.30 3.30 NA
section 3710(a) to purchase or
construct a dwelling with 0-down, or
any other subsequent loan described
in section 3710(a) (closed on or
after October 1, 2004, and before
January 1, 2020).
(B)(ii) Subsequent loan described in 3.60 3.60 NA
section 3710(a) to purchase or
construct a dwelling with 0-down, or
any other subsequent loan described
in section 3710(a) (closed on or
after January 1, 2020, and before
April 7, 2023).
(B)(iii) Subsequent loan described in 3.30 3.30 NA
section 3710(a) to purchase or
construct a dwelling with 0-down, or
any other subsequent loan described
in section 3710(a) (closed on or
after April 7, 2023, and before
[November 14, 2031] January 26, 2032
).
(B)(iv) Subsequent loan described in 1.25 1.25 NA
section 3710(a) to purchase or
construct a dwelling with 0-down, or
any other subsequent loan described
in section 3710(a) (closed on or
after [November 14, 2031] January
26, 2032 ).
(C)(i) Loan described in section 1.50 1.75 NA
3710(a) to purchase or construct a
dwelling with 5-down (closed before
January 1, 2020).
(C)(ii) Loan described in section 1.65 1.65 NA
3710(a) to purchase or construct a
dwelling with 5-down (closed on or
after January 1, 2020, and before
April 7, 2023).
(C)(iii) Loan described in section 1.50 1.50 NA
3710(a) to purchase or construct a
dwelling with 5-down (closed on or
after April 7, 2023, and before
[November 14, 2031] January 26, 2032
).
(C)(iv) Loan described in section 0.75 0.75 NA
3710(a) to purchase or construct a
dwelling with 5-down (closed on or
after [November 14, 2031] January
26, 2032 ).
(D)(i) Loan described in section 1.25 1.50 NA
3710(a) to purchase or construct a
dwelling with 10-down (closed before
January 1, 2020).
(D)(ii) Loan described in section 1.40 1.40 NA
3710(a) to purchase or construct a
dwelling with 10-down (closed on or
after January 1, 2020, and before
April 7, 2023).
(D)(iii) Loan described in section 1.25 1.25 NA
3710(a) to purchase or construct a
dwelling with 10-down (closed on or
after April 7, 2023, and before
[November 14, 2031] January 26, 2032
).
(D)(iv) Loan described in section 0.50 0.50 NA
3710(a) to purchase or construct a
dwelling with 10-down (closed on or
after [November 14, 2031] January
26, 2032 ).
(E) Interest rate reduction 0.50 0.50 NA
refinancing loan.
(F) Direct loan under section 3711... 1.00 1.00 NA
(G) Manufactured home loan under 1.00 1.00 NA
section 3712 (other than an interest
rate reduction refinancing loan).
(H) Loan to Native American veteran 1.25 1.25 NA
under section 3762 (other than an
interest rate reduction refinancing
loan).
(I) Loan assumption under section 0.50 0.50 0.50
3714.
(J) Loan under section 3733(a)....... 2.25 2.25 2.25.
----------------------------------------------------------------------------------------------------------------
(3) Any reference to a section in the ``Type of loan'' column
in the loan fee table in paragraph (2) refers to a section of
this title.
(4) For the purposes of paragraph (2):
(A) The term ``active duty veteran'' means any
veteran eligible for the benefits of this chapter other
than a Reservist.
(B) The term ``Reservist'' means a veteran described
in section 3701(b)(5)(A) of this title who is eligible
under section 3702(a)(2)(E) of this title.
(C) The term ``other obligor'' means a person who is
not a veteran, as defined in section 101 of this title
or other provision of this chapter.
(D)(i) The term ``initial loan'' means a loan to a
veteran guaranteed under section 3710 or made under
section 3711 of this title if the veteran has never
obtained a loan guaranteed under section 3710 or made
under section 3711 of this title.
(ii) If a veteran has obtained a loan guaranteed
under section 3710 or made under section 3711 of this
title and the dwelling securing such loan was
substantially damaged or destroyed by a major disaster
declared by the President under section 401 of the
Robert T. Stafford Disaster Relief and Emergency
Assistance Act (42 U.S.C. 5170), the Secretary shall
treat as an initial loan, as defined in clause (i), the
next loan the Secretary guarantees or makes to such
veteran under section 3710 or 3711, respectively, if--
(I) such loan is guaranteed or made before
the date that is three years after the date on
which the dwelling was substantially damaged or
destroyed; and
(II) such loan is only for repairs or
construction of the dwelling, as determined by
the Secretary.
(E) The term ``subsequent loan'' means a loan to a
veteran, other than an interest rate reduction
refinancing loan, guaranteed under section 3710 or made
under section 3711 of this title that is not an initial
loan.
(F) The term ``interest rate reduction refinancing
loan'' means a loan described in section 3710(a)(8),
3710(a)(9)(B)(i), 3710(a)(11), 3712(a)(1)(F), or
3762(h) of this title.
(G) The term ``0-down'' means a downpayment, if any,
of less than 5 percent of the total purchase price or
construction cost of the dwelling.
(H) The term ``5-down'' means a downpayment of at
least 5 percent or more, but less than 10 percent, of
the total purchase price or construction cost of the
dwelling.
(I) The term ``10-down'' means a downpayment of 10
percent or more of the total purchase price or
construction cost of the dwelling.
(c) Waiver of Fee.--(1) A fee may not be collected under this
section from a veteran who is receiving compensation (or who,
but for the receipt of retirement pay or active service pay,
would be entitled to receive compensation), from a surviving
spouse of any veteran (including a person who died in the
active military, naval, air, or space service) who died from a
service-connected disability, or from a member of the Armed
Forces who is serving on active duty and who provides, on or
before the date of loan closing, evidence of having been
awarded the Purple Heart.
(2)(A) A veteran described in subparagraph (B) shall be
treated as receiving compensation for purposes of this
subsection as of the date of the rating described in such
subparagraph without regard to whether an effective date of the
award of compensation is established as of that date.
(B) A veteran described in this subparagraph is a veteran who
is rated eligible to receive compensation--
(i) as the result of a pre-discharge disability
examination and rating; or
(ii) based on a pre-discharge review of existing
medical evidence (including service medical and
treatment records) that results in the issuance of a
memorandum rating.
* * * * * * *
[all]