[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).
---------------------------------------------------------------------------
    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).
---------------------------------------------------------------------------
    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\
---------------------------------------------------------------------------
    \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\
---------------------------------------------------------------------------
    \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).
---------------------------------------------------------------------------
    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.
---------------------------------------------------------------------------
    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\
---------------------------------------------------------------------------
    \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.
---------------------------------------------------------------------------
    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
--------------------------------------------------------------------------------------------------------------------------------------------------------
                                                                                       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
--------------------------------------------------------------------------------------------------------------------------------------------------------
* = 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




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PART II--GENERAL BENEFITS

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

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

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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.

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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).

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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.

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PART III--READJUSTMENT AND RELATED BENEFITS

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CHAPTER 37--HOUSING AND SMALL BUSINESS LOANS

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SUBCHAPTER III--ADMINISTRATIVE PROVISIONS

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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.

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