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S. 2372 (115th): VA MISSION Act of 2018

The House Amendment to S. 2372 strengthens and improves the Department of Veterans Affairs (VA) healthcare system for the benefit of the nation’s veterans. The bill consolidates VA’s multiple community care programs and authorities and provides further funding for the Choice Program. It would establish an Asset and Infrastructure Review (AIR) process to recommend actions to modernize and realign VA’s massive medical infrastructure and also expands VA’s Family Caregiver Program to pre-9/11 veterans and increases VA’s internal capacity to care for veteran patients in VA medical facilities through improvements to various recruitment and retention programs. Specifically, the bill:

Title I: Caring for our Veterans

Title I of the bill establishes a robust, consolidated VA community care program, referred to as the Veterans Community Care Program (the Program). Through the Program, veterans who are enrolled in the VA healthcare system or otherwise entitled to VA care would be granted access to care in the community. Access to community care would be required under the Program if VA does not offer the care or services the veteran requires, if VA does not operate a full-service medical facility in the state in which a given veteran resides, if a given veteran was eligible for care in the community under the Choice 40-mile rule and meets certain other criteria, or if a given veteran and the referring clinician agree that furnishing care in the community is in the best medical interest of the veteran after considering certain criteria. Access to community care would also be required if VA is not able to furnish care within designated access standards developed by VA after consultation with certain other entities and published in the Federal Register and on VA’s website. Care may be authorized in the community if a given medical service line within a VA facility fails to meet certain VA quality standards developed by VA or if veterans in need of an organ or bone marrow transplant have a medically compelling reason to travel outside the region of the Organ Procurement and Transplantation Network. Additionally, eligible veterans will be authorized two visits per calendar year at participating walk-in or Federally-qualified health care clinics.. walk-in care.

To resolve disputes regarding eligibility for care in the community under the Program, title I of the bill would require VA to provide veterans with a clinical appeal process to review community care eligibility determinations but prohibit such appeals from being appealed to the Board of Veterans Appeals. Title 1 of the bill would also require VA to develop and administer a number of training programs to ensure that veterans, VA employees, and community providers are fully aware of and educated on the Program, the VA healthcare system, and mental and physical health conditions that are common among veterans.

To carry out the Program, VA would be required to enter into a contract or contracts to establish a network of community care providers and authorized to establish tiered networks pursuant to such contract or contracts but would be prohibited from prioritizing providers in one tier over another in a manner that limits a veteran’s choice of providers. Title I of the bill would authorize VA to pay for services not subject to a contract or agreement but deemed necessary by VA nevertheless. In such cases, VA would be required to take reasonable efforts to enter into a formal agreement, contract, or other legal arrangement to ensure that future care and services provided by the provider in question are covered.

Title I of the bill requires VA, to the extent practicable, to reimburse community care providers under the Program at Medicare rates, authorizes VA to pay higher rates in highly rural areas, and requires VA to incorporate value-based reimbursement models to the extent practicable to promote high-quality care. The VA is required to reimburse community care providers in a timely manner, and is authorized to contract our claims processing to a third party.

Title I of the bill authorizes VA to enter into provider agreements called Veterans Care Agreements (VCAs). VCAs would not be subject to competition or other requirements associated with federal contracts and the same affirmative action moratorium that applies to TRICARE contractors and subcontractors pursuant to OFCCP Directive 2014–01 would apply to VCA contractors and subcontractors. Veteran eligibility for care under VCAs would be subject to the same terms as VA care itself and the rates paid under VCAs would, to the extent practicable, be in accordance with rates specified for the Program. Title I of the bill would also authorize VA to enter into VCAs with State Veterans Homes and eliminate competitive contracting actions and other requirements associated with federal contracts for State Veterans Homes.

Title I of the bill requires VA to perform market area assessments on a number of key factors at least once every four years. VA would be required to submit the assessments to Congress and to use them to determine the capacity of the Program’s provider networks and access and quality standards. VA would also be required to submit a strategic plan to Congress, no later than one year after the date of enactment and at least every four years thereafter. The strategic plan would be required to specify the demand for care and the capacity to meet such demand both at each VA medical center and in the community. VA would be required to take a number of elements into consideration when developing the strategic plan and to identify emerging issues, challenges, and opportunities and recommendations to address them.

The title also addresses safe opioid prescribing practices by non-VA medical professionals, improved information sharing with community health care providers, and the participation of VA providers inthe national network of state-based prescription drug monitoring programs.

The title sunsets the Choice Program one year after enactment of the bill, which is the expected date the Program should be implemented. The title authorizes VA to use any unutilized Choice funding to sufficiently balance community care accounts.

Finally, Title I makes improvements to telemedicine efforts, embraces innovation for care and payments, improves access for veterans and live donors to transplant procedures, and expands the eligibility for the Family Caregiver Program to pre-9/11 veterans.

Title II: VA Asset and Infrastructure Review

Title II of the bill requires VA to establish a nine member Asset and Infrastructure Review (AIR) Commission. The AIR Commissioners would be appointed by the President, with the advice and consent of the Senate and in consultation with Congressional leaders and congressionally chartered, membership-based veterans service organizations. The Commission would be tasked with considering recommendations made by VA and submitting a report to the President on VHA facility modernization and realignment. The report would then be submitted to Congress and absent a joint resolution of disapproval the recommendation would become law. Title II of the bill includes additional authorities to allow VA to take action as may be necessary to carry out any recommended VHA facility modernization or realignment and to transfer or lease properties to historic preservation organizations.

The Commission must incorporate feedback from veteran service organizations, conduct meetings and hearings open to the public, and update information through online publication of any VA proposals.

Title II also calls for the improved training of construction personnel, a requirement to review enhanced use leases, and an assessment of VA health care provided throughout the US territories in the Pacific.

Title III: Improvements to Recruitment of Health Care Professionals

Title III provides scholarships to medical students in exchange for service to VA, increases the amount of education debt reduction available through Education Debt Repayment Program from $120,000 to $200,000 over five years and from $24,000 to $40,000 annually, establishes a specialty debt repayment program at the Department, and rolls back limitations on bonuses for recruitment, relocation, and retention.

Further, Title III establishes a pilot program for supporting four years of medical school education costs for two veterans at each of the five Teague-Cranston Schools and at four historically black colleges and universities. The covered medical schools would include Texas A&M College of Medicine, Quillen College of Medicine at East Tennessee State University, Boonshoft School of Medicine at Wright State University, Edwards School Medicine at Marshall University, the University of South Carolina School of Medicine, Drew University of Medicine and Science, Howard University of Medicine, Meharry Medical College, and Morehouse School of Medicine. The medical schools that opt to participate in the program would be required to reserve two seats each in the class of 2019.

Title IV: Health Care in Underserved Areas

The Department of Health and Human Services’ Health Resources and Services Administration (HRSA) defines a medically underserved area as an area designated by HRSA as having too few primary care providers, a high infant mortality, a high poverty or a high elderly population.

Title IV of the bill requires VA to: (1) develop criteria to designate VA medical facilities as underserved facilities; (2) consider a number of factors with respect to such facilities, including the ratio of veterans to providers; the range of specialties covered; whether the local community is medically underserved; the type, number, and age of open consults; and whether the facility is meeting VA’s wait time goals; (3) perform an analysis annually (if not more often) to determine which facilities qualify as underserved; and (4) submit a plan to Congress, within one year of enactment and not less frequently than annually thereafter, to address underserved facilities.

Title IV of the bill also requires VA to carry out a three-year pilot program to furnish mobile deployment teams of medical personnel to underserved facilities and to consider the medical positions of greatest need at such facilities and the size and composition of teams to be deployed. It would also require VA to establish a pilot program to establish medical residency programs at covered facilities, including VA facilities, a facility operated by an Indian tribe or tribal organization, an Indian Health Service facility, a Federally-qualified health center, or a DOD facility.

Title V: Other Matters

Title V requires a report on bonuses to high-level employees of the Department, allows podiatrists to be named to a supervisory position in the Department the same manner as a physician can be, and alters the definition of a major medical facility project from projects that exceed $10 million to projects that exceed $20 million.

Further, Title V promotes the use and integration of mental health, substance use disorder, and behavioral health services in a primary care setting by placing peer specialists in care teams and establishes a medical scribe pilot program to increase the use of medical scribes in emergency department and specialty care settings at 10 VA medical centers.

Finally, Title V extends the current funding fee rates for mortgages closed on or after September 30, 2027, through September 30, 2028, extends the reduction in an amount of pensions furnished by Department of Veterans Affairs for certain veterans covered by Medicaid plans for services furnished by nursing facilities, and authorizes $5.2 billion for the Choice Program.

Last updated Jun 5, 2018. Source: Republican Policy Committee

The summary below was written by the Congressional Research Service, which is a nonpartisan division of the Library of Congress, and was published on Jun 7, 2018.

John S. McCain III, Daniel K. Akaka, and Samuel R. Johnson VA Maintaining Internal Systems and Strengthening Integrated Outside Networks Act of 2018 or the VA MISSION Act of 2018 TITLE I--CARING FOR OUR VETERANS Caring for Our Veterans Act of 2018 Subtitle A--Developing an Integrated High-Performing Network Chapter 1--Establishing Community Care Programs

(Sec. 101) This bill revises current provisions relating to veterans' health care to establish a new Veterans Community Care Program (VCCP). This program provides hospital care, medical services, and extended care services to eligible veterans through non-Veteran Administration (VA) health care providers. The VA must coordinate health care to such veterans by: (1) ensuring timely scheduling of medical appointments, (2) ensuring the continuity of care and services, (3) coordinating among regional networks, and (4) ensuring that eligible veterans do not experience a lapse in care or an unusual or excessive burden in accessing care due to errors or delays by the VA or its contractors.

The VA shall provide an eligible veteran with health care through the VCCP if: (1) the VA does not offer the care or services the veteran requires, (2) the VA does not operate a full-service VA medical facility in the veteran's state, or (3) the veteran was eligible for care under Veterans Choice Program criteria.

The VA must report on the types and frequency of care provided under the VCCP.

(Sec. 102) The VA may enter into agreements known as Veterans Care Agreements (VCAs) if health care for veterans is not feasibly available from a VA facility. In authorizing care pursuant to a VCA, the VA must consider factors that would make the use of a VA facility or a community care network facility impracticable, such as the veteran's medical condition, the travel involved, or the nature of the care or services required.

(Sec. 103) The VA may enter into VCAs with state veterans homes. Such homes are subject to all provisions of law regarding integrity, ethics, or fraud and all provisions of law that protect against employment discrimination.

(Sec. 104) The VA must develop access and quality standards for furnishing hospital care, medical services, or extended care services to eligible veterans under the VCCP.

(Sec. 105) The VA must develop procedures to allow certain veterans to access walk-in care through community providers.

(Sec. 106) The VA must conduct a quadrennial market area assessment regarding VHA health care services. Such assessment must consider the demand for VA health care, the VA's health care capacity, the capacity of VCCP providers, and the capacity of academic affiliates and other federal partners that provide health care to veterans.

(Sec. 107) The Office of Federal Contract Compliance Programs' moratorium shall be applicable to VCAs throughout the duration of the moratorium.

(Sec. 108) The VA must deny or revoke the eligibility of certain health care providers who violated VA policies pertaining to the safe delivery of health care to veterans to provide services to veterans.

(Sec. 109) The VA must take steps to improve a medical service line that fails to meet quality standards by increasing personnel, utilizing special hiring incentives and direct hiring authority, providing improved training, and purchasing improved equipment.

Chapter 2--Paying Providers and Improving Collections

(Sec. 111) The VA must adopt prompt payment standards for care provided to eligible veterans. Health care providers must submit claims within a certain time frame and are subject to penalties for fraudulent claims.

(Sec. 112) The VA may compensate a provider for care provided to a veteran, even if the provider does not have a contract or agreement with the VA. The VA must take steps to enter into a contract or agreement with such a provider to cover future costs for care.

(Sec. 113) The VA may recover the cost of care furnished by the VA to nonveterans requiring emergency services. The VA may also recover the cost of care of a nonservice-connected disability incurred by an individual entitled to care under a private health insurance plan.

(Sec. 114) The VA may enter into an agreement with a third party to process medical claims using an electronic interface.

Chapter 3--Education and Training Programs

(Sec. 121) The VA must: (1) conduct an education program to teach veterans about their health care options through the VA health care system, as well as VCCP eligibility criteria and other financial obligations; (2) educate veterans about the interaction between Medicare, Medicaid, TRICARE, tribal health programs, and VA health care; and (3) inform veterans about the process for filing complaints about health care received from the VA.

(Sec. 122) The VA must develop and implement a training program to educate VA employees and contractors about the VCCP, reimbursement for non-VA community emergency room services, and safe opioid prescription management.

(Sec. 123) The VA must establish a continuing medical education program for non-VA medical professionals. The program must provide the same materials to such professionals as is provided to VA medical professionals

Chapter 4--Other Matters Relating to Non-Department of Veterans Affairs Providers

(Sec. 131) The VA must ensure that all non-VA, nonfederal, community providers are knowledgable about opioid-prescribing practices described in the VA "Opioid Safety Initiative."

(Sec. 132) The VA may share a veteran's medical records with non-VA entities to provide health care and with third-party insurance providers to recover charges for care provided to a veteran with a nonservice-connected condition.

(Sec. 133) The VA must establish standards and requirements for non-VA community providers when providing care to eligible veterans. Such standards and requirements must focus on clinical areas for which the VA has special expertise, including post-traumatic stress disorder, military sexual trauma-related conditions, and traumatic brain injuries.

(Sec. 134) The VA must enter into an agreement with a national network of prescription drug-monitoring programs or any state or regional drug prescription monitoring programs to allow licensed VA health care providers to question controlled substance prescriptions written in participating states or regions.

Chapter 5--Other Non-Department Health Care Matters

(Sec. 141) If the VA requests supplemental appropriations outside the annual appropriations process, it must submit a justification detailing how it will use such funds and the expected duration of the supplemental appropriations.

(Sec. 142) The VA may, beginning on March 1, 2019, use the remaining funds in the VCF for care in the community programs provided at non-VA facilities, but the VA may not use remaining VCF funds for the VCCP.

(Sec. 143) The VA may not authorize care under the VCP one year after the enactment of the Caring for Our Veterans Act of 2018 (i.e., on June 6, 2019).

Subtitle B--Improving Department of Veterans Affairs Health Care Delivery

(Sec. 151) This section removes all geographic barriers to telemedicine and protects VA providers against liability stemming from state licensure laws. The VA must report to Congress on the effectiveness of its use of telemedicine.

(Sec. 152) This section establishes within the VA a Center for Innovation for Care and Payment. The VA may implement pilot programs to develop innovative approaches to testing payment and service delivery models for the purpose of reducing expenditures and enhancing the quality of care for veterans.

(Sec. 153) The VA may furnish live donors any care or services required to provide transplants for eligible veterans.

Subtitle C--Family Caregivers

(Sec. 161) The VA family caregiver program is expanded to pre-9/11 veterans. The types of assistance available to family caregivers are also expanded to include financial planning services and legal services for injured veterans and their caregivers.

The VA must periodically evaluate the needs of veterans and the skills of their caregivers to determine if additional support is necessary. The definition of "personal care services" is modified to include services that provide a veteran with: (1) supervision or protection based on symptoms or residuals of neurological or other impairment or injury, and (2) regular instruction or supervision necessary to enable the veteran to function in daily life.

(Sec. 162) The VA must, not later than October 1, 2018, implement an IT system that fully supports the Comprehensive Caregiver Program and allows for data assessment and program monitoring. The VA must also report on the status of the planning, development, and deployment of the IT system.

(Sec. 163) The VA must expand its reporting requirements for caregiver programs to describe any barriers to accessing and receiving care and services under such programs and to evaluate the sufficiency and consistency of the training provided to family caregivers.


Subtitle A--Asset and Infrastructure Review

VA Asset and Infrastructure Review Act of 2018

(Sec. 202) This title establishes the Asset and Infrastructure Review Commission. The commission shall terminate on December 31, 2023.

(Sec. 203) The VA shall publish, not later than February 21, 2021, criteria in the Federal Register and transmit it to the congressional veterans' affairs committees for the modernization or realignment of facilities of the Veterans Health Administration.

(Sec. 204) The VA must begin to implement the recommended modernizations and realignments not later than three years after the President reports to Congress on approval or disapproval of the commission's recommendations.

(Sec. 205) The VA may take certain actions to modernize or realign a facility of the Veterans Health Administration, including environmental mitigation, abatement, or restoration.

(Sec. 206) The bill establishes the Department of Veterans Affairs Asset and Infrastructure Review Account to carry out asset and infrastructure review activities.

(Sec. 207) The bill provides for congressional approval or disapproval of the recommendations of the VHA Asset and Infrastructure Review Commission.

(Sec. 208) The bill requires online publication of communications received by the VA, the commission, or the President.

(Sec. 209) The bill defines terms relevant to asset and infrastructure review, including "modernization" and "realignment."

Subtitle B--Other Infrastructure Matters

(Sec. 211) The bill requires the VA to implement a training curriculum and certification program for construction personnel.

(Sec. 212) The bill requires the Office of Management and Budget to review each enhanced-use lease before it goes into effect. An "enhanced-use lease" is a lease for real property under the jurisdiction or control of the Department of the Army.

(Sec. 213) The VA must submit to the congressional veterans' affairs committees a report on health care furnished by the VA to veterans living in the Pacific territories (i.e., American Samoa, Guam, and the Northern Mariana Islands).


(Sec. 301) The VA shall ensure that at least 50 scholarships are awarded to individuals in a program of education or training leading to employment as a physician or dentist until the VA determines that the staffing shortage of physicians and dentists in the VA is less than 500. The scholarship program is extended through 2033.

(Sec. 302) The bill increases the maximum amount of debt that may be reduced under the VA education debt reduction program.

(Sec. 303) The VA may carry out the student loan repayment program known as the Department of Veterans Affairs Specialty Education Loan Repayment Program. The purpose of the program is to assist in meeting the staffing needs of the Veterans Health Administration for physicians in medical specialties for which the VA determines recruitment or retention of qualified personnel is difficult.

(Sec. 304) The VA must carry out a pilot program to fund the medical education of 18 eligible veterans. Such veterans shall: (1) have been discharged not more than 10 years before the date of application to a specified medical school, and (2) not been entitled to educational assistance under other specified VA or Department of Defense (DOD) programs

(Sec. 305) The bill increases amounts available for bonuses for recruitment, reallocation, and retention for VA health care professionals.

(Sec. 306) The VA must ensure that clinical staff working at Vet Centers are eligible to participate in the VA Education Debt Reduction Program.


(Sec. 401) The VA must develop criteria to designate medical centers, ambulatory care facilities, and community based outpatient VA clinics as underserved facilities, and must submit to Congress a plan to address the problem of underserved facilities of the VA.

(Sec. 402) The VA must carry out a three-year pilot program to furnish mobile deployment teams of medical personnel to underserved facilities.

(Sec. 403) The VA must establish a pilot program to establish medical residency positions at the VA, the Indian Health Service, and DOD health care facilities.


(Sec. 501) The VA must submit to the congressional veterans' affairs and appropriations committees an annual report on performance awards or bonuses awarded to: (1) a Regional Office Director, (2) a Director of a Medical Center, (3) a Director of a Veterans Integrated Service Network, and (4) a senior executive of the VA.

(Sec. 502) A doctor of podiatry is eligible for any supervisory position in the Veterans Health Administration to the same degree that a physician is eligible.

(Sec. 503) The bill revises the definition of "major medical facility project."

(Sec. 504) The bill authorizes the VA to carry out specified major medical facility projects.

(Sec. 505) The VA must make publicly available on its website, and update quarterly, information on: (1) the number of personnel encumbering positions; (2) the number of accessions and separation actions processed in the preceding quarter; (3) the number of vacancies, by occupation; and (4) the percentage of new hires for the VA who were hired within the time-to-hire target of the Office of Personnel Management. The VA must report to Congress annually on steps it is taking to achieve full staffing capacity.

(Sec. 506) The bill requires the VA to carry out a program to establish at least two peer specialists in patient-aligned care teams at VA medical centers to promote the use and integration of services for mental health, substance use disorder, and behavioral health in a primary care setting.

(Sec. 507) The bill requires the VA to carry out a two-year pilot program to increase the use of medical scribes at VA medical centers. A "medical scribe" is an unlicensed individual hired to enter information into the electronic health record or chart at the direction of a physician or licensed practitioner. The VA and the Government Accountability Office must report to Congress on the pilot program.

(Sec. 508) The bill extends through 2028 the requirement to collect fees for housing loans guaranteed by the VA.

(Sec. 509) The bill extends until September 30, 2028, the reduction in VA pensions for certain veterans covered by Medicaid plans for services furnished by nursing facilities.

(Sec. 510) The bill authorizes a certain amount to be deposited in the Veterans Choice Fund under the Veterans Access, Choice, and Accountability Act of 2014.

(Sec. 512) The budgetary effects of this bill shall not be entered on statutory or Senate PAYGO scorecards.