article: SECTION 1. SHORT TITLE. This Act may be cited as the ``Veterans' Health Care Eligibility Reform Act of 1994''. SEC. 2. VETERANS HEALTH CARE ELIGIBILITY REFORM. Chapter 17 of title 38, United States Code, is amended as follows: (1) Section 1701 is amended by adding at the end the following new paragraphs: ``(10) The term `continuum of health care' includes specialized treatment and rehabilitative services of the Department, including comprehensive prevention and health screening programs and services to treat needs of disabled veterans with spinal cord dysfunction, blindness, prosthetics, and mental illness. ``(11) The term `noninstitutional long-term care' includes the following services: ``(A) Hospital-based home care. ``(B) Adult day health care. ``(C) Fee basis care. ``(D) Hospice care. ``(E) Homemaker services. ``(F) Home health aid. ``(G) Case management services. ``(H) Congregate meals. ``(I) Home delivered meals. ``(J) Senior center services. ``(K) Shopping and transportation services. ``(L) Phone check services.''. (2) Section 1710(a)(1) is amended by striking out ``shall furnish'' and all that follows through ``which the'' and inserting in lieu thereof ``shall furnish a continuum of health care (including hospital care, outpatient medical services provided on an outpatient or ambulatory basis, and noninstitutional long-term care) which the''. (3) Subchapter II is amended by inserting after section 1710 the following new section: ``Sec. 1710A. Institutional long-term care for certain veterans ``(a) The Secretary shall provide institutional nursing home care to any veteran who is described in subparagraph (A) or (D) of section 1710(a)(1), or in subparagraph (C) of section 1712(a)(1), of this title or who is in receipt of pension from the Secretary. ``(b) If a veteran who is provided nursing home care by reason of subsection (a) is also eligible for payment for the costs of nursing home care under a State plan title XIX of the Social Security Act, the Secretary shall be entitled to recover from that State plan the amount that the State plan would pay for that care if provided by an authorized provider. For purposes of this subsection, the veteran shall be deemed to have paid any deductible or copayment otherwise required as a condition of payment by the State plan.''. (4) Section 1710(d) is amended by inserting ``1710A or'' after ``section''. (5) Subchapter III is amended by inserting after section 1729 the following new section: ``Sec. 1729A. Medicare coverage and reimbursement ``(a) For purposes of any program administered by the Secretary of Health and Human Services under title XVIII of the Social Security Act, a Department facility shall be deemed to be a Medicare provider. ``(b)(1) A VA medical center (or group of medical centers) shall be considered to be a Medicare HMO. ``(2) For purposes of this section, the term `Medicare HMO' means an eligible organization under section 1876 of the Social Security Act. ``(c) In the case of care for a non-service-connected disability that is provided to a veteran who is eligible for benefits under the Medicare program under title XVIII of the Social Security Act, the Secretary of Health and Human Services shall reimburse a Department health-care facility providing services as a Medicare provider or Medicare HMO in the same amounts and under the same terms and conditions as that Secretary reimburses other Medicare providers or Medicare HMOs, respectively. The Secretary of Health and Human Services shall include with each such reimbursement a Medicare explanation of benefits. ``(d) In the case of a veteran whose eligibility for hospital care from the Department is by reason of section 1710(a)(2) of this title, the Secretary shall, when providing care to the veteran for which the Secretary receives reimbursement under this section, require the veteran to pay to the Department any applicable deductible or copayment that is not covered by Medicare.''. SEC. 3. PLAN FOR ENTITLEMENT TO INSTITUTIONAL NURSING HOME CARE FOR OTHER VETERANS. (a) Establishment of Plan.--The Secretary of Veterans Affairs shall develop a plan to implement (over a specified period of years) the provision of institutional long-term care for any veteran described in subsection (b). The plan may provide for the provision of institutional long-term care through facilities of the Department of Veterans Affairs or through a long-term care insurance contract, or a combination thereof. In specifying benefits, or a proposed range of benefits, under the plan, the Secretary shall consider a representative range of the different types of health benefits provisions (which include cost- sharing) typically offered as long-term institutional care coverage in the small employer health coverage market. (b) Covered Veterans.--The plan shall propose to cover any veteran not covered by section 1710A of title 38, United States Code, as added by section 2, who-- (1) has a service-connected disability rated at less than 50 percent; (2) has an annual income (as determined under section 1503 of such title) that does not exceed three times the maximum annual rate of pension that would be applicable to the veteran if the veteran were eligible for pension under section 1521(d) of such title; (3) has a catastrophic nonservice-connected disability (as defined by the Secretary); or (4) requires institutional long-term care as a follow up to inpatient care, as authorized under section 1720 of this title. (c) Premiums and Copayments.--The plan shall include the establishment of a schedule of premiums and copayments for care provided through Department of Veterans Affairs institutional care programs in effect on the day before the date of the enactment of this Act. The plan shall specify a range of premiums and copayments that would apply based upon different combinations of levels of payments by the Government, copayments, and premiums, as specified in the plan. (d) Long-Term Care Insurance Contract.--For purposes of this section, the term `long-term care insurance contract' means any insurance contract issued if-- (1) the only insurance protection provided under the contract is coverage of institutional long-term care services (as specified in the contract) and benefits incidental to such coverage, (2) the maximum benefit under the policy for expenses incurred for any day does not exceed $200, (3) the contract does not cover expenses incurred for services or items to the extent that such expenses are reimbursable under title XVIII of the Social Security Act or would be so reimbursable but for the application of a deductible or coinsurance amount, (4) the contract is guaranteed renewable, (5) the contract does not have any cash surrender value, and (6) all refunds of premiums, and all policyholder dividends or similar amounts, under the contract are to be applied as a reduction in future premiums or to increase future benefits. (e) Report to Congress.--Not later than September 30, 1996, the Secretary shall submit to Congress a report on the plan. The report shall include-- (1) a cost analysis, including a range of premiums and copayments and Government cost-sharing; (2) a discussion of the cost of establishing a long-term care insurance program for veterans described in subsection (b) using contract authority (if such contract authority is provided by law); and (3) a draft of legislation to make any necessary changes in law to enable the Department to implement the plan. SEC. 4. ENROLLMENT SYSTEM FOR OTHER PERSONS. (a) In General.--(1) Title 38, United States Code, is amended by inserting after chapter 17 the following new chapter: ``CHAPTER 18--VA GROUP HEALTH PLAN ``Sec. ``1801. Definitions. ``1802. VA Group Health Plan. ``1803. Enrollment. ``1804. Limitation on preexisting conditions. ``1805. Plan to be self supporting. ``1806. Annual report. ``Sec. 1801. Definitions ``For purposes of this chapter: ``(1) The term `eligible veteran' means any veteran other than a veteran eligible for health care under section 1710(a)(1) of this title. ``(2) The term `VA enrollee' means an individual enrolled in the VA Group Health Plan. ``Sec. 1802. VA Group Health Plan ``(a) The Secretary shall administer a program of health insurance under this chapter to be known as the VA Group Health Plan. The Secretary may provide such insurance directly or may contract with an insurance provider in the private sector for the provision of such insurance. The plan may be established as a single, nation-wide plan or as a composite of regional health insurance plans. ``(b) The Secretary shall establish and carry out the VA Group Health Plan as a managed-care plan and so that it meets the following requirements: ``(1) The plan shall be designed to be self-sustaining through required premiums, copayments, deductibles, and other charges, and without appropriated funds. ``(2) The plan shall provide such benefits as the Secretary determines. ``(c) The Secretary may award contracts under this section for the operation of the VA Group plan. ``(d) The Secretary may provide treatment in Department facilities for any enrollee, if cost effective. ``Sec. 1803. Enrollment ``(a) The following individuals are eligible to enroll in the VA Group Health Plan: ``(1) Any eligible veteran. ``(2) The spouse or child of any veteran. ``(b)(1) The Secretary of Veterans Affairs shall establish an enrollment (and disenrollment) process for the VA Group Health Plan in accordance with this subsection. Such process shall be established in consultation with veterans and other individuals to be served by the plan. ``(2) For each eligible veteran, when the veteran first becomes eligible to enroll in the VA Group Health Plan, there shall be an initial enrollment period (of not less than 30 days) during which the veteran may enroll in the plan. ``(3) The Secretary shall establish an annual period, of not less than 30 days, during which eligible veterans may enroll in the VA Group Health Plan. ``(4) If a veteran enrolls in the VA Group Health Plan, the veteran may at the same time enroll, as a family enrollment, the veteran's spouse and children in the plan. ``(5) In the case of individuals who through marriage, divorce, birth or adoption of a child, or similar circumstances, experience a change in family composition, the Secretary shall provide for a special enrollment period in which the individual is permitted to change the individual or family basis of coverage. The circumstances under which such special enrollment periods are required and the duration of such periods shall be specified by the Secretary. ``(6) The Secretary shall provide for a special transitional enrollment period during which eligible individuals may first enroll. ``(c) Enrollment of the spouse (including a child of the spouse) and any dependent child of an eligible veteran shall be considered to be timely if a request for enrollment is made either-- ``(1) within 30 days of the date of the marriage or of the date of the birth or adoption of a child, if family coverage is available as of such date, or ``(2) within 30 days of the date family coverage is first made available. ``(d) Family coverage shall become effective not later than the first day of the first month beginning after the date of the marriage or the date of birth or adoption of the child (as the case may be). ``(e) The Secretary may terminate coverage for nonpayment of premiums. ``(f) Coverage of a spouse under a policy under this chapter may not be canceled by reason of the death of the veteran unless the surviving spouse remarries. ``Sec. 1804. Limitation on preexisting conditions ``(a) The VA Group Health Plan may not impose (and an insurer under that plan may not require the Secretary impose through a waiting period for coverage under the plan or similar requirement) a limitation or exclusion of benefits relating to treatment of a condition based on the fact that the condition preexisted the effective date of the plan with respect to an individual if-- ``(1) the condition relates to a condition that was not diagnosed or treated within three months before the date of coverage under the plan; ``(2) the limitation or exclusion extends over more than six months after the date of coverage under the plan; ``(3) the limitation or exclusion applies to an individual who, as of the date of birth, was covered under the plan; or ``(4) the limitation or exclusion relates to pregnancy. In the case of an individual who is eligible for coverage under a plan but for a waiting period imposed by the employer, in applying paragraphs (1) and (2), the individual shall be treated as having been covered under the plan as of the earliest date of the beginning of the waiting period. ``(b)(1) The Secretary, for purposes of the VA Group Health Plan, shall waive any period applicable to a preexisting condition for similar benefits with respect to an individual to the extent that the individual, before the date of such individual's enrollment in such plan, was covered for the condition under any other health plan that was in effect before such date. ``(2) Paragraph (1) shall no longer apply if there is a continuous period of more than 60 days (or, in the case of an individual who loses coverage under a group health plan due to termination of employment, six months) on which the individual was not covered under a group health plan. ``(3) In applying paragraph (2), any waiting period imposed by an employer before an employee is eligible to be covered under a plan shall be treated as a period in which the employee was covered under a group health plan. ``Sec. 1805. Plan to be self supporting ``The Secretary shall administer the VA Group Health Plan so as to ensure that no appropriated funds are required for the operation of the plan (other than as necessary for startup and transition costs). The Secretary shall establish such premiums, copayments, and other charges for the plan as necessary. ``Sec. 1806. Annual report ``(a) The Secretary shall submit to Congress an annual report on the VA Group Health Plan. The report shall provide information on prices, health outcomes, and enrollee satisfaction under the plan and any other information the Secretary considers appropriate concerning the quality of the plan, including a breakdown of the portion of premiums under the plan that are attributable to the overhead operations of the plan. ``(b) The report shall be submitted each year before the annual general enrollment period. The Secretary shall make such report available to other interested persons.''. (2) The table of chapters at the beginning of part II of title 38, United States Code, is amended by inserting after the item relating to chapter 17 the following new item: ``18. VA Group Health Plan.................................. 1801.''. (b) Initial Report.--The initial report of the Secretary of Veterans Affairs under section 1806 of title 38, United States Code, as added by subsection (a), shall be submitted no later than September 30, 1995. The report shall include a cost analysis for the plan and a range of premiums and copayments that may be implemented under the plan. SEC. 5. MANAGED CARE SYSTEM OF HEALTH DELIVERY. (a) Chapter 73 of title 38, United States Code, is amended by inserting after section 7306 the following new sections: ``Sec. 7307. Managed care ``(a) The Secretary shall administer the health programs of the Veterans Health Administration through use of the model of medical practice known as `managed care'. ``(b) In implementing a managed care system, the Under Secretary shall, to the extent possible-- ``(1) shift the focus of care provided by the Veterans Health Administration to primary care; ``(2) establish enhanced quality assurance mechanisms; and ``(3) establish utilization review procedures to prevent inefficient practices. ``Sec. 7308. Veterans Service Areas ``The Secretary shall organize the health care delivery services and resources of the Veterans Health Administration into geographic regions to be known as Veterans Service Areas.''. (b) The table of sections at the beginning of such chapter is amended by inserting after the item relating to section 7306 the following new items: ``7307. Managed care. ``7308. Veterans Service Areas.''. (c) If, as of the date of the enactment of this Act, the position of Under Secretary for Health of the Department of Veterans Affairs is vacant, the provisions of section 7308 of title 38, United States Code, as added by subsection (a), shall not take effect until an individual is appointed to that position. SEC. 6. AUTHORIZATION OF APPROPRIATIONS. There are authorized to be appropriated to the Secretary of Veterans Affairs for each of fiscal years 1995 through 1999 (in constant fiscal year 1995 dollars)-- (1) $200,000,000 to acquire medical equipment to relieve the existing medical equipment backlog in Department of Veterans Affairs medical facilities; and (2) $500,000,000 for improvements of infrastructure, patient care amenities, primary care services, and personnel and for medical facility construction projects (subject to section 8104 of title 38, United States Code).
summary: Veterans' Health Care Eligibility Reform Act of 1994 - Defines "continuum of health care" and "noninstitutional long-term care" under veterans' health care provisions. Directs the Secretary of Veterans Affairs to provide a continuum of health care to veterans eligible for veterans' benefits. (Sec. 2) Directs the Secretary to provide institutional nursing home care to certain disabled veterans or those in receipt of a veterans' pension. Allows for recovery of nursing home care costs by the Secretary if the veteran is also eligible for such care through a State plan under title XIX (Medicaid) of the Social Security Act. Designates a Department of Veterans Affairs facility as a Medicare provider for purposes of any program administered by the Secretary of Health and Human Services (HHS) under title XVIII (Medicare) of the Social Security Act. Declares a Department medical center as a Medicare HMO. Directs the HHS Secretary to reimburse a Department facility or medical center for providing services as a Medicare provider in the case of care for a non-service-connected disability of a veteran eligible for Medicare benefits. (Sec. 3) Directs the Secretary to develop a plan to implement the provision of institutional long-term care for veterans who: (1) have a service-connected disability of less than 50 percent; (2) have an annual income below a formulated amount; (3) have a catastrophic nonservice-connected disability; or (4) require such care as a follow-up to inpatient care. Outlines, with respect to such care, provisions concerning: (1) premiums and copayments for covered veterans; (2) the issuance of a long-term care insurance contract; and (3) a report from the Secretary to the Congress on the costs of the plan and the insurance contract and legislation required for plan implementation. (Sec. 4) Directs the Secretary to administer a program of health insurance known as the VA Group Health Plan as a managed-care plan meeting specified requirements. Allows any eligible veteran and his or her spouse or child to be enrolled in the Plan. Provides Plan enrollment requirements. Prohibits the Plan from imposing a limitation or exclusion of benefits relating to treatment for certain preexisting conditions. Directs the Secretary to administer the Plan so that no appropriated funds are required for Plan operation. Requires an annual report to the Congress by the Secretary on Plan operation, as well as an initial report. (Sec. 5) Directs the Secretary to administer the health programs of the Veterans Health Administration (VHA) through use of a managed care medical practice model, with limitations. Directs the Secretary to organize the VHA health care delivery and resources into geographic regions known as veterans service areas. (Sec. 6) Authorizes appropriations to the Secretary for FY 1995 through 1999 for: (1) acquiring medical equipment to relieve existing medical equipment backlogs in Department facilities; and (2) infrastructure improvement, patient care amenities, primary care services and personnel, and medical facility construction projects.