Improving Health Care Access for Veterans: H.R. 3230

Improving Health Care Access for Veterans: H.R. 3230

Improving Health Care Access for Veterans:
H.R. 3230
Sidath Viranga Panangala
Specialist in Veterans Policy
July 16, 2014
Congressional Research Service
7-5700
www.crs.gov
R43646

Improving Health Care Access for Veterans: H.R. 3230

Summary
Currently, a House and Senate conference committee is negotiating differences between the
House version of H.R. 3230 (Veteran Access to Care Act of 2014) and the Senate-passed version
of H.R. 3230 (Veterans’ Access to Care through Choice, Accountability, and Transparency Act of
2014). In general, among other provisions, the Senate and House versions of H.R. 3230 would
authorize the Department of Veterans Affairs (VA) to pay for care provided to eligible veterans in
non-VA facilities or by non-VA providers. Although the Department currently has authority to
provide care through non-VA facilities or providers, the existing statutory authority does not
provide specific criteria as to when VA could authorize non-VA care. Non-VA health care is
authorized at the local VA Medical Centers (VAMCs) as a clinical decision, and authorization of
patients to non-VA care providers is not uniform or standardized across VAMCs.
The Senate version of H.R. 3230 would require VA to pay for non-VA care for veterans who are
enrolled in the VA health care system and exceed the current patient wait-time goals of the
Department, or who are enrolled and live more than 40 miles from a VA medical facility. In any
case, a veteran would have to be enrolled in the VA health care system for VA to pay for non-VA
care. Additionally, the Senate version of H.R. 3230 would authorize VA to contract with Medicare
providers; Federally Qualified Health Centers (FQHCs); Department of Defense (DOD) medical
facilities; and Indian Health Service (IHS) facilities. The House version of H.R. 3230 would
require VA to pay for non-VA care to any enrolled veteran who cannot get an appointment within
VA’s wait-time goals (as of June 1, 2014), or who lives more than 40 miles from a VA medical
facility and chooses to have care in a non-VA facility. The House version of H.R. 3230 would
require VA to reimburse non-VA providers (who currently do not have a contract with the VA) at
the highest of the Medicare, TRICARE, or VA-established reimbursement rate. In both the House
and Senate versions of H.R. 3230, the expanded non-VA care authority would be valid for a
period of two years.
This report compares only major provisions contained in Title III of the Senate version and
Sections 2 and 3 of the House Version of H.R. 3230. However, though not discussed in this
report, the House version of H.R. 3230 would require the VA to conduct an independent
assessment of its health care system’s performance, and would limit awards or bonuses for VA
employees from FY2014-FY2016. Likewise, the Senate version of H.R. 3230 includes several
other Titles besides Title III. Title I would require the VA to improve the scheduling, staffing,
financial and other processes at each VA medical facility. Title II would allow the VA to utilize
direct hire authority to fill health care occupations with the largest staffing shortages. Title IV
would establish an independent commission of VA construction projects to review current
construction and maintenance projects and facility leasing programs in order to identify any
problems they may be experiencing, and also would establish a Commission on Access to Care to
examine the access of veterans to health care and to examine how best to organize the VA health
care system. Title IV would authorize the VA Secretary to remove or demote any individual from
the Senior Executive Service (SES) based on performance. Title V would expand eligibility for
care and services for Military Sexual Trauma (MST) at a VA facility to active duty
servicemembers. Title VI would authorize the VA to enter into leases to obtain the use of major
medical facilities at specified locations. Title VII and VIII address VA benefits and budgetary
matters.

Congressional Research Service

Improving Health Care Access for Veterans: H.R. 3230

Contents
Introduction ...................................................................................................................................... 1

Tables
Table 1. Side-by-Side Comparison of Major Provisions in Title III of the Veterans’ Access
to Care through Choice, Accountability, and Transparency Act of 2014 [H.R. 3230 as
amended] and Sections 2 and 3 of the Veteran Access to Care Act of 2014 [House
amendment to the Senate amendment to H.R. 3230] ................................................................... 3

Contacts
Author Contact Information........................................................................................................... 16

Congressional Research Service

Improving Health Care Access for Veterans: H.R. 3230

Introduction
Since reports about inappropriate scheduling practices surfaced in mid-April 2014 at the Phoenix
Department of Veterans Affairs (VA) Health Care System and at other VA health care facilities,
the Department of Veterans Affairs (VA) inspector general (VAOIG),1 as well as the Veterans
Health Administration (VHA), has completed reviews to identify inappropriate scheduling
practices used by employees regarding veteran preferences for appointment dates.2 Both reviews
have substantiated significant delays in access to care across VA’s health care system. However, it
should be the noted that VAOIG reviews are not complete and reviews at other VA medical
facilities (VAMCs) are ongoing to determine whether scheduling practices are in compliance with
VHA’s scheduling policies.3
Furthermore, the review conducted by the President’s Deputy Chief of Staff, Rob Nabors, found
that, among other things, the scheduling standards adopted by the VHA were “arbitrary, ill-
defined, and misunderstood” and recommended that the VHA needs to be restructured and
reformed. According to his report “[VHA] currently acts with little transparency or accountability
with regard to its management of the VA medical structure [health care system].”4
To address delays in patient care and to provide veterans with timely access to care, among other
things, the Senate and House have introduced and passed several measures. Initially, on June 9,
2014, the Veterans’ Access to Care through Choice, Accountability, and Transparency Act of 2014
(S. 2450) was introduced in the Senate, and the Veteran Access to Care Act of 2014 (H.R. 4810)
was introduced in the House. The House passed its measure on June 10, but the Senate chose to
act on its proposal by substituting the text of S. 2450 for that of H.R. 3230, a measure previously
received from the House.5 The House then amended the Senate substitute for H.R. 3230 by
substituting the text of H.R. 4810 and also that of the Department of Veterans Affairs
Management Accountability Act of 2014 (H.R. 4031), a measure it had previously passed on May
21. This action enabled the two chambers to proceed to conference on their respective versions of
H.R. 3230.6 An initial meeting of the conference committee was held on June 24, 2014, and
currently the House and Senate conferees are negotiating their differences on H.R. 3230.

1 Department of Veterans Affairs, Office of Inspector General, Veterans Health Administration - Interim Report -
Review of Patient Wait Times, Scheduling Practices, and Alleged Patient Deaths at the Phoenix Health Care System,
14-02603-178, May 28, 2014, http://www.va.gov/oig/pubs/VAOIG-14-02603-178.pdf.
2 Department of Veterans Affairs, Access Audit System-Wide Review of Access, Results of Access Audit Conducted
May12, 2014, through June 3, 2014, June 9, 2014, http://www.va.gov/health/docs/VAAccessAuditFindingsReport.pdf.
3 U.S. Congress, House Committee on Veterans’ Affairs, Oversight Hearing on Data Manipulation and Access to VA
Healthcare: Testimony from GAO, IG and VA, Statement of Richard J. Griffin Acting Inspector General Office of
Inspector General Department Of Veterans Affairs, 113th Cong., 2nd sess., June 9, 2014.
4 Rob Nabors, Issues Impacting Access to Timely Care at VA Medical Facilities, June 27, 2014,
http://www.whitehouse.gov/sites/default/files/docs/va_review.pdf.
5 The Senate took this course of action because S. 2450 contained appropriations, which the House traditionally insists
must be enacted in a measure it has originated. H.R. 3230 was available for this purpose because Congress had acted in
other legislation on issues that H.R. 3230 originally addressed.
6 The House conferees are Representatives Miller (FL), Lamborn, Roe (TN), Flores, Benishek, Coffman, Wenstrup,
Walorski, Michaud, Brown (FL), Takano, Brownley (CA), Kirkpatrick, and Walz. The Senate conferees are: Senators
Sanders; Rockefeller; Murray; Brown; Tester; Begich; Blumenthal; Hirono; Burr; Isakson; Johanns; McCain; Coburn;
and Rubio.
Congressional Research Service
1

Improving Health Care Access for Veterans: H.R. 3230

This report provides a brief comparison of the Senate (“Senate Bill”) and House (“House Bill”)
provisions that would provide expanded authority to the VA to provide care to veterans through
non-VA health care providers and facilities.
Section 301 of the “Senate Bill” would make two classes of veterans eligible to receive care in
non-VA facilities. The first class of veterans are those who are enrolled in the VA health care
system, and the second class of veterans are those who are enrolled but have not received VA
hospital care or medical services and have contacted the VA seeking an initial appointment for the
receipt of such care or services. These two classes of veterans would qualify to receive care
outside the VA health care system if they meet any of the following requirements: (1) attempts, or
has attempted to schedule an appointment but is unable to schedule an appointment within the
current wait-time goals of the Veterans Health Administration (VHA) for the furnishing of care or
services and chooses to receive care in a non-VA facility; or (2) resides more than 40 miles from
the nearest VA medical facility including a community-based outpatient clinic (CBOC); or (3)
resides in a state without a VA medical facility that provides (I) hospital care; (II) emergency
medical services; and (III) surgical care, or more than 20 miles away from such a VA medical
facility. Section 2 and 3 of the “House Bill” would authorize the VA to provide non-VA care to
any enrolled veteran who cannot get an appointment within VA’s wait-time goals (as of June 1,
2014), or who lives more than 40 miles from a VA medical facility and chooses to have care in a
non-VA facility.
Furthermore, the Congressional Budget Office (CBO) has provided a final cost estimate of
implementing provisions of Title III of the “Senate Bill.” According to CBO, enacting Title III
would cost approximately $33 billion (excluding revenues) for the period of two years.7
Additionally, CBO has released a preliminary cost estimate of enacting Sections 2 and 3 of the
“House Bill.”8
Table 1 below provides a side-by-side comparison of major provisions contained in Title III of
H.R. 3230 as passed by the Senate on June 11 and Sections 2 and 3 of H.R. 3230 as agreed to in
the House on June 18. Where appropriate, notes are provided in the notes column to provide
context to the proposed provisions in the House- and Senate-passed measures.

7 Congressional Budget Office, Cost Estimate, H.R. 3230, Veterans’ Access to Care through Choice, Accountability,
and Transparency Act of 2014, as passed by the Senate on June 11, 2014, July 10, 2014, http://www.cbo.gov/sites/
default/files/cbofiles/attachments/hr3230_1.pdf.
8 Congressional Budget Office, Letter to Rep. Jeff Miller, Chairman, Committee on Veterans’Affairs, June 17, 2014,
http://www.cbo.gov/sites/default/files/cbofiles/attachments/hr3230_0.pdf.
Congressional Research Service
2

Table 1. Side-by-Side Comparison of Major Provisions in Title III of the Veterans’ Access to Care through Choice,
Accountability, and Transparency Act of 2014 [H.R. 3230 as amended] and Sections 2 and 3 of the Veteran Access to Care Act
of 2014 [House amendment to the Senate amendment to H.R. 3230]
Veterans’ Access to Care through
Choice, Accountability, and
Veteran Access to Care Act of 2014
Transparency Act of 2014 [H.R.
[House amendment to the Senate
3230 as amended]
amendment to H.R. 3230]a
Provision
“Senate Bill”
“House Bill”
Notes
Hospital and Medical Services in Non-
In general, Section 301 of the bill would
In general, Sections 2 and 3 of the bill are Currently, the VA is authorized to pay
Department of Veterans Affairs (VA)
authorize the VA to pay for care
similar to Section 301 of the Senate bill
for care provided by non-VA providers
facilities and by non-VA providers
provided to eligible veterans in non-VA
in that the House bill would provide VA
or facilities (1) when a clinical service
facilities or by non-VA providers and
with authority to provide health services
cannot feasibly be provided at a VA
would define when VA should authorize
to eligible veterans through contracts
medical center (VAMC); (2) when a
non-VA care.
with non-VA health care providers.
veteran is unable to access VA health
care facilities due to geographic
inaccessibility; or (3) in emergencies
when delays could lead to life-
threatening situations.
Non-VA health care is authorized at the
local VAMCs as a clinical decision, and
authorization of patients to non-VA care
providers is not uniform or standardized
across VAMCs.
Recently, VA has begun implementing
two new initiatives, the Patient Centered
Community Care (PC3) program and
the Non-VA Care Coordination
(NVCC) program. In September 2013,
the VA awarded contracts to two
private companies (Health Net Federal
Services and TriWest) to implement the
PC3 program. These two companies are
responsible for developing provider
networks in six geographic regions
covering the whole country. Under the
PC3 contracts, covered care includes
CRS-3

Veterans’ Access to Care through
Choice, Accountability, and
Veteran Access to Care Act of 2014
Transparency Act of 2014 [H.R.
[House amendment to the Senate
3230 as amended]
amendment to H.R. 3230]a
Provision
“Senate Bill”
“House Bill”
Notes
specialty care, mental health care, limited
emergency care and limited newborn
care. NVCC is an internal program to
improve referral management practices.
It was formerly known as ‘Fee Basis’,
‘Purchased Care’, or ‘Non-VA Care.’
Non-VA Providers
Section 301 of the bill would authorize
Section 2 of the bill would authorize the
Medicare providers include for example,
VA to contract with Medicare providers;
VA to enter into contracts or utilize
physicians, and psychologists, as well as
Federally Qualified Health Centers
existing contracts to provide care to
patient care institutions such as
(FQHCs);b Department of Defense
eligible veterans in “non-Department
hospitals, critical access hospitals,
(DOD) medical facilities; and Indian
facilities” as defined in 38 U.S.C § 1701.”
hospices, nursing homes, and home
Health Service (IHS) facilities.
health agencies. See,

http://www.cms.gov/Medicare/Provider-
Enrollment-and-Certification/
CertificationandComplianc/index.html.
Choice of Non-VA Providers
Section 301 of the bill would allow
No comparable provision.

eligible veterans to select among any of
the following providers: Medicare
providers; Federally Qualified Health
Centers (FQHCs); Department of
Defense (DOD) medical facilities; and
Indian Health Service (IHS) facilities.
Care Coordination
Section 301 of the bill would require the
No comparable provision.
As previously noted, NVCC is an
VA to coordinate non-VA care through
internal program to improve referral
the Non-VA Care Coordination (NVCC)
management practices. It was formerly
program.
known as “Fee Basis,” “Purchased Care,”
or “Non-VA Care.”
Eligible Veterans
Section 301 of the bill defines an eligible
Sections 2 and 3 of the bill define an
As stated previously non-VA health care
veteran as :
eligible veteran as a veteran who is
is authorized for an enrolled veteran at a
enrol ed in the VA health care system
local VAMC as a clinical decision. For
•
(A) a veteran enrolled in the VA
and who:
instance, a VA health care provider
health care system;
(generally a clinician) requests a specific
CRS-4

Veterans’ Access to Care through
Choice, Accountability, and
Veteran Access to Care Act of 2014
Transparency Act of 2014 [H.R.
[House amendment to the Senate
3230 as amended]
amendment to H.R. 3230]a
Provision
“Senate Bill”
“House Bill”
Notes
or
•
has waited longer than the
health care service or procedure for the
wait-time goals of the Veterans veteran and justifies use of non-VA care
•
(B) a veteran enrolled in the VA
Health Administration (as of
because of the lack of clinical capacity or
health care system and has not
June 1, 2014) for an
capability to provide the service to the
received hospital care or medical
appointment for hospital care
veteran. After the initial consult is
services from the VA and has
or medical services in a VA
received by the fee basis care program
contacted the VA seeking an initial
facility; and has been notified
office at the local VA medical center
appointment for the receipt of such
by the VA facility that an
(VAMC), the Chief Medical Officer
care or services;
appointment for hospital care
(CMO) at the program office, or a
designated official, reviews the request
and
or medical services is not
available within such wait-time
and authorizes the care if it is
•
(1) attempts, or has attempted to
goals;
determined to be appropriate. Following
schedule an appointment for the
this first stage of review, fee basis care
receipt of hospital care or medical
or
program office staff reviews the
services but is unable to schedule an
authorization to see if the veteran is
•
resides more than 40 miles
appointment within the current
eligible for the program and whether an
from a VA medical facility,
wait-time goals of the Veterans
appropriate justification has been
including a community-based
Health Administration (VHA) for
provided. The referral of authorized
outpatient clinic (CBOCs), that
the furnishing of care or services
cases to non-VA care providers is not
is closest to the residence of
and elects to receive care in a non-
uniform or standardized across VAMCs.
the veteran;
VA facility;
and
or
•
who makes an election to
(2) resides more than 40 miles from
receive such care or services in
the nearest VA medical facility
a non-VA facility.
including a community-based
outpatient clinic (CBOC), that is
closest to the residence of the
veteran;
or
(3) resides in a State without a VA
medical facility that provides (I)
hospital care; (II) emergency
CRS-5

Veterans’ Access to Care through
Choice, Accountability, and
Veteran Access to Care Act of 2014
Transparency Act of 2014 [H.R.
[House amendment to the Senate
3230 as amended]
amendment to H.R. 3230]a
Provision
“Senate Bill”
“House Bill”
Notes
medical services; and (III) surgical
care rated by the Secretary as
having a surgical complexity
standard; and more than 20 miles
from a VA medical facility that does
not provide hospital care; (II)
emergency medical services; and
(III) surgical care rated by the
Secretary as having a surgical
complexity standard.c
Fol ow-up Care
No comparable provision.
Section 2 of the bill would require non-
Currently, VHA authorizes non-VA care
VA care authorizations to include a
on a service or procedure basis, or for
complete episode of care (but for a
limited number of visits per episode of
period not to exceed 60 days), including
care. For example, a veteran is referred
all specialty and ancillary services
to a non-VA specialist by the VA to
deemed necessary as part of an episode
examine the case of his recurring ankle
of recommended treatment (see notes
pain. During the visit the non-VA
column).
provider recognizes the need for
additional imaging tests including a MRI
(magnetic resonance imaging) which was
not authorized in the original
authorization for care. Because the
imaging tests were not covered in the
original authorization the doctor’s office
must call the referring VAMC to get a
second authorization for the imaging
tests.
In another example, a veteran is
receiving authorized non-VA physical
therapy for a shoulder injury. The
physical therapist would like to conduct
additional physical therapy sessions to
address the pain. Although the additional
CRS-6

Veterans’ Access to Care through
Choice, Accountability, and
Veteran Access to Care Act of 2014
Transparency Act of 2014 [H.R.
[House amendment to the Senate
3230 as amended]
amendment to H.R. 3230]a
Provision
“Senate Bill”
“House Bill”
Notes
therapy sessions are related to the same
episode of care, the physical therapist
must call the referring VAMC and
request an extension of the current
authorization.

For more information see,
http://www.nonvacare.va.gov/docs/
provider-resources/
ISMP_Authorizations.pdf
Authorization of Non-VA Care
Section 301 of the bill would require the
No comparable provision.
Currently, all NVCC consults MUST be
VA
authorized by the VA; except in certain
emergency situations.
•
to place an eligible veteran
who does not elect to receive
non-VA care on an electronic
waiting list if the veteran so
chooses to be on such a list
or
•
to authorize non-VA care for a
specific period if the VA
confirms that an appointment
for the receipt of hospital care
or medical services is
unavailable within the current
wait-time goals of the VA for
furnishing of such care or
services.
•
The VA would be required to
send a letter to the eligible
veteran describing the care and
CRS-7

Veterans’ Access to Care through
Choice, Accountability, and
Veteran Access to Care Act of 2014
Transparency Act of 2014 [H.R.
[House amendment to the Senate
3230 as amended]
amendment to H.R. 3230]a
Provision
“Senate Bill”
“House Bill”
Notes
services that the veteran is
eligible to receive under this
authorization.
Non-VA Care through Contracts
Section 301 of the bill would require the
No comparable provision.

VA to enter into contracts with
Medicare providers.
Rates and Reimbursement of
Section 301 of the bill would require the
Section 3 of the bill would require the

Contracted Care
VA to negotiate reimbursement rates
VA to reimburse any non-VA facility
with non-VA Medicare providers for the
with which the VA has not entered into
furnishing of care and services.
a contract to furnish hospital care or
medical services (at the time of
enactment) to an eligible veteran at the
greatest of the fol owing rates:
(1) VA PAYMENT RATE- The rate of
reimbursement established by the VA; or
(2) MEDICARE PAYMENT RATE- The
payment rate under the Medicare
program under title XVIII of the Social
Security Act; or
(3) TRICARE PAYMENT RATE- The
reimbursement established under
chapter 55 of title 10, United States
Code (U.S.C).
Limitation on Rates for Contracted
Section 301 of the bill stipulates that
No comparable provision.
Currently, VA uses applicable Medicare
Care and Exceptions
negotiated rates with non-VA Medicare
rates as its basis for reimbursing non-VA
providers can be no more than the
providers for all inpatient and outpatient
payment rate under the Medicare
services. If the VA has a sharing or
program under Title XVIII of the Social
negotiated agreement with a non-VA
Security Act, set by the Centers for
provider to reimburse at a non-Medicare
Medicare & Medicaid Services. However,
rate, VA will pay that amount instead of
the VA may negotiate a higher rate than
the Medicare rate. The rates are specific
CRS-8

Veterans’ Access to Care through
Choice, Accountability, and
Veteran Access to Care Act of 2014
Transparency Act of 2014 [H.R.
[House amendment to the Senate
3230 as amended]
amendment to H.R. 3230]a
Provision
“Senate Bill”
“House Bill”
Notes
the Medicare reimbursement rate if the
to each individual agreement. In some
VA determines that there is no other
instances it could be higher or lower
health care provider that would provide
than the Medicare rate.
services to an eligible veteran at the
Medicare reimbursement rate.
Choice Card
Section 301 of the bill would require the
No comparable provision.

VA to issue to each eligible veteran a
card that the eligible veteran would be
required to present to a health care
provider that is eligible to furnish care
before the veteran could receive care.
Among other things, the following
statement will be printed on the card:
‘‘This card is for qualifying medical care
outside the Department of Veterans
Affairs. Please call the Department of
Veterans Affairs phone number specified
on this card to ensure that treatment has
been authorized.’
Information on Care Availability
Section 301 of the bill would require the
No comparable provision.

VA to provide information on non-VA
care to veterans when they enrol in the
VA health care system or when the
veteran attempts to schedule an
appointment for the receipt of hospital
care or medical services from the VA
but is unable to schedule an appointment
within the current wait-time goals of the
VHA for the delivery of such care or
services.
Participating Providers
Section 301 of the bill would require
No comparable provision.
The VA requires its physicians to
participating providers to maintain the
undergo credentialing and privileging.
same or similar credentials and licenses
The credentialing process is used to
CRS-9

Veterans’ Access to Care through
Choice, Accountability, and
Veteran Access to Care Act of 2014
Transparency Act of 2014 [H.R.
[House amendment to the Senate
3230 as amended]
amendment to H.R. 3230]a
Provision
“Senate Bill”
“House Bill”
Notes
as required of VA health care providers,
determine whether a physician’s
and to submit verification at least
professional credentials, such as
annual y.
licensure, education, and training, are
valid. VA's privileging process is used to
determine which health care services or
clinical privileges, such as surgical
procedures a VA physician is qualified to
provide without supervision. VA
physicians must be credentialed and
privileged when they initially apply to
work and at least once every 2 years
thereafter.
Copayments
Section 301 of the bill would require the
No comparable provision.
VA provides treatment for service-
VA to charge veterans who are
connected conditions free of charge to
authorized non-VA care applicable
all enrolled veterans. Some veterans are
copayment just as they would be
required to pay copayments for
assessed a copayment if treatment was
nonservice-connected care.
provided in a VA facility.
Health Care Claims Processing Section 301 of the bill would require the
No comparable provision.

VA to establish an efficient nationwide
system for processing and paying Non-
VA care bills or claims, and the Chief
Business Office (CBO) of the VHA will
oversee the implementation and
maintenance of the claims processing
system.
Medical Records
Section 301 of the bill would require the
No comparable provision.

VA to ensure that non-VA providers
submit to the VA any medical record
information related to the care and
services provided to an eligible veteran
for inclusion in the veteran’s
Computerized Patient Record System
CRS-10

Veterans’ Access to Care through
Choice, Accountability, and
Veteran Access to Care Act of 2014
Transparency Act of 2014 [H.R.
[House amendment to the Senate
3230 as amended]
amendment to H.R. 3230]a
Provision
“Senate Bill”
“House Bill”
Notes
(CPRS) maintained by the VA.
Implementation Regulations
Section 301 of the bill would require the
The VA would be required to begin

VA to prescribe and publish interim final
implementing sections 2 and 3 of the bill
regulations on the implementation of
on the date of the enactment.
Section 301 no later than 90 days after
the date of the enactment.
Office of the Inspector General Section 301 of the bill would require the
No comparable provision.

(OIG) Report
VAOIG to submit a report the VA
Secretary no later than 540 days
following the publication of the interim
final regulations implementing this
section. The audit report will include
results of the accuracy and timeliness of
VA payments to non-VA health care
providers as well as any
recommendations, the IG may have.
Termination of Expanded
Section 301 would terminate expanded
Sections 2 and 3 of the bill would

Authority for non-VA Care
authority to provide non-VA care on the
terminate any hospital care or medical
date that is 2 years after the date on
services furnished under the authority
which the VA publishes the interim final
provided in Sections 2 and 3 at the end
regulations.
of the 2 years fol owing the date of
enactment.
Reports to Congress
Section 301 of the bill would require VA
Section 2 of the bill would require the

to submit an interim report to Congress, VA to submit quarterly reports to
not later than 90 days after the
Congress which will include quarterly
publication of interim final regulations.
data and information on:
The interim report must include
information on the number of eligible
(1) The number of veterans who
veterans and a description of the type of
received care or services at non-VA
care and services furnished to eligible
facilities as authorized under Section 2;
veterans. A final report to Congress
(2) The number of veterans who were
would be required within 540 days after
eligible to receive care or services
CRS-11

Veterans’ Access to Care through
Choice, Accountability, and
Veteran Access to Care Act of 2014
Transparency Act of 2014 [H.R.
[House amendment to the Senate
3230 as amended]
amendment to H.R. 3230]a
Provision
“Senate Bill”
“House Bill”
Notes
the publication of the interim final
pursuant to this section but who elected
regulations to address the feasibility and
to continue waiting for an appointment
advisability of continuing to furnish non-
at a VA facility;
VA care and services after 2 year
authority sunsets.
(3) The purchase methods used to
provide the care and services at non-VA
facilities, including the rate of payment
for individual authorizations for such
care and services; and
(4) Any other matters as the Secretary
determines appropriate.
Filling Prescription Medications
Section 301 of the bill would require VA
No comparable provision.
Currently, prescriptions written by a
pharmacies and Consolidated Mail Order
VHA provider are processed and filled
Pharmacies (CMOPs) to fill prescriptions
by the VHA facility or the assigned
of veterans.
Consolidated Mail Outpatient Pharmacy
(CMOP) for the preferred VAMC.
Reimbursement of Non-VA Providers
Section 302 of the bill would require the
No comparable provision.
The VA's health care system is organized
Assigned to the Chief Business Office
Secretary to transfer payment authority
into 21 geographically defined Veterans
(CBO)
for hospital care, medical services, and
Integrated Service Networks (VISNs).
other health care through non-VA
Although policies and guidelines are
providers, from the Veterans Integrated
developed at VA headquarters to be
Service Networks (VISNs) and VAMCs
applied throughout the VA health care
to the Chief Business Office (CBO) of
system, management authority for basic
VHA. This transfer will be effective on
decision making and budgetary
October 1, 2014.
responsibilities are delegated to the
VISNs.
Although, VHA's Chief Business Office
(CBO) oversees the non-VA care
program claims processing activities are
conducted at the VISN or VAMC level.
Currently, in some VISNs, claims
processing activities are centralized at
CRS-12

Veterans’ Access to Care through
Choice, Accountability, and
Veteran Access to Care Act of 2014
Transparency Act of 2014 [H.R.
[House amendment to the Senate
3230 as amended]
amendment to H.R. 3230]a
Provision
“Senate Bill”
“House Bill”
Notes
the VISN level. In other VISNs non-VA
care claims processing is the
responsibility of each VAMC.
Transfer of Reimbursement
Section 302 of the bill would require the
No comparable provision.
Currently, congressionally appropriated
Payments
VA, in each fiscal year that begins after
medical care funds are allocated to the
the date of the enactment, to include in
VISNs based on the Veterans Equitable
VHA’s CBO budget amounts to pay for
Resource Allocation (VERA) system.
hospital care, medical services, and other
VISNs in turn allocate the funds to each
health care provided through non- VA
VAMC within the VISN. VAMC and
providers; and to exclude these amounts
VISNs use a portion of these VERA
from the VISN and VAMC budgets.
allocations to reimburse non-VA
providers.
Enhanced Col aboration Between VA
Section 303 of the bill would require the
No comparable provision.
In December 2012, VA and the Indian
and the Indian Health Service (IHS)
VA in consultation with the Director of
Health Service entered into a
the Indian Health Service (IHS), to
reimbursement agreement for services
conduct outreach to each medical facility
provided to American Indian and Alaska
operated by an Indian tribe or tribal
Native Veterans. Under this agreement
organization through a contract or
VA able to reimburse the Indian Health
compact with the Indian Health Service
Service for direct care services provided
under the Indian Self-Determination and
to eligible American Indian and Alaska
Education Assistance Act (25 U.S.C. 450
Native Veterans. The national
et seq.) to raise awareness of the ability
agreement applies only to VA and IHS
of such facilities, Indian tribes, and tribal
and does not directly apply to
organizations to enter into agreements
reimbursement between the VA and
with the VA under which the VA
tribal health programs or urban Indian
reimburses such facilities, Indian tribes,
organizations. Under the agreement VA
or tribal organizations, for health care
copayments do not apply to direct care
provided to veterans eligible for care at
services provided by IHS to eligible
such facilities.
American Indian and Alaska Native
Veterans.
Performance Metrics
Section 303 of the bill would require the
No comparable provision.

VA to implement performance metrics
CRS-13

Veterans’ Access to Care through
Choice, Accountability, and
Veteran Access to Care Act of 2014
Transparency Act of 2014 [H.R.
[House amendment to the Senate
3230 as amended]
amendment to H.R. 3230]a
Provision
“Senate Bill”
“House Bill”
Notes
for assessing the performance by the VA
and the Indian Health Service under the
memorandum of understanding entitled
“Memorandum of Understanding
between the Department of Veterans
Affairs (VA) and the Indian Health
Service (IHS)” in increasing access to
health care, improving quality and
coordination of health care, among other
things.
Report to Congress
Section 303 of the bill would require the
No comparable provision.

VA in col aboration with IHS to report
to Congress on the feasibility of including
urban Indian organizations into the
current VA-IHS reimbursement
agreement. Additionally, the report
should include feasibility of entering into
reimbursement agreements with IHS
facilities or clinics run by an Indian tribe
or tribal organization for the treatment
of non-American Indian veterans on a
reimbursable basis. This report to
Congress is due 180 days fol owing
enactment.
Enhanced Col aboration Between
Section 304 of the bill would require the
No comparable provision.

Department Of Veterans Affairs and
VA, in consultation with Papa Ola Lokahi
Native Hawaiian Health Care Systems
and such other organizations involved in
the delivery of health care to Native
Hawaiians, to enter into contracts or
agreements with Native Hawaiian health
care systems that are in receipt of funds
from the Secretary of Health and Human
Services.
CRS-14

Veterans’ Access to Care through
Choice, Accountability, and
Veteran Access to Care Act of 2014
Transparency Act of 2014 [H.R.
[House amendment to the Senate
3230 as amended]
amendment to H.R. 3230]a
Provision
“Senate Bill”
“House Bill”
Notes
Prompt Payment
Section 305 of the bill would establish
No comparable provision.
In general, the Prompt Payment rule
that it is the Sense of Congress that the
ensures that federal agencies pay
VA must comply with the Prompt
vendors in a timely manner. For more
Payment rule.
information on the rule see,
http://www.fms.treas.gov/prompt/
index.html
Source: Table prepared by the Congressional Research Service (CRS).
a. Version of the bill printed in U.S. Congress, House Committee On Rules, Providing For Consideration Of The Bill (H.R. 4870) Making Appropriations For The Department
Of Defense For The Fiscal Year Ending September 30, 2015, And For Other Purposes, And Providing For Consideration Of The Senate Amendments To The Bill (H.R. 3230)
Making Continuing Appropriations During A Government, Report to accompany H.Res. 628, 113th Cong., 2nd sess., June 17, 2014, H.Rept. 113-475.
b. See CRS Report R43029, Health Care for Rural Veterans: The Example of Federally Qualified Health Centers, by Elayne J. Heisler, Sidath Viranga Panangala, and Erin
Bagalman, for aspects of the FQHCs that are most relevant to collaboration with the VA.
c. VA has assigned each of its medical centers an inpatient “surgical complexity” level—complex, intermediate or standard. Hospitals assigned a “complex” rating
require special facilities, equipment and staff for difficult operations, such as cardiac surgery and craniotomies. Those with an “intermediate” rating may perform less
complex surgeries, such as partial colon removal and complete joint replacement. Those with a “standard” rating may perform inpatient surgeries, such as hernia
repair and ear, nose, and throat (ENT) surgeries. These measures were implemented May 7, 2010. If a VA hospital cannot provide a certain type of therapy or
treatment to a patient, it will transfer the veteran to a VA facility that has these programs.

CRS-15

Improving Health Care Access for Veterans: H.R. 3230

Author Contact Information

Sidath Viranga Panangala

Specialist in Veterans Policy
spanangala@crs.loc.gov, 7-0623

Congressional Research Service
16