Senate Veterans’ Affairs Committee Issues Report on Caring for Our Veterans Act (Part 4 of 7)
TITLE III--FAMILY CAREGIVERS
Sec. 301. Expansion of family caregiver program of
Subsec. 301(a)(1). Expansion of family caregiver program of
Section 301(a)(1) of the Committee bill, which is derived from S. 591, would expand eligibility for
Background. The Caregivers and Veterans Omnibus Health Services Act of 2010 was signed into law on
In
Prior to the Program's implementation,
Committee Bill. Section 301(a)(1) would amend section 1720G of title 38, U.S.C., to require
The current eligibility criteria creates an inequity between post-9/11 veterans and pre-9/11 veterans. However,
For example, the Program's expansion in two phases, as required by this section, is intended to ensure the Program does not get overwhelmed and continues to operate as intended, providing services in a timely manner, while enrolling those who have become newly eligible. The publication of the VA Secretary's certification date in the
Subsec. 301(a)(2). Expansion of needed services in eligibility criteria.
Section 301(a)(2) of the Committee bill, which is derived from S. 591, would expand the Program's eligibility criteria for needed services.
Background. Current law, section 1720G of title 38, U.S.C., provides that veterans eligible for the Program must be in need of personal care services because of an inability to perform one or more activities of daily living, a need for supervision or protection based on symptoms or residuals of neurological or other impairment or injury, or such other matters as the Secretary considers appropriate.
Committee Bill. Section 301(a)(2) would amend subsection (a)(2)(C) of section 1720G of title 38, U.S.C., to include 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 among the criteria considered for needed personal care services. It is the intent of the Committee to ensure the Program is consistently inclusive of the caregiving needs required by mental health conditions, traumatic brain injuries or other conditions with which eligible veterans may be diagnosed.
Subsec. 301(a)(3). Expansion of services provided.
Section 301(a)(3) of the Committee bill, which is derived from S. 591, would expand the services provided to caregivers under the Program to include legal and financial planning services.
Background. In 2014, the
Committee Bill. Section 301(a)(3) would amend subsection (a)(3)(A)(ii) of section 1720G of title 38, U.S.C., to require
While section 301(a)(3) would require that financial planning and legal services be offered to caregivers in the Program, it is the Committee's intent that
Subsec. 301(a)(4). Modification of stipend calculation.
Section 301(a)(4) of the Committee bill, which is derived from S. 591, would expand the number of factors
Background. Currently, there are three levels of caregiver stipends based on the amount and degree of personal care services provided. This was established pursuant to section 1720G of title 38, U.S.C. According to current regulations, the stipend payment is based on the number of hours of caregiving required by the veteran. The maximum stipend is based on the requirement of 40 hours of caregiving each week, the median stipend is based on the requirement of 25 hours of caregiving each week, and the lowest stipend is based on the requirement of 10 hours of caregiving each week. In order to determine the degree of personal care services required by the veteran,
Committee Bill. Section 301(a)(4) would amend subsection (a)(
The Committee understands that these determinations are made at the VAMC level and the intent is to ensure consistency by
Subsec. 301(a)(5). Periodic evaluation of need for certain services.
Section 301(a)(5) of the Committee bill, which is derived from S. 591, would require
Background. Under section 1720G of title 38, U.S.C.,
Committee Bill. Section 301(a)(5) would amend subsection (a)(3) of section 1720G of title 38, U.S.C., to require that, in providing instruction, preparation, and training under subparagraph (A)(i)(I) of that section and technical support under subparagraph (A)(i)(II) of that section to each approved family caregiver, the Secretary periodically evaluate the needs of the veteran and the skills of the family caregiver to determine if additional instruction, preparation, training, or technical support is necessary.
The requirement for periodic evaluation of this support will ensure that caregivers have ongoing access to resources and support for their unique needs as they care for veterans, especially given that a veteran's needs and caregiving techniques and best practices may change over time.
Subsec. 301(a)(6). Use of primary care teams.
Section 301(a)(6) of the Committee bill, which is derived from S. 591, would require the VA Secretary to collaborate with the veteran's primary care team when evaluating applications for the Program, to the extent practicable.
Background. Under subsection (a)(5) of section 1720G of title 38, U.S.C., when reviewing applications submitted jointly by the veteran and family caregiver,
Committee Bill. Section 301(a)(6) would amend subsection (a)(5) of section 1720G of title 38, U.S.C., to require that the Secretary evaluate each application submitted jointly by an eligible veteran and family member in collaboration with the veteran's primary care team to the maximum extent practicable.
Though the veteran's primary care team maintains the veteran's treatment once in the Program, it is the intent of the Committee to ensure multidisciplinary input in the initial evaluation process, when possible.
Subsec. 301(a)(7). Assistance for family caregivers.
Section 301(a)(7) of the Committee bill, which is derived from S. 591, would authorize
Background. There are numerous public and private entities that provide caregiver services. According to
Committee Bill. Section 301(a)(7) would amend subsection (a) of section 1720G of title 38, U.S.C., to authorize
The Committee recognizes that other entities provide services the Program is required to provide, including respite care, and that
Subsec. 301(b). Modification of definition of personal care services.
Section 301(b) of the Committee bill, which is derived from S. 591, would modify the definition of personal care services.
Background. Subsection (d)(4) of section 1720G of title 38, U.S.C., defines "personal care services" as services that provide the veteran assistance with one or more independent activities of daily living (subsection (d)(4)(A) of section 1720G of title 38, U.S.C.) and any other non-institutional extended care (subsection (d)(4)(B) of section 1720G of title 38, U.S.C.).
Committee Bill. Section 301(b)(1) would strike "independent" in subsection (d)(4)(A) of section 1720G of title 38, U.S.C., and amend subsection (d)(4) to include supervision or protection based on symptoms or residuals of neurological or other impairment or injury and regular or extensive instruction or supervision without which the ability of the veteran to function in daily life would be seriously impaired.
This section is consistent with changes made by sections 301(a)(2) and 301(a)(4) of the Committee bill, which recognize the need for regular or extensive instruction or supervision within the definition of personal care services and ensure the consideration of these personal care needs when determining the caregiver stipend.
Sec. 302. Implementation of information technology system of
Section 302 of the Committee bill, a freestanding provision derived from S. 591, would require
Background. The requirement that
Committee Bill. Section 302 would outline requirements for implementing an IT system. Section 302(a) of the Committee bill would require
Section 302(b) of the Committee bill would require
Section 302(d)(1) of the Committee bill would require
The intent of this requirement is to ensure proper preparation for the expansion. The Committee expects to be kept up to date on the progress of the IT system implementation and deployment and be informed of any changes to the timeline. By including GAO as a recipient of the report, GAO will have the opportunity to review
Sec. 303. Modifications to annual evaluation report on caregiver program of
Section 303 of the Committee bill, which is derived from S. 591, would amend requirements for
Background. P.L. 111-163, the Caregivers and Veterans Omnibus Health Services Act of 2010, requires
Committee Bill. Section 303 would amend subparagraph (A)(iv) of section 101(c)(2) of the Caregivers and Veterans Omnibus Health Services Act of 2010 to require that
TITLE IV--APPROPRIATIONS OF AMOUNTS
Sec. 401. Appropriation of amounts for health care from
Section 401 of the Committee bill, a freestanding original provision, would provide
Background. Section 801 of P.L. 113-146, authorized and appropriated
Committee Bill. Section 401(a) would provide
Section 401(b) would provide that the funds would be available without fiscal year limitation. Section 401(c) would direct that the funds be used to increase the number of graduate medical education residency positions, and allow for recruitment, retention and relocation incentives as authorized under section 221 of the Committee bill. Section 401(d) would direct that the Secretary provide the appropriate committees of
Sec. 402. Appropriation of Amounts for the Veterans Choice Program.
Section 402 of the Committee bill, a freestanding original provision, would provide an additional
Background. Section 101 of P.L. 113-146 authorized veterans to receive care in the community if they would wait more than 30 days for care in a
Committee Bill. Section 402(a) would provide an additional
Committee Bill Cost Estimate
In compliance with paragraph 11(a) of rule XXVI of the Standing Rules of the
The cost estimate provided by CBO, setting forth a detailed breakdown of costs, follows:
Hon.
Chairman,
Dear Mr. Chairman: The
If you wish further details on this estimate, we will be pleased to provide them. The CBO staff contact is
Sincerely,
Director.
Enclosure.
S. 2193--Caring for Our Veterans Act of 2017
Summary: S. 2193 would increase the use of community health care and long-term care by the
In addition, S. 2193 would directly appropriate
Pay-as-you-go procedures apply because enacting S. 2193 would affect direct spending. Enacting the bill would not affect revenues.
CBO estimates that enacting S. 2193 would not increase net direct spending or on-budget deficits by more than
S. 2193 would impose an intergovernmental mandate as defined in the Unfunded Mandates Reform Act (UMRA) by preempting state laws that prohibit
The bill contains no private-sector mandates as defined in UMRA.
Estimated cost to the Federal Government: The estimated budgetary effects of S. 2193 are shown in Table 1. The costs of this legislation fall within budget function 700 (veterans benefits and services).
Table 1.--Estimated Budgetary Effects of S.2193, The Caring for Our Veterans Act of 2017
(TABLE OMITTED)
Basis of estimate: For this estimate, CBO assumes that the bill will be enacted near the beginning of calendar year 2018 and that the estimated amounts will be appropriated each year. Estimated outlays are based on historical spending patterns for the affected programs.
Spending subject to appropriation
CBO estimates that implementing S. 2193 would cost
Veterans Community Care Program. Section 101 would establish the Veterans Community Care Program (VCCP) under which
Table 2.--Estimate of the Effects on Spending Subject to Appropriation of S.2193, The Caring for Our Veterans Act of 2017
(TABLE OMITTED)
Under this program, subject to appropriations,
The veteran resides in
The veteran, as of the day before enactment, lives 40 miles away from a
The
The number of eligible veterans would be several times larger than the number eligible for the current program,
The criteria for offering community care would be broader, and
The convenience of community care could encourage more veterans to enroll in the
However, CBO expects these factors would limit the rate and ultimate extent of cost growth:
A greater number of enrolled veterans receiving community care could shorten wait times for care provided in
Many of the regulations that need to be written to implement the program could curtail use. For instance,
The community care networks could be limited in size and scope, particularly in more rural areas, reducing the accessibility of such care.
To estimate the cost of this program over the next 5 years, CBO focused primarily on the extent to which the number of veterans eligible for
After accounting for the factors that might restrict use, CBO estimates that in the early years of the program, the newly eligible population would use community care at about half the rate of veterans in the current community care program. In addition, CBO expects that the program would be implemented gradually. On that basis, CBO estimates that implementing section 101 would cost
Veterans Care Agreements. Section 102 would allow
Exempt
Require
Require
Under current law,
For 2018, the
Expansion of the Family Caregivers Program. Section 301 would expand access to the Family Caregivers Program, which provides stipends, health insurance, respite care, training, and other forms of support to caregivers of eligible veterans enrolled in the program. Veterans are eligible for the program if they require assistance in activities of daily living, such as bathing, eating, or grooming, as a result of injuries incurred during military service on or after
Under stage one, eligible veterans who were injured during service on or before
In 2016, costs for the Family Caregivers Program totaled
CBO's estimate of the cost of expanding the caregivers program is based on the patterns of use and the average costs of the existing program and the number of veterans with significant, service-connected disabilities in the cohorts that would be newly eligible. Furthermore, to account for the advanced age of the newly eligible veterans, the estimate reflects the following findings from a 2014 RAND study:1
1Rajeev Ramchand and others,
Disabled veterans rely more heavily on assistance for daily activities as they age,
Older veterans tend to rely on older caregivers, and
Health care costs for caregivers increase with age.
For stage one, CBO estimates that about 22,000 additional veterans would participate in the program in 2020, increasing to roughly 46,000 by 2022. CBO expects that the youngest would be in their late 60s. After factoring in a heavier reliance on caregiver assistance for activities of daily living and higher health care costs for an older group of caregivers, CBO estimates that the average cost per participant in 2020 would be about
For stage two, CBO estimates that about 30,000 additional veterans would use the Family Caregivers Program in 2022. Because those veterans would be younger than the group under the initial expansion, they would have less need for caregiver assistance (with a correspondingly lower stipend amount) and the caregivers would be younger (and have lower CHAMPVA costs). After accounting for existing benefits under the General Caregiver Program, the average incremental cost per participant in 2022 would be
In addition, CBO estimates that roughly 30,000 caregivers in the current Family Caregivers Program (for veterans injured during service on or after
Furthermore, in anticipation of the surge of new applications upon expansion of the Family Caregivers Program,
Pay Caps for Nurses. Section 224 would increase the maximum rate of pay for registered nurses at
Section 224 also would increase the maximum rate of pay for nurse executives at
Using information from
Agreements for
According to
As a result, after factoring in a gradual phase out of existing non-FAR agreements, CBO estimates that enacting this provision would cost
Prompt Payment to Providers. Section 111 would establish standards for prompt payment of claims for reimbursement for health care provided to veterans in the community, and it would require
Expedited Processing of Claims. Currently, department standards require
Contracted Claims Processors. Section 111 also would require
Upon entering into contracts for claims processors, CBO expects that
Accept placement in another vacant local position at
Relocate to a position that already exists in another
Voluntarily separate from
CBO estimates that placing one-third (or about 600) of the claims processors in other local positions would present minimal costs for administrative duties to select and train the staff. CBO expects that the other two-thirds (about 1,100 claims processors) would relocate or voluntarily end their employment at
Processing New Claims. In order to handle the additional claims of the
Shared
Implementing this section could reduce
Section 242 also would expand
In total, CBO estimates section 242 would cost
Staffing Vacant Medical Positions. Within 180 days of enactment, section 206 would require
Reimbursement for Education of Nurses. Section 213 would require
Transplant Donors. Section 252 would allow
Continues with Part 5 of 7
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