positions. Also established would be an Assistant Chief Medical Director for Quality Assurance. Finally, the bill would establish an Assistant Inspector General for Health-Care Quality Assurance Review. A staff of not less than two doctors of medicine, not less than one dentist, not less than one registered nurse, plus at least seven additional full-time positions would be required to support this position.

The estimate assumes that between 26 and 33 additional fulltime equivalent staff positions would be required by Title II. The salary levels for these positions are estimated to range from ES-5 to GS-5. It was assumed that the employment ceiling for the VA would be increased to accommodate these positions and that sufficient appropriations would be forthcoming to fully fund their cost.

Title III. This title sets certain restrictions on the relocation of readjustment counseling centers from their current locations to locations within VA medical centers.

It is not expected that the cost of operating readjustment counseling centers would be significantly affected by their relocation to space within VA medical centers. The effect of this title, therefore, is not expected to be significant.

6. ESTIMATED COST TO STATE AND LOCAL GOVERNMENTS:

The Congressional Budget Office has determined that the budgets of state and local governments would not be directly affected by enactment of this bill.

9. ESTIMATE PREPARED BY: K.W. Shepherd (226-2820).

10. ESTIMATE APPROVED BY:

James Blun

James L. Blum

Assistant Director
for Budget Analysis

3

REGULATORY IMPACT STATEMENT

In compliance with paragraph 11(b) of rule XXVI of the Standing Rules of the Senate, the Committee on Veterans' Affairs has made an evaluation of the regulatory impact which would be incurred in carrying out the Committee bill. The results of that evaluation are described below.

The Committee bill would restore certain Veteran's Administration beneficiary travel benefits, upgrade the VA's health-care quality-assurance efforts, expand eligibility for VA readjustment counseling, and place certain limitations and reporting requirements on moving or closing vet centers (through which readjustment counseling is furnished). The Committee finds that the Committee bill would not entail any significant impact on the personal privacy of any individuals and that the paperwork resulting from enactment would be minimal.

SECTION-BY-SECTION ANALYSIS OF S. 1464 AS REPORTED

Section 1

Subsection (a) of section 1 would provide that this Act may be cited as the "Veterans' Administration Beneficiary Travel, Quality Assurance, and Readjustment Counseling Amendments of 1987".

Subsection (b) of section 1 would provide that, except as otherwise expressly provided, whenever in this Act an amendment or a repeal is expressed in terms of an amendment to, or a repeal of, a section or other provision, the reference shall be considered to be made to a section or other provision of title 38, United States Code. This style will likewise be followed in this Analysis.

Section 101

TITLE I-BENEFICIARY TRAVEL PROGRAM

Clause (1) of section 101 would amend present section 111, relating to the authority to pay certain VA beneficiaries for the costs of their travel to and from VA facilities-generally known as "beneficiary travel" payments-to redesignate subsections (b), (c), (d), and (e) as subsections (c), (d), (e), and (f), respectively.

Clause (2) of section 101 would further amend present section 111 to insert a new subsection (b), as follows:

Paragraph (1) of new subsection (b): Would require that-except as provided in new subsection (g) (as proposed to be added by clause (4) of this section of the Committee bill) of section 111 and notwithstanding any other provision of law-if in any fiscal year the Administrator of Veterans' Affairs exercises the authority in section 111 to make any beneficiary travel payments, the Administrator must in that year make the payments provided for in section 111, subject to deductions under paragraph (2) of this new subsection, to or for the following persons traveling for VA health care or examination:

(1) A person receiving benefits under title 38 for or in connection with a service-connected disability.

(2) A veteran receiving pension under section 521 of title 38.

(3) A veteran whose annual income does not exceed the maximum annual rate of pension that would be payable to the veteran if he or she were eligible for pension under section 521.

(4) A veteran who is determined by the Administrator, under regulations prescribed by the Administrator, to be unable to defray the expenses of the travel for which payment is sought.

(5) A veteran whose travel to a VA facility was for a scheduled examination to determine eligibility for compensation or pension. In current section 111, the Administrator is authorized-and not required to pay actual necessary expenses of travel, or an allowance in lieu thereof, for travel in connection with examination, treatment, or care, vocational rehabilitation, or certain counseling. Subject to certain limitations discussed below, the persons described in foregoing items (1) through (5) are provided beneficiary travel payments under current law and VA practice. Although the authority to provide payment to all compensation and pension examinees without regard to their eligibility under one of the other four eligibility criteria is not explicit, the Congressional intent in using the phrase "receiving benefits for or in connection with a service connected disability" to denote those eligible for beneficiary travel without regard to financial resources was that the phrase be construed so as to include, among others, those "being examined in connection with a compensation claim". (S. Rept. No. 94-1206, page 77 (1976), accompanying S. 2908, provisions of which relating to beneficiary travel were enacted in section 101(2) of Public Law 94581.) Under long-standing VA regulations and practice, a claim for pension may be considered a claim for compensation (section 3151 of title 38 of the Code of Federal Regulations) and the examination give veteran claimants for disability benefits is referred to as a 'compensation and pension" examination.

Thus, the Committee bill would establish a requirement to pay beneficiary travel in certain circumstances and would clarify the authority to provide beneficiary travel payments to all veterans traveling for compensation and pension examinations.

Under current regulations (section 17.100 of title 38 of the Code of Federal Regulations as amended effective April 13, 1987 (pages 7575-77 of the Federal Register for March 12, 1987)), except for travel by ambulance in medical emergencies, other travel by a specific mode of transportation, certain interfacility transfers, or travel for a compensation and pension examination, no payments are made for travel within a 100-mile radius of the VA facility involved and, in the cases of travel to or from outside that radius, a deduction of $11 per one/way trip ($22 for a round trip) is made from the amount otherwise payable.

Subparagraph (A) of paragraph (2) of new subsection (b): Would generally require the VA, in making payments under paragraph (1) of this new subsection, to deduct from the amount otherwise payable $3.75 for each trip to or from a VA facility ($7.50 for a round trip). This deductible would not be charged for travel for a compensation and pension examination or, pursuant to subparagraph (C) of this paragraph, for travel required to be by special mode. Also, the total amount deducted in any one month in the cases of certain pre-approved frequent users of VA care would be limited under subparagraph (B) of this paragraph of new subsection (b) and the

amount of the deductible could be periodically adjusted under subparagraph (D) of this paragraph.

The Committee notes its understanding with respect to VA payment for the costs of inter-facility transfers that, although VA regulations authorize beneficiary travel only in certain cases, the VA practice has long been to pay for such transfers from one facility to another using the general health-care authorities in section 610 (relating generally to eligibility for inpatient care) and section 612 (relating to outpatient services), rather than the section 111 limited authority, and using VA medical care account funds other than beneficiary-travel funds. The Committee bill would not affect the VA's authority to provide interfacility-transfer travel either under section 111 or sections 610 and 612.

Subparagraph (B) of paragraph (2) of new subsection (b): Would provide for a cap of $22.50 on the total monthly amount which could be deducted pursuant to subparagraph (A) of this paragraph in certain cases, as follows: In the case of a person who the Administrator determines is required to make six or more one-way trips to or from a VA facility for needed care or services under chapter 17 of title 38, relating to VA health care, during the remainder of the month in which the determination is made or any subsequent calendar month during the one-year period following the month in which the determination is made, no more than $22.50 would be deducted with respect to any travel to or from that facility during any such month. The amount of the cap could be adjusted pursuant to subparagraph (D) of this paragraph of this new subsection (b). Subparagraph (C) of paragraph (2) of new subsection (b): Would provide (1) that no deduction shall be made pursuant to subparagraph (A) of this paragraph in the case of a person whose travel is required to be performed by a special mode where either authorized in advance or performed in connection with a medical emergency of such a nature that the delay incident to obtaining advance authorization would be hazardous to the patient's life or health, and (2) when it is determined to be in the best interest of furnishing care and services, the VA may, prior to determining the patient's beneficiary travel eligibility, pay the provider of specialmode transportation, subject to later charging the patient for the amount of the travel if the patient is subsequently determined to be ineligible for beneficiary travel benefits.

The Committee notes with respect to special-mode travel that the Committee bill is consistent with current VA regulations, under which no deductible is imposed for such travel and with current law and VA regulations limiting eligibility to those covered by the general eligibility criteria (as described in the foregoing discussion of paragraph (1) of new subsection (b)).

With respect to the provision giving the VA express authority to pay ambulance companies and other providers of special-mode transportation before determining the patient's eligibility, the Committee notes that this provision is intended to clarify the agency's authority to do so, which-in cases not covered by the VA's authority, under section 611(b) of title 38, to furnish hospital care and medical services (which include, by virtue of the definitions in section 601(5) and (6), beneficiary travel benefits under section 111) to

ineligible persons in emergencies subject to charging for the care thereafter-may be questionable.

Subparagraph (D) of paragraph (2) of new subsection (b): Would require the Administrator, whenever the Administrator increases or decreases the rates of beneficiary travel allowances or reimbursements paid under section 111, to adjust proportionately, effective on the date on which the increase or decrease takes effect, the deductible amount then in effect under subparagraph (A) of this paragraph and the monthly cap on such deductibles under subparagraph (B). Such alterations of allowances or reimbursements are required to occur in connection with the Administrator's conduct of periodic investigations of VA beneficiary travel costs, which the Administrator must, under subsection (f) (as proposed to be redesignated by clause (1) of this section of the Committee bill) of section 111, conduct immediately after any alteration in the rates of Federal employee travel payments under title 5, United States Codes, and not less often than annually.

Clause (3) of section 101 would amend subsection (f) (as proposed to be redesignated by clause (1) of this section of the Committee bill) of present section 111 to make certain conforming changes in light of new subsection (b) (as proposed to be added by clause (2) of this section of the Committee bill). Thus, this clause would repeal clause (A) of subsection (f), specifying the categories of persons to whom beneficiary travel payments may be made; would redesignate clauses (B) and (C) of subsection (f) as clauses (A) and (B), respectively; and would amend paragraph (4) of subsection (f)—which requires the Administrator, before determining rates under section 111 and no more than 60 days after any alteration in Federal employees' travel rates, to submit to the House and Senate Committees on Veterans' Affairs a report containing the rates that the Administrator proposes to establish or continue-to expand the report to cover the justification for adjusting or leaving unchanged the deductible amount under subparagraph (A) of new subsection_(b)(2) and the monthly deductible cap under subparagraph (B) of new subsection (b)(2).

Clause (4) of section 101 would further amend present section 111 to add two new subsections, as follows:

Paragraph (1) of new subsection (g): Would require that, with respect to any fiscal year as to which the Administrator exercises the authority under section 111 to make beneficiary travel payments for travel performed during that fiscal year, the Administrator must, by the later of two dates, the 15th day after the date on which this authority is so exercised or October 1 of that fiscal year, provide each VA medical facility with an allocation for beneficiary travel payments. That allocation would be required to be sufficient to enable the facility to make payments, during the portion of the year beginning on the first day as to which the authority is exercised and ending on the last day of the fiscal year, to all persons eligible for such payments under new subsection (b) of this section (proposed to be added by clause (2) of this section of the Committee bill).

Subparagraph (A) of paragraph (2) of new subsection (g): Would require that, in any fiscal year in which allocations are made pursuant to paragraph (1) of this new subsection, the head of each VA