S.Amdt. 88

SA 88. Mr. TESTER submitted an amendment intended to be proposed by
him to the bill S. 326, to direct the Secretary of Veterans Affairs to
carry out a study and clinical trials on the effects of cannabis on
certain health outcomes of veterans with chronic pain and post-
traumatic stress disorder, and for other purposes; which was ordered to
lie on the table; as follows:

Strike all after the enacting clause and insert the
following:

[[Page S1393]]

SECTION 1. SHORT TITLE; TABLE OF CONTENTS.

(a) Short Title.--This Act may be cited as the ``Elizabeth
Dole Veterans Programs Improvement Act of 2023''.
(b) Table of Contents.--The table of contents for this Act
is as follows:

Sec. 1. Short title; table of contents.

TITLE I--IMPROVEMENTS TO HOME AND COMMUNITY BASED SERVICES

Sec. 101. Short title.
Sec. 102. Definitions.
Sec. 103. Coordination with Program of All-Inclusive Care for the
Elderly.
Sec. 104. Home and community based services: programs.
Sec. 105. Coordination with assistance and support services for
caregivers.
Sec. 106. Development of centralized website for program information.
Sec. 107. Improvements relating to Home Maker and Home Health Aide
program.
Sec. 108. Reviews and other improvements relating to home and community
based services.

TITLE II--IMPROVEMENTS TO FAMILY CAREGIVER PROGRAM

Sec. 201. Modification of family caregiver program of Department of
Veterans Affairs to include services related to mental
health and neurological disorders.
Sec. 202. Requirements relating to evaluations, assessments, and
reassessments relating to eligibility of veterans and
caregivers for family caregiver program.
Sec. 203. Authority for Secretary of Veterans Affairs to award grants
to entities to improve provision of mental health support
to family caregivers of veterans.
Sec. 204. Comptroller General report on mental health support for
caregivers.

TITLE III--MEDICINAL CANNABIS RESEARCH

Sec. 301. Definitions.
Sec. 302. Department of Veterans Affairs large-scale, mixed methods,
retrospective qualitative study on the effects of
cannabis on certain health outcomes of veterans with
chronic pain and post-traumatic stress disorder.
Sec. 303. Department of Veterans Affairs clinical trials on the effects
of cannabis on certain health outcomes of veterans with
chronic pain and post-traumatic stress disorder.
Sec. 304. Administration of study and clinical trials.

TITLE IV--HOUSING MATTERS

Sec. 401. Improvements to program for direct housing loans made to
Native American veterans by the Secretary of Veterans
Affairs.
Sec. 402. Native community development financial institution relending
program.
Sec. 403. Department of Veterans Affairs housing loan fees.

TITLE V--OTHER MATTERS

Sec. 501. Authority for Secretary of Veterans Affairs to award grants
to States to improve outreach to veterans.
Sec. 502. Oversight of Cost of War Toxic Exposures Fund.

TITLE I--IMPROVEMENTS TO HOME AND COMMUNITY BASED SERVICES

SEC. 101. SHORT TITLE.

This title may be cited as the ``Elizabeth Dole Home Care
Act''.

SEC. 102. DEFINITIONS.

In this title:
(1) Caregiver; family caregiver.--The terms ``caregiver''
and ``family caregiver'' have the meanings given those terms
under section 1720K(g) of title 38, United States Code (as
added by section 104(a)(1)).
(2) Covered program.--The term ``covered program''--
(A) means any program of the Department for home and
community based services; and
(B) includes the programs specified in section 1720K of
title 38, United States Code (as added by section 104(a)(1)).
(3) Department.--The term ``Department'' means the
Department of Veterans Affairs.
(4) Home and community based services.--The term ``home and
community based services''--
(A) means the services referred to in section 1701(6)(E) of
title 38, United States Code; and
(B) includes services furnished under a program specified
in section 1720K of such title (as added by section
104(a)(1)).
(5) Home based primary care program; home maker and home
health aide program; veteran directed care program.--The
terms ``Home Based Primary Care program'', ``Home Maker and
Home Health Aide program'', and ``Veteran Directed Care
program'' mean the programs of the Department specified in
subsections (d), (c), and (b) of such section 1720K,
respectively.
(6) Home health aide; native american veteran, tribal
health program; urban indian organization.--The terms ``home
health aide'', ``Native American veteran'', ``tribal health
program'', and ``Urban Indian organization'' have the
meanings given those terms in subsection (g) of such section
1720K.
(7) Secretary.--The term ``Secretary'' means the Secretary
of Veterans Affairs.
(8) Veterans service organization.--The term ``veterans
service organization'' means any organization recognized by
the Secretary under section 5902 of title 38, United States
Code.

SEC. 103. COORDINATION WITH PROGRAM OF ALL-INCLUSIVE CARE FOR
THE ELDERLY.

Section 1720C of title 38, United States Code, is amended
by adding at the end the following new subsection:
``(f) In furnishing services to a veteran under the program
conducted pursuant to subsection (a), if a medical center of
the Department through which such program is administered is
located in a geographic area in which services are available
to the veteran under a PACE program (as such term is defined
in sections 1894(a)(2) and 1934(a)(2) of the Social Security
Act (42 U.S.C. 1395eee(a)(2); 1396u-4(a)(2))), the Secretary
shall establish a partnership with the PACE program operating
in that area for the furnishing of such services.''.

SEC. 104. HOME AND COMMUNITY BASED SERVICES: PROGRAMS.

(a) Programs.--
(1) In general.--Subchapter II of chapter 17 of title 38,
United States Code, is amended by inserting after section
1720J the following new section:

``Sec. 1720K. Home and community based services: programs

``(a) In General.--In furnishing noninstitutional
alternatives to nursing home care under the authority of
section 1720C of this title (or any other authority under
this chapter or other provision of law administered by the
Secretary of Veterans Affairs), the Secretary shall carry out
each of the programs specified in this section in accordance
with such relevant authorities except as otherwise provided
in this section.
``(b) Veteran Directed Care Program.--(1) The Secretary of
Veterans Affairs, in collaboration with the Secretary of
Health and Human Services, shall carry out a program to be
known as the `Veteran Directed Care program' under which the
Secretary of Veterans Affairs may enter into agreements with
the providers described in paragraph (2) to provide to
eligible veterans funds to obtain such in-home care services
and related items that support clinical need and improve
quality of life as determined appropriate by the Secretary of
Veterans Affairs and selected by the veteran, including
through the veteran hiring individuals to provide such
services and items or directly purchasing such services and
items.
``(2) The providers described in this paragraph are the
following:
``(A) An Aging and Disability Resource Center, an area
agency on aging, or a State agency.
``(B) A center for independent living.
``(C) Any other entity as determined appropriate by the
Secretary of Veterans Affairs, in consultation with the
Secretary of Health and Human Services.
``(3) In carrying out the Veteran Directed Care program,
the Secretary of Veterans Affairs shall--
``(A) administer such program through each medical center
of the Department of Veterans Affairs;
``(B) ensure the availability of such program in American
Samoa, Guam, the Commonwealth of the Northern Mariana
Islands, the Commonwealth of Puerto Rico, the Virgin Islands
of the United States, and any other territory or possession
of the United States; and
``(C) ensure the availability of such program for eligible
veterans who are Native American veterans receiving care and
services furnished by the Indian Health Service, a tribal
health program, an Urban Indian organization, or (in the case
of a Native Hawaiian veteran) a Native Hawaiian health care
system.
``(4) If a veteran participating in the Veteran Directed
Care program is hospitalized, the veteran may continue to use
funds under the program during a period of hospitalization in
the same manner that the veteran would be authorized to use
such funds under the program if the veteran were not
hospitalized, as determined appropriate by the Secretary.
``(c) Home Maker and Home Health Aide Program.--(1) The
Secretary shall carry out a program to be known as the `Home
Maker and Home Health Aide program' under which the Secretary
may enter into agreements with home health agencies to
provide to eligible veterans such home health aide services
as may be determined appropriate by the Secretary.
``(2) In carrying out the Home Maker and Home Health Aide
program, the Secretary shall ensure the availability of such
program--
``(A) in the locations specified in subparagraph (B) of
subsection (b)(3); and
``(B) for the veteran populations specified in subparagraph
(C) of such subsection.

[[Page 2]]

``(d) Home Based Primary Care Program.--The Secretary shall
carry out a program to be known as the `Home Based Primary
Care program' under which the Secretary may furnish to
eligible veterans in-home health care, the provision of which
is overseen by a health care provider of the Department.
``(e) Purchased Skilled Home Care Program.--The Secretary
shall carry out a program to be known as the `Purchased
Skilled Home Care program' under which the Secretary may
furnish to eligible veterans such in-home care services as
may be determined appropriate and selected by the Secretary
for the veteran.

[[Page S1394]]

``(f) Caregiver Support.--(1) With respect to a caregiver
of a veteran participating in a program under this section
who is a family caregiver, the Secretary shall--
``(A) if the veteran meets the requirements of a covered
veteran under section 1720G(b) of this title, provide to such
caregiver the option of enrolling in the program of general
caregiver support services under such section;
``(B) subject to paragraph (2), provide to such caregiver
not fewer than 14 days of covered respite care each year; and
``(C) conduct on an annual basis (and, to the extent
practicable, in connection with in-person services provided
under the program in which the veteran is participating), a
wellness check of such caregiver.
``(2) The Secretary shall provide not fewer than 30 days of
covered respite care each year to any caregiver who provides
services funded under the Veteran Directed Care program under
subsection (b).
``(3) Covered respite care provided to a caregiver of a
veteran under paragraph (1) or (2), as the case may be, may
exceed 14 days annually or 30 days annually, respectively, if
an extension is requested by the caregiver or veteran and
determined medically appropriate by the Secretary.
``(g) Definitions.--In this section:
``(1) The terms `Aging and Disability Resource Center',
`area agency on aging', and `State agency' have the meanings
given those terms in section 102 of the Older Americans Act
of 1965 (42 U.S.C. 3002).
``(2) The terms `caregiver' and `family caregiver', with
respect to a veteran, have the meanings given those terms,
respectively, under subsection (d) of section 1720G of this
title with respect to an eligible veteran under subsection
(a) of such section or a covered veteran under subsection (b)
of such section, as the case may be.
``(3) The term `center for independent living' has the
meaning given that term in section 702 of the Rehabilitation
Act of 1973 (29 U.S.C. 796a).
``(4) The term `covered respite care' means, with respect
to a caregiver of a veteran, respite care that--
``(A) includes 24-hour per day care of the veteran
commensurate with the care provided by the caregiver;
``(B) is medically and age-appropriate; and
``(C) includes in-home care services.
``(5) The term `eligible veteran' means any veteran--
``(A) for whom the Secretary determines participation in a
specific program under this section is medically necessary to
promote, preserve, or restore the health of the veteran; and
``(B) who absent such participation would be at increased
risk for hospitalization, placement in a nursing home, or
emergency room care.
``(6) The term `home health aide' means an individual
employed by a home health agency to provide in-home care
services.
``(7) The term `in-home care service' means any service,
including a personal care service, provided to enable the
recipient of such service to live at home.
``(8) The term `Native American veteran' has the meaning
given that term in section 3765 of this title.
``(9) The terms `Native Hawaiian' and `Native Hawaiian
health care system' have the meanings given those terms in
section 12 of the Native Hawaiian Health Care Improvement Act
(42 U.S.C. 11711).
``(10) The terms `tribal health program' and `Urban Indian
organization' have the meanings given those terms in section
4 of the Indian Health Care Improvement Act (25 U.S.C.
1603).''.
(2) Clerical amendment.--The table of sections at the
beginning of such subchapter is amended by inserting after
the item relating to section 1720J the following new item:

``1720K. Home and community based services: programs.''.
(b) Deadline for Improved Administration.--The Secretary
shall ensure that the Veteran Directed Care program and the
Home Maker and Home Health Aide program are administered
through each medical center of the Department in accordance
with section 1720K of title 38, United States Code (as added
by subsection (a)(1)), by not later than two years after the
date of the enactment of this Act.
(c) Administration of Veteran Directed Care Program.--
(1) Procedures.--The Secretary shall establish procedures
to identify staffing needs for the Program and define the
roles and responsibilities of personnel of the Program at the
national, Veterans Integrated Service Network, and facility
levels, including responsibilities for engagement with
veterans participating in the Program, veterans interested in
the Program, and providers described in section 1720K(b)(2),
as added by subsection (a)(1).
(2) Staffing model.--
(A) In general.--The Secretary shall establish a staffing
model for the administration of the Program at each medical
center of the Department.
(B) Staffing ratio.--The Secretary shall establish a
staffing ratio for administration of the Program at each
facility of the Department at which the Program is carried
out, which shall include a specified number of full-time
equivalent employees, with no collateral duties, per number
of veterans served by the Program.
(3) Funding for program.--
(A) Cost estimates.--The Secretary shall develop methods
for tracking and reporting demand by veterans for and use by
veterans of services under the Program to inform yearly cost
estimates for the Program.
(B) Specific request.--In the budget justification
materials submitted to Congress in support of the budget of
the Department for any fiscal year (as submitted with the
budget of the President under section 1105(a) of title 31,
United States Code), the Secretary shall include a separate
statement of the amount requested for the Program.
(4) Program defined.--In this subsection, the term
``Program'' means the Veteran Directed Care program.

SEC. 105. COORDINATION WITH ASSISTANCE AND SUPPORT SERVICES
FOR CAREGIVERS.

(a) Coordination With Program of Comprehensive Assistance
for Family Caregivers.--
(1) Coordination.--Section 1720G(a) of title 38, United
States Code, is amended by adding at the end the following
new paragraph:
``(14)(A) In the case of a veteran or caregiver who seeks
services under this subsection and is denied such services,
or a veteran or the family caregiver of a veteran who is
discharged from the program under this subsection, the
Secretary shall--
``(i) if the veteran meets the requirements of a covered
veteran under subsection (b), provide to such caregiver the
option of enrolling in the program of general caregiver
support services under such subsection;
``(ii) assess the veteran or caregiver for participation in
any other available program of the Department for home and
community based services (including the programs specified in
section 1720K of this title) for which the veteran or
caregiver may be eligible and, with respect to the veteran,
store (and make accessible to the veteran) the results of
such assessment in the electronic medical record of the
veteran; and
``(iii) provide to the veteran or caregiver written
information on any such program identified pursuant to the
assessment under clause (ii), including information about
facilities, eligibility requirements, and relevant contact
information for each such program.
``(B)(i) Subject to clause (ii), for each veteran or family
caregiver who is discharged from the program under this
subsection, a caregiver support coordinator shall provide for
a smooth and personalized transition from such program to an
appropriate program of the Department for home and community
based services (including the programs specified in section
1720K of this title), including by integrating caregiver
support across programs.
``(ii) To the extent practicable, the Secretary shall not
discharge a veteran or family caregiver from the program
under this subsection until appropriate home and community
based services are selected by the veteran or caregiver and
are being provided to the veteran and caregiver pursuant to
clause (i).''.
(2) Applicability.--The amendment made by paragraph (1)
shall apply with respect to denials and discharges described
in paragraph (14) of such section, as added by paragraph (1),
occurring on or after the date of the enactment of this Act.
(b) Technical and Conforming Amendments.--Section 1720G(d)
of such title is amended--
(1) by striking ``or a covered veteran'' each place it
appears and inserting ``, a veteran denied or discharged as
specified in paragraph (14) of such subsection, or a covered
veteran''; and
(2) by striking ``under subsection (a), means'' each place
it appears and inserting ``under subsection (a) or a veteran
denied or discharged as specified in paragraph (14) of such
subsection, means''.
(c) Review Relating to Caregiver Contact.--The Secretary
shall conduct a review of the capacity of the Department to
establish a streamlined system for contacting all caregivers
enrolled in the program of general caregiver support services
under section 1720G(b) of title 38, United States Code, to
provide to such caregivers program updates and alerts
relating to emerging services for which such caregivers or
the veterans for which they provide care may be eligible.

SEC. 106. DEVELOPMENT OF CENTRALIZED WEBSITE FOR PROGRAM
INFORMATION.

(a) Centralized Website.--The Secretary shall develop and
maintain a centralized and publicly accessible internet
website of the Department as a clearinghouse for information
and resources relating to covered programs.
(b) Contents.--The website under subsection (a) shall
contain the following:
(1) A description of each covered program.
(2) An informational assessment tool that enables users
to--

[[Page 3]]

(A) assess the eligibility of a veteran, or a caregiver of
a veteran, for any covered program; and
(B) receive information, as a result of such assessment, on
any covered program for which the veteran or caregiver (as
the case may be) may be eligible.
(3) A list of required procedures for the directors of
medical facilities of the Department to follow in determining
the eligibility and suitability of veterans for participation
in a covered program, including procedures applicable to
instances in which the resource constraints of a facility (or
of a community in which a facility is located) may result in
the inability to address the health needs of a

[[Page S1395]]

veteran under a covered program in a timely manner.
(c) Updates.--The Secretary shall ensure the website under
subsection (a) is updated on a periodic basis.

SEC. 107. IMPROVEMENTS RELATING TO HOME MAKER AND HOME HEALTH
AIDE PROGRAM.

(a) Pilot Program for Communities With Shortage of Home
Health Aides.--
(1) Program.--Not later than two years after the date of
the enactment of this Act, the Secretary shall carry out a
pilot program under which the Secretary shall provide home
maker and home health aide services to veterans who reside in
communities with a shortage of home health aides.
(2) Locations.--The Secretary shall select 10 geographic
locations in which the Secretary determines there is a
shortage of home health aides at which to carry out the pilot
program under paragraph (1).
(3) Nursing assistants.--
(A) In general.--In carrying out the pilot program under
paragraph (1), the Secretary may hire nursing assistants as
new employees of the Department, or reassign nursing
assistants who are existing employees of the Department, to
provide to veterans in-home care services (including basic
tasks authorized by the State certification of the nursing
assistant) under the pilot program, in lieu of or in addition
to the provision of such services through non-Department home
health aides.
(B) Relationship to existing programs.--Nursing assistants
hired or reassigned under subparagraph (A) may provide
services to a veteran under the pilot program under paragraph
(1) while serving as part of a health care team for the
veteran under the Home Based Primary Care program or any
other program as determined appropriate by the Secretary.
(4) Duration.--The pilot program under paragraph (1) shall
be for a duration of three years.
(5) Report to congress.--Not later than one year prior to
the termination of the pilot program under paragraph (1), the
Secretary shall submit to the Committee on Veterans' Affairs
of the Senate and the Committee on Veterans' Affairs of the
House of Representatives a report on the results of the pilot
program as of the date of the report and the feasibility and
advisability of extending the pilot program or making the
pilot program permanent.
(b) Report on Use of Funds.--Not later than one year after
the date of the enactment of this Act, the Secretary shall
submit to the Committee on Veterans' Affairs of the Senate
and the Committee on Veterans' Affairs of the House of
Representatives a report containing, with respect to the
period beginning in fiscal year 2011 and ending in fiscal
year 2022, the following:
(1) An identification of the amount of funds that were
included in a budget of the Department during such period for
the provision of in-home care to veterans under the Home
Maker and Home Health Aide program in effect during such
period but were not expended for the provision of such care,
disaggregated by medical center of the Department for which
such unexpended funds were budgeted.
(2) An identification of the number of veterans for whom,
during such period, the hours during which a home health aide
was authorized to provide services to the veteran under such
program were reduced, including a detailed description of why
such reduction occurred, such as clinical need or provider
availability.
(c) Updated Guidance on Program.--
(1) In general.--Not later than one year after the date of
the enactment of this Act, the Secretary shall issue updated
guidance for the Home Maker and Home Health Aide program.
(2) Matters to include.--Guidance updated under paragraph
(1) shall include the following:
(A) A process for the transition of veterans from the Home
Maker and Home Health Aide program to other covered programs.
(B) A requirement for the directors of the medical
facilities of the Department to complete such process
whenever a veteran with care needs has been denied services
from home health agencies under the Home Maker and Home
Health Aide program as a result of the clinical needs or
behavioral issues of the veteran.

SEC. 108. REVIEWS AND OTHER IMPROVEMENTS RELATING TO HOME AND
COMMUNITY BASED SERVICES.

(a) Office of Geriatric and Extended Care.--
(1) Review of programs.--The Under Secretary for Health of
the Department shall conduct a review of each program
administered through the Office of Geriatric and Extended
Care of the Department or the Caregiver Support Program
Office of the Department, or any successor office, to--
(A) ensure consistency in program management;
(B) eliminate service gaps at the medical center level;
(C) ensure the clinical needs of veterans are being met;
(D) ensure the availability of, and the access by veterans
to, home and community based services, including for veterans
living in rural areas; and
(E) ensure proper coordination between covered programs.
(2) Assessment of staffing needs.--The Secretary shall
conduct an assessment of the staffing needs of the Office of
Geriatric and Extended Care of the Department and the
Caregiver Support Program Office of the Department, or any
successor office.
(3) Goals for geographic alignment of care.--
(A) Establishment of goals.--The Director of the Office of
Geriatric and Extended Care and the head of the Caregiver
Support Program Office, or the head of any successor office,
shall establish quantitative goals to enable aging or
disabled veterans who are not located near medical centers of
the Department to access extended care services (including by
improving access to home and community based services for
such veterans).
(B) Implementation timeline.--Each goal established under
subparagraph (A) shall include a timeline for the
implementation of the goal at each medical center of the
Department.
(4) Goals for in-home specialty care.--The Director of the
Office of Geriatric and Extended Care and the head of the
Caregiver Support Program Office, or the head of any
successor office, shall establish quantitative goals to
address the specialty care needs of veterans through in-home
care, including by ensuring the education of home health
aides and caregivers of veterans in the following areas:
(A) Dementia care.
(B) Care for spinal cord injuries and diseases.
(C) Ventilator care.
(D) Other specialty care areas as determined by the
Secretary.
(5) Report to congress.--Not later than one year after the
date of the enactment of this Act, the Secretary shall submit
to the Committee on Veterans' Affairs of the Senate and the
Committee on Veterans' Affairs of the House of
Representatives a report containing the findings of the
review under paragraph (1), the results of the assessment
under paragraph (2), and the goals established under
paragraphs (3) and (4).
(b) Review of Incentives and Efforts Relating to Home and
Community Based Services.--
(1) Review.--The Secretary shall conduct a review of the
following:
(A) The financial and organizational incentives and
disincentives for the directors of medical centers of the
Department to establish or expand covered programs at such
medical centers.
(B) Any incentives or disincentives for such directors to
provide to veterans home and community based services in lieu
of institutional care.
(C) The efforts taken by the Secretary to enhance spending
of the Department for extended care by balancing spending
between institutional care and home and community based
services.
(D) The plan of the Under Secretary for Health of the
Department to accelerate efforts to enhance spending as
specified in subparagraph (C), to match the progress of
similar efforts taken by the Administrator of the Centers for
Medicare & Medicaid Services with respect to spending of the
Centers for Medicare & Medicaid Services for extended care.
(2) Report to congress.--Not later than one year after the
date of the enactment of this Act, the Secretary shall submit
to the Committee on Veterans' Affairs of the Senate and the
Committee on Veterans' Affairs of the House of
Representatives a report on the findings of the review under
paragraph (1).
(c) Review of Respite Care Services.--Not later than two
years after the date of the enactment of this Act, the
Secretary shall conduct a review of the use, availability,
cost, and effectiveness of the respite care services
furnished by the Secretary under chapter 17 of title 38,
United States Code, to include--
(1) the frequency in which Department is unable to meet the
need for such services;
(2) a detailed description of why the Department is unable
to meet the need for such services; and
(3) a detailed description of the actions the Department
has taken or plans to take to ensure that the need for such
services is met.
(d) Collaboration To Improve Home and Community Based
Services.--
(1) Feedback and recommendations on caregiver support.--
(A) Feedback and recommendations.--The Secretary shall
solicit from the entities described in subparagraph (B)
feedback and recommendations regarding opportunities for the
Secretary to enhance home and community based services for
veterans and caregivers of veterans, including through the
potential provision by the entity of care and respite
services to veterans and caregivers who may not be eligible
for any program under section 1720G of title 38, United
States Code, or section 1720K of such title (as added by
section 104(a)(1)), but have a need for assistance.

[[Page 4]]

(B) Covered entities.--The entities described in this
subparagraph are veterans service organizations and nonprofit
organizations with a focus on caregiver support or long-term
care (as determined by the Secretary).
(2) Collaboration for native american veterans.--The
Secretary shall collaborate with the Director of the Indian
Health Service and representatives from tribal health
programs and Urban Indian organizations to ensure the
availability of home and community based services for Native
American veterans, including Native American veterans
receiving health care and medical services under multiple
health care systems.

[[Page S1396]]

TITLE II--IMPROVEMENTS TO FAMILY CAREGIVER PROGRAM

SEC. 201. MODIFICATION OF FAMILY CAREGIVER PROGRAM OF
DEPARTMENT OF VETERANS AFFAIRS TO INCLUDE
SERVICES RELATED TO MENTAL HEALTH AND
NEUROLOGICAL DISORDERS.

(a) In General.--Section 1720G of title 38, United States
Code, as amended by section 105, is further amended--
(1) in subsection (a)--
(A) in paragraph (2)(C)(ii), by striking ``neurological''
and inserting ``a neurological disorder'';
(B) in paragraph (3)--
(i) in subparagraph (A)(ii)(II), by inserting ``, including
through public or private entities'' before the semicolon;
and
(ii) in subparagraph (C), by adding at the end the
following new clause:
``(v)(I) For purposes of determining the amount and degree
of personal care services provided under clause (i) with
respect to a veteran described in subclause (II), the
Secretary shall take into account relevant documentation
evidencing the provision of personal care services with
respect to the veteran during the preceding three-year
period.
``(II) A veteran described in this subclause is a veteran
whose need for personal care services as described in
paragraph (2)(C) is based in whole or in part on--
``(aa) a diagnosis of mental illness or history of suicidal
ideation that puts the veteran at risk of self-harm; or
``(bb) a neurological disorder.''; and
(C) by adding at the end the following new paragraph:
``(15) The Secretary shall establish a process and
requirements for clinicians of facilities of the Department--
``(A) to document incidents in which an eligible veteran
participating in the program established under paragraph
(1)--
``(i) presents at such a facility for treatment for an
emergent or urgent mental health crisis; or
``(ii) is assessed by such a clinician to be at risk for
suicide; and
``(B) to provide such documentation, including any safety
plans developed and referrals made to a suicide prevention
coordinator of the Department, to such program.'';
(2) in subsection (b)(2)(B), by striking ``neurological''
and inserting ``a neurological disorder''; and
(3) in subsection (d)--
(A) by redesignating paragraph (4) as paragraph (5);
(B) by inserting after paragraph (3) the following new
paragraph (4):
``(4) the term `neurological disorder' means a disease of
the brain, spinal cord, nerves, or neuromuscular system.'';
and
(C) in paragraph (5)(B), as redesignated by subparagraph
(A), by striking ``neurological'' and inserting ``a
neurological disorder''.
(b) Timing for Establishment of Requirements and
Processes.--
(1) Report.--Not later than one year after the date of the
enactment of this Act, the Secretary of Veterans Affairs
shall--
(A) establish the process and requirements required under
paragraph (15) of section 1720G(a) of title 38, United States
Code, as added by subsection (a)(1)(B); and
(B) submit to the Committee on Veterans' Affairs of the
Senate and the Committee on Veterans' Affairs of the House of
Representatives a description of such process and
requirements.
(2) Certification.--
(A) In general.--Not later than one year after the date of
the enactment of this Act, the Secretary of Veterans Affairs
shall require all clinicians of facilities of the Department
to certify to the Secretary that the clinician understands
the process and requirements established under paragraph
(1)(A).
(B) Facilities of the department defined.--In this
paragraph, the term ``facilities of the Department'' has the
meaning given that term in section 1701 of title 38, United
States Code.

SEC. 202. REQUIREMENTS RELATING TO EVALUATIONS, ASSESSMENTS,
AND REASSESSMENTS RELATING TO ELIGIBILITY OF
VETERANS AND CAREGIVERS FOR FAMILY CAREGIVER
PROGRAM.

(a) In General.--Subsection (a) of section 1720G of title
38, United States Code, as amended by section 201(a)(1), is
further amended by adding at the end the following new
paragraphs:
``(16)(A) For purposes of conducting evaluations and
assessments to determine eligibility of a veteran and
caregiver for the program established under paragraph (1) or
conducting reassessments to determine continued eligibility
for such program, the Secretary shall--
``(i) take into account relevant documentation and medical
records generated by Department and non-Department health
care providers, including qualified mental health
professionals and neurological specialists;
``(ii) if the caregiver of the veteran claims that the
serious injury or need for personal care services of the
veteran as described in paragraph (2) is based in whole or in
part on psychological trauma or another mental disorder,
ensure--
``(I) a qualified mental health professional that treats
the veteran participates in the evaluation process; and
``(II) a qualified mental health professional participates
in the assessment or reassessment process; and
``(iii) if the caregiver of the veteran claims that the
serious injury or need for personal care services of the
veteran as described in paragraph (2) is based in whole or in
part on a neurological disorder, ensure--
``(I) a neurological specialist that treats the veteran
participates in the evaluation process; and
``(II) a neurological specialist participates in the
assessment or reassessment process.
``(B)(i) The Secretary shall establish an appropriate time
limit during a 24-hour period for the active participation of
a veteran in an evaluation, assessment, or reassessment to
determine eligibility of the veteran for the program
established under paragraph (1).
``(ii) In determining an appropriate time limit for a
veteran under clause (i), the Secretary shall--
``(I) take into consideration necessary accommodations for
the veteran stemming from the disability or medical condition
of the veteran; and
``(II) consult with the primary care provider, neurological
specialist, or qualified mental health professional that is
treating the veteran.
``(C) The Secretary shall not require the presence of a
veteran during portions of an evaluation, assessment, or
reassessment to determine eligibility of the veteran for the
program established under paragraph (1) that only require the
active participation of the caregiver.
``(D)(i) The Secretary shall make reasonable efforts to
assist a caregiver and veteran in obtaining evidence
necessary to substantiate the claims of the caregiver and
veteran in the application process for evaluation,
assessment, or reassessment for the program established under
paragraph (1).
``(ii)(I) As part of the assistance provided to a caregiver
or veteran under clause (i), the Secretary shall make
reasonable efforts to obtain relevant private records that
the caregiver or veteran adequately identifies to the
Secretary.
``(II) Whenever the Secretary, after making reasonable
efforts under subclause (I), is unable to obtain all of the
relevant records sought, the Secretary shall notify the
caregiver and veteran that the Secretary is unable to obtain
records with respect to the claim, which shall include--
``(aa) an identification of the records the Secretary is
unable to obtain;
``(bb) a brief explanation of the efforts that the
Secretary made to obtain such records; and
``(cc) an explanation that the Secretary will make a
determination based on the evidence of record and that this
clause does not prohibit the submission of records at a later
date if such submission is otherwise allowed.
``(III) The Secretary shall make not fewer than two
requests to a custodian of a private record in order for an
effort to obtain such record to be treated as reasonable
under subclause (I), unless it is made evident by the first
request that a second request would be futile in obtaining
such record.
``(iii) Under regulations prescribed by the Secretary, the
Secretary--
``(I) shall encourage a caregiver and veteran to submit
relevant private medical records of the veteran to the
Secretary to substantiate the claims of the caregiver and
veteran in the application process for evaluation,
assessment, or reassessment for the program established under
paragraph (1) if such submission does not burden the
caregiver or veteran; and
``(II) may require the caregiver or veteran to authorize
the Secretary to obtain such relevant private medical records
if such authorization is required to comply with Federal,
State, or local law.
``(17)(A) The Secretary, in consultation with a health care
provider, neurological specialist, or qualified mental health
professional that is treating a veteran, shall waive the
reassessment requirement for the veteran for participation in
the program established under paragraph (1) if--
``(i) the serious injury of the veteran under paragraph (2)
is significantly caused by a degenerative or chronic
condition; and
``(ii) such condition is unlikely to improve the dependency
of the veteran for personal care services.
``(B) The Secretary shall require a health care provider,
neurological specialist, or qualified mental health
professional that is treating a veteran to certify at
appropriate intervals determined by the Secretary the
clinical decision of the provider, specialist, or
professional under subparagraph (A).
``(C) The Secretary may rescind a waiver under subparagraph
(A) with respect to a veteran and require a reassessment of
the veteran if a health care provider, neurological
specialist, or qualified mental health professional that is
treating the veteran makes a clinical determination that the
level of dependency of the veteran for personal care services
has diminished since the last certification of the clinical
decision of

[[Page 5]]

the provider, specialist, or professional under subparagraph
(B).''.
(b) Definitions.--Subsection (d) of such section, as
amended by section 201(a)(3), is further amended--
(1) by redesignating paragraph (5) as paragraph (6);
(2) by inserting after paragraph (4) the following new
paragraph (5):
``(5) The term `neurological specialist' means a
neurologist, neuropsychiatrist, physiatrist, geriatrician,
certified brain injury specialist, neurology nurse, neurology

[[Page S1397]]

nurse practitioner, neurology physician assistant, or such
other licensed medical professional as the Secretary
considers appropriate.''; and
(3) by adding at the end the following new paragraph:
``(7) The term `qualified mental health professional' means
a psychiatrist, psychologist, licensed clinical social
worker, psychiatric nurse, licensed professional mental
health counselor, or other licensed mental health
professional as the Secretary considers appropriate.''.

SEC. 203. AUTHORITY FOR SECRETARY OF VETERANS AFFAIRS TO
AWARD GRANTS TO ENTITIES TO IMPROVE PROVISION
OF MENTAL HEALTH SUPPORT TO FAMILY CAREGIVERS
OF VETERANS.

(a) In General.--Subchapter II of chapter 17 of title 38,
United States Code, as amended by section 104(a)(1), is
further amended by adding at the end the following new
section:

``Sec. 1720L. Grants to provide mental health support to
family caregivers of veterans

``(a) Purpose.--It is the purpose of this section to
provide for assistance by the Secretary to entities to carry
out programs that improve the provision of mental health
support to the family caregivers of veterans participating in
the family caregiver program.
``(b) Authority.--The Secretary may award grants to carry
out, coordinate, improve, or otherwise enhance mental health
counseling, treatment, or support to the family caregivers of
veterans participating in the family caregiver program.
``(c) Application.--(1) To be eligible for a grant under
this section, an entity shall submit to the Secretary an
application therefor at such time, in such manner, and
containing such information as the Secretary may require.
``(2) Each application submitted under paragraph (1) shall
include the following:
``(A) A detailed plan for the use of the grant.
``(B) A description of the programs or efforts through
which the entity will meet the outcome measures developed by
the Secretary under subsection (g).
``(C) A description of how the entity will distribute grant
amounts equitably among areas with varying levels of
urbanization.
``(d) Distribution.--The Secretary shall seek to ensure
that grants awarded under this section are equitably
distributed among entities located in States with varying
levels of urbanization.
``(e) Priority.--The Secretary shall prioritize awarding
grants under this section that will serve the following
areas:
``(1) Areas with high rates of veterans enrolled in the
family caregiver program.
``(2) Areas with high rates of--
``(A) suicide among veterans; or
``(B) referrals to the Veterans Crisis Line.
``(f) Required Activities.--Any grant awarded under this
section shall be used--
``(1) to expand existing programs, activities, and
services;
``(2) to establish new or additional programs, activities,
and services; or
``(3) for travel and transportation to facilitate carrying
out paragraph (1) or (2).
``(g) Outcome Measures.--(1) The Secretary shall develop
and provide to each entity that receives a grant under this
section written guidance on the following:
``(A) Outcome measures.
``(B) Policies of the Department.
``(2) In developing outcome measures under paragraph (1),
the Secretary shall consider the following goals:
``(A) Increasing the utilization of mental health services
among family caregivers of veterans participating in the
family caregiver program.
``(B) Reducing barriers to mental health services among
family caregivers of veterans participating in such program.
``(h) Tracking Requirements.--(1) The Secretary shall
establish appropriate tracking requirements with respect to
the entities receiving a grant under this section.
``(2) Not less frequently than annually, the Secretary
shall submit to Congress a report on such tracking
requirements.
``(i) Performance Review.--The Secretary shall--
``(1) review the performance of each entity that receives a
grant under this section; and
``(2) make information regarding such performance publicly
available.
``(j) Remediation Plan.--(1) In the case of an entity that
receives a grant under this section and does not meet the
outcome measures developed by the Secretary under subsection
(g), the Secretary shall require the entity to submit to the
Secretary a remediation plan under which the entity shall
describe how and when it plans to meet such outcome measures.
``(2) The Secretary may not award a subsequent grant under
this section to an entity described in paragraph (1) unless
the Secretary approves the remediation plan submitted by the
entity under such paragraph.
``(k) Funding Request.--In the budget justification
materials submitted to Congress in support of the budget of
the Department for any fiscal year (as submitted with the
budget of the President under section 1105(a) of title 31),
the Secretary shall include a separate statement of the
amount requested to be appropriated for that fiscal year to
carry out this section.
``(l) Authorization of Appropriations.--There is authorized
to be appropriated to the Secretary for each of fiscal years
2023 through 2025 $50,000,000 to carry out this section.
``(m) Definitions.--In this section:
``(1) The terms `caregiver' and `family caregiver' have the
meanings given those terms in section 1720G(d) of this title.
``(2) The term `family caregiver program' means the program
of comprehensive assistance for family caregivers under
section 1720G(a) of this title.
``(3) The term `Veterans Crisis Line' means the toll-free
hotline for veterans established under section 1720F(h) of
this title.''.
(b) Clerical Amendment.--The table of sections at the
beginning of such subchapter, as amended by section
104(a)(2), is further amended by adding at the end the
following new item:

``1720L. Grants to provide mental health support to family caregivers
of veterans.''.

SEC. 204. COMPTROLLER GENERAL REPORT ON MENTAL HEALTH SUPPORT
FOR CAREGIVERS.

(a) Report Required.--Not later than one year after the
date of the enactment of this Act, the Comptroller General of
the United States shall submit to the Committee on Veterans'
Affairs of the Senate and the Committee on Veterans' Affairs
of the House of Representatives a report on the provision of
mental health support to caregivers of veterans.
(b) Contents.--The report submitted under subsection (a)
shall include the following:
(1) An assessment of the need for mental health support
among caregivers participating in the caregiver programs.
(2) An assessment of options for mental health support in
facilities of the Department of Veterans Affairs and in the
community for caregivers participating in the caregiver
programs.
(3) An assessment of the availability and accessibility of
mental health support in facilities of the Department and in
the community for caregivers participating in the caregiver
programs.
(4) An assessment of the awareness among caregivers of the
availability of mental health support in facilities of the
Department and in the community for caregivers participating
in the caregiver programs.
(5) An assessment of barriers to mental health support in
facilities of the Department and in the community for
caregivers participating in the caregiver programs.
(c) Definitions.--In this section:
(1) Caregiver.--The term ``caregiver'' has the meaning
given that term in section 1720G(d) of title 38, United
States Code.
(2) Caregiver programs.--The term ``caregiver programs''
means--
(A) the program of comprehensive assistance for family
caregivers under subsection (a) of section 1720G of title 38,
United States Code; and
(B) the program of support services for caregivers under
subsection (b) of such section.

TITLE III--MEDICINAL CANNABIS RESEARCH

SEC. 301. DEFINITIONS.

In this title:
(1) Covered veteran.--The term ``covered veteran'' means a
veteran who is enrolled in the patient enrollment system of
the Department of Veterans Affairs established and operated
under section 1705(a) of title 38, United States Code.
(2) Secretary.-- The term ``Secretary'' means the Secretary
of Veterans Affairs.

SEC. 302. DEPARTMENT OF VETERANS AFFAIRS LARGE-SCALE, MIXED
METHODS, RETROSPECTIVE QUALITATIVE STUDY ON THE
EFFECTS OF CANNABIS ON CERTAIN HEALTH OUTCOMES
OF VETERANS WITH CHRONIC PAIN AND POST-
TRAUMATIC STRESS DISORDER.

(a) Study Required.--
(1) In general.--The Secretary, through the Office of
Research and Development of the Department of Veterans
Affairs, shall carry out a large-scale, mixed methods,
retrospective, and qualitative study on the effects of
cannabis on the health outcomes of covered veterans diagnosed
with chronic pain and covered veterans diagnosed with post-
traumatic stress disorder.
(2) Observational study.--The study required by paragraph
(1) shall be conducted as an observational study on the
effects of cannabis use on the health of covered veterans.
(3) Elements.--
(A) In general.--The study required by paragraph (1)
shall--
(i) triangulate a range of data sources;
(ii) compare the positive and negative health outcomes of
covered veterans who use cannabis, utilizing outcomes that
can be measured in an electronic health record of the
Department and through data sets of the Department relating
to claims for benefits under the laws administered by the
Secretary;
(iii) elicit the positive and negative outcomes of cannabis
use for covered veterans through semi-structured interviews;

[[Page 6]]

(iv) estimate current and future health system needs to
address positive and negative outcomes of cannabis use for
covered veterans;
(v) include a qualitative, open-ended survey provided to
covered veterans who have sought care from the Department for
chronic pain or post-traumatic stress disorder during the
five-year period preceding the survey; and
(vi) include an assessment of--

(I) all records within the Veterans Health Administration
for covered veterans participating in the study; and

[[Page S1398]]

(II) all records within the Veterans Benefits
Administration for covered veterans participating in the
study.

(B) Health outcomes.--A comparison of health outcomes under
subparagraph (A)(ii) shall include an assessment of the
following:
(i) The reduction or increase in opiate use or dosage.
(ii) The reduction or increase in benzodiazepine use or
dosage.
(iii) The reduction or change in use of other types of
medication.
(iv) The reduction or increase in alcohol use.
(v) The reduction or increase in the prevalence of
substance abuse disorders.
(vi) Sleep quality.
(vii) Osteopathic pain (including pain intensity and pain-
related outcomes).
(viii) Agitation.
(ix) Quality of life.
(x) Mortality and morbidity.
(xi) Hospital readmissions.
(xii) Any newly developed or exacerbated health conditions,
including mental health conditions.
(b) Implementation.--Not later than 180 days after the date
of the enactment of this Act, the Secretary shall commence
the implementation of the study required by subsection
(a)(1).
(c) Duration of Study.--The study required by subsection
(a)(1) shall be carried out for an 18-month period.
(d) Report.--
(1) In general.--Not later than 90 days after the
completion of the study required by subsection (a)(1), the
Secretary shall submit to the Committee on Veterans' Affairs
of the Senate and the Committee on Veterans' Affairs of the
House of Representatives a report on the study.
(2) Ability to conduct clinical trials.--The Secretary
shall include in the report required by paragraph (1) an
assessment of whether the Secretary is able to meet the
criteria necessary to conduct the clinical trials required
under section 303, including consideration of subsection
(e)(1) of such section.

SEC. 303. DEPARTMENT OF VETERANS AFFAIRS CLINICAL TRIALS ON
THE EFFECTS OF CANNABIS ON CERTAIN HEALTH
OUTCOMES OF VETERANS WITH CHRONIC PAIN AND
POST-TRAUMATIC STRESS DISORDER.

(a) Clinical Trials Required.--
(1) In general.--If the Secretary indicates in the report
required by section 302(d) that the Secretary is able to meet
the criteria necessary to proceed to clinical trials,
commencing not later than 180 days after the submittal of
that report, the Secretary shall carry out a series of
clinical trials on the effects of cannabis appropriate for
investigational use, as determined by the Food and Drug
Administration under section 505(i) of the Federal Food,
Drug, and Cosmetic Act (21 U.S.C. 355(i)), on the health
outcomes of covered veterans diagnosed with chronic pain and
covered veterans diagnosed with post-traumatic stress
disorder.
(2) Considerations.--The clinical trials required by
paragraph (1) shall include, as appropriate, an evaluation of
key symptoms, clinical outcomes, and conditions associated
with chronic pain and post-traumatic stress disorder, which
may include--
(A) with respect to covered veterans diagnosed with chronic
pain, an evaluation of the effects of the use of cannabis
on--
(i) osteopathic pain (including pain intensity and pain-
related outcomes);
(ii) the reduction or increase in opioid use or dosage;
(iii) the reduction or increase in benzodiazepine use or
dosage;
(iv) the reduction or increase in alcohol use;
(v) the reduction or increase in the prevalence of
substance use disorders;
(vi) inflammation;
(vii) sleep quality;
(viii) agitation;
(ix) quality of life;
(x) exacerbated or new mental health conditions; and
(xi) suicidal ideation.
(B) with respect to covered veterans diagnosed with post-
traumatic stress disorder, an evaluation of the effects of
the use of cannabis on--
(i) the symptoms of post-traumatic stress disorder (PTSD)
as established by or derived from the clinician administered
PTSD scale, the PTSD checklist, the PTSD symptom scale, the
post-traumatic diagnostic scale, and other applicable methods
of evaluating symptoms of post-traumatic stress disorder;
(ii) the reduction or increase in benzodiazepine use or
dosage;
(iii) the reduction or increase in alcohol use;
(iv) the reduction or increase in the prevalence of
substance use disorders;
(v) mood;
(vi) anxiety;
(vii) social functioning;
(viii) agitation;
(ix) suicidal ideation; and
(x) sleep quality, including frequency of nightmares and
night terrors.
(3) Optional elements.--The clinical trials required by
paragraph (1) may include, as appropriate, an evaluation of
the effects of the use of cannabis to treat chronic pain and
post-traumatic stress disorder on other symptoms, clinical
outcomes, and conditions not covered by paragraph (2), which
may include--
(A) pulmonary function;
(B) cardiovascular events;
(C) head, neck, and oral cancer;
(D) testicular cancer;
(E) ovarian cancer;
(F) transitional cell cancer;
(G) intestinal inflammation;
(H) motor vehicle accidents; or
(I) spasticity.
(b) Long-term Observational Study.--The Secretary may carry
out a long-term observational study of the participants in
the clinical trials required by subsection (a).
(c) Type of Cannabis.--
(1) In general.--In carrying out the clinical trials
required by subsection (a), the Secretary shall study varying
forms of cannabis, including whole plant raw material and
extracts, and may study varying routes of administration.
(2) Plant cultivars.--Of the varying forms of cannabis
required under paragraph (1), the Secretary shall study plant
cultivars with varying ratios of tetrahydrocannabinol to
cannabidiol.
(d) Implementation.--Not later than 18 months after the
date of the enactment of this Act, the Secretary shall--
(1) develop a plan to implement this section and submit
such plan to the Committee on Veterans' Affairs of the Senate
and the Committee on Veterans' Affairs of the House of
Representatives; and
(2) issue any requests for proposals the Secretary
determines appropriate for such implementation.
(e) Termination of Clinical Trials.--
(1) Clinical guideline requirements or excessive risk.--The
Secretary may terminate the clinical trials required by
subsection (a) if the Secretary determines that the
Department of Veterans Affairs is unable to meet clinical
guideline requirements necessary to conduct such trials or
the clinical trials would create excessive risk to
participants.
(2) Completion upon submittal of final report.--The
Secretary may terminate the clinical trials required by
subsection (a) upon submittal of the final report required
under subsection (f)(2).
(f) Reports.--
(1) Periodic reports.--During the five-year period
beginning on the date of the commencement of clinical trials
required by subsection (a), the Secretary shall submit
periodically, but not less frequently than annually, to the
Committee on Veterans' Affairs of the Senate and the
Committee on Veterans' Affairs of the House of
Representatives reports on the implementation of this
section.
(2) Final report.--Not later than one year after the
completion of the five-year period specified in paragraph
(1), the Secretary shall submit to the Committee on Veterans'
Affairs of the Senate and the Committee on Veterans' Affairs
of the House of Representatives a final report on the
implementation of this section.

SEC. 304. ADMINISTRATION OF STUDY AND CLINICAL TRIALS.

(a) Demographic Representation.--In carrying out the study
required by section 302 and the clinical trials required by
section 303, the Secretary shall ensure representation in
such study and trials of demographics that represent the
population of veterans in the United States, as determined by
the most recently available data from the American Community
Survey of the Bureau of the Census.
(b) Data Preservation.--The Secretary shall ensure that the
study required by section 302 and the clinical trials
required by section 303 include a mechanism to ensure--
(1) the preservation of all data, including all data sets
and survey results, collected or used for purposes of such
study and trials in a manner that will facilitate further
research; and
(2) registration of such data in the database of privately
and publicly funded clinical studies maintained by the
National Library of Medicine (or successor database).
(c) Anonymous Data.--The Secretary shall ensure that data
relating to any study or clinical trial conducted under this
Act is anonymized and cannot be traced back to an individual
patient.
(d) Effect on Other Benefits.--The eligibility or
entitlement of a covered veteran to any other benefit under
the laws administered by the Secretary or any other provision
of law shall not be affected by the participation of the
covered veteran in the study under section 302, a clinical
trial under section 303(a), or a study under section 303(b).
(e) Effect on Other Laws.--Nothing in this Act shall affect
or modify--
(1) the Federal Food, Drug, and Cosmetic Act (21 U.S.C. 301
et seq.);
(2) section 351 of the Public Health Service Act (42 U.S.C.
262); or
(3) the authority of the Commissioner of Food and Drugs and
the Secretary of Health and Human Services--
(A) under--

[[Page 7]]

(i) the Federal Food, Drug, and Cosmetic Act (21 U.S.C. 301
et seq.); or
(ii) section 351 of the Public Health Service Act (42
U.S.C. 262); or
(B) to promulgate Federal regulations and guidelines
pertaining to cannabidiol, marijuana, or other subject matter
addressed in this title.

TITLE IV--HOUSING MATTERS

SEC. 401. IMPROVEMENTS TO PROGRAM FOR DIRECT HOUSING LOANS
MADE TO NATIVE AMERICAN VETERANS BY THE
SECRETARY OF VETERANS AFFAIRS.

(a) General Authorities and Requirements.--

[[Page S1399]]

(1) Direct housing loans to native american veterans.--
Section 3762(a) of title 38, United States Code, is amended
to read as follows:
``(a) The Secretary may make a direct housing loan to a
Native American veteran under this subchapter if the
Secretary ensures the following:
``(1) That each Native American veteran to whom the
Secretary makes a direct housing loan under this subchapter--
``(A) holds, possesses, or purchases using the proceeds of
the loan a meaningful interest in a lot or dwelling (or both)
that is located on trust land; and
``(B) will purchase, construct, or improve (as the case may
be) a dwelling on the lot using the proceeds of the loan.
``(2) That each such Native American veteran will convey to
the Secretary by an appropriate instrument the interest
referred to in paragraph (1)(A) as security for a direct
housing loan under this subchapter.
``(3) That the Secretary, including the Secretary's
employees or agents, may enter upon the trust land for the
purposes of carrying out such actions as the Secretary
determines are necessary, including--
``(A) to evaluate the advisability of the loan;
``(B) to monitor any purchase, construction, or
improvements carried out using the proceeds of the loan; and
``(C) to manage any servicing or post-foreclosure
activities, including acquisition, property inspections, and
property management.
``(4) That there are established standards and procedures
that apply to the foreclosure of the interest conveyed by a
Native American veteran pursuant to paragraph (2),
including--
``(A) procedures for foreclosing the interest; and
``(B) procedures for the resale of the lot or dwelling (or
both) purchased, constructed, or improved using the proceeds
of the loan.
``(5) That the loan is made in a responsible and prudent
manner, subject to standards and procedures as are necessary
for the reasonable protection of the financial interests of
the United States.''.
(2) Memorandums of understanding, agreements, and
determinations.--Section 3762(b) of such title is amended to
read as follows:
``(b)(1) To carry out the purpose of subsection (a), the
Secretary may--
``(A) enter into a memorandum of understanding with a
tribal organization, other entity, or individual;
``(B) rely on agreements or determinations of other Federal
agencies to guarantee, insure, or make loans on trust land;
and
``(C) enter into other agreements or take such other
actions as the Secretary determines necessary.
``(2) If the Secretary determines that the requirements
under subsection (a) are not being enforced by a tribal
organization, other entity, or individual that is a party to
any memorandum of understanding, agreement, or determination
described in paragraph (1), the Secretary may cease making
new direct housing loans to Native Americans veterans under
this subchapter within the area of the authority of the
tribal organization, other entity, or individual (as the case
may be).''.
(b) Direct Loans to Native American Veterans to Refinance
Existing Mortgage Loans.--Section 3762(h) of such title is
amended to read as follows:
``(h) The Secretary may make direct loans to Native
American veterans in order to enable such veterans to
refinance existing mortgage loans for any of the following
purposes:
``(1) To refinance an existing loan made under this
section, if the loan--
``(A) meets the requirements set forth in subparagraphs
(B), (C), and (E) of paragraph (1) of section 3710(e) of this
title;
``(B) will bear an interest rate at least one percentage
point less than the interest rate borne by the loan being
refinanced; and
``(C) complies with paragraphs (2) and (3) of section
3710(e) of this title, except that for the purposes of this
subsection the reference to subsection (a)(8) of section 3710
of this title in such paragraphs (2) and (3) shall be deemed
to be a reference to this subsection.
``(2) To refinance an existing mortgage loan not made under
this section on a dwelling owned and occupied by the veteran
as the veteran's home, if all of the following requirements
are met:
``(A) The loan will be secured by the same dwelling as was
the loan being refinanced.
``(B) The loan will provide the veteran with a net tangible
benefit.
``(C) The nature and condition of the property is such as
to be suitable for dwelling purposes.
``(D) The amount of the loan does not exceed either of the
following:
``(i) 100 percent of the reasonable value of the dwelling,
with such reasonable value determined under the procedures
established by the Secretary under subsection (d)(2).
``(ii) An amount equal to the sum of the balance of the
loan being refinanced and such closing costs (including any
discount points) as may be authorized by the Secretary to be
included in the loan.
``(E) Notwithstanding subparagraph (D), if a loan is made
for both the purpose of this paragraph and to make energy
efficiency improvements, the loan must not exceed either of
the following:
``(i) 100 percent of the reasonable value of the dwelling
as improved for energy efficiency, with such reasonable value
determined under the procedures established by the Secretary
under subsection (d)(2).
``(ii) The amount referred to under subparagraph (D)(ii),
plus the applicable amount specified under section 3710(d)(2)
of this title.
``(F) The loan meets all other requirements the Secretary
may establish under this subchapter.
``(G) The existing mortgage being refinanced is a first
lien on the property and secured of record.
``(3) To refinance an existing mortgage loan to repair,
alter, or improve a dwelling owned by the veteran and
occupied by the veteran as the veteran's home, if all of the
following requirements are met:
``(A) The loan will be secured by the same dwelling as was
the loan being refinanced.
``(B) The nature and condition of the property is such as
to be suitable for dwelling purposes, and the repair,
alteration, or improvement substantially protects or improves
the basic livability or utility of such property.
``(C) The amount of the loan, including the costs of
repairs, alterations, and improvements, does not exceed
either of the following:
``(i) 100 percent of the reasonable value of the dwelling
as repaired, altered, or improved, with such reasonable value
determined under the procedures established by the Secretary
under subsection (d)(2).
``(ii) An amount equal to the sum of--

``(I) the balance of the loan being refinanced;
``(II) the actual cost of repairs, alterations, or
improvements; and
``(III) such closing costs (including any discount points)
as may be authorized by the Secretary to be included in the
loan.

``(D) The loan meets all other requirements the Secretary
may establish under this subchapter.
``(E) The existing mortgage loan being refinanced is a
first lien on the property and secured of record.''.
(c) Expansion of Outreach Program on Availability of Direct
Housing Loans for Native American Veterans.--Section
3762(i)(2) of such title is amended by adding at the end the
following new subparagraph:
``(G) Pursuant to subsection (g)(4), assisting Native
American veterans in qualifying for mortgage financing by--
``(i) partnering with local service providers, such as
tribal organizations, tribally designated housing entities,
Native community development financial institutions, and
nonprofit organizations, for conducting outreach, homebuyer
education, housing counseling, and post-purchase education;
and
``(ii) providing other technical assistance as needed.
``(H) Attending conferences and conventions conducted by
the network of Native community development financial
institutions and other Native American homeownership
organizations to provide information and training to Native
community development financial institutions about the
availability of the relending program under section 3762A of
this title.''.
(d) Adequate Personnel.--Section 3762 of such title is
amended by adding at the end the following new subsection:
``(k) The Secretary shall assign a sufficient number of
personnel of the Department dedicated to carrying out the
authority of the Secretary under this subchapter, including
construction and valuation specialists to assist with issues
unique to new construction and renovations on trust land.''.
(e) Definitions.--Section 3765 of such title is amended--
(1) in paragraph (1)--
(A) by amending subparagraph (C) to read as follows:
``(C) is located in the State of Alaska within a region
established under section 7(a) of the Alaska Native Claims
Settlement Act (43 U.S.C. 1606(a));'';
(B) in subparagraph (D), by striking the period at the end
and inserting a semicolon; and
(C) by adding at the end the following new subparagraphs:
``(E) is defined by the Secretary of the Interior and
recognized by the United States as land over which an Indian
Tribe has governmental dominion; or
``(F) is on any land that the Secretary determines is
provided to Native American veterans because of their status
as Native Americans.''; and
(2) by adding at the end the following new paragraphs:
``(6) The term `community development financial
institution' has the meaning given that term in section 103
of the Community Development Banking and Financial
Institutions Act of 1994 (12 U.S.C. 4702).
``(7) The term `Indian Tribe' means any Indian tribe, band,
nation, or other organized

[[Page 8]]

group or community, including any Alaska Native village or
regional or village corporation as defined in or established
pursuant to the Alaska Native Claims Settlement Act (43
U.S.C. 1601 et seq.), which is recognized as eligible for the
special programs and services provided by the United States
to Indians because of their status as Indians.
``(8) The term `Native community development financial
institution' means any entity--
``(A) that has been certified as a community development
financial institution by the Secretary of the Treasury;

[[Page S1400]]

``(B) that is not less than 51 percent owned or controlled
by Native Americans; and
``(C) for which not less than 51 percent of the activities
of the entity serve Native Americans.
``(9) The term `net tangible benefit' shall have such
meaning as the Secretary determines appropriate, but shall
include the refinance of an interim construction loan.
``(10) The term `other technical assistance' means services
to assist a Native American veteran to navigate the steps
necessary for securing a mortgage loan on trust land,
including pre-development activities related to utilities,
identifying appropriate residential construction services,
and obtaining lease clearances and title status reports from
the applicable tribal organization or the Bureau of Indian
Affairs.
``(11) The term `tribally designated housing entity' has
the meaning given that term in section 4 of the Native
American Housing Assistance and Self-Determination Act of
1996 (25 U.S.C. 4103).''.
(f) Interest Rate Reduction Financing Loan.--Section
3729(b)(4)(F) of such title is amended by striking
``3762(h)'' and inserting ``3762(h)(1)''.
(g) Regulations.--Section 3761 of such title is amended by
adding at the end the following new subsection:
``(c) The Secretary shall prescribe such regulations as may
be necessary to carry out this subchapter.''.

SEC. 402. NATIVE COMMUNITY DEVELOPMENT FINANCIAL INSTITUTION
RELENDING PROGRAM.

(a) In General.--Subchapter V of chapter 37 of title 38,
United States Code, is amended by inserting after section
3762 the following new section:

``Sec. 3762A. Native community development financial
institution relending program

``(a) Purpose.--The Secretary may make a loan to a Native
community development financial institution for the purpose
of allowing the institution to relend loan amounts to
qualified Native American veterans, subject to the
requirements of this section.
``(b) Standards.--
``(1) In general.--The Secretary shall establish standards
to be used in evaluating whether to make a loan to a Native
community development financial institution under this
section.
``(2) Requirements.--In establishing standards under
paragraph (1), the Secretary shall ensure that a Native
community development financial institution--
``(A) is able to originate and service loans for single-
family homes;
``(B) is able to operate the relending program in a manner
consistent with the mission of the Department to serve
veterans; and
``(C) uses loan amounts received under this section only
for the purpose of relending, as described in subsection (c),
to Native American veterans.
``(c) Relending Requirements.--
``(1) In general.--A Native community development financial
institution that receives a loan under this section shall use
the loan amounts to make loans to Native American veterans
residing on trust land.
``(2) Requirements.--A loan to a Native American veteran
made by a Native community development financial institution
under paragraph (1) shall--
``(A) be limited either to the purpose of purchase,
construction, or improvement of a dwelling located on trust
land or to the refinance of an existing mortgage loan for a
dwelling on trust land, consistent with the requirements of
section 3762(h) of this title; and
``(B) comply with such terms and conditions as the
Secretary determines are necessary to protect against
predatory lending, including the interest rate charged on a
loan to a Native American veteran.
``(d) Repayment.--A loan made to a Native community
development financial institution under this section shall--
``(1) be payable to the Secretary upon such terms and
conditions as are prescribed in regulations pursuant to this
subchapter; and
``(2) bear interest at a rate of one percent.
``(e) Oversight.--Subject to notice and opportunity for a
hearing, whenever the Secretary finds with respect to loans
made under subsections (a) or (c) that any Native community
development financial institution has failed to maintain
adequate loan accounting records, to demonstrate proper
ability to service loans adequately, or to exercise proper
credit judgment, or that such Native community development
financial institution has willfully or negligently engaged in
practices otherwise detrimental to the interest of veterans
or of the Government, the Secretary may take such actions as
the Secretary determines necessary to protect veterans or the
Government, such as requiring immediate repayment of any
loans made under subsection (a) and the assignment to the
Secretary of loans made under subsection (c).''.
(b) Clerical Amendment.--The table of sections at the
beginning of chapter 37 of such title is amended by inserting
after the item relating to section 3762 the following new
item:

``3762A. Native community development financial institution relending
program.''.
(c) Native American Veteran Housing Loan Program Account.--
Section 3763 of such title is amended by adding at the end
the following new subsection:
``(c) Of amounts available in the Account, the Secretary
may use for loans made under section 3762A of this title--
``(1) in fiscal year 2024, not more than $5,000,000; and
``(2) in any fiscal year after fiscal year 2024, an amount
as determined necessary by the Secretary to meet the demand
for such loans.''.

SEC. 403. DEPARTMENT OF VETERANS AFFAIRS HOUSING LOAN FEES.

The loan fee table in section 3729(b)(2) of title 38,
United States Code, as most recently amended by section 204
of the Joseph Maxwell Cleland and Robert Joseph Dole Memorial
Veterans Benefits and Health Care Improvement Act of 2022
(division U of Public Law 117-328), is further amended by
striking ``November 14, 2031'' each place it appears and
inserting ``March 14, 2032''.

TITLE V--OTHER MATTERS

SEC. 501. AUTHORITY FOR SECRETARY OF VETERANS AFFAIRS TO
AWARD GRANTS TO STATES TO IMPROVE OUTREACH TO
VETERANS.

(a) In General.--Chapter 63 of title 38, United States
Code, is amended--
(1) by redesignating sections 6307 and 6308 and sections
6308 and 6309, respectively; and
(2) by inserting after section 6306 the following new
section 6307:

``Sec. 6307. Grants to States to improve outreach to veterans

``(a) Purpose.--It is the purpose of this section to
provide for assistance by the Secretary to States to carry
out programs that improve outreach and assistance to veterans
and the spouses, children, and parents of veterans, to ensure
that such individuals are fully informed about, and assisted
in applying for, any veterans and veterans-related benefits
and programs (including State veterans programs) for which
they may be eligible.
``(b) Authority.--The Secretary may award grants to
States--
``(1) to carry out, coordinate, improve, or otherwise
enhance--
``(A) outreach activities; or
``(B) activities to assist in the development and submittal
of claims for veterans and veterans-related benefits; or
``(2) to increase the number of county or tribal veterans
service officers serving in the State by hiring new,
additional such officers.
``(c) Application.--(1) To be eligible for a grant under
this section, a State shall submit to the Secretary an
application therefor at such time, in such manner, and
containing such information as the Secretary may require.
``(2) Each application submitted under paragraph (1) shall
include the following:
``(A) A detailed plan for the use of the grant.
``(B) A description of the programs through which the State
will meet the outcome measures developed by the Secretary
under subsection (i).
``(C) A description of how the State will distribute grant
amounts equitably among counties with varying levels of
urbanization.
``(D) A plan for how the grant will be used to meet the
unique needs of American Indian veterans, Alaska Native
veterans, or Native Hawaiian veterans, elderly veterans, and
veterans from other underserved communities.
``(d) Distribution.--The Secretary shall seek to ensure
that grants awarded under this section are equitably
distributed among States with varying levels of urbanization.
``(e) Priority.--The Secretary shall prioritize awarding
grants under this section that will serve the following
areas:
``(1) Areas with a critical shortage of county or tribal
veterans service officers.
``(2) Areas with high rates of--
``(A) suicide among veterans; or
``(B) referrals to the Veterans Crisis Line.
``(f) Use of County or Tribal Veterans Service Officers.--A
State that receives a grant under this section to carry out
an activity described in subsection (b)(1) shall carry out
the activity through--
``(1) a county or tribal veterans service officer of the
State; or
``(2) if the State does not have a county or tribal
veterans service officer, or if the county or tribal veterans
service officers of the State cover only a portion of that
State, an appropriate entity of a State, local, or tribal
government, or another publicly funded entity, as determined
by the Secretary.
``(g) Required Activities.--Any grant awarded under this
section shall be used--
``(1) to expand existing programs, activities, and
services;
``(2) to hire new, additional county or tribal veterans
service officers; or
``(3) for travel and transportation to facilitate carrying
out paragraph (1) or (2).
``(h) Authorized Activities.--A grant under this section
may be used to provide education and training, including on-
the-job training, for State, county, local, and tribal
government employees who provide (or when trained will
provide) veterans outreach services in order for those
employees to obtain

[[Page 9]]

accreditation in accordance with procedures approved by the
Secretary.
``(i) Outcome Measures.--(1) The Secretary shall develop
and provide to each State that receives a grant under this
section written guidance on the following:
``(A) Outcome measures.
``(B) Policies of the Department.
``(2) In developing outcome measures under paragraph (1),
the Secretary shall consider the following goals:
``(A) Increasing the use of veterans and veterans-related
benefits, particularly among vulnerable populations.
``(B) Increasing the number of county and tribal veterans
service officers recognized by

[[Page S1401]]

the Secretary for the representation of veterans under
chapter 59 of this title.
``(j) Tracking Requirements.--(1) With respect to each
grant awarded under this section, the Secretary shall track
the use of veterans and veterans-related benefits among the
population served by the grant, including the average period
of time between the date on which a veteran applies for such
a benefit and the date on which the veteran receives the
benefit, disaggregated by type of benefit.
``(2) Not less frequently than annually, the Secretary
shall submit to Congress a report on the information tracked
under paragraph (1).
``(k) Performance Review.--(1) The Secretary shall--
``(A) review the performance of each State that receives a
grant under this section; and
``(B) make information regarding such performance publicly
available.
``(l) Remediation Plan.--(1) In the case of a State that
receives a grant under this section and does not meet the
outcome measures developed by the Secretary under subsection
(i), the Secretary shall require the State to submit a
remediation plan under which the State shall describe how and
when it plans to meet such outcome measures.
``(2) The Secretary may not award a subsequent grant under
this section to a State described in paragraph (1) unless the
Secretary approves the remediation plan submitted by the
State.
``(m) Definitions.--In this section:
``(1) The term `county or tribal veterans service officer'
includes a local equivalent veterans service officer.
``(2) The term `Veterans Crisis Line' means the toll-free
hotline for veterans established under section 1720F(h) of
this title.
``(n) Funding Request.--In the budget justification
materials submitted to Congress in support of the Department
budget for any fiscal year (as submitted with the budget of
the President under section 1105(a) of title 31), the
Secretary shall include a separate statement of the amount
requested to be appropriated for that fiscal year to carry
out this section.
``(o) Authorization of Appropriations.--There is authorized
to be appropriated to the Secretary for each of fiscal years
2023, 2024, and 2025, $50,000,000 to carry out this
section.''.
(b) Clerical Amendment.--The table of sections at the
beginning of chapter 63 of such title is amended by striking
the items relating to sections 6307 and 6308 and inserting
the following new items:

``6307. Grants to States to improve outreach to veterans.
``6308. Outreach for eligible dependents.
``6309. Biennial report to Congress.''.

SEC. 502. OVERSIGHT OF COST OF WAR TOXIC EXPOSURES FUND.

(a) Plan Required.--Not later July 1, 2023, the Secretary
of Veterans Affairs shall submit to the Committee on
Veterans' Affairs of the Senate and the Committee on
Veterans' Affairs of the House of Representatives a plan for
obligating and expending amounts in the Cost of War Toxic
Exposures Fund established by section 324(a) of title 38,
United States Code.
(b) Contents.--The plan submitted pursuant to subsection
(a) shall include the following:
(1) A detailed explanation for how the Secretary interprets
``the delivery of veterans' health care associated with
exposure to environmental hazards'' for purposes of section
324(c)(1) of title 38, United States Code.
(2) A list of the medical services most commonly sought
from the Department in connection with exposure to
environmental hazards in the active military, naval, air, or
space service.
(3) A list of the medical conditions for which services
described in paragraph (2) of this subsection are most
commonly sought from the Department.
(4) A detailed explanation of how the Secretary interprets
``expenses incident to the delivery of veterans' health care
and benefits associated with exposure to environmental
hazards'' for purposes of paragraph (2) of such section.
(5) A list of the expenses described in paragraph (4) of
this subsection.
(6) A detailed description of how the Secretary interprets
``medical and other research relating to exposure to
environmental hazards'' for purposes of paragraph (3) of such
section.
(7) A list of the research described by such paragraph.
(8) A detailed plan for tracking the following:
(A) The health care furnished to individuals who became
eligible for or entitled to such heath care because of a
provision of or amendment made by the Honoring our PACT Act
of 2022 (Public Law 117-168; 136 Stat. 1759).
(B) Reliance by toxic-exposed veterans on health care
provided to such veterans pursuant to the Honoring our PACT
Act of 2022 (Public Law 117-168; 136 Stat. 1759).
(C) The costs incurred by the Department for the furnishing
of health care to toxic exposed veterans for conditions that
can be reasonably attributed to toxic exposure.
(c) Monthly Reports.--
(1) In general.--Not later than two weeks after the date of
the enactment of this Act, and not less frequently than once
every month thereafter, the Secretary shall submit to the
appropriate committees of Congress a report detailing the
obligations and expenditures by the Secretary with respect to
the amounts in the Cost of War Toxic Exposures Fund,
disaggregated by obligations and expenditures of the Veterans
Benefits Administration and the Veterans Health
Administration, including with respect to information
technology, general administration, operating expenses, and
research.
(2) Appropriate committees of congress defined.--In this
subsection, the term ``appropriate committees of Congress''
means--
(A) the Committee on Veterans' Affairs, the Committee on
the Budget, and the Committee on Appropriations of the
Senate; and
(B) the Committee on Veterans' Affairs, the Committee on
the Budget, and the Committee on Appropriations of the House
of Representatives.
(d) Annual Audits.--Not later than one year after the date
of the enactment of this Act and not less frequently than
once each year thereafter, the Inspector General of the
Department of Veterans Affairs shall conduct an audit of the
obligation and expenditure of amounts in the Cost of War
Toxic Exposures Fund.
(e) Comptroller General of the United States Reports.--
(1) In general.--The Comptroller General of the United
States shall submit to the Committee on Veterans' Affairs of
the Senate and the Committee on Veterans' Affairs of the
House of Representatives an interim report and a final report
on the degree to which the Secretary follows and executes the
plan submitted pursuant to subsection (a).
(2) Contents.--Each report submitted under paragraph (1)
shall include the following:
(A) An assessment of the methodology the Secretary uses to
create an annual budget for the Cost of War Toxic Exposures
Fund for inclusion in each budget of the President submitted
to Congress for a fiscal year pursuant to section 1105(a) of
title 31, United States Code.
(B) Identification of such adverse consequences to programs
of the Department as the Comptroller General may find is
created by the implementation of such Fund.
(C) An assessment of the long-term viability of the Cost of
War Toxic Exposures Fund, including budgetary implications on
future authorizing and appropriations legislation.
(D) Recommendations for such legislative or administrative
action as may resolve or mitigate the adverse consequences
identified pursuant to subparagraph (B) or any long-term
viability issues that may be identified pursuant to the
assessment required by subparagraph (C).
(f) Definitions of Toxic Exposure and Toxic-exposed
Veteran.--In this section, the terms ``toxic exposure'' and
``toxic-exposed veteran'' have the meanings given such terms
in section 101 of title 38, United States Code.

____________________