CONGRESSIONAL RECORD -- OCTOBER 17, 2000

***House Passes Alaska Native and American Indian Direct
Reimbursement:*** S. 406, to amend the Indian Health Care Improvement
Act to make permanent the demonstration program that allows for direct
billing of medicare, medicaid, and other third party payors, and to
expand the eligibility under such program to other tribes and tribal
organizations\--[clearing the measure for the President.]{.underline}
*\[ Congressional Record Pages H9957-59\]*

[House Floor Debate, Bill Language]{.underline}:

\[Page: H9957\]

Mr. CALVERT. Madam Speaker, I move to suspend the rules and pass the
Senate bill (S. 406) to amend the Indian Health Care Improvement Act to
make permanent the demonstration program that allows for direct billing
of medicare, medicaid, and other third party payers, and to expand the
eligibility under such program to other tribes and tribal organizations.

The Clerk read as follows:

#### S406

Be it enacted by the Senate and House of Representatives of the United
States of America in Congress assembled,

SECTION 1. SHORT TITLE.

This Act may be cited as the \`Alaska Native and American Indian Direct
Reimbursement Act of 1999\'.

SEC. 2. FINDINGS.

Congress finds the following:

\(1\) In 1988, Congress enacted section 405 of the Indian Health Care
Improvement Act (25 U.S.C. 1645) that established a demonstration
program to authorize 4 tribally-operated Indian Health Service hospitals
or clinics to test methods for direct billing and receipt of payment for
health services provided to patients eligible for reimbursement under
the medicare or medicaid programs under titles XVIII and XIX of the
Social Security Act (42 U.S.C. 1395 et seq.; 1396 et seq.), and other
third-party payors.

\(2\) The 4 participants selected by the Indian Health Service for the
demonstration program began the direct billing and collection program in
fiscal year 1989 and unanimously expressed success and satisfaction with
the program. Benefits of the program include dramatically increased
collections for services provided under the medicare and medicaid
programs, a significant reduction in the turn-around time between
billing and receipt of payments for services provided to eligible
patients, and increased efficiency of participants being able to track
their own billings and collections.

\(3\) The success of the demonstration program confirms that the direct
involvement of tribes and tribal organizations in the direct billing of,
and collection of payments from, the medicare and medicaid programs, and
other third payor reimbursements, is more beneficial to Indian tribes
than the current system of Indian Health Service-managed collections.

\(4\) Allowing tribes and tribal organizations to directly manage their
medicare and medicaid billings and collections, rather than channeling
all activities through the Indian Health Service, will enable the Indian
Health Service to reduce its administrative costs, is consistent with
the provisions of the Indian Self-Determination Act, and furthers the
commitment of the Secretary to enable tribes and tribal organizations to
manage and operate their health care programs.

\(5\) The demonstration program was originally to expire on September
30, 1996, but was extended by Congress, so that the current participants
would not experience an interruption in the program while Congress
awaited a recommendation from the Secretary of Health and Human Services
on whether to make the program permanent.

\(6\) It would be beneficial to the Indian Health Service and to Indian
tribes, tribal organizations, and Alaska Native organizations to provide
permanent status to the demonstration program and to extend
participation in the program to other Indian tribes, tribal
organizations, and Alaska Native health organizations who operate a
facility of the Indian Health Service.

\[Page: H9958\]

SEC. 3. DIRECT BILLING OF MEDICARE, MEDICAID, AND OTHER THIRD PARTY
PAYORS.

\(a\) **Permanent Authorization**: Section 405 of the Indian Health Care
Improvement Act (25 U.S.C. 1645) is amended to read as follows:

\`(a) **Establishment of Direct Billing Program**:

\`(1) **In general**: The Secretary shall establish a program under
which Indian tribes, tribal organizations, and Alaska Native health
organizations that contract or compact for the operation of a hospital
or clinic of the Service under the Indian Self-Determination and
Education Assistance Act may elect to directly bill for, and receive
payment for, health care services provided by such hospital or clinic
for which payment is made under title XVIII of the Social Security Act
(42 U.S.C. 1395 et seq.) (in this section referred to as the \`medicare
program\'), under a State plan for medical assistance approved under
title XIX of the Social Security Act (42 U.S.C. 1396 et seq.) (in this
section referred to as the \`medicaid program\'), or from any other
third party payor.

\`(2) **Application of 100 percent fmap**: The third sentence of section
1905(b) of the Social Security Act (42 U.S.C. 1396d(b)) shall apply for
purposes of reimbursement under the medicaid program for health care
services directly billed under the program established under this
section.

\`(b) **Direct Reimbursement**:

\`(1) **Use of funds**: Each hospital or clinic participating in the
program described in subsection (a) of this section shall be reimbursed
directly under the medicare and medicaid programs for services
furnished, without regard to the provisions of section 1880(c) of the
Social Security Act (42 U.S.C. 1395qq(c)) and sections 402(a) and
813(b)(2)(A), but all funds so reimbursed shall first be used by the
hospital or clinic for the purpose of making any improvements in the
hospital or clinic that may be necessary to achieve or maintain
compliance with the conditions and requirements applicable generally to
facilities of such type under the medicare or medicaid programs. Any
funds so reimbursed which are in excess of the amount necessary to
achieve or maintain such conditions shall be used\--

> \`(A) solely for improving the health resources deficiency level of
> the Indian tribe; and
>
> \`(B) in accordance with the regulations of the Service applicable to
> funds provided by the Service under any contract entered into under
> the Indian Self-Determination Act (25 U.S.C. 450f et seq.).

\`(2) **Audits**: The amounts paid to the hospitals and clinics
participating in the program established under this section shall be
subject to all auditing requirements applicable to programs administered
directly by the Service and to facilities participating in the medicare
and medicaid programs.

\`(3) **Secretarial oversight**: The Secretary shall monitor the
performance of hospitals and clinics participating in the program
established under this section, and shall require such hospitals and
clinics to submit reports on the program to the Secretary on an annual
basis.

\`(4) **No payments from special funds**: Notwithstanding section
1880(c) of the Social Security Act (42 U.S.C. 1395qq(c)) or section
402(a), no payment may be made out of the special funds described in
such sections for the benefit of any hospital or clinic during the
period that the hospital or clinic participates in the program
established under this section.

\`(c) **Requirements for Participation**:

\`(1) **Application**: Except as provided in paragraph (2)(B), in order
to be eligible for participation in the program established under this
section, an Indian tribe, tribal organization, or Alaska Native health
organization shall submit an application to the Secretary that
establishes to the satisfaction of the Secretary that\--

\`(A) the Indian tribe, tribal organization, or Alaska Native health
organization contracts or compacts for the operation of a facility of
the Service;

> \`(B) the facility is eligible to participate in the medicare or
> medicaid programs under section 1880 or 1911 of the Social Security
> Act (42 U.S.C. 1395qq; 1396j);
>
> \`(C) the facility meets the requirements that apply to programs
> operated directly by the Service; and
>
> \`(D) the facility\--
>
> \`(i) is accredited by an accrediting body as eligible for
> reimbursement under the medicare or medicaid programs; or
>
> \`(ii) has submitted a plan, which has been approved by the Secretary,
> for achieving such accreditation.
>
> \`(2) **Approval**:
>
> \`(A) **In general**: The Secretary shall review and approve a
> qualified application not later than 90 days after the date the
> application is submitted to the Secretary unless the Secretary
> determines that any of the criteria set forth in paragraph (1) are not
> met.
>
> \`(B) **Grandfather of demonstration program participants**: Any
> participant in the demonstration program authorized under this section
> as in effect on the day before the date of enactment of the Alaska
> Native and American Indian Direct Reimbursement Act of 1999 shall be
> deemed approved for participation in the program established under
> this section and shall not be required to submit an application in
> order to participate in the program.
>
> \`(C) **Duration**: An approval by the Secretary of a qualified
> application under subparagraph (A), or a deemed approval of a
> demonstration program under subparagraph (B), shall continue in effect
> as long as the approved applicant or the deemed approved demonstration
> program meets the requirements of this section.

\`(d) **Examination and Implementation of Changes**:

\`(1) **In general**: The Secretary, acting through the Service, and
with the assistance of the Administrator of the Health Care Financing
Administration, shall examine on an ongoing basis and implement\--

> \`(A) any administrative changes that may be necessary to facilitate
> direct billing and reimbursement under the program established under
> this section, including any agreements with States that may be
> necessary to provide for direct billing under the medicaid program;
> and
>
> \`(B) any changes that may be necessary to enable participants in the
> program established under this section to provide to the Service
> medical records information on patients served under the program that
> is consistent with the medical records information system of the
> Service.

\`(2) **Accounting information**: The accounting information that a
participant in the program established under this section shall be
required to report shall be the same as the information required to be
reported by participants in the demonstration program authorized under
this section as in effect on the day before the date of enactment of the
Alaska Native and American Indian Direct Reimbursement Act of 1999. The
Secretary may from time to time, after consultation with the program
participants, change the accounting information submission requirements.

\`(e) **Withdrawal From Program**: A participant in the program
established under this section may withdraw from participation in the
same manner and under the same conditions that a tribe or tribal
organization may retrocede a contracted program to the Secretary under
authority of the Indian Self-Determination Act (25 U.S.C. 450 et seq.).
All cost accounting and billing authority under the program established
under this section shall be returned to the Secretary upon the
Secretary\'s acceptance of the withdrawal of participation in this
program.\'.

\(b\) **Conforming Amendments**:

\(1\) Section 1880 of the Social Security Act (42 U.S.C. 1395qq) is
amended by adding at the end the following:

\`(e) For provisions relating to the authority of certain Indian tribes,
tribal organizations, and Alaska Native health organizations to elect to
directly bill for, and receive payment for, health care services
provided by a hospital or clinic of such tribes or organizations and for
which payment may be made under this title, see section 405 of the
Indian Health Care Improvement Act (25 U.S.C. 1645).\'.

\(2\) Section 1911 of the Social Security Act (42 U.S.C. 1396j) is
amended by adding at the end the following:

\`(d) For provisions relating to the authority of certain Indian tribes,
tribal organizations, and Alaska Native health organizations to elect to
directly bill for, and receive payment for, health care services
provided by a hospital or clinic of such tribes or organizations and for
which payment may be made under this title, see section 405 of the
Indian Health Care Improvement Act (25 U.S.C. 1645).\'.

\(c\) **Effective Date**: The amendments made by this section shall take
effect on October 1, 2000.

SEC. 4. TECHNICAL AMENDMENT.

\(a\) **In General**: Effective November 9, 1998, section 405 of the
Indian Health Care Improvement Act (25 U.S.C. 1645(e)) is reenacted as
in effect on that date.

\(b\) **Reports**: Effective November 10, 1998, section 405 of the
Indian Health Care Improvement Act is amended by striking subsection
(e).

The SPEAKER pro tempore. Pursuant to the rule, the gentleman from
California (Mr. **Calvert**) and the gentleman from New Jersey (Mr.
**Holt**) each will control 20 minutes.

The Chair recognizes the gentleman from California (Mr. **Calvert**).

Mr. CALVERT. Madam Speaker, I yield myself such time as I may consume.

Madam Speaker, S. 406 amends Section 405 of the Indian Health Care
Improvement Act to make permanent the demonstration program at four
tribally operated Indian Health Service hospitals that allows for direct
billing of Medicare, Medicaid and other third-party payers. It will also
extend the direct billing option to other tribes and tribal
organizations.

This demonstration program dramatically increases collections for
Medicare and Medicaid services, and significantly reduces the turnaround
time between billings and receipt of payment for Medicaid and Medicare
services. Additionally, it increased the administrative efficiency of
the participating health care providers. All the participants, two of
which are in Alaska, as well as the Department of Health and Human
Services and the Indian Health Service, report that the program is a
great success.

S. 406 will make permanent the demonstration program and will end much
of the bureaucracy for Indian Health Care Service facilities involved
with Medicare and Medicaid reimbursement. The bottom line is that it
will mean more Medicaid and Medicare dollars to Indian facilities to use
for improving health care for their members.

Madam Speaker, I urge an aye vote on this important bill for American
Indians and Alaskan Natives.

Madam Speaker, I reserve the balance of my time.

\[Page: H9959\]

Mr. HOLT. Madam Speaker, I yield myself such time as I may consume.

(Mr. HOLT asked and was given permission to revise and extend his
remarks.)

Mr. HOLT. Madam Speaker, in 1988, a dozen years ago, Congress authorized
the Indian Health Service to select up to four tribally controlled IHS
hospitals to participate in a demonstration project whereby the
hospitals could conduct direct billing and receipt of payment for health
services to Medicare and Medicaid eligible patients.

Under the current practice, Medicare and Medicaid billings and
collections are first sent through the IHS and then redirected to health
care providers. Since 1991, the Bristol Bay Health Corporation, the
Southeast Alaska Regional Health Corporation, Mississippi Choctaw Health
Center, and the Choctaw Tribe of Oklahoma have taken part in the
demonstration project.

The participants established in-house administrative operations to
perform Medicare and Medicaid billing and collection and have been
extremely satisfied with the results. Reports have shown dramatically
increased collections which have been turned into additional health
services. The demonstration program has resulted in a much shorter
turnaround time between billing and receipt of payment, as well as
improved accreditation, ratings and an overall higher level of health
care quality for patients.

Madam Speaker, S. 406 would make permanent the demonstration program and
would authorize additional tribes and tribal organizations to
participate in the direct billing. This legislation is supported by the
administration. It is good policy, and I urge my colleagues to support
its passage.

Madam Speaker, I yield back the balance of my time.

Mr. CALVERT. Madam Speaker, I yield back the balance of my time.

The SPEAKER pro tempore. The question is on the motion offered by the
gentleman from California (Mr. **Calvert**) that the House suspend the
rules and pass the Senate bill, S. 406.

The question was taken; and (two-thirds having voted in favor thereof)
[the rules were suspended and the Senate bill was passed.]{.underline}