**National Steering Committee for the **

**Reauthorization of the**

**Indian Health Care Improvement Act, P.L. 94-437**

**TITLE IV \-- ACCESS TO HEALTH SERVICES**

**DRAFT 1 --- July 16, 1999**

**For Review and Comment Only**

+-----------------------------------------------------------------+---+
| +-                                                              |   |
| --------------------------------------------------------------+ |   |
| |                                                               |   |
| +-----------------------------------------------------------+ | |   |
| |                                                               |   |
| | **Indian Health Care Improvement Act (with DRAFT proposed | | |   |
| |                                                               |   |
| | amendments, if any)**                                     | | |   |
| |                                                               |   |
| +-----------------------------------------------------------+ | |   |
| |                                                               |   |
|                                                               | |   |
| |                                                               |   |
| ***Comments and **Options***                                  | |   |
| +-                                                              |   |
| --------------------------------------------------------------+ |   |
| |                                                               |   |
|                                                               | |   |
| +-                                                              |   |
| --------------------------------------------------------------+ |   |
|                                                                 |   |
| **TITLE IV -- ACCESS TO HEALTH SERVICES**                       |   |
+-----------------------------------------------------------------+---+
|                                                                 |   |
+-----------------------------------------------------------------+---+

***1.**** The United States owes a duty to Indian tribes to provide
their members with health care services. The Congress has chosen to
satisfy this duty in part by providing direct appropriations to fund the
Indian Health Service (IHS), tribes, tribal organizations, and urban
Indian organizations and in part by authorizing the IHS, tribes and
tribal organizations to bill Medicare, Medicaid and CHIP. This draft is
intended to remove limitations on the latter so that Indian health
programs can take maximum advantage of this funding stream. The Indian
health system remains so underfunded, and there continue to be severe
health status deficiencies among American Indians and Alaska Native.
Even if every one of these proposals went into law, the Indian health
system will remain underfunded.*

***2.**** The objectives of these amendments are intended to: *

***3.**** References to "facilities" have generally been deleted in
favor of "programs" so that home- and community-based services and other
non-facility based services will be reimbursed. This will ensure
reimbursement for Medicare Part B services.*

***4.**** The Steering Committee has asked the Health Care Financing
Administration (HFCA) to provide technical assistance about this and
other provisions. This meeting will occur July 26, 1999, and will
undoubtedly result in recommendations for further amendment. The Title
IV provisions are very technical and will benefit from continued review.
*

***5.**** Some tribes proposed during the Regional Meetings that the
Social Security Act be amended to allow tribes to form a direct
relationship with HCFA under the Medicaid program. The Navajo Nation is
working on a specific proposal to become a Medicaid Agency. The National
Steering Committee determined that this demonstration should be
authorized and evaluated before trying to obtain more general
authority.*

+-----------------------------------------------------------------+---+
| [C]{.underline}*C maximize recovery from all third-party        |   |
| coverages, including Medicaid, Medicare and the Child Health    |   |
| Insurance Program;*                                             |   |
|                                                                 |   |
| [C]{.underline}*C ensure that American Indians and Alaska       |   |
| Natives have access to culturally competent care provided by    |   |
| the Indian Health Service, tribes and tribal organizations, and |   |
| urban Indian organizations, and therefore are not assigned to a |   |
| managed care organization (MCO) without their approval to       |   |
| non-Indian managed care plans;*                                 |   |
|                                                                 |   |
| [C]{.underline}*C ensure that when services are provided by an  |   |
| Indian health program that the full cost of providing the       |   |
| service will be made available.*                                |   |
|                                                                 |   |
| ***6.**** There is concern that many states have not committed  |   |
| an adequate amount of their CHIP block grant to delivering      |   |
| services to Indians. During the meeting with HCFA, the tribal   |   |
| representatives hope to obtain direction about how to require   |   |
| States to direct more of the block grant satisfying unmet needs |   |
| for children health care or about how to create tribal block    |   |
| grants directly with HCFA.*                                     |   |
+-----------------------------------------------------------------+---+
|                                                                 |   |
+-----------------------------------------------------------------+---+

**TREATMENT OF PAYMENTS UNDER MEDICARE PROGRAM **

**SEC. 401. **(a) Any payments received by ~~a hospital or skilled
nursing facility of~~ the Service ~~(whether operated by the Service~~
or by an Indian tribe or tribal organization pursuant to a [funding
agreement]{.underline} ~~contract~~ under the Indian Self-Determination
[and Education Assistance]{.underline} Act) for services provided to
Indians eligible for benefits under title XVIII of the Social Security
Act shall not be considered in determining appropriations for health
care and services to Indians.

+----------------------------------------------------------------------+
| +----------------------------------------------------------------+   |
| | +----------------------------------------------------------+   |   |
| | |   -------                                                |   |   |
| | | -------------------------------------------------------- |   |   |
| | | -------------------------------------------------------- |   |   |
| | | -------------------------------------------------------- |   |   |
| | | -------------------------------------------------------- |   |   |
| | |   \(b\)                                                  |   |   |
| | |  Nothing in this Act authorizes the Secretary to provide |   |   |
| | |  services to an Indian beneficiary with coverage under t |   |   |
| | | itle XVIII of the Social Security Act, as amended, in pr |   |   |
| | | eference to an Indian beneficiary without such coverage. |   |   |
| | |   -------                                                |   |   |
| | | -------------------------------------------------------- |   |   |
| | | -------------------------------------------------------- |   |   |
| | | -------------------------------------------------------- |   |   |
| | | -------------------------------------------------------- |   |   |
| | |                                                          |   |   |
| | | *Makes the IHS and tribes and tribal organizations       |   |   |
| | | eligible for Medicare reimbursement for all services for |   |   |
| | | which Medicare otherwise pays; extends these rights      |   |   |
| | | clearly to self-governance programs; and continues the   |   |   |
| | | assurance that such payments will not be considered      |   |   |
| | | during the appropriations process.*                      |   |   |
| | +----------------------------------------------------------+   |   |
| | |                                                          |   |   |
| | +----------------------------------------------------------+   |   |
| |                                                                |   |
| | [(c) Section 1880 of the Social Security Act is amended, as    |   |
| | follows:]{.underline}                                          |   |
| +----------------------------------------------------------------+   |
|                                                                      |
| *The actual authority for receipt of Medicare payments is found in   |
| Sec. 1880 of the Social Security Act (SSA), 42 U.S.C. § 1395qq. It   |
| was originally amended through the IHCIA. We propose amendment       |
| through the same vehicle.*                                           |
+----------------------------------------------------------------------+
|                                                                      |
+----------------------------------------------------------------------+

**INDIAN HEALTH SERVICE FACILITIES**

+----------------------------------------------------------------------+
| +----------------------------------------------------------------+   |
| | +----------------------------------------------------------+   |   |
| | | +----------------------------------------------------+   |   |   |
| | | | +----------------------------------------------+   |   |   |   |
| | | | |   -                                          |   |   |   |   |
| | | | | -------------------------------------------- |   |   |   |   |
| | | | | -------------------------------------------- |   |   |   |   |
| | | | | -------------------------------------------- |   |   |   |   |
| | | | | -------------------------------------------- |   |   |   |   |
| | | | | -------------------------------------------- |   |   |   |   |
| | | | | -------------------------------------------- |   |   |   |   |
| | | | | -------------------------------------------- |   |   |   |   |
| | | | | -------------------------------------------- |   |   |   |   |
| | | | | -------------------------------------------- |   |   |   |   |
| | | | | -------------------------------------------- |   |   |   |   |
| | | | | -------------------------------------------- |   |   |   |   |
| | | | | -------------------------------------------- |   |   |   |   |
| | | | | -------------------------------------------- |   |   |   |   |
| | | | | -------------------------------------------- |   |   |   |   |
| | | | | -------------------------------------------- |   |   |   |   |
| | | | | -------------------------------------------- |   |   |   |   |
| | | | | -------------------------------------------- |   |   |   |   |
| | | | |                                              |   |   |   |   |
| | | | |  **Sec. 1880.** (a) ~~A hospital or skilled  |   |   |   |   |
| | | | | nursing facility of t~~ [T]{.underline}he In |   |   |   |   |
| | | | | dian Health Service [and]{.underline} ~~, wh |   |   |   |   |
| | | | | ether operated by such Service or by~~ an In |   |   |   |   |
| | | | | dian tribe or tribal organization (as those  |   |   |   |   |
| | | | | terms are defined in section 4 of the Indian |   |   |   |   |
| | | | |  Health Care Improvement Act), shall be elig |   |   |   |   |
| | | | | ible for payments under this title, notwiths |   |   |   |   |
| | | | | tanding sections 1814(c) and 1835(d), if and |   |   |   |   |
| | | | |  for so long as it meets ~~all of~~ the cond |   |   |   |   |
| | | | | itions and requirements for such payments wh |   |   |   |   |
| | | | | ich are applicable generally to [the service |   |   |   |   |
| | | | |  for which it seeks payment]{.underline} ~~h |   |   |   |   |
| | | | | ospitals or skilled nursing facilities (as t |   |   |   |   |
| | | | | he case may be)~~ under this title [and for  |   |   |   |   |
| | | | | services provided by a qualified Indian heal |   |   |   |   |
| | | | | th program under section 1880A]{.underline}. |   |   |   |   |
| | | | |   -                                          |   |   |   |   |
| | | | | -------------------------------------------- |   |   |   |   |
| | | | | -------------------------------------------- |   |   |   |   |
| | | | | -------------------------------------------- |   |   |   |   |
| | | | | -------------------------------------------- |   |   |   |   |
| | | | | -------------------------------------------- |   |   |   |   |
| | | | | -------------------------------------------- |   |   |   |   |
| | | | | -------------------------------------------- |   |   |   |   |
| | | | | -------------------------------------------- |   |   |   |   |
| | | | | -------------------------------------------- |   |   |   |   |
| | | | | -------------------------------------------- |   |   |   |   |
| | | | | -------------------------------------------- |   |   |   |   |
| | | | | -------------------------------------------- |   |   |   |   |
| | | | | -------------------------------------------- |   |   |   |   |
| | | | | -------------------------------------------- |   |   |   |   |
| | | | | -------------------------------------------- |   |   |   |   |
| | | | | -------------------------------------------- |   |   |   |   |
| | | | | -------------------------------------------- |   |   |   |   |
| | | | |                                              |   |   |   |   |
| | | | | *Makes the IHS and tribes and tribal         |   |   |   |   |
| | | | | organizations eligible for Medicare          |   |   |   |   |
| | | | | reimbursement for all services for which     |   |   |   |   |
| | | | | Medicare otherwise pays and extends these    |   |   |   |   |
| | | | | rights clearly to self-governance programs.  |   |   |   |   |
| | | | | This will cover Part B services currently    |   |   |   |   |
| | | | | excluded. It also provides for payment under |   |   |   |   |
| | | | | the newly proposed "qualified Indian health  |   |   |   |   |
| | | | | program," which is described in the new      |   |   |   |   |
| | | | | section 1880A. *                             |   |   |   |   |
| | | | +----------------------------------------------+   |   |   |   |
| | | | |                                              |   |   |   |   |
| | | | +----------------------------------------------+   |   |   |   |
| | | |                                                    |   |   |   |
| | | | \(b\) Notwithstanding subsection (a),              |   |   |   |
| | | | [if]{.underline} ~~a facility of~~ the Indian      |   |   |   |
| | | | Health Service [or an Indian tribe or tribal       |   |   |   |
| | | | organization,]{.underline} ~~(including a          |   |   |   |
| | | | hospital, nursing facility, or any other type of   |   |   |   |
| | | | facility~~ which provides services of a type       |   |   |   |
| | | | otherwise covered under the State                  |   |   |   |
| | | | plan[,]{.underline} ~~) which~~ does not meet all  |   |   |   |
| | | | of the conditions and requirements of this title   |   |   |   |
| | | | which are applicable generally to such             |   |   |   |
| | | | [service]{.underline} ~~facility, but which~~      |   |   |   |
| | | | submits to the Secretary within six months after   |   |   |   |
| | | | the date [on which it first sought reimbursement   |   |   |   |
| | | | for the service]{.underline} ~~of enactment of     |   |   |   |
| | | | this section~~ an acceptable plan for achieving    |   |   |   |
| | | | compliance with such conditions and requirements,  |   |   |   |
| | | | [it]{.underline} shall be deemed to meet such      |   |   |   |
| | | | conditions and requirements (and to be eligible    |   |   |   |
| | | | for reimbursement under this title), without       |   |   |   |
| | | | regard to the extent of its actual compliance with |   |   |   |
| | | | such conditions and requirements, during the first |   |   |   |
| | | | twelve months after the month in which such plan   |   |   |   |
| | | | is submitted.                                      |   |   |   |
| | | +----------------------------------------------------+   |   |   |
| | |                                                          |   |   |
| | | *Provides an eighteen month window in which the Indian   |   |   |
| | | health program may bill and receive payment before it    |   |   |
| | | must meet the applicable program requirements. Although  |   |   |
| | | this would rarely be needed for hospitals or clinics,    |   |   |
| | | many Indian health programs have lacked a reasonable     |   |   |
| | | opportunity to fully develop other health programs. This |   |   |
| | | provides that opportunity.*                              |   |   |
| | +----------------------------------------------------------+   |   |
| | |                                                          |   |   |
| | +----------------------------------------------------------+   |   |
| |                                                                |   |
| | \(c\) Notwithstanding any other provision of this title,       |   |
| | payments to which any hospital or skilled nursing facility of  |   |
| | the Indian Health Service is entitled by reason of this        |   |
| | section shall be placed in a special fund to be held by the    |   |
| | Secretary and used by him (to such extent or in such amounts   |   |
| | as are provided in appropriation Acts) exclusively for the     |   |
| | purpose of making any improvements in the hospitals and        |   |
| | skilled nursing facilities of such Service which may be        |   |
| | necessary to achieve compliance with the applicable conditions |   |
| | and requirements of this title. The preceding sentence shall   |   |
| | cease to apply when the Secretary determines and certifies     |   |
| | that substantially all of the hospitals and skilled nursing    |   |
| | facilities of such Service in the United States are in         |   |
| | compliance with such conditions and requirements [or upon the  |   |
| | election of an Indian tribe or tribal organization under       |   |
| | section 405 of the Indian Health Care Improvement Act to       |   |
| | receive payments directly]{.underline}.                        |   |
| +----------------------------------------------------------------+   |
|                                                                      |
| *This amendment ties together with the amendment to section 405      |
| under which all tribal health programs are permitted to bill and be  |
| reimbursed directly without the funds having to pass through the IHS |
| special fund, which in fact no longer exists. No change is made      |
| regarding IHS operated hospitals and skilled nursing facilities. If  |
| IHS believes it would benefit from amendment, it can propose that    |
| most appropriate to its own operation. *                             |
+----------------------------------------------------------------------+
|                                                                      |
+----------------------------------------------------------------------+

\(d\) The annual report of the Secretary which is required by section
701 \[now 801\] of the Indian Health Care Improvement Act shall include
(along with the matters specified in section 403 of such Act) a detailed
statement of the status of the hospitals and skilled nursing facilities
of the Service in terms of their compliance with the applicable
conditions and requirements of this title and of the progress being made
by such hospitals and facilities (under plans submitted under subsection
(b) and otherwise) toward the achievement of such compliance.

+----------------------------------------------------------------------+
| +----------------------------------------------------------------+   |
| | +----------------------------------------------------------+   |   |
| | | +----------------------------------------------------+   |   |   |
| | | | +----------------------------------------------+   |   |   |   |
| | | | | +----------------------------------------+   |   |   |   |   |
| | | | | | +----------------------------------+   |   |   |   |   |   |
| | | | | | |   --                             |   |   |   |   |   |   |
| | | | | | |   --                             |   |   |   |   |   |   |
| | | | | | |                                  |   |   |   |   |   |   |
| | | | | | | *Again, no change is made here   |   |   |   |   |   |   |
| | | | | | | in deference to IHS determining  |   |   |   |   |   |   |
| | | | | | | how best to report about its own |   |   |   |   |   |   |
| | | | | | | facilities.*                     |   |   |   |   |   |   |
| | | | | | +----------------------------------+   |   |   |   |   |   |
| | | | | | |                                  |   |   |   |   |   |   |
| | | | | | +----------------------------------+   |   |   |   |   |   |
| | | | | |                                        |   |   |   |   |   |
| | | | | | [(e) The Indian Health Service or an   |   |   |   |   |   |
| | | | | | Indian tribe or tribal organization    |   |   |   |   |   |
| | | | | | providing a service otherwise eligible |   |   |   |   |   |
| | | | | | for payment under this section through |   |   |   |   |   |
| | | | | | the use of a community health aide or  |   |   |   |   |   |
| | | | | | practitioner certified under the       |   |   |   |   |   |
| | | | | | provisions of section 119 of the       |   |   |   |   |   |
| | | | | | Indian Health Care Improvement Act (25 |   |   |   |   |   |
| | | | | | U.S.C. §                               |   |   |   |   |   |
| | | | | | 1616]{.underline}*[l]{.underline}*[)   |   |   |   |   |   |
| | | | | | shall be paid for such services on the |   |   |   |   |   |
| | | | | | same basis that such services are      |   |   |   |   |   |
| | | | | | reimbursed under State Plans approved  |   |   |   |   |   |
| | | | | | under Title XIX of the Social Security |   |   |   |   |   |
| | | | | | Act.]{.underline}                      |   |   |   |   |   |
| | | | | +----------------------------------------+   |   |   |   |   |
| | | | |                                              |   |   |   |   |
| | | | | *This new subsection provides Medicare       |   |   |   |   |
| | | | | payments for the CHAP program in Alaska. If  |   |   |   |   |
| | | | | the CHR program is expanded to be modeled    |   |   |   |   |
| | | | | more like the CHAP program, this section     |   |   |   |   |
| | | | | could be amended to cover CHRs, also.*       |   |   |   |   |
| | | | +----------------------------------------------+   |   |   |   |
| | | | |                                              |   |   |   |   |
| | | | +----------------------------------------------+   |   |   |   |
| | | |                                                    |   |   |   |
| | | | [(f) Notwithstanding any other provision of law, a |   |   |   |
| | | | health program operated by the Indian Health       |   |   |   |
| | | | Service or an Indian tribe or tribal organization, |   |   |   |
| | | | which is affiliated with a hospital operated by    |   |   |   |
| | | | the Indian Health Service or an Indian tribe or    |   |   |   |
| | | | tribal organization, shall, at the option of the   |   |   |   |
| | | | Indian tribe or tribal organization, be paid for   |   |   |   |
| | | | services for which it would otherwise be eligible  |   |   |   |
| | | | under Section 1880 of the Social Security Act (42  |   |   |   |
| | | | USC § 1395qq) as if it were an outpatient          |   |   |   |
| | | | department of the hospital. In situations where    |   |   |   |
| | | | the health program is on a separate campus from    |   |   |   |
| | | | the hospital, billing as an outpatient department  |   |   |   |
| | | | of the hospital shall not subject such a health    |   |   |   |
| | | | program to the requirements of section 1867 (42    |   |   |   |
| | | | U.S.C. § 1395dd) \[the Emergency Medical Treatment |   |   |   |
| | | | and Active Labor Act\].]{.underline}               |   |   |   |
| | | +----------------------------------------------------+   |   |   |
| | |                                                          |   |   |
| | | *To the extent that an IHS or tribal clinic continues to |   |   |
| | | need to be part of an IHS or tribal hospital to bill     |   |   |
| | | Medicare, this new section ensures that they are         |   |   |
| | | permitted to do so and that EMTALA does not apply to     |   |   |
| | | off-site programs. The latter should be unnecessary      |   |   |
| | | given the plain language of the EMTALA statute, but      |   |   |
| | | court rulings have been inconsistent and HCFA has        |   |   |
| | | proposed rules that would expand the impact of EMTALA.   |   |   |
| | | HCFA could eliminate the need for this through           |   |   |
| | | regulations*                                             |   |   |
| | +----------------------------------------------------------+   |   |
| | |                                                          |   |   |
| | +----------------------------------------------------------+   |   |
| |                                                                |   |
| | [(g) The Service or an Indian tribe or tribal organization     |   |
| | providing visiting nurse services in a Home Health Agency      |   |
| | Shortage Area shall be paid for such services on the same      |   |
| | basis that such services are reimbursed for other primary care |   |
| | providers.]{.underline}                                        |   |
| +----------------------------------------------------------------+   |
|                                                                      |
| *Currently available to Federally Qualified Health Centers (FQHCs).  |
| Provides an opportunity to continue home health services if FQHC     |
| certification sunsets.*                                              |
+----------------------------------------------------------------------+
|                                                                      |
+----------------------------------------------------------------------+

[(d) Title XVIII of the Social Security Act is amended by the addition
of a new section 1880A, as follows:]{.underline}

**QUALIFIED INDIAN HEALTH PROGRAM**

**Sec. 1880A**. (a) A qualified Indian health program shall be eligible
for payments under this title, notwithstanding sections 1814(c) and
1835(d), if and for so long as it meets all the conditions and
requirements set forth in this section.

(b)(1)The term "qualified Indian health program" means a health program
operated by

\(A\) the Indian Health Service;

\(B\) a tribe or tribal organization (as those terms are defined in
section 4 of the Indian Health Care Improvement Act) and which is funded
in whole or part by the Indian Health Service under the Indian Self
Determination and Education Assistance Act; and

\(C\) an urban Indian organization (as that term is defined in section 4
of the Indian Health Care Improvement Act) and which is funded in whole
or part under the Indian Self Determination and Education Assistance Act
or Title V of the Indian Health Care Improvement Act.

\(2\) A qualified Indian health program may include one or more
hospitals, nursing homes, home health programs, clinics, ambulance
services or other health programs providing a service for which payments
may be made under this title and which is covered in the Medicare or
Medicaid cost report for such qualified Indian health program.

(c)(1) Notwithstanding any other provision in the law, a qualified
Indian health program shall be entitled to receive payment based on an
all-inclusive rate which shall be calculated to provide full cost
recovery for the cost of furnishing services provided under this
section.

\(2\) The term "full cost recovery" shall mean:

\(A\) the direct costs, which are reasonable and related to the cost of
furnishing such services, which shall include direct program,
administrative and overhead costs, without regard to the customary or
other charge or any fee schedule that would otherwise be applicable,
plus

\(B\) indirect costs which for a qualified Indian health program
operated by a tribe or tribal organization shall be not less than an
amount determined on the basis of the indirect cost rate as that term is
defined in section 4(g) of the Indian Self-Determination and Education
Assistance Act.

\(C\) Notwithstanding any other provision of law, the amount determined
to be payable as full cost recovery may not be reduced for co-insurance,
co-payments or deductibles when the service was provided to an American
Indian or Alaska Native entitled under Federal law to receive service
from the Indian Health Service, a tribe or tribal organization, or an
urban Indian organization or because of any limitations on payment
provided for in any managed care plan.

\(3\) In addition to full cost recovery, a qualified Indian health
program shall be entitled to reasonable outstationing costs, which shall
include all administrative costs associated with outreach and acceptance
of eligibility applications for any federal or state health program
including, but not limited to Medicare, Medicaid and the Children's
Health Insurance Program.

\(4\) Costs identified for services addressed in a cost report submitted
by the qualified Indian health program shall be used to determine an
all-inclusive encounter or per diem payment amount for such services.
Not all health programs provided or administered by the Indian Health
Service, a tribe or tribal organization, or an urban Indian organization
must be combined into a single cost report. A full cost recovery payment
for services not covered by such cost report shall be made on a
fee-for-service, encounter, or per diem basis.

\(5\) The portion of the full cost recovery rate provided for in
paragraph (1) through (3) of this subsection may be determined, at the
election of the qualified Indian health program, by the Health Care
Financing Administration or by a State Medicaid agency and shall be
valid for reimbursement made under Title XVIII (medicare), Title XIX
(medicaid), and Title XXI (children's health insurance program)
purposes. The costs described in subparagraph (A) of paragraph (1) shall
be calculated under whatever methodology yields the greatest aggregate
payment for the cost reporting period, provided that such methodology
shall be adjusted to include adjustments to its payment to take into
account for qualified Indian health programs that include hospitals

\(A\) a significant decreases in discharges,

\(B\) costs for graduate medical education programs;

\(C\) additional payment as a disproportionate share hospital with a
payment adjustment factor of 10;

\(D\) payment for outlier cases;

\(6\) A qualified Indian health program may elect to receive payment for
services provided under this section--

\(A\) on the full cost recovery basis provided in subsection (c)(1) -
(5)

\(B\) on the basis of the inpatient or outpatient encounter rates
established for Indian Health Service facilities and published annually
in the Federal Register;

\(C\) on the same basis as other providers are reimbursed under this
title, provided that to this amount shall be added the amounts
determined under subparagraph (B) of subsection (c)(2);

\(D\) on the basis of any other rate or methodology applicable to the
Service, an Indian tribe or tribal organization; or

\(E\) on the basis of any rate or methodology negotiated with the agency
responsible for making payment.

\(d\) A qualified Indian health program may under this section provide
and be reimbursed for any service the Indian Health Service, a tribe or
tribal organization or an urban Indian organization may be reimbursed
under section 1880 for the Medicare program and section 1911 for the
Medicaid program, provided that in either event such services may also
include, at the election of the qualified Indian health program,

\(1\) any service when furnished by an employee of the qualified Indian
health program who is licensed or certified to perform such a service to
the same extent that such service would be reimburseable if performed by
a physician and any service or supplies furnished as incident to a
physician's service as would otherwise be covered if furnished by a
physician or as an incident to a physician's service;

\(2\) screening, diagnostic and therapeutic outpatient services
including, but not limited to, part-time or intermittent screening,
diagnostic and therapeutic skilled nursing care and related medical
supplies (other than drugs and biologicals), furnished by an employee of
the qualified Indian health program who is licensed or certified to
perform such a service to an individual in the individual's home or in a
community health setting under a written plan of treatment established
and periodically reviewed by a physician, when furnished to an
individual as an outpatient of a qualified Indian health program;

\(3\) preventive primary health services as described under sections
329, 330 and 340 of the Public Health Service Act, when provided by an
employee of the qualified Indian health program who is licensed or
certified to perform such a service, regardless of the location in which
the service is provided;

\(4\) for children, all services specified as part of the State Medicaid
plan, Children's Health Insurance Program and EPSDT;

\(5\) influenza and pneumococccal immunizations;

\(6\) other immunizations for prevention of communicable diseases when
targeted; and

  ---------------------------------------------------------------------------------------------------------
  \(7\) the cost of transportation for providers or patients necessary to facilitate access for patients.
  ---------------------------------------------------------------------------------------------------------

*This new section creates a new provider type for both Medicare and
Medicaid, a "qualified Indian health program" or QIHP (pronounced
"quip"). A QIHP is entitled to full cost recovery similar to that of
FQHCs before the phasing out began ****plus**** indirect costs. A QIHP
may include facility and non-facility based programs. It will require a
cost report to determine its rate. *

*Features of the QIHP are that it can use any licensed or certified
provider to carry out services within the scope of that provider's
practice even though ordinarily only a physician could perform the
service for reimbursement and it may recover for certain preventive
services and transportation costs. Rates are to be calculated by the
most advantageous method available.*

*Many additional sections of Title XVIII and XIX will have to be amended
to take into account this new provider type. Refinements will be made
through additional consultation with other tribes and tribal
organizations, IHS, the State Medicaid agencies, and HCFA.*

*The primary objective of creating this new provider type is to ensure
that the Federal responsibility for providing health services is not
compromised by limiting reimbursement to an amount below actual cost,
including indirect costs.*

*Full cost recovery is not unprecedented. States are allowed to charge
100% of actual costs for services that they deliver through direct State
operated programs. *

*Some measure of efficiency will have to be added. It must be written
however so that it does not limit access to services in rural and remote
sites.*

*Under (c)(6), each Indian health provider will be given an option about
which reimbursement methodology to rely upon and the list of options has
been expanded.*

  --
  --

**TREATMENT OF PAYMENTS UNDER MEDICAID PROGRAM **

+----------------------------------------------------------------------+
| +----------------------------------------------------------------+   |
| | +----------------------------------------------------------+   |   |
| | | +----------------------------------------------------+   |   |   |
| | | | +----------------------------------------------+   |   |   |   |
| | | | |   --                                         |   |   |   |   |
| | | | | -------------------------------------------- |   |   |   |   |
| | | | | -------------------------------------------- |   |   |   |   |
| | | | | -------------------------------------------- |   |   |   |   |
| | | | | -------------------------------------------- |   |   |   |   |
| | | | | -------------------------------------------- |   |   |   |   |
| | | | | -------------------------------------------- |   |   |   |   |
| | | | | -------------------------------------------- |   |   |   |   |
| | | | | -------------------------------------------- |   |   |   |   |
| | | | | -------------------------------------------- |   |   |   |   |
| | | | | -------------------------------------------- |   |   |   |   |
| | | | | -------------------------------------------- |   |   |   |   |
| | | | | -------------------------------------------- |   |   |   |   |
| | | | | -------------------------------------------- |   |   |   |   |
| | | | | -------------------------------------------- |   |   |   |   |
| | | | | -------------------------------------------- |   |   |   |   |
| | | | | -------------------------------------------- |   |   |   |   |
| | | | | -------------------------------------------- |   |   |   |   |
| | | | | -------------------------------------------- |   |   |   |   |
| | | | | -------------------------------------------- |   |   |   |   |
| | | | | -------------------------------------------- |   |   |   |   |
| | | | | -------------------------------------------- |   |   |   |   |
| | | | | -------------------------------------------- |   |   |   |   |
| | | | | -------------------------------------------- |   |   |   |   |
| | | | | -------------------------------------------- |   |   |   |   |
| | | | | -------------------------------------------- |   |   |   |   |
| | | | | -------------------------------------------- |   |   |   |   |
| | | | | -------------------------------------------- |   |   |   |   |
| | | | | -------------------------------------------- |   |   |   |   |
| | | | | -------------------------------------------- |   |   |   |   |
| | | | | -------------------------------------------- |   |   |   |   |
| | | | | -------------------------------------------- |   |   |   |   |
| | | | | -------------------------------------------- |   |   |   |   |
| | | | | -------------------------------------------- |   |   |   |   |
| | | | |                                              |   |   |   |   |
| | | | | ** SEC. 402.** (a) Notwithstanding any other |   |   |   |   |
| | | | |  provision of law, payments to which any fac |   |   |   |   |
| | | | | ility of the Service (including a hospital,  |   |   |   |   |
| | | | | nursing facility, intermediate care facility |   |   |   |   |
| | | | |  for the mentally retarded, or any other typ |   |   |   |   |
| | | | | e of facility which provides services for wh |   |   |   |   |
| | | | | ich payment is available under title XIX of  |   |   |   |   |
| | | | | the Social Security Act) is entitled under a |   |   |   |   |
| | | | |  State plan by reason of section 1911 of suc |   |   |   |   |
| | | | | h Act shall be placed in a special fund to b |   |   |   |   |
| | | | | e held by the Secretary and used by him (to  |   |   |   |   |
| | | | | such extent or in such amounts as are provid |   |   |   |   |
| | | | | ed in appropriation Acts) exclusively for th |   |   |   |   |
| | | | | e purpose of making any improvements in the  |   |   |   |   |
| | | | | facilities of such Service which may be nece |   |   |   |   |
| | | | | ssary to achieve compliance with the applica |   |   |   |   |
| | | | | ble conditions and requirements of such titl |   |   |   |   |
| | | | | e. In making payments from such fund, the Se |   |   |   |   |
| | | | | cretary shall ensure that each service unit  |   |   |   |   |
| | | | | of the Service receives at least 80 percent  |   |   |   |   |
| | | | | of the amounts to which the facilities of th |   |   |   |   |
| | | | | e Service, for which such service unit makes |   |   |   |   |
| | | | |  collections, are entitled by reason of sect |   |   |   |   |
| | | | | ion 1911 of the Social Security Act. [The fi |   |   |   |   |
| | | | | rst sentence of this subsection shall cease  |   |   |   |   |
| | | | | to apply when the Secretary determines and c |   |   |   |   |
| | | | | ertifies that substantially all of the facil |   |   |   |   |
| | | | | ities of such Service in the United States a |   |   |   |   |
| | | | | re in compliance with such conditions and re |   |   |   |   |
| | | | | quirements or upon the election of an Indian |   |   |   |   |
| | | | |  tribe or tribal organization under Section  |   |   |   |   |
| | | | | 405 of the Indian Health Care Improvement Ac |   |   |   |   |
| | | | | t to receive payments directly.]{.underline} |   |   |   |   |
| | | | |   --                                         |   |   |   |   |
| | | | | -------------------------------------------- |   |   |   |   |
| | | | | -------------------------------------------- |   |   |   |   |
| | | | | -------------------------------------------- |   |   |   |   |
| | | | | -------------------------------------------- |   |   |   |   |
| | | | | -------------------------------------------- |   |   |   |   |
| | | | | -------------------------------------------- |   |   |   |   |
| | | | | -------------------------------------------- |   |   |   |   |
| | | | | -------------------------------------------- |   |   |   |   |
| | | | | -------------------------------------------- |   |   |   |   |
| | | | | -------------------------------------------- |   |   |   |   |
| | | | | -------------------------------------------- |   |   |   |   |
| | | | | -------------------------------------------- |   |   |   |   |
| | | | | -------------------------------------------- |   |   |   |   |
| | | | | -------------------------------------------- |   |   |   |   |
| | | | | -------------------------------------------- |   |   |   |   |
| | | | | -------------------------------------------- |   |   |   |   |
| | | | | -------------------------------------------- |   |   |   |   |
| | | | | -------------------------------------------- |   |   |   |   |
| | | | | -------------------------------------------- |   |   |   |   |
| | | | | -------------------------------------------- |   |   |   |   |
| | | | | -------------------------------------------- |   |   |   |   |
| | | | | -------------------------------------------- |   |   |   |   |
| | | | | -------------------------------------------- |   |   |   |   |
| | | | | -------------------------------------------- |   |   |   |   |
| | | | | -------------------------------------------- |   |   |   |   |
| | | | | -------------------------------------------- |   |   |   |   |
| | | | | -------------------------------------------- |   |   |   |   |
| | | | | -------------------------------------------- |   |   |   |   |
| | | | | -------------------------------------------- |   |   |   |   |
| | | | | -------------------------------------------- |   |   |   |   |
| | | | | -------------------------------------------- |   |   |   |   |
| | | | | -------------------------------------------- |   |   |   |   |
| | | | | -------------------------------------------- |   |   |   |   |
| | | | |                                              |   |   |   |   |
| | | | | *This amendment ties together with the       |   |   |   |   |
| | | | | amendment to section 405 under which all     |   |   |   |   |
| | | | | tribal health programs are permitted to bill |   |   |   |   |
| | | | | and be reimbursed directly without the funds |   |   |   |   |
| | | | | having to pass through the IHS special fund, |   |   |   |   |
| | | | | which in fact no longer exists. No change is |   |   |   |   |
| | | | | made regarding IHS operated facilities. If   |   |   |   |   |
| | | | | IHS believes it would benefit from           |   |   |   |   |
| | | | | amendment, it can propose that most          |   |   |   |   |
| | | | | appropriate to its own operation. *          |   |   |   |   |
| | | | +----------------------------------------------+   |   |   |   |
| | | | |                                              |   |   |   |   |
| | | | +----------------------------------------------+   |   |   |   |
| | | |                                                    |   |   |   |
| | | | \(b\) Any payments received [under section 1911 of |   |   |   |
| | | | the Social Security Act]{.underline} ~~by such     |   |   |   |
| | | | facility~~ for services provided to Indians        |   |   |   |
| | | | eligible for benefits under title XIX of the       |   |   |   |
| | | | Social Security Act shall not be considered in     |   |   |   |
| | | | determining appropriations for the provision of    |   |   |   |
| | | | health care and services to Indians.               |   |   |   |
| | | +----------------------------------------------------+   |   |   |
| | |                                                          |   |   |
| | | *This ensures that none of the services reimburseable    |   |   |
| | | under Medicaid will be considered in determining         |   |   |
| | | appropriations.*                                         |   |   |
| | +----------------------------------------------------------+   |   |
| | |                                                          |   |   |
| | +----------------------------------------------------------+   |   |
| |                                                                |   |
| | [(c) Section 1911 of the Social Security Act is amended, as    |   |
| | follows:]{.underline}                                          |   |
| +----------------------------------------------------------------+   |
|                                                                      |
| *The actual authority for receipt of Medicaid payments is found in   |
| Sec. 1911 of the Social Security Act, 42 U.S.C. § 1396j. It was      |
| originally amended through the IHCIA. We propose amendment through   |
| the same vehicle.*                                                   |
+----------------------------------------------------------------------+
|                                                                      |
+----------------------------------------------------------------------+

**INDIAN HEALTH SERVICE [PROGRAMS]{.underline} ~~FACILITIES~~**

+----------------------------------------------------------------------+
| +----------------------------------------------------------------+   |
| | +----------------------------------------------------------+   |   |
| | | +----------------------------------------------------+   |   |   |
| | | | +----------------------------------------------+   |   |   |   |
| | | | |   ------                                     |   |   |   |   |
| | | | | -------------------------------------------- |   |   |   |   |
| | | | | -------------------------------------------- |   |   |   |   |
| | | | | -------------------------------------------- |   |   |   |   |
| | | | | -------------------------------------------- |   |   |   |   |
| | | | | -------------------------------------------- |   |   |   |   |
| | | | | -------------------------------------------- |   |   |   |   |
| | | | | -------------------------------------------- |   |   |   |   |
| | | | | -------------------------------------------- |   |   |   |   |
| | | | | -------------------------------------------- |   |   |   |   |
| | | | | -------------------------------------------- |   |   |   |   |
| | | | | -------------------------------------------- |   |   |   |   |
| | | | | -------------------------------------------- |   |   |   |   |
| | | | | -------------------------------------------- |   |   |   |   |
| | | | | -------------------------------------------- |   |   |   |   |
| | | | | -------------------------------------------- |   |   |   |   |
| | | | | -------------------------------------------- |   |   |   |   |
| | | | | -------------------------------------------- |   |   |   |   |
| | | | | -------------------------------------------- |   |   |   |   |
| | | | | -------------------------------------------- |   |   |   |   |
| | | | | -------------------------------------------- |   |   |   |   |
| | | | |   **Se                                       |   |   |   |   |
| | | | | c. 1911.** (a) ~~A facility of t~~ [T]{.unde |   |   |   |   |
| | | | | rline}he Indian Health Service [and]{.underl |   |   |   |   |
| | | | | ine} ~~(including a hospital, nursing facili |   |   |   |   |
| | | | | ty, or any other type facility which provide |   |   |   |   |
| | | | | s services of a type otherwise covered under |   |   |   |   |
| | | | |  the State plan), whether operated by such S |   |   |   |   |
| | | | | ervice or by~~ an Indian tribe or tribal org |   |   |   |   |
| | | | | anization (as those terms are defined in sec |   |   |   |   |
| | | | | tion 4 of the Indian Health Care Improvement |   |   |   |   |
| | | | |  Act)~~,~~ shall be eligible for reimburseme |   |   |   |   |
| | | | | nt for medical assistance provided under a S |   |   |   |   |
| | | | | tate plan if and for so long as it [provides |   |   |   |   |
| | | | |  services of a type otherwise covered under  |   |   |   |   |
| | | | | the State plan and]{.underline} meets ~~all  |   |   |   |   |
| | | | | of~~ the conditions and requirements which a |   |   |   |   |
| | | | | re applicable generally to [the service for  |   |   |   |   |
| | | | | which it seeks reimbursement]{.underline} ~~ |   |   |   |   |
| | | | | such facilities~~ under this title [and for  |   |   |   |   |
| | | | | services provided by a qualified Indian heal |   |   |   |   |
| | | | | th program under section 1880A]{.underline}. |   |   |   |   |
| | | | |   ------                                     |   |   |   |   |
| | | | | -------------------------------------------- |   |   |   |   |
| | | | | -------------------------------------------- |   |   |   |   |
| | | | | -------------------------------------------- |   |   |   |   |
| | | | | -------------------------------------------- |   |   |   |   |
| | | | | -------------------------------------------- |   |   |   |   |
| | | | | -------------------------------------------- |   |   |   |   |
| | | | | -------------------------------------------- |   |   |   |   |
| | | | | -------------------------------------------- |   |   |   |   |
| | | | | -------------------------------------------- |   |   |   |   |
| | | | | -------------------------------------------- |   |   |   |   |
| | | | | -------------------------------------------- |   |   |   |   |
| | | | | -------------------------------------------- |   |   |   |   |
| | | | | -------------------------------------------- |   |   |   |   |
| | | | | -------------------------------------------- |   |   |   |   |
| | | | | -------------------------------------------- |   |   |   |   |
| | | | | -------------------------------------------- |   |   |   |   |
| | | | | -------------------------------------------- |   |   |   |   |
| | | | | -------------------------------------------- |   |   |   |   |
| | | | | -------------------------------------------- |   |   |   |   |
| | | | | -------------------------------------------- |   |   |   |   |
| | | | |                                              |   |   |   |   |
| | | | | *Makes the IHS and tribes and tribal         |   |   |   |   |
| | | | | organizations eligible for Medicaid          |   |   |   |   |
| | | | | reimbursement for all services for which     |   |   |   |   |
| | | | | Medicaid otherwise pays regardless of        |   |   |   |   |
| | | | | whether they are provided in a "facility" or |   |   |   |   |
| | | | | not. It also provides for payment under the  |   |   |   |   |
| | | | | newly proposed "qualified Indian health      |   |   |   |   |
| | | | | program," which for is described in the new  |   |   |   |   |
| | | | | section 1880A. (In a final version of this   |   |   |   |   |
| | | | | bill, sec. 1880A would either have a         |   |   |   |   |
| | | | | Medicaid parallel or be moved to a more      |   |   |   |   |
| | | | | generic part of the Social Security Act.)*   |   |   |   |   |
| | | | +----------------------------------------------+   |   |   |   |
| | | | |                                              |   |   |   |   |
| | | | +----------------------------------------------+   |   |   |   |
| | | |                                                    |   |   |   |
| | | | \(b\) Notwithstanding subsection (a),              |   |   |   |
| | | | [if]{.underline} ~~a facility of~~ the Indian      |   |   |   |
| | | | Health Service [or an Indian tribe or tribal       |   |   |   |
| | | | organization,]{.underline} ~~(including a          |   |   |   |
| | | | hospital, nursing facility, or any other type of   |   |   |   |
| | | | facility~~ which provides services of a type       |   |   |   |
| | | | otherwise covered under the State                  |   |   |   |
| | | | plan[,]{.underline} ~~) which~~ does not meet all  |   |   |   |
| | | | of the conditions and requirements of this title   |   |   |   |
| | | | which are applicable generally to such             |   |   |   |
| | | | [services]{.underline} ~~facility, but which~~     |   |   |   |
| | | | submits to the Secretary within six months after   |   |   |   |
| | | | the date [on which it first sought reimbursement   |   |   |   |
| | | | for the service]{.underline} ~~of enactment of     |   |   |   |
| | | | this section~~ an acceptable plan for achieving    |   |   |   |
| | | | compliance with such conditions and requirements,  |   |   |   |
| | | | [it]{.underline} shall be deemed to meet such      |   |   |   |
| | | | conditions and requirements (and to be eligible    |   |   |   |
| | | | for reimbursement under this title), without       |   |   |   |
| | | | regard to the extent of its actual compliance with |   |   |   |
| | | | such conditions and requirements, during the first |   |   |   |
| | | | twelve months after the month in which such plan   |   |   |   |
| | | | is submitted.                                      |   |   |   |
| | | +----------------------------------------------------+   |   |   |
| | |                                                          |   |   |
| | | *Provides an eighteen month window in which the Indian   |   |   |
| | | health program may bill and receive payment before it    |   |   |
| | | must meet the applicable program requirements. Although  |   |   |
| | | this would rarely be needed for hospitals or clinics,    |   |   |
| | | many Indian health programs have lacked a reasonable     |   |   |
| | | opportunity to fully develop other health programs. This |   |   |
| | | provides that opportunity.*                              |   |   |
| | +----------------------------------------------------------+   |   |
| | |                                                          |   |   |
| | +----------------------------------------------------------+   |   |
| |                                                                |   |
| | \(c\) The Secretary is authorized to enter into agreements     |   |
| | with the State agency for the purpose of reimbursing such      |   |
| | agency for health care and services provided [by               |   |
| | the]{.underline} ~~in~~ Indian Health Service [and Indian      |   |
| | tribes and tribal organizations, directly, through referral,   |   |
| | or under contracts or other arrangements between the Indian    |   |
| | Health Service, Indian tribe or tribal organization and        |   |
| | another health provider]{.underline} ~~facilities~~ to Indians |   |
| | who are eligible for medical assistance under the State plan.  |   |
| +----------------------------------------------------------------+   |
|                                                                      |
| *This amendment permits the Indian health program to be reimbursed   |
| for all services it provides directly or acquires for IHS            |
| beneficiaries through referral, contracts or managed care            |
| agreements.*                                                         |
+----------------------------------------------------------------------+
|                                                                      |
+----------------------------------------------------------------------+

[(d) The last sentence of Section 1905(b) of the Social Security Act is
amended, as follows:]{.underline}

  -----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
  Notwithstanding the first sentence of this section, the Federal medical assistance percentage shall be 100 per centum with respect to amounts expended as medical assistance for services which are received through [the]{.underline} ~~an~~ Indian Health Service ~~facility whether operated by the Indian Health Service~~ or ~~by~~ an Indian tribe or tribal organization (as defined in section 4 of the Indian Health Care Improvement Act) [under Section 1911 of the Social Security Act]{.underline}. ["Through" in this subsection shall include services provided directly, by referral, or under contracts or other arrangements between the Indian Health Service, Indian tribe or tribal organization and another health provider.]{.underline}
  -----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

*States are currently reimbursed 100 percent for payments made to IHS
facilities. This amendment extends that to payments it makes to Indian
health programs for all services they provide directly or acquire for
IHS beneficiaries through referral, contracts or managed care
agreements. *

  -----------------------------------------------
  *100 % FMAP for CHIP is provided under §414.*
  -----------------------------------------------

**REPORT**

**Sec. 403.** [(a)]{.underline} The Secretary shall submit to the
President, for inclusion in the report required to be transmitted to the
Congress under section 801,** **an accounting on the amount and use of
funds made available to the Service pursuant to this title as a result
of reimbursements through title XVIII and XIX of the Social Security
Act, as amended.

+----------------------------------------------------------------------+
|   -----------------------------------------                          |
| -------------------------------------------------------------------- |
| -------------------------------------------------------------------- |
| -------------------------------------------------------------------- |
| -------------------------------------------------------------------- |
| -------------------------------------------------------------------- |
| -------------------------------------------------------------------- |
|   [(b) An Indian tribe or tribal organiza                            |
| tion that receives funding from the Service under the Indian Self-De |
| termination and Education Assistance Act and reimbursements or payme |
| nts under Title XVIII (Medicare), Title XIX (Medicaid) or Title XXI  |
| (children's health insurance program) of the Social Security Act sha |
| ll provide to the Service a list of each provider enrollment number  |
| (or other identifier) under which it receives payments.]{.underline} |
|   -----------------------------------------                          |
| -------------------------------------------------------------------- |
| -------------------------------------------------------------------- |
| -------------------------------------------------------------------- |
| -------------------------------------------------------------------- |
| -------------------------------------------------------------------- |
| -------------------------------------------------------------------- |
|                                                                      |
| *The new subsection is intended to permit IHS and HCFA to track      |
| receipts by tribal programs. It is in lieu of other reporting        |
| requirements proposed for those tribes that receive direct payment.  |
| This represents the bare minimum in reporting.*                      |
+----------------------------------------------------------------------+
|                                                                      |
+----------------------------------------------------------------------+

**GRANTS TO AND [FUNDING AGREEMENTS]{.underline} ~~CONTRACTS~~ WITH [THE
]{.underline}[SERVICE, TRIBES AND]{.underline} TRIBAL ORGANIZATIONS**

** Sec. 404. **(a) The Secretary~~, acting through the Service,~~ shall
make grants to or enter into [funding agreements]{.underline}
~~contract~~ with [Indian tribes and ]{.underline}tribal organizations
to assist such organizations in establishing and administering programs
on or near Federal Indian reservations and trust areas and in or near
Alaska Native villages to assist individual Indians to\--

\(1\) enroll under section 1818 of part A and sections 1836 and 1837 of
part B of title XVIII of the Social Security Act;

\(2\) pay monthly premiums for coverage due to financial need of such
individual; and

\(3\) apply for medical assistance provided pursuant to title XIX
[(medicaid) and XXI (children's health insurance program)]{.underline}
of the Social Security Act.

\(b\) The Secretary, acting through the Service, shall place conditions
as deemed necessary to effect the purpose of this section in any
[funding agreement]{.underline} ~~contract~~ or grant which the
Secretary makes with any [Indian tribe or]{.underline} tribal
organization pursuant to this section. Such conditions shall include,
but are not limited to, requirements that the organization successfully
undertake to\--

\(1\) determine the population of Indians to be served that are or could
be recipients of benefits under titles XVIII[,]{.underline} ~~and~~ XIX
[and XXI]{.underline} of the Social Security Act;

\(2\) assist individual Indians in becoming familiar with and utilizing
such benefits;

\(3\) provide transportation to such individual Indians to the
appropriate offices for enrollment or applications for medical
assistance;

\(4\) develop and implement\--

\(A\) a schedule of income levels to determine the extent of payments of
premiums by such organizations for coverage of needy individuals; and

+----------------------------------------------------------------------+
| +----------------------------------------------------------------+   |
| | +----------------------------------------------------------+   |   |
| | |   --------------------                                   |   |   |
| | | -------------------------------------------------------- |   |   |
| | | -------------------------------------------------------- |   |   |
| | | -------------------------------------------------------- |   |   |
| | |   \(B\) methods of i                                     |   |   |
| | | mproving the participation of Indians in receiving the b |   |   |
| | | enefits provided under titles XVIII[,]{.underline} ~~and |   |   |
| | | ~~ XIX [and XXI]{.underline} of the Social Security Act. |   |   |
| | |   --------------------                                   |   |   |
| | | -------------------------------------------------------- |   |   |
| | | -------------------------------------------------------- |   |   |
| | | -------------------------------------------------------- |   |   |
| | |                                                          |   |   |
| | | *Reauthorize with amendments consistent with other       |   |   |
| | | sections discussed herein. By deleting "acting through   |   |   |
| | | the Service," any agency of the Department could enter   |   |   |
| | | into an agreement with a tribe or tribal organization.   |   |   |
| | | Adds references to CHIP (Title XXI of the Social         |   |   |
| | | Security Act).*                                          |   |   |
| | +----------------------------------------------------------+   |   |
| | |                                                          |   |   |
| | +----------------------------------------------------------+   |   |
| |                                                                |   |
| | \(c\) The Secretary~~, acting through the Service,~~ may enter |   |
| | into an agreement with an Indian tribe, tribal organization,   |   |
| | or urban Indian organization which provides for the receipt    |   |
| | and processing of applications for medical assistance under    |   |
| | title XIX of the Social Security Act and benefits under title  |   |
| | XVIII [and XXI]{.underline} of the Social Security Act         |   |
| | [by]{.underline} ~~at~~ a Service facility or a health care    |   |
| | [program ]{.underline} ~~facility~~ administered by such       |   |
| | [Indian]{.underline} tribe or [tribal]{.underline}             |   |
| | organization pursuant to a [funding agreement]{.underline}     |   |
| | ~~contract~~ under the Indian Self-Determination [and          |   |
| | Education Assistance]{.underline} Act. [Notwithstanding any    |   |
| | other provision of law, such agreements shall provide for      |   |
| | reimbursement of the cost of outreach, education regarding     |   |
| | eligibility and benefits, and translation when such services   |   |
| | are provided. The reimbursement may be included in an          |   |
| | encounter rate or be made on a fee for service basis as        |   |
| | appropriate for the provider. When necessary to carry out the  |   |
| | terms of this section, the Secretary, acting through the       |   |
| | Health Care Financing Agency or the Service, may enter into    |   |
| | agreements with a State to facilitate cooperation between the  |   |
| | State and the Service, Indian tribe or tribal                  |   |
| | organization.]{.underline}                                     |   |
| +----------------------------------------------------------------+   |
|                                                                      |
| *This amendment ensures reimbursement for outreach, education        |
| regarding eligibility and benefits and translation. HCFA suggested   |
| adding the provision allowing agreements between HCFA and the State  |
| to facilitate agreement between HCFA and the Indian health program.  |
| *                                                                    |
+----------------------------------------------------------------------+
|                                                                      |
+----------------------------------------------------------------------+

**~~DEMONSTRATION PROGRAM FOR~~ DIRECT BILLING [AND
]{.underline}[REIMBURSEMENT]{.underline}**

**OF MEDICARE, MEDICAID, AND OTHER THIRD PARTY PAYORS**

** [Sec. 405. (a) ]{.underline}[[Direct
billing.]{.underline}]{.smallcaps}[[---]{.underline}]{.smallcaps}**

**[(1) ]{.underline}[[In
general.]{.underline}]{.smallcaps}[[---]{.underline}]{.smallcaps}**[An
Indian tribe or tribal organization (as defined in section 4 of the
Indian Health Care Improvement Act) may directly bill for, and receive
payment for, health care services provided by such health program for
which payment is made under title XVIII of the Social Security Act \[42
U.S.C. § 1395 et seq.\] (medicare), under a State plan for medical
assistance approved under title XIX of the Social Security Act \[42
U.S.C. § 1396 et seq.\] (medicaid), under a State's children's health
insurance plan approved under title XXI of the Social Security Act \[ 42
U.S.C. § 1397aa et seq.\] or from any other third party payor. The last
sentence of section 1905(b) of the Social Security Act \[42 U.S.C. §
1396d(b)\] shall apply to any Indian tribe or tribal organization (as
defined in section 4 of the Indian Health Care Improvement Act)
exercising this option.]{.underline}

**[(2) ]{.underline}[[Application of 100 percent
fmap.]{.underline}]{.smallcaps}[[---]{.underline}]{.smallcaps}**[The
third sentence of section 1905(b) of the Social Security Act (42 USC §
1396d(b)) and the second sentence of section 2101(c) of the Social
Security Act (42 U.S.C. § 1397aa(c)) shall apply for purposes of
reimbursement under the medicaid or children's health insurance program
for health care services directly billed under the program established
under this section.]{.underline}

** [(b) ]{.underline}[[Direct
reimbursement.]{.underline}]{.smallcaps}[[---]{.underline}]{.smallcaps}**

**[(1) ]{.underline}[[Use of
Funds.]{.underline}]{.smallcaps}[[---]{.underline}]{.smallcaps}**[Each
Indian tribe or tribal organization exercising the option described in
subsection (a) of this section shall be reimbursed directly under the
medicare, medicaid and children's health insurance programs for services
furnished, without regard to the provisions of sections 1880(b)(2)(A)
and (c) of the Social Security Act (42 U.S.C. § 1395qq(b)(2)A) and (c))
and section 402(a) of this title, but all funds so reimbursed shall
first be used by the health program for the purpose of making any
improvements in the facility or health programs that may be necessary to
achieve or maintain compliance with the conditions and requirements
applicable generally to such health services under the medicare,
medicaid or children's health insurance program. Any funds so reimbursed
which are in excess of the amount necessary to achieve or maintain such
conditions or requirements shall be used to provide additional health
services or improvements in its health care facilities.]{.underline}

**[(2)
]{.underline}[[Audits.]{.underline}]{.smallcaps}[[---]{.underline}]{.smallcaps}**[
The amounts paid to the health programs exercising the option described
in subsection (a) of this section shall be subject to all auditing
requirements applicable to programs administered directly by the Service
and to facilities participating in the medicare, medicaid and children's
health insurance programs. ]{.underline}

[ ]{.smallcaps}**[[(3) No payments from special
funds.]{.underline}]{.smallcaps}[[---]{.underline}]{.smallcaps}**[
Notwithstanding section 1880(c) of the Social Security Act (42 U.S.C. §
1395qq(c)) or section 1642(a) of this title, no payment may be made out
of the special fund described in section 1880(c) of the Social Security
Act (42 U.S.C. § 1395qq(c)), or section 1642(a) of this title, for the
benefit of any health program exercising the option described in
subsection (a) of this section during the period of such
participation.]{.underline}

**[(c) ]{.underline}[[Examination and Implementation of
Changes.]{.underline}]{.smallcaps}[[---]{.underline}]{.smallcaps}**[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 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 or children's health insurance program.]{.underline}

**[(d) ]{.underline}[[Withdrawal from
Program.]{.underline}]{.smallcaps}[[---]{.underline}]{.smallcaps}[[
]{.underline}]{.smallcaps}**[ 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 and Education Assistance Act (25 USC § 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.]{.underline}

~~Sec. 405. (a) The Secretary shall establish a demonstration program
under which Indian tribes, tribal organizations, and Alaska Native
health organizations, which are contracting the entire operation of an
entire hospital or clinic of the Service under the authority of the
Indian Self-Determination Act, shall 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
(medicare), under a State plan for medical assistance approved under
title XIX of the Social Security Act (medicaid), or from any other
third-party payor. The last sentence of section 1905(b) of the Social
Security Act shall apply for purposes of the demonstration program.~~

~~ (b)(1) Each hospital or clinic participating in the demonstration
program described in subsection (a) 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 and
sections 402(c) and 713(b)(2(A) of this Act, 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 program. Any funds to reimbursed which are in excess of the
amount necessary to achieve or maintain such conditions requirements
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.~~

~~(2) The amounts paid to the hospitals and clinics participating in the
demonstration program described in subsection (a) 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) The Secretary shall monitor the performance of hospitals and
clinics participating in the demonstration program described in
subsection (a), and shall require such hospitals and clinics to submit
reports on the program to the Secretary on a quarterly basis (or more
frequently if the Secretary deems it necessary).~~

~~(4) Notwithstanding section 1880(c) of the Social Security Act or
section 402(c) of this Act, no payment may be made out of the special
fund described in section 1880(c) of the Social Security Act, or section
402(c) of this Act for the benefit of any hospital or clinic
participating in the demonstration program described in subsection (a)
during the period of such participation.~~

~~ (c)(1) In order to be considered for participation in the
demonstration program described in subsection (a), a hospital or clinic
must submit an application to the Secretary which establishes to the
satisfaction of the Secretary that\--~~

~~(A) The Indian tribe, tribal organization, or Alaska Native health
organization contracts the entire operation of the Service facility;~~

~~(B) The facility is eligible to participate in the medicare and
medicaid programs under sections 1880 and 1911 of the Social Security
Act;~~

~~(C) The facility meets any requirements which apply to the programs
operated directly by the Service; and~~

~~(D) The facility is accredited by the Joint Commission on
Accreditation of Hospitals, or has submitted a plan, which has been
approved by the Secretary, for achieving such accreditation prior to
October 1, 1990.~~

~~(2) From among the qualified applicants, the Secretary shall, prior to
October 1, 1989, select no more than 4 facilities to participate in the
demonstration program described in subsection (a). The demonstration
program described in subsection (a) shall begin by no later than October
1, 1991, and end 1998.~~

~~ (d)(1) Upon the enactment of the Indian Health Care Amendments of
1988, the Secretary, acting through the Service, shall commence an
examination of\--~~

~~(A) any administrative changes which may be necessary to allow direct
billing and reimbursement under the demonstration program described in
subsection(a),including any agreements with States which may be
necessary to provide for such direct billing under the medicaid program;
and~~

~~(B) any changes which may be necessary to enable participants in such
demonstration program to provide to the Service medical records
information on patients served by such demonstration program which is
consistent with the medical records information system of the Service.~~

~~(2) Prior to the commencement of the demonstration program described
in subsection (a), the Secretary shall implement all changes required as
a result of the examinations conducted under paragraph (1).~~

~~(3) Prior to October 1, 1990, the Secretary shall determine any
accounting information which a participant in the demonstration program
described in subsection (a) would be required to report.~~

~~ (e) The Secretary shall submit a final report at the end of fiscal
year 1996, on the activities carried out under the demonstration program
described in subsection (a) which have fulfilled the objectives of such
program. In such report the Secretary shall provide a recommendation,
based upon the results of such demonstration program, as to whether
direct billing or, and reimbursement by, the medicare and medicaid
programs and other third-party payors should be authorized for all
Indian tribes and Alaska Native Health organizations which are
contracting the entire operation of a facility of a Service.~~

+----------------------------------------------------------------------+
| +----------------------------------------------------------------+   |
| |   -------                                                      |   |
| | -------------------------------------------------------------- |   |
| | -------------------------------------------------------------- |   |
| | -------------------------------------------------------------- |   |
| | -------------------------------------------------------------- |   |
| | -------------------------------------------------------------- |   |
| | -------------------------------------------------------------- |   |
| |   ~~ (f                                                        |   |
| | ) The Secretary shall provide for the retrocession of any cont |   |
| | ract entered into between a participant in the demonstration p |   |
| | rogram described in subsection (a) and the Service under the a |   |
| | uthority of the Indian Self-Determination Act. All cost accoun |   |
| | ting and billing authority shall be retroceded to the Secretar |   |
| | y upon the Secretary\'s acceptance of a retroceded contract.~~ |   |
| |   -------                                                      |   |
| | -------------------------------------------------------------- |   |
| | -------------------------------------------------------------- |   |
| | -------------------------------------------------------------- |   |
| | -------------------------------------------------------------- |   |
| | -------------------------------------------------------------- |   |
| | -------------------------------------------------------------- |   |
| |                                                                |   |
| | *Repeal and reenact Section 405 (25 U.S.C. § 1645). This       |   |
| | reenacted provision allows tribes and tribal organizations to  |   |
| | be paid directly for Medicare, Medicaid and CHIP services      |   |
| | without funds having to go through the IHS' special fund. It   |   |
| | leaves the special fund in effect for the IHS. Currently and   |   |
| | in a bill pending before the Congress, S. 406, tribes that     |   |
| | receive direct payment under this section are required to make |   |
| | reports to the IHS. In lieu of such a reporting requirement as |   |
| | a condition of direct payment, a new requirement has been      |   |
| | added that requires all tribes and tribal organizations        |   |
| | receiving funding under the Indian Self-Determination and      |   |
| | Education Assistance Act to report to IHS all Medicare,        |   |
| | Medicaid and CHIP provider enrollment numbers. With that       |   |
| | information, IHS and HCFA can generate the information they    |   |
| | need for budgeting and other purposes.*                        |   |
| +----------------------------------------------------------------+   |
| |                                                                |   |
| +----------------------------------------------------------------+   |
|                                                                      |
| *Section 406, Authorization for Emergency Contract Health Services,  |
| has been moved to Title II where the other contract health           |
| provisions are located.*                                             |
+----------------------------------------------------------------------+
|                                                                      |
+----------------------------------------------------------------------+

**[CO-INSURANCE, CO-PAYMENTS, DEDUCTIBLES, AND CHIP
PREMIUMS]{.underline}**

  --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
  ** [SEC. 406. (a) CO-INSURANCE, CO-PAYMENTS AND DEDUCTIBLES.]{.underline}**[ Notwithstanding any other provision of Federal or State law, no Indian who is eligible for services under Title XVIII, XIX or XXI of the Social Security Act, or any other federally funded health programs may be charged a deductible, co-payment or co-insurance for any service provided by or through the Indian Health Service or an Indian tribe or tribal organization (as defined in Section 4 of the Indian Health Care Improvement Act), nor may the payment or reimbursement due to the Indian Health Service or an Indian tribe or tribal organization be reduced by the amount of the deductible, co-payment or co-insurance that would be due from the Indian or Alaska Native but for the operation of this section. For the purposes of this section, "through" shall include services provided directly, by referral, or under contracts or other arrangements between the Indian Health Service, Indian tribe or tribal organization and another health provider.]{.underline}
  --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

*Subsection (a) protects IHS beneficiaries from Medicare and Medicaid
co-payments, co-insurance, and deductibles when they use an IHS, tribal
or urban Indian health program. *

+----------------------------------------------------------------------+
| +-                                                                   |
| -------------------------------------------------------------------+ |
| |                                                                    |
| +----------------------------------------------------------------+ | |
| |                                                                    |
| | +----------------------------------------------------------+   | | |
| |                                                                    |
| | | +----------------------------------------------------+   |   | | |
| |                                                                    |
| | | | +----------------------------------------------+   |   |   | | |
| |                                                                    |
| | | | |   ---------                                  |   |   |   | | |
| |                                                                    |
| | | | | -------------------------------------------- |   |   |   | | |
| |                                                                    |
| | | | | -------------------------------------------- |   |   |   | | |
| |                                                                    |
| | | | |   *This i                                    |   |   |   | | |
| |                                                                    |
| | | | | s not intended to apply to Federal employee  |   |   |   | | |
| |                                                                    |
| | | | | benefit programs and may require revisions.* |   |   |   | | |
| |                                                                    |
| | | | |   ---------                                  |   |   |   | | |
| |                                                                    |
| | | | | -------------------------------------------- |   |   |   | | |
| |                                                                    |
| | | | | -------------------------------------------- |   |   |   | | |
| |                                                                    |
| | | | |                                              |   |   |   | | |
| |                                                                    |
| | | | | **[(b) MEDICAID AND CHILD HEALTH INSURANCE   |   |   |   | | |
| |                                                                    |
| | | | | PROGRAM                                      |   |   |   | | |
| |                                                                    |
| | | | | ]{.underline}[PREMIUMS.]{.underline}**[      |   |   |   | | |
| |                                                                    |
| | | | | Notwithstanding any other provision of       |   |   |   | | |
| |                                                                    |
| | | | | Federal or State law, no Indian who is       |   |   |   | | |
| |                                                                    |
| | | | | otherwise eligible for services under Title  |   |   |   | | |
| |                                                                    |
| | | | | XIX (medicaid) or Title XXI (children's      |   |   |   | | |
| |                                                                    |
| | | | | health insurance program) of the Social      |   |   |   | | |
| |                                                                    |
| | | | | Security Act may be charged a premium as a   |   |   |   | | |
| |                                                                    |
| | | | | condition of receiving benefits from the     |   |   |   | | |
| |                                                                    |
| | | | | program. ]{.underline}                       |   |   |   | | |
| |                                                                    |
| | | | +----------------------------------------------+   |   |   | | |
| |                                                                    |
| | | |                                                    |   |   | | |
| |                                                                    |
| | | | *Subsection (b) permits Indian children to         |   |   | | |
| |                                                                    |
| | | | participate in CHIP and Medicaid expansion         |   |   | | |
| |                                                                    |
| | | | programs without paying a premium. Premiums are    |   |   | | |
| |                                                                    |
| | | | not exempted for Medicare because the Medicaid     |   |   | | |
| |                                                                    |
| | | | program must pay premiums whenever a Medicare      |   |   | | |
| |                                                                    |
| | | | eligible person is also eligible for Medicaid.*    |   |   | | |
| |                                                                    |
| | | +----------------------------------------------------+   |   | | |
| |                                                                    |
| | | |                                                    |   |   | | |
| |                                                                    |
| | | +----------------------------------------------------+   |   | | |
| |                                                                    |
| | |                                                          |   | | |
| |                                                                    |
| | | **[(c) MEDICALLY NEEDY PROGRAM                           |   | | |
| |                                                                    |
| | | SPEND-DOWN.]{.underline}**[ For the purposes of any      |   | | |
| |                                                                    |
| | | medically needy option under a State's Medicaid plan     |   | | |
| |                                                                    |
| | | under Title XIX of the Social Security Act, the cost of  |   | | |
| |                                                                    |
| | | providing services to an Indian in a health program of   |   | | |
| |                                                                    |
| | | the Service, a tribe or tribal organization shall be     |   | | |
| |                                                                    |
| | | deemed to have been an expenditure for health care by    |   | | |
| |                                                                    |
| | | the person applying for Medicaid.]{.underline}           |   | | |
| |                                                                    |
| | +----------------------------------------------------------+   | | |
| |                                                                    |
| |                                                                | | |
| |                                                                    |
| | *Subsection (c) is a place-holder for more precise language to | | |
| |                                                                    |
| | be drafted after obtaining technical assistance from HCFA. It  | | |
| |                                                                    |
| | is intended to allow expenditures of Indian health programs to | | |
| |                                                                    |
| | be counted for the purposes of "spend-down" requirements of    | | |
| |                                                                    |
| | certain Medicaid eligibility requirements, as if the applicant | | |
| |                                                                    |
| | actually paid for them..*                                      | | |
| |                                                                    |
| +----------------------------------------------------------------+ | |
| |                                                                    |
| |                                                                | | |
| |                                                                    |
| +----------------------------------------------------------------+ | |
| |                                                                    |
|                                                                    | |
| |                                                                    |
| **[(d) ESTATE RECOVERY.]{.underline}**                             | |
| +-                                                                   |
| -------------------------------------------------------------------+ |
|                                                                      |
| *Subsection (d) is a place-holder for language to be drafted to      |
| minimize the impact of estate recovery rules either by exempting all |
| assets that would not be counted in determining eligibility or, more |
| narrowly, exempting a specified list including trust assets, real    |
| property on trust land or former trust lands, and certain other      |
| items like tribal regalia, objects of cultural significance, and     |
| possessions necessary for carrying out subsistence or traditional    |
| activities (whether commercial or not).*                             |
+----------------------------------------------------------------------+
|                                                                      |
+----------------------------------------------------------------------+

**[WAIVER OF MEDICARE AND MEDICAID SANCTIONS]{.underline}**

  --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
  **[Sec. 407. ]{.underline}**[Notwithstanding any other provision of law, the Indian Health Service or an Indian tribe or tribal organization operating a health program under the Indian Self-Determination and Education Assistance Act shall be entitled to seek a waiver of sanctions imposed under Titles XVIII, XIX or XXI of the Social Security Act as if it were directly responsible for administering the State health care program. ]{.underline}
  --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

*Certain violations of Medicaid and Medicare rules can result in
exclusion from federal health care programs under 42 USC § 1320a-7 and
Section 4331(c) of the Balanced Budget Act of 1997, Pub. L. 105-33.
Under 42 C.F.R. § 1001.1801(a), the Health Care Financing Administration
permits waiver of these sanctions upon the request of*

*an individual directly responsible for administering the State health
care program.*

  ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
  *HCFA has neither amended this rule to extend the right to make such a request to the Indian Health Service or tribes and tribal organizations operating health programs under the Indian Self-Determination and Education Assistance Act, nor has it been willing to interpret the current regulation to permit such requests. Despite the fact that no State funds are expended (due to the provisions that provide for 100 percent FMAP), this limitation means that the IHS and tribes and tribal organizations may not seek a waiver unless the state in which the individual is located will seek a waiver. *
  ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

**REIMBURSEMENT FROM CERTAIN THIRD PARTIES OF COSTS OF HEALTH SERVICES**

** SEC. [408]{.underline} ~~206.~~ ** (a) Except as provided in
subsection (f), the United States, an Indian tribe or tribal
organization shall have the right to recover the reasonable [charges
billed or]{.underline} expenses incurred by the Secretary, an Indian
tribe or tribal organization in providing health services, through the
Service, an Indian tribe, or tribal organization to any individual to
the same extent that such individual, or any nongovernmental provider of
such services, would be eligible to receive reimbursement or
indemnification for such [charges or]{.underline} expenses if--

\(1\) such services had been provided by a nongovernmental provider, and

\(2\) such individual had been required to pay such [charges
or]{.underline} expenses and did pay such expenses.

\(b\) Subsection (a) shall provide a right of recovery against any
State, only if the injury, illness, or disability for which health
services were provided is covered under\--

\(1\) workers\' compensation laws, or

\(2\) a no-fault automobile accident insurance plan or program.

\(c\) No law of any State, or of any political subdivision of a State
and no provision of any contract entered into or renewed after the date
of enactment of the Indian Health Care Amendments of 1988, shall prevent
or hinder the right of recovery of the United States, an Indian tribe,
or tribal organization under subsection (a).

\(d\) No action taken by the United States, an Indian tribe, or tribal
organization to enforce the right of recovery provided under subsection
(a) shall affect the right of any person to any damages (other than
damages for the cost of health services provided by the Secretary
through the Service).

\(e\) The United States, an Indian tribe, or tribal organization, may
enforce the right of recovery provided under subsection (a) by\--

\(1\) intervening or joining in any civil action or proceeding
brought\--

\(A\) by the individual for whom health services were provided by the
Secretary, an Indian tribe or tribal organization or

\(B\) by any representative or heirs of such individual, or

+----------------------------------------------------------------------+
|   ---------------------------------------------------                |
| -------------------------------------------------------------------- |
| -------------------------------------------------------------------- |
| -------------------------------------------------------------------- |
| -------------------------------------------------------------------- |
| -------------------------------------------------------------------- |
| -------------------------------------------------------------------- |
|   \(2\) instituting a ~~separate~~ civil action[. A                  |
| ll reasonable efforts shall be made to provide notice of such action |
|  to the individual to whom health services were provided, either bef |
| ore or during the pendency of such action.]{.underline} ~~, after pr |
| oviding such individual, or to the representative or heirs of such i |
| ndividual, notice of the intention of the United States, an Indian t |
| ribe, or tribal organization to institute a separate civil action.~~ |
|   ---------------------------------------------------                |
| -------------------------------------------------------------------- |
| -------------------------------------------------------------------- |
| -------------------------------------------------------------------- |
| -------------------------------------------------------------------- |
| -------------------------------------------------------------------- |
| -------------------------------------------------------------------- |
|                                                                      |
| *As amended this section, which was moved from Title II, tries to    |
| close loopholes that may exist in efforts to force insurance         |
| companies to pay Indian health programs for services they provide.*  |
+----------------------------------------------------------------------+
|                                                                      |
+----------------------------------------------------------------------+

\(f\) The United States shall not have a right of recovery under this
section if the injury, illness, or disability for which health services
were provided is covered under a self-insurance plan funded by an Indian
tribe or tribal organization, unless such tribe or tribal organization
has authorized in writing such a right of recovery.

+----------------------------------------------------------------------+
|   --                                                                 |
|   --                                                                 |
|                                                                      |
| *Some self-insurance plans already make voluntary payments, however  |
| OGC has issued an opinion that such payments may not be permissible  |
| without authority. *                                                 |
+----------------------------------------------------------------------+
|                                                                      |
+----------------------------------------------------------------------+

[(g) In any action brought to enforce the provisions of this section, a
prevailing plaintiff shall be awarded its reasonable attorneys fees and
costs of litigation.]{.underline}

  -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- --
  [(h) Where an insurance company or employee benefit plan fails or refuses to pay the amount due under (a) of this section for services provided to an individual who is a beneficiary, participant, or insured of such company or plan, the United States, Indian tribe, or tribal organization shall have a right to assert and pursue all the claims and remedieis against such company or plan, and against the fiduciaries of such company or plan, that the individual could assert or pursue under applicable Federal or State law.]{.underline}   
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
  -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- --

**CREDITING OF REIMBURSEMENTS**

**SEC. [409]{.underline} ~~207~~. **(a) Except as provided in section
202(d), title IV, and section 813 of this Act, all reimbursements
received or recovered, under authority of this Act, Public Law 87-693
(42 U.S.C. § 2651, et seq.), or any other provision of law, by reason of
the provision of health services by the Service or by a tribe or tribal
organization under a contract pursuant to the Indian Self-Determination
[and Education Assistance]{.underline} Act shall be retained by the
Service or that tribe or tribal organization and shall be available for
the facilities, and to carry out the programs, of the Service or that
tribe or tribal organization to provide health care services to Indians.

  ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ --
  \(b\) The Service may not offset or limit the amount of funds obligated to any service unit or entity under contract with the Service because of the receipt of reimbursements under subsection (a).   
                                                                                                                                                                                                         
  ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ --

**MANAGED CARE**

** SEC. [410]{.underline} ~~210~~. (a) [PURCHASING MANAGED CARE
COVERAGE.]{.underline}**[ Tribes and tribal organizations are authorized
to utilize funding from the Secretary under this Act to purchase managed
care coverage for IHS beneficiaries]{.underline}

~~ (b) The Secretary, acting through the Service, shall[
]{.underline}conduct a study to assess the feasibility of allowing an
Indian tribe to purchase, directly or through the Service, managed care
coverage for all members of the tribe~~ from--

\(1\) a tribally owned and operated managed care plan; or

\(2\) a State [or locally-authorized or]{.underline} licensed managed
care plan.

~~ (b[c]{.underline}) Not later than the date which is 12 months after
the date of the enactment of this section, the Secretary shall transmit
to the Congress a report containing--~~

~~(1) a detailed description of the [any]{.underline} study conducted
pursuant to this section; and~~

+----------------------------------------------------------------------+
|   -------------------                                                |
| -------------------------------------------------------------------- |
|   ~~(2) a discussio                                                  |
| n of the findings and conclusions of [any]{.underline} such study.~~ |
|   -------------------                                                |
| -------------------------------------------------------------------- |
|                                                                      |
| *Subsection (a) is a revision of former section 210. All of the rest |
| is new and is intended to ensure that managed care plans must        |
| reimburse I/T/Us for the services they provide. *                    |
+----------------------------------------------------------------------+
|                                                                      |
+----------------------------------------------------------------------+

** [(b) RECOVERY FROM MANAGED CARE PLANS.]{.underline}**[ (1)
Notwithstanding any other provision in law, the Indian Health Service,
an Indian tribe or tribal organization shall have a right of recovery
from all private and public health plans, including Medicare, Medicaid,
children's health insurance and privately managed care plans for the
reasonable costs of delivering health services to Indians entitled to
receive services from the Service, a tribe or tribal organization.
]{.underline}

[(2) No provision of a contract, regulation or statute may be relied
upon or interpreted to deny or reduce payments otherwise due under this
section, except to the extent the Service, Indian tribe or tribal
organization has entered into an agreement with the managed care plan
regarding services to be provided or rates to be paid, provided that
such an agreement may not be made a prerequisite for such payments to be
made.]{.underline}

[(3) Payments due under this section may not be less than those paid to
a "preferred provider" under the managed care plan or, in the event
there is no such rate, the usual and customary fee for equivalent
services.]{.underline}

+----------------------------------------------------------------------+
| +----------------------------------------------------------------+   |
| | +----------------------------------------------------------+   |   |
| | | +----------------------------------------------------+   |   |   |
| | | | +----------------------------------------------+   |   |   |   |
| | | | | +----------------------------------------+   |   |   |   |   |
| | | | | | +----------------------------------+   |   |   |   |   |   |
| | | | | | | +----------------------------+   |   |   |   |   |   |   |
| | | | | | | | +----------------------+   |   |   |   |   |   |   |   |
| | | | | | | | |   --                 |   |   |   |   |   |   |   |   |
| | | | | | | | | -------------------- |   |   |   |   |   |   |   |   |
| | | | | | | | | -------------------- |   |   |   |   |   |   |   |   |
| | | | | | | | | -------------------- |   |   |   |   |   |   |   |   |
| | | | | | | | | -------------------- |   |   |   |   |   |   |   |   |
| | | | | | | | | -------------------- |   |   |   |   |   |   |   |   |
| | | | | | | | | -------------------- |   |   |   |   |   |   |   |   |
| | | | | | | | | -------------------- |   |   |   |   |   |   |   |   |
| | | | | | | | | -------------------- |   |   |   |   |   |   |   |   |
| | | | | | | | |                      |   |   |   |   |   |   |   |   |
| | | | | | | | | [(4) A managed care  |   |   |   |   |   |   |   |   |
| | | | | | | | | plan may not deny pa |   |   |   |   |   |   |   |   |
| | | | | | | | | yment under this sec |   |   |   |   |   |   |   |   |
| | | | | | | | | tion because the ins |   |   |   |   |   |   |   |   |
| | | | | | | | | ured or covered bene |   |   |   |   |   |   |   |   |
| | | | | | | | | ficiary of the plan  |   |   |   |   |   |   |   |   |
| | | | | | | | | has not submitted a  |   |   |   |   |   |   |   |   |
| | | | | | | | | claim. ]{.underline} |   |   |   |   |   |   |   |   |
| | | | | | | | |   --                 |   |   |   |   |   |   |   |   |
| | | | | | | | | -------------------- |   |   |   |   |   |   |   |   |
| | | | | | | | | -------------------- |   |   |   |   |   |   |   |   |
| | | | | | | | | -------------------- |   |   |   |   |   |   |   |   |
| | | | | | | | | -------------------- |   |   |   |   |   |   |   |   |
| | | | | | | | | -------------------- |   |   |   |   |   |   |   |   |
| | | | | | | | | -------------------- |   |   |   |   |   |   |   |   |
| | | | | | | | | -------------------- |   |   |   |   |   |   |   |   |
| | | | | | | | | -------------------- |   |   |   |   |   |   |   |   |
| | | | | | | | |                      |   |   |   |   |   |   |   |   |
| | | | | | | | | *HCFA has expressed  |   |   |   |   |   |   |   |   |
| | | | | | | | | concern about        |   |   |   |   |   |   |   |   |
| | | | | | | | | State's recouping    |   |   |   |   |   |   |   |   |
| | | | | | | | | twice for payments   |   |   |   |   |   |   |   |   |
| | | | | | | | | made if the Indian   |   |   |   |   |   |   |   |   |
| | | | | | | | | health provider      |   |   |   |   |   |   |   |   |
| | | | | | | | | receives payment     |   |   |   |   |   |   |   |   |
| | | | | | | | | directly from the    |   |   |   |   |   |   |   |   |
| | | | | | | | | State. When the      |   |   |   |   |   |   |   |   |
| | | | | | | | | Finance Work Group   |   |   |   |   |   |   |   |   |
| | | | | | | | | subcommittee meets   |   |   |   |   |   |   |   |   |
| | | | | | | | | with HCFA on         |   |   |   |   |   |   |   |   |
| | | | | | | | | 7/26/99, perhaps     |   |   |   |   |   |   |   |   |
| | | | | | | | | HCFA will suggest    |   |   |   |   |   |   |   |   |
| | | | | | | | | some language.*      |   |   |   |   |   |   |   |   |
| | | | | | | | +----------------------+   |   |   |   |   |   |   |   |
| | | | | | | | |                      |   |   |   |   |   |   |   |   |
| | | | | | | | +----------------------+   |   |   |   |   |   |   |   |
| | | | | | | |                            |   |   |   |   |   |   |   |
| | | | | | | | [(5) Notwithstanding       |   |   |   |   |   |   |   |
| | | | | | | | subsections (1) through    |   |   |   |   |   |   |   |
| | | | | | | | (4) of this section, the   |   |   |   |   |   |   |   |
| | | | | | | | Indian Health Service, an  |   |   |   |   |   |   |   |
| | | | | | | | Indian tribe or tribal     |   |   |   |   |   |   |   |
| | | | | | | | organization that provides |   |   |   |   |   |   |   |
| | | | | | | | a health service to an     |   |   |   |   |   |   |   |
| | | | | | | | Indian entitled under      |   |   |   |   |   |   |   |
| | | | | | | | Title XIX (medicaid) or    |   |   |   |   |   |   |   |
| | | | | | | | Title XXI (children's      |   |   |   |   |   |   |   |
| | | | | | | | health insurance program)  |   |   |   |   |   |   |   |
| | | | | | | | of the Social Security Act |   |   |   |   |   |   |   |
| | | | | | | | to receive such services   |   |   |   |   |   |   |   |
| | | | | | | | shall have the right to be |   |   |   |   |   |   |   |
| | | | | | | | paid directly by the       |   |   |   |   |   |   |   |
| | | | | | | | state's Medicaid or        |   |   |   |   |   |   |   |
| | | | | | | | children's health          |   |   |   |   |   |   |   |
| | | | | | | | insurance program          |   |   |   |   |   |   |   |
| | | | | | | | notwithstanding any        |   |   |   |   |   |   |   |
| | | | | | | | agreements the State may   |   |   |   |   |   |   |   |
| | | | | | | | have entered into with     |   |   |   |   |   |   |   |
| | | | | | | | managed care organizations |   |   |   |   |   |   |   |
| | | | | | | | or providers.]{.underline} |   |   |   |   |   |   |   |
| | | | | | | +----------------------------+   |   |   |   |   |   |   |
| | | | | | |                                  |   |   |   |   |   |   |
| | | | | | | *This is intended to minimize    |   |   |   |   |   |   |
| | | | | | | the extent to which Indian       |   |   |   |   |   |   |
| | | | | | | health programs are forced to do |   |   |   |   |   |   |
| | | | | | | business with MCOs as a          |   |   |   |   |   |   |
| | | | | | | condition of getting paid. It    |   |   |   |   |   |   |
| | | | | | | creates the need for             |   |   |   |   |   |   |
| | | | | | | reconciliation by the State with |   |   |   |   |   |   |
| | | | | | | the MCOs so they don't benefit   |   |   |   |   |   |   |
| | | | | | | unjustly. No language has been   |   |   |   |   |   |   |
| | | | | | | written yet to address that.*    |   |   |   |   |   |   |
| | | | | | +----------------------------------+   |   |   |   |   |   |
| | | | | | |                                  |   |   |   |   |   |   |
| | | | | | +----------------------------------+   |   |   |   |   |   |
| | | | | |                                        |   |   |   |   |   |
| | | | | | *During the HCFA meeting the tribes    |   |   |   |   |   |
| | | | | | would like technical assistance about  |   |   |   |   |   |
| | | | | | how to require MCOs to enter into      |   |   |   |   |   |
| | | | | | contracts with Indian health programs  |   |   |   |   |   |
| | | | | | so that they can be providers under    |   |   |   |   |   |
| | | | | | the MCO.*                              |   |   |   |   |   |
| | | | | +----------------------------------------+   |   |   |   |   |
| | | | | |                                        |   |   |   |   |   |
| | | | | +----------------------------------------+   |   |   |   |   |
| | | | |                                              |   |   |   |   |
| | | | | **[(c) PROHIBIT AUTO- AND DEFAULT            |   |   |   |   |
| | | | | ASSIGNMENT.]{.underline}**[ Notwithstanding  |   |   |   |   |
| | | | | any other provision of law or any waiver     |   |   |   |   |
| | | | | granted by the Secretary, no Indian may be   |   |   |   |   |
| | | | | assigned automatically or by default under   |   |   |   |   |
| | | | | any managed care plan paid under Title XIX   |   |   |   |   |
| | | | | (medicaid) or Title XXI (children's health   |   |   |   |   |
| | | | | insurance program) of the Social Security    |   |   |   |   |
| | | | | Act unless the person had the option of      |   |   |   |   |
| | | | | enrolling in a managed care plan or health   |   |   |   |   |
| | | | | program administered by the Service or an    |   |   |   |   |
| | | | | Indian tribe or tribal organization in which |   |   |   |   |
| | | | | case an Indian may be assigned only to such  |   |   |   |   |
| | | | | a managed care plan or health                |   |   |   |   |
| | | | | program.]{.underline}                        |   |   |   |   |
| | | | +----------------------------------------------+   |   |   |   |
| | | |                                                    |   |   |   |
| | | | *This section is intended to ensure that Indians   |   |   |   |
| | | | are not assigned without their consent to          |   |   |   |
| | | | non-Indian managed care plans.*                    |   |   |   |
| | | +----------------------------------------------------+   |   |   |
| | | |                                                    |   |   |   |
| | | +----------------------------------------------------+   |   |   |
| | |                                                          |   |   |
| | | **[(d) INDIAN MANAGED CARE PLANS.]{.underline}**[        |   |   |
| | | Notwithstanding any other provision of law, any State    |   |   |
| | | entering into agreements with one or more managed care   |   |   |
| | | organizations to provide services under Title XIX or     |   |   |
| | | Title XXI of the Social Security Act must enter into     |   |   |
| | | such an agreement with the Service, an Indian tribe or   |   |   |
| | | tribal organization that can provide services to Indians |   |   |
| | | who may be eligible or required to enroll in such a      |   |   |
| | | managed care plan similar to those to be offered by      |   |   |
| | | other managed care organizations. The Secretary and the  |   |   |
| | | State are hereby authorized to waive requirements        |   |   |
| | | regarding discrimination, capitalization and other       |   |   |
| | | matters that might otherwise prevent the Indian managed  |   |   |
| | | care organization or health program from meeting Federal |   |   |
| | | or State standards applicable to such organizations,     |   |   |
| | | provided such Indian managed care organization or health |   |   |
| | | program must be able to offer its Indian enrollees       |   |   |
| | | services of an equivalent quality to that required of    |   |   |
| | | other managed care organizations.]{.underline}           |   |   |
| | +----------------------------------------------------------+   |   |
| |                                                                |   |
| | *This section is intended to allow Indian health programs and  |   |
| | managed care plans to be offered to Medicaid and CHIP          |   |
| | beneficiaries in States that have implemented managed care. It |   |
| | allows waiver of any requirement except those related to the   |   |
| | quality of the health services to be delivered. *              |   |
| +----------------------------------------------------------------+   |
| |                                                                |   |
| +----------------------------------------------------------------+   |
|                                                                      |
| *After obtaining technical assistance from HCFA, a section will be   |
| added requiring tribal approval for an MCO to advertise on a         |
| reservation as a condition of including advertising costs in a cost  |
| report. *                                                            |
+----------------------------------------------------------------------+
|                                                                      |
+----------------------------------------------------------------------+

**[FORM OF CLAIMS]{.underline}**

+----------------------------------------------------------------------+
|   ------------------------------------------                         |
| -------------------------------------------------------------------- |
| -------------------------------------------------------------------- |
| -------------------------------------------------------------------- |
| -------------------------------------------------------------------- |
| -------------------------------------------------------------------- |
| -------------------------------------------------------------------- |
|   ** [SEC. 411.]{.underline}**[ Notwithsta                           |
| nding any other provision in law, the Indian Health Service, a tribe |
|  or tribal organization, and an urban Indian organization shall have |
|  a right of recovery for any claim filed on a current HCFA-1500 or U |
| B-92 form, or the current NSF electronic format, or their successors |
| . No health plan shall deny payment because a claim has not been sub |
| mitted in a unique format that differs from such forms.]{.underline} |
|   ------------------------------------------                         |
| -------------------------------------------------------------------- |
| -------------------------------------------------------------------- |
| -------------------------------------------------------------------- |
| -------------------------------------------------------------------- |
| -------------------------------------------------------------------- |
| -------------------------------------------------------------------- |
|                                                                      |
| *This new subsection is intended to prevent imposition of unique     |
| claims filing requirements.*                                         |
+----------------------------------------------------------------------+
|                                                                      |
+----------------------------------------------------------------------+

**INDIAN HEALTH SERVICE,~~ AND~~ DEPARTMENT OF VETERAN\'S AFFAIRS,[ AND
OTHER FEDERAL AGENCY ]{.underline} HEALTH FACILITIES AND SERVICES
SHARING**

**Sec. [412]{.underline} ~~816~~.** (a) The Secretary shall examine the
feasibility of entering into ~~an~~ arrangement[s]{.underline} [or
expanding existing arrangements]{.underline} for the sharing of medical
facilities and services between the Indian Health Service and the
Veterans' Administration, [and other appropriate federal agencies,
including those within the Department,]{.underline} and shall, in
accordance with subsection (b), prepare a report on the feasibility of
such an arrangement and submit such report to the Congress by no later
than September 30, ~~1990~~[ 2000, provided that the Secretary may not
finalize any such agreement without first consulting with the affected
Indian tribes]{.underline}.

\(b\) The Secretary shall not take any action under this section or
under subchapter IV of chapter 81 of title 38, United States Code, which
would impair\--

\(1\) the priority access of any Indian to health care services provided
through the Indian Health Service;

\(2\) the quality of health care services provided to any Indian through
the Indian Health Service;

\(3\) the priority access of any veteran to health care services
provided by the Veterans\' Administration;

\(4\) the quality of health care services provided to any veteran by the
Veteran\'s Administration;

\(5\) the eligibility of any Indian to receive health services through
the Indian Health Service; or

\(6\) the eligibility of any Indian who is a veteran to receive health
services through the Veterans\' Administration[ provided, however, the
Service or the Indian tribe or tribal organization shall be reimbursed
by the VA where services are provided through the Service, Indian tribes
or tribal organizations to beneficiaries eligible for services from the
VA, notwithstanding any other provision of law]{.underline}.

(c)(1) Within 30 days after the date of enactment of this section, the
Director of the Indian Health Service and the Administrator of
Veterans\' Affairs are authorized and directed to implement an agreement
which\--

\(A\) individuals in the vicinity of Roosevelt, Utah, who are eligible
for health care from the Veterans\' Administration could obtain health
care services at the facilities of the Indian Health Service located at
Fort Duchesne, Utah; and

\(B\) individuals eligible for health care from the Indian Health
Service at Fort Duchesne, Utah, could obtain health care services at the
Veterans\' Administration medical center located in Salt Lake City,
Utah.

+----------------------------------------------------------------------+
| +----------------------------------------------------------------+   |
| | +----------------------------------------------------------+   |   |
| | |   ----------------------                                 |   |   |
| | | -------------------------------------------------------- |   |   |
| | | -------------------------------------------------------- |   |   |
| | | -------------------------------------------------------- |   |   |
| | | -------------------------------------------------------- |   |   |
| | |   \(2\) Not later than                                   |   |   |
| | |  2 years after the date of enactment of this section, th |   |   |
| | | e Secretary and the Administrator of Veterans\' Affairs  |   |   |
| | | shall jointly submit a report to the Congress on the hea |   |   |
| | | lth care services provided as a result of paragraph (1). |   |   |
| | |   ----------------------                                 |   |   |
| | | -------------------------------------------------------- |   |   |
| | | -------------------------------------------------------- |   |   |
| | | -------------------------------------------------------- |   |   |
| | | -------------------------------------------------------- |   |   |
| | |                                                          |   |   |
| | | *This section is intended to assure that the IHS is the  |   |   |
| | | payor of last resort vis-a-vis VA and to permit          |   |   |
| | | additional sharing of facilities and other resources.*   |   |   |
| | +----------------------------------------------------------+   |   |
| | |                                                          |   |   |
| | +----------------------------------------------------------+   |   |
| |                                                                |   |
| | \(d\) [The Director of the IHS is authorized to enter into     |   |
| | agreements with other Federal agencies to assist in achieving  |   |
| | parity in services for American Indians. Agreements under this |   |
| | subsection shall be subject to the contracting and funding     |   |
| | agreements provision of the Indian Self-Determination and      |   |
| | Education Assistance Act. ]{.underline}Nothing in this section |   |
| | may be construed as creating any right of a veteran to obtain  |   |
| | health services from the Indian Health Service except as       |   |
| | provided in an agreement under subsection (c).                 |   |
| +----------------------------------------------------------------+   |
|                                                                      |
| *We need to ensure that there is no conflict with the permanent      |
| self-governance legislation.*                                        |
+----------------------------------------------------------------------+
|                                                                      |
+----------------------------------------------------------------------+

**[CHILDREN]{.underline}[']{.underline}[S HEALTH INSURANCE PROGRAM
FEDERAL MEDICAL ]{.underline}[ASSISTANCE PERCENTAGE]{.underline}**

**[Sec. 413.]{.underline}**[ Section 2101(c) of the Social Security Act
is amended by the addition of a new sentence, to read:]{.underline}

+----------------------------------------------------------------------+
|   --------------------                                               |
| -------------------------------------------------------------------- |
| -------------------------------------------------------------------- |
| -------------------------------------------------------------------- |
| -------------------------------------------------------------------- |
| -------------------------------------------------------------------- |
| -------------------------------------------------------------------- |
|   [Without regard to                                                 |
|  which option a state chooses under section 2101(a), the Federal med |
| ical assistance percentage shall be 100 per centum with respect to a |
| mounts expended as medical assistance for services which are provide |
| d through a health program operated by the Indian Health Service or  |
| an Indian tribe or tribal organization (as those terms are defined i |
| n section 4 of the Indian Health Care Improvement Act).]{.underline} |
|   --------------------                                               |
| -------------------------------------------------------------------- |
| -------------------------------------------------------------------- |
| -------------------------------------------------------------------- |
| -------------------------------------------------------------------- |
| -------------------------------------------------------------------- |
| -------------------------------------------------------------------- |
|                                                                      |
| *Makes the Federal match rate for CHIP 100% for states that operate  |
| freestanding programs, as well as those operated under the Medicaid  |
| program. *                                                           |
+----------------------------------------------------------------------+
|                                                                      |
+----------------------------------------------------------------------+

**[NAVAJO NATION DEMONSTRATION PROJECTS]{.underline}**

+----------------------------------------------------------------------+
|   ------------------------------------------------------------       |
| -------------------------------------------------------------------- |
| -------------------------------------------------------------------- |
| -------------------------------------------------------------------- |
| -------------------------------------------------------------------- |
| -------------------------------------------------------------------- |
| -------------------------------------------------------------------- |
|   **[Sec. 414. (a) TUBA CITY DEMONSTRATION PROJECT.]{.underl         |
| ine}**[ Notwithstanding any other provision of law, including the An |
| ti-Deficiency Act, provided the Indian tribes to be served approve,  |
| the Service is authorized to enter into a demonstration project with |
|  the State of Arizona under which the Service would provide certain  |
| specified Medicaid services to IHS/Medicaid eligibles in return for  |
| payment on a capitated basis from the State of Arizona.]{.underline} |
|   ------------------------------------------------------------       |
| -------------------------------------------------------------------- |
| -------------------------------------------------------------------- |
| -------------------------------------------------------------------- |
| -------------------------------------------------------------------- |
| -------------------------------------------------------------------- |
| -------------------------------------------------------------------- |
|                                                                      |
| *This is the language provided by the Navajo Nation that is          |
| necessary to permit the IHS to act as an MCO in Arizona. *           |
+----------------------------------------------------------------------+
|                                                                      |
+----------------------------------------------------------------------+

** [(b)NAVAJO NATION MEDICAID AGENCY.]{.underline}**[ (1)
Notwithstanding any other provision of law, the Secretary shall have the
authority to officially designate the Navajo Nation as a single state
medicaid agency as defined in Title XIX the Social Security Act, for
purposes of creating a unified Navajo Nation medicaid agency for the
provision of services to Indians living within the boundaries of the
Navajo Nation.]{.underline}

[(2) Notwithstanding any other provision of law, the Secretary shall
have the authority to assign and pay all funds for the provision of
services to Indians living within the boundaries of the Navajo Nation
under Title XIX of the Social Security Act and related administrative
funds under Title XIX (medicaid) of the Social Security Act, which are
currently paid to or would otherwise be paid to the states of Arizona,
New Mexico and Utah, to an entity established by the Navajo Nation and
approved by the Secretary, which shall be denominated the Navajo Nation
Medicaid Agency.]{.underline}

[(3) The Navajo Nation Medicaid Agency shall serve Indians living within
the boundaries of the Navajo Nation and shall have the same authority
and perform the same functions as other single state medicaid agencies.
]{.underline}

[(4) The Secretary is authorized to directly assist the Navajo Nation in
the development and implementation of a Navajo Nation Medicaid Agency
for the administration, eligibility, payment and delivery of Medicaid
eligible services, including western and traditional Navajo healing
services, within the Navajo Nation.]{.underline}

[(5) Notwithstanding section 1905(b) of the Social Security Act, the
Federal medical assistance percentage shall be 100 per centum with
respect to amounts the Navajo Nation Medicaid agency expends for medical
assistance for services and for related administrative
costs.]{.underline}

[(6) The Secretary is further authorized to assist the Navajo Nation by
providing funding including demonstration grant funding for this
project.]{.underline}

[(7) The Secretary shall have the authority to waive applicable
provisions of Title XIX of the Social Security Act to establish, develop
and implement the Navajo Nation Medicaid Agency.]{.underline}

+--------------------------------------------------------------------------+
| +----------------------------------------------------------------------+ |
| |   -------------------                                                | |
| | -------------------------------------------------------------------- | |
| | -------------------------------------------------------------------- | |
| | -------------------------------------------------------------------- | |
| | -------------------------------------------------------------------- | |
| |   [(8) In the optio                                                  | |
| | n of the Navajo Nation, the Navajo Nation Medicaid Agency may also a | |
| | ssume responsibility for delivery of services under Title XXI (child | |
| | ren's health insurance program) under terms equivalent to those desc | |
| | ribed in paragraphs (1) through (7) of this subsection.]{.underline} | |
| |   -------------------                                                | |
| | -------------------------------------------------------------------- | |
| | -------------------------------------------------------------------- | |
| | -------------------------------------------------------------------- | |
| | -------------------------------------------------------------------- | |
| |                                                                      | |
| | *This subsection authorizes the Navajo Nation to establish a         | |
| | Medicaid agency to serve Indians residing within the boundaries of   | |
| | the Nation. This will provide an opportunity to test a direct        | |
| | relationship with HCFA.*                                             | |
| +----------------------------------------------------------------------+ |
| |                                                                      | |
| +----------------------------------------------------------------------+ |
|                                                                          |
| **[(c) INSURANCE CARD FEASIBILITY STUDY.]{.underline}**                  |
+--------------------------------------------------------------------------+

*This is a placeholder for the possible inclusion of an additional
feasibility study that the Navajo Nation is considering. The Nation is
concerned with mechanisms to assure all Navajo health beneficiaries
access to health services when residing off reservation, perhaps through
establishing relationships with providers who offer services outside the
boundaries of the Nation and providing its members with an insurance
card. *

  ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
  *The Navajo Nation wishes to determine the feasibility of such a program. This study would include: (a) determining the numbers of tribal menbers to be served; (b) defining a benefit package; (c) analysis of the cost associated with the plan; (d) identification of potential legal and regulatory barriers; (e) consultation with other I/T/U providers who might be involved; (f) analysis of overall costs and benefits and (g) identification of possible test sites. The findings of this feasibility study will then be used to determine whether to proceed with an actual test phase of the study. The Secretary acting through the Service would, through grant or contract make funds available for the study and waive any regulatory or legal barriers for a study and to provide assistance and support including funding for certain aspects of the study. *
  ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

**[CONSULTATION AND RULEMAKING]{.underline}**

**[Sec. 415. (a) CONSULTATION.]{.underline}**[ Prior to the adoption of
any policy or regulation, the Health Care Financing Administration shall
\-- ]{.underline}

[(1) identify the impact such policy or regulation may have on the
Service, Indian tribes and tribal organizations; ]{.underline}

[(2) provide to the Service, Indian tribes and tribal organizations the
information described in paragraph (1); ]{.underline}

[(3) engage in consultation with the Service, Indian tribes and tribal
organizations entities prior to enacting any such policy or regulation.
Such consultation shall be consistent with the requirements of Executive
Order 13084 of May 14, 1998.]{.underline}

+----------------------------------------------------------------------+
|   ----------------------------------------------------               |
| -------------------------------------------------------------------- |
| -------------------------------------------------------------------- |
| -------------------------------------------------------------------- |
| -------------------------------------------------------------------- |
| -------------------------------------------------------------------- |
|   **[(b) RULEMAKING.]{.underline}**[ The Health Care                 |
|  Financing Administration shall participate in the negotiated rulema |
| king provided for under Title VIII of this Act with regard to any re |
| gulations necessary to implement the provisions of this Title IV. No |
|  rules may be adopted regarding any matter addressed in this Title I |
| V, except as agreed upon in such negotiated rulemaking.]{.underline} |
|   ----------------------------------------------------               |
| -------------------------------------------------------------------- |
| -------------------------------------------------------------------- |
| -------------------------------------------------------------------- |
| -------------------------------------------------------------------- |
| -------------------------------------------------------------------- |
|                                                                      |
| *This section is intended to ensure that HCFA provides meaningful    |
| consultation, which requires that it first analyze the impact of its |
| proposed action on the Indian health system, and limits HCFA's       |
| authority to adopt rules regarding the matters covered by this title |
| except through negotiated rulemaking.*                               |
+----------------------------------------------------------------------+
|                                                                      |
+----------------------------------------------------------------------+

**[SAFE HARBOR]{.underline}**

**[Sec. 416.]{.underline}**[ (a) The term "remuneration" as used in
sections 1128A and 1128B of the Social Security Act \[42 U.S.C. 1320a-7a
and 42 U.S.C. 1320a-7b\] shall not include any exchange of anything of
value from or to any Indian tribe or tribal organization that
administers health programs under the authority of the Indian
Self-Determination and Education Assistance Act \[ 25 U.S.C. 450 et
seq.)\], provided the exchange relates to a health program administered
by the Indian Health Service or such tribe or tribal
organization.]{.underline}

+----------------------------------------------------------------------+
| +----------------------------------------------------------------+   |
| | +----------------------------------------------------------+   |   |
| | | +----------------------------------------------------+   |   |   |
| | | | +----------------------------------------------+   |   |   |   |
| | | | |   -----------------                          |   |   |   |   |
| | | | | -------------------------------------------- |   |   |   |   |
| | | | | -------------------------------------------- |   |   |   |   |
| | | | | -------------------------------------------- |   |   |   |   |
| | | | | -------------------------------------------- |   |   |   |   |
| | | | | -------------------------------------------- |   |   |   |   |
| | | | | -------------------------------------------- |   |   |   |   |
| | | | | -------------------------------------------- |   |   |   |   |
| | | | | -------------------------------------------- |   |   |   |   |
| | | | | -------------------------------------------- |   |   |   |   |
| | | | | -------------------------------------------- |   |   |   |   |
| | | | | -------------------------------------------- |   |   |   |   |
| | | | | -------------------------------------------- |   |   |   |   |
| | | | | -------------------------------------------- |   |   |   |   |
| | | | |   [(b) An Indian                             |   |   |   |   |
| | | | | tribe or tribal organization that administer |   |   |   |   |
| | | | | s health programs under the authority of the |   |   |   |   |
| | | | |  Indian Self-Determination and Education Ass |   |   |   |   |
| | | | | istance Act \[25 U.S.C. 450 et seq.\] shall  |   |   |   |   |
| | | | | be deemed to be an agency of the United Stat |   |   |   |   |
| | | | | es and immune from liability under the Sherm |   |   |   |   |
| | | | | an Act \[15 U.S.C. 1 et seq.\], the Clayton  |   |   |   |   |
| | | | | Act \[15 U.S.C. 12 et seq.\], the Robinson-P |   |   |   |   |
| | | | | atman Act, the Federal Trade Commission Act  |   |   |   |   |
| | | | | \[15 U.S.C 41 et seq.\] and any other federa |   |   |   |   |
| | | | | l, state, or local antitrust laws, with rega |   |   |   |   |
| | | | | rd to any transaction, agreement, or conduct |   |   |   |   |
| | | | |  that relates to such programs.]{.underline} |   |   |   |   |
| | | | |   -----------------                          |   |   |   |   |
| | | | | -------------------------------------------- |   |   |   |   |
| | | | | -------------------------------------------- |   |   |   |   |
| | | | | -------------------------------------------- |   |   |   |   |
| | | | | -------------------------------------------- |   |   |   |   |
| | | | | -------------------------------------------- |   |   |   |   |
| | | | | -------------------------------------------- |   |   |   |   |
| | | | | -------------------------------------------- |   |   |   |   |
| | | | | -------------------------------------------- |   |   |   |   |
| | | | | -------------------------------------------- |   |   |   |   |
| | | | | -------------------------------------------- |   |   |   |   |
| | | | | -------------------------------------------- |   |   |   |   |
| | | | | -------------------------------------------- |   |   |   |   |
| | | | | -------------------------------------------- |   |   |   |   |
| | | | |                                              |   |   |   |   |
| | | | | *This section was recommended by the Finance |   |   |   |   |
| | | | | Work Group, but was not reviewed by the full |   |   |   |   |
| | | | | Steering Committee. It is intended to ensure |   |   |   |   |
| | | | | that limitations on patient referral and     |   |   |   |   |
| | | | | other inter-provider arrangements do not     |   |   |   |   |
| | | | | apply within the Indian health system.*      |   |   |   |   |
| | | | +----------------------------------------------+   |   |   |   |
| | | | |                                              |   |   |   |   |
| | | | +----------------------------------------------+   |   |   |   |
| | | |                                                    |   |   |   |
| | | | **[Sec. 417. URBAN INDIAN ORGANIZATIONS.           |   |   |   |
| | | | ]{.underline}**[For the sole purpose of providing  |   |   |   |
| | | | for recovery from and participation in programs    |   |   |   |
| | | | under Title XVIII (medicare), Title XIX (medicaid) |   |   |   |
| | | | and Title XXI (children's health insurance         |   |   |   |
| | | | program) of the Social Security Act and ensuring   |   |   |   |
| | | | that Indians residing in areas served by urban     |   |   |   |
| | | | Indian organizations receive culturally competent  |   |   |   |
| | | | care through programs controlled by Indians, in    |   |   |   |
| | | | Title IV of this Act the term "tribal              |   |   |   |
| | | | organization" shall include urban Indian           |   |   |   |
| | | | organizations as that term is defined in Section 4 |   |   |   |
| | | | of this Act. This provision shall not be           |   |   |   |
| | | | interpreted to extend to urban Indian              |   |   |   |
| | | | organizations any other right or privilege of a    |   |   |   |
| | | | tribe or tribal organization unless explicitly set |   |   |   |
| | | | forth in law.]{.underline}                         |   |   |   |
| | | +----------------------------------------------------+   |   |   |
| | |                                                          |   |   |
| | | *This section is a placeholder to reflect the            |   |   |
| | | recommendation that urban Indian organizations, which    |   |   |
| | | provide direct health care services, should have full    |   |   |
| | | access to the reimbursement and protections provided by  |   |   |
| | | this Title. A further more detailed review of each       |   |   |
| | | section needs to be done to be sure that only            |   |   |
| | | appropriate sections are referenced here. In addition,   |   |   |
| | | it is likely that additional provisions will be needed   |   |   |
| | | to ensure the Social Security Act is appropriately       |   |   |
| | | amended to carry out the intent of this provision.*      |   |   |
| | +----------------------------------------------------------+   |   |
| | |                                                          |   |   |
| | +----------------------------------------------------------+   |   |
| |                                                                |   |
| | **[Sec. 418. TRIBAL                                            |   |
| | EMPLOYMENT]{.underline}[[                                      |   |
| | .]{.underline}]{.smallcaps}[[---]{.underline}]{.smallcaps}**[[ |   |
| | ]{.underline}]{.smallcaps}[For purposes of section 2(2), Act   |   |
| | of July 5, 1935, as amended (49 Stat. 450, chapter 372), an    |   |
| | Indian tribe or tribal organization carrying out a funding     |   |
| | agreement under the Self-Determination and Education           |   |
| | Assistance Act shall not be considered an                      |   |
| | "employer."]{.underline}                                       |   |
| +----------------------------------------------------------------+   |
|                                                                      |
| *This section is referred for review at the National Tribal meeting. |
| It was not reviewed by the full Steering Committee. This section     |
| exempts tribal health programs from the NLRB. It probably should be  |
| in Title I or VIII.*                                                 |
+----------------------------------------------------------------------+
|                                                                      |
+----------------------------------------------------------------------+

**[PRIME VENDOR]{.underline}**

+----------------------------------------------------------------------+
|   ----------------------------------------------------               |
| -------------------------------------------------------------------- |
| -------------------------------------------------------------------- |
| -------------------------------------------------------------------- |
| -------------------------------------------------------------------- |
| -------------------------------------------------------------------- |
| -------------------------------------------------------------------- |
| -------------------------------------------------------------------- |
| -------------------------------------------------------------------- |
| -------------------------------------------------------------------- |
|   ** [Sec. 419.]{.underline}**[ For purposes of sec                  |
| tion 4 of Public Law 102-585 (38 U.S.C. Section 8126) tribes and tri |
| bal organizations carrying out a grant, cooperative agreement or fun |
| ding agreement under the Indian Self-Determination and Education Ass |
| istance Act (25 U.S.C. Section 450 et. seq.) shall be deemed to be a |
| n executive agency and part of the Indian Health Service in the Depa |
| rtment of Health and Human Services and, as such, may act as an orde |
| ring agent of the Indian Health Service and the employees of the tri |
| be or tribal organization may order supplies on behalf thereof on th |
|  same basis as employees of the Indian Health Service. ]{.underline} |
|   ----------------------------------------------------               |
| -------------------------------------------------------------------- |
| -------------------------------------------------------------------- |
| -------------------------------------------------------------------- |
| -------------------------------------------------------------------- |
| -------------------------------------------------------------------- |
| -------------------------------------------------------------------- |
| -------------------------------------------------------------------- |
| -------------------------------------------------------------------- |
| -------------------------------------------------------------------- |
|                                                                      |
| *This ensures that tribal health programs have full access to the VA |
| and other Federal purchasing programs. It probably should be in      |
| Title I or VIII.*                                                    |
+----------------------------------------------------------------------+
|                                                                      |
+----------------------------------------------------------------------+

**[MEDICAID FEDERALLY QUALIFIED HEALTH CENTER PAYMENTS]{.underline}**

**[Sec. 420. ]{.underline}**[Section 1902(a)(13) of the Social Security
Act is amended by adding the following:]{.underline}

+----------------------------------------------------------------------+
|   -----------------------------------------------------              |
| -------------------------------------------------------------------- |
| -------------------------------------------------------------------- |
| -------------------------------------------------------------------- |
| -------------------------------------------------------------------- |
| -------------------------------------------------------------------- |
| -------------------------------------------------------------------- |
| -------------------------------------------------------------------- |
| -------------------------------------------------------------------- |
|   [(D)(i) for payment for services described in claus                |
| e (C) of section 1905(a)(2) under the plan furnished by the Service, |
|  an Indian tribe, tribal organization or urban Indian organization ( |
| as defined in section 4 of the Indian Health Care Improvement Act) o |
| f 100 percent of costs which are reasonable and related to the cost  |
| of furnishing such services or based on other tests of reasonablenes |
| s as the Secretary prescribes in regulations under section 1833(a)(3 |
| ), or, in the case of services to which those regulations do not app |
| ly, the same methodology used under section 1833(a)(3).]{.underline} |
|   -----------------------------------------------------              |
| -------------------------------------------------------------------- |
| -------------------------------------------------------------------- |
| -------------------------------------------------------------------- |
| -------------------------------------------------------------------- |
| -------------------------------------------------------------------- |
| -------------------------------------------------------------------- |
| -------------------------------------------------------------------- |
| -------------------------------------------------------------------- |
|                                                                      |
| *This section has not been reviewed by the Finance Work Group or the |
| full Steering Committee, but was agreed upon conceptually.*          |
+----------------------------------------------------------------------+
|                                                                      |
+----------------------------------------------------------------------+

**[MEDICAID MANAGED CARE ORGANIZATION PAYMENTS TO
]{.underline}[FEDERALLY QUALIFIED HEALTH CENTERS]{.underline}**

** [Sec. 421.]{.underline}**[ Section 1902(a)(13) of the Social Security
Act is amended by adding the following:]{.underline}

+----------------------------------------------------------------------+
|   ---------------------------------------------------------          |
| -------------------------------------------------------------------- |
| -------------------------------------------------------------------- |
| -------------------------------------------------------------------- |
| -------------------------------------------------------------------- |
| -------------------------------------------------------------------- |
| -------------------------------------------------------------------- |
| -------------------------------------------------------------------- |
| -------------------------------------------------------------------- |
|   [(D)(ii) in carrying out clause (i) in the case of serv            |
| ices furnished by a Federally-qualified health center that is operat |
| ed by the Service, an Indian tribe, tribal organization or urban Ind |
| ian organization (as defined in section 4 of the Indian Health Care  |
| Improvement Act) pursuant to a contract between the center and an or |
| ganization under section 1903(m), for payment to the center at least |
|  quarterly by the State of a supplemental payment equal to the amoun |
| t (if any) by which the amount determined under clause (i) exceeds t |
| he amount of the payments provided under such contract.]{.underline} |
|   ---------------------------------------------------------          |
| -------------------------------------------------------------------- |
| -------------------------------------------------------------------- |
| -------------------------------------------------------------------- |
| -------------------------------------------------------------------- |
| -------------------------------------------------------------------- |
| -------------------------------------------------------------------- |
| -------------------------------------------------------------------- |
| -------------------------------------------------------------------- |
|                                                                      |
| *This section has not been reviewed by the Finance Work Group or the |
| full Steering Committee, but was agreed upon conceptually.*          |
+----------------------------------------------------------------------+
|                                                                      |
+----------------------------------------------------------------------+

**[LIMITATION ON SECRETARY]{.underline}[']{.underline}[S WAIVER
AUTHORITY]{.underline}**

  ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
  ** [Sec. 422. ]{.underline}**[Notwithstanding any other provision of law, the Secretary may not waive the application of section 1902(a)(13)(D) to any state Plan under Title XIX of the Social Security Act.]{.underline}
  ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

*This section has not been reviewed by the Finance Work Group or the
full Steering Committee, but was agreed upon conceptually.*

  -----------------------------------------------------------
  *Waivers granted or renewed on or after October 1, 1999.*
  -----------------------------------------------------------

**AUTHORIZATION OF APPROPRIATIONS **

  --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- --
  **SEC. [423]{.underline} ~~407~~.** There are authorized to be appropriated such sums as may be necessary for each fiscal year through fiscal year [2012]{.underline} ~~2000~~ to carry out this title.   
  --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- --