```

[Senate Report 114-376]
[From the U.S. Government Publishing Office]

                                                      Calendar No. 671
114th Congress     }                                    {       Report
                                 SENATE
 2d Session        }                                    {      114-376

======================================================================
 
  A BILL TO AMEND THE INDIAN HEALTH CARE IMPROVEMENT ACT TO ALLOW THE 
INDIAN HEALTH SERVICE TO COVER THE COST OF A COPAYMENT OF AN INDIAN OR 
   ALASKA NATIVE VETERAN RECEIVING MEDICAL CARE OR SERVICES FROM THE 
         DEPARTMENT OF VETERANS AFFAIRS, AND FOR OTHER PURPOSES

                                _______
                                

               November 16, 2016.--Ordered to be printed

                                _______
                                

          Mr. Barrasso, from the Committee on Indian Affairs, 
                        submitted the following

                              R E P O R T

                         [To accompany S. 2417]

    The Committee on Indian Affairs, to which was referred the 
bill (S. 2417) to amend the Indian Health Care Improvement Act 
to allow the Indian Health Service to cover the cost of a 
copayment of an Indian or Alaska Native veteran receiving 
medical care or services from the Department of Veterans 
Affairs, and for other purposes, having considered the same, 
reports favorably thereon without amendment and recommends that 
the bill do pass.

                                Purpose

    The purpose of this bill is to amend section 222(a) of the 
Indian Health Care Improvement Act (IHCIA). It would authorize 
the Indian Health Service (IHS) to cover the cost of copayments 
for American Indian or Alaska Native (collectively referred to 
as ``Indian'') veterans receiving medical care or services from 
the Department of Veterans Affairs (VA) upon an authorized 
referral from the IHS. The bill would require an MOU between 
the IHS and VA that allows the IHS to use Purchase Referred 
Care Program funds (PRC) to cover the cost of VA copayments 
assessed upon Indian veterans who are treated, through a IHS 
referral, at a VA facility. Under the PRC program, the IHS may 
reimburse private non-IHS healthcare providers for treating 
Indian patients using PRC funds (PRC funds).

                          Need for Legislation

    This bill is needed to amend current federal law to clarify 
that the IHS is authorized to use PRC funding to cover the 
copayment cost of an Indian veteran being treated at a VA 
healthcare facility with an approved referral from an IHS 
provider.

                               Background

    Originally enacted in 1976,\1\ the IHCIA was permanently 
authorized as part of the Patient Protection and Affordable 
Care Act.\2\ The IHCIA governs many programs for the provision 
of health care services and programs for Indians.
---------------------------------------------------------------------------
    \1\Pub. L. No. 94-437, Sept. 30, 1976, 90 Stat. 1400 (codified at 
25 U.S.C. Sec. Sec. 1601-1683).
    \2\Pub. L. No. 111-148, Mar. 23, 2010, 124 Stat. 119 (codified at 
42 U.S.C. Sec. 18001 et seq.).
---------------------------------------------------------------------------
    The IHS is the primary agency responsible for providing 
federal health care services to Indians either directly or 
through contracts or compacts negotiated with Indian tribes. 
When specific healthcare services are not available through IHS 
or tribal providers, the IHS may, through the PRC program, 
provide referrals to Indian patients so that they can be 
treated by non-IHS healthcare providers.
    The IHCIA allows for the IHS and VA to enter into 
agreements for the reimbursement of healthcare services.\3\ 
Under federal law, IHS can be reimbursed by the VA for 
providing services for eligible beneficiaries.\4\ However, 
according to IHS, under federal law\5\ there is no authority 
for a provider, including the VA, to impose financial liability 
on an IHS patient pursuant to an authorized PRC referral.\6\ 
The prohibition against liability of payment for health 
services to Indian patients would include a VA copay assessed 
for Indian veterans that receive care at VA facilities pursuant 
to an IHS referral. As a result, VA is not able to be 
reimbursed from PRC funds for the copay assessed upon an Indian 
veteran who, pursuant to the PRC referral, has received 
services at a VA facility.
---------------------------------------------------------------------------
    \3\25 U.S.C. Sec. 1645(a)(1)
    \4\25 U.S.C. Sec. 1645(c)
    \5\See 25 U.S.C. Sec. 1623(b) and 25 U.S.C. Sec. 1647(c)) as cited 
in official congressional correspondence with IHS.
    \6\25 U.S.C. 1621u
---------------------------------------------------------------------------

                          Legislative History

    On December 15, 2015, Senator Thune introduced S. 2417 with 
Senator Rounds as a cosponsor. On May 11, 2016, the Committee 
held a legislative hearing on the bill in which Roger Trudell, 
Chairman of the Santee Sioux Tribe and Indian veteran, 
testified in favor of the bill. The administration did not 
provide testimony on the bill at the hearing. On June 6, 2016 
the Committee met in a duly called business meeting to consider 
the bill. The Committee then ordered the bill to be reported 
favorably without amendment to the Senate.

        Section-by-Section Analysis of Bill as Ordered Reported

Section 1--Short title

    Section 1 states that the Act may be cited as the ``Tribal 
Veterans Health Care Enhancement Act''.

Section 2--Copayments for Indian veterans receiving certain medical 
        services

    Section 2(a) amends Section 222(a) of the Indian Health 
Care Improvement Act (25 U.S.C. 1621u(a)) by authorizing the 
IHS to pay for copayments assessed to eligible Indian veterans 
by the Department of Veterans Affairs.
    Section 2(b) provides a definition of eligible Indian 
veterans as a veteran that (1) receives an authorized referral 
from IHS and (2) has their healthcare services administered at 
a VA facility.
    Section 2(b) amends section 2901(b) of the Patient 
Protection and Affordable Care Act (25 U.S.C. 1623(b)) to 
provide authorization for the VA to accept copayments from the 
IHS.
    Section 2(c) requires the IHS and VA to enter into a 
Memorandum of Understanding (MOU) to provide for the payment of 
copayments.
    Section 2(c) provides that the required MOU can be waived 
if the IHS and VA certify to Congress that doing so would 
decrease the quality of care or impede access to medical care 
for the patients that they serve.
    Section 2(c) requires the Director of the IHS and Secretary 
of the VA to submit, within 45 days of enactment, a report to 
the Committee on Indian Affairs of the Senate, Committee on 
Veterans Affairs of the Senate, the Committee on Veterans 
Affairs of the House of Representatives, and Committee on 
Natural Resources of the House of Representatives a report that 
includes:
           the number, by state, of eligible Indian 
        veterans utilizing VA medical facilities;
           the number of referrals, by state, received 
        annually from the Indian Health Service from 2010 to 
        2015; and
           an update on efforts at the VA and IHS to 
        streamline care for eligible Indian veterans who 
        receive care at both the VA and the IHS including 
        changes required under the Indian Health Care 
        Improvement Act and any barriers to achieve 
        efficiencies.

                   Cost and Budgetary Considerations

    The following cost estimate for S. 2417, as provided by the 
Congressional Budget Office, dated September 12, 2016.

                                                September 12, 2016.
Hon. John Barrasso,
Chairman, Committee on Indian Affairs,
U.S. Senate, Washington, DC.
    Dear Mr. Chairman: The Congressional Budget Office has 
prepared the enclosed cost estimate for S. 2417, the Tribal 
Veterans Health Care Enhancement Act.
    If you wish further details on this estimate, we will be 
pleased to provide them. The CBO staff contact is Robert 
Stewart.
            Sincerely,
                                                        Keith Hall.
    Enclosure.

S. 2417--Tribal Veterans Health Care Enhancement Act

    S. 2417 would allow the Indian Health Service (IHS) to 
cover the cost of any copayment assessed by the Department of 
Veterans Affairs (VA) to an eligible Indian veteran who is 
referred to the VA for treatment. Based on an analysis of 
information from an IHS report regarding Indian veterans, CBO 
estimates that there would be, on average, about 5,000 Indian 
veterans treated annually at IHS facilities over the 2017 to 
2021 period. Some of these Indian veterans would be referred to 
VA health facilities for more complex care that could not be 
provided at IHS facilities. A small percentage of those 
referred veterans would make copayments to the VA based on 
their VA priority group. Using information provided by the VA 
regarding the collection of copayments from veterans, CBO 
estimates that S. 2417 would cost less than $500,000 over the 
2017 to 2021 period; such spending would be subject to the 
availability of appropriated funds. Enacting S. 2417 would not 
affect direct spending or revenues; therefore, pay-as-you-go 
procedures do not apply.
    CBO estimates that enacting S. 2417 would not increase net 
direct spending or on-budget deficits in any of the four 
consecutive 10-year periods beginning in 2027.
    S. 2417 contains no intergovernmental or private-sector 
mandates as defined in the Unfunded Mandates Reform Act and 
would not affect the budgets of state, local, or tribal 
governments. American Indian and Alaska Native military 
veterans would benefit from provisions in the bill that 
authorize copayments for medical treatment received from the 
VA.
    The CBO staff contact for this estimate is Robert Stewart. 
The estimate was approved by Holly Harvey, Deputy Assistant 
Director for Budget Analysis.

                        Executive Communications

    The Committee has received no communications from the 
Executive Branch regarding S. 2417.

               Regulatory and Paperwork Impact Statement

    Paragraph 11(b) of rule XXVI of the Standing Rules of the 
Senate requires each report accompanying a bill to evaluate the 
regulatory and paperwork impact that would be incurred in 
carrying out the bill. The Committee believes that S. 2417 will 
have a minimal impact on regulatory or paperwork requirements.

                 Changes in Existing Law (Cordon Rule)

    In accordance with subsection 12 of rule XXVI of the 
Standing Rules of the Senate, changes in existing law made by 
S. 2417, as ordered reported, are shown as follows (existing 
law proposed to be omitted is enclosed in black brackets, new 
matter is printed in italic):

        25 U.S.C. Sec. 1621 (Indian Healthcare Improvement Act)

SEC. 222. LIABILITY FOR PAYMENT.

    (a) No Patient Liability.--
          [A patient] (1) In general.--Subject to paragraph 
        (2), a patient who receives contract health care 
        services that are authorized by the Service shall not 
        be liable for the payment of any charges or costs 
        associated with the provision of such services. 
          (2) Veterans affairs copayments.--The Service may 
        pay, in accordance with section 405(d), the cost of a 
        copayment assessed by the Department of Veterans 
        Affairs to an eligible Indian veteran (as defined in 
        section 405(d)(1)).

        25 U.S.C. Sec. 1645 (Indian Healthcare Improvement Act)

SEC. 405. SHARING ARRANGEMENTS WITH FEDERAL AGENCIES.

    (a) Authority.--
          (1) In general.--The Secretary may enter into (or 
        expand) arrangements for the sharing of medical 
        facilities and services between the Service, Indian 
        tribes, and tribal organizations and the Department of 
        Veterans Affairs and the Department of Defense.
          (2) Consultation by secretary required.--The 
        Secretary may not finalize any arrangement between the 
        Service and a Department described in paragraph (1) 
        without first consulting with the Indian tribes which 
        will be significantly affected by the arrangement.
    (b) Limitations.--The Secretary shall not take any action 
under this section or under subchapter IV of chapter 81 of 
title 38 which would impair--
          (1) the priority access of any Indian to health care 
        services provided through the Service and the 
        eligibility of any Indian to receive health services 
        through the Service;
          (2) the quality of health care services provided to 
        any Indian through the Service;
          (3) the priority access of any veteran to health care 
        services provided by the Department of Veterans 
        Affairs;
          (4) the quality of health care services provided by 
        the Department of Veterans Affairs or the Department of 
        Defense; or
          (5) the eligibility of any Indian who is a veteran to 
        receive health services through the Department of 
        Veterans Affairs.
    (c) Reimbursement.--The Service, Indian tribe, or tribal 
organization shall be reimbursed by the Department of Veterans 
Affairs or the Department of Defense (as the case may be) where 
services are provided through the Service, an Indian tribe, or 
a tribal organization to beneficiaries eligible for services 
from either such Department, notwithstanding any other 
provision of law.
    (d) Payments for Eligible Indian Veterans Receiving Medical 
Services at VA Facilities.--
          (1) Definition of eligible indian veteran.--In this 
        subsection, the term ``eligible Indian veteran'' means 
        an Indian or Alaska Native veteran who receives any 
        medical care or service that is--
                  (A) authorized on referral by the Service; 
                and
                  (B) administered at a facility of the 
                Department of Veterans Affairs.
          (2) Payment by service.--Notwithstanding any other 
        provision of law, the Service may cover the cost of any 
        copayment assessed by the Department of Veterans 
        Affairs to an eligible Indian veteran receiving 
        services authorized under the Purchased/Referred Care 
        program.
          (3) Authorization to accept funds.--Notwithstanding 
        section 407(c) of this Act, section 2901(b) of the 
        Patient Protection and Affordable Care Act (25 U.S.C. 
        1623(b)), or any other provision of law, the Secretary 
        of Veterans Affairs may accept a payment from the 
        Service under paragraph (2).
    [(d)](e) Construction.--Nothing in this section may be 
construed as creating any right of a non-Indian veteran to 
obtain health services from the Service.

                                  [all]
```