### §1616a. Indian Health Service Loan Repayment Program

#### (a) Establishment

(1) The Secretary, acting through the Service, shall establish a program to be known as the Indian Health Service Loan Repayment Program (hereinafter referred to as the "Loan Repayment Program") in order to assure an adequate supply of trained health professionals necessary to maintain accreditation of, and provide health care services to Indians through, Indian health programs.

(2) For the purposes of this section—

(A) the term "Indian health program" means any health program or facility funded, in whole or part, by the Service for the benefit of Indians and administered—

(i) directly by the Service;

(ii) by any Indian tribe or tribal or Indian organization pursuant to a contract under—

(I) the Indian Self-Determination Act [25 U.S.C. 5321 et seq.], or

(II) section 23 of the Act of April 30, 1908 1 (25 U.S.C. 47), popularly known as the "Buy-Indian" Act; or

(iii) by an urban Indian organization pursuant to subchapter IV of this chapter; and

(B) the term "State" has the same meaning given such term in section 254d(i)(4) 1 of title 42.

#### (b) Eligibility

To be eligible to participate in the Loan Repayment Program, an individual must—

(1)(A) be enrolled—

(i) in a course of study or program in an accredited institution, as determined by the Secretary, within any State and be scheduled to complete such course of study in the same year such individual applies to participate in such program; or

(ii) in an approved graduate training program in a health profession; or

(B) have—

(i) a degree in a health profession; and

(ii) a license to practice a health profession in a State;

(2)(A) be eligible for, or hold, an appointment as a commissioned officer in the Regular or Reserve Corps 2 of the Public Health Service;

(B) be eligible for selection for civilian service in the Regular or Reserve Corps 2 of the Public Health Service;

(C) meet the professional standards for civil service employment in the Indian Health Service; or

(D) be employed in an Indian health program without a service obligation; and

(3) submit to the Secretary an application for a contract described in subsection (f).

#### (c) Application and contract forms

(1) In disseminating application forms and contract forms to individuals desiring to participate in the Loan Repayment Program, the Secretary shall include with such forms a fair summary of the rights and liabilities of an individual whose application is approved (and whose contract is accepted) by the Secretary, including in the summary a clear explanation of the damages to which the United States is entitled under subsection (l) in the case of the individual's breach of the contract. The Secretary shall provide such individuals with sufficient information regarding the advantages and disadvantages of service as a commissioned officer in the Regular or Reserve Corps 2 of the Public Health Service or a civilian employee of the Indian Health Service to enable the individual to make a decision on an informed basis.

(2) The application form, contract form, and all other information furnished by the Secretary under this section shall be written in a manner calculated to be understood by the average individual applying to participate in the Loan Repayment Program.

(3) The Secretary shall make such application forms, contract forms, and other information available to individuals desiring to participate in the Loan Repayment Program on a date sufficiently early to ensure that such individuals have adequate time to carefully review and evaluate such forms and information.

#### (d) Vacancies; priority

(1) Consistent with paragraph (3), the Secretary, acting through the Service and in accordance with subsection (k), shall annually—

(A) identify the positions in each Indian health program for which there is a need or a vacancy, and

(B) rank those positions in order of priority.

(2) Consistent with the priority determined under paragraph (1), the Secretary, in determining which applications under the Loan Repayment Program to approve (and which contracts to accept), shall give priority to applications made by—

(A) Indians; and

(B) individuals recruited through the efforts of Indian tribes or tribal or Indian organizations.

(3)(A) Subject to subparagraph (B), of the total amounts appropriated for each of the fiscal years 1993, 1994, and 1995 for loan repayment contracts under this section, the Secretary shall provide that—

(i) not less than 25 percent be provided to applicants who are nurses, nurse practitioners, or nurse midwives; and

(ii) not less than 10 percent be provided to applicants who are mental health professionals (other than applicants described in clause (i)).

(B) The requirements specified in clause (i) or clause (ii) of subparagraph (A) shall not apply if the Secretary does not receive the number of applications from the individuals described in clause (i) or clause (ii), respectively, necessary to meet such requirements.

#### (e) Approval

(1) An individual becomes a participant in the Loan Repayment Program only upon the Secretary and the individual entering into a written contract described in subsection (f).

(2) The Secretary shall provide written notice to an individual promptly on—

(A) the Secretary's approving, under paragraph (1), of the individual's participation in the Loan Repayment Program, including extensions resulting in an aggregate period of obligated service in excess of 4 years; or

(B) the Secretary's disapproving an individual's participation in such Program.

#### (f) Contract terms

The written contract referred to in this section between the Secretary and an individual shall contain—

(1) an agreement under which—

(A) subject to paragraph (3), the Secretary agrees—

(i) to pay loans on behalf of the individual in accordance with the provisions of this section, and

(ii) to accept (subject to the availability of appropriated funds for carrying out this section) the individual into the Service or place the individual with a tribe or Indian organization as provided in subparagraph (B)(iii), and

(B) subject to paragraph (3), the individual agrees—

(i) to accept loan payments on behalf of the individual;

(ii) in the case of an individual described in subsection (b)(1)—

(I) to maintain enrollment in a course of study or training described in subsection (b)(1)(A) until the individual completes the course of study or training, and

(II) while enrolled in such course of study or training, to maintain an acceptable level of academic standing (as determined under regulations of the Secretary by the educational institution offering such course of study or training);

(iii) to serve for a time period (hereinafter in this section referred to as the "period of obligated service") equal to 2 years or such longer period as the individual may agree to serve in the full-time clinical practice of such individual's profession in an Indian health program to which the individual may be assigned by the Secretary;

(2) a provision permitting the Secretary to extend for such longer additional periods, as the individual may agree to, the period of obligated service agreed to by the individual under paragraph (1)(B)(iii);

(3) a provision that any financial obligation of the United States arising out of a contract entered into under this section and any obligation of the individual which is conditioned thereon is contingent upon funds being appropriated for loan repayments under this section;

(4) a statement of the damages to which the United States is entitled under subsection (l) for the individual's breach of the contract; and

(5) such other statements of the rights and liabilities of the Secretary and of the individual, not inconsistent with this section.

#### (g) Loan repayment purposes; maximum amount; tax liability reimbursement; schedule of payments

(1) A loan repayment provided for an individual under a written contract under the Loan Repayment Program shall consist of payment, in accordance with paragraph (2), on behalf of the individual of the principal, interest, and related expenses on government and commercial loans received by the individual regarding the undergraduate or graduate education of the individual (or both), which loans were made for—

(A) tuition expenses;

(B) all other reasonable educational expenses, including fees, books, and laboratory expenses, incurred by the individual; and

(C) reasonable living expenses as determined by the Secretary.

(2)(A) For each year of obligated service that an individual contracts to serve under subsection (f) the Secretary may pay up to $35,000 (or an amount equal to the amount specified in section 254l–1(g)(2)(A) of title 42) on behalf of the individual for loans described in paragraph (1). In making a determination of the amount to pay for a year of such service by an individual, the Secretary shall consider the extent to which each such determination—

(i) affects the ability of the Secretary to maximize the number of contracts that can be provided under the Loan Repayment Program from the amounts appropriated for such contracts;

(ii) provides an incentive to serve in Indian health programs with the greatest shortages of health professionals; and

(iii) provides an incentive with respect to the health professional involved remaining in an Indian health program with such a health professional shortage, and continuing to provide primary health services, after the completion of the period of obligated service under the Loan Repayment Program.

(B) Any arrangement made by the Secretary for the making of loan repayments in accordance with this subsection shall provide that any repayments for a year of obligated service shall be made no later than the end of the fiscal year in which the individual completes such year of service.

(3) For the purpose of providing reimbursements for tax liability resulting from payments under paragraph (2) on behalf of an individual, the Secretary—

(A) in addition to such payments, may make payments to the individual in an amount not less than 20 percent and not more than 39 percent of the total amount of loan repayments made for the taxable year involved; and

(B) may make such additional payments as the Secretary determines to be appropriate with respect to such purpose.

(4) The Secretary may enter into an agreement with the holder of any loan for which payments are made under the Loan Repayment Program to establish a schedule for the making of such payments.

#### (h) Effect on employment ceiling of Department of Health and Human Services

Notwithstanding any other provision of law, individuals who have entered into written contracts with the Secretary under this section, while undergoing academic training, shall not be counted against any employment ceiling affecting the Department of Health and Human Services.

#### (i) Recruiting programs

The Secretary shall conduct recruiting programs for the Loan Repayment Program and other health professional programs of the Service at educational institutions training health professionals or specialists identified in subsection (a).

#### (j) Prohibition of assignment to other government departments

Section 215 of title 42 shall not apply to individuals during their period of obligated service under the Loan Repayment Program.

#### (k) Staff needs of health programs administered by Indian tribes

The Secretary, in assigning individuals to serve in Indian health programs pursuant to contracts entered into under this section, shall—

(1) ensure that the staffing needs of Indian health programs administered by an Indian tribe or tribal or health organization receive consideration on an equal basis with programs that are administered directly by the Service; and

(2) give priority to assigning individuals to Indian health programs that have a need for health professionals to provide health care services as a result of individuals having breached contracts entered into under this section.

#### (l) Voluntary termination of study or dismissal from educational institution; collection of damages

(1) An individual who has entered into a written contract with the Secretary under this section and who—

(A) is enrolled in the final year of a course of study and who—

(i) fails to maintain an acceptable level of academic standing in the educational institution in which he is enrolled (such level determined by the educational institution under regulations of the Secretary);

(ii) voluntarily terminates such enrollment; or

(iii) is dismissed from such educational institution before completion of such course of study; or

(B) is enrolled in a graduate training program, fails to complete such training program, and does not receive a waiver from the Secretary under subsection (b)(1)(B)(ii),

shall be liable, in lieu of any service obligation arising under such contract, to the United States for the amount which has been paid on such individual's behalf under the contract.

(2) If, for any reason not specified in paragraph (1), an individual breaches his written contract under this section by failing either to begin, or complete, such individual's period of obligated service in accordance with subsection (f), the United States shall be entitled to recover from such individual an amount to be determined in accordance with the following formula:

### A=3Z(t-s/t)

in which—

(A) "A" is the amount the United States is entitled to recover;

(B) "Z" is the sum of the amounts paid under this section to, or on behalf of, the individual and the interest on such amounts which would be payable if, at the time the amounts were paid, they were loans bearing interest at the maximum legal prevailing rate, as determined by the Treasurer of the United States;

(C) "t" is the total number of months in the individual's period of obligated service in accordance with subsection (f); and

(D) "s" is the number of months of such period served by such individual in accordance with this section.

Amounts not paid within such period shall be subject to collection through deductions in Medicare payments pursuant to section 1395ccc of title 42.

(3)(A) Any amount of damages which the United States is entitled to recover under this subsection shall be paid to the United States within the 1-year period beginning on the date of the breach or such longer period beginning on such date as shall be specified by the Secretary.

(B) If damages described in subparagraph (A) are delinquent for 3 months, the Secretary shall, for the purpose of recovering such damages—

(i) utilize collection agencies contracted with by the Administrator of the General Services Administration; or

(ii) enter into contracts for the recovery of such damages with collection agencies selected by the Secretary.

(C) Each contract for recovering damages pursuant to this subsection shall provide that the contractor will, not less than once each 6 months, submit to the Secretary a status report on the success of the contractor in collecting such damages. Section 3718 of title 31 shall apply to any such contract to the extent not inconsistent with this subsection.

#### (m) Cancellation or waiver of obligations; bankruptcy discharge

(1) Any obligation of an individual under the Loan Repayment Program for service or payment of damages shall be canceled upon the death of the individual.

(2) The Secretary shall by regulation provide for the partial or total waiver or suspension of any obligation of service or payment by an individual under the Loan Repayment Program whenever compliance by the individual is impossible or would involve extreme hardship to the individual and if enforcement of such obligation with respect to any individual would be unconscionable.

(3) The Secretary may waive, in whole or in part, the rights of the United States to recover amounts under this section in any case of extreme hardship or other good cause shown, as determined by the Secretary.

(4) Any obligation of an individual under the Loan Repayment Program for payment of damages may be released by a discharge in bankruptcy under title 11 only if such discharge is granted after the expiration of the 5-year period beginning on the first date that payment of such damages is required, and only if the bankruptcy court finds that nondischarge of the obligation would be unconscionable.

#### (n) Annual report

The Secretary shall submit to the President, for inclusion in each report required to be submitted to the Congress under section 1671 of this title, a report concerning the previous fiscal year which sets forth—

(1) the health professional positions maintained by the Service or by tribal or Indian organizations for which recruitment or retention is difficult;

(2) the number of Loan Repayment Program applications filed with respect to each type of health profession;

(3) the number of contracts described in subsection (f) that are entered into with respect to each health profession;

(4) the amount of loan payments made under this section, in total and by health profession;

(5) the number of scholarship grants that are provided under section 1613a of this title with respect to each health profession;

(6) the amount of scholarship grants provided under section 1613a of this title, in total and by health profession;

(7) the number of providers of health care that will be needed by Indian health programs, by location and profession, during the three fiscal years beginning after the date the report is filed; and

(8) the measures the Secretary plans to take to fill the health professional positions maintained by the Service or by tribes or tribal or Indian organizations for which recruitment or retention is difficult.

(Pub. L. 94–437, title I, §108, as added Pub. L. 100–713, title I, §108, Nov. 23, 1988, 102 Stat. 4789; amended Pub. L. 102–573, title I, §§106(a)–(g)(1), (h), (i), 117(b)(3), title IX, §902(2)(C), (D), Oct. 29, 1992, 106 Stat. 4535–4537, 4544, 4591.)

#### **Editorial Notes**

#### References in Text

The Indian Self-Determination Act, referred to in subsec. (a)(2)(A)(ii)(I), is title I of Pub. L. 93–638, Jan. 4, 1975, 88 Stat. 2206, which is classified principally to subchapter I (§5321 et seq.) of chapter 46 of this title. For complete classification of this Act to the Code, see Short Title note set out under section 5301 of this title and Tables.

Section 23 of the Act of April 30, 1908, referred to in subsec. (a)(2)(A)(ii)(II), probably should be a reference to section 23 of act June 25, 1910, ch. 431, 36 Stat. 861, which is popularly known as the "Buy Indian Act", and is classified to section 47 of this title. Act Apr. 30, 1908, ch. 153, 35 Stat. 70, does not contain a section 23 but does have provisions (at 35 Stat. 71) similar to those in section 23 of act June 25, 1910, ch. 431, 36 Stat. 861.

Section 254d(i)(4) of title 42, referred to in subsec. (a)(2)(B), was redesignated section 254d(j)(4) of title 42 by Pub. L. 107–251, title III, §310(b)(1), Oct. 26, 2002, 116 Stat. 1643.

#### Amendments

1992—Subsec. (a)(1). Pub. L. 102–573, §106(a)(1), substituted "health professionals" for "physicians, dentists, nurses, nurse practitioners, physician assistants, clinical and counseling psychologists, graduates of schools of public health, graduates of schools of social work, and other health professionals".

Subsec. (b)(1)(A)(i). Pub. L. 102–573, §106(a)(2)(A)(i), amended cl. (i) generally. Prior to amendment, cl. (i) read as follows: "as a full-time student in the final year of a course of study or program in an accredited institution, as determined by the Secretary, within any State; or".

Subsec. (b)(1)(A)(ii). Pub. L. 102–573, §106(a)(2)(A)(ii), substituted "a health profession" for "medicine, osteopathy, dentistry, or other health profession".

Subsec. (b)(1)(B). Pub. L. 102–573, §106(a)(2)(B), in cl. (i), substituted "a degree in a health profession; and" for "a degree in medicine, osteopathy, dentistry, or other health profession;", redesignated cl. (iii) as (ii) and substituted "a health profession" for "medicine, osteopathy, dentistry, or other health profession", and struck out former cl. (ii) which read as follows: "completed an approved graduate training program in medicine, osteopathy, dentistry, or other health profession in a State, except that the Secretary may waive the completion requirement of this clause for good cause; and".

Subsec. (b)(2) to (4). Pub. L. 102–573, §106(a)(2)(C), inserted "and" at end of par. (2)(D), added par. (3), and struck out former pars. (3) and (4) which read as follows:

"(3) submit an application to participate in the Loan Repayment Program; and

"(4) sign and submit to the Secretary, at the time of submission of such application, a written contract (described in subsection (f) of this section) to accept repayment of educational loans and to serve (in accordance with this section) for the applicable period of obligated service in an Indian health program."

Subsec. (d)(1). Pub. L. 102–573, §106(b)(1), substituted "Consistent with paragraph (3), the" for "The".

Subsec. (d)(1)(A). Pub. L. 102–573, §902(2)(C), substituted "Indian health" for "Indian Health".

Subsec. (d)(3). Pub. L. 102–573, §106(b)(2), added par. (3).

Subsec. (e)(1). Pub. L. 102–573, §106(c), amended par. (1) generally. Prior to amendment, par. (1) read as follows: "An individual becomes a participant in the Loan Repayment Program only on the Secretary's approval of the individual's application submitted under subsection (b)(3) of this section and the Secretary's acceptance of the contract submitted by the individual under subsection (b)(4) of this section."

Subsec. (e)(2)(A). Pub. L. 102–573, §106(d), inserted ", including extensions resulting in an aggregate period of obligated service in excess of 4 years" before "; or".

Subsec. (g)(1). Pub. L. 102–573, §106(e), in introductory provisions, substituted "loans received by the individual regarding the undergraduate or graduate education of the individual (or both), which loans were made for" for "loans received by the individual for".

Subsec. (g)(2)(A). Pub. L. 102–573, §106(f), amended subpar. (A) generally. Prior to amendment, subpar. (A) read as follows: "Except as provided in subparagraph (B) and paragraph (3), for each year of obligated service for which an individual contracts to serve under subsection (f) of this section, the Secretary may pay up to $25,000 on behalf of the individual for loans described in paragraph (1)."

Subsec. (g)(3). Pub. L. 102–573, §106(g)(1), amended par. (3) generally. Prior to amendment, par. (3) read as follows: "In addition to payments made under paragraph (2), in any case in which payments on behalf of an individual under the Loan Repayment Program result in an increase in Federal, State, or local income tax liability for such individual, the Secretary may, on the request of such individual, make payments to such individual in a reasonable amount, as determined by the Secretary, to reimburse such individual for all or part of the increased tax liability of the individual."

Subsec. (i). Pub. L. 102–573, §902(2)(D), substituted "health professional programs of the Service" for "Service manpower programs".

Subsec. (k). Pub. L. 102–573, §106(h), amended subsec. (k) generally. Prior to amendment, subsec. (k) read as follows: "The Secretary shall ensure that the staffing needs of Indian health programs administered by any Indian tribe or tribal or Indian organization receive consideration on an equal basis with programs that are administered directly by the Service."

Subsec. (n). Pub. L. 102–573, §106(i), amended subsec. (n) generally. Prior to amendment, subsec. (n) consisted of pars. (1) and (2) requiring submission of annual reports to Congress by the first of March and the first of July of each year.

Subsec. (o). Pub. L. 102–573, §117(b)(3), struck out subsec. (o) which read as follows: "There are authorized to be appropriated such sums as may be necessary for each fiscal year to carry out the provisions of this section."

#### **Statutory Notes and Related Subsidiaries**

#### Change of Name

Reference to Reserve Corps of the Public Health Service deemed to be a reference to the Ready Reserve Corps, see section 204(c)(3) of Title 42, The Public Health and Welfare.

#### Effective Date of 1992 Amendment

Pub. L. 102–573, title I, §106(g)(2), Oct. 29, 1992, 106 Stat. 4537, provided that: "The amendment made by paragraph (1) [amending this section] shall apply only with respect to contracts under section 108 of the Indian Health Care Improvement Act [this section] entered into on or after the date of enactment of this Act [Oct. 29, 1992]."

1 See References in Text note below.

2 See Change of Name note below.