I 

108TH CONGRESS 

1ST SESSION H. R. 2440

To improve the implementation of the Federal responsibility for the care 

and education of Indian people by improving the services and facilities 

of Federal health programs for Indians and encouraging maximum participation of Indians in such programs, and for other purposes. 

IN THE HOUSE OF REPRESENTATIVES 

JUNE 11, 2003

Mr. YOUNG of Alaska (for himself, Mr. HAYWORTH, Mr. RENZI, Mr. COLE, 

Mr. HUNTER, Mr. MCKEON, Mr. PALLONE, Mr. RAHALL, Mr. GEORGE

MILLER of California, Mr. KILDEE, Mr. DINGELL, Mr. WAXMAN, Mr. 

RANGEL, Mr. CONYERS, Mr. OBERSTAR, Mr. GRIJALVA, Ms. 

MILLENDER-MCDONALD, Mr. FROST, Mr. KENNEDY of Rhode Island, 

Mr. FRANK of Massachusetts, Mr. FILNER, Mr. HONDA, Mr. CARSON of 

Oklahoma, Mr. ALLEN, Mr. ABERCROMBIE, Ms. LEE, Mrs. NAPOLITANO, 

Mr. FALEOMAVAEGA, Ms. MCCOLLUM, Mr. TOWNS, Mr. UDALL of New 

Mexico, Mr. UDALL of Colorado, Mr. KIND, Mr. LANTOS, Mr. INSLEE, 

Mr. STUPAK, Mr. BACA, Ms. KILPATRICK, Mrs. CHRISTENSEN, Mr. 

BLUMENAUER, and Ms. NORTON) introduced the following bill; which was 

referred to the Committee on Resources, and in addition to the Committees on Energy and Commerce, and Ways and Means, for a period to be 

subsequently determined by the Speaker, in each case for consideration 

of such provisions as fall within the jurisdiction of the committee concerned 

A BILL

To improve the implementation of the Federal responsibility 

for the care and education of Indian people by improving 

the services and facilities of Federal health programs 

for Indians and encouraging maximum participation of 

Indians in such programs, and for other purposes.
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1 Be it enacted by the Senate and House of Representa2 tives of the United States of America in Congress assembled, 

3 SECTION 1. SHORT TITLE. 

4 This Act may be cited as the ‘‘Indian Health Care 

5 Improvement Act Amendments of 2003’’. 

6 SEC. 2. INDIAN HEALTH CARE IMPROVEMENT ACT AMEND7 ED. 

8 The Indian Health Care Improvement Act (25 U.S.C. 

9 1601 et seq.) is amended to read as follows: 

10 ‘‘SECTION 1. SHORT TITLE; TABLE OF CONTENTS. 

11 ‘‘(a) SHORT TITLE.—This Act may be cited as the 

12 ‘Indian Health Care Improvement Act’. 

13 ‘‘(b) TABLE OF CONTENTS.—The table of contents 

14 for this Act is as follows:

Sec. 1. Short title. 

Sec. 2. Indian Health Care Improvement Act amended. 

‘‘Sec. 1. Short title; table of contents. 

‘‘Sec. 2. Findings. 

‘‘Sec. 3. Declaration of National Indian health policy. 

‘‘Sec. 4. Definitions. 

‘‘TITLE I—INDIAN HEALTH, HUMAN RESOURCES, AND 

DEVELOPMENT 

‘‘Sec. 101. Purpose. 

‘‘Sec. 102. Health Professions Recruitment Program for Indians. 

‘‘Sec. 103. Health Professions Preparatory Scholarship Program for Indians. 

‘‘Sec. 104. Indian health professions scholarships. 

‘‘Sec. 105. American Indians into psychology program. 

‘‘Sec. 106. Funding for tribes for scholarship programs. 

‘‘Sec. 107. Indian Health Service extern programs. 

‘‘Sec. 108. Continuing education allowances. 

‘‘Sec. 109. Community Health Representative Program. 

‘‘Sec. 110. Indian Health Service Loan Repayment Program. 

‘‘Sec. 111. Scholarship and loan repayment recovery fund. 

‘‘Sec. 112. Recruitment activities. 

‘‘Sec. 113. Indian recruitment and retention program. 

‘‘Sec. 114. Advanced training and research. 
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‘‘Sec. 115. Quentin N. Burdick American Indians into nursing program. 

‘‘Sec. 116. Tribal cultural orientation. 

‘‘Sec. 117. Inmed program. 

‘‘Sec. 118. Health training programs of community colleges. 

‘‘Sec. 119. Retention bonus. 

‘‘Sec. 120. Nursing residency program. 

‘‘Sec. 121. Community Health Aide Program for Alaska. 

‘‘Sec. 122. Tribal health program administration. 

‘‘Sec. 123. Health professional chronic shortage demonstration programs. 

‘‘Sec. 124. Treatment of scholarships for certain purposes. 

‘‘Sec. 125. National Health Service Corps. 

‘‘Sec. 126. Substance abuse counselor educational curricula demonstration 

programs. 

‘‘Sec. 127. Mental health training and community education programs. 

‘‘Sec. 128. Designation of shortage areas. 

‘‘Sec. 129. Authorization of appropriations. 

‘‘TITLE II—HEALTH SERVICES 

‘‘Sec. 201. Indian Health Care Improvement Fund. 

‘‘Sec. 202. Catastrophic Health Emergency Fund. 

‘‘Sec. 203. Health promotion and disease prevention services. 

‘‘Sec. 204. Diabetes prevention, treatment, and control. 

‘‘Sec. 205. Shared services for long-term care. 

‘‘Sec. 206. Health services research. 

‘‘Sec. 207. Mammography and other cancer screening. 

‘‘Sec. 208. Patient travel costs. 

‘‘Sec. 209. Epidemiology centers. 

‘‘Sec. 210. Comprehensive school health education programs. 

‘‘Sec. 211. Indian Youth Program. 

‘‘Sec. 212. Prevention, control, and elimination of communicable and infectious diseases. 

‘‘Sec. 213. Authority for provision of other services. 

‘‘Sec. 214. Indian women’s health care. 

‘‘Sec. 215. Environmental and nuclear health hazards. 

‘‘Sec. 216. Arizona as a contract health service delivery area. 

‘‘Sec. 216A. North Dakota as a contract health service delivery area. 

‘‘Sec. 216B. South Dakota as a contract health service delivery area. 

‘‘Sec. 217. California contract health services program. 

‘‘Sec. 218. California as a contract health service delivery area. 

‘‘Sec. 219. Contract health services for the Trenton Service Area. 

‘‘Sec. 220. Programs operated by Indian tribes and tribal organizations. 

‘‘Sec. 221. Licensing. 

‘‘Sec. 222. Notification of provision of emergency contract health services. 

‘‘Sec. 223. Prompt action on payment of claims. 

‘‘Sec. 224. Liability for payment. 

‘‘Sec. 225. Authorization of appropriations. 

‘‘TITLE III—FACILITIES 

‘‘Sec. 301. Consultation; construction and renovation of facilities; reports. 

‘‘Sec. 302. Sanitation facilities. 

‘‘Sec. 303. Preference to Indians and Indian firms. 

‘‘Sec. 304. Expenditure of nonservice funds for renovation. 

‘‘Sec. 305. Funding for the construction, expansion, and modernization of 

small ambulatory care facilities. 
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‘‘Sec. 306. Indian Health Care Delivery Demonstration Project. 

‘‘Sec. 307. Land transfer. 

‘‘Sec. 308. Leases, contracts, and other agreements. 

‘‘Sec. 309. Loans, loan guarantees, and loan repayment. 

‘‘Sec. 310. Tribal leasing. 

‘‘Sec. 311. Indian Health Service/tribal facilities joint venture program. 

‘‘Sec. 312. Location of facilities. 

‘‘Sec. 313. Maintenance and improvement of health care facilities. 

‘‘Sec. 314. Tribal management of federally owned quarters. 

‘‘Sec. 315. Applicability of Buy American Act requirement. 

‘‘Sec. 316. Other funding for facilities. 

‘‘Sec. 317. Authorization of appropriations. 

‘‘TITLE IV—ACCESS TO HEALTH SERVICES 

‘‘Sec. 401. Treatment of payments under Social Security Act health care 

programs. 

‘‘Sec. 402. Grants to and funding agreements with the Service, Indian 

tribes, tribal organizations, and urban Indian organizations. 

‘‘Sec. 403. Reimbursement from certain third parties of costs of health 

services. 

‘‘Sec. 404. Crediting of reimbursements. 

‘‘Sec. 405. Purchasing health care coverage. 

‘‘Sec. 406. Sharing arrangements with Federal agencies. 

‘‘Sec. 407. Payor of last resort. 

‘‘Sec. 408. Nondiscrimination in qualifications for reimbursement for services. 

‘‘Sec. 409. Consultation. 

‘‘Sec. 410. State children’s health insurance program (SCHIP). 

‘‘Sec. 411. Social Security Act sanctions. 

‘‘Sec. 412. Cost sharing. 

‘‘Sec. 413. Treatment under medicaid managed care. 

‘‘Sec. 414. Navajo nation medicaid agency. 

‘‘Sec. 415. Authorization of appropriations. 

‘‘TITLE V—HEALTH SERVICES FOR URBAN INDIANS 

‘‘Sec. 501. Purpose. 

‘‘Sec. 502. Contracts with, and grants to, urban Indian organizations. 

‘‘Sec. 503. Contracts and grants for the provision of health care and referral services. 

‘‘Sec. 504. Contracts and grants for the determination of unmet health 

care needs. 

‘‘Sec. 505. Evaluations; renewals. 

‘‘Sec. 506. Other contract and grant requirements. 

‘‘Sec. 507. Reports and records. 

‘‘Sec. 508. Limitation on contract authority. 

‘‘Sec. 509. Facilities. 

‘‘Sec. 510. Office of Urban Indian Health. 

‘‘Sec. 511. Grants for alcohol and substance abuse-related services. 

‘‘Sec. 512. Treatment of certain demonstration projects. 

‘‘Sec. 513. Urban NIAAA transferred programs. 

‘‘Sec. 514. Consultation with urban Indian organizations. 

‘‘Sec. 515. Federal Tort Claims Act coverage. 

‘‘Sec. 516. Urban youth treatment center demonstration.
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‘‘Sec. 517. Use of Federal government facilities and sources of supply. 

‘‘Sec. 518. Grants for diabetes prevention, treatment, and control. 

‘‘Sec. 519. Community health representatives. 

‘‘Sec. 520. Regulations. 

‘‘Sec. 521. Eligibility for services. 

‘‘Sec. 522. Authorization of appropriations. 

‘‘TITLE VI—ORGANIZATIONAL IMPROVEMENTS 

‘‘Sec. 601. Establishment of the Indian Health Service as an agency of the 

Public Health Service. 

‘‘Sec. 602. Automated management information system. 

‘‘Sec. 603. Authorization of appropriations. 

‘‘TITLE VII—BEHAVIORAL HEALTH PROGRAMS 

‘‘Sec. 701. Behavioral health prevention and treatment services. 

‘‘Sec. 702. Memoranda of agreement with the Department of the Interior. 

‘‘Sec. 703. Comprehensive behavioral health prevention and treatment program. 

‘‘Sec. 704. Mental health technician program. 

‘‘Sec. 705. Licensing requirement for mental health care workers. 

‘‘Sec. 706. Indian women treatment programs. 

‘‘Sec. 707. Indian Youth Program. 

‘‘Sec. 708. Inpatient and community-based mental health facilities design, 

construction, and staffing. 

‘‘Sec. 709. Training and community education. 

‘‘Sec. 710. Behavioral health program. 

‘‘Sec. 711. Fetal alcohol disorder funding. 

‘‘Sec. 712. Child sexual abuse and prevention treatment programs. 

‘‘Sec. 713. Behavioral health research. 

‘‘Sec. 714. Definitions. 

‘‘Sec. 715. Authorization of appropriations. 

‘‘TITLE VIII—MISCELLANEOUS 

‘‘Sec. 801. Reports. 

‘‘Sec. 802. Regulations. 

‘‘Sec. 803. Plan of implementation. 

‘‘Sec. 804. Availability of funds. 

‘‘Sec. 805. Limitation on use of funds appropriated to the Indian Health 

Service. 

‘‘Sec. 806. Eligibility of California Indians. 

‘‘Sec. 807. Health services for ineligible persons. 

‘‘Sec. 808. Reallocation of base resources. 

‘‘Sec. 809. Results of demonstration projects. 

‘‘Sec. 810. Provision of services in Montana. 

‘‘Sec. 811. Moratorium. 

‘‘Sec. 812. Tribal employment. 

‘‘Sec. 813. Prime vendor. 

‘‘Sec. 814. Severability provisions. 

‘‘Sec. 815. Establishment of National Bipartisan Commission on Indian 

Health Care Entitlement. 

‘‘Sec. 816. Appropriations; availability. 

‘‘Sec. 817. Confidentiality of medical quality assurance records: qualified 

immunity for participants. 
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‘‘Sec. 818. Authorization of appropriations. 

Sec. 3. Soboba sanitation facilities. 

Sec. 4. Amendments to medicare program. 

Sec. 5. Amendments to medicaid program and State Children’s Health Insurance Program (SCHIP).

1 ‘‘SEC. 2. FINDINGS. 

2 ‘‘Congress finds the following: 

3 ‘‘(1) Federal delivery of health services and 

4 funding of Indian and Urban Indian Health Pro5 grams to maintain and improve the health of Indi6 ans are consonant with and required by the Federal 

7 Government’s historical and unique legal relation8 ship with Indians, as reflected in the Constitution, 

9 treaties, Federal statutes and the course of dealings 

10 of the United States with Indian Tribes and the 

11 United States’ resulting government-to-government 

12 relationship with Indian Tribes and trust respon13 sibilities and obligations to Indians. 

14 ‘‘(2) From the time of European occupation 

15 and colonization through the 20th century, policies 

16 and practices of the United States caused and/or 

17 contributed to the severe health conditions of Indi18 ans. 

19 ‘‘(3) Through the cession of over 400,000,000 

20 acres of land to the United States in exchange for 

21 promises, often reflected in treaties, of health care, 

22 Indian Tribes have secured a de facto contract which 

23 entitles Indians to health care in perpetuity, based 
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1 on the moral, legal, and historic obligation of the 

2 United States. 

3 ‘‘(4) The population growth of Indians that 

4 began in the later part of the 20th century increases 

5 the need for Federal health care services. 

6 ‘‘(5) A major national goal of the United States 

7 is to provide the quantity and quality of health serv8 ices which will permit the health status of Indians 

9 regardless of where they live to be raised to the 

10 highest possible level that is no less than that of the 

11 general population and to provide for the maximum 

12 participation of Indian Tribes, Tribal Organizations, 

13 and Urban Indian Organizations in the planning, de14 livery and management of those health services. 

15 ‘‘(6) Federal health services to Indians have re16 sulted in a reduction in the prevalence and incidence 

17 of illnesses among, and unnecessary and premature 

18 deaths of, Indians. 

19 ‘‘(7) Despite such services, the unmet health 

20 needs of Indians remain alarmingly severe and the 

21 health status of Indians is far below the health sta22 tus of the general population of the United States. 

23 ‘‘(8) The disparity to be addressed is formi24 dable. For example, Indians suffer a death rate for 

25 diabetes mellitus that is 318 percent higher than the 
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1 all races rate for the United States, a pneumonia 

2 and influenza death rate 52 percent greater, a tuber3 culosis death rate that is 650 percent greater, and 

4 a death rate from alcoholism that is 670 percent 

5 higher than that of the all races United States rate. 

6 ‘‘SEC. 3. DECLARATION OF NATIONAL INDIAN HEALTH POL7 ICY. 

8 ‘‘Congress hereby declares that it is the policy of this 

9 Nation, in fulfillment of its special trust responsibilities 

10 and legal obligations to Indians— 

11 ‘‘(1) to assure the highest possible health status 

12 for Indians and to provide all resources necessary to 

13 effect that policy; 

14 ‘‘(2) to raise the health status of Indians by the 

15 year 2010 to at least the levels set forth in the goals 

16 contained within the Healthy People 2010 or suc17 cessor objectives; 

18 ‘‘(3) to the greatest extent possible, to allow In19 dians to set their own health care priorities and es20 tablish goals that reflect their unmet needs; 

21 ‘‘(4) to increase the proportion of all degrees in 

22 the health professions and allied and associated 

23 health professions awarded to Indians so that the 

24 proportion of Indian health professionals in each 
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1 Service Area is raised to at least the level of that of 

2 the general population; 

3 ‘‘(5) to require meaningful consultation with In4 dian Tribes, Tribal Organizations, and Urban Indian 

5 Organizations to implement this Act and the na6 tional policy of Indian self-determination; and 

7 ‘‘(6) to provide funding for programs and facili8 ties operated by Indian Tribes and Tribal Organiza9 tions in amounts that are not less than the amounts 

10 provided to programs and facilities operated directly 

11 by the Service. 

12 ‘‘SEC. 4. DEFINITIONS. 

13 ‘‘For purposes of this Act: 

14 ‘‘(1) The term ‘accredited and accessible’ means 

15 on or near a reservation and accredited by a na16 tional or regional organization with accrediting au17 thority. 

18 ‘‘(2) The term ‘Area Office’ means an adminis19 trative entity including a program office, within the 

20 Service through which services and funds are pro21 vided to the Service Units within a defined geo22 graphic area. 

23 ‘‘(3) The term ‘California Indians’ shall mean 

24 those Indians who are eligible for health services of 

25 the Service pursuant to section 806.
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1 ‘‘(4) The term ‘community college’ means—

2 ‘‘(A) a tribal college or university, or 

3 ‘‘(B) a junior or community college. 

4 ‘‘(5) The term ‘contract health service’ means 

5 health services provided at the expense of the Serv6 ice or a Tribal Health Program by public or private 

7 medical providers or hospitals, other than the Serv8 ice Unit or the Tribal Health Program at whose ex9 pense the services are provided. 

10 ‘‘(6) The term ‘Department’ means, unless oth11 erwise designated, the Department of Health and 

12 Human Services. 

13 ‘‘(7) The term ‘Director’ means the Director of 

14 the Indian Health Service. 

15 ‘‘(8) The term ‘disease prevention’ means the 

16 reduction, limitation, and prevention of disease and 

17 its complications and reduction in the consequences 

18 of disease, including, but not limited to—

19 ‘‘(A) controlling—

20 ‘‘(i) development of diabetes; 

21 ‘‘(ii) high blood pressure; 

22 ‘‘(iii) infectious agents; 

23 ‘‘(iv) injuries; 

24 ‘‘(v) occupational hazards and disabil25 ities; 
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1 ‘‘(vi) sexually transmittable diseases; 

2 and 

3 ‘‘(vii) toxic agents; and 

4 ‘‘(B) providing—

5 ‘‘(i) fluoridation of water; and 

6 ‘‘(ii) immunizations. 

7 ‘‘(9) The term ‘fund’ or ‘funding’ means the 

8 transfer of moneys from the Department to any eli9 gible entity or individual under this Act by any legal 

10 means, including Funding Agreements, contracts, 

11 memoranda of understanding, contracts pursuant to 

12 section 23 of the Act of April 20, 1908 (25 U.S.C. 

13 47; popularly known as the ‘Buy Indian Act’), or 

14 otherwise. 

15 ‘‘(10) The term ‘Funding Agreement’ means 

16 any agreement to transfer funds for the planning, 

17 conduct, and administration of programs, services, 

18 functions, and activities to Indian Tribes and Tribal 

19 Organizations from the Secretary under the Indian 

20 Self-Determination and Education Assistance Act. 

21 ‘‘(11) The term ‘health profession’ means 

22 allopathic medicine, family medicine, internal medi23 cine, pediatrics, geriatric medicine, obstetrics and 

24 gynecology, podiatric medicine, nursing, public 

25 health nursing, dentistry, psychiatry, osteopathy, op-
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1 tometry, pharmacy, psychology, public health, social 

2 work, marriage and family therapy, chiropractic 

3 medicine, environmental health and engineering, al4 lied health professions, and any other health profes5 sion. 

6 ‘‘(12) The term ‘health promotion’ means—

7 ‘‘(A) fostering social, economic, environ8 mental, and personal factors conducive to 

9 health, including raising public awareness about 

10 health matters and enabling the people to cope 

11 with health problems by increasing their knowl12 edge and providing them with valid information; 

13 ‘‘(B) encouraging adequate and appro14 priate diet, exercise, and sleep; 

15 ‘‘(C) promoting education and work in con16 formity with physical and mental capacity; 

17 ‘‘(D) making available suitable housing, 

18 safe water, and sanitary facilities; 

19 ‘‘(E) improving the physical, economic, cul20 tural, psychological, and social environment; 

21 ‘‘(F) promoting adequate opportunity for 

22 spiritual, religious, and Traditional Health Care 

23 Practices; and 

24 ‘‘(G) providing adequate and appropriate 

25 programs, including, but not limited to—
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1 ‘‘(i) abuse prevention (mental and 

2 physical); 

3 ‘‘(ii) community health; 

4 ‘‘(iii) community safety; 

5 ‘‘(iv) consumer health education; 

6 ‘‘(v) diet and nutrition; 

7 ‘‘(vi) immunization and other preven8 tion of communicable diseases, including 

9 HIV/AIDS; 

10 ‘‘(vii) environmental health; 

11 ‘‘(viii) exercise and physical fitness; 

12 ‘‘(ix) avoidance of fetal alcohol dis13 orders; 

14 ‘‘(x) first aid and CPR education; 

15 ‘‘(xi) human growth and development; 

16 ‘‘(xii) injury prevention and personal 

17 safety; 

18 ‘‘(xiii) mental health; 

19 ‘‘(xiv) personal health and wellness 

20 practices; 

21 ‘‘(xv) personal capacity building; 

22 ‘‘(xvi) prenatal, pregnancy, and infant 

23 care; 

24 ‘‘(xvii) psychological well-being; 
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1 ‘‘(xviii) reproductive health and family 

2 planning; 

3 ‘‘(xix) safe and adequate water; 

4 ‘‘(xx) safe housing; 

5 ‘‘(xxi) safe work environments; 

6 ‘‘(xxii) stress control; 

7 ‘‘(xxiii) substance abuse; 

8 ‘‘(xxiv) sanitary facilities; 

9 ‘‘(xxv) tobacco use cessation and re10 duction; 

11 ‘‘(xxvi) violence prevention; and 

12 ‘‘(xxvii) such other activities identified 

13 by the Service, a Tribal Health Program, 

14 or an Urban Indian Organization, to pro15 mote achievement of any of the objectives 

16 described in section 3(2). 

17 ‘‘(13) The term ‘Indian’ shall have the meaning 

18 given that term in the Indian Self-Determination 

19 and Education Assistance Act. 

20 ‘‘(14) The term ‘Indian Health Program’ means 

21 the following—

22 ‘‘(A) any health program administered di23 rectly by the Service; 

24 ‘‘(B) any Tribal Health Program; or
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1 ‘‘(C) any Indian Tribe or Tribal Organiza2 tion to which the Secretary provides funding 

3 pursuant to section 23 of the Act of April 30, 

4 1908 (25 U.S.C. 47), popularly known as the 

5 ‘Buy Indian Act’. 

6 ‘‘(15) The term ‘Indian Tribe’ shall have the 

7 meaning given that term in the Indian Self-Deter8 mination and Education Assistance Act. 

9 ‘‘(16) The term ‘junior or community college’ 

10 has the meaning given to such term by section 

11 312(e) of the Higher Education Act of 1965 (20 

12 U.S.C. 1058(e)). 

13 ‘‘(17) The term ‘reservation’ means any feder14 ally recognized Indian Tribe’s reservation, Pueblo, or 

15 colony, including former reservations in Oklahoma, 

16 Indian allotments, and Alaska Native Regions estab17 lished pursuant to the Alaska Native Claims Settle18 ment Act (25 U.S.C. 1601 et seq.). 

19 ‘‘(18) The term ‘Secretary’, unless otherwise 

20 designated, means the Secretary of Health and 

21 Human Services. 

22 ‘‘(19) The term ‘Service’ means the Indian 

23 Health Service. 

24 ‘‘(20) The term ‘Service Area’ means the geo25 graphical area served by each Area Office.
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1 ‘‘(21) The term ‘Service Unit’ means an admin2 istrative entity of the Service, or a Tribal Health 

3 Program through which services are provided, di4 rectly or by contract, to eligible Indians within a de5 fined geographic area. 

6 ‘‘(22) The term ‘Traditional Health Care Prac7 tices’ means the application by Native healing prac8 titioners of the Native healing sciences (as opposed 

9 or in contradistinction to Western healing sciences) 

10 which embody the influences or forces of innate 

11 Tribal discovery, history, description, explanation 

12 and knowledge of the states of wellness and illness 

13 and which call upon these influences or forces, in14 cluding physical, mental, and spiritual forces in the 

15 promotion, restoration, preservation, and mainte16 nance of health, well-being, and life’s harmony. 

17 ‘‘(23) The term ‘tribal college or university’ 

18 shall have the meaning given that term in section 

19 316(b)(3) of the Higher Education Act (20 U.S.C. 

20 1059c(b)(3)). 

21 ‘‘(24) The term ‘Tribal Health Program’ means 

22 an Indian Tribe or Tribal Organization that oper23 ates any health program, service, function, activity, 

24 or facility funded, in whole or part, by the Service 

25 through, or provided for in, a Funding Agreement 
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1 with the Service under the Indian Self-Determina2 tion and Education Assistance Act. 

3 ‘‘(25) The term ‘Tribal Organization’ shall have 

4 the meaning given that term in the Indian Self-De5 termination and Education Assistance Act. 

6 ‘‘(26) The term ‘Urban Center’ means any com7 munity which has a sufficient Urban Indian popu8 lation with unmet health needs to warrant assistance 

9 under title V, as determined by the Secretary. 

10 ‘‘(27) The term ‘Urban Indian’ means any indi11 vidual who resides in an Urban Center and who 

12 meets 1 or more of the following criteria: 

13 ‘‘(A) Irrespective of whether the individual 

14 lives on or near a reservation, the individual is 

15 a member of a tribe, band, or other organized 

16 group of Indians, including those tribes, bands, 

17 or groups terminated since 1940 and those 

18 tribes, bands, or groups that are recognized by 

19 the States in which they reside, or who is a de20 scendant in the first or second degree of any 

21 such member. 

22 ‘‘(B) The individual is an Eskimo, Aleut, 

23 or other Alaskan Native. 
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1 ‘‘(C) The individual is considered by the 

2 Secretary of the Interior to be an Indian for 

3 any purpose. 

4 ‘‘(D) The individual is determined to be an 

5 Indian under regulations promulgated by the 

6 Secretary. 

7 ‘‘(28) The term ‘Urban Indian Organization’ 

8 means a nonprofit corporate body that (A) is situ9 ated in an Urban Center; (B) is governed by an 

10 Urban Indian-controlled board of directors; (C) pro11 vides for the participation of all interested Indian 

12 groups and individuals; and (D) is capable of legally 

13 cooperating with other public and private entities for 

14 the purpose of performing the activities described in 

15 section 503(a).

16 ‘‘TITLE I—INDIAN HEALTH, 

17 HUMAN RESOURCES, AND DE18 VELOPMENT 

19 ‘‘SEC. 101. PURPOSE. 

20 ‘‘The purpose of this title is to increase, to the max21 imum extent feasible, the number of Indians entering the 

22 health professions and providing health services, and to 

23 assure an optimum supply of health professionals to the 

24 Indian Health Programs and Urban Indian Organizations 

25 involved in the provision of health services to Indians. 
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1 ‘‘SEC. 102. HEALTH PROFESSIONS RECRUITMENT PROGRAM 

2 FOR INDIANS. 

3 ‘‘(a) IN GENERAL.—The Secretary, acting through 

4 the Service, shall make funds available to public or non5 profit private health entities or Tribal Health Programs 

6 to assist such entities in meeting the costs of—

7 ‘‘(1) identifying Indians with a potential for 

8 education or training in the health professions and 

9 encouraging and assisting them—

10 ‘‘(A) to enroll in courses of study in such 

11 health professions; or 

12 ‘‘(B) if they are not qualified to enroll in 

13 any such courses of study, to undertake such 

14 postsecondary education or training as may be 

15 required to qualify them for enrollment; 

16 ‘‘(2) publicizing existing sources of financial aid 

17 available to Indians enrolled in any course of study 

18 referred to in paragraph (1) or who are undertaking 

19 training necessary to qualify them to enroll in any 

20 such course of study; or 

21 ‘‘(3) establishing other programs which the Sec22 retary determines will enhance and facilitate the en23 rollment of Indians in, and the subsequent pursuit 

24 and completion by them of, courses of study referred 

25 to in paragraph (1). 

26 ‘‘(b) FUNDING.—
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1 ‘‘(1) APPLICATION.—Funds under this section 

2 shall require that an application has been submitted 

3 to, and approved by, the Secretary. Such application 

4 shall be in such form, submitted in such manner, 

5 and contain such information, as the Secretary shall 

6 by regulation prescribe pursuant to this Act. The 

7 Secretary shall give a preference to applications sub8 mitted by Tribal Health Programs or Urban Indian 

9 Organizations. 

10 ‘‘(2) AMOUNT OF FUNDS; PAYMENT.—The 

11 amount of funds provided to entities under this sec12 tion shall be determined by the Secretary. Payments 

13 pursuant to this section may be made in advance or 

14 by way of reimbursement, and at such intervals and 

15 on such conditions as provided for in regulations 

16 issued pursuant to this Act. To the extent not other17 wise prohibited by law, funding commitments shall 

18 be for 3 years, as provided in regulations published 

19 pursuant to this Act. 

20 ‘‘(c) DEFINITION OF INDIAN.—For purposes of this 

21 section and sections 103 and 104, the term ‘Indian’ shall, 

22 in addition to the meaning given that term in section 4, 

23 also mean any individual who is an Urban Indian. 
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1 ‘‘SEC. 103. HEALTH PROFESSIONS PREPARATORY SCHOL2 ARSHIP PROGRAM FOR INDIANS. 

3 ‘‘(a) SCHOLARSHIPS AUTHORIZED.—The Secretary, 

4 acting through the Service, shall provide scholarships to 

5 Indians who—

6 ‘‘(1) have successfully completed their high 

7 school education or high school equivalency; and 

8 ‘‘(2) have demonstrated the potential to suc9 cessfully complete courses of study in the health pro10 fessions. 

11 ‘‘(b) PURPOSES.—Scholarships provided pursuant to 

12 this section shall be for the following purposes: 

13 ‘‘(1) Compensatory preprofessional education of 

14 any recipient, such scholarship not to exceed 2 years 

15 on a full-time basis (or the part-time equivalent 

16 thereof, as determined by the Secretary pursuant to 

17 regulations issued under this Act). 

18 ‘‘(2) Pregraduate education of any recipient 

19 leading to a baccalaureate degree in an approved 

20 course of study preparatory to a field of study in a 

21 health profession, such scholarship not to exceed 4 

22 years. An extension of up to 2 years (or the part23 time equivalent thereof, as determined by the Sec24 retary pursuant to regulations issued pursuant to 

25 this Act) may be approved. 
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1 ‘‘(c) OTHER CONDITIONS.—Scholarships under this 

2 section—

3 ‘‘(1) may cover costs of tuition, books, trans4 portation, board, and other necessary related ex5 penses of a recipient while attending school; 

6 ‘‘(2) shall not be denied solely on the basis of 

7 the applicant’s scholastic achievement if such appli8 cant has been admitted to, or maintained good 

9 standing at, an accredited institution; and 

10 ‘‘(3) shall not be denied solely by reason of such 

11 applicant’s eligibility for assistance or benefits under 

12 any other Federal program. 

13 ‘‘SEC. 104. INDIAN HEALTH PROFESSIONS SCHOLARSHIPS. 

14 ‘‘(a) IN GENERAL.—

15 ‘‘(1) AUTHORITY.—The Secretary, acting 

16 through the Service, shall make scholarships to Indi17 ans who are enrolled full or part time in accredited 

18 schools pursuing courses of study in the health pro19 fessions. Such scholarships shall be designated In20 dian Health Scholarships and shall be made in ac21 cordance with section 338A of the Public Health 

22 Services Act (42 U.S.C. 2541), except as provided in 

23 subsection (b) of this section. 

24 ‘‘(2) ALLOCATION BY FORMULA.—Except as 

25 provided in paragraph (3), the funding authorized 
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1 by this section shall be allocated by Service Area by 

2 a formula developed in consultation with Indian 

3 Tribes, Tribal Organizations, and Urban Indian Or4 ganizations. Such formula shall consider the human 

5 resource development needs in each Service Area. 

6 ‘‘(3) CONTINUITY OF PRIOR SCHOLARSHIPS.—

7 Paragraph (2) shall not apply with respect to indi8 vidual recipients of scholarships provided under this 

9 section (as in effect 1 day prior to the date of the 

10 enactment of the Indian Health Care Improvement 

11 Act Amendments of 2003) until such time as the in12 dividual completes the course of study that is sup13 ported through such scholarship. 

14 ‘‘(4) CERTAIN DELEGATION NOT ALLOWED.—

15 The administration of this section shall be a respon16 sibility of the Director and shall not be delegated in 

17 a Funding Agreement. 

18 ‘‘(b) ACTIVE DUTY SERVICE OBLIGATION.—

19 ‘‘(1) OBLIGATION MET.—The active duty serv20 ice obligation under a written contract with the Sec21 retary under section 338A of the Public Health 

22 Service Act (42 U.S.C. 254l) that an Indian has en23 tered into under that section shall, if that individual 

24 is a recipient of an Indian Health Scholarship, be 

25 met in full-time practice on an equivalent year-for-
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1 year obligation, by service in one or more of the fol2 lowing: 

3 ‘‘(A) In an Indian Health Program. 

4 ‘‘(B) In a program assisted under title V. 

5 ‘‘(C) In the private practice of the applica6 ble profession if, as determined by the Sec7 retary, in accordance with guidelines promul8 gated by the Secretary, such practice is situated 

9 in a physician or other health professional 

10 shortage area and addresses the health care 

11 needs of a substantial number of Indians. 

12 ‘‘(2) OBLIGATION DEFERRED.—At the request 

13 of any individual who has entered into a contract re14 ferred to in paragraph (1) and who receives a degree 

15 in medicine (including osteopathic or allopathic med16 icine), dentistry, optometry, podiatry, or pharmacy, 

17 the Secretary shall defer the active duty service obli18 gation of that individual under that contract, in 

19 order that such individual may complete any intern20 ship, residency, or other advanced clinical training 

21 that is required for the practice of that health pro22 fession, for an appropriate period (in years, as deter23 mined by the Secretary), subject to the following 

24 conditions:
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1 ‘‘(A) No period of internship, residency, or 

2 other advanced clinical training shall be counted 

3 as satisfying any period of obligated service 

4 under this subsection. 

5 ‘‘(B) The active duty service obligation of 

6 that individual shall commence not later than 

7 90 days after the completion of that advanced 

8 clinical training (or by a date specified by the 

9 Secretary). 

10 ‘‘(C) The active duty service obligation will 

11 be served in the health profession of that indi12 vidual in a manner consistent with paragraph 

13 (1). 

14 ‘‘(D) A recipient of a scholarship under 

15 this section may, at the election of the recipient, 

16 meet the active duty service obligation described 

17 in paragraph (1) by service in a program speci18 fied under that paragraph that—

19 ‘‘(i) is located on the reservation of 

20 the Indian Tribe in which the recipient is 

21 enrolled; or 

22 ‘‘(ii) serves the Indian Tribe in which 

23 the recipient is enrolled. 

24 ‘‘(3) PRIORITY WHEN MAKING ASSIGNMENTS.—

25 Subject to paragraph (2), the Secretary, in making 
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1 assignments of Indian Health Scholarship recipients 

2 required to meet the active duty service obligation 

3 described in paragraph (1), shall give priority to as4 signing individuals to service in those programs 

5 specified in paragraph (1) that have a need for 

6 health professionals to provide health care services 

7 as a result of individuals having breached contracts 

8 entered into under this section. 

9 ‘‘(c) PART-TIME STUDENTS.—In the case of an indi10 vidual receiving a scholarship under this section who is 

11 enrolled part time in an approved course of study—

12 ‘‘(1) such scholarship shall be for a period of 

13 years not to exceed the part-time equivalent of 4 

14 years, as determined by the Area Office; 

15 ‘‘(2) the period of obligated service described in 

16 subsection (b)(1) shall be equal to the greater of—

17 ‘‘(A) the part-time equivalent of 1 year for 

18 each year for which the individual was provided 

19 a scholarship (as determined by the Area Of20 fice); or 

21 ‘‘(B) 2 years; and 

22 ‘‘(3) the amount of the monthly stipend speci23 fied in section 338A(g)(1)(B) of the Public Health 

24 Service Act (42 U.S.C. 254l(g)(1)(B)) shall be re25 duced pro rata (as determined by the Secretary) 
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1 based on the number of hours such student is en2 rolled. 

3 ‘‘(d) BREACH OF CONTRACT.—

4 ‘‘(1) SPECIFIED BREACHES.—An individual 

5 shall be liable to the United States for the amount 

6 which has been paid to the individual, or on behalf 

7 of the individual, under a contract entered into with 

8 the Secretary under this section on or after the date 

9 of the enactment of the Indian Health Care Im10 provement Act Amendments of 2003 if that indi11 vidual—

12 ‘‘(A) fails to maintain an acceptable level 

13 of academic standing in the educational institu14 tion in which he or she is enrolled (such level 

15 determined by the educational institution under 

16 regulations of the Secretary); 

17 ‘‘(B) is dismissed from such educational 

18 institution for disciplinary reasons; 

19 ‘‘(C) voluntarily terminates the training in 

20 such an educational institution for which he or 

21 she is provided a scholarship under such con22 tract before the completion of such training; or 

23 ‘‘(D) fails to accept payment, or instructs 

24 the educational institution in which he or she is 

25 enrolled not to accept payment, in whole or in 
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1 part, of a scholarship under such contract, in 

2 lieu of any service obligation arising under such 

3 contract. 

4 ‘‘(2) OTHER BREACHES.—If for any reason not 

5 specified in paragraph (1) an individual breaches a 

6 written contract by failing either to begin such indi7 vidual’s service obligation required under such con8 tract or to complete such service obligation, the 

9 United States shall be entitled to recover from the 

10 individual an amount determined in accordance with 

11 the formula specified in subsection (l) of section 110 

12 in the manner provided for in such subsection. 

13 ‘‘(3) CANCELLATION UPON DEATH OF RECIPI14 ENT.—Upon the death of an individual who receives 

15 an Indian Health Scholarship, any outstanding obli16 gation of that individual for service or payment that 

17 relates to that scholarship shall be canceled. 

18 ‘‘(4) WAIVERS AND SUSPENSIONS.—The Sec19 retary shall provide for the partial or total waiver or 

20 suspension of any obligation of service or payment of 

21 a recipient of an Indian Health Scholarship if the 

22 Secretary, in consultation with the Area Office, In23 dian Tribes, Tribal Organizations, and Urban Indian 

24 Organizations, determines that—
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1 ‘‘(A) it is not possible for the recipient to 

2 meet that obligation or make that payment; 

3 ‘‘(B) requiring that recipient to meet that 

4 obligation or make that payment would result 

5 in extreme hardship to the recipient; or 

6 ‘‘(C) the enforcement of the requirement to 

7 meet the obligation or make the payment would 

8 be unconscionable. 

9 ‘‘(5) EXTREME HARDSHIP.—Notwithstanding 

10 any other provision of law, in any case of extreme 

11 hardship or for other good cause shown, the Sec12 retary may waive, in whole or in part, the right of 

13 the United States to recover funds made available 

14 under this section. 

15 ‘‘(6) BANKRUPTCY.—Notwithstanding any 

16 other provision of law, with respect to a recipient of 

17 an Indian Health Scholarship, no obligation for pay18 ment may be released by a discharge in bankruptcy 

19 under title 11, United States Code, unless that dis20 charge is granted after the expiration of the 5-year 

21 period beginning on the initial date on which that 

22 payment is due, and only if the bankruptcy court 

23 finds that the nondischarge of the obligation would 

24 be unconscionable.
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1 ‘‘SEC. 105. AMERICAN INDIANS INTO PSYCHOLOGY PRO2 GRAM. 

3 ‘‘(a) GRANTS AUTHORIZED.—The Secretary, acting 

4 through the Service, shall provide funding grants to at 

5 least 3 colleges and universities for the purpose of devel6 oping and maintaining Indian psychology career recruit7 ment programs as a means of encouraging Indians to 

8 enter the mental health field. These programs shall be lo9 cated at various locations throughout the country to maxi10 mize their availability to Indian students and new pro11 grams shall be established in different locations from time 

12 to time. 

13 ‘‘(b) QUENTIN N. BURDICK PROGRAM GRANT.—The 

14 Secretary shall provide a grant authorized under sub15 section (a) to develop and maintain a program at the Uni16 versity of North Dakota to be known as the ‘Quentin N. 

17 Burdick American Indians Into Psychology Program’. 

18 Such program shall, to the maximum extent feasible, co19 ordinate with the Quentin N. Burdick Indian Health Pro20 grams authorized under section 117(b), the Quentin N. 

21 Burdick American Indians Into Nursing Program author22 ized under section 115(e), and existing university research 

23 and communications networks. 

24 ‘‘(c) REGULATIONS.—The Secretary shall issue regu25 lations pursuant to this Act for the competitive awarding 

26 of funds provided under this section. 
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1 ‘‘(d) CONDITIONS OF GRANT.—Applicants under this 

2 section shall agree to provide a program which, at a min3 imum—

4 ‘‘(1) provides outreach and recruitment for 

5 health professions to Indian communities including 

6 elementary, secondary, and accredited and accessible 

7 community colleges that will be served by the pro8 gram; 

9 ‘‘(2) incorporates a program advisory board 

10 comprised of representatives from the tribes and 

11 communities that will be served by the program; 

12 ‘‘(3) provides summer enrichment programs to 

13 expose Indian students to the various fields of psy14 chology through research, clinical, and experimental 

15 activities; 

16 ‘‘(4) provides stipends to undergraduate and 

17 graduate students to pursue a career in psychology; 

18 ‘‘(5) develops affiliation agreements with tribal 

19 colleges and universities, the Service, university af20 filiated programs, and other appropriate accredited 

21 and accessible entities to enhance the education of 

22 Indian students; 

23 ‘‘(6) to the maximum extent feasible, uses exist24 ing university tutoring, counseling, and student sup25 port services; and 
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1 ‘‘(7) to the maximum extent feasible, employs 

2 qualified Indians in the program. 

3 ‘‘(e) ACTIVE DUTY SERVICE REQUIREMENT.—The 

4 active duty service obligation prescribed under section 

5 338C of the Public Health Service Act (42 U.S.C. 254m) 

6 shall be met by each graduate who receives a stipend de7 scribed in subsection (d)(4) that is funded under this sec8 tion. Such obligation shall be met by service—

9 ‘‘(1) in an Indian Health Program; 

10 ‘‘(2) in a program assisted under title V; or 

11 ‘‘(3) in the private practice of psychology if, as 

12 determined by the Secretary, in accordance with 

13 guidelines promulgated by the Secretary, such prac14 tice is situated in a physician or other health profes15 sional shortage area and addresses the health care 

16 needs of a substantial number of Indians. 

17 ‘‘SEC. 106. FUNDING FOR TRIBES FOR SCHOLARSHIP PRO18 GRAMS. 

19 ‘‘(a) IN GENERAL.—

20 ‘‘(1) FUNDING AUTHORIZED.—The Secretary, 

21 acting through the Service, shall make funds avail22 able to Tribal Health Programs for the purpose of 

23 assisting such Tribal Health Programs in educating 

24 Indians to serve as health professionals in Indian 

25 communities. 
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1 ‘‘(2) AMOUNT.—Amounts available under para2 graph (1) for any fiscal year shall not exceed 5 per3 cent of the amounts available for each fiscal year for 

4 Indian Health Scholarships under section 104. 

5 ‘‘(3) APPLICATION.—An application for funds 

6 under paragraph (1) shall be in such form and con7 tain such agreements, assurances, and information 

8 as consistent with this section. 

9 ‘‘(b) REQUIREMENTS.—

10 ‘‘(1) IN GENERAL.—A Tribal Health Program 

11 receiving funds under subsection (a) shall provide 

12 scholarships to Indians in accordance with the re13 quirements of this section. 

14 ‘‘(2) COSTS.—With respect to costs of providing 

15 any scholarship pursuant to subsection (a)—

16 ‘‘(A) 80 percent of the costs of the scholar17 ship shall be paid from the funds made avail18 able pursuant to subsection (a)(1) provided to 

19 the Tribal Health Program; and 

20 ‘‘(B) 20 percent of such costs may be paid 

21 from any other source of funds. 

22 ‘‘(c) COURSE OF STUDY.—A Tribal Health Program 

23 shall provide scholarships under this section only to Indi24 ans enrolled or accepted for enrollment in a course of 
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1 study (approved by the Secretary) in one of the health pro2 fessions contemplated by this Act. 

3 ‘‘(d) CONTRACT.—In providing scholarships under 

4 subsection (b), the Secretary and the Tribal Health Pro5 gram shall enter into a written contract with each recipi6 ent of such scholarship. Such contract shall—

7 ‘‘(1) obligate such recipient to provide service in 

8 an Indian Health Program or Urban Indian Organi9 zation, in the same Service Area where the Tribal 

10 Health Program providing the scholarship is located, 

11 for—

12 ‘‘(A) a number of years for which the 

13 scholarship is provided (or the part-time equiva14 lent thereof, as determined by the Secretary), 

15 or for a period of 2 years, whichever period is 

16 greater; or 

17 ‘‘(B) such greater period of time as the re18 cipient and the Tribal Health Program may 

19 agree; 

20 ‘‘(2) provide that the amount of the scholar21 ship—

22 ‘‘(A) may only be expended for—

23 ‘‘(i) tuition expenses, other reasonable 

24 educational expenses, and reasonable living
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•HR 2440 IH 

1 expenses incurred in attendance at the 

2 educational institution; and 

3 ‘‘(ii) payment to the recipient of a 

4 monthly stipend of not more than the 

5 amount authorized by section 338(g)(1)(B) 

6 of the Public Health Service Act (42 

7 U.S.C. 254m(g)(1)(B)), such amount to be 

8 reduced pro rata (as determined by the 

9 Secretary) based on the number of hours 

10 such student is enrolled; and may not ex11 ceed, for any year of attendance for which 

12 the scholarship is provided, the total 

13 amount required for the year for the pur14 poses authorized in this clause; and 

15 ‘‘(B) may not exceed, for any year of at16 tendance for which the scholarship is provided, 

17 the total amount required for the year for the 

18 purposes authorized in subparagraph (A); 

19 ‘‘(3) require the recipient of such scholarship to 

20 maintain an acceptable level of academic standing as 

21 determined by the educational institution in accord22 ance with regulations issued pursuant to this Act; 

23 and 
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1 ‘‘(4) require the recipient of such scholarship to 

2 meet the educational and licensure requirements ap3 propriate to each health profession. 

4 ‘‘(e) BREACH OF CONTRACT.—

5 ‘‘(1) SPECIFIC BREACHES.—An individual who 

6 has entered into a written contract with the Sec7 retary and a Tribal Health Program under sub8 section (d) shall be liable to the United States for 

9 the Federal share of the amount which has been 

10 paid to him or her, or on his or her behalf, under 

11 the contract if that individual—

12 ‘‘(A) fails to maintain an acceptable level 

13 of academic standing in the educational institu14 tion in which he or she is enrolled (such level 

15 as determined by the educational institution 

16 under regulations of the Secretary); 

17 ‘‘(B) is dismissed from such educational 

18 institution for disciplinary reasons; 

19 ‘‘(C) voluntarily terminates the training in 

20 such an educational institution for which he or 

21 she is provided a scholarship under such con22 tract before the completion of such training; or 

23 ‘‘(D) fails to accept payment, or instructs 

24 the educational institution in which he or she is 

25 enrolled not to accept payment, in whole or in 
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1 part, of a scholarship under such contract, in 

2 lieu of any service obligation arising under such 

3 contract. 

4 ‘‘(2) OTHER BREACHES.—If for any reason not 

5 specified in paragraph (1), an individual breaches a 

6 written contract by failing to either begin such indi7 vidual’s service obligation required under such con8 tract or to complete such service obligation, the 

9 United States shall be entitled to recover from the 

10 individual an amount determined in accordance with 

11 the formula specified in subsection (l) of section 110 

12 in the manner provided for in such subsection. 

13 ‘‘(3) CANCELLATION UPON DEATH OF RECIPI14 ENT.—Upon the death of an individual who receives 

15 an Indian Health Scholarship, any outstanding obli16 gation of that individual for service or payment that 

17 relates to that scholarship shall be canceled. 

18 ‘‘(4) INFORMATION.—The Secretary may carry 

19 out this subsection on the basis of information re20 ceived from Tribal Health Programs involved or on 

21 the basis of information collected through such other 

22 means as the Secretary deems appropriate. 

23 ‘‘(f) RELATION TO SOCIAL SECURITY ACT.—The re24 cipient of a scholarship under this section shall agree, in 
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1 providing health care pursuant to the requirements here2 in—

3 ‘‘(1) not to discriminate against an individual 

4 seeking care on the basis of the ability of the indi5 vidual to pay for such care or on the basis that pay6 ment for such care will be made pursuant to a pro7 gram established in title XVIII of the Social Secu8 rity Act or pursuant to the programs established in 

9 title XIX or title XXI of such Act; and 

10 ‘‘(2) to accept assignment under section 

11 1842(b)(3)(B)(ii) of the Social Security Act for all 

12 services for which payment may be made under part 

13 B of title XVIII of such Act, and to enter into an 

14 appropriate agreement with the State agency that 

15 administers the State plan for medical assistance 

16 under title XIX, or the State child health plan under 

17 title XXI, of such Act to provide service to individ18 uals entitled to medical assistance or child health as19 sistance, respectively, under the plan. 

20 ‘‘(g) CONTINUANCE OF FUNDING.—The Secretary 

21 shall make payments under this section to a Tribal Health 

22 Program for any fiscal year subsequent to the first fiscal 

23 year of such payments unless the Secretary determines 

24 that, for the immediately preceding fiscal year, the Tribal
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1 Health Program has not complied with the requirements 

2 of this section. 

3 ‘‘SEC. 107. INDIAN HEALTH SERVICE EXTERN PROGRAMS. 

4 ‘‘(a) EMPLOYMENT PREFERENCE.—Any individual 

5 who receives a scholarship pursuant to sections 104 or 106 

6 shall be given preference for employment in the Service, 

7 or may be employed by a Tribal Health Program or an 

8 Urban Indian Organization, or other agencies of the De9 partment as available, during any nonacademic period of 

10 the year. 

11 ‘‘(b) NOT COUNTED TOWARD ACTIVE DUTY SERVICE

12 OBLIGATION.—Periods of employment pursuant to this 

13 subsection shall not be counted in determining fulfillment 

14 of the service obligation incurred as a condition of the 

15 scholarship. 

16 ‘‘(c) TIMING; LENGTH OF EMPLOYMENT.—Any indi17 vidual enrolled in a program, including a high school pro18 gram, authorized under section 102(a) may be employed 

19 by the Service or by a Tribal Health Program or an Urban 

20 Indian Organization during any nonacademic period of the 

21 year. Any such employment shall not exceed 120 days dur22 ing any calendar year. 

23 ‘‘(d) NONAPPLICABILITY OF COMPETITIVE PER24 SONNEL SYSTEM.—Any employment pursuant to this sec25 tion shall be made without regard to any competitive per-
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1 sonnel system or agency personnel limitation and to a po2 sition which will enable the individual so employed to re3 ceive practical experience in the health profession in which 

4 he or she is engaged in study. Any individual so employed 

5 shall receive payment for his or her services comparable 

6 to the salary he or she would receive if he or she were 

7 employed in the competitive system. Any individual so em8 ployed shall not be counted against any employment ceil9 ing affecting the Service or the Department. 

10 ‘‘SEC. 108. CONTINUING EDUCATION ALLOWANCES. 

11 ‘‘In order to encourage health professionals, including 

12 community health representatives and emergency medical 

13 technicians, to join or continue in an Indian Health Pro14 gram or an Urban Indian Organization and to provide 

15 their services in the rural and remote areas where a sig16 nificant portion of Indians reside, the Secretary, acting 

17 through the Service Area, may provide allowances to 

18 health professionals employed in an Indian Health Pro19 gram or an Urban Indian Organization to enable them 

20 for a period of time each year prescribed by regulation 

21 of the Secretary to take leave of their duty stations for 

22 professional consultation and refresher training courses. 
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1 ‘‘SEC. 109. COMMUNITY HEALTH REPRESENTATIVE PRO2 GRAM. 

3 ‘‘(a) IN GENERAL.—Under the authority of the Act 

4 of November 2, 1921 (25 U.S.C. 13; popularly known as 

5 the Snyder Act), the Secretary, acting through the Serv6 ice, shall maintain a Community Health Representative 

7 Program under which Indian Health Programs—

8 ‘‘(1) provide for the training of Indians as com9 munity health representatives; and 

10 ‘‘(2) use such community health representatives 

11 in the provision of health care, health promotion, 

12 and disease prevention services to Indian commu13 nities. 

14 ‘‘(b) DUTIES.—The Community Health Representa15 tive Program of the Service, shall—

16 ‘‘(1) provide a high standard of training for 

17 community health representatives to ensure that the 

18 community health representatives provide quality 

19 health care, health promotion, and disease preven20 tion services to the Indian communities served by 

21 the Program; 

22 ‘‘(2) in order to provide such training, develop 

23 and maintain a curriculum that—

24 ‘‘(A) combines education in the theory of 

25 health care with supervised practical experience 

26 in the provision of health care; and 
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1 ‘‘(B) provides instruction and practical ex2 perience in health promotion and disease pre3 vention activities, with appropriate consider4 ation given to lifestyle factors that have an im5 pact on Indian health status, such as alco6 holism, family dysfunction, and poverty; 

7 ‘‘(3) maintain a system which identifies the 

8 needs of community health representatives for con9 tinuing education in health care, health promotion, 

10 and disease prevention and develop programs that 

11 meet the needs for continuing education; 

12 ‘‘(4) maintain a system that provides close su13 pervision of Community Health Representatives; 

14 ‘‘(5) maintain a system under which the work 

15 of Community Health Representatives is reviewed 

16 and evaluated; and 

17 ‘‘(6) promote Traditional Health Care Practices 

18 of the Indian Tribes served consistent with the Serv19 ice standards for the provision of health care, health 

20 promotion, and disease prevention. 

21 ‘‘SEC. 110. INDIAN HEALTH SERVICE LOAN REPAYMENT 

22 PROGRAM. 

23 ‘‘(a) ESTABLISHMENT.—The Secretary, acting 

24 through the Service, shall establish and administer a pro25 gram to be known as the Service Loan Repayment Pro-
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1 gram (hereinafter referred to as the ‘Loan Repayment 

2 Program’) in order to ensure an adequate supply of 

3 trained health professionals necessary to maintain accredi4 tation of, and provide health care services to Indians 

5 through, Indian Health Programs and Urban Indian Or6 ganizations. 

7 ‘‘(b) ELIGIBLE INDIVIDUALS.—To be eligible to par8 ticipate in the Loan Repayment Program, an individual 

9 must—

10 ‘‘(1)(A) be enrolled—

11 ‘‘(i) in a course of study or program in an 

12 accredited educational institution (as deter13 mined by the Secretary under section 

14 338B(b)(1)(c)(i) of the Public Health Service 

15 Act (42 U.S.C. 254l–1(b)(1)(c)(i))) and be 

16 scheduled to complete such course of study in 

17 the same year such individual applies to partici18 pate in such program; or 

19 ‘‘(ii) in an approved graduate training pro20 gram in a health profession; or 

21 ‘‘(B) have—

22 ‘‘(i) a degree in a health profession; and 

23 ‘‘(ii) a license to practice a health profes24 sion;
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1 ‘‘(2)(A) be eligible for, or hold, an appointment 

2 as a commissioned officer in the Regular or Reserve 

3 Corps of the Public Health Service; 

4 ‘‘(B) be eligible for selection for civilian service 

5 in the Regular or Reserve Corps of the Public 

6 Health Service; 

7 ‘‘(C) meet the professional standards for civil 

8 service employment in the Service; or 

9 ‘‘(D) be employed in an Indian Health Program 

10 or Urban Indian Organization without a service obli11 gation; and 

12 ‘‘(3) submit to the Secretary an application for 

13 a contract described in subsection (e). 

14 ‘‘(c) APPLICATION.—

15 ‘‘(1) INFORMATION TO BE INCLUDED WITH

16 FORMS.—In disseminating application forms and 

17 contract forms to individuals desiring to participate 

18 in the Loan Repayment Program, the Secretary 

19 shall include with such forms a fair summary of the 

20 rights and liabilities of an individual whose applica21 tion is approved (and whose contract is accepted) by 

22 the Secretary, including in the summary a clear ex23 planation of the damages to which the United States 

24 is entitled under subsection (l) in the case of the in25 dividual’s breach of contract. The Secretary shall 
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1 provide such individuals with sufficient information 

2 regarding the advantages and disadvantages of serv3 ice as a commissioned officer in the Regular or Re4 serve Corps of the Public Health Service or a civil5 ian employee of the Service to enable the individual 

6 to make a decision on an informed basis. 

7 ‘‘(2) CLEAR LANGUAGE.—The application form, 

8 contract form, and all other information furnished 

9 by the Secretary under this section shall be written 

10 in a manner calculated to be understood by the aver11 age individual applying to participate in the Loan 

12 Repayment Program. 

13 ‘‘(3) TIMELY AVAILABILITY OF FORMS.—The 

14 Secretary shall make such application forms, con15 tract forms, and other information available to indi16 viduals desiring to participate in the Loan Repay17 ment Program on a date sufficiently early to ensure 

18 that such individuals have adequate time to carefully 

19 review and evaluate such forms and information. 

20 ‘‘(d) PRIORITIES.—

21 ‘‘(1) LIST.—Consistent with subsection (k), the 

22 Secretary shall annually—

23 ‘‘(A) identify the positions in each Indian 

24 Health Program or Urban Indian Organization 

25 for which there is a need or a vacancy; and 
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1 ‘‘(B) rank those positions in order of pri2 ority. 

3 ‘‘(2) APPROVALS.—Notwithstanding the pri4 ority determined under paragraph (1), the Secretary, 

5 in determining which applications under the Loan 

6 Repayment Program to approve (and which con7 tracts to accept), shall—

8 ‘‘(A) give first priority to applications 

9 made by individual Indians; and 

10 ‘‘(B) after making determinations on all 

11 applications submitted by individual Indians as 

12 required under subparagraph (A), give priority 

13 to—

14 ‘‘(i) individuals recruited through the 

15 efforts of a Tribal Health Program or 

16 Urban Indian Organization; and 

17 ‘‘(ii) other individuals based on the 

18 priority rankings under paragraph (1). 

19 ‘‘(e) RECIPIENT CONTRACTS.—

20 ‘‘(1) CONTRACT REQUIRED.—An individual be21 comes a participant in the Loan Repayment Pro22 gram only upon the Secretary and the individual en23 tering into a written contract described in paragraph 

24 (2). 
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1 ‘‘(2) CONTENTS OF CONTRACT.—The written 

2 contract referred to in this section between the Sec3 retary and an individual shall contain—

4 ‘‘(A) an agreement under which—

5 ‘‘(i) subject to subparagraph (C), the 

6 Secretary agrees—

7 ‘‘(I) to pay loans on behalf of the 

8 individual in accordance with the pro9 visions of this section; and 

10 ‘‘(II) to accept (subject to the 

11 availability of appropriated funds for 

12 carrying out this section) the indi13 vidual into the Service or place the in14 dividual with a Tribal Health Pro15 gram or Urban Indian Organization 

16 as provided in clause (ii)(III); and 

17 ‘‘(ii) subject to subparagraph (C), the 

18 individual agrees—

19 ‘‘(I) to accept loan payments on 

20 behalf of the individual; 

21 ‘‘(II) in the case of an individual 

22 described in subsection (b)(1)—

23 ‘‘(aa) to maintain enrollment 

24 in a course of study or training 

25 described in subsection (b)(1)(A)
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1 until the individual completes the 

2 course of study or training; and 

3 ‘‘(bb) while enrolled in such 

4 course of study or training, to 

5 maintain an acceptable level of 

6 academic standing (as deter7 mined under regulations of the 

8 Secretary by the educational in9 stitution offering such course of 

10 study or training); and 

11 ‘‘(III) to serve for a time period 

12 (hereinafter in this section referred to 

13 as the ‘period of obligated service’) 

14 equal to 2 years or such longer period 

15 as the individual may agree to serve 

16 in the full-time clinical practice of 

17 such individual’s profession in an In18 dian Health Program or Urban In19 dian Organization to which the indi20 vidual may be assigned by the Sec21 retary; 

22 ‘‘(B) a provision permitting the Secretary 

23 to extend for such longer additional periods, as 

24 the individual may agree to, the period of obli-
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•HR 2440 IH 

1 gated service agreed to by the individual under 

2 subparagraph (A)(ii)(III); 

3 ‘‘(C) a provision that any financial obliga4 tion of the United States arising out of a con5 tract entered into under this section and any 

6 obligation of the individual which is conditioned 

7 thereon is contingent upon funds being appro8 priated for loan repayments under this section; 

9 ‘‘(D) a statement of the damages to which 

10 the United States is entitled under subsection 

11 (l) for the individual’s breach of the contract; 

12 and 

13 ‘‘(E) such other statements of the rights 

14 and liabilities of the Secretary and of the indi15 vidual, not inconsistent with this section. 

16 ‘‘(f) DEADLINE FOR DECISION ON APPLICATION.—

17 The Secretary shall provide written notice to an individual 

18 within 21 days on—

19 ‘‘(1) the Secretary’s approving, under sub20 section (e)(1), of the individual’s participation in the 

21 Loan Repayment Program, including extensions re22 sulting in an aggregate period of obligated service in 

23 excess of 4 years; or 

24 ‘‘(2) the Secretary’s disapproving an individ25 ual’s participation in such Program. 
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1 ‘‘(g) PAYMENTS.—

2 ‘‘(1) IN GENERAL.—A loan repayment provided 

3 for an individual under a written contract under the 

4 Loan Repayment Program shall consist of payment, 

5 in accordance with paragraph (2), on behalf of the 

6 individual of the principal, interest, and related ex7 penses on government and commercial loans received 

8 by the individual regarding the undergraduate or 

9 graduate education of the individual (or both), which 

10 loans were made for—

11 ‘‘(A) tuition expenses; 

12 ‘‘(B) all other reasonable educational ex13 penses, including fees, books, and laboratory ex14 penses, incurred by the individual; and 

15 ‘‘(C) reasonable living expenses as deter16 mined by the Secretary. 

17 ‘‘(2) AMOUNT.—For each year of obligated 

18 service that an individual contracts to serve under 

19 subsection (e), the Secretary may pay up to $35,000 

20 or an amount equal to the amount specified in sec21 tion 338B(g)(2)(A) of the Public Health Service 

22 Act, whichever is more, on behalf of the individual 

23 for loans described in paragraph (1). In making a 

24 determination of the amount to pay for a year of 

25 such service by an individual, the Secretary shall 
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•HR 2440 IH 

1 consider the extent to which each such determina2 tion—

3 ‘‘(A) affects the ability of the Secretary to 

4 maximize the number of contracts that can be 

5 provided under the Loan Repayment Program 

6 from the amounts appropriated for such con7 tracts; 

8 ‘‘(B) provides an incentive to serve in In9 dian Health Programs and Urban Indian Orga10 nizations with the greatest shortages of health 

11 professionals; and 

12 ‘‘(C) provides an incentive with respect to 

13 the health professional involved remaining in an 

14 Indian Health Program or Urban Indian Orga15 nization with such a health professional short16 age, and continuing to provide primary health 

17 services, after the completion of the period of 

18 obligated service under the Loan Repayment 

19 Program. 

20 ‘‘(3) TIMING.—Any arrangement made by the 

21 Secretary for the making of loan repayments in ac22 cordance with this subsection shall provide that any 

23 repayments for a year of obligated service shall be 

24 made no later than the end of the fiscal year in 

25 which the individual completes such year of service. 
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•HR 2440 IH 

1 ‘‘(4) PAYMENT SCHEDULE.—The Secretary 

2 may enter into an agreement with the holder of any 

3 loan for which payments are made under the Loan 

4 Repayment Program to establish a schedule for the 

5 making of such payments. 

6 ‘‘(h) EMPLOYMENT CEILING.—Notwithstanding any 

7 other provision of law, individuals who have entered into 

8 written contracts with the Secretary under this section 

9 shall not be counted against any employment ceiling af10 fecting the Department while those individuals are under11 going academic training. 

12 ‘‘(i) RECRUITMENT.—The Secretary shall conduct re13 cruiting programs for the Loan Repayment Program and 

14 other Service manpower programs of the Service at edu15 cational institutions training health professionals or spe16 cialists identified in subsection (a). 

17 ‘‘(j) APPLICABILITY OF LAW.—Section 214 of the 

18 Public Health Service Act (42 U.S.C. 215) shall not apply 

19 to individuals during their period of obligated service 

20 under the Loan Repayment Program. 

21 ‘‘(k) ASSIGNMENT OF INDIVIDUALS.—The Secretary, 

22 in assigning individuals to serve in Indian Health Pro23 grams or Urban Indian Organizations pursuant to con24 tracts entered into under this section, shall—
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•HR 2440 IH 

1 ‘‘(1) ensure that the staffing needs of Tribal 

2 Health Programs and Urban Indian Organizations 

3 receive consideration on an equal basis with pro4 grams that are administered directly by the Service; 

5 and 

6 ‘‘(2) give priority to assigning individuals to In7 dian Health Programs and Urban Indian Organiza8 tions that have a need for health professionals to 

9 provide health care services as a result of individuals 

10 having breached contracts entered into under this 

11 section. 

12 ‘‘(l) BREACH OF CONTRACT.—

13 ‘‘(1) SPECIFIC BREACHES.—An individual who 

14 has entered into a written contract with the Sec15 retary under this section and has not received a 

16 waiver under subsection (m) shall be liable, in lieu 

17 of any service obligation arising under such contract, 

18 to the United States for the amount which has been 

19 paid on such individual’s behalf under the contract 

20 if that individual—

21 ‘‘(A) is enrolled in the final year of a 

22 course of study and—

23 ‘‘(i) fails to maintain an acceptable 

24 level of academic standing in the edu25 cational institution in which he or she is 
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1 enrolled (such level determined by the edu2 cational institution under regulations of 

3 the Secretary); 

4 ‘‘(ii) voluntarily terminates such en5 rollment; or 

6 ‘‘(iii) is dismissed from such edu7 cational institution before completion of 

8 such course of study; or 

9 ‘‘(B) is enrolled in a graduate training pro10 gram and fails to complete such training pro11 gram. 

12 ‘‘(2) OTHER BREACHES; FORMULA FOR

13 AMOUNT OWED.—If, for any reason not specified in 

14 paragraph (1), an individual breaches his or her 

15 written contract under this section by failing either 

16 to begin, or complete, such individual’s period of ob17 ligated service in accordance with subsection (e)(2), 

18 the United States shall be entitled to recover from 

19 such individual an amount to be determined in ac20 cordance with the following formula: A=3Z(t-s/t) in 

21 which—

22 ‘‘(A) ‘A’ is the amount the United States 

23 is entitled to recover; 

24 ‘‘(B) ‘Z’ is the sum of the amounts paid 

25 under this section to, or on behalf of, the indi-
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•HR 2440 IH 

1 vidual and the interest on such amounts which 

2 would be payable if, at the time the amounts 

3 were paid, they were loans bearing interest at 

4 the maximum legal prevailing rate, as deter5 mined by the Secretary of the Treasury; 

6 ‘‘(C) ‘t’ is the total number of months in 

7 the individual’s period of obligated service in 

8 accordance with subsection (f); and 

9 ‘‘(D) ‘s’ is the number of months of such 

10 period served by such individual in accordance 

11 with this section. 

12 ‘‘(3) DEDUCTIONS IN MEDICARE PAYMENTS.—

13 Amounts not paid within such period shall be sub14 ject to collection through deductions in medicare 

15 payments pursuant to section 1892 of the Social Se16 curity Act. 

17 ‘‘(4) TIME PERIOD FOR REPAYMENT.—Any 

18 amount of damages which the United States is enti19 tled to recover under this subsection shall be paid to 

20 the United States within the 1-year period beginning 

21 on the date of the breach or such longer period be22 ginning on such date as shall be specified by the 

23 Secretary. 

24 ‘‘(5) RECOVERY OF DELINQUENCY.—
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1 ‘‘(A) IN GENERAL.—If damages described 

2 in paragraph (4) are delinquent for 3 months, 

3 the Secretary shall, for the purpose of recov4 ering such damages—

5 ‘‘(i) use collection agencies contracted 

6 with by the Administrator of General Serv7 ices; or 

8 ‘‘(ii) enter into contracts for the re9 covery of such damages with collection 

10 agencies selected by the Secretary. 

11 ‘‘(B) REPORT.—Each contract for recov12 ering damages pursuant to this subsection shall 

13 provide that the contractor will, not less than 

14 once each 6 months, submit to the Secretary a 

15 status report on the success of the contractor in 

16 collecting such damages. Section 3718 of title 

17 31, United States Code, shall apply to any such 

18 contract to the extent not inconsistent with this 

19 subsection. 

20 ‘‘(m) WAIVER OR SUSPENSION OF OBLIGATION.—

21 ‘‘(1) IN GENERAL.—The Secretary shall by reg22 ulation provide for the partial or total waiver or sus23 pension of any obligation of service or payment by 

24 an individual under the Loan Repayment Program 

25 whenever compliance by the individual is impossible 
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1 or would involve extreme hardship to the individual 

2 and if enforcement of such obligation with respect to 

3 any individual would be unconscionable. 

4 ‘‘(2) CANCELED UPON DEATH.—Any obligation 

5 of an individual under the Loan Repayment Pro6 gram for service or payment of damages shall be 

7 canceled upon the death of the individual. 

8 ‘‘(3) HARDSHIP WAIVER.—The Secretary may 

9 waive, in whole or in part, the rights of the United 

10 States to recover amounts under this section in any 

11 case of extreme hardship or other good cause shown, 

12 as determined by the Secretary. 

13 ‘‘(4) BANKRUPTCY.—Any obligation of an indi14 vidual under the Loan Repayment Program for pay15 ment of damages may be released by a discharge in 

16 bankruptcy under title 11 of the United States Code 

17 only if such discharge is granted after the expiration 

18 of the 5-year period beginning on the first date that 

19 payment of such damages is required, and only if 

20 the bankruptcy court finds that nondischarge of the 

21 obligation would be unconscionable. 

22 ‘‘(n) REPORT.—The Secretary shall submit to the 

23 President, for inclusion in each report required to be sub24 mitted to Congress under section 801, a report concerning
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1 the previous fiscal year which sets forth by Service Area 

2 the following: 

3 ‘‘(1) A list of the health professional positions 

4 maintained by Indian Health Programs and Urban 

5 Indian Organizations for which recruitment or reten6 tion is difficult. 

7 ‘‘(2) The number of Loan Repayment Program 

8 applications filed with respect to each type of health 

9 profession. 

10 ‘‘(3) The number of contracts described in sub11 section (e) that are entered into with respect to each 

12 health profession. 

13 ‘‘(4) The amount of loan payments made under 

14 this section, in total and by health profession. 

15 ‘‘(5) The number of scholarships that are pro16 vided under section 104 and 106 with respect to 

17 each health profession. 

18 ‘‘(6) The amount of scholarship grants provided 

19 under section 104 and 106, in total and by health 

20 profession. 

21 ‘‘(7) The number of providers of health care 

22 that will be needed by Indian Health Programs and 

23 Urban Indian Organizations, by location and profes24 sion, during the 3 fiscal years beginning after the 

25 date the report is filed. 
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1 ‘‘(8) The measures the Secretary plans to take 

2 to fill the health professional positions maintained 

3 by Indian Health Programs or Urban Indian Orga4 nizations for which recruitment or retention is dif5 ficult. 

6 ‘‘SEC. 111. SCHOLARSHIP AND LOAN REPAYMENT RECOV7 ERY FUND. 

8 ‘‘(a) ESTABLISHMENT.—There is established in the 

9 Treasury of the United States a fund to be known as the 

10 Indian Health Scholarship and Loan Repayment Recovery 

11 Fund (hereafter in this section referred to as the ‘LRRF’). 

12 The LRRF shall consist of such amounts as may be col13 lected from individuals under section 104(d), section 

14 106(e), and section 110(l) for breach of contract, such 

15 funds as may be appropriated to the LRRF, and interest 

16 earned on amounts in the LRRF. All amounts collected, 

17 appropriated, or earned relative to the LRRF shall remain 

18 available until expended. 

19 ‘‘(b) USE OF FUNDS.—

20 ‘‘(1) BY SECRETARY.—Amounts in the LRRF 

21 may be expended by the Secretary, acting through 

22 the Service, to make payments to an Indian Health 

23 Program—

24 ‘‘(A) to which a scholarship recipient under 

25 section 104 and 106 or a loan repayment pro-
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1 gram participant under section 110 has been 

2 assigned to meet the obligated service require3 ments pursuant to such sections; and 

4 ‘‘(B) that has a need for a health profes5 sional to provide health care services as a result 

6 of such recipient or participant having breached 

7 the contract entered into under section 104, 

8 106, or section 110. 

9 ‘‘(2) BY TRIBAL HEALTH PROGRAMS.—A Tribal 

10 Health Program receiving payments pursuant to 

11 paragraph (1) may expend the payments to provide 

12 scholarships or recruit and employ, directly or by 

13 contract, health professionals to provide health care 

14 services. 

15 ‘‘(c) INVESTMENT OF FUNDS.—The Secretary of the 

16 Treasury shall invest such amounts of the LRRF as the 

17 Secretary of Health and Human Services determines are 

18 not required to meet current withdrawals from the LRRF. 

19 Such investments may be made only in interest bearing 

20 obligations of the United States. For such purpose, such 

21 obligations may be acquired on original issue at the issue 

22 price, or by purchase of outstanding obligations at the 

23 market price. 
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1 ‘‘(d) SALE OF OBLIGATIONS.—Any obligation ac2 quired by the LRRF may be sold by the Secretary of the 

3 Treasury at the market price. 

4 ‘‘SEC. 112. RECRUITMENT ACTIVITIES. 

5 ‘‘(a) REIMBURSEMENT FOR TRAVEL.—The Sec6 retary, acting through the Service, may reimburse health 

7 professionals seeking positions with Indian Health Pro8 grams or Urban Indian Organizations, including unpaid 

9 student volunteers and individuals considering entering 

10 into a contract under section 110, and their spouses, for 

11 actual and reasonable expenses incurred in traveling to 

12 and from their places of residence to an area in which 

13 they may be assigned for the purpose of evaluating such 

14 area with respect to such assignment. 

15 ‘‘(b) RECRUITMENT PERSONNEL.—The Secretary, 

16 acting through the Service, shall assign one individual in 

17 each Area Office to be responsible on a full-time basis for 

18 recruitment activities. 

19 ‘‘SEC. 113. INDIAN RECRUITMENT AND RETENTION PRO20 GRAM. 

21 ‘‘(a) IN GENERAL.—The Secretary, acting through 

22 the Service, shall fund innovative demonstration projects 

23 for a period not to exceed 3 years to enable Tribal Health 

24 Programs and Urban Indian Organizations to recruit,
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1 place, and retain health professionals to meet their staff2 ing needs. 

3 ‘‘(b) ELIGIBLE ENTITIES; APPLICATION.—Any Trib4 al Health Program or Urban Indian Organization may 

5 submit an application for funding of a project pursuant 

6 to this section. 

7 ‘‘SEC. 114. ADVANCED TRAINING AND RESEARCH. 

8 ‘‘(a) DEMONSTRATION PROGRAM.—The Secretary, 

9 acting through the Service, shall establish a demonstration 

10 project to enable health professionals who have worked in 

11 an Indian Health Program or Urban Indian Organization 

12 for a substantial period of time to pursue advanced train13 ing or research areas of study for which the Secretary de14 termines a need exists. 

15 ‘‘(b) SERVICE OBLIGATION.—An individual who par16 ticipates in a program under subsection (a), where the 

17 educational costs are borne by the Service, shall incur an 

18 obligation to serve in an Indian Health Program or Urban 

19 Indian Organization for a period of obligated service equal 

20 to at least the period of time during which the individual 

21 participates in such program. In the event that the indi22 vidual fails to complete such obligated service, the indi23 vidual shall be liable to the United States for the period 

24 of service remaining. In such event, with respect to indi25 viduals entering the program after the date of the enact-
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1 ment of the Indian Health Care Improvement Act Amend2 ments of 2003, the United States shall be entitled to re3 cover from such individual an amount to be determined 

4 in accordance with the formula specified in subsection (l) 

5 of section 110 in the manner provided for in such sub6 section. 

7 ‘‘(c) EQUAL OPPORTUNITY FOR PARTICIPATION.—

8 Health professionals from Tribal Health Programs and 

9 Urban Indian Organizations shall be given an equal oppor10 tunity to participate in the program under subsection (a). 

11 ‘‘SEC. 115. QUENTIN N. BURDICK AMERICAN INDIANS INTO 

12 NURSING PROGRAM. 

13 ‘‘(a) GRANTS AUTHORIZED.—For the purpose of in14 creasing the number of nurses, nurse midwives, and nurse 

15 practitioners who deliver health care services to Indians, 

16 the Secretary, acting through the Service, shall provide 

17 grants to the following: 

18 ‘‘(1) Public or private schools of nursing. 

19 ‘‘(2) Tribal colleges or universities.

20 ‘‘(3) Nurse midwife programs and advanced 

21 practice nurse programs that are provided by any 

22 tribal college or university accredited nursing pro23 gram, or in the absence of such, any other public or 

24 private institutions. 
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1 ‘‘(b) USE OF GRANTS.—Grants provided under sub2 section (a) may be used for one or more of the following: 

3 ‘‘(1) To recruit individuals for programs which 

4 train individuals to be nurses, nurse midwives, or 

5 advanced practice nurses. 

6 ‘‘(2) To provide scholarships to Indians enrolled 

7 in such programs that may pay the tuition charged 

8 for such program and other expenses incurred in 

9 connection with such program, including books, fees, 

10 room and board, and stipends for living expenses. 

11 ‘‘(3) To provide a program that encourages 

12 nurses, nurse midwives, and advanced practice 

13 nurses to provide, or continue to provide, health care 

14 services to Indians. 

15 ‘‘(4) To provide a program that increases the 

16 skills of, and provides continuing education to, 

17 nurses, nurse midwives, and advanced practice 

18 nurses. 

19 ‘‘(5) To provide any program that is designed 

20 to achieve the purpose described in subsection (a). 

21 ‘‘(c) APPLICATIONS.—Each application for funding 

22 under subsection (a) shall include such information as the 

23 Secretary may require to establish the connection between 

24 the program of the applicant and a health care facility 

25 that primarily serves Indians. 
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1 ‘‘(d) PREFERENCES FOR GRANT RECIPIENTS.—In 

2 providing grants under subsection (a), the Secretary shall 

3 extend a preference to the following: 

4 ‘‘(1) Programs that provide a preference to In5 dians. 

6 ‘‘(2) Programs that train nurse midwives or ad7 vanced practice nurses. 

8 ‘‘(3) Programs that are interdisciplinary. 

9 ‘‘(4) Programs that are conducted in coopera10 tion with a program for gifted and talented Indian 

11 students. 

12 ‘‘(e) QUENTIN N. BURDICK PROGRAM GRANT.—The 

13 Secretary shall provide one of the grants authorized under 

14 subsection (a) to establish and maintain a program at the 

15 University of North Dakota to be known as the ‘Quentin 

16 N. Burdick American Indians Into Nursing Program’. 

17 Such program shall, to the maximum extent feasible, co18 ordinate with the Quentin N. Burdick Indian Health Pro19 grams established under section 117(b) and the Quentin 

20 N. Burdick American Indians Into Psychology Program 

21 established under section 105(b). 

22 ‘‘(f) ACTIVE DUTY SERVICE OBLIGATION.—The ac23 tive duty service obligation prescribed under section 338C 

24 of the Public Health Service Act (42 U.S.C. 254m) shall 

25 be met by each individual who receives training or assist-
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1 ance described in paragraph (1) or (2) of subsection (b) 

2 that is funded by a grant provided under subsection (a). 

3 Such obligation shall be met by service—

4 ‘‘(1) in the Service; 

5 ‘‘(2) in a program of an Indian Tribe or Tribal 

6 Organization conducted under the Indian Self-Deter7 mination Act (including programs under agreements 

8 with the Bureau of Indian Affairs); 

9 ‘‘(3) in a program assisted under title V of this 

10 Act; or 

11 ‘‘(4) in the private practice of nursing if, as de12 termined by the Secretary, in accordance with guide13 lines promulgated by the Secretary, such practice is 

14 situated in a physician or other health shortage area 

15 and addresses the health care needs of a substantial 

16 number of Indians. 

17 ‘‘SEC. 116. TRIBAL CULTURAL ORIENTATION. 

18 ‘‘(a) CULTURAL EDUCATION OF EMPLOYEES.—The 

19 Secretary, acting through the Service, shall require that 

20 appropriate employees of the Service who serve Indian 

21 Tribes in each Service Area receive educational instruction 

22 in the history and culture of such Indian Tribes and their 

23 relationship to the Service.
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1 ‘‘(b) PROGRAM.—In carrying out subsection (a), the 

2 Secretary shall establish a program which shall, to the ex3 tent feasible—

4 ‘‘(1) be developed in consultation with the af5 fected Indian Tribes, Tribal Organizations, and 

6 Urban Indian Organizations; 

7 ‘‘(2) be carried out through tribal colleges or 

8 universities; 

9 ‘‘(3) include instruction in American Indian 

10 studies; and 

11 ‘‘(4) describe the use and place of Traditional 

12 Health Care Practices of the Indian Tribes in the 

13 Service Area. 

14 ‘‘SEC. 117. INMED PROGRAM. 

15 ‘‘(a) GRANTS AUTHORIZED.—The Secretary, acting 

16 through the Service, is authorized to provide grants to col17 leges and universities for the purpose of maintaining and 

18 expanding the Indian health careers recruitment program 

19 known as the ‘Indians Into Medicine Program’ (herein20 after in this section referred to as ‘INMED’) as a means 

21 of encouraging Indians to enter the health professions. 

22 ‘‘(b) QUENTIN N. BURDICK GRANT.—The Secretary 

23 shall provide one of the grants authorized under sub24 section (a) to maintain the INMED program at the Uni25 versity of North Dakota, to be known as the ‘Quentin N. 
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1 Burdick Indian Health Programs’, unless the Secretary 

2 makes a determination, based upon program reviews, that 

3 the program is not meeting the purposes of this section. 

4 Such program shall, to the maximum extent feasible, co5 ordinate with the Quentin N. Burdick American Indians 

6 Into Psychology Program established under section 105(b) 

7 and the Quentin N. Burdick American Indians Into Nurs8 ing Program established under section 115. 

9 ‘‘(c) REGULATIONS.—The Secretary, pursuant to this 

10 Act, shall develop regulations to govern grants pursuant 

11 to this section. 

12 ‘‘(d) REQUIREMENTS.—Applicants for grants pro13 vided under this section shall agree to provide a program 

14 which—

15 ‘‘(1) provides outreach and recruitment for 

16 health professions to Indian communities including 

17 elementary and secondary schools and community 

18 colleges located on reservations which will be served 

19 by the program; 

20 ‘‘(2) incorporates a program advisory board 

21 comprised of representatives from the Indian Tribes 

22 and Indian communities which will be served by the 

23 program; 

24 ‘‘(3) provides summer preparatory programs for 

25 Indian students who need enrichment in the subjects 
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1 of math and science in order to pursue training in 

2 the health professions; 

3 ‘‘(4) provides tutoring, counseling, and support 

4 to students who are enrolled in a health career pro5 gram of study at the respective college or university; 

6 and 

7 ‘‘(5) to the maximum extent feasible, employs 

8 qualified Indians in the program. 

9 ‘‘SEC. 118. HEALTH TRAINING PROGRAMS OF COMMUNITY 

10 COLLEGES. 

11 ‘‘(a) GRANTS TO ESTABLISH PROGRAMS.—

12 ‘‘(1) IN GENERAL.—The Secretary, acting 

13 through the Service, shall award grants to accredited 

14 and accessible community colleges for the purpose of 

15 assisting such community colleges in the establish16 ment of programs which provide education in a 

17 health profession leading to a degree or diploma in 

18 a health profession for individuals who desire to 

19 practice such profession on or near a reservation or 

20 in an Indian Health Program. 

21 ‘‘(2) AMOUNT OF GRANTS.—The amount of any 

22 grant awarded to a community college under para23 graph (1) for the first year in which such a grant 

24 is provided to the community college shall not exceed 

25 $100,000. 
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1 ‘‘(b) GRANTS FOR MAINTENANCE AND RECRUIT2 ING.—

3 ‘‘(1) IN GENERAL.—The Secretary, acting 

4 through the Service, shall award grants to accredited 

5 and accessible community colleges that have estab6 lished a program described in subsection (a)(1) for 

7 the purpose of maintaining the program and recruit8 ing students for the program. 

9 ‘‘(2) REQUIREMENTS.—Grants may only be 

10 made under this section to a community college 

11 which—

12 ‘‘(A) is accredited; 

13 ‘‘(B) has a relationship with a hospital fa14 cility, Service facility, or hospital that could 

15 provide training of nurses or health profes16 sionals; 

17 ‘‘(C) has entered into an agreement with 

18 an accredited college or university medical 

19 school, the terms of which—

20 ‘‘(i) provide a program that enhances 

21 the transition and recruitment of students 

22 into advanced baccalaureate or graduate 

23 programs which train health professionals; 

24 and 
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1 ‘‘(ii) stipulate certifications necessary 

2 to approve internship and field placement 

3 opportunities at Indian Health Programs; 

4 ‘‘(D) has a qualified staff which has the 

5 appropriate certifications; 

6 ‘‘(E) is capable of obtaining State or re7 gional accreditation of the program described in 

8 subsection (a)(1); and 

9 ‘‘(F) agrees to provide for Indian pref10 erence for applicants for programs under this 

11 section. 

12 ‘‘(c) TECHNICAL ASSISTANCE.—The Secretary shall 

13 encourage community colleges described in subsection 

14 (b)(2) to establish and maintain programs described in 

15 subsection (a)(1) by—

16 ‘‘(1) entering into agreements with such col17 leges for the provision of qualified personnel of the 

18 Service to teach courses of study in such programs; 

19 and 

20 ‘‘(2) providing technical assistance and support 

21 to such colleges. 

22 ‘‘(d) ADVANCED TRAINING.—

23 ‘‘(1) REQUIRED.—Any program receiving as24 sistance under this section that is conducted with re25 spect to a health profession shall also offer courses
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1 of study which provide advanced training for any 

2 health professional who—

3 ‘‘(A) has already received a degree or di4 ploma in such health profession; and 

5 ‘‘(B) provides clinical services on or near a 

6 reservation or for an Indian Health Program. 

7 ‘‘(2) MAY BE OFFERED AT ALTERNATE SITE.—

8 Such courses of study may be offered in conjunction 

9 with the college or university with which the commu10 nity college has entered into the agreement required 

11 under subsection (b)(2)(C). 

12 ‘‘(e) FUNDING PRIORITY.—Where the requirements 

13 of subsection (b) are met, funding priority shall be pro14 vided to tribal colleges and universities in Service Areas 

15 where they exist. 

16 ‘‘SEC. 119. RETENTION BONUS. 

17 ‘‘(a) BONUS AUTHORIZED.—The Secretary may pay 

18 a retention bonus to any health professional employed by, 

19 or assigned to, and serving in, an Indian Health Program 

20 or Urban Indian Organization either as a civilian employee 

21 or as a commissioned officer in the Regular or Reserve 

22 Corps of the Public Health Service who—

23 ‘‘(1) is assigned to, and serving in, a position 

24 for which recruitment or retention of personnel is 

25 difficult; 
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1 ‘‘(2) the Secretary determines is needed by In2 dian Health Programs and Urban Indian Organiza3 tions; 

4 ‘‘(3) has—

5 ‘‘(A) completed 3 years of employment 

6 with an Indian Health Program or Urban In7 dian Organization; or 

8 ‘‘(B) completed any service obligations in9 curred as a requirement of—

10 ‘‘(i) any Federal scholarship program; 

11 or 

12 ‘‘(ii) any Federal education loan re13 payment program; and 

14 ‘‘(4) enters into an agreement with an Indian 

15 Health Program or Urban Indian Organization for 

16 continued employment for a period of not less than 

17 1 year. 

18 ‘‘(b) RATES.—The Secretary may establish rates for 

19 the retention bonus which shall provide for a higher an20 nual rate for multiyear agreements than for single year 

21 agreements referred to in subsection (a)(4), but in no 

22 event shall the annual rate be more than $25,000 per 

23 annum. 

24 ‘‘(c) DEFAULT OF RETENTION AGREEMENT.—Any 

25 health professional failing to complete the agreed upon 
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1 term of service, except where such failure is through no 

2 fault of the individual, shall be obligated to refund to the 

3 Government the full amount of the retention bonus for the 

4 period covered by the agreement, plus interest as deter5 mined by the Secretary in accordance with section 

6 110(l)(2)(B). 

7 ‘‘(d) OTHER RETENTION BONUS.—The Secretary 

8 may pay a retention bonus to any health professional em9 ployed by a Tribal Health Program if such health profes10 sional is serving in a position which the Secretary deter11 mines is—

12 ‘‘(1) a position for which recruitment or reten13 tion is difficult; and 

14 ‘‘(2) necessary for providing health care services 

15 to Indians. 

16 ‘‘SEC. 120. NURSING RESIDENCY PROGRAM. 

17 ‘‘(a) ESTABLISHMENT OF PROGRAM.—The Sec18 retary, acting through the Service, shall establish a pro19 gram to enable Indians who are licensed practical nurses, 

20 licensed vocational nurses, and registered nurses who are 

21 working in an Indian Health Program or Urban Indian 

22 Organization, and have done so for a period of not less 

23 than 1 year, to pursue advanced training. Such program 

24 shall include a combination of education and work study 

25 in an Indian Health Program or Urban Indian Organiza-
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1 tion leading to an associate or bachelor’s degree (in the 

2 case of a licensed practical nurse or licensed vocational 

3 nurse), a bachelor’s degree (in the case of a registered 

4 nurse), or advanced degrees in nursing and public health. 

5 ‘‘(b) SERVICE OBLIGATION.—An individual who par6 ticipates in a program under subsection (a), where the 

7 educational costs are paid by the Service, shall incur an 

8 obligation to serve in an Indian Health Program or Urban 

9 Indian Organization for a period of obligated service equal 

10 to the amount of time during which the individual partici11 pates in such program. In the event that the individual 

12 fails to complete such obligated service, the United States 

13 shall be entitled to recover from such individual an amount 

14 determined in accordance with the formula specified in 

15 subsection (l) of section 110 in the manner provided for 

16 in such subsection. 

17 ‘‘SEC. 121. COMMUNITY HEALTH AIDE PROGRAM FOR ALAS18 KA. 

19 ‘‘(a) GENERAL PURPOSES OF PROGRAM.—Under the 

20 authority of the Act of November 2, 1921 (25 U.S.C. 13; 

21 popularly known as the Snyder Act), the Secretary, acting 

22 through the Service, shall develop and operate a Commu23 nity Health Aide Program in Alaska under which the 

24 Service—
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1 ‘‘(1) provides for the training of Alaska Natives 

2 as health aides or community health practitioners; 

3 ‘‘(2) uses such aides or practitioners in the pro4 vision of health care, health promotion, and disease 

5 prevention services to Alaska Natives living in vil6 lages in rural Alaska; and 

7 ‘‘(3) provides for the establishment of tele8 conferencing capacity in health clinics located in or 

9 near such villages for use by community health aides 

10 or community health practitioners. 

11 ‘‘(b) SPECIFIC PROGRAM REQUIREMENTS.—The Sec12 retary, acting through the Community Health Aide Pro13 gram of the Service, shall—

14 ‘‘(1) using trainers accredited by the Program, 

15 provide a high standard of training to community 

16 health aides and community health practitioners to 

17 ensure that such aides and practitioners provide 

18 quality health care, health promotion, and disease 

19 prevention services to the villages served by the Pro20 gram; 

21 ‘‘(2) in order to provide such training, develop 

22 a curriculum that—

23 ‘‘(A) combines education in the theory of 

24 health care with supervised practical experience 

25 in the provision of health care;
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1 ‘‘(B) provides instruction and practical ex2 perience in the provision of acute care, emer3 gency care, health promotion, disease preven4 tion, and the efficient and effective manage5 ment of clinic pharmacies, supplies, equipment, 

6 and facilities; and 

7 ‘‘(C) promotes the achievement of the 

8 health status objectives specified in section 

9 3(2); 

10 ‘‘(3) establish and maintain a Community 

11 Health Aide Certification Board to certify as com12 munity health aides or community health practi13 tioners individuals who have successfully completed 

14 the training described in paragraph (1) or can dem15 onstrate equivalent experience; 

16 ‘‘(4) develop and maintain a system which iden17 tifies the needs of community health aides and com18 munity health practitioners for continuing education 

19 in the provision of health care, including the areas 

20 described in paragraph (2)(B), and develop pro21 grams that meet the needs for such continuing edu22 cation; 

23 ‘‘(5) develop and maintain a system that pro24 vides close supervision of community health aides 

25 and community health practitioners; and 
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1 ‘‘(6) develop a system under which the work of 

2 community health aides and community health prac3 titioners is reviewed and evaluated to assure the pro4 vision of quality health care, health promotion, and 

5 disease prevention services. 

6 ‘‘(c) NATIONAL COMMUNITY HEALTH AIDE PRO7 GRAM.—The Secretary, acting through the Service, shall 

8 develop and operate a national Community Health Aide 

9 Program consistent with the requirements of this section 

10 without reducing funds for the Community Health Aide 

11 Program for Alaska. 

12 ‘‘SEC. 122. TRIBAL HEALTH PROGRAM ADMINISTRATION. 

13 ‘‘The Secretary, acting through the Service, shall, by 

14 funding agreement or otherwise, provide training for Indi15 ans in the administration and planning of Tribal Health 

16 Programs. 

17 ‘‘SEC. 123. HEALTH PROFESSIONAL CHRONIC SHORTAGE 

18 DEMONSTRATION PROGRAMS. 

19 ‘‘(a) DEMONSTRATION PROGRAMS AUTHORIZED.— 

20 The Secretary, acting through the Service, may fund dem21 onstration programs for Tribal Health Programs to ad22 dress the chronic shortages of health professionals. 

23 ‘‘(b) PURPOSES OF PROGRAMS.—The purposes of 

24 demonstration programs funded under subsection (a) shall 

25 be—
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1 ‘‘(1) to provide direct clinical and practical ex2 perience at a Service Unit to health profession stu3 dents and residents from medical schools; 

4 ‘‘(2) to improve the quality of health care for 

5 Indians by assuring access to qualified health care 

6 professionals; and 

7 ‘‘(3) to provide academic and scholarly opportu8 nities for health professionals serving Indians by 

9 identifying all academic and scholarly resources of 

10 the region. 

11 ‘‘(c) ADVISORY BOARD.—The demonstration pro12 grams established pursuant to subsection (a) shall incor13 porate a program advisory board composed of representa14 tives from the Indian Tribes and Indian communities in 

15 the area which will be served by the program. 

16 ‘‘SEC. 124. TREATMENT OF SCHOLARSHIPS FOR CERTAIN 

17 PURPOSES. 

18 ‘‘Scholarships provided to individuals pursuant to 

19 this title shall be deemed ‘qualified Scholarships’ for pur20 poses of section 11 of the Internal Revenue Code of 1986. 

21 ‘‘SEC. 125. NATIONAL HEALTH SERVICE CORPS. 

22 ‘‘(a) NO REDUCTION IN SERVICES.—The Secretary 

23 shall not—
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1 ‘‘(1) remove a member of the National Health 

2 Service Corps from an Indian Health Program or 

3 Urban Indian Organization; or 

4 ‘‘(2) withdraw funding used to support such 

5 member, unless the Secretary, acting through the 

6 Service, Indian Tribes, or Tribal Organizations, has 

7 ensured that the Indians receiving services from 

8 such member will experience no reduction in serv9 ices. 

10 ‘‘(b) EXEMPTION FROM LIMITATIONS.—National 

11 Health Service Corps scholars qualifying for the Commis12 sioned Corps in the United States Public Health Service 

13 shall be exempt from the full-time equivalent limitations 

14 of the National Health Service Corps and the Service 

15 when serving as a commissioned corps officer in a Tribal 

16 Health Program or an Urban Indian Organization. 

17 ‘‘SEC. 126. SUBSTANCE ABUSE COUNSELOR EDUCATIONAL 

18 CURRICULA DEMONSTRATION PROGRAMS. 

19 ‘‘(a) GRANTS AND CONTRACTS.—The Secretary, act20 ing through the Service, may enter into contracts with, 

21 or make grants to, accredited tribal colleges and univer22 sities and eligible accredited and accessible community col23 leges to establish demonstration programs to develop edu24 cational curricula for substance abuse counseling.
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1 ‘‘(b) USE OF FUNDS.—Funds provided under this 

2 section shall be used only for developing and providing 

3 educational curriculum for substance abuse counseling (in4 cluding paying salaries for instructors). Such curricula 

5 may be provided through satellite campus programs. 

6 ‘‘(c) TIME PERIOD OF ASSISTANCE; RENEWAL.—A 

7 contract entered into or a grant provided under this sec8 tion shall be for a period of 1 year. Such contract or grant 

9 may be renewed for an additional 1-year period upon the 

10 approval of the Secretary. 

11 ‘‘(d) CRITERIA FOR REVIEW AND APPROVAL OF AP12 PLICATIONS.—Not later than 180 days after the date of 

13 the enactment of the Indian Health Care Improvement 

14 Act Amendments of 2003, the Secretary, after consulta15 tion with Indian Tribes and administrators of tribal col16 leges and universities and eligible accredited and acces17 sible community colleges, shall develop and issue criteria 

18 for the review and approval of applications for funding (in19 cluding applications for renewals of funding) under this 

20 section. Such criteria shall ensure that demonstration pro21 grams established under this section promote the develop22 ment of the capacity of such entities to educate substance 

23 abuse counselors. 

24 ‘‘(e) ASSISTANCE.—The Secretary shall provide such 

25 technical and other assistance as may be necessary to en-
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1 able grant recipients to comply with the provisions of this 

2 section. 

3 ‘‘(f) REPORT.—Each fiscal year, the Secretary shall 

4 submit to the President, for inclusion in the report which 

5 is required to be submitted under section 801 for that fis6 cal year, a report on the findings and conclusions derived 

7 from the demonstration programs conducted under this 

8 section during that fiscal year. 

9 ‘‘(g) DEFINITION.—For the purposes of this section 

10 the term ‘educational curriculum’ means 1 or more of the 

11 following—

12 ‘‘(1) classroom education; 

13 ‘‘(2) clinical work experience; and 

14 ‘‘(3) continuing education workshops. 

15 ‘‘SEC. 127. MENTAL HEALTH TRAINING AND COMMUNITY 

16 EDUCATION PROGRAMS. 

17 ‘‘(a) STUDY; LIST.—The Secretary, acting through 

18 the Service, and the Secretary of the Interior, in consulta19 tion with Indian Tribes and Tribal Organizations, shall 

20 conduct a study and compile a list of the types of staff 

21 positions specified in subsection (b) whose qualifications 

22 include, or should include, training in the identification, 

23 prevention, education, referral, or treatment of mental ill24 ness, or dysfunctional and self destructive behavior. 
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1 ‘‘(b) POSITIONS.—The positions referred to in sub2 section (a) are—

3 ‘‘(1) staff positions within the Bureau of Indian 

4 Affairs, including existing positions, in the fields 

5 of—

6 ‘‘(A) elementary and secondary education; 

7 ‘‘(B) social services and family and child 

8 welfare; 

9 ‘‘(C) law enforcement and judicial services; 

10 and 

11 ‘‘(D) alcohol and substance abuse; 

12 ‘‘(2) staff positions within the Service; and 

13 ‘‘(3) staff positions similar to those identified in 

14 paragraphs (1) and (2) established and maintained 

15 by Indian Tribes, Tribal Organizations, (without re16 gard to the funding source) and Urban Indian Orga17 nizations. 

18 ‘‘(c) TRAINING CRITERIA.—

19 ‘‘(1) IN GENERAL.—The appropriate Secretary 

20 shall provide training criteria appropriate to each 

21 type of position identified in subsection (b)(1) and 

22 (b)(2) and ensure that appropriate training has 

23 been, or shall be provided to any individual in any 

24 such position. With respect to any such individual in 

25 a position identified pursuant to subsection (b)(3), 
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1 the respective Secretaries shall provide appropriate 

2 training to, or provide funds to, an Indian Tribe, 

3 Tribal Organization, or Urban Indian Organization 

4 for training of appropriate individuals. In the case of 

5 positions funded under a funding agreement, the ap6 propriate Secretary shall ensure that funds to cover 

7 the costs of such training costs are included in the 

8 funding agreement. 

9 ‘‘(2) POSITION SPECIFIC TRAINING CRITERIA.—

10 Position specific training criteria shall be culturally 

11 relevant to Indians and Indian Tribes and shall en12 sure that appropriate information regarding Tradi13 tional Health Care Practices is provided. 

14 ‘‘(d) COMMUNITY EDUCATION ON MENTAL ILL15 NESS.—The Service shall develop and implement, on re16 quest of an Indian Tribe or Tribal Organization, or assist 

17 the Indian Tribe or Tribal Organization to develop and 

18 implement a program of community education on mental 

19 illness. In carrying out this subsection, the Service shall, 

20 upon request of an Indian Tribe or Tribal Organization, 

21 provide technical assistance to the Indian Tribe or Tribal 

22 Organization to obtain and develop community edu23 cational materials on the identification, prevention, refer24 ral, and treatment of mental illness and dysfunctional and 

25 self-destructive behavior. 
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1 ‘‘(e) PLAN.—Not later than 90 days after the date 

2 of the enactment of the Indian Health Care Improvement 

3 Act Amendments of 2003, the Secretary shall develop a 

4 plan under which the Service will increase the health care 

5 staff providing mental health services by at least 500 posi6 tions within 5 years after the date of the enactment of 

7 this section, with at least 200 of such positions devoted 

8 to child, adolescent, and family services. The plan devel9 oped under this subsection shall be implemented under the 

10 Act of November 2, 1921 (25 U.S.C. 13, popularly known 

11 as the Snyder Act). 

12 ‘‘SEC. 128. DESIGNATION OF SHORTAGE AREAS. 

13 ‘‘A Service Area served by an Indian Health Program 

14 or Urban Indian Organization shall be designated under 

15 the Public Health Services Act (42 U.S.C. 250 et seq.) 

16 as a shortage area immediately upon request of an Indian 

17 Health Program without further evaluation by the Sec18 retary. 

19 ‘‘SEC. 129. AUTHORIZATION OF APPROPRIATIONS. 

20 ‘‘There are authorized to be appropriated such sums 

21 as may be necessary for each fiscal year through fiscal 

22 year 2015 to carry out this title.
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1 ‘‘TITLE II—HEALTH SERVICES 

2 ‘‘SEC. 201. INDIAN HEALTH CARE IMPROVEMENT FUND. 

3 ‘‘(a) USE OF FUNDS.—The Secretary, acting through 

4 the Service, is authorized to expend funds, directly or 

5 under the authority of the Indian Self-Determination and 

6 Education Assistance Act, which are appropriated under 

7 the authority of this section, for the purposes of—

8 ‘‘(1) eliminating the deficiencies in health sta9 tus and health resources of all Indian Tribes; 

10 ‘‘(2) eliminating backlogs in the provision of 

11 health care services to Indians; 

12 ‘‘(3) meeting the health needs of Indians in an 

13 efficient and equitable manner; 

14 ‘‘(4) eliminating inequities in funding for both 

15 direct care and contract health service programs; 

16 and 

17 ‘‘(5) augmenting the ability of the Service to 

18 meet the following health service responsibilities with 

19 respect to those Indian Tribes with the highest levels 

20 of health status deficiencies and resource defi21 ciencies: 

22 ‘‘(A) Clinical care, including, but not lim23 ited to, inpatient care, outpatient care (includ24 ing audiology, clinical eye, and vision care), pri-
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1 mary care, secondary and tertiary care, and 

2 long-term care. 

3 ‘‘(B) Preventive health, including mam4 mography and other cancer screening in accord5 ance with section 207. 

6 ‘‘(C) Dental care. 

7 ‘‘(D) Mental health, including community 

8 mental health services, inpatient mental health 

9 services, dormitory mental health services, 

10 therapeutic and residential treatment centers, 

11 and training of traditional health care practi12 tioners. 

13 ‘‘(E) Emergency medical services. 

14 ‘‘(F) Treatment and control of, and reha15 bilitative care related to, alcoholism and drug 

16 abuse (including fetal alcohol syndrome) among 

17 Indians. 

18 ‘‘(G) Accident prevention programs. 

19 ‘‘(H) Home health care. 

20 ‘‘(I) Community health representatives. 

21 ‘‘(J) Maintenance and repair. 

22 ‘‘(K) Traditional Health Care Practices. 

23 ‘‘(b) NO OFFSET OR LIMITATION.—Any funds appro24 priated under the authority of this section shall not be 

25 used to offset or limit any other appropriations made to 
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1 the Service under this Act or the Act of November 2, 1921 

2 (25 U.S.C. 13, popularly known as the Snyder Act), or 

3 any other provision of law. 

4 ‘‘(c) ALLOCATION; USE.—

5 ‘‘(1) IN GENERAL.—Funds appropriated under 

6 the authority of this section shall be allocated to 

7 Service Units, Indian Tribes, or Tribal Organiza8 tions. The funds allocated to each Indian Tribe, 

9 Tribal Organization, or Service Unit under this 

10 paragraph shall be used by the Indian Tribe, Tribal 

11 Organization, or Service Unit under this paragraph 

12 to improve the health status and reduce the resource 

13 deficiency of each Indian Tribe served by such Serv14 ice Unit, Indian Tribe, or Tribal Organization. 

15 ‘‘(2) APPORTIONMENT OF ALLOCATED

16 FUNDS.—The apportionment of funds allocated to a 

17 Service Unit, Indian Tribe, or Tribal Organization 

18 under paragraph (1) among the health service re19 sponsibilities described in subsection (a)(5) shall be 

20 determined by the Service in consultation with, and 

21 with the active participation of, the affected Indian 

22 Tribes and Tribal Organizations. 

23 ‘‘(d) PROVISIONS RELATING TO HEALTH STATUS

24 AND RESOURCE DEFICIENCIES.—For the purposes of this 

25 section, the following definitions apply: 
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1 ‘‘(1) DEFINITION.—The term ‘health status 

2 and resource deficiency’ means the extent to 

3 which—

4 ‘‘(A) the health status objectives set forth 

5 in section 3(2) are not being achieved; and 

6 ‘‘(B) the Indian Tribe or Tribal Organiza7 tion does not have available to it the health re8 sources it needs, taking into account the actual 

9 cost of providing health care services given local 

10 geographic, climatic, rural, or other cir11 cumstances. 

12 ‘‘(2) AVAILABLE RESOURCES.—The health re13 sources available to an Indian Tribe or Tribal Orga14 nization include health resources provided by the 

15 Service as well as health resources used by the In16 dian Tribe or Tribal Organization, including services 

17 and financing systems provided by any Federal pro18 grams, private insurance, and programs of State or 

19 local governments. 

20 ‘‘(3) PROCESS FOR REVIEW OF DETERMINA21 TIONS.—The Secretary shall establish procedures 

22 which allow any Indian Tribe or Tribal Organization 

23 to petition the Secretary for a review of any deter24 mination of the extent of the health status and re-
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1 source deficiency of such Indian Tribe or Tribal Or2 ganization. 

3 ‘‘(e) ELIGIBILITY FOR FUNDS.—Tribal Health Pro4 grams shall be eligible for funds appropriated under the 

5 authority of this section on an equal basis with programs 

6 that are administered directly by the Service. 

7 ‘‘(f) REPORT.—By no later than the date that is 3 

8 years after the date of the enactment of the Indian Health 

9 Care Improvement Act Amendments of 2003, the Sec10 retary shall submit to Congress the current health status 

11 and resource deficiency report of the Service for each 

12 Service Unit, including newly recognized or acknowledged 

13 Indian Tribes. Such report shall set out—

14 ‘‘(1) the methodology then in use by the Service 

15 for determining Tribal health status and resource 

16 deficiencies, as well as the most recent application of 

17 that methodology; 

18 ‘‘(2) the extent of the health status and re19 source deficiency of each Indian Tribe served by the 

20 Service or a Tribal Health Program; 

21 ‘‘(3) the amount of funds necessary to eliminate 

22 the health status and resource deficiencies of all In23 dian Tribes served by the Service or a Tribal Health 

24 Program; and 

25 ‘‘(4) an estimate of—
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1 ‘‘(A) the amount of health service funds 

2 appropriated under the authority of this Act, or 

3 any other Act, including the amount of any 

4 funds transferred to the Service for the pre5 ceding fiscal year which is allocated to each 

6 Service Unit, Indian Tribe, or Tribal Organiza7 tion; 

8 ‘‘(B) the number of Indians eligible for 

9 health services in each Service Unit or Indian 

10 Tribe or Tribal Organization; and 

11 ‘‘(C) the number of Indians using the 

12 Service resources made available to each Service 

13 Unit, Indian Tribe or Tribal Organization, and, 

14 to the extent available, information on the wait15 ing lists and number of Indians turned away for 

16 services due to lack of resources. 

17 ‘‘(g) INCLUSION IN BASE BUDGET.—Funds appro18 priated under this section for any fiscal year shall be in19 cluded in the base budget of the Service for the purpose 

20 of determining appropriations under this section in subse21 quent fiscal years. 

22 ‘‘(h) CLARIFICATION.—Nothing in this section is in23 tended to diminish the primary responsibility of the Serv24 ice to eliminate existing backlogs in unmet health care 

25 needs, nor are the provisions of this section intended to 
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1 discourage the Service from undertaking additional efforts 

2 to achieve equity among Indian Tribes and Tribal Organi3 zations. 

4 ‘‘(i) FUNDING DESIGNATION.—Any funds appro5 priated under the authority of this section shall be des6 ignated as the ‘Indian Health Care Improvement Fund’. 

7 ‘‘SEC. 202. CATASTROPHIC HEALTH EMERGENCY FUND. 

8 ‘‘(a) ESTABLISHMENT.—There is hereby established 

9 an Indian Catastrophic Health Emergency Fund (here10 after in this section referred to as the ‘CHEF’) consisting 

11 of—

12 ‘‘(1) the amounts deposited under subsection 

13 (f); and 

14 ‘‘(2) the amounts appropriated to CHEF under 

15 this section. 

16 ‘‘(b) ADMINISTRATION.—CHEF shall be adminis17 tered by the Secretary, acting through the central office 

18 of the Service, solely for the purpose of meeting the ex19 traordinary medical costs associated with the treatment of 

20 victims of disasters or catastrophic illnesses who are with21 in the responsibility of the Service. 

22 ‘‘(c) CONDITIONS ON USE OF FUND.—No part of 

23 CHEF or its administration shall be subject to contract 

24 or grant under any law, including the Indian Self-Deter25 mination Act, nor shall CHEF funds be allocated, appor-
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1 tioned, or delegated on an Area Office, Service Unit, or 

2 other similar basis. 

3 ‘‘(d) REGULATIONS.—The Secretary shall, through 

4 the negotiated rulemaking process under title VIII, pro5 mulgate regulations consistent with the provisions of this 

6 section to—

7 ‘‘(1) establish a definition of disasters and cata8 strophic illnesses for which the cost of the treatment 

9 provided under contract would qualify for payment 

10 from CHEF; 

11 ‘‘(2) provide that a Service Unit shall not be el12 igible for reimbursement for the cost of treatment 

13 from CHEF until its cost of treating any victim of 

14 such catastrophic illness or disaster has reached a 

15 certain threshold cost which the Secretary shall es16 tablish at—

17 ‘‘(A) the 2000 level of $19,000; and 

18 ‘‘(B) for any subsequent year, not less 

19 than the threshold cost of the previous year in20 creased by the percentage increase in the med21 ical care expenditure category of the consumer 

22 price index for all urban consumers (United 

23 States city average) for the 12-month period 

24 ending with December of the previous year; and 
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1 ‘‘(3) establish a procedure for the reimburse2 ment of the portion of the costs that exceeds such 

3 threshold cost incurred by—

4 ‘‘(A) Service Units; or 

5 ‘‘(B) whenever otherwise authorized by the 

6 Service, non-Service facilities or providers; 

7 ‘‘(4) establish a procedure for payment from 

8 CHEF in cases in which the exigencies of the med9 ical circumstances warrant treatment prior to the 

10 authorization of such treatment by the Service; and 

11 ‘‘(5) establish a procedure that will ensure that 

12 no payment shall be made from CHEF to any pro13 vider of treatment to the extent that such provider 

14 is eligible to receive payment for the treatment from 

15 any other Federal, State, local, or private source of 

16 reimbursement for which the patient is eligible. 

17 ‘‘(e) NO OFFSET OR LIMITATION.—Amounts appro18 priated to CHEF under this section shall not be used to 

19 offset or limit appropriations made to the Service under 

20 the authority of the Act of November 2, 1921 (25 U.S.C. 

21 13, popularly known as the Snyder Act), or any other law. 

22 ‘‘(f) DEPOSIT OF REIMBURSEMENT FUNDS.—There 

23 shall be deposited into CHEF all reimbursements to which 

24 the Service is entitled from any Federal, State, local, or 

25 private source (including third party insurance) by reason 
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1 of treatment rendered to any victim of a disaster or cata2 strophic illness the cost of which was paid from CHEF. 

3 ‘‘SEC. 203. HEALTH PROMOTION AND DISEASE PREVENTION 

4 SERVICES. 

5 ‘‘(a) FINDINGS.—Congress finds that health pro6 motion and disease prevention activities—

7 ‘‘(1) improve the health and well-being of Indi8 ans; and 

9 ‘‘(2) reduce the expenses for health care of In10 dians. 

11 ‘‘(b) PROVISION OF SERVICES.—The Secretary, act12 ing through the Service and Tribal Health Programs, shall 

13 provide health promotion and disease prevention services 

14 to Indians to achieve the health status objectives set forth 

15 in section 3(2). 

16 ‘‘(c) EVALUATION.—The Secretary, after obtaining 

17 input from the affected Tribal Health Programs, shall 

18 submit to the President for inclusion in each report which 

19 is required to be submitted to Congress under section 801 

20 an evaluation of—

21 ‘‘(1) the health promotion and disease preven22 tion needs of Indians; 

23 ‘‘(2) the health promotion and disease preven24 tion activities which would best meet such needs;
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1 ‘‘(3) the internal capacity of the Service and 

2 Tribal Health Programs to meet such needs; and 

3 ‘‘(4) the resources which would be required to 

4 enable the Service and Tribal Health Programs to 

5 undertake the health promotion and disease preven6 tion activities necessary to meet such needs. 

7 ‘‘SEC. 204. DIABETES PREVENTION, TREATMENT, AND CON8 TROL. 

9 ‘‘(a) DETERMINATIONS REGARDING DIABETES.—

10 The Secretary, acting through the Service, and in con11 sultation with Indian Tribes and Tribal Organizations, 

12 shall determine—

13 ‘‘(1) by an Indian Tribe, Tribal Organization, 

14 and by Service Unit, the incidence of, and the types 

15 of complications resulting from, diabetes among In16 dians; and 

17 ‘‘(2) based on the determinations made pursu18 ant to paragraph (1), the measures (including pa19 tient education) each Service Unit should take to re20 duce the incidence of, and prevent, treat, and control 

21 the complications resulting from, diabetes among In22 dian Tribes within that Service Unit. 

23 ‘‘(b) DIABETES SCREENING.—To the extent medi24 cally indicated and with informed consent, the Secretary 

25 shall screen each Indian who receives services from the 
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1 Service for diabetes and for conditions which indicate a 

2 high risk that the individual will become diabetic. Such 

3 screening may be done by a Tribal Health Program. 

4 ‘‘(c) FUNDING FOR DIABETES.—The Secretary shall 

5 continue to fund each model diabetes project in existence 

6 on the date of the enactment of the Indian Health Amend7 ments Care Improvement Act of 2003, any such other dia8 betes programs operated by the Service or Tribal Health 

9 Programs, and any additional diabetes projects. Tribal 

10 Health Programs shall receive recurring funding for the 

11 diabetes projects that they operate pursuant to this sec12 tion, both at the date of enactment of the Indian Health 

13 Care Improvement Act Amendments of 2003 and for 

14 projects which are added and funded thereafter. 

15 ‘‘(d) FUNDING FOR DIALYSIS PROGRAMS.—The Sec16 retary shall provide funding through the Service, Indian 

17 Tribes, and Tribal Organizations to establish dialysis pro18 grams, including funding to purchase dialysis equipment 

19 and provide necessary staffing. 

20 ‘‘(e) OTHER DUTIES OF THE SECRETARY.—The Sec21 retary shall, to the extent funding is available—

22 ‘‘(1) in each Area Office, consult with Indian 

23 Tribes and Tribal Organizations regarding programs 

24 for the prevention, treatment, and control of diabe25 tes; 
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1 ‘‘(2) establish in each Area Office a registry of 

2 patients with diabetes to track the incidence of dia3 betes and the complications from diabetes in that 

4 area; and 

5 ‘‘(3) ensure that data collected in each Area Of6 fice regarding diabetes and related complications 

7 among Indians is disseminated to all other Area Of8 fices. 

9 ‘‘SEC. 205. SHARED SERVICES FOR LONG-TERM CARE. 

10 ‘‘(a) FUNDING AGREEMENTS FOR LONG-TERM

11 CARE.—Notwithstanding any other provisions of law, the 

12 Secretary, acting through the Service, is authorized to 

13 enter into Funding Agreements or other arrangements 

14 with Indian Tribes or Tribal Organizations for the delivery 

15 of long-term care and similar services to Indians. Such 

16 funding agreements or other arrangements shall provide 

17 for the sharing of staff or other services between the Serv18 ice or a Tribal Health Program and a long-term care or 

19 other similar facility owned and operated (directly or 

20 through a Funding Agreement) by such Indian Tribe or 

21 Tribal Organization. 

22 ‘‘(b) CONTENTS OF FUNDING AGREEMENTS.—A 

23 Funding Agreement or other arrangement entered into 

24 pursuant to subsection (a)—
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1 ‘‘(1) may, at the request of the Indian Tribe or 

2 Tribal Organization, delegate to such Indian Tribe 

3 or Tribal Organization such powers of supervision 

4 and control over Service employees as the Secretary 

5 deems necessary to carry out the purposes of this 

6 section; 

7 ‘‘(2) shall provide that expenses (including sala8 ries) relating to services that are shared between the 

9 Service and the Tribal Health Program be allocated 

10 proportionately between the Service and the Indian 

11 Tribe or Tribal Organization; and 

12 ‘‘(3) may authorize such Indian Tribe or Tribal 

13 Organization to construct, renovate, or expand a 

14 long-term care or other similar facility (including the 

15 construction of a facility attached to a Service facil16 ity). 

17 ‘‘(c) MINIMUM REQUIREMENT.—Any nursing facility 

18 provided for under this section shall meet the require19 ments for nursing facilities under section 1919 of the So20 cial Security Act. 

21 ‘‘(d) OTHER ASSISTANCE.—The Secretary shall pro22 vide such technical and other assistance as may be nec23 essary to enable applicants to comply with the provisions 

24 of this section. 
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1 ‘‘(e) USE OF EXISTING OR UNDERUSED FACILI2 TIES.—The Secretary shall encourage the use of existing 

3 facilities that are underused or allow the use of swing beds 

4 for long-term or similar care. 

5 ‘‘SEC. 206. HEALTH SERVICES RESEARCH. 

6 ‘‘The Secretary, acting through the Service, shall 

7 make funding available for research to further the per8 formance of the health service responsibilities of Indian 

9 Health Programs and shall coordinate the activities of 

10 other agencies within the Department to address these re11 search needs. The funding shall be divided equitably 

12 among the Area Offices. Then each Area Office shall 

13 award the funds competitively within that Area. The Sec14 retary shall consult with Indian Tribes and Tribal Organi15 zations in developing the methodology used to allocate 

16 these funds among Area Offices for competitive awards. 

17 Tribal Health Programs shall be given an equal oppor18 tunity to compete for, and receive, research funds under 

19 this section. This funding may be used for both clinical 

20 and nonclinical research. 

21 ‘‘SEC. 207. MAMMOGRAPHY AND OTHER CANCER SCREEN22 ING. 

23 ‘‘The Secretary, acting through the Service or Tribal 

24 Health Programs, shall provide for screening as follows:
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1 ‘‘(1) Screening mammography (as defined in 

2 section 1861(jj) of the Social Security Act) for In3 dian women at a frequency appropriate to such 

4 women under national standards, such as those of 

5 the National Cancer Institute for the National Insti6 tutes for Health, and under such terms and condi7 tions as are consistent with standards established by 

8 the Secretary to ensure the safety and accuracy of 

9 screening mammography under part B of title XVIII 

10 of such Act. 

11 ‘‘(2) Other cancer screening meeting national 

12 standards, such as those of the National Cancer In13 stitute. 

14 ‘‘SEC. 208. PATIENT TRAVEL COSTS. 

15 ‘‘The Secretary, acting through the Service and Trib16 al Health Programs, shall provide funds for the following 

17 patient travel costs, including appropriate and necessary 

18 qualified escorts, associated with receiving health care 

19 services provided (either through direct or contract care 

20 or through Funding Agreements) under this Act—

21 ‘‘(1) emergency air transportation and non22 emergency air transportation where ground trans23 portation is infeasible; 

24 ‘‘(2) transportation by private vehicle, specially 

25 equipped vehicle, and ambulance; and 
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1 ‘‘(3) transportation by such other means as 

2 may be available and required when air or motor ve3 hicle transportation is not available. 

4 ‘‘SEC. 209. EPIDEMIOLOGY CENTERS. 

5 ‘‘(a) ADDITIONAL CENTERS.—In addition to those 

6 epidemiology centers already established at the time of en7 actment of this Act, (including those for which funding 

8 is currently being provided in Funding Agreements), and 

9 without reducing the funding levels for such centers, not 

10 later than 180 days after the date of the enactment of 

11 the Indian Health Care Improvement Act Amendments of 

12 2003, the Secretary, acting through the Service, shall es13 tablish and fund an epidemiology center in each Service 

14 Area which does not yet have one to carry out the func15 tions described in subsection (b). Any new centers so es16 tablished may be operated by Tribal Health Programs, but 

17 such funding shall not be divisible. 

18 ‘‘(b) FUNCTIONS OF CENTERS.—In consultation with 

19 and upon the request of Indian Tribes, Tribal Organiza20 tions, and Urban Indian Organizations, each Service Area 

21 epidemiology center established under this subsection 

22 shall, with respect to such Service Area—

23 ‘‘(1) collect data relating to, and monitor 

24 progress made toward meeting, each of the health 

25 status objectives of the Service, the Indian Tribes, 
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1 Tribal Organizations, and Urban Indian Organiza2 tions in the Service Area; 

3 ‘‘(2) evaluate existing delivery systems, data 

4 systems, and other systems that impact the improve5 ment of Indian health; 

6 ‘‘(3) assist Indian Tribes, Tribal Organizations, 

7 and Urban Indian Organizations in identifying their 

8 highest priority health status objectives and the 

9 services needed to achieve such objectives, based on 

10 epidemiological data; 

11 ‘‘(4) make recommendations for the targeting 

12 of services needed by the populations served; 

13 ‘‘(5) make recommendations to improve health 

14 care delivery systems for Indians and Urban Indi15 ans; 

16 ‘‘(6) provide requested technical assistance to 

17 Indian Tribes, Tribal Organizations, and Urban In18 dian Organizations in the development of local 

19 health service priorities and incidence and prevalence 

20 rates of disease and other illness in the community; 

21 and 

22 ‘‘(7) provide disease surveillance and assist In23 dian Tribes, Tribal Organizations, and Urban Indian 

24 Organizations to promote public health. 
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1 ‘‘(c) TECHNICAL ASSISTANCE.—The Director of the 

2 Centers for Disease Control and Prevention shall provide 

3 technical assistance to the centers in carrying out the re4 quirements of this subsection. 

5 ‘‘(d) FUNDING FOR STUDIES.—The Secretary may 

6 make funding available to Indian Tribes, Tribal Organiza7 tions, and Urban Indian Organizations to conduct epide8 miological studies of Indian communities. 

9 ‘‘SEC. 210. COMPREHENSIVE SCHOOL HEALTH EDUCATION 

10 PROGRAMS. 

11 ‘‘(a) FUNDING FOR DEVELOPMENT OF PROGRAMS.—

12 The Secretary, acting through the Service, shall provide 

13 funding to Indian Tribes, Tribal Organizations, and 

14 Urban Indian Organizations to develop comprehensive 

15 school health education programs for children from pre16 school through grade 12 in schools for the benefit of In17 dian and Urban Indian children. 

18 ‘‘(b) USE OF FUNDS.—Funding provided under this 

19 section may be used for purposes which may include, but 

20 are not limited to, the following: 

21 ‘‘(1) Developing and implementing health edu22 cation curricula both for regular school programs 

23 and afterschool programs. 

24 ‘‘(2) Training teachers in comprehensive school 

25 health education curricula. 
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1 ‘‘(3) Integrating school-based, community2 based, and other public and private health promotion 

3 efforts. 

4 ‘‘(4) Encouraging healthy, tobacco-free school 

5 environments. 

6 ‘‘(5) Coordinating school-based health programs 

7 with existing services and programs available in the 

8 community. 

9 ‘‘(6) Developing school programs on nutrition 

10 education, personal health, oral health, and fitness. 

11 ‘‘(7) Developing mental health wellness pro12 grams. 

13 ‘‘(8) Developing chronic disease prevention pro14 grams. 

15 ‘‘(9) Developing substance abuse prevention 

16 programs. 

17 ‘‘(10) Developing injury prevention and safety 

18 education programs. 

19 ‘‘(11) Developing activities for the prevention 

20 and control of communicable diseases. 

21 ‘‘(12) Developing community and environmental 

22 health education programs that include traditional 

23 health care practitioners. 

24 ‘‘(13) Violence prevention.
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1 ‘‘(14) Such other health issues as are appro2 priate. 

3 ‘‘(c) TECHNICAL ASSISTANCE.—Upon request, the 

4 Secretary, acting through the Service, shall provide tech5 nical assistance to Indian Tribes, Tribal Organizations, 

6 and Urban Indian Organizations in the development of 

7 comprehensive health education plans and the dissemina8 tion of comprehensive health education materials and in9 formation on existing health programs and resources. 

10 ‘‘(d) CRITERIA FOR REVIEW AND APPROVAL OF AP11 PLICATIONS.—The Secretary, acting through the Service, 

12 and in consultation with Indian Tribes, Tribal Organiza13 tions, and Urban Indian Organizations, shall establish cri14 teria for the review and approval of applications for fund15 ing provided pursuant to this section. 

16 ‘‘(e) DEVELOPMENT OF PROGRAM FOR BIA FUNDED

17 SCHOOLS.—

18 ‘‘(1) IN GENERAL.—The Secretary of the Inte19 rior, acting through the Bureau of Indian Affairs 

20 and in cooperation with the Secretary, acting 

21 through the Service, and affected Indian Tribes and 

22 Tribal Organizations, shall develop a comprehensive 

23 school health education program for children from 

24 preschool through grade 12 in schools for which sup25 port is provided by the Bureau of Indian Affairs. 
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1 ‘‘(2) REQUIREMENTS FOR PROGRAMS.—Such 

2 programs shall include the following—

3 ‘‘(A) school programs on nutrition edu4 cation, personal health, oral health, and fitness; 

5 ‘‘(B) mental health wellness programs; 

6 ‘‘(C) chronic disease prevention programs; 

7 ‘‘(D) substance abuse prevention pro8 grams; 

9 ‘‘(E) injury prevention and safety edu10 cation programs; and 

11 ‘‘(F) activities for the prevention and con12 trol of communicable diseases. 

13 ‘‘(3) DUTIES OF THE SECRETARY.—The Sec14 retary of the Interior shall—

15 ‘‘(A) provide training to teachers in com16 prehensive school health education curricula; 

17 ‘‘(B) ensure the integration and coordina18 tion of school-based programs with existing 

19 services and health programs available in the 

20 community; and 

21 ‘‘(C) encourage healthy, tobacco-free school 

22 environments. 

23 ‘‘SEC. 211. INDIAN YOUTH PROGRAM. 

24 ‘‘(a) PROGRAM AUTHORIZED.—The Secretary, acting 

25 through the Service, is authorized to establish and admin-
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1 ister a program to provide funding to Indian Tribes, Trib2 al Organizations, and Urban Indian Organizations for in3 novative mental and physical disease prevention and 

4 health promotion and treatment programs for Indian and 

5 Urban Indian preadolescent and adolescent youths. 

6 ‘‘(b) USE OF FUNDS.—

7 ‘‘(1) ALLOWABLE USES.—Funds made available 

8 under this section may be used to—

9 ‘‘(A) develop prevention and treatment 

10 programs for Indian youth which promote men11 tal and physical health and incorporate cultural 

12 values, community and family involvement, and 

13 traditional health care practitioners; and 

14 ‘‘(B) develop and provide community train15 ing and education. 

16 ‘‘(2) PROHIBITED USE.—Funds made available 

17 under this section may not be used to provide serv18 ices described in section 707(c). 

19 ‘‘(c) DUTIES OF THE SECRETARY.—The Secretary 

20 shall—

21 ‘‘(1) disseminate to Indian Tribes, Tribal Orga22 nizations, and Urban Indian Organizations informa23 tion regarding models for the delivery of comprehen24 sive health care services to Indian and Urban Indian 

25 adolescents; 
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1 ‘‘(2) encourage the implementation of such 

2 models; and 

3 ‘‘(3) at the request of an Indian Tribe, Tribal 

4 Organization, or Urban Indian Organization, provide 

5 technical assistance in the implementation of such 

6 models. 

7 ‘‘(d) CRITERIA FOR REVIEW AND APPROVAL OF AP8 PLICATIONS.—The Secretary, in consultation with Indian 

9 Tribes, Tribal Organization, and Urban Indian Organiza10 tions, shall establish criteria for the review and approval 

11 of applications or proposals under this section. 

12 ‘‘SEC. 212. PREVENTION, CONTROL, AND ELIMINATION OF 

13 COMMUNICABLE AND INFECTIOUS DISEASES. 

14 ‘‘(a) FUNDING AUTHORIZED.—The Secretary, acting 

15 through the Service, and after consultation with Indian 

16 Tribes, Tribal Organizations, Urban Indian Organiza17 tions, and the Centers for Disease Control and Prevention, 

18 may make funding available to Indian Tribes and Tribal 

19 Organizations for the following: 

20 ‘‘(1) Projects for the prevention, control, and 

21 elimination of communicable and infectious diseases 

22 including, but not limited to, tuberculosis, hepatitis, 

23 HIV, respiratory syncitial virus, hanta virus, sexu24 ally transmitted diseases, and H. Pylori. 
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1 ‘‘(2) Public information and education pro2 grams for the prevention, control, and elimination of 

3 communicable and infectious diseases. 

4 ‘‘(3) Education, training, and clinical skills im5 provement activities in the prevention, control, and 

6 elimination of communicable and infectious diseases 

7 for health professionals, including allied health pro8 fessionals. 

9 ‘‘(4) Demonstration projects for the screening, 

10 treatment, and prevention of hepatitis C virus 

11 (HCV). 

12 ‘‘(b) APPLICATION REQUIRED.—The Secretary may 

13 provide funding under subsection (a) only if an application 

14 or proposal for funding is submitted to the Secretary. 

15 ‘‘(c) COORDINATION WITH HEALTH AGENCIES.—In16 dian Tribes and Tribal Organizations receiving funding 

17 under this section are encouraged to coordinate their ac18 tivities with the Centers for Disease Control and Preven19 tion and State and local health agencies. 

20 ‘‘(d) TECHNICAL ASSISTANCE; REPORT.—In carrying 

21 out this section, the Secretary—

22 ‘‘(1) may, at the request of an Indian Tribe or 

23 Tribal Organization, provide technical assistance; 

24 and
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1 ‘‘(2) shall prepare and submit a report to Con2 gress biennially on the use of funds under this sec3 tion and on the progress made toward the preven4 tion, control, and elimination of communicable and 

5 infectious diseases among Indians and Urban Indi6 ans. 

7 ‘‘SEC. 213. AUTHORITY FOR PROVISION OF OTHER SERV8 ICES. 

9 ‘‘(a) FUNDING AUTHORIZED.—The Secretary, acting 

10 through the Service, Indian Tribes, and Tribal Organiza11 tions, may provide funding under this Act to meet the ob12 jectives set forth in section 3 through health care-related 

13 services and programs not otherwise described in this Act, 

14 which shall include, but not be limited to—

15 ‘‘(1) hospice care and assisted living; 

16 ‘‘(2) long-term health care; 

17 ‘‘(3) home- and community-based services; 

18 ‘‘(4) public health functions; and 

19 ‘‘(5) Traditional Health Care Practices. 

20 ‘‘(b) SERVICES TO OTHERWISE INELIGIBLE PER21 SONS.—At the discretion of the Service, Indian Tribes, or 

22 Tribal Organizations, services provided for hospice care, 

23 home health care, home- and community-based care, as24 sisted living, and long-term care may be provided (subject 

25 to reimbursement of reasonable charges) to persons other-
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1 wise ineligible for the health care benefits of the Service. 

2 Any funds received under this subsection shall not be used 

3 to offset or limit the funding allocated to an Indian Tribe 

4 or Tribal Organization. 

5 ‘‘(c) DEFINITIONS.—For the purposes of this section, 

6 the following definitions shall apply: 

7 ‘‘(1) The term ‘home- and community-based 

8 services’ means 1 or more of the following: 

9 ‘‘(A) Homemaker/home health aide serv10 ices. 

11 ‘‘(B) Chore services. 

12 ‘‘(C) Personal care services. 

13 ‘‘(D) Nursing care services provided out14 side of a nursing facility by, or under the super15 vision of, a registered nurse. 

16 ‘‘(E) Respite care. 

17 ‘‘(F) Training for family members. 

18 ‘‘(G) Adult day care. 

19 ‘‘(H) Such other home- and community20 based services as the Secretary, an Indian 

21 Tribe, or Tribal Organization may approve. 

22 ‘‘(2) The term ‘hospice care’ means the items 

23 and services specified in subparagraphs (A) through 

24 (H) of section 1861(dd)(1) of the Social Security 

25 Act (42 U.S.C. 1395x(dd)(1)), and such other serv-
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1 ices which an Indian Tribe or Tribal Organization 

2 determines are necessary and appropriate to provide 

3 in furtherance of this care. 

4 ‘‘(3) The term ‘public health functions’ means 

5 the provision of public health-related programs, 

6 functions, and services including, but not limited to, 

7 assessment, assurance, and policy development which 

8 Indian Tribes and Tribal Organizations are author9 ized and encouraged, in those circumstances where 

10 it meets their needs, to do by forming collaborative 

11 relationships with all levels of local, State, and Fed12 eral Government. 

13 ‘‘SEC. 214. INDIAN WOMEN’S HEALTH CARE. 

14 ‘‘The Secretary, acting through the Service and In15 dian Tribes, Tribal Organizations, and Urban Indian Or16 ganizations, shall provide funding to monitor and improve 

17 the quality of health care for Indian women of all ages 

18 through the planning and delivery of programs adminis19 tered by the Service, in order to improve and enhance the 

20 treatment models of care for Indian women. 

21 ‘‘SEC. 215. ENVIRONMENTAL AND NUCLEAR HEALTH HAZ22 ARDS. 

23 ‘‘(a) STUDIES AND MONITORING.—The Secretary 

24 and the Service shall conduct, in conjunction with other 

25 appropriate Federal agencies and in consultation with con-
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1 cerned Indian Tribes and Tribal Organizations, studies 

2 and ongoing monitoring programs to determine trends in 

3 the health hazards to Indian miners and to Indians on 

4 or near reservations and Indian communities as a result 

5 of environmental hazards which may result in chronic or 

6 life threatening health problems, such as nuclear resource 

7 development, petroleum contamination, and contamination 

8 of water source and of the food chain. Such studies shall 

9 include—

10 ‘‘(1) an evaluation of the nature and extent of 

11 health problems caused by environmental hazards 

12 currently exhibited among Indians and the causes of 

13 such health problems; 

14 ‘‘(2) an analysis of the potential effect of ongo15 ing and future environmental resource development 

16 on or near reservations and Indian communities, in17 cluding the cumulative effect over time on health; 

18 ‘‘(3) an evaluation of the types and nature of 

19 activities, practices, and conditions causing or affect20 ing such health problems including, but not limited 

21 to, uranium mining and milling, uranium mine tail22 ing deposits, nuclear power plant operation and con23 struction, and nuclear waste disposal; oil and gas 

24 production or transportation on or near reservations 

25 or Indian communities; and other development that
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1 could affect the health of Indians and their water 

2 supply and food chain; 

3 ‘‘(4) a summary of any findings and rec4 ommendations provided in Federal and State stud5 ies, reports, investigations, and inspections during 

6 the 5 years prior to the date of the enactment of the 

7 Indian Health Care Improvement Act Amendments 

8 of 2003 that directly or indirectly relate to the ac9 tivities, practices, and conditions affecting the health 

10 or safety of such Indians; and 

11 ‘‘(5) the efforts that have been made by Federal 

12 and State agencies and resource and economic devel13 opment companies to effectively carry out an edu14 cation program for such Indians regarding the 

15 health and safety hazards of such development. 

16 ‘‘(b) HEALTH CARE PLANS.—Upon completion of 

17 such studies, the Secretary and the Service shall take into 

18 account the results of such studies and, in consultation 

19 with Indian Tribes and Tribal Organizations, develop 

20 health care plans to address the health problems studied 

21 under subsection (a). The plans shall include—

22 ‘‘(1) methods for diagnosing and treating Indi23 ans currently exhibiting such health problems; 

24 ‘‘(2) preventive care and testing for Indians 

25 who may be exposed to such health hazards, includ-
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1 ing the monitoring of the health of individuals who 

2 have or may have been exposed to excessive amounts 

3 of radiation or affected by other activities that have 

4 had or could have a serious impact upon the health 

5 of such individuals; and 

6 ‘‘(3) a program of education for Indians who, 

7 by reason of their work or geographic proximity to 

8 such nuclear or other development activities, may ex9 perience health problems. 

10 ‘‘(c) SUBMISSION OF REPORT AND PLAN TO CON11 GRESS.—The Secretary and the Service shall submit to 

12 Congress the study prepared under subsection (a) no later 

13 than 18 months after the date of the enactment of the 

14 Indian Health Care Improvement Act Amendments of 

15 2003. The health care plan prepared under subsection (b) 

16 shall be submitted in a report no later than 1 year after 

17 the study prepared under subsection (a) is submitted to 

18 Congress. Such report shall include recommended activi19 ties for the implementation of the plan, as well as an eval20 uation of any activities previously undertaken by the Serv21 ice to address such health problems. 

22 ‘‘(d) INTERGOVERNMENTAL TASK FORCE.—

23 ‘‘(1) ESTABLISHMENT; MEMBERS.—There is es24 tablished an Intergovernmental Task Force to be 
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1 composed of the following individuals (or their des2 ignees): 

3 ‘‘(A) The Secretary of Energy. 

4 ‘‘(B) The Secretary of the Environmental 

5 Protection Agency. 

6 ‘‘(C) The Director of the Bureau of Mines. 

7 ‘‘(D) The Assistant Secretary for Occupa8 tional Safety and Health. 

9 ‘‘(E) The Secretary of the Interior. 

10 ‘‘(F) The Secretary of Health and Human 

11 Services. 

12 ‘‘(G) The Director of the Indian Health 

13 Service. 

14 ‘‘(2) DUTIES.—The Task Force shall—

15 ‘‘(A) identify existing and potential oper16 ations related to nuclear resource development 

17 or other environmental hazards that affect or 

18 may affect the health of Indians on or near a 

19 reservation or in an Indian community; and 

20 ‘‘(B) enter into activities to correct exist21 ing health hazards and ensure that current and 

22 future health problems resulting from nuclear 

23 resource or other development activities are 

24 minimized or reduced. 
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1 ‘‘(3) CHAIRMAN; MEETINGS.—The Secretary of 

2 Health and Human Services shall be the Chairman 

3 of the Task Force. The Task Force shall meet at 

4 least twice each year. 

5 ‘‘(e) HEALTH SERVICES TO CERTAIN EMPLOYEES.—

6 In the case of any Indian who—

7 ‘‘(1) as a result of employment in or near a 

8 uranium mine or mill or near any other environ9 mental hazard, suffers from a work-related illness or 

10 condition; 

11 ‘‘(2) is eligible to receive diagnosis and treat12 ment services from an Indian Health Program; and 

13 ‘‘(3) by reason of such Indian’s employment, is 

14 entitled to medical care at the expense of such mine 

15 or mill operator or entity responsible for the environ16 mental hazard, the Indian Health Program shall, at 

17 the request of such Indian, render appropriate med18 ical care to such Indian for such illness or condition 

19 and may be reimbursed for any medical care so ren20 dered to which such Indian is entitled at the expense 

21 of such operator or entity from such operator or en22 tity. Nothing in this subsection shall affect the 

23 rights of such Indian to recover damages other than 

24 such amounts paid to the Indian Health Program
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1 from the employer for providing medical care for 

2 such illness or condition. 

3 ‘‘SEC. 216. ARIZONA AS A CONTRACT HEALTH SERVICE DE4 LIVERY AREA. 

5 ‘‘(a) IN GENERAL.—For fiscal years beginning with 

6 the fiscal year ending September 30, 1983, and ending 

7 with the fiscal year ending September 30, 2015, the State 

8 of Arizona shall be designated as a contract health service 

9 delivery area by the Service for the purpose of providing 

10 contract health care services to members of federally rec11 ognized Indian Tribes of Arizona. 

12 ‘‘(b) MAINTENANCE OF SERVICES.—The Service 

13 shall not curtail any health care services provided to Indi14 ans residing on reservations in the State of Arizona if such 

15 curtailment is due to the provision of contract services in 

16 such State pursuant to the designation of such State as 

17 a contract health service delivery area pursuant to sub18 section (a).

19 ‘‘SEC. 216A. NORTH DAKOTA AS A CONTRACT HEALTH 

20 SERVICE DELIVERY AREA. 

21 ‘‘(a) IN GENERAL.—For fiscal years beginning with 

22 the fiscal year ending September 30, 2003, and ending 

23 with the fiscal year ending September 30, 2015, the State 

24 of North Dakota shall be designated as a contract health 

25 service delivery area by the Service for the purpose of pro-
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1 viding contract health care services to members of feder2 ally recognized Indian Tribes of North Dakota. 

3 ‘‘(b) LIMITATION.—The Service shall not curtail any 

4 health care services provided to Indians residing on res5 ervations in the State of North Dakota if such curtailment 

6 is due to the provision of contract services in such State 

7 pursuant to the designation of such State as a contract 

8 health service delivery area pursuant to subsection (a). 

9 ‘‘SEC. 216B. SOUTH DAKOTA AS A CONTRACT HEALTH SERV10 ICE DELIVERY AREA. 

11 ‘‘(a) IN GENERAL.—For fiscal years beginning with 

12 the fiscal year ending September 30, 2003, and ending 

13 with the fiscal year ending on September 30, 2015, the 

14 State of South Dakota shall be designated as a contract 

15 health service delivery area by the Service for the purpose 

16 of providing contract health care services to members of 

17 federally recognized Indian Tribes of South Dakota. 

18 ‘‘(b) LIMITATION.—The Service shall not curtail any 

19 health care services provided to Indians residing on res20 ervations in the State of South Dakota if such curtailment 

21 is due to the provision of contract services in such State 

22 pursuant to the designation of such State as a contract 

23 health service delivery area pursuant to subsection (a). 
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1 ‘‘SEC. 217. CALIFORNIA CONTRACT HEALTH SERVICES PRO2 GRAM. 

3 ‘‘(a) FUNDING AUTHORIZED.—The Secretary is au4 thorized to fund a program using the California Rural In5 dian Health Board (hereafter in this section referred to 

6 as the ‘CRIHB’) as a contract care intermediary to im7 prove the accessibility of health services to California Indi8 ans. 

9 ‘‘(b) REIMBURSEMENT CONTRACT.—The Secretary 

10 shall enter into an agreement with the CRIHB to reim11 burse the CRIHB for costs (including reasonable adminis12 trative costs) incurred pursuant to this section, in pro13 viding medical treatment under contract to California In14 dians described in section 806(a) throughout the Cali15 fornia contract health services delivery area described in 

16 section 218 with respect to high cost contract care cases. 

17 ‘‘(c) ADMINISTRATIVE EXPENSES.—Not more than 5 

18 percent of the amounts provided to the CRIHB under this 

19 section for any fiscal year may be for reimbursement for 

20 administrative expenses incurred by the CRIHB during 

21 such fiscal year. 

22 ‘‘(d) LIMITATION ON PAYMENT.—No payment may 

23 be made for treatment provided hereunder to the extent 

24 payment may be made for such treatment under the In25 dian Catastrophic Health Emergency Fund described in 

26 section 202 or from amounts appropriated or otherwise 
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1 made available to the California contract health service de2 livery area for a fiscal year. 

3 ‘‘(e) ADVISORY BOARD.—There is hereby established 

4 an advisory board which shall advise the CRIHB in car5 rying out this section. The advisory board shall be com6 posed of representatives, selected by the CRIHB, from not 

7 less than 8 Tribal Health Programs serving California In8 dians covered under this section at least one half of whom 

9 of whom are not affiliated with the CRIHB. 

10 ‘‘SEC. 218. CALIFORNIA AS A CONTRACT HEALTH SERVICE 

11 DELIVERY AREA. 

12 ‘‘The State of California, excluding the counties of 

13 Alameda, Contra Costa, Los Angeles, Marin, Orange, Sac14 ramento, San Francisco, San Mateo, Santa Clara, Kern, 

15 Merced, Monterey, Napa, San Benito, San Joaquin, San 

16 Luis Obispo, Santa Cruz, Solano, Stanislaus, and Ven17 tura, shall be designated as a contract health service deliv18 ery area by the Service for the purpose of providing con19 tract health services to California Indians. However, any 

20 of the counties listed herein may only be included in the 

21 contract health services delivery area if funding is specifi22 cally provided by the Service for such services in those 

23 counties. 
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1 ‘‘SEC. 219. CONTRACT HEALTH SERVICES FOR THE TREN2 TON SERVICE AREA. 

3 ‘‘(a) AUTHORIZATION FOR SERVICES.—The Sec4 retary, acting through the Service, is directed to provide 

5 contract health services to members of the Turtle Moun6 tain Band of Chippewa Indians that reside in the Trenton 

7 Service Area of Divide, McKenzie, and Williams counties 

8 in the State of North Dakota and the adjoining counties 

9 of Richland, Roosevelt, and Sheridan in the State of Mon10 tana. 

11 ‘‘(b) NO EXPANSION OF ELIGIBILITY.—Nothing in 

12 this section may be construed as expanding the eligibility 

13 of members of the Turtle Mountain Band of Chippewa In14 dians for health services provided by the Service beyond 

15 the scope of eligibility for such health services that applied 

16 on May 1, 1986. 

17 ‘‘SEC. 220. PROGRAMS OPERATED BY INDIAN TRIBES AND 

18 TRIBAL ORGANIZATIONS. 

19 ‘‘The Service shall provide funds for health care pro20 grams and facilities operated by Tribal Health Programs 

21 on the same basis as such funds are provided to programs 

22 and facilities operated directly by the Service. 

23 ‘‘SEC. 221. LICENSING. 

24 ‘‘Health care professionals employed by a Tribal 

25 Health Program shall, if licensed in any State, be exempt 

26 from the licensing requirements of the State in which the
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1 Tribal Health Program performs the services described in 

2 its Funding Agreement. 

3 ‘‘SEC. 222. NOTIFICATION OF PROVISION OF EMERGENCY 

4 CONTRACT HEALTH SERVICES. 

5 ‘‘With respect to an elderly Indian or an Indian with 

6 a disability receiving emergency medical care or services 

7 from a non-Service provider or in a non-Service facility 

8 under the authority of this Act, the time limitation (as 

9 a condition of payment) for notifying the Service of such 

10 treatment or admission shall be 30 days. 

11 ‘‘SEC. 223. PROMPT ACTION ON PAYMENT OF CLAIMS. 

12 ‘‘(a) DEADLINE FOR RESPONSE.—The Service shall 

13 respond to a notification of a claim by a provider of a 

14 contract care service with either an individual purchase 

15 order or a denial of the claim within 5 working days after 

16 the receipt of such notification. 

17 ‘‘(b) EFFECT OF UNTIMELY RESPONSE.—If the 

18 Service fails to respond to a notification of a claim in ac19 cordance with subsection (a), the Service shall accept as 

20 valid the claim submitted by the provider of a contract 

21 care service. 

22 ‘‘(c) DEADLINE FOR PAYMENT OF VALID CLAIM.—

23 The Service shall pay a valid contract care service claim 

24 within 30 days after the completion of the claim. 
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1 ‘‘SEC. 224. LIABILITY FOR PAYMENT. 

2 ‘‘(a) NO PATIENT LIABILITY.—A patient who re3 ceives contract health care services that are authorized by 

4 the Service shall not be liable for the payment of any 

5 charges or costs associated with the provision of such serv6 ices. 

7 ‘‘(b) NOTIFICATION.—The Secretary shall notify a 

8 contract care provider and any patient who receives con9 tract health care services authorized by the Service that 

10 such patient is not liable for the payment of any charges 

11 or costs associated with the provision of such services not 

12 later than 5 business days after receipt of a notification 

13 of a claim by a provider of contract care services. 

14 ‘‘(c) NO RECOURSE.—Following receipt of the notice 

15 provided under subsection (b), or, if a claim has been 

16 deemed accepted under section 223(b), the provider shall 

17 have no further recourse against the patient who received 

18 the services. 

19 ‘‘SEC. 225. AUTHORIZATION OF APPROPRIATIONS. 

20 ‘‘There are authorized to be appropriated such sums 

21 as may be necessary for each fiscal year through fiscal 

22 year 2015 to carry out this title. 
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1 ‘‘TITLE III—FACILITIES 

2 ‘‘SEC. 301. CONSULTATION; CONSTRUCTION AND RENOVA3 TION OF FACILITIES; REPORTS. 

4 ‘‘(a) PREREQUISITES FOR EXPENDITURE OF

5 FUNDS.—Prior to the expenditure of, or the making of 

6 any binding commitment to expend, any funds appro7 priated for the planning, design, construction, or renova8 tion of facilities pursuant to the Act of November 2, 1921 

9 (25 U.S.C. 13; popularly known as the Snyder Act), the 

10 Secretary, acting through the Service, shall—

11 ‘‘(1) consult with any Indian Tribe that would 

12 be significantly affected by such expenditure for the 

13 purpose of determining and, whenever practicable, 

14 honoring tribal preferences concerning size, location, 

15 type, and other characteristics of any facility on 

16 which such expenditure is to be made; and 

17 ‘‘(2) ensure, whenever practicable and applica18 ble, that such facility meets the construction stand19 ards of any accrediting body recognized by the Sec20 retary for the purposes of the medicare, medicaid, 

21 and SCHIP programs under title XVIII, XIX, and 

22 XXI of the Social Security Act by not later than 1 

23 year after the date on which the construction or ren24 ovation of such facility is completed. 

25 ‘‘(b) CLOSURES.—
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1 ‘‘(1) EVALUATION REQUIRED.—Notwith2 standing any other provision of law, no facility oper3 ated by the Service may be closed if the Secretary 

4 has not submitted to Congress at least 1 year prior 

5 to the date of the proposed closure an evaluation of 

6 the impact of the proposed closure which specifies, 

7 in addition to other considerations the following: 

8 ‘‘(A) The accessibility of alternative health 

9 care resources for the population served by such 

10 facility. 

11 ‘‘(B) The cost-effectiveness of such closure. 

12 ‘‘(C) The quality of health care to be pro13 vided to the population served by such facility 

14 after such closure. 

15 ‘‘(D) The availability of contract health 

16 care funds to maintain existing levels of service. 

17 ‘‘(E) The views of the Indian Tribes served 

18 by such facility concerning such closure. 

19 ‘‘(F) The level of use of such facility by all 

20 eligible Indians. 

21 ‘‘(G) The distance between such facility 

22 and the nearest operating Service hospital. 

23 ‘‘(2) EXCEPTION FOR CERTAIN TEMPORARY

24 CLOSURES.—Paragraph (1) shall not apply to any 

25 temporary closure of a facility or any portion of a
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1 facility if such closure is necessary for medical, envi2 ronmental, or construction safety reasons. 

3 ‘‘(c) HEALTH CARE FACILITY PRIORITY SYSTEM.—

4 ‘‘(1) IN GENERAL.—

5 ‘‘(A) ESTABLISHMENT.—The Secretary, 

6 acting through the Service, shall establish a 

7 health care facility priority system, which 

8 shall—

9 ‘‘(i) be developed with Indian Tribes 

10 and Tribal Organizations through nego11 tiated rulemaking under section 802; 

12 ‘‘(ii) give Indian Tribes’ needs the 

13 highest priority; and 

14 ‘‘(iii) at a minimum, include the lists 

15 required in paragraph (2)(B) and the 

16 methodology required in paragraph (2)(E). 

17 ‘‘(B) PRIORITY OF CERTAIN PROJECTS

18 PROTECTED.—The priority of any project estab19 lished under the construction priority system in 

20 effect on the date of the Indian Health Care 

21 Improvement Act Amendments of 2003 shall 

22 not be affected by any change in the construc23 tion priority system taking place thereafter if 

24 the project was identified as 1 of the 10 top25 priority inpatient projects, 1 of the 10 top-pri-
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1 ority outpatient projects, 1 of the 10 top-pri2 ority staff quarters developments, or 1 of the 

3 10 top-priority Youth Regional Treatment Cen4 ters in the fiscal year 2004 Indian Health Serv5 ice budget justification, or if the project had 

6 completed both Phase I and Phase II of the 

7 construction priority system in effect on the 

8 date of the enactment of such Act. 

9 ‘‘(2) REPORT; CONTENTS.—The Secretary shall 

10 submit to the President, for inclusion in each report 

11 required to be transmitted to Congress under section 

12 801, a report which sets forth the following: 

13 ‘‘(A) A description of the health care facil14 ity priority system of the Service, established 

15 under paragraph (1). 

16 ‘‘(B) Health care facilities lists, including 

17 but not limited to—

18 ‘‘(i) the total health care facilities 

19 planning, design, construction, and renova20 tion needs for Indians, identified by na21 tional and Service Area priorities; 

22 ‘‘(ii) the 10 top-priority inpatient 

23 health care facilities; 

24 ‘‘(iii) the 10 top-priority outpatient 

25 health care facilities; 
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1 ‘‘(iv) the 10 top-priority specialized 

2 health care facilities (such as long-term 

3 care and alcohol and drug abuse treat4 ment); 

5 ‘‘(v) the 10 top-priority staff quarters 

6 developments associated with health care 

7 facilities; and 

8 ‘‘(vi) the 10 top-priority hostels asso9 ciated with health care facilities. 

10 ‘‘(C) The justification for such order of 

11 priority. 

12 ‘‘(D) The projected cost of such projects. 

13 ‘‘(E) The methodology adopted by the 

14 Service in establishing priorities under its 

15 health care facility priority system. 

16 ‘‘(3) REQUIREMENTS FOR PREPARATION OF RE17 PORTS.—In preparing each report required under 

18 paragraph (2) (other than the initial report), the 

19 Secretary shall annually—

20 ‘‘(A) consult with and obtain information 

21 on all health care facilities needs from Indian 

22 Tribes, Tribal Organizations, and Urban Indian 

23 Organizations; and 

24 ‘‘(B) review the total unmet needs of all 

25 Indian Tribes and Tribal Organizations for 
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1 health care facilities (including hostels and staff 

2 quarters), including needs for renovation and 

3 expansion of existing facilities. 

4 ‘‘(4) CRITERIA FOR EVALUATING NEEDS.—For 

5 purposes of this subsection, the Secretary shall, in 

6 evaluating the needs of facilities operated under any 

7 Funding Agreement use the same criteria that the 

8 Secretary uses in evaluating the needs of facilities 

9 operated directly by the Service. 

10 ‘‘(5) NEEDS OF FACILITIES UNDER ISDEAA

11 AGREEMENTS.—The Secretary shall ensure that the 

12 planning, design, construction, and renovation needs 

13 of Service and non-Service facilities operated under 

14 funding agreements in accordance with the Indian 

15 Self-Determination and Education Assistance Act 

16 are fully and equitably integrated into the health 

17 care facility priority system. 

18 ‘‘(d) REVIEW OF NEED FOR FACILITIES.—

19 ‘‘(1) INITIAL REPORT.—In the year 2005, the 

20 General Accounting Office shall prepare and finalize 

21 a report which sets forth the needs of the Service, 

22 Indian Tribes, Tribal Organizations, and Urban In23 dian Organizations, for the facilities listed under 

24 subsection (c)(2)(B), including the needs for renova25 tion and expansion of existing facilities. The General
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1 Accounting Office shall submit the report to the ap2 propriate authorizing and appropriations committees 

3 of the Congress and to the Secretary. 

4 ‘‘(2) Beginning in the year 2006, the Secretary 

5 shall annually update the report required under 

6 paragraph (1). 

7 ‘‘(3) The Comptroller General and the Sec8 retary shall consult with Indian Tribes, Tribal Orga9 nizations, and Urban Indian Organizations. In pre10 paring the reports required by paragraphs (1) and 

11 (2), the Secretary shall submit the report to the 

12 President for inclusion in the report required to be 

13 transmitted to the Congress under section 801. 

14 ‘‘(4) For purposes of this subsection, the re15 ports shall, regarding the needs of facilities operated 

16 under any Funding Agreement be based on the same 

17 criteria that the Secretary uses in evaluating the 

18 needs of facilities operated directly by the Service. 

19 ‘‘(5) The planning, design, construction, and 

20 renovation needs of facilities operated under Fund21 ing Agreements shall be fully and equitably inte22 grated into the development of the health facility 

23 priority system. 

24 ‘‘(6) Beginning in the year 2006 and each fiscal 

25 year thereafter, the Secretary shall provide an op-
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1 portunity for nomination of planning, design, and 

2 construction projects by the Service, Indian Tribes, 

3 and Tribal Organizations for consideration under 

4 the health care facility priority system. 

5 ‘‘(e) FUNDING CONDITION.—All funds appropriated 

6 under the Act of November 2, 1921 (25 U.S.C. 13), for 

7 the planning, design, construction, or renovation of health 

8 facilities for the benefit of 1 or more Indian Tribes shall 

9 be subject to the provisions of the Indian Self-Determina10 tion and Education Assistance Act. 

11 ‘‘(f) DEVELOPMENT OF INNOVATIVE APPROACHES.—

12 The Secretary shall consult and cooperate with Indian 

13 Tribes, Tribal Organizations, and Urban Indian Organiza14 tions in developing innovative approaches to address all 

15 or part of the total unmet need for construction of health 

16 facilities, including those provided for in other sections of 

17 this title and other approaches. 

18 ‘‘SEC. 302. SANITATION FACILITIES. 

19 ‘‘(a) FINDINGS.—Congress finds the following: 

20 ‘‘(1) The provision of sanitation facilities is pri21 marily a health consideration and function. 

22 ‘‘(2) Indian people suffer an inordinately high 

23 incidence of disease, injury, and illness directly at24 tributable to the absence or inadequacy of sanitation 

25 facilities. 
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1 ‘‘(3) The long-term cost to the United States of 

2 treating and curing such disease, injury, and illness 

3 is substantially greater than the short-term cost of 

4 providing sanitation facilities and other preventive 

5 health measures. 

6 ‘‘(4) Many Indian homes and Indian commu7 nities still lack sanitation facilities. 

8 ‘‘(5) It is in the interest of the United States, 

9 and it is the policy of the United States, that all In10 dian communities and Indian homes, new and exist11 ing, be provided with sanitation facilities. 

12 ‘‘(b) FACILITIES AND SERVICES.—In furtherance of 

13 the findings made in subsection (a), Congress reaffirms 

14 the primary responsibility and authority of the Service to 

15 provide the necessary sanitation facilities and services as 

16 provided in section 7 of the Act of August 5, 1954 (42 

17 U.S.C. 2004a). Under such authority, the Secretary, act18 ing through the Service, shall provide the following: 

19 ‘‘(1) Financial and technical assistance to In20 dian Tribes, Tribal Organizations, and Indian com21 munities in the establishment, training, and equip22 ping of utility organizations to operate and maintain 

23 sanitation facilities, including the provision of exist24 ing plans, standard details, and specifications avail25 able in the Department, to be used at the option of 
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1 the Indian Tribe, Tribal Organization, or Indian 

2 community. 

3 ‘‘(2) Ongoing technical assistance and training 

4 to Indian Tribes, Tribal Organizations, and Indian 

5 communities in the management of utility organiza6 tions which operate and maintain sanitation facili7 ties. 

8 ‘‘(3) Priority funding for operation and mainte9 nance assistance for, and emergency repairs to, sani10 tation facilities operated by an Indian Tribe, Tribal 

11 Organization or Indian community when necessary 

12 to avoid an imminent health threat or to protect the 

13 investment in sanitation facilities and the investment 

14 in the health benefits gained through the provision 

15 of sanitation facilities. 

16 ‘‘(c) FUNDING.—Notwithstanding any other provi17 sion of law—

18 ‘‘(1) the Secretary of Housing and Urban De19 velopment is authorized to transfer funds appro20 priated under the Native American Housing Assist21 ance and Self-Determination Act of 1996 to the Sec22 retary of Health and Human Services; 

23 ‘‘(2) the Secretary of Health and Human Serv24 ices is authorized to accept and use such funds for 

25 the purpose of providing sanitation facilities and 
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1 services for Indians under section 7 of the Act of 

2 August 5, 1954 (42 U.S.C. 2004a); 

3 ‘‘(3) unless specifically authorized otherwise 

4 when funds are appropriated, the Secretary of 

5 Health and Human Services shall use funds appro6 priated under section 7 of the Act of August 5, 1954 

7 (42 U.S.C. 2004a), to provide additional priority of 

8 sanitation facilities assistance to eligible new and ex9 isting Indian homes other than the following—

10 ‘‘(A) new homes constructed using housing 

11 funds provided by the Department of Housing 

12 and Urban Development; and 

13 ‘‘(B) existing homes owned or managed by 

14 a tribally designated housing entity (as that 

15 term is defined in section 4(21) of the Native 

16 American Housing Assistance and Self-Deter17 mination Act of 1996 (25 U.S.C. 4103(21)) 

18 that were constructed using housing funds pro19 vided by the Department of Housing and Urban 

20 Development; 

21 ‘‘(4) the Secretary of Health and Human Serv22 ices is authorized to accept from any source, includ23 ing Federal and State agencies, funds for the pur24 pose of providing sanitation facilities and services 

25 and place these funds into Funding Agreements;
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1 ‘‘(5) funds appropriated under the authority of 

2 section 7 of the Act of August 5, 1954 (42 U.S.C. 

3 2004a) may be used to fund up to 100 percent of 

4 the amount of an Indian Tribe’s loan obtained under 

5 any Federal program for new projects to construct 

6 eligible sanitation facilities to serve Indian homes; 

7 ‘‘(6) funds appropriated under the authority of 

8 section 7 of the Act of August 5, 1954 (42 U.S.C. 

9 2004a) may be used to meet matching or cost par10 ticipation requirements under other Federal and 

11 non-Federal programs for new projects to construct 

12 eligible sanitation facilities; 

13 ‘‘(7) all Federal agencies are authorized to 

14 transfer to the Secretary funds identified, granted, 

15 loaned, or appropriated whereby the Department’s 

16 applicable policies, rules, and regulations shall apply 

17 in the implementation of such projects; 

18 ‘‘(8) the Secretary of Health and Human Serv19 ices shall enter into interagency agreements with 

20 Federal and State agencies for the purpose of pro21 viding financial assistance for sanitation facilities 

22 and services under this Act; and 

23 ‘‘(9) the Secretary of Health and Human Serv24 ices shall, by regulation developed through rule25 making under section 802, establish standards appli-
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1 cable to the planning, design, and construction of 

2 sanitation facilities funded under this Act. 

3 ‘‘(d) FUNDING PLAN.—The Secretary, acting 

4 through the Service, and in consultation with Indian 

5 Tribes and Tribal Organizations, shall develop and begin 

6 implementation of a 10-year funding plan to provide sani7 tation facilities to serve existing Indian homes and Indian 

8 communities and new and renovated Indian homes. 

9 ‘‘(e) CERTAIN CAPABILITIES NOT PREREQUISITE.—

10 The financial and technical capability of an Indian Tribe, 

11 Tribal Organization, or Indian community to safely oper12 ate, manage, and maintain a sanitation facility shall not 

13 be a prerequisite to the provision or construction of sanita14 tion facilities by the Secretary. 

15 ‘‘(f) FINANCIAL ASSISTANCE.—The Secretary is au16 thorized to provide financial assistance to Indian Tribes, 

17 Tribal Organizations, and Indian communities for oper18 ation, management, and maintenance of their sanitation 

19 facilities. 

20 ‘‘(g) OPERATION, MANAGEMENT, AND MAINTENANCE

21 OF FACILITIES.—The Indian Tribe, Tribal Organization, 

22 Indian family, or Indian community has the primary re23 sponsibility to establish, collect, and use reasonable user 

24 fees, or otherwise set aside funding, for the purpose of 

25 operating, managing, and maintaining sanitation facilities. 
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1 If a sanitation facility serving a community that is oper2 ated by an Indian Tribe, Tribal Organization, or Indian 

3 community is threatened with imminent failure and such 

4 operator lacks capacity to maintain the integrity or the 

5 health benefits of the sanitation facility, then the Sec6 retary is authorized to assist the Indian Tribe, Tribal Or7 ganization, or Indian community in the resolution of the 

8 problem on a short-term basis through cooperation with 

9 the emergency coordinator or by providing operation, man10 agement, and maintenance service. 

11 ‘‘(h) ISDEAA PROGRAM FUNDED ON EQUAL

12 BASIS.—Tribal Health Programs shall be eligible (on an 

13 equal basis with programs that are administered directly 

14 by the Service) for—

15 ‘‘(1) any funds appropriated pursuant to this 

16 section; and 

17 ‘‘(2) any funds appropriated for the purpose of 

18 providing sanitation facilities. 

19 ‘‘(i) REPORT.—

20 ‘‘(1) REQUIRED; CONTENTS.—The Secretary 

21 shall submit to the President, for inclusion in each 

22 report required to be transmitted to Congress under 

23 section 801, a report which sets forth—

24 ‘‘(A) the current Indian sanitation facility 

25 priority system of the Service; 
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1 ‘‘(B) the methodology for determining 

2 sanitation deficiencies; 

3 ‘‘(C) the level of initial and final sanitation 

4 deficiency for each type of sanitation facility for 

5 each project of each Indian Tribe or Indian 

6 community; and 

7 ‘‘(D) the amount of funds necessary to re8 duce the identified sanitation deficiency levels of 

9 all Indian Tribes and Indian communities to 

10 level I sanitation deficiency as defined in para11 graph (4)(A). 

12 ‘‘(2) CONSULTATION.—In preparing each report 

13 required under paragraph (1), the Secretary shall 

14 consult with Indian Tribes and Tribal Organizations 

15 to determine the sanitation facility needs of each In16 dian Tribe. The criteria on which the needs will be 

17 evaluated shall be developed through negotiated rule18 making pursuant to section 802. 

19 ‘‘(3) UNIFORM METHODOLOGY.—The method20 ology used by the Secretary in determining, pre21 paring cost estimates for, and reporting sanitation 

22 deficiencies for purposes of paragraph (1) shall be 

23 applied uniformly to all Indian Tribes and Indian 

24 communities.
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1 ‘‘(4) SANITATION DEFICIENCY LEVELS.—For 

2 purposes of this subsection, the sanitation deficiency 

3 levels for an individual, Indian Tribe or Indian com4 munity sanitation facility to serve Indian homes are 

5 determined as follows: 

6 ‘‘(A) A level I deficiency exists if a sanita7 tion facility serving an individual, Indian Tribe, 

8 or Indian community—

9 ‘‘(i) complies with all applicable water 

10 supply, pollution control, and solid waste 

11 disposal laws; and 

12 ‘‘(ii) deficiencies relate to routine re13 placement, repair, or maintenance needs. 

14 ‘‘(B) A level II deficiency exists if a sanita15 tion facility serving an individual, Indian Tribe, 

16 or Indian community substantially or recently 

17 complied with all applicable water supply, pollu18 tion control, and solid waste laws and any defi19 ciencies relate to—

20 ‘‘(i) small or minor capital improve21 ments needed to bring the facility back 

22 into compliance; 

23 ‘‘(ii) capital improvements that are 

24 necessary to enlarge or improve the facili-
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1 ties in order to meet the current needs for 

2 domestic sanitation facilities; or 

3 ‘‘(iii) the lack of equipment or train4 ing by an Indian Tribe, Tribal Organiza5 tion, or an Indian community to properly 

6 operate and maintain the sanitation facili7 ties. 

8 ‘‘(C) A level III deficiency exists if a sani9 tation facility serving an individual, Indian 

10 Tribe or Indian community meets one or more 

11 of the following conditions—

12 ‘‘(i) water or sewer service in the 

13 home is provided by a haul system with 

14 holding tanks and interior plumbing; 

15 ‘‘(ii) major significant interruptions to 

16 water supply or sewage disposal occur fre17 quently, requiring major capital improve18 ments to correct the deficiencies; or 

19 ‘‘(iii) there is no access to or no ap20 proved or permitted solid waste facility 

21 available. 

22 ‘‘(D) A level IV deficiency exists if—

23 ‘‘(i) a sanitation facility of an indi24 vidual, Indian Tribe, Tribal Organization, 

25 or Indian community has no piped water 
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1 or sewer facilities in the home or the facil2 ity has become inoperable due to major 

3 component failure; or 

4 ‘‘(ii) where only a washeteria or cen5 tral facility exists in the community. 

6 ‘‘(E) A level V deficiency exists in the ab7 sence of a sanitation facility, where individual 

8 homes do not have access to safe drinking 

9 water or adequate wastewater (including sew10 age) disposal. 

11 ‘‘(j) DEFINITIONS.—For purposes of this section, the 

12 following terms apply: 

13 ‘‘(1) INDIAN COMMUNITY.—The term ‘Indian 

14 community’ means a geographic area, a significant 

15 proportion of whose inhabitants are Indians and 

16 which is served by or capable of being served by a 

17 facility described in this section. 

18 ‘‘(2) SANITATION FACILITIES.—The terms 

19 ‘sanitation facility’ and ‘sanitation facilities’ mean 

20 safe and adequate water supply systems, sanitary 

21 sewage disposal systems, and sanitary solid waste 

22 systems (and all related equipment and support in23 frastructure). 
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1 ‘‘SEC. 303. PREFERENCE TO INDIANS AND INDIAN FIRMS. 

2 ‘‘(a) BUY INDIAN ACT.—The Secretary, acting 

3 through the Service, may use the negotiating authority of 

4 section 23 of the Act of June 25, 1910 (25 U.S.C. 47, 

5 commonly known as the ‘Buy Indian Act’), to give pref6 erence to any Indian or any enterprise, partnership, cor7 poration, or other type of business organization owned and 

8 controlled by an Indian or Indians including former or 

9 currently federally recognized Indian Tribes in the State 

10 of New York (hereinafter referred to as an ‘Indian firm’) 

11 in the construction and renovation of Service facilities pur12 suant to section 301 and in the construction of sanitation 

13 facilities pursuant to section 302. Such preference may be 

14 accorded by the Secretary unless the Secretary finds, pur15 suant to regulations adopted pursuant to section 802, that 

16 the project or function to be contracted for will not be 

17 satisfactory or such project or function cannot be properly 

18 completed or maintained under the proposed contract. The 

19 Secretary, in arriving at such a finding, shall consider 

20 whether the Indian or Indian firm will be deficient with 

21 respect to—

22 ‘‘(1) ownership and control by Indians; 

23 ‘‘(2) equipment; 

24 ‘‘(3) bookkeeping and accounting procedures; 

25 ‘‘(4) substantive knowledge of the project or 

26 function to be contracted for; 
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1 ‘‘(5) adequately trained personnel; or 

2 ‘‘(6) other necessary components of contract 

3 performance. 

4 ‘‘(b) LABOR STANDARDS.—

5 ‘‘(1) IN GENERAL.—For the purposes of imple6 menting the provisions of this title, contracts for the 

7 construction or renovation of health care facilities, 

8 staff quarters, and sanitation facilities, and related 

9 support infrastructure, funded in whole or in part 

10 with funds made available pursuant to this title, 

11 shall contain a provision requiring compliance with 

12 the Act of March 3, 1931 (40 U.S.C. 276a—276a–

13 5, known as the Davis-Bacon Act), unless such con14 struction or renovation—

15 ‘‘(A) is performed by a contractor pursu16 ant to a contract with an Indian Tribe or Trib17 al Organization with funds supplied through a 

18 contract, compact or funding agreement author19 ized by the Indian Self-Determination and Edu20 cation Assistance Act, or other statutory au21 thority; and 

22 ‘‘(B) is subject to prevailing wage rates for 

23 similar construction or renovation in the locality 

24 as determined by the Indian Tribes or Tribal
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1 Organizations to be served by the construction 

2 or renovation. 

3 ‘‘(2) EXCEPTION.—This subsection shall not 

4 apply to construction or renovation carried out by an 

5 Indian Tribe or Tribal Organization with its own 

6 employees. 

7 ‘‘SEC. 304. EXPENDITURE OF NONSERVICE FUNDS FOR REN8 OVATION. 

9 ‘‘(a) IN GENERAL.—Notwithstanding any other pro10 vision of law, if the requirements of subsection (c) are met, 

11 the Secretary, acting through the Service, is authorized 

12 to accept any major expansion, renovation, or moderniza13 tion by any Indian Tribe or Tribal Organization of any 

14 Service facility or of any other Indian health facility oper15 ated pursuant to a Funding Agreement, including—

16 ‘‘(1) any plans or designs for such expansion, 

17 renovation, or modernization; and 

18 ‘‘(2) any expansion, renovation, or moderniza19 tion for which funds appropriated under any Federal 

20 law were lawfully expended. 

21 ‘‘(b) PRIORITY LIST.—

22 ‘‘(1) IN GENERAL.—The Secretary shall main23 tain a separate priority list to address the needs for 

24 increased operating expenses, personnel, or equip25 ment for such facilities. The methodology for estab-
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1 lishing priorities shall be developed through nego2 tiated rulemaking under section 802. The list of pri3 ority facilities will be revised annually in consulta4 tion with Indian Tribes and Tribal Organizations. 

5 ‘‘(2) REPORT.—The Secretary shall submit to 

6 the President, for inclusion in each report required 

7 to be transmitted to Congress under section 801, the 

8 priority list maintained pursuant to paragraph (1). 

9 ‘‘(c) REQUIREMENTS.—The requirements of this sub10 section are met with respect to any expansion, renovation, 

11 or modernization if—

12 ‘‘(1) the Indian Tribe or Tribal Organization—

13 ‘‘(A) provides notice to the Secretary of its 

14 intent to expand, renovate, or modernize; and 

15 ‘‘(B) applies to the Secretary to be placed 

16 on a separate priority list to address the needs 

17 of such new facilities for increased operating ex18 penses, personnel, or equipment; and 

19 ‘‘(2) the expansion, renovation, or moderniza20 tion—

21 ‘‘(A) is approved by the appropriate area 

22 director of the Service for Federal facilities; and 

23 ‘‘(B) is administered by the Indian Tribe 

24 or Tribal Organization in accordance with any 

25 applicable regulations prescribed by the Sec-
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1 retary with respect to construction or renova2 tion of Service facilities. 

3 ‘‘(d) CLOSURE OR CONVERSION OF FACILITIES.—If 

4 any Service facility which has been expanded, renovated, 

5 or modernized by an Indian Tribe or Tribal Organization 

6 under this section ceases to be used as a Service facility 

7 during the 20-year period beginning on the date such ex8 pansion, renovation, or modernization is completed, such 

9 Indian Tribe or Tribal Organization shall be entitled to 

10 recover from the United States an amount which bears 

11 the same ratio to the value of such facility at the time 

12 of such cessation as the value of such expansion, renova13 tion, or modernization (less the total amount of any funds 

14 provided specifically for such facility under any Federal 

15 program that were expended for such expansion, renova16 tion, or modernization) bore to the value of such facility 

17 at the time of the completion of such expansion, renova18 tion, or modernization. 

19 ‘‘SEC. 305. FUNDING FOR THE CONSTRUCTION, EXPANSION, 

20 AND MODERNIZATION OF SMALL AMBULA21 TORY CARE FACILITIES. 

22 ‘‘(a) FUNDING.—

23 ‘‘(1) IN GENERAL.—The Secretary, acting 

24 through the Service, in consultation with Indian 

25 Tribes and Tribal Organizations, shall make funding 
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1 available to Indian Tribes and Tribal Organizations 

2 for the construction, expansion, or modernization of 

3 facilities for the provision of ambulatory care serv4 ices to eligible Indians (and noneligible persons pur5 suant to subsections (b)(2) and (c)(1)(C)). Funding 

6 made under this section may cover up to 100 per7 cent of the costs of such construction, expansion, or 

8 modernization. For the purposes of this section, the 

9 term ‘construction’ includes the replacement of an 

10 existing facility. 

11 ‘‘(2) FUNDING AGREEMENT REQUIRED.—Fund12 ing under paragraph (1) may only be made available 

13 to a Tribal Health Program operating an Indian 

14 health facility (other than a facility owned or con15 structed by the Service, including a facility originally 

16 owned or constructed by the Service and transferred 

17 to an Indian Tribe or Tribal Organization). 

18 ‘‘(b) USE OF FUNDS.—

19 ‘‘(1) ALLOWABLE USES.—Funding provided 

20 under this section may be used only for debt reduc21 tion or the construction, expansion, or modernization 

22 (including the planning and design of such construc23 tion, expansion, or modernization) of an ambulatory 

24 care facility—

25 ‘‘(A) located apart from a hospital;
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1 ‘‘(B) not funded under section 301 or sec2 tion 307; and 

3 ‘‘(C) which, upon completion of such con4 struction or modernization will—

5 ‘‘(i) have a total capacity appropriate 

6 to its projected service population; 

7 ‘‘(ii) provide annually no fewer than 

8 500 patient visits by eligible Indians and 

9 other users who are eligible for services in 

10 such facility in accordance with section 

11 807(c)(2); and 

12 ‘‘(iii) provide ambulatory care in a 

13 Service Area (specified in the Funding 

14 Agreement) with a population of no fewer 

15 than 1,500 eligible Indians and other users 

16 who are eligible for services in such facility 

17 in accordance with section 807(c)(2). 

18 ‘‘(2) USE ONLY FOR CERTAIN PORTION OF

19 COSTS.—Funding provided under this section may 

20 be used only for the cost of that portion of a con21 struction, expansion, or modernization project that 

22 benefits the Service population identified above in 

23 subsection (b)(1)(C)(ii) and (iii). The requirements 

24 of clauses (ii) and (iii) of paragraph (1)(C) shall not 

25 apply to an Indian Tribe or Tribal Organization ap-
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1 plying for funding under this section whose principal 

2 office for health care administration is located on an 

3 island or when such office is not located on a road 

4 system providing direct access to an inpatient hos5 pital where care is available to the Service popu6 lation. 

7 ‘‘(c) FUNDING.—

8 ‘‘(1) APPLICATION.—No funding may be made 

9 available under this section unless an application or 

10 proposal for such funding has been approved by the 

11 Secretary in accordance with applicable regulations 

12 and has forth reasonable assurance by the applicant 

13 that, at all times after the construction, expansion, 

14 or modernization of a facility carried out pursuant 

15 to funding received under this section—

16 ‘‘(A) adequate financial support will be 

17 available for the provision of services at such 

18 facility; 

19 ‘‘(B) such facility will be available to eligi20 ble Indians without regard to ability to pay or 

21 source of payment; and 

22 ‘‘(C) such facility will, as feasible without 

23 diminishing the quality or quantity of services 

24 provided to eligible Indians, serve noneligible 

25 persons on a cost basis. 
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1 ‘‘(2) PRIORITY.—In awarding funding under 

2 this section, the Secretary shall give priority to In3 dian Tribes and Tribal Organizations that dem4 onstrate—

5 ‘‘(A) a need for increased ambulatory care 

6 services; and 

7 ‘‘(B) insufficient capacity to deliver such 

8 services. 

9 ‘‘(3) PEER REVIEW PANELS.—The Secretary 

10 may provide for the establishment of peer review 

11 panels, as necessary, to review and evaluate applica12 tions and proposals and to advise the Secretary re13 garding such applications using the criteria devel14 oped during consultations pursuant to subsection 

15 (a)(1). 

16 ‘‘(d) REVERSION OF FACILITIES.—If any facility (or 

17 portion thereof) with respect to which funds have been 

18 paid under this section, ceases, within 5 years after com19 pletion of the construction, expansion, or modernization 

20 carried out with such funds, to be used for the purposes 

21 of providing health care services to eligible Indians, all of 

22 the right, title, and interest in and to such facility (or por23 tion thereof) shall transfer to the United States unless 

24 otherwise negotiated by the Service and the Indian Tribe 

25 or Tribal Organization. 
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1 ‘‘(e) FUNDING NONRECURRING.—Funding provided 

2 under this section shall be nonrecurring and shall not be 

3 available for inclusion in any individual Indian Tribe’s 

4 tribal share for an award under the Indian Self-Deter5 mination and Education Assistance Act or for reallocation 

6 or redesign thereunder. 

7 ‘‘SEC. 306. INDIAN HEALTH CARE DELIVERY DEMONSTRA8 TION PROJECT. 

9 ‘‘(a) HEALTH CARE DEMONSTRATION PROJECTS.—

10 The Secretary, acting through the Service, and in con11 sultation with Indian Tribes and Tribal Organizations, is 

12 authorized to enter into Funding Agreements with, or 

13 make grants or loan guarantees to, Indian Tribes or Trib14 al Organizations for the purpose of carrying out a health 

15 care delivery demonstration project to test alternative 

16 means of delivering health care and services to Indians 

17 through facilities, including but not limited to hospice, tra18 ditional Indian health, and child care facilities. 

19 ‘‘(b) USE OF FUNDS.—The Secretary, in approving 

20 projects pursuant to this section, may authorize funding 

21 for the construction and renovation of hospitals, health 

22 centers, health stations, and other facilities to deliver 

23 health care services and is authorized to—

24 ‘‘(1) waive any leasing prohibition; 
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1 ‘‘(2) permit carryover of funds appropriated for 

2 the provision of health care services; 

3 ‘‘(3) permit the use of other available funds; 

4 ‘‘(4) permit the use of funds or property do5 nated from any source for project purposes; 

6 ‘‘(5) provide for the reversion of donated real or 

7 personal property to the donor; and 

8 ‘‘(6) permit the use of Service funds to match 

9 other funds, including Federal funds. 

10 ‘‘(c) REGULATIONS.—The Secretary shall develop 

11 and publish regulations, through rulemaking under section 

12 802, for the review and approval of applications submitted 

13 under this section. 

14 ‘‘(d) CRITERIA.—The Secretary may enter into a con15 tract or Funding Agreement or award a grant under this 

16 section for projects which meet the following criteria: 

17 ‘‘(1) There is a need for a new facility or pro18 gram or the reorientation of an existing facility or 

19 program. 

20 ‘‘(2) A significant number of Indians, including 

21 those with low health status, will be served by the 

22 project. 

23 ‘‘(3) The project has the potential to deliver 

24 services in an efficient and effective manner. 

25 ‘‘(4) The project is economically viable.
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1 ‘‘(5) The Indian Tribe or Tribal Organization 

2 has the administrative and financial capability to ad3 minister the project. 

4 ‘‘(6) The project is integrated with providers of 

5 related health and social services and is coordinated 

6 with, and avoids duplication of, existing services. 

7 ‘‘(e) PEER REVIEW PANELS.—The Secretary may 

8 provide for the establishment of peer review panels, as nec9 essary, to review and evaluate applications using the cri10 teria developed pursuant to subsection (d). 

11 ‘‘(f) PRIORITY.—The Secretary shall give priority to 

12 applications for demonstration projects in each of the fol13 lowing Service Units to the extent that such applications 

14 are timely filed and meet the criteria specified in sub15 section (d): 

16 ‘‘(1) Cass Lake, Minnesota. 

17 ‘‘(2) Clinton, Oklahoma. 

18 ‘‘(3) Harlem, Montana. 

19 ‘‘(4) Mescalero, New Mexico. 

20 ‘‘(5) Owyhee, Nevada. 

21 ‘‘(6) Parker, Arizona. 

22 ‘‘(7) Schurz, Nevada. 

23 ‘‘(8) Winnebago, Nebraska. 

24 ‘‘(9) Ft. Yuma, California. 
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1 ‘‘(g) TECHNICAL ASSISTANCE.—The Secretary shall 

2 provide such technical and other assistance as may be nec3 essary to enable applicants to comply with the provisions 

4 of this section. 

5 ‘‘(h) SERVICE TO INELIGIBLE PERSONS.—The au6 thority to provide services to persons otherwise ineligible 

7 for the health care benefits of the Service and the author8 ity to extend hospital privileges in Service facilities to non9 Service health practitioners as provided in section 807 

10 may be included, subject to the terms of such section, in 

11 any demonstration project approved pursuant to this sec12 tion. 

13 ‘‘(i) EQUITABLE TREATMENT.—For purposes of sub14 section (d)(1), the Secretary shall, in evaluating facilities 

15 operated under any Funding Agreement, use the same cri16 teria that the Secretary uses in evaluating facilities oper17 ated directly by the Service. 

18 ‘‘(j) EQUITABLE INTEGRATION OF FACILITIES.—The 

19 Secretary shall ensure that the planning, design, construc20 tion, renovation, and expansion needs of Service and non21 Service facilities which are the subject of a Funding 

22 Agreement for health services are fully and equitably inte23 grated into the implementation of the health care delivery 

24 demonstration projects under this section. 
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1 ‘‘SEC. 307. LAND TRANSFER. 

2 ‘‘(a) CHEMAWA INDIAN SCHOOL.—The Bureau of In3 dian Affairs is authorized to transfer, at no cost, up to 

4 5 acres of land at the Chemawa Indian School, Salem, 

5 Oregon, to the Service for the provision of health care 

6 services. The land authorized to be transferred by this sec7 tion is that land adjacent to land under the jurisdiction 

8 of the Service and occupied by the Chemawa Indian 

9 Health Center. 

10 ‘‘(b) FEDERAL LAND TO THE SERVICE.—Notwith11 standing any other provision of law, the Bureau of Indian 

12 Affairs and all other agencies and departments of the 

13 United States are authorized to transfer, at no cost, land 

14 and improvements to the Service for the provision of 

15 health care services. The Secretary is authorized to accept 

16 such land and improvements for such purposes. 

17 ‘‘SEC. 308. LEASES, CONTRACTS, AND OTHER AGREEMENTS. 

18 ‘‘The Secretary, acting through the Service, may 

19 enter into leases, contracts, and other agreements with In20 dian Tribes and Tribal Organizations which hold (1) title 

21 to, (2) a leasehold interest in, or (3) a beneficial interest 

22 in (when title is held by the United States in trust for 

23 the benefit of an Indian Tribe) facilities used or to be used 

24 for the administration and delivery of health services by 

25 an Indian Health Program. Such leases, contracts, or 

26 agreements may include provisions for construction or ren-
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1 ovation and provide for compensation to the Indian Tribe 

2 or Tribal Organization of rental and other costs consistent 

3 with section 105(l) of the Indian Self-Determination Act 

4 and regulations thereunder. Notwithstanding any other 

5 provision of law, such leases, contracts, or other agree6 ments shall be considered as operating leases for the pur7 pose of scoring under the Budget Enforcement Act. 

8 ‘‘SEC. 309. LOANS, LOAN GUARANTEES, AND LOAN REPAY9 MENT. 

10 ‘‘(a) ESTABLISHMENT OF FUND.—There is estab11 lished in the Treasury of the United States a fund to be 

12 known as the Health Care Facilities Loan Fund (herein13 after referred to as the ‘HCFLF’) to provide to Indian 

14 Tribes and Tribal Organizations direct loans, or guaran15 tees for loans, for construction of health care facilities (in16 cluding but not limited to inpatient facilities, outpatient 

17 facilities, staff quarters, hostels, and specialized care fa18 cilities such as behavioral health and elder care facilities). 

19 ‘‘(b) REGULATIONS; STANDARDS AND PROCE20 DURES.—The Secretary, acting through the Service, is au21 thorized to issue regulations, developed through rule22 making as set out in section 802, to provide standards 

23 and procedures for governing such loans and loan guaran24 tees, subject to the following conditions:
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1 ‘‘(1) The principal amount of a loan or loan 

2 guarantee may cover 100 percent of eligible costs, 

3 including but not limited to planning, design, financ4 ing, site land development, construction, rehabilita5 tion, renovation, conversion, improvements, medical 

6 equipment and furnishings, other facility-related 

7 costs and capital purchase (but excluding staffing). 

8 ‘‘(2) The cumulative total of the principal of di9 rect loans and loan guarantees, respectively, out10 standing at any one time shall not exceed such limi11 tations as may be specified in appropriation Acts. 

12 ‘‘(3) In the discretion of the Secretary, the pro13 gram may be administered by the Service or the 

14 Health Resources and Services Administration 

15 (which shall be specified by regulation). 

16 ‘‘(4) The Secretary may make or guarantee a 

17 loan with a term of the useful estimated life of the 

18 facility, or 25 years, whichever is shorter. 

19 ‘‘(5) The Secretary may allocate up to 100 per20 cent of the funds available for loans or loan guaran21 tees in any year for the purpose of planning and ap22 plying for a loan or loan guarantee. 

23 ‘‘(6) The Secretary may accept an assignment 

24 of the revenue of an Indian Tribe or Tribal Organi-
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1 zation as security for any direct loan or loan guar2 antee under this section. 

3 ‘‘(7) In the planning and design of health facili4 ties under this section, users eligible under section 

5 807(c) may be included in any projection of patient 

6 population. 

7 ‘‘(8) The Secretary shall not collect loan appli8 cation, processing, or other similar fees from Indian 

9 Tribes or Tribal Organizations applying for direct 

10 loans or loan guarantees under this section. 

11 ‘‘(9) Service funds authorized under loans or 

12 loan guarantees in this section shall be eligible for 

13 use in matching other Federal funds. 

14 ‘‘(c) AMOUNT FOR HCFLF.—

15 ‘‘(1) IN GENERAL.—The HCFLF shall consist 

16 of—

17 ‘‘(A) such sums as may be initially appro18 priated to the HCFLF and as may be subse19 quently appropriated to the fund under para20 graph (2); 

21 ‘‘(B) such amounts as may be collected 

22 from borrowers; and 

23 ‘‘(C) all interest earned on amounts in the 

24 HCFLF. 
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1 ‘‘(2) INITIAL FUNDS.—There are authorized to 

2 be appropriated such sums as may be necessary to 

3 initiate the HCFLF. For each fiscal year after the 

4 initial year in which funds are appropriated to the 

5 HCFLF, there is authorized to be appropriated an 

6 amount equal to the sum of the amount collected by 

7 the HCFLF during the preceding fiscal year and all 

8 accrued interest. 

9 ‘‘(3) AVAILABLE UNTIL EXPENDED.—All 

10 amounts appropriated, collected, or earned relative 

11 to the HCFLF shall remain available until ex12 pended. 

13 ‘‘(4) INVESTMENTS.—The Secretary of the 

14 Treasury shall invest such amounts of the HCFLF 

15 as such Secretary determines are not required to 

16 meet current withdrawals from the HCFLF. Such 

17 investments may be made only in interest-bearing 

18 obligations of the United States. For such purpose, 

19 such obligations may be acquired on original issue at 

20 the issue price or by purchase of outstanding obliga21 tions at the market price. Any obligation acquired by 

22 the fund may be sold by the Secretary of the Treas23 ury at the market price. 

24 ‘‘(d) LOANS UNDER ISDEAA.—Amounts in the 

25 HCFLF and available pursuant to appropriation Acts may 
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1 be expended by the Secretary to make loans under this 

2 section to a Tribal Health Program. 

3 ‘‘(e) GRANTS TO REPAY LOANS.—The Secretary is 

4 authorized to establish a program to provide grants to In5 dian Tribes and Tribal Organizations for the purpose of 

6 repaying all or part of any loan obtained by an Indian 

7 Tribe or Tribal Organization for construction and renova8 tion of health care facilities (including inpatient facilities, 

9 outpatient facilities, small ambulatory care, staff quarters, 

10 and specialized care facilities). Loans eligible for such re11 payment grants shall include loans that have been ob12 tained under this section or otherwise. 

13 ‘‘SEC. 310. TRIBAL LEASING. 

14 ‘‘A Tribal Health Program may lease permanent 

15 structures for the purpose of providing health care services 

16 without obtaining advance approval in appropriation Acts. 

17 ‘‘SEC. 311. INDIAN HEALTH SERVICE/TRIBAL FACILITIES 

18 JOINT VENTURE PROGRAM. 

19 ‘‘(a) IN GENERAL.—The Secretary, acting through 

20 the Service, shall make arrangements with Indian Tribes 

21 and Tribal Organizations to establish joint venture dem22 onstration projects under which an Indian Tribe or Tribal 

23 Organization shall expend tribal, private, or other avail24 able funds, for the acquisition or construction of a health 

25 facility for a minimum of 10 years, under a no-cost lease, 
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1 in exchange for agreement by the Service to provide the 

2 equipment, supplies, and staffing for the operation and 

3 maintenance of such a health facility. An Indian Tribe or 

4 Tribal Organization may use tribal funds, private sector, 

5 or other available resources, including loan guarantees, to 

6 fulfill its commitment under a joint venture entered into 

7 under this subsection. An Indian Tribe or Tribal Organi8 zation shall be eligible to establish a joint venture project 

9 if, when it submits a letter of intent, it—

10 ‘‘(1) has begun but not completed the process 

11 of acquisition or construction of a health facility to 

12 be used in the joint venture project; or 

13 ‘‘(2) has not begun the process of acquisition or 

14 construction of a health facility for use in the joint 

15 venture project. 

16 ‘‘(b) REQUIREMENTS.—The Secretary shall make 

17 such an arrangement with an Indian Tribe or Tribal Orga18 nization only if—

19 ‘‘(1) the Secretary first determines that the In20 dian Tribe or Tribal Organization has the adminis21 trative and financial capabilities necessary to com22 plete the timely acquisition or construction of the 

23 relevant health facility; and 

24 ‘‘(2) the Indian Tribe or Tribal Organization 

25 meets the need criteria which shall be developed
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1 through the negotiated rulemaking process provided 

2 for under section 802. 

3 ‘‘(c) CONTINUED OPERATION.—The Secretary shall 

4 negotiate an agreement with the Indian Tribe or Tribal 

5 Organization regarding the continued operation of the fa6 cility at the end of the initial 10 year no-cost lease period. 

7 ‘‘(d) BREACH OF AGREEMENT.—An Indian Tribe or 

8 Tribal Organization that has entered into a written agree9 ment with the Secretary under this section, and that 

10 breaches or terminates without cause such agreement, 

11 shall be liable to the United States for the amount that 

12 has been paid to the Indian Tribe or Tribal Organization, 

13 or paid to a third party on the Indian Tribe’s or Tribal 

14 Organization’s behalf, under the agreement. The Sec15 retary has the right to recover tangible property (including 

16 supplies) and equipment, less depreciation, and any funds 

17 expended for operations and maintenance under this sec18 tion. The preceding sentence does not apply to any funds 

19 expended for the delivery of health care services, per20 sonnel, or staffing. 

21 ‘‘(e) RECOVERY FOR NONUSE.—An Indian Tribe or 

22 Tribal Organization that has entered into a written agree23 ment with the Secretary under this subsection shall be en24 titled to recover from the United States an amount that 

25 is proportional to the value of such facility if, at any time 
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1 within the 10-year term of the agreement, the Service 

2 ceases to use the facility or otherwise breaches the agree3 ment. 

4 ‘‘(f) DEFINITION.—For the purposes of this section, 

5 the term ‘health facility’ or ‘health facilities’ includes 

6 quarters needed to provide housing for staff of the rel7 evant Tribal Health Program. 

8 ‘‘SEC. 312. LOCATION OF FACILITIES. 

9 ‘‘(a) IN GENERAL.—In all matters involving the reor10 ganization or development of Service facilities or in the 

11 establishment of related employment projects to address 

12 unemployment conditions in economically depressed areas, 

13 the Bureau of Indian Affairs and the Service shall give 

14 priority to locating such facilities and projects on Indian 

15 lands if requested by the Indian owner and the Indian 

16 Tribe with jurisdiction over such lands or other lands 

17 owned or leased by the Indian Tribe or Tribal Organiza18 tion. Top priority shall be given to Indian land owned by 

19 1 or more Indian Tribes. 

20 ‘‘(b) DEFINITION.—For purposes of this section, the 

21 term ‘Indian lands’ means—

22 ‘‘(1) all lands within the exterior boundaries of 

23 any reservation; 

24 ‘‘(2) any lands title to which is held in trust by 

25 the United States for the benefit of any Indian 
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1 Tribe or individual Indian or held by any Indian 

2 Tribe or individual Indian subject to restriction by 

3 the United States against alienation and over which 

4 an Indian Tribe exercises governmental power; and 

5 ‘‘(3) all lands in Alaska owned by any Alaska 

6 Native village, or village or regional corporation 

7 under the Alaska Native Claims Settlement Act, or 

8 any land allotted to any Alaska Native. 

9 ‘‘SEC. 313. MAINTENANCE AND IMPROVEMENT OF HEALTH 

10 CARE FACILITIES. 

11 ‘‘(a) REPORT.—The Secretary shall submit to the 

12 President, for inclusion in the report required to be trans13 mitted to Congress under section 801, a report which iden14 tifies the backlog of maintenance and repair work required 

15 at both Service and tribal health care facilities, including 

16 new health care facilities expected to be in operation in 

17 the next fiscal year. The report shall also identify the need 

18 for renovation and expansion of existing facilities to sup19 port the growth of health care programs. 

20 ‘‘(b) MAINTENANCE OF NEWLY CONSTRUCTED

21 SPACE.—The Secretary, acting through the Service, is au22 thorized to expend maintenance and improvement funds 

23 to support maintenance of newly constructed space only 

24 if such space falls within the approved supportable space 

25 allocation for the Indian Tribe or Tribal Organization. 
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1 Supportable space allocation shall be defined through the 

2 negotiated rulemaking process provided for under section 

3 802. 

4 ‘‘(c) REPLACEMENT FACILITIES.—In addition to 

5 using maintenance and improvement funds for renovation, 

6 modernization, and expansion of facilities, an Indian Tribe 

7 or Tribal Organization may use maintenance and improve8 ment funds for construction of a replacement facility if 

9 the costs of renovation of such facility would exceed a 

10 maximum renovation cost threshold. The maximum ren11 ovation cost threshold shall be determined through the ne12 gotiated rulemaking process provided for under section 

13 802. 

14 ‘‘SEC. 314. TRIBAL MANAGEMENT OF FEDERALLY OWNED 

15 QUARTERS. 

16 ‘‘(a) RENTAL RATES.—

17 ‘‘(1) ESTABLISHMENT.—Notwithstanding any 

18 other provision of law, a Tribal Health Program 

19 which operates a hospital or other health facility and 

20 the federally owned quarters associated therewith 

21 pursuant to a Funding Agreement shall have the au22 thority to establish the rental rates charged to the 

23 occupants of such quarters by providing notice to 

24 the Secretary of its election to exercise such author25 ity. 
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1 ‘‘(2) OBJECTIVES.—In establishing rental rates 

2 pursuant to authority of this subsection, a Tribal 

3 Health Program shall endeavor to achieve the fol4 lowing objectives: 

5 ‘‘(A) To base such rental rates on the rea6 sonable value of the quarters to the occupants 

7 thereof. 

8 ‘‘(B) To generate sufficient funds to pru9 dently provide for the operation and mainte10 nance of the quarters, and subject to the discre11 tion of the Tribal Health Program, to supply 

12 reserve funds for capital repairs and replace13 ment of the quarters. 

14 ‘‘(3) EQUITABLE FUNDING.—Any quarters 

15 whose rental rates are established by a Tribal 

16 Health Program pursuant to this subsection shall 

17 remain eligible for quarters improvement and repair 

18 funds to the same extent as all federally owned 

19 quarters used to house personnel in Services-sup20 ported programs. 

21 ‘‘(4) NOTICE OF RATE CHANGE.—A Tribal 

22 Health Program which exercises the authority pro23 vided under this subsection shall provide occupants 

24 with no less than 60 days notice of any change in 

25 rental rates.
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1 ‘‘(b) DIRECT COLLECTION OF RENT.—

2 ‘‘(1) IN GENERAL.—Notwithstanding any other 

3 provision of law, and subject to paragraph (2), a 

4 Tribal Health Program shall have the authority to 

5 collect rents directly from Federal employees who oc6 cupy such quarters in accordance with the following: 

7 ‘‘(A) The Tribal Health Program shall no8 tify the Secretary and the subject Federal em9 ployees of its election to exercise its authority 

10 to collect rents directly from such Federal em11 ployees. 

12 ‘‘(B) Upon receipt of a notice described in 

13 subparagraph (A), the Federal employees shall 

14 pay rents for occupancy of such quarters di15 rectly to the Tribal Health Program and the 

16 Secretary shall have no further authority to col17 lect rents from such employees through payroll 

18 deduction or otherwise. 

19 ‘‘(C) Such rent payments shall be retained 

20 by the Tribal Health Program and shall not be 

21 made payable to or otherwise be deposited with 

22 the United States. 

23 ‘‘(D) Such rent payments shall be depos24 ited into a separate account which shall be used 

25 by the Tribal Health Program for the mainte-
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1 nance (including capital repairs and replace2 ment) and operation of the quarters and facili3 ties as the Tribal Health Program shall deter4 mine. 

5 ‘‘(2) RETROCESSION OF AUTHORITY.—If a 

6 Tribal Health Program which has made an election 

7 under paragraph (1) requests retrocession of its au8 thority to directly collect rents from Federal employ9 ees occupying federally owned quarters, such ret10 rocession shall become effective on the earlier of—

11 ‘‘(A) the first day of the month that begins 

12 no less than 180 days after the Tribal Health 

13 Program notifies the Secretary of its desire to 

14 retrocede; or 

15 ‘‘(B) such other date as may be mutually 

16 agreed by the Secretary and the Tribal Health 

17 Program. 

18 ‘‘(c) RATES IN ALASKA.—To the extent that a Tribal 

19 Health Program, pursuant to authority granted in sub20 section (a), establishes rental rates for federally owned 

21 quarters provided to a Federal employee in Alaska, such 

22 rents may be based on the cost of comparable private rent23 al housing in the nearest established community with a 

24 year-round population of 1,500 or more individuals. 
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1 ‘‘SEC. 315. APPLICABILITY OF BUY AMERICAN ACT RE2 QUIREMENT. 

3 ‘‘(a) APPLICABILITY.—The Secretary shall ensure 

4 that the requirements of the Buy American Act apply to 

5 all procurements made with funds provided pursuant to 

6 section 317. Indian Tribes and Tribal Organizations shall 

7 be exempt from these requirements. 

8 ‘‘(b) EFFECT OF VIOLATION.—If it has been finally 

9 determined by a court or Federal agency that any person 

10 intentionally affixed a label bearing a ‘Made in America’ 

11 inscription or any inscription with the same meaning, to 

12 any product sold in or shipped to the United States that 

13 is not made in the United States, such person shall be 

14 ineligible to receive any contract or subcontract made with 

15 funds provided pursuant to section 317, pursuant to the 

16 debarment, suspension, and ineligibility procedures de17 scribed in sections 9.400 through 9.409 of title 48, Code 

18 of Federal Regulations. 

19 ‘‘(c) DEFINITIONS.—For purposes of this section, the 

20 term ‘Buy American Act’ means title III of the Act enti21 tled ‘An Act making appropriations for the Treasury and 

22 Post Office Departments for the fiscal year ending June 

23 30, 1934, and for other purposes’, approved March 3, 

24 1933 (41 U.S.C. 10a et seq.). 
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1 ‘‘SEC. 316. OTHER FUNDING FOR FACILITIES. 

2 ‘‘(a) AUTHORITY TO ACCEPT FUNDS.—The Sec3 retary is authorized to accept from any source, including 

4 Federal and State agencies, funds that are available for 

5 the construction of health care facilities and use such 

6 funds to plan, design, and construct health care facilities 

7 for Indians and to place such funds into Funding Agree8 ments. Receipt of such funds shall have no effect on the 

9 priorities established pursuant to section 301. 

10 ‘‘(b) INTERAGENCY AGREEMENTS.—The Secretary is 

11 authorized to enter into interagency agreements with 

12 other Federal agencies or State agencies and other entities 

13 and to accept funds from such Federal or State agencies 

14 or other sources to provide for the planning, design, and 

15 construction of health care facilities to be administered by 

16 Indian Health Programs in order to carry out the pur17 poses of this Act and the purposes for which the funds 

18 were appropriated or for which the funds were otherwise 

19 provided. 

20 ‘‘(c) TRANSFERRED FUNDS.—Any Federal agency to 

21 which funds for the construction of health care facilities 

22 are appropriated is authorized to transfer such funds to 

23 the Secretary for the construction of health care facilities 

24 to carry out the purposes of this Act as well as the pur25 poses for which such funds are appropriated to such other 

26 Federal agency. 
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1 ‘‘(d) ESTABLISHMENT OF STANDARDS.—The Sec2 retary, through the Service, shall establish standards by 

3 regulation, developed by rulemaking under section 802, for 

4 the planning, design, and construction of health care fa5 cilities serving Indians under this Act. 

6 ‘‘SEC. 317. AUTHORIZATION OF APPROPRIATIONS. 

7 ‘‘There are authorized to be appropriated such sums 

8 as may be necessary for each fiscal year through fiscal 

9 year 2015 to carry out this title.

10 ‘‘TITLE IV—ACCESS TO HEALTH 

11 SERVICES

12 ‘‘SEC. 401. TREATMENT OF PAYMENTS UNDER SOCIAL SE13 CURITY ACT HEALTH CARE PROGRAMS. 

14 ‘‘(a) DISREGARD OF MEDICARE, MEDICAID, AND

15 SCHIP PAYMENTS IN DETERMINING APPROPRIATIONS.—

16 Any payments received by an Indian Health Program or 

17 by an Urban Indian Organization made under title XVIII, 

18 XIX, or XXI of the Social Security Act for services pro19 vided to Indians eligible for benefits under such respective 

20 titles shall not be considered in determining appropria21 tions for the provision of health care and services to Indi22 ans. 

23 ‘‘(b) NONPREFERENTIAL TREATMENT.—Nothing in 

24 this Act authorizes the Secretary to provide services to an 

25 Indian with coverage under title XVIII, XIX, or XXI of
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1 the Social Security Act in preference to an Indian without 

2 such coverage. 

3 ‘‘(c) USE OF FUNDS.—

4 ‘‘(1) SPECIAL FUND.—Notwithstanding any 

5 other provision of law, but subject to paragraph (2), pay6 ments to which a facility of the Service is entitled by rea7 son of a provision of the Social Security Act shall be 

8 placed in a special fund to be held by the Secretary and 

9 first used (to such extent or in such amounts as are pro10 vided in appropriation Acts) for the purpose of making 

11 any improvements in the programs of the Service which 

12 may be necessary to achieve or maintain compliance with 

13 the applicable conditions and requirements of titles 

14 XVIII, XIX, and XXI of the Social Security Act. Any 

15 amounts to be reimbursed that are in excess of the 

16 amount necessary to achieve or maintain such conditions 

17 and requirements shall, subject to the consultation with 

18 Indian Tribes being served by the Service Unit, be used 

19 for reducing the health resource deficiencies of the Indian 

20 Tribes. In making payments from such fund, the Sec21 retary shall ensure that each Service Unit of the Service 

22 receives 100 percent of the amount to which the facilities 

23 of the Service, for which such Service Unit makes collec24 tions, are entitled by reason of a provision of the Social 

25 Security Act. 
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1 ‘‘(2) DIRECT PAYMENT OPTION.—Paragraph 

2 (1) shall not apply upon the election of a Tribal 

3 Health Program under subsection (d) to receive pay4 ments directly. No payment may be made out of the 

5 special fund described in such paragraph with re6 spect to reimbursement made for services provided 

7 during the period of such election. 

8 ‘‘(d) DIRECT BILLING.—

9 ‘‘(1) IN GENERAL.—A Tribal Health Program 

10 may directly bill for, and receive payment for, health 

11 care items and services provided by such Indian 

12 tribe or organization for which payment is made 

13 under title XVIII, XIX, or XXI of the Social Secu14 rity Act or from any other third party payor. 

15 ‘‘(2) DIRECT REIMBURSEMENT.—

16 ‘‘(A) USE OF FUNDS.—Each Tribal Health 

17 Program exercising the option described in 

18 paragraph (1) with respect to a program under 

19 a title of the Social Security Act shall be reim20 bursed directly by that program for items and 

21 services furnished without regard to any other 

22 provision of law, but all amounts so reimbursed 

23 shall be used by the Tribal Health Program for 

24 the purpose of making any improvements in 

25 Tribal facilities or Tribal Health Programs that 
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1 may be necessary to achieve or maintain com2 pliance with the conditions and requirements 

3 applicable generally to such items and services 

4 under the program under such title and to pro5 vide additional health care services, improve6 ments in health care facilities and Tribal 

7 Health Programs, any health care-related pur8 pose, or otherwise to achieve the objectives pro9 vided in section 3 of this Act. 

10 ‘‘(B) AUDITS.—The amounts paid to an 

11 Indian Tribe or Tribal Organization exercising 

12 the option described in paragraph (1) with re13 spect to a program under a title of the Social 

14 Security Act shall be subject to all auditing re15 quirements applicable to programs administered 

16 by an Indian Health Program. 

17 ‘‘(3) EXAMINATION AND IMPLEMENTATION OF

18 CHANGES.—The Secretary, acting through the Serv19 ice and with the assistance of the Administrator of 

20 the Centers for Medicare & Medicaid Services, shall 

21 examine on an ongoing basis and implement any ad22 ministrative changes that may be necessary to facili23 tate direct billing and reimbursement under the pro24 gram established under this subsection, including 

25 any agreements with States that may be necessary 
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1 to provide for direct billing under a program under 

2 a title of the Social Security Act. 

3 ‘‘(4) WITHDRAWAL FROM PROGRAM.—A Tribal 

4 Health Program that bills directly under the pro5 gram established under this subsection may with6 draw from participation in the same manner and 

7 under the same conditions that an Indian Tribe or 

8 Tribal Organization may retrocede a contracted pro9 gram to the Secretary under the authority of the In10 dian Self-Determination and Education Assistance 

11 Act (25 U.S.C. 450 et seq.). All cost accounting and 

12 billing authority under the program established 

13 under this subsection shall be returned to the Sec14 retary upon the Secretary’s acceptance of the with15 drawal of participation in this program.

16 ‘‘SEC. 402. GRANTS TO AND FUNDING AGREEMENTS WITH 

17 THE SERVICE, INDIAN TRIBES, TRIBAL ORGA18 NIZATIONS, AND URBAN INDIAN ORGANIZA19 TIONS. 

20 ‘‘(a) INDIAN TRIBES AND TRIBAL ORGANIZA21 TIONS.—The Secretary, acting through the Service, shall 

22 make grants to or enter into Funding Agreements with 

23 Indian Tribes and Tribal Organizations to assist such 

24 Tribes and Tribal Organizations in establishing and ad-
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1 ministering programs on or near reservations and trust 

2 lands to assist individual Indians—

3 ‘‘(1) to enroll for benefits under title XVIII, 

4 XIX, or XXI of the Social Security Act and other 

5 health benefits programs; and 

6 ‘‘(2) to pay premiums for coverage for such 

7 benefits, which may be based on financial need (as 

8 determined by the Indian Tribe or Tribes being 

9 served based on a schedule of income levels devel10 oped or implemented by such Tribe or Tribes). 

11 ‘‘(b) CONDITIONS.—The Secretary, acting through 

12 the Service, shall place conditions as deemed necessary to 

13 effect the purpose of this section in any grant or Funding 

14 Agreement which the Secretary makes with any Indian 

15 Tribe or Tribal Organization pursuant to this section. 

16 Such conditions shall include requirements that the Indian 

17 Tribe or Tribal Organization successfully undertake—

18 ‘‘(1) to determine the population of Indians eli19 gible for the benefits described in subsection (a); 

20 ‘‘(2) to educate Indians with respect to the ben21 efits available under the respective programs; 

22 ‘‘(3) to provide transportation to such indi23 vidual Indians to the appropriate offices for enroll24 ment or applications for such benefits; and
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1 ‘‘(4) to develop and implement methods of im2 proving the participation of Indians in receiving the 

3 benefits provided under titles XVIII, XIX, and XXI 

4 of the Social Security Act. 

5 ‘‘(c) AGREEMENTS RELATING TO IMPROVING EN6 ROLLMENT OF INDIANS UNDER SOCIAL SECURITY ACT

7 PROGRAMS.—

8 ‘‘(1) AGREEMENTS WITH SECRETARY TO IM9 PROVE RECEIPT AND PROCESSING OF APPLICA10 TIONS.—

11 ‘‘(A) AUTHORIZATION.—The Secretary, 

12 acting through the Service, may enter into an 

13 agreement with an Indian Tribe, Tribal Organi14 zation, or Urban Indian Organization which 

15 provides for the receipt and processing of appli16 cations by Indians for assistance under titles 

17 XIX and XXI of the Social Security Act, and 

18 benefits under title XVIII of such Act, by an 

19 Indian Health Program or Urban Indian Orga20 nization. 

21 ‘‘(B) REIMBURSEMENT OF COSTS.—Such 

22 agreements may provide for reimbursement of 

23 costs of outreach, education regarding eligibility 

24 and benefits, and translation when such services 

25 are provided. The reimbursement may, as ap-
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1 propriate, be added to the applicable rate per 

2 encounter or be provided as a separate fee-for3 service payment to the Indian Tribe or Tribal 

4 Organization. 

5 ‘‘(C) PROCESSING CLARIFIED.—In this 

6 paragraph, the term ‘processing’ does not in7 clude a final determination of eligibility. 

8 ‘‘(2) AGREEMENTS WITH STATES FOR OUT9 REACH ON OR NEAR RESERVATION.—

10 ‘‘(A) IN GENERAL.—In order to improve 

11 the access of Indians residing on or near a res12 ervation to obtain benefits under title XIX or 

13 XXI of the Social Security Act, as a condition 

14 of continuing approval of a State plan under 

15 such title, the State shall take steps as to pro16 vide for enrollment on or near the reservation. 

17 Such steps may include outreach efforts such as 

18 the outstationing of eligibility workers, entering 

19 into agreements with Indian Tribes and Tribal 

20 Organizations to provide outreach, education re21 garding eligibility and benefits, enrollment, and 

22 translation services when such services are pro23 vided. 

24 ‘‘(B) CONSTRUCTION.—Nothing in sub25 paragraph (A) shall be construed as affecting 
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1 arrangements entered into between States and 

2 Indian Tribes and Tribal Organizations for 

3 such Indian Tribes and Tribal Organizations to 

4 conduct administrative activities under such ti5 tles.

6 ‘‘(d) FACILITATING COOPERATION.—The Secretary, 

7 acting through the Centers for Medicare & Medicaid Serv8 ices, shall take such steps as are necessary to facilitate 

9 cooperation with, and agreements between, States and the 

10 Service, Indian Tribes, Tribal Organizations, or Urban In11 dian Organizations. 

12 ‘‘(e) APPLICATION TO URBAN INDIAN ORGANIZA13 TIONS.—

14 ‘‘(1) IN GENERAL.—The provisions of sub15 section (a) shall apply with respect to grants and 

16 other funding to Urban Indian Organizations with 

17 respect to populations served by such organizations 

18 in the same manner they apply to grants and Fund19 ing Agreements with Indian tribes and Tribal Orga20 nizations with respect to programs on or near res21 ervations. 

22 ‘‘(2) REQUIREMENTS.—The Secretary shall in23 clude in the grants or Funding Agreements made or 

24 provided under paragraph (1) requirements that 

25 are—
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1 ‘‘(A) consistent with the requirements im2 posed by the Secretary under subsection (b); 

3 ‘‘(B) appropriate to Urban Indian Organi4 zations and Urban Indians; and 

5 ‘‘(C) necessary to effect the purposes of 

6 this section.

7 ‘‘SEC. 403. REIMBURSEMENT FROM CERTAIN THIRD PAR8 TIES OF COSTS OF HEALTH SERVICES. 

9 ‘‘(a) RIGHT OF RECOVERY.—Except as provided in 

10 subsection (f), the United States, an Indian Tribe, or 

11 Tribal Organization shall have the right to recover from 

12 an insurance company, health maintenance organization, 

13 employee benefit plan, third-party tortfeasor, or any other 

14 responsible or liable third party (including a political sub15 division or local governmental entity of a State) the rea16 sonable charges billed (or, if charges are not billed, the 

17 operational, administrative, and other expenses incurred) 

18 by the Secretary, an Indian Tribe, or Tribal Organization 

19 in providing health services, through the Service, an In20 dian Tribe, or Tribal Organization to any individual to the 

21 same extent that such individual, or any nongovernmental 

22 provider of such services, would be eligible to receive dam23 ages, reimbursement, or indemnification for such charges 

24 or expenses if—
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1 ‘‘(1) such services had been provided by a non2 governmental provider; and 

3 ‘‘(2) such individual had been required to pay 

4 such charges or expenses and did pay such charges 

5 or expenses. 

6 ‘‘(b) LIMITATIONS ON RECOVERIES FROM STATES.—

7 Subsection (a) shall provide a right of recovery against 

8 any State, only if the injury, illness, or disability for which 

9 health services were provided is covered under—

10 ‘‘(1) workers’ compensation laws; or 

11 ‘‘(2) a no-fault automobile accident insurance 

12 plan or program. 

13 ‘‘(c) NONAPPLICATION OF OTHER LAWS.—No law of 

14 any State, or of any political subdivision of a State and 

15 no provision of any contract, insurance or health mainte16 nance organization policy, employee benefit plan, self-in17 surance plan, managed care plan, or other health care plan 

18 or program entered into or renewed after the date of the 

19 enactment of the Indian Health Care Amendments of 

20 1988, shall prevent or hinder the right of recovery of the 

21 United States, an Indian Tribe, or Tribal Organization 

22 under subsection (a). 

23 ‘‘(d) NO EFFECT ON PRIVATE RIGHTS OF ACTION.—

24 No action taken by the United States, an Indian Tribe, 

25 or Tribal Organization to enforce the right of recovery
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1 provided under subsection (a) shall operate to deny to the 

2 injured person the recovery for that portion of the person’s 

3 damage not covered hereunder. 

4 ‘‘(e) ENFORCEMENT.—

5 ‘‘(1) IN GENERAL.—The United States, an In6 dian Tribe, or Tribal Organization may enforce the 

7 right of recovery provided under subsection (a) by—

8 ‘‘(A) intervening or joining in any civil ac9 tion or proceeding brought—

10 ‘‘(i) by the individual for whom health 

11 services were provided by the Secretary, an 

12 Indian Tribe, or Tribal Organization; or 

13 ‘‘(ii) by any representative or heirs of 

14 such individual, or 

15 ‘‘(B) instituting a civil action, including a 

16 civil action for injunctive relief and other relief 

17 and including, with respect to a political sub18 division or local governmental entity of a State, 

19 such an action against an official thereof. 

20 ‘‘(2) NOTICE.—All reasonable efforts shall be 

21 made to provide notice of action instituted under 

22 paragraph (1)(B) to the individual to whom health 

23 services were provided, either before or during the 

24 pendency of such action. 
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1 ‘‘(f) LIMITATION.—Absent specific written authoriza2 tion by the governing body of an Indian Tribe for the pe3 riod of such authorization (which may not be for a period 

4 of more than 1 year and which may be revoked at any 

5 time upon written notice by the governing body to the 

6 Service), the United States shall not have a right of recov7 ery under this section if the injury, illness, or disability 

8 for which health services were provided is covered under 

9 a self-insurance plan funded by an Indian Tribe, Tribal 

10 Organization, or Urban Indian Organization. Where such 

11 authorization is provided, the Service may receive and ex12 pend such amounts for the provision of additional health 

13 services consistent with such authorization. 

14 ‘‘(g) COSTS AND ATTORNEYS’ FEES.—In any action 

15 brought to enforce the provisions of this section, a pre16 vailing plaintiff shall be awarded its reasonable attorneys’ 

17 fees and costs of litigation. 

18 ‘‘(h) RIGHT OF ACTION AGAINST INSURERS, HMOS, 

19 EMPLOYEE BENEFIT PLANS, SELF-INSURANCE PLANS, 

20 AND OTHER HEALTH CARE PLANS OR PROGRAMS.—

21 Where an insurance company, health maintenance organi22 zation, employee benefit plan, self-insurance plan, man23 aged care plan, or other health care plan or program fails 

24 or refuses to pay the amount due under subsection (a) 

25 for services provided to an individual who is a beneficiary, 
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1 participant, or insured of such company, organization, 

2 plan, or program, the United States, Indian Tribe, or 

3 Tribal Organization shall have a right to assert and pur4 sue all the claims and remedies against such company, or5 ganization, plan, or program and against the fiduciaries 

6 of such company, organization, plan, or program that the 

7 individual could assert or pursue under the terms of the 

8 contract, program, or plan or applicable Federal, State, 

9 or Tribal law. 

10 ‘‘(i) NONAPPLICATION OF CLAIMS FILING REQUIRE11 MENTS.—An insurance company, health maintenance or12 ganization, self-insurance plan, managed care plan, or 

13 other health care plan or program (under the Social Secu14 rity Act or otherwise) may not deny a claim for benefits 

15 submitted by the Service or by an Indian Tribe or Tribal 

16 Organization based on the format in which the claim is 

17 submitted if such format complies with the format re18 quired for submission of claims under title XVIII of the 

19 Social Security Act or recognized under section 1175 of 

20 such Act. 

21 ‘‘(j) APPLICATION TO URBAN INDIAN ORGANIZA22 TIONS.—The previous provisions of this section shall apply 

23 to Urban Indian Organizations with respect to populations 

24 served by such Organizations in the same manner they 

25 apply to Indian Tribes and Tribal Organizations with re-
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1 spect to populations served by such Indian Tribes and 

2 Tribal Organizations. 

3 ‘‘(k) STATUTE OF LIMITATIONS.—The provisions of 

4 section 2415 of title 28, United States Code, shall apply 

5 to all actions commenced under this section, and the ref6 erences therein to the United States are deemed to include 

7 Indian Tribes, Tribal Organizations, and Urban Indian 

8 Organizations. 

9 ‘‘(l) SAVINGS.—Nothing in this section shall be con10 strued to limit any right of recovery available to the 

11 United States, an Indian Tribe, or Tribal Organization 

12 under the provisions of any applicable, Federal, State, or 

13 Tribal law, including medical lien laws and the Federal 

14 Medical Care Recovery Act (42 U.S.C. 2651 et seq.). 

15 ‘‘SEC. 404. CREDITING OF REIMBURSEMENTS. 

16 ‘‘(a) USE OF AMOUNTS.—

17 ‘‘(1) RETENTION BY PROGRAM.—Except as pro18 vided in section 202(g) (relating to the Catastrophic 

19 Health Emergency Fund) and section 807 (relating 

20 to health services for ineligible persons), all reim21 bursements received or recovered under any of the 

22 programs described in paragraph (2), including 

23 under section 807, by reason of the provision of 

24 health services by the Service, by an Indian Tribe or 

25 Tribal Organization, or by an Urban Indian Organi-
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1 zation, shall be credited to the Service, such Indian 

2 Tribe or Tribal Organization, or such Urban Indian 

3 Organization, respectively, and may be used as pro4 vided in section 401. In the case of such a service 

5 provided by or through a Service Unit, such 

6 amounts shall be credited to such unit and used for 

7 such purposes. 

8 ‘‘(2) PROGRAMS COVERED.—The programs re9 ferred to in paragraph (1) are the following: 

10 ‘‘(A) Titles XVIII, XIX, and XXI of the 

11 Social Security Act. 

12 ‘‘(B) This Act, including section 807. 

13 ‘‘(C) Public Law 87–693. 

14 ‘‘(D) Any other provision of law. 

15 ‘‘(b) NO OFFSET OF AMOUNTS.—The Service may 

16 not offset or limit any amount obligated to any Service 

17 Unit or entity receiving funding from the Service because 

18 of the receipt of reimbursements under subsection (a). 

19 ‘‘SEC. 405. PURCHASING HEALTH CARE COVERAGE. 

20 ‘‘(a) IN GENERAL.—Insofar as amounts are made 

21 available under law (including a provision of the Social 

22 Security Act, the Indian Self-Determination and Edu23 cation Assistance Act, or other law, other than under sec24 tion 402) to Indian Tribes, Tribal Organizations, and 

25 Urban Indian Organizations for health benefits for Service
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1 beneficiaries, Indian Tribes, Tribal Organizations, and 

2 Urban Indian Organizations may use such amounts to 

3 purchase health benefits coverage for such beneficiaries in 

4 any manner, including through—

5 ‘‘(1) a tribally owned and operated health care 

6 plan; 

7 ‘‘(2) a State or locally authorized or licensed 

8 health care plan; 

9 ‘‘(3) a health insurance provider or managed 

10 care organization; or 

11 ‘‘(4) a self-insured plan. 

12 The purchase of such coverage by an Indian Tribe, Tribal 

13 Organization, or Urban Indian Organization may be based 

14 on the financial needs of such beneficiaries (as determined 

15 by the Indian Tribe or Tribes being served based on a 

16 schedule of income levels developed or implemented by 

17 such Indian Tribe or Tribes). 

18 ‘‘(b) EXPENSES FOR SELF-INSURED PLAN.—In the 

19 case of a self-insured plan under subsection (a)(4), the 

20 amounts may be used for expenses of operating the plan, 

21 including administration and insurance to limit the finan22 cial risks to the entity offering the plan. 

23 ‘‘(c) CONSTRUCTION.—Nothing in this section shall 

24 be construed as affecting the use of any amounts not re25 ferred to in subsection (a). 
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1 ‘‘SEC. 406. SHARING ARRANGEMENTS WITH FEDERAL AGEN2 CIES. 

3 ‘‘(a) AUTHORITY.—

4 ‘‘(1) IN GENERAL.—The Secretary may enter 

5 into (or expand) arrangements for the sharing of 

6 medical facilities and services between the Service, 

7 Indian Tribes, and Tribal Organizations and the De8 partment of Veterans Affairs and the Department of 

9 Defense. 

10 ‘‘(2) CONSULTATION BY SECRETARY RE11 QUIRED.—The Secretary may not finalize any ar12 rangement between the Service and a Department 

13 described in paragraph (1) without first consulting 

14 with the Indian Tribes which will be significantly af15 fected by the arrangement. 

16 ‘‘(b) LIMITATIONS.—The Secretary shall not take 

17 any action under this section or under subchapter IV of 

18 chapter 81 of title 38, United States Code, which would 

19 impair—

20 ‘‘(1) the priority access of any Indian to health 

21 care services provided through the Service and the 

22 eligibility of any Indian to receive health services 

23 through the Service; 

24 ‘‘(2) the quality of health care services provided 

25 to any Indian through the Service; 
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1 ‘‘(3) the priority access of any veteran to health 

2 care services provided by the Department of Vet3 erans Affairs; 

4 ‘‘(4) the quality of health care services provided 

5 by the Department of Veterans Affairs or the De6 partment of Defense; or 

7 ‘‘(5) the eligibility of any Indian who is a vet8 eran to receive health services through the Depart9 ment of Veterans Affairs. 

10 ‘‘(c) REIMBURSEMENT.—The Service, Indian Tribe, 

11 or Tribal Organization shall be reimbursed by the Depart12 ment of Veterans Affairs or the Department of Defense 

13 (as the case may be) where services are provided through 

14 the Service, an Indian Tribe, or a Tribal Organization to 

15 beneficiaries eligible for services from either such Depart16 ment, notwithstanding any other provision of law. 

17 ‘‘(d) CONSTRUCTION.—Nothing in this section may 

18 be construed as creating any right of a non-Indian veteran 

19 to obtain health services from the Service. 

20 ‘‘SEC. 407. PAYOR OF LAST RESORT. 

21 ‘‘Indian Health Programs and health care programs 

22 operated by Urban Indian Organizations shall be the 

23 payor of last resort for services provided to persons eligible 

24 for services from Indian Health Programs and Urban In-
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1 dian Organizations, notwithstanding any Federal, State, 

2 or local law to the contrary. 

3 ‘‘SEC. 408. NONDISCRIMINATION IN QUALIFICATIONS FOR 

4 REIMBURSEMENT FOR SERVICES. 

5 ‘‘For purposes of determining the eligibility of an en6 tity that is operated by the Service, an Indian Tribe, Trib7 al Organization, or Urban Indian Organization to receive 

8 payment or reimbursement from any federally funded 

9 health care program for health care services it furnishes 

10 to an Indian, any requirement that the entity be licensed 

11 or recognized under State or local law to furnish such 

12 services shall be deemed to have been met if the entity 

13 meets quality requirements for the furnishing of such serv14 ices recognized by the Secretary. 

15 ‘‘SEC. 409. CONSULTATION. 

16 ‘‘(a) NATIONAL INDIAN TECHNICAL ADVISORY

17 GROUP (TAG).—

18 ‘‘(1) ESTABLISHMENT AND MEMBERSHIP.—The 

19 Secretary shall establish a National Indian Technical 

20 Advisory Group (in this subsection referred to as the 

21 ‘Advisory Group’) which shall have no fewer than 14 

22 members including at least 1 member designated by 

23 the Indian Tribes and Tribal Organizations in each 

24 Service Area, 1 Urban Indian Organization rep25 resentative, and 1 member representing the Service.
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1 The Secretary may appoint additional members 

2 upon the recommendation of the Advisory Group. 

3 ‘‘(2) DUTIES.—

4 ‘‘(A) IDENTIFICATION OF ISSUES.—The 

5 Advisory Group shall assist the Secretary in 

6 identifying and addressing issues regarding the 

7 health care programs under the Social Security 

8 Act (including medicare, medicaid, and SCHIP) 

9 that have implications for Indian Health Pro10 grams or Urban Indian Organizations. The Ad11 visory Group shall provide advice to the Sec12 retary with respect to those issues and with re13 spect to the need for the Secretary to engage in 

14 consultation with Indian Tribes, Tribal Organi15 zations, and Urban Indian Organizations. 

16 ‘‘(B) CONSTRUCTION.—Nothing in sub17 paragraph (A) shall be construed as affecting 

18 any requirement under any applicable Executive 

19 order for the Secretary to consult with Indian 

20 Tribes in cases of health care policies that have 

21 implications for Indian Health Programs or 

22 Urban Indian Organizations. 

23 ‘‘(3) FUNDING.—The Secretary shall pay the 

24 expenses of the Advisory Group using the general 
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1 administrative funds of the Centers for Medicare & 

2 Medicaid Services. 

3 ‘‘(4) NONAPPLICATION OF FEDERAL ADVISORY

4 COMMITTEE ACT.—The Federal Advisory Committee 

5 Act (5 U.S.C. App.) shall not apply to the Advisory 

6 Group. 

7 ‘‘(5) MEETINGS.—The Secretary shall convene 

8 meetings of the Advisory Group no less frequently 

9 than quarterly. 

10 ‘‘(b) SOLICITATION OF MEDICAID ADVICE.—

11 ‘‘(1) IN GENERAL.—As a requirement for pay12 ment under title XIX of the Social Security Act to 

13 a State in which the Service operates or funds 

14 health care programs or in which 1 or more Indian 

15 Health Programs or Urban Indian Organizations 

16 provide health care in the State for which medical 

17 assistance is available under such title, the State 

18 shall establish a process under which the State seeks 

19 advice on a regular, ongoing basis (at least on a 

20 quarterly basis) from designees of such Indian 

21 Health Programs and Urban Indian Organizations 

22 on matters relating to the application of such title 

23 to such Indian Health Programs and Urban Indian 

24 Organizations. 
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1 ‘‘(2) MANNER OF ADVICE.—Such process shall 

2 be in addition to (and not in lieu of) any consulta3 tion otherwise required by law and shall apply before 

4 the submittal of plan amendments, waiver requests, 

5 and proposals for demonstration projects. Such proc6 ess may include appointment of an advisory com7 mittee and of a designee of such Indian Health Pro8 grams and Urban Indian Organizations to the med9 ical care advisory committee advising the State on 

10 its medicaid plan. 

11 ‘‘(3) PAYMENT OF EXPENSES.—Expenses in 

12 carrying out this subsection shall be treated as rea13 sonable administrative expenses for which reimburse14 ment may be made under section 1903(a) of the So15 cial Security Act. 

16 ‘‘(c) CONSTRUCTION.—Nothing in this section shall 

17 be construed as superseding existing advisory committees, 

18 working groups, or other advisory procedures established 

19 by the Secretary or by any State. 

20 ‘‘SEC. 410. STATE CHILDREN’S HEALTH INSURANCE PRO21 GRAM (SCHIP).

22 ‘‘(a) AUTHORIZATION FOR ARRANGEMENTS.—Not23 withstanding any other provision of law, insofar as the 

24 State health plan of a State under title XXI of the Social 

25 Security Act may provide (whether through its medicaid 
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1 plan under title XIX of such Act or otherwise) child or 

2 other health assistance to individuals who are otherwise 

3 served by the Service or by an Indian Tribe or Tribal Or4 ganization, the Secretary may enter into an arrangement 

5 with the State and with the Service or 1 or more Indian 

6 Tribes and Tribal Organizations in the State under which 

7 a portion of the funds otherwise made available to the 

8 State under such title with respect to such individuals is 

9 provided to the Service, Indian Tribe, or Tribal Organiza10 tion, respectively, for the purpose of providing such assist11 ance to such individuals consistent with the purposes of 

12 such title. 

13 ‘‘(b) ENTERING INTO ARRANGEMENTS.—

14 ‘‘(1) IN GENERAL.—Notwithstanding any other 

15 provision of law, in the case of a State which has an 

16 unexpended allotment amount described in para17 graph (2) for a fiscal year, before effecting any real18 lotment of such amount to other States, at the re19 quest of the Service or 1 or more Indian Tribes or 

20 Tribal Organizations that operate in the State with 

21 respect to individuals who are served by such Serv22 ice, Indian Tribes, or Tribal Organizations, the Sec23 retary shall enter into an arrangement with the 

24 Service, Indian Tribes, or Tribal Organizations 

25 under which the Indian child proportion (as defined
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1 in paragraph (3)) for such Service, Indian Tribes, 

2 or Tribal Organizations of such unexpended allot3 ment amount is made available to the Service or 

4 such Indian Tribes or Tribal Organizations for the 

5 purpose of providing child health or other assistance 

6 to individuals who are otherwise served by the Serv7 ice or by such Indian Tribes or Tribal Organizations 

8 consistent with the purposes of title XXI of the So9 cial Security Act. Insofar as amounts are made 

10 available under the preceding sentence, such 

11 amounts shall be treated (for purposes of title XXI 

12 of the Social Security Act) as if they had been ex13 pended during the period referred to in paragraph 

14 (2). 

15 ‘‘(2) UNEXPENDED ALLOTMENT AMOUNT.—For 

16 purposes of this subsection, the term ‘unexpended 

17 allotment amount’ means, with respect to an allot18 ment to a State under section 2104 of the Social Se19 curity Act for a fiscal year, the portion of such allot20 ment which was not expended by the State during 

21 the period in which such allotment is available for 

22 expenditure by the State and which would, but for 

23 this subsection, be realloted to other States. 

24 ‘‘(3) INDIAN CHILD PROPORTION.—For pur25 poses of this subsection, the term ‘Indian child pro-
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1 portion’ means, with respect to an unexpended allot2 ment amount for a State and an arrangement under 

3 paragraph (1) with the Service or Indian Tribes or 

4 Tribal Organizations, the proportion of targeted low5 income children in the State (as defined in section 

6 2110(b) of the Social Security Act) who are Indians 

7 who would be served under an arrangement with the 

8 Service or such Indian Tribes or Tribal Organiza9 tions under such paragraph, as estimated by the 

10 Secretary of Health and Human Services based 

11 upon the best available data before a portion of the 

12 unexpended allotment amount is made available 

13 under this subsection. 

14 ‘‘SEC. 411. SOCIAL SECURITY ACT SANCTIONS. 

15 ‘‘(a) REQUESTS FOR WAIVER OF SANCTIONS.—For 

16 purposes of applying any authority under a provision of 

17 title XI, XVIII, XIX, or XXI of the Social Security Act 

18 to seek a waiver of a sanction imposed against a health 

19 care provider insofar as that provider provides services to 

20 individuals through an Indian Health Program, any re21 quirement that a State request such a waiver shall be 

22 deemed to be met if such Indian Health Program requests 

23 such a waiver. 

24 ‘‘(b) SAFE HARBOR FOR TRANSACTIONS BETWEEN

25 AND AMONG INDIAN HEALTH CARE PROGRAMS.—For 
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1 purposes of applying section 1128B(b) of the Social Secu2 rity Act, the exchange of anything of value between or 

3 among the following shall not be treated as remuneration 

4 if the exchange arises from or relates to any of the fol5 lowing health programs: 

6 ‘‘(1) An exchange between or among the fol7 lowing: 

8 ‘‘(A) Any Indian Health Program. 

9 ‘‘(B) Any Urban Indian Organization. 

10 ‘‘(2) An exchange between an Indian Tribe, 

11 Tribal Organization, or an Urban Indian Organiza12 tion and any patient served or eligible for service 

13 from an Indian Tribe, Tribal Organization, or 

14 Urban Indian Organization, including patients 

15 served or eligible for service pursuant to section 807, 

16 but only if such exchange—

17 ‘‘(A) is for the purpose of transporting the 

18 patient for the provision of health care items or 

19 services; 

20 ‘‘(B) is for the purpose of providing hous21 ing to the patient (including a pregnant pa22 tient) and immediate family members or an es23 cort incidental to assuring the timely provision 

24 of health care items and services to the patient; 
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1 ‘‘(C) is for the purpose of paying pre2 miums, copayments, deductibles, or other cost3 sharing on behalf of patients; or 

4 ‘‘(D) consists of an item or service of small 

5 value that is provided as a reasonable incentive 

6 to secure timely and necessary preventive and 

7 other items and services. 

8 ‘‘(3) Such other exchanges involving an Indian 

9 Health Program, an Urban Indian Organization, or 

10 an Indian Tribe or Tribal Organization as meet such 

11 standards as the Secretary of Health and Human 

12 Services, in consultation with the Attorney General, 

13 determines is appropriate, taking into account the 

14 special circumstances of such Indian Health Pro15 grams, Urban Indian Organizations, Indian Tribes, 

16 and Tribal Organizations and of patients served by 

17 Indian Health Programs, Urban Indian Organiza18 tions, Indian Tribes, and Tribal Organizations. 

19 ‘‘SEC. 412. COST SHARING. 

20 ‘‘(a) COINSURANCE, COPAYMENTS, AND

21 DEDUCTIBLES.—Notwithstanding any other provision of 

22 Federal or State law—

23 ‘‘(1) PROTECTION FOR ELIGIBLE INDIANS

24 UNDER SOCIAL SECURITY ACT HEALTH PRO25 GRAMS.—No Indian who is furnished an item or 
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1 service for which payment may be made under title 

2 XVIII, XIX, or XXI of the Social Security Act may 

3 be charged a deductible, copayment, or coinsurance 

4 if the item or service is furnished by, or upon refer5 ral made by, the Service, an Indian Tribe, Tribal 

6 Organization, or Urban Indian Organization. 

7 ‘‘(2) PROTECTION FOR INDIANS.—No Indian 

8 who is furnished an item or service by the Service 

9 may be charged a deductible, copayment, or coinsur10 ance. 

11 ‘‘(3) NO REDUCTION IN AMOUNT OF PAYMENT

12 TO INDIAN HEALTH PROVIDERS.—The payment or 

13 reimbursement due to the Service, Indian Tribe, 

14 Tribal Organization, or Urban Indian Organization 

15 under title XVIII, XIX, or XXI of the Social Secu16 rity Act may not be reduced by the amount of the 

17 deductible, copayment, or coinsurance that would be 

18 due from the Indian but for the operation of this 

19 section. 

20 ‘‘(b) EXEMPTION FROM MEDICAID AND SCHIP PRE21 MIUMS.—Notwithstanding any other provision of Federal 

22 or State law, no Indian who is otherwise eligible for serv23 ices under title XIX of the Social Security Act (relating 

24 to the medicaid program) or title XXI of such Act (relat25 ing to the State children’s health insurance program) may
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1 be charged a premium as a condition of receiving benefits 

2 under the program under the respective title.

3 ‘‘(c) MEDICALLY NEEDY PROGRAM SPEND-DOWN.—

4 For the purposes of determining the eligibility of an In5 dian for medical assistance under any medically needy op6 tion under a State’s medicaid plan under title XIX of the 

7 Social Security Act, the cost of providing services to an 

8 Indian in a health program of the Service, an Indian 

9 Tribe, Tribal Organization, or Urban Indian Organization 

10 shall be deemed to have been an expenditure for health 

11 care by the Indian. 

12 ‘‘(d) LIMITATION ON MEDICAL CHILD SUPPORT RE13 COVERY.—Notwithstanding any other provision of law, a 

14 parent (whether or not an Indian) of an Indian child shall 

15 not be responsible for reimbursing a State or the Federal 

16 Government under title XIX or XXI of the Social Security 

17 Act for the cost of medical services relating to the child 

18 (including childbirth and including, where such child is a 

19 minor parent, any child of such minor parent) under cir20 cumstances in which payment would have been made 

21 under the contract health services program of an Indian 

22 Health Program but for the child’s (or, in the case of med23 ical services relating to childbirth, mother’s, or grand24 child’s, as the case may be) eligibility under title XIX or 

25 XXI of the Social Security Act. 
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1 ‘‘(e) TREATMENT OF CERTAIN PROPERTY FOR MED2 ICAID ELIGIBILITY.—Notwithstanding any other provision 

3 of Federal or State law, the following property may not 

4 be included when determining eligibility for services under 

5 title XIX of the Social Security Act: 

6 ‘‘(1) Property, including interests in real prop7 erty currently or formerly held in trust by the Fed8 eral Government which is protected under applicable 

9 Federal, State, or Tribal law or custom from re10 course and including public domain allotments. 

11 ‘‘(2) Property that has unique religious or cul12 tural significance or that supports subsistence or 

13 traditional lifestyle according to applicable Tribal 

14 law or custom. 

15 ‘‘(f) CONTINUATION OF CURRENT LAW PROTEC16 TIONS OF CERTAIN INDIAN PROPERTY FROM MEDICAID

17 ESTATE RECOVERY.—Income, resources, and property 

18 that are exempt from medicaid estate recovery under title 

19 XIX of the Social Security Act as of April 1, 2003, under 

20 manual instructions issued to carry out section 1917(b)(3) 

21 of such Act because of Federal responsibility for Indian 

22 Tribes and Alaska Native Villages shall remain so exempt. 

23 Nothing in this subsection shall be construed as pre24 venting the Secretary from providing additional medicaid 

25 estate recovery exemptions for Indians. 
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1 ‘‘SEC. 413. TREATMENT UNDER MEDICAID MANAGED CARE.

2 ‘‘(a) PAYMENT FOR SERVICES FURNISHED TO INDI3 ANS.—In the case of an Indian who is enrolled with a 

4 managed care entity under section 1932 of the Social Se5 curity Act (or otherwise under a waiver under title XIX 

6 of such Act) and who receives covered services from an 

7 Indian Health Program or an Urban Indian Organization, 

8 either—

9 ‘‘(1) the entity shall make payment to the In10 dian Health Program or Urban Indian Organization 

11 at a rate established by the entity for such services 

12 that is not less than the rate for preferred providers 

13 (or at such other rate as may be negotiated between 

14 the entity and such Indian Health Program or 

15 Urban Indian Organization) and shall not require 

16 submittal of a claim by the enrollee as a condition 

17 of payment to the Indian Health Program or Urban 

18 Indian Organization; or 

19 ‘‘(2) the State shall provide for payment to the 

20 Indian Health Program or Urban Indian Organiza21 tion under its State plan under title XIX of such 

22 Act at the rate otherwise applicable and shall pro23 vide for an appropriate adjustment of the capitation 

24 payment made to the entity to take into account 

25 such payment. 

26 ‘‘(b) OFFERING OF MANAGED CARE.—If—
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1 ‘‘(1) a State elects under its State plan under 

2 title XIX of the Social Security Act to provide serv3 ices through medicaid managed care organizations 

4 or through primary care case managers under sec5 tion 1932 or under a waiver under such title; and 

6 ‘‘(2) the Indian Health Program or Urban In7 dian Organization that is funded in whole or in part 

8 by the Service, or a consortium thereof, has estab9 lished a medicaid managed care organization or a 

10 primary care case manager that meets quality stand11 ards equivalent to those required of such an organi12 zation or manager under such section or waiver, 

13 the State shall enter into an agreement under such section 

14 with the Service, Indian Tribe, Tribal Organization, or 

15 Urban Indian Organization, or such consortium, to serve 

16 as a medicaid managed care organization or a primary 

17 care case manager, respectively with respect to Indians 

18 served by such entity. In carrying out this subsection, the 

19 Secretary and the State may waive requirements regard20 ing enrollment, capitalization, and such other matters that 

21 might otherwise prevent the application of the previous 

22 sentence. 

23 ‘‘SEC. 414. NAVAJO NATION MEDICAID AGENCY. 

24 ‘‘(a) IN GENERAL.—Notwithstanding any other pro25 vision of law, the Secretary is authorized to treat the Nav-
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1 ajo Nation as a State for the purposes of title XIX of 

2 the Social Security Act, to provide services to Indians liv3 ing within the boundaries of the Navajo Nation. 

4 ‘‘(b) ASSIGNMENT AND PAYMENT.—Notwithstanding 

5 any other provision of law, the Secretary may assign and 

6 pay all expenditures for the provision of services to Indi7 ans living within the boundaries of the Navajo Nation 

8 under title XIX of the Social Security Act and related ad9 ministrative funds under such title, which are currently 

10 paid to or would otherwise be paid to the States of Ari11 zona, New Mexico, and Utah, to an entity established by 

12 the Navajo Nation and approved by the Secretary, which 

13 shall be denominated the Navajo Nation Medicaid Agency. 

14 ‘‘(c) AUTHORITY.—The Navajo Nation Medicaid 

15 Agency shall serve Indians living within the boundaries of 

16 the Navajo Nation and shall have the same authority and 

17 perform the same functions as other single State medicaid 

18 agencies responsible for the administration of the State 

19 plan under title XIX of the Social Security Act. 

20 ‘‘(d) TECHNICAL ASSISTANCE.—The Secretary may 

21 directly assist the Navajo Nation in the development and 

22 implementation of a Navajo Nation Medicaid Agency for 

23 the administration, eligibility, payment, and delivery of 

24 medical assistance under title XIX of the Social Security 

25 Act (which shall, for purposes of reimbursement to such
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1 Nation, include Western and traditional Navajo healing 

2 services) within the Navajo Nation. 

3 ‘‘(e) FMAP.—Notwithstanding section 1905(b) of 

4 the Social Security Act, the Federal medical assistance 

5 percentage shall be 100 per centum with respect to 

6 amounts the Navajo Nation Medicaid Agency expends for 

7 medical assistance for services and for related administra8 tive costs. 

9 ‘‘(f) DEMONSTRATION FUNDING.—The Secretary is 

10 further authorized to assist the Navajo Nation by pro11 viding funding including demonstration grant funding for 

12 this project. 

13 ‘‘(g) WAIVER AUTHORITY.—The Secretary shall have 

14 the authority to waive applicable provisions of title XIX 

15 of the Social Security Act to establish, develop, and imple16 ment the Navajo Nation Medicaid Agency. 

17 ‘‘(h) OPTIONAL APPLICATION TO SCHIP.—In the 

18 option of the Navajo Nation, the Secretary is authorized 

19 to treat the Navajo Nation as a State for the purposes 

20 of title XXI of the Social Security Act (relating to the 

21 State children’s health insurance program) under terms 

22 equivalent to those described in subsections (a) through 

23 (g). 
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1 ‘‘SEC. 415. AUTHORIZATION OF APPROPRIATIONS. 

2 ‘‘There are authorized to be appropriated such sums 

3 as may be necessary for each fiscal year through fiscal 

4 year 2015 to carry out this title.

5 ‘‘TITLE V—HEALTH SERVICES 

6 FOR URBAN INDIANS 

7 ‘‘SEC. 501. PURPOSE. 

8 ‘‘The purpose of this title is to establish programs 

9 in Urban Centers to make health services more accessible 

10 and available to Urban Indians. 

11 ‘‘SEC. 502. CONTRACTS WITH, AND GRANTS TO, URBAN IN12 DIAN ORGANIZATIONS. 

13 ‘‘Under authority of the Act of November 2, 1921 

14 (25 U.S.C. 13; popularly known as the Snyder Act), the 

15 Secretary, acting through the Service, shall enter into con16 tracts with, or make grants to, Urban Indian Organiza17 tions to assist such organizations in the establishment and 

18 administration, within Urban Centers, of programs which 

19 meet the requirements set forth in this title. Subject to 

20 section 506, the Secretary, acting through the Service, 

21 shall include such conditions as the Secretary considers 

22 necessary to effect the purpose of this title in any contract 

23 into which the Secretary enters with, or in any grant the 

24 Secretary makes to, any Urban Indian Organization pur25 suant to this title. 
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1 ‘‘SEC. 503. CONTRACTS AND GRANTS FOR THE PROVISION 

2 OF HEALTH CARE AND REFERRAL SERVICES. 

3 ‘‘(a) REQUIREMENTS FOR GRANTS AND CON4 TRACTS.—Under authority of the Act of November 2, 

5 1921 (25 U.S.C. 13; popularly known as the Snyder Act), 

6 the Secretary, acting through the Service, shall enter into 

7 contracts with, and make grants to, Urban Indian Organi8 zations for the provision of health care and referral serv9 ices for Urban Indians. Any such contract or grant shall 

10 include requirements that the Urban Indian Organization 

11 successfully undertake to—

12 ‘‘(1) estimate the population of Urban Indians 

13 residing in the Urban Center or centers that the or14 ganization proposes to serve who are or could be re15 cipients of health care or referral services; 

16 ‘‘(2) estimate the current health status of 

17 Urban Indians residing in such Urban Center or 

18 centers; 

19 ‘‘(3) estimate the current health care needs of 

20 Urban Indians residing in such Urban Center or 

21 centers; 

22 ‘‘(4) provide basic health education, including 

23 health promotion and disease prevention education, 

24 to Urban Indians; 

25 ‘‘(5) make recommendations to the Secretary 

26 and Federal, State, local, and other resource agen-
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1 cies on methods of improving health service pro2 grams to meet the needs of Urban Indians; and 

3 ‘‘(6) where necessary, provide, or enter into 

4 contracts for the provision of, health care services 

5 for Urban Indians. 

6 ‘‘(b) CRITERIA.—The Secretary, acting through the 

7 Service, shall by regulation adopted pursuant to section 

8 520 prescribe the criteria for selecting Urban Indian Or9 ganizations to enter into contracts or receive grants under 

10 this section. Such criteria shall, among other factors, in11 clude—

12 ‘‘(1) the extent of unmet health care needs of 

13 Urban Indians in the Urban Center or centers in14 volved; 

15 ‘‘(2) the size of the Urban Indian population in 

16 the Urban Center or centers involved; 

17 ‘‘(3) the extent, if any, to which the activities 

18 set forth in subsection (a) would duplicate any 

19 project funded under this title; 

20 ‘‘(4) the capability of an Urban Indian Organi21 zation to perform the activities set forth in sub22 section (a) and to enter into a contract with the Sec23 retary or to meet the requirements for receiving a 

24 grant under this section; 
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1 ‘‘(5) the satisfactory performance and success2 ful completion by an Urban Indian Organization of 

3 other contracts with the Secretary under this title; 

4 ‘‘(6) the appropriateness and likely effectiveness 

5 of conducting the activities set forth in subsection 

6 (a) in an Urban Center or centers; and 

7 ‘‘(7) the extent of existing or likely future par8 ticipation in the activities set forth in subsection (a) 

9 by appropriate health and health-related Federal, 

10 State, local, and other agencies. 

11 ‘‘(c) ACCESS TO HEALTH PROMOTION AND DISEASE

12 PREVENTION PROGRAMS.—The Secretary, acting through 

13 the Service, shall facilitate access to or provide health pro14 motion and disease prevention services for Urban Indians 

15 through grants made to Urban Indian Organizations ad16 ministering contracts entered into or receiving grants 

17 under subsection (a). 

18 ‘‘(d) IMMUNIZATION SERVICES.—

19 ‘‘(1) ACCESS OR SERVICES PROVIDED.—The 

20 Secretary, acting through the Service, shall facilitate 

21 access to, or provide, immunization services for 

22 Urban Indians through grants made to Urban In23 dian Organizations administering contracts entered 

24 into or receiving grants under this section.
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1 ‘‘(2) DEFINITION.—For purposes of this sub2 section, the term ‘immunization services’ means 

3 services to provide without charge immunizations 

4 against vaccine-preventable diseases. 

5 ‘‘(e) MENTAL HEALTH SERVICES.—

6 ‘‘(1) ACCESS OR SERVICES PROVIDED.—The 

7 Secretary, acting through the Service, shall facilitate 

8 access to, or provide, mental health services for 

9 Urban Indians through grants made to Urban In10 dian Organizations administering contracts entered 

11 into or receiving grants under subsection (a). 

12 ‘‘(2) ASSESSMENT REQUIRED.—Except as pro13 vided by paragraph (3)(A), a grant may not be made 

14 under this subsection to an Urban Indian Organiza15 tion until that organization has prepared, and the 

16 Service has approved, an assessment of the fol17 lowing: 

18 ‘‘(A) The mental health needs of the 

19 Urban Indian population concerned. 

20 ‘‘(B) The mental health services and other 

21 related resources available to that population. 

22 ‘‘(C) The barriers to obtaining those serv23 ices and resources. 

24 ‘‘(D) The needs that are unmet by such 

25 services and resources. 
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1 ‘‘(3) PURPOSES OF GRANTS.—Grants may be 

2 made under this subsection for the following: 

3 ‘‘(A) To prepare assessments required 

4 under paragraph (2). 

5 ‘‘(B) To provide outreach, educational, and 

6 referral services to Urban Indians regarding the 

7 availability of direct behavioral health services, 

8 to educate Urban Indians about behavioral 

9 health issues and services, and effect coordina10 tion with existing behavioral health providers in 

11 order to improve services to Urban Indians. 

12 ‘‘(C) To provide outpatient behavioral 

13 health services to Urban Indians, including the 

14 identification and assessment of illness, thera15 peutic treatments, case management, support 

16 groups, family treatment, and other treatment. 

17 ‘‘(D) To develop innovative behavioral 

18 health service delivery models which incorporate 

19 Indian cultural support systems and resources. 

20 ‘‘(f) PREVENTION OF CHILD ABUSE.—

21 ‘‘(1) ACCESS OR SERVICES PROVIDED.—The 

22 Secretary, acting through the Service, shall facilitate 

23 access to or provide services for Urban Indians 

24 through grants to Urban Indian Organizations ad25 ministering contracts entered into or receiving 
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1 grants under subsection (a) to prevent and treat 

2 child abuse (including sexual abuse) among Urban 

3 Indians. 

4 ‘‘(2) EVALUATION REQUIRED.—Except as pro5 vided by paragraph (3)(A), a grant may not be made 

6 under this subsection to an Urban Indian Organiza7 tion until that organization has prepared, and the 

8 Service has approved, an assessment that documents 

9 the prevalence of child abuse in the Urban Indian 

10 population concerned and specifies the services and 

11 programs (which may not duplicate existing services 

12 and programs) for which the grant is requested. 

13 ‘‘(3) PURPOSES OF GRANTS.—Grants may be 

14 made under this subsection for the following: 

15 ‘‘(A) To prepare assessments required 

16 under paragraph (2). 

17 ‘‘(B) For the development of prevention, 

18 training, and education programs for Urban In19 dians, including child education, parent edu20 cation, provider training on identification and 

21 intervention, education on reporting require22 ments, prevention campaigns, and establishing 

23 service networks of all those involved in Indian 

24 child protection. 
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1 ‘‘(C) To provide direct outpatient treat2 ment services (including individual treatment, 

3 family treatment, group therapy, and support 

4 groups) to Urban Indians who are child victims 

5 of abuse (including sexual abuse) or adult sur6 vivors of child sexual abuse, to the families of 

7 such child victims, and to Urban Indian per8 petrators of child abuse (including sexual 

9 abuse). 

10 ‘‘(4) CONSIDERATIONS WHEN MAKING

11 GRANTS.—In making grants to carry out this sub12 section, the Secretary shall take into consideration—

13 ‘‘(A) the support for the Urban Indian Or14 ganization demonstrated by the child protection 

15 authorities in the area, including committees or 

16 other services funded under the Indian Child 

17 Welfare Act of 1978 (25 U.S.C. 1901 et seq.), 

18 if any; 

19 ‘‘(B) the capability and expertise dem20 onstrated by the Urban Indian Organization to 

21 address the complex problem of child sexual 

22 abuse in the community; and 

23 ‘‘(C) the assessment required under para24 graph (2). 
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1 ‘‘(g) OTHER GRANTS.—The Secretary, acting 

2 through the Service, may enter into a contract with or 

3 make grants to an Urban Indian Organization that pro4 vides or arranges for the provision of health care services 

5 (through satellite facilities, provider networks, or other6 wise) to Urban Indians in more than 1 Urban Center. 

7 ‘‘SEC. 504. CONTRACTS AND GRANTS FOR THE DETERMINA8 TION OF UNMET HEALTH CARE NEEDS. 

9 ‘‘(a) GRANTS AND CONTRACTS AUTHORIZED.—

10 Under authority of the Act of November 2, 1921 (25 

11 U.S.C. 13; popularly known as the Snyder Act), the Sec12 retary, acting through the Service, may enter into con13 tracts with or make grants to Urban Indian Organizations 

14 situated in Urban Centers for which contracts have not 

15 been entered into or grants have not been made under sec16 tion 503. 

17 ‘‘(b) PURPOSE.—The purpose of a contract or grant 

18 made under this section shall be the determination of the 

19 matters described in subsection (c)(1) in order to assist 

20 the Secretary in assessing the health status and health 

21 care needs of Urban Indians in the Urban Center involved 

22 and determining whether the Secretary should enter into 

23 a contract or make a grant under section 503 with respect 

24 to the Urban Indian Organization which the Secretary has
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1 entered into a contract with, or made a grant to, under 

2 this section. 

3 ‘‘(c) GRANT AND CONTRACT REQUIREMENTS.—Any 

4 contract entered into, or grant made, by the Secretary 

5 under this section shall include requirements that—

6 ‘‘(1) the Urban Indian Organization success7 fully undertakes to—

8 ‘‘(A) document the health care status and 

9 unmet health care needs of Urban Indians in 

10 the Urban Center involved; and 

11 ‘‘(B) with respect to Urban Indians in the 

12 Urban Center involved, determine the matters 

13 described in paragraphs (2), (3), (4), and (7) of 

14 section 503(b); and 

15 ‘‘(2) the Urban Indian Organization complete 

16 performance of the contract, or carry out the re17 quirements of the grant, within 1 year after the date 

18 on which the Secretary and such organization enter 

19 into such contract, or within 1 year after such orga20 nization receives such grant, whichever is applicable. 

21 ‘‘(d) NO RENEWALS.—The Secretary may not renew 

22 any contract entered into or grant made under this sec23 tion. 
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1 ‘‘SEC. 505. EVALUATIONS; RENEWALS. 

2 ‘‘(a) PROCEDURES FOR EVALUATIONS.—The Sec3 retary, acting through the Service, shall develop proce4 dures to evaluate compliance with grant requirements and 

5 compliance with and performance of contracts entered into 

6 by Urban Indian Organizations under this title. Such pro7 cedures shall include provisions for carrying out the re8 quirements of this section. 

9 ‘‘(b) EVALUATIONS.—The Secretary, acting through 

10 the Service, shall evaluate the compliance of each Urban 

11 Indian Organization which has entered into a contract or 

12 received a grant under section 503 with the terms of such 

13 contract or grant. For purposes of this evaluation, in de14 termining the capacity of an Urban Indian Organization 

15 to deliver quality patient care the Secretary shall, at the 

16 option of the organization—

17 ‘‘(1) acting through the Service, conduct an an18 nual onsite evaluation of the organization; or 

19 ‘‘(2) accept in lieu of such onsite evaluation evi20 dence of the organization’s provisional or full accred21 itation by a private independent entity recognized by 

22 the Secretary for purposes of conducting quality re23 views of providers participating in the Medicare pro24 gram under title XVIII of the Social Security Act. 

25 ‘‘(c) NONCOMPLIANCE; UNSATISFACTORY PERFORM26 ANCE.—If, as a result of the evaluations conducted under 
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1 this section, the Secretary determines that an Urban In2 dian Organization has not complied with the requirements 

3 of a grant or complied with or satisfactorily performed a 

4 contract under section 503, the Secretary shall, prior to 

5 renewing such contract or grant, attempt to resolve with 

6 the organization the areas of noncompliance or unsatisfac7 tory performance and modify the contract or grant to pre8 vent future occurrences of noncompliance or unsatisfac9 tory performance. If the Secretary determines that the 

10 noncompliance or unsatisfactory performance cannot be 

11 resolved and prevented in the future, the Secretary shall 

12 not renew the contract or grant with the organization and 

13 is authorized to enter into a contract or make a grant 

14 under section 503 with another Urban Indian Organiza15 tion which is situated in the same Urban Center as the 

16 Urban Indian Organization whose contract or grant is not 

17 renewed under this section. 

18 ‘‘(d) CONSIDERATIONS FOR RENEWALS.—In deter19 mining whether to renew a contract or grant with an 

20 Urban Indian Organization under section 503 which has 

21 completed performance of a contract or grant under sec22 tion 504, the Secretary shall review the records of the 

23 Urban Indian Organization, the reports submitted under 

24 section 507, and shall consider the results of the onsite 

25 evaluations or accreditations under subsection (b). 
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1 ‘‘SEC. 506. OTHER CONTRACT AND GRANT REQUIREMENTS. 

2 ‘‘(a) PROCUREMENT.—Contracts with Urban Indian 

3 Organizations entered into pursuant to this title shall be 

4 in accordance with all Federal contracting laws and regu5 lations relating to procurement except that in the discre6 tion of the Secretary, such contracts may be negotiated 

7 without advertising and need not conform to the provisions 

8 of sections 1304, 3131, and 3133 of title 40, United 

9 States Code. 

10 ‘‘(b) PAYMENTS UNDER CONTRACTS OR GRANTS.—

11 Payments under any contracts or grants pursuant to this 

12 title shall, notwithstanding any term or condition of such 

13 contract or grant—

14 ‘‘(1) be made in their entirety by the Secretary 

15 to the Urban Indian Organization by no later than 

16 the end of the first 30 days of the funding period 

17 with respect to which the payments apply, unless the 

18 Secretary determines through an evaluation under 

19 section 505 that the organization is not capable of 

20 administering such payments in their entirety; and 

21 ‘‘(2) if any portion thereof is unexpended by the 

22 Urban Indian Organization during the funding pe23 riod with respect to which the payments initially 

24 apply, shall be carried forward for expenditure with 

25 respect to allowable or reimbursable costs incurred 

26 by the organization during 1 or more subsequent
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1 funding periods without additional justification or 

2 documentation by the organization as a condition of 

3 carrying forward the availability for expenditure of 

4 such funds. 

5 ‘‘(c) REVISION OR AMENDMENT OF CONTRACTS.—

6 Notwithstanding any provision of law to the contrary, the 

7 Secretary may, at the request or consent of an Urban In8 dian Organization, revise or amend any contract entered 

9 into by the Secretary with such organization under this 

10 title as necessary to carry out the purposes of this title. 

11 ‘‘(d) FAIR AND UNIFORM SERVICES AND ASSIST12 ANCE.—Contracts with or grants to Urban Indian Organi13 zations and regulations adopted pursuant to this title shall 

14 include provisions to assure the fair and uniform provision 

15 to Urban Indians of services and assistance under such 

16 contracts or grants by such organizations. 

17 ‘‘SEC. 507. REPORTS AND RECORDS. 

18 ‘‘(a) REPORTS.—For each fiscal year during which 

19 an Urban Indian Organization receives or expends funds 

20 pursuant to a contract entered into or a grant received 

21 pursuant to this title, such Urban Indian Organization 

22 shall submit to the Secretary not more frequently than 

23 every 6 months, a report that includes the following: 
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1 ‘‘(1) In the case of a contract or grant under 

2 section 503, recommendations pursuant to section 

3 503(a)(5). 

4 ‘‘(2) Information on activities conducted by the 

5 organization pursuant to the contract or grant. 

6 ‘‘(3) An accounting of the amounts and purpose 

7 for which Federal funds were expended. 

8 ‘‘(4) A minimum set of data, using uniformly 

9 defined elements, that is specified by the Secretary 

10 in consultation, consistent with section 514, with 

11 Urban Indian Organizations. 

12 ‘‘(b) AUDIT.—The reports and records of the Urban 

13 Indian Organization with respect to a contract or grant 

14 under this title shall be subject to audit by the Secretary 

15 and the Comptroller General of the United States. 

16 ‘‘(c) COSTS OF AUDITS.—The Secretary shall allow 

17 as a cost of any contract or grant entered into or awarded 

18 under section 502 or 503 the cost of an annual inde19 pendent financial audit conducted by—

20 ‘‘(1) a certified public accountant; or 

21 ‘‘(2) a certified public accounting firm qualified 

22 to conduct Federal compliance audits. 

23 ‘‘SEC. 508. LIMITATION ON CONTRACT AUTHORITY. 

24 ‘‘The authority of the Secretary to enter into con25 tracts or to award grants under this title shall be to the 
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1 extent, and in an amount, provided for in appropriation 

2 Acts. 

3 ‘‘SEC. 509. FACILITIES. 

4 ‘‘(a) GRANTS.—The Secretary, acting through the 

5 Service, may make grants to contractors or grant recipi6 ents under this title for the lease, purchase, renovation, 

7 construction, or expansion of facilities, including leased fa8 cilities, in order to assist such contractors or grant recipi9 ents in complying with applicable licensure or certification 

10 requirements. 

11 ‘‘(b) LOANS.—The Secretary, acting through the 

12 Service or through the Health Resources and Services Ad13 ministration, may provide to contractors or grant recipi14 ents under this title loans from the Urban Indian Health 

15 Care Facilities Revolving Loan Fund described in sub16 section (c), or guarantees for loans, for the construction, 

17 renovation, expansion, or purchase of health care facilities, 

18 subject to the following requirements: 

19 ‘‘(1) The principal amount of a loan or loan 

20 guarantee may cover 100 percent of the costs (other 

21 than staffing) relating to the facility, including plan22 ning, design, financing, site land development, con23 struction, rehabilitation, renovation, conversion, 

24 medical equipment, furnishings, and capital pur25 chase. 
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1 ‘‘(2) The total of the principal of loans and loan 

2 guarantees, respectively, outstanding at any one 

3 time shall not exceed such limitations as may be 

4 specified in appropriation Acts. 

5 ‘‘(3) The loan or loan guarantee may have a 

6 term of the shorter of the estimated useful life of the 

7 facility or 25 years. 

8 ‘‘(4) An Urban Indian Organization may as9 sign, and the Secretary may accept assignment of, 

10 the revenue of the Urban Indian Organization as se11 curity for a loan or loan guarantee under this sub12 section. 

13 ‘‘(5) The Secretary shall not collect application, 

14 processing, or similar fees from Urban Indian Orga15 nizations applying for loans or loan guarantees 

16 under this subsection. 

17 ‘‘(c) FUND.—

18 ‘‘(1) ESTABLISHMENT.—There is established in 

19 the Treasury of the United States a fund to be 

20 known as the Urban Indian Health Care Facilities 

21 Revolving Loan Fund (hereafter in this section re22 ferred to as the ‘‘URLF’’). The URLF shall consist 

23 of—

24 ‘‘(A) such amounts as may be appropriated 

25 to the URLF;
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1 ‘‘(B) amounts received from Urban Indian 

2 Organizations in repayment of loans made to 

3 such organizations under paragraph (2); and 

4 ‘‘(C) interest earned on amounts in the 

5 URLF under paragraph (3). 

6 ‘‘(2) USE OF AMOUNT IN FUND.—Amounts in 

7 the URLF may be expended by the Secretary, acting 

8 through the Service or the Health Resources and 

9 Services Administration, to make loans available to 

10 Urban Indian Organizations receiving grants or con11 tracts under this title for the purposes, and subject 

12 to the requirements, described in subsection (b). 

13 Amounts appropriated to the URLF, amounts re14 ceived from Urban Indian Organizations in repay15 ment of loans, and interest on amounts in the 

16 URLF shall remain available until expended. 

17 ‘‘(3) INVESTMENT OF AMOUNTS IN FUND.—The 

18 Secretary of the Treasury shall invest such amounts 

19 of the URLF as such Secretary determines are not 

20 required to meet current withdrawals from the 

21 URLF. Such investments may be made only in in22 terest-bearing obligations of the United States. For 

23 such purpose, such obligations may be acquired on 

24 original issue at the issue price or by purchase of 

25 outstanding obligations at the market price. Any ob-
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1 ligation acquired by the URLF may be sold by the 

2 Secretary of the Treasury at the market price. 

3 ‘‘(4) INITIAL FUNDS.—There are authorized to 

4 be appropriated such sums as may be necessary to 

5 initiate the URLF. For each fiscal year after the ini6 tial year in which funds are appropriated to the 

7 URLF, there is authorized to be appropriated an 

8 amount equal to the sum of the amount collected by 

9 the URLF during the preceding fiscal year and all 

10 accrued interest. 

11 ‘‘SEC. 510. OFFICE OF URBAN INDIAN HEALTH. 

12 ‘‘There is hereby established within the Service an 

13 Office of Urban Indian Health, which shall be responsible 

14 for—

15 ‘‘(1) carrying out the provisions of this title; 

16 ‘‘(2) providing central oversight of the pro17 grams and services authorized under this title; and 

18 ‘‘(3) providing technical assistance to Urban In19 dian Organizations. 

20 ‘‘SEC. 511. GRANTS FOR ALCOHOL AND SUBSTANCE ABUSE21 RELATED SERVICES. 

22 ‘‘(a) GRANTS AUTHORIZED.—The Secretary, acting 

23 through the Service, may make grants for the provision 

24 of health-related services in prevention of, treatment of, 

25 rehabilitation of, or school- and community-based edu-
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1 cation regarding, alcohol and substance abuse in Urban 

2 Centers to those Urban Indian Organizations with which 

3 the Secretary has entered into a contract under this title 

4 or under section 201. 

5 ‘‘(b) GOALS.—Each grant made pursuant to sub6 section (a) shall set forth the goals to be accomplished 

7 pursuant to the grant. The goals shall be specific to each 

8 grant as agreed to between the Secretary and the grantee. 

9 ‘‘(c) CRITERIA.—The Secretary shall establish cri10 teria for the grants made under subsection (a), including 

11 criteria relating to the following: 

12 ‘‘(1) The size of the Urban Indian population. 

13 ‘‘(2) Capability of the organization to ade14 quately perform the activities required under the 

15 grant. 

16 ‘‘(3) Satisfactory performance standards for the 

17 organization in meeting the goals set forth in such 

18 grant. The standards shall be negotiated and agreed 

19 to between the Secretary and the grantee on a 

20 grant-by-grant basis. 

21 ‘‘(4) Identification of the need for services. 

22 ‘‘(d) ALLOCATION OF GRANTS.—The Secretary shall 

23 develop a methodology for allocating grants made pursu24 ant to this section based on the criteria established pursu25 ant to subsection (c). 
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1 ‘‘(e) GRANTS SUBJECT TO CRITERIA.—Any funds re2 ceived by an Urban Indian Organization under this Act 

3 for substance abuse prevention, treatment, and rehabilita4 tion shall be subject to the criteria set forth in subsection 

5 (c). 

6 ‘‘SEC. 512. TREATMENT OF CERTAIN DEMONSTRATION 

7 PROJECTS. 

8 ‘‘Notwithstanding any other provision of law, the 

9 Tulsa Clinic and Oklahoma City Clinic demonstration 

10 projects shall—

11 ‘‘(1) be permanent programs within the Serv12 ice’s direct care program; 

13 ‘‘(2) continue to be treated as Service Units in 

14 the allocation of resources and coordination of care; 

15 and 

16 ‘‘(3) shall be subject to the provisions of the In17 dian Self-Determination and Education Assistance 

18 Act, except that the programs shall not be divisible. 

19 ‘‘SEC. 513. URBAN NIAAA TRANSFERRED PROGRAMS. 

20 ‘‘(a) GRANTS AND CONTRACTS.—The Secretary, 

21 through the Office of Urban Indian Health, shall make 

22 grants or enter into contracts with Urban Indian Organi23 zations for the administration of Urban Indian alcohol 

24 programs that were originally established under the Na25 tional Institute on Alcoholism and Alcohol Abuse (here-
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1 after in this section referred to as ‘NIAAA’) and trans2 ferred to the Service. Such grants and contracts shall be3 come effective no later than September 30, 2004. 

4 ‘‘(b) USE OF FUNDS.—Grants provided or contracts 

5 entered into under this section shall be used to provide 

6 support for the continuation of alcohol prevention and 

7 treatment services for Urban Indian populations and such 

8 other objectives as are agreed upon between the Service 

9 and a recipient of a grant or contract under this section. 

10 ‘‘(c) ELIGIBILITY.—Urban Indian Organizations that 

11 operate Indian alcohol programs originally funded under 

12 the NIAAA and subsequently transferred to the Service 

13 are eligible for grants or contracts under this section. 

14 ‘‘(d) REPORT.—The Secretary shall evaluate and re15 port to Congress on the activities of programs funded 

16 under this section not less than every 5 years. 

17 ‘‘SEC. 514. CONSULTATION WITH URBAN INDIAN ORGANIZA18 TIONS. 

19 ‘‘(a) IN GENERAL.—The Secretary shall ensure that 

20 the Service, the Centers for Medicare & Medicaid Services, 

21 and other operating divisions and staff divisions of the De22 partment consult, to the greatest extent practicable, with 

23 Urban Indian Organizations prior to taking any action, 

24 or approving Federal financial assistance for any action
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1 of a State, that may affect Urban Indians or Urban Indian 

2 Organizations. 

3 ‘‘(b) DEFINITION OF CONSULTATION.—For purposes 

4 of subsection (a), consultation is the open and free ex5 change of information and opinion among Urban Indian 

6 Organizations and the operating and staff divisions of the 

7 Department which leads to mutual understanding and 

8 comprehension and which emphasizes trust, respect, and 

9 shared responsibility. 

10 ‘‘SEC. 515. FEDERAL TORT CLAIM ACT COVERAGE. 

11 ‘‘(a) IN GENERAL.—With respect to claims resulting 

12 from the performance of functions during fiscal year 2004 

13 and thereafter, or claims asserted after September 30, 

14 2003, but resulting from the performance of functions 

15 prior to fiscal year 2004, under a contract, grant agree16 ment, or any other agreement authorized under this title, 

17 an Urban Indian Organization is deemed hereafter to be 

18 part of the Service in the Department of Health and 

19 Human Services while carrying out any such contract or 

20 agreement and its employees are deemed employees of the 

21 Service while acting within the scope of their employment 

22 in carrying out the contract or agreement. After Sep23 tember 30, 2003, any civil action or proceeding involving 

24 such claims brought hereafter against any Urban Indian 

25 Organization or any employee of such Urban Indian Orga-
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1 nization covered by this provision shall be deemed to be 

2 an action against the United States and will be defended 

3 by the Attorney General and be afforded the full protec4 tion and coverage of the Federal Tort Claims Act (28 

5 U.S.C. 1346(b), 2671 et seq.). 

6 ‘‘(b) CLAIMS RESULTING FROM PERFORMANCE OF

7 CONTRACT OR GRANT.—Beginning with the fiscal year 

8 ending September 30, 2003, and thereafter, the appro9 priate Secretary shall request through annual appropria10 tions funds sufficient to reimburse the Treasury for any 

11 claims paid in the prior fiscal year pursuant to the fore12 going provisions. 

13 ‘‘(c) EFFECT ON ISDEAA.—Nothing in this section 

14 shall in any way affect the provisions of section 102(d) 

15 of the Indian Self-Determination and Education Assist16 ance Act of 1975 (25 U.S.C. 450f(d)). 

17 ‘‘SEC. 516. URBAN YOUTH TREATMENT CENTER DEM18 ONSTRATION. 

19 ‘‘(a) CONSTRUCTION AND OPERATION.—The Sec20 retary, acting through the Service, through grant or con21 tract, shall make payment for the construction and oper22 ation of at least 2 residential treatment centers in each 

23 State described in subsection (b) to demonstrate the provi24 sion of alcohol and substance abuse treatment services to 
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1 Urban Indian youth in a culturally competent residential 

2 setting. 

3 ‘‘(b) DEFINITION OF STATE.—A State described in 

4 this subsection is a State in which—

5 ‘‘(1) there resides Urban Indian youth with 

6 need for alcohol and substance abuse treatment serv7 ices in a residential setting; and 

8 ‘‘(2) there is a significant shortage of culturally 

9 competent residential treatment services for Urban 

10 Indian youth. 

11 ‘‘SEC. 517. USE OF FEDERAL GOVERNMENT FACILITIES AND 

12 SOURCES OF SUPPLY. 

13 ‘‘(a) AUTHORIZATION FOR USE.—The Secretary, act14 ing through the Service, shall allow an Urban Indian Or15 ganization that has entered into a contract or received a 

16 grant pursuant to this title, in carrying out such contract 

17 or grant, to use existing facilities and all equipment there18 in or pertaining thereto and other personal property 

19 owned by the Federal Government within the Secretary’s 

20 jurisdiction under such terms and conditions as may be 

21 agreed upon for their use and maintenance. 

22 ‘‘(b) DONATIONS.—Subject to subsection (d), the 

23 Secretary may donate to an Urban Indian Organization 

24 that has entered into a contract or received a grant pursu25 ant to this title any personal or real property determined 
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1 to be excess to the needs of the Service or the General 

2 Services Administration for purposes of carrying out the 

3 contract or grant. 

4 ‘‘(c) ACQUISITION OF PROPERTY FOR DONATION.—

5 The Secretary may acquire excess or surplus government 

6 personal or real property for donation (subject to sub7 section (d)), to an Urban Indian Organization that has 

8 entered into a contract or received a grant pursuant to 

9 this title if the Secretary determines that the property is 

10 appropriate for use by the Urban Indian Organization for 

11 a purpose for which a contract or grant is authorized 

12 under this title. 

13 ‘‘(d) PRIORITY.—In the event that the Secretary re14 ceives a request for donation of a specific item of personal 

15 or real property described in subsection (b) or (c) from 

16 both an Urban Indian Organization and from an Indian 

17 Tribe or Tribal Organization, the Secretary shall give pri18 ority to the request for donation of the Indian Tribe or 

19 Tribal Organization if the Secretary receives the request 

20 from the Indian Tribe or Tribal Organization before the 

21 date the Secretary transfers title to the property or, if ear22 lier, the date the Secretary transfers the property phys23 ically to the Urban Indian Organization. 

24 ‘‘(e) URBAN INDIAN ORGANIZATIONS DEEMED EX25 ECUTIVE AGENCY FOR CERTAIN PURPOSES.—For pur-
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1 poses of section 501 of title 40, United States Code, (relat2 ing to Federal sources of supply, including lodging pro3 viders, airlines, and other transportation providers), an 

4 Urban Indian Organization that has entered into a con5 tract or received a grant pursuant to this title shall be 

6 deemed an executive agency when carrying out such con7 tract or grant, and the employees of the Urban Indian 

8 Organization shall be eligible to have access to such 

9 sources of supply on the same basis as employees of an 

10 executive agency have such access. 

11 ‘‘SEC. 518. GRANTS FOR DIABETES PREVENTION, TREAT12 MENT, AND CONTROL. 

13 ‘‘(a) GRANTS AUTHORIZED.—The Secretary may 

14 make grants to those Urban Indian Organizations that 

15 have entered into a contract or have received a grant 

16 under this title for the provision of services for the preven17 tion and treatment of, and control of the complications 

18 resulting from, diabetes among Urban Indians. 

19 ‘‘(b) GOALS.—Each grant made pursuant to sub20 section (a) shall set forth the goals to be accomplished 

21 under the grant. The goals shall be specific to each grant 

22 as agreed to between the Secretary and the grantee. 

23 ‘‘(c) ESTABLISHMENT OF CRITERIA.—The Secretary 

24 shall establish criteria for the grants made under sub25 section (a) relating to the following:
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1 ‘‘(1) The size and location of the Urban Indian 

2 population to be served. 

3 ‘‘(2) The need for prevention of and treatment 

4 of, and control of the complications resulting from, 

5 diabetes among the Urban Indian population to be 

6 served. 

7 ‘‘(3) Performance standards for the organiza8 tion in meeting the goals set forth in such grant 

9 that are negotiated and agreed to by the Secretary 

10 and the grantee. 

11 ‘‘(4) The capability of the organization to ade12 quately perform the activities required under the 

13 grant. 

14 ‘‘(5) The willingness of the organization to col15 laborate with the registry, if any, established by the 

16 Secretary under section 204(e) in the Area Office of 

17 the Service in which the organization is located. 

18 ‘‘(d) FUNDS SUBJECT TO CRITERIA.—Any funds re19 ceived by an Urban Indian Organization under this Act 

20 for the prevention, treatment, and control of diabetes 

21 among Urban Indians shall be subject to the criteria devel22 oped by the Secretary under subsection (c). 

23 ‘‘SEC. 519. COMMUNITY HEALTH REPRESENTATIVES. 

24 ‘‘The Secretary, acting through the Service, may 

25 enter into contracts with, and make grants to, Urban In-
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1 dian Organizations for the employment of Indians trained 

2 as health service providers through the Community Health 

3 Representatives Program under section 109 in the provi4 sion of health care, health promotion, and disease preven5 tion services to Urban Indians. 

6 ‘‘SEC. 520. REGULATIONS. 

7 ‘‘(a) REQUIREMENTS FOR REGULATIONS.—The Sec8 retary may promulgate regulations to implement the provi9 sions of this title in accordance with the following: 

10 ‘‘(1) Proposed regulations to implement this 

11 Act shall be published in the Federal Register by the 

12 Secretary no later than 9 months after the date of 

13 the enactment of this Act and shall have no less 

14 than a 4-month comment period. 

15 ‘‘(2) The authority to promulgate regulations 

16 under this Act shall expire 18 months from the date 

17 of the enactment of this Act. 

18 ‘‘(b) EFFECTIVE DATE OF TITLE.—The amendments 

19 to this title made by the Indian Health Care Improvement 

20 Act Amendments of 2003 shall be effective on the date 

21 of the enactment of such amendments, regardless of 

22 whether the Secretary has promulgated regulations imple23 menting such amendments have been promulgated. 
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1 ‘‘SEC. 521. ELIGIBILITY FOR SERVICES. 

2 ‘‘Urban Indians shall be eligible for health care or 

3 referral services provided pursuant to this title. 

4 ‘‘SEC. 522. AUTHORIZATION OF APPROPRIATIONS. 

5 ‘‘There are authorized to be appropriated such sums 

6 as may be necessary for each fiscal year through fiscal 

7 year 2015 to carry out this title. 

8 ‘‘TITLE VI—ORGANIZATIONAL 

9 IMPROVEMENTS 

10 ‘‘SEC. 601. ESTABLISHMENT OF THE INDIAN HEALTH SERV11 ICE AS AN AGENCY OF THE PUBLIC HEALTH 

12 SERVICE.

13 ‘‘(a) ESTABLISHMENT.—In order to more effectively 

14 and efficiently carry out the responsibilities, authorities, 

15 and functions of the United States to provide health care 

16 services provided under Federal statute or treaties to Indi17 ans and Indian Tribes, there was established within the 

18 Public Health Service of the Department the Indian 

19 Health Service. 

20 ‘‘(b) DIRECTOR.—The Indian Health Service is an 

21 agency within the Public Health Service of the Depart22 ment, and shall not be an office, component, or unit of 

23 any other agency of the Department. The Indian Health 

24 Service shall be administered by a Director, who shall be 

25 appointed by the President, by and with the advice and 

26 consent of the Senate. The Director of the Indian Health 
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1 Service shall report to the Secretary through the Assistant 

2 Secretary for Health of the Department of Health and 

3 Human Services. Effective with respect to an individual 

4 appointed by the President, by and with the advice and 

5 consent of the Senate, after January 1, 1993, the term 

6 of service of the Director shall be 4 years. A Director may 

7 serve more than 1 term. 

8 ‘‘(c) DUTIES.—The Secretary shall carry out through 

9 the Director of the Indian Health Service—

10 ‘‘(1) all functions which were, on the day before 

11 the date of the enactment of the Indian Health Care 

12 Amendments of 1988, carried out by or under the 

13 direction of the individual serving as Director of the 

14 Indian Health Service on such day; 

15 ‘‘(2) all functions of the Secretary relating to 

16 the maintenance and operation of hospital and 

17 health facilities for Indians and the planning for, 

18 and provision and use of, health services for Indians; 

19 ‘‘(3) all health programs under which health 

20 care is provided to Indians based upon their status 

21 as Indians which are administered by the Secretary, 

22 including but not limited to programs under—

23 ‘‘(A) this Act; 

24 ‘‘(B) the Act of November 2, 1921 (25 

25 U.S.C. 13); 
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1 ‘‘(C) the Act of August 5, 1954 (42 U.S.C. 

2 2001 et seq.); 

3 ‘‘(D) the Act of August 16, 1957 (42 

4 U.S.C. 2005 et seq.); and 

5 ‘‘(E) the Indian Self-Determination and 

6 Education Assistance Act (25 U.S.C. 450 et 

7 seq.); and 

8 ‘‘(4) all scholarship and loan functions carried 

9 out under title I. 

10 ‘‘(d) AUTHORITIES.—(1) The Director shall have the 

11 authority—

12 ‘‘(A) except to the extent provided in paragraph 

13 (2), to appoint and compensate employees for the 

14 Service in accordance with title 5, United States 

15 Code; 

16 ‘‘(B) to enter into contracts for the procure17 ment of goods and services to carry out the func18 tions of the Service; and 

19 ‘‘(C) to manage, expend, and obligate all funds 

20 appropriated for the Service. 

21 ‘‘(2) Notwithstanding any other law, the provisions 

22 of section 12 of the Act of June 18, 1934 (48 Stat. 986; 

23 25 U.S.C. 472), shall apply to all personnel actions taken 

24 with respect to new positions created within the Service 

25 as a result of its establishment under subsection (a).
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1 ‘‘SEC. 602. AUTOMATED MANAGEMENT INFORMATION SYS2 TEM. 

3 ‘‘(a)(1) The Secretary shall establish an automated 

4 management information system for the Service. 

5 ‘‘(2) The information system established under para6 graph (1) shall include—

7 ‘‘(A) a financial management system; 

8 ‘‘(B) a patient care information system for each 

9 area served by the Service; 

10 ‘‘(C) a privacy component that protects the pri11 vacy of patient information held by, or on behalf of, 

12 the Service; 

13 ‘‘(D) a services-based cost accounting compo14 nent that provides estimates of the costs associated 

15 with the provision of specific medical treatments or 

16 services in each Area Office of the Service; 

17 ‘‘(E) an interface mechanism for patient billing 

18 and accounts receivable system; and 

19 ‘‘(F) a training component. 

20 ‘‘(b) The Secretary shall provide each Tribal Health 

21 Program automated management information systems 

22 which—

23 ‘‘(1) meet the management information needs 

24 of such Tribal Health Program with respect to the 

25 treatment by the Tribal Health Program of patients 

26 of the Service; and 
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1 ‘‘(2) meet the management information needs 

2 of the Service. 

3 ‘‘(c) Notwithstanding any other provision of law, each 

4 patient shall have reasonable access to the medical or 

5 health records of such patient which are held by, or on 

6 behalf of, the Service. 

7 ‘‘(d) The Director shall have the authority to enter 

8 into contracts, agreements, or joint ventures with other 

9 Federal agencies, States, private and nonprofit organiza10 tions, for the purpose of enhancing information technology 

11 in Indian Health Programs and facilities. 

12 ‘‘SEC. 603. AUTHORIZATION OF APPROPRIATIONS. 

13 ‘‘There are authorized to be appropriated such sums 

14 as may be necessary for each fiscal year through fiscal 

15 year 2015 to carry out this title.

16 ‘‘TITLE VII—BEHAVIORAL 

17 HEALTH PROGRAMS 

18 ‘‘SEC. 701. BEHAVIORAL HEALTH PREVENTION AND TREAT19 MENT SERVICES. 

20 ‘‘(a) PURPOSES.—The purposes of this section are as 

21 follows: 

22 ‘‘(1) To authorize and direct the Secretary, act23 ing through the Service, Indian Tribes, Tribal Orga24 nizations, and Urban Indian Organizations, to de25 velop a comprehensive behavioral health prevention 
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1 and treatment program which emphasizes collabora2 tion among alcohol and substance abuse, social serv3 ices, and mental health programs. 

4 ‘‘(2) To provide information, direction, and 

5 guidance relating to mental illness and dysfunction 

6 and self-destructive behavior, including child abuse 

7 and family violence, to those Federal, tribal, State, 

8 and local agencies responsible for programs in In9 dian communities in areas of health care, education, 

10 social services, child and family welfare, alcohol and 

11 substance abuse, law enforcement, and judicial serv12 ices. 

13 ‘‘(3) To assist Indian Tribes to identify services 

14 and resources available to address mental illness and 

15 dysfunctional and self-destructive behavior. 

16 ‘‘(4) To provide authority and opportunities for 

17 Indian Tribes and Tribal Organizations to develop, 

18 implement, and coordinate with community-based 

19 programs which include identification, prevention, 

20 education, referral, and treatment services, including 

21 through multidisciplinary resource teams. 

22 ‘‘(5) To ensure that Indians, as citizens of the 

23 United States and of the States in which they re24 side, have the same access to behavioral health serv25 ices to which all citizens have access. 
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1 ‘‘(6) To modify or supplement existing pro2 grams and authorities in the areas identified in 

3 paragraph (2). 

4 ‘‘(b) PLANS.—

5 ‘‘(1) DEVELOPMENT.—The Secretary, acting 

6 through the Service, Indian Tribes, Tribal Organiza7 tions, and Urban Indian Organizations, shall encour8 age Indian Tribes and Tribal Organizations to de9 velop tribal plans, and Urban Indian Organizations 

10 to develop local plans, and for all such groups to 

11 participate in developing areawide plans for Indian 

12 Behavioral Health Services. The plans shall include, 

13 to the extent feasible, the following components: 

14 ‘‘(A) An assessment of the scope of alcohol 

15 or other substance abuse, mental illness, and 

16 dysfunctional and self-destructive behavior, in17 cluding suicide, child abuse, and family vio18 lence, among Indians, including—

19 ‘‘(i) the number of Indians served who 

20 are directly or indirectly affected by such 

21 illness or behavior; or 

22 ‘‘(ii) an estimate of the financial and 

23 human cost attributable to such illness or 

24 behavior. 
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1 ‘‘(B) An assessment of the existing and 

2 additional resources necessary for the preven3 tion and treatment of such illness and behavior, 

4 including an assessment of the progress toward 

5 achieving the availability of the full continuum 

6 of care described in subsection (c). 

7 ‘‘(C) An estimate of the additional funding 

8 needed by the Service, Indian Tribes, Tribal 

9 Organizations, and Urban Indian Organizations 

10 to meet their responsibilities under the plans. 

11 ‘‘(2) NATIONAL CLEARINGHOUSE.—The Sec12 retary, acting through the Service, shall establish a 

13 national clearinghouse of plans and reports on the 

14 outcomes of such plans developed by Indian Tribes, 

15 Tribal Organizations, Urban Indian Organizations, 

16 and Service Areas relating to behavioral health. The 

17 Secretary shall ensure access to these plans and out18 comes by any Indian Tribe, Tribal Organization, 

19 Urban Indian Organization, or the Service. 

20 ‘‘(3) TECHNICAL ASSISTANCE.—The Secretary 

21 shall provide technical assistance to Indian Tribes, 

22 Tribal Organizations, and Urban Indian Organiza23 tions in preparation of plans under this section and 

24 in developing standards of care that may be used 

25 and adopted locally.
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1 ‘‘(c) PROGRAMS.—The Secretary, acting through the 

2 Service, Indian Tribes, and Tribal Organizations, shall 

3 provide, to the extent feasible and if funding is available, 

4 programs including the following: 

5 ‘‘(1) COMPREHENSIVE CARE.—A comprehensive 

6 continuum of behavioral health care which pro7 vides—

8 ‘‘(A) community-based prevention, inter9 vention, outpatient, and behavioral health 

10 aftercare; 

11 ‘‘(B) detoxification (social and medical); 

12 ‘‘(C) acute hospitalization; 

13 ‘‘(D) intensive outpatient/day treatment; 

14 ‘‘(E) residential treatment; 

15 ‘‘(F) transitional living for those needing a 

16 temporary, stable living environment that is 

17 supportive of treatment and recovery goals; 

18 ‘‘(G) emergency shelter; 

19 ‘‘(H) intensive case management; and 

20 ‘‘(I) Traditional Health Care Practices. 

21 ‘‘(2) CHILD CARE.—Behavioral health services 

22 for Indians from birth through age 17, including the 

23 following: 
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1 ‘‘(A) Preschool and school age fetal alcohol 

2 disorder services, including assessment and be3 havioral intervention. 

4 ‘‘(B) Mental health and substance abuse 

5 services (emotional, organic, alcohol, drug, in6 halant, and tobacco). 

7 ‘‘(C) Identification and treatment of co-oc8 curring disorders and comorbidity. 

9 ‘‘(D) Prevention of alcohol, drug, inhalant, 

10 and tobacco use. 

11 ‘‘(E) Early intervention, treatment, and 

12 aftercare. 

13 ‘‘(F) Promotion of healthy choices and life14 style (related to sexually transmitted diseases, 

15 domestic violence, sexual abuse, suicide, teen 

16 pregnancy, obesity, and other risk/safety 

17 issues). 

18 ‘‘(G) Identification and treatment of ne19 glect and physical, mental, and sexual abuse. 

20 ‘‘(3) ADULT CARE.—Behavioral health services 

21 for Indians from age 18 through 55, including the 

22 following: 

23 ‘‘(A) Early intervention, treatment, and 

24 aftercare. 
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1 ‘‘(B) Mental health and substance abuse 

2 services (emotional, alcohol, drug, inhalant, and 

3 tobacco), including gender specific services. 

4 ‘‘(C) Identification and treatment of co-oc5 curring disorders (dual diagnosis) and comor6 bidity. 

7 ‘‘(D) Promotion of gender specific healthy 

8 choices and lifestyle (related to parenting, part9 ners, domestic violence, sexual abuse, suicide, 

10 obesity, and other risk-related behavior). 

11 ‘‘(E) Treatment services for women at risk 

12 of giving birth to a child with a fetal alcohol 

13 disorder. 

14 ‘‘(F) Gender specific treatment for sexual 

15 assault and domestic violence. 

16 ‘‘(4) FAMILY CARE.—Behavioral health services 

17 for families, including the following: 

18 ‘‘(A) Early intervention, treatment, and 

19 aftercare for affected families. 

20 ‘‘(B) Treatment for sexual assault and do21 mestic violence. 

22 ‘‘(C) Promotion of healthy choices and life23 style (related to parenting, partners, domestic 

24 violence, and other abuse issues). 
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1 ‘‘(5) ELDER CARE.—Behavioral health services 

2 for Indians 56 years of age and older, including the 

3 following: 

4 ‘‘(A) Early intervention, treatment, and 

5 aftercare. 

6 ‘‘(B) Mental health and substance abuse 

7 services (emotional, alcohol, drug, inhalant, and 

8 tobacco), including gender specific services. 

9 ‘‘(C) Identification and treatment of co-oc10 curring disorders (dual diagnosis) and comor11 bidity. 

12 ‘‘(D) Promotion of healthy choices and life13 style (managing conditions related to aging). 

14 ‘‘(E) Gender specific treatment for sexual 

15 assault, domestic violence, neglect, physical and 

16 mental abuse and exploitation. 

17 ‘‘(F) Identification and treatment of de18 mentias regardless of cause. 

19 ‘‘(d) COMMUNITY BEHAVIORAL HEALTH PLAN.—

20 ‘‘(1) ESTABLISHMENT.—The governing body of 

21 any Indian Tribe, Tribal Organization, or Urban In22 dian Organization may adopt a resolution for the es23 tablishment of a community behavioral health plan 

24 providing for the identification and coordination of 

25 available resources and programs to identify, pre-
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1 vent, or treat substance abuse, mental illness, or 

2 dysfunctional and self-destructive behavior, including 

3 child abuse and family violence, among its members 

4 or its service population. This plan should include 

5 behavioral health services, social services, intensive 

6 outpatient services, and continuing aftercare. 

7 ‘‘(2) TECHNICAL ASSISTANCE.—At the request 

8 of an Indian Tribe, Tribal Organization, or Urban 

9 Indian Organization, the Bureau of Indian Affairs 

10 and the Service shall cooperate with and provide 

11 technical assistance to the Indian Tribe, Tribal Or12 ganization, or Urban Indian Organization in the de13 velopment and implementation of such plan. 

14 ‘‘(3) FUNDING.—The Secretary, acting through 

15 the Service, may make funding available to Indian 

16 Tribes and Tribal Organizations which adopt a reso17 lution pursuant to paragraph (1) to obtain technical 

18 assistance for the development of a community be19 havioral health plan and to provide administrative 

20 support in the implementation of such plan. 

21 ‘‘(e) COORDINATION FOR AVAILABILITY OF SERV22 ICES.—The Secretary, acting through the Service, Indian 

23 Tribes, Tribal Organizations, and Urban Indian Organiza24 tions, shall coordinate behavioral health planning, to the 

25 extent feasible, with other Federal agencies and with State
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1 agencies, to encourage comprehensive behavioral health 

2 services for Indians regardless of their place of residence. 

3 ‘‘(f) MENTAL HEALTH CARE NEED ASSESSMENT.—

4 Not later than 1 year after the date of the enactment of 

5 the Indian Health Care Improvement Act Amendments of 

6 2003, the Secretary, acting through the Service, shall 

7 make an assessment of the need for inpatient mental 

8 health care among Indians and the availability and cost 

9 of inpatient mental health facilities which can meet such 

10 need. In making such assessment, the Secretary shall con11 sider the possible conversion of existing, underused Service 

12 hospital beds into psychiatric units to meet such need. 

13 ‘‘SEC. 702. MEMORANDA OF AGREEMENT WITH THE DE14 PARTMENT OF THE INTERIOR. 

15 ‘‘(a) CONTENTS.—Not later than 12 months after the 

16 date of the enactment of the Indian Health Care Improve17 ment Act Amendments of 2003, the Secretary, acting 

18 through the Service, and the Secretary of the Interior shall 

19 develop and enter into a memoranda of agreement, or re20 view and update any existing memoranda of agreement, 

21 as required by section 4205 of the Indian Alcohol and 

22 Substance Abuse Prevention and Treatment Act of 1986 

23 (25 U.S.C. 2411) under which the Secretaries address the 

24 following: 
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1 ‘‘(1) The scope and nature of mental illness and 

2 dysfunctional and self-destructive behavior, including 

3 child abuse and family violence, among Indians. 

4 ‘‘(2) The existing Federal, tribal, State, local, 

5 and private services, resources, and programs avail6 able to provide mental health services for Indians. 

7 ‘‘(3) The unmet need for additional services, re8 sources, and programs necessary to meet the needs 

9 identified pursuant to paragraph (1). 

10 ‘‘(4)(A) The right of Indians, as citizens of the 

11 United States and of the States in which they re12 side, to have access to mental health services to 

13 which all citizens have access. 

14 ‘‘(B) The right of Indians to participate in, and 

15 receive the benefit of, such services. 

16 ‘‘(C) The actions necessary to protect the exer17 cise of such right. 

18 ‘‘(5) The responsibilities of the Bureau of In19 dian Affairs and the Service, including mental health 

20 identification, prevention, education, referral, and 

21 treatment services (including services through multi22 disciplinary resource teams), at the central, area, 

23 and agency and Service Unit, Service Area, and 

24 headquarters levels to address the problems identi25 fied in paragraph (1). 
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1 ‘‘(6) A strategy for the comprehensive coordina2 tion of the mental health services provided by the 

3 Bureau of Indian Affairs and the Service to meet 

4 the problems identified pursuant to paragraph (1), 

5 including—

6 ‘‘(A) the coordination of alcohol and sub7 stance abuse programs of the Service, the Bu8 reau of Indian Affairs, and Indian Tribes and 

9 Tribal Organizations (developed under the In10 dian Alcohol and Substance Abuse Prevention 

11 and Treatment Act of 1986) with mental health 

12 initiatives pursuant to this Act, particularly 

13 with respect to the referral and treatment of 

14 dually diagnosed individuals requiring mental 

15 health and substance abuse treatment; and 

16 ‘‘(B) ensuring that the Bureau of Indian 

17 Affairs and Service programs and services (in18 cluding multidisciplinary resource teams) ad19 dressing child abuse and family violence are co20 ordinated with such non-Federal programs and 

21 services. 

22 ‘‘(7) Directing appropriate officials of the Bu23 reau of Indian Affairs and the Service, particularly 

24 at the agency and Service Unit levels, to cooperate 

25 fully with tribal requests made pursuant to commu-
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1 nity behavioral health plans adopted under section 

2 701(c) and section 4206 of the Indian Alcohol and 

3 Substance Abuse Prevention and Treatment Act of 

4 1986 (25 U.S.C. 2412). 

5 ‘‘(8) Providing for an annual review of such 

6 agreement by the Secretaries which shall be provided 

7 to Congress and Indian Tribes and Tribal Organiza8 tions. 

9 ‘‘(b) SPECIFIC PROVISIONS REQUIRED.—The memo10 randa of agreement updated or entered into pursuant to 

11 subsection (a) shall include specific provisions pursuant to 

12 which the Service shall assume responsibility for—

13 ‘‘(1) the determination of the scope of the prob14 lem of alcohol and substance abuse among Indians, 

15 including the number of Indians within the jurisdic16 tion of the Service who are directly or indirectly af17 fected by alcohol and substance abuse and the finan18 cial and human cost; 

19 ‘‘(2) an assessment of the existing and needed 

20 resources necessary for the prevention of alcohol and 

21 substance abuse and the treatment of Indians af22 fected by alcohol and substance abuse; and 

23 ‘‘(3) an estimate of the funding necessary to 

24 adequately support a program of prevention of alco-
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1 hol and substance abuse and treatment of Indians 

2 affected by alcohol and substance abuse. 

3 ‘‘(c) CONSULTATION.—The Secretary, acting through 

4 the Service, and the Secretary of the Interior shall, in de5 veloping the memoranda of agreement under subsection 

6 (a), consult with and solicit the comments from—

7 ‘‘(1) Indian Tribes and Tribal Organizations; 

8 ‘‘(2) Indians; 

9 ‘‘(3) Urban Indian Organizations and other In10 dian organizations; and 

11 ‘‘(4) behavioral health service providers. 

12 ‘‘(d) PUBLICATION.—Each memorandum of agree13 ment entered into or renewed (and amendments or modi14 fications thereto) under subsection (a) shall be published 

15 in the Federal Register. At the same time as publication 

16 in the Federal Register, the Secretary shall provide a copy 

17 of such memoranda, amendment, or modification to each 

18 Indian Tribe, Tribal Organization, and Urban Indian Or19 ganization. 

20 ‘‘SEC. 703. COMPREHENSIVE BEHAVIORAL HEALTH PRE21 VENTION AND TREATMENT PROGRAM. 

22 ‘‘(a) ESTABLISHMENT.—

23 ‘‘(1) IN GENERAL.—The Secretary, acting 

24 through the Service, Indian Tribes, and Tribal Orga25 nizations, shall provide a program of comprehensive
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1 behavioral health, prevention, treatment, and 

2 aftercare, including Traditional Health Care Prac3 tices, which shall include—

4 ‘‘(A) prevention, through educational inter5 vention, in Indian communities; 

6 ‘‘(B) acute detoxification, psychiatric hos7 pitalization, and residential and intensive out8 patient treatment; 

9 ‘‘(C) community-based rehabilitation and 

10 aftercare; 

11 ‘‘(D) community education and involve12 ment, including extensive training of health 

13 care, educational, and community-based per14 sonnel; and 

15 ‘‘(E) specialized residential treatment pro16 grams for high-risk populations, including but 

17 not limited to pregnant and postpartum women 

18 and their children. 

19 ‘‘(2) TARGET POPULATIONS.—The target popu20 lation of such program shall be members of Indian 

21 Tribes. Efforts to train and educate key members of 

22 the Indian community shall target employees of 

23 health, education, judicial, law enforcement, legal, 

24 and social service programs. 

25 ‘‘(b) CONTRACT HEALTH SERVICES.—
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1 ‘‘(1) IN GENERAL.—The Secretary, acting 

2 through the Service, Indian Tribes, and Tribal Orga3 nizations, may enter into contracts with public or 

4 private providers of behavioral health treatment 

5 services for the purpose of carrying out the program 

6 required under subsection (a). 

7 ‘‘(2) PROVISION OF ASSISTANCE.—In carrying 

8 out this subsection, the Secretary shall provide as9 sistance to Indian Tribes and Tribal Organizations 

10 to develop criteria for the certification of behavioral 

11 health service providers and accreditation of service 

12 facilities which meet minimum standards for such 

13 services and facilities. 

14 ‘‘SEC. 704. MENTAL HEALTH TECHNICIAN PROGRAM. 

15 ‘‘(a) IN GENERAL.—Under the authority of the Act 

16 of November 2, 1921 (25 U.S.C. 13) (commonly known 

17 as the Snyder Act), the Secretary shall establish and 

18 maintain a mental health technician program within the 

19 Service which—

20 ‘‘(1) provides for the training of Indians as 

21 mental health technicians; and 

22 ‘‘(2) employs such technicians in the provision 

23 of community-based mental health care that includes 

24 identification, prevention, education, referral, and 

25 treatment services. 
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1 ‘‘(b) PARAPROFESSIONAL TRAINING.—In carrying 

2 out subsection (a), the Secretary, acting through the Serv3 ice, Indian Tribes, and Tribal Organizations, shall provide 

4 high-standard paraprofessional training in mental health 

5 care necessary to provide quality care to the Indian com6 munities to be served. Such training shall be based upon 

7 a curriculum developed or approved by the Secretary 

8 which combines education in the theory of mental health 

9 care with supervised practical experience in the provision 

10 of such care. 

11 ‘‘(c) SUPERVISION AND EVALUATION OF TECHNI12 CIANS.—The Secretary, acting through the Service, Indian 

13 Tribes, and Tribal Organizations, shall supervise and 

14 evaluate the mental health technicians in the training pro15 gram. 

16 ‘‘(d) TRADITIONAL HEALTH CARE PRACTICES.—The 

17 Secretary, acting through the Service, shall ensure that 

18 the program established pursuant to this subsection in19 volves the use and promotion of the Traditional Health 

20 Care Practices of the Indian Tribes to be served. 

21 ‘‘SEC. 705. LICENSING REQUIREMENT FOR MENTAL 

22 HEALTH CARE WORKERS. 

23 ‘‘Subject to the provisions of section 221, any person 

24 employed as a psychologist, social worker, or marriage and 

25 family therapist for the purpose of providing mental health 
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1 care services to Indians in a clinical setting under this Act 

2 or through a Funding Agreement shall, in the case of a 

3 person employed as a psychologist, social worker, or mar4 riage and family therapist, be licensed as a clinical psy5 chologist, social worker, or marriage and family therapist, 

6 respectively, or working under the direct supervision of a 

7 licensed clinical psychologist, social worker, or marriage 

8 and family therapist, respectively. 

9 ‘‘SEC. 706. INDIAN WOMEN TREATMENT PROGRAMS. 

10 ‘‘(a) FUNDING.—The Secretary, consistent with sec11 tion 701, shall make funds available to Indian Tribes, 

12 Tribal Organizations, and Urban Indian Organizations to 

13 develop and implement a comprehensive behavioral health 

14 program of prevention, intervention, treatment, and re15 lapse prevention services that specifically addresses the 

16 spiritual, cultural, historical, social, and child care needs 

17 of Indian women, regardless of age. 

18 ‘‘(b) USE OF FUNDS.—Funds made available pursu19 ant to this section may be used to—

20 ‘‘(1) develop and provide community training, 

21 education, and prevention programs for Indian 

22 women relating to behavioral health issues, including 

23 fetal alcohol disorders; 
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1 ‘‘(2) identify and provide psychological services, 

2 counseling, advocacy, support, and relapse preven3 tion to Indian women and their families; and 

4 ‘‘(3) develop prevention and intervention models 

5 for Indian women which incorporate Traditional 

6 Health Care Practices, cultural values, and commu7 nity and family involvement. 

8 ‘‘(c) CRITERIA.—The Secretary, in consultation with 

9 Indian Tribes and Tribal Organizations, shall establish 

10 criteria for the review and approval of applications and 

11 proposals for funding under this section. 

12 ‘‘(d) EARMARK OF CERTAIN FUNDS.—Twenty per13 cent of the funds appropriated pursuant to this section 

14 shall be used to make grants to Urban Indian Organiza15 tions. 

16 ‘‘SEC. 707. INDIAN YOUTH PROGRAM. 

17 ‘‘(a) DETOXIFICATION AND REHABILITATION.—The 

18 Secretary, acting through the Service, consistent with sec19 tion 701, shall develop and implement a program for acute 

20 detoxification and treatment for Indian youths, including 

21 behavioral health services. The program shall include re22 gional treatment centers designed to include detoxification 

23 and rehabilitation for both sexes on a referral basis and 

24 programs developed and implemented by Indian Tribes or 

25 Tribal Organizations at the local level under the Indian
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1 Self-Determination and Education Assistance Act. Re2 gional centers shall be integrated with the intake and re3 habilitation programs based in the referring Indian com4 munity. 

5 ‘‘(b) ALCOHOL AND SUBSTANCE ABUSE TREATMENT

6 CENTERS OR FACILITIES.—

7 ‘‘(1) ESTABLISHMENT.—

8 ‘‘(A) IN GENERAL.—The Secretary, acting 

9 through the Service, Indian Tribes, and Tribal 

10 Organizations, shall construct, renovate, or, as 

11 necessary, purchase, and appropriately staff 

12 and operate, at least 1 youth regional treatment 

13 center or treatment network in each area under 

14 the jurisdiction of an Area Office. 

15 ‘‘(B) AREA OFFICE IN CALIFORNIA.—For 

16 the purposes of this subsection, the Area Office 

17 in California shall be considered to be 2 Area 

18 Offices, 1 office whose jurisdiction shall be con19 sidered to encompass the northern area of the 

20 State of California, and 1 office whose jurisdic21 tion shall be considered to encompass the re22 mainder of the State of California for the pur23 pose of implementing California treatment net24 works. 
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1 ‘‘(2) FUNDING.—For the purpose of staffing 

2 and operating such centers or facilities, funding 

3 shall be pursuant to the Act of November 2, 1921 

4 (25 U.S.C. 13). 

5 ‘‘(3) LOCATION.—A youth treatment center 

6 constructed or purchased under this subsection shall 

7 be constructed or purchased at a location within the 

8 area described in paragraph (1) agreed upon (by ap9 propriate tribal resolution) by a majority of the In10 dian Tribes to be served by such center. 

11 ‘‘(4) SPECIFIC PROVISION OF FUNDS.—

12 ‘‘(A) IN GENERAL.—Notwithstanding any 

13 other provision of this title, the Secretary may, 

14 from amounts authorized to be appropriated for 

15 the purposes of carrying out this section, make 

16 funds available to—

17 ‘‘(i) the Tanana Chiefs Conference, 

18 Incorporated, for the purpose of leasing, 

19 constructing, renovating, operating, and 

20 maintaining a residential youth treatment 

21 facility in Fairbanks, Alaska; and 

22 ‘‘(ii) the Southeast Alaska Regional 

23 Health Corporation to staff and operate a 

24 residential youth treatment facility without 

25 regard to the proviso set forth in section 
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1 4(l) of the Indian Self-Determination and 

2 Education Assistance Act (25 U.S.C. 

3 450b(l)). 

4 ‘‘(B) PROVISION OF SERVICES TO ELIGI5 BLE YOUTHS.—Until additional residential 

6 youth treatment facilities are established in 

7 Alaska pursuant to this section, the facilities 

8 specified in subparagraph (A) shall make every 

9 effort to provide services to all eligible Indian 

10 youths residing in such State. 

11 ‘‘(c) INTERMEDIATE ADOLESCENT BEHAVIORAL

12 HEALTH SERVICES.—

13 ‘‘(1) IN GENERAL.—The Secretary, acting 

14 through the Service, Indian Tribes, and Tribal Orga15 nizations, may provide intermediate behavioral 

16 health services, which may incorporate Traditional 

17 Health Care Practices, to Indian children and ado18 lescents, including—

19 ‘‘(A) pretreatment assistance; 

20 ‘‘(B) inpatient, outpatient, and aftercare 

21 services; 

22 ‘‘(C) emergency care; 

23 ‘‘(D) suicide prevention and crisis interven24 tion; and 
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1 ‘‘(E) prevention and treatment of mental 

2 illness and dysfunctional and self-destructive 

3 behavior, including child abuse and family vio4 lence. 

5 ‘‘(2) USE OF FUNDS.—Funds provided under 

6 this subsection may be used—

7 ‘‘(A) to construct or renovate an existing 

8 health facility to provide intermediate behav9 ioral health services; 

10 ‘‘(B) to hire behavioral health profes11 sionals; 

12 ‘‘(C) to staff, operate, and maintain an in13 termediate mental health facility, group home, 

14 sober housing, transitional housing or similar 

15 facilities, or youth shelter where intermediate 

16 behavioral health services are being provided; 

17 ‘‘(D) to make renovations and hire appro18 priate staff to convert existing hospital beds 

19 into adolescent psychiatric units; and 

20 ‘‘(E) for intensive home- and community21 based services. 

22 ‘‘(3) CRITERIA.—The Secretary, acting through 

23 the Service, shall, in consultation with Indian Tribes 

24 and Tribal Organizations, establish criteria for the 
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1 review and approval of applications or proposals for 

2 funding made available pursuant to this subsection. 

3 ‘‘(d) FEDERALLY OWNED STRUCTURES.—

4 ‘‘(1) IN GENERAL.—The Secretary, in consulta5 tion with Indian Tribes and Tribal Organizations, 

6 shall—

7 ‘‘(A) identify and use, where appropriate, 

8 federally owned structures suitable for local res9 idential or regional behavioral health treatment 

10 for Indian youths; and 

11 ‘‘(B) establish guidelines, in consultation 

12 with Indian Tribes and Tribal Organizations, 

13 for determining the suitability of any such fed14 erally owned structure to be used for local resi15 dential or regional behavioral health treatment 

16 for Indian youths. 

17 ‘‘(2) TERMS AND CONDITIONS FOR USE OF

18 STRUCTURE.—Any structure described in paragraph 

19 (1) may be used under such terms and conditions as 

20 may be agreed upon by the Secretary and the agency 

21 having responsibility for the structure and any In22 dian Tribe or Tribal Organization operating the pro23 gram. 

24 ‘‘(e) REHABILITATION AND AFTERCARE SERVICES.—
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1 ‘‘(1) IN GENERAL.—The Secretary, Indian 

2 Tribes, or Tribal Organizations, in cooperation with 

3 the Secretary of the Interior, shall develop and im4 plement within each Service Unit, community-based 

5 rehabilitation and follow-up services for Indian 

6 youths who are having significant behavioral health 

7 problems, and require long-term treatment, commu8 nity reintegration, and monitoring to support the In9 dian youths after their return to their home commu10 nity. 

11 ‘‘(2) ADMINISTRATION.—Services under para12 graph (1) shall be provided by trained staff within 

13 the community who can assist the Indian youths in 

14 their continuing development of self-image, positive 

15 problem-solving skills, and nonalcohol or substance 

16 abusing behaviors. Such staff may include alcohol 

17 and substance abuse counselors, mental health pro18 fessionals, and other health professionals and para19 professionals, including community health represent20 atives. 

21 ‘‘(f) INCLUSION OF FAMILY IN YOUTH TREATMENT

22 PROGRAM.—In providing the treatment and other services 

23 to Indian youths authorized by this section, the Secretary, 

24 acting through the Service, Indian Tribes, and Tribal Or25 ganizations, shall provide for the inclusion of family mem-
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1 bers of such youths in the treatment programs or other 

2 services as may be appropriate. Not less than 10 percent 

3 of the funds appropriated for the purposes of carrying out 

4 subsection (e) shall be used for outpatient care of adult 

5 family members related to the treatment of an Indian 

6 youth under that subsection. 

7 ‘‘(g) MULTIDRUG ABUSE PROGRAM.—The Secretary, 

8 acting through the Service, Indian Tribes, Tribal Organi9 zations, and Urban Indian Organizations, shall provide, 

10 consistent with section 701, programs and services to pre11 vent and treat the abuse of multiple forms of substances, 

12 including, but not limited to, alcohol, drugs, inhalants, and 

13 tobacco, among Indian youths residing in Indian commu14 nities, on or near reservations, and in urban areas and 

15 provide appropriate mental health services to address the 

16 incidence of mental illness among such youths. 

17 ‘‘SEC. 708. INPATIENT AND COMMUNITY-BASED MENTAL 

18 HEALTH FACILITIES DESIGN, CONSTRUC19 TION, AND STAFFING. 

20 ‘‘Not later than 1 year after the date of the enact21 ment of the Indian Health Care Improvement Act Amend22 ments of 2003, the Secretary, acting through the Service, 

23 Indian Tribes, and Tribal Organizations, shall provide, in 

24 each area of the Service, not less than 1 inpatient mental 

25 health care facility, or the equivalent, for Indians with be-
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1 havioral health problems. For the purposes of this sub2 section, California shall be considered to be 2 Area Offices, 

3 1 office whose location shall be considered to encompass 

4 the northern area of the State of California and 1 office 

5 whose jurisdiction shall be considered to encompass the 

6 remainder of the State of California. The Secretary shall 

7 consider the possible conversion of existing, underused 

8 Service hospital beds into psychiatric units to meet such 

9 need. 

10 ‘‘SEC. 709. TRAINING AND COMMUNITY EDUCATION. 

11 ‘‘(a) PROGRAM.—The Secretary, in cooperation with 

12 the Secretary of the Interior, shall develop and implement 

13 or provide funding for Indian Tribes and Tribal Organiza14 tions to develop and implement, within each Service Unit 

15 or tribal program, a program of community education and 

16 involvement which shall be designed to provide concise and 

17 timely information to the community leadership of each 

18 tribal community. Such program shall include education 

19 about behavioral health issues to political leaders, Tribal 

20 judges, law enforcement personnel, members of tribal 

21 health and education boards, health care providers includ22 ing traditional practitioners, and other critical members 

23 of each tribal community. Community-based training (ori24 ented toward local capacity development) shall also include 

25 tribal community provider training (designed for adult 
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1 learners from the communities receiving services for pre2 vention, intervention, treatment, and aftercare). 

3 ‘‘(b) INSTRUCTION.—The Secretary, acting through 

4 the Service, shall, either directly or through Indian Tribes 

5 and Tribal Organizations, provide instruction in the area 

6 of behavioral health issues, including instruction in crisis 

7 intervention and family relations in the context of alcohol 

8 and substance abuse, child sexual abuse, youth alcohol and 

9 substance abuse, and the causes and effects of fetal alco10 hol disorders to appropriate employees of the Bureau of 

11 Indian Affairs and the Service, and to personnel in schools 

12 or programs operated under any contract with the Bureau 

13 of Indian Affairs or the Service, including supervisors of 

14 emergency shelters and halfway houses described in sec15 tion 4213 of the Indian Alcohol and Substance Abuse Pre16 vention and Treatment Act of 1986 (25 U.S.C. 2433). 

17 ‘‘(c) TRAINING MODELS.—In carrying out the edu18 cation and training programs required by this section, the 

19 Secretary, in consultation with Indian Tribes, Tribal Or20 ganizations, Indian behavioral health experts, and Indian 

21 alcohol and substance abuse prevention experts, shall de22 velop and provide community-based training models. Such 

23 models shall address—

24 ‘‘(1) the elevated risk of alcohol and behavioral 

25 health problems faced by children of alcoholics; 
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1 ‘‘(2) the cultural, spiritual, and 

2 multigenerational aspects of behavioral health prob3 lem prevention and recovery; and 

4 ‘‘(3) community-based and multidisciplinary 

5 strategies for preventing and treating behavioral 

6 health problems. 

7 ‘‘SEC. 710. BEHAVIORAL HEALTH PROGRAM. 

8 ‘‘(a) INNOVATIVE PROGRAMS.—The Secretary, acting 

9 through the Service, Indian Tribes, and Tribal Organiza10 tions, consistent with section 701, may plan, develop, im11 plement, and carry out programs to deliver innovative 

12 community-based behavioral health services to Indians. 

13 ‘‘(b) FUNDING; CRITERIA.—The Secretary may 

14 award such funding for a project under subsection (a) to 

15 an Indian Tribe or Tribal Organization and may consider 

16 the following criteria: 

17 ‘‘(1) The project will address significant unmet 

18 behavioral health needs among Indians. 

19 ‘‘(2) The project will serve a significant number 

20 of Indians. 

21 ‘‘(3) The project has the potential to deliver 

22 services in an efficient and effective manner. 

23 ‘‘(4) The Indian Tribe or Tribal Organization 

24 has the administrative and financial capability to ad25 minister the project.
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1 ‘‘(5) The project may deliver services in a man2 ner consistent with Traditional Health Care Prac3 tices. 

4 ‘‘(6) The project is coordinated with, and avoids 

5 duplication of, existing services. 

6 ‘‘(c) EQUITABLE TREATMENT.—For purposes of this 

7 subsection, the Secretary shall, in evaluating applications 

8 or proposals for funding for projects to be operated under 

9 any Funding Agreement, use the same criteria that the 

10 Secretary uses in evaluating any other application or pro11 posal for such funding. 

12 ‘‘SEC. 711. FETAL ALCOHOL DISORDER FUNDING. 

13 ‘‘(a) PROGRAMS.—

14 ‘‘(1) ESTABLISHMENT.—The Secretary, con15 sistent with section 701, acting through Indian 

16 Tribes and Tribal Organizations, shall establish and 

17 operate fetal alcohol disorder programs as provided 

18 in this section for the purposes of meeting the health 

19 status objectives specified in section 3. 

20 ‘‘(2) USE OF FUNDS.—Funding provided pursu21 ant to this section shall be used for the following: 

22 ‘‘(A) To develop and provide for Indians 

23 community and in school training, education, 

24 and prevention programs relating to fetal alco25 hol disorders. 
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1 ‘‘(B) To identify and provide behavioral 

2 health treatment to high-risk Indian women 

3 and high-risk women pregnant with an Indian’s 

4 child. 

5 ‘‘(C) To identify and provide appropriate 

6 psychological services, educational and voca7 tional support, counseling, advocacy, and infor8 mation to fetal alcohol disorder affected Indians 

9 and their families or caretakers. 

10 ‘‘(D) To develop and implement counseling 

11 and support programs in schools for fetal alco12 hol disorder affected Indian children. 

13 ‘‘(E) To develop prevention and interven14 tion models which incorporate practitioners of 

15 Traditional Health Care Practices, cultural and 

16 spiritual values, and community involvement. 

17 ‘‘(F) To develop, print, and disseminate 

18 education and prevention materials on fetal al19 cohol disorder. 

20 ‘‘(G) To develop and implement, through 

21 the tribal consultation process, culturally sen22 sitive assessment and diagnostic tools including 

23 dysmorphology clinics and multidisciplinary 

24 fetal alcohol disorder clinics for use in Indian 

25 communities and Urban Centers. 
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1 ‘‘(H) To develop early childhood interven2 tion projects from birth on to mitigate the ef3 fects of fetal alcohol disorder among Indians. 

4 ‘‘(I) To develop and fund community-based 

5 adult fetal alcohol disorder housing and support 

6 services for Indians and for women pregnant 

7 with an Indian’s child. 

8 ‘‘(3) CRITERIA FOR APPLICATIONS.—The Sec9 retary shall establish criteria for the review and ap10 proval of applications for funding under this section. 

11 ‘‘(b) SERVICES.—The Secretary, acting through the 

12 Service and Indian Tribes, Tribal Organizations, and 

13 Urban Indian Organizations, shall—

14 ‘‘(1) develop and provide services for the pre15 vention, intervention, treatment, and aftercare for 

16 those affected by fetal alcohol disorder in Indian 

17 communities; and 

18 ‘‘(2) provide supportive services, directly or 

19 through an Indian Tribe, Tribal Organization, or 

20 Urban Indian Organization, including services to 

21 meet the special educational, vocational, school-to22 work transition, and independent living needs of ad23 olescent and adult Indians with fetal alcohol dis24 order. 
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1 ‘‘(c) TASK FORCE.—The Secretary shall establish a 

2 task force to be known as the Fetal Alcohol Disorder Task 

3 Force to advise the Secretary in carrying out subsection 

4 (b). Such task force shall be composed of representatives 

5 from the following: 

6 ‘‘(1) The National Institute on Drug Abuse. 

7 ‘‘(2) The National Institute on Alcohol and Al8 coholism. 

9 ‘‘(3) The Office of Substance Abuse Prevention. 

10 ‘‘(4) The National Institute of Mental Health. 

11 ‘‘(5) The Service. 

12 ‘‘(6) The Office of Minority Health of the De13 partment of Health and Human Services. 

14 ‘‘(7) The Administration for Native Americans. 

15 ‘‘(8) The National Institute of Child Health 

16 and Human Development (NICHD). 

17 ‘‘(9) The Centers for Disease Control and Pre18 vention. 

19 ‘‘(10) The Bureau of Indian Affairs. 

20 ‘‘(11) Indian Tribes. 

21 ‘‘(12) Tribal Organizations. 

22 ‘‘(13) Urban Indian Organizations. 

23 ‘‘(14) Indian fetal alcohol disorder experts. 

24 ‘‘(d) APPLIED RESEARCH PROJECTS.—The Sec25 retary, acting through the Substance Abuse and Mental 
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1 Health Services Administration, shall make funding avail2 able to Indian Tribes, Tribal Organizations, and Urban 

3 Indian Organizations for applied research projects which 

4 propose to elevate the understanding of methods to pre5 vent, intervene, treat, or provide rehabilitation and behav6 ioral health aftercare for Indians and Urban Indians af7 fected by fetal alcohol disorder. 

8 ‘‘(e) FUNDING FOR URBAN INDIAN ORGANIZA9 TIONS.—Ten percent of the funds appropriated pursuant 

10 to this section shall be used to make grants to Urban In11 dian Organizations funded under title V. 

12 ‘‘SEC. 712. CHILD SEXUAL ABUSE AND PREVENTION TREAT13 MENT PROGRAMS. 

14 ‘‘(a) ESTABLISHMENT.—The Secretary, acting 

15 through the Service, and the Secretary of the Interior, In16 dian Tribes, and Tribal Organizations shall establish, con17 sistent with section 701, in every Service Area, programs 

18 involving treatment for—

19 ‘‘(1) victims of sexual abuse who are Indian 

20 children or children in an Indian household; and 

21 ‘‘(2) perpetrators of child sexual abuse who are 

22 Indian or members of an Indian household. 

23 ‘‘(b) USE OF FUNDS.—Funding provided pursuant to 

24 this section shall be used for the following:
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1 ‘‘(1) To develop and provide community edu2 cation and prevention programs related to sexual 

3 abuse of Indian children or children in an Indian 

4 household. 

5 ‘‘(2) To identify and provide behavioral health 

6 treatment to victims of sexual abuse who are Indian 

7 children or children in an Indian household, and to 

8 their family members who are affected by sexual 

9 abuse. 

10 ‘‘(3) To develop prevention and intervention 

11 models which incorporate Traditional Health Care 

12 Practices, cultural and spiritual values, and commu13 nity involvement. 

14 ‘‘(4) To develop and implement, through the 

15 tribal consultation process, culturally sensitive as16 sessment and diagnostic tools for use in Indian com17 munities and Urban Centers. 

18 ‘‘(5) To identify and provide behavioral health 

19 treatment to Indian perpetrators and perpetrators 

20 who are members of an Indian household—

21 ‘‘(A) making efforts to begin offender and 

22 behavioral health treatment while the perpe23 trator is incarcerated or at the earliest possible 

24 date if the perpetrator is not incarcerated; and 
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1 ‘‘(B) providing treatment after the perpe2 trator is released, until it is determined that the 

3 perpetrator is not a threat to children. 

4 ‘‘SEC. 713. BEHAVIORAL HEALTH RESEARCH. 

5 ‘‘The Secretary, in consultation with appropriate 

6 Federal agencies, shall provide funding to Indian Tribes, 

7 Tribal Organizations, and Urban Indian Organizations or 

8 enter into contracts with, or make grants to appropriate 

9 institutions for, the conduct of research on the incidence 

10 and prevalence of behavioral health problems among Indi11 ans served by the Service, Indian Tribes, or Tribal Organi12 zations and among Indians in urban areas. Research pri13 orities under this section shall include—

14 ‘‘(1) the interrelationship and interdependence 

15 of behavioral health problems with alcoholism and 

16 other substance abuse, suicide, homicides, other in17 juries, and the incidence of family violence; and 

18 ‘‘(2) the development of models of prevention 

19 techniques. 

20 The effect of the interrelationships and interdependencies 

21 referred to in paragraph (1) on children, and the develop22 ment of prevention techniques under paragraph (2) appli23 cable to children, shall be emphasized. 
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1 ‘‘SEC. 714. DEFINITIONS. 

2 ‘‘For the purpose of this title, the following defini3 tions shall apply: 

4 ‘‘(1) ASSESSMENT.—The term ‘assessment’ 

5 means the systematic collection, analysis, and dis6 semination of information on health status, health 

7 needs, and health problems. 

8 ‘‘(2) ALCOHOL-RELATED NEURODEVELOP9 MENTAL DISORDERS OR ARND.—The term ‘alcohol10 related neurodevelopmental disorders’ or ‘ARND’ 

11 means, with a history of maternal alcohol consump12 tion during pregnancy, central nervous system in13 volvement such as developmental delay, intellectual 

14 deficit, or neurologic abnormalities. Behaviorally, 

15 there can be problems with irritability, and failure to 

16 thrive as infants. As children become older there will 

17 likely be hyperactivity, attention deficit, language 

18 dysfunction, and perceptual and judgment problems. 

19 ‘‘(3) BEHAVIORAL HEALTH.—The term ‘behav20 ioral health’ means the blending of substance (alco21 hol, drugs, inhalants, and tobacco) abuse and mental 

22 health prevention and treatment, for the purpose of 

23 providing comprehensive services. This can include 

24 the joint development of substance abuse and mental 

25 health treatment planning and coordinated case 

26 management using a multidisciplinary approach. 
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1 ‘‘(4) BEHAVIORAL HEALTH AFTERCARE.—The 

2 term ‘behavioral health aftercare’ includes those ac3 tivities and resources used to support recovery fol4 lowing inpatient, residential, intensive substance 

5 abuse, or mental health outpatient or outpatient 

6 treatment. The purpose is to help prevent or deal 

7 with relapse by ensuring that by the time a client or 

8 patient is discharged from a level of care, such as 

9 outpatient treatment, an aftercare plan has been de10 veloped with the client. An aftercare plan may use 

11 such resources a as community-based therapeutic 

12 group, transitional living facilities, a 12-step spon13 sor, a local 12-step or other related support group, 

14 and other community-based providers (mental health 

15 professionals, traditional health care practitioners, 

16 community health aides, community health rep17 resentatives, mental health technicians, ministers, 

18 etc.) 

19 ‘‘(5) DUAL DIAGNOSIS.—The term ‘dual diag20 nosis’ means coexisting substance abuse and mental 

21 illness conditions or diagnosis. Such clients are 

22 sometimes referred to as mentally ill chemical abus23 ers (MICAs). 

24 ‘‘(6) FETAL ALCOHOL DISORDERS.—The term 

25 ‘fetal alcohol disorders’ means fetal alcohol syn-
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1 drome, partial fetal alcohol syndrome and alcohol re2 lated neurodevelopmental disorder (ARND). 

3 ‘‘(7) FETAL ALCOHOL SYNDROME OR FAS.—

4 The term ‘fetal alcohol syndrome’ or ‘FAS’ means a 

5 syndrome in which, with a history of maternal alco6 hol consumption during pregnancy, the following cri7 teria are met: 

8 ‘‘(A) Central nervous system involvement 

9 such as developmental delay, intellectual deficit, 

10 microencephaly, or neurologic abnormalities. 

11 ‘‘(B) Craniofacial abnormalities with at 

12 least 2 of the following: microophthalmia, short 

13 palpebral fissures, poorly developed philtrum, 

14 thin upper lip, flat nasal bridge, and short 

15 upturned nose. 

16 ‘‘(C) Prenatal or postnatal growth delay. 

17 ‘‘(8) PARTIAL FAS.—The term ‘partial FAS’ 

18 means, with a history of maternal alcohol consump19 tion during pregnancy, having most of the criteria of 

20 FAS, though not meeting a minimum of at least 2 

21 of the following: microophthalmia, short palpebral 

22 fissures, poorly developed philtrum, thin upper lip, 

23 flat nasal bridge, and short upturned nose.

24 ‘‘(9) REHABILITATION.—The term ‘rehabilita25 tion’ means to restore the ability or capacity to en-
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1 gage in usual and customary life activities through 

2 education and therapy. 

3 ‘‘(10) SUBSTANCE ABUSE.—The term ‘sub4 stance abuse’ includes inhalant abuse. 

5 ‘‘SEC. 715. AUTHORIZATION OF APPROPRIATIONS. 

6 ‘‘There is authorized to be appropriated such sums 

7 as may be necessary for each fiscal year through fiscal 

8 year 2015 to carry out the provisions of this title.

9 ‘‘TITLE VIII—MISCELLANEOUS 

10 ‘‘SEC. 801. REPORTS. 

11 ‘‘The President shall, at the time the budget is sub12 mitted under section 1105 of title 31, United States Code, 

13 for each fiscal year transmit to Congress a report con14 taining the following: 

15 ‘‘(1) A report on the progress made in meeting 

16 the objectives of this Act, including a review of pro17 grams established or assisted pursuant to this Act 

18 and assessments and recommendations of additional 

19 programs or additional assistance necessary to, at a 

20 minimum, provide health services to Indians and en21 sure a health status for Indians, which are at a par22 ity with the health services available to and the 

23 health status of the general population, including 

24 specific comparisons of appropriations provided and 

25 those required for such parity. 
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1 ‘‘(2) A report on whether, and to what extent, 

2 new national health care programs, benefits, initia3 tives, or financing systems have had an impact on 

4 the purposes of this Act and any steps that the Sec5 retary may have taken to consult with Indian Tribes, 

6 Tribal Organizations, and Urban Indian Organiza7 tions to address such impact, including a report on 

8 proposed changes in allocation of funding pursuant 

9 to section 808. 

10 ‘‘(3) A report on the use of health services by 

11 Indians—

12 ‘‘(A) on a national and area or other rel13 evant geographical basis; 

14 ‘‘(B) by gender and age; 

15 ‘‘(C) by source of payment and type of 

16 service; 

17 ‘‘(D) comparing such rates of use with 

18 rates of use among comparable non-Indian pop19 ulations; and 

20 ‘‘(E) on the services provided under Fund21 ing Agreements. 

22 ‘‘(4) A report of contractors to the Secretary on 

23 Health Care Educational Loan Repayments every 6 

24 months required by section 110. 
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1 ‘‘(5) A general audit report of the Secretary on 

2 the Health Care Educational Loan Repayment Pro3 gram as required by section 110(n). 

4 ‘‘(6) A report of the findings and conclusions of 

5 demonstration programs on development of edu6 cational curricula for substance abuse counseling as 

7 required in section 126(f). 

8 ‘‘(7) A separate statement which specifies the 

9 amount of funds requested to carry out the provi10 sions of section 201. 

11 ‘‘(8) A report of the evaluations of health pro12 motion and disease prevention as required in section 

13 203(c). 

14 ‘‘(9) A biennial report to Congress on infectious 

15 diseases as required by section 212. 

16 ‘‘(10) A report on environmental and nuclear 

17 health hazards as required by section 215. 

18 ‘‘(11) An annual report on the status of all 

19 health care facilities needs as required by section 

20 301(c)(2) and 301(d). 

21 ‘‘(12) Reports on safe water and sanitary waste 

22 disposal facilities as required by section 302(i). 

23 ‘‘(13) An annual report on the expenditure of 

24 nonservice funds for renovation as required by sec25 tions 304(b)(2). 
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1 ‘‘(14) A report identifying the backlog of main2 tenance and repair required at Service and tribal fa3 cilities required by section 313(a). 

4 ‘‘(15) A report providing an accounting of reim5 bursement funds made available to the Secretary 

6 under titles XVIII, XIX, and XXI of the Social Se7 curity Act. 

8 ‘‘(16) A report on any arrangements for the 

9 sharing of medical facilities or services between the 

10 Service, Indian Tribes, and Tribal Organizations, 

11 and the Department of Veterans Affairs and the De12 partment of Defense, as authorized by section 406. 

13 ‘‘(17) A report on evaluation and renewal of 

14 Urban Indian programs under section 505. 

15 ‘‘(18) A report on the evaluation of programs 

16 as required by section 513(d). 

17 ‘‘(19) A report on alcohol and substance abuse 

18 as required by section 701(f). 

19 ‘‘SEC. 802. REGULATIONS. 

20 ‘‘(a) DEADLINES.—

21 ‘‘(1) PROCEDURES.—Not later than 90 days 

22 after the date of the enactment of the Indian Health 

23 Care Improvement Act Amendments of 2003, the 

24 Secretary shall initiate procedures under subchapter 

25 III of chapter 5 of title 5, United States Code, to 
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1 negotiate and promulgate such regulations or 

2 amendments thereto that are necessary to carry out 

3 titles I, II, III, IV, and VII and section 817. The 

4 Secretary may promulgate regulations to carry out 

5 sections 105, 115, 117, and title V, using the proce6 dures required by the Administrative Procedures 

7 Act. The Secretary shall issue no regulations to 

8 carry out titles VI and VIII, except as necessary to 

9 carry out section 817. 

10 ‘‘(2) PROPOSED REGULATIONS.—Proposed reg11 ulations to implement this Act shall be published in 

12 the Federal Register by the Secretary no later than 

13 270 days after the date of the enactment of the In14 dian Health Care Improvement Act Amendments of 

15 2003 and shall have no less than a 120-day com16 ment period. 

17 ‘‘(3) EXPIRATION OF AUTHORITY.—The author18 ity to promulgate regulations under this Act shall 

19 expire 18 months from the date of the enactment of 

20 this Act. 

21 ‘‘(b) COMMITTEE.—A negotiated rulemaking com22 mittee established pursuant to section 565 of title 5,

23 United States Code, to carry out this section shall have 

24 as its members only representatives of the Federal Gov25 ernment and representatives of Indian Tribes and Tribal 
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1 Organizations, a majority of whom shall be nominated by 

2 and be representatives of Indian Tribes, Tribal Organiza3 tions, and Urban Indian Organizations from each Service 

4 Area. 

5 ‘‘(c) ADAPTATION OF PROCEDURES.—The Secretary 

6 shall adapt the negotiated rulemaking procedures to the 

7 unique context of self-governance and the government-to8 government relationship between the United States and 

9 Indian Tribes. 

10 ‘‘(d) LACK OF REGULATIONS.—The lack of promul11 gated regulations shall not limit the effect of this Act. 

12 ‘‘(e) INCONSISTENT REGULATIONS.—The provisions 

13 of this Act shall supersede any conflicting provisions of 

14 law (including any conflicting regulations) in effect on the 

15 day before the date of the enactment of the Indian Health 

16 Care Improvement Act Amendments of 2003, and the Sec17 retary is authorized to repeal any regulation inconsistent 

18 with the provisions of this Act. 

19 ‘‘SEC. 803. PLAN OF IMPLEMENTATION. 

20 ‘‘Not later than 8 months after the date of the enact21 ment of the Indian Health Care Improvement Act Amend22 ments of 2003, the Secretary in consultation with Indian 

23 Tribes, Tribal Organizations, and Urban Indian Organiza24 tions, shall submit to Congress a plan explaining the man25 ner and schedule (including a schedule of appropriation 
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1 requests), by title and section, by which the Secretary will 

2 implement the provisions of this Act. 

3 ‘‘SEC. 804. AVAILABILITY OF FUNDS. 

4 ‘‘The funds appropriated pursuant to this Act shall 

5 remain available until expended. 

6 ‘‘SEC. 805. LIMITATION ON USE OF FUNDS APPROPRIATED 

7 TO THE INDIAN HEALTH SERVICE. 

8 ‘‘Any limitation on the use of funds contained in an 

9 Act providing appropriations for the Department for a pe10 riod with respect to the performance of abortions shall 

11 apply for that period with respect to the performance of 

12 abortions using funds contained in an Act providing ap13 propriations for the Service. 

14 ‘‘SEC. 806. ELIGIBILITY OF CALIFORNIA INDIANS. 

15 ‘‘(a) IN GENERAL.—The following California Indians 

16 shall be eligible for health services provided by the Service: 

17 ‘‘(1) Any member of a federally recognized In18 dian Tribe. 

19 ‘‘(2) Any descendant of an Indian who was re20 siding in California on June 1, 1852, if such de21 scendant—

22 ‘‘(A) is a member of the Indian community 

23 served by a local program of the Service; and 

24 ‘‘(B) is regarded as an Indian by the com25 munity in which such descendant lives. 
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1 ‘‘(3) Any Indian who holds trust interests in 

2 public domain, national forest, or reservation allot3 ments in California. 

4 ‘‘(4) Any Indian in California who is listed on 

5 the plans for distribution of the assets of California 

6 rancherias and reservations under the Act of August 

7 18, 1958 (72 Stat. 619), and any descendant of 

8 such an Indian. 

9 ‘‘(b) CLARIFICATION.—Nothing in this section may 

10 be construed as expanding the eligibility of California Indi11 ans for health services provided by the Service beyond the 

12 scope of eligibility for such health services that applied on 

13 May 1, 1986. 

14 ‘‘SEC. 807. HEALTH SERVICES FOR INELIGIBLE PERSONS. 

15 ‘‘(a) CHILDREN.—Any individual who—

16 ‘‘(1) has not attained 19 years of age; 

17 ‘‘(2) is the natural or adopted child, stepchild, 

18 foster child, legal ward, or orphan of an eligible In19 dian; and 

20 ‘‘(3) is not otherwise eligible for health services 

21 provided by the Service, 

22 shall be eligible for all health services provided by the 

23 Service on the same basis and subject to the same rules 

24 that apply to eligible Indians until such individual attains 

25 19 years of age. The existing and potential health needs 
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1 of all such individuals shall be taken into consideration 

2 by the Service in determining the need for, or the alloca3 tion of, the health resources of the Service. If such an indi4 vidual has been determined to be legally incompetent prior 

5 to attaining 19 years of age, such individual shall remain 

6 eligible for such services until 1 year after the date of a 

7 determination of competency. 

8 ‘‘(b) SPOUSES.—Any spouse of an eligible Indian who 

9 is not an Indian, or who is of Indian descent but not other10 wise eligible for the health services provided by the Serv11 ice, shall be eligible for such health services if all such 

12 spouses or spouses who are married to members of the 

13 Indian Tribe(s) being served are made eligible, as a class, 

14 by an appropriate resolution of the governing body of the 

15 Indian Tribe or Tribal Organization providing such serv16 ices. The health needs of persons made eligible under this 

17 paragraph shall not be taken into consideration by the 

18 Service in determining the need for, or allocation of, its 

19 health resources. 

20 ‘‘(c) PROVISION OF SERVICES TO OTHER INDIVID21 UALS.—

22 ‘‘(1) IN GENERAL.—The Secretary is authorized 

23 to provide health services under this subsection 

24 through health programs operated directly by the 

25 Service to individuals who reside within the Service 
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1 Unit and who are not otherwise eligible for such 

2 health services if—

3 ‘‘(A) the Indian Tribes served by such 

4 Service Unit request such provision of health 

5 services to such individuals; and 

6 ‘‘(B) the Secretary and the served Indian 

7 Tribes have jointly determined that—

8 ‘‘(i) the provision of such health serv9 ices will not result in a denial or diminu10 tion of health services to eligible Indians; 

11 and 

12 ‘‘(ii) there is no reasonable alternative 

13 health facilities or services, within or with14 out the Service Unit, available to meet the 

15 health needs of such individuals. 

16 ‘‘(2) ISDEAA PROGRAMS.—In the case of a 

17 Tribal Health Program, the governing body of the 

18 Indian Tribe or Tribal Organization providing health 

19 services under such Tribal Health Program is au20 thorized to determine whether health services should 

21 be provided under its Funding Agreement to individ22 uals who are not otherwise eligible for such services. 

23 In making such determination, the governing body 

24 shall take into account the considerations described 

25 in clauses (i) and (ii) of paragraph (1)(B). 
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1 ‘‘(3) PAYMENT FOR SERVICES.—

2 ‘‘(A) IN GENERAL.—Persons receiving 

3 health services provided by the Service under of 

4 this subsection shall be liable for payment of 

5 such health services under a schedule of charges 

6 prescribed by the Secretary which, in the judg7 ment of the Secretary, results in reimbursement 

8 in an amount not less than the actual cost of 

9 providing the health services. Notwithstanding 

10 section 1880(c) of the Social Security Act, sec11 tion 404 of this Act, or any other provision of 

12 law, amounts collected under this subsection, 

13 including medicare, medicaid, or SCHIP reim14 bursements under titles XVIII, XIX, and XXI 

15 of the Social Security Act, shall be credited to 

16 the account of the program providing the serv17 ice and shall be used for the purposes listed in 

18 section 401(d)(2) and amounts collected under 

19 this subsection shall be available for expendi20 ture within such program. 

21 ‘‘(B) INDIGENT PEOPLE.—Health services 

22 may be provided by the Secretary through the 

23 Service under this subsection to an indigent in24 dividual who would not be otherwise eligible for 

25 such health services but for the provisions of 
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1 paragraph (1) only if an agreement has been 

2 entered into with a State or local government 

3 under which the State or local government 

4 agrees to reimburse the Service for the expenses 

5 incurred by the Service in providing such health 

6 services to such indigent individual. 

7 ‘‘(4) REVOCATION OF CONSENT FOR SERV8 ICES.—

9 ‘‘(A) SINGLE TRIBE SERVICE AREA.—In 

10 the case of a Service Area which serves only 1 

11 Indian Tribe, the authority of the Secretary to 

12 provide health services under paragraph (1) 

13 shall terminate at the end of the fiscal year suc14 ceeding the fiscal year in which the governing 

15 body of the Indian Tribe revokes its concur16 rence to the provision of such health services. 

17 ‘‘(B) MULTITRIBAL SERVICE AREA.—In 

18 the case of a multitribal Service Area, the au19 thority of the Secretary to provide health serv20 ices under paragraph (1) shall terminate at the 

21 end of the fiscal year succeeding the fiscal year 

22 in which at least 51 percent of the number of 

23 Indian Tribes in the Service Area revoke their 

24 concurrence to the provisions of such health 

25 services. 
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1 ‘‘(d) OTHER SERVICES.—The Service may provide 

2 health services under this subsection to individuals who 

3 are not eligible for health services provided by the Service 

4 under any other provision of law in order to—

5 ‘‘(1) achieve stability in a medical emergency; 

6 ‘‘(2) prevent the spread of a communicable dis7 ease or otherwise deal with a public health hazard; 

8 ‘‘(3) provide care to non-Indian women preg9 nant with an eligible Indian’s child for the duration 

10 of the pregnancy through postpartum; or 

11 ‘‘(4) provide care to immediate family members 

12 of an eligible person if such care is directly related 

13 to the treatment of the eligible individual. 

14 ‘‘(e) HOSPITAL PRIVILEGES FOR PRACTITIONERS.—

15 Hospital privileges in health facilities operated and main16 tained by the Service or operated under a Funding Agree17 ment may be extended to non-Service health care practi18 tioners who provide services to individuals described in 

19 subsection (a), (b), (c), or (d). Such non-Service health 

20 care practitioners may be regarded as employees of the 

21 Federal Government for purposes of section 1346(b) and 

22 chapter 171 of title 28, United States Code (relating to 

23 Federal tort claims) only with respect to acts or omissions 

24 which occur in the course of providing services to eligible 
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1 persons as a part of the conditions under which such hos2 pital privileges are extended. 

3 ‘‘(f) ELIGIBLE INDIAN.—For purposes of this sec4 tion, the term ‘eligible Indian’ means any Indian who is 

5 eligible for health services provided by the Service without 

6 regard to the provisions of this section. 

7 ‘‘SEC. 808. REALLOCATION OF BASE RESOURCES. 

8 ‘‘(a) REPORT REQUIRED.—Notwithstanding any 

9 other provision of law, any allocation of Service funds for 

10 a fiscal year that reduces by 5 percent or more from the 

11 previous fiscal year the funding for any recurring pro12 gram, project, or activity of a Service Unit may be imple13 mented only after the Secretary has submitted to the 

14 President, for inclusion in the report required to be trans15 mitted to Congress under section 801, a report on the pro16 posed change in allocation of funding, including the rea17 sons for the change and its likely effects. 

18 ‘‘(b) EXCEPTION.—Subsection (a) shall not apply if 

19 the total amount appropriated to the Service for a fiscal 

20 year is at least 5 percent less than the amount appro21 priated to the Service for the previous fiscal year.

22 ‘‘SEC. 809. RESULTS OF DEMONSTRATION PROJECTS. 

23 ‘‘The Secretary shall provide for the dissemination to 

24 Indian Tribes, Tribal Organizations, and Urban Indian 
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1 Organizations of the findings and results of demonstration 

2 projects conducted under this Act. 

3 ‘‘SEC. 810. PROVISION OF SERVICES IN MONTANA. 

4 ‘‘(a) CONSISTENT WITH COURT DECISION.—The 

5 Secretary, acting through the Service, shall provide serv6 ices and benefits for Indians in Montana in a manner con7 sistent with the decision of the United States Court of Ap8 peals for the Ninth Circuit in McNabb for McNabb v. 

9 Bowen, 829 F.2d 787 (9th Cir. 1987). 

10 ‘‘(b) CLARIFICATION.—The provisions of subsection 

11 (a) shall not be construed to be an expression of the sense 

12 of Congress on the application of the decision described 

13 in subsection (a) with respect to the provision of services 

14 or benefits for Indians living in any State other than Mon15 tana. 

16 ‘‘SEC. 811. MORATORIUM. 

17 ‘‘During the period of the moratorium imposed on 

18 implementation of the final rule published in the Federal 

19 Register on September 16, 1987, by the Health Resources 

20 and Services Administration of the Public Health Service, 

21 relating to eligibility for the health care services of the 

22 Indian Health Service, the Indian Health Service shall 

23 provide services pursuant to the criteria for eligibility for 

24 such services that were in effect on September 15, 1987, 

25 subject to the provisions of sections 806 and 807 until 
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1 such time as new criteria governing eligibility for services 

2 are developed in accordance with section 802. 

3 ‘‘SEC. 812. TRIBAL EMPLOYMENT. 

4 ‘‘For purposes of section 2(2) of the Act of July 5, 

5 1935 (49 Stat. 450, chapter 372), an Indian Tribe or 

6 Tribal Organization carrying out a Funding Agreement 

7 shall not be considered an ‘employer’. 

8 ‘‘SEC. 813. PRIME VENDOR. 

9 ‘‘(a) EXECUTIVE AGENCY STATUS.—For purposes of 

10 section 201(a) of the Federal Property and Administrative 

11 Services Act (40 U.S.C. 481(a)) (relating to Federal 

12 sources of supply, including lodging providers, airlines, 

13 and other transportation providers), a Tribal Health Pro14 gram shall be deemed an executive agency when carrying 

15 out a contract, grant, cooperative agreement, or Funding 

16 Agreement with the Service and shall have access to the 

17 Federal Supply Schedule and any other Federal source of 

18 supply to which executive agencies have access. 

19 ‘‘(b) HHS STATUS.—For purposes of section 4 of 

20 Public Law 102–585 (38 U.S.C. 8126), a Tribal Health 

21 Program shall have the status of the Indian Health Serv22 ice and shall have direct access to the Veterans Adminis23 tration prime vendor provided for in section 4 of Public 

24 Law 102–585. 
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1 ‘‘(c) EMPLOYEE STATUS.—The employees of such 

2 Tribal Health Programs may order supplies under such 

3 respective programs on the same basis as employees of the 

4 Service. 

5 ‘‘SEC. 814. SEVERABILITY PROVISIONS. 

6 ‘‘If any provision of this Act, any amendment made 

7 by the Act, or the application of such provision or amend8 ment to any person or circumstances is held to be invalid, 

9 the remainder of this Act, the remaining amendments 

10 made by this Act, and the application of such provisions 

11 to persons or circumstances other than those to which it 

12 is held invalid, shall not be affected thereby. 

13 ‘‘SEC. 815. ESTABLISHMENT OF NATIONAL BIPARTISAN 

14 COMMISSION ON INDIAN HEALTH CARE ENTI15 TLEMENT. 

16 ‘‘(a) ESTABLISHMENT.—There is hereby established 

17 the National Bipartisan Indian Health Care Entitlement 

18 Commission (the ‘Commission’). 

19 ‘‘(b) DUTIES OF COMMISSION.—The duties of the 

20 Commission are the following: 

21 ‘‘(1) To establish a study committee composed 

22 of those members of the Commission appointed by 

23 the Director and at least 4 members of Congress 

24 from among the members of the Commission, the 

25 duties of which shall be the following: 
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1 ‘‘(A) To the extent necessary to carry out 

2 its duties, collect and compile data necessary to 

3 understand the extent of Indian needs with re4 gard to the provision of health services, regard5 less of the location of Indians, including holding 

6 hearings and soliciting the views of Indians, In7 dian Tribes, Tribal Organizations, and Urban 

8 Indian Organizations, which may include au9 thorizing and making funds available for feasi10 bility studies of various models for providing 

11 and funding health services for all Indian bene12 ficiaries, including those who live outside of a 

13 reservation, temporarily or permanently. 

14 ‘‘(B) To make recommendations to the 

15 Commission for legislation that will provide for 

16 the delivery of health services for Indians as an 

17 entitlement, which will address, among other 

18 things, issues of eligibility, benefits to be pro19 vided, including recommendations regarding 

20 from whom such health services are to be pro21 vided and the cost, including mechanisms for 

22 making funds available for the health services 

23 to be provided.

24 ‘‘(C) To determine the effect of the enact25 ment of such recommendations on (i) the exist-
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1 ing system of delivery of health services for In2 dians, and (ii) the sovereign status of Indian 

3 Tribes. 

4 ‘‘(D) Not later than 12 months after the 

5 appointment of all members of the Commission, 

6 to submit a written report of its findings and 

7 recommendations to the full Commission. The 

8 report shall include a statement of the minority 

9 and majority position of the Committee and 

10 shall be disseminated, at a minimum, to every 

11 Indian Tribe, Tribal Organization, and Urban 

12 Indian Organization for comment to the Com13 mission. 

14 ‘‘(E) To report regularly to the full Com15 mission regarding the findings and rec16 ommendations developed by the study com17 mittee in the course of carrying out its duties 

18 under this section. 

19 ‘‘(2) To review and analyze the recommenda20 tions of the report of the study committee. 

21 ‘‘(3) To make recommendations to Congress for 

22 providing health services for Indians as an entitle23 ment, giving due regard to the effects of such a pro24 gram on existing health care delivery systems for In-
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1 dians and the effect of such a program on the sov2 ereign status of Indian Tribes. 

3 ‘‘(4) Not later than 18 months following the 

4 date of appointment of all members of the Commis5 sion, submit a written report to Congress containing 

6 a recommendation of policies and legislation to im7 plement a policy that would establish a health care 

8 system for Indians based on delivery of health serv9 ices as an entitlement, together with a determination 

10 of the implications of such an entitlement system on 

11 existing health care delivery systems for Indians and 

12 on the sovereign status of Indian Tribes. 

13 ‘‘(c) MEMBERS.—

14 ‘‘(1) APPOINTMENT.—The Commission shall be 

15 composed of 25 members, appointed as follows: 

16 ‘‘(A) Ten members of Congress, including 

17 3 from the United States House of Representa18 tives and 2 from the United States Senate, ap19 pointed by their respective majority leaders, and 

20 3 from the United States House of Representa21 tives and 2 from the United States Senate, ap22 pointed by their respective minority leaders, and 

23 who shall be members of the standing commit24 tees of Congress that consider legislation affect25 ing health care to Indians. 
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1 ‘‘(B) Twelve persons chosen by the Con2 gressional members of the Commission, 1 from 

3 each Service Area as currently designated by 

4 the Director to be chosen from among 3 nomi5 nees from each Service Area put forward by the 

6 Indian Tribes within the area, with due regard 

7 being given to the experience and expertise of 

8 the nominees in the provision of health care to 

9 Indians and to a reasonable representation on 

10 the commission of members who are familiar 

11 with various health care delivery modes and 

12 who represent Indian Tribes of various size 

13 populations. 

14 ‘‘(C) Three persons appointed by the Di15 rector who are knowledgeable about the provi16 sion of health care to Indians, at least one of 

17 whom shall be appointed from among 3 nomi18 nees put forward by those programs whose 

19 funds are provided in whole or in part by the 

20 Service primarily or exclusively for the benefit 

21 of Urban Indians. 

22 ‘‘(D) All those persons chosen by the Con23 gressional members of the Commission and by 

24 the Director shall be members of federally rec25 ognized Indian Tribes. 
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1 ‘‘(2) CHAIR; VICE CHAIR.—The Chair and Vice 

2 Chair of the Commission shall be selected by the 

3 Congressional members of the Commission. 

4 ‘‘(3) TERMS.—The terms of members of the 

5 Commission shall be for the life of the Commission. 

6 ‘‘(4) DEADLINE FOR APPOINTMENTS.—Con7 gressional members of the Commission shall be ap8 pointed not later than 90 days after the date of the 

9 enactment of the Indian Health Care Improvement 

10 Act Amendments of 2003, and the remaining mem11 bers of the Commission shall be appointed not later 

12 than 60 days following the appointment of the Con13 gressional members. 

14 ‘‘(5) VACANCY.—A vacancy in the Commission 

15 shall be filled in the manner in which the original 

16 appointment was made. 

17 ‘‘(d) COMPENSATION.—

18 ‘‘(1) CONGRESSIONAL MEMBERS.—Each Con19 gressional member of the Commission shall receive 

20 no additional pay, allowances, or benefits by reason 

21 of their service on the Commission and shall receive 

22 travel expenses and per diem in lieu of subsistence 

23 in accordance with sections 5702 and 5703 of title 

24 5, United States Code. 
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1 ‘‘(2) OTHER MEMBERS.—Remaining members 

2 of the Commission, while serving on the business of 

3 the Commission (including travel time), shall be en4 titled to receive compensation at the per diem equiv5 alent of the rate provided for level IV of the Execu6 tive Schedule under section 5315 of title 5, United 

7 States Code, and while so serving away from home 

8 and the member’s regular place of business, a mem9 ber may be allowed travel expenses, as authorized by 

10 the Chairman of the Commission. For purpose of 

11 pay (other than pay of members of the Commission) 

12 and employment benefits, rights, and privileges, all 

13 personnel of the Commission shall be treated as if 

14 they were employees of the United States Senate. 

15 ‘‘(e) MEETINGS.—The Commission shall meet at the 

16 call of the Chair. 

17 ‘‘(f) QUORUM.—A quorum of the Commission shall 

18 consist of not less than 15 members, provided that no less 

19 than 6 of the members of Congress who are Commission 

20 members are present and no less than 9 of the members 

21 who are Indians are present. 

22 ‘‘(g) EXECUTIVE DIRECTOR; STAFF; FACILITIES.—

23 ‘‘(1) APPOINTMENT; PAY.—The Commission 

24 shall appoint an executive director of the Commis-
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1 sion. The executive director shall be paid the rate of 

2 basic pay for level V of the Executive Schedule. 

3 ‘‘(2) STAFF APPOINTMENT.—With the approval 

4 of the Commission, the executive director may ap5 point such personnel as the executive director deems 

6 appropriate. 

7 ‘‘(3) STAFF PAY.—The staff of the Commission 

8 shall be appointed without regard to the provisions 

9 of title 5, United States Code, governing appoint10 ments in the competitive service, and shall be paid 

11 without regard to the provisions of chapter 51 and 

12 subchapter III of chapter 53 of such title (relating 

13 to classification and General Schedule pay rates). 

14 ‘‘(4) TEMPORARY SERVICES.—With the ap15 proval of the Commission, the executive director may 

16 procure temporary and intermittent services under 

17 section 3109(b) of title 5, United States Code. 

18 ‘‘(5) FACILITIES.—The Administrator of Gen19 eral Services shall locate suitable office space for the 

20 operation of the Commission. The facilities shall 

21 serve as the headquarters of the Commission and 

22 shall include all necessary equipment and incidentals 

23 required for the proper functioning of the Commis24 sion. 
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1 ‘‘(h) HEARINGS.—(1) For the purpose of carrying 

2 out its duties, the Commission may hold such hearings 

3 and undertake such other activities as the Commission de4 termines to be necessary to carry out its duties, provided 

5 that at least 6 regional hearings are held in different areas 

6 of the United States in which large numbers of Indians 

7 are present. Such hearings are to be held to solicit the 

8 views of Indians regarding the delivery of health care serv9 ices to them. To constitute a hearing under this sub10 section, at least 5 members of the Commission, including 

11 at least 1 member of Congress, must be present. Hearings 

12 held by the study committee established in this section 

13 may count towards the number of regional hearings re14 quired by this subsection. 

15 ‘‘(2) Upon request of the Commission, the Comp16 troller General shall conduct such studies or investigations 

17 as the Commission determines to be necessary to carry 

18 out its duties. 

19 ‘‘(3)(A) The Director of the Congressional Budget 

20 Office or the Chief Actuary of the Centers for Medicare 

21 and Medicaid Services, or both, shall provide to the Com22 mission, upon the request of the Commission, such cost 

23 estimates as the Commission determines to be necessary 

24 to carry out its duties. 
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1 ‘‘(B) The Commission shall reimburse the Director 

2 of the Congressional Budget Office for expenses relating 

3 to the employment in the office of the Director of such 

4 additional staff as may be necessary for the Director to 

5 comply with requests by the Commission under subpara6 graph (A). 

7 ‘‘(4) Upon the request of the Commission, the head 

8 of any Federal agency is authorized to detail, without re9 imbursement, any of the personnel of such agency to the 

10 Commission to assist the Commission in carrying out its 

11 duties. Any such detail shall not interrupt or otherwise 

12 affect the civil service status or privileges of the Federal 

13 employee. 

14 ‘‘(5) Upon the request of the Commission, the head 

15 of a Federal agency shall provide such technical assistance 

16 to the Commission as the Commission determines to be 

17 necessary to carry out its duties. 

18 ‘‘(6) The Commission may use the United States 

19 mails in the same manner and under the same conditions 

20 as Federal agencies and shall, for purposes of the frank, 

21 be considered a commission of Congress as described in 

22 section 3215 of title 39, United States Code. 

23 ‘‘(7) The Commission may secure directly from any 

24 Federal agency information necessary to enable it to carry 

25 out its duties, if the information may be disclosed under 
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1 section 552 of title 4, United States Code. Upon request 

2 of the Chairman of the Commission, the head of such 

3 agency shall furnish such information to the Commission. 

4 ‘‘(8) Upon the request of the Commission, the Ad5 ministrator of General Services shall provide to the Com6 mission on a reimbursable basis such administrative sup7 port services as the Commission may request. 

8 ‘‘(9) For purposes of costs relating to printing and 

9 binding, including the cost of personnel detailed from the 

10 Government Printing Office, the Commission shall be 

11 deemed to be a committee of Congress. 

12 ‘‘(i) AUTHORIZATION OF APPROPRIATIONS.—There is 

13 authorized to be appropriated $4,000,000 to carry out the 

14 provisions of this section, which sum shall not be deducted 

15 from or affect any other appropriation for health care for 

16 Indian persons. 

17 ‘‘(j) FACA.—The Federal Advisory Committee Act 

18 (5 U.S.C. App.) shall not apply to the Commission. 

19 ‘‘SEC. 816. APPROPRIATIONS; AVAILABILITY. 

20 ‘‘Any new spending authority (described in subsection 

21 (c)(2)(A) or (B) of section 401 of the Congressional Budg22 et Act of 1974) which is provided under this Act shall 

23 be effective for any fiscal year only to such extent or in 

24 such amounts as are provided in appropriation Acts. 
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1 ‘‘SEC. 817. CONFIDENTIALITY OF MEDICAL QUALITY ASSUR2 ANCE RECORDS: QUALIFIED IMMUNITY FOR 

3 PARTICIPANTS. 

4 ‘‘(a) CONFIDENTIALITY OF RECORDS.—Medical qual5 ity assurance records created by or for any Indian Health 

6 Program or a health program of an Urban Indian Organi7 zation as part of a medical quality assurance program are 

8 confidential and privileged. Such records may not be dis9 closed to any person or entity, except as provided in sub10 section (c). 

11 ‘‘(b) PROHIBITION ON DISCLOSURE AND TESTI12 MONY.—

13 ‘‘(1) No part of any medical quality assurance 

14 record described in subsection (a) may be subject to 

15 discovery or admitted into evidence in any judicial or 

16 administrative proceeding, except as provided in sub17 section (c). 

18 ‘‘(2) A person who reviews or creates medical 

19 quality assurance records for any Indian health pro20 gram or who participates in any proceeding that re21 views or creates such records may not be permitted 

22 or required to testify in any judicial or administra23 tive proceeding with respect to such records or with

24 respect to any finding, recommendation, evaluation, 

25 opinion, or action taken by such person or body in 
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1 connection with such records except as provided in 

2 this section. 

3 ‘‘(c) AUTHORIZED DISCLOSURE AND TESTIMONY.—

4 ‘‘(1) Subject to paragraph (2), a medical qual5 ity assurance record described in subsection (a) may 

6 be disclosed, and a person referred to in subsection 

7 (b) may give testimony in connection with such a 

8 record, only as follows: 

9 ‘‘(A) To a Federal executive agency or pri10 vate organization, if such medical quality assur11 ance record or testimony is needed by such 

12 agency or organization to perform licensing or 

13 accreditation functions related to any Indian 

14 Health Program or to a health program of an 

15 Urban Indian Organization to perform moni16 toring, required by law, of such program or or17 ganization. 

18 ‘‘(B) To an administrative or judicial pro19 ceeding commenced by a present or former In20 dian Health Program or Urban Indian Organi21 zation provider concerning the termination, sus22 pension, or limitation of clinical privileges of 

23 such health care provider. 

24 ‘‘(C) To a governmental board or agency 

25 or to a professional health care society or orga-
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1 nization, if such medical quality assurance 

2 record or testimony is needed by such board, 

3 agency, society, or organization to perform li4 censing, credentialing, or the monitoring of pro5 fessional standards with respect to any health 

6 care provider who is or was an employee of any 

7 Indian Health Program or Urban Indian Orga8 nization. 

9 ‘‘(D) To a hospital, medical center, or 

10 other institution that provides health care serv11 ices, if such medical quality assurance record or 

12 testimony is needed by such institution to as13 sess the professional qualifications of any health 

14 care provider who is or was an employee of any 

15 Indian Health Program or Urban Indian Orga16 nization and who has applied for or been grant17 ed authority or employment to provide health 

18 care services in or on behalf of such program or 

19 organization. 

20 ‘‘(E) To an officer, employee, or contractor 

21 of any Indian Health Program or Urban Indian 

22 Organization who has a need for such record or 

23 testimony to perform official duties. 

24 ‘‘(F) To a criminal or civil law enforce25 ment agency or instrumentality charged under 
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1 applicable law with the protection of the public 

2 health or safety, if a qualified representative of 

3 such agency or instrumentality makes a written 

4 request that such record or testimony be pro5 vided for a purpose authorized by law. 

6 ‘‘(G) In an administrative or judicial pro7 ceeding commenced by a criminal or civil law 

8 enforcement agency or instrumentality referred 

9 to in subparagraph (F), but only with respect 

10 to the subject of such proceeding. 

11 ‘‘(2) With the exception of the subject of a 

12 quality assurance action, the identity of any person 

13 receiving health care services from any Indian 

14 Health Program or Urban Indian Organization or 

15 the identity of any other person associated with such 

16 program or organization for purposes of a medical 

17 quality assurance program that is disclosed in a 

18 medical quality assurance record described in sub19 section (a) shall be deleted from that record or docu20 ment before any disclosure of such record is made 

21 outside such program or organization. Such require22 ment does not apply to the release of information 

23 pursuant to section 552a of title 5. 

24 ‘‘(d) DISCLOSURE FOR CERTAIN PURPOSES.—
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1 ‘‘(1) Nothing in this section shall be construed 

2 as authorizing or requiring the withholding from any 

3 person or entity aggregate statistical information re4 garding the results of any Indian Health Program or 

5 Urban Indian Organizations’s medical quality assur6 ance programs. 

7 ‘‘(2) Nothing in this section shall be construed 

8 as authority to withhold any medical quality assur9 ance record from a committee of either House of 

10 Congress, any joint committee of Congress, or the 

11 General Accounting Office if such record pertains to 

12 any matter within their respective jurisdictions. 

13 ‘‘(e) PROHIBITION ON DISCLOSURE OF RECORD OR

14 TESTIMONY.—A person or entity having possession of or 

15 access to a record or testimony described by this section 

16 may not disclose the contents of such record or testimony 

17 in any manner or for any purpose except as provided in 

18 this section. 

19 ‘‘(f) EXEMPTION FROM FREEDOM OF INFORMATION

20 ACT.—Medical quality assurance records described in sub21 section (a) may not be made available to any person under 

22 section 552 of title 5. 

23 ‘‘(g) LIMITATION ON CIVIL LIABILITY.—A person 

24 who participates in or provides information to a person 

25 or body that reviews or creates medical quality assurance 
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1 records described in subsection (a) shall not be civilly lia2 ble for such participation or for providing such informa3 tion if the participation or provision of information was 

4 in good faith based on prevailing professional standards 

5 at the time the medical quality assurance program activity 

6 took place. 

7 ‘‘(h) APPLICATION TO INFORMATION IN CERTAIN

8 OTHER RECORDS.—Nothing in this section shall be con9 strued as limiting access to the information in a record 

10 created and maintained outside a medical quality assur11 ance program, including a patient’s medical records, on 

12 the grounds that the information was presented during 

13 meetings of a review body that are part of a medical qual14 ity assurance program. 

15 ‘‘(i) REGULATIONS.—The Secretary, acting through 

16 the Service, shall promulgate regulations pursuant to sec17 tion 802 of this title. 

18 ‘‘(j) DEFINITIONS.—In this section: 

19 ‘‘(1) The term ‘medical quality assurance pro20 gram’ means any activity carried out before, on, or 

21 after the date of enactment of this Act by or for any 

22 Indian Health Program or Urban Indian Organiza23 tion to assess the quality of medical care, including

24 activities conducted by individuals, military medical 

25 or dental treatment facility committees, or other re-
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1 view bodies responsible for quality assurance, cre2 dentials, infection control, patient care assessment 

3 (including treatment procedures, blood, drugs, and 

4 therapeutics), medical records, health resources 

5 management review and identification and preven6 tion of medical or dental incidents and risks. 

7 ‘‘(2) The term ‘medical quality assurance 

8 record’ means the proceedings, records, minutes, and 

9 reports that emanate from quality assurance pro10 gram activities described in paragraph (1) and are 

11 produced or compiled by an Indian Health Program 

12 or Urban Indian Organization as part of a medical 

13 quality assurance program. 

14 ‘‘(3) The term ‘health care provider’ means any 

15 health care professional, including community health 

16 aides and practitioners certified under section 121, 

17 who are granted clinical practice privileges or em18 ployed to provide health care services in an Indian 

19 Health Program or health program of an Urban In20 dian Organization, who is licensed or certified to 

21 perform health care services by a governmental 

22 board or agency or professional health care society 

23 or organization. 
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1 ‘‘SEC. 818. AUTHORIZATION OF APPROPRIATIONS. 

2 ‘‘There are authorized to be appropriated such sums 

3 as may be necessary for each fiscal year through fiscal 

4 year 2015 to carry out this title.’’. 

5 SEC. 3. SOBOBA SANITATION FACILITIES. 

6 The Act of December 17, 1970 (84 Stat. 1465), is 

7 amended by adding at the end the following new section: 

8 ‘‘SEC. 9. Nothing in this Act shall preclude the 

9 Soboba Band of Mission Indians and the Soboba Indian 

10 Reservation from being provided with sanitation facilities 

11 and services under the authority of section 7 of the Act 

12 of August 5, 1954 (68 Stat. 674), as amended by the Act 

13 of July 31, 1959 (73 Stat. 267).’’.

14 SEC. 4. AMENDMENTS TO MEDICARE PROGRAM. 

15 (a) EXPANSION OF MEDICARE PAYMENT FOR ALL

16 COVERED SERVICES FURNISHED BY INDIAN HEALTH

17 PROGRAMS.—

18 (1) EXPANSION TO ALL COVERED SERVICES.—

19 Section 1880 of the Social Security Act (42 U.S.C. 

20 1395qq) is amended—

21 (A) by amending the heading to read as 

22 follows: 

23 ‘‘INDIAN HEALTH PROGRAMS’’; 

24 (B) by amending subsection (a) to read as 

25 follows: 
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1 ‘‘(a) An Indian Health Program (as that term is de2 fined in section 4 of the Indian Health Care Improvement 

3 Act) shall be eligible for payments under this title, not4 withstanding sections 1814(c) and 1835(d), with respect 

5 to covered items and services it furnishes if (subject to 

6 section 408 of such Act) it meets the conditions and re7 quirements for such payments which apply to the fur8 nishing of such items and services under this title.’’; and 

9 (C) by striking subsection (e). 

10 (2) ELIMINATION OF TEMPORARY DEEMING

11 PROVISION, SEPARATE FUND REQUIREMENT, AND

12 DUPLICATIVE ANNUAL REPORT.—Such section is 

13 amended by striking subsections (b) through (d). 

14 (3) REFERENCE CORRECTION.—Subsection (f) 

15 of such section is redesignated as subsection (b) and 

16 is amended by striking ‘‘section 405’’ and inserting 

17 ‘‘section 401(d)’’. 

18 (b) LIMITATION ON CHARGES FOR HOSPITAL CON19 TRACT HEALTH SERVICES PROVIDED TO INDIANS BY

20 MEDICARE PARTICIPATING HOSPITALS.—

21 (1) IN GENERAL.—Section 1866(a)(1) of the 

22 Social Security Act (42 U.S.C. 1395cc(a)(1)) is 

23 amended—

24 (A) in subparagraph (R), by striking 

25 ‘‘and’’ at the end; 
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1 (B) in subparagraph (S), by striking the 

2 period and inserting ‘‘, and’’; and 

3 (C) by adding at the end the following new 

4 subparagraph: 

5 ‘‘(T) in the case of hospitals and critical 

6 access hospitals which furnish services for 

7 which payment may be made under this title to 

8 be a participating provider—

9 ‘‘(i) under the contract health services 

10 program operated by an Indian Health 

11 Program (as those terms are defined in 

12 section 4 of the Indian Health Care Im13 provement Act), with respect to items and 

14 services that are covered under and fur15 nished to an individual eligible for such 

16 program; and 

17 ‘‘(ii) under a program funded by the 

18 Indian Health Service and operated by an 

19 Urban Indian Organization with respect to 

20 the purchase of items and services for an 

21 eligible Urban Indian (as those terms are 

22 defined in section 4 of the Indian Health 

23 Care Improvement Act (25 U.S.C. 1603); 

24 in accordance with regulations promulgated by 

25 the Secretary regarding admission practices, 
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1 payment methodology, and rates of payment 

2 (including the acceptance of not more than such 

3 payment rate as payment in full for such items 

4 and services).’’. 

5 (2) EFFECTIVE DATE.—The amendments made 

6 by paragraph (1) shall apply as of a date specified 

7 by the Secretary of Health and Human Services (but 

8 in no case later than 6 months after the date of the 

9 enactment of this Act) to medicare participation 

10 agreements in effect (or entered into) on or after 

11 such date. 

12 (c) MEDICARE COVERAGE OF SERVICES OF COMMU13 NITY HEALTH AIDES OR PRACTITIONERS.—

14 (1) IN GENERAL.—Section 1861 of such Act 

15 (42 U.S.C. 1395x) is amended—

16 (A) in subsection (s)(2)(K)—

17 (i) in clause (ii), by adding ‘‘and’’ at 

18 the end; and 

19 (ii) by adding at the end the following 

20 new clause: 

21 ‘‘(iii) services which would be physicians’ serv22 ices if furnished by a physician (as defined in sub23 section (r)(1)) and which are performed by a com24 munity health aide or practitioner which the aide or 

25 practitioner is legally authorized to perform, and
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1 such services and supplies furnished as incident to 

2 such services as would be covered under subpara3 graph (A) if furnished incident to a physician’s pro4 fessional service but only if no other provider 

5 charges or is paid any amounts with respect to the 

6 professional fee for furnishing of such services (and, 

7 in the case of a telehealth service described in sec8 tion 1834(m), treating services at the originating 

9 site and the distant site as separate services);’’; and 

10 (B) by adding at the end the following new 

11 subsection: 

12 ‘‘Community Health Aides or Practitioners 

13 ‘‘(ww) The term ‘community health aides or practi14 tioner’ means such an aide or practitioner who has been 

15 certified under the provisions of section 121 of the Indian 

16 Health Care Improvement Act and who only provides serv17 ices as an employee of the Indian Health Service, an In18 dian Tribe, or Tribal Organization.’’. 

19 (2) PAYMENT.—

20 (A) PAYMENT RATE.—Section 

21 1833(a)(1)(O) of such Act (42 U.S.C. 

22 1395l(a)(1)(O)) is amended—

23 (i) by striking ‘‘or’’ before ‘‘(ii)’’; and 

24 (ii) by adding at the end the fol25 lowing: ‘‘or (iii) in the case of services of 
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1 a community health aide or practitioner, 

2 the lesser of the actual charge or 80 per3 cent of the fee schedule amount provided 

4 under section 1848,’’. 

5 (B) LIMITATION ON BALANCE BILLING.—

6 Section 1842(b)(18)(C) of such Act (42 U.S.C. 

7 1395u(b)(18)(C)) is amended by adding at the 

8 end the following new clause: 

9 ‘‘(vii) A community health aide or practi10 tioner.’’. 

11 (3) EFFECTIVE DATE.—The amendments made 

12 by this subsection shall apply to services furnished 

13 on or after January 1, 2004. 

14 (d) CONTINUATION OF SPECIAL TREATMENT FOR

15 COLLABORATIVE ARRANGEMENTS BETWEEN INDIAN

16 HEALTH PROGRAMS AND HOSPITAL OUTPATIENT DE17 PARTMENTS.—Section 1833(t)(13) of the Social Security 

18 Act (42 U.S.C. 1395l(t)(13)) is amended by adding at the 

19 end the following new subparagraph: 

20 ‘‘(B) EXTENSION OF TREATMENT OF CER21 TAIN COLLABORATIVE ARRANGEMENTS.—With 

22 respect to the treatment under this subsection 

23 of collaborative arrangements between a health 

24 program operated by the Indian Health Service, 

25 an Indian Tribe, or Tribal Organization and a 
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1 hospital operated by such Service or such an 

2 Indian Tribe or Tribal Organization, the Sec3 retary shall reinstate treatment (as in effect on 

4 January 1, 2000) and extend it to such collabo5 rative arrangements regardless of when they 

6 were entered into.’’. 

7 (e) COVERAGE OF VISITING NURSE SERVICES OF

8 TRIBAL CLINICS.—

9 (1) IN GENERAL.—Section 1861(aa)(1) of the 

10 Social Security Act (42 U.S.C. 1395x(aa)(1)) is 

11 amended by adding at the end the following: 

12 ‘‘For purposes of applying subparagraph (C) (relating to 

13 visiting nurse services), an ambulatory care clinic or other 

14 outpatient program of the Indian Health Service or of an 

15 Indian Tribe or a Tribal Organization (as such terms are 

16 defined in section 4 of the Indian Health Care Improve17 ment Act) shall be treated as if it were a rural health clinic 

18 located in an area described in such subparagraph, and 

19 nursing care and supplies described in such subparagraph 

20 and furnished to an individual as an outpatient of such 

21 a tribal clinic or program shall be reimbursable under this 

22 title using the methodology specified in section 4(f) of the 

23 Indian Health Care Improvement Act Amendments of 

24 2003, and, for purposes of this sentence, any reference 
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1 in such subparagraph (C) to a licensed practical nurse is 

2 also deemed to include a reference to a home health aide.’’. 

3 (2) EFFECTIVE DATE.—The amendment made 

4 by paragraph (1) shall apply services furnished on or 

5 after January 1, 2004. 

6 (f) MEDICARE PAYMENT FOR OUTPATIENT CLIN7 ICS.—

8 (1) IN GENERAL.—Notwithstanding any other 

9 provision of law, for purposes of determining the 

10 rate of reimbursement under title XVIII of the So11 cial Security Act, any outpatient or ambulatory care 

12 clinic (whether freestanding or provider-based) oper13 ated by the Indian Health Service, by an Indian 

14 Tribe, or by a Tribal Organization (as such terms 

15 are defined for purposes of the Indian Health Care 

16 Improvement Act) shall, upon the election of such 

17 clinic, be reimbursed on the same basis as if such 

18 clinic were a hospital outpatient department of the 

19 Indian Health Service. 

20 (2) EFFECTIVE DATE.—Paragraph (1) shall 

21 apply to payment for services furnished on or after 

22 January 1, 2004. 

23 (g) REVIEW OF MEDICARE AND MEDICAID PAYMENT

24 SYSTEMS.—

25 (1) STUDY.—
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1 (A) IN GENERAL.—The Secretary of 

2 Health and Human Services shall conduct a re3 view of the extent to which the payment meth4 odologies applicable under titles XVIII and XIX 

5 of the Social Security Act (including under sec6 tion 1880 of such Act, as amended by this sec7 tion, section 1911 of such Act, as amended by 

8 section 5(a), and including payment methodolo9 gies in effect at the time the review is under10 taken and payment methodologies effected 

11 under this section or section 5) take into ac12 count the unique or special circumstances of the 

13 provision of covered services to Indians by the 

14 Indian Health Service, Indian Tribes, Tribal 

15 Organizations, and Urban Indian Organizations 

16 (as such terms are defined in section 4 of the 

17 Indian Health Care Improvement Act). 

18 (B) MATTERS CONSIDERED.—In par19 ticular, the Secretary shall review the suffi20 ciency of the payment amounts under such 

21 methodologies in assuring access to care and 

22 payment rates consistent with the payment 

23 rates for most favored providers. 

24 (C) CONSULTATION.—In conducting the 

25 study, the Secretary shall consult with the In-
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1 dian Health Service, Indian Tribes, Tribal Or2 ganizations, and Urban Indian Organizations. 

3 (2) REPORT.—Not later than 2 years after the 

4 date of implementation of the amendments made by 

5 subsection (a) (or, if later, the date of implementa6 tion of the amendments made by section 5(a)), the 

7 Secretary shall submit to Congress a report on the 

8 review under paragraph (1). Such report shall in9 clude recommendations for such adjustments to such 

10 payment methodologies as may be necessary to as11 sure that payment amounts under the medicare and 

12 medicaid programs to such Service, Indian Tribes, 

13 Tribal Organizations, and Urban Indian Organiza14 tions are sufficient to provide access to quality care. 

15 (3) RETENTION OF CURRENT PAYMENT METH16 ODOLOGY.—Notwithstanding any other provision of 

17 law, the Secretary shall retain the all-inclusive pay18 ment methodology for encounter rates for the Indian 

19 Health Service, Indian Tribes, and Tribal Organiza20 tions under titles XVIII and XIX of the Social Secu21 rity Act unless the use of such methodology is ex22 pressly prohibited or otherwise superceded by Act of 

23 Congress. 
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1 SEC. 5. AMENDMENTS TO MEDICAID PROGRAM AND STATE 

2 CHILDREN’S HEALTH INSURANCE PROGRAM 

3 (SCHIP). 

4 (a) EXPANSION OF MEDICAID PAYMENT FOR ALL

5 COVERED SERVICES FURNISHED BY INDIAN HEALTH

6 PROGRAMS.—

7 (1) EXPANSION TO ALL COVERED SERVICES.—

8 Section 1911 of the Social Security Act (42 U.S.C. 

9 1396j) is amended—

10 (A) by amending the heading to read as 

11 follows: 

12 ‘‘INDIAN HEALTH PROGRAMS’’; and 

13 (B) by amending subsection (a) to read as 

14 follows: 

15 ‘‘(a) The Indian Health Service and an Indian Tribe 

16 or Tribal Organization (as those terms are defined in sec17 tion 4 of the Indian Health Care Improvement Act) shall 

18 be eligible for reimbursement for medical assistance pro19 vided under a State plan with respect to covered items 

20 and services it furnishes if it meets all the conditions and 

21 requirements which are applicable generally to the fur22 nishing of such items and services under this title.’’. 

23 (2) ELIMINATION OF TEMPORARY DEEMING

24 PROVISION—Such section is amended by striking 

25 subsection (b). 
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1 (3) REVISION OF AUTHORITY TO ENTER INTO

2 AGREEMENTS.—Subsection (c) of such section is re3 designated as subsection (b) and is amended to read 

4 as follows: 

5 ‘‘(b) The Secretary may enter into agreements with 

6 the State agency for the purpose of reimbursing such 

7 agency for health care and services provided by the Indian 

8 Health Service, Indian Tribes, Tribal Organizations, or 

9 Urban Indian Organizations (as such terms are defined 

10 in section 4 of the Indian Health Care Improvement Act), 

11 directly, through referral, or under contracts or other ar12 rangements between the Indian Health Service, an Indian 

13 Tribe or Tribal Organization, or an Urban Indian Organi14 zation and another health care provider to Indians who 

15 are eligible for medical assistance under the State plan.’’. 

16 (4) REFERENCE CORRECTION.—Subsection (d) 

17 of such section is redesignated as subsection (c) and 

18 is amended by striking ‘‘section 405’’ and inserting 

19 ‘‘section 401(d)’’. 

20 (b) SEEKING ADVICE FROM INDIAN HEALTH PRO21 GRAMS.—Section 1902(a) of the Social Security Act (42 

22 U.S.C. 1396a(a)) is amended—

23 (1) in paragraph (64), by striking ‘‘and’’ at the 

24 end; 
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1 (2) in paragraph (65), by striking the period 

2 and inserting ‘‘; and’’; and 

3 (3) by inserting after paragraph (65), the fol4 lowing new paragraph: 

5 ‘‘(66) if the Indian Health Service operates or 

6 funds health programs in the State or if there are 

7 Indian Tribes, Tribal Organizations, or Urban In8 dian Organizations (as those terms are defined in 

9 section 4 of the Indian Health Care Improvement 

10 Act) providing health care in the State for which 

11 medical assistance is available, provide for the estab12 lishment and maintenance of the advisory process 

13 described in section 409(b) of such Act.’’. 

14 (c) SCHIP TREATMENT OF INDIAN TRIBES, TRIBAL

15 ORGANIZATIONS, AND URBAN INDIAN ORGANIZATIONS.—

16 Section 2105(c)(6)(B) of such Act (42 U.S.C. 

17 1397ee(c)(6)(B)) is amended by inserting ‘‘or by an In18 dian Tribe, Tribal Organization, or Urban Indian Organi19 zation (as such terms are defined in section 4 of the In20 dian Health Care Improvement Act)’’ after ‘‘Service’’.

Æ