69–010 

1The original Act defines the term ‘‘Indian’’ to include Indians and Alaska Natives. 

2 Healthy People 2010 is the major health agenda for the Nation. ‘‘It is a statement of national 

health objectives designed to identify the most significant preventable threats to health and to 

establish national goals to reduce these threats.’’ U.S. Department of Health and Human Services, www.healthypeople.gov. 

Calendar No. 421 

110TH CONGRESS REPORT " ! SENATE 1st Session 110–197 

INDIAN HEALTH CARE IMPROVEMENT ACT AMENDMENTS 

OF 2007 

OCTOBER 16, 2007.—Ordered to be printed 

Mr. DORGAN, from the Committee on Indian Affairs, 

submitted the following 

R E P O R T 

[To accompany S. 1200] 

The Committee on Indian Affairs, to which was referred the bill 

(S. 1200) to amend the Indian Health Care Improvement Act to revise and extend that Act, having considered the same, reports favorably thereon without amendment and recommends that the bill 

do pass. 

PURPOSE

The purpose of the Indian Health Care Improvement Act Amendments of 2007 (S. 1200) is to reauthorize the Act to maintain and 

improve the Indian health care delivery system. This legislation is 

intended to raise the health status of American Indians and Alaska 

Natives 1 to the highest possible level in accordance with Healthy 

People 2010.2

S. 1200 builds upon current law to set forth policies, programs 

and procedures designed to address health care deficiencies in Indian and urban Indian communities, and to streamline service delivery to those communities. In addition, S. 1200 addresses the 

health problems and associated socio-economic conditions in Native 

American communities by authorizing the Indian Health Service 

(IHS) and tribes to adopt current health industry ‘‘best practices.’’ 


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2 

3S. 2526 (106th Congress), S. 212 (107th Congress), S. 556 (108th Congress), S. 1200 and S. 

4122 (109th Congress). 

BACKGROUND

Enacted in 1976, the Act established the first comprehensive 

framework for the delivery of health care services for Native people, including various health programs, projects, and facilities. The 

Act was last reauthorized in 1992, and authorized funding for various programs through Fiscal Year 2000. Public Law 106–568 included a simple extension of the Act’s authority through FY 2001. 

Congress has continued to fund programs under the Act through 

the general permanent authority under the Snyder Act (25 U.S.C. 

13). 

THE REAUTHORIZATION PROCESS

The work on the latest reauthorization of the Indian Health Care 

Improvement Act began in 1999. Bills have been introduced since 

the 106th Congress 3 to provide numerous improvements and updates to current law, many of which are contained in S. 1200. 

In June, 1999, the Director of the IHS convened a National Tribal Steering Committee on the Reauthorization of the Indian Health 

Care Improvement Act (NSC), which was comprised of tribal leaders and representatives from Indian health organizations to facilitate the Act’s reauthorization. The NSC held a series of meetings 

in 1999, during which extensive discussions were held between the 

NSC and Department of Health and Human Services (DHHS) officials. The NSC also received technical assistance from DHHS officials during these meetings. 

The NSC set out to craft a comprehensive legislative proposal 

that would reflect a consensus of the Indian tribes. With over 560 

federally-recognized Indian tribes, each with unique histories, cultures, locations and needs, the NSC faced serious challenges. Despite the many differences, they coalesced around a draft document 

which formed the basis of the bills introduced, S. 2526 (106th Congress) and S. 212 (107th Congress). Neither bill was enacted. 

During the 108th Congress, the Committee, the NSC and the Administration engaged in extensive negotiations over reauthorization 

issues, but action on a final version of that Congress’ bill, S. 556, 

did not occur before the conclusion of the 108th Congress. Several 

recommendations developed during these negotiations were incorporated into S. 1057, which was introduced in the 109th Congress. 

In the first session of the 109th Congress, the Indian Affairs 

Committee favorably reported an amendment in the nature of a 

substitute to S. 1057. In the ensuing months, the Committee engaged in discussions with the Administration—not only DHHS, but 

also the Department of Justice. Changes based on these discussions 

were made in an amendment in the nature of a substitute to S. 

1057. In addition, the Committee worked extensively with the Senate Finance Committee on provisions in the jurisdiction of that 

committee, which were separately reported out by the Finance 

Committee on June 8, 2006, as S. 3524, and incorporated in to the 

amendment in the nature of a substitute to S. 1057. Comments 

were also received from the Senate Health, Education, Labor and 

Pensions Committee, on provisions over which that Committee 

maintains an interest, and many were incorporated. A new bill, 


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4 Charles J. Kappler, Indian Affairs: Laws & Treaties, Vol. II, at 861. 

5 Report on Indian Health by Task Force Six: Indian Health in the Final Report to the American Indian Policy Review Commission (Final Report) at 32. 

based on the amendment in the nature of a substitute, was introduced as S. 4122 on December 8, 2006, the last day of the second 

session of the 109th Congress. No further consideration of that 

measure occurred. 

OVERVIEW OF INDIAN HEALTH CARE HISTORY

The history of the Federal responsibility for Indian health care 

is quite extensive and well-documented in numerous sources, including past Senate reports accompanying prior legislation, (see, 

e.g., Senate Report Nos. 94–133, 102–392, 108–411 and 109–222). 

Based on the U.S. Constitution, treaties, statutes and the historical, political and legal relationship with the Indian tribes, the 

United States has assumed a trust responsibility for the provision 

of health care to Indian people. Those laws and relationships serve 

as the backdrop for the government-to-government relationship. 

Extensive research indicates that the health of Indians deteriorated after contact with the European colonists, as the aboriginal 

inhabitants had no natural immunities to the diseases carried by 

the new arrivals. Decades later, when Federal policy forced the Indians to relocate from their homelands and settle on reservations 

and, in many cases, prohibited the conduct of traditional practices—including traditional healing—the health of Indians continued to plummet. Thus, health care became a particularly significant element of the treaties and other agreements between the Indian tribes and the United States. 

During the early 1800s, the health care provided was little more 

than vaccinations for the Indians around federal military posts in 

order to protect the soldiers and non-Indians from the possibility 

that Indians might spread diseases. During the late 1800s, physicians and hospitals were added to the reservations and other outposts. Mention of the provision of health care was included in treaties. For example, the Treaty with the Chippewa, Red Lake and 

Pembina Bands, of 1864, stated in Article 4, 

The United States also agree[s] to furnish said bands of 

Indians, for the period of fifteen years, one blacksmith, one 

physician, one miller, and one farmer; and will also furnish them annually, during the same period, with fifteen 

hundred dollars’ worth of iron, steel, and other articles for 

blacksmithing purposes, and one thousand dollars for carpentering, and other purposes (emphasis added).4

With respect to federal agencies overseeing the responsibility for 

Indian health, the task was first assigned to the War Department 

in 1803, then to the Interior Department in 1849, before finally 

being transferred to the Department of Health, Education and Welfare (DHEW), the predecessor of the DHHS, in 1955. The Division 

of Indian Health within DHEW had initial responsibility for Indian 

health before eventually being renamed the Indian Health Service.5

In 1921, Congress enacted the Snyder Act (25 U.S.C. 13), to provide for permanent appropriations authority for Indian health programs and services. However, the Snyder Act did not provide 


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6 Id. at 12. 

7S. Rep. No. 94–133, at 36 (1976). 8 Id. 

9 Id. 

meaningful standards by which to measure progress in Indian 

health status or other improvements in services. 

The lack of standards in the Snyder Act and other organized efforts led the American Indian Policy Review Commission to conclude in 1976 that 

there [was] no clear overall direction or policy for implementation of the various programs. As a result, the Indian 

Health Services operates primarily an emergency and crisis oriented service. . . . This has resulted in increased 

prevalence of certain health deficiencies which are virtually unknown in the general population.6

Shortly after the responsibility for Indian health was transferred 

to DHEW, Congress passed the Indian Sanitation Facilities and 

Services Act, 42 U.S.C. 2004, which authorized the IHS to provide 

sanitation facilities to Indian communities. These sanitation facilities were critical to eliminating many health maladies associated 

with the lack of proper sanitation, such as dysentery and infectious 

hepatitis. 

The administration of Indian health had initially been managed 

in a piecemeal approach, then ultimately was placed within the 

IHS, an agency of the DHHS. Based on that history and in fulfillment of the special trust obligation to Indian people, Congress 

passed the Indian Health Care Improvement Act to provide coordinated programs and meaningful direction in Indian health care administration. The underlying responsibility to provide health care 

did not originate with the Act; rather, the Act was passed after 

Congress recognized that a sea-change in administration and management was needed to ensure improvements were achieved in Indian health status and services. 

THE PRE-IHCIA INDIAN HEALTH SYSTEM

At the time of passage of the Act in 1976, the information on Indian health painted a stark portrait of existence in Indian communities. Senate Report No. 94–133 accompanying S. 522, the Indian 

Health Care Improvement Act of 1976, which was signed into law 

as Public Law 94–437, indicated that the ‘‘vast majority of Indians 

still live in an environment characterized by inadequate and understaffed health facilities, improper or nonexistent waste disposal and 

water supply systems, and continuing dangers of deadly or disabling diseases.’’ 7

Health Status. These conclusions were based upon the statistics 

at the time. For example, the ‘‘incidence of tuberculosis for Indians 

and Alaska Natives [was] 7.3 times higher than the rate for all citizens of the United States. . . . [T]he suicide rate . . . [was] approximately twice as high as in the total U.S. population.’’ 8 Also 

troubling was the infant mortality rate for Indian babies, which 

was significantly higher than the national average.9

Health Professionals. Compounding the low health status were 

the difficulties in recruiting and retaining qualified health professionals—Indian health professionals, in particular—to work in the 


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10 Id., at 55. 11 Headlands Indian Health Careers, Program History, available at http:// 

www.headlands.ouhsc.edu/history.asp. 12S. Rep. No. 94–133, at 42 (1976). 13 Id. at 36–37. 14 Id., at 37. 15 Id. 16 U.S. Department of Health and Human Services, Indian Health Service, 2000–2001 Trends 

in Indian Health, at 68. 17 U.S. Department of Health and Human Services, Indian Health Service, 2000–2001 Trends 

in Indian Health, at 162. 

Indian communities. The available information indicated that out 

of 500 doctors in the Indian Health Service, only 3 were Indian.10

Overall, ‘‘in 1975, there were only 72 American Indian physicians 

to serve the needs of 1,000,000 American Indians, most of whom 

lived on Reservations.’’ 11 Likewise, only half of the number of 

pharmacists needed was employed in these Indian communities.12

Health Facilities. The conditions and availability of health facilities did not fare any better. A significant number of the existing 

facilities were over twenty years old. Many others were ‘‘old onestory, wooden buildings with inadequate electricity, ventilation, insulation and fire protection systems, and of such insufficient size 

as to jeopardize the health and safety of their occupants.’’ 13 The 

Joint Committee on Accreditation of Hospitals (JCAHO) found that 

‘‘only 24 of the 51 existing IHS hospitals’’ met accreditation standards and ‘‘two-thirds [were] obsolete and that 22 need[ed] complete 

replacement.’’ 14

Funding. The funding available for the provision of health services to Indians also revealed significant disparities. For example, 

‘‘[p]er capita expenditures for Indian health purposes [were] 25 percent below per capita expenditures for health care in the average 

American community.’’ 15

Accordingly, the goals of the Act held great promise for the advancement of Indian health by improving the direction in programs 

and access to other programs, such as Medicare and Medicaid. 

CURRENT INDIAN HEALTH SYSTEM

Since 1976, significant improvements have been made in the programs and funding levels authorized for Indian health through the 

Act and the amendments thereto. Yet, a comparison of historic statistics with current status indicators shows that, while real 

progress has been made, significant disparities still persist. 

Indian Health Status. The Indian Health Service report 2000–

2001 Trends in Indian Health indicates the age-adjusted death 

rates for American Indians and Alaska Natives for 1996–1998 was 

five times the rate for U.S. all-races in 1997.16 Despite a decrease 

of 64% over a period spanning 1972 to 1999, Indian infant mortality rates still remained 24% higher than other U.S. populations.17 Other Indian mortality rates far exceeded the mortality 

rates of other U.S. populations for causes including alcoholism 

(638%), diabetes mellitus (291%), unintentional injuries (215%), 

pneumonia and influenza (67%), gastrointestinal disease (38–40%) 

and heart disease (20%). 

Even during the short period of 1997 to 2004, the ‘‘prevalence of 

diagnosed diabetes increased by 47 percent in all major regions (all 

ages) served by the Indian Health Service.’’ The most alarming increase, however, has occurred among younger American Indians 


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18 U.S. Department of Health and Human Services, Indian Health Service, Fiscal Year 2008, 

Justification of Estimates for Appropriations Committees, at CJ–147. 19 United States Government Accountability Office, Report to the Committee on Indian Affairs, U.S. Senate, Indian Health Service: Health Care Services Are Not Always Available to 

Native Americans, GAO Report No. GAO–05–789, (August, 2005) at 18. 20GAO Report No. GAO–05–789 at 18. 21 U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Office of Applied Studies, National Survey on Drug Use and Health, The 

NSDUH Report, September 16, 2005, http://oas.samhsa.gov/2k5/meth/meth.htm. 22 U.S. Department of Health and Human Services, Indian Health Service, Fiscal Year 2008, 

Justification of Estimates for Appropriations Committees, at CJ–251. 23 U.S. Department of Health and Human Services, Indian Health Service, chart of Health 

Care Facilities FY 2009 Planned Construction Budget (March 30, 2007). 24 U.S. Department of Health and Human Services, Indian Health Service, Fiscal Year 2008, 

Justification of Estimates for Appropriations Committees, at CJ–164. 

and Alaska Natives, with a 160 percent increase from 1990–2004 

for young adults aged 25–34 years, and a 128 percent increase for 

adolescents aged 15–19 years from 1990–2004.18

Recent information also indicates that suicide rates among youth 

in Indian Country are predominately higher than for non-Indian 

youth. In 2005, the Committee held two hearings on the issue of 

Indian youth suicide. A field hearing was held in Bismarck, N.D. 

on May 2, 2005, and an oversight hearing was held in Washington, 

D.C. on June 15, 2005. During the second session of the 109th Congress, on May 17, 2006, the Committee held an oversight hearing 

on suicide prevention programs and their application in Indian 

Country. 

According to national data for 2002, suicide was the second leading cause of death for Indians of both sexes in the 15–34 year age 

range, and the fourth leading cause of death for both sexes in the 

10–14 year age range. On the reservations of the Northern Great 

Plains (States of North and South Dakota, Iowa, Minnesota and 

Nebraska), the rate of Indian youth suicide is up to 10 times higher 

than it is elsewhere in the country. At several Indian health facilities, the demand for mental health care outstripped capacity.19 In 

at least one facility, the mental health services were to be cut by 

20% in FY 2005 because funding had been depleted.20

Another alarming and growing problem arising in Indian communities is the use of methamphetamines. The Committee held an 

oversight hearing on the problem of methamphetamine in Indian 

Country on April 5, 2006. According to the National Survey on 

Drug Use and Health, the past-year use rate during a 2002–2004 

survey period among American Indians and Alaska Natives aged 

12 and older is higher than every other population except Native 

Hawaiians or other Pacific Islanders and youth reporting two or 

more races.21

Health Facilities. According to the Indian Health Service’s FY 

2008 budget request, the IHS health care facilities system is made 

up of 163 Service Units (63 IHS, 100 tribal); 48 Hospitals (33 IHS, 

15 tribal); and 603 Ambulatory Care Centers (92 IHS and 511 tribal) (consisting of Health Centers, School Health Centers, Health 

Stations and Alaska Village Clinics).22

According to the IHS Health Facilities Construction Priority System, the estimated unfunded total cost to meet the need was nearly 

$3.5 billion as of FY 2008.23 In addition, the backlog for the maintenance and improvement needs of current facilities was estimated 

at $408,956,000.24


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25 Id., at CJ–167. 26 U.S. Department of Health and Human Services, Indian Health Service. The Sanitation Facilities Construction Program of the Indian Health Service, Public Law 86–121, Annual Report 

for 2005, at 1. 27 Id., at 21. 28 Id. 29 Id. 30 U.S. Department of Health and Human Services, Indian Health Service. The Sanitation Facilities Construction Program of the Indian Health Service, Public Law 86–121, Annual Report 

for 2005, at 5. 31 Id. 32 U.S. Department of Health and Human Services, Indian Health Service, Justification of Estimates for Appropriations Committees for Fiscal Year 2008, at CJ–170. 33 U.S. Census Bureau, American FactFinder, Census 2000 Summary File 4, Table PCT86. 

The numbers are for individuals reporting only the American Indian and Alaska Native race. 

However, on the positive side, ‘‘All IHS and Tribally-operated 

hospitals are accredited by the Joint Commission on Accreditation 

of Healthcare Organizations (JCAHO) or certified by the Centers 

for Medicare and Medicaid Services (CMS).’’ 25

In addition, since the Indian Sanitation Facilities and Services 

Act, Public Law 86–121, codified at 42 U.S.C. 2004, was passed in 

1959, ‘‘over 270,000 Indian homes have been provided sanitation 

facilities’’ which served to reduce ‘‘[t]he gastroenteric and post-neonatal death rates among the Indian people . . . primarily because 

of the increased prevalence of safe drinking water supplies and 

sanitary waste disposal systems.’’ 26 The IHS noted that ‘‘[i]n 1955, 

more than 80 percent of American Indians and Alaska Natives 

were living in homes without essential sanitation facilities.’’ 27 The 

age-adjusted gastrointestinal death rate was ‘‘15.4 per 100,000 population. . . . 4.3 times higher than that for all other races in the 

United States.’’ 28 But by 1995, that death rate was reduced to 1.7 

per 100,000, although that 1995 rate is still 40% higher than the 

rate for all races in the United States.29

In FY 2005, approximately $132 million was appropriated for 

sanitation facilities construction, of which $91.7 million was appropriated to the Indian Health Service and more than $40.4 million 

came from other Federal agencies and non-Federal sources such as 

tribes and state agencies.30 IHS estimated that in FY 2005, the 

Sanitation Construction Program provided sanitation facilities to a 

total of 24,072 homes.31 However, the total estimated costs needed 

to address the sanitation deficiencies in existing homes as of the 

end of FY 2006 totaled over $2.2 billion, with projects considered 

economically feasible totaling $1 billion. There were more than 

155,000 Indian and Alaska Native homes in need of sanitation facilities, including more than 38,000 which are without potable 

water. 32

Health Professionals. The number of Indian health professionals 

has increased since the Act was first signed into law. According to 

the latest Census information, there were over 1,300 Indian physicians and surgeons and over 10,000 Indian registered nurses.33

These numbers suggest that the incentives in the Act have assisted 

in increasing these numbers. However, vacancy rates for key health 

professionals indicate that a substantial need still exists for qualified health professionals in the Indian health system. The December, 2006, vacancy rates for health professions with the greatest 


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34 U.S. Department of Health and Human Services, Indian Health Service, Justification of Estimates for Appropriations Committees for Fiscal Year 2008, at CJ–125. 35 U.S. Department of Health and Human Services, Indian Health Service, Fiscal Year 2008, 

Justification of Estimates for Appropriations Committees, at CJ–71. 36GAO Report No. GAO–05–789, at 15. 37 Id., at 19. 38 Id. 39GAO Report No. GAO–05–789, at 16. 40 Id., at 21. 

shortfalls consist of Dentists (32%), Optometrists (12%), Nurses 

(17%), and Pharmacists and Physicians (both 12%).34

Types and Level of Services. The IHS, tribal and urban Indian 

health programs provide an array of basic medical, dental and vision services, including inpatient care, and routine and emergency 

ambulatory care; and medical support services including laboratory, pharmacy, nutrition, diagnostic imaging, medical records, 

physical therapy, etc., 35 as well as other preventive, clinical and 

environmental health services. When these services are not available at their facilities, IHS, tribal and urban programs purchase 

medical care and urgent care services through the Contract Health 

Services program. 

Even though basic services may be available at an Indian health 

facility, access to these services is not assured. In its study on the 

availability of health services to Indians in August, 2005, the Government Accountability Office (GAO) found that Indian patients 

often had to wait more than 30 days—in some cases two to six 

months—between setting the appointment for services and receiving the services, a time frame ‘‘in excess of standards and goals 

identified in other federally operated health service delivery systems.’’ 36 Moreover, ‘‘[t]he most frequent gaps were for services 

aimed at the diagnosis and treatment of medical conditions that 

caused discomfort, pain, or some degree of disability but that were 

not emergent or acutely urgent.’’ 37 For example, in some cases, 

adult Indian patients ‘‘could wait as long as 120 days to get approval for eyeglasses.’’ 38 According to one tribal official interviewed 

by the GAO, these situations create an environment in which Indian patients become demoralized and may wait until their condition becomes ‘‘an emergency that required a higher level of treatment.’’ 39

The Committee is deeply concerned with the GAO’s findings and 

its conclusions that the disturbing result of these gaps are ‘‘diagnosis or treatment delays that exacerbate[] the severity of a patient’s condition and create[] a need for more intensive treatment.’’ 40 The Committee is further concerned that these gaps increase the costs of health care and diminish the potential for prevention efforts. 

The Committee appreciates the Administration’s efforts in promoting prevention as a key to reducing health care costs, but believes a much greater effort is needed to reduce gaps in health 

services to Indians. Improvements are needed in all areas of the Indian health care system to ameliorate problems and delays in service delivery. The improvements outlined in S. 1200 for programs 

and policies, provisions in S. 1200 which would be new to the Act, 

including services for home- and community-based care, youth suicide prevention and convenient care services, and the National Bipartisan Commission on Indian Health Care study on the delivery 


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41Senate Report No. 94–133, at 13. 42President’s Special Message to Congress on Indian Affairs, 213 Pub. Papers 564 (July 8, 

1970). 43President’s Special Message to Congress on Indian Affairs, 213 Pub. Papers 565 (July 8, 

1970). 44See, e.g., U.S. General Accounting Office, now, U.S. Government Accountability Office, Report to the Chairman, Select Committee on Indian Affairs, U.S. Senate, Indian Health Service, 

Contracting under the Indian Self-Determination Act, GAO Report No. GAO/HRD–86–99, September, 1986. 45 U.S. Department of Health and Human Services, Indian Health Service, Fiscal Year 2008, 

Justification of Estimates for Appropriations Committees, at CJ–258. 

of federal health care services to Indians are all designed to help 

address these problems. 

THE INDIAN HEALTH CARE IMPROVEMENT ACT

In passing the Indian Health Care Improvement Act of 1976, 

Congress set forth ambitious goals for improving the health of Indians, including encouraging Indian participation in ‘‘the planning 

and management’’ of health services (25 U.S.C. 1601(b)). The Act 

‘‘would provide the direction and financial resources to overcome 

the inadequacies in the existing Federal Indian health care program.’’ 41 These goals built upon the foundation laid in President 

Nixon’s 1970 ‘‘Special Message to the Congress on Indian Affairs.’’ 42 In his ‘‘Special Message,’’ President Nixon declared that 

‘‘[t]he time ha[d] come to break decisively with the past and to create the conditions for a new era in which the Indian future is determined by Indians acts and Indian decisions.’’ 43

Breaking decisively with the past meant a radical change in 

health care delivery, beginning with the administration of the programs and policy-making. Placing administrative and decisionmaking authority in the hands of Indian tribal governments, rather 

than solely in the agency’s hands, was both a fundamental and logical change in the approach in health care delivery. Reconfirming 

the tribes’ authority to administer health programs, however, took 

several years to achieve.44

Today, nearly half of the IHS budget is administered through 

tribal contracts or compacts under the Indian Self-Determination 

and Education Assistance Act of 1976 (ISDEAA), 25 U.S.C. 450 et 

seq. Title I contracts and Title V compacts total more than $1.6 billion. The IHS currently administers contracts and Annual Funding 

Agreements with 245 tribes or tribal organizations, and 72 compacts and 93 funding agreements with 322 tribes.45 These numbers 

not only reflect congressional policy of promoting tribal self-determination, but generate a higher level of cooperation among Indian 

health providers. 

GENERAL PRINCIPLES IN THE REAUTHORIZATION

During the reauthorization process, a critical assessment of the 

Act was undertaken by the Committee and the Indian health community and several basic principles emerged. The history of Indian 

health and the interplay between the ISDEAA and the Act are key 

considerations in the development of sound Indian health policy. 

Self-Determination. Since self-determination was declared to be 

the new direction in Federal Indian policy, tribal participation has 

significantly contributed to improving both health and other servVerDate Aug 31 2005 01:51 Oct 27, 2007 Jkt 069010 PO 00000 Frm 00009 Fmt 6659 Sfmt 6602 E:\HR\OC\SR197.XXX SR197

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46See e.g., National Indian Health Board, Tribal Perspectives on Indian Self-Determination 

and Self-Governance in Health Care Management, 1998. 47See, e.g., No Child Left Behind Act, Pub. L. 107–110, 25 U.S.C. 2001, et seq.; Native American Housing Assistance and Self-Determination Act, Pub. L. 104–330, 25 U.S.C. 4116; Indian 

Self-Determination and Education Assistance Act, Pub. L. 106–477, 25 U.S.C. 458aa–16. 48 Indian Health Care Improvement Act Amendments of 2005: Joint Hearing on S. 1057 Before the Senate Committee on Indian Affairs and Senate Committee on Health, Education, 

Labor and Pensions, 109th Cong., 1st Session, S. Hrg. 109–162 at 725 (July 14, 2005) (statement 

of Don Kashaveroff, President, Seldovia Village Tribe). 

ices for Indian people.46 Meaningful participation by tribes in administering programs through contracting or compacting has been 

a principal means of implementing the self-determination policy. 

However, simply administering a program designed and handed 

down by the agency does not accomplish the vision embodied in 

self-determination. Indian and Alaska Native participation is critical in the development of the framework of these programs and 

services. Tribal self-determination involves tribes designing or 

modifying programs, as well as formulating new ideas, concepts 

and methodologies of how those programs or services should be delivered to their own communities. 

Negotiated Rulemaking and Consultation. Such participation 

means appreciable engagement between the agency and Indian 

tribes, and numerous tools have successfully increased that involvement. For example, negotiated rulemaking under the Administrative Procedures Act has been found to be useful in several initiatives such as education, housing and Self-Governance.47

The Committee has received testimony from tribal participants 

in negotiated rulemaking that ‘‘true understanding among tribes 

and with IHS is achieved’’ 48 through that process. That ‘‘true understanding’’ is consistent with the Committee’s desire to foster 

consensus-building and reduce obstacles that negatively impact 

health care service delivery, as well as to carry out the government-to-government relationship between Indian tribes and the 

federal government. 

The Administration has expressed concerns about the time and 

resource constraints involved in negotiated rulemaking. The Committee strongly supports fiscal accountability and decreased bureaucracy, but believes that the long-term benefits of negotiated 

rulemaking more than justify the costs which may be required in 

the short-term. 

The Committee believes that the Indian tribal and urban health 

providers—as first responders in the health system—should be directly involved in developing health programs and the regulations 

that affect their service populations. Tribal involvement in rulemaking not only leads to a more informed rule, but it fosters tribal 

support. In addition, negotiated rulemaking can save costs to all 

parties in the long run. By building a higher level of consensus in 

the regulations, the IHS lowers the potential for legal challenges 

to the rules and associated litigation costs. The Committee favors 

consensus-building over litigation and encourages this long-term 

view. The concerns are further abated by the limited number of 

program criteria or requirements under the Act which are subject 

to negotiated rulemaking. Section 802 outlines the scope for negotiated rulemaking which is limited to Titles II (except for section 

202) and VII, a few sections in Title III, and section 807. 

Besides negotiated rulemaking, the Committee has favored consultation with tribes as another tool to increase tribal participation, 


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49See www.hhs.gov/iga/tribal. 50 U.S. Department of Health and Human Services, Department Tribal Consultation Policy, 

January, 2005, available at www.hhs.gov/ofta/docs/FnlCnsltPlcywl.pdf. 51Flexibility also eliminates the need to identify each and every program that may be administered by IHS, the tribal or urban programs (e.g., the definition of ‘‘health professions’’ does 

not identify every profession that may be authorized). Many of the decisions or priorities are 

left to the Indian health providers to determine to implement as needed. The Committee is 

aware that the IHS, Indian tribes and urban programs engage in extensive budget consultations, sometimes two years in advance of implementation, where programs and professions to 

emphasize for scholarships is discussed. 52S. Hrg. 109–162 at 589 (statement of Dr. Grim, Director, U.S. Department of Health and 

Human Services, Indian Health Service). 53 Id., at 596, and S. Hrg. 110–53 at 38 (March 8, 2007) (statement of Admiral John 

Agwunobi). 

but has generally left the manner or method of consultation to the 

discretion of the Secretary. 

For example, the ISDEAA simply requires an annual consultation on the budget. However, the Secretary has in the past implemented a rigorous regional and national schedule for budget consultation, holding the 9th Annual HHS Tribal Budget Formulation 

and Policy Consultation Session in Washington, DC, March 28 and 

29, 2007.49

The Committee recognizes that the Administration has made efforts to involve Indian tribes in decision-making through the consultation policy issued by the DHHS.50 The Committee also recognizes that the Department’s policy has attempted to address a wide 

variety of matters affecting Indian communities. However, the 

Committee is concerned that the scope of the Department policy 

may not fully encompass all critical matters for which the Committee believes consultation should be used, or that comments received are fully considered. 

Such matters involve the development of program eligibility or 

criteria, or relate to specific tribes, Indian population groups (e.g., 

women) or to special tribal history, customs, or practices. Consequently, remaining committed to promoting tribal input by institutionalizing consultation, the Committee has provided for robust 

consultation requirements in several key areas, while leaving the 

manner of consultation to Secretarial discretion. 

Flexibility. In addition, the Committee believes that less bureaucracy and more flexibility are needed to tailor programs or 

services to address local community health needs.51 The Committee 

is pleased that the Administration has joined in supporting flexibility and new approaches to health care, and expanding the range 

of options of health services.52

However, in the course of negotiating this legislation, the Administration has repeatedly indicated its preference to change mandatory programs to discretionary ones to meet budgetary constraints 

and to give the Secretary maximum flexibility.53 The Committee 

has accommodated these principles based on the understanding 

that Indian tribes would also be accorded the same flexibility under 

the Act and the ISDEAA. 

The Committee has been informed that, in the past, the Indian 

tribes had been foreclosed from implementing programs that the 

agency did not actually implement either under the Act or the Snyder Act, 25 U.S.C. 13. Simple program authorizations under the 

Act and the Snyder Act were deemed insufficient to allow the Indian tribes to administer the programs even under the redesign 

provisions of the ISDEAA. 


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54See also GAO Report No. GAO–05–789, at 4. 

It is the Committee’s intent, however, that simple authorizations 

are sufficient to enable tribes to implement programs, even if the 

Federal agency chooses not to, provided all other applicable provisions of the Act, the Snyder Act and the ISDEAA are met. The 

Committee believes that this interpretation is necessary to enable 

Indian tribes to meet the needs of their communities and required, 

if the Secretary is to experience the flexibility desired. 

Oversight and Reporting. In the past, the Committee has been 

reluctant to eliminate certain mandates, such as those requiring 

studies. For example, many studies and reports mandated by the 

1976 Act have never been completed. These studies were intended 

to provide insight into the accomplishments and challenges in Indian health and to assist the Congress in seeking new approaches 

to service delivery. The Committee is troubled that the health status of Indians reflects many of the same problems it did in 1976, 

and that several mandated studies, reports and programs in current law have been disregarded. 

Consequently, the Committee has included in S. 1200 provisions 

which will establish a National Bipartisan Commission on Indian 

Health Care to thoroughly review opportunities for improvement of 

the Indian health care system. During the 108th Congress, the bill 

to reauthorize the Act, S. 556, contained provisions requiring the 

Bipartisan Commission to study the potential of funding Indian 

health as an entitlement. Based on the Administration’s recommendations offered during the 108th Congress, the Committee 

modified the Commission’s objectives to what is now included in S. 

1200. 

In addition, the Committee has included authorization of the Native American Health and Wellness Foundation, provisions to promote the mission of IHS in improving Indian health. This Foundation is not a substitute for the federal obligation to provide health 

services to Indians, but is intended to complement the federal obligation in ways in which the United States has fallen short. 

While much discretion and flexibility is provided to the IHS 

throughout S. 1200, the Committee must preserve the necessary 

mechanisms to fulfill its oversight function. The primary means is 

through active reporting requirements by the Secretary. Congress 

simply cannot leave unfettered the operations of these important 

programs without appropriate assurances that Indian people are 

being served consistent with Congressional intent and priorities. 

Moreover, Congress should be informed of how and when these programs meet—or fall short of meeting—the basic health needs of Indian people. 

KEY PROVISIONS

Several key improvements to the Act contained in S. 1200 are 

particularly noteworthy: 

Health Professions. Difficulties in recruiting and retaining qualified health professionals have long been recognized as a significant 

factor impairing Indians’ access to health care services.54 Noting 

that many Indian communities are often in remote locations and 

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55GAO Report No. GAO–05–789, at 4. 56 Id. 57Senate Report No. 94–133, at 55–57. 58 Id., at 55–56. 

ties for employees and their families,55 the GAO reported that 

some critical positions such as for pharmacists and dentists remained vacant for several years in some locations.56

The provisions in Title I address the health professional shortage 

in Indian communities. Congress specifically included these provisions in 1976 because the existing programs to improve manpower 

capabilities were woefully inadequate or completely unsuitable for 

Indian health providers and communities.57

The programs existing in 1976 did ‘‘not link the recipients [of 

scholarships] directly to the Indian Health Service,’’ were ‘‘not designed to recruit and support Indians,’’ and were too limited in the ‘‘category of health professionals’’ supported by these programs.58

Consequently, Congress developed a new approach and the IHS 

scholarship program was born. Fears of duplication were quickly 

disproven by the obvious need for and success of these programs 

in filling vacancies and returning Indian health professionals to the 

Indian communities. Today, the program has expanded to include 

a wide variety of health professions as determined by the priorities 

set by the IHS and the Indian tribes. Besides the scholarships, the 

program also now includes loan repayments, a tribal scholarship 

program, and bonus incentive payments. 

These programs specifically target the needs of the Indian health 

system. For example, the scholarship priorities are developed 

through a year-long consultation process wherein the IHS sends 

the program information and request for priority to each Indian 

tribe and the tribal education and health programs. The comprehensive list is developed based on the IHS and tribal health professional projected needs, vacancies and available positions. By focusing on the specific needs of Indian communities, the Committee 

believes that this approach has significantly improved Indian 

health. 

Targeting the specific needs of the Indian health system has become the hallmark of the Indian health professional policy. Likewise, a continuous and seamless transitional approach also is a key 

policy component in increasing the number of Indian health professionals. The Committee strongly encourages the Secretary to evaluate all opportunities to improve the chances of success for Indian 

health professionals, including obtaining the licenses or certifications necessary for providing health care services. The Committee has been made aware of the need to increase the number 

of licensed health professionals in the Indian health system and included provisions in S. 1200 to address that need. S. 1200 provides 

for portability of current licenses for tribal health professionals consistent with other Federal health licensing provisions. In addition, 

S. 1200 authorizes programs to enhance and facilitate enrollment 

in and completion of courses of study in health professions. 

The Committee believes that the Title I programs should fully 

equip the Indian student trainees with the tools needed to transition into the health profession, including successfully completing 

all courses of study and passing the required licensing or board examinations. In addition, the Committee expects that the IHS would 


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59 Joseph F. McDonald, Ed.D., President, Salish-Kootenai College, Letter to Chairman John 

McCain, U.S. Senate Committee on Indian Affairs, September 22, 2005. 

also ensure that scholarship recipients are provided every opportunity to fulfill their service obligations, including technical assistance in understanding their obligations. 

The remedial programs, scholarships, grants, externships, service 

obligations and advanced training established in Title I are all designed to provide seamless opportunities for successfully recruiting 

and training Indians for health professions. As part of the longterm view of Indian health professions, the Committee believes 

continuity is necessary in administering the Title I programs. 

The incentives fostered by scholarships, loan repayments, and bonuses are multiplied when combined with professional development 

programs for health professionals which the Committee believes to 

be essential components of recruitment and retention programs in 

the Indian health system. S. 1200 establishes several professional 

development programs in Title I such as opportunities for advanced 

training and research, tribal cultural orientation, training in the 

administration and planning of tribal health programs and tribal 

demonstration projects for innovative recruitment, placement and 

retention programs, which may include professional development 

programs. 

Such additional training for health professionals is particularly 

important in developing leadership and collaboration skills and ensuring that a culturally-competent workforce exists within the Indian health system. The Committee strongly encourages the Secretary and tribal and urban Indian health providers to develop innovative programs or take advantage of existing models for such 

professional development to increase and maintain the number of 

Indian health professionals in the Indian health system. 

In addition, the Committee takes a long-term view of health professions in S. 1200. The most urgent placement needs are in the 

direct care positions, such as dentists, doctors, nurses, and pharmacists. In the long-term, Indian health professionals are also 

needed in educational positions to bolster recruitment levels and 

improve the new Indian health professionals’ chances of success. 

The Committee has been informed that significant need exists at 

the tribal colleges and universities to increase the number of Indian instructors in the nursing programs.59 The Committee recognizes that Indian instructors often have personal knowledge of the 

health disparities in Indian communities and a deep commitment 

to serve these communities for the long-term. Indian educators increase the likelihood of success for Indian students and bring to the 

classroom the unique cultural competence required in the Indian 

health field. 

With that in mind, the Committee included provisions in Title I 

of S. 1200 allowing a scholarship recipient to fulfill his or her service obligation (required in exchange for the scholarship) by teaching 

in a tribal college or university nursing or other health related program, provided the Secretary determines that health services to Indians will not be decreased. In addition, the Secretary may, prior 

to waiving any service obligation or repayment of a scholarship, 

consider placement of a scholarship recipient in a teaching capacity 

in a tribal college or university nursing or related health program. 


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60 Joseph F. McDonald, Ed.D., President, Salish-Kootenai College, Letter to Honorable Don 

Young, U.S. House of Representatives, November 1, 2005. 61 Joseph F. McDonald, Ed.D., President, Salish-Kootenai College, Letter to Honorable Don 

Young, U.S. House of Representatives, November 1, 2005. 

Other provisions for nursing grants were added to extend a preference in grant awards to tribal college and university nursing programs. 

Prior to including these provisions, the Committee considered the 

likelihood that inexperienced, new graduates might be placed in 

teaching positions. One tribal college president indicated that 

‘‘these [instructors] are clinically seasoned, mature [Bachelor of 

Science—Nursing] prepared nurses returning to school for educational and career mobility.’’ 60 Teaching positions available for 

these individuals would include lab coordinators and clinical instructors. This tribal college President also indicated that ‘‘new 

[registered nurse] graduates of associate or generic baccalaureate 

programs would not be qualified to teach.’’ 61

The Committee believes these positions should be filled by experienced faculty and expects that the Secretary and the tribal colleges or universities would coordinate these opportunities and be 

selective in placing these individuals to avoid compromising the 

quality of education and accreditation. 

The Committee strongly encourages the Secretary to examine the 

Title I programs with targeted, holistic, long-term approaches in 

mind and to develop more opportunities to increase the number of 

Indians in the health professions. The Committee believes that in 

the long-run, improving health educational opportunities at every 

level will also contribute to improving the health of Indian communities. 

Home Health Care. Current law authorizes a feasibility study to 

be conducted on hospice care services. However, the IHS has never 

conducted that study and, now, 14 years later, to conduct such a 

study would greatly delay what have already been demonstrated to 

be much needed services. 

The Committee has been informed that some Indian tribes and 

tribal organizations, through pilot projects, have provided this type 

of service or other services such as home health care with great 

success. The Committee is concerned that not authorizing these 

and other long-term or home health care services through the Indian health care system—services that have been an accepted part 

of the national health care system and Medicare since 1983—will 

prevent IHS and tribes from utilizing a proven, effective health delivery vehicle. 

Currently, home health care, long-term care and hospice care are 

not readily available to most Native communities. Many Indians 

must travel long distances, only to be placed in facilities that are 

far from home, culturally unfamiliar, and not conducive to their 

overall well-being. Home health care is crucial for these individuals. Having culturally-appropriate facilities close to Indian communities not only promotes the patient’s well-being, but enables 

family members to more easily visit the patient. 

Section 213 of S. 1200 authorizes services such as home health 

care, long-term care and hospice care, which are a standard part 

of the health care industry. If the Indian health system is to advance into the 21st Century, then Indian health programs must be 


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62S. Hrg. 110–53 at 41 (March 8, 2007) (statement of C. Frederick Beckner III, Deputy Assistant Attorney General, Civil Division, Department of Justice). 63See 25 U.S.C. 450f(a)(2). ‘‘The contractor shall include in the proposal of the contractor the 

standards under which the tribal organization will operate the contracted program, service, 

function, or activity. . . .’’

authorized to make these services available for their Indian patients, if circumstances warrant. 

However, the Department of Justice has indicated that it has 

concerns regarding the provision of services for which no standards 

exist.62 To address those concerns, S. 4122 in the 109th Congress 

included language that required standards to be in place from either the Secretary or the state in which the Indian health program 

was located. This type of requirement has been a part of the Indian 

health system as required in the Indian Self-Determination and 

Education Assistance Act.63

Indian tribes want to ensure that the services authorized in Section 213 are consistent with those services reimbursable by Medicaid and, in particular, those services already authorized in compacts or contracts entered into by the tribes or tribal organizations 

and the IHS pursuant to the ISDEAA. 

To that end, S. 1200 authorizes the Secretary to promulgate 

standards to govern any service in the absence of state standards. 

It is the intent of the Committee that those services already authorized in compacts or contracts will remain so authorized and 

that the Secretary is authorized to issue interim standards in the 

absence of either state standards or final Secretarial standards. 

The Committee expects the Secretary to act promptly to promulgate these standards, so that services to Indian patients are not 

disrupted or denied. 

Convenient Care Services. Section 213 also authorizes the Secretary to provide funding to meet the health status objectives of the 

Act for convenient care services programs pursuant to section 

306(c)(2)(A). Section 213 further authorizes health care delivery 

demonstration projects that include a ‘‘convenient care services’’

program as an alternative means of delivering health care services 

to Indians. 

In including this new provision, the Committee seeks to address 

the lack of access to health care services that exists in so many 

tribal communities, which may be due to limited hours of operation 

at existing health care facilities, lack of staff, or other factors. It 

is the Committee’s hope that these convenient care services 

projects may expand the availability of health care, as well as decrease the need for more-costly emergency room visits, thereby reducing the over-stressed Contract Health Services budget. 

Traditional Health Care Practices. For much of America’s history, the federal government’s policy of assimilation and termination sought to destroy Indian cultures and religions, as well as 

tribal legal, political and economic institutions. Indian people were 

denied the exercise of traditional practices or punished, should 

those ceremonies be practiced, as well as were punished for speaking their own languages and observing other traditional ways. 

However, federal policy toward Native people has run the gamut, 

with the policy of one period often contradicting that of another. An 

example of such a policy shift occurred following the 1928 Merriam 

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64Merriam, Lewis (ed.), Institute for Government Research, The Problem of Indian Administration (1928) (commonly referred to as the ‘‘Merriam Report’’). 

ditions for Native Americans.64 One reform was the active solicitation of traditional Indian healers to participate in federal health 

services to Indians. 

The Indian Health Care Improvement Act currently contains provisions to promote long-practiced traditional health care practices 

of the Indian tribes served by IHS, tribal and urban Indian health 

programs, consistent with the standards for the provision of health 

care, health promotion, and disease prevention. Authority also exists for culturally appropriate health care with respect to specific 

programs (the Community Health Representative Program), specific elements of the Indian population (Indian youth and Indian 

women), and specific services and training (mental health). These 

practices encourage respect for and affirmation of concepts of Indian and Alaska Native cultural values, beliefs and traditions that 

Indian people define for themselves as a complement to western 

medical practices in promoting good health and curing illness. 

Former IHS Director Dr. Emery A. Johnson, in ‘‘Policy and Procedures in reference to P.L. 95–341,’’ the American Indian Religious Freedom Act of 1978, stated the Service’s views as follows: 

The Indian Health Service has continued to recognize 

the value and efficacy to [sic] traditional beliefs, ceremonies, and practices of the healing of body, mind and 

spirit. . . . It is, therefore, the policy of the Indian Health 

Service to encourage a climate of respect and acceptance in 

which an individual’s private traditional beliefs become a 

part of the healing and harmonizing force within his/her 

life. 

More recently, in 1994, IHS Director Michael H. Trujillo issued 

a ‘‘Traditional Cultural Advocacy Program Policy Statement’’ which 

states: 

The Indian Health Service (IHS) recognizes the value of 

traditional beliefs, ceremonies, and practices in the healing 

of body, mind, and spirit. The IHS encourages a climate of 

respect and acceptance in which traditional beliefs are 

honored as a healing and harmonizing force with individual lives, a vital support for purposeful living, and an 

integral component of the healing process. It is the policy 

of the IHS to facilitate [sic] right of American Indian and 

Alaska Native people to their beliefs and health practices 

as defined by the tribe’s or village’s traditional culture. 

This policy is meant to complement and support previously 

stated IHS policy for implementing the American Indian 

Religious Freedom Act of 1978 (Public Law 95–341, as 

amended). 

The Department of Veterans Affairs’ National Center for PostTraumatic Stress Disorder is adding traditional healing methods, 

such as talking circles and healing herbs, to modern medical treatments for American Indian and Alaska Native veterans and service 

personnel returning from active duty in the Middle East and sufVerDate Aug 31 2005 01:51 Oct 27, 2007 Jkt 069010 PO 00000 Frm 00017 Fmt 6659 Sfmt 6602 E:\HR\OC\SR197.XXX SR197

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65See Department of Veterans Affairs’ National Center for Posttraumatic Stress Disorder 

website, www.ncptsd.va.gov/ncmain/index.jsp, and, e.g., www.adn.com/front/v-printer/story/ 

9137819p-9054019c.html. 66www.cancer.org/docroot/ETO/content/ 

ETOl5l3XlNativelAmericanlHealing.asp?sitearea=ETO. 67S. Hrg. 110–53 at 14 (March 8, 2007) (statement of C. Frederick Beckner III, Deputy Assistant Attorney General, Civil Division, Department of Justice). See also S. Hrg. 110–53 at 104, 

testimony of Duke McCloud. 

fering from post-traumatic stress disorder problems.65 The American Cancer Society (Society) includes Native American healing in 

a section on its website concerning treatment decisions.66 The Society, in connection with work at Montana State University, is providing funding to a group of Indian women health care workers on 

the Crow Reservation in Montana to help IHS providers understand traditional Crow healing practices and customs. 

The Committee believes that health care treatment should be relevant to and effective for the population to be served, and thus regards traditional health care practices as an important part of culturally appropriate care for Indian people. These practices have 

been a part of the IHS, tribal and urban Indian health care system 

for years, are provided only at the request of the patient or family 

members, and are within the traditional culture of that individual. 

It is the Committee’s understanding, based on Department of Justice testimony to the Committee on March 8, 2007, that no medical 

malpractice suit has ever been filed arising from a traditional 

health care practice.67 Thus, the risk for the United States in 

terms of liability appears to be insignificant, compared to the benefits of allowing Indian patients to obtain this care. DOJ’s concerns 

are unfounded in light of the fact that traditional health care practices are based in Native healing sciences. The bill has the legislative purpose of providing for the highest possible health status for 

Indians without intruding on Indian self-determination. 

Behavioral Health. S. 1200 has a strong focus on behavioral 

health. Title VII takes a comprehensive and integrative approach 

to behavioral health, providing both prevention and treatment programs for Indian children, youth, women and elders. The bill also 

emphasizes the interconnectedness of services related to alcohol 

and substance abuse, child welfare, suicide prevention and social 

services. Particular programs are authorized for Indian youth, Indian women, those affected by fetal alcohol disorder in Indian communities, and both the victims and perpetrators of child sexual 

abuse in Indian households. 

In addition to a comprehensive approach to addressing behavioral health services, the Committee recognizes and affirms the importance of providing care within the context of an individual’s 

family, community and particular tribal culture, such as is used by 

the systems of care model. 

Indian Youth Suicide Prevention. The alarming suicide rates 

among Indian youth indicate a great need for improved, comprehensive behavioral health care services. 

The nation was shocked in March, 2005, when a troubled 16- 

year-old member of the Red Lake Band of Chippewa Indians in 

Minnesota shot and killed his grandfather, his grandfather’s partner, five fellow high school students, a high school teacher and a 

security guard and seriously wounded several others at Red Lake 

High School on the reservation before killing himself. Several other 


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68Senate Report No. 94–133, at 136. In 1972, Congress added funding to the IHS appropriations for a pilot program in Minneapolis. Others followed in 1973 in Oklahoma City, Seattle and 

California (which covered nine urban Indian organizations). 69See Senate Report Nos. 94–133, 100–508 and 108–411. 

young people from that reservation subsequently took their own 

lives. 

The publicity around the Red Lake incident, which was then the 

nation’s second-most deadly school shooting, brought attention to 

the fact that, in Indian Country, suicide impacts a younger population than in the rest of the country. The suicide rate for Indian 

and Alaska Native youth, aged 15–24, is two and one-half times 

higher than the national average. Youth suicide ‘‘clusters’’ have 

also occurred on reservations in North and South Dakota, New 

Mexico and Arizona and in Native communities in Alaska. 

During the 109th Congress, the Committee held three hearings 

specifically on the issue of Indian youth suicide: one in Bismarck, 

North Dakota on May 2, 2005, and two oversight hearings in 

Washington, DC (on June 15, 2005, and on May 17, 2006), to discuss the kinds of resources and services being provided to Indian 

youth who have expressed suicidal thoughts or attempted suicide. 

Based on the information developed through hearings, the Committee has included provisions in S. 1200 which address youth suicide as part of the behavioral health program provisions and in a 

culturally-appropriate manner. Section 708 authorizes the Secretary to award grants for telemental health demonstration 

projects to provide counseling to Indian youth and health providers, 

training for Indian community leaders, and the development of culturally-relevant materials. The Committee recognizes that suicide 

prevention for Indian youth is a long-term effort that must address 

many multi-factorial causes. Questions such as whether the loss of 

cultural identity contributes to the youth suicide problem remain 

unanswered. Therefore, S. 1200 also makes suicide a priority for 

the IHS research agenda, particularly the identification of various 

factors that either protect the tribal community or make that community at risk for suicides, and the role the loss of tribal identity 

plays in suicidal behavior. Finally, provisions included in Title I encourage more Indian people to enter into the psychology profession 

by increasing the number of grants for the program commonly referred to as In-Psych (Indians into the Psychology) from three to 

nine and by authorizing a specific level of funding. 

Urban Indians. Providing health care services to urban Indians 

has been a part of Federal policy for nearly 40 years. Congress 

began funding urban Indian clinics in 1967 when $321,000 was 

provided for an Indian clinic in Rapid City, South Dakota.68

Congress specifically included urban Indian health programs as 

part of the Indian health care system in the Act in 1976, recognizing that the Federal obligation for health care extended to these 

individuals. These provisions sought to correct disparities in health 

levels for Indians living in urban areas, first as pilot programs and 

later permanently in the Indian health care system.69

The policies and status of Indians and Indian tribes under Federal laws, treaties and judicial decisions provide ample support for 

continuing and improving programs for urban Indians. Under this 

varied history, the Federal Government had dealt with Indian 

tribes in a variety of ways: some by treaty, others not by treaty. 


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70 U.S. Const., Art. I, Sec. 8, cl. 3. See also Cohen, Felix. Handbook of Federal Indian Law, 

at 23. 1982 ed.; U.S. v. Holliday, 70 U.S. 407, 417 (1865) (the broad power also includes Congress’ dealings with individual Indians). As the courts suggest, Federal policy for Indians cannot 

be confined to reservation boundaries. (‘‘The overriding duty of our Federal Government to deal 

fairly with Indians wherever located has been recognized by this Court on many occasions.’’ Morton v. Ruiz, 415 U.S. 199 (1974) (citing Seminole Nation v. U.S., 316 U.S. 286, 296 (1942); 

(‘‘Patterns of cross or circular migration on and off the reservations make it misleading to suggest that reservations and urban Indians are two well-defined groups.’’ U.S. v. Raszkiewicz, 169 

F.3d 459, 465 (7th Cir. 1999).) 71See, e.g., Indian Arts and Crafts Act, Pub.L. 101–644, 25 U.S.C. 305; No Child Left Behind 

Act, Pub. L. 107–110, 25 U.S.C. 7491; and the American Indian Probate Reform Act of 2004, 

Pub. L. 108–374, 25 U.S.C. 2201. 

The Federal Government had ignored some Indian tribes completely. Other Indian tribes were legislatively excluded from receiving services under some administrative programs, yet were allowed 

to exercise treaty rights. Some Indian tribes were ‘‘terminated,’’ yet 

later ‘‘restored’’ to a government-to-government relationship with 

the United States. 

Courts have long held that Congress has the broad power to legislate for the benefit of Indians, even if located off of the reservation, and to define who is an Indian and for what purposes they 

may be provided services, even if they may not be an enrolled 

member of a federally-recognized Indian tribe.70

For example, Congress has enacted laws which define Indians in 

different ways for different purposes.71 Even the criminal statutes 

under Title 18 of the U.S. Code regarding crimes on Indian reservations do not define who is an Indian. In other cases, Congress 

did not define Indians, or place geographical limitations on the 

service areas in which they may be served. The Snyder Act, 25 

U.S.C. 13, authorizes permanent funding for health care for ‘‘the 

Indians throughout the United States.’’ This statute does not confine the services to Indians who are members of current federallyrecognized tribes or to those living only on reservations. The Snyder Act has never been repealed nor otherwise limited in this respect. Under this Act, Congress has provided a more inclusive definition of urban Indian than mere membership in a federally-recognized Indian tribe, including members of ‘‘terminated’’ tribes, that 

is, groups that once had a political government relationship with 

the United States which was ended under the ‘‘termination’’ policy 

of Federal-Indian relations. 

Termination was another failed Federal Indian policy designed to 

end the government-to-government relationship with Indian tribes 

and assimilate their members into the larger society. When that 

policy gave way to self-determination, however, and Congress 

sought to try to remedy the devastating effects of termination, Congress saw fit to continue the health services in the Act to those individuals. See Menominee Tribe v. U.S., 391 U.S. 404 (1968). Likewise, by including members of state-recognized tribes, Congress 

recognized that several Indian tribes had treaty relations with individual states before the Federal Government was established. 

Congress did not in this Act recognize either the ‘‘terminated 

tribes’’ or the state-recognized tribes on the same basis or for the 

same purposes as the federally-recognized tribes under this Act. 

However, the U.S. Supreme Court has found that extending Federal protection for limited purposes, such as for services provided 

in this Act, is within Congress’ power. 

Further, in adopting S. 1200, the Committee is of the opinion 

that the Congress was on firm constitutional footing based on longVerDate Aug 31 2005 01:51 Oct 27, 2007 Jkt 069010 PO 00000 Frm 00020 Fmt 6659 Sfmt 6602 E:\HR\OC\SR197.XXX SR197

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72Senate Report 94–133, at 131. 73Felix Cohen, Handbook of Federal Indian Law (1982 ed.), at 169. 74 Id. 75Senate Report No. 94–133, at 138. 76 Id., at 140. 

standing precedent. Indeed, the U.S. Supreme Court has held that 

‘‘it is not meant . . . that Congress may bring a community or body 

of people within the range of this power by arbitrarily calling them 

an Indian tribe, but only that in respect of distinctly Indian communities the questions, whether, to what extent and for what time 

they shall be recognized and dealt with as dependent tribes requiring the guardianship and protection of the United States are to be 

determined by Congress, and not by the courts.’’ U.S. v. Sandoval, 

231 U.S. 28, 46 (1913) (emphasis added). Accordingly, the Act extends health benefits to members of these groups (terminated 

tribes and state-recognized tribes) without extending Federal recognition to them for all purposes. 

In enacting this Act, the Committee has found ample justification 

for extending health services to the Indians who ended up in these 

urban areas because of several major developments: 

First, Indians were provided an opportunity to work and 

share in the Nation’s prosperity in industries prior to and 

during World War II; second, thousands of Indian men and 

women served in the Armed Forces away from their reservation, traditional communities or Alaska Native villages; third, formal government relocation programs moved 

many Indian families from low employment, rural areas to 

urban areas where ‘‘employment opportunities’’ were considered more readily available; and fourth, countless numbers of Indians attempting to escape depressed conditions 

on their reservations voluntarily relocated.72

The comprehensive approach of this Act is needed to more fully 

implement the Federal responsibility for Indian health care, and, 

even more so today, to address health disparities facing the Indians 

who had moved from the reservations as a result of the relocation 

policies. Relocating Indians from reservations to urban areas was 

the Federal policy and program first begun in 1931.73 ‘‘Relocation 

complemented other termination programs designed to promote 

rapid assimilation. Once relocated, Indians were cut off from the 

special federal services that had been available to them as reservation residents.’’ 74

Congress has previously recognized that the establishment of 

urban Indian health programs was necessary to rectify the errors 

of failed Federal Indian policies such as relocation.75 The Committee further found that Title V of the original Act ‘‘represent[ed] 

a Federal policy commitment to provide the essential authorities 

and financial resources to permit urban Indian organizations to develop needed health services and to strengthen relationships with 

existing community health and medical care programs.’’ 76

The justifications for this policy are still valid today. Recent statistics indicate that urban Indians suffer health disparities, as do 

Indians living on reservations. For example, the mortality rates are 

higher due to accidents (38% higher than other populations), chronic liver disease and cirrhosis (126% higher), diabetes (54% higher), 


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77The Health Status of Urban American Indians and Alaska Natives, Urban Indian Health 

Institute, March 16, 2004, at v. Available at www.uihi.org. See also American Journal of Public 

Health, August 2006, Vol. 96, No. 8, ‘‘A Nationwide Population-Based Study Identifying Health 

Disparities Between American Indians/Alaska Natives and the General Populations Living in 

Select Urban Counties.’’

alcoholism (178% higher), and sudden infant death syndrome 

(157% higher).77

The Committee believes that continuation of services to urban 

Indians, recognized in the original Act and affirmed by S. 1200, 

makes sense from both policy and fiscal perspectives. The Committee has received testimony that these urban Indian health programs improve health services for Indians located in the urban centers in a highly cost-effective manner. 

In addition, the Committee has received testimony that without 

the urban Indian health programs, urban Indians would not seek 

care or could delay seeking proper medical attention until their 

health problems erupt into emergency situations or reach advanced 

stages when treatment is costlier and the rate of survival is much 

lower. 

By being located closer to the urban Indians than the tribal 

health programs on the reservations, urban Indian health programs reduce the number of emergency room visits by providing 

early disease prevention services. 

For example, the South Dakota Urban Indian Health Center operates three clinics with more than 17,500 patient encounters per 

year under the Title V program. This center provides such services 

as a foot care home visit program whereby Community Health Representatives conduct home visits to assess diabetic patients (or 

those at risk for diabetes). These home visits are a critical part of 

chronic disease management, particularly in avoiding amputations 

due to diabetes. 

The First Nations Community Health Source in Albuquerque, 

New Mexico provides dental, primary, and behavioral health care 

for approximately 45,000 urban Indians and handles approximately 

12,700 patient encounters per year under the Title V program. 

The Native Americans for Community Action in Flagstaff, Arizona provides immunizations, mental health and youth substance 

abuse prevention services among several other primary care services for urban Indians. The Committee has received testimony suggesting that the patients at this urban Indian health center would 

either have to travel 100 or more miles to visit an IHS clinic on 

the reservation or wait two or three weeks for an appointment at 

the local Community Health Center. Either alternative would impose significantly more burdens on the patient, and the testimony 

further suggests that most patients would simply avoid the care altogether. 

The Tucson Indian Center in Tucson, Arizona also provides important disease prevention services such as substance abuse prevention, wellness programs and immunizations. This Center provides services for over 2,500 patient encounters under the Title V 

programs. 

The health program operated by the Nevada Urban Indians, Inc. 

in Reno, Nevada provides, among other things, immunization and 

diabetes education programs and experienced over 9,000 patient 

encounters in 2005. The Native American Rehabilitation AssociaVerDate Aug 31 2005 01:51 Oct 27, 2007 Jkt 069010 PO 00000 Frm 00022 Fmt 6659 Sfmt 6602 E:\HR\OC\SR197.XXX SR197

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78The Health Status of Urban American Indians and Alaska Natives, Urban Indian Health 

Institute, at v. 

tion of the Northwest, Inc. in Portland, Oregon experiences nearly 

9,300 patient encounters per year, including 1,040 for mental 

health care and 3,400 for alcohol and drug treatment. The 

N.A.T.I.V.E. Project in Spokane, Washington provides a community 

wellness program and community outreach services for diabetes 

screening and health education for a community of approximately 

12,000 urban Indians. 

These programs, particularly the wellness, diabetes, and behavioral health programs are critical to preventing the development of 

diseases which may require long-term disease management such as 

for diabetes and alcohol or drug addictions. In addition, the outreach, screening and home-based care programs are vital in ensuring the patients receive early intervention and care rather than 

waiting until they need emergency services which cost far more 

than intervention services. 

Urban Indian health programs provide culturally-appropriate 

health care for Indians. The Committee has received testimony 

that Indians may avoid non-Indian (or ‘‘mainstream’’) health providers who are unfamiliar with or insensitive to Indian culture. 

The urban Indians have confidence in the urban Indian health programs and are more likely to seek care when the provider recognizes and respects culturally-appropriate care. 

Urban Indian health programs also address continuity of care for 

Indians migrating between the urban areas and reservations. Even 

though the disavowed policy of relocation no longer forces such migration, moving from the reservation to urban areas is not uncommon for these individuals, and neither is their return to the reservation. For example, the urban Indians may travel to the reservation for traditional ceremonies, tribal political (elections) or 

cultural events (such as pow-wows), clan or family events, and so 

on. On the other hand, Indians may move to the urban areas for 

job or educational opportunities—and carry with them the need for 

continuity of care. The Committee has received testimony that 

these programs recognize the migration and account for it in their 

patient care, particularly for quality follow-up care. 

The urban Indian health programs provide services for the uninsured Indians who might not be able to obtain care elsewhere. 

With poverty rates of urban Indians hovering at 25% (compared to 

14% for the general population), and nearly half living below 200% 

of the Federal poverty level (compared to 30% for the general population),78 it is no surprise that many urban Indians are uninsured. 

The Committee has received testimony that in Boston, MA, 87% of 

the Boston Indian Center’s clients have no health insurance. In Arizona, nearly two out of three urban Indians have no insurance. 

The Committee believes that the urban Indian health programs 

are a crucial component in the overall Federal effort to reduce the 

health disparities for the urban Indians. Without such services by 

the Title V health programs, it is quite likely that the health disparities among the urban Indians will increase. This result would 

contradict the Congressional policy set forth in this Act and in 

other statutes of increasing access to health care and of remedying 


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24 

health disparities that result from the past failed Federal Indian 

policies. 

Dental Health Aide Therapists. Decades of inadequate access to 

dental care, along with other factors that contribute to the generally worse health condition of Indians as compared to the general 

population, have led to a true epidemic of dental disease in Indian 

communities, and in Alaska Native communities, in particular. 

During the 108th and 109th Congresses, there was considerable 

discussion surrounding the Dental Health Aide Therapists (DHAT) 

Program in Alaska Native communities. The Committee received 

testimony regarding the crisis in oral health care in Alaska Native 

communities and how the DHAT program was a result of Alaska 

Native leaders and health providers searching for a means of addressing it. The Committee believes that the use of Alaska Natives 

trained through the DHAT program to serve as dental health aide 

therapists in Alaska is a necessary response to this access to care 

crisis. 

The DHAT program in Alaska has been part of the Community 

Health Aide Program since 2002, and DHATs provide a wide range 

of oral health care promotion and disease prevention services. For 

the most part, the DHAT program is supported and applauded for 

its efforts in reducing the extraordinary dental crisis in Alaska Native communities. However, some activities have generated controversy because they require the performance of certain irreversible procedures, specifically, the treatment of dental caries, 

pulpotomies and extractions of teeth. 

In January, 2006, the American Dental Association (ADA), the 

Alaska Dental Society (ADS) and several individual dentists filed 

a lawsuit in Alaska Superior Court, seeking to stop the practice of 

dentistry and dental surgery by non-dentists by asking the court to 

declare the Alaska Native Tribal Health Consortium and its Dental 

Health Aide Therapists program in violation of state dental licensing laws. On June 27, 2007, the Alaska Superior Court dismissed 

the case, noting in its decision that DHAT is part of the Community Health Aide Practitioner Program and Congress clearly intended the utilization of paraprofessionals in providing care 

through both CHAP and DHAT. 

When the House Resources Committee marked up its version of 

the Indian health reauthorization in the second session of the 

109th Congress, the Committee agreed to an amendment offered by 

Representative Young (R–AK) regarding the Dental Health Aide 

Therapist program in Alaska. The language, which the Committee 

has been informed was agreed to by the American Dental Association and the Alaska Native Health Board, prohibits dental health 

aide therapists from performing all oral and jaw surgeries except 

pulpal therapy or extraction of adult teeth after consultation with 

a licensed dentist in a dental emergency. That agreed-upon bill language is carried forward and included in S. 1200. 

National Bipartisan Commission on Indian Health Care. The 

Committee intends that S. 1200 will provide many much-needed 

improvements to the Indian health system. However, adequate 

funding levels remain a significant factor in achieving those improvements. 


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79See Hearing on the President’s Fiscal Year 2008 Budget Request for Indian Programs Before the Senate Comm. on Indian Affairs, 110th Cong., 1st Sess., February 15, 2007, S. Hrg. 

110–48; Hearings on the President’s Fiscal Year 2007 Budget Request for Indian Programs Before the Senate Comm. on Indian Affairs, 109th Cong., 2nd Sess., February 14, 2006, S. Hrg. 

109–396, Pt. 1 and February 23, 2006, S. Hrg. 109–396, Pt. 2; Hearing on the President’s Fiscal 

Year 2006 Budget Request for Indian Programs Before the Senate Comm. on Indian Affairs, 

109th Cong., 1st Sess., February 16, 2005, S. Hrg. 109–9; Hearings on the President’s Fiscal 

Year 2005 Budget Request for Indian Programs Before the Senate Comm. on Indian Affairs, 

108th Cong., 2nd Sess., February 11 and 25, 2004, S. Hrg. 108–420; Hearing on the President’s 

Fiscal Year 2004 Budget Request for Indian Programs Before the Senate Comm. on Indian Affairs, 108th Cong., 1st Sess., February 26, 2003, S. Hrg. 108–60; Hearings on the President’s 

Fiscal Year 2003 Budget Request for Indian Programs Before the Senate Comm. on Indian Affairs, 107th Cong., 2nd Sess., March 5, 7, and 14, 2002, S. Hrg. 107–360. 80See, e.g., ‘‘LNF Primer,’’ U.S. Department of Health and Human Services, Indian Health 

Service, located at http://www.ihs.gov/NonMedicalPrograms/Lnf/docs2003/Primer.pdf. 

For several years, the Committee has received testimony regarding the substantial funding needs for Indian health.79 Federal appropriations have increased over time, but, as evident in the IHS 

Level of Need Funded Study, have not reached optimal levels.80

While the reimbursements from Medicaid and Medicare have been 

beneficial in adding additional resources, they are not a complete 

solution to the funding deficiencies. 

The Committee has concluded that an overarching assessment of 

need and financing mechanisms is warranted to address the health 

disparities and financing for Indian health care. Accordingly, section 814 establishes the National Bipartisan Commission on Indian 

Health Care to study the optimal manner in which to provide and 

finance health care services to Indians. 

This Commission will have broad authority to conduct hearings 

and other activities needed to provide Congress with comprehensive and thoughtful recommendations regarding the optimal means 

of delivering health care services to Indians. The Committee intends that this Commission will also serve as an appropriate forum 

for addressing outstanding questions relative to financing, including, among others, balancing concerns about overutilization and deficiencies. 

Indian Health Care Facilities Construction. During the 109th 

Congress, much discussion between the National Steering Committee and the Committee centered around section 301, which directs the Secretary to maintain a health care facility priority system for construction. 

Background: Development of the Priority System. In the early 

1980’s, the IHS developed a health care facilities priority system 

(Priority System) for construction of various types of health care facilities in Indian communities. In 1988, pursuant to Public Law 

100–713 (as amended by Public Law 102–573), Congress required 

the IHS to provide an annual report which set forth (1) the current 

priority system; (2) the planning, design, construction and renovation needs of the top-10 priority inpatient and outpatient facilities 

(including staff quarters); (3) the justification and projected costs of 

these projects; and (4) the methodology for establishing the priorities. 

In this Priority System, construction projects for hospitals, health 

centers, staff quarters and youth regional treatment centers go 

through three key phases, wherein the IHS solicits proposals for 


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26 

81For a detailed discussion on the Priority System and the three phases, see U.S. Department 

of Health and Human Services, Indian Health Service, ‘‘Healthcare Facilities Construction Priority System Methodology,’’ June 3, 2004, located at http://www.ihs.gov/TribalLeaders/ 

triballetters/2004lLetters/06-28-2004lEnclosure.pdf; and ‘‘Health Care and Related Facilities,’’ located at http://www.ihs.gov/NonMedicalPrograms/DFEE/InfoSheets/infosheet.PDF. 82 House Report 106–406, at 138–139. 

health facility construction and ranks the proposals according to 

their relative need for construction.81

The projects are selected for inclusion on a ‘‘Priority List’’ after 

completion of Phases I and II, then move up the Priority List as 

Phase III is completed and appropriations for the projects are provided. 

Congressional Directive To Revise the Priority List. In 1999, in 

the conference report accompanying the FY 2000 Interior Appropriations Act (House Report 106–406), Congress directed the IHS, 

working closely with Indian tribes, to review and revise the Priority System. In recognizing the ‘‘extreme need for new and replacement hospitals and clinics,’’ Congress noted that ‘‘there should 

be a base funding amount, which serves as a minimum annual 

amount in the budget request.’’ Congress further noted that several 

issues needed to be considered in revising the Priority System and 

that ‘‘a more flexible and responsive program can be developed that 

will more readily accommodate the wide variances in tribal needs 

and capabilities.’’ 82

In response to this directive, the IHS Director convened a Facilities Appropriations Advisory Board (FAAB) and a Facilities Needs 

Assessment Workgroup to review the Priority System and make 

recommendations for revision. According to the IHS, the FAAB was 

comprised of 12 members representing Indian tribes and two members representing the IHS, and the Workgroup was established by 

the IHS Director to make recommendations to the FAAB. The 

Committee has been informed that, earlier this year, the FAAB 

submitted final recommendations to the IHS Director, but no final 

decision has been made on these recommendations. 

Meanwhile, in 1999, the National Steering Committee developed 

language regarding the Priority System contained in section 301 of 

the various iterations of bills introduced for the reauthorization of 

the Act. The language in section 301 remained primarily the same 

until 2006, when the Committee refined certain provisions and included an additional protected category in section 301(c)(1)(D), referred to as the ‘‘grandfather’’ provision, in S. 4122, introduced at 

the end of the 109th Congress. 

Grandfather Provision. The ‘‘grandfather’’ provision of section 

301(c)(1)(D) protects the priority status of health care facilities (in 

certain categories) on the Priority List from being affected by 

changes to the Priority System being contemplated by the IHS, 

pursuant to the 1999 Interior Appropriations Conference Report instruction. These projects have been on the Priority List since at 

least 1991. 

Under the ‘‘grandfather’’ provision, the protected categories include: 

(1) Top 10 Projects. Projects in the FY 2008 IHS budget justification for the 10 top-priority inpatient, outpatient, staff quarters and 

Youth Regional Treatment Centers (YRTC) projects. Currently, 

those projects include: 

Inpatient: Phoenix and Whiteriver, AZ; Barrow and Nome, AK. 


bajohnson on PROD1PC71 with REPORTS
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Outpatient: Ft. Yuma, Red Mesa, Kayenta, San Carlos and Winslow-Dilkon, AZ; St. Paul, AK; Sisseton, Eagle Butte and Rapid 

City, SD. 

YRTC: Wadsworth, NV; Central-Southern and Northern California. 

(2) Phase I and II. Projects that have completed Phases I and II 

of the Priority System in effect on the date of enactment of the Indian Health Care Improvement Act Amendments. Currently, these 

projects include: Ft. Belknap, MT; Wagner, SD; Sells and BodawayCoppermine, AZ; Gallup, Alamo, Albuquerque, Pueblo Pintado, 

Crownpoint and Shiprock, NM. 

During the 109th Congress, a third category was added: 

(3) Secretarial Discretion. Projects not in the other two protected 

categories and selected on the initiative of the Secretary or at the 

request of an Indian tribe or tribal organization. 

During the 109th Congress, the IHS, FAAB and Workgroup 

began finalizing their recommendations and draft revisions to the 

Priority System. The Committee had been informed that these 

drafts purported to revise what would constitute Phases I and II 

of the Priority System. These proposed changes could then have affected what projects would be ‘‘grandfathered’’ under section 

301(c)(1)(D) and thus change the priority of several projects which 

have been waiting on the Priority List for many years. 

Due to the uncertainty of when the IHS will approve the final 

changes (before or after the Act is reauthorized) and what those 

changes will consist of, the third category was added to ensure that 

the Secretary still has authority to prioritize projects which might 

no longer qualify under the other two protected categories. 

Innovative Approaches. Currently, construction funding generally 

has been applied to the projects on the Priority List. The Committee has been informed that the total cost of the current Priority 

List is in excess of $200 million as of FY 2008, with other unmet 

needs in the billions of dollars. At the time of the congressional directive in 1999, the construction appropriations was over $41 million and even reached over $94 million in FY 2004. The amount of 

appropriations increased slightly until FY 2006, after which it has 

decreased quite significantly. 

Ideally, with a continuation of the level of funding appropriated 

following the conference report directive in FY 2000, the current 

Priority List should have been nearing completion by the time revisions to the Priority System were finalized. Unfortunately, significant unforeseen national events occurred since the Appropriations 

Committee’s directive, which affected the amount of available appropriations for closing out the current Priority List and allowing 

other projects to be added to the List and built. Thus, the current 

Priority List has not been completed, whereas the revisions to the 

Prriority System are nearing completion. 

The Committee has been informed that while projects have been 

on the Priority List for a number of years, many other needed 

projects have never been on the Priority List. The Committee had 

been requested to include an alternative approach in S. 1200 to address the remaining unmet needs through the concept of an Area 

Distribution Fund. Under an Area Distribution Fund, a portion of 

construction funding could be devoted to IHS Area priorities. This 

localized approach would allow other smaller projects to be comVerDate Aug 31 2005 01:51 Oct 27, 2007 Jkt 069010 PO 00000 Frm 00027 Fmt 6659 Sfmt 6602 E:\HR\OC\SR197.XXX SR197

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83 Indian Health Care Improvement Act: Hearing of the Senate Indian Affairs Committee, 

110th Cong., 1st Session, S. Hrg. 110–53 at 74 (March 8, 2007) (statement of Rachel Joseph). 

pleted, instead of waiting until the entire current Priority List is 

completed. 

In light of the facilities backlog, section 301(f) of S. 1200 encourages the Secretary to seek innovative approaches to address unmet 

needs for health care facility construction, and requires the Secretary to consult and cooperate with Indian tribes in developing 

these innovative approaches. The Committee recognizes that the 

Secretary has engaged in considerable work revising the Priority 

System thus far. These proposed revisions may also be useful in developing innovative approaches. 

However, the Committee encourages the Secretary, prior to finalizing the revisions, to take into consideration the fiscal circumstances under which the 1999 congressional directive occurred, 

relative to those experienced today, and how innovative approaches 

to financing construction may be implemented in such a manner 

which is fair and equitable to those Indian tribes to be served by 

the projects on the current Priority List and those Indian tribes 

which have not had the opportunity to have their projects placed 

on the list. 

The Committee expects the IHS to work with Indian tribes in developing the types of innovative approaches to pursue, as well the 

contours of those approaches. The Secretary has used broad authority to develop and maintain the Priority System since the 1980s, 

and section 301(f) also provides broad authority to implement innovative approaches, such as an Area Distribution Fund, if, after consultation with the Indian tribes, it is determined that this is an appropriate system to address the health facility needs of Indian communities. The Committee also expects the IHS to work with Indian 

tribes and to submit a minimum budget request consistent with the 

congressional directive which will accommodate both the current 

Priority List and any innovative approaches. 

Elevation of the IHS Director. Section 601 of S. 1200 elevates the 

Director of the IHS to the position of Assistant Secretary for Indian 

Health within the Department of Health and Human Services. The 

purpose of this elevation is to foster the government-to-government 

relationship between Indian tribes and the United States, facilitate 

advocacy for Indian health policy, and promote consultation on Indian health matters. Presently, the Director of the Indian Health 

Service is appointed by the President and confirmed by the Senate 

pursuant to 25 U.S.C. 1661(a). The Director reports to the DHHS 

Secretary through the Assistant Secretary for Health. 

During the 109th Congress, the provisions elevating the Director 

to the Assistant Secretary were included in the introduced bill, S. 

1057, but not in the final iteration, S. 4122, due to objections by 

the Administration. The Committee has continued to receive testimony in strong support of elevation from the Indian tribes.83 The 

testimony received by the Committee and consultation with Indian 

tribes during the 110th Congress have counseled in favor of including the provisions in S. 1200 as part of the IHCIA reauthorization. 

Previous bills establishing this position in the Department have 

either been favorably approved by the Committee or passed the 

Senate: S. 558 (108th Congress, passed by the Senate), S. 214 


bajohnson on PROD1PC71 with REPORTS
29 

84S. Hrg. 110–48 at 184 (testimony of H. Sally Smith). 85 Id. 86 U.S. Department of Health and Human Services, Indian Health Service, Fiscal Year 2007, 

Justification of Estimates for Appropriations Committees, at IHS–49, and U.S. Department of 

Health and Human Services, Indian Health Service, Fiscal Year 2008, Justification of Estimates 

for Appropriations Committees, at CJ–121. 

(107th Congress, ordered reported by the Committee), S. 299 

(106th Congress, passed by the Senate), S. 1770 (105th Congress, 

passed by the Senate), S. 311 (104th Congress, ordered reported by 

the Committee), and S. 2067 (103rd Congress, passed by the Senate). 

Like these legislative predecessors, S. 1200 facilitates the government-to-government relationship between the United States and 

Indian tribes by providing the necessary leadership within the Administration on Indian health issues to bring focus, priority and 

national attention to the health care status and needs of Indians. 

Section 601 is intended to enhance the Federal capacity to respond 

to the ongoing health crisis in Indian Country and the continuing 

frustration of Indian tribes and patients that their needs and concerns are not adequately addressed under the current administrative policy and budgetary processes. 

Previous Senate reports further elaborate upon the evolution of 

the IHS and the need and purposes for establishing this position. 

(See Senate Report Nos. 108–76, 107–170, 106–148, 105–319, and 

103–327.) Nevertheless, an abbreviated discourse is necessary to 

inform the continuing need for elevating the Director to the Assistant Secretary for Indian Health. 

Budgetary Improvement. The IHS operates a comprehensive 

health care delivery system nationwide through a variety of health 

care facilities and services and through contracts and compacts 

with Indian tribes under the Indian Self-Determination and Education Assistance Act, with Urban Indian Organizations, or with 

private health care providers through the contract health services 

program. 

Efforts to address Indian health care needs have been tempered 

by the steady decline in purchasing power of the IHS budget. Indeed, the IHS 2004 study on Level of Need Funding indicated that 

the funding fell short of meeting the health care needs of Indian 

people and was operating at approximately a 40% deficiency. 

The Committee has not seen appreciable decreases to this deficiency to convince it that elevation is not necessary. One of the 

principal justifications for the elevation has been past Administrations’ failure to incorporate tribal recommendations in the final 

budget request, despite tribal participation throughout the budget 

process. 

For example, the Committee received testimony estimating 

health care needs in excess of $19.7 billion to achieve parity for Indian people.84 Past budgets have reflected marginal increases, even 

in the era of tight budgets, but these increases have not closed the 

gap on the ‘‘level of need’’ funding deficiency. 

In addition, the Committee has also received testimony that Indian tribes requested continued funding for the Urban Indian Organizations during the annual budget formulation sessions.85 However, the FY 2007 and FY 2008 President’s Budget Requests zeroed 

out funding for the Urban Indian Organizations.86 These decreases 


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30 

87See, for example, footnotes 46 and 76, above. 88GAO Report No. GAO–05–789, at 4. 89 Id., at 5. 90S. 1200 includes amendments to the ISDEAA which authorize the Native American Health 

and Wellness Foundation to promote the mission of IHS through such means as receiving donations which supplement, not offset, appropriations. Offsetting in Indian health care programs 

is generally prohibited by law. See 25 U.S.C. Sec. 1641(a). 

are disturbing in light of the alarming disparities that exist between the health status of the Indian population and other populations in the United States. These disparities have been well-documented in past Committee reports, legislation and testimony before 

the Committee.87

Although the Committee has received testimony that the Director has access and policy input within the DHHS, the health care 

status of Indians remains at such levels which necessitate a modified level of leadership and advocacy. The establishment of the Assistant Secretary for Indian Health will facilitate advocacy within 

DHHS and the Office of Management and Budget for the funding 

resources and policies that are necessary to effectively and efficiently address the health care needs and concerns of the Indian 

people. 

Regulatory and Administrative Improvement. The Indian health 

care system presents cross-cutting issues which involve DHHS 

agencies other than the IHS. The Committee recognizes the current 

attention given to Indian health issues as well as the revitalization 

of the Intra-departmental Council on Native American Affairs 

within the DHHS which would address matters in DHHS agencies 

affecting Indian health. 

Despite this revitalization, concerns have been raised with the 

Committee that broad administrative and regulatory matters within DHHS affecting Indian health have not been addressed either 

properly or timely. The Committee intends that this position would 

create an opportunity for the Assistant Secretary for Indian Health 

to be involved in the formulation of policy and regulatory authority 

on these larger issues which affect Indian health rather than simply addressing matters which are solely Indian in nature. 

As stated in previous Committee reports, the Committee continues to believe that the institutionalization of a senior policy official responsible for Indian health within the DHHS is necessary to 

bring parity and reduce deficiencies in the delivery of Indian health 

care services. This institutionalization is also important to ensure 

that the advocacy and the knowledge of the United States legal and 

moral obligations for Indian health and the mission of the IHS is 

carried forward in future Administrations. 

Third Party Reimbursements. Funding from sources other than 

IHS appropriations has been identified as a factor affecting the 

availability of health care services for Indians.88 Those funding 

sources include third-party reimbursements from Medicaid and 

Medicare. In some cases, these reimbursements constitute up to 

50% of the medical care budget for a particular Indian health program.89

With more resources, the Indian health care system could provide more services, and the Committee strongly encourages IHS 

and the Indian tribes to seek additional resources to supplement 

the appropriated sums provided annually.90 The GAO noted that 

‘‘[f]acilities with higher reimbursements had additional funds with 


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31 

91GAO Report No. GAO–05–789, at 26. 92 Id. 93 As a general rule, these special types of property are not included in eligibility calculations 

for income taxes or federal benefits. 94This provision is modeled after the current Centers for Medicare and Medicaid Services 

State Children’s Health Insurance Program regulation prohibiting cost-sharing for Indian children (42 C.F.R. Section 457.535). 

which they could hire staff, purchase equipment and supplies, and 

renovate their buildings.’’ 91 In one case, 31 percent of a facility’s 

clinical providers and other staff was funded by third party reimbursements.92

S. 1200 provides for an increase in access to Medicaid by removing barriers through waivers of premiums and cost-sharing at Indian health facilities and by codifying agency regulations or practices which recognize the unique nature of and special circumstances applying to Indian property, particularly trust and restricted property.93 Likewise, S. 1200 provides other means of removing barriers to obtaining third-party reimbursements, such as 

the process for seeking waivers of sanctions, which promotes favorable state-tribal relations. 

Waiver of Medicaid Co-Pays. One fundamental purpose of the Indian Health Care Improvement Act is to improve access to health 

care for Indian people. Removing barriers to such access is a critical aspect in accomplishing that purpose. To that end, section 204 

of Title II of S. 1200 prohibits cost-sharing under Medicaid.94

Indian tribes have strongly advocated that this policy waiving 

Medicaid co-pays reflects the federal trust obligation for Indian 

health wherein the health care has been ‘‘pre-paid’’—for example, 

by the treaty agreements exchanging tribal lands for health care. 

As additional justification, the Indian tribes contend that this policy is not unusual to the Medicaid system, since other Medicaid 

policies reflect that federal obligation. An example of this is the 

100% FMAP or Federal Matching Assistance Percentage, wherein 

the federal government provides 100% of the reimbursement to 

states of Medicaid reimbursements for services provided by the IHS 

or tribal health programs. 

Moreover, Indian tribes contend that the waiver of the co-pay is 

necessary to create incentives to enroll in Medicaid. Recognizing 

the federal obligation for Indian health care, the IHS, tribal and 

urban health programs do not charge the Indian patients cost-sharing for participating in the Indian health system to which Medicaid 

provides reimbursements. Charging the Indian patient a Medicaid 

co-pay will create a disincentive to enroll, essentially barring that 

Indian patient’s access to Medicaid; as a result, the overall Indian 

health budget, along with the ability to provide additional services, 

may suffer. On the other hand, waiver of the co-pay will continue 

to encourage Indian patients to enroll in Medicaid programs, thus 

‘‘stretching’’ IHS appropriated dollars. 

The Committee is aware of concerns that cost sharing discourages overutilization of health care services, which should be of particular concern to a system which is overburdened already. However, this concern may be addressed in several ways. 

Cost-sharing would not achieve the intended purpose of modifying behavior to avoid overutilization within the Indian health 

system. Overutilization assumes that there are otherwise adequate 

levels of services available to a population of non-overutilizers. PuVerDate Aug 31 2005 01:51 Oct 27, 2007 Jkt 069010 PO 00000 Frm 00031 Fmt 6659 Sfmt 6602 E:\HR\OC\SR197.XXX SR197

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95GAO Report No. GAO–05–789, (August, 2005). 96Senate Report 94–133, at 23. 97See American Indian Policy Review Commission, Task Force Six, Final Report to the Commission, Vol. 6, at 28. 98S. Hrg. 109–162, at 585 (statement of Dr. Grim, Director, U.S. Department of Health and 

Human Services, Indian Health Service). 99 Id. at 589. 

nitive or disincentive measures will not work if the service is not 

available or delayed. Services being unavailable or delayed have 

been documented by the GAO study,95 and the IHS Level of Need 

Funded (LNF) Study. The data in the GAO study reported that 

many Indian people are not seeking health care services until it is 

too late. There was no evidence in this GAO report that overutilization of the health care services occurred at the Indian health programs. 

The data in the LNF Study also suggests that many Indian patients may have to delay seeking health care because services are 

rationed, rather than available for every health care need. In other 

words, Indian patients are not running to the clinic for every sniffle, but may wait until their health care needs become emergent 

problems. Thus, it is unlikely that overutilization occurs, so there 

is no problem that the cost-sharing would obviate. Imposing costsharing, on the other hand, may serve to further exacerbate the 

problem of delaying health care by requiring a co-pay by Indian patients who can ill afford it. 

Removing barriers to enrollment will enable Indian patients to 

enroll in Medicaid, and the ensuing Medicaid reimbursements will 

assist the Indian health program in providing more services, thereby diminishing the potential of overburdening the system. Costsharing is, in reality, cost-shifting. If Indian patients are eligible 

and qualify for Medicaid, then the patient should take advantage 

of the available program. By not enrolling, the cost that should be 

borne by Medicaid continues to strain the IHS budget, which has 

been documented to be insufficient to meet the needs of Indian 

communities. 

Consequently, S. 1200 continues the policy and provisions regarding Medicaid co-pays that were reported favorably by the Senate Finance Committee in S. 3524 during the 109th Congress. 

Non-Eligibles. Congress has recognized that ‘‘without a proper 

health status, the Indian people will be unable to fully avail themselves of the many economic, educational, and social programs already directed to them.’’ 96 Providing services to Indian people improves the health of Indians in a direct manner. 

However, protecting the health of Indians requires attention to 

issues other than direct services to Indians. In the 1800s, services 

such as vaccinations were provided to Indians located near forts to 

protect the health of soldiers.97 Now the tables are turned. Under 

certain circumstances, individuals not otherwise eligible for Indian 

health care may receive a limited scope of health services under 

the Act to protect the health of Indians. 

Serving ‘‘non-eligibles’’ for these purposes comports with the Administration’s goals of promoting ‘‘healthy Indian . . . communities’’ 98 and ‘‘including new approaches to delivering care.’’ 99

Serving non-eligibles has been a policy of the Act for many years 


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33 

100See GAO Report No. GAO–05–789. 

and it reflects a logical and reasonable approach to protect Indian 

health. 

For example, the Act provides that services may be provided to 

a non-eligible pregnant woman carrying an Indian’s child. 25 

U.S.C. 1680c(c)(3) (Section 807(d)(3) of S. 1200). In addition, services may be provided to prevent the outbreak of communicable diseases such as tuberculosis. 25 U.S.C. 1680c(c)(2) (Section 807(d)(2) 

of S. 1200). 

In including these ‘‘non-eligible individuals’’ in the service delivery system, Congress has set forth considerations for the IHS and 

Indian tribes to address prior to providing the services—the ‘‘twopart determination’’ contained at 25 U.S.C. 1680c(b)(1)(A): 

(i) the provision of such health services will not result in a 

denial or diminution of health services to eligible Indians; and 

(ii) there is no reasonable alternative health facility or services, within or without the service area of such service unit, 

available to meet the health needs of such individuals. 

However, the Committee is aware that questions have arisen regarding how the two-part determination applies to Indian tribes 

with contracts or compacts under ISDEAA. 

Where services are directly provided by the IHS, the Indian 

tribe(s) served by the Service Unit and the IHS jointly make the 

two-part determination (25 U.S.C. 1680c(b)(1)(A)). Section 807 of S. 

1200 provides that, for programs administered by an Indian tribe 

pursuant to a contract or compact under the ISDEAA, the Indian 

tribe is authorized to provide services to non-eligibles, but ‘‘shall 

take into account’’ the two-part determination. 

Congress has made it clear that the determination shall be made 

in both instances: in the case of direct services it is made by both 

IHS and the Indian tribes and, in the case of ISDEAA contracts or 

compacts, by Indian tribes. Congress did not provide in the Act express substantive or procedural provisions governing how the determinations should be made, given the innumerable variations in 

circumstances for the Indian communities. 

However, Section 807 does provide some guidance on how the 

parties may determine whether there will be no diminution of services. For example, the non-eligibles receiving services ‘‘shall be liable for payment of such health services under a schedule of charges 

prescribed by the Secretary’’ (25 U.S.C. 1680c(b)(2)(A)). In other 

words, no diminution may be experienced if the funded used to 

serve these people is replaced by other funding. 

In addition, health services may be provided to indigent non- eligibles if there is a reimbursement agreement with the State or 

local governments. These provisions, however, do not limit the ability of either the IHS or Indian tribes to include additional considerations in determining whether services would be decreased. Other 

budgetary factors, delays in services, and appointment waiting 

times,100 are all other considerations that may be appropriate, depending on the particular circumstances. 

Likewise, when assessing reasonable alternatives, the IHS and 

Indian tribes may be confronted by factors such as remote locations, distances to other health facilities and other unique difficulties, which render other health care alternatives unavailable. QuesVerDate Aug 31 2005 01:51 Oct 27, 2007 Jkt 069010 PO 00000 Frm 00033 Fmt 6659 Sfmt 6602 E:\HR\OC\SR197.XXX SR197

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tions surrounding what is available should be placed in the context 

of the following policy considerations. First, services under this Act 

are for the ultimate protection of Indian health. Second, the IHS 

and tribal health programs are the payors of last resort which 

means, in this situation, that all other avenues of obtaining health 

services should be exhausted by the non- eligible individual prior 

to seeking assistance from either IHS or the tribal health programs. 

The Committee has been informed that some health providers 

may refuse to serve Medicaid beneficiaries, thus making any other 

health service alternatives unavailable. In those situations, if good 

faith efforts have been made to obtain services and all avenues 

have been exhausted, it appears that there may be an arguable 

case of unavailability. 

When making these determinations, Indian tribal leaders are 

placed in a difficult situation. On the one hand, the federal obligation for Indian health—which the Indian tribe is administering—

is secured for the benefit of Indians. Authorizing services for noneligibles is a determination not made lightly by Indian tribal leaders. On the other hand, withholding services from these non-eligibles under the limited circumstances enumerated in this Act may 

serve to do harm to Indian people by not eliminating general 

health hazards. 

Evaluations were left in S. 1200 to the IHS and Indian tribes 

based on their particular circumstances and, if appropriate, could 

be developed more fully through negotiated rulemaking or consultation. 

SECTION-BY-SECTION ANALYSIS

A significant portion of current law has been carried forward by 

S. 1200 and reorganized in the various titles according to subject 

matter. S. 1200 also adds several new provisions to current law 

which may (1) amend current law, such as turning a demonstration 

project into a permanent program, (2) clarify or make small additions, such as including Tribal Organizations in various sections, or 

(3) introduce brand new programs to the Indian health care system, such as Indian youth suicide prevention, intervention and 

treatment through the use of telemedicine, and convenient care 

services. 

The following section-by-section analysis will, where relevant, 

identify whether current law has been changed followed by an explanation of the current law to be reauthorized by S. 1200. In addition, the codified section in current law is also noted to provide 

ease of reference. 

Section 1. Short title; table of contents 

Section 1 provides that this Act may be cited as the ‘‘Indian 

Health Care Improvement Act Amendments of 2007,’’ and contains 

the table of contents. 

TITLE I—AMENDMENTS TO INDIAN LAWS 

The provisions of Title I are within the jurisdiction of the Senate 

Indian Affairs Committee. 


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Section 101. Indian Health Care Improvement Act amended 

This section sets forth a host of provisions which incorporate provisions of current law and make amendments to the Act. 

Section 1. Short title; table of contents 

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

Act.’’ Section 1 also sets for the table of contents for Title I. 

Section 2. Findings 

Section 2 sets out Congressional findings for the Act, which indicate that the health levels of Indians are below that of the rest of 

the U.S. population and that the provision of health care is consonant with the Federal relationship and responsibility to Indian 

people. 

Amendments: This section maintains current law. 

Current Law: This section is Section 1601 of current law. 

Section 3. Declaration of national Indian health policy 

This section declares national policy, in fulfillment of the special 

trust responsibilities and legal obligations to Indians, to assure the 

highest possible health status for and raise the health status of Indians and Urban Indians through the provision of health services. 

Amendments: This section amends current law by (1) replacing 

the enumerated list of health level objectives with the goals contained in the Healthy People 2010 national health agenda; and (2) 

adding new language to (a) add trust to the responsibilities being 

fulfilled by the national policy, (b) allow Indians to set their priorities according to their needs, (c) increase the health profession degrees awarded to Indians so the levels of Indian health professionals in each Service Area is at least the level of the general population, (d) require consultation with Indian Tribes, Tribal Organizations and Urban Indian Organizations, consistent with the policy 

of Indian self-determination, and (e) provide funding to Indian tribal programs and facilities consistent with levels of IHS programs 

and facilities. 

Current Law: This section is Section 1602 of current law. 

Section 4. Definitions 

Section 4 provides definitions for terms used throughout the Act. 

Amendments: This section maintains current law and adds several new definitions. Assistant Secretary, behavioral health, tribal 

college or university, telehealth, contract health service, and telemedicine are examples of new definitions not now in current law. 

Current Law: Section 1603 of current law provides definitions for 

terms used throughout the Act. 

TITLE I—INDIAN HEALTH, HUMAN RESOURCES, AND 

DEVELOPMENT 

Section 101. Purpose 

This section states the purpose of this title, which is to increase 

the number of Indians entering health professions and providing 

health services, and to assure an optimum supply of health professionals to provide health services to Indians. 


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Amendments: This section maintains current law and adds language indicating congressional intent to maximize the number, and 

assure an optimum (not merely adequate) supply, of health professionals in the Indian health system. 

Current Law: Section 1611 of current law states the purpose of 

increasing the number of Indian health professionals and assuring 

an adequate supply of health professionals to provide health services to Indians. 

Section 102. Health professions recruitment program for Indians 

This section authorizes grants for recruitment programs, including identifying Indians with potential for entering health professions, publicizing sources of financial aid, and establishing programs to facilitate enrollment in applicable courses of study. This 

section also addresses funding applications and amount of funding 

to be provided, as well as outlining the eligibility for these programs. 

Amendments: This section maintains current law. 

Current Law: This section is Section 1612 of current law. 

Section 103. Health professions preparatory scholarship program for 

Indians 

Section 103 authorizes scholarships to Indians for compensatory 

preprofessional education, as well as pregraduate education leading 

to a baccalaureate degree in a preparatory field for a health profession. This section specifies certain conditions on these scholarships 

which include costs which may be covered by the scholarships, and 

prohibits denial of a scholarship based solely on scholastic achievement if applicant has already been admitted or maintains good 

standing at an accredited institution, or if the applicant is eligible 

for assistance under another federal program. 

Amendments: This section maintains current law and adds new 

provisions, authorizing extensions of pregraduate scholarship 

award terms up to 2 years, according to Secretarial regulations, 

and authorizing regulations for determining part-time equivalents 

for the compensatory preprofessional scholarships. 

Current Law: This section is Section 1613 in current law. 

Section 104. Indian health professions scholarships 

Section 104 authorizes scholarships to Indians who are enrolled 

full- or part-time in accredited schools, pursuing courses of study 

in the health professions. Such scholarships are designated as Indian Health Scholarships. The section further sets forth how the 

funding for these scholarships is to be allocated and addresses all 

the requirements of the active duty service obligation incurred as 

a result of the scholarship, including breach of contract situations. 

Amendments: This section maintains current law and adds new 

provisions that (1) require a year-for-year service obligation for 

scholarship recipients; (2) require Secretarial guidelines for fulfilling the service obligation in private practice; and (3) allow a recipient to fulfill the service obligation by teaching in a tribal college 

or university nursing program if health services to Indians are not 

diminished 

Current Law: This section is Section 1613a of current law. 


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Section 105. American Indians into psychology program 

This section authorizes grants of not more than $300,000 to each 

of 9 colleges and universities for developing and maintaining Indian psychology career recruitment programs, including a Quentin 

N. Burdick Program Grant at the University of North Dakota. This 

section directs the Secretary to issue regulations for competitive 

funding, and specifies conditions of the grants and active duty service requirements. $2.7 million is authorized for each of FY 2008 

through 2017. 

Amendments: This section maintains current law and adds new 

language which (1) sets the number of colleges or universities that 

may receive grants from at least 3 to 9, and (2) establishes a maximum grant amount of $300,000, for a total of $2.7 million for each 

of FY 2008 through 2017. 

Current Law: The section is Section 1621p of current law. 

Section 106. Scholarship programs for Indian tribes 

Section 106 authorizes the Secretary to make funds available to 

Tribal Health Programs for the purpose of educating Indians to 

serve as health professionals in Indian communities. The requirements for receiving such funds; the course of study; contract requirements; specific parameters for a breach of contract; the relationship of a scholarship under this section to the Social Security 

Act; and conditions of continuance of funding are all specified in 

this section. The recipient is required to fulfill service obligations 

and use the scholarship for tuition and reasonable education or living expenses. The recipient cannot discriminate against patients 

who receive assistance under Titles XVIII and XIX of the Social Security Act. 

Amendments: This section maintains current law and adds new 

language which (1) amends the source of funds for the scholarship 

costs by allowing 20% to be from any source instead of only nonfederal sources; (2) requires that licensing and educational requirements be met for all health professions, not only for the doctor and 

nursing professions; (3) provides that the scholarship may allow 

the recipient to serve in another Service Area, provided the Tribal 

Health Program and Secretary approve and services are not diminished to Indians in the Service Area where the Tribal Health Program providing the scholarship is located; and (4) adds Title XXI 

of the Social Security Act to the non- discriminatory provisions. 

Current Law: This section is Section 1616m of current law. 

Section 107. Indian Health Service extern programs 

Section 107 gives preference for employment with the Service, a 

Tribal Health Program, Urban Indian Organization or other agencies within the Department, to any recipient of a scholarship pursuant to section 104 or 106. The section specifies that such employment does not count toward any active duty service obligation. It 

specifies the timing and length of employment and exempts the 

program from any competitive personnel system or agency personnel limitation. The section further specifies that an individual 

employed under this section will receive practical experience in the 

health profession in which he or she is engaged in study. 

Amendments: This section maintains current law and adds the 

following new provisions: (1) extends the extern program to Tribal 


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Health Programs, Urban Indian Organizations or urban Indian 

health providers (on a discretionary basis) or other Department 

agencies, instead of only the IHS; and (2) gives the extern, including an extern in a high school program, a preference for employment with the IHS, instead of entitling them to employment. 

Current Law: This section is Section 1614 of current law. 

Section 108. Continuing education allowances 

This section permits the Secretary to provide programs or allowances to (a) transition in to an Indian Health Program, including 

licensing, board or certification examination and technical assistance, in fulfilling service obligations, and (b) health professionals 

employed in an Indian Health Program to enable them to take 

leave of their duty stations for a period of time each year for professional consultation and refresher training courses. 

Amendments: This section maintains current law, but also deletes the set-aside of not more than $1 million for postdoctoral 

training contained in current law, and adds language which extends the continuing education allowances to Tribal Health Programs and Urban Indian Organizations, in addition to the IHS, 

and includes all health professionals, rather than specified select 

health professionals. 

Current Law: This section is Section 1615 of current law. 

Section 109. Community Health Representative Program 

Section 109 authorizes the Community Health Representative 

Program for training and using Indians as community health representatives. The section specifies the duties of the Service regarding this program, including providing a high standard of training 

for Community Health Representatives to ensure that these representatives provide quality health services to Indian communities 

served by this program. This program may also promote traditional 

health care practices consistent with IHS standards for health care. 

Amendments: This section maintains current law, and adds language which formally identifies the health paraprofessionals as 

Community Health Representatives (CHRs) and extends the use of 

CHRs to Tribal Health Programs and Urban Indian Organizations 

as well as IHS programs. 

Current Law: The section is Section 1616 of current law. 

Section 110. Indian Health Service Loan Repayment Program 

This section directs the Secretary to establish and administer the 

Service Loan Repayment Program in order to ensure an adequate 

supply of trained health professionals needed to maintain accreditation of, and provide health care services to Indians through, Indian Health Programs and Urban Indian Organizations. The section includes provisions addressing eligibility for the program; application information; priorities; recipient contracts; deadlines for 

decisions on applications; a loan repayment program; a waiver from 

any employment ceiling; a recruitment program; non-applicability 

of Section 214 of the Public Health Service Act (which concerns employees or officers being assigned to other agencies) during the period of obligated service; assignment of individuals; breach of contract; waiver or suspension of obligation; and the requirement of an 

annual report to Congress under Section 801. 


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Amendments: This section maintains current law. In addition, it 

(1) eliminates the set-asides during FY 1993–1995 for nursing and 

mental health professions; and (2) establishes priorities among applications rather than requiring the priorities be subject to the list 

of positions established by the Secretary, and sets a 21-day notice 

requirement instead of merely prompt notice. 

Current Law: This section is Section 1616a of current law. 

Section 111. Scholarship and Loan Repayment Recovery Fund 

Section 111 establishes an Indian Health Scholarship and Loan 

Repayment Recovery Fund within the Treasury of the United 

States. The section specifies the use of these funds, the investment 

of the funds, and the sale of obligations by the Secretary of the 

Treasury. 

Amendments: This section maintains current law, and adds provisions expanding the source of funds for this Recovery Fund to include funds collected from individuals for breach of contract under 

the scholarship or loan repayment programs and interest, in addition to appropriations. Tribal Health Programs may also use payments received to provide scholarships, in addition to the current 

uses of recruitment and employment of health care professionals. 

The Secretary of Health and Human Services may now determine 

what amounts are not required to meet current withdrawals from 

the Fund, rather than the Secretary of the Treasury, as in current 

law. 

Current Law: This section is Section 1616a–1 of current law. It 

establishes an Indian Health Scholarship and Loan Repayment Recovery Fund within the Treasury of the United States, wherein 

funds collected for breaches of contractual obligations under the 

IHS or tribal scholarships or loan repayment programs are placed. 

Section 112. Recruitment activities 

Section 112 permits the Secretary to reimburse certain travel expenses to health professionals seeking positions with Indian Health 

Programs or Urban Indian Organizations. Potential candidates for 

contracts under section 110 and their spouses are all eligible for 

such reimbursement of travel. In addition, this section requires the 

Secretary to assign one individual in each Area Office to have fulltime responsibility for recruitment activities. 

Amendments: This section maintains current law and adds language to allow reimbursement for health professionals seeking positions with Tribal and Urban Indian Health Programs, in addition 

to the IHS. 

Current Law: This section is Section 1616b of current law. 

Section 113. Indian recruitment and retention program 

Section 113 requires the Secretary to fund innovative demonstration projects to enable Tribal Health Programs and Urban Indian 

Organizations to recruit, place, and retain health professionals to 

meet their staffing needs. The section also specifies that any Tribal 

Health Program or Urban Indian Organization is eligible to apply 

for these funds. 

Amendments: This section maintains current law and adds language which (1) sets a time limit of three years for demonstration 

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frame under current law; and (2) clarifies that the entities eligible 

to compete are Tribal Health Programs and Urban Indian Organizations. 

Current Law: This section is Section 1616c of current law. 

Section 114. Advanced training and research 

This section establishes a demonstration project to enable health 

professionals who have worked in an Indian Health Program or 

Urban Indian Organization for a substantial period of time to pursue advanced training or research areas of study, where a need exists. Each individual who participates shall incur a service obligation. The section also specifies equal opportunity for participating 

in the program. 

Amendments: This section maintains current law and adds language which limits the advanced training or research opportunities 

to health professionals who have worked for the IHS, tribal or 

urban Indian health programs for a substantial period of time, instead of merely being employed by one of these programs at the 

time of application. 

Current Law: This section is Section 1616d of current law. 

Section 115. Quentin N. Burdick American Indians into Nursing 

Program 

Section 115 authorizes the Quentin N. Burdick American Indians 

into Nursing Program for the purpose of increasing the number of 

nurses, nurse midwives, and nurse practitioners who deliver health 

care services to Indians. The section specifies potential grant recipients; how grants may be used; information which must be included 

in applications for the grant; preferences for grant recipients; establishment and maintenance of a program at the University of 

North Dakota; and an active duty service obligation. 

Amendments: This section maintains current law and adds language which (1) includes advanced practice nurse programs in addition to nurse practitioners; (2) authorizes grants for midwife or 

nursing programs at tribal colleges and universities or, in their absence, other colleges and universities, instead of only at the other 

public or private institutions; and (3) includes tribal colleges and 

universities in the preferences among grant applicants. 

Current Law: This section is Section 1616e of current law. 

Section 116. Tribal cultural orientation 

This section requires certain employees of the Service who serve 

Indian Tribes in each Service Area to receive instruction in the history and culture of the Indian Tribes they serve. The section requires that the program be developed in consultation with the affected Indian entities, be implemented through tribal colleges or 

universities, include instruction in American Indian studies, and 

describe the use and place of traditional health care practices of 

the Indian Tribes in the Service Area. 

Amendments: This section maintains current law and adds language which (1) ensures that employees in each Service Area obtain cultural orientation, rather than merely establishing a program for cultural orientation; (2) requires the program to include 

instruction on the relationship of the Indian Tribes with the IHS, 

rather than simply a history of the IHS, and a description of the 


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traditional health care practices of the Indian tribes in the Service 

Area; and (3) requires consultation with affected Tribes, Tribal Organizations and Urban Indian Organizations. 

Current Law: This section is Section 1616f of current law. 

Section 117. INMED Program 

Section 117 authorizes the Secretary to provide grants to colleges 

and universities to maintain and expand the Indian health careers 

recruitment program known as the Indians Into Medicine Program 

(INMED). The Quentin N. Burdick Grant at the University of 

North Dakota is to be one of the authorized grants. This section 

also specifies requirements for institutional applicants for these 

grants. 

Amendments: This section maintains current law and adds language which (1) authorizes grants to an unspecified number of colleges or universities instead of the previous mandate of at least 3 

schools; (2) clarifies that the regulations govern the grants, including substantive provisions, such as criteria and application requirements, rather than govern only the competitive award process; and 

(3) eliminates an old 1988 requirement of a report to Congress on 

the program and recommendations for changes. 

Current Law: This section is Section 1616g of current law. 

Section 118. Health training programs of community colleges 

This section requires the Secretary to award grants to accredited, 

accessible community colleges to assist in establishing health profession education leading to a degree or diploma for individuals 

who desire to practice such profession on or near a reservation or 

in an Indian Health Program. The Secretary is also required to 

award grants to accredited, accessible community colleges that already have these programs. The Secretary must provide technical 

assistance to encourage community colleges to establish and maintain such programs. Any program receiving assistance under this 

section is required to provide advanced training for health professionals. Grant award priority is provided to tribal colleges and universities in Service Areas where they exist. 

Amendments: This section maintains current law and adds language which (1) recognizes accredited and accessible community 

colleges as eligible recipients of grants; (2) requires the colleges to 

have a relationship with a hospital, rather than merely having access to a hospital; (3) requires Indian preference for program participants; (4) increases the ceiling amount of the grant from 

$100,000 to $250,000; and (5) establishes priority for tribally-controlled colleges in Service Areas where they exist, if other requirements in the section are met. 

Current Law: This section is Section 1616h of current law. 

Section 119. Retention bonus 

Section 119 permits the Secretary to provide retention bonuses 

to any health professional where recruitment or retention is difficult or is needed by Indian Health Programs and Urban Indian 

Organizations, if the individual has completed 2 years of employment with an Indian Health Program or Urban Indian Organization or any service obligation from federal scholarships or loan repayment programs, and enters into an agreement with an Indian 


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Health Program or Urban Indian Organization for continued employment for a period of not less than 1 year. Rates for retention 

bonuses may cover multiple years, but not exceed an annual rate 

of $25,000. Refunds shall be required if the health professional 

does not complete the term of service under any retention agreement, unless the default is not the fault of the individual. 

Amendments: This section maintains current law and adds language expanding the bonuses (1) to any health professional, rather 

than only doctors and nurses, so language specifying funding setasides between these 2 professions has been deleted; and (2) to 

health professionals employed by the tribal or urban health programs, rather than employed only by the Service. Language also 

eliminates the current requirement that the retention bonus be 

paid at the beginning of the term of service. 

Current Law: This section is Section 1616j in current law. 

Section 120. Nursing residency program 

This section establishes a program to enable Indians who are 

nurses working for an Indian Health Program or Urban Indian Organization to pursue advanced training. The participants are required to enter a service obligation to serve in an Indian Health 

Program or Urban Indian Organization. The program shall include 

a combination of education and work study leading to either an associate or bachelor’s degree or advanced degrees or certifications. 

Amendments: This section maintains current law and adds language which establishes this program for Indian nurses and includes advanced degrees or certifications in nursing or public 

health as eligible programs, instead of a Master’s degree, as appropriate post-baccalaureate training. 

Current Law: This section is Section 1616k of current law. 

Section 121. Community Health Aide Program 

Section 121 directs the Secretary to develop and operate a Community Health Aide Program in Alaska. Requirements are specified 

for the Alaska program. Dental Health Aide Therapists under the 

Program would be prohibited from performing all oral and jaw surgeries except pulpal therapy or extraction of adult teeth after consultation with a licensed dentist in a dental emergency. In addition, the Secretary is directed to establish a neutral panel to conduct a study of the dental health aide therapist services provided 

by the Community Health Aide Program. Specifications of the 

study, which will lead to a report to Congress, are delineated. This 

section also allows the Secretary to establish a national Community Health Aide Program, which shall not include dental health 

aide therapist services, and shall not reduce funds for the Alaska 

program. 

Amendments: This section maintains current law and adds provisions which (1) require the Secretary to establish a neutral panel, 

whose membership is also set forth in this section, to study the 

dental health aide therapist program in Alaska Native communities and to submit a report on the study to appropriate Congressional Committees and (2) authorizes the expansion of the Community Health Aide Program, except for the dental health aide therapist program, to Indian communities in the lower 48 states. 

Current Law: This section is Section 1616l of current law. 


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Section 122. Tribal Health Program administration 

This section requires the Secretary to provide training for Indians in the administration and planning of Tribal Health Programs. 

Amendments: This section maintains current law and adds language which specifies that the training shall be for individuals who 

are Indian. 

Current Law: This section is Section 1616n of current law. 

Section 123. Health professional chronic shortage demonstration 

programs 

This section permits the Secretary to fund demonstration programs for Tribal Health Programs to address the chronic shortages 

of health professionals. Each demonstration program shall incorporate a program advisory board, which is to be composed of representatives from the Indian Tribes and Indian communities which 

are served by the program. 

Amendments: This section amends current law by changing a single pilot program at the School of Medicine at the University of 

South Dakota to address health professional shortages into a national demonstration project. 

Current Law: This section is Section 1616o in current law. Current law authorizes the Secretary to make a grant to the School of 

Medicine at the University of South Dakota to fund a pilot program 

on an Indian reservation at one or more Service Units in South Dakota to address the chronic manpower shortages in the Aberdeen 

Area of the IHS. 

Section 124. National Health Service Corps 

This section prohibits the Secretary from removing a member of 

the National Health Service Corps from an Indian Health Program 

or Urban Indian Organization or withdrawing funding used to support such member, unless the Secretary ensures that Indians will 

experience no reduction in services. The section also exempts Corps 

scholars qualifying for the Commissioned Corps in the United 

States Public Health Service from full-time equivalent limitations 

when serving as a commissioned corps officer in a Tribal Health 

Program or an Urban Indian Organization. 

Amendments: This section maintains current law and adds 

Urban Indian organizations. Language which exempts National 

Health Service Corps scholars qualifying for the Commissioned 

Corps in the United States Public Health Service from full-time 

equivalent limitations when serving as a commissioned corps officer in a Tribal Health Program or an Urban Indian Organization 

is new to current law. 

Current Law: This section is Section 1680b of current law. 

Section 125. Substance abuse counselor educational curricula demonstration programs 

Section 125 allows the Secretary to enter into contracts with or 

make grants to accredited colleges and universities (including tribal) to establish demonstration programs developing curricula for 

substance abuse counseling. Duration and renewal of the grants is 

specified. The section also states the criteria for review and approval of the applications; requires the Secretary to provide technical and other assistance to grant recipients; requires the SecVerDate Aug 31 2005 01:51 Oct 27, 2007 Jkt 069010 PO 00000 Frm 00043 Fmt 6659 Sfmt 6602 E:\HR\OC\SR197.XXX SR197

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retary to submit an annual report to the President under section 

801; and defines the term ‘‘educational curriculum.’’

Amendments: This section maintains current law, and adds language including accredited and accessible qualifications for the 

community colleges eligible for these programs and extending the 

initial grant period from one year to three years and the renewal 

periods from one year to two years. 

Current Law: This section is Section 1665j of current law. 

Section 126. Behavioral health training and community education 

programs 

This section requires the Secretary, with the Secretary of the Interior and in consultation with Indian Tribes and Tribal Organizations, to conduct a study and compile a list of certain types of staff 

positions within the Bureau of Indian Affairs, the Service, Indian 

Tribes, Tribal Organizations and Urban Indian Organizations, 

which should include training in any aspect of mental illness, dysfunction, or self-destructive behavior. 

The Secretary is then required to provide training criteria appropriate for each type of position and ensure that this training is provided. Upon request of the appropriate Indian entity, the Secretary 

is required to develop and implement a program of community education on mental illness, as well as to provide technical assistance 

to tribal entities to obtain and develop community education materials. 

Within 90 days of enactment of this Act, the Secretary is required to develop a plan to increase behavioral health services by 

at least 500 staff positions within 5 years, with at least 200 of such 

positions being devoted to child, adolescent, and family services. 

Amendments: This section maintains current law and (1) adds 

Tribal Organizations and Urban Indian Organizations as participants in the program; (2) clarifies that Tribal Organizations are to 

be part of the consultation process; (3) changes the focus from solely on mental health to behavioral health; and (4) eliminates the requirement that the staff be assigned primarily to the IHS Service 

Units. 

Current Law: This section is Section 1621h(d) of current law. 

Section 127. Authorization of appropriations 

Section 127 authorizes to be appropriated such sums as may be 

necessary to carry out this title for each fiscal year through 2017. 

Amendments: The section updates the authorization period 

through fiscal year 2017, instead of fiscal year 2000. 

Current Law: This section is Section 1616p of current law. 

TITLE II—HEALTH SERVICES 

Section 201. Indian Health Care Improvement Fund 

This section authorizes the use of funds for the purposes of eliminating the deficiencies in health status and resources for tribes; 

eliminating backlogs and meeting the needs in health care services; 

eliminating the inequities in funding for direct care and contract 

health service programs; and augmenting the ability of the Indian 

Health Service to meet its various responsibilities. Funding authorized by this section may not be used to offset appropriated funds 


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and must be used to improve the health status and reduce the resource deficiencies of tribes. 

This section also defines ‘‘health status and resource deficiency’’ and requires that Tribal Health Programs be equally eligible for 

funds as programs administered by the Indian Health Service. A 

report is required to be submitted to Congress 3 years after enactment which addresses the current health status and resource deficiency for each Service Unit. Funds appropriated under this section 

are to be included in the base budget of the Indian Health Service 

for determining appropriations in subsequent years. 

Nothing in this section is intended to diminish the primary responsibility of the Indian Health Service to eliminate backlogs in 

unmet health care, or to discourage additional efforts of the Service 

to achieve equity among Tribes and Tribal Organizations. 

Funds appropriated under this section are to be designated as 

the ‘‘Indian Health Care Improvement Fund.’’ Amendments: This section maintains current law and adds provisions clarifying that the Secretary may expend funds either directly 

or through contracts or compacts under the Indian Self-Determination and Education Assistance Act, as well as provisions regarding 

the use of telehealth and telemedicine. Language has been added 

specifying the kinds of injury prevention programs that may be offered. 

Current Law: This section is Section 1621 of current law. 

Section 202. Catastrophic Health Emergency Fund 

Section 202 establishes the Catastrophic Health Emergency 

Fund (CHEF), which is to be administered by the Secretary 

through the headquarters of the Indian Health Service in order to 

meet the extraordinary medical costs associated with the treatment 

of victims of disasters or catastrophic illnesses. No part of the 

CHEF or the administration thereof is to be subject to contract or 

grant, nor shall these funds be apportioned on an Area Office, 

Service Unit, or other similar basis. The Secretary is required to 

promulgate regulations for the administration of these funds. This 

section prohibits funds appropriated to CHEF from being used to 

offset or limit other appropriations made to the Indian Health 

Service. It also requires that all reimbursements to which the Service is entitled from any source by reason of treatment rendered to 

any victim of a disaster or catastrophic illness the cost of which 

was paid from CHEF shall be deposited into CHEF. 

Amendments: This section maintains current law. 

Current Law: This section is Section 1621a in current law. 

Section 203. Health promotion and disease prevention services 

This section finds that health promotion and disease prevention 

activities improve health and well-being and reduce the expenses 

for health care. It requires the Secretary to provide these services 

and, with input from the affected Tribal Health Programs, to report 

to Congress on an evaluation statement of the status, capacity and 

resources needed to promote health and prevent disease. 

Amendments: This section maintains current law, but moves the 

definition of health promotion and disease prevention to the definitions section and adds Congressional findings. 

Current Law: This section is Section 1621b of current law. 


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Section 204. Diabetes prevention, treatment, and control 

Section 204 requires the Secretary to determine the incidence of 

diabetes and its complications among Indians and the measures 

needed to prevent, treat and control this disease. The Secretary is 

also required, when medically indicated and with informed consent, 

to screen Indians for diabetes and for conditions which indicate a 

high risk for diabetes. 

The Secretary is required to continue to fund model diabetes 

projects and dialysis programs. To the extent that funding is available, the Secretary is required to work with each Area Office to 

consult with Tribes and Tribal Organizations regarding diabetes 

programs; establish patient registries in Area Offices; and ensure 

that data collected are disseminated to other Area Offices, subject 

to privacy laws. The Secretary is also allowed to maintain diabetes 

control officers, but if these positions and activities are administered by the Tribes or Tribal Organizations, then the funding and 

activities would not be divisible under the Indian Self-Determination and Education Assistance Act. 

Amendments: This section maintains current law and (1) adds (a) 

Tribal Organizations as eligible participants in these programs, (b) 

effective ongoing monitoring of disease indicators, (c) the requirement that screening shall be to the extent medically indicated and 

with informed consent, and (d) funding for dialysis programs; (2) 

changes the model diabetes projects into permanent programs to be 

continued along with any new programs developed with recurring 

funding; and (3) still allows for diabetes control officers in each 

Area Office, but provides that if these positions and activities are 

administered by the Tribes or Tribal Organizations, then the funding and activities would not be divisible under the Indian Self-Determination and Education Assistance Act. 

Current Law: This section is Section 1621c of current law. 

Section 205. Shared services for long-term care 

This section allows the Secretary to enter into funding agreements with Tribes and Tribal Organizations for the delivery of 

long-term care services to Indians. Contents of these funding agreements are specified. Any nursing facility funded under this section 

must meet the requirements for such facilities under section 1919 

of the Social Security Act. In addition, the Secretary is required to 

provide necessary technical and other assistance to enable applicants to comply with the provisions of this section. The Secretary 

shall encourage the use of existing underused facilities or allow the 

use of swing beds for long-term or similar care. 

Amendments: This section amends current law by changing a 

demonstration project into a permanent program and adding new 

provisions which (1) include health care services associated with 

long- term care provided in a facility for Indians; and (2) encourage 

the use of existing underused facilities or allow the use of swing 

beds for long-term or similar care. 

Current Law: This section is Section 1680l of current law. 

Section 206. Health services research 

This section requires the Secretary to make funding available for 

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cies within the Department to address this need. Tribal Health 

Programs are to be given equal opportunity to compete for these research funds. The Secretary shall also periodically evaluate the impact of research conducted under this section, and disseminate to 

Tribal Health Programs information regarding that research. 

Amendments: This section amends current law by (1) eliminating the specific set-aside of $200,000 for research and replacing it with 

general authority to fund research for Indian health programs, instead of only the IHS; (2) requiring the Secretary to coordinate, to 

the extent practical, the resources and activities for Indian health 

research needs; (3) authorizing funding for both clinical and nonclinical research; and (4) providing for a periodic evaluation and 

dissemination of the research to Tribal Health Programs. 

Current Law: This section is Section 1621g of current law. 

Section 207. Mammography and other cancer screening 

This section requires the Secretary to provide for mammography 

and other cancer screening, consistent with the screening recommendations of the United States Preventive Services Task 

Force. 

Amendments: This section amends current law by authorizing 

other cancer screening, and eliminating the minimum age requirement of 35 for Indian women and opening the mammography 

screening to all Indian women, at a frequency under appropriate 

national standards. 

Current Law: This section is Section 1621k of current law. 

Section 208. Patient travel costs 

Section 208 requires the Secretary to provide funds for the travel 

costs of patients and their qualified escorts, associated with receiving health care services. A definition of ‘‘qualified escort’’ for purposes of accompanying a patient who is traveling to receive health 

care services is provided. 

Amendments: This section maintains current law and adds language which allows the use of qualified escorts and transportation 

by private vehicle (where no other transportation is available), specially equipped vehicle, ambulance or by other means required 

when air or motor vehicle transport is not available. 

Current Law: This section is Section 1621l of current law. 

Section 209. Epidemiology centers 

This section directs the Secretary to establish an epidemiology 

center in each Service Area. The functions of these centers are delineated. The Director of the Centers for Disease Control and Prevention is required to provide technical assistance to the centers. 

The Secretary is also authorized to make grants to Tribes, Tribal 

Organizations, Urban Indian Organizations and eligible intertribal 

consortia to conduct epidemiological studies of Indian communities. 

Eligibility requirements for consortia, application requirements and 

use of grant funds are specified. This section also authorizes the 

Secretary to provide access to information in the possession of the 

Secretary to an epidemiology center operated by a grantee pursuant to a grant awarded under this section. 

Amendments: This section amends current law by (1) maintaining the centers in existence on the date of passage of this Act, but 


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still requiring the establishment of centers in the remaining Areas; 

(2) allowing new centers to be operated under a grant under this 

section, but the funding under such a grant shall not be divisible; 

(3) eliminating the requirements in current law that the Secretary 

establish the data and formats for reporting and establish the system for monitoring progress toward the health objectives; and (4) 

providing that an epidemiology center operated under this section 

shall be treated as a public health authority for purposes of the 

Health Insurance Portability and Accountability Act of 1996 and 

directing the Secretary to grant grantees access to and use of data 

and other protected health information in the possession of the Secretary. 

Current Law: This section is Section 1621m of current law. 

Section 210. Comprehensive school health education programs 

Section 210 allows the Secretary to provide grants to Indian 

Tribes, Tribal Organizations and Urban Indian Organizations to 

develop comprehensive school health education programs for children from pre-school through grade 12 in schools for the benefit of 

Indian and Urban Indian children. The specific purposes for which 

grant funds may be used are delineated. Upon request, the Secretary shall provide technical assistance in the development and 

dissemination of comprehensive health education plans, materials 

and information. The Secretary, through the Service and in consultation with Tribes, Tribal Organizations and Urban Indian Organizations, shall establish criteria for review and approval of applications for this funding. For Bureau of Indian Affairs-funded 

schools, the Secretary of the Interior shall develop a similar school 

health education program. 

Amendments: This section maintains current law and adds language which (1) clarifies the types of purposes for which the funds 

may be used, such as for both regular school and after school programs, for the benefit of Indian and urban Indian children, for oral 

health programs, for violence prevention and for other health 

issues, as appropriate; (2) expands the grants to include Tribal Organizations and Urban Indian Health Organizations as eligible for 

funding, as well as Tribes; (3) deletes the reporting requirements 

of current law; and (4) requires that the application criteria be established in consultation with Indian Tribes, Tribal Organizations 

and Urban Indian Organizations. 

Current Law: This section is Section 1621n of current law. 

Section 211. Indian youth program 

This section authorizes the Secretary to establish and administer 

a program for innovative mental and physical disease prevention 

and health promotion and treatment for Indian and Urban Indian 

preadolescent and adolescent youths. Allowable and prohibited uses 

of the funds authorized by this section are delineated. The Secretary is required to disseminate information regarding models for 

delivery of comprehensive health care services to Indian youth; to 

encourage the implementation of these models; and to provide technical assistance upon request. The Secretary will establish criteria 

for review and approval of applications under this section in consultation with Tribes, Tribal Organizations and Urban Indian Organizations. 


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Amendments: This section maintains current law and adds Tribal 

Organizations and Urban Indian Organizations as participants in 

the program and consultation, and includes urban Indian youth as 

beneficiaries of program services. The specific authorization of this 

program in current law is deleted. 

Current Law: This section is Section 1621o of current law. 

Section 212. Prevention, control, and elimination of communicable 

and infectious diseases 

Section 212 authorizes the Secretary to make grants available to 

projects specifically for the purpose of preventing, controlling and 

eliminating communicable and infectious diseases. Funding is also 

authorized for public information and education programs; education, training and clinical skills improvement activities for health 

professionals; and demonstration projects for the screening, treatment and prevention of the hepatitis C virus. Funding under this 

section requires an application or proposal to be submitted. Entities which receive funding under this section are encouraged to coordinate their activities with the Centers for Disease Control and 

Prevention, as well as with state and local health agencies. Finally, 

in carrying out this section, the Secretary may provide technical assistance, upon request, and shall submit a biennial report to Congress on the use of the funds and the progress made toward prevention, control, and elimination of communicable and infectious 

diseases among Indians and Urban Indians. 

Amendments: This section amends current law by (1) including 

Urban Indian Organizations; (2) expanding the communicable diseases from simply tuberculosis to other communicable and infectious diseases; (3) by encouraging, rather than requiring, that entities funded under this section coordinate with the Centers for Disease Control and state and local health agencies; and (4) by eliminating provisions of current law which would reduce the grant 

amount for expenses incurred by the federal government or for supplies or equipment furnished to the grant recipient. 

Current Law: This section is Section 1621q of current law. 

Section 213. Other authority for provision of services 

This section authorizes the Secretary to fund other activities 

which meet the objectives set forth in Section 3 of this Act through 

health care-related services and programs not otherwise described 

in the Act, including hospice care, assisted living, long-term health 

care, and home- and community-based services. Services are to be 

in provided in accordance with accepted and appropriate standards 

relating to the service, including any licensing term or condition. 

The Secretary is authorized to establish standards, by regulation, 

for a service provided under this section, provided that those standards are not more stringent than the standards required by the 

state in which the service is provided. If the Secretary does not establish standards by regulation, state standards shall apply. If a 

service under this section is provided by an Indian Tribe or Tribal 

Organization pursuant to the Indian Self-Determination and Education Assistance Act, the verification by the Secretary that the 

service meets any standards required by the state in which the 

service is or will be provided shall be considered to meet the terms 

and conditions required. The individuals who are eligible to receive 


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long-term care under this section are specified, and the terms 

‘‘home- and community-based services’’ and ‘‘hospice care’’ are defined. This section also authorizes the Secretary to provide funding 

to meet the objectives set forth in Section 3 of this Act for convenient care services programs pursuant to section 306(c)(2)(A). 

Amendments: This section amends current law by making permanent a demonstration project for home- and community-based care. 

New provisions also (1) add standards; (2) add several definitions 

and deletes the definition of ‘‘functionally disabled’’ found in current law; and (3) eliminates the exclusion of cash payments, room 

and board, construction and nursing facility services. The provision 

authorizing the Secretary to provide funding to meet the objectives 

set forth in Section 3 of this Act for convenient care services programs is new. 

Current Law: Section 1680k authorizes the Secretary to establish 

not more than 24 demonstration projects for home-and communitybased care (excluding cash payments, room and board, construction 

and nursing facility services), for functionally disabled Indians. 

Discretion is provided to the Indian Health Service, Indian Tribes, 

or Tribal Organizations to provide such care to persons otherwise 

ineligible for the health care benefits of the Indian Health Service 

(on a cost basis). The Secretary is required to submit to the President for inclusion in a report to Congress the findings of these 

projects. ‘‘Home- and community-based services’’ and ‘‘functionally 

disabled’’ are defined. 

Section 214. Indian women’s health care 

This section requires the Secretary, acting through the Service, 

Indian Tribes, Tribal Organizations and Urban Indian Organizations, to monitor and improve health care for Indian women of all 

ages through the planning and delivery of programs administered 

by the Service. 

Amendments: This section amends current law by eliminating 

the Office of Indian Women’s Health and, instead, requiring the 

Secretary to monitor and improve the quality of Indian women’s 

health through the various programs administered by IHS. 

Current Law: Section 1621v establishes an Office of Indian Women’s Health Care to oversee efforts of the IHS to monitor and improve health care for Indian women of all ages. 

Section 215. Environmental and nuclear health hazards 

Section 215 requires the Secretary, in conjunction with other 

Federal agencies and in consultation with concerned Tribes and 

Tribal Organizations, to conduct studies and ongoing monitoring 

programs to determine trends in the health hazards to Indian miners and other Indians as a result of environmental hazards, such 

as nuclear resource development, petroleum contamination, and 

contamination of water sources and the food chain. Upon completion of such studies, the Secretary shall develop health care plans 

to address these health problems. The Secretary is required to submit the study to Congress 18 months after the date of enactment 

and a report no later than 1 year after the study which shall include recommendations for the implementation of the health care 

plan and evaluation activities. This section establishes an Intergovernmental Task Force to identify environmental hazards and to 


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take corrective action. The Secretary is to chair this Task Force, 

which shall meet at least twice yearly. If an Indian who is employed in or around any environmental hazard suffers from a workrelated condition, the Indian Health Program which treats him 

may be reimbursed by the Indian’s employer. 

Amendments: This section maintains current law and adds language which (1) requires ongoing monitoring of trends in health 

hazards to Indians and other environmental hazards to Indian 

communities; and (2) provides additional elements of the studies 

conducted under this section. 

Current Law: This section is Section 1677 of current law. 

Section 216. Arizona as a contract health service delivery area 

This section designates the State of Arizona as a contract health 

service delivery area for providing contract health care services to 

members of federally recognized Indian Tribes of Arizona. The Indian Health Service is not to curtail any services as a result of this 

provision. 

Amendments: This section maintains current law and extends 

the date to 2017, instead of 2000, for the designation as a contract 

health service delivery area. 

Current Law: This section is Section 1678 of current law. 

Section 216A. North Dakota and South Dakota as contract health 

service delivery area 

This section designates the States of North Dakota and South 

Dakota as one contract health service delivery area for providing 

contract health care services to members of federally recognized Indian Tribes in North and South Dakota. The Indian Health Service 

is not to curtail any services as a result of this provision. 

Amendments: This section is new to the Act and is not contained 

in current law. 

Section 217. California contract health services program 

This section authorizes the Secretary to fund a program using 

the California Rural Indian Health Board (CRIHB) as a contract 

care intermediary to improve the accessibility of health services to 

California Indians. The Secretary will reimburse the CRIHB for 

costs incurred pursuant to this section. Not more than 5 percent of 

the amounts provided under this section to the CRIHB in any fiscal 

year may be for administrative expenses. No payment may be 

made for treatment under this section to the extent payment may 

be made under the Indian Catastrophic Health Emergency Fund or 

from amounts appropriated or otherwise made available to the 

California contract health service delivery area. This section also 

establishes an Advisory Board to advise the CRIHB in carrying out 

this section. The Advisory Board shall be comprised of representatives from not less than 8 Tribal Health Programs serving California Indians covered under this section, and at least one-half of 

whom are not affiliated with the CRIHB. 

Amendments: This section amends current law by turning the 

demonstration project for the California Indians into a permanent 

program. 

Current Law: This section is Section 1621j of current law. 


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Section 218. California as a contract health service delivery area 

This section designates the State of California, excluding certain 

specified counties, as a contract health service delivery area for the 

purpose of providing contract health care services to California Indians. The excluded counties may be included only if funding is 

specifically provided by the Indian Health Service for such services 

in those counties. 

Amendments: This section maintains current law, but allows the 

excluded counties to become a part of the contract service delivery 

area if funding is specifically provided for such services in those 

counties. 

Current Law: This section is Section 1680 of current law. 

Section 219. Contract health services for the Trenton service area 

This section directs the Secretary to provide contract health services to members of the Turtle Mountain Band of Chippewa Indians 

who reside in the Trenton Service Area of Divide, McKenzie, and 

Williams counties in North Dakota and the counties of Richland, 

Roosevelt, and Sheridan in Montana. Nothing in this section is to 

be construed as expanding the eligibility of members of the Turtle 

Mountain Band of Chippewa Indians for health services provided 

by the Service beyond the scope of eligibility for these services that 

applied on May 1, 1986. 

Amendments: This section maintains current law. 

Current Law: This section is Section 1680e of current law. 

Section 220. Programs operated by Indian tribes and tribal organizations 

This section requires the Indian Health Service to provide funds 

to Tribal Health Programs for health care programs and facilities 

on the same basis as funds are provided to these programs operated directly by the Indian Health Service. 

Amendments: This section maintains current law, but eliminates 

language which specifies the particular use of funds for which the 

Indian Tribes and Tribal Organizations can receive funding on the 

same basis as the IHS. 

Current Law: Section 1680a requires the Indian Health Service 

to provide funds to tribes and tribal organizations health care programs and facilities to (1) maintain and repair clinics, (2) train employees, (3) provide cost-of-living expenses, and (4) provide for other 

expenses related to health services on the same basis as funds are 

provided to these programs operated directly by the Indian Health 

Service. 

Section 221. Licensing 

Section 221 requires that health care professionals employed by 

a Tribal Health Program shall, if licensed in any State, be exempt 

from the licensing requirements of the State in which the Tribal 

Health Program provides the services. 

Amendments: This section is new to the Act and is not contained 

in current law. 


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Section 222. Notification of provision of emergency contract health 

services 

This section allows 30 days (as a condition of payment) for an elderly or disabled Indian to notify the Service of any emergency 

medical care or services received from a non-Service provider or in 

a non-Service facility. 

Amendments: This section maintains current law. 

Current Law: This section is Section 1646 of current law. 

Section 223. Prompt action on payment of claims 

Section 223 provides a deadline for the Service to respond to notification of a claim by a provider of a contract care service. The 

section also provides that if the Service fails to respond within the 

required time, the Service shall accept the claim submitted by the 

provider as valid. The IHS shall pay a valid claim within 30 days 

after the completion of the claim. 

Amendments: This section maintains current law, but changes 

the requirement of a completed claim to a valid claim. 

Current Law: This section is Section 1621s of current law. 

Section 224. Liability for payment 

This section provides that a patient who receives authorized contract health care services will not be held liable for any charges or 

costs associated with those authorized services. The Secretary is required to notify the contract care provider and the patient who receives such services that the patient is not liable within a specified 

time. Following receipt of this notice or an acceptable claim under 

the previous section, the provider shall have no further recourse 

against the patient who received the health care. 

Amendments: This section maintains current law and adds language which limits the recourse against the patient if the claim has 

been deemed accepted under Section 223. 

Current Law: This section is Section 1621u of current law. 

Section 225. Office of Indian Men’s Health 

This section provides that the Secretary may establish the Office 

of Indian Men’s Health to coordinate and promote the health status 

of Indian men. The Office will be headed by a director, who is to 

be appointed by the Secretary. The Secretary is also required to 

submit a report to Congress within two years of enactment, describing any activity and finding about the health of Indian men 

of the director. 

Amendments: This section is new to the Act and is not contained 

in current law. 

Section 226. Authorization of appropriations 

This section authorizes to be appropriated such sums as may be 

necessary to carry out this title for each fiscal year through fiscal 

year 2017. 

Amendments: This section maintains current law, but extends 

the authorization from fiscal year 2000 to fiscal year 2017 and 

eliminates the references to specific sections which had a separate 

authorization period. 

Current Law: This section is Section 1621w of current law. 


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TITLE III—FACILITIES 

Section 301. Consultation; Construction and renovation of facilities; 

Reports 

This section requires that prior to expending construction funds, 

the Secretary shall consult with impacted Indian Tribes, and ensure that facilities built pursuant to this section meet certain construction standards within one year after the date on which the 

construction or renovation of such facility is completed. In addition, 

Section 301 sets forth requirements to be met prior to closing any 

facility. 

This section also directs the Secretary to maintain a health care 

facility priority system which shall be developed in consultation 

with Indian Tribes and Tribal Organizations and meet other requirements. The priority of any project established under the construction priority system in effect on the date of enactment, if the 

project meets certain criteria, is protected. Not later than 1 year 

after the date of enactment of the Indian Health Care Improvement Act Amendments of 2007, the Secretary shall submit to Congress a report that describes the comprehensive, national, ranked 

list of all health care facilities needs for the Service, Indian Tribes, 

and Tribal Organizations. Beginning in calendar year 2011, the 

Secretary shall update this report not less frequently than once 

every 5 years. Annual reports are also required under this section. 

Not later than 1 year after the establishment of the health care 

facilities construction priority system under this section, the Comptroller General of the United States shall prepare and finalize a report to Congress, that reviews the methodologies applied, and the 

processes followed, by the Service in making each assessment of 

needs for the priority system. This section also directs the Secretary to consult and cooperate with Indian Tribes, Tribal Organizations, and Urban Indian Organizations in developing innovative 

approaches to address all or part of the total unmet need for construction of health facilities. 

Amendments: This section maintains current law and builds on 

it substantially. Language is added which (1) requires an evaluation of the impact of a proposed closure prior to closing; (2) requires 

the Secretary to maintain a health care facility priority system developed through consultation, which prioritizes certain facilities; (3) 

adds specific requirements for the initial, comprehensive report to 

Congress and subsequent annual reports; (4) requires the Secretary 

to consult and cooperate with Indian Tribes, Tribal Organizations, 

and Urban Indian Organizations in developing innovative approaches to meet facilities needs; and (5) requires the Comptroller 

General to prepare a report to Congress which reviews the methodology used for the health facilities construction priority list. 

Current Law: This section is Section 1631 of current law. 

Section 302. Sanitation facilities 

This section provides findings, certain responsibilities of the 

Service for sanitation, authorized uses of sanitation funding and facilities, and reporting requirements, and establishes the deficiency 

levels for those facilities. This section requires training or technical 

assistance in the operation and maintenance of sanitation facilities, 


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and priority funding for operation and maintenance or emergency 

repairs. 

Section 302 authorizes the Secretary to accept funds from any 

source, including funds appropriated under the Native American 

Housing Assistance and Self-Determination Act, for construction of 

sanitation facilities. The Secretary, after consulting with the Secretary of Housing and Urban Development and Indian Tribes, Tribal Organizations and tribally designated housing entities, is also 

required to submit a report to Congress on the sanitation facilities 

priority system and a 10-year plan to provide sanitation facilities 

to new and renovated Indian homes. Deficiency levels for sanitation 

facilities are defined. 

Amendments: This section maintains current law and adds language which (1) establishes priority funding for emergency repairs 

and operation or maintenance to avoid imminent health threats or 

to protect the investment in health benefits gained through the 

sanitation facilities; (2) prohibits the use of IHS funding to provide 

sanitation facilities to new homes constructed using Department of 

Housing and Urban Development funds; (3) allows the Secretary to 

accept funds from any source, including federal and state agencies, 

for sanitation facilities and services, and to place those funds into 

contracts or compacts under the Indian Self-Determination and 

Education Assistance Act; (4) authorizes the Secretary to allow certain funding to be used to fund tribal loans or matching or cost 

participation requirements to construct sanitation facilities; (5) requires the Secretary enter into interagency agreements for financial assistance; (6) requires consultation in preparation of the report to Congress, and clarifies the information required to be in the 

annual report; and (7) establishes an Indian Tribe’s primary responsibility for collecting user fees and the Secretary’s responsibility in assisting tribes when the facility is threatened with imminent failure. 

Current Law: This section is Section 1632 of current law. 

Section 303. Preference to Indians and Indian firms 

This section authorizes the Secretary to give preference to Indians or Indian or tribal enterprises or other businesses in the construction and renovation of Service facilities pursuant to section 

301, and in the construction of sanitation facilities pursuant to section 302. Compliance with certain labor standards is required. 

Amendments: This section maintains current law and adds new 

language to clarify rates of pay requirements and other wage requirements similar to local rates as determined by the Indian 

tribes or Tribal Organizations to be served by the construction. 

Current Law: This section is Section 1633 of current law. 

Section 304. Expenditure of non-service funds for renovation 

This section authorizes the Secretary to accept any expansion, 

renovation or modernization of any Service or tribal health facility 

funded with non-Service funds in accordance with certain criteria. 

The Secretary is required to maintain a separate priority list for 

these facilities, which shall be submitted to Congress as part of the 

annual report to Congress. Indian Tribes or Tribal Organizations 

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ice facility which has been expanded, renovated, or modernized 

under this section ceases to be used as a Service facility during the 

20-year period beginning on the date such expansion, renovation, 

or modernization is completed, such Indian Tribe or Tribal Organization shall be entitled to recover from the United States an 

amount which bears the same ratio to the value of such facility at 

the time of such cessation as the value of such expansion, renovation, or modernization bore to the value of such facility at the time 

of the completion of such expansion, renovation, or modernization. 

Amendments: This section maintains current law and adds language which (1) includes major expansion as an authorized use of 

funds, in addition to renovation and modernization, but requires 

the Indian Tribes or Tribal Organizations to provide certain information to the Secretary regarding staffing, equipment and other 

costs associated with the expansion; and (2) requires the methodology for determining priorities to be developed through regulations. 

Current Law: This section is Section 1634 of current law. 

Section 305. Funding for the construction, expansion and modernization of small ambulatory care facilities 

This section authorizes the Secretary to make grants to Indian 

Tribes and Tribal Organizations for the construction, expansion, or 

modernization of facilities for the provision of ambulatory care 

services. Use of funds, grant application requirements, priorities, 

and conditions for reversion of facilities are set forth. 

Amendments: This section maintains current law and adds language which (1) requires the funding to be used for the portion of 

costs which benefits the eligible population, but exempts from the 

specific eligibility requirements applicants whose principal health 

administration offices are located where there is no road system 

providing direct access to inpatient hospitals; (2) adds additional 

capacity requirements for a facility constructed with a grant under 

this section; (3) makes reduction of an outstanding debt for construction, expansion or modernization an additional allowable use 

of funds; and (4) authorizes peer review panels to be established to 

evaluate applications and proposals. 

Current Law: This section is Section 1636 of current law. 

Section 306. Indian health care delivery demonstration projects 

This section authorizes the Secretary to establish a health care 

delivery demonstration project to test alternative means of delivering health care and services to Indians through facilities. There 

would be two kinds of demonstration projects. General projects 

would be authorized, with priority given to projects located in specific Service Areas, if they meet the specified criteria, such as the 

need for such facility, number of Indians to be served, the economic 

viability of the project, and the administrative and financial capability of Indian Tribes or Tribal Organizations to administer the 

project. Health care delivery demonstration projects would also be 

authorized that include a convenient care services program as an 

alternative means of delivering health care services to Indians. 

This section also requires technical assistance and use of the same 

criteria in evaluating tribal and IHS facilities. 


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Amendments: This section maintains current law and adds language which (1) permits the use of IHS funds to match other funds; 

(2) authorizes the convenient care services demonstration projects; 

and (3) authorizes peer review panels to be established to review 

and evaluate applications. Language of current law authorizing reports to Congress on the findings and conclusions of the demonstration projects has been deleted. 

Current Law: This section is Section 1637 of current law. 

Section 307. Land transfer 

This section authorizes the Secretary to accept any land and improvements transferred, at no cost, from the Bureau of Indian Affairs or other federal agencies for the provision of health care services. 

Amendments: This section amends current law by changing a 

specific authorization into a general authorization whereby federal 

agencies may transfer land and improvements to the IHS for the 

provision of health care services. 

Current Law: Section 1638 provides specific authorization for 

transferring 5 acres of land at the Chemawa Indian School in 

Salem, OR, to the IHS. 

Section 308. Leases, contracts and other agreements 

This section authorizes the Secretary to enter into leases, contracts and other agreements with Indian Tribes and Tribal Organizations which have facilities for the delivery of health services at 

those facilities. The agreements may also include provisions for 

construction, renovation and compensation. 

Amendments: This section essentially maintains current law. The 

provision of current law authorizing the Secretary to enter into 20–

year leases with Tribes that may specify reconstruction or renovation of property has been deleted. 

Current Law: This section is Section 1674 of current law. 

Section 309. Study for loans, loan guarantees and loan repayment 

This section directs the Secretary to conduct a study to determine the feasibility of establishing a loan fund to provide Indian 

Tribes and Tribal Organizations direct loans or loan guarantees for 

health care facilities construction. A number of study requirements 

are delineated. The results of the study shall be reported to Congress. 

Amendments: This section is new and is not now contained in 

current law. 

Section 310. Tribal leasing 

This section authorizes a tribal health program to lease permanent structures for the purpose of providing health care services 

without obtaining prior approval in appropriation Acts. 

Amendments: This section maintains current law, and expands 

the program to include Tribal Organizations. 

Current Law: This section is Section 1680j of current law. 


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Section 311. Indian Health Service/Tribal Facilities Joint Venture 

Program. 

This section authorizes the Secretary to make arrangements with 

Indian Tribes and Tribal Organizations to establish joint venture 

demonstration projects, under which an Indian Tribe or Tribal Organization would expend tribal, private, or other available funds 

for the acquisition or construction of a health facility for a minimum of 10 years, under a no-cost lease. In exchange, the Service 

will agree to provide the equipment, supplies, and staffing for the 

operation and maintenance of such a health facility. Certain capabilities and other requirements are set forth. There are provisions 

for breach of agreement by either the Tribe or Tribal Organization 

or the IHS. 

Amendments: This section maintains current law and adds (1) 

Tribal Organizations to the eligible participants and those Tribes 

that have begun, but not completed the process of acquisition or 

construction of a health care facility; (2) requires negotiation for 

the continued operation of the facility at the end of the 10-year 

lease; (3) authorizes recovery in a proportional amount from the 

IHS if the IHS ceases to use the facility within the 10-year lease 

period; and (4) includes staff quarters in the definition of the 

health facilities under this section. 

Current Law: This section is Section 1680h(e) of current law. 

Section 312. Location of facilities 

This section directs the Bureau of Indian Affairs and the Service 

to give priority to locating health care facilities and employment 

projects in economically depressed areas to Indian and Alaska Native lands, if requested by the Indian owner and Indian Tribe with 

jurisdiction over such lands. 

Amendments: This section maintains current law and adds language to (1) include lands in Alaska owned by any Alaska Native 

village, or village or regional corporation under the Alaska Native 

Claims Settlement Act, or any land allotted to any Alaska Native; 

and (2) gives top priority to Indian land owned by 1 or more Indian 

Tribes. The definition of ‘‘Indian lands’’ is modified from current 

law. 

Current Law: This section is Section 1680n of current law. 

Section 313. Maintenance and improvement of health care facilities 

This section requires the Secretary to report to Congress on the 

backlog of maintenance and repair work required at both Service 

and tribal health care facilities. This section also authorizes an Indian Tribe or Tribal Organization to use maintenance and improvement funds for construction of a replacement facility, as well as for 

renovation, modernization, and expansion of facilities, under certain circumstances. 

Amendments: This section is new and is not now contained in 

current law. 

Section 314. Tribal management of federally-owned quarters 

This section authorizes Tribal Health Programs operating a 

health care facility and federally-owned quarters pursuant to a contract or compact under the Indian Self-Determination and Education Assistance Act to establish reasonable rental rates for the 


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federally-owned quarters, and to collect the rent directly from federal employees who occupy such quarters. These quarters shall remain eligible for improvement and repair funds as other federallyowned quarters. The Tribal Health Program operating the quarters 

is required to provide at least 60 days notice before changing the 

rental rate. 

Amendments: This section is new and is not now contained in 

current law. 

Section 315. Applicability of Buy American Act requirement 

This section requires application of the Buy American Act for all 

procurements under this title. Indian Tribes and Tribal Organizations are exempt from this requirement. 

Amendments: This section maintains current law, but exempts 

Indian Tribes and Tribal Organizations from the requirements of 

the Buy American Act, and eliminates the reporting requirement 

contained in current law. 

Current Law: This section is Section 1638b of current law. 

Section 316. Other funding for facilities 

This section authorizes the Secretary to accept funds from other 

sources for the construction of health care facilities and to place 

such funds into a contract or compact under the Indian Self-Determination and Education Assistance Act. The Secretary is also authorized to enter into interagency agreements with other federal or 

state agencies for the planning, design and construction of health 

care facilities to be administered by Indian Health Programs. 

Amendments: This section is new and is not now contained in 

current law. 

Section 317. Authorization of appropriations 

This section authorizes to be appropriated such sums as may be 

necessary for each fiscal year through fiscal year 2017 to carry out 

this title. 

Amendments: This section maintains current law but extends the 

authorization for appropriations beyond fiscal year 2000 through 

fiscal year 2017. 

Current Law: This section is Section 1638a of current law. 

TITLE IV—ACCESS TO HEALTH SERVICES 

Section 401. Treatment of payments under Social Security Act 

health care benefits programs 

This section requires that any Medicare, Medicaid, or State Children’s Health Insurance Program (SCHIP) payments received by 

an Indian Health Program or Urban Indian Organization for services provided to eligible Indians shall not be considered in determining appropriations for the provision of health care and services. 

Indians without Medicare, Medicaid or SCHIP coverage are to be 

given equal consideration as Indians who are covered by these Social Security Act health benefit programs. Payments to which a facility of the Service is entitled by reason of a provision of the Social 

Security Act are to be placed in a special fund to be held by the 

Secretary. In making payments from such fund, the Secretary is to 

ensure that each Service Unit receives 100% of the amount to 


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which the facility of the Service, for which such Service Unit makes 

collections, is entitled. How funds collected from Medicare, Medicaid, or SCHIP are to be used is specified. This section also allows 

Tribal Health Programs to elect to directly bill for, and receive payment for, health care items and services provided by that Tribal 

Health Program for which payment is made under Medicare, Medicaid, SCHIP, or third party payors. 

Amendments: This section maintains current law and (1) adds 

Tribal Organizations and Urban Indian Organizations, in addition 

to Tribes and the IHS, for whom reimbursements would not be considered in determining appropriations; (2) authorizes the 100% 

pass-through of payments due to Service facilities from the special 

fund; and (3) expands the authorized uses of the reimbursements 

from improvements only to hospitals or skilled facilities to also include programs and the excess used to reduce health deficiencies, 

subject to consultation by the Indian Tribes served. However, this 

provision authorizing the Secretary to determine the uses shall not 

apply when the Indian Tribes elect to receive reimbursements directly. 

Current Law: Sections 1641 and 1642 address treatment of payments under Medicare or Medicaid. Section 1645 established a program under which tribes could elect to directly bill and be reimbursed for health care services provided under Medicare, Medicaid 

or other third parties. 

Section 402. Grants to and contracts with the service, Indian tribes, 

tribal organizations, and urban Indian organizations to facilitate outreach, enrollment, and coverage of Indians under Social 

Security Act health benefit programs and other health benefits 

programs 

This section directs the Secretary to make grants to or enter into 

contracts with Tribes and Tribal Organizations to improve enrollment and participation in Medicare, Medicaid or SCHIP programs, 

including paying premiums or cost sharing (which terms are defined in this section). In doing so, the Secretary shall place such 

conditions as are deemed necessary to affect the purpose of this 

section, including certain requirements of the Indian Tribe or Tribal Organization. Specifications for applying this section to Urban 

Indian Organizations are included. This section also directs the 

Secretary, acting through the Centers for Medicare and Medicaid 

Services, to take such steps as are necessary to facilitate cooperation with, and agreements between, States and the Service, Indian 

Tribes, Tribal Organizations, or Urban Indian Organizations with 

respect to the provision of health care items and services to Indians 

and to improving the enrollment of Indians under Social Security 

Act health benefits programs. This section also provides a cross-reference to the relevant section of the Social Security Act for provisions related to agreements between the Secretary and Indian 

Tribes, Tribal Organizations, and Urban Indian Organizations for 

the collection, preparation, and submission of applications by Indians for assistance under Medicare, Medicaid and SCHIP. 

Amendments: This section maintains current law and adds provisions which outline the agreements between the Secretary and the 

Tribes, Tribal or Urban Indian Organizations to improve the enrollment of Indians in Social Security Act programs. 


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Current Law: This section is Section 1644 of current law. 

Section 403. Reimbursement from certain third parties of costs of 

health services 

Section 403 provides that the United States, an Indian Tribe, or 

Tribal Organization has the right to recover from an insurance 

company, health maintenance organization, employee benefit plan, 

or any third party the reasonable charges billed by the Secretary, 

an Indian Tribe, or Tribal Organization in providing health services to any individual to the same extent that such individual, or 

any nongovernmental provider of such services, would be eligible to 

receive damages, reimbursement, or indemnification. This right of 

recovery is extended against any state, under certain conditions. 

Certain state or local laws are deemed nonapplicable to prevent or 

hinder this right of recovery. This section has no effect on private 

rights of action. Enforcement measures for the right of recovery, 

notice, costs and attorneys’ fees are all specified in this section. 

Section 403 limits the Indian Health Service right of recovery 

against a tribal self-insured plan absent written consent from the 

Tribe. Other items covered in this section include nonapplication of 

claims filing requirements; application to Urban Indian Organizations; statute of limitations; and a savings clause. 

This section adds a new provision which would extend to Tribes 

and Tribal Organizations the same authority the U.S. has under 

the Federal Medical Care Recovery Act (FMCRA) to recover the 

costs of medical care from a tortfeasor whose action caused an injury or disease to a patient whom a federal health care provider is 

obliged to treat. While the Department of Justice brings such suits 

against tortfeasors for federal health care providers such as the 

IHS, it does not currently do so for Tribes which operate IHS-funded health programs. 

Amendments: This section maintains current law and adds language (1) to enable Urban Indian Organizations to seek recovery 

from third parties; (2) to require reasonable efforts be taken to provide notice to the patient either before or during the pendency of 

the action; (3) to limit the IHS right of recovery against a tribal 

self-insured plan absent written consent; (4) to include awards of 

reasonable attorneys’ fees and costs of litigation; (5) to prohibit denial of reimbursement on the basis of a different format or form; 

and (6) to extend to Tribes and Tribal Organizations the same authority the U.S. has under the Federal Medical Care Recovery Act 

(FMCRA) to recover the costs of medical care from a tortfeasor. 

Current Law: This section is Section 1621e of current law. 

Section 404. Crediting of reimbursements 

This section authorizes the retention of the reimbursements received or recovered under this Act, Medicare, Medicaid or SCHIP 

and other provisions of law, from third parties and specifies the use 

of those reimbursements. This section also disallows any offset or 

limitation of amount obligated to any Service Unit, Indian Tribe or 

Tribal or Urban Indian Organization because of the receipt of reimbursements under this section. 

Amendments: This section maintains current law and adds language which specifies which programs are included in the reimbursements. 


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Current Law: This section is Section 1621f of current law. 

Section 405. Purchasing health care coverage 

Section 405 allows Tribes, Tribal Organizations and Urban Indian Organizations to use funding for health benefits for Indians 

to be used to purchase health benefits coverage for Service beneficiaries in any manner (including through a tribally owned and operated health care plan, a state or locally authorized or licensed 

health care plan, a health insurance provider or managed care organization, or a self-insured plan), based on the financial needs of 

such beneficiaries. 

Amendments: This section replaces a provision of current law 

which authorized a managed care feasibility study. 

Current Law: Section 1621i of current law authorized the Secretary to conduct a study to assess the feasibility of allowing an Indian Tribe to purchase managed care coverage for tribal members 

from a tribally owned and operated managed care plan or a state 

or licensed managed care plan. 

Section 406. Sharing arrangements with Federal agencies 

This section allows the Secretary to enter into or expand arrangements to share medical facilities and services with the Departments of Veterans Affairs and Defense, with certain limitations. If health care services are provided to beneficiaries eligible 

for services from either the Department of Veterans Affairs or the 

Department of Defense, then the Service, Indian Tribe, or Tribal 

Organization providing the service shall be reimbursed from the 

appropriate Department. The Secretary shall not take action which 

would impair priority access to or quality of care for Indians at IHS 

or priority of veterans to care by the VA. 

Amendments: This section amends current law by (1) authorizing 

the Secretary to enter agreements for sharing of medical facilities 

with the Departments of Veterans Affairs (VA) and Defense, instead of merely examining the feasibility of entering agreements 

with the VA; (2) requiring consultation with the affected Indian 

Tribes prior to entering the agreements; (3) requiring reimbursement to the IHS, Tribes, or Tribal Organizations; and (4) eliminating the specific cross-utilization of services in Utah only (expanding it, generally). 

Current Law: Section 1680f of current law authorizes the Secretary to examine the feasibility of entering agreements to share 

medical facilities and services with the Department of Veterans Affairs, with a specific agreement for Utah. 

Section 407. Payor of last resort 

This section specifies that Indian Health Programs and health 

care programs operated by Urban Indian Organizations shall be 

the payor of last resort for services provided to eligible persons. 

Amendments: This section is new and is not contained in current 

law. 

Section 408. Nondiscrimination under Federal health care programs in qualifications for reimbursement for services 

Section 408 provides that a federal health care program must accept an entity that is operated by the Service, an Indian Tribe, 


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Tribal Organization, or Urban Indian Organization as a provider 

eligible to receive payment under the program for health care services furnished to an Indian on the same basis as any other provider 

qualified to participate as a provider of health care services under 

the program if the entity meets generally applicable state or other 

requirements for participation as a provider of health care services 

under the program. This section also provides that state or local licensure or recognition requirements by a provider of health care 

services shall be deemed to have been met in the case of an entity 

operated by the Service, an Indian Tribe, Tribal Organization, or 

Urban Indian Organization, if the entity meets all the applicable 

standards for such licensure or recognition, regardless of whether 

the entity obtains a license or other documentation under such 

state or local law. Certain entities operated by the Service, an Indian Tribe, Tribal Organization, or Urban Indian Organization, or 

individuals who have been excluded from participation in any federal health care program or for which a license is under suspension 

or has been revoked by the state where the entity or individual is 

located, shall not be eligible to receive payment or reimbursement 

under any such program for health care services furnished to an 

Indian. 

Amendments: This section is new and is not contained in current 

law. 

Section 409. Consultation 

This section provides a cross-reference to the relevant section of 

the Social Security Act for provisions related to consultation with 

representatives of Indian Health Programs and Urban Indian Organizations with respect to the health care programs established 

under Medicare, Medicaid and SCHIP. 

Amendments: This section is new and is not contained in current 

law. 

Section 410. State Children’s Health Insurance Program (SCHIP) 

This section provides cross-references to relevant sections of the 

Social Security Act for provisions relating to outreach to families 

of Indian children likely to be eligible for child health assistance 

under SCHIP, and ensuring that child health assistance is provided under such program to targeted low-income children who are 

Indians and that payments are made under that program. 

Amendments: This section is new and is not contained in current 

law. 

Section 411. Exclusion waiver authority for affected Indian health 

programs and safe harbor transactions under the Social Security Act 

This section provides cross-references to relevant sections of the 

Social Security Act for provisions relating to exclusion waiver authority for affected Indian Health Programs, and certain transactions involving Indian Health Programs deemed to be in safe 

harbors under the Social Security Act. 

Amendments: This section is new and is not contained in current 

law. 


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Section 412. Premium and cost sharing protections and eligibility 

determinations under Medicaid and SCHIP and protection of 

certain Indian property from Medicaid estate recovery 

This section provides cross-references to relevant sections of the 

Social Security Act for provisions relating to premiums or cost 

sharing protections for Indians furnished items or services directly 

by Indian Health Programs or through referral under the contract 

health service under Medicaid; rules regarding the treatment of 

certain property for purposes of determining eligibility under Social 

Security Act programs; and the protection of certain property from 

estate recovery provisions under Medicaid. 

Amendments: This section is new and is not contained in current 

law. 

Section 413. Treatment under Medicaid and SCHIP managed care 

Section 413 provides cross-references to relevant sections of the 

Social Security Act for provisions relating to the treatment of Indians enrolled in a managed care entity under Medicaid, and Indian 

Health Programs and Urban Indian Organizations that are providers of items or services to such Indian enrollees. 

Amendments: This section is new and is not contained in current 

law. 

Section 414. Navajo Nation Medicaid Agency feasibility study 

Section 414 requires the Secretary to conduct a study to determine the feasibility of treating the Navajo Nation as a State for 

Medicaid purposes. Considerations for a report to Congress on the 

results of the study are described in this section. 

Amendments: This section is new and is not contained in current 

law. 

Section 415. General exceptions 

Section 415 provides that the requirements of this title shall not 

apply to any excepted benefits described in paragraph (1)(A) or (3) 

of section 2791(c) of the Public Health Service Act, which relates 

to supplemental insurance products. 

Amendments: This is a new provision and is not contained in current law. 

Section 416. Authorization of appropriations 

Section 416 authorizes to be appropriated such sums as may be 

necessary for each fiscal year through fiscal year 2017 to carry out 

this title. 

Amendments: This section extends the authorization beyond FY 

fiscal year 2000 to fiscal year 2017. 

Current Law: The authorization of appropriations section for the 

Access to Health Services title of current law is Section 1647, and 

extends through fiscal year 2000. 

TITLE V—HEALTH SERVICES FOR URBAN INDIANS 

Section 501. Purpose 

This section sets forth the purpose of the title as establishing and 

maintaining programs in Urban Centers to make health services 

more accessible and available to Urban Indians. 


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Amendments: This section maintains current law and adds language to maintain the programs and make health services available, in addition to being accessible, to Urban Indians. 

Current Law: This section is Section 1651 of current law. 

Section 502. Contracts with, and grants to, urban Indian organizations 

This section provides that the Secretary shall enter into contracts 

with, or make grants to, Urban Indian Organizations to assist such 

organizations in the establishment and administration, within 

Urban Centers, of programs which meet the requirements set forth 

in this title. 

Amendments: This section maintains current law. 

Current Law: This section is Section 1652 of current law. 

Section 503. Contracts and grants for the provision of health care 

and referral services 

This section sets forth the authority of the Secretary to enter into 

contracts with or make grants to Urban Indian Organizations to establish and administer programs under this title, which shall meet 

certain requirements. This section prescribes the criteria for selecting Urban Indian Organizations for contracts or grants. Such contracts or grants shall facilitate access to or provide services for 

health promotion and disease prevention, immunization services, 

behavioral health services, prevention of child abuse, and other 

services to Urban Indians. 

Amendments: This section maintains current law, generally, 

while (1) modifying contract and grant requirements and criteria; 

and (2) deleting factors to be considered for immunization services 

contracts or grants that are set forth in current law. 

Current Law: This section is Section 1653 of current law. 

Section 504. Contracts and grants for the determination of unmet 

health care needs 

This section authorizes the Secretary to enter into contracts with 

or make grants to Urban Indian Organizations for which contracts 

or grants have not been entered into under the prior section. The 

purpose of these contracts/grants would be to determine unmet 

health care needs of urban Indians. Grant and contract requirements are set forth. 

Amendments: This section maintains current law. 

Current Law: This section is Section 1654 of current law. 

Section 505. Evaluations; renewals 

This section authorizes the Secretary to develop evaluation and 

renewal procedures and standards for the various contracts and 

grants entered into by Urban Indian Organizations under this title, 

including considerations for renewals of contracts/grants. The Secretary shall also evaluate the urban Indian programs through onsite annual evaluations. 

Amendments: This section maintains current law and adds a provision which would allow the Secretary to evaluate the urban Indian organization through acceptance of evidence of the organization’s accreditation as an alternative to the onsite annual evaluation. 


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Current Law: This section is Section 1655 of current law. 

Section 506. Other contract and grant requirements 

This section sets forth other specific contract and grant requirements, such as payment methods, revisions and amendments to 

contracts, and assurance of the fair and uniform provision of services to Urban Indians. 

Amendments: This section maintains current law and adds provisions which (1) would allow a single advance payment, unless the 

urban Indian organization is not capable of administering the payments in their entirety and allows the funding to be carried forward; and (2) would allow payments to be made in semiannual or 

quarterly payments or by way of reimbursement. This section deletes provisions of current law allowing an Urban Indian Organization to use existing federal facilities. 

Current Law: This section is Section 1656 of current law. 

Section 507. Reports and records 

This section sets forth certain reporting and recordkeeping requirements for Urban Indian Organizations. This section also provides that not later than 18 months after the date of enactment, 

the Secretary, in consultation with Urban Indian Organizations, 

shall submit to Congress a report evaluating the health status of 

Urban Indians; the services provided to Indians pursuant to this 

title; and areas of unmet needs in the delivery of health services 

to Urban Indians. This section also provides that reports and 

records of the Urban Indian Organization shall be subject to audit 

by the Secretary and the Comptroller General of the United States. 

Amendments: This section maintains current law and (1) adds 

language which extends the reporting period to semi-annual, rather 

than quarterly; (2) adds the requirement of a minimum set of data 

using uniform elements; (3) adds that the audits may also be conducted by a certified public accounting firm; and (4) deletes the requirement that IHS and the Department of the Interior report to 

Congress by March 31, 1992, on the health status, unmet needs 

and welfare of urban Indian children. 

Current Law: This section is Section 1657 of current law. 

Section 508. Limitation on contract authority 

This section limits the authority of the Secretary to enter into 

contracts or to award grants under this title to the extent and 

amount provided for in appropriations Acts. 

Amendments: This section maintains current law and adds language which includes the Secretary’s authority to award grants 

under this title. 

Current Law: This section is Section 1658 of current law. 

Section 509. Facilities 

This section provides that the Secretary, acting through the 

Service, may make grants for the lease, purchase, renovation, construction, or expansion of facilities. This section also allows the 

Secretary to carry out a study to determine the feasibility of establishing a loan fund to provide direct loans or guarantees for loans 

to Urban Indian Organizations for the construction of health care 

facilities. 


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Amendments: This section replaces current law by adding provisions which would allow for leasing, purchasing, renovating, constructing and expanding, in addition to repairing, facilities. The 

provision regarding the feasibility study of a loan fund to construct 

facilities is new. 

Current Law: Section 1659 of current law authorizes the Secretary to make funds available to contractors or grant recipients to 

make minor renovations to the urban health facilities to meet or 

maintain compliance with the requirements of the Joint Commission on Accrediting Health Care Organizations. 

Section 510. Division of Urban Indian Health 

This section establishes a Division of Urban Indian Health within the Service to carry out the provisions of this title, provide oversight of the programs, and provide technical assistance to Urban 

Indian Organizations. 

Amendments: This section maintains current law, but (1) changes 

the Branch of Urban Indian programs into an Office within the 

IHS; (2) adds technical assistance; and (3) deletes provisions of current law regarding staffing, services and equipment. 

Current Law: This section is Section 1660 of current law. 

Section 511. Grants for alcohol and substance abuse-related services 

This section provides that the Secretary may make grants to 

Urban Indian Organizations for the provision of health-related 

services in prevention of, treatment of, rehabilitation of, or schooland community-based education regarding, alcohol and substance 

abuse in Urban Centers. Goals and criteria are set forth. 

Amendments: This section essentially maintains current law. 

Current Law: This section is Section 1660a of current law. 

Section 512. Treatment of certain demonstration projects 

This section makes permanent the Tulsa Clinic and Oklahoma 

City Clinic demonstration projects in Oklahoma and parallels the 

language of the Interior Appropriations Act which first contained 

this provision (Public Law 108–447). 

Amendments: This section maintains provisions which make permanent certain demonstration projects in Oklahoma, but modifies 

the language of current law of this Act to parallel the language of 

the Interior Appropriations Act which first contained this provision 

(Public Law 108–447). 

Current Law: This section is Section 1660b of current law. 

Section 513. Urban NIAAA transferred programs 

This section authorizes the Secretary, through the Division of 

Urban Indian Health, to make grants to or enter into contracts 

with Urban Indian Organizations, to take effect not later than September 30, 2010, for the administration of Urban Indian alcohol 

programs that were originally established under the National Institute on Alcoholism and Alcohol Abuse (NIAAA). Use of funds, eligibility and reporting requirements are set forth. 

Amendments: This section maintains current law, but (1) changes 

references to the Branch of Urban Indian Health to the Division; 

and (2) deletes the provision of current law allowing the Secretary 

to combine NIAAA alcohol funds with other substance abuse funds. 


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Current Law: This section is Section 1660c of current law. 

Section 514. Consultation with urban Indian organizations 

This section provides that the Secretary shall ensure that the 

Service consults, to the greatest extent practicable, with Urban Indian Organizations, and defines ‘‘consultation.’’

Amendments: This section is new and is not contained in current 

law. 

Section 515. Urban youth treatment center demonstration 

This section authorizes the Secretary to fund the construction 

and operation of at least 2 Indian youth residential treatment centers in certain states to demonstrate the provision of alcohol and 

substance abuse treatment services to Urban Indian youth in a culturally competent residential setting. 

Amendments: This section is new and is not contained in current 

law. 

Section 516. Grants for diabetes prevention, treatment, and control 

This section authorizes the Secretary to make grants to Urban 

Indian Organizations to provide services for the prevention and 

treatment of, and control of the complications resulting from, diabetes among Urban Indians, based on certain grant criteria that are 

set forth. 

Amendments: This section is new and is not contained in current 

law. 

Section 517. Community health representatives 

This section authorizes the Secretary to make grants to or enter 

into contracts with Urban Indian Organizations for the employment of Indians trained as health service providers through the 

Community Health Representatives Program. 

Amendments: This section is new and is not contained in current 

law. 

Section 518. Effective date 

This section establishes that the amendments made by the Act 

to this title shall take effect on the date of enactment, regardless 

of whether the Secretary has promulgated regulations implementing these amendments. 

Amendments: This section is new and is not contained in current 

law. 

Section 519. Eligibility for services 

This section provides that Urban Indians shall be eligible for, 

and the ultimate beneficiaries of, health care or referral services 

provided pursuant to this title. 

Amendments: This section is new and is not contained in current 

law. 

Section 520. Authorization of appropriations 

This section authorizes to be appropriated such sums as may be 

necessary for each fiscal year through fiscal year 2017 to carry out 

this title. 


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Amendments: This section maintains current law and extends 

the authorization from fiscal year 2000 to fiscal year 2017. 

Current Law: This section is Section 1660d of current law. 

TITLE VI—ORGANIZATIONAL IMPROVEMENTS 

Section 601. Establishment of the Indian Health Service as an agency of the Public Health Service 

This section establishes the Indian Health Service within the 

Public Health Service of the Department, and elevates the position 

of Director of the Indian Health Service to that of the Assistant 

Secretary for Indian Health. The Assistant Secretary for Indian 

Health shall be confirmed by the Senate with a term of four years, 

and shall administer the Indian Health Service. This section also 

specifies the duties and responsibilities of the Assistant Secretary 

and deems that any reference to the Director of the Indian Health 

Service in any Federal law, Executive order, rule, regulation, or 

delegation of authority, is deemed to refer to the Assistant Secretary. 

Amendments: This section amends current law to (1) change the 

position of the Director into an Assistant Secretary; (2) provide that 

the individual serving in the position of Director of the Service on 

the day before the date of enactment shall serve as Assistant Secretary; (3) provide that the position of Assistant Secretary is established to facilitate advocacy and promote consultation on matters 

relating to Indian health; (4) give the Assistant Secretary additional duties; and (5) deem current law or regulatory references to 

the Director to refer to the Assistant Secretary. 

Current Law: This section is Section 1661 of current law. 

Section 602. Automated management information system 

Section 602 requires the Secretary to establish automated management information systems for the Service and each Tribal 

Health Program which meets certain requirements. This section 

also requires that patients have access to their own health records, 

and authorizes the Secretary to enter in to contracts, agreements, 

or joint ventures with other federal agencies, states, private and 

nonprofit organizations for the purpose of enhancing information 

technology in Indian Health Programs and facilities. 

Amendments: This section maintains current law and adds Secretarial authority to enter contracts or joint ventures to enhance information technology in Indian health programs. 

Current Law: This section is Section 1662 of current law. 

Section 603. Authorization of appropriations 

This section authorizes to be appropriated such sums as may be 

necessary to carry out this title, for each fiscal year through fiscal 

year 2017. 

Amendments: This section maintains current law and extends 

the authorization from fiscal year 2000 to fiscal year 2017. 

Current Law: This section is Section 1663 of current law. 


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TITLE VII—BEHAVIORAL HEALTH PROGRAMS 

Section 701. Behavioral health prevention and treatment services 

Section 701 states the purposes of the section, including directing 

the Secretary, acting through the Service, Indian Tribes, Tribal Organizations, and Urban Indian Organizations, to develop a comprehensive behavioral health prevention and treatment program 

which emphasizes collaboration among alcohol and substance 

abuse, social services, and mental health programs. This section 

also requires the Secretary to encourage the development of plans 

for areawide Indian Behavioral Health Services; directs the Secretary to coordinate with existing national clearinghouses and information centers to include plans and reports of outcomes of such 

behavioral health plans developed by Indian Tribes, Tribal Organizations, Urban Indian Organizations, and Service Areas; directs 

the Secretary to provide comprehensive behavioral health care programs; facilitates the governing body of any Indian Tribe, Tribal 

Organization, or Urban Indian Organization to establish community behavioral health plans; requires the Secretary to coordinate 

behavioral health planning with other federal and state agencies; 

and directs the Secretary to assess the need, availability and cost 

for inpatient mental health care for Indians within 1 year. 

Amendments: This section maintains current law and adds language which (1) authorizes the Secretary, Indian Tribes, Tribal Organizations, and Urban Indian Organizations to develop programs 

which emphasize collaboration for behavioral health; (2) requires 

technical assistance to Indian Tribes, Tribal Organizations and 

Urban Indian Organizations; and (3) requires a continuum of care 

for behavioral health to the extent feasible, including acute hospitalization, detoxification, and emergency shelter. 

Current Law: This section is Section 1621h and Section 1665 of 

current law. 

Section 702. Memoranda of agreement with the Department of the 

Interior 

This section requires the Secretary and the Secretary of the Interior to develop and enter, or review and update, within 1 year, 

memoranda of agreement to, among other things, make a comprehensive assessment, coordination, and annual review of all the 

behavioral health care needs and services available or unavailable 

to Indians. Specific provisions that are required in this memorandum are delineated. Each memorandum of agreement under 

this section shall be published in the Federal Register. This section 

also directs the Secretaries to address a strategy for the comprehensive coordination of the behavioral health services provided 

by the Bureau of Indian Affairs and the Service, including the coordination of alcohol and substance abuse programs of the Service, 

the BIA, and Indian Tribes and Tribal Organizations developed 

under the Indian Alcohol and Substance Abuse Prevention and 

Treatment Act of 1986 with behavioral health initiatives pursuant 

to this Act. 

Amendments: This section maintains current law and adds language which (1) requires the Secretary to update existing memoranda of agreement; and (2) includes Tribal Organizations. 

Current Law: This section is Section 1621h(b) of current law. 


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Section 703. Comprehensive behavioral health prevention and treatment program 

Section 703 requires the Secretary to provide a program of comprehensive behavioral health, prevention, treatment, and aftercare. 

Elements to be included in this program and target populations are 

specified. The Secretary may provide these services through Contract Health Services. 

Amendments: This section amends current law by (1) expanding 

beyond the alcohol and substance abuse focus to comprehensive behavioral health; and (2) adding more specific types of treatment. 

Language of current law, authorizing a grant to the Standing Rock 

Sioux Tribe to develop a community-based demonstration project, 

has been deleted. 

Current Law: This section is Section 1665a of current law. 

Section 704. Mental health technician program 

This section directs the Secretary to establish and maintain a 

mental health technician program within the Service to train and 

employ Indians as mental health technicians. The Secretary is to 

provide high-standard paraprofessional training in mental health 

care, supervise and evaluate the technicians, and ensure that the 

program involves the use and promotion of traditional health care 

practices of the Indian Tribes to be served. 

Amendments: This section maintains current law. 

Current Law: This section is Section 1621h(g) of current law. 

Section 705. Licensing requirement for mental health care workers 

This section requires that any individual employed as a psychologist, social worker, or marriage and family therapist for the purpose of providing mental health care services to Indians in a clinical setting under this Act to be licensed to provide these services. 

This section also sets forth requirements for individuals who may 

be employed as trainees in psychology, social work, or marriage 

and family therapy to provide mental health care services. 

Amendments: This section maintains current law. 

Current Law: This section is Section 1621h(l) of current law. 

Section 706. Indian women treatment programs 

This section authorizes the Secretary, consistent with section 

701, to make grants to Tribes, Tribal Organizations and Urban Indian Organizations to develop and implement a comprehensive behavioral health program of prevention, intervention, treatment, 

and relapse prevention services that specifically address the cultural, historical, social, and child care needs of Indian women. Use 

of grant funds, criteria for applications for funding, and a specified 

amount of funding for grants to Urban Indian Organizations are 

also specified. 

Amendments: This section maintains current law and (1) adds 

language which requires the implementation of this section to be 

consistent with section 701; (2) recognizes the behavioral health 

focus, beyond just alcohol and substance abuse; and (3) requires 

consultation with Indian Tribes and Tribal Organizations in establishing criteria for the review and approval of applications. 

Current Law: This section is Section 1665b of current law. 


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Section 707. Indian youth program 

This section requires the Secretary to develop and implement, 

consistent with section 701, a program for acute detoxification and 

treatment for Indian youth. The construction and staffing of alcohol 

and substance abuse treatment centers or facilities for Indian 

youths, including behavioral health services, is authorized. Additional provisions addressed in this section are: Construction and 

staffing of at least 1 youth regional treatment center in each IHS 

Area; the provision of intermediate adolescent behavioral health 

services; use of federally-owned structures for local residential or 

regional behavioral health treatment for Indian youths; the development and implementation of community-based rehabilitation and 

aftercare services; inclusion of family in youth treatment programs; 

programs and services to prevent and treat the abuse of multiple 

forms of substances among Indian youth; and data collection and 

a report to Congress concerning Indian youth and mental health 

services. 

Amendments: This section maintains current law and adds language which (1) requires implementation of this section to be consistent with section 701; (2) recognizes the behavioral health focus, 

beyond alcohol and substance abuse; (3) includes programs developed at the local tribal level; (4) includes treatment networks in addition to treatment programs; (5) includes sober or transitional 

housing in the intermediate adolescent services; (6) requires community reintegration as part of the rehabilitation and aftercare 

services; (7) establishes a program to prevent and treat multi-drug 

abuse; and (8) requires the Secretary to collect data for an Indian 

youth mental health report. 

Current Law: This section is Section 1665c of current law. 

Section 708. Indian youth telemental health demonstration project 

This section authorizes the Secretary to carry out a four-year 

demonstration project under which five Tribes or Tribal Organizations with telehealth capabilities could use telemental health services in youth suicide prevention and treatment. In awarding the 

grants, the Secretary would give priority to Tribes and Tribal Organizations serving a particular tribal community where there is a 

demonstrated need to address Indian youth suicide or which is isolated and has limited access to mental health services; entering 

into collaborative partnerships to provide the services; or operating 

a detention facility at which Indian youth are detained. The demonstration project would permit the use of telemedicine for psychotherapy, psychiatric assessments and diagnostic interviews of Indian youth; the provision of clinical expertise and other medical advice to frontline health care providers working with Indian youth; 

training and related support for community leaders, family members and health and education workers who work with Indian 

youth; the development of culturally-relevant educational materials 

on suicide prevention and intervention; and data collection and reporting. 

Amendments: This section is new and is not contained in current 

law. 


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Section 709. Inpatient and community-based mental health facilities 

design, construction, and staffing 

This section allows the Secretary, not later than 1 year after the 

date of enactment, to provide, in each IHS Area, not less than 1 

inpatient mental health care facility, or the equivalent, for Indians 

with behavioral health problems. The Secretary shall consider the 

possible conversion of existing underutilized hospital beds into psychiatric units to meet the needs. 

Amendments: This section amends current law by (1) requiring 

the establishment in each Area of at least 1 inpatient mental 

health facility, rather than an assessment of the need; and (2) providing that California shall be considered two Area Offices. 

Current Law: Section 1621h(i) of current law provides that within one year after enactment, the Secretary shall make an assessment of the need for inpatient mental health care facilities. 

Section 710. Training and community education 

Section 710 requires that the Secretary, in cooperation with the 

Secretary of the Interior, develop and implement, or assist Indian 

Tribes and Tribal Organizations to develop and implement, a program of community education and involvement in the area of behavioral health. This section also addresses specifics of instruction 

and the development of community-based training models. 

Amendments: This section maintains current law and (1) adds 

language which authorizes the Indian Tribes and Tribal Organizations to develop training and community education programs; (2) 

adds child sexual abuse to the types of training authorized; and (3) 

recognizes the behavioral health focus of the program. 

Current Law: This section is Section 1621h(d) of current law. 

Section 711. Behavioral health program 

This section allows the Secretary, consistent with section 701, to 

plan, develop, implement, and carry out programs to deliver innovative community-based behavioral health services to Indians. The 

section sets forth criteria to be used for grant awards for such programs, and requires that the same criteria as are used in evaluating other funding proposals be used for programs under this section. 

Amendments: This section maintains current law and adds Tribal 

Organizations as eligible recipients for funding under this section. 

Current Law: This section is Section 1621h of current law. 

Section 712. Fetal alcohol disorder programs 

Section 712 authorizes the Secretary, consistent with section 701, 

to establish and operate fetal alcohol disorder programs, to include 

the development and provision of services for the prevention, intervention, treatment, and aftercare for those affected by fetal alcohol 

disorder in Indian communities. Use of funds and criteria for applications are specified. In addition, the Secretary is directed to establish a Fetal Alcohol Disorder Task Force to advise the Secretary. 

This section also authorizes funding for applied research projects 

which propose to elevate the understanding of methods to prevent, 

intervene, treat or provide rehabilitation and aftercare for Indians 

affected by this disorder. Urban Indians are to receive a certain 

amount of funds appropriated for this program. 


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Amendments: This section maintains current law and adds language (1) requiring these programs to be implemented consistent 

with section 701; (2) consolidating fetal alcohol syndrome and fetal 

alcohol effects into fetal alcohol disorders (FAD); (3) authorizing appropriate psychological services, early childhood intervention 

projects, community-based support services and housing as allowable uses of funding under this section; and (4) including the National Institute for Child Health and Human Development and the 

Centers for Disease Control and Prevention in the national Fetal 

Alcohol Disorder Task Force. Provisions of current law establishing 

a national clearinghouse for prevention and educational materials 

and other information on FAS and FAE effect in Indian and Alaska 

Native communities, and requirements for a report to Congress 

contained in current law have been deleted. 

Current Law: This section is Section 1665g of current law. 

Section 713. Child sexual abuse and prevention treatment programs 

This section directs the Secretary to establish, consistent with 

section 701, treatment programs in every IHS Area for both Indian 

victims of child sexual abuse and Indian perpetrators of child sexual abuse. This section specifies the use of funds for these programs, and directs that they be carried out in coordination with 

programs and services authorized under the Indian Child Protection and Family Violence Prevention Act (25 U.S.C. 3201 et seq.). 

Amendments: This section amends current law by (1) turning two 

specific demonstration projects into permanent programs; (2) making the establishment of these programs consistent with section 

701; (3) authorizing services for Indian child victims of sexual 

abuse and perpetrators of child sexual abuse who are members of 

an Indian household; (4) including authorized uses of funds such as 

developing community education, identifying and providing treatment to victims, developing culturally-sensitive prevention models 

and diagnostic tools, and providing treatment to the perpetrators; 

and (5) providing that these programs are carried out in coordination with programs and services authorized under the Indian Child 

Protection and Family Violence Prevention Act. 

Current Law: Section 1680i of current law establishes demonstration programs involving treatment for child sexual abuse through 

the Hopi Tribe and the Assiniboine and Sioux Tribes of the Fort 

Peck Reservation. The Secretary may establish other demonstration projects, but must have an equal number of projects for the 

IHS Areas. 

Section 714. Behavioral health research 

Section 714 authorizes the Secretary to make grants to, or enter 

into contracts with, Indian Tribes, Tribal Organizations, and Urban 

Indian Organizations or enter into contracts with, or make grants 

to appropriate institutions for, the conduct of research on the incidence and prevalence of behavioral health problems among Indians. Research priorities are specified, including youth suicide, the 

interrelationship of mental disorders with alcoholism, suicide, 

homicide, and the incidence of family violence, and prevention models. 


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Amendments: This section maintains current law and adds language which emphasizes the focus on behavioral health instead of 

only mental health problems. 

Current Law: This section is Section 1621h of current law. 

Section 715. Definitions 

This section provides definitions for the following terms used in 

this title: assessment; alcohol-related neurodevelopmental disorders 

or ARND; behavioral health aftercare; dual diagnosis; fetal alcohol 

disorders; fetal alcohol syndrome or FAS; partial FAS; rehabilitation; and substance abuse. 

Amendments: This section is new and is not contained in current 

law. 

Section 716. Authorization of appropriations 

This section authorizes to be appropriated such sums as may be 

necessary for each fiscal year through fiscal year 2017 to carry out 

this title. 

Amendments: This section maintains current law and extends 

the authorization from fiscal year 2000 to fiscal year 2017 and 

eliminates the exceptions for sections that had specific terms of authorization. 

Current Law: This section is Section 1621w of current law. 

TITLE VIII—MISCELLANEOUS 

Section 801. Reports 

This section outlines requirements under this Act for various reports (and their contents) and audits which shall be submitted to 

Congress. 

Amendments: This section maintains current law and adds provisions which either establish new reporting requirements or consolidate the information required in other sections in one organized 

list, such as requiring as part of the annual reports to Congress information on services provided under Indian Self-Determination 

Act agreements, loan repayment programs, infectious diseases, environmental hazards, status of health care and sanitation facilities, 

sharing of services between the IHS and other federal agencies, 

and urban Indian programs. 

Current Law: This section is Section 1671 of current law. 

Section 802. Regulations 

This section sets forth the various requirements for regulations, 

including regulations developed through negotiated rulemaking, for 

selected titles and sections, and timelines for issuance of regulations under this Act. The membership of the negotiated rulemaking 

committee and its procedures are delineated. 

Amendments: This section is new and is not contained in current 

law. 

Section 803. Plan of implementation 

This section requires the Secretary, in consultation with Indian 

Tribes, Tribal Organizations, and Urban Indian Organizations, to 

submit to Congress a plan of implementation of this Act within 9 

months. 


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Amendments: This section is new and is not contained in current 

law. 

Section 804. Availability of funds 

This section authorizes funds appropriated pursuant to this Act 

to remain available until expended. 

Amendments: This section maintains current law. 

Current Law: This section is Section 1675 of current law. 

Section 805. Limitation on use of funds appropriated to Indian 

Health Service 

This section provides that any limitation on the use of funds contained in an Act that provides appropriations for the Department 

of Health and Human Services with respect to the performance of 

abortions shall apply for that fiscal year to the performance of 

abortions using funds contained in an Act providing appropriations 

for the Service. 

Amendments: This section maintains current law. 

Current Law: This section is Section 1676 of current law. 

Section 806. Eligibility of California Indians 

This section clarifies the eligibility of California Indians for 

health services provided by the Service to include members of federally-recognized tribes, descendants of Indians residing in California as of June 1, 1852, Indians holding trust interests in certain 

types of land, and Indians listed on the plans for assets distribution in California. 

Amendments: This section maintains current law, but eliminates 

the report to Congress developing data on the Indians located in 

California, health status and needs and other information. 

Current Law: This section is Section 1679 of current law. 

Section 807. Health services for ineligible persons 

This section authorizes services for certain persons (such as children and spouses) and other individuals otherwise ineligible for 

health services provided by the Service under limited circumstances, and outlines criteria for providing and paying for those 

services. 

Amendments: This section maintains current law and adds compacts, in addition to contracts, entered in to under the Indian SelfDetermination Act. 

Current Law: This section is Section 1680c of current law. 

Section 808. Reallocation of base services 

This section requires the Secretary to submit a report to Congress on any allocation of Service funds for a fiscal year that reduces by 5% or more from the previous fiscal year the funding for 

any recurring program, project, or activity of a Service Unit. 

Amendments: This section maintains current law. 

Current Law: This section is Section 1680g of current law. 

Section 809. Results of demonstration projects 

This section requires the Secretary to disseminate to Indian 

Tribes, Tribal Organizations, and Urban Indian Organizations the 


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findings and results of demonstration projects conducted under this 

Act. 

Amendments: This section maintains current law, and adds Tribal Organizations and Urban Indian Organizations. 

Current Law: This section is Section 1680m of current law. 

Section 810. Provision of services in Montana 

This section recognizes a court decision governing the provision 

of services and benefits for certain Indians in Montana. 

Amendments: This section is new and is not contained in current 

law. 

Section 811. Moratorium 

This section authorizes the Service to provide certain health care 

services according to eligibility criteria in effect on a certain date 

until the Service submits to Congress and the Congress enacts an 

appropriations Act that reflects the increased costs associated with 

the Department’s proposed final rule, implementing other eligibility criteria. 

Amendments: This section is new and is not contained in the current Indian health law. However, similar language has appeared 

for several years in Interior Appropriations Acts. 

Section 812. Tribal employment 

This section provides that an Indian Tribe or Tribal Organization 

carrying out a contract or compact pursuant to the Indian Self-Determination and Education Assistance Act shall not be considered 

an ‘‘employer.’’ Amendments: This section is new and is not contained in current 

law. 

Section 813. Severability provisions 

This section retains remaining provisions of the Act if other provisions are stricken by any court. 

Amendments: This section is new and is not contained in current 

law. 

Section 814. Establishment of national bipartisan commission on 

Indian health care 

This section establishes a Commission to study the delivery of 

health care services to Indians, and sets forth the duties, membership, compensation, and meeting, hearing and reporting requirements. This section also authorizes the appointment of a Director 

and staff for the Commission; establishes their compensation; and 

authorizes details of federal employees, hearings, use of mails, 

technical assistance and administrative support services. $4 million 

is authorized for the Commission. 

Amendments: This section is new and is not contained in current 

law. 

Section 815. Confidentiality of medical quality assurance records; 

qualified immunity for participants 

This section would establish requirements for quality assurance 

such as confidentiality, privacy, disclosure and liability. Section 815 

also sets forth the limits of such disclosure. 


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Amendments: This section is new and is not contained in current 

law. 

Section 816. Appropriations; availability 

This section subjects new spending authority to amounts provided in appropriations Acts. 

Amendments: This section is new and is not contained in current 

law. 

Section 817. Authorization of appropriations 

This section authorizes to be appropriated such sums as may be 

necessary for each fiscal year through fiscal year 2017 to carry out 

this title. 

Amendments: This section maintains current law and extends 

the authorization through fiscal year 2017. 

Current Law: Section 1680o authorizes appropriations through 

fiscal year 2000. 

Section 101(b). Indian Health Care Improvement Act amended 

Section 101(b) includes provisions amending other laws for the 

references to the ‘‘Director of Indian Health Service’’ which would 

be changed to ‘‘Assistant Secretary for Indian Health’’. 

Amendments: This section is new and is not contained in current 

law. 

Section 102. Soboba sanitation facilities 

Section 102 authorizes sanitation facilities and services to be provided to the Soboba Band of Mission Indians and the Soboba Indian Reservation. 

Amendments: This section is new and is not contained in current 

law. 

Section 103. Native American Health and Wellness Foundation 

Section 103 amends the Indian Self-Determination and Education Assistance Act to include a new Title VIII under which a 

Native American Health and Wellness Foundation would be established, in the following sections: 

Section 801. Definitions 

This section includes definitions for the Board, Committee, Foundation, and other terms used in this section. 

Section 802. Native American Health and Wellness Foundation 

This section establishes the perpetual existence of the 

Foundation, the nature and duties of the Foundation and 

the place of incorporation. This section also authorizes the 

Secretary to establish an initial Committee to assist in establishing the Foundation. Section 802 establishes the authority of the Board of Directors, including their terms, the 

officers (including the extent of their liabilities) and the 

powers of the Foundation. This section also establishes 

limits on the administrative costs, audit requirements, and 

authorizes $500,000 for the fiscal years. 


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Section 803. Administrative services and support 

This section authorizes the Secretary to provide administrative support to the Foundation and initial operating 

funds on a reimbursement basis for up to five years. 

Amendments: This section is new and is not contained in current 

law. 

Title II 

Title II of the bill is amendments to the Social Security Act that 

is under the jurisdiction of the Senate Finance Committee. These 

provisions include waivers of cost-sharing and premiums for Medicaid for Indians receiving services at IHS, tribal or urban Indian 

health programs, Medicaid managed care provisions, and safe harbor protections from the anti-kickback statutes. 

Section 201. Expansion of payments under Medicare, Medicaid and 

SCHIP for all covered services furnished by Indian health programs 

Section 201 authorizes IHS, tribal and urban Indian health programs to be reimbursed for Medicaid, if the services meet the conditions and requirements generally applicable to the delivery of 

such care. In addition, this section requires IHS, tribal or urban Indian health facilities to make improvements to achieve or maintain 

compliance. The Secretary is also authorized to enter into an agreement with a State to reimburse the State for Medicaid services provided by the IHS, tribal or urban Indian health programs. This section cross-references the special fund to which Medicaid reimbursements are placed for IHS and direct billing requirements for the 

IHS and tribal health programs under the Act. This section also 

authorizes Medicare payments to IHS, tribal and urban Indian 

health programs so long as they are compliant with Medicare requirements. The section cross-references the Act’s provisions under 

which Medicare payments made are placed in a special fund for the 

purpose of making improvements to maintain compliance. 

Section 202. Increased outreach to Indians under Medicaid and 

SCHIP and improved cooperation in the provision of items and 

services to Indians under Social Security Act health benefit programs 

Section 202 authorizes the Secretary to encourage States to take 

steps to increase enrollment and outreach for Indian children in 

the State Children’s Health Insurance Program and requires the 

Secretary to facilitate cooperation between States and the IHS, 

tribal and urban Indian health programs. 

Section 203. Additional provisions to increase outreach to, and enrollment of, Indians in SCHIP and Medicaid for outreach 

Section 203 excludes certain activities, such as outreach activities for families of Indian children likely to be eligible for SCHIP 

and enrollment assistance activities, from the current 10% cap on 

certain SCHIP payments. 


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Section 204. Premiums and cost sharing protections under Medicaid, eligibility determinations under Medicaid and SCHIP, 

and protection of certain Indian property from Medicaid estate 

recovery 

Section 204 prohibits the imposition of enrollment fees, premiums and cost-sharing on Indians served at the IHS, tribal or 

urban Indian health programs or through the referrals to contract 

health and the reduction of the reimbursement to the IHS, tribal 

or urban Indian health program for the fees or cost-sharing. In addition, this section exempts certain Indian property, such as trust 

land, from being included in determining eligibility of an individual 

who is an Indian for Medicaid, and continues protections of certain 

Indian property from Medicaid estate recovery. 

Section 205. Nondiscrimination in qualifications for payment for 

services under Federal health care programs 

Section 205 allows the IHS, Tribal or urban Indian health programs to be accepted on the same basis as any other provider eligible for reimbursement, if the program meets generally applicable 

participation requirements. The provision would prohibit payments 

if the program was excluded from any other Federal health care 

program and if any State licenses were suspended or revoked. 

Section 206. Consultation on Medicaid, SCHIP, and other health 

care programs funded under the Social Security Act involving 

Indian health programs and urban Indian organizations 

Section 206 maintains the Tribal Technical Advisory Group established to provide technical assistance or advice to the Centers 

for Medicare and Medicaid Services. This section also requires the 

States to establish a process for consultation with the tribal or 

urban Indian health programs on matters relating to Medicaid 

which are likely to have a direct effect on Indians or Indian health 

programs. 

Section 207. Exclusion waiver authority for affected Indian health 

programs and safe harbor transactions under the Social Security Act 

Section 207 establishes a process whereby the administrator of 

an Indian Health Program may request a waiver of sanctions imposed on a health provider. This section also specifies that certain 

transactions not be considered remuneration under Section 

1128B(b) of the Social Security Act for certain transfers between 

the Indian health programs or patient for the purpose of providing 

necessary health care services to the patient. 

Section 208. Rules applicable under Medicaid and SCHIP to managed care entities with respect to Indian enrollees and Indian 

health care providers and Indian managed care entities 

Section 208 allows Indians, enrolled in a non-Indian Medicaid 

managed care entity (MCE) with an Indian health program participating in the network, to choose the Indian health program as the 

primary care provider. It also requires MCEs with significant Indian enrollees to meet other requirements. The Indian health programs would also be required to comply with all generally applicable Medicaid requirements to the extent the requirements do not 


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conflict with other Federal statutes applicable to the Indian health 

programs. This section also sets forth special rules applicable to Indian MCEs, such as the ability to restrict enrollment to Indians 

and other enrollment rules. In regard to a Medicaid managed care 

program, if a health care provider is required to have medical malpractice insurance as a condition of contracting with a Medicaid 

MCE, an Indian health care provider would be deemed to satisfy 

such a requirement if it is an FQHC covered under the Federal 

Tort Claims Act, a provider that delivers services pursuant to a 

contract under the Indian Self-Determination and Education Assistance Act, or the Indian Health Service, which is covered under 

the Federal Tort Claims Act. 

Section 209. Annual report on Indians served by Social Security Act 

health benefit programs 

Section 209 requires annual reports to Congress regarding the 

enrollment and health status of Indians receiving items or services 

under the health benefit programs. 

LEGISLATIVE HISTORY

On April 24, 2007, Senators Dorgan, Thomas, Boxer, Reid, Cantwell, Johnson, Tester, Inouye, Domenici, Bingaman, Baucus, 

Klobuchar, Obama and Murkowski introduced S. 1200, the Indian 

Health Care Improvement Act Amendments of 2007. Senators 

Cochran and Murray were added as cosponsors on April 26, 2007; 

Senator Clinton on May 3, 2007; and Senators Brown and Stevens 

on May 21, 2007. Senator Stabenow was added as a cosponsor on 

September 4, 2007. 

The Committee held a hearing on the Indian Health Care Improvement Act on March 8, 2007. This was the tenth hearing since 

the 106th Congress on the reauthorization of the Act. 

On May 10, 2007, the Committee on Indian Affairs convened a 

business meeting to consider S. 1200 and other measures that had 

been referred to it, and ordered the bill favorably reported. 

COMMITTEE RECOMMENDATION AND TABULATION OF VOTE

On May 10, 2007, the Committee on Indian Affairs convened a 

business meeting to consider S. 1200 and other measures, and 

voted to have the bill favorably reported to the full Senate, without 

amendment, with the recommendation that the bill do pass. 

REGULATORY AND PAPERWORK IMPACT STATEMENT

Paragraph 11(b) of rule XXVI of the Standing Rules of the Senate requires that each report accompanying a bill evaluate the regulatory and paperwork impact that would be incurred in carrying 

out the bill. The Committee has concluded that S. 1200 will not require the promulgation of regulations so the regulatory and paperwork impact should be minimal. 

EXECUTIVE COMMUNICATIONS

On May 1, 2007, Chairman Dorgan sent letters to both Secretary 

Michael Leavitt and Attorney General Gonzales, asking the DeVerDate Aug 31 2005 01:51 Oct 27, 2007 Jkt 069010 PO 00000 Frm 00081 Fmt 6659 Sfmt 6602 E:\HR\OC\SR197.XXX SR197

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partment of Health and Human Services and the Department of 

Justice to provide the Committee with their views on S. 1200. 

The Department of Justice submitted a letter of comments on 

June 13, 2007, which is attached, below. 

DEPARTMENT OF JUSTICE, 

OFFICE OF LEGISLATIVE AFFAIRS, 

Washington, DC, June 13, 2007. 

Hon. BYRON L. DORGAN, 

Chairman, Committee on Indian Affairs, 

U.S. Senate, Washington, DC. 

DEAR MR. CHAIRMAN: Thank you for the opportunity to comment 

upon S. 1200, the Indian Health Care Improvement Act Amendments of 2007. The Department of Justice fully supports the purposes of this legislation—improving access to health care for American Indians and Alaska natives. The Department has worked with 

the Committee on Indian Affairs on previous versions of this legislation and believes that most of its prior concerns have been addressed by S. 1200. The Department does, however, continue to 

have a few concerns with the legislation that we have noted in the 

past. As explained below, the Department believes that these concerns can be addressed with relatively modest changes to bill language that would not detract from the overall goal of improving 

health care for Native Americans but would, in the Department’s 

view, benefit both the Native American community specifically and 

taxpayers generally. 

1. The legislation authorizes funding and encourages the use of 

traditional health care practices. The Department does not oppose 

the provision of traditional health care practices as an adjunct to 

‘‘Western’’ medical practices. We note that on March 8, 2007, Ms. 

Rachel Joseph, Co-Chairperson of the National Steering Committee 

for the Reauthorization of the Indian Health Care Improvement 

Act, testified that ‘‘[t]raditional health care practices are usually 

provided as complementary services to Western medical practices 

at the request of family members.’’ Ms. Joseph also testified that 

‘‘[i]n most cases, the traditional health care practitioners are not 

employees of the IHS or tribes so FTCA coverage would not apply 

in the event that a malpractice claim was ever filed.’’

A prior version of this legislation contained language clarifying 

that traditional health care practitioners are not covered by the 

Federal Tort Claims Act (‘‘FTCA’’), and we recommend that this 

language be added back to S. 1200. Specifically, we recommend the 

following provision as an addition to section 805: 

(b) NO LIABILITY.—Although the Secretary may promote traditional health care practices, consistent with the Service standards 

for the provision of health care, health promotion, and disease prevention under this Act, the United States is not liable for the acts 

or omissions of any person in providing traditional health care 

practices under this Act that result in damage, injury, death, or 

any outcome to any patient. 

This language is intended to confirm existing law that there is 

no valid cause of action under the FTCA for injuries resulting from 

traditional tribal healing practices provided pursuant to self determination contracts because state law generally does not make private parties liable for ‘‘malpractice’’ involving traditional tribal 


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healing practices. See 28 U.S.C. § 2674. Thus, this provision would 

ensure that the United States would not face potential tort liability 

for the provision of treatment through traditional health care practices for which no state standard of care exists and would prevent 

costly litigation about whether the United States could be held liable under the FTCA for such practices. Moreover, it would preclude 

intrusive discovery regarding the nature and purpose of traditional 

health care practices. Such litigation would almost certainly raise 

questions as to the advisability of Tribal health practices and potentially create unnecessary conflict between these practices and 

Western medical standards. Additionally, we believe the proposed 

language would ameliorate any Tribal sovereignty concerns that 

would arise in FTCA litigation regarding inquiry into traditional 

health care practices. At the same time, this language would not 

scale back in any way the current liability protections that the 

Tribes enjoy in carrying out self-determination contracts. 

We also have concerns regarding changes made to section 213 of 

the legislation. The current version of section 213(b)(1) was modified to provide: 

(b) TERMS AND CONDITIONS.—

(1) IN GENERAL.—Any service provided under this section shall be 

in accordance with such terms and conditions as are consistent 

with accepted and appropriate standards relating to the service, including any licensing term or condition required under this Act. 

The previous version of the legislation, unlike S. 1200, made explicit that the Secretary ‘‘shall require’’ that any service provided 

be in accordance with terms and conditions that the Secretary determined to be consistent with accepted and appropriate standards 

relating to the service. We think S. 1200 is unclear in this regard, 

as it fails to explicitly specify who is responsible for requiring that 

any services provided are in accordance ‘‘with such terms and conditions as are consistent with the accepted and appropriate standards relating to the service.’’ We suggest revising subsection 

213(b)(1) to provide: 

(1) IN GENERAL.—The Secretary shall require that any service 

provided pursuant to this Act is in compliance with the accepted 

and appropriate standards relating to the service, including any licensing term or condition under this Act. 

Relatedly, S. 1200 made changes to the prior language of subsection 213(b)(2). That subsection now reads: 

(b)(2)(A) STANDARDS.—

IN GENERAL.—The Secretary may establish, by regulation, the 

standards for a service provided under this section, provided that 

such standards shall not be more stringent than the standards required by the State in which the service is provided. 

We have concerns about this language. For the purposes of tort 

liability under the FTCA, state law provides the standards governing the conduct at issue. If the Secretary, by regulation, establishes standards that fall below the standards required by the 

State, there is a risk the United States could be held liable under 

the FTCA, even if the care complied with the standards promulgated by the Secretary. Moreover, and more likely troublesome, if 

the Secretary approves services for which there are no applicable 

state standards, subsection (b)(2), by its plain language, would appear to prevent the Secretary from establishing any appropriate 


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standards because those standards would, by their very existence, 

be more stringent than what is required by the State. Where no 

state standards are applicable, it is in the interests of both the 

United States and the Tribes to whom such services might be provided to have some applicable and appropriate standards of care 

set by the Secretary. Thus, along with the Department of Health 

and Human Services, we propose working with the Committee to 

revise subsection (b)(2)(A) to address this concern. 

Finally, S. 1200 also includes this new provision to section 213: 

(b)(2)(B) USE OF STATE STANDARDS.— If the Secretary does not, by regulation, establish standards for 

a service provided under this section, the standards required by the 

State in which the service is or will be provided shall apply to such 

service. 

We agree that state standards should be applicable, since liability under the FTCA would be measured by those standards. Again, 

however, if there is no applicable state standard, the Secretary 

should be permitted to set some meaningful and appropriate standard of care, which is arguably not possible given the limitation of 

subsection (b)(2)(A). 

2. The Department believes that the legislation continues to raise 

a constitutional concern to the extent that it provides government 

benefits to individuals who are not members of, or closely affiliated 

with, a Federally recognized Indian tribe. As the Department has 

noted in the past, the Supreme Court has held that classifications 

based on affiliation with a Federally recognized tribe are ‘‘political 

rather than racial,’’ and therefore will be upheld as long as there 

is a rational basis for them. To the extent, however, that programs 

benefiting ‘‘Urban Indians’’ under this legislation could be viewed 

as authorizing the award of grants and other Government benefits 

on the basis of racial or ethnic criteria, rather than tribal affiliation, these programs would be subject to strict scrutiny under the 

equal protection component of the Due Process Clause. Both this 

bill and the current statute broadly define ‘‘Urban Indian’’ to include individuals who are not necessarily affiliated with a federally 

recognized Indian tribe. Under the Supreme Court’s decisions, 

there is a substantial likelihood that legislation providing special 

benefits to individuals of Indian or Alaska Native descent who do 

not have a clear and close affiliation with a federally recognized 

tribe would be regarded by the courts as creating a racial preference subject to strict constitutional scrutiny, rather than a political preference subject to rational basis review. In the event the 

legislation is regarded as awarding Government benefits based on 

a racial classification, it would be constitutional only if the bill is 

supported by a factual record demonstrating that its use of racebased criteria to award the benefits at issue is ‘‘narrowly tailored’’

to serve a ‘‘compelling’’ Government interest. 

The bill’s extension of benefits to members of State-recognized 

tribes raise the same concern. As a threshold matter, it is not clear 

whether the courts would agree that Congress can constitutionally 

delegate its tribal recognition authority to the States and, even if 

Congress can do so as a general matter, the delegation in this bill 

would allow States to designate as ‘‘tribal members’’ eligible for 

Federal benefits individuals who: (i) do not belong to a ‘‘distinctly 

Indian community’’ or other group that conforms to the Supreme 


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Court’s definitions of ‘‘the Indian tribes’’ referenced in the Commerce Clause, but instead are considered a member of a State 

‘‘tribe’’ solely on the basis of race or affiliation with a group that 

lacks the sovereign attributes the Supreme Court has identified as 

important to classification as an ‘‘Indian tribe’’ for purposes of 

Commerce Clause legislation; and/or (ii) are otherwise outside the 

class of beneficiaries that Congress intended to reach with this bill. 

In this regard, as you may know, the American Indian Heritage 

Support Center (‘‘AIHSC’’), in a March 29, 2007, letter to the Department, with copies to Members of Congress, voiced concerns 

about the extension of benefits under this legislation to ‘‘state recognized tribes’’ because, according to the AIHSC, some of these 

‘‘tribes’’ ‘‘have no historical background past the last 10 to 20 

years’’ and simply seek ‘‘tribal’’ recognition to take advantage of 

certain recent Government benefits such as gaming privileges. 

The Department recommends that, consistent with the settled 

practice of avoiding unnecessary constitutional issues, Congress revise the bill to extend benefits only to individuals who, in addition 

to satisfying whatever other criteria Congress may wish to impose, 

qualify as ‘‘members of, or individuals having a clear and close affiliation with, a federally-recognized tribe.’’ Such a revision would 

avoid the constitutional concerns outlined above in a way that the 

Department believes would not detract from the overall goal of improving health care for Native Americans, and might actually better ensure that benefits under the bill would extend only to the 

class of beneficiaries contemplated by Congress and the Constitution. 

Thank you for the opportunity to comment upon this very important legislation. We are committed to working with the Committee 

to have this legislation passed. The Office of Management and 

Budget has advised us that there is no objection to this letter from 

the perspective of the Administration’s program. 

Sincerely, 

RICHARD A. HERTLING, 

Principal Deputy Assistant Attorney General. 

The Committee has not received any formal communication on S. 

1200 from the Department of Health and Human Services other 

than the testimony presented to the Committee at the hearing on 

reauthorization of the Indian Health Care Improvement Act on 

March 8, 2007, which is also attached, below. 

STATEMENT OF ADMIRAL JOHN O. AGWUNOBI, MD, MBA, 

MPH, ASSISTANT SECRETARY FOR HEALTH, U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES

MR. CHAIRMAN AND MEMBERS OF THE COMMITTEE: My 

name is John Agwunobi and I am the Assistant Secretary 

for Health for the U.S. Department of Health and Human 

Services (HHS). As the Assistant Secretary, I serve as the 

Secretary’s primary advisor on matters involving the nation’s public health. I also oversee the U.S. Public Health 

Service and its Commissioned Corps for the Secretary. 

This landmark legislation forms the backbone of the system through which Federal health programs serve American Indians/Alaska Natives and encourages participation 


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of eligible American Indians/Alaska Natives in these and 

other programs. 

The IHS has the responsibility for the delivery of health 

services to more than 1.8 million Federally-recognized 

American Indians/Alaska Natives through a system of 

IHS, tribal, and urban (I/T/U) health programs governed 

by judicial decisions and statutes. The mission of the agency is to raise the physical, mental, social, and spiritual 

health of American Indian/Alaska Natives to the highest 

level, in partnership with the population we serve. The 

agency goal is to assure that comprehensive, culturally acceptable personal and public health services are available 

and accessible to the service population. Our duty is to uphold the Federal government’s responsibility to promote 

healthy American Indian and Alaska Native people, communities, and cultures and to honor and protect the inherent sovereign rights of Tribes. 

Two major statutes are at the core of the Federal government’s responsibility for meeting the health needs of 

American Indians/Alaska Natives: The Snyder Act of 1921, 

P.L. 67–85, and the Indian Health Care Improvement Act 

(IHCIA), P.L. 94–437, as amended. The Snyder Act authorized regular appropriations for ‘‘the relief of distress and 

conservation of health’’ of American Indians/Alaska Natives. The IHCIA was enacted ‘‘to implement the Federal 

responsibility for the care and education of the Indian people by improving the services and facilities of Federal Indian health programs and encouraging maximum participation of Indians in such programs.’’ Like the Snyder Act, 

the IHCIA provides the authority for the Federal government programs that deliver health services to Indian people, but it also provides additional guidance in several 

areas. The IHCIA contains specific language addressing 

the recruitment and retention of health professionals serving Indian communities; the provision of health services; 

the construction, replacement, and repair of health care facilities; access to health services; and the provision of 

health services for urban Indian people. 

DHHS ACTIVITIES

Since enactment of the IHCIA in 1976, Congress has 

substantially expanded the statutory authority for programs and activities in order to keep pace with changes in 

healthcare services and administration. Federal funding 

for the IHCIA has contributed billions of dollars to improve the health status of American Indians/Alaska Natives. And, much progress has been made particularly in 

the areas of infant and maternal mortality. 

The Department under this Administration’s leadership 

reactivated the Intradepartmental Council on Native 

American Affairs (ICNAA) to provide for a consistent HHS 

policy when working with the more than 560 Federally 

recognized Tribes. This Council’s vice chairperson is the 

IHS Director, giving him a highly visible role within the 

Department on Indian policy. 


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In January of 2005 the Department completed work ushering through a revised HHS Tribal consultation policy 

and involving Tribal leaders in the process. This policy further emphasizes the unique government-to-government relationship between Indian Tribes and the Federal government and assists in improving services to the Indian community through better communications. Consultation may 

take place at many different levels. To ensure the active 

participation of Tribes in the development of the Department’s budget request, an HHS-wide budget consultation 

session is held annually. This meeting provides Tribes 

with an opportunity to meet directly with leadership from 

all Department agencies and identify their priorities for 

upcoming program requests. For FY 2008, Tribes identified 

population growth and increases in the cost of providing 

health care as their top budget priorities and IHS’s FY 

2008 budget request included an increase of $88 million for 

these items. 

Through the Centers for Medicare & Medicaid Services 

(CMS), a Technical Tribal Advisory Group was established 

which provides Tribes with a vehicle for communicating 

concerns and comments to CMS on Medicare, Medicaid 

and SCHIP policies impacting their members. And the IHS 

has been vigilant about improving outcomes for Indian 

children and families with diabetes by increasing education and physical activity programs aimed at preventing 

and addressing the needs of those susceptible to, or struggling with, this potentially disabling disease. In addition, 

a Tribal Leaders Diabetes Committee continues to meet 

several times a year at the direction of the IHS Director 

to review information on the progress of the Special Diabetes Program for Indians activities and to provide general 

recommendations to IHS. 

It is clear the Department has not been a passive observer of the health needs of eligible American Indians/ 

Alaska Natives. Yet, we recognize that health disparities 

among this population do exist and are among some of the 

highest in the Nation for certain diseases (e.g., alcoholism, 

cardiovascular disease, diabetes, and injuries), and that 

improvements in access to IHS and other Federal and private sector programs will result in improved health status 

for Indian people. 

The IHCIA was enacted to provide primary and preventive services in recognition of the Federal government’s 

unique relationship with members of Federally recognized 

Tribes. Members of Federally recognized Tribes and their 

descendants are also eligible for other Federal health programs (such as Medicare, Medicaid and SCHIP) on the 

same basis as other Americans, and many also receive 

health care through employer-sponsored or other 

healthcare coverage. 

It is within the context of current law and programs that 

we turn our attention to reauthorization of the ‘‘Indian 

Health Care Improvement Act.’’


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REAUTHORIZATION

We are here today to discuss reauthorization of the 

IHCIA, and its impact on programs and services provided 

for in current law. In December of 2006, the Department 

submitted to this Committee comments on proposed legislation that the 109th Congress was considering. These 

comments are the basis for our testimony today, and any 

changes introduced by the bill under review in the 110th 

Congress will be considered once we have had an opportunity to review newly introduced legislation. Improving 

access to healthcare for all eligible American Indians and 

Alaska Natives is a priority for all those involved in the 

administration of the IHS program. We have worked closely with this Committee in the past and we have made 

progress in moving toward a program supportive of existing authority while maintaining the Secretary’s flexibility 

to effectively manage the IHS program. However, in the 

last bill, S. 1057, there continued to be provisions which 

could negatively impact our ability to provide needed access to services. Such provisions established program mandates and burdensome requirements that could, or would, 

divert resources from important services. To the extent 

that those provisions are included in the new legislation, 

we hope to work with you to continue to address these concerns. 

The Department is supportive of reauthorization of the 

IHCIA and supports provisions that maintain or increase 

the Secretary’s flexibility to work with Tribes, and to increase the availability of health care. Committee leadership previously responded to some concerns raised about 

certain provisions and some of the changes went a long 

way toward improving the Secretary’s ability to effectively 

manage the program within current budgetary resources. 

I would like to note for you today our particular interest 

in provisions previously reported out of this Committee. 

OVERARCHING CONCERNS

We have a number of general objections to previous language, including, expanded requirements for negotiated 

rulemaking and consultation; new requirements using 

‘‘shall’’ instead of ‘‘may’’; use of the term ‘‘funding’’ in place 

of ‘‘grant’’; expansion of authorities for Urban Indian Organizations; new permissive authorities; provisions governing 

traditional health care practices; new reporting requirements; establishment of the Bipartisan Commission on Indian Health Care; and new provisions that contemplate 

the Secretary exercising authority through the Service, 

Tribes and Tribal Organizations which is not tied to agreements entered into under the Indian Self-Determination 

and Education Assistance Act (ISDEAA). In addition, we 

noted concerns in previous language about modifying current law with respect to Medicaid and the State Children’s 

Health Insurance Program (SCHIP) and, in some cases, we 

believe maintaining the current structure of Medicaid and 


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the State Children’s Health Insurance Program (SCHIP) 

preserves access, delivery, efficiency, and quality of services to American Indians. 

We also have some more specific comments on proposals 

we have previously reviewed for comment. 

In the area of behavioral health, proposed title VII provisions provided for the needs of Indian women and youth 

and expands behavioral health services to include a much 

needed child sexual abuse and prevention treatment program. The Department supports this effort, but opposes 

language in Sections 704, 706, 711(b) and 712 that requires the establishment or expansion of specific additional 

services. The Department should be given the flexibility to 

provide for all Behavioral Health Programs in a manner 

that supports the local control and priorities of Tribes, and 

to address their specific needs within IHS overall budgetary levels. 

REPORTING REQUIREMENTS

The last version of S. 1057 that we reviewed contained 

various new requirements for reporting to Congress, including requirements for specific information to be included within the President’s Budget and a new annual report to Congress by the Centers for Medicare & Medicaid 

Services and the IHS on Indians served by Social Security 

Act health benefit programs. The IHS, CMS, and HHS will 

work with Congress to provide the most complete and relevant information on IHS programs, activities, and performance and other Indian health matters. However, we 

recommend striking language that requires additional 

specificity about what should be included in the President’s budget request and new requirements for annual reports. 

FACILITIES

Sanitation facilities construction is conducted in 38 

States with Federally recognized Tribes who take ownership of the facilities to operate and maintain them once 

completed. IHS and Tribes operate 49 hospitals, 247 

health centers, 5 school health centers, over 2000 units of 

staff housing, and 309 health stations, satellite clinics, and 

Alaska village clinics supporting the delivery of health 

care to Indian people. 

HEALTH CARE FACILITIES NEEDS ASSESSMENT & REPORT

One provision in last year’s bill, section 301(d)(1), required Government Accountability Office (GAO) to complete a report, after consultation with Tribes, on the needs 

for health care facilities construction, including renovation 

and expansion needs. However, efforts are currently underway to develop a complete description of need similar 

to what would have been required by the bill. The IHS 

plan is to base our future facilities construction priority 

system methodology application on a more complete listing 


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of tribal and Federal facilities needs for delivery of health 

care services funded through the IHS. We will continue to 

explore with the Tribes less resource intensive means for 

acquiring and updating the information that would be required in these reports. 

We recommend the deletion of the reference to the Government Accountability Office undertaking the report because it would be redundant of and a setback for IHS’s 

current efforts to develop an improved facilities construction methodology. 

RETROACTIVE FUNDING OF JOINT VENTURE CONSTRUCTION

PROJECTS

In last year’s bill, section 311(a)(1) would permit a tribe 

that has ‘‘begun or substantially completed’’ the process of 

acquisition of a facility to participate in the Joint Venture 

Program, regardless of government involvement or lack 

thereof in the facility acquisition. A Joint Venture Program agreement implies that all parties have participated 

in the development of a plan and have arrived at some 

kind of consensus regarding the actions to be taken. By 

permitting a tribe that has ‘‘begun or substantially completed’’ the process of acquisition or construction, the proposed provisions could force IHS to commit the government to support already completed actions that have not 

included the government in the review and approval process. We are concerned that this language could put the 

government in the position of accepting space that is inefficient or ineffective to operate. We, therefore, would oppose 

such a provision. 

SANITATION FACILITIES DEFICIENCY DEFINITIONS

Another section 302(h)(4) would provide ambiguous definitions of the sanitation deficiencies used to identify and 

prioritize water and sewer projects in Indian country. As 

previously proposed ‘‘deficiency level III’’ could be interpreted to mean all methods of service delivery (including 

methods where water and sewer service is provided by 

hauling rather than through piping systems directly into 

the home) are adequate to meet the level III requirements 

and only the operating condition, such as frequent service 

interruptions, makes that facility deficient. This description assumes that water haul delivery systems and piped 

systems provide a similar level of service. We believe it is 

important to distinguish between the two. 

In addition, the definition for deficiency level V and deficiency level IV, though phrased differently, have essentially the same meaning. Level IV should refer to an individual home or community lacking either water or wastewater facilities, whereas, level V should refer to an individual home or community lacking both water and wastewater facilities. 

We recommend retaining current law to distinguish the 

various levels of deficiencies which determine the allocation of existing resources. 


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THRESHOLD CRITERIA FOR SMALL AMBULATORY PROGRAM

Yet another Section 305(b)(1) would amend current law 

to set two minimum thresholds for the Small Ambulatory 

Program—one for number of patient visits and another for 

the number of eligible Indians. In order to be eligible for 

the Small Ambulatory Program under the previously proposed criteria, a facility must provide at least 150 patient 

visits annually in a service area with no fewer than 1,500 

eligible Indians. Aside from the fact that these are both 

minimum thresholds and so somewhat contradictory, the 

proposed provisions would make implementation difficult. 

First, the IHS cannot validate patient visits unless the applicant participates in the Resource Patient Management 

System (RPMS). Since some tribes do not participate in 

the RPMS, it is difficult to ensure a fair evaluation of all 

applicants. Second, the term ‘‘eligible Indians’’ refers to the 

census population figures, which cannot be verified, since 

they are based on the individual’s statement regarding 

ethnicity. 

NEW NEGOTIATED RULEMAKING AND CONSULTATION

REQUIREMENTS

In addition, we are concerned about the requirements for 

negotiated rulemaking and increased requirements for consultation in the bill because of the high cost and staff time 

associated with this approach. We are committed to our 

on-going consultation with Tribes under current Executive 

Orders, as well as using the authority of Chapter V of title 

5, United States Code (commonly known as the Administrative Procedures Act) to promulgate regulations where 

necessary to carry out IHCIA. 

The comments expressed today in this testimony do not 

represent a comprehensive list of our current concerns. 

And, we will be reviewing legislation introduced in this 

Congress for any provisions that might be addressed in the 

future. 

I reiterate our commitment to working with you to reauthorize the Indian Health Care Improvement Act, and the 

strengthening of Indian health care programs. And we will 

continue to work with the Committee, other Committees of 

Congress, and representatives of Indian country to develop 

a bill that all stakeholders in these important programs 

can support. Again, I appreciate the opportunity to appear 

before you today to discuss reauthorization of the ‘‘Indian 

Health Care Improvement Act’’ and I will answer any 

questions that you may have at this time. Thank you. 

COST ESTIMATES

The Congressional Budget Office prepared a cost estimate for S. 

1200, dated June 8, 2007. However, an error was made in that estimate, so a revised estimate was sent to the Committee on September 11, 2007, which follows. 


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S. 1200—Indian Health Care Improvement Act Amendments of 

2007 

Summary: S. 1200 would authorize the appropriation of such 

sums as are necessary through 2017 for activities under the Indian 

Health Care Improvement Act, the primary authorizing legislation 

for the Indian Health Service (IHS). The bill also contains specific 

authorizations for a program to encourage Indians to pursue careers related to behavioral health, a demonstration project to provide suicide prevention services, a commission on Indian health 

care, and administrative costs for a new nonprofit corporation. Enacting the bill also would affect direct spending, primarily through 

provisions affecting the Medicaid program. 

CBO estimates that implementing S. 1200 would have discretionary costs of $2.7 billion in 2008, about $16 billion over the 

2008–2012 period, and about $35 billion over the 2008–2017 period, 

assuming appropriation of the necessary amounts. We also estimate that enacting the bill would increase direct spending by $9 

million in 2008, $53 million over the 2008–2012 period, and $129 

million over the 2008–2017 period. 

S. 1200 would preempt state licensing laws in certain cases, and 

this preemption would be an intergovernmental mandate as defined in the Unfunded Mandates Reform Act (UMRA); however, 

CBO estimates that the costs of that mandate would be small and 

would not approach the threshold established in UMRA ($66 million in 2007, adjusted annually for inflation). The bill also would 

place new requirements on Medicaid that would result in additional spending of about $80 million over the 2008–2017 period. 

Those requirements, however, would not be intergovernmental 

mandates as defined by UMRA. Other provisions of the bill would 

benefit tribal governments by establishing new or expanding existing programs for Indian health care. This bill contains no privatesector mandates as defined in UMRA. 

Estimated cost to the Federal Government: The estimated budgetary impact of S. 1200 is summarized in Table 1. The costs of this 

legislation fall within budget function 550 (health). 

TABLE 1.—ESTIMATED BUDGETARY EFFECTS OF S. 1200 

By fiscal year, in millions of dollars— 

2008 2009 2010 2011 2012 

CHANGES IN SPENDING SUBJECT TO APPROPRIATION 

Estimated Authorization Level ...................................................................... 3,257 3,326 3,402 3,481 3,558 

Estimated Outlays ......................................................................................... 2,682 3,141 3,310 3,449 3,534 

CHANGES IN DIRECT SPENDING a

Estmated Budget Authority ........................................................................... 9 10 11 12 12 

Estimated Outlays ......................................................................................... 9 10 11 12 12 

a Direct spending changes through 2017 are shown in Table 3. 

Basis of estimate: For the purpose of this estimate, CBO assumes 

that S. 1200 will be enacted near the start of fiscal year 2008 and 

that the necessary amounts will be appropriated for each year. 

Spending subject to appropriation 

The estimated effects of S. 1200 on spending subject to appropriation for the next five years are detailed in Table 2. ImpleVerDate Aug 31 2005 01:51 Oct 27, 2007 Jkt 069010 PO 00000 Frm 00092 Fmt 6659 Sfmt 6602 E:\HR\OC\SR197.XXX SR197

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menting the legislation would result in discretionary costs of about 

$16 billion over the 2008–2012 period. Because the bill would authorize funding through 2017, such discretionary cost would continue, with an estimated cost of about $35 billion over the 2008– 2017 period. 

TABLE 2.—ESTIMATED EFFECTS OF S. 1200 ON DISCRETIONARY SPENDING 

By fiscal year, in millions of dollars—

2007 2008 2009 2010 2011 2012 

SPENDING SUBJECT TO APPROPRIATION 

IHS Spending Under Current Law a

Budget Authority .................................................................. 3,169 0 0 0 0 0 

Estimated Outlays ............................................................... 3,203 553 164 72 12 2 

Proposed Changes: 

Existing Indian Health Service Activities: 

Estimated Authorization Level .................................... 0 3,247 3,320 3,396 3,475 3,554 

Estimated Outlays ...................................................... 0 2,679 3,134 3,303 3,443 3,529 

Recruitment Program for Behavioral Health Careers: 

Authorization Level ..................................................... 0 3 3 3 3 3 

Estimated Outlays ...................................................... 0 2 3 3 3 3 

Mental Health Demonstration Project: 

Authorization Level ..................................................... 0 2 2 2 2 0 

Estimated Outlays ...................................................... 0 * 1 2 2 1 

Commission on Indian Health Care: 

Authorization Level ..................................................... 0 4 0 0 0 0 

Estimated Outlays ...................................................... 0 1 2 1 0 0 

Native American Health and Wellness Foundation: 

Authorization Level ..................................................... 0 1 1 1 1 1 

Estimated Outlays ...................................................... 0 * 1 1 1 1 

Total Changes: 

Estimated Authorization Level ........................... 0 3,257 3,326 3,402 3,481 3,558 

Estimated Outlays ............................................. 0 2,682 3,141 3,310 3,449 3,534 

Spending Under S. 1200 

Estimated Authorization Level a .......................................... 3,169 3,257 3,326 3,402 3,481 3,558 

Estimated Outlays ............................................................... 3,203 3,235 3,305 3,382 3,461 3,536 

a.The 2007 level is the amount appropriated for that year for IHS. 

*Note: *=less than $500,000. 

Existing Indian Health Service Activities. S. 1200 would authorize the appropriation of such sums as are necessary for the Indian 

Health Service through 2017. The agency’s responsibilities under 

the bill would be broadly similar to those in current law. In 2007, 

the agency received an appropriation of $3.2 billion. CBO’s estimate of the authorized level for IHS programs is the appropriated 

amount for 2007 adjusted for inflation in later years. (That level 

would grow to nearly $4 billion by 2017.) The estimated outlays reflect historical spending patterns for IHS activities. 

Recruitment Program for Behavioral Health Careers. Section 105 

of the bill would authorize the appropriation of $2.7 million annually through 2017 for grants to develop and maintain programs 

that encourage Indians to pursue careers in a field related to behavioral health. Assuming the appropriation of the authorized 

amounts, CBO estimates that implementing this provision would 

cost $2 million in 2008, $13 million over the 2008–2012 period, and 

$26 million over the 2008–2017 period. 

Mental Health Demonstration Project. Section 708 would authorize the appropriation of $1.5 million annually for fiscal years 2008 

through 2011 for grants to examine the feasibility of using telecommunication technology to provide suicide prevention services to 

Indians. Assuming the appropriation of the authorized amounts, 


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CBO estimates that implementing this provision would cost less 

than $500,000 in 2008 and about $6 million over the 2008–2012 period. 

Commission on Indian Health Care. Section 814 would authorize 

the appropriation of $4 million for a commission that would examine how the federal government provides health care services to Indians. The members of the commission would have to be appointed 

within eight months of the bill’s enactment and would be required 

to submit a final report to the Congress no later than 18 months 

after that. Assuming the appropriation of the authorized amount, 

CBO estimates that implementing this provision would cost $1 million in 2008, $2 million in 2009, and $1 million in 2010. 

Native American Health and Wellness Foundation. S. 1200 

would establish a charitable and nonprofit corporation called the 

Native American Health and Wellness Foundation to assist federal, 

state, tribal, and other entities in efforts to further health and 

wellness activities and opportunities for Indians. The bill would authorize the appropriation of $500,000 annually for the foundation’s 

administrative expenses; this amount would be adjusted in later 

years for inflation. Assuming the appropriation of the authorized 

amounts, CBO estimates that implementing this provision would 

cost less than $500,000 in 2008 and about $2 million over the 

2008–2012 period. 

Direct spending 

S. 1200 contains several provisions, primarily related to the Medicaid program, that would affect direct spending. The bill’s estimated effects on direct spending are shown in Table 3. Overall, 

CBO estimates that enacting the bill would increase direct spending by $9 million in 2008 and $129 million over the 2008–2017 period. 


bajohnson on PROD1PC71 with REPORTS
TABLE 3.

—ESTIMATED EFFECTS OF S. 1200 ON DIRECT SPENDING 

By fiscal year, in millions of dollars

—

2008 2009 201O 2011 2012 2013 2014 2015 2016 2017 2008

201

CHANGES IN DIRECT SPENDING 

Exemption from Medicaid Cost Sharing and Premiums: 

Estimated Budget Authority .................................................................................................................. 5 6 6 7 7 8 8 9 9 10 Estimated Outlays ................................................................................................................................. 5 6 6 7 7 8 8 9 9 10 

Consultation with Indian Health Programs: 

Estimated Budget Authority .................................................................................................................. * * 1 1 1 1 1 1 1 1 Estimated Outlays ................................................................................................................................. * * 1 1 1 1 1 1 1 1 

Medicaid Managed Care Provisions: 

Estimated Budget Authority .................................................................................................................. 3 3 4 4 4 5 5 5 6 6 Estimated Outlays ................................................................................................................................. 3 3 4 4 4 5 5 5 6 6 

Scholarship and Loan Repayment Recovery Fund: 

Estimated Budget Authority .................................................................................................................. * * * * * * * * * * Estimated Outlays ................................................................................................................................. * * * * * * * * * * 

Total Changes: 

Estimated Budget Authority .................................................................................................................. 9 10 11 12 12 14 14 15 16 17 Estimated Outlays ................................................................................................................................. 9 10 11 12 12 14 14 15 16 17 

* = costs savings of less than $500,000. Notes: Components may not sum to totals because of rounding. 


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IHS-funded health programs are commonly divided into three 

groups: those operated directly by the Indian Health Service, those 

operated by tribes and tribal organizations under self-governance 

agreements, and those operated by urban Indian organizations. For 

this estimate, they are referred to collectively as Indian health programs. 

Exemption from Medicaid Cost Sharing and Premiums. Section 

204 would prohibit Medicaid programs from charging premiums or 

other cost-sharing payments to Indians for services that are provided directly or upon referral by Indian health programs. The provision also would prohibit states from reducing payments to providers for those services by the amount of cost sharing that Indians 

otherwise would pay. 

CBO anticipates that this provision’s budgetary effect would 

stem largely from eliminating cost sharing for referral services. 

Current law already prohibits Indian health programs from charging cost sharing to Indians who use their services. In addition, 

Medicaid pays almost all facilities operated by IHS and tribes 

based on an all-inclusive rate that is not reduced to account for any 

cost sharing that Indians would otherwise have to pay. Finally, 

very few states charge premiums to their Medicaid enrollees. 

Using Medicaid administrative data, CBO estimates that about 

280,000 Indians are Medicaid recipients who also use IHS, and 

that federal Medicaid spending on affected services would be about 

$225 per person annually in 2008. The amount of affected spending 

would be relatively low because Medicaid already prohibits cost 

sharing in many instances, such as long-term care services, emergency services, and services for many children and pregnant 

women. For the affected spending, CBO assumes that cost-sharing 

payments by individuals equal 2 percent of total spending—Medicaid law limits the extent to which states can impose cost sharing 

and that eliminating cost sharing would increase total spending by 

about 5 percent as individuals consume more services. Overall, 

CBO estimates that the provision would increase federal Medicaid 

spending by $5 million in 2008 and by $74 million over the 2008–

2017 period. 

Consultation with Indian Health Programs. Section 206 would 

encourage state Medicaid programs to consult regularly with Indian health programs on outstanding Medicaid issues by allowing 

states to receive federal matching funds for the cost of those consultations. Those costs would be treated as an administrative expense under Medicaid and divided equally between the federal government and the states. CBO anticipates that a small number of 

states would take advantage of this provision, increasing federal 

Medicaid spending by less than $500,000 in 2008 and by $7 million 

over the 2008–2017 period. 

Medicaid Managed Care Provisions. Section 208 would make several changes to improve the ability of Indian health programs to receive payments for Indians who receive Medicaid benefits through 

managed care arrangements. Those changes include: 

• Managed care organizations (MCOs) would have to pay Indian 

health programs at least the rates used for non-preferred providers. 

States also would have the option of making those payments directly to Indian health programs. 


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97 

• MCOs would have to accept claims submitted by Indian health 

programs instead of requiring enrollees to submit claims personally. • Some requirements that MCOs must now meet to participate 

in Medicaid would be waived or modified for Indian health programs that seek to operate as MCOs. (For example, MCOs run by 

Indian health programs would be able to limit enrollment to Indians only.) • States would be required to offer contracts to Indian health 

programs seeking to operate their own MCOs. 

Based on administrative data on Medicaid enrollment and spending for Indians who receive benefits via managed care, CBO estimates that those provisions would increase federal Medicaid spending by $3 million in 2008 and $45 million over the 2008–2017 period. We anticipate that the additional costs would be relatively 

modest because some states already use similar rules in their Medicaid managed care programs and Indian health programs would 

have a limited interest in participating as MCOs. 

Scholarship and Loan Repayment Recovery Fund. S. 1200 would 

allow the Secretary of Health and Human Services to spend 

amounts collected for breach of contract from recipients of certain 

IHS scholarships. Under current law, those funds are deposited in 

the Treasury and not spent. Because the Secretary’s ability to 

spend those funds would not be subject to appropriation, the provision would increase direct spending. Based on historical information from IHS, CBO estimates that the provision would increase 

spending by less than $500,000 a year, but would total about $4 

million over the 2008–2017 period. 

Estimated impact on state, local, and tribal governments: 

Intergovernmental mandates 

S. 1200 would preempt state licensing laws in cases where a 

health care professional is licensed in one state but is performing 

services in another state under a contract or compact with a tribal 

health program. This preemption would be an intergovernmental 

mandate as defined in the UMRA; however, CBO estimates that 

the loss of any licensing fees resulting from the mandate would be 

small and would not approach the threshold established in UMRA 

($66 million in 2007, adjusted annually for inflation). 

Other impacts 

S. 1200 would reauthorize and expand grant and assistance programs available to Indian tribes, tribal organizations, and urban 

Indian organizations for a range of health care programs, including 

prevention, treatment, and ongoing care. The bill also would allow 

IHS and tribal entities to share facilities, and it would authorize 

joint ventures between IHS and Indian tribes or tribal organizations for the construction and operation of health facilities. The bill 

would authorize funding for a variety of health services including 

hospice care, long-term care, public health services, and home and 

community-based services. 

The bill would prohibit states from charging cost sharing or premiums in the Medicaid program to Indians who receive services or 

benefits through an Indian health program. CBO estimates that 

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98 

ing by states of about $80 million over the 2008–2017 period. Those 

requirements, however, would not be intergovernmental mandates 

as defined by UMRA because Medicaid provides states with significant flexibility to make programmatic adjustments to accommodate 

the changes. Some tribal entities, particularly those operating managed care systems, may realize some savings as a result of these 

provisions. 

Estimated impact on the private sector: This bill contains no private-sector mandates as defined in UMRA. 

Previous CBO estimate: This estimate supersedes the cost estimate for S. 1200 that CBO transmitted on June 8, 2007. Our June 

8 cost estimate erroneously indicated that section 204 of the bill 

(exempting Indians from paying certain types of cost sharing and 

premiums) would apply to both Medicaid and the State Children’s 

Health Insurance Program. The provision would apply only to Medicaid, and we have lowered our estimate of the bill’s impact on direct spending by $4 million over the 2008–2012 period and by $8 

million over the 2008–2017 period as a result. 

On September 11, 2007, CBO also issued a revised estimate for 

H.R. 1328, the Indian Health Care Improvement Act Amendments 

of 2007, as ordered reported by the House Committee on Natural 

Resources on April 25, 2007. There are only minor differences between the two bills, and CBO’s revised estimates for them are identical. 

Estimate prepared by: Federal Costs: Eric Rollins; Impact on 

State, Local, and Tribal Governments: Lisa Ramirez-Branum; Impact on the Private Sector: Paige Shevlin. 

Estimate approved by: Peter H. Fontaine, Assistant Director for 

Budget Analysis. 

CHANGES IN EXISTING LAW

In accordance with subsection 12 of rule XXVI of the Standing 

Rules of the Senate, changes in existing law made by the bill S. 

1200, as ordered reported, are shown as follows (existing law proposed to be omitted is enclosed in black brackets, new language to 

be added in italic, existing law to which no change is proposed is 

shown in roman): 

UNITED STATES CODE ANNOTATED 

TITLE 25. INDIANS 

CHAPTER 18—INDIAN HEALTH CARE 

ø§1601. Congressional¿ 

S 1200 IS 

110th CONGRESS 

1st Session 

S. 1200 

To amend the Indian Health Care Improvement Act to revise and 

extend that Act. 

IN THE SENATE OF THE UNITED STATES 

April 24, 2007 


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99 

Mr. DORGAN (for himself, Mrs. BOXER, Mr. REID, Ms. CANTWELL, Mr. JOHNSON, Mr. TESTER, Mr. INOUYE, Mr. DOMENICI, Mr. BINGA- MAN, Mr. BAUCUS, Ms. KLOBUCHAR, Mr. THOMAS, Mr. OBAMA, and 

Ms. MURKOWSKI) introduced the following bill; which was read 

twice and referred to the Committee on Indian Affairs 

A BILL 

To amend the Indian Health Care Improvement Act to revise and 

extend that Act. 

Be it enacted by the Senate and House of Representatives of the 

United States of America in Congress assembled, 

SECTION 1. SHORT TITLE; TABLE OF CONTENTS. 

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

Care Improvement Act Amendments of 2007’’. (b) TABLE OF CONTENTS.—The table of contents of this Act is as 

follows: 

Sec. 1. Short title; table of contents. 

TITLE I—AMENDMENTS TO INDIAN LAWS 

Sec. 101. Indian Health Care Improvement Act amended. 

Sec. 102. Soboba sanitation facilities. 

Sec. 103. Native American Health and Wellness Foundation. 

TITLE II—IMPROVEMENT OF INDIAN HEALTH CARE PROVIDED UNDER 

THE SOCIAL SECURITY ACT 

Sec. 201. Expansion of payments under Medicare, Medicaid, and SCHIP for all covered services furnished by Indian Health Programs. 

Sec. 202. Increased outreach to Indians under Medicaid and SCHIP and improved 

cooperation in the provision of items and services to Indians under Social Security Act health benefit programs. 

Sec. 203. Additional provisions to increase outreach to, and enrollment of, Indians 

in SCHIP and Medicaid. 

Sec. 204. Premiums and cost sharing protections under Medicaid, eligibility determinations under Medicaid and SCHIP, and protection of certain Indian 

property from Medicaid estate recovery. 

Sec. 205. Nondiscrimination in qualifications for payment for services under Federal health care programs. 

Sec. 206. Consultation on Medicaid, SCHIP, and other health care programs funded 

under the Social Security Act involving Indian Health Programs and 

Urban Indian Organizations. 

Sec. 207. Exclusion waiver authority for affected Indian Health Programs and safe 

harbor transactions under the Social Security Act. 

Sec. 208. Rules applicable under Medicaid and SCHIP to managed care entities 

with respect to Indian enrollees and Indian health care providers and 

Indian managed care entities. 

Sec. 209. Annual report on Indians served by Social Security Act health benefit programs. 

TITLE I—AMENDMENTS TO INDIAN LAWS 

SEC. 101. INDIAN HEALTH CARE IMPROVEMENT ACT AMENDED. 

(a) IN GENERAL.—The Indian Health Care Improvement Act (25 

U.S.C. 1601 et seq.) is amended to read as follows: 

SECTION 1. SHORT TITLE; TABLE OF CONTENTS. 

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

Care Improvement Act’’. 

(b) TABLE OF CONTENTS.—The table of contents for this Act is as 

follows: 

Sec. 1. Short title; table of contents. 

Sec. 2. Findings. 

Sec. 3. Declaration of national Indian health policy. 

Sec. 4. Definitions. 


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100 

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. Scholarship programs for Indian Tribes. 

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. 

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. 

Sec. 122. Tribal Health Program administration. 

Sec. 123. Health professional chronic shortage demonstration programs. 

Sec. 124. National Health Service Corps. 

Sec. 125. Substance abuse counselor educational curricula demonstration programs. 

Sec. 126. Behavioral health training and community education programs. 

Sec. 127. 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. Other authority for provision of 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 and South Dakota as 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. Office of Indian Men’s Health. 

Sec. 226. 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 non-Service funds for renovation. 

Sec. 305. Funding for the construction, expansion, and modernization of small ambulatory care facilities. 

Sec. 306. Indian health care delivery demonstration projects. 

Sec. 307. Land transfer. 


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101 

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

Sec. 309. Study on 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 benefits programs. 

Sec. 402. Grants to and contracts with the Service, Indian Tribes, Tribal Organizations, and Urban Indian Organizations to facilitate outreach, enrollment, and coverage of Indians under Social Security Act health benefit 

programs and other health benefits programs. 

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 under Federal health care programs in qualifications 

for reimbursement for services. 

Sec. 409. Consultation. 

Sec. 410. State Children’s Health Insurance Program (SCHIP). 

Sec. 411. Exclusion waiver authority for affected Indian Health Programs and safe 

harbor transactions under the Social Security Act. 

Sec. 412. Premium and cost sharing protections and eligibility determinations under 

Medicaid and SCHIP and protection of certain Indian property from 

Medicaid estate recovery. 

Sec. 413. Treatment under Medicaid and SCHIP managed care. 

Sec. 414. Navajo Nation Medicaid Agency feasibility study. 

Sec. 415. General exceptions. 

Sec. 416. 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. Division 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. Urban youth treatment center demonstration. 

Sec. 516. Grants for diabetes prevention, treatment, and control. 

Sec. 517. Community Health Representatives. 

Sec. 518. Effective date. 

Sec. 519. Eligibility for services. 

Sec. 520. 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. 


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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. Indian youth telemental health demonstration project. 

Sec. 709. Inpatient and community-based mental health facilities design, construction, and staffing. 

Sec. 710. Training and community education. 

Sec. 711. Behavioral health program. 

Sec. 712. Fetal alcohol disorder programs. 

Sec. 713. Child sexual abuse and prevention treatment programs. 

Sec. 714. Behavioral health research. 

Sec. 715. Definitions. 

Sec. 716. 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 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. Severability provisions. 

Sec. 814. Establishment of National Bipartisan Commission on Indian Health Care. 

Sec. 815. Confidentiality of medical quality assurance records; qualified immunity 

for participants. 

Sec. 816. Appropriations; availability. 

Sec. 817. Authorization of appropriations. 

SEC. 2. FINDINGS. 

Congress makes the following findings: 

øThe Congress finds the following: 

ø(a¿ (1) Federal health services to maintain and improve the 

health of the Indians are consonant with and required by the 

Federal Government’s historical and unique legal relationship 

with, and resulting responsibility to, the American Indian people. 

ø(b¿ (2) A major national goal of the United States is to provide the quantity and quality of health services which will permit the health status of Indians to be raised to the highest possible level and to encourage the maximum participation of Indians in the planning and management of those services. 

ø(c¿ (3) Federal health services to Indians have resulted in 

a reduction in the prevalence and incidence of preventable illnesses among, and unnecessary and premature deaths of, Indians. 

ø(d¿ (4) Despite such services, the unmet health needs of the 

American Indian people are severe and the health status of the 

Indians is far below that of the general population of the 

United States. 

ø§ 1602. Declaration of health objectives¿ 

SEC. 3. DECLARATION OF NATIONAL INDIAN HEALTH POLICY. 

ø(a) The¿ Congress øhereby¿ declares that it is the policy of this 

Nation, in fulfillment of its special trust responsibilities and legal 


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øobligation to the American Indian people,¿ obligations to Indians—

(1) to assure the highest possible health status for Indians 

and øurban¿Urban Indians and to provide all resources necessary to effect that policyø.¿; 

ø(b) It is the intent of the Congress that the Nation meet the following health status objectives with respect to Indians and urban 

Indians by the year 2000: 

ø(1) Reduce coronary heart disease deaths to a level of no 

more than 100 per 100,000. 

ø(2) Reduce the prevalence of overweight individuals to no 

more than 30 percent. 

ø(3) Reduce the prevalence of anemia to less than 10 percent 

among children aged 1 through 5. 

ø(4) Reduce the level of cancer deaths to a rate of no more 

than 130 per 100,000. 

ø(5) Reduce the level of lung cancer deaths to a rate of no 

more than 42 per 100,000. 

ø(6) Reduce the level of chronic obstructive pulmonary disease related deaths to a rate of no more than 25 per 100,000. 

ø(7) Reduce deaths among men caused by alcohol-related 

motor vehicle crashes to no more than 44.8 per 100,000. 

ø(8) Reduce cirrhosis deaths to no more than 13 per 100,000. 

ø(9) Reduce drug-related deaths to no more than 3 per 

100,000. 

ø(10) Reduce pregnancies among girls aged 17 and younger 

to no more than 50 per 1,000 adolescents. 

ø(11) Reduce suicide among men to no more than 12.8 per 

100,000. 

ø(12) Reduce by 15 percent the incidence of injurious suicide 

attempts among adolescents aged 14 through 17. 

ø(13) Reduce to less than 10 percent the prevalence of mental disorders among children and adolescents. 

ø(14) Reduce the incidence of child abuse or neglect to less 

than 25.2 per 1,000 children under age 18. 

ø(15) Reduce physical abuse directed at women by male partners to no more than 27 per 1,000 couples. 

ø(16) Increase years of healthy life to at least 65 years. 

ø(17) Reduce deaths caused by unintentional injuries to no 

more than 66.1 per 100,000. 

ø(18) Reduce deaths caused by motor vehicle crashes to no 

more than 39.2 per 100,000. 

ø(19) Among children aged 6 months through 5 years, reduce 

the prevalence of blood lead levels exceeding 15ug/dl and reduce to zero the prevalence of blood lead levels exceeding 25 

ug/dl. 

ø(20) Reduce dental caries (cavities) so that the proportion of 

children with one or more caries (in permanent or primary 

teeth) is no more than 45 percent among children aged 6 

through 8 and no more than 60 percent among adolescents 

aged 15. 

ø(21) Reduce untreated dental caries so that the proportion 

of children with untreated caries (in permanent or primary 

teeth) is no more than 20 percent among children aged 6 


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104 

through 8 and no more than 40 percent among adolescents 

aged 15. 

ø(22) Reduce to no more than 20 percent the proportion of 

individuals aged 65 and older who have lost all of their natural 

teeth. 

ø(23) Increase to at least 45 percent the proportion of individuals aged 35 to 44 who have never lost a permanent tooth 

due to dental caries or periodontal disease. 

ø(24) Reduce destructive periodontal disease to a prevalence 

of no more than 15 percent among individuals aged 35 to 44. 

ø(25) Increase to at least 50 percent the proportion of children who have received protective sealants on the occlusal 

(chewing) surfaces of permanent molar teeth. 

ø(26) Reduce the prevalence of gingivitis among individuals 

aged 35 to 44 to no more than 50 percent. 

ø(27) Reduce the infant mortality rate to no more than 8.5 

per 1,000 live births. 

ø(28) Reduce the fetal death rate (20 or more weeks of gestation) to no more than 4 per 1,000 live births plus fetal deaths. 

ø(29) Reduce the maternal mortality rate to no more than 

3.3 per 100,000 live births. 

ø(30) Reduce the incidence of fetal alcohol syndrome to no 

more than 2 per 1,000 live births. 

ø(31) Reduce stroke deaths to no more than 20 per 100,000. 

ø(32) Reverse the increase in end-stage renal disease (requiring maintenance dialysis or transplantation) to attain an incidence of no more than 13 per 100,000. 

ø(33) Reduce breast cancer deaths to no more than 20.6 per 

100,000 women. 

ø(34) Reduce deaths from cancer of the uterine cervix to no 

more than 1.3 per 100,000 women. 

ø(35) Reduce colorectal cancer deaths to no more than 13.2 

per 100,000. 

ø(36) Reduce to no more than 11 percent the proportion of 

individuals who experience a limitation in major activity due 

to chronic conditions. 

ø(37) Reduce significant hearing impairment to a prevalence 

of no more than 82 per 1,000. 

ø(38) Reduce significant visual impairment to a prevalence of 

no more than 30 per 1,000. 

ø(39) Reduce diabetes-related deaths to no more than 48 per 

100,000. 

ø(40) Reduce diabetes to an incidence of no more than 2.5 

per 1,000 and a prevalence of no more than 62 per 1,000. 

ø(41) Reduce the most severe complications of diabetes as 

follows: 

ø(A) End-stage renal disease, 1.9 per 1,000. 

ø(B) Blindness, 1.4 per 1,000. 

ø(C) Lower extremity amputation, 4.9 per 1,000. 

ø(D) Perinatal mortality, 2 percent. 

ø(E) Major congenital malformations, 4 percent. 

ø(42) Confine annual incidence of diagnosed AIDS cases to 

no more than 1,000 cases. 

ø(43) Confine the prevalence of HIV infection to no more 

than 100 per 100,000. 


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105 

ø(44) Reduce gonorrhea to an incidence of no more than 225 

cases per 100,000. 

ø(45) Reduce chlamydia trachomatis infections, as measured 

by a decrease in the incidence of nongonococcal urethritis to no 

more than 170 cases per 100,000. 

ø(46) Reduce primary and secondary syphilis to an incidence 

of no more than 10 cases per 100,000. 

ø(47) Reduce the incidence of pelvic inflammatory disease, as 

measured by a reduction in hospitalization for pelvic inflammatory disease to no more than 250 per 100,000 women aged 

15 through 44. 

ø(48) Reduce viral hepatitis B infection to no more than 40 

per 100,000 cases. 

ø(49) Reduce indigenous cases of vaccine-preventable diseases as follows: 

ø(A) Diphtheria among individuals aged 25 and younger, 

0. 

ø(B) Tetanus among individuals aged 25 and younger, 0. 

ø(C) Polio (wild-type virus), 0. 

ø(D) Measles, 0. 

ø(E) Rubella, 0. 

ø(F) Congenital Rubella Syndrome, 0. 

ø(G) Mumps, 500. 

ø(H) Pertussis, 1,000. 

ø(50) Reduce epidemic-related pneumonia and influenza 

deaths among individuals aged 65 and older to no more than 

7.3 per 100,000. 

ø(51) Reduce the number of new carriers of viral hepatitis B 

among Alaska Natives to no more than 1 case. 

ø(52) Reduce tuberculosis to an incidence of no more than 5 

cases per 100,000. 

ø(53) Reduce bacterial meningitis to no more than 8 cases 

per 100,000. 

ø(54) Reduce infectious diarrhea by at least 25 percent 

among children. 

ø(55) Reduce acute middle ear infections among children 

aged 4 and younger, as measured by days of restricted activity 

or school absenteeism, to no more than 105 days per 100 children. 

ø(56) Reduce cigarette smoking to a prevalence of no more 

than 20 percent. 

ø(57) Reduce smokeless tobacco use by youth to a prevalence 

of no more than 10 percent. 

ø(58) Increase to at least 65 percent the proportion of parents and caregivers who use feeding practices that prevent 

baby bottle tooth decay. 

ø(59) Increase to at least 75 percent the proportion of mothers who breast feed their babies in the early postpartum period, and to at least 50 percent the proportion who continue 

breast feeding until their babies are 5 to 6 months old. 

ø(60) Increase to at least 90 percent the proportion of pregnant women who receive prenatal care in the first trimester of 

pregnancy. 

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priate interval, all of the screening and immunization services 

and at least one of the counseling services appropriate for their 

age and gender as recommended by the United States Preventive Services Task Force.¿ 

(2) to raise the health status of Indians and Urban Indians 

to at least the levels set forth in the goals contained within the 

Healthy People 2010 or successor objectives; 

(3) to the greatest extent possible, to allow Indians to set their 

own health care priorities and establish goals that reflect their 

unmet needs; 

ø(c) It is the intent of the Congress that the Nation¿ (4) to 

increase the proportion of all degrees in the health professions 

and allied and associated health øprofession fields awarded to 

Indians to 0.6 percent.¿professions awarded to Indians so that 

the proportion of Indian health professionals in each Service 

Area is raised to at least the level of that of the general population; 

ø(d) The Secretary shall submit to the President, for inclusion in 

each report required to be transmitted to the Congress under section 1671 of this title, a report on the progress made in each area 

of the Service toward meeting each of the objectives described in 

subsection (b) of this section.¿ 

(5) to require meaningful consultation with Indian Tribes, 

Tribal Organizations, and Urban Indian Organizations to implement this Act and the national policy of Indian self-determination; and 

ø§ 1603. Definitions¿ 

(6) to provide funding for programs and facilities operated by 

Indian Tribes and Tribal Organizations in amounts that are 

not less than the amounts provided to programs and facilities 

operated directly by the Service. 

SEC. 4. DEFINITIONS. 

For purposes of this øchapter—¿Act: 

(1) The term ‘‘accredited and accessible’’ means on or near a 

reservation and accredited by a national or regional organization with accrediting authority. 

(2) The term ‘‘Area Office’’ means an administrative entity, 

including a program office, within the Service through which 

services and funds are provided to the Service Units within a 

defined geographic area. 

(3) The term ‘‘Assistant Secretary’’ means the Assistant Secretary for Indian Health. 

(4)(A) The term ‘‘behavioral health’’ means the blending of 

substance (alcohol, drugs, inhalants, and tobacco) abuse and 

mental health prevention and treatment, for the purpose of providing comprehensive services. 

(B) The term ‘‘behavioral health’’ includes the joint development of substance abuse and mental health treatment planning 

and coordinated case management using a multidisciplinary 

approach. 

(5) The term ‘‘California Indians’’ means those Indians who 

are eligible for health services of the Service pursuant to section 

806. 

(6) The term ‘‘community college’’ means—


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(A) a tribal college or university, or 

(B) a junior or community college. 

(7) The term ‘‘contract health service’’ means health services 

provided at the expense of the Service or a Tribal Health Program by public or private medical providers or hospitals, other 

than the Service Unit or the Tribal Health Program at whose 

expense the services are provided. 

ø(a) ‘‘Secretary’’¿ (8) The term ‘‘Department’’ means, unless 

otherwise designated, ømeans the Secretary¿the Department of 

Health and Human Services. 

ø(b) ‘‘Service’’ means the Indian Health Service.¿ 

(9) The term ‘‘disease prevention’’ means the reduction, limitation, and prevention of disease and its complications and reduction in the consequences of disease, including—

(A) controlling—

(i) the development of diabetes; 

(ii) high blood pressure; 

(iii) infectious agents; 

(iv) injuries; 

(v) occupational hazards and disabilities; 

(vi) sexually transmittable diseases; and 

(vii) toxic agents; and 

(B) providing—

(i) fluoridation of water; and 

(ii) immunizations. 

(10) The term ‘‘health profession’’ means allopathic medicine, 

family medicine, internal medicine, pediatrics, geriatric medicine, obstetrics and gynecology, podiatric medicine, nursing, 

public health nursing, dentistry, psychiatry, osteopathy, optometry, pharmacy, psychology, public health, social work, marriage and family therapy, chiropractic medicine, environmental 

health and engineering, allied health professions, and any other 

health profession. 

(11) The term ‘‘health promotion’’ means—

(A) fostering social, economic, environmental, and personal factors conducive to health, including raising public 

awareness about health matters and enabling the people to 

cope with health problems by increasing their knowledge 

and providing them with valid information; 

(B) encouraging adequate and appropriate diet, exercise, 

and sleep; 

(C) promoting education and work in conformity with 

physical and mental capacity; 

(D) making available safe water and sanitary facilities; 

(E) improving the physical, economic, cultural, psychological, and social environment; 

(F) promoting culturally competent care; and 

(G) providing adequate and appropriate programs, which 

may include—

(i) abuse prevention (mental and physical); 

(ii) community health; 

(iii) community safety; 

(iv) consumer health education; 

(v) diet and nutrition; 


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(vi) immunization and other prevention of communicable diseases, including HIV/AIDS; 

(vii) environmental health; 

(viii) exercise and physical fitness; 

(ix) avoidance of fetal alcohol disorders; 

(x) first aid and CPR education; 

(xi) human growth and development; 

(xii) injury prevention and personal safety; 

(xiii) behavioral health; 

(xiv) monitoring of disease indicators between health 

care provider visits, through appropriate means, including Internet-based health care management systems; 

(xv) personal health and wellness practices; 

(xvi) personal capacity building; 

(xvii) prenatal, pregnancy, and infant care; 

(xviii) psychological well-being; 

(xix) reproductive health and family planning; 

(xx) safe and adequate water; 

(xxi) healthy work environments; 

(xxii) elimination, reduction, and prevention of contaminants that create unhealthy household conditions 

(including mold and other allergens); 

(xxiii) stress control; 

(xxiv) substance abuse; 

(xxv) sanitary facilities; 

(xxvi) sudden infant death syndrome prevention; 

(xxvii) tobacco use cessation and reduction; 

(xxviii) violence prevention; and 

(xxix) such other activities identified by the Service, 

a Tribal Health Program, or an Urban Indian Organization, to promote achievement of any of the objectives 

described in section 3(2). 

ø(c) ‘‘Indians’’ or¿ (12) The term ‘‘Indian’’, unless otherwise 

designated, means any person who is a member of an Indian 

øtribe, as defined in subsection (d) of this section,¿ Tribe or is 

eligible for health services under section 806, except that, for 

the purpose of sections ø1612 and 1613 of this title, such terms 

shall mean¿ 102 and 103, the term also means any individual 

who ø(1),¿—

(A)(i) irrespective of whether øhe or she¿ the individual 

lives on or near a reservation, is a member of a tribe, 

band, or other organized group of Indians, including those 

tribes, bands, or groups terminated since 1940 and those 

recognized now or in the future by the State in which they 

resideø,¿; or øwho¿ 

(ii) is a descendant, in the first or second degree, of any 

such memberø, or (2)¿; 

(B) is an Eskimo or Aleut or other Alaska Nativeø, or 

(3)¿; 

(C) is considered by the Secretary of the Interior to be 

an Indian for any purposeø, or (4)¿; or 

(D) is determined to be an Indian under regulations promulgated by the Secretary. 

(13) The term ‘‘Indian Health Program’’ means—


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109 

(A) any health program administered directly by the 

Service; 

(B) any Tribal Health Program; or 

(C) any Indian Tribe or Tribal Organization to which the 

Secretary provides funding pursuant to section 23 of the 

Act of June 25, 1910 (25 U.S.C. 47) (commonly known as 

the ‘‘Buy Indian Act’’). 

(14) The term ‘‘Indian Tribe’’ has the meaning given the term 

in the Indian Self-Determination and Education Assistance Act 

(25 U.S.C. 450 et seq.). 

(15) The term ‘‘junior or community college’’ has the meaning 

given the term by section 312(e) of the Higher Education Act of 

1965 (20 U.S.C. 1058(e)). 

ø(d) ‘‘Indian tribe’’ means any Indian tribe, band, nation, or 

other organized group or community, including any Alaska Native village or group or regional or village corporation as defined in or¿ (16) The term ‘‘reservation’’ means any federally 

recognized Indian Tribe’s reservation, Pueblo, or colony, including former reservations in Oklahoma, Indian allotments, and 

Alaska Native Regions established pursuant to the Alaska Native Claims Settlement Act (ø85 Stat. 688) [¿43 U.S.C.øA 

§ 1601 et seq.], which is recognized as eligible for the special 

programs and services provided by the United States to Indians because of their status as Indians.¿ 1601 et seq.). 

ø(e) ‘‘Tribal organization’’ means the elected governing body of 

any Indian tribe or any legally established organization of Indians 

which is controlled by one or more such bodies or by a board of directors elected or selected by one or more such bodies (or elected 

by the Indian population to be served by such organization) and 

which includes the maximum participation of Indians in all phases 

of its activities. 

ø(f) ‘‘Urban Indian’’ means any individual who resides in an 

urban center, as defined in subsection (g) hereof, and who meets 

one or more of the four criteria in subsection (c)(1) through (4) of 

this section.¿ 

(17) The term ‘‘Secretary’’, unless otherwise designated, means 

the Secretary of Health and Human Services. 

(18) The term ‘‘Service’’ means the Indian Health Service. 

(19) The term ‘‘Service Area’’ means the geographical area 

served by each Area Office. 

(20) The term ‘‘Service Unit’’ means an administrative entity 

of the Service, or a Tribal Health Program through which services are provided, directly or by contract, to eligible Indians 

within a defined geographic area. 

(21) The term ‘‘telehealth’’ has the meaning given the term in 

section 330K(a) of the Public Health Service Act (42 U.S.C. 

254c–16(a)). 

(22) The term ‘‘telemedicine’’ means a telecommunications 

link to an end user through the use of eligible equipment that 

electronically links health professionals or patients and health 

professionals at separate sites in order to exchange health care 

information in audio, video, graphic, or other format for the 

purpose of providing improved health care services. 


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(23) The term ‘‘tribal college or university’’ has the meaning 

given the term in section 316(b)(3) of the Higher Education Act 

(20 U.S.C. 1059c(b)(3)). 

(24) The term ‘‘Tribal Health Program’’ means an Indian 

Tribe or Tribal Organization that operates any health program, 

service, function, activity, or facility funded, in whole or part, 

by the Service through, or provided for in, a contract or compact with the Service under the Indian Self-Determination and 

Education Assistance Act (25 U.S.C. 450 et seq.). 

(25) The term ‘‘Tribal Organization’’ has the meaning given 

the term in the Indian Self-Determination and Education Assistance Act (25 U.S.C. 450 et seq.). 

ø(g)¿ (26) ø‘‘¿The term ‘‘Urban øcenter’’¿ Center’’ means any 

community which has a sufficient øurban¿ Urban Indian population with unmet health needs to warrant assistance under 

øsubchapter IV¿ title V of this øchapter¿ Act, as determined by 

the Secretary. 

(27) The term ‘‘Urban Indian’’ means any individual who resides in an Urban Center and who meets 1 or more of the following criteria: 

(A) Irrespective of whether the individual lives on or near 

a reservation, the individual is a member of a tribe, band, 

or other organized group of Indians, including those tribes, 

bands, or groups terminated since 1940 and those tribes, 

bands, or groups that are recognized by the States in which 

they reside, or who is a descendant in the first or second 

degree of any such member. 

(B) The individual is an Eskimo, Aleut, or other Alaska 

Native. 

(C) The individual is considered by the Secretary of the 

Interior to be an Indian for any purpose. 

(D) The individual is determined to be an Indian under 

regulations promulgated by the Secretary. 

ø(h)¿ (28) The term ‘‘Urban Indian øorganization’’¿ Organization’’ means a nonprofit corporate body that (A) is situated in 

an øurban center,¿ Urban Center; (B) is governed by an 

øurban¿ Urban Indian-controlled board of directorsø, and providing¿; (C) provides for the ømaximum¿ participation of all interested Indian groups and individualsø, which body¿; and (D) 

is capable of legally cooperating with other public and private 

entities for the purpose of performing the activities described 

in section ø1653¿ 503(a). 

TITLE I—INDIAN HEALTH, HUMAN RESOURCES, AND 

DEVELOPMENT 

SEC. 101. PURPOSE. 

The purpose of this titleø.¿ 

ø(i) ‘‘Area office’’ means an administrative entity including a program office, within the Indian Health Service through which services and funds are provided to the service units within a defined 

geographic area. 

ø(j) ‘‘Service unit’’ means— ø(1) an administrative entity within the Indian Health Service, or 


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ø(2) a tribe or tribal organization operating health care programs or facilities with funds from the Service under the Indian Self-Determination Act [25 U.S.C.A. § 450f et seq.], 

through which services are provided, directly or by contract, to 

the eligible Indian population within a defined geographic 

area. 

ø(k) ‘‘Health promotion’’ includes—

ø(1) cessation of tobacco smoking, 

ø(2) reduction in the misuse of alcohol and drugs, 

ø(3) improvement of nutrition, 

ø(4) improvement in physical fitness, 

ø(5) family planning, 

ø(6) control of stress, and 

ø(7) pregnancy and infant care (including prevention of fetal 

alcohol syndrome). 

ø(l) ‘‘Disease prevention’’ includes—

ø(1) immunizations, 

ø(2) control of high blood pressure, 

ø(3) control of sexually transmittable diseases, 

ø(4) prevention and control of diabetes, 

ø(5) control of toxic agents, 

ø(6) occupational safety and health, 

ø(7) accident prevention, 

ø(8) fluoridation of water, and 

ø(9) control of infectious agents. 

ø(m) ‘‘Service area’’ means the geographical area served by each 

area office. 

ø(n) ‘‘Health profession’’ means allopathic medicine, family medicine, internal medicine, pediatrics, geriatric medicine, obstetrics 

and gynecology, podiatric medicine, nursing, public health nursing, 

dentistry, psychiatry, osteopathy, optometry, pharmacy, psychology, 

public health, social work, marriage and family therapy, chiropractic medicine, environmental health and engineering, an allied 

health profession, or any other health profession. 

ø(o) ‘‘Substance abuse’’ includes inhalant abuse. 

ø(p) ‘‘FAE’’ means fetal alcohol effect. 

ø(q) ‘‘FAS’’ means fetal alcohol syndrome. 

ø§ 1611. Congressional statement of purpose The purpose of this 

subchapter¿ is to increase, to the maximum extent feasible, the 

number of Indians entering the health professions and providing 

health services, and to assure an øadequate¿ optimum supply of 

health professionals to the øService, Indian tribes, tribal organizations, and urban Indian organizations¿ Indian Health Programs 

and Urban Indian Organizations involved in the provision of 

health øcare¿ services to øIndian people¿ Indians. 

ø§ 1612. Health professions recruitment program for Indians¿ 

SEC. 102. HEALTH PROFESSIONS RECRUITMENT PROGRAM FOR INDIANS. 

ø(a) Grants for education and training¿ 

(a) IN GENERAL.—The Secretary, acting through the Service, 

shall make grants to public or nonprofit private health or educational entities, Tribal Health Programs, or Urban Indian øtribes 


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112 

or tribal organizations¿ Organizations to assist such entities in 

meeting the costs of—

(1) identifying Indians with a potential for education or 

training in the health professions and encouraging and assisting them—

(A) to enroll in courses of study in such health professions; or 

(B) if they are not qualified to enroll in any such courses 

of study, to undertake such postsecondary education or 

training as may be required to qualify them for enrollment; 

(2) publicizing existing sources of financial aid available to 

Indians enrolled in any course of study referred to in paragraph (1) øof this subsection¿ or who are undertaking training 

necessary to qualify them to enroll in any such course of study; 

or 

(3) establishing other programs which the Secretary determines will enhance and facilitate the enrollment of Indians in, 

and the subsequent pursuit and completion by them of, courses 

of study referred to in paragraph (1) øof this subsection¿. 

ø(b) Application for grant; submittal and approval; preference; 

payment¿ 

(b) GRANTS.—

ø(1) No¿ (1) Application.—The Secretary shall not make a 

grant ømay be made¿ under this section unless an application 

øtherefor¿ has been submitted to, and approved by, the Secretary. Such application shall be in such form, submitted in 

such manner, and contain such information, as the Secretary 

shall by regulation prescribe pursuant to this Act. The Secretary shall give a preference to applications submitted by øIndian tribes or tribal organizations¿ Tribal Health Programs or 

Urban Indian Organizations. 

(2) AMOUNT OF GRANTS; PAYMENT.—The amount of øany¿ a 

grant under this section shall be determined by the Secretary. 

Payments pursuant to øgrants under¿ this section may be 

made in advance or by way of reimbursement, and at such intervals and on such conditions as øthe Secretary finds necessary¿ provided for in regulations issued pursuant to this Act. 

To the extent not otherwise prohibited by law, grants shall be 

for 3 years, as provided in regulations issued pursuant to this 

Act. 

ø§ 1613. Health professions preparatory scholarship program 

for Indians¿ 

SEC. 103. HEALTH PROFESSIONS PREPARATORY SCHOLARSHIP PROGRAM FOR INDIANS. 

ø(a) REQUIREMENTS¿ 

(a) SCHOLARSHIPS AUTHORIZED.—The Secretary, acting through 

the Service, shall ømake¿ provide scholarship grants to Indians 

who—

(1) have successfully completed their high school education 

or high school equivalency; and 

(2) have demonstrated the øcapability¿ potential to successfully complete courses of study in the health professions. 


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(b) PURPOSES. øand duration of grants; preprofessional and 

pregraduate education¿—Scholarship grants ømade¿ provided pursuant to this section shall be for the following purposes: 

(1) Compensatory preprofessional education of any øgrantee¿ 

recipient, such scholarship not to exceed øtwo¿ 2 years on a 

full-time basis (or the part-time equivalent thereof, as determined by the Secretary pursuant to regulations issued under 

this Act). 

(2) Pregraduate education of any øgrantee¿ recipient leading 

to a baccalaureate degree in an approved course of study preparatory to a field of study in a health profession, such scholarship not to exceed 4 years. An extension of up to 2 years (or 

the part-time equivalent thereof, as determined by the 

Secretaryø).¿ pursuant to regulations issued pursuant to this 

Act) may be approved. 

ø(c) COVERED EXPENSES¿ 

øScholarship grants made¿ (c) OTHER CONDITIONS.—Scholarships under this section—

(1) may cover costs of tuition, books, transportation, board, 

and other necessary related expenses of a øgrantee¿ recipient 

while attending schoolø.¿; 

ø(d) BASIS FOR DENIAL OF ASSISTANCE¿ 

øThe Secretary¿ (2) shall not ødeny scholarship assistance to 

an eligible applicant under this section¿ be denied solely on the 

basis of the applicant’s scholastic achievement if such applicant 

has been admitted to, or maintained good standing at, an accredited institutionø.¿; and 

ø(e) ELIGIBILITY FOR ASSISTANCE UNDER OTHER FEDERAL PROGRAMS¿ 

øThe Secretary¿ (3) shall not ødeny scholarship assistance to 

an eligible applicant under this section¿ be denied solely by 

reason of such applicant’s eligibility for assistance or benefits 

under any other Federal program. 

ø§ 1613a. Indian health professions scholarships¿ 

SEC. 104. INDIAN HEALTH PROFESSIONS SCHOLARSHIPS. 

ø(a) GENERAL AUTHORITY¿ (a) IN GENERAL.—

øIn order to provide health professionals to Indians, Indian 

tribes, tribal organizations, and urban Indian organizations, 

the¿ (1) AUTHORITY.—The Secretary, acting through the Service øand in accordance with this section¿, shall make scholarship grants to Indians who are enrolled full or part time in 

øappropriately¿ accredited schools øand¿ pursuing courses of 

study in the health professions. Such scholarships shall be designated Indian Health Scholarships and shall be made in accordance with section ø254l of Title 42,¿ 338A of the Public 

Health Services Act (42 U.S.C. 254l), except as provided in subsection (b) of this section. 

ø(b) Recipients; active duty service obligation¿ 

ø(1)¿ (2) DETERMINATIONS BY SECRETARY.—The Secretary, 

acting through the Service, shall determine—

(A) who shall receive øscholarships¿ scholarship grants 

under subsection (a); and øshall determine¿ 

(B) the distribution of øsuch¿ the scholarships among 

øsuch¿ health professions on the basis of the relative 


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114 

needs of Indians for additional service in øsuch¿ the health 

professions. ø(2) An individual shall be eligible for a scholarship under subsection (a) of this section in any year in 

which such individual is enrolled full or part time in a 

course of study referred to in subsection (a) of this section.¿ 

(3) CERTAIN DELEGATION NOT ALLOWED.—The administration 

of this section shall be a responsibility of the Assistant Secretary and shall not be delegated in a contract or compact 

under the Indian Self-Determination and Education Assistance 

Act (25 U.S.C. 450 et seq.). 

(b) ACTIVE DUTY SERVICE OBLIGATION—

ø(3)(A)¿ (1) OBLIGATION MET.—The active duty service obligation under a written contract with the Secretary under this 

section ø254l of Title 42¿ that an øindividual¿ Indian has entered into øunder that section¿ shall, if that individual is a recipient of an Indian Health Scholarship, be met in full-time 

practiceø, by service—¿ equal to 1 year for each school year for 

which the participant receives a scholarship award under this 

part, or 2 years, whichever is greater, by service in 1 or more 

of the following: 

ø(i) in the Indian Health Service;¿ 

ø(ii) in a program conducted under a contract entered 

into under the Indian Self-Determination Act [25 U.S.C.A. 

§ 450f et seq.];¿ 

(A) In an Indian Health Program. 

ø(iii)¿ (B) øin¿ In a program assisted under øsubchapter 

IV of this chapter;¿ title V of this Act. 

ø(iv)¿ (C) øin¿In the private practice of the applicable 

profession if, as determined by the Secretary, in accordance with guidelines promulgated by the Secretary, such 

practice is situated in a physician or other health professional shortage area and addresses the health care needs 

of a substantial number of Indiansø; or¿. 

(D) In a teaching capacity in a tribal college or university 

nursing program (or a related health profession program) 

if, as determined by the Secretary, the health service provided to Indians would not decrease. 

ø(B)¿ (2) OBLIGATION DEFERRED.—At the request of any individual who has entered into a contract referred to in øsubparagraph (A¿paragraph (1) and who receives a degree in medicine 

(including osteopathic or allopathic medicine), dentistry, optometry, podiatry, or pharmacy, the Secretary shall defer the 

active duty service obligation of that individual under that contract, in order that such individual may complete any internship, residency, or other advanced clinical training that is required for the practice of that health profession, for an appropriate period (in years, as determined by the Secretary), subject to the following conditions: 

ø(i)¿ (A) No period of internship, residency, or other advanced clinical training shall be counted as satisfying any 

period of obligated service øthat is required¿ under this 

øsection¿subsection. 

ø(ii)¿ (B) The active duty service obligation of that individual shall commence not later than 90 days after the 


bajohnson on PROD1PC71 with REPORTS
115 

completion of that advanced clinical training (or by a date 

specified by the Secretary). 

ø(iii)¿ (C) The active duty service obligation will be 

served in the health profession of that individual, in a 

manner consistent with øclauses (i) through (v) of subparagraph (A)¿ paragraph (1). ø(C)¿ (D) A recipient of øan Indian Health Scholarship¿a scholarship under this section may, at the election 

of the recipient, meet the active duty service obligation described in øsubparagraph (A)¿ paragraph (1) by service in 

a program specified øin¿ under that øsubparagraph¿ paragraph that— (i) is located on the reservation of the øtribe¿ Indian 

Tribe in which the recipient is enrolled; or 

(ii) serves the øtribe¿ Indian Tribe in which the recipient is enrolled. 

ø(D)¿ (3) PRIORITY WHEN MAKING ASSIGNMENTS.—Subject to 

øsubparagraph (C¿ paragraph (2), the Secretary, in making assignments of Indian Health Scholarship recipients required to 

meet the active duty service obligation described in øsubparagraph (A)¿ paragraph (1), shall give priority to assigning individuals to service in those programs specified in øsubparagraph (A)¿ paragraph (1) that have a need for health professionals to provide health care services as a result of individuals 

having breached contracts entered into under this section. 

ø(4)¿ (c) PART-TIME STUDENTS.—In the case of an individual receiving a scholarship under this section who is enrolled part time 

in an approved course of study— ø(A)¿ (1) such scholarship shall be for a period of years not 

to exceed the part-time equivalent of 4 years, as determined by 

the Secretary; 

ø(B)¿ (2) the period of obligated service described in øparagraph (3)(A)¿ subsection (b)(1) shall be equal to the greater 

of—

ø(i)¿ (A) the part-time equivalent of øone¿ 1 year for 

each year for which the individual was provided a scholarship (as determined by the Secretary); or 

ø(ii)¿ (B) øtwo¿ 2 years; and 

ø(C)¿ (3) the amount of the monthly stipend specified in section 338A(g)(1)(B) of the Public Health Service Act (42 U.S.C. 

254l(g)(1)(B) øof Title 42¿) shall be reduced pro rata (as determined by the Secretary) based on the number of hours such 

student is enrolled. 

ø(5)(A) An individual who has, on or after October 29, 1992, 

entered into a written contract with the Secretary under this 

section and who—¿ 

(d) BREACH OF CONTRACT.—

(1) SPECIFIED BREACHES.—An individual shall be liable to 

the United States for the amount which has been paid to the 

individual, or on behalf of the individual, under a contract entered into with the Secretary under this section on or after the 

date of enactment of the Indian Health Care Improvement Act 

Amendments of 2007 if that individual—

ø(i)¿ (A) fails to maintain an acceptable level of academic standing in the educational institution in which he 


bajohnson on PROD1PC71 with REPORTS
116 

or she is enrolled (such level determined by the educational institution under regulations of the Secretary)ø,¿; 

ø(ii)¿ (B) is dismissed from such educational institution 

for disciplinary reasonsø,¿; 

ø(iii)¿ (C) voluntarily terminates the training in such an 

educational institution for which he or she is provided a 

scholarship under such contract before the completion of 

such trainingø,¿; or 

ø(iv)¿ (D) fails to accept payment, or instructs the educational institution in which he or she is enrolled not to accept payment, in whole or in part, of a scholarship under 

such contract, in lieu of any service obligation arising 

under such contractø, shall be liable to the United States 

for the amount which has been paid to him, or on his behalf, under the contract¿. ø(B)¿ (2) OTHER BREACHES.—If for any reason not specified 

in øsubparagraph (A)¿ paragraph (1) an individual breaches 

øhis¿ a written contract by failing either to begin such individual’s service obligation required under øthis section¿ such contract or to complete such service obligation, the United States 

shall be entitled to recover from the individual an amount determined in accordance with the formula specified in subsection (l) of section ø1616a(l) of this title¿ 110 in the manner 

provided for in such subsection. 

ø(C)¿ (3) CANCELLATION UPON DEATH OF RECIPIENT.—Upon 

the death of an individual who receives an Indian Health 

Scholarship, any outstanding obligation of that individual for 

service or payment that relates to that scholarship shall be 

canceled. 

(4) WAIVERS AND SUSPENSIONS.—

ø(D)¿ (A) IN GENERAL.—The Secretary shall provide for 

the partial or total waiver or suspension of any obligation 

of service or payment of a recipient of an Indian Health 

Scholarship if the Secretary determines that—

(i) it is not possible for the recipient to meet that obligation or make that payment; 

(ii) requiring that recipient to meet that obligation 

or make that payment would result in extreme hardship to the recipient; or 

(iii) the enforcement of the requirement to meet the 

obligation or make the payment would be unconscionable. 

(B) FACTORS FOR CONSIDERATION.—Before waiving or 

suspending an obligation of service or payment under subparagraph (A), the Secretary shall consult with the affected 

Area Office, Indian Tribes, Tribal Organizations, or Urban 

Indian Organizations, and may take into consideration 

whether the obligation may be satisfied in a teaching capacity at a tribal college or university nursing program 

under subsection (b)(1)(D). 

ø(E)¿ (5) EXTREME HARDSHIP.—Notwithstanding any other 

provision of law, in any case of extreme hardship or for other 

good cause shown, the Secretary may waive, in whole or in 

part, the right of the United States to recover funds made 

available under this section. 


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117 

ø(F)¿ (6) BANKRUPTCY.—Notwithstanding any other provision of law, with respect to a recipient of an Indian Health 

Scholarship, no obligation for payment may be released by a 

discharge in bankruptcy under øTitle¿ title 11, United States 

Code, unless that discharge is granted after the expiration of 

the 5-year period beginning on the initial date on which that 

payment is due, and only if the bankruptcy court finds that the 

nondischarge of the obligation would be unconscionable. 

ø(c) Placement Office¿ 

SEC. 105. AMERICAN INDIANS INTO PSYCHOLOGY PROGRAM. 

(a) GRANTS AUTHORIZED.—The Secretary, acting through the Service, shall make grants of not more than $300,000 to each of 9 

colleges and universities for the purpose of developing and maintaining Indian psychology career recruitment programs as a means 

of encouraging Indians to enter the behavioral health field. These 

programs shall be located at various locations throughout the country to maximize their availability to Indian students and new programs shall be established in different locations from time to time. 

(b) QUENTIN N. BURDICK PROGRAM GRANT.—The Secretary shall 

provide a grant authorized under subsection (a) to develop and 

maintain a program at the University of North Dakota to be known 

as the ‘Quentin N. Burdick American Indians Into Psychology Program’. Such program shall, to the maximum extent feasible, coordinate with the Quentin N. Burdick Indian Health Programs authorized under section 117(b), the Quentin N. Burdick American Indians Into Nursing Program authorized under section 115(e), and existing university research and communications networks. 

(c) REGULATIONS.—The Secretary shall issue regulations pursuant 

to this Act for the competitive awarding of grants provided under 

this section. 

(d) CONDITIONS OF GRANT.—Applicants under this section shall 

agree to provide a program which, at a minimum— (1) provides outreach and recruitment for health professions 

to Indian communities including elementary, secondary, and 

accredited and accessible community colleges that will be served 

by the program; 

(2) incorporates a program advisory board comprised of representatives from the tribes and communities that will be served 

by the program; 

(3) provides summer enrichment programs to expose Indian 

students to the various fields of psychology through research, 

clinical, and experimental activities; 

(4) provides stipends to undergraduate and graduate students 

to pursue a career in psychology; 

(5) develops affiliation agreements with tribal colleges and 

universities, the Service, university affiliated programs, and 

other appropriate accredited and accessible entities to enhance 

the education of Indian students; 

(6) to the maximum extent feasible, uses existing university 

tutoring, counseling, and student support services; and 

(7) to the maximum extent feasible, employs qualified Indians 

in the program. 

øThe Secretary shall, acting through the Service, establish a 

Placement Office to develop and implement a national policy for 

the placement, to available vacancies within the Service, of Indian 


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118 

Health Scholarship recipients required to meet the active duty 

service obligation prescribed under section 254m of Title 42 without regard to any competitive personnel system, agency personnel 

limitation, or Indian preference policy.¿ 

(e) ACTIVE DUTY SERVICE REQUIREMENT.—The active duty service 

obligation prescribed under section 338C of the Public Health Service Act (42 U.S.C. 254m) shall be met by each graduate who receives 

a stipend described in subsection (d)(4) that is funded under this 

section. Such obligation shall be met by service—

(1) in an Indian Health Program; 

(2) in a program assisted under title V of this Act; or 

(3) in the private practice of psychology if, as determined by 

the Secretary, in accordance with guidelines promulgated by the 

Secretary, such practice is situated in a physician or other 

health professional shortage area and addresses the health care 

needs of a substantial number of Indians. 

(f) AUTHORIZATION OF APPROPRIATIONS.—There is authorized to 

be appropriated to carry out this section $2,700,000 for each of fiscal years 2008 through 2017. 

SEC. 106. SCHOLARSHIP PROGRAMS FOR INDIAN TRIBES. 

(a) IN GENERAL.—

(1) GRANTS AUTHORIZED.—The Secretary, acting through the 

Service, shall make grants to Tribal Health Programs for the 

purpose of providing scholarships for Indians to serve as health 

professionals in Indian communities. 

(2) AMOUNT.—Amounts available under paragraph (1) for 

any fiscal year shall not exceed 5 percent of the amounts available for each fiscal year for Indian Health Scholarships under 

section 104. 

(3) APPLICATION.—An application for a grant under paragraph (1) shall be in such form and contain such agreements, 

assurances, and information as consistent with this section. 

(b) REQUIREMENTS.—

(1) IN GENERAL.—A Tribal Health Program receiving a grant 

under subsection (a) shall provide scholarships to Indians in 

accordance with the requirements of this section. 

(2) COSTS.—With respect to costs of providing any scholarship 

pursuant to subsection (a)—

(A) 80 percent of the costs of the scholarship shall be paid 

from the funds made available pursuant to subsection 

(a)(1) provided to the Tribal Health Program; and 

(B) 20 percent of such costs may be paid from any other 

source of funds. 

(c) COURSE OF STUDY.—A Tribal Health Program shall provide 

scholarships under this section only to Indians enrolled or accepted 

for enrollment in a course of study (approved by the Secretary) in 

1 of the health professions contemplated by this Act. 

(d) CONTRACT.—

(1) IN GENERAL.—In providing scholarships under subsection 

(b), the Secretary and the Tribal Health Program shall enter 

into a written contract with each recipient of such scholarship. 

(2) REQUIREMENTS.—Such contract shall—

(A) obligate such recipient to provide service in an Indian 

Health Program or Urban Indian Organization, in the 


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119 

same Service Area where the Tribal Health Program providing the scholarship is located, for—

(i) a number of years for which the scholarship is 

provided (or the part-time equivalent thereof, as determined by the Secretary), or for a period of 2 years, 

whichever period is greater; or 

(ii) such greater period of time as the recipient and 

the Tribal Health Program may agree; 

(B) provide that the amount of the scholarship—

(i) may only be expended for—

(I) tuition expenses, other reasonable educational 

expenses, and reasonable living expenses incurred 

in attendance at the educational institution; and 

(II) payment to the recipient of a monthly stipend of not more than the amount authorized by 

section 338(g)(1)(B) of the Public Health Service 

Act (42 U.S.C. 254m(g)(1)(B)), with such amount 

to be reduced pro rata (as determined by the Secretary) based on the number of hours such student 

is enrolled, and not to exceed, for any year of attendance for which the scholarship is provided, the 

total amount required for the year for the purposes 

authorized in this clause; and 

(ii) may not exceed, for any year of attendance for 

which the scholarship is provided, the total amount required for the year for the purposes authorized in 

clause (i); 

(C) require the recipient of such scholarship to maintain 

an acceptable level of academic standing as determined by 

the educational institution in accordance with regulations 

issued pursuant to this Act; and 

(D) require the recipient of such scholarship to meet the 

educational and licensure requirements appropriate to each 

health profession. 

(3) SERVICE IN OTHER SERVICE AREAS.—The contract may 

allow the recipient to serve in another Service Area, provided 

the Tribal Health Program and Secretary approve and services 

are not diminished to Indians in the Service Area where the 

Tribal Health Program providing the scholarship is located. 

(e) BREACH OF CONTRACT.—

(1) SPECIFIC BREACHES.—An individual who has entered into 

a written contract with the Secretary and a Tribal Health Program under subsection (d) shall be liable to the United States 

for the Federal share of the amount which has been paid to him 

or her, or on his or her behalf, under the contract if that individual—

(A) fails to maintain an acceptable level of academic 

standing in the educational institution in which he or she 

is enrolled (such level as determined by the educational institution under regulations of the Secretary); 

(B) is dismissed from such educational institution for 

disciplinary reasons; 

(C) voluntarily terminates the training in such an educational institution for which he or she is provided a scholVerDate Aug 31 2005 01:51 Oct 27, 2007 Jkt 069010 PO 00000 Frm 00119 Fmt 6659 Sfmt 6603 E:\HR\OC\SR197.XXX SR197

bajohnson on PROD1PC71 with REPORTS
120 

arship under such contract before the completion of such 

training; or 

(D) fails to accept payment, or instructs the educational 

institution in which he or she is enrolled not to accept payment, in whole or in part, of a scholarship under such contract, in lieu of any service obligation arising under such 

contract. 

(2) OTHER BREACHES.—If for any reason not specified in 

paragraph (1), an individual breaches a written contract by 

failing to either begin such individual’s service obligation required under such contract or to complete such service obligation, the United States shall be entitled to recover from the individual an amount determined in accordance with the formula 

specified in subsection (l) of section 110 in the manner provided 

for in such subsection. 

(3) CANCELLATION UPON DEATH OF RECIPIENT.—Upon the 

death of an individual who receives an Indian Health Scholarship, any outstanding obligation of that individual for service 

or payment that relates to that scholarship shall be canceled. 

(4) INFORMATION.—The Secretary may carry out this subsection on the basis of information received from Tribal Health 

Programs involved or on the basis of information collected 

through such other means as the Secretary deems appropriate. 

(f) RELATION TO SOCIAL SECURITY ACT.—The recipient of a 

scholarship under this section shall agree, in providing health care 

pursuant to the requirements herein—

(1) not to discriminate against an individual seeking care on 

the basis of the ability of the individual to pay for such care 

or on the basis that payment for such care will be made pursuant to a program established in title XVIII of the Social Security Act or pursuant to the programs established in title XIX or 

title XXI of such Act; and 

(2) to accept assignment under section 1842(b)(3)(B)(ii) of the 

Social Security Act for all services for which payment may be 

made under part B of title XVIII of such Act, and to enter into 

an appropriate agreement with the State agency that administers the State plan for medical assistance under title XIX, or 

the State child health plan under title XXI, of such Act to provide service to individuals entitled to medical assistance or 

child health assistance, respectively, under the plan. 

(g) CONTINUANCE OF FUNDING.—The Secretary shall make payments under this section to a Tribal Health Program for any fiscal 

year subsequent to the first fiscal year of such payments unless the 

Secretary determines that, for the immediately preceding fiscal year, 

the Tribal Health Program has not complied with the requirements 

of this section. 

ø§ 1614. Indian Health Service extern programs¿ 

SEC. 107. INDIAN HEALTH SERVICE EXTERN PROGRAMS. 

(a) EMPLOYMENT øof scholarship grantees during nonacademic 

periods¿ PREFERENCE.—Any individual who receives a scholarship 

øgrant¿ pursuant to section ø1613a of this title¿ 104 or 106 shall 

be øentitled to¿ given preference for employment in the Service 

øduring any nonacademic period of the year.¿, or may be employed 

by a Tribal Health Program or an Urban Indian Organization, or 


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121 

other agencies of the Department as available, during any nonacademic period of the year. 

(b) NOT COUNTED TOWARD ACTIVE DUTY SERVICE OBLIGATION.— Periods of employment pursuant to this subsection shall not be 

counted in determining øthe¿ fulfillment of the service obligation 

incurred as a condition of the scholarship øgrant¿. ø(b)¿(c) TIMING; LENGTH OF EMPLOYMENT øof medical and other 

students during nonacademic periods¿.—Any individual enrolled in 

a øcourse of study in the health professions¿ program, including a 

high school program, authorized under section 102(a) may be employed by the Service or by a Tribal Health Program or an Urban 

Indian Organization during any nonacademic period of the year. 

Any such employment shall not exceed øone hundred and twenty¿ 

120 days during any calendar year. 

ø(c) Employment without regard to competitive personnel system 

or agency personnel limitation; compensation¿ (d) NONAPPLICABILITY OF COMPETITIVE PERSONNEL SYSTEM.—Any employment 

pursuant to this section shall be made without regard to any competitive personnel system or agency personnel limitation and to a 

position which will enable the individual so employed to receive 

practical experience in the health profession in which he or she is 

engaged in study. Any individual so employed shall receive payment for his or her services comparable to the salary he or she 

would receive if he or she were employed in the competitive system. Any individual so employed shall not be counted against any 

employment ceiling affecting the Service or the Departmentøof 

Health and Human Services¿. 

ø§ 1615. Continuing education allowances¿ 

SEC. 108. CONTINUING EDUCATION ALLOWANCES. 

ø(a) Discretionary authority; scope of activities¿ 

In order to encourage øphysicians, dentists, nurses, and other¿ 

scholarship and stipend recipients under sections 104, 105, 106, and 

115 and health professionals, including community health representatives and emergency medical technicians, to join or continue 

in øthe Service¿ an Indian Health Program and to provide their 

services in the rural and remote areas where a significant portion 

of øthe Indian people resides¿ Indians reside, the Secretary, acting 

through the Service, may øprovide¿—

(1) provide programs or allowances to transition into an Indian Health Program, including licensing, board or certification examination assistance, and technical assistance in fulfilling service obligations under sections 104, 105, 106, and 115; 

and 

(2) provide programs or allowances to health professionals 

employed in øthe Service¿ an Indian Health Program to enable 

them for a period of time each year prescribed by regulation 

of the Secretary to take leave of their duty stations for professional consultation, management, leadership, and refresher 

training courses. 

ø(b) Limitation 

øOf amounts appropriated under the authority of this subchapter 

for each fiscal year to be used to carry out this section, not more 

than $1,000,000 may be used to establish postdoctoral training programs for health professionals. 


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122 

ø§ 1616. Community Health Representative Program¿ 

SEC. 109. COMMUNITY HEALTH REPRESENTATIVE PROGRAM. 

(a) IN GENERAL.—Under the authority of the Act of November 2, 

1921 (25 U.S.C. 13)ø, popularly¿ (commonly known as the ‘‘Snyder 

Act’’), the Secretary, acting through the Service, shall maintain a 

Community Health Representative Program under which øthe 

Service¿Indian Health Programs—

(1) øprovides¿ provide for the training of Indians as øhealth 

paraprofessionals, and¿ community health representatives; and 

ø(2) uses such paraprofessionals¿ (2) use such community 

health representatives in the provision of health care, health 

promotion, and disease prevention services to Indian communities. 

ø(b) The Secretary, acting through the Community Health Representative Program of the Service, shall—¿ 

(b) DUTIES.—The Community Health Representative Program of 

the Service, shall—

(1) provide a high standard of training for øparaprofessionals 

to Community Health Representatives¿ community health representatives to ensure that the øCommunity Health Representatives¿ community health representatives provide quality 

health care, health promotion, and disease prevention services 

to the Indian communities served by øsuch¿ the Programø,¿; 

(2) in order to provide such training, develop and maintain 

a curriculum that—

(A) combines education in the theory of health care with 

supervised practical experience in the provision of health 

careø,¿; and 

(B) provides instruction and practical experience in 

health promotion and disease prevention activities, with 

appropriate consideration given to lifestyle factors that 

have an impact on Indian health status, such as alcoholism, family dysfunction, and povertyø,¿; 

(3) maintain a system which identifies the needs of øCommunity Health Representatives¿ community health representatives 

for continuing education in health care, health promotion, and 

disease prevention and develop programs that meet the needs 

for øsuch¿ continuing educationø,¿; 

(4) maintain a system that provides close supervision of 

Community Health Representativesø,¿; 

(5) maintain a system under which the work of Community 

Health Representatives is reviewed and evaluatedø,¿; and 

(6) promote traditional health care practices of the Indian 

øtribes¿ Tribes served consistent with the Service standards 

for the provision of health care, health promotion, and disease 

prevention. 

ø§1616a. Indian Health Service Loan Repayment Program¿ 

SEC. 110. INDIAN HEALTH SERVICE LOAN REPAYMENT PROGRAM. 

(a) ESTABLISHMENT.—ø(1)¿The Secretary, acting through the 

Service, shall establish and administer a program to be known as 

the øIndian Health¿ Service Loan Repayment Program (hereinafter 

referred to as the ø‘‘¿‘Loan Repayment Programø’’¿’) in order to 

øassure¿ ensure an adequate supply of trained health professionals 


bajohnson on PROD1PC71 with REPORTS
123 

necessary to maintain accreditation of, and provide health care 

services to Indians through, Indian øhealth programs¿ Health Programs and Urban Indian Organizations. 

ø(2) For the purposes of this section—¿ 

ø(A) the term ‘‘Indian health program’’ means any health 

program or facility funded, in whole or part, by the Service for 

the benefit of Indians and administered— ø(i) directly by the Service; 

ø(ii) by any Indian tribe or tribal or Indian organization 

pursuant to a contract under— ø(I) the Indian Self-Determination Act [25 U.S.C.A. 

§ 450f et seq.], or 

ø(II) section 23 of the Act of April 30, 1908 (25 

U.S.C. 47), popularly known as the ‘‘Buy-Indian’’ Act; 

or 

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

ø(B) the term ‘‘State’’ has the same meaning given such term 

in section 254d of Title 42.¿ 

ø(b) ELIGIBILITY¿ (b) ELIGIBLE INDIVIDUALS.—To be eligible to 

participate in the Loan Repayment Program, an individual must—

(1)(A) be enrolled—

(i) in a course of study or program in an accredited educational institutionø,¿ (as determined by the Secretaryø, 

within any State¿ under section 338B(b)(1)(c)(i) of the Public Health Service Act (42 U.S.C. 254l–1(b)(1)(c)(i))) and be 

scheduled to complete such course of study in the same 

year such individual applies to participate in such program; or 

(ii) in an approved graduate training program in a 

health profession; or 

(B) have—

(i) a degree in a health profession; and 

(ii) a license to practice a health profession øin a State¿; 

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

Health Service; 

(B) be eligible for selection for civilian service in the Regular 

or Reserve Corps of the Public Health Service; 

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

(D) be employed in an Indian øhealth program¿ Health Program or Urban Indian Organization without a service obligation; and 

(3) submit to the Secretary an application for a contract described in subsection ø(f) of this section¿ (e). (c) APPLICATION øAND CONTRACT FORMS¿.—

ø(1)¿ (1) INFORMATION TO BE INCLUDED WITH FORMS.—In disseminating application forms and contract forms to individuals 

desiring to participate in the Loan Repayment Program, the 

Secretary shall include with such forms a fair summary of the 

rights and liabilities of an individual whose application is approved (and whose contract is accepted) by the Secretary, including in the summary a clear explanation of the damages to 

which the United States is entitled under subsection ø(1)¿ (l) 


bajohnson on PROD1PC71 with REPORTS
124 

øof this section¿ in the case of the individual’s breach of øthe¿ 

contract. The Secretary shall provide such individuals with sufficient information regarding the advantages and disadvantages of service as a commissioned officer in the Regular or Reserve Corps of the Public Health Service or a civilian employee 

of the øIndian health¿ Service to enable the individual to make 

a decision on an informed basis. 

(2) CLEAR LANGUAGE.—The application form, contract form, 

and all other information furnished by the Secretary under 

this section shall be written in a manner calculated to be understood by the average individual applying to participate in 

the Loan Repayment Program. 

ø(3)¿ (3) TIMELY AVAILABILITY OF FORMS.—The Secretary 

shall make such application forms, contract forms, and other 

information available to individuals desiring to participate in 

the Loan Repayment Program on a date sufficiently early to 

ensure that such individuals have adequate time to carefully 

review and evaluate such forms and information. 

ø(d) Vacancies; priority¿ 

(d) PRIORITIES.—

(1) LIST.—Consistent øwith paragraph (3), the Secretary, acting through the Service and in accordance¿ with subsection (k) 

øof this section¿, the Secretary shall annually— (A) identify the positions in each Indian øhealth program¿ Health Program or Urban Indian Organization for 

which there is a need or a vacancyø,¿; and 

(B) rank those positions in order of priority. 

(2) øConsistent with¿ APPROVALS.—Notwithstanding the priority determined under paragraph (1), the Secretary, in determining which applications under the Loan Repayment Program to approve (and which contracts to accept), shall— (A) give first priority to applications made byø— (A)¿ individual Indians; and 

(B) after making determinations on all applications submitted by individual Indians as required under subparagraph (A), give priority to—

ø(B)¿ (i) individuals recruited through the efforts of 

an Indian øtribes or tribal or Indian organizations.¿ 

ø(3)(A) Subject to subparagraph (B), of the total amounts appropriated for each of the fiscal years 1993, 1994, and 1995 for 

loan repayment contracts under this section, the Secretary 

shall provide that—

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

midwives¿ Health Program or Urban Indian Organization; and 

ø(ii) not less than 10 percent be provided to applicants who are mental health professionals (other than 

applicants described in clause (i)). 

ø(B) The requirements specified in clause (i) or clause 

(ii) of subparagraph (A) shall not apply if the Secretary 

does not receive the number of applications from the individuals described in clause (i) or clause (ii), respectively, 

necessary to meet such requirements. 

ø(e) Approval¿ 


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125 

(ii) other individuals based on the priority rankings 

under paragraph (1). 

(e) RECIPIENT CONTRACTS.— (1) CONTRACT REQUIRED.—An individual becomes a participant in the Loan Repayment Program only upon the Secretary 

and the individual entering into a written contract described in 

øsubsection (f) of this section.¿ paragraph (2). 

ø(2) The Secretary shall provide written notice to an individual promptly on— ø(A) the Secretary’s approving, under paragraph (1), of 

the individual’s participation in the Loan Repayment Program, including extensions resulting in an aggregate period of obligated service in excess of 4 years; or 

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

ø(f) Contract terms¿ 

(2) CONTENTS OF CONTRACT.—The written contract referred 

to in this section between the Secretary and an individual shall 

contain—

ø(1)¿ (A) an agreement under which—

ø(A)¿ (i) subject to øparagraph (3)¿ subparagraph 

(C), the Secretary agrees—

ø(i)¿ (I) to pay loans on behalf of the individual 

in accordance with the provisions of this 

sectionø,¿; and 

ø(ii)¿(II) to accept (subject to the availability of 

appropriated funds for carrying out this section) 

the individual into the Service or place the individual with a øtribe¿ Tribal Health Program or 

Urban Indian øorganization¿ Organization as provided in øsubparagraph (B)(iii),¿ clause (ii)(III); 

and 

ø(B¿ (ii) subject to øparagraph (3¿ subparagraph 

(C), the individual agrees— ø(i)¿ (I) to accept loan payments on behalf of the 

individual; 

ø(ii)¿ (II) in the case of an individual described 

in subsection (b)(1)— ø(I)¿ (aa) to maintain enrollment in a 

course of study or training described in subsection (b)(1)(A) øof this section¿ until the individual completes the course of study or 

trainingø,¿; and 

ø(II)¿ (bb) while enrolled in such course of 

study or training, to maintain an acceptable 

level of academic standing (as determined 

under regulations of the Secretary by the educational institution offering such course of 

study or training); and 

ø(iii)¿ (III) to serve for a time period (hereinafter in this section referred to as the ‘‘period of 

obligated service’’) equal to 2 years or such longer 

period as the individual may agree to serve in the 

full-time clinical practice of such individual’s profession in an Indian øhealth program¿ Health ProVerDate Aug 31 2005 01:51 Oct 27, 2007 Jkt 069010 PO 00000 Frm 00125 Fmt 6659 Sfmt 6602 E:\HR\OC\SR197.XXX SR197

bajohnson on PROD1PC71 with REPORTS
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gram or Urban Indian Organization to which the 

individual may be assigned by the Secretary; 

ø(2)¿ (B) a provision permitting the Secretary to extend for such longer additional periods, as the individual may agree to, the period of obligated service 

agreed to by the individual under øparagraph 

(1)(B)(iii)¿ subparagraph (A)(ii)(III); 

ø(3)¿ (C) a provision that any financial obligation of 

the United States arising out of a contract entered 

into under this section and any obligation of the individual which is conditioned thereon is contingent upon 

funds being appropriated for loan repayments under 

this section; 

ø(4)¿ (D) a statement of the damages to which the 

United States is entitled under subsection (ø1¿l) øof 

this section¿ for the individual’s breach of the contract; and 

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

ø(g) Loan repayment purposes; maximum amount; tax liability 

reimbursement; schedule of payments¿ 

(f) DEADLINE FOR DECISION ON APPLICATION.—The Secretary 

shall provide written notice to an individual within 21 days on—

(1) the Secretary’s approving, under subsection (e)(1), of the 

individual’s participation in the Loan Repayment Program, including extensions resulting in an aggregate period of obligated 

service in excess of 4 years; or 

(2) the Secretary’s disapproving an individual’s participation 

in such Program. 

(g) PAYMENTS.—

ø(1)¿ (1) IN GENERAL.—A loan repayment provided for an individual under a written contract under the Loan Repayment 

Program shall consist of payment, in accordance with paragraph (2), on behalf of the individual of the principal, interest, 

and related expenses on government and commercial loans received by the individual regarding the undergraduate or graduate education of the individual (or both), which loans were 

made for—

(A) tuition expenses; 

(B) all other reasonable educational expenses, including 

fees, books, and laboratory expenses, incurred by the individual; and 

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

(2) ø(A)¿ AMOUNT.—For each year of obligated service that 

an individual contracts to serve under subsection (øf¿e), the 

Secretary may pay up to $35,000 ø(¿or an amount equal to the 

amount specified in section ø254l–l¿338B(g)(2)(A) of øTitle 42¿ 

the Public Health Service Act, whichever is more, on behalf of 

the individual for loans described in paragraph (1). In making 

a determination of the amount to pay for a year of such service 

by an individual, the Secretary shall consider the extent to 

which each such determination—


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127 

ø(i)¿ (A) affects the ability of the Secretary to maximize 

the number of contracts that can be provided under the 

Loan Repayment Program from the amounts appropriated 

for such contracts; 

ø(ii)¿ (B) provides an incentive to serve in Indian 

øhealth programs¿Health Programs and Urban Indian Organizations with the greatest shortages of health professionals; and 

ø(iii)¿ (C) provides an incentive with respect to the 

health professional involved remaining in an Indian 

øhealth program¿ Health Program or Urban Indian Organization with such a health professional shortage, and continuing to provide primary health services, after the completion of the period of obligated service under the Loan 

Repayment Program. 

ø(B)¿ (3) TIMING.—Any arrangement made by the Secretary 

for the making of loan repayments in accordance with this subsection shall provide that any repayments for a year of obligated service shall be made no later than the end of the fiscal 

year in which the individual completes such year of service. 

ø(3)¿ (4) REIMBURSEMENTS FOR TAX LIABILITY.—For the purpose of providing reimbursements for tax liability resulting 

from øpayments¿ a payment under paragraph (2) on behalf of 

an individual, the Secretary—

(A) in addition to such payments, may make payments 

to the individual in an amount equal to not less than 20 

percent and not more than 39 percent of the total amount 

of loan repayments made for the taxable year involved; 

and 

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

purpose. 

ø(4)¿ (5) PAYMENT SCHEDULE.—The Secretary may enter into 

an agreement with the holder of any loan for which payments 

are made under the Loan Repayment Program to establish a 

schedule for the making of such payments. 

ø(h) EFFECT ON EMPLOYMENT CEILING OF DEPARTMENT OF

HEALTH AND HUMAN SERVICES¿ 

(h) EMPLOYMENT CEILING.—Notwithstanding any other provision 

of law, individuals who have entered into written contracts with 

the Secretary under this sectionø, while undergoing academic 

training,¿ shall not be counted against any employment ceiling affecting the Department øof Health and Human Services¿ while 

those individuals are undergoing academic training. 

(i) øRecruiting programs¿ RECRUITMENT.—The Secretary shall 

conduct recruiting programs for the Loan Repayment Program and 

other øhealth professional¿ manpower programs of the Service at 

educational institutions training health professionals or specialists 

identified in subsection (a)øof this section¿. 

(j) øProhibition of assignment to other government departments.—Section 215 of Title 42¿ APPLICABILITY OF LAW.—Section 

214 of the Public Health Service Act (42 U.S.C. 215) shall not apply 

to individuals during their period of obligated service under the 

Loan Repayment Program. 


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128 

ø(k) Staff needs of health programs administered by Indian 

tribes¿ (k) ASSIGNMENT OF INDIVIDUALS.—The Secretary, in assigning individuals to serve in Indian øhealth programs¿ Health Programs or Urban Indian Organizations pursuant to contracts entered into under this section, shall— (1) ensure that the staffing needs of øIndian health programs 

administered by an Indian tribe or tribal or health organization¿ Tribal Health Programs and Urban Indian Organizations 

receive consideration on an equal basis with programs that are 

administered directly by the Service; and 

(2) give priority to assigning individuals to Indian øhealth 

programs¿ Health Programs and Urban Indian Organizations 

that have a need for health professionals to provide health care 

services as a result of individuals having breached contracts 

entered into under this section. 

ø(l) Voluntarily termination of study or dismissal from educational institution; collection of damages¿ 

(l) BREACH OF CONTRACT.— (1) SPECIFIC BREACHES.—An individual who has entered into 

a written contract with the Secretary under this section and 

øwho—¿ has not received a waiver under subsection (m) shall 

be liable, in lieu of any service obligation arising under such 

contract, to the United States for the amount which has been 

paid on such individual’s behalf under the contract if that individual—

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

øwho¿—

(i) fails to maintain an acceptable level of academic 

standing in the educational institution in which he or 

she is enrolled (such level determined by the educational institution under regulations of the Secretary); 

(ii) voluntarily terminates such enrollment; or 

(iii) is dismissed from such educational institution 

before completion of such course of study; or 

(B) is enrolled in a graduate training programø,¿ and 

fails to complete such training programø, and does not receive a waiver from the Secretary under subsection 

(b)(1)(B)(ii), shall be liable, in lieu of any service obligation 

arising under such contract, to the United States for the 

amount which has been paid on such individual’s behalf 

under the contract.¿. ø(2)¿ (2) OTHER BREACHES; FORMULA FOR AMOUNT OWED.—If, 

for any reason not specified in paragraph (1), an individual 

breaches his or her written contract under this section by failing either to begin, or complete, such individual’s period of obligated service in accordance with subsection ø(f) of this section¿ (e)(2), the United States shall be entitled to recover from 

such individual an amount to be determined in accordance 

with the following formula: A=3Z(t¥s/t) in which— (A) ‘‘A’’ is the amount the United States is entitled to recover; 

(B) ‘‘Z’’ is the sum of the amounts paid under this section 

to, or on behalf of, the individual and the interest on such 

amounts which would be payable if, at the time the 


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129 

amounts were paid, they were loans bearing interest at the 

maximum legal prevailing rate, as determined by the 

øTreasurer¿ Secretary of the øUnited States¿ Treasury; 

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

period of obligated service in accordance with subsection (f) 

øof this section¿; and 

(D) ‘‘s’’ is the number of months of such period served by 

such individual in accordance with this section. 

(3) DEDUCTIONS IN MEDICARE PAYMENTS.—Amounts not paid 

within such period shall be subject to collection through deductions in Medicare payments pursuant to section ø1395ccc of 

Title 42.¿ 1892 of the Social Security Act. ø(3)(A)¿ (4) TIME PERIOD FOR REPAYMENT.—Any amount of 

damages which the United States is entitled to recover under 

this subsection shall be paid to the United States within the 

1-year period beginning on the date of the breach or such 

longer period beginning on such date as shall be specified by 

the Secretary. 

(5) RECOVERY OF DELINQUENCY.—

ø(B)¿ (A) IN GENERAL.—If damages described in øsubparagraph (A)¿ paragraph (4) are delinquent for 3 months, 

the Secretary shall, for the purpose of recovering such 

damages—

(i) øutilize¿ use collection agencies contracted with 

by the Administrator of øthe¿ General Services øAdministration¿; or 

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

ø(C)¿ (B) REPORT.—Each contract for recovering damages pursuant to this subsection shall provide that the 

contractor will, not less than once each 6 months, submit 

to the Secretary a status report on the success of the contractor in collecting such damages. Section 3718 of øTitle 

31¿ title 31, United States Code, shall apply to any such 

contract to the extent not inconsistent with this subsection. 

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

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

(m) WAIVER OR SUSPENSION OF OBLIGATION.—

ø(2)¿(1) IN GENERAL.—The Secretary shall by regulation provide for the partial or total waiver or suspension of any obligation of service or payment by an individual under the Loan Repayment Program whenever compliance by the individual is 

impossible or would involve extreme hardship to the individual 

and if enforcement of such obligation with respect to any individual would be unconscionable. 

(2) CANCELED UPON DEATH.—Any obligation of an individual 

under the Loan Repayment Program for service or payment of 

damages shall be canceled upon the death of the individual. (3) HARDSHIP WAIVER.—The Secretary may waive, in whole 

or in part, the rights of the United States to recover amounts 

under this section in any case of extreme hardship or other 

good cause shown, as determined by the Secretary. 


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130 

(4) BANKRUPTCY.—Any obligation of an individual under the 

Loan Repayment Program for payment of damages may be released by a discharge in bankruptcy under øTitle¿ title 11 of 

the United States Code only if such discharge is granted after 

the expiration of the 5-year period beginning on the first date 

that payment of such damages is required, and only if the 

bankruptcy court finds that nondischarge of the obligation 

would be unconscionable. 

(n) øAnnual report¿ REPORT.—The Secretary shall submit to the 

President, for inclusion in øeach¿ the report required to be submitted to øthe¿ Congress under section ø1671 of this title,¿ 801, a 

report concerning the previous fiscal year which sets forthø—¿ by 

Service Area the following: 

(1) A list of the health professional positions maintained by 

øthe Service or by tribal or Indian organizations¿ Indian 

Health Programs and Urban Indian Organizations for which 

recruitment or retention is difficultø;¿. 

(2) øthe¿ The number of Loan Repayment Program applications filed with respect to each type of health professionø;¿. 

(3) øthe¿ The number of contracts described in subsection 

ø(f) of this section¿ (e) that are entered into with respect to 

each health professionø;¿. 

(4) øthe¿ The amount of loan payments made under this section, in total and by health professionø;¿. 

(5) øthe¿ The number of øscholarship grants¿ scholarships 

that are provided under øsection 1613a of this title¿ sections 

104 and 106 with respect to each health professionø;¿. 

(6) øthe¿ The amount of scholarship grants provided under 

section ø1613a of this title,¿ 104 and 106, in total and by 

health professionø;¿. 

(7) øthe¿ The number of providers of health care that will be 

needed by Indian øhealth programs¿ Health Programs and 

Urban Indian Organizations, by location and profession, during the øthree¿ 3 fiscal years beginning after the date the report is filedø; and¿. 

(8) øthe¿ The measures the Secretary plans to take to fill the 

health professional positions maintained by øthe Service or by 

tribes or tribal or Indian organizations¿ Indian Health Programs or Urban Indian Organizations for which recruitment or 

retention is difficult. 

ø§1616a–1. Scholarship and Loan Repayment Recovery 

Fund¿ 

SEC. 111. SCHOLARSHIP AND LOAN REPAYMENT RECOVERY FUND. 

(a) ESTABLISHMENT.—There is established in the Treasury of the 

United States a fund to be known as the Indian Health Scholarship 

and Loan Repayment Recovery Fund (hereafter in this section referred to as the ø‘‘Fund’’¿ ‘‘LRRF’’). The øFund¿ LRRF shall consist 

of such amounts as may be øappropriated to the Fund under subsection (b) of this section. Amounts appropriated for the Fund¿ collected from individuals under section 104(d), section 106(e), and section 110(l) for breach of contract, such funds as may be appropriated to the LRRF, and interest earned on amounts in the LRRF. 

All amounts collected, appropriated, or earned relative to the LRRF 

shall remain available until expended. 


bajohnson on PROD1PC71 with REPORTS
131 

ø(b) Authorization of appropriations 

øFor each fiscal year, there is authorized to be appropriated to 

the Fund an amount equal to the sum of— ø(1) the amount collected during the preceding fiscal year by 

the Federal Government pursuant to— ø(A) the liability of individuals under subparagraph (A) 

or (B) of section 1613a(b)(5) of this title for the breach of 

contracts entered into under 1613a of this title; and 

ø(B) the liability of individuals under section 1616a(l) of 

this title for the breach of contracts entered into under section 1616a of this title; and 

ø(2) the aggregate amount of interest accruing during the 

preceding fiscal year on obligations held in the Fund pursuant 

to subsection (d) of this section and the amount of proceeds 

from the sale or redemption of such obligations during such fiscal year. 

ø(c)¿ (b) Use of øfunds¿ FUNDS.—

(1) BY SECRETARY.—Amounts in the øFund and available 

pursuant to appropriation Acts¿ LRRF may be expended by 

the Secretary, acting through the Service, to make payments 

to an Indian øtribe or tribal organization administering a 

health care program pursuant to a contract entered into under 

the Indian Self-Determination Act [25 U.S.C.A. § 450f et 

seq.]—¿ Health Program—

(A) to which a scholarship recipient under section 

ø1613a of this title¿ 104 and 106 or a loan repayment program participant under section ø1616a of this title¿ 110 

has been assigned to meet the obligated service requirements pursuant to such sections; and 

(B) that has a need for a health professional to provide 

health care services as a result of such recipient or participant having breached the contract entered into under section ø1613a of this title, or section 1616a of this title.¿ 

104, 106, or section 110. 

ø(2) An Indian tribe or tribal organization¿ (2) BY TRIBAL

HEALTH PROGRAMS.—A Tribal Health Program receiving payments pursuant to paragraph (1) may expend the payments to 

provide scholarships or recruit and employ, directly or by contract, health professionals to provide health care services. 

ø(d)¿ (c) INVESTMENT OF øexcess funds (1)¿ FUNDS.—The Secretary of the Treasury shall invest such amounts of the øFund¿ 

LRRF as øsuch¿ the Secretary of Health and Human Services determines are not required to meet current withdrawals from the 

øFund¿ LRRF. Such investments may be made only in interestbearing obligations of the United States. For such purpose, such 

obligations may be acquired on original issue at the issue price, or 

by purchase of outstanding obligations at the market price. 

ø(2)¿ (d) SALE OF OBLIGATIONS.—Any obligation acquired by the 

øFund¿ LRRF may be sold by the Secretary of the Treasury at the 

market price. 

ø§ 1616b. Recruitment activities¿ 

SEC. 112. RECRUITMENT ACTIVITIES. 

(a) REIMBURSEMENT FOR TRAVEL.—The Secretary, acting through 

the Service, may reimburse health professionals seeking positions 


bajohnson on PROD1PC71 with REPORTS
132 

øin the Service¿ with Indian Health Programs or Urban Indian Organizations, including individuals considering entering into a contract under section ø1616a of this title,¿ 110 and their spouses, for 

actual and reasonable expenses incurred in traveling to and from 

their places of residence to an area in which they may be assigned 

for the purpose of evaluating such area with respect to such assignment. 

ø(b)¿ (b) RECRUITMENT PERSONNEL.—The Secretary, acting 

through the Service, shall assign øone¿ 1 individual in each øarea 

office¿ Area Office to be responsible on a full-time basis for recruitment activities. 

ø§ 1616c. Tribal recruitment and retention program¿ 

SEC. 113. INDIAN RECRUITMENT AND RETENTION PROGRAM. 

ø(a) Projects funded on competitive basis¿ 

(a) IN GENERAL.—The Secretary, acting through the Service, 

shall fund, on a competitive basis, innovative demonstration 

projects for a period not to exceed 3 years to enable øIndian tribes 

and tribal and Indian organizations¿ Tribal Health Programs and 

Urban Indian Organizations to recruit, place, and retain health 

professionals to meet øthe¿ their staffing needs øof Indian health 

programs (as defined in section 1616a(a)(2) of this title)¿. 

ø(b) Eligibility¿ 

ø(1) Any Indian tribe or tribal or Indian organization¿(b) ELIGIBLE ENTITIES; APPLICATION.—Any Tribal Health Program or Urban 

Indian Organization may submit an application for funding of a 

project pursuant to this section. 

ø(2) Indian tribes and tribal and Indian organizations under the 

authority of the Indian Self-Determination Act [25 U.S.C.A. § 450f 

et seq.] shall be given an equal opportunity with programs that are 

administered directly by the Service to compete for, and receive, 

grants under subsection (a) of this section for such projects. 

ø§ 1616d. Advanced training and research¿ 

SEC. 114. ADVANCED TRAINING AND RESEARCH 

ø(a) Establishment of program¿ 

(a) DEMONSTRATION PROGRAM.—The Secretary, acting through 

the Service, shall establish a øprogram¿ demonstration project to 

enable health professionals who have worked in an Indian Health 

Program or Urban Indian Organization for a substantial period of 

time to pursue advanced training or research øin¿ areas of study 

for which the Secretary determinates a need exists. øIn selecting 

participants for a program established under this subsection, the 

Secretary, acting through the Service, shall give priority to applicants who are employed by the Indian Health Service, Indian 

tribes, tribal organizations, and urban Indian organizations, at the 

time of the submission of the applications.¿ 

ø(b) Obligated service¿ 

(b) SERVICE OBLIGATION.—An individual who participates in a 

program under subsection (a) øof this section¿, where the educational costs are borne by the Service, shall incur an obligation to 

serve in an Indian øhealth program (as defined in section 

1616a(a)(2) of this title)¿ Health Program or Urban Indian Organization for a period of obligated service equal to at least the period 

of time during which the individual participates in such program. 


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133 

In the event that the individual fails to complete such obligated 

service, the individual shall be liable to the United States for the 

period of service remaining. In such event, with respect to individuals entering the program after øOctober 29, 1992,¿ the date of enactment of the Indian Health Care Improvement Act Amendments 

of 2007, the United States shall be entitled to recover from such 

individual an amount to be determined in accordance with the formula specified in subsection (1) of section ø1616a of this title¿ 110 

in the manner provided for in such subsection. 

ø(c) Eligibility¿ 

(c) EQUAL OPPORTUNITY FOR PARTICIPATION.—Health professionals from øIndian tribes and tribal and Indian organizations 

under the authority of the Indian Self Determination Act [25 

U.S.C.A. § 450f et seq.¿ Tribal Health Programs and Urban Indian 

Organizations shall be given an equal opportunity to participate in 

the program under subsection (a)øof this section¿. 

ø§ 1616e. Nursing program¿ 

SEC. 115. QUENTIN N. BURDICK AMERICAN INDIANS INTO NURSING 

PROGRAM. 

(a) GRANTS. 

øThe Secretary, acting through the Service, shall provide grants 

to—

ø(1) public or private schools of nursing, 

ø(2) tribally controlled community colleges and tribally controlled postsecondary vocational institutions (as defined in section 2397h(2) of Title 20), and¿ 

ø(3) nurse midwife programs, and nurse practitioner programs, that are provided by any public or private institution, 

for¿ AUTHORIZED.—For the purpose of increasing the number 

of nurses, nurse midwives, and nurse practitioners who deliver 

health care services to Indians, the Secretary, acting through 

the Service, shall provide grants to the following: 

(1) Public or private schools of nursing. 

(2) Tribal colleges or universities. 

(3) Nurse midwife programs and advanced practice nurse 

programs that are provided by any tribal college or university 

accredited nursing program, or in the absence of such, any 

other public or private institutions. 

(b) øPurposes¿ USE OF GRANTS.—Grants provided under subsection (a) øof this section¿ may be used øto—¿ for 1 or more of 

the following: 

(1) To recruit individuals for programs which train individuals to be nurses, nurse midwives, or ønurse practitioners,¿ 

advanced practice nurses. 

(2) To provide scholarships to øindividuals¿ Indians enrolled 

in such programs that may pay the tuition charged for such 

program and other expenses incurred in connection with such 

program, including books, fees, room and board, and stipends 

for living expensesø,¿. 

(3) To provide a program that encourages nurses, nurse midwives, and ønurse practitioners¿ advanced practice nurses to 

provide, or continue to provide, health care services to 

Indiansø,¿. 


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134 

(4) To provide a program that increases the skills of, and 

provides continuing education to, nurses, nurse midwives, and 

ønurse practitioners, or¿ advanced practice nurses. 

(5) To provide any program that is designed to achieve the 

purpose described in subsection (a) øof this section¿. 

(c) ƒApplication≈ APPLICATIONS.—Each application for a grant 

under subsection (a) øof this section¿ shall include such information as the Secretary may require to establish the connection between the program of the applicant and a health care facility that 

primarily serves Indians. 

ø(d) Preference¿ 

(d) PREFERENCES FOR GRANT RECIPIENTS.—In providing grants 

under subsection (a) øof this section¿, the Secretary shall extend a 

preference toø—¿ the following: 

(1) øprograms¿ Programs that provide a preference to 

Indiansø,¿. 

(2) øprograms¿ Programs that train nurse midwives or 

ønurse practitioners,¿ advanced practice nurses. 

(3) øprograms¿ Programs that are interdisciplinaryø, and¿. 

(4) øprograms¿ Programs that are conducted in cooperation 

with a øcenter¿ program for gifted and talented Indian students øestablished under section 2624(a) of this title¿. 

(5) Programs conducted by tribal colleges and universities. 

(e) QUENTIN N. BURDICK øAmerican Indians Into Nursing¿ PROGRAM GRANT.—The Secretary shall provide øone¿ 1 of the grants 

authorized under subsection (a)øof this section¿ to establish and 

maintain a program at the University of North Dakota to be known 

as the ‘‘Quentin N. Burdick American Indians Into Nursing Program’’. Such program shall, to the maximum extent feasible, coordinate with the Quentin N. Burdick Indian Health Programs established under section ø1616g¿ 117(b) øof this title¿ and the Quentin 

N. Burdick American Indians Into Psychology Program established 

under section ø1621p¿ 105(b) øof this title¿. 

(f) ACTIVE DUTY SERVICE øobligation¿ OBLIGATION.—The active 

duty service obligation prescribed under section ø254m of this 

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

be met by each individual who receives training or assistance described in paragraph (1) or (2) of subsection (b) øof this section¿ 

that is funded by a grant provided under subsection (a) øof this 

section¿. Such obligation shall be met by service—

ø(A)¿ (1) in the øIndian Health¿ Service; 

ø(B)¿ (2) in a program of an Indian Tribe or Tribal Organization conducted under øa contract entered into under¿ the Indian Self-Determination and Education Assistance Act ø[¿(25 

U.S.C.øA. §¿ 450øf et seq.]; (C¿ et seq.) (including programs 

under agreements with the Bureau of Indian Affairs); 

(3) in a program assisted under øsubchapter IV¿ title V of 

this øchapter; or¿ Act; 

ø(D)¿(4) in the private practice of nursing if, as determined 

by the Secretary, in accordance with guidelines promulgated by 

the Secretary, such practice is situated in a physician or other 

health øprofessional¿ shortage area and addresses the health 

care needs of a substantial number of Indiansø.¿; or 

ø(g) Authorization of appropriations 


bajohnson on PROD1PC71 with REPORTS
135 

øBeginning with fiscal year 1993, of the amounts appropriated 

under the authority of this subchapter for each fiscal year to be 

used to carry out this section, not less than $1,000,000 shall be 

used to provide grants under subsection (a) of this section for the 

training of nurse midwives, nurse anesthetists, and nurse practitioners. 

ø§1616e–1. Nursing school clinics 

ø(a) Grants 

øIn addition to the authority of the Secretary under section 

1616e(a)(1) of this title, the Secretary, acting through the Service, 

is authorized to provide grants to public or private schools of nursing for the purpose of establishing, developing, operating, and administering clinics to address the health care needs of Indians, and 

to provide primary health care services to Indians who reside on 

or within 50 miles of Indian country, as defined in section 1151 of 

Title 18. 

ø(b) Purposes 

øGrants provided under subsection (a) of this section may be 

used to—

ø(1) establish clinics, to be run and staffed by the faculty and 

students of a grantee school, to provide primary care services 

in areas in or within 50 miles of Indian country (as defined in 

section 1151 of Title 18); 

ø(2) provide clinical training, program development, faculty 

enhancement, and student scholarships in a manner that 

would benefit such clinics; and 

ø(3) carry out any other activities determined appropriate by 

the Secretary. 

ø(c) Amount and conditions 

øThe Secretary may award grants under this section in such 

amounts and subject to such conditions as the Secretary deems appropriate. 

ø(d) Design 

øThe clinics established under this section shall be designed to 

provide nursing students with a structured clinical experience that 

is similar in nature to that provided by residency training programs for physicians. 

ø(e) Regulations 

øThe Secretary shall prescribe such regulations as may be necessary to carry out the provisions of this section. 

ø(f) Authorization to use amounts 

øOut of amounts appropriated to carry out this subchapter for 

each of the fiscal years 1993 through 2000 not more than 

$5,000,000 may be used to carry out this section.¿ 

(5) in a teaching capacity in a tribal college or university 

nursing program (or a related health profession program) if, as 

determined by the Secretary, health services provided to Indians 

would not decrease. 

ø§1616f. Tribal culture and history] 

SEC. 116. TRIBAL CULTURAL ORIENTATION. 

ø(a) Program established¿ 

(a) CULTURAL EDUCATION OF EMPLOYEES.—The Secretary, acting 

through the Service, shall øestablish a program under 


bajohnson on PROD1PC71 with REPORTS
136 

which¿require that appropriate employees of the Service who serve 

øparticular¿ Indian øtribes shall¿Tribes in each Service Area receive educational instruction in the history and culture of such 

øtribes and in the history of¿Indian Tribes and their relationship 

to the Service. 

(b) øTribally-controlled community collegesTo the extent feasible, 

the program established under subsection (a) of this section shall¿ 

PROGRAM.—In carrying out subsection (a), the Secretary shall establish a program which shall, to the extent feasible—

ø(1) be carried out through tribally-controlled community colleges (within the meaning of section 1801(4) of this title) and 

tribally controlled postsecondary vocational institutions (as defined in section 2397h(2) of Title 20), 

ø(2) be developed in consultation with the affected tribal government, and¿ 

(1) be developed in consultation with the affected Indian 

Tribes, Tribal Organizations, and Urban Indian Organizations; 

(2) be carried out through tribal colleges or universities; 

(3) include instruction in Native American Indian studies; 

and 

(4) describe the use and place of traditional health care practices of the Indian Tribes in the Service Area. 

ø§1616g.¿ 

SEC. 117. INMED øprogram¿ PROGRAM. 

(a) GRANTS AUTHORIZED.—The Secretary, acting through the 

Service, is authorized to provide grants to øat least 3¿ colleges and 

universities for the purpose of maintaining and expanding the øNative American¿ Indian health careers recruitment program known 

as the ø‘‘¿‘Indians øinto¿ Into Medicine Program’’’ (hereinafter in 

this section referred to as ‘‘‘INMED’’’) as a means of encouraging 

Indians to enter the health professions. 

ø(b) University of North Dakota¿ 

(b) QUENTIN N. BURDICK GRANT.—The Secretary shall provide 

one1 of the grants authorized under subsection (a) to maintain the 

INMED program at the University of North Dakota, to be known 

as the ø‘‘¿‘Quentin N. Burdick Indian Health Programsø’’¿’, unless 

the Secretary makes a determination, based upon program reviews, 

that the program is not meeting the purposes of this section. Such 

program shall, to the maximum extent feasible, coordinate with the 

Quentin N. Burdick American Indians Into Psychology Program established under section ø1621p¿ 105(b) øof this title¿ and the 

Quentin N. Burdick American Indians Into Nursing Program established under section ø1616e(e) of this title.¿ 115. 

(c) REGULATIONSø; contents of recruitment program (1)¿.—The 

Secretary, pursuant to this Act, shall develop regulations øfor the 

competitive awarding of the¿ to govern grants øprovided under¿ 

pursuant to this section. 

ø(2)¿ (d) REQUIREMENTS.—Applicants for grants provided under 

this section shall agree to provide a program which—

ø(A)¿ (1) provides outreach and recruitment for health professions to Indian communities including elementaryø,¿ and 

secondary schools and community colleges located on øIndian¿ 

reservations which will be served by the programø,¿; 


bajohnson on PROD1PC71 with REPORTS
137 

ø(B)¿ (2) incorporates a program advisory board comprised of 

representatives from the øtribes¿ Indian Tribes and Indian 

communities which will be served by the programø,¿; 

ø(C)¿ (3) provides summer preparatory programs for Indian 

students who need enrichment in the subjects of math and 

science in order to pursue training in the health professionsø,¿; 

ø(D)¿ (4) provides tutoring, counseling, and support to students who are enrolled in a health career program of study at 

the respective college or universityø,¿; and 

ø(E)¿ (5) to the maximum extent feasible, employs qualified 

Indians in the program. 

ø(d) Report to Congress 

øBy no later than the date that is 3 years after November 23, 

1988, the Secretary shall submit a report to the Congress on the 

program established under this section including recommendations 

for expansion or changes to the program. 

ø§ 1616h. Health training programs of community colleges¿ 

SEC. 118. HEALTH TRAINING PROGRAMS OF COMMUNITY COLLEGES. 

(a) GRANTS TO ESTABLISH PROGRAMS.— (1) IN GENERAL.—The Secretary, acting through the Service, 

shall award grants to accredited and accessible community colleges for the purpose of assisting øthe community college¿ such 

community colleges in the establishment of programs which 

provide education in a health profession leading to a degree or 

diploma in a health profession for individuals who desire to 

practice such profession on øan Indian¿ or near a reservation 

or in øa tribal clinic¿ an Indian Health Program. (2) AMOUNT OF GRANTS.—The amount of any grant awarded 

to a community college under paragraph (1) for the first year 

in which such a grant is provided to the community college 

shall not exceed $ø100,000.¿ 250,000. 

ø(b) Eligibility¿ 

(b) GRANTS FOR MAINTENANCE AND RECRUITING.—

ø(1)¿ (1) IN GENERAL.—The Secretary, acting through the 

Service, shall award grants to accredited and accessible community colleges that have established a program described in 

subsection (a)(1) øof this section¿ for the purpose of maintaining the program and recruiting students for the program. 

(2) REQUIREMENTS.—Grants may only be made under this 

section to a community college which—

(A) is accreditedø,¿; 

(B) has øaccess to¿ a relationship with a hospital facility, Service facility, or hospital that could provide training 

of nurses or health professionalsø,¿; 

(C) has entered into an agreement with an accredited 

college or university medical school, the terms of which—

(i) provide a program that enhances the transition 

and recruitment of students into advanced baccalaureate or graduate programs øwhich¿ that train 

health professionalsø,¿; and 

(ii) stipulate certifications necessary to approve internship and field placement opportunities at øservice 

unit facilities of the Service or at tribal health facilities,¿ Indian Health Programs; 


bajohnson on PROD1PC71 with REPORTS
138 

(D) has a qualified staff which has the appropriate 

certificationsø, and¿; 

(E) is capable of obtaining State or regional accreditation 

of the program described in subsection (a)(1) øof¿; and 

(F) agrees to provide for Indian preference for applicants 

for programs under this section. 

ø(c) Agreements and technical assistance¿ 

(c) TECHNICAL ASSISTANCE.—The Secretary shall encourage community colleges described in subsection (b)(2) øof this section¿ to 

establish and maintain programs described in subsection (a)(1) øof 

this section¿ by—

(1) entering into agreements with such colleges for the provision of qualified personnel of the Service to teach courses of 

study in such programs[,]; and 

(2) providing technical assistance and support to such colleges. 

(d) ADVANCED øTRAINING¿ TRAINING.—

(1) REQUIRED.—Any program receiving assistance under this 

section that is conducted with respect to a health profession 

shall also offer courses of study which provide advanced training for any health professional who—

ø(1)¿ (A) has already received a degree or diploma in 

such health professionø,¿; and 

ø(2)¿ (B) provides clinical services on øan Indian¿ or 

near a reservationø, at a Service facility, or at a tribal clinic¿ or for an Indian Health Program. 

(2) MAY BE OFFERED AT ALTERNATE SITE.—Such courses of 

study may be offered in conjunction with the college or university with which the community college has entered into the 

agreement required under subsection (b)(2)(C) øof this section¿. 

ø(e) Definitions 

øFor purposes of this section— ø(1) The term ‘‘community college’’ means—

ø(A) a tribally controlled community college, or 

ø(B) a junior or community college. 

ø(2) The term ‘‘tribally controlled community college’’ has the 

meaning given to such term by section 1801(4) of this title. 

ø(3) The term ‘‘junior or community college’’ has the meaning 

given to such term by section 1058(e) of Title 20.¿ 

(e) PRIORITY.—Where the requirements of subsection (b) are met, 

grant award priority shall be provided to tribal colleges and universities in Service Areas where they exist. 

ø§ 1616i. Additional incentives for health professionals¿ 

SEC. 119. RETENTION BONUS. 

ø(a) Incentive special pay 

øThe Secretary may provide the incentive special pay authorized 

under section 302(b) of Title 37, to civilian medical officers of the 

Indian Health Service who are assigned to, and serving in, positions included in the list established under subsection (b)(1) of this 

section for which recruitment or retention of personnel is difficult. 

ø(b) List of positions; bonus pay 

ø(1) The Secretary shall establish and update on an annual 

basis a list of positions of health care professionals¿ (a) BONUS


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139 

AUTHORIZED.—The Secretary may pay a retention bonus to any 

health professional employed by, or assigned to, øthe Service 

for which recruitment or retention is difficult. 

ø(2)(A) The Secretary may pay a bonus to any commissioned 

officer or civil service employee, other than a commissioned 

medical officer, dental officer, optometrist, and veterinarian, 

who is employed in or assigned to, and serving in, a position 

in the Service included in the list established by the Secretary 

under paragraph (1). 

ø(B) The total amount of bonus payments made by the Secretary under this paragraph to any employee during any 1- 

year period shall not exceed $2,000. 

ø(c) Work schedules 

øThe Secretary may establish programs to allow the use of flexible work schedules, and compressed work schedules, in accordance 

with the provisions of subchapter II of chapter 61 of Title 5, for 

health professionals employed by, or assigned to, the Service. 

ø§ 1616j. Retention bonus 

ø(a) ELIGIBILITY.—The Secretary may pay a retention bonus to 

any physician or nurse employed by, or assigned to, and serving in, 

the Service¿ and serving in, an Indian Health Program or Urban 

Indian Organization either as a civilian employee or as a commissioned officer in the Regular or Reserve Corps of the Public Health 

Service who—

(1) is assigned to, and serving in, a position øincluded in the 

list established under section 1616i(b)(1) of this title¿ for which 

recruitment or retention of personnel is difficultø,¿; 

(2) the Secretary determines is needed by øthe Service,¿ Indian Health Programs and Urban Indian Organizations; 

(3) has—

(A) completed ø3¿ 2 years of employment with øthe 

Service, or¿ an Indian Health Program or Urban Indian 

Organization; or 

(B) completed any service obligations incurred as a requirement of— (i) any Federal scholarship programø,¿; or 

(ii) any Federal education loan repayment 

programø,¿; and 

(4) enters into an agreement with øthe Service¿ an Indian 

Health Program or Urban Indian Organization for continued 

employment for a period of not less than 1 year. 

ø(b) Minimum award percentage to nurses 

øBeginning with fiscal year 1993, not less than 25 percent of the 

retention bonuses awarded each year under subsection (a) of this 

section shall be awarded to nurses. 

ø(c)¿ (b) RATESø; maximum rate¿.—The Secretary may establish 

rates for the retention bonus which shall provide for a higher annual rate for multiyear agreements than for single year agreements 

referred to in subsection (a)(4)øof this section¿, but in no event 

shall the annual rate be more than $25,000 per annum. 

ø(d) Time of payment 

øThe retention bonus for the entire period covered by the agreement described in subsection (a)(4) of this section shall be paid at 

the beginning of the agreed upon term of service. 


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ø(e) Refund; interest 

øAny physician or nurse¿ (c) DEFAULT OF RETENTION AGREEMENT.—Any health professional failing to complete the agreed upon 

term of service, except where such failure is through no fault of the 

individual, shall be obligated to refund to the Government the full 

amount of the retention bonus for the period covered by the agreement, plus interest as determined by the Secretary in accordance 

with section ø1616a¿ 110(l)(2)(B)øof this title¿. 

ø(f) Physicians and nurses employed under Indian Self-Determination Act¿ (d) OTHER RETENTION BONUS.—The Secretary may 

pay a retention bonus to any øphysician or nurse employed by an 

organization providing health care services to Indians pursuant to 

a contract under the Indian Self-Determination Act [25 U.S.C.A. 

§450f et seq.] if such physician or nurse¿ health professional employed by a Tribal Health Program if such health professional is 

serving in a position which the Secretary determines is—

(1) a position for which recruitment or retention is difficult; 

and 

(2) necessary for providing health care services to Indians. 

ø§1616k. Nursing residency program¿ 

SEC. 120. NURSING RESIDENCY PROGRAM. 

(a) ESTABLISHMENT OF PROGRAM.—The Secretary, acting through 

the Service, shall establish a program to enable Indians who are 

licensed practical nurses, licensed vocational nurses, and registered 

nurses who are working in an Indian øhealth program (as defined 

in section 1616a(a)(2)(A) of this title¿ Health Program or Urban Indian Organization, and have done so for a period of not less than 

øone¿ 1 year, to pursue advanced training. 

ø(b) Program components¿Such program shall include a combination of education and work study in an Indian øhealth program (as 

defined in section 1616a(a)(2)(A) of this title)¿ Health Program or 

Urban Indian Organization leading to an associate or bachelor’s 

degree (in the case of a licensed practical nurse or licensed vocational nurse)øor¿, a bachelor’s degree (in the case of a registered 

nurse)øor a Master’s degree¿, or advanced degrees or certifications 

in nursing and public health. 

ø(c)¿ (b) SERVICE øobligation of program participant¿OBLIGATION.— An individual who participates in a program 

under subsection (a) øof this section¿, where the educational costs 

are paid by the Service, shall incur an obligation to serve in an Indian øhealth program¿ Health Program or Urban Indian Organization for a period of obligated service equal to øat least three times 

the period of time during which the individual¿ 1 year for every 

year that nonprofessional employee (licensed practical nurses, licensed vocational nurses, nursing assistants, and various health 

care technicals), or 2 years for every year that professional nurse 

(associate degree and bachelor-prepared registered nurses), participates in such program. In the event that the individual fails to 

complete such obligated service, the United States shall be entitled 

to recover from such individual an amount determined in accordance with the formula specified in subsection (l) of section ø1616a 

of this title¿ 110 in the manner provided for in such subsection. 


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141 

ø§ 1616l. Community Health Aide Program for Alaska¿ 

SEC. 121. COMMUNITY HEALTH AIDE PROGRAM. 

ø(a) Maintenance of program¿ 

(a) GENERAL PURPOSES OF PROGRAM.—Under the authority of 

øsection 13 of this title¿ the Act of November 2, 1921 (25 U.S.C. 13) 

(commonly known as the ‘‘Snyder Act’’, the Secretary, acting 

through the Service, shall ømaintain¿ develop and operate a Community Health Aide Program in Alaska under which the Service—

(1) provides for the training of Alaska Natives as health 

aides or community health practitioners; 

(2) uses such aides or practitioners in the provision of health 

care, health promotion, and disease prevention services to 

Alaska Natives living in villages in rural Alaska; and 

(3) provides for the establishment of teleconferencing capacity in health clinics located in or near such villages for use by 

community health aides or community health practitioners. 

ø(b) Training; curriculum; Certification Board¿ 

(b) SPECIFIC PROGRAM REQUIREMENTS.—The Secretary, acting 

through the Community Health Aide Program of the Service, 

shall—

(1) using trainers accredited by the Program, provide a high 

standard of training to community health aides and community health practitioners to ensure that such aides and practitioners provide quality health care, health promotion, and disease prevention services to the villages served by the Program; 

(2) in order to provide such training, develop a curriculum 

that—

(A) combines education in the theory of health care with 

supervised practical experience in the provision of health 

care; 

(B) provides instruction and practical experience in the 

provision of acute care, emergency care, health promotion, 

disease prevention, and the efficient and effective management of clinic pharmacies, supplies, equipment, and facilities; and 

(C) promotes the achievement of the health status objectives specified in section ø1602(b) of this title¿ 3(2); 

(3) establish and maintain a Community Health Aide Certification Board to certify as community health aides or community health practitioners individuals who have successfully 

completed the training described in paragraph (1) or can demonstrate equivalent experience; 

(4) develop and maintain a system which identifies the needs 

of community health aides and community health practitioners 

for continuing education in the provision of health care, including the areas described in paragraph (2)(B), and develop programs that meet the needs for such continuing education; 

(5) develop and maintain a system that provides close supervision of community health aides and community health practitioners; øand¿ 

(6) develop a system under which the work of community 

health aides and community health practitioners is reviewed 

and evaluated to assure the provision of quality health care, 

health promotion, and disease prevention servicesø.¿; and 


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(7) ensure that pulpal therapy (not including pulpotomies on 

deciduous teeth) or extraction of adult teeth can be performed 

by a dental health aide therapist only after consultation with 

a licensed dentist who determines that the procedure is a medical emergency that cannot be resolved with palliative treatment, and further that dental health aide therapists are strictly 

prohibited from performing all other oral or jaw surgeries, provided that uncomplicated extractions shall not be considered 

oral surgery under this section. 

(c) PROGRAM REVIEW.— (1) NEUTRAL PANEL.— (A) ESTABLISHMENT.—The Secretary, acting through the 

Service, shall establish a neutral panel to carry out the 

study under paragraph (2). 

(B) MEMBERSHIP.—Members of the neutral panel shall be 

appointed by the Secretary from among clinicians, economists, community practitioners, oral epidemiologists, and 

Alaska Natives. 

(2) STUDY.—

(A) IN GENERAL.—The neutral panel established under 

paragraph (1) shall conduct a study of the dental health 

aide therapist services provided by the Community Health 

Aide Program under this section to ensure that the quality 

of care provided through those services is adequate and appropriate. 

(B) PARAMETERS OF STUDY.—The Secretary, in consultation with interested parties, including professional dental 

organizations, shall develop the parameters of the study. 

(C) INCLUSIONS.—The study shall include a determination by the neutral panel with respect to—

(i) the ability of the dental health aide therapist services under this section to address the dental care needs 

of Alaska Natives; 

(ii) the quality of care provided through those services, including any training, improvement, or additional oversight required to improve the quality of care; 

and 

(iii) whether safer and less costly alternatives to the 

dental health aide therapist services exist. 

(D) CONSULTATION.—In carrying out the study under this 

paragraph, the neutral panel shall consult with Alaska 

Tribal Organizations with respect to the adequacy and accuracy of the study. 

(3) REPORT.—The neutral panel shall submit to the Secretary, 

the Committee on Indian Affairs of the Senate, and the Committee on Natural Resources of the House of Representatives a 

report describing the results of the study under paragraph (2), 

including a description of—

(A) any determination of the neutral panel under paragraph (2)(C); and 

(B) any comments received from an Alaska Tribal Organization under paragraph (2)(D). 

(d) NATIONALIZATION OF PROGRAM.—

(1) IN GENERAL.—Except as provided in paragraph (2), the 

Secretary, acting through the Service, may establish a national 


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Community Health Aide Program in accordance with the program under this section, as the Secretary determines to be appropriate. 

ø§ 1616m. Matching grants to tribes for scholarship programs¿ 

(2) EXCEPTION.—The national Community Health Aide Program under paragraph (1) shall not include dental health aide 

therapist services. 

ø(a) In general 

ø(1) The Secretary shall make grants to Indian tribes and 

tribal organizations for the purpose of assisting such tribes and 

tribal organizations in educating Indians to serve as health 

professionals in Indian communities. 

ø(2) Amounts available for grants under paragraph (1) for 

any fiscal year shall not exceed 5 percent of amounts available 

for such fiscal year for Indian Health Scholarships under section 1613a of this title. 

ø(3) An application for a grant under paragraph (1) shall be 

in such form and contain such agreements, assurances, and information as the Secretary determines are necessary to carryout this section. 

ø(b) Compliance with requirements 

ø(1) An Indian tribe or tribal organization receiving a grant 

under subsection (a) of this section shall agree to provide scholarships to Indians pursuing education in the health professions 

in accordance with the requirements of this section. 

ø(2) With respect to the costs of providing any scholarship 

pursuant to paragraph (1)— ø(A) 80 percent of the costs of the scholarship shall be 

paid from the grant made under subsection (a) of this section to the Indian tribe or tribal organization; and 

ø(B) 20 percent of such costs shall be paid from non-Federal contributions by the Indian tribe or tribal organization through which the scholarship is provided. 

ø(3) In determining the amount of non-Federal contributions 

that have been provided for purposes of subparagraph (B) of 

paragraph (2), any amounts provided by the Federal Government to the Indian tribe or tribal organization involved or to 

any other entity shall not be included. 

ø(4) Non-Federal contributions required by subparagraph (B) 

of paragraph (2) may be provided directly by the Indian tribe 

or tribal organization involved or through donations from public and private entities. 

ø(c) Course of study in health professions 

An Indian tribe or tribal organization shall provide scholarships 

under subsection (b) of this section only to Indians enrolled or accepted for enrollment in a course of study (approved by the Secretary) in one of the health professions described in section 

1613a(a) of this title. 

ø(d) Contract requirements 

In providing scholarships under subsection (b) of this section, the 

Secretary and the Indian tribe or tribal organization shall enter 

into a written contract with each recipient of such scholarship. 

Such contract shall—


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144 

ø(1) obligate such recipient to provide service in an Indian 

health program (as defined in section 1616a(a)(2)(A) of this 

title), in the same service area where the Indian tribe or tribal 

organization providing the scholarship is located, for— ø(A) a number of years equal to the number of years for 

which the scholarship is provided (or the part-time equivalent thereof, as determined by the Secretary), or for a period of 2 years, whichever period is greater; or 

ø(B) such greater period of time as the recipient and the 

Indian tribe or tribal organization may agree; 

ø(2) provide that the amount of such scholarship— ø(A) may be expended only for— ø(i) tuition expenses, other reasonable educational 

expenses, and reasonable living expenses incurred in 

attendance at the educational institution; and 

ø(ii) payment to the recipient of a monthly stipend 

of not more than the amount authorized by section 

254m(g)(1)(B) of Title 42, such amount to be reduced 

pro rata (as determined by the Secretary) based on the 

number of hours such student is enrolled; and 

ø(B) may not exceed, for any year of attendance for 

which the scholarship is provided, the total amount required for the year for the purposes authorized in subparagraph (A); 

ø(3) require the recipient of such scholarship to maintain an 

acceptable level of academic standing (as determined by the 

educational institution in accordance with regulations issued 

by the Secretary); and 

ø(4) require the recipient of such scholarship to meet the 

educational and licensure requirements necessary to be a physician, certified nurse practitioner, certified nurse midwife, or 

physician assistant. 

ø(e) Breach of contract 

ø(1) An individual who has entered into a written contract 

with the Secretary and an Indian tribe or tribal organization 

under subsection (d) of this section and who—

ø(A) fails to maintain an acceptable level of academic 

standing in the educational institution in which he is enrolled (such level determined by the educational institution 

under regulations of the Secretary), 

ø(B) is dismissed from such educational institution for 

disciplinary reasons, 

ø(C) voluntarily terminates the training in such an educational institution for which he is provided a scholarship 

under such contract before the completion of such training, 

or 

ø(D) fails to accept payment, or instructs the educational 

institution in which he is enrolled not to accept payment, 

in whole or in part, of a scholarship under such contract, 

in lieu of any service obligation arising under such contract, shall be liable to the United States for the Federal 

share of the amount which has been paid to him, or on his 

behalf, under the contract. 

ø(2) If for any reason not specified in paragraph (1), an individual breaches his written contract by failing either to begin 


bajohnson on PROD1PC71 with REPORTS
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such individual’s service obligation required under such contract or to complete such service obligation, the United States 

shall be entitled to recover from the individual an amount determined in accordance with the formula specified in subsection (l) of section 1616a(l) of this title in the manner provided for in such subsection. 

ø(3) The Secretary may carryout this subsection on the basis 

of information submitted by the tribes or tribal organizations 

involved, or on the basis of information collected through such 

other means as the Secretary determines to be appropriate. 

ø(f) Nondiscriminatory practice 

The recipient of a scholarship under subsection (b) of this section shall agree, in providing health care pursuant to the requirements of subsection (d)(1) of this section— ø(1) not to discriminate against an individual seeking such 

care on the basis of the ability of the individual to pay for such 

care or on the basis that payment for such care will be made 

pursuant to the program established in title XVIII of the Social 

Security Act [42 U.S.C.A. § 1395 et seq] or pursuant to the program established in title XIX of such Act [42 U.S.C.A. § 1396 

et seq.]; and 

ø(2) to accept assignment under section 1842(b)(3)(B)(ii) of 

the Social Security Act [42 U.S.C.A. § 1395u(b)(3)(B)(ii)] for all 

services for which payment may be made under part B of title 

XVIII of such Act [42 U.S.C.A. § 1395j et seq.], and to enter 

into an appropriate agreement with the State agency that administers the State plan for medical assistance under title XIX 

of such Act [42 U.S.C.A. § 1396 et seq.] to provide service to individuals entitled to medical assistance under the plan. 

ø(g) Payments for subsequent fiscal years 

øThe Secretary may not make any payments under subsection (a) 

of this section to an Indian tribe or tribal organization for any fiscal year subsequent to the first fiscal year of such payments unless 

the Secretary determines that, for the immediately preceding fiscal 

year, the Indian tribe or tribal organization has complied with requirements of this section.¿ 

(3) REQUIREMENT.—In establishing a national program 

under paragraph (1), the Secretary shall not reduce the amount 

of funds provided for the Community Health Aide Program described in subsections (a) and (b). 

ø§ 1616n. Tribal health program administration¿ 

SEC. 122. TRIBAL HEALTH PROGRAM ADMINISTRATION. 

øThe Secretary¿ The Secretary, acting through the Service, shall, 

by contract or otherwise, provide training for øindividuals¿ Indians 

in the administration and planning of øtribal health programs¿ 

Tribal Health Programs. 

SEC. 123. HEALTH PROFESSIONAL CHRONIC SHORTAGE DEMONSTRATION PROGRAMS. 

ø§ 1616o. University of South Dakota pilot program¿ 

(a) DEMONSTRATION PROGRAMS AUTHORIZED.—The Secretary, acting through the Service, may fund demonstration programs for 

Tribal Health Programs to address the chronic shortages of health 

professionals. 


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146 

ø(a) Establishment 

øThe Secretary may make a grant to the School of Medicine of 

the University of South Dakota (hereafter in this section referred 

to as ‘‘USDSM’’) to establish a pilot program on an Indian reservation at one or more service units in South Dakota to address the 

chronic manpower shortage in the Aberdeen Area of the Service.¿ 

(b) PURPOSES OF PROGRAMS.—The purposes of øthe program established pursuant to a grant provided¿ demonstration programs 

funded under subsection (a) øare¿ shall be—

(1) to provide direct clinical and practical experience at a 

øservice unit to medical¿ Service Unit to health profession students and residents from øUSDSM and other¿ medical schools; 

(2) to improve the quality of health care for Indians by assuring access to qualified health care professionals; and 

(3) to provide academic and scholarly opportunities for physicians, øphysician assistants, nurse practitioners, nurses, and 

other allied¿ health professionals serving øIndian people¿ Indians by identifying øand utilizing¿ all academic and scholarly 

resources of the region. 

ø(c) Composition; designation 

øThe pilot program¿ (c) ADVISORY BOARD.—The demonstration 

programs established pursuant to a øgrant provided under¿ subsection (a) shallø—(1)¿ incorporate a program advisory board composed of representatives from the øtribes¿ Indian Tribes and Indian communities in the area which will be served by the 

programø; and¿. 

ø(2) shall be designated as an extension of the USDSM campus and program participants shall be under the direct supervision and instruction of qualified medical staff serving at the 

service unit who shall be members of the USDSM faculty. 

ø(d) Coordination with other schools 

øThe USDSM shall coordinate the program established pursuant 

to a grant provided under subsection (a) of this section with other 

medical schools in the region, nursing schools, tribal community 

colleges, and other health professional schools. 

ø(e) Development of additional professional opportunities 

øThe USDSM, in cooperation with the Service, shall develop additional professional opportunities for program participants on Indian reservations in order to improve the recruitment and retention of qualified health professionals in the Aberdeen Area of the 

Service.¿ 

SEC. 124. NATIONAL HEALTH SERVICE CORPS. 

(a) NO REDUCTION IN SERVICES.—The Secretary shall not—

(1) remove a member of the National Health Service Corps 

from an Indian Health Program or Urban Indian Organization; or 

(2) withdraw funding used to support such member, unless 

the Secretary, acting through the Service, has ensured that the 

Indians receiving services from such member will experience no 

reduction in services. 

(b) EXEMPTION FROM LIMITATIONS—National Health Service 

Corps scholars qualifying for the Commissioned Corps in the Public 

Health Service shall be exempt from the full-time equivalent limitations of the National Health Service Corps and the Service when 


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serving as a commissioned corps officer in a Tribal Health Program 

or an Urban Indian Organization. 

SEC. 125. SUBSTANCE ABUSE COUNSELOR EDUCATIONAL CURRICULA 

DEMONSTRATION PROGRAMS. 

(a) CONTRACTS AND GRANTS.—The Secretary, acting through the 

Service, may enter into contracts with, or make grants to, accredited 

tribal colleges and universities and eligible accredited and accessible community colleges to establish demonstration programs to develop educational curricula for substance abuse counseling. 

(b) USE OF FUNDS.—Funds provided under this section shall be 

used only for developing and providing educational curriculum for 

substance abuse counseling (including paying salaries for instructors). Such curricula may be provided through satellite campus programs. 

(c) TIME PERIOD OF ASSISTANCE; RENEWAL.—A contract entered 

into or a grant provided under this section shall be for a period of 

3 years. Such contract or grant may be renewed for an additional 

2-year period upon the approval of the Secretary. 

(d) CRITERIA FOR REVIEW AND APPROVAL OF APPLICATIONS.—Not 

later than 180 days after the date of enactment of the Indian Health 

Care Improvement Act Amendments of 2007, the Secretary, after 

consultation with Indian Tribes and administrators of tribal colleges and universities and eligible accredited and accessible community colleges, shall develop and issue criteria for the review and approval of applications for funding (including applications for renewals of funding) under this section. Such criteria shall ensure that 

demonstration programs established under this section promote the 

development of the capacity of such entities to educate substance 

abuse counselors. 

(e) ASSISTANCE.—The Secretary shall provide such technical and 

other assistance as may be necessary to enable grant recipients to 

comply with the provisions of this section. 

(f) REPORT.—Each fiscal year, the Secretary shall submit to the 

President, for inclusion in the report which is required to be submitted under section 801 for that fiscal year, a report on the findings and conclusions derived from the demonstration programs conducted under this section during that fiscal year. 

(g) DEFINITION.—For the purposes of this section, the term ‘‘educational curriculum’’ means 1 or more of the following: 

(1) Classroom education. 

(2) Clinical work experience. 

(3) Continuing education workshops. 

SEC. 126. BEHAVIORAL HEALTH TRAINING AND COMMUNITY EDUCATION PROGRAMS. 

(a) STUDY; LIST.—The Secretary, acting through the Service, and 

the Secretary of the Interior, in consultation with Indian Tribes and 

Tribal Organizations, shall conduct a study and compile a list of 

the types of staff positions specified in subsection (b) whose qualifications include, or should include, training in the identification, 

prevention, education, referral, or treatment of mental illness, or 

dysfunctional and self destructive behavior. 

(b) POSITIONS.—The positions referred to in subsection (a) are—

(1) staff positions within the Bureau of Indian Affairs, including existing positions, in the fields of—

(A) elementary and secondary education; 


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(B) social services and family and child welfare; 

(C) law enforcement and judicial services; and 

(D) alcohol and substance abuse; 

(2) staff positions within the Service; and 

(3) staff positions similar to those identified in paragraphs (1) 

and (2) established and maintained by Indian Tribes, Tribal 

Organizations (without regard to the funding source), and 

Urban Indian Organizations. 

(c) TRAINING CRITERIA.—

(1) IN GENERAL.—The appropriate Secretary shall provide 

training criteria appropriate to each type of position identified 

in subsection (b)(1) and (b)(2) and ensure that appropriate 

training has been, or shall be provided to any individual in any 

such position. With respect to any such individual in a position 

identified pursuant to subsection (b)(3), the respective Secretaries shall provide appropriate training to, or provide funds to, 

an Indian Tribe, Tribal Organization, or Urban Indian Organization for training of appropriate individuals. In the case of positions funded under a contract or compact under the Indian 

Self-Determination and Education Assistance Act (25 U.S.C. 

450 et seq.), the appropriate Secretary shall ensure that such 

training costs are included in the contract or compact, as the 

Secretary determines necessary. 

(2) POSITION SPECIFIC TRAINING CRITERIA.—Position specific 

training criteria shall be culturally relevant to Indians and Indian Tribes and shall ensure that appropriate information regarding traditional health care practices is provided. 

(d) COMMUNITY EDUCATION ON MENTAL ILLNESS.—The Service 

shall develop and implement, on request of an Indian Tribe, Tribal 

Organization, or Urban Indian Organization, or assist the Indian 

Tribe, Tribal Organization, or Urban Indian Organization to develop and implement, a program of community education on mental 

illness. In carrying out this subsection, the Service shall, upon request of an Indian Tribe, Tribal Organization, or Urban Indian Organization, provide technical assistance to the Indian Tribe, Tribal 

Organization, or Urban Indian Organization to obtain and develop 

community educational materials on the identification, prevention, 

referral, and treatment of mental illness and dysfunctional and selfdestructive behavior. 

ø§ 1616p. Authorization of appropriations¿ 

(e) PLAN.—Not later than 90 days after the date of enactment of 

the Indian Health Care Improvement Act Amendments of 2007, the 

Secretary shall develop a plan under which the Service will increase 

the health care staff providing behavioral health services by at least 

500 positions within 5 years after the date of enactment of this section, with at least 200 of such positions devoted to child, adolescent, 

and family services. The plan developed under this subsection shall 

be implemented under the Act of November 2, 1921 (25 U.S.C. 13) 

(commonly known as the ‘‘Snyder Act’’). 

SEC. 127. AUTHORIZATION OF APPROPRIATIONS. 

There are authorized to be appropriated such sums as may be 

necessary for each fiscal year through fiscal year ø2000¿ 2017 to 

carry out this øsubchapter¿ title. 


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149 

TITLE II—HEALTH SERVICES 

ø§ 1621. Indian Health Care Improvement Fund¿ 

SEC. 201. INDIAN HEALTH CARE IMPROVEMENT FUND. 

ø(a) Approved expenditures¿ 

(a) USE OF FUNDS.—The Secretary, acting through the Service, is 

authorized to expend funds, directly or under the authority of the 

Indian Self-Determination and Education Assistance Act (25 U.S.C. 

450 et seq.), which are appropriated under the authority of this section, øthrough the Service,¿ for the purposes of— (1) eliminating the deficiencies in health status and health 

resources of all Indian øtribes,¿ Tribes; 

(2) eliminating backlogs in the provision of health care services to Indiansø,¿; 

(3) meeting the health needs of Indians in an efficient and 

equitable manner, øand¿ including the use of telehealth and 

telemedicine when appropriate; 

(4) eliminating inequities in funding for both direct care and 

contract health service programs; and 

ø(4)¿ (5) augmenting the ability of the Service to meet the 

following health service responsibilitiesø, either through direct 

or contract care or through contracts entered into pursuant to 

the Indian Self-Determination Act [25 U.S.C.A. § 450f et seq.],¿ 

with respect to those Indian øtribes¿ Tribes with the highest 

levels of health status deficiencies and resource deficiencies: 

(A) øclinical¿ Clinical care ø(direct and indirect)¿, including inpatient care, outpatient care (including audiology, clinical eye, and vision careø;¿), primary care, secondary and tertiary care, and long-term care. 

(B) øpreventive¿ Preventive health, including øscreening¿ mammography and other cancer screening in accordance with section ø1621k of this title;¿ 207. 

ø(C) dental care (direct and indirect);¿ (C) Dental care. 

(D) ømental¿ Mental health, including community mental health services, inpatient mental health services, dormitory mental health services, therapeutic and residential 

treatment centers, and training of traditional øIndian¿ 

health care practitionersø;¿. (E) øemergency¿ Emergency medical servicesø;¿. (F) øtreatment¿ Treatment and control of, and rehabilitative care related to, alcoholism and drug abuse (including fetal alcohol syndrome) among Indiansø;¿. (G) øaccident¿ Injury prevention programsø;¿, including 

data collection and evaluation, demonstration projects, 

training, and capacity building. 

(H) øhome¿ Home health careø;¿. (I) øcommunity¿ Community health representativesø; 

and¿. ø(J) maintenance and repair.¿ 

ø(b) Effect of other appropriations; allocation to service units¿ 

(J) Maintenance and improvement. 

ø(1)¿ (b) NO OFFSET OR LIMITATION.—Any funds appropriated 

under the authority of this section shall not be used to offset or 

limit any other appropriations made to the Service under øsection 

13 of this title¿ this Act or the Act of November 2, 1921 (25 U.S.C. 


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150 

13) (commonly known as the ‘‘Snyder Act’’), or any other provision 

of law. 

(c) ALLOCATION; USE.—

ø(2)¿ (1)ø(A)¿ IN GENERAL.—Funds appropriated under the 

authority of this section ømay¿ shall be allocated øon a service 

unit basis¿ to Service Units, Indian Tribes, or Tribal Organizations. The funds allocated to each øservice unit¿ Indian Tribe, 

Tribal Organization, or Service Unit under this øsubparagraph¿ paragraph shall be used by the øservice unit to reduce¿ 

Indian Tribe, Tribal Organization, or Service Unit under this 

paragraph to improve the health status and reduce the resource deficiency of each øtribe¿ Indian Tribe served by such 

øservice unit¿ Service Unit, Indian Tribe, or Tribal Organization. 

øB¿ (2) APPORTIONMENT OF ALLOCATED FUNDS.—The apportionment of funds allocated to a øservice unit under subparagraph (A)¿ Service Unit, Indian Tribe, or Tribal Organization 

under paragraph (1) among the health service responsibilities 

described in subsection (a)ø(4) of this section¿ (5) shall be determined by the Service in consultation with, and with the active participation of, the affected Indian øtribes¿ Tribes and 

Tribal Organizations. 

ø(c) Health Resources Deficiency Levels.—For¿ (d) PROVISIONS

RELATING TO HEALTH STATUS AND RESOURCE DEFICIENCIES.—For 

the purposes of this section—, the following definitions apply: 

(1) DEFINITION.—The term ‘‘health status and resource deficiency’’ means the extent to which—

(A) the health status objectives set forth in section 

ø1602(b) of this title¿ 3(2) are not being achieved; and 

(B) the Indian øtribe¿ Tribe or Tribal Organization does 

not have available to it the health resources it needs, taking into account the actual cost of providing health care 

services given local geographic, climatic, rural, or other circumstances. 

(2) AVAILABLE RESOURCES.—The health resources available 

to an Indian øtribe¿ Tribe or Tribal Organization include 

health resources provided by the Service as well as health resources used by the Indian øtribe¿ Tribe or Tribal Organization, including services and financing systems provided by any 

Federal programs, private insurance, and programs of State or 

local governments. 

(3) PROCESS FOR REVIEW OF DETERMINATIONS.—The Secretary shall establish procedures which allow any Indian 

øtribe¿ Tribe or Tribal Organization to petition the Secretary 

for a review of any determination of the extent of the health 

status and resource deficiency of such øtribe¿ Indian Tribe or 

Tribal Organization. 

ø(d) Programs administered by Indian tribe¿ 

ø(1) Programs administered by any Indian tribe or tribal organization under the authority of the Indian Self-Determination Act¿ (e) ELIGIBILITY FOR FUNDS.—Tribal Health Programs 

shall be eligible for funds appropriated under the authority of 

this section on an equal basis with programs that are administered directly by the Service. 


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ø(2) If any funds allocated to a tribe or service unit under 

the authority of this section are used for a contract entered 

into under the Indian Self-Determination Act [25 U.S.C.A. 

§450f et seq.], a reasonable portion of such funds may be used 

for health planning, training, technical assistance, and other 

administrative support functions.¿ 

ø(e)¿ (f) REPORT øTO CONGRESS¿.—By no later than the date that 

is 3 years after øOctober 29, 1992,¿ the date of enactment of the Indian Health Care Improvement Act Amendments of 2007, the Secretary shall submit to the Congress the current health status and 

resource deficiency report of the Service for each øIndian tribe or 

service unit¿ Service Unit, including newly recognized or acknowledged øtribes¿ Indian Tribes. Such report shall set out— (1) the methodology then in use by the Service for determining øtribal¿ Tribal health status and resource deficiencies, 

as well as the most recent application of that methodology; 

(2) the extent of the health status and resource deficiency of 

each Indian øtribe¿ Tribe served by the Service or a Tribal 

Health Program; 

(3) the amount of funds necessary to eliminate the health 

status and resource deficiencies of all Indian øtribes¿ Tribes 

served by the Service or a Tribal Health Program; and 

(4) an estimate of— (A) the amount of health service funds appropriated 

under the authority of this øchapter¿ Act, or any other 

Act, including the amount of any funds transferred to the 

Serviceø,¿ for the preceding fiscal year which is allocated 

to each øservice unit¿ Service Unit, Indian øtribe¿ Tribe, or øcomparable entity¿ Tribal Organization; 

(B) the number of Indians eligible for health services in 

each øservice unit¿ Service Unit or Indian øtribe; and¿ 

Tribe or Tribal Organization; and 

(C) the number of Indians using the Service resources 

made available to each øservice unit or Indian tribe.¿ 

Service Unit, Indian Tribe or Tribal Organization, and, to 

the extent available, information on the waiting lists and 

number of Indians turned away for services due to lack of 

resources. 

ø(f) Appropriated funds included in base budget of Service¿ 

(g) INCLUSION IN BASE BUDGET.—Funds appropriated under øauthority of¿ this section for any fiscal year shall be included in the 

base budget of the Service for the purpose of determining appropriations under this section in subsequent fiscal years. 

ø(g) Continuation of Service responsibilities for backlogs and parity ¿ 

(h) CLARIFICATION.—Nothing in this section is intended to diminish the primary responsibility of the Service to eliminate existing 

backlogs in unmet health care needs, nor are the provisions of this 

section intended to discourage the Service from undertaking additional efforts to achieve øparity¿ equity among Indian øtribes.¿ 

Tribes and Tribal Organizations. 

ø(h) Authorization of appropriations¿ 

(i) FUNDING DESIGNATION.—Any funds appropriated under the 

authority of this section shall be designated as the ø‘‘¿‘Indian 

Health Care Improvement Fund.ø’’¿’


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152 

ø§ 1621a. Catastrophic Health Emergency Fund¿ 

SEC. 202. CATASTROPHIC HEALTH EMERGENCY FUND. 

(a) ESTABLISHMENTø; ADMINISTRATION; PURPOSE (1)¿.—There is 

øhereby¿ established an Indian Catastrophic Health Emergency 

Fund (hereafter in this section referred to as the ø‘‘Fund’’¿ 

‘‘CHEF’’) consisting of—

ø(A)¿ (1) the amounts deposited under subsection ø(d) of this 

section,¿ (f); and 

ø(B)¿ (2)) the amounts appropriated to øthe Fund¿ CHEF 

under this section. 

ø(2) The Fund¿(b) ADMINISTRATION.—CHEF shall be administered by the Secretary, acting through the øcentral office¿ 

headquarters of the Service, solely for the purpose of meeting 

the extraordinary medical costs associated with the treatment 

of victims of disasters or catastrophic illnesses who are within 

the responsibility of the Service. 

ø(3) The Fund shall not¿ (c) CONDITIONS ON USE OF FUND.—

No part of CHEF or its administration shall be subject to contract or grant under any law, including the Indian Self-Determination and Education Assistance Act (25 U.S.C. 450 et seq.), 

nor shall CHEF funds be allocated, apportioned, or delegated 

on øa service unit, area office, or any other¿ an Area Office, 

Service Unit, or other similar basis. 

ø(4) No part of the Fund or its administration shall be subject to contract or grant under any law, including the Indian 

Self-Determination Act [25 U.S.C.A. § 450f et seq.].¿ 

ø(b) Regulations; procedures for payment¿ 

(d) REGULATIONS.—The Secretary shallø, through the promulgation of¿ promulgate regulations consistent with the provisions of 

this section to—

(1) establish a definition of disasters and catastrophic illnesses for which the cost of the treatment provided under contract would qualify for payment from øthe Fund¿ CHEF; 

(2) provide that a øservice unit¿ Service Unit shall not be eligible for reimbursement for the cost of treatment from øthe 

Fund¿ CHEF until its cost of treating any victim of such catastrophic illness or disaster has reached a certain threshold cost 

which the Secretary shall establish at—

ø(A) for 1993, not less than $15,000 or not more than 

$25,000; and¿ 

(A) the 2000 level of $19,000; and 

(B) for any subsequent year, not less than the threshold 

cost of the previous year increased by the percentage increase in the medical care expenditure category of the consumer price index for all urban consumers (United States 

city average) for the 12-month period ending with December of the previous year; 

(3) establish a procedure for the reimbursement of the portion of the costs that exceeds such threshold cost incurred by—

ø(A) service units or facilities of the Service, or¿ 

(A) Service Units; or 

(B) whenever otherwise authorized by the Service, nonService facilities or providersø, in rendering treatment 

that exceeds such threshold cost¿; 


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(4) establish a procedure for payment from øthe Fund¿ 

CHEF in cases in which the exigencies of the medical circumstances warrant treatment prior to the authorization of 

such treatment by the Service; and 

(5) establish a procedure that will ensure that no payment 

shall be made from øthe Fund¿ CHEF to any provider of treatment to the extent that such provider is eligible to receive payment for the treatment from any other Federal, State, local, or 

private source of reimbursement for which the patient is eligible. 

ø(c) Effect on other appropriations¿ 

(e) NO OFFSET OR LIMITATION.—Amounts appropriated to øthe 

Fund¿ CHEF under this section shall not be used to offset or limit 

appropriations made to the Service under the authority of øsection 

13 of this title¿ the Act of November 2, 1921 (25 U.S.C. 13) (commonly known as the ‘‘Snyder Act’’), or any other law. 

ø(d) Reimbursements to fund¿ 

(f) DEPOSIT OF REIMBURSEMENT FUNDS.—There shall be deposited into øthe Fund¿ CHEF all reimbursements to which the Service is entitled from any Federal, State, local, or private source (including third party insurance) by reason of treatment rendered to 

any victim of a disaster or catastrophic illness the cost of which 

was paid from øthe Fund¿ CHEF. 

SEC. 203. HEALTH PROMOTION AND DISEASE PREVENTION SERVICES. 

(a) FINDINGS.—Congress finds that health promotion and disease 

prevention activities— (1) improve the health and well-being of Indians; and 

ø§1621b. Health promotion and disease prevention services¿ 

(2) reduce the expenses for health care of Indians. 

ø(a) Authorization¿ 

(b) PROVISION OF SERVICES.—The Secretary, acting through the 

Service and Tribal Health Programs, shall provide health promotion and disease prevention services to Indians øso as¿ to 

achieve the health status objectives set forth in section ø1602(b) of 

this title¿3(2). ø(b)¿(c) EVALUATION østatement for Presidential budget¿.—The 

Secretary, after obtaining input from the affected Tribal Health 

Programs, shall submit to the President for inclusion in øeach 

statement¿ the report which is required to be submitted to øthe¿ 

Congress under section ø1671 of this title¿ 801 an evaluation of— (1) the health promotion and disease prevention needs of 

Indiansø,¿; 

(2) the health promotion and disease prevention activities 

which would best meet such needsø,¿; 

(3) the internal capacity of the Service and Tribal Health 

Programs to meet such needsø,¿; and 

(4) the resources which would be required to enable the Service and Tribal Health Programs to undertake the health promotion and disease prevention activities necessary to meet 

such needs. 

ø§ 1621c. Diabetes prevention, treatment, and control¿ 

SEC. 204. DIABETES PREVENTION, TREATMENT, AND CONTROL. 

ø(a) Incidence and complications¿ 


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154 

(a) DETERMINATIONS REGARDING DIABETES.—The Secretary, acting through the Service, and in consultation with øthe tribes¿ Indian Tribes and Tribal Organizations, shall determine— (1) by øtribe¿ Indian Tribe and by Service øunit of the Service¿ Unit, the incidence of, and the types of complications resulting from, diabetes among Indians; and 

(2) based on the determinations made pursuant to paragraph 

(1), the measures (including patient education and effective ongoing monitoring of disease indicators) each Service øunit¿ 

Unit should take to reduce the incidence of, and prevent, treat, 

and control the complications resulting from, diabetes among 

øtribes¿ Indian Tribes within that Service øunit¿ Unit. (b) DIABETES SCREENING.—øThe¿To the extent medically indicated and with informed consent, the Secretary shall screen each 

Indian who receives services from the Service for diabetes and for 

conditions which indicate a high risk that the individual will become diabetic and establish a cost-effective approach to ensure ongoing monitoring of disease indicators. Such screening ømay be done 

by a tribe or tribal organization operating health care programs or 

facilities with funds from the Service under the Indian Self-Determination Act [25 U.S.C.A. § 450f et seq.].¿ and monitoring may be 

conducted by a Tribal Health Program and may be conducted 

through appropriate Internet-based health care management programs. 

ø(c) Model diabetes projects¿ 

ø(1)¿ (c) DIABETES PROJECTS.—The Secretary shall continue to 

maintain through øfiscal year 2000¿ each model diabetes project in 

existence on øOctober 29, 1992 and located—¿ the date of enactment of the Indian Health Care Improvement Act Amendments of 

2007, any such other diabetes programs operated by the Service or 

Tribal Health Programs, and any additional diabetes projects, such 

as the Medical Vanguard program provided for in title IV of Public 

Law 108–87, as implemented to serve Indian Tribes. Tribal Health 

Programs shall receive recurring funding for the diabetes projects 

that they operate pursuant to this section, both at the date of enactment of the Indian Health Care Improvement Act Amendments of 

2007 and for projects which are added and funded thereafter. 

ø(A) at the Claremore Indian Hospital in Oklahoma; 

ø(B) at the Fort Totten Health Center in North Dakota; 

ø(C) at the Sacaton Indian Hospital in Arizona; 

ø(D) at the Winnebago Indian Hospital in Nebraska; 

ø(E) at the Albuquerque Indian Hospital in New Mexico; 

ø(F) at the Perry, Princeton, and Old Town Health Centers in Maine; 

ø(G) at the Bellingham Health Center in Washington; 

ø(H) at the Fort Berthold Reservation; 

ø(I) at the Navajo Reservation; 

ø(J) at the Papago Reservation; 

ø(K) at the Zuni Reservation; or 

ø(L) in the States of Alaska, California, Minnesota, Montana, Oregon, or Utah. 

ø(2) The Secretary may establish new model diabetes projects 

under this section taking into consideration applications received under this section from all service areas, except that the 

Secretary may not establish a greater number of such projects 


bajohnson on PROD1PC71 with REPORTS
155 

in one service area than in any other service area until there 

is an equal number of such projects established with respect to 

all service areas from which the Secretary receives qualified 

applications during the application period (as determined by 

the Secretary). 

ø(d) Control officer; registry of patients 

øThe Secretary shall—¿ 

(d) DIALYSIS PROGRAMS.—The Secretary is authorized to provide, 

through the Service, Indian Tribes, and Tribal Organizations, dialysis programs, including the purchase of dialysis equipment and 

the provision of necessary staffing. (e) OTHER DUTIES OF THE SECRETARY.— (1) IN GENERAL.—The Secretary shall, to the extent funding is 

available— ø(1) employ in each area office of the Service at least one diabetes control officer who shall coordinate and manage on a 

full-time basis activities within that area office¿ (A) in each 

Area Office, consult with Indian Tribes and Tribal Organizations regarding programs for the prevention, treatment, and 

control of diabetes; 

ø(2) establish in each area office of the Service¿ (B) establish 

in each Area Office a registry of patients with diabetes to track 

the incidence of diabetes and the complications from diabetes 

in that area; and 

ø(3)¿(C) ensure that data collected in each øarea office¿ Area 

Office regarding diabetes and related complications among Indians øis¿ are disseminated to all other øarea offices; and (4) 

evaluate the effectiveness of services provided through model 

diabetes projects established under this section¿ Area Offices, 

subject to applicable patient privacy laws. ø(e) Authorization of appropriations 

øFunds appropriated under this section in any fiscal year shall 

be in addition to base resources appropriated to the Service for that 

year.¿ 

(2) DIABETES CONTROL OFFICERS.— (A) IN GENERAL.—The Secretary may establish and maintain in each Area Office a position of diabetes control officer to coordinate and manage any activity of that Area Office relating to the prevention, treatment, or control of diabetes to assist the Secretary in carrying out a program 

under this section or section 330C of the Public Health 

Service Act (42 U.S.C. 254c–3). 

(B) CERTAIN ACTIVITIES.—Any activity carried out by a 

diabetes control officer under subparagraph (A) that is the 

subject of a contract or compact under the Indian Self-Determination and Education Assistance Act (25 U.S.C. 450 

et seq.), and any funds made available to carry out such an 

activity, shall not be divisible for purposes of that Act. 

SEC. 205. SHARED SERVICES FOR LONG-TERM CARE. 

(a) LONG-TERM CARE.—Notwithstanding any other provision of 

law, the Secretary, acting through the Service, is authorized to provide directly, or enter into contracts or compacts under the Indian 

Self-Determination and Education Assistance Act (25 U.S.C. 450 et 

seq.) with Indian Tribes or Tribal Organizations for, the delivery of 

long-term care (including health care services associated with longVerDate Aug 31 2005 01:51 Oct 27, 2007 Jkt 069010 PO 00000 Frm 00155 Fmt 6659 Sfmt 6603 E:\HR\OC\SR197.XXX SR197

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156 

term care) provided in a facility to Indians. Such agreements shall 

provide for the sharing of staff or other services between the Service 

or a Tribal Health Program and a long-term care or related facility 

owned and operated (directly or through a contract or compact 

under the Indian Self-Determination and Education Assistance Act 

(25 U.S.C. 450 et seq.)) by such Indian Tribe or Tribal Organization. 

(b) CONTENTS OF AGREEMENTS.—An agreement entered into pursuant to subsection (a)—

ƒ§ 1621d. Hospice care feasibility study≈ 

(1) may, at the request of the Indian Tribe or Tribal Organization, delegate to such Indian Tribe or Tribal Organization 

such powers of supervision and control over Service employees 

as the Secretary deems necessary to carry out the purposes of 

this section; 

ø(a) Duty of Secretary 

øThe Secretary, acting through the Service and in consultation 

with representatives of Indian tribes, tribal organizations, Indian 

Health Service personnel, and hospice providers, shall conduct a 

study—

ø(1) to assess the feasibility and desirability of furnishing 

hospice care to terminally ill Indians; and 

ø(2) to determine the most efficient and effective means of 

furnishing such care. 

ø(b) Functions of study 

øSuch study shall— ø(1) assess the impact of Indian culture and beliefs concerning death and dying on the provision of hospice care to Indians; 

ø(2) estimate the number of Indians for whom hospice care 

may be appropriate and determine the geographic distribution 

of such individuals; 

ø(3) determine the most appropriate means to facilitate the 

participation of Indian tribes and tribal organizations in providing hospice care; 

ø(4) identify and evaluate various means for providing hospice care, including—

ø(A) the provision of such care by the personnel of a 

Service hospital pursuant to a hospice program established 

by the Secretary at such hospital; and 

ø(B) the provision of such care by a community-based 

hospice program under contract to the Service; and 

ø(5) identify and assess any difficulties in furnishing such 

care and the actions needed to resolve such difficulties. 

ø(c) Report to Congress 

øNot later than the date which is 12 months after October 29, 

1992, the Secretary shall transmit to the Congress a report containing—

ø(1) a detailed description of the study conducted pursuant 

to this section; and 

ø(2) a discussion of the findings and conclusions of such 

study. 

ø(d) Definitions 

øFor the purposes of this section—


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ø(1) the term ‘‘terminally ill’’ means any Indian who has a 

medical prognosis (as certified by a physician) of a life expectancy of six months or less; and 

ø(2) the term ‘‘hospice program’’ means any program which 

satisfies the requirements of section 1395x(dd)(2) of Title 42; 

and 

ø(3) the term ‘‘hospice care’’ means the items and services 

specified in subparagraphs (A) through (H) of section 

1395x(dd)(1) of Title 42.¿ 

(2) shall provide that expenses (including salaries) relating to 

services that are shared between the Service and the Tribal 

Health Program be allocated proportionately between the Service and the Indian Tribe or Tribal Organization; and 

ø§ 1621e. Reimbursement from certain third parties of costs 

of health services¿ 

(3) may authorize such Indian Tribe or Tribal Organization 

to construct, renovate, or expand a long-term care or other similar facility (including the construction of a facility attached to 

a Service facility). 

ø(a) Right of recovery 

øExcept as provided in subsection (f) of this section, the United 

States, an Indian tribe, or a tribal organization shall have the right 

to recover the reasonable expenses incurred by the Secretary, an 

Indian tribe, or a tribal organization in providing health services, 

through the Service, an Indian tribe, or a tribal organization, to 

any individual to the same extent that such individual, or any nongovernmental provider of such services, would be eligible to receive 

reimbursement or indemnification for such expenses if— ø(1) such services had been provided by a nongovernmental 

provider, and 

ø(2) such individual had been required to pay such expenses 

and did pay such expenses. 

ø(b) Recovery against State with workers’ compensation laws or 

no-fault automobile accident insurance program 

øSubsection (a) of this section shall provide a right of recovery 

against any State only if the injury, illness, or disability for which 

health services were provided is covered under—

ø(1) workers’ compensation laws, or 

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

ø(c) Prohibition of State law or contract provision impeding right 

of recovery 

øNo law of any State, or of any political subdivision of a State, 

and no provision of any contract entered into or renewed after November 23, 1988, shall prevent or hinder the right of recovery of 

the United States, an Indian tribe, or a tribal organization under 

subsection (a) of this section. 

ø(d) Right to damages 

øNo action taken by the United States, an Indian tribe, or a tribal organization to enforce the right of recovery provided under subsection (a) of this section shall affect the right of any person to any 

damages (other than damages for the cost of health services provided by the Secretary through the Service). 

ø(e) Intervention or separate civil action 


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øThe United States, an Indian tribe, or a tribal organization may 

enforce the right of recovery provided under subsection (a) of this 

section by— ø(1) intervening or joining in any civil action or proceeding 

brought—

ø(A) by the individual for whom health services were 

provided by the Secretary, an Indian tribe, or a tribal organization, or 

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

ø(2) instituting a separate civil action, after providing to 

such individual, or to the representative or heirs of such individual, notice of the intention of the United States, an Indian 

tribe, or a tribal organization to institute a separate civil action. 

ø(f) Right of recovery for services when self-insurance plan provides coverage 

øThe United States shall not have a right of recovery under this 

section if the injury, illness, or disability for which health services 

were provided is covered under a self-insurance plan funded by an 

Indian tribe or tribal organization.¿ 

(c) MINIMUM REQUIREMENT.—Any nursing facility provided for 

under this section shall meet the requirements for nursing facilities 

under section 1919 of the Social Security Act. 

ø§ 1621f. Crediting of reimbursements¿ 

(d) OTHER ASSISTANCE.—The Secretary shall provide such technical and other assistance as may be necessary to enable applicants 

to comply with the provisions of this section. 

ø(a) Except as provided in section 1621a(d) of this title, subchapter III–A of this chapter, and section 1680c of this title, all reimbursements received or recovered, under authority of this chapter, Public Law 87–693 (42 U.S.C. 2651, et seq.), or any other provision of law, by reason of the provision of health services by the 

Service or by a tribe or tribal organization under a contract pursuant to the Indian Self-Determination Act [25 U.S.C.A. § 450f et 

seq.] shall be retained by the Service or that tribe or tribal organization and shall be available for the facilities, and to carry out the 

programs, of the Service or that tribe or tribal organization to provide health care services to Indians. 

ø(b) The Service may not offset or limit the amount of funds obligated to any service unit or any entity under contract with the 

Service because of the receipt of reimbursements under subsection 

(a) of this section.¿ 

(e) USE OF EXISTING OR UNDERUSED FACILITIES.—The Secretary 

shall encourage the use of existing facilities that are underused or 

allow the use of swing beds for long-term or similar care. 

ø§ 1621g. Health services research¿ 

SEC. 206. HEALTH SERVICES RESEARCH. 

øOf the amounts appropriated for¿ 

(a) IN GENERAL.—The Secretary, acting through the Service øin 

any fiscal year, other than amounts made available for the Indian 

Health Care Improvement Fund, not less than $200,000 shall be 

available only¿, shall make funding available for research to further the performance of the health service responsibilities of øthe 


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159 

Service. Indian tribes and tribal organizations contracting with the 

Service under the authority of the Indian Self-Determination Act 

[25 U.S.C.A. § 450f et seq.]¿ Indian Health Programs. 

(b) COORDINATION OF RESOURCES AND ACTIVITIES.—The Secretary shall also, to the maximum extent practicable, coordinate departmental research resources and activities to address relevant Indian Health Program research needs. 

(c) AVAILABILITY.—Tribal Health Programs shall be given an 

equal opportunity to compete for, and receive, research funds under 

this section. 

ø§ 1621h. Mental health prevention and treatment services 

ø(a) National plan for Indian Mental Health Services 

ø(1) Not later than 120 days after November 28, 1990, the 

Secretary, acting through the Service, shall develop and publish in the Federal Register a final national plan for Indian 

Mental Health Services. The plan shall include—

ø(A) an assessment of the scope of the problem of mental 

illness and dysfunctional and self-destructive behavior, including child abuse and family violence, among Indians, 

including—

ø(i) the number of Indians served by the Service 

who are directly or indirectly affected by such illness 

or behavior, and 

ø(ii) an estimate of the financial and human cost attributable to such illness or behavior; 

ø(B) an assessment of the existing and additional resources necessary for the prevention and treatment of such 

illness and behavior; and 

ø(C) an estimate of the additional funding needed by the 

Service to meet its responsibilities under the plan. 

ø(2) The Secretary shall submit a copy of the national plan 

to the Congress. 

ø(b) Memorandum of agreement 

øNot later than 180 days after November 28, 1990, the Secretary 

and the Secretary of the Interior shall develop and enter into a 

memorandum of agreement under which the Secretaries shall, 

among other things—

ø(1) determine and define the scope and nature of mental illness and dysfunctional and self-destructive behavior, including 

child abuse and family violence, among Indians; 

ø(2) make an assessment of the existing Federal, tribal, 

State, local, and private services, resources, and programs 

available to provide mental health services for Indians; 

ø(3) make an initial determination of the unmet need for additional services, resources, and programs necessary to meet 

the needs identified pursuant to paragraph (1); 

ø(4)(A) ensure that Indians, as citizens of the United States 

and of the States in which they reside, have access to mental 

health services to which all citizens have access; 

ø(B) determine the right of Indians to participate in, and receive the benefit of, such services; and 

ø(C) take actions necessary to protect the exercise of such 

right; 


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ø(5) delineate the responsibilities of the Bureau of Indian Affairs and the Service, including mental health identification, 

prevention, education, referral, and treatment services (including services through multidisciplinary resource teams), at the 

central, area, and agency and service unit levels to address the 

problems identified in paragraph (1); 

ø(6) provide a strategy for the comprehensive coordination of 

the mental health services provided by the Bureau of Indian 

Affairs and the Service to meet the needs identified pursuant 

to paragraph (1), including— ø(A) the coordination of alcohol and substance abuse programs of the Service, the Bureau of Indian Affairs, and the 

various tribes (developed under the Indian Alcohol and 

Substance Abuse Prevention and Treatment Act of 1986) 

[25 U.S.C.A. § 2401 et seq.] with the mental health initiatives pursuant to this Act, particularly with respect to the 

referral and treatment of dually-diagnosed individuals requiring mental health and substance abuse treatment; and 

ø(B) ensuring that Bureau of Indian Affairs and Service 

programs and services (including multidisciplinary resource teams) addressing child abuse and family violence 

are coordinated with such non-Federal programs and services; 

ø(7) direct appropriate officials of the Bureau of Indian Affairs and the Service, particularly at the agency and service 

unit levels, to cooperate fully with tribal requests made pursuant to subsection (d) of this section; and 

ø(8) provide for an annual review of such agreement by the 

two Secretaries. 

ø(c) Community mental health plan 

ø(1) The governing body of any Indian tribe may, at its discretion, adopt a resolution for the establishment of a community mental health plan providing for the identification and coordination of available resources and programs to identify, prevent, or treat mental illness or dysfunctional and self-destructive behavior, including child abuse and family violence, among 

its members. 

ø(2) In furtherance of a plan established pursuant to paragraph (1) and at the request of a tribe, the appropriate agency, 

service unit, or other officials of the Bureau of Indian Affairs 

and the Service shall cooperate with, and provide technical assistance to, the tribe in the development of such plan. Upon 

the establishment of such a plan and at the request of the 

tribe, such officials, as directed by the memorandum of agreement developed pursuant to subsection (c), of this section, shall 

cooperate with the tribe in the implementation of such plan. 

ø(3) Two or more Indian tribes may form a coalition for the 

adoption of resolutions and the establishment and development 

of a joint community mental health plan under this subsection. 

ø(4) The Secretary, acting through the Service, may make 

grants to Indian tribes adopting a resolution pursuant to paragraph (1) to obtain technical assistance for the development of 

a community mental health plan and to provide administrative 

support in the implementation of such plan. 

ø(d) Mental health training and community education programs 


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ø(1) The Secretary and the Secretary of the Interior, in consultation with representatives of Indian tribes, shall conduct a 

study and compile a list, of the types of staff positions specified 

in paragraph (2) whose qualifications include, or should include, training in the identification, prevention, education, referral, or treatment of mental illness or dysfunctional and selfdestructive behavior. 

ø(2) The positions referred to in paragraph (1) are— ø(A) staff positions within the Bureau of Indian Affairs, 

including existing positions, in the fields of— ø(i) elementary and secondary education; 

ø(ii) social services and family and child welfare; 

ø(iii) law enforcement and judicial services; and 

ø(iv) alcohol and substance abuse; 

ø(B) staff positions with the Service; and 

ø(C) staff positions similar to those identified in subparagraphs (A) and (B) established and maintained by Indian tribes, including positions established in contracts entered into under the Indian Self-Determination Act [25 

U.S.C.A. § 450f et seq.]. 

ø(3)(A) The appropriate Secretary shall provide training criteria appropriate to each type of position identified in paragraph (2)(A) and ensure that appropriate training has been, or 

will be, provided to any individual in any such position. With 

respect to any such individual in a position identified pursuant 

to paragraph (2)(C), the respective Secretaries shall provide appropriate training to, or provide funds to an Indian tribe for 

the training of, such individual. In the case of positions funded 

under a contract entered into under the Indian Self-Determination Act [25 U.S.C.A. § 450f et seq.], the appropriate Secretary 

shall ensure that such training costs are included in the contract, if necessary. 

ø(B) Funds authorized to be appropriated pursuant to this 

section may be used to provide training authorized by this 

paragraph for community education programs described in 

paragraph (5) if a plan adopted pursuant to subsection (d) of 

this section identifies individuals or employment categories, 

other than those identified pursuant to paragraph (1), for 

which such training or community education is deemed necessary or desirable. 

ø(4) Position-specific training criteria described in paragraph 

(3) shall be culturally relevant to Indians and Indian tribes 

and shall ensure that appropriate information regarding traditional Indian healing and treatment practices is provided. 

ø(5) The Service shall develop and implement or, upon the 

request of an Indian tribe, assist such tribe to develop and implement, a program of community education on mental illness 

and dysfunctional and self-destructive behavior for individuals, 

as determined in a plan adopted pursuant to subsection (d) of 

this section. In carrying out this paragraph, the Service shall 

provide, upon the request of an Indian tribe, technical assistance to the Indian tribe to obtain or develop community education and training materials on the identification, prevention, 

referral, and treatment of mental illness and dysfunctional and 

self-destructive behavior. 


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ø(e) Staffing 

ø(1) Within 90 days after November 28, 1990, the Secretary 

shall develop a plan under which the Service will increase the 

health care staff providing mental health services by at least 

500 positions within five years after November 28, 1990, with 

at least 200 of such positions devoted to child, adolescent, and 

family services. Such additional staff shall be primarily assigned to the service unit level for services which shall include 

outpatient, emergency, aftercare and follow-up, and prevention 

and education services. 

ø(2) The plan developed under paragraph (1) shall be implemented section 13 of this title. 

ø(f) Staff recruitment and retention 

ø(1) The Secretary shall provide for the recruitment of the 

additional personnel required by subsection (f) of this section 

and the retention of all Service personnel providing mental 

health services. In carrying out this subsection, the Secretary 

shall give priority to practitioners providing mental health 

services to children and adolescents with mental health problems. 

ø(2) In carrying out paragraph (1), the Secretary shall develop a program providing for—

ø(A) the payment of bonuses (which shall not be more favorable than those provided for under sections 1616i and 

1616j of this title) for service in hardship posts; 

ø(B) the repayment of loans (for which the provisions of 

repayment contracts shall not be more favorable than the 

repayment contracts under section 1616a of this title) for 

health professions education as a recruitment incentive; 

and 

ø(C) a system of postgraduate rotations as a retention 

incentive. 

ø(3) This subsection shall be carried out in coordination with 

the recruitment and retention programs under subchapter I of 

this chapter. 

ø(g) Mental Health Technician program 

ø(1) Under the authority of section 13 of this title, the Secretary shall establish and maintain a Mental Health Technician program within the Service which—

ø(A) provides for the training of Indians as mental 

health technicians; and 

ø(B) employs such technicians in the provision of community-based mental health care that includes identification, prevention, education, referral, and treatment services. 

ø(2) In carrying out paragraph (1)(A), the Secretary shall 

provide high standard paraprofessional training in mental 

health care necessary to provide quality care to the Indian 

communities to be served. Such training shall be based upon 

a curriculum developed or approved by the Secretary which 

combines education in the theory of mental health care with 

supervised practical experience in the provision of such care. 

ø(3) The Secretary shall supervise and evaluate the mental 

health technicians in the training program. 


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ø(4) The Secretary shall ensure that the program established 

pursuant to this subsection involves the utilization and promotion of the traditional Indian health care and treatment 

practices of the Indian tribes to be served. 

ø(h) Mental health research 

øThe Secretary, acting through the Service and in consultation 

with the National Institute of Mental Health, shall enter into contracts with, or make grants to, appropriate institutions for the conduct of research on the incidence and prevalence of mental disorders among Indians on Indian reservations and in urban areas. 

Research priorities under this subsection shall include—

ø(1) the inter-relationship and inter-dependence of mental 

disorders with alcoholism, suicide, homicides, accidents, and 

the incidence of family violence, and 

ø(2) the development of models of prevention techniques. 

øThe effect of the inter-relationships and interdependencies referred to in paragraph (1) on children, and the development of prevention techniques under paragraph (2) applicable to children, 

shall be emphasized. 

ø(i) Facilities assessment 

øWithin one year after November 28, 1990, the Secretary, acting 

through the Service, shall make an assessment of the need for inpatient mental health care among Indians and the availability and 

cost of inpatient mental health facilities which can meet such need. 

In making such assessment, the Secretary shall consider the possible conversion of existing, under-utilized service hospital beds 

into psychiatric units to meet such need. 

ø(j) Annual report 

øThe Service shall develop methods for analyzing and evaluating 

the overall status of mental health programs and services for Indians and shall submit to the President, for inclusion in each report 

required to be transmitted to the Congress under section 1671 of 

this title, a report on the mental health status of Indians which 

shall describe the progress being made to address mental health 

problems of Indian communities. 

ø(k) Mental health demonstration grant program 

ø(1) The Secretary, acting through the Service, is authorized 

to make grants to Indian tribes and inter-tribal consortia to 

pay 75 percent of the cost of planning, developing, and implementing programs to deliver innovative community-based mental health services to Indians. The 25 percent tribal share of 

such cost may be provided in cash or through the provision of 

property or services. 

ø(2) The Secretary may award a grant for a project under 

paragraph (1) to an Indian tribe or inter-tribal consortium 

which meets the following criteria: 

ø(A) The project will address significant unmet mental 

health needs among Indians. 

ø(B) The project will serve a significant number of Indians. 

ø(C) The project has the potential to deliver services in 

an efficient and effective manner. 

ø(D) The tribe or consortium has the administrative and 

financial capability to administer the project. 


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ø(E) The project will deliver services in a manner consistent with traditional Indian healing and treatment practices. 

ø(F) The project is coordinated with, and avoids duplication of, existing services. 

ø(3) For purposes of this subsection, the Secretary shall, in 

evaluating applications for grants for projects to be operated 

under any contract entered into with the Service under the Indian Self-Determination Act [25 U.S.C.A. § 450f et seq.], use 

the same criteria that the Secretary uses in evaluating any 

other application for such a grant. 

ø(4) The Secretary may only award one grant under this subsection with respect to a service area until the Secretary has 

awarded grants for all service areas with respect to which the 

Secretary receives applications during the application period, 

as determined by the Secretary, which meet the criteria specified in paragraph (2). 

ø(5) Not later than 180 days after the close of the term of 

the last grant awarded pursuant to this subsection, the Secretary shall submit to the Congress a report evaluating the effectiveness of the innovative community-based projects demonstrated pursuant to this subsection. Such report shall include findings and recommendations, if any, relating to the reorganization of the programs of the Service for delivery of mental health services to Indians. 

ø(6) Grants made pursuant to this section may be expended 

over a period of three years and no grant may exceed 

$1,000,000 for the fiscal years involved. 

ø(l) Licensing requirement for mental health care workers 

øAny person employed as a psychologist, social worker, or marriage and family therapist for the purpose of providing mental 

health care services to Indians in a clinical setting under the authority of this chapter or through a contract pursuant to the Indian 

Self-Determination Act [25 U.S.C.A. § 450f et seq.] shall—

ø(1) in the case of a person employed as a psychologist, be 

licensed as a clinical psychologist or working under the direct 

supervision of a licensed clinical psychologist; 

ø(2) in the case of a person employed as a social worker, be 

licensed as a social worker or working under the direct supervision of a licensed social worker; or 

ø(3) in the case of a person employed as a marriage and family therapist, be licensed as a marriage and family therapist or 

working under the direct supervision of a licensed marriage 

and family therapist. 

ø(m) Intermediate adolescent mental health services 

ø(1) The Secretary, acting through the Service, may make 

grants to Indian tribes and tribal organizations to provide intermediate mental health services to Indian children and adolescents, including—

ø(A) inpatient and outpatient services; 

ø(B) emergency care; 

ø(C) suicide prevention and crisis intervention; and 

ø(D) prevention and treatment of mental illness, and 

dysfunctional and self-destructive behavior, including child 

abuse and family violence. 


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ø(2) Funds provided under this subsection may be used—

ø(A) to construct or renovate an existing health facility 

to provide intermediate mental health services; 

ø(B) to hire mental health professionals; 

ø(C) to staff, operate, and maintain an intermediate 

mental health facility, group home, or youth shelter where 

intermediate mental health services are being provided; 

and 

ø(D) to make renovations and hire appropriate staff to 

convert existing hospital beds into adolescent psychiatric 

units. 

ø(3) Funds provided under this subsection may not be used 

for the purposes described in section 1625o(b)(1) of this title. 

ø(4) An Indian tribe or tribal organization receiving a grant 

under this subsection shall ensure that intermediate adolescent mental health services are coordinated with other tribal, 

Service, and Bureau of Indian Affairs mental health, alcohol 

and substance abuse, and social services programs on the reservation of such tribe or tribal organization. 

ø(5) The Secretary shall establish criteria for the review and 

approval of applications for grants made pursuant to this subsection. 

ø(6) There are authorized to be appropriated to carry out 

this section $10,000,000 for fiscal year 1993 and such sums as 

may be necessary for each of the fiscal years 1994, 1995, 1996, 

1997, 1998, 1999, and 2000. 

(d) USE OF FUNDS.—This funding may be used for both clinical 

and nonclinical research. 

ø§ 1621i. Managed care feasibility study¿ 

(e) EVALUATION AND DISSEMINATION.—The Secretary shall periodically—

ø(a) The Secretary, acting through the Service, shall conduct a 

study to assess the feasibility of allowing an Indian tribe to purchase, directly or through the Service, managed care coverage for 

all members of the tribe from—

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

ø(2) a State licensed managed care plan. 

ø(b) Not later than the date which is 12 months after October 29, 

1992, the Secretary shall transmit to the Congress a report containing—

ø(1) a detailed description of the study conducted pursuant 

to this section; and 

ø(2) a discussion of the findings and conclusions of such 

study. 

(1) evaluate the impact of research conducted under this section; and 

ø§ 1621j. California contract health services demonstration 

program¿ 

(2) disseminate to Tribal Health Programs information regarding that research as the Secretary determines to be appropriate. 

ø(a) Establishment 


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øThe Secretary shall establish a demonstration program to 

evaluate the use of a contract care intermediary to improve the accessibility of health services to California Indians. 

ø(b) Agreement with California Rural Indian Health Board 

ø(1) In establishing such program, the Secretary shall enter 

into an agreement with the California Rural Indian Health 

Board to reimburse the Board for costs (including reasonable 

administrative costs) incurred, during the period of the demonstration program, in providing medical treatment under contract to California Indians described in section 1679(b) of this 

title throughout the California contract health services delivery 

area described in section 1680 of this title with respect to highcost contract care cases. 

ø(2) Not more than 5 percent of the amounts provided to the 

Board under this section for any fiscal year may be for reimbursement for administrative expenses incurred by the Board 

during such fiscal year. 

ø(3) No payment may be made for treatment provided under 

the demonstration program to the extent payment may be 

made for such treatment under the Catastrophic Health Emergency Fund described in section 1621a of this title or from 

amounts appropriated or otherwise made available to the California contract health service delivery area for a fiscal year. 

ø(c) Advisory board 

øThere is hereby established an advisory board which shall advise the California Rural Indian Health Board in carrying out the 

demonstration pursuant to this section. The advisory board shall be 

composed of representatives, selected by the California Rural Indian Health Board, from not less than 8 tribal health programs 

serving California Indians covered under such demonstration, at 

least one half of whom are not affiliated with the California Rural 

Indian Health Board. 

ø(d) Commencement and termination dates 

øThe demonstration program described in this section shall begin 

on January 1, 1993, and shall terminate on September 30, 1997. 

ø(e) Report 

øNot later than July 1, 1998, the California Rural Indian Health 

Board shall submit to the Secretary a report on the demonstration 

program carried out under this section, including a statement of its 

findings regarding the impact of using a contract care intermediary 

on—

ø(1) access to needed health services; 

ø(2) waiting periods for receiving such services; and 

ø(3) the efficient management of high-cost contract care 

cases. 

ø(f) ‘‘High-cost contract care cases’’ defined 

øFor the purposes of this section, the term ‘‘high-cost contract 

care cases’’ means those cases in which the cost of the medical 

treatment provided to an individual—

ø(1) would otherwise be eligible for reimbursement from the 

Catastrophic Health Emergency Fund established under section 1621a of this title, except that the cost of such treatment 

does not meet the threshold cost requirement established pursuant to section 1621a(b)(2) of this title; and 

ø(2) exceeds $1,000. 


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ø(g) Authorization of appropriations 

øThere are authorized to be appropriated for each of the fiscal 

years 1996 through 2000 such sums as may be necessary to carry 

out the purposes of this section.¿ 

SEC. 207. MAMMOGRAPHY AND OTHER CANCER SCREENING. 

ø§ 1621k. Coverage of screening mammography¿ 

The Secretary, acting through the Service or Tribal Health Programs, shall provide for screening as follows: 

øThe Secretary, through the Service, shall provide for 

screening¿ (1) Screening mammography (as defined in section 

1861(jj) of the Social Security Act ø[42 U.S.C.A. § 1395x(jj)]¿) 

for Indian øand urban Indian women 35 years of age or older 

at a frequency, determined by the Secretary (in consultation 

with the Director of the National Cancer Institute),¿ women at 

a frequency appropriate to such women under accepted and appropriate national standards, and under such terms and conditions as are consistent with standards established by the Secretary to øassure¿ ensure the safety and accuracy of screening 

mammography under part B of title XVIII of øthe Social Security Act [42 U.S.C.A. § 1395j et seq.].¿ such Act. 

(2) Other cancer screening that receives an A or B rating as 

recommended by the United States Preventive Services Task 

Force established under section 915(a)(1) of the Public Health 

Service Act (42 U.S.C. 299b–4(a)(1)). The Secretary shall ensure 

that screening provided for under this paragraph complies with 

the recommendations of the Task Force with respect to—

(A) frequency; 

(B) the population to be served; 

(C) the procedure or technology to be used; 

(D) evidence of effectiveness; and 

(E) other matters that the Secretary determines appropriate. 

SEC. 208. PATIENT TRAVEL COSTS. 

(a) DEFINITION OF QUALIFIED ESCORT.—In this section, the term 

‘qualified escort’ means—

(1) an adult escort (including a parent, guardian, or other 

family member) who is required because of the physical or mental condition, or age, of the applicable patient; 

(2) a health professional for the purpose of providing necessary medical care during travel by the applicable patient; or 

ø§ 1621l. Patient travel costs¿ 

(3) other escorts, as the Secretary or applicable Indian Health 

Program determines to be appropriate. 

ø(a) The Secretary, acting through the Service, shall provide 

funds for the following patient travel costs¿ (b) PROVISION OF

FUNDS.—The Secretary, acting through the Service and Tribal 

Health Programs, is authorized to provide funds for the following 

patient travel costs, including qualified escorts, associated with receiving health care services provided (either through direct or contract care or through øcontracts entered into pursuant to the Indian Self-Determination Act [25 U.S.C.A. § 450f et seq.]) under this 

Act—¿ a contract or compact under the Indian Self-Determination 


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and Education Assistance Act (25 U.S.C. 450 et seq.)) under this 

Act—

(1) emergency air transportationø;¿ and ø(2) nonemergency¿ 

non-emergency air transportation where ground transportation 

is infeasibleø.¿; 

ø(b) There are authorized to be appropriated to carry out this 

section $15,000,000 for fiscal year 1993 and such sums as may be 

necessary for each of the fiscal years 1994, 1995, 1996, 1997, 1998, 

1999, and 2000.¿ 

(2) transportation by private vehicle (where no other means of 

transportation is available), specially equipped vehicle, and ambulance; and 

(3) transportation by such other means as may be available 

and required when air or motor vehicle transportation is not 

available. 

ø§ 1621m. Epidemiology centers¿ 

SEC. 209. EPIDEMIOLOGY CENTERS. 

(a)ø(1)¿ ESTABLISHMENT OF CENTERS.—The Secretary shall establish an epidemiology center in each Service øarea¿ Area to carry 

out the functions described in øparagraph (3).¿ subsection (b). Any 

new center established after the date of enactment of the Indian 

Health Care Improvement Act Amendments of 2007 may be operated under a grant authorized by subsection (d), but funding under 

such a grant shall not be divisible. 

ø(2) To assist such centers in carrying out such functions, 

the Secretary shall perform the following: 

ø(A) In consultation with the Centers for Disease Control and Indian tribes, develop sets of data (which to the 

extent practicable, shall be consistent with the uniform 

data sets used by the States with respect to the year 2000 

health objectives) for uniformly defining health status for 

purposes of the objectives specified in section 1602(b) of 

this title. Such sets shall consist of one or more categories 

of information. The Secretary shall develop formats for the 

uniform collecting and reporting of information on such 

categories. 

ø(B) Establish and maintain a system for monitoring the 

progress made toward meeting each of the health status 

objectives described in section 1602(b) of this title. 

ø(3) In consultation with Indian tribes and urban Indian 

communities, each area epidemiology center established under 

this subsection shall, with respect to such area—

(b) FUNCTIONS OF CENTERS.—In consultation with and upon the 

request of Indian Tribes, Tribal Organizations, and Urban Indian 

Organizations, each Service Area epidemiology center established 

under this section shall, with respect to such Service Area—

øA¿ (1) collect data relating to, and monitor progress made toward meeting, each of the health status objectives ødescribed 

in section 1602(b) of this title using the data sets and monitoring system developed by the Secretary pursuant to paragraph (2);¿ of the Service, the Indian Tribes, Tribal Organizations, and Urban Indian Organizations in the Service Area; 


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ø(B)¿(2) evaluate existing delivery systems, data systems, 

and other systems that impact the improvement of Indian 

health; 

ø(C)¿(3) assist øtribes and urban Indian communities¿ Indian Tribes, Tribal Organizations, and Urban Indian Organizations in identifying their highest priority health status objectives and the services needed to achieve such objectives, based 

on epidemiological data; 

ø(D)¿(4) make recommendations for the targeting of services 

needed by øtribal, urban, and other Indian communities¿ the 

populations served; 

ø(E)¿(5) make recommendations to improve health care delivery systems for Indians and øurban¿ Urban Indians; 

ø(F) work cooperatively with tribal providers of health and 

social services in order to avoid duplication of existing services; 

and¿ 

ø(G)¿ (6) provide requested technical assistance to Indian 

øtribes and urban Indian organizations¿ Tribes, Tribal Organizations, and Urban Indian Organizations in the development 

of local health service priorities and incidence and prevalence 

rates of disease and other illness in the communityø.¿; and 

ø(4) Epidemiology centers established under this subsection 

shall be subject to the provisions of the Indian Self-Determination Act (25 U.S.C. 450f et seq.).¿ 

(7) provide disease surveillance and assist Indian Tribes, 

Tribal Organizations, and Urban Indian Organizations to promote public health. 

ø(5)¿ (c) TECHNICAL ASSISTANCE.—The ødirector¿ Director of the 

Centers for Disease Control and Prevention shall provide technical 

assistance to the centers in carrying out the requirements of this 

øsubsection¿ section. 

ø(6) The Service shall assign one epidemiologist from each of 

its area offices to each area epidemiology center to provide 

such center with technical assistance necessary to carry out 

this subsection.¿ 

(d) GRANTS FOR STUDIES.—

ø(b)¿ (1) IN GENERAL.—The Secretary may make grants to 

Indian øtribes, tribal organizations¿ Tribes, Tribal Organizations, Urban Indian Organizations, and eligible intertribal consortia øor Indian organizations¿ to conduct epidemiological 

studies of Indian communities. 

ø(2)¿ (2) ELIGIBLE INTERTRIBAL CONSORTIA.—An intertribal 

øconsortia or Indian organization¿ consortium is eligible to receive a grant under this subsection if—

ø(A) it¿ (A) the intertribal consortium is incorporated for 

the primary purpose of improving Indian health; and 

ø(B) it¿ (B) the intertribal consortium is representative 

of the øtribes¿ Indian Tribes or urban Indian communities 

in which øit¿ the intertribal consortium is located. 

(3) APPLICATIONS.—An application for a grant under this 

subsection shall be submitted in such manner and at such time 

as the Secretary shall prescribe. 

ø(4) Applicants for grants¿ (4) REQUIREMENTS.—An applicant for a grant under this subsection shall—


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(A) demonstrate the technical, administrative, and financial expertise necessary to carry out the functions described in paragraph (5); 

(B) consult and cooperate with providers of related 

health and social services in order to avoid duplication of 

existing services; and 

(C) demonstrate cooperation from Indian øtribes¿ Tribes 

or øurban¿ Urban Indian øorganizations¿ Organizations in 

the area to be served. 

(5) USE OF FUNDS.—A grant awarded under paragraph (1) 

may be used øto¿—

(A) to carry out the functions described in subsection 

(øa¿b); 

ø(3) of this section;¿ (B) to provide information to and 

consult with tribal leaders, urban Indian community leaders, and related health staffø,¿ on health care and health 

øservices¿service management issues; and 

(C) øprovide,¿ in collaboration with øtribes¿ Indian 

Tribes, Tribal Organizations, and urban Indian communities, to provide the Service with information regarding 

ways to improve the health status of øIndian people¿ Indians. 

ø(6) There are authorized to be appropriated to carry out the 

purposes of this subsection not more than $12,000,000 for fiscal year 1993 and such sums as may be necessary for each of 

the fiscal years 1994, 1995, 1996, 1997, 1998, 1999, and 2000.¿ 

(e) ACCESS TO INFORMATION.—An epidemiology center operated by 

a grantee pursuant to a grant awarded under subsection (d) shall 

be treated as a public health authority for purposes of the Health 

Insurance Portability and Accountability Act of 1996 (Public Law 

104–191; 110 Stat. 2033), as such entities are defined in part 

164.501 of title 45, Code of Federal Regulations (or a successor regulation). The Secretary shall grant such grantees access to and use 

of data, data sets, monitoring systems, delivery systems, and other 

protected health information in the possession of the Secretary. 

ø§ 1621n. Comprehensive school health education programs¿ 

SEC. 210. COMPREHENSIVE SCHOOL HEALTH EDUCATION PROGRAMS. 

ø(a) Award of grants 

øThe¿ (a) FUNDING FOR DEVELOPMENT OF PROGRAMS.—In addition to carrying out any other program for health promotion or disease prevention, the Secretary, acting through the Service øand in 

consultation with the Secretary of the Interior, may¿, is authorized 

to award grants to Indian øtribes¿ Tribes, Tribal Organizations, 

and Urban Indian Organizations to develop comprehensive school 

health education programs for children from øpreschool¿ pre-school 

through grade 12 in schools ølocated on¿ for the benefit of Indian 

øreservations.¿ and Urban Indian children. 

(b) USE OF øgrantsGrants¿ GRANT FUNDS.—A grant awarded 

under this section may be used øto—¿ for purposes which may include, but are not limited to, the following: 

ø(1) develop health education curricula;¿ 

(1) Developing health education materials both for regular 

school programs and afterschool programs. 


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(2) øtrain¿ Training teachers in comprehensive school health 

education øcurricula;¿ materials. 

(3) øintegrate¿ Integrating school-based, community-based, 

and other public and private health promotion effortsø;¿. (4) øencourage¿ Encouraging healthy, tobacco-free school 

environmentsø;¿. (5) øcoordinate¿ Coordinating school-based health programs 

with existing services and programs available in the 

communityø;¿. (6) ødevelop¿ Developing school programs on nutrition education, personal health, oral health, and fitnessø;¿. ø(7) develop mental¿ (7) Developing behavioral health 

wellness programsø;¿. (8) ødevelop¿ Developing chronic disease prevention 

programsø;¿. (9) ødevelop¿ Developing substance abuse prevention 

programsø;¿. (10) ødevelop accident¿ Developing injury prevention and 

safety education programsø;¿. (11) ødevelop¿ Developing activities for the prevention and 

control of communicable diseasesø; and¿. (12) ødevelop¿ Developing community and environmental 

health education programs that include traditional health care 

practitioners. 

(13) Violence prevention. 

(14) Such other health issues as are appropriate. 

(c) TECHNICAL ASSISTANCE øThe¿.—Upon request, the Secretary, 

acting through the Service, shall provide technical assistance to Indian øtribes¿ Tribes, Tribal Organizations, and Urban Indian Organizations in the development of comprehensive health education 

plansø,¿ and the dissemination of comprehensive health education 

materials and information on existing health programs and resources. 

(d) CRITERIA FOR øreview and approval of applications. The Secretary¿ REVIEW AND APPROVAL OF APPLICATIONS.—The Secretary, 

acting through the Service, and in consultation with Indian Tribes, 

Tribal Organizations, and Urban Indian Organizations, shall establish criteria for the review and approval of applications for 

grants ømade pursuant to this section.¿ awarded under this section. 

(e) øReport¿ DEVELOPMENT OF ørecipient¿ 

øRecipients of grants under this section shall submit to the Secretary an annual report on activities undertaken with funds provided under this section. Such reports shall include a statement 

of—

ø(1) the number of preschools, elementary schools, and secondary schools served; 

ø(2) the number of students served; 

ø(3) any new curricula established with funds provided 

under this section; 

ø(4) the number of teachers trained in the health curricula; 

and 

ø(5) the involvement of parents, members of the community, 

and community health workers in programs established with 

funds provided under this section.¿ 


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ø(f)¿ PROGRAM øDEVELOPMENT¿ FOR BIA-FUNDED SCHOOLS.— (1) IN GENERAL.—The Secretary of the Interior, acting 

through the Bureau of Indian Affairs and in cooperation with 

the Secretary, acting through the Service, and affected Indian 

Tribes and Tribal Organizations, shall develop a comprehensive school health education program for children from preschool through grade 12 in schools øoperated¿ for which support is provided by the Bureau of Indian Affairs. 

ø(2) Such program shall include—¿ 

(2) REQUIREMENTS FOR PROGRAMS.—Such programs shall include—

(A) school programs on nutrition education, personal 

health, oral health, and fitness; 

(B) ømental¿ behavioral health wellness programs; 

(C) chronic disease prevention programs; 

(D) substance abuse prevention programs; 

(E) øaccident¿ injury prevention and safety education 

programs; and 

(F) activities for the prevention and control of communicable diseases. 

ø(3) The Secretary of the Interior shall—¿ 

(3) DUTIES OF THE SECRETARY.—The Secretary of the Interior 

shall—

ø(A) provide training to teachers in comprehensive 

school health education øcurricula;¿ materials; 

(B) ensure the integration and coordination of schoolbased programs with existing services and health programs available in the community; and 

(C) encourage healthy, tobacco-free school environments. 

ø(g) Authorization of appropriations 

øThere are authorized to be appropriated to carry out this section $15,000,000 for fiscal year 1993 and such sums as may be necessary for each of the fiscal years 1994, 1995, 1996, 1997, 1998, 

1999, and 2000. 

ø§ 1621o. Indian youth grant program¿ 

SEC. 211. INDIAN YOUTH PROGRAM. 

ø(a) Grants¿ 

(a) PROGRAM AUTHORIZED.—The Secretary, acting through the 

Service, is authorized to ømake¿ establish and administer a program to provide grants to Indian øtribes, tribal organizations, and 

urban Indian organizations¿ Tribes, Tribal Organizations, and 

Urban Indian Organizations for innovative mental and physical 

disease prevention and health promotion and treatment programs 

for Indian and Urban Indian preadolescent and adolescent youths. 

(b) USE OF øFUNDS¿ FUNDS.—

(1) Allowable Uses.—Funds made available under this section may be used to—

(A) develop prevention and treatment programs for Indian youth which promote mental and physical health and 

incorporate cultural values, community and family involvement, and traditional øhealers¿ health care practitioners; 

and 

(B) develop and provide community training and education. 


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(2) PROHIBITED USE.—Funds made available under this section may not be used to provide services described in section 

ø1621h(m) of this title.¿ 707(c). 

ø(c) Models for delivery of comprehensive health care services 

øThe¿ 

(c) DUTIES OF THE SECRETARYøshall¿.—The Secretary shall— (1) disseminate to Indian øtribes¿ Tribes, Tribal Organizations, and Urban Indian Organizations information regarding 

models for the delivery of comprehensive health care services 

to Indian and øurban¿ Urban Indian adolescents; 

(2) encourage the implementation of such models; and 

(3) at the request of an Indian øtribe¿ Tribe, Tribal Organization, or Urban Indian Organization, provide technical assistance in the implementation of such models. 

(d) CRITERIA FOR øthe review and approval of applications¿ REVIEW AND APPROVAL OF APPLICATIONS.—The Secretary, in consultation with Indian Tribes, Tribal Organizations, and Urban Indian 

Organizations, shall establish criteria for the review and approval 

of applications or proposals under this section. 

ø(e) Authorization of appropriations 

øThere are authorized to be appropriated to carry out this section $5,000,000 for fiscal year 1993 and such sums as may be necessary for each of the fiscal years 1994, 1995, 1996, 1997, 1998, 

1999, and 2000. 

ø§ 1621p. American Indians Into Psychology Program 

ø(a) Grants 

øThe Secretary may provide grants to at least 3 colleges and universities for the purpose of developing and maintaining American 

Indian psychology career recruitment programs as a means of encouraging Indians to enter the mental health field. 

ø(b) Quentin N. Burdick American Indians Into Psychology Program 

øThe Secretary shall provide one of the grants authorized under 

subsection (a) of this section to develop and maintain a program at 

the University of North Dakota to be known as the ‘‘Quentin N. 

Burdick American Indians Into Psychology Program’’. Such program shall, to the maximum extent feasible, coordinate with the 

Quentin N. Burdick Indian Health Programs authorized under section 1616g(b) of this title, the Quentin N. Burdick American Indians Into Nursing Program authorized under section 1616e(e) of this 

title, and existing university research and communications networks. 

ø(c) Issuance of regulations 

ø(1) The Secretary shall issue regulations for the competitive 

awarding of the grants provided under this section. 

ø(2) Applicants for grants under this section shall agree to 

provide a program which, at a minimum— ø(A) provides outreach and recruitment for health professions to Indian communities including elementary, secondary and community colleges located on Indian reservations that will be served by the program; 

ø(B) incorporates a program advisory board comprised of 

representatives from the tribes and communities that will 

be served by the program; 


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ø(C) provides summer enrichment programs to expose 

Indian students to the varied fields of psychology through 

research, clinical, and experiential activities; 

ø(D) provides stipends to undergraduate and graduate 

students to pursue a career in psychology; 

ø(E) develops affiliation agreements with tribal community colleges, the Service, university affiliated programs, 

and other appropriate entities to enhance the education of 

Indian students; 

ø(F) to the maximum extent feasible, utilizes existing 

university tutoring, counseling and student support services; and 

ø(G) to the maximum extent feasible, employs qualified 

Indians in the program. 

ø(d) Active duty service obligation 

øThe active duty service obligation prescribed under section 

254m of Title 42 shall be met by each graduate student who receives a stipend described in subsection (c)(2)(D) of this section that 

is funded by a grant provided under this section. Such obligation 

shall be met by service—

ø(1) in the Indian Health Service; 

ø(2) in a program conducted under a contract entered into 

under the Indian Self-Determination Act [25 U.S.C.A. §450f et 

seq.]; 

ø(3) in a program assisted under subchapter IV of this chapter; or 

ø(4) in the private practice of psychology if, as determined by 

the Secretary, in accordance with guidelines promulgated by 

the Secretary, such practice is situated in a physician or other 

health professional shortage area and addresses the health 

care needs of a substantial number of Indians. 

ø§1621q. Prevention, control, and elimination of tuberculosis 

SEC. 212. PREVENTION, CONTROL, AND ELIMINATION OF COMMUNICABLE AND INFECTIOUS DISEASES. 

ø(a) Grants¿ 

(a) GRANTS AUTHORIZED.—The Secretary, acting through the 

Service, and after consultation with the Centers for Disease Control and Prevention, may make grants øto Indian tribes and tribal 

organizations for—¿ available to Indian Tribes, Tribal Organizations, and Urban Indian Organizations for the following: 

ø(1) projects for the prevention, control, and elimination of 

tuberculosis; 

ø(2) public information and education programs for the prevention, control, and elimination of tuberculosis; and¿ 

(1) Projects for the prevention, control, and elimination of 

communicable and infectious diseases, including tuberculosis, 

hepatitis, HIV, respiratory syncytial virus, hanta virus, sexually 

transmitted diseases, and H. Pylori. 

(2) Public information and education programs for the prevention, control, and elimination of communicable and infectious diseases. 

(3) øeducation¿ Education, training, and clinical skills improvement activities in the prevention, control, and elimination 


bajohnson on PROD1PC71 with REPORTS
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of øtuberculosis¿ communicable and infectious diseases for 

health professionals, including allied health professionals. 

(4) Demonstration projects for the screening, treatment, and 

prevention of hepatitis C virus (HCV). 

(b) APPLICATION øfor grant¿ REQUIRED.—The Secretary may 

ømake a grant¿ provide funding under subsection (a) øof this section¿ only if an application øfor the grant¿ or proposal for funding 

is submitted to the Secretary øand the application is in such form, 

is made in such manner, and contains the assurances required by 

subsection (c) of this section and such other agreements, assurances, and information as the Secretary may require.¿. ø(c) Eligibility for grant 

øTo be eligible for a grant under subsection (a) of this section, 

an applicant must provide assurances satisfactory to the Secretary 

that—¿ 

ø(1) the applicant will coordinate its activities for the prevention, control, and elimination of tuberculosis with activities of¿ 

(c) COORDINATION WITH HEALTH AGENCIES.—Indian Tribes, 

Tribal Organizations, and Urban Indian Organizations receiving funding under this section are encouraged to coordinate 

their activities with the Centers for Disease Controlø,¿ and 

Prevention and State and local health agenciesø; and¿. ø(2) the applicant will submit to the Secretary an annual report on its activities for the prevention, control, and elimination of tuberculosis. 

ø(d) Duty of Secretary¿ 

(d) TECHNICAL ASSISTANCE; REPORT.—In carrying out this section, the Secretary— ø(1) shall establish criteria for the review and approval of 

applications for grants under subsection (a) of this section, including requirement of public health qualifications of applicants; 

ø(2) shall, subject to available appropriations, make at least 

one grant under subsection (a) of this section within each area 

office; 

ø(3¿ (1) may, at the request of an Indian øtribe or tribal organization¿ Tribe, Tribal Organization, or Urban Indian Organization, provide technical assistance; and 

ø(4¿ (2) shall prepare and submit a report to øthe Committee 

on Energy and Commerce and the Committee on Natural Resources of the House and the Committee on Indian Affairs of 

the Senate not later than February 1, 1994, and biennially 

thereafter,¿ Congress biennially on the use of funds under this 

section and on the progress made toward the prevention, control, and elimination of øtuberculosis among Indian tribes and 

tribal organizations.¿ communicable and infectious diseases 

among Indians and Urban Indians. 

ø(e) Reduction of amount of grant 

øThe Secretary may, at the request of a recipient of a grant 

under subsection (a) of this section, reduce the amount of such 

grant by—

ø(1) the fair market value of any supplies or equipment furnished the grant recipient; and 

ø(2) the amount of the pay, allowances, and travel expenses 

of any officer or employee of the Government when detailed to 


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the grant recipient and the amount of any other costs incurred 

in connection with the detail of such officer or employee, 

when the furnishing of such supplies or equipment or the detail of such an officer or employee is for the convenience of and 

at the request of such grant recipient and for the purpose of 

carrying out a program with respect to which the grant under 

subsection (a) of this section is made. The amount by which 

any such grant is so reduced shall be available for payment by 

the Secretary of the costs incurred in furnishing the supplies 

or equipment, or in detailing the personnel, on which the reduction of such grant is based, and such amount shall be 

deemed as part of the grant and shall be deemed to have been 

paid to the grant recipient.¿ 

SEC. 213. OTHER AUTHORITY FOR PROVISION OF SERVICES. 

(a) FUNDING AUTHORIZED.—The Secretary, acting through the 

Service, Indian Tribes, and Tribal Organizations, may provide 

funding under this Act to meet the objectives set forth in section 3 

of this Act through health care-related services and programs not 

otherwise described in this Act, including—

(1) hospice care; 

(2) assisted living; 

(3) long-term care; and 

(4) home- and community-based services. 

(b) TERMS AND CONDITIONS.—

(1) IN GENERAL.—Any service provided under this section 

shall be in accordance with such terms and conditions as are 

consistent with accepted and appropriate standards relating to 

the service, including any licensing term or condition under this 

Act. 

(2) STANDARDS.—

(A) IN GENERAL.—The Secretary may establish, by regulation, the standards for a service provided under this section, provided that such standards shall not be more stringent than the standards required by the State in which the 

service is provided. 

(B) USE OF STATE STANDARDS.—If the Secretary does not, 

by regulation, establish standards for a service provided 

under this section, the standards required by the State in 

which the service is or will be provided shall apply to such 

service. 

(C) INDIAN TRIBES.—If a service under this section is provided by an Indian Tribe or Tribal Organization pursuant 

to the Indian Self-Determination and Education Assistance 

Act (25 U.S.C. 450 et seq.), the verification by the Secretary 

that the service meets any standards required by the State 

in which the service is or will be provided shall be considered to meet the terms and conditions required under this 

subsection. 

(3) ELIGIBILITY.—The following individuals shall be eligible 

to receive long-term care under this section: 

(A) Individuals who are unable to perform a certain 

number of activities of daily living without assistance. 

(B) Individuals with a mental impairment, such as dementia, Alzheimer’s disease, or another disabling mental 


bajohnson on PROD1PC71 with REPORTS
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illness, who may be able to perform activities of daily living 

under supervision. 

(C) Such other individuals as an applicable Indian 

Health Program determines to be appropriate. 

(c) DEFINITIONS.—For the purposes of this section, the following 

definitions shall apply: 

(1) The term ‘‘home- and community-based services’’ means 1 

or more of the services specified in paragraphs (1) through (9) 

of section 1929(a) of the Social Security Act (42 U.S.C. 1396t(a)) 

(whether provided by the Service or by an Indian Tribe or Tribal Organization pursuant to the Indian Self-Determination and 

Education Assistance Act (25 U.S.C. 450 et seq.)) that are or 

will be provided in accordance with the standards described in 

subsection (b). 

(2) The term ‘‘hospice care’’ means the items and services 

specified in subparagraphs (A) through (H) of section 

1861(dd)(1) of the Social Security Act (42 U.S.C. 1395x(dd)(1)), 

and such other services which an Indian Tribe or Tribal Organization determines are necessary and appropriate to provide in 

furtherance of this care. 

(d) AUTHORIZATION OF CONVENIENT CARE SERVICES.—The Secretary, acting through the Service, Indian Tribes, and Tribal Organizations, may also provide funding under this Act to meet the objectives set forth in section 3 of this Act for convenient care services 

programs pursuant to section 306(c)(2)(A). 

SEC. 214. INDIAN WOMEN’S HEALTH CARE. 

The Secretary, acting through the Service and Indian Tribes, 

Tribal Organizations, and Urban Indian Organizations, shall monitor and improve the quality of health care for Indian women of all 

ages through the planning and delivery of programs administered 

by the Service, in order to improve and enhance the treatment models of care for Indian women. 

SEC. 215. ENVIRONMENTAL AND NUCLEAR HEALTH HAZARDS. 

(a) STUDIES AND MONITORING.—The Secretary and the Service 

shall conduct, in conjunction with other appropriate Federal agencies and in consultation with concerned Indian Tribes and Tribal 

Organizations, studies and ongoing monitoring programs to determine trends in the health hazards to Indian miners and to Indians 

on or near reservations and Indian communities as a result of environmental hazards which may result in chronic or life threatening 

health problems, such as nuclear resource development, petroleum 

contamination, and contamination of water source and of the food 

chain. Such studies shall include—

(1) an evaluation of the nature and extent of health problems 

caused by environmental hazards currently exhibited among Indians and the causes of such health problems; 

(2) an analysis of the potential effect of ongoing and future 

environmental resource development on or near reservations 

and Indian communities, including the cumulative effect over 

time on health; 

(3) an evaluation of the types and nature of activities, practices, and conditions causing or affecting such health problems, 

including uranium mining and milling, uranium mine tailing 

deposits, nuclear power plant operation and construction, and 


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nuclear waste disposal; oil and gas production or transportation on or near reservations or Indian communities; and other 

development that could affect the health of Indians and their 

water supply and food chain; 

(4) a summary of any findings and recommendations provided in Federal and State studies, reports, investigations, and 

inspections during the 5 years prior to the date of enactment of 

the Indian Health Care Improvement Act Amendments of 2007 

that directly or indirectly relate to the activities, practices, and 

conditions affecting the health or safety of such Indians; and 

(5) the efforts that have been made by Federal and State 

agencies and resource and economic development companies to 

effectively carry out an education program for such Indians regarding the health and safety hazards of such development. 

(b) HEALTH CARE PLANS.—Upon completion of such studies, the 

Secretary and the Service shall take into account the results of such 

studies and develop health care plans to address the health problems studied under subsection (a). The plans shall include—

(1) methods for diagnosing and treating Indians currently exhibiting such health problems; 

(2) preventive care and testing for Indians who may be exposed to such health hazards, including the monitoring of the 

health of individuals who have or may have been exposed to excessive amounts of radiation or affected by other activities that 

have had or could have a serious impact upon the health of 

such individuals; and 

(3) a program of education for Indians who, by reason of 

their work or geographic proximity to such nuclear or other development activities, may experience health problems. 

(c) SUBMISSION OF REPORT AND PLAN TO CONGRESS.—The Secretary and the Service shall submit to Congress the study prepared 

under subsection (a) no later than 18 months after the date of enactment of the Indian Health Care Improvement Act Amendments of 

2007. The health care plan prepared under subsection (b) shall be 

submitted in a report no later than 1 year after the study prepared 

under subsection (a) is submitted to Congress. Such report shall include recommended activities for the implementation of the plan, as 

well as an evaluation of any activities previously undertaken by the 

Service to address such health problems. 

(d) INTERGOVERNMENTAL TASK FORCE.—

(1) ESTABLISHMENT; MEMBERS.—There is established an 

Intergovernmental Task Force to be composed of the following 

individuals (or their designees): 

(A) The Secretary of Energy. 

(B) The Secretary of the Environmental Protection Agency. 

(C) The Director of the Bureau of Mines. 

(D) The Assistant Secretary for Occupational Safety and 

Health. 

(E) The Secretary of the Interior. 

(F) The Secretary of Health and Human Services. 

(G) The Assistant Secretary. 

(2) DUTIES.—The Task Force shall—

(A) identify existing and potential operations related to 

nuclear resource development or other environmental hazVerDate Aug 31 2005 01:51 Oct 27, 2007 Jkt 069010 PO 00000 Frm 00178 Fmt 6659 Sfmt 6603 E:\HR\OC\SR197.XXX SR197

bajohnson on PROD1PC71 with REPORTS
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ards that affect or may affect the health of Indians on or 

near a reservation or in an Indian community; and 

(B) enter into activities to correct existing health hazards 

and ensure that current and future health problems resulting from nuclear resource or other development activities 

are minimized or reduced. 

(3) CHAIRMAN; MEETINGS.—The Secretary of Health and 

Human Services shall be the Chairman of the Task Force. The 

Task Force shall meet at least twice each year. 

(e) HEALTH SERVICES TO CERTAIN EMPLOYEES.—In the case of 

any Indian who—

(1) as a result of employment in or near a uranium mine or 

mill or near any other environmental hazard, suffers from a 

work-related illness or condition; 

(2) is eligible to receive diagnosis and treatment services from 

an Indian Health Program; and 

(3) by reason of such Indian’s employment, is entitled to medical care at the expense of such mine or mill operator or entity 

responsible for the environmental hazard, the Indian Health 

Program shall, at the request of such Indian, render appropriate medical care to such Indian for such illness or condition 

and may be reimbursed for any medical care so rendered to 

which such Indian is entitled at the expense of such operator or 

entity from such operator or entity. Nothing in this subsection 

shall affect the rights of such Indian to recover damages other 

than such amounts paid to the Indian Health Program from 

the employer for providing medical care for such illness or condition. 

SEC. 216. ARIZONA AS A CONTRACT HEALTH SERVICE DELIVERY AREA. 

(a) IN GENERAL.—For fiscal years beginning with the fiscal year 

ending September 30, 1983, and ending with the fiscal year ending 

September 30, 2016, the State of Arizona shall be designated as a 

contract health service delivery area by the Service for the purpose 

of providing contract health care services to members of federally 

recognized Indian Tribes of Arizona. 

(b) MAINTENANCE OF SERVICES.—The Service shall not curtail 

any health care services provided to Indians residing on reservations in the State of Arizona if such curtailment is due to the provision of contract services in such State pursuant to the designation 

of such State as a contract health service delivery area pursuant to 

subsection (a). 

SEC. 216A. NORTH DAKOTA AND SOUTH DAKOTA AS CONTRACT 

HEALTH SERVICE DELIVERY AREA. 

(a) IN GENERAL.—Beginning in fiscal year 2003, the States of 

North Dakota and South Dakota shall be designated as a contract 

health service delivery area by the Service for the purpose of providing contract health care services to members of federally recognized Indian Tribes of North Dakota and South Dakota. 

(b) LIMITATION.—The Service shall not curtail any health care 

services provided to Indians residing on any reservation, or in any 

county that has a common boundary with any reservation, in the 

State of North Dakota or South Dakota if such curtailment is due 

to the provision of contract services in such States pursuant to the 


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designation of such States as a contract health service delivery area 

pursuant to subsection (a). 

SEC. 217. CALIFORNIA CONTRACT HEALTH SERVICES PROGRAM. 

(a) FUNDING AUTHORIZED.—The Secretary is authorized to fund 

a program using the California Rural Indian Health Board (hereafter in this section referred to as the ‘‘CRIHB′′) as a contract care 

intermediary to improve the accessibility of health services to California Indians. 

(b) REIMBURSEMENT CONTRACT.—The Secretary shall enter into 

an agreement with the CRIHB to reimburse the CRIHB for costs 

(including reasonable administrative costs) incurred pursuant to 

this section, in providing medical treatment under contract to California Indians described in section 806(a) throughout the California 

contract health services delivery area described in section 218 with 

respect to high cost contract care cases. 

(c) ADMINISTRATIVE EXPENSES.—Not more than 5 percent of the 

amounts provided to the CRIHB under this section for any fiscal 

year may be for reimbursement for administrative expenses incurred 

by the CRIHB during such fiscal year. 

(d) LIMITATION ON PAYMENT.—No payment may be made for 

treatment provided hereunder to the extent payment may be made 

for such treatment under the Indian Catastrophic Health Emergency Fund described in section 202 or from amounts appropriated 

or otherwise made available to the California contract health service 

delivery area for a fiscal year. 

(e) ADVISORY BOARD.—There is established an advisory board 

which shall advise the CRIHB in carrying out this section. The advisory board shall be composed of representatives, selected by the 

CRIHB, from not less than 8 Tribal Health Programs serving California Indians covered under this section at least 1⁄2 of whom of 

whom are not affiliated with the CRIHB. 

SEC. 218. CALIFORNIA AS A CONTRACT HEALTH SERVICE DELIVERY 

AREA. 

The State of California, excluding the counties of Alameda, 

Contra Costa, Los Angeles, Marin, Orange, Sacramento, San Francisco, San Mateo, Santa Clara, Kern, Merced, Monterey, Napa, San 

Benito, San Joaquin, San Luis Obispo, Santa Cruz, Solano, 

Stanislaus, and Ventura, shall be designated as a contract health 

service delivery area by the Service for the purpose of providing contract health services to California Indians. However, any of the 

counties listed herein may only be included in the contract health 

services delivery area if funding is specifically provided by the Service for such services in those counties. 

SEC. 219. CONTRACT HEALTH SERVICES FOR THE TRENTON SERVICE 

AREA. 

(a) AUTHORIZATION FOR SERVICES.—The Secretary, acting 

through the Service, is directed to provide contract health services 

to members of the Turtle Mountain Band of Chippewa Indians that 

reside in the Trenton Service Area of Divide, McKenzie, and Williams counties in the State of North Dakota and the adjoining counties of Richland, Roosevelt, and Sheridan in the State of Montana. 

(b) NO EXPANSION OF ELIGIBILITY.—Nothing in this section may 

be construed as expanding the eligibility of members of the Turtle 

Mountain Band of Chippewa Indians for health services provided 


bajohnson on PROD1PC71 with REPORTS
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by the Service beyond the scope of eligibility for such health services 

that applied on May 1, 1986. 

SEC. 220. PROGRAMS OPERATED BY INDIAN TRIBES AND TRIBAL ORGANIZATIONS. 

The Service shall provide funds for health care programs and facilities operated by Tribal Health Programs on the same basis as 

such funds are provided to programs and facilities operated directly 

by the Service. 

SEC. 221. LICENSING. 

Health care professionals employed by a Tribal Health Program 

shall, if licensed in any State, be exempt from the licensing requirements of the State in which the Tribal Health Program performs the 

services described in its contract or compact under the Indian SelfDetermination and Education Assistance Act (25 U.S.C. 450 et seq.). 

ø§ 1621r. Contract health services payment study¿ 

SEC. 222. NOTIFICATION OF PROVISION OF EMERGENCY CONTRACT 

HEALTH SERVICES. 

ø(a) Duties of Secretary 

øThe Secretary, acting through the Service and in consultation 

with representatives of Indian tribes and tribal organizations operating contract health care programs under the Indian Self-Determination Act (25 U.S.C. 450f et seq.) or under self-governance compacts, Service personnel, private contract health services providers, 

the Indian Health Service Fiscal Intermediary, and other appropriate experts, shall conduct a study—

ø(1) to assess and identify administrative barriers that 

hinder the timely payment for services delivered by private 

contract health services providers to individual Indians by the 

Service and the Indian Health Service Fiscal Intermediary; 

ø(2) to assess and identify the impact of such delayed payments upon the personal credit histories of individual Indians 

who have been treated by such providers; and 

ø(3) to determine the most efficient and effective means of 

improving the Service’s contract health services payment system and ensuring the development of appropriate consumer 

protection policies to protect individual Indians who receive authorized services from private contract health services providers from billing and collection practices, including the development of materials and programs explaining patients’ rights 

and responsibilities. 

ø(b) Functions of study 

øThe study required by subsection (a) of this section shall—

ø(1) assess the impact of the existing contract health services 

regulations and policies upon the ability of the Service and the 

Indian Health Service Fiscal Intermediary to process, on a 

timely and efficient basis, the payment of bills submitted by 

private contract health services providers; 

ø(2) assess the financial and any other burdens imposed 

upon individual Indians and private contract health services 

providers by delayed payments; 

ø(3) survey the policies and practices of collection agencies 

used by contract health services providers to collect payments 

for services rendered to individual Indians; 


bajohnson on PROD1PC71 with REPORTS
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ø(4) identify appropriate changes in Federal policies, administrative procedures, and regulations, to eliminate the problems experienced by private contract health services providers 

and individual Indians as a result of delayed payments; and 

ø(5) compare the Service’s payment processing requirements 

with private insurance claims processing requirements to 

evaluate the systemic differences or similarities employed by 

the Service and private insurers. 

ø(c) Report to Congress 

øNot later than 12 months after October 29, 1992, the Secretary 

shall transmit to the Congress a report that includes—

ø(1) a detailed description of the study conducted pursuant 

to this section; and 

ø(2) a discussion of the findings and conclusions of such 

study.¿ 

With respect to an elderly Indian or an Indian with a disability 

receiving emergency medical care or services from a non-Service provider or in a non-Service facility under the authority of this Act, the 

time limitation (as a condition of payment) for notifying the Service 

of such treatment or admission shall be 30 days. 

ø§ 1621s. Prompt action on payment of claims¿ 

SEC. 223. PROMPT ACTION ON PAYMENT OF CLAIMS. 

ø(a) Time of response¿ 

(a) DEADLINE FOR RESPONSE.—The Service shall respond to a notification of a claim by a provider of a contract care service with 

either an individual purchase order or a denial of the claim within 

5 working days after the receipt of such notification. 

ø(b) Failure to timely respond¿ 

(b) EFFECT OF UNTIMELY RESPONSE.—If the Service fails to respond to a notification of a claim in accordance with subsection (a) 

øof this section¿, the Service shall accept as valid the claim submitted by the provider of a contract care service. 

ø(c) Time of payment¿ 

(c) DEADLINE FOR PAYMENT OF VALID CLAIM.—The Service shall 

pay a øcompleted¿ valid contract care service claim within 30 days 

after the completion of the claim. 

ø§ 1621t. Demonstration of electronic claims processing¿ 

ø(a) Not later than June 15, 1993, the Secretary shall develop 

and implement, directly or by contract, 2 projects to demonstrate 

in a pilot setting the use of claims processing technology to improve 

the accuracy and timeliness of the billing for, and payment of, contract health services. 

ø(b) The Secretary shall conduct one of the projects authorized 

in subsection (a) of this section in the Service area served by the 

area office located in Phoenix, Arizona.¿ 

SEC. 224. LIABILITY FOR PAYMENT. 

ø§ 1621u.¿ 

(a) NO PATIENT LIABILITYøfor payment (a)¿.—A patient who receives contract health care services that are authorized by the 

Service shall not be liable for the payment of any charges or costs 

associated with the provision of such services. 


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(b) NOTIFICATION.—øThe Secretary shall notify a contract care 

provider and any patient who receives contract health care services 

authorized by the Service that such patient is not liable for the 

payment of any charges or costs associated with the provision of 

such services not later than 5 business days after receipt of a notification of a claim by a provider of contract care services. 

(c) NO RECOURSE.—Following receipt of the notice provided under 

subsection (b), or, if a claim has been deemed accepted under section 

223(b), the provider shall have no further recourse against the patient who received the services. 

SEC. 225. OFFICE OF INDIAN MEN’S HEALTH. 

(a) ESTABLISHMENT.—The Secretary may establish within the 

Service an office to be known as the ‘‘Office of Indian Men’s Health’’ (referred to in this section as the ‘‘Office’’). 

(b) DIRECTOR.— (1) IN GENERAL.—The Office shall be headed by a director, to 

be appointed by the Secretary. 

(2) DUTIES.—The director shall coordinate and promote the 

status of the health of Indian men in the United States. 

(c) REPORT.—Not later than 2 years after the date of enactment 

of the Indian Health Care Improvement Act Amendments of 2007, 

the Secretary, acting through the director of the Office, shall submit 

to Congress a report describing—

ø§ 1621v. Office of Indian Women’s Health Care¿ 

(1) any activity carried out by the director as of the date on 

which the report is prepared; and 

øThere is established within the Service an Office of Indian 

Women’s Health Care to oversee efforts of the Service to monitor and improve the quality of health care for Indian women 

of all ages through the planning and delivery of programs administered by the Service, in order to improve and enhance the 

treatment models of care for Indian women.¿ 

(2) any finding of the director with respect to the health of Indian men. 

ø§ 1621w. Authorization of appropriations¿ 

SEC. 226. AUTHORIZATION OF APPROPRIATIONS. 

øExcept as provided in sections 1621h(m), 1621j, 1621l, 

1621m(b)(5), 1621n, and 1621o of this title, there¿ There are authorized to be appropriated such sums as may be necessary for 

each fiscal year through fiscal year ø2000 to carry out this subchapter¿ 2017 to carry out this title. 

ø§ 1621x. Limitation on use of funds 

øAmounts appropriated to carry out this subchapter may not be 

used in a manner inconsistent with the Assisted Suicide Funding 

Restriction Act of 1997 [42 U.S.C.A. §14401 et seq.].¿ 

TITLE III—FACILITIES 

ø§ 1631. Consultation; closure of facilities; reports¿ 

SEC. 301. CONSULTATION; CONSTRUCTION AND RENOVATION OF FACILITIES; REPORTS. 

ø(a) Consultation; standards for accreditation¿ 


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(a) PREREQUISITES FOR EXPENDITURE OF FUNDS.—Prior to the 

expenditure of, or the making of any øfirm¿ binding commitment 

to expend, any funds appropriated for the planning, design, construction, or renovation of facilities pursuant to the Act of November 2, 1921 (25 U.S.C. 13)ø,¿ øpopularly¿ (commonly known as the 

‘‘Snyder Act’’), the Secretary, acting through the Service, shall—

(1) consult with any Indian øtribe¿ Tribe that would be significantly affected by such expenditure for the purpose of determining and, whenever practicable, honoring tribal preferences concerning size, location, type, and other characteristics of any facility on which such expenditure is to be madeø,¿; 

and 

(2) ensure, whenever practicable and applicable, that such 

facility meets the construction standards of øthe Joint Commission on Accreditation of Health Care Organizations¿ any accrediting body recognized by the Secretary for the purposes of 

the Medicare, Medicaid, and SCHIP programs under titles 

XVIII, XIX, and XXI of the Social Security Act by not later 

than 1 year after the date on which the construction or renovation of such facility is completed. 

ø(b) Closure; report on proposed closure¿ 

(b) CLOSURES.—

(1) EVALUATION REQUIRED.—Notwithstanding any other provision of law øother than this subsection¿, no facility operated 

by the Service øhospital or outpatient health care facility of the 

Service¿, or any portion of such øa hospital or¿ facility, may 

be closed if the Secretary has not submitted to øthe Congress 

at least 1 year prior to the date such hospital or facility (or 

portion thereof) is proposed to be closed on evaluation of the 

impact of such proposed closure which¿ Congress not less than 

1 year, and not more than 2 years, before the date of the proposed closure an evaluation, completed not more than 2 years 

before the submission, of the impact of the proposed closure that 

specifies, in addition to other considerations—

(A) the accessibility of alternative health care resources 

for the population served by such øhospital or¿ facility; 

(B) the cost-effectiveness of such closure; 

(C) the quality of health care to be provided to the population served by such øhospital or¿ facility after such closure; 

(D) the availability of contract health care funds to 

maintain existing levels of service; 

(E) the views of the Indian øtribes¿ Tribes served by 

such øhospital or¿ facility concerning such closure; 

(F) the level of øutilization¿ use of such øhospital or¿ facility by all eligible Indians; and 

(G) the distance between such øhospital or¿ facility and 

the nearest operating Service hospital. 

(2) EXCEPTION FOR CERTAIN TEMPORARY CLOSURES.—Paragraph (1) shall not apply to any temporary closure of a facility 

or øof¿ any portion of a facility if such closure is necessary for 

medical, environmental, or construction safety reasons. 

ø(c) Annual report on health facility priority system 


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ø(1) The Secretary shall submit to the President, for inclusion in each report required to be transmitted to the Congress 

under section 1671 of this title, a report which sets forth— ø(A) the current health facility priority system of the 

Service, 

ø(B) the planning, design, construction, and renovation 

needs for the 10 top-priority inpatient care facilities and 

the 10 top-priority ambulatory care facilities (together with 

required staff quarters), 

ø(C) the justification for such order of priority, 

ø(D) the projected cost of such projects, and 

ø(E) the methodology adopted by the Service in establishing priorities under its health facility priority system. 

ø(2) In preparing each report required under paragraph (1) 

(other than the initial report), the Secretary shall— ø(A) consult with Indian tribes and tribal organizations 

including those tribes or tribal organizations operating 

health programs or facilities under any contract entered 

into with the Service under the Indian Self-Determination 

Act [25 U.S.C.A. § 450f et seq.], and 

ø(B) review the needs of such tribes and tribal organizations for inpatient and outpatient facilities, including their 

needs for renovation and expansion of existing facilities. 

ø(3) For purposes of this subsection, the Secretary shall, in 

evaluating the needs of facilities operated under any contract 

entered into with the Service under the Indian Self-Determination Act [25 U.S.C.A. § 450f et seq.], use the same criteria that 

the Secretary uses in evaluating the needs of facilities operated 

directly by the Service.¿ 

(c) HEALTH CARE FACILITY PRIORITY SYSTEM.—

(1) IN GENERAL.— (A) PRIORITY SYSTEM.—The Secretary, acting through the 

Service, shall maintain a health care facility priority system, which— (i) shall be developed in consultation with Indian 

Tribes and Tribal Organizations; 

(ii) shall give Indian Tribes’ needs the highest priority; 

(iii)(I) may include the lists required in paragraph 

(2)(B)(ii); and 

(II) shall include the methodology required in paragraph (2)(B)(v); and 

(III) may include such other facilities, and such renovation or expansion needs of any health care facility, 

as the Service, Indian Tribes, and Tribal Organizations may identify; and 

(iv) shall provide an opportunity for the nomination 

of planning, design, and construction projects by the 

Service, Indian Tribes, and Tribal Organizations for 

consideration under the priority system at least once 

every 3 years, or more frequently as the Secretary determines to be appropriate. 

ø(4)¿ (B) NEEDS OF FACILITIES UNDER ISDEAA AGREEMENTS.—The Secretary shall ensure that the planning, design, construction, øand¿ renovation, and expansion needs 


bajohnson on PROD1PC71 with REPORTS
186 

of Service and non-Service facilities øwhich are the subject 

of a contract for health services entered into with the Service under¿ operated under contracts or compacts in accordance with the Indian Self-Determination and Education 

Assistance Act ø[¿(25 U.S.C.øA. § 450f¿ 450 et seq.ø]¿)are 

fully and equitably integrated into the ødevelopment of 

the¿ health care facility priority system. 

ø(d) Funds appropriated subject to section 450f of this title¿ 

(C) CRITERIA FOR EVALUATING NEEDS.—For purposes of 

this subsection, the Secretary, in evaluating the needs of facilities operated under a contract or compact under the Indian Self-Determination and Education Assistance Act (25 

U.S.C. 450 et seq.), shall use the criteria used by the Secretary in evaluating the needs of facilities operated directly 

by the Service. 

(D) PRIORITY OF CERTAIN PROJECTS PROTECTED.—The 

priority of any project established under the construction 

priority system in effect on the date of enactment of the Indian Health Care Improvement Act Amendments of 2007 

shall not be affected by any change in the construction priority system taking place after that date if the project—

(i) was identified in the fiscal year 2008 Service 

budget justification as—

(I) 1 of the 10 top-priority inpatient projects; 

(II) 1 of the 10 top-priority outpatient projects; 

(III) 1 of the 10 top-priority staff quarters developments; or 

(IV) 1 of the 10 top-priority Youth Regional 

Treatment Centers; 

(ii) had completed both Phase I and Phase II of the 

construction priority system in effect on the date of enactment of such Act; or 

(iii) is not included in clause (i) or (ii) and is selected, as determined by the Secretary— (I) on the initiative of the Secretary; or 

(II) pursuant to a request of an Indian Tribe or 

Tribal Organization. 

(2) REPORT; CONTENTS.— (A) INITIAL COMPREHENSIVE REPORT.— (i) DEFINITIONS.—In this subparagraph: 

(I) FACILITIES APPROPRIATION ADVISORY

BOARD.—The term ‘‘Facilities Appropriation Advisory Board’’ means the advisory board, comprised 

of 12 members representing Indian tribes and 2 

members representing the Service, established at 

the discretion of the Assistant Secretary—

(aa) to provide advice and recommendations 

for policies and procedures of the programs 

funded pursuant to facilities appropriations; 

and 

(bb) to address other facilities issues. 

(II) FACILITIES NEEDS ASSESSMENT

WORKGROUP.—The term ‘‘Facilities Needs Assessment Workgroup’’ means the workgroup established at the discretion of the Assistant Secretary—


bajohnson on PROD1PC71 with REPORTS
187 

(aa) to review the health care facilities construction priority system; and 

(bb) to make recommendations to the Facilities Appropriation Advisory Board for revising 

the priority system. 

(ii) INITIAL REPORT.—

(I) IN GENERAL.—Not later than 1 year after the 

date of enactment of the Indian Health Care Improvement Act Amendments of 2007, the Secretary 

shall submit to the Committee on Indian Affairs of 

the Senate and the Committee on Natural Resources of the House of Representatives a report 

that describes the comprehensive, national, ranked 

list of all health care facilities needs for the Service, Indian Tribes, and Tribal Organizations (including inpatient health care facilities, outpatient 

health care facilities, specialized health care facilities (such as for long-term care and alcohol and 

drug abuse treatment), wellness centers, staff quarters and hostels associated with health care facilities, and the renovation and expansion needs, if 

any, of such facilities) developed by the Service, Indian Tribes, and Tribal Organizations for the Facilities Needs Assessment Workgroup and the Facilities Appropriation Advisory Board. 

(II) INCLUSIONS.—The initial report shall include—

(aa) the methodology and criteria used by 

the Service in determining the needs and establishing the ranking of the facilities needs; 

and 

(bb) such other information as the Secretary 

determines to be appropriate. 

(iii) UPDATES OF REPORT.—Beginning in calendar 

year 2011, the Secretary shall—

(I) update the report under clause (ii) not less 

frequently than once every 5 years; and 

(II) include the updated report in the appropriate annual report under subparagraph (B) for 

submission to Congress under section 801. 

(B) ANNUAL REPORTS.—The Secretary shall submit to the 

President, for inclusion in the report required to be transmitted to Congress under section 801, a report which sets 

forth the following: 

(i) A description of the health care facility priority 

system of the Service established under paragraph (1). 

(ii) Health care facilities lists, which may include—

(I) the 10 top-priority inpatient health care facilities; 

(II) the 10 top-priority outpatient health care facilities; 

(III) the 10 top-priority specialized health care 

facilities (such as long-term care and alcohol and 

drug abuse treatment); 


bajohnson on PROD1PC71 with REPORTS
188 

(IV) the 10 top-priority staff quarters developments associated with health care facilities; and 

(V) the 10 top-priority hostels associated with 

health care facilities. 

(iii) The justification for such order of priority. 

(iv) The projected cost of such projects. 

(v) The methodology adopted by the Service in establishing priorities under its health care facility priority 

system. 

(3) REQUIREMENTS FOR PREPARATION OF REPORTS.—In preparing the report required under paragraph (2), the Secretary 

shall—

(A) consult with and obtain information on all health 

care facilities needs from Indian Tribes, Tribal Organizations, and Urban Indian Organizations; and 

(B) review the total unmet needs of all Indian Tribes, 

Tribal Organizations, and Urban Indian Organizations for 

health care facilities (including hostels and staff quarters), 

including needs for renovation and expansion of existing facilities. 

(d) REVIEW OF METHODOLOGY USED FOR HEALTH FACILITIES

CONSTRUCTION PRIORITY SYSTEM.— (1) IN GENERAL.—Not later than 1 year after the establishment of the priority system under subsection (c)(1)(A), the 

Comptroller General of the United States shall prepare and finalize a report reviewing the methodologies applied, and the 

processes followed, by the Service in making each assessment of 

needs for the list under subsection (c)(2)(A)(ii) and developing 

the priority system under subsection (c)(1), including a review 

of— (A) the recommendations of the Facilities Appropriation 

Advisory Board and the Facilities Needs Assessment 

Workgroup (as those terms are defined in subsection 

(c)(2)(A)(i)); and 

(B) the relevant criteria used in ranking or prioritizing 

facilities other than hospitals or clinics. 

(2) SUBMISSION TO CONGRESS.—The Comptroller General of 

the United States shall submit the report under paragraph (1) 

to— (A) the Committees on Indian Affairs and Appropriations 

of the Senate; 

(B) the Committees on Natural Resources and Appropriations of the House of Representatives; and 

(C) the Secretary. 

(e) FUNDING CONDITION.— All funds appropriated under the Act 

of November 2, 1921 (25 U.S.C. 13) (commonly known as the ‘‘Snyder Act’’), for the planning, design, construction, or renovation of 

health facilities for the benefit of øan¿ 1 or more Indian øtribe or 

tribes¿ Tribes shall be subject to the provisions of øsection 102 of¿ 

the Indian Self-Determination and Education Assistance Act [(25 

U.S.C.øA. § 450f].¿ 450 et seq.). 

(f) DEVELOPMENT OF INNOVATIVE APPROACHES.—The Secretary 

shall consult and cooperate with Indian Tribes, Tribal Organizations, and Urban Indian Organizations in developing innovative approaches to address all or part of the total unmet need for construcVerDate Aug 31 2005 01:51 Oct 27, 2007 Jkt 069010 PO 00000 Frm 00188 Fmt 6659 Sfmt 6602 E:\HR\OC\SR197.XXX SR197

bajohnson on PROD1PC71 with REPORTS
189 

tion of health facilities, including those provided for in other sections of this title and other approaches. 

ø§ 1632. Safe water and sanitary waste disposal facilities¿ 

SEC. 302. SANITATION FACILITIES. 

ø(a) Congressional findings 

øThe¿ (a) FINDINGS.—Congress øhereby¿ finds øand declares 

that—¿ the following: 

(1) øthe¿The provision of øsafe water supply systems and 

sanitary sewage and solid waste disposal systems¿sanitation 

facilities is primarily a health consideration and functionø;¿. (2) Indian people suffer an inordinately high incidence of disease, injury, and illness directly attributable to the absence or 

inadequacy of øsuch systems;¿sanitation facilities. 

(3) øthe¿The long-term cost to the United States of treating 

and curing such disease, injury, and illness is substantially 

greater than the short-term cost of providing øsuch systems¿sanitation facilities and other preventive health 

measuresø;¿. (4) ømany¿Many Indian homes and Indian communities still 

lack øsafe water supply systems and sanitary sewage and solid 

waste disposal systems; and¿sanitation facilities. 

(5) øit¿It is in the interest of the United States, and it is the 

policy of the United States, that all Indian communities and 

Indian homes, new and existing, be provided with øsafe and 

adequate water supply systems and sanitary sewage waste disposal systems as soon as possible¿sanitation facilities. 

ø(b) Authority; assistance; transfer of funds¿ 

ø(1)¿(b) FACILITIES AND SERVICES.—In furtherance of the findings øand declarations¿ made in subsection (a) øof this section¿ , Congress reaffirms the primary responsibility and authority of the 

Service to provide the necessary sanitation facilities and services as 

provided in section ø2004a of Title 42. (2) The¿ 7 of the Act of August 5, 1954 (42 U.S.C. 2004a). Under such authority, the Secretary, acting through the Service, is authorized to provide øunder 

section 2004a of Title 42—¿ the following: 

ø(A) financial¿(1) Financial and technical assistance to Indian øtribes and¿Tribes, Tribal Organizations, and Indian 

communities in the establishment, training, and equipping of 

utility organizations to operate and maintain øIndian sanitation facilities;¿sanitation facilities, including the provision of 

existing plans, standard details, and specifications available in 

the Department, to be used at the option of the Indian Tribe, 

Tribal Organization, or Indian community. 

ø(B)¿ (2) øongoing¿Ongoing technical assistance and training 

to Indian Tribes, Tribal Organizations, and Indian communities in the management of utility organizations which operate and maintain sanitation facilitiesø; and¿. 

ø(C)¿(3) Priority funding for operation and maintenance assistance for, and emergency repairs to, øtribal¿ sanitation facilities operated by an Indian Tribe, Tribal Organization or Indian community when necessary to avoid øa¿ an imminent 

health øhazard¿ threat or to protect the øFederal¿ investment 

in sanitation facilitiesø.¿ and the investment in the health benefits gained through the provision of sanitation facilities. 


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190 

ø(3)¿(c) FUNDING.—Notwithstanding any other provision of law— ø(A) the Secretary of Housing and Urban Affairs is authorized to transfer funds appropriated under the Housing 

and Community Development Act of 1974 (42 U.S.C. 5301, 

et seq.) to the Secretary of Health and Human Services; 

and¿ 

(1) the Secretary of Housing and Urban Development is authorized to transfer funds appropriated under the Native American Housing Assistance and Self-Determination Act of 1996 

(25 U.S.C. 4101 et seq.) to the Secretary of Health and Human 

Services; 

ø(B)¿(2) the Secretary of Health and Human Services is authorized to accept and use such funds for the purpose of providing sanitation facilities and services for Indians under section ƒ2004a of Title 42.≈ 7 of the Act of August 5, 1954 (42 

U.S.C. 2004a); 

ø(c) 10-year plan 

øBeginning in fiscal year 1990, the Secretary, acting through the 

Service, shall develop and begin implementation of a 10-year plan 

to provide safe water supply and sanitation sewage and solid waste 

disposal facilities to existing Indian homes and communities and to 

new and renovated Indian homes 

ø(d) Tribal capability¿ 

(3) unless specifically authorized when funds are appropriated, the Secretary shall not use funds appropriated under 

section 7 of the Act of August 5, 1954 (42 U.S.C. 2004a), to provide sanitation facilities to new homes constructed using funds 

provided by the Department of Housing and Urban Development; 

(4) the Secretary of Health and Human Services is authorized 

to accept from any source, including Federal and State agencies, funds for the purpose of providing sanitation facilities and 

services and place these funds into contracts or compacts under 

the Indian Self-Determination and Education Assistance Act 

(25 U.S.C. 450 et seq.); 

(5) except as otherwise prohibited by this section, the Secretary may use funds appropriated under the authority of section 7 of the Act of August 5, 1954 (42 U.S.C. 2004a), to fund 

up to 100 percent of the amount of an Indian Tribe’s loan obtained under any Federal program for new projects to construct 

eligible sanitation facilities to serve Indian homes; 

(6) except as otherwise prohibited by this section, the Secretary may use funds appropriated under the authority of section 7 of the Act of August 5, 1954 (42 U.S.C. 2004a) to meet 

matching or cost participation requirements under other Federal and non-Federal programs for new projects to construct eligible sanitation facilities; 

(7) all Federal agencies are authorized to transfer to the Secretary funds identified, granted, loaned, or appropriated whereby the Department’s applicable policies, rules, and regulations 

shall apply in the implementation of such projects; 

(8) the Secretary of Health and Human Services shall enter 

into interagency agreements with Federal and State agencies for 

the purpose of providing financial assistance for sanitation facilities and services under this Act; 


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191 

(9) the Secretary of Health and Human Services shall, by regulation, establish standards applicable to the planning, design, 

and construction of sanitation facilities funded under this Act; 

and 

(10) the Secretary of Health and Human Services is authorized to accept payments for goods and services furnished by the 

Service from appropriate public authorities, nonprofit organizations or agencies, or Indian Tribes, as contributions by that authority, organization, agency, or tribe to agreements made 

under section 7 of the Act of August 5, 1954 (42 U.S.C. 2004a), 

and such payments shall be credited to the same or subsequent 

appropriation account as funds appropriated under the authority of section 7 of the Act of August 5, 1954 (42 U.S.C. 2004a). 

(d) CERTAIN CAPABILITIES NOT PREREQUISITE.—The financial and 

technical capability of an Indian øtribe or¿ Tribe, Tribal Organization, or Indian community to safely operate, manage, and maintain 

a sanitation facility shall not be a prerequisite to the provision or 

construction of sanitation facilities by the Secretary. 

ø(e) Amount of assistance¿ 

ø(1)¿ (e) FINANCIAL ASSISTANCE.—The Secretary is authorized to 

provide financial assistance to Indian øtribes and communities in 

an amount equal to the Federal share of the costs of operating, 

managing, and maintaining the facilities provided under the plan 

described in subsection (c) of this section.¿ Tribes, Tribal Organizations, and Indian communities for operation, management, and 

maintenance of their sanitation facilities. 

ø(2) For the purposes of paragraph (1), the term ‘‘Federal 

share’’ means 80 percent of the costs described in paragraph 

(1). 

ø(3) With respect to Indian tribes with fewer than 1,000 enrolled members, the non-Federal portion of the costs of operating, managing, and maintaining such facilities may be provided, in part, through cash donations or in kind property, fairly evaluated. 

ø(f) Eligibility of programs administered by Indian tribes 

øPrograms administered by Indian tribes or tribal organizations 

under the authority of the Indian Self-Determination Act [25 

U.S.C.A. §450f et seq.] shall be eligible for— ø(1) any funds appropriated pursuant to this section, and 

ø(2) any funds appropriated for the purpose of providing 

water supply or sewage disposal services, 

øon an equal basis with programs that are administered directly by 

the Service. 

ø(g) Annual¿ 

(f) OPERATION, MANAGEMENT, AND MAINTENANCE OF FACILITIES.—The Indian Tribe has the primary responsibility to establish, 

collect, and use reasonable user fees, or otherwise set aside funding, 

for the purpose of operating, managing, and maintaining sanitation 

facilities. If a sanitation facility serving a community that is operated by an Indian Tribe or Tribal Organization is threatened with 

imminent failure and such operator lacks capacity to maintain the 

integrity or the health benefits of the sanitation facility, then the 

Secretary is authorized to assist the Indian Tribe, Tribal Organization, or Indian community in the resolution of the problem on a 

short-term basis through cooperation with the emergency coordiVerDate Aug 31 2005 01:51 Oct 27, 2007 Jkt 069010 PO 00000 Frm 00191 Fmt 6659 Sfmt 6603 E:\HR\OC\SR197.XXX SR197

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192 

nator or by providing operation, management, and maintenance 

service. 

(g) ISDEAA PROGRAM FUNDED ON EQUAL BASIS.—Tribal Health 

Programs shall be eligible (on an equal basis with programs that 

are administered directly by the Service) for—

(1) any funds appropriated pursuant to this section; and 

(2) any funds appropriated for the purpose of providing sanitation facilities. 

(h) REPORT.—

(1) REQUIRED; CONTENTS.—The Secretary, in consultation 

with the Secretary of Housing and Urban Development, Indian 

Tribes, Tribal Organizations, and tribally designated housing 

entities (as defined in section 4 of the Native American Housing 

Assistance and Self-Determination Act of 1996 (25 U.S.C. 

4103)) shall submit to the President, for inclusion in the 

reportø; sanitation deficiency levels¿ 

ø(1) The Secretary shall submit to the President, for inclusion in each report required to be transmitted to the øCongress 

under section 1671 of this title,¿ Congress under section 801, 

a report which sets forth—

ø(A) the current Indian sanitation facility priority system of the Service;¿ 

(A) the current Indian sanitation facility priority system 

of the Service; 

(B) the methodology for determining sanitation 

deficienciesø;¿ 

ø(C) the level of sanitation deficiency for each sanitation 

facilities project of each Indian tribe or community; 

ø(D) the amount of funds necessary to raise all Indian 

tribes and communities to a level I sanitation deficiency; 

and 

ø(E) the amount of funds necessary to raise all Indian 

tribes and communities to zero sanitation deficiency. 

ø(2) In preparing each report required under paragraph (1) 

(other than the initial report), the Secretary shall consult with 

Indian tribes and tribal organizations (including those tribes or 

tribal organizations operating health care programs or facilities under any contract entered into with the Service under the 

Indian Self-Determination Act [25 U.S.C.A. §450f et seq.]) to 

determine the sanitation needs of each tribe.¿ and needs; 

(C) the criteria on which the deficiencies and needs will 

be evaluated; 

(D) the level of initial and final sanitation deficiency for 

each type of sanitation facility for each project of each Indian Tribe or Indian community; 

(E) the amount and most effective use of funds, derived 

from whatever source, necessary to accommodate the sanitation facilities needs of new homes assisted with funds 

under the Native American Housing Assistance and SelfDetermination Act (25 U.S.C. 4101 et seq.), and to reduce 

the identified sanitation deficiency levels of all Indian 

Tribes and Indian communities to level I sanitation deficiency as defined in paragraph (3)(A); and 


bajohnson on PROD1PC71 with REPORTS
193 

(F) a 10-year plan to provide sanitation facilities to serve 

existing Indian homes and Indian communities and new 

and renovated Indian homes. 

ø(3)¿ (2) UNIFORM METHODOLOGY.—The methodology used by 

the Secretary in determining, preparing cost estimates for, and 

reporting sanitation deficiencies for purposes of paragraph (1) 

shall be applied uniformly to all Indian øtribes and¿ Tribes 

and Indian communities. 

ø(4)¿ (3) SANITATION DEFICIENCY LEVELS.—For purposes of 

this subsection, the sanitation deficiency levels for an øIndian 

tribe or community are¿ individual, Indian Tribe, or Indian 

community sanitation facility to serve Indian homes are determined as follows: 

ø(A) level I is an Indian tribe or community with a sanitation system—¿ 

(A) A level I deficiency exists if a sanitation facility serving an individual, Indian Tribe, or Indian community—

(i) øwhich¿ complies with all applicable water supply øand,¿ pollution control, and solid waste disposal 

lawsø,¿; and 

(ii) øin which the¿ deficiencies relate to routine replacement, repair, or maintenance needsø;¿. 

(B) A level II øis an Indian tribe or community with a 

sanitation system—¿ 

ø(i) which complies¿ deficiency exists if a sanitation 

facility serving an individual, Indian Tribe, or Indian 

community substantially or recently complied with all 

applicable water supply øand¿, pollution control 

ølaws, and (ii) in which the¿, and solid waste laws 

and any deficiencies relate to—

(i) small or minor capital improvements needed to 

bring the facility back into compliance; 

(ii) capital improvements that are necessary to enlarge or improve the facilities in order to meet the current needs øof such tribe or community¿ for domestic 

sanitation facilities; or 

(iii) the lack of equipment or training by an Indian 

Tribe, Tribal Organization, or an Indian community to 

properly operate and maintain the sanitation facilities. 

(C) A level III øis an Indian tribe or community with a 

sanitation system which—¿ deficiency exists if a sanitation 

facility serving an individual, Indian Tribe or Indian community meets 1 or more of the following conditions—

ø(i) has an inadequate or partial water supply and 

a sewage disposal facility that does not comply with 

applicable water supply and pollution control laws, or 

ø(ii) has no solid waste disposal facility; 

ø(D) level IV is an Indian tribe or community with a 

sanitation system which lacks either a safe water supply 

system or a sewage disposal system; and 

ø(E) level V is an Indian tribe or community that lacks 

a safe water supply and a sewage disposal system. 

ø(5) For purposes of this subsection, any Indian tribe or community that lacks the operation and maintenance capability to 


bajohnson on PROD1PC71 with REPORTS
194 

enable its sanitation system to meet pollution control laws may 

not be treated as having a level I or II sanitation deficiency.¿ 

(i) water or sewer service in the home is provided by 

a haul system with holding tanks and interior plumbing; 

(ii) major significant interruptions to water supply or 

sewage disposal occur frequently, requiring major capital improvements to correct the deficiencies; or 

(iii) there is no access to or no approved or permitted 

solid waste facility available. 

(D) A level IV deficiency exists—

(i) if a sanitation facility for an individual home, an 

Indian Tribe, or an Indian community exists but—

(I) lacks—

(aa) a safe water supply system; or 

(bb) a waste disposal system; 

(II) contains no piped water or sewer facilities; 

or 

(III) has become inoperable due to a major component failure; or 

(ii) if only a washeteria or central facility exists in 

the community. 

(E) A level V deficiency exists in the absence of a sanitation facility, where individual homes do not have access to 

safe drinking water or adequate wastewater (including sewage) disposal. 

(i) DEFINITIONS.—For purposes of this section, the 

following terms apply: 

(1) INDIAN COMMUNITY.—The term ‘‘Indian community’’

means a geographic area, a significant proportion of whose inhabitants are Indians and which is served by or capable of 

being served by a facility described in this section. 

(2) SANITATION FACILITIES.—The terms ‘‘sanitation facility’’

and ‘‘sanitation facilities’’ mean safe and adequate water supply 

systems, sanitary sewage disposal systems, and sanitary solid 

waste systems (and all related equipment and support infrastructure). 

ø§1633. Preference to Indians and Indian firms¿ 

SEC. 303. PREFERENCE TO INDIANS AND INDIAN FIRMS. 

ø(a) Discretionary authority; covered activities¿ 

(a) BUY INDIAN ACT.—The Secretary, acting through the Service, 

may øutilize¿ use the negotiating authority of section ø47 of this 

title¿ 23 of the Act of June 25, 1910 (25 U.S.C. 47, commonly 

known as the ‘‘Buy Indian Act’’), to give preference to any Indian 

or any enterprise, partnership, corporation, or other type of business organization owned and controlled by an Indian or Indians including former or currently federally recognized Indian øtribes¿ 

Tribes in the State of New York (hereinafter referred to as an ‘‘Indian firm’’) in the construction and renovation of Service facilities 

pursuant to section ø1631 of this title and in the construction of 

safe water and sanitary waste disposal¿ 301 and in the construction of sanitation facilities pursuant to section ø1632 of this title.¿ 

302. Such preference may be accorded by the Secretary unless øhe¿ 

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gated by him¿, that the project or function to be contracted for will 

not be satisfactory or such project or function cannot be properly 

completed or maintained under the proposed contract. The Secretary, in arriving at øhis¿ such a finding, shall consider whether 

the Indian or Indian firm will be deficient with respect to— (1) ownership and control by Indiansø,¿; 

(2) equipmentø,¿; 

(3) bookkeeping and accounting proceduresø,¿; 

(4) substantive knowledge of the project or function to be 

contracted forø,¿; 

(5) adequately trained personnelø,¿; or 

(6) other necessary components of contract performance. 

ø(b) Pay rates¿ 

(b) LABOR STANDARDS.—

(1) IN GENERAL.—For the øpurpose¿ purposes of implementing the provisions of this øsubchapter, the Secretary shall 

assure that the rates of pay for personnel engaged in¿ title, 

contracts for the construction or renovation of øfacilities constructed or renovated¿ health care facilities, staff quarters, and 

sanitation facilities, and related support infrastructure, funded 

in whole or in part øby¿ with funds made available pursuant 

to this title ø[25 U.S.C.A. §§ 1631 et seq.] are not less than the 

prevailing local wage rates for similar work as determined in 

accordance with the Act of March 3, 1931 (40 U.S.C. 276a to 

276a–5, known as the Davis-Bacon Act).¿, shall contain a provision requiring compliance with subchapter IV of chapter 31 of 

title 40, United States Code (commonly known as the ‘‘DavisBacon Act’’), unless such construction or renovation—

(A) is performed by a contractor pursuant to a contract 

with an Indian Tribe or Tribal Organization with funds 

supplied through a contract or compact authorized by the 

Indian Self-Determination and Education Assistance Act 

(25 U.S.C. 450 et seq.), or other statutory authority; and 

(B) is subject to prevailing wage rates for similar construction or renovation in the locality as determined by the 

Indian Tribes or Tribal Organizations to be served by the 

construction or renovation. 

(2) EXCEPTION.—This subsection shall not apply to construction or renovation carried out by an Indian Tribe or Tribal Organization with its own employees. 

ø§ 1634. Expenditure of non-Service funds for renovation¿ 

SEC. 304. EXPENDITURE OF NON-SERVICE FUNDS FOR RENOVATION. 

ø(a) Authority of Secretary¿ 

ø(1)¿ (a) IN GENERAL.—Notwithstanding any other provision of 

law, øthe Secretary¿if the requirements of subsection (c) are met, 

the Secretary, acting through the Service, is authorized to accept 

any major ørenovation¿ expansion, renovation, or modernization by 

any Indian øtribe of any Service facility,¿ Tribe or Tribal Organization of any Service facility or of any other Indian health facility operated pursuant to a contract øentered into¿ or compact under the 

Indian Self-Determination øAct[¿ and Education Assistance Act (25 

U.S.C.øA. §¿ ø450¿(f) et seq.ø]¿), including— ø(A)¿ (1) any plans or designs for such expansion, renovation, or modernization; and 


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196 

ø(B)¿ (2) any expansion, renovation, or modernization for 

which funds appropriated under any Federal law were lawfully 

expendedø, but only if the requirements of subsection (b) of 

this section are met¿. (b) PRIORITY LIST.— ø(2)¿ (1) IN GENERAL.—The Secretary shall maintain a separate priority list to address the needs øof such facilities¿ for increased operating expenses, personnel, or equipmentø.¿ for such 

facilities. The methodology for establishing priorities shall be 

developed through regulations. The list of priority facilities will 

be revised annually in consultation with Indian Tribes and 

Tribal Organizations. 

ø(3)¿(2) REPORT.—The Secretary shall submit to the President, for inclusion in øeach¿ the report required to be transmitted to øthe¿ Congress under section ø1671 of this title,¿ 

801, the priority list maintained pursuant to paragraph (ø2¿1). 

(øb¿c) REQUIREMENTS.—The requirements of this subsection are 

met with respect to any expansion, renovation, or modernization 

if—

(1) the øtribe or tribal organization¿ Indian Tribe or Tribal 

Organization—

(A) provides notice to the Secretary of its intent to expand, renovate, or modernize; and 

(B) applies to the Secretary to be placed on a separate 

priority list to address the needs of such new facilities for 

increased operating expenses, personnel øor equipment; 

and¿, or equipment; and 

(2) the ørenovation¿ expansion, renovation, or modernization—

(A) is approved by the appropriate area director of the 

Serviceø; and¿ for Federal facilities; and 

(B) is administered by the øtribe¿ Indian Tribe or Tribal 

Organization in accordance with øthe rules and¿ any applicable regulations prescribed by the Secretary with respect to construction or renovation of Service facilities. 

ø(c) Recovery for non-use as Service facility¿ 

(d) ADDITIONAL REQUIREMENT FOR EXPANSION.—In addition to 

the requirements under subsection (c), for any expansion, the Indian 

Tribe or Tribal Organization shall provide to the Secretary additional information pursuant to regulations, including additional 

staffing, equipment, and other costs associated with the expansion. 

(e) CLOSURE OR CONVERSION OF FACILITIES.—If any Service facility which has been expanded, renovated, or modernized by an Indian øtribe¿ Tribe or Tribal Organization under this section ceases 

to be used as a Service facility during the 20-year period beginning 

on the date such expansion, renovation, or modernization is completed, such Indian øtribe¿ Tribe or Tribal Organization shall be 

entitled to recover from the United States an amount which bears 

the same ratio to the value of such facility at the time of such cessation as the value of such expansion, renovation, or modernization 

(less the total amount of any funds provided specifically for such 

facility under any Federal program that were expended for such expansion, renovation, or modernization) bore to the value of such facility at the time of the completion of such expansion, renovation, or modernization. 


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SEC. 305. FUNDING FOR THE CONSTRUCTION, EXPANSION, AND MODERNIZATION OF SMALL AMBULATORY CARE FACILITIES. 

ø§ 1636. Grant program for the construction, expansion, and 

modernization of small ambulatory care facilities¿ 

(a) GRANTS.—

ø(a) Authorization¿ 

(1) IN GENERAL.—The Secretary, acting through the Service, 

shall make grants to øtribes and tribal organizations¿ Indian 

Tribes and Tribal Organizations for the construction, expansion, or modernization of facilities for the provision of ambulatory care services to eligible Indians (and noneligible persons 

øas provided in subsection¿ pursuant to subsections (b)(2) and 

(c)(1)(C)ø of this section¿). A grant made under this section 

may cover up to 100 percent of the costs of such construction, 

expansion, or modernization. For the purposes of this section, 

the term ‘‘construction’’ includes the replacement of an existing 

facility. 

(2) GRANT AGREEMENT REQUIRED.—A grant under paragraph 

(1) may only be made øto a tribe or tribal organization¿ available to a Tribal Health Program operating an Indian health facility (other than a facility owned or constructed by the Service, including a facility originally owned or constructed by the 

Service and transferred to øa tribe or tribal organization) pursuant to a contract entered into under the Indian Self-Determination Act [25 U.S.C.A. § 450f et seq.].¿ an Indian Tribe or 

Tribal Organization). 

ø(b) Use of grant 

(1) A grant provided under this section may be used only for 

the construction, expansion, or modernization (including the 

planning and design of such construction, expansion, or modernization) of an ambulatory care facility—¿ 

(b) USE OF GRANT FUNDS.—

(1) ALLOWABLE USES.—A grant awarded under this section 

may be used for the construction, expansion, or modernization 

(including the planning and design of such construction, expansion, or modernization) of an ambulatory care facility—

(A) located apart from a hospital; 

(B) not funded under section ø1631¿ 301 or section 

ø1637 of this title¿ 306; and 

(C) which, upon completion of such constructionø, expansion,¿ or modernization will—

(i) have a total capacity appropriate to its projected 

service population; 

ø(ii) serve no less than 500¿(ii) provide annually no 

fewer than 150 patient visits by eligible Indians øannually;¿ and other users who are eligible for services in 

such facility in accordance with section 807(c)(2); and 

(iii) provide ambulatory care in a øservice area¿ 

Service Area (specified in the contract øentered into¿ 

or compact under the Indian Self-Determination and 

Education Assistance Act ø[¿(25 U.S.C.øA. § ¿450øf et 

seq.]¿ et seq.)) with a population of ønot less than 

2,000¿ no fewer than 1,500 eligible Indiansø.¿ and 


bajohnson on PROD1PC71 with REPORTS
198 

other users who are eligible for services in such facility 

in accordance with section 807(c)(2). 

(2) ADDITIONAL ALLOWABLE USE.—The Secretary may also reserve a portion of the funding provided under this section and 

use those reserved funds to reduce an outstanding debt incurred 

by Indian Tribes or Tribal Organizations for the construction, 

expansion, or modernization of an ambulatory care facility that 

meets the requirements under paragraph (1). The provisions of 

this section shall apply, except that such applications for funding under this paragraph shall be considered separately from 

applications for funding under paragraph (1). 

ø(2)¿ (3) USE ONLY FOR CERTAIN PORTION OF COSTS.—A grant 

provided under this section may be used only for the cost of that 

portion of a construction, expansion, or modernization project 

that benefits the Service population identified above in subsection (b)(1)(C) (ii) and (iii). The requirements of clauses (ii) 

and (iii) of paragraph (1)(C) shall not apply to øa tribe or tribal 

organization¿ an Indian Tribe or Tribal Organization applying 

for a grant under this section øwhose tribal government offices 

are located on an island¿ for a health care facility located or 

to be constructed on an island or when such facility is not located on a road system providing direct access to an inpatient 

hospital where care is available to the Service population. 

ø(c) Application of grant¿ 

(C) GRANTS.— (1) APPLICATION.—No grant may be made under this section 

unless an application or proposal for øsuch a¿ the grant has 

beenø submitted to and¿ approved by the Secretaryø. An application for a grant under this section shall be submitted in such 

form and manner as the Secretary shall by regulation prescribe and shall¿ in accordance with applicable regulations and 

has set forth reasonable assurance by the applicant that, at all 

times after the construction, expansion, or modernization of a 

facility carried out øpursuant to¿ using a grant received under 

this section—

(A) adequate financial support will be available for the 

provision of services at such facility; 

(B) such facility will be available to eligible Indians 

without regard to ability to pay or source of payment; and 

(C) such facility will, as feasible without diminishing the 

quality or quantity of services provided to eligible Indians, 

serve noneligible persons on a cost basis. 

(2) PRIORITY.—In awarding grants under this section, the 

Secretary shall give priority to øtribes and tribal organizations¿Indian Tribes and Tribal Organizations that demonstrate—

(A) a need for increased ambulatory care services; and 

(B) insufficient capacity to deliver such services. 

(3) PEER REVIEW PANELS.—The Secretary may provide for the 

establishment of peer review panels, as necessary, to review and 

evaluate applications and proposals and to advise the Secretary 

regarding such applications using the criteria developed pursuant to subsection (a)(1). 

(d) øTransfer of interest to United States upon cessation of facility¿REVERSION OF FACILITIES.—If any facility (or portion thereof) 


bajohnson on PROD1PC71 with REPORTS
199 

with respect to which funds have been paid under this section, 

ceases, at any time after completion of the construction, expansion, 

or modernization carried out with such funds, to be øutilized¿ used 

for the purposes of providing øambulatory¿ health care services to 

eligible Indians, all of the right, title, and interest in and to such 

facility (or portion thereof) shall transfer to the United States unless otherwise negotiated by the Service and the Indian Tribe or 

Tribal Organization. 

(e) FUNDING NONRECURRING.—Funding provided under this section shall be nonrecurring and shall not be available for inclusion 

in any individual Indian Tribe’s tribal share for an award under 

the Indian Self-Determination and Education Assistance Act (25 

U.S.C. 450 et seq.) or for reallocation or redesign thereunder. 

ø§1637. Indian health care delivery demonstration project¿ 

SEC. 306. INDIAN HEALTH CARE DELIVERY DEMONSTRATION 

PROJECTS. 

ø(a) Health care delivery demonstration projects¿ 

(a) IN GENERAL.—The Secretary, acting through the Service, is 

authorized to carry out, or to enter into contracts øwith, or make 

grants to, Indian tribes or tribal organizations for the purpose of 

carrying out¿under the Indian Self-Determination and Education 

Assistance Act (25 U.S.C. 450 et seq.) with Indian Tribes or Tribal 

Organizations to carry out, a health care delivery demonstration 

project to test alternative means of delivering health care and services to Indians through øhealth¿ facilities øto Indians¿. 

(b) USE OF øFUNDS¿FUNDS.—The Secretary, in approving projects 

pursuant to this section, may authorize øfunding¿ such contracts 

for the construction and renovation of hospitals, health centers, 

health stations, and other facilities to deliver health care services 

and is authorized to—

(1) waive any leasing prohibition; 

(2) permit carryover of funds appropriated for the provision 

of health care services; 

(3) permit the use of ønon-Service Federal funds and nonFederal¿other available funds; 

(4) permit the use of funds or property donated from any 

source for project purposes; øand¿ 

(5) provide for the reversion of donated real or personal property to the donorø.¿; and 

ø(c) Criteria¿ 

(6) permit the use of Service funds to match other funds, including Federal funds. 

(c) HEALTH CARE DEMONSTRATION PROJECTS.—

(1) GENERAL PROJECTS.—

ø(1) Within 180 days after November 28, 1990, the Secretary, after consultation with Indian tribes and tribal organizations, shall develop and publish in the Federal Register criteria for the review and approval of applications submitted 

under this section. The Secretary may enter into a contract or 

award a grant under this section for projects which¿ 

(A) CRITERIA.—The Secretary may approve under this 

section demonstration projects that meet the following criteria: 


bajohnson on PROD1PC71 with REPORTS
200 

ø(A)¿ (i)There is a need for a new facility or program, such as a program for convenient care services, 

or the reorientation of an existing facility or program. 

ø(B)¿ (ii) A significant number of Indians, including 

øthose¿ Indians with low health status, will be served 

by the project. 

ø(C) The project has the potential to address the 

health needs of Indians in an innovative manner.¿ 

ø(D)¿ (iii) The project has the potential to deliver 

services in an efficient and effective manner. 

ø(E)¿ (iv) The project is economically viable. 

ø(F)¿ (v) øThe Indian tribe or tribal organization¿ 

For projects carried out by an Indian Tribe or Tribal 

Organization, the Indian Tribe or Tribal Organization 

has the administrative and financial capability to administer the project. 

ø(G)¿ (vi) The project is integrated with providers of 

related health and social services and is coordinated 

with, and avoids duplication of, existing services in 

order to expand the availability of services. 

ø(2) The Secretary may provide for the establishment of peer 

review panels, as necessary, to review and evaluate applications and to advise the Secretary regarding such applications 

using the criteria developed pursuant to paragraph (1). 

ø(3)(A) On or before September 30, 1995, the Secretary shall 

enter into contracts or award grants under this section for a 

demonstration project in each of the following service units 

which meets the criteria specified in paragraph (1) and for 

which a completed application has been received by the Secretary:¿ 

(B) PRIORITY.—In approving demonstration projects 

under this paragraph, the Secretary shall give priority to 

demonstration projects, to the extent the projects meet the 

criteria described in subparagraph (A), located in any of 

the following Service Units: 

(i) Cass Lake, Minnesota. 

(iiø) Clinton, Oklahoma. 

ø(iii) Harlem, Montana. 

(iv¿) Mescalero, New Mexico. 

(øv¿iii) Owyhee, Nevada. 

ø(vi) Parker, Arizona.¿ 

(øvii¿iv) Schurz, Nevada. 

ø(viii) Winnebago, Nebraska.¿ 

(øix¿v) Ft. Yuma, California. 

ø(B) The Secretary may also enter into contracts or 

award grants under this section taking into consideration 

applications received under this section from all service 

areas. The Secretary may not award a greater number of 

such contracts or grants in one service area than in any 

other service area until there is an equal number of such 

contracts or grants awarded with respect to all service 

areas from which the Secretary receives applications during the application period (as determined by the Secretary) 

which meet the criteria specified in paragraph (1).¿ 

(2) CONVENIENT CARE SERVICE PROJECTS.—


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201 

(A) DEFINITION OF CONVENIENT CARE SERVICE.—In this 

paragraph, the term ‘‘convenient care service’’ means any 

primary health care service, such as urgent care services, 

nonemergent care services, prevention services and 

screenings, and any service authorized by sections 203 or 

213(d), that is— (i) provided outside the regular hours of operation of 

a health care facility; or 

(ii) offered at an alternative setting. 

(B) APPROVAL.—In addition to projects described in paragraph (1), in any fiscal year, the Secretary is authorized to 

approve not more than 10 applications for health care delivery demonstration projects that— (i) include a convenient care services program as an 

alternative means of delivering health care services to 

Indians; and 

(ii) meet the criteria described in subparagraph (C). 

(C) CRITERIA.—The Secretary shall approve under subparagraph (B) demonstration projects that meet all of the 

following criteria: 

(i) The criteria set forth in paragraph (1)(A). 

(ii) There is a lack of access to health care services 

at existing health care facilities, which may be due to 

limited hours of operation at those facilities or other 

factors. 

(iii) The project— (I) expands the availability of services; or 

(II) reduces— (aa) the burden on Contract Health Services; 

or 

(bb) the need for emergency room visits. 

(d) PEER REVIEW PANELS.—The Secretary may provide for the establishment of peer review panels, as necessary, to review and 

evaluate applications using the criteria described in paragraphs 

(1)(A) and (2)(C) of subsection (c). 

(ød¿e) TECHNICAL øassistance¿ ASSISTANCE.—The Secretary shall 

provide such technical and other assistance as may be necessary to 

enable applicants to comply with øthe provisions of¿ this section. 

(øe¿f) SERVICE TO øineligible persons The¿INELIGIBLE PER- SONS.— Subject to section 807, the authority to provide services to 

persons otherwise ineligible for the health care benefits of the Service, and the authority to extend hospital privileges in øservice¿Service facilities to non-Service health øcare¿ practitioners as 

provided in section ø1680c of this title¿ 807, may be included, subject to the terms of øsuch¿ that section, in any demonstration 

project approved pursuant to this section. 

(øf¿g) EQUITABLE øTREATMENT¿ TREATMENT.—For purposes of 

subsection (c)ø(1)(A) of this section,¿ the Secretary øshall¿, in evaluating facilities operated under any contract øentered into with the 

Service¿ or compact under the Indian Self-Determination and Education Assistance Actø [¿(25 U.S.C.øA. §¿450øf¿ et seq.¿,), shall use 

the same criteria that the Secretary uses in evaluating facilities operated directly by the Service. 

(øg¿h EQUITABLE øintegration of facilities¿ INTEGRATION OF FACILITIES.—The Secretary shall ensure that the planning, design, 


bajohnson on PROD1PC71 with REPORTS
202 

construction, øand¿ renovation, and expansion needs of Service and 

non-Service facilities øwhich¿ that are the subject of a contract øfor 

health services entered into with the Service¿or compact under the 

Indian Self-Determination and Education Assistance Act ø[¿(25 

U.S.C.øA. §¿450øf¿ et seq.],) for health services are fully and equitably integrated into the implementation of the health care delivery 

demonstration projects under this section. 

ø(h) Reports to Congress 

ø(1) The Secretary shall submit to the President, for inclusion in the report which is required to be submitted to the Congress under section 1671 of this title for fiscal year 1997, an 

interim report on the findings and conclusions derived from the 

demonstration projects established under this section. 

ø(2) The Secretary shall submit to the President, for inclusion in the report which is required to be submitted to the Congress under section 1671 of this title for fiscal year 1999, a 

final report on the findings and conclusions derived from the 

demonstration projects established under this section, together 

with legislative recommendations. 

SEC. 307. LAND TRANSFER. 

Notwithstanding any other provision of law, the Bureau of Indian 

Affairs and all other agencies and departments of the United States 

are authorized to transfer, at no cost, land and improvements to the 

Service for the provision of health care services. The Secretary is authorized to accept such land and improvements for such purposes. 

SEC. 308. LEASES, CONTRACTS, AND OTHER AGREEMENTS. 

The Secretary, acting through the Service, may enter into leases, 

contracts, and other agreements with Indian Tribes and Tribal Organizations which hold (1) title to, (2) a leasehold interest in, or (3) 

a beneficial interest in (when title is held by the United States in 

trust for the benefit of an Indian Tribe) facilities used or to be used 

for the administration and delivery of health services by an Indian 

Health Program. Such leases, contracts, or agreements may include 

provisions for construction or renovation and provide for compensation to the Indian Tribe or Tribal Organization of rental and other 

costs consistent with section 105(l) of the Indian Self-Determination 

and Education Assistance Act (25 U.S.C. 450j(l)) and regulations 

thereunder. 

SEC. 309. STUDY ON LOANS, LOAN GUARANTEES, AND LOAN REPAYMENT. 

(a) IN GENERAL.—The Secretary, in consultation with the Secretary of the Treasury, Indian Tribes, and Tribal Organizations, 

shall carry out a study to determine the feasibility of establishing 

a loan fund to provide to Indian Tribes and Tribal Organizations 

direct loans or guarantees for loans for the construction of health 

care facilities, including—

(1) inpatient facilities; 

(2) outpatient facilities; 

(3) staff quarters; 

(4) hostels; and 

(5) specialized care facilities, such as behavioral health and 

elder care facilities. 

(b) DETERMINATIONS.—In carrying out the study under subsection 

(a), the Secretary shall determine—


bajohnson on PROD1PC71 with REPORTS
203 

(1) the maximum principal amount of a loan or loan guarantee that should be offered to a recipient from the loan fund; 

(2) the percentage of eligible costs, not to exceed 100 percent, 

that may be covered by a loan or loan guarantee from the loan 

fund (including costs relating to planning, design, financing, 

site land development, construction, rehabilitation, renovation, 

conversion, improvements, medical equipment and furnishings, 

and other facility-related costs and capital purchase (but excluding staffing)); 

(3) the cumulative total of the principal of direct loans and 

loan guarantees, respectively, that may be outstanding at any 

one time; 

(4) the maximum term of a loan or loan guarantee that may 

be made for a facility from the loan fund; 

(5) the maximum percentage of funds from the loan fund that 

should be allocated for payment of costs associated with planning and applying for a loan or loan guarantee; 

(6) whether acceptance by the Secretary of an assignment of 

the revenue of an Indian Tribe or Tribal Organization as security for any direct loan or loan guarantee from the loan fund 

would be appropriate; 

(7) whether, in the planning and design of health facilities 

under this section, users eligible under section 807(c) may be included in any projection of patient population; 

(8) whether funds of the Service provided through loans or 

loan guarantees from the loan fund should be eligible for use 

in matching other Federal funds under other programs; 

(9) the appropriateness of, and best methods for, coordinating 

the loan fund with the health care priority system of the Service 

under section 301; and 

(10) any legislative or regulatory changes required to implement recommendations of the Secretary based on results of the 

study. 

(c) REPORT.—Not later than September 30, 2009, the Secretary 

shall submit to the Committee on Indian Affairs of the Senate and 

the Committee on Natural Resources and the Committee on Energy 

and Commerce of the House of Representatives a report that describes—

(1) the manner of consultation made as required by subsection (a); and 

(2) the results of the study, including any recommendations 

of the Secretary based on results of the study. 

SEC. 310. TRIBAL LEASING. 

A Tribal Health Program may lease permanent structures for the 

purpose of providing health care services without obtaining advance 

approval in appropriation Acts. 

SEC. 311. INDIAN HEALTH SERVICE/TRIBAL FACILITIES JOINT VENTURE PROGRAM. 

(a) IN GENERAL.—The Secretary, acting through the Service, shall 

make arrangements with Indian Tribes and Tribal Organizations to 

establish joint venture demonstration projects under which an Indian Tribe or Tribal Organization shall expend tribal, private, or 

other available funds, for the acquisition or construction of a health 

facility for a minimum of 10 years, under a no-cost lease, in exVerDate Aug 31 2005 01:51 Oct 27, 2007 Jkt 069010 PO 00000 Frm 00203 Fmt 6659 Sfmt 6603 E:\HR\OC\SR197.XXX SR197

bajohnson on PROD1PC71 with REPORTS
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change for agreement by the Service to provide the equipment, supplies, and staffing for the operation and maintenance of such a 

health facility. An Indian Tribe or Tribal Organization may use 

tribal funds, private sector, or other available resources, including 

loan guarantees, to fulfill its commitment under a joint venture entered into under this subsection. An Indian Tribe or Tribal Organization shall be eligible to establish a joint venture project if, when 

it submits a letter of intent, it— (1) has begun but not completed the process of acquisition or 

construction of a health facility to be used in the joint venture 

project; or 

(2) has not begun the process of acquisition or construction of 

a health facility for use in the joint venture project. 

(b) REQUIREMENTS.—The Secretary shall make such an arrangement with an Indian Tribe or Tribal Organization only if— (1) the Secretary first determines that the Indian Tribe or 

Tribal Organization has the administrative and financial capabilities necessary to complete the timely acquisition or construction of the relevant health facility; and 

(2) the Indian Tribe or Tribal Organization meets the need 

criteria determined using the criteria developed under the 

health care facility priority system under section 301, unless the 

Secretary determines, pursuant to regulations, that other criteria will result in a more cost-effective and efficient method of 

facilitating and completing construction of health care facilities. 

(c) CONTINUED OPERATION.—The Secretary shall negotiate an 

agreement with the Indian Tribe or Tribal Organization regarding 

the continued operation of the facility at the end of the initial 10 

year no-cost lease period. 

(d) BREACH OF AGREEMENT.—An Indian Tribe or Tribal Organization that has entered into a written agreement with the Secretary 

under this section, and that breaches or terminates without cause 

such agreement, shall be liable to the United States for the amount 

that has been paid to the Indian Tribe or Tribal Organization, or 

paid to a third party on the Indian Tribe’s or Tribal Organization’s 

behalf, under the agreement. The Secretary has the right to recover 

tangible property (including supplies) and equipment, less depreciation, and any funds expended for operations and maintenance 

under this section. The preceding sentence does not apply to any 

funds expended for the delivery of health care services, personnel, or 

staffing. 

(e) RECOVERY FOR NONUSE.—An Indian Tribe or Tribal Organization that has entered into a written agreement with the Secretary 

under this subsection shall be entitled to recover from the United 

States an amount that is proportional to the value of such facility 

if, at any time within the 10-year term of the agreement, the Service 

ceases to use the facility or otherwise breaches the agreement. 

(f) DEFINITION.—For the purposes of this section, the term ‘‘health 

facility’’ or ‘‘health facilities’’ includes quarters needed to provide 

housing for staff of the relevant Tribal Health Program. 

SEC. 312. LOCATION OF FACILITIES. 

(a) IN GENERAL.—In all matters involving the reorganization or 

development of Service facilities or in the establishment of related 

employment projects to address unemployment conditions in economically depressed areas, the Bureau of Indian Affairs and the 


bajohnson on PROD1PC71 with REPORTS
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Service shall give priority to locating such facilities and projects on 

Indian lands, or lands in Alaska owned by any Alaska Native village, or village or regional corporation under the Alaska Native 

Claims Settlement Act (43 U.S.C. 1601 et seq.), or any land allotted 

to any Alaska Native, if requested by the Indian owner and the Indian Tribe with jurisdiction over such lands or other lands owned 

or leased by the Indian Tribe or Tribal Organization. Top priority 

shall be given to Indian land owned by 1 or more Indian Tribes. 

(b) DEFINITION.—For purposes of this section, the term ‘‘Indian 

lands’’ means—

(1) all lands within the exterior boundaries of any reservation; and 

(2) any lands title to which is held in trust by the United 

States for the benefit of any Indian Tribe or individual Indian 

or held by any Indian Tribe or individual Indian subject to restriction by the United States against alienation. 

SEC. 313. MAINTENANCE AND IMPROVEMENT OF HEALTH CARE FACILITIES. 

(a) REPORT.—The Secretary shall submit to the President, for inclusion in the report required to be transmitted to Congress under 

section 801, a report which identifies the backlog of maintenance 

and repair work required at both Service and tribal health care facilities, including new health care facilities expected to be in operation in the next fiscal year. The report shall also identify the need 

for renovation and expansion of existing facilities to support the 

growth of health care programs. 

(b) MAINTENANCE OF NEWLY CONSTRUCTED SPACE.—The Secretary, acting through the Service, is authorized to expend maintenance and improvement funds to support maintenance of newly constructed space only if such space falls within the approved supportable space allocation for the Indian Tribe or Tribal Organization. 

Supportable space allocation shall be defined through the health 

care facility priority system under section 301(c). 

(c) REPLACEMENT FACILITIES.—In addition to using maintenance 

and improvement funds for renovation, modernization, and expansion of facilities, an Indian Tribe or Tribal Organization may use 

maintenance and improvement funds for construction of a replacement facility if the costs of renovation of such facility would exceed 

a maximum renovation cost threshold. The maximum renovation 

cost threshold shall be determined through the negotiated rulemaking process provided for under section 802. 

SEC. 314. TRIBAL MANAGEMENT OF FEDERALLY-OWNED QUARTERS. 

(a) RENTAL RATES.—

(1) ESTABLISHMENT.—Notwithstanding any other provision of 

law, a Tribal Health Program which operates a hospital or 

other health facility and the federally-owned quarters associated therewith pursuant to a contract or compact under the Indian Self-Determination and Education Assistance Act (25 

U.S.C. 450 et seq.) shall have the authority to establish the 

rental rates charged to the occupants of such quarters by providing notice to the Secretary of its election to exercise such authority. 


bajohnson on PROD1PC71 with REPORTS
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(2) OBJECTIVES.—In establishing rental rates pursuant to authority of this subsection, a Tribal Health Program shall endeavor to achieve the following objectives: 

(A) To base such rental rates on the reasonable value of 

the quarters to the occupants thereof. 

(B) generate sufficient funds to prudently provide for the 

operation and maintenance of the quarters, and subject to 

the discretion of the Tribal Health Program, to supply reserve funds for capital repairs and replacement of the quarters. 

(3) EQUITABLE FUNDING.—Any quarters whose rental rates are 

established by a Tribal Health Program pursuant to this subsection shall remain eligible for quarters improvement and repair funds to the same extent as all federally-owned quarters 

used to house personnel in Services-supported programs. 

(4) NOTICE OF RATE CHANGE.—A Tribal Health Program 

which exercises the authority provided under this subsection 

shall provide occupants with no less than 60 days notice of any 

change in rental rates. 

(b) DIRECT COLLECTION OF RENT.—

(1) IN GENERAL.—Notwithstanding any other provision of 

law, and subject to paragraph (2), a Tribal Health Program 

shall have the authority to collect rents directly from Federal 

employees who occupy such quarters in accordance with the following: 

(A) The Tribal Health Program shall notify the Secretary 

and the subject Federal employees of its election to exercise 

its authority to collect rents directly from such Federal employees. 

(B) Upon receipt of a notice described in subparagraph 

(A), the Federal employees shall pay rents for occupancy of 

such quarters directly to the Tribal Health Program and 

the Secretary shall have no further authority to collect rents 

from such employees through payroll deduction or otherwise. 

(C) Such rent payments shall be retained by the Tribal 

Health Program and shall not be made payable to or otherwise be deposited with the United States. 

(D) Such rent payments shall be deposited into a separate account which shall be used by the Tribal Health Program for the maintenance (including capital repairs and 

replacement) and operation of the quarters and facilities as 

the Tribal Health Program shall determine. 

(2) RETROCESSION OF AUTHORITY.—If a Tribal Health Program which has made an election under paragraph (1) requests 

retrocession of its authority to directly collect rents from Federal 

employees occupying federally-owned quarters, such retrocession 

shall become effective on the earlier of—

ø§ 1638. Land transfer¿ 

(A) the first day of the month that begins no less than 

180 days after the Tribal Health Program notifies the Secretary of its desire to retrocede; or 

øThe Bureau of Indian Affairs is authorized to transfer, at no 

cost, up to 5 acres of land at the Chemawa Indian School, Salem, 


bajohnson on PROD1PC71 with REPORTS
207 

Oregon, to the Service for the provision of health care services. The 

land authorized to be transferred by this section is that land adjacent to land under the jurisdiction of the Service and occupied by 

the Chemawa Indian Health Center.¿ 

(B) such other date as may be mutually agreed by the Secretary and the Tribal Health Program. 

ø§1638a. Authorization of appropriations¿ 

(c) RATES IN ALASKA.—To the extent that a Tribal Health Program, pursuant to authority granted in subsection (a), establishes 

rental rates for federally-owned quarters provided to a Federal employee in Alaska, such rents may be based on the cost of comparable 

private rental housing in the nearest established community with a 

year-round population of 1,500 or more individuals. 

øThere are authorized to be appropriated such sums as may be 

necessary for each fiscal year through fiscal year 2000 to carry out 

this subchapter.¿ 

SEC. 315. APPLICABILITY OF BUY AMERICAN ACT REQUIREMENT. 

ø§ 1638b.¿ 

(a) APPLICABILITY øof Buy American requirement (a) Duty of Secretary¿.—The Secretary shall ensure that the requirements of the 

Buy American Act ø[41 U.S.C.A. § 10a et seq.]¿ apply to all procurements made with funds provided pursuant to øthe authorization contained in section 1638a of this title.¿ section 317. Indian 

Tribes and Tribal Organizations shall be exempt from these requirements. 

ø(b) Report to Congress 

øThe Secretary shall submit to the Congress a report on the 

amount of procurements from foreign entities made in fiscal years 

1993 and 1994 with funds provided pursuant to the authorization 

contained in section 1638a of this title. Such report shall separately 

indicate the dollar value of items procured with such funds for 

which the Buy American Act [41 U.S.C.A. § 10a et seq.] was waived 

pursuant to the Trade Agreement Act of 1979 [19 U.S.C.A. § 250 

et seq.] or any international agreement to which the United States 

is a party. 

ø(c) Fraudulent use of Made-in-America label¿ 

(b) EFFECT OF VIOLATION.—If it has been finally determined by 

a court or Federal agency that any person intentionally affixed a 

label bearing a ‘‘Made in America’’ inscriptionø,¿ or any inscription 

with the same meaning, to any product sold in or shipped to the 

United States that is not made in the United States, such person 

shall be ineligible to receive any contract or subcontract made with 

funds provided pursuant to øthe authorization contained in¿ section ø1638a of this title,¿ 317, pursuant to the debarment, suspension, and ineligibility procedures described in sections 9.400 

through 9.409 of title 48, Code of Federal Regulations. 

ø(d) ‘‘Buy American Act’’ defined¿ (c) DEFINITIONS.—For purposes 

of this section, the term ø‘‘Buy American Act’’¿ ‘‘Buy American Act’’

means title III of the Act entitled ‘‘An Act making appropriations 

for the Treasury and Post Office Departments for the fiscal year 

ending June 30, 1934, and for other purposes’’, approved March 3, 

1933 (41 U.S.C. 10a et seq.). 


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ø§ 1638c. Contracts for provision of personal services in Indian Health Service facilities 

øIn fiscal year 1995 and thereafter—¿ 

SEC. 316. OTHER FUNDING FOR FACILITIES. 

ø(a) In general 

øThe Secretary may enter into personal services contracts with 

entities, either individuals or organizations, for the provision of 

services in facilities owned, operated or constructed under the jurisdiction of the Indian Health Service.¿ 

(a) AUTHORITY TO ACCEPT FUNDS.—The Secretary is authorized 

to accept from any source, including Federal and State agencies, 

funds that are available for the construction of health care facilities 

and use such funds to plan, design, and construct health care facilities for Indians and to place such funds into a contract or compact 

under the Indian Self-Determination and Education Assistance Act 

(25 U.S.C. 450 et seq.). Receipt of such funds shall have no effect 

on the priorities established pursuant to section 301. 

ø(b) Exemption from competitive contracting requirements 

øThe Secretary may exempt such a contract from competitive 

contracting requirements upon adequate notice of contracting opportunities to individuals and organizations residing in the geographic vicinity of the health facility.¿ 

(b) INTERAGENCY AGREEMENTS.—The Secretary is authorized to 

enter into interagency agreements with other Federal agencies or 

State agencies and other entities and to accept funds from such Federal or State agencies or other sources to provide for the planning, 

design, and construction of health care facilities to be administered 

by Indian Health Programs in order to carry out the purposes of 

this Act and the purposes for which the funds were appropriated or 

for which the funds were otherwise provided. 

ø(c) Consideration of individuals and organizations 

øConsideration of individuals and organizations shall be based 

solely on the qualifications established for the contract and the proposed contract price.¿ 

(c) ESTABLISHMENT OF STANDARDS.—The Secretary, through the 

Service, shall establish standards by regulation for the planning, 

design, and construction of health care facilities serving Indians 

under this Act. 

ø(d) Liability 

øIndividuals providing health care services pursuant to these 

contracts are covered by the Federal Tort Claims Act.¿ 

SEC. 317. AUTHORIZATION OF APPROPRIATIONS. 

ø§ 1638d. Crediting of money collected for meals served at 

Indian Health Service facilities¿ 

There are authorized to be appropriated such sums as may be 

necessary for each fiscal year through fiscal year 2017 to carry out 

this title. 

øMoney heretofore and hereafter collected for meals served at Indian Health Service facilities will be credited to the appropriations 

from which the services were furnished and shall be credited to the 

appropriation when received.¿ 


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209 

TITLE IV—ACCESS TO HEALTH SERVICES 

ø§ 1641. Treatment of payments under medicare program¿ 

SEC. 401. TREATMENT OF PAYMENTS UNDER SOCIAL SECURITY ACT 

HEALTH BENEFITS PROGRAMS. 

ø(a) Determination of appropriations 

øAny payments received by a hospital or skilled nursing facility 

of the Service (whether operated by the Service or by an Indian 

tribe or tribal organization pursuant to a contract under the Indian 

Self-Determination Act [25 U.S.C.A. § 450f et seq.])¿ 

(a) DISREGARD OF MEDICARE, MEDICAID, AND SCHIP PAYMENTS

IN DETERMINING APPROPRIATIONS.—Any payments received by an 

Indian Health Program or by an Urban Indian Organization under 

title XVIII, XIX, or XXI of the Social Security Act for services provided to Indians eligible for benefits under øtitle XVIII of the Social 

Security Act [42 U.S.C.A. §1395 et seq.]¿ such respective titles shall 

not be considered in determining appropriations for øhealth care 

and services to Indians.¿ the provision of health care and services 

to Indians. 

ø(b) Preferences¿ 

(b) NONPREFERENTIAL TREATMENT.—Nothing in this øchapter¿ 

Act authorizes the Secretary to provide services to an Indian øbeneficiary¿ with coverage under title XVIII, XIX, or XXI of the Social 

Security øAct [42 U.S.C.A. § 1395 et seq.], as amended,¿ Act in 

preference to an Indian øbeneficiary¿ without such coverage. 

(c) USE OF FUNDS.—

ø§ 1642. Treatment of payments under medicaid program¿ 

(1) SPECIAL FUND.—

ø(a) Payments to special fund¿ 

(A) 100 PERCENT PASS-THROUGH OF PAYMENTS DUE TO

FACILITIES.—Notwithstanding any other provision of law, 

øpayments to which any facility of the Service (including 

a hospital, nursing facility, intermediate care facility for 

the mentally retarded, or any other type of facility which 

provides services for which payment is available under 

title XIX of the Social Security Act [42 U.S.C.A. § 1396 et 

seq.]) is entitled under a State plan by reason of section 

1911 of such Act [42 U.S.C.A. § 1396j]¿but subject to paragraph (2), payments to which a facility of the Service is entitled by reason of a provision of the Social Security Act 

shall be placed in a special fund to be held by the Secretary øand used by him (to such extent or in such 

amounts as are provided in appropriation Acts) exclusively 

for the purpose of making any improvements in the facilities of such Service which may be necessary to achieve 

compliance with the applicable conditions and requirements of such title¿. In making payments from such fund, 

the Secretary shall ensure that each øservice unit¿ Service 

Unit of the Service receives øat least 80¿ 100 percent of 

the øamounts¿ amount to which the facilities of the Service, for which such øservice unit¿ Service Unit makes collections, are entitled by reason of øsection 1911 of the Social Security Act [42 U.S.C.A. § 1396j].¿ a provision of the 

Social Security Act. 


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210 

ø(b) Determination of appropriation 

øAny payments received by such facility for services provided to 

Indians eligible for benefits under title XIX of the Social Security 

Act [42 U.S.C.A. § 1396 et seq.] shall not be considered in determining appropriations for the provision of health care and services 

to Indians. 

ø§ 1643. Amount and use of funds reimbursed through medicare and medicaid available to Indian Health Service¿ 

øThe Secretary shall submit to the President, for inclusion in the 

report required to be transmitted to the Congress under section 

1671 of this title, an accounting on the amount and use of funds 

made available to the Service pursuant to this subchapter as a result of reimbursements through titles XVIII and XIX of the Social 

Security Act [42 U.S.C.A. §§ 1395 et seq., 1396 et seq.], as amended.¿ 

ø§1644. Grants to and contracts with tribal organizations¿ 

(B) USE OF FUNDS.—Amounts received by a facility of the 

Service under subparagraph (A) shall first be used (to such 

extent or in such amounts as are provided in appropriation 

Acts) for the purpose of making any improvements in the 

programs of the Service operated by or through such facility which may be necessary to achieve or maintain compliance with the applicable conditions and requirements of titles XVIII and XIX of the Social Security Act. Any amounts 

so received that are in excess of the amount necessary to 

achieve or maintain such conditions and requirements 

shall, subject to consultation with the Indian Tribes being 

served by the Service Unit, be used for reducing the health 

resource deficiencies (as determined under section 201(d)) of 

such Indian Tribes. 

ø(a) Access to health services 

øThe Secretary, acting through the Service, shall make grants to 

or enter into contracts with tribal organizations to assist such organizations in establishing and administering programs on or near 

Federal Indian reservations and trust areas and in or near Alaska 

Native villages to assist individual Indians to—

ø(1) enroll under section 1818 of part A and sections 1836 

and 1837 of part B of title XVIII of the Social Security Act [42 

U.S.C.A. §§ 1395i–2, 1395o, and 1395p]; 

ø(2) pay monthly premiums for coverage due to financial 

need of such individual; and 

ø(3) apply for medical assistance provided pursuant to title 

XIX of the Social Security Act [42 U.S.C.A. § 1396 et seq.]. 

ø(b) Terms and conditions 

øThe Secretary, acting through the Service, shall place conditions 

as deemed necessary to effect the purpose of this section in any 

contract or grant which the Secretary makes with any tribal organization pursuant to this section. Such conditions shall include, but 

are not limited to, requirements that the organization successfully 

undertake to—

ø(1) determine the population of Indians to be served that 

are or could be recipients of benefits under titles XVIII and 


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211 

XIX of the Social Security Act [42 U.S.C.A. §§ 1395 et seq., 

1396 et seq.]; 

ø(2) assist individual Indians in becoming familiar with and 

utilizing such benefits; 

ø(3) provide transportation to such individual Indians to the 

appropriate offices for enrollment or application for medical assistance; 

ø(4) develop and implement— ø(A) a schedule of income levels to determine the extent 

of payments of premiums by such organizations for coverage of needy individuals; and 

ø(B) methods of improving the participation of Indians 

in receiving the benefits provided under titles XVIII and 

XIX of the Social Security Act [42 U.S.C.A. §§ 1395 et seq., 

1396 et seq.]. 

ø(c) Application for medical assistance 

øThe Secretary, acting through the Service, may enter into an 

agreement with an Indian tribe, tribal organization, or urban Indian organization which provides for the receipt and processing of 

applications for medical assistance under title XIX of the Social Security Act [42 U.S.C.A. §§ 1396 et seq.] and benefits under title 

XVIII of the Social Security Act [42 U.S.C.A. §§ 1395 et seq.] at a 

Service facility or a health care facility administered by such tribe 

or organization pursuant to a contract under the Indian Self-Determination Act [25 U.S.C.A. § 450f et seq.]. 

(2) DIRECT PAYMENT OPTION.—Paragraph (1) shall not apply 

to a Tribal Health Program upon the election of such Program 

under subsection (d) to receive payments directly. No payment 

may be made out of the special fund described in such paragraph with respect to reimbursement made for services provided 

by such Program during the period of such election. 

ø§ 1645. Direct billing of Medicare, Medicaid, and other third 

party payors¿ 

(d) DIRECT BILLING.— ø(a) Establishment of direct billing program 

ø(1) In general 

øThe Secretary shall establish a program under which Indian tribes, tribal organizations, and Alaska Native health organizations that contract or compact for the operation of a hospital or clinic of the Service under the Indian Self-Determination and Education Assistance Act¿ 

(1) IN GENERAL.—Subject to complying with the requirements 

of paragraph (2), a Tribal Health Program may elect to directly 

bill for, and receive payment for, health care items and services 

provided by such øhospital or clinic¿ Program for which payment is made under title XVIII or XIX of the Social Security 

Act ø(42 U.S.C. 1395 et seq.) (in this section referred to as the 

‘‘medicare program’’), under a State plan for medical assistance 

approved under title XIX of the Social Security Act (42 U.S.C. 

1396 et seq.) (in this section referred to as the ‘‘medicaid program’’),¿ or from any other third party payor. 

ø(2) Application of 100 percent FMAP 

øThe third sentence of section 1396d(b) of Title 42 shall 

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gram for health care services directly billed under the program 

established under this section. 

ø(b) Direct reimbursement 

ø(1) Use of funds¿ 

(2) DIRECT REIMBURSEMENT.— øEach hospital or clinic participating in the program described in subsection (a) of this section¿ 

(A) USE OF FUNDS.—Each Tribal Health Program making the election described in paragraph (1) with respect to 

a program under a title of the Social Security Act shall be 

reimbursed directly øunder the medicare and medicaid 

programs for services furnished, without regard to the provisions of section 1395qq(c) of Title 42 and sections 602(a) 

and 1013(b)(2)(A) of Title 42, but all funds¿ by that program for items and services furnished without regard to 

subsection (c)(1), but all amounts so reimbursed shall 

øfirst¿ be used by øthe hospital or clinic¿ Tribal Health 

Program for the purpose of making any improvements in 

the øhospital or clinic¿ facilities of the Tribal Health Program that may be necessary to achieve or maintain compliance with the conditions and requirements applicable 

generally to øfacilities of such type under the medicare or 

medicaid programs. Any funds so reimbursed which are in 

excess of the amount necessary to achieve or maintain 

such conditions shall be used—¿ such items and services 

under the program under such title and to provide additional health care services, improvements in health care facilities and Tribal Health Programs, any health care related purpose, or otherwise to achieve the objectives provided in section 3 of this Act. 

ø(A) solely for improving the health resources deficiency 

level of the Indian tribe; and 

ø(B) in accordance with the regulations of the Service 

applicable to funds provided by the Service under any contract entered into under the Indian Self-Determination Act 

(25 U.S.C. 450f et seq.). 

ø(2) Audits 

øThe amounts paid to the hospitals and clinics participating 

in the program established under this section¿ 

(B) AUDITS.—The amounts paid to a Tribal Health Program making the election described in paragraph (1) with 

respect to a program under a title of the Social Security Act 

shall be subject to all auditing requirements applicable to 

øprograms administered directly by the Service and to facilities participating in the medicare and medicaid programs. 

ø(3) Secretarial oversight 

øThe Secretary shall monitor the performance of hospitals 

and clinics participating in the program established under this 

section, and shall require such hospitals and clinics to submit 

reports on the program to the Secretary on an annual basis. 

ø(4) No payments from special funds 

øNotwithstanding section 1395qq(c) of Title 42 or section 

602(a) of Title 42, no payment may be made out of the special 

funds described in such sections for the benefit of any hospital 


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213 

or clinic during the period that the hospital or clinic participates in the program established under this section. 

ø(c) Requirements for participation 

ø(1) Application 

øExcept as provided in paragraph (2)(B), in order to be eligible for participation in the program established under this section, an Indian tribe, tribal organization, or Alaska Native 

health organization shall submit an application to the Secretary that establishes to the satisfaction of the øSecretary 

that—

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

ø(B) the facility is eligible to participate in the medicare 

or medicaid programs under section 1395qq or 1396j of 

Title 42; 

ø(C) the facility meets the requirements that apply to 

programs operated directly by the Service; and 

ø(D) the facility—

ø(i) is accredited by an accrediting body as eligible 

for reimbursement under the medicare or medicaid 

programs; or 

ø(ii) has submitted a plan, which has been approved 

by the Secretary, for achieving such accreditation. 

ø(2) Approval 

ø(A) In general 

øThe Secretary shall review and approve a qualified application 

not later than 90 days after the date the application is submitted 

to the Secretary unless the Secretary determines that any of the 

criteria set forth in paragraph (1) are not met. 

ø(B) Grandfather of demonstration program participants 

øAny participant in the demonstration program authorized under 

this section as in effect on the day before the date of enactment of 

the Alaska Native and American Indian Direct Reimbursement Act 

of 1999 shall be deemed approved for participation in the program 

established under this section and shall not be required to submit 

an application in order to participate in the program. 

ø(C) Duration 

øAn approval by the Secretary of a qualified application under 

subparagraph (A), or a deemed approval of a demonstration program under subparagraph (B), shall continue in effect as long as 

the approved applicant or the deemed approved demonstration program meets the requirements of this section. 

ø(d) Examination and implementation of changes 

ø(1) In general¿ the program under such title, as well as all 

auditing requirements applicable to programs administered by 

an Indian Health Program. Nothing in the preceding sentence 

shall be construed as limiting the application of auditing requirements applicable to amounts paid under title XVIII, XIX, 

or XXI of the Social Security Act. 

(C) IDENTIFICATION OF SOURCE OF PAYMENTS.—Any Tribal Health Program that receives reimbursements or payments under title XVIII, XIX, or XXI of the Social Security 

Act, shall provide to the Service a list of each provider enVerDate Aug 31 2005 01:51 Oct 27, 2007 Jkt 069010 PO 00000 Frm 00213 Fmt 6659 Sfmt 6602 E:\HR\OC\SR197.XXX SR197

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rollment number (or other identifier) under which such 

Program receives such reimbursements or payments. 

(3) EXAMINATION AND IMPLEMENTATION OF CHANGES.— (A) IN GENERAL.—The Secretary, acting through the 

Service, and with the assistance of the Administrator of 

the øHealth Care Financing Administration¿ Centers for 

Medicare & Medicaid Services, shall examine on an ongoing basis and implementø— (A)¿ any administrative 

changes that may be necessary to facilitate direct billing 

and reimbursement under the program established under 

this øsection¿ subsection, including any agreements with 

States that may be necessary to provide for direct billing 

under the ømedicaid¿ a programø; and¿ under a title of the 

Social Security Act. 

ø(B) any changes that may be necessary to enable participants in the program established under this section to 

provide to the Service medical records information on patients served under the program that is consistent with 

the medical records information system of the Service. 

ø(2) Accounting information 

øThe accounting information that a participant in the program 

established under this section shall be required to report shall be 

the same as the information required to be reported by participants 

in the demonstration program authorized under this section as in 

effect on the day before the date of enactment of the Alaska Native 

and American Indian Direct Reimbursement Act of 1999. The Secretary may from time to time, after consultation with the program 

participants, change the accounting information submission requirements. 

ø(e) Withdrawal from program¿ 

(B) COORDINATION OF INFORMATION.—The Service shall 

provide the Administrator of the Centers for Medicare & 

Medicaid Services with copies of the lists submitted to the 

Service under paragraph (2)(C), enrollment data regarding 

patients served by the Service (and by Tribal Health Programs, to the extent such data is available to the Service), 

and such other information as the Administrator may require for purposes of administering title XVIII, XIX, or XXI 

of the Social Security Act. 

øA participant in¿ 

(4) WITHDRAWAL FROM PROGRAM.—A Tribal Health Program 

that bills directly under the program established under this 

øsection¿ subsection may withdraw from participation in the 

same manner and under the same conditions that øa tribe or 

tribal organization¿ an Indian Tribe or Tribal Organization 

may retrocede a contracted program to the Secretary under the 

authority of the Indian Self-Determination and Education Assistance Act (25 U.S.C. 450 et seq.). All cost accounting and 

billing authority under the program established under this 

øsection¿ subsection shall be returned to the Secretary upon 

the Secretary’s acceptance of the withdrawal of participation in 

this program. 

(5) TERMINATION FOR FAILURE TO COMPLY WITH REQUIREMENTS.—The Secretary may terminate the participation of a 

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bajohnson on PROD1PC71 with REPORTS
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lished under this subsection if the Secretary determines that the 

Program has failed to comply with the requirements of paragraph (2). The Secretary shall provide a Tribal Health Program 

with notice of a determination that the Program has failed to 

comply with any such requirement and a reasonable opportunity to correct such noncompliance prior to terminating the 

Program’s participation in the direct billing program established under this subsection. 

(e) RELATED PROVISIONS UNDER THE SOCIAL SECURITY ACT.—For 

provisions related to subsections (c) and (d), see sections 1880, 1911, 

and 2107(e)(1)(D) of the Social Security Act. 

SEC. 402. GRANTS TO AND CONTRACTS WITH THE SERVICE, INDIAN 

TRIBES, TRIBAL ORGANIZATIONS, AND URBAN INDIAN ORGANIZATIONS TO FACILITATE OUTREACH, ENROLLMENT, 

AND COVERAGE OF INDIANS UNDER SOCIAL SECURITY 

ACT HEALTH BENEFIT PROGRAMS AND OTHER HEALTH 

BENEFITS PROGRAMS. 

(a) INDIAN TRIBES AND TRIBAL ORGANIZATIONS.—From funds appropriated to carry out this title in accordance with section 416, the 

Secretary, acting through the Service, shall make grants to or enter 

into contracts with Indian Tribes and Tribal Organizations to assist 

such Tribes and Tribal Organizations in establishing and administering programs on or near reservations and trust lands to assist 

individual Indians— (1) to enroll for benefits under a program established under 

title XVIII, XIX, or XXI of the Social Security Act and other 

health benefits programs; and 

(2) with respect to such programs for which the charging of 

premiums and cost sharing is not prohibited under such programs, to pay premiums or cost sharing for coverage for such 

benefits, which may be based on financial need (as determined 

by the Indian Tribe or Tribes or Tribal Organizations being 

served based on a schedule of income levels developed or implemented by such Tribe, Tribes, or Tribal Organizations). 

(b) CONDITIONS.—The Secretary, acting through the Service, shall 

place conditions as deemed necessary to effect the purpose of this 

section in any grant or contract which the Secretary makes with any 

Indian Tribe or Tribal Organization pursuant to this section. Such 

conditions shall include requirements that the Indian Tribe or Tribal Organization successfully undertake— (1) to determine the population of Indians eligible for the benefits described in subsection (a); 

(2) to educate Indians with respect to the benefits available 

under the respective programs; 

(3) to provide transportation for such individual Indians to 

the appropriate offices for enrollment or applications for such 

benefits; and 

(4) to develop and implement methods of improving the participation of Indians in receiving benefits under such programs. 

(c) APPLICATION TO URBAN INDIAN ORGANIZATIONS.—

(1) IN GENERAL.—The provisions of subsection (a) shall apply 

with respect to grants and other funding to Urban Indian Organizations with respect to populations served by such organizations in the same manner they apply to grants and contracts 

with Indian Tribes and Tribal Organizations with respect to 

programs on or near reservations. 


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216 

(2) REQUIREMENTS.—The Secretary shall include in the 

grants or contracts made or provided under paragraph (1) requirements that are— (A) consistent with the requirements imposed by the Secretary under subsection (b); 

(B) appropriate to Urban Indian Organizations and 

Urban Indians; and 

(C) necessary to effect the purposes of this section. 

(d) FACILITATING COOPERATION.—The Secretary, acting through 

the Centers for Medicare & Medicaid Services, shall take such steps 

as are necessary to facilitate cooperation with, and agreements between, States and the Service, Indian Tribes, Tribal Organizations, 

or Urban Indian Organizations with respect to the provision of 

health care items and services to Indians under the programs established under title XVIII, XIX, or XXI of the Social Security Act. 

(e) AGREEMENTS RELATING TO IMPROVING ENROLLMENT OF INDI- ANS UNDER SOCIAL SECURITY ACT HEALTH BENEFITS PROGRAMS.— For provisions relating to agreements between the Secretary, acting 

through the Service, and Indian Tribes, Tribal Organizations, and 

Urban Indian Organizations for the collection, preparation, and 

submission of applications by Indians for assistance under the Medicaid and State children’s health insurance programs established 

under titles XIX and XXI of the Social Security Act, and benefits 

under the Medicare program established under title XVIII of such 

Act, see subsections (a) and (b) of section 1139 of the Social Security 

Act. 

(f) DEFINITION OF PREMIUMS AND COST SHARING.—In this section: 

(1) PREMIUM.—The term ‘‘premium’’ includes any enrollment 

fee or similar charge. 

(2) COST SHARING.—The term ‘‘cost sharing’’ includes any deduction, deductible, copayment, coinsurance, or similar charge. 

SEC. 403. REIMBURSEMENT FROM CERTAIN THIRD PARTIES OF COSTS 

OF HEALTH SERVICES. 

(a) RIGHT OF RECOVERY.—Except as provided in subsection (f), the 

United States, an Indian Tribe, or Tribal Organization shall have 

the right to recover from an insurance company, health maintenance 

organization, employee benefit plan, third-party tortfeasor, or any 

other responsible or liable third party (including a political subdivision or local governmental entity of a State) the reasonable charges 

billed by the Secretary, an Indian Tribe, or Tribal Organization in 

providing health services through the Service, an Indian Tribe, or 

Tribal Organization to any individual to the same extent that such 

individual, or any nongovernmental provider of such services, 

would be eligible to receive damages, reimbursement, or indemnification for such charges or expenses if—

(1) such services had been provided by a nongovernmental 

provider; and 

(2) such individual had been required to pay such charges or 

expenses and did pay such charges or expenses. 

(b) LIMITATIONS ON RECOVERIES FROM STATES.—Subsection (a) 

shall provide a right of recovery against any State, only if the injury, illness, or disability for which health services were provided is 

covered under—

(1) workers’ compensation laws; or 

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


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217 

(c) NONAPPLICATION OF OTHER LAWS.—No law of any State, or of 

any political subdivision of a State and no provision of any contract, insurance or health maintenance organization policy, employee benefit plan, self-insurance plan, managed care plan, or other 

health care plan or program entered into or renewed after the date 

of the enactment of the Indian Health Care Amendments of 1988, 

shall prevent or hinder the right of recovery of the United States, 

an Indian Tribe, or Tribal Organization under subsection (a). 

(d) NO EFFECT ON PRIVATE RIGHTS OF ACTION.—No action taken 

by the United States, an Indian Tribe, or Tribal Organization to enforce the right of recovery provided under this section shall operate 

to deny to the injured person the recovery for that portion of the person’s damage not covered hereunder. 

(e) ENFORCEMENT.—

(1) IN GENERAL.—The United States, an Indian Tribe, or 

Tribal Organization may enforce the right of recovery provided 

under subsection (a) by—

(A) intervening or joining in any civil action or proceeding brought—

(i) by the individual for whom health services were 

provided by the Secretary, an Indian Tribe, or Tribal 

Organization; or 

(ii) by any representative or heirs of such individual, 

or 

(B) instituting a civil action, including a civil action for 

injunctive relief and other relief and including, with respect 

to a political subdivision or local governmental entity of a 

State, such an action against an official thereof. 

(2) NOTICE.—All reasonable efforts shall be made to provide 

notice of action instituted under paragraph (1)(B) to the individual to whom health services were provided, either before or 

during the pendency of such action. 

(3) RECOVERY FROM TORTFEASORS.—

(A) IN GENERAL.—In any case in which an Indian Tribe 

or Tribal Organization that is authorized or required under 

a compact or contract issued pursuant to the Indian SelfDetermination and Education Assistance Act (25 U.S.C. 

450 et seq.) to furnish or pay for health services to a person 

who is injured or suffers a disease on or after the date of 

enactment of the Indian Health Care Improvement Act 

Amendments of 2007 under circumstances that establish 

grounds for a claim of liability against the tortfeasor with 

respect to the injury or disease, the Indian Tribe or Tribal 

Organization shall have a right to recover from the 

tortfeasor (or an insurer of the tortfeasor) the reasonable 

value of the health services so furnished, paid for, or to be 

paid for, in accordance with the Federal Medical Care Recovery Act (42 U.S.C. 2651 et seq.), to the same extent and 

under the same circumstances as the United States may recover under that Act. 

(B) TREATMENT.—The right of an Indian Tribe or Tribal 

Organization to recover under subparagraph (A) shall be 

independent of the rights of the injured or diseased person 

served by the Indian Tribe or Tribal Organization. 


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218 

(f) LIMITATION.—Absent specific written authorization by the governing body of an Indian Tribe for the period of such authorization 

(which may not be for a period of more than 1 year and which may 

be revoked at any time upon written notice by the governing body 

to the Service), the United States shall not have a right of recovery 

under this section if the injury, illness, or disability for which 

health services were provided is covered under a self-insurance plan 

funded by an Indian Tribe, Tribal Organization, or Urban Indian 

Organization. Where such authorization is provided, the Service 

may receive and expend such amounts for the provision of additional health services consistent with such authorization. 

(g) COSTS AND ATTORNEYS’ FEES.—In any action brought to enforce the provisions of this section, a prevailing plaintiff shall be 

awarded its reasonable attorneys’ fees and costs of litigation. 

(h) NONAPPLICATION OF CLAIMS FILING REQUIREMENTS.—An insurance company, health maintenance organization, self-insurance 

plan, managed care plan, or other health care plan or program 

(under the Social Security Act or otherwise) may not deny a claim 

for benefits submitted by the Service or by an Indian Tribe or Tribal 

Organization based on the format in which the claim is submitted 

if such format complies with the format required for submission of 

claims under title XVIII of the Social Security Act or recognized 

under section 1175 of such Act. 

(i) APPLICATION TO URBAN INDIAN ORGANIZATIONS.—The previous 

provisions of this section shall apply to Urban Indian Organizations 

with respect to populations served by such Organizations in the 

same manner they apply to Indian Tribes and Tribal Organizations 

with respect to populations served by such Indian Tribes and Tribal 

Organizations. 

(j) STATUTE OF LIMITATIONS.—The provisions of section 2415 of 

title 28, United States Code, shall apply to all actions commenced 

under this section, and the references therein to the United States 

are deemed to include Indian Tribes, Tribal Organizations, and 

Urban Indian Organizations. 

(k) SAVINGS.—Nothing in this section shall be construed to limit 

any right of recovery available to the United States, an Indian 

Tribe, or Tribal Organization under the provisions of any applicable, Federal, State, or Tribal law, including medical lien laws. 

SEC. 404. CREDITING OF REIMBURSEMENTS. 

(a) USE OF AMOUNTS.— (1) RETENTION BY PROGRAM.—Except as provided in section 

202(f) (relating to the Catastrophic Health Emergency Fund) 

and section 807 (relating to health services for ineligible persons), all reimbursements received or recovered under any of the 

programs described in paragraph (2), including under section 

807, by reason of the provision of health services by the Service, 

by an Indian Tribe or Tribal Organization, or by an Urban Indian Organization, shall be credited to the Service, such Indian 

Tribe or Tribal Organization, or such Urban Indian Organization, respectively, and may be used as provided in section 401. 

In the case of such a service provided by or through a Service 

Unit, such amounts shall be credited to such unit and used for 

such purposes. 

(2) PROGRAMS COVERED.—The programs referred to in paragraph (1) are the following: 


bajohnson on PROD1PC71 with REPORTS
219 

(A) Titles XVIII, XIX, and XXI of the Social Security Act. 

(B) This Act, including section 807. 

(C) Public Law 87–693. 

(D) Any other provision of law. 

(b) NO OFFSET OF AMOUNTS.—The Service may not offset or limit 

any amount obligated to any Service Unit or entity receiving funding from the Service because of the receipt of reimbursements under 

subsection (a). 

SEC. 405. PURCHASING HEALTH CARE COVERAGE. 

(a) IN GENERAL.—Insofar as amounts are made available under 

law (including a provision of the Social Security Act, the Indian 

Self-Determination and Education Assistance Act (25 U.S.C. 450 et 

seq.), or other law, other than under section 402) to Indian Tribes, 

Tribal Organizations, and Urban Indian Organizations for health 

benefits for Service beneficiaries, Indian Tribes, Tribal Organizations, and Urban Indian Organizations may use such amounts to 

purchase health benefits coverage for such beneficiaries in any manner, including through—

(1) a tribally owned and operated health care plan; 

(2) a State or locally authorized or licensed health care plan; 

(3) a health insurance provider or managed care organization; or 

(4) a self-insured plan. 

The purchase of such coverage by an Indian Tribe, Tribal Organization, or Urban Indian Organization may be based on the financial needs of such beneficiaries (as determined by the Indian Tribe 

or Tribes being served based on a schedule of income levels developed or implemented by such Indian Tribe or Tribes). 

(b) EXPENSES FOR SELF-INSURED PLAN.—In the case of a self-insured plan under subsection (a)(4), the amounts may be used for expenses of operating the plan, including administration and insurance to limit the financial risks to the entity offering the plan. 

(c) CONSTRUCTION.—Nothing in this section shall be construed as 

affecting the use of any amounts not referred to in subsection (a). 

SEC. 406. SHARING ARRANGEMENTS WITH FEDERAL AGENCIES. 

(a) AUTHORITY.—

(1) IN GENERAL.—The Secretary may enter into (or expand) 

arrangements for the sharing of medical facilities and services 

between the Service, Indian Tribes, and Tribal Organizations 

and the Department of Veterans Affairs and the Department of 

Defense. 

(2) CONSULTATION BY SECRETARY REQUIRED.—The Secretary 

may not finalize any arrangement between the Service and a 

Department described in paragraph (1) without first consulting 

with the Indian Tribes which will be significantly affected by 

the arrangement. 

(b) LIMITATIONS.—The Secretary shall not take any action under 

this section or under subchapter IV of chapter 81 of title 38, United 

States Code, which would impair— (1) the priority access of any Indian to health care services 

provided through the Service and the eligibility of any Indian 

to receive health services through the Service; 

(2) the quality of health care services provided to any Indian 

through the Service; 


bajohnson on PROD1PC71 with REPORTS
220 

(3) the priority access of any veteran to health care services 

provided by the Department of Veterans Affairs; 

(4) the quality of health care services provided by the Department of Veterans Affairs or the Department of Defense; or 

(5) the eligibility of any Indian who is a veteran to receive 

health services through the Department of Veterans Affairs. 

(c) REIMBURSEMENT.—The Service, Indian Tribe, or Tribal Organization shall be reimbursed by the Department of Veterans Affairs 

or the Department of Defense (as the case may be) where services are 

provided through the Service, an Indian Tribe, or a Tribal Organization to beneficiaries eligible for services from either such Department, notwithstanding any other provision of law. 

(d) CONSTRUCTION.—Nothing in this section may be construed as 

creating any right of a non-Indian veteran to obtain health services 

from the Service. 

SEC. 407. PAYOR OF LAST RESORT. 

Indian Health Programs and health care programs operated by 

Urban Indian Organizations shall be the payor of last resort for 

services provided to persons eligible for services from Indian Health 

Programs and Urban Indian Organizations, notwithstanding any 

Federal, State, or local law to the contrary. 

SEC. 408. NONDISCRIMINATION UNDER FEDERAL HEALTH CARE PROGRAMS IN QUALIFICATIONS FOR REIMBURSEMENT FOR 

SERVICES. 

(a) REQUIREMENT TO SATISFY GENERALLY APPLICABLE PARTICIPA- TION REQUIREMENTS.— (1) IN GENERAL.—A Federal health care program must accept 

an entity that is operated by the Service, an Indian Tribe, Tribal Organization, or Urban Indian Organization as a provider 

eligible to receive payment under the program for health care 

services furnished to an Indian on the same basis as any other 

provider qualified to participate as a provider of health care 

services under the program if the entity meets generally applicable State or other requirements for participation as a provider 

of health care services under the program. 

(2) SATISFACTION OF STATE OR LOCAL LICENSURE OR REC- OGNITION REQUIREMENTS.—Any requirement for participation 

as a provider of health care services under a Federal health 

care program that an entity be licensed or recognized under the 

State or local law where the entity is located to furnish health 

care services shall be deemed to have been met in the case of 

an entity operated by the Service, an Indian Tribe, Tribal Organization, or Urban Indian Organization if the entity meets all 

the applicable standards for such licensure or recognition, regardless of whether the entity obtains a license or other documentation under such State or local law. In accordance with 

section 221, the absence of the licensure of a health care professional employed by such an entity under the State or local law 

where the entity is located shall not be taken into account for 

purposes of determining whether the entity meets such standards, if the professional is licensed in another State. 

(b) APPLICATION OF EXCLUSION FROM PARTICIPATION IN FEDERAL

HEALTH CARE PROGRAMS.—

(1) EXCLUDED ENTITIES.—No entity operated by the Service, 

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zation that has been excluded from participation in any Federal 

health care program or for which a license is under suspension 

or has been revoked by the State where the entity is located 

shall be eligible to receive payment or reimbursement under any 

such program for health care services furnished to an Indian. 

(2) EXCLUDED INDIVIDUALS.—No individual who has been excluded from participation in any Federal health care program 

or whose State license is under suspension shall be eligible to 

receive payment or reimbursement under any such program for 

health care services furnished by that individual, directly or 

through an entity that is otherwise eligible to receive payment 

for health care services, to an Indian. 

(3) FEDERAL HEALTH CARE PROGRAM DEFINED.—In this subsection, the term, ‘Federal health care program’ has the meaning given that term in section 1128B(f) of the Social Security 

Act (42 U.S.C. 1320a–7b(f)), except that, for purposes of this 

subsection, such term shall include the health insurance program under chapter 89 of title 5, United States Code. 

(c) RELATED PROVISIONS.—For provisions related to nondiscrimination against providers operated by the Service, an Indian Tribe, Tribal Organization, or Urban Indian Organization, see section 1139(c) of the Social Security Act (42 U.S.C. 

1320b–9(c)). 

SEC. 409. CONSULTATION. 

For provisions related to consultation with representatives of Indian Health Programs and Urban Indian Organizations with respect to the health care programs established under titles XVIII, 

XIX, and XXI of the Social Security Act, see section 1139(d) of the 

Social Security Act (42 U.S.C. 1320b–9(d)). 

SEC. 410. STATE CHILDREN’S HEALTH INSURANCE PROGRAM (SCHIP). 

For provisions relating to—

(1) outreach to families of Indian children likely to be eligible 

for child health assistance under the State children’s health insurance program established under title XXI of the Social Security Act, see sections 2105(c)(2)(C) and 1139(a) of such Act (42 

U.S.C. 1397ee(c)(2), 1320b–9); and 

(2) ensuring that child health assistance is provided under 

such program to targeted low-income children who are Indians 

and that payments are made under such program to Indian 

Health Programs and Urban Indian Organizations operating in 

the State that provide such assistance, see sections 

2102(b)(3)(D) and 2105(c)(6)(B) of such Act (42 U.S.C. 

1397bb(b)(3)(D), 1397ee(c)(6)(B)). 

SEC. 411. EXCLUSION WAIVER AUTHORITY FOR AFFECTED INDIAN 

HEALTH PROGRAMS AND SAFE HARBOR TRANSACTIONS 

UNDER THE SOCIAL SECURITY ACT. 

For provisions relating to—

(1) exclusion waiver authority for affected Indian Health Programs under the Social Security Act, see section 1128(k) of the 

Social Security Act (42 U.S.C. 1320a–7(k)); and 

(2) certain transactions involving Indian Health Programs 

deemed to be in safe harbors under that Act, see section 

1128B(b)(4) of the Social Security Act (42 U.S.C. 1320a– 7b(b)(4)). 


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222 

SEC. 412. PREMIUM AND COST SHARING PROTECTIONS AND ELIGIBILITY DETERMINATIONS UNDER MEDICAID AND SCHIP 

AND PROTECTION OF CERTAIN INDIAN PROPERTY FROM 

MEDICAID ESTATE RECOVERY. 

For provisions relating to—

(1) premiums or cost sharing protections for Indians furnished items or services directly by Indian Health Programs or 

through referral under the contract health service under the 

Medicaid program established under title XIX of the Social Security Act, see sections 1916(j) and 1916A(a)(1) of the Social Security Act (42 U.S.C. 1396o(j), 1396o–1(a)(1)); 

(2) rules regarding the treatment of certain property for purposes of determining eligibility under such programs, see sections 1902(e)(13) and 2107(e)(1)(B) of such Act (42 U.S.C. 

1396a(e)(13), 1397gg(e)(1)(B)); and 

(3) the protection of certain property from estate recovery provisions under the Medicaid program, see section 1917(b)(3)(B) 

of such Act (42 U.S.C. 1396p(b)(3)(B)). 

SEC. 413. TREATMENT UNDER MEDICAID AND SCHIP MANAGED CARE. 

For provisions relating to the treatment of Indians enrolled in a 

managed care entity under the Medicaid program under title XIX 

of the Social Security Act and Indian Health Programs and Urban 

Indian Organizations that are providers of items or services to such 

Indian enrollees, see sections 1932(h) and 2107(e)(1)(H) of the Social 

Security Act (42 U.S.C. 1396u–2(h), 1397gg(e)(1)(H)). 

SEC. 414. NAVAJO NATION MEDICAID AGENCY FEASIBILITY STUDY. 

(a) STUDY.—The Secretary shall conduct a study to determine the 

feasibility of treating the Navajo Nation as a State for the purposes 

of title XIX of the Social Security Act, to provide services to Indians 

living within the boundaries of the Navajo Nation through an entity 

established having the same authority and performing the same 

functions as single-State medicaid agencies responsible for the administration of the State plan under title XIX of the Social Security 

Act. 

(b) CONSIDERATIONS.—In conducting the study, the Secretary 

shall consider the feasibility of—

(1) assigning and paying all expenditures for the provision of 

services and related administration funds, under title XIX of 

the Social Security Act, to Indians living within the boundaries 

of the Navajo Nation that are currently paid to or would otherwise be paid to the State of Arizona, New Mexico, or Utah; 

(2) providing assistance to the Navajo Nation in the development and implementation of such entity for the administration, 

eligibility, payment, and delivery of medical assistance under 

title XIX of the Social Security Act; 

(3) providing an appropriate level of matching funds for Federal medical assistance with respect to amounts such entity expends for medical assistance for services and related administrative costs; and 

(4) authorizing the Secretary, at the option of the Navajo Nation, to treat the Navajo Nation as a State for the purposes of 

title XIX of the Social Security Act (relating to the State children’s health insurance program) under terms equivalent to 

those described in paragraphs (2) through (4). 


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(c) REPORT.—Not later than 3 years after the date of enactment 

of the Indian Health Care Improvement Act Amendments of 2007, 

the Secretary shall submit to the Committee on Indian Affairs and 

Committee on Finance of the Senate and the Committee on Natural 

Resources and Committee on Energy and Commerce of the House of 

Representatives a report that includes— (1) the results of the study under this section; 

(2) a summary of any consultation that occurred between the 

Secretary and the Navajo Nation, other Indian Tribes, the 

States of Arizona, New Mexico, and Utah, counties which include Navajo Lands, and other interested parties, in conducting 

this study; 

(3) projected costs or savings associated with establishment of 

such entity, and any estimated impact on services provided as 

described in this section in relation to probable costs or savings; 

and 

(4) legislative actions that would be required to authorize the 

establishment of such entity if such entity is determined by the 

Secretary to be feasible. 

ø§ 1646. Authorization for emergency contract health services¿ 

SEC. 415. GENERAL EXCEPTIONS. 

øWith respect to an elderly or disabled Indian receiving emergency medical care or services from a non-Service provider or in a 

non-Service facility under the authority of this Act, the time limitation (as a condition of payment) for notifying the Service of such 

treatment or admission shall be 30 days.¿ 

The requirements of this title shall not apply to any excepted 

benefits described in paragraph (1)(A) or (3) of section 2791(c) of 

the Public Health Service Act (42 U.S.C. 300gg–91). 

ø§ 1647. Authorization of appropriations¿ 

SEC. 416. AUTHORIZATION OF APPROPRIATIONS. 

There are authorized to be appropriated such sums as may be 

necessary for each fiscal year through fiscal year ø2000¿ 2017 to 

carry out this øsubchapter¿ title. 

TITLE V—HEALTH SERVICES FOR URBAN INDIANS 

ø§ 1651. Purpose¿ 

SEC. 501. PURPOSE. 

The purpose of this øsubchapter¿ title is to establish and maintain programs in øurban centers¿ Urban Centers to make health 

services more accessible and available to øurban¿ Urban Indians. 

ø§ 1652. Contracts with, and grants to, urban Indian organizations¿ 

SEC. 502. CONTRACTS WITH, AND GRANTS TO, URBAN INDIAN ORGANIZATIONS. 

Under authority of the Act of November 2, 1921 (25 U.S.C. 13), 

øpopularly¿ (commonly known as the ‘‘Snyder Act’’), the Secretary, 

acting through the Service, shall enter into contracts with, or make 

grants to, øurban¿ Urban Indian øorganizations¿ Organizations to 

assist such organizations in the establishment and administration, 


bajohnson on PROD1PC71 with REPORTS
224 

within øthe urban centers in which such organizations are situated¿ Urban Centers, of programs which meet the requirements set 

forth in this øsubchapter. The¿ title. Subject to section 506, the Secretary, acting through the Service, shall include such conditions as 

the Secretary considers necessary to effect the purpose of this øsubchapter¿ title in any contract into which the Secretary enters 

øinto¿ with, or in any grant the Secretary makes to, any øurban¿ 

Urban Indian øorganization¿ Organization pursuant to this øsubchapter¿ title. 

ø§ 1653. Contracts and grants for the provision of health 

care and referral services¿ 

SEC. 503. CONTRACTS AND GRANTS FOR THE PROVISION OF HEALTH 

CARE AND REFERRAL SERVICES. 

(a) REQUIREMENTS FOR GRANTS AND CONTRACTS.—Under authority of the Act of November 2, 1921 (25 U.S.C. 13)ø, popularly¿ 

(commonly known as the ‘‘Snyder Act’’), the Secretary, acting 

through the Service, shall enter into contracts with, øor¿ and make 

grants to, øurban¿ Urban Indian øorganizations¿ Organizations for 

the provision of health care and referral services for øurban Indians residing in the urban centers in which such organizations are 

situated¿ Urban Indians. Any such contract or grant shall include 

requirements that the øurban¿ Urban Indian øorganization¿ Organization successfully undertake to—

(1) estimate the population of øurban¿ Urban Indians residing in the øurban center in which such¿ Urban Center or centers that the organization øis situated¿ proposes to serve who 

are or could be recipients of health care or referral services; 

(2) estimate the current health status of øurban¿ Urban Indians residing in such øurban center¿ Urban Center or centers; 

(3) estimate the current health care needs of øurban¿ Urban 

Indians residing in such øurban center¿ Urban Center or centers; 

ø(4) identify all public and private health services resources 

within such urban center which are or may be available to 

urban Indians; 

ø(5) determine the use of public and private health services 

resources by the urban Indians residing in such urban center; 

ø(6) assist such health services resources in providing services to urban Indians; 

ø(7) assist urban Indians in becoming familiar with and utilizing such health services resources;¿ 

ø(8)¿ (4) provide basic health education, including health 

promotion and disease prevention education, to øurban¿ Urban 

Indians; 

ø(9) establish and implement training programs to accomplish the referral and education tasks set forth in paragraphs 

(6) through (8) of this subsection; 

ø(10) identify gaps between unmet health needs of urban Indians and the resources available to meet such needs;¿ 

ø(11)¿ (5) make recommendations to the Secretary and Federal, State, local, and other resource agencies on methods of 

improving health service programs to meet the needs of 

øurban¿ Urban Indians; and 


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225 

ø(12)¿ (6) where necessary, provide, or enter into contracts 

for the provision of, health care services for øurban¿ Urban Indians. 

(b) CRITERIA FOR SELECTION OF ORGANIZATIONS TO ENTER INTO

CONTRACTS OR RECEIVE GRANTS.—THE SECRETARY, acting through 

the Service, shall, by regulation, prescribe the criteria for selecting 

øurban¿ Urban Indian øorganizations¿ Organizations to enter into 

contracts or receive grants under this section. Such criteria shall, 

among other factors, include— (1) the extent of unmet health care needs of øurban¿ Urban 

Indians in the øurban center¿ Urban Center or centers involved; 

(2) the size of the øurban¿ Urban Indian population in the 

øurban center¿ Urban Center or centers involved; 

ø(3) the accessibility to, and utilization of, health care services (other than services provided under this subchapter) by 

urban Indians in the urban center involved;¿ 

ø(4)¿ (3) the extent, if any, to which the activities set forth 

in subsection (a) øof this section¿ would duplicateø— (A) any 

previous or¿ any project funded under this title, or under any 

current public øor private health services project in an urban 

center that was or is¿ health service project funded in a manner other than pursuant to this øsubchapter; or¿ title; 

ø(B) any project funded under this subchapter;¿ 

ø(5)¿ (4) the capability of an øurban¿ Urban Indian øorganization¿ Organization to perform the activities set forth in subsection ø(a) of this section¿ and to enter into a contract with 

the Secretary or to meet the requirements for receiving a grant 

under this section; 

ø(6)¿ (5) the satisfactory performance and successful completion by an øurban¿ Urban Indian øorganization¿ Organization 

of other contracts with the Secretary under this øsubchapter;¿ 

title; 

ø(7)¿ (6) the appropriateness and likely effectiveness of conducting the activities set forth in subsection (a) øof this section 

in an urban center; and¿ in an Urban Center or centers; and 

ø(8)¿ (7) the extent of existing or likely future participation 

in the activities set forth in subsection (a) øof this section¿ by 

appropriate health and health-related Federal, State, local, and 

other agencies. 

ø(c) Grants for health promotion and disease prevention services¿ 

(c) ACCESS TO HEALTH PROMOTION AND DISEASE PREVENTION

PROGRAMS.—The Secretary, acting through the Service, shall facilitate access to, or provide, health promotion and disease prevention 

services for øurban¿ Urban Indians through grants made to 

øurban¿ Urban Indian øorganizations¿ Organizations administering contracts entered into øpursuant to this section¿ or receiving grants under subsection (a) øof this section¿. ø(d) Grants for immunization services¿ 

(d) IMMUNIZATION SERVICES.— ø(1)¿ (1) ACCESS OR SERVICES PROVIDED.—The Secretary, 

acting through the Service, shall facilitate access to, or provide, 

immunization services for øurban¿ Urban Indians through 

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zations administering contracts entered into øpursuant to this 

section¿ or receiving grants under øsubsection (a) of¿ this section. 

ø(2) In making any grant to carry out this subsection, the 

Secretary shall take into consideration— ø(A) the size of the urban Indian population to be 

served; 

ø(B) the immunization levels of the urban Indian population, particularly the immunization levels of infants, children, and the elderly; 

ø(C) the utilization by the urban Indians of alternative 

resources from State and local governments for no-cost or 

low-cost immunization services to the general population; 

and 

ø(D) the capability of the urban Indian organization to 

carry out services pursuant to this subsection.¿ 

ø(3)¿ (2) DEFINITION.—For purposes of this subsection, the 

term ‘‘immunization services’’ means services to provide without charge immunizations against vaccine-preventable diseases. 

ø(e) Grants for mental health services¿ 

(e) BEHAVIORAL HEALTH SERVICES.— ø(1)¿ (1) ACCESS OR SERVICES PROVIDED.—The Secretary, 

acting through the Service, shall facilitate access to, or provide, 

ømental¿ behavioral health services for øurban¿ Urban Indians through grants made to øurban¿ Urban Indian øorganizations¿ Organizations administering contracts entered into 

øpursuant to this section¿ or receiving grants under subsection 

ø(a) of this section¿. ø(2)A¿ (2) ASSESSMENT REQUIRED.—Except as provided by 

paragraph (3)(A), a grant may not be made under this subsection to an øurban¿ Urban Indian øorganization¿ Organization until that organization has prepared, and the Service has 

approved, an assessment of the ømental¿ following: 

(A) The behavioral health needs of the øurban¿ Urban 

Indian population concerned, øthe mental¿. (B) The behavioral health services and other related resources available to that populationø, the¿ . (C) The barriers to obtaining those services and resources, øand the¿ . (D) The needs that are unmet by such services and resources. 

(3) PURPOSES OF GRANTS.—Grants may be made under this 

subsectionø—¿for the following: 

(A) øto¿ To prepare assessments required under paragraph (2)ø;¿ . 

(B) øto¿ To provide outreach, educational, and referral 

services to øurban¿ Urban Indians regarding the availability of direct ømental¿ behavioral health services, to 

educate øurban¿ Urban Indians about ømental¿ behavioral health issues and services, and effect coordination 

with existing ømental¿ behavioral health providers in 

order to improve services to øurban¿ Urban Indiansø;¿ . (C) øto¿ To provide outpatient ømental¿ behavioral 

health services to øurban¿ Urban Indians, including the 


bajohnson on PROD1PC71 with REPORTS
227 

identification and assessment of illness, therapeutic treatments, case management, support groups, family treatment, and other treatmentø; and¿ . (D) øto¿ To develop innovative ømental¿ behavioral 

health service delivery models which incorporate Indian 

cultural support systems and resources. 

ø(f) Grants for prevention and treatment of child abuse¿ 

(f) PREVENTION OF CHILD ABUSE.— ø(1)¿ (1) ACCESS OR SERVICES PROVIDED.—The Secretary, 

acting through the Service, shall facilitate access toø,¿ or 

provideø,¿ services for øurban¿ Urban Indians through grants 

to øurban¿ Urban Indian øorganizations¿ Organizations administering contracts entered into øpursuant to this section¿ or 

receiving grants under subsection (a) øof this section¿ to prevent and treat child abuse (including sexual abuse) among 

øurban¿ Urban Indians. 

ø(2) A¿ (2) EVALUATION REQUIRED.—Except as provided by 

paragraph (3)(A), a grant may not be made under this subsection to an øurban¿ Urban Indian øorganization¿ Organization until that organization has prepared, and the Service has 

approved, an assessment that documents the prevalence of 

child abuse in the øurban¿ Urban Indian population concerned 

and specifies the services and programs (which may not duplicate existing services and programs) for which the grant is requested. 

(3) PURPOSES OF GRANTS.—Grants may be made under this 

subsectionø—¿ for the following: 

(A) øto¿ To prepare assessments required under paragraph (2)ø;¿ . (B) øfor¿ For the development of prevention, training, 

and education programs for øurban Indian populations¿ 

Urban Indians, including child education, parent education, provider training on identification and intervention, 

education on reporting requirements, prevention campaigns, and establishing service networks of all those involved in Indian child protectionø; and¿ . 

(C) øto¿ To provide direct outpatient treatment services 

(including individual treatment, family treatment, group 

therapy, and support groups) to øurban¿ Urban Indians 

who are child victims of abuse (including sexual abuse) or 

adult survivors of child sexual abuse, to the families of 

such child victims, and to øurban¿ Urban Indian perpetrators of child abuse (including sexual abuse). 

ø(4)¿ (4) CONSIDERATIONS WHEN MAKING GRANTS.—In making grants to carry out this subsection, the Secretary shall take 

into consideration—

(A) the support for the øurban¿ Urban Indian øorganization¿ Organization demonstrated by the child protection 

authorities in the area, including committees or other services funded under the Indian Child Welfare Act of 1978 (25 

U.S.C. 1901 et seq.), if any; 

(B) the capability and expertise demonstrated by the 

øurban¿ Urban Indian øorganization¿ Organization to address the complex problem of child sexual abuse in the 

community; and 


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228 

(C) the assessment required under paragraph (2). 

(g) OTHER GRANTS.—The Secretary, acting through the Service, 

may enter into a contract with or make grants to an Urban Indian 

Organization that provides or arranges for the provision of health 

care services (through satellite facilities, provider networks, or otherwise) to Urban Indians in more than 1 Urban Center. 

SEC. 504. CONTRACTS AND GRANTS FOR THE DETERMINATION OF 

UNMET HEALTH CARE NEEDS. 

ø(C) the assessment required under paragraph (2).¿ 

ø§ 1654. Contracts and grants for determination of unmet 

health care needs¿ 

ø(a) Authority¿ (a) GRANTS AND CONTRACTS AUTHORIZED.—

Under authority of the Act of November 2, 1921 (25 U.S.C. 13)ø, 

popularly¿ (commonly known as the ‘‘Snyder Act’’), the Secretary, 

acting through the Service, may enter into contracts withø,¿ or 

make grants toø, urban¿ Urban Indian øorganizations¿ Organizations situated in øurban centers¿ Urban Centers for which contracts have not been entered intoø,¿ or grants have not been 

madeø,¿ under section ø1653 of this title.¿ 503. 

(b) PURPOSE.—The purpose of a contract or grant made under 

this section shall be the determination of the matters described in 

subsection ø(b)¿ (c)(1) in order to assist the Secretary in assessing 

the health status and health care needs of øurban¿ Urban Indians 

in the øurban center¿ Urban Center involved and determining 

whether the Secretary should enter into a contract or make a grant 

under section ø1653 of this title¿ 503 with respect to the øurban¿ 

Urban Indian øorganization¿ Organization which the Secretary has 

entered into a contract with, or made a grant to, under this section. 

ø(b)¿ (c) GRANT AND CONTRACT REQUIREMENTS.—Any contract 

entered into, or grant made, by the Secretary under this section 

shall include requirements that—

(1) the øurban¿ Urban Indian øorganization¿ Organization 

successfully øundertake¿ undertakes to—

(A) document the health care status and unmet health 

care needs of øurban¿ Urban Indians in the øurban center¿ Urban Center involved; and 

(B) with respect to øurban¿ Urban Indians in the 

øurban center¿ Urban Center involved, determine the matters described in øclauses¿ paragraphs (2), (3), (4), and 

ø(8)¿ (7) of section ø1653¿ 503(b) øof this title¿; and 

(2) the øurban¿ Urban Indian øorganization¿ Organization 

complete performance of the contract, or carry out the requirements of the grant, within øone¿ 1 year after the date on 

which the Secretary and such organization enter into such contract, or within øone¿ 1 year after such organization receives 

such grant, whichever is applicable. 

ø(c) Renewal¿ (d) NO RENEWALS.—The Secretary may not renew 

any contract entered intoø,¿ or grant madeø,¿ under this section. 

SEC. 505. EVALUATIONS; RENEWALS. 

ø§ 1655.¿ (a) PROCEDURES FOR EVALUATIONSø; renewals¿ 

ø(a) Contract compliance and performance¿.—The Secretary, acting through the Service, shall develop procedures to evaluate compliance with grant requirements øunder this subchapter¿ and comVerDate Aug 31 2005 01:51 Oct 27, 2007 Jkt 069010 PO 00000 Frm 00228 Fmt 6659 Sfmt 6602 E:\HR\OC\SR197.XXX SR197

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pliance withø,¿ and performance of contracts entered into by 

øurban¿ Urban Indian øorganizations¿ Organizations under this 

øsubchapter¿ title. Such procedures shall include provisions for carrying out the requirements of this section. 

ø(b) Annual onsite evaluation¿ 

(b) EVALUATIONS.—The Secretary, acting through the Service, 

shall øconduct an annual onsite evaluation of each urban Indian 

organization¿ evaluate the compliance of each Urban Indian Organization which has entered into a contract or received a grant 

under section ø1653 of this title for purposes of determining the 

compliance of such organization with, and evaluating the performance of such organization under, such contract or the terms of 

such¿ 503 with the terms of such contract or grant. For purposes 

of this evaluation, the Secretary shall—

(1) acting through the Service, conduct an annual onsite evaluation of the organization; or 

(2) accept in lieu of such onsite evaluation evidence of the organization’s provisional or full accreditation by a private independent entity recognized by the Secretary for purposes of conducting quality reviews of providers participating in the Medicare program under title XVIII of the Social Security Act. 

(c) NONCOMPLIANCE øor unsatisfactory performance¿; UNSATISFACTORY PERFORMANCE.—If, as a result of the evaluations conducted under this section, the Secretary determines that an 

øurban¿ Urban Indian øorganization¿ Organization has not complied with the requirements of a grant or complied with or satisfactorily performed a contract under section ø1653 of this title,¿ 503, 

the Secretary shall, prior to renewing such contract or grant, attempt to resolve with øsuch¿ the organization the areas of noncompliance or unsatisfactory performance and modify øsuch¿ the 

contract or grant to prevent future occurrences of øsuch¿ noncompliance or unsatisfactory performance. If the Secretary determines that øsuch¿ the noncompliance or unsatisfactory performance cannot be resolved and prevented in the future, the Secretary 

shall not renew øsuch¿ the contract or grant with øsuch¿ the organization and is authorized to enter into a contract or make a grant 

under section ø1653 of this title¿ 503 with another øurban¿ Urban 

Indian øorganization¿ Organization which is situated in the same 

øurban center¿ Urban Center as the øurban¿ Urban Indian øorganization¿ Organization whose contract or grant is not renewed 

under this section. 

ø(d) Contract and grant renewals¿ 

(d) CONSIDERATIONS FOR RENEWALS.—In determining whether to 

renew a contract or grant with an øurban¿ Urban Indian øorganization¿ Organization under section ø1653 of this title¿ 503 which 

has completed performance of a contract or grant under section 

ø1654 of this title,¿ 504, the Secretary shall review the records of 

the øurban¿ Urban Indian øorganization¿ Organization, the reports submitted under section ø1657 of this title, and, in the case 

of a renewal of a contract or grant under section 1653 of this title,¿ 

507, and shall consider the results of the onsite evaluations øconducted¿ or accreditations under subsection (b) øof this section¿. 


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ø§ 1656. Other contract and grant requirements¿ 

SEC. 506. OTHER CONTRACT AND GRANT REQUIREMENTS. 

ø(a) Federal regulations; exceptions¿ 

(a) PROCUREMENT.—Contracts with øurban Indian organizations¿ Urban Indian Organizations entered into pursuant to this 

øsubchapter¿ title shall be in accordance with all Federal contracting laws and regulations relating to procurement except that, 

in the discretion of the Secretary, such contracts may be negotiated 

without advertising and need not conform to the provisions of øthe 

Act of August 24, 1935 (40 U.S.C 270a, et seq.).¿ sections 1304 and 

3131 through 3133 of title 40, United States Code. 

ø(b) Payment¿ 

(b) PAYMENTS UNDER CONTRACTS OR GRANTS.— (1) IN GENERAL.—Payments under any contracts or grants 

pursuant to this øsubchapter may be made in advance or by 

way of reimbursement and in such installments and on such 

conditions as the Secretary deems necessary to carry out the 

purposes of this subchapter.¿ title, notwithstanding any term 

or condition of such contract or grant— (A) may be made in a single advance payment by the Secretary to the Urban Indian Organization by no later than 

the end of the first 30 days of the funding period with respect to which the payments apply, unless the Secretary determines through an evaluation under section 505 that the 

organization is not capable of administering such a single 

advance payment; and 

(B) if any portion thereof is unexpended by the Urban Indian Organization during the funding period with respect 

to which the payments initially apply, shall be carried forward for expenditure with respect to allowable or reimbursable costs incurred by the organization during 1 or more 

subsequent funding periods without additional justification 

or documentation by the organization as a condition of carrying forward the availability for expenditure of such 

funds. 

(2) SEMIANNUAL AND QUARTERLY PAYMENTS AND REIMBURSE- MENTS.—If the Secretary determines under paragraph (1)(A) 

that an Urban Indian organization is not capable of administering an entire single advance payment, on request of the 

Urban Indian Organization, the payments may be made— (A) in semiannual or quarterly payments by not later 

than 30 days after the date on which the funding period 

with respect to which the payments apply begins; or 

(B) by way of reimbursement. 

(c) REVISION OR øamendment¿ AMENDMENT OF CONTRACTS.— Notwithstanding any provision of law to the contrary, the Secretary 

may, at the request øor¿ and consent of an øurban¿ Urban Indian 

øorganization¿ Organization, revise or amend any contract entered 

into by the Secretary with such organization under this øsubchapter¿ title as necessary to carry out the purposes of this øsubchapter¿ title. 

ø(d) Existing Government facilities¿ 

øIn connection with any contract or grant entered into pursuant 

to this subchapter, the Secretary may permit an urban Indian organization to utilize, in carrying out such contract or grant, existVerDate Aug 31 2005 01:51 Oct 27, 2007 Jkt 069010 PO 00000 Frm 00230 Fmt 6659 Sfmt 6602 E:\HR\OC\SR197.XXX SR197

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ing facilities owned by the Federal Government within the Secretary’s jurisdiction under such terms and conditions as may be 

agreed upon for the use and maintenance of such facilities.¿ 

ø(e)¿ (d) FAIR AND UNIFORM øprovision of services and assistance¿ SERVICES AND ASSISTANCE.—Contracts with, or grants toø, urban¿ Urban Indian øorganizations¿ Organizations and regulations adopted pursuant to this øsubchapter¿ title shall include provisions to assure the fair and uniform provision to øurban¿ Urban 

Indians of services and assistance under such contracts or grants 

by such organizations. 

ø(f) Eligibility for health care or referral services 

øUrban Indians, as defined in section 1603(f) of this title, shall 

be eligible for health care or referral services provided pursuant to 

this subchapter.¿ 

SEC. 507. REPORTS AND RECORDS. 

ø§ 1657.¿ (a) REPORTS øand records¿.— ø(a) Quarterly reports¿ 

(1) IN GENERAL.—For each fiscal year during which an 

øurban¿ Urban Indian øorganization¿ Organization receives or 

expends funds pursuant to a contract entered intoø,¿ or a 

grant receivedø,¿ pursuant to this øsubchapter¿ title, such øorganization¿ Urban Indian Organization shall submit to the 

Secretary øa quarterly report including—¿ not more frequently 

than every 6 months, a report that includes the following: 

ø(1)¿ (A) øin¿ In the case of a contract or grant under 

section ø1653 of this title, information gathered pursuant 

to clauses (10) and (11) of subsection (a) of such section;¿ 

503, recommendations pursuant to section 503(a)(5). 

ø(2) information¿ (B) Information on activities conducted 

by the organization pursuant to the contract or grantø;¿. ø(3)¿ (C) øan¿ An accounting of the amounts and øpurposes¿ purpose for which Federal funds were expendedø; 

and¿. ø(4) such other information as the Secretary may request.¿ 

(D) A minimum set of data, using uniformly defined elements, as specified by the Secretary after consultation with 

Urban Indian Organizations. 

(2) HEALTH STATUS AND SERVICES.— (A) IN GENERAL.—Not later than 18 months after the 

date of enactment of the Indian Health Care Improvement 

Act Amendments of 2007, the Secretary, acting through the 

Service, shall submit to Congress a report evaluating—

(i) the health status of Urban Indians; 

(ii) the services provided to Indians pursuant to this 

title; and 

(iii) areas of unmet needs in the delivery of health 

services to Urban Indians. 

(B) CONSULTATION AND CONTRACTS.—In preparing the 

report under paragraph (1), the Secretary—

(i) shall consult with Urban Indian Organizations; 

and 

(ii) may enter into a contract with a national organization representing Urban Indian Organizations to 

conduct any aspect of the report. 


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(b) AUDIT øby Secretary and Comptroller General¿.—The reports 

and records of the øurban¿ Urban Indian øorganization¿ Organization with respect to a contract or grant under this øsubchapter¿ 

title shall be subject to audit by the Secretary and the Comptroller 

General of the United States. 

(c) øCost¿ COSTS OF øannual private audit¿ AUDITS.—The Secretary shall allow as a cost of any contract or grant entered into 

or awarded under section ø1653 of this title¿ 502 or 503 the cost 

of an annual øprivate¿ independent financial audit conducted by— (1) a certified public accountantø.¿ ; or 

ø(d) Health status, services, and areas of unmet needs; child welfare 

ø(1) The Secretary, acting through the Service, shall submit 

a report to the Congress not later than March 31, 1992, evaluating—

ø(A) the health status of urban Indians; 

ø(B) the services provided to Indians through this subchapter; 

ø(C) areas of unmet needs in urban areas served under 

this subchapter; and 

ø(D) areas of unmet needs in urban areas not served 

under this subchapter. 

ø(2) In preparing the report under paragraph (1), the Secretary shall consult with urban Indian health providers and 

may contract with a national organization representing urban 

Indian health concerns to conduct any aspect of the report. 

ø(3) The Secretary and the Secretary of the Interior, shall¿ 

(2) a certified public accounting firm qualified to conduct 

Federal compliance audits. 

SEC. 508. LIMITATION ON CONTRACT AUTHORITY. 

ø(A) assess the status of the welfare of urban Indian 

children, including the volume of child protection cases, 

the prevalence of child sexual abuse, and the extent of 

urban Indian coordination with tribal authorities with respect to child sexual abuse; and 

ø(B) submit a report on the assessment required under 

subparagraph (A), together with recommended legislation 

to improve Indian child protection in urban Indian populations, to the Congress no later than March 31, 1992.¿ 

ø§ 1658. Limitation on contract authority¿ 

The authority of the Secretary to enter into contracts or to award 

grants under this title shall be to the extent, and in an amount, 

provided for in appropriation Acts. 

ø§ 1659. Facilities renovation¿ 

SEC. 509. FACILITIES. 

(a) GRANTS.—The Secretary, acting through the Service, may 

make øfunds available¿ grants to contractors or grant recipients 

under this øsubchapter for minor renovations to¿ title for the lease, 

purchase, renovation, construction, or expansion of facilities, including leased facilities, in order to assist such contractors or grant recipients in ømeeting or maintaining the Joint Commission for Accreditation of Health Care Organizations (JCAHO) standards¿ complying with applicable licensure or certification requirements. 


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(b) LOAN FUND STUDY.—The Secretary, acting through the Service, may carry out a study to determine the feasibility of establishing a loan fund to provide to Urban Indian Organizations direct 

loans or guarantees for loans for the construction of health care facilities in a manner consistent with section 309, including by submitting a report in accordance with subsection (c) of that section. 

ø§ 1660. Urban Health Programs Branch¿ 

SEC. 510. DIVISION OF URBAN INDIAN HEALTH. 

ø(a) Establishment 

There is øhereby¿ established within the Service a øBranch¿ Division of Urban Indian HealthøPrograms¿, which shall be responsible for—

(1) carrying out the provisions of this øsubchapter and for¿ 

title; 

(2) providing central oversight of the programs and services 

authorized under this øsubchapter.¿ title; and 

ø(b) Staff, services, and equipment 

øThe Secretary shall appoint such employees to work in the 

branch, including a program director, and shall provide such services and equipment, as may be necessary for it to carry out its responsibilities. The Secretary shall also analyze the need to provide 

at least one urban health program analyst for each area office of 

the Indian Health Service and shall submit his findings to the Congress as a part of the Department’s fiscal year 1993 budget request.¿ 

(3) providing technical assistance to Urban Indian Organizations. 

ø§ 1660a. Grants for alcohol and substance abuse related 

services 

SEC. 511. GRANTS FOR ALCOHOL AND SUBSTANCE ABUSE-RELATED 

SERVICES. 

ø(a) Grants¿ 

øThe Secretary¿ (a) GRANTS AUTHORIZED.—The Secretary, acting 

through the Service, may make grants for the provision of healthrelated services in prevention of, treatment of, rehabilitation of, or 

school- and community-based education øin¿ regarding, alcohol and 

substance abuse in øurban centers¿ Urban Centers to those 

øurban¿ Urban Indian øorganizations¿ Organizations with 

øwhom¿ which the Secretary has entered into a contract under this 

øsubchapter¿ title or under section ø1621 of this title.¿ 201. 

(b) GOALS øof grant¿.—Each grant made pursuant to subsection 

(a) øof this section¿ shall set forth the goals to be accomplished 

pursuant to the grant. The goals shall be specific to each grant as 

agreed to between the Secretary and the grantee. 

(c) CRITERIA.—The Secretary shall establish criteria for the 

grants made under subsection (a) of this section, including criteria 

relating to theø—¿ following: 

(1) The size of the øurban¿ Urban Indian populationø;¿. 

ø(2) accessibility to, and utilization of, other health resources 

available to such population; 

ø(3) duplication of existing Service or other Federal grants or 

contracts; 


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ø(4) capability of the organization to adequately perform the 

activities required under the grant;¿ 

(2) Capability of the organization to adequately perform the 

activities required under the grant. 

ø(5) satisfactory¿ (3) Satisfactory performance standards for 

the organization in meeting the goals set forth in such grantø, which¿. The standards shall be negotiated and agreed to between the Secretary and the grantee on a grant-by-grant 

basisø; and¿. ø(6) identification of¿ (4) Identification of the need for services. 

(d) ALLOCATION OF GRANTS.—The Secretary shall develop a 

methodology for allocating grants made pursuant to this section 

based on øsuch¿ the criteria established pursuant to subsection (c). 

ø(d) Treatment of funds received by urban Indian 

organizationsAny funds¿ 

(e) GRANTS SUBJECT TO CRITERIA.—Any grant received by an 

øurban¿ Urban Indian øorganization¿ Organization under this 

øchapter¿ Act for substance abuse prevention, treatment, and rehabilitation shall be subject to the criteria set forth in subsection 

(c)øof this section¿. 

ø§1660b. Treatment of certain demonstration projects¿ 

SEC. 512. TREATMENT OF CERTAIN DEMONSTRATION PROJECTS. 

ø(a)¿ Notwithstanding any other provision of law, the Tulsa Clinic and Oklahoma City Clinic demonstration øproject and the Tulsa 

Clinic demonstration project shall be treated as service units¿ 

projects shall—

(1) be permanent programs within the Service’s direct care 

program; 

(2) continue to be treated as Service Units and Operating 

Units in the allocation of resources and coordination of care; 

and 

(3) continue to meet the requirements and definitions of an 

Urban Indian Organization in this Act, and shall not be subject to the provisions of the Indian Self-Determination and 

Education Assistance Act ø[¿(25 U.S.C.øA. § 450f et seq.] for 

the term of such projects. The Secretary shall provide assistance to such projects in the development of resources and 

equipment and facility needs.¿ 450 et seq.). 

ø(b) The Secretary shall submit to the President, for inclusion in 

the report required to be submitted to the Congress under section 

1671 of this title for fiscal year 1999, a report on the findings and 

conclusions derived from the demonstration projects specified in 

subsection (a) of this section. 

ø(c) In addition to the amounts made available under section 

1660d of this title to carry out this section through fiscal year 2000, 

there are authorized to be appropriated such sums as may be necessary to carry out this section for each of fiscal years 2001 and 

2002.¿ 

ø§ 1660c. Urban NIAAA transferred programs¿ 

SEC. 513. URBAN NIAAA TRANSFERRED PROGRAMS. 

ø(a) Duty of Secretary 

øThe Secretary shall, within¿ 


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235 

(a) GRANTS AND CONTRACTS.—The Secretary, through the 

øBranch¿ Division of Urban øHealth Programs of the Service,¿ Indian Health, shall make grants or enter into contracts with Urban 

Indian Organizations, to take effect not later than September 30, 

2010, for the administration of øurban¿ Urban Indian alcohol programs that were originally established under the National Institute 

on Alcoholism and Alcohol Abuse (hereafter in this section referred 

to as ‘‘NIAAA’’) and transferred to the Service. 

(b) USE OF øgrants¿ FUNDS.—Grants provided or contracts entered into under this section shall be used to provide support for 

the continuation of alcohol prevention and treatment services for 

øurban¿ Urban Indian populations and such other objectives as are 

agreed upon between the Service and a recipient of a grant or contract under this section. 

(c) ELIGIBILITY øfor grants¿.—Urban Indian øorganizations¿ Organizations that operate Indian alcohol programs originally funded 

under the NIAAA and subsequently transferred to the Service are 

eligible for grants or contracts under this section. 

ø(d) Combination of funds 

øFor the purpose of carrying out this section, the Secretary may 

combine NIAAA alcohol funds with other substance abuse funds 

currently administered through the Branch of Urban Health Programs of the Service. 

ø(e) Evaluation and report to Congress¿ 

(d) REPORT.—The Secretary shall evaluate and report to øthe¿ 

Congress on the activities of programs funded under this section 

øat least¿ not less than every 5 years. 

SEC. 514. CONSULTATION WITH URBAN INDIAN ORGANIZATIONS. 

(a) IN GENERAL.—The Secretary shall ensure that the Service 

consults, to the greatest extent practicable, with Urban Indian Organizations. 

(b) DEFINITION OF CONSULTATION.—For purposes of subsection 

(a), consultation is the open and free exchange of information and 

opinions which leads to mutual understanding and comprehension 

and which emphasizes trust, respect, and shared responsibility. 

SEC. 515. URBAN YOUTH TREATMENT CENTER DEMONSTRATION. 

(a) CONSTRUCTION AND OPERATION.—The Secretary, acting 

through the Service, through grant or contract, is authorized to 

fund the construction and operation of at least 2 residential treatment centers in each State described in subsection (b) to demonstrate the provision of alcohol and substance abuse treatment 

services to Urban Indian youth in a culturally competent residential 

setting. 

(b) DEFINITION OF STATE.—A State described in this subsection is 

a State in which—

(1) there resides Urban Indian youth with need for alcohol 

and substance abuse treatment services in a residential setting; 

and 

(2) there is a significant shortage of culturally competent residential treatment services for Urban Indian youth. 

SEC. 516. GRANTS FOR DIABETES PREVENTION, TREATMENT, AND 

CONTROL. 

(a) GRANTS AUTHORIZED.—The Secretary may make grants to 

those Urban Indian Organizations that have entered into a contract 


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or have received a grant under this title for the provision of services 

for the prevention and treatment of, and control of the complications 

resulting from, diabetes among Urban Indians. 

(b) GOALS.—Each grant made pursuant to subsection (a) shall set 

forth the goals to be accomplished under the grant. The goals shall 

be specific to each grant as agreed to between the Secretary and the 

grantee. 

(c) ESTABLISHMENT OF CRITERIA.—The Secretary shall establish 

criteria for the grants made under subsection (a) relating to—

(1) the size and location of the Urban Indian population to 

be served; 

(2) the need for prevention of and treatment of, and control 

of the complications resulting from, diabetes among the Urban 

Indian population to be served; 

(3) performance standards for the organization in meeting the 

goals set forth in such grant that are negotiated and agreed to 

by the Secretary and the grantee; 

(4) the capability of the organization to adequately perform 

the activities required under the grant; and 

(5) the willingness of the organization to collaborate with the 

registry, if any, established by the Secretary under section 

204(e) in the Area Office of the Service in which the organization is located. 

(d) FUNDS SUBJECT TO CRITERIA.—Any funds received by an 

Urban Indian Organization under this Act for the prevention, treatment, and control of diabetes among Urban Indians shall be subject 

to the criteria developed by the Secretary under subsection (c). 

SEC. 517. COMMUNITY HEALTH REPRESENTATIVES. 

The Secretary, acting through the Service, may enter into contracts with, and make grants to, Urban Indian Organizations for 

the employment of Indians trained as health service providers 

through the Community Health Representatives Program under section 109 in the provision of health care, health promotion, and disease prevention services to Urban Indians. 

SEC. 518. EFFECTIVE DATE. 

The amendments made by the Indian Health Care Improvement 

Act Amendments of 2007 to this title shall take effect beginning on 

the date of enactment of that Act, regardless of whether the Secretary has promulgated regulations implementing such amendments. 

SEC. 519. ELIGIBILITY FOR SERVICES. 

Urban Indians shall be eligible for, and the ultimate beneficiaries 

of, health care or referral services provided pursuant to this title. 

ø§ 1660d. Authorization of appropriations¿ 

SEC. 520. AUTHORIZATION OF APPROPRIATIONS. 

There are authorized to be appropriated such sums as may be 

necessary for each fiscal year through fiscal year ø2000¿ 2017 to 

carry out this øsubchapter¿ title. 


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TITLE VI—ORGANIZATIONAL IMPROVEMENTS 

ø§ 1661. Establishment of the Indian Health Service as an 

agency of Public Health Service¿ 

SEC. 601. ESTABLISHMENT OF THE INDIAN HEALTH SERVICE AS AN 

AGENCY OF THE PUBLIC HEALTH SERVICE. 

(a) ESTABLISHMENT.—

(1) IN GENERAL.—In order to more effectively and efficiently 

carry out the responsibilities, authorities, and functions of the 

United States to provide health care services to Indians and 

Indian øtribes¿ Tribes, as are or may be øon and after November 23, 1988,¿ hereafter provided by Federal statute or treaties, 

there is established within the Public Health Service of the Department øof Health and Human Services¿ the Indian Health 

Service. 

(2) ASSISTANT SECRETARY FOR INDIAN HEALTH.—The øIndian 

Health¿ Service shall be administered by øa Director¿ an Assistant Secretary for Indian Health, who shall be appointed by 

the President, by and with the advice and consent of the Senate. The øDirector of the Indian Health Service¿ Assistant Secretary shall report to the Secretary øthrough the Assistant Secretary for Health of the Department of Health and Human 

Services¿. Effective with respect to an individual appointed by 

the President, by and with the advice and consent of the Senate, after January 1, ø1993,¿ 2007, the term of service of the 

øDirector¿ Assistant Secretary shall be 4 years. øA Director¿ 

An Assistant Secretary may serve more than 1 term. 

(3) INCUMBENT.—The individual serving in the position of Director of the Service on the day before the date of enactment of 

the Indian Health Care Improvement Act Amendments of 2007 

shall serve as Assistant Secretary. 

(4) ADVOCACY AND CONSULTATION.—The position of Assistant 

Secretary is established to, in a manner consistent with the government-to-government relationship between the United States 

and Indian Tribes—

(A) facilitate advocacy for the development of appropriate 

Indian health policy; and 

(B) promote consultation on matters relating to Indian 

health. 

(b) AGENCY.—østatus¿ The øIndian Health¿Service shall be an 

agency within the Public Health Service of the Department øof 

Health and Human Services¿, and shall not be an office, component, or unit of any other agency of the Department. 

(c) DUTIES.—The Assistant Secretary shall øcarry out through 

the Director of the Indian Health Service¿—

(1) perform all functions øwhich¿ that were, on the day before øNovember 23, 1988,¿ the date of enactment of the Indian 

Health Care Improvement Act Amendments of 2007, carried out 

by or under the direction of the individual serving as Director 

of the øIndian Health¿Service onøsuch¿ that day; 

(2) perform all functions of the Secretary relating to the 

maintenance and operation of hospital and health facilities for 

Indians and the planning for, and provision and utilization of, 

health services for Indians; 


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(3) administer all health programs under which health care 

is provided to Indians based upon their status as Indians 

which are administered by the Secretary, includingø(but not 

limited to)¿programs under— (A) thisøchapter¿ Act; 

(B) the Act of November 2, 1921 (25 U.S.C. 13); 

(C) the Act of August 5, 1954 (42 U.S.C. ø2001,¿ 2001 

et seq.); 

(D) the Act of August 16, 1957 (42 U.S.C. 2005 et seq.); 

and 

(E) the Indian Self-Determination and Education Assistance Act (25 U.S.C. 450øf¿ et seq.); øand¿ 

(4) administer all scholarship and loan functions carried out 

under øsubchapter I of this chapter.¿ title I; 

(5) report directly to the Secretary concerning all policy- and 

budget-related matters affecting Indian health; 

(6) collaborate with the Assistant Secretary for Health concerning appropriate matters of Indian health that affect the 

agencies of the Public Health Service; 

(7) advise each Assistant Secretary of the Department concerning matters of Indian health with respect to which that Assistant Secretary has authority and responsibility; 

(8) advise the heads of other agencies and programs of the 

Department concerning matters of Indian health with respect to 

which those heads have authority and responsibility; 

(9) coordinate the activities of the Department concerning 

matters of Indian health; and 

(10) perform such other functions as the Secretary may designate. 

(d) AUTHORITY øof Secretary¿.—

(1) IN GENERAL.—The Secretary, acting through the øDirector of the Indian Health Service¿ Assistant Secretary, shall 

have the authority—

(A) except to the extent provided for in paragraph (2), to 

appoint and compensate employees for the Service in accordance with øTitle 5¿ title 5, United States Code; 

(B) to enter into contracts for the procurement of goods 

and services to carry out the functions of the Service; and 

(C) to manage, expend, and obligate all funds appropriated for the Service. 

(2) PERSONNEL ACTIONS.—Notwithstanding any other provision of law, the provisions of section ø472 of this title¿ 12 of 

the Act of June 18, 1934 (48 Stat. 986; 25 U.S.C. 472), shall 

apply to all personnel actions taken with respect to new positions created within the Service as a result of its establishment 

under subsection (a)øof this section¿. 

(e) REFERENCES.—Any reference to the Director of the Indian 

Health Service in any other Federal law, Executive order, rule, regulation, or delegation of authority, or in any document of or relating 

to the Director of the Indian Health Service, shall be deemed to refer 

to the Assistant Secretary. 

ø§ 1662. Automated management information system¿ 

SEC. 602. AUTOMATED MANAGEMENT INFORMATION SYSTEM. 

(a) ESTABLISHMENT.—


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(1) IN GENERAL.—The Secretary shall establish an automated 

management information system for the Service. 

(2) REQUIREMENTS OF SYSTEM.—The information system established under paragraph (1) shall include— (A) a financial management systemø,¿; 

(B) a patient care information system for each area 

served by the Serviceø,¿; 

(C) a privacy component that protects the privacy of patient information held by, or on behalf of, the Serviceø, and¿; 

(D) a services-based cost accounting component that provides estimates of the costs associated with the provision 

of specific medical treatments or services in each øarea¿ 

Area office of the Service; 

(E) an interface mechanism for patient billing and accounts receivable system; and 

(F) a training component. 

(b) PROVISION øto Indian tribes and organizations; reimbursement (1) The Secretary shall provide each Indian tribe and tribal 

organization that provides health services under a contract entered 

into with the Service under the Indian Self-Determination Act [25 

U.S.C.A. § 450f et seq.¿ OF SYSTEMS TO TRIBES AND ORGANIZATIONS.—The Secretary shall provide each Tribal Health Program 

automated management information systems which—

ø(A)¿ (1) meet the management information needs of such 

øIndian tribe or tribal organization¿Tribal Health Program 

with respect to the treatment by the øIndian tribe or tribal organization¿ Tribal Health Program of patients of the 

Serviceø,¿; and 

ø(B)¿ (2) meet the management information needs of the 

Service. 

ø(2) The Secretary shall reimburse each Indian tribe or tribal organization for the part of the cost of the operation of a system provided under paragraph (1) which is attributable to the 

treatment by such Indian tribe or tribal organization of patients of the Service. 

ø(3) The Secretary shall provide systems under paragraph 

(1) to Indian tribes and tribal organizations providing health 

services in California by no later than September 30, 1990.¿ 

(c) ACCESS TO ørecords¿ RECORDS.—Notwithstanding any other 

provision of law, each patient shall have reasonable access to the 

medical or health records of such patient which are held by, or on 

behalf of, the Service. 

(d) AUTHORITY TO ENHANCE INFORMATION TECHNOLOGY.—The 

Secretary, acting through the Assistant Secretary, shall have the authority to enter into contracts, agreements, or joint ventures with 

other Federal agencies, States, private and nonprofit organizations, 

for the purpose of enhancing information technology in Indian 

Health Programs and facilities. 

ø§ 1663. Authorization of appropriations¿ 

SEC. 603. AUTHORIZATION OF APPROPRIATIONS. 

There øare¿ is authorized to be appropriated such sums as may 

be necessary for each fiscal year through fiscal year ø2000¿ 2017 

to carry out this øsubchapter¿ title. 


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240 

TITLE VII—BEHAVIORAL HEALTH PROGRAMS 

SEC. 701. BEHAVIORAL HEALTH PREVENTION AND TREATMENT SERVICES. 

(a) PURPOSES.—The purposes of this section are as follows: 

(1) To authorize and direct the Secretary, acting through the 

Service, Indian Tribes, Tribal Organizations, and Urban Indian Organizations, to develop a comprehensive behavioral 

health prevention and treatment program which emphasizes 

collaboration among alcohol and substance abuse, social services, and mental health programs. 

(2) To provide information, direction, and guidance relating 

to mental illness and dysfunction and self-destructive behavior, 

including child abuse and family violence, to those Federal, 

tribal, State, and local agencies responsible for programs in Indian communities in areas of health care, education, social 

services, child and family welfare, alcohol and substance abuse, 

law enforcement, and judicial services. 

(3) To assist Indian Tribes to identify services and resources 

available to address mental illness and dysfunctional and selfdestructive behavior. 

(4) To provide authority and opportunities for Indian Tribes 

and Tribal Organizations to develop, implement, and coordinate with community-based programs which include identification, prevention, education, referral, and treatment services, including through multidisciplinary resource teams. 

(5) To ensure that Indians, as citizens of the United States 

and of the States in which they reside, have the same access to 

behavioral health services to which all citizens have access. 

(6) To modify or supplement existing programs and authorities in the areas identified in paragraph (2). 

(b) PLANS.—

(1) DEVELOPMENT.—The Secretary, acting through the Service, Indian Tribes, Tribal Organizations, and Urban Indian Organizations, shall encourage Indian Tribes and Tribal Organizations to develop tribal plans, and Urban Indian Organizations to develop local plans, and for all such groups to participate in developing areawide plans for Indian Behavioral Health 

Services. The plans shall include, to the extent feasible, the following components: 

(A) An assessment of the scope of alcohol or other substance abuse, mental illness, and dysfunctional and self-destructive behavior, including suicide, child abuse, and family violence, among Indians, including—

(i) the number of Indians served who are directly or 

indirectly affected by such illness or behavior; or 

(ii) an estimate of the financial and human cost attributable to such illness or behavior. 

(B) An assessment of the existing and additional resources necessary for the prevention and treatment of such 

illness and behavior, including an assessment of the 

progress toward achieving the availability of the full continuum of care described in subsection (c). 

(C) An estimate of the additional funding needed by the 

Service, Indian Tribes, Tribal Organizations, and Urban 


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Indian Organizations to meet their responsibilities under 

the plans. 

(2) NATIONAL CLEARINGHOUSE.—The Secretary, acting 

through the Service, shall coordinate with existing national 

clearinghouses and information centers to include at the clearinghouses and centers plans and reports on the outcomes of 

such plans developed by Indian Tribes, Tribal Organizations, 

Urban Indian Organizations, and Service Areas relating to behavioral health. The Secretary shall ensure access to these 

plans and outcomes by any Indian Tribe, Tribal Organization, 

Urban Indian Organization, or the Service. 

(3) TECHNICAL ASSISTANCE.—The Secretary shall provide 

technical assistance to Indian Tribes, Tribal Organizations, 

and Urban Indian Organizations in preparation of plans under 

this section and in developing standards of care that may be 

used and adopted locally. 

(c) PROGRAMS.—The Secretary, acting through the Service, Indian 

Tribes, and Tribal Organizations, shall provide, to the extent feasible and if funding is available, programs including the following: 

(1) COMPREHENSIVE CARE.—A comprehensive continuum of 

behavioral health care which provides—

(A) community-based prevention, intervention, outpatient, 

and behavioral health aftercare; 

(B) detoxification (social and medical); 

(C) acute hospitalization; 

(D) intensive outpatient/day treatment; 

(E) residential treatment; 

(F) transitional living for those needing a temporary, stable living environment that is supportive of treatment and 

recovery goals; 

(G) emergency shelter; 

(H) intensive case management; and 

(I) diagnostic services. 

(2) CHILD CARE.—Behavioral health services for Indians from 

birth through age 17, including—

(A) preschool and school age fetal alcohol disorder services, including assessment and behavioral intervention; 

(B) mental health and substance abuse services (emotional, organic, alcohol, drug, inhalant, and tobacco); 

(C) identification and treatment of co-occurring disorders 

and comorbidity; 

(D) prevention of alcohol, drug, inhalant, and tobacco 

use; 

(E) early intervention, treatment, and aftercare; 

(F) promotion of healthy approaches to risk and safety 

issues; and 

(G) identification and treatment of neglect and physical, 

mental, and sexual abuse. 

(3) ADULT CARE.—Behavioral health services for Indians from 

age 18 through 55, including—

(A) early intervention, treatment, and aftercare; 

(B) mental health and substance abuse services (emotional, alcohol, drug, inhalant, and tobacco), including sex 

specific services; 


bajohnson on PROD1PC71 with REPORTS
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(C) identification and treatment of co-occurring disorders 

(dual diagnosis) and comorbidity; 

(D) promotion of healthy approaches for risk-related behavior; 

(E) treatment services for women at risk of giving birth 

to a child with a fetal alcohol disorder; and 

(F) sex specific treatment for sexual assault and domestic 

violence. 

(4) FAMILY CARE.—Behavioral health services for families, including—

(A) early intervention, treatment, and aftercare for affected families; 

(B) treatment for sexual assault and domestic violence; 

and 

(C) promotion of healthy approaches relating to parenting, domestic violence, and other abuse issues. 

(5) ELDER CARE.—Behavioral health services for Indians 56 

years of age and older, including—

(A) early intervention, treatment, and aftercare; 

(B) mental health and substance abuse services (emotional, alcohol, drug, inhalant, and tobacco), including sex 

specific services; 

(C) identification and treatment of co-occurring disorders 

(dual diagnosis) and comorbidity; 

(D) promotion of healthy approaches to managing conditions related to aging; 

(E) sex specific treatment for sexual assault, domestic violence, neglect, physical and mental abuse and exploitation; 

and 

(F) identification and treatment of dementias regardless 

of cause. 

(d) COMMUNITY BEHAVIORAL HEALTH PLAN.—

(1) ESTABLISHMENT.—The governing body of any Indian 

Tribe, Tribal Organization, or Urban Indian Organization may 

adopt a resolution for the establishment of a community behavioral health plan providing for the identification and coordination of available resources and programs to identify, prevent, or 

treat substance abuse, mental illness, or dysfunctional and selfdestructive behavior, including child abuse and family violence, 

among its members or its service population. This plan should 

include behavioral health services, social services, intensive outpatient services, and continuing aftercare. 

(2) TECHNICAL ASSISTANCE.—At the request of an Indian 

Tribe, Tribal Organization, or Urban Indian Organization, the 

Bureau of Indian Affairs and the Service shall cooperate with 

and provide technical assistance to the Indian Tribe, Tribal Organization, or Urban Indian Organization in the development 

and implementation of such plan. 

(3) FUNDING.—The Secretary, acting through the Service, may 

make funding available to Indian Tribes and Tribal Organizations which adopt a resolution pursuant to paragraph (1) to obtain technical assistance for the development of a community 

behavioral health plan and to provide administrative support 

in the implementation of such plan. 


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(e) COORDINATION FOR AVAILABILITY OF SERVICES.—The Secretary, acting through the Service, Indian Tribes, Tribal Organizations, and Urban Indian Organizations, shall coordinate behavioral 

health planning, to the extent feasible, with other Federal agencies 

and with State agencies, to encourage comprehensive behavioral 

health services for Indians regardless of their place of residence. 

(f) MENTAL HEALTH CARE NEED ASSESSMENT.—Not later than 1 

year after the date of enactment of the Indian Health Care Improvement Act Amendments of 2007, the Secretary, acting through the 

Service, shall make an assessment of the need for inpatient mental 

health care among Indians and the availability and cost of inpatient mental health facilities which can meet such need. In making 

such assessment, the Secretary shall consider the possible conversion of existing, underused Service hospital beds into psychiatric 

units to meet such need. 

SEC. 702. MEMORANDA OF AGREEMENT WITH THE DEPARTMENT OF 

THE INTERIOR. 

(a) CONTENTS.—Not later than 12 months after the date of enactment of the Indian Health Care Improvement Act Amendments of 

2007, the Secretary, acting through the Service, and the Secretary 

of the Interior shall develop and enter into a memoranda of agreement, or review and update any existing memoranda of agreement, 

as required by section 4205 of the Indian Alcohol and Substance 

Abuse Prevention and Treatment Act of 1986 (25 U.S.C. 2411) 

under which the Secretaries address the following: 

(1) The scope and nature of mental illness and dysfunctional 

and self-destructive behavior, including child abuse and family 

violence, among Indians. 

(2) The existing Federal, tribal, State, local, and private services, resources, and programs available to provide behavioral 

health services for Indians. 

(3) The unmet need for additional services, resources, and 

programs necessary to meet the needs identified pursuant to 

paragraph (1). 

(4)(A) The right of Indians, as citizens of the United States 

and of the States in which they reside, to have access to behavioral health services to which all citizens have access. 

(B) The right of Indians to participate in, and receive the benefit of, such services. 

(C) The actions necessary to protect the exercise of such right. 

(5) The responsibilities of the Bureau of Indian Affairs and 

the Service, including mental illness identification, prevention, 

education, referral, and treatment services (including services 

through multidisciplinary resource teams), at the central, area, 

and agency and Service Unit, Service Area, and headquarters 

levels to address the problems identified in paragraph (1). 

(6) A strategy for the comprehensive coordination of the behavioral health services provided by the Bureau of Indian Affairs and the Service to meet the problems identified pursuant 

to paragraph (1), including—

(A) the coordination of alcohol and substance abuse programs of the Service, the Bureau of Indian Affairs, and Indian Tribes and Tribal Organizations (developed under the 

Indian Alcohol and Substance Abuse Prevention and Treatment Act of 1986 (25 U.S.C. 2401 et seq.)) with behavioral 


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244 

health initiatives pursuant to this Act, particularly with respect to the referral and treatment of dually diagnosed individuals requiring behavioral health and substance abuse 

treatment; and 

(B) ensuring that the Bureau of Indian Affairs and Service programs and services (including multidisciplinary resource teams) addressing child abuse and family violence 

are coordinated with such non-Federal programs and services. 

(7) Directing appropriate officials of the Bureau of Indian Affairs and the Service, particularly at the agency and Service 

Unit levels, to cooperate fully with tribal requests made pursuant to community behavioral health plans adopted under section 701(c) and section 4206 of the Indian Alcohol and Substance Abuse Prevention and Treatment Act of 1986 (25 U.S.C. 

2412). 

ø§ 1665. Indian Health Service responsibilities¿ 

(8) Providing for an annual review of such agreement by the 

Secretaries which shall be provided to Congress and Indian 

Tribes and Tribal Organizations. 

øThe Memorandum of Agreement¿ 

(b) SPECIFIC PROVISIONS REQUIRED.—The memoranda of agreement updated or entered into pursuant to øsection 2411 of this 

title¿ subsection (a) shall include specific provisions pursuant to 

which the Service shall assume responsibility for—

(1) the determination of the scope of the problem of alcohol 

and substance abuse among øIndian people¿ Indians, including 

the number of Indians within the jurisdiction of the Service 

who are directly or indirectly affected by alcohol and substance 

abuse and the financial and human cost; 

(2) an assessment of the existing and needed resources necessary for the prevention of alcohol and substance abuse and 

the treatment of Indians affected by alcohol and substance 

abuse; and 

(3) an estimate of the funding necessary to adequately support a program of prevention of alcohol and substance abuse 

and treatment of Indians affected by alcohol and substance 

abuse. 

(c) PUBLICATION.—Each memorandum of agreement entered into 

or renewed (and amendments or modifications thereto) under subsection (a) shall be published in the Federal Register. At the same 

time as publication in the Federal Register, the Secretary shall provide a copy of such memoranda, amendment, or modification to 

each Indian Tribe, Tribal Organization, and Urban Indian Organization. 

SEC. 703. COMPREHENSIVE BEHAVIORAL HEALTH PREVENTION AND 

TREATMENT PROGRAM. 

ø§ 1665a. Indian Health Service program¿ 

(a) ESTABLISHMENT.— ø(a) Comprehensive prevention and treatment program¿ 

(1) IN GENERAL.—The Secretary, acting through the Service, 

Indian Tribes, and Tribal Organizations, shall provide a program of comprehensive øalcohol and substance abuse prevenVerDate Aug 31 2005 01:51 Oct 27, 2007 Jkt 069010 PO 00000 Frm 00244 Fmt 6659 Sfmt 6602 E:\HR\OC\SR197.XXX SR197

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tion and treatment¿ behavioral health, prevention, treatment, 

and aftercare, which shall include—

(A) prevention, through educational intervention, in Indian communities; 

(B) acute detoxification øand treatment;¿, psychiatric 

hospitalization, residential, and intensive outpatient treatment; 

(C) community-based rehabilitationø;¿ and aftercare; 

(D) community education and involvement, including extensive training of health care, educational, and community-based personnel; øand¿ 

(E) specialized residential treatment programs for highrisk populations, including pregnant and øpost partum¿ 

postpartum women and their children; and 

(F) diagnostic services. 

(2) TARGET POPULATIONS.—The target population of such 

øprogram¿ programs shall be members of Indian øtribes¿ 

Tribes. Efforts to train and educate key members of the Indian 

community shall also target employees of health, education, judicial, law enforcement, legal, and social service programs. 

(b) CONTRACT øhealth services¿ HEALTH SERVICES.—

(1) IN GENERAL.—The Secretary, acting through the Service, 

Indian Tribes, and Tribal Organizations, may enter into contracts with public or private providers of øalcohol and substance abuse¿ behavioral health treatment services for the purpose of øassisting the Service in¿ carrying out the program required under subsection (a) øof this section¿. 

(2) PROVISION OF ASSISTANCE.—In carrying out this subsection, the Secretary shall provide assistance to Indian 

øtribes¿ Tribes and Tribal Organizations to develop criteria for 

the certification of øalcohol and substance abuse¿ behavioral 

health service providers and accreditation of service facilities 

which meet minimum standards for such services and facilities 

øas may be determined pursuant to section 2411(a)(3) of this 

title¿. 

ø(c) Grants for model program 

ø(1) The Secretary, acting through the Service shall make a 

grant to the Standing Rock Sioux Tribe to develop a community-based demonstration project to reduce drug and alcohol 

abuse on the Standing Rock Sioux Reservation and to rehabilitate Indian families afflicted by such abuse. 

ø(2) Funds shall be used by the Tribe to—

ø(A) develop and coordinate community-based alcohol 

and substance abuse prevention and treatment services for 

Indian families; 

ø(B) develop prevention and intervention models for Indian families; 

ø(C) conduct community education on alcohol and substance abuse; and 

ø(D) coordinate with existing Federal, State, and tribal 

services on the reservation to develop a comprehensive alcohol and substance abuse program that assists in the rehabilitation of Indian families that have been or are afflicted by alcoholism. 


bajohnson on PROD1PC71 with REPORTS
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ø(3) The Secretary shall submit to the President for inclusion 

in the report to be transmitted to the Congress under section 

1671 of this title for fiscal year 1995 an evaluation of the demonstration project established under paragraph (1).¿ 

SEC. 704. MENTAL HEALTH TECHNICIAN PROGRAM. 

(a) IN GENERAL.—Under the authority of the Act of November 2, 

1921 (25 U.S.C. 13) (commonly known as the ‘‘Snyder Act’’), the Secretary shall establish and maintain a mental health technician program within the Service which—

(1) provides for the training of Indians as mental health technicians; and 

(2) employs such technicians in the provision of communitybased mental health care that includes identification, prevention, education, referral, and treatment services. 

(b) PARAPROFESSIONAL TRAINING.—In carrying out subsection (a), 

the Secretary, acting through the Service, Indian Tribes, and Tribal 

Organizations, shall provide high-standard paraprofessional training in mental health care necessary to provide quality care to the 

Indian communities to be served. Such training shall be based upon 

a curriculum developed or approved by the Secretary which combines education in the theory of mental health care with supervised 

practical experience in the provision of such care. 

(c) SUPERVISION AND EVALUATION OF TECHNICIANS.—The Secretary, acting through the Service, Indian Tribes, and Tribal Organizations, shall supervise and evaluate the mental health technicians in the training program. 

(d) TRADITIONAL HEALTH CARE PRACTICES.—The Secretary, acting through the Service, shall ensure that the program established 

pursuant to this subsection involves the use and promotion of the 

traditional health care practices of the Indian Tribes to be served. 

SEC. 705. LICENSING REQUIREMENT FOR MENTAL HEALTH CARE 

WORKERS. 

(a) IN GENERAL.—Subject to the provisions of section 221, and except as provided in subsection (b), any individual employed as a 

psychologist, social worker, or marriage and family therapist for the 

purpose of providing mental health care services to Indians in a 

clinical setting under this Act is required to be licensed as a psychologist, social worker, or marriage and family therapist, respectively. 

(b) TRAINEES.—An individual may be employed as a trainee in 

psychology, social work, or marriage and family therapy to provide 

mental health care services described in subsection (a) if such individual—

(1) works under the direct supervision of a licensed psychologist, social worker, or marriage and family therapist, respectively; 

(2) is enrolled in or has completed at least 2 years of course 

work at a post-secondary, accredited education program for psychology, social work, marriage and family therapy, or counseling; and 

(3) meets such other training, supervision, and quality review 

requirements as the Secretary may establish. 


bajohnson on PROD1PC71 with REPORTS
247 

ø§ 1665b. Indian women treatment programs¿ 

SEC. 706. INDIAN WOMEN TREATMENT PROGRAMS. 

ø(a) Grants 

øThe Secretary¿ 

(a) GRANTS.—The Secretary, consistent with section 701, may 

make grants to Indian øtribes and tribal organizations¿ Tribes, 

Tribal Organizations, and Urban Indian Organizations to develop 

and implement a comprehensive øalcohol and substance abuse¿ behavioral health program of prevention, intervention, treatment, 

and relapse prevention services that specifically addresses the cultural, historical, social, and child care needs of Indian women, regardless of age. 

(b) USE OF øgrantsGrants¿ GRANT FUNDS.—A grant made pursuant to this section may be used to—

(1) develop and provide community training, education, and 

prevention programs for Indian women relating to øalcohol and 

substance abuse¿ behavioral health issues, including fetal alcohol øsyndrome and fetal alcohol effect¿ disorders; 

(2) identify and provide øappropriate¿ psychological services, 

counseling, advocacy, support, and relapse prevention to Indian 

women and their families; and 

(3) develop prevention and intervention models for Indian 

women which incorporate traditional øhealers¿ health care 

practices, cultural values, and community and family involvement. 

(c) CRITERIA øfor the review and approval of grant applications¿.—The Secretary, in consultation with Indian Tribes and 

Tribal Organizations, shall establish criteria for the review and approval of applications and proposals for øgrants¿ funding under 

this section. 

ø(d) Authorization of appropriations 

øThere are authorized to be appropriated to carry out this section $10,000,000 for fiscal year 1993 and such sums as are necessary for each of the fiscal years 1994, 1995, 1996, 1997, 1998, 

1999, and 2000. 

ø(2)¿ (d) EARMARK OF CERTAIN FUNDS.—Twenty percent of the 

funds appropriated pursuant to this øsubsection¿ section shall be 

used to make grants to øurban¿ Urban Indian øorganizations funded under subchapter IV of this chapter¿ Organizations. 

ø§ 1665c. Indian Health Service youth program¿ 

SEC. 707. INDIAN YOUTH PROGRAM. 

(a) DETOXIFICATION AND øREHABILITATION¿ REHABILITATION.—

The Secretary, acting through the Service, consistent with section 

701, shall develop and implement a program for acute detoxification and treatment for Indian øyouth who are alcohol and substance abusers¿ youths, including behavioral health services. The 

program shall include regional treatment centers designed to include detoxification and rehabilitation for both sexes on a referral 

basis. øThese regional¿ and programs developed and implemented 

by Indian Tribes or Tribal Organizations at the local level under 

the Indian Self-Determination and Education Assistance Act (25 

U.S.C. 450 et seq.). Regional centers shall be integrated with the 


bajohnson on PROD1PC71 with REPORTS
248 

intake and rehabilitation programs based in the referring Indian 

community. 

(b) ALCOHOL AND SUBSTANCE ABUSE TREATMENT øcenters or facilities¿ CENTERS OR FACILITIES.—

(1) ESTABLISHMENT.—

(A) IN GENERAL.—The Secretary, acting through the 

Service, Indian Tribes, and Tribal Organizations, shall 

construct, renovate, or, as necessary, purchase, and appropriately staff and operate, øa¿ at least 1 youth regional 

treatment center or treatment network in each area under 

the jurisdiction of an øarea office¿ Area Office. 

(B) AREA OFFICE IN CALIFORNIA.—For the purposes of 

this subsection, the øarea offices of the Service in Tucson 

and Phoenix, Arizona, shall be considered one area office 

and the area office¿ Area Office in California shall be considered to be øtwo area offices, one¿ 2 Area Offices, 1 office 

whose jurisdiction shall be considered to encompass the 

northern area of the State of California, and øone¿ 1 office 

whose jurisdiction shall be considered to encompass the remainder of the State of California for the purpose of implementing California treatment networks. 

(2) FUNDING.—For the purpose of staffing and operating such 

centers or facilities, funding shall be pursuant to the Act of November 2, 1921 (25 U.S.C. 13). 

(3) LOCATION.—A youth treatment center constructed or purchased under this subsection shall be constructed or purchased 

at a location within the area described in paragraph (1) agreed 

upon (by appropriate tribal resolution) by a majority of the 

øtribes¿ Indian Tribes to be served by such center. 

(4) SPECIFIC PROVISION OF FUNDS.—

(4A) ø(A)¿ IN GENERAL.—Notwithstanding any other provision of this øsubchapter¿ title, the Secretary may, from 

amounts authorized to be appropriated for the purposes of carrying out this section, make funds available to—

(i) the Tanana Chiefs Conference, Incorporated, for the 

purpose of leasing, constructing, renovating, operatingø,¿ 

and maintaining a residential youth treatment facility in 

Fairbanks, Alaska; and 

(ii) the Southeast Alaska Regional Health Corporation to 

staff and operate a residential youth treatment facility 

without regard to the proviso set forth in section ø450b(l) 

of this title¿ 4(l) of the Indian Self-Determination and 

Education Assistance Act (25 U.S.C. 450b(l)). 

(B) PROVISION OF SERVICES TO ELIGIBLE YOUTHS.—Until additional residential youth treatment facilities are established in 

Alaska pursuant to this section, the facilities specified in subparagraph (A) shall make every effort to provide services to all 

eligible Indian youths residing in Alaska. 

ø(B) Until additional residential youth treatment facilities 

are established in Alaska pursuant to this section, the facilities 

specified in subparagraph (A) shall make every effort to provide services to all eligible Indian youth residing in such 

State.¿ 

(c) INTERMEDIATE ADOLESCENT BEHAVIORAL HEALTH SERVICES.—


bajohnson on PROD1PC71 with REPORTS
249 

(1) IN GENERAL.—The Secretary, acting through the Service, 

Indian Tribes, and Tribal Organizations, may provide intermediate behavioral health services to Indian children and adolescents, including— (A) pretreatment assistance; 

(B) inpatient, outpatient, and aftercare services; 

(C) emergency care; 

(D) suicide prevention and crisis intervention; and 

(E) prevention and treatment of mental illness and dysfunctional and self-destructive behavior, including child 

abuse and family violence. 

(2) USE OF FUNDS.—Funds provided under this subsection 

may be used—

(A) to construct or renovate an existing health facility to 

provide intermediate behavioral health services; 

(B) to hire behavioral health professionals; 

(C) to staff, operate, and maintain an intermediate mental health facility, group home, sober housing, transitional 

housing or similar facilities, or youth shelter where intermediate behavioral health services are being provided; 

(D) to make renovations and hire appropriate staff to 

convert existing hospital beds into adolescent psychiatric 

units; and 

(E) for intensive home- and community-based services. 

(3) CRITERIA.—The Secretary, acting through the Service, 

shall, in consultation with Indian Tribes and Tribal Organizations, establish criteria for the review and approval of applications or proposals for funding made available pursuant to this 

subsection. 

ø(c)¿ (d) FEDERALLYøowned structures¿-OWNED STRUCTURES.—

(1) IN GENERAL.—The Secretary, øacting through the Service, 

shall,¿ in consultation with Indian øtribes¿ Tribes and Tribal 

Organizations, shall— (A) identify and use, where appropriate, federally-owned 

structures suitable øas¿ for local residential or regional 

øalcohol and substance abuse¿ behavioral health treatment øcenters¿ for Indian øyouth¿ youths; and 

(B) establish guidelines for determining the suitability of 

any such federally-owned structure to be used øas a¿ for 

local residential or regional øalcohol and substance abuse¿ 

behavioral health treatment øcenter¿ for Indian øyouth¿ 

youths. 

ø(2)¿ (2) TERMS AND CONDITIONS FOR USE OF STRUCTURE.—Any 

structure described in paragraph (1) may be used under such terms 

and conditions as may be agreed upon by the Secretary and the 

agency having responsibility for the structure and any Indian Tribe 

or Tribal Organization operating the program. 

ø(d)¿ (e) REHABILITATION AND øaftercare services¿ AFTERCARE

SERVICES.— (1) IN GENERAL.—The Secretary, Indian Tribes, or Tribal Organizations, in cooperation with the Secretary of the Interior, 

shall develop and implement within each Service øservice 

unit¿ Unit, community-based rehabilitation and follow-up services for Indian øyouth who are alcohol or substance abusers 

which are designed to integrate¿ youths who are having signifiVerDate Aug 31 2005 01:51 Oct 27, 2007 Jkt 069010 PO 00000 Frm 00249 Fmt 6659 Sfmt 6602 E:\HR\OC\SR197.XXX SR197

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cant behavioral health problems, and require long-term treatment, community reintegration, and monitoring to ømonitor 

and¿ support the Indian øyouth¿ youths after their return to 

their home community. 

(2) ADMINISTRATION.—Services under paragraph (1) shall be 

øadministered within each service unit¿ provided by trained 

staff within the community who can assist the Indian øyouth¿ 

youths in their continuing development of self-image, positive 

problem-solving skills, and nonalcohol or substance abusing behaviors. Such staff øshall¿ may include alcohol and substance 

abuse counselors, mental health professionals, and other 

health professionals and paraprofessionals, including community health representatives. 

ø(e)¿ (f) INCLUSION OF øFAMILY IN YOUTH TREATMENT PROGRAM¿ 

FAMILY IN YOUTH TREATMENT PROGRAM.—In providing the treatment and other services to Indian øyouth¿ youths authorized by 

this section, the Secretary, acting through the Service, Indian 

Tribes, and Tribal Organizations, shall provide for the inclusion of 

family members of such øyouth¿ youths in the treatment programs 

or other services as may be appropriate. Not less than 10 percent 

of the funds appropriated for the purposes of carrying out subsection ø(d) of this section¿ (e) shall be used for outpatient care of 

adult family members related to the treatment of an Indian youth 

under that subsection. 

ø(f) Multidrug abuse study (1) The Secretary shall conduct a 

study to determine the incidence and prevalence of¿ (g) MULTIDRUG

ABUSE PROGRAM.—The Secretary, acting through the Service, Indian Tribes, Tribal Organizations, and Urban Indian Organizations, shall provide, consistent with section 701, programs and services to prevent and treat the abuse of multiple forms of ødrugs¿ 

substances, including alcohol, drugs, inhalants, and tobacco, among 

Indian øyouth¿ youths residing øon Indian¿ in Indian communities, 

on or near reservations, and in urban areas and øthe interrelationship of such abuse with¿ provide appropriate mental health services 

to address the incidence of mental illness among such øyouth¿ 

youths. 

ø(2) The Secretary shall submit a report detailing the findings of 

such study, together with recommendations based on such findings, 

to the Congress no later than two years after October 29, 1992.¿ 

(h) INDIAN YOUTH MENTAL HEALTH.—The Secretary, acting 

through the Service, shall collect data for the report under section 

801 with respect to—

(1) the number of Indian youth who are being provided mental health services through the Service and Tribal Health Programs; 

(2) a description of, and costs associated with, the mental 

health services provided for Indian youth through the Service 

and Tribal Health Programs; 

(3) the number of youth referred to the Service or Tribal 

Health Programs for mental health services; 

(4) the number of Indian youth provided residential treatment 

for mental health and behavioral problems through the Service 

and Tribal Health Programs, reported separately for on- and 

off-reservation facilities; and 

(5) the costs of the services described in paragraph (4). 


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SEC. 708. INDIAN YOUTH TELEMENTAL HEALTH DEMONSTRATION 

PROJECT. 

(a) PURPOSE.—The purpose of this section is to authorize the Secretary to carry out a demonstration project to test the use of telemental health services in suicide prevention, intervention and treatment of Indian youth, including through—

(1) the use of psychotherapy, psychiatric assessments, diagnostic interviews, therapies for mental health conditions predisposing to suicide, and alcohol and substance abuse treatment; 

(2) the provision of clinical expertise to, consultation services 

with, and medical advice and training for frontline health care 

providers working with Indian youth; 

(3) training and related support for community leaders, family members and health and education workers who work with 

Indian youth; 

(4) the development of culturally-relevant educational materials on suicide; and 

(5) data collection and reporting. 

(b) DEFINITIONS.—For the purpose of this section, the following 

definitions shall apply: 

(1) DEMONSTRATION PROJECT.—The term ‘‘demonstration 

project’’ means the Indian youth telemental health demonstration project authorized under subsection (c). 

(2) TELEMENTAL HEALTH.—The term ‘‘telemental health’’

means the use of electronic information and telecommunications 

technologies to support long distance mental health care, patient and professional-related education, public health, and 

health administration. 

(c) AUTHORIZATION.—

(1) IN GENERAL.—The Secretary is authorized to award 

grants under the demonstration project for the provision of telemental health services to Indian youth who—

(A) have expressed suicidal ideas; 

(B) have attempted suicide; or 

(C) have mental health conditions that increase or could 

increase the risk of suicide. 

(2) ELIGIBILITY FOR GRANTS.—Such grants shall be awarded 

to Indian Tribes and Tribal Organizations that operate 1 or 

more facilities—

(A) located in Alaska and part of the Alaska Federal 

Health Care Access Network; 

(B) reporting active clinical telehealth capabilities; or 

(C) offering school-based telemental health services relating to psychiatry to Indian youth. 

(3) GRANT PERIOD.—The Secretary shall award grants under 

this section for a period of up to 4 years. 

(4) AWARDING OF GRANTS.—Not more than 5 grants shall be 

provided under paragraph (1), with priority consideration given 

to Indian Tribes and Tribal Organizations that—

(A) serve a particular community or geographic area 

where there is a demonstrated need to address Indian 

youth suicide; 

(B) enter into collaborative partnerships with Indian 

Health Service or Tribal Health Programs or facilities to 

provide services under this demonstration project; 


bajohnson on PROD1PC71 with REPORTS
252 

(C) serve an isolated community or geographic area 

which has limited or no access to behavioral health services; or 

(D) operate a detention facility at which Indian youth are 

detained. 

(d) USE OF FUNDS.—

(1) IN GENERAL.—An Indian Tribe or Tribal Organization 

shall use a grant received under subsection (c) for the following 

purposes: 

(A) To provide telemental health services to Indian youth, 

including the provision of—

(i) psychotherapy; 

(ii) psychiatric assessments and diagnostic interviews, therapies for mental health conditions predisposing to suicide, and treatment; and 

(iii) alcohol and substance abuse treatment. 

(B) To provide clinician-interactive medical advice, guidance and training, assistance in diagnosis and interpretation, crisis counseling and intervention, and related assistance to Service, tribal, or urban clinicians and health services providers working with youth being served under this 

demonstration project. 

(C) To assist, educate and train community leaders, 

health education professionals and paraprofessionals, tribal outreach workers, and family members who work with 

the youth receiving telemental health services under this 

demonstration project, including with identification of suicidal tendencies, crisis intervention and suicide prevention, 

emergency skill development, and building and expanding 

networks among these individuals and with State and local 

health services providers. 

(D) To develop and distribute culturally appropriate community educational materials on—

(i) suicide prevention; 

(ii) suicide education; 

(iii) suicide screening; 

(iv) suicide intervention; and 

(v) ways to mobilize communities with respect to the 

identification of risk factors for suicide. 

(E) For data collection and reporting related to Indian 

youth suicide prevention efforts. 

(2) TRADITIONAL HEALTH CARE PRACTICES.—In carrying out 

the purposes described in paragraph (1), an Indian Tribe or 

Tribal Organization may use and promote the traditional 

health care practices of the Indian Tribes of the youth to be 

served. 

(e) APPLICATIONS.—To be eligible to receive a grant under subsection (c), an Indian Tribe or Tribal Organization shall prepare 

and submit to the Secretary an application, at such time, in such 

manner, and containing such information as the Secretary may require, including—

(1) a description of the project that the Indian Tribe or Tribal 

Organization will carry out using the funds provided under the 

grant; 


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(2) a description of the manner in which the project funded 

under the grant would—

(A) meet the telemental health care needs of the Indian 

youth population to be served by the project; or 

(B) improve the access of the Indian youth population to 

be served to suicide prevention and treatment services; 

(3) evidence of support for the project from the local community to be served by the project; 

(4) a description of how the families and leadership of the 

communities or populations to be served by the project would be 

involved in the development and ongoing operations of the 

project; 

(5) a plan to involve the tribal community of the youth who 

are provided services by the project in planning and evaluating 

the mental health care and suicide prevention efforts provided, 

in order to ensure the integration of community, clinical, environmental, and cultural components of the treatment; and 

(6) a plan for sustaining the project after Federal assistance 

for the demonstration project has terminated. 

(f) COLLABORATION; REPORTING TO NATIONAL CLEARINGHOUSE—

(1) COLLABORATION.—The Secretary, acting through the Service, shall encourage Indian Tribes and Tribal Organizations receiving grants under this section to collaborate to enable comparisons about best practices across projects. 

(2) REPORTING TO NATIONAL CLEARINGHOUSE.—The Secretary, acting through the Service, shall also encourage Indian 

Tribes and Tribal Organizations receiving grants under this 

section to submit relevant, declassified project information to 

the national clearinghouse authorized under section 701(b)(2) in 

order to better facilitate program performance and improve suicide prevention, intervention, and treatment services. 

(g) ANNUAL REPORT.—Each grant recipient shall submit to the 

Secretary an annual report that—

(1) describes the number of telemental health services provided; and 

(2) includes any other information that the Secretary may require. 

(h) REPORT TO CONGRESS.—Not later than 270 days after the termination of the demonstration project, the Secretary shall submit to 

the Committee on Indian Affairs of the Senate and the Committee 

on Natural Resources and Committee on Energy and Commerce of 

the House of Representatives a final report, based on the annual reports provided by grant recipients under subsection (h), that—

(1) describes the results of the projects funded by grants 

awarded under this section, including any data available which 

indicates the number of attempted suicides; 

(2) evaluates the impact of the telemental health services 

funded by the grants in reducing the number of completed suicides among Indian youth; 

(3) evaluates whether the demonstration project should be—

(A) expanded to provide more than 5 grants; and 

(B) designated a permanent program; and 

(4) evaluates the benefits of expanding the demonstration 

project to include Urban Indian Organizations. 


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254 

(i) AUTHORIZATION OF APPROPRIATIONS.—There is authorized to 

be appropriated to carry out this section $1,500,000 for each of fiscal years 2008 through 2011. 

SEC. 709. INPATIENT AND COMMUNITY-BASED MENTAL HEALTH FACILITIES DESIGN, CONSTRUCTION, AND STAFFING. 

Not later than 1 year after the date of enactment of the Indian 

Health Care Improvement Act Amendments of 2007, the Secretary, 

acting through the Service, Indian Tribes, and Tribal Organizations, may provide, in each area of the Service, not less than 1 inpatient mental health care facility, or the equivalent, for Indians with 

behavioral health problems. For the purposes of this subsection, 

California shall be considered to be 2 Area Offices, 1 office whose 

location shall be considered to encompass the northern area of the 

State of California and 1 office whose jurisdiction shall be considered to encompass the remainder of the State of California. The Secretary shall consider the possible conversion of existing, underused 

Service hospital beds into psychiatric units to meet such need. 

ø§ 1665d. Training and community education¿ 

SEC. 710. TRAINING AND COMMUNITY EDUCATION. 

ø(a) Community education¿ 

(a) PROGRAM.—The Secretary, in cooperation with the Secretary 

of the Interior, shall develop and implement or assist Indian Tribes 

and Tribal Organizations to develop and implement, within each 

øservice unit¿ Service Unit or tribal program, a program of community education and involvement which shall be designed to provide 

concise and timely information to the community leadership of each 

tribal community. Such program shall include education øin alcohol 

and substance abuse¿ about behavioral health issues to political 

leaders, øtribal¿ Tribal judges, law enforcement personnel, members of tribal health and education boards, health care providers including traditional practitioners, and other critical members of 

each tribal community. Such program may also include communitybased training to develop local capacity and tribal community provider training for prevention, intervention, treatment, and aftercare. 

(b) øTraining¿ INSTRUCTION.—The Secretary, acting through the 

Service, shall, either directly or øby contract¿ through Indian 

Tribes and Tribal Organizations, provide instruction in the area of 

øalcohol and substance abuse¿ behavioral health issues, including 

instruction in crisis intervention and family relations in the context 

of alcohol and substance abuse, child sexual abuse, youth alcohol 

and substance abuse, and the causes and effects of fetal alcohol 

øsyndrome¿ disorders to appropriate employees of the Bureau of 

Indian Affairs and the Service, and to personnel in schools or programs operated under any contract with the Bureau of Indian Affairs or the Service, including supervisors of emergency shelters 

and halfway houses described in section ø2433 of this title¿ 4213 

of the Indian Alcohol and Substance Abuse Prevention and Treatment Act of 1986 (25 U.S.C. 2433). 

ø(c) Community-based training models¿ (c) TRAINING MODELS.—

In carrying out the education and training programs required by 

this section, the Secretary, øacting through the Service and¿ in 

consultation with øtribes¿ Indian Tribes, Tribal Organizations, Indian behavioral health experts, and Indian alcohol and substance 


bajohnson on PROD1PC71 with REPORTS
255 

abuse prevention experts, shall develop and provide communitybased training models. Such models shall address—

ø(1) the elevated risk of alcohol and øsubstance abuse¿ behavioral health problems faced by children of alcoholics; 

ø(2) the cultural, spiritual, and multigenerational aspects of 

øalcohol and substance abuse¿ behavioral health problem prevention and recovery; and 

ø(3) community-based and multidisciplinary strategies for 

preventing and treating øalcohol and substance abuse¿ behavioral health problems. 

SEC. 711. BEHAVIORAL HEALTH PROGRAM. 

(a) INNOVATIVE PROGRAMS.—The Secretary, acting through the 

Service, Indian Tribes, and Tribal Organizations, consistent with 

section 701, may plan, develop, implement, and carry out programs 

to deliver innovative community-based behavioral health services to 

Indians. 

(b) AWARDS; CRITERIA.—The Secretary may award a grant for a 

project under subsection (a) to an Indian Tribe or Tribal Organization and may consider the following criteria: 

(1) The project will address significant unmet behavioral 

health needs among Indians. 

(2) The project will serve a significant number of Indians. 

(3) The project has the potential to deliver services in an efficient and effective manner. 

(4) The Indian Tribe or Tribal Organization has the administrative and financial capability to administer the project. 

ø§ 1665e. Gallup alcohol and substance abuse treatment center¿ 

(5) The project may deliver services in a manner consistent 

with traditional health care practices. 

ø(a) Grants for residential treatment 

øThe Secretary shall make grants to the Navajo Nation for the 

purpose of providing residential treatment for alcohol and substance abuse for adult and adolescent members of the Navajo Nation and neighboring tribes. 

ø(b) Purposes of grants 

øGrants made pursuant to this section shall (to the extent appropriations are made available) be used to—

ø(1) provide at least 15 residential beds each year for adult 

long-term treatment, including beds for specialized services 

such as polydrug abusers, dual diagnosis, and specialized services for women with fetal alcohol syndrome children; 

ø(2) establish clinical assessment teams consisting of a clinical psychologist, a part-time addictionologist, a master’s level 

assessment counselor, and a certified medical records technician which shall be responsible for conducting individual assessments and matching Indian clients with the appropriate 

available treatment; 

ø(3) provide at least 12 beds for an adolescent shelterbed 

program in the city of Gallup, New Mexico, which shall serve 

as a satellite facility to the Acoma/Canoncito/Laguna Hospital 

and the adolescent center located in Shiprock, New Mexico, for 

emergency crisis services, assessment, and family intervention; 


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256 

ø(4) develop a relapse program for the purposes of identifying sources of job training and job opportunity in the Gallup 

area and providing vocational training, job placement, and job 

retention services to recovering substance abusers; and 

ø(5) provide continuing education and training of treatment 

staff in the areas of intensive outpatient services, development 

of family support systems, and case management in cooperation with regional colleges, community colleges, and universities. 

ø(c) Contract for residential treatment 

øThe Navajo Nation, in carrying out the purposes of this section, 

shall enter into a contract with an institution in the Gallup, New 

Mexico, area which is accredited by the Joint Commission of the 

Accreditation of Health Care Organizations to provide comprehensive alcohol and drug treatment as authorized in subsection (b) of 

this section. 

ø(d) Authorization of appropriations 

øThere are authorized to be appropriated, for each of fiscal years 

1996 through 2000, such sums as may be necessary to carry out 

subsection (b) of this section.¿ 

(6) The project is coordinated with, and avoids duplication of, 

existing services. 

ø§ 1665f. Reports¿ 

(c) EQUITABLE TREATMENT.—For purposes of this subsection, the 

Secretary shall, in evaluating project applications or proposals, use 

the same criteria that the Secretary uses in evaluating any other application or proposal for such funding. 

ø(a) Compilation of data 

øThe Secretary, with respect to the administration of any health 

program by a service unit, directly or through contract, including 

a contract under the Indian Self-Determination Act [25 U.S.C.A. 

§ 450f et seq.], shall require the compilation of data relating to the 

number of cases or incidents in which any Service personnel or 

services were involved and which were related, either directly or 

indirectly, to alcohol or substance abuse. Such report shall include 

the type of assistance provided and the disposition of these cases. 

ø(b) Referral of data 

øThe data compiled under subsection (a) of this section shall be 

provided annually to the affected Indian tribe and Tribal Coordinating Committee to assist them in developing or modifying a Tribal Action Plan under section 2412 of this title. 

ø(c) Comprehensive report 

øEach service unit director shall be responsible for assembling 

the data compiled under this section and section 2434 of this title 

into an annual tribal comprehensive report. Such report shall be 

provided to the affected tribe and to the Director of the Service who 

shall develop and publish a biennial national report based on such 

tribal comprehensive reports.¿ 

SEC. 712. FETAL ALCOHOL DISORDER PROGRAMS. 

ø§ 1665g. Fetal alcohol syndrome and fetal alcohol effect 

grants¿ 

(a) PROGRAMS.—

ø(a) Award; use; review; criteria¿ 


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257 

ø(1) The Secretary may make grants to Indian tribes and 

tribal organizations to establish fetal alcohol syndrome and 

fetal alcohol effect¿ (1) ESTABLISHMENT.—The Secretary, consistent with section 701, acting through the Service, Indian 

Tribes, and Tribal Organizations, is authorized to establish 

and operate fetal alcohol disorder programs as provided in this 

section for the purposes of meeting the health status objectives 

specified in section ø1602(b) of this title.¿ 3. 

ø(2) Grants made pursuant to this section shall be used 

to—¿ 

(2) USE OF FUNDS.—

(A) IN GENERAL.—Funding provided pursuant to this section shall be used for the following: 

ø(A) develop and provide¿ (i) To develop and provide for 

Indians community and in-school training, education, and 

prevention programs relating to øFAS and FAE;¿ fetal alcohol disorders. 

ø(B) identify and provide alcohol and substance abuse¿ 

(ii) To identify and provide behavioral health treatment to high-risk øwomen;¿ Indian women and highrisk women pregnant with an Indian’s child. 

ø(C)¿ (iii) To identify and provide appropriate psychological services, educational and vocational support, 

counseling, advocacy, and information to øFAS and 

FAE¿ fetal alcohol disorder affected øpersons¿ Indians 

and their families or caretakersø;¿. 

ø(D)¿ (iv) To develop and implement counseling and 

support programs in schools for øFAS and FAE¿ fetal 

alcohol disorder affected Indian childrenø;¿. 

ø(E)¿ (v) To develop prevention and intervention 

models which incorporate practitioners of traditional 

øhealers¿ health care practices, cultural values, and 

community involvementø;¿. 

ø(F)¿ (vi) To develop, print, and disseminate education and prevention materials on øFAS and FAE; 

and¿ fetal alcohol disorder. 

ø(G)¿ (vii) To develop and implement, øthrough the 

tribal¿in consultation øprocess¿ with Indian Tribes, 

Tribal Organizations, and Urban Indian Organizations, culturally sensitive assessment and diagnostic 

tools øfor use in tribal and urban Indian communities¿including dysmorphology clinics and multidisciplinary fetal alcohol disorder clinics for use in Indian 

communities and Urban Centers. 

(B) ADDITIONAL USES.—In addition to any purpose under 

subparagraph (A), funding provided pursuant to this section may be used for 1 or more of the following: 

(i) Early childhood intervention projects from birth 

on to mitigate the effects of fetal alcohol disorder 

among Indians. 

(ii) Community-based support services for Indians 

and women pregnant with Indian children. 

(iii) Community-based housing for adult Indians 

with fetal alcohol disorder. 


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258 

(3) CRITERIA FOR APPLICATIONS.—The Secretary shall establish criteria for the review and approval of applications 

for øgrants under this section.¿funding under this section. 

ø(b) Plan; study; national clearinghouse¿ 

(b) SERVICES.—The Secretary, acting through the Serviceø, shall—¿ and Indian Tribes, Tribal Organizations, and Urban Indian Organizations, shall— ø(1) develop an annual plan¿ (1) develop and provide services 

for the prevention, intervention, treatment, and aftercare for 

those affected by øFAS and FAE in Indian communities;¿ fetal 

alcohol disorder in Indian communities; and 

ø(2) conduct a study, directly or by contract with any organization, entity, or institution of higher education with significant knowledge of FAS and FAE and Indian communities, of¿ 

(2) provide supportive services, including services to meet the 

special educational, vocational, school-to-work transition, and 

independent living needs of adolescent and adult Indians øand 

Alaska Natives with FAS or FAE; and (3) establish a national 

clearinghouse for prevention and educational materials and 

other information on FAS and FAE effect in Indian and Alaska 

Native communities and ensure access to clearinghouse materials by any Indian tribe or urban Indian organization¿ with 

fetal alcohol disorder. (c) TASK øforce¿FORCE.—The Secretary shall establish a task 

force to be known as the øFAS/FAE¿ Fetal Alcohol Disorder Task 

Force to advise the Secretary in carrying out subsection (b) øof this 

section¿. Such task force shall be composed of representatives from 

the following: 

(1) The National Institute on Drug Abuse ø, the¿. (2) The National Institute on Alcohol and Alcoholismø, the¿. (3) The Office of Substance Abuse Preventionø, the¿. (4) The National Institute of Mental Healthø, the¿. (5) The Serviceø, the¿. (6) The Office of Minority Health of the Department of 

Health and Human Servicesø, the¿. 

(7) The Administration for Native Americansø, the Bureau of 

Indian Affairs, Indian tribes, tribal organizations, urban Indian communities, and Indian FAS/FAE¿. 

(8) The National Institute of Child Health and Human Development (NICHD). 

(9) The Centers for Disease Control and Prevention. 

(10) The Bureau of Indian Affairs. 

(11) Indian Tribes. 

(12) Tribal Organizations. 

(13) Urban Indian Organizations. 

(14) Indian fetal alcohol disorder experts. 

ø(d) Cooperative projects; research projects¿ 

(d) APPLIED RESEARCH PROJECTS.—The Secretary, acting 

through the Substance Abuse and Mental Health Services Administration, shall make grants to Indian øtribes, tribal organizations, 

universities working with Indian tribes on cooperative projects, and 

urban Indian organizations¿ Tribes, Tribal Organizations, and 

Urban Indian Organizations for applied research projects which 

propose to elevate the understanding of methods to prevent, intervene, treat, or provide rehabilitation and behavioral health 


bajohnson on PROD1PC71 with REPORTS
259 

aftercare for Indians and øurban¿ Urban Indians affected by øFAS 

or FAE¿ fetal alcohol disorder. 

ø(e) Report 

ø(1) The Secretary shall submit to the President, for inclusion in each report required to be transmitted to the Congress 

under section 1671 of this title, a report on the status of FAS 

and FAE in the Indian population. Such report shall include, 

in addition to the information required under section 1602(d) 

of this title with respect to the health status objective specified 

in section 1602(b)(27) of this title, the following: 

ø(A) The progress of implementing a uniform assessment 

and diagnostic methodology in Service and tribally based 

service delivery systems. 

ø(B) The incidence of FAS and FAE babies born for all 

births by reservation and urban-based sites. 

ø(C) The prevalence of FAS and FAE affected Indian 

persons in Indian communities, their primary means of 

support, and recommendations to improve the support system for these individuals and their families or caretakers. 

ø(D) The level of support received from the entities specified in subsection (c) in the area of FAS and FAE. 

ø(E) The number of inpatient and outpatient substance 

abuse treatment resources which are specifically designed 

to meet the unique needs of Indian women, and the volume of care provided to Indian women through these 

means. 

ø(F) Recommendations regarding the prevention, intervention, and appropriate vocational, educational and other 

support services for FAS and FAE affected individuals in 

Indian communities. 

ø(2) The Secretary may contract the production of this report 

to a national organization specifically addressing FAS and FAE 

in Indian communities. 

ø(f) Authorization of appropriations 

ø(1) There are authorized to be appropriated to carry out 

this section $22,000,000 for fiscal year 1993 and such sums as 

may be necessary for each of the fiscal years 1994, 1995, 1996, 

1997, 1998, 1999, and 2000.¿ 

ø(2)¿ (e) FUNDING FOR URBAN INDIAN ORGANIZATIONS.—Ten 

percent of the funds appropriated pursuant to this section shall 

be used to make grants to øurban Indian organizations¿ Urban 

Indian Organizations funded under øsubchapter IV of this 

chapter¿ title V. 

ø§ 1665h. Pueblo substance abuse treatment project for San 

Juan Pueblo, New Mexico¿ 

SEC. 713. CHILD SEXUAL ABUSE AND PREVENTION TREATMENT PROGRAMS. 

(a) ESTABLISHMENT.—The Secretary, acting through the Service, 

øshall continue to make grants, through fiscal year 1995, to the 8 

Northern Indian Pueblos Council, San Juan Pueblo, New Mexico, 

for the purpose of providing substance abuse treatment services to 

Indians in need of such services.¿ and the Secretary of the Interior, 

Indian Tribes, and Tribal Organizations, shall establish, consistent 


bajohnson on PROD1PC71 with REPORTS
260 

with section 701, in every Service Area, programs involving treatment for—

(1) victims of sexual abuse who are Indian children or children in an Indian household; and 

(2) perpetrators of child sexual abuse who are Indian or 

members of an Indian household. 

(b) USE OF FUNDS.—Funding provided pursuant to this section 

shall be used for the following: 

(1) To develop and provide community education and prevention programs related to sexual abuse of Indian children or 

children in an Indian household. 

(2) To identify and provide behavioral health treatment to 

victims of sexual abuse who are Indian children or children in 

an Indian household, and to their family members who are affected by sexual abuse. 

(3) To develop prevention and intervention models which incorporate traditional health care practices, cultural values, and 

community involvement. 

(4) To develop and implement culturally sensitive assessment 

and diagnostic tools for use in Indian communities and Urban 

Centers. 

(5) To identify and provide behavioral health treatment to Indian perpetrators and perpetrators who are members of an Indian household—

(A) making efforts to begin offender and behavioral 

health treatment while the perpetrator is incarcerated or at 

the earliest possible date if the perpetrator is not incarcerated; and 

(B) providing treatment after the perpetrator is released, 

until it is determined that the perpetrator is not a threat 

to children. 

(c) COORDINATION.—The programs established under subsection 

(a) shall be carried out in coordination with programs and services 

authorized under the Indian Child Protection and Family Violence 

Prevention Act (25 U.S.C. 3201 et seq.). 

SEC. 714. BEHAVIORAL HEALTH RESEARCH. 

The Secretary, in consultation with appropriate Federal agencies, 

shall make grants to, or enter into contracts with, Indian Tribes, 

Tribal Organizations, and Urban Indian Organizations or enter 

into contracts with, or make grants to appropriate institutions for, 

the conduct of research on the incidence and prevalence of behavioral health problems among Indians served by the Service, Indian 

Tribes, or Tribal Organizations and among Indians in urban areas. 

Research priorities under this section shall include—

(1) the multifactorial causes of Indian youth suicide, including—

(A) protective and risk factors and scientific data that 

identifies those factors; and 

(B) the effects of loss of cultural identity and the development of scientific data on those effects; 

(2) the interrelationship and interdependence of behavioral 

health problems with alcoholism and other substance abuse, 

suicide, homicides, other injuries, and the incidence of family 

violence; and 


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261 

ø§ 1665i. Thunder Child Treatment Center¿ 

(3) the development of models of prevention techniques. 

ø(a) The Secretary, acting through the Service, shall make a 

grant to the Intertribal Addictions Recovery Organization, Inc. 

(commonly known as the Thunder Child Treatment Center) at 

Sheridan, Wyoming, for the completion of construction of a multiple 

approach substance abuse treatment center which specializes in 

the treatment of alcohol and drug abuse of Indians. 

ø(b) For the purposes of carrying out subsection (a) of this sec- tion, there are authorized to be appropriated $2,000,000 for fiscal 

years 1993 and 1994. No funding shall be available for staffing or 

operation of this facility. None of the funding appropriated to carry 

out subsection (a) of this section shall be used for administrative 

purposes.¿ 

The effect of the interrelationships and interdependencies referred 

to in paragraph (2) on children, and the development of prevention 

techniques under paragraph (3) applicable to children, shall be emphasized. 

ø§ 1665j. Substance abuse counselor education demonstration project¿ 

SEC. 715. DEFINITIONS. 

ø(a) Contracts and grants 

øThe Secretary, acting through the Service, may enter into contracts with, or make grants to, accredited tribally controlled community colleges, tribally controlled postsecondary vocational institutions, and eligible community colleges to establish demonstration 

projects to develop educational curricula for substance abuse counseling. 

ø(b) Use of funds 

øFunds provided under this section shall be used only for developing and providing educational curricula for substance abuse 

counseling (including paying salaries for instructors). Such curricula may be provided through satellite campus programs. 

ø(c) Effective period of contract or grant; renewal 

øA contract entered into or a grant provided under this section 

shall be for a period of one year. Such contract or grant may be 

renewed for an additional one year period upon the approval of the 

Secretary. 

ø(d) Criteria for review and approval of applications 

øNot later than 180 days after October 29, 1992, the Secretary, 

after consultation with Indian tribes and administrators of accredited tribally controlled community colleges, tribally controlled postsecondary vocational institutions, and eligible community colleges, 

shall develop and issue criteria for the review and approval of applications for funding (including applications for renewals of funding) under this section. Such criteria shall ensure that demonstration projects established under this section promote the development of the capacity of such entities to educate substance abuse 

counselors. 

ø(e) Assistance to recipients 

øThe Secretary shall provide such technical and other assistance 

as may be necessary to enable grant recipients to comply with the 

provisions of this section. 

ø(f) Report 


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262 

øThe Secretary shall submit to the President, for inclusion in the 

report which is required to be submitted under section 1671 of this 

title for fiscal year 1999, a report on the findings and conclusions 

derived from the demonstration projects conducted under this section. 

ø(g) Definitions¿ 

For the øpurposes¿ purpose of this øsection¿ title, the following 

definitions shall apply: 

ø(1) The term ‘‘educational curriculum’’ means one or more 

of the following: 

ø(A) Classroom education. 

ø(B) Clinical work experience. 

ø(C) Continuing education workshops. 

ø(2) The term ‘‘eligible community college’’ means an accredited community college that— ø(i) is located on or near an Indian reservation; 

ø(ii) has entered into a cooperative agreement with the 

governing body of such Indian reservation to carry out a 

demonstration project under this section; and 

ø(iii) has a student enrollment of not less than 10 percent Indian. 

ø(3) The term ‘‘tribally controlled community college’’ has the 

meaning given such term in section 1801(a)(4) of this title. 

ø(4) The term ‘‘tribally controlled postsecondary vocational 

institution’’ has the meaning given such term in section 

2397h(2) of Title 20. 

ø(h) Authorization of appropriations 

øThere are authorized to be appropriated for each of fiscal years 

1996 through 2000, such sums as may be necessary to carry out 

the purposes of this section. Such sums shall remain available until 

expended.¿ 

(1) ASSESSMENT.—The term ‘‘assessment’’ means the systematic collection, analysis, and dissemination of information on 

health status, health needs, and health problems. 

(2) ALCOHOL-RELATED NEURODEVELOPMENTAL DISORDERS OR

ARND.—The term ‘‘alcohol-related neurodevelopmental disorders’’ or ‘‘ARND’’ means, with a history of maternal alcohol 

consumption during pregnancy, central nervous system involvement such as developmental delay, intellectual deficit, or 

neurologic abnormalities. Behaviorally, there can be problems 

with irritability, and failure to thrive as infants. As children 

become older there will likely be hyperactivity, attention deficit, 

language dysfunction, and perceptual and judgment problems. 

(3) BEHAVIORAL HEALTH AFTERCARE.—The term ‘‘behavioral 

health aftercare’’ includes those activities and resources used to 

support recovery following inpatient, residential, intensive substance abuse, or mental health outpatient or outpatient treatment. The purpose is to help prevent or deal with relapse by ensuring that by the time a client or patient is discharged from 

a level of care, such as outpatient treatment, an aftercare plan 

has been developed with the client. An aftercare plan may use 

such resources as a community-based therapeutic group, transitional living facilities, a 12-step sponsor, a local 12-step or 

other related support group, and other community-based providers. 


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(4) DUAL DIAGNOSIS.—The term ‘‘dual diagnosis’’ means coexisting substance abuse and mental illness conditions or diagnosis. Such clients are sometimes referred to as mentally ill 

chemical abusers (MICAs). 

(5) FETAL ALCOHOL DISORDERS.—The term ‘‘fetal alcohol disorders’’ means fetal alcohol syndrome, partial fetal alcohol syndrome and alcohol related neurodevelopmental disorder 

(ARND). 

(6) FETAL ALCOHOL SYNDROME OR FAS.—The term ‘‘fetal alcohol syndrome’’ or ‘‘FAS’’ means a syndrome in which, with a 

history of maternal alcohol consumption during pregnancy, the 

following criteria are met: 

(A) Central nervous system involvement such as developmental delay, intellectual deficit, microencephaly, or 

neurologic abnormalities. 

(B) Craniofacial abnormalities with at least 2 of the following: microophthalmia, short palpebral fissures, poorly 

developed philtrum, thin upper lip, flat nasal bridge, and 

short upturned nose. 

(C) Prenatal or postnatal growth delay. 

ø§ 1665k. Gila River alcohol and substance abuse treatment 

facility¿ 

(7) PARTIAL FAS.—The term ‘‘partial FAS’’ means, with a history of maternal alcohol consumption during pregnancy, having 

most of the criteria of FAS, though not meeting a minimum of 

at least 2 of the following: microophthalmia, short palpebral 

fissures, poorly developed philtrum, thin upper lip, flat nasal 

bridge, and short upturned nose. 

ø(a) Regional center 

øThe Secretary, acting through the Service, shall establish a regional youth alcohol and substance abuse prevention and treatment 

center in Sacaton, Arizona, on the Gila River Indian Reservation. 

The center shall be established within facilities leased, with the 

consent of the Gila River Indian Community, by the Service from 

such Community. 

ø(b) Name of regional center 

øThe center established pursuant to this section shall be known 

as the ‘‘Regional Youth Alcohol and Substance Abuse Prevention 

and Treatment Center’’. 

ø(c) Unit of regional center 

øThe Secretary, acting through the Service, shall establish, as a 

unit of the regional center, a youth alcohol and substance abuse 

prevention and treatment facility in Fallon, Nevada.¿ 

(8) REHABILITATION.—The term ‘‘rehabilitation’’ means to restore the ability or capacity to engage in usual and customary 

life activities through education and therapy. 

ø§ 1665l. Alaska Native drug and alcohol abuse demonstration project¿ 

(9) SUBSTANCE ABUSE.—The term ‘‘substance abuse’’ includes 

inhalant abuse. 

ø(a) The Secretary, acting through the Service, shall make grants 

to the Alaska Native Health Board for the conduct of a two-part 

community-based demonstration project to reduce drug and alcohol 


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264 

abuse in Alaska Native villages and to rehabilitate families afflicted by such abuse. Sixty percent of such grant funds shall be 

used by the Health Board to stimulate coordinated community development programs in villages seeking to organize to combat alcohol and drug use. Forty percent of such grant funds shall be transferred to a qualified nonprofit corporation providing alcohol recovery services in the village of St. Mary’s, Alaska, to enlarge and 

strengthen a family life demonstration program of rehabilitation 

for families that have been or are afflicted by alcoholism. 

ø(b) The Secretary shall submit to the President for inclusion in 

the report required to be submitted to the Congress under section 

1671 of this title for fiscal year 1995 an evaluation of the demonstration project established under subsection (a) of this section.¿ 

SEC. 716. AUTHORIZATION OF APPROPRIATIONS. 

ø§ 1665m. Authorization of appropriations¿ 

There is authorized to be appropriated such sums as may be necessary for each fiscal year through fiscal year 2017 to carry out the 

provisions of this title. 

øExcept as provided in sections 1665b, 1665e, 1665g, 1665i, and 

1665j of this title, there are authorized to be appropriated such 

sums as may be necessary for each fiscal year through fiscal year 

2000 to carry out the provisions of this subchapter.¿ 

TITLE VIII—MISCELLANEOUS 

ø§ 1671. Reports¿ 

SEC. 801. REPORTS. 

øThe President shall, at the time the budget is submitted under 

section 1105 of Title 31, United States Code, for each fiscal year 

transmit to the¿ For each fiscal year following the date of enactment of the Indian Health Care Improvement Act Amendments of 

2007, the Secretary shall transmit to Congress a report containing—the following: 

(1) øa¿ A report on the progress made in meeting the objectives of this øchapter¿ Act, including a review of programs established or assisted pursuant to this øchapter¿ Act and øan 

assessment¿ assessments and recommendations of additional 

programs or additional assistance necessary to, at a minimum, 

provide health services to Indiansø,¿ and ensure a health status for Indians, which are at a parity with the health services 

available to and the health status ofø,¿ the general 

populationø;¿. 

(2) øa¿ A report on whether, and to what extent, new national health care programs, benefits, initiatives, or financing 

systems have had an impact on the purposes of this øchapter¿ 

Act and any steps that the Secretary may have taken to consult with Indian øtribes¿ Tribes, Tribal Organizations, and 

Urban Indian Organizations to address such impactø; (3)¿ , including a report on proposed changes in allocation of funding 

pursuant to section 808. 

(3) A report on the use of health services by Indians—

(A) on a national and area or other relevant geographical 

basis; 

(B) by gender and age; 


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(C) by source of payment and type of service; øand¿ 

(D) comparing such rates of use with rates of use among 

comparable non-Indian populationsø.¿ ; and 

(E) provided under contracts. 

(4) A report of contractors to the Secretary on Health Care 

Educational Loan Repayments every 6 months required by section 110. 

(5) A general audit report of the Secretary on the Health Care 

Educational Loan Repayment Program as required by section 

110(n). 

(6) A report of the findings and conclusions of demonstration 

programs on development of educational curricula for substance 

abuse counseling as required in section 125(f). 

ø(4)¿ (7) øa¿ A separate statement which specifies the 

amount of funds requested to carry out the provisions of section ø1621 of this title;¿ 201. 

ø(5) a separate statement of the total amount obligated or 

expended in the most recently completed fiscal year to achieve 

each of the objectives described in section 1680d of this title, 

relating to infant and maternal mortality and fetal alcohol syndrome; 

ø(6) the reports required by sections 1602(d), 1616a(n), 

1621b(b), 1621h(j), 1631(c), 1632(g), 1634(a)(3), 1643, 1665g(e), 

1680g(a), and 1680l(f) of this title; 

ø(7) for fiscal year 1995, the report required by sections 

1665a(c)(3) and 1665l(b) of this title; 

ø(8) for fiscal year 1997, the interim report required by section 1637(h)(1) of this title; and 

ø(9) for fiscal year 1999, the reports required by sections 

1637(h)(2), 1660b(b), and 1680k(g) of this title.¿ 

(8) A report of the evaluations of health promotion and disease prevention as required in section 203(c). 

(9) A biennial report to Congress on infectious diseases as required by section 212. 

(10) A report on environmental and nuclear health hazards as 

required by section 215. 

(11) An annual report on the status of all health care facilities 

needs as required by section 301(c)(2)(B) and 301(d). 

(12) Reports on safe water and sanitary waste disposal facilities as required by section 302(h). 

(13) An annual report on the expenditure of non-Service funds 

for renovation as required by sections 304(b)(2). 

(14) A report identifying the backlog of maintenance and repair required at Service and tribal facilities required by section 

313(a). 

(15) A report providing an accounting of reimbursement funds 

made available to the Secretary under titles XVIII, XIX, and 

XXI of the Social Security Act. 

(16) A report on any arrangements for the sharing of medical 

facilities or services, as authorized by section 406. 

(17) A report on evaluation and renewal of Urban Indian programs under section 505. 

(18) A report on the evaluation of programs as required by section 513(d). 


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(19) A report on alcohol and substance abuse as required by 

section 701(f). 

(20) A report on Indian youth mental health services as required by section 707(h). 

(21) A report on the reallocation of base resources if required 

by section 808. 

SEC. 802. REGULATIONS. 

(a) DEADLINES.— (1) PROCEDURES.—Not later than 90 days after the date of enactment of the Indian Health Care Improvement Act Amendments of 2007, the Secretary shall initiate procedures under 

subchapter III of chapter 5 of title 5, United States Code, to negotiate and promulgate such regulations or amendments thereto 

that are necessary to carry out titles II (except section 202) and 

VII, the sections of title III for which negotiated rulemaking is 

specifically required, and section 807. Unless otherwise required, the Secretary may promulgate regulations to carry out 

titles I, III, IV, and V, and section 202, using the procedures 

required by chapter V of title 5, United States Code (commonly 

known as the ‘‘Administrative Procedure Act’’). 

(2) PROPOSED REGULATIONS.—Proposed regulations to implement this Act shall be published in the Federal Register by the 

Secretary no later than 2 years after the date of enactment of 

the Indian Health Care Improvement Act Amendments of 2007 

and shall have no less than a 120-day comment period. 

(3) FINAL REGULATIONS.—The Secretary shall publish in the 

Federal Register final regulations to implement this Act by not 

later than 3 years after the date of enactment of the Indian 

Health Care Improvement Act Amendments of 2007. 

(b) COMMITTEE.—A negotiated rulemaking committee established 

pursuant to section 565 of title 5, United States Code, to carry out 

this section shall have as its members only representatives of the 

Federal Government and representatives of Indian Tribes, and Tribal Organizations, a majority of whom shall be nominated by and 

be representatives of Indian Tribes and Tribal Organizations from 

each Service Area. 

(c) ADAPTATION OF PROCEDURES.—The Secretary shall adapt the 

negotiated rulemaking procedures to the unique context of self-governance and the government-to-government relationship between the 

United States and Indian Tribes. 

ø§ 1672.¿ 

(d) LACK OF REGULATIONS.—The lack of promulgated regulations 

shall not limit the effect of this Act. 

øPrior to any revision of or amendment to rules or regulations 

promulgated pursuant to this chapter, the Secretary shall consult 

with Indian tribes and appropriate national or regional Indian organizations and shall publish any proposed revision or amendment 

in the Federal Register not less than sixty days prior to the effective date of such revision or amendment in order to provide adequate notice to, and receive comments from, other interested parties.¿ 

(e) INCONSISTENT REGULATIONS.—The provisions of this Act shall 

supersede any conflicting provisions of law in effect on the day before the date of enactment of the Indian Health Care Improvement 


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Act Amendments of 2007, and the Secretary is authorized to repeal 

any regulation inconsistent with the provisions of this Act. 

ø§ 1674. Leases with Indian tribes¿ 

SEC. 803. PLAN OF IMPLEMENTATION. 

ø(a) Notwithstanding any other provision of law, the Secretary is 

authorized, in carrying out the purposes of this chapter, to enter 

into leases with Indian tribes for periods not in excess of twenty 

years. Property leased by the Secretary from an Indian tribe may 

be reconstructed or renovated by the Secretary pursuant to an 

agreement with such Indian tribe. 

ø(b) The Secretary may enter into leases, contracts, and other 

legal agreements with Indian tribes or tribal organizations which 

hold—

ø(1) title to; 

ø(2) a leasehold interest in; or 

ø(3) a beneficial interest in (where title is held by the United 

States in trust for the benefit of a tribe);¿ 

øfacilities used for the administration and delivery of health services by the Service or by programs operated by Indian tribes or 

tribal organizations to compensate such Indian tribes or tribal organizations for costs associated with the use of such facilities for 

such purposes. Such costs include rent, depreciation based on the 

useful life of the building, principal and interest paid or accrued, 

operation and maintenance expenses, and other expenses determined by regulation to be allowable.¿ 

Not later than 9 months after the date of enactment of the Indian 

Health Care Improvement Act Amendments of 2007, the Secretary, 

in consultation with Indian Tribes, Tribal Organizations, and 

Urban Indian Organizations, shall submit to Congress a plan explaining the manner and schedule, by title and section, by which 

the Secretary will implement the provisions of this Act. This consultation may be conducted jointly with the annual budget consultation pursuant to the Indian Self-Determination and Education Assistance Act (25 U.S.C. 450 et seq.). 

ø§ 1675. Availability of funds¿ 

SEC. 804. AVAILABILITY OF FUNDS. 

The funds appropriated pursuant to this øchapter¿ Act shall remain available until expended. 

ø§ 1676. Limitation on use of funds appropriated to the Indian Health Service¿ 

SEC. 805. LIMITATION ON USE OF FUNDS APPROPRIATED TO INDIAN 

HEALTH SERVICE. 

Any limitation on the use of funds contained in an Act providing 

appropriations for the Department øof Health and Human Services¿ for a period with respect to the performance of abortions shall 

apply for that period with respect to the performance of abortions 

using funds contained in an Act providing appropriations for the 

øIndian Health¿ Service. 

ø§ 1677. Nuclear resource development health hazards¿ 

ø(a) Study 


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øThe Secretary and the Service shall conduct, in conjunction 

with other appropriate Federal agencies and in consultation with 

concerned Indian tribes and organizations, a study of the health 

hazards to Indian miners and Indians on or near Indian reservations and in Indian communities as a result of nuclear resource development. Such study shall include— ø(1) an evaluation of the nature and extent of nuclear resource development related health problems currently exhibited among Indians and the causes of such health problems; 

ø(2) an analysis of the potential effect of ongoing and future 

nuclear resource development on or near Indian reservations 

and communities; 

ø(3) an evaluation of the types and nature of activities, practices, and conditions causing or affecting such health problems, 

including uranium mining and milling, uranium mine tailing 

deposits, nuclear power plant operation and construction, and 

nuclear waste disposal; 

ø(4) a summary of any findings and recommendations provided in Federal and State studies, reports, investigations, and 

inspections during the five years prior to December 17, 1980, 

that directly or indirectly relate to the activities, practices, and 

conditions affecting the health or safety of such Indians; and 

ø(5) the efforts that have been made by Federal and State 

agencies and mining and milling companies to effectively carry 

out an education program for such Indians regarding the 

health and safety hazards of such nuclear resource development. 

ø(b) Health care plan; development 

øUpon completion of such study the Secretary and the Service 

shall take into account the results of such study and develop a 

health care plan to address the health problems studied under subsection (a) of this section. The plan shall include— ø(1) methods for diagnosing and treating Indians currently 

exhibiting such health problems; 

ø(2) preventive care for Indians who may be exposed to such 

health hazards, including the monitoring of the health of individuals who have or may have been exposed to excessive 

amounts of radiation, or affected by other nuclear development 

activities that have had or could have a serious impact upon 

the health of such individuals; and 

ø(3) a program of education for Indians who, by reason of 

their work or geographic proximity to such nuclear development activities, may experience health problems. 

ø(c) Reports to Congress 

øThe Secretary and the Service shall submit to Congress the 

study prepared under subsection (a) of this section no later than 

the date eighteen months after December 17, 1980. The health care 

plan prepared under subsection (b) of this section shall be submitted in a report no later than the date one year after the date 

that the study prepared under subsection (a) of this section is submitted to Congress. Such report shall include recommended activities for the implementation of the plan, as well as an evaluation 

of any activities previously undertaken by the Service to address 

such health problems. 

ø(d) Intergovernmental Task Force; establishment and functions 


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ø(1) There is established an Intergovernmental Task Force to 

be composed of the following individuals (or their designees): 

the Secretary of Energy, the Administrator of the Environmental Protection Agency, the Director of the United States 

Bureau of Mines, the Assistant Secretary for Occupational 

Safety and Health, and the Secretary of the Interior. 

ø(2) The Task Force shall identify existing and potential operations related to nuclear resource development that affect or 

may affect the health of Indians on or near an Indian reservation or in an Indian community and enter into activities to correct existing health hazards and insure that current and future 

health problems resulting from nuclear resource development 

activities are minimized or reduced. 

ø(3) The Secretary shall be Chairman of the Task Force. The 

Task Force shall meet at least twice each year. Each member 

of the Task Force shall furnish necessary assistance to the 

Task Force. 

ø(e) Medical care 

øIn the case of any Indian who—

ø(1) as a result of employment in or near a uranium mine 

or mill, suffers from a work related illness or condition; 

ø(2) is eligible to receive diagnosis and treatment services 

from a Service facility; and 

ø(3) by reason of such Indian’s employment is entitled to 

medical care at the expense of such mine or mill operator; 

øthe Service shall, at the request of such Indian, render appropriate medical care to such Indian for such illness or condition and 

may recover the costs of any medical care so rendered to which 

such Indian is entitled at the expense of such operator from such 

operation. Nothing in this subsection shall affect the rights of such 

Indian to recover damages other than such costs paid to the Service from the employer for such illness or condition. 

ø 1678. Arizona as a contract health service delivery area 

ø(a) Designation 

øFor the fiscal years beginning with the fiscal year ending September 30, 1982, and ending with the fiscal year ending September 

30, 2000, the State of Arizona shall be designated as a contract 

health service delivery area by the Service for the purpose of providing contract health care services to members of federally recognized Indian tribes of Arizona. 

ø(b) Curtailment of health services prohibited 

øThe Service shall not curtail any health care services provided 

to Indians residing on Federal reservations in the State of Arizona 

if such curtailment is due to the provision of contract services in 

such State pursuant to the designation of such State as a contract 

health service delivery area pursuant to subsection (a) of this section.¿ 

SEC. 806. ELIGIBILITY OF CALIFORNIA INDIANS. 

ø§1679. Eligibility of¿ 

(a) IN GENERAL.—The following California Indians shall be eligible for health services provided by the Service: 

ø(a) Report to Congress 


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ø(1) In order to provide the Congress with sufficient data to 

determine which Indians in the State of California should be 

eligible for health services provided by the Service, the Secretary shall, by no later than the date that is 3 years after November 23, 1988, prepare and submit to the Congress a report 

which sets forth— ø(A) a determination by the Secretary of the number of 

Indians described in subsection (b)(2) of this section, and 

the number of Indians described in subsection (b)(3) of this 

section, who are not members of an Indian tribe recognized 

by the Federal Government, 

ø(B) the geographic location of such Indians, 

ø(C) the Indian tribes of which such Indians are members, 

ø(D) an assessment of the current health status, and 

health care needs, of such Indians, and 

ø(E) an assessment of the actual availability and accessibility of alternative resources for the health care of such 

Indians that such Indians would have to rely on if the 

Service did not provide for the health care of such Indians. 

ø(2) The report required under paragraph (1) shall be prepared by the Secretary— ø(A) in consultation with the Secretary of the Interior, 

and 

ø(B) with the assistance of the tribal health programs 

providing services to the Indians described in paragraph 

(2) or (3) of subsection (b) of this section who are not members of any Indian tribe recognized by the Federal Government. 

ø(b) Eligible Indians 

øUntil such time as any subsequent law may otherwise provide, 

the following California Indians shall be eligible for health services 

provided by the Service:¿ 

(1) Any member of a federally recognized Indian øtribe.¿ 

Tribe. 

(2) Any descendant of an Indian who was residing in California on June 1, 1852, øbut only¿ if such descendant—

(A) is øliving in California, (B) is¿ a member of the Indian community served by a local program of the 

Serviceø,¿; and 

ø(C)¿ (B) is regarded as an Indian by the community in 

which such descendant lives. 

(3) Any Indian who holds trust interests in public domain, 

national forest, or øIndian¿ reservation allotments in California. 

(4) Any Indian in California who is listed on the plans for 

distribution of the assets of øCalifornia¿ rancherias and reservations located within the State of California under the Act 

of August 18, 1958 (72 Stat. 619), and any descendant of such 

an Indian. 

ø(c) Scope of eligibility 

øNothing in this section may be construed as expanding the eligibility of California Indians for health services provided by the Service beyond the scope of eligibility for such health services that applied on May 1, 1986. 


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ø§1680. California as a contract health service delivery area 

øThe State of California, excluding the counties of Alameda, 

Contra Costa, Los Angeles, Marin, Orange, Sacramento, San Francisco, San Mateo, Santa Clara, Kern, Merced, Monterey, Napa, San 

Benito, San Joaquin, San Luis Obispo, Santa Cruz, Solano, 

Stanislaus, and Ventura shall be designated as a contract health 

service delivery area by the Service for the purpose of providing 

contract health services to Indians in such State. 

ø§1680a. Contract health facilities 

øThe Service shall provide funds for health care programs and 

facilities operated by tribes and tribal organizations under contracts with the Service entered into under the Indian Self-Determination Act [25 U.S.C.A. §450f et seq.]—

ø(1) for the maintenance and repair of clinics owned or 

leased by such tribes or tribal organizations, 

ø(2) for employee training, 

ø(3) for cost-of-living increases for employees, and 

ø(4) for any other expenses relating to the provision of health 

services, 

øon the same basis as such funds are provided to programs and facilities operated directly by the Service. 

ø§ 1680b. National Health Service Corps 

øThe Secretary of Health and Human Services shall not—

ø(1) remove a member of the National Health Service Corps 

from a health facility operated by the Indian Health Service or 

by a tribe or tribal organization under contract with the Indian 

Health Service under the Indian Self-Determination Act [25 

U.S.C.A. § 450f et seq.], or 

ø(2) withdraw funding used to support such member, unless 

the Secretary, acting through the Service, has ensured that the 

Indians receiving services from such member will experience 

no reduction in services. 

ø§ 1680c. Health services for ineligible persons 

ø(a) Individuals not otherwise eligible 

ø(1) Any individual who—¿ 

ø(A¿ (b) CLARIFICATION.—Nothing in this section may be construed as expanding the eligibility of California Indians for health 

services provided by the Service beyond the scope of eligibility for 

such health services that applied on May 1, 1986. 

SEC. 807. HEALTH SERVICES FOR INELIGIBLE PERSONS. 

(a) CHILDREN.—Any individual who—

(1) has not attained 19 years of ageø,¿; 

ø(B¿ (2) is the natural or adopted child, østepchild¿stepchild, foster-child, legal ward, or orphan of an eligible Indianø,¿; and 

ø(C¿ (3) is not otherwise eligible for øthe¿ health services 

provided by the Service, shall be eligible for all health services 

provided by the Service on the same basis and subject to the 

same rules that apply to eligible Indians until such individual 

attains 19 years of age. The existing and potential health 

needs of all such individuals shall be taken into consideration 


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by the Service in determining the need for, or the allocation of, 

the health resources of the Service. If such an individual has 

been determined to be legally incompetent prior to attaining 19 

years of age, such individual shall remain eligible for such 

services until øone¿ 1 year after the date øsuch disability has 

been removed¿ of a determination of competency. ø(2)¿ (b) SPOUSES.—Any spouse of an eligible Indian who is not 

an Indian, or who is of Indian descent but is not otherwise eligible 

for the health services provided by the Service, shall be eligible for 

such health services if all øof¿ such spouses or spouses who are 

married to members of each Indian Tribe being served are made eligible, as a class, by an appropriate resolution of the governing body 

of the Indian øtribe of the eligible Indian¿ Tribe or Tribal Organization providing such services. The health needs of persons made 

eligible under this paragraph shall not be taken into consideration 

by the Service in determining the need for, or allocation of, its 

health resources. 

ø(b) Health facilities providing health services 

ø(1)(A) The Secretary is authorized to provide health services 

under this subsection through health facilities operated directly by the Service to individuals who reside within the service area of a service unit and who are not eligible for such 

health services under any other subsection of this section or 

under any other provision of law if— ø(i) the Indian tribe (or, in the case of a multi-tribal 

service area, all the Indian tribes) served by such service 

unit requests such provision of health services to such individuals, and 

ø(ii) the Secretary and the Indian tribe or tribes have 

jointly determined that—¿ 

(c) PROVISION OF SERVICES TO OTHER INDIVIDUALS.— ø(I)¿ (1) IN GENERAL.—The Secretary is authorized to provide 

health services under this subsection through health programs 

operated directly by the Service to individuals who reside within the Service Unit and who are not otherwise eligible for such 

health services if— (A) the Indian Tribes served by such Service Unit request 

such provision of health services to such individuals; and 

(B) the Secretary and the served Indian Tribes have 

jointly determined that— (i) the provision of such health services will not result in a denial or diminution of health services to eligible Indiansø,¿; and 

ø(II)¿ (ii) there is no reasonable alternative health 

øfacility¿facilities or services, within or without the 

øservice area of such service unit¿Service Unit, available to meet the health needs of such individuals. 

ø(B)¿ (2) ISDEAA PROGRAMS.—In the case of health programs and facilities operated under a contract or compact entered into under the Indian Self-Determination and Education 

Assistance Act ø[¿(25 U.S.C.øA. § ¿450øf¿ et seq.ø]¿), the governing body of the Indian øtribe or tribal organization¿ Tribe 

or Tribal Organization providing health services under such 

contract or compact is authorized to determine whether health 

services should be provided under such contract to individuals 


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273 

who are not eligible for such health services under any other 

subsection of this section or under any other provision of law. 

In making such determinations, the governing body of the Indian øtribe or tribal organization¿ Tribe or Tribal Organization 

shall take into account the considerations described in øsubparagraph (A)(ii¿ paragraph (1)(B). 

(3) PAYMENT FOR SERVICES.— ø(2)¿(A) IN GENERAL.—Persons receiving health services 

provided by the Service øby reason of¿ under this subsection shall be liable for payment of such health services 

under a schedule of charges prescribed by the Secretary 

which, in the judgment of the Secretary, results in reimbursement in an amount not less than the actual cost of 

providing the health services. Notwithstanding section 

ø1880(c) of the Social Security Act [42 U.S.C.A. 

§ 1395qq(c)], section 1642(a) of this title,¿ 404 of this Act 

or any other provision of law, amounts collected under this 

subsection, including ømedicare or medicaid¿ Medicare, 

Medicaid, or SCHIP reimbursements under titles XVIIIø 

and¿, XIX, and XXI of the Social Security Act ø42 U.S.C.A. 

§§ 1395 et seq. and 1396 et seq.¿, shall be credited to the 

account of the øfacility¿ program providing the service and 

shall be used øsolely for the provision of health services 

within that facility. Amounts¿ for the purposes listed in 

section 401(d)(2) and amounts collected under this subsection shall be available for expenditure within such øfacility for not to exceed one fiscal year after the fiscal year 

in which collected¿ program. (B) INDIGENT PEOPLE.—Health services may be provided 

by the Secretary through the Service under this subsection 

to an indigent øperson¿ individual who would not be otherwise eligible for such health services but for the provisions of paragraph (1) only if an agreement has been entered into with a State or local government under which 

the State or local government agrees to reimburse the 

Service for the expenses incurred by the Service in providing such health services to such indigent øperson¿ individual. (4) REVOCATION OF CONSENT FOR SERVICES.— ø(3)(A)¿ (A) SINGLE TRIBE SERVICE AREA.—In the case of 

a øservice area¿ Service Area which serves only øone¿ 1 

Indian øtribe¿ Tribe, the authority of the Secretary to provide health services under paragraph (1)ø(A)¿ shall terminate at the end of the fiscal year succeeding the fiscal year 

in which the governing body of the Indian øtribe¿ Tribe revokes its concurrence to the provision of such health services. 

(B) MULTITRIBAL SERVICE AREA.—In the case of a ømultitribal service area¿ multitribal Service Area, the authority 

of the Secretary to provide health services under paragraph (1)ø(A)¿ shall terminate at the end of the fiscal year 

succeeding the fiscal year in which at least 51 percent of 

the number of Indian øtribes¿ Tribes in the øservice area¿ 

Service Area revoke their concurrence to the øprovision¿ 

provisions of such health services. 


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274 

ø(c) Purposes served in providing health services to otherwise ineligible individuals¿ (d) OTHER SERVICES.—The Service may provide health services under this subsection to individuals who are 

not eligible for health services provided by the Service under any 

other øsubsection of this section or under any other¿ provision of 

law in order to— (1) achieve stability in a medical emergencyø,¿; 

(2) prevent the spread of a communicable disease or otherwise deal with a public health hazardø,¿; 

(3) provide care to non-Indian women pregnant with an eligible Indian’s child for the duration of the pregnancy through 

øpost partum,¿ postpartum; or 

(4) provide care to immediate family members of an eligible 

øperson¿individual if such care is directly related to the treatment of the eligible øperson¿ individual. 

ø(d) Extension of hospital privileges to non-Service health care 

practitioners¿ (e) HOSPITAL PRIVILEGES FOR PRACTITIONERS.—Hospital privileges in health facilities operated and maintained by the 

Service or operated under a contract øentered into under¿ or compact pursuant to the Indian Self-Determination and Education Assistance Act ø[¿(25 U.S.C.øA. §¿ 450øf¿ et seq.ø]¿) may be extended 

to non-Service health care practitioners who provide services to 

øpersons¿ individuals described in subsection (a) øor¿, (b) øof this 

section¿, (c), or (d). Such non-Service health care practitioners may 

øbe regarded¿, as part of the privileging process, be designated as 

employees of the Federal Government for purposes of section 

1346(b) and chapter 171 of øTitle¿ title 28, United States Code (relating to Federal tort claims) only with respect to acts or omissions 

which occur in the course of providing services to eligible øpersons¿ 

individuals as a part of the conditions under which such hospital 

privileges are extended. 

ø(e)¿ (f) ø‘‘¿ELIGIBLE INDIANø’’ defined¿.—For purposes of this 

section, the term ‘‘eligible Indian’’ means any Indian who is eligible 

for health services provided by the Service without regard to the 

provisions of this section. 

ø§ 1680d. Infant and maternal mortality; fetal alcohol syndrome¿ 

SEC. 808. REALLOCATION OF BASE RESOURCES. 

øBy no later than January 1, 1990, the Secretary shall develop 

and begin implementation of a plan to achieve the following objectives by January 1, 1994: 

ø(1) reduction of the rate of Indian infant mortality in each 

area office of the Service to the lower of—

ø(A) twelve deaths per one thousand live births, or 

ø(B) the rate of infant mortality applicable to the United 

States population as a whole; 

ø(2) reduction of the rate of maternal mortality in each area 

office of the Service to the lower of—

ø(A) five deaths per one hundred thousand live births, or 

ø(B) the rate of maternal mortality applicable to the 

United States population as a whole; and 

ø(3) reduction of the rate of fetal alcohol syndrome among 

Indians served by, or on behalf of, the Service to one per one 

thousand live births. 


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ø§ 1680e. Contract health services for the Trenton service 

area 

ø(a) Service to Turtle Mountain Band 

øThe Secretary, acting through the Service, is directed to provide 

contract health services to members of the Turtle Mountain Band 

of Chippewa Indians that reside in the Trenton Service Area of Divide, McKenzie, and Williams counties in the State of North Dakota and the adjoining counties of Richland, Roosevelt, and Sheridan in the State of Montana. 

ø(b) Band member eligibility not expanded 

øNothing in this section may be construed as expanding the eligibility of members of the Turtle Mountain Band of Chippewa Indians for health services provided by the Service beyond the scope of 

eligibility for such health services that applied on May 1, 1986. 

ø§ 1680f. Indian Health Service and Department of Veterans 

Affairs health facilities and services sharing 

ø(a) Feasibility study and report 

øThe Secretary shall examine the feasibility of entering into an 

arrangement for the sharing of medical facilities and services between the Indian Health Service and the Department of Veterans 

Affairs and shall, in accordance with subsection (b) of this section, 

prepare a report on the feasibility of such an arrangement and submit such report to the Congress by no later than September 30, 

1990. 

ø(b) Non-impairment of service quality, eligibility, or priority of 

access 

øThe Secretary shall not take any action under this section or 

under subchapter IV of chapter 81 of Title 38 which would impair—ø(1) the priority access of any Indian to health care services 

provided through the Indian Health Service; 

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

ø(3) the priority access of any veteran to health care services 

provided by the Department of Veterans Affairs; 

ø(4) the quality of health care services provided to any veteran by the Department of Veterans Affairs; 

ø(5) the eligibility of any Indian to receive health services 

through the Indian Health Service; or 

ø(6) the eligibility of any Indian who is a veteran to receive 

health services through the Department of Veterans Affairs. 

ø(c) Cross utilization of services 

ø(1) Not later than December 23, 1988, the Director of the 

Indian Health Service and the Secretary of Veterans Affairs 

shall implement an agreement under which— ø(A) individuals in the vicinity of Roosevelt, Utah, who 

are eligible for health care from the Department of Veterans Affairs could obtain health care services at the facilities of the Indian Health Service located at Fort Duchesne, 

Utah; and 

ø(B) individuals eligible for health care from the Indian 

Health Service at Fort Duchesne, Utah, could obtain 

health care services at the Department of Veterans Affairs 

medical center located in Salt Lake City, Utah. 


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276 

ø(2) Not later than November 23, 1990, the Secretary and 

the Secretary of Veterans Affairs shall jointly submit a report 

to the Congress on the health care services provided as a result 

of paragraph (1). 

ø(d) Right to health services 

øNothing in this section may be construed as creating any right 

of a veteran to obtain health services from the Indian Health Service except as provided in an agreement under subsection (c) of this 

section. 

ø§ 1680g. Reallocation of base resources 

ø(a) Report to Congress¿ (a) REPORT REQUIRED.—Notwithstanding any other provision of law, any allocation of Service funds 

for a fiscal year that reduces by 5 percent or more from the previous fiscal year the funding for any recurring program, project, or 

activity of a øservice unit¿ Service Unit may be implemented only 

after the Secretary has submitted to øthe President, for inclusion 

in the report required to be transmitted to the¿ Congress, under 

section ø1671 of this title,¿ 801, a report on the proposed change 

in allocation of funding, including the reasons for the change and 

its likely effects. 

(b) øAppropriated amounts¿ EXCEPTION.—Subsection (a) shall 

not apply if the total amount appropriated to the Service for a fiscal year is at least 5 percent less than the amount appropriated to 

the Service for the previous fiscal year. 

SEC. 809. RESULTS OF DEMONSTRATION PROJECTS. 

The Secretary shall provide for the dissemination to Indian 

Tribes, Tribal Organizations, and Urban Indian Organizations of 

the findings and results of demonstration projects conducted under 

this Act. 

SEC. 810. PROVISION OF SERVICES IN MONTANA. 

(a) CONSISTENT WITH COURT DECISION.—The Secretary, acting 

through the Service, shall provide services and benefits for Indians 

in Montana in a manner consistent with the decision of the United 

States Court of Appeals for the Ninth Circuit in McNabb for 

McNabb v. Bowen, 829 F.2d 787 (9th Cir. 1987). 

(b) CLARIFICATION.—The provisions of subsection (a) shall not be 

construed to be an expression of the sense of Congress on the application of the decision described in subsection (a) with respect to the 

provision of services or benefits for Indians living in any State other 

than Montana. 

SEC. 811. MORATORIUM. 

During the period of the moratorium imposed on implementation 

of the final rule published in the Federal Register on September 16, 

1987, by the Department of Health and Human Services, relating 

to eligibility for the health care services of the Indian Health Service, the Indian Health Service shall provide services pursuant to the 

criteria for eligibility for such services that were in effect on September 15, 1987, subject to the provisions of sections 806 and 807, 

until the Service has submitted to the Committees on Appropriations of the Senate and the House of Representatives a budget request reflecting the increased costs associated with the proposed 

final rule, and the request has been included in an appropriations 

Act and enacted into law. 


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SEC. 812. TRIBAL EMPLOYMENT. 

For purposes of section 2(2) of the Act of July 5, 1935 (49 Stat. 

450, chapter 372), an Indian Tribe or Tribal Organization carrying 

out a contract or compact pursuant to the Indian Self-Determination and Education Assistance Act (25 U.S.C. 450 et seq.) shall not 

be considered an ‘‘employer’’. 

SEC. 813. SEVERABILITY PROVISIONS. 

If any provision of this Act, any amendment made by the Act, or 

the application of such provision or amendment to any person or 

circumstances is held to be invalid, the remainder of this Act, the 

remaining amendments made by this Act, and the application of 

such provisions to persons or circumstances other than those to 

which it is held invalid, shall not be affected thereby. 

SEC. 814. ESTABLISHMENT OF NATIONAL BIPARTISAN COMMISSION 

ON INDIAN HEALTH CARE. 

(a) ESTABLISHMENT.—There is established the National Bipartisan Indian Health Care Commission (the ‘‘Commission’’). 

(b) DUTIES OF COMMISSION.—The duties of the Commission are 

the following: 

(1) To establish a study committee composed of those members of the Commission appointed by the Director of the Service 

and at least 4 members of Congress from among the members 

of the Commission, the duties of which shall be the following: 

(A) To the extent necessary to carry out its duties, collect 

and compile data necessary to understand the extent of Indian needs with regard to the provision of health services, 

regardless of the location of Indians, including holding 

hearings and soliciting the views of Indians, Indian Tribes, 

Tribal Organizations, and Urban Indian Organizations, 

which may include authorizing and making funds available for feasibility studies of various models for providing 

and funding health services for all Indian beneficiaries, including those who live outside of a reservation, temporarily 

or permanently. 

(B) To make legislative recommendations to the Commission regarding the delivery of Federal health care services 

to Indians. Such recommendations shall include those related to issues of eligibility, benefits, the range of service 

providers, the cost of such services, financing such services, 

and the optimal manner in which to provide such services. 

(C) To determine the effect of the enactment of such recommendations on (i) the existing system of delivery of 

health services for Indians, and (ii) the sovereign status of 

Indian Tribes. 

(D) Not later than 12 months after the appointment of all 

members of the Commission, to submit a written report of 

its findings and recommendations to the full Commission. 

The report shall include a statement of the minority and 

majority position of the Committee and shall be disseminated, at a minimum, to every Indian Tribe, Tribal Organization, and Urban Indian Organization for comment to the 

Commission. 

(E) To report regularly to the full Commission regarding 

the findings and recommendations developed by the study 


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committee in the course of carrying out its duties under this 

section. 

(2) To review and analyze the recommendations of the report 

of the study committee. 

(3) To make legislative recommendations to Congress regarding the delivery of Federal health care services to Indians. Such 

recommendations shall include those related to issues of eligibility, benefits, the range of service providers, the cost of such 

services, financing such services, and the optimal manner in 

which to provide such services. 

(4) Not later than 18 months following the date of appointment of all members of the Commission, submit a written report 

to Congress regarding the delivery of Federal health care services to Indians. Such recommendations shall include those related to issues of eligibility, benefits, the range of service providers, the cost of such services, financing such services, and the 

optimal manner in which to provide such services. 

(c) MEMBERS.— (1) APPOINTMENT.—The Commission shall be composed of 25 

members, appointed as follows: 

(A) Ten members of Congress, including 3 from the 

House of Representatives and 2 from the Senate, appointed 

by their respective majority leaders, and 3 from the House 

of Representatives and 2 from the Senate, appointed by 

their respective minority leaders, and who shall be members of the standing committees of Congress that consider 

legislation affecting health care to Indians. 

(B) Twelve persons chosen by the congressional members 

of the Commission, 1 from each Service Area as currently 

designated by the Director of the Service to be chosen from 

among 3 nominees from each Service Area put forward by 

the Indian Tribes within the area, with due regard being 

given to the experience and expertise of the nominees in the 

provision of health care to Indians and to a reasonable representation on the commission of members who are familiar 

with various health care delivery modes and who represent 

Indian Tribes of various size populations. 

(C) Three persons appointed by the Director who are 

knowledgeable about the provision of health care to Indians, at least 1 of whom shall be appointed from among 3 

nominees put forward by those programs whose funds are 

provided in whole or in part by the Service primarily or exclusively for the benefit of Urban Indians. 

(D) All those persons chosen by the congressional members of the Commission and by the Director shall be members of federally recognized Indian Tribes. 

(2) CHAIR; VICE CHAIR.—The Chair and Vice Chair of the 

Commission shall be selected by the congressional members of 

the Commission. 

(3) TERMS.—The terms of members of the Commission shall 

be for the life of the Commission. 

(4) DEADLINE FOR APPOINTMENTS.—Congressional members 

of the Commission shall be appointed not later than 180 days 

after the date of enactment of the Indian Health Care Improvement Act Amendments of 2007, and the remaining members of 


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the Commission shall be appointed not later than 60 days following the appointment of the congressional members. 

(5) VACANCY.—A vacancy in the Commission shall be filled in 

the manner in which the original appointment was made. 

(d) COMPENSATION.— (1) CONGRESSIONAL MEMBERS.—Each congressional member 

of the Commission shall receive no additional pay, allowances, 

or benefits by reason of their service on the Commission and 

shall receive travel expenses and per diem in lieu of subsistence 

in accordance with sections 5702 and 5703 of title 5, United 

States Code. 

(2) OTHER MEMBERS.—Remaining members of the Commission, while serving on the business of the Commission (including travel time), shall be entitled to receive compensation at the 

per diem equivalent of the rate provided for level IV of the Executive Schedule under section 5315 of title 5, United States 

Code, and while so serving away from home and the member’s 

regular place of business, a member may be allowed travel expenses, as authorized by the Chairman of the Commission. For 

purpose of pay (other than pay of members of the Commission) 

and employment benefits, rights, and privileges, all personnel of 

the Commission shall be treated as if they were employees of the 

United States Senate. 

(e) MEETINGS.—The Commission shall meet at the call of the 

Chair. 

(f) QUORUM.—A quorum of the Commission shall consist of not 

less than 15 members, provided that no less than 6 of the members 

of Congress who are Commission members are present and no less 

than 9 of the members who are Indians are present. 

(g) EXECUTIVE DIRECTOR; STAFF; FACILITIES.—

(1) APPOINTMENT; PAY.—The Commission shall appoint an 

executive director of the Commission. The executive director 

shall be paid the rate of basic pay for level V of the Executive 

Schedule. 

(2) STAFF APPOINTMENT.—With the approval of the Commission, the executive director may appoint such personnel as the 

executive director deems appropriate. 

(3) STAFF PAY.—The staff of the Commission shall be appointed without regard to the provisions of title 5, United States 

Code, governing appointments in the competitive service, and 

shall be paid without regard to the provisions of chapter 51 and 

subchapter III of chapter 53 of such title (relating to classification and General Schedule pay rates). 

(4) TEMPORARY SERVICES.—With the approval of the Commission, the executive director may procure temporary and intermittent services under section 3109(b) of title 5, United States 

Code. 

(5) FACILITIES.—The Administrator of General Services shall 

locate suitable office space for the operation of the Commission. 

The facilities shall serve as the headquarters of the Commission 

and shall include all necessary equipment and incidentals required for the proper functioning of the Commission. 

(h) HEARINGS.—

(1) For the purpose of carrying out its duties, the Commission 

may hold such hearings and undertake such other activities as 


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the Commission determines to be necessary to carry out its duties, provided that at least 6 regional hearings are held in different areas of the United States in which large numbers of Indians are present. Such hearings are to be held to solicit the 

views of Indians regarding the delivery of health care services 

to them. To constitute a hearing under this subsection, at least 

5 members of the Commission, including at least 1 member of 

Congress, must be present. Hearings held by the study committee established in this section may count toward the number 

of regional hearings required by this subsection. 

(2) Upon request of the Commission, the Comptroller General 

shall conduct such studies or investigations as the Commission 

determines to be necessary to carry out its duties. 

(3)(A) The Director of the Congressional Budget Office or the 

Chief Actuary of the Centers for Medicare & Medicaid Services, 

or both, shall provide to the Commission, upon the request of 

the Commission, such cost estimates as the Commission determines to be necessary to carry out its duties. 

(B) The Commission shall reimburse the Director of the Congressional Budget Office for expenses relating to the employment in the office of that Director of such additional staff as 

may be necessary for the Director to comply with requests by the 

Commission under subparagraph (A). 

(4) Upon the request of the Commission, the head of any Federal agency is authorized to detail, without reimbursement, any 

of the personnel of such agency to the Commission to assist the 

Commission in carrying out its duties. Any such detail shall not 

interrupt or otherwise affect the civil service status or privileges 

of the Federal employee. 

(5) Upon the request of the Commission, the head of a Federal 

agency shall provide such technical assistance to the Commission as the Commission determines to be necessary to carry out 

its duties. 

(6) The Commission may use the United States mails in the 

same manner and under the same conditions as Federal agencies and shall, for purposes of the frank, be considered a commission of Congress as described in section 3215 of title 39, 

United States Code. 

(7) The Commission may secure directly from any Federal 

agency information necessary to enable it to carry out its duties, 

if the information may be disclosed under section 552 of title 4, 

United States Code. Upon request of the Chairman of the Commission, the head of such agency shall furnish such information 

to the Commission. 

(8) Upon the request of the Commission, the Administrator of 

General Services shall provide to the Commission on a reimbursable basis such administrative support services as the Commission may request. 

(9) For purposes of costs relating to printing and binding, including the cost of personnel detailed from the Government 

Printing Office, the Commission shall be deemed to be a committee of Congress. 

(i) AUTHORIZATION OF APPROPRIATIONS.—There is authorized to 

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tion, which sum shall not be deducted from or affect any other appropriation for health care for Indian persons. 

(j) NONAPPLICABILITY OF FACA.—The Federal Advisory Committee Act (5 U.S.C. App.) shall not apply to the Commission. 

SEC. 815. CONFIDENTIALITY OF MEDICAL QUALITY ASSURANCE 

RECORDS; QUALIFIED IMMUNITY FOR PARTICIPANTS. 

(a) CONFIDENTIALITY OF RECORDS.—Medical quality assurance 

records created by or for any Indian Health Program or a health 

program of an Urban Indian Organization as part of a medical 

quality assurance program are confidential and privileged. Such 

records may not be disclosed to any person or entity, except as provided in subsection (c). 

(b) PROHIBITION ON DISCLOSURE AND TESTIMONY.— (1) IN GENERAL.—No part of any medical quality assurance 

record described in subsection (a) may be subject to discovery 

or admitted into evidence in any judicial or administrative proceeding, except as provided in subsection (c). 

(2) TESTIMONY.—A person who reviews or creates medical 

quality assurance records for any Indian Health Program or 

Urban Indian Organization who participates in any proceeding 

that reviews or creates such records may not be permitted or required to testify in any judicial or administrative proceeding 

with respect to such records or with respect to any finding, recommendation, evaluation, opinion, or action taken by such person or body in connection with such records except as provided 

in this section. 

(c) AUTHORIZED DISCLOSURE AND TESTIMONY.— (1) IN GENERAL.—Subject to paragraph (2), a medical quality 

assurance record described in subsection (a) may be disclosed, 

and a person referred to in subsection (b) may give testimony 

in connection with such a record, only as follows: 

(A) To a Federal executive agency or private organization, 

if such medical quality assurance record or testimony is 

needed by such agency or organization to perform licensing 

or accreditation functions related to any Indian Health 

Program or to a health program of an Urban Indian Organization to perform monitoring, required by law, of such 

program or organization. 

(B) To an administrative or judicial proceeding commenced by a present or former Indian Health Program or 

Urban Indian Organization provider concerning the termination, suspension, or limitation of clinical privileges of 

such health care provider. 

(C) To a governmental board or agency or to a professional health care society or organization, if such medical 

quality assurance record or testimony is needed by such 

board, agency, society, or organization to perform licensing, 

credentialing, or the monitoring of professional standards 

with respect to any health care provider who is or was an 

employee of any Indian Health Program or Urban Indian 

Organization. 

(D) To a hospital, medical center, or other institution 

that provides health care services, if such medical quality 

assurance record or testimony is needed by such institution 

to assess the professional qualifications of any health care 


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provider who is or was an employee of any Indian Health 

Program or Urban Indian Organization and who has applied for or been granted authority or employment to provide health care services in or on behalf of such program 

or organization. 

(E) To an officer, employee, or contractor of the Indian 

Health Program or Urban Indian Organization that created the records or for which the records were created. If 

that officer, employee, or contractor has a need for such 

record or testimony to perform official duties. 

(F) To a criminal or civil law enforcement agency or instrumentality charged under applicable law with the protection of the public health or safety, if a qualified representative of such agency or instrumentality makes a written request that such record or testimony be provided for a 

purpose authorized by law. 

(G) In an administrative or judicial proceeding commenced by a criminal or civil law enforcement agency or instrumentality referred to in subparagraph (F), but only 

with respect to the subject of such proceeding. 

(2) IDENTITY OF PARTICIPANTS.—With the exception of the 

subject of a quality assurance action, the identity of any person 

receiving health care services from any Indian Health Program 

or Urban Indian Organization or the identity of any other person associated with such program or organization for purposes 

of a medical quality assurance program that is disclosed in a 

medical quality assurance record described in subsection (a) 

shall be deleted from that record or document before any disclosure of such record is made outside such program or organization. Such requirement does not apply to the release of information pursuant to section 552a of title 5. 

(d) DISCLOSURE FOR CERTAIN PURPOSES.—

(1) IN GENERAL.—Nothing in this section shall be construed 

as authorizing or requiring the withholding from any person or 

entity aggregate statistical information regarding the results of 

any Indian Health Program or Urban Indian Organizations’s 

medical quality assurance programs. 

(2) WITHHOLDING FROM CONGRESS.—Nothing in this section 

shall be construed as authority to withhold any medical quality 

assurance record from a committee of either House of Congress, 

any joint committee of Congress, or the Government Accountability Office if such record pertains to any matter within their 

respective jurisdictions. 

(e) PROHIBITION ON DISCLOSURE OF RECORD OR TESTIMONY.—A 

person or entity having possession of or access to a record or testimony described by this section may not disclose the contents of such 

record or testimony in any manner or for any purpose except as provided in this section. 

(f) EXEMPTION FROM FREEDOM OF INFORMATION ACT.—Medical 

quality assurance records described in subsection (a) may not be 

made available to any person under section 552 of title 5. 

(g) LIMITATION ON CIVIL LIABILITY.—A person who participates in 

or provides information to a person or body that reviews or creates 

medical quality assurance records described in subsection (a) shall 

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formation if the participation or provision of information was in 

good faith based on prevailing professional standards at the time 

the medical quality assurance program activity took place. 

(h) APPLICATION TO INFORMATION IN CERTAIN OTHER RECORDS.—

Nothing in this section shall be construed as limiting access to the 

information in a record created and maintained outside a medical 

quality assurance program, including a patient’s medical records, 

on the grounds that the information was presented during meetings 

of a review body that are part of a medical quality assurance program. 

(i) REGULATIONS.—The Secretary, acting through the Service, 

shall promulgate regulations pursuant to section 802. 

(j) DEFINITIONS.—In this section: 

(1) The term ‘‘health care provider’’ means any health care 

professional, including community health aides and practitioners certified under section 121, who are granted clinical 

practice privileges or employed to provide health care services 

in an Indian Health Program or health program of an Urban 

Indian Organization, who is licensed or certified to perform 

health care services by a governmental board or agency or professional health care society or organization. 

(2) The term ‘‘medical quality assurance program’’ means any 

activity carried out before, on, or after the date of enactment of 

this Act by or for any Indian Health Program or Urban Indian 

Organization to assess the quality of medical care, including 

activities conducted by or on behalf of individuals, Indian 

Health Program or Urban Indian Organization medical or dental treatment review committees, or other review bodies responsible for quality assurance, credentials, infection control, patient 

safety, patient care assessment (including treatment procedures, 

blood, drugs, and therapeutics), medical records, health resources management review and identification and prevention 

of medical or dental incidents and risks. 

(3) The term ‘‘medical quality assurance record’’ means the 

proceedings, records, minutes, and reports that emanate from 

quality assurance program activities described in paragraph (2) 

and are produced or compiled by or for an Indian Health Program or Urban Indian Organization as part of a medical quality assurance program. 

SEC. 816. APPROPRIATIONS; AVAILABILITY. 

Any new spending authority (described in subparagraph (A) or 

(B) of section 401(c)(2) of the Congressional Budget Act of 1974 

(Public Law 93–344; 88 Stat. 317)) which is provided under this Act 

shall be effective for any fiscal year only to such extent or in such 

amounts as are provided in appropriation Acts. 

SEC. 817. AUTHORIZATION OF APPROPRIATIONS. 

‘‘There are authorized to be appropriated such sums as may be 

necessary for each fiscal year through fiscal year 2017 to carry out 

this title.’’

(b) RATE OF PAY.—

(1) POSITIONS AT LEVEL IV.—Section 5315 of title 5, United 

States Code, is amended by striking ‘‘Assistant Secretaries of 

Health and Human Services (6).’’ and inserting ‘‘Assistant Secretaries of Health and Human Services (7)’’. 


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(2) POSITIONS AT LEVEL V.—Section 5316 of title 5, United 

States Code, is amended by striking ‘‘Director, Indian Health 

Service, Department of Health and Human Services’’. 

(c) AMENDMENTS TO OTHER PROVISIONS OF LAW.—

(1) Section 3307(b)(1)(C) of the Children’s Health Act of 2000 

(25 U.S.C. 1671 note; Public Law 106–310) is amended by striking ‘‘Director of the Indian Health Service’’ and inserting ‘‘Assistant Secretary for Indian Health’’. 

(2) The Indian Lands Open Dump Cleanup Act of 1994 is 

amended—

(A) in section 3 (25 U.S.C. 3902)—

(i) by striking paragraph (2); 

(ii) by redesignating paragraphs (1), (3), (4), (5), and 

(6) as paragraphs (4), (5), (2), (6), and (1), respectively, 

and moving those paragraphs so as to appear in numerical order; and 

(iii) by inserting before paragraph (4) (as redesignated by subclause (II)) the following: 

‘‘(3) ASSISTANT SECRETARY.—The term ‘Assistant Secretary’

means the Assistant Secretary for Indian Health.’’; 

(B) in section 5 (25 U.S.C. 3904), by striking the section 

designation and heading and inserting the following: 

‘‘SEC. 5. AUTHORITY OF ASSISTANT SECRETARY FOR INDIAN 

HEALTH.’’; 

(C) in section 6(a) (25 U.S.C. 3905(a)), in the subsection 

heading, by striking ‘‘Director’’ and inserting ‘‘Assistant 

Secretary’’; 

(D) in section 9(a) (25 U.S.C. 3908(a)), in the subsection 

heading, by striking ‘‘Director’’ and inserting ‘‘Assistant 

Secretary’’; and 

(E) by striking ‘‘Director’’ each place it appears and inserting ‘‘Assistant Secretary’’. 

(3) Section 5504(d)(2) of the Augustus F. Hawkins-Robert T. 

Stafford Elementary and Secondary School Improvement 

Amendments of 1988 (25 U.S.C. 2001 note; Public Law 100–

297) is amended by striking ‘‘Director of the Indian Health 

Service’’ and inserting ‘‘Assistant Secretary for Indian Health’’. 

(4) Section 203(a)(1) of the Rehabilitation Act of 1973 (29 

U.S.C. 763(a)(1)) is amended by striking ‘‘Director of the Indian 

Health Service’’ and inserting ‘‘Assistant Secretary for Indian 

Health’’. 

(5) Subsections (b) and (e) of section 518 of the Federal Water 

Pollution Control Act (33 U.S.C. 1377) are amended by striking 

‘‘Director of the Indian Health Service’’ each place it appears 

and inserting ‘‘Assistant Secretary for Indian Health’’. 

(6) Section 317M(b) of the Public Health Service Act (42 

U.S.C. 247b–14(b)) is amended—

(A) by striking ‘‘Director of the Indian Health Service’’

each place it appears and inserting ‘‘Assistant Secretary for 

Indian Health’’; and 

(B) in paragraph (2)(A), by striking ‘‘the Directors referred to in such paragraph’’ and inserting ‘‘the Director of 

the Centers for Disease Control and Prevention and the Assistant Secretary for Indian Health’’. 


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(7) Section 417C(b) of the Public Health Service Act (42 

U.S.C. 285–9(b)) is amended by striking ‘‘Director of the Indian 

Health Service’’ and inserting ‘‘Assistant Secretary for Indian 

Health’’. 

(8) Section 1452(i) of the Safe Drinking Water Act (42 U.S.C. 

300j–12(i)) is amended by striking ‘‘Director of the Indian 

Health Service’’ each place it appears and inserting ‘‘Assistant 

Secretary for Indian Health’’. 

(9) Section 803B(d)(1) of the Native American Programs Act 

of 1974 (42 U.S.C. 2991b–2(d)(1)) is amended in the last sentence by striking ‘‘Director of the Indian Health Service’’ and inserting ‘‘Assistant Secretary for Indian Health’’. 

(10) Section 203(b) of the Michigan Indian Land Claims Settlement Act (Public Law 105–143; 111 Stat. 2666) is amended 

by striking ‘‘Director of the Indian Health Service’’ and inserting ‘‘Assistant Secretary for Indian Health’’. 

SEC. 102. SOBOBA SANITATION FACILITIES. 

The Act of December 17, 1970 (84 Stat. 1465), is amended by adding at the end the following: 

‘‘SEC. 9. Nothing in this Act shall preclude the Soboba Band of 

Mission Indians and the Soboba Indian Reservation from being provided with sanitation facilities and services under the authority of 

section 7 of the Act of August 5, 1954 (68 Stat. 674), as amended 

by the Act of July 31, 1959 (73 Stat. 267).’’. 

SEC. 103. NATIVE AMERICAN HEALTH AND WELLNESS FOUNDATION. 

(a) IN GENERAL.—The Indian Self-Determination and Education 

Assistance Act (25 U.S.C. 450 et seq.) is amended by adding at the 

end the following: 

‘‘TITLE VIII—NATIVE AMERICAN HEALTH AND WELLNESS 

FOUNDATION 

‘‘SEC. 801. DEFINITIONS. 

‘‘In this title: 

‘‘(1) BOARD.—The term ‘Board’ means the Board of Directors 

of the Foundation. 

‘‘(2) COMMITTEE.—The term ‘Committee’ means the Committee for the Establishment of Native American Health and 

Wellness Foundation established under section 802(f). 

‘‘(3) FOUNDATION.—The term ‘Foundation’ means the Native 

American Health and Wellness Foundation established under 

section 802. 

‘‘(4) SECRETARY.—The term ‘Secretary’ means the Secretary of 

Health and Human Services. 

‘‘(5) SERVICE.—The term ‘Service’ means the Indian Health 

Service of the Department of Health and Human Services. 

‘‘SEC. 802. NATIVE AMERICAN HEALTH AND WELLNESS FOUNDATION. 

‘‘(a) ESTABLISHMENT.—

‘‘(1) IN GENERAL.—As soon as practicable after the date of enactment of this title, the Secretary shall establish, under the 

laws of the District of Columbia and in accordance with this 

title, the Native American Health and Wellness Foundation. 


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‘‘(2) FUNDING DETERMINATIONS.—No funds, gift, property, or 

other item of value (including any interest accrued on such an 

item) acquired by the Foundation shall—

‘‘(A) be taken into consideration for purposes of determining Federal appropriations relating to the provision of 

health care and services to Indians; or 

‘‘(B) otherwise limit, diminish, or affect the Federal responsibility for the provision of health care and services to 

Indians. 

‘‘(b) PERPETUAL EXISTENCE.—The Foundation shall have perpetual existence. 

‘‘(c) NATURE OF CORPORATION.—The Foundation—

‘‘(1) shall be a charitable and nonprofit federally chartered 

corporation; and 

‘‘(2) shall not be an agency or instrumentality of the United 

States. 

‘‘(d) PLACE OF INCORPORATION AND DOMICILE.—The Foundation 

shall be incorporated and domiciled in the District of Columbia. 

‘‘(e) DUTIES.—The Foundation shall—

‘‘(1) encourage, accept, and administer private gifts of real 

and personal property, and any income from or interest in such 

gifts, for the benefit of, or in support of, the mission of the Service; 

‘‘(2) undertake and conduct such other activities as will further the health and wellness activities and opportunities of Native Americans; and 

‘‘(3) participate with and assist Federal, State, and tribal governments, agencies, entities, and individuals in undertaking 

and conducting activities that will further the health and 

wellness activities and opportunities of Native Americans. 

‘‘(f) COMMITTEE FOR THE ESTABLISHMENT OF NATIVE AMERICAN

HEALTH AND WELLNESS FOUNDATION.—

‘‘(1) IN GENERAL.—The Secretary shall establish the Committee for the Establishment of Native American Health and 

Wellness Foundation to assist the Secretary in establishing the 

Foundation. 

‘‘(2) DUTIES.—Not later than 180 days after the date of enactment of this section, the Committee shall—

‘‘(A) carry out such activities as are necessary to incorporate the Foundation under the laws of the District of Columbia, including acting as incorporators of the Foundation; 

‘‘(B) ensure that the Foundation qualifies for and maintains the status required to carry out this section, until the 

Board is established; 

‘‘(C) establish the constitution and initial bylaws of the 

Foundation; 

‘‘(D) provide for the initial operation of the Foundation, 

including providing for temporary or interim quarters, 

equipment, and staff; and 

‘‘(E) appoint the initial members of the Board in accordance with the constitution and initial bylaws of the Foundation. 

‘‘(g) BOARD OF DIRECTORS.—


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‘‘(1) IN GENERAL.—The Board of Directors shall be the governing body of the Foundation. ‘‘(2) POWERS.—The Board may exercise, or provide for the exercise of, the powers of the Foundation. ‘‘(3) SELECTION.— ‘‘(A) IN GENERAL.—Subject to subparagraph (B), the 

number of members of the Board, the manner of selection 

of the members (including the filling of vacancies), and the 

terms of office of the members shall be as provided in the 

constitution and bylaws of the Foundation. ‘‘(B) REQUIREMENTS.— ‘‘(i) NUMBER OF MEMBERS.—The Board shall have at 

least 11 members, who shall have staggered terms. 

‘‘(ii) INITIAL VOTING MEMBERS.—The initial voting 

members of the Board—

‘‘(I) shall be appointed by the Committee not 

later than 180 days after the date on which the 

Foundation is established; and 

‘‘(II) shall have staggered terms. 

‘‘(iii) QUALIFICATION.—The members of the Board 

shall be United States citizens who are knowledgeable 

or experienced in Native American health care and related matters. 

‘‘(C) COMPENSATION.—A member of the Board shall not 

receive compensation for service as a member, but shall be 

reimbursed for actual and necessary travel and subsistence 

expenses incurred in the performance of the duties of the 

Foundation. ‘‘(h) OFFICERS.—

‘‘(1) IN GENERAL.—The officers of the Foundation shall be—

‘‘(A) a secretary, elected from among the members of the 

Board; and 

‘‘(B) any other officers provided for in the constitution 

and bylaws of the Foundation. ‘‘(2) CHIEF OPERATING OFFICER.—The secretary of the Foundation may serve, at the direction of the Board, as the chief operating officer of the Foundation, or the Board may appoint a 

chief operating officer, who shall serve at the direction of the 

Board. ‘‘(3) ELECTION.—The manner of election, term of office, and 

duties of the officers of the Foundation shall be as provided in 

the constitution and bylaws of the Foundation. 

‘‘(i) POWERS.—The Foundation—

‘‘(1) shall adopt a constitution and bylaws for the management of the property of the Foundation and the regulation of the 

affairs of the Foundation; 

‘‘(2) may adopt and alter a corporate seal; 

‘‘(3) may enter into contracts; 

‘‘(4) may acquire (through a gift or otherwise), own, lease, encumber, and transfer real or personal property as necessary or 

convenient to carry out the purposes of the Foundation; ‘‘(5) may sue and be sued; and 

‘‘(6) may perform any other act necessary and proper to carry 

out the purposes of the Foundation. ‘‘(j) PRINCIPAL OFFICE.—


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‘‘(1) IN GENERAL.—The principal office of the Foundation 

shall be in the District of Columbia. ‘‘(2) ACTIVITIES; OFFICES.—The activities of the Foundation 

may be conducted, and offices may be maintained, throughout 

the United States in accordance with the constitution and bylaws of the Foundation. ‘‘(k) SERVICE OF PROCESS.—The Foundation shall comply with 

the law on service of process of each State in which the Foundation 

is incorporated and of each State in which the Foundation carries 

on activities. ‘‘(l) LIABILITY OF OFFICERS, EMPLOYEES, AND AGENTS.— ‘‘(1) IN GENERAL.—The Foundation shall be liable for the acts 

of the officers, employees, and agents of the Foundation acting 

within the scope of their authority. 

‘‘(2) PERSONAL LIABILITY.—A member of the Board shall be 

personally liable only for gross negligence in the performance of 

the duties of the member. 

‘‘(m) RESTRICTIONS.— ‘‘(1) LIMITATION ON SPENDING.—Beginning with the fiscal 

year following the first full fiscal year during which the Foundation is in operation, the administrative costs of the Foundation shall not exceed the percentage described in paragraph (2) 

of the sum of—

‘‘(A) the amounts transferred to the Foundation under 

subsection (o) during the preceding fiscal year; and 

‘‘(B) donations received from private sources during the 

preceding fiscal year. 

‘‘(2) PERCENTAGES.—The percentages referred to in paragraph 

(1) are—

‘‘(A) for the first fiscal year described in that paragraph, 

20 percent; ‘‘(B) for the following fiscal year, 15 percent; and 

‘‘(C) for each fiscal year thereafter, 10 percent. ‘‘(3) APPOINTMENT AND HIRING.—The appointment of officers 

and employees of the Foundation shall be subject to the availability of funds. 

‘‘(4) STATUS.—A member of the Board or officer, employee, or 

agent of the Foundation shall not by reason of association with 

the Foundation be considered to be an officer, employee, or 

agent of the United States. ‘‘(n) AUDITS.—The Foundation shall comply with section 10101 of 

title 36, United States Code, as if the Foundation were a corporation under part B of subtitle II of that title. 

‘‘(o) FUNDING.—

‘‘(1) AUTHORIZATION OF APPROPRIATIONS.—There is authorized to be appropriated to carry out subsection (e)(1) $500,000 

for each fiscal year, as adjusted to reflect changes in the Consumer Price Index for all-urban consumers published by the Department of Labor. ‘‘(2) TRANSFER OF DONATED FUNDS.—The Secretary shall 

transfer to the Foundation funds held by the Department of 

Health and Human Services under the Act of August 5, 1954 

(42 U.S.C. 2001 et seq.), if the transfer or use of the funds is 

not prohibited by any term under which the funds were donated. 


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‘‘SEC. 803. ADMINISTRATIVE SERVICES AND SUPPORT. 

‘‘(a) PROVISION OF SUPPORT BY SECRETARY.—Subject to subsection 

(b), during the 5-year period beginning on the date on which the 

Foundation is established, the Secretary— ‘‘(1) may provide personnel, facilities, and other administrative support services to the Foundation; ‘‘(2) may provide funds for initial operating costs and to reimburse the travel expenses of the members of the Board; and ‘‘(3) shall require and accept reimbursements from the Foundation for— ‘‘(A) services provided under paragraph (1); and 

‘‘(B) funds provided under paragraph (2). ‘‘(b) REIMBURSEMENT.—Reimbursements accepted under subsection (a)(3)— ‘‘(1) shall be deposited in the Treasury of the United States 

to the credit of the applicable appropriations account; and ‘‘(2) shall be chargeable for the cost of providing services described in subsection (a)(1) and travel expenses described in 

subsection (a)(2). ‘‘(c) CONTINUATION OF CERTAIN SERVICES.—The Secretary may 

continue to provide facilities and necessary support services to the 

Foundation after the termination of the 5-year period specified in 

subsection (a) if the facilities and services— ‘‘(1) are available; and 

‘‘(2) are provided on reimbursable cost basis.’’ (b) TECHNICAL AMENDMENTS.—The Indian Self-Determination 

and Education Assistance Act is amended— (1) by redesignating title V (25 U.S.C. 458bbb et seq.) as title 

VII; 

(2) by redesignating sections 501, 502, and 503 (25 U.S.C. 

458bbb, 458bbb–1, 458bbb–2) as sections 701, 702, and 703, respectively; and 

(3) in subsection (a)(2) of section 702 and paragraph (2) of 

section 703 (as redesignated by paragraph (2)), by striking ‘‘section 501’’ and inserting ‘‘section 701’’. 

TITLE II—IMPROVEMENT OF INDIAN HEALTH CARE 

PROVIDED UNDER THE SOCIAL SECURITY ACT 

SEC. 201. EXPANSION OF PAYMENTS UNDER MEDICARE, MEDICAID, 

AND SCHIP FOR ALL COVERED SERVICES FURNISHED BY 

INDIAN HEALTH PROGRAMS. 

(a) MEDICAID.—

(1) EXPANSION TO ALL COVERED SERVICES.—Section 1911 of 

the Social Security Act (42 U.S.C. 1396j) is amended—

(A) by amending the heading to read as follows: 

‘‘SEC. 1911. INDIAN HEALTH PROGRAMS.’’; 

and 

(B) by amending subsection (a) to read as follows: 

‘‘(a) ELIGIBILITY FOR PAYMENT FOR MEDICAL ASSISTANCE.—The 

Indian Health Service and an Indian Tribe, Tribal Organization, or 

an Urban Indian Organization shall be eligible for payment for 

medical assistance provided under a State plan or under waiver authority with respect to items and services furnished by the Indian 

Health Service, Indian Tribe, Tribal Organization, or Urban Indian 

Organization if the furnishing of such services meets all the condiVerDate Aug 31 2005 01:51 Oct 27, 2007 Jkt 069010 PO 00000 Frm 00289 Fmt 6659 Sfmt 6603 E:\HR\OC\SR197.XXX SR197

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tions and requirements which are applicable generally to the furnishing of items and services under this title and under such plan 

or waiver authority.’’ (2) COMPLIANCE WITH CONDITIONS AND REQUIREMENTS.—Subsection (b) of such section is amended to read as follows: ‘‘(b) COMPLIANCE WITH CONDITIONS AND REQUIREMENTS.—A facility of the Indian Health Service or an Indian Tribe, Tribal Organization, or an Urban Indian Organization which is eligible for 

payment under subsection (a) with respect to the furnishing of items 

and services, but which does not meet all of the conditions and requirements of this title and under a State plan or waiver authority 

which are applicable generally to such facility, shall make such improvements as are necessary to achieve or maintain compliance with 

such conditions and requirements in accordance with a plan submitted to and accepted by the Secretary for achieving or maintaining compliance with such conditions and requirements, and shall be 

deemed to meet such conditions and requirements (and to be eligible 

for payment under this title), without regard to the extent of its actual compliance with such conditions and requirements, during the 

first 12 months after the month in which such plan is submitted.’’. (3) REVISION OF AUTHORITY TO ENTER INTO AGREEMENTS.— Subsection (c) of such section is amended to read as follows: ‘‘(c) AUTHORITY TO ENTER INTO AGREEMENTS.—The Secretary 

may enter into an agreement with a State for the purpose of reimbursing the State for medical assistance provided by the Indian 

Health Service, an Indian Tribe, Tribal Organization, or an Urban 

Indian Organization (as so defined), directly, through referral, or 

under contracts or other arrangements between the Indian Health 

Service, an Indian Tribe, Tribal Organization, or an Urban Indian 

Organization and another health care provider to Indians who are 

eligible for medical assistance under the State plan or under waiver 

authority.’’. (4) CROSS-REFERENCES TO SPECIAL FUND FOR IMPROVEMENT

OF IHS FACILITIES; DIRECT BILLING OPTION; DEFINITIONS.—Such 

section is further amended by striking subsection (d) and adding at the end the following new subsections: 

‘‘(d) SPECIAL FUND FOR IMPROVEMENT OF IHS FACILITIES.—For 

provisions relating to the authority of the Secretary to place payments to which a facility of the Indian Health Service is eligible for 

payment under this title into a special fund established under section 401(c)(1) of the Indian Health Care Improvement Act, and the 

requirement to use amounts paid from such fund for making improvements in accordance with subsection (b), see subparagraphs 

(A) and (B) of section 401(c)(1) of such Act. ‘‘(e) DIRECT BILLING.—For provisions relating to the authority of 

a Tribal Health Program or an Urban Indian Organization to elect 

to directly bill for, and receive payment for, health care items and 

services provided by such Program or Organization for which payment is made under this title, see section 401(d) of the Indian 

Health Care Improvement Act. ‘‘(f) DEFINITIONS.—In this section, the terms ‘Indian Health Program’, ‘Indian Tribe’, ‘Tribal Health Program’, ‘Tribal Organization’, and ‘Urban Indian Organization’ have the meanings given 

those terms in section 4 of the Indian Health Care Improvement 

Act.’’. 


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(b) MEDICARE.— (1) EXPANSION TO ALL COVERED SERVICES.—Section 1880 of 

such Act (42 U.S.C. 1395qq) is amended— (A) by amending the heading to read as follows: 

‘‘SEC. 1880. INDIAN HEALTH PROGRAMS.’’; 

and 

(B) by amending subsection (a) to read as follows: ‘‘(a) ELIGIBILITY FOR PAYMENTS.—Subject to subsection (e), the Indian Health Service and an Indian Tribe, Tribal Organization, or 

an Urban Indian Organization shall be eligible for payments under 

this title with respect to items and services furnished by the Indian 

Health Service, Indian Tribe, Tribal Organization, or Urban Indian 

Organization if the furnishing of such services meets all the conditions and requirements which are applicable generally to the furnishing of items and services under this title.’’. (2) COMPLIANCE WITH CONDITIONS AND REQUIREMENTS.—Subsection (b) of such section is amended to read as follows: ‘‘(b) COMPLIANCE WITH CONDITIONS AND REQUIREMENTS.—Subject to subsection (e), a facility of the Indian Health Service or an 

Indian Tribe, Tribal Organization, or an Urban Indian Organization which is eligible for payment under subsection (a) with respect 

to the furnishing of items and services, but which does not meet all 

of the conditions and requirements of this title which are applicable 

generally to such facility, shall make such improvements as are necessary to achieve or maintain compliance with such conditions and 

requirements in accordance with a plan submitted to and accepted 

by the Secretary for achieving or maintaining compliance with such 

conditions and requirements, and shall be deemed to meet such conditions and requirements (and to be eligible for payment under this 

title), without regard to the extent of its actual compliance with such 

conditions and requirements, during the first 12 months after the 

month in which such plan is submitted.’’. (3) CROSS-REFERENCES TO SPECIAL FUND FOR IMPROVEMENT

OF IHS FACILITIES; DIRECT BILLING OPTION; DEFINITIONS.— (A) IN GENERAL.—Such section is further amended by 

striking subsections (c) and (d) and inserting the following 

new subsections: ‘‘(c) SPECIAL FUND FOR IMPROVEMENT OF IHS FACILITIES.—For 

provisions relating to the authority of the Secretary to place payments to which a facility of the Indian Health Service is eligible for 

payment under this title into a special fund established under section 401(c)(1) of the Indian Health Care Improvement Act, and the 

requirement to use amounts paid from such fund for making improvements in accordance with subsection (b), see subparagraphs 

(A) and (B) of section 401(c)(1) of such Act. 

‘‘(d) DIRECT BILLING.—For provisions relating to the authority of 

a Tribal Health Program or an Urban Indian Organization to elect 

to directly bill for, and receive payment for, health care items and 

services provided by such Program or Organization for which payment is made under this title, see section 401(d) of the Indian 

Health Care Improvement Act.’’. 

(B) CONFORMING AMENDMENT.—Paragraph (3) of section 

1880(e) of such Act (42 U.S.C. 1395qq(e)) is amended by inserting ‘‘and section 401(c)(1) of the Indian Health Care 

Improvement Act’’ after ‘‘Subsection (c)’’. 


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(4) DEFINITIONS.—Such section is further amended by 

amending subsection (f) to read as follows: 

‘‘(f) DEFINITIONS.—In this section, the terms ‘Indian Health Program’, ‘Indian Tribe’, ‘Service Unit’, ‘Tribal Health Program’, ‘Tribal Organization’, and ‘Urban Indian Organization’ have the meanings given those terms in section 4 of the Indian Health Care Improvement Act.’’. 

(c) APPLICATION TO SCHIP.—Section 2107(e)(1) of the Social Security Act (42 U.S.C. 1397gg(e)(1)) is amended—

(1) by redesignating subparagraph (D) as subparagraph (E); 

and 

(2) by inserting after subparagraph (C), the following new 

subparagraph: 

‘‘(D) Section 1911 (relating to Indian Health Programs, 

other than subsection (d) of such section).’’

SEC. 202. INCREASED OUTREACH TO INDIANS UNDER MEDICAID AND 

SCHIP AND IMPROVED COOPERATION IN THE PROVISION 

OF ITEMS AND SERVICES TO INDIANS UNDER SOCIAL SECURITY ACT HEALTH BENEFIT PROGRAMS. 

Section 1139 of the Social Security Act (42 U.S.C. 1320b–9) is 

amended to read as follows: 

SEC. 1139. IMPROVED ACCESS TO, AND DELIVERY OF, HEALTH CARE 

FOR INDIANS UNDER TITLES XVIII, XIX, AND XXI. 

(a) AGREEMENTS WITH STATES FOR MEDICAID AND SCHIP OUTREACH ON OR NEAR RESERVATIONS TO INCREASE THE ENROLLMENT

OF INDIANS IN THOSE PROGRAMS.—

(1) IN GENERAL.—In order to improve the access of Indians 

residing on or near a reservation to obtain benefits under the 

Medicaid and State children’s health insurance programs established under titles XIX and XXI, the Secretary shall encourage the State to take steps to provide for enrollment on or near 

the reservation. Such steps may include outreach efforts such as 

the outstationing of eligibility workers, entering into agreements 

with the Indian Health Service, Indian Tribes, Tribal Organizations, and Urban Indian Organizations to provide outreach, 

education regarding eligibility and benefits, enrollment, and 

translation services when such services are appropriate. 

(2) CONSTRUCTION.—Nothing in subparagraph (A) shall be 

construed as affecting arrangements entered into between States 

and the Indian Health Service, Indian Tribes, Tribal Organizations, or Urban Indian Organizations for such Service, Tribes, 

or Organizations to conduct administrative activities under 

such titles. 

(b) REQUIREMENT TO FACILITATE COOPERATION.—The Secretary, 

acting through the Centers for Medicare & Medicaid Services, shall 

take such steps as are necessary to facilitate cooperation with, and 

agreements between, States and the Indian Health Service, Indian 

Tribes, Tribal Organizations, or Urban Indian Organizations with 

respect to the provision of health care items and services to Indians 

under the programs established under title XVIII, XIX, or XXI. 

(c) DEFINITION OF INDIAN; INDIAN TRIBE; INDIAN HEALTH PROGRAM; TRIBAL ORGANIZATION; URBAN INDIAN ORGANIZATION.—In 

this section, the terms ‘‘Indian’’, ‘‘Indian Tribe’’, ‘‘Indian Health Program’’, ‘‘Tribal Organization’’, and ‘‘Urban Indian Organization’’


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have the meanings given those terms in section 4 of the Indian 

Health Care Improvement Act. 

SEC. 203. ADDITIONAL PROVISIONS TO INCREASE OUTREACH TO, AND 

ENROLLMENT OF, INDIANS IN SCHIP AND MEDICAID. 

(a) NONAPPLICATION OF 10 PERCENT LIMIT ON OUTREACH AND

CERTAIN OTHER EXPENDITURES.—Section 2105(c)(2) of the Social 

Security Act (42 U.S.C. 1397ee(c)(2)) is amended by adding at the 

end the following new subparagraph: ‘‘(C) NONAPPLICATION TO EXPENDITURES FOR OUTREACH

TO INCREASE THE ENROLLMENT OF INDIAN CHILDREN UNDER

THIS TITLE AND TITLE XIX.—The limitation under subparagraph (A) on expenditures for items described in subsection 

(a)(1)(D) shall not apply in the case of expenditures for outreach activities to families of Indian children likely to be eligible for child health assistance under the plan or medical 

assistance under the State plan under title XIX (or under 

a waiver of such plan), to inform such families of the availability of, and to assist them in enrolling their children in, 

such plans, including such activities conducted under 

grants, contracts, or agreements entered into under section 

1139(a).’’. (b) ASSURANCE OF PAYMENTS TO INDIAN HEALTH CARE PRO- VIDERS FOR CHILD HEALTH ASSISTANCE.—Section 2102(b)(3)(D) of 

such Act (42 U.S.C. 1397bb(b)(3)(D)) is amended by striking ‘(as defined in section 4(c) of the Indian Health Care Improvement Act, 25 

U.S.C. 1603(c))’ and inserting ‘, including how the State will ensure 

that payments are made to Indian Health Programs and Urban Indian Organizations operating in the State for the provision of such 

assistance’. (c) INCLUSION OF OTHER INDIAN FINANCED HEALTH CARE PRO- GRAMS IN EXEMPTION FROM PROHIBITION ON CERTAIN PAYMENTS.— Section 2105(c)(6)(B) of such Act (42 U.S.C. 1397ee(c)(6)(B)) is 

amended by striking ‘insurance program, other than an insurance 

program operated or financed by the Indian Health Service’ and inserting ‘program, other than a health care program operated or financed by the Indian Health Service or by an Indian Tribe, Tribal 

Organization, or Urban Indian Organization’. 

(d) SATISFACTION OF MEDICAID DOCUMENTATION REQUIREMENTS.—

(1) IN GENERAL.—Section 1903(x)(3)(B) of the Social Security 

Act (42 U.S.C. 1396b(x)(3)(B)) is amended—

(A) by redesignating clause (v) as clause (vi); and 

(B) by inserting after clause (iv), the following new 

clause: 

‘‘(v)(I) Except as provided in subclause (II), a document issued by a federally-recognized Indian tribe evidencing membership or enrollment in, or affiliation 

with, such tribe. 

‘‘(II) With respect to those federally-recognized Indian 

tribes located within States having an international 

border whose membership includes individuals who 

are not citizens of the United States, the Secretary 

shall, after consulting with such tribes, issue regulations authorizing the presentation of such other forms 

of documentation (including tribal documentation, if 


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appropriate) that the Secretary determines to be satisfactory documentary evidence of citizenship or nationality for purposes of satisfying the requirement of this 

subsection.’’. 

(2) TRANSITION RULE.—During the period that begins on July 

1, 2006, and ends on the effective date of final regulations 

issued under subclause (II) of section 1903(x)(3)(B)(v) of the Social Security Act (42 U.S.C. 1396b(x)(3)(B)(v)) (as added by 

paragraph (1)), an individual who is a member of a federallyrecognized Indian tribe described in subclause (II) of that section who presents a document described in subclause (I) of such 

section that is issued by such Indian tribe, shall be deemed to 

have presented satisfactory evidence of citizenship or nationality 

for purposes of satisfying the requirement of subsection (x) of 

section 1903 of such Act. 

(e) DEFINITIONS.—Section 2110(c) of such Act (42 U.S.C. 

1397jj(c)) is amended by adding at the end the following new paragraph: 

‘‘(9) INDIAN; INDIAN HEALTH PROGRAM; INDIAN TRIBE; ETC.—

The terms ‘Indian’, ‘Indian Health Program’, ‘Indian Tribe’, 

‘Tribal Organization’, and ‘Urban Indian Organization’ have 

the meanings given those terms in section 4 of the Indian 

Health Care Improvement Act.’’. 

SEC. 204. PREMIUMS AND COST SHARING PROTECTIONS UNDER MEDICAID, ELIGIBILITY DETERMINATIONS UNDER MEDICAID 

AND SCHIP, AND PROTECTION OF CERTAIN INDIAN PROPERTY FROM MEDICAID ESTATE RECOVERY. 

(a) PREMIUMS AND COST SHARING PROTECTION UNDER MEDICAID.—

(1) IN GENERAL.—Section 1916 of the Social Security Act (42 

U.S.C. 1396o) is amended—

(A) in subsection (a), in the matter preceding paragraph 

(1), by striking ‘‘and (i)’’ and inserting ‘‘, (i), and (j)’’; and 

(B) by adding at the end the following new subsection: 

‘‘(j) NO PREMIUMS OR COST SHARING FOR INDIANS FURNISHED

ITEMS OR SERVICES DIRECTLY BY INDIAN HEALTH PROGRAMS OR

THROUGH REFERRAL UNDER THE CONTRACT HEALTH SERVICE.—

‘‘(1) NO COST SHARING FOR ITEMS OR SERVICES FURNISHED TO

INDIANS THROUGH INDIAN HEALTH PROGRAMS.—

‘‘(A) IN GENERAL.—No enrollment fee, premium, or similar charge, and no deduction, copayment, cost sharing, or 

similar charge shall be imposed against an Indian who is 

furnished an item or service directly by the Indian Health 

Service, an Indian Tribe, Tribal Organization, or Urban 

Indian Organization or through referral under the contract 

health service for which payment may be made under this 

title. 

‘‘(B) NO REDUCTION IN AMOUNT OF PAYMENT TO INDIAN

HEALTH PROVIDERS.—Payment due under this title to the 

Indian Health Service, an Indian Tribe, Tribal Organization, or Urban Indian Organization, or a health care provider through referral under the contract health service for 

the furnishing of an item or service to an Indian who is eligible for assistance under such title, may not be reduced by 

the amount of any enrollment fee, premium, or similar 


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charge, or any deduction, copayment, cost sharing, or similar charge that would be due from the Indian but for the 

operation of subparagraph (A). ‘‘(2) RULE OF CONSTRUCTION.—Nothing in this subsection 

shall be construed as restricting the application of any other 

limitations on the imposition of premiums or cost sharing that 

may apply to an individual receiving medical assistance under 

this title who is an Indian. ‘‘(3) DEFINITIONS.—In this subsection, the terms ‘contract 

health service’, ‘Indian’, ‘Indian Tribe’, ‘Tribal Organization’, and ‘Urban Indian Organization’ have the meanings given 

those terms in section 4 of the Indian Health Care Improvement 

Act’’. 

(2) CONFORMING AMENDMENT.—Section 1916A (a)(1) of such 

Act (42 U.S.C. 1396o–1(a)(1)) is amended by striking ‘‘section 

1916(g)’’ and inserting ‘‘subsections (g), (i), or (j) of section 

1916’’. 

(b) TREATMENT OF CERTAIN PROPERTY FOR MEDICAID AND SCHIP 

ELIGIBILITY.—

(1) MEDICAID.—Section 1902(e) of the Social Security Act (42 

U.S.C. 1396a) is amended by adding at the end the following 

new paragraph: 

‘‘(13) Notwithstanding any other requirement of this title or 

any other provision of Federal or State law, a State shall disregard the following property for purposes of determining the 

eligibility of an individual who is an Indian (as defined in section 4 of the Indian Health Care Improvement Act) for medical 

assistance under this title: 

‘‘(A) Property, including real property and improvements, 

that is held in trust, subject to Federal restrictions, or otherwise under the supervision of the Secretary of the Interior, located on a reservation, including any federally recognized Indian Tribe’s reservation, pueblo, or colony, including former reservations in Oklahoma, Alaska Native regions established by the Alaska Native Claims Settlement 

Act, and Indian allotments on or near a reservation as designated and approved by the Bureau of Indian Affairs of 

the Department of the Interior. ‘‘(B) For any federally recognized Tribe not described in 

subparagraph (A), property located within the most recent 

boundaries of a prior Federal reservation. ‘‘(C) Ownership interests in rents, leases, royalties, or 

usage rights related to natural resources (including extraction of natural resources or harvesting of timber, other 

plants and plant products, animals, fish, and shellfish) resulting from the exercise of federally protected rights. ‘‘(D) Ownership interests in or usage rights to items not 

covered by subparagraphs (A) through (C) that have unique 

religious, spiritual, traditional, or cultural significance or 

rights that support subsistence or a traditional lifestyle according to applicable tribal law or custom.’’. 

(2) APPLICATION TO SCHIP.—Section 2107(e)(1) of such Act (42 

U.S.C. 1397gg(e)(1)) is amended— (A) by redesignating subparagraphs (B) through (E), as 

subparagraphs (C) through (F), respectively; and 


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(B) by inserting after subparagraph (A), the following 

new subparagraph: ‘‘(B) Section 1902(e)(13) (relating to disregard of certain 

property for purposes of making eligibility determinations).’’. (c) CONTINUATION OF CURRENT LAW PROTECTIONS OF CERTAIN

INDIAN PROPERTY FROM MEDICAID ESTATE RECOVERY.—Section 

1917(b)(3) of the Social Security Act (42 U.S.C. 1396p(b)(3)) is 

amended— (1) by inserting ‘‘(A)’’ after ‘‘(3)’’; and 

(2) by adding at the end the following new subparagraph: ‘‘(B) The standards specified by the Secretary under subparagraph (A) shall require that the procedures established 

by the State agency under subparagraph (A) exempt income, resources, and property that are exempt from the application of this subsection as of April 1, 2003, under manual instructions issued to carry out this subsection (as in 

effect on such date) because of the Federal responsibility for 

Indian Tribes and Alaska Native Villages. Nothing in this 

subparagraph shall be construed as preventing the Secretary from providing additional estate recovery exemptions 

under this title for Indians.’’. 

SEC. 205. NONDISCRIMINATION IN QUALIFICATIONS FOR PAYMENT 

FOR SERVICES UNDER FEDERAL HEALTH CARE PROGRAMS. 

Section 1139 of the Social Security Act (42 U.S.C. 1320b–9), as 

amended by section 202, is amended by redesignating subsection (c) 

as subsection (d), and inserting after subsection (b) the following 

new subsection: ‘‘(c) NONDISCRIMINATION IN QUALIFICATIONS FOR PAYMENT FOR

SERVICES UNDER FEDERAL HEALTH CARE PROGRAMS.— ‘‘(1) REQUIREMENT TO SATISFY GENERALLY APPLICABLE PARTICIPATION REQUIREMENTS.— (A) IN GENERAL.—A Federal health care program must 

accept an entity that is operated by the Indian Health Service, an Indian Tribe, Tribal Organization, or Urban Indian 

Organization as a provider eligible to receive payment 

under the program for health care services furnished to an 

Indian on the same basis as any other provider qualified 

to participate as a provider of health care services under 

the program if the entity meets generally applicable State 

or other requirements for participation as a provider of 

health care services under the program. 

‘‘(B) SATISFACTION OF STATE OR LOCAL LICENSURE OR

RECOGNITION REQUIREMENTS.—Any requirement for participation as a provider of health care services under a Federal 

health care program that an entity be licensed or recognized under the State or local law where the entity is located to furnish health care services shall be deemed to 

have been met in the case of an entity operated by the Indian Health Service, an Indian Tribe, Tribal Organization, 

or Urban Indian Organization if the entity meets all the 

applicable standards for such licensure or recognition, regardless of whether the entity obtains a license or other 

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ance with section 221 of the Indian Health Care Improvement Act, the absence of the licensure of a health care professional employed by such an entity under the State or 

local law where the entity is located shall not be taken into 

account for purposes of determining whether the entity 

meets such standards, if the professional is licensed in another State. 

‘‘(2) PROHIBITION ON FEDERAL PAYMENTS TO ENTITIES OR INDIVIDUALS EXCLUDED FROM PARTICIPATION IN FEDERAL HEALTH

CARE PROGRAMS OR WHOSE STATE LICENSES ARE UNDER SUSPENSION OR HAVE BEEN REVOKED.—

‘‘(A) EXCLUDED ENTITIES.—No entity operated by the Indian Health Service, an Indian Tribe, Tribal Organization, 

or Urban Indian Organization that has been excluded from 

participation in any Federal health care program or for 

which a license is under suspension or has been revoked by 

the State where the entity is located shall be eligible to receive payment under any such program for health care 

services furnished to an Indian. 

‘‘(B) EXCLUDED INDIVIDUALS.—No individual who has 

been excluded from participation in any Federal health 

care program or whose State license is under suspension or 

has been revoked shall be eligible to receive payment under 

any such program for health care services furnished by that 

individual, directly or through an entity that is otherwise 

eligible to receive payment for health care services, to an Indian. 

‘‘(C) FEDERAL HEALTH CARE PROGRAM DEFINED.—In this 

subsection, the term, ‘Federal health care program’ has the 

meaning given that term in section 1128B(f), except that, 

for purposes of this subsection, such term shall include the 

health insurance program under chapter 89 of title 5, 

United States Code.’’. 

SEC. 206. CONSULTATION ON MEDICAID, SCHIP, AND OTHER HEALTH 

CARE PROGRAMS FUNDED UNDER THE SOCIAL SECURITY 

ACT INVOLVING INDIAN HEALTH PROGRAMS AND URBAN 

INDIAN ORGANIZATIONS. 

(a) IN GENERAL.—Section 1139 of the Social Security Act (42 

U.S.C. 1320b–9), as amended by sections 202 and 205, is amended 

by redesignating subsection (d) as subsection (e), and inserting after 

subsection (c) the following new subsection: 

‘‘(d) CONSULTATION WITH TRIBAL TECHNICAL ADVISORY GROUP

(TTAG).—The Secretary shall maintain within the Centers for Medicaid & Medicare Services (CMS) a Tribal Technical Advisory 

Group, established in accordance with requirements of the charter 

dated September 30, 2003, and in such group shall include a representative of the Urban Indian Organizations and the Service. The 

representative of the Urban Indian Organization shall be deemed to 

be an elected officer of a tribal government for purposes of applying 

section 204(b) of the Unfunded Mandates Reform Act of 1995 (2 

U.S.C. 1534(b)).’’. 

(b) SOLICITATION OF ADVICE UNDER MEDICAID AND SCHIP.—

(1) MEDICAID STATE PLAN AMENDMENT.—Section 1902(a) of 

the Social Security Act (42 U.S.C. 1396a(a)) is amended—

(A) in paragraph (69), by striking ‘and’ at the end; 


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(B) in paragraph (70)(B)(iv), by striking the period at the 

end and inserting ‘; and’; and 

(C) by inserting after paragraph (70)(B)(iv), the following 

new paragraph: ‘‘(71) in the case of any State in which the Indian Health 

Service operates or funds health care programs, or in which 1 

or more Indian Health Programs or Urban Indian Organizations (as such terms are defined in section 4 of the Indian 

Health Care Improvement Act) provide health care in the State 

for which medical assistance is available under such title, provide for a process under which the State seeks advice on a regular, ongoing basis from designees of such Indian Health Programs and Urban Indian Organizations on matters relating to 

the application of this title that are likely to have a direct effect 

on such Indian Health Programs and Urban Indian Organizations and that— ‘‘(A) shall include solicitation of advice prior to submission of any plan amendments, waiver requests, and proposals for demonstration projects likely to have a direct effect on Indians, Indian Health Programs, or Urban Indian 

Organizations; and ‘‘(B) may include appointment of an advisory committee 

and of a designee of such Indian Health Programs and 

Urban Indian Organizations to the medical care advisory 

committee advising the State on its State plan under this 

title.’’. (2) APPLICATION TO SCHIP.—Section 2107(e)(1) of such Act (42 

U.S.C. 1397gg(e)(1)), as amended by section 204(b)(2), is 

amended— (A) by redesignating subparagraphs (B) through (F) as subparagraphs (C) through (G), respectively; and 

(B) by inserting after subparagraph (A), the following 

new subparagraph: ‘‘(B) Section 1902(a)(71) (relating to the option of certain 

States to seek advice from designees of Indian Health Programs and Urban Indian Organizations).’’. 

(c) RULE OF CONSTRUCTION.—Nothing in the amendments made 

by this section shall be construed as superseding existing advisory 

committees, working groups, guidance, or other advisory procedures 

established by the Secretary of Health and Human Services or by 

any State with respect to the provision of health care to Indians. 

SEC. 207. EXCLUSION WAIVER AUTHORITY FOR AFFECTED INDIAN 

HEALTH PROGRAMS AND SAFE HARBOR TRANSACTIONS 

UNDER THE SOCIAL SECURITY ACT. 

(a) EXCLUSION WAIVER AUTHORITY.—Section 1128 of the Social 

Security Act (42 U.S.C. 1320a–7) is amended by adding at the end 

the following new subsection: 

‘‘(k) ADDITIONAL EXCLUSION WAIVER AUTHORITY FOR AFFECTED

INDIAN HEALTH PROGRAMS.—In addition to the authority granted 

the Secretary under subsections (c)(3)(B) and (d)(3)(B) to waive an 

exclusion under subsection (a)(1), (a)(3), (a)(4), or (b), the Secretary 

may, in the case of an Indian Health Program, waive such an exclusion upon the request of the administrator of an affected Indian 

Health Program (as defined in section 4 of the Indian Health Care 

Improvement Act) who determines that the exclusion would impose 


bajohnson on PROD1PC71 with REPORTS
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a hardship on individuals entitled to benefits under or enrolled in 

a Federal health care program.’’. (b) CERTAIN TRANSACTIONS INVOLVING INDIAN HEALTH CARE

PROGRAMS DEEMED TO BE IN SAFE HARBORS.—Section 1128B(b) of 

the Social Security Act (42 U.S.C. 1320a–7b(b)) is amended by adding at the end the following new paragraph: ‘‘(4) Subject to such conditions as the Secretary may promulgate 

from time to time as necessary to prevent fraud and abuse, for purposes of paragraphs (1) and (2) and section 1128A(a), the following 

transfers shall not be treated as remuneration: ‘‘(A) TRANSFERS BETWEEN INDIAN HEALTH PROGRAMS, INDIAN TRIBES, TRIBAL ORGANIZATIONS, AND URBAN INDIAN

ORGANIZATIONS.—Transfers of anything of value between or 

among an Indian Health Program, Indian Tribe, Tribal 

Organization, or Urban Indian Organization, that are 

made for the purpose of providing necessary health care 

items and services to any patient served by such Program, 

Tribe, or Organization and that consist of—

‘‘(i) services in connection with the collection, transport, analysis, or interpretation of diagnostic specimens 

or test data; 

‘‘(ii) inventory or supplies; 

‘‘(iii) staff; or 

‘‘(iv) a waiver of all or part of premiums or cost sharing. 

‘‘(B) TRANSFERS BETWEEN INDIAN HEALTH PROGRAMS, IN- DIAN TRIBES, TRIBAL ORGANIZATIONS, OR URBAN INDIAN OR- GANIZATIONS AND PATIENTS.—Transfers of anything of 

value between an Indian Health Program, Indian Tribe, 

Tribal Organization, or Urban Indian Organization and 

any patient served or eligible for service from an Indian 

Health Program, Indian Tribe, Tribal Organization, or 

Urban Indian Organization, including any patient served 

or eligible for service pursuant to section 807 of the Indian 

Health Care Improvement Act, but only if such transfers—

‘‘(i) consist of expenditures related to providing transportation for the patient for the provision of necessary 

health care items or services, provided that the provision of such transportation is not advertised, nor an incentive of which the value is disproportionately large in 

relationship to the value of the health care item or 

service (with respect to the value of the item or service 

itself or, for preventative items or services, the future 

health care costs reasonably expected to be avoided); 

‘‘(ii) consist of expenditures related to providing 

housing to the patient (including a pregnant patient) 

and immediate family members or an escort necessary 

to assuring the timely provision of health care items 

and services to the patient, provided that the provision 

of such housing is not advertised nor an incentive of 

which the value is disproportionately large in relationship to the value of the health care item or service 

(with respect to the value of the item or service itself or, 

for preventative items or services, the future health care 

costs reasonably expected to be avoided); or 


bajohnson on PROD1PC71 with REPORTS
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‘‘(iii) are for the purpose of paying premiums or cost 

sharing on behalf of such a patient, provided that the 

making of such payment is not subject to conditions 

other than conditions agreed to under a contract for 

the delivery of contract health services. 

‘‘(C) CONTRACT HEALTH SERVICES.—A transfer of anything of value negotiated as part of a contract entered into 

between an Indian Health Program, Indian Tribe, Tribal 

Organization, Urban Indian Organization, or the Indian 

Health Service and a contract care provider for the delivery 

of contract health services authorized by the Indian Health 

Service, provided that—

‘‘(i) such a transfer is not tied to volume or value of 

referrals or other business generated by the parties; 

and 

‘‘(ii) any such transfer is limited to the fair market 

value of the health care items or services provided or, 

in the case of a transfer of items or services related to 

preventative care, the value of the future health care 

costs reasonably expected to be avoided. 

‘‘(D) OTHER TRANSFERS.—Any other transfer of anything 

of value involving an Indian Health Program, Indian 

Tribe, Tribal Organization, or Urban Indian Organization, 

or a patient served or eligible for service from an Indian 

Health Program, Indian Tribe, Tribal Organization, or 

Urban Indian Organization, that the Secretary, in consultation with the Attorney General, determines is appropriate, taking into account the special circumstances of 

such Indian Health Programs, Indian Tribes, Tribal Organizations, and Urban Indian Organizations, and of patients served by such Programs, Tribes, and Organizations.’’. 

SEC. 208. RULES APPLICABLE UNDER MEDICAID AND SCHIP TO MANAGED CARE ENTITIES WITH RESPECT TO INDIAN ENROLLEES AND INDIAN HEALTH CARE PROVIDERS AND INDIAN 

MANAGED CARE ENTITIES. 

(a) IN GENERAL.—Section 1932 of the Social Security Act (42 

U.S.C. 1396u–2) is amended by adding at the end the following new 

subsection: 

‘‘(h) SPECIAL RULES WITH RESPECT TO INDIAN ENROLLEES, IN- DIAN HEALTH CARE PROVIDERS, AND INDIAN MANAGED CARE ENTI- TIES.—

‘‘(1) ENROLLEE OPTION TO SELECT AN INDIAN HEALTH CARE

PROVIDER AS PRIMARY CARE PROVIDER.—In the case of a non-Indian Medicaid managed care entity that—

‘‘(A) has an Indian enrolled with the entity; and 

‘‘(B) has an Indian health care provider that is participating as a primary care provider within the network of the 

entity, 

insofar as the Indian is otherwise eligible to receive services from 

such Indian health care provider and the Indian health care provider has the capacity to provide primary care services to such Indian, the contract with the entity under section 1903(m) or under 

section 1905(t)(3) shall require, as a condition of receiving payment 

under such contract, that the Indian shall be allowed to choose such 


bajohnson on PROD1PC71 with REPORTS
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Indian health care provider as the Indian’s primary care provider 

under the entity. 

‘‘(2) ASSURANCE OF PAYMENT TO INDIAN HEALTH CARE PROVIDERS FOR PROVISION OF COVERED SERVICES.—Each contract 

with a managed care entity under section 1903(m) or under section 1905(t)(3) shall require any such entity that has a significant percentage of Indian enrollees (as determined by the Secretary), as a condition of receiving payment under such contract 

to satisfy the following requirements: 

‘‘(A) DEMONSTRATION OF PARTICIPATING INDIAN HEALTH

CARE PROVIDERS OR APPLICATION OF ALTERNATIVE PAYMENT

ARRANGEMENTS.—Subject to subparagraph (E), to—

‘‘(i) demonstrate that the number of Indian health 

care providers that are participating providers with respect to such entity are sufficient to ensure timely access to covered Medicaid managed care services for 

those enrollees who are eligible to receive services from 

such providers; or 

‘‘(ii) agree to pay Indian health care providers who 

are not participating providers with the entity for covered Medicaid managed care services provided to those 

enrollees who are eligible to receive services from such 

providers at a rate equal to the rate negotiated between 

such entity and the provider involved or, if such a rate 

has not been negotiated, at a rate that is not less than 

the level and amount of payment which the entity 

would make for the services if the services were furnished by a participating provider which is not an Indian health care provider. 

‘‘(B) PROMPT PAYMENT.—To agree to make prompt payment (in accordance with rules applicable to managed care 

entities) to Indian health care providers that are participating providers with respect to such entity or, in the case 

of an entity to which subparagraph (A)(ii) or (E) applies, 

that the entity is required to pay in accordance with that 

subparagraph. 

‘‘(C) SATISFACTION OF CLAIM REQUIREMENT.—To deem 

any requirement for the submission of a claim or other documentation for services covered under subparagraph (A) by 

the enrollee to be satisfied through the submission of a 

claim or other documentation by an Indian health care provider that is consistent with section 403(h) of the Indian 

Health Care Improvement Act. 

‘‘(D) COMPLIANCE WITH GENERALLY APPLICABLE REQUIREMENTS.—

‘‘(i) IN GENERAL.—Subject to clause (ii), as a condition of payment under subparagraph (A), an Indian 

health care provider shall comply with the generally 

applicable requirements of this title, the State plan, 

and such entity with respect to covered Medicaid managed care services provided by the Indian health care 

provider to the same extent that non-Indian providers 

participating with the entity must comply with such requirements. 


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‘‘(ii) LIMITATIONS ON COMPLIANCE WITH MANAGED

CARE ENTITY GENERALLY APPLICABLE REQUIREMENTS.— An Indian health care provider— ‘‘(I) shall not be required to comply with a generally applicable requirement of a managed care 

entity described in clause (i) as a condition of payment under subparagraph (A) if such compliance 

would conflict with any other statutory or regulatory requirements applicable to the Indian health 

care provider; and ‘‘(II) shall only need to comply with those generally applicable requirements of a managed care 

entity described in clause (i) as a condition of payment under subparagraph (A) that are necessary 

for the entity’s compliance with the State plan, 

such as those related to care management, quality 

assurance, and utilization management. ‘‘(E) APPLICATION OF SPECIAL PAYMENT REQUIREMENTS

FOR FEDERALLY-QUALIFIED HEALTH CENTERS AND ENCOUNTER RATE FOR SERVICES PROVIDED BY CERTAIN INDIAN

HEALTH CARE PROVIDERS.— ‘‘(i) FEDERALLY-QUALIFIED HEALTH CENTERS.— ‘‘(I) MANAGED CARE ENTITY PAYMENT REQUIRE- MENT.—To agree to pay any Indian health care 

provider that is a Federally-qualified health center 

but not a participating provider with respect to the 

entity, for the provision of covered Medicaid managed care services by such provider to an Indian 

enrollee of the entity at a rate equal to the amount 

of payment that the entity would pay a Federallyqualified health center that is a participating provider with respect to the entity but is not an Indian health care provider for such services. ‘‘(II) CONTINUED APPLICATION OF STATE REQUIREMENT TO MAKE SUPPLEMENTAL PAYMENT.— Nothing in subclause (I) or subparagraph (A) or 

(B) shall be construed as waiving the application 

of section 1902(bb)(5) regarding the State plan requirement to make any supplemental payment due 

under such section to a Federally-qualified health 

center for services furnished by such center to an 

enrollee of a managed care entity (regardless of 

whether the Federally-qualified health center is or 

is not a participating provider with the entity). ‘‘(ii) CONTINUED APPLICATION OF ENCOUNTER RATE

FOR SERVICES PROVIDED BY CERTAIN INDIAN HEALTH

CARE PROVIDERS.—If the amount paid by a managed 

care entity to an Indian health care provider that is 

not a Federally-qualified health center and that has 

elected to receive payment under this title as an Indian 

Health Service provider under the July 11, 1996, 

Memorandum of Agreement between the Health Care 

Financing Administration (now the Centers for Medicare & Medicaid Services) and the Indian Health Service for services provided by such provider to an Indian 


bajohnson on PROD1PC71 with REPORTS
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enrollee with the managed care entity is less than the 

encounter rate that applies to the provision of such 

services under such memorandum, the State plan shall 

provide for payment to the Indian health care provider 

of the difference between the applicable encounter rate 

under such memorandum and the amount paid by the 

managed care entity to the provider for such services. ‘‘(F) CONSTRUCTION.—Nothing in this paragraph shall be 

construed as waiving the application of section 

1902(a)(30)(A) (relating to application of standards to assure that payments are consistent with efficiency, economy, 

and quality of care). ‘‘(3) OFFERING OF MANAGED CARE THROUGH INDIAN MEDICAID

MANAGED CARE ENTITIES.—If—

‘‘(A) a State elects to provide services through Medicaid 

managed care entities under its Medicaid managed care 

program; and 

‘‘(B) an Indian health care provider that is funded in 

whole or in part by the Indian Health Service, or a consortium composed of 1 or more Tribes, Tribal Organizations, 

or Urban Indian Organizations, and which also may include the Indian Health Service, has established an Indian 

Medicaid managed care entity in the State that meets generally applicable standards required of such an entity 

under such Medicaid managed care program, the State 

shall offer to enter into an agreement with the entity to 

serve as a Medicaid managed care entity with respect to eligible Indians served by such entity under such program. 

‘‘(4) SPECIAL RULES FOR INDIAN MANAGED CARE ENTITIES.—

The following are special rules regarding the application of a 

Medicaid managed care program to Indian Medicaid managed 

care entities: 

‘‘(A) ENROLLMENT.— ‘‘(i) LIMITATION TO INDIANS.—An Indian Medicaid 

managed care entity may restrict enrollment under 

such program to Indians and to members of specific 

Tribes in the same manner as Indian Health Programs 

may restrict the delivery of services to such Indians 

and tribal members. 

‘‘(ii) NO LESS CHOICE OF PLANS.—Under such program the State may not limit the choice of an Indian 

among Medicaid managed care entities only to Indian 

Medicaid managed care entities or to be more restrictive than the choice of managed care entities offered to 

individuals who are not Indians. 

‘‘(iii) DEFAULT ENROLLMENT.—

‘‘(I) IN GENERAL.—If such program of a State requires the enrollment of Indians in a Medicaid 

managed care entity in order to receive benefits, 

the State, taking into consideration the criteria 

specified in subsection (a)(4)(D)(ii)(I), shall provide 

for the enrollment of Indians described in subclause (II) who are not otherwise enrolled with 

such an entity in an Indian Medicaid managed 

care entity described in such clause. 


bajohnson on PROD1PC71 with REPORTS
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‘‘(II) INDIAN DESCRIBED.—An Indian described in 

this subclause, with respect to an Indian Medicaid 

managed care entity, is an Indian who, based 

upon the service area and capacity of the entity, is 

eligible to be enrolled with the entity consistent 

with subparagraph (A). 

‘‘(iv) EXCEPTION TO STATE LOCK-IN.—A request by an 

Indian who is enrolled under such program with a 

non-Indian Medicaid managed care entity to change 

enrollment with that entity to enrollment with an Indian Medicaid managed care entity shall be considered 

cause for granting such request under procedures specified by the Secretary. 

‘‘(B) FLEXIBILITY IN APPLICATION OF SOLVENCY.—In applying section 1903(m)(1) to an Indian Medicaid managed 

care entity—

‘‘(i) any reference to a ‘State’ in subparagraph (A)(ii) 

of that section shall be deemed to be a reference to the 

‘Secretary’; and 

‘‘(ii) the entity shall be deemed to be a public entity 

described in subparagraph (C)(ii) of that section. 

‘‘(C) EXCEPTIONS TO ADVANCE DIRECTIVES.—The Secretary may modify or waive the requirements of section 

1902(w) (relating to provision of written materials on advance directives) insofar as the Secretary finds that the requirements otherwise imposed are not an appropriate or effective way of communicating the information to Indians. 

‘‘(D) FLEXIBILITY IN INFORMATION AND MARKETING.—

‘‘(i) MATERIALS.—The Secretary may modify requirements under subsection (a)(5) to ensure that information described in that subsection is provided to enrollees and potential enrollees of Indian Medicaid managed care entities in a culturally appropriate and understandable manner that clearly communicates to 

such enrollees and potential enrollees their rights, protections, and benefits. 

‘‘(ii) DISTRIBUTION OF MARKETING MATERIALS.—The 

provisions of subsection (d)(2)(B) requiring the distribution of marketing materials to an entire service 

area shall be deemed satisfied in the case of an Indian 

Medicaid managed care entity that distributes appropriate materials only to those Indians who are potentially eligible to enroll with the entity in the service 

area. 

ø§ 1680h. Demonstration projects for tribal management of 

health care services¿ 

‘‘(5) MALPRACTICE INSURANCE.—Insofar as, under a Medicaid managed care program, a health care provider is required to have medical malpractice insurance coverage as 

a condition of contracting as a provider with a Medicaid 

managed care entity, an Indian health care provider that 

is—

ø(a) Establishment; grants 


bajohnson on PROD1PC71 with REPORTS
305 

ø(1) The Secretary, acting through the Service, shall make 

grants to Indian tribes to establish demonstration projects 

under which the Indian tribe will develop and test a phased 

approach to assumption by the Indian tribe of the health care 

delivery system of the Service for members of the Indian tribe 

living on or near the reservations of the Indian tribe through 

the use of Service, tribal, and private sector resources. 

ø(2) A grant may be awarded to an Indian tribe under paragraph (1) only if the Secretary determines that the Indian tribe 

has the administrative and financial capabilities necessary to 

conduct a demonstration project described in paragraph (1). 

ø(b) Health care contracts 

øDuring the period in which a demonstration project established 

under subsection (a) of this section is being conducted by an Indian 

tribe, the Secretary shall award all health care contracts, including 

community, behavioral, and preventive health care contracts, to the 

Indian tribe in the form of a single grant to which the regulations 

prescribed under part A of title XIX of the Public Health Service 

Act [42 U.S.C.A. § 300w et seq.] (as modified as necessary by any 

agreement entered into between the Secretary and the Indian tribe 

to achieve the purposes of the demonstration project established 

under subsection (a) of this section) shall apply. 

ø(c) Waiver of procurement laws 

øThe Secretary may waive such provisions of Federal procurement law as are necessary to enable any Indian tribe to develop 

and test administrative systems under the demonstration project 

established under subsection (a) of this section, but only if such 

waiver does not diminish or endanger the delivery of health care 

services to Indians. 

ø(d) Termination; evaluation and report 

ø(1) The demonstration project established under subsection 

(a) of this section shall terminate on September 30, 1993, or, 

in the case of a demonstration project for which a grant is 

made after September 30, 1990, three years after the date on 

which such grant is made. 

ø(2) By no later than September 30, 1996, the Secretary 

shall evaluate the performance of each Indian tribe that has 

participated in a demonstration project established under subsection (a) of this section and shall submit to the Congress a 

report on such evaluations and demonstration projects. 

ø(e) Joint venture demonstration projects 

ø(1) The Secretary, acting through the Service, shall make 

arrangements with Indian tribes to establish joint venture 

demonstration projects under which an Indian tribe shall expend tribal, private, or other available nontribal funds, for the 

acquisition or construction of a health facility for a minimum 

of 20 years, under a no-cost lease, in exchange for agreement 

by the Service to provide the equipment, supplies, and staffing 

for the operation and maintenance of such a health facility. A 

tribe may utilize tribal funds, private sector, or other available 

resources, including loan guarantees, to fulfill its commitment 

under this subsection. 

ø(2) The Secretary shall make such an arrangement with an 

Indian tribe only if the Secretary first determines that the Indian tribe has the administrative and financial capabilities 


bajohnson on PROD1PC71 with REPORTS
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necessary to complete the timely acquisition or construction of 

the health facility described in paragraph (1). 

ø(3) An Indian tribe or tribal organization that has entered 

into a written agreement with the Secretary under this subsection, and that breaches or terminates without cause such 

agreement, shall be liable to the United States for the amount 

that has been paid to the tribe, or paid to a third party on the 

tribe’s behalf, under the agreement. The Secretary has the 

right to recover tangible property (including supplies), and 

equipment, less depreciation, and any funds expended for operations and maintenance under this section. The preceding sentence does not apply to any funds expended for the delivery of 

health care services, or for personnel or staffing, shall be recoverable.¿ 

‘‘(A) a Federally-qualified health center that is covered 

under the Federal Tort Claims Act (28 U.S.C. 1346(b), 

2671 et seq.); 

ø§ 1680i. Child sexual abuse treatment programs¿ 

‘‘(B) providing health care services pursuant to a contract 

or compact under the Indian Self-Determination and Education Assistance Act (25 U.S.C. 450 et seq.) that are covered under the Federal Tort Claims Act (28 U.S.C. 1346(b), 

2671 et seq.); or 

ø(a) Continuation of existing demonstration programs 

øThe Secretary and the Secretary of the Interior shall, for each 

fiscal year through fiscal year 1995, continue the demonstration 

programs involving treatment for child sexual abuse provided 

through the Hopi Tribe and the Assiniboine and Sioux Tribes of the 

Fort Peck Reservation. 

ø(b) Establishment of new demonstration programs 

øBeginning October 1, 1995, the Secretary and the Secretary of 

the Interior may establish, in any service area, demonstration programs involving treatment for child sexual abuse, except that the 

Secretaries may not establish a greater number of such programs 

in one service area than in any other service area until there is an 

equal number of such programs established with respect to all 

service areas from which the Secretary receives qualified applications during the application period (as determined by the Secretary).¿ 

‘‘(C) the Indian Health Service providing health care 

services that are covered under the Federal Tort Claims Act 

(28 U.S.C. 1346(b), 2671 et seq.); 

ø§ 1680j. Tribal leasing¿ 

are deemed to satisfy such requirement. 

øIndian tribes providing health care services pursuant to a contract entered into under the Indian Self-Determination Act [25 

U.S.C.A. § 450f et seq.] may lease permanent structures for the 

purpose of providing such health care services without obtaining 

advance approval in appropriation Acts.¿ 

‘‘(6) DEFINITIONS.—For purposes of this subsection: 


bajohnson on PROD1PC71 with REPORTS
307 

ø§ 1680k. Home- and community-based care demonstration 

project¿ 

‘‘(A) INDIAN HEALTH CARE PROVIDER.—The term ‘Indian 

health care provider’ means an Indian Health Program or 

an Urban Indian Organization. 

ø(a) Authority of Secretary 

øThe Secretary, acting through the Service, is authorized to 

enter into contracts with, or make grants to, Indian tribes or tribal 

organizations providing health care services pursuant to a contract 

entered into under the Indian Self-Determination Act [25 U.S.C.A. 

§ 450f et seq.], to establish demonstration projects for the delivery 

of home- and community-based services to functionally disabled Indians. 

ø(b) Use of funds 

ø(1) Funds provided for a demonstration project under this 

section shall be used only for the delivery of home- and community-based services (including transportation services) to 

functionally disabled Indians. 

ø(2) Such funds may not be used— ø(A) to make cash payments to functionally disabled Indians; 

ø(B) to provide room and board for functionally disabled 

Indians; 

ø(C) for the construction or renovation of facilities or the 

purchase of medical equipment; or 

ø(D) for the provision of nursing facility services. 

ø(c) Criteria for approval of applications 

øNot later than 180 days after October 29, 1992, the Secretary, 

after consultation with Indian tribes and tribal organizations, shall 

develop and issue criteria for the approval of applications submitted under this section. Such criteria shall ensure that demonstration projects established under this section promote the development of the capacity of tribes and tribal organizations to deliver, or arrange for the delivery of, high quality, culturally appropriate home- and community-based services to functionally disabled 

Indians; 

ø(d) Assistance to applicants 

øThe Secretary shall provide such technical and other assistance 

as may be necessary to enable applicants to comply with the provisions of this section. 

ø(e) Services to ineligible persons 

øAt the discretion of the tribe or tribal organization, services provided under a demonstration project established under this section 

may be provided (on a cost basis) to persons otherwise ineligible for 

the health care benefits of the Service. 

ø(f) Maximum number of demonstration projects 

øThe Secretary shall establish not more than 24 demonstration 

projects under this section. The Secretary may not establish a 

greater number of demonstration projects under this section in one 

service area than in any other service area until there is an equal 

number of such demonstration projects established with respect to 

all service areas from which the Secretary receives applications 

during the application period (as determined by the Secretary) 

which meet the criteria issued pursuant to subsection (c) of this 

section. 


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308 

ø(g) Report 

øThe Secretary shall submit to the President, for inclusion in the 

report which is required to be submitted under section 1671 of this 

title for fiscal year 1999, a report on the findings and conclusions 

derived from the demonstration projects conducted under this section, together with legislative recommendations. 

ø(h) Definitions 

øFor the purposes of this section, the following definitions shall 

apply: 

ø(1) The term ‘‘home- and community-based services’’ means 

one or more of the following: 

ø(A) Homemaker/home health aide services. 

ø(B) Chore services. 

ø(C) Personal care services. 

ø(D) Nursing care services provided outside of a nursing 

facility by, or under the supervision of, a registered nurse. 

ø(E) Respite care. 

ø(F) Training for family members in managing a functionally disabled individual. 

ø(G) Adult day care. 

ø(H) Such other home- and community-based services as 

the Secretary may approve. 

ø(2) The term ‘‘functionally disabled’’ means an individual 

who is determined to require home- and community-based 

services based on an assessment that uses criteria (including, 

at the discretion of the tribe or tribal organization, activities 

of daily living) developed by the tribe or tribal organization. 

ø(i) Authorization of appropriations 

øThere are authorized to be appropriated for each of the fiscal 

years 1996 through 2000 such sums as may be necessary to carry 

out this section. Such sums shall remain available until expended.¿ 

‘‘(B) INDIAN; INDIAN HEALTH PROGRAM; SERVICE; TRIBE; 

TRIBAL ORGANIZATION; URBAN INDIAN ORGANIZATION.—The 

terms ‘Indian’, ‘Indian Health Program’, ‘Service’, ‘Tribe’, 

‘tribal organization’, ‘Urban Indian Organization’ have the 

meanings given such terms in section 4 of the Indian 

Health Care Improvement Act. 

ø§ 1680l. Shared services demonstration project¿ 

‘‘(C) INDIAN MEDICAID MANAGED CARE ENTITY.—The term 

‘Indian Medicaid managed care entity’ means a managed 

care entity that is controlled (within the meaning of the last 

sentence of section 1903(m)(1)(C)) by the Indian Health 

Service, a Tribe, Tribal Organization, or Urban Indian Organization, or a consortium, which may be composed of 1 

or more Tribes, Tribal Organizations, or Urban Indian Organizations, and which also may include the Service. 

ø(a) Authority of Secretary 

øThe Secretary, acting through the Service and notwithstanding 

any other provision of law, is authorized to enter into contracts 

with Indian tribes or tribal organizations to establish not more 

than 6 shared services demonstration projects for the delivery of 

long-term care to Indians. Such projects shall provide for the sharing of staff or other services between a Service facility and a nursVerDate Aug 31 2005 01:51 Oct 27, 2007 Jkt 069010 PO 00000 Frm 00308 Fmt 6659 Sfmt 6602 E:\HR\OC\SR197.XXX SR197

bajohnson on PROD1PC71 with REPORTS
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ing facility owned and operated (directly or by contract) by such Indian tribe or tribal organization. 

ø(b) Contract requirements 

øA contract entered into pursuant to subsection (a) of this section—

ø(1) may, at the request of the Indian tribe or tribal organization, delegate to such tribe or tribal organization such powers of supervision and control over Service employees as the 

Secretary deems necessary to carry out the purposes of this 

section; 

ø(2) shall provide that expenses (including salaries) relating 

to services that are shared between the Service facility and the 

tribal facility be allocated proportionately between the Service 

and the tribe or tribal organization; and 

ø(3) may authorize such tribe or tribal organization to construct, renovate, or expand a nursing facility (including the 

construction of a facility attached to a Service facility), except 

that no funds appropriated for the Service shall be obligated or 

expended for such purpose. 

ø(c) Eligibility 

øTo be eligible for a contract under this section, a tribe or tribal 

organization, shall, as of October 29, 1992—

ø(1) own and operate (directly or by contract) a nursing facility; 

ø(2) have entered into an agreement with a consultant to develop a plan for meeting the long-term needs of the tribe or 

tribal organization; or 

ø(3) have adopted a tribal resolution providing for the construction of a nursing facility. 

ø(d) Nursing facilities 

øAny nursing facility for which a contract is entered into under 

this section shall meet the requirements for nursing facilities under 

section 1396r of Title 42. 

ø(e) Assistance to applicants 

øThe Secretary shall provide such technical and other assistance 

as may be necessary to enable applicants to comply with the provisions of this section. 

ø(f) Report 

øThe Secretary shall submit to the President, for inclusion in 

each report required to be transmitted to the Congress under section 1671 of this title, a report on the findings and conclusions derived from the demonstration projects conducted under this section.¿ 

‘‘(D) NON-INDIAN MEDICAID MANAGED CARE ENTITY.—The 

term ‘non-Indian Medicaid managed care entity’ means a 

managed care entity that is not an Indian Medicaid managed care entity. 

ø§ 1680m. Results of demonstration projects¿ 

‘‘(E) COVERED MEDICAID MANAGED CARE SERVICES.—The 

term ‘covered Medicaid managed care services’ means, with 

respect to an individual enrolled with a managed care entity, items and services that are within the scope of items 

and services for which benefits are available with respect to 


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the individual under the contract between the entity and 

the State involved. 

øThe Secretary shall provide for the dissemination to Indian 

tribes of the findings and results of demonstration projects conducted under this chapter.¿ 

‘‘(F) MEDICAID MANAGED CARE PROGRAM.—The term 

‘Medicaid managed care program’ means a program under 

sections 1903(m) and 1932 and includes a managed care 

program operating under a waiver under section 1915(b) or 

1115 or otherwise.’’. 

ø§ 1680n. Priority for Indian reservations¿ 

(b) APPLICATION TO SCHIP.—Section 2107(e)(1) of such Act (42 

U.S.C. 1397gg(1)), as amended by section 206(b)(2), is amended by 

adding at the end the following new subparagraph: 

ø(a) Facilities and projects 

øBeginning on October 29, 1992, the Bureau of Indian Affairs 

and the Service shall, in all matters involving the reorganization 

or development of Service facilities, or in the establishment of related employment projects to address unemployment conditions in 

economically depressed areas, give priority to locating such facilities and projects on Indian lands if requested by the Indian tribe 

with jurisdiction over such lands. 

ø(b) ‘‘Indian lands’’ defined 

øFor purposes of this section, the term ‘‘Indian lands’’ means—

ø(1) all lands within the limits of any Indian reservation; 

and 

ø(2) any lands title which is held in trust by the United 

States for the benefit of any Indian tribe or individual Indian, 

or held by any Indian tribe or individual Indian subject to restriction by the United States against alienation and over 

which an Indian tribe exercises governmental power.¿ 

‘‘(H) Subsections (a)(2)(C) and (h) of section 1932.’’. 

ø§ 1680o. Authorization of appropriations¿ 

SEC. 209. ANNUAL REPORT ON INDIANS SERVED BY SOCIAL SECURITY 

ACT HEALTH BENEFIT PROGRAMS. 

øExcept as provided in section 1680k of this title, there are authorized to be appropriated such sums as may be necessary for 

each fiscal year through fiscal year 2000 to carry out this subchapter.¿ 

Section 1139 of the Social Security Act (42 U.S.C. 1320b–9), as 

amended by the sections 202, 205, and 206, is amended by redesignating subsection (e) as subsection (f), and inserting after subsection 

(d) the following new subsection: 

ø§ 1681. Billing of Indians by Indian Health Service¿ 

‘‘(e) ANNUAL REPORT ON INDIANS SERVED BY HEALTH BENEFIT

PROGRAMS FUNDED UNDER THIS ACT.—Beginning January 1, 2007, 

and annually thereafter, the Secretary, acting through the Administrator of the Centers for Medicare & Medicaid Services and the Director of the Indian Health Service, shall submit a report to Congress regarding the enrollment and health status of Indians receiving items or services under health benefit programs funded under 


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this Act during the preceding year. Each such report shall include 

the following: 

øThe Indian Health Service shall neither bill nor charge those 

Indians who may have the economic means to pay unless and until 

such time as Congress has agreed upon a specific policy to do so 

and has directed the Indian Health Service to implement such a 

policy.¿ 

‘‘(1) The total number of Indians enrolled in, or receiving 

items or services under, such programs, disaggregated with respect to each such program. 

ø§ 1682. Subrogation of claims by¿ 

‘‘(2) The number of Indians described in paragraph (1) that 

also received health benefits under programs funded by the Indian Health Service. øHereafter the Indian Health Service may seek subrogation of 

claims including but not limited to auto accident claims, including 

no-fault claims, personal injury, disease, or disability claims, and 

worker’s compensation claims, the proceeds of which shall be credited to the funds established by sections 401 and 402 of the Indian 

Health Care Improvement Act.¿ ‘‘(3) General information regarding the health status of the 

Indians described in paragraph (1), disaggregated with respect 

to specific diseases or conditions and presented in a manner 

that is consistent with protections for privacy of individually 

identifiable health information under section 264(c) of the 

Health Insurance Portability and Accountability Act of 1996. 

ø§ 1683. Indian Catastrophic Health Emergency Fund¿ 

‘‘(4) A detailed statement of the status of facilities of the Indian Health Service or an Indian Tribe, Tribal Organization, 

or an Urban Indian Organization with respect to such facilities’ compliance with the applicable conditions and requirements of 

titles XVIII, XIX, and XXI, and, in the case of title XIX or XXI, 

under a State plan under such title or under waiver authority, 

and of the progress being made by such facilities (under plans 

submitted under section 1880(b), 1911(b) or otherwise) toward 

the achievement and maintenance of such compliance. 

ø$10,000,000 shall remain available until expended, for the establishment of an Indian Catastrophic Health Emergency Fund 

(hereinafter referred to as the ‘‘Fund’’). Hereafter, the Fund is to 

cover the Indian Health Service portion of the medical expenses of 

catastrophic illness falling within the responsibility of the Service 

and shall be administered by the Secretary of Health and Human 

Services, acting through the central office of the Indian Health 

Service. No part of the Fund or its administration shall be subject 

to contract or grant under the Indian Self-Determination and Education Assistance Act (Public Law 93–638). There shall be deposited into the Fund all amounts recovered under the authority of the 

Federal Medical Care Recovery Act (42 U.S.C. 2651 et seq.), which 

shall become available for obligation upon receipt and which shall 

remain available for obligation until expended. The Fund shall not 

be used to pay for health services provided to eligible Indians to 

the extent that alternate Federal, State, local, or private insurance 

resources for payment: (1) are available and accessible to the beneVerDate Aug 31 2005 01:51 Oct 27, 2007 Jkt 069010 PO 00000 Frm 00311 Fmt 6659 Sfmt 6602 E:\HR\OC\SR197.XXX SR197

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ficiary; or (2) would be available and accessible if the beneficiary 

were to apply for them; or (3) would be available and accessible to 

other citizens similarly situated under Federal, State, or local law 

or regulation or private insurance program notwithstanding Indian 

Health Service eligibility or residency on or off a Federal Indian 

reservation.¿ ‘‘(5) Such other information as the Secretary determines is appropriate.’’. 

Æ 


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