49–010 

1 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 those threats.’’ U.S. Department of Health and Human Services, www.healthypeople.gov (last reviewed November 8, 2005). 

Calendar No. 375 

109TH CONGRESS REPORT " ! SENATE 2d Session 109–222 

INDIAN HEALTH CARE IMPROVEMENT ACT AMENDMENTS 

OF 2005 

MARCH 16 (legislative day, MARCH 15), 2006.—Ordered to be printed 

Mr. MCCAIN, from the Committee on Indian Affairs, 

submitted the following 

R E P O R T 

[To accompany S. 1057] 

The Senate Committee on Indian Affairs, to which was referred 

the bill (S. 1057), to amend the Indian Health Care Improvement 

Act to revise and extend that Act, having considered the same, reports favorably thereon with an amendment in the nature of a substitute and recommends that the bill, as amended, do pass. 

PURPOSE

The purpose of the Indian Health Care Improvement Act Amendments of 2005 (S. 1057) is to reauthorize the Act and improve the 

Indian health care delivery system. This legislation is intended to 

raise the health status of American Indians and Alaska Natives to 

the highest possible level in accordance with Healthy People 2010.1

S. 1057 sets forth policies, programs and procedures designed to 

address health care deficiencies in native and urban Indian communities and streamline service delivery to those communities. In 

addition, S. 1057 addresses the health problems and associated 

socio-economic conditions in native communities by authorizing the 

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


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2S. 2526 (106th Congress), S. 212 (107th Congress), S. 556 (108th 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. 

THE REAUTHORIZATION PROCESS

The work on the latest reauthorization began in 1999. Bills have 

been introduced since the 106th Congress 2 to enact a series of improvements and updates to current law, most of which are contained in S. 1057. 

NATIONAL STEERING COMMITTEE (NSC)

In June, 1999, the Director of the IHS convened the NSC comprised of tribal leaders and representatives from Indian health organizations to facilitate the 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 

the 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, but 

S. 212 did receive significant attention from the Administration. 

By letter dated September 27, 2001, the Administration provided 

its views on S. 212 to the Committee. During 2002, tribal officials 

and Committee staff reconvened to address the Administration’s 

concerns. The legislation was not passed by Congress that year, 

and S. 556 was introduced in the next Congress. 

During the 108th Congress, the Committee, the NSC and the Administration engaged in extensive negotiations over the reauthorization, but a final bill was not concluded before the 108th Congress ended. Several recommendations developed during these negotiations were incorporated into S. 1057. 

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 on prior legislation. See e.g., Senate 

Report Nos. 94–133, 102–392 and 108–411. 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 was needed to ensure improvements were 

achieved in Indian health status and services. 


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3The responsibility for Indian health first fell 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. See Task Force on Indian Health in the Final Report to the 

American Indian Policy Review Commission (Final Report) at 32. 4 Based on the U.S. Constitution, treaties, statutes and the historical, political and legal relationship with the Indian tribes, the United States has assumed responsibility for the provision 

of health care to Indian people. Those laws and relationships serve as the backdrop for the government-to-government relationship. 5S. Rep. No. 94–133, at 36 (1976). 6 Id. 

7 Id. 

8 Id., at 55. 

9 Headlands Indian Health Careers, Program History, available at http://www.headlands. 

ouhsc.edu/history.asp (Last reviewed December 14, 2005). 10S. Rep. No. 94–133, at 42 (1976). 11S. Rep. No. 94–133, at 36–37 (1976). 

The administration of Indian health had initially been managed 

in a piecemeal approach, then ultimately coalesced within the IHS, 

an agency of the DHHS.3

Based on that history and in fulfillment of the special obligation 

to Indian people,4 Congress passed the Act to provide coordinated 

programs and meaningful direction in Indian health care administration. 

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. The Senate Report accompanying S. 522, the Indian Health 

Care Improvement Act, which was signed into law as Public Law 

No. 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.’’ 5

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.’’ 6 Also 

troubling was the infant mortality rate for Indian babies which was 

significantly higher than the national average.7

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 

Indian communities. The available information indicated that out 

of 500 doctors in the Indian Health Service, only 3 were Indian.8

Overall, ‘‘in 1975, there were only 72 American Indian physicians.’’ 9 Likewise, only half of the number of pharmacists needed 

were employed in these Indian communities.10

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.’’ 11 The 

Joint Committee on Accreditation of Hospitals (JCAHO) found that 

‘‘only 24 of the 51 existing IHS hospitals’’ met accreditation standVerDate Aug 31 2005 11:50 Mar 23, 2006 Jkt 049010 PO 00000 Frm 00003 Fmt 6659 Sfmt 6602 E:\HR\OC\SR222.XXX SR222

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12 Id., at 37. 13 Id. 14 U.S. Department of Health and Human Services, Indian Health Service, 2000–2001 Trends 

in Indian Health, at 7. 15 U.S. Department of Health and Human Services, Indian Health Service, 2000–2001 Trends 

in Indian Health, at 49. 16 U.S. Department of Health and Human Services, Indian Health Service, Fiscal Year 2006, 

Justification of Estimates for Appropriations Committees, at IHS–81. 17 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. 

ards and ‘‘two-thirds [were] obsolete and that 22 need[ed] complete 

replacement.’’ 12

Funding. The funding situation 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.’’ 13

Thus, the goals of the Act, by improving funding, direction in 

programs, and access to other programs such as Medicare and 

Medicaid, held great promise for the advancement of Indian health. 

CURRENT INDIAN HEALTH SYSTEM

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

the amendments thereto. Yet, a comparison of historic statistics 

with current status indicators show that, while real progress has 

been made, significant disparities still persist. 

Indian health status. Indian mortality rates from tuberculosis 

were 400% greater than other U.S. populations.14 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.15 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 2001, the overall ‘‘prevalence of diabetes increased by 33% in all major regions served by 

the Indian Health Service.’’ The most alarming increase, however, 

occurred among the Indian youth ages 15–19, for whom diabetes 

increased by 106% from 1990–2002.16

Recent information on suicide indicates that these rates are also 

astonishing. 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. 

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. 

Yet, in terms of services at several Indian health facilities, the 

demand for mental health care outstripped their capacity.17 In at 


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18GAO Report No. GAO–05–789, at 18. 19 U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Office of Applied Studies, The NSDUH Report, September 16, 2005, http:// 

oas.samhsa.gov/2k5/meth/meth.htm, (Last reviewed on December 2, 2005). 20 U.S. Department of Health and Human Services, Indian Health Service, Fiscal Year 2006, 

Justification of Estimates for Appropriations Committees, at IHS–5. 21GAO Report No. GAO–05–789, at 9. 22 Id. 23 Id. 24 U.S. Department of Health and Human Services, Indian Health Service, Health Care Facilities FY 2007 Planned Construction Budget (February 11, 2005). 25 U.S. Department of Health and Human Services, Indian Health Service, Fiscal Year 2006, 

Justification of Estimates for Appropriations Committees, at IHF–4. 26 Id., at IHS–5. 27 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 2004, at 1. 28 Id., at 20. 29 Id. 30 Id. 

least one facility, the mental health services would be cut by 20% 

in FY 2005 because funding had been depleted.18

Another alarming and growing problem arising in Indian communities is the use of methamphetamines. According to the National 

Survey on Drug Use and Health, the use rate during a 2002–2004 

survey period among Indians, aged 12 and older, is higher than 

nearly every other population.19

Health facilities. According to the most recent data, 413 facilities 

exist within the Indian health system with an average age of 30 

years.20 Approximately 49 of those facilities are hospitals ranging 

in capacity from 4 to 156 beds, but only 19 of the hospitals have 

operating rooms.21

Besides hospitals, ‘‘there were 231 health centers * * * offering 

primary care and some ancillary services such as pharmacy, laboratory and X-ray’’.22 Also, the 133 health stations in the Indian 

health system provided primary services.23

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

$1.5 billion as of FY 2005.24 In addition, the backlog for the maintenance and improvement needs of current facilities was estimated 

at $482,956,000.25 However, on the bright side, ‘‘[f]ully 100 percent 

of IHS hospitals and health clinics met accreditation standards in 

FY 2004.’’ 26

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 265,000 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.’’ 27

The IHS noted that ‘‘in 1955, more than 80% of American Indians and Alaska Natives were living in homes without essential 

sanitation facilities.’’ 28 The gastrointestinal death rate was ‘‘15.4 

per 100,000 population, * * * 4.3 times higher than that for all 

other races in the United States.’’ 29 But by 1995, that death rate 

was reduced to 1.7 per 100,000, although it is still 38–40% higher 

than the rate for all races in the United States.30

In FY 2004, approximately $139 million was available for sanitation facilities construction, of which nearly $93 million came from 

Indian Health Service funds and more than $46.5 million came 


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31 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 2004, at 5. 32 Id. 33 U.S. Department of Health and Human Services, Indian Health Service, Justification of Estimates for Appropriations Committees for Fiscal Year 2006, p. IHF–9 and 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 2003. 34 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. 35 Hearings on Interior, Environment and Related Agencies Appropriations for 2006 Before the 

U.S. House of Representatives, Committee on Appropriations, 109th Cong., 1st Sess., April 14, 

2005, at 278–279. 36 U.S. Department of Health and Human Services, Indian Health Service, Fiscal Year 2006, 

Justification of Estimates for Appropriations Committees, at IHS–3. 37GAO Report No. GAO–05–789, at 15. 38 Id., at 19. 39 Id. 

from other Federal agencies and non-Federal sources.31 The Indian 

Health Service estimated that in FY 2004 sanitation facilities were 

provided to a total of 24,928 homes.32 However, the total estimated 

costs to address the sanitation deficiencies in existing homes was 

nearly $1.9 billion, with nearly 150,000 Indian homes still needing 

sanitation facilities, 36,000 of which did not have potable water.33

Health professionals. The number of Indian health professionals 

has increased since the Act was 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.34 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 vacancy rates for health professions 

with the greatest shortfalls consist of Dentists (24%), Certified Registered Nurse Anesthetists (33%), Medical Imaging (including xrays, ultrasounds, CT scans etc.) (20%), Nurses (14%) Pharmacists 

and Physicians (both 11%).35

Types and level of services. The IHS and tribal and urban Indian 

health programs provide an array of basic medical, dental and vision services. For example, the personal health 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.36

Even though basic services may be available, access to those 

services is not assured. In its study on the availability of health 

services to Indians, the Government Accountability Office (GAO) 

found that Indian patients often had to wait more than 30 days— in some cases 2 to 6 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.’’ 37

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.’’ 38 For example, in some cases, adult Indian 

patients ‘‘could wait as long as 120 days to get approval for eyeglasses.’’ 39

According to one tribal official interviewed by the GAO, these situations create an environment in which Indian patients become deVerDate Aug 31 2005 11:50 Mar 23, 2006 Jkt 049010 PO 00000 Frm 00006 Fmt 6659 Sfmt 6602 E:\HR\OC\SR222.XXX SR222

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40 Id., at 16. 41GAO Report No. GAO–05–789, at 21. 42President’s Special Message to Congress on Indian Affairs, 213 Pub. Papers 564 (July 8, 

1970). 43 Id., at 565. 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. 

moralized and may wait until their condition becomes ‘‘an emergency that required a higher level of treatment.’’ 40 The GAO also 

noted that gaps in care were common. 

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.’’ 41 The Committee is further concerned that these gaps are 

increasing health care costs and diminishing 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 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. 1057 for programs and policies, 

the Bi-partisan Commission study on health service delivery, and 

other new provisions in S. 1057 are designed to help address these 

problems. 

THE INDIAN HEALTH CARE IMPROVEMENT ACT

In passing the Act, Congress set forth ambitious goals for improving the health of Indians, including encouraging their 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.’’ Senate Report No. 94–133, at 13. 

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 tribes, rather than solely 

in the agency’s hands, was a fundamental and logical approach in 

health care delivery. Such a modification took several years to 

overcome difficulties in achieving tribal participation in the administration of these programs.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), U.S.C. 450 et seq. 

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45 U.S. Department of Health and Human Services, Indian Health Service, Fiscal Year 2006, 

Justification of Estimates for Appropriations Committees. 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. 48The Indian Health Care Improvement Act Amendments of 2005: Hearings on S. 1057 Before 

the Senate Comm. on Indian Affairs and Senate Comm. 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). 

determination, but generates a higher level of cooperation between 

the Indian health providers.45

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 evolved. As a general matter, 

the history of Indian health and the interplay between the ISDEAA 

and the Act must be kept in mind when developing 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 services 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 participation is critical in the development of the framework of these programs and services. Tribal selfdetermination involves tribes initiating programs, and the ideas, 

concepts and methodology of how those programs or services should 

be delivered to their own communities. 

Such involvement means appreciable engagement between the 

agency and Indian tribes. Numerous tools have successfully increased that involvement. For example, negotiated rulemaking 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 service 

delivery. 

The Administration has expressed concerns about the time and 

resource constraints involved in negotiated rulemaking. The Committee strongly supports fiscal accountability, but believes that the 

long-term benefits of negotiated rulemaking exceed the short-term 

costs. 

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 govern them. Tribal involvement in rulemaking not only leads 

to a more informed rule, but it fosters tribal support. 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 


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49See e.g., http://www.hhs.gov/iga/tribal/0506lbudgetlsessionltranscript.doc, (Last reviewed December 12, 2005), and http://www.hhs.gov/iga/tribal/9707.html, (Last reviewed December 9, 2005), but see http://www.npaihb.org/legis/IHS%20Budget/Budg- etlIntrolPage.htm, (Last reviewed December 9, 2005). 50 U.S. Department of Health and Human Services, Department Tribal Consultation Policy, 

January, 2005, available at http://www.hhs.gov/ofta/docs/FnlCnsltPlcywl.pdf. (Last reviewed 

December 15, 2005). 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 

involving which programs and professions to implement, sometimes two years in advance of implementation. 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. 

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. 

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

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.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 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. 

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, the Committee has provided for robust consultation in 

several key areas, leaving the manner of consultation to Secretarial 

discretion, and it remains committed to promoting tribal input by 

institutionalizing consultation. 

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, 

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 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 understands 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, 


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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. 

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. 

In the past, the Committee has been apprehensive about eliminating certain mandates such as those requiring studies. In reviewing the studies conducted and annual reporting information, it appears that quite a few studies mandated by the Act were not completed. These studies were intended to provide insight into the accomplishments and challenges in Indian health and assist the 

Committee 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 mandates in current law have been disregarded. 

Consequently, the Committee has included in S. 1057, a Bi-partisan Commission to thoroughly review opportunities for improvement. During the 108th Congress, the bill to reauthorize the Act, 

S. 556, contained provisions wherein the Bi-partisan Commission 

would 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 in S. 1057. 

In addition, the Committee has included 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 Indian health, but is intended 

to complement the federal obligation in ways in which the United 

States has fallen short. 

Oversight and Reporting. While much discretion and flexibility is 

provided, 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 and provisions of S. 1057 are particularly noteworthy: 

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. * * *’’ Senate Report No. 94–133, at 23. 

Providing services to Indian people improves the health of Indians 

in a direct manner. 


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54See American Indian Policy Review Commission, Task Force Six, Final Report to the Commission, Vol. 6. 55S. Hrg 109–162, at 589 (statement of Dr. Grim, Director, U.S. Department of Health and 

Human Services, Indian Health Service). 

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.54 Now the tables are turned. 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’’ and ‘‘including new approaches to delivering care’’.55 Serving non-eligibles has been a policy of the Act for many years 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. 1057). 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. 1057). 

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

tribes to address prior to providing the services—the ‘‘two-part determination’’. This two-part determination consists of determining 

that 

(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. 25 

U.S.C. 1680c(b)(1)(A). 

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 (direct services), 

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. 1057 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 variances 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 liaVerDate Aug 31 2005 11:50 Mar 23, 2006 Jkt 049010 PO 00000 Frm 00011 Fmt 6659 Sfmt 6602 E:\HR\OC\SR222.XXX SR222

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56See GAO Report No. GAO–05–789. 57GAO Report No. GAO–05–789, at 4. 58 Id., at 5. 

ble for payment of such health services under a schedule of charges 

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

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, appointment waiting times,56

etc. 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. Questions 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 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 alternative unavailable. If all entities have made 

good faith efforts 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. It may also be politically disastrous for tribal leaders to authorize services for non-eligibles, so 

the determinations are 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. 1057 to the IHS and Indian tribes 

based on their individual circumstances and, if appropriate, could 

be developed more fully through negotiated rule-making or consultation. 

Third Party Reimbursements. Funding from sources other than 

IHS was identified as a factor which affected the availability of 

health care services for Indians.57 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.58

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 


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59S. 1057 adds 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 USC § 1641(a). 60GAO Report No. GAO–05–789, at 26. 61 Id. 62 As a general rule, these special types of property are not included in eligibility calculations 

for income taxes or federal benefits. 63See also GAO Report No. GAO–05–789, at 4. 64 Id. 65 Id. 66Senate Report No. 94–133, at 55–57. 67 Id., at 55–56. 

appropriated sums provided annually.59 The GAO noted that ‘‘[f]acilities with higher reimbursements had additional funds with 

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

renovate their buildings.’’ 60 In one case, 31 percent of a facility’s 

clinical providers and other staff was funded by third party reimbursements.61

S. 1057 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.62 Likewise, S. 1057 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. 

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.63 Noting 

that many Indian communities are often in remote locations and 

lack adequate housing and educational and recreational opportunities for employees and their families,64 the GAO reported that 

some critical positions such as for pharmacists and dentists remained vacant for several years in some locations.65

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.66

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.67

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. The program also now includes, besides the scholarships, 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 tribal 


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leader 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. 

Just as targeting the specific needs of the Indian health system 

became the hallmark of the health professional policy, a holistic approach also became 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. 1057 to address that 

need. S. 1057 provides for portability of current licenses for tribal 

health professionals consistent with other Federal health licensing 

provisions. In addition, S. 1057 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 individuals 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 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 

transitioning Indians into health professions. As part of the longterm view of Indian health professions, the Committee believes 

continuity is appropriate 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. 1057 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. 


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68 Joseph F. McDonald, Ed.D., President, Salish-Kootnai College, Letter to Chairman John 

McCain, U.S. Senate Committee on Indian Affairs, September 22, 2005. 69 Joseph F. McDonald, Ed.D., President, Salish-Kootenai College, Letter to Honorable Don 

Young, U.S. House of Representatives, November 1, 2005. 70 Id. 

In addition, the Committee took a long-term view of health professions in S. 1057. The most dire placement needs are in the direct care positions, such as doctors, nurses, and pharmacists. In the 

long-term, Indian health professionals are also needed in educational positions to bolster recruitment and improve the new Indian health professionals’ chances of success. 

The Committee has been informed that an appreciable need exists at the tribal colleges and universities to increase the number 

of Indian instructors in the nursing programs.68 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. 1057 wherein a scholarship recipient may 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 the 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. 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 are clinically seasoned, mature [Bachelor of Science-Nursing] prepared nurses returning to school for educational and career 

mobility.’’ 69 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. * * *’’ 70

The Committee believes these positions should be filled by experienced faculty and expects that the Secretary and the tribal colleges or universities would 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 authorized a feasibility study to 

be conducted on hospice care services. However, the IHS never conVerDate Aug 31 2005 11:50 Mar 23, 2006 Jkt 049010 PO 00000 Frm 00015 Fmt 6659 Sfmt 6602 E:\HR\OC\SR222.XXX SR222

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ducted that study and now, thirteen 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 through 

the Indian health care system these services and other long-term 

or home health care 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. Indians must 

travel long distances only to be placed in facilities that are far from 

home, culturally unfamiliar, and not conducive to their well-being. 

Having culturally-appropriate facilities close to Indian communities 

will not only promote the patient’s well-being, but will enable family members to more easily visit the patient. 

Section 213 of S. 1057 authorizes the Secretary to fund other 

services which meet the policy objectives set forth in section 3 of 

the legislation. A partial list of such other services includes hospice 

care, assisted living, long-term health care, home- and communitybased services, public health functions, and traditional health care 

practices. 

Concerns have been raised regarding the economic feasibility of 

facilities providing these types of services, if access is limited to 

just Indians. Therefore, subject to the ‘‘two-part determination’’

under Section 807 of the bill, the IHS, Indian tribes, or tribal organizations may provide the types of care authorized in Section 213 

to persons otherwise ineligible for the health care benefits of the 

IHS, provided that such persons furnish reimbursement of reasonable charges for such services. The inclusion of these individuals 

may be necessary in some circumstances to achieve the minimum 

patient base needed to make the venture economically feasible and 

to realize the cost efficiencies of providing these services. 

With regard to the services authorized by Section 213, the Department of Justice informally expressed concerns with a subset of 

the home- and community-based services, specifically ‘‘chore services’’. These concerns primarily focus on potential liability for the 

Federal government that may arise under the Federal Tort Claims 

Act from: (1) services provided in a setting other than an IHS or 

tribal facility that are not directly associated with the medical condition being treated, (2) whether the providers will be adequately 

trained, and (3) family members’ support being included as a 

standard service. 

To address these concerns the Committee struck the words 

‘‘homemaker’’ and ‘‘chore services’’ from the definitions in the substitute amendment adopted in Committee. The substitute amendment further clarified the ‘‘Personal care services’’ definition to 

specify that ancillary tasks, when performed, must be associated 

with support services related to activities of daily living. Last, the 

substitute amendment makes clear that home- and communitybased services do not include services provided by an individual 


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71Merriam, Lewis (ed.), Institute for Government Research, The Problem of Indian Administration (1928) (commonly referred to as the ‘‘Merriam Report’’). 72Other federal agencies also appear to be consider the value of traditional healing in assisting Indian people recover from various maladies such as post-traumatic stress disorders. See 

e.g., www.helenair.com/articles/2005/11/30/montana/a06113005l01.txt, (Last reviewed November 30, 2005). 

who is legally responsible for the provision of such services, such 

as a family member or legal guardian. 

Traditional Health Care. The 1928 Merriam Report 71 generated 

several initiatives to improve health conditions for Native Americans. One reform was the active solicitation of traditional Indian 

healers to participate in federal health services to Indians—an abrupt change from the prior assimilationist policies promoted by the 

Federal Government. 

Several provisions in the Act reflected those reforms as well.72 In 

particular, the Community Health Representatives in the Act were 

required to ‘‘promote traditional health care practices of the Indian 

tribes served consistent with the Service standards for the provision of health care, health promotion and disease prevention.’’ 25 

U.S.C. 1616(b)(6). 

The Committee is aware that Indian tribes have long sought to 

promote traditional healing in the framework of the Indian health 

system, but that concerns have been raised regarding inclusion of 

traditional healing in the IHCIA. 

One concern involves the possible legal liability to the Federal 

Government in connection with the traditional practices. Under the 

ISDEAA, Federal Tort Claim Act (FTCA) coverage applies when Indian tribes or tribal organizations administer programs or services 

pursuant to a contract or compact. If traditional health practices 

were services provided under an ISDEAA contract or compact, such 

practices would be covered by the FTCA. 

Other concerns have been raised regarding whether the Federal 

Government or courts should be scrutinizing tribal traditions in the 

defense against claims arising under the FTCA. To address these 

concerns, the Committee encourages the Secretary and Indian 

tribes to thoroughly examine the traditional healing provisions 

through the implementation plan under Section 803 of S. 1057, or 

through consultation, particularly on how the traditional practices 

and healers fit within the FTCA framework. 

Behavioral Health. S. 1057 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. 


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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 

young people subsequently took their own lives. 

The publicity around the nation’s second-most deadly school 

shooting on the Red Lake reservation brought attention to the fact 

that in Indian Country, suicide is characterized by higher rates 

among a younger group than is experienced 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. 

In response to this tragedy, a number of resources were provided 

to the Red Lake reservation, including services by such Federal 

agencies as the IHS, SAMHSA and Office of Juvenile Justice and 

Delinquency Prevention, as well as by state and tribal agencies. 

The Committee held two hearings specifically on the issue of Indian youth suicide, one in Bismarck, North Dakota on May 2, 2005, 

and the other in Washington, DC, on June 15, 2005, to discuss the 

kinds of resources and services being provided to Indian youth who 

have expressed suicidal thoughts or attempted suicide, and to explore what more might be done. 

Based on the information developed through hearings, the Committee added provisions to Title VII of S. 1057 which address youth 

suicide as part of the behavioral health program provisions. Other 

provisions added 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 3 to 9 and by authorizing a specific level of funding. 

The provisions also add a significant cultural component to the 

suicide programs. They authorize 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 is aware 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. Consequently, S. 

1057 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. 

Urban Indians. Providing for urban Indian health has been a 

part of Federal policy for nearly 40 years. Congress began funding 


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73Senate Report No. 94–133, pg 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). 74 U.S. Const., Art. I § 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). 

urban Indian clinics in 1967 when $321,000 was provided for an 

Indian clinic in Rapid City, South Dakota.73

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, to correct disparities in health levels for Indians living 

in urban areas first as pilot programs and then permanently in the 

Indian health care system. See Senate Report Nos. 94–133, 100– 508 and 108–411. 

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. 

For some Indian tribes, the Federal Government had ignored completely. Some Indian tribes were legislatively blocked from some 

administrative programs, yet were allowed to exercise treaty 

rights. Some Indian tribes were ‘‘terminated’’, yet later ‘‘restored’’. Courts have long held with great favor that Congress has the 

broad power to legislate for the benefit of Indians, even if located 

off the reservation, and to define who is an Indian, even if they 

may not be an enrolled member of a federally-recognized Indian 

tribe, and for what purposes they may be provided services.74

For example, Congress has enacted laws which define Indians in 

different ways for different purposes. See e.g., Indian Arts and 

Crafts Act, Pub.L. 101–644, 25 USC 305; No Child Left Behind Act, 

Pub.L. 107–110, 25 USC 7491; and the American Indian Probate 

Reform Act of 2004, Pub.L. 108–374. 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, nor place geographical limitations on the service areas in which they may be 

served. The Snyder Act, 25 USC 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 Federally-recognized 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. 

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. However in 


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75Senate Report 94–133, page 131. 76Felix Cohen, Handbook of Federal Indian Law (1982 ed.), at 169. 

remedying the devastating effect 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, often referred to as 

‘‘state-recognized tribes’’. 

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 in this Act, is within 

Congressional power. 

Further, in adopting S. 1057, the Committee is of the opinion 

that the Congress was on firm constitutional footing based on longstanding 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.75

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 

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

policies. Relocating Indians from reservations to urban areas is the 

Federal policy and program first begun in 1931.76 ‘‘Relocation complemented other termination programs designed to promote rapid 

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


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

Institute, March 16, 2004, available at www.uihi.org (Last reviewed March 16, 2006). 

federal services that had been available to them as reservation 

residents.’’ 77

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. See Senate Report No. 94–133 at 138. The Committee further found that Title V ‘‘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.’’ Senate Report No. 94–133 at 140. 

The justifications for that policy are still valid today. The most 

recent statistics indicate that urban Indians suffer health disparities as do Indians located 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), alcoholism (178% higher), and sudden infant 

death syndrome (157% higher).78

The Committee believes that continuation of services to urban 

Indians, recognized by S. 1057, 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 3 clinics and experiences over 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 HealthSource 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 


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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 Association 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 a vital component 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 (e.g., pow-wows, festivals), 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% 

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79The Health Status of Urban American Indians and Alaska Natives, Urban Indian Health 

Institute, March 16, 2004. 80 U.S. Department of Health and Human Services, U.S. Public Health Service, National Institute of Dental and Craniofacial Research, National Institutes of Health, Oral Health in America: 

A Report of the Surgeon General (2000) at 77. 81 Indian Health, Hearing Before the Senate Comm. on Indian Affairs, 109th Cong., 1st Sess., 

S. Hrg. 109–26, at 168 (April 13, 2005) (statement of Sally H. Smith, Chairman, National Indian 

Health Board). 82S. Hrg. 109–162, at 784 (statement of Dr. Mary Willard, Yukon-Kuskokwim Health Corporation). 83Fiset, Louis. ‘‘A Report on Quality Assessment of Primary Care Provided by Dental Therapists to Alaska Natives.’’ August, 2005. 

lation) 79, it is no surprise that many urban Indians are uninsured. 

The Committee has received testimony that in Boston, Massachusetts, 87% of the Boston Indian Center’s clients have no health insurance and nearly two out of three urban Indians in Arizona 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 embodied in this Act and other 

statutes of increasing access to health care and of remedying 

health disparities resulting from the past failed Federal Indian 

policies. 

Dental health aides. 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 for Alaska Natives in particular. 

According to Oral Health in America: A Report of the Surgeon 

General, the incidence rates for periodontal disease among Indians 

is 21⁄2 times that of the general public.80 In Alaska Native communities, it is not uncommon for the children to require extraction of 

all of their baby teeth due to pervasive caries. Nor is it uncommon 

for the nutritional status of Alaska Native elders to be compromised by their inability to consume healthy foods due to dental 

pain or missing teeth. 

This situation is exacerbated by a chronic shortage of dentists. 

Alaska Tribal health programs are currently experiencing a persistent 25 percent vacancy rate among dentists, with an annual 30 

percent turnover rate.81 Even if the number of dentists in the IHS/ 

tribal system were doubled, it would take 10 years to address the 

unmet need for dental services.82 A recent independent evaluation 

of the DHAT Program in Alaska reports that ‘‘five full-time paid 

dentist positions in the Yukon-Kuskokwim Delta have remained 

vacant for six years despite a salary/benefits package starting at 

$177,000.’’ 83

At its joint hearing on S. 1057 on July 14, 2005, with the Senate 

Health, Education, Labor and Pensions Committee, the Committee 

examined issues surrounding the Dental Health Aide Therapist 

(DHAT) program currently operated under the Community Health 

Aide/Practitioner (CHAP) 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 


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84 Because no U.S. dental school provides mid-level dental training, DHATs are trained at the 

University of Otago, New Zealand, under a two-year program. The Committee has been informed that the DHAT Program is operated with wide success in Canada and 40 other countries. See World Oral Health Country/Area Profile Programme, World Health Organization Collaborating Center. 85S. Hrg. 109–162, at 363–363 (statement of Dr. Mary Willard, Yukon-Kuskokwim Health 

Corporation). 86See also Id., at 716 et seq. (statement of Don Kashaveroff, President, Seldovia Village 

Tribe). 

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.84

At the July 14 joint hearing, Dr. Willard, who serves as a dentist 

for the Yukon-Kuskokwim Health Corporation in Bethel, Alaska, 

testified before the Committee that the CHAP program has been 

used in Alaska for 30 years and that the dental health aides are 

part of the often-remote Native communities.85 She further testified that DHATs must meet the same dental standards and quality 

assessments that IHS uses for dentists, and that their skills are 

equal. 

The DHAT program in Alaska has been part of the CHAP 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. 

Despite strong concerns expressed by the American Dental Association about the quality of care that would be provided by the 

DHATs, the Committee has received letters indicating strong support of the DHAT Program in Alaska from the State of Alaska’s 

Department of Health and Human Services, the Alaska Native 

Health Board, the Alaska Native Tribal Health Consortium, the 

American Dental Hygienists’ Association, and others.86

The Committee wants to ensure that Alaska Natives receive the 

best feasible care and appreciates the concerns for patient safety 

regarding the use of DHATs to perform surgical dental procedures 

(extractions, pulpotomies and diagnosis and treatment of caries). 

However, the difficult policy decisions lie in balancing perceived 

risks to patient safety against the alternative reality of their receiving no care at all. 

Consequently, the Committee has determined to limit the DHAT 

program to Alaska and require a study of the program. The study 

will be conducted by a panel of neutral experts, including clinicians 

with experience in providing care to remote populations and clinicians who can measure and evaluate oral and medical complications, community practitioners from Alaska, economists with experience in dental delivery, oral epidemiologists, and Alaskan Natives 

with experience in the health delivery system. 

In developing the study parameters, the Secretary must consult 

with appropriate professional organizations, among other parties. 

The Committee expects that the American Dental Association will 

be specifically included in that consultation given their concerns 

and expertise in these matters. 


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Furthermore, the Committee believes that the study should compare the care provided by the DHATs with care provided by other 

dental delivery systems, such as the ‘‘Integrated Dental Health 

Program for Alaska Native Populations’’ model developed by Drs. 

Howard Bailit, Tryfon Beazoglou, Amid Ismail, and Thomas 

Kovaleski. During the term of this study, the Secretary should engage in appropriate oversight and take actions necessary to ensure 

that patient health and safety is not compromised. 

SECTION-BY-SECTION ANALYSIS

A significant portion of current law has been carried forward by 

S. 1057 and reorganized in the various titles according to subject 

matter. S. 1057 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) simply 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 hospice care. 

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. 1057. In addition, the codified section in current law will also be noted to provide ease of reference. 

Section 1. Short title. This Act may be cited as the ‘‘Indian 

Health Care Improvement Act Amendments of 2005’’. 

Section 2(a). Indian Health Care Improvement Act Amended. This 

section begins the provisions of the Act ending with Section 816. 

The following section numbers of this analysis will reflect the section numbers of the Act. 

Section 1. Short title; table of contents 

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

Act’’. Section 1 also contains the table of contents. 

Section 2. Findings 

This section maintains current law. 

Current law: Section 1601 of current law (25 U.S.C. 1601) 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. 

Section 3. Declaration of national Indian health policy 

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, (4) require consultation consistent with Indian self-determination, and 

(5) provide funding to Indian tribal programs and facilities consistent with levels of IHS programs and facilities. 


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Current law: In Section 1602, Congress declares that the national policy, in fulfillment of special responsibilities and legal obligation to Indians, is to assure the highest possible health status for 

Indians and urban Indians and to provide all resources necessary 

to effect the policy. In addition, the policy is to meet an enumerated list of health status objectives for Indians such as reducing 

coronary heart disease to no more than 100 per 100,000. It is also 

the intent of Congress that the proportion of degrees awarded in 

the health professions to Indians be increased to 0.6 percent. The 

Secretary is also required to report on the progress made in each 

objective annually. 

Section 4. Definitions 

This section (Section 1603 in current law) maintains current law 

and adds several new definitions to reflect current practices, significant updates and coordination in health services to Indians, as 

follows: accredited and accessible, Area Office, Assistant Secretary, 

behavioral health, community college, contract health service, Department, Indian health program, junior or community college, reservation, telehealth, telemedicine, Traditional Health Care Practices, tribal college or university, and Tribal Health Program. 

TITLE I—INDIAN HEALTH, HUMAN RESOURCES, AND 

DEVELOPMENT 

Section 101. Purpose 

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: Under Section 1611, the purpose of Title I is to increase the number of Indian health professionals and to assure an 

adequate supply of health professionals to provide health services 

to Indians. 

Section 102. Health professions recruitment program for Indians 

This section maintains current law. 

Current law: Section 1612 authorizes funding for recruitment 

programs, to include identifying Indians with potential for entering 

health professions, publicizing funding sources, 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. 

Section 103. Health professions preparatory scholarship program for 

Indians 

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. Section 1613 authorizes scholarships to Indians for 

compensatory preprofessional education as well as pregraduate 

education leading to a baccalaureate degree in a preparatory field 


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for a health profession. The compensatory preprofessions scholarships are awarded for up to two years on a full or part-time basis 

and pregraduate scholarships are for up to four years (S. 1057 adds 

2-year extensions). This section specifies certain conditions on these 

scholarships which include the types of costs that may be covered 

and prohibits denial of a scholarship based solely on scholastic 

achievement if the 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. 

Section 104. Indian Health Professions Scholarships 

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. Section 1613a authorizes scholarships, designated 

as Indian Health Scholarships, to Indians who are enrolled full or 

part time in accredited schools pursuing courses of study in the 

health professions. Scholarship recipients are then required to fulfill a service obligation by either working for an IHS, tribal or 

urban Indian health program or in private practice located in a 

health professional shortage area with the length not specified in 

statute. 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. 

Section 105. American Indians Into Psychology Program 

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 

2006 through 2015. 

Current law: Section 1621p authorizes grants to at least 3 colleges and universities for developing and maintaining Indian psychology career recruitment programs, including one to develop and 

maintain the Quentin N. Burdick American Indians Into Psychology Program 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. 

Section 106. Scholarship programs for Indian tribes 

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 non-federal 

sources, (2) requires that licensing and educational requirements 

for all health professions, instead of only the doctor and nursing 

professions, be met, and (3) adds Title XXI of the Social Security 

Act to the non-discriminatory provisions. 

Current law: Section 1616m authorizes the Secretary to make 

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nities. This section specifies the requirements for receiving such 

funds; the course of study; contract conditions; 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 cannot discriminate against patients who receive assistance under Titles 

XVIII and XIX of the Social Security Act. The recipients shall be 

required to fulfill service obligations and use the scholarship for 

tuition and reasonable education or living expenses. 

Section 107. Indian health service extern programs 

This section maintains current law and adds provisions (1) extending the extern program to tribal or urban Indian health providers (on a discretionary basis) or other DHHS agencies (as available) instead of only the IHS, (2) instead of entitling the externs 

to employment, gives them a preference for employment with the 

IHS, and allowing an extern program for high school programs. 

Current law: Section 1614 gives preference for employment in 

the Service (and as added by S. 1057, a Tribal Health Program, 

Urban Indian Organization or other agencies within the Department), to any recipient of a scholarship pursuant to section 1613a 

or 1616m. 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. 

Section 108. Continuing education allowances 

This section maintains current law, except for the deletion of the 

set-aside for postdoctoral training, and adds language which extends the continuing education allowances to tribal and urban Indian health providers, not just the IHS, and includes all health professionals. 

Current law: To encourage health professionals to join the IHS 

and continue working in rural or remote areas where significant 

numbers of Indians reside, Section 1615 permits the Secretary to 

provide allowances to health professionals employed by the IHS to 

enable them to take leave of their duty stations for a period of time 

each year for professional consultation and refresher training 

courses. Section 108 also authorizes a set-aside of not more than 

$1 million for postdoctoral training programs. 

Section 109. Community Health Representative Program 

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 and 

urban Indian health programs. 

Current law: Section 1616 authorizes the CHR Program for 

training and using Indians as CHRs. This section specifies the duties of the Service regarding this program, including providing supervision, an evaluation system and a high standard of training for 

CHRs to ensure that they 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. 


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Section 110. Indian Health Service Loan Repayment Program 

This section maintains current law and (1) eliminates the obsolete set asides during FY 1993–1995 for nursing and mental health 

professions, (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: Section 1616a establishes the Indian Health Service 

Loan Repayment Program in order to ensure an adequate supply 

of trained health professionals needed to maintain accreditation 

and provide health care services to Indians. The section specifies 

eligibility for the program which includes individuals with a degree 

or license in a health profession, in graduate training or about to 

complete an approved course of study. The application information 

must clearly explain rights and obligations and be available very 

early so individuals can timely complete the applications. This section outlines how the priorities for program participants will be established. Recipient contracts are required which set forth the 

rights and obligations. This section establishes deadlines for decisions on applications (21 days under S. 1057). The loan repayment 

program includes payment of principal, interest and related expenses of school loans up to $35,000 for each year of obligated service and, in addition to this payment, may include an amount to 

cover tax liability incurred for this payment. This section also includes a waiver from any employment ceiling; recruitment programs; non-applicability of Section 215 of the Public Health Service 

Act; assignment of individuals; breach of contract; waiver or suspension of obligation; and the requirement of an annual report to 

Congress. 

Section 111. Scholarship and Loan Repayment Recovery Fund 

This section maintains current law and adds provisions expanding the source of funds for this Recovery Fund, in addition to appropriations, to include collections from contract breaches for the 

scholarships or loan repayment programs and interest. 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 DHHS may now 

determine what amounts are not required to meet withdrawals for 

the Fund, rather than the Secretary of the Treasury. 

Current law: Section 1616a–1 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 

under loan repayment programs. The section specifies the use of 

these funds which includes employment or recruitment of health 

professionals, the investment of the funds, and the sale of obligations by the Secretary of the Treasury. The Secretary of the Treasury may also invest funds in this Fund which are not necessary to 

meet withdrawals for the uses specified in this Section. 

Section 112. Recruitment activities 

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. 


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Current law: Section 1616b permits the Secretary to reimburse 

certain travel expenses to health professionals seeking positions 

with the IHS. 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 full-time responsibility for recruitment activities. 

Section 113. Indian Recruitment and Retention Program 

This section maintains current law and adds language which (1) 

sets a time limit of three years for demonstration projects funded 

under this section instead of an open-ended timeframe under current law and (2) clarifies that the Indian organizations eligible to 

compete are urban Indian organizations. 

Current law: Section 1616c requires the Secretary to fund innovative demonstration projects (under S. 1057 for up to 3 years) to 

enable Indian tribes, tribal and Indian organizations to recruit, 

place, and retain health professionals to meet the staffing needs of 

Indian health programs. The section also specifies that any Indian 

tribe, tribal or Indian organization is eligible to apply for these 

funds and compete on the same basis as IHS programs which receive grants under this section. 

Section 114. Advanced training and research 

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: Section 1616d establishes a demonstration project 

to enable health professionals who are employed in an Indian 

Health Program or Urban Indian Organization at the time of application to pursue advanced training or research areas of study, 

where a need exists. The section also imposes a service obligation 

for the recipients and requires equal opportunity for participating 

in the program. 

Section 115. Quentin N. Burdick American Indians into Nursing 

Program 

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, (3) includes tribal colleges and universities in the 

preferences among grant applicants. 

Current law: Section 1616e 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 and requires that one of them be for the 

program at the University of North Dakota; how grants may be 

used; information which must be included in applications for the 

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nance of a program at the University of North Dakota; and an active duty service obligation. 

Section 116. Tribal cultural orientation 

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 traditional health 

care practices of the Indian tribes in the Service Area and (3) requires consultation with affected tribal and urban Indian organizations. 

Current law: Section 1616f requires appropriate employees of the 

Service who serve particular Indian Tribes to receive instruction in 

the history and culture of the tribes they serve and in the history 

of the IHS. The section requires the Secretary to develop such a 

program in consultation with the affected Indian tribes, which 

shall, to the extent feasible, be implemented through tribal colleges 

or universities and include instruction in Native American studies. 

Section 117. INMED Program 

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 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: Section 1616g authorizes the Secretary to provide 

grants to at least 3 colleges and universities to maintain and expand the Indian health careers recruitment program (Indians Into 

Medicine Program). The Quentin N. Burdick Indian Health Programs 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. 

Section 118. Health training programs of community colleges 

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: Section 1616h requires the Secretary to award 

grants to (under S. 1057, 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 a tribal clinic. The Secretary 

is also required to award grants to the colleges that already have 

these programs. The Secretary must provide technical assistance to 

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grams. Finally, any program receiving assistance under this section 

is required to provide advanced training for health professionals. 

Section 119. Retention bonus 

This section maintains current law and adds language expanding 

the bonuses (1) to any health professional, rather than only doctors 

and nurses, so funding set-asides between these 2 professions have 

been deleted, (2) to health professionals employed by the tribal or 

urban health programs, rather than employed only by the Service, 

and eliminates the requirement that the retention bonus be paid 

at the beginning of the term of service. 

Current law: Section 1616j permits the Secretary to provide retention bonuses for health professions where recruitment or retention is difficult if the individual has completed 3 years of employment and any service obligation from federal scholarships or loan 

repayment programs. 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. 

Section 120. Nursing residency program 

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, besides a Master’s degree as appropriate post-baccalaureate 

training. 

Current law: Section 1616k establishes a program to enable 

nurses working for an Indian Health Program or Urban Indian Organization to pursue advanced training. The participants are required to enter a service obligation. The program shall include a 

combination of education and work study leading to either an associate or bachelor’s degree in nursing degrees or a Master’s degree. 

Section 121. Community health aide program 

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: Section 1616e directs the Secretary to develop and 

operate a Community Health Aide Program in Alaska. Requirements are specified for the Alaska program including the (1) development of training and curriculum combining theory and practical 

experience, (2) instruction in acute care, health promotion, (3) establishment of a certification Board, and (4) development of systems for continuing education and supervision. 

Section 122 Tribal health program administration 

This section maintains current law and adds language which 

specifies that the training shall be for Indian individuals. 


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Current law: Section 1616n requires the Secretary to provide 

training in the administration and planning of Tribal Health Programs. 

Section 123. Health professional chronic shortage demonstration 

programs 

This section amends current law by changing a lone pilot program to address health professional shortages into a national demonstration project. 

Current law: Section 1616o 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. The pilot program shall 

incorporate a program advisory board composed of representatives 

from the tribes and Indian communities which are served by the 

program. 

Section 124. National health service corps 

This section maintains current law and adds urban Indian health 

programs within the protections against removal of any member of 

the Corps working in the programs. The section also exempts National Health Service Corps scholars qualifying for the Commissioned Corps in the United States Public Health Service from fulltime equivalent limitations when serving as a commissioned corps 

officer in a Tribal Health Program or an Urban Indian Organization. 

Current law: Section 1680b prohibits the Secretary from removing a member of this Corps from an Indian health program or withdrawing funding to support such member, unless the Secretary ensures that Indians will experience no reduction in services. 

Section 125. Substance abuse counselor educational curricula demonstration programs 

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: Section 1665j allows the Secretary to enter into contracts with or make grants to colleges and universities (including 

tribal) to establish demonstration programs developing curricula 

for substance abuse counseling. Duration and renewal of the grant 

are both for periods of one year each. 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 Secretary to submit an annual report to the 

President for inclusion in the annual report to Congress and defines the term ‘‘educational curriculum’’ and ‘‘eligible community 

college’’. 

Section 126. Behavioral health training and community education 

programs 

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gram, (2) clarifies that the tribal and urban Indian organizations 

are 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: Section 1621h(d) requires the Secretary, with the 

Secretary of the Interior and in consultation with representatives 

of the Indian Tribes, to conduct a study and compile a list of certain types of staff positions within the Bureau of Indian Affairs, 

the Service and Indian Tribes, 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. On 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 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 mental health services by at 

least 500 staff positions within 5 years, with at least 200 of such 

positions devoted to child, adolescent, and family services. Such 

staff would be assigned primarily to the IHS service unit levels. 

Section 127. Authorization of appropriations 

Section 127 authorizes appropriations as are necessary to carry 

out this title for each fiscal year through 2015. 

TITLE II—HEALTH SERVICES 

Section 201. Indian Health Care Improvement Fund 

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 telemedicine and Traditional Health Care Practices. 

Current law: Section 1621 authorizes the use of funds, designated as the ‘‘Indian Health Care Improvement Fund’’, 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 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 the IHS. 

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 IHS for determining appropriations in subsequent years. Finally, nothing in this 

section is intended to diminish the primary responsibility of the 

IHS to eliminate backlogs in unmet health care, or to discourage 

additional efforts of IHS to achieve parity among Tribes. 


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Section 202. Catastrophic Health Emergency Fund 

This section maintains current law and adds language which requires the use of negotiated rulemaking for promulgation of regulations issued for this section. 

Current law: Section 1621a establishes the Catastrophic Health 

Emergency Fund (CHEF) to be administered by the Secretary 

through the central office 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 be deposited into CHEF. 

Section 203. Health promotion and disease prevention services 

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: Section 1621b directs the Secretary to provide 

health promotion and disease prevention services to Indians in 

order to meet the Act’s health status objectives. An evaluation 

statement of the resources required to undertake these health promotion and disease prevention activities would be included in a required report to Congress. 

Section 204. Diabetes prevention, treatment, and control 

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, (d) funding for dialysis programs, (e) consultation 

requirements; (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 employment of 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. 

Current law: Section 1621c requires the Secretary to determine 

the incidence of this disease and its complications among Indians 

and the measures needed to prevent, treat and control it. The Secretary is also required 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 under S. 

1057, dialysis programs). To the extent that funding is available, 

the Secretary is required to work with each Area Office to establish 

patient registries in Area Offices and ensure that data collected are 

disseminated to other Area Offices, subject to privacy laws. The 


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Secretary is also allowed to maintain diabetes control officers in 

each Area. 

Section 205. Shared services for long-term care 

This section amends current law by changing a demonstration 

project into a permanent program and adding new provisions which 

(1) authorize other services similar in nature to long-term care and 

construction for facilities for the similar services and (2) encourage 

the use of existing underused facilities or allow the use of swing 

beds for long-term or similar care. 

Current law: Section 1680l allows the Secretary to enter contracts for 6 demonstration projects to deliver long-term care services to Indians which may also authorize sharing of staff, construction and proportionate allocation of funding between the tribes and 

IHS. 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. 

Section 206. Health services research 

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, and (3) authorizing the funding for both clinical and nonclinical research. 

Current law: Section 1621g authorizes funding for research to 

further the performance of the health service responsibilities of the 

IHS. Indian tribes and tribal organizations contracting under the 

Indian Self-Determination and Education Assistance Act are to be 

given equal opportunity to compete for these research funds. 

Section 207. Mammography and other cancer screening 

This section amends current law by authorizing other cancer 

screening, 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: Section 1621k requires the Secretary to provide for 

mammography for Indian women 35 years or older at a frequency 

determined by the Secretary in consultation with the National Cancer Institute and consistent with appropriate standards to ensure 

the safety and accuracy of the mammogram under the Social Security Act. 

Section 208. Patient travel costs 

This section maintains current law and adds language which allows the use of appropriate and necessary 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: Section 1631l requires the Secretary to provide 

funds for the travel costs of patients, for emergency and non-emerVerDate Aug 31 2005 11:50 Mar 23, 2006 Jkt 049010 PO 00000 Frm 00036 Fmt 6659 Sfmt 6602 E:\HR\OC\SR222.XXX SR222

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gency air transport where ground transport is not feasible, associated with receiving health care services. 

Section 209. Epidemiology centers 

This section amends current law by (1) maintaining the centers 

in existence on the date of passage of this Act, but still requiring 

the establishment of centers in the remaining Areas without reducing funds for the existing centers, (2) allowing the funding for any 

new centers to be administered, but not divisible, by tribes and 

tribal organizations under the Indian Self-Determination and Education Assistance Act, but no longer by tribal consortia and (3) 

eliminating the requirements that the Secretary establish the data 

and formats for reporting and establish the system for monitoring 

progress toward the health objectives. 

Current law: Section 1621m requires the Secretary establish epidemiology centers in each Service Area. Newly established centers 

may be operated by Tribal Health Programs. The functions of these 

centers are delineated in this section. The Director of the Centers 

for Disease Control and Prevention is required to provide technical 

assistance to the centers and the Secretary is authorized to provide 

funding to Tribes and Tribal Organizations to conduct epidemiological studies of Indian communities. 

Section 210. Comprehensive school health education programs 

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) includes tribal organizations and urban Indian health organizations as eligible for funding, (3) consolidates the reporting requirements into the application criteria which is now subject to 

consultation between the Secretary and the Indian tribes, tribal organizations and urban Indian organizations. 

Current law: Section 1621n allows the Secretary to provide 

grants to Indian Tribes for the development of comprehensive 

school health education programs for children from pre-school 

through grade 12. The specific purposes for which funds may be 

used are delineated. Upon request, the Secretary is required to provide technical assistance in the development and dissemination of 

comprehensive health education plans, materials and information. 

The Secretary 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 similar programs. 

Section 211. Indian Youth Program 

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. 

Current law: Section 1621o allows the Secretary to establish and 

administer programs for innovative mental and physical disease 

prevention and health promotion and treatment for Indian preadolescent and adolescent youths. Allowable and prohibited uses of 


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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. 

Section 212. Prevention, control, and elimination of communicable 

and infectious diseases. 

This section amends current law by expanding the communicable 

diseases from simply tuberculosis to other communicable and infectious diseases, by encouraging the Indian tribes to coordinate with 

the Centers for Disease Control, by eliminating superfluous provisions which reduce the grant amount for expenses incurred by the 

federal government or for supplies or equipment furnished to the 

grant recipient. 

Current law: Section 1621q authorizes the Secretary to fund 

projects specifically for the purpose of preventing, controlling and 

eliminating tuberculosis. Funding is also authorized for public information and education programs, and skills improvement activities. Funding under this section requires an application or proposal 

for funding. Entities which receive funding under this section must 

provide assurances they will coordinate their activities with the 

Centers for Disease Control and Prevention as well as State and 

local health agencies. Finally, in carrying out this section, the Secretary may provide technical assistance upon request and shall 

submit a report to Congress on the use of the funds and the 

progress made toward prevention, control, and elimination of tuberculosis among Indians. 

Section 213. Authority for provision of other services 

This section amends current law by making permanent a demonstration project for home- and community-based care. The new 

provisions also (1) add special requirements for the home- and community-based care, (2) add several definitions, and (3) eliminate 

the exclusion of cash payments, room and board, construction and 

nursing facility services. 

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 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. 


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Current law: Section 1621v establishes an Office of Indian women’s health 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 

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, (2) provides additional considerations for the studies conducted under this 

section and (3) requires consultation with Indian tribes and tribal 

organizations in developing plans for addressing the health problems. 

Current law: Section 1677 requires the Secretary, in conjunction 

with other Federal agencies, to conduct studies to determine trends 

in the health hazards to Indian miners and other Indians as a result of nuclear resource development. Upon completion of such 

studies, the Secretary shall develop health plans to address the 

health problems studied. 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 includes recommendations for the implementation of the plan and evaluation 

activities. This section establishes an Intergovernmental Task 

Force to identify environmental hazards and to 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 work-related condition, the 

Indian Health Program which treats him may be reimbursed by 

the Indian’s employer. 

Section 216. Arizona as a contract health service delivery area 

This section maintains current law and extends the date to 2015, 

instead of 2000, for the designation as a contract health service delivery area. 

Current law: Under Section 1678, the State of Arizona is designated as a contract health service delivery area for the purpose 

of providing contract health care services to members of federally 

recognized Indian Tribes of Arizona effective fiscal years 1984 to 

2000. The Indian Health Service will not curtail any services as a 

result of this provision. 

Section 216A. North Dakota and South Dakota as a contract health 

service delivery area 

This section is new. 

New provisions: The States of North Dakota and South Dakota 

are designated as one contract health service delivery area for the 

purpose of providing contract health care services to members of 

federally recognized Indian Tribes in North and South Dakota. The 

Indian Health Service will not curtail any services as a result of 

this provision. 

Section 217. California Contract Health Services Program 

This section amends current law by turning the demonstration 

project for the California Indians into a permanent program. 

Current law: Section 1621j requires the Secretary to establish a 

demonstration project using the California Rural Indian Health 


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Board (CRIHB) to serve as the contract care intermediary to improve the accessibility of health services to California Indians. The 

Secretary will reimburse CRIHB for costs incurred pursuant to this 

section. Not more than 5 percent of the amounts provided under 

this section 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, 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. The Advisory Board will advise the 

CRIHB in carrying out this section. The CRIHB is also required to 

report to the Secretary on the demonstration project findings. 

Section 218. California as a contract health service delivery area 

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 those counties. 

Current law: Section 1680 designates the State of California, excluding certain specified counties, as a contract health service delivery area for providing contract health care services to California 

Indians. 

Section 219. Contract health services for the Trenton service area 

This section maintains current law. 

Current law: Section 1680e directs the Secretary 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 North Dakota and the 

counties of Richland, Roosevelt, and Sheridan in Montana. This 

section does not expand 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. 

Section 220. Programs operated by Indian tribes and tribal organizations 

This section maintains current law, but eliminates language 

which limits 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 Tribal Health Programs for 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 

This section is new. 

New provision: Section 221 requires that health care professionals employed by a Tribal Health Program shall, if licensed in 


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any State, be exempt from the licensing requirements of the State 

in which the Tribal Health Program provides the services. 

Section 222. Notification of provision of emergency contract health 

services 

This section maintains current law. 

Current law: Section 1646 allows 30 days (as a condition of payment) for an elderly or disabled Indian to notify the Service of any 

emergency care or health services received from a non-Service provider or in a non-Service facility. 

Section 223. Prompt action on payment of claims 

This section maintains current law, but changes the requirement 

of a completed claim to a valid claim. 

Current law: Section 1621s 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 

as valid. The IHS shall pay a completed claim within 30 days after 

completion of the claim. 

Section 224. Liability for payment 

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: Section 1621u 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. In 

addition, the Secretary is required to notify the provider of such 

services and the patient who receives them of the same, within a 

specified time. 

Section 225. Office of Indian Men’s Health 

This section is new. 

New provision: Section 225 directs the Secretary to establish the 

Office of Indian Men’s Health, which shall be headed by a Director, 

to coordinate and promote the health status of Indian men. The 

Secretary is also required to submit a report to Congress within 

two years of enactment, describing any activity and finding of the 

Director. 

Section 226. Authorization of appropriations 

This section maintains current law, but extends the authorization to 2015 and eliminates the references to specific sections which 

had a separate authorization period. 

Current law: Section 226 authorizes appropriations as necessary 

to carry out this title, for each fiscal year through 2000, except for 

certain specific sections. 

TITLE III—FACILITIES 

Section 301. Consultation; construction and renovation of facilities; 

reports 

This section maintains current law and adds language which (1) 

expands the accrediting bodies whose standards may be met for 


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construction, (2) requires an evaluation of the impact of a proposed 

closure prior to closing, (3) requires the Secretary to establish a 

health care facility priority system developed through negotiated 

rule-making which prioritizes certain types of facilities such as outpatient, specialized care facilities, (4) adds specific requirements for 

the report to be submitted to Congress such as the types of facilities to be included, the method for evaluating the needs, the opportunity for nomination of facilities and consultation, (5) requires the 

Secretary to consult and cooperate with Indian tribes in finding innovative approaches to meet the facilities needs; and (6) requires 

a GAO study of the baseline facility needs and requires the Secretary to update this report every 5 years. 

Current law: Section 1631 requires consultation with Indian 

tribes prior to expending construction funds. In addition, it sets 

forth requirements to be met prior to closing any facility. This section also establishes and defines criteria for closure of health care 

facilities and sets forth reporting requirements. 

Section 302. Sanitation Facilities 

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 for new homes constructed 

using Department of Housing and Urban Development funds, (3) 

allows the Secretary to accept funds from all federal sources and 

may place those funds in ISDEAA agreements for sanitation facilities construction, (4) authorizes the Secretary to allows 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 standards for planning, design and construction of sanitation facilities to be developed through negotiated rulemaking, (7) requires consultation with Indian tribes in developing 

the 10-year plan for sanitation facilities, (8) 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, (9) clarifies the information required 

to be in the annual report and, (10) sets forth the definitions of the 

different levels of deficiencies. 

Current law: Section 1632 provides the findings, certain duties 

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. 

The Secretary is also required to submit a report to Congress on 

the status of sanitation facilities backlog and a 10-year plan for addressing it. 

Section 303. Preference to Indians and Indian firms 

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. 

Current law: Section 1633 authorizes the Secretary to use Indian 

preference for certain construction activities. 


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Section 304. Expenditure of nonservice funds for renovation 

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 negotiated rule-making 

with annual revisions developed through consultation. 

Current law: Section 1634 authorizes the Secretary to accept any 

expansion or renovation funded with non-Service funds in accordance with certain criteria. The Secretary is required to maintain a 

separate priority list for these facilities. 

Section 305. Funding for the construction, expansion and modernization of small ambulatory care facilities 

This section maintains current law and adds language which 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. 

Current law: Section 1636 establishes criteria for small ambulatory care facilities, including use of funds, grant application requirement priorities, and conditions for reversion of facilities. 

Section 306. Indian health care delivery demonstration project 

This section maintains current law and adds language which (1) 

requires consultation, (2) permits the use of IHS funds to match 

other funds, and (3) authorizes regulations to be developed through 

negotiated rule-making. 

Current law: Section 1637 authorizes the Secretary to establish 

demonstration projects to test alternative health care delivery systems through the construction and renovation of hospitals, health 

centers, health stations and other facilities. Section 1637 establishes criteria for the projects 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. This section also requires technical assistance and use of the same criteria 

in evaluating tribal and IHS facilities. 

Section 307. Land transfer 

This section amends current law by changing a specific authorization into a general authorization whereby Federal agencies may 

transfer, at no cost, land and improvements to the IHS for the provision of health care services, and the Secretary is authorized to accept the land. 

Current law: Section 1638 provides specific authorization for 

transferring 5 acres of land at the Chemawa Indian School to the 

IHS. 

Section 308. Leases, contracts and other agreements 

This section maintains current law and adds tribal organizations 

as eligible lessors. 


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Current law: Section 1674 authorizes the Secretary to enter into 

leases, contracts or other agreements with Indian Tribes for the delivery of health services at those facilities. The leases may also include provisions for construction, renovation and compensation. 

Section 309. Study for loans, loan guarantees and loan repayment 

This section is new. 

New provisions: Section 309 authorizes a study, using consultation, to determine the feasibility of a loan or loan guarantee fund 

for Indian health care facilities construction. A number of study requirements are delineated such as the maximum principal amount 

and term of the loan that should be offered, amount attributable 

for planning, appropriate security for the loan, and legislative or 

regulatory changes needed. 

Section 310. Tribal leasing 

This section is new. 

New provision: Section 310 authorizes a tribal health program to 

lease permanent structures without prior approval in appropriation 

Acts. 

Section 311. Indian Health Service/Tribal Facilities Joint Venture 

Program 

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 the criteria to be developed 

through negotiated rule-making, (3) requires negotiation for the 

continued operation of the facility at the end of the 10-year lease, 

(4) authorizes recovery in a proportional amount from the IHS if 

the IHS ceases to use the facility within the 10-year lease period, 

and (5) includes staff quarters in the definition of the health facilities under this section. 

Current law: Section 1680h(e) authorizes the Secretary to enter 

joint ventures with Indian Tribes, and provide staffing, equipment 

and supplies for the operation of the facility under a no-cost 10- 

year lease with the Indian Tribes in exchange for the tribal construction of the facility, in accordance with certain criteria. 

Section 312. Location of facilities 

This section maintains current law and adds language which (1) 

allows an Indian owner to request that the IHS locate facilities on 

his or her lands within tribal jurisdiction, subject to the priority for 

location being given to the Indian tribe and (2) adds, as part of the 

Indian lands for consideration under this section, all lands in Alaska owned by any Alaska Native village, or regional corporation 

under the Alaska Native Claims Settlement Act, or land allotted to 

an Alaska Native. 

Current law: Section 1680n sets forth certain priorities in locating health care facilities on Indian lands to address unemployment 

conditions in the economically depressed Indian communities, if requested by the Indian tribe with jurisdiction over the Indian lands. 

Section 1680n also defines ‘‘Indian lands’’. 


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Section 313. Maintenance and improvement of health care facilities 

This section is new. 

New provisions: Section 313 requires reporting of backlogs in 

maintenance and improvements for facilities and authorizes the 

use of funds to construct a replacement facility if the costs of renovation would exceed a maximum threshold cost to be developed 

through negotiated rule-making. 

Section 314. Tribal management of federally-owned quarters 

This section is new. 

New provisions: Section 314 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 federally-owned quarters and directly collect the rent. These 

quarters shall remain eligible for improvement and repair funds as 

other federally-owned quarters. The Tribal Health Programs operating the quarters are required to provide at least 60 days notice 

before changing the rental rate. 

Section 315. Applicability of Buy American Act requirement 

This section maintains current law, but exempts Indian tribes 

and tribal organizations from the requirements of the Buy American Act and eliminates a reporting requirement for purchases from 

FY 1993 to FY 1994. 

Current law: Section 1638b requires application of the Buy 

American Act for all procurement. 

Section 316. Other funding for facilities 

This section is new. 

New provisions: Section 316 authorizes the Secretary to accept 

funding from other sources for the construction of health care facilities and to transfer such funds to Indian tribes. The Secretary may 

also enter into interagency agreements for the planning, design 

and construction of health care facilities. 

Section 317. Authorization of appropriations 

This section maintains current law (found in Section 1638a), but 

extends the authorization for appropriations through fiscal year 

2015. 

TITLE IV—ACCESS TO HEALTH SERVICES 

Section 401. Treatment of payments under Social Security Act 

health care programs 

This section maintains current law and adds (1) tribal organizations and urban Indian organizations, in addition to tribes and the 

IHS for whom reimbursements would not be considered in determining appropriations, and (2) 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. 

However, this provision authorizing the Secretary to determine the 

uses shall not apply when the Indian tribes elect to receive reimbursements directly. 


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Current law: Sections 1641 and 1642 require that any Medicare 

or Medicaid payments received by the IHS or Indian tribes shall 

not be considered in determining appropriations for health care 

services, and that Indians without Medicare or Medicaid are given 

equal consideration as those Indians are who are covered by these 

programs. Section 1645 established a program under which tribes 

could elect to directly bill and be reimbursed health care services 

provided under Medicare, Medicaid or other third parties. Specifications are made as to how funds collected from Medicare or Medicaid are to be used. 

Section 402. Grants to and contracts with the service, Indian tribes, 

tribal organizations, and urban Indian organizations 

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 the Social Security Act programs. 

Current law: Section 402 requires the Secretary to make grants 

or enter into contracts with Tribes and Tribal Organizations to improve enrollment and participation in Medicare, Medicaid or 

SCHIP programs, such as paying premiums. In doing so, the Secretary shall place conditions as deemed necessary to effect the purpose of such funding. Additional agreements may be made in order 

to improve the receipt and processing of applications for enrollment 

of Indians under Social Security Act programs and to facilitate cooperation between States, the Service, Indian Tribes, Tribal Organizations, or Urban Indian Organizations. 

Section 403. Reimbursement from certain third parties of costs of 

health services 

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 from the tribe, (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. 

Current law: Section 403 allows an Indian Tribe or Tribal Organization to recover payment from third parties for health services 

provided to the same extent that an individual, or any nongovernmental provider of health 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 are all 

specified in this section. 

Section 404. Crediting of reimbursements 

This section maintains current law and adds language which 

identifies which programs are included in the reimbursements. 

Current law: Section 404 authorizes the retention of the reimbursements received from third parties and specifies the use of 

those amounts collected. This section also disallows any offset or 


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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. 

Section 405. Purchasing health care coverage 

This section is new. 

New provisions: Section 405 allows funding to be used for purchasing health insurance for Indians or to be used for a tribal selfinsurance plan and eliminates the study previously required to determine the feasibility of allowing Indian tribes to purchase managed care coverage for their members and the report to Congress 

on the study. 

Section 406. Sharing arrangements with Federal agencies 

This section amends current law by (1) authorizing the Secretary 

to enter agreements for sharing of medical facilities with the Departments of Veterans Affairs and Defense, instead of merely examining the feasibility of entering the agreements, (2) requiring 

consultation with Indian tribes prior to entering the agreements, 

(3) require reimbursement to the IHS, tribes, or tribal organizations by the VA where VA eligible beneficiaries receive care from 

the IHS, tribes or tribal organizations, (4) eliminating the specific 

cross-utilization of services in Utah only (expanding it generally), 

and (5) authorizing the Director of IHS to enter into interagency 

agreements to assist in achieving parity in services for Indians. 

Current law: Section 406 authorizes the Secretary to examine the 

feasibility of entering agreements to share medical facilities and 

services with the Departments of Veterans Affairs and Defense. 

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 Veterans’ Administration. 

Section 407. Payor of last resort 

This section is new. 

New provision: Section 407 codifies long-standing policy and 

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. 

Section 408. Nondiscrimination in qualifications for reimbursement 

for services 

This section is new. 

New provision: Section 408 codifies regulations under Title 42 of 

the Code of Federal Regulations and deems entities that are operated by the Service, an Indian Tribe, Tribal Organization, or Urban 

Indian Organization to be licensed or recognized under State or 

local law to furnish such services, for purposes of receiving payment or reimbursement from any federally funded health care program so long as these entities meet all applicable standards for licensure. 

Section 409. Consultation 

This section is new. 

New provision: Section 409 codifies the Centers for Medicaid and 

Medicare Services charter which recognized the Tribal Technical 


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Advisory Group established to assist the Secretary in identifying 

and addressing issues affecting Indians in health care programs 

under the Social Security Act. It also encourages a State to establish a process to seek advice on a regular basis from designees of 

Indian Health Programs and Urban Indian Organizations. 

Section 410. State Children’s Health Insurance Program (SCHIP) 

This section is new. 

New provision: Section 410 allows the Secretary to enter arrangements with individual States to allow SCHIP funds for Indians to be provided to Indian Health Programs for providing child 

health assistance to targeted low-income Indian children, consistent with the purposes of SCHIP. 

Section 411. Social Security Act sanctions 

This section is new. 

New provision: Section 411 allows Indian Health Programs to request a waiver of a sanction imposed against a health care provider 

in the event the State does not act upon a tribal request to the 

State to seek the waiver. A safe harbor clause from anti-kickback 

sanctions is included in this section for referrals, transactions or 

exchanges between and among Indian Health Care Programs. 

Section 412. Cost sharing 

This section is new. 

New provisions: Section 412 addresses coinsurance, copayments, 

and deductibles, and exempts Indians from such cost sharing. Section 412 provides an exemption from premium payments for Indians eligible for Medicaid and SCHIP programs. Section 412 also excludes certain trust, restricted, cultural or subsistence Indian property from the Medicaid eligibility determinations or Medicaid estate recovery. 

Section 413. Treatment under Medicaid managed care 

This section is new. 

New provisions: Section 413 specifies actions to be taken for payment for services furnished to Indians in Medicaid managed care 

programs. This section also allows Medicaid managed care programs to be offered by Indian Health Programs and provides the 

requirements for these programs. 

Section 414. Navajo Nation Medicaid Agency feasibility study 

This section is new. 

New provisions: 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 and a report of 

the results of the study are described in this section. 

Section 415. Authorization of appropriations 

This section maintains current law and extends the authorization for appropriations to fiscal year 2015. 

Current law: Section 415 authorizes appropriations of such sums 

as may be necessary for each fiscal year through fiscal year 2000 

to carry out this title. 


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TITLE V—HEALTH SERVICES FOR URBAN INDIANS 

Section 501. Purpose 

This section maintains current law and adds language to maintain and make health services available, in addition to being accessible to urban Indians. 

Current law: Section 1651 sets forth the purpose of the title 

which is to establish programs in urban center to make health care 

accessible to urban Indians. 

Section 502. Contracts with, and grants to, urban Indian organizations 

This section maintains current law. 

Current law: Section 1652 sets forth the authority of the Secretary to enter contracts with or make grants to Urban Indian Organizations including prescribing the criteria for selecting urban 

Indian organizations and making recommendations for improving 

health programs for urban Indians. 

Section 503. Contracts and grants for the provision of health care 

and referral services 

This section maintains current law. 

Current law: Section 1653 sets forth the standards, criteria and 

uses of funds for contracts and grants for health care services. The 

grants require that the urban Indian organization estimate the 

service population, health care needs and status of the urban Indians, provide basic health education and make recommendations for 

improving health programs. The grants may be made to provide 

outreach, educational, outpatient behavioral health services, develop innovative service delivery models, health promotion and immunization services. 

Section 504. Contracts and grants for the determination of unmet 

health care needs 

This section maintains current law. 

Current law: Section 1654 authorizes the Secretary to enter into 

contracts under the Snyder Act, 25 U.S.C. 13, to urban Indian organizations who does not have a contract under section 1654. Section 1654 sets forth the standards, criteria and uses of funds for 

contracts and grants to determine unmet health care needs of 

urban Indians. 

Section 505. Evaluations; renewals 

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. 

Current law: Section 1655 authorizes the Secretary to develop 

evaluation and renewal standards for the various contracts and 

grants. The Secretary shall also evaluate the urban Indian programs through onsite annual evaluations. 

Section 506. Other contract and grant requirements 

This section maintains current law and adds provisions which 

would allow lump sum payments unless the urban Indian organizaVerDate Aug 31 2005 11:50 Mar 23, 2006 Jkt 049010 PO 00000 Frm 00049 Fmt 6659 Sfmt 6602 E:\HR\OC\SR222.XXX SR222

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tion is not capable of administering the payments in their entirety 

and allows the funding to be carried forward. 

Current law: Section 1656 sets forth other specific contract and 

grant requirements such as payment methods, procurement and 

amendments. 

Section 507. Reports and records 

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 and that the audits may also be conducted by a certified 

public accounting firm and (3) deletes the requirement that IHS 

and the Department of Interior report to Congress by March 31, 

1992, on the health status, unmet needs and welfare of urban Indian children. 

Current law: Section 1657 sets forth certain reporting and recordkeeping requirements for Urban Indian Organizations. 

Section 508. Limitation on contract authority 

This section maintains current law and adds language which includes authority to award grants. 

Current law: Section 1658 limits contracts to the amount of appropriations. 

Section 509. Facilities 

This section maintains current law and adds provisions which 

would allow for leasing, purchasing, renovating, constructing and 

expanding, in addition to repairing, facilities and authorizes a 

study for a revolving loan fund to construct facilities. 

Current law: Section 1659 sets forth the various requirements 

governing the funding for urban health care facilities and 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 maintains current law, but changes the Branch of 

Urban Indian programs into an Office within the IHS. 

Current law: Section 1660 establishes a Branch of Urban Indian 

Health within the IHS. 

Section 511. Grants for alcohol and substance abuse related services 

This section maintains current law. 

Current law: Section 1660a authorizes the Secretary to make 

grants for alcohol and substance abuse services to urban Indian organizations. Section 511 also establishes criteria for alcohol and 

substance abuse grants. 

Section 512. Treatment of certain demonstration projects 

This section maintains provisions which makes permanent certain demonstration projects in Oklahoma and requires them to 

meet the requirements of Title V, but will be treated as service 

units, and the funding shall not be subject to the ISDEAA. 


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Section 513. Urban NIAAA transferred programs 

This section maintains current law, but changes the date of the 

transfer from September 30, 2001 to September 30, 2008. 

Current law: Section 1660c authorizes the Secretary to transfer 

to Urban Indian Organizations alcohol programs that had been 

previously transferred to the Secretary. 

Section 514. Consultation with urban Indian organizations 

This section is new. 

New provision: Section 514 establishes consultation requirements 

with Urban Indian Organizations including a definition of consultation. 

Section 515. Federal Tort Claim Act coverage 

This section is new. 

New provision: Section 515 authorizes Urban Indian Organizations to be deemed an executive agency for Federal Tort Claim Act 

coverage. 

Section 516. Urban youth treatment center demonstration 

This section is new. 

New provision: Section 516 authorizes the Secretary to fund at 

least 2 Indian youth treatment centers in certain states where 

urban centers are located. 

Section 517. Use of Federal Government facilities and sources of 

supply 

This section is new. 

New provisions: Section 517 authorizes the Urban Indian Organizations to receive donations of Federal excess property and, for purposes of 40 CFR 501, and deems them to be executive agencies for 

access to the Federal sources of supply. 

Section 518. Grants for diabetes prevention, treatment and control 

This section is new. 

New provisions: Section 518 authorizes the Secretary to make 

grants for diabetes prevention, treatment and control. Section 518 

sets forth requirements and criteria for diabetes grants, such as 

the size and location of the urban Indian population, the need and 

performance standards. 

Section 519. Community health representatives 

This section is new. 

New provision: Section 519 authorizes the Secretary to contract 

with the urban Indian organizations to provide community health 

representatives. 

Section 520. Effective date 

This section is new. 

New provision: Section 520 establishes that the effective date for 

the amendments made by this Act begins on the date of enactment 

regardless of whether the Secretary has issued regulations. 

Section 521. Eligibility for services 

This section is new. 


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New provision: Section 521 establishes that urban Indians are 

the ultimate beneficiaries of the services under this title. 

Section 522. Authorization of appropriations 

This section maintains current law and extends the authorization to fiscal year 2015. 

Current law: Section 522 authorizes appropriations through fiscal year 2015. 

TITLE VI—ORGANIZATIONAL IMPROVEMENTS 

Section 601. Establishment of the Indian Health Service as an agency of the Public Health Service 

This section amends current law by changing the position of the 

Director into an Assistant Secretary. 

Current law: Section 1661 establishes the Indian Health Service 

within the Public Health Service of the Department, and the position of Director of the Indian Health Service who shall be confirmed by the Senate with a term of four years. The Director shall 

administer the Indian Health Service and the Director’s duties and 

responsibilities are outlined in this section, including managing 

funds, entering contracts, all functions relating to the management 

of hospitals and facilities. 

Section 602. Automated management information system 

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: Section 1662 requires the Secretary to establish an 

automated management information system for the Service and 

each Tribal Health Program. It requires that patients have access 

to their own health records. 

Section 603. Authorization of appropriations 

This section maintains current law and extends the authorization to fiscal year 2015. 

Current law: Section 1663 authorizes appropriated funds in sums 

that may be necessary to carry out this title, for each fiscal year 

through fiscal year 2000. 

TITLE VII—BEHAVIORAL HEALTH PROGRAMS 

Section 701. Behavioral health prevention and treatment services 

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 and urban Indian organizations, (3) requires 

a continuum of care for behavioral health to the extent feasible including acute hospitalization, detoxification, and emergency shelter. 

Current law: Section 1621h and Section 1665 state the purposes 

of the section; requires the Secretary to encourage the development 

of plans for delivery of Indian mental Health Services; directs the 

Secretary to provide comprehensive mental health care programs; 


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facilitates the governing body of any Indian Tribe, Tribal Organization, or Urban Indian Organization to establish community mental 

health plans; requires the Secretary to coordinate mental health 

planning; and directs the Secretary to assess the need, availability 

and cost for inpatient mental health care for Indians. 

Section 702. Memoranda of agreement with the Department of the 

Interior 

This section maintains current law and adds language which requires the Secretary to update existing Memoranda of Agreement 

and adds tribal organizations and to consult with Indian tribes, 

tribal and urban Indian organizations in developing the Memoranda which shall be published in the Federal Register. 

Current law: Section 1621h(b) requires the Secretary to develop 

and enter memoranda of agreement with the Secretary of the Interior 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. 

Section 703. Comprehensive Behavioral Health Prevention and 

Treatment Program 

This section amends current law by changing the alcohol and 

substance abuse focus to comprehensive behavioral health and 

adds more specific types of treatment such as residential and intensive outpatient treatment and by requiring consent of Indian tribes 

to be served before the Secretary enters contracts with private or 

other public health providers to provide the services under this section. 

Current law: Section 1665a requires the Secretary to provide a 

program of comprehensive behavioral health, prevention, treatment, and aftercare. The Secretary may provide these services 

through Contract Health Services. 

Section 704. Mental Health Technician Program 

This section maintains current law and adds the use and promotion of traditional health care practices. 

Current law: Section 1621h(g) establishes a mental health technician program within the Service, requiring high-standard paraprofessional training in mental health care, supervision and evaluation of technicians. 

Section 705. Licensing requirement for mental health care workers 

This section maintains current law. 

Current law: Section 1621h(l) requires that any person employed 

as a psychologist, social worker, or marriage and family therapist, 

be licensed to provide those services or be supervised by one who 

is licensed. 

Section 706. Indian women treatment programs 

This section maintains current law and adds language which requires the implementation of this section to be consistent with section 701, recognizes the behavioral health focus and requires consultation with Indian tribes and tribal organizations in establishing 

criteria for applications. 


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Current law: Section 1665b authorizes funding to develop and 

implement a program of prevention, intervention, treatment, and 

relapse prevention services for alcohol and substance abuse, specifically addressing the cultural, historical, social, and childcare needs 

of Indian women. How funds are to be used is specified in this section, including the development of community training, counseling 

and prevention models. 

Section 707. Indian Youth Program 

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, (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: Section 1665c requires the development and implementation of a program for detoxification and rehabilitation of Indian youth. It also establishes alcohol and substance abuse treatment centers or facilities for Indian youth. Additional provisions 

addressed in this section are: intermediate adolescent behavioral 

health services; use of Federally owned structures; rehabilitation 

and aftercare services; inclusion of family in youth treatment programs; and a study for the feasibility of multi-drug abuse programs. 

Section 708. Indian Youth Telemental Health Demonstration Project 

This section is new. 

New provisions: This section authorizes the Secretary to carry 

out a four-year demonstration project under which five Tribes, 

Tribal Organizations or Urban Indian 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, Tribal Organizations or Urban 

Indian 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 partnership to provide the services; or 

operating a detention facility at which 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. 


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Section 709. Inpatient and community-based mental health facilities 

design, construction, and staffing 

This section amends current law by requiring the establishment 

in each Area at least one inpatient mental health facility and determining that California shall be considered two Areas. 

Current law: Section 1621h(i) states within one year after enactment, the Secretary shall make an assessment of the need for inpatient mental health care facilities, including the conversion of 

under utilized hospital beds into psychiatric units to meet the 

needs. 

Section 710. Training and community education 

This section maintains current law and adds language which authorizes the Indian tribes and tribal organizations to develop training and community education programs, defines community based 

training, adds child sexual abuse to the types of training authorized and recognizes the behavioral health focus. 

Current law: Section 1621h(d) requires that the Secretary, in cooperation with the Secretary of the Interior, provide either directly 

or through funding, a program of community education in the area 

of behavioral health. Specifics of instruction are delineated. This 

section also requires the Secretary to develop and provide community-based training models. 

Section 711. Behavioral Health Program 

This section maintains current law and adds the tribal organizations as eligible recipients for funding under this section. 

Current law: Section 1621h allows for the development of innovative community-based behavioral health programs; suggests criteria to be used for funding such programs; and requires that the 

same criteria as used in evaluating other funding proposals be used 

for programs under this section. 

Section 712. Fetal alcohol disorder programs 

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, the development of early childhood intervention 

projects, supportive services, (4) including the National Institute 

for Child Health and Human Development and the Centers for Disease Control and Prevention in the national task force on FAD. 

Current law: Section 1665g authorizes the Secretary to establish 

fetal alcohol syndrome and effects programs, to include the development and provision of services for the prevention, intervention, 

treatment, and aftercare for those affected by fetal alcohol disorders in Indian communities. In addition a Fetal Alcohol Task 

Force is established to advise the Secretary. Funding is to be made 

available 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 included and 10% of the funding is set aside for 

urban programs. 


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Section 713. Child sexual abuse and prevention treatment programs 

This section amends current law by (1) turning two specific demonstration projects into permanent programs, (2) authorizing services for Indian child victims of sexual abuse and perpetrators of 

child sexual abuse who are members of an Indian household, and 

(3) including authorized uses of funds such as developing community education, identifying and providing treatment to victims, developing culturally-sensitive prevention models and diagnostic 

tools, providing treatment to the perpetrators. 

Current law: Section 1680i establishes demonstration projects for 

Child Sexual Abuse and Prevention Treatment Programs through 

the Hopi Tribe 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 Areas. 

Section 714. Behavioral health research 

This section maintains current law and adds language which emphasizes the focus on behavioral health instead of only mental 

health problems. 

Current law: Section 1621h provides for funding for research on 

the incidence and prevalence of behavioral health problems among 

Indians. Research priorities are specified such as the interrelationship of mental disorders with alcoholism, suicide, homicide, and the 

incidence of family violence. 

Section 715. Definitions 

This section is new. 

New provisions: Section 715 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. 

Section 716. Authorization of appropriations 

This section maintains current law and extends the authorization to fiscal year 2015 and eliminates the exceptions for sections 

that had specific terms of authorization. 

Current law: Section 1621w authorizes such sums as may be necessary to carry out this section, for each fiscal year through fiscal 

year 2000, except for section 703, 706, 708, 710 and 711. 

TITLE VIII—MISCELLANEOUS 

Section 801. Reports 

This section maintains current law and adds provisions which either establish new reporting requirements or consolidates the information required in other sections in one organized list such as (1) 

requiring as part of the annual reports to Congress (a) comparisons 

of appropriations provided and required for parity in health services, (b) services provided under ISDEAA agreements, (c) information on the loan repayments, 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. 


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Current law: Section 1671 requires annual reports which outline 

the progress made in meeting health objectives, whether new national programs are needed, steps taken to consult with Indian 

tribes, separate statements for funding requested and obligated 

and other reporting requirements under this Act. 

Section 802. Regulations 

This section is new. 

New provision: Section 802 sets forth the various requirements 

for regulations, including negotiated rule-making, for certain titles 

under this Act. Proposed regulations are required to be published 

in the Federal Register no later than 270 days after enactment. 

This section authorizes a negotiated rule-making committee consisting of Indian tribes, tribal and urban Indian organizations. 

Section 803. Plan of implementation 

This new section requires a plan of implementation of this Act 

to be submitted to Congress. 

Section 804. Availability of funds 

This section maintains current law. 

Current law: Section 1675 authorizes funding to remain available 

until expended. 

Section 805. Limitation on use of funds appropriated to the Indian 

Health Service 

This section maintains current law. 

Current law: Section 1676 recognizes that any limitation contained in DHHS appropriations on the use of federal funds for 

abortions shall apply for that period with respect to use of IHS 

funds. 

Section 806. Eligibility of California Indians 

This section maintains current law, but eliminates the Secretarial report developing data on the Indians located in California, 

health status and needs and other information. 

Current law: Section 1679 requires that until other federal law 

provides otherwise, Indians located in California shall be eligible 

for health services from under this Act, including 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 asset distribution 

in California. 

Section 807. Health services for ineligible persons 

This section maintains current law and adds language to include 

compacts, in addition to contracts, under the ISDEAA. 

Current law: Section 1680c authorizes services for certain ineligible persons under limited circumstances, including spouses or 

children of eligible Indians, non-Indian women carrying Indian babies, persons in need of emergency stabilization or prevention of 

communicable diseases, and outlines criteria for providing services 

such as requiring reimbursement and tribal approval. 


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Section 808. Reallocation of base services 

This section maintains current law. 

Current law: Section 1680g limits the reallocation of base funding upon certain requirements, such as reporting to Congress on 

the proposed changes and likely effects, the Secretary must fulfill. 

Section 809. Results of demonstration projects 

This section maintains current law. 

Current law: Section 1680m requires that results of demonstration projects be made available to Indian tribes. 

Section 810. Provision of services in Montana 

This section is new. 

Current law: Section 810 requires that services and benefits for 

Indians in Montana be provided consistent with the court decision 

McNabb v. Bowen, 829 F.2d 787 (9th Cir. 1987), but that this requirement shall not be construed as the sense of the Congress for 

Indians in any other state. 

Section 811. Moratorium 

This section authorizes the Service to provide certain services according to eligibility criteria in effect on a certain date. 

Section 812. Tribal employment 

This section is new. 

New provision: Section 812 recognizes the governmental purposes of health care by treating Indian tribes or tribal organizations not as an employer for certain purposes. 

Section 813. Severability provisions 

This section retains remaining provisions if others are stricken 

by any court. 

Section 814. Establishment of national bipartisan commission on 

Indian health care 

This section is new. 

New provisions: Section 814 establishes a bi-partisan commission 

to study the delivery of health care services to Indians and sets 

forth (1) duties, such as holding hearings, consulting with Indian 

tribes, making recommendations and findings which have evaluated the needs, services available, costs and mechanisms for funding, (2) membership made up of 25 members, 10 from Congress, 12 

chosen by Congressional Members from each IHS Area and shall 

be members of federally-recognized tribes, 3 chosen by the Assistant Secretary for Indian Health, and (3) reporting requirements. 

This section (1) authorizes appointment of a Director and staff for 

the Commission, (2) establishes their compensation, and (3) authorizes details of federal employees, use of mails, technical assistance 

and administrative support services. This section authorizes $4 

million for the Commission. 

Section 815. Appropriations; availability 

This section maintains current law subjects new spending authority to the availability of appropriations. 


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Section 816. Authorization of appropriations. 

This section maintains current law and extends the authorization to fiscal year 2015. 

Current law: Section 1680o authorizes appropriations through 

fiscal year 2000. 

OTHER SECTIONS OF THE BILL 

Section 2(b). Indian Health Care Improvement Act amended. 

Section 2 of the bill is new. 

New provision: Section 2(b) also 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’’. 

Section 3. Soboba sanitation facilities. Section 3 of the bill retains 

current law. 

Current law: Section 3 authorizes sanitation facilities to the 

Soboba Band of Mission Indians, pursuant to the Act of December 

17, 1970 (84 Stat. 1465). 

Section 4. Amendments to the Medicaid and State Children’s 

Health Insurance Programs. Section 4 of the bill sets forth conforming amendments to the Social Security Act for Medicaid and 

State Children’s Health Insurance Programs which authorize reimbursement to Indian Health Programs for medical assistance provided. 

Section 5. Native American Health and Wellness Foundation. 

Section 5 is new and sets forth amendments to the Indian Self-Determination and Education Assistance Act to establish a Native 

American Health and Wellness Foundation in the following sections 801 to 803. 

Section 801. Definitions 

This section sets forth definitions for the Foundation, the Foundation Board of Directors and establishment Committee. 

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. 

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. 


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87Senate Report No. 108–411 provides a detailed chronology of the legislative activity that 

has occurred since the 106th Congress. 

LEGISLATIVE HISTORY

LEGISLATIVE ACTION

During the 109th Congress,87 Senator McCain introduced S. 

1057, the Indian Health Care Improvement Act Amendments of 

2005, on May 17, 2005, for himself and Senator Dorgan. The bill 

was referred to the Committee on Indian Affairs and reported favorably with amendments on October 27, 2005. 

On June 7, 2005, Senator Johnson was added as a cosponsor. On 

July 14, 2005, Senators Kennedy and Bingaman were added as cosponsors. On October 24, 2005, Senators Cantwell and Murray 

were added as cosponsors. 

LEGISLATIVE HEARINGS

The Committee has held nine hearings since the 106th Congress 

on the reauthorization of the Act. 

During the 109th Congress, on July 14, 2005, the Committee 

held a joint hearing with the Senate Committee on Health, Education, Labor and Pensions to reauthorize the IHCIA. The hearing 

addressed the need for reauthorization and several key issues, including negotiated rulemaking, Federal Tort Claim Act coverage 

and the DHAT program. The witnesses included DHHS, members 

of the National Steering Committee, tribal leaders and health providers and the American Dental Association. 

COMMITTEE RECOMMENDATION AND TABULATION OF VOTES

In an open business session on October 27, 2005, the Committee 

considered a substitute amendment proposed by Senator McCain 

and other amendments offered by Senators Dorgan, Crapo, Coburn, 

and McCain. The Committee adopted the amendment offered by 

Senator McCain by unanimous consent. 

The Committee adopted by voice vote the amendments offered by 

Senators Dorgan and Crapo. The Committee, by roll call vote, rejected the amendment offered by Senator Coburn. Then, by a unanimous vote, the Committee ordered the substitute amendment, as 

amended, favorably reported to the full Senate 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 to evaluate the 

regulatory and paperwork impact that would be incurred in carrying out the bill. The Committee has concluded that S. 1057 will 

not require the promulgation of regulations so the regulatory and 

paperwork impact should be minimal. 

EXECUTIVE COMMUNICATIONS

The Committee has not received any formal communication on S. 

1057 from the Administration other than the written testimony 

from the Department of Health and Human Services submitted at 


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the Joint Hearing on S. 1057 on July 14, 2005, which is attached 

hereto as an Exhibit. 

STATEMENT OF DR. CHARLES W. GRIM, DIRECTOR, INDIAN

HEALTH SERVICE, DEPARTMENT OF HEALTH AND HUMAN

SERVICES

Mr. Chairmen and Members of the Committees: 

I am honored to testify before you today on the important issue of reauthorization of the Indian Health Care Improvement Act (IHCIA). Accompanying me today are Robert McSwain, Deputy Directory, Craig Vanderwagen, M.D., 

Acting Chief Medical Officer, and Gary Hartz, Director, Office of Environmental Health and Engineering. 

This landmark legislation forms the backbone of the system through which Federal health programs serve American Indians/Alaska Natives and encourages participation 

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 based on 

judicial decisions and statutes. The mission of the agency 

is to raise the physical, mental, social, and spiritual health 

of American Indians/Alaska Natives to the highest levels, 

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 foundation 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. 


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DHHS ACTIVITIES

Since enactment of the IHCIA in 1976, statutory authority has substantially expanded programs and activities 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 gives the IHS Director a 

highly visible role within the Department on Indian policy, 

where he serves as vice chairperson of the Council. 

The Department has also recently completed work ushering through a revised HHS Tribal consultation policy 

and involving Tribal leaders in the process. This new 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 its 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. Last year, Tribes identified inflation 

and population growth as their top budget priorities and 

IHS’s FY 2006 budget request included an increase of $80 

million for these items. Both the House and the Senate 

have included these increases in FY 2006 appropriations 

action, and we appreciate their efforts in this regard. 

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 of 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. 

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, 

tuberculosis, 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. 


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The IHCIA was enacted to provide basic primary and 

preventive services in recognition of the Federal government’s unique relationship with members of Federally recognized Tribes. Members of Federally recognized Tribes 

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 S. 1057. 

S. 1057

We are here today to discuss reauthorization of the 

IHCIA, and its impact on programs and services provided 

for in current law. Improving access to healthcare for all 

eligible American Indians and Alaska Natives is critical to 

the Department and a priority for all of those involved in 

the administration of these important programs. We, 

therefore, commend your interest and will note positive 

provisions in S. 1057. However, we will also note concern 

on provisions which may negatively impact our ability to 

provide needed access to services by establishing program 

mandates and burdensome requirements that may divert 

resources from important services. We hope to work with 

you to address these issues. 

The Department brings a keen awareness of the health 

care needs of Indian country and is supportive of reauthorization of the IHCIA. We support provisions that increase 

the flexibility of the Department to work with Tribes, to 

increase the availability of health care, including new approaches to delivering care, and to expand the range of options of health services available to eligible American Indians and Alaska Natives. Accordingly, I commend Congress 

for including in S. 1057 various changes that respond to 

concerns raised in previous proposals. Some of these 

changes go a long way toward improving the ability of the 

Secretary to effectively manage the program within current budgetary resources. 

Moreover, I would like to note our particular interest in 

other provisions of S. 1057. 

In the area of behavioral health, title VII of S. 1057 provides 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. 

PROVISIONS RELATED TO MEDICARE AND MEDICAID

In general, we believe the provisions of the bill that relate to the Medicaid and State Children’s Health InsurVerDate Aug 31 2005 11:50 Mar 23, 2006 Jkt 049010 PO 00000 Frm 00063 Fmt 6659 Sfmt 6969 E:\HR\OC\SR222.XXX SR222

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ance (SCHIP) programs should be considered by the authorizing committees and in a framework consistent with 

the FY 2006 Budget Resolution and the Reconciliation 

process. As part of the larger Resolution and Reconciliation 

process, a Medicaid Commission was established to examine many aspects of that program. The Commission is 

charged with advising the Secretary on ways to modernize 

the Medicaid program so that it can provide high-quality 

health care to its beneficiaries in a financially sustainable 

way. Tribes are represented on the Commission through 

Secretary Leavitt’s recent appointment of the Chair of the 

Centers for Medicaid and Medicaid Services Tribal Technical Advisory Group. 

REPORTING REQUIREMENTS

S. 1057 includes new requirements for reporting to Congress within the President’s Budget. The IHS and HHS 

will work with Congress to provide the most complete and 

relevant information on IHS programs, activities, and performance. However, we recommend striking language that 

provides additional specificity about what should be included in the President’s budget request. 

INDIAN HEALTH PROFESSIONS SCHOLARSHIPS

Currently, the scholarship program regularly consults 

with the I/T/U’s to determine the priorities. Each year, the 

program sends letters to all tribal chairmen, tribal health 

directors, urban program directors, IHS clinical directors, 

and IHS headquarters offices. Through this communication, scholarship program staff will update the relevant 

parties regarding the health professions for which awards 

were made in the current year and ask for their recommendations for the professions for which awards should 

be made in the coming year. Recommendations are aggregated and reviewed with the Office of Public Health and 

the Office of Management Support to determine which professions will be funded for the coming year. 

New section 104(a)(2) proposes to allocate the program 

funding by formula to the twelve IHS areas. If allocation 

by formula is authorized Indian, students will not be given 

an opportunity to apply for a scholarship if their area does 

not receive adequate allocation and if their profession is 

not considered a priority in their area; e.g., dental hygienist, physical therapist, medical technology. This would 

even impact a medical student who has identified general 

surgery or general psychiatry as a specialty. They will not 

receive the scholarship, because it is not a priority or there 

are no positions available for these disciplines/specialties. 

We are concerned that the large areas will receive the 

greatest amount of appropriated funds, leaving the smaller 

areas with amounts sufficient to fund only a small portion 

of their health professional needs. If an area chooses to allocate the funds among the tribes within the area, funds 

available to many will be insufficient to support even one 

student. 


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We recommend retaining the provision in current law 

which would maintain the national focus of the scholarship 

program to more appropriately meet the health professions 

needs of Indian country. 

DIABETES EVALUATION AND COORDINATION

The bill has eliminated the current requirement for an 

evaluation of the 20 model diabetes programs for effectiveness and for each Area to employ at least one diabetes control officer, commonly now known as the Area Diabetes 

Consultant/Coordinator, to coordinate and manage on a 

full-time basis activities within the Area Office for the prevention, treatment, and control of diabetes. Area Diabetes 

Consultants/Coordinators are critical to the ability of the 

Service to provide support to the local Indian health programs as they implement the Special Diabetes for Indians 

Program formula and competitive grants programs. The 

evaluation provision for the model diabetes programs also 

is important to ensure that this program’s effectiveness is 

assessed to make sure it maintains a productive role in the 

context of the implementation of the Special Diabetes for 

Indians Program at the local level. Both the National Diabetes Program and the Tribal Leaders Diabetes Committee 

(TLDC) have advocated for Area Diabetes Consultant/Coordinators. 

We recommend that the requirement to employ at least 

one diabetes control officer in each of the 12 areas, as well 

as the requirement to evaluate the effectiveness of services 

provided through model diabetes projects established 

under this section, be retained. 

HEALTH CARE 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. There are 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 AND REPORT

New section 301(d)91) authorizes 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 be required by 

the bill. The plan is to base our future facilities construction priority system methodology application on a more 

complete listing 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 


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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. This would allow the IHS to complete its 

new priority construction methodology which will address 

the future federal and tribal health facility needs. 

RETROACTIVE FUNDING OF JOINT VENTURE CONSTRUCTION

PROJECTS

New 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. An 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 and recommend that it be deleted. 

SANITATION FACILITIES DEFICIENCY DEFINITIONS

New section 302(h)(4) provides definitions of the sanitation deficiencies used to identify and prioritize water and 

sewer projects in Indian country, which are ambiguous. As 

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, through 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 as more appropriate for distinguishing the various levels of deficiencies 

which determine the allocation of existing resources. 


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THRESHOLD CRITERIA FOR SMALL AMBULATORY PROGRAM

New Section 305(b)(1) amends current law to set two 

minimum thresholds—one for number of patient visits and 

another for the number of eligible Indians. In order to be 

eligible under the criteria of S. 1057, a facility must provide at least 150 patient visits annually in a service area 

with no fewer than 1500 eligible Indians. Aside from the 

fact that these are both minimum thresholds and so somewhat contradictory, the new makes implementation difficult. First, the IHS cannot validate patient visits unless 

the applicant participates in the Resource Patient Management System (RPNS). 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. In order to make the language clear and equitable, the provision should provide one minimum threshold that can be validated. 

NEW NEGOTIATED RULEMAKING AND CONSULTATION

REQUIREMENTS

We are concerned about the remaining 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 and urban Indian organizations under current Executive Orders, as well as promulgating regulations where necessary to carry out IHCIA 

using the procedures required by Chapter V of title 6, 

United States Code (commonly known as the Administrative Procedures Act). 

We have other objections to S. 1057, including, for example: new requirements using ‘‘shall’’ instead of ‘‘may’’ in 

provisions that will create budget pressures on current 

program activity; expansion of the scope of Federal Torts 

Claim Coverage for service provided to otherwise ineligible 

non-Indians; expansion of authorities for Urban Indian Organizations; elimination of the term ‘‘grant’’ and replacement with the term ‘‘funding’’; 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). The 

Administration may also have additional views on this legislation. 

I reiterate our commitment to working with you to reauthorize of the Indian Health Care Improvement Act, and 

the strengthening of Indian health care programs. I hope 

to work with this Committee and other Committees of the 

Congress, the National Tribal Steering Committee, and 

other 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 


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you today to discuss this important legislative proposal. I 

will be pleased to try to answer any questions that you 

may have. Thank you. 

COST ESTIMATES

The Committee has not yet received the final cost estimate from 

the Congressional Budget Office. 

CHANGES IN EXISTING LAW

In compliance with subsection 12 of rule XXVI of the Standing 

Rules of the Senate, the Committee states that the enactment of 

S. 1057 will result in the following changes in existing law (existing 

law proposed to be omitted enclosed in black brackets, new language to be added in italic, and existing law in which no change 

is proposed shown in roman): 

UNITED STATES CODE ANNOTATED 

TITLE 25. INDIANS 

CHAPTER 18—INDIAN HEALTH CARE 

GENERAL PROVISIONS 

Sec. 

1. Short title; table of contents 

1601. øCongressional f¿Findings. 

1602. Declaration of National Indian health øobjectives¿ policy. 

1603. Definitions. 

øSUBCHAPTER¿ TITLE I—INDIAN HEALTH, 

HUMAN RESOURCES, AND DEVELOPMENT 

øPROFESSIONAL PERSONNEL¿ 

1611. øCongressional statement of p¿Purpose. 

1612. Health øp¿Professions ør¿Recruitment øp¿Program for Indians. 

1613. Health øp¿Professions øp¿Preparatory øs¿Scholarship øp¿Program for Indians. 

1613a. Indian health professions scholarships. 

105. American Indians into Psychology program. 

106. Scholarship programs for Indian Tribes. 

1614. Indian health service extern programs. 

1615. Continuing education allowances. 

1616. Community Health Representative Program. 

1616a. Indian Health Service Loan Repayment Program. 

1616a–1. Scholarship and øL¿loan øR¿repayment øR¿recovery øF¿fund. 

1616b. Recruitment activities. 

1616c. øTribal¿ Indian recruitment and retention program. 

1616d. Advanced training and research. 

1616e. Quentin N. Burdick American Indians into øN¿nursing program. 

ø1616e–1. Nursing school clinics.¿ 

1616f. Tribal cultural orientation øculture and history.¿ 

1616g. INMED Program. 

1616h. Health training programs of community colleges. 

ø1616i. Additional incentives for health professionals.¿ 

1616j. Retention bonus. 

1616k. Nursing residency program. 

1616l. Community Health Aide Program. 

ø1616m. Matching grants to tribes for scholarship programs.¿ 


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1616n. Tribal health program administration. 

123. Health professional chronic shortage demonstration programs. 

124. National Health Service Corps. 

125. Substance abuse counselor education curricula demonstration programs. 

126. Behavioral health training and community education programs. 

ø1616o. University of South Dakota pilot program.¿ 

1616p. Authorization of appropriations. 

øSUBCHAPTER¿ TITLE II—HEALTH SERVICES 

1621. Indian Health Care Improvement Fund. 

1621a. Catastrophic øh¿Health øe¿Emergency øf¿Fund. 

1621b. Health promotion and disease prevention services. 

1621c. Diabetes prevention, treatment, and control. 

205. Shared services for long-term care. 

ø1621d. Hospice care feasibility study.¿ 

ø1621e. Reimbursement from certain third parties of costs of health services.¿ 

ø1621f. Crediting of reimbursements.¿ 

1621g. Health services research. 

207. Mammography and other cancer screening. 

ø1621h. Mental health prevention and treatment services.¿ 

ø1621i. Managed care feasibility study.¿ 

ø1621j. California contract health services demonstration program.¿ 

ø1621k. Coverage of screening mammography.¿ 

1621l. Patient travel costs. 

1621m. Epidemiology centers. 

1621n. Comprehensive øschool¿ health education programs. 

1621o. Indian øy¿Youth øgrant¿ øp¿Program. 

ø1621p. American Indians Into Psychology Program.¿ 

1621q. Prevention, control, and elimination of øtuberculosis¿ communicable and infectious diseases. 

213. Authority for provision of other services. 

214. Indian women’s health care. 

215. Environmental and nuclear health hazards. 

216. Arizona as a contract health service delivery area. 

216A. North Dakota and South Dakota as a contract health service delivery area. 

217. California contract health services program. 

218. California as a contract health service delivery area. 

219. Contract health services for the Trenton Service Area. 

220. Programs operated by Indian Tribes and Tribal Organizations. 

221. Licensing. 

222. Notification of provision of emergency contract health services. 

223. Prompt action on payment of claims. 

ø1621r. Contract health services payment study.¿ 

ø1621s. Prompt action on payment of claims.¿ 

ø1621t. Demonstration of electronic claims processing.¿ 

1621u. Liability for payment. 

ø1621v. Office of Indian Women’s Health Care.¿ 

225. Office of Indian Men’s Health. 

1621w. Authorization of appropriations. 

ø1621x. Limitation on use of funds.¿ 

ø1622. Transferred.¿ 

øSUBCHAPTER¿ TITLE III—øHEALTH¿ 

FACILITIES 

1631. Consultation; øclosure¿ construction and renovation of facilities; reports. 

1632. øSafe water and sanitary waste disposal¿ Sanitation facilities. 

1633. Preference to Indians and Indian firms. 

1634. Expenditure of ønon-Service¿ nonservice funds for renovation. 

ø1635. Repealed.¿ 

1636. øGrant program¿ Funding for the construction, expansion, and modernization 

of small ambulatory care facilities. 

1637. Indian øh¿Health øc¿Care ød¿Delivery ød¿Demonstration øp¿Project. 

1638. Land transfer. 

308. Leases, contracts, and other agreements. 


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309. Study on loans, loan guarantees, and loan repayment. 

310. Tribal leasing. 

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

312. Location of facilities. 

313. Maintenance and improvement of health care facilities. 

314. Tribal management of Federally owned quarters. 

ø1638a. Authorization of appropriations.¿ 

1638b. Applicability of Buy American requirement. 

316. Other funding for facilities. 

317. Authorization of appropriations. 

ø1638c. Contracts for personal services in Indian Health Service facilities.¿ 

ø1638d. Credit to appropriations of money collected for meals at Indian Health 

Service facilities.¿ 

øSUBCHAPTER III–A¿ TITLE IV—ACCESS TO 

HEALTH SERVICES 

1641. Treatment of payments under ømedicare program¿ Social Security Act health 

care programs. 

ø1642. Treatment of payments under medicaid program.¿ 

ø1643. Amount and use of funds reimbursed through medicare and medicaid available to Indian Health Service.¿ 

1644. Grants to and contracts with the Service, Indian Tribes, øt¿Tribal 

øo¿Organizations, and Urban Indian Organizations. 

403. Reimbursement from certain third parties of costs of health services. 

404. Crediting of reimbursements. 

405. Purchasing health care coverage. 

406. Sharing arrangements with Federal agencies. 

407. Payor of last resort. 

408. Nondiscrimination in qualifications for reimbursement for services. 

409. Consultation. 

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

411. Social Security Act sanctions. 

412. Cost sharing. 

413. Treatment under medicaid managed care. 

414. Navajo nation medicaid agency feasibility study. 

ø1645. Direct billing of Medicare, Medicaid, and other third party payors.¿ 

ø1646. Authorization for emergency contract health services.¿ 

1647. Authorization of appropriations. 

øSUBCHAPTER IV¿ TITLE V—HEALTH 

SERVICES FOR URBAN INDIANS 

1651. Purpose. 

1652. Contracts with, and grants to, øu¿Urban Indian øo¿Organizations. 

1653. Contracts and grants for the provision of health care and referral services. 

1654. Contracts and grants for the determination of unmet health care needs. 

1655. Evaluations; renewals. 

1656. Other contract and grant requirements. 

1657. Reports and records. 

1658. Limitation on contract authority. 

1659. Facilities ørenovation¿. 

1660. Division of Urban Indian Health øPrograms Branch¿. 

1660a. Grants for alcohol and substance abuse-related services. 

1660b. Treatment of certain demonstration projects. 

1660c. Urban NIAAA transferred programs. 

514. Consultation with Urban Indian Organizations. 

515. Federal Tort Claim Act coverage. 

516. Urban youth treatment center demonstration. 

517. Use of Federal government facilities and sources of supply. 

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

519. Community health representatives. 

520. Effective date. 

521. Eligibility for services. 

1660d. Authorization of appropriations. 


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øSUBCHAPTER V¿ TITLE VI—ORGANIZATIONAL 

IMPROVEMENTS 

1661. Establishment of the Indian Health Service as an agency of the Public Health 

Service. 

1662. Automated management information system. 

1663. Authorization of appropriations. 

øSUBCHAPTER V—A—SUBSTANCE ABUSE¿ 

TITLE VII—BEHAVIORAL HEALTH PROGRAMS 

ø1665. Indian Health Service responsibilities.¿ 

ø1665a. Indian Health Service program.¿ 

701. Behavioral health prevention and treatment services. 

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

703. Comprehensive behavioral health prevention and treatment program. 

704. Mental health technician program. 

705. Licensing requirement for mental health care workers. 

1665b. Indian women treatment programs. 

1665c. Indian øHealth Service y¿Youth øp¿Program. 

708. Indian youth telemental health demonstration project. 

709. Inpatient and community-based mental health facilities design, construction, 

and staffing. 

1665d. Training and community education. 

ø1665e. Gallup alcohol and substance abuse treatment center.¿ 

ø1665f. Reports.¿ 

711. Behavioral health program. 

1665g. Fetal alcohol øsyndrome and fetal alcohol effect grants¿ disorder programs. 

ø1665h. Pueblo substance abuse treatment project for San Juan Pueblo, New Mexico.¿ 

ø1665i. Thunder Child Treatment Center.¿ 

ø1665j. Substance abuse counselor education demonstration project.¿ 

ø1665k. Gila River alcohol and substance abuse treatment facility.¿ 

ø1665l. Alaska Native drug and alcohol abuse demonstration project.¿ 

713. Child sexual abuse and prevention treatment programs. 

714. Behavioral health research. 

715. Definitions. 

1665m. Authorization of appropriations. 

øSUBCHAPTER VI¿ TITLE VIII— MISCELLANEOUS 

1671. Reports. 

1672. Regulations. 

ø1673. Repealed.¿ 

ø1674. Leases with Indian tribes.¿ 

803. Plan of implementation. 

1675. Availability of funds. 

1676. Limitation on use of funds appropriated to the Indian Health Service. 

ø1677. Nuclear resource development health hazards.¿ 

ø1678. Arizona as a contract health service delivery area.¿ 

1679. Eligibility of California Indians. 

ø1680. California as a contract health service delivery area.¿ 

ø1680a. Contract health facilities.¿ 

ø1680b. National Health Service Corps.¿ 

1680c. Health services for ineligible persons. 

ø1680d. Infant and maternal mortality; fetal alcohol syndrome.¿ 

ø1680e. Contract health services for the Trenton Service Area.¿ 

ø1680f. Indian Health Service and Department of Veterans Affairs health facilities 

and services sharing.¿ 

1680g. Reallocation of base resources. 

ø1680h. Demonstration projects for tribal management of health care services.¿ 

ø1680i. Child sexual abuse treatment programs.¿ 

ø1680j. Tribal leasing.¿ 


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ø1680k. Home- and community-based care demonstration project.¿ 

ø1680l. Shared services demonstration project.¿ 

1680m. Results of demonstration projects. 

810. Provision of services in Montana. 

811. Moratorium. 

812. Tribal employment. 

813. Severability provisions. 

814. Establishment of National Bipartisan Commission on Indian Health Care. 

815. Appropriations; availability. 

ø1680n. Priority for Indian reservations.¿ 

1680o. Authorization of appropriations. 

ø1681. Omitted.¿ 

ø1682. Subrogation of claims by Indian Health Service.¿ 

ø1683. Indian Catastrophic Health Emergency Fund.¿ 

GENERAL PROVISIONS 

§1601. øCongressional f¿Findings 

øThe¿ Congress makes the following findings: 

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 

øthe American¿ Indians øpeople¿ are severe and the health 

status of the Indians is far below that of the general population of the United States. 

§1602. Declaration of øhealth objectives¿ 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 

obligations to øthe American¿ Indians.—øpeople,¿ 

(1) to assure the highest possible health status for Indians 

øand 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.¿ 


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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 15 ug/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 

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.¿ 


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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 death 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.¿ 

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 

to 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:¿ 


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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 postSE 1)partum 

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.¿ 

ø(61) Increase to at least 70 percent the proportion of individuals who have received, as a minimum within the appropriate 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.¿ 

ø(c) It is the intent of the Congress that the Nation increase the 

proportion of all degrees in the health professions and allied and 

associated health profession fields awarded to Indians to 0.6 percent.¿ 

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.¿ 


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(2) to raise the health status of Indians by the year 2010 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; 

(4) to increase the proportion of all degrees in the health professions and allied and associated health 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; 

(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 

(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. 

§ 1603. Definitions 

For purposes of this øchapter¿ Actø—¿: 

(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 of Indian Health. 

(4) 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. This definition can include 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—

(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. 

(8) The term ‘Department’ means, unless otherwise designated, the Department of Health and Human Services. 

(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—


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(i) 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 suitable housing, safe water, and 

sanitary facilities; 

(E) improving the physical, economic, cultural, psychological, and social environment; 

(F) promoting adequate opportunity for spiritual, religious, and Traditional Health Care Practices; and 

(G) providing adequate and appropriate programs, including—

(i) abuse prevention (mental and physical); 

(ii) community health; 

(iii) community safety; 

(iv) consumer health education; 

(v) diet and nutrition; 

(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; 


hsrobinson on PROD1PC72 with HEARING
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(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) safe housing relating to the elimination, reduction, and prevention of contaminants that create 

unhealthy housing conditions; 

(xxii) safe work environments; 

(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). 

(12) The term ‘Indian’, unless otherwise designated, means 

any person who is a member of an Indian Tribe or is eligible 

for health services under section 806, except that, for the purpose of section 102 and 104, the term also means any individual who— (A)(i) irrespective of whether 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 reside; or 

(ii) is a descendant, in the first or second degree, or any 

such member; 

(B) is an Eskimo or Aleut or other Alaska Native; 

(C) is considered by the Secretary of the Interior to be an 

Indian for any purpose; or 

(D) is determined to be an Indian under regulations promulgated by the Secretary. 

(13) The term ‘Indian Health Program’ means—

(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)). 

(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 (25 U.S.C. 1601 et seq.). 


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ø(a)¿(17) The term ø‘‘¿‘Secretaryø’’¿’ , unless otherwise designated, means the Secretary of Health and Human Services. 

ø(b)¿(18) The term ø‘‘¿‘Serviceø’’¿’ means the Indian Health Service. 

ø(c) ‘‘Indians’’ or ‘‘Indian’’, unless otherwise designated, means 

any person who is a member of an Indian tribe, as defined in subsection (d) of this section, except that, for the purpose of sections 

1612 and 1613 of this title, such terms shall mean any individual 

who (1), irrespective of whether he or she 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 reside, or who is a descendant, in the first or second 

degree, of any such member, or (2) is an Eskimo or Aleut or other 

Alaska Native, or (3) is considered by the Secretary of the Interior 

to be an Indian for any purpose, or (4) is determined to be an Indian under regulations promulgated by the Secretary.¿ 

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 established pursuant to the Alaska Native Claims Settlement Act (85 

Stat. 688) [43 U.S.C.A. §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.¿ 

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.¿ 

(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. 

(23) The term ‘Traditional Health Care Practices’ means the 

application by Native healing practitioners of the Native healing sciences (as opposed or in contradistinction to Western healing sciences) which embody the influences or forces of innate 

Tribal discovery, history, description, explanation and knowledge of the states of wellness and illness and which call upon 

these influences or forces in the promotion, restoration, preservation, and maintenance of health, well-being, and life’s harmony. 


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(24) 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)). 

(25) 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.). 

(26) 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.). 

(27) The term ‘Urban Center’ means any community which 

has a sufficient Urban Indian population with unmet health 

needs to warrant assistance under title V of this Act, as determined by the Secretary. 

ø(f) ‘‘¿ (28) The term ‘Urban Indianø’’¿’ means any individual 

who resides in an øu¿Urban øc¿Center ø, as defined in subsection (g) of this section,¿ and who meets øone¿ 1 or more of 

the øfour¿ following criteria: øin subsection (c)(1) through (4) 

of this section.¿ 

(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. 

(29) The term ‘Urban Indian Organization’ means a nonprofit 

corporate body that (A) is situated in an Urban Center; (B) is 

governed by an Urban Indian-controlled board of directors; (C) 

provides for the participation of all interested Indian groups 

and individuals; and (D) is capable of legally cooperating with 

other public and private entities for the purpose of performing 

the activities described in section 503(a). 

ø(g) ‘‘Urban center’’ means any community which has a sufficient 

urban Indian population with unmet health needs to warrant assistance under subchapter IV of this chapter, as determined by the 

Secretary.¿ 

ø(h) ‘‘Urban Indian organization’’ means a nonprofit corporate 

body situated in an urban center, governed by an urban Indian 

controlled board of directors, and providing for the maximum participation of all interested Indian groups and individuals, which 

body is capable of legally cooperating with other public and private 

entities for the purpose of performing the activities described in 

section 1653(a) of this title.¿ 

ø(i) ‘‘Area office’’ means an administrative entity including a program office, within the Indian Health Service through which servVerDate Aug 31 2005 11:50 Mar 23, 2006 Jkt 049010 PO 00000 Frm 00080 Fmt 6659 Sfmt 6602 E:\HR\OC\SR222.XXX SR222

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ices 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¿ 

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.],¿ 

øthrough 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.¿ 

øSUBCHAPTER¿ TITLE I—INDIAN 

HEALTH, HUMAN RESOURCES, AND 

DEVELOPMENT øPROFESSIONAL PERSONNEL¿ 

§ 1611. øCongressional statement of p¿Purpose 

The purpose of this øsubchapter¿ title 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 Indian 

Health Programs øService, Indian tribes, tribal organizations,¿ and 


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øu¿Urban Indian øo¿Organizations involved in the provision of 

health care to Indians øpeople¿. 

§ 1612. Health Pøp¿rofessions Rør¿ecruitment Pøp¿rogram 

for Indians 

(a) øGRANTS FOR EDUCATION AND TRAINING¿ 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 Organizations øor Indian tribes or tribal 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¿. 

(b) øAPPLICATION FOR GRANT; SUBMITTAL AND APPROVAL; PREFERENCE; PAYMENT¿ FUNDING.—

(1) APPLICATION.—The Secretary shall not make a grant 

under this section øNo grant may 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 Tribal Health Programs or Urban Indian Organizations øIndian tribes or tribal organizations¿. 

(2) AMOUNT OF GRANTS; PAYMENT.—The amount of a øany¿ 

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, funding commitments shall be for 3 years, as provided in regulations issued 

pursuant to this Act. 

§ 1613. Health Pøp¿rofessions Pƒp¿reparatory 

Sƒs¿cholarship Pƒp¿rogram for Indians 

(a) øREQUIREMENTS¿ SCHOLARSHIPS AUTHORIZED.—The Secretary, acting through the Service, shall provide scholarship ømake 

scholarship¿ grants to Indians who—


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(1) have successfully completed their high school education 

or high school equivalency; and 

(2) have demonstrated the potential øcapability¿ to successfully complete courses of study in the health professions. 

(b) PURPOSES.—øAND DURATION OF GRANTS; PREPROFESSIONAL

AND PREGRADUATE EDUCATION¿ Scholarship grants provided 

øgrants made¿ pursuant to this section shall be for the following 

purposes: 

(1) Compensatory preprofessional education of any recipient 

øgrantee¿, 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 recipient øgrantee¿ 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 ø(or the part-time equivalent thereof, as determined by the Secretary)¿. An extension of up to 2 

years (or the part-time equivalent thereof, as determined by the 

Secretary pursuant to regulations issued pursuant to this Act) 

may be approved. 

(c) øCOVERED EXPENSES¿ OTHER CONDITIONS.—Scholarships 

øgrants made¿ under this section— (1) may cover costs of tuition, books, transportation, board, 

and other necessary related expenses of a recipient øgrantee¿ 

while attending schoolø.¿; 

(2) shall not 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 institution; and 

(3) shall not be denied solely by reason of such applicant’s eligibility for assistance or benefits under any other Federal program. 

ø(d) BASIS FOR DENIAL OF ASSISTANCE¿ 

øThe Secretary shall not deny scholarship assistance to an eligible applicant under this section solely on the basis of the applicant’s scholastic achievement if such applicant has been admitted 

to, or maintained good standing at, an accredited institution.¿ 

ø(e) ELIGIBILITY FOR ASSISTANCE UNDER OTHER FEDERAL PRO- GRAMS¿ 

øThe Secretary shall not deny scholarship assistance to an eligible applicant under this section solely by reason of such applicant’s 

eligibility for assistance or benefits under any other Federal program.¿ 

§ 1613a. Indian Høh¿ealth Pƒp¿rofessions Sƒs¿cholarships 

(a) IN GENERAL.— øAUTHORITY¿ 

(1) AUTHORITY.—øIn order to provide health professionals to 

Indians, Indian tribes, tribal organizations, and urban Indian 

organizations, t¿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 338A of the Public Health Services Act (42 U.S.C. 


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254l) øof Title 42¿, except as provided in subsection (b) of this 

section. 

(2) DETERMINATIONS BY SECRETARY.—The Secretary, acting 

through the Service, shall determine— (A) who shall receive scholarship grants under subsection 

(a); and 

(B) the distribution of the scholarships among health professionals on the basis of the relative needs of Indians for 

additional service in the health professions. 

(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) øRECIPIENTS; A¿ACTIVE DøD¿UTY SøS¿ERVICE

OøO¿BLIGATION.—

ø(1) The Secretary, acting through the Service, shall determine who shall receive scholarships under subsection (a) of 

this section and shall determine the distribution of such scholarships among such health professions on the basis of the relative needs of Indians for additional service in such 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.¿ 

(1)ø(3)(A)¿ OBLIGATION MET.—The øA¿active duty service obligation under a written contract with the Secretary under this 

section øof 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 practice 

on an equivalent year-for-year obligation, by service in 1 or 

more of the following:ø—¿ 

(A)ø(i) i¿In an øthe¿ Indian Health Program. øService;¿ 

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.];¿ 

(B)ø(iii) i¿In a program assisted under title V øsubchapter IV¿ of this Act. øchapter;¿ 

(C)ø(iv) i¿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 Indians.ø; 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. 

(2)ø(B)¿ OBLIGATION DEFERRED.—At the request of any individual who has entered into a contract referred to in paragraph (1) øsubparagraph (A)¿ 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 


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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: 

(A)ø(i)¿ 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 

subsection. 

(B)ø(ii)¿ The active duty service obligation of that individual shall commence not later than 90 days after the 

completion of that advanced clinical training (or by a date 

specified by the Secretary). 

(C)ø(iii)¿ The active duty service obligation will be 

served in the health profession of that individualø,¿ in a 

manner consistent with paragraph (1) øclauses (i) through 

(v) of subparagraph (A)¿. (D)ø(C)¿ A recipient of aøn Indian Health S¿scholarship 

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

meet the active duty service obligation described in paragraph (1) øsubparagraph (A)¿ by service in a program 

specified under øin¿ that paragraph øsubparagraph¿ 

that—(i) is located on the reservation of the Indian 

Tøt¿ribe in which the recipient is enrolled; or 

(ii) serves the Indian Tøt¿ribe in which the recipient 

is enrolled. 

(3)ø(D)¿ PRIORITY WHEN MAKING ASSIGNMENTS.—Subject to 

paragraph (2) øsubparagraph (C)¿, the Secretary, in making 

assignments of Indian Health Scholarship recipients required 

to meet the active duty service obligation described in paragraph (1) øsubparagraph (A)¿, shall give priority to assigning 

individuals to service in those programs specified in paragraph 

(1) øsubparagraph (A)¿ 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. 

(c)ø(4)¿ 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— (1)ø(A)¿ such scholarship shall be for a period of years not 

to exceed the part-time equivalent of 4 years, as determined by 

the Area Office øSecretary¿; 

(2)ø(B)¿ the period of obligated service described in subsection (b)(1) øparagraph (3)(A)¿ shall be equal to the greater 

of— (A)ø(i)¿ the part-time equivalent of 1øone¿ year for each 

year for which the individual was provided a scholarship 

(as determined by the Area Office øSecretary¿); or 

(B)ø(ii) two¿ 2 years; and 

(3)ø(C)¿ 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. 

(d) BREACH OF CONTRACT.—


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(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 the enactment of the Indian Health Care Improvement 

Act Amendments of 2005 if that individual—

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—¿ 

(A)ø(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)ø,¿; 

(B)ø(ii)¿ is dismissed from such educational institution 

for disciplinary reasonsø,¿; 

(C)ø(iii)¿ 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 

(D)ø(iv)¿ 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, on his behalf, 

under the contract¿. 

(2)ø(B)¿ OTHER BREACHES.—If for any reason not specified in 

paragraph (1) øsubparagraph (A)¿ an individual breaches a 

øhis¿ written contract by failing either to begin such individual’s service obligation required under such contract øthis section¿ 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 ø1616a of this title¿ in the manner 

provided for in such subsection. 

(3)ø(C)¿ CANCELLATION UPON DEATH OF RECIPIENT.—Upon 

the death of an individual who receives an Indian Health 

Scholarship, any obligation of that individual for service or 

payment that relates to that scholarship shall be canceled. 

(4)ø(D)¿ WAIVERS AND SUSPENSIONS.—

(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, in consultation with the affected Area Office, Indian Tribes, Tribal Organizations, 

and Urban Indian Organizations, 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. 


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(B) FACTORS FOR CONSIDERATION.—Before waiving or 

suspending an obligation of service or payment under subparagraph (A), the Secretary 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). 

(5)ø(E)¿ 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. 

(6)ø(F)¿ 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 øT¿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¿ 

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 

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.¿ 

§ 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 the health professions to Indian communities including elementary, secondary, 

and accredited and accessible community colleges that will be 

served by the program; 


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(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. 

(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 2006 through 2015. 

§ 106. Scholarship programs for Indian tribes 

(a) IN GENERAL.—

(1) GRANTS AUTHORIZED.—The Secretary, acting through the 

Service, shall make grants available 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 


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(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.—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. Such contract shall— (1) obligate such recipient to provide service in an Indian 

Health Program or Urban Indian Organization, in the same 

Service Area where the Tribal Health Program providing the 

scholarship is located, for— (A) 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 

(B) such greater period of time as the recipient and the 

Tribal Health Program may agree; 

(2) provide that the amount of the scholarship— (A) 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 

(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); 

(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 pursuant to this Act; and 

(4) require the recipient of such scholarship to meet the educational and licensure requirements appropriate to each health 

profession. 

(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); 


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(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 scholarship 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. 

§ 1614. Indian Høh¿ealth Søs¿ervice Eøe¿xtern Pøp¿rograms 

(a) EMPLOYMENT PREFERENCE.—øOF SCHOLARSHIP GRANTEES

DURING NONACADEMIC PERIODS¿ Any individual who receives a 

scholarship pursuant to section 104 or 106 shall be given preference 


hsrobinson on PROD1PC72 with HEARING
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for employment in the Service, or may be employed by a Tribal 

Health Program or an Urban Indian Organization, or other agencies of the Department as available, during any nonacademic period 

of the year. 

(b) NOT COUNTED TOWARD ACTIVE DUTY SERVICE OBLIGATION.—

øAny individual who receives a scholarship grant pursuant to 

section 1613a of this title shall be entitled to employment in the 

Service during any nonacademic period of the year.¿ 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¿. 

(c) TIMING; LENGTH OF EMPLOYMENT.—

ø(b) EMPLOYMENT OF MEDICAL AND OTHER STUDENTS DURING

NONACADEMIC PERIODS¿ 

Any individual enrolled in a program, including a high school 

program, authorized under section 102(a) øcourse of study in the 

health professions¿ 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 

ø120¿ øone hundred and twenty¿ days during any calendar year. 

(d) NONAPPLICABILITY OF COMPETITIVE PERSONNEL SYSTEM.—

ø(c) EMPLOYMENT WITHOUT REGARD TO COMPETITIVE PERSONNEL

SYSTEM OR AGENCY PERSONNEL LIMITATION; COMPENSATION¿ 

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 Department øof Health and Human Services¿. 

§ 1615. Continuing Eøe¿ducation Aøa¿llowances 

ø(a) DISCRETIONARY AUTHORITY; SCOPE OF ACTIVITIES¿ 

In order to encourage health professionals, including community 

health representatives and emergency medical technicians, øphysicians, dentists, nurses, and other health professionals¿ to join or 

continue in an Indian Health Program or an Urban Indian Organization øthe Service¿ and to provide their services in the rural and 

remote areas where a significant portion of øthe¿ Indians øpeople¿ 

resideøs¿, the Secretary, acting through the Service, may provide 

allowances to health professionals employed in an Indian Health 

Program or an Urban Indian Organization øthe Service¿ 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 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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§ 1616. Community Health Representative Program 

(a) IN GENERAL.—Under the authority of the Act of November 2, 

1921 (25 U.S.C. 13) (commonlyø, popularly¿ known as the (Snyder 

Act), the Secretary, acting through the Service, shall maintain a 

Community Health Representative Program under which Indian 

Health Programs øthe Service¿—

(1) provideøs¿ for the training of Indians as community 

health representatives; øhealth paraprofessionals,¿ and 

(2) useøs¿ such community health representatives øparaprofessionals¿ in the provision of health care, health promotion, and disease prevention services to Indian communities. 

(b) DUTIES.—The øSecretary, acting through the¿ Community 

Health Representative Program of the Service, shall—

(1) provide a high standard of training for øparaprofessionals 

to C¿community øH¿health øR¿representatives to ensure that 

the øC¿community øH¿health øR¿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 

øC¿community øH¿health øR¿representatives for continuing 

education in health care, health promotion, and disease prevention, and develop ømaintain¿ 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 øt¿Traditional øh¿Health øc¿Care øp¿Practices 

of the Indian øt¿Tribes served consistent with the Service 

standards for the provision of health care, health promotion, 

and disease prevention. 

§ 1616a. 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 ‘‘Loan Repayment Program’’) in order to ensure 

øassure¿ an adequate supply of trained health professionals 

necessary to maintain accreditation of, and provide health care 

services to Indians through, Indian øh¿Health øp¿Programs 

and Urban Indian Organizations. 

ø(2) For the purposes of this section—¿ 


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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(i)(4) of Title 42.¿ 

(b) ELIGIBLE INDIVIDUALS.—øELIGIBILITY¿ 

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 

institutionø,¿ (as determined by the Secretary under section 338B(b)(1)(c)(i) of the Public Health Service Act (42 

U.S.C. 254l–1(b)(1)(c)(i)) ø, within any State¿ and be 

scheduled to complete such course of study in the same 

year such individual applies to participate in such program; or 

(ii) in an approved graduate training program in a 

health profession; or 

(B) have—

(i) a degree in a health profession; and 

(ii) a license to practice a health profession 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 øh¿Health øp¿Program or 

Urban Indian Organization without a service obligation; and 

(3) submit to the Secretary an application for a contract described in subsection (e) ø(f) of this section¿. (c) APPLICATION øAND CONTRACT FORMS¿.—

(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 (l) øof 

this section¿ in the case of the individual’s breach of the contract. The Secretary shall provide such individuals with sufficient information regarding the advantages and disadvantages 

of service as a commissioned officer in the Regular or Reserve 


hsrobinson on PROD1PC72 with HEARING
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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. 

(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. 

(d) PRIORITIES.—øVACANCIES; PRIORITY¿ 

(1) LIST.—Consistent with subsection (k) øparagraph (3)¿, 

the Secretaryø, acting through the Service and in accordance 

with subsection (k), of this section,¿ shall annually—

(A) identify the positions in each Indian øh¿Health 

øp¿Program or Urban Indian Organization for which there 

is a need or a vacancyø,¿; and 

(B) rank those positions in order of priority. 

(2) APPROVALS.—Notwithstanding øConsistent with¿ the priority determined under paragraph (1), the Secretary, in determining which applications under the Loan Repayment Program to approve (and which contracts to accept), shall—

(A) give first priority to applications made by individual 

Indians; and 

(B) after making determinations on all applications submitted by individual Indians as required under subparagraph (A), give priority to—

(i) individuals recruited through the efforts of an Indian Health Program or Urban Indian Organization; 

and øtribes or tribal or Indian organizations.¿ 

(ii) other individuals based on the priority rankings 

under paragraph (1). 

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; 

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.¿ 

(e) RECIPIENT CONTRACTS.—øAPPROVAL¿ 

(1) CONTRACT REQUIRED.—An individual becomes a participant in the Loan Repayment Program only upon the Secretary 


hsrobinson on PROD1PC72 with HEARING
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and the individual entering into a written contract described in 

paragraph (2) øsubsection (f) of this section¿. 

(2) CONTENTS OF CONTRACT.—øThe 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¿ 

The written contract referred to in this section between the 

Secretary and an individual shall contain—

(A)ø(1)¿ an agreement under which—

(i)ø(A)¿ subject to subparagraph (C)ø(3)¿, the Secretary agrees—

(I)ø(i)¿ to pay loans on behalf of the individual 

in accordance with the provisions of this 

sectionø,¿; and 

(II)ø(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 Tribal Health Program or Urban Indian Organization øtribe or Indian organization¿ 

as provided in clause (ii)(III); øsubparagraph 

(B)(iii),¿ and 

(ii)ø(B)¿ subject to subparagraph (C)ø(3)¿, the individual agrees—

(I)ø(i)¿ to accept loan payments on behalf of the 

individual; 

(II)ø(ii)¿ in the case of an individual described 

in subsection (b)(1)—

(aa)ø(I)¿ 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 

(bb)ø(II)¿ while enrolled in such course of 

study or training, to maintain an acceptable 

level of academic standing (as determined 

under regulations of the Secretary by the educational institution offering such course of 

study or training); and 

(III)ø(iii)¿ to serve for a time period (hereinafter 

in this section referred to as the ø‘‘¿ ‘period of obligated service’ø’’¿) 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 øh¿Health øp¿Program or 

Urban Indian Organization to which the individual may be assigned by the Secretary; 

(B)ø(2)¿ a provision permitting the Secretary to extend 

for such longer additional periods, as the individual may 

agree to, the period of obligated service agreed to by the 


hsrobinson on PROD1PC72 with HEARING
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individual under subparagraph (A)(ii)(III) øparagraph 

(1)(B)(iii)¿; 

(C)ø(3)¿ a provision that any financial obligation of the 

United States arising out of a contract entered into under 

this section and any obligation of the individual which is 

conditioned thereon is contingent upon funds being appropriated for loan repayments under this section; 

(D)ø(4)¿ a statement of the damages to which the United 

States is entitled under subsection (l) øof this section¿ for 

the individual’s breach of the contract; and 

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

(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.—øLOAN REPAYMENT PURPOSES; MAXIMUM

AMOUNT; TAX LIABILITY REIMBURSEMENT; SCHEDULE OF PAYMENTS¿ 

(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)[(A)] AMOUNT.—For each year of obligated service that an 

individual contracts to serve under subsection (e),ø(f) of this 

section¿ the Secretary may pay up to $35,000 ø(¿or an amount 

equal to the amount specified in section 338B(g)(2)(A) of the 

Public Health Service Act, whichever is more, ø254l–1(g)(2)(A) 

of Title 42)¿ on behalf of the individual for loans described in 

paragraph (1). In making a determination of the amount to pay 

for a year of such service by an individual, the Secretary shall 

consider the extent to which each such determination— (A)ø(i)¿ affects the ability of the Secretary to maximize 

the number of contracts that can be provided under the 

Loan Repayment Program from the amounts appropriated 

for such contracts; 

(B)ø(ii)¿ provides an incentive to serve in Indian 

øh¿Health øp¿Programs and Urban Indian Organizations 

with the greatest shortages of health professionals; and 

(C)ø(iii)¿ provides an incentive with respect to the 

health professional involved remaining in an Indian 


hsrobinson on PROD1PC72 with HEARING
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øh¿Health øp¿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. 

(3)ø(B)¿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. 

(4)ø(3)¿ REIMBURSEMENTS FOR TAX LIABILITY.—For the purpose of providing reimbursements for tax liability resulting 

from 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. 

(5)ø(4)¿ 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. 

(h) EMPLOYMENT CEILING.—øEFFECT ON EMPLOYMENT CEILING OF

DEPARTMENT OF HEALTH AND HUMAN SERVICES¿ Notwithstanding 

any other provision of law, individuals who have entered into written contracts with the Secretary under this 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) RECRUITMENT.—øRECRUITING PROGRAMS¿ The Secretary shall 

conduct recruiting programs for the Loan Repayment Program and 

other øhealth professional programs of the¿ manpower programs of 

the Service at educational institutions training health professionals 

or specialists identified in subsection (a) øof this section¿. 

(j) APPLICABILITY OF LAW.—øPROHIBITION OF ASSIGNMENT TO

OTHER GOVERNMENT DEPARTMENTS¿ Section 214 of the Public 

Health Service Act (42 U.S.C. 215) ø215 of Title 42¿ shall not apply 

to individuals during their period of obligated service under the 

Loan Repayment Program. 

(k) ASSIGNMENT OF INDIVIDUALS.—øSTAFF NEEDS OF HEALTH PROGRAMS ADMINISTERED BY INDIAN TRIBES¿ The Secretary, in assigning individuals to serve in Indian øh¿Health øp¿Programs or 

Urban Indian Organizations pursuant to contracts entered into 

under this section, shall—

(1) ensure that the staffing needs of Tribal øIndian h¿Health 

øp¿Programs and Urban Indian Organizations øadministered 

by an Indian tribe or tribal or health organization¿ receive consideration on an equal basis with programs that are administered directly by the Service; and 


hsrobinson on PROD1PC72 with HEARING
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(2) give priority to assigning individuals to Indian øh¿Health 

øp¿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. 

(l) BREACH OF CONTRACT.—øVOLUNTARY TERMINATION OF STUDY

OR DISMISSAL FROM EDUCATIONAL INSTITUTION; COLLECTION OF

DAMAGES¿ 

(1) SPECIFIC BREACHES.—An individual who has entered into 

a written contract with the Secretary under this section and 

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 

øwho¿—

(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) of this section,¿. øshall be liable, in lieu of any service obligation arising under such 

contract, to the United States for the amount which has been paid 

on such individual’s behalf under the contract.¿ 

(2) 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 (e)(2) ø(f) of this 

section¿, 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) ø‘‘¿‘A’ø’’¿ is the amount the United States is entitled 

to recover; 

(B) ø‘‘¿‘Z’ø’’¿ is the sum of the amounts paid under this section to, or on behalf of, the individual and the interest on such 

amounts which would be payable if, at the time the amounts 

were paid, they were loans bearing interest at the maximum 

legal prevailing rate, as determined by the Treasurer of the 

United States; 

(C) ø‘‘¿ ‘t’ø’’¿ is the total number of months in the individual’s period of obligated service in accordance with subsection 

(f) øof this section¿; and 

(D) ø‘‘¿‘s’ø’’¿ 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 deducVerDate Aug 31 2005 11:50 Mar 23, 2006 Jkt 049010 PO 00000 Frm 00098 Fmt 6659 Sfmt 6602 E:\HR\OC\SR222.XXX SR222

hsrobinson on PROD1PC72 with HEARING
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tions in øM¿medicare payments pursuant to section 1892 of the 

Social Security Act ø1395ccc of Title 42¿. (4)ø(3)(A)¿ 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.— (A)ø(B)¿ IN GENERAL.—If damages described in paragraph (4) øsubparagraph (A)¿ are delinquent for 3 months, 

the Secretary shall, for the purpose of recovering such 

damages—(i) use øutilize¿ 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. 

(B)ø(C)¿ 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 øT¿title 

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

the extent not inconsistent with this subsection. 

(m) WAIVER OR SUSPENSION OF OBLIGATION.—øCANCELLATION 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.¿ 

(1)ø(2)¿ 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. 

(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 øT¿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 R¿REPORT.—The Secretary shall submit to the 

President, for inclusion in the øeach¿ report required to be submitted to øthe¿ Congress under section 801 ø1671 of this title¿, a 


hsrobinson on PROD1PC72 with HEARING
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report concerning the previous fiscal year which sets forth by Service Area the following:ø—¿ 

(1) A list of the health professional positions maintained by 

Indian Health Programs and Urban Indian Organizations øthe 

Service or by tribal or Indian organizations¿ for which recruitment or retention is difficultø;¿. (2) øt¿The number of Loan Repayment Program applications 

filed with respect to each type of health professionø;¿. (3) øt¿The number of contracts described in subsection (e) 

ø(f) of this section¿ that are entered into with respect to each 

health professionø;¿. (4) øt¿The amount of loan payments made under this section, in total and by health professionø;¿. (5) øt¿The number of scholarships øgrants¿ that are provided under sections 104 and 106 ø1613a of this title¿ with respect to each health professionø;¿. (6) øt¿The amount of scholarships øgrants¿ provided under 

section 104 and 106 ø1613a of this title¿, in total and by 

health professionø;¿. (7) øt¿The number of providers of health care that will be 

needed by Indian øh¿Health øp¿Programs and Urban Indian 

Organizations, by location and profession, during the 3 øthree¿ 

fiscal years beginning after the date the report is filedø; and¿. (8) øt¿The measures the Secretary plans to take to fill the 

health professional positions maintained by Indian Health Programs or Urban Indian Organizations øthe Service or by tribes 

or tribal or Indian organizations¿ for which recruitment or retention is difficult. 

§1616a–1. 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 (hereinafter in this section referred to as the ‘LRRF’ ø‘‘Fund’’¿). The LRRF øFund¿ shall consist 

of such amounts as may be collected from individuals øappropriated to the Fund¿ 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 

øsubsection (b) of this section¿. All øA¿amounts collected, appropriated, or earned relative to the LRRF øfor the Fund¿ shall remain 

available until expended. 

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 section 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 


hsrobinson on PROD1PC72 with HEARING
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to subsection (d) of this section and the amount of proceeds 

from the sale or redemption of such obligations during such fiscal year.¿ 

(b) ø(c)¿ USE OF FUNDS.—

(1) BY SECRETARY.—Amounts in the LRRF øFund and available pursuant to appropriation Acts¿ may be expended by the 

Secretary, acting through the Service, to make payments to an 

Indian Health Program—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.]—¿ 

(A) to which a scholarship recipient under section 104 

and 106 ø1613a of this title¿ or a loan repayment program 

participant under section 110 ø1616a of this title¿ 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 104, 106, or 110. ø1613a of this title or section 1616a 

of this title.¿ 

(2) BY TRIBAL HEALTH PROGRAMS.—A Tribal Health Program 

øAn Indian tribe or tribal organization¿ 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. 

(c) ø(d)¿ INVESTMENT OF øEXCESS F¿FUNDS.—

ø(1)¿ The Secretary of the Treasury shall invest such 

amounts of the LRRF, øFund as such¿ as the Secretary of 

Health and Human Services determines are not required to 

meet current withdrawals from the LRRF øFund¿. Such investments may be made only in interestø-¿ bearing 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. 

(d) SALE OF OBLIGATIONS.—ø(2)¿ Any obligation acquired by the 

LRRF øFund¿ may be sold by the Secretary of the Treasury at the 

market price. 

§ 1616b. Recruitment A[a]ctivities 

(a) REIMBURSEMENT FOR TRAVEL.—The Secretary, acting through 

the Service, may reimburse health professionals seeking positions 

with Indian Health Programs or Urban Indian Organizations øin 

the Service¿, including individuals considering entering into a contract under section 110 ø1616a of this title¿, 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. 

(b) RECRUITMENT PERSONNEL.—The Secretary, acting through 

the Service, shall assign 1 individual in each øa¿ Area øo¿ Office 

to be responsible on a full-time basis for recruitment activities. 


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§ 1616c. Indian øTribal r¿Recruitment and Rør¿etention 

Pøp¿rogram 

(a) IN GENERAL.—øPROJECTS FUNDED ON COMPETITIVE BASIS¿ 

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 Tribal Health Programs and Urban Indian 

Organizations to recruit, place, and retain health professionals to 

meet their staffing needs. ø, on a competitive basis, projects to enable Indian tribes and tribal and Indian organization to recruit, 

place, and retain health professionals to meet the staffing needs of 

Indian health programs (as defined in section 1616a(a)(2) of this 

title).¿ 

(b) ELIGIBLE ENTITIES; APPLICATION.—øELIGIBILITY¿ ø(1)¿ Any 

Tribal Health Program or Urban Indian Organization øIndian tribe 

or tribal or 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.¿ 

§ 1616d. Advanced Tøt¿raining and Rør¿esearch 

(a) DEMONSTRATION øESTABLISHMENT OF P¿PROGRAM.—The Secretary, acting through the Service, shall establish a demonstration 

project øprogram¿ 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 

in areas of study for which the Secretary determines 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 organization, and urban Indian organizations, 

at the time of the submission of the applications.¿ 

(b) SERVICE OBLIGATION.—øOBLIGATED SERVICE¿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 øh¿Health øp¿Program or 

Urban Indian Organization ø(as defined in section 1616a(a)(2) of 

this title)¿ for a period of obligated service equal to at least the period of time during which the individual participates in such program. 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 the date of the enactment of the 

Indian Health Care Improvement Act Amendments of 2005, øOctober 29, 1992,¿ the United States shall be entitled to recover from 

such individual an amount to be determined in accordance with the 

formula specified in subsection (l) of section 110 ø1616a of this 

title¿ in the manner provided for in such subsection. 

(c) EQUAL OPPORTUNITY FOR PARTICIPATION.—øELIGIBILITY¿ 

Health professionals from Tribal Health Programs and Urban Indian Organizations øIndian tribes and tribal and Indian organizations under the authority of the Indian Self-Determination Act [25 


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U.S.C.A. § 450f et seq.]¿ shall be given an equal opportunity to participate in the program under subsection (a) øof this section¿. 

ø§ 1616e. Nursing program¿ 

ø(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,¿ 

øfor the purpose of increasing the number of nurses, nurse midwives, and nurse practitioners who deliver health care services to 

Indians.¿ 

ø(b) PURPOSES¿ 

øGrants provided under subsection (a) of this section may be 

used to—¿ 

ø(1) recruit individuals for programs which train individuals 

to be nurses, nurse midwives, or nurse practitioners,¿ 

ø(2) provide scholarships to individuals 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 expenses,¿ 

ø(3) provide a program that encourages nurses, nurse midwives, and nurse practitioners to provide, or continue to provide, health care services to Indians,¿ 

ø(4) provide a program that increases the skills of, and provides continuing education to, nurses, nurse midwives, and 

nurse practitioners, or¿ 

ø(5) provide any program that is designed to achieve the purpose described in subsection (a) of this section.¿ 

ø(c) APPLICATION¿ 

øEach application for a grant under subsection (a) of 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¿ 

øIn providing grants under subsection (a) of this section, the Secretary shall extend a preference to—¿ 

ø(1) programs that provide a preference to Indians,¿ 

ø(2) programs that train nurse midwives or nurse practitioners,¿ 

ø(3) programs that are interdisciplinary, and¿ 

ø(4) programs that are conducted in cooperation with a center for gifted and talented Indian students established under 

section 2624(a) of this title.¿ 

§ 115. ø(e)¿ Quentin N. Burdick American Indians Into Nursing Program 

(a) GRANTS AUTHORIZED.—For the purpose of increasing the number of nurses, nurse midwives, and nurse practitioners who deliver 


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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) USE OF GRANTS.—Grants provided under subsection (a) may 

be used for one or more of the following: 

(1) To recruit individuals for programs which train individuals to be nurses, nurse midwives, or advanced practice nurses. 

(2) To provide scholarships to 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 expenses. 

(3) To provide a program that encourages nurses, nurse midwives, and advanced practice nurses to provide, or continue to 

provide, health care services to Indians. 

(4) To provide a program that increases the skills of, and provides continuing education to, nurses, nurse midwives, and advanced practice nurses. 

(5) To provide any program that is designed to achieve the 

purpose described in subsection (a). 

(c) APPLICATIONS.—Each application for funding under subsection 

(a) 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. 

(d) PREFERENCES FOR GRANT RECIPIENTS.—In providing grants 

under subsection (a), the Secretary shall extend a preference to the 

following: 

(1) Programs that provide a preference to Indians. 

(2) Programs that train nurse midwives or advanced practice 

nurses. 

(3) Programs that are interdisciplinary. 

(4) Programs that are conducted in cooperation with a program for gifted and talented Indian students. 

(e) QUENTIN N. BURDICK PROGRAM GRANT.—The Secretary shall 

provide 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 ø‘‘¿‘Quentin N. Burdick American 

Indians Into Nursing Program’ø’’¿. Such program shall, to the maximum extent feasible, coordinate with the Quentin N. Burdick Indian Health Programs established under section 117(b) ø1616g(b) 

of this title¿ and the Quentin N. Burdick American Indians Into 

Psychology Program established under section 105(b) ø1621p(b) of 

this title¿. (f) ACTIVE DUTY SERVICE OøO¿BLIGATION.—The active duty service obligation prescribed under section 338C of the Public Health 

Service Act (42 U.S.C. 254m) øof Title 42¿ 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—


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(1)ø(A)¿ in the øIndian Health¿ Service; 

(2)ø(B)¿ in a program of an Indian Tribe or Tribal Organization conducted under the Indian Self-Determination and Education Assistance Act (25 U.S.C. 450 et seq.) (including programs under agreements with the Bureau of Indian Affairs) øa 

contract entered into under the Indian Self-Determination Act 

[25 U.S.C.A. § 450f et seq.]¿; 

(3)ø(C)¿ in a program assisted under title V øsubchapter IV¿ 

of this Act øchapter¿; or 

(4)ø(D)¿ 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 Indians. 

(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(g) AUTHORIZATION OF APPROPRIATIONS¿ 

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 


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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.¿ 

§1616f. Tribal Cultural Orientation øculture and history¿ 

(a) CULTURAL EDUCATION OF EMPLOYEES.—øPROGRAM ESTAB- LISHED¿ The Secretary, acting through the Service, shall require 

that øestablish a program under which¿ appropriate employees of 

the Service who serve øparticular¿ Indian øt¿Tribes in each Service 

Area øshall¿ receive educational instruction in the history and culture of such Indian Tøt¿ribes and their relationship to øin the history of¿ the Service. 

(b) PROGRAM.—øTRIBALLY-CONTROLLED COMMUNITY COLLEGES¿ 

In carrying out subsection (a), the Secretary shall establish a program which shall, to the extent feasible— øTo the extent feasible, the program established under subsection (a) of this section shall—¿ 

(1) be developed in consultation with the affected Indian 

Tribes, Tribal Organizations, and Urban Indian Organizations; 

øbe 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),¿ 

(2) be carried out through tribal colleges or universities; øbe 

developed in consultation with the affected tribal government, 

and¿ 

(3) include instruction in American Indian øNative American¿ studies; andø.¿ 

(4) describe the use and place of Traditional Health Care 

Practices of the Indian Tribes in the Service Area. 

§1616g. INMED 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 Indian øNative American¿ health careers recruitment program 

known as the ø‘‘¿‘Indians into Medicine Program’ø’’¿ (hereinafter in 

this section referred to as ø‘‘¿‘INMED’ø’’¿) as a means of encouraging Indians to enter the health professions. 

(b) QUENTIN N. BURDICK GRANT.—øUNIVERSITY OF NORTH DAKOTA¿ The Secretary shall provide one of the grants authorized 

under subsection (a) øof this section¿ to maintain the INMED program at the University of North Dakota, to be known as the ‘Quentin N. Burdick Indian Health Programs’, 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 105(b) ø1621p(b) of this title¿ and the Quentin N. 


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Burdick American Indians Into Nursing Program established under 

section 115 ø1616e of this title¿. 

(c) REGULATIONS.—ø; CONTENTS OF RECRUITMENT PROGRAM¿ 

ø(1)¿ The Secretary, pursuant to this Act, shall develop regulations to govern øfor the competitive awarding of the¿ grants 

pursuant to øprovided under¿ this section. 

(d) REQUIREMENTS.—ø(2)¿ Applicants for grants provided under 

this section shall agree to provide a program which—

(1) ø(A)¿ 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,¿; 

(2) ø(B)¿ incorporates a program advisory board comprised of 

representatives from the Indian tribes and Indian communities 

which will be served by the programø,¿; 

(3) ø(C)¿ 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,¿; 

(4) ø(D)¿ provides tutoring, counseling, and support to students who are enrolled in a health career program of study at 

the respective college or universityø,¿; and 

(5) ø(E)¿ 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.¿ 

§ 1616h. Health øt¿Training øp¿Programs of øc¿Community 

øc¿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 such øthe¿ 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 or near a øan Indian¿ reservation or in an Indian Health Program øa tribal clinic¿. 

(2) AMOUNT OF GRANTS.—Tøt¿he 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 $250,000. 

(b) GRANTS FOR MAINTENANCE AND RECRUITING.—øELIGIBILITY¿ 

(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,¿; 


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(B) has a relationship with øaccess to¿ 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 that train health 

professionalsø,¿; and 

(ii) stipulate certifications necessary to approved internship and field placement opportunities at Indian 

Health Programs; øservice unit facilities of the Service 

or at tribal health facilities,¿ 

(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 this section.¿; and 

(F) agrees to provide for Indian preference for applicants 

for programs under this section. 

(c) øAGREEMENTS AND T¿TECHNICAL øA¿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 programsø,¿; and 

(2) providing technical assistance and support to such colleges. 

(d) ADVANCED 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—

(A)ø(1)¿ has already received a degree or diploma in 

such health professionø,¿; and 

(B)ø(2)¿ provides clinical services on or near a øan Indian¿ reservation or for an Indian Health Programø, at a 

Service facility, or at a tribal clinic¿. 

(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¿. 

(e) FUNDING PRIORITY.—Where the requirements of subsection (b) 

are met, funding priority shall be provided to tribal colleges and 

universities in Service Areas where they exist. 

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.¿ 


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ø(3) The term ‘‘junior or community college’’ has the meaning 

given to such term by section 1058(e) of Title 20.¿ 

ø§ 1616i. Additional incentives for health professionals¿ 

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 employed 

by, or assigned to, the 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.¿ 

§ 1616j. Retention bonus 

(a) BONUS AUTHORIZED.—øELIGIBILITY¿The Secretary may pay a 

retention bonus to any health professional øphysician or nurse¿ 

employed by, or assigned to, and serving in, an Indian Health Program or Urban Indian Organization øthe Service¿ 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 Indian Health Programs and Urban Indian Organizations; øthe Service,¿ 

(3) has— (A) completed 3 years of employment with an Indian 

Health Program or Urban Indian Organization; øthe Service,¿ 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 an Indian Health Program 

or Urban Indian Organization øthe Service¿ for continued employment for a period of not less than 1 year. 

ø(b) MINIMUM AWARD PERCENTAGE TO NURSES¿ 


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øBeginning with fiscal year 1993, not less than 25 percent of the 

retention bonuses awarded each year under subsection (a) of the 

section shall be awarded to nurses.¿ 

(b)ø(c)¿ RATES.—ø; 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.¿ 

ø(e) REFUND; INTEREST¿ 

(c) DEFAULT OF RETENTION AGREEMENT.—Any health professional øphysician or nurse¿ 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 110(l)(2)(B) ø1616a(l)(2)(B) of this title¿. 

(d) OTHER RETENTION BONUS.— ø(f) PHYSICIANS AND NURSES EMPLOYED UNDER INDIAN SELF-DE- TERMINATION ACT¿ 

The Secretary may pay a retention bonus to any health professional øphysician or nurse¿ employed by a Tribal Health Program 

øan 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 health professional øphysician or 

nurse¿ 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. 

§ 1616k. 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 Høh¿ealth Pøp¿rogram or 

Urban Indian Organization ø(as defined in section 1616a(a)(2)(A) of 

this title)¿, and have done so for a period of not less than 1 øone¿ 

year, to pursue advanced training. 

ø(b) PROGRAM COMPONENTS¿ 

Such program shall include a combination of education and work 

study in an Indian Høh¿ealth Pøp¿rogram or Urban Indian Organization ø(as defined in section 1616a(a)(2)(A) of this title)¿ 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) or advanced degrees or certification in nursing and public health øa Master’s degree¿. (b)ø(c)¿ SERVICE OøO¿BLIGATION.—øOF PROGRAM PARTICIPANT¿ 

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 Høh¿ealth 

Pøp¿rogram or Urban Indian Organization for a period of obligated 

service equal to the amount of øat least three times the period of 


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the¿ time during which the individual 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 110 ø1616a of this title¿ 

in the manner provided for in such subsection. 

§1616l. Community Health Aide Program 

(a) GENERAL PURPOSES øMAINTENANCE¿ OF PROGRAM.—Under 

the authority of the Act of November 2, 1921 (25 U.S.C. 13) (commonly known as the ‘Snyder Act’) øsection 13 of this title¿, the Secretary, acting through the Service, shall develop and operate ømaintain¿ 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. 

(b) SPECIFIC PROGRAM REQUIREMENTS.—øTRAINING; CUR- RICULUM; CERTIFICATION BOARD¿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 3(2) ø1602(b) of this title¿; 

(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; and 


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(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 services. 

(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 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 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 

Community Health Aide Program in accordance with the program under this section, as the Secretary determines to be appropriate. 


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(2) EXCEPTION.—The national Community Health Aide Program under paragraph (10) shall not include dental health aide 

therapist services. 

(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§1616m. Matching grants to tribes for scholarship programs¿ 

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 carry 

out 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¿ 

øAn Indian tribe or tribal organization shall provide scholarships 

under subsection (b) of this section only to Indians enrolled or accepted for enrollment in the 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¿ 

øIn providing scholarships under subsection (b) of this section, 

the Secretary and the Indian tribe or tribal organization shall enter 


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into a written contract with each recipient of such scholarship. 

Such contract shall—¿ 

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 

254l(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,¿ 

øin 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.¿ 


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ø(2) If for any reason not specified in paragraph (1), an individual breaches his written contract by failing either to 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 1616a of this title in the manner provided 

for in such subsection.¿ 

ø(3) The Secretary may carry out this subsection on the basis 

of information submitted by the tribes or tribal organization involved, or on the basis of information collected through such 

other means as the Secretary determines to be appropriate.¿ 

ø(f) NONDISCRIMINATORY PRACTICE¿ 

øThe 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.¿ 

§1616n. Tribal Høh¿ealth Pøp¿rogram Aøa¿dministration 

The Secretary, acting through the Service, shall, by contract or 

otherwise, provide training for Indians øindividuals¿ in the administration and planning of Tøt¿ribal Høh¿ealth Pøp¿rograms 

§ 123. Health Professional Chronic Shortage Demonstration 

Programs 

(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. 

(b) PURPOSES OF PROGRAMS.—The purposes of demonstration programs funded under subsection (a) shall be— (1) to provide direct clinical and practical experience at a 

Service Unit to health profession students and residents from 

medical schools; 


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(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 health 

professionals serving Indians by identifying all academic and 

scholarly resources of the region. 

(c) ADVISORY BOARD.—The demonstration programs established 

pursuant to subsection (a) shall incorporate a program advisory 

board composed of representatives from the Indian Tribes and Indian communities in the area which will be served by the program. 

§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, Indian Tribes, or 

Tribal Organizations, 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 United 

States Public Health Service shall be exempt from the full-time 

equivalent limitations of the National Health Service Corps and the 

Service when serving as a commissioned corps officer in a Tribal 

Health Program or an Urban Indian Organization. 

§125. Substance abuse counselor educational curricula demonstration programs 

(a) GRANTS AND CONTRACTS.—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 the enactment of the Indian 

Health Care Improvement Act Amendments of 2005, 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. 


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(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. 

§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; 

(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. 


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(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. 

(e) PLAN.—Not later than 90 days after the date of the enactment 

of the Indian Health Care Improvement Act Amendments of 2005, 

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 the 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’). 

ø§1616o. University of South Dakota pilot program¿ 

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.¿ 

ø(b) PURPOSES¿ 

øThe purposes of the program established pursuant to a grant 

provided under subsection (a) of this section are—¿ 

ø(1) to provide direct clinical and practical experience at the 

service unit to medical students and residents from USDSM 

and other medical schools;¿ 

ø(2) to improve the quality of health care for Indians by assuring access to qualified health care professionals; and¿ 

ø(3) to provide academic and scholarly opportunities for physicians, physician assistants, nurse practitioners, nurse and 

other allied health professionals serving Indian people by identifying and utilizing all academic and scholarly resources of the 

region.¿ 

ø(c) COMPOSITION; DESIGNATION¿ 

øThe pilot program established pursuant to a grant provided 

under subsection (a) of this section shall—¿ 

ø(1) incorporate a program advisory board composed of representatives from the tribes and communities in the area 

which will be served by the program; 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 


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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.¿ 

§ 1616p. Authorization of øa¿Appropriations 

There are authorized to be appropriated such sums as may be 

necessary for each fiscal year through fiscal year 2015 ø2000¿ to 

carry out this title øsubchapter¿. 

TITLE øSUBCHAPTER¿ II—HEALTH 

SERVICES 

§ 1621. Indian Health Care Improvement Fund 

(a) USE OF FUNDS.—øAPPROVED EXPENDITURES¿ 

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 øt¿Tribesø,¿; 

(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, including the use of telehealth and telemedicine when appropriate; øand¿ 

(4) eliminating inequities in funding for both direct care and 

contract health service programs; and 

(5) ø(4)¿ 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 øt¿Tribes with the highest levels 

of health status deficiencies and resource deficiencies: 

(A) øc¿Clinical care, ø(direct and indirect)¿ including inpatient care, outpatient care (including audiology, clinical 

eye and vision care), primary care, secondary and tertiary 

care, and long-term care.ø;¿ 

(B) øp¿Preventive health, including øscreening¿ mammography and other cancer screening in accordance with 

section 207. ø1621k of this title;¿ 

(C) ød¿Dental care. ø(direct and indirect);¿ 

(D) øm¿Mental health, including community mental 

health services, inpatient mental health services, dormitory mental health services, therapeutic and residential 

treatment centers, and training of traditional health care 

øIndian¿ practitioners.ø;¿ 

(E) øe¿Emergency medical services.ø;¿ 


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(F) øt¿Treatment and control of, and rehabilitative care 

related to, alcoholism and drug abuse (including fetal alcohol syndrome) among Indians.ø;¿ 

(G) øa¿Accident prevention programs.ø;¿ 

(H) øh¿Home health care.ø;¿ 

(I) øc¿Community health representatives.ø; and¿ 

(J) øm¿Maintenance and repair. 

(K) Traditional Health Care Practices. 

(b) NO OFFSET OR LIMITATION.—øEFFECT ON OTHER APPROPRIA- TIONS; ALLOCATION TO SERVICE UNITS¿ 

ø(1)¿ 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 this Act or the Act of November 

2, 1921 (25 U.S.C. 13) (commonly known as the ‘Snyder Act’), 

øsection 13 of this title,¿ or any other provision of law. 

(c) ALLOCATION; USE.—ø(2)(A)¿ 

(1) IN GENERAL.—Funds appropriated under the authority of 

this section shall ømay¿ be allocated to Service Units, Indian 

Tribes, or Tribal Organizations øon a service unit basis¿. The 

funds allocated to each Indian Tribe, Tribal Organization, or 

Søs¿ervice Uøu¿nit under this øsub¿paragraph shall be used 

by the Indian Tribe, Tribal Organization, or Søs¿ervice 

Uøu¿nit under this paragraph to improve øreduce¿ the health 

status and reduce the resource deficiency of each Indian Tribe 

served by such Søs¿ervice Uøu¿nit, Indian Tribe, or Tribal Organization. 

(2) ø(B)¿ APPORTIONMENT OF ALLOCATED FUNDS.—The apportionment of funds allocated to a Søs¿ervice Uøu¿nit, Indian 

Tribe, or Tribal Organization under øsub¿paragraph (1) ø(A)¿ 

among the health service responsibilities described in subsection (a)(5) ø(4) of this section¿ shall be determined by the 

Service in consultation with, and with the active participation 

of, the affected Indian Tribes and Tribal Organizations. 

(d) ø(c)¿ PROVISIONS RELATING TO HEALTH STATUS AND

RøR¿ESOURCEøS D¿DEFICIENCƒY≈IES øLEVELS¿ 

For purposes of this section, the following definitions apply:ø—¿ 

(1) DEFINITION.—The term ø‘‘¿‘health status and resource 

deficiency’ø’’¿ means the extent to which— (A) the health status objectives set forth in section 

3(2)ø1602(b) of this title¿ are not being achieved; and 

(B) the Indian øt¿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 øt¿Tribe or Tribal Organization include health resources provided by the Service as well as health resources 

used by the Indian øt¿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 

øt¿Tribe or Tribal Organization to petition the Secretary for a 


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review of any determination of the extent of the health status 

and resource deficiency of such Indian Tøt¿ribe or Tribal Organization. 

(e) ø(d)¿ ELIGIBILITY FOR FUNDS.—øPROGRAMS ADMINISTERED BY

INDIAN TRIBE¿ 

ø(1)¿ Tribal Health Programs øadministered by any Indian 

tribe or tribal organization under the authority of the Indian 

Self-Determination Act¿ 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. 

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.¿ 

(f) ø(e)¿ REPORT øTO CONGRESS¿.—

By no later than the date that is 3 years after the date of the enactment of the Indian Health Care Improvement Act Amendments 

of 2005 øOctober 29, 1992¿, the Secretary shall submit to øthe¿ 

Congress the current health status and resource deficiency report 

of the Service for each øIndian tribe or s¿Service øu¿Unit, including newly recognized or acknowledged Indian Tøt¿ribes. Such report shall set out—

(1) the methodology then in use by the Service for determining øt¿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 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 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 Act øchapter¿, or any other 

Act, including the amount of any funds transferred to the 

Serviceø,¿ for the preceding fiscal year which is allocated 

to each Søs¿ervice Uøu¿nit, Indian øt¿Tribe, or Tribal Organization øcomparable entity¿; 

(B) the number of Indians eligible for health services in 

each øs¿Service øu¿Unit or Indian øt¿Tribe or Tribal Organization; and 

(C) the number of Indians using the Service resources 

made available to each øs¿Service øu¿Unit, øor¿ Indian 

øt¿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. 

(g) ø(f)¿ INCLUSION øAPPROPRIATED FUNDS INCLUDED¿ IN

øB¿BASE øB¿BUDGET øOF SERVICE¿.—

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. 


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(h)ø(g)¿ CLARIFICATION.—øCONTINUATION OF SERVICE RESPONSIBILITIES FOR BACKLOGS AND PARITY¿ 

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 equity øparity¿ among Indianøs t¿Tribes and Tribal Organizations. 

(i)ø(h)¿ FUNDING DESIGNATION.— øAUTHORIZATION OF APPROPRIATIONS¿ 

Any funds appropriated under the authority of this section shall 

be designated as the ø‘‘¿‘Indian Health Care Improvement 

Fund’ø’’¿. 

§ 1621a. Catastrophic øh¿Health øe¿Emergency øf¿Fund. 

(a) ESTABLISHMENT.—ø; ADMINISTRATION; PURPOSE¿ 

ø(1)¿ There is established an Indian Catastrophic Health Emergency Fund (hereafter in this section referred to as the ‘CHEF’

ø‘‘Fund’’¿) consisting of—

(1)ø(A)¿ the amounts deposited under subsection (f)ø(d) of 

this section,¿; and 

(2)ø(B)¿ the amounts appropriated to CHEF øthe Fund¿ 

under this section. 

(b) ADMINISTRATION.—ø(2) The Fund¿ CHEF shall be administered by the Secretary, acting through the central office 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 be allocated, apportioned, or delegated on a service unit, area office, or any other basis.¿ 

(c) CONDITIONS ON USE OF FUND.—ø(4)¿ No part of CHEF øthe 

Fund¿ 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.), ø[25 U.S.C.A. § 450f 

et seq.].¿ nor shall CHEF funds be allocated, apportioned, or delegated on an Areaffice, Service Unit, or other similar basis. 

(d)ø(b)¿ REGULATIONS.—ø; PROCEDURES FOR PAYMENT¿ 

The Secretary shall, through the negotiated rulemaking process 

under title VIII, promulgate øpromulgation of¿ 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 CHEF øthe Fund¿; 

(2) provide that a øs¿Service øu¿Unit shall not be eligible for 

reimbursement for the cost of treatment from CHEF øthe 

Fund¿ 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—

(A) the 2000 level of $19,000 øfor 1993, not less than 

$15,000 or not more than $25,000¿; 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 


hsrobinson on PROD1PC72 with HEARING
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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— (A) øs¿Service øu¿Units; øor facilities of the Service,¿ or 

(B) whenever otherwise authorized by the Service, nonService facilities or providersø, in rendering treatment 

that exceeds such threshold cost¿; 

(4) establish a procedure for payment from CHEF øthe 

Fund¿ 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 CHEF øthe Fund¿ 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. 

(e) NO OFFSET OR LIMITATION.—ø(c) EFFECT ON OTHER APPROPRIATIONS¿ 

Amounts appropriated to CHEF øthe Fund¿ under this section 

shall not be used to offset or limit appropriations made to the Service under authority of the Act of November 2, 1921 (25 U.S.C. 13) 

(commonly known as the ‘Snyder Act’) øsection 13 of this title¿, or 

any other law. 

(f)ø(d)¿ DEPOSIT OF REIMBURSEMENTøS TO¿ FUNDS.— There shall be deposited into CHEF øthe Fund¿ 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 CHEF øthe Fund¿. 

§1621b. Health øp¿Promotion and ød¿Disease øp¿Prevention 

øs¿Services 

(a) FINDINGS.—Congress finds that health promotion and disease 

prevention activities— (1) improve the health and well-being of Indians; and 

(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 3(2)ø1602(b) of this title¿. 

(c)ø(b)¿ EVALUATION.—øSTATEMENT FOR PRESIDENTIAL BUDGET¿ 

The Secretary, after obtaining input from the affected Tribal 

Health Programs, shall submit to the President for inclusion in the 

report øeach statement¿ which is required to be submitted to øthe¿ 

Congress under section 801ø1671 of this title¿ 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 


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(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. 

§1621c. Diabetes øp¿Prevention, øt¿Treatment, and 

øc¿Control 

(a) DETERMINATIONS REGARDING DIABETES.—øINCIDENCE AND

COMPLICATIONS¿ 

The Secretary, acting through the Service, and in consultation 

with øthe¿ Indian Tøt¿ribes and Tribal Organizations, shall determine—

(1) by Indian Tøt¿ribe and by Service øu¿Unit øof the Service¿, 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 øu¿Unit 

should take to reduce the incidence of, and prevent, treat, and 

control the complications resulting from, diabetes among Indian Tøt¿ribes within that Service unit. 

(b) DIABETES SCREENING.— To the extent medically indicated and with informed consent, 

tøT¿he 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, in consultation with Indian Tribes, Urban Indian Organizations, and appropriate health care providers, establish a cost-effective approach to 

ensure ongoing monitoring of disease indicators. Such screening 

and monitoring may be conducted ødone¿ by a Tribal Health Program and may be conducted through appropriate Internet-based 

health care management programs. øtribe 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.].¿ 

(c) FUNDING FOR DIABETES.—The Secretary shall continue to 

maintain each model diabetes project in existence on the date 

of the enactment of the Indian Health Care Improvement Act 

Amendments of 2005, 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 2005 and 

for projects which are added and funded thereafter. 

ø(c) MODEL DIABETES PROJECTS¿ 

ø(1) The Secretary shall continue to maintain through fiscal 

year 2000 each model diabetes project in existence October 29, 

1992 and located—¿ 

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;¿ 


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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 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).¿ 

(d) FUNDING FOR DIALYSIS PROGRAMS.—The Secretary is authorized to provide funding through the Service, Indian Tribes, and 

Tribal Organizations to establish dialysis programs, including 

funding to purchase dialysis equipment and provide necessary staffing. 

ø(d) CONTROL OFFICER; REGISTRY OF PATIENTS¿ 

øThe Secretary shall—¿ 

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 for the prevention, treatment, and control of diabetes;¿ 

ø(2) establish in each area office of the Service a registry of 

patients with diabetes to track the incidence of diabetes and 

the complications from diabetes in that area;¿ 

ø(3) ensure that data collected in each area office regarding 

diabetes and related complications among Indians is disseminated to all other area offices; and¿ 

ø(4) evaluate the effectiveness of services provided through 

model diabetes projects established under this section.¿ 

(e) OTHER DUTIES OF THE SECRETARY.—

(1) IN GENERAL.—The Secretary shall, to the extent funding 

is available—

(A) in each Area Office, consult with Indian Tribes and 

Tribal Organizations regarding programs for the prevention, treatment, and control of diabetes; 

(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 

(C) ensure that data collected in each Area Office regarding diabetes and related complications among Indians are 

disseminated to all other Area Offices, subject to applicable 

patient privacy laws. 

(2) DIABETES CONTROL OFFICERS.—

(A) IN GENERAL.—The Secretary may establish and maintain in each Area Office a position of diabetes control offiVerDate Aug 31 2005 11:50 Mar 23, 2006 Jkt 049010 PO 00000 Frm 00125 Fmt 6659 Sfmt 6603 E:\HR\OC\SR222.XXX SR222

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cer 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. 

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.¿ 

§ 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 Act (25 U.S.C. 450 et seq.) with 

Indian Tribes or Tribal Organizations for, the delivery of long-term 

care and similar services 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 other similar facility owned and operated (directly or through a contract or compact 

under the Indian Self-Determination and Education Act) (25 U.S.C. 

450 et seq.)) by such Indian Tribe or Tribal Organization. 

(b) CONTENTS OF AGREEMENTS.—An agreement or other arrangement entered into pursuant to subsection (a)—

(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; 

(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 

(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). 

(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. 

(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. 

(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§ 1621d. Hospice care feasibility study¿ 

ø(a) DUTY OF SECRETARY¿ 


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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—¿ 

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.¿ 

§ 206. Health services research 

The Secretary, acting through the Service, shall make funding 

available for research to further the performance of the health service responsibilities of Indian Health Programs. The Secretary shall 

also, to the maximum extent practicable, coordinate departmental 

research resources and activities to address relevant Indian Health 

Program research needs. Tribal Health Programs shall be given an 


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equal opportunity to compete for, and receive, research funds under 

this section. This funding may be used for both clinical and nonclinical research. 

ø§ 1621e. Reimbursement from certain third parties of costs 

of health services¿ 

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 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¿ 

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 


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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.¿ 

§ 207. Mammography and other cancer screening 

The Secretary, acting through the Service or Tribal Health Programs, shall provide for screening as follows: 

(1) Screening mammography (as defined in section 1861(jj) of 

the Social Security Act) for Indian 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 ensure 

the safety and accuracy of screening mammography under part 

B of title XVIII of such Act. 

(2) Other cancer screening meeting accepted and appropriate 

national standards. 

ø§ 1621f. Crediting of reimbursements¿ 

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.¿ 

§ 208. Patient travel costs 

The Secretary, acting through the Service and Tribal Health Programs, is authorized to provide funds for the following patient travel costs, including appropriate and necessary qualified escorts, associated with receiving health care services provided (either through 

direct or contract care or through a contract or compact under the 

Indian Self-Determination and Education Act (25 U.S.C. 450 et 

seq.)) under this Act—

(1) emergency air transportation and non-emergency air 

transportation where ground transportation is infeasible; 

(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. 


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ø§ 1621g. Health services research¿ 

øOf the amounts appropriated for the Service in any fiscal year, 

other than amounts made available for the Indian Health Care Improvement Fund, not less than $200,000 shall be available only for 

research to further the performance of the health service responsibilities of the 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.] shall be given an equal 

opportunity to compete for, and receive, research funds under this 

section.¿ 

§ 209. Epidemiology centers 

(a) ADDITIONAL CENTERS.—In addition to those epidemiology centers already established as of the date of enactment of this Act, and 

without reducing the funding levels for such centers, not later than 

180 days after the date of the enactment of the Indian Health Care 

Improvement Act Amendments of 2005, the Secretary, acting 

through the Service, shall establish an epidemiology center in each 

Service Area which does not yet have one to carry out the functions 

described in subsection (b). Any new centers so established may be 

operated by Tribal Health Programs, but such funding shall not be 

divisible. 

(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 subsection shall, with respect to such Service Area— (1) collect data relating to, and monitor progress made toward meeting, each of the health status objectives of the Service, 

the Indian Tribes, Tribal Organizations, and Urban Indian Organizations in the Service Area; 

(2) evaluate existing delivery systems, data systems, and other 

systems that impact the improvement of Indian health; 

(3) assist 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; 

(4) make recommendations for the targeting of services needed 

by the populations served; 

(5) make recommendations to improve health care delivery 

systems for Indians and Urban Indians; 

(6) provide requested technical assistance to Indian 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 community; 

and 

(7) provide disease surveillance and assist Indian Tribes, 

Tribal Organizations, and Urban Indian Organizations to promote public health. 

(c) TECHNICAL ASSISTANCE.—The Director of the Centers for Disease Control and Prevention shall provide technical assistance to 

the centers in carrying out the requirements of this subsection. 

(d) FUNDING FOR STUDIES.—The Secretary may make funding 

available to Indian Tribes, Tribal Organizations, and Urban Indian 

Organizations to conduct epidemiological studies of Indian communities. 


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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;¿ 

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 


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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 chapter, 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¿ 

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—¿ 


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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.¿ 

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 


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outpatient, emergency, aftercare and follow-up, and prevention 

and education services.¿ 

ø(2) The plan developed under paragraph (1) shall be implemented under 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 section 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.¿ 

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 disVerDate Aug 31 2005 11:50 Mar 23, 2006 Jkt 049010 PO 00000 Frm 00134 Fmt 6659 Sfmt 6602 E:\HR\OC\SR222.XXX SR222

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orders 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.¿ 

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 


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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 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 WORK- ERS¿ 

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.¿ 

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¿ 


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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 1621o(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 year 1993 and such 

sums as may be necessary for each of the fiscal years 1994, 

1995, 1996, 1997, 1998, 1999, and 2000.¿ 

§210. Comprehensive school health education programs 

(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, is authorized to 

award 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. 

(b) USE OF GRANT FUNDS.—A grant awarded under this section 

may be used for purposes which may include, but are not limited 

to, the following: 

(1) Developing and implementing health education curricula 

both for regular school programs and afterschool programs. 

(2) Training teachers in comprehensive school health education curricula. 

(3) Integrating school-based, community-based, and other 

public and private health promotion efforts. 

(4) Encouraging healthy, tobacco-free school environments. 

(5) Coordinating school-based health programs with existing 

services and programs available in the community. 

(6) Developing school programs on nutrition education, personal health, oral health, and fitness. 

(7) Developing behavioral health wellness programs. 

(8) Developing chronic disease prevention programs. 

(9) Developing substance abuse prevention programs. 

(10) Developing injury prevention and safety education programs. 

(11) Developing activities for the prevention and control of 

communicable diseases. 

(12) Developing community and environmental health education programs that include traditional health care practitioners. 

(13) Violence prevention. 

(14) Such other health issues as are appropriate. 


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(c) TECHNICAL ASSISTANCE.—Upon request, the Secretary, acting 

through the Service, shall provide technical assistance to Indian 

Tribes, Tribal Organizations, and Urban Indian Organizations in 

the development of comprehensive health education plans and the 

dissemination of comprehensive health education materials and information on existing health programs and resources. 

(d) CRITERIA FOR 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 funding provided pursuant to this section. 

(e) DEVELOPMENT OF PROGRAM 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 for which support is provided by 

the Bureau of Indian Affairs. 

(2) REQUIREMENTS FOR PROGRAMS.—Such programs shall include—

(A) school programs on nutrition education, personal 

health, oral health, and fitness; 

(B) behavioral health wellness programs; 

(C) chronic disease prevention programs; 

(D) substance abuse prevention programs; 

(E) injury prevention and safety education programs; and 

(F) activities for the prevention and control of communicable diseases. 

(3) DUTIES OF THE SECRETARY.—The Secretary of the Interior 

shall—

(A) provide training to teachers in comprehensive school 

health education curricula; 

(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§ 1621i. Managed care feasibility study¿ 

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.¿ 


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§ 211. Indian Youth Program 

(a) PROGRAM AUTHORIZED.—The Secretary, acting through the 

Service, is authorized to establish and administer a program to provide funding to Indian 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 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 health care practitioners; and 

(B) develop and provide community training and education. 

(2) PROHIBITED USE.—Funds made available under this section may not be used to provide services described in section 

707(c). 

(c) DUTIES OF THE SECRETARY.—The Secretary shall—

(1) disseminate to Indian Tribes, Tribal Organizations, and 

Urban Indian Organizations information regarding models for 

the delivery of comprehensive health care services to Indian and 

Urban Indian adolescents; 

(2) encourage the implementation of such models; and 

(3) at the request of an Indian Tribe, Tribal Organization, or 

Urban Indian Organization, provide technical assistance in the 

implementation of such models. 

(d) CRITERIA FOR 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§ 1621j. California contract health services demonstration 

program¿ 

ø(a) ESTABLISHMENT¿ 

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.¿ 


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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.¿ 

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.¿ 

§ 212. Prevention, control, and elimination of communicable 

and infectious diseases 

(a) FUNDING AUTHORIZED.—The Secretary, acting through the 

Service, and after consultation with Indian Tribes, Tribal Organizations, Urban Indian Organizations, and the Centers for Disease 

Control and Prevention, may make funding available to Indian 

Tribes, Tribal Organizations, and Urban Indian Organizations for 

the following: 

(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. 


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(2) Public information and education programs for the prevention, control, and elimination of communicable and infectious diseases. 

(3) Education, training, and clinical skills improvement activities in the prevention, control, and elimination of 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 REQUIRED.—The Secretary may provide funding 

under subsection (a) only if an application or proposal for funding 

is submitted to the Secretary. 

(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 Control and Prevention and State and 

local health agencies. 

(d) TECHNICAL ASSISTANCE; REPORT.—In carrying out this section, the Secretary— (1) may, at the request of an Indian Tribe, Tribal Organization, or Urban Indian Organization, provide technical assistance; and 

(2) shall prepare and submit a report to Congress biennially 

on the use of funds under this section and on the progress made 

toward the prevention, control, and elimination of communicable and infectious diseases among Indians and Urban Indians. 

ø§ 1621k. Coverage of screening mammography¿ 

øThe Secretary, through the Service, shall provide for screening 

mammography (as defined in section 1861(jj) of the Social Security 

Act [42 U.S.C.A. § 1395x9JJ0]) for Indian and 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), appropriate to such women, and under such terms and 

conditions as are consistent with standards established by the Secretary to assure the safety and accuracy of screening mammography under part B of title XVIII of the Social Security Act [42 

U.S.C.A. § 1395j et. seq.].¿ 

§ 213. Authority for provision of other 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 

through health care-related services and programs not otherwise described in this Act, including—

(1) hospice care; 

(2) assisted living; 

(3) long-term health care; 

(4) home- and community-based services, in accordance with 

subsection (d); and 

(5) public health functions. 

(b) SERVICES TO OTHERWISE INELIGIBLE PERSONS.—Subject to 

section 807, at the discretion of the Service, Indian Tribes, or Tribal 

Organizations, services provided for hospice care, home- and comVerDate Aug 31 2005 11:50 Mar 23, 2006 Jkt 049010 PO 00000 Frm 00141 Fmt 6659 Sfmt 6603 E:\HR\OC\SR222.XXX SR222

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munity-based care, assisted living, and long-term care may be provided (subject to reimbursement) to persons otherwise ineligible for 

the health care benefits of the Service. Any funds received under this 

subsection shall not be used to offset or limit the funding allocated 

to the Service or an Indian Tribe or Tribal Organization. 

(c) TERMS AND CONDITIONS.—The Secretary shall require that 

any service provided under this section shall be in accordance with 

such terms and conditions as the Secretary determines to be consistent with accepted and appropriate standards relating to the 

service, including any licensing term or condition under this Act. 

(d) DEFINITIONS.—For the purposes of this section, the following 

definitions shall apply: 

(1)(A) The term ‘home- and community-based services’ means 

1 or more of the following: 

(i) Home health aide services. 

(ii) Personal care services. 

(iii) Nursing care services provided outside of a nursing 

facility by, or under the supervision of, a registered nurse. 

(iv) Respite care. 

(v) Training for family members. 

(vi) Adult day care. 

(vii) Such other home- and community-based services as 

the Secretary, an Indian Tribe, or a Tribal Organization 

may approve. 

(B) The term ‘home- and community-based services’ does not 

include a service provided by an individual that is legally responsible for providing the service. 

(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. 

(3)(A) The term ‘personal care services’ means services relating to assistance in carrying out activities of daily living. 

(B) The term ‘personal care services’ does not include a service solely relating to assistance in carrying out an ancillary activity, such as housekeeping or household chores, as determined 

by the Secretary. 

(4) The term ‘public health functions’ means the provision of 

public health-related programs, functions, and services including assessment, assurance, and policy development which Indian Tribes and Tribal Organizations are authorized and encouraged, in those circumstances where it meets their needs, to 

do by forming collaborative relationships with all levels of 

local, State, and Federal Government. 

ø§1621l. Patient travel costs¿ 

ø(a) The Secretary, acting through the Service, shall provide 

funds for the following patient travel costs associated with receiving health care services provided (either through direct or contract 

care or through contracts entered into pursuant to the Indian SelfDetermination Act [25 U.S.C.A. § 450f et seq.]) under this chapter—¿ 

ø(1) emergency air transportation; and¿ 


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ø(2) nonemergency air transportation where ground transportation is infeasible.¿ 

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.¿ 

§ 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. 

ø§1621m. Epidemiology centers¿ 

ø(a)(1) The Secretary shall establish an epidemiology center in 

each Service area to carry out the functions described in paragraph 

(3).¿ 

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—¿ 

ø(A) collect data relating to, and monitor progress made toward meeting, each of the health status objectives described in 

section 1602(b) of this title using the data sets and monitoring 

system developed by the Secretary pursuant to paragraph (2);¿ 

ø(B) evaluate existing delivery systems, data systems, and 

other systems that impact the improvement of Indian health;¿ 

ø(C) assist tribes and urban Indian communities in identifying their highest priority health status objectives and the 

services needed to achieve such objectives, based on epidemiological data;¿ 

ø(D) make recommendations for the targeting of services 

needed by tribal, urban, and other Indian communities;¿ 

ø(E) make recommendations to improve health care delivery 

systems for Indians and 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) provide technical assistance to Indian tribes and urban 

Indian organizations in the development of local health service 


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priorities and incidence and prevalence rates of disease and 

other illness in the community.¿ 

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.).¿ 

ø(5) The director of the Centers for Disease Control shall provide 

technical assistance to the centers in carrying out the requirements 

of this subsection.¿ 

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.¿ 

ø(b)(1) The Secretary may make grants to Indian tribes, tribal organizations, and eligible intertribal consortia or Indian organization to conduct epidemiological studies of Indian communities.¿ 

ø(2) An intertribal consortia or Indian organization is eligible to 

receive a grant under this subsection if—¿ 

ø(A) it is incorporated for the primary purpose of improving 

Indian health; and¿ 

ø(B) it is representative of the tribes or urban Indian communities in which it is located.¿ 

ø(3) 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 under this subsection shall—¿ 

ø(A) demonstrate the technical, administrative, and financial 

expertise necessary to carry out the functions described in 

paragraph (5);¿ 

ø(B) consult and cooperate with providers of related health 

and social services in order to avoid duplication of existing 

services; and¿ 

ø(C) demonstrate cooperation from Indian tribes or urban Indian organizations in the area to be served.¿ 

ø(5) A grant awarded under paragraph (1) may be used to—¿ 

ø(A) carry out the functions described in subsection (a)(3) of 

this section;¿ 

ø(B) provide information to and consult with tribal leaders, 

urban Indian community leaders, and related health staff, on 

health care and health services management issues; and¿ 

ø(C) provide, in collaboration with tribes and urban Indian 

communities, the Service with information regarding ways to 

improve the health status of Indian people.¿ 

ø(6) There are authorized to be appropriated to carry out the 

purposes of this subsection not more that $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.¿ 

§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 


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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) and evaluation of the types and nature of activities, practices, and conditions causing or affecting such health problems 

including uranium mining and milling, uranium mining tailing deposits, nuclear power plant operation and construction, 

and 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 the enactment 

of the Indian Health Care Improvement Act Amendments of 

2005 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, in consultation with Indian Tribes and Tribal Organizations, 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 the 

enactment of the Indian Health Care Improvement Act Amendments 

of 2005. 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.—


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(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 Director of the Indian Health Service. 

(2) DUTIES.—The Task Force shall—

(A) identify existing and potential operations related to 

nuclear resource development or other environmental hazards 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. 

ø§ 1621n. Comprehensive school health education programs¿ 

ø(a) AWARD OF GRANTS¿ 

øThe Secretary, acting through the Service and in consultation 

with the Secretary of the Interior, may award grants to Indian 

tribes to develop comprehensive school health education programs 

for children from preschool through grade 12 in schools located on 

Indian reservations.¿ 

ø(b) USE OF GRANTS¿ 

øGrants awarded under this section may be used to—¿ 

ø(1) develop health education curricula;¿ 


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ø(2) train teachers in comprehensive school health education 

curricula;¿ 

ø(3) integrate school-based, community-based, and other public and private health promotion efforts;¿ 

ø(4) encourage healthy, tobacco-free school environments;¿ 

ø(5) coordinate school-based health programs with existing 

services and programs available in the community;¿ 

ø(6) develop school programs on nutrition education, personal health, and fitness;¿ 

ø(7) develop mental health wellness programs;¿ 

ø(8) develop chronic disease prevention programs;¿ 

ø(9) develop substance abuse prevention programs;¿ 

ø(10) develop accident prevention and safety education programs;¿ 

ø(11) develop activities for the prevention and control of communicable diseases; and¿ 

ø(12) develop community and environmental health education programs.¿ 

ø(c) ASSISTANCE¿ 

øThe Secretary shall provide technical assistance to Indian tribes 

in the development of health education plans, and the dissemination of health education materials and information on existing 

health programs and resources.¿ 

ø(d) CRITERIA FOR REVIEW AND APPROVAL OF APPLICATIONS¿ 

øThe Secretary shall establish criteria for the review and approval of applications for grants made pursuant to this section.¿ 

ø(e) REPORT OF RECIPIENT¿ 

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.¿ 

ø(f) PROGRAM DEVELOPMENT¿ 

ø(1) The Secretary of the Interior, acting through the Bureau 

of Indian Affairs and in cooperation with the Secretary, shall 

develop a comprehensive school health education program for 

children from preschool through grade 12 in schools operated 

by the Bureau of Indian Affairs.¿ 

ø(2) Such program shall include—¿ 

ø(A) school programs on nutrition education, personal 

health, and fitness;¿ 

ø(B) mental health wellness programs;¿ 

ø(C) chronic disease prevention programs;¿ 

ø(D) substance abuse prevention programs;¿ 

ø(E) accident prevention and safety education programs; 

and¿ 


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ø(F) activities for the prevention and control of communicable diseases.¿ 

ø(3) The Secretary of the Interior shall—¿ 

ø(A) provide training to teachers in comprehensive 

school health education curricula;¿ 

ø(B) ensure the integration and coordination of schoolbased programs with existing services and health programs available in the community; and¿ 

ø(C) encourage healthy, tobacco-free school environments.¿ 

ø(g) AUTHORIZATION OF APPROPRIATIONS¿ 

øThere are authorized to be appropriated to carry out this sec- tion $15,000,000 for the fiscal year 1993 and such sums as may be 

necessary for each of the fiscal years 1994, 1995, 1996, 1997, 1998, 

1999, and 2000.¿ 

§ 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, 2015, 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). 

§ 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 

designation of such States as a contract health service delivery area 

pursuant to subsection (a). 

ø§1621o. Indian youth grant program¿ 

ø(a) Grants¿ 

øThe Secretary, acting through the Service, is authorized to 

make grants to Indian tribes, tribal organizations, and urban Indian organizations for innovative mental and physical disease prevention and health promotion and treatment programs for Indian 

preadolescent and adolescent youths.¿ 

ø(b) USE OF FUNDS¿ 

ø(1) Funds made available under this section may be used 

to—¿ 


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ø(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 healers; and¿ 

ø(B) develop and provide community training and education.¿ 

ø(2) Funds made available under this section may not be 

used to provide services described in section 1621h(m) of this 

title.¿ 

ø(c) MODELS FOR DELIVERY OF COMPREHENSIVE HEALTH CARE

SERVICES¿ 

øThe Secretary shall—¿ 

ø(1) disseminate to Indian tribes information regarding models for the delivery of comprehensive health care services to Indian and urban Indian adolescents;¿ 

ø(2) encourage the implementation of such models; and¿ 

ø(3) at the request of an Indian tribe, provide technical assistance in the implementation of such models.¿ 

ø(d) CRITERIA FOR REVIEW AND APPROVAL OF APPLICATIONS¿ 

øThe Secretary shall establish criteria for the review and approval of applications 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.¿ 

§ 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 

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fornia Indians covered under this section at least one half of whom 

are not affiliated with the CRIHB. 

§ 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. 

§ 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 

by the Service beyond the scope of eligibility for such health services 

that applied on May 1, 1986. 

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;¿ 


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ø(B) incorporates a program advisory board comprised of 

representatives from the tribes and communities that will 

be served by the program;¿ 

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¿ 

ø(a) GRANTS¿ 

øThe Secretary, acting through the Service after consultation 

with the Centers for Disease Control, may make grants to Indian 

tribes and tribal organizations for—¿ 

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¿ 

ø(3) education, training, and clinical skills improvement activities in the prevention, control, and elimination of tuberculosis for health professionals, including allied health professionals.¿ 

ø(b) APPLICATION FOR GRANT¿ 

øThe Secretary may make a grant under subsection (a) of this 

section only if an application for the grant is submitted to the Secretary and the application is in such form, is made in such manner, 

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tion 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 

the Centers for Disease Control, and State and local health 

agencies; 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) DUTIES OF SECRETARY¿ 

øIn 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) may, at the request of an Indian tribe or tribal organization, provide technical assistance; and¿ 

ø(4) shall prepare and submit a report to the 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, on the use of funds under this section and on the 

progress made toward the prevention, control, and elimination 

of tuberculosis among Indian tribes and tribal organizations.¿ 

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 

the grant recipient and the amount of any other costs incurred 

in connection with the detail of such officer or employee,¿ 

øwhen 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.¿ 

ø§ 1621r. Contract health services payment study¿ 

ø(a) DUTY OF SECRETARY¿ 


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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;¿ 

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 requirement 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.¿ 

ø§ 1621s. Prompt action on payment of claims¿ 

ø(a) TIME OF RESPONSE¿ 

øThe Service shall respond to a notification of a claim by a provider of a contract care service with either an individual purchase 


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order or a denial of the claim within 5 working days after the receipt of such notification.¿ 

ø(b) FAILURE TO TIMELY RESPOND¿ 

øIf the Service fails to respond to a notification of a claim in accordance with subsection (a) of this section, the Service shall accept 

as valid the claim submitted by the provider of a contract care 

service.¿ 

ø(c) TIME OF PAYMENT¿ 

øThe Service shall pay a completed contract care service claim 

within 30 days after 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.¿ 

ø§ 1621u. Liability for payment¿ 

ø(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.¿ 

ø(b) The 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.¿ 

ø§ 1621v. Office of Indian Women’s Health Care¿ 

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.¿ 

§ 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. 

§ 221. Licensing 

Health care professionals employed by a Tribal Health Program 

shall, if licensed or certified 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 Self-Determination and Education Assistance Act (25 U.S.C. 

450 et seq.). 


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§ 222. Notification of provision of emergency contract health 

services 

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. 

§ 223. Prompt action on payment of claims 

(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. 

(b) EFFECT OF UNTIMELY RESPONSE.—If the Service fails to respond to a notification of a claim in accordance with subsection (a), 

the Service shall accept as valid the claim submitted by the provider 

of a contract care service. 

(c) DEADLINE FOR PAYMENT OF VALID CLAIM.—The Service shall 

pay a valid contract care service claim within 30 days after the completion of the claim. 

§ 224. Liability for payment 

(a) NO PATIENT LIABILITY.—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. 

(b) NOTIFICATION.—The 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 

233(b), the provider shall have no further recourse against the patient who received the services. 

§ 225. Office of Indian men’s health 

(a) ESTABLISHMENT.—The Secretary shall 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 2005, 

the Secretary, acting through the Director of the Office, shall submit 

to Congress a report describing—

(1) any activity carried out by the Director as of the date on 

which the report is prepared; and 

(2) any finding of the Director with respect to the health of 

Indian men. 


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§ 1621w. Authorization of appropriations 

øExcept as provided in sections 1621h(m), 1621j, 1621l, 1621m(b)(5), 1621n, and 1621o of this title, t¿ There are authorized 

to be appropriated such sums as may be necessary for each fiscal 

year through fiscal year 2015 ø2000¿ to carry out this title øsubchapter¿. 

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.¿. 

ø§ 1622. Transferred¿ 

TITLE øSUBCHAPTER¿ III—øHEALTH¿ 

FACILITIES 

§ 1631. Consultation; Construction and Renovation of Facilities; øclosure of facilities; r¿Reports 

(a) PREREQUISITES FOR EXPENDITURE OF FUNDS.—øCONSULTA- TION; STANDARDS FOR ACCREDITATION¿ 

Prior to the expenditure of, or the making of any binding øfirm¿ 

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) (commonly known as the ‘Snyder Act’) øsection 13 of this title, popularly known as the Snyder 

Act¿, the Secretary, acting through the Service, shall— (1) consult with any Indian øt¿ 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 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 øthe Joint Commission on 

Accreditation of Health Care Organizations¿ by not later than 

1 year after the date on which the construction or renovation 

of such facility is completed. 

(b) CLOSURES.—ø; REPORT ON PROPOSED CLOSURE¿ 

(1) EVALUATION REQUIRED.—Notwithstanding any other provision of law, no facility operated by the Service øother than 

this subsection, no Service hospital or outpatient health care 

facility of the Service, or any portion of such a hospital or facility,¿ may be closed if the Secretary has not submitted to øthe¿ 

Congress at least 1 year prior to the date of the proposed closure øsuch hospital or facility (or portion thereof) is proposed 

to be closed¿ an evaluation of the impact of the øsuch¿ proposed closure which 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; 


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(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 øt¿ Tribes served by such 

øhospital or¿ facility concerning such closure; 

(F) the level of use of such øutilization of such hospital 

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. 

(c) HEALTH CARE FACILITY PRIORITY SYSTEM.—øANNUAL REPORT

ON HEALTH FACILITY PRIORITY SYSTEM¿ 

(1) IN GENERAL.— (A) ESTABLISHMENT.—The Secretary, acting through the 

Service, shall establish a health care facility priority system, which shall—

(i) be developed with Indian Tribes and Tribal Organizations through negotiated rulemaking under section 

802; 

(ii) give Indian Tribes’ needs the highest priority; 

and 

(iii) at a minimum, include the lists required in 

paragraph (2)(B) and the methodology required in 

paragraph (2)(E). 

(B) PRIORITY OF CERTAIN PROJECTS PROTECTED.—The 

priority of any project established under the construction 

priority system in effect on the date of the Indian Health 

Care Improvement Act Amendments of 2005 shall not be affected by any change in the construction priority system 

taking place thereafter if the project was identified as 1 of 

the 10 top-priority inpatient projects, 1 of the 10 top-priority outpatient projects, 1 of the 10 top-priority staff quarters developments, or 1 of the 10 top-priority Youth Regional Treatment Centers in the fiscal year 2005 Indian 

Health Service budget justification, or if the project had 

completed both Phase I and Phase II of the construction 

priority system in effect on the date of the enactment of 

such Act. 

(2) ø(1)¿ REPORT; CONTENTS.—The Secretary shall submit to 

the President, for inclusion in øeach¿ the report required to be 

transmitted to øthe¿ Congress under section 801 ø1671 of this 

title¿, a report which sets forth the following:ø—¿ 

(A) A description of the øcurrent¿ health care facility 

priority system of the Service, established under paragraph (1). 

(B) HEALTH CARE FACILITIES LISTS, INCLUDING—øthe 

planning, design, construction, and renovation needs for 

the 10 top-priority inpatient care facilities and the 10 toppriority ambulatory care facilities (together with required 

staff quarters),¿ 


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(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); 

(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. 

(C) øt¿The justification for such order of priorityø,¿. 

(D) øt¿The projected cost of such projects.ø, and¿ 

(E) øt¿The methodology adopted by the Service in establishing priorities under its health facility priority system. 

(3)ø(2)¿ REQUIREMENTS FOR PREPARATION OF REPORTS.—In 

preparing each report required under paragraph (2) ø(1)¿ 

(other than the initial report), the Secretary shall annually—

(A) consult with and obtain information on all health 

care facilities needs from Indian [t]Tribes, Tribal Organizations, and Urban Indian Organizations; øand 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 

(B) review the total unmet needs of all Indian øsuch 

t¿Tribes, Tribal Organizations, and Urban Indian Organizations øand tribal organizations¿ for health care øinpatient and outpatient¿ facilities (including hostels and staff 

quarters), including øtheir¿ needs for renovation and expansion of existing facilities. 

(4)ø(3)¿ CRITERIA FOR EVALUATING NEEDS.—For purposes of 

this subsection, the Secretary shall, in evaluating the needs of 

facilities operated under any contract or compact øentered into 

with the Service¿ under the Indian Self-Determination and 

Education Act (25 U.S.C. 450 et seq.) [25 U.S.C. § 450f et seq],¿ 

use the same criteria that the Secretary uses in evaluating the 

needs of facilities operated directly by the Service. 

(5)ø(4)¿ NEEDS OF FACILITIES UNDER ISDEAA AGREEMENTS.—

The Secretary shall ensure that the planning, design, construction, and renovation needs of Service and non-Service facilities 

operated under contracts or compacts in accordance with the 

øwhich are the subject of a contract for health services entered 

into with the Service under the¿ Indian Self-Determination 

and Education Assistance Act (25 U.S.C. 450 et seq.) [25 U.S.C. 

§ 450f et seq] are fully and equitably integrated into [the development of] the health care facility priority system. 

(d) REVIEW OF NEED FOR FACILITIES

(1) INITIAL REPORT.—In the year 2006, the Government Accountability Office shall prepare and finalize a report which 

sets forth the needs of the Service, Indian Tribes, Tribal Organizations, and Urban Indian Organizations, for the facilities 

listed under subsection (c)(2)(B), including the needs for renovation and expansion of existing facilities. The Government Accountability Office shall submit the report to the appropriate 


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authorizing and appropriations committees of Congress and to 

the Secretary. 

(2) Beginning in the year 2006, the Secretary shall update the 

report required under paragraph (1) every 5 years. 

(3) In preparing an updated report under paragraph (2), the 

Secretary shall consult with Indian Tribes, Tribal Organizations, and Urban Indian Organizations. The Secretary shall 

submit the report under paragraph (2) for inclusion in the report required to be transmitted to Congress under section 801. 

(4) For purposes of this subsection, the reports shall, regarding the needs of facilities operated under any contracts or compacts under the Indian Self-Determination and Education Assistance Act (25 U.S.C. 450 et seq.), be based on the same criteria that the Secretary uses in evaluating the needs of facilities 

operated directly by the Service. 

(5) The planning, design, construction, and renovation needs 

of facilities operated under contracts or compacts under the Indian Self-Determination and Education Assistance Act (25 

U.S.C. 450 et seq.) shall be fully and equitably integrated into 

the development of the health facility priority system. 

(6) Beginning in the year 2007 and each fiscal year thereafter, the Secretary shall provide an opportunity for nomination 

of planning, design, and construction projects by the Service, 

Indian Tribes, and Tribal Organizations for consideration 

under the health care facility priority system. 

(e) FUNDING CONDITION.—ø(d) FUNDS APPROPRIATED SUBJECT TO

SECTION 450F OF THIS TITLE¿ 

All funds appropriated under the Act of November 2, 1921 (25 

U.S.C. 13) (commonly known as the ‘Snyder Act’), øsection 13 of 

this title,¿ for the planning, design, construction, or renovation of 

health facilities for the benefit of 1 or more øan¿ Indian [tribe or 

t]Tribes shall be subject to the provisions of øsection 102 of¿ the 

Indian Self-Determination and Education Assistance Act (25 U.S.C. 

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 construction of health facilities, including those provided for in other sections of this title and other approaches. 

§ 1632. Sanitation øSafe water and sanitary waste disposal 

f¿Facilities 

(a) øCONGRESSIONAL F¿FINDINGS.—

øThe¿ Congress øhereby¿ finds the following: øand declares 

that—¿ 

(1) øt¿The provision of sanitation facilities øsafe water supply systems and sanitary sewage and solid waste disposal systems¿ 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 sanitation facilities. øsuch systems;¿ 

(3) øt¿The long-term cost to the United States of treating 

and curing such disease, injury, and illness is substantially 


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greater than the short-term cost of providing sanitation facilities øsuch systems¿ and other preventive health measuresø;¿. (4) øm¿Many Indian homes and Indian communities still 

lack sanitation facilities. øsafe water supply systems and sanitary sewage and solid waste disposal systems; and¿ 

(5) øi¿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 sanitation 

facilities. øsafe and adequate water supply systems and sanitary sewage waste disposal systems as soon as possible.¿ 

(b) FACILITIES AND SERVICES.—øAUTHORITY; ASSISTANCE; TRANSFER OF FUNDS¿ 

ø(1)¿ 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 7 of the Act 

of August 5, 1954 (42 U.S.A. 2004a) ø2004a of Title 42¿. Under 

such authority, ø(2) T¿the Secretary, acting through the Service, is 

authorized to provide the following: øunder section 2004a of Title 

42.¿ 

(1)ø(A) f¿Financial and technical assistance to Indian 

øt¿Tribes, Tribal Organizations, and Indian communities in 

the establishment, training, and equipping of utility organizations to operate and maintain øIndian¿ sanitation facilitiesø;¿, 

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. 

(2)ø(B) o¿Ongoing technical assistance and training to Indian Tribes, Tribal Organizations, and Indian communities in 

the management of utility organizations which operate and 

maintain sanitation facilities.ø; and¿ 

(3)ø(C)¿ 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 an imminent øa¿ 

health threat øhazard¿ or to protect the øFederal¿ investment 

in sanitation facilities and the investment in the health benefits 

gained through the provision of sanitation facilities. 

(c) FUNDING.—ø(3)¿ Notwithstanding any other provision of 

law—

(1)ø(A)¿ the Secretary of Housing and Urban Development 

øAffairs¿ is authorized to transfer funds appropriated under 

the Native American Housing Assistance and Self-Determination øCommunity Development¿ Act of 1996 ø1974 (42 U.S.C. 

5301 et seq.)¿ to the Secretary of Health and Human Services;ø, and¿ 

(2)ø(B)¿ 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 7 of the Act of August 5, 1954 (42 U.S.C. 2004a); ø2004a 

of Title 42.¿ 

(3) unless specifically authorized when funds are appropriated, the Secretary shall not use funds appropriated under 

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vide 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 purposes of providing sanitation facilities 

and services and place these funds into contracts or compacts 

under the Indian Self-Determination and Education 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; and 

(9) the Secretary of Health and Human Services shall, by regulation developed through rulemaking under section 802, establish standards applicable to the planning, design, and construction of sanitation facilities funded under this Act. 

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.¿ 

(d) CERTAIN CAPABILITIES NOT PREREQUISITE.—øTRIBAL CAPABILITY¿ 

The financial and technical capability of an Indian øt¿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. 

(e) FINANCIAL øAMOUNT OF A¿ASSISTANCE.—

ø(1)¿ The Secretary is authorized to provide financial assistance to Indian øt¿Tribes, Tribal Organizations and Indian 

communities for operation, management, and maintenance of 

their sanitation facilities. øin 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.¿ 


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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.¿ 

(f) OPERATION, MANAGEMENT, AND MAINTENANCE OF FACILI- TIES.—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 coordinator 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. 

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.¿ 

(h) REPORT.—ø(g) ANNUAL REPORT; SANITATION DEFICIENCY LEV- ELS¿ 

(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 øeach¿ 

the report required to be transmitted to øthe¿ Congress under 

section 801ø1671 of this title¿, a report which sets forth— (A) the current Indian sanitation facility priority system 

of the Service; 

(B) the methodology for determining sanitation deficiencies and needs; 

(C) the level of initial and final sanitation deficiency for 

each type of sanitation facility øfacilities¿ for each type of 

project of each Indian øt¿Tribe or Indian community; 

(D) the amount and most effective use of funds, derived 

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tation facilities needs of new homes assisted with funds 

under the Native American Housing Assistance and SelfDetermination Act, and to reduce the identified sanitation 

deficiency levels of øraise¿ all Indian øt¿Tribes and Indian 

communities to øa¿ level I sanitation deficiency as defined 

in paragraph (4)(A); and 

(E) a 10-year plan to provide sanitation facilities to serve 

existing Indian homes and Indian communities and new 

and renovated Indian homes. øthe amount of funds necessary to raise all Indian tribes and communities to zero 

sanitation deficiency.¿ 

(2) CRITERIA.—The criteria on which the deficiencies and needs 

will be evaluated shall be developed through negotiated rulemaking 

pursuant to section 802. 

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.¿ 

(3) 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 øt¿Tribes and Indian 

communities. 

(4) SANITATION DEFICIENCY LEVELS.—For purposes of this 

subsection, the sanitation deficiency levels for an individual, 

Indian øt¿Tribe or Indian community sanitation facility to 

serve Indian homes are determined as follows: 

(A) A level I deficiency exists if a sanitation facility serving øis¿ an individual, Indian øt¿Tribe or Indian community øwith a sanitation system¿— (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 deficiency exists if a sanitation facility serving an individual, øis an¿ Indian øt¿Tribe, or Indian community substantially or recently complied with all applicable water supply, pollution control, and solid waste laws 

and any deficiencies relate to øwith a sanitation system¿—

(i) small or minor capital improvements needed to 

bring the facility back into compliance; øwhich complies with all applicable water supply and pollution 

control laws, and¿ 

(ii) øin which the deficiencies relate to¿ 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. 


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(C) A level III deficiency exists if a sanitation facility 

serving an individual, øis an¿ Indian øt¿Tribe or Indian 

community meets one or more of the following conditions 

øwith a sanitation system which¿—

(i) water or sewer service in the home is provided by 

a haul system with holding tanks and interior plumbing; øhas an inadequate or partial water supply and a 

sewage disposal facility that does not comply with applicable water supply and pollution control laws, or¿ 

(ii) major significant interruptions to water supply or 

sewage disposal occur frequently, requiring major capital improvements to correct the deficiencies; or øhas no 

solid waste disposal facility;¿ 

(iii) there is no access to or no approved or permitted 

solid waste facility available. 

(D) A LEVEL IV DEFICIENCY EXISTS.—ø(IV) is an Indian 

tribe or community with a sanitary system which lacks either a safe water supply system or a sewage disposal system: and¿ 

(i) if a sanitation facility of 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. ø(V) is an Indian tribe or community that 

lacks a safe water supply and a sewage disposal system.¿ 

(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(5) For purposes of this subsection, any Indian tribe or community that lacks the operation and maintenance capability to 

enable its sanitation system to meet pollution control laws may 

not be treated as having a level I or II sanitation deficiency.¿ 

§1633. Preference to Indians and Indian firms 

(a) BUY INDIAN ACT.—øDISCRETIONARY AUTHORITY; COVERED ACTIVITIES¿ 


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The Secretary, acting through the Service, may use øutilize¿ the 

negotiating authority of section 23 ø47¿ of the Act of June 25, 1910 

(25 U.S.C. 47, commonly known as the ‘Buy Indian Act’) øthis 

title¿, 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 øt¿Tribes in the State of New York 

(hereinafter referred to as an ø‘‘¿ ‘Indian firm’ ø’’¿) in the construction and renovation of Service facilities pursuant to section 301 

ø1631 of this title¿ and in the construction of sanitation øsafe 

water and sanitary waste disposal¿ facilities pursuant to section 

302 ø1632 of this title¿. Such preference may be accorded by the 

Secretary unless the Secretary øhe¿ finds, pursuant to ørules and¿ 

regulations øpromulgated¿ adopted pursuant to section 802 øby 

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 such a øhis¿ 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. 

(b) LABOR STANDARDS.—øPAY RATES¿ 

(1) IN GENERAL.—For the purpose of implementing the provisions of this title øsubchapter¿, contracts for the construction or 

renovation of health care facilities, staff quarters, and sanitation facilities, and related support infrastructure, funded in 

whole or in part with funds made available pursuant to this 

title, shall contain a provision requiring compliance with subchapter IV of chapter 31 of title 40, United States Code (commonly known as the ‘Davis-Bacon Act’), unless such construction or renovation—øthe secretary shall assure that the rates 

of pay for personnel engaged in the construction or renovation 

of facilities constructed or renovated in whole or in part by 

funds made available pursuant to this subchapter are not less 

than the prevailing local wage rates for similar work as determined in accordance with sections 3141 to 3144, 3146, 3147 of 

Title 40.¿ 

(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. 


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§ 1634. Expenditure of øn¿Nonø-S¿service øf¿Funds for 

ør¿Renovation 

(a) IN GENERAL.—øAUTHORITY OF SECRETARY¿ ø(1)¿ Notwithstanding any other provision of law, if the requirements of subsection (c) are met, the Secretary, acting through the Service, is authorized to accept any major expansion, renovation or modernization by any Indian øt¿Tribe or Tribal Organization of any Service 

facility or of any other Indian health facility operated pursuant to 

a contract or compact øentered into¿ under the Indian Self-Determination Act and Education Assistance Act (25 U.S.C. 450 et seq.), 

ø25 U.S.C.A. § 450f et seq.¿ including—

(1)ø(A)¿ any plans or designs for such expansion, renovation 

or modernization; and 

(2)ø(B)¿ any expansion, renovation or modernization for 

which funds appropriated under any Federal law were lawfully 

expended. ø, but only if the requirements of subsection (b) of 

this section are met.¿ 

(b) PRIORITY LIST.—

(1)ø(2)¿ IN GENERAL.—The Secretary shall maintain a separate priority list to address the needs for increased operating 

expenses, øof such facilities for¿ personnel, or equipment for 

such facilities. The methodology for establishing priorities shall 

be developed through negotiated rulemaking under section 802. 

The list of priority facilities will be revised annually in consultation with Indian Tribes and Tribal Organizations. 

(2)ø(3)¿ REPORT.—The Secretary shall submit to the President, for inclusion in øeach¿ the report required to be transmitted to øthe¿ Congress under section 801 ø1671 of this section¿, the priority list maintained pursuant to paragraph 

(1)ø(2)¿. 

(c)ø(b)¿ REQUIREMENTS—The requirements of this subsection are 

met with respect to any expansion, renovation or modernization 

if—

(1) the Indian Tøt¿ribe or øt¿Tribal øo¿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 or equipment; and 

(2) the expansion, renovation or modernization—

(A) is approved by the appropriate area director of the 

Service for Federal facilities; and 

(B) is administered by the Indian Tøt¿ribe or Tribal Organization in accordance with any applicable øthe rules 

and¿ regulations prescribed by the Secretary with respect 

to construction or renovation of Service facilities. 

(d) ADDITIONAL REQUIREMENT FOR EXPANSION.—In addition to 

the requirements in subsection (c), for any expansion, the Indian 

Tribe or Tribal Organization shall provide to the Secretary additional information developed through negotiated rulemaking under 

section 802, including additional staffing, equipment, and other 

costs associated with the expansion. 

(e) CLOSURE OR CONVERSION OF FACILITIES.—ø(c) RECOVERY FOR

NON-USE AS SERVICE FACILITY¿ 


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If any Service facility which has been expanded, renovated or 

modernized by an Indian øt¿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 øt¿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. 

ø§1635. Repealed. Pub. L. 100–713, Title III, § 303(b), Nov. 23, 

1988, 102 Stat. 4817¿ 

§1636. Funding øGrant program¿ for the øc¿Construction, 

øe¿Expansion, and øm¿Modernization of øs¿Small 

øa¿Ambulatory øc¿Care øf¿Facilities 

(a) FUNDING.—øAUTHORIZATION¿ 

(1) IN GENERAL.—The Secretary, acting through the Service, 

shall make grants to Indian Tøt¿ribes and øt¿Tribal 

øo¿Organizations for the construction, expansion, or modernization of facilities for the provision of ambulatory care 

services to eligible Indians (and noneligible persons pursuant 

to subsections (b)(2) and (c)(1)(C) øas provided in subsection 

(c)(1)(C) 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 ø‘‘¿‘construction’ø’’¿ includes the replacement of an existing facility. 

(2) GRANT AGREEMENT REQUIRED.—A grant under paragraph 

(1) may only be available ømade¿ to a Tribal Health Program 

øtribe or tribal organization¿ 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 a Indian Tøt¿ribe or øt¿Tribal 

øo¿Organization) øpursuant to a contract entered into under 

the Indian Self-Determination Act [25 U.S.C.A. § 450f et seq.]¿. 

(b) USE OF øG¿ Grant FUNDS

(1) ALLOWABLE USES.—A grant provided under this section 

may be used øonly¿ 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 301ø1631¿ or section 

307ø1637 of this title¿; and 

(C) which, upon completion of such construction, expansion, or modernization will—

(i) have a total capacity appropriate to its projected 

service population; 

(ii) provide annually no fewer than 150 patient visits 

by eligible Indians and other users who are eligible for 


hsrobinson on PROD1PC72 with HEARING
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services in such facility in accordance with section 

807(c)(2) øserve no less than 500 eligible Indians annually¿; and 

(iii) provide ambulatory care in a øs¿Service 

øa¿Area (specified in the contract or compact øentered 

into¿ under the Indian Self-Determination and Education Assistance Act (25 U.S.C. 450 et seq.)ø25 

U.S.C.A. § 450f et seq.]¿) with a population of no fewer 

than 1,500 ønot less than 2,000¿ eligible Indians and 

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). 

(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). ø(2)¿ The requirements of clauses 

(ii) and (iii) of paragraph (1)(C) shall not apply to an Indian 

Tribe øa tribe¿ or øt¿Tribal øo¿Organization applying for a 

grant under this section for a health care facility øwhose tribal 

government offices are¿ 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. 

(c) øAPPLICATION FOR G¿GRANTS.—

(1) APPLICATION.—No grant may be made available under 

this section unless an application or proposal for øthe¿ a grant 

has been øsubmitted to and¿ approved by the Secretary in accordance with applicable regulations and has forth reasonable 

assurance by the applicant that, at all times after the construction, expansion, or modernization of a facility carried out pursuant to funding received under this section—ø. 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 set forth reasonable assurance by the applicant that, at 

all times after the construction, expansion, or modernization of 

a facility carried out pursuant to 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. 


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(2) PRIORITY.—In awarding grants under this section, the 

Secretary shall give priority to Indian Tøt¿ribes and øt¿Tribal 

øo¿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 during 

consultations pursuant to subsection (a)(1). 

(d) REVERSION OF FACILITIES.—øTRANSFER OF INTEREST TO

UNITED STATES UPON CESSATION OF FACILITY¿ If any facility (or 

portion thereof) with respect to which funds have been paid under 

this section, ceases, within 5 years øat any time¿ after completion 

of the construction, expansion, or modernization carried out with 

such funds, to be used øutilized¿ for the purposes of providing 

health øambulatory¿ 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. 

§ 1637. Indian øh¿Health øc¿Care ød¿Delivery 

ød¿Demonstration øp¿Project 

(a) HEALTH øC¿CARE øDELIVERY D¿DEMONSTRATION

øP¿PROJECTS.—THE SECRETARY, ACTING THROUGH THE SERVICE, 

and in consultation with Indian Tribes and Tribal Organizations, 

is authorized to enter into construction agreements under the Indian Self-Determination and Education Assistance Act (25 U.S.C. 

450 et seq.) withø, or make grants to,¿ Indian øt¿Tribes or 

øt¿Tribal øo¿Organizations for the purpose of carrying out a health 

care delivery demonstration project to test alternative means of delivering health care and services through øhealth¿ facilities øto Indians¿. 

(b) USE OF øF¿Funds.—The Secretary, in approving projects pursuant to this section, may authorize funding 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 other available ønon-Service Federal 

funds and non-Federal¿ 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 

(6) permit the use of Service funds to match other funds, including Federal funds. 

(c) REGULATIONS.—øCRITERIA¿ 


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ø(1) Within 180 days after November 28, 1990, t¿The 

Secretaryø, after consultation with Indian tribes and tribal organizations,¿ shall develop and promulgate regulations not 

later than 1 year after the enactment of the Indian Health Care 

Improvement Act Amendments of 2005. If the Secretary has not 

promulgated regulations by that date, the Secretary shall develop and publish regulations, through rulemaking under 802, 

øin the Federal Register criteria¿ for the review and approval 

of applications submitted under this section. 

(d) CRITERIA.—The Secretary may approve øenter into a contract 

or award a grant under this section for¿ projects that øwhich¿ meet 

the following criteria: 

(1)ø(A)¿ There is a need for a new facility or program or the 

reorientation of an existing facility or program. 

(2)ø(B)¿ A significant number of Indians, including those 

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.¿ 

(3)ø(D)¿ The project has the potential to deliver services in 

an efficient and effective manner. 

(4)ø(E)¿ The project is economically viable. 

(5)ø(F)¿ The Indian øt¿Tribe or øt¿Tribal øo¿Organization 

has the administrative and financial capability to administer 

the project. 

(6)ø(G)¿ The project is integrated with providers of related 

health and social services and is coordinated with, and avoids 

duplication of, existing services. 

(e) PEER REVIEW PANELS.—ø(2)¿ The Secretary may provide for 

the establishment of peer review panels, as necessary, to review 

and evaluate applications øand to advise the Secretary regarding 

such applications¿ using the criteria developed pursuant to subsection (d) øparagraph (1)¿. (f) PRIORITY.—The Secretary shall give priority to applications for 

demonstration projects 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 

øs¿Service øu¿Units to the extent that such applications are timely 

filed and meet the criteria specified in subsection (d): øwhich meets 

the criteria specified in paragraph (1) and for which a completed 

application has been received by the Secretary:¿ 

(1)ø(i)¿ Cass Lake, Minnesota. 

(2)ø(ii)¿ Clinton, Oklahoma. 

(3)ø(iii)¿ Harlem, Montana. 

(4)ø(iv)¿ Mescalero, New Mexico. 

(5)ø(v)¿ Owyhee, Nevada. 

(6)ø(vi)¿ Parker, Arizona. 

(7)ø(vii)¿ Schurz, Nevada. 

(8)ø(viii)¿ Winnebago, Nebraska. 

(9)ø(ix)¿ 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 


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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).¿ 

(g)ø(d)¿ TECHNICAL øA¿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. 

(h)ø(e)¿ SERVICE TO øI¿INELIGIBLE øP¿PERSONS.—Subject to section 807, øT¿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 øs¿Service facilities to non-Service health care practitioners as provided in section 807ø1680c of 

this title¿ may be included, subject to the terms of such section, in 

any demonstration project approved pursuant to this section. 

(i)ø(f)¿ EQUITABLE øT¿TREATMENT.—For purposes of subsection 

(d)(1)ø(c)(1)(A) of this section¿, the Secretary shall, in evaluating 

facilities operated under any contract or compact entered into with 

the Service under the Indian Self-Determination and Education Assistance Act (25 U.S.C. 450 et seq.) ø25 U.S.C.A. § 450f et seq.¿, use 

the same criteria that the Secretary uses in evaluating facilities operated directly by the Service. 

(j)ø(g)¿ EQUITABLE øI¿INTEGRATION OF øF¿FACILITIES.—The Secretary shall ensure that the planning, design, construction, øand¿ 

renovation, and expansion needs of Service and non-Service facilities which are the subject of a contract or compact øentered into 

with the Service¿ under the Indian Self-Determination and Education Assistance Act (25 U.S.C. 450 et seq.) (25 U.S.C. 450 et seq.) 

ø25 U.S.C.A. 450f 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) REPORT 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.¿ 

§1638. Land øt¿Transfer 

Notwithstanding any other provision of law, øT¿the Bureau of Indian Affairs and all other agencies and departments of the United 

States are øis¿ 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. øup to 5 acres of land at the Chemawa Indian 

School, Salem, 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.¿ 


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§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 Organization 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. 

§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—

(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 

1 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; 


hsrobinson on PROD1PC72 with HEARING
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(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, 2007, the Secretary 

shall submit to the Committee on Indian Affairs of the Senate and 

the Committee on 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. 

§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. 

§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 exchange 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 which shall be developed through the negotiated rulemaking process provided for under section 802. 

(c) CONTINUED OPERATION.—The Secretary shall negotiate an 

agreement with the Indian Tribe or Tribal Organization regarding 


hsrobinson on PROD1PC72 with HEARING
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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. 

§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 

Service shall give priority to locating such facilities and projects on 

Indian lands, or lands owned by any Alaska Native village, or village or regional corporation under the Alaska Native Claims Settlement Act, or any lands 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; 

(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. 

§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. 


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(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 negotiated rulemaking process provided for under section 802. 

(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. 

§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. 

(2) OBJECTIVES.—In establishing rental rates pursuant to authority of this subsection, a Tribal Health Program shall endeavor to achieve the following objections: 

(A) To base such rental rates on the reasonable value of 

the quarters to the occupants thereof. 

(B) To 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 


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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—

(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 

(B) such other date as may be mutually agreed by the 

Secretary and the Tribal Health Program. 

(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. 

ø§ 1638a. Authorization of appropriations¿ 

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.¿ 

§ 1638b. Applicability of Buy American Act Rør¿equirement 

(a) APPLICABILITY.—øDUTY 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 317ø1638a of this title¿. 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 ø41 U.S.C.A. § 10a et seq.¿ was 

waived pursuant to the Trade Agreement Act of 1979 ø19 U.S.C.A. 

§ 2501 et seq.¿ or any international agreement to which the United 

States is a party.¿ 


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(b)ø(c)¿ EFFECT OF VIOLATION.—øFRAUDULENT USE OF MADE-IN- AMERICA LABEL¿ If it has been finally determined by a court or 

Federal agency that any person intentionally affixed a label bearing a ø‘‘¿‘Made in America’ø’’¿ 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 317 ø1638a of this title¿, pursuant to the debarment, suspension, and ineligibility procedures described in sections 9.400 

through 9.409 of title 48, Code of Federal Regulations. 

(c)ø(d)¿ DEFINITIONS.—ø‘‘BUY AMERICAN ACT’’ DEFINED¿ For purposes of this section, the term ø‘‘¿‘Buy American Act’ø’’¿ 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.). 

§ 316. Other funding for facilities 

(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. 

(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. 

(c) TRANSFERRED FUNDS.—Any Federal agency to which funds for 

the construction of health care facilities are appropriated is authorized to transfer such funds to the Secretary for the construction of 

health care facilities to carry out the purposes of this Act as well 

as the purposes for which such funds are appropriated to such other 

Federal agency. 

(d) ESTABLISHMENT OF STANDARDS.—The Secretary, through the 

Service, shall establish standards by regulation, developed by rulemaking under section 802, for the planning, design, and construction of health care facilities serving Indians under this Act. 

§ 317. Authorization of appropriations 

There are authorized to be appropriated such sums as may be 

necessary for each fiscal year through fiscal year 2015 to carry out 

this title. 

ø§ 1638c. Contracts for personal services in Indian Health 

Service facilities¿ 

øIn fiscal year 1995 and thereafter—¿ 

ø(a) IN GENERAL¿ 


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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.¿ 

ø(b) EXEMPTION FROM COMPETITIVE CONTRACTING REQUIRE- MENTS¿ 

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.¿ 

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.¿ 

ø(d) LIABILITY¿ 

øIndividuals providing health care services pursuant to these 

contracts are covered by the Federal Tort Claims Act.¿ 

ø§ 1638d. Credit to appropriations of money collected for 

meals at Indian Health Service facilities¿ 

øMoney before, on, and after September 30, 1994, 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.¿ 

TITLE IV øSUBCHAPTER III–A¿—ACCESS 

TO HEALTH SERVICES 

§ 1641. Treatment of øp¿Payments øu¿Under Social Security 

Act Health Care ømedicare¿ Pøp¿rograms 

(a) DISREGARD OF MEDICARE, MEDICAID, AND SCHIP PAYMENTS

IN DETERMINING APPROPRIATIONS øDETERMINATION OF APPROPRIA- TIONS¿ 

Any payments received by an Indian Health Program or by an 

Urban Indian Organization made under title XVIII, XIX, or XXI of 

the Social Security Act øa 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 SelfDetermination Act [25 U.S.C.A.§ 450f et seq.])¿ for services provided to Indians eligible for benefits under such respective titles 

øTitle XVIII of the Social Security Act [42 U.S.C.A. § 1395 et seq.]¿ 

shall not be considered in determining appropriations for the provision of health care and services to Indians. 

(b) NONPREFERENTIAL TREATMENT.—øPREFERENCES¿ Nothing in 

this Act øchapter¿ authorizes the Secretary to provide services to 

an Indian [beneficiary] with coverage under title XVIII, XIX, or 

XXI of the Social Security Act ø[42 U.S.C.A. § 1395 et seq.], as 

amended,¿ in preference to an Indian øbeneficiary¿ without such 

coverage. 

ø§ 1642. Treatment of payments under medicaid program¿ 

(c)ø(a)¿ USE OF FUNDS.—øPAYMENTS TO SPECIAL FUND¿ 

(1) SPECIAL FUND.—Notwithstanding any other provision of 

law, but subject to paragraph (2), payments to which aøny¿ faVerDate Aug 31 2005 11:50 Mar 23, 2006 Jkt 049010 PO 00000 Frm 00178 Fmt 6659 Sfmt 6602 E:\HR\OC\SR222.XXX SR222

hsrobinson on PROD1PC72 with HEARING
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cility of the Service ø(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 øunder a State plan¿ by 

reason of a provision of the Social Security Act øsection 1911 

of such Act [42 U.S.C.A.§1396j]¿ shall be placed in a special 

fund to be held by the Secretary and first used øby him¿ (to 

such extent or in such amounts as are provided in appropriation Acts) øexclusively¿ for the purpose of making any improvements in the programs øfacilities¿ of the øsuch¿ Service 

which may be necessary to achieve or maintain compliance 

with the applicable conditions and requirements of øsuch¿ titles XVIII, XIX, and XXI of the Social Security Act. Any 

amounts to be reimbursed that are in excess of the amount necessary to achieve or maintain such conditions and requirements 

shall, subject to the consultation with Indian Tribes being 

served by the Service Unit, be used for reducing the health resource deficiencies of the Indian Tribes. In making payments 

from such fund, the Secretary shall ensure that each 

øs¿Service øu¿Unit of the Service receives 100 øat least 80¿ 

percent of the amountøs¿ to which the facilities of the Service, 

for which such øs¿Service øu¿Unit makes collections, are entitled by reason of a provision øsection 1911¿ of the Social Security Act ø[42 U.S.C.A. § 1396j]¿. (2) DIRECT PAYMENT OPTION.—Paragraph (1) shall not apply 

upon the election of a Tribal Health 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 during the period of 

such election. 

(d) DIRECT BILLING.—

(1) IN GENERAL.—A Tribal Health Program may directly bill 

for, and receive payment for, health care items and services provided by such Indian Tribe or Tribal organization for which 

payment is made under title XVIII, XIX, or XXI of the Social 

Security Act or from any other third party payor. 

(2) DIRECT REIMBURSEMENT.— (A) USE OF FUNDS.—Each Tribal Health Program exercising the option described in paragraph (1) with respect to 

a program under a title of the Social Security Act shall be 

reimbursed directly by that program for items and services 

furnished without regard to section 401(c), but all amounts 

so reimbursed shall be used by the Tribal Health Program 

for the purpose of making any improvements in Tribal facilities or Tribal Health Programs that may be necessary to 

achieve or maintain compliance with the conditions and requirements applicable generally to 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. 

(B) AUDITS.—The amounts paid to an Indian Tribe or 

Tribal Organization exercising the option described in 


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paragraph (1) with respect to a program under a title of the 

Social Security Act shall be subject to all auditing requirements applicable to programs administered by an Indian 

Health Program. 

(C) IDENTIFICATION OF SOURCE OF PAYMENTS.—If an Indian Tribe or Tribal Organization receives funding from 

the Service under the Indian Self-Determination and Education Assistance Act (25 U.S.C. 450 et seq.) or an Urban 

Indian Organization receives funding from the Service 

under title V of this Act and receives reimbursements or 

payments under title XVIII, XIX, or XXI of the Social Security Act, such Indian Tribe or Tribal Organization, or 

Urban Indian Organization, shall provide to the Service a 

list of each provider enrollment number (or other identifier) 

under which it receives such reimbursements or payments. 

(3) EXAMINATION AND IMPLEMENTATION OF CHANGES.—The 

Secretary, acting through the Service and with the assistance of 

the Administrator of the Centers for Medicare & Medicaid Services, shall examine on an ongoing basis and implement any administrative changes that may be necessary to facilitate direct 

billing and reimbursement under the program established 

under this subsection, including any agreements with States 

that may be necessary to provide for direct billing under a program under a title of the Social Security Act. 

(4) WITHDRAWAL FROM PROGRAM.—A Tribal Health Program 

that bills directly under the program established under this 

subsection may withdraw from participation in the same manner and under the same conditions that 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 subsection shall be returned to the Secretary upon 

the Secretary’s acceptance of the withdrawal of participation in 

this program. 

ø(b) DETERMINATION OF APPROPRIATIONS¿ 

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.¿ 


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§ 1644. Grants to and Cøc¿ontracts with the Service, Indian 

Tribes, T øt¿ribal øo≈Organizations, and Urban Indian Organizations 

(a) INDIAN TRIBES AND TRIBAL ORGANIZATIONS.—øACCESS TO

HEALTH SERVICES¿ The Secretary, acting through the Service, shall 

make grants to or enter into contracts with Indian Tribes and T 

øt¿ribal Oøo¿rganizations to assist such Tribes and Tribal 

Oøo¿rganizations in establishing and administering programs on or 

near øFederal Indian¿ reservations and trust areas øand in or near 

Alaska Native villages¿ to assist individual Indians øto¿— (1) to enroll for benefits under title XVIII, XIX, or XXI øsection 1818 of part A and sections 1836 and 1837 of part B of 

Title XVIII¿ of the Social Security Act and other health benefits 

programs ø42 U.S.C.A. §§ 1395i–2, 1395o, 1395p¿; and 

(2) to pay ømonthly¿ premiums for coverage for such benefits, which may be based on financial need (as determined by 

the Indian Tribe or Tribes being served based on a schedule of 

income levels developed or implemented by such Tribe or 

Tribes). ødue 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.].¿ 

(b) øTERMS AND C¿CONDITIONS.—The Secretary, acting through 

the Service, shall place conditions as deemed necessary to effect the 

purpose of this section in any øcontract or¿ grant or contract which 

the Secretary makes with any Indian Tribe or Tøt¿ribal 

Oøo¿rganization pursuant to this section. Such conditions shall 

includeø, by are not limited to,¿ requirements that the Indian 

Tribe or Tribal Oøo¿rganization successfully undertake øto¿— (1) to determine the population of Indians eligible for the øto 

be served that are or could be recipients of¿ benefits described 

in subsection (a) øunder Titles XVIII and XIX of the Social Security Act [42 U.S.C.A. §§ 1395 et seq., 1396 et seq.]¿; 

(2) to educate øassist individual¿ Indians with respect to the 

benefits available under the respective programs øin becoming 

familiar with and utilizing such benefits¿; 

(3) to provide transportation for øto¿ such individual Indians 

to the appropriate offices for enrollment or applications for 

such benefits ømedical assistance¿; and 

(4) to develop and implementø—¿ 

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, 

øand¿ XIX, and XXI of the Social Security Act ø[42 

U.S.C.A. §§ 1395 et seq. And 1396 et seq.]¿. (c) AGREEMENTS RELATING TO IMPROVING ENROLLMENT OF INDIANS UNDER SOCIAL SECURITY ACT PROGRAMS.—øAPPLICATION FOR

MEDICAL ASSISTANCE¿ 

(1) AGREEMENTS WITH SECRETARY TO IMPROVE RECEIPT AND

PROCESSING OF APPLICATIONS.—

(A) AUTHORIZATION.—The Secretary, acting through the 

Service, may enter into an agreement with an Indian 

øt¿Tribe, øt¿Tribal øo¿Organization, or øu¿Urban Indian 

øo¿Organization which provides for the receipt and procVerDate Aug 31 2005 11:50 Mar 23, 2006 Jkt 049010 PO 00000 Frm 00181 Fmt 6659 Sfmt 6602 E:\HR\OC\SR222.XXX SR222

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essing of applications by Indians for ømedical¿ assistance 

under titles XIX and XXI of the Social Security Act, ø[42 

U.S.C.A. § 1396 et seq.]¿ and benefits under title XVIII of 

such øthe Social Security¿ Act, by an Indian Health Program or Urban Indian Organization. ø[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 ø25 

U.S.C.A. § 450f et seq.].¿ 

(B) REIMBURSEMENT OF COSTS.—Such agreements may 

provide for reimbursement of costs of outreach, education 

regarding eligibility and benefits, and translation when 

such services are provided. The reimbursement may, as appropriate, be added to the applicable rate per encounter or 

be provided as a separate fee-for-service payment to the Indian Tribe or Tribal Organization. 

(C) PROCESSING CLARIFIED.—In this paragraph, the term 

‘processing’ does not include a final determination of eligibility. 

(2) AGREEMENTS WITH STATES FOR OUTREACH ON OR NEAR

RESERVATION.— (A) IN GENERAL.—In order to improve the access of Indians residing on or near a reservation to obtain benefits 

under title XIX or XXI of the Social Security Act, 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 Indian Tribes and 

Tribal Organizations to provide outreach, education regarding eligibility and benefits, enrollment, and translation 

services when such services are provided. 

(B) CONSTRUCTION.—Nothing in subparagraph (A) shall 

be construed as affecting arrangements entered into between States and Indian Tribes and Tribal Organizations 

for such Indian Tribes and Tribal Organizations to conduct 

administrative activities under such titles. 

(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. 

(e) 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. 

(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 


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(C) necessary to effect the purposes of this section. 

ø§ 1645. Direct billing of Medicare, Medicaid, and other third 

party payors¿ 

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 (25 U.S.C. 450 et seq.) may elect to directly bill for, 

and receive payment for, health care services provided by such hospital or clinic for which payment is made under title XVIII of the 

Social Security Act (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 apply for 

purposes of reimbursement under the medicaid program for health 

care services directly billed under the program established under 

this section.¿ 

ø(b) DIRECT REIMBURSEMENT¿ 

ø(1) USE OF FUNDS¿ 

øEach hospital or clinic participating in the program described in 

subsection (a) of this section shall be reimbursed directly under the 

medicare and medicaid programs for services furnished, without regard to the provisions of section 1880(c) of the Social Security Act 

(42 U.S.C. 1395qq(c)) and sections 1642(a) and 1680c(b)(2)(A) of 

this title, but all funds so reimbursed shall first be used by the hospital or clinic for the purpose of making any improvements in the 

hospital or clinic that may be necessary to achieve or maintain 

compliance with the conditions and requirements applicable generally to facilities of such type under the medicare or medicaid programs. Any funds so reimbursed which are in excess of the amount 

necessary to achieve or maintain such conditions shall be used—¿ 

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 shall be subject to all 

auditing requirements applicable to programs administered directly 

by the Service and to facilities participating in the medicare and 

medicaid programs.¿ 

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¿ 


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øNotwithstanding section 1880(c) of the Social Security Act (42 

U.S.C.A. § 1395qq(c)) or section 1642(a) of this title, no payment 

may be made out of the special funds described in such sections for 

the benefit of any hospital 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 Secretary 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 that 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 November 1, 2000, 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¿ 

øThe Secretary, acting through the Service, and with the assistance of the Administrator of the Centers for Medicare & Medicaid 

Services, shall examine on an ongoing basis and implement—¿ 

ø(A) any administrative changes that may be necessary 

to facilitate direct bill and reimbursement under the program established under this section, including any agreeVerDate Aug 31 2005 11:50 Mar 23, 2006 Jkt 049010 PO 00000 Frm 00184 Fmt 6659 Sfmt 6602 E:\HR\OC\SR222.XXX SR222

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ments with States that may be necessary to provide for direct billing under the medicaid program; and¿ 

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 November 1, 2000. The Secretary may from 

time to time, after consultation with the program participants, 

change the accounting information submission requirements.¿ 

ø(e) WITHDRAWAL FROM PROGRAM¿ 

øA participant in the program established under this section may 

withdraw from participation in the same manner and under the 

same conditions that a tribe or tribal organization may retrocede 

a contracted program to the Secretary under authority of the Indian Self-Determination Act [25 U.S.C.A. § 450f et seq.¿. All cost 

accounting and billing authority under the program established 

under this section shall be returned to the Secretary upon the Secretary’s acceptance of the withdrawal of participation in this program.¿ 

§ 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 

as determined by the Secretary, and 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. 

(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 


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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. 

(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 


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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 and 

the Federal Medical Care Recovery Act (42 U.S.C. 2651 et seq.). 

§ 404. Crediting of reimbursements 

(a) USE OF AMOUNTS.—

(1) RETENTION BY PROGRAM.—Except as provided in section 

202(g) (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: 

(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). 

§ 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. 


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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). 

§ 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; 

(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. 

§ 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. 


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§ 408. Nondiscrimination in qualifications for reimbursement 

for services 

For purposes of determining the eligibility of an entity that is operated by the Service, an Indian Tribe, Tribal Organization, or 

Urban Indian Organization to receive payment or reimbursement 

from any federally funded health care program for health care services it furnishes to an Indian, such program must provide that such 

entity, meeting generally applicable State or other requirements applicable for participation, must be accepted as a provider on the 

same basis as any other qualified provider, except that any requirement that the entity be licensed or recognized under State or local 

law to furnish such services shall be deemed to have been met if the 

entity meets all the applicable standards for such licensure, but the 

entity need not obtain a license or other documentation. In determining whether the entity meets such standards, the absence of licensure of any staff member of the entity may not be taken into account. 

§ 409. Consultation 

(a) TRIBAL INDIAN TECHNICAL ADVISORY GROUP (TTAG).—The 

Secretary shall maintain within the Centers for Medicare & Medicaid Services (CMS) a Tribal Indian 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 MEDICAID ADVICE.—

(1) IN GENERAL.—As part of its plan for payment under title 

XIX of the Social Security Act, a State in which the Service operates or funds health care programs or in which 1 or more Indian Health Programs or Urban Indian Organizations provide 

health care in the State for which medical assistance is available under such title, may establish 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 such title to and 

likely to have a direct effect on such Indian Health Programs 

and Urban Indian Organizations. 

(2) MANNER OF ADVICE.—The process described in paragraph 

(1) should 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. Such 

process 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 medicaid plan. 

(3) PAYMENT OF EXPENSES.—The reasonable expenses of carrying out this subsection shall be eligible for reimbursement 

under section 1903(a) of the Social Security Act. 


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(c) CONSTRUCTION.—Nothing in this section shall be construed as 

superseding existing advisory committees, working groups, or other 

advisory procedures established by the Secretary or by any State. 

§ 410. State Children’s Health Insurance Program (SCHIP) 

(a) OPTIONAL USE OF FUNDS FOR INDIAN HEALTH PAYMENTS.—

Subject to the succeeding provisions of this section, a State may provide under its State child health plan under title XXI of the Social 

Security Act (regardless of whether such plan is implemented under 

such title, title XIX of such Act, or both) for payments under this 

section to Indian Health Programs and Urban Indian Organizations operating in the State. Such payment shall be treated under 

title XXI of the Social Security Act as expenditures described in section 2105(a)(1)(A) of such Act. 

(b) USE OF FUNDS.—Payments under this section may be used 

only for expenditures described in clauses (i) through (iii) of section 

2105 (a)(1)(D) of the Social Security Act for targeted low-income 

children or other low-income children (as defined in 2110 of such 

Act) who are—

(1) Indians; or 

(2) otherwise eligible for health services from the Indian 

Health Program involved. 

(c) SPECIAL RESTRICTIONS.—The following conditions apply to a 

State electing to provide payments under this section: 

(1) NO LIMITATION ON OTHER SCHIP PARTICIPATION OF, OR

PROVIDER PAYMENTS TO, INDIAN HEALTH PROGRAMS.—The State 

may not exclude or limit participation of otherwise eligible Indian Health Programs in its State child health program under 

title XXI of the Social Security Act or its medicaid program 

under title XIX of such Act or pay such Programs less then they 

otherwise would as participating providers on the basis that 

payments are made to such Programs under this section. 

(2) NO LIMITATION ON OTHER SCHIP ELIGIBILITY OF INDIANS.—

The State may not exclude or limit participation of otherwise eligible Indian children in such State child health or medicaid 

program on the basis that payments are made for assistance for 

such children under this section. 

(3) LIMITATION ON ACCEPTANCE OF CONTRIBUTIONS.—

(A) IN GENERAL.—The State may not accept contributions 

or condition making of payments under this section upon 

contribution of funds from an Indian Health Program to 

meet the State’s non-Federal matching fund requirements 

under titles XIX and XXI of the Social Security Act. 

(B) CONTRIBUTION DEFINED.—For purposes of subparagraph (A), the term ‘contribution’ includes any tax, donation, fee, or other payment made, whether made voluntarily 

or involuntarily. 

(d) APPLICATION OF SEPARATE 10 PERCENT LIMITATION.—Payment may be made under section 2105(a) of the Social Security Act 

to a State for a fiscal year for payments under this section up to an 

amount equal to 10 percent of the total amount available under title 

XXI of such Act (including allotments and reallotments available 

from previous fiscal years) to the State with respect to the fiscal 

year. 


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(e) GENERAL TERMS.—A payment under this section shall only be 

made upon application to the State from the Indian Health Program involved and under such terms and conditions, and in a form 

and manner, as the Secretary determines appropriate. 

§ 411. Social Security Act sanctions 

(a) REQUESTS FOR WAIVER OF SANCTIONS.— (1) IN GENERAL.—For purposes of applying any authority 

under a provision of title XI, XVIII, XIX, or XXI of the Social 

Security Act to seek a waiver of a sanction imposed against a 

health care provider insofar as that provider provides services 

to individuals through an Indian Health Program, the Indian 

Health Program shall request the State to seek such waiver, 

and if such State has not sought the waiver within 60 days of 

the Indian Health Program request, the Indian Health Program 

itself may petition the Secretary for such waiver. 

(2) PROCEDURE.—In seeking a waiver under paragraph (1), 

the Indian Health Program much provide notice an a copy of 

the request, including the reasons for the waiver sought, to the 

State. The Secretary may consider the State’s views in the determination of the waiver request, but may not withhold or delay 

a determination based on the lack of the State’s views. 

(b) SAFE HARBOR FOR TRANSACTIONS BETWEEN AND AMONG IN- DIAN HEALTH CARE PROGRAMS.—For purposes of applying section 

1128B(b) of the Social Security Act, the exchange of anything of 

value between or among the following shall not be treated as remuneration if the exchange arises from or relates to any of the following health programs: 

(1) An exchange between or among the following: 

(A) Any Indian Health Program. 

(B) Any Urban Indian Organization. 

(2) An exchange between an Indian Tribe, Tribal Organization, or an Urban Indian Organization and any patient served 

or eligible for service from an Indian Tribe, Tribal Organization, or Urban Indian Organization, including patients served 

or eligible for service pursuant to section 807, but only if such 

exchange—

(A) is for the purpose of transporting the patient for the 

provision of health care items or services; 

(B) is for the purpose of providing housing to the patient 

(including a pregnant patient) and immediate family members or an escort incidental to assuring the timely provision 

of health care items and services to the patient; 

(C) is for the purpose of paying premiums, copayments, 

deductibles, or other cost-sharing on behalf of patients; or 

(D) consists of an item or service of small value that is 

provided as a reasonable incentive to secure timely and necessary preventive and other items and services. 

(3) Other exchanges involving an Indian Health Program, an 

Urban Indian Organization, or an Indian Tribe or Tribal Organization that meet such standards as the Secretary of Health 

and Human Services, in consultation with the Attorney General, determines is appropriate, taking into account the special 

circumstances of such Indian Health Programs, Urban Indian 

Organizations, Indian Tribes, and Tribal Organizations and of 


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patients served by Indian Health Programs, Urban Indian Organizations, Indian Tribes, and Tribal Organizations. 

§ 412. Cost sharing 

(a) COINSURANCE, COPAYMENTS, AND DEDUCTIBLES.—Notwithstanding any other provision of Federal or State law— (1) PROTECTION FOR ELIGIBLE INDIANS UNDER SOCIAL SECU- RITY ACT HEALTH PROGRAMS.—No Indian who is furnished an 

item or service for which payment may be made under title XIX 

or XXI of the Social Security Act may be charged a deductible, 

copayment, or coinsurance. 

(2) PROTECTION FOR INDIANS.—No Indian who is furnished 

an item or service by the Service may be charged a deductible, 

copayment, or coinsurance. 

(3) NO REDUCTION IN AMOUNT OF PAYMENT TO INDIAN HEALTH

PROVIDERS.—The payment or reimbursement due to the Service, 

Indian Tribe, Tribal Organization, or Urban Indian Organization under title XIX or XXI of the Social Security Act may not 

be reduced by the amount of the deductible, copayment, or coinsurance that would be due from the Indian but for the operation of this section. 

(b) EXEMPTION FROM MEDICAID AND SCHIP PREMIUMS.—Notwithstanding any other provision of Federal or State law, no Indian 

who is otherwise eligible for services under title XIX of the Social 

Security Act (relating to the medicaid program) or title XXI of such 

Act (relating to the State children’s health insurance program) may 

be charged a premium as a condition of receiving benefits under the 

program under the respective title. 

(c) TREATMENT OF CERTAIN PROPERTY FOR MEDICAID ELIGIBILITY.—Notwithstanding any other provision of Federal or State 

law, the following property may not be included when determining 

eligibility for services under title XIX of the Social Security Act: 

(1) Property, including real property and improvements, located on the 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 the reservation as designated and approved by the 

Bureau of Indian Affairs of the Department of the Interior. 

(2) For any federally recognized Tribe not described in paragraph (1), property located within the most recent boundaries of 

a prior Federal reservation. 

(3) Ownership interests in rents, leases, royalties, or usage 

rights related to natural resources (including extraction of natural resources or harvesting of timber, or other plants and 

plant products, animals, fish, and shellfish) resulting from the 

exercise of federally protected rights. 

(4) Ownership interests in or usage rights to items not covered by paragraphs (1) through (3) that have unique religious, 

spiritual, traditional, or cultural significance or rights that 

support subsistence or a traditional life style according to applicable tribal law and custom. 

(d) CONTINUATION OF CURRENT LAW PROTECTIONS OF CERTAIN

INDIAN PROPERTY FROM MEDICAID ESTATE RECOVERY.—Income, resources, and property that are exempt from medicaid estate recovery 


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under title XIX of the Social Security Act as of April 1, 2003, under 

manual instructions issued to carry out section 1917 (b)(3) of such 

Act because of Federal responsibility for Indian Tribes and Alaska 

Native Villages shall remain so exempt. Nothing in this subsection 

shall be construed as preventing the Secretary from providing additional medicaid estate recovery exemptions for Indians. 

§ 413. Treatment under Medicaid Managed Care 

(a) PROVISION OF SERVICES, TO ENROLLEES WITH NON-INDIAN

MEDICAID MANAGED CARE ENTITIES, BY INDIAN HEALTH PROGRAMS

AND URBAN INDIAN ORGANIZATIONS.—

(1) PAYMENT RULES.—

(A) IN GENERAL.—Subject to subparagraph (B), in the 

case of an Indian who is enrolled with a non-Indian medicaid managed care entity (as defined in subsection (c)) and 

who receives covered medicaid managed care services from 

an Indian Health Program or an Urban Indian Organization, whether or not it is a participating provider with respect to such entity, the following rules apply: 

(i) DIRECT PAYMENT.—The entity shall make prompt 

payment (in accordance with rules applicable to medicaid managed care entities under title XIX of the Social Security Act) to the Indian Health Program or 

Urban Indian Organization at a rate established by 

the entity for such services that is equal to the rate negotiated between such entity and the Program or Organization involved or, if such a rate has not been negotiated, 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 provider which 

is not a Program or Organization. 

(ii) PAYMENT THROUGH STATE.—If there is no arrangement for direct payment under clause (i) or if the 

State provides for this clause to apply in lieu of clause 

(i), the State shall provide for payment to the Indian 

Health Program or Urban Indian Organization under 

its State program under title XIX of such Act at the 

rate that would be otherwise applicable for such services under such program and shall provide for an appropriate adjustment of the capitation payment made 

to the entity to take into account such payment. 

(B) COMPLIANCE WITH GENERALLY APPLICABLE REQUIREMENTS.—

(i) IN GENERAL.—Except as otherwise provided, as a 

condition of payment under subparagraph (A), the Indian Health Program or Urban Indian Organization 

shall comply with the generally applicable requirements of title XIX of the Social Security Act with respect to covered services. 

(ii) SATISFACTION OF CLAIM REQUIREMENT.—Any requirement for the submission of a claim or other documentation for services covered under subparagraph (A) 

by the enrollee is deemed to be satisfied through the 

submission of a claim or other documentation by the 


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Indian Health Program or Urban Indian Organization 

consistent with section 403(h). 

(C) CONSTRUCTION.—Nothing in this subsection shall be 

construed as waiving the application of section 

1902(a)(30)(A) of the Social Security Act (relating to application of standards to assure that payments are consistent 

with efficiency, economy, and quality of care). 

(2) ENROLLEE OPTION TO SELECT AN INDIAN HEALTH PROGRAM

OR URBAN INDIAN ORGANIZATION 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 Program or Urban Indian Organization 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 Program or 

Organization and the Program or Organization has the capacity to provide primary care services to such Indian, the 

Indian shall be allowed to choose such Program or Organization as the Indian’s primary care provider under the entity. 

(b) OFFERING OF MANAGED CARE THROUGH INDIAN MEDICAID

MANAGED CARE ENTITIES.—if— (1) a State elects to provide services through medicaid managed care entities under its medicaid managed care program; 

and 

(2) an Indian Health Program or Urban Indian Organization 

that is funded in whole or in part by the Service, or a consortium thereof, 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. 

(c) 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: 

(1) ENROLLMENT.— (A) 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. 

(B) 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 individual who are not 

Indians. 

(C) DEFAULT ENROLLMENT.— (i) IN GENERAL.—If such program of a State required 

the enrollment of Indians in a medicaid managed care 

entity in order to receive benefits, the State shall provide for the enrollment of Indians described in clause 


hsrobinson on PROD1PC72 with HEARING
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(ii) who are not otherwise enrolled with such an entity 

in an Indian medicaid managed care entity described 

in such clause. 

(ii) INDIAN DESCRIBED.—An Indian described in this 

clause, 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). 

(D) 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. 

(2) FLEXIBILITY IN APPLICATION OF SOLVENCY.—In applying 

section 1903(m)(1) of the Social Security Act to an Indian medicaid managed care entity—

(A) any reference to a ’State’ in subparagraph (A)(ii) of 

that section shall be deemed to be a reference to the ’Secretary’; and 

(B) the entity shall be deemed to be a public entity described in subparagraph (C)(ii) of that section. 

(3) EXCEPTIONS TO ADVANCE DIRECTIVES.—The Secretary may 

modify or waive the requirement of section 1902(w) of the Social 

Security Act (relating to provision of written materials of 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. 

(4) FLEXIBILITY IN INFORMATION AND MARKETING.—

(A) MATERIALS.—The Secretary may modify requirements 

under section 1932(a)(5) of the Social Security Act in a 

manner that improves the materials to take into account 

the special circumstances of such entities and their enrollees while maintaining and clearly communicating to potential enrollees their rights, protections, and benefits. 

(B) DISTRIBUTION OF MARKETING MATERIALS.—The provisions of section 1931(d)(2)(B) of the Social Security Act 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. 

(d) MALPRACTICE INSURANCE.—Insofar as, under a medicaid 

managed care program, a health care provider is required to have 

a medical malpractice insurance coverage as a condition of contracting as a provider with a medicaid managed care entity, an Indian Health Program, or an Urban Indian Organization that is a 

Federally-qualified health center under title XIX of the Social Security Act, that is covered under the Federal Tort Claims Act 28 

U.S.C. 1346(b), 2671 et seq.) is deemed to satisfy such requirement. 

(e) DEFINITIONS.—For purposes of this section: 

(1) MEDICAID MANAGED CARE ENTITY.—The term ‘medicaid 

managed care entity’ means a managed care entity (whether a 

managed care organization or a primary care case manager) 

under title XIX of the Social Security Act, whether pursuant to 


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section 1903(m) or section 1932 of such Act, a waiver under section 1115 or 1915(b) of such Act, or otherwise. 

(2) 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) of the Social Security Act) by the Indian Health Service, a Tribe, Tribal Organization, or Urban Indian Organization (as such terms are defined in section 4), 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. 

(3) NON-INDIAN MEDICAID MANAGED CARE ENTITY.—The term 

‘non-Indian medicaid managed care entity’ means a medicaid 

managed care entity that is not an Indian medicaid managed 

care entity. 

(4) COVERED MEDICAID MANAGED CARE SERVICES.—The term 

‘covered medicaid managed care services’ means, with respect to 

an individual enrolled with a medicaid managed care entity, 

items and services that are within the scope of items and services for which benefits are available with respect to the individual under the contract between the entity and the State involved. 

(5) MEDICAID MANAGED CARE PROGRAM.—The term ‘medicaid 

managed care program’ means a program under sections 

1903(m) and 1932 of the Social Security Act and includes a 

managed care program operating under a waiver under section 

1915(b) or 1115 of such Act or otherwise. 

§ 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 

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dren’s health insurance program) under terms equivalent to 

those described in paragraphs (2) through (4). 

(c) REPORT.—Not later then 3 years after the date of enactment 

of the Indian Health Act Improvement Act Amendments of 2005, the 

Secretary shall submit to the Committee on Indian Affairs and 

Committee on Finance of the Senate and the Committee on 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¿ 

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 chapter, the time 

limitation (as a condition of payment) for notifying the Service of 

such treatment or admission shall be 30 days.¿ 

§ 1647. Authorization of øa¿Appropriations 

There are authorized to be appropriated such sums as may be 

necessary for each fiscal year through fiscal year 2015 ø2000¿ to 

carry out this title øsubchapter¿. 

TITLE V øSUBCHAPTER IV¿—HEALTH 

SERVICES FOR URBAN INDIANS 

§ 1651. Purpose 

The purpose of this title øsubchapter¿ is to establish and maintain programs in øu¿Urban øc¿Centers to make health services 

more accessible and available to øu¿Urban Indians. 

§ 1652. Contracts øw¿With, and øg¿Grants to, øu¿Urban Indian øo¿Organizations 

Under authority of the Act of November 2, 1921 (25 U.S.C. 13), 

(commonly øpopularly¿ known as the ‘Snyder Act’), the Secretary, 

acting through the Service, shall enter into contracts with, or make 

grants to, øu¿Urban Indian øo¿Organizations to assist such organizations in the establishment and administration, within øthe 

u¿Urban øc¿Centers øin which such organizations are situated¿, of 

programs which meet the requirements set forth in this title øsubchapter¿. Subject to section 506, tøT¿he Secretary, acting through 

the Service, shall include such conditions as the Secretary conVerDate Aug 31 2005 11:50 Mar 23, 2006 Jkt 049010 PO 00000 Frm 00197 Fmt 6659 Sfmt 6602 E:\HR\OC\SR222.XXX SR222

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siders necessary to effect the purpose of this title øsubchapter¿ in 

any contract into which the Secretary enters øinto¿ with, or in any 

grant the Secretary makes to, any Uøu¿rban Indian 

Oøo¿rganization pursuant to this title øsubchapter¿. 

§ 1653. Contracts and Gøg¿rants for the Pøp¿rovision of 

Høh¿ealth Cøc¿are and Rør¿eferral Søs¿ervices 

(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, and make 

grants to, øu¿Urban Indian øo¿Organizations for the provision of 

health care and referral services for øu¿Urban Indians øresiding in 

the urban centers in which such organizations are situated¿. Any 

such contract or grant shall include requirements that the 

øu¿Urban Indian øo¿Organization successfully undertake to—

(1) estimate the population of øu¿Urban Indians residing in 

the øu¿Urban øc¿Center or centers that the organization proposes to serve øin which such organization is situated¿ who are 

or could be recipients of health care or referral services; 

(2) estimate the current health status of øu¿Urban Indians 

residing in such øu¿Urban øc¿Center or centers; 

(3) estimate the current health care needs of øu¿Urban Indians residing in such øu¿Urban øc¿Center or centers; 

(4) provide basic health education, including health promotion and disease prevention education, to Urban Indians 

øidentify all public and private health services resources within such urban center which are or may be available to urban 

Indians¿; 

(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 Urban Indians 

ødetermine the use of public and private health services resources by the urban Indians residing in such urban center¿; 

and 

(6) where necessary, provide, or enter into contracts for the 

provision of, health care services for Urban Indians. øassist 

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) provide basic health education, including health promotion and disease prevention education, to 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) 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 urban Indians; and¿ 

ø(12) where necessary, provide, or enter into contracts for 

the provision of, health care services for urban Indians.¿ 


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(b) CRITERIA øFOR SELECTION OF ORGANIZATIONS TO ENTER

INTO CONTRACTS OR RECEIVE GRANTS¿.—The Secretary, acting 

through the Service, shall, by regulation, prescribe the criteria 

for selecting øu¿Urban Indian øo¿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 øu¿Urban Indians in the øu¿Urban øc¿Center or centers involved; 

(2) the size of the øu¿Urban Indian population in the 

øu¿Urban øc¿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;¿ 

(3)ø(4)¿ the extent, if any, to which the activities set forth 

in subsection (a) øof this section¿ would duplicate any project 

funded under this title;ø—¿ 

ø(A) any previous or current public or private health 

services project in an urban center that was or is funded 

in a manner other than pursuant to this subchapter; or¿ 

ø(B) any project funded under this subchapter;¿ 

(4)ø(5)¿ the capability of an øu¿Urban Indian 

øo¿Organization to perform the activities set forth in subsection (a) øof this section¿ and to enter into a contract with 

the Secretary or to meet the requirements for receiving a grant 

under this section; 

(5)ø(6)¿ the satisfactory performance and successful completion by an øu¿Urban Indian øo¿Organization of other contracts 

with the Secretary under this title øsubchapter¿; 

(6)ø(7)¿ the appropriateness and likely effectiveness of conducting the activities set forth in subsection (a) øof this section¿ in an øu¿Urban øc¿Center or centers; and 

(7)ø(8)¿ 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. 

(c) ACCESS TO HEALTH PROMOTION AND DISEASE PREVENTION

PROGRAMS.—øGRANTS FOR HEALTH PROMOTION AND DISEASE PRE- VENTION SERVICES¿ The Secretary, acting through the Service, 

shall facilitate access toø,¿ or provideø,¿ health promotion and disease prevention services for øu¿Urban Indians through grants 

made to øu¿Urban Indian øo¿Organizations administering contracts entered into øpursuant to this section¿ or receiving grants 

under subsection (a) øof this section¿. (d) øGRANTS FOR I¿IMMUNIZATION øS¿SERVICES

(1) ACCESS OR SERVICES PROVIDED.—The Secretary, acting 

through the Service, shall facilitate access to, or provide, immunization services for øu¿Urban Indians through grants 

made to øu¿Urban Indian øo¿Organizations administering contracts entered into øpursuant to this section¿ or receiving 

grants under øsubsection (a) of¿ this section. 

(2) DEFINITION.—For purposes of this subsection, the term ‘immunization services’ means services to provide without 

charge immunizations against vaccine-preventable diseases. 

ø(2) In making any grant to carry out this subsection, the 

Secretary shall take into consideration—¿ 


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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) For purposes of this subsection, the term ‘‘immunization 

services’’ means services to provide without charge immunizations against vaccine-preventable diseases.¿ 

(e) BEHAVIORAL øGRANTS FOR PROVISION OF MENTAL H¿HEALTH

øS¿SERVICES.—

(1) ACCESS OR SERVICES PROVIDED.—The Secretary, acting 

through the Service, shall facilitate access to, or provide, behavioral ømental¿ health services for øu¿Urban Indians 

through grants made to øu¿Urban Indian øo¿Organizations 

administering contracts entered into øpursuant to this section¿ 

or receiving grants under subsection (a) øof this section¿. 

(2) ASSESSMENT REQUIRED.—Except as provided by paragraph (3)(A), a øA¿ grant may not be made under this subsection to an øu¿Urban Indian øo¿Organization until that organization has prepared, and the Service has approved, an assessment of the following: ømental health needs of the urban 

Indian population concerned, the mental health services and 

other related resources available to that population, the barriers to obtaining those services and resources, and the needs 

that are unmet by such services and resources.¿ 

(A) The behavioral health needs of the Urban Indian 

population concerned. 

(B) The behavioral health services and other related resources available to that population. 

(C) The barriers to obtaining those services and resources. 

(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) øt¿To prepare assessments required under paragraph (2)ø;¿. 

(B) øt¿To provide outreach, educational, and referral 

services to øu¿Urban Indians regarding the availability of 

direct behavioral ømental¿ health services, to educate 

øu¿Urban Indians about behavioral ømental¿ health 

issues and services, and effect coordination with existing 

behavioral ømental¿ health providers in order to improve 

services to øu¿Urban Indiansø;¿. (C) øt¿To provide outpatient behavioral ømental¿ health 

services to øu¿Urban Indians, including the identification 

and assessment of illness, therapeutic treatments, case 

management, support groups, family treatment, and other 

treatment.ø; and¿ 


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(D) øt¿To develop innovative behavioral ømental¿ health 

service delivery models which incorporate Indian cultural 

support systems and resources. 

(f) øGRANTS FOR P¿PREVENTION øAND TREATMENT¿ OF øC¿CHILD

øA¿ABUSE

(1) ACCESS OR SERVICES PROVIDED.—The Secretary, acting 

through the Service, shall facilitate access toø,¿ or provideø,¿ 

services for øu¿Urban Indians through grants to øu¿Urban Indian øo¿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 øu¿Urban Indians. 

(2) EVALUATION REQUIRED.—Except as provided by paragraph (3)(A), a øA¿ grant may not be made under this subsection to an øu¿Urban Indian øo¿Organization until that organization has prepared, and the Service has approved, an assessment that documents the prevalence of child abuse in the 

øu¿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) øt¿To prepare assessments required under paragraph (2)ø;¿. 

(B) øf¿For the development of prevention, training, and 

education programs for øu¿Urban Indians øpopulations¿, 

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 protection.ø; and¿ 

(C) øt¿To provide direct outpatient treatment services 

(including individual treatment, family treatment, group 

therapy, and support groups) to øu¿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 øu¿Urban Indian perpetrators of child 

abuse (including sexual abuse). 

(4) CONSIDERATIONS WHEN MAKING GRANTS.—In making 

grants to carry out this subsection, the Secretary shall take 

into consideration—

(A) the support for the øu¿Urban Indian 

øo¿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 

øu¿Urban Indian øo¿Organization to address the complex 

problem of child sexual abuse in the community; and (C) 

the assessment required under paragraph (2). 

(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 


hsrobinson on PROD1PC72 with HEARING
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care services (through satellite facilities, provider networks, or otherwise) to Urban Indians in more than 1 Urban Center. 

§ 1654. Contracts and øg¿Grants for the ød¿Determination of 

øu¿Unmet øh¿Health øc¿Care øn¿Needs 

(a) GRANTS AND CONTRACTS AUTHORIZED.—øAUTHORITY¿ 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, u¿Urban Indian øo¿Organizations situated in 

øu¿Urban øc¿Centers for which contracts have not been entered 

intoø,¿ or grants have not been madeø,¿ under section 503 ø1653 

of this title¿. (b) PURPOSE.—The purpose of a contract or grant made under 

this section shall be the determination of the matters described in 

subsection (c)ø(b)¿(1) øof this section¿ in order to assist the Secretary in assessing the health status and health care needs of 

øu¿Urban Indians in the øu¿Urban øc¿Center involved and determining whether the Secretary should enter into a contract or make 

a grant under section 503ø1653 of this title¿ with respect to the 

øu¿Urban Indian øo¿Organization which the Secretary has entered 

into a contract with, or made a grant to, under this section. 

(c)ø(b)¿ GRANT AND CONTRACT REQUIREMENTS.—Any contract entered into, or grant made, by the Secretary under this section shall 

include requirements that— (1) the øu¿Urban Indian øo¿Organization successfully undertakes to—

(A) document the health care status and unmet health 

care needs of øu¿Urban Indians in the øu¿Urban 

øc¿Center involved; and 

(B) with respect to øu¿Urban Indians in the øu¿Urban 

øc¿Center involved, determine the matters described in 

paragraphs øclauses¿ (2), (3), (4), and (7)ø(8)¿ of section 

503(b)ø1653(b) of this title¿; and 

(2) the øu¿Urban Indian øo¿Organization complete performance of the contract, or carry out the requirements of the 

grant, within 1øone¿ year after the date on which the Secretary and such organization enter into such contract, or within 1øone¿ year after such organization receives such grant, 

whichever is applicable. 

(d)ø(c)¿ NO RENEWALS.—The Secretary may not renew any contract entered into ø,¿ or grant made ø,¿ under this section. 

§ 1655. Evaluations; ør¿Renewals 

(a) PROCEDURES FOR EVALUATIONS.—øCONTRACT COMPLIANCE

AND PERFORMANCE¿ The Secretary, acting through the Service, 

shall develop procedures to evaluate compliance with grant requirements øunder this subchapter¿ and compliance withø,¿ and performance of contracts entered into by øu¿Urban Indian 

øo¿Organizations under this title øsubchapter¿. Such procedures 

shall include provisions for carrying out the requirements of this 

section. 

(b) øANNUAL ONSITE E¿EVALUATIONS.—The Secretary, acting 

through the Service, shall evaluate the compliance øconduct an annual onsite evaluation¿ of each øu¿Urban Indian øo¿Organization 


hsrobinson on PROD1PC72 with HEARING
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which has entered into a contract or received a grant under section 

503 with the terms of 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 contract or grant. For purposes of this evaluation, in determining the capacity of an Urban Indian Organization to deliver 

quality patient care 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 U¿UNSATISFACTORY

øP¿PERFORMANCE.— If, as a result of the evaluations conducted 

under this section, the Secretary determines that an øu¿Urban Indian øo¿Organization has not complied with the requirements of a 

grant or complied with or satisfactorily performed a contract under 

section 503 ø1653 of this title¿, the Secretary shall, prior to renewing such contract or grant, attempt to resolve with the øsuch¿ organization the areas of noncompliance or unsatisfactory performance 

and modify the øsuch¿ contract or grant to prevent future occurrences of øsuch¿ noncompliance or unsatisfactory performance. If 

the Secretary determines that the øsuch¿ noncompliance or unsatisfactory performance cannot be resolved and prevented in the future, the Secretary shall not renew the øsuch¿ contract or grant 

with the øsuch¿ organization and is authorized to enter into a contract or make a grant under section 503 ø1653 of this title¿ with 

another øu¿Urban Indian øo¿Organization which is situated in the 

same øu¿Urban øc¿Center as the øu¿Urban Indian 

øo¿Organization whose contract or grant is not renewed under this 

section. 

(d) CONSIDERATIONS FOR øCONTRACT AND GRANT R¿RENEWALS.—

In determining whether to renew a contract or grant with an 

øu¿Urban Indian øo¿Organization under section 503 ø1653 of this 

title¿ which has completed performance of a contract or grant 

under section 504 ø1654 of this title¿, the Secretary shall review 

the records of the øu¿Urban Indian øo¿Organization, the reports 

submitted under section 507 ø1657 of this title, and, in the case of 

a renewal of a contract or grant under section 1653 of this title¿, 

and shall consider the results of the onsite evaluations or accreditations øconducted¿ under subsection (b) øof this section¿. 

§ 1656. Other øc¿Contract and øg¿Grant ør¿Requirements 

(a) PROCUREMENT.—øFEDERAL REGULATIONS; EXCEPTIONS¿ Contracts with øu¿Urban Indian øo¿Organizations entered into pursuant to this title øsubchapter¿ shall be in accordance with all Federal contracting laws and regulations relating to procurement except thatø,¿ in the discretion of the Secretary, such contracts may 

be negotiated without advertising and need not conform to the provisions of sections 1304 and 3131 through ø3131 to¿ 3133 of 

øT¿title 40, United States Code. (b) PAYMENT UNDER CONTRACTS OR GRANTS.—Payments under 

any contracts or grants pursuant to this title shall, notwithstanding 


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any term or condition of such contract or grant—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.¿ 

(1) be made in their entirety 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 payments in their entirety; and 

(2) 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. 

(c) REVISION OR øA¿AMENDMENT OF CONTRACTS.—Notwithstanding any provision of law to the contrary, the Secretary may, 

at the request and consent of an øu¿Urban Indian 

øo¿Organization, revise or amend any contract entered into by the 

Secretary with such organization under this title øsubchapter¿ as 

necessary to carry out the purposes of this title øsubchapter¿. 

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, existing 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.¿ 

(d) FAIR AND ø(e)¿ UNIFORM øPROVISION OF S¿SERVICES AND

øA¿ASSISTANCE.—Contracts withø,¿ or grants toø, u¿Urban Indian 

øo¿Organizations and regulations adopted pursuant to this title 

øsubchapter¿ shall include provisions to assure the fair and uniform provision to øu¿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.¿ 

§ 1657. Reports and ør¿Records 

(a) øQUARTERLY R¿REPORTS.—For each fiscal year during which 

an øu¿Urban Indian øo¿Organization receives or expends funds 

pursuant to a contract entered intoø,¿ or a grant receivedø,¿ pursuant to this title øsubchapter¿, such Urban Indian Oøo¿rganization 

shall submit to the Secretary not more frequently than every 6 

months, a øquarterly¿ report that includes the following: øincluding—¿ 

(1) øi¿In the case of a contract or grant under section 503, 

recommendations pursuant to section 503(a)(5). ø1653 of this 

title, information gathered pursuant to clauses (10) and (11) of 

this subsection (a) of such section;¿ 


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(2) øi¿Information on activities conducted by the organization pursuant to the contract or grantø;¿. 

(3) øa¿An accounting of the amounts and purposeøs¿ for 

which Federal funds were expended.ø; and¿ 

(4) A minimum set of data, using uniformly defined elements, 

as specified by the Secretary after consultation with Urban Indian Organizations. øsuch other information as the Secretary 

may request.¿ 

(b) AUDIT øBY SECRETARY AND COMPTROLLER GENERAL¿.—

The reports and records of the øu¿Urban Indian øo¿Organization 

with respect to a contract or grant under this title øsubchapter¿ 

shall be subject to audit by the Secretary and the Comptroller General of the United States. 

(c) COST OF øANNUAL PRIVATE A¿AUDITS.—The Secretary shall 

allow as a cost of any contract or grant entered into or awarded 

under section 502 or 503 ø1653 of this title¿ the cost of an annual 

independent financial øprivate¿ audit conducted by—

(1) a certified public accountantø.¿; or 

(2) a certified public accounting firm qualified to conduct 

Federal compliance audits. 

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—¿ 

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.¿ 

§ 1658. Limitation on øc¿Contract øa¿Authority 

The authority of the Secretary to enter into contracts or to award 

grants under this title øsubchapter¿ shall be to the extent, and in 

an amount, provided for in appropriation Acts. 


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§ 1659. FACILITIES øRENOVATION¿ 

(a) GRANTS.—The Secretary, acting through the Service, may 

make grants øfunds available¿ to contractors or grant recipients 

under this title øsubchapter¿ for the lease, purchase, renovation, 

construction, or expansion of øminor renovations to¿ facilities, including leased facilities, in order to assist such contractors or grant 

recipients in complying with applicable licensure or certification requirements ømeeting or maintaining the Joint Commission for Accreditation of Health Care Organizations (JCAHO) standards¿. (b) LOAN FUND STUDY.—The Secretary, acting through the Services, 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. 

§ 1660. Division of Urban Indian Health øPrograms Branch¿ 

ø(a) ESTABLISHMENT¿ 

There is established within the Service a Division øa Branch¿ of 

Urban Indian Health, øPrograms¿ which shall be responsible for— (1) carrying out the provisions of this title; øsubchapter and 

for¿ 

(2) providing central oversight of the programs and services 

authorized under this title; and øsubchapter.¿ 

(3) providing technical assistance to Urban Indian Organizations. 

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.¿ 

§ 1660a. Grants for øa¿Alcohol and øs¿Substance øa¿Abuse 

ƒr≈Related øs¿Services 

(a) GRANTS AUTHORIZED.—The Secretary, acting through the 

Service, may make grants for the provision of health-related services in prevention of, treatment of, rehabilitation of, or school and 

community-based education regarding øin¿, alcohol and substance 

abuse in øu¿Urban øc¿Centers to those øu¿Urban Indian 

øo¿Organizations with which øwhom¿ the Secretary has entered 

into a contract under this title øsubchapter¿ or under section 

201ø1621 of this title¿. 

(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) øof this section¿, including criteria relating to the following:ø—¿ 

(1) The size of the øu¿Urban Indian populationø;¿. ø(2) accessibility to, and utilization of, other health resources 

available to such population;¿ 


hsrobinson on PROD1PC72 with HEARING
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ø(3) duplication of existing Service or other Federal grants or 

contracts;¿ 

(2) ø(4) c¿Capability of the organization to adequately perform the activities required under the grantø;¿. (3)ø(5) s¿Satisfactory performance standards for the organization in meeting the goals set forth in such grant.ø, which¿ 

The standards shall be negotiated and agreed to between the 

Secretary and the grantee on a grant-by-grant basis.ø; and¿ 

(4)ø(6) i¿Identification of need for services. 

(d) ALLOCATION OF GRANTS.—The Secretary shall develop a 

methodology for allocating grants made pursuant to this section 

based on the øsuch¿ criteria established pursuant to subsection (c). 

(e)ø(d)¿ GRANTS SUBJECT TO CRITERIA.—øTREATMENT OF FUNDS

RECEIVED BY URBAN INDIAN ORGANIZATIONS¿ Any funds received by 

an øu¿Urban Indian øo¿Organization under this Act øchapter¿ for 

substance abuse prevention, treatment, and rehabilitation shall be 

subject to the criteria set forth in subsection (c) øof this section¿. 

§ 1660b. Treatment of øc¿Certain ød¿Demonstration 

øp¿Projects 

ø(a)¿ Notwithstanding any other provision of law, the Tulsa Clinic and Oklahoma City Clinic demonstration projects shall—øand 

the Tulsa Clinic demonstration project shall be treated as service 

units in the allocation of resources and coordination of care and 

shall not be subject to the provisions of the Indian Self-Determination Act [25 U.S.C.A. § 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.¿ 

(1) be permanent programs within the Service’s direct care 

program; 

(2) continue to be treated as Service 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 (25 U.S.C. 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.¿ 

§ 1660c. Urban NIAAA øt¿Transferred øp¿Programs 

(a) GRANTS AND CONTRACTS.—øDUTY OF SECRETARY¿ The Secretary, through the Division øshall, within the Branch¿ of Urban 

Indian Health, shall øPrograms of the Service,¿ make grants or 

enter into contracts with Urban Indian Organizations, to take effect 

not later than September 30, 2008, for the administration of 

øu¿Urban Indian alcohol programs that were originally established 

under the National Institute on Alcoholism and Alcohol Abuse 


hsrobinson on PROD1PC72 with HEARING
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(hereafter in this section referred to as ø‘‘¿ ‘NIAAA’ ø’’¿) and transferred to the Service. 

(b) USE OF FUNDS.—øGRANTS¿ 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 

øu¿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 øo¿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¿ 

[For 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.¿ 

(d)ø(e) EVALUATION AND R¿REPORT.—øTO CONGRESS¿ The Secretary shall evaluate and report to øthe¿ Congress on the activities 

of programs funded under this section not less than øat least¿ 

every 5 years. 

§ 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. 

§ 515. Federal Tort Claim Act Coverage 

(a) IN GENERAL.—With respect to claims resulting from the performance of functions during fiscal year 2005 and thereafter, or 

claims asserted after September 30, 2004, but resulting from the 

performance of functions prior to fiscal year 2005, under a contract, 

grant agreement, or any other agreement authorized under this title, 

an Urban Indian Organization is deemed hereafter to be part of the 

Service in the Department of Health and Human Services while carrying out any such contract or agreement and its employees are 

deemed employees of the Service while acting within the scope of 

their employment in carrying out the contract or agreement. After 

September 30, 2003, any civil action or proceeding involving such 

claims brought hereafter against any Urban Indian Organization or 

any employee of such Urban Indian Organization covered by this 

provision shall be deemed to be an action against the United States 

and will be defended by the Attorney General and be afforded the 

full protection and coverage of the Federal Tort Claims Act (28 

U.S.C. 1346(b), 2671 et seq.). Future coverage under that Act shall 

be contingent on cooperation of the Urban Indian Organization with 

the Attorney General in prosecuting past claims. 

(b) CLAIMS RESULTING FROM PERFORMANCE OF CONTRACT OR

GRANT.—Beginning for fiscal year 2005 and thereafter, the Secretary shall request through annual appropriations funds sufficient 


hsrobinson on PROD1PC72 with HEARING
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to reimburse the Treasury for any claims paid in the prior fiscal 

year pursuant to the foregoing provisions. 

§ 516. 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. 

§ 517. Use of Federal Government Facilities and Sources of 

Supply 

(a) AUTHORIZATION FOR USE.—The Secretary, acting through the 

Service, shall allow an Urban Indian Organization that has entered 

into a contract or received a grant pursuant to this title, in carrying 

out such contract or grant, to use existing facilities and all equipment therein or pertaining thereto and other personal property 

owned by the Federal Government within the Secretary’s jurisdiction under such terms and conditions as may be agreed upon for 

their use and maintenance. 

(b) DONATIONS.—Subject to subsection (d), the Secretary may donate to an Urban Indian Organization that has entered into a contract or received a grant pursuant to this title any personal or real 

property determined to be excess to the needs of the Service or the 

General Services Administration for purposes of carrying out the 

contract or grant. 

(c) ACQUISITION OF PROPERTY FOR DONATION.—The Secretary 

may acquire excess or surplus government personal or real property 

for donation (subject to subsection (d)), to an Urban Indian Organization that has entered into a contract or received a grant pursuant 

to this title if the Secretary determines that the property is appropriate for use by the Urban Indian Organization for a purpose for 

which a contract or grant is authorized under this title. 

(d) PRIORITY.—In the event that the Secretary receives a request 

for donation of a specific item of personal or real property described 

in subsection (b) or (c) from both an Urban Indian Organization 

and from an Indian Tribe or Tribal Organization, the Secretary 

shall give priority to the request for donation of the Indian Tribe 

or Tribal Organization if the Secretary receives the request from the 

Indian Tribe or Tribal Organization before the date the Secretary 

transfers title to the property or, if earlier, the date the Secretary 

transfers the property physically to the Urban Indian Organization. 

(e) URBAN INDIAN ORGANIZATIONS DEEMED EXECUTIVE AGENCY

FOR CERTAIN PURPOSES.—For purposes of section 501 of title 40, 

United States Code, (relating to Federal sources of supply, including 

lodging providers, airlines, and other transportation providers), an 


hsrobinson on PROD1PC72 with HEARING
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Urban Indian Organization that has entered into a contract or received a grant pursuant to this title shall be deemed an executive 

agency when carrying out such contract or grant. 

§ 518. 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 

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). 

§ 519. 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. 

§ 520. Effective Date 

The amendments made by the Indian Health Care Improvement 

Act Amendments of 2005 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. 

§ 521. Eligibility for Services 

Urban Indians shall be eligible and the ultimate beneficiaries for 

health care or referral services provided pursuant to this title. 


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§ 1660d. Authorization of øa¿Appropriations 

There are authorized to be appropriated such sums as may be 

necessary for each fiscal year through fiscal year 2015 ø2000¿ to 

carry out this title øsubchapter¿. 

TITLE VI øSUBCHAPTER V¿—

ORGANIZATIONAL IMPROVEMENTS 

§ 1661. Establishment of the Indian Health Service as an A 

ƒa≈gency 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 øt¿Tribes, as are or may be hereafter øon and after November 23,1988,¿ 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 OF INDIAN HEALTH.—The øIndian 

Health¿ Service shall be administered by an Assistant Secretary of Indian Health øa Director¿, who shall be appointed 

by the President, by and with the advice and consent of the 

Senate. The Assistant Secretary øDirector of the Indian Health 

Service¿ 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, 2005ø1993¿, the term of service of the Assistant Secretary øDirector¿ shall be 4 years. An Assistant Secretary øA Director¿ may serve more that 1 term. 

(3) INCUMBENT.—The individual serving in the position of Director of the Indian Health Service on the day before the date 

of enactment of the Indian Health Care Improvement Act 

Amendments of 2005 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 øshall carry out through 

the Director¿ of øthe¿ Indian Health øService¿ shall—

(1) perform all functions that øwhich¿ were, on the day before the date of enactment of the Indian Health Care Improvement Act Amendments of 2005, øNovember 23, 1988,¿ carried 


hsrobinson on PROD1PC72 with HEARING
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out by or under the direction of the individual serving as Director of the Indian Health Service on that øsuch¿ 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; 

(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, including ø(but not 

limited to)¿ programs under—

(A) this Act øchapter¿; 

(B) the Act of November 2, 1921 (25 U.S.C. 13); 

(C) the Act of August 5, 1954 (42 U.S.C. 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 title øsubchapter¿ I øof this chapter.¿; 

(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 Assistant 

Secretary øDirector of the Indian Health Service¿, shall have 

the authority—

(A) except to the extent provided in paragraph (2), to appoint and compensate employees for the Service in accordance with øT¿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 provisions of law, the provisions of section 12 ø472¿ of the Act of 

June 18, 1934 (48 Stat. 986; 25 U.S.C. 472) øthis title¿, 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 


hsrobinson on PROD1PC72 with HEARING
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to the Director of the Indian Health Service, shall be deemed to refer 

to the Assistant Secretary. 

§ 1662. Automated øm¿Management øi¿Information 

øs¿System 

(a) ESTABLISHMENT.— (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 øs¿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 øa¿Area 

office of the Serviceø.¿; 

(E) an interface mechanism for patient billing and accounts receivable system; and 

(F) a training component. 

(b) PROVISION OF SYSTEMS TO øINDIAN T¿TRIBES AND

øO¿ORGANIZATIONS.—ø; REIMBURSEMENT¿ ø(1)¿ The Secretary shall 

provide each Tribal Health Program øIndian 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.]¿ automated management information systems which— (1)ø(A)¿ meet the management information needs of such 

Tribal Health Program øIndian tribe or tribal organization¿ 

with respect to the treatment by the Tribal Health Program 

øIndian tribe or tribal organization¿ of patients of the 

Serviceø,¿; and 

(2)ø(B)¿ 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 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. 


hsrobinson on PROD1PC72 with HEARING
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§ 603. Authorization of Appropriations 

There is authorized to be appropriated such sums as may be necessary for each fiscal year through fiscal year 2015 to carry out this 

title. 

TITLE VII—BEHAVIORAL HEALTH øSUBCHAPTER V—A—SUBSTANCE ABUSE¿ 

PROGRAMS 

§ 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 behavior 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 


hsrobinson on PROD1PC72 with HEARING
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(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 

Indian Organizations to meet their responsibilities under 

the plans. 

(2) NATIONAL CLEARINGHOUSE.—The Secretary, acting 

through the Service, shall establish a national clearinghouse of 

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; 

(I) Traditional Health Care Practices; and 

(J) 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 


hsrobinson on PROD1PC72 with HEARING
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(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; 

(C) identification and treatment of co-occurring disorders 

(dual diagnosis) and comorbidity; 

(D) promotion of healthy approached to risk-related behaviors; 

(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 OrVerDate Aug 31 2005 11:50 Mar 23, 2006 Jkt 049010 PO 00000 Frm 00216 Fmt 6659 Sfmt 6603 E:\HR\OC\SR222.XXX SR222

hsrobinson on PROD1PC72 with HEARING
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ganization, 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. 

(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 the enactment of the Indian Health Care Improvement Act Amendments of 2005, 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. 

§ 702. Memoranda of Agreement with the Department of the 

Interior 

ø§ 1665. Indian Health Service responsibilities¿ 

(a) CONTENTS.—Not later than 12 months after the date of the enactment of the Indian Health Care Improvement Act Amendments 

of 2005, 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, 


hsrobinson on PROD1PC72 with HEARING
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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) with behavioral 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). 

(8) Providing for an annual review of such agreement by the 

Secretaries which shall be provided to Congress and Indian 

Tribes and Tribal Organizations. 

(b) SPECIFIC PROVISIONS REQUIRED.—The øMemorandum¿ 

memoranda of øA¿agreement updated or entered into pursuant to 

subsection (a) øsection 2411 of this title¿ shall include specific provisions pursuant to which the Service shall assue responsibility 

for— (1) the determination of the scope of the problem of alcohol 

and substance abuse among Indians øpeople¿, 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) CONSULTATION.—The Secretary, acting through the Service, 

and the Secretary of the Interior shall, in developing the memoranda of agreement under subsection (a), consult with and solicit 

the comments from—

(1) Indian Tribes and Tribal Organizations; 

(2) Indians; 

(3) Urban Indian Organizations and other Indian organizations; and 


hsrobinson on PROD1PC72 with HEARING
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(4) behavioral health service providers. 

(d) PUBLICATION.—Each memorandum of agreement entered into 

or renewed (and amendments or modifications thereof) 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. 

ø§ 1665a. Indian Health Service program¿ 

§ 703. ø(a)¿ Comprehensive Behavioral Health øp¿ 

Prevention and øt¿Treatment øp¿Program 

(a) ESTABLISHMENT.—

(1) IN GENERAL.—The Secretary, acting through the Service, 

Indian Tribes, and Tribal Organizations, shall provide a program of comprehensive behavioral health, øalcohol and substance abuse¿ prevention, øand¿ treatment, and aftercare, including Traditional Health Care Practices, which shall include—

(A) prevention, through educational intervention, in Indian communities; 

(B) acute detoxification, psychiatric hospitalization, residential, and intensive outpatient øand¿ treatment; 

(C) community-based rehabilitation 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 postpartum øpost 

partum¿ women and their childrenø.¿; and 

(F) diagnostic services. 

(2) TARGET POPULATIONS.—The target population of such 

programs shall be members of Indian øt¿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 øH¿HEALTH øS¿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 behavioral health øalcohol and substance abuse¿ 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 

øt¿Tribes and Tribal Organizations to develop criteria for the 

certification of behavioral health øalcohol and substance 

abuse¿ 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¿. 


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§ 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. 

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.¿ 

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).¿ 

§ 705. Licensing Requirement for Mental Health Care Workers 

Subject to the provisions of section 221, any person employed as 

a psychologist, social worker, or marriage and family therapist for 

the purpose of providing mental health care services to Indians in 


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a clinical setting under this Act is required to be licensed as a clinical psychologist, social worker, or marriage and family therapist, 

respectively, or working under the direct supervision of a licensed 

clinical psychologist, social worker, or marriage and family therapist, respectively. 

§ 1665b. Indian øw¿Women øt¿Treatment øp¿Programs 

(a) GRANTS.—The Secretary, consistent with section 701, may 

make grants to Indian øt¿Tribes, øand t¿Tribal øo¿Organizations, and Urban Indian Organizations to develop and implement a comprehensive behavioral health øalcohol and substance abuse¿ program of prevention, intervention, treatment, and relapse prevention services that specifically addresses the spiritual, cultural, historical, social, and child care needs of Indian women, regardless of 

age. 

(b) USE OF GRANTøS¿ 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 behavioral 

health øalcohol and substance abuse¿ issues, including fetal alcohol disorders øsyndrome and fetal alcohol effect¿; 

(2) identify and provide psychological services, øappropriate¿ 

counseling, advocacy, support, and relapse prevention to Indian 

women and their families; and 

(3) develop prevention and intervention models for Indian 

women which incorporate øt¿Traditional Health Care Practices 

øhealers¿, cultural values, and community and family involvement. 

(c) CRITERIA.—øFOR 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 funding øgrants¿ under this section. 

(d) EARMARK OF CERTAIN FUNDS.—Twenty percent of the funds 

appropriated pursuant to this section shall be used to make grants 

to Urban Indian Organizations. 

ø(d) AUTHORIZATION OF APPROPRIATIONS¿ 

ø(1) There 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) Twenty percent of the funds appropriated pursuant to 

this subsection shall be used to make grants to urban Indian 

organizations funded under subchapter IV of this chapter.¿ 

§ 1665c. Indian øHealth Service y¿Youth øp¿Program 

(a) DETOXIFICATION AND øR¿REHABILITATION.—The Secretary, 

acting through the Service, consistent with section 701, shall develop and implement a program for acute detoxification and treatment for Indian youths, including behavioral health services øwho 

are alcohol and substance abusers¿. The program shall include regional treatment centers designed to include detoxification and rehabilitation for both sexes on a referral basis and programs developed and implemented by Indian Tribes or Tribal Organizations at 

the local level under the Indian Self-Determination and Education 


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Assistance Act (25 U.S.C. 450 et seq.). øThese r¿Regional centers 

shall be integrated with the intake and rehabilitation programs 

based in the referring Indian community. 

(b) ALCOHOL AND SUBSTANCE ABUSE TREATMENT øC¿CENTERS OR

øF¿FACILITIES

(1) ESTABLISHMENT.— ø(1)¿(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, at least 1øa¿ youth regional 

treatment center or treatment network in each area under 

the jurisdiction of an øa¿Area øo¿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 a¿Area øo¿Office in California shall be considered 

to be 2 øtwo a¿Area øo¿Offices, 1øone¿ office whose jurisdiction shall be considered to encompass the northern area 

of the State of California, and 1øone¿ 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 Indian Tøt¿ribes to be served by such center. 

(4) SPECIFIC PROVISION OF FUNDS.— (A) IN GENERAL.—Notwithstanding any other provision 

of this title øsubchapter¿, 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, operating 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 4ø50b¿(l) of the Indian Self-Determination and 

Education Assistance Act (25 U.S.C. 450b(l)) øthis 

title¿. (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 øsuch State¿. (c) INTERMEDIATE ADOLESCENT BEHAVIORAL HEALTH SERVICES.— (1) IN GENERAL.—The Secretary, acting through the Service, 

Indian Tribes, and Tribal Organizations, may provide intermediate behavioral health services, which may incorporate TraVerDate Aug 31 2005 11:50 Mar 23, 2006 Jkt 049010 PO 00000 Frm 00222 Fmt 6659 Sfmt 6603 E:\HR\OC\SR222.XXX SR222

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ditional Health Care Practices, 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. 

(d)ø(c)¿ FEDERALLY øO¿OWNED øS¿STRUCTURES.—

(1) IN GENERAL.—The Secretary, øacting through the Service, 

shall,¿ in consultation with Indian øt¿Tribes and Tribal Organizations, shall—

(A) identify and use, where appropriate, federally owned 

structures suitable for øas¿ local residential or regional behavioral health øalcohol and substance abuse¿ treatment 

øcenters¿ for Indian youths; and 

(B) establish guidelines, in consultation with Indian 

Tribes and Tribal Organizations, for determining the suitability of any such federally owned structure to be used for 

øas a¿ local residential or regional behavioral health øalcohol and substance abuse¿ treatment øcenter¿ for Indian 

youths. 

(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. 

(e)ø(d)¿ REHABILITATION AND øA¿AFTERCARE øS¿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 

u¿Unit, community-based rehabilitation and follow-up services 

for Indian youths who are having significant behavioral health 

problems and require øalcohol or substance abusers which are 

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integration, and monitoring to ømonitor and¿ support the Indian youths after their return to their home community. 

(2) ADMINISTRATION.—Services under paragraph (1) shall be 

provided øadministered within each service unit¿ by trained 

staff within the community who can assist the Indian youths 

in their continuing development of self-image, positive problem-solving skills, and nonalcohol or substance abusing behaviors. Such staff may øshall¿ include alcohol and substance 

abuse counselors, mental health professionals, and other 

health professionals and paraprofessionals, including community health representatives. 

(f)ø(e)¿ INCLUSION OF øF¿FAMILY IN øY¿YOUTH øT¿TREATMENT

øP¿PROGRAM.—IN PROVIDING THE TREATMENT AND OTHER SERVICES

TO INDIAN 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 

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 (e)ø(d) of this section¿ shall 

be used for outpatient care of adult family members related to the 

treatment of an Indian youth under that subsection. 

(g)ø(f)¿ MULTIDRUG øA¿ABUSE PROGRAM.—øSTUDY¿ 

ø(1)¿ 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 øconduct a study to determine the incidence and prevalence of¿ the abuse of multiple forms of substances ødrugs¿, including alcohol, drugs, inhalants, and tobacco, among Indian youths residing in Indian communities, on 

or near øIndian¿ reservations, and in urban areas and provide 

appropriate mental health services to address øthe interrelationship of such abuse with¿ the incidence of mental illness 

among such 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 from 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 offreservation facilities; and 

(5) the cost of the services described in paragraph (4). 


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§ 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, Tribal Organizations, and Urban Indian 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, Tribal Organizations, and Urban Indian Organizations that—

(A) serve a particular community or geographic area 

where there is a demonstrated need to address Indian 

youth suicide; 


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(B) enter into collaborative partnerships with Indian 

Health Service or other Tribal Health Programs or facilities to provide services under this demonstration project; 

(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 youth are detained. 

(d) USE OF FUNDS.—An Indian Tribe, Tribal Organization, or 

Urban Indian Organization shall use a grant received under subsection (c) for the following purposes: 

(1) To provide telemental health services to Indian youth, including the provision of— (A) psychotherapy; 

(B) psychiatric assessments and diagnostic interviews, 

therapies for mental health conditions predisposing to suicide, and treatment; and 

(C) alcohol and substance abuse treatment. 

(2) 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. 

(3) 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. 

(4) To develop and distribute culturally appropriate community educational materials on— (A) suicide prevention; 

(B) suicide education; 

(C) suicide screening; 

(D) suicide intervention; and 

(E) ways to mobilize communities with respect to the 

identification of risk factors for suicide. 

(5) For data collection and reporting related to Indian youth 

suicide prevention efforts. 

(e) APPLICATIONS.—To be eligible to receive a grant under subsection (c), an Indian Tribe, Tribal Organization, or Urban Indian 

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, Tribal 

Organization, or Urban Indian Organization will carry out 

using the funds provided under the grant; 

(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; 


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(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) TRADITIONAL HEALTH CARE PRACTICES.—The Secretary, acting 

through the Service, shall ensure that the demonstration project established pursuant to this section involves the use and promotion of 

the Traditional Health Care Practices of the Indian Tribes of the 

youth to be served. 

(g) COLLABORATION; REPORTING TO NATIONAL CLEARINGHOUSE.—

(1) COLLABORATION.—The Secretary, acting through the Service, shall encourage Indian Tribes, Tribal Organizations, and 

Urban Indian 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, Tribal Organizations, and Urban Indian 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. 

(h) 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. 

(i) 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 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; and 

(2) evaluates the impact of the telemental health services 

funded by the grants in reducing the number of completed suicides among Indian youth. 

(j) AUTHORIZATION OF APPROPRIATIONS.—There is authorized to 

be appropriated to carry out this section $1,500,000 for each of fiscal years 2006 through 2009.’’


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§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 2005, 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 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. 

§1665d. Training and øc¿Community øe¿Education 

(a) PROGRAM.—øCOMMUNITY EDUCATION¿ The Secretary, in cooperation with the Secretary of the Interior, shall develop and implement or provide funding for Indian Tribes and Tribal Organizations to develop and implement, within each øs¿Service øu¿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 about behavioral health 

issues øin alcohol and substance abuse¿ to political leaders, 

øt¿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. Community-based training (oriented toward local capacity 

development) shall also include tribal community provider training 

(designed for adult learners from the communities receiving services 

for prevention, intervention, treatment, and aftercare.) 

(b) INSTRUCTION.—øTRAINING¿ The Secretary, acting through the 

Service, shall, either directly or through Indian Tribes and Tribal 

Organizations øby contract¿, provide instruction in the area of behavioral health issues øalcohol and substance abuse¿, 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 disorders øsyndrome¿ 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 4213 of the Indian Alcohol 

and Substance Abuse Prevention and Treatment Act of 1986 (25 

U.S.C. 2433) ø2433 of this title¿. 

(c) TRAINING øCOMMUNITY-BASED TRAINING M¿MODELS.— In carrying out the education and training programs required by this section, the Secretary, øacting through the Service and¿ in consultation with Indian Tøt¿ribes, Tribal Organizations, Indian behavioral health experts, and Indian alcohol and substance abuse prevention experts, shall develop and provide community-based training models. Such models shall address—

(1) the elevated risk of alcohol and behavioral health problems øsubstance abuse¿ faced by children of alcoholics; 


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(2) the cultural, spiritual, and multigenerational aspects of 

behavioral health problem øalcohol and substance abuse¿ prevention and recovery; and 

(3) community-based and multidisciplinary strategies for preventing and treating behavioral health problems øalcohol and 

substance abuse¿. 

§ 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) FUNDING; CRITERIA.—The Secretary may award such funding 

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. 

(5) The project may deliver services in a manner consistent 

with Traditional Health Care Practices. 

(6) The project is coordinated with, and avoids duplication of, 

existing services. 

(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§ 1665e. Gallup alcohol and substance abuse treatment center¿ 

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 


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and the adolescent center located in Shiprock, New Mexico, for 

emergency crisis services, assessment, and family intervention;¿ 

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.¿ 

ø§ 1665f. Reports¿ 

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.¿ 

§ 1665g. Fetal øa¿Alcohol Disorder Programs.— øsyndrome 

and fetal alcohol effect grants¿ 

(a) PROGRAMS.—øAWARD; USE; REVIEW CRITERIA¿ 

(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 øsyndrome and fetal alcohol effect¿ programs as proVerDate Aug 31 2005 11:50 Mar 23, 2006 Jkt 049010 PO 00000 Frm 00230 Fmt 6659 Sfmt 6602 E:\HR\OC\SR222.XXX SR222

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vided in this section for the purposes of meeting the health status objectives specified in section 3ø1602(b) of this title¿. (2) USE OF FUNDS.—Funding provided øGrants made¿ pursuant to this section shall be used for the following:ø to—¿ 

(A) To develop and provide for Indians community and 

inø-¿school training, education, and prevention programs 

relating to fetal alcohol disorders. øFAS and FAE;¿ 

(B) To identify and provide behavioral health øalcohol 

and substance abuse¿ treatment to high-risk Indian 

women and high-risk women pregnant with an Indian’s 

child.ø;¿ 

(C) To identify and provide appropriate psychological 

services, educational and vocational support, counseling, 

advocacy, and information to fetal alcohol disorder øFAS 

and FAE¿ affected Indians øpersons¿ and their families or 

caretakersø;¿. (D) To develop and implement counseling and support 

programs in schools for fetal alcohol disorder øFAS and 

FAE¿ affected Indian childrenø;¿. (E) To develop prevention and intervention models 

which incorporate practitioners of Tøt¿raditional Health 

Care Practices øhealers¿, cultural and spiritual values, 

and community involvementø;¿. (F) To develop, print, and disseminate education and 

prevention materials on fetal alcohol disorder. øFAS and 

FAE; and¿ 

(G) To develop and implement, through the tribal consultation with Indian Tribes, Tribal Organizations, and 

Urban Indian Organizations, culturally sensitive assessment and diagnostic tools including dysmorphology clinics 

and multidisciplinary fetal alcohol and disorder clinics for 

use in øtribal and urban¿ Indian communities and Urban 

Centers. 

(H) To develop early childhood intervention projects from 

birth on to mitigate the effects of fetal alcohol disorder 

among Indians. 

(I) To develop—

(i) community-based support service for Indians and 

for women pregnant with Indian children; and 

(ii) to the extent funding is available, communitybased housing for adult Indians with fetal alcohol disorder. 

(3) CRITERIA FOR APPLICATIONS.—The Secretary shall establish criteria for the review and approval of applications for 

funding øgrants¿ under this section. 

(b) SERVICES.—øPLAN; STUDY; NATIONAL CLEARINGHOUSE¿ The 

Secretary, acting through the Service and Indian Tribes, Tribal Organizations, and Urban Indian Organizations, shall—

(1) develop and provide services øan annual plan¿ for the 

prevention, intervention, treatment, and aftercare for those affected by fetal alcohol disorder øFAS and FAE¿ in Indian communities; and 

(2) provide supportive services, directly or through an Indian 

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tract with any organization, entity, or institution of higher 

education with significant knowledge of FAS and FAE and Indian communities, of¿ the special educational, vocational, 

school-to-work transition, and independent living needs of adolescent and adult Indians with fetal alcohol disorder. øand 

Alaska Natives with FAS or FAE; and¿ 

ø(3) establish a national clearinghouse for prevention and 

educational materials and other information of FAS and FAE 

effect in Indian and Alaska Native communities and ensure access to clearinghouse materials by any Indian tribe or urban 

Indian organization.¿ 

(c) TASK øF¿FORCE.—The Secretary shall establish a task force to 

be known as the Fetal Alcohol Disorder øFAS/FAE¿ 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,¿ 

(2) Tøt¿he National Institute on Alcohol and Alcoholism.ø,¿ 

(3) Tøt¿he Office of Substance Abuse Prevention.ø,¿ 

(4) Tøt¿he National Institute of Mental Health.ø,¿ 

(5) Tøt¿he Service.ø,¿ 

(6) Tøt¿he Office of Minority Health of the Department of 

Health and Human Services.ø,¿ 

(7) Tøt¿he Administration for Native Americans.ø,¿ 

(8) The National Institute of Child Health and Human Development (NICHD). 

(9) The Centers for Disease Control and Prevention. 

(10) Tøt¿he Bureau of Indian Affairs.ø,¿ 

(11) Indian Tøt¿ribes.ø,¿ 

(12) Tøt¿ribal Oøo¿rganizations.ø,¿ 

(13) Uøu¿rban Indian Organizations. øcommunities, and¿ 

(14) Indian fetal alcohol disorder øFAS/FAE¿ experts. 

(d) øCOOPERATIVE PROJECTS;¿ APPLIED RøR¿ESEARCH

PøP¿ROJECTS.—The Secretary, acting through the Substance Abuse 

and Mental Health Services Administration, shall make grants to 

Indian Tøt¿ribes, Tøt¿ribal Oøo¿rganizations, and Urban Indian 

Organizations øuniversities working with Indian tribes on cooperative projects, 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 aftercare for Indians and Uøu¿rban Indians affected by fetal 

alcohol disorder øFAS or FAE¿. 

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.¿ 


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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) of this section 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.¿ 

(e) FUNDING FOR URBAN INDIAN ORGANIZATIONS.—ø(2)¿ Ten percent of the funds appropriated pursuant to this section shall be 

used to make grants to Uøu¿rban Indian Oøo¿rganizations funded 

under title V øsubchapter IV of this chapter¿. 

ø§ 1665h. Pueblo substance abuse treatment project for San 

Juan Pueblo, New Mexico¿ 

øThe Secretary, acting through the Service, shall 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.¿ 

ø§ 1665i. Thunder Child Treatment Center¿ 

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 section, 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.¿ 

ø§ 1665j. Substance abuse counselor education demonstration project¿ 

ø(a) CONTRACTS AND GRANTS¿ 


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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 education 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¿ 

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.¿ 

§ 713. Child Sexual Abuse and Prevention Treatment Programs 

(a) ESTABLISHMENT.—The Secretary, acting through the Service, 

and the Secretary of the Interior, Indian Tribes, and Tribal Organizations shall establish, consistent 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 


hsrobinson on PROD1PC72 with HEARING
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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 and spiritual values, and community involvement. 

(4) To develop and implement, in consultation with Indian 

Tribes, Tribal Organizations, and Urban Indian Organizations, 

cultural 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. 

§ 714. Behavioral Health Research 

The Secretary, in consultation with appropriate Federal agencies, 

shall provide grants to, or enter into contracts with, Indian Tribes, 

Tribal Organizations, and Urban Indian Organizations 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 

(3) the development of models of prevention techniques. 

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. 

§ 715. ø(g)¿ Definitions 

For the purposes of this title øsection¿, the following definitions 

shall apply: 

(1) ASSESSMENT.—The term ‘assessment’ means the systematic collection, analysis, and dissemination of information on 

health status, health needs, and health problems. øThe term ‘‘educational curriculum’’ means one or more of the following:¿ 

ø(A) Classroom education.¿ 

ø(B) Clinical work experience.¿ 

ø(C) Continuing education workshops.¿ 


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(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 (mental health professionals, traditional health care 

practitioners, community health aides, community health representatives, mental health technicians, ministers, etc.) 

ø(3) The term ‘‘tribally controlled community college’’ has the 

meaning given such term in section 1801(a)(4) of this title.¿ 

(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). 

ø(4) The term ‘‘tribally controlled postsecondary vocational 

institution’’ has the meaning given such term in section 

2397h(2) of Title 20.¿ 

(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. 

(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. 


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(8) REHABILITATION.—The term ‘rehabilitation’ means to restore the ability or capacity to engage in usual and customary 

life activities through education and therapy. 

(9) SUBSTANCE ABUSE.—The term ‘substance abuse’ includes 

inhalant abuse. 

§ 716. ø(h)¿ Authorization of Aøa¿ppropriations 

There is øare¿ authorized to be appropriated øfor each of fiscal 

years 1996 through 2000,¿ such sums as may be necessary for each 

fiscal year through fiscal year 2015 to carry out the provisions 

øpurposes¿ of this title øsection¿. øSuch sums shall remain available until expended.¿ 

ø§ 1665k. Gila River alcohol and substance abuse treatment 

facility¿ 

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.¿ 

ø§ 1665l. Alaska Native drug and alcohol abuse demonstration project¿ 

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 

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.¿ 

ø§ 1665m. Authorization of appropriations¿ 

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.¿ 


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TITLE VIII [SUBCHAPTER VI]— MISCELLANEOUS 

§ 1671. Reports 

For each fiscal year following the date of enactment of the Indian 

Health Care Improvement Act Amendments of 2005, the Secretary 

shall transmit to Congress a report containing the following: 

øThe President shall, at the time the budget is submitted under 

section 1105 of Title 31, for each fiscal year transmit to the Congress a report containing—¿ 

(1) Aøa¿ report on the progress made in meeting the objectives of this Act øchapter¿, including a review of programs established or assisted pursuant to this Act øchapter¿ and øan¿ 

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 population, including 

specific comparisons of appropriations provided and those required for such parity.ø;¿ 

(2) Aøa¿ 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 Act øchapter¿ and any steps that the Secretary may have taken to consult with Indian øt¿Tribes, Tribal Organizations, and Urban 

Indian Organizations to address such impact, including a report on proposed changes in allocation of funding pursuant to 

section 808.ø;¿ 

(3) Aøa¿ 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; 

(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). 

(7)ø(4) a¿A separate statement which specifies the amount of 

funds requested to carry out the provisions of section 201. 

ø1621 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. 


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(11) An annual report on the status of all health care facilities needs as required by section 301(c)(2) 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 nonservice 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). 

(19) A report on alcohol and substance abuse as required by 

section 701(f). 

(20) A report on Indian youth mental health services are required by section 707(h). 

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 the sections 1602(d), 1616a(n), 

1621b(b), 1621h(j), 1631(c), 1632(g), 1634(a)(3), 1643, 1665g(e), 

and 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), 1665j(f), and 1680k(g) of this title.¿ 

§ 1672. Regulations 

(a) DEADLINES.—

(1) PROCEDURES.—Not later than 90 days after the date of the 

enactment of the Indian Health Care Improvement Act Amendments of 2005, 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 I (except section 105, 115 

and 117), II, III, and VII. The Secretary may promulgate regulations to carry out sections 105,115, 117, and titles IV and V, 

using the procedures required by chapter V of title 5, United 

States Code (commonly known as the ‘Administrative Procedure 

Act’). The Secretary shall issue no regulations to carry out titles 

VI and VIII. 

(2) PROPOSED REGULATIONS.—Proposed regulations to implement this Act shall be published in the Federal Register by the 

Secretary no later than 1 year after the date of the enactment 


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of the Indian Health Care Improvement Act Amendments of 

2005 and shall have no less than a 120-day comment period. 

(3) EXPIRATION OF AUTHORITY.—The authority to promulgate 

regulations under this Act shall expire 24 months from the date 

of the enactment of this Act. 

(b) COMMITTEE.—A negotiated rulemaking committee established 

pursuant to section 565 of title 5, United State 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, Tribal Organizations, and 

Urban Indian Organizations from each Service Area. The representative of the Urban Indian Organizations shall be deemed to be an 

elected officer of a tribal government for purposes fo applying section 204(b) of the Unfunded Mandates Reform Act of 1995 (2 U.S.C. 

1534(b). 

(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. 

(d) LACK OF REGULATIONS.—The lack of promulgated regulations 

shall not limit the effect of this Act. 

(e) INCONSISTENT REGULATIONS.—The provisions of this Act shall 

supersede any conflicting provisions of law in effect on the day before the date of the enactment of the Indian Health Care Improvement Act Amendments of 2005, and the Secretary is authorized to 

repeal any regulation inconsistent with the provisions 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.¿ 

ø§ 1673. Repealed.¿ 

ø§ 1674. Leases with Indian tribes¿ 

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 

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ganizations 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.¿ 

§ 803. Plan of Implementation. 

Not later than 9 months after the date of the enactment of the Indian Health Care Improvement Act Amendments of 2005, the Secretary in consultation with Indian Tribes, Tribal Organizations, 

and Urban Indian Organizations, shall submit to Congress a plan 

explaining the manner and schedule (including a schedule of appropriation requests), by title and section, by which the Secretary will 

implement the provisions of this Act. 

§ 1675. Availability of Fƒf¿unds 

The funds appropriated pursuant to this Act øchapter¿ shall remain available until expended. 

§ 1676. Limitation on Uøu¿se of Føf¿unds Aøa¿ppropriated to 

the 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¿ 

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 


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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¿ 

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¿ 


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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 

operator. 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.¿ 

§ 1679. Eligibility of California Indians 

(a) IN GENERAL.—øREPORT TO CONGRESS¿ The following California Indians shall be eligible for health services provided by the 

Service: 

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¿ 


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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 Tøt¿ribe. 

(2) Any descendant of an Indian who was residing in California on June 1, 1852, øbut only¿ if such descendant—

ø(A) is living in California,¿ 

(A)ø(B)¿ is a member of the Indian community served by 

a local program of the Serviceø,¿; and 

(B)ø(C)¿ 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. 

(b)ø(c)¿ CLARIFICATION.—øSCOPE OF ELIGIBILITY¿ 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. 

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, Sant 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.¿ 


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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,¿ 

øunless the Secretary, acting through the Service, has ensured that 

the Indians receiving services from such member will experience no 

reduction in services.¿ 

§ 1680c. Health Søs¿ervices for Iøi¿neligible Pøp¿ersons 

(a) CHILDREN.—øINDIVIDUALS NOT OTHERWISE ELIGIBLE¿ 

ø(1)¿ Any individual who—

(1)ø(A)¿ has not attained 19 years of ageø,¿; 

(2)ø(B)¿ is the natural or adopted child, stepø-¿child, 

fosterø-¿child, legal ward, or orphan of an eligible Indianø,¿; 

and 

(3)ø(C)¿ is not otherwise eligible for the 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 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 1øone¿ year after the date of a determination 

of competency øsuch disability has been removed¿. 

(b) SPOUSES.—ø(2)¿ 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 of such spouses or spouses who are married to members of each Indian Tribe served are made eligible, as 

a class, by an appropriate resolution of the governing body of the 

Indian tribe or Tribal Organization providing such services øof the 

eligible Indian¿. 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. 

(c)ø(b)¿ PROVISION OF SERVICES TO OTHER INDIVIDUALS.—

øHEALTH FACILITIES PROVIDING HEALTH SERVICE¿ 

(1)ø(A)¿ IN GENERAL.—The Secretary is authorized to provide 

health services under this subsection through health programs 

øfacilities¿ operated directly by the Service to individuals who 

reside within the øservice area of a s¿Service øu¿Unit and who 

are not otherwise eligible for such health services øunder any 

other subsection of this section or under any other provision of 

law¿ if—

(A)ø(i)¿ the Indian Tøt¿ribes ø(or, in the case of a multitribal service are, all the Indian tribes)¿ served by such 

øs¿Service øu¿Unit requestøs¿ such provision of health 

services to such individualsø,¿; and 


hsrobinson on PROD1PC72 with HEARING
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(B)ø(ii)¿ the Secretary and the served Indian øtribe or 

t¿Tribes have jointly determined that— (i)ø(I)¿ the provision of such health services will not 

result in a denial or diminution of health services to 

eligible Indiansø,¿; and 

(ii)ø(II)¿ there is no reasonable alternative health 

facilitøy¿ies or services, within or without the øservice 

area of such s¿Service øu¿Unit, available to meet the 

health needs of such individuals. 

(2)ø(B)¿ 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 (25 U.S.C. 450 et seq.), ø[25 U.S.C.A. § 450f et 

seq.],¿ the governing body of the Indian øt¿Tribe or Tøt¿ribal 

Oøo¿rganization providing health services under such contract 

or compact is authorized to determine whether health services 

should be provided under such contract or compact to individuals who are not otherwise eligible for such øhealth¿ services 

under any other subsection of this section or under any other 

provision of law. In making such determinationøs¿, the governing body of the Indian øt¿Tribe or øt¿Tribal 

øo¿Organization shall take into account the considerations described in clauses (i) and (ii) of paragraph (1)(B) øsubparagraph (A)(ii)¿. (3)ø(2)¿ PAYMENT FOR SERVICES.— (A) IN GENERAL.—Persons receiving health services provided by the Service under øby reason of¿ 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 404ø1880(c)¿ of 

this øthe Social Security¿ Act ø[42 U.S.C.A. § 1395qq(c)], 

section 1642(a) of this title,¿ or any other provision of law, 

amounts collected under this subsection, including medicare, øor¿ medicaid or SCHIP reimbursements under titles 

XVIII, øand¿ XIX, and XXI of the Social Security Act ø[42 

U.S.C.A. §§ 1395 et seq., 1396 et seq.]¿, shall be credited 

to the account of the program øfacility¿ providing the service and shall be used øsolely¿ for the purposes listed in section 401(d)(2) and øprovision of health services within that 

facility. A¿amounts collected under this subsection shall be 

available for expenditure within such program øfacility for 

not to exceed one fiscal year after the fiscal year in which 

collected¿. 

(B) INDIGENT PEOPLE.—Health services may be provided 

by the Secretary through the Service under this subsection 

to an indigent individual øperson¿ 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 individual 

øperson¿. 


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(4)ø(3)¿ REVOCATION OF CONSENT FOR SERVICES.—

(A) SINGLE TRIBE SERVICE AREA.—In the case of a 

Søs¿ervice Aøa¿rea which serves only 1øone¿ Indian 

Tøt¿ribe, 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 Tøt¿ribe revokes its concurrence to the provision of such health services. 

(B) MULTITRIBAL SERVICE AREA.—In the case of a 

multiø-¿tribal Søs¿ervice Aøa¿rea, 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 Tøt¿ribes in the Søs¿ervice Aøa¿rea revoke their concurrence to the provision of such health services. 

(d)ø(c)¿ OTHER SERVICES.—øPURPOSES SERVED IN PROVIDING

HEALTH SERVICES TO OTHERWISE INELIGIBLE INDIVIDUALS¿ 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 

postø ¿partumø,¿; or 

(4) provide care to immediate family members of an eligible 

individual øperson¿ if such care is directly related to the treatment of the eligible individual øperson¿. 

(e)ø(d) EXTENSION OF H¿HOSPITAL øP¿PRIVILEGES FOR øTO NONSERVICE HEALTH CARE P¿PRACTITIONERS.—Hospital privileges in 

health facilities operated and maintained by the Service or operated under a contract or compact øentered into under¿ pursuant to 

the Indian Self-Determination and Education Assistance Act (25 

U.S.C. 450 et seq.) ø[25 U.S.C.A. § 450f et seq.]¿ may be extended 

to non-Service health care practitioners who provide services to individuals øpersons¿ described in subsection (a), øor¿ (b), (c), or (d) 

øof this section¿. Such non-Service health care practitioners may, 

as part of the privileging process, be designated øregarded¿ as employees of the Federal Government for purposes of section 1346(b) 

and chapter 171 of 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 individuals øpersons¿ as 

a part of the conditions under which such hospital privileges are 

extended. 

(f)ø(e) ‘‘¿ELIGIBLE INDIANø’’ ‘‘defined¿.—For purposes of this section, the term ø‘‘¿ ‘eligible Indian’ ø’’¿ means any Indian who is eligible for health services provided by the Service without regard to 

the provisions of this section. 


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ø§ 1680d. Infant and maternal mortality; fetal alcohol syndrome¿ 

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 births.¿ 

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) NONIMPAIRMENT 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;¿ 


hsrobinson on PROD1PC72 with HEARING
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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 George E. Wahlen Department 

of Veterans Affairs Medical Center located in Salt Lake 

City, Utah.¿ 

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.¿ 

§ 1680g. Reallocation of Bøb¿aseRør¿esources 

(a) REPORT REQUIRED.—øTO CONGRESS¿ 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 Søs¿ervice Uøu¿nit may be implemented only after the Secretary 

has submitted to the President, for inclusion in the report required 

to be transmitted to øthe¿ Congress under section 801ø1671 of this 

title¿, a report on the proposed change in allocation of funding, including the reasons for the change and its likely effects. 

(b) EXCEPTION.—øAPPROPRIATED AMOUNTS¿ Subsection (a) øof 

this section¿ 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. 

ø§ 1680h. Demonstration projects for tribal management of 

health care services¿ 

ø(a) ESTABLISHMENT; GRANTS¿ 

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 


hsrobinson on PROD1PC72 with HEARING
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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 demonstrative 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 

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 


hsrobinson on PROD1PC72 with HEARING
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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.¿ 

ø§ 1680i. Child sexual abuse treatment programs¿ 

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).¿ 

ø§ 1680j. Tribal leasing¿ 

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.¿ 

ø§ 1680k. Home- and community-based care demonstration 

project¿ 

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 by used—¿ 

ø(A) to make cash payments to functionally disabled Indians;¿ 

ø(B) to provide room and board for functionally disabled 

Indians;¿ 


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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.¿ 

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.¿ 


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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.¿ 

ø§ 1680l. Shared services demonstration project¿ 

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 nursing 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 or 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.¿ 


hsrobinson on PROD1PC72 with HEARING
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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.¿ 

§ 1680m. Results of ød¿Demonstration øp¿Projects 

The Secretary shall provide for the dissemination to Indian 

Tøt¿ribes, Tribal Organizations, and Urban Indian Organizations 

of the findings and results of demonstration projects conducted 

under this Act øchapter¿. 

ø§ 1680n. Priority for Indian reservations¿ 

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.¿ 

§ 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. 

ø§ 1680o. Authorization of appropriations¿ 

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.¿ 

§ 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 Health Resources and Services Administration of the 


hsrobinson on PROD1PC72 with HEARING
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Public Health Service, 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 such time as new criteria governing eligibility for services are developed in accordance with section 802. 

ø§ 1681. Omitted¿ 

§ 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’. 

ø§ 1682. Subrogation of claims by Indian Health Service¿ 

øOn and after October 18, 1986, 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.¿ 

ø§ 1683. Indian Catastrophic Health Emergency Fund¿ 

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’’). On and after October 18, 

1986, 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) [25 

U.S.C.A. § 450 et seq.]. 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 beneficiary; 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.¿ 

§ 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 


hsrobinson on PROD1PC72 with HEARING
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such provisions to persons or circumstances other than those to 

which it is held invalid, shall not be affected thereby. 

§ 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 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 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 

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 health care services to Indians. Such recommendation 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. 


hsrobinson on PROD1PC72 with HEARING
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(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 recommendation 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 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 the enactment of the Indian Health Care Improvement Act Amendments of 2005, and the remaining members of 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 


hsrobinson on PROD1PC72 with HEARING
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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 

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 comVerDate Aug 31 2005 11:50 Mar 23, 2006 Jkt 049010 PO 00000 Frm 00258 Fmt 6659 Sfmt 6603 E:\HR\OC\SR222.XXX SR222

hsrobinson on PROD1PC72 with HEARING
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mittee 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 the 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 

be appropriated $4,000,000 to carry out the provisions of this section, which sum shall not be deducted from or affect any other appropriations for health care for Indian persons. 

(j) FACA.—The Federal Advisory Committee Act (5 U.S.C. App.) 

shall not apply to the Commission. 

§ 815. Appropriations; Availability 

Any new spending authority (described in subsection (c)(2)(A) or 

(B) of section 401 of the Congressional Budget Act of 1974) which 

is provided under this Act shall be effective for any fiscal year only 


hsrobinson on PROD1PC72 with HEARING
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to such extent or in such amounts as are provided in appropriation 

Acts. 

§ 816. Authorization of Appropriations 

(a) IN GENERAL.—There are authorized to be appropriated such 

sums as may be necessary for each fiscal year through fiscal year 

2015 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)’’. (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 

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 


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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’’. 

(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. 3. SOBOBA SANITATION FACILITIES. 

The Act of December 17, 1970 (84 Stat. 1465), is amended by 

adding at the end the following new section: 

‘‘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. 4. AMENDMENTS TO THE MEDICAID AND STATE CHILDREN’S 

HEALTH INSURANCE PROGRAMS. 

(a) EXPANSION OF MEDICAID PAYMENT FOR ALL COVERED SERVICES FURNISHED BY INDIAN HEALTH PROGRAMS.—

(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 REIMBURSEMENT FOR MEDICAL ASSISTANCE.—The Indian Health Service and an Indian Tribe, Tribal Organization, or an Urban Indian Organization (as such terms are defined in section 4 of the Indian Health Care Improvement Act) shall 

be eligible for reimbursement 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 conditions and requirements which are 


hsrobinson on PROD1PC72 with HEARING
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applicable generally to the furnishing of items and services under 

this title and under such plan or waiver authority.’’. (2) ELIMINATION OF TEMPORARY DEEMING PROVISION.—Such 

section is amended by striking subsection (b). 

(3) REVISION OF AUTHORITY TO ENTER INTO AGREEMENTS.— Subsection (c) of such section is redesignated as subsection (b) 

and is amended to read as follows: ‘‘(b) 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 Organizations, 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) REFERENCE CORRECTION.—Subsection (d) of such section 

is redesignated as subsection (c) and is amended— (A) by striking ‘‘For’’ and inserting ‘‘DIRECT BILLING.—For’’; and 

(B) by striking ‘‘section 405’’ and inserting ‘‘section 

401(d)’’. (b) SPECIAL RULES FOR INDIANS, INDIAN HEALTH CARE PRO- VIDERS, AND INDIAN MANAGED CARE ENTITIES.— (1) 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 FOR INDIANS, INDIAN HEALTH CARE PRO- VIDERS, AND INDIAN MANAGED CARE ENTITIES.—A State shall comply with the provisions of section 413 of the Indian Health Care Improvement Act (relating to the treatment of Indians, Indian health 

care providers, and Indian managed care entities under a medicaid 

managed care program).’’. (2) APPLICATION TO SCHIP.—Section 2107(e)(1) of the Social 

Security Act (42 U.S.C. 1397gg(1)) is amended by adding at the 

end the following: ‘‘(E) Subsections (a)(2)(C) and (h) of section 1932.’’. (c) SCHIP TREATMENT OF INDIAN TRIBES, TRIBAL ORGANIZA- TIONS, AND URBAN INDIAN ORGANIZATIONS.—Section 2105(c) of the 

Social Security Act (42 U.S.C. 1397ee(c)) is amended—

(1) in paragraph (2), by adding at the end the following: 

‘‘(C) INDIAN HEALTH PROGRAM PAYMENTS.—For provisions relating to authorizing use of allotments under this 

title for payments to Indian Health Programs and Urban 

Indian Organizations, see section 410 of the Indian Health 

Care Improvement Act.’’; and 

(2) in paragraph (6)(B), by inserting ‘‘or by an Indian Tribe, 

Tribal Organization, or Urban Indian Organization (as such 

terms are defined in section 4 of the Indian Health Care Improvement Act)’’ after ‘‘Service’’. 

SEC. 5. 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: 


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‘‘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. 

‘‘(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. 


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‘‘(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.—

‘‘(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—


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‘‘(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) SECRETARY.—The secretary of the Foundation shall serve, 

at the direction of the Board, as the chief operating officer of 

the Foundation. 

‘‘(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.—

‘‘(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 10 percent 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) APPOINTMENT AND HIRING.—The appointment of officers 

and employees of the Foundation shall be subject to the availability of funds. 

‘‘(3) STATUS.—A member of the Board or officer, employee, or 

agent of the Foundation shall not by reason of association with 


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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. 

‘‘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 (25 U.S.C. 450 et seq.) 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’’. 

Æ 


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