" ! HOUSE OF REPRESENTATIVES 109TH CONGRESS

2d Session 

REPT. 109–661 

Part 1 

INDIAN HEALTH CARE IMPROVEMENT ACT 

AMENDMENTS OF 2006 

R E P O R T 

OF THE

COMMITTEE ON RESOURCES 

[TO ACCOMPANY H.R. 5312]

SEPTEMBER 15, 2006.—Ordered to be printed 


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INDIAN HEALTH CARE IMPROVEMENT ACT AMENDMENTS OF 2006 


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109TH CONGRESS REPT. 109–661 " ! HOUSE OF REPRESENTATIVES 2d Session Part 1 

INDIAN HEALTH CARE IMPROVEMENT ACT AMENDMENTS 

OF 2006 

SEPTEMBER 15, 2006.—Ordered to be printed 

Mr. POMBO, from the Committee on Resources, 

submitted the following 

R E P O R T 

[To accompany H.R. 5312] 

[Including cost estimate of the Congressional Budget Office] 

The Committee on Resources, to whom was referred the bill 

(H.R. 5312) to amend the Indian Health Care Improvement Act to 

revise and extend that Act, having considered the same, report favorably thereon with an amendment and recommend that the bill 

as amended do pass. 

The amendment is as follows: 

Strike all after the enacting clause and insert the following: 

SECTION 1. SHORT TITLE. 

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

of 2006’’. 

TITLE I—INDIAN HEALTH CARE 

IMPROVEMENT ACT AMENDMENTS 

SEC. 101. INDIAN HEALTH CARE IMPROVEMENT ACT AMENDED. 

(a) IN GENERAL.—The Indian Health Care Improvement Act (25 U.S.C. 1601 et 

seq.) is amended to read as follows: 

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

‘‘(a) SHORT TITLE.—This Act may be cited as the ‘Indian Health Care Improvement Act’. 

‘‘(b) TABLE OF CONTENTS.—The table of contents for this Act is as follows: 

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

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

‘‘Sec. 101. Purpose. 

‘‘Sec. 102. Health professions recruitment program for Indians. 

‘‘Sec. 103. Health professions preparatory scholarship program for Indians. 

‘‘Sec. 104. Indian health professions scholarships. 

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


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‘‘Sec. 106. Scholarship programs for Indian tribes. 

‘‘Sec. 107. Indian health service extern programs. 

‘‘Sec. 108. Continuing education allowances. 

‘‘Sec. 109. Community health representative program. 

‘‘Sec. 110. Indian health service loan repayment program. 

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

‘‘Sec. 112. Recruitment activities. 

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

‘‘Sec. 114. Advanced training and research. 

‘‘Sec. 115. Quentin N. Burdick American Indians into nursing program. 

‘‘Sec. 116. Tribal cultural orientation. 

‘‘Sec. 117. Inmed program. 

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

‘‘Sec. 119. Retention bonus. 

‘‘Sec. 120. Nursing residency program. 

‘‘Sec. 121. Community health aide program for Alaska. 

‘‘Sec. 122. Tribal health program administration. 

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

‘‘Sec. 124. National Health Service Corps. 

‘‘Sec. 125. Substance abuse counselor educational curricula demonstration programs. 

‘‘Sec. 126. Behavioral health training and community education programs. 

‘‘TITLE II—HEALTH SERVICES 

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

‘‘Sec. 202. Catastrophic Health Emergency Fund. 

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

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

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

‘‘Sec. 206. Health services research. 

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

‘‘Sec. 208. Patient travel costs. 

‘‘Sec. 209. Epidemiology centers. 

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

‘‘Sec. 211. Indian youth program. 

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

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

‘‘Sec. 214. Indian women’s health care. ‘‘Sec. 215. Environmental and nuclear health hazards. 

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

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

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

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

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

‘‘Sec. 219. Contract health services for the Trenton service area. 

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

‘‘Sec. 221. Licensing. 

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

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

‘‘Sec. 224. Liability for payment. 

‘‘Sec. 225. Authorization of appropriations. 

‘‘TITLE III—FACILITIES 

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

‘‘Sec. 302. Sanitation facilities. 

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

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

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

‘‘Sec. 306. Indian health care delivery demonstration project. 

‘‘Sec. 307. Land transfer. 

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

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

‘‘Sec. 310. Tribal leasing. 

‘‘Sec. 311. Indian health service/tribal facilities joint venture program. 

‘‘Sec. 312. Location of facilities. 

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

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

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

‘‘Sec. 316. Other funding for facilities. 

‘‘Sec. 317. Authorization of appropriations. 

‘‘TITLE IV—ACCESS TO HEALTH SERVICES 

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

‘‘Sec. 402. Grants to and contracts with the service, Indian tribes, tribal organizations, and urban indian organizations to facilitate outreach, enrollment, and coverage of indians under social security act health 

benefit programs and other health benefits programs. 

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

‘‘Sec. 404. Crediting of reimbursements. 

‘‘Sec. 405. Purchasing health care coverage. 

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

‘‘Sec. 407. Payor of last resort. 

‘‘Sec. 408. Nondiscrimination under Federal health care programs in qualifications for reimbursement for services. 

‘‘Sec. 409. Consultation. 

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

‘‘Sec. 411. Exclusion waiver authority for affected Indian health programs and safe harbor transactions under 

the Social Security Act. 

‘‘Sec. 412. Premium and cost sharing protections and eligibility determinations under Medicaid and SCHIP and 

protection of certain Indian property from Medicaid estate recovery. 

‘‘Sec. 413. Treatment under Medicaid and SCHIP managed care. 

‘‘Sec. 414. Navajo nation Medicaid agency feasibility study. 

‘‘Sec. 415. Authorization of appropriations. 


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‘‘TITLE V—HEALTH SERVICES FOR URBAN INDIANS 

‘‘Sec. 501. Purpose. 

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

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

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

‘‘Sec. 505. Evaluations; renewals. 

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

‘‘Sec. 507. Reports and records. 

‘‘Sec. 508. Limitation on contract authority. 

‘‘Sec. 509. Facilities. 

‘‘Sec. 510. Division of urban Indian health. 

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

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

‘‘Sec. 513. Urban NIAAA transferred programs. 

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

‘‘Sec. 515. Urban youth treatment center demonstration. 

‘‘Sec. 516. Use of Federal Government facilities and sources of supply. 

‘‘Sec. 517. Grants for diabetes prevention, treatment, and control. 

‘‘Sec. 518. Community health representatives. 

‘‘Sec. 519. Effective date. 

‘‘Sec. 520. Eligibility for services. 

‘‘Sec. 521. Authorization of appropriations. 

‘‘TITLE VI—ORGANIZATIONAL IMPROVEMENTS 

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

‘‘Sec. 602. Automated management information system. 

‘‘Sec. 603. Authorization of appropriations. 

‘‘TITLE VII—BEHAVIORAL HEALTH PROGRAMS 

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

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

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

‘‘Sec. 704. Mental health technician program. 

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

‘‘Sec. 706. Indian women treatment programs. 

‘‘Sec. 707. Indian youth program. 

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

‘‘Sec. 709. Training and community education. 

‘‘Sec. 710. Behavioral health program. 

‘‘Sec. 711. Fetal alcohol disorder programs. 

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

‘‘Sec. 713. Behavioral health research. 

‘‘Sec. 714. Definitions. 

‘‘Sec. 715. Authorization of appropriations. 

‘‘TITLE VIII—MISCELLANEOUS 

‘‘Sec. 801. Reports. 

‘‘Sec. 802. Regulations. 

‘‘Sec. 803. Plan of implementation. 

‘‘Sec. 804. Availability of funds. 

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

‘‘Sec. 806. Eligibility of California Indians. 

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

‘‘Sec. 808. Reallocation of base resources. 

‘‘Sec. 809. Results of demonstration projects. 

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

‘‘Sec. 811. Moratorium. 

‘‘Sec. 812. Tribal employment. 

‘‘Sec. 813. Severability provisions. 

‘‘Sec. 814. Appropriations; availability. 

‘‘Sec. 815. Authorization of appropriations. 

‘‘SEC. 2. DECLARATION OF NATIONAL INDIAN HEALTH POLICY. 

‘‘Congress hereby declares that it is the policy of this Nation, in fulfillment of its 

special trust responsibilities and legal obligations to Indians—

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

all resources necessary to effect that policy; 

‘‘(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. 


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‘‘SEC. 3. DEFINITIONS. 

‘‘For purposes of this Act: ‘‘(1) The term ‘accredited and accessible’ means on or near a reservation and 

accredited by a national or regional organization with accrediting authority. ‘‘(2) The term ‘Area Office’ means an administrative entity including a program office, within the Service through which services and funds are provided 

to the Service Units within a defined geographic area. ‘‘(3) The term ‘Assistant Secretary’ means the Assistant Secretary of Indian 

Health. ‘‘(4) The term ‘behavioral health’ means the blending of substance (alcohol, 

drugs, inhalants, and tobacco) abuse and mental illness prevention and treatment, for the purpose of providing comprehensive services. This definition can 

include the joint development of substance abuse and mental illness treatment 

planning and coordinated case management using a multidisciplinary approach. ‘‘(5) The term ‘California Indians’ shall mean 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—

‘‘(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, advanced practice nursing, 

dentistry, psychiatry, osteopathy, optometry, pharmacy, psychology, public 

health, social work, marriage and family therapy, chiropractic medicine, environmental health and engineering, allied health professions, naturopathic medicine 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, but not 

limited to—

‘‘(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; 


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‘‘(vii) environmental health; 

‘‘(viii) exercise and physical fitness; 

‘‘(ix) avoidance of fetal alcohol disorders; 

‘‘(x) first aid and CPR education; 

‘‘(xi) human growth and development; 

‘‘(xii) injury prevention and personal safety; 

‘‘(xiii) behavioral health; 

‘‘(xiv) monitoring of disease indicators between health care provider 

visits, through appropriate means, including Internet-based health care 

management systems; ‘‘(xv) personal health and wellness practices; 

‘‘(xvi) personal capacity building; 

‘‘(xvii) prenatal, pregnancy, and infant care; 

‘‘(xviii) psychological well-being; 

‘‘(xix) reproductive health and family planning; 

‘‘(xx) safe and adequate water; 

‘‘(xxi) safe housing relative to eliminating, reducing, or preventing 

contaminants which 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 sections 102 and 103, 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, of 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 in 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 April 30, 1908 (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.). 

‘‘(17) The term ‘Secretary’, unless otherwise designated, means the Secretary 

of Health and Human Services. 

‘‘(18) The term ‘Service’ means the Indian Health Service. 

‘‘(19) The term ‘Service Area’ means the geographical area served by each 

Area Office. 

‘‘(20) The term ‘Service Unit’ means an administrative entity of the Service, 

or a Tribal Health Program through which services are provided, directly or by 

contract, to eligible Indians within a defined geographic area. 

‘‘(21) The term ‘telehealth’ has the meaning given the term in section 330K(a) 

of the Public Health Service Act (42 U.S.C. 254c–16(a)). 

‘‘(22) The term ‘telemedicine’ means a telecommunications link to an end user 

through the use of eligible equipment that electronically links health professionals or patients and health professionals at separate sites in order to exVerDate Aug 31 2005 06:24 Sep 16, 2006 Jkt 049006 PO 00000 Frm 00007 Fmt 6659 Sfmt 6621 E:\HR\OC\HR661P1.XXX HR661P1

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change health care information in audio, video, graphic, or other format for the 

purpose of providing improved health care services. 

‘‘(23) The term ‘tribal college or university’ has the meaning given the term 

in section 316(b)(3) of the Higher Education Act (20 U.S.C. 1059c(b)(3)). 

‘‘(24) The term ‘Tribal Health Program’ means an Indian Tribe or Tribal Organization that operates any health program, service, function, activity, or facility funded, in whole or part, by the Service through, or provided for in, a Funding Agreement with the Service under the Indian Self-Determination and Education Assistance Act (25 U.S.C. 450 et seq.). 

‘‘(25) The term ‘Tribal Organization’ has the meaning given the term in the 

Indian Self-Determination and Education Assistance Act (25 U.S.C. 450 et seq.). 

‘‘(26) 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. 

‘‘(27) The term ‘Urban Indian’ means any individual who resides in an Urban 

Center and who meets 1 or more of the following criteria: 

‘‘(A) Irrespective of whether the individual lives on or near a reservation, 

the individual is a member of a tribe, band, or other organized group of Indians, including those tribes, bands, or groups terminated since 1940 and 

those tribes, bands, or groups that are recognized by the States in which 

they reside, or who is a descendant in the first or second degree of any such 

member. 

‘‘(B) The individual is an Eskimo, Aleut, or other Alaskan 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. 

‘‘(28) The term ‘Urban Indian Organization’ means a nonprofit corporate body 

that (A) is situated in an Urban Center; (B) is governed by an Urban Indiancontrolled 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). 

‘‘TITLE I—INDIAN HEALTH, HUMAN 

RESOURCES, AND DEVELOPMENT 

‘‘SEC. 101. PURPOSE. 

‘‘The purpose of this 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 optimum supply of health professionals to the Indian Health Programs 

and Urban Indian Organizations involved in the provision of health services to Indians. 

‘‘SEC. 102. HEALTH PROFESSIONS RECRUITMENT PROGRAM FOR INDIANS. 

‘‘(a) IN GENERAL.—The Secretary, acting through the Service, shall make funds 

available to public or nonprofit private health or educational entities, Tribal Health 

Programs, or Urban Indian 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) 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). 

‘‘(b) FUNDING.—

‘‘(1) APPLICATION.—The Secretary shall not make a grant under this section 

unless an application 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 


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Act. The Secretary shall give a preference to applications submitted by Tribal 

Health Programs or Urban Indian Organizations. 

‘‘(2) AMOUNT OF GRANTS; PAYMENT.—The amount of a grant under this section 

shall be determined by the Secretary. Payments pursuant to this section may 

be made in advance or by way of reimbursement, and at such intervals and on 

such conditions as 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. 

‘‘SEC. 103. HEALTH PROFESSIONS PREPARATORY SCHOLARSHIP PROGRAM FOR INDIANS. 

‘‘(a) SCHOLARSHIPS AUTHORIZED.—The Secretary, acting through the Service, shall 

provide scholarships to Indians who—

‘‘(1) have successfully completed their high school education or high school 

equivalency; and 

‘‘(2) have demonstrated the potential to successfully complete courses of study 

in the health professions. 

‘‘(b) PURPOSES.—Scholarship grants provided pursuant to this section shall be for 

the following purposes: 

‘‘(1) Compensatory preprofessional education of any recipient, such scholarship not to exceed 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 leading to a baccalaureate degree 

in an approved course of study preparatory to a field of study in a health profession, such scholarship not to exceed 4 years. An extension of up to 2 years (or 

the part-time equivalent thereof, as determined by the Secretary pursuant to 

regulations issued pursuant to this Act) may be approved. 

‘‘(c) OTHER CONDITIONS.—Scholarships under this section—

‘‘(1) may cover costs of tuition, books, transportation, board, and other necessary related expenses of a recipient while attending school; 

‘‘(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. 

‘‘SEC. 104. INDIAN HEALTH PROFESSIONS SCHOLARSHIPS. 

‘‘(a) IN GENERAL.—

‘‘(1) AUTHORITY.—The Secretary, acting through the Service, shall make scholarship grants to Indians who are enrolled full or part time in accredited schools 

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. 254l), except as provided in subsection (b) of this section. 

‘‘(2) DETERMINATION 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 professions 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) ACTIVE DUTY SERVICE OBLIGATION.—

‘‘(1) OBLIGATION MET.—The active duty service obligation under a written contract with the Secretary under section 338A of the Public Health Service Act 

(42 U.S.C. 254l) that an Indian has entered into under 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 one or more of 

the following: 

‘‘(A) In an Indian Health Program. 

‘‘(B) In a program assisted under title V of this Act. 

‘‘(C) 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. 


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‘‘(D) In a teaching capacity in a tribal college or university program (or 

a related health profession program) if, as determined by the Secretary, the 

health service provided to Indians would not decrease. 

‘‘(2) OBLIGATION DEFERRED.—At the request of any individual who has entered into a contract referred to in paragraph (1) and who receives a degree in 

medicine (including osteopathic or allopathic medicine), dentistry, optometry, 

podiatry, or pharmacy, the Secretary shall defer the active duty service obligation of that individual under that contract, in order that such individual may 

complete any internship, residency, or other advanced clinical training that is 

required for the practice of that health profession, for an appropriate period (in 

years, as determined by the Secretary), subject to the following conditions: 

‘‘(A) No period of internship, residency, or other advanced clinical training 

shall be counted as satisfying any period of obligated service under this 

subsection. 

‘‘(B) 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) The active duty service obligation will be served in the health profession of that individual in a manner consistent with paragraph (1). 

‘‘(D) A recipient of a scholarship under this section may, at the election 

of the recipient, meet the active duty service obligation described in paragraph (1) by service in a program specified under that paragraph that—

‘‘(i) is located on the reservation of the Indian Tribe in which the recipient is enrolled; or 

‘‘(ii) serves the Indian Tribe in which the recipient is enrolled. 

‘‘(3) PRIORITY WHEN MAKING ASSIGNMENTS.—Subject to paragraph (2), the Secretary, in making assignments of Indian Health Scholarship recipients required 

to meet the active duty service obligation described in paragraph (1), shall give 

priority to assigning individuals to service in those programs specified in paragraph (1) that have a need for health professionals to provide health care services as a result of individuals having breached contracts entered into under this 

section. 

‘‘(c) PART-TIME STUDENTS.—In the case of an individual receiving a scholarship 

under this section who is enrolled part-time in an approved course of study parttime equivalent of 4 years, as determined by the Area Office—

‘‘(1) the period of obligated service described in subsection (b)(1) shall be equal 

to the greater of—

‘‘(A) the part-time equivalent of 1 year for each year for which the individual was provided a scholarship (as determined by the Area Office); or 

‘‘(B) 2 years; and 

‘‘(2) 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)) shall be reduced pro rata 

(as determined by the Secretary) based on the number of hours such student 

is enrolled. 

‘‘(d) BREACH OF CONTRACT.—

‘‘(1) SPECIFIED BREACHES.—An individual shall be liable to the United States 

for the amount which has been paid to the individual, or on behalf of the individual, under a contract entered into with the Secretary under this section on 

or after the date of the enactment of the Indian Health Care Improvement Act 

Amendments of 2006 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 determined 

by the educational institution under regulations of the Secretary); 

‘‘(B) is dismissed from such educational institution for disciplinary reasons; 

‘‘(C) voluntarily terminates the training in such an educational institution 

for which he or she is provided a 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 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 110 in the manner provided for in such subsection. 


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‘‘(3) CANCELLATION UPON DEATH OF RECIPIENT.—Upon the death of an individual who receives an Indian Health Scholarship, any outstanding obligation 

of that individual for service or payment that relates to that scholarship shall 

be canceled. 

‘‘(4) WAIVERS AND SUSPENSIONS.—

‘‘(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 would result in extreme hardship to the recipient; or 

‘‘(ii) requiring that recipient to meet that obligation or make that 

payment would result in extreme hardship to the recipient; or 

‘‘(iii) the enforcement of the requirement to meet the obligation or 

make the payment would be unconscionable. 

‘‘(B) FACTORS FOR CONSIDERATION.—Before waiving or suspending an obligation of service or payment under subparagraph (A), the Secretary 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) 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) 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 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. 

‘‘SEC. 105. AMERICAN INDIANS INTO PSYCHOLOGY PROGRAM. 

‘‘(a) GRANTS AUTHORIZED.—The Secretary, acting through the Service, shall make 

grants of not more than $300,000 to each of 9 colleges and universities for the purpose of developing and maintaining Indian psychology career recruitment programs 

as a means of encouraging Indians to enter the mental 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 funds provided under this section. 

‘‘(d) CONDITIONS OF GRANT.—Applicants under this section shall agree to provide 

a program which, at a minimum—

‘‘(1) provides outreach and recruitment for health professions to Indian communities including elementary, secondary, and accredited and accessible community colleges that will be served by the program; 

‘‘(2) incorporates a program advisory board comprised of representatives from 

the tribes and communities that will be served by the program; 

‘‘(3) provides summer enrichment programs to expose Indian students to the 

various fields of psychology through research, clinical, and experimental activities; 

‘‘(4) provides stipends to undergraduate and graduate students to pursue a career in psychology; 

‘‘(5) develops affiliation agreements with tribal colleges and universities, the 

Service, university affiliated programs, and other appropriate accredited and accessible entities to enhance the education of Indian students; 

‘‘(6) to the maximum extent feasible, uses existing university tutoring, counseling, and student support services; and 


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‘‘(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. 

‘‘SEC. 106. SCHOLARSHIP PROGRAMS FOR INDIAN TRIBES. 

‘‘(a) IN GENERAL.—

‘‘(1) GRANTS AUTHORIZED.—The Secretary, acting through the Service, shall 

make grants to Tribal Health Programs for the purpose of providing scholarships for Indians to serve as health professionals in Indian communities. 

‘‘(2) AMOUNT.—Amounts available under paragraph (1) for any fiscal year 

shall not exceed 5 percent of the amounts available for each fiscal year for Indian Health Scholarships under section 104. 

‘‘(3) APPLICATION.—An application for a grant under paragraph (1) shall be 

in such form and contain such agreements, assurances, and information as consistent with this section. 

‘‘(b) REQUIREMENTS.—

‘‘(1) IN GENERAL.—A Tribal Health Program receiving funds under subsection 

(a) shall provide scholarships to Indians in accordance with the requirements 

of this section. 

‘‘(2) COSTS.—With respect to costs of providing any scholarship pursuant to 

subsection (a)—

‘‘(A) 80 percent of the costs of the scholarship shall be paid from the 

funds made available pursuant to subsection (a)(1) provided to the Tribal 

Health Program; and 

‘‘(B) 20 percent of such costs may be paid from any other source of funds. 

‘‘(c) COURSE OF STUDY.—A Tribal Health Program shall provide scholarships 

under this section only to Indians enrolled or accepted for enrollment in a course 

of study (approved by the Secretary) in one 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 parttime 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)), such amount to be reduced pro 

rata (as determined by the Secretary) based on the number of hours 

such student is enrolled; and 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 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 licensing requirements appropriate to each health profession. 


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‘‘(e) BREACH OF CONTRACT.—

‘‘(1) SPECIFIC BREACHES.—An individual who has entered into a written contract with the Secretary and a Tribal Health Program under subsection (d) shall 

be liable to the United States for the Federal share of the amount which has 

been paid to him or her, or on his or her behalf, under the contract if that individual—

‘‘(A) fails to maintain an acceptable level of academic standing in the educational institution in which he or she is enrolled (such level as determined 

by the educational institution under regulations of the Secretary); 

‘‘(B) is dismissed from such educational institution for disciplinary reasons; 

‘‘(C) voluntarily terminates the training in such an educational institution 

for which he or she is provided a 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. 

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

‘‘(a) EMPLOYMENT PREFERENCE.—Any individual who receives a scholarship pursuant to section 104 or 106 shall be given preference 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.—Periods of employment pursuant to this subsection shall not be counted in determining fulfillment 

of the service obligation incurred as a condition of the scholarship. 

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

by the Service or by a Tribal Health Program or an Urban Indian Organization during any nonacademic period of the year. Any such employment shall not exceed 120 

days during any calendar year. 

‘‘(d) NONAPPLICABILITY OF COMPETITIVE PERSONNEL SYSTEM.—Any employment 

pursuant to this section shall be made without regard to any competitive personnel 

system or agency personnel limitation and to a position which will enable the indiVerDate Aug 31 2005 06:24 Sep 16, 2006 Jkt 049006 PO 00000 Frm 00013 Fmt 6659 Sfmt 6621 E:\HR\OC\HR661P1.XXX HR661P1

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vidual 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. 

‘‘SEC. 108. CONTINUING EDUCATION ALLOWANCES. 

‘‘In order to encourage health professionals, including community health representatives and emergency medical technicians, to join or continue in an Indian 

Health Program or an Urban Indian Organization and to provide their services in 

the rural and remote areas where a significant portion of Indians reside, the Secretary, acting through the Service, may provide allowances to health professionals 

employed in an Indian Health Program or an Urban Indian Organization 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. 

‘‘SEC. 109. COMMUNITY HEALTH REPRESENTATIVE 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, acting through the Service, shall maintain a Community Health Representative Program under which Indian Health Programs—

‘‘(1) provide for the training of Indians as community health representatives; 

and 

‘‘(2) use such community health representatives in the provision of health 

care, health promotion, and disease prevention services to Indian communities. 

‘‘(b) DUTIES.—The Community Health Representative Program of the Service, 

shall—

‘‘(1) provide a high standard of training for community health representatives 

to ensure that the community health representatives provide quality health 

care, health promotion, and disease prevention services to the Indian communities served by the Program; 

‘‘(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 care; 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 poverty; 

‘‘(3) maintain a system which identifies the needs of community health representatives for continuing education in health care, health promotion, and disease prevention, and develop programs that meet the needs for continuing education; 

‘‘(4) maintain a system that provides close supervision of Community Health 

Representatives; 

‘‘(5) maintain a system under which the work of Community Health Representatives is reviewed and evaluated; and 

‘‘(6) 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. 

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

‘‘(a) ESTABLISHMENT.—The Secretary, acting through the Service, shall establish 

and administer a program to be known as the Service Loan Repayment Program 

(hereinafter referred to as the ‘Loan Repayment Program’) in order to ensure an 

adequate supply of trained health professionals necessary to maintain accreditation 

of, and provide health care services to Indians through, Indian Health Programs 

and Urban Indian Organizations. 

‘‘(b) ELIGIBLE INDIVIDUALS.—To be eligible to participate in the Loan Repayment 

Program, an individual must—

‘‘(1)(A) be enrolled—

‘‘(i) in a course of study or program in an accredited educational institution (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))) 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 


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‘‘(ii) a license to practice a health profession; ‘‘(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 Service; or ‘‘(D) be employed in an Indian Health Program or Urban Indian Organization 

without a service obligation; and ‘‘(3) submit to the Secretary an application for a contract described in subsection (e). 

In the administration of this section, naturopathic medicine is included among the 

other health professions. ‘‘(c) APPLICATION.— ‘‘(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) in the case of the individual’s breach of contract. The Secretary shall 

provide such individuals with sufficient information regarding the advantages 

and disadvantages of service as a commissioned officer in the Regular or Reserve Corps of the Public Health Service or a civilian employee of the 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.—

‘‘(1) LIST.—Consistent with subsection (k), the Secretary shall annually—

‘‘(A) identify the positions in each Indian Health Program or Urban Indian Organization for which there is a need or a vacancy; and 

‘‘(B) rank those positions in order of priority. 

‘‘(2) APPROVALS.—Notwithstanding the priority determined under paragraph 

(1), the Secretary, in determining which applications under the Loan Repayment Program to approve (and which contracts to accept), shall—

‘‘(A) give first priority to applications made 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 

‘‘(ii) other individuals based on the priority rankings under paragraph (1). 

‘‘(e) RECIPIENT CONTRACTS.—

‘‘(1) CONTRACT REQUIRED.—An individual becomes a participant in the Loan 

Repayment Program only upon the Secretary and the individual entering into 

a written contract described in paragraph (2). 

‘‘(2) CONTENTS OF CONTRACT.—The written contract referred to in this section 

between the Secretary and an individual shall contain—

‘‘(A) an agreement under which—

‘‘(i) subject to subparagraph (C), the Secretary agrees—

‘‘(I) to pay loans on behalf of the individual in accordance with 

the provisions of this section; and 

‘‘(II) to accept (subject to the availability of appropriated funds 

for carrying out this section) the individual into the Service or 

place the individual with a Tribal Health Program or Urban Indian 

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

‘‘(ii) subject to subparagraph (C), the individual agrees—

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

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

‘‘(aa) to maintain enrollment in a course of study or training 

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

the course of study or training; and 


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‘‘(bb) while enrolled in such course of study or training, to 

maintain an acceptable level of academic standing (as determined under regulations of the Secretary by the educational 

institution offering such course of study or training); and ‘‘(III) to serve for a time period (hereinafter in this section referred to as the ‘period of obligated service’) equal to 2 years or 

such longer period as the individual may agree to serve in the fulltime clinical practice of such individual’s profession in an Indian 

Health Program or Urban Indian Organization to which the individual may be assigned by the Secretary; ‘‘(B) a provision permitting the Secretary to extend for such longer additional periods, as the individual may agree to, the period of obligated service agreed to by the individual under subparagraph (A)(ii)(III); ‘‘(C) a provision that any financial obligation of the United States arising 

out of a contract entered into under this section and any obligation of the 

individual which is conditioned thereon is contingent upon funds being appropriated for loan repayments under this section; ‘‘(D) a statement of the damages to which the United States is entitled 

under subsection (l) for the individual’s breach of the contract; and ‘‘(E) 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 approval, 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 disapproval of an individual’s participation in such Program. 

‘‘(g) 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) AMOUNT.—For each year of obligated service that an individual contracts 

to serve under subsection (e), the Secretary may pay up to $35,000 or an 

amount equal to the amount specified in section 338B(g)(2)(A) of the Public 

Health Service Act, whichever is more, on behalf of the individual for loans described in paragraph (1). In making a determination of the amount to pay for 

a year of such service by an individual, the Secretary shall consider the extent 

to which each such determination—

‘‘(A) affects the ability of the Secretary to maximize the number of contracts that can be provided under the Loan Repayment Program from the 

amounts appropriated for such contracts; 

‘‘(B) provides an incentive to serve in Indian Health Programs and Urban 

Indian Organizations with the greatest shortages of health professionals; 

and 

‘‘(C) provides an incentive with respect to the health professional involved 

remaining in an Indian Health Program or Urban Indian Organization with 

such a health professional shortage, and continuing to provide primary 

health services, after the completion of the period of obligated service under 

the Loan Repayment Program. 

‘‘(3) TIMING.—Any arrangement made by the Secretary for the making of loan 

repayments in accordance with this subsection shall provide that any repayments for a year of obligated service shall be made no later than the end of the 

fiscal year in which the individual completes such year of service. 

‘‘(4) REIMBURSEMENTS FOR TAX LIABILITY.—For the purpose of providing reimbursements for tax liability resulting from payments under paragraph (2) on behalf of an individual, the Secretary—

‘‘(A) in addition to such payments, may make payments to the individual 

in an amount not less than 20 percent and not more than 39 percent of the 

total amount of loan repayments made for the taxable year involved; and 

‘‘(B) may make such additional payments as the Secretary determines to 

be appropriate with respect to such purpose. 


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‘‘(5) PAYMENT SCHEDULE.—The Secretary may enter into an agreement with 

the holder of any loan for which payments are made under the Loan Repayment 

Program to establish a schedule for the making of such payments. 

‘‘(h) EMPLOYMENT CEILING.—Notwithstanding any other provision of law, individuals who have entered into written contracts with the Secretary under this section 

shall not be counted against any employment ceiling affecting the Department while 

those individuals are undergoing academic training. 

‘‘(i) RECRUITMENT.—The Secretary shall conduct recruiting programs for the Loan 

Repayment Program and other Service manpower programs at educational institutions training health professionals or specialists identified in subsection (a). 

‘‘(j) APPLICABILITY OF LAW.—Section 214 of the Public Health Service Act (42 

U.S.C. 215) shall not apply to individuals during their period of obligated service 

under the Loan Repayment Program. 

‘‘(k) ASSIGNMENT OF INDIVIDUALS.—The Secretary, in assigning individuals to 

serve in Indian Health Programs or Urban Indian Organizations pursuant to contracts entered into under this section, shall—

‘‘(1) ensure that the staffing needs of Tribal Health Programs and Urban Indian Organizations receive consideration on an equal basis with programs that 

are administered directly by the Service; and 

‘‘(2) give priority to assigning individuals to Indian Health Programs and 

Urban Indian Organizations that have a need for health professionals to provide 

health care services as a result of individuals having breached contracts entered 

into under this section. 

‘‘(l) BREACH OF CONTRACT.—

‘‘(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—

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

‘‘(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 program and fails to complete such 

training program. 

‘‘(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), the United States 

shall be entitled to recover from such individual an amount to be determined 

in accordance with the following formula: A=3Z(t¥s/t) in which—

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

‘‘(B) ‘Z’ is the sum of the amounts paid under this section to, or on behalf 

of, the individual and the interest on such amounts which would be payable 

if, at the time the amounts were paid, they were loans bearing interest at 

the maximum legal prevailing rate, as determined by the Secretary of the 

Treasury; 

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

‘‘(D) ‘s’ is the number of months of such period served by such individual 

in accordance with this section. 

‘‘(3) DEDUCTIONS IN MEDICARE PAYMENTS.—Amounts not paid within such period shall be subject to collection through deductions in Medicare payments pursuant to section 1892 of the Social Security Act. 

‘‘(4) TIME PERIOD FOR REPAYMENT.—Any amount of damages which the United 

States is entitled to recover under this subsection shall be paid to the United 

States within the 1-year period beginning on the date of the breach or such 

longer period beginning on such date as shall be specified by the Secretary. 

‘‘(5) RECOVERY OF DELINQUENCY.—

‘‘(A) IN GENERAL.—If damages described in paragraph (4) are delinquent 

for 3 months, the Secretary shall, for the purpose of recovering such damages—

‘‘(i) use collection agencies contracted with by the Administrator of 

General Services; or 


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

‘‘(B) REPORT.—Each contract for recovering damages pursuant to this 

subsection shall provide that the contractor will, not less than once each 6 

months, submit to the Secretary a status report on the success of the contractor in collecting such damages. Section 3718 of 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.—

‘‘(1) IN GENERAL.—The Secretary shall by regulation provide for the partial 

or total waiver or suspension of any obligation of service or payment by an individual under the Loan Repayment Program whenever compliance by the individual is impossible or would involve extreme hardship to the individual and 

if enforcement of such obligation with respect to any individual would be unconscionable. 

‘‘(2) CANCELED UPON DEATH.—Any obligation of an individual under the Loan 

Repayment Program for service or payment of damages shall be canceled upon 

the death of the individual. 

‘‘(3) HARDSHIP WAIVER.—The Secretary may waive, in whole or in part, the 

rights of the United States to recover amounts under this section in any case 

of extreme hardship or other good cause shown, as determined by the Secretary. 

‘‘(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 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) REPORT.—The Secretary shall submit to the President, for inclusion in each 

report required to be submitted to Congress under section 801, a report concerning 

the previous fiscal year which sets forth by Service Area the following: 

‘‘(1) A list of the health professional positions maintained by Indian Health 

Programs and Urban Indian Organizations for which recruitment or retention 

is difficult. 

‘‘(2) The number of Loan Repayment Program applications filed with respect 

to each type of health profession. 

‘‘(3) The number of contracts described in subsection (e) that are entered into 

with respect to each health profession. 

‘‘(4) The amount of loan payments made under this section, in total and by 

health profession. 

‘‘(5) The number of scholarships that are provided under sections 104 and 106 

with respect to each health profession. 

‘‘(6) The amount of scholarship grants provided under section 104 and 106, 

in total and by health profession. 

‘‘(7) The number of providers of health care that will be needed by Indian 

Health Programs and Urban Indian Organizations, by location and profession, 

during the 3 fiscal years beginning after the date the report is filed. 

‘‘(8) The measures the Secretary plans to take to fill the health professional 

positions maintained by Indian Health Programs or Urban Indian Organizations for which recruitment or retention is difficult. 

‘‘SEC. 111. SCHOLARSHIP AND LOAN REPAYMENT RECOVERY FUND. 

‘‘(a) ESTABLISHMENT.—There is established in the Treasury of the United States 

a fund to be known as the Indian Health Scholarship and Loan Repayment Recovery Fund (hereafter in this section referred to as the ‘LRRF’). The LRRF shall consist of such amounts as may be collected from individuals under section 104(d), section 106(e), and section 110(l) for breach of contract, such funds as may be appropriated to the LRRF, and interest earned on amounts in the LRRF. All amounts collected, appropriated, or earned relative to the LRRF shall remain available until expended. 

‘‘(b) USE OF FUNDS.—

‘‘(1) BY SECRETARY.—Amounts in the LRRF may be expended by the Secretary, acting through the Service, to make payments to an Indian Health Program—

‘‘(A) to which a scholarship recipient under section 104 and 106 or a loan 

repayment program participant under section 110 has been assigned to 

meet the obligated service requirements pursuant to such sections; and 

‘‘(B) that has a need for a health professional to provide health care services as a result of such recipient or participant having breached the contract entered into under section 104, 106, or section 110. 


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‘‘(2) BY TRIBAL HEALTH PROGRAMS.—A Tribal Health Program receiving payments pursuant to paragraph (1) may expend the payments to provide scholarships or recruit and employ, directly or by contract, health professionals to provide health care services. 

‘‘(c) INVESTMENT OF FUNDS.—The Secretary of the Treasury shall invest such 

amounts of the LRRF, except for the appropriated funds, as the Secretary determines are not required to meet current withdrawals from the LRRF. Such investments may be made only in interest 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.—Any obligation acquired by the LRRF may be sold by 

the Secretary of the Treasury at the market price. 

‘‘SEC. 112. RECRUITMENT ACTIVITIES. 

‘‘(a) REIMBURSEMENT FOR TRAVEL.—The Secretary, acting through the Service, 

may reimburse health professionals seeking positions with Indian Health Programs 

or Urban Indian Organizations, including unpaid student volunteers and individuals 

considering entering into a contract under section 110, and their spouses, for actual 

and reasonable expenses incurred in traveling to and from their places of residence 

to an area in which they may be assigned for the purpose of evaluating such area 

with respect to such assignment. 

‘‘(b) RECRUITMENT PERSONNEL.—The Secretary, acting through the Service, shall 

assign one individual in each Area Office to be responsible on a full-time basis for 

recruitment activities. 

‘‘SEC. 113. INDIAN RECRUITMENT AND RETENTION PROGRAM. 

‘‘(a) IN GENERAL.—The Secretary, acting through the Service, shall fund 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. 

‘‘(b) ELIGIBLE ENTITIES; APPLICATION.—Any Tribal Health Program or Urban Indian Organization may submit an application for funding of a project pursuant to 

this section. 

‘‘SEC. 114. ADVANCED TRAINING AND RESEARCH. 

‘‘(a) DEMONSTRATION PROGRAM.—The Secretary, acting through the Service, shall 

establish a demonstration project to enable health professionals who have worked 

in an Indian Health Program or Urban Indian Organization for a substantial period 

of time to pursue advanced training or research areas of study for which the Secretary determines a need exists. 

‘‘(b) SERVICE OBLIGATION.—An individual who participates in a program under 

subsection (a), where the educational costs are borne by the Service, shall incur an 

obligation to serve in an Indian Health Program or Urban Indian Organization for 

a period of obligated service equal to at least the period of time during which the 

individual participates in such program. 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 2006, 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 in the manner provided for in such subsection. 

‘‘(c) EQUAL OPPORTUNITY FOR PARTICIPATION.—Health professionals from Tribal 

Health Programs and Urban Indian Organizations shall be given an equal opportunity to participate in the program under subsection (a). 

‘‘SEC. 115. 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 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 

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nection 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. ‘‘(5) Programs conducted by tribal colleges and universities. ‘‘(e) QUENTIN N. BURDICK PROGRAM GRANT.—The Secretary shall provide one of 

the grants authorized under subsection (a) to establish and maintain a program at 

the University of North Dakota to be known as the ‘Quentin N. Burdick American 

Indians Into Nursing Program’. Such program shall, to the maximum extent feasible, coordinate with the Quentin N. Burdick Indian Health Programs established 

under section 117(b) and the Quentin N. Burdick American Indians Into Psychology 

Program established under section 105(b). ‘‘(f) ACTIVE DUTY SERVICE OBLIGATION.—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 individual who receives training or assistance described in paragraph (1) or (2) of subsection (b) that is funded by a grant provided under subsection 

(a). Such obligation shall be met by service— ‘‘(1) in the Service; 

‘‘(2) 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); ‘‘(3) in a program assisted under title V of this Act; 

‘‘(4) in the private practice of nursing if, as determined by the Secretary, in 

accordance with guidelines promulgated by the Secretary, such practice is situated in a physician or other health shortage area and addresses the health care 

needs of a substantial number of Indians; or 

‘‘(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. 

‘‘SEC. 116. TRIBAL CULTURAL ORIENTATION. 

‘‘(a) CULTURAL EDUCATION OF EMPLOYEES.—The Secretary, acting through the 

Service, shall require that appropriate employees of the Service who serve Indian 

Tribes in each Service Area receive educational instruction in the history and culture of such Indian Tribes and their relationship to the Service. 

‘‘(b) PROGRAM.—In carrying out subsection (a), the Secretary shall establish a program which shall, to the extent feasible—

‘‘(1) be developed in consultation with the affected Indian Tribes, Tribal Organizations, and Urban Indian Organizations; 

‘‘(2) be carried out through tribal colleges or universities; and 

‘‘(3) include instruction in American Indian studies. 

‘‘SEC. 117. INMED PROGRAM. 

‘‘(a) GRANTS AUTHORIZED.—The Secretary, acting through the Service, is authorized to provide grants to colleges and universities for the purpose of maintaining 

and expanding the Indian health careers recruitment program known as the ‘Indians Into Medicine Program’ (hereinafter in this section referred to as ‘INMED’) as 

a means of encouraging Indians to enter the health professions. 

‘‘(b) QUENTIN N. BURDICK GRANT.—The Secretary shall provide one of the grants 

authorized under subsection (a) 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 

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ans Into Psychology Program established under section 105(b) and the Quentin N. 

Burdick American Indians Into Nursing Program established under section 115. 

‘‘(c) REGULATIONS.—The Secretary, pursuant to this Act, shall develop regulations 

to govern grants pursuant to this section. 

‘‘(d) REQUIREMENTS.—Applicants for grants provided under this section shall 

agree to provide a program which—

‘‘(1) provides outreach and recruitment for health professions to Indian communities, including elementary and secondary schools and community colleges 

located on reservations, which will be served by the program; 

‘‘(2) incorporates a program advisory board comprised of representatives from 

the Indian Tribes and Indian communities which will be served by the program; 

‘‘(3) provides summer preparatory programs for Indian students who need enrichment in the subjects of math and science in order to pursue training in the 

health professions; 

‘‘(4) provides tutoring, counseling, and support to students who are enrolled 

in a health career program of study at the respective college or university; and 

‘‘(5) to the maximum extent feasible, employs qualified Indians in the program. 

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

‘‘(a) GRANTS TO ESTABLISH PROGRAMS.—

‘‘(1) IN GENERAL.—The Secretary, acting through the Service, shall award 

grants to accredited and accessible community colleges for the purpose of assisting such community colleges in the establishment of programs which provide 

education in a health profession leading to a degree or diploma in a health profession for individuals who desire to practice such profession on or near a reservation or in an Indian Health Program. 

‘‘(2) AMOUNT OF GRANTS.—The amount of any grant awarded to a community 

college under paragraph (1) for the first year in which such a grant is provided 

to the community college shall not exceed $100,000. 

‘‘(b) GRANTS FOR MAINTENANCE AND RECRUITING.—

‘‘(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) 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 accredited; 

‘‘(B) has a relationship with a hospital facility, Service facility, or hospital 

that could provide training of nurses or health professionals; 

‘‘(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 which 

train health professionals; and 

‘‘(ii) stipulate certifications necessary to approve internship and field 

placement opportunities at Indian Health Programs; 

‘‘(D) has a qualified staff which has the appropriate certifications; 

‘‘(E) is capable of obtaining State or regional accreditation of the program 

described in subsection (a)(1); and 

‘‘(F) agrees to provide for Indian preference for applicants for programs 

under this section. 

‘‘(c) TECHNICAL ASSISTANCE.—The Secretary shall encourage community colleges 

described in subsection (b)(2) to establish and maintain programs described in subsection (a)(1) by—

‘‘(1) entering into agreements with such colleges for the provision of qualified 

personnel of the Service to teach courses of study in such programs; and 

‘‘(2) providing technical assistance and support to such colleges. 

‘‘(d) ADVANCED 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) has already received a degree or diploma in such health profession; 

and 

‘‘(B) provides clinical services on or near a reservation or for an Indian 

Health Program. 

‘‘(2) MAY BE OFFERED AT ALTERNATE SITE.—Such courses of study may be offered in conjunction with the college or university with which the community 

college has entered into the agreement required under subsection (b)(2)(C). 


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‘‘(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. 

‘‘SEC. 119. RETENTION BONUS. 

‘‘(a) BONUS AUTHORIZED.—The Secretary may pay a retention bonus to any health 

professional employed by, or assigned to, and serving in, an Indian Health Program 

or Urban Indian Organization either as a civilian employee or as a commissioned 

officer in the Regular or Reserve Corps of the Public Health Service who—

‘‘(1) is assigned to, and serving in, a position for which recruitment or retention of personnel is difficult; 

‘‘(2) the Secretary determines is needed by Indian Health Programs and 

Urban Indian Organizations; 

‘‘(3) has—

‘‘(A) completed 3 years of employment with an Indian Health Program or 

Urban Indian Organization; or 

‘‘(B) completed any service obligations incurred as a requirement of—

‘‘(i) any Federal scholarship program; or 

‘‘(ii) any Federal education loan repayment program; and 

‘‘(4) enters into an agreement with an Indian Health Program or Urban Indian Organization for continued employment for a period of not less than 1 

year. 

‘‘(b) RATES.—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), but in no event shall the annual rate 

be more than $25,000 per annum. 

‘‘(c) DEFAULT OF RETENTION AGREEMENT.—Any health professional failing to complete the agreed upon term of service, except where such failure is through no fault 

of the individual, shall be obligated to refund to the Government the full amount 

of the retention bonus for the period covered by the agreement, plus interest as determined by the Secretary in accordance with section 110(l)(2)(B). 

‘‘(d) OTHER RETENTION BONUS.—The Secretary may pay a retention bonus to any 

health professional employed by a Tribal Health Program if such health professional 

is serving in a position which the Secretary determines is—

‘‘(1) a position for which recruitment or retention is difficult; and 

‘‘(2) necessary for providing health care services to Indians. 

‘‘SEC. 120. NURSING RESIDENCY PROGRAM. 

‘‘(a) ESTABLISHMENT OF PROGRAM.—The Secretary, acting through the Service, 

shall establish a program to enable Indians who are licensed practical nurses, licensed vocational nurses, and registered nurses who are working in an Indian 

Health Program or Urban Indian Organization, and have done so for a period of not 

less than 1 year, to pursue advanced training. Such program shall include a combination of education and work study in an Indian Health Program or Urban Indian 

Organization leading to an associate or bachelor’s degree (in the case of a licensed 

practical nurse or licensed vocational nurse), a bachelor’s degree (in the case of a 

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

‘‘(b) SERVICE OBLIGATION.—An individual who participates in a program under 

subsection (a), where the educational costs are paid by the Service, shall incur an 

obligation to serve in an Indian Health Program or Urban Indian Organization for 

a period of obligated service equal to the amount of 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 in the manner provided for in such subsection. 

‘‘SEC. 121. COMMUNITY HEALTH AIDE PROGRAM FOR ALASKA. 

‘‘(a) GENERAL PURPOSES OF PROGRAM.—Under the authority of the Act of November 2, 1921 (25 U.S.C. 13) (commonly known as the ‘Snyder Act’), the Secretary, acting through the Service, shall develop and operate a Community Health Aide Program in Alaska under which the Service—

‘‘(1) provides for the training of Alaska Natives as health aides or community 

health practitioners; 

‘‘(2) uses such aides or practitioners in the provision of health care, health 

promotion, and disease prevention services to Alaska Natives living in villages 

in rural Alaska; and 

‘‘(3) provides for the establishment of teleconferencing capacity in health clinics located in or near such villages for use by community health aides or community health practitioners. 


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‘‘(b) SPECIFIC PROGRAM REQUIREMENTS.—The Secretary, acting through the Community Health Aide Program of the Service, shall— ‘‘(1) using trainers accredited by the Program, provide a high standard of 

training to community health aides and community health practitioners to ensure that such aides and practitioners provide quality health care, health promotion, and disease prevention services to the villages served by the Program; ‘‘(2) in order to provide such training, develop a curriculum that— ‘‘(A) combines education in the theory of health care with supervised 

practical experience in the provision of health care; ‘‘(B) provides instruction and practical experience in the provision of 

acute care, emergency care, health promotion, disease prevention, and the 

efficient and effective management of clinic pharmacies, supplies, equipment, and facilities; and ‘‘(C) promotes the achievement of the health status objectives specified in 

section 3(2); ‘‘(3) establish and maintain a Community Health Aide Certification Board to 

certify as community health aides or community health practitioners individuals who have successfully completed the training described in paragraph (1) 

or can demonstrate equivalent experience; ‘‘(4) develop and maintain a system which identifies the needs of community 

health aides and community health practitioners for continuing education in the 

provision of health care, including the areas described in paragraph (2)(B), and 

develop programs that meet the needs for such continuing education; 

‘‘(5) develop and maintain a system that provides close supervision of community health aides and community health practitioners; 

‘‘(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; 

and 

‘‘(7) ensure that pupal therapy (not including pulpotomies of deciduary teeth) 

or extraction of adult teeth can be performed by a dental health aide therapist 

only after consultation with a licensed dentist who determines that the procedure is a medical emergency that cannot be resolved with palliative treatment, 

and further that dental health aide therapists are strictly prohibited from performing all other oral or jaw surgeries, provided that uncomplicated extractions 

shall not be considered oral surgery under this section. 

‘‘(c) PROGRAM REVIEW.—

‘‘(1) NEUTRAL PANEL.—

‘‘(A) ESTABLISHMENT.—The Secretary, acting through the Service, shall 

establish a neutral panel to carry out the study under paragraph (2). 

‘‘(B) MEMBERSHIP.—Members of the neutral panel shall be appointed by 

the Secretary from among clinicians, economists, community practitioners, 

oral epidemiologists, and Alaska Natives. 

‘‘(2) STUDY.—

‘‘(A) IN GENERAL.—The neutral panel established under paragraph (1) 

shall conduct a study of the dental health aide therapist services provided 

by the Community Health Aide Program under this section to ensure that 

the quality of care provided through those services is adequate and appropriate. 

‘‘(B) PARAMETERS OF STUDY.—The Secretary, in consultation with interested parties, including professional dental organizations, shall develop the 

parameters of the study. 

‘‘(C) INCLUSIONS.—The study shall include a determination by the neutral 

panel with respect to—

‘‘(i) the ability of the dental health aide therapist services under this 

section to address the dental care needs of Alaska Natives; 

‘‘(ii) the quality of care provided through those services, including any 

training, improvement, or additional oversight required to improve the 

quality of care; and 

‘‘(iii) whether safer and less costly alternatives to the dental health 

aide therapist services exist. 

‘‘(D) CONSULTATION.—In carrying out the study under this paragraph, the 

neutral panel shall consult with Alaska Tribal Organizations with respect 

to the adequacy and accuracy of the study. 

‘‘(3) REPORT.—The neutral panel shall submit to the Secretary, the Committee 

on Indian Affairs of the Senate, and the Committee on 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 


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‘‘(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. ‘‘(2) EXCEPTION.—The national Community Health Aide Program under paragraph (1) 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). 

‘‘SEC. 122. TRIBAL HEALTH PROGRAM ADMINISTRATION. 

‘‘The Secretary, acting through the Service, shall, by contract or otherwise, provide training for Indians in the administration and planning of Tribal Health Programs. 

‘‘SEC. 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; ‘‘(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. 

‘‘SEC. 124. NATIONAL HEALTH SERVICE CORPS. 

‘‘(a) NO REDUCTION IN SERVICES.—The Secretary shall not— ‘‘(1) remove a member of the National Health Service Corps from an Indian 

Health Program or Urban Indian Organization; or ‘‘(2) withdraw funding used to support such member; 

unless the Secretary, acting through the Service, 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. 

‘‘SEC. 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 1 year. Such contract or grant 

may be renewed for an additional 1-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 2006, 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 


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this section promote the development of the capacity of such entities to educate substance abuse counselors. 

‘‘(e) ASSISTANCE.—The Secretary shall provide such technical and other assistance 

as may be necessary to enable grant recipients to comply with the provisions of this 

section. 

‘‘(f) REPORT.—Each fiscal year, the Secretary shall submit to the President, for inclusion in the report which is required to be submitted under section 801 for that 

fiscal year, a report on the findings and conclusions derived from the demonstration 

programs conducted under this section during that fiscal year. 

‘‘(g) DEFINITION.—For the purposes of this section, the term ‘educational curriculum’ means 1 or more of the following: 

‘‘(1) Classroom education. 

‘‘(2) Clinical work experience. 

‘‘(3) Continuing education workshops. 

‘‘SEC. 126. BEHAVIORAL HEALTH TRAINING AND COMMUNITY EDUCATION PROGRAMS. 

‘‘(a) STUDY; LIST.—The Secretary, acting through the Service, and the Secretary 

of the Interior, in consultation with Indian Tribes and Tribal Organizations, shall 

conduct a study and compile a list of the types of staff positions specified in subsection (b) whose qualifications include, or should include, training in the identification, prevention, education, referral, or treatment of mental illness, or dysfunctional 

and self destructive behavior. 

‘‘(b) POSITIONS.—The positions referred to in subsection (a) are—

‘‘(1) staff positions within the Bureau of Indian Affairs, including existing positions, in the fields of—

‘‘(A) elementary and secondary education; 

‘‘(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 SelfDetermination 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 Indian health care and treatment 

practices is provided. 

‘‘(d) COMMUNITY EDUCATION ON MENTAL ILLNESS.—The Service shall develop and 

implement, on request of an Indian Tribe, Tribal Organization, or Urban Indian Organization, or assist the Indian Tribe, Tribal Organization, or Urban Indian Organization to develop and implement, a program of community education on mental illness. In carrying out this subsection, the Service shall, upon request of an Indian 

Tribe, Tribal Organization, or Urban Indian Organization, provide technical assistance to the Indian Tribe, Tribal Organization, or Urban Indian Organization to obtain and develop community educational materials on the identification, prevention, 

referral, and treatment of mental illness and dysfunctional and self-destructive behavior. 

‘‘(e) PLAN.—Not later than 90 days after the date of the enactment of the Indian 

Health Care Improvement Act Amendments of 2006, 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’). 


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‘‘TITLE II—HEALTH SERVICES 

‘‘SEC. 201. INDIAN HEALTH CARE IMPROVEMENT FUND. 

‘‘(a) USE OF FUNDS.—The Secretary, acting through the Service, is authorized to 

expend funds, directly or under the authority of the Indian Self-Determination and 

Education Assistance Act, (25 U.S.C. 450 et seq.), which are appropriated under the 

authority of this section, for the purposes of— ‘‘(1) eliminating the deficiencies in health status and health resources of all 

Indian Tribes; ‘‘(2) eliminating backlogs in the provision of health care services to Indians; 

‘‘(3) meeting the health needs of Indians in an efficient and equitable manner, 

including the use of telehealth and telemedicine when appropriate; ‘‘(4) eliminating inequities in funding for both direct care and contract health 

service programs; and ‘‘(5) augmenting the ability of the Service to meet the following health service 

responsibilities with respect to those Indian Tribes with the highest levels of 

health status deficiencies and resource deficiencies: ‘‘(A) Clinical care, including, inpatient care, outpatient care (including 

audiology, clinical eye, and vision care), primary care, secondary and tertiary care, and long-term care. ‘‘(B) Preventive health, including mammography and other cancer screening in accordance with section 207. ‘‘(C) Dental care. 

‘‘(D) Mental health, including community mental health services, inpatient mental health services, dormitory mental health services, therapeutic 

and residential treatment centers, and training of traditional Indian practitioners. ‘‘(E) Emergency medical services. 

‘‘(F) Treatment and control of, and rehabilitative care related to, alcoholism and drug abuse (including fetal alcohol syndrome) among Indians. ‘‘(G) Injury prevention programs. 

‘‘(H) Home health care. 

‘‘(I) Community health representatives. 

‘‘(J) Maintenance and repair. ‘‘(b) NO OFFSET OR LIMITATION.—Any funds appropriated under the authority of 

this section shall not be used to offset or limit any other appropriations made to 

the Service under this Act or the Act of November 2, 1921 (25 U.S.C. 13) (commonly 

known as the ‘Snyder Act’), or any other provision of law. ‘‘(c) ALLOCATION; USE.— ‘‘(1) IN GENERAL.—Funds appropriated under the authority of this section 

shall be allocated to Service Units, Indian Tribes, or Tribal Organizations. The 

funds allocated to each Indian Tribe, Tribal Organization, or Service Unit under 

this paragraph shall be used by the Indian Tribe, Tribal Organization, or Service Unit under this paragraph to improve the health status and reduce the resource deficiency of each Indian Tribe served by such Service Unit, Indian 

Tribe, or Tribal Organization. 

‘‘(2) APPORTIONMENT OF ALLOCATED FUNDS.—The apportionment of funds allocated to a Service Unit, Indian Tribe, or Tribal Organization under paragraph 

(1) among the health service responsibilities described in subsection (a)(5) shall 

be determined by the Service in consultation with, and with the active participation of, the affected Indian Tribes and Tribal Organizations. 

‘‘(d) PROVISIONS RELATING TO HEALTH STATUS AND RESOURCE DEFICIENCIES.—For 

the purposes of this section, the following definitions apply: 

‘‘(1) DEFINITION.—The term ‘health status and resource deficiency’ means the 

extent to which—

‘‘(A) the health status objectives set forth in section 3(2) are not being 

achieved; and 

‘‘(B) the Indian 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 

Tribe or Tribal Organization include health resources provided by the Service 

as well as health resources used by the Indian 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 Tribe or Tribal Organization to petition the 


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Secretary for a review of any determination of the extent of the health status 

and resource deficiency of such Indian Tribe or Tribal Organization. 

‘‘(e) ELIGIBILITY FOR FUNDS.—Tribal Health Programs shall be eligible for funds 

appropriated under the authority of this section on an equal basis with programs 

that are administered directly by the Service. 

‘‘(f) REPORT.—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 2006, the Secretary shall submit to Congress the current health status and resource deficiency 

report of the Service for each Service Unit, including newly recognized or acknowledged Indian Tribes. Such report shall set out—

‘‘(1) the methodology then in use by the Service for determining 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, or any other Act, including the amount of any funds transferred 

to the Service for the preceding fiscal year which is allocated to each Service Unit, Indian Tribe, or Tribal Organization; 

‘‘(B) the number of Indians eligible for health services in each Service 

Unit or Indian Tribe or Tribal Organization; and 

‘‘(C) the number of Indians using the Service resources made available to 

each Service Unit, Indian Tribe or Tribal Organization, and, to the extent 

available, information on the waiting lists and number of Indians turned 

away for services due to lack of resources. 

‘‘(g) INCLUSION IN BASE BUDGET.—Funds appropriated under 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. 

‘‘(h) CLARIFICATION.—Nothing in this section is intended to diminish the primary 

responsibility of the Service to eliminate existing backlogs in unmet health care 

needs, nor are the provisions of this section intended to discourage the Service from 

undertaking additional efforts to achieve equity among Indian Tribes and Tribal Organizations. 

‘‘(i) FUNDING DESIGNATION.—Any funds appropriated under the authority of this 

section shall be designated as the ‘Indian Health Care Improvement Fund’. 

‘‘SEC. 202. CATASTROPHIC HEALTH EMERGENCY FUND. 

‘‘(a) ESTABLISHMENT.—There is hereby established an Indian Catastrophic Health 

Emergency Fund (hereafter in this section referred to as the ‘CHEF’) consisting of—

‘‘(1) the amounts deposited under subsection (f); and 

‘‘(2) the amounts appropriated to CHEF under this section. 

‘‘(b) ADMINISTRATION.—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. 

‘‘(c) CONDITIONS ON USE OF FUND.—No part of CHEF or its administration shall 

be subject to contract or grant under any law, including the Indian Self-Determination and Education Assistance Act, (25 U.S.C. 450 et seq.), nor shall CHEF funds 

be allocated, apportioned, or delegated on an Area Office, Service Unit, or other 

similar basis. 

‘‘(d) REGULATIONS.—The Secretary shall, through the negotiated rulemaking process under title VIII, promulgate regulations consistent with the provisions of this 

section to—

‘‘(1) establish a definition of disasters and catastrophic illnesses for which the 

cost of the treatment provided under contract would qualify for payment from 

CHEF; 

‘‘(2) provide that a Service Unit shall not be eligible for reimbursement for 

the cost of treatment from CHEF until its cost of treating any victim of such 

catastrophic illness or disaster has reached a certain threshold cost which the 

Secretary shall establish at—

‘‘(A) the 2000 level of $19,000; and 

‘‘(B) for any subsequent year, not less than the threshold cost of the previous year increased by the percentage increase in the medical care expenditure category of the consumer price index for all urban consumers (United 


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States city average) for the 12-month period ending with December of the 

previous year; ‘‘(3) establish a procedure for the reimbursement of the portion of the costs 

that exceeds such threshold cost incurred by— ‘‘(A) Service Units; or 

‘‘(B) whenever otherwise authorized by the Service, non-Service facilities 

or providers; ‘‘(4) establish a procedure for payment from CHEF in cases in which the exigencies of the medical circumstances warrant treatment prior to the authorization of such treatment by the Service; and ‘‘(5) establish a procedure that will ensure that no payment shall be made 

from CHEF to any provider of treatment to the extent that such provider is eligible to receive payment for the treatment from any other Federal, State, local, 

or private source of reimbursement for which the patient is eligible. ‘‘(e) NO OFFSET OR LIMITATION.—Amounts appropriated to CHEF under this section shall not be used to offset or limit appropriations made to the Service under 

the authority of the Act of November 2, 1921 (25 U.S.C. 13) (commonly known as 

the ‘Snyder Act’), or any other law. ‘‘(f) DEPOSIT OF REIMBURSEMENT FUNDS.—There shall be deposited into CHEF all 

reimbursements to which the Service is entitled from any Federal, State, local, or 

private source (including third party insurance) by reason of treatment rendered to 

any victim of a disaster or catastrophic illness the cost of which was paid from 

CHEF. 

‘‘SEC. 203. HEALTH PROMOTION AND DISEASE PREVENTION SERVICES. 

‘‘(a) FINDINGS.—Congress finds that health promotion and disease prevention activities—

‘‘(1) improve the health and well-being of Indians; and 

‘‘(2) reduce the expenses for health care of Indians. ‘‘(b) PROVISION OF SERVICES.—The Secretary, acting through the Service and Tribal Health Programs, shall provide health promotion and disease prevention services 

to Indians to achieve the health status objectives set forth in section 3(2). ‘‘(c) EVALUATION.—The Secretary, after obtaining input from the affected Tribal 

Health Programs, shall submit to the President for inclusion in each report which 

is required to be submitted to Congress under section 801 an evaluation of— ‘‘(1) the health promotion and disease prevention needs of Indians; 

‘‘(2) the health promotion and disease prevention activities which would best 

meet such needs; ‘‘(3) the internal capacity of the Service and Tribal Health Programs to meet 

such needs; and ‘‘(4) the resources which would be required to enable the Service and Tribal 

Health Programs to undertake the health promotion and disease prevention activities necessary to meet such needs. 

‘‘SEC. 204. DIABETES PREVENTION, TREATMENT, AND CONTROL. 

‘‘(a) DETERMINATIONS REGARDING DIABETES.—The Secretary, acting through the 

Service, and in consultation with Indian Tribes and Tribal Organizations, shall determine—

‘‘(1) by an Indian Tribe, Tribal Organization, and by Service Unit, the incidence of, and the types of complications resulting from, diabetes among Indians; 

and 

‘‘(2) based on the determinations made pursuant to paragraph (1), the measures (including patient education and effective ongoing monitoring of disease indicators) each Service Unit should take to reduce the incidence of, and prevent, 

treat, and control the complications resulting from, diabetes among Indian 

Tribes within that Service Unit. 

‘‘(b) DIABETES SCREENING.—To the extent medically indicated and with informed 

consent, the Secretary shall screen each Indian who receives services from the Service for diabetes and for conditions which indicate a high risk that the individual will 

become diabetic and, 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 by a Tribal Health Program and may be conducted through appropriate Internet-based health care management programs. 

‘‘(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 Amendments Act of 2006, 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 


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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 2006 and for projects which are added and funded thereafter. ‘‘(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. ‘‘(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 officer to coordinate and manage 

any activity of that Area Office relating to the prevention, treatment, or 

control of diabetes to assist the Secretary in carrying out a program under 

this section or section 330C of the Public Health Service Act (42 U.S.C. 

254c–3). ‘‘(B) CERTAIN ACTIVITIES.—Any activity carried out by a diabetes control 

officer under subparagraph (A) that is the subject of a contract or compact 

under the Indian Self-Determination and Education Assistance Act (25 

U.S.C. 450 et seq.), and any funds made available to carry out such an activity, shall not be divisible for purposes of that Act. 

‘‘SEC. 205. SHARED SERVICES FOR LONG-TERM CARE. 

‘‘(a) LONG-TERM CARE.—Notwithstanding any other provision of law, the Secretary, acting through the Service, is authorized to provide directly, or enter into 

contracts or compacts under the Indian Self-Determination and Education Assistance Act (25 U.S.C. 450 et seq.) with Indian Tribes or Tribal Organizations for, the 

delivery of long-term care 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 Assistance 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. 

‘‘SEC. 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 


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Health Program research needs. Tribal Health Programs shall be given an equal opportunity to compete for, and receive, research funds under this section. This funding may be used for both clinical and nonclinical research. 

‘‘SEC. 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 

national standards, such as those of the National Cancer Institute for the National Institutes for Health, 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 national standards, such as those of the 

National Cancer Institute. 

‘‘SEC. 208. PATIENT TRAVEL COSTS. 

‘‘The Secretary, acting through the Service and Tribal Health Programs, shall 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 Assistance Act (25 U.S.C. 450 eq 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. 

‘‘SEC. 209. EPIDEMIOLOGY CENTERS. 

‘‘(a) ADDITIONAL CENTERS.—In addition to those epidemiology centers already established at the time 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 2006, 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 at 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. 

‘‘SEC. 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 


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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 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. 

‘‘(13) Violence prevention. 

‘‘(14) Such other health issues as are appropriate. 

‘‘(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 grants awarded under 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) 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 school-based programs 

with existing services and health programs available in the community; and 

‘‘(C) encourage healthy, tobacco-free school environments. 

‘‘SEC. 211. INDIAN YOUTH PROGRAM. 

‘‘(a) PROGRAM AUTHORIZED.—The Secretary, acting through the Service, is authorized to establish and administer a program to provide 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 

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 healers; and 

‘‘(B) develop and provide community training and education. 


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‘‘(2) PROHIBITED USE.—Funds made available under this section may not be 

used to provide services described in section 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. 

‘‘SEC. 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. 

‘‘(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. 

‘‘SEC. 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 community-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.—Any service provided under this section shall be 

consistent with accepted and appropriate standards relating to the service, including 

any licensing term or condition under this Act. 


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‘‘(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) Homemaker/home health aide services. 

‘‘(ii) Personal care services. 

‘‘(iii) Chore services. 

‘‘(iv) Nursing care services provided outside of a nursing facility by, or 

under the supervision of, a registered nurse. ‘‘(v) Respite care. 

‘‘(vi) Training for family members. 

‘‘(vii) Adult day care. 

‘‘(viii) 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 immediate relative who 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) The term ‘public health functions’ means the provision of public healthrelated 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. 

‘‘SEC. 214. INDIAN WOMEN’S HEALTH CARE. 

‘‘The Secretary, acting through the Service and Indian Tribes, Tribal Organizations, and Urban Indian Organizations, shall monitor and improve the quality of 

health care for Indian women of all ages through the planning and delivery of programs administered by the Service, in order to improve and enhance the treatment 

models of care for Indian women. 

‘‘SEC. 215. ENVIRONMENTAL AND NUCLEAR HEALTH HAZARDS. 

‘‘(a) STUDIES AND MONITORING.—The Secretary and the Service shall conduct, in 

conjunction with other appropriate Federal agencies and in consultation with concerned Indian Tribes and Tribal Organizations, studies and ongoing monitoring programs to determine trends in the health hazards to Indian miners and to Indians 

on or near reservations and Indian communities as a result of environmental hazards which may result in chronic or life threatening health problems, such as nuclear resource development, petroleum contamination, and contamination of water 

source and of the food chain. Such studies shall include—

‘‘(1) an evaluation of the nature and extent of health problems caused by environmental hazards currently exhibited among Indians and the causes of such 

health problems; 

‘‘(2) an analysis of the potential effect of ongoing and future environmental 

resource development on or near reservations and Indian communities, including the cumulative effect over time on health; 

‘‘(3) an evaluation of the types and nature of activities, practices, and conditions causing or affecting such health problems, including uranium mining and 

milling, uranium mine tailing deposits, nuclear power plant operation and construction, and 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 2006 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—


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‘‘(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 2006. The health care plan prepared under subsection (b) 

shall be submitted in a report no later than 1 year after the study prepared under 

subsection (a) is submitted to Congress. Such report shall include recommended activities for the implementation of the plan, as well as an evaluation of any activities 

previously undertaken by the Service to address such health problems. 

‘‘(d) INTERGOVERNMENTAL TASK FORCE.—

‘‘(1) ESTABLISHMENT; MEMBERS.—There is established an Intergovernmental 

Task Force to be composed of the following individuals (or their designees): 

‘‘(A) The Secretary of Energy. 

‘‘(B) The Administrator of the Environmental Protection Agency. 

‘‘(C) The Director of the Bureau of Mines. 

‘‘(D) The Assistant Secretary for Occupational Safety and Health. 

‘‘(E) The Secretary of the Interior. 

‘‘(F) The Secretary of Health and Human Services. 

‘‘(G) The Assistant Secretary of Indian Health. 

‘‘(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. 

‘‘SEC. 216. ARIZONA AS A CONTRACT HEALTH SERVICE DELIVERY AREA. 

‘‘(a) IN GENERAL.—For fiscal years beginning with the fiscal year ending September 30, 1983, and ending with the fiscal year ending September 30, 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). 

‘‘SEC. 216A. NORTH DAKOTA AS A CONTRACT HEALTH SERVICE DELIVERY AREA. 

‘‘(a) IN GENERAL.—For fiscal years beginning with the fiscal year ending September 30, 2003, and ending with the fiscal year ending September 30, 2015, the 

State of North Dakota shall be designated as a contract health service delivery area 


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by the Service for the purpose of providing contract health care services to members 

of federally recognized Indian Tribes of North Dakota. 

‘‘(b) LIMITATION.—The Service shall not curtail any health care services provided 

to Indians residing on reservations in the State of North Dakota if such curtailment 

is due to the provision of contract services in such State pursuant to the designation 

of such State as a contract health service delivery area pursuant to subsection (a). 

‘‘SEC. 216B. SOUTH DAKOTA AS A CONTRACT HEALTH SERVICE DELIVERY AREA. 

‘‘(a) IN GENERAL.—For fiscal years beginning with the fiscal year ending September 30, 2003, and ending with the fiscal year ending on September 30, 2015, the 

State of 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 South Dakota. 

‘‘(b) LIMITATION.—The Service shall not curtail any health care services provided 

to Indians residing on reservations in the State of South Dakota if such curtailment 

is due to the provision of contract services in such State pursuant to the designation 

of such State as a contract health service delivery area pursuant to subsection (a). 

‘‘SEC. 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 hereby established an advisory board which shall 

advise the CRIHB in carrying out this section. The advisory board shall be composed of representatives, selected by the CRIHB, from not less than 8 Tribal Health 

Programs serving California Indians covered under this section at least one half of 

whom are not affiliated with the CRIHB. 

‘‘SEC. 218. CALIFORNIA AS A CONTRACT HEALTH SERVICE DELIVERY AREA. 

‘‘The State of California, excluding the counties of Alameda, Contra Costa, Los 

Angeles, Marin, Orange, Sacramento, San Francisco, San Mateo, Santa Clara, Kern, 

Merced, Monterey, Napa, San Benito, San Joaquin, San Luis Obispo, Santa Cruz, 

Solano, Stanislaus, and Ventura, shall be designated as a contract health service delivery area by the Service for the purpose of providing contract health services to 

California Indians. However, any of the counties listed herein may only be included 

in the contract health services delivery area if funding is specifically provided by 

the Service for such services in those counties. 

‘‘SEC. 219. CONTRACT HEALTH SERVICES FOR THE TRENTON SERVICE AREA. 

‘‘(a) AUTHORIZATION FOR SERVICES.—The Secretary, acting through the Service, is 

directed to provide contract health services to members of the Turtle Mountain 

Band of Chippewa Indians that reside in the Trenton Service Area of Divide, 

McKenzie, and Williams counties in the State of North Dakota and the adjoining 

counties of Richland, Roosevelt, and Sheridan in the State of Montana. 

‘‘(b) NO EXPANSION OF ELIGIBILITY.—Nothing in this section may be construed as 

expanding the eligibility of members of the Turtle Mountain Band of Chippewa Indians for health services provided by the Service beyond the scope of eligibility for 

such health services that applied on May 1, 1986. 

‘‘SEC. 220. PROGRAMS OPERATED BY INDIAN TRIBES AND TRIBAL ORGANIZATIONS. 

‘‘The Service shall provide funds for health care programs and facilities operated 

by Tribal Health Programs on the same basis as such funds are provided to programs and facilities operated directly by the Service. 


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‘‘SEC. 221. LICENSING. 

‘‘Health care professionals employed by a Tribal Health Program shall, if licensed 

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

Tribal Health Program performs the services described in its contract or compact 

under the Indian Self-Determination and Education Assistance Act (25 U.S.C. 450 

et seq.). 

‘‘SEC. 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. 

‘‘SEC. 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. 

‘‘SEC. 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 223(b), the provider shall 

have no further recourse against the patient who received the services. 

‘‘SEC. 225. 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. 

‘‘TITLE III—FACILITIES 

‘‘SEC. 301. CONSULTATION: CONSTRUCTION AND RENOVATION OF FACILITIES; REPORTS. 

‘‘(a) PREREQUISITES FOR EXPENDITURE OF FUNDS.—Prior to the expenditure of, or 

the making of any binding commitment to expend, any funds appropriated for the 

planning, design, construction, or renovation of facilities pursuant to the Act of November 2, 1921 (25 U.S.C. 13) (commonly known as the ‘Snyder Act’), the Secretary, 

acting through the Service, shall—

‘‘(1) consult with any Indian 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 made; 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 by not later than 1 year after 

the date on which the construction or renovation of such facility is completed. 

‘‘(b) CLOSURES.—

‘‘(1) EVALUATION REQUIRED.—Notwithstanding any other provision of law, no 

facility operated by the Service may be closed if the Secretary has not submitted 

to Congress at least 1 year prior to the date of the proposed closure an evaluation of the impact of the proposed closure which specifies, in addition to other 

considerations—

‘‘(A) the accessibility of alternative health care resources for the population served by such facility; 

‘‘(B) the cost-effectiveness of such closure; 

‘‘(C) the quality of health care to be provided to the population served by 

such facility after such closure; 


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‘‘(D) the availability of contract health care funds to maintain existing 

levels of service; ‘‘(E) the views of the Indian Tribes served by such facility concerning 

such closure; ‘‘(F) the level of use of such facility by all eligible Indians; and 

‘‘(G) the distance between such 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 any portion of a facility if such 

closure is necessary for medical, environmental, or construction safety reasons. ‘‘(c) HEALTH CARE 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 2006 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 toppriority 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) REPORT; CONTENTS.—The Secretary shall submit to the President, for inclusion in each report required to be transmitted to Congress under section 801, 

a report which sets forth the following: 

‘‘(A) A description of the health care facility priority system of the Service, established under paragraph (1). 

‘‘(B) Health care facilities lists, including—

‘‘(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 patient hostels associated with health care facilities. 

‘‘(C) The justification for such order of priority. 

‘‘(D) The projected cost of such projects. 

‘‘(E) The methodology adopted by the Service in establishing priorities 

under its health care facility priority system. 

‘‘(3) REQUIREMENTS FOR PREPARATION OF REPORTS.—In preparing each report 

required under paragraph (2) (other than the initial report), the Secretary shall 

annually—

‘‘(A) consult with and obtain information on all health care facilities 

needs from Indian Tribes, Tribal Organizations, and Urban Indian Organizations; and 

‘‘(B) review the total unmet needs of all Indian Tribes, Tribal Organizations, and Urban Indian Organizations for health care facilities (including 

hostels and staff quarters), including needs for renovation and expansion of 

existing facilities. 

‘‘(4) CRITERIA FOR EVALUATING NEEDS.—For purposes of this subsection, the 

Secretary shall, in evaluating the needs of facilities operated under any contract 

or compact under the Indian Self-Determination and Education Assistance Act 

(25 U.S.C. 450 et seq.) use the same criteria that the Secretary uses in evaluating the needs of facilities operated directly by the Service. 

‘‘(5) 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 funding agreements in accordance 

with the Indian Self-Determination and Education Assistance Act (25 U.S.C. 

450 et seq.) are fully and equitably integrated into the health care facility priority system. 


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‘‘(d) REVIEW OF NEED FOR FACILITIES.—

‘‘(1) 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 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 contract or compact 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 Funding Agreement 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.—All funds appropriated under the Act of November 2, 

1921 (25 U.S.C. 13) (commonly known as the ‘Snyder Act’), for the planning, design, 

construction, or renovation of health facilities for the benefit of 1 or more Indian 

Tribes shall be subject to the provisions 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. 

‘‘SEC. 302. SANITATION FACILITIES. 

‘‘(a) FINDINGS.—Congress finds the following: 

‘‘(1) The provision of sanitation facilities is primarily a health consideration 

and function. 

‘‘(2) Indian people suffer an inordinately high incidence of disease, injury, and 

illness directly attributable to the absence or inadequacy of sanitation facilities. 

‘‘(3) The long-term cost to the United States of treating and curing such disease, injury, and illness is substantially greater than the short-term cost of providing sanitation facilities and other preventive health measures. 

‘‘(4) Many Indian homes and Indian communities still lack sanitation facilities. 

‘‘(5) 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. 

‘‘(b) FACILITIES AND SERVICES.—In furtherance of the findings made in subsection 

(a), 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.C. 2006a). Under such authority, the Secretary, 

acting through the Service, is authorized to provide the following: 

‘‘(1) Financial and technical assistance to Indian Tribes, Tribal Organizations, 

and Indian communities in the establishment, training, and equipping of utility 

organizations to operate and maintain sanitation facilities, including the provision of existing plans, standard details, and specifications available in the Department, to be used at the option of the Indian Tribe, Tribal Organization, or 

Indian community. 

‘‘(2) 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. 

‘‘(3) Priority funding for operation and maintenance assistance for, and emergency repairs to, sanitation facilities operated by an Indian Tribe, Tribal Organization or Indian community when necessary to avoid an imminent health 


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threat or to protect the investment in sanitation facilities and the investment 

in the health benefits gained through the provision of sanitation facilities. ‘‘(c) FUNDING.—Notwithstanding any other provision of law— ‘‘(1) the Secretary of Housing and Urban Development is authorized to transfer funds appropriated under the Native American Housing Assistance and SelfDetermination Act of 1996 to the Secretary of Health and Human Services; ‘‘(2) the Secretary of Health and Human Services is authorized to accept and 

use such funds for the purpose of providing sanitation facilities and services for 

Indians under section 7 of the Act of August 5, 1954 (42 U.S.C. 2004a); ‘‘(3) unless specifically authorized when funds are appropriated, the Secretary 

shall not use funds appropriated under section 7 of the Act of August 5, 1954 

(42 U.S.C. 2004a), to provide sanitation facilities to new homes constructed 

using funds provided by the Department of Housing and Urban Development; ‘‘(4) the Secretary of Health and Human Services is authorized to accept from 

any source, including Federal and State agencies, funds for the purpose of providing sanitation facilities and services and place these funds into contracts or 

compacts under the Indian Self-Determination and Education Assistance Act 

(25 U.S.C. 450 et seq.); ‘‘(5) except as otherwise prohibited by this section, the Secretary may use 

funds appropriated under the authority of section 7 of the Act of August 5, 1954 

(42 U.S.C. 2004a) to fund up to 100 percent of the amount of an Indian Tribe’s 

loan obtained under any Federal program for new projects to construct eligible 

sanitation facilities to serve Indian homes; 

‘‘(6) except as otherwise prohibited by this section, the Secretary may use 

funds appropriated under the authority of section 7 of the Act of August 5, 1954 

(42 U.S.C. 2004a) to meet matching or cost participation requirements under 

other Federal and non-Federal programs for new projects to construct eligible 

sanitation facilities; 

‘‘(7) all Federal agencies are authorized to transfer to the Secretary funds 

identified, granted, loaned, or appropriated whereby the Department’s applicable policies, rules, and regulations shall apply in the implementation of such 

projects; 

‘‘(8) the Secretary 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 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. 

‘‘(d) CERTAIN CAPABILITIES NOT PREREQUISITE.—The financial and technical capability of an Indian 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 ASSISTANCE.—The Secretary is authorized to provide financial assistance to Indian Tribes, Tribal Organizations, and Indian communities for operation, management, and maintenance of their sanitation facilities. 

‘‘(f) OPERATION, MANAGEMENT, AND MAINTENANCE OF FACILITIES.—The Indian 

Tribe, Tribal Organization, or Indian community 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, Tribal Organization, or Indian community 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. 

‘‘(h) REPORT.—

‘‘(1) REQUIRED; CONTENTS.—The Secretary, in consultation with the Secretary 

of Housing and Urban Development, Indian Tribes, Tribal Organizations, and 

tribally designated housing entities (as defined in section 4 of the Native American Housing Assistance and Self-Determination Act of 1996 (25 U.S.C. 4103)) 

shall submit to the President, for inclusion in each report required to be transmitted to Congress under section 801, a report which sets forth—

‘‘(A) the current Indian sanitation facility priority system of the Service; 


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‘‘(B) the methodology for determining sanitation deficiencies and needs; 

‘‘(C) the level of initial and final sanitation deficiency for each type of 

sanitation facility for each project of each Indian Tribe or Indian community; 

‘‘(D) the amount and most effective use of funds, derived from whatever 

source, necessary to accommodate the sanitation facilities needs of new 

homes assisted with funds under the Native American Housing Assistance 

and Self-Determination Act, and to reduce the identified sanitation deficiency levels of all Indian Tribes and Indian communities to 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. 

‘‘(2) CRITERIA.—The criteria on which the deficiencies and needs will be evaluated shall be developed through negotiated rulemaking pursuant to section 802. 

‘‘(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 Tribes and 

Indian communities. 

‘‘(4) SANITATION DEFICIENCY LEVELS.—For purposes of this subsection, the 

sanitation deficiency levels for an individual, Indian 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 an individual, Indian Tribe, or Indian community—

‘‘(i) complies with all applicable water supply, pollution control, and 

solid waste disposal laws; and 

‘‘(ii) deficiencies relate to routine replacement, repair, or maintenance 

needs. 

‘‘(B) A level II deficiency exists if a sanitation facility serving an individual, Indian Tribe, or Indian community substantially or recently complied with all applicable water supply, pollution control, and solid waste 

laws and any deficiencies relate to—

‘‘(i) small or minor capital improvements needed to bring the facility 

back into compliance; 

‘‘(ii) capital improvements that are necessary to enlarge or improve 

the facilities in order to meet the current needs for domestic sanitation 

facilities; or 

‘‘(iii) the lack of equipment or training by an Indian Tribe, Tribal Organization, or an Indian community to properly operate and maintain 

the sanitation facilities. 

‘‘(C) A level III deficiency exists if a sanitation facility serving an individual, Indian Tribe or Indian community meets one or more of the following conditions—

‘‘(i) water or sewer service in the home is provided by a haul system 

with holding tanks and interior plumbing; 

‘‘(ii) major significant interruptions to water supply or sewage disposal occur frequently, requiring major capital improvements to correct 

the deficiencies; or 

‘‘(iii) there is no access to or no approved or permitted solid waste facility available. 

‘‘(D) A level IV deficiency exists—

‘‘(i) if a sanitation facility for an individual home, an Indian Tribe, 

or an Indian community exists but—

‘‘(I) lacks—

‘‘(aa) a safe water supply system; or 

‘‘(bb) a waste disposal system; 

‘‘(II) contains no piped water or sewer facilities; or 

‘‘(III) has become inoperable due to a major component failure; 

or 

‘‘(ii) if only a washeteria or central facility exists in the community. 

‘‘(E) A level V deficiency exists in the absence of a sanitation facility, 

where individual homes do not have access to safe drinking water or adequate wastewater (including sewage) disposal. 

‘‘(i) DEFINITIONS.—For purposes of this section, the following terms apply: 

‘‘(1) INDIAN COMMUNITY.—The term ‘Indian community’ means a geographic 

area, a significant proportion of whose inhabitants are Indians and which is 

served by or capable of being served by a facility described in this section. 

‘‘(2) SANITATION FACILITIES.—The terms ‘sanitation facility’ and ‘sanitation facilities’ mean safe and adequate water supply systems, sanitary sewage disposal 


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systems, and sanitary solid waste systems (and all related equipment and support infrastructure). 

‘‘SEC. 303. PREFERENCE TO INDIANS AND INDIAN FIRMS. 

‘‘(a) BUY INDIAN ACT.—The Secretary, acting through the Service, may use the negotiating authority of section 23 of the Act of June 25, 1910 (25 U.S.C. 47, commonly 

known as the ‘Buy Indian Act’), to give preference to any Indian or any enterprise, 

partnership, corporation, or other type of business organization owned and controlled by an Indian or Indians including former or currently federally recognized 

Indian Tribes in the State of New York (hereinafter referred to as an ‘Indian firm’) 

in the construction and renovation of Service facilities pursuant to section 301 and 

in the construction of sanitation facilities pursuant to section 302. Such preference 

may be accorded by the Secretary unless the Secretary finds, pursuant to regulations adopted pursuant to section 802, 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 

finding, shall consider whether the Indian or Indian firm will be deficient with respect to—

‘‘(1) ownership and control by Indians; 

‘‘(2) equipment; 

‘‘(3) bookkeeping and accounting procedures; 

‘‘(4) substantive knowledge of the project or function to be contracted for; 

‘‘(5) adequately trained personnel; or 

‘‘(6) other necessary components of contract performance. 

‘‘(b) LABOR STANDARDS.—

‘‘(1) IN GENERAL.—For the purposes of implementing the provisions of this 

title, 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—

‘‘(A) is performed by a contractor pursuant to a contract with an Indian 

Tribe or Tribal Organization with funds supplied through a contract, compact or funding agreement 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. 

‘‘SEC. 304. EXPENDITURE OF NONSERVICE FUNDS FOR RENOVATION. 

‘‘(a) IN GENERAL.—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 

Tribe or Tribal Organization of any Service facility or of any other Indian health 

facility operated pursuant to a contract or compact under the Indian Self-Determination and Education Assistance Act (25 U.S.C. 450 et seq.) including—

‘‘(1) any plans or designs for such expansion, renovation, or modernization; 

and 

‘‘(2) any expansion, renovation, or modernization for which funds appropriated 

under any Federal law were lawfully expended. 

‘‘(b) PRIORITY LIST.—

‘‘(1) IN GENERAL.—The Secretary shall maintain a separate priority list to address the needs for increased operating expenses, 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) REPORT.—The Secretary shall submit to the President, for inclusion in 

each report required to be transmitted to Congress under section 801, the priority list maintained pursuant to paragraph (1). 

‘‘(c) REQUIREMENTS.—The requirements of this subsection are met with respect to 

any expansion, renovation, or modernization if—

‘‘(1) the Indian Tribe or Tribal Organization—

‘‘(A) provides notice to the Secretary of its intent to expand, renovate, or 

modernize; and 


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‘‘(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 Tribe or Tribal Organization in accordance with any applicable 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 expansions, 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.—If any Service facility which has 

been expanded, renovated, or modernized by an Indian 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 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. 

‘‘SEC. 305. FUNDING FOR THE CONSTRUCTION, EXPANSION, AND MODERNIZATION OF SMALL 

AMBULATORY CARE FACILITIES. 

‘‘(a) FUNDING.—

‘‘(1) IN GENERAL.—The Secretary, acting through the Service, in consultation 

with Indian Tribes and Tribal Organizations, shall make grants to Indian 

Tribes and Tribal Organizations for the construction, expansion, or modernization of facilities for the provision of ambulatory care services to eligible Indians 

(and noneligible persons pursuant to subsections (b)(2) and (c)(1)(C)). Funding 

made under this section may cover up to 100 percent of the costs of such construction, expansion, or modernization. For the purposes of this section, the 

term ‘construction’ includes the replacement of an existing facility. 

‘‘(2) GRANTS AGREEMENT REQUIRED.—A grant under paragraph (1) may only 

be made available to a Tribal Health Program operating an Indian health facility (other than a facility owned or constructed by the Service, including a facility originally owned or constructed by the Service and transferred to an Indian 

Tribe or Tribal Organization). 

‘‘(b) USE OF GRANT.—

‘‘(1) ALLOWABLE USES.—Grant awarded under this section may be used for the 

construction, expansion, or modernization (including the planning and design of 

such construction, expansion, or modernization) of an ambulatory care facility—

‘‘(A) located apart from a hospital; 

‘‘(B) not funded under section 301 or section 307; and 

‘‘(C) which, upon completion of such construction 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 services in such facility in 

accordance with section 807(c)(2); and 

‘‘(iii) provide ambulatory care in a Service Area (specified in the contract or compact under the Indian Self-Determination and Education 

Assistance Act (25 U.S.C. 450 et seq.) with a population of no fewer 

than 1,500 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, expanVerDate Aug 31 2005 06:24 Sep 16, 2006 Jkt 049006 PO 00000 Frm 00042 Fmt 6659 Sfmt 6621 E:\HR\OC\HR661P1.XXX HR661P1

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sion, or modernization project or debt reduction that benefits the Service population identified above in subsection (b)(1)(C) (ii) and (iii). 

‘‘(4) APPLICABILITY OF REQUIREMENTS IN THE CASE OF ISOLATED FACILITIES.—

The requirements of clauses (ii) and (iii) of paragraph (1)(C) shall not apply to 

an Indian Tribe or Tribal Organization applying for a grant under this section 

for a health care facility located or to be constructed on an island or when such 

facility is not located on a road system providing direct access to an inpatient 

hospital where care is available to the Service population. 

‘‘(c) GRANTS.—

‘‘(1) APPLICATION.—No grant may be made available under this section unless 

an application or proposal for the grant has been approved by the Secretary in 

accordance with applicable regulations and has provided reasonable assurance 

by the applicant that, at all times after the construction, expansion, or modernization of a facility carried out using a grant received under this section—

‘‘(A) adequate financial support will be available for the provision of services at such facility; 

‘‘(B) such facility will be available to eligible Indians without regard to 

ability to pay or source of payment; and 

‘‘(C) such facility will, as feasible without diminishing the quality or 

quantity of services provided to eligible Indians, serve noneligible persons 

on a cost basis. 

‘‘(2) PRIORITY.—In awarding grants under this section, the Secretary shall 

give priority to Indian Tribes and Tribal Organizations that demonstrate—

‘‘(A) a need for increased ambulatory care services; and 

‘‘(B) insufficient capacity to deliver such services. 

‘‘(3) PEER REVIEW PANELS.—The Secretary may provide for the establishment 

of peer review panels, as necessary, to review and evaluate applications and 

proposals and to advise the Secretary regarding such applications using the criteria developed during consultations pursuant to subsection (a)(1). 

‘‘(d) REVERSION OF FACILITIES.—If any facility (or portion thereof) with respect to 

which funds have been paid under this section, ceases, within 5 years after completion of the construction, expansion, or modernization carried out with such funds, 

to be used for the purposes of providing health care services to eligible Indians, all 

of the right, title, and interest in and to such facility (or portion thereof) shall transfer to the United States unless otherwise negotiated by the Service and the Indian 

Tribe or Tribal Organization. 

‘‘(e) FUNDING NONRECURRING.—Funding provided under this section shall be nonrecurring and shall not be available for inclusion in any individual Indian Tribe’s 

tribal share for an award under the Indian Self-Determination and Education Assistance Act (25 U.S.C. 450 et seq.) or for reallocation or redesign thereunder. 

‘‘SEC. 306. INDIAN HEALTH CARE DELIVERY DEMONSTRATION PROJECT. 

‘‘(a) HEALTH CARE DEMONSTRATION PROJECTS.—The Secretary, acting through the 

Service, and in consultation with Indian Tribes and Tribal Organizations, is authorized to enter into construction project agreements and construction contracts under 

the Indian Self-Determination and Education Assistance Act (25 U.S.C. 450 et seq.) 

with Indian Tribes or Tribal Organizations for the purpose of carrying out a health 

care delivery demonstration project to test alternative means of delivering health 

care and services to Indians through facilities, including hospice, traditional Indian 

health, and child care facilities. 

‘‘(b) USE OF 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 funds; 

‘‘(4) permit the use of funds or property donated from any source for project 

purposes; 

‘‘(5) provide for the reversion of donated real or personal property to the 

donor; and 

‘‘(6) permit the use of Service funds to match other funds, including Federal 

funds. 

‘‘(c) REGULATIONS.—The Secretary shall develop and promulgate regulations not 

later than 1 year after the date of enactment of the Indian Health Care Improvement Act Amendments of 2006. If the Secretary has not promulgated regulations 

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making under section 802, for the review and approval of applications submitted 

under this section. 

‘‘(d) CRITERIA.—The Secretary may approve projects that meet the following criteria: 

‘‘(1) There is a need for a new facility or program or the reorientation of an 

existing facility or program. 

‘‘(2) A significant number of Indians, including those with low health status, 

will be served by the project. 

‘‘(3) The project has the potential to deliver services in an efficient and effective manner. 

‘‘(4) The project is economically viable. 

‘‘(5) The Indian Tribe or Tribal Organization has the administrative and financial capability to administer the project. 

‘‘(6) 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.—The Secretary may provide for the establishment of 

peer review panels, as necessary, to review and evaluate applications using the criteria developed pursuant to subsection (d). 

‘‘(f) PRIORITY.—The Secretary shall give priority to applications for demonstration 

projects in each of the following Service Units to the extent that such applications 

are timely filed and meet the criteria specified in subsection (d): 

‘‘(1) Cass Lake, Minnesota. 

‘‘(2) Clinton, Oklahoma. 

‘‘(3) Harlem, Montana. 

‘‘(4) Mescalero, New Mexico. 

‘‘(5) Owyhee, Nevada. 

‘‘(6) Parker, Arizona. 

‘‘(7) Schurz, Nevada. 

‘‘(8) Winnebago, Nebraska. 

‘‘(9) Ft. Yuma, California. 

‘‘(g) TECHNICAL 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) SERVICE TO INELIGIBLE PERSONS.—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 Service facilities to non-Service health practitioners as provided in section 807 may be included, subject to the terms of such section, in any demonstration project approved pursuant to this section. 

‘‘(i) EQUITABLE TREATMENT.—For purposes of subsection (d)(1), the Secretary 

shall, in evaluating facilities operated under any contract or compact under the Indian Self-Determination and Education Assistance Act (25 U.S.C. 450 et seq.) use 

the same criteria that the Secretary uses in evaluating facilities operated directly 

by the Service. 

‘‘(j) EQUITABLE INTEGRATION OF FACILITIES.—The Secretary shall ensure that the 

planning, design, construction, renovation, and expansion needs of Service and nonService facilities which are the subject of a contract or compact under the Indian 

Self-Determination and Education Assistance Act (25 U.S.C. 450 et seq.) for health 

services are fully and equitably integrated into the implementation of the health 

care delivery demonstration projects under this section. 

‘‘SEC. 307. LAND TRANSFER. 

‘‘Notwithstanding any other provision of law, the Bureau of Indian Affairs and all 

other agencies and departments of the United States are authorized to transfer, at 

no cost, land and improvements to the Service for the provision of health care services. The Secretary is authorized to accept such land and improvements for such 

purposes. 

‘‘SEC. 308. LEASES, CONTRACTS, AND OTHER AGREEMENTS. 

‘‘The Secretary, acting through the Service, may enter into leases, contracts, and 

other agreements with Indian Tribes and Tribal Organizations which hold (1) title 

to, (2) a leasehold interest in, or (3) a beneficial interest in (when title is held by 

the United States in trust for the benefit of an Indian Tribe) facilities used or to 

be used for the administration and delivery of health services by an Indian Health 

Program. Such leases, contracts, or agreements may include provisions for construction or renovation and provide for compensation to the Indian Tribe or Tribal Organization of rental and other costs consistent with section 105(l) of the Indian SelfDetermination and Education Assistance Act (25 U.S.C. 450 et seq.) and regulations 

thereunder. 


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‘‘SEC. 309. STUDY ON LOANS, LOAN GUARANTEES, AND LOAN REPAYMENT. 

‘‘(a) IN GENERAL.—The Secretary, in consultation with the Secretary of the Treasury, Indian Tribes, and Tribal Organizations, shall carry out a study to determine 

the feasibility of establishing a loan fund to provide to Indian Tribes and Tribal Organizations direct loans or guarantees for loans for the construction of health care 

facilities, including— ‘‘(1) inpatient facilities; 

‘‘(2) outpatient facilities; 

‘‘(3) staff quarters; 

‘‘(4) hostels; and 

‘‘(5) specialized care facilities, such as behavioral health and elder care facilities. ‘‘(b) DETERMINATIONS.—In carrying out the study under subsection (a), the Secretary shall determine— ‘‘(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; ‘‘(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. 

‘‘SEC. 310. TRIBAL LEASING. 

‘‘A Tribal Health Program may lease permanent structures for the purpose of providing health care services without obtaining advance approval in appropriation 

Acts. 

‘‘SEC. 311. INDIAN HEALTH SERVICE/TRIBAL FACILITIES JOINT VENTURE PROGRAM. 

‘‘(a) IN GENERAL.—The Secretary, acting through the Service, shall make arrangements with Indian Tribes and Tribal Organizations to establish joint venture demonstration projects under which an Indian Tribe or Tribal Organization shall expend 

tribal, private, or other available funds, for the acquisition or construction of a 

health facility for a minimum of 10 years, under a no-cost lease, in 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 under this 

section 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. 


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‘‘(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 the continued operation of the facility at the end of the initial 10 year no-cost lease period. 

‘‘(d) BREACH OF AGREEMENT.—An Indian Tribe or Tribal Organization that has 

entered into a written agreement with the Secretary under this section, and that 

breaches or terminates without cause such agreement, shall be liable to the United 

States for the amount that has been paid to the Indian Tribe or Tribal Organization, 

or paid to a third party on the Indian Tribe’s or Tribal Organization’s behalf, under 

the agreement. The Secretary has the right to recover tangible property (including 

supplies) and equipment, less depreciation, and any funds expended for operations 

and maintenance under this section. The preceding sentence does not apply to any 

funds expended for the delivery of health care services, personnel, or staffing. 

‘‘(e) RECOVERY FOR NONUSE.—An Indian Tribe or Tribal Organization that has entered into a written agreement with the Secretary under this subsection shall be 

entitled to recover from the United States an amount that is proportional to the 

value of such facility if, at any time within the 10-year term of the agreement, the 

Service ceases to use the facility or otherwise breaches the agreement. 

‘‘(f) DEFINITION.—For the purposes of this section, the term ‘health facility’ or 

‘health facilities’ includes quarters needed to provide housing for staff of the relevant Tribal Health Program. 

‘‘SEC. 312. LOCATION OF FACILITIES. 

‘‘(a) IN GENERAL.—In all matters involving the reorganization or development of 

Service facilities or in the establishment of related employment projects to address 

unemployment conditions in economically depressed areas, the Bureau of Indian Affairs and the Service shall give priority to locating such facilities and projects on 

Indian lands or lands in Alaska owned by any Alaska Native village, or village or 

regional corporation under the Alaska Native Claims Settlement Act, or any land 

allotted to any Alaska Native, if requested by the Indian owner and the Indian 

Tribe with jurisdiction over such lands or other lands owned or leased by the Indian 

Tribe or Tribal Organization. Top priority shall be given to Indian land owned by 

1 or more Indian Tribes. 

‘‘(b) DEFINITION.—For purposes of this section, the term ‘Indian lands’ means—

‘‘(1) all lands within the exterior boundaries of any reservation; and 

‘‘(2) any lands title to which is held in trust by the United States for the benefit of any Indian Tribe or individual Indian or held by any Indian Tribe or individual Indian subject to restriction by the United States against alienation. 

‘‘SEC. 313. MAINTENANCE AND IMPROVEMENT OF HEALTH CARE FACILITIES. 

‘‘(a) REPORT.—The Secretary shall submit to the President, for inclusion in the report required to be transmitted to Congress under section 801, a report which identifies the backlog of maintenance and repair work required at both Service and tribal health care facilities, including new health care facilities expected to be in operation in the next fiscal year. The report shall also identify the need for renovation 

and expansion of existing facilities to support the growth of health care programs. 

‘‘(b) MAINTENANCE OF NEWLY CONSTRUCTED SPACE.—The Secretary, acting 

through the Service, is authorized to expend maintenance and improvement funds 

to support maintenance of newly constructed space only if such space falls within 

the approved supportable space allocation for the Indian Tribe or Tribal Organization. Supportable space allocation shall be defined through the 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. 

‘‘SEC. 314. TRIBAL MANAGEMENT OF FEDERALLY OWNED QUARTERS. 

‘‘(a) RENTAL RATES.—


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‘‘(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 objectives: 

‘‘(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 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. 

‘‘SEC. 315. APPLICABILITY OF BUY AMERICAN ACT REQUIREMENT. 

‘‘(a) APPLICABILITY.—The Secretary shall ensure that the requirements of the Buy 

American Act apply to all procurements made with funds provided pursuant to section 317. Indian Tribes and Tribal Organizations shall be exempt from these requirements. 

‘‘(b) EFFECT OF VIOLATION.—If it has been finally determined by a court or Federal agency that any person intentionally affixed a label bearing a ‘Made in America’ inscription 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 section 317, pursuant to the debarment, suspension, and ineligibility 


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procedures described in sections 9.400 through 9.409 of title 48, Code of Federal 

Regulations. 

‘‘(c) DEFINITIONS.—For purposes of this section, the term ‘Buy American Act’

means title III of the Act entitled ‘An Act making appropriations for the Treasury 

and Post Office Departments for the fiscal year ending June 30, 1934, and for other 

purposes’, approved March 3, 1933 (41 U.S.C. 10a et seq.). 

‘‘SEC. 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 transfer such funds to Indian Tribes 

or Tribal Organizations through construction project agreements or construction 

contracts 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. 

‘‘SEC. 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. 

‘‘TITLE IV—ACCESS TO HEALTH SERVICES 

‘‘SEC. 401. TREATMENT OF PAYMENTS UNDER SOCIAL SECURITY ACT HEALTH BENEFITS PROGRAMS. 

‘‘(a) DISREGARD OF MEDICARE, MEDICAID, AND SCHIP PAYMENTS IN DETERMINING

APPROPRIATIONS.—Any payments received by an Indian Health Program or by an 

Urban Indian Organization under title XVIII, XIX, or XXI of the Social Security Act 

for services provided to Indians eligible for benefits under such respective titles 

shall not be considered in determining appropriations for the provision of health 

care and services to Indians. 

‘‘(b) NONPREFERENTIAL TREATMENT.—Nothing in this Act authorizes the Secretary 

to provide services to an Indian with coverage under title XVIII, XIX, or XXI of the 

Social Security Act in preference to an Indian without such coverage. 

‘‘(c) USE OF FUNDS.—

‘‘(1) SPECIAL FUND.—

‘‘(A) 100 PERCENT PASS-THROUGH OF PAYMENTS DUE TO FACILITIES.—Notwithstanding any other provision of law, but subject to paragraph (2), payments to which a facility of the Service is entitled by reason of a provision 

of the Social Security Act shall be placed in a special fund to be held by 

the Secretary. In making payments from such fund, the Secretary shall ensure that each Service Unit of the Service receives 100 percent of the 

amount to which the facilities of the Service, for which such Service Unit 

makes collections, are entitled by reason of a provision of the Social Security Act. 

‘‘(B) USE OF FUNDS.—Amounts received by a facility of the Service under 

subparagraph (A) shall first be used (to such extent or in such amounts as 

are provided in appropriation Acts) for the purpose of making any improvements in the programs of the Service operated by or through such facility 

which may be necessary to achieve or maintain compliance with the applicable conditions and requirements of titles XVIII and XIX of the Social Security Act. Any amounts so received that are in excess of the amount necVerDate Aug 31 2005 06:24 Sep 16, 2006 Jkt 049006 PO 00000 Frm 00048 Fmt 6659 Sfmt 6621 E:\HR\OC\HR661P1.XXX HR661P1

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essary to achieve or maintain such conditions and requirements shall, subject to consultation with the Indian Tribes being served by the Service Unit, 

be used for reducing the health resource deficiencies (as determined under 

section 201(d)) of such Indian Tribes. ‘‘(2) DIRECT PAYMENT OPTION.—Paragraph (1) shall not apply to a Tribal 

Health Program or Urban Indian Organization upon the election of such Program or Organization under subsection (d) to receive payments directly. No payment may be made out of the special fund described in such paragraph with 

respect to reimbursement made for services provided by such Program during 

the period of such election. ‘‘(d) DIRECT BILLING.— ‘‘(1) IN GENERAL.—Subject to complying with the requirements of paragraph 

(2), a Tribal Health Program or Urban Indian Organization may elect to directly 

bill for, and receive payment for, health care items and services provided by 

such Program or Organization for which payment is made under title XVIII or 

XIX of the Social Security Act or from any other third party payor. ‘‘(2) DIRECT REIMBURSEMENT.— ‘‘(A) USE OF FUNDS.—Each Tribal Health Program or Urban Indian Organization making the election 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 subsection (c)(1), but all amounts so reimbursed shall be used by the Tribal 

Health Program or Urban Indian Organization for the purpose of making 

any improvements in facilities of the Tribal Health Program or Urban Indian Organization 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 a Tribal Health Program or Urban Indian Organization making the election described in paragraph (1) with respect to a program under a title of the Social Security Act shall be subject 

to all auditing requirements applicable to the program under such title, as 

well as all auditing requirements applicable to programs administered by 

an Indian Health Program. Nothing in the preceding sentence shall be construed as limiting the application of auditing requirements applicable to 

amounts paid under title XVIII, XIX, or XXI of the Social Security Act. 

‘‘(C) IDENTIFICATION OF SOURCE OF PAYMENTS.—Any Tribal Health Program or Urban Indian Organization that receives reimbursements or payments under title XVIII, XIX, or XXI of the Social Security Act, shall provide to the Service a list of each provider enrollment number (or other identifier) under which such Program or Organization receives such reimbursements or payments. 

‘‘(3) EXAMINATION AND IMPLEMENTATION OF CHANGES.—

‘‘(A) IN GENERAL.—The Secretary, acting through the Service and with 

the assistance of the Administrator of the 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. 

‘‘(B) COORDINATION OF INFORMATION.—The Service shall provide the Administrator of the Centers for Medicare & Medicaid Services with copies of 

the lists submitted to the Service under paragraph (2)(C), enrollment data 

regarding patients served by the Service (and by Tribal Health Programs 

and Urban Indian Organizations, to the extent such data is available to the 

Service), and such other information as the Administrator may require for 

purposes of administering title XVIII, XIX, or XXI of the Social Security 

Act. 

‘‘(4) WITHDRAWAL FROM PROGRAM.—A Tribal Health Program or Urban Indian 

Organization 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. 


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‘‘(5) TERMINATION FOR FAILURE TO COMPLY WITH REQUIREMENTS.—The Secretary may terminate the participation of a Tribal Health Program or an Urban 

Indian Organization in the direct billing program established under this subsection if the Secretary determines that the Program or Organization has failed 

to comply with the requirements of paragraph (2). The Secretary shall provide 

a Tribal Health Program or Urban Indian Organization with notice of a determination that the Program or Organization has failed to comply with any such 

requirement and a reasonable opportunity to correct such noncompliance prior 

to terminating the Program’s or Organization’s participation in the direct billing 

program established under this subsection. ‘‘(e) RELATED PROVISIONS UNDER THE SOCIAL SECURITY ACT.—For provisions related to subsections (c) and (d), see sections 1880, 1911, and 2107(e)(1)(D) of the Social Security Act. 

‘‘SEC. 402. GRANTS TO AND CONTRACTS WITH THE SERVICE, INDIAN TRIBES, TRIBAL ORGANIZATIONS, AND URBAN INDIAN ORGANIZATIONS TO FACILITATE OUTREACH, ENROLLMENT, AND COVERAGE OF INDIANS UNDER SOCIAL SECURITY ACT HEALTH 

BENEFIT PROGRAMS AND OTHER HEALTH BENEFITS PROGRAMS. 

‘‘(a) INDIAN TRIBES AND TRIBAL ORGANIZATIONS.—From funds appropriated to 

carry out this title in accordance with section 415, the Secretary, acting through the 

Service, shall make grants to or enter into contracts with Indian Tribes and Tribal 

Organizations to assist such Tribes and Tribal Organizations in establishing and administering programs on or near reservations and trust lands to assist individual 

Indians—

‘‘(1) to enroll for benefits under a program established under title XVIII, XIX, 

or XXI of the Social Security Act and other health benefits programs; and ‘‘(2) with respect to such programs for which the charging of premiums and 

cost sharing is not prohibited under such programs, to pay premiums or cost 

sharing for coverage for such benefits, which may be based on financial need 

(as determined by the Indian Tribe or Tribes or Tribal Organizations being 

served based on a schedule of income levels developed or implemented by such 

Tribe, Tribes, or Tribal Organizations). ‘‘(b) CONDITIONS.—The Secretary, acting through the Service, shall place conditions as deemed necessary to effect the purpose of this section in any grant or contract which the Secretary makes with any Indian Tribe or Tribal Organization pursuant to this section. Such conditions shall include requirements that the Indian 

Tribe or Tribal Organization successfully undertake— ‘‘(1) to determine the population of Indians eligible for the benefits described 

in subsection (a); ‘‘(2) to educate Indians with respect to the benefits available under the respective programs; ‘‘(3) to provide transportation for such individual Indians to the appropriate 

offices for enrollment or applications for such benefits; and 

‘‘(4) to develop and implement methods of improving the participation of Indians in receiving benefits under such programs. 

‘‘(c) APPLICATION TO URBAN INDIAN ORGANIZATIONS.—

‘‘(1) IN GENERAL.—The provisions of subsection (a) shall apply with respect to 

grants and other funding to Urban Indian Organizations with respect to populations served by such organizations in the same manner they apply to grants 

and contracts with Indian Tribes and Tribal Organizations with respect to programs on or near reservations. 

‘‘(2) REQUIREMENTS.—The Secretary shall include in the grants or contracts 

made or provided under paragraph (1) requirements that are—

‘‘(A) consistent with the requirements imposed by the Secretary under 

subsection (b); 

‘‘(B) appropriate to Urban Indian Organizations and Urban Indians; and 

‘‘(C) necessary to effect the purposes of this section. 

‘‘(d) FACILITATING COOPERATION.—The Secretary, acting through the Centers for 

Medicare & Medicaid Services, shall take such steps as are necessary to facilitate 

cooperation with, and agreements between, States and the Service, Indian Tribes, 

Tribal Organizations, or Urban Indian Organizations with respect to the provision 

of health care items and services to Indians under the programs established under 

title XVIII, XIX, or XXI of the Social Security Act. 

‘‘(e) AGREEMENTS RELATING TO IMPROVING ENROLLMENT OF INDIANS UNDER SOCIAL SECURITY ACT HEALTH BENEFITS PROGRAMS.—For provisions relating to agreements between the Secretary, acting through the Service, and Indian Tribes, Tribal 

Organizations, and Urban Indian Organization for the collection, preparation, and 

submission of applications by Indians for assistance under the Medicaid and State 

children’s health insurance programs established under titles XIX and XXI of the 

Social Security Act, and benefits under the Medicare program established under 


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title XVIII of such Act, see subsections (a) and (b) of section 1139 of the Social Security Act. ‘‘(f) DEFINITION OF PREMIUMS AND COST SHARING.—In this section: ‘‘(1) PREMIUM.—The term ‘premium’ includes any enrollment fee or similar 

charge. ‘‘(2) COST SHARING.—The term ‘cost sharing’ includes any deduction, deductible, copayment, coinsurance, or similar charge. 

‘‘SEC. 403. REIMBURSEMENT FROM CERTAIN THIRD PARTIES OF COSTS OF HEALTH SERVICES. 

‘‘(a) RIGHT OF RECOVERY.—Except as provided in subsection (f), the United States, 

an Indian Tribe, or Tribal Organization shall have the right to recover from an insurance company, health maintenance organization, employee benefit plan, thirdparty tortfeasor, or any other responsible or liable third party (including a political 

subdivision or local governmental entity of a State) the reasonable expenses 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 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 


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complies with the format required for submission of claims under title XVIII of the 

Social Security Act or recognized under section 1175 of such Act. 

‘‘(i) APPLICATION TO URBAN INDIAN ORGANIZATIONS.—The previous provisions of 

this section shall apply to Urban Indian Organizations with respect to populations 

served by such Organizations in the same manner they apply to Indian Tribes and 

Tribal Organizations with respect to populations served by such Indian Tribes and 

Tribal Organizations. 

‘‘(j) STATUTE OF LIMITATIONS.—The provisions of section 2415 of title 28, United 

States Code, shall apply to all actions commenced under this section, and the references therein to the United States are deemed to include Indian Tribes, Tribal Organizations, and Urban Indian Organizations. 

‘‘(k) SAVINGS.—Nothing in this section shall be construed to limit any right of recovery available to the United States, an Indian Tribe, or Tribal Organization under 

the provisions of any applicable, Federal, State, or Tribal law, including medical lien 

laws and the Federal Medical Care Recovery Act (42 U.S.C. 2651 et seq.). 

‘‘SEC. 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). 

‘‘SEC. 405. PURCHASING HEALTH CARE COVERAGE. 

‘‘(a) IN GENERAL.—Insofar as amounts are made available under law (including 

a provision of the Social Security Act, the Indian Self-Determination and Education 

Assistance Act (25 U.S.C. 450 et seq.), or other law, other than under section 402) 

to Indian Tribes, Tribal Organizations, and Urban Indian Organizations for health 

benefits for Service beneficiaries, Indian Tribes, Tribal Organizations, and Urban 

Indian Organizations may use such amounts to purchase health benefits coverage 

for such beneficiaries in any manner, including through—

‘‘(1) a tribally owned and operated health care plan; 

‘‘(2) a State or locally authorized or licensed health care plan; 

‘‘(3) a health insurance provider or managed care organization; or 

‘‘(4) a self-insured plan. 

The purchase of such coverage by an Indian Tribe, Tribal Organization, or Urban 

Indian Organization may be based on the financial needs of such beneficiaries (as 

determined by the Indian Tribe or Tribes being served based on a schedule of income levels developed or implemented by such Indian Tribe or Tribes). 

‘‘(b) EXPENSES FOR SELF-INSURED PLAN.—In the case of a self-insured plan under 

subsection (a)(4), the amounts may be used for expenses of operating the plan, including administration and insurance to limit the financial risks to the entity offering the plan. 

‘‘(c) CONSTRUCTION.—Nothing in this section shall be construed as affecting the 

use of any amounts not referred to in subsection (a). 

‘‘SEC. 406. SHARING ARRANGEMENTS WITH FEDERAL AGENCIES. 

‘‘(a) AUTHORITY.—

‘‘(1) IN GENERAL.—The Secretary may enter into (or expand) arrangements for 

the sharing of medical facilities and services between the Service, Indian Tribes, 

and Tribal Organizations and the Department of Veterans Affairs and the Department of Defense. 

‘‘(2) CONSULTATION BY SECRETARY REQUIRED.—The Secretary may not finalize 

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graph (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. 

‘‘SEC. 407. PAYOR OF LAST RESORT. 

‘‘Indian Health Programs and health care programs operated by Urban Indian Organizations shall be the payor of last resort for services provided to persons eligible 

for services from Indian Health Programs and Urban Indian Organizations, notwithstanding any Federal, State, or local law to the contrary. 

‘‘SEC. 408. NONDISCRIMINATION UNDER FEDERAL HEALTH CARE PROGRAMS IN QUALIFICATIONS FOR REIMBURSEMENT FOR SERVICES. 

‘‘(a) REQUIREMENT TO SATISFY GENERALLY APPLICABLE PARTICIPATION REQUIREMENTS.—

‘‘(1) IN GENERAL.—A Federal health care program must accept an entity that 

is operated by the Service, an Indian Tribe, Tribal Organization, or Urban Indian Organization as a provider eligible to receive payment under the program 

for health care services furnished to an Indian on the same basis as any other 

provider qualified to participate as a provider of health care services under the 

program if the entity meets generally applicable State or other requirements for 

participation as a provider of health care services under the program. 

‘‘(2) SATISFACTION OF STATE OR LOCAL LICENSURE OR RECOGNITION REQUIREMENTS.—Any requirement for participation as a provider of health care services 

under a Federal health care program that an entity be licensed or recognized 

under the State or local law where the entity is located to furnish health care 

services shall be deemed to have been met in the case of an entity operated by 

the Service, an Indian Tribe, Tribal Organization, or Urban Indian Organization if the entity meets all the applicable standards for such licensure or recognition, regardless of whether the entity obtains a license or other documentation under such State or local law. In accordance with section 221, the absence 

of the licensure of a health care professional employed by such an entity under 

the State or local law where the entity is located shall not be taken into account 

for purposes of determining whether the entity meets such standards, if the professional is licensed in another State. 

‘‘(b) APPLICATION OF EXCLUSION FROM PARTICIPATION IN FEDERAL HEALTH CARE

PROGRAMS.—

‘‘(1) EXCLUDED ENTITIES.—No entity operated by the Service, an Indian Tribe, 

Tribal Organization, or Urban Indian Organization that has been excluded from 

participation in any Federal health care program or for which a license is suspended or has been revoked by the State where the entity is located shall be 

eligible to receive payment or reimbursement under any such program for 

health care services furnished to an Indian. 

‘‘(2) EXCLUDED INDIVIDUALS.—No individual who has been excluded from participation in any Federal health care program or whose State license is under 

suspension shall be eligible to receive payment or reimbursement under any 

such program for health care services furnished by that individual, directly or 

through an entity that is otherwise eligible to receive payment for health care 

services, to an Indian. 

‘‘(3) FEDERAL HEALTH CARE PROGRAM DEFINED.—In this subsection, the term, 

‘Federal health care program’ has the meaning given that term in section 


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1128B(f) of the Social Security Act (42 U.S.C. 1320a–7b(f)), except that, for purposes of this subsection, such term shall include the health insurance program 

under chapter 89 of title 5, United States Code. 

‘‘(c) RELATED PROVISIONS.—For provisions related to nondiscrimination against 

providers operated by the Service, an Indian Tribe, Tribal Organization, or Urban 

Indian Organization, see section 1139(c) of the Social Security Act (42 U.S.C. 1320b–

9(c)). 

‘‘SEC. 409. CONSULTATION. 

‘‘For provisions related to consultation with representatives of Indian Health Programs and Urban Indian Organizations with respect to the health care programs 

established under titles XVIII, XIX, and XXI of the Social Security Act, see section 

1139(d) of the Social Security Act (42 U.S.C. 1320b–9(d)). 

‘‘SEC. 410. STATE CHILDREN’S HEALTH INSURANCE PROGRAM (SCHIP). 

‘‘For provisions relating to—

‘‘(1) outreach to families of Indian children likely to be eligible for child health 

assistance under the State children’s health insurance program established 

under title XXI of the Social Security Act, see sections 2105(c)(2)(C) and 1139(a) 

of such Act (42 U.S.C. 1397ee(c)(2), 1320b–9); and 

‘‘(2) ensuring that child health assistance is provided under such program to 

targeted low-income children who are Indians and that payments are made 

under such program to Indian Health Programs and Urban Indian Organizations operating in the State that provide such assistance, see sections 

2102(b)(3)(D) and 2105(c)(6)(B) of such Act (42 U.S.C. 1397bb(b)(3)(D), 

1397ee(c)(6)(B)). 

‘‘SEC. 411. EXCLUSION WAIVER AUTHORITY FOR AFFECTED INDIAN HEALTH PROGRAMS AND 

SAFE HARBOR TRANSACTIONS UNDER THE SOCIAL SECURITY ACT. 

‘‘For provisions relating to—

‘‘(1) exclusion waiver authority for affected Indian Health Programs under the 

Social Security Act, see section 1128(k) of the Social Security Act (42 U.S.C. 

1320a–7(k)); and 

‘‘(2) certain transactions involving Indian Health Programs deemed to be in 

safe harbors under that Act, see section 1128B(b)(4) of the Social Security Act 

(42 U.S.C. 1320a–7b(b)(4)). 

‘‘SEC. 412. PREMIUM AND COST SHARING PROTECTIONS AND ELIGIBILITY DETERMINATIONS 

UNDER MEDICAID AND SCHIP AND PROTECTION OF CERTAIN INDIAN PROPERTY 

FROM MEDICAID ESTATE RECOVERY. 

‘‘For provisions relating to—

‘‘(1) premiums or cost sharing protections for Indians furnished items or services directly by Indian Health Programs or through referral under the contract 

health service under the Medicaid program established under title XIX of the 

Social Security Act, see sections 1916(j) and 1916A(a)(1) of the Social Security 

Act (42 U.S.C. 1396o(j), 1396o–1(a)(1)); 

‘‘(2) rules regarding the treatment of certain property for purposes of determining eligibility under such programs, see sections 1902(e)(13) and 

2107(e)(1)(B) of such Act (42 U.S.C. 1396a(e)(13), 1397gg(e)(1)(B)); and 

‘‘(3) the protection of certain property from estate recovery provisions under 

the Medicaid program, see section 1917(b)(3)(B) of such Act (42 U.S.C. 

1396p(b)(3)(B)). 

‘‘SEC. 413. TREATMENT UNDER MEDICAID AND SCHIP MANAGED CARE. 

‘‘For provisions relating to the treatment of Indians enrolled in a managed care 

entity under the Medicaid program under title XIX of the Social Security Act and 

Indian Health Programs and Urban Indian Organizations that are providers of 

items or services to such Indian enrollees, see sections 1932(h) and 2107(e)(1)(H) of 

the Social Security Act (42 U.S.C. 1396u–2(h), 1397gg(e)(1)(H)). 

‘‘SEC. 414. NAVAJO NATION MEDICAID AGENCY FEASIBILITY STUDY. 

‘‘(a) STUDY.—The Secretary shall conduct a study to determine the feasibility of 

treating the Navajo Nation as a State for the purposes of title XIX of the Social Security Act, to provide services to Indians living within the boundaries of the Navajo 

Nation through an entity established having the same authority and performing the 

same functions as single-State medicaid agencies responsible for the administration 

of the State plan under title XIX of the Social Security Act. 

‘‘(b) CONSIDERATIONS.—In conducting the study, the Secretary shall consider the 

feasibility of—

‘‘(1) assigning and paying all expenditures for the provision of services and 

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ans living within the boundaries of the Navajo Nation that are currently paid 

to or would otherwise be paid to the State of Arizona, New Mexico, or Utah; 

‘‘(2) providing assistance to the Navajo Nation in the development and implementation of such entity for the administration, eligibility, payment, and delivery of medical assistance under title XIX of the Social Security Act; 

‘‘(3) providing an appropriate level of matching funds for Federal medical assistance with respect to amounts such entity expends for medical assistance for 

services and related administrative costs; and 

‘‘(4) authorizing the Secretary, at the option of the Navajo Nation, to treat the 

Navajo Nation as a State for the purposes of title XIX of the Social Security 

Act (relating to the State children’s health insurance program) under terms 

equivalent to those described in paragraphs (2) through (4). 

‘‘(c) REPORT.—Not later then 3 years after the date of enactment of the Indian 

Health Act Improvement Act Amendments of 2006, 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. 

‘‘SEC. 415. 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. 

‘‘TITLE V—HEALTH SERVICES FOR URBAN 

INDIANS 

‘‘SEC. 501. PURPOSE. 

‘‘The purpose of this title is to establish and maintain programs in Urban Centers 

to make health services more accessible and available to Urban Indians. 

‘‘SEC. 502. CONTRACTS WITH, AND GRANTS TO, URBAN INDIAN ORGANIZATIONS. 

‘‘Under authority of the Act of November 2, 1921 (25 U.S.C. 13) (commonly known 

as the ‘Snyder Act’), the Secretary, acting through the Service, shall enter into contracts with, or make grants to, Urban Indian Organizations to assist such organizations in the establishment and administration, within Urban Centers, of programs 

which meet the requirements set forth in this title. Subject to section 506, the Secretary, acting through the Service, shall include such conditions as the Secretary 

considers necessary to effect the purpose of this title in any contract into which the 

Secretary enters with, or in any grant the Secretary makes to, any Urban Indian 

Organization pursuant to this title. 

‘‘SEC. 503. CONTRACTS AND GRANTS FOR THE PROVISION OF HEALTH CARE AND REFERRAL 

SERVICES. 

‘‘(a) REQUIREMENTS FOR GRANTS AND CONTRACTS.—Under authority of the Act of 

November 2, 1921 (25 U.S.C. 13) (commonly known as the ‘Snyder Act’), the Secretary, acting through the Service, shall enter into contracts with, or make grants 

to, Urban Indian Organizations for the provision of health care and referral services 

for Urban Indians. Any such contract or grant shall include requirements that the 

Urban Indian Organization successfully undertake to—

‘‘(1) estimate the population of Urban Indians residing in the Urban Center 

or centers that the organization proposes to serve who are or could be recipients 

of health care or referral services; 

‘‘(2) estimate the current health status of Urban Indians residing in such 

Urban Center or centers; 

‘‘(3) estimate the current health care needs of Urban Indians residing in such 

Urban Center or centers; 

‘‘(4) provide basic health education, including health promotion and disease 

prevention education, to Urban Indians; 


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‘‘(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; and 

‘‘(6) where necessary, provide, or enter into contracts for the provision of, 

health care services for Urban Indians. 

‘‘(b) CRITERIA.—The Secretary, acting through the Service, shall, by regulation 

adopted pursuant to section 520, prescribe the criteria for selecting Urban Indian 

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 Urban Indians in the Urban 

Center or centers involved; 

‘‘(2) the size of the Urban Indian population in the Urban Center or centers 

involved; 

‘‘(3) the extent, if any, to which the activities set forth in subsection (a) would 

duplicate any project funded under this title; 

‘‘(4) the capability of an Urban Indian Organization to perform the activities 

set forth in subsection (a) and to enter into a contract with the Secretary or to 

meet the requirements for receiving a grant under this section; 

‘‘(5) the satisfactory performance and successful completion by an Urban Indian Organization of other contracts with the Secretary under this title; 

‘‘(6) the appropriateness and likely effectiveness of conducting the activities 

set forth in subsection (a) in an Urban Center or centers; and 

‘‘(7) the extent of existing or likely future participation in the activities set 

forth in subsection (a) by appropriate health and health-related Federal, State, 

local, and other agencies. 

‘‘(c) ACCESS TO HEALTH PROMOTION AND DISEASE PREVENTION PROGRAMS.—The 

Secretary, acting through the Service, shall facilitate access to or provide health promotion and disease prevention services for Urban Indians through grants made to 

Urban Indian Organizations administering contracts entered into or receiving 

grants under subsection (a). 

‘‘(d) IMMUNIZATION SERVICES.—

‘‘(1) ACCESS OR SERVICES PROVIDED.—The Secretary, acting through the Service, shall facilitate access to, or provide, immunization services for Urban Indians through grants made to Urban Indian Organizations administering contracts entered into or receiving grants under this section. 

‘‘(2) DEFINITION.—For purposes of this subsection, the term ‘immunization 

services’ means services to provide without charge immunizations against vaccine-preventable diseases. 

‘‘(e) BEHAVIORAL HEALTH SERVICES.—

‘‘(1) ACCESS OR SERVICES PROVIDED.—The Secretary, acting through the Service, shall facilitate access to, or provide, behavioral health services for Urban 

Indians through grants made to Urban Indian Organizations administering contracts entered into or receiving grants under subsection (a). 

‘‘(2) ASSESSMENT REQUIRED.—Except as provided by paragraph (3)(A), a grant 

may not be made under this subsection to an Urban Indian Organization until 

that organization has prepared, and the Service has approved, an assessment 

of the following: 

‘‘(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 subsection for the 

following: 

‘‘(A) To prepare assessments required under paragraph (2). 

‘‘(B) To provide outreach, educational, and referral services to Urban Indians regarding the availability of direct behavioral health services, to educate Urban Indians about behavioral health issues and services, and effect 

coordination with existing behavioral health providers in order to improve 

services to Urban Indians. 

‘‘(C) To provide outpatient behavioral health services to Urban Indians, 

including the identification and assessment of illness, therapeutic treatments, case management, support groups, family treatment, and other 

treatment. 

‘‘(D) To develop innovative behavioral health service delivery models 

which incorporate Indian cultural support systems and resources. 

‘‘(f) PREVENTION OF CHILD ABUSE.—


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‘‘(1) ACCESS OR SERVICES PROVIDED.—The Secretary, acting through the Service, shall facilitate access to or provide services for Urban Indians through 

grants to Urban Indian Organizations administering contracts entered into or 

receiving grants under subsection (a) to prevent and treat child abuse (including 

sexual abuse) among Urban Indians. 

‘‘(2) EVALUATION REQUIRED.—Except as provided by paragraph (3)(A), a grant 

may not be made under this subsection to an Urban Indian Organization until 

that organization has prepared, and the Service has approved, an assessment 

that documents the prevalence of child abuse in the 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 subsection for the 

following: 

‘‘(A) To prepare assessments required under paragraph (2). 

‘‘(B) For the development of prevention, training, and education programs 

for Urban Indians, including child education, parent education, provider 

training on identification and intervention, education on reporting requirements, prevention campaigns, and establishing service networks of all those 

involved in Indian child protection. 

‘‘(C) To provide direct outpatient treatment services (including individual 

treatment, family treatment, group therapy, and support groups) to 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 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 Urban Indian 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 Urban Indian Organization to address the complex problem of child sexual abuse in the community; and 

‘‘(C) the assessment required under paragraph (2). 

‘‘(g) OTHER GRANTS.—The Secretary, acting through the Service, may enter into 

a contract with or make grants to an Urban Indian Organization that provides or 

arranges for the provision of health care services (through satellite facilities, provider networks, or otherwise) to Urban Indians in more than 1 Urban Center. 

‘‘SEC. 504. CONTRACTS AND GRANTS FOR THE DETERMINATION OF UNMET HEALTH CARE 

NEEDS. 

‘‘(a) GRANTS AND CONTRACTS AUTHORIZED.—Under authority of the Act of November 2, 1921 (25 U.S.C. 13) (commonly known as the ‘Snyder Act’), the Secretary, acting through the Service, may enter into contracts with or make grants to Urban Indian Organizations situated in Urban Centers for which contracts have not been entered into or grants have not been made under section 503. 

‘‘(b) PURPOSE.—The purpose of a contract or grant made under this section shall 

be the determination of the matters described in subsection (c)(1) in order to assist 

the Secretary in assessing the health status and health care needs of Urban Indians 

in the Urban Center involved and determining whether the Secretary should enter 

into a contract or make a grant under section 503 with respect to the Urban Indian 

Organization which the Secretary has entered into a contract with, or made a grant 

to, under this section. 

‘‘(c) GRANT AND CONTRACT REQUIREMENTS.—Any contract entered into, or grant 

made, by the Secretary under this section shall include requirements that—

‘‘(1) the Urban Indian Organization successfully undertakes to—

‘‘(A) document the health care status and unmet health care needs of 

Urban Indians in the Urban Center involved; and 

‘‘(B) with respect to Urban Indians in the Urban Center involved, determine the matters described in paragraphs (2), (3), (4), and (7) of section 

503(b); and 

‘‘(2) the Urban Indian Organization complete performance of the contract, or 

carry out the requirements of the grant, within 1 year after the date on which 

the Secretary and such organization enter into such contract, or within 1 year 

after such organization receives such grant, whichever is applicable. 

‘‘(d) NO RENEWALS.—The Secretary may not renew any contract entered into or 

grant made under this section. 


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‘‘SEC. 505. EVALUATIONS; RENEWALS. 

‘‘(a) PROCEDURES FOR EVALUATIONS.—The Secretary, acting through the Service, 

shall develop procedures to evaluate compliance with grant requirements and compliance with and performance of contracts entered into by Urban Indian Organizations under this title. Such procedures shall include provisions for carrying out the 

requirements of this section. ‘‘(b) EVALUATIONS.—The Secretary, acting through the Service, shall evaluate the 

compliance of each Urban Indian Organization which has entered into a contract or 

received a grant under section 503 with 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; UNSATISFACTORY PERFORMANCE.—If, as a result of the evaluations conducted under this section, the Secretary determines that an Urban Indian Organization has not complied with the requirements of a grant or complied 

with or satisfactorily performed a contract under section 503, the Secretary shall, 

prior to renewing such contract or grant, attempt to resolve with the organization 

the areas of noncompliance or unsatisfactory performance and modify the contract 

or grant to prevent future occurrences of noncompliance or unsatisfactory performance. If the Secretary determines that the noncompliance or unsatisfactory performance cannot be resolved and prevented in the future, the Secretary shall not renew 

the contract or grant with the organization and is authorized to enter into a contract or make a grant under section 503 with another Urban Indian Organization 

which is situated in the same Urban Center as the Urban Indian Organization 

whose contract or grant is not renewed under this section. ‘‘(d) CONSIDERATIONS FOR RENEWALS.—In determining whether to renew a contract or grant with an Urban Indian Organization under section 503 which has completed performance of a contract or grant under section 504, the Secretary shall review the records of the Urban Indian Organization, the reports submitted under section 507, and shall consider the results of the onsite evaluations or accreditations 

under subsection (b). 

‘‘SEC. 506. OTHER CONTRACT AND GRANT REQUIREMENTS. 

‘‘(a) PROCUREMENT.—Contracts with Urban Indian Organizations entered into 

pursuant to this title shall be in accordance with all Federal contracting laws and 

regulations relating to procurement except that in the discretion of the Secretary, 

such contracts may be negotiated without advertising and need not conform to the 

provisions of sections 1304 and 3131 through 3133 of title 40, United States Code. 

‘‘(b) PAYMENTS UNDER CONTRACTS OR GRANTS.—Payments under any contracts or 

grants pursuant to this title shall, notwithstanding any term or condition of such 

contract or grant—

‘‘(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 AMENDMENT OF CONTRACTS.—Notwithstanding any provision of 

law to the contrary, the Secretary may, at the request or consent of an Urban Indian Organization, revise or amend any contract entered into by the Secretary with 

such organization under this title as necessary to carry out the purposes of this 

title. 

‘‘(d) FAIR AND UNIFORM SERVICES AND ASSISTANCE.—Contracts with or grants to 

Urban Indian Organizations and regulations adopted pursuant to this title shall include provisions to assure the fair and uniform provision to Urban Indians of services and assistance under such contracts or grants by such organizations. 

‘‘SEC. 507. REPORTS AND RECORDS. 

‘‘(a) REPORTS.—For each fiscal year during which an Urban Indian Organization 

receives or expends funds pursuant to a contract entered into or a grant received 


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pursuant to this title, such Urban Indian Organization shall submit to the Secretary 

not more frequently than every 6 months, a report that includes the following: 

‘‘(1) In the case of a contract or grant under section 503, recommendations 

pursuant to section 503(a)(5). 

‘‘(2) Information on activities conducted by the organization pursuant to the 

contract or grant. 

‘‘(3) An accounting of the amounts and purpose for which Federal funds were 

expended. 

‘‘(4) A minimum set of data, using uniformly defined elements, that is specified by the Secretary in consultation, consistent with section 514, with Urban 

Indian Organizations. 

‘‘(b) AUDIT.—The reports and records of the Urban Indian Organization with respect to a contract or grant under this title shall be subject to audit by the Secretary 

and the Comptroller General of the United States. 

‘‘(c) COSTS OF AUDITS.—The Secretary shall allow as a cost of any contract or 

grant entered into or awarded under section 502 or 503 the cost of an annual independent financial audit conducted by—

‘‘(1) a certified public accountant; or 

‘‘(2) a certified public accounting firm qualified to conduct Federal compliance 

audits. 

‘‘SEC. 508. LIMITATION ON CONTRACT AUTHORITY. 

‘‘The authority of the Secretary to enter into contracts or to award grants under 

this title shall be to the extent, and in an amount, provided for in appropriation 

Acts. 

‘‘SEC. 509. FACILITIES. 

‘‘(a) GRANTS.—The Secretary, acting through the Service, may make grants to contractors or grant recipients under this title for the lease, purchase, renovation, construction, or expansion of facilities, including leased facilities, in order to assist such 

contractors or grant recipients in complying with applicable licensing or certification 

requirements. 

‘‘(b) LOANS.—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. 

‘‘SEC. 510. DIVISION OF URBAN INDIAN HEALTH. 

‘‘There is hereby established within the Service a Division of Urban Indian 

Health, which shall be responsible for—

‘‘(1) carrying out the provisions of this title; 

‘‘(2) providing central oversight of the programs and services authorized under 

this title; and 

‘‘(3) providing technical assistance to Urban Indian Organizations. 

‘‘SEC. 511. GRANTS FOR ALCOHOL AND SUBSTANCE ABUSE-RELATED 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, alcohol and 

substance abuse in Urban Centers to those Urban Indian Organizations with which 

the Secretary has entered into a contract under this title or under section 201. 

‘‘(b) GOALS.—Each grant made pursuant to subsection (a) 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), including criteria relating to the following: 

‘‘(1) The size of the Urban Indian population. 

‘‘(2) Capability of the organization to adequately perform the activities required under the grant. 

‘‘(3) Satisfactory performance standards for the organization in meeting the 

goals set forth in such grant. The standards shall be negotiated and agreed to 

between the Secretary and the grantee on a grant-by-grant basis. 

‘‘(4) Identification of the need for services. 

‘‘(d) ALLOCATION OF GRANTS.—The Secretary shall develop a methodology for allocating grants made pursuant to this section based on the criteria established pursuant to subsection (c). 

‘‘(e) GRANTS SUBJECT TO CRITERIA.—Any funds received by an Urban Indian Organization under this Act for substance abuse prevention, treatment, and rehabilitation shall be subject to the criteria set forth in subsection (c). 


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‘‘SEC. 512. TREATMENT OF CERTAIN DEMONSTRATION PROJECTS. 

‘‘Notwithstanding any other provision of law, the Tulsa Clinic and Oklahoma City 

Clinic demonstration projects shall— ‘‘(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.). 

‘‘SEC. 513. URBAN NIAAA TRANSFERRED PROGRAMS. 

‘‘(a) GRANTS AND CONTRACTS.—The Secretary, through the Office of Urban Indian 

Health, shall make grants or enter into contracts with Urban Indian Organizations, 

to take effect not later than September 30, 2008, for the administration of Urban 

Indian alcohol programs that were originally established under the National Institute on Alcoholism and Alcohol Abuse (hereafter in this section referred to as 

‘NIAAA’) and transferred to the Service. ‘‘(b) USE OF FUNDS.—Grants provided or contracts entered into under this section 

shall be used to provide support for the continuation of alcohol prevention and treatment services for 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.—Urban Indian 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. ‘‘(d) REPORT.—The Secretary shall evaluate and report to Congress on the activities of programs funded under this section not less than every 5 years. 

‘‘SEC. 514. CONSULTATION WITH URBAN INDIAN ORGANIZATIONS. 

‘‘(a) IN GENERAL.—The Secretary shall ensure that the Service consults, to the 

greatest extent practicable, with Urban Indian Organizations. ‘‘(b) DEFINITION OF CONSULTATION.—For purposes of subsection (a), consultation 

is the open and free exchange of information and opinions which leads to mutual 

understanding and comprehension and which emphasizes trust, respect, and shared 

responsibility. 

‘‘SEC. 515. URBAN YOUTH TREATMENT CENTER DEMONSTRATION. 

‘‘(a) CONSTRUCTION AND OPERATION.—The Secretary, acting through the Service, 

through grant or contract, is authorized to fund the construction and operation of 

at least 2 residential treatment centers in each State described in subsection (b) to 

demonstrate the provision of alcohol and substance abuse treatment services to 

Urban Indian youth in a culturally competent residential setting. ‘‘(b) DEFINITION OF STATE.—A State described in this subsection is a State in 

which—

‘‘(1) there resides Urban Indian youth with need for alcohol and substance 

abuse treatment services in a residential setting; and ‘‘(2) there is a significant shortage of culturally competent residential treatment services for Urban Indian youth. 

‘‘SEC. 516. 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 real and 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 


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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 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. 

‘‘SEC. 517. 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). 

‘‘SEC. 518. COMMUNITY HEALTH REPRESENTATIVES. 

‘‘The Secretary, acting through the Service, may enter into contracts with, and 

make grants to, Urban Indian Organizations for the employment of Indians trained 

as health service providers through the Community Health Representatives Program under section 109 in the provision of health care, health promotion, and disease prevention services to Urban Indians. 

‘‘SEC. 519. EFFECTIVE DATE. 

‘‘The amendments made by the Indian Health Care Improvement Act Amendments of 2006 to this title shall take effect beginning on the date of enactment of 

that Act, regardless of whether the Secretary has promulgated regulations implementing such amendments. 

‘‘SEC. 520. ELIGIBILITY FOR SERVICES. 

‘‘Urban Indians shall be eligible and the ultimate beneficiaries for health care or 

referral services provided pursuant to this title. 

‘‘SEC. 521. 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. 

‘‘TITLE VI—ORGANIZATIONAL IMPROVEMENTS 

‘‘SEC. 601. ESTABLISHMENT OF THE INDIAN HEALTH SERVICE AS AN AGENCY OF THE PUBLIC 

HEALTH SERVICE. 

‘‘(a) ESTABLISHMENT.— ‘‘(1) IN GENERAL.—In order to more effectively and efficiently carry out the responsibilities, authorities, and functions of the United States to provide health 

care services to Indians and Indian Tribes, as are or may be hereafter provided 

by Federal statute or treaties, there is established within the Public Health 

Service of the Department the Indian Health Service. 

‘‘(2) ASSISTANT SECRETARY OF INDIAN HEALTH.—The Service shall be administered by an Assistant Secretary of Indian Health, who shall be appointed by the 


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President, by and with the advice and consent of the Senate. The Assistant Secretary shall report to the Secretary. Effective with respect to an individual appointed by the President, by and with the advice and consent of the Senate, 

after January 1, 2005, the term of service of the Assistant Secretary shall be 

4 years. An Assistant Secretary may serve more than 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 2006 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.—The Service shall be an agency within the Public Health Service 

of the Department, and shall not be an office, component, or unit of any other agency of the Department. 

‘‘(c) DUTIES.—The Assistant Secretary of Indian Health shall—

‘‘(1) perform all functions that were, on the day before the date of enactment 

of the Indian Health Care Improvement Act Amendments of 2006, carried out 

by or under the direction of the individual serving as Director of the Service 

on that day; 

‘‘(2) perform all functions of the Secretary relating to the maintenance and 

operation of hospital and health facilities for Indians and the planning for, and 

provision and utilization of, health services for Indians; 

‘‘(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 programs under—

‘‘(A) this Act; 

‘‘(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. 450 et seq.); 

‘‘(4) administer all scholarship and loan functions carried out under title I; 

‘‘(5) report directly to the Secretary concerning all policy- and budget-related 

matters affecting Indian health; 

‘‘(6) collaborate with the Assistant Secretary for Health concerning appropriate matters of Indian health that affect the agencies of the Public Health 

Service; 

‘‘(7) advise each Assistant Secretary of the Department concerning matters of 

Indian health with respect to which that Assistant Secretary has authority and 

responsibility; 

‘‘(8) advise the heads of other agencies and programs of the Department concerning matters of Indian health with respect to which those heads have authority and responsibility; 

‘‘(9) coordinate the activities of the Department concerning matters of Indian 

health; and 

‘‘(10) perform such other functions as the Secretary may designate. 

‘‘(d) AUTHORITY.—

‘‘(1) IN GENERAL.—The Secretary, acting through the Assistant Secretary, 

shall have the authority—

‘‘(A) except to the extent provided for in paragraph (2), to appoint and 

compensate employees for the Service in accordance with title 5, United 

States Code; 

‘‘(B) to enter into contracts for the procurement of goods and services to 

carry out the functions of the Service; and 

‘‘(C) to manage, expend, and obligate all funds appropriated for the Service. 

‘‘(2) PERSONNEL ACTIONS.—Notwithstanding any other provision of law, the 

provisions of section 12 of the Act of June 18, 1934 (48 Stat. 986; 25 U.S.C. 

472), shall apply to all personnel actions taken with respect to new positions 

created within the Service as a result of its establishment under subsection (a). 

‘‘(e) REFERENCES.—Any reference to the Director of the Indian Health Service in 

any Federal law, Executive order, rule, regulation, or delegation of authority, or in 

any document of or relating to the Director of the Indian Health Service, shall be 

deemed to refer to the Assistant Secretary. 


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‘‘SEC. 602. AUTOMATED MANAGEMENT INFORMATION 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 system; 

‘‘(B) a patient care information system for each area served by the Service; ‘‘(C) a privacy component that protects the privacy of patient information 

held by, or on behalf of, the Service; ‘‘(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 Area office of the Service; ‘‘(E) an interface mechanism for patient billing and accounts receivable 

system; and ‘‘(F) a training component. ‘‘(b) PROVISION OF SYSTEMS TO TRIBES AND ORGANIZATIONS.—The Secretary shall 

provide each Tribal Health Program automated management information systems 

which—

‘‘(1) meet the management information needs of such Tribal Health Program 

with respect to the treatment by the Tribal Health Program of patients of the 

Service; and ‘‘(2) meet the management information needs of the Service. ‘‘(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, and private and 

nonprofit organizations, for the purpose of enhancing information technology in Indian health programs and facilities. 

‘‘SEC. 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 PROGRAMS 

‘‘SEC. 701. BEHAVIORAL HEALTH PREVENTION AND TREATMENT SERVICES. 

‘‘(a) PURPOSES.—The purposes of this section are as follows: 

‘‘(1) To authorize and direct the Secretary, acting through the Service, Indian 

Tribes, Tribal Organizations, and Urban Indian Organizations, to develop a 

comprehensive behavioral health prevention and treatment program which emphasizes collaboration among alcohol and substance abuse, social services, and 

mental health programs. 

‘‘(2) To provide information, direction, and guidance relating to mental illness 

and dysfunction and self-destructive behavior, including child abuse and family 

violence, to those Federal, tribal, State, and local agencies responsible for programs in Indian communities in areas of health care, education, social services, 

child and family welfare, alcohol and substance abuse, law enforcement, and judicial services. 

‘‘(3) To assist Indian Tribes to identify services and resources available to address mental illness and dysfunctional and self-destructive 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 


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in developing areawide plans for Indian Behavioral Health Services. The plans 

shall include, to the extent feasible, the following components: ‘‘(A) An assessment of the scope of alcohol or other substance abuse, mental illness, and dysfunctional and self-destructive behavior, including suicide, child abuse, and family violence, among Indians, including— ‘‘(i) the number of Indians served who are directly or indirectly affected by such illness or behavior; or ‘‘(ii) an estimate of the financial and human cost attributable to such 

illness or behavior. ‘‘(B) An assessment of the existing and additional resources necessary for 

the prevention and treatment of such illness and behavior, including an assessment of the progress toward achieving the availability of the full continuum of care described in subsection (c). ‘‘(C) An estimate of the additional funding needed by the Service, Indian 

Tribes, Tribal Organizations, and Urban 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; and 

‘‘(I) diagnostic services. 

‘‘(2) CHILD CARE.—Behavioral health services for Indians from birth through 

age 17, including—

‘‘(A) preschool and school age fetal alcohol disorder services, including assessment and behavioral intervention; 

‘‘(B) mental health and substance abuse services (emotional, organic, alcohol, drug, inhalant, and tobacco); 

‘‘(C) identification and treatment of co-occurring disorders and comorbidity; 

‘‘(D) prevention of alcohol, drug, inhalant, and tobacco use; 

‘‘(E) early intervention, treatment, and aftercare; 

‘‘(F) promotion of healthy choices and lifestyle (related to sexually transmitted diseases, domestic violence, sexual abuse, suicide, teen pregnancy, 

obesity, and other risk/safety issues); and 

‘‘(G) identification and treatment of neglect and physical, mental, and 

sexual abuse. 

‘‘(3) ADULT CARE.—Behavioral health services for Indians from age 18 through 

55, including—

‘‘(A) early intervention, treatment, and aftercare; 

‘‘(B) mental health and substance abuse services (emotional, alcohol, 

drug, inhalant, and tobacco), including gender specific services; 

‘‘(C) identification and treatment of co-occurring disorders (dual diagnosis) and comorbidity; 

‘‘(D) promotion of gender specific healthy choices and lifestyle (related to 

parenting, partners, domestic violence, sexual abuse, suicide, obesity, and 

other risk-related behavior); 

‘‘(E) treatment services for women at risk of giving birth to a child with 

a fetal alcohol disorder; and 


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‘‘(F) gender 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 choices and lifestyle (related to parenting, partners, 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 gender specific services; 

‘‘(C) identification and treatment of co-occurring disorders (dual diagnosis) and comorbidity; 

‘‘(D) promotion of healthy choices and lifestyle (managing conditions related to aging); 

‘‘(E) gender 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 self-destructive behavior, 

including child abuse and family violence, among its members or its service population. This plan should include behavioral health services, social services, intensive outpatient services, and continuing aftercare. 

‘‘(2) TECHNICAL ASSISTANCE.—At the request of an Indian Tribe, Tribal Organization, or Urban Indian Organization, the Bureau of Indian Affairs and the 

Service shall cooperate with and provide technical assistance to the Indian 

Tribe, Tribal Organization, or Urban Indian Organization in the development 

and implementation of such plan. 

‘‘(3) FUNDING.—The Secretary, acting through the Service, may make funding 

available to Indian Tribes and Tribal Organizations which adopt a resolution 

pursuant to paragraph (1) to obtain technical assistance for the development of 

a community behavioral health plan and to provide administrative support in 

the implementation of such plan. 

‘‘(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 

2006, the Secretary, acting through the Service, shall make an assessment of the 

need for inpatient mental health care among Indians and the availability and cost 

of inpatient mental health facilities which can meet such need. In making such assessment, the Secretary shall consider the possible conversion of existing, underused 

Service hospital beds into psychiatric units to meet such need. 

‘‘SEC. 702. MEMORANDA OF AGREEMENT WITH THE DEPARTMENT OF THE INTERIOR. 

‘‘(a) CONTENTS.—Not later than 12 months after the date of the enactment of the 

Indian Health Care Improvement Act Amendments of 2006, the Secretary, acting 

through the Service, and the Secretary of the Interior shall develop and enter into 

one or more 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. 


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‘‘(C) The actions necessary to protect the exercise of such right. 

‘‘(5) The responsibilities of the Bureau of Indian Affairs and the Service, including mental illness identification, prevention, education, referral, and treatment services (including services through multidisciplinary resource teams), at 

the central, area, and agency and Service Unit, Service Area, and headquarters 

levels to address the problems identified in paragraph (1). 

‘‘(6) A strategy for the comprehensive coordination of the behavioral health 

services provided by the Bureau of Indian Affairs and the Service to meet the 

problems identified pursuant to paragraph (1), including—

‘‘(A) the coordination of alcohol and substance abuse programs of the 

Service, the Bureau of Indian Affairs, and Indian Tribes and Tribal Organizations (developed under the Indian Alcohol and Substance Abuse Prevention and Treatment Act of 1986) 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 memoranda of agreement updated or 

entered into pursuant to subsection (a) shall include specific provisions pursuant to 

which the Service shall assume responsibility for—

‘‘(1) the determination of the scope of the problem of alcohol and substance 

abuse among Indians, including the number of Indians within the jurisdiction 

of the Service who are directly or indirectly affected by alcohol and substance 

abuse and the financial and human cost; 

‘‘(2) an assessment of the existing and needed resources necessary for the prevention of alcohol and substance abuse and the treatment of Indians affected 

by alcohol and substance abuse; and 

‘‘(3) an estimate of the funding necessary to adequately support a program of 

prevention of alcohol and substance abuse and treatment of Indians affected by 

alcohol and substance abuse. 

‘‘(c) 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 

‘‘(4) behavioral health service providers. 

‘‘(d) PUBLICATION.—Each memorandum of agreement entered into or renewed (and 

amendments or modifications thereto) under subsection (a) shall be published in the 

Federal Register. At the same time as publication in the Federal Register, the Secretary shall provide a copy of each such memorandum, amendment, or modification 

to each Indian Tribe, Tribal Organization, and Urban Indian Organization. 

‘‘SEC. 703. COMPREHENSIVE BEHAVIORAL HEALTH PREVENTION AND TREATMENT 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, prevention, 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 treatment; 

‘‘(C) community-based rehabilitation and aftercare; 

‘‘(D) community education and involvement, including extensive training 

of health care, educational, and community-based personnel; 

‘‘(E) specialized residential treatment programs for high-risk populations, 

including pregnant and postpartum women and their children; and 

‘‘(F) diagnostic services. 


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‘‘(2) TARGET POPULATIONS.—The target population of such programs shall be 

members of Indian 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 HEALTH SERVICES.—

‘‘(1) IN GENERAL.—The Secretary, acting through the Service, Indian Tribes, 

and Tribal Organizations, may enter into contracts with public or private providers of behavioral health treatment services for the purpose of carrying out 

the program required under subsection (a). 

‘‘(2) PROVISION OF ASSISTANCE.—In carrying out this subsection, the Secretary 

shall provide assistance to Indian Tribes and Tribal Organizations to develop 

criteria for the certification of behavioral health service providers and accreditation of service facilities which meet minimum standards for such services and 

facilities. 

‘‘SEC. 704. MENTAL HEALTH TECHNICIAN PROGRAM. 

‘‘(a) IN GENERAL.—Under the authority of the Act of November 2, 1921 (25 U.S.C. 

13) (commonly known as the ‘Snyder Act’), the Secretary shall establish and maintain a mental health technician program within the Service which—

‘‘(1) provides for the training of Indians as mental health technicians; and 

‘‘(2) employs such technicians in the provision of community-based mental 

health care that includes identification, prevention, education, referral, and 

treatment services. 

‘‘(b) PARAPROFESSIONAL TRAINING.—In carrying out subsection (a), the Secretary, 

acting through the Service, Indian Tribes, and Tribal Organizations, shall provide 

high-standard paraprofessional training in mental health care necessary to provide 

quality care to the Indian communities to be served. Such training shall be based 

upon a curriculum developed or approved by the Secretary which combines education in the theory of mental health care with supervised practical experience in 

the provision of such care. 

‘‘(c) SUPERVISION AND EVALUATION OF TECHNICIANS.—The Secretary, acting 

through the Service, Indian Tribes, and Tribal Organizations, shall supervise and 

evaluate the mental health technicians in the training program. 

‘‘(d) TRADITIONAL HEALTH CARE PRACTICES.—The Secretary, acting through the 

Service, shall ensure that the program established pursuant to this subsection involves the use and promotion of the Traditional Health Care Practices of the Indian 

Tribes to be served. 

‘‘SEC. 705. LICENSING REQUIREMENT FOR MENTAL HEALTH CARE WORKERS. 

‘‘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 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. 

‘‘SEC. 706. INDIAN WOMEN TREATMENT PROGRAMS. 

‘‘(a) FUNDING.—The Secretary, consistent with section 701, shall make funds 

available to Indian Tribes, Tribal Organizations, and Urban Indian Organizations 

to develop and implement a comprehensive behavioral health program of prevention, intervention, treatment, and relapse prevention services that specifically addresses the spiritual, cultural, historical, social, and child care needs of Indian 

women, regardless of age. 

‘‘(b) USE OF GRANT.—A grant made available 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 issues, including fetal alcohol disorders; 

‘‘(2) identify and provide psychological services, counseling, advocacy, support, 

and relapse prevention to Indian women and their families; and 

‘‘(3) develop prevention and intervention models for Indian women which incorporate Traditional Health Care Practices, cultural values, and community 

and family involvement. 

‘‘(c) CRITERIA.—The Secretary, in consultation with Indian Tribes and Tribal Organizations, shall establish criteria for the review and approval of applications and 

proposals for funding 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. 


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‘‘SEC. 707. INDIAN YOUTH PROGRAM. 

‘‘(a) DETOXIFICATION AND 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. 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 Assistance Act. Regional centers shall be integrated with the intake and rehabilitation programs based in the 

referring Indian community. ‘‘(b) ALCOHOL AND SUBSTANCE ABUSE TREATMENT CENTERS OR FACILITIES.— ‘‘(1) ESTABLISHMENT.— ‘‘(A) IN GENERAL.—The Secretary, acting through the Service, Indian 

Tribes, and Tribal Organizations, shall construct, renovate, or, as necessary, purchase, and appropriately staff and operate, at least 1 youth regional treatment center or treatment network in each area under the jurisdiction of an Area Office. ‘‘(B) AREA OFFICE IN CALIFORNIA.—For the purposes of this subsection, 

the Area Office in California shall be considered to be 2 Area Offices, 1 office whose jurisdiction 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 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 Tribes to be served by such center. 

‘‘(4) SPECIFIC PROVISION OF FUNDS.—

‘‘(A) IN GENERAL.—Notwithstanding any other provision of this title, the 

Secretary may, from amounts authorized to be appropriated for the purposes of carrying out this section, make funds available to—

‘‘(i) the Tanana Chiefs Conference, Incorporated, for the purpose of 

leasing, constructing, renovating, 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 4(l) of the Indian Self-Determination and Education Assistance Act (25 U.S.C. 450b(l)). 

‘‘(B) PROVISION OF SERVICES TO ELIGIBLE YOUTHS.—Until additional residential youth treatment facilities are established in Alaska pursuant to this 

section, the facilities specified in subparagraph (A) shall make every effort 

to provide services to all eligible Indian youths residing in Alaska. 

‘‘(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 Traditional 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 reVerDate Aug 31 2005 06:24 Sep 16, 2006 Jkt 049006 PO 00000 Frm 00068 Fmt 6659 Sfmt 6621 E:\HR\OC\HR661P1.XXX HR661P1

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view and approval of applications or proposals for funding made available pursuant to this subsection. 

‘‘(d) FEDERALLY OWNED STRUCTURES.—

‘‘(1) IN GENERAL.—The Secretary, in consultation with Indian Tribes and Tribal Organizations, shall—

‘‘(A) identify and use, where appropriate, federally owned structures suitable for local residential or regional behavioral health treatment 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 local residential or regional behavioral health treatment 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) REHABILITATION AND AFTERCARE SERVICES.—

‘‘(1) IN GENERAL.—The Secretary, Indian Tribes, or Tribal Organizations, in 

cooperation with the Secretary of the Interior, shall develop and implement 

within each Service Unit, community-based rehabilitation and follow-up services 

for Indian youths who are having significant behavioral health problems, and 

require long-term treatment, community reintegration, and monitoring to support the Indian youths after their return to their home community. 

‘‘(2) ADMINISTRATION.—Services under paragraph (1) shall be provided 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 include alcohol and substance abuse counselors, mental health professionals, and other health professionals and paraprofessionals, including community health representatives. 

‘‘(f) INCLUSION OF FAMILY IN YOUTH TREATMENT 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) shall be used for outpatient care of adult family members related to the treatment of an Indian youth 

under that subsection. 

‘‘(g) MULTIDRUG ABUSE PROGRAM.—The Secretary, acting through the Service, Indian Tribes, Tribal Organizations, and Urban Indian Organizations, shall provide, 

consistent with section 701, programs and services to prevent and treat the abuse 

of multiple forms of substances, including alcohol, drugs, inhalants, and tobacco, 

among Indian youths residing in Indian communities, on or near reservations, and 

in urban areas and provide appropriate mental health services to address the incidence of mental illness among such youths. 

‘‘SEC. 708. INPATIENT AND COMMUNITY-BASED MENTAL HEALTH FACILITIES DESIGN, CONSTRUCTION, AND STAFFING. 

‘‘Not later than 1 year after the date of the enactment of the Indian Health Care 

Improvement Act Amendments of 2006, the Secretary, acting through the Service, 

Indian Tribes, and Tribal Organizations, may provide, in each area of the Service, 

not less than 1 inpatient mental health care facility, or the equivalent, for Indians 

with behavioral health problems. For the purposes of this subsection, California 

shall be considered to be 2 Area Offices, 1 office whose location shall be considered 

to encompass the northern area of the State of California and 1 office whose jurisdiction shall be considered to encompass the remainder of the State of California. 

The Secretary shall consider the possible conversion of existing, underused Service 

hospital beds into psychiatric units to meet such need. 

‘‘SEC. 709. TRAINING AND COMMUNITY EDUCATION. 

‘‘(a) PROGRAM.—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 Service Unit or tribal program, a 

program of community education and involvement which shall be designed to provide concise and timely information to the community leadership of each tribal community. Such program shall include education about behavioral health issues to political leaders, 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 proVerDate Aug 31 2005 06:24 Sep 16, 2006 Jkt 049006 PO 00000 Frm 00069 Fmt 6659 Sfmt 6621 E:\HR\OC\HR661P1.XXX HR661P1

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vider training (designed for adult learners from the communities receiving services 

for prevention, intervention, treatment, and aftercare). 

‘‘(b) INSTRUCTION.—The Secretary, acting through the Service, shall, either directly or through Indian Tribes and Tribal Organizations, provide instruction in the 

area of behavioral health issues, including instruction in crisis intervention and 

family relations in the context of alcohol and substance abuse, child sexual abuse, 

youth alcohol and substance abuse, and the causes and effects of fetal alcohol disorders to appropriate employees of the Bureau of Indian Affairs and the Service, 

and to personnel in schools or programs operated under any contract with the Bureau of Indian Affairs or the Service, including supervisors of emergency shelters 

and halfway houses described in section 4213 of the Indian Alcohol and Substance 

Abuse Prevention and Treatment Act of 1986 (25 U.S.C. 2433). 

‘‘(c) TRAINING MODELS.—In carrying out the education and training programs required by this section, the Secretary, in consultation with Indian Tribes, 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 faced by children of alcoholics; 

‘‘(2) the cultural, spiritual, and multigenerational aspects of behavioral health 

problem prevention and recovery; and 

‘‘(3) community-based and multidisciplinary strategies for preventing and 

treating behavioral health problems. 

‘‘SEC. 710. 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 

Indian healing and treatment 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 applications or proposals for funding for projects to be operated under 

any contract or compact under the Indian Self-Determination and Education Assistance Act (25 U.S.C. 450 et seq.), use the same criteria that the Secretary uses in 

evaluating any other application or proposal for such funding. 

‘‘SEC. 711. FETAL ALCOHOL DISORDER PROGRAMS. 

‘‘(a) PROGRAMS.—

‘‘(1) ESTABLISHMENT.—The Secretary, consistent with section 701, acting 

through the Service, Indian Tribes, and Tribal Organizations, is authorized to 

establish and operate fetal alcohol disorder programs as provided in this section 

for the purposes of meeting the health status objectives specified in section 3. 

‘‘(2) USE OF FUNDS.—Funding provided pursuant to this section shall be used 

for the following: 

‘‘(A) To develop and provide for Indians community and in-school training, education, and prevention programs relating to fetal alcohol disorders. 

‘‘(B) To identify and provide behavioral health treatment to high-risk Indian women and high-risk women pregnant with an Indian’s child. 

‘‘(C) To identify and provide appropriate psychological services, educational and vocational support, counseling, advocacy, and information to 

fetal alcohol disorder affected Indians and their families or caretakers. 

‘‘(D) To develop and implement counseling and support programs in 

schools for fetal alcohol disorder affected Indian children. 

‘‘(E) To develop prevention and intervention models which incorporate 

traditional healers, cultural and spiritual values, and community involvement. 


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‘‘(F) To develop, print, and disseminate education and prevention materials on fetal alcohol disorder. 

‘‘(G) To develop and implement, through the tribal consultation process, 

culturally sensitive assessment and diagnostic tools including 

dysmorphology clinics and multidisciplinary fetal alcohol disorder clinics for 

use in 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 services for Indians and women pregnant with Indian children; and 

‘‘(ii) to the extent funding is available, community-based 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 under this section. 

‘‘(b) SERVICES.—The Secretary, acting through the Service and Indian Tribes, 

Tribal Organizations, and Urban Indian Organizations, shall—

‘‘(1) develop and provide services for the prevention, intervention, treatment, 

and aftercare for those affected by fetal alcohol disorder in Indian communities; 

and 

‘‘(2) provide supportive services, directly or through an Indian Tribe, Tribal 

Organization, or Urban Indian Organization, including services to meet the special educational, vocational, school-to-work transition, and independent living 

needs of adolescent and adult Indians with fetal alcohol disorder. 

‘‘(c) TASK FORCE.—The Secretary shall establish a task force to be known as the 

Fetal Alcohol Disorder Task Force to advise the Secretary in carrying out subsection 

(b). Such task force shall be composed of representatives from the following: 

‘‘(1) The National Institute on Drug Abuse. 

‘‘(2) The National Institute on Alcohol and Alcoholism. 

‘‘(3) The Office of Substance Abuse Prevention. 

‘‘(4) The National Institute of Mental Health. 

‘‘(5) The Service. 

‘‘(6) The Office of Minority Health of the Department of Health and Human 

Services. 

‘‘(7) The Administration for Native Americans. 

‘‘(8) The National Institute of Child Health and Human Development 

(NICHD). 

‘‘(9) The Centers for Disease Control and Prevention. 

‘‘(10) The Bureau of Indian Affairs. 

‘‘(11) Indian Tribes. 

‘‘(12) Tribal Organizations. 

‘‘(13) Urban Indian Organizations. 

‘‘(14) experts on Indian fetal alcohol disorder. 

‘‘(d) APPLIED RESEARCH PROJECTS.—The Secretary, acting through the Substance 

Abuse and Mental Health Services Administration, shall make grants available to 

Indian Tribes, Tribal Organizations, and Urban Indian Organizations for applied research projects which propose to elevate the understanding of methods to prevent, 

intervene, treat, or provide rehabilitation and behavioral health aftercare for Indians and Urban Indians affected by fetal alcohol disorder. 

‘‘(e) FUNDING FOR URBAN INDIAN ORGANIZATIONS.—Ten percent of the funds appropriated pursuant to this section shall be used to make grants to Urban Indian 

Organizations funded under title V. 

‘‘SEC. 712. 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 an Indian household, and to their 

family members who are affected by sexual abuse. 


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‘‘(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, through the tribal consultation process, culturally sensitive assessment and diagnostic tools for use in Indian communities 

and Urban Centers. ‘‘(5) To identify and provide behavioral health treatment to Indian perpetrators and perpetrators who are members of an Indian household— ‘‘(A) making efforts to begin offender and behavioral health treatment 

while the perpetrator is incarcerated or at the earliest possible date if the 

perpetrator is not incarcerated; and ‘‘(B) providing treatment after the perpetrator is released, until it is determined that the perpetrator is not a threat to children. 

‘‘SEC. 713. BEHAVIORAL HEALTH RESEARCH. 

‘‘The Secretary, in consultation with appropriate Federal agencies, shall provide 

funding to Indian Tribes, Tribal Organizations, and Urban Indian Organizations or 

enter into contracts with, or make grants to appropriate institutions for, the conduct 

of research on the incidence and prevalence of behavioral health problems among 

Indians served by the Service, Indian Tribes, or Tribal Organizations and among Indians in urban areas. Research priorities under this section shall include— ‘‘(1) the multifactorial causes of Indian youth suicide, including— ‘‘(A) protective and risk factors and scientific data that identifies those 

factors; and ‘‘(B) the effects of loss of cultural identity and the development of scientific data on those effects; ‘‘(2) the interrelationship and interdependence of behavioral health problems 

with alcoholism and other substance abuse, suicide, homicides, other injuries, 

and the incidence of family violence; and ‘‘(3) the development of models of prevention techniques. 

The effect of the interrelationships and interdependencies referred to in paragraph 

(1) on children, and the development of prevention techniques under paragraph (2) 

applicable to children, shall be emphasized. 

‘‘SEC. 714. DEFINITIONS. 

‘‘For the purpose of this title, 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. ‘‘(2) ALCOHOL-RELATED NEURODEVELOPMENTAL DISORDERS OR ARND.—The 

term ‘alcohol-related neurodevelopmental disorders’ or ‘ARND’ means a central 

nervous system or behavioral disorder, following a maternal history of alcohol 

consumption during pregnancy, that may involve—

‘‘(A) physical manifestations such as development delay, intellectual deficit, neurologic abnormalities, or failure to thrive as infants; or 

‘‘(B) behavioral manifestations such as irritability, or for older children, 

hyperactivity, attention deficit, language dysfunction, or perceptual or judgment difficulties. 

‘‘(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, community health aides, community health representatives, mental health technicians, ministers, etc.). 

‘‘(4) DUAL DIAGNOSIS.—The term ‘dual diagnosis’ means coexisting substance 

abuse and mental illness conditions or diagnosis. Such clients are sometimes referred to as mentally ill chemical abusers (MICAs). 

‘‘(5) FETAL ALCOHOL DISORDERS.—The term ‘fetal alcohol disorders’ means 

fetal alcohol syndrome, partial fetal alcohol syndrome and alcohol related 

neurodevelopmental disorder (ARND). 

‘‘(6) FETAL ALCOHOL SYNDROME OR FAS.—The term ‘fetal alcohol syndrome’ or 

‘FAS’ means a syndrome in which, with a history of maternal alcohol consumption during pregnancy, the following criteria are met: 

‘‘(A) Central nervous system involvement such as developmental delay, 

intellectual deficit, microencephaly, or neurologic abnormalities. 


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‘‘(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. 

‘‘(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. 

‘‘SEC. 715. 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 the provisions of this title. 

‘‘TITLE VIII—MISCELLANEOUS 

‘‘SEC. 801. REPORTS. 

‘‘The President shall, at the time the budget is submitted under section 1105 of 

title 31, United States Code, for each fiscal year transmit to Congress a report containing the following: 

‘‘(1) A report on the progress made in meeting the objectives of this Act, including a review of programs established or assisted pursuant to this Act and 

assessments and recommendations of additional programs or additional assistance necessary to, at a minimum, provide health services to Indians and ensure 

a health status for Indians, which are at a parity with the health services available to and the health status of the general population, including specific comparisons of appropriations provided and those required for such parity. 

‘‘(2) A report on whether, and to what extent, new national health care programs, benefits, initiatives, or financing systems have had an impact on the 

purposes of this Act and any steps that the Secretary may have taken to consult 

with Indian 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. 

‘‘(3) A report on the use of health services by Indians—

‘‘(A) on a national and area or other relevant geographical basis; 

‘‘(B) by gender and age; 

‘‘(C) by source of payment and type of service; 

‘‘(D) comparing such rates of use with rates of use among comparable 

non-Indian populations; 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 126(f). 

‘‘(7) A separate statement which specifies the amount of funds requested to 

carry out the provisions of section 201. 

‘‘(8) A report of the evaluations of health promotion and disease prevention 

as required in section 203(c). 

‘‘(9) A biennial report to Congress on infectious diseases as required by section 212. 

‘‘(10) A report on environmental and nuclear health hazards as required by 

section 215. 

‘‘(11) An annual report on the status of all health care facilities needs as required by sections 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). 


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‘‘(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 between the Service, Indian Tribes, and Tribal Organizations, and the 

Department of Veterans Affairs and the Department of Defense, 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 as required by section 

707(h). 

‘‘SEC. 802. 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 2006, 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, II, III, and VII and section 817. 

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, except 

as necessary to carry out section 817. ‘‘(2) PROPOSED REGULATIONS.—Proposed regulations to implement this Act 

shall be published in the Federal Register by the Secretary no later than 270 

days after the date of the enactment of the Indian Health Care Improvement 

Act Amendments of 2006 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 18 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 States Code, to carry out this section shall have as 

its members only representatives of the Federal Government and representatives of 

Indian Tribes and Tribal Organizations, a majority of whom shall be nominated by 

and be representatives of Indian Tribes, Tribal Organizations, and Urban Indian 

Organizations from each Service Area. 

‘‘(c) ADAPTATION OF PROCEDURES.—The Secretary shall adapt the negotiated rulemaking procedures to the unique context of self-governance and the government-togovernment 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 2006, and the Secretary 

is authorized to repeal any regulation inconsistent with the provisions of this Act. 

‘‘SEC. 803. PLAN OF IMPLEMENTATION. 

‘‘Not later than 9 months after the date of the enactment of the Indian Health 

Care Improvement Act Amendments of 2006, 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. 

‘‘SEC. 804. AVAILABILITY OF FUNDS. 

‘‘The funds appropriated pursuant to this Act shall remain available until expended. 

‘‘SEC. 805. LIMITATION ON USE OF FUNDS APPROPRIATED TO THE INDIAN HEALTH SERVICE. 

‘‘Any limitation on the use of funds contained in an Act providing appropriations 

for the Department 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 Service. 

‘‘SEC. 806. ELIGIBILITY OF CALIFORNIA INDIANS. 

‘‘(a) IN GENERAL.—The following California Indians shall be eligible for health 

services provided by the Service: 


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‘‘(1) Any member of a federally recognized Indian Tribe. 

‘‘(2) Any descendant of an Indian who was residing in California on June 1, 

1852, if such descendant—

‘‘(A) is a member of the Indian community served by a local program of 

the Service; and 

‘‘(B) is regarded as an Indian by the community in which such descendant 

lives. 

‘‘(3) Any Indian who holds trust interests in public domain, national forest, 

or reservation allotments in California. 

‘‘(4) Any Indian in California who is listed on the plans for distribution of the 

assets of 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) CLARIFICATION.—Nothing in this section may be construed as expanding the 

eligibility of California Indians for health services provided by the Service beyond 

the scope of eligibility for such health services that applied on May 1, 1986. 

‘‘SEC. 807. HEALTH SERVICES FOR INELIGIBLE PERSONS. 

‘‘(a) CHILDREN.—Any individual who—

‘‘(1) has not attained 19 years of age; 

‘‘(2) is the natural or adopted child, stepchild, foster child, legal ward, or orphan of an eligible Indian; and 

‘‘(3) is not otherwise eligible for 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 1 year after the date of a determination of competency. 

‘‘(b) SPOUSES.—Any spouse of an eligible Indian who is not an Indian, or who is 

of Indian descent but not otherwise eligible for the health services provided by the 

Service, shall be eligible for such health services if all such spouses or spouses who 

are married to members of the Indian Tribe(s) being 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. 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) PROVISION OF SERVICES TO OTHER INDIVIDUALS.—

‘‘(1) IN GENERAL.—The Secretary is authorized to provide health services 

under this subsection through health programs operated directly by the Service 

to individuals who reside within the Service Unit and who are not otherwise 

eligible for such health services if—

‘‘(A) the Indian Tribes served by such Service Unit request such provision 

of health services to such individuals; and 

‘‘(B) the Secretary and the served Indian Tribes have jointly determined 

that—

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

or diminution of health services to eligible Indians; and 

‘‘(ii) there is no reasonable alternative health facilities or services, 

within or without the Service Unit, available to meet the health needs 

of such individuals. 

‘‘(2) PROGRAMS.—In the case of a Tribal Health Program, the governing body 

of the Indian Tribe or Tribal Organization providing health services under such 

Tribal Health Program is authorized to determine whether health services 

should be provided under its Funding Agreement to individuals who are not 

otherwise eligible for such services. In making such determination, the governing body shall take into account the considerations described in clauses (i) 

and (ii) of paragraph (1)(B). 

‘‘(3) PAYMENT FOR SERVICES.—

‘‘(A) IN GENERAL.—Persons receiving health services provided by the 

Service under this subsection shall be liable for payment of such health 

services under a schedule of charges prescribed by the Secretary which, in 

the judgment of the Secretary, results in reimbursement in an amount not 

less than the actual cost of providing the health services. Notwithstanding 

section 404 of this Act or any other provision of law, amounts collected 

under this subsection, including Medicare, Medicaid, or SCHIP reimbursements under titles XVIII, XIX, and XXI of the Social Security Act, shall be 


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credited to the account of the program providing the service and shall be 

used for the purposes listed in section 401(d)(2) and amounts collected 

under this subsection shall be available for expenditure within such program. ‘‘(B) INDIGENT PEOPLE.—Health services may be provided by the Secretary through the Service under this subsection to an indigent individual 

who would not be otherwise eligible for such health services but for the provisions of paragraph (1) only if an agreement has been entered into with 

a State or local government under which the State or local government 

agrees to reimburse the Service for the expenses incurred by the Service 

in providing such health services to such indigent individual. 

‘‘(4) REVOCATION OF CONSENT FOR SERVICES.—

‘‘(A) SINGLE TRIBE SERVICE AREA.—In the case of a Service Area which 

serves only 1 Indian Tribe, the authority of the Secretary to provide health 

services under paragraph (1) shall terminate at the end of the fiscal year 

succeeding the fiscal year in which the governing body of the Indian Tribe 

revokes its concurrence to the provision of such health services. 

‘‘(B) MULTITRIBAL SERVICE AREA.—In the case of a multitribal Service 

Area, the authority of the Secretary to provide health services under paragraph (1) shall terminate at the end of the fiscal year succeeding the fiscal 

year in which at least 51 percent of the number of Indian Tribes in the 

Service Area revoke their concurrence to the provisions of such health services. 

‘‘(d) OTHER SERVICES.—The Service may provide health services under this subsection to individuals who are not eligible for health services provided by the Service 

under any other provision of law in order to—

‘‘(1) achieve stability in a medical emergency; 

‘‘(2) prevent the spread of a communicable disease or otherwise deal with a 

public health hazard; 

‘‘(3) provide care to non-Indian women pregnant with an eligible Indian’s 

child for the duration of the pregnancy through postpartum; or 

‘‘(4) provide care to immediate family members of an eligible individual if 

such care is directly related to the treatment of the eligible individual. 

‘‘(e) HOSPITAL PRIVILEGES FOR PRACTITIONERS.—Hospital privileges in health facilities operated and maintained by the Service or operated under a Funding Agreement may be extended to non-Service health care practitioners who provide services 

to individuals described in subsection (a), (b), (c), or (d). Such non-Service health 

care practitioners may, as part of the privileging process, be designated 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 as a part of the conditions under which such hospital privileges are extended. 

‘‘(f) ELIGIBLE INDIAN.—For purposes of this section, the term ‘eligible Indian’

means any Indian who is eligible for health services provided by the Service without 

regard to the provisions of this section. 

‘‘SEC. 808. REALLOCATION OF BASE RESOURCES. 

‘‘(a) REPORT REQUIRED.—Notwithstanding any other provision of law, any allocation of Service funds for a fiscal year that reduces by 5 percent or more from the 

previous fiscal year the funding for any recurring program, project, or activity of a 

Service Unit may be implemented only after the Secretary has submitted to the 

President, for inclusion in the report required to be transmitted to Congress under 

section 801, a report on the proposed change in allocation of funding, including the 

reasons for the change and its likely effects. 

‘‘(b) EXCEPTION.—Subsection (a) shall not apply if the total amount appropriated 

to the Service for a fiscal year is at least 5 percent less than the amount appropriated to the Service for the previous fiscal year. 

‘‘SEC. 809. RESULTS OF DEMONSTRATION PROJECTS. 

‘‘The Secretary shall provide for the dissemination to Indian Tribes, Tribal Organizations, and Urban Indian Organizations of the findings and results of demonstration projects conducted under this Act. 

‘‘SEC. 810. PROVISION OF SERVICES IN MONTANA. 

‘‘(a) CONSISTENT WITH COURT DECISION.—The Secretary, acting through the Service, shall provide services and benefits for Indians in Montana in a manner consistent with the decision of the United States Court of Appeals for the Ninth Circuit 

in McNabb 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 


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in subsection (a) with respect to the provision of services or benefits for Indians living in any State other than Montana. 

‘‘SEC. 811. MORATORIUM. 

‘‘During the period of the moratorium imposed on implementation of the final rule 

published in the Federal Register on September 16, 1987, by the Health Resources 

and Services Administration of the 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. 

‘‘SEC. 812. TRIBAL EMPLOYMENT. 

‘‘For purposes of section 2(2) of the Act of July 5, 1935 (49 Stat. 450, chapter 372), 

an Indian Tribe or Tribal Organization carrying out a Funding Agreement shall not 

be considered an ‘employer’. 

‘‘SEC. 813. SEVERABILITY PROVISIONS. 

‘‘If any provision of this Act, any amendment made by the Act, or the application 

of such provision or amendment to any person or circumstances is held to be invalid, 

the remainder of this Act, the remaining amendments made by this Act, and the 

application of such provisions to persons or circumstances other than those to which 

it is held invalid, shall not be affected thereby. 

‘‘SEC. 814. 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 to such extent or in such amounts as are provided in appropriation Acts. 

‘‘SEC. 815. 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.’’. 

(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 clause (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’’. 


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(4) Section 203(a)(1) of the Rehabilitation Act of 1973 (29 U.S.C. 763(a)(1)) is 

amended by striking ‘‘Director of the Indian Health Service’’ and inserting ‘‘Assistant Secretary for Indian Health’’. (5) Subsections (b) and (e) of section 518 of the Federal Water Pollution Control Act (33 U.S.C. 1377) are amended by striking ‘‘Director of the Indian 

Health Service’’ each place it appears and inserting ‘‘Assistant Secretary for Indian Health’’. (6) Section 317M(b) of the Public Health Service Act (42 U.S.C. 247b–14(b)) 

is amended— (A) by striking ‘‘Director of the Indian Health Service’’ each place it appears and inserting ‘‘Assistant Secretary for Indian Health’’; and 

(B) in paragraph (2)(A), by striking ‘‘the Directors referred to in such 

paragraph’’ and inserting ‘‘the Director of the Centers for Disease Control 

and Prevention and the Assistant Secretary for Indian Health’’. (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’’. 

TITLE II—IMPROVEMENT OF INDIAN HEALTH 

CARE PROVIDED UNDER THE SOCIAL SECURITY ACT 

SEC. 201. EXPANSION OF PAYMENTS UNDER MEDICARE, MEDICAID, AND SCHIP FOR ALL COVERED SERVICES FURNISHED BY INDIAN HEALTH PROGRAMS. 

(a) MEDICAID.—

(1) EXPANSION TO ALL COVERED SERVICES.—Section 1911 of the Social Security 

Act (42 U.S.C. 1396j) is amended—

(A) by amending the designation and heading to read as follows: 

‘‘SEC. 1911. INDIAN HEALTH PROGRAMS.’’

; and 

(B) by amending subsection (a) to read as follows: 

‘‘(a) ELIGIBILITY FOR PAYMENT FOR MEDICAL ASSISTANCE.—The Indian Health 

Service and an Indian Tribe, Tribal Organization, or an Urban Indian Organization 

shall be eligible for payment for medical assistance provided under a State plan or 

under waiver authority with respect to items and services furnished by the Indian 

Health Service, Indian Tribe, Tribal Organization, or Urban Indian Organization if 

the furnishing of such services meets all the conditions and requirements which are 

applicable generally to the furnishing of items and services under this title and 

under such plan or waiver authority.’’. 

(2) COMPLIANCE WITH CONDITIONS AND REQUIREMENTS.—Subsection (b) of such 

section is amended to read as follows: 

‘‘(b) COMPLIANCE WITH CONDITIONS AND REQUIREMENTS.—A facility of the Indian 

Health Service or an Indian Tribe, Tribal Organization, or an Urban Indian Organization which is eligible for payment under subsection (a) with respect to the furnishing of items and services, but which does not meet all of the conditions and requirements of this title and under a State plan or waiver authority which are applicable generally to such facility, shall make such improvements as are necessary to 

achieve or maintain compliance with such conditions and requirements in accordance with a plan submitted to and accepted by the Secretary for achieving or maintaining compliance with such conditions and requirements, and shall be deemed to 

meet such conditions and requirements (and to be eligible for payment under this 

title), without regard to the extent of its actual compliance with such conditions and 

requirements, during the first 12 months after the month in which such plan is submitted.’’. 

(3) REVISION OF AUTHORITY TO ENTER INTO AGREEMENTS.—Subsection (c) of 

such section is amended to read as follows: 


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‘‘(c) AUTHORITY TO ENTER INTO AGREEMENTS.—The Secretary may enter into an 

agreement with a State for the purpose of reimbursing the State for medical assistance provided by the Indian Health Service, an Indian Tribe, Tribal Organization, 

or an Urban Indian Organization (as so defined), directly, through referral, or under 

contracts or other arrangements between the Indian Health Service, an Indian 

Tribe, Tribal Organization, or an Urban Indian Organization and another health 

care provider to Indians who are eligible for medical assistance under the State plan 

or under waiver authority.’’. 

(4) CROSS-REFERENCES TO SPECIAL FUND FOR IMPROVEMENT OF IHS FACILITIES; 

DIRECT BILLING OPTION; DEFINITIONS.—Such section is further amended by striking subsection (d) and adding at the end the following new subsections: 

‘‘(d) SPECIAL FUND FOR IMPROVEMENT OF IHS FACILITIES.—For provisions relating 

to the authority of the Secretary to place payments to which a facility of the Indian 

Health Service is eligible for payment under this title into a special fund established 

under section 401(c)(1) of the Indian Health Care Improvement Act, and the requirement to use amounts paid from such fund for making improvements in accordance with subsection (b), see subparagraphs (A) and (B) of section 401(c)(1) of such 

Act. 

‘‘(e) DIRECT BILLING.—For provisions relating to the authority of a Tribal Health 

Program or an Urban Indian Organization to elect to directly bill for, and receive 

payment for, health care items and services provided by such Program or Organization for which payment is made under this title, see section 401(d) of the Indian 

Health Care Improvement Act. 

‘‘(f) DEFINITIONS.—In this section, the terms ‘Indian Health Program’, ‘Indian 

Tribe’, ‘Tribal Health Program’, ‘Tribal Organization’, and ‘Urban Indian Organization’ have the meanings given those terms in section 4 of the Indian Health Care 

Improvement Act.’’. 

(b) MEDICARE.—

(1) EXPANSION TO ALL COVERED SERVICES.—Section 1880 of such Act (42 

U.S.C. 1395qq) is amended—

(A) by amending the designation and heading to read as follows: 

‘‘SEC. 1880. INDIAN HEALTH PROGRAMS.’’

; and 

(B) by amending subsection (a) to read as follows: 

‘‘(a) ELIGIBILITY FOR PAYMENTS.—Subject to subsection (e), the Indian Health 

Service and an Indian Tribe, Tribal Organization, or an Urban Indian Organization 

shall be eligible for payments under this title with respect to items and services furnished by the Indian Health Service, Indian Tribe, Tribal Organization, or Urban 

Indian Organization if the furnishing of such services meets all the conditions and 

requirements which are applicable generally to the furnishing of items and services 

under this title.’’. 

(2) COMPLIANCE WITH CONDITIONS AND REQUIREMENTS.—Subsection (b) of such 

section is amended to read as follows: 

‘‘(b) COMPLIANCE WITH CONDITIONS AND REQUIREMENTS.—Subject to subsection 

(e), a facility of the Indian Health Service or an Indian Tribe, Tribal Organization, 

or an Urban Indian Organization which is eligible for payment under subsection (a) 

with respect to the furnishing of items and services, but which does not meet all 

of the conditions and requirements of this title which are applicable generally to 

such facility, shall make such improvements as are necessary to achieve or maintain 

compliance with such conditions and requirements in accordance with a plan submitted to and accepted by the Secretary for achieving or maintaining compliance 

with such conditions and requirements, and shall be deemed to meet such conditions 

and requirements (and to be eligible for payment under this title), without regard 

to the extent of its actual compliance with such conditions and requirements, during 

the first 12 months after the month in which such plan is submitted.’’. 

(3) CROSS-REFERENCES TO SPECIAL FUND FOR IMPROVEMENT OF IHS FACILITIES; 

DIRECT BILLING OPTION; DEFINITIONS.—

(A) IN GENERAL.—Such section is further amended by striking subsections 

(c) and (d) and inserting the following new subsections: 

‘‘(c) SPECIAL FUND FOR IMPROVEMENT OF IHS FACILITIES.—For provisions relating 

to the authority of the Secretary to place payments to which a facility of the Indian 

Health Service is eligible for payment under this title into a special fund established 

under section 401(c)(1) of the Indian Health Care Improvement Act, and the requirement to use amounts paid from such fund for making improvements in accordance with subsection (b), see subparagraphs (A) and (B) of section 401(c)(1) of such 

Act. 

‘‘(d) DIRECT BILLING.—For provisions relating to the authority of a Tribal Health 

Program or an Urban Indian Organization to elect to directly bill for, and receive 


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payment for, health care items and services provided by such Program or Organization for which payment is made under this title, see section 401(d) of the Indian 

Health Care Improvement Act.’’. 

(B) CONFORMING AMENDMENT.—Paragraph (3) of section 1880(e) of such 

Act (42 U.S.C. 1395qq(e)) is amended by inserting ‘‘and section 401(c)(1) of 

the Indian Health Care Improvement Act’’ after ‘‘Subsection (c)’’. 

(4) DEFINITIONS.—Such section is further amended by amending subsection (f) 

to read as follows: 

‘‘(f) DEFINITIONS.—In this section, the terms ‘Indian Health Program’, ‘Indian 

Tribe’, ‘Service Unit’, ‘Tribal Health Program’, ‘Tribal Organization’, and ‘Urban Indian Organization’ have the meanings given those terms in section 4 of the Indian 

Health Care Improvement Act.’’. 

(c) APPLICATION TO SCHIP.—Section 2107(e)(1) of the Social Security Act (42 

U.S.C. 1397gg(e)(1)) is amended—

(1) by redesignating subparagraph (D) as subparagraph (E); and 

(2) by inserting after subparagraph (C), the following new subparagraph: 

‘‘(D) Section 1911 (relating to Indian Health Programs, other than subsection (d) of such section).’’. 

SEC. 202. INCREASED OUTREACH TO INDIANS UNDER MEDICAID AND SCHIP AND IMPROVED 

COOPERATION IN THE PROVISION OF ITEMS AND SERVICES TO INDIANS UNDER 

SOCIAL SECURITY ACT HEALTH BENEFIT PROGRAMS. 

Section 1139 of the Social Security Act (42 U.S.C. 1320b–9) is amended to read 

as follows: 

‘‘SEC. 1139. IMPROVED ACCESS TO, AND DELIVERY OF, HEALTH CARE FOR INDIANS UNDER TITLES XVIII, XIX, AND XXI. 

‘‘(a) AGREEMENTS WITH STATES FOR MEDICAID AND SCHIP OUTREACH ON OR NEAR

RESERVATIONS TO INCREASE THE ENROLLMENT OF INDIANS IN THOSE PROGRAMS.—

‘‘(1) IN GENERAL.—In order to improve the access of Indians residing on or 

near a reservation to obtain benefits under the Medicaid and State children’s 

health insurance programs established under titles XIX and XXI, the Secretary 

shall encourage the State to take steps to provide for enrollment on or near the 

reservation. Such steps may include outreach efforts such as the outstationing 

of eligibility workers, entering into agreements with the Indian Health Service, 

Indian Tribes, Tribal Organizations, and Urban Indian Organizations to provide 

outreach, education regarding eligibility and benefits, enrollment, and translation services when such services are appropriate. 

‘‘(2) CONSTRUCTION.—Nothing in subparagraph (A) shall be construed as affecting arrangements entered into between States and the Indian Health Service, Indian Tribes, Tribal Organizations, or Urban Indian Organizations for 

such Service, Tribes, or Organizations to conduct administrative activities under 

such titles. 

‘‘(b) REQUIREMENT TO FACILITATE COOPERATION.—The Secretary, acting through 

the Centers for Medicare and Medicaid Services, shall take such steps as are necessary to facilitate cooperation with, and agreements between, States and the Indian Health Service, Indian Tribes, Tribal Organizations, or Urban Indian Organizations with respect to the provision of health care items and services to Indians 

under the programs established under title XVIII, XIX, or XXI. 

‘‘(c) DEFINITION OF INDIAN TRIBE; INDIAN HEALTH PROGRAM; TRIBAL ORGANIZATION; URBAN INDIAN ORGANIZATION.—In this section, the terms ‘Indian Tribe’, ‘Indian Health Program’, ‘Tribal Organization’, and ‘Urban Indian Organization’ have 

the meanings given those terms in section 4 of the Indian Health Care Improvement 

Act.’’. 

SEC. 203. ADDITIONAL PROVISIONS TO INCREASE OUTREACH TO, AND ENROLLMENT OF, INDIANS IN SCHIP AND MEDICAID. 

(a) NONAPPLICATION OF 10 PERCENT LIMIT ON OUTREACH AND CERTAIN OTHER EXPENDITURES.—Section 2105(c)(2) of the Social Security Act (42 U.S.C. 1397ee(c)(2)) 

is amended by adding at the end the following new subparagraph: 

‘‘(C) NONAPPLICATION TO EXPENDITURES FOR OUTREACH TO INCREASE THE

ENROLLMENT OF INDIAN CHILDREN UNDER THIS TITLE AND TITLE XIX.—The 

limitation under subparagraph (A) on expenditures for items described in 

subsection (a)(1)(D) shall not apply in the case of expenditures for outreach 

activities to families of Indian children likely to be eligible for child health 

assistance under the plan or medical assistance under the State plan under 

title XIX (or under a waiver of such plan), to inform such families of the 

availability of, and to assist them in enrolling their children in, such plans, 

including such activities conducted under grants, contracts, or agreements 

entered into under section 1139(a).’’. 


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(b) ASSURANCE OF PAYMENTS TO INDIAN HEALTH CARE PROVIDERS FOR CHILD

HEALTH ASSISTANCE.—Section 2102(b)(3)(D) of such Act (42 U.S.C. 1397bb(b)(3)(D)) 

is amended by striking ‘‘(as defined in section 4(c) of the Indian Health Care Improvement Act, 25 U.S.C. 1603(c))’’ and inserting ‘‘, including how the State will ensure that payments are made to Indian Health Programs and Urban Indian Organizations operating in the State for the provision of such assistance’’. (c) INCLUSION OF OTHER INDIAN FINANCED HEALTH CARE PROGRAMS IN EXEMP- TION FROM PROHIBITION ON CERTAIN PAYMENTS.—Section 2105(c)(6)(B) of such Act 

(42 U.S.C. 1397ee(c)(6)(B)) is amended by striking ‘‘insurance program, other than 

an insurance program operated or financed by the Indian Health Service’’ and inserting ‘‘program, other than a health care program operated or financed by the Indian Health Service or by an Indian Tribe, Tribal Organization, or Urban Indian 

Organization’’. (d) SATISFACTION OF MEDICAID DOCUMENTATION REQUIREMENTS.— (1) IN GENERAL.—Section 1903(x)(3)(B) of the Social Security Act (42 U.S.C. 

1396b(x)(3)(B)) is amended— (A) by redesignating clause (v) as clause (vi); and 

(B) by inserting after clause (iv), the following new clause: ‘‘(v)(I) Except as provided in subclause (II), a document issued by a federallyrecognized Indian tribe evidencing membership or enrollment in, or affiliation 

with, such tribe. ‘‘(II) With respect to those federally-recognized Indian tribes located within 

States having an international border whose membership includes individuals 

who are not citizens of the United States, the Secretary shall, after consulting 

with such tribes, issue regulations authorizing the presentation of such other 

forms of documentation (including tribal documentation, if appropriate) that the 

Secretary determines to be satisfactory documentary evidence of citizenship or 

nationality for purposes of satisfying the requirement of this subsection.’’. (2) TRANSITION RULE.—During the period that begins on July 1, 2006, and 

ends on the effective date of final regulations issued under subclause (II) of section 1903(x)(3)(B)(v) of the Social Security Act (42 U.S.C. 1396b(x)(3)(B)(v)) (as 

added by paragraph (1)), an individual who is a member of a federally-recognized Indian tribe described in subclause (II) of that section who presents a document described in subclause (I) of such section that is issued by such Indian 

tribe, shall be deemed to have presented satisfactory evidence of citizenship or 

nationality for purposes of satisfying the requirement of subsection (x) of section 

1903 of such Act. 

(e) DEFINITIONS.—Section 2110(c) of such Act (42 U.S.C. 1397jj(c)) is amended by 

adding at the end the following new paragraph: ‘‘(9) INDIAN; INDIAN HEALTH PROGRAM; INDIAN TRIBE; ETC.—The terms ‘Indian’, ‘Indian Health Program’, ‘Indian Tribe’, ‘Tribal Organization’, and ‘Urban Indian Organization’ have the meanings given those terms in section 4 of the Indian Health Care Improvement Act.’’. 

SEC. 204. PREMIUMS AND COST SHARING PROTECTIONS UNDER MEDICAID, ELIGIBILITY DETERMINATIONS UNDER MEDICAID AND SCHIP, AND PROTECTION OF CERTAIN INDIAN PROPERTY FROM MEDICAID ESTATE RECOVERY. 

(a) PREMIUMS AND COST SHARING PROTECTION UNDER MEDICAID.— (1) IN GENERAL.—Section 1916 of the Social Security Act (42 U.S.C. 1396o) is 

amended— (A) in subsection (a), in the matter preceding paragraph (1), by striking ‘‘and (i)’’ and inserting ‘‘, (i), and (j)’’; and 

(B) by adding at the end the following new subsection: 

‘‘(j) NO PREMIUMS OR COST SHARING FOR INDIANS FURNISHED ITEMS OR SERVICES

DIRECTLY BY INDIAN HEALTH PROGRAMS OR THROUGH REFERRAL UNDER THE CONTRACT HEALTH SERVICE.—

‘‘(1) NO COST SHARING FOR ITEMS OR SERVICES FURNISHED TO INDIANS

THROUGH INDIAN HEALTH PROGRAMS.—

‘‘(A) IN GENERAL.—No enrollment fee, premium, or similar charge, and no 

deduction, copayment, cost sharing, or similar charge shall be imposed 

against an Indian who is furnished an item or service directly by the Indian 

Health Service, an Indian Tribe, Tribal Organization, or Urban Indian Organization or through referral under the contract health service for which 

payment may be made under this title. 

‘‘(B) NO REDUCTION IN AMOUNT OF PAYMENT TO INDIAN HEALTH PROVIDERS.—Payment due under this title to the Indian Health Service, an Indian Tribe, Tribal Organization, or Urban Indian Organization, or a health 

care provider through referral under the contract health service for the furnishing of an item or service to an Indian who is eligible for assistance 

under such title, may not be reduced by the amount of any enrollment fee, 


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premium, or similar charge, or any deduction, copayment, cost sharing, or 

similar charge that would be due from the Indian but for the operation of 

subparagraph (A). ‘‘(2) RULE OF CONSTRUCTION.—Nothing in this subsection shall be construed 

as restricting the application of any other limitations on the imposition of premiums or cost sharing that may apply to an individual receiving medical assistance under this title who is an Indian. ‘‘(3) DEFINITIONS.—In this subsection, the terms ‘contract health service’, ‘Indian’, ‘Indian Tribe’, ‘Tribal Organization’, and ‘Urban Indian Organization’ have the meanings given those terms in section 4 of the Indian Health Care 

Improvement Act.’’. (2) CONFORMING AMENDMENT.—Section 1916A(a)(1) of such Act (42 U.S.C. 

1396o–1(a)(1)) is amended by striking ‘‘section 1916(g)’’ and inserting ‘‘subsections (g), (i), or (j) of section 1916’’. (b) TREATMENT OF CERTAIN PROPERTY FOR MEDICAID AND SCHIP ELIGIBILITY.— (1) MEDICAID.—Section 1902(e) of the Social Security Act (42 U.S.C. 1396a) 

is amended by adding at the end the following new paragraph: ‘‘(13) Notwithstanding any other requirement of this title or any other provision 

of Federal or State law, a State shall disregard the following property for purposes 

of determining eligibility for medical assistance under this title: ‘‘(A) Property, including real property and improvements, located on a reservation, including any federally recognized Indian Tribe’s reservation, pueblo, 

or colony, including former reservations in Oklahoma, Alaska Native regions established by the Alaska Native Claims Settlement Act, and Indian allotments 

on or near a reservation as designated and approved by the Bureau of Indian 

Affairs of the Department of the Interior. ‘‘(B) For any federally recognized Tribe not described in subparagraph (A), 

property located within the most recent boundaries of a prior Federal reservation. ‘‘(C) Ownership interests in rents, leases, royalties, or usage rights related to 

natural resources (including extraction of natural resources or harvesting of 

timber, other plants and plant products, animals, fish, and shellfish) resulting 

from the exercise of federally protected rights. ‘‘(D) Ownership interests in or usage rights to items not covered by subparagraphs (A) through (C) that have unique religious, spiritual, traditional, or cultural significance or rights that support subsistence or a traditional lifestyle according to applicable tribal law or custom.’’. (2) APPLICATION TO SCHIP.—Section 2107(e)(1) of such Act (42 U.S.C. 

1397gg(e)(1)), as amended by section 201(c), is amended— (A) by redesignating subparagraphs (B) through (E), as subparagraphs 

(C) through (F), respectively; and 

(B) by inserting after subparagraph (A), the following new subparagraph: 

‘‘(B) Section 1902(e)(13) (relating to disregard of certain property for purposes of making eligibility determinations).’’. (c) CONTINUATION OF CURRENT LAW PROTECTIONS OF CERTAIN INDIAN PROPERTY

FROM MEDICAID ESTATE RECOVERY.—Section 1917(b)(3) of the Social Security Act 

(42 U.S.C. 1396p(b)(3)) is amended— (1) by inserting ‘‘(A)’’ after ‘‘(3)’’; and 

(2) by adding at the end the following new subparagraph: ‘‘(B) The standards specified by the Secretary under subparagraph (A) shall require that the procedures established by the State agency under subparagraph (A) 

exempt income, resources, and property that are exempt from the application of this 

subsection as of April 1, 2003, under manual instructions issued to carry out this 

subsection (as in effect on such date) because of the Federal responsibility for Indian 

Tribes and Alaska Native Villages. Nothing in this subparagraph shall be construed 

as preventing the Secretary from providing additional estate recovery exemptions 

under this title for Indians.’’. 

SEC. 205. NONDISCRIMINATION IN QUALIFICATIONS FOR PAYMENT FOR SERVICES UNDER 

FEDERAL HEALTH CARE PROGRAMS. 

Section 1139 of the Social Security Act (42 U.S.C. 1320b–9), as amended by section 202, is amended by redesignating subsection (c) as subsection (d), and inserting 

after subsection (b) the following new subsection: 

‘‘(c) NONDISCRIMINATION IN QUALIFICATIONS FOR PAYMENT FOR SERVICES UNDER

FEDERAL HEALTH CARE PROGRAMS.—

‘‘(1) REQUIREMENT TO SATISFY GENERALLY APPLICABLE PARTICIPATION REQUIRE- MENTS.—

‘‘(A) IN GENERAL.—A Federal health care program must accept an entity 

that is operated by the Indian Health Service, an Indian Tribe, Tribal Organization, or Urban Indian Organization as a provider eligible to receive payVerDate Aug 31 2005 06:24 Sep 16, 2006 Jkt 049006 PO 00000 Frm 00082 Fmt 6659 Sfmt 6621 E:\HR\OC\HR661P1.XXX HR661P1

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ment under the program for health care services furnished to an Indian on 

the same basis as any other provider qualified to participate as a provider 

of health care services under the program if the entity meets generally applicable State or other requirements for participation as a provider of 

health care services under the program. 

‘‘(B) SATISFACTION OF STATE OR LOCAL LICENSING OR RECOGNITION REQUIREMENTS.—Any requirement for participation as a provider of health 

care services under a Federal health care program that an entity be licensed or recognized under the State or local law where the entity is located to furnish health care services shall be deemed to have been met in 

the case of an entity operated by the Indian Health Service, an Indian 

Tribe, Tribal Organization, or Urban Indian Organization if the entity 

meets all the applicable standards for such licensing or recognition, regardless of whether the entity obtains a license or other documentation under 

such State or local law. In accordance with section 221 of the Indian Health 

Care Improvement Act, the absence of the licensing of a health care professional employed by such an entity under the State or local law where the 

entity is located shall not be taken into account for purposes of determining 

whether the entity meets such standards, if the professional is licensed in 

another State. 

‘‘(2) PROHIBITION ON FEDERAL PAYMENTS TO ENTITIES OR INDIVIDUALS EXCLUDED FROM PARTICIPATION IN FEDERAL HEALTH CARE PROGRAMS OR WHOSE

STATE LICENSES ARE UNDER SUSPENSION OR HAVE BEEN REVOKED.—

‘‘(A) EXCLUDED ENTITIES.—No entity operated by the Indian Health Service, an Indian Tribe, Tribal Organization, or Urban Indian Organization 

that has been excluded from participation in any Federal health care program or for which a license is suspended or has been revoked by the State 

where the entity is located shall be eligible to receive payment under any 

such program for health care services furnished to an Indian. 

‘‘(B) EXCLUDED INDIVIDUALS.—No individual who has been excluded from 

participation in any Federal health care program or whose State license is 

suspended or has been revoked shall be eligible to receive payment under 

any such program for health care services furnished by that individual, directly or through an entity that is otherwise eligible to receive payment for 

health care services, to an Indian. 

‘‘(C) FEDERAL HEALTH CARE PROGRAM DEFINED.—In this subsection, the 

term, ‘Federal health care program’ has the meaning given that term in 

section 1128B(f), except that, for purposes of this subsection, such term 

shall include the health insurance program under chapter 89 of title 5, 

United States Code.’’. 

SEC. 206. CONSULTATION ON MEDICAID, SCHIP, AND OTHER HEALTH CARE PROGRAMS FUNDED UNDER THE SOCIAL SECURITY ACT INVOLVING INDIAN HEALTH PROGRAMS 

AND URBAN INDIAN ORGANIZATIONS. 

(a) IN GENERAL.—Section 1139 of the Social Security Act (42 U.S.C. 1320b–9), as 

amended by sections 202 and 205, is amended by redesignating subsection (d) as 

subsection (e), and inserting after subsection (c) the following new subsection: 

‘‘(d) CONSULTATION WITH TRIBAL TECHNICAL ADVISORY GROUP.—The Secretary 

shall maintain within the Centers for Medicaid and Medicare Services a Tribal 

Technical Advisory Group, established in accordance with requirements of the charter dated September 30, 2003, and in such group shall include a representative of 

the Urban Indian Organizations and the Service. The representative of the Urban 

Indian Organization shall be deemed to be an elected officer of a tribal government 

for purposes of applying section 204(b) of the Unfunded Mandates Reform Act of 

1995 (2 U.S.C. 1534(b)).’’. 

(b) SOLICITATION OF ADVICE UNDER MEDICAID AND SCHIP.—

(1) MEDICAID STATE PLAN AMENDMENT.—Section 1902(a) of the Social Security 

Act (42 U.S.C. 1396a(a)) is amended—

(A) in paragraph (69), by striking ‘‘and’’ at the end; 

(B) in paragraph (70)(B)(iv), by striking the period at the end and inserting ‘‘; and’’; and 

(C) by inserting after paragraph (70)(B)(iv), the following new paragraph: 

‘‘(71) in the case of any State in which the Indian Health Service operates 

or funds health care programs, or in which 1 or more Indian Health Programs 

or Urban Indian Organizations (as such terms are defined in section 4 of the 

Indian Health Care Improvement Act) provide health care in the State for 

which medical assistance is available under such title, provide for a process 

under which the State seeks advice on a regular, ongoing basis from designees 

of such Indian Health Programs and Urban Indian Organizations on matters 


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relating to the application of this title that are likely to have a direct effect on 

such Indian Health Programs and Urban Indian Organizations and that—

‘‘(A) shall include solicitation of advice prior to submission of any plan 

amendments, waiver requests, and proposals for demonstration projects 

likely to have a direct effect on Indians, Indian Health Programs, or Urban 

Indian Organizations; and 

‘‘(B) may include appointment of an advisory committee and of a designee 

of such Indian Health Programs and Urban Indian Organizations to the 

medical care advisory committee advising the State on its State plan under 

this title.’’. 

(2) APPLICATION TO SCHIP.—Section 2107(e)(1) of such Act (42 U.S.C. 

1397gg(e)(1)), as amended by sections 201(c) and 204(b)(2), is amended—

(A) by redesignating subparagraphs (B) through (F) as subparagraphs (C) 

through (G), respectively; and 

(B) by inserting after subparagraph (A), the following new subparagraph: 

‘‘(B) Section 1902(a)(71) (relating to the option of certain States to seek 

advice from designees of Indian Health Programs and Urban Indian Organizations).’’. 

(c) RULE OF CONSTRUCTION.—Nothing in the amendments made by this section 

shall be construed as superseding existing advisory committees, working groups, 

guidance, or other advisory procedures established by the Secretary of Health and 

Human Services or by any State with respect to the provision of health care to Indians. 

SEC. 207. EXCLUSION WAIVER AUTHORITY FOR AFFECTED INDIAN HEALTH PROGRAMS AND 

SAFE HARBOR TRANSACTIONS UNDER THE SOCIAL SECURITY ACT. 

(a) EXCLUSION WAIVER AUTHORITY.—Section 1128 of the Social Security Act (42 

U.S.C. 1320a–7) is amended by adding at the end the following new subsection: 

‘‘(k) ADDITIONAL EXCLUSION WAIVER AUTHORITY FOR AFFECTED INDIAN HEALTH

PROGRAMS.—In addition to the authority granted the Secretary under subsections 

(c)(3)(B) and (d)(3)(B) to waive an exclusion under subsection (a)(1), (a)(3), (a)(4), or 

(b), the Secretary may, in the case of an Indian Health Program, waive such an exclusion upon the request of the administrator of an affected Indian Health Program 

(as defined in section 4 of the Indian Health Care Improvement Act) who determines that the exclusion would impose a hardship on individuals entitled to benefits 

under or enrolled in a Federal health care program.’’. 

(b) CERTAIN TRANSACTIONS INVOLVING INDIAN HEALTH CARE PROGRAMS DEEMED

TO BE IN SAFE HARBORS.—Section 1128B(b) of the Social Security Act (42 U.S.C. 

1320a–7b(b)) is amended by adding at the end the following new paragraph: 

‘‘(4) RENUMERATION.—Subject to such conditions as the Secretary may promulgate 

from time to time as necessary to prevent fraud and abuse, for purposes of paragraphs (1) and (2) and section 1128A(a), the following transfers shall not be treated 

as remuneration: 

‘‘(A) TRANSFERS BETWEEN INDIAN HEALTH PROGRAMS, INDIAN TRIBES, TRIBAL

ORGANIZATIONS, AND URBAN INDIAN ORGANIZATIONS.—Transfers of anything of 

value between or among an Indian Health Program, Indian Tribe, Tribal Organization, or Urban Indian Organization, that are made for the purpose of providing necessary health care items and services to any patient served by such 

Program, Tribe, or Organization and that consist of—

‘‘(i) services in connection with the collection, transport, analysis, or interpretation of diagnostic specimens or test data; 

‘‘(ii) inventory or supplies; 

‘‘(iii) staff; or 

‘‘(iv) a waiver of all or part of premiums or cost sharing. 

‘‘(B) TRANSFERS BETWEEN INDIAN HEALTH PROGRAMS, INDIAN TRIBES, TRIBAL

ORGANIZATIONS, OR URBAN INDIAN ORGANIZATIONS AND PATIENTS.—Transfers of 

anything of value between an Indian Health Program, Indian Tribe, Tribal Organization, or Urban Indian Organization and any patient served or eligible for 

service from an Indian Health Program, Indian Tribe, Tribal Organization, or 

Urban Indian Organization, including any patient served or eligible for service 

pursuant to section 807 of the Indian Health Care Improvement Act, but only 

if such transfers—

‘‘(i) consist of expenditures related to providing transportation for the patient for the provision of necessary health care items or services, provided 

that the provision of such transportation is not advertised, nor an incentive 

of which the value is disproportionately large in relationship to the value 

of the health care item or service (with respect to the value of the item or 

service itself or, for preventative items or services, the future health care 

costs reasonably expected to be avoided); 


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‘‘(ii) consist of expenditures related to providing housing to the patient 

(including a pregnant patient) and immediate family members or an escort 

necessary to assuring the timely provision of health care items and services 

to the patient, provided that the provision of such housing is not advertised 

nor an incentive of which the value is disproportionately large in relationship to the value of the health care item or service (with respect to the 

value of the item or service itself or, for preventative items or services, the 

future health care costs reasonably expected to be avoided); or ‘‘(iii) are for the purpose of paying premiums or cost sharing on behalf 

of such a patient, provided that the making of such payment is not subject 

to conditions other than conditions agreed to under a contract for the delivery of contract health services. ‘‘(C) CONTRACT HEALTH SERVICES.—A transfer of anything of value negotiated 

as part of a contract entered into between an Indian Health Program, Indian 

Tribe, Tribal Organization, Urban Indian Organization, or the Indian Health 

Service and a contract care provider for the delivery of contract health services 

authorized by the Indian Health Service, provided that— ‘‘(i) such a transfer is not tied to volume or value of referrals or other 

business generated by the parties; and ‘‘(ii) any such transfer is limited to the fair market value of the health 

care items or services provided or, in the case of a transfer of items or services related to preventative care, the value of the future health care costs 

reasonably expected to be avoided. ‘‘(D) OTHER TRANSFERS.—Any other transfer of anything of value involving an 

Indian Health Program, Indian Tribe, Tribal Organization, or Urban Indian Organization, or a patient served or eligible for service from an Indian Health Program, Indian Tribe, Tribal Organization, or Urban Indian Organization, that 

the Secretary, in consultation with the Attorney General, determines is appropriate, taking into account the special circumstances of such Indian Health Programs, Indian Tribes, Tribal Organizations, and Urban Indian Organizations, 

and of patients served by such Programs, Tribes, and Organizations.’’. 

SEC. 208. RULES APPLICABLE UNDER MEDICAID AND SCHIP TO MANAGED CARE ENTITIES 

WITH RESPECT TO INDIAN ENROLLEES AND INDIAN HEALTH CARE PROVIDERS 

AND INDIAN MANAGED CARE ENTITIES. 

(a) IN GENERAL.—Section 1932 of the Social Security Act (42 U.S.C. 1396u–2) is 

amended by adding at the end the following new subsection: ‘‘(h) SPECIAL RULES WITH RESPECT TO INDIAN ENROLLEES, INDIAN HEALTH CARE

PROVIDERS, AND INDIAN MANAGED CARE ENTITIES.— ‘‘(1) ENROLLEE OPTION TO SELECT AN INDIAN HEALTH CARE PROVIDER AS PRI- MARY CARE PROVIDER.—In the case of a non-Indian Medicaid managed care entity that—

‘‘(A) has an Indian enrolled with the entity; and 

‘‘(B) has an Indian health care provider that is participating as a primary 

care provider within the network of the entity, 

insofar as the Indian is otherwise eligible to receive services from such Indian 

health care provider and the Indian health care provider has the capacity to 

provide primary care services to such Indian, the contract with the entity under 

section 1903(m) or under section 1905(t)(3) shall require, as a condition of receiving payment under such contract, that the Indian shall be allowed to choose 

such Indian health care provider as the Indian’s primary care provider under 

the entity. 

‘‘(2) ASSURANCE OF PAYMENT TO INDIAN HEALTH CARE PROVIDERS FOR PROVISION OF COVERED SERVICES.—Each contract with a managed care entity under 

section 1903(m) or under section 1905(t)(3) shall require any such entity that 

has a significant percentage of Indian enrollees (as determined by the Secretary), as a condition of receiving payment under such contract to satisfy the 

following requirements: 

‘‘(A) DEMONSTRATION OF PARTICIPATING INDIAN HEALTH CARE PROVIDERS

OR APPLICATION OF ALTERNATIVE PAYMENT ARRANGEMENTS.—Subject to subparagraph (E), to—

‘‘(i) demonstrate that the number of Indian health care providers that 

are participating providers with respect to such entity are sufficient to 

ensure timely access to covered Medicaid managed care services for 

those enrollees who are eligible to receive services from such providers; 

or 

‘‘(ii) agree to pay Indian health care providers who are not participating providers with the entity for covered Medicaid managed care 

services provided to those enrollees who are eligible to receive services 

from such providers at a rate equal to the rate negotiated between such 


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entity and the provider involved or, if such a rate has not been negotiated, at a rate that is not less than the level and amount of payment 

which the entity would make for the services if the services were furnished by a participating provider which is not an Indian health care 

provider. ‘‘(B) PROMPT PAYMENT.—To agree to make prompt payment (in accordance with rules applicable to managed care entities) to Indian health care 

providers that are participating providers with respect to such entity or, in 

the case of an entity to which subparagraph (A)(ii) or (E) applies, that the 

entity is required to pay in accordance with that subparagraph. ‘‘(C) SATISFACTION OF CLAIM REQUIREMENT.—To deem any requirement 

for the submission of a claim or other documentation for services covered 

under subparagraph (A) by the enrollee to be satisfied through the submission of a claim or other documentation by an Indian health care provider 

that is consistent with section 403(h) of the Indian Health Care Improvement Act. ‘‘(D) COMPLIANCE WITH GENERALLY APPLICABLE REQUIREMENTS.— ‘‘(i) IN GENERAL.—Subject to clause (ii), as a condition of payment 

under subparagraph (A), an Indian health care provider shall comply 

with the generally applicable requirements of this title, the State plan, 

and such entity with respect to covered Medicaid managed care services 

provided by the Indian health care provider to the same extent that 

non-Indian providers participating with the entity must comply with 

such requirements. 

‘‘(ii) LIMITATIONS ON COMPLIANCE WITH MANAGED CARE ENTITY GENERALLY APPLICABLE REQUIREMENTS.—An Indian health care provider—

‘‘(I) shall not be required to comply with a generally applicable 

requirement of a managed care entity described in clause (i) as a 

condition of payment under subparagraph (A) if such compliance 

would conflict with any other statutory or regulatory requirements 

applicable to the Indian health care provider; and 

‘‘(II) shall only need to comply with those generally applicable requirements of a managed care entity described in clause (i) as a 

condition of payment under subparagraph (A) that are necessary 

for the entity’s compliance with the State plan, such as those related to care management, quality assurance, and utilization management. 

‘‘(E) APPLICATION OF SPECIAL PAYMENT REQUIREMENTS FOR FEDERALLYQUALIFIED HEALTH CENTERS AND ENCOUNTER RATE FOR SERVICES PROVIDED

BY CERTAIN INDIAN HEALTH CARE PROVIDERS.—

‘‘(i) FEDERALLY-QUALIFIED HEALTH CENTERS.—

‘‘(I) MANAGED CARE ENTITY PAYMENT REQUIREMENT.—To agree to 

pay any Indian health care provider that is a Federally-qualified 

health center but not a participating provider with respect to the 

entity, for the provision of covered Medicaid managed care services 

by such provider to an Indian enrollee of the entity at a rate equal 

to the amount of payment that the entity would pay a Federallyqualified health center that is a participating provider with respect 

to the entity but is not an Indian health care provider for such 

services. 

‘‘(II) CONTINUED APPLICATION OF STATE REQUIREMENT TO MAKE

SUPPLEMENTAL PAYMENT.—Nothing in subclause (I) or subparagraph (A) or (B) shall be construed as waiving the application of 

section 1902(bb)(5) regarding the State plan requirement to make 

any supplemental payment due under such section to a Federallyqualified health center for services furnished by such center to an 

enrollee of a managed care entity (regardless of whether the Federally-qualified health center is or is not a participating provider 

with the entity). 

‘‘(ii) CONTINUED APPLICATION OF ENCOUNTER RATE FOR SERVICES PROVIDED BY CERTAIN INDIAN HEALTH CARE PROVIDERS.—If the amount paid 

by a managed care entity to an Indian health care provider that is not 

a Federally-qualified health center and that has elected to receive payment under this title as an Indian Health Service provider under the 

July 11, 1996, Memorandum of Agreement between the Health Care Financing Administration (now the Centers for Medicare and Medicaid 

Services) and the Indian Health Service for services provided by such 

provider to an Indian enrollee with the managed care entity is less 

than the encounter rate that applies to the provision of such services 


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under such memorandum, the State plan shall provide for payment to 

the Indian health care provider of the difference between the applicable 

encounter rate under such memorandum and the amount paid by the 

managed care entity to the provider for such services. ‘‘(F) CONSTRUCTION.—Nothing in this paragraph shall be construed as 

waiving the application of section 1902(a)(30)(A) (relating to application of 

standards to assure that payments are consistent with efficiency, economy, 

and quality of care). ‘‘(3) OFFERING OF MANAGED CARE THROUGH INDIAN MEDICAID MANAGED CARE

ENTITIES.—If— ‘‘(A) a State elects to provide services through Medicaid managed care entities under its Medicaid managed care program; and ‘‘(B) an Indian health care provider that is funded in whole or in part by 

the Indian Health Service, or a consortium composed of 1 or more Tribes, 

Tribal Organizations, or Urban Indian Organizations, and which also may 

include the Indian Health Service, has established an Indian Medicaid 

managed care entity in the State that meets generally applicable standards 

required of such an entity under such Medicaid managed care program, 

the State shall offer to enter into an agreement with the entity to serve as a 

Medicaid managed care entity with respect to eligible Indians served by such 

entity under such program. 

‘‘(4) SPECIAL RULES FOR INDIAN MANAGED CARE ENTITIES.—The following are 

special rules regarding the application of a Medicaid managed care program to 

Indian Medicaid managed care entities: 

‘‘(A) ENROLLMENT.—

‘‘(i) LIMITATION TO INDIANS.—An Indian Medicaid managed care entity may restrict enrollment under such program to Indians and to members of specific Tribes in the same manner as Indian Health Programs 

may restrict the delivery of services to such Indians and tribal members. 

‘‘(ii) NO LESS CHOICE OF PLANS.—Under such program the State may 

not limit the choice of an Indian among Medicaid managed care entities 

only to Indian Medicaid managed care entities or to be more restrictive 

than the choice of managed care entities offered to individuals who are 

not Indians. 

‘‘(iii) DEFAULT ENROLLMENT.—

‘‘(I) IN GENERAL.—If such program of a State requires the enrollment of Indians in a Medicaid managed care entity in order to receive benefits, the State, taking into consideration the criteria specified in subsection (a)(4)(D)(ii)(I), shall provide for the enrollment 

of Indians described in subclause (II) who are not otherwise enrolled with such an entity in an Indian Medicaid managed care entity described in such clause. 

‘‘(II) INDIAN DESCRIBED.—An Indian described in this subclause, 

with respect to an Indian Medicaid managed care entity, is an Indian who, based upon the service area and capacity of the entity, 

is eligible to be enrolled with the entity consistent with subparagraph (A). 

‘‘(iv) EXCEPTION TO STATE LOCK-IN.—A request by an Indian who is 

enrolled under such program with a non-Indian Medicaid managed care 

entity to change enrollment with that entity to enrollment with an Indian Medicaid managed care entity shall be considered cause for granting such request under procedures specified by the Secretary. 

‘‘(B) FLEXIBILITY IN APPLICATION OF SOLVENCY.—In applying section 

1903(m)(1) to an Indian Medicaid managed care entity—

‘‘(i) any reference to a ‘State’ in subparagraph (A)(ii) of that section 

shall be deemed to be a reference to the ‘Secretary’; and 

‘‘(ii) the entity shall be deemed to be a public entity described in subparagraph (C)(ii) of that section. 

‘‘(C) EXCEPTIONS TO ADVANCE DIRECTIVES.—The Secretary may modify or 

waive the requirements of section 1902(w) (relating to provision of written 

materials on advance directives) insofar as the Secretary finds that the requirements otherwise imposed are not an appropriate or effective way of 

communicating the information to Indians. 

‘‘(D) FLEXIBILITY IN INFORMATION AND MARKETING.—

‘‘(i) MATERIALS.—The Secretary may modify requirements under subsection (a)(5) to ensure that information described in that subsection is 

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ner that clearly communicates to such enrollees and potential enrollees 

their rights, protections, and benefits. 

‘‘(ii) DISTRIBUTION OF MARKETING MATERIALS.—The provisions of subsection (d)(2)(B) requiring the distribution of marketing materials to an 

entire service area shall be deemed satisfied in the case of an Indian 

Medicaid managed care entity that distributes appropriate materials 

only to those Indians who are potentially eligible to enroll with the entity in the service area. 

‘‘(5) MALPRACTICE INSURANCE.—Insofar as, under a Medicaid managed care 

program, a health care provider is required to have medical malpractice insurance coverage as a condition of contracting as a provider with a Medicaid managed care entity, an Indian health care provider that is—

‘‘(A) a Federally-qualified health center that is covered under the Federal 

Tort Claims Act (28 U.S.C. 1346(b), 2671 et seq.); 

‘‘(B) providing health care services pursuant to a contract or compact 

under the Indian Self-Determination and Education Assistance Act (25 

U.S.C. 450 et seq.) that are covered under the Federal Tort Claims Act (28 

U.S.C. 1346(b), 2671 et seq.); or 

‘‘(C) the Indian Health Service providing health care services that are 

covered under the Federal Tort Claims Act (28 U.S.C. 1346(b), 2671 et 

seq.); 

are deemed to satisfy such requirement. 

‘‘(6) DEFINITIONS.—For purposes of this subsection: 

‘‘(A) INDIAN HEALTH CARE PROVIDER.—The term ‘Indian health care provider’ means an Indian Health Program or an Urban Indian Organization. 

‘‘(B) INDIAN; INDIAN HEALTH PROGRAM; SERVICE; TRIBE, TRIBAL ORGANIZATION; URBAN INDIAN ORGANIZATION.—The terms ‘Indian’, ‘Indian Health Program’, ‘Service’, ‘Tribe’, ‘Tribal Organization’, ‘Urban Indian Organization’

have the meanings given such terms in section 4 of the Indian Health Care 

Improvement Act. 

‘‘(C) INDIAN MEDICAID MANAGED CARE ENTITY.—The term ‘Indian Medicaid 

managed care entity’ means a managed care entity that is controlled (within the meaning of the last sentence of section 1903(m)(1)(C)) by the Indian 

Health Service, a Tribe, Tribal Organization, or Urban Indian Organization, 

or a consortium, which may be composed of 1 or more Tribes, Tribal Organizations, or Urban Indian Organizations, and which also may include the 

Service. 

‘‘(D) NON-INDIAN MEDICAID MANAGED CARE ENTITY.—The term ‘non-Indian 

Medicaid managed care entity’ means a managed care entity that is not an 

Indian Medicaid managed care entity. 

‘‘(E) COVERED MEDICAID MANAGED CARE SERVICES.—The term ‘covered 

Medicaid managed care services’ means, with respect to an individual enrolled with a managed care entity, items and services that are within the 

scope of items and services for which benefits are available with respect to 

the individual under the contract between the entity and the State involved. 

‘‘(F) MEDICAID MANAGED CARE PROGRAM.—The term ‘Medicaid managed 

care program’ means a program under sections 1903(m) and 1932 and includes a managed care program operating under a waiver under section 

1915(b) or 1115 or otherwise.’’. 

(b) APPLICATION TO SCHIP.—Section 2107(e)(1) of such Act (42 U.S.C. 1397gg(1)), 

as amended by sections 201(c), 204(b)(2), and 206(b)(2), is amended by adding at the 

end the following new subparagraph: 

‘‘(H) Subsections (a)(2)(C) and (h) of section 1932.’’. 

SEC. 209. ANNUAL REPORT ON INDIANS SERVED BY SOCIAL SECURITY ACT HEALTH BENEFIT 

PROGRAMS. 

Section 1139 of the Social Security Act (42 U.S.C. 1320b–9), as amended by the 

sections 202, 205, and 206, is amended by redesignating subsection (e) as subsection 

(f), and inserting after subsection (d) the following new subsection: 

‘‘(e) ANNUAL REPORT ON INDIANS SERVED BY HEALTH BENEFIT PROGRAMS FUNDED

UNDER THIS ACT.—Beginning January 1, 2007, and annually thereafter, the Secretary, acting through the Administrator of the Centers for Medicare and Medicaid 

Services and the Director of the Indian Health Service, shall submit a report to Congress regarding the enrollment and health status of Indians receiving items or services under health benefit programs funded under this Act during the preceding year. 

Each such report shall include the following: 

‘‘(1) The total number of Indians enrolled in, or receiving items or services 

under, such programs, disaggregated with respect to each such program. 


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‘‘(2) The number of Indians described in paragraph (1) that also received 

health benefits under programs funded by the Indian Health Service. 

‘‘(3) General information regarding the health status of the Indians described 

in paragraph (1), disaggregated with respect to specific diseases or conditions 

and presented in a manner that is consistent with protections for privacy of individually identifiable health information under section 264(c) of the Health Insurance Portability and Accountability Act of 1996. 

‘‘(4) A detailed statement of the status of facilities of the Indian Health Service or an Indian Tribe, Tribal Organization, or an Urban Indian Organization 

with respect to such facilities’ compliance with the applicable conditions and requirements of titles XVIII, XIX, and XXI, and, in the case of title XIX or XXI, 

under a State plan under such title or under waiver authority, and of the 

progress being made by such facilities (under plans submitted under sections 

1880(b), 1911(b) or otherwise) toward the achievement and maintenance of such 

compliance. 

‘‘(5) Such other information as the Secretary determines is appropriate.’’. 

PURPOSE OF THE BILL

The purpose of H.R. 5312 is to amend the Indian Health Care 

Improvement Act to revise and extend that Act. 

BACKGROUND AND NEED FOR LEGISLATION

The Indian Health Care Improvement Act (IHCIA) became Public Law 94–437 in the 94th Congress (1976), and was subsequently 

amended seven times. IHCIA provides health care to over two million American Indians and Alaska Natives. Congress enacted a 

one-year reauthorization of appropriations for IHCIA through fiscal 

year (FY) 2001 but efforts at further extensions were interrupted 

due to 9/11 events. Appropriations for Indian health have continued through appropriations for the Snyder Act, a permanent law 

authorizing expenditures of funds for a variety of Indian programs, 

including health. For FY 2006, Congress appropriated just over $3 

billion to help provide health care services to American Indians and 

Alaska Natives. 

In 1998, the Indian Health Service (IHS) of the Department of 

Health and Human Services started the IHCIA reauthorization 

process under the IHS’s Tribal Consultation Policy by convening a 

roundtable. Coordinators from the 12 IHS areas formed working 

groups to examine various areas of existing law. These meetings 

were to inform the tribal representatives about the reauthorization 

process, and provide opportunities to discuss and reach consensus 

on recommendations for IHCIA amendments. Four regional meetings were held to provide further opportunities for tribes to provide 

input, share recommendations from the 12 IHS areas, and build 

consensus among participants for a unified position. 

The IHS Director also convened a National Steering Committee 

(NSC) to be responsible for drafting the report on the IHCIA recommendations. The NSC is composed of one elected and one alternative tribal representative from each of the 12 IHS areas, a representative from the National Indian Health Board, the National 

Council of Urban Indian Health, and the Self-Governance Advisory 

Committee. During the course of the four meetings, this group’s responsibility evolved from compiling a final report of recommendaVerDate Aug 31 2005 06:24 Sep 16, 2006 Jkt 049006 PO 00000 Frm 00089 Fmt 6659 Sfmt 6602 E:\HR\OC\HR661P1.XXX HR661P1

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1The final report, entitled ‘‘Speaking with One Voice,’’ identified areas of consensus and differences. 

tions 1 to the drafting of the actual IHCIA reauthorization bill language. 

H.R. 5312 is the result of the NSC Committee’s work. Both the 

NSC and the Committee on Resources worked carefully to ensure 

that whenever possible, H.R. 5312 did not represent a regression 

from the authorities provided in current law. In addition, while 

changes to the Medicare system as it related to Indian health care 

had been proposed, the bill as reported has no changes because of 

concern that any changes so soon after the enactment of the Medicare Modernization Act (Public Law 108–173) may be burdensome. 

As follows is a discussion of several notable sections of the reported bill. 

Section 3 and Section 104. Definitions; Indian health professions 

scholarships 

Sections 3 and 104 of the legislation, as amended, references the 

practice of marriage and family therapy. Practitioners of this therapy focus on the general mental and emotional health of families 

and couples. Congress, in the past two years, has shown an increased focus and concern regarding improving the mental health 

of both parents and children living on tribal lands across the country. Marriage and family therapists are one way to achieve this 

goal, and the bill supports scholarships for students who desire to 

practice in this area under the Indian Health Service (IHS). 

The Committee supports the existing process by which the IHS 

works with limited funds to provide the scholarships under to those 

students pursuing degrees in the fields that the Service determines 

to be the most relevant. Still, given the clear statutory language of 

25 U.S.C. 1603 regarding health professions, the Committee is 

hopeful that all professions listed will receive equal consideration 

for students who will eventually work within the IHS system. 

Should the support come from Indian Country, including the National Steering Committee, for increased focus on the services offered by marriage and family therapists, then the Committee would 

be supportive of more scholarship monies being made available, as 

the needs of tribes evolve within the urban Indian health clinics 

and other IHS or tribal programs. 

Section 121. Community Health Aide Program for Alaska 

Section 121, subject to the availability of new funding, authorizes 

IHS to expand the existing community health aide program nationally. The Committee considered various options prior to amending 

this section. The reported text will continue to allow the Community Health Aide Program (CHAP), except for Dental Health Aide 

Therapists’ certification, to expand nationally. The dental health 

aide therapist program will be limited to Alaska only, and the 

therapists’ scope of practice will be limited to the procedures as 

stated in the January 31, 2005, Community Health Aide Program 

Certification Board’s Standards and Procedures. The Committee 

believes the importance of the dental health aide program as part 

of a comprehensive oral health care delivery system led by licensed 

dentists should not be understated. This program provides an imVerDate Aug 31 2005 06:24 Sep 16, 2006 Jkt 049006 PO 00000 Frm 00090 Fmt 6659 Sfmt 6602 E:\HR\OC\HR661P1.XXX HR661P1

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portant extension of the community health aide program because 

dental health aides will work and live in the villages, helping to 

establish disease prevention and health education programs that 

can break the dental disease cycle affecting many American Indians and Alaska Natives. With the emphasis on prevention, the 

amount of new active disease can be reduced and treatment of any 

new active disease can be more easily managed. 

The Committee crafted the language with input from other concerned Members, after consideration of the endorsement of the dental health aide therapist program by national Indian organizations 

and public health organizations, and with the assistance of the 

American Dental Association, to ensure safety and continued quality care in the larger CHAP program by imposing certain limitations on the practice of dental health aide therapists found in paragraph (b)(7). To help ensure the continued quality of the dental 

health aides certified by the Federal CHAP Certification Board in 

Alaska, the board should include at least one dentist from outside 

the tribal community who has actively practiced dentistry and who 

has expertise in setting quality standards for evaluating competence in education and practice. In paragraph (b)(7), ‘‘medical 

emergency’’ is defined as an injury or illness, including infection, 

that poses an immediate threat to a person’s well being, health or 

life. Also in paragraph (b)(7), deciduous teeth are defined as primary teeth and adult teeth are defined as permanent teeth. The 

amended provision also provides for the Secretary of Health and 

Human Services to establish a neutral panel to conduct a study of 

the dental health aide therapist services and the services of other 

mid-level providers, such as the Community Dental Health Coordinator, as developed by the American Dental Association. 

Section 512. Treatment of certain demonstration projects 

In H.R. 5312 as introduced, Section 512 would make the Oklahoma City Clinic and Tulsa Clinic demonstration projects subject 

to the provisions of the Indian Self-Determination and Education 

Assistance Act (25 U.S.C. 450 et seq.). The reported text will allow 

the clinics the continued authority to manage their specific health 

care delivery programs. There was concern expressed among the 

clinics, including statements reflected in dozens of letters received 

by the Committee, that the current framework of administration by 

the clinics was most beneficial to service the over 33,000 patients 

that visit the two cities from all over the State of Oklahoma. Further support of the provision in the reported text is evidenced in 

the letter sent by four members of the Oklahoma Congressional 

delegation appended to this report. 

Title VII—Behavioral health programs 

When the Committee references behavioral, community, or homebased mental health services for children or youth in Sections 

70l(c)(1), 707(c)(2)(E), and 709(c)(3) of the bill, the Committee also 

intends that systems of care programs are appropriate. Systems of 

care employs family-centered, community based, culturally appropriate and collaborative approaches to mental health services. This 

is an approach that is being widely used by the Substance Abuse 

and Mental Health Services Administration (SAMHSA) in coordination with the IHS and other agencies, and over 30 tribal commuVerDate Aug 31 2005 06:24 Sep 16, 2006 Jkt 049006 PO 00000 Frm 00091 Fmt 6659 Sfmt 6602 E:\HR\OC\HR661P1.XXX HR661P1

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nities have implemented the systems of care approach in developing a child mental health system. SAMHSA has documented the 

benefit of the system of care for children’s mental health services, 

including its application in tribal communities. The Committee encourages the use by IHS and tribes of the systems of care for children and youth mental health services. 

Title IV—Access to health services 

These provisions are a reflection of language that was negotiated 

with the Senate Finance Committee in June of 2006 and is also 

contained in S. 3524, as ordered reported by that Committee. 

The Committee would also like to note that the introduced 

version of H.R. 5312 in the 108th Congress, H.R. 2440, included a 

section regarding the review of Medicare and Medicaid Payment 

system. At the request of the Department of Health and Human 

Services, the Committee omitted a provision requiring the Secretary of Health and Human Services to examine the extent to 

which Medicare and Medicaid payment methodologies take into account the unique and special circumstances of the provision of covered services by health programs operated by the relevant Service 

and tribal entities. 

The Department indicated to the Committee that it has sufficient 

authority under existing law to undertake this payment methodology review. Therefore, the Committee expects the Secretary will 

perform such a review pursuant to existing authority. The review 

should include the current payment methodologies applicable to the 

Indian health system. The objectives of the review should be to determine the sufficiency of payments to the providers in the Indian 

health system under various payment methodologies both in terms 

of assuring access to care and payment at rates consistent with 

those for most favored providers. The Committee looks forward to 

the recommendations made by the Department of Health and 

Human Services to Congress. 

While this study is being performed and during the time Congress reviews the Secretary’s recommendations for potential legislative action, the Committee expects the Department to maintain 

in place the current payment methodology for Indian health programs. 

COMMITTEE ACTION

H.R. 5312 was introduced on May 9, 2006, by Congressman Don 

Young (R–AK). The bill was referred primarily to the Committee 

on Resources, and additionally to the Committee on Energy and 

Commerce and the Committee on Ways and Means. On June 21, 

2006, the Full Resources Committee met to consider the bill. Chairman Richard Pombo (R–CA) offered an amendment in the nature 

of a substitute to make numerous technical changes to the bill, 

which included removal of various new authorization levels that 

were not included in the version of this legislation ordered reported 

by the Committee on Resources in 2004, such as Section 708 of 

H.R. 5312, as introduced. Congressman Don Young (R–AK) offered 

an amendment to amendment in the nature of a substitute reflecting agreement on language pertaining to Section 121. The amendment was adopted by unanimous consent. The amendment in the 

nature of a substitute, as amended, was adopted by unanimous 


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consent. The bill, as amended, was then ordered favorably reported 

to the House of Representatives by unanimous consent. 

COMMITTEE OVERSIGHT FINDINGS AND RECOMMENDATIONS

Regarding clause 2(b)(1) of rule X and clause 3(c)(1) of rule XIII 

of the Rules of the House of Representatives, the Committee on Resources’ oversight findings and recommendations are reflected in 

the body of this report. 

FEDERAL ADVISORY COMMITTEE STATEMENT

The functions of the proposed advisory committee authorized in 

the bill are not currently being nor could they be performed by one 

or more agencies, an advisory committee already in existence or by 

enlarging the mandate of an existing advisory committee. 

CONSTITUTIONAL AUTHORITY STATEMENT

Article I, section 8, section 3 of the Constitution of the United 

States grants Congress the authority to enact this bill. 

COMPLIANCE WITH HOUSE RULE XIII 

1. Cost of Legislation. Clause 3(d)(2) of rule XIII of the Rules of 

the House of Representatives requires an estimate and a comparison by the Committee of the costs which would be incurred in carrying out this bill. However, clause 3(d)(3)(B) of that rule provides 

that this requirement does not apply when the Committee has included in its report a timely submitted cost estimate of the bill prepared by the Director of the Congressional Budget Office under section 402 of the Congressional Budget Act of 1974. 

2. Congressional Budget Act. As required by clause 3(c)(2) of rule 

XIII of the Rules of the House of Representatives and section 

308(a) of the Congressional Budget Act of 1974, this bill does not 

contain any new budget authority, credit authority, or an increase 

or decrease in revenues or tax expenditures. According to the Congressional Budget Office, enactment of H.R. 5312 would increase 

direct spending by $8 million in 2007, by $67 million over the 

2007–2011 period, and by $163 million over the 2007–2016 time 

frame. 

3. General Performance Goals and Objectives. As required by 

clause 3(c)(4) of rule XIII, the general performance goal or objective 

of this bill is to amend the Indian Health Care Improvement Act 

to revise and extend that Act. 

4. Congressional Budget Office Cost Estimate. Under clause 

3(c)(3) of rule XIII of the Rules of the House of Representatives and 

section 403 of the Congressional Budget Act of 1974, the Committee has received the following cost estimate for this bill from the 

Director of the Congressional Budget Office: 

H.R. 5312—Indian Health Care Improvement Act Amendments of 

2006 

Summary: H.R. 5312 would authorize the appropriation of such 

sums as are necessary through 2015 for the Indian Health Care 

Improvement Act, the primary authorizing legislation for the InVerDate Aug 31 2005 06:24 Sep 16, 2006 Jkt 049006 PO 00000 Frm 00093 Fmt 6659 Sfmt 6602 E:\HR\OC\HR661P1.XXX HR661P1

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dian Health Service (IHS). The bill also contains provisions that 

would affect direct spending, primarily in the Medicaid program. CBO estimates that implementing H.R. 5312 would cost $2.6 bil- lion in 2007 and $30.4 billion over the 2007–2016 period, assuming 

appropriation of the necessary amounts. We also estimate that enacting the bill would increase direct spending by $8 million in 

2007, by $67 million over the 2007–2011 period, and by $163 million over the 2007–2016 period. 

H.R. 5312 would preempt state licensing laws in certain cases, 

and this preemption would be an intergovernmental mandate as 

defined in the Unfunded Mandates Reform Act (UMRA); however, 

CBO estimates that the costs of that mandate would be small and 

would not approach the threshold established in UMRA ($64 million in 2006, adjusted annually for inflation). The bill also would 

place new requirements on Medicaid and the State Children’s 

Health Insurance Program (SCHIP) that would result in additional 

spending of about $93 million over the 2007–2016 period. Other 

provisions of the bill would benefit tribal governments by establishing new or expanding existing programs for Indian health care. 

This bill contains no private-sector mandates as defined in UMRA. 

Estimated cost to the Federal Government: The estimated budgetary impact of H.R. 5312 is shown in Table 1. The costs of this 

legislation fall within budget function 550 (health). 

TABLE 1.—ESTIMATED BUDGETARY EFFECTS OF H.R. 5312 

By fiscal year, in millions of dollars— 

2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 

CHANGES IN SPENDING SUBJECT TO APPROPRIATION 

Estimated Authorization Level ...... 3,117 3,188 3,261 3,336 3,412 3,491 3,571 3,654 3,740 0 

Estimated Outlays ......................... 2,571 2,998 3,160 3,303 3,378 3,456 3,536 3,617 3,702 634 

CHANGES IN DIRECT SPENDING 

Estimated Budget Authority .......... 7 14 14 15 15 15 16 21 21 22 

Estimated Outlays ......................... 8 15 14 15 15 15 16 21 21 23 

Basis of estimate: For the purpose of this estimate, CBO assumes 

that H.R. 5312 will be enacted near the start of fiscal year 2007 

and that the necessary amounts will be appropriated for each fiscal 

year. 

Spending subject to appropriation 

H.R. 5312 would authorize the appropriation of such sums as are 

necessary for the Indian Health Service through 2015. The agency’s 

responsibilities under the bill would be broadly similar to those in 

current law. In 2006, the agency received an appropriation just 

over $3 billion. CBO’s estimate of the authorized level for IHS programs is the appropriated amount for 2006 adjusted for anticipated 

inflation in later years. The estimated outlays reflect historical 

spending patterns for IHS activities. 

Direct spending 

H.R. 5312 contains several provisions, primarily related to the 

Medicaid program, that would affect direct spending. The bill’s estimated effects on direct spending are shown in Table 2. Overall, 

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ing by $8 million in 2007 and $163 million over the 2007–2016 period. 

TABLE 2.—ESTIMATED EFFECTS OF H.R. 5312 ON DIRECT SPENDING 

By fiscal year, in millions of dollars—

2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 

Exemption from Cost Sharing and Premiums: 

Medicaid: 

Estimated Budget Authority ............ 5 10 10 10 10 10 10 15 15 15 

Estimated Outlays ........................... 5 10 10 10 10 10 10 15 15 15 

SCHlP: 

Budget Authority ............................. 0 0 0 0 0 0 0 0 0 0 

Estimated Outlays ........................... 1 1 * ¥1 * * * * * * 

Consultation with Indian Health Programs: 

Estimated Budget Authority ..................... * * 1 1 1 1 1 1 1 1 

Estimated Outlays .................................... * * 1 1 1 1 1 1 1 1 

Medicaid Managed Care Provisions: 

Estimated Budget Authority ..................... 2 3 3 4 4 4 5 5 5 6 

Estimated Outlays .................................... 2 3 3 4 4 4 5 5 5 6 

Exclude Outreach Spending from Limit on Administrative Costs: 

Estimated Budget Authority ..................... * * * * * * * * * * 

Estimated Outlays .................................... * * * * * * * * * * 

Scholarship and Loan Repayment Recovery 

Fund: 

Estimated Budget Authority ..................... * * * * * * * * * * 

Estimated Outlays .................................... * * * * * * * * * * 

Total Changes in Direct Spending: 

Estimated Budget Authority ..................... 7 14 14 15 15 15 16 21 21 22 

Estimated Outlays .................................... 8 15 14 15 15 15 16 21 21 23 

* = Costs or savings of less than $500,000. 

Notes.—Components may not sum to totals because of rounding. SCHIP is the State Children’s Health Insurance Program. 

The effects of each provision are discussed in more detail below. 

IHS-funded health programs are commonly divided into three 

groups: those operated directly by the Indian Health Service, those 

operated by tribes and tribal organizations under self-governance 

agreements, and those operated by urban Indian organizations. For 

this estimate, they are referred to collectively as Indian health programs. 

Exemption from Cost Sharing and Premiums. Section 204 

would prohibit Medicaid and SCHIP programs from charging cost 

sharing or premiums to Indians for services that are provided directly or upon referral by Indian health programs. The provision 

also would prohibit states from reducing payments to providers for 

those services by the amount of cost sharing that Indians otherwise 

would pay. 

Medicaid. CBO anticipates that this provision’s budgetary effect 

would stem largely from eliminating cost sharing for referral services. Current law already prohibits Indian health programs from 

charging cost sharing to Indians who use their services. In addition, Medicaid pays almost all facilities operated by IHS and tribes 

based on an all-inclusive rate that is not reduced to account for any 

cost sharing that Indians would otherwise have to pay. Finally, 

very few states charge premiums to their Medicaid enrollees. 

Using Medicaid administrative data, CBO estimates that about 

270,000 Indians are Medicaid recipients who also use IHS, and 

that federal Medicaid spending on affected services would be about 

$275 per person annually in 2007. The amount of affected spending 

would be relatively low because Medicaid already prohibits cost 


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sharing in many instances, such as long-term care services, emergency services, and services for many children and pregnant 

women. For the affected spending, CBO assumes that cost sharing 

paid by individuals equals 2 percent of total spending—Medicaid 

law limits the extent to which states can impose cost sharing—and 

that eliminating cost sharing would increase total spending by 

about 5 percent as individuals consume more services. Overall, 

CBO estimates that the provision would increase federal Medicaid 

spending by $5 million in 2007 and by $110 million over the 2007– 2016 period. 

State Children’s Health Insurance Program. SCHIP regulations 

already prohibit states from charging cost sharing or premiums to 

Indian children enrolled in the program. As a result, the provision’s 

impact on SCHIP spending largely reflects higher payments to Indian health programs and the use of additional services by adult 

enrollees that a handful of states cover in waiver programs. CBO 

estimates that the additional spending would total $2 million over 

the 2007–2016 period. The provision’s effects would be limited in 

later years because total funding for the program is capped. 

Consultation with Indian Health Programs. Section 206 

would encourage state Medicaid programs to consult regularly with 

Indian health programs on outstanding Medicaid issues by allowing states to receive federal matching funds for the cost of those 

consultations. Those costs would be treated as an administrative 

expense under Medicaid and divided equally between the federal 

government and the states. CBO anticipates that a small number 

of states would take advantage of this provision, increasing federal 

Medicaid spending by less than $500,000 in 2007 and by $7 million 

over the 2007–2016 period. 

Medicaid Managed Care Provisions. Section 208 would make 

several changes to improve the ability of Indian health programs 

to receive payments for Indians who receive Medicaid benefits 

through managed care arrangements. Those changes include: • Managed care organizations (MCOs) would have to pay Indian 

health programs at least the rates used for preferred providers. 

States also would have the option of making those payments directly to Indian health programs. 

• MCOs would have to accept claims submitted by Indian health 

programs instead of requiring enrollees to submit claims personally. 

• Some requirements that MCOs must now meet to participate 

in Medicaid would be waived or modified for Indian health programs that seek to operate as MCOs. (For example, MCOs run by 

Indian health programs would be able to limit enrollment to Indians only.) 

• States would be required to offer contracts to Indian health 

programs seeking to operate their own MCOs. 

Based on administrative data on Medicaid enrollment and spending for Indians who receive benefits via managed care, CBO estimates that those provisions would increase federal Medicaid spending by $2 million in 2007 and $41 million over the 2007–2016 period. We anticipate that the additional costs would be relatively 

modest because some states already use similar rules in their Medicaid managed care programs and Indian health programs would 

have a limited interest in participating as MCOs. 


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Exclude Outreach Spending from Limit on Administrative 

Costs. Under current law, spending by SCHIP programs on administration and certain other activities cannot exceed 10 percent of 

overall spending. Section 203 would exclude spending on outreach 

activities to enroll additional Indian children from the 10 percent 

limit. 

CBO estimates that this provision would increase or decrease 

SCHIP spending by less than $500,000 in any fiscal year. Federal 

funding for SCHIP is limited, and we anticipate that most states 

with a significant Indian population would spend all of their 

SCHIP funds under current law. In addition, some of the states 

with unspent funds are not currently constrained by the 10 percent 

limit and thus would not be affected by the provision. 

Scholarship and Loan Repayment Recovery Fund. H.R. 

5312 would allow the Secretary of Health and Human Services to 

spend amounts collected for breach of contract from recipients of 

certain IHS scholarships. Under current law, those funds are deposited in the Treasury and not spent. Because the Secretary’s ability to spend those funds would not be subject to appropriation, the 

provision would increase direct spending. Based on historical information from IRS, CBO estimated that the provision would increase 

spending by less than $500,000 a year and about $4 million over 

the 2007–2016 period. 

Estimated long-term direct spending effects: Pursuant to section 

407 of H. Con. Res. 95 (the Concurrent Resolution on the Budget, 

Fiscal Year 2006), CBO estimates that enacting H.R. 5312 would 

not cause an increase in direct spending greater than $5 billion in 

any of the 10–year periods from 2016 to 2055. 

Estimated impact on state, local, and tribal governments 

Intergovernmental mandates 

H.R. 5312 would preempt state licensing laws in cases where a 

health care professional is licensed in one state but is performing 

services in another state under a contract or compact with a tribal 

health program. This preemption would be an intergovernmental 

mandate as defined in the UMRA; however, CBO estimates that 

the loss of any licensing fees resulting from the mandate would be 

small and would not approach the threshold established in UMRA 

($64 million in 2006, adjusted annually for inflation). 

Other impacts 

H.R. 5312 would reauthorize and expand grant and assistance 

programs available to Indian tribes, tribal organizations, and 

urban Indian organizations for a range of health care programs, including prevention, treatment, and ongoing care. The bill also 

would allow IRS and tribal entities to share facilities, and it would 

authorize joint ventures between IRS and Indian tribes or tribal organizations for the construction and operation of health facilities. 

The bill would authorize funding for a variety of health services including hospice care, long-term care, public health services, and 

home and community-based services. 

The bill would prohibit states from charging cost sharing or premiums in the Medicaid or SCHIP programs to Indians who receive 

services or benefits through an Indian health program. CBO estiVerDate Aug 31 2005 06:24 Sep 16, 2006 Jkt 049006 PO 00000 Frm 00097 Fmt 6659 Sfmt 6602 E:\HR\OC\HR661P1.XXX HR661P1

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mates that the new requirements in the bill would result in additional spending by states of about $93 million over the 2007–2016 

period. Some tribal entities, particularly those operating managed 

care systems, may realize some savings as a result of these provisions. 

Estimated impact on the private sector: This bill contains no private-sector mandates as defined in UMRA. 

Previous CBO estimates: On April 26, 2006, CBO transmitted a 

cost estimate for S. 1057, the Indian Health Care Improvement Act 

Amendments of 2005, as reported by the Senate Committee on Indian Affairs on March 16, 2006. That bill contains provisions that 

would affect direct spending that are similar to those in H.R. 5312; 

we estimated that enacting S. 1057 would increase direct spending 

by $27 million in 2007 and by $398 million over the 2007–2016 period. The estimated costs for S. 1057 are higher largely because 

that bill would exempt all Indians enrolled in Medicaid or SCHIP 

from any cost sharing or premiums. By comparison, the exemption 

in H.R. 5312 would apply to fewer individuals (Medicaid or SCHIP 

recipients who also use IHS) and to a narrower range of services 

(those provided directly or upon referral by Indian health programs). 

On July 10, 2006, CBO transmitted a cost estimate for S. 3524, 

the Medicare, Medicaid, and SCRIP Indian Health Care Improvement Act of 2006, as reported by the Senate Committee on Finance 

on June 15, 2006. The provisions in H.R. 5312 that would affect 

Medicaid and SCHIP spending are identical to S. 3524, and CBO’s 

estimates of their budgetary effects are the same. 

Estimate prepared by: Federal costs: Eric Rollins. Impact on 

state, local, and tribal governments: Leo Lex. Impact on the private 

sector: Paige Shevlin. 

Estimate approved by: Peter H. Fontaine, Deputy Assistant Director for Budget Analysis. 

COMPLIANCE WITH PUBLIC LAW 104–4 

This bill contains no unfunded mandates. 

PREEMPTION OF STATE, LOCAL OR TRIBAL LAW

This bill is not intended to preempt any State, local or tribal law 

other than State licensing laws in certain cases where a health 

care professional is licensed in one State but is performing services 

in another State under a contract or compact with a tribal health 

program. 

CHANGES IN EXISTING LAW MADE BY THE BILL, AS REPORTED

In compliance with clause 3(e) of rule XIII of the Rules of the 

House of Representatives, changes in existing law made by the bill, 

as reported, are shown as follows (existing law proposed to be omitted is enclosed in black brackets, new matter is printed in italic, 

existing law in which no change is proposed is shown in roman): 


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INDIAN HEALTH CARE IMPROVEMENT ACT 

Be it enacted by the Senate and House of Representatives of the 

United States of America in Congress assembled, øThat this Act 

may be cited as the ‘‘Indian Health Care Improvement Act’’. 

øFINDINGS

øSEC. 2. The Congress finds the following: 

ø(a) 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) 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) 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) Despite such services, the unmet health needs of the American Indian people are severe and the health status of the Indians 

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

øDECLARATION OF HEALTH OBJECTIVES

øSEC. 3. (a) The Congress hereby declares that it is the policy of 

this Nation, in fulfillment of its special responsibilities and legal 

obligation to the American Indian people, to assure the highest possible health status for Indians and urban Indians and to provide 

all resources necessary to effect that policy. 

ø(b) It is the intent of the Congress that the Nation meet the following health status objectives with respect to Indians and urban 

Indians by the year 2000: 

ø(1) Reduce coronary heart disease deaths to a level of no 

more than 100 per 100,000. 

ø(2) Reduce the prevalence of overweight individuals to no 

more than 30 percent. 

ø(3) Reduce the prevalence of anemia to less than 10 percent 

among children aged 1 through 5. 

ø(4) Reduce the level of cancer deaths to a rate of no more 

than 130 per 100,000. 

ø(5) Reduce the level of lung cancer deaths to a rate of no 

more than 42 per 100,000. 

ø(6) Reduce the level of chronic obstructive pulmonary disease related deaths to a rate of no more than 25 per 100,000. 

ø(7) Reduce deaths among men caused by alcohol-related 

motor vehicle crashes to no more than 44.8 per 100,000. 

ø(8) Reduce cirrhosis deaths to no more than 13 per 100,000. 

ø(9) Reduce drug-related deaths to no more than 3 per 

100,000. 

ø(10) Reduce pregnancies among girls aged 17 and younger 

to no more than 50 per 1,000 adolescents. 

ø(11) Reduce suicide among men to no more than 12.8 per 

100,000. 


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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. 

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. 


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ø(34) Reduce deaths from cancer of the uterine cervix to no 

more than 1.3 per 100,000 women. 

ø(35) Reduce colorectal cancer deaths to no more than 13.2 

per 100,000. 

ø(36) Reduce to no more than 11 percent the proportion of 

individuals who experience a limitation in major activity due 

to chronic conditions. 

ø(37) Reduce significant hearing impairment to a prevalence 

of no more than 82 per 1,000. 

ø(38) Reduce significant visual impairment to a prevalence of 

no more than 30 per 1,000. 

ø(39) Reduce diabetes-related deaths to no more than 48 per 

100,000. 

ø(40) Reduce diabetes to an incidence of no more than 2.5 

per 1,000 and a prevalence of no more than 62 per 1,000. 

ø(41) Reduce the most severe complications of diabetes as 

follows: 

ø(A) End-stage renal disease, 1.9 per 1,000. 

ø(B) Blindness, 1.4 per 1,000. 

ø(C) Lower extremity amputation, 4.9 per 1,000. 

ø(D) Perinatal mortality, 2 percent. 

ø(E) Major congenital malformations, 4 percent. 

ø(42) Confine annual incidence of diagnosed AIDS cases to 

no more than 1,000 cases. 

ø(43) Confine the prevalence of HIV infection to no more 

than 100 per 100,000. 

ø(44) Reduce gonorrhea to an incidence of no more than 225 

cases per 100,000. 

ø(45) Reduce chlamydia trachomatis infections, as measured 

by a decrease in the incidence of nongonococcal urethritis to no 

more than 170 cases per 100,000. 

ø(46) Reduce primary and secondary syphilis to an incidence 

of no more than 10 cases per 100,000. 

ø(47) Reduce the incidence of pelvic inflammatory disease, as 

measured by a reduction in hospitalization for pelvic inflammatory disease to no more than 250 per 100,000 women aged 

15 through 44. 

ø(48) Reduce viral hepatitis B infection to no more than 40 

per 100,000 cases. 

ø(49) Reduce indigenous cases of vaccine-preventable diseases as follows: 

ø(A) Diphtheria among individuals aged 25 and younger, 

0. 

ø(B) Tetanus among individuals aged 25 and younger, 0. 

ø(C) Polio (wild-type virus), 0. 

ø(D) Measles, 0. 

ø(E) Rubella, 0. 

ø(F) Congenital Rubella Syndrome, 0. 

ø(G) Mumps, 500. 

ø(H) Pertussis, 1,000. 

ø(50) Reduce epidemic-related pneumonia and influenza 

deaths among individuals aged 65 and older to no more than 

7.3 per 100,000. 

ø(51) Reduce the number of new carriers of viral hepatitis B 

among Alaska Natives to no more than 1 case. 


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ø(52) Reduce tuberculosis to an incidence of no more than 5 

cases per 100,000. 

ø(53) Reduce bacterial meningitis to no more than 8 cases 

per 100,000. 

ø(54) Reduce infectious diarrhea by at least 25 percent 

among children. 

ø(55) Reduce acute middle ear infections among children 

aged 4 and younger, as measured by days of restricted activity 

or school absenteeism, to no more than 105 days per 100 children. 

ø(56) Reduce cigarette smoking to a prevalence of no more 

than 20 percent. 

ø(57) Reduce smokeless tobacco use by youth to a prevalence 

of no more than 10 percent. 

ø(58) Increase to at least 65 percent the proportion of parents and caregivers who use feeding practices that prevent 

baby bottle tooth decay. 

ø(59) Increase to at least 75 percent the proportion of mothers who breast feed their babies in the early postpartum period, and to at least 50 percent the proportion who continue 

breast feeding until their babies are 5 to 6 months old. 

ø(60) Increase to at least 90 percent the proportion of pregnant women who receive prenatal care in the first trimester of 

pregnancy. 

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 801, a report on the progress made in each area of the Service 

toward meeting each of the objectives described in subsection (b). 

øDEFINITIONS

øSEC. 4. For purposes of this Act—

ø(a) ‘‘Secretary’’, unless otherwise designated, means the Secretary of Health and Human Services. 

ø(b) ‘‘Service’’ 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) hereof, except that, for the purpose of sections 102 and 

103, 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 


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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), 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. 

ø(f) ‘‘Urban Indian’’ means any individual who resides in an 

urban center, as defined in subsection (g) hereof, and who meets 

one or more of the four criteria in subsection (c)(1) through (4) of 

this section. 

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

urban Indian population with unmet health needs to warrant assistance under title V, 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 503(a). 

ø(i) ‘‘Area office’’ means an administrative entity including a program office, within the Indian Health Service through which services and funds are provided to the service units within a defined 

geographic area. 

ø(j) ‘‘Service unit’’ means—

ø(1) an administrative entity within the Indian Health Service, or 

ø(2) a tribe or tribal organization operating health care programs or facilities with funds from the Service under the Indian Self-Determination Act, 

through which services are provided, directly or by contract, to the 

eligible Indian population within a defined geographic area. 

ø(k) ‘‘Health promotion’’ includes—

ø(1) cessation of tobacco smoking, 

ø(2) reduction in the misuse of alcohol and drugs, 

ø(3) improvement of nutrition, 

ø(4) improvement in physical fitness, 

ø(5) family planning, 

ø(6) control of stress, and 

ø(7) pregnancy and infant care (including prevention of fetal 

alcohol syndrome). 

ø(l) ‘‘Disease prevention’’ includes—

ø(1) immunizations, 

ø(2) control of high blood pressure, 

ø(3) control of sexually transmittable diseases, 


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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. 

øTITLE I—INDIAN HEALTH MANPOWER 

øPURPOSE

øSEC. 101. The purpose of this title is to increase the number of 

Indians entering the health professions and to assure an adequate 

supply of health professionals to the Service, Indian tribes, tribal 

organizations, and urban Indian organizations involved in the provision of health care to Indian people. 

øHEALTH PROFESSIONS RECRUITMENT PROGRAM FOR INDIANS

øSEC. 102. (a) The Secretary, acting through the Service, shall 

make grants to public or nonprofit private health, or educational 

entities, or Indian tribes or tribal organizations to assist such entities in meeting the costs of— ø(1) identifying Indians with a potential for education or 

training in the health professions and encouraging and assisting them—

ø(A) to enroll in courses of study in such health professions; or 

ø(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; 

ø(2) publicizing existing sources of financial aid available to 

Indians enrolled in any course of study referred to in paragraph (1) of this subsection or who are undertaking training 

necessary to quality them to enroll in any such course of study; 

or 

ø(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) of this subsection. 

ø(b)(1) No grant may be made under this section unless an application therefor 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 


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regulation prescribe. The Secretary shall give a preference to applications submitted by Indian tribes or tribal organizations. 

ø(2) The amount of any grant under this section shall be determined by the Secretary. Payments pursuant to grants under this 

section may be made in advance or by way of reimbursement, and 

at such intervals and on such conditions as the Secretary finds necessary. 

øHEALTH PROFESSIONS PREPARATORY SCHOLARSHIP PROGRAM FOR

INDIANS

øSEC. 103. (a) The Secretary, acting through the Service, shall 

make scholarship grants to Indians who—

ø(1) have successfully completed their high school education 

or high school equivalency; and 

ø(2) have demonstrated the capability to successfully complete courses of study in the health professions. 

ø(b) Scholarship grants made pursuant to this section shall be for 

the following purposes: 

ø(1) Compensatory preprofessional education of any grantee, 

such scholarship not to exceed two years on a full-time basis 

(or the part-time equivalent thereof, as determined by the Secretary). 

ø(2) Pregraduate education of any grantee 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 (or the part-time equivalent thereof, as determined by the Secretary). 

ø(c) Scholarship grants made under this section may cover costs 

of tuition, books, transportation, board, and other necessary related 

expenses of a grantee while attending school. 

ø(d) The 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) The 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. 

øINDIAN HEALTH PROFESSIONS SCHOLARSHIPS

øSEC. 104. (a) In order to provide health professionals to Indians, 

Indian tribes, tribal organizations, and urban Indian organizations, 

the Secretary, acting through the Service and in accordance with 

this section, shall make scholarship grants to Indians who are enrolled full or part time in appropriately accredited schools and 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 Service Act 

(42 U.S.C. 254l), except as provided in subsection (b) of this section. 

ø(b)(1) The Secretary, acting through the Service, shall determine who shall receive scholarships under subsection (a) 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. 


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ø(2) An individual shall be eligible for a scholarship under subsection (a) in any year in which such individual is enrolled full or 

part time in a course of study referred to in subsection (a). 

ø(3)(A) The active duty service obligation under a written contract with the Secretary under section 338A of the Public Health 

Service Act (42 U.S.C. 254l) that an individual has entered into 

under that section shall, if that individual is a recipient of an Indian Health Scholarship, be met in full-time practice, by service— ø(i) in the Indian Health Service; 

ø(ii) in a program conducted under a contract entered into 

under the Indian Self-Determination Act; 

ø(iii) in a program assisted under title V of this Act; 

ø(iv) 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; or 

ø(B) At the request of any individual who has entered into a contract referred to in subparagraph (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 that contract, 

in order that such individual may complete any internship, residency, or other advanced clinical training that is required for the 

practice of that health profession, for an appropriate period (in 

years, as determined by the Secretary), subject to the following conditions: 

ø(i) No period of internship, residency, or other advanced 

clinical training shall be counted as satisfying any period of obligated service that is required under this section. 

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). 

ø(iii) The active duty service obligation will be served in the 

health profession of that individual, in a manner consistent 

with clauses (i) through (v) of subparagraph (A). 

ø(C) A recipient of an Indian Health Scholarship may, at the 

election of the recipient, meet the active duty service obligation described in subparagraph (A) by service in a program specified in 

that subparagraph that—

ø(i) is located on the reservation of the tribe in which the recipient is enrolled; or 

ø(ii) serves the tribe in which the recipient is enrolled. 

ø(D) Subject to subparagraph (C), the Secretary, in making assignments of Indian Health Scholarship recipients required to meet 

the active duty service obligation described in subparagraph (A), 

shall give priority to assigning individuals to service in those programs specified in subparagraph (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. 

ø(4) In the case of an individual receiving a scholarship under 

this section who is enrolled part time in an approved course of 

study—


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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 

Secretary; 

ø(B) the period of obligated service described in paragraph 

(3)(A) shall be equal to the greater of—

ø(i) the part-time equivalent of one year for each year for 

which the individual was provided a scholarship (as determined by the Secretary); or 

ø(ii) two years; and 

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)) shall be reduced pro rata (as determined by the 

Secretary) based on the number of hours such student is enrolled. 

ø(5)(A) An individual who has, on or after the date of the enactment of this paragraph, entered into a written contract with the 

Secretary under this section and who—

ø(i) fails to maintain an acceptable level of academic standing in the educational institution in which he is enrolled (such 

level determined by the educational institution under regulations of the Secretary), 

ø(ii) is dismissed from such educational institution for disciplinary reasons, 

ø(iii) 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(iv) fails to accept payment, or instructs the educational institution in which he is enrolled not to accept payment, in 

whole or in part, of a scholarship under such contract, 

in lieu of any service obligation arising under such contract, shall 

be liable to the United States for the amount which has been paid 

to him, or on his behalf, under the contract. 

ø(B) If for any reason not specified in subparagraph (A) an individual breaches his written contract by failing either to begin such 

individual’s service obligation under this 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 108 in the 

manner provided for in such subsection. 

ø(C) 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. 

ø(D) The Secretary shall provide for the partial or total waiver 

or suspension of any obligation of service or payment of a recipient 

of an Indian Health Scholarship if the Secretary determines that—

ø(i) it is not possible for the recipient to meet that obligation 

or make that payment; 

ø(ii) requiring that recipient to meet that obligation or make 

that payment would result in extreme hardship to the recipient; or 

ø(iii) the enforcement of the requirement to meet the obligation or make the payment would be unconscionable. 

ø(E) Notwithstanding any other provision of law, in any case of 

extreme hardship or for other good cause shown, the Secretary may 


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waive, in whole or in part, the right of the United States to recover 

funds made available under this section. 

ø(F) 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 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) The 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 338C of the Public 

Health Service Act (42 U.S.C. 254m) without regard to any competitive personnel system, agency personnel limitation, or Indian 

preference policy. 

øINDIAN HEALTH SERVICE EXTERN PROGRAMS

øSEC. 105. (a) Any individual who receives a scholarship grant 

pursuant to section 104 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 the fulfillment of the service obligation incurred as a condition of the scholarship grant. 

ø(b) Any individual enrolled in a course of study in the health 

professions may be employed by the Service during any nonacademic period of the year. Any such employment shall not exceed 

one hundred and twenty days during any calendar year. 

ø(c) 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 of Health and Human Services. 

øCONTINUING EDUCATION ALLOWANCES

øSEC. 106. (a) In order to encourage physicians, dentists, nurses, 

and other health professionals to join or continue in the Service 

and to provide their services in the rural and remote areas where 

a significant portion of the Indian people resides, the Secretary, 

acting through the Service, may provide allowances to health professionals employed in the 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) Of amounts appropriated under the authority of this title 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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øCOMMUNITY HEALTH REPRESENTATIVE PROGRAM

øSEC. 107. (a) Under the authority of the Act of November 2, 

1921 (25 U.S.C. 13), popularly known as the Snyder Act, the Secretary shall maintain a Community Health Representative Program under which the Service—

ø(1) provides for the training of Indians as health paraprofessionals, and 

ø(2) uses such paraprofessionals in the provision of health 

care, health promotion, and disease prevention services to Indian communities. 

ø(b) The Secretary, acting through the Community Health Representative Program of the Service, shall—

ø(1) provide a high standard of training for paraprofessionals 

to Community Health Representatives to ensure that the Community Health Representatives provide quality health care, 

health promotion, and disease prevention services to the Indian communities served by such Program, 

ø(2) in order to provide such training, develop and maintain 

a curriculum that—

ø(A) combines education in the theory of health care 

with supervised practical experience in the provision of 

health care, and 

ø(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 poverty, 

ø(3) maintain a system which identifies the needs of Community Health Representatives for continuing education in health 

care, health promotion, and disease prevention and maintain 

programs that meet the needs for such continuing education, 

ø(4) maintain a system that provides close supervision of 

Community Health Representatives, 

ø(5) maintain a system under which the work of Community 

Health Representatives is reviewed and evaluated, and 

ø(6) 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. 

øINDIAN HEALTH SERVICE LOAN REPAYMENT PROGRAM

øSEC. 108. (a)(1) The Secretary, acting through the Service, shall 

establish a program to be known as the Indian Health Service 

Loan Repayment Program (hereinafter referred to as the ‘‘Loan Repayment Program’’) in order to assure an adequate supply of 

trained health professionals necessary to maintain accreditation of, 

and provide health care services to Indians through, Indian health 

programs. 

ø(2) For the purposes of this section—

ø(A) the term ‘‘Indian health program’’ means any health 

program or facility funded, in whole or part, by the Service for 

the benefit of Indians and administered—

ø(i) directly by the Service; 

ø(ii) by any Indian tribe or tribal or Indian organization 

pursuant to a contract under—


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ø(I) the Indian Self-Determination Act, 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 title 

V of this Act; and 

ø(B) the term ‘‘State’’ has the same meaning given such term 

in section 331(i)(4) of the Public Health Service Act. 

ø(b) To be eligible to participate in the Loan Repayment Program, an individual must—

ø(1)(A) be enrolled—

ø(i) in a course of study or program in an accredited institution, as determined by the Secretary, within any State 

and be scheduled to complete such course of study in the 

same year such individual applies to participate in such 

program; or 

ø(ii) in an approved graduate training program in a 

health profession; or 

ø(B) have—

ø(i) a degree in a health profession; and 

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

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

Health Service; 

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

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

ø(D) be employed in an Indian health program without a 

service obligation; and 

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

ø(c)(1) In disseminating application forms and contract forms to 

individuals desiring to participate in the Loan Repayment Program, the Secretary shall include with such forms a fair summary 

of the rights and liabilities of an individual whose application is approved (and whose contract is accepted) by the Secretary, including 

in the summary a clear explanation of the damages to which the 

United States is entitled under subsection (l) in the case of the individual’s breach of the contract. The Secretary shall provide such 

individuals with sufficient information regarding the advantages 

and disadvantages of service as a commissioned officer in the Regular or Reserve Corps of the Public Health Service or a civilian employee of the Indian Health Service to enable the individual to 

make a decision on an informed basis. 

ø(2) The application form, contract form, and all other information furnished by the Secretary under this section shall be written 

in a manner calculated to be understood by the average individual 

applying to participate in the Loan Repayment Program. 

ø(3) The Secretary shall make such application forms, contract 

forms, and other information available to individuals desiring to 

participate in the Loan Repayment Program on a date sufficiently 

early to ensure that such individuals have adequate time to carefully review and evaluate such forms and information. 


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ø(d)(1) Consistent with paragraph (3), the Secretary, acting 

through the Service and in accordance with subsection (k), shall 

annually—ø(A) identify the positions in each Indian health program for 

which there is a need or a vacancy, and 

ø(B) rank those positions in order of priority. 

ø(2) Consistent with the priority determined under paragraph 

(1), the Secretary, in determining which applications under the 

Loan Repayment Program to approve (and which contracts to accept), shall give priority to applications made by— ø(A) Indians; and 

ø(B) individuals recruited through the efforts of Indian tribes 

or tribal or Indian organizations. 

ø(3)(A) Subject to subparagraph (B), of the total amounts appropriated for each of the fiscal years 1993, 1994, and 1995 for 

loan repayment contracts under this section, the Secretary 

shall provide that— ø(i) not less than 25 percent be provided to applicants 

who are nurses, nurse practitioners, or nurse midwives; 

and 

ø(ii) not less than 10 percent be provided to applicants 

who are mental health professionals (other than applicants 

described in clause (i)). 

ø(B) The requirements specified in clause (i) or clause (ii) of 

subparagraph (A) shall not apply if the Secretary does not receive the number of applications from the individuals described 

in clause (i) or clause (ii), respectively, necessary to meet such 

requirements. 

ø(e)(1) An individual becomes a participant in the Loan Repayment Program only upon the Secretary and the individual entering 

into a written contract described in subsection (f). 

ø(2) The Secretary shall provide written notice to an individual 

promptly on— ø(A) the Secretary’s approving, under paragraph (1), of the 

individual’s participation in the Loan Repayment Program, including extensions resulting in an aggregate period of obligated 

service in excess of 4 years; or 

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

ø(f) The written contract referred to in this section between the 

Secretary and an individual shall contain—

ø(1) an agreement under which—

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

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

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 

tribe or Indian organization as provided in subparagraph (B)(iii), and 

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

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

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


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ø(I) to maintain enrollment in a course of study 

or training described in subsection (b)(1)(A) until 

the individual completes the course of study or 

training, and 

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); 

ø(iii) to serve for a time period (hereinafter in this 

section referred to as the ‘‘period of obligated service’’) 

equal to 2 years or such longer period as the individual may agree to serve in the full-time clinical 

practice of such individual’s profession in an Indian 

health program to which the individual may be assigned by the Secretary; 

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 individual under 

paragraph (1)(B)(iii); 

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; 

ø(4) a statement of the damages to which the United States 

is entitled under subsection (l) for the individual’s breach of 

the contract; and 

ø(5) such other statements of the rights and liabilities of the 

Secretary and of the individual, not inconsistent with this section. 

ø(g)(1) A loan repayment provided for an individual under a written contract under the Loan Repayment Program shall consist of 

payment, in accordance with paragraph (2), on behalf of the individual of the principal, interest, and related expenses on government and commercial loans received by the individual regarding 

the undergraduate or graduate education 

of the individual (or both), which loans were made for—

ø(A) tuition expenses; 

ø(B) all other reasonable educational expenses, including 

fees, books, and laboratory expenses, incurred by the individual; and 

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

ø(2)(A) For each year of obligated service that an individual contracts to serve under subsection (f) the Secretary may pay up to 

$35,000 (or an amount equal to the amount specified in section 

338B(g)(2)(A) of the Public Health Service Act) 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—

ø(i) affects the ability of the Secretary to maximize the number of contracts that can be provided under the Loan RepayVerDate Aug 31 2005 06:24 Sep 16, 2006 Jkt 049006 PO 00000 Frm 00112 Fmt 6659 Sfmt 6602 E:\HR\OC\HR661P1.XXX HR661P1

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ment Program from the amounts appropriated for such contracts; 

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

ø(iii) provides an incentive with respect to the health professional involved remaining in an Indian health program with 

such a health professional shortage, and continuing to provide 

primary health services, after the completion of the period of 

obligated service under the Loan Repayment Program. 

ø(B) Any arrangement made by the Secretary for the making of 

loan repayments in accordance with this subsection shall provide 

that any repayments for a year of obligated service shall be made 

no later than the end of the fiscal year in which the individual 

completes such year of service. 

ø(3) For the purpose of providing reimbursements for tax liability 

resulting from payments under paragraph (2) on behalf of an individual, the Secretary—

ø(A) in addition to such payments, may make payments to 

the individual in an amount not less than 20 percent and not 

more than 39 percent of the total amount of loan repayments 

made for the taxable year involved; and 

ø(B) may make such additional payments as the Secretary 

determines to be appropriate with respect to such purpose. 

ø(4) The Secretary may enter into an agreement with the holder 

of any loan for which payments are made under the Loan Repayment Program to establish a schedule for the making of such payments. 

ø(h) Notwithstanding any other provision of law, individuals who 

have entered into written contracts with the Secretary under this 

section, while undergoing academic training, shall not be counted 

against any employment ceiling affecting the Department of Health 

and Human Services. 

ø(i) The Secretary shall conduct recruiting programs for the Loan 

Repayment Program and other health professional programs of the 

Service at educational institutions training health professionals or 

specialists identified in subsection (a). 

ø(j) Section 214 of the Public Health Service Act (42 U.S.C. 215) 

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

ø(k) The Secretary, in assigning individuals to serve in Indian 

health programs pursuant to contracts entered into under this section, shall—

ø(1) ensure that the staffing needs of Indian health programs 

administered by an Indian tribe or tribal or health organization receive consideration on an equal basis with programs 

that are administered directly by the Service; and 

ø(2) give priority to assigning individuals to Indian health 

programs that have a need for health professionals to provide 

health care services as a result of individuals having breached 

contracts entered into under this section. 

ø(l)(1) An individual who has entered into a written contract 

with the Secretary under this section and who—

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

who—


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ø(i) fails to maintain an acceptable level of academic 

standing in the educational institution in which he is enrolled (such level determined by the educational institution 

under regulations of the Secretary); 

ø(ii) voluntarily terminates such enrollment; or 

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

ø(B) is enrolled in a graduate training program, fails to complete such training program, and does not receive a waiver 

from the Secretary under subsection (b)(1)(B)(ii), 

shall be liable, in lieu of any service obligation arising under such 

contract, to the United States for the amount which has been paid 

on such individual’s behalf under the contract. 

ø(2) If, for any reason not specified in paragraph (1), an individual breaches his written contract under this section by failing 

either to begin, or complete, such individual’s period of obligated 

service in accordance with subsection (f), the United States shall be 

entitled to recover from such individual an amount to be determined in accordance with the following formula: 

øA=3Z(t-s/t) 

in which—

ø(A) ‘‘A’’ is the amount the United States is entitled to recover; 

ø(B) ‘‘Z’’ is the sum of the amounts paid under this section 

to, or on behalf of, the individual and the interest on such 

amounts which would be payable if, at the time the amounts 

were paid, they were loans bearing interest at the maximum 

legal prevailing rate, as determined by the Treasurer of the 

United States; 

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

ø(D) ‘‘s’’ is the number of months of such period served by 

such individual in accordance with this section. 

Amounts not paid within such period shall be subject to collection 

through deductions in Medicare payments pursuant to section 1892 

of the Social Security Act. 

ø(3)(A) Any amount of damages which the United States is entitled to recover under this subsection shall be paid to the United 

States within the 1-year period beginning on the date of the breach 

or such longer period beginning on such date as shall be specified 

by the Secretary. 

ø(B) If damages described in subparagraph (A) are delinquent for 

3 months, the Secretary shall, for the purpose of recovering such 

damages—

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

ø(ii) enter into contracts for the recovery of such damages 

with collection agencies selected by the Secretary. 

ø(C) Each contract for recovering damages pursuant to this subsection shall provide that the contractor will, not less than once 

each 6 months, submit to the Secretary a status report on the success of the contractor in collecting such damages. Section 3718 of 


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title 31, United States Code, shall apply to any such contract to the 

extent not inconsistent with this subsection. 

ø(m)(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. 

ø(2) The Secretary shall by regulation provide for the partial or 

total waiver or suspension of any obligation of service or payment 

by an individual under the Loan Repayment Program whenever 

compliance by the individual is impossible or would involve extreme hardship to the individual and if enforcement of such obligation with respect to any individual would be unconscionable. 

ø(3) The Secretary may waive, in whole or in part, the rights of 

the United States to recover amounts under this section in any 

case of extreme hardship or other good cause shown, as determined 

by the Secretary. 

ø(4) Any obligation of an individual under the Loan Repayment 

Program for payment of damages may be released by a discharge 

in bankruptcy under title 11 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. 

ø(n) The Secretary shall submit to the President, for inclusion in 

each report required to be submitted to the Congress under section 

801, a report concerning the previous fiscal year which sets forth—

ø(1) the health professional positions maintained by the 

Service or by tribal or Indian organizations for which recruitment or retention is difficult; 

ø(2) the number of Loan Repayment Program applications 

filed with respect to each type of health profession; 

ø(3) the number of contracts described in subsection (f) that 

are entered into with respect to each health profession; 

ø(4) the amount of loan payments made under this section, 

in total and by health profession; 

ø(5) the number of scholarship grants that are provided 

under section 104 with respect to each health profession; 

ø(6) the amount of scholarship grants provided under section 

104, in total and by health profession; 

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

is filed; and 

ø(8) the measures the Secretary plans to take to fill the 

health professional positions maintained by the Service or by 

tribes or tribal or Indian organizations for which recruitment 

or retention is difficult. 

øSCHOLARSHIP AND LOAN REPAYMENT RECOVERY FUND

øSEC. 108A. (a) There is established in the Treasury of the 

United States a fund to be known as the Indian Health Scholarship 

and Loan Repayment Recovery Fund (hereafter in this section referred to as the ‘‘Fund’’). The Fund shall consist of such amounts 

as may be appropriated to the Fund under subsection (b). Amounts 

appropriated for the Fund shall remain available until expended. 


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ø(b) For 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 104(b)(5) for the breach of contracts entered into under section 104; and 

ø(B) the liability of individuals under section 108(l) for 

the breach of contracts entered into under section 108; and 

ø(2) the aggregate amount of interest accruing during the 

preceding fiscal year on obligations held in the Fund pursuant 

to subsection (d) and the amount of proceeds from the sale or 

redemption of such obligations during such fiscal year. 

ø(c)(1) Amounts in the Fund and available pursuant to appropriation Acts may be expended by the Secretary, acting through the 

Service, to make payments to an Indian tribe or tribal organization 

administering a health care program pursuant to a contract entered into under the Indian Self-Determination Act— ø(A) to which a scholarship recipient under section 104 or a 

loan repayment program participant under section 108 has 

been assigned to meet the obligated service requirements pursuant to sections; and 

ø(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 or 

section 108. 

ø(2) An Indian tribe or tribal organization receiving payments 

pursuant to paragraph (1) may expend the payments to recruit and 

employ, directly or by contract, health professionals to provide 

health care services. 

ø(d)(1) The Secretary of the Treasury shall invest such amounts 

of the Fund as such Secretary determines are not required to meet 

current withdrawals from the Fund. Such investments may be 

made only in interest-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. 

ø(2) Any obligation acquired by the Fund may be sold by the Secretary of the Treasury at the market price. 

øRECRUITMENT ACTIVITIES

øSEC. 109. (a) The Secretary may reimburse health professionals 

seeking positions in the Service, including individuals considering 

entering into a contract under section 108, and their spouses, for 

actual and reasonable expenses incurred in traveling to and from 

their places of residence to an area in which they may be assigned 

for the purpose of evaluating such area with respect to such assignment. 

ø(b) The Secretary, acting through the Service, shall assign one 

individual in each area office to be responsible on a full-time basis 

for recruitment activities. 

øTRIBAL RECRUITMENT AND RETENTION PROGRAM

øSEC. 110. (a) The Secretary, acting through the Service, shall 

fund, on a competitive basis, projects to enable Indian tribes and 


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tribal and Indian organizations to recruit, place, and retain health 

professionals to meet the staffing needs of Indian health programs 

(as defined in section 108(a)(2)). 

ø(b)(1) Any Indian 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 shall be given an 

equal opportunity with programs that are administered directly by 

the Service to compete for, and receive, grants under subsection (a) 

for such projects. 

øADVANCED TRAINING AND RESEARCH

øSEC. 111. (a) The Secretary, acting through the Service, shall 

establish a program to enable health professionals to pursue advanced training or research in areas of study for which the Secretary determines a need exists. In selecting participants for a program established under this subsection, the Secretary, acting 

through the Service, shall give priority to applicants who are employed by the Indian Health Service, Indian tribes, tribal organizations, and urban Indian organizations, at the time of the submission of the applications. 

ø(b) An individual who participates in a program under subsection (a), where the educational costs are borne by the Service, 

shall incur an obligation to serve in an Indian health program (as 

defined in section 108(a)(2)) 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 Amendments of 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 108 in the manner provided for in such 

subsection. 

ø(c) Health professionals from Indian tribes and tribal and Indian organizations under the authority of the Indian Self-Determination Act shall be given an equal opportunity to participate in 

the program under subsection (a). 

øNURSING PROGRAM

øSEC. 112. (a) The 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 390(2) of the Tribally Controlled Vocational Institutions 

Support Act of 1990 (20 U.S.C. 2397h(2)), and 

ø(3) nurse midwife programs, and nurse practitioner programs, that are provided by any public or private institution, 

for the purpose of increasing the number of nurses, nurse midwives, and nurse practitioners who deliver health care services to 

Indians. 

ø(b) Grants provided under subsection (a) may be used to—


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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). 

ø(c) Each application for a grant 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. 

ø(d) In providing grants under subsection (a), 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 5324(a) of the Indian Education Act of 1988. 

ø(e) The Secretary shall provide one of the grants authorized 

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

University of North Dakota to be known as the ‘‘Quentin N. Burdick American Indians Into Nursing Program’’. Such program shall, 

to the maximum extent feasible, coordinate with the Quentin N. 

Burdick Indian Health Programs established under section 114(b) 

and the Quentin N. Burdick American Indians Into Psychology Program established under section 217(b). 

ø(f) 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 individual who receives training or assistance described in paragraph (1) or (2) of subsection (b) that is funded by 

a grant provided under subsection (a). Such obligation shall be met 

by service—

ø(A) in the Indian Health Service; 

ø(B) in a program conducted under a contract entered into 

under the Indian Self-Determination Act; 

ø(C) in a program assisted under title V of this Act; or 

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 professional shortage area and addresses the health 

care needs of a substantial number of Indians. 

ø(g) Beginning with fiscal year 1993, of the amounts appropriated under the authority of this title for each fiscal year to be 

used to carry out this section, not less than $1,000,000 shall be 


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used to provide grants under subsection (a) for the training of 

nurse midwives, nurse anesthetists, and nurse practitioners. 

øNURSING SCHOOL CLINICS

øSEC. 112A. (a) GRANTS.—In addition to the authority of the Secretary under section 112(a)(1), 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, United States Code. 

ø(b) PURPOSES.—Grants provided under subsection (a) 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, United States Code); 

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.—The Secretary may award grants 

under this section in such amounts and subject to such conditions 

as the Secretary deems appropriate. 

ø(d) DESIGN.—The clinics established under this section shall be 

designed to provide nursing students with a structured clinical experience that is similar in nature to that provided by residency 

training programs for physicians. 

ø(e) REGULATIONS.—The Secretary shall prescribe such regulations as may be necessary to carry out the provisions of this section. 

ø(f) AUTHORIZATION TO USE AMOUNTS.—Out of amounts appropriated to carry out this title for each of the fiscal years 1993 

through 2000 not more than $5,000,000 may be used to carry out 

this section. 

øTRIBAL CULTURE AND HISTORY

øSEC. 113. (a) The Secretary, acting through the Service, shall 

establish a program under which appropriate employees of the 

Service who serve particular Indian tribes shall receive educational 

instruction in the history and culture of such tribes and in the history of the Service. 

ø(b) To the extent feasible, the program established under subsection (a) shall—

ø(1) be carried out through tribally-controlled community colleges (within the meaning of section 2(4) of the Tribally Controlled Community College Assistance Act of 1978) and tribally 

controlled postsecondary vocational institutions (as defined in 

section 390(2) of the Tribally Controlled Vocational Institutions 

Support Act of 1990 (20 U.S.C. 2397h(2)), 

ø(2) be developed in consultation with the affected tribal government, and 

ø(3) include instruction in Native American studies. 


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øINMED PROGRAM

øSEC. 114. (a) The Secretary is authorized to provide grants to 

at least 3 colleges and universities for the purpose of maintaining 

and expanding the Native American health careers recruitment 

program known as the ‘‘Indians into Medicine Program’’ (hereinafter in this section referred to as ‘‘INMED’’) as a means of encouraging Indians to enter the health professions. 

ø(b) The Secretary shall provide one of the grants authorized 

under subsection (a) 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 217(b) 

and the Quentin N. Burdick American Indians Into Nursing Program established under section 112(e). 

ø(c)(1) The Secretary shall develop regulations for the competitive awarding of the grants provided under this section. 

ø(2) Applicants for grants provided under this section shall agree 

to provide a program which—

ø(A) provides outreach and recruitment for health professions to Indian communities including elementary, secondary 

and community colleges located on Indian reservations which 

will be served by the program, 

ø(B) incorporates a program advisory board comprised of representatives from the tribes and communities which will be 

served by the program, 

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 professions, 

ø(D) provides tutoring, counseling and support to students 

who are enrolled in a health career program of study at the respective college or university, and 

ø(E) to the maximum extent feasible, employs qualified Indians in the program. 

ø(d) By no later than the date that is 3 years after the date of 

enactment of the Indian Health Care Amendments of 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. 

øHEALTH TRAINING PROGRAMS OF COMMUNITY COLLEGES

øSEC. 115. (a)(1) The Secretary, acting through the Service, shall 

award grants to community colleges for the purpose of assisting the 

community college 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 an Indian reservation or in a tribal clinic. 

ø(2) The amount of any grant awarded to a community college 

under paragraph (1) for the first year in which such a grant is provided to the community college shall not exceed $100,000. 

ø(b)(1) The Secretary, acting through the Service, shall award 

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scribed in subsection (a)(1) for the purpose of maintaining the program and recruiting students for the program. 

ø(2) Grants may only be made under this section to a community 

college which— ø(A) is accredited, 

ø(B) has access to a hospital facility, Service facility, or hospital that could provide training of nurses or health professionals, 

ø(C) has entered into an agreement with an accredited college or university medical school, the terms of which— ø(i) provide a program that enhances the transition and 

recruitment of students into advanced baccalaureate or 

graduate programs which train health professionals, and 

ø(ii) stipulate certifications necessary to approve internship and field placement opportunities at service unit facilities of the Service or at tribal health facilities, 

ø(D) has a qualified staff which has the appropriate certifications, and 

ø(E) is capable of obtaining State or regional accreditation of 

the program described in subsection (a)(1). 

ø(c) The Secretary shall encourage community colleges described 

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

in subsection (a)(1) by—

ø(1) entering into agreements with such colleges for the provision of qualified personnel of the Service to teach courses of 

study in such programs, and 

ø(2) providing technical assistance and support to such colleges. 

ø(d) Any program receiving assistance under this section that is 

conducted with respect to a health profession shall also offer 

courses of study which provide advanced training for any health 

professional who— ø(1) has already received a degree or diploma in such health 

profession, and 

ø(2) provides clinical services on an Indian reservation, at a 

Service facility, or at a tribal clinic. 

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). 

ø(e) For 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 2(4) of the Tribally Controlled Community College Assistance Act of 1978. 

ø(3) The term ‘‘junior or community college’’ has the meaning 

given to such term by section 312(e) of the Higher Education 

Act of 1965 (20 U.S.C. 1058(e)). 

øADDITIONAL INCENTIVES FOR HEALTH PROFESSIONALS

øSEC. 116. (a) The Secretary may provide the incentive special 

pay authorized under section 302(b) of title 37, United States Code, 

to civilian medical officers of the Indian Health Service who are assigned to, and serving in, positions included in the list established 


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under subsection (b)(1) for which recruitment or retention of personnel is difficult. 

ø(b)(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) The 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, 

United States Code, for health professionals employed by, or assigned to, the Service. 

øRETENTION BONUS

øSEC. 117. (a) The Secretary may pay a retention bonus to any 

physician or nurse employed by, or assigned to, and serving in, the 

Service either as a civilian employee or as a commissioned officer 

in the Regular or Reserve Corps of the Public Health Service who—

ø(1) is assigned to, and serving in, a position included in the 

list established under section 116(b)(1) for which recruitment 

or retention of personnel is difficult, 

ø(2) the Secretary determines is needed by the Service, 

ø(3) has—

ø(A) completed 3 years of employment with the Service, 

or 

ø(B) completed any service obligations incurred as a requirement of—

ø(i) any Federal scholarship program, or 

ø(ii) any Federal education loan repayment program, 

and 

ø(4) enters into an agreement with the Service for continued 

employment for a period of not less than 1 year. 

ø(b) Beginning with fiscal year 1993, not less than 25 percent of 

the retention bonuses awarded each year under subsection (a) shall 

be awarded to nurses. 

ø(c) 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), but in no event shall the annual rate be more than $25,000 

per annum. 

ø(d) The retention bonus for the entire period covered by the 

agreement described in subsection (a)(4) shall be paid at the beginning of the agreed upon term of service. 

ø(e) Any physician 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 agreeVerDate Aug 31 2005 06:24 Sep 16, 2006 Jkt 049006 PO 00000 Frm 00122 Fmt 6659 Sfmt 6602 E:\HR\OC\HR661P1.XXX HR661P1

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ment, plus interest as determined by the Secretary in accordance 

with section 108(l)(2)(B). 

ø(f) The Secretary may pay a retention bonus to any physician 

or nurse employed by an organization providing health care services to Indians pursuant to a contract under the Indian Self-Determination Act if such physician or nurse is serving in a position 

which the Secretary determines is— ø(1) a position for which recruitment or retention is difficult; 

and 

ø(2) necessary for providing health care services to Indians. 

øNURSING RESIDENCY PROGRAM

øSEC. 118. (a) The Secretary, acting through the Service, shall 

establish a program to enable licensed practical nurses, licensed vocational nurses, and registered nurses who are working in an Indian health program (as defined in section 108(a)(2)(A)), and have 

done so for a period of not less than one year, to pursue advanced 

training. 

ø(b) Such program shall include a combination of education and 

work study in an Indian health program (as defined in section 

108(a)(2)(A)) leading to an associate or bachelor’s degree (in the 

case of a licensed practical nurse or licensed vocational nurse) or 

a bachelor’s degree (in the case of a registered nurse) or a Master’s 

degree. 

ø(c) An individual who participates in a program under subsection (a), where the educational costs are paid by the Service, 

shall incur an obligation to serve in an Indian health program for 

a period of obligated service equal to at least three times 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 United States shall be entitled to recover from such individual an amount determined in accordance with the formula 

specified in subsection (l) of section 108 in the manner provided for 

in such subsection. 

øCOMMUNITY HEALTH AIDE PROGRAM FOR ALASKA

øSEC. 119. (a) Under the authority of the Act of November 2, 

1921 (25 U.S.C. 13; popularly known as the Snyder Act), the Secretary shall maintain a Community Health Aide Program in Alaska under which the Service— ø(1) provides for the training of Alaska Natives as health 

aides or community health practitioners; 

ø(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 

ø(3) provides for the establishment of teleconferencing capacity in health clinics located in or near such villages for use by 

community health aides or community health practitioners. 

ø(b) The Secretary, acting through the Community Health Aide 

Program of the Service, shall—

ø(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; 


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ø(2) in order to provide such training, develop a curriculum 

that—

ø(A) combines education in the theory of health care 

with supervised practical experience in the provision of 

health care; 

ø(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 

ø(C) promotes the achievement of the health status objectives specified in section 3(b); 

ø(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; 

ø(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; 

ø(5) develop and maintain a system that provides close supervision of community health aides and community health 

practitioners; and 

ø(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. 

øMATCHING GRANTS TO TRIBES FOR SCHOLARSHIP PROGRAMS

øSEC. 120. (a)(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 104. 

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)(1) An Indian tribe or tribal organization receiving a grant 

under subsection (a) 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) 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. 


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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) An Indian tribe or tribal organization shall provide scholarships under subsection (b) only to Indians enrolled or accepted for 

enrollment in a course of study (approved by the Secretary) in one 

of the health professions described in section 104(a). 

ø(d) In providing scholarships under subsection (b), the Secretary 

and the Indian tribe or tribal organization shall enter 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 108(a)(2)(A)), 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 

338A(g)(1)(B) of the Public Health Service Act (42 

U.S.C. 254m(g)(1)(B)), 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)(1) An individual who has entered into a written contract 

with the Secretary and an Indian tribe or tribal organization under 

subsection (d) and who—

ø(A) fails to maintain an acceptable level of academic standing in the educational institution in which he is enrolled (such 


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level determined by the educational institution under regulations of the Secretary), 

ø(B) is dismissed from such educational institution for disciplinary reasons, 

ø(C) voluntarily terminates the training in such an educational institution for which he is provided a scholarship 

under such contract before the completion of such training, or 

ø(D) fails to accept payment, or instructs the educational institution in which he is enrolled not to accept payment, in 

whole or in part, of a scholarship under such contract, 

in lieu of any service obligation arising under such contract, shall 

be liable to the United States for the Federal share of the amount 

which has been paid to him, or on his behalf, under the contract. 

ø(2) If for any reason not specified in paragraph (1), an individual breaches his written contract by failing either to begin 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 108 

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 organizations involved, or on the basis of information collected through such other 

means as the Secretary determines to be appropriate. 

ø(f) The recipient of a scholarship under subsection (b) shall 

agree, in providing health care pursuant to the requirements of 

subsection (d)(1)— 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 or pursuant to the program established in title 

XIX of such Act; and 

ø(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 

of such Act to provide service to individuals entitled to medical 

assistance under the plan. 

ø(g) The Secretary may not make any payments under subsection 

(a) 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. 

øTRIBAL HEALTH PROGRAM ADMINISTRATION

øSEC. 121. The Secretary shall, by contract or otherwise, provide 

training for individuals in the administration and planning of tribal health programs. 

øUNIVERSITY OF SOUTH DAKOTA PILOT PROGRAM

øSEC. 122. (a) The Secretary may make a grant to the School of 

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tion 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) The purposes of the program established pursuant to a grant 

provided under subsection (a) are— ø(1) to provide direct clinical and practical experience at a 

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, nurses, and 

other allied health professionals serving Indian people by identifying and utilizing all academic and scholarly resources of the 

region. 

ø(c) The pilot program established pursuant to a grant provided 

under subsection (a) 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) The USDSM shall coordinate the program established pursuant to a grant provided under subsection (a) with other medical 

schools in the region, nursing schools, tribal community colleges, 

and other health professional schools. 

ø(e) The 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. 

øAUTHORIZATION OF APPROPRIATIONS

øSEC. 123. There are authorized to be appropriated such sums as 

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

carry out this title. 

øTITLE II—HEALTH SERVICES 

øINDIAN HEALTH CARE IMPROVEMENT FUND

øSEC. 201. (a) The Secretary is authorized to expend funds which 

are appropriated under the authority of this section, through the 

Service, for the purposes of—

ø(1) eliminating the deficiencies in health status and resources of all Indian tribes, 

ø(2) eliminating backlogs in the provision of health care services to Indians, 

ø(3) meeting the health needs of Indians in an efficient and 

equitable manner, and 

ø(4) augmenting the ability of the Service to meet the following health service responsibilities, either through direct or 

contract care or through contracts entered into pursuant to the 


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Indian Self-Determination Act, with respect to those Indian 

tribes with the highest levels of health status and resource deficiencies: 

ø(A) clinical care (direct and indirect) including clinical 

eye and vision care; 

ø(B) preventive health; 

ø(C) dental care (direct and indirect); 

ø(D) mental health, including community mental health 

services, inpatient mental health services, dormitory mental health services, therapeutic and residential treatment 

centers, and training of traditional Indian practitioners; 

ø(E) emergency medical services; 

ø(F) treatment and control of, and rehabilitative care related to, alcoholism and drug abuse (including fetal alcohol 

syndrome) among Indians; 

ø(G) accident prevention programs; 

ø(H) home health care; 

ø(I) community health representatives; and 

ø(J) maintenance and repair. 

ø(b)(1) Any funds appropriated under the authority of this section shall not be used to offset or limit any appropriations made 

to the Service under the Act of November 2, 1921 (25 U.S.C. 13), 

popularly known as the Snyder Act, or any other provision of law. 

ø(2)(A) Funds appropriated under the authority of this section 

may be allocated on a service unit basis. The funds allocated to 

each service unit under this subparagraph shall be used by the 

service unit to reduce the health status and resource deficiency of 

each tribe served by such service unit. 

ø(B) The apportionment of funds allocated to a service unit under 

subparagraph (A) among the health service responsibilities described in subsection (a)(4) shall be determined by the Service in 

consultation with, and with the active participation of, the affected 

Indian tribes. 

ø(c) For purposes of this section—

ø(1) The term ‘‘health status and resource deficiency’’ means 

the extent to which—

ø(A) the health status objectives set forth in section 3(b) 

are not being achieved; and 

ø(B) the Indian tribe 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. 

ø(2) The health resources available to an Indian tribe include 

health resources provided by the Service as well as health resources used by the Indian tribe, including services and financing systems provided by any Federal programs, private insurance, and programs of State or local governments. 

ø(3) The Secretary shall establish procedures which allow 

any Indian tribe to petition the Secretary for a review of any 

determination of the extent of the health status and resource 

deficiency of such tribe. 

ø(d)(1) Programs administered 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 


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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, a reasonable portion of such 

funds may be used for health planning, training, technical assistance, and other administrative support functions. 

ø(e) By no later than the date that is 3 years after the date of 

enactment of the Indian Health Amendments of 1992, the Secretary shall submit to the Congress the current health status and 

resource deficiency report of the Service for each Indian tribe or 

service unit, including newly recognized or acknowledged tribes. 

Such report shall set out—

ø(1) the methodology then in use by the Service for determining tribal health status and resource deficiencies, as well 

as the most recent application of that methodology; 

ø(2) the extent of the health status and resource deficiency 

of each Indian tribe served by the Service; 

ø(3) the amount of funds necessary to eliminate the health 

status and resource deficiencies of all Indian tribes served by 

the Service; and 

ø(4) an estimate of—

ø(A) the amount of health service funds appropriated 

under the authority of this Act, or any other Act, including 

the amount of any funds transferred to the Service, for the 

preceding fiscal year which is allocated to each service 

unit, Indian tribe, or comparable entity; 

ø(B) the number of Indians eligible for health services in 

each service unit or Indian tribe; and 

ø(C) the number of Indians using the Service resources 

made available to each service unit or Indian tribe. 

ø(f) Funds appropriated under authority of this section for any 

fiscal year shall be included in the base budget of the Service for 

the purpose of determining appropriations under this section in 

subsequent fiscal years. 

ø(g) 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 parity among Indian tribes. 

ø(h) Any funds appropriated under the authority of this section 

shall be designated as the ‘‘Indian Health Care Improvement 

Fund’’. 

øCATASTROPHIC HEALTH EMERGENCY FUND

øSEC. 202. (a)(1) There is hereby established an Indian Catastrophic Health Emergency Fund (hereafter in this section referred 

to as the ‘‘Fund’’) consisting of—

ø(A) the amounts deposited under subsection (d), and 

ø(B) the amounts appropriated to the Fund under this section. 

ø(2) The Fund 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 treatVerDate Aug 31 2005 06:24 Sep 16, 2006 Jkt 049006 PO 00000 Frm 00129 Fmt 6659 Sfmt 9001 E:\HR\OC\HR661P1.XXX HR661P1

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ment 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. 

ø(4) No part of the Fund or its administration shall be subject 

to contract or grant under any law, including the Indian Self-Determination Act. 

ø(b) The Secretary shall, through the promulgation of regulations 

consistent with the provisions of this section— ø(1) establish a definition of disasters and catastrophic illnesses for which the cost of treatment provided under contract 

would qualify for payment from the Fund; 

ø(2) provide that a service unit shall not be eligible for reimbursement for the cost of treatment from the 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— ø(A) for 1993, not less than $15,000 or not more than 

$25,000; and 

ø(B) for any subsequent year, not less than the threshold 

cost of the previous year increased by the percentage increase in the medical care expenditure category of the consumer price index for all urban consumers (United States 

city average) for the 12-month period ending with December of the previous year; 

ø(3) establish a procedure for the reimbursement of the portion of the costs incurred by—

ø(A) service units or facilities of the Service, or 

ø(B) whenever otherwise authorized by the Service, nonService facilities or providers, 

in rendering treatment that exceeds such threshold cost; 

ø(4) establish a procedure for payment from the Fund in 

cases in which the exigencies of the medical circumstances 

warrant treatment prior to the authorization of such treatment 

by the Service; and 

ø(5) establish a procedure that will ensure that no payment 

shall be made from the 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. 

ø(c) Amounts appropriated to the 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), popularly known as the Snyder Act, or any other law. 

ø(d) There shall be deposited into the 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 the Fund. 

øHEALTH PROMOTION AND DISEASE PREVENTION SERVICES

øSEC. 203. (a) The Secretary, acting through the Service, shall 

provide health promotion and disease prevention services to Indians so as to achieve the health status objectives set forth in section 

3(b). 


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ø(b) The Secretary shall submit to the President for inclusion in 

each statement which is required to be submitted to the Congress 

under section 801 an evaluation of— ø(1) the health promotion and disease prevention needs of 

Indians, 

ø(2) the health promotion and disease prevention activities 

which would best meet such needs, 

ø(3) the internal capacity of the Service to meet such needs, 

and 

ø(4) the resources which would be required to enable the 

Service to undertake the health promotion and disease prevention activities necessary to meet such needs. 

øDIABETES PREVENTION, TREATMENT, AND CONTROL

øSEC. 204. (a) The Secretary, in consultation with the tribes, 

shall determine— ø(1) by tribe and by Service unit of the Service, the incidence 

of, and the types of complications resulting from, diabetes 

among Indians; and 

ø(2) based on paragraph (1), the measures (including patient 

education) each Service unit should take to reduce the incidence of, and prevent, treat, and control the complications resulting from, diabetes among tribes within that Service unit. 

ø(b) The Secretary shall screen each Indian who receives services 

from the Service for diabetes and for conditions which indicate a 

high risk that the individual will become diabetic. Such screening 

may be done by a tribe or tribal organization operating health care 

programs or facilities with funds from the Service under the Indian 

Self-Determination Act. 

ø(c)(1) The Secretary shall continue to maintain through fiscal 

year 2000 each model diabetes project in existence on the date of 

the enactment of the Indian Health Amendments of 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; 

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). 


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ø(d) The 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. 

ø(e) Funds appropriated under this section in any fiscal year 

shall be in addition to base resources appropriated to the Service 

for that year. 

øHOSPICE CARE FEASIBILITY STUDY

øSEC. 205. (a) The 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) Such 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) Not later than the date which is 12 months after the date 

of the enactment of this section, 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) For the purposes of this section—


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ø(1) the term ‘‘terminally ill’’ means any Indian who has a 

medical prognosis (as certified by a physician) of a life expectancy of six months or less; and 

ø(2) the term ‘‘hospice program’’ means any program which 

satisfies the requirements of section 1861(dd)(2) of the Social 

Security Act (42 U.S.C. 1395x(dd)(2)); and 

ø(3) 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)). 

øREIMBURSEMENT FROM CERTAIN THIRD PARTIES OF COSTS OF

HEALTH SERVICES

øSEC. 206. (a) Except as provided in subsection (f), the United 

States, an Indian tribe, or a tribal organization shall have the right 

to recover the reasonable expenses incurred by the Secretary, an 

Indian tribe, or a tribal organization in providing health services, 

through the Service, an Indian tribe, or a tribal organization, to 

any individual to the same extent that such individual, or any nongovernmental provider of such services, would be eligible to receive 

reimbursement or indemnification for such expenses if—

ø(1) such services had been provided by a nongovernmental 

provider, and 

ø(2) such individual had been required to pay such expenses 

and did pay such expenses. 

ø(b) 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—

ø(1) workers’ compensation laws, or 

ø(2) a no-fault automobile accident insurance plan or program. 

ø(c) No law of any State, or of any political subdivision of a State, 

and no provision of any contract entered into or renewed after the 

date of 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 a tribal organization under subsection (a). 

ø(d) No action taken by the United States, an Indian tribe, or a 

tribal organization to enforce the right of recovery provided under 

subsection (a) 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) The United States, an Indian tribe, or a tribal organization 

may enforce the right of recovery provided under subsection (a) 

by—

ø(1) intervening or joining in any civil action or proceeding 

brought—

ø(A) by the individual for whom health services were 

provided by the Secretary, an Indian tribe, or a tribal organization, or 

ø(B) by any representative or heirs of such individual, or 

ø(2) instituting a separate civil action, after providing to 

such individual, or to the representative or heirs of such individual, notice of the intention of the United States, an Indian 

tribe, or a tribal organization to institute a separate civil action. 


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ø(f) 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 or tribal organization. 

øCREDITING OF REIMBURSEMENTS

øSEC. 207. (a) Except as provided in section 202(d), title IV, and 

section 813 of this Act, all reimbursements received or recovered, 

under authority of this Act, 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 

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). 

øHEALTH SERVICES RESEARCH

øSEC. 208. Of 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 shall be given an equal opportunity 

to compete for, and receive, research funds under this section. 

øMENTAL HEALTH PREVENTION AND TREATMENT SERVICES

øSEC. 209. (a) NATIONAL PLAN FOR INDIAN MENTAL HEALTH

SERVICES.—(1) Not later than 120 days after the date of enactment 

of this section, 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.—Not later than 180 days 

after the date of enactment of this section, the Secretary and the 


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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 

various tribes (developed under the Indian Alcohol and 

Substance Abuse Prevention and Treatment Act of 1986) 

with the mental health initiatives pursuant to this Act, 

particularly with respect to the referral and treatment of 

dually-diagnosed individuals requiring mental health and 

substance abuse treatment; and 

ø(B) ensuring that Bureau of Indian Affairs and Service 

programs and services (including multidisciplinary resource teams) addressing child abuse and family violence 

are coordinated with such non-Federal programs and services; 

ø(7) direct appropriate officials of the Bureau of Indian Affairs and the Service, particularly at the agency and service 

unit levels, to cooperate fully with tribal requests made pursuant to subsection (d); and 

ø(8) provide for an annual review of such agreement by the 

two Secretaries. 

ø(c) COMMUNITY MENTAL HEALTH PLAN.—(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. 


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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), 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.—(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 self-destructive 

behavior. 

ø(2) The positions referred to in paragraph (1) are—

ø(A) staff positions within the Bureau of Indian Affairs, including existing positions, in the fields of—

ø(i) elementary and secondary education; 

ø(ii) social services and family and child welfare; 

ø(iii) law enforcement and judicial services; and 

ø(iv) alcohol and substance abuse; 

ø(B) staff positions with the Service; and 

ø(C) staff positions similar to those identified in subparagraphs (A) and (B) established and maintained by Indian 

tribes, including positions established in contracts entered into 

under the Indian Self-Determination Act. 

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, 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) 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. 


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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). 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.—(1) Within 90 days after the date of enactment 

of this section, 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 the date 

of enactment of this section, with at least 200 of such positions devoted to child, adolescent, and family services. Such additional staff 

shall be primarily assigned to the service unit level for services 

which shall include outpatient, emergency, aftercare and follow-up, 

and prevention and education services. 

ø(2) The plan developed under paragraph (1) shall be implemented under the Act of November 2, 1921 (25 U.S.C. 13) popularly known as the ‘‘Snyder Act’’. 

ø(f) STAFF RECRUITMENT AND RETENTION.—(1) The Secretary 

shall provide for the recruitment of the additional personnel required by subsection (f) and the retention of all Service personnel 

providing mental health services. In carrying out this subsection, 

the Secretary shall give priority to practitioners providing mental 

health services to children and adolescents with mental health 

problems. 

ø(2) In carrying out paragraph (1), the Secretary shall develop a 

program providing for—

ø(A) the payment of bonuses (which shall not be more favorable than those provided for under sections 116 and 117) 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 108) 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 title I. 

ø(g) MENTAL HEALTH TECHNICIAN PROGRAM.—(1) Under the authority of the Snyder Act of November 2, 1921 (25 U.S.C. 13), 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 communitybased mental health care that includes identification, prevention, education, referral, and treatment services. 


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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.—The Secretary, acting through 

the Service and in consultation with the National Institute of Mental Health, shall enter into contracts with, or make grants to, appropriate institutions for the conduct of research on the incidence 

and prevalence of mental disorders among Indians on Indian reservations and in urban areas. Research priorities under this subsection shall include—

ø(1) the inter-relationship and inter-dependence of mental 

disorders with alcoholism, suicide, homicides, accidents, and 

the incidence of family violence, and 

ø(2) the development of models of prevention techniques. 

The 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.—Within one year after the date of 

enactment of this section, 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.—The 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 801, 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.—(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. 


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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, use the same criteria that the Secretary uses in evaluating any other application for such a grant. 

ø(4) The Secretary may only award one grant under this subsection with respect to a service area until the Secretary has 

awarded grants for all service areas with respect to which the Secretary receives applications during the application period, as determined by the Secretary, which meet the criteria specified in paragraph (2). 

ø(5) Not later than 180 days after the close of the term of the 

last grant awarded pursuant to this subsection, the Secretary shall 

submit to the Congress a report evaluating the effectiveness of the 

innovative community-based projects demonstrated pursuant to 

this subsection. Such report shall include findings and recommendations, if any, relating to the reorganization of the programs of the Service for delivery of mental health services to Indians. 

ø(6) Grants made pursuant to this section may be expended over 

a period of three years and no grant may exceed $1,000,000 for the 

fiscal years involved. 

ø(l) LICENSING REQUIREMENT FOR MENTAL HEALTH CARE WORKERS.—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 a clinical setting under the authority of this Act or through a contract pursuant to the Indian 

Self-Determination Act 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.—(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 


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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 

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 216(b)(1). 

ø(4) An Indian tribe or tribal organization receiving a grant 

under this subsection shall ensure that intermediate adolescent 

mental health services are coordinated with other tribal, Service, 

and Bureau of Indian Affairs mental health, alcohol and substance 

abuse, and social services programs on the reservation of such tribe 

or tribal organization. 

ø(5) The Secretary shall establish criteria for the review and approval of applications for grants made pursuant to this subsection. 

ø(6) There are authorized to be appropriated to carry out this 

section $10,000,000 for fiscal year 1993 and such sums as may be 

necessary for each of the fiscal years 1994, 1995, 1996, 1997, 1998, 

1999, and 2000. 

øMANAGED CARE FEASIBILITY STUDY

øSEC. 210. (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 the date 

of the enactment of this section, 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. 

øCALIFORNIA CONTRACT HEALTH SERVICES DEMONSTRATION PROGRAM

øSEC. 211. (a) The 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)(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 809(b) throughout the California contract health services delivery area described in section 810 with respect to high-cost contract care cases. 


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ø(2) Not more than 5 percent of the amounts provided to the 

Board under this section for any fiscal year may be for reimbursement for administrative expenses incurred by the Board during 

such fiscal year. 

ø(3) No payment may be made for treatment provided under the 

demonstration program to the extent payment may be made for 

such treatment under the Catastrophic Health Emergency Fund 

described in section 202 or from amounts appropriated or otherwise 

made available to the California contract health service delivery 

area for a fiscal year. 

ø(c) There 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) The demonstration program described in this section shall 

begin on January 1, 1993, and shall terminate on September 30, 

1997. 

ø(e) Not 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) For 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 202, except that the cost of such treatment does not meet 

the threshold cost requirement established pursuant to section 

202(b)(2); and 

ø(2) exceeds $1,000. 

ø(g) There 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. 

øCOVERAGE OF SCREENING MAMMOGRAPHY

øSEC. 212. The Secretary, through the Service, shall provide for 

screening mammography (as defined in section 1861(jj) of the Social Security Act) 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. 


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øPATIENT TRAVEL COSTS

øSEC. 213. (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 Self-Determination Act) under this Act—

ø(1) emergency air transportation; and 

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. 

øEPIDEMIOLOGY CENTERS

øSEC. 214. (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 3(b). 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 3(b). 

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 3(b) 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 organizations 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); 

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 than $12,000,000 for fiscal 

year 1993 and such sums as may be necessary for each of the fiscal 

years 1994, 1995, 1996, 1997, 1998, 1999, and 2000. 

øCOMPREHENSIVE SCHOOL HEALTH EDUCATION PROGRAMS

øSEC. 215. (a) The 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) Grants awarded under this section may be used to—

ø(1) develop health education curricula; 

ø(2) train teachers in comprehensive school health education 

curricula; 


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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) The 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) The Secretary shall establish criteria for the review and approval of applications for grants made pursuant to this section. 

ø(e) Recipients 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)(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 

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; 


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ø(B) ensure the integration and coordination of school-based 

programs with existing services and health programs available 

in the community; and 

ø(C) encourage healthy, tobacco-free school environments. 

ø(g) 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. 

øINDIAN YOUTH GRANT PROGRAM

øSEC. 216. (a) The 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)(1) Funds made available under this section may be used to— 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 209(m). 

ø(c) The 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) The Secretary shall establish criteria for the review and approval of applications under this section. 

ø(e) There 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. 

øAMERICAN INDIANS INTO PSYCHOLOGY PROGRAM

øSEC. 217. (a) The 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) The Secretary shall provide one of the grants 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 

114(b), the Quentin N. Burdick American Indians Into Nursing 

Program authorized under section 112(e), and existing university 

research and communications networks. 

ø(c)(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—


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ø(A) provides outreach and recruitment for health professions to Indian communities including elementary, secondary 

and community colleges located on Indian reservations that 

will be served by the program; 

ø(B) incorporates a program advisory board comprised of representatives from the tribes and communities that will be 

served by the program; 

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) 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 student who receives a stipend described in 

subsection (c)(2)(D) 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; 

ø(3) in a program assisted under title V of this Act; 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. 

øPREVENTION, CONTROL, AND ELIMINATION OF TUBERCULOSIS

øSEC. 218. (a) The 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) The Secretary may make a grant under subsection (a) only 

if an application for the grant is submitted to the Secretary and the 

application is in such form, is made in such manner, and contains 

the assurances required by subsection (c) and such other agreements, assurances, and information as the Secretary may require. 

ø(c) To be eligible for a grant under subsection (a), an applicant 

must provide assurances satisfactory to the Secretary that—


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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) In carrying out this section, the Secretary—

ø(1) shall establish criteria for the review and approval of 

applications for grants under subsection (a), including requirement of public health qualifications of applicants; 

ø(2) shall, subject to available appropriations, make at least 

one grant under subsection (a) 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) The Secretary may, at the request of a recipient of a grant 

under subsection (a), 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, 

when the furnishing of such supplies or equipment or the detail of 

such an officer or employee is for the convenience of and at the request of such grant recipient and for the purpose of carrying out 

a program with respect to which the grant under subsection (a) 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. 

øCONTRACT HEALTH SERVICES PAYMENT STUDY

øSEC. 219. (a) The 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; 


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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) The study required by subsection (a) shall—

ø(1) assess the impact of the existing contract health services 

regul ations 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 requirements to 

evaluate the systemic differences or similarities employed by 

the Service and private insurers. 

ø(c) Not later than 12 months after the date of the enactment of 

this section, 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. 

øPROMPT ACTION ON PAYMENT OF CLAIMS

øSEC. 220. (a) The Service shall respond to a notification of a 

claim by a provider of a contract care service with either an individual purchase order or a denial of the claim within 5 working 

days after the receipt of such notification. 

ø(b) 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. 

ø(c) The Service shall pay a completed contract care service claim 

within 30 days after completion of the claim. 

øDEMONSTRATION OF ELECTRONIC CLAIMS PROCESSING

øSEC. 221. (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 


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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) in the Service area served by the area office located in Phoenix, Arizona. 

øLIABILITY FOR PAYMENT

øSEC. 222. (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. 

øOFFICE OF INDIAN WOMEN’S HEALTH CARE

øSEC. 223. There 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. 

øAUTHORIZATION OF APPROPRIATIONS

øSEC. 224. Except as provided in sections 209(m), 211, 213, 

214(b)(5), 215, and 216, there are authorized to be appropriated 

such sums as may be necessary for each fiscal year through fiscal 

year 2000 to carry out this title. 

øLIMITATION ON USE OF FUNDS

øSEC. 225. Amounts appropriated to carry out this title may not 

be used in a manner inconsistent with the Assisted Suicide Funding Restriction Act of 1997. 

øTITLE III—HEALTH FACILITIES 

øCONSULTATION; CLOSURE OF FACILITIES; REPORTS

øSEC. 301. (a) Prior to the expenditure of, or the making of any 

firm 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), popularly known as 

the Snyder Act, the Secretary, acting through the Service, shall—

ø(1) consult with any Indian 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 made, and 

ø(2) ensure, whenever practicable, that such facility meets 

the standards of the 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. 


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ø(b)(1) Notwithstanding any provision of law other 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 the Congress at least 1 year 

prior to the date such hospital or facility (or portion thereof) is proposed to be closed an evaluation of the impact of such proposed closure which specifies, in addition to other considerations— ø(A) the accessibility of alternative health care resources for 

the population served by such hospital or facility; 

ø(B) the cost effectiveness of such closure; 

ø(C) the quality of health care to be provided to the population served by such hospital or facility after such closure; 

ø(D) the availability of contract health care funds to maintain existing levels of service; 

ø(E) the views of the Indian tribes served by such hospital 

or facility concerning such closure; 

ø(F) the level of utilization of such hospital or facility by all 

eligible Indians; and 

ø(G) the distance between such hospital or facility and the 

nearest operating Service hospital. 

ø(2) Paragraph (1) shall not apply to any temporary closure of a 

facility or of any portion of a facility if such closure is necessary 

for medical, environmental, or safety reasons. 

ø(c)(1) The Secretary shall submit to the President, for inclusion 

in each report required to be transmitted to the Congress under 

section 801, a report which sets forth— ø(A) the current health facility priority system of the Service, 

ø(B) the planning, design, construction, and renovation needs 

for the 10 top-priority inpatient care facilities and the 10 toppriority ambulatory care facilities (together with required staff 

quarters), 

ø(C) the justification for such order of priority, 

ø(D) the projected cost of such projects, and 

ø(E) the methodology adopted by the Service in establishing 

priorities under its health facility priority system. 

ø(2) In preparing each report required under paragraph (1) 

(other than the initial report), the Secretary shall—

ø(A) consult with Indian tribes and tribal organizations including those tribes or tribal organizations operating health 

programs or facilities under any contract entered into with the 

Service under the Indian Self-Determination Act, and 

ø(B) review the needs of such tribes and tribal organizations 

for inpatient and outpatient facilities, including their needs for 

renovation and expansion of existing facilities. 

ø(3) For purposes of this subsection, the Secretary shall, in evaluating the needs of facilities operated under any contract entered 

into with the Service under the Indian Self-Determination Act, use 

the same criteria that the Secretary uses in evaluating the needs 

of facilities operated directly by the Service. 

ø(4) The Secretary shall ensure that the planning, design, construction, and renovation needs of Service and non-Service facilities 

which are the subject of a contract for health services entered into 

with the Service under the Indian Self-Determination Act are fully 

and equitably integrated into the development of the health facility 

priority system. 


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ø(d) All funds appropriated under the Act of November 2, 1921 

(25 U.S.C. 13), for the planning, design, construction, or renovation 

of health facilities for the benefit of an Indian tribe or tribes shall 

be subject to the provisions of section 102 of the Indian Self-Determination Act. 

øSAFE WATER AND SANITARY WASTE DISPOSAL FACILITIES

øSEC. 302. (a) The Congress hereby finds and declares that—

ø(1) the provision of safe water supply systems and sanitary 

sewage and solid waste disposal systems is primarily a health 

consideration and function; 

ø(2) Indian people suffer an inordinately high incidence of 

disease, injury, and illness directly attributable to the absence 

or inadequacy of such systems; 

ø(3) the long-term cost to the United States of treating and 

curing such disease, injury, and illness is substantially greater 

than the short-term cost of providing such systems and other 

preventive health measures; 

ø(4) many Indian homes and communities still lack safe 

water supply systems and sanitary sewage and solid waste disposal systems; and 

ø(5) 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 safe and 

adequate water supply systems and sanitary sewage waste disposal systems as soon as possible. 

ø(b)(1) In furtherance of the findings and declarations made in 

subsection (a), 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.C. 2004a). 

ø(2) The Secretary, acting through the Service, is authorized to 

provide under section 7 of the Act of August 5, 1954 (42 U.S.C. 

2004a)—

ø(A) financial and technical assistance to Indian tribes and 

communities in the establishment, training, and equipping of 

utility organizations to operate and maintain Indian sanitation 

facilities; 

ø(B) ongoing technical assistance and training in the management of utility organizations which operate and maintain 

sanitation facilities; and 

ø(C) operation and maintenance assistance for, and emergency repairs to, tribal sanitation facilities when necessary to 

avoid a health hazard or to protect the Federal investment in 

sanitation facilities. 

ø(3) Notwithstanding any other provision of law—

ø(A) the Secretary of Housing and Urban Affairs is authorized to transfer funds appropriated under the Housing and 

Community Development Act of 1974 (42 U.S.C. 5301, et seq.) 

to the Secretary of Health and Human Services, and 

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). 


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ø(c) Beginning in fiscal year 1990, the Secretary, acting through 

the Service, shall develop and begin implementation of a 10-year 

plan to provide safe water supply and sanitation sewage and solid 

waste disposal facilities to existing Indian homes and communities 

and to new and renovated Indian homes. 

ø(d) The financial and technical capability of an Indian tribe or 

community to safely operate and maintain a sanitation facility 

shall not be a prerequisite to the provision or construction of sanitation facilities by the Secretary. 

ø(e)(1) The Secretary is authorized to provide financial assistance 

to Indian tribes and communities in an amount equal to the Federal share of the costs of operating, managing, and maintaining the 

facilities provided under the plan described in subsection (c). 

ø(2) For the purposes of paragraph (1), the term ‘‘Federal share’’

means 80 percent of the costs described in paragraph (1). 

ø(3) With respect to Indian tribes with fewer than 1,000 enrolled 

members, the non-Federal portion of the costs of operating, managing, and maintaining such facilities may be provided, in part, 

through cash donations or in kind property, fairly evaluated. 

ø(f) Programs administered by Indian tribes or tribal organizations under the authority of the Indian Self-Determination Act 

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, 

on an equal basis with programs that are administered directly by 

the Service. 

ø(g)(1) The Secretary shall submit to the President, for inclusion 

in each report required to be transmitted to the Congress under 

section 801, a report which sets forth—

ø(A) the current Indian sanitation facility priority system of 

the Service; 

ø(B) the methodology for determining sanitation deficiencies; 

ø(C) the level of sanitation deficiency for each sanitation facilities project of each Indian tribe or community; 

ø(D) the amount of funds necessary to raise all Indian tribes 

and communities to a level I sanitation deficiency; and 

ø(E) the amount of funds necessary to raise all Indian tribes 

and communities to zero sanitation deficiency. 

ø(2) In preparing each report required under paragraph (1) 

(other than the initial report), the Secretary shall consult with Indian tribes and tribal organizations (including those tribes or tribal 

organizations operating health care programs or facilities under 

any contract entered into with the Service under the Indian SelfDetermination Act) to determine the sanitation needs of each tribe. 

ø(3) The methodology used by the Secretary in determining sanitation deficiencies for purposes of paragraph (1) shall be applied 

uniformly to all Indian tribes and communities. 

ø(4) For purposes of this subsection, the sanitation deficiency levels for an Indian tribe or community are as follows: 

ø(A) level I is an Indian tribe or community with a sanitation system—

ø(i) which complies with all applicable water supply and 

pollution control laws, and 


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ø(ii) in which the deficiencies relate to routine replacement, repair, or maintenance needs; 

ø(B) level II is an Indian tribe or community with a sanitation system—

ø(i) which complies with all applicable water supply and 

pollution control laws, and 

ø(ii) in which the deficiencies relate to capital improvements that are necessary to improve the facilities in order 

to meet the needs of such tribe or community for domestic 

sanitation facilities; 

ø(C) level III is an Indian tribe or community with a sanitation system which—

ø(i) has an inadequate or partial water supply and a 

sewage disposal facility that does not comply with applicable water supply and pollution control laws, or 

ø(ii) has no solid waste disposal facility; 

ø(D) level IV is an Indian tribe or community with a sanitation system which lacks either a safe water supply system or 

a sewage disposal system; and 

ø(E) level V is an Indian tribe or community that lacks a 

safe water supply and a sewage disposal system. 

ø(5) For purposes of this subsection, any Indian tribe or community that lacks the operation and maintenance capability to enable 

its sanitation system to meet pollution control laws may not be 

treated as having a level I or II sanitation deficiency. 

øPREFERENCE TO INDIANS AND INDIAN FIRMS

øSEC. 303. (a) The Secretary, acting through the Service, may 

utilize the negotiating authority of the Act of June 25, 1910 (25 

U.S.C. 47), 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 tribes in the State of New York 

(hereinafter referred to as an ‘‘Indian firm’’) in the construction and 

renovation of Service facilities pursuant to section 301 and in the 

construction of safe water and sanitary waste disposal facilities 

pursuant to section 302. Such preference may be accorded by the 

Secretary unless he finds, pursuant to rules and regulations promulgated by him, that the project or function to be contracted for 

will not be satisfactory or such project or function cannot be properly completed or maintained under the proposed contract. The 

Secretary, in arriving at his finding, shall consider whether the Indian or Indian firm will be deficient with respect to (1) ownership 

and control by Indians, (2) equipment, (3) bookkeeping and accounting procedures, (4) substantive knowledge of the project or 

function to be contracted for, (5) adequately trained personnel, or 

(6) other necessary components of contract performance. 

ø(b) For the purpose of implementing the provisions of this title, 

the 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 title are not less than the prevailing local wage rates for similar work as determined in accordance with the Act of March 3, 

1931 (40 U.S.C. 276a—276a–5, known as the Davis-Bacon Act). 


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øSOBOBA SANITATION FACILITIES

øSEC. 304. The Act of December 17, 1970 (84 Stat. 1465), is hereby amended by adding the following new section 9 at the end thereof: 

ø‘‘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).’’. 

øEXPENDITURE OF NONSERVICE FUNDS FOR RENOVATION

øSEC. 305. (a)(1) Notwithstanding any other provision of law, the 

Secretary is authorized to accept any major renovation or modernization by any Indian tribe of any Service facility, or of any 

other Indian health facility operated pursuant to a contract entered 

into under the Indian Self-Determination Act, including—

ø(A) any plans or designs for such renovation or modernization; and 

ø(B) any renovation or modernization for which funds appropriated under any Federal law were lawfully expended, 

but only if the requirements of subsection (b) are met. 

ø(2) The Secretary shall maintain a separate priority list to address the needs of such facilities for personnel or equipment. 

ø(3) The Secretary shall submit to the President, for inclusion in 

each report required to be transmitted to the Congress under section 801, the priority list maintained pursuant to paragraph (2). 

ø(b) The requirements of this subsection are met with respect to 

any renovation or modernization if—

ø(1) the tribe or tribal organization—

ø(A) provides notice to the Secretary of its intent to renovate or modernize; and 

ø(B) applies to the Secretary to be placed on a separate 

priority list to address the needs of such new facilities for 

personnel or equipment; and 

ø(2) the renovation or modernization—

ø(A) is approved by the appropriate area director of the 

Service; and 

ø(B) is administered by the tribe in accordance with the 

rules and regulations prescribed by the Secretary with respect to construction or renovation of Service facilities. 

ø(c) If any Service facility which has been renovated or modernized by an Indian tribe under this section ceases to be used as a 

Service facility during the 20-year period beginning on the date 

such renovation or modernization is completed, such Indian tribe 

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 renovation or modernization 

(less the total amount of any funds provided specifically for such 

facility under any Federal program that were expended for such 

renovation or modernization) bore to the value of such facility at 

the time of the completion of such renovation or modernization. 


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øGRANT PROGRAM FOR THE CONSTRUCTION, EXPANSION, AND

MODERNIZATION OF SMALL AMBULATORY CARE FACILITIES

øSEC. 306. (a)(1) The Secretary, acting through the Service, shall 

make grants to tribes and tribal organizations for the construction, 

expansion, or modernization of facilities for the provision of ambulatory care services to eligible Indians (and noneligible persons as 

provided in subsection (c)(1)(C)). A grant made under this section 

may cover up to 100 percent of the costs of such construction, expansion, or modernization. For the purposes of this section, the 

term ‘‘construction’’ includes the replacement of an existing facility. 

ø(2) A grant under paragraph (1) may only be made to a tribe 

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 tribe or tribal organization) pursuant to a contract entered into under the Indian Self-Determination Act. 

ø(b)(1) A grant provided under this section may be used only for 

the construction, expansion, or modernization (including the planning and design of such construction, expansion, or modernization) 

of an ambulatory care facility—

ø(A) located apart from a hospital; 

ø(B) not funded under section 301 or section 307; and 

ø(C) which, upon completion of such construction, expansion, 

or modernization will—

ø(i) have a total capacity appropriate to its projected 

service population; 

ø(ii) serve no less than 500 eligible Indians annually; 

and 

ø(iii) provide ambulatory care in a service area (specified 

in the contract entered into under the Indian Self-Determination Act) with a population of not less than 2,000 eligible Indians. 

ø(2) The requirements of clauses (ii) and (iii) of paragraph (1)(C) 

shall not apply to a tribe or tribal organization applying for a grant 

under this section whose tribal government offices are located on 

an island. 

ø(c)(1) No grant may be made under this section unless an application for such a grant has been submitted to and approved by the 

Secretary. 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—

ø(A) adequate financial support will be available for the provision of services at such facility; 

ø(B) such facility will be available to eligible Indians without 

regard to ability to pay or source of payment; and 

ø(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. 

ø(2) In awarding grants under this section, the Secretary shall 

give priority to tribes and tribal organizations that demonstrate—

ø(A) a need for increased ambulatory care services; and 


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ø(B) insufficient capacity to deliver such services. 

ø(d) If any facility (or portion thereof) with respect to which 

funds have been paid under this section, ceases, at any time after 

completion of the construction, expansion, or modernization carried 

out with such funds, to be utilized for the purposes of providing 

ambulatory 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. 

øINDIAN HEALTH CARE DELIVERY DEMONSTRATION PROJECT

øSEC. 307. (a) HEALTH CARE DELIVERY DEMONSTRATION

PROJECTS.—The Secretary, acting through the Service, is authorized to enter into contracts with, or make grants to, Indian tribes 

or tribal organizations for the purpose of carrying out a health care 

delivery demonstration project to test alternative means of delivering health care and services through health facilities to Indians. 

ø(b) USE OF 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—

ø(1) waive any leasing prohibition; 

ø(2) permit carryover of funds appropriated for the provision 

of health care services; 

ø(3) permit the use of non-Service Federal funds and nonFederal funds; 

ø(4) permit the use of funds or property donated from any 

source for project purposes; and 

ø(5) provide for the reversion of donated real or personal 

property to the donor. 

ø(c) CRITERIA.—(1) Within 180 days after the date of enactment 

of this section, the Secretary, after consultation with Indian tribes 

and tribal organizations, shall develop and publish in the Federal 

Register criteria for the review and approval of applications submitted under this section. The Secretary may enter into a contract 

or award a grant under this section for projects which meet the following criteria: 

ø(A) There is a need for a new facility or program or the reorientation of an existing facility or program. 

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. 

ø(D) The project has the potential to deliver services in an 

efficient and effective manner. 

ø(E) The project is economically viable. 

ø(F) The Indian tribe or tribal organization has the administrative and financial capability to administer the project. 

ø(G) The project is integrated with providers of related 

health and social services and is coordinated with, and avoids 

duplication of, existing services. 

ø(2) The Secretary may provide for the establishment of peer review panels, as necessary, to review and evaluate applications and 

to advise the Secretary regarding such applications using the criteria developed pursuant to paragraph (1). 


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ø(3)(A) On or before September 30, 1995, the Secretary shall 

enter into contracts or award grants under this section for a demonstration project in each of the following service units which 

meets the criteria specified in paragraph (1) and for which a completed application has been received by the Secretary: 

ø(i) Cass Lake, Minnesota. 

ø(ii) Clinton, Oklahoma. 

ø(iii) Harlem, Montana. 

ø(iv) Mescalero, New Mexico. 

ø(v) Owyhee, Nevada. 

ø(vi) Parker, Arizona. 

ø(vii) Schurz, Nevada. 

ø(viii) Winnebago, Nebraska. 

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 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). 

ø(d) TECHNICAL ASSISTANCE.—The Secretary shall provide such 

technical and other assistance as may be necessary to enable applicants to comply with the provisions of this section. 

ø(e) SERVICE TO INELIGIBLE PERSONS.—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 

service facilities to non-Service health care practitioners as provided in section 813 may be included, subject to the terms of such 

section, in any demonstration project approved pursuant to this 

section. 

ø(f) EQUITABLE TREATMENT.—For purposes of subsection 

(c)(1)(A), the Secretary shall, in evaluating facilities operated under 

any contract entered into with the Service under the Indian SelfDetermination Act, use the same criteria that the Secretary uses 

in evaluating facilities operated directly by the Service. 

ø(g) EQUITABLE INTEGRATION OF FACILITIES.—The Secretary 

shall ensure that the planning, design, construction, and renovation needs of Service and non-Service facilities which are the subject of a contract for health services entered into with the Service 

under the Indian Self-Determination Act, are fully and equitably 

integrated into the implementation of the health care delivery demonstration projects under this section. 

ø(h)(1) The Secretary shall submit to the President, for inclusion 

in the report which is required to be submitted to the Congress 

under section 801 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 801 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. 


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øLAND TRANSFER

øSEC. 308. The Bureau of Indian Affairs is authorized to transfer, at no cost, up 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. 

øAUTHORIZATION OF APPROPRIATIONS

øSEC. 309. There are authorized to be appropriated such sums as 

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

carry out this title. 

øAPPLICABILITY OF BUY AMERICAN REQUIREMENT

øSEC. 310. (a) The Secretary shall ensure that the requirements 

of the Buy American Act apply to all procurements made with 

funds provided pursuant to the authorization contained in section 

309. 

ø(b) The 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 309. Such report shall separately indicate the 

dollar value of items procured with such funds for which the Buy 

American Act was waived pursuant to the Trade Agreement Act of 

1979 or any international agreement to which the United States is 

a party. 

ø(c) If it has been finally determined by a court or Federal agency that any person intentionally affixed a label bearing a ‘‘Made in 

America’’ inscription, 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 the authorization contained in section 309, pursuant to the 

debarment, suspension, and ineligibility procedures described in 

sections 9.400 through 9.409 of title 48, Code of Federal Regulations. 

ø(d) For purposes of this section, the term ‘‘Buy American Act’’

means title III of the Act entitled ‘‘An Act making appropriations 

for the Treasury and Post Office Departments for the fiscal year 

ending June 30, 1934, and for other purposes’’, approved March 3, 

1933 (41 U.S.C. 10a et seq.). 

øTITLE IV—ACCESS TO HEALTH SERVICES 

øTREATMENT OF PAYMENTS UNDER MEDICARE PROGRAM

øSEC. 401. (a) Any payments received by a hospital or skilled 

nursing facility of the Service (whether operated by the Service or 

by an Indian tribe or tribal organization pursuant to a contract 

under the Indian Self-Determination Act) for services provided to 

Indians eligible for benefits under title XVIII of the Social Security 

Act shall not be considered in determining appropriations for 

health care and services to Indians. 

ø(b) Nothing in this Act authorizes the Secretary to provide services to an Indian beneficiary with coverage under title XVIII of the 


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Social Security Act, as amended, in preference to an Indian beneficiary without such coverage. 

øTREATMENT OF PAYMENTS UNDER MEDICAID PROGRAM

øSEC. 402. (a) Notwithstanding any other provision of law, payments to which any facility of the Service (including a hospital, 

nursing facility, intermediate care facility for the mentally retarded, or any other type of facility which provides services for 

which payment is available under title XIX of the Social Security 

Act) is entitled under a State plan by reason of section 1911 of such 

Act shall be placed in a special fund to be held by the Secretary 

and used by him (to such extent or in such amounts as are provided in appropriation Acts) exclusively for the purpose of making 

any improvements in the facilities of such Service which may be 

necessary to achieve compliance with the applicable conditions and 

requirements of such title. In making payments from such fund, 

the Secretary shall ensure that each service unit of the Service receives at least 80 percent of the amounts to which the facilities of 

the Service, for which such service unit makes collections, are entitled by reason of section 1911 of the Social Security Act. 

ø(b) Any payments received by such facility for services provided 

to Indians eligible for benefits under title XIX of the Social Security 

Act shall not be considered in determining appropriations for the 

provision of health care and services to Indians. 

øREPORT

øSEC. 403. The Secretary shall submit to the President, for inclusion in the report required to be transmitted to the Congress under 

section 801, an accounting on the amount and use of funds made 

available to the Service pursuant to this title as a result of reimbursements through title XVIII and XIX of the Social Security Act, 

as amended. 

øGRANTS TO AND CONTRACTS WITH TRIBAL ORGANIZATIONS

øSEC. 404. (a) The Secretary, acting through the Service, shall 

make grants to or enter into contracts with tribal organizations to 

assist such organizations in establishing and administering programs on or near Federal Indian reservations and trust areas and 

in or near Alaska Native villages to assist individual Indians to—

ø(1) enroll under section 1818 of part A and sections 1836 

and 1837 of part B of title XVIII of the Social Security Act; 

ø(2) pay monthly premiums for coverage due to financial 

need of such individual; and 

ø(3) apply for medical assistance provided pursuant to title 

XIX of the Social Security Act. 

ø(b) The Secretary, acting through the Service, shall place conditions as deemed necessary to effect the purpose of this section in 

any contract or grant which the Secretary makes with any tribal 

organization pursuant to this section. Such conditions shall include, but are not limited to, requirements that the organization 

successfully undertake to—

ø(1) determine the population of Indians to be served that 

are or could be recipients of benefits under titles XVIII and 

XIX of the Social Security Act; 


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ø(2) assist individual Indians in becoming familiar with and 

utilizing such benefits; 

ø(3) provide transportation to such individual Indians to the 

appropriate offices for enrollment or application for medical assistance; 

ø(4) develop and implement—

ø(A) a schedule of income levels to determine the extent 

of payments of premiums by such organizations for coverage of needy individuals; and 

ø(B) methods of improving the participation of Indians 

in receiving the benefits provided under titles XVIII and 

XIX of the Social Security Act. 

ø(c) The Secretary, acting through the Service, may enter into an 

agreement with an Indian tribe, tribal organization, or urban Indian organization which provides for the receipt and processing of 

applications for medical assistance under title XIX of the Social Security Act and benefits under title XVIII of the Social Security Act 

at a Service facility or a health care facility administered by such 

tribe or organization pursuant to a contract under the Indian SelfDetermination Act. 

ø(a) ESTABLISHMENT OF DIRECT BILLING PROGRAM.—

ø(1) IN GENERAL.—The 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 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.—The third sentence 

of section 1905(b) of the Social Security Act (42 U.S.C. 

1396d(b)) 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.—Each 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 402(a) and 813(b)(2)(A), 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—


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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.—The 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.—The 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.—Notwithstanding 

section 1880(c) of the Social Security Act (42 U.S.C. 1395qq(c)) 

or section 402(a), 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.—Except 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 1880 or 1911 of the 

Social Security Act (42 U.S.C. 1395qq; 1396j); 

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.—The Secretary shall review and approve a qualified application not later than 90 days after 

the date the application is submitted to the Secretary unless the Secretary determines that any of the criteria set 

forth in paragraph (1) are not met. 

ø(B) GRANDFATHER OF DEMONSTRATION PROGRAM PAR- TICIPANTS.—Any participant in the demonstration program 

authorized under this section as in effect on the day before 

the date of enactment of the Alaska Native and American 

Indian Direct Reimbursement Act of 1999 shall be deemed 

approved for participation in the program established 


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under this section and shall not be required to submit an 

application in order to participate in the program. 

ø(C) DURATION.—An approval by the Secretary of a 

qualified application under subparagraph (A), or a deemed 

approval of a demonstration program under subparagraph 

(B), shall continue in effect as long as the approved applicant or the deemed approved demonstration program 

meets the requirements of this section. 

ø(d) EXAMINATION AND IMPLEMENTATION OF CHANGES.—

ø(1) IN GENERAL.—The 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 billing and reimbursement under the 

program established under this section, including any 

agreements 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.—The accounting information 

that a participant in the program established under this section shall be required to report shall be the same as the information required to be reported by participants in the demonstration program authorized under this section as in effect 

on the day before the date of enactment of the Alaska Native 

and American Indian Direct Reimbursement Act of 1999. The 

Secretary may from time to time, after consultation with the 

program participants, change the accounting information submission requirements. 

ø(e) WITHDRAWAL FROM PROGRAM.—A 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. 450 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. 

øAUTHORIZATION FOR EMERGENCY CONTRACT HEALTH SERVICES

øSEC. 406. With respect to an elderly or disabled Indian receiving 

emergency medical care or services from a non-Service provider or 

in a non-Service facility under the authority of this Act, the time 

limitation (as a condition of payment) for notifying the Service of 

such treatment or admission shall be 30 days. 

øAUTHORIZATION OF APPROPRIATIONS

øSEC. 407. There are authorized to be appropriated such sums as 

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

carry out this title. 


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øTITLE V—HEALTH SERVICES FOR URBAN INDIANS 

øPURPOSE

øSEC. 501. The purpose of this title is to establish programs in 

urban centers to make health services more accessible to urban Indians. 

øCONTRACTS WITH, AND GRANTS TO, URBAN INDIAN ORGANIZATIONS

øSEC. 502. Under authority of the Act of November 2, 1921 (25 

U.S.C. 13), popularly known as the Snyder Act, the Secretary, 

through the Service, shall enter into contracts with, or make grants 

to, urban Indian organizations to assist such organizations in the 

establishment and administration, within the urban centers in 

which such organizations are situated, of programs which meet the 

requirements set forth in this title. The Secretary, through the 

Service, shall include such conditions as the Secretary considers 

necessary to effect the purpose of this title in any contract which 

the Secretary enters into with, or in any grant the Secretary makes 

to, any urban Indian organization pursuant to this title. 

øCONTRACTS AND GRANTS FOR THE PROVISION OF HEALTH CARE AND

REFERRAL SERVICES

øSEC. 503. (a) Under authority of the Act of November 2, 1921 

(25 U.S.C. 13), popularly known as the Snyder Act, the Secretary, 

through the Service, shall enter into contracts with, or make grants 

to, urban Indian organizations for the provision of health care and 

referral services for urban Indians residing in the urban centers in 

which such organizations are situated. Any such contract or grant 

shall include requirements that the urban Indian organization successfully undertake to—

ø(1) estimate the population of urban Indians residing in the 

urban center in which such organization is situated who are or 

could be recipients of health care or referral services; 

ø(2) estimate the current health status of urban Indians residing in such urban center; 

ø(3) estimate the current health care needs of urban Indians 

residing in such urban center; 

ø(4) identify all public and private health services resources 

within such urban center which are or may be available to 

urban Indians; 

ø(5) determine the use of public and health services resources by the urban Indians residing in such urban center; 

ø(6) assist such health services resources in providing services to urban Indians; 

ø(7) assist urban Indians in becoming familiar with and utilizing such health services resources; 

ø(8) 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; 


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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. 

ø(b) The Secretary, through the Service, shall by regulation prescribe the criteria for selecting urban Indian organizations to enter 

into contracts or receive grants under this section. Such criteria 

shall, among other factors, include— ø(1) the extent of unmet health care needs of urban Indians 

in the urban center involved; 

ø(2) the size of the urban Indian population in the urban 

center involved; 

ø(3) the accessibility to, and utilization of, health care services (other than services provided under this title) by urban Indians in the urban center involved; 

ø(4) the extent, if any, to which the activities set forth in 

subsection (a) would duplicate— 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 title; or 

ø(B) any project funded under this title; 

ø(5) the capability of an urban Indian organization to perform the activities set forth in subsection (a) and to enter into 

a contract with the Secretary or to meet the requirements for 

receiving a grant under this section; 

ø(6) the satisfactory performance and successful completion 

by an urban Indian organization of other contracts with the 

Secretary under this title; 

ø(7) the appropriateness and likely effectiveness of conducting the activities set forth in subsection (a) in an urban 

center; and 

ø(8) the extent of existing or likely future participation in 

the activities set forth in subsection (a) by appropriate health 

and health-related Federal, State, local, and other agencies. 

ø(c) The Secretary, acting through the Service, shall facilitate access to, or provide, health promotion and disease prevention services for urban Indians through grants made to urban Indian organizations administering contracts entered into pursuant to this section or receiving grants under subsection (a). 

ø(d)(1) The Secretary, acting through the Service, shall facilitate 

access to, or provide, immunization services for urban Indians 

through grants made to urban Indian organizations administering 

contracts entered into pursuant to this section or receiving grants 

under subsection (a). 

ø(2) In making any grant to carry out this subsection, the Secretary shall take into consideration—

ø(A) the size of the urban Indian population to be served; 

ø(B) the immunization levels of the urban Indian population, 

particularly the immunization levels of infants, children, and 

the elderly; 

ø(C) the utilization by the urban Indians of alternative resources from State and local governments for no-cost or lowcost immunization services to the general population; and 


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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. 

ø(e)(1) The Secretary, acting through the Service, shall facilitate 

access to, or provide, mental health services for urban Indians 

through grants made to urban Indian organizations administering 

contracts entered into pursuant to this section or receiving grants 

under subsection (a). 

ø(2) A grant may not be made under this subsection to an urban 

Indian organization until that organization has prepared, and the 

Service has approved, an assessment of the mental 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. 

ø(3) Grants may be made under this subsection— ø(A) to prepare assessments required under paragraph (2); 

ø(B) to provide outreach, educational, and referral services to 

urban Indians regarding the availability of direct mental 

health services, to educate urban Indians about mental health 

issues and services, and effect coordination with existing mental health providers in order to improve services to urban Indians; 

ø(C) to provide outpatient mental health services to urban 

Indians, including the identification and assessment of illness, 

therapeutic treatments, case management, support groups, 

family treatment, and other treatment; and 

ø(D) to develop innovative mental health service delivery 

models which incorporate Indian cultural support systems and 

resources. 

ø(f)(1) The Secretary, acting through the Service, shall facilitate 

access to, or provide, services for urban Indians through grants to 

urban Indian organizations administering contracts entered into 

pursuant to this section or receiving grants under subsection (a) to 

prevent and treat child abuse (including sexual abuse) among 

urban Indians. 

ø(2) A grant may not be made under this subsection to an urban 

Indian organization until that organization has prepared, and the 

Service has approved, an assessment that documents the prevalence of child abuse in the urban Indian population concerned and 

specifies the services and programs (which may not duplicate existing services and programs) for which the grant is requested. 

ø(3) Grants may be made under this subsection—

ø(A) to prepare assessments required under paragraph (2); 

ø(B) for the development of prevention, training, and education programs for urban Indian populations, 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; and 

ø(C) to provide direct outpatient treatment services (including individual treatment, family treatment, group therapy, and 

support groups) to urban Indians who are child victims of 


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abuse (including sexual abuse) or adult survivors of child sexual abuse, to the families of such child victims, and to urban 

Indian perpetrators of child abuse (including sexual abuse). 

ø(4) In making grants to carry out this subsection, the Secretary 

shall take into consideration— ø(A) the support for the urban Indian 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; 

ø(B) the capability and expertise demonstrated by the urban 

Indian organization to address the complex problem of child 

sexual abuse in the community; and 

ø(C) the assessment required under paragraph (2). 

øCONTRACTS AND GRANTS FOR THE DETERMINATION OF UNMET

HEALTH CARE NEEDS

øSEC. 504. (a) Under authority of the Act of November 2, 1921 

(25 U.S.C. 13), popularly known as the Snyder Act, the Secretary, 

through the Service, may enter into contracts with, or make grants 

to, urban Indian organizations situated in urban centers for which 

contracts have not been entered into, or grants have not been 

made, under section 503. The purpose of a contract or grant made 

under this section shall be the determination of the matters described in subsection (b)(1) in order to assist the Secretary in assessing the health status and health care needs of urban Indians 

in the urban center involved and determining whether the Secretary should enter into a contract or make a grant under section 

503 with respect to the urban Indian organization which the Secretary has entered into a contract with, or made a grant to, under 

this section. 

ø(b) Any contract entered into, or grant made, by the Secretary 

under this section shall include requirements that— ø(1) the urban Indian organization successfully undertake 

to— ø(A) document the health care status and unmet health 

care needs of urban Indians in the urban center involved; 

and 

ø(B) with respect to urban Indians in the urban center 

involved, determine the matters described in clauses (2), 

(3), (4), and (8) of section 503(b); and 

ø(2) the urban Indian organization complete performance of 

the contract, or carry out the requirements of the grant, within 

one year after the date on which the Secretary and such organization enter into such contract, or within one year after such 

organization receives such grant, whichever is applicable. 

ø(c) The Secretary may not renew any contract entered into, or 

grant made, under this section. 

øEVALUATIONS; RENEWALS

øSEC. 505. (a) The Secretary, through the Service, shall develop 

procedures to evaluate compliance with grant requirements under 

this title and compliance with, and performance of contracts entered into by urban Indian organizations under this title. Such procedures shall include provisions for carrying out the requirements 

of this section. 


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ø(b) The Secretary, through the Service, shall conduct an annual 

onsite evaluation of each urban Indian organization which has entered into a contract or received a grant under section 503 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 grant. 

ø(c) If, as a result of the evaluations conducted under this section, the Secretary determines that an urban Indian organization 

has not complied with the requirements of a grant or complied with 

or satisfactorily performed a contract under section 503, the Secretary shall, prior to renewing such contract or grant, attempt to 

resolve with such organization the areas of noncompliance or unsatisfactory performance and modify such contract or grant to prevent future occurrences of such noncompliance or unsatisfactory 

performance. If the Secretary determines that such noncompliance 

or unsatisfactory performance cannot be resolved and prevented in 

the future, the Secretary shall not renew such contract or grant 

with such organization and is authorized to enter into a contract 

or make a grant under section 503 with another urban Indian organization which is situated in the same urban center as the urban 

Indian organization whose contract or grant is not renewed under 

this section. 

ø(d) In determining whether to renew a contract or grant with 

an urban Indian organization under section 503 which has completed performance of a contract or grant under section 504, the 

Secretary shall review the records of the urban Indian organization, the reports submitted under section 507, and, in the case of 

a renewal of a contract or grant under section 503, shall consider 

the results of the onsite evaluations conducted under subsection 

(b). 

øOTHER CONTRACT AND GRANT REQUIREMENTS

øSEC. 506. (a) Contracts with urban Indian organizations entered 

into pursuant to this title shall be in accordance with all Federal 

contracting laws and regulations except that, in the discretion of 

the Secretary, such contracts may be negotiated without advertising and need not conform to the provisions of the Act of August 

24, 1935 (40 U.S.C. 270a, et seq.). 

ø(b) Payments under any contracts or grants pursuant to this 

title 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 title. 

ø(c) Notwithstanding any provision of law to the contrary, the 

Secretary may, at the request or consent of an urban Indian organization, revise or amend any contract entered into by the Secretary with such organization under this title as necessary to carry 

out the purposes of this title. 

ø(d) In connection with any contract or grant entered into pursuant to this title, 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. 

ø(e) Contracts with, or grants to, urban Indian organizations and 

regulations adopted pursuant to this title shall include provisions 


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to assure the fair and uniform provision to urban Indians of services and assistance under such contracts or grants by such organizations. 

ø(f) Urban Indians, as defined in section 4(f) of this Act, shall be 

eligible for health care or referral services provided pursuant to 

this title. 

øREPORTS AND RECORDS

øSEC. 507. (a) For each fiscal year during which an urban Indian 

organization receives or expends funds pursuant to a contract entered into, or a grant received, pursuant to this title, such organization shall submit to the Secretary a quarterly report including—

ø(1) in the case of a contract or grant under section 503, information gathered pursuant to clauses (10) and (11) of subsection (a) of such section; 

ø(2) information on activities conducted by the organization 

pursuant to the contract or grant; 

ø(3) an accounting of the amounts and purposes for which 

Federal funds were expended; and 

ø(4) such other information as the Secretary may request. 

ø(b) The reports and records of the urban Indian organization 

with respect to a contract or grant under this title shall be subject 

to audit by the Secretary and the Comptroller General of the 

United States. 

ø(c) The Secretary shall allow as a cost of any contract or grant 

entered into under section 503 the cost of an annual private audit 

conducted by a certified public accountant. 

ø(d)(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 title; 

ø(C) areas of unmet needs in urban areas served under this 

title; and 

ø(D) areas of unmet needs in urban areas not served under 

this title. 

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. 

øLIMITATION ON CONTRACT AUTHORITY

øSEC. 508. The authority of the Secretary to enter into contracts 

under this title shall be to the extent, and in an amount, provided 

for in appropriation Acts. 


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øFACILITIES RENOVATION

øSEC. 509. The Secretary may make funds available to contractors or grant recipients under this title for minor renovations to facilities, including leased facilities, to assist such contractors or 

grant recipients in meeting or maintaining the Joint Commission 

for Accreditation of Health Care Organizations (JCAHO) standards. 

øURBAN HEALTH PROGRAMS BRANCH

øSEC. 510. (a) ESTABLISHMENT.—There is hereby established 

within the Service a Branch of Urban Health Programs which shall 

be responsible for carrying out the provisions of this title and for 

providing central oversight of the programs and services authorized 

under this title. 

ø(b) STAFF, SERVICES, AND EQUIPMENT.—The 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. 

øGRANTS FOR ALCOHOL AND SUBSTANCE ABUSE RELATED SERVICES

øSEC. 511. (a) GRANTS.—The Secretary may make grants for the 

provision of health-related services in prevention of, treatment of, 

rehabilitation of, or school and community-based education in, alcohol and substance abuse in urban centers to those urban Indian organizations with whom the Secretary has entered into a contract 

under this title or under section 201. 

ø(b) GOALS OF GRANT.—Each grant made pursuant to subsection 

(a) 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. 

ø(c) CRITERIA.—The Secretary shall establish criteria for the 

grants made under subsection (a), including criteria relating to 

the—

ø(1) size of the urban Indian population; 

ø(2) accessibility to, and utilization of, other health resources 

available to such population; 

ø(3) duplication of existing Service or other Federal grants or 

contracts; 

ø(4) capability of the organization to adequately perform the 

activities required under the grant; 

ø(5) satisfactory performance standards for the organization 

in meeting the goals set forth in such grant, which standards 

shall be negotiated and agreed to between the Secretary and 

the grantee on a grant-by-grant basis; and 

ø(6) identification of need for services. 

The Secretary shall develop a methodology for allocating grants 

made pursuant to this section based on such criteria. 

ø(d) TREATMENT OF FUNDS RECEIVED BY URBAN INDIAN ORGANIZATIONS.—Any funds received by an urban Indian organization 

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habilitation shall be subject to the criteria set forth in subsection 

(c). 

øTREATMENT OF CERTAIN DEMONSTRATION PROJECTS

øSEC. 512. (a) Notwithstanding any other provision of law, the 

Oklahoma City Clinic demonstration project and 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 for the term 

of such projects. The Secretary shall provide assistance to such 

projects in the development of resources and equipment and facility 

needs. 

ø(b) The Secretary shall submit to the President, for inclusion in 

the report required to be submitted to the Congress under section 

801 for fiscal year 1999, a report on the findings and conclusions 

derived from the demonstration projects specified in subsection (a). 

ø(c) In addition to the amounts made available under section 514 

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. 

øURBAN NIAAA TRANSFERRED PROGRAMS

øSEC. 513. (a) The Secretary shall, within the Branch of Urban 

Health Programs of the Service, make grants or enter into contracts for the administration of urban Indian alcohol programs that 

were originally established under the National Institute on Alcoholism and Alcohol Abuse (hereafter in this section referred to as 

‘‘NIAAA’’) and transferred to the Service. 

ø(b) 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 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. 

ø(c) Urban Indian organizations that operate Indian alcohol programs originally funded under NIAAA and subsequently transferred to the Service are eligible for grants or contracts under this 

section. 

ø(d) 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. 

ø(e) The Secretary shall evaluate and report to the Congress on 

the activities of programs funded under this section at least every 

5 years. 

øAUTHORIZATION OF APPROPRIATIONS

øSEC. 514. There are authorized to be appropriated such sums as 

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

carry out this title. 


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øTITLE VI—ORGANIZATIONAL IMPROVEMENTS 

øESTABLISHMENT OF THE INDIAN HEALTH SERVICE AS AN AGENCY OF

THE PUBLIC HEALTH SERVICE

øSEC. 601. (a) 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 tribes, 

as are or may be hereafter provided by Federal statute or treaties, 

there is established within the Public Health Service of the Department of Health and Human Services the Indian Health Service. 

The Indian Health Service shall be administered by a Director, who 

shall be appointed by the President, by and with the advice and 

consent of the Senate. The Director of the Indian Health Service 

shall report to the Secretary through 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, 1993, 

the term of service of the Director shall be 4 years. A Director may 

serve more than 1 term. 

ø(b) The Indian Health Service shall be an agency within the 

Public Health Service of the Department of Health and Human 

Services, and shall not be an office, component, or unit of any other 

agency of the Department. 

ø(c) The Secretary shall carry out through the Director of the Indian Health Service— ø(1) all functions which were, on the day before the date of 

enactment of the Indian Health Care Amendments of 1988, 

carried out by or under the direction of the individual serving 

as Director of the Indian Health Service on such day; 

ø(2) 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; 

ø(3) all health programs under which health care is provided 

to Indians based upon their status as Indians which are administered by the Secretary, including (but not limited to) programs under—

ø(A) this Act; 

ø(B) the Act of November 2, 1921 (25 U.S.C. 13); 

ø(C) the Act of August 5, 1954 (42 U.S.C. 2001, et seq.); 

ø(D) the Act of August 16, 1957 (42 U.S.C. 2005 et seq.); 

and 

ø(E) the Indian Self-Determination Act (25 U.S.C. 450f, 

et seq.); and 

ø(4) all scholarship and loan functions carried out under title 

I. 

ø(d)(1) The Secretary, acting through the Director of the Indian 

Health Service, shall have the authority—

ø(A) except to the extent provided in paragraph (2), to appoint and compensate employees for the Service in accordance 

with title 5, United States Code; 

ø(B) to enter into contracts for the procurement of goods and 

services to carry out the functions of the Service; and 

ø(C) to manage, expend, and obligate all funds appropriated 

for the Service. 


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ø(2) Notwithstanding any other law, the provisions of section 12 

of the Act of June 18, 1934 (48 Stat. 986; 25 U.S.C. 472), shall 

apply to all personnel actions taken with respect to new positions 

created within the Service as a result of its establishment under 

subsection (a). 

øAUTOMATED MANAGEMENT INFORMATION SYSTEM

øSEC. 602. (a)(1) The Secretary shall establish an automated 

management information system for the Service. 

ø(2) The information system established under paragraph (1) 

shall include—

ø(A) a financial management system, 

ø(B) a patient care information system for each area served 

by the Service, 

ø(C) a privacy component that protects the privacy of patient 

information held by, or on behalf of, the Service, and 

ø(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 area office of 

the Service. 

ø(b)(1) The Secretary shall provide each Indian tribe and tribal 

organization that provides health services under a contract entered 

into with the Service under the Indian Self-Determination Act 

automated management information systems which—

ø(A) meet the management information needs of such Indian 

tribe or tribal organization with respect to the treatment by 

the Indian tribe or tribal organization of patients of the Service, and 

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. 

ø(c) 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. 

øAUTHORIZATION OF APPROPRIATIONS

øSEC. 603. There are authorized to be appropriated such sums as 

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

carry out this title. 

øTITLE VII—SUBSTANCE ABUSE PROGRAMS 

øINDIAN HEALTH SERVICE RESPONSIBILITIES

øSEC. 701. The Memorandum of Agreement entered into pursuant to section 4205 of the Indian Alcohol and Substance Abuse Prevention and Treatment Act of 1986 (25 U.S.C. 2411) shall include 

specific provisions pursuant to which the Service shall assume responsibility for—


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ø(1) the determination of the scope of the problem of alcohol 

and substance abuse among Indian people, 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; 

ø(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 

ø(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. 

øINDIAN HEALTH SERVICE PROGRAM

øSEC. 702. (a) COMPREHENSIVE PREVENTION AND TREATMENT

PROGRAM.—(1) The Secretary, acting through the Service, shall 

provide a program of comprehensive alcohol and substance abuse 

prevention and treatment which shall include— ø(A) prevention, through educational intervention, in Indian 

communities; 

ø(B) acute detoxification and treatment; 

ø(C) community-based rehabilitation; 

ø(D) community education and involvement, including extensive training of health care, educational, and community-based 

personnel; and 

ø(E) residential treatment programs for pregnant and post 

partum women and their children. 

ø(2) The target population of such program shall be members of 

Indian tribes. Efforts to train and educate key members of the Indian community shall target employees of health, education, judicial, law enforcement, legal, and social service programs. 

ø(b) CONTRACT HEALTH SERVICES.—(1) The Secretary, acting 

through the Service, may enter into contracts with public or private 

providers of alcohol and substance abuse treatment services for the 

purpose of assisting the Service in carrying out the program required under subsection (a). 

ø(2) In carrying out this subsection, the Secretary shall provide 

assistance to Indian tribes to develop criteria for the certification 

of alcohol and substance abuse service providers and accreditation 

of service facilities which meet minimum standards for such services and facilities as may be determined pursuant to section 

4205(a)(3) of the Indian Alcohol and Substance Abuse Prevention 

and Treatment Act of 1986 (25 U.S.C. 2411(a)(3)). 

ø(c) GRANTS FOR MODEL PROGRAM.—(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; 


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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 801 for 

fiscal year 1995 an evaluation of the demonstration project established under paragraph (1). 

øINDIAN WOMEN TREATMENT PROGRAMS

øSEC. 703. (a) The Secretary may make grants to Indian tribes 

and tribal organizations to develop and implement a comprehensive 

alcohol and substance abuse program of prevention, intervention, 

treatment, and relapse prevention services that specifically addresses the cultural, historical, social, and child care needs of Indian women, regardless of age. 

ø(b) Grants made pursuant to this section may be used to— ø(1) develop and provide community training, education, and 

prevention programs for Indian women relating to alcohol and 

substance abuse issues, including fetal alcohol syndrome and 

fetal alcohol effect; 

ø(2) identify and provide appropriate counseling, advocacy, 

support, and relapse prevention to Indian women and their 

families; and 

ø(3) develop prevention and intervention models for Indian 

women which incorporate traditional healers, cultural values, 

and community and family involvement. 

ø(c) The Secretary shall establish criteria for the review and approval of applications for grants under this section. 

ø(d)(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 title V. 

øINDIAN HEALTH SERVICE YOUTH PROGRAM

øSEC. 704. (a) DETOXIFICATION AND REHABILITATION.—The Secretary shall develop and implement a program for acute detoxification and treatment for Indian youth who 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. These regional centers shall be integrated with the 

intake and rehabilitation programs based in the referring Indian 

community. 

ø(b) TREATMENT CENTERS OR FACILITIES.—(1) The Secretary 

shall construct, renovate, or, as necessary, purchase, and appropriately staff and operate, a youth regional treatment center in 

each area under the jurisdiction of an area office. For the purposes 

of this subsection, the area offices of the Service in Tucson and 

Phoenix, Arizona, shall be considered one area office and the area 

office in California shall be considered to be two area offices, one 


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office whose jurisdiction shall be considered to encompass the 

northern area of the State of California, and one office whose jurisdiction shall be considered to encompass the remainder of the State 

of California. 

ø(2) 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). 

ø(3) 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 tribes to be served by 

such center. 

ø(4)(A) Notwithstanding any other provision of this title, the Secretary may, from amounts authorized to be appropriated for the 

purposes of carrying out this section, make funds available to— ø(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 

ø(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 4(l) of the Indian SelfDetermination and Education Assistance Act (25 U.S.C. 

450b(l)). 

ø(B) Until additional residential youth treatment facilities are established in Alaska pursuant to this section, the facilities specified 

in subparagraph (A) shall make every effort to provide services to 

all eligible Indian youth residing in such State. 

ø(c) FEDERALLY OWNED STRUCTURES.—

ø(1) The Secretary, acting through the Service, shall, in consultation with Indian tribes—

ø(A) identify and use, where appropriate, federally 

owned structures suitable as local residential or regional 

alcohol and substance abuse treatment centers for Indian 

youth; and 

ø(B) establish guidelines for determining the suitability 

of any such federally owned structure to be used as a local 

residential or regional alcohol and substance abuse treatment center for Indian youth. 

ø(2) 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. 

ø(d) REHABILITATION AND AFTERCARE SERVICES.—

ø(1) The Secretary, in cooperation with the Secretary of the 

Interior, shall develop and implement within each Service service unit community-based rehabilitation and follow-up services 

for Indian youth who are alcohol or substance abusers which 

are designed to integrate long-term treatment and to monitor 

and support the Indian youth after their return to their home 

community. 

ø(2) Services under paragraph (1) shall be administered 

within each service unit by trained staff within the community 

who can assist the Indian youth in continuing development of 

self-image, positive problem-solving skills, and nonalcohol or 


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substance abusing behaviors. Such staff shall include alcohol 

and substance abuse counselors, mental health professionals, 

and other health professionals and paraprofessionals, including 

community health representatives. 

ø(e) INCLUSION OF FAMILY IN YOUTH TREATMENT PROGRAM.—In 

providing the treatment and other services to Indian youth authorized by this section, the Secretary shall provide for the inclusion of 

family members of such youth 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 (d) 

shall be used for outpatient care of adult family members related 

to the treatment of an Indian youth under that subsection. 

ø(f) MULTIDRUG ABUSE STUDY.—(1) The Secretary shall conduct 

a study to determine the incidence and prevalence of the abuse of 

multiple forms of drugs, including alcohol, among Indian youth residing on Indian reservations and in urban areas and the interrelationship of such abuse with the incidence of mental illness 

among such youth. 

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 the date of the enactment of this section. 

øTRAINING AND COMMUNITY EDUCATION

øSEC. 705. (a) COMMUNITY EDUCATION.—The Secretary, in cooperation with the Secretary of the Interior, shall develop and implement within each service unit 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 in alcohol and 

substance abuse to political leaders, tribal judges, law enforcement 

personnel, members of tribal health and education boards, and 

other critical members of each tribal community. 

ø(b) TRAINING.—The Secretary shall, either directly or by contract, provide instruction in the area of alcohol and substance 

abuse, including instruction in crisis intervention and family relations in the context of alcohol and substance abuse, youth alcohol 

and substance abuse, and the causes and effects of fetal alcohol 

syndrome 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). 

ø(c) COMMUNITY-BASED TRAINING MODELS.—In carrying out the 

education and training programs required by this section, the Secretary, acting through the Service and in consultation with tribes 

and Indian alcohol and substance abuse prevention experts, shall 

develop and provide community-based training models. Such models shall address—

ø(1) the elevated risk of alcohol and substance abuse faced 

by children of alcoholics; 

ø(2) the cultural and multigenerational aspects of alcohol 

and substance abuse prevention and recovery; and 


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ø(3) community-based and multidisciplinary strategies for 

preventing and treating alcohol and substance abuse. 

øGALLUP ALCOHOL AND SUBSTANCE ABUSE TREATMENT CENTER

øSEC. 706. (a) GRANTS FOR RESIDENTIAL TREATMENT.—The 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.—Grants made pursuant to this section shall (to the extent appropriations are made available) be used 

to—

ø(1) provide at least 15 residential beds each year for adult 

long-term treatment, including beds for specialized services 

such as polydrug abusers, dual diagnosis, and specialized services for women with fetal alcohol syndrome children; 

ø(2) establish clinical assessment teams consisting of a clinical psychologist, a part-time addictionologist, a master’s level 

assessment counselor, and a certified medical records technician which shall be responsible for conducting individual assessments and matching Indian clients with the appropriate 

available treatment; 

ø(3) provide at least 12 beds for an adolescent shelterbed 

program in the city of Gallup, New Mexico, which shall serve 

as a satellite facility to the Acoma/Canoncito/Laguna Hospital 

and the adolescent center located in Shiprock, New Mexico, for 

emergency crisis services, assessment, and family intervention; 

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.—The 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). 

ø(d) AUTHORIZATION OF APPROPRIATIONS.—There are authorized 

to be appropriated, for each of fiscal years 1996 through 2000, such 

sums as may be necessary to carry out subsection (b). 

øREPORTS

øSEC. 707. (a) COMPILATION OF DATA.—The 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, 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. 


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Such report shall include the type of assistance provided and the 

disposition of these cases. 

ø(b) REFERRAL OF DATA.—The data compiled under subsection (a) 

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 4206 of the Indian Alcohol and 

Substance Abuse Prevention and Treatment Act of 1986 (25 U.S.C. 

2471 et seq.). 

ø(c) COMPREHENSIVE REPORT.—Each service unit director shall 

be responsible for assembling the data compiled under this section 

and section 4214 of the Indian Alcohol and Substance Abuse Prevention and Treatment Act of 1986 (25 U.S.C. 2434) 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. 

øFETAL ALCOHOL SYNDROME AND FETAL ALCOHOL EFFECT GRANTS

øSEC. 708. (a)(1) The Secretary may make grants to Indian tribes 

and tribal organizations to establish fetal alcohol syndrome and 

fetal alcohol effect programs as provided in this section for the purposes of meeting the health status objectives specified in section 

3(b). 

ø(2) Grants made pursuant to this section shall be used to— ø(A) develop and provide community and in-school training, 

education, and prevention programs relating to FAS and FAE; 

ø(B) identify and provide alcohol and substance abuse treatment to high-risk women; 

ø(C) identify and provide appropriate educational and vocational support, counseling, advocacy, and information to FAS 

and FAE affected persons and their families or caretakers; 

ø(D) develop and implement counseling and support programs in schools for FAS and FAE affected children; 

ø(E) develop prevention and intervention models which incorporate traditional healers, cultural values and community 

involvement; 

ø(F) develop, print, and disseminate education and prevention materials on FAS and FAE; and 

ø(G) develop and implement, through the tribal consultation 

process, culturally sensitive assessment and diagnostic tools for 

use in tribal and urban Indian communities. 

ø(3) The Secretary shall establish criteria for the review and approval of applications for grants under this section. 

ø(b) The Secretary, acting through the Service, shall—

ø(1) develop an annual plan for the prevention, intervention, 

treatment, and aftercare for those affected by FAS and FAE in 

Indian communities; 

ø(2) conduct a study, directly or by contract with any organization, entity, or institution of higher education with significant knowledge of FAS and FAE and Indian communities, of 

the special educational, vocational, school-to-work transition, 

and independent living needs of adolescent and adult Indians 

and Alaska Natives with FAS or FAE; and 

ø(3) establish a national clearinghouse for prevention and 

educational materials and other information on FAS and FAE 


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effect in Indian and Alaska Native communities and ensure access to clearinghouse materials by any Indian tribe or urban 

Indian organization. 

ø(c) The Secretary shall establish a task force to be known as the 

FAS/FAE Task Force to advise the Secretary in carrying out subsection (b). Such task force shall be composed of representatives 

from the National Institute on Drug Abuse, the National Institute 

on Alcohol and Alcoholism, the Office of Substance Abuse Prevention, the National Institute of Mental Health, the Service, the Office of Minority Health of the Department of Health and Human 

Services, the Administration for Native Americans, the Bureau of 

Indian Affairs, Indian tribes, tribal organizations, urban Indian 

communities, and Indian FAS/FAE experts. 

ø(d) The Secretary, acting through the Substance Abuse and 

Mental Health Services Administration, shall make grants to Indian tribes, tribal organizations, universities 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 

aftercare for Indians and urban Indians affected by FAS or FAE. 

ø(e)(1) The Secretary shall submit to the President, for inclusion 

in each report required to be transmitted to the Congress under 

section 801, 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 (3)(d) with respect to the health status 

objective specified in section (3)(b)(27), the following: 

ø(A) The progress of implementing a uniform assessment 

and diagnostic methodology in Service and tribally based service delivery systems. 

ø(B) The incidence of FAS and FAE babies born for all births 

by reservation and urban-based sites. 

ø(C) The prevalence of FAS and FAE affected Indian persons 

in Indian communities, their primary means of support, and 

recommendations to improve the support system for these individuals and their families or caretakers. 

ø(D) The level of support received from the entities specified 

in subsection (c) in the area of FAS and FAE. 

ø(E) The number of inpatient and outpatient substance 

abuse treatment resources which are specifically designed to 

meet the unique needs of Indian women, and the volume of 

care provided to Indian women through these means. 

ø(F) Recommendations regarding the prevention, intervention, and appropriate vocational, educational and other support 

services for FAS and FAE affected individuals in Indian communities. 

ø(2) The Secretary may contract the production of this report to 

a national organization specifically addressing FAS and FAE in Indian communities. 

ø(f)(1) There are authorized to be appropriated to carry out this 

section $22,000,000 for fiscal year 1993 and such sums as may be 

necessary for each of the fiscal years 1994, 1995, 1996, 1997, 1998, 

1999, and 2000. 

ø(2) Ten percent of the funds appropriated pursuant to this section shall be used to make grants to urban Indian organizations 

funded under title V. 


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øPUEBLO SUBSTANCE ABUSE TREATMENT PROJECT FOR SAN JUAN

PUEBLO, NEW MEXICO

øSEC. 709. The 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. 

øTHUNDER CHILD TREATMENT CENTER

øSEC. 710. (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), 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) shall be used for administrative purposes. 

øSUBSTANCE ABUSE COUNSELOR EDUCATION DEMONSTRATION

PROJECT

øSEC. 711. (a) The 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) Funds 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) A 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) Not later than 180 days after the date of the enactment of 

this section, the Secretary, after consultation with Indian tribes 

and administrators of accredited tribally controlled community colleges, tribally controlled postsecondary vocational institutions, and 

eligible community colleges, shall develop and issue criteria for the 

review and approval of applications for funding (including applications for renewals of funding) under this section. Such criteria shall 

ensure that demonstration projects established under this section 

promote the development of the capacity of such entities to educate 

substance abuse counselors. 

ø(e) 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. 

ø(f) The Secretary shall submit to the President, for inclusion in 

the report which is required to be submitted under section 801 for 

fiscal year 1999, a report on the findings and conclusions derived 

from the demonstration projects conducted under this section. 


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ø(g) For the purposes of this section, the following definitions 

apply: 

ø(1) The term ‘‘educational curriculum’’ means one or more 

of the following: 

ø(A) Classroom education. 

ø(B) Clinical work experience. 

ø(C) Continuing education workshops. 

ø(2) The term ‘‘eligible community college’’ means an accredited community college that—

ø(i) is located on or near an Indian reservation; 

ø(ii) has entered into a cooperative agreement with 

the governing body of such Indian reservation to carry 

out a demonstration project under this section; and 

ø(iii) has a student enrollment of not less than 10 

percent Indian. 

ø(3) The term ‘‘tribally controlled community college’’ has the 

meaning given such term in section 2(a)(4) of the Tribally Controlled Community College Assistance Act of 1978 (25 U.S.C. 

1801(a)(4)). 

ø(4) The term ‘‘tribally controlled postsecondary vocational 

institution’’ has the meaning given such term in section 390(2) 

of the Tribally Controlled Vocational Institutions Support Act 

of 1990 (20 U.S.C. 2397h(2)). 

ø(h) There are authorized to be appropriated for each of fiscal 

years 1996 through 2000, such sums as may be necessary to carry 

out the purposes of this section. Such sums shall remain available 

until expended. 

øGILA RIVER ALCOHOL AND SUBSTANCE ABUSE TREATMENT FACILITY

øSEC. 712. (a) The 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) The center established pursuant to this section shall be 

known as the ‘‘Regional Youth Alcohol and Substance Abuse Prevention and Treatment Center’’. 

ø(c) The 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. 

øALASKA NATIVE DRUG AND ALCOHOL ABUSE DEMONSTRATION

PROJECT

øSEC. 713. (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 


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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 

801 for fiscal year 1995 an evaluation of the demonstration project 

established under subsection (a). 

øAUTHORIZATION OF APPROPRIATIONS

øSEC. 714. Except as provided in sections 703, 706, 708, 710, and 

711, 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 title. 

øTITLE VIII—MISCELLANEOUS 

øREPORTS

øSEC. 801. The President shall, at the time the budget is submitted under section 1105 of title 31, United States Code, for each 

fiscal year transmit to the Congress a report containing—

ø(1) a report on the progress made in meeting the objectives 

of this Act, including a review of programs established or assisted pursuant to this Act and an assessment and recommendations of additional programs or additional assistance 

necessary to, at a minimum, provide health services to Indians, 

and ensure a health status for Indians, which are at a parity 

with the health services available to and the health status of, 

the general population; 

ø(2) a report on whether, and to what extent, new national 

health care programs, benefits, initiatives, or financing systems have had an impact on the purposes of this Act and any 

steps that the Secretary may have taken to consult with Indian 

tribes to address such impact; 

ø(3) a report on the use of health services by Indians—

ø(A) on a national and area or other relevant geographical basis; 

ø(B) by gender and age; 

ø(C) by source of payment and type of service; and 

ø(D) comparing such rates of use with rates of use 

among comparable non-Indian populations. 

ø(4) a separate statement which specifies the amount of 

funds requested to carry out the provisions of section 201; 

ø(5) a separate statement of the total amount obligated or 

expended in the most recently completed fiscal year to achieve 

each of the objectives described in section 814, relating to infant and maternal mortality and fetal alcohol syndrome; 

ø(6) the reports required by sections 3(d), 108(n), 203(b), 

209(j), 301(c), 302(g), 305(a)(3), 403, 708(e), and 817(a), and 

822(f); 

ø(7) for fiscal year 1995, the report required by sections 

702(c)(3) and 713(b); 

ø(8) for fiscal year 1997, the interim report required by section 307(h)(1); and 

ø(9) for fiscal year 1999, the reports required by sections 

307(h)(2), 512(b), 711(f), and 821(g). 


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øREGULATIONS

øSEC. 802. Prior to any revision of or amendment to rules or regulations promulgated pursuant to this Act, 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. 

øLEASES WITH INDIAN TRIBES

øSEC. 804. (a) Notwithstanding any other provision of law, the 

Secretary is authorized, in carrying out the purposes of this Act, 

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); 

facilities used for the administration and delivery of health services 

by the Service or by programs operated by Indian tribes or tribal 

organizations to compensate such Indian tribes or tribal organizations for costs associated with the use of such facilities for such 

purposes. Such costs include rent, depreciation based on the useful 

life of the building, principal and interest paid or accrued, operation and maintenance expenses, and other expenses determined 

by regulation to be allowable. 

øAVAILABILITY OF FUNDS

øSEC. 805. The funds appropriated pursuant to this Act shall remain available until expended. 

øLIMITATION ON USE OF FUNDS APPROPRIATED TO THE INDIAN

HEALTH SERVICE

øSEC. 806. Any limitation on the use of funds contained in an Act 

providing appropriations for the Department of 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 Indian Health Service. 

øNUCLEAR RESOURCE DEVELOPMENT HEALTH HAZARDS

øSEC. 807. (a) The 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 communities as a result of nuclear 

resource development. Such study shall include—


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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 powerplant 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 the date of the enactment of this section that directly or indirectly relate to the activities, practices, and conditions affecting the health or safety 

of such Indians; and 

ø(5) the efforts that have been made by Federal and State 

agencies and mining and milling companies to effectively carry 

out an education program for such Indians regarding the 

health and safety hazards of such nuclear resource development. 

ø(b) Upon 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). 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 radiations, 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) The Secretary and the Service shall submit to Congress the 

study prepared under subsection (a) no later than the date eighteen months after the date of enactment of this section. The health 

care plan prepared under subsection (b) shall be submitted in a report no later than the date one year after the date that 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. 

ø(d)(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 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 


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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) In the case of any Indian who—

ø(1) as a result of employment in or near a uranium mine 

or mill, suffers from a work related illness or condition; 

ø(2) is eligible to receive diagnosis and treatment services 

from a service facility; and 

ø(3) by reason of such Indian’s employment, is entitled to 

medical care at the expense of such mine or mill operator; the 

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. 

øARIZONA AS A CONTRACT HEALTH SERVICE DELIVERY AREA

øSEC. 808. (a) For 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) The 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). 

øELIGIBILITY OF CALIFORNIA INDIANS

øSEC. 809. (a)(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 the date 

of enactment of the Indian Health Care Amendments of 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), and the number of Indians 

described in subsection (b)(3), 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. 


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ø(2) The report required under paragraph (1) shall be prepared 

by the Secretary—

ø(A) in consultation with the Secretary of the Interior, and 

ø(B) with the assistance of the tribal health programs providing services to the Indians described in paragraph (2) or (3) 

of subsection (b) who are not members of any Indian tribe recognized by the Federal Government. 

ø(b) Until such time as any subsequent law may otherwise provide, the following California Indians shall be eligible for health 

services provided by the Service: 

ø(1) Any member of a federally recognized Indian tribe. 

ø(2) Any descendant of an Indian who was residing in California on June 1, 1852, but only if such descendant—

ø(A) is living in California, 

ø(B) is a member of the Indian community served by a 

local program of the Service, and 

ø(C) is regarded as an Indian by the community in 

which such descendant lives. 

ø(3) Any Indian who holds trust interests in public domain, 

national forest, or Indian reservation allotments in California. 

ø(4) Any Indian in California who is listed on the plans for 

distribution of the assets of California rancherias and reservations under the Act of August 18, 1958 (72 Stat. 619), and any 

descendant of such an Indian. 

ø(c) 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. 

øCALIFORNIA AS A CONTRACT HEALTH SERVICE DELIVERY AREA

øSEC. 810. 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 Indians in such State. 

øCONTRACT HEALTH FACILITIES

øSEC. 811. The 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—

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, 

on the same basis as such funds are provided to programs and facilities operated directly by the Service. 


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øNATIONAL HEALTH SERVICE CORPS

øSEC. 812. The 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, or 

ø(2) withdraw funding used to support such member, 

unless the Secretary, acting through the Service, has ensured that 

the Indians receiving services from such member will experience no 

reduction in services. 

øHEALTH SERVICES FOR INELIGIBLE PERSONS

øSEC. 813. (a)(1) Any individual who—

ø(A) has not attained 19 years of age, 

ø(B) is the natural or adopted child, step-child, foster-child, 

legal ward, or orphan of an eligible Indian, and 

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 one year after the date such disability has been 

removed. 

ø(2) Any spouse of an eligible Indian who is not an Indian, or 

who is of Indian descent but not otherwise eligible for the health 

services provided by the Service, shall be eligible for such health 

services if all of such spouses are made eligible, as a class, by an 

appropriate resolution of the governing body of the Indian tribe of 

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. 

ø(b)(1)(A) The Secretary is authorized to provide health services 

under this subsection through health facilities operated directly by 

the Service to individuals who reside within the service area of a 

service unit and who are not eligible for such health services under 

any other subsection of this section or under any other provision 

of law if—

ø(i) the Indian tribe (or, in the case of a multi-tribal service 

area, all the Indian tribes) served by such service unit requests 

such provision of health services to such individuals, and 

ø(ii) the Secretary and the Indian tribe or tribes have jointly 

determined that—

ø(I) the provision of such health services will not result 

in a denial or diminution of health services to eligible Indians, and 

ø(II) there is no reasonable alternative health facility or 

services, within or without the service area of such service 


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unit, available to meet the health needs of such individuals. 

ø(B) In the case of health facilities operated under a contract entered into under the Indian Self-Determination Act, the governing 

body of the Indian tribe or tribal organization providing health 

services under such contract is authorized to determine whether 

health services should be provided under such contract to individuals who are not eligible for such health services under any other 

subsection of this section or under any other provision of law. In 

making such determinations, the governing body of the Indian tribe 

or tribal organization shall take into account the considerations described in subparagraph (A)(ii). 

ø(2)(A) Persons receiving health services provided by the Service 

by 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 1880(c) of the Social 

Security Act, section 402(a) of this Act, or any other provision of 

law, amounts collected under this subsection, including medicare or 

medicaid reimbursements under titles XVIII and XIX of the Social 

Security Act, shall be credited to the account of the facility providing the service and shall be used solely for the provision of 

health services within that facility. Amounts collected under this 

subsection shall be available for expenditure within such facility for 

not to exceed one fiscal year after the fiscal year in which collected. 

ø(B) Health services may be provided by the Secretary through 

the Service under this subsection to an indigent person who would 

not be 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 person. 

ø(3)(A) In the case of a service area which serves only one Indian 

tribe, the authority of the Secretary to provide health services 

under paragraph (1)(A) shall terminate at the end of the fiscal year 

succeeding the fiscal year in which the governing body of the Indian tribe revokes its concurrence to the provision of such health 

services. 

ø(B) In the case of a multi-tribal service area, the authority of 

the Secretary to provide health services under paragraph (1)(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 tribes 

in the service area revoke their concurrence to the provision of 

such health services. 

ø(c) 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 subsection of this section or 

under any other provision of law in order to—

ø(1) achieve stability in a medical emergency, 

ø(2) prevent the spread of a communicable disease or otherwise deal with a public health hazard, 


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ø(3) provide care to non-Indian women pregnant with an eligible Indian’s child for the duration of the pregnancy through 

post partum, or 

ø(4) provide care to immediate family members of an eligible 

person if such care is directly related to the treatment of the 

eligible person. 

ø(d) Hospital privileges in health facilities operated and maintained by the Service or operated under a contract entered into 

under the Indian Self-Determination Act may be extended to nonService health care practitioners who provide services to persons 

described in subsection (a) or (b). Such non-Service health care 

practitioners may be regarded 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 persons as a part of the conditions under which 

such hospital privileges are extended. 

ø(e) For purposes of this section, the term ‘‘eligible Indian’’

means any Indian who is eligible for health services provided by 

the Service without regard to the provisions of this section. 

øINFANT AND MATERNAL MORTALITY; FETAL ALCOHOL SYNDROME

øSEC. 814. By no later than January 1, 1990, the Secretary shall 

develop and begin implementation of a plan to achieve the following objectives by January 1, 1994: 

ø(1) reduction of the rate of Indian infant mortality in each 

area office of the Service to the lower of—

ø(A) twelve deaths per one thousand live births, or 

ø(B) the rate of infant mortality applicable to the United 

States population as a whole; 

ø(2) reduction of the rate of maternal mortality in each area 

office of the Service to the lower of—

ø(A) five deaths per one hundred thousand live births, or 

ø(B) the rate of maternal mortality applicable to the 

United States population as a whole; and 

ø(3) reduction of the rate of fetal alcohol syndrome among 

Indians served by, or on behalf of, the Service to one per one 

thousand live births. 

øCONTRACT HEALTH SERVICES FOR THE TRENTON SERVICE AREA

øSEC. 815. (a) 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. 

ø(b) 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. 


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øINDIAN HEALTH SERVICE AND DEPARTMENT OF VETERANS AFFAIRS

HEALTH FACILITIES AND SERVICES SHARING

øSEC. 816. (a) The 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), 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) 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—

ø(1) the priority access of any Indian to health care services 

provided through the Indian Health Service; 

ø(2) the quality of health care services provided to any Indian through the Indian Health Service; 

ø(3) the priority access of any veteran to health care services 

provided by the Department of Veterans Affairs; 

ø(4) the quality of health care services provided to any veteran by the Department of Veterans Affairs; 

ø(5) the eligibility of any Indian to receive health services 

through the Indian Health Service; or 

ø(6) the eligibility of any Indian who is a veteran to receive 

health services through the Department of Veterans Affairs. 

ø(c)(1) Not later than December 23, 1988, the Director of the Indian Health Service and the Secretary of Veterans Affairs shall implement an agreement under which—

ø(A) individuals in the vicinity of Roosevelt, Utah, who are 

eligible for health care from the Department of Veterans Affairs could obtain health care services at the facilities of the Indian Health Service located at Fort Duchesne, Utah; and 

ø(B) individuals eligible for health care from the Indian 

Health Service at Fort Duchesne, Utah, could obtain health 

care services at the Department of Veterans Affairs medical 

center located in Salt Lake City, Utah. 

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) Nothing 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). 

øREALLOCATION OF BASE RESOURCES

øSEC. 817. (a) 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 service unit may be implemented only after the Secretary has submitted to the President, for 

inclusion in the report required to be transmitted to the Congress 

under section 801, a report on the proposed change in allocation of 

funding, including the reasons for the change and its likely effects. 

ø(b) Subsection (a) shall not apply if the total amount appropriated to the Service for a fiscal year is less than the amount appropriated to the Service for previous fiscal year. 


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øDEMONSTRATION PROJECTS FOR TRIBAL MANAGEMENT OF HEALTH

CARE SERVICES

øSEC. 818. (a)(1) The Secretary, acting through the Service, shall 

make grants to Indian tribes to establish demonstration projects 

under which the Indian tribe will develop and test a phased approach to assumption by the Indian tribe of the health care delivery system of the Service for members of the Indian tribe living on 

or near the reservations of the Indian tribe through the use of 

Service, tribal, and private sector resources. 

ø(2) A grant may be awarded to an Indian tribe under paragraph 

(1) only if the Secretary determines that the Indian tribe has the 

administrative and financial capabilities necessary to conduct a 

demonstration project described in paragraph (1). 

ø(b) During the period in which a demonstration project established under subsection (a) 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 (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)) shall 

apply. 

ø(c) The 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), but only if such waiver does not 

diminish or endanger the delivery of health care services to Indians. 

ø(d)(1) The demonstration project established under subsection 

(a) 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) and 

shall submit to the Congress a report on such evaluations and demonstration projects. 

ø(e)(1) The Secretary, acting through the Service, shall make arrangements with Indian tribes to establish joint venture demonstration projects under which an Indian tribe shall expend tribal, 

private, or other available nontribal funds, for the acquisition or 

construction of a health facility for a minimum of 20 years, under 

a no-cost lease, in exchange for agreement by the Service to provide 

the equipment, supplies, and staffing for the operation and maintenance of such a health facility. A tribe may utilize tribal funds, private sector, or other available resources, including loan guarantees, 

to fulfill its commitment under this subsection. 

ø(2) The Secretary shall make such an arrangement with an Indian tribe only if the Secretary first determines that the Indian 

tribe has the administrative and financial capabilities necessary to 

complete the timely acquisition or construction of the health facility 

described in paragraph (1). 


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ø(3) An Indian tribe or tribal organization that has entered into 

a written agreement with the Secretary under this subsection, and 

that breaches or terminates without cause such agreement, shall 

be liable to the United States for the amount that has been paid 

to the tribe, or paid to a third party on the tribe’s behalf, under 

the agreement. The Secretary has the right to recover tangible 

property (including supplies), and equipment, less depreciation, 

and any funds expended for operations and maintenance under this 

section. The preceding sentence does not apply to any funds expended for the delivery of health care services, or for personnel or 

staffing, shall be recoverable. 

øCHILD SEXUAL ABUSE TREATMENT PROGRAMS

øSEC. 819. (a) The 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) Beginning 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). 

øTRIBAL LEASING

øSEC. 820. Indian tribes providing health care services pursuant 

to a contract entered into under the Indian Self-Determination Act 

may lease permanent structures for the purpose of providing such 

health care services without obtaining advance approval in appropriation Acts. 

øHOME- AND COMMUNITY-BASED CARE DEMONSTRATION PROJECT

øSEC. 821. (a) The 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, to establish demonstration projects for the delivery of homeand community-based services to functionally disabled Indians. 

ø(b)(1) Funds provided for a demonstration project under this 

section shall be used only for the delivery of home- and communitybased services (including transportation services) to functionally 

disabled Indians. 

ø(2) Such funds may not be used—

ø(A) to make cash payments to functionally disabled Indians; 

ø(B) to provide room and board for functionally disabled Indians; 

ø(C) for the construction or renovation of facilities or the 

purchase of medical equipment; or 

ø(D) for the provision of nursing facility services. 


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ø(c) Not later than 180 days after the date of the enactment of 

this section, 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) The Secretary shall provide such technical and other assistance as may be necessary to enable applicants to comply with the 

provisions of this section. 

ø(e) At 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) The 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). 

ø(g) The Secretary shall submit to the President, for inclusion in 

the report which is required to be submitted under section 801 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) For the purposes of this section, the following definitions 

shall apply: 

ø(1) The term ‘‘home- and community-based services’’ means 

one or more of the following: 

ø(A) Homemaker/home health aide services. 

ø(B) Chore services. 

ø(C) Personal care services. 

ø(D) Nursing care services provided outside of a nursing 

facility by, or under the supervision of, a registered nurse. 

ø(E) Respite care. 

ø(F) Training for family members in managing a functionally disabled individual. 

ø(G) Adult day care. 

ø(H) Such other home- and community-based services as 

the Secretary may approve. 

ø(2) The term ‘‘functionally disabled’’ means an individual 

who is determined to require home- and community-based 

services based on an assessment that uses criteria (including, 

at the discretion of the tribe or tribal organization, activities 

of daily living) developed by the tribe or tribal organization. 

ø(i) There 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. 


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øSHARED SERVICES DEMONSTRATION PROJECT

øSEC. 822. (a) The 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) A contract entered into pursuant to subsection (a)—

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) To be eligible for a contract under this section, a tribe or 

tribal organization, shall, as of the date of the enactment of this 

Act—

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) Any nursing facility for which a contract is entered into 

under this section shall meet the requirements for nursing facilities 

under section 1919 of the Social Security Act. 

ø(e) The Secretary shall provide such technical and other assistance as may be necessary to enable applicants to comply with the 

provisions of this section. 

ø(f) The Secretary shall submit to the President, for inclusion in 

each report required to be transmitted to the Congress under section 801, a report on the findings and conclusions derived from the 

demonstration projects conducted under this section. 

øRESULTS OF DEMONSTRATION PROJECTS

øSEC. 823. The Secretary shall provide for the dissemination to 

Indian tribes of the findings and results of demonstration projects 

conducted under this Act. 

øPRIORITY FOR INDIAN RESERVATIONS

øSEC. 824. (a) Beginning on the date of the enactment of this section, the Bureau of Indian Affairs and the Service shall, in all matters involving the reorganization or development of Service faciliVerDate Aug 31 2005 06:29 Sep 16, 2006 Jkt 049006 PO 00000 Frm 00194 Fmt 6659 Sfmt 9001 E:\HR\OC\HR661P1.XXX HR661P1

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ties, 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) For 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. 

øAUTHORIZATION OF APPROPRIATIONS

øSEC. 825. Except as provided in section 821, there are authorized to be appropriated such sums as may be necessary for each fiscal year through fiscal year 2000 to carry out this title.¿ 

SECTION 1. SHORT TITLE; TABLE OF CONTENTS. 

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

Care Improvement Act’’. 

(b) TABLE OF CONTENTS.—The table of contents for this Act is as 

follows: 

Sec. 1. Short title; table of contents. 

TITLE I—INDIAN HEALTH, HUMAN RESOURCES, AND DEVELOPMENT 

Sec. 101. Purpose. 

Sec. 102. Health professions recruitment program for Indians. 

Sec. 103. Health professions preparatory scholarship program for Indians. 

Sec. 104. Indian health professions scholarships. 

Sec. 105. American Indians into psychology program. 

Sec. 106. Scholarship programs for Indian tribes. 

Sec. 107. Indian health service extern programs. 

Sec. 108. Continuing education allowances. 

Sec. 109. Community health representative program. 

Sec. 110. Indian health service loan repayment program. 

Sec. 111. Scholarship and loan repayment recovery fund. 

Sec. 112. Recruitment activities. 

Sec. 113. Indian recruitment and retention program. 

Sec. 114. Advanced training and research. 

Sec. 115. Quentin N. Burdick American Indians into nursing program. 

Sec. 116. Tribal cultural orientation. 

Sec. 117. Inmed program. 

Sec. 118. Health training programs of community colleges. 

Sec. 119. Retention bonus. 

Sec. 120. Nursing residency program. 

Sec. 121. Community health aide program for Alaska. 

Sec. 122. Tribal health program administration. 

Sec. 123. Health professional chronic shortage demonstration programs. 

Sec. 124. National Health Service Corps. 

Sec. 125. Substance abuse counselor educational curricula demonstration programs. 

Sec. 126. Behavioral health training and community education programs. 

TITLE II—HEALTH SERVICES 

Sec. 201. Indian Health Care Improvement Fund. 

Sec. 202. Catastrophic Health Emergency Fund. 

Sec. 203. Health promotion and disease prevention services. 

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

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

Sec. 206. Health services research. 

Sec. 207. Mammography and other cancer screening. 

Sec. 208. Patient travel costs. 


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Sec. 209. Epidemiology centers. 

Sec. 210. Comprehensive school health education programs. 

Sec. 211. Indian youth program. 

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

Sec. 213. Authority for provision of other services. 

Sec. 214. Indian women’s health care. 

Sec. 215. Environmental and nuclear health hazards. 

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

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

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

Sec. 217. California contract health services program. 

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

Sec. 219. Contract health services for the Trenton service area. 

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

Sec. 221. Licensing. 

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

Sec. 223. Prompt action on payment of claims. 

Sec. 224. Liability for payment. 

Sec. 225. Authorization of appropriations. 

TITLE III—FACILITIES 

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

Sec. 302. Sanitation facilities. 

Sec. 303. Preference to Indians and Indian firms. 

Sec. 304. Expenditure of nonservice funds for renovation. 

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

Sec. 306. Indian health care delivery demonstration project. 

Sec. 307. Land transfer. 

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

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

Sec. 310. Tribal leasing. 

Sec. 311. Indian health service/tribal facilities joint venture program. 

Sec. 312. Location of facilities. 

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

Sec. 314. Tribal management of federally owned quarters. 

Sec. 315. Applicability of Buy American Act requirement. 

Sec. 316. Other funding for facilities. 

Sec. 317. Authorization of appropriations. 

TITLE IV—ACCESS TO HEALTH SERVICES 

Sec. 401. Treatment of payments under Social Security Act health benefits programs. 

Sec. 402. Grants to and contracts with the service, Indian tribes, tribal organizations, and urban indian organizations to facilitate outreach, enrollment, 

and coverage of indians under social security act health benefit programs and other health benefits programs. 

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

Sec. 404. Crediting of reimbursements. 

Sec. 405. Purchasing health care coverage. 

Sec. 406. Sharing arrangements with Federal agencies. 

Sec. 407. Payor of last resort. 

Sec. 408. Nondiscrimination under Federal health care programs in qualifications 

for reimbursement for services. 

Sec. 409. Consultation. 

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

Sec. 411. Exclusion waiver authority for affected Indian health programs and safe 

harbor transactions under the Social Security Act. 

Sec. 412. Premium and cost sharing protections and eligibility determinations under 

Medicaid and SCHIP and protection of certain Indian property from 

Medicaid estate recovery. 

Sec. 413. Treatment under Medicaid and SCHIP managed care. 

Sec. 414. Navajo nation Medicaid agency feasibility study. 

Sec. 415. Authorization of appropriations. 

TITLE V—HEALTH SERVICES FOR URBAN INDIANS 

Sec. 501. Purpose. 


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

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

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

Sec. 505. Evaluations; renewals. 

Sec. 506. Other contract and grant requirements. 

Sec. 507. Reports and records. 

Sec. 508. Limitation on contract authority. 

Sec. 509. Facilities. 

Sec. 510. Division of urban Indian health. 

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

Sec. 512. Treatment of certain demonstration projects. 

Sec. 513. Urban NIAAA transferred programs. 

Sec. 514. Consultation with urban Indian organizations. 

Sec. 515. Urban youth treatment center demonstration. 

Sec. 516. Use of Federal Government facilities and sources of supply. 

Sec. 517. Grants for diabetes prevention, treatment, and control. 

Sec. 518. Community health representatives. 

Sec. 519. Effective date. 

Sec. 520. Eligibility for services. 

Sec. 521. Authorization of appropriations. 

TITLE VI—ORGANIZATIONAL IMPROVEMENTS 

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

Health Service. 

Sec. 602. Automated management information system. 

Sec. 603. Authorization of appropriations. 

TITLE VII—BEHAVIORAL HEALTH PROGRAMS 

Sec. 701. Behavioral health prevention and treatment services. 

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

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

Sec. 704. Mental health technician program. 

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

Sec. 706. Indian women treatment programs. 

Sec. 707. Indian youth program. 

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

Sec. 709. Training and community education. 

Sec. 710. Behavioral health program. 

Sec. 711. Fetal alcohol disorder programs. 

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

Sec. 713. Behavioral health research. 

Sec. 714. Definitions. 

Sec. 715. Authorization of appropriations. 

TITLE VIII—MISCELLANEOUS 

Sec. 801. Reports. 

Sec. 802. Regulations. 

Sec. 803. Plan of implementation. 

Sec. 804. Availability of funds. 

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

Sec. 806. Eligibility of California Indians. 

Sec. 807. Health services for ineligible persons. 

Sec. 808. Reallocation of base resources. 

Sec. 809. Results of demonstration projects. 

Sec. 810. Provision of services in Montana. 

Sec. 811. Moratorium. 

Sec. 812. Tribal employment. 

Sec. 813. Severability provisions. 

Sec. 814. Appropriations; availability. 

Sec. 815. Authorization of appropriations. 

SEC. 2. DECLARATION OF NATIONAL INDIAN HEALTH POLICY. 

Congress hereby declares that it is the policy of this Nation, in 

fulfillment of its special trust responsibilities and legal obligations 

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

and to provide all resources necessary to effect that policy; 


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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. 

SEC. 3. DEFINITIONS. 

For purposes of this Act: 

(1) The term ‘‘accredited and accessible’’ means on or near a 

reservation and accredited by a national or regional organization with accrediting authority. 

(2) The term ‘‘Area Office’’ means an administrative entity including a program office, within the Service through which 

services and funds are provided to the Service Units within a 

defined geographic area. 

(3) The term ‘‘Assistant Secretary’’ means the Assistant Secretary of Indian Health. 

(4) The term ‘‘behavioral health’’ means the blending of substance (alcohol, drugs, inhalants, and tobacco) abuse and mental illness prevention and treatment, for the purpose of providing comprehensive services. This definition can include the 

joint development of substance abuse and mental illness treatment planning and coordinated case management using a multidisciplinary approach. 

(5) The term ‘‘California Indians’’ shall mean 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—

(i) development of diabetes; 


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(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, advanced practice nursing, dentistry, 

psychiatry, osteopathy, optometry, pharmacy, psychology, public 

health, social work, marriage and family therapy, chiropractic 

medicine, environmental health and engineering, allied health 

professions, naturopathic medicine 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, but not limited to—

(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; 


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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 relative to eliminating, reducing, 

or preventing contaminants which 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 sections 102 and 103, 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, of 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 in 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 April 30, 1908 (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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(17) The term ‘‘Secretary’’, unless otherwise designated, means 

the Secretary of Health and Human Services. 

(18) The term ‘‘Service’’ means the Indian Health Service. 

(19) The term ‘‘Service Area’’ means the geographical area 

served by each Area Office. 

(20) The term ‘‘Service Unit’’ means an administrative entity 

of the Service, or a Tribal Health Program through which services are provided, directly or by contract, to eligible Indians 

within a defined geographic area. 

(21) The term ‘‘telehealth’’ has the meaning given the term in 

section 330K(a) of the Public Health Service Act (42 U.S.C. 

254c–16(a)). 

(22) The term ‘‘telemedicine’’ means a telecommunications 

link to an end user through the use of eligible equipment that 

electronically links health professionals or patients and health 

professionals at separate sites in order to exchange health care 

information in audio, video, graphic, or other format for the 

purpose of providing improved health care services. 

(23) The term ‘‘tribal college or university’’ has the meaning 

given the term in section 316(b)(3) of the Higher Education Act 

(20 U.S.C. 1059c(b)(3)). 

(24) The term ‘‘Tribal Health Program’’ means an Indian 

Tribe or Tribal Organization that operates any health program, 

service, function, activity, or facility funded, in whole or part, 

by the Service through, or provided for in, a Funding Agreement with the Service under the Indian Self-Determination and 

Education Assistance Act (25 U.S.C. 450 et seq.). 

(25) The term ‘‘Tribal Organization’’ has the meaning given 

the term in the Indian Self-Determination and Education Assistance Act (25 U.S.C. 450 et seq.). 

(26) 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. 

(27) The term ‘‘Urban Indian’’ means any individual who resides in an Urban Center and who meets 1 or more of the following criteria: 

(A) Irrespective of whether the individual lives on or near 

a reservation, the individual is a member of a tribe, band, 

or other organized group of Indians, including those tribes, 

bands, or groups terminated since 1940 and those tribes, 

bands, or groups that are recognized by the States in which 

they reside, or who is a descendant in the first or second 

degree of any such member. 

(B) The individual is an Eskimo, Aleut, or other Alaskan 

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. 

(28) 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 

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ating with other public and private entities for the purpose of 

performing the activities described in section 503(a). 

TITLE I—INDIAN HEALTH, HUMAN 

RESOURCES, AND DEVELOPMENT 

SEC. 101. PURPOSE. 

The purpose of this 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 optimum supply of 

health professionals to the Indian Health Programs and Urban Indian Organizations involved in the provision of health services to 

Indians. 

SEC. 102. HEALTH PROFESSIONS RECRUITMENT PROGRAM FOR INDIANS. 

(a) IN GENERAL.—The Secretary, acting through the Service, shall 

make funds available to public or nonprofit private health or educational entities, Tribal Health Programs, or Urban Indian 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) 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). 

(b) FUNDING.—

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

under this section unless an application 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. 

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

under this section shall be determined by the Secretary. Payments pursuant to this section may be made in advance or by 

way of reimbursement, and at such intervals and on such conditions as 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. 


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SEC. 103. HEALTH PROFESSIONS PREPARATORY SCHOLARSHIP PROGRAM FOR INDIANS. 

(a) SCHOLARSHIPS AUTHORIZED.—The Secretary, acting through 

the Service, shall provide scholarships to Indians who— (1) have successfully completed their high school education or 

high school equivalency; and 

(2) have demonstrated the potential to successfully complete 

courses of study in the health professions. 

(b) PURPOSES.—Scholarship grants provided pursuant to this section shall be for the following purposes: 

(1) Compensatory preprofessional education of any recipient, 

such scholarship not to exceed 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 leading to a baccalaureate degree in an approved course of study preparatory to 

a field of study in a health profession, such scholarship not to 

exceed 4 years. An extension of up to 2 years (or the part-time 

equivalent thereof, as determined by the Secretary pursuant to 

regulations issued pursuant to this Act) may be approved. 

(c) OTHER CONDITIONS.—Scholarships under this section—

(1) may cover costs of tuition, books, transportation, board, 

and other necessary related expenses of a recipient while attending school; 

(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. 

SEC. 104. INDIAN HEALTH PROFESSIONS SCHOLARSHIPS. 

(a) IN GENERAL.—

(1) AUTHORITY.—The Secretary, acting through the Service, 

shall make scholarship grants to Indians who are enrolled full 

or part time in accredited schools 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. 

254l), except as provided in subsection (b) of this section. 

(2) DETERMINATION 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 professions 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) ACTIVE DUTY SERVICE OBLIGATION.—

(1) OBLIGATION MET.—The active duty service obligation 

under a written contract with the Secretary under section 338A 

of the Public Health Service Act (42 U.S.C. 254l) that an Indian 


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has entered into under 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 

one or more of the following: 

(A) In an Indian Health Program. 

(B) In a program assisted under title V of this Act. 

(C) 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. 

(D) In a teaching capacity in a tribal college or university 

program (or a related health profession program) if, as determined by the Secretary, the health service provided to Indians would not decrease. 

(2) OBLIGATION DEFERRED.—At the request of any individual 

who has entered into a contract referred to in paragraph (1) 

and who receives a degree in medicine (including osteopathic or 

allopathic medicine), dentistry, optometry, podiatry, or pharmacy, the Secretary shall defer the active duty service obligation 

of that individual under that contract, in order that such individual may complete any internship, residency, or other advanced clinical training that is required for the practice of that 

health profession, for an appropriate period (in years, as determined by the Secretary), subject to the following conditions: 

(A) No period of internship, residency, or other advanced 

clinical training shall be counted as satisfying any period 

of obligated service under this subsection. 

(B) 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) The active duty service obligation will be served in 

the health profession of that individual in a manner consistent with paragraph (1). 

(D) A recipient of a scholarship under this section may, 

at the election of the recipient, meet the active duty service 

obligation described in paragraph (1) by service in a program specified under that paragraph that—

(i) is located on the reservation of the Indian Tribe 

in which the recipient is enrolled; or 

(ii) serves the Indian Tribe in which the recipient is 

enrolled. 

(3) PRIORITY WHEN MAKING ASSIGNMENTS.—Subject to paragraph (2), the Secretary, in making assignments of Indian 

Health Scholarship recipients required to meet the active duty 

service obligation described in paragraph (1), shall give priority 

to assigning individuals to service in those programs specified 

in paragraph (1) that have a need for health professionals to 

provide health care services as a result of individuals having 

breached contracts entered into under this section. 

(c) PART-TIME STUDENTS.—In the case of an individual receiving 

a scholarship under this section who is enrolled part-time in an apVerDate Aug 31 2005 06:29 Sep 16, 2006 Jkt 049006 PO 00000 Frm 00204 Fmt 6659 Sfmt 6603 E:\HR\OC\HR661P1.XXX HR661P1

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proved course of study part-time equivalent of 4 years, as determined by the Area Office—

(1) the period of obligated service described in subsection 

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

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

which the individual was provided a scholarship (as determined by the Area Office); or 

(B) 2 years; and 

(2) 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)) shall be reduced pro rata (as determined by the 

Secretary) based on the number of hours such student is enrolled. 

(d) BREACH OF CONTRACT.—

(1) SPECIFIED BREACHES.—An individual shall be liable to 

the United States for the amount which has been paid to the 

individual, or on behalf of the individual, under a contract entered into with the Secretary under this section on or after the 

date of the enactment of the Indian Health Care Improvement 

Act Amendments of 2006 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 determined by the educational institution under regulations of the Secretary); 

(B) is dismissed from such educational institution for 

disciplinary reasons; 

(C) voluntarily terminates the training in such an educational institution for which he or she is provided a 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 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 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) 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—


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(i) it is not possible for the recipient to meet that obligation or make that payment would result in extreme 

hardship to the recipient; or 

(ii) requiring that recipient to meet that obligation or 

make that payment would result in extreme hardship 

to the recipient; or 

(iii) the enforcement of the requirement to meet the 

obligation or make the payment would be unconscionable. 

(B) FACTORS FOR CONSIDERATION.—Before waiving or 

suspending an obligation of service or payment under subparagraph (A), the Secretary 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) 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) 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 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. 

SEC. 105. AMERICAN INDIANS INTO PSYCHOLOGY PROGRAM. 

(a) GRANTS AUTHORIZED.—The Secretary, acting through the Service, shall make grants of not more than $300,000 to each of 9 

colleges and universities for the purpose of developing and maintaining Indian psychology career recruitment programs as a means 

of encouraging Indians to enter the mental 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 funds provided under 

this section. 

(d) CONDITIONS OF GRANT.—Applicants under this section shall 

agree to provide a program which, at a minimum—

(1) provides outreach and recruitment for health professions 

to Indian communities including elementary, secondary, and 

accredited and accessible community colleges that will be served 

by the program; 


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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. 

SEC. 106. SCHOLARSHIP PROGRAMS FOR INDIAN TRIBES. 

(a) IN GENERAL.—

(1) GRANTS AUTHORIZED.—The Secretary, acting through the 

Service, shall make grants to Tribal Health Programs for the 

purpose of providing scholarships for Indians to serve as health 

professionals in Indian communities. 

(2) AMOUNT.—Amounts available under paragraph (1) for 

any fiscal year shall not exceed 5 percent of the amounts available for each fiscal year for Indian Health Scholarships under 

section 104. 

(3) APPLICATION.—An application for a grant under paragraph (1) shall be in such form and contain such agreements, 

assurances, and information as consistent with this section. 

(b) REQUIREMENTS.—

(1) IN GENERAL.—A Tribal Health Program receiving funds 

under subsection (a) shall provide scholarships to Indians in 

accordance with the requirements of this section. 

(2) COSTS.—With respect to costs of providing any scholarship 

pursuant to subsection (a)—

(A) 80 percent of the costs of the scholarship shall be paid 

from the funds made available pursuant to subsection 

(a)(1) provided to the Tribal Health Program; and 

(B) 20 percent of such costs may be paid from any other 

source of funds. 

(c) COURSE OF STUDY.—A Tribal Health Program shall provide 

scholarships under this section only to Indians enrolled or accepted 


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for enrollment in a course of study (approved by the Secretary) in 

one 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)), such amount to be reduced pro rata (as 

determined by the Secretary) based on the number of 

hours such student is enrolled; and 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 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 licensing 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); 

(B) is dismissed from such educational institution for 

disciplinary reasons; 

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arship under such contract before the completion of such 

training; or 

(D) fails to accept payment, or instructs the educational 

institution in which he or she is enrolled not to accept payment, in whole or in part, of a scholarship under such contract, in lieu of any service obligation arising under such 

contract. 

(2) OTHER BREACHES.—If for any reason not specified in 

paragraph (1), an individual breaches a written contract by 

failing to either begin such individual’s service obligation required under such contract or to complete such service obligation, the United States shall be entitled to recover from the individual an amount determined in accordance with the formula 

specified in subsection (l) of section 110 in the manner provided 

for in such subsection. 

(3) CANCELLATION UPON DEATH OF RECIPIENT.—Upon the 

death of an individual who receives an Indian Health Scholarship, any outstanding obligation of that individual for service 

or payment that relates to that scholarship shall be canceled. 

(4) INFORMATION.—The Secretary may carry out this subsection on the basis of information received from Tribal Health 

Programs involved or on the basis of information collected 

through such other means as the Secretary deems appropriate. 

(f) RELATION TO SOCIAL SECURITY ACT.—The recipient of a scholarship under this section shall agree, in providing health care pursuant to the requirements herein— (1) not to discriminate against an individual seeking care on 

the basis of the ability of the individual to pay for such care 

or on the basis that payment for such care will be made pursuant to a program established in title XVIII of the Social Security Act or pursuant to the programs established in title XIX or 

title XXI of such Act; and 

(2) to accept assignment under section 1842(b)(3)(B)(ii) of the 

Social Security Act for all services for which payment may be 

made under part B of title XVIII of such Act, and to enter into 

an appropriate agreement with the State agency that administers the State plan for medical assistance under title XIX, or 

the State child health plan under title XXI, of such Act to provide service to individuals entitled to medical assistance or 

child health assistance, respectively, under the plan. 

(g) CONTINUANCE OF FUNDING.—The Secretary shall make payments under this section to a Tribal Health Program for any fiscal 

year subsequent to the first fiscal year of such payments unless the 

Secretary determines that, for the immediately preceding fiscal year, 

the Tribal Health Program has not complied with the requirements 

of this section. 

SEC. 107. INDIAN HEALTH SERVICE EXTERN PROGRAMS. 

(a) EMPLOYMENT PREFERENCE.—Any individual who receives a 

scholarship pursuant to section 104 or 106 shall be given preference 

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.—

Periods of employment pursuant to this subsection shall not be 


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counted in determining fulfillment of the service obligation incurred 

as a condition of the scholarship. 

(c) TIMING; LENGTH OF EMPLOYMENT.—Any individual enrolled 

in a program, including a high school program, authorized under 

section 102(a) may be employed by the Service or by a Tribal Health 

Program or an Urban Indian Organization during any nonacademic period of the year. Any such employment shall not exceed 120 

days during any calendar year. 

(d) NONAPPLICABILITY OF COMPETITIVE PERSONNEL SYSTEM.—

Any employment pursuant to this section shall be made without regard to any competitive personnel system or agency personnel limitation and to a position which will enable the individual so employed to receive practical experience in the health profession in 

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

shall receive payment for his or her services comparable to the salary he or she would receive if he or she were employed in the competitive system. Any individual so employed shall not be counted 

against any employment ceiling affecting the Service or the Department. 

SEC. 108. CONTINUING EDUCATION ALLOWANCES. 

In order to encourage health professionals, including community 

health representatives and emergency medical technicians, to join or 

continue in an Indian Health Program or an Urban Indian Organization and to provide their services in the rural and remote areas 

where a significant portion of Indians reside, the Secretary, acting 

through the Service, may provide allowances to health professionals 

employed in an Indian Health Program or an Urban Indian Organization 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. 

SEC. 109. COMMUNITY HEALTH REPRESENTATIVE 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, acting through the Service, shall maintain a Community 

Health Representative Program under which Indian Health Programs—

(1) provide for the training of Indians as community health 

representatives; and 

(2) use such community health representatives in the provision of health care, health promotion, and disease prevention 

services to Indian communities. 

(b) DUTIES.—The Community Health Representative Program of 

the Service, shall—

(1) provide a high standard of training for community health 

representatives to ensure that the community health representatives provide quality health care, health promotion, and disease 

prevention services to the Indian communities served by the 

Program; 

(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 

care; and 


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(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 poverty; 

(3) maintain a system which identifies the needs of community health representatives for continuing education in health 

care, health promotion, and disease prevention, and develop 

programs that meet the needs for continuing education; 

(4) maintain a system that provides close supervision of Community Health Representatives; 

(5) maintain a system under which the work of Community 

Health Representatives is reviewed and evaluated; and 

(6) 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. 

SEC. 110. INDIAN HEALTH SERVICE LOAN REPAYMENT PROGRAM. 

(a) ESTABLISHMENT.—The Secretary, acting through the Service, 

shall establish and administer a program to be known as the Service Loan Repayment Program (hereinafter referred to as the ‘‘Loan 

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

trained health professionals necessary to maintain accreditation of, 

and provide health care services to Indians through, Indian Health 

Programs and Urban Indian Organizations. 

(b) ELIGIBLE INDIVIDUALS.—To be eligible to participate in the 

Loan Repayment Program, an individual must— (1)(A) be enrolled— (i) in a course of study or program in an accredited educational institution (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))) 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; 

(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 Service; or 

(D) be employed in an Indian Health Program or Urban Indian Organization without a service obligation; and 

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

In the administration of this section, naturopathic medicine is included among the other health professions. 

(c) APPLICATION.—

(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 SecVerDate Aug 31 2005 06:29 Sep 16, 2006 Jkt 049006 PO 00000 Frm 00211 Fmt 6659 Sfmt 6603 E:\HR\OC\HR661P1.XXX HR661P1

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retary shall include with such forms a fair summary of the 

rights and liabilities of an individual whose application is approved (and whose contract is accepted) by the Secretary, including in the summary a clear explanation of the damages to 

which the United States is entitled under subsection (l) in the 

case of the individual’s breach of contract. The Secretary shall 

provide such individuals with sufficient information regarding 

the advantages and disadvantages of service as a commissioned 

officer in the Regular or Reserve Corps of the Public Health 

Service or a civilian employee of the 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.—

(1) LIST.—Consistent with subsection (k), the Secretary shall 

annually—

(A) identify the positions in each Indian Health Program 

or Urban Indian Organization for which there is a need or 

a vacancy; and 

(B) rank those positions in order of priority. 

(2) APPROVALS.—Notwithstanding the priority determined 

under paragraph (1), the Secretary, in determining which applications under the Loan Repayment Program to approve (and 

which contracts to accept), shall—

(A) give first priority to applications made 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 

(ii) other individuals based on the priority rankings 

under paragraph (1). 

(e) RECIPIENT CONTRACTS.—

(1) CONTRACT REQUIRED.—An individual becomes a participant in the Loan Repayment Program only upon the Secretary 

and the individual entering into a written contract described in 

paragraph (2). 

(2) CONTENTS OF CONTRACT.—The written contract referred to 

in this section between the Secretary and an individual shall 

contain—

(A) an agreement under which—

(i) subject to subparagraph (C), the Secretary 

agrees—


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

(II) to accept (subject to the availability of appropriated funds for carrying out this section) the individual into the Service or place the individual 

with a Tribal Health Program or Urban Indian 

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

(ii) subject to subparagraph (C), the individual 

agrees—

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

(II) in the case of an individual described in 

subsection (b)(1)— (aa) to maintain enrollment in a course of 

study or training described in subsection 

(b)(1)(A) until the individual completes the 

course of study or training; and 

(bb) while enrolled in such course of study 

or training, to maintain an acceptable level of 

academic standing (as determined under regulations of the Secretary by the educational institution offering such course of study or training); and 

(III) to serve for a time period (hereinafter in 

this section referred to as the ‘‘period of obligated 

service’’) equal to 2 years or such longer period as 

the individual may agree to serve in the full-time 

clinical practice of such individual’s profession in 

an Indian Health Program or Urban Indian Organization to which the individual may be assigned 

by the Secretary; 

(B) a provision permitting the Secretary to extend for 

such longer additional periods, as the individual may agree 

to, the period of obligated service agreed to by the individual under subparagraph (A)(ii)(III); 

(C) a provision that any financial obligation of the 

United States arising out of a contract entered into under 

this section and any obligation of the individual which is 

conditioned thereon is contingent upon funds being appropriated for loan repayments under this section; 

(D) a statement of the damages to which the United 

States is entitled under subsection (l) for the individual’s 

breach of the contract; and 

(E) 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 approval, 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 disapproval of an individual’s participation in such Program. 

(g) PAYMENTS.—


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(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) AMOUNT.—For each year of obligated service that an individual contracts to serve under subsection (e), the Secretary may 

pay up to $35,000 or an amount equal to the amount specified 

in section 338B(g)(2)(A) of the Public Health Service Act, whichever is more, on behalf of the individual for loans described in 

paragraph (1). In making a determination of the amount to pay 

for a year of such service by an individual, the Secretary shall 

consider the extent to which each such determination—

(A) affects the ability of the Secretary to maximize the 

number of contracts that can be provided under the Loan 

Repayment Program from the amounts appropriated for 

such contracts; 

(B) provides an incentive to serve in Indian Health Programs and Urban Indian Organizations with the greatest 

shortages of health professionals; and 

(C) provides an incentive with respect to the health professional involved remaining in an Indian Health Program 

or Urban Indian Organization with such a health professional shortage, and continuing to provide primary health 

services, after the completion of the period of obligated service under the Loan Repayment Program. 

(3) TIMING.—Any arrangement made by the Secretary for the 

making of loan repayments in accordance with this subsection 

shall provide that any repayments for a year of obligated service shall be made no later than the end of the fiscal year in 

which the individual completes such year of service. 

(4) REIMBURSEMENTS FOR TAX LIABILITY.—For the purpose of 

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

(A) in addition to such payments, may make payments to 

the individual in an amount not less than 20 percent and 

not more than 39 percent of the total amount of loan repayments made for the taxable year involved; and 

(B) may make such additional payments as the Secretary 

determines to be appropriate with respect to such purpose. 

(5) PAYMENT SCHEDULE.—The Secretary may enter into an 

agreement with the holder of any loan for which payments are 

made under the Loan Repayment Program to establish a schedule for the making of such payments. 


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(h) EMPLOYMENT CEILING.—Notwithstanding any other provision 

of law, individuals who have entered into written contracts with the 

Secretary under this section shall not be counted against any employment ceiling affecting the Department while those individuals 

are undergoing academic training. 

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

(j) APPLICABILITY OF LAW.—Section 214 of the Public Health Service Act (42 U.S.C. 215) shall not apply to individuals during their 

period of obligated service under the Loan Repayment Program. 

(k) ASSIGNMENT OF INDIVIDUALS.—The Secretary, in assigning individuals to serve in Indian Health Programs or Urban Indian Organizations pursuant to contracts entered into under this section, 

shall—

(1) ensure that the staffing needs of Tribal Health Programs 

and Urban Indian Organizations receive consideration on an 

equal basis with programs that are administered directly by the 

Service; and 

(2) give priority to assigning individuals to Indian Health 

Programs and Urban Indian Organizations that have a need 

for health professionals to provide health care services as a result of individuals having breached contracts entered into 

under this section. 

(l) BREACH OF CONTRACT.— (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— (A) is enrolled in the final year of a course of study and— (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 program and fails 

to complete such training program. 

(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), the United 

States shall be entitled to recover from such individual an 

amount to be determined in accordance with the following formula: A=3Z(t¥s/t) in which— (A) ‘‘A’’ is the amount the United States is entitled to recover; 

(B) ‘‘Z’’ is the sum of the amounts paid under this section 

to, or on behalf of, the individual and the interest on such 

amounts which would be payable if, at the time the 


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amounts were paid, they were loans bearing interest at the 

maximum legal prevailing rate, as determined by the Secretary of the Treasury; 

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

period of obligated service in accordance with subsection 

(f); and 

(D) ‘‘s’’ is the number of months of such period served by 

such individual in accordance with this section. 

(3) DEDUCTIONS IN MEDICARE PAYMENTS.—Amounts not paid 

within such period shall be subject to collection through deductions in Medicare payments pursuant to section 1892 of the Social Security Act. 

(4) TIME PERIOD FOR REPAYMENT.—Any amount of damages 

which the United States is entitled to recover under this subsection shall be paid to the United States within the 1-year period beginning on the date of the breach or such longer period 

beginning on such date as shall be specified by the Secretary. 

(5) RECOVERY OF DELINQUENCY.— (A) IN GENERAL.—If damages described in paragraph (4) 

are delinquent for 3 months, the Secretary shall, for the 

purpose of recovering such damages—

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

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

(B) REPORT.—Each contract for recovering damages pursuant to this subsection shall provide that the contractor 

will, not less than once each 6 months, submit to the Secretary a status report on the success of the contractor in collecting such damages. Section 3718 of 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.— (1) IN GENERAL.—The Secretary shall by regulation provide 

for the partial or total waiver or suspension of any obligation 

of service or payment by an individual under the Loan Repayment Program whenever compliance by the individual is impossible or would involve extreme hardship to the individual and 

if enforcement of such obligation with respect to any individual 

would be unconscionable. 

(2) CANCELED UPON DEATH.—Any obligation of an individual 

under the Loan Repayment Program for service or payment of 

damages shall be canceled upon the death of the individual. 

(3) HARDSHIP WAIVER.—The Secretary may waive, in whole or 

in part, the rights of the United States to recover amounts 

under this section in any case of extreme hardship or other good 

cause shown, as determined by the Secretary. 

(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 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. 


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(n) REPORT.—The Secretary shall submit to the President, for inclusion in each report required to be submitted to Congress under 

section 801, a report concerning the previous fiscal year which sets 

forth by Service Area the following: 

(1) A list of the health professional positions maintained by 

Indian Health Programs and Urban Indian Organizations for 

which recruitment or retention is difficult. 

(2) The number of Loan Repayment Program applications 

filed with respect to each type of health profession. 

(3) The number of contracts described in subsection (e) that 

are entered into with respect to each health profession. 

(4) The amount of loan payments made under this section, in 

total and by health profession. 

(5) The number of scholarships that are provided under sections 104 and 106 with respect to each health profession. 

(6) The amount of scholarship grants provided under section 

104 and 106, in total and by health profession. 

(7) The number of providers of health care that will be needed 

by Indian Health Programs and Urban Indian Organizations, 

by location and profession, during the 3 fiscal years beginning 

after the date the report is filed. 

(8) The measures the Secretary plans to take to fill the health 

professional positions maintained by Indian Health Programs 

or Urban Indian Organizations for which recruitment or retention is difficult. 

SEC. 111. SCHOLARSHIP AND LOAN REPAYMENT RECOVERY FUND. 

(a) ESTABLISHMENT.—There is established in the Treasury of the 

United States a fund to be known as the Indian Health Scholarship 

and Loan Repayment Recovery Fund (hereafter in this section referred to as the ‘‘LRRF’’). The LRRF shall consist of such amounts 

as may be collected from individuals under section 104(d), section 

106(e), and section 110(l) for breach of contract, such funds as may 

be appropriated to the LRRF, and interest earned on amounts in the 

LRRF. All amounts collected, appropriated, or earned relative to the 

LRRF shall remain available until expended. 

(b) USE OF FUNDS.— (1) BY SECRETARY.—Amounts in the LRRF may be expended 

by the Secretary, acting through the Service, to make payments 

to an Indian Health Program— (A) to which a scholarship recipient under section 104 

and 106 or a loan repayment program participant under 

section 110 has been assigned to meet the obligated service 

requirements pursuant to such sections; and 

(B) that has a need for a health professional to provide 

health care services as a result of such recipient or participant having breached the contract entered into under section 104, 106, or section 110. 

(2) BY TRIBAL HEALTH PROGRAMS.—A Tribal Health Program 

receiving payments pursuant to paragraph (1) may expend the 

payments to provide scholarships or recruit and employ, directly or by contract, health professionals to provide health care 

services. 

(c) INVESTMENT OF FUNDS.—The Secretary of the Treasury shall 

invest such amounts of the LRRF, except for the appropriated funds, 

as the Secretary determines are not required to meet current withVerDate Aug 31 2005 06:29 Sep 16, 2006 Jkt 049006 PO 00000 Frm 00217 Fmt 6659 Sfmt 6603 E:\HR\OC\HR661P1.XXX HR661P1

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drawals from the LRRF. Such investments may be made only in interest 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.—Any obligation acquired by the LRRF 

may be sold by the Secretary of the Treasury at the market price. 

SEC. 112. RECRUITMENT ACTIVITIES. 

(a) REIMBURSEMENT FOR TRAVEL.—The Secretary, acting through 

the Service, may reimburse health professionals seeking positions 

with Indian Health Programs or Urban Indian Organizations, including unpaid student volunteers and individuals considering entering into a contract under section 110, and their spouses, for actual and reasonable expenses incurred in traveling to and from 

their places of residence to an area in which they may be assigned 

for the purpose of evaluating such area with respect to such assignment. 

(b) RECRUITMENT PERSONNEL.—The Secretary, acting through the 

Service, shall assign one individual in each Area Office to be responsible on a full-time basis for recruitment activities. 

SEC. 113. INDIAN RECRUITMENT AND RETENTION PROGRAM. 

(a) IN GENERAL.—The Secretary, acting through the Service, shall 

fund 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. 

(b) ELIGIBLE ENTITIES; APPLICATION.—Any Tribal Health Program or Urban Indian Organization may submit an application for 

funding of a project pursuant to this section. 

SEC. 114. ADVANCED TRAINING AND RESEARCH. 

(a) DEMONSTRATION PROGRAM.—The Secretary, acting through 

the Service, shall establish a demonstration project to enable health 

professionals who have worked in an Indian Health Program or 

Urban Indian Organization for a substantial period of time to pursue advanced training or research areas of study for which the Secretary determines a need exists. 

(b) SERVICE OBLIGATION.—An individual who participates in a 

program under subsection (a), where the educational costs are borne 

by the Service, shall incur an obligation to serve in an Indian 

Health Program or Urban Indian Organization for a period of obligated service equal to at least the period of time during which the 

individual participates in such program. 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 2006, 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 in 

the manner provided for in such subsection. 

(c) EQUAL OPPORTUNITY FOR PARTICIPATION.—Health professionals from Tribal Health Programs and Urban Indian Organizations shall be given an equal opportunity to participate in the program under subsection (a). 


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SEC. 115. 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 

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. 

(5) Programs conducted by tribal colleges and universities. 

(e) QUENTIN N. BURDICK PROGRAM GRANT.—The Secretary shall 

provide one of the grants authorized under subsection (a) to establish and maintain a program at the University of North Dakota to 

be known as the ‘‘Quentin N. Burdick American Indians Into Nursing Program’’. Such program shall, to the maximum extent feasible, 

coordinate with the Quentin N. Burdick Indian Health Programs 

established under section 117(b) and the Quentin N. Burdick American Indians Into Psychology Program established under section 

105(b). 

(f) ACTIVE DUTY SERVICE OBLIGATION.—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 individual who reVerDate Aug 31 2005 06:29 Sep 16, 2006 Jkt 049006 PO 00000 Frm 00219 Fmt 6659 Sfmt 6603 E:\HR\OC\HR661P1.XXX HR661P1

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ceives training or assistance described in paragraph (1) or (2) of 

subsection (b) that is funded by a grant provided under subsection 

(a). Such obligation shall be met by service—

(1) in the Service; 

(2) 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); 

(3) in a program assisted under title V of this Act; 

(4) in the private practice of nursing if, as determined by the 

Secretary, in accordance with guidelines promulgated by the 

Secretary, such practice is situated in a physician or other 

health shortage area and addresses the health care needs of a 

substantial number of Indians; or 

(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. 

SEC. 116. TRIBAL CULTURAL ORIENTATION. 

(a) CULTURAL EDUCATION OF EMPLOYEES.—The Secretary, acting 

through the Service, shall require that appropriate employees of the 

Service who serve Indian Tribes in each Service Area receive educational instruction in the history and culture of such Indian Tribes 

and their relationship to the Service. 

(b) PROGRAM.—In carrying out subsection (a), the Secretary shall 

establish a program which shall, to the extent feasible—

(1) be developed in consultation with the affected Indian 

Tribes, Tribal Organizations, and Urban Indian Organizations; 

(2) be carried out through tribal colleges or universities; and 

(3) include instruction in American Indian studies. 

SEC. 117. INMED PROGRAM. 

(a) GRANTS AUTHORIZED.—The Secretary, acting through the 

Service, is authorized to provide grants to colleges and universities 

for the purpose of maintaining and expanding the Indian health careers recruitment program known as the ‘‘Indians Into Medicine 

Program’’ (hereinafter in this section referred to as ‘‘INMED’’) as a 

means of encouraging Indians to enter the health professions. 

(b) QUENTIN N. BURDICK GRANT.—The Secretary shall provide 

one of the grants authorized under subsection (a) 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) and the Quentin N. Burdick American Indians Into Nursing Program established under section 115. 

(c) REGULATIONS.—The Secretary, pursuant to this Act, shall develop regulations to govern grants pursuant to this section. 

(d) REQUIREMENTS.—Applicants for grants provided under this 

section shall agree to provide a program which—

(1) provides outreach and recruitment for health professions 

to Indian communities, including elementary and secondary 


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schools and community colleges located on reservations, which 

will be served by the program; 

(2) incorporates a program advisory board comprised of representatives from the Indian Tribes and Indian communities 

which will be served by the program; 

(3) provides summer preparatory programs for Indian students who need enrichment in the subjects of math and science 

in order to pursue training in the health professions; 

(4) provides tutoring, counseling, and support to students who 

are enrolled in a health career program of study at the respective college or university; and 

(5) to the maximum extent feasible, employs qualified Indians 

in the program. 

SEC. 118. HEALTH TRAINING PROGRAMS OF COMMUNITY COLLEGES. 

(a) GRANTS TO ESTABLISH PROGRAMS.—

(1) IN GENERAL.—The Secretary, acting through the Service, 

shall award grants to accredited and accessible community colleges for the purpose of assisting such community colleges in the 

establishment of programs which provide education in a health 

profession leading to a degree or diploma in a health profession 

for individuals who desire to practice such profession on or 

near a reservation or in an Indian Health Program. 

(2) AMOUNT OF GRANTS.—The amount of any grant awarded 

to a community college under paragraph (1) for the first year 

in which such a grant is provided to the community college 

shall not exceed $100,000. 

(b) GRANTS FOR MAINTENANCE AND RECRUITING.—

(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) 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 accredited; 

(B) has a relationship with a hospital facility, Service facility, or hospital that could provide training of nurses or 

health professionals; 

(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 which train health professionals; and 

(ii) stipulate certifications necessary to approve internship and field placement opportunities at Indian 

Health Programs; 

(D) has a qualified staff which has the appropriate certifications; 

(E) is capable of obtaining State or regional accreditation 

of the program described in subsection (a)(1); and 

(F) agrees to provide for Indian preference for applicants 

for programs under this section. 


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(c) TECHNICAL ASSISTANCE.—The Secretary shall encourage community colleges described in subsection (b)(2) to establish and maintain programs described in subsection (a)(1) by—

(1) entering into agreements with such colleges for the provision of qualified personnel of the Service to teach courses of 

study in such programs; and 

(2) providing technical assistance and support to such colleges. 

(d) ADVANCED 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) has already received a degree or diploma in such 

health profession; and 

(B) provides clinical services on or near a reservation or 

for an Indian Health Program. 

(2) MAY BE OFFERED AT ALTERNATE SITE.—Such courses of 

study may be offered in conjunction with the college or university with which the community college has entered into the 

agreement required under subsection (b)(2)(C). 

(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. 

SEC. 119. RETENTION BONUS. 

(a) BONUS AUTHORIZED.—The Secretary may pay a retention 

bonus to any health professional employed by, or assigned to, and 

serving in, an Indian Health Program or Urban Indian Organization either as a civilian employee or as a commissioned officer in 

the Regular or Reserve Corps of the Public Health Service who—

(1) is assigned to, and serving in, a position for which recruitment or retention of personnel is difficult; 

(2) the Secretary determines is needed by Indian Health Programs and Urban Indian Organizations; 

(3) has—

(A) completed 3 years of employment with an Indian 

Health Program or Urban Indian Organization; or 

(B) completed any service obligations incurred as a requirement of—

(i) any Federal scholarship program; or 

(ii) any Federal education loan repayment program; 

and 

(4) enters into an agreement with an Indian Health Program 

or Urban Indian Organization for continued employment for a 

period of not less than 1 year. 

(b) RATES.—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), but in no event shall the annual rate be more than $25,000 

per annum. 

(c) DEFAULT OF RETENTION AGREEMENT.—Any health professional failing to complete the agreed upon term of service, except 

where such failure is through no fault of the individual, shall be obligated to refund to the Government the full amount of the retention 


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bonus for the period covered by the agreement, plus interest as determined by the Secretary in accordance with section 110(l)(2)(B). 

(d) OTHER RETENTION BONUS.—The Secretary may pay a retention bonus to any health professional employed by a Tribal Health 

Program if such health professional is serving in a position which 

the Secretary determines is—

(1) a position for which recruitment or retention is difficult; 

and 

(2) necessary for providing health care services to Indians. 

SEC. 120. NURSING RESIDENCY PROGRAM. 

(a) ESTABLISHMENT OF PROGRAM.—The Secretary, acting through 

the Service, shall establish a program to enable Indians who are licensed practical nurses, licensed vocational nurses, and registered 

nurses who are working in an Indian Health Program or Urban Indian Organization, and have done so for a period of not less than 

1 year, to pursue advanced training. Such program shall include a 

combination of education and work study in an Indian Health Program or Urban Indian Organization leading to an associate or 

bachelor’s degree (in the case of a licensed practical nurse or licensed vocational nurse), a bachelor’s degree (in the case of a registered nurse), or advanced degrees or certification in nursing and 

public health. 

(b) SERVICE OBLIGATION.—An individual who participates in a 

program under subsection (a), where the educational costs are paid 

by the Service, shall incur an obligation to serve in an Indian 

Health Program or Urban Indian Organization for a period of obligated service equal to the amount of 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 in the manner provided for in such subsection. 

SEC. 121. COMMUNITY HEALTH AIDE PROGRAM FOR ALASKA. 

(a) GENERAL PURPOSES OF PROGRAM.—Under the authority of the 

Act of November 2, 1921 (25 U.S.C. 13) (commonly known as the 

‘‘Snyder Act’’), the Secretary, acting through the Service, shall develop and operate a Community Health Aide Program in Alaska 

under which the Service—

(1) provides for the training of Alaska Natives as health aides 

or community health practitioners; 

(2) uses such aides or practitioners in the provision of health 

care, health promotion, and disease prevention services to Alaska Natives living in villages in rural Alaska; and 

(3) provides for the establishment of teleconferencing capacity 

in health clinics located in or near such villages for use by community health aides or community health practitioners. 

(b) SPECIFIC PROGRAM REQUIREMENTS.—The Secretary, acting 

through the Community Health Aide Program of the Service, 

shall—

(1) using trainers accredited by the Program, provide a high 

standard of training to community health aides and community 

health practitioners to ensure that such aides and practitioners 

provide quality health care, health promotion, and disease prevention services to the villages served by the Program; 


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(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); 

(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; 

(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; and 

(7) ensure that pupal therapy (not including pulpotomies of 

deciduary teeth) or extraction of adult teeth can be performed 

by a dental health aide therapist only after consultation with 

a licensed dentist who determines that the procedure is a medical emergency that cannot be resolved with palliative treatment, and further that dental health aide therapists are strictly 

prohibited from performing all other oral or jaw surgeries, provided that uncomplicated extractions shall not be considered 

oral surgery under this section. 

(c) PROGRAM REVIEW.—

(1) NEUTRAL PANEL.—

(A) ESTABLISHMENT.—The Secretary, acting through the 

Service, shall establish a neutral panel to carry out the 

study under paragraph (2). 

(B) MEMBERSHIP.—Members of the neutral panel shall be 

appointed by the Secretary from among clinicians, economists, community practitioners, oral epidemiologists, and 

Alaska Natives. 

(2) STUDY.—

(A) IN GENERAL.—The neutral panel established under 

paragraph (1) shall conduct a study of the dental health 

aide therapist services provided by the Community Health 

Aide Program under this section to ensure that the quality 

of care provided through those services is adequate and appropriate. 


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(B) PARAMETERS OF STUDY.—The Secretary, in consultation with interested parties, including professional dental 

organizations, shall develop the parameters of the study. 

(C) INCLUSIONS.—The study shall include a determination by the neutral panel with respect to—

(i) the ability of the dental health aide therapist services under this section to address the dental care needs 

of Alaska Natives; 

(ii) the quality of care provided through those services, including any training, improvement, or additional oversight required to improve the quality of care; 

and 

(iii) whether safer and less costly alternatives to the 

dental health aide therapist services exist. 

(D) CONSULTATION.—In carrying out the study under this 

paragraph, the neutral panel shall consult with Alaska 

Tribal Organizations with respect to the adequacy and accuracy of the study. 

(3) REPORT.—The neutral panel shall submit to the Secretary, 

the Committee on Indian Affairs of the Senate, and the Committee on 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. 

(2) EXCEPTION.—The national Community Health Aide Program under paragraph (1) 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). 

SEC. 122. TRIBAL HEALTH PROGRAM ADMINISTRATION. 

The Secretary, acting through the Service, shall, by contract or 

otherwise, provide training for Indians in the administration and 

planning of Tribal Health Programs. 

SEC. 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—


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(1) to provide direct clinical and practical experience at a 

Service Unit to health profession students and residents from 

medical schools; 

(2) to improve the quality of health care for Indians by assuring access to qualified health care professionals; and 

(3) to provide academic and scholarly opportunities for 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. 

SEC. 124. NATIONAL HEALTH SERVICE CORPS. 

(a) NO REDUCTION IN SERVICES.—The Secretary shall not—

(1) remove a member of the National Health Service Corps 

from an Indian Health Program or Urban Indian Organization; or 

(2) withdraw funding used to support such member; 

unless the Secretary, acting through the Service, 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. 

SEC. 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 

1 year. Such contract or grant may be renewed for an additional 1- 

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 2006, 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. 

SEC. 126. BEHAVIORAL HEALTH TRAINING AND COMMUNITY EDUCATION PROGRAMS. 

(a) STUDY; LIST.—The Secretary, acting through the Service, and 

the Secretary of the Interior, in consultation with Indian Tribes and 

Tribal Organizations, shall conduct a study and compile a list of 

the types of staff positions specified in subsection (b) whose qualifications include, or should include, training in the identification, 

prevention, education, referral, or treatment of mental illness, or 

dysfunctional and self destructive behavior. 

(b) POSITIONS.—The positions referred to in subsection (a) are—

(1) staff positions within the Bureau of Indian Affairs, including existing positions, in the fields of—

(A) elementary and secondary education; 

(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 Indian health care and treatment 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 2006, 

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’’). 

TITLE II—HEALTH SERVICES 

SEC. 201. INDIAN HEALTH CARE IMPROVEMENT FUND. 

(a) USE OF FUNDS.—The Secretary, acting through the Service, is 

authorized to expend funds, directly or under the authority of the 

Indian Self-Determination and Education Assistance Act, (25 

U.S.C. 450 et seq.), which are appropriated under the authority of 

this section, for the purposes of—

(1) eliminating the deficiencies in health status and health resources of all Indian Tribes; 

(2) eliminating backlogs in the provision of health care services to Indians; 

(3) meeting the health needs of Indians in an efficient and equitable manner, including the use of telehealth and telemedicine when appropriate; 

(4) eliminating inequities in funding for both direct care and 

contract health service programs; and 

(5) augmenting the ability of the Service to meet the following 

health service responsibilities with respect to those Indian 

Tribes with the highest levels of health status deficiencies and 

resource deficiencies: 

(A) Clinical care, including, inpatient care, outpatient 

care (including audiology, clinical eye, and vision care), 

primary care, secondary and tertiary care, and long-term 

care. 

(B) Preventive health, including mammography and 

other cancer screening in accordance with section 207. 

(C) Dental care. 

(D) Mental health, including community mental health 

services, inpatient mental health services, dormitory mental 

health services, therapeutic and residential treatment centers, and training of traditional Indian practitioners. 


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(E) Emergency medical services. 

(F) Treatment and control of, and rehabilitative care related to, alcoholism and drug abuse (including fetal alcohol 

syndrome) among Indians. 

(G) Injury prevention programs. 

(H) Home health care. 

(I) Community health representatives. 

(J) Maintenance and repair. 

(b) NO OFFSET OR LIMITATION.—Any funds appropriated under 

the authority of this section shall not be used to offset or limit any 

other appropriations made to the Service under this Act or the Act 

of November 2, 1921 (25 U.S.C. 13) (commonly known as the ‘‘Snyder Act’’), or any other provision of law. 

(c) ALLOCATION; USE.—

(1) IN GENERAL.—Funds appropriated under the authority of 

this section shall be allocated to Service Units, Indian Tribes, 

or Tribal Organizations. The funds allocated to each Indian 

Tribe, Tribal Organization, or Service Unit under this paragraph shall be used by the Indian Tribe, Tribal Organization, 

or Service Unit under this paragraph to improve the health status and reduce the resource deficiency of each Indian Tribe 

served by such Service Unit, Indian Tribe, or Tribal Organization. 

(2) APPORTIONMENT OF ALLOCATED FUNDS.—The apportionment of funds allocated to a Service Unit, Indian Tribe, or 

Tribal Organization under paragraph (1) among the health 

service responsibilities described in subsection (a)(5) shall be determined by the Service in consultation with, and with the active participation of, the affected Indian Tribes and Tribal Organizations. 

(d) PROVISIONS RELATING TO HEALTH STATUS AND RESOURCE DEFICIENCIES.—For the purposes of this section, the following definitions apply: 

(1) DEFINITION.—The term ‘‘health status and resource deficiency’’ means the extent to which—

(A) the health status objectives set forth in section 3(2) 

are not being achieved; and 

(B) the Indian 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 Tribe or Tribal Organization include health resources provided by the Service as well as health resources used 

by the Indian 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 Tribe 

or Tribal Organization to petition the Secretary for a review of 

any determination of the extent of the health status and resource deficiency of such Indian Tribe or Tribal Organization. 

(e) ELIGIBILITY FOR FUNDS.—Tribal Health Programs shall be eligible for funds appropriated under the authority of this section on 


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an equal basis with programs that are administered directly by the 

Service. 

(f) REPORT.—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 2006, the Secretary shall submit to Congress the 

current health status and resource deficiency report of the Service 

for each Service Unit, including newly recognized or acknowledged 

Indian Tribes. Such report shall set out— (1) the methodology then in use by the Service for determining 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, or any other Act, including 

the amount of any funds transferred to the Service for the 

preceding fiscal year which is allocated to each Service 

Unit, Indian Tribe, or Tribal Organization; 

(B) the number of Indians eligible for health services in 

each Service Unit or Indian Tribe or Tribal Organization; 

and 

(C) the number of Indians using the Service resources 

made available to each Service Unit, Indian Tribe or Tribal Organization, and, to the extent available, information 

on the waiting lists and number of Indians turned away for 

services due to lack of resources. 

(g) INCLUSION IN BASE BUDGET.—Funds appropriated under 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. 

(h) CLARIFICATION.—Nothing in this section is intended to diminish the primary responsibility of the Service to eliminate existing 

backlogs in unmet health care needs, nor are the provisions of this 

section intended to discourage the Service from undertaking additional efforts to achieve equity among Indian Tribes and Tribal Organizations. 

(i) FUNDING DESIGNATION.—Any funds appropriated under the 

authority of this section shall be designated as the ‘‘Indian Health 

Care Improvement Fund’’. 

SEC. 202. CATASTROPHIC HEALTH EMERGENCY FUND. 

(a) ESTABLISHMENT.—There is hereby established an Indian Catastrophic Health Emergency Fund (hereafter in this section referred 

to as the ‘‘CHEF’’) consisting of—

(1) the amounts deposited under subsection (f); and 

(2) the amounts appropriated to CHEF under this section. 

(b) ADMINISTRATION.—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. 


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(c) CONDITIONS ON USE OF FUND.—No part of CHEF or its administration shall be subject to contract or grant under any law, including the Indian Self-Determination and Education Assistance 

Act, (25 U.S.C. 450 et seq.), nor shall CHEF funds be allocated, apportioned, or delegated on an Area Office, Service Unit, or other 

similar basis. 

(d) REGULATIONS.—The Secretary shall, through the negotiated 

rulemaking process under title VIII, promulgate regulations consistent with the provisions of this section to—

(1) establish a definition of disasters and catastrophic illnesses for which the cost of the treatment provided under contract would qualify for payment from CHEF; 

(2) provide that a Service Unit shall not be eligible for reimbursement for the cost of treatment from CHEF until its cost of 

treating any victim of such catastrophic illness or disaster has 

reached a certain threshold cost which the Secretary shall establish at—

(A) the 2000 level of $19,000; and 

(B) for any subsequent year, not less than the threshold 

cost of the previous year increased by the percentage increase in the medical care expenditure category of the consumer price index for all urban consumers (United States 

city average) for the 12-month period ending with December 

of the previous year; 

(3) establish a procedure for the reimbursement of the portion 

of the costs that exceeds such threshold cost incurred by—

(A) Service Units; or 

(B) whenever otherwise authorized by the Service, nonService facilities or providers; 

(4) establish a procedure for payment from CHEF in cases in 

which the exigencies of the medical circumstances warrant 

treatment prior to the authorization of such treatment by the 

Service; and 

(5) establish a procedure that will ensure that no payment 

shall be made from CHEF to any provider of treatment to the 

extent that such provider is eligible to receive payment for the 

treatment from any other Federal, State, local, or private source 

of reimbursement for which the patient is eligible. 

(e) NO OFFSET OR LIMITATION.—Amounts appropriated to CHEF 

under this section shall not be used to offset or limit appropriations 

made to the Service under the authority of the Act of November 2, 

1921 (25 U.S.C. 13) (commonly known as the ‘‘Snyder Act’’), or any 

other law. 

(f) DEPOSIT OF REIMBURSEMENT FUNDS.—There shall be deposited into CHEF all reimbursements to which the Service is entitled 

from any Federal, State, local, or private source (including third 

party insurance) by reason of treatment rendered to any victim of 

a disaster or catastrophic illness the cost of which was paid from 

CHEF. 

SEC. 203. HEALTH PROMOTION AND DISEASE PREVENTION SERVICES. 

(a) FINDINGS.—Congress finds that health promotion and disease 

prevention activities—

(1) improve the health and well-being of Indians; and 

(2) reduce the expenses for health care of Indians. 


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(b) PROVISION OF SERVICES.—The Secretary, acting through the 

Service and Tribal Health Programs, shall provide health promotion and disease prevention services to Indians to achieve the 

health status objectives set forth in section 3(2). 

(c) EVALUATION.—The Secretary, after obtaining input from the 

affected Tribal Health Programs, shall submit to the President for 

inclusion in each report which is required to be submitted to Congress under section 801 an evaluation of— (1) the health promotion and disease prevention needs of Indians; 

(2) the health promotion and disease prevention activities 

which would best meet such needs; 

(3) the internal capacity of the Service and Tribal Health Programs to meet such needs; and 

(4) the resources which would be required to enable the Service and Tribal Health Programs to undertake the health promotion and disease prevention activities necessary to meet such 

needs. 

SEC. 204. DIABETES PREVENTION, TREATMENT, AND CONTROL. 

(a) DETERMINATIONS REGARDING DIABETES.—The Secretary, acting through the Service, and in consultation with Indian Tribes and 

Tribal Organizations, shall determine— (1) by an Indian Tribe, Tribal Organization, and by Service 

Unit, the incidence of, and the types of complications resulting 

from, diabetes among Indians; and 

(2) based on the determinations made pursuant to paragraph 

(1), the measures (including patient education and effective ongoing monitoring of disease indicators) each Service Unit 

should take to reduce the incidence of, and prevent, treat, and 

control the complications resulting from, diabetes among Indian 

Tribes within that Service Unit. 

(b) DIABETES SCREENING.—To the extent medically indicated and 

with informed consent, the Secretary shall screen each Indian who 

receives services from the Service for diabetes and for conditions 

which indicate a high risk that the individual will become diabetic 

and, 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 by a Tribal 

Health Program and may be conducted through appropriate Internet-based health care management programs. 

(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 Amendments Act 

of 2006, 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 2006 and for projects which are added and funded thereafter. 

(d) FUNDING FOR DIALYSIS PROGRAMS.—The Secretary is authorized to provide funding through the Service, Indian Tribes, and 


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Tribal Organizations to establish dialysis programs, including 

funding to purchase dialysis equipment and provide necessary staffing. 

(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 officer to coordinate and manage any activity of that Area Office relating to the prevention, treatment, or control of diabetes to assist the Secretary in carrying out a program 

under this section or section 330C of the Public Health 

Service Act (42 U.S.C. 254c–3). 

(B) CERTAIN ACTIVITIES.—Any activity carried out by a 

diabetes control officer under subparagraph (A) that is the 

subject of a contract or compact under the Indian Self-Determination and Education Assistance Act (25 U.S.C. 450 

et seq.), and any funds made available to carry out such an 

activity, shall not be divisible for purposes of that Act. 

SEC. 205. SHARED SERVICES FOR LONG-TERM CARE. 

(a) LONG-TERM CARE.—Notwithstanding any other provision of 

law, the Secretary, acting through the Service, is authorized to provide directly, or enter into contracts or compacts under the Indian 

Self-Determination and Education Assistance Act (25 U.S.C. 450 et 

seq.) with Indian Tribes or Tribal Organizations for, the delivery of 

long-term care 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 Assistance 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 


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(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. 

SEC. 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 

equal opportunity to compete for, and receive, research funds under 

this section. This funding may be used for both clinical and nonclinical research. 

SEC. 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 national standards, such as those 

of the National Cancer Institute for the National Institutes for 

Health, 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 national standards, such 

as those of the National Cancer Institute. 

SEC. 208. PATIENT TRAVEL COSTS. 

The Secretary, acting through the Service and Tribal Health Programs, shall 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 SelfDetermination and Education Assistance Act (25 U.S.C. 450 eq 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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SEC. 209. EPIDEMIOLOGY CENTERS. 

(a) ADDITIONAL CENTERS.—In addition to those epidemiology centers already established at the time 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 2006, 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 at 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. 

SEC. 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 FUNDS.—A grant awarded under this section may be 

used for purposes which may include, but are not limited to, the following: 


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(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. 

(13) Violence prevention. 

(14) Such other health issues as are appropriate. 

(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 grants awarded under 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) 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; 


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(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. 

SEC. 211. INDIAN YOUTH PROGRAM. 

(a) PROGRAM AUTHORIZED.—The Secretary, acting through the 

Service, is authorized to establish and administer a program to provide 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 

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 healers; 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. 

SEC. 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. 

(2) Public information and education programs for the prevention, control, and elimination of communicable and infectious diseases. 

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nicable 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. 

SEC. 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 community-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.—Any service provided under this section shall 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) Homemaker/home health aide services. 

(ii) Personal care services. 

(iii) Chore services. 

(iv) Nursing care services provided outside of a nursing 

facility by, or under the supervision of, a registered nurse. 


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(v) Respite care. 

(vi) Training for family members. 

(vii) Adult day care. 

(viii) 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 immediate relative who 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) 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. 

SEC. 214. INDIAN WOMEN’S HEALTH CARE. 

The Secretary, acting through the Service and Indian Tribes, 

Tribal Organizations, and Urban Indian Organizations, shall monitor and improve the quality of health care for Indian women of all 

ages through the planning and delivery of programs administered 

by the Service, in order to improve and enhance the treatment models of care for Indian women. 

SEC. 215. ENVIRONMENTAL AND NUCLEAR HEALTH HAZARDS. 

(a) STUDIES AND MONITORING.—The Secretary and the Service 

shall conduct, in conjunction with other appropriate Federal agencies and in consultation with concerned Indian Tribes and Tribal 

Organizations, studies and ongoing monitoring programs to determine trends in the health hazards to Indian miners and to Indians 

on or near reservations and Indian communities as a result of environmental hazards which may result in chronic or life threatening 

health problems, such as nuclear resource development, petroleum 

contamination, and contamination of water source and of the food 

chain. Such studies shall include—

(1) an evaluation of the nature and extent of health problems 

caused by environmental hazards currently exhibited among Indians and the causes of such health problems; 

(2) an analysis of the potential effect of ongoing and future 

environmental resource development on or near reservations 

and Indian communities, including the cumulative effect over 

time on health; 

(3) an evaluation of the types and nature of activities, practices, and conditions causing or affecting such health problems, 

including uranium mining and milling, uranium mine tailing 

deposits, nuclear power plant operation and construction, and 

nuclear waste disposal; oil and gas production or transportation on or near reservations or Indian communities; and other 


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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 

2006 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 2006. The health care plan prepared under subsection (b) shall 

be submitted in a report no later than 1 year after the study prepared under subsection (a) is submitted to Congress. Such report 

shall include recommended activities for the implementation of the 

plan, as well as an evaluation of any activities previously undertaken by the Service to address such health problems. 

(d) INTERGOVERNMENTAL TASK FORCE.—

(1) ESTABLISHMENT; MEMBERS.—There is established an 

Intergovernmental Task Force to be composed of the following 

individuals (or their designees): 

(A) The Secretary of Energy. 

(B) The Administrator of the Environmental Protection 

Agency. 

(C) The Director of the Bureau of Mines. 

(D) The Assistant Secretary for Occupational Safety and 

Health. 

(E) The Secretary of the Interior. 

(F) The Secretary of Health and Human Services. 

(G) The Assistant Secretary of Indian Health. 

(2) DUTIES.—The Task Force shall—

(A) identify existing and potential operations related to 

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ards that affect or may affect the health of Indians on or 

near a reservation or in an Indian community; and 

(B) enter into activities to correct existing health hazards 

and ensure that current and future health problems resulting from nuclear resource or other development activities 

are minimized or reduced. 

(3) CHAIRMAN; MEETINGS.—The Secretary of Health and 

Human Services shall be the Chairman of the Task Force. The 

Task Force shall meet at least twice each year. 

(e) HEALTH SERVICES TO CERTAIN EMPLOYEES.—In the case of 

any Indian who—

(1) as a result of employment in or near a uranium mine or 

mill or near any other environmental hazard, suffers from a 

work-related illness or condition; 

(2) is eligible to receive diagnosis and treatment services from 

an Indian Health Program; and 

(3) by reason of such Indian’s employment, is entitled to medical care at the expense of such mine or mill operator or entity 

responsible for the environmental hazard, the Indian Health 

Program shall, at the request of such Indian, render appropriate medical care to such Indian for such illness or condition 

and may be reimbursed for any medical care so rendered to 

which such Indian is entitled at the expense of such operator or 

entity from such operator or entity. Nothing in this subsection 

shall affect the rights of such Indian to recover damages other 

than such amounts paid to the Indian Health Program from 

the employer for providing medical care for such illness or condition. 

SEC. 216. ARIZONA AS A CONTRACT HEALTH SERVICE DELIVERY AREA. 

(a) IN GENERAL.—For fiscal years beginning with the fiscal year 

ending September 30, 1983, and ending with the fiscal year ending 

September 30, 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). 

SEC. 216A. NORTH DAKOTA AS A CONTRACT HEALTH SERVICE DELIVERY AREA. 

(a) IN GENERAL.—For fiscal years beginning with the fiscal year 

ending September 30, 2003, and ending with the fiscal year ending 

September 30, 2015, the State of North 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. 

(b) LIMITATION.—The Service shall not curtail any health care 

services provided to Indians residing on reservations in the State of 

North Dakota 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). 


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SEC. 216B. SOUTH DAKOTA AS A CONTRACT HEALTH SERVICE DELIVERY AREA. 

(a) IN GENERAL.—For fiscal years beginning with the fiscal year 

ending September 30, 2003, and ending with the fiscal year ending 

on September 30, 2015, the State of 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 South Dakota. 

(b) LIMITATION.—The Service shall not curtail any health care 

services provided to Indians residing on reservations in the State of 

South Dakota if such curtailment is due to the provision of contract 

services in such State pursuant to the designation of such State as 

a contract health service delivery area pursuant to subsection (a). 

SEC. 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 hereby established an advisory 

board which shall advise the CRIHB in carrying out this section. 

The advisory board shall be composed of representatives, selected by 

the CRIHB, from not less than 8 Tribal Health Programs serving 

California Indians covered under this section at least one half of 

whom are not affiliated with the CRIHB. 

SEC. 218. CALIFORNIA AS A CONTRACT HEALTH SERVICE DELIVERY 

AREA. 

The State of California, excluding the counties of Alameda, 

Contra Costa, Los Angeles, Marin, Orange, Sacramento, San Francisco, San Mateo, Santa Clara, Kern, Merced, Monterey, Napa, San 

Benito, San Joaquin, San Luis Obispo, Santa Cruz, Solano, 

Stanislaus, and Ventura, shall be designated as a contract health 

service delivery area by the Service for the purpose of providing contract health services to California Indians. However, any of the 

counties listed herein may only be included in the contract health 

services delivery area if funding is specifically provided by the Service for such services in those counties. 


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SEC. 219. CONTRACT HEALTH SERVICES FOR THE TRENTON SERVICE 

AREA. 

(a) AUTHORIZATION FOR SERVICES.—The Secretary, acting 

through the Service, is directed to provide contract health services 

to members of the Turtle Mountain Band of Chippewa Indians that 

reside in the Trenton Service Area of Divide, McKenzie, and Williams counties in the State of North Dakota and the adjoining counties of Richland, Roosevelt, and Sheridan in the State of Montana. 

(b) NO EXPANSION OF ELIGIBILITY.—Nothing in this section may 

be construed as expanding the eligibility of members of the Turtle 

Mountain Band of Chippewa Indians for health services provided 

by the Service beyond the scope of eligibility for such health services 

that applied on May 1, 1986. 

SEC. 220. PROGRAMS OPERATED BY INDIAN TRIBES AND TRIBAL ORGANIZATIONS. 

The Service shall provide funds for health care programs and facilities operated by Tribal Health Programs on the same basis as 

such funds are provided to programs and facilities operated directly 

by the Service. 

SEC. 221. LICENSING. 

Health care professionals employed by a Tribal Health Program 

shall, if licensed in any State, be exempt from the licensing requirements of the State in which the Tribal Health Program performs the 

services described in its contract or compact under the Indian SelfDetermination and Education Assistance Act (25 U.S.C. 450 et seq.). 

SEC. 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. 

SEC. 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. 

SEC. 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 


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services not later than 5 business days after receipt of a notification 

of a claim by a provider of contract care services. 

(c) NO RECOURSE.—Following receipt of the notice provided under 

subsection (b), or, if a claim has been deemed accepted under section 

223(b), the provider shall have no further recourse against the patient who received the services. 

SEC. 225. 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. 

TITLE III—FACILITIES 

SEC. 301. CONSULTATION: CONSTRUCTION AND RENOVATION OF FACILITIES; REPORTS. 

(a) PREREQUISITES FOR EXPENDITURE OF FUNDS.—Prior to the expenditure of, or the making of any binding commitment to expend, 

any funds appropriated for the planning, design, construction, or 

renovation of facilities pursuant to the Act of November 2, 1921 (25 

U.S.C. 13) (commonly known as the ‘‘Snyder Act’’), the Secretary, 

acting through the Service, shall—

(1) consult with any Indian 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 made; 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 by not later than 1 year after the 

date on which the construction or renovation of such facility is 

completed. 

(b) CLOSURES.—

(1) EVALUATION REQUIRED.—Notwithstanding any other provision of law, no facility operated by the Service may be closed 

if the Secretary has not submitted to Congress at least 1 year 

prior to the date of the proposed closure an evaluation of the 

impact of the proposed closure which specifies, in addition to 

other considerations—

(A) the accessibility of alternative health care resources 

for the population served by such facility; 

(B) the cost-effectiveness of such closure; 

(C) the quality of health care to be provided to the population served by such facility after such closure; 

(D) the availability of contract health care funds to maintain existing levels of service; 

(E) the views of the Indian Tribes served by such facility 

concerning such closure; 

(F) the level of use of such facility by all eligible Indians; 

and 

(G) the distance between such facility and the nearest operating Service hospital. 


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(2) EXCEPTION FOR CERTAIN TEMPORARY CLOSURES.—Paragraph (1) shall not apply to any temporary closure of a facility 

or any portion of a facility if such closure is necessary for medical, environmental, or construction safety reasons. 

(c) HEALTH CARE 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 2006 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) REPORT; CONTENTS.—The Secretary shall submit to the 

President, for inclusion in each report required to be transmitted to Congress under section 801, a report which sets forth 

the following: 

(A) A description of the health care facility priority system of the Service, established under paragraph (1). 

(B) Health care facilities lists, including—

(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 patient hostels associated with 

health care facilities. 

(C) The justification for such order of priority. 

(D) The projected cost of such projects. 

(E) The methodology adopted by the Service in establishing priorities under its health care facility priority system. 


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(3) REQUIREMENTS FOR PREPARATION OF REPORTS.—In preparing each report required under paragraph (2) (other than 

the initial report), the Secretary shall annually— (A) consult with and obtain information on all health 

care facilities needs from Indian Tribes, Tribal Organizations, and Urban Indian Organizations; and 

(B) review the total unmet needs of all Indian Tribes, 

Tribal Organizations, and Urban Indian Organizations for 

health care facilities (including hostels and staff quarters), 

including needs for renovation and expansion of existing facilities. 

(4) CRITERIA FOR EVALUATING NEEDS.—For purposes of this 

subsection, the Secretary shall, in evaluating the needs of facilities operated under any contract or compact under the Indian 

Self-Determination and Education Assistance Act (25 U.S.C. 

450 et seq.) use the same criteria that the Secretary uses in evaluating the needs of facilities operated directly by the Service. 

(5) 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 funding agreements in accordance with the Indian 

Self-Determination and Education Assistance Act (25 U.S.C. 

450 et seq.) are fully and equitably integrated into the health 

care facility priority system. 

(d) REVIEW OF NEED FOR FACILITIES.— (1) 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 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 contract or compact 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 Funding Agreement 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. 


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(e) FUNDING CONDITION.—All funds appropriated under the Act of 

November 2, 1921 (25 U.S.C. 13) (commonly known as the ‘‘Snyder 

Act’’), for the planning, design, construction, or renovation of health 

facilities for the benefit of 1 or more Indian Tribes shall be subject 

to the provisions 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. 

SEC. 302. SANITATION FACILITIES. 

(a) FINDINGS.—Congress finds the following: 

(1) The provision of sanitation facilities is primarily a health 

consideration and function. 

(2) Indian people suffer an inordinately high incidence of disease, injury, and illness directly attributable to the absence or 

inadequacy of sanitation facilities. 

(3) The long-term cost to the United States of treating and 

curing such disease, injury, and illness is substantially greater 

than the short-term cost of providing sanitation facilities and 

other preventive health measures. 

(4) Many Indian homes and Indian communities still lack 

sanitation facilities. 

(5) 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. 

(b) FACILITIES AND SERVICES.—In furtherance of the findings 

made in subsection (a), 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.C. 2006a). Under such authority, the Secretary, 

acting through the Service, is authorized to provide the following: 

(1) Financial and technical assistance to Indian Tribes, Tribal Organizations, and Indian communities in the establishment, training, and equipping of utility organizations to operate 

and maintain sanitation facilities, including the provision of existing plans, standard details, and specifications available in 

the Department, to be used at the option of the Indian Tribe, 

Tribal Organization, or Indian community. 

(2) 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. 

(3) Priority funding for operation and maintenance assistance 

for, and emergency repairs to, sanitation facilities operated by 

an Indian Tribe, Tribal Organization or Indian community 

when necessary to avoid an imminent health threat or to protect 

the investment in sanitation facilities and the investment in the 

health benefits gained through the provision of sanitation facilities. 

(c) FUNDING.—Notwithstanding any other provision of law—


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(1) the Secretary of Housing and Urban Development is authorized to transfer funds appropriated under the Native American Housing Assistance and Self-Determination Act of 1996 to 

the Secretary of Health and Human Services; 

(2) the Secretary of Health and Human Services is authorized 

to accept and use such funds for the purpose of providing sanitation facilities and services for Indians under section 7 of the 

Act of August 5, 1954 (42 U.S.C. 2004a); 

(3) unless specifically authorized when funds are appropriated, the Secretary shall not use funds appropriated under 

section 7 of the Act of August 5, 1954 (42 U.S.C. 2004a), to provide sanitation facilities to new homes constructed using funds 

provided by the Department of Housing and Urban Development; 

(4) the Secretary of Health and Human Services is authorized 

to accept from any source, including Federal and State agencies, funds for the purpose of providing sanitation facilities and 

services and place these funds into contracts or compacts under 

the Indian Self-Determination and Education Assistance Act 

(25 U.S.C. 450 et seq.); 

(5) except as otherwise prohibited by this section, the Secretary may use funds appropriated under the authority of section 7 of the Act of August 5, 1954 (42 U.S.C. 2004a) to fund 

up to 100 percent of the amount of an Indian Tribe’s loan obtained under any Federal program for new projects to construct 

eligible sanitation facilities to serve Indian homes; 

(6) except as otherwise prohibited by this section, the Secretary may use funds appropriated under the authority of section 7 of the Act of August 5, 1954 (42 U.S.C. 2004a) to meet 

matching or cost participation requirements under other Federal and non-Federal programs for new projects to construct eligible sanitation facilities; 

(7) all Federal agencies are authorized to transfer to the Secretary funds identified, granted, loaned, or appropriated whereby the Department’s applicable policies, rules, and regulations 

shall apply in the implementation of such projects; 

(8) the Secretary 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 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. 

(d) CERTAIN CAPABILITIES NOT PREREQUISITE.—The financial 

and technical capability of an Indian 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 ASSISTANCE.—The Secretary is authorized to provide financial assistance to Indian Tribes, Tribal Organizations, 

and Indian communities for operation, management, and maintenance of their sanitation facilities. 

(f) OPERATION, MANAGEMENT, AND MAINTENANCE OF FACILITIES.—The Indian Tribe, Tribal Organization, or Indian community 


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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, Tribal Organization, or Indian community 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. 

(h) REPORT.—

(1) REQUIRED; CONTENTS.—The Secretary, in consultation 

with the Secretary of Housing and Urban Development, Indian 

Tribes, Tribal Organizations, and tribally designated housing 

entities (as defined in section 4 of the Native American Housing 

Assistance and Self-Determination Act of 1996 (25 U.S.C. 

4103)) shall submit to the President, for inclusion in each report required to be transmitted to Congress under section 801, 

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 for each project of each Indian Tribe or Indian community; 

(D) the amount and most effective use of funds, derived 

from whatever source, necessary to accommodate the sanitation facilities needs of new homes assisted with funds 

under the Native American Housing Assistance and SelfDetermination Act, and to reduce the identified sanitation 

deficiency levels of all Indian Tribes and Indian communities to 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. 

(2) CRITERIA.—The criteria on which the deficiencies and 

needs will be evaluated shall be developed through negotiated 

rulemaking pursuant to section 802. 

(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 Tribes and Indian 

communities. 

(4) SANITATION DEFICIENCY LEVELS.—For purposes of this 

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dian 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 an individual, Indian Tribe, or Indian community—

(i) complies with all applicable water supply, pollution control, and solid waste disposal laws; and 

(ii) deficiencies relate to routine replacement, repair, 

or maintenance needs. 

(B) A level II deficiency exists if a sanitation facility serving an individual, Indian Tribe, or Indian community substantially or recently complied with all applicable water 

supply, pollution control, and solid waste laws and any deficiencies relate to—

(i) small or minor capital improvements needed to 

bring the facility back into compliance; 

(ii) capital improvements that are necessary to enlarge or improve the facilities in order to meet the current needs for domestic sanitation facilities; or 

(iii) the lack of equipment or training by an Indian 

Tribe, Tribal Organization, or an Indian community to 

properly operate and maintain the sanitation facilities. 

(C) A level III deficiency exists if a sanitation facility 

serving an individual, Indian Tribe or Indian community 

meets one or more of the following conditions—

(i) water or sewer service in the home is provided by 

a haul system with holding tanks and interior plumbing; 

(ii) major significant interruptions to water supply or 

sewage disposal occur frequently, requiring major capital improvements to correct the deficiencies; or 

(iii) there is no access to or no approved or permitted 

solid waste facility available. 

(D) A level IV deficiency exists—

(i) if a sanitation facility for an individual home, an 

Indian Tribe, or an Indian community exists but—

(I) lacks—

(aa) a safe water supply system; or 

(bb) a waste disposal system; 

(II) contains no piped water or sewer facilities; 

or 

(III) has become inoperable due to a major component failure; or 

(ii) if only a washeteria or central facility exists in 

the community. 

(E) A level V deficiency exists in the absence of a sanitation facility, where individual homes do not have access to 

safe drinking water or adequate wastewater (including sewage) disposal. 

(i) DEFINITIONS.—For purposes of this section, the following terms 

apply: 

(1) INDIAN COMMUNITY.—The term ‘‘Indian community’’

means a geographic area, a significant proportion of whose inhabitants are Indians and which is served by or capable of 

being served by a facility described in this section. 


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(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). 

SEC. 303. PREFERENCE TO INDIANS AND INDIAN FIRMS. 

(a) BUY INDIAN ACT.—The Secretary, acting through the Service, 

may use the negotiating authority of section 23 of the Act of June 

25, 1910 (25 U.S.C. 47, commonly known as the ‘‘Buy Indian Act’’), 

to give preference to any Indian or any enterprise, partnership, corporation, or other type of business organization owned and controlled by an Indian or Indians including former or currently federally recognized Indian Tribes in the State of New York (hereinafter 

referred to as an ‘‘Indian firm’’) in the construction and renovation 

of Service facilities pursuant to section 301 and in the construction 

of sanitation facilities pursuant to section 302. Such preference may 

be accorded by the Secretary unless the Secretary finds, pursuant to 

regulations adopted pursuant to section 802, 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 finding, 

shall consider whether the Indian or Indian firm will be deficient 

with respect to—

(1) ownership and control by Indians; 

(2) equipment; 

(3) bookkeeping and accounting procedures; 

(4) substantive knowledge of the project or function to be contracted for; 

(5) adequately trained personnel; or 

(6) other necessary components of contract performance. 

(b) LABOR STANDARDS.—

(1) IN GENERAL.—For the purposes of implementing the provisions of this title, 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—

(A) is performed by a contractor pursuant to a contract 

with an Indian Tribe or Tribal Organization with funds 

supplied through a contract, compact or funding agreement 

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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SEC. 304. EXPENDITURE OF NONSERVICE FUNDS FOR RENOVATION. 

(a) IN GENERAL.—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 Tribe or Tribal Organization of any Service facility or of any other Indian health facility 

operated pursuant to a contract or compact under the Indian SelfDetermination and Education Assistance Act (25 U.S.C. 450 et seq.) 

including—

(1) any plans or designs for such expansion, renovation, or 

modernization; and 

(2) any expansion, renovation, or modernization for which 

funds appropriated under any Federal law were lawfully expended. 

(b) PRIORITY LIST.—

(1) IN GENERAL.—The Secretary shall maintain a separate 

priority list to address the needs for increased operating expenses, 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) REPORT.—The Secretary shall submit to the President, for 

inclusion in each report required to be transmitted to Congress 

under section 801, the priority list maintained pursuant to 

paragraph (1). 

(c) REQUIREMENTS.—The requirements of this subsection are met 

with respect to any expansion, renovation, or modernization if—

(1) the Indian Tribe or Tribal Organization—

(A) provides notice to the Secretary of its intent to expand, renovate, or modernize; and 

(B) applies to the Secretary to be placed on a separate 

priority list to address the needs of such new facilities for 

increased operating expenses, personnel, 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 Tribe or Tribal Organization in accordance with any applicable 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 expansions, 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.—If any Service facility which has been expanded, renovated, or modernized by an Indian 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 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 


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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. 

SEC. 305. FUNDING FOR THE CONSTRUCTION, EXPANSION, AND MODERNIZATION OF SMALL AMBULATORY CARE FACILITIES. 

(a) FUNDING.—

(1) IN GENERAL.—The Secretary, acting through the Service, 

in consultation with Indian Tribes and Tribal Organizations, 

shall make grants to Indian Tribes and Tribal Organizations 

for the construction, expansion, or modernization of facilities for 

the provision of ambulatory care services to eligible Indians 

(and noneligible persons pursuant to subsections (b)(2) and 

(c)(1)(C)). Funding made under this section may cover up to 100 

percent of the costs of such construction, expansion, or modernization. For the purposes of this section, the term ‘‘construction’’ includes the replacement of an existing facility. 

(2) GRANTS AGREEMENT REQUIRED.—A grant under paragraph (1) may only be made available to a Tribal Health Program operating an Indian health facility (other than a facility 

owned or constructed by the Service, including a facility originally owned or constructed by the Service and transferred to an 

Indian Tribe or Tribal Organization). 

(b) USE OF GRANT.—

(1) ALLOWABLE USES.—Grant awarded under this section 

may be used for the construction, expansion, or modernization 

(including the planning and design of such construction, expansion, or modernization) of an ambulatory care facility—

(A) located apart from a hospital; 

(B) not funded under section 301 or section 307; and 

(C) which, upon completion of such construction 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 

services in such facility in accordance with section 

807(c)(2); and 

(iii) provide ambulatory care in a Service Area (specified in the contract or compact under the Indian SelfDetermination and Education Assistance Act (25 

U.S.C. 450 et seq.) with a population of no fewer than 

1,500 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 

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ing 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 or 

debt reduction that benefits the Service population identified 

above in subsection (b)(1)(C) (ii) and (iii). 

(4) APPLICABILITY OF REQUIREMENTS IN THE CASE OF ISOLATED FACILITIES.—The requirements of clauses (ii) and (iii) of 

paragraph (1)(C) shall not apply to an Indian Tribe or Tribal 

Organization applying for a grant under this section for a 

health care facility located or to be constructed on an island or 

when such facility is not located on a road system providing direct access to an inpatient hospital where care is available to 

the Service population. 

(c) GRANTS.—

(1) APPLICATION.—No grant may be made available under 

this section unless an application or proposal for the grant has 

been approved by the Secretary in accordance with applicable 

regulations and has provided reasonable assurance by the applicant that, at all times after the construction, expansion, or 

modernization of a facility carried out using a grant received 

under this section—

(A) adequate financial support will be available for the 

provision of services at such facility; 

(B) such facility will be available to eligible Indians 

without regard to ability to pay or source of payment; and 

(C) such facility will, as feasible without diminishing the 

quality or quantity of services provided to eligible Indians, 

serve noneligible persons on a cost basis. 

(2) PRIORITY.—In awarding grants under this section, the 

Secretary shall give priority to Indian Tribes and Tribal Organizations that demonstrate—

(A) a need for increased ambulatory care services; and 

(B) insufficient capacity to deliver such services. 

(3) PEER REVIEW PANELS.—The Secretary may provide for the 

establishment of peer review panels, as necessary, to review and 

evaluate applications and proposals and to advise the Secretary 

regarding such applications using the criteria developed during 

consultations pursuant to subsection (a)(1). 

(d) REVERSION OF FACILITIES.—If any facility (or portion thereof) 

with respect to which funds have been paid under this section, 

ceases, within 5 years after completion of the construction, expansion, or modernization carried out with such funds, to be used for 

the purposes of providing health care services to eligible Indians, all 

of the right, title, and interest in and to such facility (or portion 

thereof) shall transfer to the United States unless otherwise negotiated by the Service and the Indian Tribe or Tribal Organization. 

(e) FUNDING NONRECURRING.—Funding provided under this section shall be nonrecurring and shall not be available for inclusion 

in any individual Indian Tribe’s tribal share for an award under 

the Indian Self-Determination and Education Assistance Act (25 

U.S.C. 450 et seq.) or for reallocation or redesign thereunder. 


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SEC. 306. INDIAN HEALTH CARE DELIVERY DEMONSTRATION 

PROJECT. 

(a) HEALTH CARE DEMONSTRATION PROJECTS.—The Secretary, 

acting through the Service, and in consultation with Indian Tribes 

and Tribal Organizations, is authorized to enter into construction 

project agreements and construction contracts under the Indian 

Self-Determination and Education Assistance Act (25 U.S.C. 450 et 

seq.) with Indian Tribes or Tribal Organizations for the purpose of 

carrying out a health care delivery demonstration project to test alternative means of delivering health care and services to Indians 

through facilities, including hospice, traditional Indian health, and 

child care facilities. 

(b) USE OF 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 funds; 

(4) permit the use of funds or property donated from any 

source for project purposes; 

(5) provide for the reversion of donated real or personal property to the donor; and 

(6) permit the use of Service funds to match other funds, including Federal funds. 

(c) REGULATIONS.—The Secretary shall develop and promulgate 

regulations not later than 1 year after the date of enactment of the 

Indian Health Care Improvement Act Amendments of 2006. If the 

Secretary has not promulgated regulations by that date, the Secretary shall develop and publish regulations, through rulemaking 

under section 802, for the review and approval of applications submitted under this section. 

(d) CRITERIA.—The Secretary may approve projects that meet the 

following criteria: 

(1) There is a need for a new facility or program or the reorientation of an existing facility or program. 

(2) A significant number of Indians, including those with low 

health status, will be served by the project. 

(3) The project has the potential to deliver services in an efficient and effective manner. 

(4) The project is economically viable. 

(5) The Indian Tribe or Tribal Organization has the administrative and financial capability to administer the project. 

(6) 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.—The Secretary may provide for the establishment of peer review panels, as necessary, to review and 

evaluate applications using the criteria developed pursuant to subsection (d). 

(f) PRIORITY.—The Secretary shall give priority to applications for 

demonstration projects in each of the following Service Units to the 

extent that such applications are timely filed and meet the criteria 

specified in subsection (d): 


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(1) Cass Lake, Minnesota. 

(2) Clinton, Oklahoma. 

(3) Harlem, Montana. 

(4) Mescalero, New Mexico. 

(5) Owyhee, Nevada. 

(6) Parker, Arizona. 

(7) Schurz, Nevada. 

(8) Winnebago, Nebraska. 

(9) Ft. Yuma, California. 

(g) TECHNICAL 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) SERVICE TO INELIGIBLE PERSONS.—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 

Service facilities to non-Service health practitioners as provided in 

section 807 may be included, subject to the terms of such section, 

in any demonstration project approved pursuant to this section. 

(i) EQUITABLE TREATMENT.—For purposes of subsection (d)(1), the 

Secretary shall, in evaluating facilities operated under any contract 

or compact under the Indian Self-Determination and Education Assistance Act (25 U.S.C. 450 et seq.) use the same criteria that the 

Secretary uses in evaluating facilities operated directly by the Service. 

(j) EQUITABLE INTEGRATION OF FACILITIES.—The Secretary shall 

ensure that the planning, design, construction, renovation, and expansion needs of Service and non-Service facilities which are the 

subject of a contract or compact under the Indian Self-Determination and Education Assistance Act (25 U.S.C. 450 et seq.) for health 

services are fully and equitably integrated into the implementation 

of the health care delivery demonstration projects under this section. 

SEC. 307. LAND TRANSFER. 

Notwithstanding any other provision of law, the Bureau of Indian 

Affairs and all other agencies and departments of the United States 

are authorized to transfer, at no cost, land and improvements to the 

Service for the provision of health care services. The Secretary is authorized to accept such land and improvements for such purposes. 

SEC. 308. LEASES, CONTRACTS, AND OTHER AGREEMENTS. 

The Secretary, acting through the Service, may enter into leases, 

contracts, and other agreements with Indian Tribes and Tribal Organizations which hold (1) title to, (2) a leasehold interest in, or (3) 

a beneficial interest in (when title is held by the United States in 

trust for the benefit of an Indian Tribe) facilities used or to be used 

for the administration and delivery of health services by an Indian 

Health Program. Such leases, contracts, or agreements may include 

provisions for construction or renovation and provide for compensation to the Indian Tribe or Tribal Organization of rental and other 

costs consistent with section 105(l) of the Indian Self-Determination 

and Education Assistance Act (25 U.S.C. 450 et seq.) and regulations thereunder. 

SEC. 309. STUDY ON LOANS, LOAN GUARANTEES, AND LOAN REPAYMENT. 

(a) IN GENERAL.—The Secretary, in consultation with the Secretary of the Treasury, Indian Tribes, and Tribal Organizations, 


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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; 

(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. 


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SEC. 310. TRIBAL LEASING. 

A Tribal Health Program may lease permanent structures for the 

purpose of providing health care services without obtaining advance 

approval in appropriation Acts. 

SEC. 311. INDIAN HEALTH SERVICE/TRIBAL FACILITIES JOINT VENTURE PROGRAM. 

(a) IN GENERAL.—The Secretary, acting through the Service, shall 

make arrangements with Indian Tribes and Tribal Organizations to 

establish joint venture demonstration projects under which an Indian Tribe or Tribal Organization shall expend tribal, private, or 

other available funds, for the acquisition or construction of a health 

facility for a minimum of 10 years, under a no-cost lease, in 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 under this section 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 

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 


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if, at any time within the 10-year term of the agreement, the Service 

ceases to use the facility or otherwise breaches the agreement. 

(f) DEFINITION.—For the purposes of this section, the term ‘‘health 

facility’’ or ‘‘health facilities’’ includes quarters needed to provide 

housing for staff of the relevant Tribal Health Program. 

SEC. 312. LOCATION OF FACILITIES. 

(a) IN GENERAL.—In all matters involving the reorganization or 

development of Service facilities or in the establishment of related 

employment projects to address unemployment conditions in economically depressed areas, the Bureau of Indian Affairs and the 

Service shall give priority to locating such facilities and projects on 

Indian lands or lands in Alaska owned by any Alaska Native village, or village or regional corporation under the Alaska Native 

Claims Settlement Act, or any land allotted to any Alaska Native, 

if requested by the Indian owner and the Indian Tribe with jurisdiction over such lands or other lands owned or leased by the Indian 

Tribe or Tribal Organization. Top priority shall be given to Indian 

land owned by 1 or more Indian Tribes. 

(b) DEFINITION.—For purposes of this section, the term ‘‘Indian 

lands’’ means—

(1) all lands within the exterior boundaries of any reservation; and 

(2) any lands title to which is held in trust by the United 

States for the benefit of any Indian Tribe or individual Indian 

or held by any Indian Tribe or individual Indian subject to restriction by the United States against alienation. 

SEC. 313. MAINTENANCE AND IMPROVEMENT OF HEALTH CARE FACILITIES. 

(a) REPORT.—The Secretary shall submit to the President, for inclusion in the report required to be transmitted to Congress under 

section 801, a report which identifies the backlog of maintenance 

and repair work required at both Service and tribal health care facilities, including new health care facilities expected to be in operation in the next fiscal year. The report shall also identify the need 

for renovation and expansion of existing facilities to support the 

growth of health care programs. 

(b) MAINTENANCE OF NEWLY CONSTRUCTED SPACE.—The Secretary, acting through the Service, is authorized to expend maintenance and improvement funds to support maintenance of newly constructed space only if such space falls within the approved supportable space allocation for the Indian Tribe or Tribal Organization. 

Supportable space allocation shall be defined through the 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. 

SEC. 314. TRIBAL MANAGEMENT OF FEDERALLY OWNED QUARTERS. 

(a) RENTAL RATES.—


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(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 objectives: 

(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 

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 


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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. 

SEC. 315. APPLICABILITY OF BUY AMERICAN ACT REQUIREMENT. 

(a) APPLICABILITY.—The Secretary shall ensure that the requirements of the Buy American Act apply to all procurements made 

with funds provided pursuant to section 317. Indian Tribes and 

Tribal Organizations shall be exempt from these requirements. 

(b) EFFECT OF VIOLATION.—If it has been finally determined by 

a court or Federal agency that any person intentionally affixed a 

label bearing a ‘‘Made in America’’ inscription 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 section 317, pursuant to the debarment, 

suspension, and ineligibility procedures described in sections 9.400 

through 9.409 of title 48, Code of Federal Regulations. 

(c) DEFINITIONS.—For purposes of this section, the term ‘‘Buy 

American Act’’ means title III of the Act entitled ‘‘An Act making appropriations for the Treasury and Post Office Departments for the 

fiscal year ending June 30, 1934, and for other purposes’’, approved 

March 3, 1933 (41 U.S.C. 10a et seq.). 

SEC. 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 transfer such funds to Indian Tribes or Tribal Organizations through construction project agreements or construction contracts 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 


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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. 

SEC. 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. 

TITLE IV—ACCESS TO HEALTH 

SERVICES 

SEC. 401. TREATMENT OF PAYMENTS UNDER SOCIAL SECURITY ACT 

HEALTH BENEFITS PROGRAMS. 

(a) DISREGARD OF MEDICARE, MEDICAID, AND SCHIP PAYMENTS

IN DETERMINING APPROPRIATIONS.—Any payments received by an 

Indian Health Program or by an Urban Indian Organization under 

title XVIII, XIX, or XXI of the Social Security Act for services provided to Indians eligible for benefits under such respective titles 

shall not be considered in determining appropriations for the provision of health care and services to Indians. 

(b) NONPREFERENTIAL TREATMENT.—Nothing in this Act authorizes the Secretary to provide services to an Indian with coverage 

under title XVIII, XIX, or XXI of the Social Security Act in preference to an Indian without such coverage. 

(c) USE OF FUNDS.—

(1) SPECIAL FUND.—

(A) 100 PERCENT PASS-THROUGH OF PAYMENTS DUE TO

FACILITIES.—Notwithstanding any other provision of law, 

but subject to paragraph (2), payments to which a facility 

of the Service is entitled by reason of a provision of the Social Security Act shall be placed in a special fund to be 

held by the Secretary. In making payments from such fund, 

the Secretary shall ensure that each Service Unit of the 

Service receives 100 percent of the amount to which the facilities of the Service, for which such Service Unit makes 

collections, are entitled by reason of a provision of the Social Security Act. 

(B) USE OF FUNDS.—Amounts received by a facility of the 

Service under subparagraph (A) shall first be used (to such 

extent or in such amounts as are provided in appropriation 

Acts) for the purpose of making any improvements in the 

programs of the Service operated by or through such facility which may be necessary to achieve or maintain compliance with the applicable conditions and requirements of titles XVIII and XIX of the Social Security Act. Any amounts 

so received that are in excess of the amount necessary to 

achieve or maintain such conditions and requirements 

shall, subject to consultation with the Indian Tribes being 

served by the Service Unit, be used for reducing the health 


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resource deficiencies (as determined under section 201(d)) of 

such Indian Tribes. 

(2) DIRECT PAYMENT OPTION.—Paragraph (1) shall not apply 

to a Tribal Health Program or Urban Indian Organization 

upon the election of such Program or Organization under subsection (d) to receive payments directly. No payment may be 

made out of the special fund described in such paragraph with 

respect to reimbursement made for services provided by such 

Program during the period of such election. 

(d) DIRECT BILLING.—

(1) IN GENERAL.—Subject to complying with the requirements 

of paragraph (2), a Tribal Health Program or Urban Indian 

Organization may elect to directly bill for, and receive payment 

for, health care items and services provided by such Program 

or Organization for which payment is made under title XVIII 

or XIX of the Social Security Act or from any other third party 

payor. 

(2) DIRECT REIMBURSEMENT.—

(A) USE OF FUNDS.—Each Tribal Health Program or 

Urban Indian Organization making the election 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 

subsection (c)(1), but all amounts so reimbursed shall be 

used by the Tribal Health Program or Urban Indian Organization for the purpose of making any improvements in facilities of the Tribal Health Program or Urban Indian Organization 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 a Tribal Health Program or Urban Indian Organization making the election 

described in paragraph (1) with respect to a program under 

a title of the Social Security Act shall be subject to all auditing requirements applicable to the program under such 

title, as well as all auditing requirements applicable to programs administered by an Indian Health Program. Nothing in the preceding sentence shall be construed as limiting 

the application of auditing requirements applicable to 

amounts paid under title XVIII, XIX, or XXI of the Social 

Security Act. 

(C) IDENTIFICATION OF SOURCE OF PAYMENTS.—Any Tribal Health Program or Urban Indian Organization that receives reimbursements or payments under title XVIII, XIX, 

or XXI of the Social Security Act, shall provide to the Service a list of each provider enrollment number (or other identifier) under which such Program or Organization receives 

such reimbursements or payments. 

(3) EXAMINATION AND IMPLEMENTATION OF CHANGES.—


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(A) IN GENERAL.—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. 

(B) COORDINATION OF INFORMATION.—The Service shall 

provide the Administrator of the Centers for Medicare & 

Medicaid Services with copies of the lists submitted to the 

Service under paragraph (2)(C), enrollment data regarding 

patients served by the Service (and by Tribal Health Programs and Urban Indian Organizations, to the extent such 

data is available to the Service), and such other information as the Administrator may require for purposes of administering title XVIII, XIX, or XXI of the Social Security 

Act. 

(4) WITHDRAWAL FROM PROGRAM.—A Tribal Health Program 

or Urban Indian Organization 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. 

(5) TERMINATION FOR FAILURE TO COMPLY WITH REQUIRE- MENTS.—The Secretary may terminate the participation of a 

Tribal Health Program or an Urban Indian Organization in 

the direct billing program established under this subsection if 

the Secretary determines that the Program or Organization has 

failed to comply with the requirements of paragraph (2). The 

Secretary shall provide a Tribal Health Program or Urban Indian Organization with notice of a determination that the Program or Organization has failed to comply with any such requirement and a reasonable opportunity to correct such noncompliance prior to terminating the Program’s or Organization’s participation in the direct billing program established 

under this subsection. 

(e) RELATED PROVISIONS UNDER THE SOCIAL SECURITY ACT.—For 

provisions related to subsections (c) and (d), see sections 1880, 1911, 

and 2107(e)(1)(D) of the Social Security Act. 

SEC. 402. GRANTS TO AND CONTRACTS WITH THE SERVICE, INDIAN 

TRIBES, TRIBAL ORGANIZATIONS, AND URBAN INDIAN ORGANIZATIONS TO FACILITATE OUTREACH, ENROLLMENT, 

AND COVERAGE OF INDIANS UNDER SOCIAL SECURITY 

ACT HEALTH BENEFIT PROGRAMS AND OTHER HEALTH 

BENEFITS PROGRAMS. 

(a) INDIAN TRIBES AND TRIBAL ORGANIZATIONS.—From funds appropriated to carry out this title in accordance with section 415, the 

Secretary, acting through the Service, shall make grants to or enter 

into contracts with Indian Tribes and Tribal Organizations to assist 


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such Tribes and Tribal Organizations in establishing and administering programs on or near reservations and trust lands to assist 

individual Indians— (1) to enroll for benefits under a program established under 

title XVIII, XIX, or XXI of the Social Security Act and other 

health benefits programs; and 

(2) with respect to such programs for which the charging of 

premiums and cost sharing is not prohibited under such programs, to pay premiums or cost sharing for coverage for such 

benefits, which may be based on financial need (as determined 

by the Indian Tribe or Tribes or Tribal Organizations being 

served based on a schedule of income levels developed or implemented by such Tribe, Tribes, or Tribal Organizations). 

(b) CONDITIONS.—The Secretary, acting through the Service, shall 

place conditions as deemed necessary to effect the purpose of this 

section in any grant or contract which the Secretary makes with any 

Indian Tribe or Tribal Organization pursuant to this section. Such 

conditions shall include requirements that the Indian Tribe or Tribal Organization successfully undertake—

(1) to determine the population of Indians eligible for the benefits described in subsection (a); 

(2) to educate Indians with respect to the benefits available 

under the respective programs; 

(3) to provide transportation for such individual Indians to 

the appropriate offices for enrollment or applications for such 

benefits; and 

(4) to develop and implement methods of improving the participation of Indians in receiving benefits under such programs. 

(c) APPLICATION TO URBAN INDIAN ORGANIZATIONS.—

(1) IN GENERAL.—The provisions of subsection (a) shall apply 

with respect to grants and other funding to Urban Indian Organizations with respect to populations served by such organizations in the same manner they apply to grants and contracts 

with Indian Tribes and Tribal Organizations with respect to 

programs on or near reservations. 

(2) REQUIREMENTS.—The Secretary shall include in the 

grants or contracts made or provided under paragraph (1) requirements that are— (A) consistent with the requirements imposed by the Secretary under subsection (b); 

(B) appropriate to Urban Indian Organizations and 

Urban Indians; and 

(C) necessary to effect the purposes of this section. 

(d) FACILITATING COOPERATION.—The Secretary, acting through 

the Centers for Medicare & Medicaid Services, shall take such steps 

as are necessary to facilitate cooperation with, and agreements between, States and the Service, Indian Tribes, Tribal Organizations, 

or Urban Indian Organizations with respect to the provision of 

health care items and services to Indians under the programs established under title XVIII, XIX, or XXI of the Social Security Act. 

(e) AGREEMENTS RELATING TO IMPROVING ENROLLMENT OF INDI- ANS UNDER SOCIAL SECURITY ACT HEALTH BENEFITS PROGRAMS.— For provisions relating to agreements between the Secretary, acting 

through the Service, and Indian Tribes, Tribal Organizations, and 

Urban Indian Organization for the collection, preparation, and subVerDate Aug 31 2005 06:29 Sep 16, 2006 Jkt 049006 PO 00000 Frm 00265 Fmt 6659 Sfmt 6603 E:\HR\OC\HR661P1.XXX HR661P1

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mission of applications by Indians for assistance under the Medicaid and State children’s health insurance programs established 

under titles XIX and XXI of the Social Security Act, and benefits 

under the Medicare program established under title XVIII of such 

Act, see subsections (a) and (b) of section 1139 of the Social Security 

Act. 

(f) DEFINITION OF PREMIUMS AND COST SHARING.—In this section: 

(1) PREMIUM.—The term ‘‘premium’’ includes any enrollment 

fee or similar charge. 

(2) COST SHARING.—The term ‘‘cost sharing’’ includes any deduction, deductible, copayment, coinsurance, or similar charge. 

SEC. 403. REIMBURSEMENT FROM CERTAIN THIRD PARTIES OF COSTS 

OF HEALTH SERVICES. 

(a) RIGHT OF RECOVERY.—Except as provided in subsection (f), the 

United States, an Indian Tribe, or Tribal Organization shall have 

the right to recover from an insurance company, health maintenance 

organization, employee benefit plan, third-party tortfeasor, or any 

other responsible or liable third party (including a political subdivision or local governmental entity of a State) the reasonable expenses 

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 

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—


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(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 

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.). 

SEC. 404. CREDITING OF REIMBURSEMENTS. 

(a) USE OF AMOUNTS.—


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(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). 

SEC. 405. PURCHASING HEALTH CARE COVERAGE. 

(a) IN GENERAL.—Insofar as amounts are made available under 

law (including a provision of the Social Security Act, the Indian 

Self-Determination and Education Assistance Act (25 U.S.C. 450 et 

seq.), or other law, other than under section 402) to Indian Tribes, 

Tribal Organizations, and Urban Indian Organizations for health 

benefits for Service beneficiaries, Indian Tribes, Tribal Organizations, and Urban Indian Organizations may use such amounts to 

purchase health benefits coverage for such beneficiaries in any manner, including through—

(1) a tribally owned and operated health care plan; 

(2) a State or locally authorized or licensed health care plan; 

(3) a health insurance provider or managed care organization; or 

(4) a self-insured plan. 

The purchase of such coverage by an Indian Tribe, Tribal Organization, or Urban Indian Organization may be based on the financial 

needs of such beneficiaries (as determined by the Indian Tribe or 

Tribes being served based on a schedule of income levels developed 

or implemented by such Indian Tribe or Tribes). 

(b) EXPENSES FOR SELF-INSURED PLAN.—In the case of a self-insured plan under subsection (a)(4), the amounts may be used for expenses of operating the plan, including administration and insurance to limit the financial risks to the entity offering the plan. 

(c) CONSTRUCTION.—Nothing in this section shall be construed as 

affecting the use of any amounts not referred to in subsection (a). 

SEC. 406. SHARING ARRANGEMENTS WITH FEDERAL AGENCIES. 

(a) AUTHORITY.—

(1) IN GENERAL.—The Secretary may enter into (or expand) 

arrangements for the sharing of medical facilities and services 

between the Service, Indian Tribes, and Tribal Organizations 


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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. 

SEC. 407. PAYOR OF LAST RESORT. 

Indian Health Programs and health care programs operated by 

Urban Indian Organizations shall be the payor of last resort for 

services provided to persons eligible for services from Indian Health 

Programs and Urban Indian Organizations, notwithstanding any 

Federal, State, or local law to the contrary. 

SEC. 408. NONDISCRIMINATION UNDER FEDERAL HEALTH CARE PROGRAMS IN QUALIFICATIONS FOR REIMBURSEMENT FOR 

SERVICES. 

(a) REQUIREMENT TO SATISFY GENERALLY APPLICABLE PARTICIPA- TION REQUIREMENTS.—

(1) IN GENERAL.—A Federal health care program must accept 

an entity that is operated by the Service, an Indian Tribe, Tribal Organization, or Urban Indian Organization as a provider 

eligible to receive payment under the program for health care 

services furnished to an Indian on the same basis as any other 

provider qualified to participate as a provider of health care 

services under the program if the entity meets generally applicable State or other requirements for participation as a provider 

of health care services under the program. 

(2) SATISFACTION OF STATE OR LOCAL LICENSURE OR RECOGNITION REQUIREMENTS.—Any requirement for participation 

as a provider of health care services under a Federal health 

care program that an entity be licensed or recognized under the 

State or local law where the entity is located to furnish health 


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care services shall be deemed to have been met in the case of 

an entity operated by the Service, an Indian Tribe, Tribal Organization, or Urban Indian Organization if the entity meets all 

the applicable standards for such licensure or recognition, regardless of whether the entity obtains a license or other documentation under such State or local law. In accordance with 

section 221, the absence of the licensure of a health care professional employed by such an entity under the State or local law 

where the entity is located shall not be taken into account for 

purposes of determining whether the entity meets such standards, if the professional is licensed in another State. 

(b) APPLICATION OF EXCLUSION FROM PARTICIPATION IN FEDERAL

HEALTH CARE PROGRAMS.—

(1) EXCLUDED ENTITIES.—No entity operated by the Service, 

an Indian Tribe, Tribal Organization, or Urban Indian Organization that has been excluded from participation in any Federal 

health care program or for which a license is suspended or has 

been revoked by the State where the entity is located shall be 

eligible to receive payment or reimbursement under any such 

program for health care services furnished to an Indian. 

(2) EXCLUDED INDIVIDUALS.—No individual who has been excluded from participation in any Federal health care program 

or whose State license is under suspension shall be eligible to 

receive payment or reimbursement under any such program for 

health care services furnished by that individual, directly or 

through an entity that is otherwise eligible to receive payment 

for health care services, to an Indian. 

(3) FEDERAL HEALTH CARE PROGRAM DEFINED.—In this subsection, the term, ‘‘Federal health care program’’ has the meaning given that term in section 1128B(f) of the Social Security 

Act (42 U.S.C. 1320a–7b(f)), except that, for purposes of this 

subsection, such term shall include the health insurance program under chapter 89 of title 5, United States Code. 

(c) RELATED PROVISIONS.—For provisions related to nondiscrimination against providers operated by the Service, an Indian 

Tribe, Tribal Organization, or Urban Indian Organization, see section 1139(c) of the Social Security Act (42 U.S.C. 1320b–9(c)). 

SEC. 409. CONSULTATION. 

For provisions related to consultation with representatives of Indian Health Programs and Urban Indian Organizations with respect to the health care programs established under titles XVIII, 

XIX, and XXI of the Social Security Act, see section 1139(d) of the 

Social Security Act (42 U.S.C. 1320b–9(d)). 

SEC. 410. STATE CHILDREN’S HEALTH INSURANCE PROGRAM (SCHIP). 

For provisions relating to—

(1) outreach to families of Indian children likely to be eligible 

for child health assistance under the State children’s health insurance program established under title XXI of the Social Security Act, see sections 2105(c)(2)(C) and 1139(a) of such Act (42 

U.S.C. 1397ee(c)(2), 1320b–9); and 

(2) ensuring that child health assistance is provided under 

such program to targeted low-income children who are Indians 

and that payments are made under such program to Indian 

Health Programs and Urban Indian Organizations operating in 


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the State that provide such assistance, see sections 

2102(b)(3)(D) and 2105(c)(6)(B) of such Act (42 U.S.C. 

1397bb(b)(3)(D), 1397ee(c)(6)(B)). 

SEC. 411. EXCLUSION WAIVER AUTHORITY FOR AFFECTED INDIAN 

HEALTH PROGRAMS AND SAFE HARBOR TRANSACTIONS 

UNDER THE SOCIAL SECURITY ACT. 

For provisions relating to—

(1) exclusion waiver authority for affected Indian Health Programs under the Social Security Act, see section 1128(k) of the 

Social Security Act (42 U.S.C. 1320a–7(k)); and 

(2) certain transactions involving Indian Health Programs 

deemed to be in safe harbors under that Act, see section 

1128B(b)(4) of the Social Security Act (42 U.S.C. 1320a–

7b(b)(4)). 

SEC. 412. PREMIUM AND COST SHARING PROTECTIONS AND ELIGIBILITY DETERMINATIONS UNDER MEDICAID AND SCHIP 

AND PROTECTION OF CERTAIN INDIAN PROPERTY FROM 

MEDICAID ESTATE RECOVERY. 

For provisions relating to—

(1) premiums or cost sharing protections for Indians furnished items or services directly by Indian Health Programs or 

through referral under the contract health service under the 

Medicaid program established under title XIX of the Social Security Act, see sections 1916(j) and 1916A(a)(1) of the Social Security Act (42 U.S.C. 1396o(j), 1396o–1(a)(1)); 

(2) rules regarding the treatment of certain property for purposes of determining eligibility under such programs, see sections 1902(e)(13) and 2107(e)(1)(B) of such Act (42 U.S.C. 

1396a(e)(13), 1397gg(e)(1)(B)); and 

(3) the protection of certain property from estate recovery provisions under the Medicaid program, see section 1917(b)(3)(B) 

of such Act (42 U.S.C. 1396p(b)(3)(B)). 

SEC. 413. TREATMENT UNDER MEDICAID AND SCHIP MANAGED CARE. 

For provisions relating to the treatment of Indians enrolled in a 

managed care entity under the Medicaid program under title XIX 

of the Social Security Act and Indian Health Programs and Urban 

Indian Organizations that are providers of items or services to such 

Indian enrollees, see sections 1932(h) and 2107(e)(1)(H) of the Social 

Security Act (42 U.S.C. 1396u–2(h), 1397gg(e)(1)(H)). 

SEC. 414. NAVAJO NATION MEDICAID AGENCY FEASIBILITY STUDY. 

(a) STUDY.—The Secretary shall conduct a study to determine the 

feasibility of treating the Navajo Nation as a State for the purposes 

of title XIX of the Social Security Act, to provide services to Indians 

living within the boundaries of the Navajo Nation through an entity 

established having the same authority and performing the same 

functions as single-State medicaid agencies responsible for the administration of the State plan under title XIX of the Social Security 

Act. 

(b) CONSIDERATIONS.—In conducting the study, the Secretary 

shall consider the feasibility of—

(1) assigning and paying all expenditures for the provision of 

services and related administration funds, under title XIX of 

the Social Security Act, to Indians living within the boundaries 


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of the Navajo Nation that are currently paid to or would otherwise be paid to the State of Arizona, New Mexico, or Utah; 

(2) providing assistance to the Navajo Nation in the development and implementation of such entity for the administration, 

eligibility, payment, and delivery of medical assistance under 

title XIX of the Social Security Act; 

(3) providing an appropriate level of matching funds for Federal medical assistance with respect to amounts such entity expends for medical assistance for services and related administrative costs; and 

(4) authorizing the Secretary, at the option of the Navajo Nation, to treat the Navajo Nation as a State for the purposes of 

title XIX of the Social Security Act (relating to the State children’s health insurance program) under terms equivalent to 

those described in paragraphs (2) through (4). 

(c) REPORT.—Not later than 3 years after the date of enactment 

of the Indian Health Act Improvement Act Amendments of 2006, 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. 

SEC. 415. 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. 

TITLE V—HEALTH SERVICES FOR 

URBAN INDIANS 

SEC. 501. PURPOSE. 

The purpose of this title is to establish and maintain programs 

in Urban Centers to make health services more accessible and available to Urban Indians. 

SEC. 502. CONTRACTS WITH, AND GRANTS TO, URBAN INDIAN ORGANIZATIONS. 

Under authority of the Act of November 2, 1921 (25 U.S.C. 13) 

(commonly known as the ‘‘Snyder Act’’), the Secretary, acting 

through the Service, shall enter into contracts with, or make grants 

to, Urban Indian Organizations to assist such organizations in the 

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grams which meet the requirements set forth in this title. Subject to 

section 506, the Secretary, acting through the Service, shall include 

such conditions as the Secretary considers necessary to effect the 

purpose of this title in any contract into which the Secretary enters 

with, or in any grant the Secretary makes to, any Urban Indian Organization pursuant to this title. 

SEC. 503. CONTRACTS AND GRANTS FOR THE PROVISION OF HEALTH 

CARE AND REFERRAL SERVICES. 

(a) REQUIREMENTS FOR GRANTS AND CONTRACTS.—Under authority of the Act of November 2, 1921 (25 U.S.C. 13) (commonly known 

as the ‘‘Snyder Act’’), the Secretary, acting through the Service, shall 

enter into contracts with, or make grants to, Urban Indian Organizations for the provision of health care and referral services for 

Urban Indians. Any such contract or grant shall include requirements that the Urban Indian Organization successfully undertake 

to— (1) estimate the population of Urban Indians residing in the 

Urban Center or centers that the organization proposes to serve 

who are or could be recipients of health care or referral services; 

(2) estimate the current health status of Urban Indians residing in such Urban Center or centers; 

(3) estimate the current health care needs of Urban Indians 

residing in such Urban Center or centers; 

(4) provide basic health education, including health promotion and disease prevention education, 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; and 

(6) where necessary, provide, or enter into contracts for the 

provision of, health care services for Urban Indians. 

(b) CRITERIA.—The Secretary, acting through the Service, shall, 

by regulation adopted pursuant to section 520, prescribe the criteria 

for selecting Urban Indian 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 Urban Indians 

in the Urban Center or centers involved; 

(2) the size of the Urban Indian population in the Urban Center or centers involved; 

(3) the extent, if any, to which the activities set forth in subsection (a) would duplicate any project funded under this title; 

(4) the capability of an Urban Indian Organization to perform the activities set forth in subsection (a) and to enter into 

a contract with the Secretary or to meet the requirements for receiving a grant under this section; 

(5) the satisfactory performance and successful completion by 

an Urban Indian Organization of other contracts with the Secretary under this title; 

(6) the appropriateness and likely effectiveness of conducting 

the activities set forth in subsection (a) in an Urban Center or 

centers; and 

(7) the extent of existing or likely future participation in the 

activities set forth in subsection (a) by appropriate health and 

health-related Federal, State, local, and other agencies. 


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(c) ACCESS TO HEALTH PROMOTION AND DISEASE PREVENTION

PROGRAMS.—The Secretary, acting through the Service, shall facilitate access to or provide health promotion and disease prevention 

services for Urban Indians through grants made to Urban Indian 

Organizations administering contracts entered into or receiving 

grants under subsection (a). 

(d) IMMUNIZATION SERVICES.— (1) ACCESS OR SERVICES PROVIDED.—The Secretary, acting 

through the Service, shall facilitate access to, or provide, immunization services for Urban Indians through grants made to 

Urban Indian Organizations administering contracts entered 

into or receiving grants under this section. 

(2) DEFINITION.—For purposes of this subsection, the term 

‘‘immunization services’’ means services to provide without 

charge immunizations against vaccine-preventable diseases. 

(e) BEHAVIORAL HEALTH SERVICES.—

(1) ACCESS OR SERVICES PROVIDED.—The Secretary, acting 

through the Service, shall facilitate access to, or provide, behavioral health services for Urban Indians through grants made to 

Urban Indian Organizations administering contracts entered 

into or receiving grants under subsection (a). 

(2) ASSESSMENT REQUIRED.—Except as provided by paragraph (3)(A), a grant may not be made under this subsection to 

an Urban Indian Organization until that organization has prepared, and the Service has approved, an assessment of the following: 

(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 

subsection for the following: 

(A) To prepare assessments required under paragraph 

(2). 

(B) To provide outreach, educational, and referral services to Urban Indians regarding the availability of direct 

behavioral health services, to educate Urban Indians about 

behavioral health issues and services, and effect coordination with existing behavioral health providers in order to 

improve services to Urban Indians. 

(C) To provide outpatient behavioral health services to 

Urban Indians, including the identification and assessment 

of illness, therapeutic treatments, case management, support groups, family treatment, and other treatment. 

(D) To develop innovative behavioral health service delivery models which incorporate Indian cultural support systems and resources. 

(f) PREVENTION OF CHILD ABUSE.— (1) ACCESS OR SERVICES PROVIDED.—The Secretary, acting 

through the Service, shall facilitate access to or provide services 

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tions administering contracts entered into or receiving grants 

under subsection (a) to prevent and treat child abuse (including 

sexual abuse) among Urban Indians. 

(2) EVALUATION REQUIRED.—Except as provided by paragraph (3)(A), a grant may not be made under this subsection to 

an Urban Indian Organization until that organization has prepared, and the Service has approved, an assessment that documents the prevalence of child abuse in the 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 

subsection for the following: 

(A) To prepare assessments required under paragraph 

(2). 

(B) For the development of prevention, training, and education programs for Urban Indians, including child education, parent education, provider training on identification 

and intervention, education on reporting requirements, prevention campaigns, and establishing service networks of all 

those involved in Indian child protection. 

(C) To provide direct outpatient treatment services (including individual treatment, family treatment, group therapy, and support groups) to 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 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 Urban Indian 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 

Urban Indian Organization to address the complex problem of child sexual abuse in the community; and 

(C) the assessment required under paragraph (2). 

(g) OTHER GRANTS.—The Secretary, acting through the Service, 

may enter into a contract with or make grants to an Urban Indian 

Organization that provides or arranges for the provision of health 

care services (through satellite facilities, provider networks, or otherwise) to Urban Indians in more than 1 Urban Center. 

SEC. 504. CONTRACTS AND GRANTS FOR THE DETERMINATION OF 

UNMET HEALTH CARE NEEDS. 

(a) GRANTS AND CONTRACTS AUTHORIZED.—Under authority of 

the Act of November 2, 1921 (25 U.S.C. 13) (commonly known as 

the ‘‘Snyder Act’’), the Secretary, acting through the Service, may 

enter into contracts with or make grants to Urban Indian Organizations situated in Urban Centers for which contracts have not been 

entered into or grants have not been made under section 503. 

(b) PURPOSE.—The purpose of a contract or grant made under 

this section shall be the determination of the matters described in 


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subsection (c)(1) in order to assist the Secretary in assessing the 

health status and health care needs of Urban Indians in the Urban 

Center involved and determining whether the Secretary should enter 

into a contract or make a grant under section 503 with respect to 

the Urban Indian Organization which the Secretary has entered 

into a contract with, or made a grant to, under this section. 

(c) GRANT AND CONTRACT REQUIREMENTS.—Any contract entered 

into, or grant made, by the Secretary under this section shall include requirements that— (1) the Urban Indian Organization successfully undertakes 

to— (A) document the health care status and unmet health 

care needs of Urban Indians in the Urban Center involved; 

and 

(B) with respect to Urban Indians in the Urban Center 

involved, determine the matters described in paragraphs 

(2), (3), (4), and (7) of section 503(b); and 

(2) the Urban Indian Organization complete performance of 

the contract, or carry out the requirements of the grant, within 

1 year after the date on which the Secretary and such organization enter into such contract, or within 1 year after such organization receives such grant, whichever is applicable. 

(d) NO RENEWALS.—The Secretary may not renew any contract 

entered into or grant made under this section. 

SEC. 505. EVALUATIONS; RENEWALS. 

(a) PROCEDURES FOR EVALUATIONS.—The Secretary, acting 

through the Service, shall develop procedures to evaluate compliance with grant requirements and compliance with and performance of contracts entered into by Urban Indian Organizations under 

this title. Such procedures shall include provisions for carrying out 

the requirements of this section. 

(b) EVALUATIONS.—The Secretary, acting through the Service, 

shall evaluate the compliance of each Urban Indian Organization 

which has entered into a contract or received a grant under section 

503 with 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; UNSATISFACTORY PERFORMANCE.—If, as a 

result of the evaluations conducted under this section, the Secretary 

determines that an Urban Indian Organization has not complied 

with the requirements of a grant or complied with or satisfactorily 

performed a contract under section 503, the Secretary shall, prior 

to renewing such contract or grant, attempt to resolve with the organization the areas of noncompliance or unsatisfactory performance 

and modify the contract or grant to prevent future occurrences of 

noncompliance or unsatisfactory performance. If the Secretary determines that the noncompliance or unsatisfactory performance cannot 

be resolved and prevented in the future, the Secretary shall not 


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renew the contract or grant with the organization and is authorized 

to enter into a contract or make a grant under section 503 with another Urban Indian Organization which is situated in the same 

Urban Center as the Urban Indian Organization whose contract or 

grant is not renewed under this section. 

(d) CONSIDERATIONS FOR RENEWALS.—In determining whether to 

renew a contract or grant with an Urban Indian Organization 

under section 503 which has completed performance of a contract or 

grant under section 504, the Secretary shall review the records of 

the Urban Indian Organization, the reports submitted under section 

507, and shall consider the results of the onsite evaluations or accreditations under subsection (b). 

SEC. 506. OTHER CONTRACT AND GRANT REQUIREMENTS. 

(a) PROCUREMENT.—Contracts with Urban Indian Organizations 

entered into pursuant to this title shall be in accordance with all 

Federal contracting laws and regulations relating to procurement 

except that in the discretion of the Secretary, such contracts may be 

negotiated without advertising and need not conform to the provisions of sections 1304 and 3131 through 3133 of title 40, United 

States Code. 

(b) PAYMENTS UNDER CONTRACTS OR GRANTS.—Payments under 

any contracts or grants pursuant to this title shall, notwithstanding 

any term or condition of such contract or grant—

(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 AMENDMENT OF CONTRACTS.—Notwithstanding 

any provision of law to the contrary, the Secretary may, at the request or consent of an Urban Indian Organization, revise or amend 

any contract entered into by the Secretary with such organization 

under this title as necessary to carry out the purposes of this title. 

(d) FAIR AND UNIFORM SERVICES AND ASSISTANCE.—Contracts 

with or grants to Urban Indian Organizations and regulations 

adopted pursuant to this title shall include provisions to assure the 

fair and uniform provision to Urban Indians of services and assistance under such contracts or grants by such organizations. 

SEC. 507. REPORTS AND RECORDS. 

(a) REPORTS.—For each fiscal year during which an Urban Indian Organization receives or expends funds pursuant to a contract 

entered into or a grant received pursuant to this title, such Urban 

Indian Organization shall submit to the Secretary not more frequently than every 6 months, a report that includes the following: 


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(1) In the case of a contract or grant under section 503, recommendations pursuant to section 503(a)(5). 

(2) Information on activities conducted by the organization 

pursuant to the contract or grant. 

(3) An accounting of the amounts and purpose for which Federal funds were expended. 

(4) A minimum set of data, using uniformly defined elements, 

that is specified by the Secretary in consultation, consistent 

with section 514, with Urban Indian Organizations. 

(b) AUDIT.—The reports and records of the Urban Indian Organization with respect to a contract or grant under this title shall be 

subject to audit by the Secretary and the Comptroller General of the 

United States. 

(c) COSTS OF AUDITS.—The Secretary shall allow as a cost of any 

contract or grant entered into or awarded under section 502 or 503 

the cost of an annual independent financial audit conducted by— (1) a certified public accountant; or 

(2) a certified public accounting firm qualified to conduct 

Federal compliance audits. 

SEC. 508. LIMITATION ON CONTRACT AUTHORITY. 

The authority of the Secretary to enter into contracts or to award 

grants under this title shall be to the extent, and in an amount, provided for in appropriation Acts. 

SEC. 509. FACILITIES. 

(a) GRANTS.—The Secretary, acting through the Service, may 

make grants to contractors or grant recipients under this title for 

the lease, purchase, renovation, construction, or expansion of facilities, including leased facilities, in order to assist such contractors 

or grant recipients in complying with applicable licensing or certification requirements. 

(b) LOANS.—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. 

SEC. 510. DIVISION OF URBAN INDIAN HEALTH. 

There is hereby established within the Service a Division of 

Urban Indian Health, which shall be responsible for— (1) carrying out the provisions of this title; 

(2) providing central oversight of the programs and services 

authorized under this title; and 

(3) providing technical assistance to Urban Indian Organizations. 

SEC. 511. GRANTS FOR ALCOHOL AND SUBSTANCE ABUSE-RELATED 

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, alcohol and substance abuse in 

Urban Centers to those Urban Indian Organizations with which the 

Secretary has entered into a contract under this title or under section 201. 

(b) GOALS.—Each grant made pursuant to subsection (a) shall set 

forth the goals to be accomplished pursuant to the grant. The goals 


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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), including criteria relating to the following: 

(1) The size of the Urban Indian population. 

(2) Capability of the organization to adequately perform the 

activities required under the grant. 

(3) Satisfactory performance standards for the organization 

in meeting the goals set forth in such grant. The standards 

shall be negotiated and agreed to between the Secretary and the 

grantee on a grant-by-grant basis. 

(4) Identification of the need for services. 

(d) ALLOCATION OF GRANTS.—The Secretary shall develop a methodology for allocating grants made pursuant to this section based 

on the criteria established pursuant to subsection (c). 

(e) GRANTS SUBJECT TO CRITERIA.—Any funds received by an 

Urban Indian Organization under this Act for substance abuse prevention, treatment, and rehabilitation shall be subject to the criteria 

set forth in subsection (c). 

SEC. 512. TREATMENT OF CERTAIN DEMONSTRATION PROJECTS. 

Notwithstanding any other provision of law, the Tulsa Clinic and 

Oklahoma City Clinic demonstration projects shall—

(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.). 

SEC. 513. URBAN NIAAA TRANSFERRED PROGRAMS. 

(a) GRANTS AND CONTRACTS.—The Secretary, through the Office 

of Urban Indian Health, shall make grants or enter into contracts 

with Urban Indian Organizations, to take effect not later than September 30, 2008, for the administration of Urban Indian alcohol 

programs that were originally established under the National Institute on Alcoholism and Alcohol Abuse (hereafter in this section referred to as ‘‘NIAAA’’) and transferred to the Service. 

(b) USE OF FUNDS.—Grants provided or contracts entered into 

under this section shall be used to provide support for the continuation of alcohol prevention and treatment services for 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.—Urban Indian 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. 

(d) REPORT.—The Secretary shall evaluate and report to Congress 

on the activities of programs funded under this section not less than 

every 5 years. 


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SEC. 514. CONSULTATION WITH URBAN INDIAN ORGANIZATIONS. 

(a) IN GENERAL.—The Secretary shall ensure that the Service 

consults, to the greatest extent practicable, with Urban Indian Organizations. 

(b) DEFINITION OF CONSULTATION.—For purposes of subsection 

(a), consultation is the open and free exchange of information and 

opinions which leads to mutual understanding and comprehension 

and which emphasizes trust, respect, and shared responsibility. 

SEC. 515. URBAN YOUTH TREATMENT CENTER DEMONSTRATION. 

(a) CONSTRUCTION AND OPERATION.—The Secretary, acting 

through the Service, through grant or contract, is authorized to 

fund the construction and operation of at least 2 residential treatment centers in each State described in subsection (b) to demonstrate the provision of alcohol and substance abuse treatment 

services to Urban Indian youth in a culturally competent residential 

setting. 

(b) DEFINITION OF STATE.—A State described in this subsection is 

a State in which— (1) there resides Urban Indian youth with need for alcohol 

and substance abuse treatment services in a residential setting; 

and 

(2) there is a significant shortage of culturally competent residential treatment services for Urban Indian youth. 

SEC. 516. 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 real and 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. 


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(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 

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. 

SEC. 517. 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). 

SEC. 518. COMMUNITY HEALTH REPRESENTATIVES. 

The Secretary, acting through the Service, may enter into contracts with, and make grants to, Urban Indian Organizations for 

the employment of Indians trained as health service providers 

through the Community Health Representatives Program under section 109 in the provision of health care, health promotion, and disease prevention services to Urban Indians. 

SEC. 519. EFFECTIVE DATE. 

The amendments made by the Indian Health Care Improvement 

Act Amendments of 2006 to this title shall take effect beginning on 

the date of enactment of that Act, regardless of whether the Secretary has promulgated regulations implementing such amendments. 

SEC. 520. 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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SEC. 521. 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. 

TITLE VI—ORGANIZATIONAL 

IMPROVEMENTS 

SEC. 601. ESTABLISHMENT OF THE INDIAN HEALTH SERVICE AS AN 

AGENCY OF THE PUBLIC HEALTH SERVICE. 

(a) ESTABLISHMENT.—

(1) IN GENERAL.—In order to more effectively and efficiently 

carry out the responsibilities, authorities, and functions of the 

United States to provide health care services to Indians and Indian Tribes, as are or may be hereafter provided by Federal 

statute or treaties, there is established within the Public Health 

Service of the Department the Indian Health Service. 

(2) ASSISTANT SECRETARY OF INDIAN HEALTH.—The Service 

shall be administered by an Assistant Secretary of Indian 

Health, who shall be appointed by the President, by and with 

the advice and consent of the Senate. The Assistant Secretary 

shall report to the Secretary. Effective with respect to an individual appointed by the President, by and with the advice and 

consent of the Senate, after January 1, 2005, the term of service 

of the Assistant Secretary shall be 4 years. An Assistant Secretary may serve more than 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 2006 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.—The Service shall be an agency within the Public 

Health Service of the Department, and shall not be an office, component, or unit of any other agency of the Department. 

(c) DUTIES.—The Assistant Secretary of Indian Health shall— (1) perform all functions that were, on the day before the date 

of enactment of the Indian Health Care Improvement Act 

Amendments of 2006, carried out by or under the direction of 

the individual serving as Director of the Service on that day; 

(2) perform all functions of the Secretary relating to the 

maintenance and operation of hospital and health facilities for 

Indians and the planning for, and provision and utilization of, 

health services for Indians; 

(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 programs 

under—


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(A) this Act; 

(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. 450 et seq.); 

(4) administer all scholarship and loan functions carried out 

under title I; 

(5) report directly to the Secretary concerning all policy- and 

budget-related matters affecting Indian health; 

(6) collaborate with the Assistant Secretary for Health concerning appropriate matters of Indian health that affect the 

agencies of the Public Health Service; 

(7) advise each Assistant Secretary of the Department concerning matters of Indian health with respect to which that Assistant Secretary has authority and responsibility; 

(8) advise the heads of other agencies and programs of the 

Department concerning matters of Indian health with respect to 

which those heads have authority and responsibility; 

(9) coordinate the activities of the Department concerning 

matters of Indian health; and 

(10) perform such other functions as the Secretary may designate. 

(d) AUTHORITY.— (1) IN GENERAL.—The Secretary, acting through the Assistant 

Secretary, shall have the authority— (A) except to the extent provided for in paragraph (2), to 

appoint and compensate employees for the Service in accordance with title 5, United States Code; 

(B) to enter into contracts for the procurement of goods 

and services to carry out the functions of the Service; and 

(C) to manage, expend, and obligate all funds appropriated for the Service. 

(2) PERSONNEL ACTIONS.—Notwithstanding any other provision of law, the provisions of section 12 of the Act of June 18, 

1934 (48 Stat. 986; 25 U.S.C. 472), shall apply to all personnel 

actions taken with respect to new positions created within the 

Service as a result of its establishment under subsection (a). 

(e) REFERENCES.—Any reference to the Director of the Indian 

Health Service in any Federal law, Executive order, rule, regulation, 

or delegation of authority, or in any document of or relating to the 

Director of the Indian Health Service, shall be deemed to refer to 

the Assistant Secretary. 

SEC. 602. AUTOMATED MANAGEMENT INFORMATION 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 system; 

(B) a patient care information system for each area 

served by the Service; 

(C) a privacy component that protects the privacy of patient information held by, or on behalf of, the Service; 


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(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 Area office 

of the Service; 

(E) an interface mechanism for patient billing and accounts receivable system; and 

(F) a training component. 

(b) PROVISION OF SYSTEMS TO TRIBES AND ORGANIZATIONS.—The 

Secretary shall provide each Tribal Health Program automated 

management information systems which— (1) meet the management information needs of such Tribal 

Health Program with respect to the treatment by the Tribal 

Health Program of patients of the Service; and 

(2) meet the management information needs of the Service. 

(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, and private and nonprofit organizations, for the purpose of enhancing information technology in Indian 

health programs and facilities. 

SEC. 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 

PROGRAMS 

SEC. 701. BEHAVIORAL HEALTH PREVENTION AND TREATMENT SERVICES. 

(a) PURPOSES.—The purposes of this section are as follows: 

(1) To authorize and direct the Secretary, acting through the 

Service, Indian Tribes, Tribal Organizations, and Urban Indian Organizations, to develop a comprehensive behavioral 

health prevention and treatment program which emphasizes 

collaboration among alcohol and substance abuse, social services, and mental health programs. 

(2) To provide information, direction, and guidance relating 

to mental illness and dysfunction and self-destructive behavior, 

including child abuse and family violence, to those Federal, 

tribal, State, and local agencies responsible for programs in Indian communities in areas of health care, education, social 

services, child and family welfare, alcohol and substance abuse, 

law enforcement, and judicial services. 

(3) To assist Indian Tribes to identify services and resources 

available to address mental illness and dysfunctional and selfdestructive behavior. 

(4) To provide authority and opportunities for Indian Tribes 

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tion, prevention, education, referral, and treatment services, including through multidisciplinary resource teams. 

(5) To ensure that Indians, as citizens of the United States 

and of the States in which they reside, have the same access to 

behavioral health services to which all citizens have access. 

(6) To modify or supplement existing programs and authorities in the areas identified in paragraph (2). 

(b) PLANS.— (1) DEVELOPMENT.—The Secretary, acting through the Service, Indian Tribes, Tribal Organizations, and Urban Indian Organizations, shall encourage Indian Tribes and Tribal Organizations to develop tribal plans, and Urban Indian Organizations to develop local plans, and for all such groups to participate in developing areawide plans for Indian Behavioral Health 

Services. The plans shall include, to the extent feasible, the following components: 

(A) An assessment of the scope of alcohol or other substance abuse, mental illness, and dysfunctional and self-destructive behavior, including suicide, child abuse, and family violence, among Indians, including— (i) the number of Indians served who are directly or 

indirectly affected by such illness or behavior; or 

(ii) an estimate of the financial and human cost attributable to such illness or behavior. 

(B) An assessment of the existing and additional resources necessary for the prevention and treatment of such 

illness and behavior, including an assessment of the 

progress toward achieving the availability of the full continuum of care described in subsection (c). 

(C) An estimate of the additional funding needed by the 

Service, Indian Tribes, Tribal Organizations, and Urban 

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; 


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(D) intensive outpatient/day treatment; 

(E) residential treatment; 

(F) transitional living for those needing a temporary, stable living environment that is supportive of treatment and 

recovery goals; 

(G) emergency shelter; 

(H) intensive case management; and 

(I) diagnostic services. 

(2) CHILD CARE.—Behavioral health services for Indians from 

birth through age 17, including— (A) preschool and school age fetal alcohol disorder services, including assessment and behavioral intervention; 

(B) mental health and substance abuse services (emotional, organic, alcohol, drug, inhalant, and tobacco); 

(C) identification and treatment of co-occurring disorders 

and comorbidity; 

(D) prevention of alcohol, drug, inhalant, and tobacco 

use; 

(E) early intervention, treatment, and aftercare; 

(F) promotion of healthy choices and lifestyle (related to 

sexually transmitted diseases, domestic violence, sexual 

abuse, suicide, teen pregnancy, obesity, and other risk/safety issues); and 

(G) identification and treatment of neglect and physical, 

mental, and sexual abuse. 

(3) ADULT CARE.—Behavioral health services for Indians from 

age 18 through 55, including— (A) early intervention, treatment, and aftercare; 

(B) mental health and substance abuse services (emotional, alcohol, drug, inhalant, and tobacco), including gender specific services; 

(C) identification and treatment of co-occurring disorders 

(dual diagnosis) and comorbidity; 

(D) promotion of gender specific healthy choices and lifestyle (related to parenting, partners, domestic violence, sexual abuse, suicide, obesity, and other risk-related behavior); 

(E) treatment services for women at risk of giving birth 

to a child with a fetal alcohol disorder; and 

(F) gender 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 choices and lifestyle (related to 

parenting, partners, 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 gender specific services; 


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(C) identification and treatment of co-occurring disorders 

(dual diagnosis) and comorbidity; 

(D) promotion of healthy choices and lifestyle (managing 

conditions related to aging); 

(E) gender specific treatment for sexual assault, domestic 

violence, neglect, physical and mental abuse and exploitation; and 

(F) identification and treatment of dementias regardless 

of cause. 

(d) COMMUNITY BEHAVIORAL HEALTH PLAN.— (1) ESTABLISHMENT.—The governing body of any Indian 

Tribe, Tribal Organization, or Urban Indian Organization may 

adopt a resolution for the establishment of a community behavioral health plan providing for the identification and coordination of available resources and programs to identify, prevent, or 

treat substance abuse, mental illness, or dysfunctional and selfdestructive behavior, including child abuse and family violence, 

among its members or its service population. This plan should 

include behavioral health services, social services, intensive outpatient services, and continuing aftercare. 

(2) TECHNICAL ASSISTANCE.—At the request of an Indian 

Tribe, Tribal Organization, or Urban Indian Organization, the 

Bureau of Indian Affairs and the Service shall cooperate with 

and provide technical assistance to the Indian Tribe, Tribal Organization, or Urban Indian Organization in the development 

and implementation of such plan. 

(3) FUNDING.—The Secretary, acting through the Service, may 

make funding available to Indian Tribes and Tribal Organizations which adopt a resolution pursuant to paragraph (1) to obtain technical assistance for the development of a community 

behavioral health plan and to provide administrative support 

in the implementation of such plan. 

(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 2006, the Secretary, acting through 

the Service, shall make an assessment of the need for inpatient mental health care among Indians and the availability and cost of inpatient mental health facilities which can meet such need. In making 

such assessment, the Secretary shall consider the possible conversion of existing, underused Service hospital beds into psychiatric 

units to meet such need. 

SEC. 702. MEMORANDA OF AGREEMENT WITH THE DEPARTMENT OF 

THE INTERIOR. 

(a) CONTENTS.—Not later than 12 months after the date of the enactment of the Indian Health Care Improvement Act Amendments 

of 2006, the Secretary, acting through the Service, and the Secretary 

of the Interior shall develop and enter into one or more memoranda 

of agreement, or review and update any existing memoranda of 

agreement, as required by section 4205 of the Indian Alcohol and 


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Substance Abuse Prevention and Treatment Act of 1986 (25 U.S.C. 

2411) under which the Secretaries address the following: 

(1) The scope and nature of mental illness and dysfunctional 

and self-destructive behavior, including child abuse and family 

violence, among Indians. 

(2) The existing Federal, tribal, State, local, and private services, resources, and programs available to provide behavioral 

health services for Indians. 

(3) The unmet need for additional services, resources, and 

programs necessary to meet the needs identified pursuant to 

paragraph (1). 

(4)(A) The right of Indians, as citizens of the United States 

and of the States in which they reside, to have access to behavioral health services to which all citizens have access. 

(B) The right of Indians to participate in, and receive the benefit of, such services. 

(C) The actions necessary to protect the exercise of such right. 

(5) The responsibilities of the Bureau of Indian Affairs and 

the Service, including mental illness identification, prevention, 

education, referral, and treatment services (including services 

through multidisciplinary resource teams), at the central, area, 

and agency and Service Unit, Service Area, and headquarters 

levels to address the problems identified in paragraph (1). 

(6) A strategy for the comprehensive coordination of the behavioral health services provided by the Bureau of Indian Affairs and the Service to meet the problems identified pursuant 

to paragraph (1), including—

(A) the coordination of alcohol and substance abuse programs of the Service, the Bureau of Indian Affairs, and Indian Tribes and Tribal Organizations (developed under the 

Indian Alcohol and Substance Abuse Prevention and Treatment Act of 1986) 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 memoranda of agreement updated or entered into pursuant to subsection (a) shall include specific provisions pursuant to which the Service shall assume 

responsibility for—


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(1) the determination of the scope of the problem of alcohol 

and substance abuse among Indians, including the number of 

Indians within the jurisdiction of the Service who are directly 

or indirectly affected by alcohol and substance abuse and the financial and human cost; 

(2) an assessment of the existing and needed resources necessary for the prevention of alcohol and substance abuse and 

the treatment of Indians affected by alcohol and substance 

abuse; and 

(3) an estimate of the funding necessary to adequately support 

a program of prevention of alcohol and substance abuse and 

treatment of Indians affected by alcohol and substance abuse. 

(c) 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 

(4) behavioral health service providers. 

(d) PUBLICATION.—Each memorandum of agreement entered into 

or renewed (and amendments or modifications thereto) under subsection (a) shall be published in the Federal Register. At the same 

time as publication in the Federal Register, the Secretary shall provide a copy of each such memorandum, amendment, or modification 

to each Indian Tribe, Tribal Organization, and Urban Indian Organization. 

SEC. 703. COMPREHENSIVE BEHAVIORAL HEALTH PREVENTION AND 

TREATMENT 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, prevention, 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 treatment; 

(C) community-based rehabilitation and aftercare; 

(D) community education and involvement, including extensive training of health care, educational, and community-based personnel; 

(E) specialized residential treatment programs for highrisk populations, including pregnant and postpartum 

women and their children; and 

(F) diagnostic services. 

(2) TARGET POPULATIONS.—The target population of such programs shall be members of Indian 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 HEALTH SERVICES.—


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(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 

treatment services for the purpose of carrying out the program 

required under subsection (a). 

(2) PROVISION OF ASSISTANCE.—In carrying out this subsection, the Secretary shall provide assistance to Indian Tribes 

and Tribal Organizations to develop criteria for the certification 

of behavioral health service providers and accreditation of service facilities which meet minimum standards for such services 

and facilities. 

SEC. 704. MENTAL HEALTH TECHNICIAN PROGRAM. 

(a) IN GENERAL.—Under the authority of the Act of November 2, 

1921 (25 U.S.C. 13) (commonly known as the ‘‘Snyder Act’’), the Secretary shall establish and maintain a mental health technician program within the Service which—

(1) provides for the training of Indians as mental health technicians; and 

(2) employs such technicians in the provision of communitybased mental health care that includes identification, prevention, education, referral, and treatment services. 

(b) PARAPROFESSIONAL TRAINING.—In carrying out subsection (a), 

the Secretary, acting through the Service, Indian Tribes, and Tribal 

Organizations, shall provide high-standard paraprofessional training in mental health care necessary to provide quality care to the 

Indian communities to be served. Such training shall be based upon 

a curriculum developed or approved by the Secretary which combines education in the theory of mental health care with supervised 

practical experience in the provision of such care. 

(c) SUPERVISION AND EVALUATION OF TECHNICIANS.—The Secretary, acting through the Service, Indian Tribes, and Tribal Organizations, shall supervise and evaluate the mental health technicians in the training program. 

(d) TRADITIONAL HEALTH CARE PRACTICES.—The Secretary, acting through the Service, shall ensure that the program established 

pursuant to this subsection involves the use and promotion of the 

Traditional Health Care Practices of the Indian Tribes to be served. 

SEC. 705. LICENSING REQUIREMENT FOR MENTAL HEALTH CARE 

WORKERS. 

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 

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. 

SEC. 706. INDIAN WOMEN TREATMENT PROGRAMS. 

(a) FUNDING.—The Secretary, consistent with section 701, shall 

make funds available to Indian Tribes, Tribal Organizations, and 

Urban Indian Organizations to develop and implement a comprehensive behavioral health program of prevention, intervention, 

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es the spiritual, cultural, historical, social, and child care needs of 

Indian women, regardless of age. 

(b) USE OF GRANT.—A grant made available 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 issues, including fetal alcohol disorders; 

(2) identify and provide psychological services, counseling, 

advocacy, support, and relapse prevention to Indian women and 

their families; and 

(3) develop prevention and intervention models for Indian 

women which incorporate Traditional Health Care Practices, 

cultural values, and community and family involvement. 

(c) CRITERIA.—The Secretary, in consultation with Indian Tribes 

and Tribal Organizations, shall establish criteria for the review and 

approval of applications and proposals for funding 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. 

SEC. 707. INDIAN YOUTH PROGRAM. 

(a) DETOXIFICATION AND 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. 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 Assistance Act. Regional centers shall be integrated with the intake and rehabilitation programs based in the referring Indian community. 

(b) ALCOHOL AND SUBSTANCE ABUSE TREATMENT CENTERS OR

FACILITIES.— (1) ESTABLISHMENT.— (A) IN GENERAL.—The Secretary, acting through the Service, Indian Tribes, and Tribal Organizations, shall construct, renovate, or, as necessary, purchase, and appropriately staff and operate, at least 1 youth regional treatment center or treatment network in each area under the 

jurisdiction of an Area Office. 

(B) AREA OFFICE IN CALIFORNIA.—For the purposes of 

this subsection, the Area Office in California shall be considered to be 2 Area Offices, 1 office whose jurisdiction 

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 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 


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upon (by appropriate tribal resolution) by a majority of the Indian Tribes to be served by such center. 

(4) SPECIFIC PROVISION OF FUNDS.— (A) IN GENERAL.—Notwithstanding any other provision of 

this title, the Secretary may, from amounts authorized to be 

appropriated for the purposes of carrying out this section, 

make funds available to— (i) the Tanana Chiefs Conference, Incorporated, for 

the purpose of leasing, constructing, renovating, 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 4(l) of the Indian Self-Determination and Education Assistance Act (25 U.S.C. 450b(l)). 

(B) PROVISION OF SERVICES TO ELIGIBLE YOUTHS.—Until 

additional residential youth treatment facilities are established in Alaska pursuant to this section, the facilities specified in subparagraph (A) shall make every effort to provide 

services to all eligible Indian youths residing in Alaska. 

(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 Traditional 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) FEDERALLY OWNED STRUCTURES.—

(1) IN GENERAL.—The Secretary, in consultation with Indian 

Tribes and Tribal Organizations, shall—


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(A) identify and use, where appropriate, federally owned 

structures suitable for local residential or regional behavioral health treatment 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 

local residential or regional behavioral health treatment 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) REHABILITATION AND AFTERCARE SERVICES.— (1) IN GENERAL.—The Secretary, Indian Tribes, or Tribal Organizations, in cooperation with the Secretary of the Interior, 

shall develop and implement within each Service Unit, community-based rehabilitation and follow-up services for Indian 

youths who are having significant behavioral health problems, 

and require long-term treatment, community reintegration, and 

monitoring to support the Indian youths after their return to 

their home community. 

(2) ADMINISTRATION.—Services under paragraph (1) shall be 

provided 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 include alcohol and substance abuse counselors, mental health professionals, and other 

health professionals and paraprofessionals, including community health representatives. 

(f) INCLUSION OF FAMILY IN YOUTH TREATMENT 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) shall be used for outpatient care of adult family members related 

to the treatment of an Indian youth under that subsection. 

(g) MULTIDRUG ABUSE PROGRAM.—The Secretary, acting through 

the Service, Indian Tribes, Tribal Organizations, and Urban Indian 

Organizations, shall provide, consistent with section 701, programs 

and services to prevent and treat the abuse of multiple forms of substances, including alcohol, drugs, inhalants, and tobacco, among Indian youths residing in Indian communities, on or near reservations, and in urban areas and provide appropriate mental health 

services to address the incidence of mental illness among such 

youths. 

SEC. 708. INPATIENT AND COMMUNITY-BASED MENTAL HEALTH FACILITIES DESIGN, CONSTRUCTION, AND STAFFING. 

Not later than 1 year after the date of the enactment of the Indian 

Health Care Improvement Act Amendments of 2006, 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 


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behavioral health problems. For the purposes of this subsection, 

California shall be considered to be 2 Area Offices, 1 office whose 

location shall be considered to encompass the northern area of the 

State of California and 1 office whose jurisdiction shall be considered to encompass the remainder of the State of California. The Secretary shall consider the possible conversion of existing, underused 

Service hospital beds into psychiatric units to meet such need. 

SEC. 709. TRAINING AND COMMUNITY EDUCATION. 

(a) PROGRAM.—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 Service Unit or tribal program, a program of community education and involvement which shall be designed to provide 

concise and timely information to the community leadership of each 

tribal community. Such program shall include education about behavioral health issues to political leaders, 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. Communitybased 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.—The Secretary, acting through the Service, 

shall, either directly or through Indian Tribes and Tribal Organizations, provide instruction in the area of behavioral health issues, including instruction in crisis intervention and family relations in the 

context of alcohol and substance abuse, child sexual abuse, youth alcohol and substance abuse, and the causes and effects of fetal alcohol disorders to appropriate employees of the Bureau of Indian Affairs and the Service, and to personnel in schools or programs operated under any contract with the Bureau of Indian Affairs or the 

Service, including supervisors of emergency shelters and halfway 

houses described in section 4213 of the Indian Alcohol and Substance Abuse Prevention and Treatment Act of 1986 (25 U.S.C. 

2433). 

(c) TRAINING MODELS.—In carrying out the education and training programs required by this section, the Secretary, in consultation 

with Indian Tribes, 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 faced by children of alcoholics; 

(2) the cultural, spiritual, and multigenerational aspects of 

behavioral health problem prevention and recovery; and 

(3) community-based and multidisciplinary strategies for preventing and treating behavioral health problems. 

SEC. 710. 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. 


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(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 Indian healing and treatment 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 applications or proposals for funding 

for projects to be operated under any contract or compact under the 

Indian Self-Determination and Education Assistance Act (25 U.S.C. 

450 et seq.), use the same criteria that the Secretary uses in evaluating any other application or proposal for such funding. 

SEC. 711. FETAL ALCOHOL DISORDER PROGRAMS. 

(a) PROGRAMS.— (1) ESTABLISHMENT.—The Secretary, consistent with section 

701, acting through the Service, Indian Tribes, and Tribal Organizations, is authorized to establish and operate fetal alcohol 

disorder programs as provided in this section for the purposes 

of meeting the health status objectives specified in section 3. 

(2) USE OF FUNDS.—Funding provided pursuant to this section shall be used for the following: 

(A) To develop and provide for Indians community and 

in-school training, education, and prevention programs relating to fetal alcohol disorders. 

(B) To identify and provide behavioral health treatment 

to high-risk Indian women and high-risk women pregnant 

with an Indian’s child. 

(C) To identify and provide appropriate psychological 

services, educational and vocational support, counseling, 

advocacy, and information to fetal alcohol disorder affected 

Indians and their families or caretakers. 

(D) To develop and implement counseling and support 

programs in schools for fetal alcohol disorder affected Indian children. 

(E) To develop prevention and intervention models which 

incorporate traditional healers, cultural and spiritual values, and community involvement. 

(F) To develop, print, and disseminate education and prevention materials on fetal alcohol disorder. 

(G) To develop and implement, through the tribal consultation process, culturally sensitive assessment and diagnostic tools including dysmorphology clinics and multidisciplinary fetal alcohol disorder clinics for use in 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. 


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(I) To develop— (i) community-based support services for Indians and 

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 under this section. 

(b) SERVICES.—The Secretary, acting through the Service and Indian Tribes, Tribal Organizations, and Urban Indian Organizations, shall— (1) develop and provide services for the prevention, intervention, treatment, and aftercare for those affected by fetal alcohol 

disorder in Indian communities; and 

(2) provide supportive services, directly or through an Indian 

Tribe, Tribal Organization, or Urban Indian Organization, including services to meet the special educational, vocational, 

school-to-work transition, and independent living needs of adolescent and adult Indians with fetal alcohol disorder. 

(c) TASK FORCE.—The Secretary shall establish a task force to be 

known as the Fetal Alcohol Disorder Task Force to advise the Secretary in carrying out subsection (b). Such task force shall be composed of representatives from the following: 

(1) The National Institute on Drug Abuse. 

(2) The National Institute on Alcohol and Alcoholism. 

(3) The Office of Substance Abuse Prevention. 

(4) The National Institute of Mental Health. 

(5) The Service. 

(6) The Office of Minority Health of the Department of Health 

and Human Services. 

(7) The Administration for Native Americans. 

(8) The National Institute of Child Health and Human Development (NICHD). 

(9) The Centers for Disease Control and Prevention. 

(10) The Bureau of Indian Affairs. 

(11) Indian Tribes. 

(12) Tribal Organizations. 

(13) Urban Indian Organizations. 

(14) experts on Indian fetal alcohol disorder. 

(d) APPLIED RESEARCH PROJECTS.—The Secretary, acting through 

the Substance Abuse and Mental Health Services Administration, 

shall make grants available to Indian Tribes, Tribal Organizations, 

and Urban Indian Organizations for applied research projects 

which propose to elevate the understanding of methods to prevent, 

intervene, treat, or provide rehabilitation and behavioral health 

aftercare for Indians and Urban Indians affected by fetal alcohol 

disorder. 

(e) FUNDING FOR URBAN INDIAN ORGANIZATIONS.—Ten percent of 

the funds appropriated pursuant to this section shall be used to 

make grants to Urban Indian Organizations funded under title V. 

SEC. 712. CHILD SEXUAL ABUSE AND PREVENTION TREATMENT PROGRAMS. 

(a) ESTABLISHMENT.—The Secretary, acting through the Service, 

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zations 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 

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, through the tribal consultation 

process, culturally sensitive assessment and diagnostic tools for 

use in Indian communities and Urban Centers. 

(5) To identify and provide behavioral health treatment to Indian perpetrators and perpetrators who are members of an Indian household— (A) making efforts to begin offender and behavioral 

health treatment while the perpetrator is incarcerated or at 

the earliest possible date if the perpetrator is not incarcerated; and 

(B) providing treatment after the perpetrator is released, 

until it is determined that the perpetrator is not a threat 

to children. 

SEC. 713. BEHAVIORAL HEALTH RESEARCH. 

The Secretary, in consultation with appropriate Federal agencies, 

shall provide funding to Indian Tribes, Tribal Organizations, and 

Urban Indian Organizations or enter into contracts with, or make 

grants to appropriate institutions for, the conduct of research on the 

incidence and prevalence of behavioral health problems among Indians served by the Service, Indian Tribes, or Tribal Organizations 

and among Indians in urban areas. Research priorities under this 

section shall include— (1) the multifactorial causes of Indian youth suicide, including— (A) protective and risk factors and scientific data that 

identifies those factors; and 

(B) the effects of loss of cultural identity and the development of scientific data on those effects; 

(2) the interrelationship and interdependence of behavioral 

health problems with alcoholism and other substance abuse, 

suicide, homicides, other injuries, and the incidence of family 

violence; and 

(3) the development of models of prevention techniques. 

The effect of the interrelationships and interdependencies referred to 

in paragraph (1) on children, and the development of prevention 

techniques under paragraph (2) applicable to children, shall be emphasized. 


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SEC. 714. DEFINITIONS. 

For the purpose of this title, 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. 

(2) ALCOHOL-RELATED NEURODEVELOPMENTAL DISORDERS OR

ARND.—The term ‘‘alcohol-related neurodevelopmental disorders’’ or ‘‘ARND’’ means a central nervous system or behavioral disorder, following a maternal history of alcohol consumption during pregnancy, that may involve—

(A) physical manifestations such as development delay, 

intellectual deficit, neurologic abnormalities, or failure to 

thrive as infants; or 

(B) behavioral manifestations such as irritability, or for 

older children, hyperactivity, attention deficit, language 

dysfunction, or perceptual or judgment difficulties. 

(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, community health aides, 

community health representatives, mental health technicians, 

ministers, etc.). 

(4) DUAL DIAGNOSIS.—The term ‘‘dual diagnosis’’ means coexisting substance abuse and mental illness conditions or diagnosis. Such clients are sometimes referred to as mentally ill 

chemical abusers (MICAs). 

(5) FETAL ALCOHOL DISORDERS.—The term ‘‘fetal alcohol disorders’’ means fetal alcohol syndrome, partial fetal alcohol syndrome and alcohol related neurodevelopmental disorder 

(ARND). 

(6) FETAL ALCOHOL SYNDROME OR FAS.—The term ‘‘fetal alcohol syndrome’’ or ‘‘FAS’’ means a syndrome in which, with a 

history of maternal alcohol consumption during pregnancy, the 

following criteria are met: 

(A) Central nervous system involvement such as developmental delay, intellectual deficit, microencephaly, or 

neurologic abnormalities. 

(B) Craniofacial abnormalities with at least 2 of the following: microophthalmia, short palpebral fissures, poorly 

developed philtrum, thin upper lip, flat nasal bridge, and 

short upturned nose. 

(C) Prenatal or postnatal growth delay. 

(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 


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fissures, poorly developed philtrum, thin upper lip, flat nasal 

bridge, and short upturned nose. 

(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. 

SEC. 715. 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 the 

provisions of this title. 

TITLE VIII—MISCELLANEOUS 

SEC. 801. REPORTS. 

The President shall, at the time the budget is submitted under 

section 1105 of title 31, United States Code, for each fiscal year 

transmit to Congress a report containing the following: 

(1) A report on the progress made in meeting the objectives of 

this Act, including a review of programs established or assisted 

pursuant to this Act and assessments and recommendations of 

additional programs or additional assistance necessary to, at a 

minimum, provide health services to Indians and ensure a 

health status for Indians, which are at a parity with the health 

services available to and the health status of the general population, including specific comparisons of appropriations provided and those required for such parity. 

(2) A report on whether, and to what extent, new national 

health care programs, benefits, initiatives, or financing systems 

have had an impact on the purposes of this Act and any steps 

that the Secretary may have taken to consult with Indian 

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. 

(3) A report on the use of health services by Indians—

(A) on a national and area or other relevant geographical 

basis; 

(B) by gender and age; 

(C) by source of payment and type of service; 

(D) comparing such rates of use with rates of use among 

comparable non-Indian populations; 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 126(f). 

(7) A separate statement which specifies the amount of funds 

requested to carry out the provisions of section 201. 


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(8) A report of the evaluations of health promotion and disease prevention as required in section 203(c). 

(9) A biennial report to Congress on infectious diseases as required by section 212. 

(10) A report on environmental and nuclear health hazards 

as required by section 215. 

(11) An annual report on the status of all health care facilities needs as required by sections 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 between the Service, Indian Tribes, and 

Tribal Organizations, and the Department of Veterans Affairs 

and the Department of Defense, 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 as required by section 707(h). 

SEC. 802. 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 2006, 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, II, III, and VII and section 817. 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, 

except as necessary to carry out section 817. 

(2) PROPOSED REGULATIONS.—Proposed regulations to implement this Act shall be published in the Federal Register by the 

Secretary no later than 270 days after the date of the enactment 

of the Indian Health Care Improvement Act Amendments of 

2006 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 18 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 States Code, to carry out 

this section shall have as its members only representatives of the 


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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. 

(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 2006, and the Secretary is authorized to 

repeal any regulation inconsistent with the provisions of this Act. 

SEC. 803. PLAN OF IMPLEMENTATION. 

Not later than 9 months after the date of the enactment of the Indian Health Care Improvement Act Amendments of 2006, 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. 

SEC. 804. AVAILABILITY OF FUNDS. 

The funds appropriated pursuant to this Act shall remain available until expended. 

SEC. 805. LIMITATION ON USE OF FUNDS APPROPRIATED TO THE INDIAN HEALTH SERVICE. 

Any limitation on the use of funds contained in an Act providing 

appropriations for the Department 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 Service. 

SEC. 806. ELIGIBILITY OF CALIFORNIA INDIANS. 

(a) IN GENERAL.—The following California Indians shall be eligible for health services provided by the Service: 

(1) Any member of a federally recognized Indian Tribe. 

(2) Any descendant of an Indian who was residing in California on June 1, 1852, if such descendant—

(A) is a member of the Indian community served by a 

local program of the Service; and 

(B) is regarded as an Indian by the community in which 

such descendant lives. 

(3) Any Indian who holds trust interests in public domain, 

national forest, or reservation allotments in California. 

(4) Any Indian in California who is listed on the plans for 

distribution of the assets of 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) CLARIFICATION.—Nothing in this section may be construed as 

expanding the eligibility of California Indians for health services 

provided by the Service beyond the scope of eligibility for such 

health services that applied on May 1, 1986. 


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SEC. 807. HEALTH SERVICES FOR INELIGIBLE PERSONS. 

(a) CHILDREN.—Any individual who—

(1) has not attained 19 years of age; 

(2) is the natural or adopted child, stepchild, foster child, 

legal ward, or orphan of an eligible Indian; and 

(3) is not otherwise eligible for 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 1 year after the date of a determination of competency. 

(b) SPOUSES.—Any spouse of an eligible Indian who is not an Indian, or who is of Indian descent but not otherwise eligible for the 

health services provided by the Service, shall be eligible for such 

health services if all such spouses or spouses who are married to 

members of the Indian Tribe(s) being 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. 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) PROVISION OF SERVICES TO OTHER INDIVIDUALS.—

(1) IN GENERAL.—The Secretary is authorized to provide 

health services under this subsection through health programs 

operated directly by the Service to individuals who reside within the Service Unit and who are not otherwise eligible for such 

health services if—

(A) the Indian Tribes served by such Service Unit request 

such provision of health services to such individuals; and 

(B) the Secretary and the served Indian Tribes have 

jointly determined that—

(i) the provision of such health services will not result in a denial or diminution of health services to eligible Indians; and 

(ii) there is no reasonable alternative health facilities 

or services, within or without the Service Unit, available to meet the health needs of such individuals. 

(2) PROGRAMS.—In the case of a Tribal Health Program, the 

governing body of the Indian Tribe or Tribal Organization providing health services under such Tribal Health Program is authorized to determine whether health services should be provided under its Funding Agreement to individuals who are not 

otherwise eligible for such services. In making such determination, the governing body shall take into account the considerations described in clauses (i) and (ii) of paragraph (1)(B). 

(3) PAYMENT FOR SERVICES.—

(A) IN GENERAL.—Persons receiving health services provided by the Service under this subsection shall be liable 

for payment of such health services under a schedule of 


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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 404 of this Act or any other 

provision of law, amounts collected under this subsection, 

including Medicare, Medicaid, or SCHIP reimbursements 

under titles XVIII, XIX, and XXI of the Social Security Act, 

shall be credited to the account of the program providing 

the service and shall be used for the purposes listed in section 401(d)(2) and amounts collected under this subsection 

shall be available for expenditure within such program. 

(B) INDIGENT PEOPLE.—Health services may be provided 

by the Secretary through the Service under this subsection 

to an indigent individual who would not be otherwise eligible for such health services but for the provisions of paragraph (1) only if an agreement has been entered into with 

a State or local government under which the State or local 

government agrees to reimburse the Service for the expenses 

incurred by the Service in providing such health services to 

such indigent individual. 

(4) REVOCATION OF CONSENT FOR SERVICES.— (A) SINGLE TRIBE SERVICE AREA.—In the case of a Service 

Area which serves only 1 Indian Tribe, the authority of the 

Secretary to provide health services under paragraph (1) 

shall terminate at the end of the fiscal year succeeding the 

fiscal year in which the governing body of the Indian Tribe 

revokes its concurrence to the provision of such health services. 

(B) MULTITRIBAL SERVICE AREA.—In the case of a multitribal Service Area, the authority of the Secretary to provide health services under paragraph (1) shall terminate at 

the end of the fiscal year succeeding the fiscal year in 

which at least 51 percent of the number of Indian Tribes 

in the Service Area revoke their concurrence to the provisions of such health services. 

(d) OTHER SERVICES.—The Service may provide health services 

under this subsection to individuals who are not eligible for health 

services provided by the Service under any other provision of law in 

order to—

(1) achieve stability in a medical emergency; 

(2) prevent the spread of a communicable disease or otherwise 

deal with a public health hazard; 

(3) provide care to non-Indian women pregnant with an eligible Indian’s child for the duration of the pregnancy through 

postpartum; or 

(4) provide care to immediate family members of an eligible 

individual if such care is directly related to the treatment of the 

eligible individual. 

(e) HOSPITAL PRIVILEGES FOR PRACTITIONERS.—Hospital privileges in health facilities operated and maintained by the Service or 

operated under a Funding Agreement may be extended to non-Service health care practitioners who provide services to individuals described in subsection (a), (b), (c), or (d). Such non-Service health 

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tion 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 as a part of the conditions under which such hospital privileges are extended. 

(f) ELIGIBLE INDIAN.—For purposes of this section, the term ‘‘eligible Indian’’ means any Indian who is eligible for health services 

provided by the Service without regard to the provisions of this section. 

SEC. 808. REALLOCATION OF BASE RESOURCES. 

(a) REPORT REQUIRED.—Notwithstanding any other provision of 

law, any allocation of Service funds for a fiscal year that reduces 

by 5 percent or more from the previous fiscal year the funding for 

any recurring program, project, or activity of a Service Unit may be 

implemented only after the Secretary has submitted to the President, for inclusion in the report required to be transmitted to Congress under section 801, a report on the proposed change in allocation of funding, including the reasons for the change and its likely 

effects. 

(b) EXCEPTION.—Subsection (a) shall not apply if the total 

amount appropriated to the Service for a fiscal year is at least 5 

percent less than the amount appropriated to the Service for the previous fiscal year. 

SEC. 809. RESULTS OF DEMONSTRATION PROJECTS. 

The Secretary shall provide for the dissemination to Indian 

Tribes, Tribal Organizations, and Urban Indian Organizations of 

the findings and results of demonstration projects conducted under 

this Act. 

SEC. 810. PROVISION OF SERVICES IN MONTANA. 

(a) CONSISTENT WITH COURT DECISION.—The Secretary, acting 

through the Service, shall provide services and benefits for Indians 

in Montana in a manner consistent with the decision of the United 

States Court of Appeals for the Ninth Circuit in McNabb v. Bowen, 

829 F.2d 787 (9th Cir. 1987). 

(b) CLARIFICATION.—The provisions of subsection (a) shall not be 

construed to be an expression of the sense of Congress on the application of the decision described in subsection (a) with respect to the 

provision of services or benefits for Indians living in any State other 

than Montana. 

SEC. 811. MORATORIUM. 

During the period of the moratorium imposed on implementation 

of the final rule published in the Federal Register on September 16, 

1987, by the Health Resources and Services Administration of the 

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. 


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SEC. 812. TRIBAL EMPLOYMENT. 

For purposes of section 2(2) of the Act of July 5, 1935 (49 Stat. 

450, chapter 372), an Indian Tribe or Tribal Organization carrying 

out a Funding Agreement shall not be considered an ‘‘employer’’. 

SEC. 813. SEVERABILITY PROVISIONS. 

If any provision of this Act, any amendment made by the Act, or 

the application of such provision or amendment to any person or 

circumstances is held to be invalid, the remainder of this Act, the 

remaining amendments made by this Act, and the application of 

such provisions to persons or circumstances other than those to 

which it is held invalid, shall not be affected thereby. 

SEC. 814. 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 

to such extent or in such amounts as are provided in appropriation 

Acts. 

SEC. 815. 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. 

CHAPTER 53 OF TITLE 5, UNITED STATES CODE 

CHAPTER 53—PAY RATES AND SYSTEMS 

* * * * * * * 

SUBCHAPTER II—EXECUTIVE SCHEDULE PAY RATES 

§ 5315. Positions at level IV 

Level IV of the Executive Schedule applies to the following positions, for which the annual rate of basic pay shall be the rate determined with respect to such level under chapter 11 of title 2, as 

adjusted by section 5318 of this title: 

Deputy Administrator of General Services. 

* * * * * * * 

øAssistant Secretaries of Health and Human Services (6).¿ Assistant Secretaries of Health and Human Services (7). 

* * * * * * * 

§ 5316. Positions at level V 

Level V of the Executive Schedule applies to the following positions, for which the annual rate of basic pay shall be the rate determined with respect to such level under chapter 11 of title 2, as 

adjusted by section 5318 of this title: 

Administrator, Bonneville Power Administration, Department 

of the Interior. 

* * * * * * * 


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øDirector, Indian Health Service, Department of Health and 

Human Services.¿ 

* * * * * * * 

SECTION 3307 OF THE CHILDREN’S HEALTH ACT OF 2000 

SEC. 3307. ESTABLISHMENT OF COMMISSION. 

(a) * * * 

(b) MEMBERSHIP.— (1) IN GENERAL.—The Commission established under subsection (a) shall consist of— (A) * * * 

* * * * * * * 

(C) the øDirector of the Indian Health Service¿ Assistant 

Secretary for Indian Health and the Commissioner of Indian Affairs, who shall be nonvoting members. 

* * * * * * * 

INDIAN LANDS OPEN DUMP CLEANUP ACT OF 1994 

* * * * * * * 

SEC. 3. DEFINITIONS. 

For the purposes of this Act, the following definitions shall apply: 

ø(2) DIRECTOR.—The term ‘‘Director’’ means the Director of 

the Indian Health Service.¿ 

ø(6)¿ (1) ALASKA NATIVE ENTITY.—The term ‘‘Alaska Native 

entity’’ includes native corporations established pursuant to 

the Alaska Native Claims Settlement Act (43 U.S.C. 1600 et 

seq.) and any Alaska Native village or municipal entity which 

owns Alaska Native land. 

ø(4)¿ (2) ALASKA NATIVE LAND.—The term ‘‘Alaska Native 

land’’ means (A) land conveyed or to be conveyed pursuant to 

the Alaska Native Claims Settlement Act (43 U.S.C. 1600 et 

seq.), including any land reconveyed under section 14(c)(3) of 

that Act (43 U.S.C. 1613(c)(3)), and (B) land conveyed pursuant 

to the Act of November 2, 1966 (16 U.S.C. 1151 et seq.; commonly known as the ‘‘Fur Seal Act of 1966’’). 

(3) ASSISTANT SECRETARY.—The term ‘‘Assistant Secretary’’

means the Assistant Secretary for Indian Health. 

ø(1)¿ (4) CLOSURE OR CLOSE.—The term ‘‘closure or close’’

means the termination of operations at open dumps on Indian 

land or Alaska Native land and bringing such dumps into compliance with applicable Federal standards and regulations, or 

standards promulgated by an Indian tribal government or 

Alaska Native entity, if such standards are more stringent 

than the Federal standards and regulations. 

ø(3)¿ (5) INDIAN LAND.—The term ‘‘Indian land’’ means—

(A) * * * 

* * * * * * * 

ø(5)¿ (6) INDIAN TRIBAL GOVERNMENT.—The term ‘‘Indian 

tribal government’’ means the governing body of any Indian 

tribe, band, nation, pueblo, or other organized group or commuVerDate Aug 31 2005 06:29 Sep 16, 2006 Jkt 049006 PO 00000 Frm 00306 Fmt 6659 Sfmt 6601 E:\HR\OC\HR661P1.XXX HR661P1

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nity which is recognized as eligible for the special programs 

and services provided by the United States to Indians because 

of their status as Indians. 

* * * * * * * 

SEC. 4. INVENTORY OF OPEN DUMPS. 

(a) STUDY AND INVENTORY.—Not later than 12 months after the 

date of enactment of this Act, the øDirector¿ Assistant Secretary 

shall conduct a study and inventory of open dumps on Indian lands 

and Alaska Native lands. The inventory shall list the geographic location of all open dumps, an evaluation of the contents of each 

dump, and an assessment of the relative severity of the threat to 

public health and the environment posed by each dump. Such assessment shall be carried out cooperatively with the Administrator 

of the Environmental Protection Agency. The øDirector¿ Assistant 

Secretary shall obtain the concurrence of the Administrator in the 

determination of relative severity made by any such assessment. 

(b) ANNUAL REPORTS.—Upon completion of the study and inventory under subsection (a), the øDirector¿ Assistant Secretary shall 

report to the Congress, and update such report annually—

(1) * * * 

* * * * * * * 

(c) 10-YEAR PLAN.—The øDirector¿ Assistant Secretary shall develop and begin implementation of a 10-year plan to address solid 

waste disposal needs on Indian lands and Alaska Native lands. 

This 10-year plan shall identify—

(1) * * * 

* * * * * * * 

øSEC. 5. AUTHORITY OF THE DIRECTOR OF THE INDIAN HEALTH 

SERVICE.¿ 

SEC. 5. AUTHORITY OF ASSISTANT SECRETARY FOR INDIAN HEALTH. 

(a) RESERVATION INVENTORY.—(1) Upon request by an Indian 

tribal government or Alaska Native entity, the øDirector¿ Assistant 

Secretary shall—

(A) * * * 

(B) determine the relative severity of the threat to public 

health and the environment posed by each dump based on information available to the øDirector¿ Assistant Secretary and 

the Indian tribal government or Alaska Native entity unless 

the øDirector¿ Assistant Secretary, in consultation with the Indian tribal government or Alaska Native entity, determines 

that additional actions such as soil testing or water monitoring 

would be appropriate in the circumstances; and 

(C) develop cost estimates for the closure and postclosure 

maintenance of such dumps. 

(2) The inventory and evaluation authorized under paragraph 

(1)(A) shall be carried out cooperatively with the Administrator of 

the Environmental Protection Agency. The øDirector¿ Assistant 

Secretary shall obtain the concurrence of the Administrator in the 

determination of relative severity made under paragraph (1)(B). 

(b) ASSISTANCE.—Upon completion of the activities required to be 

performed pursuant to subsection (a), the øDirector¿ Assistant Secretary shall, subject to subsection (c), provide financial and techVerDate Aug 31 2005 06:29 Sep 16, 2006 Jkt 049006 PO 00000 Frm 00307 Fmt 6659 Sfmt 6601 E:\HR\OC\HR661P1.XXX HR661P1

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nical assistance to the Indian tribal government or Alaska Native 

entity to carry out the activities necessary to—

(1) close such dumps; and 

(2) provide for postclosure maintenance of such dumps. 

(c) CONDITIONS.—All assistance provided pursuant to subsection 

(b) shall be made available on a site-specific basis in accordance 

with priorities developed by the øDirector¿ Assistant Secretary. Priorities on specific Indian lands or Alaska Native lands shall be developed in consultation with the Indian tribal government or Alaska Native entity. The priorities shall take into account the relative 

severity of the threat to public health and the environment posed 

by each open dump and the availability of funds necessary for closure and postclosure maintenance. 

SEC. 6. CONTRACT AUTHORITY. 

(a) AUTHORITY OF øDIRECTOR¿ ASSISTANT SECRETARY.—To the 

maximum extent feasible, the øDirector¿ Assistant Secretary shall 

carry out duties under this Act through contracts, compacts, or 

memoranda of agreement with Indian tribal governments or Alaska 

Native entities pursuant to the Indian Self-Determination and 

Education Assistance Act (25 U.S.C. 450 et seq.), section 7 of the 

Act of August 5, 1954 (42 U.S.C. 2004a), or section 302 of the Indian Health Care Improvement Act (25 U.S.C. 1632). 

(b) COOPERATIVE AGREEMENTS.—The øDirector¿ Assistant Secretary is authorized, for purposes of carrying out the duties of the 

øDirector¿ Assistant Secretary under this Act, to contract with or 

enter into such cooperative agreements with such other Federal 

agencies as is considered necessary to provide cost-sharing for closure and postclosure activities, to obtain necessary technical and financial assistance and expertise, and for such other purposes as 

the øDirector¿ Assistant Secretary considers necessary. 

SEC. 7. TRIBAL DEMONSTRATION PROJECT. 

(a) IN GENERAL.—The øDirector¿ Assistant Secretary may establish and carry out a program providing for demonstration projects 

involving open dumps on Indian land or Alaska Native land. It 

shall be the purpose of such projects to determine if there are 

unique cost factors involved in the cleanup and maintenance of 

open dumps on such land, and the extent to which advanced closure planning is necessary. Under the program, the øDirector¿ Assistant Secretary is authorized to select no less than three Indian 

tribal governments or Alaska Native entities to participate in such 

demonstration projects. 

(b) CRITERIA.—Criteria established by the øDirector¿ Assistant 

Secretary for the selection and participation of an Indian tribal government or Alaska Native entity in the demonstration project shall 

provide that in order to be eligible to participate, an Indian tribal 

government or Alaska Native entity must—

(1) * * * 

* * * * * * * 

SEC. 8. AUTHORIZATION OF APPROPRIATIONS. 

(a) * * * 

(b) COORDINATION.—The activities required to be performed by 

the øDirector¿ Assistant Secretary under this Act shall be coordiVerDate Aug 31 2005 06:29 Sep 16, 2006 Jkt 049006 PO 00000 Frm 00308 Fmt 6659 Sfmt 6601 E:\HR\OC\HR661P1.XXX HR661P1

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nated with activities related to solid waste and sanitation facilities 

funded pursuant to other authorizations. 

SEC. 9. DISCLAIMERS. 

(a) AUTHORITY OF øDIRECTOR¿ ASSISTANT SECRETARY.—Nothing 

in this Act shall be construed to alter, diminish, repeal, or supersede any authority conferred on the øDirector¿ Assistant Secretary 

pursuant to section 302 of the Indian Health Care Improvement 

Act (25 U.S.C. 1632), and section 7 of the Act of August 5, 1954 

(42 U.S.C. 2004a). 

* * * * * * * 

SECTION 5504 OF THE AUGUSTUS F. HAWKINS-ROBERT 

T. STAFFORD ELEMENTARY AND SECONDARY SCHOOL 

IMPROVEMENT AMENDMENTS OF 1988 

SEC. 5504. ADMINISTRATIVE PROVISIONS. 

(a) * * * 

* * * * * * * 

(d) FEDERAL AGENCY COOPERATION AND ASSISTANCE.—

(1) * * * 

(2) The Commissioner of the Administration for Native 

Americans of the Department of Health and Human Services 

and the øDirector of the Indian Health Service¿ Assistant Secretary for Indian Health of the Department of Health and 

Human Services are authorized to detail personnel to the Task 

Force, upon request, to enable the Task Force to carry out its 

functions under this part. 

* * * * * * * 

SECTION 203 OF THE REHABILITATION ACT OF 1973 

INTERAGENCY COMMITTEE

SEC. 203. (a)(1) In order to promote coordination and cooperation 

among Federal departments and agencies conducting rehabilitation 

research programs, including programs relating to assistive technology research and research that incorporates the principles of 

universal design, there is established within the Federal Government an Interagency Committee on Disability Research (hereinafter in this section referred to as the ‘‘Committee’’), chaired by the 

Director and comprised of such members as the President may designate, including the following (or their designees): the Director, 

the Commissioner of the Rehabilitation Services Administration, 

the Assistant Secretary for Special Education and Rehabilitative 

Services, the Secretary of Education, the Secretary of Veterans Affairs, the Director of the National Institutes of Health, the Director 

of the National Institute of Mental Health, the Administrator of 

the National Aeronautics and Space Administration, the Secretary 

of Transportation, the Assistant Secretary of the Interior for Indian 

Affairs, the øDirector of the Indian Health Service¿ Assistant SecVerDate Aug 31 2005 06:29 Sep 16, 2006 Jkt 049006 PO 00000 Frm 00309 Fmt 6659 Sfmt 6601 E:\HR\OC\HR661P1.XXX HR661P1

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retary for Indian Health, and the Director of the National Science 

Foundation. 

* * * * * * * 

SECTION 518 OF THE FEDERAL WATER POLLUTION 

CONTROL ACT 

SEC. 518. INDIAN TRIBES. 

(a) * * * 

* * * * * * * 

(b) ASSESSMENT OF SEWAGE TREATMENT NEEDS; REPORT.—The 

Administrator, in cooperation with the øDirector of the Indian 

Health Service¿ Assistant Secretary for Indian Health, shall assess 

the need for sewage treatment works to serve Indian tribes, the degree to which such needs will be met through funds allotted to 

States under section 205 of this Act and priority lists under section 

216 of this Act, and any obstacles which prevent such needs from 

being met. Not later than one year after the date of the enactment 

of this section, the Administrator shall submit a report to Congress 

on the assessment under this subsection, along with recommendations specifying (1) how the Administrator intends to provide assistance to Indian tribes to develop waste treatment management 

plans and to construct treatment works under this Act, and (2) 

methods by which the participation in and administration of programs under this Act by Indian tribes can be maximized. 

* * * * * * * 

(e) TREATMENT AS STATES.—The Administrator is authorized to 

treat an Indian tribe as a State for purposes of title II and sections 

104, 106, 303, 305, 308, 309, 314, 319, 401, 402, 404, and 406 of 

this Act to the degree necessary to carry out the objectives of this 

section, but only if— (1) * * * 

* * * * * * * 

Such treatment as a State may include the direct provision of 

funds reserved under subsection (c) to the governing bodies of Indian tribes, and the determination of priorities by Indian tribes, 

where not determined by the Administrator in cooperation with the 

øDirector of the Indian Health Service¿ Assistant Secretary for Indian Health. The Administrator, in cooperation with the øDirector 

of the Indian Health Service¿ Assistant Secretary for Indian 

Health, is authorized to make grants under title II of this Act in 

an amount not to exceed 100 percent of the cost of a project. Not 

later than 18 months after the date of the enactment of this section, the Administrator shall, in consultation with Indian tribes, 

promulgate final regulations which specify how Indian tribes shall 

be treated as States for purposes of this Act. The Administrator 

shall, in promulgating such regulations, consult affected States 

sharing common water bodies and provide a mechanism for the resolution of any unreasonable consequences that may arise as a result of differing water quality standards that may be set by States 

and Indian tribes located on common bodies of water. Such mechanism shall provide for explicit consideration of relevant factors inVerDate Aug 31 2005 06:29 Sep 16, 2006 Jkt 049006 PO 00000 Frm 00310 Fmt 6659 Sfmt 9001 E:\HR\OC\HR661P1.XXX HR661P1

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cluding, but not limited to, the effects of differing water quality 

permit requirements on upstream and downstream dischargers, 

economic impacts, and present and historical uses and quality of 

the waters subject to such standards. Such mechanism should provide for the avoidance of such unreasonable consequences in a 

manner consistent with the objective of this Act. 

* * * * * * * 

PUBLIC HEALTH SERVICE ACT 

* * * * * * * 

TITLE III—GENERAL POWERS AND DUTIES OF PUBLIC 

HEALTH SERVICE 

* * * * * * * 

PART B—FEDERAL-STATE COOPERATION

* * * * * * * 

ORAL HEALTH PROMOTION AND DISEASE PREVENTION

SEC. 317M. (a) * * * 

(b) COMMUNITY WATER FLUORIDATION.—

(1) IN GENERAL.—The Secretary, acting through the Director 

of the Centers for Disease Control and Prevention and in collaboration with the øDirector of the Indian Health Service¿ Assistant Secretary for Indian Health, shall establish a demonstration project that is designed to assist rural water systems in successfully implementing the water fluoridation 

guidelines of the Centers for Disease Control and Prevention 

that are entitled ‘‘Engineering and Administrative Recommendations for Water Fluoridation, 1995’’ (referred to in 

this subsection as the ‘‘EARWF’’). 

(2) REQUIREMENTS.—

(A) COLLABORATION.—In collaborating under paragraph 

(1), øthe Directors referred to in such paragraph¿ the Director of the Centers for Disease Control and Prevention 

and the Assistant Secretary for Indian Health shall ensure 

that technical assistance and training are provided to tribal programs located in each of the 12 areas of the Indian 

Health Service. The øDirector of the Indian Health Service¿ Assistant Secretary for Indian Health shall provide coordination and administrative support to tribes under this 

section. 

* * * * * * * 

TITLE IV—NATIONAL RESEARCH INSTITUTES 

* * * * * * * 


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PART C—SPECIFIC PROVISIONS RESPECTING NATIONAL RESEARCH

INSTITUTES

Subpart 1—National Cancer Institute 

* * * * * * * 

SEC. 417C. GRANTS FOR EDUCATION, PREVENTION, AND EARLY DETECTION OF RADIOGENIC CANCERS AND DISEASES. 

(a) * * * 

(b) IN GENERAL.—The Secretary, acting through the Administrator of the Health Resources and Services Administration in consultation with the Director of the National Institutes of Health and 

the øDirector of the Indian Health Service¿ Assistant Secretary for 

Indian Health, may make competitive grants to any entity for the 

purpose of carrying out programs to—

(1) * * * 

* * * * * * * 

SECTION 1452 OF THE SAFE DRINKING WATER ACT 

STATE REVOLVING LOAN FUNDS

SEC. 1452. (a) * * * 

* * * * * * * 

(i) INDIAN TRIBES.—

(1) * * * 

(2) USE OF FUNDS.—Funds reserved pursuant to paragraph 

(1) shall be used to address the most significant threats to public health associated with public water systems that serve Indian Tribes, as determined by the Administrator in consultation with the øDirector of the Indian Health Service¿ Assistant 

Secretary for Indian Health and Indian Tribes. 

* * * * * * * 

(4) NEEDS ASSESSMENT.—The Administrator, in consultation 

with the øDirector of the Indian Health Service¿ Assistant Secretary for Indian Health and Indian Tribes, shall, in accordance with a schedule that is consistent with the needs surveys 

conducted pursuant to subsection (h), prepare surveys and assess the needs of drinking water treatment facilities to serve 

Indian Tribes, including an evaluation of the public water systems that pose the most significant threats to public health. 

* * * * * * * 

SECTION 803B OF THE NATIVE AMERICAN PROGRAMS 

ACT OF 1974 

ESTABLISHMENT OF ADMINISTRATION FOR NATIVE AMERICANS

SEC. 803B. (a) * * * 

* * * * * * * 

(d)(1) There is established in the Office of the Secretary the 

Intra-Departmental Council on Native American Affairs. The Commissioner shall be the chairperson of such Council and shall advise 

the Secretary on all matters affecting Native Americans that inVerDate Aug 31 2005 06:29 Sep 16, 2006 Jkt 049006 PO 00000 Frm 00312 Fmt 6659 Sfmt 9001 E:\HR\OC\HR661P1.XXX HR661P1

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volve the Department. The øDirector of the Indian Health Service¿ 

Assistant Secretary for Indian Health shall serve as vice chairperson of the Council. 

* * * * * * * 

SECTION 203 OF THE MICHIGAN INDIAN LAND CLAIMS 

SETTLEMENT ACT 

SEC. 203. LIMITATION. 

(a) * * * 

(b) CONSIDERATION.—In any case in which the Secretary, acting 

through the øDirector of the Indian Health Service¿ Assistant Secretary for Indian Health, is required to select from more than 1 application for a contract or compact described in subsection (a), in 

awarding the contract or compact, the Secretary shall take into 

consideration—

(1) * * * 

* * * * * * * 

SOCIAL SECURITY ACT 

* * * * * * * 

TITLE XI—GENERAL PROVISIONS, PEER REVIEW, AND 

ADMINISTRATIVE SIMPLIFICATION 

PART A—GENERAL PROVISIONS

* * * * * * * 

EXCLUSION OF CERTAIN INDIVIDUALS AND ENTITIES FROM

PARTICIPATION IN MEDICARE AND STATE HEALTH CARE PROGRAMS

SEC. 1128. (a) * * * 

* * * * * * * 

(k) ADDITIONAL EXCLUSION WAIVER AUTHORITY FOR AFFECTED

INDIAN HEALTH PROGRAMS.—In addition to the authority granted 

the Secretary under subsections (c)(3)(B) and (d)(3)(B) to waive an 

exclusion under subsection (a)(1), (a)(3), (a)(4), or (b), the Secretary 

may, in the case of an Indian Health Program, waive such an exclusion upon the request of the administrator of an affected Indian 

Health Program (as defined in section 4 of the Indian Health Care 

Improvement Act) who determines that the exclusion would impose 

a hardship on individuals entitled to benefits under or enrolled in 

a Federal health care program. 

* * * * * * * 

CRIMINAL PENALTIES FOR ACTS INVOLVING FEDERAL HEALTH CARE

PROGRAMS

SEC. 1128B. (a) * * * 

(b)(1) * * * 

* * * * * * * 


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(4) RENUMERATION.—Subject to such conditions as the Secretary 

may promulgate from time to time as necessary to prevent fraud 

and abuse, for purposes of paragraphs (1) and (2) and section 

1128A(a), the following transfers shall not be treated as remuneration: 

(A) TRANSFERS BETWEEN INDIAN HEALTH PROGRAMS, INDIAN

TRIBES, TRIBAL ORGANIZATIONS, AND URBAN INDIAN ORGANIZA- TIONS.—Transfers of anything of value between or among an 

Indian Health Program, Indian Tribe, Tribal Organization, or 

Urban Indian Organization, that are made for the purpose of 

providing necessary health care items and services to any patient served by such Program, Tribe, or Organization and that 

consist of— (i) services in connection with the collection, transport, 

analysis, or interpretation of diagnostic specimens or test 

data; 

(ii) inventory or supplies; 

(iii) staff; or 

(iv) a waiver of all or part of premiums or cost sharing. 

(B) TRANSFERS BETWEEN INDIAN HEALTH PROGRAMS, INDIAN

TRIBES, TRIBAL ORGANIZATIONS, OR URBAN INDIAN ORGANIZA- TIONS AND PATIENTS.—Transfers of anything of value between 

an Indian Health Program, Indian Tribe, Tribal Organization, 

or Urban Indian Organization and any patient served or eligible for service from an Indian Health Program, Indian Tribe, 

Tribal Organization, or Urban Indian Organization, including 

any patient served or eligible for service pursuant to section 807 

of the Indian Health Care Improvement Act, but only if such 

transfers—(i) consist of expenditures related to providing transportation for the patient for the provision of necessary health 

care items or services, provided that the provision of such 

transportation is not advertised, nor an incentive of which 

the value is disproportionately large in relationship to the 

value of the health care item or service (with respect to the 

value of the item or service itself or, for preventative items 

or services, the future health care costs reasonably expected 

to be avoided); 

(ii) consist of expenditures related to providing housing to 

the patient (including a pregnant patient) and immediate 

family members or an escort necessary to assuring the timely provision of health care items and services to the patient, 

provided that the provision of such housing is not advertised nor an incentive of which the value is disproportionately large in relationship to the value of the health care 

item or service (with respect to the value of the item or service itself or, for preventative items or services, the future 

health care costs reasonably expected to be avoided); or 

(iii) are for the purpose of paying premiums or cost sharing on behalf of such a patient, provided that the making 

of such payment is not subject to conditions other than conditions agreed to under a contract for the delivery of contract health services. 

(C) CONTRACT HEALTH SERVICES.—A transfer of anything of 

value negotiated as part of a contract entered into between an 


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Indian Health Program, Indian Tribe, Tribal Organization, 

Urban Indian Organization, or the Indian Health Service and 

a contract care provider for the delivery of contract health services authorized by the Indian Health Service, provided that— (i) such a transfer is not tied to volume or value of referrals or other business generated by the parties; and 

(ii) any such transfer is limited to the fair market value 

of the health care items or services provided or, in the case 

of a transfer of items or services related to preventative 

care, the value of the future health care costs reasonably expected to be avoided. 

(D) OTHER TRANSFERS.—Any other transfer of anything of 

value involving an Indian Health Program, Indian Tribe, Tribal Organization, or Urban Indian Organization, or a patient 

served or eligible for service from an Indian Health Program, 

Indian Tribe, Tribal Organization, or Urban Indian Organization, that the Secretary, in consultation with the Attorney General, determines is appropriate, taking into account the special 

circumstances of such Indian Health Programs, Indian Tribes, 

Tribal Organizations, and Urban Indian Organizations, and of 

patients served by such Programs, Tribes, and Organizations. 

øNATIONAL COMMISSION ON CHILDREN

øSEC. 1139. (a)(1) There is hereby established a commission to be 

known as the National Commission on Children (in this section referred to as the ‘‘Commission’’). 

ø(b)(1) The Commission shall consist of— ø(A) 12 members to be appointed by the President, 

ø(B) 12 members to be appointed by the Speaker of the 

House of Representatives, and 

ø(C) 12 members to be appointed by the President pro tempore of the Senate. 

ø(2) The President, the Speaker, and the President pro tempore 

shall each appoint as members of the Commission—

ø(A) 4 individuals who—

ø(i) are representatives of organizations providing services to children, 

ø(ii) are involved in activities on behalf of children, or 

ø(iii) have engaged in academic research with respect to 

the problems and needs of children, 

ø(B) 4 individuals who are elected or appointed public officials (at the Federal, State, or local level) involved in issues 

and programs relating to children, and 

ø(C) 4 individuals who are parents or representatives of parents or parents’ organizations. 

ø(3) The appointments made pursuant to subparagraphs (B) and 

(C) of paragraph (1) shall be made in consultation with the chairmen of committees of the House of Representatives and the Senate, 

respectively, having jurisdiction over relevant Federal programs. 

ø(c)(1) It shall be the duty and function of the Commission to 

serve as a forum on behalf of the children of the Nation and to conduct the studies and issue the report required by subsection (d). 

ø(2) The Commission (and any committees that it may form) 

shall conduct public hearings in different geographic areas of the 

country, both urban and rural, in order to receive the views of a 


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broad spectrum of the public on the status of the Nation’s children 

and on ways to safeguard and enhance the physical, mental, and 

emotional well-being of all of the children of the Nation, including 

those with physical or mental disabilities, and others whose circumstances deny them a full share of the opportunities that parents of the Nation may rightfully expect for their children. 

ø(3) The Commission shall receive testimony from individuals, 

and from representatives of public and private organizations and 

institutions with an interest in the welfare of children, including 

educators, health care professionals, religious leaders, providers of 

social services, representatives of organizations with children as 

members, elected and appointed public officials, and from parents 

and children speaking in their own behalf. 

ø(d) The Commission shall submit to the President, and to the 

Committees on Finance and Labor and Human Resources of the 

Senate and the Committees on Ways and Means, Education and 

Labor, and Energy and Commerce of the House of Representatives, 

an interim report no later than March 31, 1990, and a final report 

no later than March 31, 1991, setting forth recommendations with 

respect to the following subjects: 

ø(1) Questions relating to the health of children that the 

Commission shall address include—

ø(A) how to reduce infant mortality, 

ø(B) how to reduce the number of low-birth-weight babies, 

ø(C) how to reduce the number of children with chronic 

illnesses and disabilities, 

ø(D) how to improve the nutrition of children, 

ø(E) how to promote the physical fitness of children, 

ø(F) how to ensure that pregnant women receive adequate prenatal care, 

ø(G) how to ensure that all children have access to both 

preventive and acute care health services, and 

ø(H) how to improve the quality and availability of 

health care for children. 

ø(2) Questions relating to social and support services for children and their parents that the Commission shall address include—

ø(A) how to prevent and treat child neglect and abuse, 

ø(B) how to provide help to parents who seek assistance 

in meeting the problems of their children, 

ø(C) how to provide counseling services for children, 

ø(D) how to strengthen the family unit, 

ø(E) how children can be assured of adequate care while 

their parents are working or participating in education or 

training programs, 

ø(F) how to improve foster care and adoption services, 

ø(G) how to reduce drug and alcohol abuse by children 

and youths, and 

ø(H) how to reduce the incidence of teenage pregnancy. 

ø(3) Questions relating to education that the Commission 

shall address include—

ø(A) how to encourage academic excellence for all children at all levels of education, 


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ø(B) how to use preschool experiences to enhance educational achievement, 

ø(C) how to improve the qualifications of teachers, 

ø(D) how schools can better prepare the Nation’s youth 

to compete in the labor market, 

ø(E) how parents and schools can work together to help 

children achieve success at each step of the academic ladder, 

ø(F) how to encourage teenagers to complete high school 

and remain in school to fulfill their academic potential, 

ø(G) how to address the problems of drug and alcohol 

abuse by young people, 

ø(H) how schools might lend support to efforts aimed at 

reducing the incidence of teenage pregnancy, and 

ø(I) how schools might better meet the special needs of 

children who have physical or mental handicaps. 

ø(4) Questions relating to income security that the Commission shall address include—

ø(A) how to reduce poverty among children, 

ø(B) how to ensure that parents support their children 

to the fullest extent possible through improved child support collection services, including services on behalf of children whose parents are unmarried, and 

ø(C) how to ensure that cash assistance to needy children is adequate. 

ø(5) Questions relating to tax policy that the Commission 

shall address include—

ø(A) how to assure the equitable tax treatment of families with children, 

ø(B) the effect of existing tax provisions, including the 

dependent care tax credit, the earned income tax credit, 

and the targeted jobs tax credit, on children living in poverty, 

ø(C) whether the dependent care tax credit should be refundable and the effect of such a policy, 

ø(D) whether the earned income tax credit should be adjusted for family size and the effect of such a policy, and 

ø(E) whether there are other tax-related policies which 

would reduce poverty among children. 

ø(6) In addition to addressing the questions specified in 

paragraphs (1) through (5), the Commission shall—

ø(A) seek to identify ways in which public and private 

organizations and institutions can work together at the 

community level to identify deficiencies in existing services 

for families and children and to develop recommendations 

to ensure that the needs of families and children are met, 

using all available resources, in a coordinated and comprehensive manner, and 

ø(B) assess the existing capacities of agencies to collect 

and analyze data on the status of children and on relevant 

programs, identify gaps in the data collection system, and 

recommend ways to improve the collection of data and the 

coordination among agencies in the collection and utilization of data. 


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The reports required by this subsection shall be based upon the 

testimony received in the hearings conducted pursuant to subsection (c), and upon other data and findings developed by the 

Commission. 

ø(e)(1)(A) Members of the Commission shall first be appointed 

not later than 60 days after the date of the enactment of this section, for terms ending on March 31, 1991. 

ø(B) A vacancy in the Commission shall not affect its powers, but 

shall be filled in the same manner as the vacant position was first 

filled. 

ø(2) The Commission shall elect one of its members to serve as 

Chairman of the Commission. The Chairman shall be a nonvoting 

member of the Commission. 

ø(3) A majority of the members of the Commission shall constitute a quorum for the transaction of business. 

ø(4)(A) The Commission shall meet at the call of the Chairman, 

or at the call of a majority of the members of the Commission. 

ø(B) The Commission shall meet not less than 4 times during the 

period beginning with the date of the enactment of this section and 

ending with September 30, 1990. 

ø(5) Decisions of the Commission shall be according to the vote 

of a simple majority of those present and voting at a properly 

called meeting. 

ø(6) Members of the Commission shall serve without compensation, but shall be reimbursed for travel, subsistence, and other necessary expenses incurred in the performance of their duties as 

members of the Commission. 

ø(f)(1) The Commission shall appoint an Executive Director of 

the Commission. In addition to the Executive Director, the Commission may appoint and fix the compensation of such personnel as 

it deems advisable. Such appointments and compensation may be 

made without regard to title 5, United States Code, that govern appointments in the competitive services, and the provisions of chapter 51 and subchapter III of chapter 53 of such title that relate to 

classifications and the General Schedule pay rates. 

ø(2) The Commission may procure such temporary and intermittent services of consultants under section 3109(b) of title 5, United 

States Code, as the Commission determines to be necessary to 

carry out the duties of the Commission. 

ø(g) In carrying out its duties, the Commission, or any duly organized committee thereof, is authorized to hold such hearings, sit 

and act at such times and places, and take such testimony, with 

respect to matters for which it has a responsibility under this section, as the Commission or committee may deem advisable. 

ø(h)(1) The Commission may secure directly from any department or agency of the United States such data and information as 

may be necessary to carry out its responsibilities. 

ø(2) Upon request of the Commission, any such department or 

agency shall furnish any such data or information. 

ø(i) The General Services Administration shall provide to the 

Commission, on a reimbursable basis, such administrative support 

services as the Commission may request. 

ø(j) There are authorized to be appropriated through fiscal year 

1991, such sums as may be necessary to carry out this section for 

each of fiscal years 1989 and 1990. 


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ø(k)(1) The Commission is authorized to accept donations of 

money, property, or personal services. Funds received from donations shall be deposited in the Treasury in a separate fund created 

for this purpose. Funds appropriated for the Commission and donated funds may be expended for such purposes as official reception and representation expenses, public surveys, public service announcements, preparation of special papers, analyses, and documentaries, and for such other purposes as determined by the Commission to be in furtherance of its mission to review national issues 

affecting children. 

ø(2) For purposes of Federal income, estate, and gift taxation, 

money and other property accepted under paragraph (1) of this 

subsection shall be considered as a gift or bequest to or for the use 

of the United States. 

ø(3) Expenditure of appropriated and donated funds shall be subject to such rules and regulations as may be adopted by the Commission and shall not be subject to Federal procurement requirements. 

ø(l) The Commission is authorized to conduct such public surveys 

as it deems necessary in support of its review of national issues affecting children and, in conducting such surveys, the Commission 

shall not be deemed to be an ‘‘agency’’ for the purpose of section 

3502 of title 44, United States Code.¿ 

SEC. 1139. IMPROVED ACCESS TO, AND DELIVERY OF, HEALTH CARE 

FOR INDIANS UNDER TITLES XVIII, XIX, AND XXI. 

(a) AGREEMENTS WITH STATES FOR MEDICAID AND SCHIP OUT- REACH ON OR NEAR RESERVATIONS TO INCREASE THE ENROLLMENT

OF INDIANS IN THOSE PROGRAMS.— (1) IN GENERAL.—In order to improve the access of Indians 

residing on or near a reservation to obtain benefits under the 

Medicaid and State children’s health insurance programs established under titles XIX and XXI, the Secretary shall encourage the State to take steps to provide for enrollment on or near 

the reservation. Such steps may include outreach efforts such as 

the outstationing of eligibility workers, entering into agreements 

with the Indian Health Service, Indian Tribes, Tribal Organizations, and Urban Indian Organizations to provide outreach, 

education regarding eligibility and benefits, enrollment, and 

translation services when such services are appropriate. 

(2) CONSTRUCTION.—Nothing in subparagraph (A) shall be 

construed as affecting arrangements entered into between States 

and the Indian Health Service, Indian Tribes, Tribal Organizations, or Urban Indian Organizations for such Service, Tribes, 

or Organizations to conduct administrative activities under 

such titles. 

(b) REQUIREMENT TO FACILITATE COOPERATION.—The Secretary, 

acting through the Centers for Medicare and Medicaid Services, 

shall take such steps as are necessary to facilitate cooperation with, 

and agreements between, States and the Indian Health Service, Indian Tribes, Tribal Organizations, or Urban Indian Organizations 

with respect to the provision of health care items and services to Indians under the programs established under title XVIII, XIX, or 

XXI. 

(c) NONDISCRIMINATION IN QUALIFICATIONS FOR PAYMENT FOR

SERVICES UNDER FEDERAL HEALTH CARE PROGRAMS.—


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(1) REQUIREMENT TO SATISFY GENERALLY APPLICABLE PAR- TICIPATION REQUIREMENTS.— (A) IN GENERAL.—A Federal health care program must 

accept an entity that is operated by the Indian Health Service, an Indian Tribe, Tribal Organization, or Urban Indian 

Organization as a provider eligible to receive payment 

under the program for health care services furnished to an 

Indian on the same basis as any other provider qualified 

to participate as a provider of health care services under 

the program if the entity meets generally applicable State 

or other requirements for participation as a provider of 

health care services under the program. 

(B) SATISFACTION OF STATE OR LOCAL LICENSING OR RECOGNITION REQUIREMENTS.—Any requirement for participation as a provider of health care services under a Federal 

health care program that an entity be licensed or recognized under the State or local law where the entity is located to furnish health care services shall be deemed to 

have been met in the case of an entity operated by the Indian Health Service, an Indian Tribe, Tribal Organization, 

or Urban Indian Organization if the entity meets all the 

applicable standards for such licensing or recognition, regardless of whether the entity obtains a license or other 

documentation under such State or local law. In accordance with section 221 of the Indian Health Care Improvement Act, the absence of the licensing of a health care professional employed by such an entity under the State or 

local law where the entity is located shall not be taken into 

account for purposes of determining whether the entity 

meets such standards, if the professional is licensed in another State. 

(2) PROHIBITION ON FEDERAL PAYMENTS TO ENTITIES OR INDIVIDUALS EXCLUDED FROM PARTICIPATION IN FEDERAL HEALTH

CARE PROGRAMS OR WHOSE STATE LICENSES ARE UNDER SUSPENSION OR HAVE BEEN REVOKED.— (A) EXCLUDED ENTITIES.—No entity operated by the Indian Health Service, an Indian Tribe, Tribal Organization, 

or Urban Indian Organization that has been excluded from 

participation in any Federal health care program or for 

which a license is suspended or has been revoked by the 

State where the entity is located shall be eligible to receive 

payment under any such program for health care services 

furnished to an Indian. 

(B) EXCLUDED INDIVIDUALS.—No individual who has 

been excluded from participation in any Federal health 

care program or whose State license is suspended or has 

been revoked shall be eligible to receive payment under any 

such program for health care services furnished by that individual, directly or through an entity that is otherwise eligible to receive payment for health care services, to an Indian. 

(C) FEDERAL HEALTH CARE PROGRAM DEFINED.—In this 

subsection, the term, ‘‘Federal health care program’’ has the 

meaning given that term in section 1128B(f), except that, 

for purposes of this subsection, such term shall include the 


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health insurance program under chapter 89 of title 5, 

United States Code. 

(d) CONSULTATION WITH TRIBAL TECHNICAL ADVISORY GROUP.—

The Secretary shall maintain within the Centers for Medicaid and 

Medicare Services a Tribal Technical Advisory Group, established 

in accordance with requirements of the charter dated September 30, 

2003, and in such group shall include a representative of the Urban 

Indian Organizations and the Service. The representative of the 

Urban Indian Organization shall be deemed to be an elected officer 

of a tribal government for purposes of applying section 204(b) of the 

Unfunded Mandates Reform Act of 1995 (2 U.S.C. 1534(b)). 

(e) ANNUAL REPORT ON INDIANS SERVED BY HEALTH BENEFIT

PROGRAMS FUNDED UNDER THIS ACT.—Beginning January 1, 2007, 

and annually thereafter, the Secretary, acting through the Administrator of the Centers for Medicare and Medicaid Services and the 

Director of the Indian Health Service, shall submit a report to Congress regarding the enrollment and health status of Indians receiving items or services under health benefit programs funded under 

this Act during the preceding year. Each such report shall include 

the following: 

(1) The total number of Indians enrolled in, or receiving 

items or services under, such programs, disaggregated with respect to each such program. 

(2) The number of Indians described in paragraph (1) that 

also received health benefits under programs funded by the Indian Health Service. 

(3) General information regarding the health status of the Indians described in paragraph (1), disaggregated with respect to 

specific diseases or conditions and presented in a manner that 

is consistent with protections for privacy of individually identifiable health information under section 264(c) of the Health Insurance Portability and Accountability Act of 1996. 

(4) A detailed statement of the status of facilities of the Indian Health Service or an Indian Tribe, Tribal Organization, 

or an Urban Indian Organization with respect to such facilities’

compliance with the applicable conditions and requirements of 

titles XVIII, XIX, and XXI, and, in the case of title XIX or XXI, 

under a State plan under such title or under waiver authority, 

and of the progress being made by such facilities (under plans 

submitted under sections 1880(b), 1911(b) or otherwise) toward 

the achievement and maintenance of such compliance. 

(5) Such other information as the Secretary determines is appropriate. 

(f) DEFINITION OF INDIAN TRIBE; INDIAN HEALTH PROGRAM; TRIB- AL ORGANIZATION; URBAN INDIAN ORGANIZATION.—In this section, 

the terms ‘‘Indian Tribe’’, ‘‘Indian Health Program’’, ‘‘Tribal Organization’’, and ‘‘Urban Indian Organization’’ have the meanings given 

those terms in section 4 of the Indian Health Care Improvement Act. 

* * * * * * * 

TITLE XVIII—HEALTH INSURANCE FOR THE AGED AND 

DISABLED 

* * * * * * * 


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PART E—MISCELLANEOUS PROVISIONS

* * * * * * * 

øINDIAN HEALTH SERVICE FACILITIES

øSEC. 1880. (a) A hospital or skilled nursing facility of the Indian 

Health Service, whether operated by such Service or by an Indian 

tribe or tribal organization (as those terms are defined in section 

4 of the Indian Health Care Improvement Act), shall be eligible for 

payments under this title, notwithstanding sections 1814(c) and 

1835(d), if and for so long as it meets all of the conditions and requirements for such payments which are applicable generally to 

hospitals or skilled nursing facilities (as the case may be) under 

this title. 

ø(b) Notwithstanding subsection (a), a hospital or skilled nursing 

facility of the Indian Health Service which does not meet all of the 

conditions and requirements of this title which are applicable generally to hospitals or skilled nursing facilities (as the case may be), 

but which submits to the Secretary within six months after the 

date of the enactment of this section an acceptable plan for achieving compliance with such conditions and requirements, shall be 

deemed to meet such conditions and requirements (and to be eligible for payments under this title), without regard to the extent of 

its actual compliance with such conditions and requirements, during the first 12 months after the month in which such plan is submitted. 

ø(c) Notwithstanding any other provision of this title, payments 

to which any hospital or skilled nursing facility of the Indian 

Health Service is entitled by reason of this section shall be placed 

in a special fund to be held by the Secretary and used by him (to 

such extent or in such amounts as are provided in appropriation 

Acts) exclusively for the purpose of making any improvements in 

the hospitals and skilled nursing facilities of such Service which 

may be necessary to achieve compliance with the applicable conditions and requirements of this title. The preceding sentence shall 

cease to apply when the Secretary determines and certifies that 

substantially all of the hospitals and skilled nursing facilities of 

such Service in the United States are in compliance with such conditions and requirements. 

ø(d) The annual report of the Secretary which is required by section 701 of the Indian Health Care Improvement Act shall include 

(along with the matters specified in section 403 of such Act) a detailed statement of the status of the hospitals and skilled nursing 

facilities of the Service in terms of their compliance with the applicable conditions and requirements of this title and of the progress 

being made by such hospitals and facilities (under plans submitted 

under subsection (b) and otherwise) toward the achievement of 

such compliance.¿ 

SEC. 1880. INDIAN HEALTH PROGRAMS. 

(a) ELIGIBILITY FOR PAYMENTS.—Subject to subsection (e), the Indian Health Service and an Indian Tribe, Tribal Organization, or 

an Urban Indian Organization shall be eligible for payments under 

this title with respect to items and services furnished by the Indian 

Health Service, Indian Tribe, Tribal Organization, or Urban Indian 

Organization if the furnishing of such services meets all the condiVerDate Aug 31 2005 06:29 Sep 16, 2006 Jkt 049006 PO 00000 Frm 00322 Fmt 6659 Sfmt 6603 E:\HR\OC\HR661P1.XXX HR661P1

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tions and requirements which are applicable generally to the furnishing of items and services under this title. 

(b) COMPLIANCE WITH CONDITIONS AND REQUIREMENTS.—Subject 

to subsection (e), a facility of the Indian Health Service or an Indian Tribe, Tribal Organization, or an Urban Indian Organization 

which is eligible for payment under subsection (a) with respect to 

the furnishing of items and services, but which does not meet all of 

the conditions and requirements of this title which are applicable 

generally to such facility, shall make such improvements as are necessary to achieve or maintain compliance with such conditions and 

requirements in accordance with a plan submitted to and accepted 

by the Secretary for achieving or maintaining compliance with such 

conditions and requirements, and shall be deemed to meet such conditions and requirements (and to be eligible for payment under this 

title), without regard to the extent of its actual compliance with such 

conditions and requirements, during the first 12 months after the 

month in which such plan is submitted. 

(c) SPECIAL FUND FOR IMPROVEMENT OF IHS FACILITIES.—For 

provisions relating to the authority of the Secretary to place payments to which a facility of the Indian Health Service is eligible for 

payment under this title into a special fund established under section 401(c)(1) of the Indian Health Care Improvement Act, and the 

requirement to use amounts paid from such fund for making improvements in accordance with subsection (b), see subparagraphs 

(A) and (B) of section 401(c)(1) of such Act. 

(d) DIRECT BILLING.—For provisions relating to the authority of 

a Tribal Health Program or an Urban Indian Organization to elect 

to directly bill for, and receive payment for, health care items and 

services provided by such Program or Organization for which payment is made under this title, see section 401(d) of the Indian 

Health Care Improvement Act. 

(e)(1) * * * 

* * * * * * * 

(3) Subsection (c) and section 401(c)(1) of the Indian Health Care 

Improvement Act shall not apply to payments made under this subsection. 

ø(f) For provisions relating to the authority of certain Indian 

tribes, tribal organizations, and Alaska Native health organizations 

to elect to directly bill for, and receive payment for, health care 

services provided by a hospital or clinic of such tribes or organizations and for which payment may be made under this title, see section 405 of the Indian Health Care Improvement Act (25 U.S.C. 

1645).¿ 

(f) DEFINITIONS.—In this section, the terms ‘‘Indian Health Program’’, ‘‘Indian Tribe’’, ‘‘Service Unit’’, ‘‘Tribal Health Program’’, 

‘‘Tribal Organization’’, and ‘‘Urban Indian Organization’’ have the 

meanings given those terms in section 4 of the Indian Health Care 

Improvement Act. 

* * * * * * * 

TITLE XIX—GRANTS TO STATES FOR MEDICAL ASSISTANCE 

PROGRAMS 

* * * * * * * 


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STATE PLANS FOR MEDICAL ASSISTANCE

SEC. 1902. (a) A State plan for medical assistance must—

(1) * * * 

* * * * * * * 

(69) provide that the State must comply with any requirements determined by the Secretary to be necessary for carrying 

out the Medicaid Integrity Program established under section 

1936; øand¿ 

(70) at the option of the State and notwithstanding paragraphs (1), (10)(B), and (23), provide for the establishment of 

a non-emergency medical transportation brokerage program in 

order to more cost-effectively provide transportation for individuals eligible for medical assistance under the State plan 

who need access to medical care or services and have no other 

means of transportation which—

(A) * * * 

(B) may be conducted under contract with a broker 

who—

(i) * * * 

* * * * * * * 

(iv) complies with such requirements related to prohibitions on referrals and conflict of interest as the 

Secretary shall establish (based on the prohibitions on 

physician referrals under section 1877 and such other 

prohibitions and requirements as the Secretary determines to be appropriate)ø.¿; and 

(71) in the case of any State in which the Indian Health Service operates or funds health care programs, or in which 1 or 

more Indian Health Programs or Urban Indian Organizations 

(as such terms are defined in section 4 of the Indian Health 

Care Improvement Act) provide health care in the State for 

which medical assistance is available under such title, provide 

for a process under which the State seeks advice on a regular, 

ongoing basis from designees of such Indian Health Programs 

and Urban Indian Organizations on matters relating to the application of this title that are likely to have a direct effect on 

such Indian Health Programs and Urban Indian Organizations 

and that—(A) shall include solicitation of advice prior to submission of any plan amendments, waiver requests, and proposals for demonstration projects likely to have a direct effect on Indians, Indian Health Programs, or Urban Indian 

Organizations; and 

(B) may include appointment of an advisory committee 

and of a designee of such Indian Health Programs and 

Urban Indian Organizations to the medical care advisory 

committee advising the State on its State plan under this 

title. 

* * * * * * * 

(e)(1) * * * 

* * * * * * * 


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(13) Notwithstanding any other requirement of this title or any 

other provision of Federal or State law, a State shall disregard the 

following property for purposes of determining eligibility for medical 

assistance under this title: 

(A) Property, including real property and improvements, located on a reservation, including any federally recognized Indian Tribe’s reservation, pueblo, or colony, including former 

reservations in Oklahoma, Alaska Native regions established by 

the Alaska Native Claims Settlement Act, and Indian allotments on or near a reservation as designated and approved by 

the Bureau of Indian Affairs of the Department of the Interior. 

(B) For any federally recognized Tribe not described in subparagraph (A), property located within the most recent boundaries of a prior Federal reservation. 

(C) Ownership interests in rents, leases, royalties, or usage 

rights related to natural resources (including extraction of natural resources or harvesting of timber, other plants and plant 

products, animals, fish, and shellfish) resulting from the exercise of federally protected rights. 

(D) Ownership interests in or usage rights to items not covered by subparagraphs (A) through (C) that have unique religious, spiritual, traditional, or cultural significance or rights 

that support subsistence or a traditional lifestyle according to 

applicable tribal law or custom. 

* * * * * * * 

PAYMENT TO STATES

SEC. 1903. (a) * * * 

* * * * * * * 

(x)(1) * * * 

* * * * * * * 

(3)(A) * * * 

(B) The following are documents described in this subparagraph: 

(i) * * * 

* * * * * * * 

(v)(I) Except as provided in subclause (II), a document issued 

by a federally-recognized Indian tribe evidencing membership 

or enrollment in, or affiliation with, such tribe. 

(II) With respect to those federally-recognized Indian tribes located within States having an international border whose membership includes individuals who are not citizens of the United 

States, the Secretary shall, after consulting with such tribes, 

issue regulations authorizing the presentation of such other 

forms of documentation (including tribal documentation, if appropriate) that the Secretary determines to be satisfactory documentary evidence of citizenship or nationality for purposes of 

satisfying the requirement of this subsection. 

ø(v)¿ (vi) Such other document as the Secretary may specify, 

by regulation, that provides proof of United States citizenship 

or nationality and that provides a reliable means of documentation of personal identity. 

* * * * * * * 


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øINDIAN HEALTH SERVICE FACILITIES

øSEC. 1911. (a) A facility of the Indian Health Service (including 

a hospital, nursing facility, or any other type of facility which provides services of a type otherwise covered under the State plan), 

whether operated by such Service or by an Indian tribe or tribal 

organization (as those 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 if and for so 

long as it meets all of the conditions and requirements which are 

applicable generally to such facilities under this title. 

ø(b) Notwithstanding subsection (a), a facility of the Indian 

Health Service (including a hospital, nursing facility, or any other 

type of facility which provides services of a type otherwise covered 

under the State plan) which does not meet all of the conditions and 

requirements of this title which are applicable generally to such facility, but which submits to the Secretary within six months after 

the date of the enactment of this section an acceptable plan for 

achieving compliance with such conditions and requirements, shall 

be deemed to meet such conditions and requirements (and to be eligible for reimbursement under this title), without regard to the extent of its actual compliance with such conditions and requirements, during the first twelve months after the month in which 

such plan is submitted. 

ø(c) The Secretary is authorized to enter into agreements with 

the State agency for the purpose of reimbursing such agency for 

health care and services provided in Indian Health Service facilities to Indians who are eligible for medical assistance under the 

State plan. 

ø(d) For provisions relating to the authority of certain Indian 

tribes, tribal organizations, and Alaska Native health organizations 

to elect to directly bill for, and receive payment for, health care 

services provided by a hospital or clinic of such tribes or organizations and for which payment may be made under this title, see section 405 of the Indian Health Care Improvement Act (25 U.S.C. 

1645).¿ 

SEC. 1911. INDIAN HEALTH PROGRAMS. 

(a) ELIGIBILITY FOR PAYMENT FOR MEDICAL ASSISTANCE.—The 

Indian Health Service and an Indian Tribe, Tribal Organization, or 

an Urban Indian Organization shall be eligible for payment for 

medical assistance provided under a State plan or under waiver authority with respect to items and services furnished by the Indian 

Health Service, Indian Tribe, Tribal Organization, or Urban Indian 

Organization if the furnishing of such services meets all the conditions and requirements which are applicable generally to the furnishing of items and services under this title and under such plan 

or waiver authority. 

(b) COMPLIANCE WITH CONDITIONS AND REQUIREMENTS.—A facility of the Indian Health Service or an Indian Tribe, Tribal Organization, or an Urban Indian Organization which is eligible for payment under subsection (a) with respect to the furnishing of items 

and services, but which does not meet all of the conditions and requirements of this title and under a State plan or waiver authority 

which are applicable generally to such facility, shall make such improvements as are necessary to achieve or maintain compliance with 


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such conditions and requirements in accordance with a plan submitted to and accepted by the Secretary for achieving or maintaining compliance with such conditions and requirements, and shall be 

deemed to meet such conditions and requirements (and to be eligible 

for payment under this title), without regard to the extent of its actual compliance with such conditions and requirements, during the 

first 12 months after the month in which such plan is submitted. 

(c) AUTHORITY TO ENTER INTO AGREEMENTS.—The Secretary may 

enter into an agreement with a State for the purpose of reimbursing 

the State for medical assistance provided by the Indian Health 

Service, an Indian Tribe, Tribal Organization, or an Urban Indian 

Organization (as so defined), directly, through referral, or under 

contracts or other arrangements between the Indian Health Service, 

an Indian Tribe, Tribal Organization, or an Urban Indian Organization and another health care provider to Indians who are eligible 

for medical assistance under the State plan or under waiver authority. 

(d) SPECIAL FUND FOR IMPROVEMENT OF IHS FACILITIES.—For 

provisions relating to the authority of the Secretary to place payments to which a facility of the Indian Health Service is eligible for 

payment under this title into a special fund established under section 401(c)(1) of the Indian Health Care Improvement Act, and the 

requirement to use amounts paid from such fund for making improvements in accordance with subsection (b), see subparagraphs 

(A) and (B) of section 401(c)(1) of such Act. 

(e) DIRECT BILLING.—For provisions relating to the authority of a 

Tribal Health Program or an Urban Indian Organization to elect 

to directly bill for, and receive payment for, health care items and 

services provided by such Program or Organization for which payment is made under this title, see section 401(d) of the Indian 

Health Care Improvement Act. 

(f) DEFINITIONS.—In this section, the terms ‘‘Indian Health Program’’, ‘‘Indian Tribe’’, ‘‘Tribal Health Program’’, ‘‘Tribal Organization’’, and ‘‘Urban Indian Organization’’ have the meanings given 

those terms in section 4 of the Indian Health Care Improvement Act. 

* * * * * * * 

USE OF ENROLLMENT FEES, PREMIUMS, DEDUCTIONS, COST SHARING, AND SIMILAR CHARGES

SEC. 1916. (a) Subject to subsections (g) øand (i)¿, (i), and (j), the 

State plan shall provide that in the case of individuals described 

in subparagraph (A) or (E)(i) of section 1902(a)(10) who are eligible 

under the plan—

(1) * * * 

* * * * * * * 

(j) NO PREMIUMS OR COST SHARING FOR INDIANS FURNISHED

ITEMS OR SERVICES DIRECTLY BY INDIAN HEALTH PROGRAMS OR

THROUGH REFERRAL UNDER THE CONTRACT HEALTH SERVICE.—

(1) NO COST SHARING FOR ITEMS OR SERVICES FURNISHED TO

INDIANS THROUGH INDIAN HEALTH PROGRAMS.—

(A) IN GENERAL.—No enrollment fee, premium, or similar 

charge, and no deduction, copayment, cost sharing, or similar charge shall be imposed against an Indian who is furnished an item or service directly by the Indian Health 


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Service, an Indian Tribe, Tribal Organization, or Urban 

Indian Organization or through referral under the contract 

health service for which payment may be made under this 

title. 

(B) NO REDUCTION IN AMOUNT OF PAYMENT TO INDIAN

HEALTH PROVIDERS.—Payment due under this title to the 

Indian Health Service, an Indian Tribe, Tribal Organization, or Urban Indian Organization, or a health care provider through referral under the contract health service for 

the furnishing of an item or service to an Indian who is eligible for assistance under such title, may not be reduced by 

the amount of any enrollment fee, premium, or similar 

charge, or any deduction, copayment, cost sharing, or similar charge that would be due from the Indian but for the 

operation of subparagraph (A). 

(2) RULE OF CONSTRUCTION.—Nothing in this subsection 

shall be construed as restricting the application of any other 

limitations on the imposition of premiums or cost sharing that 

may apply to an individual receiving medical assistance under 

this title who is an Indian. 

(3) DEFINITIONS.—In this subsection, the terms ‘‘contract 

health service’’, ‘‘Indian’’, ‘‘Indian Tribe’’, ‘‘Tribal Organization’’, and ‘‘Urban Indian Organization’’ have the meanings given 

those terms in section 4 of the Indian Health Care Improvement 

Act. 

STATE OPTION FOR ALTERNATIVE PREMIUMS AND COST SHARING

SEC. 1916A. (a) STATE FLEXIBILITY.— (1) IN GENERAL.—Notwithstanding sections 1916 and 

1902(a)(10)(B), a State, at its option and through a State plan 

amendment, may impose premiums and cost sharing for any 

group of individuals (as specified by the State) and for any type 

of services (other than drugs for which cost sharing may be imposed under subsection (c)), and may vary such premiums and 

cost sharing among such groups or types, consistent with the 

limitations established under this section. Nothing in this section shall be construed as superseding (or preventing the application of) øsection 1916(g)¿ subsections (g), (i), or (j) of section 

1916. 

* * * * * * * 

LIENS, ADJUSTMENTS AND RECOVERIES, AND TRANSFERS OF ASSETS

SEC. 1917. (a) * * * 

(b)(1) * * * 

* * * * * * * 

(3)(A) The State agency shall establish procedures (in accordance 

with standards specified by the Secretary) under which the agency 

shall waive the application of this subsection (other than paragraph (1)(C)) if such application would work an undue hardship as 

determined on the basis of criteria established by the Secretary. 

(B) The standards specified by the Secretary under subparagraph 

(A) shall require that the procedures established by the State agency 

under subparagraph (A) exempt income, resources, and property 

that are exempt from the application of this subsection as of April 


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1, 2003, under manual instructions issued to carry out this subsection (as in effect on such date) because of the Federal responsibility for Indian Tribes and Alaska Native Villages. Nothing in this 

subparagraph shall be construed as preventing the Secretary from 

providing additional estate recovery exemptions under this title for 

Indians. 

* * * * * * * 

PROVISIONS RELATING TO MANAGED CARE

SEC. 1932. (a) * * * 

* * * * * * * 

(h) SPECIAL RULES WITH RESPECT TO INDIAN ENROLLEES, INDIAN

HEALTH CARE PROVIDERS, AND INDIAN MANAGED CARE ENTITIES.—

(1) ENROLLEE OPTION TO SELECT AN INDIAN HEALTH CARE

PROVIDER AS PRIMARY CARE PROVIDER.—In the case of a non-Indian Medicaid managed care entity that—

(A) has an Indian enrolled with the entity; and 

(B) has an Indian health care provider that is participating as a primary care provider within the network of the 

entity, 

insofar as the Indian is otherwise eligible to receive services 

from such Indian health care provider and the Indian health 

care provider has the capacity to provide primary care services 

to such Indian, the contract with the entity under section 

1903(m) or under section 1905(t)(3) shall require, as a condition 

of receiving payment under such contract, that the Indian shall 

be allowed to choose such Indian health care provider as the Indian’s primary care provider under the entity. 

(2) ASSURANCE OF PAYMENT TO INDIAN HEALTH CARE PROVIDERS FOR PROVISION OF COVERED SERVICES.—Each contract 

with a managed care entity under section 1903(m) or under section 1905(t)(3) shall require any such entity that has a significant percentage of Indian enrollees (as determined by the Secretary), as a condition of receiving payment under such contract 

to satisfy the following requirements: 

(A) DEMONSTRATION OF PARTICIPATING INDIAN HEALTH

CARE PROVIDERS OR APPLICATION OF ALTERNATIVE PAYMENT

ARRANGEMENTS.—Subject to subparagraph (E), to—

(i) demonstrate that the number of Indian health 

care providers that are participating providers with respect to such entity are sufficient to ensure timely access to covered Medicaid managed care services for 

those enrollees who are eligible to receive services from 

such providers; or 

(ii) agree to pay Indian health care providers who 

are not participating providers with the entity for covered Medicaid managed care services provided to those 

enrollees who are eligible to receive services from such 

providers at a rate equal to the rate negotiated between 

such entity and the provider involved or, if such a rate 

has not been negotiated, at a rate that is not less than 

the level and amount of payment which the entity 

would make for the services if the services were furVerDate Aug 31 2005 06:29 Sep 16, 2006 Jkt 049006 PO 00000 Frm 00329 Fmt 6659 Sfmt 6603 E:\HR\OC\HR661P1.XXX HR661P1

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nished by a participating provider which is not an Indian health care provider. 

(B) PROMPT PAYMENT.—To agree to make prompt payment (in accordance with rules applicable to managed care 

entities) to Indian health care providers that are participating providers with respect to such entity or, in the case 

of an entity to which subparagraph (A)(ii) or (E) applies, 

that the entity is required to pay in accordance with that 

subparagraph. 

(C) SATISFACTION OF CLAIM REQUIREMENT.—To deem any 

requirement for the submission of a claim or other documentation for services covered under subparagraph (A) by 

the enrollee to be satisfied through the submission of a 

claim or other documentation by an Indian health care provider that is consistent with section 403(h) of the Indian 

Health Care Improvement Act. 

(D) COMPLIANCE WITH GENERALLY APPLICABLE REQUIRE- MENTS.—

(i) IN GENERAL.—Subject to clause (ii), as a condition 

of payment under subparagraph (A), an Indian health 

care provider shall comply with the generally applicable requirements of this title, the State plan, and such 

entity with respect to covered Medicaid managed care 

services provided by the Indian health care provider to 

the same extent that non-Indian providers participating with the entity must comply with such requirements. 

(ii) LIMITATIONS ON COMPLIANCE WITH MANAGED

CARE ENTITY GENERALLY APPLICABLE REQUIREMENTS.—

An Indian health care provider—

(I) shall not be required to comply with a generally applicable requirement of a managed care 

entity described in clause (i) as a condition of payment under subparagraph (A) if such compliance 

would conflict with any other statutory or regulatory requirements applicable to the Indian health 

care provider; and 

(II) shall only need to comply with those generally applicable requirements of a managed care 

entity described in clause (i) as a condition of payment under subparagraph (A) that are necessary 

for the entity’s compliance with the State plan, 

such as those related to care management, quality 

assurance, and utilization management. 

(E) APPLICATION OF SPECIAL PAYMENT REQUIREMENTS

FOR FEDERALLY-QUALIFIED HEALTH CENTERS AND ENCOUNTER RATE FOR SERVICES PROVIDED BY CERTAIN INDIAN

HEALTH CARE PROVIDERS.—

(i) FEDERALLY-QUALIFIED HEALTH CENTERS.— (I) MANAGED CARE ENTITY PAYMENT REQUIRE- MENT.—To agree to pay any Indian health care 

provider that is a Federally-qualified health center 

but not a participating provider with respect to the 

entity, for the provision of covered Medicaid managed care services by such provider to an Indian 


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enrollee of the entity at a rate equal to the amount 

of payment that the entity would pay a Federallyqualified health center that is a participating provider with respect to the entity but is not an Indian health care provider for such services. 

(II) CONTINUED APPLICATION OF STATE REQUIRE- MENT TO MAKE SUPPLEMENTAL PAYMENT.—Nothing 

in subclause (I) or subparagraph (A) or (B) shall 

be construed as waiving the application of section 

1902(bb)(5) regarding the State plan requirement 

to make any supplemental payment due under 

such section to a Federally-qualified health center 

for services furnished by such center to an enrollee 

of a managed care entity (regardless of whether the 

Federally-qualified health center is or is not a participating provider with the entity). 

(ii) CONTINUED APPLICATION OF ENCOUNTER RATE

FOR SERVICES PROVIDED BY CERTAIN INDIAN HEALTH

CARE PROVIDERS.—If the amount paid by a managed 

care entity to an Indian health care provider that is 

not a Federally-qualified health center and that has 

elected to receive payment under this title as an Indian 

Health Service provider under the July 11, 1996, 

Memorandum of Agreement between the Health Care 

Financing Administration (now the Centers for Medicare and Medicaid Services) and the Indian Health 

Service for services provided by such provider to an Indian enrollee with the managed care entity is less than 

the encounter rate that applies to the provision of such 

services under such memorandum, the State plan shall 

provide for payment to the Indian health care provider 

of the difference between the applicable encounter rate 

under such memorandum and the amount paid by the 

managed care entity to the provider for such services. 

(F) CONSTRUCTION.—Nothing in this paragraph shall be 

construed as waiving the application of section 

1902(a)(30)(A) (relating to application of standards to assure that payments are consistent with efficiency, economy, 

and quality of care). 

(3) OFFERING OF MANAGED CARE THROUGH INDIAN MEDICAID

MANAGED CARE ENTITIES.—If—

(A) a State elects to provide services through Medicaid 

managed care entities under its Medicaid managed care 

program; and 

(B) an Indian health care provider that is funded in 

whole or in part by the Indian Health Service, or a consortium composed of 1 or more Tribes, Tribal Organizations, 

or Urban Indian Organizations, and which also may include the Indian Health Service, has established an Indian 

Medicaid managed care entity in the State that meets generally applicable standards required of such an entity 

under such Medicaid managed care program, 

the State shall offer to enter into an agreement with the entity 

to serve as a Medicaid managed care entity with respect to eligible Indians served by such entity under such program. 


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(4) SPECIAL RULES FOR INDIAN MANAGED CARE ENTITIES.— The following are special rules regarding the application of a 

Medicaid managed care program to Indian Medicaid managed 

care entities: 

(A) ENROLLMENT.— (i) LIMITATION TO INDIANS.—An Indian Medicaid 

managed care entity may restrict enrollment under 

such program to Indians and to members of specific 

Tribes in the same manner as Indian Health Programs 

may restrict the delivery of services to such Indians 

and tribal members. 

(ii) NO LESS CHOICE OF PLANS.—Under such program the State may not limit the choice of an Indian 

among Medicaid managed care entities only to Indian 

Medicaid managed care entities or to be more restrictive than the choice of managed care entities offered to 

individuals who are not Indians. 

(iii) DEFAULT ENROLLMENT.— (I) IN GENERAL.—If such program of a State requires the enrollment of Indians in a Medicaid 

managed care entity in order to receive benefits, 

the State, taking into consideration the criteria 

specified in subsection (a)(4)(D)(ii)(I), shall provide 

for the enrollment of Indians described in subclause (II) who are not otherwise enrolled with 

such an entity in an Indian Medicaid managed 

care entity described in such clause. 

(II) INDIAN DESCRIBED.—An Indian described in 

this subclause, with respect to an Indian Medicaid 

managed care entity, is an Indian who, based 

upon the service area and capacity of the entity, is 

eligible to be enrolled with the entity consistent 

with subparagraph (A). 

(iv) EXCEPTION TO STATE LOCK-IN.—A request by an 

Indian who is enrolled under such program with a 

non-Indian Medicaid managed care entity to change 

enrollment with that entity to enrollment with an Indian Medicaid managed care entity shall be considered 

cause for granting such request under procedures specified by the Secretary. 

(B) FLEXIBILITY IN APPLICATION OF SOLVENCY.—In applying section 1903(m)(1) to an Indian Medicaid managed 

care entity—

(i) any reference to a ‘‘State’’ in subparagraph (A)(ii) 

of that section shall be deemed to be a reference to the 

‘‘Secretary’’; and 

(ii) the entity shall be deemed to be a public entity 

described in subparagraph (C)(ii) of that section. 

(C) EXCEPTIONS TO ADVANCE DIRECTIVES.—The Secretary 

may modify or waive the requirements of section 1902(w) 

(relating to provision of written materials on advance directives) insofar as the Secretary finds that the requirements 

otherwise imposed are not an appropriate or effective way 

of communicating the information to Indians. 

(D) FLEXIBILITY IN INFORMATION AND MARKETING.—


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(i) MATERIALS.—The Secretary may modify requirements under subsection (a)(5) to ensure that information described in that subsection is provided to enrollees and potential enrollees of Indian Medicaid managed care entities in a culturally appropriate and understandable manner that clearly communicates to 

such enrollees and potential enrollees their rights, protections, and benefits. 

(ii) DISTRIBUTION OF MARKETING MATERIALS.—The 

provisions of subsection (d)(2)(B) requiring the distribution of marketing materials to an entire service 

area shall be deemed satisfied in the case of an Indian 

Medicaid managed care entity that distributes appropriate materials only to those Indians who are potentially eligible to enroll with the entity in the service 

area. 

(5) MALPRACTICE INSURANCE.—Insofar as, under a Medicaid 

managed care program, a health care provider is required to 

have medical malpractice insurance coverage as a condition of 

contracting as a provider with a Medicaid managed care entity, 

an Indian health care provider that is—

(A) a Federally-qualified health center that is covered 

under the Federal Tort Claims Act (28 U.S.C. 1346(b), 

2671 et seq.); 

(B) providing health care services pursuant to a contract 

or compact under the Indian Self-Determination and Education Assistance Act (25 U.S.C. 450 et seq.) that are covered under the Federal Tort Claims Act (28 U.S.C. 1346(b), 

2671 et seq.); or 

(C) the Indian Health Service providing health care services that are covered under the Federal Tort Claims Act (28 

U.S.C. 1346(b), 2671 et seq.); 

are deemed to satisfy such requirement. 

(6) DEFINITIONS.—For purposes of this subsection: 

(A) INDIAN HEALTH CARE PROVIDER.—The term ‘‘Indian 

health care provider’’ means an Indian Health Program or 

an Urban Indian Organization. 

(B) INDIAN; INDIAN HEALTH PROGRAM; SERVICE; TRIBE, TRIBAL ORGANIZATION; URBAN INDIAN ORGANIZATION.—The 

terms ‘‘Indian’’, ‘‘Indian Health Program’’, ‘‘Service’’, ‘‘Tribe’’, ‘‘Tribal Organization’’, ‘‘Urban Indian Organization’’ have the meanings given such terms in section 4 of 

the Indian Health Care Improvement Act. 

(C) INDIAN MEDICAID MANAGED CARE ENTITY.—The term 

‘‘Indian Medicaid managed care entity’’ means a managed 

care entity that is controlled (within the meaning of the last 

sentence of section 1903(m)(1)(C)) by the Indian Health 

Service, a Tribe, Tribal Organization, or Urban Indian Organization, or a consortium, which may be composed of 1 

or more Tribes, Tribal Organizations, or Urban Indian Organizations, and which also may include the Service. 

(D) NON-INDIAN MEDICAID MANAGED CARE ENTITY.—The 

term ‘‘non-Indian Medicaid managed care entity’’ means a 

managed care entity that is not an Indian Medicaid managed care entity. 


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(E) COVERED MEDICAID MANAGED CARE SERVICES.—The 

term ‘‘covered Medicaid managed care services’’ means, 

with respect to an individual enrolled with a managed care 

entity, items and services that are within the scope of items 

and services for which benefits are available with respect to 

the individual under the contract between the entity and 

the State involved. 

(F) MEDICAID MANAGED CARE PROGRAM.—The term ‘‘Medicaid managed care program’’ means a program under sections 1903(m) and 1932 and includes a managed care program operating under a waiver under section 1915(b) or 

1115 or otherwise. 

* * * * * * * 

TITLE XXI—STATE CHILDREN’S HEALTH INSURANCE 

PROGRAM 

* * * * * * * 

SEC. 2102. GENERAL CONTENTS OF STATE CHILD HEALTH PLAN; ELIGIBILITY; OUTREACH. 

(a) * * * 

(b) GENERAL DESCRIPTION OF ELIGIBILITY STANDARDS AND METH- ODOLOGY.— (1) * * * 

* * * * * * * 

(3) ELIGIBILITY SCREENING; COORDINATION WITH OTHER

HEALTH COVERAGE PROGRAMS.—The plan shall include a description of procedures to be used to ensure—

(A) * * * 

* * * * * * * 

(D) the provision of child health assistance to targeted 

low-income children in the State who are Indians ø(as defined in section 4(c) of the Indian Health Care Improvement Act, 25 U.S.C. 1603(c))¿, including how the State will 

ensure that payments are made to Indian Health Programs 

and Urban Indian Organizations operating in the State for 

the provision of such assistance; and 

* * * * * * * 

SEC. 2105. PAYMENTS TO STATES. 

(a) * * * 

* * * * * * * 

(c) LIMITATION ON CERTAIN PAYMENTS FOR CERTAIN EXPENDI- TURES.—

(1) * * * 

(2) LIMITATION ON EXPENDITURES NOT USED FOR MEDICAID OR

HEALTH INSURANCE ASSISTANCE.—

(A) * * * 

* * * * * * * 

(C) NONAPPLICATION TO EXPENDITURES FOR OUTREACH

TO INCREASE THE ENROLLMENT OF INDIAN CHILDREN UNDER

THIS TITLE AND TITLE XIX.—The limitation under subparagraph (A) on expenditures for items described in subsection 


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(a)(1)(D) shall not apply in the case of expenditures for outreach activities to families of Indian children likely to be eligible for child health assistance under the plan or medical 

assistance under the State plan under title XIX (or under 

a waiver of such plan), to inform such families of the availability of, and to assist them in enrolling their children in, 

such plans, including such activities conducted under 

grants, contracts, or agreements entered into under section 

1139(a). 

* * * * * * * 

(6) PREVENTION OF DUPLICATIVE PAYMENTS.— (A) * * * 

(B) OTHER FEDERAL GOVERNMENTAL PROGRAMS.—Except 

as provided in subparagraph (A) or (B) of subsection (a)(1) 

or any other provision of law, no payment shall be made 

to a State under this section for expenditures for child 

health assistance provided for a targeted low-income child 

under its plan to the extent that payment has been made 

or can reasonably be expected to be made promptly (as determined in accordance with regulations) under any other 

federally operated or financed health care øinsurance program, other than an insurance program operated or financed by the Indian Health Service¿ program, other than 

a health care program operated or financed by the Indian 

Health Service or by an Indian Tribe, Tribal Organization, 

or Urban Indian Organization, as identified by the Secretary. For purposes of this paragraph, rules similar to the 

rules for overpayments under section 1903(d)(2) shall 

apply. 

* * * * * * * 

SEC. 2107. STRATEGIC OBJECTIVES AND PERFORMANCE GOALS; PLAN 

ADMINISTRATION. 

(a) * * * 

* * * * * * * 

(e) APPLICATION OF CERTAIN GENERAL PROVISIONS.—The following sections of this Act shall apply to States under this title in 

the same manner as they apply to a State under title XIX: 

(1) TITLE XIX PROVISIONS.—

(A) * * * 

(B) Section 1902(a)(71) (relating to the option of certain 

States to seek advice from designees of Indian Health Programs and Urban Indian Organizations). 

(C) Section 1902(e)(13) (relating to disregard of certain 

property for purposes of making eligibility determinations). 

ø(B)¿ (D) Paragraphs (2), (16), and (17) of section 1903(i) 

(relating to limitations on payment). 

ø(C)¿ (E) Section 1903(w) (relating to limitations on provider taxes and donations). 

(F) Section 1911 (relating to Indian Health Programs, 

other than subsection (d) of such section). 

ø(D)¿ (G) Section 1920A (relating to presumptive eligibility for children). 


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(H) Subsections (a)(2)(C) and (h) of section 1932. 

* * * * * * * 

SEC. 2110. DEFINITIONS. 

(a) * * * 

* * * * * * * 

(c) ADDITIONAL DEFINITIONS.—For purposes of this title: 

(1) * * * 

* * * * * * * 

(9) INDIAN; INDIAN HEALTH PROGRAM; INDIAN TRIBE; ETC.—

The terms ‘‘Indian’’, ‘‘Indian Health Program’’, ‘‘Indian Tribe’’, 

‘‘Tribal Organization’’, and ‘‘Urban Indian Organization’’ have 

the meanings given those terms in section 4 of the Indian 

Health Care Improvement Act. 

* * * * * * * 


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pwalker on PRODPC60 with HEARINGInsert graphic folio 350 here HR661.001
336 


pwalker on PRODPC60 with HEARINGInsert graphic folio 351 here HR661.002