II 

Calendar No. 469 

109TH CONGRESS 

2D SESSION S. 3524 

To amend titles XVIII, XIX, and XXI of the Social Security Act to improve 

health care provided to Indians under the Medicare, Medicaid, and State 

Children’s Health Insurance Programs, and for other purposes. 

IN THE SENATE OF THE UNITED STATES 

JUNE 15, 2006 

Mr. GRASSLEY, from the Committee on Finance, reported the following 

original bill; which was read twice and placed on the calendar 

A BILL 

To amend titles XVIII, XIX, and XXI of the Social Security 

Act to improve health care provided to Indians under 

the Medicare, Medicaid, and State Children’s Health Insurance Programs, and for other purposes. 

1 Be it enacted by the Senate and House of Representa2 tives of the United States of America in Congress assembled, 

3 SECTION 1. SHORT TITLE; TABLE OF CONTENTS. 

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

5 ‘‘Medicare, Medicaid, and SCHIP Indian Health Care Im6 provement Act of 2006’’. 


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1 (b) TABLE OF CONTENTS.—The table of contents for 

2 this Act is as follows: 

Sec. 1. Short title; table of contents. 

Sec. 2. Expansion of payments under Medicare, Medicaid, and SCHIP for all 

covered services furnished by Indian health programs. 

Sec. 3. Increased outreach to Indians under Medicaid and SCHIP and improved cooperation in the provision of items and services to Indians under Social Security Act health benefit programs. 

Sec. 4. Additional provisions to increase outreach to, and enrollment of, Indians 

in SCHIP and Medicaid. 

Sec. 5. Premiums and cost sharing protections and eligibility determinations 

under Medicaid and SCHIP, and protection of certain Indian 

property from Medicaid estate recovery. 

Sec. 6. Nondiscrimination in qualifications for payment for services under Federal health care programs. 

Sec. 7. Consultation on Medicaid, SCHIP, and other health care programs 

funded under the Social Security Act involving Indian Health 

Programs and Urban Indian Organizations. 

Sec. 8. Exclusion waiver authority for affected Indian Health Programs and 

safe harbor transactions under the Social Security Act. 

Sec. 9. Rules applicable under Medicaid and SCHIP to managed care entities 

with respect to Indian enrollees and Indian health care providers and Indian managed care entities. 

Sec. 10. Annual report on Indians served by Social Security Act health benefit 

programs. 

Sec. 11. Effective Date. 

3 SEC. 2. EXPANSION OF PAYMENTS UNDER MEDICARE, MED4 ICAID, AND SCHIP FOR ALL COVERED SERV5 ICES FURNISHED BY INDIAN HEALTH PRO6 GRAMS. 

7 (a) MEDICAID.— 

8 (1) EXPANSION TO ALL COVERED SERVICES.— 

9 Section 1911 of the Social Security Act (42 U.S.C. 

10 1396j) is amended— 

11 (A) by amending the heading to read as 

12 follows: 


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1 ‘‘SEC. 1911. INDIAN HEALTH PROGRAMS.’’; and 

2 (B) by amending subsection (a) to read as 

3 follows: 

4 ‘‘(a) ELIGIBILITY FOR PAYMENT FOR MEDICAL AS5 SISTANCE.—The Indian Health Service and an Indian 

6 Tribe, Tribal Organization, or an Urban Indian Organiza7 tion shall be eligible for payment for medical assistance 

8 provided under a State plan or under waiver authority 

9 with respect to items and services furnished by the Indian 

10 Health Service, Indian Tribe, Tribal Organization, or 

11 Urban Indian Organization if the furnishing of such serv12 ices meets all the conditions and requirements which are 

13 applicable generally to the furnishing of items and services 

14 under this title and under such plan or waiver authority.’’. 

15 (2) COMPLIANCE WITH CONDITIONS AND RE16 QUIREMENTS.—Subsection (b) of such section is 

17 amended to read as follows: 

18 ‘‘(b) COMPLIANCE WITH CONDITIONS AND REQUIRE19 MENTS.—A facility of the Indian Health Service or an In20 dian Tribe, Tribal Organization, or an Urban Indian Or21 ganization which is eligible for payment under subsection 

22 (a) with respect to the furnishing of items and services, 

23 but which does not meet all of the conditions and require24 ments of this title and under a State plan or waiver au25 thority which are applicable generally to such facility, shall 

26 make such improvements as are necessary to achieve or 


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1 maintain compliance with such conditions and require2 ments in accordance with a plan submitted to and accept3 ed by the Secretary for achieving or maintaining compli4 ance with such conditions and requirements, and shall be 

5 deemed to meet such conditions and requirements (and to 

6 be eligible for payment under this title), without regard 

7 to the extent of its actual compliance with such conditions 

8 and requirements, during the first 12 months after the 

9 month in which such plan is submitted.’’. 

10 (3) REVISION OF AUTHORITY TO ENTER INTO

11 AGREEMENTS.—Subsection (c) of such section is 

12 amended to read as follows: 

13 ‘‘(c) AUTHORITY TO ENTER INTO AGREEMENTS.— 

14 The Secretary may enter into an agreement with a State 

15 for the purpose of reimbursing the State for medical as16 sistance provided by the Indian Health Service, an Indian 

17 Tribe, Tribal Organization, or an Urban Indian Organiza18 tion (as so defined), directly, through referral, or under 

19 contracts or other arrangements between the Indian 

20 Health Service, an Indian Tribe, Tribal Organization, or 

21 an Urban Indian Organization and another health care 

22 provider to Indians who are eligible for medical assistance 

23 under the State plan or under waiver authority.’’. 

24 (4) CROSS-REFERENCES TO SPECIAL FUND FOR

25 IMPROVEMENT OF IHS FACILITIES; DIRECT BILLING


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1 OPTION; DEFINITIONS.—Such section is further 

2 amended by striking subsection (d) and adding at 

3 the end the following new subsections: 

4 ‘‘(d) SPECIAL FUND FOR IMPROVEMENT OF IHS FA5 CILITIES.—For provisions relating to the authority of the 

6 Secretary to place payments to which a facility of the In7 dian Health Service is eligible for payment under this title 

8 into a special fund established under section 401(c)(1) of 

9 the Indian Health Care Improvement Act, and the require10 ment to use amounts paid from such fund for making im11 provements in accordance with subsection (b), see sub12 paragraphs (A) and (B) of section 401(c)(1) of such Act. 

13 ‘‘(e) DIRECT BILLING.—For provisions relating to 

14 the authority of a Tribal Health Program or an Urban 

15 Indian Organization to elect to directly bill for, and receive 

16 payment for, health care items and services provided by 

17 such Program or Organization for which payment is made 

18 under this title, see section 401(d) of the Indian Health 

19 Care Improvement Act. 

20 ‘‘(f) DEFINITIONS.—In this section, the terms ‘In21 dian Health Program’, ‘Indian Tribe’,‘Tribal Health Pro22 gram’, ‘Tribal Organization’, and ‘Urban Indian Organi23 zation’ have the meanings given those terms in section 4 

24 of the Indian Health Care Improvement Act.’’. 

25 (b) MEDICARE.— 


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1 (1) EXPANSION TO ALL COVERED SERVICES.— 

2 Section 1880 of such Act (42 U.S.C. 1395qq) is 

3 amended— 

4 (A) by amending the heading to read as 

5 follows: 

6 ‘‘SEC. 1880. INDIAN HEALTH PROGRAMS.’’; and 

7 (B) by amending subsection (a) to read as 

8 follows: 

9 ‘‘(a) ELIGIBILITY FOR PAYMENTS.—Subject to sub10 section (e), the Indian Health Service and an Indian 

11 Tribe, Tribal Organization, or an Urban Indian Organiza12 tion shall be eligible for payments under this title with 

13 respect to items and services furnished by the Indian 

14 Health Service, Indian Tribe, Tribal Organization, or 

15 Urban Indian Organization if the furnishing of such serv16 ices meets all the conditions and requirements which are 

17 applicable generally to the furnishing of items and services 

18 under this title.’’. 

19 (2) COMPLIANCE WITH CONDITIONS AND RE20 QUIREMENTS.—Subsection (b) of such section is 

21 amended to read as follows: 

22 ‘‘(b) COMPLIANCE WITH CONDITIONS AND REQUIRE23 MENTS.—Subject to subsection (e), a facility of the Indian 

24 Health Service or an Indian Tribe, Tribal Organization, 

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1 ment under subsection (a) with respect to the furnishing 

2 of items and services, but which does not meet all of the 

3 conditions and requirements of this title which are applica4 ble generally to such facility, shall make such improve5 ments as are necessary to achieve or maintain compliance 

6 with such conditions and requirements in accordance with 

7 a plan submitted to and accepted by the Secretary for 

8 achieving or maintaining compliance with such conditions 

9 and requirements, and shall be deemed to meet such con10 ditions and requirements (and to be eligible for payment 

11 under this title), without regard to the extent of its actual 

12 compliance with such conditions and requirements, during 

13 the first 12 months after the month in which such plan 

14 is submitted.’’. 

15 (3) CROSS-REFERENCES TO SPECIAL FUND FOR

16 IMPROVEMENT OF IHS FACILITIES; DIRECT BILLING

17 OPTION; DEFINITIONS.— 

18 (A) IN GENERAL.—Such section is further 

19 amended by striking subsections (c) and (d) 

20 and inserting the following new subsections: 

21 ‘‘(c) SPECIAL FUND FOR IMPROVEMENT OF IHS FA22 CILITIES.—For provisions relating to the authority of the 

23 Secretary to place payments to which a facility of the In24 dian Health Service is eligible for payment under this title 

25 into a special fund established under section 401(c)(1) of 


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1 the Indian Health Care Improvement Act, and the require2 ment to use amounts paid from such fund for making im3 provements in accordance with subsection (b), see sub4 paragraphs (A) and (B) of section 401(c)(1) of such Act. 

5 ‘‘(d) DIRECT BILLING.—For provisions relating to 

6 the authority of a Tribal Health Program or an Urban 

7 Indian Organization to elect to directly bill for, and receive 

8 payment for, health care items and services provided by 

9 such Program or Organization for which payment is made 

10 under this title, see section 401(d) of the Indian Health 

11 Care Improvement Act.’’. 

12 (B) CONFORMING AMENDMENT.—Para13 graph (3) of section 1880(e) of such Act (42 

14 U.S.C. 1395qq(e)) is amended by inserting 

15 ‘‘and section 401(c)(1) of the Indian Health 

16 Care Improvement Act’’ after ‘‘Subsection (c)’’. 

17 (4) DEFINITIONS.—Such section is further 

18 amended by amending subsection (f) to read as fol19 lows: 

20 ‘‘(f) DEFINITIONS.—In this section, the terms ‘In21 dian Health Program’, ‘Indian Tribe’, ‘Service Unit’, 

22 ‘Tribal Health Program’, ‘Tribal Organization’, and 

23 ‘Urban Indian Organization’ have the meanings given 

24 those terms in section 4 of the Indian Health Care Im25 provement Act.’’. 


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1 (c) APPLICATION TO SCHIP.—Section 2107(e)(1) of 

2 the Social Security Act (42 U.S.C. 1397gg(e)(1)) is 

3 amended— 

4 (1) by redesignating subparagraph (D) as sub5 paragraph (E); and 

6 (2) by inserting after subparagraph (C), the fol7 lowing new subparagraph: 

8 ‘‘(D) Section 1911 (relating to Indian 

9 Health Programs, other than subsection (d) of 

10 such section).’’. 

11 SEC. 3. INCREASED OUTREACH TO INDIANS UNDER MED12 ICAID AND SCHIP AND IMPROVED COOPERA13 TION IN THE PROVISION OF ITEMS AND 

14 SERVICES TO INDIANS UNDER SOCIAL SECU15 RITY ACT HEALTH BENEFIT PROGRAMS. 

16 Section 1139 of the Social Security Act (42 U.S.C. 

17 1320b–9) is amended to read as follows: 

18 ‘‘SEC. 1139. IMPROVED ACCESS TO, AND DELIVERY OF, 

19 HEALTH CARE FOR INDIANS UNDER TITLES 

20 XVIII, XIX, AND XXI. 

21 ‘‘(a) AGREEMENTS WITH STATES FOR MEDICAID

22 AND SCHIP OUTREACH ON OR NEAR RESERVATIONS TO

23 INCREASE THE ENROLLMENT OF INDIANS IN THOSE

24 PROGRAMS.— 


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1 ‘‘(1) IN GENERAL.—In order to improve the ac2 cess of Indians residing on or near a reservation to 

3 obtain benefits under the Medicaid and State chil4 dren’s health insurance programs established under 

5 titles XIX and XXI, the Secretary shall encourage 

6 the State to take steps to provide for enrollment on 

7 or near the reservation. Such steps may include out8 reach efforts such as the outstationing of eligibility 

9 workers, entering into agreements with the Indian 

10 Health Service, Indian Tribes, Tribal Organizations, 

11 and Urban Indian Organizations to provide out12 reach, education regarding eligibility and benefits, 

13 enrollment, and translation services when such serv14 ices are appropriate. 

15 ‘‘(2) CONSTRUCTION.—Nothing in subpara16 graph (A) shall be construed as affecting arrange17 ments entered into between States and the Indian 

18 Health Service, Indian Tribes, Tribal Organizations, 

19 or Urban Indian Organizations for such Service, 

20 Tribes, or Organizations to conduct administrative 

21 activities under such titles. 

22 ‘‘(b) REQUIREMENT TO FACILITATE COOPERA23 TION.—The Secretary, acting through the Centers for 

24 Medicare & Medicaid Services, shall take such steps as are 

25 necessary to facilitate cooperation with, and agreements 


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1 between, States and the Indian Health Service, Indian 

2 Tribes, Tribal Organizations, or Urban Indian Organiza3 tions with respect to the provision of health care items 

4 and services to Indians under the programs established 

5 under title XVIII, XIX, or XXI. 

6 ‘‘(c) DEFINITION OF INDIAN TRIBE; INDIAN HEALTH

7 PROGRAM; TRIBAL ORGANIZATION; URBAN INDIAN ORGA8 NIZATION.—In this section, the terms ‘Indian Tribe’, ‘In9 dian Health Program’, ‘Tribal Organization’, and ‘Urban 

10 Indian Organization’ have the meanings given those terms 

11 in section 4 of the Indian Health Care Improvement Act.’’. 

12 SEC. 4. ADDITIONAL PROVISIONS TO INCREASE OUTREACH 

13 TO, AND ENROLLMENT OF, INDIANS IN SCHIP 

14 AND MEDICAID. 

15 (a) NONAPPLICATION OF 10 PERCENT LIMIT ON

16 OUTREACH AND CERTAIN OTHER EXPENDITURES.—Sec17 tion 2105(c)(2) of the Social Security Act (42 U.S.C. 

18 1397ee(c)(2)) is amended by adding at the end the fol19 lowing new subparagraph: 

20 ‘‘(C) NONAPPLICATION TO EXPENDITURES

21 FOR OUTREACH TO INCREASE THE ENROLL22 MENT OF INDIAN CHILDREN UNDER THIS TITLE

23 AND TITLE XIX.—The limitation under sub24 paragraph (A) on expenditures for items de25 scribed in subsection (a)(1)(D) shall not apply 


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1 in the case of expenditures for outreach activi2 ties to families of Indian children likely to be el3 igible for child health assistance under the plan 

4 or medical assistance under the State plan 

5 under title XIX (or under a waiver of such 

6 plan), to inform such families of the availability 

7 of, and to assist them in enrolling their children 

8 in, such plans, including such activities con9 ducted under grants, contracts, or agreements 

10 entered into under section 1139(a).’’. 

11 (b) ASSURANCE OF PAYMENTS TO INDIAN HEALTH

12 CARE PROVIDERS FOR CHILD HEALTH ASSISTANCE.— 

13 Section 2102(b)(3)(D) of such Act (42 U.S.C. 

14 1397bb(b)(3)(D)) is amended by striking ‘‘(as defined in 

15 section 4(c) of the Indian Health Care Improvement Act, 

16 25 U.S.C. 1603(c))’’ and inserting ‘‘, including how the 

17 State will ensure that payments are made to Indian 

18 Health Programs and Urban Indian Organizations oper19 ating in the State for the provision of such assistance’’. 

20 (c) INCLUSION OF OTHER INDIAN FINANCED

21 HEALTH CARE PROGRAMS IN EXEMPTION FROM PROHI22 BITION ON CERTAIN PAYMENTS.—Section 2105(c)(6)(B) 

23 of such Act (42 U.S.C. 1397ee(c)(6)(B)) is amended by 

24 striking ‘‘insurance program, other than an insurance pro25 gram operated or financed by the Indian Health Service’’ 


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1 and inserting ‘‘program, other than a health care program 

2 operated or financed by the Indian Health Service or by 

3 an Indian Tribe, Tribal Organization, or Urban Indian 

4 Organization’’. 

5 (d) SATISFACTION OF MEDICAID DOCUMENTATION

6 REQUIREMENTS.— 

7 (1) IN GENERAL.—Section 1903(x)(3)(B) of the 

8 Social Security Act (42 U.S.C. 1396b(x)(3)(B)) is 

9 amended— 

10 (A) by redesignating clause (v) as clause 

11 (vi); and 

12 (B) by inserting after clause (iv), the fol13 lowing new clause: 

14 ‘‘(v)(I) Except as provided in subclause (II), a 

15 document issued by a federally-recognized Indian 

16 tribe evidencing membership or enrollment in, or af17 filiation with, such tribe. 

18 ‘‘(II) With respect to those federally-recognized 

19 Indian tribes located within States having an inter20 national border whose membership includes individ21 uals who are not citizens of the United States, the 

22 Secretary shall, after consulting with such tribes, 

23 issue regulations authorizing the presentation of 

24 such other forms of documentation (including tribal 

25 documentation, if appropriate) that the Secretary 


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1 determines to be satisfactory documentary evidence 

2 of citizenship or nationality for purposes of satis3 fying the requirement of this subsection.’’. 

4 (2) TRANSITION RULE.—During the period that 

5 begins on July 1, 2006, and ends on the effective 

6 date of final regulations issued under subclause (II) 

7 of section 1903(x)(3)(B)(v) of the Social Security 

8 Act (42 U.S.C. 1396b(x)(3)(B)(v)) (as added by 

9 paragraph (1)), an individual who is a member of a 

10 federally-recognized Indian tribe described in sub11 clause (II) of that section who presents a document 

12 described in subclause (I) of such section that is 

13 issued by such Indian tribe, shall be deemed to have 

14 presented satisfactory evidence of citizenship or na15 tionality for purposes of satisfying the requirement 

16 of subsection (x) of section 1903 of such Act. 

17 (e) DEFINITIONS.—Section 2110(c) of such Act (42 

18 U.S.C. 1397jj(c)) is amended by adding at the end the 

19 following new paragraph: 

20 ‘‘(9) INDIAN; INDIAN HEALTH PROGRAM; IN21 DIAN TRIBE; ETC.—The terms ‘Indian’, ‘Indian 

22 Health Program’, ‘Indian Tribe’, ‘Tribal Organiza23 tion’, and ‘Urban Indian Organization’ have the 

24 meanings given those terms in section 4 of the In25 dian Health Care Improvement Act.’’. 


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1 SEC. 5. PREMIUMS AND COST SHARING PROTECTIONS 

2 UNDER MEDICAID, ELIGIBILITY DETERMINA3 TIONS UNDER MEDICAID AND SCHIP, AND 

4 PROTECTION OF CERTAIN INDIAN PROPERTY 

5 FROM MEDICAID ESTATE RECOVERY. 

6 (a) PREMIUMS AND COST SHARING PROTECTION

7 UNDER MEDICAID.— 

8 (1) IN GENERAL.—Section 1916 of the Social 

9 Security Act (42 U.S.C. 1396o) is amended— 

10 (A) in subsection (a), in the matter pre11 ceding paragraph (1), by striking ‘‘and (i)’’ and 

12 inserting ‘‘, (i), and (j)’’; and 

13 (B) by adding at the end the following new 

14 subsection: 

15 ‘‘(j) NO PREMIUMS OR COST SHARING FOR INDIANS

16 FURNISHED ITEMS OR SERVICES DIRECTLY BY INDIAN

17 HEALTH PROGRAMS OR THROUGH REFERRAL UNDER

18 THE CONTRACT HEALTH SERVICE.— 

19 ‘‘(1) NO COST SHARING FOR ITEMS OR SERV20 ICES FURNISHED TO INDIANS THROUGH INDIAN

21 HEALTH PROGRAMS.— 

22 ‘‘(A) IN GENERAL.—No enrollment fee, 

23 premium, or similar charge, and no deduction, 

24 copayment, cost sharing, or similar charge shall 

25 be imposed against an Indian who is furnished 

26 an item or service directly by the Indian Health 


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1 Service, an Indian Tribe, Tribal Organization, 

2 or Urban Indian Organization or through refer3 ral under the contract health service for which 

4 payment may be made under this title. 

5 ‘‘(B) NO REDUCTION IN AMOUNT OF PAY6 MENT TO INDIAN HEALTH PROVIDERS.—Pay7 ment due under this title to the Indian Health 

8 Service, an Indian Tribe, Tribal Organization, 

9 or Urban Indian Organization, or a health care 

10 provider through referral under the contract 

11 health service for the furnishing of an item or 

12 service to an Indian who is eligible for assist13 ance under such title, may not be reduced by 

14 the amount of any enrollment fee, premium, or 

15 similar charge, or any deduction, copayment, 

16 cost sharing, or similar charge that would be 

17 due from the Indian but for the operation of 

18 subparagraph (A). 

19 ‘‘(2) RULE OF CONSTRUCTION.—Nothing in 

20 this subsection shall be construed as restricting the 

21 application of any other limitations on the imposi22 tion of premiums or cost sharing that may apply to 

23 an individual receiving medical assistance under this 

24 title who is an Indian. 


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1 ‘‘(3) DEFINITIONS.—In this subsection, the 

2 terms ‘contract health service’, ‘Indian’, ‘Indian 

3 Tribe’, ‘Tribal Organization’, and ‘Urban Indian Or4 ganization’ have the meanings given those terms in 

5 section 4 of the Indian Health Care Improvement 

6 Act.’’. 

7 (2) CONFORMING AMENDMENT.—Section 

8 1916A (a)(1) of such Act (42 U.S.C. 1396o–1(a)(1)) 

9 is amended by striking ‘‘section 1916(g)’’ and in10 serting ‘‘subsections (g), (i), or (j) of section 1916’’. 

11 (b) TREATMENT OF CERTAIN PROPERTY FOR MED12 ICAID AND SCHIP ELIGIBILITY.— 

13 (1) MEDICAID.—Section 1902(e) of the Social 

14 Security Act (42 U.S.C. 1396a) is amended by add15 ing at the end the following new paragraph: 

16 ‘‘(13) Notwithstanding any other requirement 

17 of this title or any other provision of Federal or 

18 State law, a State shall disregard the following prop19 erty for purposes of determining eligibility for med20 ical assistance under this title: 

21 ‘‘(A) Property, including real property and 

22 improvements, located on a reservation, includ23 ing any federally recognized Indian Tribe’s res24 ervation, pueblo, or colony, including former 

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1 gions established by the Alaska Native Claims 

2 Settlement Act, and Indian allotments on or 

3 near a reservation as designated and approved 

4 by the Bureau of Indian Affairs of the Depart5 ment of the Interior. 

6 ‘‘(B) For any federally recognized Tribe 

7 not described in subparagraph (A), property lo8 cated within the most recent boundaries of a 

9 prior Federal reservation. 

10 ‘‘(C) Ownership interests in rents, leases, 

11 royalties, or usage rights related to natural re12 sources (including extraction of natural re13 sources or harvesting of timber, other plants 

14 and plant products, animals, fish, and shellfish) 

15 resulting from the exercise of federally pro16 tected rights. 

17 ‘‘(D) Ownership interests in or usage 

18 rights to items not covered by subparagraphs 

19 (A) through (C) that have unique religious, 

20 spiritual, traditional, or cultural significance or 

21 rights that support subsistence or a traditional 

22 lifestyle according to applicable tribal law or 

23 custom.’’. 


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1 (2) APPLICATION TO SCHIP.—Section 

2 2107(e)(1) of such Act (42 U.S.C. 1397gg(e)(1)) is 

3 amended— 

4 (A) by redesignating subparagraphs (B) 

5 through (E), as subparagraphs (C) through 

6 (F), respectively; and 

7 (B) by inserting after subparagraph (A), 

8 the following new subparagraph: 

9 ‘‘(B) Section 1902(e)(13) (relating to dis10 regard of certain property for purposes of mak11 ing eligibility determinations).’’. 

12 (c) CONTINUATION OF CURRENT LAW PROTECTIONS

13 OF CERTAIN INDIAN PROPERTY FROM MEDICAID ESTATE

14 RECOVERY.—Section 1917(b)(3) of the Social Security 

15 Act (42 U.S.C. 1396p(b)(3)) is amended— 

16 (1) by inserting ‘‘(A)’’ after ‘‘(3)’’; and 

17 (2) by adding at the end the following new sub18 paragraph: 

19 ‘‘(B) The standards specified by the Sec20 retary under subparagraph (A) shall require 

21 that the procedures established by the State 

22 agency under subparagraph (A) exempt income, 

23 resources, and property that are exempt from 

24 the application of this subsection as of April 1, 

25 2003, under manual instructions issued to carry 


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1 out this subsection (as in effect on such date) 

2 because of the Federal responsibility for Indian 

3 Tribes and Alaska Native Villages. Nothing in 

4 this subparagraph shall be construed as pre5 venting the Secretary from providing additional 

6 estate recovery exemptions under this title for 

7 Indians.’’. 

8 SEC. 6. NONDISCRIMINATION IN QUALIFICATIONS FOR 

9 PAYMENT FOR SERVICES UNDER FEDERAL 

10 HEALTH CARE PROGRAMS. 

11 Section 1139 of the Social Security Act (42 U.S.C. 

12 1320b–9), as amended by section 3, is amended by redes13 ignating subsection (c) as subsection (d), and inserting 

14 after subsection (b) the following new subsection: 

15 ‘‘(c) NONDISCRIMINATION IN QUALIFICATIONS FOR

16 PAYMENT FOR SERVICES UNDER FEDERAL HEALTH

17 CARE PROGRAMS.— 

18 ‘‘(1) REQUIREMENT TO SATISFY GENERALLY

19 APPLICABLE PARTICIPATION REQUIREMENTS.— 

20 ‘‘(A) IN GENERAL.—A Federal health care 

21 program must accept an entity that is operated 

22 by the Indian Health Service, an Indian Tribe, 

23 Tribal Organization, or Urban Indian Organiza24 tion as a provider eligible to receive payment 

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1 nished to an Indian on the same basis as any 

2 other provider qualified to participate as a pro3 vider of health care services under the program 

4 if the entity meets generally applicable State or 

5 other requirements for participation as a pro6 vider of health care services under the program. 

7 ‘‘(B) SATISFACTION OF STATE OR LOCAL

8 LICENSURE OR RECOGNITION REQUIRE9 MENTS.—Any requirement for participation as 

10 a provider of health care services under a Fed11 eral health care program that an entity be li12 censed or recognized under the State or local 

13 law where the entity is located to furnish health 

14 care services shall be deemed to have been met 

15 in the case of an entity operated by the Indian 

16 Health Service, an Indian Tribe, Tribal Organi17 zation, or Urban Indian Organization if the en18 tity meets all the applicable standards for such 

19 licensure or recognition, regardless of whether 

20 the entity obtains a license or other documenta21 tion under such State or local law. In accord22 ance with section 221 of the Indian Health 

23 Care Improvement Act, the absence of the licen24 sure of a health care professional employed by 

25 such an entity under the State or local law 


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1 where the entity is located shall not be taken 

2 into account for purposes of determining wheth3 er the entity meets such standards, if the pro4 fessional is licensed in another State. 

5 ‘‘(2) PROHIBITION ON FEDERAL PAYMENTS TO

6 ENTITIES OR INDIVIDUALS EXCLUDED FROM PAR7 TICIPATION IN FEDERAL HEALTH CARE PROGRAMS

8 OR WHOSE STATE LICENSES ARE UNDER SUSPEN9 SION OR HAVE BEEN REVOKED.— 

10 ‘‘(A) EXCLUDED ENTITIES.—No entity op11 erated by the Indian Health Service, an Indian 

12 Tribe, Tribal Organization, or Urban Indian 

13 Organization that has been excluded from par14 ticipation in any Federal health care program 

15 or for which a license is under suspension or 

16 has been revoked by the State where the entity 

17 is located shall be eligible to receive payment 

18 under any such program for health care serv19 ices furnished to an Indian. 

20 ‘‘(B) EXCLUDED INDIVIDUALS.—No indi21 vidual who has been excluded from participation 

22 in any Federal health care program or whose 

23 State license is under suspension or has been 

24 revoked shall be eligible to receive payment 

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1 ices furnished by that individual, directly or 

2 through an entity that is otherwise eligible to 

3 receive payment for health care services, to an 

4 Indian. 

5 ‘‘(C) FEDERAL HEALTH CARE PROGRAM

6 DEFINED.—In this subsection, the term, ‘Fed7 eral health care program’ has the meaning 

8 given that term in section 1128B(f), except 

9 that, for purposes of this subsection, such term 

10 shall include the health insurance program 

11 under chapter 89 of title 5, United States 

12 Code.’’. 

13 SEC. 7. CONSULTATION ON MEDICAID, SCHIP, AND OTHER 

14 HEALTH CARE PROGRAMS FUNDED UNDER 

15 THE SOCIAL SECURITY ACT INVOLVING IN16 DIAN HEALTH PROGRAMS AND URBAN IN17 DIAN ORGANIZATIONS. 

18 (a) IN GENERAL.—Section 1139 of the Social Secu19 rity Act (42 U.S.C. 1320b–9), as amended by sections 3 

20 and 6, is amended by redesignating subsection (d) as sub21 section (e), and inserting after subsection (c) the following 

22 new subsection: 

23 ‘‘(d) CONSULTATION WITH TRIBAL TECHNICAL AD24 VISORY GROUP (TTAG).—The Secretary shall maintain 

25 within the Centers for Medicaid & Medicare Services 


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1 (CMS) a Tribal Technical Advisory Group, established in 

2 accordance with requirements of the charter dated Sep3 tember 30, 2003, and in such group shall include a rep4 resentative of the Urban Indian Organizations and the 

5 Service. The representative of the Urban Indian Organiza6 tion shall be deemed to be an elected officer of a tribal 

7 government for purposes of applying section 204(b) of the 

8 Unfunded Mandates Reform Act of 1995 (2 U.S.C. 

9 1534(b)).’’. 

10 (b) SOLICITATION OF ADVICE UNDER MEDICAID AND

11 SCHIP.— 

12 (1) MEDICAID STATE PLAN AMENDMENT.—Sec13 tion 1902(a) of the Social Security Act (42 U.S.C. 

14 1396a(a)) is amended— 

15 (A) in paragraph (69), by striking ‘‘and’’ 

16 at the end; 

17 (B) in paragraph (70)(B)(iv), by striking 

18 the period at the end and inserting ‘‘; and’’; 

19 and 

20 (C) by inserting after paragraph 

21 (70)(B)(iv), the following new paragraph: 

22 ‘‘(71) in the case of any State in which the In23 dian Health Service operates or funds health care 

24 programs, or in which 1 or more Indian Health Pro25 grams or Urban Indian Organizations (as such 


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1 terms are defined in section 4 of the Indian Health 

2 Care Improvement Act) provide health care in the 

3 State for which medical assistance is available under 

4 such title, provide for a process under which the 

5 State seeks advice on a regular, ongoing basis from 

6 designees of such Indian Health Programs and 

7 Urban Indian Organizations on matters relating to 

8 the application of this title that are likely to have a 

9 direct effect on such Indian Health Programs and 

10 Urban Indian Organizations and that— 

11 ‘‘(A) shall include solicitation of advice 

12 prior to submission of any plan amendments, 

13 waiver requests, and proposals for demonstra14 tion projects likely to have a direct effect on In15 dians, Indian Health Programs, or Urban In16 dian Organizations; and 

17 ‘‘(B) may include appointment of an advi18 sory committee and of a designee of such In19 dian Health Programs and Urban Indian Orga20 nizations to the medical care advisory com21 mittee advising the State on its State plan 

22 under this title.’’. 

23 (2) APPLICATION TO SCHIP.—Section 

24 2107(e)(1) of such Act (42 U.S.C. 1397gg(e)(1)), as 

25 amended by section 5(b)(2), is amended— 


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1 (A) by redesignating subparagraphs (B) 

2 through (F) as subparagraphs (C) through (G), 

3 respectively; and 

4 (B) by inserting after subparagraph (A), 

5 the following new subparagraph: 

6 ‘‘(B) Section 1902(a)(71) (relating to the 

7 option of certain States to seek advice from 

8 designees of Indian Health Programs and 

9 Urban Indian Organizations).’’. 

10 (c) RULE OF CONSTRUCTION.—Nothing in the 

11 amendments made by this section shall be construed as 

12 superseding existing advisory committees, working groups, 

13 guidance, or other advisory procedures established by the 

14 Secretary of Health and Human Services or by any State 

15 with respect to the provision of health care to Indians. 

16 SEC. 8. EXCLUSION WAIVER AUTHORITY FOR AFFECTED IN17 DIAN HEALTH PROGRAMS AND SAFE HARBOR 

18 TRANSACTIONS UNDER THE SOCIAL SECU19 RITY ACT. 

20 (a) EXCLUSION WAIVER AUTHORITY.—Section 1128 

21 of the Social Security Act (42 U.S.C. 1320a–7) is amend22 ed by adding at the end the following new subsection: 

23 ‘‘(k) ADDITIONAL EXCLUSION WAIVER AUTHORITY

24 FOR AFFECTED INDIAN HEALTH PROGRAMS.—In addi25 tion to the authority granted the Secretary under subVerDate Aug 31 2005 23:11 Jun 15, 2006 Jkt 049200 PO 00000 Frm 00026 Fmt 6652 Sfmt 6201 E:\BILLS\S3524.PCS S3524

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1 sections (c)(3)(B) and (d)(3)(B) to waive an exclusion 

2 under subsection (a)(1), (a)(3), (a)(4), or (b), the Sec3 retary may, in the case of an Indian Health Program, 

4 waive such an exclusion upon the request of the adminis5 trator of an affected Indian Health Program (as defined 

6 in section 4 of the Indian Health Care Improvement Act) 

7 who determines that the exclusion would impose a hard8 ship on individuals entitled to benefits under or enrolled 

9 in a Federal health care program.’’. 

10 (b) CERTAIN TRANSACTIONS INVOLVING INDIAN

11 HEALTH CARE PROGRAMS DEEMED TO BE IN SAFE HAR12 BORS.—Section 1128B(b) of the Social Security Act (42 

13 U.S.C. 1320a–7b(b)) is amended by adding at the end the 

14 following new paragraph: 

15 ‘‘(4) Subject to such conditions as the Secretary may 

16 promulgate from time to time as necessary to prevent 

17 fraud and abuse, for purposes of paragraphs (1) and (2) 

18 and section 1128A(a), the following transfers shall not be 

19 treated as remuneration: 

20 ‘‘(A) TRANSFERS BETWEEN INDIAN HEALTH

21 PROGRAMS, INDIAN TRIBES, TRIBAL ORGANIZATIONS, 

22 AND URBAN INDIAN ORGANIZATIONS.—Transfers of 

23 anything of value between or among an Indian 

24 Health Program, Indian Tribe, Tribal Organization, 

25 or Urban Indian Organization, that are made for the 


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1 purpose of providing necessary health care items and 

2 services to any patient served by such Program, 

3 Tribe, or Organization and that consist of— 

4 ‘‘(i) services in connection with the collec5 tion, transport, analysis, or interpretation of di6 agnostic specimens or test data; 

7 ‘‘(ii) inventory or supplies; 

8 ‘‘(iii) staff; or 

9 ‘‘(iv) a waiver of all or part of premiums 

10 or cost sharing. 

11 ‘‘(B) TRANSFERS BETWEEN INDIAN HEALTH

12 PROGRAMS, INDIAN TRIBES, TRIBAL ORGANIZATIONS, 

13 OR URBAN INDIAN ORGANIZATIONS AND PA14 TIENTS.—Transfers of anything of value between an 

15 Indian Health Program, Indian Tribe, Tribal Orga16 nization, or Urban Indian Organization and any pa17 tient served or eligible for service from an Indian 

18 Health Program, Indian Tribe, Tribal Organization, 

19 or Urban Indian Organization, including any patient 

20 served or eligible for service pursuant to section 807 

21 of the Indian Health Care Improvement Act, but 

22 only if such transfers— 

23 ‘‘(i) consist of expenditures related to pro24 viding transportation for the patient for the 

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1 ices, provided that the provision of such trans2 portation is not advertised, nor an incentive of 

3 which the value is disproportionately large in 

4 relationship to the value of the health care item 

5 or service (with respect to the value of the item 

6 or service itself or, for preventative items or 

7 services, the future health care costs reasonably 

8 expected to be avoided); 

9 ‘‘(ii) consist of expenditures related to pro10 viding housing to the patient (including a preg11 nant patient) and immediate family members or 

12 an escort necessary to assuring the timely pro13 vision of health care items and services to the 

14 patient, provided that the provision of such 

15 housing is not advertised nor an incentive of 

16 which the value is disproportionately large in 

17 relationship to the value of the health care item 

18 or service (with respect to the value of the item 

19 or service itself or, for preventative items or 

20 services, the future health care costs reasonably 

21 expected to be avoided); or 

22 ‘‘(iii) are for the purpose of paying pre23 miums or cost sharing on behalf of such a pa24 tient, provided that the making of such pay25 ment is not subject to conditions other than 


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1 conditions agreed to under a contract for the 

2 delivery of contract health services. 

3 ‘‘(C) CONTRACT HEALTH SERVICES.—A trans4 fer of anything of value negotiated as part of a con5 tract entered into between an Indian Health Pro6 gram, Indian Tribe, Tribal Organization, Urban In7 dian Organization, or the Indian Health Service and 

8 a contract care provider for the delivery of contract 

9 health services authorized by the Indian Health 

10 Service, provided that— 

11 ‘‘(i) such a transfer is not tied to volume 

12 or value of referrals or other business generated 

13 by the parties; and 

14 ‘‘(ii) any such transfer is limited to the fair 

15 market value of the health care items or serv16 ices provided or, in the case of a transfer of 

17 items or services related to preventative care, 

18 the value of the future health care costs reason19 ably expected to be avoided. 

20 ‘‘(D) OTHER TRANSFERS.—Any other transfer 

21 of anything of value involving an Indian Health Pro22 gram, Indian Tribe, Tribal Organization, or Urban 

23 Indian Organization, or a patient served or eligible 

24 for service from an Indian Health Program, Indian 

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1 zation, that the Secretary, in consultation with the 

2 Attorney General, determines is appropriate, taking 

3 into account the special circumstances of such In4 dian Health Programs, Indian Tribes, Tribal Orga5 nizations, and Urban Indian Organizations, and of 

6 patients served by such Programs, Tribes, and Orga7 nizations.’’. 

8 SEC. 9. RULES APPLICABLE UNDER MEDICAID AND SCHIP 

9 TO MANAGED CARE ENTITIES WITH RESPECT 

10 TO INDIAN ENROLLEES AND INDIAN HEALTH 

11 CARE PROVIDERS AND INDIAN MANAGED 

12 CARE ENTITIES. 

13 (a) IN GENERAL.—Section 1932 of the Social Secu14 rity Act (42 U.S.C. 1396u–2) is amended by adding at 

15 the end the following new subsection: 

16 ‘‘(h) SPECIAL RULES WITH RESPECT TO INDIAN EN17 ROLLEES, INDIAN HEALTH CARE PROVIDERS, AND IN18 DIAN MANAGED CARE ENTITIES.— 

19 ‘‘(1) ENROLLEE OPTION TO SELECT AN INDIAN

20 HEALTH CARE PROVIDER AS PRIMARY CARE PRO21 VIDER.—In the case of a non-Indian Medicaid man22 aged care entity that— 

23 ‘‘(A) has an Indian enrolled with the enti24 ty; and 


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1 ‘‘(B) has an Indian health care provider 

2 that is participating as a primary care provider 

3 within the network of the entity, 

4 insofar as the Indian is otherwise eligible to receive 

5 services from such Indian health care provider and 

6 the Indian health care provider has the capacity to 

7 provide primary care services to such Indian, the 

8 contract with the entity under section 1903(m) or 

9 under section 1905(t)(3) shall require, as a condi10 tion of receiving payment under such contract, that 

11 the Indian shall be allowed to choose such Indian 

12 health care provider as the Indian’s primary care 

13 provider under the entity. 

14 ‘‘(2) ASSURANCE OF PAYMENT TO INDIAN

15 HEALTH CARE PROVIDERS FOR PROVISION OF COV16 ERED SERVICES.—Each contract with a managed 

17 care entity under section 1903(m) or under section 

18 1905(t)(3) shall require any such entity that has a 

19 significant percentage of Indian enrollees (as deter20 mined by the Secretary), as a condition of receiving 

21 payment under such contract to satisfy the following 

22 requirements: 

23 ‘‘(A) DEMONSTRATION OF PARTICIPATING

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1 TION OF ALTERNATIVE PAYMENT ARRANGE2 MENTS.—Subject to subparagraph (E), to— 

3 ‘‘(i) demonstrate that the number of 

4 Indian health care providers that are par5 ticipating providers with respect to such 

6 entity are sufficient to ensure timely access 

7 to covered Medicaid managed care services 

8 for those enrollees who are eligible to re9 ceive services from such providers; or 

10 ‘‘(ii) agree to pay Indian health care 

11 providers who are not participating pro12 viders with the entity for covered Medicaid 

13 managed care services provided to those 

14 enrollees who are eligible to receive services 

15 from such providers at a rate equal to the 

16 rate negotiated between such entity and 

17 the provider involved or, if such a rate has 

18 not been negotiated, at a rate that is not 

19 less than the level and amount of payment 

20 which the entity would make for the serv21 ices if the services were furnished by a par22 ticipating provider which is not an Indian 

23 health care provider. 

24 ‘‘(B) PROMPT PAYMENT.—To agree to 

25 make prompt payment (in accordance with 


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1 rules applicable to managed care entities) to In2 dian health care providers that are participating 

3 providers with respect to such entity or, in the 

4 case of an entity to which subparagraph (A)(ii) 

5 or (E) applies, that the entity is required to pay 

6 in accordance with that subparagraph. 

7 ‘‘(C) SATISFACTION OF CLAIM REQUIRE8 MENT.—To deem any requirement for the sub9 mission of a claim or other documentation for 

10 services covered under subparagraph (A) by the 

11 enrollee to be satisfied through the submission 

12 of a claim or other documentation by an Indian 

13 health care provider that is consistent with sec14 tion 403(h) of the Indian Health Care Improve15 ment Act. 

16 ‘‘(D) COMPLIANCE WITH GENERALLY AP17 PLICABLE REQUIREMENTS.— 

18 ‘‘(i) IN GENERAL.—Subject to clause 

19 (ii), as a condition of payment under sub20 paragraph (A), an Indian health care pro21 vider shall comply with the generally appli22 cable requirements of this title, the State 

23 plan, and such entity with respect to cov24 ered Medicaid managed care services pro25 vided by the Indian health care provider to 


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1 the same extent that non-Indian providers 

2 participating with the entity must comply 

3 with such requirements. 

4 ‘‘(ii) LIMITATIONS ON COMPLIANCE

5 WITH MANAGED CARE ENTITY GENERALLY

6 APPLICABLE REQUIREMENTS.—An Indian 

7 health care provider— 

8 ‘‘(I) shall not be required to com9 ply with a generally applicable re10 quirement of a managed care entity 

11 described in clause (i) as a condition 

12 of payment under subparagraph (A) if 

13 such compliance would conflict with 

14 any other statutory or regulatory re15 quirements applicable to the Indian 

16 health care provider; and 

17 ‘‘(II) shall only need to comply 

18 with those generally applicable re19 quirements of a managed care entity 

20 described in clause (i) as a condition 

21 of payment under subparagraph (A) 

22 that are necessary for the entity’s 

23 compliance with the State plan, such 

24 as those related to care management, 


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1 quality assurance, and utilization 

2 management. 

3 ‘‘(E) APPLICATION OF SPECIAL PAYMENT

4 REQUIREMENTS FOR FEDERALLY-QUALIFIED

5 HEALTH CENTERS AND ENCOUNTER RATE FOR

6 SERVICES PROVIDED BY CERTAIN INDIAN

7 HEALTH CARE PROVIDERS.— 

8 ‘‘(i) FEDERALLY-QUALIFIED HEALTH

9 CENTERS.— 

10 ‘‘(I) MANAGED CARE ENTITY

11 PAYMENT REQUIREMENT.—To agree 

12 to pay any Indian health care provider 

13 that is a federally-qualified health 

14 center but not a participating provider 

15 with respect to the entity, for the pro16 vision of covered Medicaid managed 

17 care services by such provider to an 

18 Indian enrollee of the entity at a rate 

19 equal to the amount of payment that 

20 the entity would pay a federally-quali21 fied health center that is a partici22 pating provider with respect to the en23 tity but is not an Indian health care 

24 provider for such services. 


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1 ‘‘(II) CONTINUED APPLICATION

2 OF STATE REQUIREMENT TO MAKE

3 SUPPLEMENTAL PAYMENT.—Nothing 

4 in subclause (I) or subparagraph (A) 

5 or (B) shall be construed as waiving 

6 the application of section 1902(bb)(5) 

7 regarding the State plan requirement 

8 to make any supplemental payment 

9 due under such section to a federally10 qualified health center for services 

11 furnished by such center to an en12 rollee of a managed care entity (re13 gardless of whether the federally14 qualified health center is or is not a 

15 participating provider with the entity). 

16 ‘‘(ii) CONTINUED APPLICATION OF

17 ENCOUNTER RATE FOR SERVICES PRO18 VIDED BY CERTAIN INDIAN HEALTH CARE

19 PROVIDERS.—If the amount paid by a 

20 managed care entity to an Indian health 

21 care provider that is not a federally-quali22 fied health center and that has elected to 

23 receive payment under this title as an In24 dian Health Service provider under the 

25 July 11, 1996, Memorandum of Agreement 


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1 between the Health Care Financing Ad2 ministration (now the Centers for Medicare 

3 & Medicaid Services) and the Indian 

4 Health Service for services provided by 

5 such provider to an Indian enrollee with 

6 the managed care entity is less than the 

7 encounter rate that applies to the provision 

8 of such services under such memorandum, 

9 the State plan shall provide for payment to 

10 the Indian health care provider of the dif11 ference between the applicable encounter 

12 rate under such memorandum and the 

13 amount paid by the managed care entity to 

14 the provider for such services. 

15 ‘‘(F) CONSTRUCTION.—Nothing in this 

16 paragraph shall be construed as waiving the ap17 plication of section 1902(a)(30)(A) (relating to 

18 application of standards to assure that pay19 ments are consistent with efficiency, economy, 

20 and quality of care). 

21 ‘‘(3) OFFERING OF MANAGED CARE THROUGH

22 INDIAN MEDICAID MANAGED CARE ENTITIES.—If— 

23 ‘‘(A) a State elects to provide services 

24 through Medicaid managed care entities under 

25 its Medicaid managed care program; and 


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1 ‘‘(B) an Indian health care provider that is 

2 funded in whole or in part by the Indian Health 

3 Service, or a consortium composed of 1 or more 

4 Tribes, Tribal Organizations, or Urban Indian 

5 Organizations, and which also may include the 

6 Indian Health Service, has established an In7 dian Medicaid managed care entity in the State 

8 that meets generally applicable standards re9 quired of such an entity under such Medicaid 

10 managed care program, 

11 the State shall offer to enter into an agreement with 

12 the entity to serve as a Medicaid managed care enti13 ty with respect to eligible Indians served by such en14 tity under such program. 

15 ‘‘(4) SPECIAL RULES FOR INDIAN MANAGED

16 CARE ENTITIES.—The following are special rules re17 garding the application of a Medicaid managed care 

18 program to Indian Medicaid managed care entities: 

19 ‘‘(A) ENROLLMENT.— 

20 ‘‘(i) LIMITATION TO INDIANS.—An In21 dian Medicaid managed care entity may re22 strict enrollment under such program to 

23 Indians and to members of specific Tribes 

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1 grams may restrict the delivery of services 

2 to such Indians and tribal members. 

3 ‘‘(ii) NO LESS CHOICE OF PLANS.— 

4 Under such program the State may not 

5 limit the choice of an Indian among Med6 icaid managed care entities only to Indian 

7 Medicaid managed care entities or to be 

8 more restrictive than the choice of man9 aged care entities offered to individuals 

10 who are not Indians. 

11 ‘‘(iii) DEFAULT ENROLLMENT.— 

12 ‘‘(I) IN GENERAL.—If such pro13 gram of a State requires the enroll14 ment of Indians in a Medicaid man15 aged care entity in order to receive 

16 benefits, the State, taking into consid17 eration the criteria specified in sub18 section (a)(4)(D)(ii)(I), shall provide 

19 for the enrollment of Indians de20 scribed in subclause (II) who are not 

21 otherwise enrolled with such an entity 

22 in an Indian Medicaid managed care 

23 entity described in such clause. 

24 ‘‘(II) INDIAN DESCRIBED.—An 

25 Indian described in this subclause, 


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1 with respect to an Indian Medicaid 

2 managed care entity, is an Indian 

3 who, based upon the service area and 

4 capacity of the entity, is eligible to be 

5 enrolled with the entity consistent 

6 with subparagraph (A). 

7 ‘‘(iv) EXCEPTION TO STATE LOCK8 IN.—A request by an Indian who is en9 rolled under such program with a non-In10 dian Medicaid managed care entity to 

11 change enrollment with that entity to en12 rollment with an Indian Medicaid managed 

13 care entity shall be considered cause for 

14 granting such request under procedures 

15 specified by the Secretary. 

16 ‘‘(B) FLEXIBILITY IN APPLICATION OF

17 SOLVENCY.—In applying section 1903(m)(1) to 

18 an Indian Medicaid managed care entity— 

19 ‘‘(i) any reference to a ‘State’ in sub20 paragraph (A)(ii) of that section shall be 

21 deemed to be a reference to the ‘Sec22 retary’; and 

23 ‘‘(ii) the entity shall be deemed to be 

24 a public entity described in subparagraph 

25 (C)(ii) of that section. 


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1 ‘‘(C) EXCEPTIONS TO ADVANCE DIREC2 TIVES.—The Secretary may modify or waive the 

3 requirements of section 1902(w) (relating to 

4 provision of written materials on advance direc5 tives) insofar as the Secretary finds that the re6 quirements otherwise imposed are not an appro7 priate or effective way of communicating the in8 formation to Indians. 

9 ‘‘(D) FLEXIBILITY IN INFORMATION AND

10 MARKETING.— 

11 ‘‘(i) MATERIALS.—The Secretary may 

12 modify requirements under subsection 

13 (a)(5) to ensure that information described 

14 in that subsection is provided to enrollees 

15 and potential enrollees of Indian Medicaid 

16 managed care entities in a culturally ap17 propriate and understandable manner that 

18 clearly communicates to such enrollees and 

19 potential enrollees their rights, protections, 

20 and benefits. 

21 ‘‘(ii) DISTRIBUTION OF MARKETING

22 MATERIALS.—The provisions of subsection 

23 (d)(2)(B) requiring the distribution of 

24 marketing materials to an entire service 

25 area shall be deemed satisfied in the case 


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1 of an Indian Medicaid managed care entity 

2 that distributes appropriate materials only 

3 to those Indians who are potentially eligi4 ble to enroll with the entity in the service 

5 area. 

6 ‘‘(5) MALPRACTICE INSURANCE.—Insofar as, 

7 under a Medicaid managed care program, a health 

8 care provider is required to have medical malpractice 

9 insurance coverage as a condition of contracting as 

10 a provider with a Medicaid managed care entity, an 

11 Indian health care provider that is— 

12 ‘‘(A) a federally-qualified health center 

13 that is covered under the Federal Tort Claims 

14 Act (28 U.S.C. 1346(b), 2671 et seq.); 

15 ‘‘(B) providing health care services pursu16 ant to a contract or compact under the Indian 

17 Self-Determination and Education Assistance 

18 Act (25 U.S.C. 450 et seq.) that are covered 

19 under the Federal Tort Claims Act (28 U.S.C. 

20 1346(b), 2671 et seq.); or 

21 ‘‘(C) the Indian Health Service providing 

22 health care services that are covered under the 

23 Federal Tort Claims Act (28 U.S.C. 1346(b), 

24 2671 et seq.); 

25 are deemed to satisfy such requirement. 


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1 ‘‘(6) DEFINITIONS.—For purposes of this sub2 section: 

3 ‘‘(A) INDIAN HEALTH CARE PROVIDER.— 

4 The term ‘Indian health care provider’ means 

5 an Indian Health Program or an Urban Indian 

6 Organization. 

7 ‘‘(B) INDIAN; INDIAN HEALTH PROGRAM; 

8 SERVICE; TRIBE, TRIBAL ORGANIZATION; URBAN

9 INDIAN ORGANIZATION.—The terms ‘Indian’, 

10 ‘Indian Health Program’, ‘Service’, ‘Tribe’, 

11 ‘tribal organization’, ‘Urban Indian Organiza12 tion’ have the meanings given such terms in 

13 section 4 of the Indian Health Care Improve14 ment Act. 

15 ‘‘(C) INDIAN MEDICAID MANAGED CARE

16 ENTITY.—The term ‘Indian Medicaid managed 

17 care entity’ means a managed care entity that 

18 is controlled (within the meaning of the last 

19 sentence of section 1903(m)(1)(C)) by the In20 dian Health Service, a Tribe, Tribal Organiza21 tion, or Urban Indian Organization, or a con22 sortium, which may be composed of 1 or more 

23 Tribes, Tribal Organizations, or Urban Indian 

24 Organizations, and which also may include the 

25 Service. 


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1 ‘‘(D) NON-INDIAN MEDICAID MANAGED

2 CARE ENTITY.—The term ‘non-Indian Medicaid 

3 managed care entity’ means a managed care en4 tity that is not an Indian Medicaid managed 

5 care entity. 

6 ‘‘(E) COVERED MEDICAID MANAGED CARE

7 SERVICES.—The term ‘covered Medicaid man8 aged care services’ means, with respect to an 

9 individual enrolled with a managed care entity, 

10 items and services that are within the scope of 

11 items and services for which benefits are avail12 able with respect to the individual under the 

13 contract between the entity and the State in14 volved. 

15 ‘‘(F) MEDICAID MANAGED CARE PRO16 GRAM.—The term ‘Medicaid managed care pro17 gram’ means a program under sections 

18 1903(m) and 1932 and includes a managed 

19 care program operating under a waiver under 

20 section 1915(b) or 1115 or otherwise.’’. 

21 (b) APPLICATION TO SCHIP.—Section 2107(e)(1) of 

22 such Act (42 U.S.C. 1397gg(1)), as amended by section 

23 7(b)(2), is amended by adding at the end the following 

24 new subparagraph: 


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1 ‘‘(H) Subsections (a)(2)(C) and (h) of sec2 tion 1932.’’. 

3 SEC. 10. ANNUAL REPORT ON INDIANS SERVED BY SOCIAL 

4 SECURITY ACT HEALTH BENEFIT PROGRAMS. 

5 Section 1139 of the Social Security Act (42 U.S.C. 

6 1320b–9), as amended by the sections 3, 6, and 7, is 

7 amended by redesignating subsection (e) as subsection (f), 

8 and inserting after subsection (d) the following new sub9 section: 

10 ‘‘(e) ANNUAL REPORT ON INDIANS SERVED BY

11 HEALTH BENEFIT PROGRAMS FUNDED UNDER THIS

12 ACT.—Beginning January 1, 2007, and annually there13 after, the Secretary, acting through the Administrator of 

14 the Centers for Medicare & Medicaid Services and the Di15 rector of the Indian Health Service, shall submit a report 

16 to Congress regarding the enrollment and health status 

17 of Indians receiving items or services under health benefit 

18 programs funded under this Act during the preceding 

19 year. Each such report shall include the following: 

20 ‘‘(1) The total number of Indians enrolled in, or 

21 receiving items or services under, such programs, 

22 disaggregated with respect to each such program. 

23 ‘‘(2) The number of Indians described in para24 graph (1) that also received health benefits under 

25 programs funded by the Indian Health Service. 


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1 ‘‘(3) General information regarding the health 

2 status of the Indians described in paragraph (1), 

3 disaggregated with respect to specific diseases or 

4 conditions and presented in a manner that is con5 sistent with protections for privacy of individually 

6 identifiable health information under section 264(c) 

7 of the Health Insurance Portability and Account8 ability Act of 1996. 

9 ‘‘(4) A detailed statement of the status of facili10 ties of the Indian Health Service or an Indian Tribe, 

11 Tribal Organization, or an Urban Indian Organiza12 tion with respect to such facilities’ compliance with 

13 the applicable conditions and requirements of titles 

14 XVIII, XIX, and XXI, and, in the case of title XIX 

15 or XXI, under a State plan under such title or 

16 under waiver authority, and of the progress being 

17 made by such facilities (under plans submitted 

18 under section 1880(b), 1911(b) or otherwise) toward 

19 the achievement and maintenance of such compli20 ance. 

21 ‘‘(5) Such other information as the Secretary 

22 determines is appropriate.’’. 


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1 SEC. 11. EFFECTIVE DATE. 

2 The amendments made by this Act take effect on the 

3 effective date of the amendments made by the Indian 

4 Health Care Improvement Act Amendments of 2006. 


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Calendar No. 469 

109TH CONGRESS 

2D SESSION S. 3524 

A BILL 

To amend titles XVIII, XIX, and XXI of the Social 

other purposes. Children’s Health Insurance Programs, and for Indians under the Medicare, Medicaid, and State Security Act to improve health care provided to 

JUNE 15, 2006 

Read twice and placed on the calendar 


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