S. HRG. 108–199

INDIAN HEALTH CARE IMPROVEMENT ACT

JOINT HEARING

BEFORE THE

COMMITTEE ON INDIAN AFFAIRS

UNITED STATES SENATE

AND THE

COMMITTEE ON RESOURCES

UNITED STATES HOUSE OF

REPRESENTATIVES

ONE HUNDRED EIGHTH CONGRESS

FIRST SESSION

ON

S. 556

TO AMEND THE INDIAN HEALTH CARE IMPROVEMENT ACT TO REVISE

AND EXTEND THAT ACT

AND

H.R. 2440

TO IMPROVE THE IMPLEMENTATION OF THE FEDERAL RESPONSIBILITY

FOR THE CARE AND EDUCATION OF INDIAN PEOPLE BY IMPROVING

THE SERVICES AND FACILITIES OF FEDERAL HEALTH PROGRAMS

FOR INDIANS AND ENCOURAGING MAXIMUM PARTICIPATION OF INDIANS IN SUCH PROGRAMS

JULY 16, 2003

WASHINGTON, DC

Serial No. 108–41

(
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88–509 PDF 2003

S. HRG. 108–199

INDIAN HEALTH CARE IMPROVEMENT ACT

JOINT HEARING

BEFORE THE

COMMITTEE ON INDIAN AFFAIRS

UNITED STATES SENATE

AND THE

COMMITTEE ON RESOURCES

UNITED STATES HOUSE OF

REPRESENTATIVES

ONE HUNDRED EIGHTH CONGRESS

FIRST SESSION

ON

S. 556

TO AMEND THE INDIAN HEALTH CARE IMPROVEMENT ACT TO REVISE

AND EXTEND THAT ACT

AND

H.R. 2440

TO IMPROVE THE IMPLEMENTATION OF THE FEDERAL RESPONSIBILITY

FOR THE CARE AND EDUCATION OF INDIAN PEOPLE BY IMPROVING

THE SERVICES AND FACILITIES OF FEDERAL HEALTH PROGRAMS

FOR INDIANS AND ENCOURAGING MAXIMUM PARTICIPATION OF INDIANS IN SUCH PROGRAMS

JULY 16, 2003

WASHINGTON, DC

Serial No. 108–41

(
COMMITTEE ON INDIAN AFFAIRS

BEN NIGHTHORSE CAMPBELL, Colorado, Chairman

DANIEL K. INOUYE, Hawaii, Vice Chairman

JOHN McCAIN, Arizona,

PETE V. DOMENICI, New Mexico

CRAIG THOMAS, Wyoming

ORRIN G. HATCH, Utah

JAMES M. INHOFE, Oklahoma

GORDON SMITH, Oregon

LISA MURKOWSKI, Alaska

KENT CONRAD, North Dakota

HARRY REID, Nevada

DANIEL K. AKAKA, Hawaii

BYRON L. DORGAN, North Dakota

TIM JOHNSON, South Dakota

MARIA CANTWELL, Washington

PAUL MOOREHEAD, Majority Staff Director/Chief Counsel

PATRICIA M. ZELL, Minority Staff Director/Chief Counsel

COMMITTEE ON RESOURCES

RICHARD W. POMBO, California, Chairman

NICK J. RAHALL II, West Virginia, Ranking Democrat Member

DON YOUNG, Alaska

W.J. ‘‘BILLY’’ TAUZIN, Louisiana

JIM SAXTON, New Jersey

ELTON GALLEGLY, California

JOHN J. DUNCAN, JR., Tennessee

WAYNE T. GILCHREST, Maryland

KEN CALVERT, California

SCOTT MCINNIS, Colorado

BARBARA CUBIN, Wyoming

GEORGE RADANOVICH, California

WALTER B. JONES, JR., North Carolina

CHRIS CANNON, Utah

JOHN E. PETERSON, Pennsylvania

JIM GIBBONS, Nevada,

Vice Chairman

MARK E. SOUDER, Indiana

GREG WALDEN, Oregon

THOMAS G. TANCREDO, Colorado

J.D. HAYWORTH, Arizona

TOM OSBORNE, Nebraska

JEFF FLAKE, Arizona

DENNIS R. REHBERG, Montana

RICK RENZI, Arizona

TOM COLE, Oklahoma

STEVAN PEARCE, New Mexico

ROB BISHOP, Utah

DEVIN NUNES, California

VACANCY

DALE E. KILDEE, Michigan

ENI F.H. FALEOMAVAEGA, American

Samoa

NEIL ABERCROMBIE, Hawaii

SOLOMON P. ORTIZ, Texas

FRANK PALLONE, JR., New Jersey

CALVIN M. DOOLEY, California

DONNA M. CHRISTENSEN, Virgin Islands

RON KIND, Wisconsin

JAY INSLEE, Washington

GRACE F. NAPOLITANO, California

TOM UDALL, New Mexico

MARK UDALL, Colorado

ANI ́BAL ACEVEDO–VILA ́ , Puerto Rico

BRAD CARSON, Oklahoma

RAU ́ L M. GRIJALVA, Arizona

DENNIS A. CARDOZA, California

MADELEINE Z. BORDALLO, Guam

GEORGE MILLER, California

EDWARD J. MARKEY, Massachusetts

RUBE ́ N HINOJOSA, Texas

CIRO D. RODRIGUEZ, Texas

JOE BACA, California

BETTY MCCOLLUM, Minnesota

STEVEN J. DING, Chief of Staff

LISA PITTMAN, Chief Counsel

JAMES H. ZOIA, Democrat Staff Director

JEFFREY P. PETRICH, Democrat Chief Counsel

(II)
(III)

C O N T E N T S

Page

S. 556 and H.R. 2440, text of .................................................................................. 2

Statements:

Campbell, Hon. Ben Nighthorse, U.S. Senator from Colorado, chairman,

Senate Committee on Indian Affairs ........................................................... 1

Carson, Hon. Carson, Hon. Brad, U.S. Representative from Oklahoma ..... 674

Christensen, Hon. Donna M., U.S. Delgate from Virgin Islands .................. 675

Cole, Hon. Tom, U.S. Representative from Oklahoma .................................. 673

Culbertson, Kay, president, Denver Indian Health and Family Services ... 698

Faleomavaega, Hon. Eni F.H., U.S. Delegate from American Samoa .......... 672

Grijalva, Hon. Rau ́l M., U.S. Representative from Arizona .......................... 673

Grim, Charles, director, Indian Health Service, Department of Health

and Human Services ..................................................................................... 676

Hartz, Gary, acting director, Office of Public Health, Indian Health Service ................................................................................................................... 676

Jimmie, Andrew, chief, Minto Traditional Council ........................................ 697

Joseph, Rachel, cochair, National Steering Committee of the Reauthorization of the Indian Health Care Improvement Act ...................................... 694

Kildee, Hon. Dale E., U.S. Representative from Michigan ........................... 671

Muneta, Dr. Ben, president, Association of American Indian Physicians ... 696

Murkowski, Hon. Lisa, U.S. Senator from Alaska ......................................... 672

Nesmith, Steve, assistant secretary for Congressional and Intergovernmental Affairs, Department of Housing and Urban Development ........... 679

Olson, Richard, acting director, Division of Clinical and Preventive Services, Indian Health Service .......................................................................... 676

Pallone, Hon. Frank, Jr., U.S. Representative from New Jersey ................. 674

Pombo, Hon. Richard W., U.S. Representative from California, chairman,

House Committee on Resources ................................................................... 671

Rhoades, Dr. Everett, Oklahoma City Urban Indian Clinic ......................... 700

Skeeter, Carmelita Wamego, executive director, Indian Health Care Resource Center of Tulsa .................................................................................. 701

Snyder, Rae, acting director, Urban Health Office, Indian Health Service . 676

Udall, Hon. Mark, U.S. Representative from Colorado ................................. 673

Weaver, Steve, director, Division of Environmental Health and Engineering, Alaska Native Tribal Health Consortium ........................................... 697

APPENDIX

Prepared statements:

Beaver, R. Perry, principal chief, Muscogee (Creek) Nation ......................... 705

Culbertson, Kay (with attachment) ................................................................. 708

Grim, Charles (with attachment) .................................................................... 725

Guzman, Victoria, Walker River Paiute Tribe ............................................... 752

Jimmie, Andrew ................................................................................................ 705

Joseph, Rachel .................................................................................................. 760

Muneta, Dr. Ben (with attachment) ............................................................... 778

Nesmith, Steve .................................................................................................. 785

Rhoades, Dr. Everett (with attachment) ........................................................ 789

Skeeter, Carmelita Wamego (with attachment) ............................................. 802

Sossamon, Russell, chairman, National American Indian Housing Council .................................................................................................................... 814

Weaver, Steve (with attachment) .................................................................... 817

Zacharof, chairman, Alaska Native Health Board ......................................... 705
Page

IV

Additional material submitted for the record:

Letters:

Citizens Potawatomi Nation ............................................................................ 839

Edwards, James Lee, Governor, Absentee Shawnee Tribe ........................... 841

Ration, Norman, executive director, National Indian Youth Council, Inc.

(with attachment) ......................................................................................... 842

Romberg, Carolyn, Health Director, AST Health Programs, Absentee

Shawnee Tribe of Oklahoma ........................................................................ 841
(1)

INDIAN HEALTH CARE IMPROVEMENT ACT

WEDNESDAY, JULY 16, 2003

U.S. SENATE, COMMITTEE ON INDIAN AFFAIRS, MEETING

JOINTLY WITH THE COMMITTEE ON RESOURCES, U.S.

HOUSE OF REPRESENTATIVES

Washington, DC.

The committees met, pursuant to notice, at 10:15 a.m. in room

106, Dirksen Senate Office Building, Hon. Ben Nighthorse Campbell (chairman of the Senate Committee on Indian Affairs) presiding.

Present from the Senate Committee on Indian Affairs: Senators

Campbell, Inouye, Reid, Conrad, Dorgan, and Murkowski.

Present from the House of Representatives Committee on Resources: Representatives Pombo, Mark Udall, Faleomavaega, Cole,

Kildee, Grijalva, Pallone, Brad Carson, Christensen, and

Napolitano.

STATEMENT OF HON. BEN NIGHTHORSE CAMPBELL, U.S. SENATOR FROM COLORADO, CHAIRMAN, COMMITTEE ON INDIAN AFFAIRS

The CHAIRMAN. We will now move to the joint hearing with the

House Resources Committee and the Senate Committee on Indian

Affairs bills to reauthorize the Indian Health Care Improvement

Act. The two bills before our committee, S. 556 and H.R. 2440, reflect literally years of hard work by tribal leaders, the National

Steering Committee and various Federal officials.

Most members know the shameful state of Indian health. Senator Dorgan just reiterated that as did Senator Conrad, so I won’t

go through the litany of statistics this morning but they are common knowledge.

Today is the second in a series of hearings on the reauthorization

bill. We will receive testimony regarding one, health disparities;

two, health facilities; and three, urban Indian health issues. In the

interest of time, I’ll place my full statement in the record but I will

say this to the members of both committees. After years of work

and countless hours of meetings and hearings, the time certainly

has come for the tribes, Congress and the Administration to roll up

our sleeves and do what we need to do to move this bill and get

the act reauthorized this year. To achieve that goal I look forward

to working with my colleagues on both committees.

[Prepared statement of Senator Campbell appears in appendix.]

[Text of S. 556 and H.R. 2440 follow:]
2

1

II

108TH CONGRESS

1ST SESSION S. 556

To amend the Indian Health Care Improvement Act to revise and extend

that Act.

IN THE SENATE OF THE UNITED STATES

MARCH 6, 2003

Mr. CAMPBELL (for himself, Mr. INOUYE, and Mr. MCCAIN) introduced the

following bill; which was read twice and referred to the Committee on Indian Affairs

A BILL

To amend the Indian Health Care Improvement Act to revise

and extend that Act.

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 ‘‘Indian Health Care Improvement Act Reauthorization of

6 2003’’.

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

8 this Act is as follows:

Sec. 1. Short title.

TITLE I—REAUTHORIZATION AND REVISIONS OF THE INDIAN

HEALTH CARE IMPROVEMENT ACT
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•S 556 IS

Sec. 101. Amendment to the Indian Health Care Improvement Act.

TITLE II—CONFORMING AMENDMENTS TO THE SOCIAL

SECURITY ACT

Subtitle A—Medicare

Sec. 201. Limitations on charges.

Sec. 202. Qualified Indian health program.

Subtitle B—Medicaid

Sec. 211. State consultation with Indian health programs.

Sec. 212. FMAP for services provided by Indian health programs.

Sec. 213. Indian Health Service programs.

Subtitle C—State Children’s Health Insurance Program

Sec. 221. Enhanced FMAP for State children’s health insurance program.

Sec. 222. Direct funding of State children’s health insurance program.

Subtitle D—Authorization of Appropriations

Sec. 231. Authorization of appropriations.

TITLE III—MISCELLANEOUS PROVISIONS

Sec. 301. Repeals.

Sec. 302. Severability provisions.

Sec. 303. Effective date.

1 TITLE I—REAUTHORIZATION

2 AND REVISIONS OF THE IN3 DIAN HEALTH CARE IM4 PROVEMENT ACT

5 SEC. 101. AMENDMENT TO THE INDIAN HEALTH CARE IM6 PROVEMENT ACT.

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

8 1601 et seq.) is amended to read as follows:

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

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

11 ‘Indian Health Care Improvement Act’.
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1 ‘‘(b) TABLE OF CONTENTS.—The table of contents

2 for this Act is as follows:

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

‘‘Sec. 2. Findings.

‘‘Sec. 3. Declaration of health objectives.

‘‘Sec. 4. Definitions.

‘‘TITLE I—INDIAN HEALTH, HUMAN RESOURCES AND

DEVELOPMENT

‘‘Sec. 101. Purpose.

‘‘Sec. 102. General requirements.

‘‘Sec. 103. Health professions recruitment program for Indians.

‘‘Sec. 104. Health professions preparatory scholarship program for Indians.

‘‘Sec. 105. Indian health professions scholarships.

‘‘Sec. 106. American Indians into psychology program.

‘‘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. Tribal recruitment and retention program.

‘‘Sec. 114. Advanced training and research.

‘‘Sec. 115. Nursing programs; Quentin N. Burdick American Indians into

Nursing Program.

‘‘Sec. 116. Tribal culture and history.

‘‘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 project.

‘‘Sec. 124. Scholarships.

‘‘Sec. 125. National Health Service Corps.

‘‘Sec. 126. Substance abuse counselor education demonstration project.

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

‘‘Sec. 128. Authorization of appropriations.

‘‘TITLE II—HEALTH SERVICES

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

‘‘Sec. 202. Catastrophic Health Emergency Fund.

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

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

‘‘Sec. 205. Shared services.

‘‘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.
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‘‘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 demonstration 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. Authorization for 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. Safe water and sanitary waste disposal facilities.

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

‘‘Sec. 304. Soboba sanitation facilities.

‘‘Sec. 305. Expenditure of nonservice funds for renovation.

‘‘Sec. 306. Funding for the construction, expansion, and modernization of

small ambulatory care facilities.

‘‘Sec. 307. Indian health care delivery demonstration project.

‘‘Sec. 308. Land transfer.

‘‘Sec. 309. Leases.

‘‘Sec. 310. Loans, loan guarantees and loan repayment.

‘‘Sec. 311. Tribal leasing.

‘‘Sec. 312. Indian Health Service/tribal facilities joint venture program.

‘‘Sec. 313. Location of facilities.

‘‘Sec. 314. Maintenance and improvement of health care facilities.

‘‘Sec. 315. Tribal management of federally-owned quarters.

‘‘Sec. 316. Applicability of buy American requirement.

‘‘Sec. 317. Other funding for facilities.

‘‘Sec. 318. Authorization of appropriations.

‘‘TITLE IV—ACCESS TO HEALTH SERVICES

‘‘Sec. 401. Treatment of payments under medicare program.

‘‘Sec. 402. Treatment of payments under medicaid program.

‘‘Sec. 403. Report.

‘‘Sec. 404. Grants to and funding agreements with the service, Indian

tribes or tribal organizations, and urban Indian organizations.

‘‘Sec. 405. Direct billing and reimbursement of medicare, medicaid, and

other third party payors.

‘‘Sec. 406. Reimbursement from certain third parties of costs of health

services.

‘‘Sec. 407. Crediting of reimbursements.

‘‘Sec. 408. Purchasing health care coverage.

‘‘Sec. 409. Indian Health Service, Department of Veteran’s Affairs, and

other Federal agency health facilities and services sharing.
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‘‘Sec. 410. Payor of last resort.

‘‘Sec. 411. Right to recover from Federal health care programs.

‘‘Sec. 412. Tuba City demonstration project.

‘‘Sec. 413. Access to Federal insurance.

‘‘Sec. 414. Consultation and rulemaking.

‘‘Sec. 415. Limitations on charges.

‘‘Sec. 416. Limitation on Secretary’s waiver authority.

‘‘Sec. 417. Waiver of medicare and medicaid sanctions.

‘‘Sec. 418. Meaning of ‘remuneration’ for purposes of safe harbor provisions; antitrust immunity.

‘‘Sec. 419. Co-insurance, co-payments, deductibles and premiums.

‘‘Sec. 420. Inclusion of income and resources for purposes of medically

needy medicaid eligibility.

‘‘Sec. 421. Estate recovery provisions.

‘‘Sec. 422. Medical child support.

‘‘Sec. 423. Provisions relating to managed care.

‘‘Sec. 424. Navajo Nation medicaid agency.

‘‘Sec. 425. Indian advisory committees.

‘‘Sec. 426. Authorization of appropriations.

‘‘TITLE V—HEALTH SERVICES FOR URBAN INDIANS

‘‘Sec. 501. Purpose.

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

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

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

care needs.

‘‘Sec. 505. Evaluations; renewals.

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

‘‘Sec. 507. Reports and records.

‘‘Sec. 508. Limitation on contract authority.

‘‘Sec. 509. Facilities.

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

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

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

‘‘Sec. 513. Urban NIAAA transferred programs.

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

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

‘‘Sec. 516. Urban youth treatment center demonstration.

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

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

‘‘Sec. 519. Community health representatives.

‘‘Sec. 520. Regulations.

‘‘Sec. 521. 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.
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‘‘Sec. 702. Memorandum 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 assessment.

‘‘Sec. 709. Training and community education.

‘‘Sec. 710. Behavioral health program.

‘‘Sec. 711. Fetal alcohol disorder funding.

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

‘‘Sec. 713. Behavioral mental health research.

‘‘Sec. 714. Definitions.

‘‘Sec. 715. Authorization of appropriations.

‘‘TITLE VIII—MISCELLANEOUS

‘‘Sec. 801. Reports.

‘‘Sec. 802. Regulations.

‘‘Sec. 803. Plan of implementation.

‘‘Sec. 804. Availability of funds.

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

Service.

‘‘Sec. 806. Eligibility of California Indians.

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

‘‘Sec. 808. Reallocation of base resources.

‘‘Sec. 809. Results of demonstration projects.

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

‘‘Sec. 811. Moratorium.

‘‘Sec. 812. Tribal employment.

‘‘Sec. 813. Prime vendor.

‘‘Sec. 814. National Bi-Partisan Commission on Indian Health Care Entitlement.

‘‘Sec. 815. Appropriations; availability.

‘‘Sec. 816. Authorization of appropriations.

1 ‘‘SEC. 2. FINDINGS.

2 ‘‘Congress makes the following findings:

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

4 funding of tribal and urban Indian health programs

5 to maintain and improve the health of the Indians

6 are consonant with and required by the Federal Gov7 ernment’s historical and unique legal relationship

8 with the American Indian people, as reflected in the
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1 Constitution, treaties, Federal laws, and the course

2 of dealings of the United States with Indian tribes,

3 and the United States’ resulting government to gov4 ernment and trust responsibility and obligations to

5 the American Indian people.

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

7 and colonization through the 20th century, the poli8 cies and practices of the United States caused or

9 contributed to the severe health conditions of Indi10 ans.

11 ‘‘(3) Indian tribes have, through the cession of

12 over 400,000,000 acres of land to the United States

13 in exchange for promises, often reflected in treaties,

14 of health care secured a de facto contract that enti15 tles Indians to health care in perpetuity, based on

16 the moral, legal, and historic obligation of the

17 United States.

18 ‘‘(4) The population growth of the Indian peo19 ple that began in the later part of the 20th century

20 increases the need for Federal health care services.

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

22 is to provide the quantity and quality of health serv23 ices which will permit the health status of Indians,

24 regardless of where they live, to be raised to the

25 highest possible level, a level that is not less than
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1 that of the general population, and to provide for the

2 maximum participation of Indian tribes, tribal orga3 nizations, and urban Indian organizations in the

4 planning, delivery, and management of those serv5 ices.

6 ‘‘(6) Federal health services to Indians have re7 sulted in a reduction in the prevalence and incidence

8 of illnesses among, and unnecessary and premature

9 deaths of, Indians.

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

11 needs of the American Indian people remain alarm12 ingly severe, and even continue to increase, and the

13 health status of the Indians is far below the health

14 status of the general population of the United

15 States.

16 ‘‘(8) The disparity in health status that is to be

17 addressed is formidable. In death rates for example,

18 Indian people suffer a death rate for diabetes

19 mellitus that is 249 percent higher than the death

20 rate for all races in the United States, a pneumonia

21 and influenza death rate that is 71 percent higher,

22 a tuberculosis death rate that is 533 percent higher,

23 and a death rate from alcoholism that is 627 percent

24 higher.
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1 ‘‘SEC. 3. DECLARATION OF HEALTH OBJECTIVES.

2 ‘‘Congress hereby declares that it is the policy of the

3 United States, in fulfillment of its special trust respon4 sibilities and legal obligations to the American Indian

5 people—

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

7 for Indians and to provide all resources necessary to

8 effect that policy;

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

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

11 contained within the Healthy People 2010, or any

12 successor standards thereto;

13 ‘‘(3) in order to raise the health status of In14 dian people to at least the levels set forth in the

15 goals contained within the Healthy People 2010, or

16 any successor standards thereto, to permit Indian

17 tribes and tribal organizations to set their own

18 health care priorities and establish goals that reflect

19 their unmet needs;

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

21 the health professions and allied and associated

22 health professions awarded to Indians so that the

23 proportion of Indian health professionals in each ge24 ographic service area is raised to at least the level

25 of that of the general population;
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1 ‘‘(5) to require meaningful, active consultation

2 with Indian tribes, Indian organizations, and urban

3 Indian organizations to implement this Act and the

4 national policy of Indian self-determination; and

5 ‘‘(6) that funds for health care programs and

6 facilities operated by tribes and tribal organizations

7 be provided in amounts that are not less than the

8 funds that are provided to programs and facilities

9 operated directly by the Service.

10 ‘‘SEC. 4. DEFINITIONS.

11 ‘‘In this Act:

12 ‘‘(1) ACCREDITED AND ACCESSIBLE.—The term

13 ‘accredited and accessible’, with respect to an entity,

14 means a community college or other appropriate en15 tity that is on or near a reservation and accredited

16 by a national or regional organization with accredit17 ing authority.

18 ‘‘(2) AREA OFFICE.—The term ‘area office’

19 means an administrative entity including a program

20 office, within the Indian Health Service through

21 which services and funds are provided to the service

22 units within a defined geographic area.

23 ‘‘(3) ASSISTANT SECRETARY.—The term ‘As24 sistant Secretary’ means the Assistant Secretary of

25 the Indian Health as established under section 601.
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1 ‘‘(4) CONTRACT HEALTH SERVICE.—The term

2 ‘contract health service’ means a health service that

3 is provided at the expense of the Service, Indian

4 tribe, or tribal organization by a public or private

5 medical provider or hospital, other than a service

6 funded under the Indian Self-Determination and

7 Education Assistance Act or under this Act.

8 ‘‘(5) DEPARTMENT.—The term ‘Department’,

9 unless specifically provided otherwise, means the De10 partment of Health and Human Services.

11 ‘‘(6) FUND.—The terms ‘fund’ or ‘funding’

12 mean the transfer of monies from the Department

13 to any eligible entity or individual under this Act by

14 any legal means, including funding agreements, con15 tracts, memoranda of understanding, Buy Indian

16 Act contracts, or otherwise.

17 ‘‘(7) FUNDING AGREEMENT.—The term ‘fund18 ing agreement’ means any agreement to transfer

19 funds for the planning, conduct, and administration

20 of programs, functions, services and activities to

21 tribes and tribal organizations from the Secretary

22 under the authority of the Indian Self-Determination

23 and Education Assistance Act.

24 ‘‘(8) HEALTH PROFESSION.—The term ‘health

25 profession’ means allopathic medicine, family medi-
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1 cine, internal medicine, pediatrics, geriatric medi2 cine, obstetrics and gynecology, podiatric medicine,

3 nursing, public health nursing, dentistry, psychiatry,

4 osteopathy, optometry, pharmacy, psychology, public

5 health, social work, marriage and family therapy,

6 chiropractic medicine, environmental health and en7 gineering, and allied health professions, or any other

8 health profession.

9 ‘‘(9) HEALTH PROMOTION; DISEASE PREVEN10 TION.—The terms ‘health promotion’ and ‘disease

11 prevention’ shall have the meanings given such

12 terms in paragraphs (1) and (2) of section 203(c).

13 ‘‘(10) INDIAN.—The term ‘Indian’ and ‘Indi14 ans’ shall have meanings given such terms for pur15 poses of the Indian Self-Determination and Edu16 cation Assistance Act.

17 ‘‘(11) INDIAN HEALTH PROGRAM.—The term

18 ‘Indian health program’ shall have the meaning

19 given such term in section 110(a)(2)(A).

20 ‘‘(12) INDIAN TRIBE.—The term ‘Indian tribe’

21 shall have the meaning given such term in section

22 4(e) of the Indian Self Determination and Education

23 Assistance Act.

24 ‘‘(13) RESERVATION.—The term ‘reservation’

25 means any federally recognized Indian tribe’s res-
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1 ervation, Pueblo or colony, including former reserva2 tions in Oklahoma, Alaska Native Regions estab3 lished pursuant to the Alaska Native Claims Settle4 ment Act, and Indian allotments.

5 ‘‘(14) SECRETARY.—The term ‘Secretary’, un6 less specifically provided otherwise, means the Sec7 retary of Health and Human Services.

8 ‘‘(15) SERVICE.—The term ‘Service’ means the

9 Indian Health Service.

10 ‘‘(16) SERVICE AREA.—The term ‘service area’

11 means the geographical area served by each area of12 fice.

13 ‘‘(17) SERVICE UNIT.—The term ‘service unit’

14 means—

15 ‘‘(A) an administrative entity within the

16 Indian Health Service; or

17 ‘‘(B) a tribe or tribal organization operat18 ing health care programs or facilities with funds

19 from the Service under the Indian Self-Deter20 mination and Education Assistance Act,

21 through which services are provided, directly or

22 by contract, to the eligible Indian population

23 within a defined geographic area.

24 ‘‘(18) TRADITIONAL HEALTH CARE PRAC25 TICES.—The term ‘traditional health care practices’
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1 means the application by Native healing practition2 ers of the Native healing sciences (as opposed or in

3 contradistinction to western healing sciences) which

4 embodies the influences or forces of innate tribal dis5 covery, history, description, explanation and knowl6 edge of the states of wellness and illness and which

7 calls upon these influences or forces, including phys8 ical, mental, and spiritual forces in the promotion,

9 restoration, preservation and maintenance of health,

10 well-being, and life’s harmony.

11 ‘‘(19) TRIBAL ORGANIZATION.—The term ‘trib12 al organization’ shall have the meaning given such

13 term in section 4(l) of the Indian Self Determination

14 and Education Assistance Act.

15 ‘‘(20) TRIBALLY CONTROLLED COMMUNITY

16 COLLEGE.—The term ‘tribally controlled community

17 college’ shall have the meaning given such term in

18 section 126 (g)(2).

19 ‘‘(21) URBAN CENTER.—The term ‘urban cen20 ter’ means any community that has a sufficient

21 urban Indian population with unmet health needs to

22 warrant assistance under title V, as determined by

23 the Secretary.
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1 ‘‘(22) URBAN INDIAN.—The term ‘urban In2 dian’ means any individual who resides in an urban

3 center and who—

4 ‘‘(A) for purposes of title V and regardless

5 of whether such individual lives on or near a

6 reservation, is a member of a tribe, band or

7 other organized group of Indians, including

8 those tribes, bands or groups terminated since

9 1940 and those tribes, bands or groups that are

10 recognized by the States in which they reside,

11 or who is a descendant in the first or second

12 degree of any such member;

13 ‘‘(B) is an Eskimo or Aleut or other Alas14 kan Native;

15 ‘‘(C) is considered by the Secretary of the

16 Interior to be an Indian for any purpose; or

17 ‘‘(D) is determined to be an Indian under

18 regulations promulgated by the Secretary.

19 ‘‘(23) URBAN INDIAN ORGANIZATION.—The

20 term ‘urban Indian organization’ means a nonprofit

21 corporate body situated in an urban center, governed

22 by an urban Indian controlled board of directors,

23 and providing for the participation of all interested

24 Indian groups and individuals, and which is capable

25 of legally cooperating with other public and private
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1 entities for the purpose of performing the activities

2 described in section 503(a).

3 ‘‘TITLE I—INDIAN HEALTH,

4 HUMAN RESOURCES AND DE5 VELOPMENT

6 ‘‘SEC. 101. PURPOSE.

7 ‘‘The purpose of this title is to increase, to the maxi8 mum extent feasible, the number of Indians entering the

9 health professions and providing health services, and to

10 assure an optimum supply of health professionals to the

11 Service, Indian tribes, tribal organizations, and urban In12 dian organizations involved in the provision of health serv13 ices to Indian people.

14 ‘‘SEC. 102. GENERAL REQUIREMENTS.

15 ‘‘(a) SERVICE AREA PRIORITIES.—Unless specifically

16 provided otherwise, amounts appropriated for each fiscal

17 year to carry out each program authorized under this title

18 shall be allocated by the Secretary to the area office of

19 each service area using a formula—

20 ‘‘(1) to be developed in consultation with Indian

21 tribes, tribal organizations and urban Indian organi22 zations;

23 ‘‘(2) that takes into account the human re24 source and development needs in each such service

25 area; and
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1 ‘‘(3) that weighs the allocation of amounts ap2 propriated in favor of those service areas where the

3 health status of Indians within the area, as meas4 ured by life expectancy based upon the most recent

5 data available, is significantly lower than the average

6 health status for Indians in all service areas, except

7 that amounts allocated to each such area using such

8 a weighted allocation formula shall not be less than

9 the amounts allocated to each such area in the pre10 vious fiscal year.

11 ‘‘(b) CONSULTATION.—Each area office receiving

12 funds under this title shall actively and continuously con13 sult with representatives of Indian tribes, tribal organiza14 tions, and urban Indian organizations to prioritize the uti15 lization of funds provided under this title within the serv16 ice area.

17 ‘‘(c) REALLOCATION.—Unless specifically prohibited,

18 an area office may reallocate funds provided to the office

19 under this title among the programs authorized by this

20 title, except that scholarship and loan repayment funds

21 shall not be used for administrative functions or expenses.

22 ‘‘(d) LIMITATION.—This section shall not apply with

23 respect to individual recipients of scholarships, loans or

24 other funds provided under this title (as this title existed

25 1 day prior to the date of enactment of this Act) until
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1 such time as the individual completes the course of study

2 that is supported through the use of such funds.

3 ‘‘SEC. 103. HEALTH PROFESSIONS RECRUITMENT PROGRAM

4 FOR INDIANS.

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

6 the Service, shall make funds available through the area

7 office to public or nonprofit private health entities, or In8 dian tribes or tribal organizations to assist such entities

9 in meeting the costs of—

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

11 education or training in the health professions and

12 encouraging and assisting them—

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

14 health professions; or

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

16 any such courses of study, to undertake such

17 postsecondary education or training as may be

18 required to qualify them for enrollment;

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

20 available to Indians enrolled in any course of study

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

22 training necessary to qualify them to enroll in any

23 such course of study; or

24 ‘‘(3) establishing other programs which the area

25 office determines will enhance and facilitate the en-
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1 rollment of Indians in, and the subsequent pursuit

2 and completion by them of, courses of study referred

3 to in paragraph (1).

4 ‘‘(b) ADMINISTRATIVE PROVISIONS.—

5 ‘‘(1) APPLICATION.—To be eligible to receive

6 funds under this section an entity described in sub7 section (a) shall submit to the Secretary, through

8 the appropriate area office, and have approved, an

9 application in such form, submitted in such manner,

10 and containing such information as the Secretary

11 shall by regulation prescribe.

12 ‘‘(2) PREFERENCE.—In awarding funds under

13 this section, the area office shall give a preference

14 to applications submitted by Indian tribes, tribal or15 ganizations, or urban Indian organizations.

16 ‘‘(3) AMOUNT.—The amount of funds to be

17 provided to an eligible entity under this section shall

18 be determined by the area office. Payments under

19 this section may be made in advance or by way of

20 reimbursement, and at such intervals and on such

21 conditions as provided for in regulations promul22 gated pursuant to this Act.

23 ‘‘(4) TERMS.—A funding commitment under

24 this section shall, to the extent not otherwise prohib-
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1 ited by law, be for a term of 3 years, as provided

2 for in regulations promulgated pursuant to this Act.

3 ‘‘(c) DEFINITION.—For purposes of this section and

4 sections 104 and 105, the terms ‘Indian’ and ‘Indians’

5 shall, in addition to the definition provided for in section

6 4, mean any individual who—

7 ‘‘(1) irrespective of whether such individual

8 lives on or near a reservation, is a member of a

9 tribe, band, or other organized group of Indians, in10 cluding those tribes, bands, or groups terminated

11 since 1940;

12 ‘‘(2) is an Eskimo or Aleut or other Alaska Na13 tive;

14 ‘‘(3) is considered by the Secretary of the Inte15 rior to be an Indian for any purpose; or

16 ‘‘(4) is determined to be an Indian under regu17 lations promulgated by the Secretary.

18 ‘‘SEC. 104. HEALTH PROFESSIONS PREPARATORY SCHOL19 ARSHIP PROGRAM FOR INDIANS.

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

21 the Service, shall provide scholarships through the area

22 offices to Indians who—

23 ‘‘(1) have successfully completed their high

24 school education or high school equivalency; and
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1 ‘‘(2) have demonstrated the capability to suc2 cessfully complete courses of study in the health pro3 fessions.

4 ‘‘(b) PURPOSE.—Scholarships provided under this

5 section shall be for the following purposes:

6 ‘‘(1) Compensatory preprofessional education of

7 any recipient. Such scholarship shall not exceed 2

8 years on a full-time basis (or the part-time equiva9 lent thereof, as determined by the area office pursu10 ant to regulations promulgated under this Act).

11 ‘‘(2) Pregraduate education of any recipient

12 leading to a baccalaureate degree in an approved

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

14 health profession, such scholarship not to exceed 4

15 years (or the part-time equivalent thereof, as deter16 mined by the area office pursuant to regulations

17 promulgated under this Act) except that an exten18 sion of up to 2 years may be approved by the Sec19 retary.

20 ‘‘(c) USE OF SCHOLARSHIP.—Scholarships made

21 under this section may be used to cover costs of tuition,

22 books, transportation, board, and other necessary related

23 expenses of a recipient while attending school.
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1 ‘‘(d) LIMITATIONS.—Scholarship assistance to an eli2 gible applicant under this section shall not be denied solely

3 on the basis of—

4 ‘‘(1) the applicant’s scholastic achievement if

5 such applicant has been admitted to, or maintained

6 good standing at, an accredited institution; or

7 ‘‘(2) the applicant’s eligibility for assistance or

8 benefits under any other Federal program.

9 ‘‘SEC. 105. INDIAN HEALTH PROFESSIONS SCHOLARSHIPS.

10 ‘‘(a) SCHOLARSHIPS.—

11 ‘‘(1) IN GENERAL.—In order to meet the needs

12 of Indians, Indian tribes, tribal organizations, and

13 urban Indian organizations for health professionals,

14 the Secretary, acting through the Service and in ac15 cordance with this section, shall provide scholarships

16 through the area offices to Indians who are enrolled

17 full or part time in accredited schools and pursuing

18 courses of study in the health professions. Such

19 scholarships shall be designated Indian Health

20 Scholarships and shall, except as provided in sub21 section (b), be made in accordance with section

22 338A of the Public Health Service Act (42 U.S.C.

23 254l).

24 ‘‘(2) NO DELEGATION.—The Director of the

25 Service shall administer this section and shall not
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23

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1 delegate any administrative functions under a fund2 ing agreement pursuant to the Indian Self-Deter3 mination and Education Assistance Act.

4 ‘‘(b) ELIGIBILITY.—

5 ‘‘(1) ENROLLMENT.—An Indian shall be eligible

6 for a scholarship under subsection (a) in any year in

7 which such individual is enrolled full or part time

8 in a course of study referred to in subsection (a)(1).

9 ‘‘(2) SERVICE OBLIGATION.—

10 ‘‘(A) PUBLIC HEALTH SERVICE ACT.—The

11 active duty service obligation under a written

12 contract with the Secretary under section 338A

13 of the Public Health Service Act (42 U.S.C.

14 254l) that an Indian has entered into under

15 that section shall, if that individual is a recipi16 ent of an Indian Health Scholarship, be met in

17 full-time practice on an equivalent year for year

18 obligation, by service—

19 ‘‘(i) in the Indian Health Service;

20 ‘‘(ii) in a program conducted under a

21 funding agreement entered into under the

22 Indian Self-Determination and Education

23 Assistance Act;

24 ‘‘(iii) in a program assisted under title

25 V; or
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1 ‘‘(iv) in the private practice of the ap2 plicable profession if, as determined by the

3 Secretary, in accordance with guidelines

4 promulgated by the Secretary, such prac5 tice is situated in a physician or other

6 health professional shortage area and ad7 dresses the health care needs of a substan8 tial number of Indians.

9 ‘‘(B) DEFERRING ACTIVE SERVICE.—At

10 the request of any Indian who has entered into

11 a contract referred to in subparagraph (A) and

12 who receives a degree in medicine (including os13 teopathic or allopathic medicine), dentistry, op14 tometry, podiatry, or pharmacy, the Secretary

15 shall defer the active duty service obligation of

16 that individual under that contract, in order

17 that such individual may complete any intern18 ship, residency, or other advanced clinical train19 ing that is required for the practice of that

20 health profession, for an appropriate period (in

21 years, as determined by the Secretary), subject

22 to the following conditions:

23 ‘‘(i) No period of internship, resi24 dency, or other advanced clinical training

25 shall be counted as satisfying any period of
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25

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1 obligated service that is required under

2 this section.

3 ‘‘(ii) The active duty service obligation

4 of that individual shall commence not later

5 than 90 days after the completion of that

6 advanced clinical training (or by a date

7 specified by the Secretary).

8 ‘‘(iii) The active duty service obliga9 tion will be served in the health profession

10 of that individual, in a manner consistent

11 with clauses (i) through (iv) of subpara12 graph (A).

13 ‘‘(C) NEW SCHOLARSHIP RECIPIENTS.—A

14 recipient of an Indian Health Scholarship that

15 is awarded after December 31, 2003, shall meet

16 the active duty service obligation under such

17 scholarship by providing service within the serv18 ice area from which the scholarship was award19 ed. In placing the recipient for active duty the

20 area office shall give priority to the program

21 that funded the recipient, except that in cases

22 of special circumstances, a recipient may be

23 placed in a different service area pursuant to an

24 agreement between the areas or programs in25 volved.
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1 ‘‘(D) PRIORITY IN ASSIGNMENT.—Subject

2 to subparagraph (C), the area office, in making

3 assignments of Indian Health Scholarship re4 cipients required to meet the active duty service

5 obligation described in subparagraph (A), shall

6 give priority to assigning individuals to service

7 in those programs specified in subparagraph

8 (A) that have a need for health professionals to

9 provide health care services as a result of indi10 viduals having breached contracts entered into

11 under this section.

12 ‘‘(3) PART-TIME ENROLLMENT.—In the case of

13 an Indian receiving a scholarship under this section

14 who is enrolled part time in an approved course of

15 study—

16 ‘‘(A) such scholarship shall be for a period

17 of years not to exceed the part-time equivalent

18 of 4 years, as determined by the appropriate

19 area office;

20 ‘‘(B) the period of obligated service de21 scribed in paragraph (2)(A) shall be equal to

22 the greater of—

23 ‘‘(i) the part-time equivalent of 1 year

24 for each year for which the individual was
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1 provided a scholarship (as determined by

2 the area office); or

3 ‘‘(ii) two years; and

4 ‘‘(C) the amount of the monthly stipend

5 specified in section 338A(g)(1)(B) of the Public

6 Health Service Act (42 U.S.C. 254l(g)(1)(B))

7 shall be reduced pro rata (as determined by the

8 Secretary) based on the number of hours such

9 student is enrolled.

10 ‘‘(4) BREACH OF CONTRACT.—

11 ‘‘(A) IN GENERAL.—An Indian who has,

12 on or after the date of the enactment of this

13 paragraph, entered into a written contract with

14 the area office pursuant to a scholarship under

15 this section and who—

16 ‘‘(i) fails to maintain an acceptable

17 level of academic standing in the edu18 cational institution in which he or she is

19 enrolled (such level determined by the edu20 cational institution under regulations of

21 the Secretary);

22 ‘‘(ii) is dismissed from such edu23 cational institution for disciplinary reasons;

24 ‘‘(iii) voluntarily terminates the train25 ing in such an educational institution for
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28

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1 which he or she is provided a scholarship

2 under such contract before the completion

3 of such training; or

4 ‘‘(iv) fails to accept payment, or in5 structs the educational institution in which

6 he or she is enrolled not to accept pay7 ment, in whole or in part, of a scholarship

8 under such contract;

9 in lieu of any service obligation arising under

10 such contract, shall be liable to the United

11 States for the amount which has been paid to

12 him or her, or on his or her behalf, under the

13 contract.

14 ‘‘(B) FAILURE TO PERFORM SERVICE OB15 LIGATION.—If for any reason not specified in

16 subparagraph (A) an individual breaches his or

17 her written contract by failing either to begin

18 such individual’s service obligation under this

19 section or to complete such service obligation,

20 the United States shall be entitled to recover

21 from the individual an amount determined in

22 accordance with the formula specified in sub23 section (l) of section 110 in the manner pro24 vided for in such subsection.
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1 ‘‘(C) DEATH.—Upon the death of an indi2 vidual who receives an Indian Health Scholar3 ship, any obligation of that individual for serv4 ice or payment that relates to that scholarship

5 shall be canceled.

6 ‘‘(D) WAIVER.—The Secretary shall pro7 vide for the partial or total waiver or suspen8 sion of any obligation of service or payment of

9 a recipient of an Indian Health Scholarship if

10 the Secretary, in consultation with the appro11 priate area office, Indian tribe, tribal organiza12 tion, and urban Indian organization, determines

13 that—

14 ‘‘(i) it is not possible for the recipient

15 to meet that obligation or make that pay16 ment;

17 ‘‘(ii) requiring that recipient to meet

18 that obligation or make that payment

19 would result in extreme hardship to the re20 cipient; or

21 ‘‘(iii) the enforcement of the require22 ment to meet the obligation or make the

23 payment would be unconscionable.

24 ‘‘(E) HARDSHIP OR GOOD CAUSE.—Not25 withstanding any other provision of law, in any
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1 case of extreme hardship or for other good

2 cause shown, the Secretary may waive, in whole

3 or in part, the right of the United States to re4 cover funds made available under this section.

5 ‘‘(F) BANKRUPTCY.—Notwithstanding any

6 other provision of law, with respect to a recipi7 ent of an Indian Health Scholarship, no obliga8 tion for payment may be released by a dis9 charge in bankruptcy under title 11, United

10 States Code, unless that discharge is granted

11 after the expiration of the 5-year period begin12 ning on the initial date on which that payment

13 is due, and only if the bankruptcy court finds

14 that the nondischarge of the obligation would

15 be unconscionable.

16 ‘‘(c) FUNDING FOR TRIBES FOR SCHOLARSHIP PRO17 GRAMS.—

18 ‘‘(1) PROVISION OF FUNDS.—

19 ‘‘(A) IN GENERAL.—The Secretary shall

20 make funds available, through area offices, to

21 Indian tribes and tribal organizations for the

22 purpose of assisting such tribes and tribal orga23 nizations in educating Indians to serve as

24 health professionals in Indian communities.
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1 ‘‘(B) LIMITATION.—The Secretary shall

2 ensure that amounts available for grants under

3 subparagraph (A) for any fiscal year shall not

4 exceed an amount equal to 5 percent of the

5 amount available for each fiscal year for Indian

6 Health Scholarships under this section.

7 ‘‘(C) APPLICATION.—An application for

8 funds under subparagraph (A) shall be in such

9 form and contain such agreements, assurances

10 and information as consistent with this section.

11 ‘‘(2) REQUIREMENTS.—

12 ‘‘(A) IN GENERAL.—An Indian tribe or

13 tribal organization receiving funds under para14 graph (1) shall agree to provide scholarships to

15 Indians in accordance with the requirements of

16 this subsection.

17 ‘‘(B) MATCHING REQUIREMENT.—With re18 spect to the costs of providing any scholarship

19 pursuant to subparagraph (A)—

20 ‘‘(i) 80 percent of the costs of the

21 scholarship shall be paid from the funds

22 provided under paragraph (1) to the In23 dian tribe or tribal organization; and

24 ‘‘(ii) 20 percent of such costs shall be

25 paid from any other source of funds.
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32

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1 ‘‘(3) ELIGIBILITY.—An Indian tribe or tribal

2 organization shall provide scholarships under this

3 subsection only to Indians who are enrolled or ac4 cepted for enrollment in a course of study (approved

5 by the Secretary) in one of the health professions

6 described in this Act.

7 ‘‘(4) CONTRACTS.—In providing scholarships

8 under paragraph (1), the Secretary and the Indian

9 tribe or tribal organization shall enter into a written

10 contract with each recipient of such scholarship.

11 Such contract shall—

12 ‘‘(A) obligate such recipient to provide

13 service in an Indian health program (as defined

14 in section 110(a)(2)(A)) in the same service

15 area where the Indian tribe or tribal organiza16 tion providing the scholarship is located, for—

17 ‘‘(i) a number of years equal to the

18 number of years for which the scholarship

19 is provided (or the part-time equivalent

20 thereof, as determined by the Secretary),

21 or for a period of 2 years, whichever period

22 is greater; or

23 ‘‘(ii) such greater period of time as

24 the recipient and the Indian tribe or tribal

25 organization may agree;
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33

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1 ‘‘(B) provide that the scholarship—

2 ‘‘(i) may only be expended for—

3 ‘‘(I) tuition expenses, other rea4 sonable educational expenses, and rea5 sonable living expenses incurred in at6 tendance at the educational institu7 tion; and

8 ‘‘(II) payment to the recipient of

9 a monthly stipend of not more than

10 the amount authorized by section

11 338(g)(1)(B) of the Public Health

12 Service Act (42 U.S.C.

13 254m(g)(1)(B), such amount to be re14 duced pro rata (as determined by the

15 Secretary) based on the number of

16 hours such student is enrolled, and

17 may not exceed, for any year of at18 tendance which the scholarship is pro19 vided, the total amount required for

20 the year for the purposes authorized

21 in this clause; and

22 ‘‘(ii) may not exceed, for any year of

23 attendance which the scholarship is pro24 vided, the total amount required for the
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34

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1 year for the purposes authorized in clause

2 (i);

3 ‘‘(C) require the recipient of such scholar4 ship to maintain an acceptable level of academic

5 standing as determined by the educational insti6 tution in accordance with regulations issued

7 pursuant to this Act; and

8 ‘‘(D) require the recipient of such scholar9 ship to meet the educational and licensure re10 quirements appropriate to the health profession

11 involved.

12 ‘‘(5) BREACH OF CONTRACT.—

13 ‘‘(A) IN GENERAL.—An individual who has

14 entered into a written contract with the Sec15 retary and an Indian tribe or tribal organiza16 tion under this subsection and who—

17 ‘‘(i) fails to maintain an acceptable

18 level of academic standing in the education

19 institution in which he or she is enrolled

20 (such level determined by the educational

21 institution under regulations of the Sec22 retary);

23 ‘‘(ii) is dismissed from such education

24 for disciplinary reasons;
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35

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1 ‘‘(iii) voluntarily terminates the train2 ing in such an educational institution for

3 which he or she has been provided a schol4 arship under such contract before the com5 pletion of such training; or

6 ‘‘(iv) fails to accept payment, or in7 structs the educational institution in which

8 he or she is enrolled not to accept pay9 ment, in whole or in part, of a scholarship

10 under such contract, in lieu of any service

11 obligation arising under such contract;

12 shall be liable to the United States for the Fed13 eral share of the amount which has been paid

14 to him or her, or on his or her behalf, under

15 the contract.

16 ‘‘(B) FAILURE TO PERFORM SERVICE OB17 LIGATION.—If for any reason not specified in

18 subparagraph (A), an individual breaches his or

19 her written contract by failing to either begin

20 such individual’s service obligation required

21 under such contract or to complete such service

22 obligation, the United States shall be entitled to

23 recover from the individual an amount deter24 mined in accordance with the formula specified
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36

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1 in subsection (l) of section 110 in the manner

2 provided for in such subsection.

3 ‘‘(C) INFORMATION.—The Secretary may

4 carry out this subsection on the basis of infor5 mation received from Indian tribes or tribal or6 ganizations involved, or on the basis of informa7 tion collected through such other means as the

8 Secretary deems appropriate.

9 ‘‘(6) REQUIRED AGREEMENTS.—The recipient

10 of a scholarship under paragraph (1) shall agree, in

11 providing health care pursuant to the requirements

12 of this subsection—

13 ‘‘(A) not to discriminate against an indi14 vidual seeking care on the basis of the ability

15 of the individual to pay for such care or on the

16 basis that payment for such care will be made

17 pursuant to the program established in title

18 XVIII of the Social Security Act or pursuant to

19 the programs established in title XIX of such

20 Act; and

21 ‘‘(B) to accept assignment under section

22 1842(b)(3)(B)(ii) of the Social Security Act for

23 all services for which payment may be made

24 under part B of title XVIII of such Act, and to

25 enter into an appropriate agreement with the
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37

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1 State agency that administers the State plan

2 for medical assistance under title XIX of such

3 Act to provide service to individuals entitled to

4 medical assistance under the plan.

5 ‘‘(7) PAYMENTS.—The Secretary, through the

6 area office, shall make payments under this sub7 section to an Indian tribe or tribal organization for

8 any fiscal year subsequent to the first fiscal year of

9 such payments unless the Secretary or area office

10 determines that, for the immediately preceding fiscal

11 year, the Indian tribe or tribal organization has not

12 complied with the requirements of this subsection.

13 ‘‘SEC. 106. AMERICAN INDIANS INTO PSYCHOLOGY PRO14 GRAM.

15 ‘‘(a) IN GENERAL.—Notwithstanding section 102,

16 the Secretary shall provide funds to at least 3 colleges and

17 universities for the purpose of developing and maintaining

18 American Indian psychology career recruitment programs

19 as a means of encouraging Indians to enter the mental

20 health field. These programs shall be located at various

21 colleges and universities throughout the country to maxi22 mize their availability to Indian students and new pro23 grams shall be established in different locations from time

24 to time.
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1 ‘‘(b) QUENTIN N. BURDICK AMERICAN INDIANS

2 INTO PSYCHOLOGY PROGRAM.—The Secretary shall pro3 vide funds under subsection (a) to develop and maintain

4 a program at the University of North Dakota to be known

5 as the ‘Quentin N. Burdick American Indians Into Psy6 chology Program’. Such program shall, to the maximum

7 extent feasible, coordinate with the Quentin N. Burdick

8 American Indians Into Nursing Program authorized under

9 section 115, the Quentin N. Burdick Indians into Health

10 Program authorized under section 117, and existing uni11 versity research and communications networks.

12 ‘‘(c) REQUIREMENTS.—

13 ‘‘(1) REGULATIONS.—The Secretary shall pro14 mulgate regulations pursuant to this Act for the

15 competitive awarding of funds under this section.

16 ‘‘(2) PROGRAM.—Applicants for funds under

17 this section shall agree to provide a program which,

18 at a minimum—

19 ‘‘(A) provides outreach and recruitment for

20 health professions to Indian communities in21 cluding elementary, secondary and accredited

22 and accessible community colleges that will be

23 served by the program;

24 ‘‘(B) incorporates a program advisory

25 board comprised of representatives from the
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1 tribes and communities that will be served by

2 the program;

3 ‘‘(C) provides summer enrichment pro4 grams to expose Indian students to the various

5 fields of psychology through research, clinical,

6 and experimental activities;

7 ‘‘(D) provides stipends to undergraduate

8 and graduate students to pursue a career in

9 psychology;

10 ‘‘(E) develops affiliation agreements with

11 tribal community colleges, the Service, univer12 sity affiliated programs, and other appropriate

13 accredited and accessible entities to enhance the

14 education of Indian students;

15 ‘‘(F) utilizes, to the maximum extent fea16 sible, existing university tutoring, counseling

17 and student support services; and

18 ‘‘(G) employs, to the maximum extent fea19 sible, qualified Indians in the program.

20 ‘‘(d) ACTIVE DUTY OBLIGATION.—The active duty

21 service obligation prescribed under section 338C of the

22 Public Health Service Act (42 U.S.C. 254m) shall be met

23 by each graduate who receives a stipend described in sub24 section (c)(2)(C) that is funded under this section. Such

25 obligation shall be met by service—
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1 ‘‘(1) in the Indian Health Service;

2 ‘‘(2) in a program conducted under a funding

3 agreement contract entered into under the Indian

4 Self-Determination and Education Assistance Act;

5 ‘‘(3) in a program assisted under title V; or

6 ‘‘(4) in the private practice of psychology if, as

7 determined by the Secretary, in accordance with

8 guidelines promulgated by the Secretary, such prac9 tice is situated in a physician or other health profes10 sional shortage area and addresses the health care

11 needs of a substantial number of Indians.

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

13 ‘‘(a) IN GENERAL.—Any individual who receives a

14 scholarship pursuant to section 105 shall be entitled to

15 employment in the Service, or may be employed by a pro16 gram of an Indian tribe, tribal organization, or urban In17 dian organization, or other agency of the Department as

18 may be appropriate and available, during any nonacademic

19 period of the year. Periods of employment pursuant to this

20 subsection shall not be counted in determining the fulfill21 ment of the service obligation incurred as a condition of

22 the scholarship.

23 ‘‘(b) ENROLLEES IN COURSE OF STUDY.—Any indi24 vidual who is enrolled in a course of study in the health

25 professions may be employed by the Service or by an In-
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1 dian tribe, tribal organization, or urban Indian organiza2 tion, during any nonacademic period of the year. Any such

3 employment shall not exceed 120 days during any calendar

4 year.

5 ‘‘(c) HIGH SCHOOL PROGRAMS.—Any individual who

6 is in a high school program authorized under section

7 103(a) may be employed by the Service, or by a Indian

8 tribe, tribal organization, or urban Indian organization,

9 during any nonacademic period of the year. Any such em10 ployment shall not exceed 120 days during any calendar

11 year.

12 ‘‘(d) ADMINISTRATIVE PROVISIONS.—Any employ13 ment pursuant to this section shall be made without re14 gard to any competitive personnel system or agency per15 sonnel limitation and to a position which will enable the

16 individual so employed to receive practical experience in

17 the health profession in which he or she is engaged in

18 study. Any individual so employed shall receive payment

19 for his or her services comparable to the salary he or she

20 would receive if he or she were employed in the competitive

21 system. Any individual so employed shall not be counted

22 against any employment ceiling affecting the Service or

23 the Department.
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1 ‘‘SEC. 108. CONTINUING EDUCATION ALLOWANCES.

2 ‘‘In order to encourage health professionals, including

3 for purposes of this section, community health representa4 tives and emergency medical technicians, to join or con5 tinue in the Service or in any program of an Indian tribe,

6 tribal organization, or urban Indian organization and to

7 provide their services in the rural and remote areas where

8 a significant portion of the Indian people reside, the Sec9 retary, acting through the area offices, may provide allow10 ances to health professionals employed in the Service or

11 such a program to enable such professionals to take leave

12 of their duty stations for a period of time each year (as

13 prescribed by regulations of the Secretary) for professional

14 consultation and refresher training courses.

15 ‘‘SEC. 109. COMMUNITY HEALTH REPRESENTATIVE PRO16 GRAM.

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

18 of November 2, 1921 (25 U.S.C. 13) (commonly known

19 as the Snyder Act), the Secretary shall maintain a Com20 munity Health Representative Program under which the

21 Service, Indian tribes and tribal organizations—

22 ‘‘(1) provide for the training of Indians as com23 munity health representatives; and

24 ‘‘(2) use such community health representatives

25 in the provision of health care, health promotion,
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1 and disease prevention services to Indian commu2 nities.

3 ‘‘(b) ACTIVITIES.—The Secretary, acting through the

4 Community Health Representative Program, shall—

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

6 community health representatives to ensure that the

7 community health representatives provide quality

8 health care, health promotion, and disease preven9 tion services to the Indian communities served by

10 such Program;

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

12 and maintain a curriculum that—

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

14 health care with supervised practical experience

15 in the provision of health care; and

16 ‘‘(B) provides instruction and practical ex17 perience in health promotion and disease pre18 vention activities, with appropriate consider19 ation given to lifestyle factors that have an im20 pact on Indian health status, such as alcohol21 ism, family dysfunction, and poverty;

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

23 needs of community health representatives for con24 tinuing education in health care, health promotion,
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1 and disease prevention and maintain programs that

2 meet the needs for such continuing education;

3 ‘‘(4) maintain a system that provides close su4 pervision of community health representatives;

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

6 of community health representatives is reviewed and

7 evaluated; and

8 ‘‘(6) promote traditional health care practices

9 of the Indian tribes served consistent with the Serv10 ice standards for the provision of health care, health

11 promotion, and disease prevention.

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

13 PROGRAM.

14 ‘‘(a) ESTABLISHMENT.—

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

16 through the Service, shall establish a program to be

17 known as the Indian Health Service Loan Repay18 ment Program (referred to in this Act as the ‘Loan

19 Repayment Program’) in order to assure an ade20 quate supply of trained health professionals nec21 essary to maintain accreditation of, and provide

22 health care services to Indians through, Indian

23 health programs.

24 ‘‘(2) DEFINITIONS.—In this section:
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1 ‘‘(A) INDIAN HEALTH PROGRAM.—The

2 term ‘Indian health program’ means any health

3 program or facility funded, in whole or part, by

4 the Service for the benefit of Indians and

5 administered—

6 ‘‘(i) directly by the Service;

7 ‘‘(ii) by any Indian tribe or tribal or

8 Indian organization pursuant to a funding

9 agreement under—

10 ‘‘(I) the Indian Self-Determina11 tion and Educational Assistance Act;

12 or

13 ‘‘(II) section 23 of the Act of

14 April 30, 1908 (25 U.S.C. 47) (com15 monly known as the ‘Buy-Indian

16 Act’); or

17 ‘‘(iii) by an urban Indian organization

18 pursuant to title V.

19 ‘‘(B) STATE.—The term ‘State’ has the

20 same meaning given such term in section

21 331(i)(4) of the Public Health Service Act.

22 ‘‘(b) ELIGIBILITY.—To be eligible to participate in

23 the Loan Repayment Program, an individual must—

24 ‘‘(1)(A) be enrolled—
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1 ‘‘(i) in a course of study or program in an

2 accredited institution, as determined by the

3 Secretary, within any State and be scheduled to

4 complete such course of study in the same year

5 such individual applies to participate in such

6 program; or

7 ‘‘(ii) in an approved graduate training pro8 gram in a health profession; or

9 ‘‘(B) have—

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

11 ‘‘(ii) a license to practice a health profes12 sion in a State;

13 ‘‘(2)(A) be eligible for, or hold, an appointment

14 as a commissioned officer in the Regular or Reserve

15 Corps of the Public Health Service;

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

17 in the Regular or Reserve Corps of the Public

18 Health Service;

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

20 service employment in the Indian Health Service; or

21 ‘‘(D) be employed in an Indian health program

22 without a service obligation; and

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

24 a contract described in subsection (f).

25 ‘‘(c) FORMS.—
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1 ‘‘(1) IN GENERAL.—In disseminating applica2 tion forms and contract forms to individuals desiring

3 to participate in the Loan Repayment Program, the

4 Secretary shall include with such forms a fair sum5 mary of the rights and liabilities of an individual

6 whose application is approved (and whose contract is

7 accepted) by the Secretary, including in the sum8 mary a clear explanation of the damages to which

9 the United States is entitled under subsection (l) in

10 the case of the individual’s breach of the contract.

11 The Secretary shall provide such individuals with

12 sufficient information regarding the advantages and

13 disadvantages of service as a commissioned officer

14 in the Regular or Reserve Corps of the Public

15 Health Service or a civilian employee of the Indian

16 Health Service to enable the individual to make a

17 decision on an informed basis.

18 ‘‘(2) FORMS TO BE UNDERSTANDABLE.—The

19 application form, contract form, and all other infor20 mation furnished by the Secretary under this section

21 shall be written in a manner calculated to be under22 stood by the average individual applying to partici23 pate in the Loan Repayment Program.

24 ‘‘(3) AVAILABILITY.—The Secretary shall make

25 such application forms, contract forms, and other in-
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1 formation available to individuals desiring to partici2 pate in the Loan Repayment Program on a date suf3 ficiently early to ensure that such individuals have

4 adequate time to carefully review and evaluate such

5 forms and information.

6 ‘‘(d) PRIORITY.—

7 ‘‘(1) ANNUAL DETERMINATIONS.—The Sec8 retary, acting through the Service and in accordance

9 with subsection (k), shall annually—

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

11 health program for which there is a need or a

12 vacancy; and

13 ‘‘(B) rank those positions in order of prior14 ity.

15 ‘‘(2) PRIORITY IN APPROVAL.—Notwithstanding

16 the priority determined under paragraph (1), the

17 Secretary, in determining which applications under

18 the Loan Repayment Program to approve (and

19 which contracts to accept), shall—

20 ‘‘(A) give first priority to applications

21 made by individual Indians; and

22 ‘‘(B) after making determinations on all

23 applications submitted by individual Indians as

24 required under subparagraph (A), give priority

25 to—
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1 ‘‘(i) individuals recruited through the

2 efforts an Indian tribe, tribal organization,

3 or urban Indian organization; and

4 ‘‘(ii) other individuals based on the

5 priority rankings under paragraph (1).

6 ‘‘(e) CONTRACTS.—

7 ‘‘(1) IN GENERAL.—An individual becomes a

8 participant in the Loan Repayment Program only

9 upon the Secretary and the individual entering into

10 a written contract described in subsection (f).

11 ‘‘(2) NOTICE.—Not later than 21 days after

12 considering an individual for participation in the

13 Loan Repayment Program under paragraph (1), the

14 Secretary shall provide written notice to the individ15 ual of—

16 ‘‘(A) the Secretary’s approving of the indi17 vidual’s participation in the Loan Repayment

18 Program, including extensions resulting in an

19 aggregate period of obligated service in excess

20 of 4 years; or

21 ‘‘(B) the Secretary’s disapproving an indi22 vidual’s participation in such Program.

23 ‘‘(f) WRITTEN CONTRACT.—The written contract re24 ferred to in this section between the Secretary and an indi25 vidual shall contain—
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1 ‘‘(1) an agreement under which—

2 ‘‘(A) subject to paragraph (3), the Sec3 retary agrees—

4 ‘‘(i) to pay loans on behalf of the indi5 vidual in accordance with the provisions of

6 this section; and

7 ‘‘(ii) to accept (subject to the avail8 ability of appropriated funds for carrying

9 out this section) the individual into the

10 Service or place the individual with a tribe,

11 tribal organization, or urban Indian orga12 nization as provided in subparagraph

13 (B)(iii); and

14 ‘‘(B) subject to paragraph (3), the individ15 ual agrees—

16 ‘‘(i) to accept loan payments on behalf

17 of the individual;

18 ‘‘(ii) in the case of an individual de19 scribed in subsection (b)(1)—

20 ‘‘(I) to maintain enrollment in a

21 course of study or training described

22 in subsection (b)(1)(A) until the indi23 vidual completes the course of study

24 or training; and
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1 ‘‘(II) while enrolled in such

2 course of study or training, to main3 tain an acceptable level of academic

4 standing (as determined under regula5 tions of the Secretary by the edu6 cational institution offering such

7 course of study or training);

8 ‘‘(iii) to serve for a time period (re9 ferred to in this section as the ‘period of

10 obligated service’) equal to 2 years or such

11 longer period as the individual may agree

12 to serve in the full-time clinical practice of

13 such individual’s profession in an Indian

14 health program to which the individual

15 may be assigned by the Secretary;

16 ‘‘(2) a provision permitting the Secretary to ex17 tend for such longer additional periods, as the indi18 vidual may agree to, the period of obligated service

19 agreed to by the individual under paragraph

20 (1)(B)(iii);

21 ‘‘(3) a provision that any financial obligation of

22 the United States arising out of a contract entered

23 into under this section and any obligation of the in24 dividual which is conditioned thereon is contingent
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1 upon funds being appropriated for loan repayments

2 under this section;

3 ‘‘(4) a statement of the damages to which the

4 United States is entitled under subsection (l) for the

5 individual’s breach of the contract; and

6 ‘‘(5) such other statements of the rights and li7 abilities of the Secretary and of the individual, not

8 inconsistent with this section.

9 ‘‘(g) LOAN REPAYMENTS.—

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

11 for an individual under a written contract under the

12 Loan Repayment Program shall consist of payment,

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

14 individual of the principal, interest, and related ex15 penses on government and commercial loans received

16 by the individual regarding the undergraduate or

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

18 loans were made for—

19 ‘‘(A) tuition expenses;

20 ‘‘(B) all other reasonable educational ex21 penses, including fees, books, and laboratory ex22 penses, incurred by the individual; and

23 ‘‘(C) reasonable living expenses as deter24 mined by the Secretary.

25 ‘‘(2) AMOUNT OF PAYMENT.—
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1 ‘‘(A) IN GENERAL.—For each year of obli2 gated service that an individual contracts to

3 serve under subsection (f) the Secretary may

4 pay up to $35,000 (or an amount equal to the

5 amount specified in section 338B(g)(2)(A) of

6 the Public Health Service Act) on behalf of the

7 individual for loans described in paragraph (1).

8 In making a determination of the amount to

9 pay for a year of such service by an individual,

10 the Secretary shall consider the extent to which

11 each such determination—

12 ‘‘(i) affects the ability of the Secretary

13 to maximize the number of contracts that

14 can be provided under the Loan Repay15 ment Program from the amounts appro16 priated for such contracts;

17 ‘‘(ii) provides an incentive to serve in

18 Indian health programs with the greatest

19 shortages of health professionals; and

20 ‘‘(iii) provides an incentive with re21 spect to the health professional involved re22 maining in an Indian health program with

23 such a health professional shortage, and

24 continuing to provide primary health serv25 ices, after the completion of the period of
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1 obligated service under the Loan Repay2 ment Program.

3 ‘‘(B) TIME FOR PAYMENT.—Any arrange4 ment made by the Secretary for the making of

5 loan repayments in accordance with this sub6 section shall provide that any repayments for a

7 year of obligated service shall be made not later

8 than the end of the fiscal year in which the in9 dividual completes such year of service.

10 ‘‘(3) SCHEDULE FOR PAYMENTS.—The Sec11 retary may enter into an agreement with the holder

12 of any loan for which payments are made under the

13 Loan Repayment Program to establish a schedule

14 for the making of such payments.

15 ‘‘(h) COUNTING OF INDIVIDUALS.—Notwithstanding

16 any other provision of law, individuals who have entered

17 into written contracts with the Secretary under this sec18 tion, while undergoing academic training, shall not be

19 counted against any employment ceiling affecting the De20 partment.

21 ‘‘(i) RECRUITING PROGRAMS.—The Secretary shall

22 conduct recruiting programs for the Loan Repayment Pro23 gram and other health professional programs of the Serv24 ice at educational institutions training health professionals

25 or specialists identified in subsection (a).
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1 ‘‘(j) NONAPPLICATION OF CERTAIN PROVISION.—

2 Section 214 of the Public Health Service Act (42 U.S.C.

3 215) shall not apply to individuals during their period of

4 obligated service under the Loan Repayment Program.

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

6 in assigning individuals to serve in Indian health programs

7 pursuant to contracts entered into under this section,

8 shall—

9 ‘‘(1) ensure that the staffing needs of Indian

10 health programs administered by an Indian tribe or

11 tribal or health organization receive consideration on

12 an equal basis with programs that are administered

13 directly by the Service; and

14 ‘‘(2) give priority to assigning individuals to In15 dian health programs that have a need for health

16 professionals to provide health care services as a re17 sult of individuals having breached contracts entered

18 into under this section.

19 ‘‘(l) BREACH OF CONTRACT.—

20 ‘‘(1) IN GENERAL.—An individual who has en21 tered into a written contract with the Secretary

22 under this section and who—

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

24 course of study and who—
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1 ‘‘(i) fails to maintain an acceptable

2 level of academic standing in the edu3 cational institution in which he is enrolled

4 (such level determined by the educational

5 institution under regulations of the Sec6 retary);

7 ‘‘(ii) voluntarily terminates such en8 rollment; or

9 ‘‘(iii) is dismissed from such edu10 cational institution before completion of

11 such course of study; or

12 ‘‘(B) is enrolled in a graduate training pro13 gram, and who fails to complete such training

14 program, and does not receive a waiver from

15 the Secretary under subsection (b)(1)(B)(ii),

16 shall be liable, in lieu of any service obligation aris17 ing under such contract, to the United States for the

18 amount which has been paid on such individual’s be19 half under the contract.

20 ‘‘(2) AMOUNT OF RECOVERY.—If, for any rea21 son not specified in paragraph (1), an individual

22 breaches his written contract under this section by

23 failing either to begin, or complete, such individual’s

24 period of obligated service in accordance with sub25 section (f), the United States shall be entitled to re-
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1 cover from such individual an amount to be deter2 mined in accordance with the following formula:

3 A=3Z(t-s/t)

4 in which—

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

6 is entitled to recover;

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

8 under this section to, or on behalf of, the indi9 vidual and the interest on such amounts which

10 would be payable if, at the time the amounts

11 were paid, they were loans bearing interest at

12 the maximum legal prevailing rate, as deter13 mined by the Treasurer of the United States;

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

15 the individual’s period of obligated service in

16 accordance with subsection (f); and

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

18 period served by such individual in accordance

19 with this section.

20 Amounts not paid within such period shall be sub21 ject to collection through deductions in medicare

22 payments pursuant to section 1892 of the Social Se23 curity Act.

24 ‘‘(3) DAMAGES.—
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1 ‘‘(A) TIME FOR PAYMENT.—Any amount

2 of damages which the United States is entitled

3 to recover under this subsection shall be paid to

4 the United States within the 1-year period be5 ginning on the date of the breach of contract or

6 such longer period beginning on such date as

7 shall be specified by the Secretary.

8 ‘‘(B) DELINQUENCIES.—If damages de9 scribed in subparagraph (A) are delinquent for

10 3 months, the Secretary shall, for the purpose

11 of recovering such damages—

12 ‘‘(i) utilize collection agencies con13 tracted with by the Administrator of the

14 General Services Administration; or

15 ‘‘(ii) enter into contracts for the re16 covery of such damages with collection

17 agencies selected by the Secretary.

18 ‘‘(C) CONTRACTS FOR RECOVERY OF DAM19 AGES.—Each contract for recovering damages

20 pursuant to this subsection shall provide that

21 the contractor will, not less than once each 6

22 months, submit to the Secretary a status report

23 on the success of the contractor in collecting

24 such damages. Section 3718 of title 31, United
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1 States Code, shall apply to any such contract to

2 the extent not inconsistent with this subsection.

3 ‘‘(m) CANCELLATION, WAIVER OR RELEASE.—

4 ‘‘(1) CANCELLATION.—Any obligation of an in5 dividual under the Loan Repayment Program for

6 service or payment of damages shall be canceled

7 upon the death of the individual.

8 ‘‘(2) WAIVER OF SERVICE OBLIGATION.—The

9 Secretary shall by regulation provide for the partial

10 or total waiver or suspension of any obligation of

11 service or payment by an individual under the Loan

12 Repayment Program whenever compliance by the in13 dividual is impossible or would involve extreme hard14 ship to the individual and if enforcement of such ob15 ligation with respect to any individual would be un16 conscionable.

17 ‘‘(3) WAIVER OF RIGHTS OF UNITED STATES.—

18 The Secretary may waive, in whole or in part, the

19 rights of the United States to recover amounts

20 under this section in any case of extreme hardship

21 or other good cause shown, as determined by the

22 Secretary.

23 ‘‘(4) RELEASE.—Any obligation of an individual

24 under the Loan Repayment Program for payment of

25 damages may be released by a discharge in bank-
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1 ruptcy under title 11 of the United States Code only

2 if such discharge is granted after the expiration of

3 the 5-year period beginning on the first date that

4 payment of such damages is required, and only if

5 the bankruptcy court finds that nondischarge of the

6 obligation would be unconscionable.

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

8 President, for inclusion in each report required to be sub9 mitted to the Congress under section 801, a report con10 cerning the previous fiscal year which sets forth—

11 ‘‘(1) the health professional positions main12 tained by the Service or by tribal or Indian organi13 zations for which recruitment or retention is dif14 ficult;

15 ‘‘(2) the number of Loan Repayment Program

16 applications filed with respect to each type of health

17 profession;

18 ‘‘(3) the number of contracts described in sub19 section (f) that are entered into with respect to each

20 health profession;

21 ‘‘(4) the amount of loan payments made under

22 this section, in total and by health profession;

23 ‘‘(5) the number of scholarship grants that are

24 provided under section 105 with respect to each

25 health profession;
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1 ‘‘(6) the amount of scholarship grants provided

2 under section 105, in total and by health profession;

3 ‘‘(7) the number of providers of health care

4 that will be needed by Indian health programs, by

5 location and profession, during the 3 fiscal years be6 ginning after the date the report is filed; and

7 ‘‘(8) the measures the Secretary plans to take

8 to fill the health professional positions maintained

9 by the Service or by tribes, tribal organizations, or

10 urban Indian organizations for which recruitment or

11 retention is difficult.

12 ‘‘SEC. 111. SCHOLARSHIP AND LOAN REPAYMENT RECOV13 ERY FUND.

14 ‘‘(a) ESTABLISHMENT.—Notwithstanding section

15 102, there is established in the Treasury of the United

16 States a fund to be known as the Indian Health Scholar17 ship and Loan Repayment Recovery Fund (referred to in

18 this section as the ‘LRRF’). The LRRF Fund shall con19 sist of—

20 ‘‘(1) such amounts as may be collected from in21 dividuals under subparagraphs (A) and (B) of sec22 tion 105(b)(4) and section 110(l) for breach of con23 tract;

24 ‘‘(2) such funds as may be appropriated to the

25 LRRF;
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1 ‘‘(3) such interest earned on amounts in the

2 LRRF; and

3 ‘‘(4) such additional amounts as may be col4 lected, appropriated, or earned relative to the

5 LRRF.

6 Amounts appropriated to the LRRF shall remain available

7 until expended.

8 ‘‘(b) USE OF LRRF.—

9 ‘‘(1) IN GENERAL.—Amounts in the LRRF

10 may be expended by the Secretary, subject to section

11 102, acting through the Service, to make payments

12 to the Service or to an Indian tribe or tribal organi13 zation administering a health care program pursuant

14 to a funding agreement entered into under the In15 dian Self-Determination and Education Assistance

16 Act—

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

18 section 105 or a loan repayment program par19 ticipant under section 110 has been assigned to

20 meet the obligated service requirements pursu21 ant to sections; and

22 ‘‘(B) that has a need for a health profes23 sional to provide health care services as a result

24 of such recipient or participant having breached
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1 the contract entered into under section 105 or

2 section 110.

3 ‘‘(2) SCHOLARSHIPS AND RECRUITING.—An In4 dian tribe or tribal organization receiving payments

5 pursuant to paragraph (1) may expend the payments

6 to provide scholarships or to recruit and employ, di7 rectly or by contract, health professionals to provide

8 health care services.

9 ‘‘(c) INVESTING OF FUND.—

10 ‘‘(1) IN GENERAL.—The Secretary of the

11 Treasury shall invest such amounts of the LRRF as

12 the Secretary determines are not required to meet

13 current withdrawals from the LRRF. Such invest14 ments may be made only in interest-bearing obliga15 tions of the United States. For such purpose, such

16 obligations may be acquired on original issue at the

17 issue price, or by purchase of outstanding obliga18 tions at the market price.

19 ‘‘(2) SALE PRICE.—Any obligation acquired by

20 the LRRF may be sold by the Secretary of the

21 Treasury at the market price.

22 ‘‘SEC. 112. RECRUITMENT ACTIVITIES.

23 ‘‘(a) REIMBURSEMENT OF EXPENSES.—The Sec24 retary may reimburse health professionals seeking posi25 tions in the Service, Indian tribes, tribal organizations, or
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1 urban Indian organizations, including unpaid student vol2 unteers and individuals considering entering into a con3 tract under section 110, and their spouses, for actual and

4 reasonable expenses incurred in traveling to and from

5 their places of residence to an area in which they may

6 be assigned for the purpose of evaluating such area with

7 respect to such assignment.

8 ‘‘(b) ASSIGNMENT OF PERSONNEL.—The Secretary,

9 acting through the Service, shall assign one individual in

10 each area office to be responsible on a full-time basis for

11 recruitment activities.

12 ‘‘SEC. 113. TRIBAL RECRUITMENT AND RETENTION PRO13 GRAM.

14 ‘‘(a) FUNDING OF PROJECTS.—The Secretary, acting

15 through the Service, shall fund innovative projects for a

16 period not to exceed 3 years to enable Indian tribes, tribal

17 organizations, and urban Indian organizations to recruit,

18 place, and retain health professionals to meet the staffing

19 needs of Indian health programs (as defined in section

20 110(a)(2)(A)).

21 ‘‘(b) ELIGIBILITY.—Any Indian tribe, tribal organi22 zation, or urban Indian organization may submit an appli23 cation for funding of a project pursuant to this section.
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1 ‘‘SEC. 114. ADVANCED TRAINING AND RESEARCH.

2 ‘‘(a) DEMONSTRATION PROJECT.—The Secretary,

3 acting through the Service, shall establish a demonstration

4 project to enable health professionals who have worked in

5 an Indian health program (as defined in section 110) for

6 a substantial period of time to pursue advanced training

7 or research in areas of study for which the Secretary de8 termines a need exists.

9 ‘‘(b) SERVICE OBLIGATION.—

10 ‘‘(1) IN GENERAL.—An individual who partici11 pates in the project under subsection (a), where the

12 educational costs are borne by the Service, shall

13 incur an obligation to serve in an Indian health pro14 gram for a period of obligated service equal to at

15 least the period of time during which the individual

16 participates in such project.

17 ‘‘(2) FAILURE TO COMPLETE SERVICE.—In the

18 event that an individual fails to complete a period of

19 obligated service under paragraph (1), the individual

20 shall be liable to the United States for the period of

21 service remaining. In such event, with respect to in22 dividuals entering the project after the date of the

23 enactment of this Act, the United States shall be en24 titled to recover from such individual an amount to

25 be determined in accordance with the formula speci-
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1 fied in subsection (l) of section 110 in the manner

2 provided for in such subsection.

3 ‘‘(c) OPPORTUNITY TO PARTICIPATE.—Health pro4 fessionals from Indian tribes, tribal organizations, and

5 urban Indian organizations under the authority of the In6 dian Self-Determination and Education Assistance Act

7 shall be given an equal opportunity to participate in the

8 program under subsection (a).

9 ‘‘SEC. 115. NURSING PROGRAMS; QUENTIN N. BURDICK

10 AMERICAN INDIANS INTO NURSING PRO11 GRAM.

12 ‘‘(a) GRANTS.—Notwithstanding section 102, the

13 Secretary, acting through the Service, shall provide funds

14 to—

15 ‘‘(1) public or private schools of nursing;

16 ‘‘(2) tribally controlled community colleges and

17 tribally controlled postsecondary vocational institu18 tions (as defined in section 390(2) of the Tribally

19 Controlled Vocational Institutions Support Act of

20 1990 (20 U.S.C. 2397h(2)); and

21 ‘‘(3) nurse midwife programs, and advance

22 practice nurse programs, that are provided by any

23 tribal college accredited nursing program, or in the

24 absence of such, any other public or private institu25 tion,
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1 for the purpose of increasing the number of nurses, nurse

2 midwives, and nurse practitioners who deliver health care

3 services to Indians.

4 ‘‘(b) USE OF GRANTS.—Funds provided under sub5 section (a) may be used to—

6 ‘‘(1) recruit individuals for programs which

7 train individuals to be nurses, nurse midwives, or

8 advanced practice nurses;

9 ‘‘(2) provide scholarships to Indian individuals

10 enrolled in such programs that may be used to pay

11 the tuition charged for such program and for other

12 expenses incurred in connection with such program,

13 including books, fees, room and board, and stipends

14 for living expenses;

15 ‘‘(3) provide a program that encourages nurses,

16 nurse midwives, and advanced practice nurses to

17 provide, or continue to provide, health care services

18 to Indians;

19 ‘‘(4) provide a program that increases the skills

20 of, and provides continuing education to, nurses,

21 nurse midwives, and advanced practice nurses; or

22 ‘‘(5) provide any program that is designed to

23 achieve the purpose described in subsection (a).

24 ‘‘(c) APPLICATIONS.—Each application for funds

25 under subsection (a) shall include such information as the
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1 Secretary may require to establish the connection between

2 the program of the applicant and a health care facility

3 that primarily serves Indians.

4 ‘‘(d) PREFERENCES.—In providing funds under sub5 section (a), the Secretary shall extend a preference to—

6 ‘‘(1) programs that provide a preference to In7 dians;

8 ‘‘(2) programs that train nurse midwives or ad9 vanced practice nurses;

10 ‘‘(3) programs that are interdisciplinary; and

11 ‘‘(4) programs that are conducted in coopera12 tion with a center for gifted and talented Indian stu13 dents established under section 5324(a) of the In14 dian Education Act of 1988.

15 ‘‘(e) QUENTIN N. BURDICK AMERICAN INDIANS INTO

16 NURSING PROGRAM.—The Secretary shall ensure that a

17 portion of the funds authorized under subsection (a) is

18 made available to establish and maintain a program at the

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

20 N. Burdick American Indians Into Nursing Program’.

21 Such program shall, to the maximum extent feasible, co22 ordinate with the Quentin N. Burdick American Indians

23 Into Psychology Program established under section 106(b)

24 and the Quentin N. Burdick Indian Health Programs es25 tablished under section 117(b).
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1 ‘‘(f) SERVICE OBLIGATION.—The active duty service

2 obligation prescribed under section 338C of the Public

3 Health Service Act (42 U.S.C. 254m) shall be met by each

4 individual who receives training or assistance described in

5 paragraph (1) or (2) of subsection (b) that is funded

6 under subsection (a). Such obligation shall be met by

7 service—

8 ‘‘(1) in the Indian Health Service;

9 ‘‘(2) in a program conducted under a contract

10 entered into under the Indian Self-Determination

11 and Education Assistance Act;

12 ‘‘(3) in a program assisted under title V; or

13 ‘‘(4) in the private practice of nursing if, as de14 termined by the Secretary, in accordance with guide15 lines promulgated by the Secretary, such practice is

16 situated in a physician or other health professional

17 shortage area and addresses the health care needs of

18 a substantial number of Indians.

19 ‘‘SEC. 116. TRIBAL CULTURE AND HISTORY.

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

21 the Service, shall require that appropriate employees of

22 the Service who serve Indian tribes in each service area

23 receive educational instruction in the history and culture

24 of such tribes and their relationship to the Service.
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1 ‘‘(b) REQUIREMENTS.—To the extent feasible, the

2 educational instruction to be provided under subsection

3 (a) shall—

4 ‘‘(1) be provided in consultation with the af5 fected tribal governments, tribal organizations, and

6 urban Indian organizations;

7 ‘‘(2) be provided through tribally-controlled

8 community colleges (within the meaning of section

9 2(4) of the Tribally Controlled Community College

10 Assistance Act of 1978) and tribally controlled post11 secondary vocational institutions (as defined in sec12 tion 390(2) of the Tribally Controlled Vocational In13 stitutions Support Act of 1990 (20 U.S.C.

14 2397h(2)); and

15 ‘‘(3) include instruction in Native American

16 studies.

17 ‘‘SEC. 117. INMED PROGRAM.

18 ‘‘(a) GRANTS.—The Secretary may provide grants to

19 3 colleges and universities for the purpose of maintaining

20 and expanding the Native American health careers recruit21 ment program known as the ‘Indians into Medicine Pro22 gram’ (referred to in this section as ‘INMED’) as a means

23 of encouraging Indians to enter the health professions.

24 ‘‘(b) QUENTIN N. BURDICK INDIAN HEALTH PRO25 GRAM.—The Secretary shall provide 1 of the grants under
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1 subsection (a) to maintain the INMED program at the

2 University of North Dakota, to be known as the ‘Quentin

3 N. Burdick Indian Health Program’, unless the Secretary

4 makes a determination, based upon program reviews, that

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

6 Such program shall, to the maximum extent feasible, co7 ordinate with the Quentin N. Burdick American Indians

8 Into Psychology Program established under section 106(b)

9 and the Quentin N. Burdick American Indians Into Nurs10 ing Program established under section 115.

11 ‘‘(c) REQUIREMENTS.—

12 ‘‘(1) IN GENERAL.—The Secretary shall develop

13 regulations to govern grants under to this section.

14 ‘‘(2) PROGRAM REQUIREMENTS.—Applicants

15 for grants provided under this section shall agree to

16 provide a program that—

17 ‘‘(A) provides outreach and recruitment for

18 health professions to Indian communities in19 cluding elementary, secondary and community

20 colleges located on Indian reservations which

21 will be served by the program;

22 ‘‘(B) incorporates a program advisory

23 board comprised of representatives from the

24 tribes and communities which will be served by

25 the program;
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1 ‘‘(C) provides summer preparatory pro2 grams for Indian students who need enrichment

3 in the subjects of math and science in order to

4 pursue training in the health professions;

5 ‘‘(D) provides tutoring, counseling and

6 support to students who are enrolled in a health

7 career program of study at the respective col8 lege or university; and

9 ‘‘(E) to the maximum extent feasible, em10 ploys qualified Indians in the program.

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

12 COLLEGES.

13 ‘‘(a) ESTABLISHMENT GRANTS.—

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

15 through the Service, shall award grants to accredited

16 and accessible community colleges for the purpose of

17 assisting such colleges in the establishment of pro18 grams which provide education in a health profes19 sion leading to a degree or diploma in a health pro20 fession for individuals who desire to practice such

21 profession on an Indian reservation, in the Service,

22 or in a tribal health program.

23 ‘‘(2) AMOUNT.—The amount of any grant

24 awarded to a community college under paragraph

25 (1) for the first year in which such a grant is pro-
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1 vided to the community college shall not exceed

2 $100,000.

3 ‘‘(b) CONTINUATION GRANTS.—

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

5 through the Service, shall award grants to accredited

6 and accessible community colleges that have estab7 lished a program described in subsection (a)(1) for

8 the purpose of maintaining the program and recruit9 ing students for the program.

10 ‘‘(2) ELIGIBILITY.—Grants may only be made

11 under this subsection to a community college that—

12 ‘‘(A) is accredited;

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

15 provide training of nurses or health profes16 sionals;

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

18 an accredited college or university medical

19 school, the terms of which—

20 ‘‘(i) provide a program that enhances

21 the transition and recruitment of students

22 into advanced baccalaureate or graduate

23 programs which train health professionals;

24 and
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1 ‘‘(ii) stipulate certifications necessary

2 to approve internship and field placement

3 opportunities at health programs of the

4 Service or at tribal health programs;

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

6 appropriate certifications;

7 ‘‘(E) is capable of obtaining State or re8 gional accreditation of the program described in

9 subsection (a)(1); and

10 ‘‘(F) agrees to provide for Indian pref11 erence for applicants for programs under this

12 section.

13 ‘‘(c) SERVICE PERSONNEL AND TECHNICAL ASSIST14 ANCE.—The Secretary shall encourage community colleges

15 described in subsection (b)(2) to establish and maintain

16 programs described in subsection (a)(1) by—

17 ‘‘(1) entering into agreements with such col18 leges for the provision of qualified personnel of the

19 Service to teach courses of study in such programs,

20 and

21 ‘‘(2) providing technical assistance and support

22 to such colleges.

23 ‘‘(d) SPECIFIED COURSES OF STUDY.—Any program

24 receiving assistance under this section that is conducted

25 with respect to a health profession shall also offer courses
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1 of study which provide advanced training for any health

2 professional who—

3 ‘‘(1) has already received a degree or diploma

4 in such health profession; and

5 ‘‘(2) provides clinical services on an Indian res6 ervation, at a Service facility, or at a tribal clinic.

7 Such courses of study may be offered in conjunction with

8 the college or university with which the community college

9 has entered into the agreement required under subsection

10 (b)(2)(C).

11 ‘‘(e) PRIORITY.—Priority shall be provided under this

12 section to tribally controlled colleges in service areas that

13 meet the requirements of subsection (b).

14 ‘‘(f) DEFINITIONS.—In this section:

15 ‘‘(1) COMMUNITY COLLEGE.—The term ‘com16 munity college’ means—

17 ‘‘(A) a tribally controlled community col18 lege; or

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

20 ‘‘(2) JUNIOR OR COMMUNITY COLLEGE.—The

21 term ‘junior or community college’ has the meaning

22 given such term by section 312(e) of the Higher

23 Education Act of 1965 (20 U.S.C. 1058(e)).

24 ‘‘(3) TRIBALLY CONTROLLED COLLEGE.—The

25 term ‘tribally controlled college’ has the meaning
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1 given the term ‘tribally controlled community college’

2 by section 2(4) of the Tribally Controlled Commu3 nity College Assistance Act of 1978.

4 ‘‘SEC. 119. RETENTION BONUS.

5 ‘‘(a) IN GENERAL.—The Secretary may pay a reten6 tion bonus to any health professional employed by, or as7 signed to, and serving in, the Service, an Indian tribe, a

8 tribal organization, or an urban Indian organization either

9 as a civilian employee or as a commissioned officer in the

10 Regular or Reserve Corps of the Public Health Service

11 who—

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

13 for which recruitment or retention of personnel is

14 difficult;

15 ‘‘(2) the Secretary determines is needed by the

16 Service, tribe, tribal organization, or urban organiza17 tion;

18 ‘‘(3) has—

19 ‘‘(A) completed 3 years of employment

20 with the Service; tribe, tribal organization, or

21 urban organization; or

22 ‘‘(B) completed any service obligations in23 curred as a requirement of—

24 ‘‘(i) any Federal scholarship program;

25 or
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1 ‘‘(ii) any Federal education loan re2 payment program; and

3 ‘‘(4) enters into an agreement with the Service,

4 Indian tribe, tribal organization, or urban Indian or5 ganization for continued employment for a period of

6 not less than 1 year.

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

8 the retention bonus which shall provide for a higher an9 nual rate for multiyear agreements than for single year

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

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

12 annum.

13 ‘‘(c) FAILURE TO COMPLETE TERM OF SERVICE.—

14 Any health professional failing to complete the agreed

15 upon term of service, except where such failure is through

16 no fault of the individual, shall be obligated to refund to

17 the Government the full amount of the retention bonus

18 for the period covered by the agreement, plus interest as

19 determined by the Secretary in accordance with section

20 110(l)(2)(B).

21 ‘‘(d) FUNDING AGREEMENT.—The Secretary may

22 pay a retention bonus to any health professional employed

23 by an organization providing health care services to Indi24 ans pursuant to a funding agreement under the Indian

25 Self-Determination and Education Assistance Act if such
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1 health professional is serving in a position which the Sec2 retary determines is—

3 ‘‘(1) a position for which recruitment or reten4 tion is difficult; and

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

6 to Indians.

7 ‘‘SEC. 120. NURSING RESIDENCY PROGRAM.

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

9 through the Service, shall establish a program to enable

10 Indians who are licensed practical nurses, licensed voca11 tional nurses, and registered nurses who are working in

12 an Indian health program (as defined in section

13 110(a)(2)(A)), and have done so for a period of not less

14 than 1 year, to pursue advanced training.

15 ‘‘(b) REQUIREMENT.—The program established

16 under subsection (a) shall include a combination of edu17 cation and work study in an Indian health program (as

18 defined in section 110(a)(2)(A)) leading to an associate

19 or bachelor’s degree (in the case of a licensed practical

20 nurse or licensed vocational nurse) or a bachelor’s degree

21 (in the case of a registered nurse) or an advanced degree

22 in nursing and public health.

23 ‘‘(c) SERVICE OBLIGATION.—An individual who par24 ticipates in a program under subsection (a), where the

25 educational costs are paid by the Service, shall incur an
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1 obligation to serve in an Indian health program for a pe2 riod of obligated service equal to the amount of time dur3 ing which the individual participates in such program. In

4 the event that the individual fails to complete such obli5 gated service, the United States shall be entitled to recover

6 from such individual an amount determined in accordance

7 with the formula specified in subsection (l) of section 110

8 in the manner provided for in such subsection.

9 ‘‘SEC. 121. COMMUNITY HEALTH AIDE PROGRAM FOR ALAS10 KA.

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

12 of November 2, 1921 (25 U.S.C. 13; commonly known as

13 the Snyder Act), the Secretary shall maintain a Commu14 nity Health Aide Program in Alaska under which the

15 Service—

16 ‘‘(1) provides for the training of Alaska Natives

17 as health aides or community health practitioners;

18 ‘‘(2) uses such aides or practitioners in the pro19 vision of health care, health promotion, and disease

20 prevention services to Alaska Natives living in vil21 lages in rural Alaska; and

22 ‘‘(3) provides for the establishment of tele23 conferencing capacity in health clinics located in or

24 near such villages for use by community health aides

25 or community health practitioners.
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1 ‘‘(b) ACTIVITIES.—The Secretary, acting through the

2 Community Health Aide Program under subsection (a),

3 shall—

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

5 provide a high standard of training to community

6 health aides and community health practitioners to

7 ensure that such aides and practitioners provide

8 quality health care, health promotion, and disease

9 prevention services to the villages served by the Pro10 gram;

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

12 a curriculum that—

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

14 health care with supervised practical experience

15 in the provision of health care;

16 ‘‘(B) provides instruction and practical ex17 perience in the provision of acute care, emer18 gency care, health promotion, disease preven19 tion, and the efficient and effective manage20 ment of clinic pharmacies, supplies, equipment,

21 and facilities; and

22 ‘‘(C) promotes the achievement of the

23 health status objective specified in section 3(b);

24 ‘‘(3) establish and maintain a Community

25 Health Aide Certification Board to certify as com-
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1 munity health aides or community health practition2 ers individuals who have successfully completed the

3 training described in paragraph (1) or who can dem4 onstrate equivalent experience;

5 ‘‘(4) develop and maintain a system which iden6 tifies the needs of community health aides and com7 munity health practitioners for continuing education

8 in the provision of health care, including the areas

9 described in paragraph (2)(B), and develop pro10 grams that meet the needs for such continuing edu11 cation;

12 ‘‘(5) develop and maintain a system that pro13 vides close supervision of community health aides

14 and community health practitioners; and

15 ‘‘(6) develop a system under which the work of

16 community health aides and community health prac17 titioners is reviewed and evaluated to assure the pro18 vision of quality health care, health promotion, and

19 disease prevention services.

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

21 ‘‘Subject to Section 102, the Secretary, acting

22 through the Service, shall, through a funding agreement

23 or otherwise, provide training for Indians in the adminis24 tration and planning of tribal health programs.
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1 ‘‘SEC. 123. HEALTH PROFESSIONAL CHRONIC SHORTAGE

2 DEMONSTRATION PROJECT.

3 ‘‘(a) PILOT PROGRAMS.—The Secretary may,

4 through area offices, fund pilot programs for tribes and

5 tribal organizations to address chronic shortages of health

6 professionals.

7 ‘‘(b) PURPOSE.—It is the purpose of the health pro8 fessions demonstration project under this section to—

9 ‘‘(1) provide direct clinical and practical experi10 ence in a service area to health professions students

11 and residents from medical schools;

12 ‘‘(2) improve the quality of health care for Indi13 ans by assuring access to qualified health care pro14 fessionals; and

15 ‘‘(3) provide academic and scholarly opportuni16 ties for health professionals serving Indian people by

17 identifying and utilizing all academic and scholarly

18 resources of the region.

19 ‘‘(c) ADVISORY BOARD.—A pilot program established

20 under subsection (a) shall incorporate a program advisory

21 board that shall be composed of representatives from the

22 tribes and communities in the service area that will be

23 served by the program.

24 ‘‘SEC. 124. SCHOLARSHIPS.

25 ‘‘Scholarships and loan reimbursements provided to

26 individuals pursuant to this title shall be treated as ‘quali-
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1 fied scholarships’ for purposes of section 117 of the Inter2 nal Revenue Code of 1986.

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

4 ‘‘(a) LIMITATIONS.—The Secretary shall not—

5 ‘‘(1) remove a member of the National Health

6 Services Corps from a health program operated by

7 Indian Health Service or by a tribe or tribal organi8 zation under a funding agreement with the Service

9 under the Indian Self-Determination and Education

10 Assistance Act, or by urban Indian organizations; or

11 ‘‘(2) withdraw the funding used to support such

12 a member;

13 unless the Secretary, acting through the Service, tribes or

14 tribal organization, has ensured that the Indians receiving

15 services from such member will experience no reduction

16 in services.

17 ‘‘(b) DESIGNATION OF SERVICE AREAS AS HEALTH

18 PROFESSIONAL SHORTAGE AREAS.—All service areas

19 served by programs operated by the Service or by a tribe

20 or tribal organization under the Indian Self-Determination

21 and Education Assistance Act, or by an urban Indian or22 ganization, shall be designated under section 332 of the

23 Public Health Service Act (42 U.S.C. 254e) as Health

24 Professional Shortage Areas.
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1 ‘‘(c) FULL TIME EQUIVALENT.—National Health

2 Service Corps scholars that qualify for the commissioned

3 corps in the Public Health Service shall be exempt from

4 the full time equivalent limitations of the National Health

5 Service Corps and the Service when such scholars serve

6 as commissioned corps officers in a health program oper7 ated by an Indian tribe or tribal organization under the

8 Indian Self-Determination and Education Assistance Act

9 or by an urban Indian organization.

10 ‘‘SEC. 126. SUBSTANCE ABUSE COUNSELOR EDUCATION

11 DEMONSTRATION PROJECT.

12 ‘‘(a) DEMONSTRATION PROJECTS.—The Secretary,

13 acting through the Service, may enter into contracts with,

14 or make grants to, accredited tribally controlled commu15 nity colleges, tribally controlled postsecondary vocational

16 institutions, and eligible accredited and accessible commu17 nity colleges to establish demonstration projects to develop

18 educational curricula for substance abuse counseling.

19 ‘‘(b) USE OF FUNDS.—Funds provided under this

20 section shall be used only for developing and providing

21 educational curricula for substance abuse counseling (in22 cluding paying salaries for instructors). Such curricula

23 may be provided through satellite campus programs.

24 ‘‘(c) TERM OF GRANT.—A contract entered into or

25 a grant provided under this section shall be for a period
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1 of 1 year. Such contract or grant may be renewed for an

2 additional 1 year period upon the approval of the Sec3 retary.

4 ‘‘(d) REVIEW OF APPLICATIONS.—Not later than 180

5 days after the date of the enactment of this Act, the Sec6 retary, after consultation with Indian tribes and adminis7 trators of accredited tribally controlled community col8 leges, tribally controlled postsecondary vocational institu9 tions, and eligible accredited and accessible community

10 colleges, shall develop and issue criteria for the review and

11 approval of applications for funding (including applica12 tions for renewals of funding) under this section. Such cri13 teria shall ensure that demonstration projects established

14 under this section promote the development of the capacity

15 of such entities to educate substance abuse counselors.

16 ‘‘(e) TECHNICAL ASSISTANCE.—The Secretary shall

17 provide such technical and other assistance as may be nec18 essary to enable grant recipients to comply with the provi19 sions of this section.

20 ‘‘(f) REPORT.—The Secretary shall submit to the

21 President, for inclusion in the report required to be sub22 mitted under section 801 for fiscal year 1999, a report

23 on the findings and conclusions derived from the dem24 onstration projects conducted under this section.

25 ‘‘(g) DEFINITIONS.—In this section:
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1 ‘‘(1) EDUCATIONAL CURRICULUM.—The term

2 ‘educational curriculum’ means 1 or more of the fol3 lowing:

4 ‘‘(A) Classroom education.

5 ‘‘(B) Clinical work experience.

6 ‘‘(C) Continuing education workshops.

7 ‘‘(2) TRIBALLY CONTROLLED COMMUNITY COL8 LEGE.—The term ‘tribally controlled community col9 lege’ has the meaning given such term in section

10 2(a)(4) of the Tribally Controlled Community Col11 lege Assistance Act of 1978 (25 U.S.C. 1801(a)(4)).

12 ‘‘(3) TRIBALLY CONTROLLED POSTSECONDARY

13 VOCATIONAL INSTITUTION.—The term ‘tribally con14 trolled postsecondary vocational institution’ has the

15 meaning given such term in section 390(2) of the

16 Tribally Controlled Vocational Institutions Support

17 Act of 1990 (20 U.S.C. 2397h(2)).

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

19 EDUCATION.

20 ‘‘(a) STUDY AND LIST.—

21 ‘‘(1) IN GENERAL.—The Secretary and the Sec22 retary of the Interior in consultation with Indian

23 tribes and tribal organizations shall conduct a study

24 and compile a list of the types of staff positions

25 specified in subsection (b) whose qualifications in-
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1 clude or should include, training in the identifica2 tion, prevention, education, referral or treatment of

3 mental illness, dysfunctional or self-destructive be4 havior.

5 ‘‘(2) POSITIONS.—The positions referred to in

6 paragraph (1) are—

7 ‘‘(A) staff positions within the Bureau of

8 Indian Affairs, including existing positions, in

9 the fields of—

10 ‘‘(i) elementary and secondary edu11 cation;

12 ‘‘(ii) social services, family and child

13 welfare;

14 ‘‘(iii) law enforcement and judicial

15 services; and

16 ‘‘(iv) alcohol and substance abuse;

17 ‘‘(B) staff positions within the Service; and

18 ‘‘(C) staff positions similar to those speci19 fied in subsection (b) and established and main20 tained by Indian tribes, tribal organizations,

21 and urban Indian organizations, including posi22 tions established pursuant to funding agree23 ments under the Indian Self-determination and

24 Education Assistance Act, and this Act.

25 ‘‘(3) TRAINING CRITERIA.—
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1 ‘‘(A) IN GENERAL.—The appropriate Sec2 retary shall provide training criteria appropriate

3 to each type of position specified in subsection

4 (b)(1) and ensure that appropriate training has

5 been or will be provided to any individual in any

6 such position.

7 ‘‘(B) TRAINING.—With respect to any such

8 individual in a position specified pursuant to

9 subsection (b)(3), the respective Secretaries

10 shall provide appropriate training or provide

11 funds to an Indian tribe, tribal organization, or

12 urban Indian organization for the training of

13 appropriate individuals. In the case of a fund14 ing agreement, the appropriate Secretary shall

15 ensure that such training costs are included in

16 the funding agreement, if necessary.

17 ‘‘(4) CULTURAL RELEVANCY.—Position specific

18 training criteria shall be culturally relevant to Indi19 ans and Indian tribes and shall ensure that appro20 priate information regarding traditional health care

21 practices is provided.

22 ‘‘(5) COMMUNITY EDUCATION.—

23 ‘‘(A) DEVELOPMENT.—The Service shall

24 develop and implement, or on request of an In25 dian tribe or tribal organization, assist an In-
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1 dian tribe or tribal organization, in developing

2 and implementing a program of community

3 education on mental illness.

4 ‘‘(B) TECHNICAL ASSISTANCE.—In carry5 ing out this paragraph, the Service shall, upon

6 the request of an Indian tribe or tribal organi7 zation, provide technical assistance to the In8 dian tribe or tribal organization to obtain and

9 develop community educational materials on the

10 identification, prevention, referral and treat11 ment of mental illness, dysfunctional and self12 destructive behavior.

13 ‘‘(b) STAFFING.—

14 ‘‘(1) IN GENERAL.—Not later than 90 days

15 after the date of enactment of the Act, the Director

16 of the Service shall develop a plan under which the

17 Service will increase the number of health care staff

18 that are providing mental health services by at least

19 500 positions within 5 years after such date of en20 actment, with at least 200 of such positions devoted

21 to child, adolescent, and family services. The alloca22 tion of such positions shall be subject to the provi23 sions of section 102(a).

24 ‘‘(2) IMPLEMENTATION.—The plan developed

25 under paragraph (1) shall be implemented under the
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1 Act of November 2, 1921 (25 U.S.C. 13) (commonly

2 know as the ‘Snyder Act’).

3 ‘‘SEC. 128. AUTHORIZATION OF APPROPRIATIONS.

4 ‘‘There are authorized to be appropriated such sums

5 as may be necessary for each fiscal year through fiscal

6 year 2015 to carry out this title.

7 ‘‘TITLE II—HEALTH SERVICES

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

9 ‘‘(a) IN GENERAL.—The Secretary may expend

10 funds, directly or under the authority of the Indian Self11 Determination and Education Assistance Act, that are ap12 propriated under the authority of this section, for the pur13 poses of—

14 ‘‘(1) eliminating the deficiencies in the health

15 status and resources of all Indian tribes;

16 ‘‘(2) eliminating backlogs in the provision of

17 health care services to Indians;

18 ‘‘(3) meeting the health needs of Indians in an

19 efficient and equitable manner;

20 ‘‘(4) eliminating inequities in funding for both

21 direct care and contract health service programs;

22 and

23 ‘‘(5) augmenting the ability of the Service to

24 meet the following health service responsibilities with
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1 respect to those Indian tribes with the highest levels

2 of health status and resource deficiencies:

3 ‘‘(A) clinical care, including inpatient care,

4 outpatient care (including audiology, clinical eye

5 and vision care), primary care, secondary and

6 tertiary care, and long term care;

7 ‘‘(B) preventive health, including mam8 mography and other cancer screening in accord9 ance with section 207;

10 ‘‘(C) dental care;

11 ‘‘(D) mental health, including community

12 mental health services, inpatient mental health

13 services, dormitory mental health services,

14 therapeutic and residential treatment centers,

15 and training of traditional health care practi16 tioners;

17 ‘‘(E) emergency medical services;

18 ‘‘(F) treatment and control of, and reha19 bilitative care related to, alcoholism and drug

20 abuse (including fetal alcohol syndrome) among

21 Indians;

22 ‘‘(G) accident prevention programs;

23 ‘‘(H) home health care;

24 ‘‘(I) community health representatives;

25 ‘‘(J) maintenance and repair; and
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1 ‘‘(K) traditional health care practices.

2 ‘‘(b) USE OF FUNDS.—

3 ‘‘(1) LIMITATION.—Any funds appropriated

4 under the authority of this section shall not be used

5 to offset or limit any other appropriations made to

6 the Service under this Act, the Act of November 2,

7 1921 (25 U.S.C. 13) (commonly known as the ‘Sny8 der Act’), or any other provision of law.

9 ‘‘(2) ALLOCATION.—

10 ‘‘(A) IN GENERAL.—Funds appropriated

11 under the authority of this section shall be allo12 cated to service units or Indian tribes or tribal

13 organizations. The funds allocated to each tribe,

14 tribal organization, or service unit under this

15 subparagraph shall be used to improve the

16 health status and reduce the resource deficiency

17 of each tribe served by such service unit, tribe

18 or tribal organization. Such allocation shall

19 weigh the amounts appropriated in favor of

20 those service areas where the health status of

21 Indians within the area, as measured by life ex22 pectancy based upon the most recent data avail23 able, is significantly lower than the average

24 health status for Indians for all service areas,

25 except that amounts allocated to each such area
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1 using such a weighted allocation formula shall

2 not be less than the amounts allocated to each

3 such area in the previous fiscal year.

4 ‘‘(B) APPORTIONMENT.—The apportion5 ment of funds allocated to a service unit, tribe

6 or tribal organization under subparagraph (A)

7 among the health service responsibilities de8 scribed in subsection (a)(4) shall be determined

9 by the Service in consultation with, and with

10 the active participation of, the affected Indian

11 tribes in accordance with this section and such

12 rules as may be established under title VIII.

13 ‘‘(c) HEALTH STATUS AND RESOURCE DEFI14 CIENCY.—In this section:

15 ‘‘(1) DEFINITION.—The term ‘health status

16 and resource deficiency’ means the extent to

17 which—

18 ‘‘(A) the health status objective set forth

19 in section 3(2) is not being achieved; and

20 ‘‘(B) the Indian tribe or tribal organization

21 does not have available to it the health re22 sources it needs, taking into account the actual

23 cost of providing health care services given local

24 geographic, climatic, rural, or other cir25 cumstances.
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1 ‘‘(2) RESOURCES.—The health resources avail2 able to an Indian tribe or tribal organization shall

3 include health resources provided by the Service as

4 well as health resources used by the Indian tribe or

5 tribal organization, including services and financing

6 systems provided by any Federal programs, private

7 insurance, and programs of State or local govern8 ments.

9 ‘‘(3) REVIEW OF DETERMINATION.—The Sec10 retary shall establish procedures which allow any In11 dian tribe or tribal organization to petition the Sec12 retary for a review of any determination of the ex13 tent of the health status and resource deficiency of

14 such tribe or tribal organization.

15 ‘‘(d) ELIGIBILITY.—Programs administered by any

16 Indian tribe or tribal organization under the authority of

17 the Indian Self-Determination and Education Assistance

18 Act shall be eligible for funds appropriated under the au19 thority of this section on an equal basis with programs

20 that are administered directly by the Service.

21 ‘‘(e) REPORT.—Not later than the date that is 3

22 years after the date of enactment of this Act, the Sec23 retary shall submit to the Congress the current health sta24 tus and resource deficiency report of the Service for each
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1 Indian tribe or service unit, including newly recognized or

2 acknowledged tribes. Such report shall set out—

3 ‘‘(1) the methodology then in use by the Service

4 for determining tribal health status and resource de5 ficiencies, as well as the most recent application of

6 that methodology;

7 ‘‘(2) the extent of the health status and re8 source deficiency of each Indian tribe served by the

9 Service;

10 ‘‘(3) the amount of funds necessary to eliminate

11 the health status and resource deficiencies of all In12 dian tribes served by the Service; and

13 ‘‘(4) an estimate of—

14 ‘‘(A) the amount of health service funds

15 appropriated under the authority of this Act, or

16 any other Act, including the amount of any

17 funds transferred to the Service, for the preced18 ing fiscal year which is allocated to each service

19 unit, Indian tribe, or comparable entity;

20 ‘‘(B) the number of Indians eligible for

21 health services in each service unit or Indian

22 tribe or tribal organization; and

23 ‘‘(C) the number of Indians using the

24 Service resources made available to each service

25 unit or Indian tribe or tribal organization, and,
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1 to the extent available, information on the wait2 ing lists and number of Indians turned away for

3 services due to lack of resources.

4 ‘‘(f) BUDGETARY RULE.—Funds appropriated under

5 the authority of this section for any fiscal year shall be

6 included in the base budget of the Service for the purpose

7 of determining appropriations under this section in subse8 quent fiscal years.

9 ‘‘(g) RULE OF CONSTRUCTION.—Nothing in this sec10 tion shall be construed to diminish the primary respon11 sibility of the Service to eliminate existing backlogs in

12 unmet health care needs or to discourage the Service from

13 undertaking additional efforts to achieve equity among In14 dian tribes and tribal organizations.

15 ‘‘(h) DESIGNATION.—Any funds appropriated under

16 the authority of this section shall be designated as the ‘In17 dian Health Care Improvement Fund’.

18 ‘‘SEC. 202. CATASTROPHIC HEALTH EMERGENCY FUND.

19 ‘‘(a) ESTABLISHMENT.—

20 ‘‘(1) IN GENERAL.—There is hereby established

21 an Indian Catastrophic Health Emergency Fund (re22 ferred to in this section as the ‘CHEF’) consisting

23 of—

24 ‘‘(A) the amounts deposited under sub25 section (d); and
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1 ‘‘(B) any amounts appropriated to the

2 CHEF under this Act.

3 ‘‘(2) ADMINISTRATION.—The CHEF shall be

4 administered by the Secretary solely for the purpose

5 of meeting the extraordinary medical costs associ6 ated with the treatment of victims of disasters or

7 catastrophic illnesses who are within the responsibil8 ity of the Service.

9 ‘‘(3) EQUITABLE ALLOCATION.—The CHEF

10 shall be equitably allocated, apportioned or delegated

11 on a service unit or area office basis, based upon a

12 formula to be developed by the Secretary in con13 sultation with the Indian tribes and tribal organiza14 tions through negotiated rulemaking under title

15 VIII. Such formula shall take into account the

16 added needs of service areas which are contract

17 health service dependent.

18 ‘‘(4) NOT SUBJECT TO CONTRACT OR GRANT.—

19 No part of the CHEF or its administration shall be

20 subject to contract or grant under any law, including

21 the Indian Self-Determination and Education Assist22 ance Act.

23 ‘‘(5) ADMINISTRATION.—Amounts provided

24 from the CHEF shall be administered by the area

25 offices based upon priorities determined by the In-
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1 dian tribes and tribal organizations within each serv2 ice area, including a consideration of the needs of

3 Indian tribes and tribal organizations which are con4 tract health service-dependent.

5 ‘‘(b) REQUIREMENTS.—The Secretary shall, through

6 the negotiated rulemaking process under title VIII, pro7 mulgate regulations consistent with the provisions of this

8 section—

9 ‘‘(1) establish a definition of disasters and cata10 strophic illnesses for which the cost of treatment

11 provided under contract would qualify for payment

12 from the CHEF;

13 ‘‘(2) provide that a service unit, Indian tribe, or

14 tribal organization shall not be eligible for reim15 bursement for the cost of treatment from the CHEF

16 until its cost of treatment for any victim of such a

17 catastrophic illness or disaster has reached a certain

18 threshold cost which the Secretary shall establish

19 at—

20 ‘‘(A) for 1999, not less than $19,000; and

21 ‘‘(B) for any subsequent year, not less

22 than the threshold cost of the previous year in23 creased by the percentage increase in the medi24 cal care expenditure category of the consumer

25 price index for all urban consumers (United
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1 States city average) for the 12-month period

2 ending with December of the previous year;

3 ‘‘(3) establish a procedure for the reimburse4 ment of the portion of the costs incurred by—

5 ‘‘(A) service units, Indian tribes, or tribal

6 organizations, or facilities of the Service; or

7 ‘‘(B) non-Service facilities or providers

8 whenever otherwise authorized by the Service;

9 in rendering treatment that exceeds threshold cost

10 described in paragraph (2);

11 ‘‘(4) establish a procedure for payment from

12 the CHEF in cases in which the exigencies of the

13 medical circumstances warrant treatment prior to

14 the authorization of such treatment by the Service;

15 and

16 ‘‘(5) establish a procedure that will ensure that

17 no payment shall be made from the CHEF to any

18 provider of treatment to the extent that such pro19 vider is eligible to receive payment for the treatment

20 from any other Federal, State, local, or private

21 source of reimbursement for which the patient is eli22 gible.

23 ‘‘(c) LIMITATION.—Amounts appropriated to the

24 CHEF under this section shall not be used to offset or

25 limit appropriations made to the Service under the author-
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1 ity of the Act of November 2, 1921 (25 U.S.C. 13) (com2 monly known as the Snyder Act) or any other law.

3 ‘‘(d) DEPOSITS.—There shall be deposited into the

4 CHEF all reimbursements to which the Service is entitled

5 from any Federal, State, local, or private source (including

6 third party insurance) by reason of treatment rendered to

7 any victim of a disaster or catastrophic illness the cost

8 of which was paid from the CHEF.

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

10 SERVICES.

11 ‘‘(a) FINDINGS.—Congress finds that health pro12 motion and disease prevention activities will—

13 ‘‘(1) improve the health and well-being of Indi14 ans; and

15 ‘‘(2) reduce the expenses for health care of In16 dians.

17 ‘‘(b) PROVISION OF SERVICES.—The Secretary, act18 ing through the Service and through Indian tribes and

19 tribal organizations, shall provide health promotion and

20 disease prevention services to Indians so as to achieve the

21 health status objective set forth in section 3(b).

22 ‘‘(c) DISEASE PREVENTION AND HEALTH PRO23 MOTION.—In this section:

24 ‘‘(1) DISEASE PREVENTION.—The term ‘disease

25 prevention’ means the reduction, limitation, and pre-
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1 vention of disease and its complications, and the re2 duction in the consequences of such diseases,

3 including—

4 ‘‘(A) controlling—

5 ‘‘(i) diabetes;

6 ‘‘(ii) high blood pressure;

7 ‘‘(iii) infectious agents;

8 ‘‘(iv) injuries;

9 ‘‘(v) occupational hazards and disabil10 ities;

11 ‘‘(vi) sexually transmittable diseases;

12 and

13 ‘‘(vii) toxic agents; and

14 ‘‘(B) providing—

15 ‘‘(i) for the fluoridation of water; and

16 ‘‘(ii) immunizations.

17 ‘‘(2) HEALTH PROMOTION.—The term ‘health

18 promotion’ means fostering social, economic, envi19 ronmental, and personal factors conducive to health,

20 including—

21 ‘‘(A) raising people’s awareness about

22 health matters and enabling them to cope with

23 health problems by increasing their knowledge

24 and providing them with valid information;
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1 ‘‘(B) encouraging adequate and appro2 priate diet, exercise, and sleep;

3 ‘‘(C) promoting education and work in con4 formity with physical and mental capacity;

5 ‘‘(D) making available suitable housing,

6 safe water, and sanitary facilities;

7 ‘‘(E) improving the physical economic, cul8 tural, psychological, and social environment;

9 ‘‘(F) promoting adequate opportunity for

10 spiritual, religious, and traditional practices;

11 and

12 ‘‘(G) adequate and appropriate programs

13 including—

14 ‘‘(i) abuse prevention (mental and

15 physical);

16 ‘‘(ii) community health;

17 ‘‘(iii) community safety;

18 ‘‘(iv) consumer health education;

19 ‘‘(v) diet and nutrition;

20 ‘‘(vi) disease prevention (commu21 nicable, immunizations, HIV/AIDS);

22 ‘‘(vii) environmental health;

23 ‘‘(viii) exercise and physical fitness;

24 ‘‘(ix) fetal alcohol disorders;

25 ‘‘(x) first aid and CPR education;
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1 ‘‘(xi) human growth and development;

2 ‘‘(xii) injury prevention and personal

3 safety;

4 ‘‘(xiii) mental health (emotional, self5 worth);

6 ‘‘(xiv) personal health and wellness

7 practices;

8 ‘‘(xv) personal capacity building;

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

10 care;

11 ‘‘(xvii) psychological well being;

12 ‘‘(xiii) reproductive health (family

13 planning);

14 ‘‘(xix) safe and adequate water;

15 ‘‘(xx) safe housing;

16 ‘‘(xxi) safe work environments;

17 ‘‘(xxii) stress control;

18 ‘‘(xxiii) substance abuse;

19 ‘‘(xxiv) sanitary facilities;

20 ‘‘(xxv) tobacco use cessation and re21 duction;

22 ‘‘(xxvi) violence prevention; and

23 ‘‘(xxvii) such other activities identified

24 by the Service, an Indian tribe or tribal or-
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1 ganization, to promote the achievement of

2 the objective described in section 3(b).

3 ‘‘(d) EVALUATION.—The Secretary, after obtaining

4 input from affected Indian tribes and tribal organizations,

5 shall submit to the President for inclusion in each state6 ment which is required to be submitted to Congress under

7 section 801 an evaluation of—

8 ‘‘(1) the health promotion and disease preven9 tion needs of Indians;

10 ‘‘(2) the health promotion and disease preven11 tion activities which would best meet such needs;

12 ‘‘(3) the internal capacity of the Service to meet

13 such needs; and

14 ‘‘(4) the resources which would be required to

15 enable the Service to undertake the health promotion

16 and disease prevention activities necessary to meet

17 such needs.

18 ‘‘SEC. 204. DIABETES PREVENTION, TREATMENT, AND CON19 TROL.

20 ‘‘(a) DETERMINATION.—The Secretary, in consulta21 tion with Indian tribes and tribal organizations, shall

22 determine—

23 ‘‘(1) by tribe, tribal organization, and service

24 unit of the Service, the prevalence of, and the types
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1 of complications resulting from, diabetes among In2 dians; and

3 ‘‘(2) based on paragraph (1), the measures (in4 cluding patient education) each service unit should

5 take to reduce the prevalence of, and prevent, treat,

6 and control the complications resulting from, diabe7 tes among Indian tribes within that service unit.

8 ‘‘(b) SCREENING.—The Secretary shall screen each

9 Indian who receives services from the Service for diabetes

10 and for conditions which indicate a high risk that the indi11 vidual will become diabetic. Such screening may be done

12 by an Indian tribe or tribal organization operating health

13 care programs or facilities with funds from the Service

14 under the Indian Self-Determination and Education As15 sistance Act.

16 ‘‘(c) CONTINUED FUNDING.—The Secretary shall

17 continue to fund, through fiscal year 2015, each effective

18 model diabetes project in existence on the date of the en19 actment of this Act and such other diabetes programs op20 erated by the Secretary or by Indian tribes and tribal or21 ganizations and any additional programs added to meet

22 existing diabetes needs. Indian tribes and tribal organiza23 tions shall receive recurring funding for the diabetes pro24 grams which they operate pursuant to this section. Model

25 diabetes projects shall consult, on a regular basis, with
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1 tribes and tribal organizations in their regions regarding

2 diabetes needs and provide technical expertise as needed.

3 ‘‘(d) DIALYSIS PROGRAMS.—The Secretary shall pro4 vide funding through the Service, Indian tribes and tribal

5 organizations to establish dialysis programs, including

6 funds to purchase dialysis equipment and provide nec7 essary staffing.

8 ‘‘(e) OTHER ACTIVITIES.—The Secretary shall, to the

9 extent funding is available—

10 ‘‘(1) in each area office of the Service, consult

11 with Indian tribes and tribal organizations regarding

12 programs for the prevention, treatment, and control

13 of diabetes;

14 ‘‘(2) establish in each area office of the Service

15 a registry of patients with diabetes to track the

16 prevalence of diabetes and the complications from

17 diabetes in that area; and

18 ‘‘(3) ensure that data collected in each area of19 fice regarding diabetes and related complications

20 among Indians is disseminated to tribes, tribal orga21 nizations, and all other area offices.

22 ‘‘SEC. 205. SHARED SERVICES.

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

24 the Service and notwithstanding any other provision of

25 law, is authorized to enter into funding agreements or
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1 other arrangements with Indian tribes or tribal organiza2 tions for the delivery of long-term care and similar services

3 to Indians. Such projects shall provide for the sharing of

4 staff or other services between a Service or tribal facility

5 and a long-term care or other similar facility owned and

6 operated (directly or through a funding agreement) by

7 such Indian tribe or tribal organization.

8 ‘‘(b) REQUIREMENTS.—A funding agreement or

9 other arrangement entered into pursuant to subsection

10 (a)—

11 ‘‘(1) may, at the request of the Indian tribe or

12 tribal organization, delegate to such tribe or tribal

13 organization such powers of supervision and control

14 over Service employees as the Secretary deems nec15 essary to carry out the purposes of this section;

16 ‘‘(2) shall provide that expenses (including sala17 ries) relating to services that are shared between the

18 Service and the tribal facility be allocated propor19 tionately between the Service and the tribe or tribal

20 organization; and

21 ‘‘(3) may authorize such tribe or tribal organi22 zation to construct, renovate, or expand a long-term

23 care or other similar facility (including the construc24 tion of a facility attached to a Service facility).
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1 ‘‘(c) TECHNICAL ASSISTANCE.—The Secretary shall

2 provide such technical and other assistance as may be nec3 essary to enable applicants to comply with the provisions

4 of this section.

5 ‘‘(d) USE OF EXISTING FACILITIES.—The Secretary

6 shall encourage the use for long-term or similar care of

7 existing facilities that are under-utilized or allow the use

8 of swing beds for such purposes.

9 ‘‘SEC. 206. HEALTH SERVICES RESEARCH.

10 ‘‘(a) FUNDING.—The Secretary shall make funding

11 available for research to further the performance of the

12 health service responsibilities of the Service, Indian tribes,

13 and tribal organizations and shall coordinate the activities

14 of other Agencies within the Department to address these

15 research needs.

16 ‘‘(b) ALLOCATION.—Funding under subsection (a)

17 shall be allocated equitably among the area offices. Each

18 area office shall award such funds competitively within

19 that area.

20 ‘‘(c) ELIGIBILITY FOR FUNDS.—Indian tribes and

21 tribal organizations receiving funding from the Service

22 under the authority of the Indian Self-Determination and

23 Education Assistance Act shall be given an equal oppor24 tunity to compete for, and receive, research funds under

25 this section.
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1 ‘‘(d) USE.—Funds received under this section may

2 be used for both clinical and non-clinical research by In3 dian tribes and tribal organizations and shall be distrib4 uted to the area offices. Such area offices may make

5 grants using such funds within each area.

6 ‘‘SEC. 207. MAMMOGRAPHY AND OTHER CANCER SCREEN7 ING.

8 ‘‘The Secretary, through the Service or through In9 dian tribes or tribal organizations, shall provide for the

10 following screening:

11 ‘‘(1) Mammography (as defined in section

12 1861(jj) of the Social Security Act) for Indian

13 women at a frequency appropriate to such women

14 under national standards, and under such terms and

15 conditions as are consistent with standards estab16 lished by the Secretary to assure the safety and ac17 curacy of screening mammography under part B of

18 title XVIII of the Social Security Act.

19 ‘‘(2) Other cancer screening meeting national

20 standards.

21 ‘‘SEC. 208. PATIENT TRAVEL COSTS.

22 ‘‘The Secretary, acting through the Service, Indian

23 tribes and tribal organizations shall provide funds for the

24 following patient travel costs, including appropriate and

25 necessary qualified escorts, associated with receiving
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1 health care services provided (either through direct or con2 tract care or through funding agreements entered into

3 pursuant to the Indian Self-Determination and Education

4 Assistance Act) under this Act:

5 ‘‘(1) Emergency air transportation and non6 emergency air transportation where ground trans7 portation is infeasible.

8 ‘‘(2) Transportation by private vehicle, specially

9 equipped vehicle and ambulance.

10 ‘‘(3) Transportation by such other means as

11 may be available and required when air or motor ve12 hicle transportation is not available.

13 ‘‘SEC. 209. EPIDEMIOLOGY CENTERS.

14 ‘‘(a) ESTABLISHMENT.—

15 ‘‘(1) IN GENERAL.—In addition to those centers

16 operating 1 day prior to the date of enactment of

17 this Act, (including those centers for which funding

18 is currently being provided through funding agree19 ments under the Indian Self-Determination and

20 Education Assistance Act), the Secretary shall, not

21 later than 180 days after such date of enactment,

22 establish and fund an epidemiology center in each

23 service area which does not have such a center to

24 carry out the functions described in paragraph (2).

25 Any centers established under the preceding sen-
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1 tence may be operated by Indian tribes or tribal or2 ganizations pursuant to funding agreements under

3 the Indian Self-Determination and Education Assist4 ance Act, but funding under such agreements may

5 not be divisible.

6 ‘‘(2) FUNCTIONS.—In consultation with and

7 upon the request of Indian tribes, tribal organiza8 tions and urban Indian organizations, each area epi9 demiology center established under this subsection

10 shall, with respect to such area shall—

11 ‘‘(A) collect data related to the health sta12 tus objective described in section 3(b), and

13 monitor the progress that the Service, Indian

14 tribes, tribal organizations, and urban Indian

15 organizations have made in meeting such health

16 status objective;

17 ‘‘(B) evaluate existing delivery systems,

18 data systems, and other systems that impact

19 the improvement of Indian health;

20 ‘‘(C) assist Indian tribes, tribal organiza21 tions, and urban Indian organizations in identi22 fying their highest priority health status objec23 tives and the services needed to achieve such

24 objectives, based on epidemiological data;
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1 ‘‘(D) make recommendations for the tar2 geting of services needed by tribal, urban, and

3 other Indian communities;

4 ‘‘(E) make recommendations to improve

5 health care delivery systems for Indians and

6 urban Indians;

7 ‘‘(F) provide requested technical assistance

8 to Indian tribes and urban Indian organizations

9 in the development of local health service prior10 ities and incidence and prevalence rates of dis11 ease and other illness in the community; and

12 ‘‘(G) provide disease surveillance and assist

13 Indian tribes, tribal organizations, and urban

14 Indian organizations to promote public health.

15 ‘‘(3) TECHNICAL ASSISTANCE.—The director of

16 the Centers for Disease Control and Prevention shall

17 provide technical assistance to the centers in carry18 ing out the requirements of this subsection.

19 ‘‘(b) FUNDING.—The Secretary may make funding

20 available to Indian tribes, tribal organizations, and eligible

21 intertribal consortia or urban Indian organizations to con22 duct epidemiological studies of Indian communities.
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1 ‘‘SEC. 210. COMPREHENSIVE SCHOOL HEALTH EDUCATION

2 PROGRAMS.

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

4 the Service, shall provide funding to Indian tribes, tribal

5 organizations, and urban Indian organizations to develop

6 comprehensive school health education programs for chil7 dren from preschool through grade 12 in schools for the

8 benefit of Indian and urban Indian children.

9 ‘‘(b) USE OF FUNDS.—Funds awarded under this

10 section may be used to—

11 ‘‘(1) develop and implement health education

12 curricula both for regular school programs and after

13 school programs;

14 ‘‘(2) train teachers in comprehensive school

15 health education curricula;

16 ‘‘(3) integrate school-based, community-based,

17 and other public and private health promotion ef18 forts;

19 ‘‘(4) encourage healthy, tobacco-free school en20 vironments;

21 ‘‘(5) coordinate school-based health programs

22 with existing services and programs available in the

23 community;

24 ‘‘(6) develop school programs on nutrition edu25 cation, personal health, oral health, and fitness;

26 ‘‘(7) develop mental health wellness programs;
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1 ‘‘(8) develop chronic disease prevention pro2 grams;

3 ‘‘(9) develop substance abuse prevention pro4 grams;

5 ‘‘(10) develop injury prevention and safety edu6 cation programs;

7 ‘‘(11) develop activities for the prevention and

8 control of communicable diseases;

9 ‘‘(12) develop community and environmental

10 health education programs that include traditional

11 health care practitioners;

12 ‘‘(13) carry out violence prevention activities;

13 and

14 ‘‘(14) carry out activities relating to such other

15 health issues as are appropriate.

16 ‘‘(c) TECHNICAL ASSISTANCE.—The Secretary shall,

17 upon request, provide technical assistance to Indian tribes,

18 tribal organizations and urban Indian organizations in the

19 development of comprehensive health education plans, and

20 the dissemination of comprehensive health education ma21 terials and information on existing health programs and

22 resources.

23 ‘‘(d) CRITERIA.—The Secretary, in consultation with

24 Indian tribes, tribal organizations, and urban Indian orga-
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1 nizations shall establish criteria for the review and ap2 proval of applications for funding under this section.

3 ‘‘(e) COMPREHENSIVE SCHOOL HEALTH EDUCATION

4 PROGRAM.—

5 ‘‘(1) DEVELOPMENT.—The Secretary of the In6 terior, acting through the Bureau of Indian Affairs

7 and in cooperation with the Secretary and affected

8 Indian tribes and tribal organizations, shall develop

9 a comprehensive school health education program for

10 children from preschool through grade 12 for use in

11 schools operated by the Bureau of Indian Affairs.

12 ‘‘(2) REQUIREMENTS.—The program developed

13 under paragraph (1) shall include—

14 ‘‘(A) school programs on nutrition edu15 cation, personal health, oral health, and fitness;

16 ‘‘(B) mental health wellness programs;

17 ‘‘(C) chronic disease prevention programs;

18 ‘‘(D) substance abuse prevention pro19 grams;

20 ‘‘(E) injury prevention and safety edu21 cation programs; and

22 ‘‘(F) activities for the prevention and con23 trol of communicable diseases.

24 ‘‘(3) TRAINING AND COORDINATION.—The Sec25 retary of the Interior shall—
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1 ‘‘(A) provide training to teachers in com2 prehensive school health education curricula;

3 ‘‘(B) ensure the integration and coordina4 tion of school-based programs with existing

5 services and health programs available in the

6 community; and

7 ‘‘(C) encourage healthy, tobacco-free school

8 environments.

9 ‘‘SEC. 211. INDIAN YOUTH PROGRAM.

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

11 the Service, is authorized to provide funding to Indian

12 tribes, tribal organizations, and urban Indian organiza13 tions for innovative mental and physical disease prevention

14 and health promotion and treatment programs for Indian

15 and urban Indian preadolescent and adolescent youths.

16 ‘‘(b) USE OF FUNDS.—

17 ‘‘(1) IN GENERAL.—Funds made available

18 under this section may be used to—

19 ‘‘(A) develop prevention and treatment

20 programs for Indian youth which promote men21 tal and physical health and incorporate cultural

22 values, community and family involvement, and

23 traditional health care practitioners; and

24 ‘‘(B) develop and provide community train25 ing and education.
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1 ‘‘(2) LIMITATION.—Funds made available

2 under this section may not be used to provide serv3 ices described in section 707(c).

4 ‘‘(c) REQUIREMENTS.—The Secretary shall—

5 ‘‘(1) disseminate to Indian tribes, tribal organi6 zations, and urban Indian organizations information

7 regarding models for the delivery of comprehensive

8 health care services to Indian and urban Indian ado9 lescents;

10 ‘‘(2) encourage the implementation of such

11 models; and

12 ‘‘(3) at the request of an Indian tribe, tribal or13 ganization, or urban Indian organization, provide

14 technical assistance in the implementation of such

15 models.

16 ‘‘(d) CRITERIA.—The Secretary, in consultation with

17 Indian tribes, tribal organization, and urban Indian orga18 nizations, shall establish criteria for the review and ap19 proval of applications under this section.

20 ‘‘SEC. 212. PREVENTION, CONTROL, AND ELIMINATION OF

21 COMMUNICABLE AND INFECTIOUS DISEASES.

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

23 the Service after consultation with Indian tribes, tribal or24 ganizations, urban Indian organizations, and the Centers
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1 for Disease Control and Prevention, may make funding

2 available to Indian tribes and tribal organizations for—

3 ‘‘(1) projects for the prevention, control, and

4 elimination of communicable and infectious diseases,

5 including tuberculosis, hepatitis, HIV, respiratory

6 syncitial virus, hanta virus, sexually transmitted dis7 eases, and H. Pylori, which projects may include

8 screening, testing and treatment for HCV and other

9 infectious and communicable diseases;

10 ‘‘(2) public information and education programs

11 for the prevention, control, and elimination of com12 municable and infectious diseases;

13 ‘‘(3) education, training, and clinical skills im14 provement activities in the prevention, control, and

15 elimination of communicable and infectious diseases

16 for health professionals, including allied health pro17 fessionals; and

18 ‘‘(4) a demonstration project that studies the

19 seroprevalence of the Hepatitis C virus among a ran20 dom sample of American Indian and Alaskan Native

21 populations and identifies prevalence rates among a

22 variety of tribes and geographic regions.

23 ‘‘(b) REQUIREMENT OF APPLICATION.—The Sec24 retary may provide funds under subsection (a) only if an

25 application or proposal for such funds is submitted.
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1 ‘‘(c) TECHNICAL ASSISTANCE AND REPORT.—In car2 rying out this section, the Secretary—

3 ‘‘(1) may, at the request of an Indian tribe or

4 tribal organization, provide technical assistance; and

5 ‘‘(2) shall prepare and submit, biennially, a re6 port to Congress on the use of funds under this sec7 tion and on the progress made toward the preven8 tion, control, and elimination of communicable and

9 infectious diseases among Indians and urban Indi10 ans.

11 ‘‘SEC. 213. AUTHORITY FOR PROVISION OF OTHER SERV12 ICES.

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

14 the Service, Indian tribes, and tribal organizations, may

15 provide funding under this Act to meet the objective set

16 forth in section 3 through health care related services and

17 programs not otherwise described in this Act. Such serv18 ices and programs shall include services and programs re19 lated to—

20 ‘‘(1) hospice care and assisted living;

21 ‘‘(2) long-term health care;

22 ‘‘(3) home- and community-based services;

23 ‘‘(4) public health functions; and

24 ‘‘(5) traditional health care practices.
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1 ‘‘(b) AVAILABILITY OF SERVICES FOR CERTAIN INDI2 VIDUALS.—At the discretion of the Service, Indian tribe,

3 or tribal organization, services hospice care, home health

4 care (under section 201), home- and community-based

5 care, assisted living, and long term care may be provided

6 (on a cost basis) to individuals otherwise ineligible for the

7 health care benefits of the Service. Any funds received

8 under this subsection shall not be used to offset or limit

9 the funding allocated to a tribe or tribal organization.

10 ‘‘(c) DEFINITIONS.—In this section:

11 ‘‘(1) HOME- AND COMMUNITY-BASED SERV12 ICES.—The term ‘home- and community-based serv13 ices’ means 1 or more of the following:

14 ‘‘(A) Homemaker/home health aide serv15 ices.

16 ‘‘(B) Chore services.

17 ‘‘(C) Personal care services.

18 ‘‘(D) Nursing care services provided out19 side of a nursing facility by, or under the super20 vision of, a registered nurse.

21 ‘‘(E) Training for family members.

22 ‘‘(F) Adult day care.

23 ‘‘(G) Such other home- and community24 based services as the Secretary or a tribe or

25 tribal organization may approve.
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1 ‘‘(2) HOSPICE CARE.—The term ‘hospice care’

2 means the items and services specified in subpara3 graphs (A) through (H) of section 1861(dd)(1) of

4 the Social Security Act (42 U.S.C. 1395x(dd)(1)),

5 and such other services which an Indian tribe or

6 tribal organization determines are necessary and ap7 propriate to provide in furtherance of such care.

8 ‘‘(3) PUBLIC HEALTH FUNCTIONS.—The term

9 ‘public health functions’ means public health related

10 programs, functions, and services including assess11 ments, assurances, and policy development that In12 dian tribes and tribal organizations are authorized

13 and encouraged, in those circumstances where it

14 meets their needs, to carry out by forming collabo15 rative relationships with all levels of local, State, and

16 Federal governments.

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

18 ‘‘The Secretary acting through the Service, Indian

19 tribes, tribal organizations, and urban Indian organiza20 tions shall provide funding to monitor and improve the

21 quality of health care for Indian women of all ages

22 through the planning and delivery of programs adminis23 tered by the Service, in order to improve and enhance the

24 treatment models of care for Indian women.
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1 ‘‘SEC. 215. ENVIRONMENTAL AND NUCLEAR HEALTH HAZ2 ARDS.

3 ‘‘(a) STUDY AND MONITORING PROGRAMS.—The

4 Secretary and the Service shall, in conjunction with other

5 appropriate Federal agencies and in consultation with con6 cerned Indian tribes and tribal organizations, conduct a

7 study and carry out ongoing monitoring programs to de8 termine the trends that exist in the health hazards posed

9 to Indian miners and to Indians on or near Indian reserva10 tions and in Indian communities as a result of environ11 mental hazards that may result in chronic or life-threaten12 ing health problems. Such hazards include nuclear re13 source development, petroleum contamination, and con14 tamination of the water source or of the food chain. Such

15 study (and any reports with respect to such study) shall

16 include—

17 ‘‘(1) an evaluation of the nature and extent of

18 health problems caused by environmental hazards

19 currently exhibited among Indians and the causes of

20 such health problems;

21 ‘‘(2) an analysis of the potential effect of ongo22 ing and future environmental resource development

23 on or near Indian reservations and communities in24 cluding the cumulative effect of such development

25 over time on health;
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1 ‘‘(3) an evaluation of the types and nature of

2 activities, practices, and conditions causing or affect3 ing such health problems including uranium mining

4 and milling, uranium mine tailing deposits, nuclear

5 power plant operation and construction, and nuclear

6 waste disposal, oil and gas production or transpor7 tation on or near Indian reservations or commu8 nities, and other development that could affect the

9 health of Indians and their water supply and food

10 chain;

11 ‘‘(4) a summary of any findings or rec12 ommendations provided in Federal and State stud13 ies, reports, investigations, and inspections during

14 the 5 years prior to the date of the enactment of

15 this Act that directly or indirectly relate to the ac16 tivities, practices, and conditions affecting the health

17 or safety of such Indians; and

18 ‘‘(5) a description of the efforts that have been

19 made by Federal and State agencies and resource

20 and economic development companies to effectively

21 carry out an education program for such Indians re22 garding the health and safety hazards of such devel23 opment.

24 ‘‘(b) DEVELOPMENT OF HEALTH CARE PLANS.—

25 Upon the completion of the study under subsection (a),
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1 the Secretary and the Service shall take into account the

2 results of such study and, in consultation with Indian

3 tribes and tribal organizations, develop a health care plan

4 to address the health problems that were the subject of

5 such study. The plans shall include—

6 ‘‘(1) methods for diagnosing and treating Indi7 ans currently exhibiting such health problems;

8 ‘‘(2) preventive care and testing for Indians

9 who may be exposed to such health hazards, includ10 ing the monitoring of the health of individuals who

11 have or may have been exposed to excessive amounts

12 of radiation, or affected by other activities that have

13 had or could have a serious impact upon the health

14 of such individuals; and

15 ‘‘(3) a program of education for Indians who,

16 by reason of their work or geographic proximity to

17 such nuclear or other development activities, may ex18 perience health problems.

19 ‘‘(c) SUBMISSION TO CONGRESS.—

20 ‘‘(1) GENERAL REPORT.—Not later than 18

21 months after the date of enactment of this Act, the

22 Secretary and the Service shall submit to Congress

23 a report concerning the study conducted under sub24 section (a).
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1 ‘‘(2) HEALTH CARE PLAN REPORT.—Not later

2 than 1 year after the date on which the report under

3 paragraph (1) is submitted to Congress, the Sec4 retary and the Service shall submit to Congress the

5 health care plan prepared under subsection (b).

6 Such plan shall include recommended activities for

7 the implementation of the plan, as well as an evalua8 tion of any activities previously undertaken by the

9 Service to address the health problems involved.

10 ‘‘(d) TASK FORCE.—

11 ‘‘(1) ESTABLISHED.—There is hereby estab12 lished an Intergovernmental Task Force (referred to

13 in this section as the ‘task force’) that shall be com14 posed of the following individuals (or their des15 ignees):

16 ‘‘(A) The Secretary of Energy.

17 ‘‘(B) The Administrator of the Environ18 mental Protection Agency.

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

20 ‘‘(D) The Assistant Secretary for Occupa21 tional Safety and Health.

22 ‘‘(E) The Secretary of the Interior.

23 ‘‘(2) DUTIES.—The Task Force shall identify

24 existing and potential operations related to nuclear

25 resource development or other environmental haz-
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1 ards that affect or may affect the health of Indians

2 on or near an Indian reservation or in an Indian

3 community, and enter into activities to correct exist4 ing health hazards and ensure that current and fu5 ture health problems resulting from nuclear resource

6 or other development activities are minimized or re7 duced.

8 ‘‘(3) ADMINISTRATIVE PROVISIONS.—The Sec9 retary shall serve as the chairperson of the Task

10 Force. The Task Force shall meet at least twice

11 each year. Each member of the Task Force shall

12 furnish necessary assistance to the Task Force.

13 ‘‘(e) PROVISION OF APPROPRIATE MEDICAL CARE.—

14 In the case of any Indian who—

15 ‘‘(1) as a result of employment in or near a

16 uranium mine or mill or near any other environ17 mental hazard, suffers from a work related illness or

18 condition;

19 ‘‘(2) is eligible to receive diagnosis and treat20 ment services from a Service facility; and

21 ‘‘(3) by reason of such Indian’s employment, is

22 entitled to medical care at the expense of such mine

23 or mill operator or entity responsible for the environ24 mental hazard;
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1 the Service shall, at the request of such Indian, render

2 appropriate medical care to such Indian for such illness

3 or condition and may recover the costs of any medical care

4 so rendered to which such Indian is entitled at the expense

5 of such operator or entity from such operator or entity.

6 Nothing in this subsection shall affect the rights of such

7 Indian to recover damages other than such costs paid to

8 the Service from the employer for such illness or condition.

9 ‘‘SEC. 216. ARIZONA AS A CONTRACT HEALTH SERVICE DE10 LIVERY AREA.

11 ‘‘(a) IN GENERAL.—For fiscal years beginning with

12 the fiscal year ending September 30, 1983, and ending

13 with the fiscal year ending September 30, 2015, the State

14 of Arizona shall be designated as a contract health service

15 delivery area by the Service for the purpose of providing

16 contract health care services to members of federally rec17 ognized Indian tribes of Arizona.

18 ‘‘(b) LIMITATION.—The Service shall not curtail any

19 health care services provided to Indians residing on Fed20 eral reservations in the State of Arizona if such curtail21 ment is due to the provision of contract services in such

22 State pursuant to the designation of such State as a con23 tract health service delivery area pursuant to subsection

24 (a).
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1 ‘‘SEC. 216A. NORTH DAKOTA AS A CONTRACT HEALTH

2 SERVICE DELIVERY AREA.

3 ‘‘(a) IN GENERAL.—For fiscal years beginning with

4 the fiscal year ending September 30, 2003, and ending

5 with the fiscal year ending September 30, 2015, the State

6 of North Dakota shall be designated as a contract health

7 service delivery area by the Service for the purpose of pro8 viding contract health care services to members of feder9 ally recognized Indian tribes of North Dakota.

10 ‘‘(b) LIMITATION.—The Service shall not curtail any

11 health care services provided to Indians residing on Fed12 eral reservations in the State of North Dakota if such cur13 tailment is due to the provision of contract services in such

14 State pursuant to the designation of such State as a con15 tract health service delivery area pursuant to subsection

16 (a).

17 ‘‘SEC. 216B. SOUTH DAKOTA AS A CONTRACT HEALTH SERV18 ICE DELIVERY AREA.

19 ‘‘(a) IN GENERAL.—For fiscal years beginning with

20 the fiscal year ending September 30, 2003, and ending

21 with the fiscal year ending September 30, 2015, the State

22 of South Dakota shall be designated as a contract health

23 service delivery area by the Service for the purpose of pro24 viding contract health care services to members of feder25 ally recognized Indian tribes of South Dakota.
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1 ‘‘(b) LIMITATION.—The Service shall not curtail any

2 health care services provided to Indians residing on Fed3 eral reservations in the State of South Dakota if such cur4 tailment is due to the provision of contract services in such

5 State pursuant to the designation of such State as a con6 tract health service delivery area pursuant to subsection

7 (a).

8 ‘‘SEC. 217. CALIFORNIA CONTRACT HEALTH SERVICES DEM9 ONSTRATION PROGRAM.

10 ‘‘(a) IN GENERAL.—The Secretary may fund a pro11 gram that utilizes the California Rural Indian Health

12 Board as a contract care intermediary to improve the ac13 cessibility of health services to California Indians.

14 ‘‘(b) REIMBURSEMENT OF BOARD.—

15 ‘‘(1) AGREEMENT.—The Secretary shall enter

16 into an agreement with the California Rural Indian

17 Health Board to reimburse the Board for costs (in18 cluding reasonable administrative costs) incurred

19 pursuant to this section in providing medical treat20 ment under contract to California Indians described

21 in section 809(b) throughout the California contract

22 health services delivery area described in section 218

23 with respect to high-cost contract care cases.

24 ‘‘(2) ADMINISTRATION.—Not more than 5 per25 cent of the amounts provided to the Board under
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1 this section for any fiscal year may be used for reim2 bursement for administrative expenses incurred by

3 the Board during such fiscal year.

4 ‘‘(3) LIMITATION.—No payment may be made

5 for treatment provided under this section to the ex6 tent that payment may be made for such treatment

7 under the Catastrophic Health Emergency Fund de8 scribed in section 202 or from amounts appropriated

9 or otherwise made available to the California con10 tract health service delivery area for a fiscal year.

11 ‘‘(c) ADVISORY BOARD.—There is hereby established

12 an advisory board that shall advise the California Rural

13 Indian Health Board in carrying out this section. The ad14 visory board shall be composed of representatives, selected

15 by the California Rural Indian Health Board, from not

16 less than 8 tribal health programs serving California Indi17 ans covered under this section, at least 50 percent of

18 whom are not affiliated with the California Rural Indian

19 Health Board.

20 ‘‘SEC. 218. CALIFORNIA AS A CONTRACT HEALTH SERVICE

21 DELIVERY AREA.

22 ‘‘The State of California, excluding the counties of

23 Alameda, Contra Costa, Los Angeles, Marin, Orange, Sac24 ramento, San Francisco, San Mateo, Santa Clara, Kern,

25 Merced, Monterey, Napa, San Benito, San Joaquin, San
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1 Luis Obispo, Santa Cruz, Solano, Stanislaus, and Ventura

2 shall be designated as a contract health service delivery

3 area by the Service for the purpose of providing contract

4 health services to Indians in such State, except that any

5 of the counties described in this section may be included

6 in the contract health services delivery area if funding is

7 specifically provided by the Service for such services in

8 those counties.

9 ‘‘SEC. 219. CONTRACT HEALTH SERVICES FOR THE TREN10 TON SERVICE AREA.

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

12 the Service, shall provide contract health services to mem13 bers of the Turtle Mountain Band of Chippewa Indians

14 that reside in the Trenton Service Area of Divide,

15 McKenzie, and Williams counties in the State of North

16 Dakota and the adjoining counties of Richland, Roosevelt,

17 and Sheridan in the State of Montana.

18 ‘‘(b) RULE OF CONSTRUCTION.—Nothing in this sec19 tion shall be construed as expanding the eligibility of mem20 bers of the Turtle Mountain Band of Chippewa Indians

21 for health services provided by the Service beyond the

22 scope of eligibility for such health services that applied on

23 May 1, 1986.
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1 ‘‘SEC. 220. PROGRAMS OPERATED BY INDIAN TRIBES AND

2 TRIBAL ORGANIZATIONS.

3 ‘‘The Service shall provide funds for health care pro4 grams and facilities operated by Indian tribes and tribal

5 organizations under funding agreements with the Service

6 entered into under the Indian Self-Determination and

7 Education Assistance Act on the same basis as such funds

8 are provided to programs and facilities operated directly

9 by the Service.

10 ‘‘SEC. 221. LICENSING.

11 ‘‘Health care professionals employed by Indian tribes

12 and tribal organizations to carry out agreements under the

13 Indian Self-Determination and Education Assistance Act,

14 shall, if licensed in any State, be exempt from the licensing

15 requirements of the State in which the agreement is per16 formed.

17 ‘‘SEC. 222. AUTHORIZATION FOR EMERGENCY CONTRACT

18 HEALTH SERVICES.

19 ‘‘With respect to an elderly Indian or an Indian with

20 a disability receiving emergency medical care or services

21 from a non-Service provider or in a non-Service facility

22 under the authority of this Act, the time limitation (as

23 a condition of payment) for notifying the Service of such

24 treatment or admission shall be 30 days.
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1 ‘‘SEC. 223. PROMPT ACTION ON PAYMENT OF CLAIMS.

2 ‘‘(a) REQUIREMENT.—The Service shall respond to

3 a notification of a claim by a provider of a contract care

4 service with either an individual purchase order or a denial

5 of the claim within 5 working days after the receipt of

6 such notification.

7 ‘‘(b) FAILURE TO RESPOND.—If the Service fails to

8 respond to a notification of a claim in accordance with

9 subsection (a), the Service shall accept as valid the claim

10 submitted by the provider of a contract care service.

11 ‘‘(c) PAYMENT.—The Service shall pay a valid con12 tract care service claim within 30 days after the comple13 tion of the claim.

14 ‘‘SEC. 224. LIABILITY FOR PAYMENT.

15 ‘‘(a) NO LIABILITY.—A patient who receives contract

16 health care services that are authorized by the Service

17 shall not be liable for the payment of any charges or costs

18 associated with the provision of such services.

19 ‘‘(b) NOTIFICATION.—The Secretary shall notify a

20 contract care provider and any patient who receives con21 tract health care services authorized by the Service that

22 such patient is not liable for the payment of any charges

23 or costs associated with the provision of such services.

24 ‘‘(c) LIMITATION.—Following receipt of the notice

25 provided under subsection (b), or, if a claim has been

26 deemed accepted under section 223(b), the provider shall
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1 have no further recourse against the patient who received

2 the services involved.

3 ‘‘SEC. 225. AUTHORIZATION OF APPROPRIATIONS.

4 ‘‘There are authorized to be appropriated such sums

5 as may be necessary for each fiscal year through fiscal

6 year 2015 to carry out this title.

7 ‘‘TITLE III—FACILITIES

8 ‘‘SEC. 301. CONSULTATION, CONSTRUCTION AND RENOVA9 TION OF FACILITIES; REPORTS.

10 ‘‘(a) CONSULTATION.—Prior to the expenditure of, or

11 the making of any firm commitment to expend, any funds

12 appropriated for the planning, design, construction, or

13 renovation of facilities pursuant to the Act of November

14 2, 1921 (25 U.S.C. 13) (commonly known as the Snyder

15 Act), the Secretary, acting through the Service, shall—

16 ‘‘(1) consult with any Indian tribe that would

17 be significantly affected by such expenditure for the

18 purpose of determining and, whenever practicable,

19 honoring tribal preferences concerning size, location,

20 type, and other characteristics of any facility on

21 which such expenditure is to be made; and

22 ‘‘(2) ensure, whenever practicable, that such fa23 cility meets the construction standards of any na24 tionally recognized accrediting body by not later
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1 than 1 year after the date on which the construction

2 or renovation of such facility is completed.

3 ‘‘(b) CLOSURE OF FACILITIES.—

4 ‘‘(1) IN GENERAL.—Notwithstanding any provi5 sion of law other than this subsection, no Service

6 hospital or outpatient health care facility or any in7 patient service or special care facility operated by

8 the Service, may be closed if the Secretary has not

9 submitted to the Congress at least 1 year prior to

10 the date such proposed closure an evaluation of the

11 impact of such proposed closure which specifies, in

12 addition to other considerations—

13 ‘‘(A) the accessibility of alternative health

14 care resources for the population served by such

15 hospital or facility;

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

17 ‘‘(C) the quality of health care to be pro18 vided to the population served by such hospital

19 or facility after such closure;

20 ‘‘(D) the availability of contract health

21 care funds to maintain existing levels of service;

22 ‘‘(E) the views of the Indian tribes served

23 by such hospital or facility concerning such clo24 sure;
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1 ‘‘(F) the level of utilization of such hos2 pital or facility by all eligible Indians; and

3 ‘‘(G) the distance between such hospital or

4 facility and the nearest operating Service hos5 pital.

6 ‘‘(2) TEMPORARY CLOSURE.—Paragraph (1)

7 shall not apply to any temporary closure of a facility

8 or of any portion of a facility if such closure is nec9 essary for medical, environmental, or safety reasons.

10 ‘‘(c) PRIORITY SYSTEM.—

11 ‘‘(1) ESTABLISHMENT.—The Secretary shall es12 tablish a health care facility priority system, that

13 shall—

14 ‘‘(A) be developed with Indian tribes and

15 tribal organizations through negotiated rule16 making under section 802;

17 ‘‘(B) give the needs of Indian tribes the

18 highest priority, with additional priority being

19 given to those service areas where the health

20 status of Indians within the area, as measured

21 by life expectancy based upon the most recent

22 data available, is significantly lower than the

23 average health status for Indians in all service

24 areas; and
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1 ‘‘(C) at a minimum, include the lists re2 quired in paragraph (2)(B) and the methodol3 ogy required in paragraph (2)(E);

4 except that the priority of any project established

5 under the construction priority system in effect on

6 the date of this Act shall not be affected by any

7 change in the construction priority system taking

8 place thereafter if the project was identified as one

9 of the top 10 priority inpatient projects or one of

10 the top 10 outpatient projects in the Indian Health

11 Service budget justification for fiscal year 2003, or

12 if the project had completed both Phase I and Phase

13 II of the construction priority system in effect on

14 the date of this Act.

15 ‘‘(2) REPORT.—The Secretary shall submit to

16 the President, for inclusion in each report required

17 to be transmitted to the Congress under section 801,

18 a report that includes—

19 ‘‘(A) a description of the health care facil20 ity priority system of the Service, as established

21 under paragraph (1);

22 ‘‘(B) health care facility lists, including—

23 ‘‘(i) the total health care facility plan24 ning, design, construction and renovation

25 needs for Indians;
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1 ‘‘(ii) the 10 top-priority inpatient care

2 facilities;

3 ‘‘(iii) the 10 top-priority outpatient

4 care facilities;

5 ‘‘(iv) the 10 top-priority specialized

6 care facilities (such as long-term care and

7 alcohol and drug abuse treatment); and

8 ‘‘(v) any staff quarters associated

9 with such prioritized facilities;

10 ‘‘(C) the justification for the order of pri11 ority among facilities;

12 ‘‘(D) the projected cost of the projects in13 volved; and

14 ‘‘(E) the methodology adopted by the Serv15 ice in establishing priorities under its health

16 care facility priority system.

17 ‘‘(3) CONSULTATION.—In preparing each report

18 required under paragraph (2) (other than the initial

19 report) the Secretary shall annually—

20 ‘‘(A) consult with, and obtain information

21 on all health care facilities needs from, Indian

22 tribes and tribal organizations including those

23 tribes or tribal organizations operating health

24 programs or facilities under any funding agree25 ment entered into with the Service under the
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1 Indian Self-Determination and Education As2 sistance Act; and

3 ‘‘(B) review the total unmet needs of all

4 tribes and tribal organizations for health care

5 facilities (including staff quarters), including

6 needs for renovation and expansion of existing

7 facilities.

8 ‘‘(4) CRITERIA.—For purposes of this sub9 section, the Secretary shall, in evaluating the needs

10 of facilities operated under any funding agreement

11 entered into with the Service under the Indian Self12 Determination and Education Assistance Act, use

13 the same criteria that the Secretary uses in evaluat14 ing the needs of facilities operated directly by the

15 Service.

16 ‘‘(5) EQUITABLE INTEGRATION.—The Secretary

17 shall ensure that the planning, design, construction,

18 and renovation needs of Service and non-Service fa19 cilities, operated under funding agreements in ac20 cordance with the Indian Self-Determination and

21 Education Assistance Act are fully and equitably in22 tegrated into the health care facility priority system.

23 ‘‘(d) REVIEW OF NEED FOR FACILITIES.—

24 ‘‘(1) REPORT.—Beginning in 2004, the Sec25 retary shall annually submit to the President, for in-
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1 clusion in the report required to be transmitted to

2 Congress under section 801 of this Act, a report

3 which sets forth the needs of the Service and all In4 dian tribes and tribal organizations, including urban

5 Indian organizations, for inpatient, outpatient and

6 specialized care facilities, including the needs for

7 renovation and expansion of existing facilities.

8 ‘‘(2) CONSULTATION.—In preparing each report

9 required under paragraph (1) (other than the initial

10 report), the Secretary shall consult with Indian

11 tribes and tribal organizations including those tribes

12 or tribal organizations operating health programs or

13 facilities under any funding agreement entered into

14 with the Service under the Indian Self-Determina15 tion and Education Assistance Act, and with urban

16 Indian organizations.

17 ‘‘(3) CRITERIA.—For purposes of this sub18 section, the Secretary shall, in evaluating the needs

19 of facilities operated under any funding agreement

20 entered into with the Service under the Indian Self21 Determination and Education Assistance Act, use

22 the same criteria that the Secretary uses in evaluat23 ing the needs of facilities operated directly by the

24 Service.
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1 ‘‘(4) EQUITABLE INTEGRATION.—The Secretary

2 shall ensure that the planning, design, construction,

3 and renovation needs of facilities operated under

4 funding agreements, in accordance with the Indian

5 Self-Determination and Education Assistance Act,

6 are fully and equitably integrated into the develop7 ment of the health facility priority system.

8 ‘‘(5) ANNUAL NOMINATIONS.—Each year the

9 Secretary shall provide an opportunity for the nomi10 nation of planning, design, and construction projects

11 by the Service and all Indian tribes and tribal orga12 nizations for consideration under the health care fa13 cility priority system.

14 ‘‘(e) INCLUSION OF CERTAIN PROGRAMS.—All funds

15 appropriated under the Act of November 2, 1921 (25

16 U.S.C. 13), for the planning, design, construction, or ren17 ovation of health facilities for the benefit of an Indian

18 tribe or tribes shall be subject to the provisions of section

19 102 of the Indian Self-Determination and Education As20 sistance Act.

21 ‘‘(f) INNOVATIVE APPROACHES.—The Secretary shall

22 consult and cooperate with Indian tribes, tribal organiza23 tions and urban Indian organizations in developing inno24 vative approaches to address all or part of the total unmet

25 need for construction of health facilities, including those
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1 provided for in other sections of this title and other ap2 proaches.

3 ‘‘SEC. 302. SAFE WATER AND SANITARY WASTE DISPOSAL

4 FACILITIES.

5 ‘‘(a) FINDINGS.—Congress finds and declares that—

6 ‘‘(1) the provision of safe water supply facilities

7 and sanitary sewage and solid waste disposal facili8 ties is primarily a health consideration and function;

9 ‘‘(2) Indian people suffer an inordinately high

10 incidence of disease, injury, and illness directly at11 tributable to the absence or inadequacy of such fa12 cilities;

13 ‘‘(3) the long-term cost to the United States of

14 treating and curing such disease, injury, and illness

15 is substantially greater than the short-term cost of

16 providing such facilities and other preventive health

17 measures;

18 ‘‘(4) many Indian homes and communities still

19 lack safe water supply facilities and sanitary sewage

20 and solid waste disposal facilities; and

21 ‘‘(5) it is in the interest of the United States,

22 and it is the policy of the United States, that all In23 dian communities and Indian homes, new and exist24 ing, be provided with safe and adequate water sup-
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1 ply facilities and sanitary sewage waste disposal fa2 cilities as soon as possible.

3 ‘‘(b) PROVISION OF FACILITIES AND SERVICES.—

4 ‘‘(1) IN GENERAL.—In furtherance of the find5 ings and declarations made in subsection (a), Con6 gress reaffirms the primary responsibility and au7 thority of the Service to provide the necessary sani8 tation facilities and services as provided in section 7

9 of the Act of August 5, 1954 (42 U.S.C. 2004a).

10 ‘‘(2) ASSISTANCE.—The Secretary, acting

11 through the Service, is authorized to provide under

12 section 7 of the Act of August 5, 1954 (42 U.S.C.

13 2004a)—

14 ‘‘(A) financial and technical assistance to

15 Indian tribes, tribal organizations and Indian

16 communities in the establishment, training, and

17 equipping of utility organizations to operate

18 and maintain Indian sanitation facilities, in19 cluding the provision of existing plans, standard

20 details, and specifications available in the De21 partment, to be used at the option of the tribe

22 or tribal organization;

23 ‘‘(B) ongoing technical assistance and

24 training in the management of utility organiza-
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1 tions which operate and maintain sanitation fa2 cilities; and

3 ‘‘(C) priority funding for the operation,

4 and maintenance assistance for, and emergency

5 repairs to, tribal sanitation facilities when nec6 essary to avoid an imminent health threat or to

7 protect the investment in sanitation facilities

8 and the investment in the health benefits

9 gained through the provision of sanitation fa10 cilities.

11 ‘‘(3) PROVISIONS RELATING TO FUNDING.—

12 Notwithstanding any other provision of law—

13 ‘‘(A) the Secretary of Housing and Urban

14 Development is authorized to transfer funds ap15 propriated under the Native American Housing

16 Assistance and Self-Determination Act of 1996

17 to the Secretary of Health and Human Serv18 ices;

19 ‘‘(B) the Secretary of Health and Human

20 Services is authorized to accept and use such

21 funds for the purpose of providing sanitation

22 facilities and services for Indians under section

23 7 of the Act of August 5, 1954 (42 U.S.C.

24 2004a);
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1 ‘‘(C) unless specifically authorized when

2 funds are appropriated, the Secretary of Health

3 and Human Services shall not use funds appro4 priated under section 7 of the Act of August 5,

5 1954 (42 U.S.C. 2004a) to provide sanitation

6 facilities to new homes constructed using funds

7 provided by the Department of Housing and

8 Urban Development;

9 ‘‘(D) the Secretary of Health and Human

10 Services is authorized to accept all Federal

11 funds that are available for the purpose of pro12 viding sanitation facilities and related services

13 and place those funds into funding agreements,

14 authorized under the Indian Self-Determination

15 and Education Assistance Act, between the Sec16 retary and Indian tribes and tribal organiza17 tions;

18 ‘‘(E) the Secretary may permit funds ap19 propriated under the authority of section 4 of

20 the Act of August 5, 1954 (42 U.S.C. 2004) to

21 be used to fund up to 100 percent of the

22 amount of a tribe’s loan obtained under any

23 Federal program for new projects to construct

24 eligible sanitation facilities to serve Indian

25 homes;
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1 ‘‘(F) the Secretary may permit funds ap2 propriated under the authority of section 4 of

3 the Act of August 5, 1954 (42 U.S.C. 2004) to

4 be used to meet matching or cost participation

5 requirements under other Federal and non-Fed6 eral programs for new projects to construct eli7 gible sanitation facilities;

8 ‘‘(G) all Federal agencies are authorized to

9 transfer to the Secretary funds identified,

10 granted, loaned or appropriated and thereafter

11 the Department’s applicable policies, rules, reg12 ulations shall apply in the implementation of

13 such projects;

14 ‘‘(H) the Secretary of Health and Human

15 Services shall enter into inter-agency agree16 ments with the Bureau of Indian Affairs, the

17 Department of Housing and Urban Develop18 ment, the Department of Agriculture, the Envi19 ronmental Protection Agency and other appro20 priate Federal agencies, for the purpose of pro21 viding financial assistance for safe water supply

22 and sanitary sewage disposal facilities under

23 this Act; and

24 ‘‘(I) the Secretary of Health and Human

25 Services shall, by regulation developed through
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1 rulemaking under section 802, establish stand2 ards applicable to the planning, design and con3 struction of water supply and sanitary sewage

4 and solid waste disposal facilities funded under

5 this Act.

6 ‘‘(c) 10-YEAR FUNDING PLAN.—The Secretary, act7 ing through the Service and in consultation with Indian

8 tribes and tribal organizations, shall develop and imple9 ment a 10-year funding plan to provide safe water supply

10 and sanitary sewage and solid waste disposal facilities

11 serving existing Indian homes and communities, and to

12 new and renovated Indian homes.

13 ‘‘(d) CAPABILITY OF TRIBE OR COMMUNITY.—The

14 financial and technical capability of an Indian tribe or

15 community to safely operate and maintain a sanitation fa16 cility shall not be a prerequisite to the provision or con17 struction of sanitation facilities by the Secretary.

18 ‘‘(e) FINANCIAL ASSISTANCE.—The Secretary may

19 provide financial assistance to Indian tribes, tribal organi20 zations and communities for the operation, management,

21 and maintenance of their sanitation facilities.

22 ‘‘(f) RESPONSIBILITY FOR FEES FOR OPERATION

23 AND MAINTENANCE.—The Indian family, community or

24 tribe involved shall have the primary responsibility to es25 tablish, collect, and use reasonable user fees, or otherwise
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1 set aside funding, for the purpose of operating and main2 taining sanitation facilities. If a community facility is

3 threatened with imminent failure and there is a lack of

4 tribal capacity to maintain the integrity or the health ben5 efit of the facility, the Secretary may assist the tribe in

6 the resolution of the problem on a short term basis

7 through cooperation with the emergency coordinator or by

8 providing operation and maintenance service.

9 ‘‘(g) ELIGIBILITY OF CERTAIN TRIBES OR ORGANI10 ZATIONS.—Programs administered by Indian tribes or

11 tribal organizations under the authority of the Indian Self12 Determination and Education Assistance Act shall be eli13 gible for—

14 ‘‘(1) any funds appropriated pursuant to this

15 section; and

16 ‘‘(2) any funds appropriated for the purpose of

17 providing water supply, sewage disposal, or solid

18 waste facilities;

19 on an equal basis with programs that are administered

20 directly by the Service.

21 ‘‘(h) REPORT.—

22 ‘‘(1) IN GENERAL.—The Secretary shall submit

23 to the President, for inclusion in each report re24 quired to be transmitted to the Congress under sec25 tion 801, a report which sets forth—
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1 ‘‘(A) the current Indian sanitation facility

2 priority system of the Service;

3 ‘‘(B) the methodology for determining

4 sanitation deficiencies;

5 ‘‘(C) the level of initial and final sanitation

6 deficiency for each type sanitation facility for

7 each project of each Indian tribe or community;

8 and

9 ‘‘(D) the amount of funds necessary to re10 duce the identified sanitation deficiency levels of

11 all Indian tribes and communities to a level I

12 sanitation deficiency as described in paragraph

13 (4)(A).

14 ‘‘(2) CONSULTATION.—In preparing each report

15 required under paragraph (1), the Secretary shall

16 consult with Indian tribes and tribal organizations

17 (including those tribes or tribal organizations operat18 ing health care programs or facilities under any

19 funding agreements entered into with the Service

20 under the Indian Self-Determination and Education

21 Assistance Act) to determine the sanitation needs of

22 each tribe and in developing the criteria on which

23 the needs will be evaluated through a process of ne24 gotiated rulemaking.
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1 ‘‘(3) METHODOLOGY.—The methodology used

2 by the Secretary in determining, preparing cost esti3 mates for and reporting sanitation deficiencies for

4 purposes of paragraph (1) shall be applied uniformly

5 to all Indian tribes and communities.

6 ‘‘(4) SANITATION DEFICIENCY LEVELS.—For

7 purposes of this subsection, the sanitation deficiency

8 levels for an individual or community sanitation fa9 cility serving Indian homes are as follows:

10 ‘‘(A) A level I deficiency is a sanitation fa11 cility serving an individual or community—

12 ‘‘(i) which complies with all applicable

13 water supply, pollution control and solid

14 waste disposal laws; and

15 ‘‘(ii) in which the deficiencies relate to

16 routine replacement, repair, or mainte17 nance needs.

18 ‘‘(B) A level II deficiency is a sanitation

19 facility serving an individual or community—

20 ‘‘(i) which substantially or recently

21 complied with all applicable water supply,

22 pollution control and solid waste laws, in

23 which the deficiencies relate to small or

24 minor capital improvements needed to

25 bring the facility back into compliance;
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1 ‘‘(ii) in which the deficiencies relate to

2 capital improvements that are necessary to

3 enlarge or improve the facilities in order to

4 meet the current needs for domestic sani5 tation facilities; or

6 ‘‘(iii) in which the deficiencies relate

7 to the lack of equipment or training by an

8 Indian tribe or community to properly op9 erate and maintain the sanitation facilities.

10 ‘‘(C) A level III deficiency is an individual

11 or community facility with water or sewer serv12 ice in the home, piped services or a haul system

13 with holding tanks and interior plumbing, or

14 where major significant interruptions to water

15 supply or sewage disposal occur frequently, re16 quiring major capital improvements to correct

17 the deficiencies. There is no access to or no ap18 proved or permitted solid waste facility avail19 able.

20 ‘‘(D) A level IV deficiency is an individual

21 or community facility where there are no piped

22 water or sewer facilities in the home or the fa23 cility has become inoperable due to major com24 ponent failure or where only a washeteria or

25 central facility exists.
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1 ‘‘(E) A level V deficiency is the absence of

2 a sanitation facility, where individual homes do

3 not have access to safe drinking water or ade4 quate wastewater disposal.

5 ‘‘(i) DEFINITIONS.—In this section:

6 ‘‘(1) FACILITY.—The terms ‘facility’ or ‘facili7 ties’ shall have the same meaning as the terms ‘sys8 tem’ or ‘systems’ unless the context requires other9 wise.

10 ‘‘(2) INDIAN COMMUNITY.—The term ‘Indian

11 community’ means a geographic area, a significant

12 proportion of whose inhabitants are Indians and

13 which is served by or capable of being served by a

14 facility described in this section.

15 ‘‘SEC. 303. PREFERENCE TO INDIANS AND INDIAN FIRMS.

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

17 the Service, may utilize the negotiating authority of the

18 Act of June 25, 1910 (25 U.S.C. 47), to give preference

19 to any Indian or any enterprise, partnership, corporation,

20 or other type of business organization owned and con21 trolled by an Indian or Indians including former or cur22 rently federally recognized Indian tribes in the State of

23 New York (hereinafter referred to as an ‘Indian firm’) in

24 the construction and renovation of Service facilities pursu25 ant to section 301 and in the construction of safe water
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1 and sanitary waste disposal facilities pursuant to section

2 302. Such preference may be accorded by the Secretary

3 unless the Secretary finds, pursuant to rules and regula4 tions promulgated by the Secretary, that the project or

5 function to be contracted for will not be satisfactory or

6 such project or function cannot be properly completed or

7 maintained under the proposed contract. The Secretary,

8 in arriving at such finding, shall consider whether the In9 dian or Indian firm will be deficient with respect to—

10 ‘‘(1) ownership and control by Indians;

11 ‘‘(2) equipment;

12 ‘‘(3) bookkeeping and accounting procedures;

13 ‘‘(4) substantive knowledge of the project or

14 function to be contracted for;

15 ‘‘(5) adequately trained personnel; or

16 ‘‘(6) other necessary components of contract

17 performance.

18 ‘‘(b) EXEMPTION FROM DAVIS-BACON.—For the

19 purpose of implementing the provisions of this title, con20 struction or renovation of facilities constructed or ren21 ovated in whole or in part by funds made available pursu22 ant to this title are exempt from the Act of March 3, 1931

23 (40 U.S.C. 276a—276a–5, known as the Davis-Bacon

24 Act). For all health facilities, staff quarters and sanitation

25 facilities, construction and renovation subcontractors shall
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1 be paid wages at rates that are not less than the prevailing

2 wage rates for similar construction in the locality involved,

3 as determined by the Indian tribe, tribes, or tribal organi4 zations served by such facilities.

5 ‘‘SEC. 304. SOBOBA SANITATION FACILITIES.

6 ‘‘Nothing in the Act of December 17, 1970 (84 Stat.

7 1465) shall be construed to preclude the Soboba Band of

8 Mission Indians and the Soboba Indian Reservation from

9 being provided with sanitation facilities and services under

10 the authority of section 7 of the Act of August 5, 1954

11 (68 Stat. 674), as amended by the Act of July 31, 1959

12 (73 Stat. 267).

13 ‘‘SEC. 305. EXPENDITURE OF NONSERVICE FUNDS FOR REN14 OVATION.

15 ‘‘(a) PERMISSIBILITY.—

16 ‘‘(1) IN GENERAL.—Notwithstanding any other

17 provision of law, the Secretary is authorized to ac18 cept any major expansion, renovation or moderniza19 tion by any Indian tribe of any Service facility, or

20 of any other Indian health facility operated pursuant

21 to a funding agreement entered into under the In22 dian Self-Determination and Education Assistance

23 Act, including—

24 ‘‘(A) any plans or designs for such expan25 sion, renovation or modernization; and
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1 ‘‘(B) any expansion, renovation or mod2 ernization for which funds appropriated under

3 any Federal law were lawfully expended;

4 but only if the requirements of subsection (b) are

5 met.

6 ‘‘(2) PRIORITY LIST.—The Secretary shall

7 maintain a separate priority list to address the need

8 for increased operating expenses, personnel or equip9 ment for such facilities described in paragraph (1).

10 The methodology for establishing priorities shall be

11 developed by negotiated rulemaking under section

12 802. The list of priority facilities will be revised an13 nually in consultation with Indian tribes and tribal

14 organizations.

15 ‘‘(3) REPORT.—The Secretary shall submit to

16 the President, for inclusion in each report required

17 to be transmitted to the Congress under section 801,

18 the priority list maintained pursuant to paragraph

19 (2).

20 ‘‘(b) REQUIREMENTS.—The requirements of this sub21 section are met with respect to any expansion, renovation

22 or modernization if—

23 ‘‘(1) the tribe or tribal organization—

24 ‘‘(A) provides notice to the Secretary of its

25 intent to expand, renovate or modernize; and
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1 ‘‘(B) applies to the Secretary to be placed

2 on a separate priority list to address the needs

3 of such new facilities for increased operating ex4 penses, personnel or equipment; and

5 ‘‘(2) the expansion renovation or

6 modernization—

7 ‘‘(A) is approved by the appropriate area

8 director of the Service for Federal facilities; and

9 ‘‘(B) is administered by the Indian tribe or

10 tribal organization in accordance with any ap11 plicable regulations prescribed by the Secretary

12 with respect to construction or renovation of

13 Service facilities.

14 ‘‘(c) RIGHT OF TRIBE IN CASE OF FAILURE OF FA15 CILITY TO BE USED AS A SERVICE FACILITY.—If any

16 Service facility which has been expanded, renovated or

17 modernized by an Indian tribe under this section ceases

18 to be used as a Service facility during the 20-year period

19 beginning on the date such expansion, renovation or mod20 ernization is completed, such Indian tribe shall be entitled

21 to recover from the United States an amount which bears

22 the same ratio to the value of such facility at the time

23 of such cessation as the value of such expansion, renova24 tion or modernization (less the total amount of any funds

25 provided specifically for such facility under any Federal
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1 program that were expended for such expansion, renova2 tion or modernization) bore to the value of such facility

3 at the time of the completion of such expansion, renova4 tion or modernization.

5 ‘‘SEC. 306. FUNDING FOR THE CONSTRUCTION, EXPANSION,

6 AND MODERNIZATION OF SMALL AMBULA7 TORY CARE FACILITIES.

8 ‘‘(a) AVAILABILITY OF FUNDING.—

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

10 through the Service and in consultation with Indian

11 tribes and tribal organization, shall make funding

12 available to tribes and tribal organizations for the

13 construction, expansion, or modernization of facili14 ties for the provision of ambulatory care services to

15 eligible Indians (and noneligible persons as provided

16 for in subsections (b)(2) and (c)(1)(C)). Funding

17 under this section may cover up to 100 percent of

18 the costs of such construction, expansion, or mod19 ernization. For the purposes of this section, the term

20 ‘construction’ includes the replacement of an exist21 ing facility.

22 ‘‘(2) REQUIREMENT.—Funding under para23 graph (1) may only be made available to an Indian

24 tribe or tribal organization operating an Indian

25 health facility (other than a facility owned or con-
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1 structed by the Service, including a facility originally

2 owned or constructed by the Service and transferred

3 to an Indian tribe or tribal organization) pursuant

4 to a funding agreement entered into under the In5 dian Self-Determination and Education Assistance

6 Act.

7 ‘‘(b) USE OF FUNDS.—

8 ‘‘(1) IN GENERAL.—Funds provided under this

9 section may be used only for the construction, ex10 pansion, or modernization (including the planning

11 and design of such construction, expansion, or mod12 ernization) of an ambulatory care facility—

13 ‘‘(A) located apart from a hospital;

14 ‘‘(B) not funded under section 301 or sec15 tion 307; and

16 ‘‘(C) which, upon completion of such con17 struction, expansion, or modernization will—

18 ‘‘(i) have a total capacity appropriate

19 to its projected service population;

20 ‘‘(ii) provide annually not less than

21 500 patient visits by eligible Indians and

22 other users who are eligible for services in

23 such facility in accordance with section

24 807(b)(1)(B); and
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1 ‘‘(iii) provide ambulatory care in a

2 service area (specified in the funding

3 agreement entered into under the Indian

4 Self-Determination and Education Assist5 ance Act) with a population of not less

6 than 1,500 eligible Indians and other users

7 who are eligible for services in such facility

8 in accordance with section 807(b)(1)(B).

9 ‘‘(2) LIMITATION.—Funding provided under

10 this section may be used only for the cost of that

11 portion of a construction, expansion or moderniza12 tion project that benefits the service population de13 scribed in clauses (ii) and (iii) of paragraph (1)(C).

14 The requirements of such clauses (ii) and (iii) shall

15 not apply to a tribe or tribal organization applying

16 for funding under this section whose principal office

17 for health care administration is located on an island

18 or where such office is not located on a road system

19 providing direct access to an inpatient hospital

20 where care is available to the service population.

21 ‘‘(c) APPLICATION AND PRIORITY.—

22 ‘‘(1) APPLICATION.—No funding may be made

23 available under this section unless an application for

24 such funding has been submitted to and approved by

25 the Secretary. An application or proposal for fund-
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1 ing under this section shall be submitted in accord2 ance with applicable regulations and shall set forth

3 reasonable assurance by the applicant that, at all

4 times after the construction, expansion, or mod5 ernization of a facility carried out pursuant to fund6 ing received under this section—

7 ‘‘(A) adequate financial support will be

8 available for the provision of services at such

9 facility;

10 ‘‘(B) such facility will be available to eligi11 ble Indians without regard to ability to pay or

12 source of payment; and

13 ‘‘(C) such facility will, as feasible without

14 diminishing the quality or quantity of services

15 provided to eligible Indians, serve noneligible

16 persons on a cost basis.

17 ‘‘(2) PRIORITY.—In awarding funds under this

18 section, the Secretary shall give priority to tribes

19 and tribal organizations that demonstrate—

20 ‘‘(A) a need for increased ambulatory care

21 services; and

22 ‘‘(B) insufficient capacity to deliver such

23 services.

24 ‘‘(d) FAILURE TO USE FACILITY AS HEALTH FACIL25 ITY.—If any facility (or portion thereof) with respect to
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1 which funds have been paid under this section, ceases,

2 within 5 years after completion of the construction, expan3 sion, or modernization carried out with such funds, to be

4 utilized for the purposes of providing health care services

5 to eligible Indians, all of the right, title, and interest in

6 and to such facility (or portion thereof) shall transfer to

7 the United States unless otherwise negotiated by the Serv8 ice and the Indian tribe or tribal organization.

9 ‘‘(e) NO INCLUSION IN TRIBAL SHARE.—Funding

10 provided to Indian tribes and tribal organizations under

11 this section shall be non-recurring and shall not be avail12 able for inclusion in any individual tribe’s tribal share for

13 an award under the Indian Self-Determination and Edu14 cation Assistance Act or for reallocation or redesign there15 under.

16 ‘‘SEC. 307. INDIAN HEALTH CARE DELIVERY DEMONSTRA17 TION PROJECT.

18 ‘‘(a) HEALTH CARE DELIVERY DEMONSTRATION

19 PROJECTS.—The Secretary, acting through the Service

20 and in consultation with Indian tribes and tribal organiza21 tions, may enter into funding agreements with, or make

22 grants or loan guarantees to, Indian tribes or tribal orga23 nizations for the purpose of carrying out a health care de24 livery demonstration project to test alternative means of

25 delivering health care and services through health facili-
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1 ties, including hospice, traditional Indian health and child

2 care facilities, to Indians.

3 ‘‘(b) USE OF FUNDS.—The Secretary, in approving

4 projects pursuant to this section, may authorize funding

5 for the construction and renovation of hospitals, health

6 centers, health stations, and other facilities to deliver

7 health care services and is authorized to—

8 ‘‘(1) waive any leasing prohibition;

9 ‘‘(2) permit carryover of funds appropriated for

10 the provision of health care services;

11 ‘‘(3) permit the use of other available funds;

12 ‘‘(4) permit the use of funds or property do13 nated from any source for project purposes;

14 ‘‘(5) provide for the reversion of donated real or

15 personal property to the donor; and

16 ‘‘(6) permit the use of Service funds to match

17 other funds, including Federal funds.

18 ‘‘(c) CRITERIA.—

19 ‘‘(1) IN GENERAL.—The Secretary shall develop

20 and publish regulations through rulemaking under

21 section 802 for the review and approval of applica22 tions submitted under this section. The Secretary

23 may enter into a contract, funding agreement or

24 award a grant under this section for projects which

25 meet the following criteria:
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1 ‘‘(A) There is a need for a new facility or

2 program or the reorientation of an existing fa3 cility or program.

4 ‘‘(B) A significant number of Indians, in5 cluding those with low health status, will be

6 served by the project.

7 ‘‘(C) The project has the potential to ad8 dress the health needs of Indians in an innova9 tive manner.

10 ‘‘(D) The project has the potential to de11 liver services in an efficient and effective man12 ner.

13 ‘‘(E) The project is economically viable.

14 ‘‘(F) The Indian tribe or tribal organiza15 tion has the administrative and financial capa16 bility to administer the project.

17 ‘‘(G) The project is integrated with provid18 ers of related health and social services and is

19 coordinated with, and avoids duplication of, ex20 isting services.

21 ‘‘(2) PEER REVIEW PANELS.—The Secretary

22 may provide for the establishment of peer review

23 panels, as necessary, to review and evaluate applica24 tions and to advise the Secretary regarding such ap-
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1 plications using the criteria developed pursuant to

2 paragraph (1).

3 ‘‘(3) PRIORITY.—The Secretary shall give prior4 ity to applications for demonstration projects under

5 this section in each of the following service units to

6 the extent that such applications are filed in a time7 ly manner and otherwise meet the criteria specified

8 in paragraph (1):

9 ‘‘(A) Cass Lake, Minnesota.

10 ‘‘(B) Clinton, Oklahoma.

11 ‘‘(C) Harlem, Montana.

12 ‘‘(D) Mescalero, New Mexico.

13 ‘‘(E) Owyhee, Nevada.

14 ‘‘(F) Parker, Arizona.

15 ‘‘(G) Schurz, Nevada.

16 ‘‘(H) Winnebago, Nebraska.

17 ‘‘(I) Ft. Yuma, California.

18 ‘‘(d) TECHNICAL ASSISTANCE.—The Secretary shall

19 provide such technical and other assistance as may be nec20 essary to enable applicants to comply with the provisions

21 of this section.

22 ‘‘(e) SERVICE TO INELIGIBLE PERSONS.—The au23 thority to provide services to persons otherwise ineligible

24 for the health care benefits of the Service and the author25 ity to extend hospital privileges in Service facilities to non-
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1 Service health care practitioners as provided in section

2 807 may be included, subject to the terms of such section,

3 in any demonstration project approved pursuant to this

4 section.

5 ‘‘(f) EQUITABLE TREATMENT.—For purposes of sub6 section (c)(1)(A), the Secretary shall, in evaluating facili7 ties operated under any funding agreement entered into

8 with the Service under the Indian Self-Determination and

9 Education Assistance Act, use the same criteria that the

10 Secretary uses in evaluating facilities operated directly by

11 the Service.

12 ‘‘(g) EQUITABLE INTEGRATION OF FACILITIES.—

13 The Secretary shall ensure that the planning, design, con14 struction, renovation and expansion needs of Service and

15 non-Service facilities which are the subject of a funding

16 agreement for health services entered into with the Service

17 under the Indian Self-Determination and Education As18 sistance Act, are fully and equitably integrated into the

19 implementation of the health care delivery demonstration

20 projects under this section.

21 ‘‘SEC. 308. LAND TRANSFER.

22 ‘‘(a) GENERAL AUTHORITY FOR TRANSFERS.—Not23 withstanding any other provision of law, the Bureau of

24 Indian Affairs and all other agencies and departments of

25 the United States are authorized to transfer, at no cost,
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1 land and improvements to the Service for the provision

2 of health care services. The Secretary is authorized to ac3 cept such land and improvements for such purposes.

4 ‘‘(b) CHEMAWA INDIAN SCHOOL.—The Bureau of In5 dian Affairs is authorized to transfer, at no cost, up to

6 5 acres of land at the Chemawa Indian School, Salem,

7 Oregon, to the Service for the provision of health care

8 services. The land authorized to be transferred by this sec9 tion is that land adjacent to land under the jurisdiction

10 of the Service and occupied by the Chemawa Indian

11 Health Center.

12 ‘‘SEC. 309. LEASES.

13 ‘‘(a) IN GENERAL.—Notwithstanding any other pro14 vision of law, the Secretary is authorized, in carrying out

15 the purposes of this Act, to enter into leases with Indian

16 tribes and tribal organizations for periods not in excess

17 of 20 years. Property leased by the Secretary from an In18 dian tribe or tribal organization may be reconstructed or

19 renovated by the Secretary pursuant to an agreement with

20 such Indian tribe or tribal organization.

21 ‘‘(b) FACILITIES FOR THE ADMINISTRATION AND DE22 LIVERY OF HEALTH SERVICES.—The Secretary may enter

23 into leases, contracts, and other legal agreements with In24 dian tribes or tribal organizations which hold—

25 ‘‘(1) title to;
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1 ‘‘(2) a leasehold interest in; or

2 ‘‘(3) a beneficial interest in (where title is held

3 by the United States in trust for the benefit of a

4 tribe);

5 facilities used for the administration and delivery of health

6 services by the Service or by programs operated by Indian

7 tribes or tribal organizations to compensate such Indian

8 tribes or tribal organizations for costs associated with the

9 use of such facilities for such purposes, and such leases

10 shall be considered as operating leases for the purposes

11 of scoring under the Budget Enforcement Act, notwith12 standing any other provision of law. Such costs include

13 rent, depreciation based on the useful life of the building,

14 principal and interest paid or accrued, operation and

15 maintenance expenses, and other expenses determined by

16 regulation to be allowable pursuant to regulations under

17 section 105(l) of the Indian Self-Determination and Edu18 cation Assistance Act.

19 ‘‘SEC. 310. LOANS, LOAN GUARANTEES AND LOAN REPAY20 MENT.

21 ‘‘(a) HEALTH CARE FACILITIES LOAN FUND.—

22 There is established in the Treasury of the United States

23 a fund to be known as the ‘Health Care Facilities Loan

24 Fund’ (referred to in this Act as the ‘HCFLF’) to provide

25 to Indian tribes and tribal organizations direct loans, or
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1 guarantees for loans, for the construction of health care

2 facilities (including inpatient facilities, outpatient facili3 ties, associated staff quarters and specialized care facili4 ties such as behavioral health and elder care facilities).

5 ‘‘(b) STANDARDS AND PROCEDURES.—The Secretary

6 may promulgate regulations, developed through rule7 making as provided for in section 802, to establish stand8 ards and procedures for governing loans and loan guaran9 tees under this section, subject to the following conditions:

10 ‘‘(1) The principal amount of a loan or loan

11 guarantee may cover up to 100 percent of eligible

12 costs, including costs for the planning, design, fi13 nancing, site land development, construction, reha14 bilitation, renovation, conversion, improvements,

15 medical equipment and furnishings, other facility re16 lated costs and capital purchase (but excluding staff17 ing).

18 ‘‘(2) The cumulative total of the principal of di19 rect loans and loan guarantees, respectively, out20 standing at any one time shall not exceed such limi21 tations as may be specified in appropriation Acts.

22 ‘‘(3) In the discretion of the Secretary, the pro23 gram under this section may be administered by the

24 Service or the Health Resources and Services Ad25 ministration (which shall be specified by regulation).
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1 ‘‘(4) The Secretary may make or guarantee a

2 loan with a term of the useful estimated life of the

3 facility, or 25 years, whichever is less.

4 ‘‘(5) The Secretary may allocate up to 100 per5 cent of the funds available for loans or loan guaran6 tees in any year for the purpose of planning and ap7 plying for a loan or loan guarantee.

8 ‘‘(6) The Secretary may accept an assignment

9 of the revenue of an Indian tribe or tribal organiza10 tion as security for any direct loan or loan guarantee

11 under this section.

12 ‘‘(7) In the planning and design of health facili13 ties under this section, users eligible under section

14 807(b) may be included in any projection of patient

15 population.

16 ‘‘(8) The Secretary shall not collect loan appli17 cation, processing or other similar fees from Indian

18 tribes or tribal organizations applying for direct

19 loans or loan guarantees under this section.

20 ‘‘(9) Service funds authorized under loans or

21 loan guarantees under this section may be used in

22 matching other Federal funds.

23 ‘‘(c) FUNDING.—

24 ‘‘(1) IN GENERAL.—The HCFLF shall consist

25 of—
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1 ‘‘(A) such sums as may be initially appro2 priated to the HCFLF and as may be subse3 quently appropriated under paragraph (2);

4 ‘‘(B) such amounts as may be collected

5 from borrowers; and

6 ‘‘(C) all interest earned on amounts in the

7 HCFLF.

8 ‘‘(2) AUTHORIZATION OF APPROPRIATIONS.—

9 There is authorized to be appropriated such sums as

10 may be necessary to initiate the HCFLF. For each

11 fiscal year after the initial year in which funds are

12 appropriated to the HCFLF, there is authorized to

13 be appropriated an amount equal to the sum of the

14 amount collected by the HCFLF during the preced15 ing fiscal year, and all accrued interest on such

16 amounts.

17 ‘‘(3) AVAILABILITY OF FUNDS.—Amounts ap18 propriated, collected or earned relative to the

19 HCFLF shall remain available until expended.

20 ‘‘(d) FUNDING AGREEMENTS.—Amounts in the

21 HCFLF and available pursuant to appropriation Acts may

22 be expended by the Secretary, acting through the Service,

23 to make loans under this section to an Indian tribe or trib24 al organization pursuant to a funding agreement entered
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1 into under the Indian Self-Determination and Education

2 Assistance Act.

3 ‘‘(e) INVESTMENTS.—The Secretary of the Treasury

4 shall invest such amounts of the HCFLF as such Sec5 retary determines are not required to meet current with6 drawals from the HCFLF. Such investments may be made

7 only in interest-bearing obligations of the United States.

8 For such purpose, such obligations may be acquired on

9 original issue at the issue price, or by purchase of out10 standing obligations at the market price. Any obligation

11 acquired by the fund may be sold by the Secretary of the

12 Treasury at the market price.

13 ‘‘(f) GRANTS.—The Secretary is authorized to estab14 lish a program to provide grants to Indian tribes and trib15 al organizations for the purpose of repaying all or part

16 of any loan obtained by an Indian tribe or tribal organiza17 tion for construction and renovation of health care facili18 ties (including inpatient facilities, outpatient facilities, as19 sociated staff quarters and specialized care facilities).

20 Loans eligible for such repayment grants shall include

21 loans that have been obtained under this section or other22 wise.

23 ‘‘SEC. 311. TRIBAL LEASING.

24 ‘‘Indian tribes and tribal organizations providing

25 health care services pursuant to a funding agreement con-
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1 tract entered into under the Indian Self-Determination

2 and Education Assistance Act may lease permanent struc3 tures for the purpose of providing such health care serv4 ices without obtaining advance approval in appropriation

5 Acts.

6 ‘‘SEC. 312. INDIAN HEALTH SERVICE/TRIBAL FACILITIES

7 JOINT VENTURE PROGRAM.

8 ‘‘(a) AUTHORITY.—

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

10 through the Service, shall make arrangements with

11 Indian tribes and tribal organizations to establish

12 joint venture demonstration projects under which an

13 Indian tribe or tribal organization shall expend trib14 al, private, or other available funds, for the acquisi15 tion or construction of a health facility for a mini16 mum of 10 years, under a no-cost lease, in exchange

17 for agreement by the Service to provide the equip18 ment, supplies, and staffing for the operation and

19 maintenance of such a health facility.

20 ‘‘(2) USE OF RESOURCES.—A tribe or tribal or21 ganization may utilize tribal funds, private sector, or

22 other available resources, including loan guarantees,

23 to fulfill its commitment under this subsection.

24 ‘‘(3) ELIGIBILITY OF CERTAIN ENTITIES.—A

25 tribe that has begun and substantially completed the
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1 process of acquisition or construction of a health fa2 cility shall be eligible to establish a joint venture

3 project with the Service using such health facility.

4 ‘‘(b) REQUIREMENTS.—

5 ‘‘(1) IN GENERAL.—The Secretary shall enter

6 into an arrangement under subsection (a)(1) with an

7 Indian tribe or tribal organization only if—

8 ‘‘(A) the Secretary first determines that

9 the Indian tribe or tribal organization has the

10 administrative and financial capabilities nec11 essary to complete the timely acquisition or con12 struction of the health facility described in sub13 section (a)(1); and

14 ‘‘(B) the Indian tribe or tribal organization

15 meets the needs criteria that shall be developed

16 through the negotiated rulemaking process pro17 vided for under section 802.

18 ‘‘(2) CONTINUED OPERATION OF FACILITY.—

19 The Secretary shall negotiate an agreement with the

20 Indian tribe or tribal organization regarding the con21 tinued operation of a facility under this section at

22 the end of the initial 10 year no-cost lease period.

23 ‘‘(3) BREACH OR TERMINATION OF AGREE24 MENT.—An Indian tribe or tribal organization that

25 has entered into a written agreement with the Sec-
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1 retary under this section, and that breaches or ter2 minates without cause such agreement, shall be lia3 ble to the United States for the amount that has

4 been paid to the tribe or tribal organization, or paid

5 to a third party on the tribe’s or tribal organiza6 tion’s behalf, under the agreement. The Secretary

7 has the right to recover tangible property (including

8 supplies), and equipment, less depreciation, and any

9 funds expended for operations and maintenance

10 under this section. The preceding sentence shall not

11 apply to any funds expended for the delivery of

12 health care services, or for personnel or staffing.

13 ‘‘(d) RECOVERY FOR NON-USE.—An Indian tribe or

14 tribal organization that has entered into a written agree15 ment with the Secretary under this section shall be enti16 tled to recover from the United States an amount that

17 is proportional to the value of such facility should at any

18 time within 10 years the Service ceases to use the facility

19 or otherwise breaches the agreement.

20 ‘‘(e) DEFINITION.—In this section, the terms ‘health

21 facility’ or ‘health facilities’ include staff quarters needed

22 to provide housing for the staff of the tribal health pro23 gram.
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1 ‘‘SEC. 313. LOCATION OF FACILITIES.

2 ‘‘(a) PRIORITY.—The Bureau of Indian Affairs and

3 the Service shall, in all matters involving the reorganiza4 tion or development of Service facilities, or in the estab5 lishment of related employment projects to address unem6 ployment conditions in economically depressed areas, give

7 priority to locating such facilities and projects on Indian

8 lands if requested by the Indian owner and the Indian

9 tribe with jurisdiction over such lands or other lands

10 owned or leased by the Indian tribe or tribal organization

11 so long as priority is given to Indian land owned by an

12 Indian tribe or tribes.

13 ‘‘(b) DEFINITION.—In this section, the term ‘Indian

14 lands’ means—

15 ‘‘(1) all lands within the exterior boundaries of

16 any Indian reservation;

17 ‘‘(2) any lands title to which is held in trust by

18 the United States for the benefit of any Indian tribe

19 or individual Indian, or held by any Indian tribe or

20 individual Indian subject to restriction by the United

21 States against alienation and over which an Indian

22 tribe exercises governmental power; and

23 ‘‘(3) all lands in Alaska owned by any Alaska

24 Native village, or any village or regional corporation

25 under the Alaska Native Claims Settlement Act, or

26 any land allotted to any Alaska Native.
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1 ‘‘SEC. 314. MAINTENANCE AND IMPROVEMENT OF HEALTH

2 CARE FACILITIES.

3 ‘‘(a) REPORT.—The Secretary shall submit to the

4 President, for inclusion in the report required to be trans5 mitted to Congress under section 801, a report that identi6 fies the backlog of maintenance and repair work required

7 at both Service and tribal facilities, including new facilities

8 expected to be in operation in the fiscal year after the year

9 for which the report is being prepared. The report shall

10 identify the need for renovation and expansion of existing

11 facilities to support the growth of health care programs.

12 ‘‘(b) MAINTENANCE OF NEWLY CONSTRUCTED

13 SPACE.—

14 ‘‘(1) IN GENERAL.—The Secretary may expend

15 maintenance and improvement funds to support the

16 maintenance of newly constructed space only if such

17 space falls within the approved supportable space al18 location for the Indian tribe or tribal organization.

19 ‘‘(2) DEFINITION.—For purposes of paragraph

20 (1), the term ‘supportable space allocation’ shall be

21 defined through the negotiated rulemaking process

22 provided for under section 802.

23 ‘‘(c) CONSTRUCTION OF REPLACEMENT FACILI24 TIES.—

25 ‘‘(1) IN GENERAL.—In addition to using main26 tenance and improvement funds for the maintenance
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1 of facilities under subsection (b)(1), an Indian tribe

2 or tribal organization may use such funds for the

3 construction of a replacement facility if the costs of

4 the renovation of such facility would exceed a maxi5 mum renovation cost threshold.

6 ‘‘(2) DEFINITION.—For purposes of paragraph

7 (1), the term ‘maximum renovation cost threshold’

8 shall be defined through the negotiated rulemaking

9 process provided for under section 802.

10 ‘‘SEC. 315. TRIBAL MANAGEMENT OF FEDERALLY-OWNED

11 QUARTERS.

12 ‘‘(a) ESTABLISHMENT OF RENTAL RATES.—

13 ‘‘(1) IN GENERAL.—Notwithstanding any other

14 provision of law, an Indian tribe or tribal organiza15 tion which operates a hospital or other health facility

16 and the federally-owned quarters associated there17 with, pursuant to a funding agreement under the In18 dian Self-Determination and Education Assistance

19 Act, may establish the rental rates charged to the

20 occupants of such quarters by providing notice to

21 the Secretary of its election to exercise such author22 ity.

23 ‘‘(2) OBJECTIVES.—In establishing rental rates

24 under paragraph (1), an Indian tribe or tribal orga-
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1 nization shall attempt to achieve the following objec2 tives:

3 ‘‘(A) The rental rates should be based on

4 the reasonable value of the quarters to the oc5 cupants thereof.

6 ‘‘(B) The rental rates should generate suf7 ficient funds to prudently provide for the oper8 ation and maintenance of the quarters, and,

9 subject to the discretion of the Indian tribe or

10 tribal organization, to supply reserve funds for

11 capital repairs and replacement of the quarters.

12 ‘‘(3) ELIGIBILITY FOR QUARTERS IMPROVE13 MENT AND REPAIR.—Any quarters whose rental

14 rates are established by an Indian tribe or tribal or15 ganization under this subsection shall continue to be

16 eligible for quarters improvement and repair funds

17 to the same extent as other federally-owned quarters

18 that are used to house personnel in Service-sup19 ported programs.

20 ‘‘(4) NOTICE OF CHANGE IN RATES.—An In21 dian tribe or tribal organization that exercises the

22 authority provided under this subsection shall pro23 vide occupants with not less than 60 days notice of

24 any change in rental rates.

25 ‘‘(b) COLLECTION OF RENTS.—
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1 ‘‘(1) IN GENERAL.—Notwithstanding any other

2 provision of law, and subject to paragraph (2), an

3 Indian tribe or a tribal organization that operates

4 federally-owned quarters pursuant to a funding

5 agreement under the Indian Self-Determination and

6 Education Assistance Act shall have the authority to

7 collect rents directly from Federal employees who oc8 cupy such quarters in accordance with the following:

9 ‘‘(A) The Indian tribe or tribal organiza10 tion shall notify the Secretary and the Federal

11 employees involved of its election to exercise its

12 authority to collect rents directly from such

13 Federal employees.

14 ‘‘(B) Upon the receipt of a notice described

15 in subparagraph (A), the Federal employees in16 volved shall pay rents for the occupancy of such

17 quarters directly to the Indian tribe or tribal

18 organization and the Secretary shall have no

19 further authority to collect rents from such em20 ployees through payroll deduction or otherwise.

21 ‘‘(C) Such rent payments shall be retained

22 by the Indian tribe or tribal organization and

23 shall not be made payable to or otherwise be

24 deposited with the United States.
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1 ‘‘(D) Such rent payments shall be depos2 ited into a separate account which shall be used

3 by the Indian tribe or tribal organization for

4 the maintenance (including capital repairs and

5 replacement expenses) and operation of the

6 quarters and facilities as the Indian tribe or

7 tribal organization shall determine appropriate.

8 ‘‘(2) RETROCESSION.—If an Indian tribe or

9 tribal organization which has made an election under

10 paragraph (1) requests retrocession of its authority

11 to directly collect rents from Federal employees oc12 cupying federally-owned quarters, such retrocession

13 shall become effective on the earlier of—

14 ‘‘(A) the first day of the month that begins

15 not less than 180 days after the Indian tribe or

16 tribal organization notifies the Secretary of its

17 desire to retrocede; or

18 ‘‘(B) such other date as may be mutually

19 agreed upon by the Secretary and the Indian

20 tribe or tribal organization.

21 ‘‘(c) RATES.—To the extent that an Indian tribe or

22 tribal organization, pursuant to authority granted in sub23 section (a), establishes rental rates for federally-owned

24 quarters provided to a Federal employee in Alaska, such

25 rents may be based on the cost of comparable private rent-
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1 al housing in the nearest established community with a

2 year-round population of 1,500 or more individuals.

3 ‘‘SEC. 316. APPLICABILITY OF BUY AMERICAN REQUIRE4 MENT.

5 ‘‘(a) IN GENERAL.—The Secretary shall ensure that

6 the requirements of the Buy American Act apply to all

7 procurements made with funds provided pursuant to the

8 authorization contained in section 318, except that Indian

9 tribes and tribal organizations shall be exempt from such

10 requirements.

11 ‘‘(b) FALSE OR MISLEADING LABELING.—If it has

12 been finally determined by a court or Federal agency that

13 any person intentionally affixed a label bearing a ‘Made

14 in America’ inscription, or any inscription with the same

15 meaning, to any product sold in or shipped to the United

16 States that is not made in the United States, such person

17 shall be ineligible to receive any contract or subcontract

18 made with funds provided pursuant to the authorization

19 contained in section 318, pursuant to the debarment, sus20 pension, and ineligibility procedures described in sections

21 9.400 through 9.409 of title 48, Code of Federal Regula22 tions.

23 ‘‘(c) DEFINITION.—In this section, the term ‘Buy

24 American Act’ means title III of the Act entitled ‘An Act

25 making appropriations for the Treasury and Post Office
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1 Departments for the fiscal year ending June 30, 1934,

2 and for other purposes’, approved March 3, 1933 (41

3 U.S.C. 10a et seq.).

4 ‘‘SEC. 317. OTHER FUNDING FOR FACILITIES.

5 ‘‘Notwithstanding any other provision of law—

6 ‘‘(1) the Secretary may accept from any source,

7 including Federal and State agencies, funds that are

8 available for the construction of health care facilities

9 and use such funds to plan, design and construct

10 health care facilities for Indians and to place such

11 funds into funding agreements authorized under the

12 Indian Self-Determination and Education Assistance

13 Act (25 U.S.C. 450f et seq.) between the Secretary

14 and an Indian tribe or tribal organization, except

15 that the receipt of such funds shall not have an ef16 fect on the priorities established pursuant to section

17 301;

18 ‘‘(2) the Secretary may enter into interagency

19 agreements with other Federal or State agencies and

20 other entities and to accept funds from such Federal

21 or State agencies or other entities to provide for the

22 planning, design and construction of health care fa23 cilities to be administered by the Service or by In24 dian tribes or tribal organizations under the Indian

25 Self-Determination and Education Assistance Act in
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1 order to carry out the purposes of this Act, together

2 with the purposes for which such funds are appro3 priated to such other Federal or State agency or for

4 which the funds were otherwise provided;

5 ‘‘(3) any Federal agency to which funds for the

6 construction of health care facilities are appropriated

7 is authorized to transfer such funds to the Secretary

8 for the construction of health care facilities to carry

9 out the purposes of this Act as well as the purposes

10 for which such funds are appropriated to such other

11 Federal agency; and

12 ‘‘(4) the Secretary, acting through the Service,

13 shall establish standards under regulations developed

14 through rulemaking under section 802, for the plan15 ning, design and construction of health care facilities

16 serving Indians under this Act.

17 ‘‘SEC. 318. AUTHORIZATION OF APPROPRIATIONS.

18 ‘‘There is authorized to be appropriated such sums

19 as may be necessary for each fiscal year through fiscal

20 year 2015 to carry out this title.
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1 ‘‘TITLE IV—ACCESS TO HEALTH

2 SERVICES

3 ‘‘SEC. 401. TREATMENT OF PAYMENTS UNDER MEDICARE

4 PROGRAM.

5 ‘‘(a) IN GENERAL.—Any payments received by the

6 Service, by an Indian tribe or tribal organization pursuant

7 to a funding agreement under the Indian Self-Determina8 tion and Education Assistance Act, or by an urban Indian

9 organization pursuant to title V of this Act for services

10 provided to Indians eligible for benefits under title XVIII

11 of the Social Security Act shall not be considered in deter12 mining appropriations for health care and services to Indi13 ans.

14 ‘‘(b) EQUAL TREATMENT.—Nothing in this Act au15 thorizes the Secretary to provide services to an Indian ben16 eficiary with coverage under title XVIII of the Social Secu17 rity Act in preference to an Indian beneficiary without

18 such coverage.

19 ‘‘(c) SPECIAL FUND.—

20 ‘‘(1) USE OF FUNDS.—Notwithstanding any

21 other provision of this title or of title XVIII of the

22 Social Security Act, payments to which any facility

23 of the Service is entitled by reason of this section

24 shall be placed in a special fund to be held by the

25 Secretary and first used (to such extent or in such
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1 amounts as are provided in appropriation Acts) for

2 the purpose of making any improvements in the pro3 grams of the Service which may be necessary to

4 achieve or maintain compliance with the applicable

5 conditions and requirements of this title and of title

6 XVIII of the Social Security Act. Any funds to be

7 reimbursed which are in excess of the amount nec8 essary to achieve or maintain such conditions and

9 requirements shall, subject to the consultation with

10 tribes being served by the service unit, be used for

11 reducing the health resource deficiencies of the In12 dian tribes.

13 ‘‘(2) NONAPPLICATION IN CASE OF ELECTION

14 FOR DIRECT BILLING.—Paragraph (1) shall not

15 apply upon the election of an Indian tribe or tribal

16 organization under section 405 to receive direct pay17 ments for services provided to Indians eligible for

18 benefits under title XVIII of the Social Security Act.

19 ‘‘SEC. 402. TREATMENT OF PAYMENTS UNDER MEDICAID

20 PROGRAM.

21 ‘‘(a) SPECIAL FUND.—

22 ‘‘(1) USE OF FUNDS.—Notwithstanding any

23 other provision of law, payments to which any facil24 ity of the Service (including a hospital, nursing facil25 ity, intermediate care facility for the mentally re-
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1 tarded, or any other type of facility which provides

2 services for which payment is available under title

3 XIX of the Social Security Act) is entitled under a

4 State plan by reason of section 1911 of such Act

5 shall be placed in a special fund to be held by the

6 Secretary and first used (to such extent or in such

7 amounts as are provided in appropriation Acts) for

8 the purpose of making any improvements in the fa9 cilities of such Service which may be necessary to

10 achieve or maintain compliance with the applicable

11 conditions and requirements of such title. Any pay12 ments which are in excess of the amount necessary

13 to achieve or maintain such conditions and require14 ments shall, subject to the consultation with tribes

15 being served by the service unit, be used for reduc16 ing the health resource deficiencies of the Indian

17 tribes. In making payments from such fund, the Sec18 retary shall ensure that each service unit of the

19 Service receives 100 percent of the amounts to which

20 the facilities of the Service, for which such service

21 unit makes collections, are entitled by reason of sec22 tion 1911 of the Social Security Act.

23 ‘‘(2) NONAPPLICATION IN CASE OF ELECTION

24 FOR DIRECT BILLING.—Paragraph (1) shall not

25 apply upon the election of an Indian tribe or tribal
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1 organization under section 405 to receive direct pay2 ments for services provided to Indians eligible for

3 medical assistance under title XIX of the Social Se4 curity Act.

5 ‘‘(b) PAYMENTS DISREGARDED FOR APPROPRIA6 TIONS.—Any payments received under section 1911 of the

7 Social Security Act for services provided to Indians eligible

8 for benefits under title XIX of the Social Security Act

9 shall not be considered in determining appropriations for

10 the provision of health care and services to Indians.

11 ‘‘(c) DIRECT BILLING.—For provisions relating to

12 the authority of certain Indian tribes and tribal organiza13 tions to elect to directly bill for, and receive payment for,

14 health care services provided by a hospital or clinic of such

15 tribes or tribal organizations and for which payment may

16 be made under this title, see section 405.

17 ‘‘SEC. 403. REPORT.

18 ‘‘(a) INCLUSION IN ANNUAL REPORT.—The Sec19 retary shall submit to the President, for inclusion in the

20 report required to be transmitted to the Congress under

21 section 801, an accounting on the amount and use of

22 funds made available to the Service pursuant to this title

23 as a result of reimbursements under titles XVIII and XIX

24 of the Social Security Act.
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1 ‘‘(b) IDENTIFICATION OF SOURCE OF PAYMENTS.—

2 If an Indian tribe or tribal organization receives funding

3 from the Service under the Indian Self-Determination and

4 Education Assistance Act or an urban Indian organization

5 receives funding from the Service under title V of this Act

6 and receives reimbursements or payments under title

7 XVIII, XIX, or XXI of the Social Security Act, such In8 dian tribe or tribal organization, or urban Indian organi9 zation, shall provide to the Service a list of each provider

10 enrollment number (or other identifier) under which it re11 ceives such reimbursements or payments.

12 ‘‘SEC. 404. GRANTS TO AND FUNDING AGREEMENTS WITH

13 THE SERVICE, INDIAN TRIBES OR TRIBAL OR14 GANIZATIONS, AND URBAN INDIAN ORGANI15 ZATIONS.

16 ‘‘(a) IN GENERAL.—The Secretary shall make grants

17 to or enter into funding agreements with Indian tribes and

18 tribal organizations to assist such organizations in estab19 lishing and administering programs on or near Federal In20 dian reservations and trust areas and in or near Alaska

21 Native villages to assist individual Indians to—

22 ‘‘(1) enroll under sections 1818, 1836, and

23 1837 of the Social Security Act;

24 ‘‘(2) pay premiums for health insurance cov25 erage; and
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1 ‘‘(3) apply for medical assistance provided pur2 suant to titles XIX and XXI of the Social Security

3 Act.

4 ‘‘(b) CONDITIONS.—The Secretary shall place condi5 tions as deemed necessary to effect the purpose of this

6 section in any funding agreement or grant which the Sec7 retary makes with any Indian tribe or tribal organization

8 pursuant to this section. Such conditions shall include, but

9 are not limited to, requirements that the organization suc10 cessfully undertake to—

11 ‘‘(1) determine the population of Indians to be

12 served that are or could be recipients of benefits or

13 assistance under titles XVIII, XIX, and XXI of the

14 Social Security Act;

15 ‘‘(2) assist individual Indians in becoming fa16 miliar with and utilizing such benefits and assist17 ance;

18 ‘‘(3) provide transportation to such individual

19 Indians to the appropriate offices for enrollment or

20 applications for such benefits and assistance;

21 ‘‘(4) develop and implement—

22 ‘‘(A) a schedule of income levels to deter23 mine the extent of payments of premiums by

24 such organizations for health insurance cov25 erage of needy individuals; and
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1 ‘‘(B) methods of improving the participa2 tion of Indians in receiving the benefits and as3 sistance provided under titles XVIII, XIX, and

4 XXI of the Social Security Act.

5 ‘‘(c) AGREEMENTS FOR RECEIPT AND PROCESSING

6 OF APPLICATIONS.—The Secretary may enter into an

7 agreement with an Indian tribe or tribal organization, or

8 an urban Indian organization, which provides for the re9 ceipt and processing of applications for medical assistance

10 under title XIX of the Social Security Act, child health

11 assistance under title XXI of such Act and benefits under

12 title XVIII of such Act by a Service facility or a health

13 care program administered by such Indian tribe or tribal

14 organization, or urban Indian organization, pursuant to

15 a funding agreement under the Indian Self-Determination

16 and Education Assistance Act or a grant or contract en17 tered into with an urban Indian organization under title

18 V of this Act. Notwithstanding any other provision of law,

19 such agreements shall provide for reimbursement of the

20 cost of outreach, education regarding eligibility and bene21 fits, and translation when such services are provided. The

22 reimbursement may be included in an encounter rate or

23 be made on a fee-for-service basis as appropriate for the

24 provider. When necessary to carry out the terms of this

25 section, the Secretary, acting through the Health Care Fi-
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1 nancing Administration or the Service, may enter into

2 agreements with a State (or political subdivision thereof)

3 to facilitate cooperation between the State and the Service,

4 an Indian tribe or tribal organization, and an urban In5 dian organization.

6 ‘‘(d) GRANTS.—

7 ‘‘(1) IN GENERAL.—The Secretary shall make

8 grants or enter into contracts with urban Indian or9 ganizations to assist such organizations in establish10 ing and administering programs to assist individual

11 urban Indians to—

12 ‘‘(A) enroll under sections 1818, 1836, and

13 1837 of the Social Security Act;

14 ‘‘(B) pay premiums on behalf of such indi15 viduals for coverage under title XVIII of such

16 Act; and

17 ‘‘(C) apply for medical assistance provided

18 under title XIX of such Act and for child health

19 assistance under title XXI of such Act.

20 ‘‘(2) REQUIREMENTS.—The Secretary shall in21 clude in the grants or contracts made or entered

22 into under paragraph (1) requirements that are—

23 ‘‘(A) consistent with the conditions im24 posed by the Secretary under subsection (b);
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1 ‘‘(B) appropriate to urban Indian organi2 zations and urban Indians; and

3 ‘‘(C) necessary to carry out the purposes of

4 this section.

5 ‘‘SEC. 405. DIRECT BILLING AND REIMBURSEMENT OF

6 MEDICARE, MEDICAID, AND OTHER THIRD

7 PARTY PAYORS.

8 ‘‘(a) ESTABLISHMENT OF DIRECT BILLING PRO9 GRAM.—

10 ‘‘(1) IN GENERAL.—The Secretary shall estab11 lish a program under which Indian tribes, tribal or12 ganizations, and Alaska Native health organizations

13 that contract or compact for the operation of a hos14 pital or clinic of the Service under the Indian Self15 Determination and Education Assistance Act may

16 elect to directly bill for, and receive payment for,

17 health care services provided by such hospital or

18 clinic for which payment is made under the medicare

19 program established under title XVIII of the Social

20 Security Act (42 U.S.C. 1395 et seq.), under the

21 medicaid program established under title XIX of the

22 Social Security Act (42 U.S.C. 1396 et seq.), or

23 from any other third party payor.

24 ‘‘(2) APPLICATION OF 100 PERCENT FMAP.—

25 The third sentence of section 1905(b) of the Social
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1 Security Act (42 U.S.C. 1396d(b)) shall apply for

2 purposes of reimbursement under title XIX of the

3 Social Security Act for health care services directly

4 billed under the program established under this sec5 tion.

6 ‘‘(b) DIRECT REIMBURSEMENT.—

7 ‘‘(1) USE OF FUNDS.—Each hospital or clinic

8 participating in the program described in subsection

9 (a) of this section shall be reimbursed directly under

10 titles XVIII and XIX of the Social Security Act for

11 services furnished, without regard to the provisions

12 of section 1880(c) of the Social Security Act (42

13 U.S.C. 1395qq(c)) and sections 402(a) and

14 807(b)(2)(A), but all funds so reimbursed shall first

15 be used by the hospital or clinic for the purpose of

16 making any improvements in the hospital or clinic

17 that may be necessary to achieve or maintain com18 pliance with the conditions and requirements appli19 cable generally to facilities of such type under title

20 XVIII or XIX of the Social Security Act. Any funds

21 so reimbursed which are in excess of the amount

22 necessary to achieve or maintain such conditions

23 shall be used—

24 ‘‘(A) solely for improving the health re25 sources deficiency level of the Indian tribe; and
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1 ‘‘(B) in accordance with the regulations of

2 the Service applicable to funds provided by the

3 Service under any contract entered into under

4 the Indian Self-Determination Act (25 U.S.C.

5 450f et seq.).

6 ‘‘(2) AUDITS.—The amounts paid to the hos7 pitals and clinics participating in the program estab8 lished under this section shall be subject to all audit9 ing requirements applicable to programs adminis10 tered directly by the Service and to facilities partici11 pating in the medicare and medicaid programs

12 under titles XVIII and XIX of the Social Security

13 Act.

14 ‘‘(3) SECRETARIAL OVERSIGHT.—The Secretary

15 shall monitor the performance of hospitals and clin16 ics participating in the program established under

17 this section, and shall require such hospitals and

18 clinics to submit reports on the program to the Sec19 retary on an annual basis.

20 ‘‘(4) NO PAYMENTS FROM SPECIAL FUNDS.—

21 Notwithstanding section 1880(c) of the Social Secu22 rity Act (42 U.S.C. 1395qq(c)) or section 402(a), no

23 payment may be made out of the special funds de24 scribed in such sections for the benefit of any hos25 pital or clinic during the period that the hospital or
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1 clinic participates in the program established under

2 this section.

3 ‘‘(c) REQUIREMENTS FOR PARTICIPATION.—

4 ‘‘(1) APPLICATION.—Except as provided in

5 paragraph (2)(B), in order to be eligible for partici6 pation in the program established under this section,

7 an Indian tribe, tribal organization, or Alaska Na8 tive health organization shall submit an application

9 to the Secretary that establishes to the satisfaction

10 of the Secretary that—

11 ‘‘(A) the Indian tribe, tribal organization,

12 or Alaska Native health organization contracts

13 or compacts for the operation of a facility of the

14 Service;

15 ‘‘(B) the facility is eligible to participate in

16 the medicare or medicaid programs under sec17 tion 1880 or 1911 of the Social Security Act

18 (42 U.S.C. 1395qq; 1396j);

19 ‘‘(C) the facility meets the requirements

20 that apply to programs operated directly by the

21 Service; and

22 ‘‘(D) the facility—

23 ‘‘(i) is accredited by an accrediting

24 body as eligible for reimbursement under

25 the medicare or medicaid programs; or
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1 ‘‘(ii) has submitted a plan, which has

2 been approved by the Secretary, for achiev3 ing such accreditation.

4 ‘‘(2) APPROVAL.—

5 ‘‘(A) IN GENERAL.—The Secretary shall

6 review and approve a qualified application not

7 later than 90 days after the date the applica8 tion is submitted to the Secretary unless the

9 Secretary determines that any of the criteria set

10 forth in paragraph (1) are not met.

11 ‘‘(B) GRANDFATHER OF DEMONSTRATION

12 PROGRAM PARTICIPANTS.—Any participant in

13 the demonstration program authorized under

14 this section as in effect on the day before the

15 date of enactment of the Alaska Native and

16 American Indian Direct Reimbursement Act of

17 2000 shall be deemed approved for participa18 tion in the program established under this sec19 tion and shall not be required to submit an ap20 plication in order to participate in the program.

21 ‘‘(C) DURATION.—An approval by the Sec22 retary of a qualified application under subpara23 graph (A), or a deemed approval of a dem24 onstration program under subparagraph (B),

25 shall continue in effect as long as the approved
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1 applicant or the deemed approved demonstra2 tion program meets the requirements of this

3 section.

4 ‘‘(d) EXAMINATION AND IMPLEMENTATION OF

5 CHANGES.—

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

7 through the Service, and with the assistance of the

8 Administrator of the Health Care Financing Admin9 istration, shall examine on an ongoing basis and

10 implement—

11 ‘‘(A) any administrative changes that may

12 be necessary to facilitate direct billing and re13 imbursement under the program established

14 under this section, including any agreements

15 with States that may be necessary to provide

16 for direct billing under title XIX of the Social

17 Security Act; and

18 ‘‘(B) any changes that may be necessary to

19 enable participants in the program established

20 under this section to provide to the Service

21 medical records information on patients served

22 under the program that is consistent with the

23 medical records information system of the Serv24 ice.
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1 ‘‘(2) ACCOUNTING INFORMATION.—The ac2 counting information that a participant in the pro3 gram established under this section shall be required

4 to report shall be the same as the information re5 quired to be reported by participants in the dem6 onstration program authorized under this section as

7 in effect on the day before the date of enactment of

8 the Alaska Native and American Indian Direct Re9 imbursement Act of 2000. The Secretary may from

10 time to time, after consultation with the program

11 participants, change the accounting information sub12 mission requirements.

13 ‘‘(e) WITHDRAWAL FROM PROGRAM.—A participant

14 in the program established under this section may with15 draw from participation in the same manner and under

16 the same conditions that a tribe or tribal organization may

17 retrocede a contracted program to the Secretary under au18 thority of the Indian Self-Determination Act (25 U.S.C.

19 450 et seq.). All cost accounting and billing authority

20 under the program established under this section shall be

21 returned to the Secretary upon the Secretary’s acceptance

22 of the withdrawal of participation in this program.
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1 ‘‘SEC. 406. REIMBURSEMENT FROM CERTAIN THIRD PAR2 TIES OF COSTS OF HEALTH SERVICES.

3 ‘‘(a) RIGHT OF RECOVERY.—Except as provided in

4 subsection (g), the United States, an Indian tribe or tribal

5 organization shall have the right to recover the reasonable

6 charges billed or expenses incurred by the Secretary or

7 an Indian tribe or tribal organization in providing health

8 services, through the Service or an Indian tribe or tribal

9 organization to any individual to the same extent that

10 such individual, or any nongovernmental provider of such

11 services, would be eligible to receive reimbursement or in12 demnification for such charges or expenses if—

13 ‘‘(1) such services had been provided by a non14 governmental provider; and

15 ‘‘(2) such individual had been required to pay

16 such charges or expenses and did pay such expenses.

17 ‘‘(b) URBAN INDIAN ORGANIZATIONS.—Except as

18 provided in subsection (g), an urban Indian organization

19 shall have the right to recover the reasonable charges

20 billed or expenses incurred by the organization in provid21 ing health services to any individual to the same extent

22 that such individual, or any other nongovernmental pro23 vider of such services, would be eligible to receive reim24 bursement or indemnification for such charges or expenses

25 if such individual had been required to pay such charges

26 or expenses and did pay such charges or expenses.
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1 ‘‘(c) LIMITATIONS ON RECOVERIES FROM STATES.—

2 Subsections (a) and (b) shall provide a right of recovery

3 against any State, only if the injury, illness, or disability

4 for which health services were provided is covered under—

5 ‘‘(1) workers’ compensation laws; or

6 ‘‘(2) a no-fault automobile accident insurance

7 plan or program.

8 ‘‘(d) NONAPPLICATION OF OTHER LAWS.—No law of

9 any State, or of any political subdivision of a State and

10 no provision of any contract entered into or renewed after

11 the date of enactment of the Indian Health Care Amend12 ments of 1988, shall prevent or hinder the right of recov13 ery of the United States or an Indian tribe or tribal orga14 nization under subsection (a), or an urban Indian organi15 zation under subsection (b).

16 ‘‘(e) NO EFFECT ON PRIVATE RIGHTS OF ACTION.—

17 No action taken by the United States or an Indian tribe

18 or tribal organization to enforce the right of recovery pro19 vided under subsection (a), or by an urban Indian organi20 zation to enforce the right of recovery provided under sub21 section (b), shall affect the right of any person to any

22 damages (other than damages for the cost of health serv23 ices provided by the Secretary through the Service).

24 ‘‘(f) METHODS OF ENFORCEMENT.—
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1 ‘‘(1) IN GENERAL.—The United States or an

2 Indian tribe or tribal organization may enforce the

3 right of recovery provided under subsection (a), and

4 an urban Indian organization may enforce the right

5 of recovery provided under subsection (b), by—

6 ‘‘(A) intervening or joining in any civil ac7 tion or proceeding brought—

8 ‘‘(i) by the individual for whom health

9 services were provided by the Secretary, an

10 Indian tribe or tribal organization, or

11 urban Indian organization; or

12 ‘‘(ii) by any representative or heirs of

13 such individual; or

14 ‘‘(B) instituting a civil action.

15 ‘‘(2) NOTICE.—All reasonable efforts shall be

16 made to provide notice of an action instituted in ac17 cordance with paragraph (1)(B) to the individual to

18 whom health services were provided, either before or

19 during the pendency of such action.

20 ‘‘(g) LIMITATION.—Notwithstanding this section, ab21 sent specific written authorization by the governing body

22 of an Indian tribe for the period of such authorization

23 (which may not be for a period of more than 1 year and

24 which may be revoked at any time upon written notice by

25 the governing body to the Service), neither the United
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1 States through the Service, nor an Indian tribe or tribal

2 organization under a funding agreement pursuant to the

3 Indian Self-Determination and Education Assistance Act,

4 nor an urban Indian organization funded under title V,

5 shall have a right of recovery under this section if the in6 jury, illness, or disability for which health services were

7 provided is covered under a self-insurance plan funded by

8 an Indian tribe or tribal organization, or urban Indian or9 ganization. Where such tribal authorization is provided,

10 the Service may receive and expend such funds for the

11 provision of additional health services.

12 ‘‘(h) COSTS AND ATTORNEYS’ FEES.—In any action

13 brought to enforce the provisions of this section, a prevail14 ing plaintiff shall be awarded reasonable attorneys’ fees

15 and costs of litigation.

16 ‘‘(i) RIGHT OF ACTION AGAINST INSURERS AND EM17 PLOYEE BENEFIT PLANS.—

18 ‘‘(1) IN GENERAL.—Where an insurance com19 pany or employee benefit plan fails or refuses to pay

20 the amount due under subsection (a) for services

21 provided to an individual who is a beneficiary, par22 ticipant, or insured of such company or plan, the

23 United States or an Indian tribe or tribal organiza24 tion shall have a right to assert and pursue all the

25 claims and remedies against such company or plan,
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1 and against the fiduciaries of such company or plan,

2 that the individual could assert or pursue under ap3 plicable Federal, State or tribal law.

4 ‘‘(2) URBAN INDIAN ORGANIZATIONS.—Where

5 an insurance company or employee benefit plan fails

6 or refuses to pay the amounts due under subsection

7 (b) for health services provided to an individual who

8 is a beneficiary, participant, or insured of such com9 pany or plan, the urban Indian organization shall

10 have a right to assert and pursue all the claims and

11 remedies against such company or plan, and against

12 the fiduciaries of such company or plan, that the in13 dividual could assert or pursue under applicable

14 Federal or State law.

15 ‘‘(j) NONAPPLICATION OF CLAIMS FILING REQUIRE16 MENTS.—Notwithstanding any other provision in law, the

17 Service, an Indian tribe or tribal organization, or an urban

18 Indian organization shall have a right of recovery for any

19 otherwise reimbursable claim filed on a current HCFA–

20 1500 or UB–92 form, or the current NSF electronic for21 mat, or their successors. No health plan shall deny pay22 ment because a claim has not been submitted in a unique

23 format that differs from such forms.
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1 ‘‘SEC. 407. CREDITING OF REIMBURSEMENTS.

2 ‘‘(a) RETENTION OF FUNDS.—Except as provided in

3 section 202(d), this title, and section 807, all reimburse4 ments received or recovered under the authority of this

5 Act, Public Law 87–693, or any other provision of law,

6 by reason of the provision of health services by the Service

7 or by an Indian tribe or tribal organization under a fund8 ing agreement pursuant to the Indian Self-Determination

9 and Education Assistance Act, or by an urban Indian or10 ganization funded under title V, shall be retained by the

11 Service or that tribe or tribal organization and shall be

12 available for the facilities, and to carry out the programs,

13 of the Service or that tribe or tribal organization to pro14 vide health care services to Indians.

15 ‘‘(b) NO OFFSET OF FUNDS.—The Service may not

16 offset or limit the amount of funds obligated to any service

17 unit or entity receiving funding from the Service because

18 of the receipt of reimbursements under subsection (a).

19 ‘‘SEC. 408. PURCHASING HEALTH CARE COVERAGE.

20 ‘‘An Indian tribe or tribal organization, and an urban

21 Indian organization may utilize funding from the Sec22 retary under this Act to purchase managed care coverage

23 for Service beneficiaries (including insurance to limit the

24 financial risks of managed care entities) from—

25 ‘‘(1) a tribally owned and operated managed

26 care plan;
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1 ‘‘(2) a State or locally-authorized or licensed

2 managed care plan; or

3 ‘‘(3) a health insurance provider.

4 ‘‘SEC. 409. INDIAN HEALTH SERVICE, DEPARTMENT OF VET5 ERAN’S AFFAIRS, AND OTHER FEDERAL

6 AGENCY HEALTH FACILITIES AND SERVICES

7 SHARING.

8 ‘‘(a) EXAMINATION OF FEASIBILITY OF ARRANGE9 MENTS.—

10 ‘‘(1) IN GENERAL.—The Secretary shall exam11 ine the feasibility of entering into arrangements or

12 expanding existing arrangements for the sharing of

13 medical facilities and services between the Service

14 and the Veterans’ Administration, and other appro15 priate Federal agencies, including those within the

16 Department, and shall, in accordance with sub17 section (b), prepare a report on the feasibility of

18 such arrangements.

19 ‘‘(2) SUBMISSION OF REPORT.—Not later than

20 September 30, 2003, the Secretary shall submit the

21 report required under paragraph (1) to Congress.

22 ‘‘(3) CONSULTATION REQUIRED.—The Sec23 retary may not finalize any arrangement described

24 in paragraph (1) without first consulting with the

25 affected Indian tribes.
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1 ‘‘(b) LIMITATIONS.—The Secretary shall not take

2 any action under this section or under subchapter IV of

3 chapter 81 of title 38, United States Code, which would

4 impair—

5 ‘‘(1) the priority access of any Indian to health

6 care services provided through the Service;

7 ‘‘(2) the quality of health care services provided

8 to any Indian through the Service;

9 ‘‘(3) the priority access of any veteran to health

10 care services provided by the Veterans’ Administra11 tion;

12 ‘‘(4) the quality of health care services provided

13 to any veteran by the Veteran’s Administration;

14 ‘‘(5) the eligibility of any Indian to receive

15 health services through the Service; or

16 ‘‘(6) the eligibility of any Indian who is a vet17 eran to receive health services through the Veterans’

18 Administration provided, however, the Service or the

19 Indian tribe or tribal organization shall be reim20 bursed by the Veterans’ Administration where serv21 ices are provided through the Service or Indian

22 tribes or tribal organizations to beneficiaries eligible

23 for services from the Veterans’ Administration, not24 withstanding any other provision of law.
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1 ‘‘(c) AGREEMENTS FOR PARITY IN SERVICES.—The

2 Service may enter into agreements with other Federal

3 agencies to assist in achieving parity in services for Indi4 ans. Nothing in this section may be construed as creating

5 any right of a veteran to obtain health services from the

6 Service.

7 ‘‘SEC. 410. PAYOR OF LAST RESORT.

8 ‘‘The Service, and programs operated by Indian

9 tribes or tribal organizations, or urban Indian organiza10 tions shall be the payor of last resort for services provided

11 to individuals eligible for services from the Service and

12 such programs, notwithstanding any Federal, State or

13 local law to the contrary, unless such law explicitly pro14 vides otherwise.

15 ‘‘SEC. 411. RIGHT TO RECOVER FROM FEDERAL HEALTH

16 CARE PROGRAMS.

17 ‘‘Notwithstanding any other provision of law, the

18 Service, Indian tribes or tribal organizations, and urban

19 Indian organizations (notwithstanding limitations on who

20 is eligible to receive services from such entities) shall be

21 entitled to receive payment or reimbursement for services

22 provided by such entities from any federally funded health

23 care program, unless there is an explicit prohibition on

24 such payments in the applicable authorizing statute.
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1 ‘‘SEC. 412. TUBA CITY DEMONSTRATION PROJECT.

2 ‘‘(a) IN GENERAL.—Notwithstanding any other pro3 vision of law, including the Anti-Deficiency Act, provided

4 the Indian tribes to be served approve, the Service in the

5 Tuba City Service Unit may—

6 ‘‘(1) enter into a demonstration project with the

7 State of Arizona under which the Service would pro8 vide certain specified medicaid services to individuals

9 dually eligible for services from the Service and for

10 medical assistance under title XIX of the Social Se11 curity Act in return for payment on a capitated

12 basis from the State of Arizona; and

13 ‘‘(2) purchase insurance to limit the financial

14 risks under the project.

15 ‘‘(b) EXTENSION OF PROJECT.—The demonstration

16 project authorized under subsection (a) may be extended

17 to other service units in Arizona, subject to the approval

18 of the Indian tribes to be served in such service units, the

19 Service, and the State of Arizona.

20 ‘‘SEC. 413. ACCESS TO FEDERAL INSURANCE.

21 ‘‘Notwithstanding the provisions of title 5, United

22 States Code, Executive Order, or administrative regula23 tion, an Indian tribe or tribal organization carrying out

24 programs under the Indian Self-Determination and Edu25 cation Assistance Act or an urban Indian organization car26 rying out programs under title V of this Act shall be enti-
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1 tled to purchase coverage, rights and benefits for the em2 ployees of such Indian tribe or tribal organization, or

3 urban Indian organization, under chapter 89 of title 5,

4 United States Code, and chapter 87 of such title if nec5 essary employee deductions and agency contributions in

6 payment for the coverage, rights, and benefits for the pe7 riod of employment with such Indian tribe or tribal organi8 zation, or urban Indian organization, are currently depos9 ited in the applicable Employee’s Fund under such title.

10 ‘‘SEC. 414. CONSULTATION AND RULEMAKING.

11 ‘‘(a) CONSULTATION.—Prior to the adoption of any

12 policy or regulation by the Health Care Financing Admin13 istration, the Secretary shall require the Administrator of

14 that Administration to—

15 ‘‘(1) identify the impact such policy or regula16 tion may have on the Service, Indian tribes or tribal

17 organizations, and urban Indian organizations;

18 ‘‘(2) provide to the Service, Indian tribes or

19 tribal organizations, and urban Indian organizations

20 the information described in paragraph (1);

21 ‘‘(3) engage in consultation, consistent with the

22 requirements of Executive Order 13084 of May 14,

23 1998, with the Service, Indian tribes or tribal orga24 nizations, and urban Indian organizations prior to

25 enacting any such policy or regulation.
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1 ‘‘(b) RULEMAKING.—The Administrator of the

2 Health Care Financing Administration shall participate in

3 the negotiated rulemaking provided for under title VIII

4 with regard to any regulations necessary to implement the

5 provisions of this title that relate to the Social Security

6 Act.

7 ‘‘SEC. 415. LIMITATIONS ON CHARGES.

8 ‘‘No provider of health services that is eligible to re9 ceive payments or reimbursements under titles XVIII,

10 XIX, or XXI of the Social Security Act or from any feder11 ally funded (whether in whole or part) health care pro12 gram may seek to recover payment for services—

13 ‘‘(1) that are covered under and furnished to an

14 individual eligible for the contract health services

15 program operated by the Service, by an Indian tribe

16 or tribal organization, or furnished to an urban In17 dian eligible for health services purchased by an

18 urban Indian organization, in an amount in excess

19 of the lowest amount paid by any other payor for

20 comparable services; or

21 ‘‘(2) for examinations or other diagnostic proce22 dures that are not medically necessary if such proce23 dures have already been performed by the referring

24 Indian health program and reported to the provider.
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1 ‘‘SEC. 416. LIMITATION ON SECRETARY’S WAIVER AUTHOR2 ITY.

3 ‘‘Notwithstanding any other provision of law, the Sec4 retary may not waive the application of section

5 1902(a)(13)(D) of the Social Security Act to any State

6 plan under title XIX of the Social Security Act.

7 ‘‘SEC. 417. WAIVER OF MEDICARE AND MEDICAID SANC8 TIONS.

9 ‘‘Notwithstanding any other provision of law, the

10 Service or an Indian tribe or tribal organization or an

11 urban Indian organization operating a health program

12 under the Indian Self-Determination and Education As13 sistance Act shall be entitled to seek a waiver of sanctions

14 imposed under title XVIII, XIX, or XXI of the Social Se15 curity Act as if such entity were directly responsible for

16 administering the State health care program.

17 ‘‘SEC. 418. MEANING OF ‘REMUNERATION’ FOR PURPOSES

18 OF SAFE HARBOR PROVISIONS; ANTITRUST

19 IMMUNITY.

20 ‘‘(a) MEANING OF REMUNERATION.—Notwithstand21 ing any other provision of law, the term ‘remuneration’

22 as used in sections 1128A and 1128B of the Social Secu23 rity Act shall not include any exchange of anything of

24 value between or among—

25 ‘‘(1) any Indian tribe or tribal organization or

26 an urban Indian organization that administers
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1 health programs under the authority of the Indian

2 Self-Determination and Education Assistance Act;

3 ‘‘(2) any such Indian tribe or tribal organiza4 tion or urban Indian organization and the Service;

5 ‘‘(3) any such Indian tribe or tribal organiza6 tion or urban Indian organization and any patient

7 served or eligible for service under such programs,

8 including patients served or eligible for service pur9 suant to section 813 of this Act (as in effect on the

10 day before the date of enactment of the Indian

11 Health Care Improvement Act Reauthorization of

12 2003); or

13 ‘‘(4) any such Indian tribe or tribal organiza14 tion or urban Indian organization and any third

15 party required by contract, section 206 or 207 of

16 this Act (as so in effect), or other applicable law, to

17 pay or reimburse the reasonable health care costs in18 curred by the United States or any such Indian tribe

19 or tribal organization or urban Indian organization;

20 provided the exchange arises from or relates to such health

21 programs.

22 ‘‘(b) ANTITRUST IMMUNITY.—An Indian tribe or

23 tribal organization or an urban Indian organization that

24 administers health programs under the authority of the

25 Indian Self-Determination and Education Assistance Act
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1 or title V shall be deemed to be an agency of the United

2 States and immune from liability under the Acts com3 monly known as the Sherman Act, the Clayton Act, the

4 Robinson-Patman Anti-Discrimination Act, the Federal

5 Trade Commission Act, and any other Federal, State, or

6 local antitrust laws, with regard to any transaction, agree7 ment, or conduct that relates to such programs.

8 ‘‘SEC. 419. CO-INSURANCE, CO-PAYMENTS, DEDUCTIBLES

9 AND PREMIUMS.

10 ‘‘(a) EXEMPTION FROM COST-SHARING REQUIRE11 MENTS.—Notwithstanding any other provision of Federal

12 or State law, no Indian who is eligible for services under

13 title XVIII, XIX, or XXI of the Social Security Act, or

14 under any other Federally funded health care programs,

15 may be charged a deductible, co-payment, or co-insurance

16 for any service provided by or through the Service, an In17 dian tribe or tribal organization or urban Indian organiza18 tion, nor may the payment or reimbursement due to the

19 Service or an Indian tribe or tribal organization or urban

20 Indian organization be reduced by the amount of the de21 ductible, co-payment, or co-insurance that would be due

22 from the Indian but for the operation of this section. For

23 the purposes of this section, the term ‘through’ shall in24 clude services provided directly, by referral, or under con25 tracts or other arrangements between the Service, an In-
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1 dian tribe or tribal organization or an urban Indian orga2 nization and another health provider.

3 ‘‘(b) EXEMPTION FROM PREMIUMS.—

4 ‘‘(1) MEDICAID AND STATE CHILDREN’S

5 HEALTH INSURANCE PROGRAM.—Notwithstanding

6 any other provision of Federal or State law, no In7 dian who is otherwise eligible for medical assistance

8 under title XIX of the Social Security Act or child

9 health assistance under title XXI of such Act may

10 be charged a premium as a condition of receiving

11 such assistance under title XIX or XXI of such Act.

12 ‘‘(2) MEDICARE ENROLLMENT PREMIUM PEN13 ALTIES.—Notwithstanding section 1839(b) of the

14 Social Security Act or any other provision of Federal

15 or State law, no Indian who is eligible for benefits

16 under part B of title XVIII of the Social Security

17 Act, but for the payment of premiums, shall be

18 charged a penalty for enrolling in such part at a

19 time later than the Indian might otherwise have

20 been first eligible to do so. The preceding sentence

21 applies whether an Indian pays for premiums under

22 such part directly or such premiums are paid by an23 other person or entity, including a State, the Serv24 ice, an Indian tribe or tribal organization, or an

25 urban Indian organization.
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1 ‘‘SEC. 420. INCLUSION OF INCOME AND RESOURCES FOR

2 PURPOSES OF MEDICALLY NEEDY MEDICAID

3 ELIGIBILITY.

4 ‘‘For the purpose of determining the eligibility under

5 section 1902(a)(10)(A)(ii)(IV) of the Social Security Act

6 of an Indian for medical assistance under a State plan

7 under title XIX of such Act, the cost of providing services

8 to an Indian in a health program of the Service, an Indian

9 tribe or tribal organization, or an urban Indian organiza10 tion shall be deemed to have been an expenditure for

11 health care by the Indian.

12 ‘‘SEC. 421. ESTATE RECOVERY PROVISIONS.

13 ‘‘Notwithstanding any other provision of Federal or

14 State law, the following property may not be included

15 when determining eligibility for services or implementing

16 estate recovery rights under title XVIII, XIX, or XXI of

17 the Social Security Act, or any other health care programs

18 funded in whole or part with Federal funds:

19 ‘‘(1) Income derived from rents, leases, or roy20 alties of property held in trust for individuals by the

21 Federal Government.

22 ‘‘(2) Income derived from rents, leases, royal23 ties, or natural resources (including timber and fish24 ing activities) resulting from the exercise of federally

25 protected rights, whether collected by an individual

26 or a tribal group and distributed to individuals.
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1 ‘‘(3) Property, including interests in real prop2 erty currently or formerly held in trust by the Fed3 eral Government which is protected under applicable

4 Federal, State or tribal law or custom from re5 course, including public domain allotments.

6 ‘‘(4) Property that has unique religious or cul7 tural significance or that supports subsistence or

8 traditional life style according to applicable tribal

9 law or custom.

10 ‘‘SEC. 422. MEDICAL CHILD SUPPORT.

11 ‘‘Notwithstanding any other provision of law, a par12 ent shall not be responsible for reimbursing the Federal

13 Government or a State for the cost of medical services pro14 vided to a child by or through the Service, an Indian tribe

15 or tribal organization or an urban Indian organization.

16 For the purposes of this subsection, the term ‘through’

17 includes services provided directly, by referral, or under

18 contracts or other arrangements between the Service, an

19 Indian tribe or tribal organization or an urban Indian or20 ganization and another health provider.

21 ‘‘SEC. 423. PROVISIONS RELATING TO MANAGED CARE.

22 ‘‘(a) RECOVERY FROM MANAGED CARE PLANS.—

23 Notwithstanding any other provision in law, the Service,

24 an Indian tribe or tribal organization or an urban Indian

25 organization shall have a right of recovery under section
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1 408 from all private and public health plans or programs,

2 including the medicare, medicaid, and State children’s

3 health insurance programs under titles XVIII, XIX, and

4 XXI of the Social Security Act, for the reasonable costs

5 of delivering health services to Indians entitled to receive

6 services from the Service, an Indian tribe or tribal organi7 zation or an urban Indian organization.

8 ‘‘(b) LIMITATION.—No provision of law or regulation,

9 or of any contract, may be relied upon or interpreted to

10 deny or reduce payments otherwise due under subsection

11 (a), except to the extent the Service, an Indian tribe or

12 tribal organization, or an urban Indian organization has

13 entered into an agreement with a managed care entity re14 garding services to be provided to Indians or rates to be

15 paid for such services, provided that such an agreement

16 may not be made a prerequisite for such payments to be

17 made.

18 ‘‘(c) PARITY.—Payments due under subsection (a)

19 from a managed care entity may not be paid at a rate

20 that is less than the rate paid to a ‘preferred provider’

21 by the entity or, in the event there is no such rate, the

22 usual and customary fee for equivalent services.

23 ‘‘(d) NO CLAIM REQUIREMENT.—A managed care

24 entity may not deny payment under subsection (a) because

25 an enrollee with the entity has not submitted a claim.
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1 ‘‘(e) DIRECT BILLING.—Notwithstanding the preced2 ing subsections of this section, the Service, an Indian tribe

3 or tribal organization, or an urban Indian organization

4 that provides a health service to an Indian entitled to med5 ical assistance under the State plan under title XIX of

6 the Social Security Act or enrolled in a child health plan

7 under title XXI of such Act shall have the right to be

8 paid directly by the State agency administering such plans

9 notwithstanding any agreements the State may have en10 tered into with managed care organizations or providers.

11 ‘‘(f) REQUIREMENT FOR MEDICAID MANAGED CARE

12 ENTITIES.—A managed care entity (as defined in section

13 1932(a)(1)(B) of the Social Security Act shall, as a condi14 tion of participation in the State plan under title XIX of

15 such Act, offer a contract to health programs administered

16 by the Service, an Indian tribe or tribal organization or

17 an urban Indian organization that provides health services

18 in the geographic area served by the managed care entity

19 and such contract (or other provider participation agree20 ment) shall contain terms and conditions of participation

21 and payment no more restrictive or onerous than those

22 provided for in this section.

23 ‘‘(g) PROHIBITION.—Notwithstanding any other pro24 vision of law or any waiver granted by the Secretary no

25 Indian may be assigned automatically or by default under
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1 any managed care entity participating in a State plan

2 under title XIX or XXI of the Social Security Act unless

3 the Indian had the option of enrolling in a managed care

4 plan or health program administered by the Service, an

5 Indian tribe or tribal organization, or an urban Indian or6 ganization.

7 ‘‘(h) INDIAN MANAGED CARE PLANS.—Notwith8 standing any other provision of law, any State entering

9 into agreements with one or more managed care organiza10 tions to provide services under title XIX or XXI of the

11 Social Security Act shall enter into such an agreement

12 with the Service, an Indian tribe or tribal organization or

13 an urban Indian organization under which such an entity

14 may provide services to Indians who may be eligible or

15 required to enroll with a managed care organization

16 through enrollment in an Indian managed care organiza17 tion that provides services similar to those offered by other

18 managed care organizations in the State. The Secretary

19 and the State are hereby authorized to waive requirements

20 regarding discrimination, capitalization, and other matters

21 that might otherwise prevent an Indian managed care or22 ganization or health program from meeting Federal or

23 State standards applicable to such organizations, provided

24 such Indian managed care organization or health program
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1 offers Indian enrollees services of an equivalent quality to

2 that required of other managed care organizations.

3 ‘‘(i) ADVERTISING.—A managed care organization

4 entering into a contract to provide services to Indians on

5 or near an Indian reservation shall provide a certificate

6 of coverage or similar type of document that is written

7 in the Indian language of the majority of the Indian popu8 lation residing on such reservation.

9 ‘‘SEC. 424. NAVAJO NATION MEDICAID AGENCY.

10 ‘‘(a) IN GENERAL.—Notwithstanding any other pro11 vision of law, the Secretary may treat the Navajo Nation

12 as a State under title XIX of the Social Security Act for

13 purposes of providing medical assistance to Indians living

14 within the boundaries of the Navajo Nation.

15 ‘‘(b) ASSIGNMENT AND PAYMENT.—Notwithstanding

16 any other provision of law, the Secretary may assign and

17 pay all expenditures related to the provision of services

18 to Indians living within the boundaries of the Navajo Na19 tion under title XIX of the Social Security Act (including

20 administrative expenditures) that are currently paid to or

21 would otherwise be paid to the States of Arizona, New

22 Mexico, and Utah, to an entity established by the Navajo

23 Nation and approved by the Secretary, which shall be de24 nominated the Navajo Nation Medicaid Agency.
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1 ‘‘(c) AUTHORITY.—The Navajo Nation Medicaid

2 Agency shall serve Indians living within the boundaries of

3 the Navajo Nation and shall have the same authority and

4 perform the same functions as other State agency respon5 sible for the administration of the State plan under title

6 XIX of the Social Security Act.

7 ‘‘(d) TECHNICAL ASSISTANCE.—The Secretary may

8 directly assist the Navajo Nation in the development and

9 implementation of a Navajo Nation Medicaid Agency for

10 the administration, eligibility, payment, and delivery of

11 medical assistance under title XIX of the Social Security

12 Act (which shall, for purposes of reimbursement to such

13 Nation, include Western and traditional Navajo healing

14 services) within the Navajo Nation. Such assistance may

15 include providing funds for demonstration projects con16 ducted with such Nation.

17 ‘‘(e) FMAP.—Notwithstanding section 1905(b) of

18 the Social Security Act, the Federal medical assistance

19 percentage shall be 100 per cent with respect to amounts

20 the Navajo Nation Medicaid agency expends for medical

21 assistance and related administrative costs.

22 ‘‘(f) WAIVER AUTHORITY.—The Secretary shall have

23 the authority to waive applicable provisions of title XIX

24 of the Social Security Act to establish, develop and imple25 ment the Navajo Nation Medicaid Agency.
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1 ‘‘(g) SCHIP.—At the option of the Navajo Nation,

2 the Secretary may treat the Navajo Nation as a State for

3 purposes of title XXI of the Social Security Act under

4 terms equivalent to those described in the preceding sub5 sections of this section.

6 ‘‘SEC. 425. INDIAN ADVISORY COMMITTEES.

7 ‘‘(a) NATIONAL INDIAN TECHNICAL ADVISORY

8 GROUP.—The Administrator of the Health Care Financ9 ing Administration shall establish and fund the expenses

10 of a National Indian Technical Advisory Group which shall

11 have no fewer than 14 members, including at least 1 mem12 ber designated by the Indian tribes and tribal organiza13 tions in each service area, 1 urban Indian organization

14 representative, and 1 member representing the Service.

15 The scope of the activities of such group shall be estab16 lished under section 802 provided that such scope shall

17 include providing comment on and advice regarding the

18 programs funded under titles XVIII, XIX, and XXI of the

19 Social Security Act or regarding any other health care pro20 gram funded (in whole or part) by the Health Care Fi21 nancing Administration.

22 ‘‘(b) INDIAN MEDICAID ADVISORY COMMITTEES.—

23 The Administrator of the Health Care Financing Adminis24 tration shall establish and provide funding for a Indian

25 Medicaid Advisory Committee made up of designees of the
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1 Service, Indian tribes and tribal organizations and urban

2 Indian organizations in each State in which the Service

3 directly operates a health program or in which there is

4 one or more Indian tribe or tribal organization or urban

5 Indian organization.

6 ‘‘SEC. 426. AUTHORIZATION OF APPROPRIATIONS.

7 There is authorized to be appropriated such sums as

8 may be necessary for each of fiscal years 2004 through

9 2015 to carry out this title.’’.

10 ‘‘TITLE V—HEALTH SERVICES

11 FOR URBAN INDIANS

12 ‘‘SEC. 501. PURPOSE.

13 ‘‘The purpose of this title is to establish programs

14 in urban centers to make health services more accessible

15 and available to urban Indians.

16 ‘‘SEC. 502. CONTRACTS WITH, AND GRANTS TO, URBAN IN17 DIAN ORGANIZATIONS.

18 ‘‘Under the authority of the Act of November 2, 1921

19 (25 U.S.C. 13) (commonly known as the Snyder Act), the

20 Secretary, through the Service, shall enter into contracts

21 with, or make grants to, urban Indian organizations to

22 assist such organizations in the establishment and admin23 istration, within urban centers, of programs which meet

24 the requirements set forth in this title. The Secretary,

25 through the Service, subject to section 506, shall include
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1 such conditions as the Secretary considers necessary to ef2 fect the purpose of this title in any contract which the

3 Secretary enters into with, or in any grant the Secretary

4 makes to, any urban Indian organization pursuant to this

5 title.

6 ‘‘SEC. 503. CONTRACTS AND GRANTS FOR THE PROVISION

7 OF HEALTH CARE AND REFERRAL SERVICES.

8 ‘‘(a) AUTHORITY.—Under the authority of the Act of

9 November 2, 1921 (25 U.S.C. 13) (commonly known as

10 the Snyder Act), the Secretary, acting through the Serv11 ice, shall enter into contracts with, and make grants to,

12 urban Indian organizations for the provision of health care

13 and referral services for urban Indians. Any such contract

14 or grant shall include requirements that the urban Indian

15 organization successfully undertake to—

16 ‘‘(1) estimate the population of urban Indians

17 residing in the urban center or centers that the or18 ganization proposes to serve who are or could be re19 cipients of health care or referral services;

20 ‘‘(2) estimate the current health status of

21 urban Indians residing in such urban center or cen22 ters;

23 ‘‘(3) estimate the current health care needs of

24 urban Indians residing in such urban center or cen25 ters;
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1 ‘‘(4) provide basic health education, including

2 health promotion and disease prevention education,

3 to urban Indians;

4 ‘‘(5) make recommendations to the Secretary

5 and Federal, State, local, and other resource agen6 cies on methods of improving health service pro7 grams to meet the needs of urban Indians; and

8 ‘‘(6) where necessary, provide, or enter into

9 contracts for the provision of, health care services

10 for urban Indians.

11 ‘‘(b) CRITERIA.—The Secretary, acting through the

12 Service, shall by regulation adopted pursuant to section

13 520 prescribe the criteria for selecting urban Indian orga14 nizations to enter into contracts or receive grants under

15 this section. Such criteria shall, among other factors,

16 include—

17 ‘‘(1) the extent of unmet health care needs of

18 urban Indians in the urban center or centers in19 volved;

20 ‘‘(2) the size of the urban Indian population in

21 the urban center or centers involved;

22 ‘‘(3) the extent, if any, to which the activities

23 set forth in subsection (a) would duplicate any

24 project funded under this title;
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1 ‘‘(4) the capability of an urban Indian organiza2 tion to perform the activities set forth in subsection

3 (a) and to enter into a contract with the Secretary

4 or to meet the requirements for receiving a grant

5 under this section;

6 ‘‘(5) the satisfactory performance and success7 ful completion by an urban Indian organization of

8 other contracts with the Secretary under this title;

9 ‘‘(6) the appropriateness and likely effectiveness

10 of conducting the activities set forth in subsection

11 (a) in an urban center or centers; and

12 ‘‘(7) the extent of existing or likely future par13 ticipation in the activities set forth in subsection (a)

14 by appropriate health and health-related Federal,

15 State, local, and other agencies.

16 ‘‘(c) HEALTH PROMOTION AND DISEASE PREVEN17 TION.—The Secretary, acting through the Service, shall

18 facilitate access to, or provide, health promotion and dis19 ease prevention services for urban Indians through grants

20 made to urban Indian organizations administering con21 tracts entered into pursuant to this section or receiving

22 grants under subsection (a).

23 ‘‘(d) IMMUNIZATION SERVICES.—

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

25 through the Service, shall facilitate access to, or pro-
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1 vide, immunization services for urban Indians

2 through grants made to urban Indian organizations

3 administering contracts entered into, or receiving

4 grants, under this section.

5 ‘‘(2) DEFINITION.—In this section, the term

6 ‘immunization services’ means services to provide

7 without charge immunizations against vaccine-pre8 ventable diseases.

9 ‘‘(e) MENTAL HEALTH SERVICES.—

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

11 through the Service, shall facilitate access to, or pro12 vide, mental health services for urban Indians

13 through grants made to urban Indian organizations

14 administering contracts entered into, or receiving

15 grants, under this section.

16 ‘‘(2) ASSESSMENT.—A grant may not be made

17 under this subsection to an urban Indian organiza18 tion until that organization has prepared, and the

19 Service has approved, an assessment of the mental

20 health needs of the urban Indian population con21 cerned, the mental health services and other related

22 resources available to that population, the barriers

23 to obtaining those services and resources, and the

24 needs that are unmet by such services and resources.
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1 ‘‘(3) USE OF FUNDS.—Grants may be made

2 under this subsection—

3 ‘‘(A) to prepare assessments required

4 under paragraph (2);

5 ‘‘(B) to provide outreach, educational, and

6 referral services to urban Indians regarding the

7 availability of direct behavioral health services,

8 to educate urban Indians about behavioral

9 health issues and services, and effect coordina10 tion with existing behavioral health providers in

11 order to improve services to urban Indians;

12 ‘‘(C) to provide outpatient behavioral

13 health services to urban Indians, including the

14 identification and assessment of illness, thera15 peutic treatments, case management, support

16 groups, family treatment, and other treatment;

17 and

18 ‘‘(D) to develop innovative behavioral

19 health service delivery models which incorporate

20 Indian cultural support systems and resources.

21 ‘‘(f) CHILD ABUSE.—

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

23 through the Service, shall facilitate access to, or pro24 vide, services for urban Indians through grants to

25 urban Indian organizations administering contracts
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1 entered into pursuant to this section or receiving

2 grants under subsection (a) to prevent and treat

3 child abuse (including sexual abuse) among urban

4 Indians.

5 ‘‘(2) ASSESSMENT.—A grant may not be made

6 under this subsection to an urban Indian organiza7 tion until that organization has prepared, and the

8 Service has approved, an assessment that documents

9 the prevalence of child abuse in the urban Indian

10 population concerned and specifies the services and

11 programs (which may not duplicate existing services

12 and programs) for which the grant is requested.

13 ‘‘(3) USE OF FUNDS.—Grants may be made

14 under this subsection—

15 ‘‘(A) to prepare assessments required

16 under paragraph (2);

17 ‘‘(B) for the development of prevention,

18 training, and education programs for urban In19 dian populations, including child education, par20 ent education, provider training on identifica21 tion and intervention, education on reporting

22 requirements, prevention campaigns, and estab23 lishing service networks of all those involved in

24 Indian child protection; and
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1 ‘‘(C) to provide direct outpatient treatment

2 services (including individual treatment, family

3 treatment, group therapy, and support groups)

4 to urban Indians who are child victims of abuse

5 (including sexual abuse) or adult survivors of

6 child sexual abuse, to the families of such child

7 victims, and to urban Indian perpetrators of

8 child abuse (including sexual abuse).

9 ‘‘(4) CONSIDERATIONS.—In making grants to

10 carry out this subsection, the Secretary shall take

11 into consideration—

12 ‘‘(A) the support for the urban Indian or13 ganization demonstrated by the child protection

14 authorities in the area, including committees or

15 other services funded under the Indian Child

16 Welfare Act of 1978 (25 U.S.C. 1901 et seq.),

17 if any;

18 ‘‘(B) the capability and expertise dem19 onstrated by the urban Indian organization to

20 address the complex problem of child sexual

21 abuse in the community; and

22 ‘‘(C) the assessment required under para23 graph (2).

24 ‘‘(g) MULTIPLE URBAN CENTERS.—The Secretary,

25 acting through the Service, may enter into a contract with,
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1 or make grants to, an urban Indian organization that pro2 vides or arranges for the provision of health care services

3 (through satellite facilities, provider networks, or other4 wise) to urban Indians in more than one urban center.

5 ‘‘SEC. 504. CONTRACTS AND GRANTS FOR THE DETERMINA6 TION OF UNMET HEALTH CARE NEEDS.

7 ‘‘(a) AUTHORITY.—

8 ‘‘(1) IN GENERAL.—Under authority of the Act

9 of November 2, 1921 (25 U.S.C. 13) (commonly

10 known as the Snyder Act), the Secretary, acting

11 through the Service, may enter into contracts with,

12 or make grants to, urban Indian organizations situ13 ated in urban centers for which contracts have not

14 been entered into, or grants have not been made,

15 under section 503.

16 ‘‘(2) PURPOSE.—The purpose of a contract or

17 grant made under this section shall be the deter18 mination of the matters described in subsection

19 (b)(1) in order to assist the Secretary in assessing

20 the health status and health care needs of urban In21 dians in the urban center involved and determining

22 whether the Secretary should enter into a contract

23 or make a grant under section 503 with respect to

24 the urban Indian organization which the Secretary
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1 has entered into a contract with, or made a grant

2 to, under this section.

3 ‘‘(b) REQUIREMENTS.—Any contract entered into, or

4 grant made, by the Secretary under this section shall in5 clude requirements that—

6 ‘‘(1) the urban Indian organization successfully

7 undertake to—

8 ‘‘(A) document the health care status and

9 unmet health care needs of urban Indians in

10 the urban center involved; and

11 ‘‘(B) with respect to urban Indians in the

12 urban center involved, determine the matters

13 described in paragraphs (2), (3), (4), and (7) of

14 section 503(b); and

15 ‘‘(2) the urban Indian organization complete

16 performance of the contract, or carry out the re17 quirements of the grant, within 1 year after the date

18 on which the Secretary and such organization enter

19 into such contract, or within 1 year after such orga20 nization receives such grant, whichever is applicable.

21 ‘‘(c) LIMITATION ON RENEWAL.—The Secretary may

22 not renew any contract entered into, or grant made, under

23 this section.
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1 ‘‘SEC. 505. EVALUATIONS; RENEWALS.

2 ‘‘(a) PROCEDURES.—The Secretary, acting through

3 the Service, shall develop procedures to evaluate compli4 ance with grant requirements under this title and compli5 ance with, and performance of contracts entered into by

6 urban Indian organizations under this title. Such proce7 dures shall include provisions for carrying out the require8 ments of this section.

9 ‘‘(b) COMPLIANCE WITH TERMS.—The Secretary,

10 acting through the Service, shall evaluate the compliance

11 of each urban Indian organization which has entered into

12 a contract or received a grant under section 503 with the

13 terms of such contract or grant. For purposes of an eval14 uation under this subsection, the Secretary, in determin15 ing the capacity of an urban Indian organization to deliver

16 quality patient care shall, at the option of the

17 organization—

18 ‘‘(1) conduct, through the Service, an annual

19 onsite evaluation of the organization; or

20 ‘‘(2) accept, in lieu of an onsite evaluation, evi21 dence of the organization’s provisional or full accred22 itation by a private independent entity recognized by

23 the Secretary for purposes of conducting quality re24 views of providers participating in the medicare pro25 gram under Title XVIII of the Social Security Act.

26 ‘‘(c) NONCOMPLIANCE.—
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1 ‘‘(1) IN GENERAL.—If, as a result of the eval2 uations conducted under this section, the Secretary

3 determines that an urban Indian organization has

4 not complied with the requirements of a grant or

5 complied with or satisfactorily performed a contract

6 under section 503, the Secretary shall, prior to re7 newing such contract or grant, attempt to resolve

8 with such organization the areas of noncompliance

9 or unsatisfactory performance and modify such con10 tract or grant to prevent future occurrences of such

11 noncompliance or unsatisfactory performance.

12 ‘‘(2) NONRENEWAL.—If the Secretary deter13 mines, under an evaluation under this section, that

14 noncompliance or unsatisfactory performance cannot

15 be resolved and prevented in the future, the Sec16 retary shall not renew such contract or grant with

17 such organization and is authorized to enter into a

18 contract or make a grant under section 503 with an19 other urban Indian organization which is situated in

20 the same urban center as the urban Indian organiza21 tion whose contract or grant is not renewed under

22 this section.

23 ‘‘(d) DETERMINATION OF RENEWAL.—In determin24 ing whether to renew a contract or grant with an urban

25 Indian organization under section 503 which has com-
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1 pleted performance of a contract or grant under section

2 504, the Secretary shall review the records of the urban

3 Indian organization, the reports submitted under section

4 507, and, in the case of a renewal of a contract or grant

5 under section 503, shall consider the results of the onsite

6 evaluations or accreditation under subsection (b).

7 ‘‘SEC. 506. OTHER CONTRACT AND GRANT REQUIREMENTS.

8 ‘‘(a) APPLICATION OF FEDERAL LAW.—Contracts

9 with urban Indian organizations entered into pursuant to

10 this title shall be in accordance with all Federal contract11 ing laws and regulations relating to procurement except

12 that, in the discretion of the Secretary, such contracts may

13 be negotiated without advertising and need not conform

14 to the provisions of the Act of August 24, 1935 (40 U.S.C.

15 270a, et seq.).

16 ‘‘(b) PAYMENTS.—Payments under any contracts or

17 grants pursuant to this title shall, notwithstanding any

18 term or condition of such contract or grant—

19 ‘‘(1) be made in their entirety by the Secretary

20 to the urban Indian organization by not later than

21 the end of the first 30 days of the funding period

22 with respect to which the payments apply, unless the

23 Secretary determines through an evaluation under

24 section 505 that the organization is not capable of

25 administering such payments in their entirety; and
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1 ‘‘(2) if unexpended by the urban Indian organi2 zation during the funding period with respect to

3 which the payments initially apply, be carried for4 ward for expenditure with respect to allowable or re5 imbursable costs incurred by the organization during

6 1 or more subsequent funding periods without addi7 tional justification or documentation by the organi8 zation as a condition of carrying forward the ex9 penditure of such funds.

10 ‘‘(c) REVISING OR AMENDING CONTRACT.—Notwith11 standing any provision of law to the contrary, the Sec12 retary may, at the request or consent of an urban Indian

13 organization, revise or amend any contract entered into

14 by the Secretary with such organization under this title

15 as necessary to carry out the purposes of this title.

16 ‘‘(d) FAIR AND UNIFORM PROVISION OF SERV17 ICES.—Contracts with, or grants to, urban Indian organi18 zations and regulations adopted pursuant to this title shall

19 include provisions to assure the fair and uniform provision

20 to urban Indians of services and assistance under such

21 contracts or grants by such organizations.

22 ‘‘(e) ELIGIBILITY OF URBAN INDIANS.—Urban Indi23 ans, as defined in section 4(f), shall be eligible for health

24 care or referral services provided pursuant to this title.
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1 ‘‘SEC. 507. REPORTS AND RECORDS.

2 ‘‘(a) REPORT.—For each fiscal year during which an

3 urban Indian organization receives or expends funds pur4 suant to a contract entered into, or a grant received, pur5 suant to this title, such organization shall submit to the

6 Secretary, on a basis no more frequent than every 6

7 months, a report including—

8 ‘‘(1) in the case of a contract or grant under

9 section 503, information gathered pursuant to para10 graph (5) of subsection (a) of such section;

11 ‘‘(2) information on activities conducted by the

12 organization pursuant to the contract or grant;

13 ‘‘(3) an accounting of the amounts and pur14 poses for which Federal funds were expended; and

15 ‘‘(4) a minimum set of data, using uniformly

16 defined elements, that is specified by the Secretary,

17 after consultations consistent with section 514, with

18 urban Indian organizations.

19 ‘‘(b) AUDITS.—The reports and records of the urban

20 Indian organization with respect to a contract or grant

21 under this title shall be subject to audit by the Secretary

22 and the Comptroller General of the United States.

23 ‘‘(c) COST OF AUDIT.—The Secretary shall allow as

24 a cost of any contract or grant entered into or awarded

25 under section 502 or 503 the cost of an annual independ26 ent financial audit conducted by—
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1 ‘‘(1) a certified public accountant; or

2 ‘‘(2) a certified public accounting firm qualified

3 to conduct Federal compliance audits.

4 ‘‘SEC. 508. LIMITATION ON CONTRACT AUTHORITY.

5 ‘‘The authority of the Secretary to enter into con6 tracts or to award grants under this title shall be to the

7 extent, and in an amount, provided for in appropriation

8 Acts.

9 ‘‘SEC. 509. FACILITIES.

10 ‘‘(a) GRANTS.—The Secretary may make grants to

11 contractors or grant recipients under this title for the

12 lease, purchase, renovation, construction, or expansion of

13 facilities, including leased facilities, in order to assist such

14 contractors or grant recipients in complying with applica15 ble licensure or certification requirements.

16 ‘‘(b) LOANS OR LOAN GUARANTEES.—The Secretary,

17 acting through the Service or through the Health Re18 sources and Services Administration, may provide loans

19 to contractors or grant recipients under this title from the

20 Urban Indian Health Care Facilities Revolving Loan

21 Fund (referred to in this section as the ‘URLF’) described

22 in subsection (c), or guarantees for loans, for the construc23 tion, renovation, expansion, or purchase of health care fa24 cilities, subject to the following requirements:
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1 ‘‘(1) The principal amount of a loan or loan

2 guarantee may cover 100 percent of the costs (other

3 than staffing) relating to the facility, including plan4 ning, design, financing, site land development, con5 struction, rehabilitation, renovation, conversion,

6 medical equipment, furnishings, and capital pur7 chase.

8 ‘‘(2) The total amount of the principal of loans

9 and loan guarantees, respectively, outstanding at

10 any one time shall not exceed such limitations as

11 may be specified in appropriations Acts.

12 ‘‘(3) The loan or loan guarantee may have a

13 term of the shorter of the estimated useful life of the

14 facility, or 25 years.

15 ‘‘(4) An urban Indian organization may assign,

16 and the Secretary may accept assignment of, the

17 revenue of the organization as security for a loan or

18 loan guarantee under this subsection.

19 ‘‘(5) The Secretary shall not collect application,

20 processing, or similar fees from urban Indian organi21 zations applying for loans or loan guarantees under

22 this subsection.

23 ‘‘(c) URBAN INDIAN HEALTH CARE FACILITIES RE24 VOLVING LOAN FUND.—
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1 ‘‘(1) ESTABLISHMENT.—There is established in

2 the Treasury of the United States a fund to be

3 known as the Urban Indian Health Care Facilities

4 Revolving Loan Fund. The URLF shall consist of—

5 ‘‘(A) such amounts as may be appropriated

6 to the URLF;

7 ‘‘(B) amounts received from urban Indian

8 organizations in repayment of loans made to

9 such organizations under paragraph (2); and

10 ‘‘(C) interest earned on amounts in the

11 URLF under paragraph (3).

12 ‘‘(2) USE OF URLF.—Amounts in the URLF

13 may be expended by the Secretary, acting through

14 the Service or the Health Resources and Services

15 Administration, to make loans available to urban In16 dian organizations receiving grants or contracts

17 under this title for the purposes, and subject to the

18 requirements, described in subsection (b). Amounts

19 appropriated to the URLF, amounts received from

20 urban Indian organizations in repayment of loans,

21 and interest on amounts in the URLF shall remain

22 available until expended.

23 ‘‘(3) INVESTMENTS.—The Secretary of the

24 Treasury shall invest such amounts of the URLF as

25 such Secretary determines are not required to meet
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1 current withdrawals from the URLF. Such invest2 ments may be made only in interest-bearing obliga3 tions of the United States. For such purpose, such

4 obligations may be acquired on original issue at the

5 issue price, or by purchase of outstanding obliga6 tions at the market price. Any obligation acquired by

7 the URLF may be sold by the Secretary of the

8 Treasury at the market price.

9 ‘‘SEC. 510. OFFICE OF URBAN INDIAN HEALTH.

10 ‘‘There is hereby established within the Service an

11 Office of Urban Indian Health which shall be responsible

12 for—

13 ‘‘(1) carrying out the provisions of this title;

14 ‘‘(2) providing central oversight of the pro15 grams and services authorized under this title; and

16 ‘‘(3) providing technical assistance to urban In17 dian organizations.

18 ‘‘SEC. 511. GRANTS FOR ALCOHOL AND SUBSTANCE ABUSE

19 RELATED SERVICES.

20 ‘‘(a) GRANTS.—The Secretary may make grants for

21 the provision of health-related services in prevention of,

22 treatment of, rehabilitation of, or school and community23 based education in, alcohol and substance abuse in urban

24 centers to those urban Indian organizations with whom
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1 the Secretary has entered into a contract under this title

2 or under section 201.

3 ‘‘(b) GOALS OF GRANT.—Each grant made pursuant

4 to subsection (a) shall set forth the goals to be accom5 plished pursuant to the grant. The goals shall be specific

6 to each grant as agreed to between the Secretary and the

7 grantee.

8 ‘‘(c) CRITERIA.—The Secretary shall establish cri9 teria for the grants made under subsection (a), including

10 criteria relating to the—

11 ‘‘(1) size of the urban Indian population;

12 ‘‘(2) capability of the organization to adequately

13 perform the activities required under the grant;

14 ‘‘(3) satisfactory performance standards for the

15 organization in meeting the goals set forth in such

16 grant, which standards shall be negotiated and

17 agreed to between the Secretary and the grantee on

18 a grant-by-grant basis; and

19 ‘‘(4) identification of need for services.

20 The Secretary shall develop a methodology for allocating

21 grants made pursuant to this section based on such cri22 teria.

23 ‘‘(d) TREATMENT OF FUNDS RECEIVED BY URBAN

24 INDIAN ORGANIZATIONS.—Any funds received by an

25 urban Indian organization under this Act for substance
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1 abuse prevention, treatment, and rehabilitation shall be

2 subject to the criteria set forth in subsection (c).

3 ‘‘SEC. 512. TREATMENT OF CERTAIN DEMONSTRATION

4 PROJECTS.

5 ‘‘(a) TULSA AND OKLAHOMA CITY CLINICS.—Not6 withstanding any other provision of law, the Tulsa and

7 Oklahoma City Clinic demonstration projects shall become

8 permanent programs within the Service’s direct care pro9 gram and continue to be treated as service units in the

10 allocation of resources and coordination of care, and shall

11 continue to meet the requirements and definitions of an

12 urban Indian organization in this title, and as such will

13 not be subject to the provisions of the Indian Self-Deter14 mination and Education Assistance Act.

15 ‘‘(b) REPORT.—The Secretary shall submit to the

16 President, for inclusion in the report required to be sub17 mitted to the Congress under section 801 for fiscal year

18 1999, a report on the findings and conclusions derived

19 from the demonstration projects specified in subsection

20 (a).

21 ‘‘SEC. 513. URBAN NIAAA TRANSFERRED PROGRAMS.

22 ‘‘(a) GRANTS AND CONTRACTS.—The Secretary, act23 ing through the Office of Urban Indian Health of the

24 Service, shall make grants or enter into contracts, effective

25 not later than September 30, 2004, with urban Indian or-
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1 ganizations for the administration of urban Indian alcohol

2 programs that were originally established under the Na3 tional Institute on Alcoholism and Alcohol Abuse (referred

4 to in this section to as ‘NIAAA’) and transferred to the

5 Service.

6 ‘‘(b) USE OF FUNDS.—Grants provided or contracts

7 entered into under this section shall be used to provide

8 support for the continuation of alcohol prevention and

9 treatment services for urban Indian populations and such

10 other objectives as are agreed upon between the Service

11 and a recipient of a grant or contract under this section.

12 ‘‘(c) ELIGIBILITY.—Urban Indian organizations that

13 operate Indian alcohol programs originally funded under

14 NIAAA and subsequently transferred to the Service are

15 eligible for grants or contracts under this section.

16 ‘‘(d) EVALUATION AND REPORT.—The Secretary

17 shall evaluate and report to the Congress on the activities

18 of programs funded under this section at least every 5

19 years.

20 ‘‘SEC. 514. CONSULTATION WITH URBAN INDIAN ORGANIZA21 TIONS.

22 ‘‘(a) IN GENERAL.—The Secretary shall ensure that

23 the Service, the Health Care Financing Administration,

24 and other operating divisions and staff divisions of the De25 partment consult, to the maximum extent practicable, with
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1 urban Indian organizations (as defined in section 4) prior

2 to taking any action, or approving Federal financial assist3 ance for any action of a State, that may affect urban Indi4 ans or urban Indian organizations.

5 ‘‘(b) REQUIREMENT.—In subsection (a), the term

6 ‘consultation’ means the open and free exchange of infor7 mation and opinion among urban Indian organizations

8 and the operating and staff divisions of the Department

9 which leads to mutual understanding and comprehension

10 and which emphasizes trust, respect, and shared respon11 sibility.

12 ‘‘SEC. 515. FEDERAL TORT CLAIMS ACT COVERAGE.

13 ‘‘For purposes of section 224 of the Public Health

14 Service Act (42 U.S.C. 233), with respect to claims by

15 any person, initially filed on or after October 1, 1999,

16 whether or not such person is an Indian or Alaska Native

17 or is served on a fee basis or under other circumstances

18 as permitted by Federal law or regulations, for personal

19 injury (including death) resulting from the performance

20 prior to, including, or after October 1, 1999, of medical,

21 surgical, dental, or related functions, including the con22 duct of clinical studies or investigations, or for purposes

23 of section 2679 of title 28, United States Code, with re24 spect to claims by any such person, on or after October

25 1, 1999, for personal injury (including death) resulting
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1 from the operation of an emergency motor vehicle, an

2 urban Indian organization that has entered into a contract

3 or received a grant pursuant to this title is deemed to be

4 part of the Public Health Service while carrying out any

5 such contract or grant and its employees (including those

6 acting on behalf of the organization as provided for in sec7 tion 2671 of title 28, United States Code, and including

8 an individual who provides health care services pursuant

9 to a personal services contract with an urban Indian orga10 nization for the provision of services in any facility owned,

11 operated, or constructed under the jurisdiction of the In12 dian Health Service) are deemed employees of the Service

13 while acting within the scope of their employment in carry14 ing out the contract or grant, except that such employees

15 shall be deemed to be acting within the scope of their em16 ployment in carrying out the contract or grant when they

17 are required, by reason of their employment, to perform

18 medical, surgical, dental or related functions at a facility

19 other than a facility operated by the urban Indian organi20 zation pursuant to such contract or grant, but only if such

21 employees are not compensated for the performance of

22 such functions by a person or entity other than the urban

23 Indian organization.
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1 ‘‘SEC. 516. URBAN YOUTH TREATMENT CENTER DEM2 ONSTRATION.

3 ‘‘(a) CONSTRUCTION AND OPERATION.—The Sec4 retary, acting through the Service, shall, through grants

5 or contracts, make payment for the construction and oper6 ation of at least 2 residential treatment centers in each

7 State described in subsection (b) to demonstrate the provi8 sion of alcohol and substance abuse treatment services to

9 urban Indian youth in a culturally competent residential

10 setting.

11 ‘‘(b) STATES.—A State described in this subsection

12 is a State in which—

13 ‘‘(1) there reside urban Indian youth with a

14 need for alcohol and substance abuse treatment serv15 ices in a residential setting; and

16 ‘‘(2) there is a significant shortage of culturally

17 competent residential treatment services for urban

18 Indian youth.

19 ‘‘SEC. 517. USE OF FEDERAL GOVERNMENT FACILITIES AND

20 SOURCES OF SUPPLY.

21 ‘‘(a) IN GENERAL.—The Secretary shall permit an

22 urban Indian organization that has entered into a contract

23 or received a grant pursuant to this title, in carrying out

24 such contract or grant, to use existing facilities and all

25 equipment therein or pertaining thereto and other per26 sonal property owned by the Federal Government within
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1 the Secretary’s jurisdiction under such terms and condi2 tions as may be agreed upon for their use and mainte3 nance.

4 ‘‘(b) DONATION OF PROPERTY.—Subject to sub5 section (d), the Secretary may donate to an urban Indian

6 organization that has entered into a contract or received

7 a grant pursuant to this title any personal or real property

8 determined to be excess to the needs of the Service or the

9 General Services Administration for purposes of carrying

10 out the contract or grant.

11 ‘‘(c) ACQUISITION OF PROPERTY.—The Secretary

12 may acquire excess or surplus government personal or real

13 property for donation, subject to subsection (d), to an

14 urban Indian organization that has entered into a contract

15 or received a grant pursuant to this title if the Secretary

16 determines that the property is appropriate for use by the

17 urban Indian organization for a purpose for which a con18 tract or grant is authorized under this title.

19 ‘‘(d) PRIORITY.—In the event that the Secretary re20 ceives a request for a specific item of personal or real

21 property described in subsections (b) or (c) from an urban

22 Indian organization and from an Indian tribe or tribal or23 ganization, the Secretary shall give priority to the request

24 for donation to the Indian tribe or tribal organization if

25 the Secretary receives the request from the Indian tribe
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1 or tribal organization before the date on which the Sec2 retary transfers title to the property or, if earlier, the date

3 on which the Secretary transfers the property physically,

4 to the urban Indian organization.

5 ‘‘(e) RELATION TO FEDERAL SOURCES OF SUP6 PLY.—For purposes of section 201(a) of the Federal

7 Property and Administrative Services Act of 1949 (40

8 U.S.C. 481(a)) (relating to Federal sources of supply, in9 cluding lodging providers, airlines, and other transpor10 tation providers), an urban Indian organization that has

11 entered into a contract or received a grant pursuant to

12 this title shall be deemed an executive agency when carry13 ing out such contract or grant, and the employees of the

14 urban Indian organization shall be eligible to have access

15 to such sources of supply on the same basis as employees

16 of an executive agency have such access.

17 ‘‘SEC. 518. GRANTS FOR DIABETES PREVENTION, TREAT18 MENT AND CONTROL.

19 ‘‘(a) AUTHORITY.—The Secretary may make grants

20 to those urban Indian organizations that have entered into

21 a contract or have received a grant under this title for

22 the provision of services for the prevention, treatment, and

23 control of the complications resulting from, diabetes

24 among urban Indians.
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1 ‘‘(b) GOALS.—Each grant made pursuant to sub2 section (a) shall set forth the goals to be accomplished

3 under the grant. The goals shall be specific to each grant

4 as agreed upon between the Secretary and the grantee.

5 ‘‘(c) CRITERIA.—The Secretary shall establish cri6 teria for the awarding of grants made under subsection

7 (a) relating to—

8 ‘‘(1) the size and location of the urban Indian

9 population to be served;

10 ‘‘(2) the need for the prevention of, treatment

11 of, and control of the complications resulting from

12 diabetes among the urban Indian population to be

13 served;

14 ‘‘(3) performance standards for the urban In15 dian organization in meeting the goals set forth in

16 such grant that are negotiated and agreed to by the

17 Secretary and the grantee;

18 ‘‘(4) the capability of the urban Indian organi19 zation to adequately perform the activities required

20 under the grant; and

21 ‘‘(5) the willingness of the urban Indian organi22 zation to collaborate with the registry, if any, estab23 lished by the Secretary under section 204(e) in the

24 area office of the Service in which the organization

25 is located.
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1 ‘‘(d) APPLICATION OF CRITERIA.—Any funds re2 ceived by an urban Indian organization under this Act for

3 the prevention, treatment, and control of diabetes among

4 urban Indians shall be subject to the criteria developed

5 by the Secretary under subsection (c).

6 ‘‘SEC. 519. COMMUNITY HEALTH REPRESENTATIVES.

7 ‘‘The Secretary, acting through the Service, may

8 enter into contracts with, and make grants to, urban In9 dian organizations for the use of Indians trained as health

10 service providers through the Community Health Rep11 resentatives Program under section 107(b) in the provi12 sion of health care, health promotion, and disease preven13 tion services to urban Indians.

14 ‘‘SEC. 520. REGULATIONS.

15 ‘‘(a) EFFECT OF TITLE.—This title shall be effective

16 on the date of enactment of this Act regardless of whether

17 the Secretary has promulgated regulations implementing

18 this title.

19 ‘‘(b) PROMULGATION.—

20 ‘‘(1) IN GENERAL.—The Secretary may promul21 gate regulations to implement the provisions of this

22 title.

23 ‘‘(2) PUBLICATION.—Proposed regulations to

24 implement this title shall be published by the Sec25 retary in the Federal Register not later than 270
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1 days after the date of enactment of this Act and

2 shall have a comment period of not less than 120

3 days.

4 ‘‘(3) EXPIRATION OF AUTHORITY.—The author5 ity to promulgate regulations under this title shall

6 expire on the date that is 18 months after the date

7 of enactment of this Act.

8 ‘‘(c) NEGOTIATED RULEMAKING COMMITTEE.—A ne9 gotiated rulemaking committee shall be established pursu10 ant to section 565 of title 5, United States Code, to carry

11 out this section and shall, in addition to Federal represent12 atives, have as the majority of its members representatives

13 of urban Indian organizations from each service area.

14 ‘‘(d) ADAPTION OF PROCEDURES.—The Secretary

15 shall adapt the negotiated rulemaking procedures to the

16 unique context of this Act.

17 ‘‘SEC. 521. AUTHORIZATION OF APPROPRIATIONS.

18 ‘‘There is authorized to be appropriated such sums

19 as may be necessary for each fiscal year through fiscal

20 year 2015 to carry out this title.
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1 ‘‘TITLE VI—ORGANIZATIONAL

2 IMPROVEMENTS

3 ‘‘SEC. 601. ESTABLISHMENT OF THE INDIAN HEALTH SERV4 ICE AS AN AGENCY OF THE PUBLIC HEALTH

5 SERVICE.

6 ‘‘(a) ESTABLISHMENT.—

7 ‘‘(1) IN GENERAL.—In order to more effectively

8 and efficiently carry out the responsibilities, authori9 ties, and functions of the United States to provide

10 health care services to Indians and Indian tribes, as

11 are or may be hereafter provided by Federal statute

12 or treaties, there is established within the Public

13 Health Service of the Department the Indian Health

14 Service.

15 ‘‘(2) ASSISTANT SECRETARY OF INDIAN

16 HEALTH.—The Service shall be administered by an

17 Assistance Secretary of Indian Health, who shall be

18 appointed by the President, by and with the advice

19 and consent of the Senate. The Assistant Secretary

20 shall report to the Secretary. Effective with respect

21 to an individual appointed by the President, by and

22 with the advice and consent of the Senate, after

23 January 1, 1993, the term of service of the Assist24 ant Secretary shall be 4 years. An Assistant Sec25 retary may serve more than 1 term.
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1 ‘‘(b) AGENCY.—The Service shall be an agency within

2 the Public Health Service of the Department, and shall

3 not be an office, component, or unit of any other agency

4 of the Department.

5 ‘‘(c) FUNCTIONS AND DUTIES.—The Secretary shall

6 carry out through the Assistant Secretary of the Service—

7 ‘‘(1) all functions which were, on the day before

8 the date of enactment of the Indian Health Care

9 Amendments of 1988, carried out by or under the

10 direction of the individual serving as Director of the

11 Service on such day;

12 ‘‘(2) all functions of the Secretary relating to

13 the maintenance and operation of hospital and

14 health facilities for Indians and the planning for,

15 and provision and utilization of, health services for

16 Indians;

17 ‘‘(3) all health programs under which health

18 care is provided to Indians based upon their status

19 as Indians which are administered by the Secretary,

20 including programs under—

21 ‘‘(A) this Act;

22 ‘‘(B) the Act of November 2, 1921 (25

23 U.S.C. 13);

24 ‘‘(C) the Act of August 5, 1954 (42 U.S.C.

25 2001, et seq.);
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1 ‘‘(D) the Act of August 16, 1957 (42

2 U.S.C. 2005 et seq.); and

3 ‘‘(E) the Indian Self-Determination Act

4 (25 U.S.C. 450f, et seq.); and

5 ‘‘(4) all scholarship and loan functions carried

6 out under title I.

7 ‘‘(d) AUTHORITY.—

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

9 through the Assistant Secretary, shall have the

10 authority—

11 ‘‘(A) except to the extent provided for in

12 paragraph (2), to appoint and compensate em13 ployees for the Service in accordance with title

14 5, United States Code;

15 ‘‘(B) to enter into contracts for the pro16 curement of goods and services to carry out the

17 functions of the Service; and

18 ‘‘(C) to manage, expend, and obligate all

19 funds appropriated for the Service.

20 ‘‘(2) PERSONNEL ACTIONS.—Notwithstanding

21 any other provision of law, the provisions of section

22 12 of the Act of June 18, 1934 (48 Stat. 986; 25

23 U.S.C. 472), shall apply to all personnel actions

24 taken with respect to new positions created within
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1 the Service as a result of its establishment under

2 subsection (a).

3 ‘‘SEC. 602. AUTOMATED MANAGEMENT INFORMATION SYS4 TEM.

5 ‘‘(a) ESTABLISHMENT.—

6 ‘‘(1) IN GENERAL.—The Secretary, in consulta7 tion with tribes, tribal organizations, and urban In8 dian organizations, shall establish an automated

9 management information system for the Service.

10 ‘‘(2) REQUIREMENTS OF SYSTEM.—The infor11 mation system established under paragraph (1) shall

12 include—

13 ‘‘(A) a financial management system;

14 ‘‘(B) a patient care information system;

15 ‘‘(C) a privacy component that protects the

16 privacy of patient information;

17 ‘‘(D) a services-based cost accounting com18 ponent that provides estimates of the costs as19 sociated with the provision of specific medical

20 treatments or services in each area office of the

21 Service;

22 ‘‘(E) an interface mechanism for patient

23 billing and accounts receivable system; and

24 ‘‘(F) a training component.
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1 ‘‘(b) PROVISION OF SYSTEMS TO TRIBES AND ORGA2 NIZATIONS.—The Secretary shall provide each Indian

3 tribe and tribal organization that provides health services

4 under a contract entered into with the Service under the

5 Indian Self-Determination Act automated management in6 formation systems which—

7 ‘‘(1) meet the management information needs

8 of such Indian tribe or tribal organization with re9 spect to the treatment by the Indian tribe or tribal

10 organization of patients of the Service; and

11 ‘‘(2) meet the management information needs

12 of the Service.

13 ‘‘(c) ACCESS TO RECORDS.—Notwithstanding any

14 other provision of law, each patient shall have reasonable

15 access to the medical or health records of such patient

16 which are held by, or on behalf of, the Service.

17 ‘‘(d) AUTHORITY TO ENHANCE INFORMATION TECH18 NOLOGY.—The Secretary, acting through the Assistant

19 Secretary, shall have the authority to enter into contracts,

20 agreements or joint ventures with other Federal agencies,

21 States, private and nonprofit organizations, for the pur22 pose of enhancing information technology in Indian health

23 programs and facilities.
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1 ‘‘SEC. 603. AUTHORIZATION OF APPROPRIATIONS.

2 ‘‘There is authorized to be appropriated such sums

3 as may be necessary for each fiscal year through fiscal

4 year 2015 to carry out this title.

5 ‘‘TITLE VII—BEHAVIORAL

6 HEALTH PROGRAMS

7 ‘‘SEC. 701. BEHAVIORAL HEALTH PREVENTION AND TREAT8 MENT SERVICES.

9 ‘‘(a) PURPOSES.—It is the purpose of this section

10 to—

11 ‘‘(1) authorize and direct the Secretary, acting

12 through the Service, Indian tribes, tribal organiza13 tions, and urban Indian organizations to develop a

14 comprehensive behavioral health prevention and

15 treatment program which emphasizes collaboration

16 among alcohol and substance abuse, social services,

17 and mental health programs;

18 ‘‘(2) provide information, direction and guid19 ance relating to mental illness and dysfunction and

20 self-destructive behavior, including child abuse and

21 family violence, to those Federal, tribal, State and

22 local agencies responsible for programs in Indian

23 communities in areas of health care, education, so24 cial services, child and family welfare, alcohol and

25 substance abuse, law enforcement and judicial serv26 ices;
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1 ‘‘(3) assist Indian tribes to identify services and

2 resources available to address mental illness and

3 dysfunctional and self-destructive behavior;

4 ‘‘(4) provide authority and opportunities for In5 dian tribes to develop and implement, and coordinate

6 with, community-based programs which include iden7 tification, prevention, education, referral, and treat8 ment services, including through multi-disciplinary

9 resource teams;

10 ‘‘(5) ensure that Indians, as citizens of the

11 United States and of the States in which they re12 side, have the same access to behavioral health serv13 ices to which all citizens have access; and

14 ‘‘(6) modify or supplement existing programs

15 and authorities in the areas identified in paragraph

16 (2).

17 ‘‘(b) BEHAVIORAL HEALTH PLANNING.—

18 ‘‘(1) AREA-WIDE PLANS.—The Secretary, acting

19 through the Service, Indian tribes, tribal organiza20 tions, and urban Indian organizations, shall encour21 age Indian tribes and tribal organizations to develop

22 tribal plans, encourage urban Indian organizations

23 to develop local plans, and encourage all such groups

24 to participate in developing area-wide plans for In-
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1 dian Behavioral Health Services. The plans shall, to

2 the extent feasible, include—

3 ‘‘(A) an assessment of the scope of the

4 problem of alcohol or other substance abuse,

5 mental illness, dysfunctional and self-destruc6 tive behavior, including suicide, child abuse and

7 family violence, among Indians, including—

8 ‘‘(i) the number of Indians served who

9 are directly or indirectly affected by such

10 illness or behavior; and

11 ‘‘(ii) an estimate of the financial and

12 human cost attributable to such illness or

13 behavior;

14 ‘‘(B) an assessment of the existing and ad15 ditional resources necessary for the prevention

16 and treatment of such illness and behavior, in17 cluding an assessment of the progress toward

18 achieving the availability of the full continuum

19 of care described in subsection (c); and

20 ‘‘(C) an estimate of the additional funding

21 needed by the Service, Indian tribes, tribal or22 ganizations and urban Indian organizations to

23 meet their responsibilities under the plans.

24 ‘‘(2) NATIONAL CLEARINGHOUSE.—The Sec25 retary shall establish a national clearinghouse of
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1 plans and reports on the outcomes of such plans de2 veloped under this section by Indian tribes, tribal or3 ganizations and by areas relating to behavioral

4 health. The Secretary shall ensure access to such

5 plans and outcomes by any Indian tribe, tribal orga6 nization, urban Indian organization or the Service.

7 ‘‘(3) TECHNICAL ASSISTANCE.—The Secretary

8 shall provide technical assistance to Indian tribes,

9 tribal organizations, and urban Indian organizations

10 in preparation of plans under this section and in de11 veloping standards of care that may be utilized and

12 adopted locally.

13 ‘‘(c) CONTINUUM OF CARE.—The Secretary, acting

14 through the Service, Indian tribes and tribal organiza15 tions, shall provide, to the extent feasible and to the extent

16 that funding is available, for the implementation of pro17 grams including—

18 ‘‘(1) a comprehensive continuum of behavioral

19 health care that provides for—

20 ‘‘(A) community based prevention, inter21 vention, outpatient and behavioral health

22 aftercare;

23 ‘‘(B) detoxification (social and medical);

24 ‘‘(C) acute hospitalization;
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1 ‘‘(D) intensive outpatient or day treat2 ment;

3 ‘‘(E) residential treatment;

4 ‘‘(F) transitional living for those needing a

5 temporary stable living environment that is sup6 portive of treatment or recovery goals;

7 ‘‘(G) emergency shelter;

8 ‘‘(H) intensive case management;

9 ‘‘(I) traditional health care practices; and

10 ‘‘(J) diagnostic services, including the utili11 zation of neurological assessment technology;

12 and

13 ‘‘(2) behavioral health services for particular

14 populations, including—

15 ‘‘(A) for persons from birth through age

16 17, child behavioral health services, that

17 include—

18 ‘‘(i) pre-school and school age fetal al19 cohol disorder services, including assess20 ment and behavioral intervention);

21 ‘‘(ii) mental health or substance abuse

22 services (emotional, organic, alcohol, drug,

23 inhalant and tobacco);

24 ‘‘(iii) services for co-occurring dis25 orders (multiple diagnosis);
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1 ‘‘(iv) prevention services that are fo2 cused on individuals ages 5 years through

3 10 years (alcohol, drug, inhalant and to4 bacco);

5 ‘‘(v) early intervention, treatment and

6 aftercare services that are focused on indi7 viduals ages 11 years through 17 years;

8 ‘‘(vi) healthy choices or life style serv9 ices (related to STD’s, domestic violence,

10 sexual abuse, suicide, teen pregnancy, obe11 sity, and other risk or safety issues);

12 ‘‘(vii) co-morbidity services;

13 ‘‘(B) for persons ages 18 years through 55

14 years, adult behavioral health services that

15 include—

16 ‘‘(i) early intervention, treatment and

17 aftercare services;

18 ‘‘(ii) mental health and substance

19 abuse services (emotional, alcohol, drug,

20 inhalant and tobacco);

21 ‘‘(iii) services for co-occurring dis22 orders (dual diagnosis) and co-morbidity;

23 ‘‘(iv) healthy choices and life style

24 services (related to parenting, partners, do-
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1 mestic violence, sexual abuse, suicide, obe2 sity, and other risk related behavior);

3 ‘‘(v) female specific treatment services

4 for—

5 ‘‘(I) women at risk of giving

6 birth to a child with a fetal alcohol

7 disorder;

8 ‘‘(II) substance abuse requiring

9 gender specific services;

10 ‘‘(III) sexual assault and domes11 tic violence; and

12 ‘‘(IV) healthy choices and life

13 style (parenting, partners, obesity,

14 suicide and other related behavioral

15 risk); and

16 ‘‘(vi) male specific treatment services

17 for—

18 ‘‘(I) substance abuse requiring

19 gender specific services;

20 ‘‘(II) sexual assault and domestic

21 violence; and

22 ‘‘(III) healthy choices and life

23 style (parenting, partners, obesity,

24 suicide and other risk related behav25 ior);
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1 ‘‘(C) family behavioral health services,

2 including—

3 ‘‘(i) early intervention, treatment and

4 aftercare for affected families;

5 ‘‘(ii) treatment for sexual assault and

6 domestic violence; and

7 ‘‘(iii) healthy choices and life style (re8 lated to parenting, partners, domestic vio9 lence and other abuse issues);

10 ‘‘(D) for persons age 56 years and older,

11 elder behavioral health services including—

12 ‘‘(i) early intervention, treatment and

13 aftercare services that include—

14 ‘‘(I) mental health and substance

15 abuse services (emotional, alcohol,

16 drug, inhalant and tobacco);

17 ‘‘(II) services for co-occurring

18 disorders (dual diagnosis) and co-mor19 bidity; and

20 ‘‘(III) healthy choices and life

21 style services (managing conditions re22 lated to aging);

23 ‘‘(ii) elder women specific services

24 that include—
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1 ‘‘(I) treatment for substance

2 abuse requiring gender specific serv3 ices and

4 ‘‘(II) treatment for sexual as5 sault, domestic violence and neglect;

6 ‘‘(iii) elder men specific services that

7 include—

8 ‘‘(I) treatment for substance

9 abuse requiring gender specific serv10 ices; and

11 ‘‘(II) treatment for sexual as12 sault, domestic violence and neglect;

13 and

14 ‘‘(iv) services for dementia regardless

15 of cause.

16 ‘‘(d) COMMUNITY BEHAVIORAL HEALTH PLAN.—

17 ‘‘(1) IN GENERAL.—The governing body of any

18 Indian tribe or tribal organization or urban Indian

19 organization may, at its discretion, adopt a resolu20 tion for the establishment of a community behavioral

21 health plan providing for the identification and co22 ordination of available resources and programs to

23 identify, prevent, or treat alcohol and other sub24 stance abuse, mental illness or dysfunctional and

25 self-destructive behavior, including child abuse and
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1 family violence, among its members or its service

2 population. Such plan should include behavioral

3 health services, social services, intensive outpatient

4 services, and continuing after care.

5 ‘‘(2) TECHNICAL ASSISTANCE.—In furtherance

6 of a plan established pursuant to paragraph (1) and

7 at the request of a tribe, the appropriate agency,

8 service unit, or other officials of the Bureau of In9 dian Affairs and the Service shall cooperate with,

10 and provide technical assistance to, the Indian tribe

11 or tribal organization in the development of a plan

12 under paragraph (1). Upon the establishment of

13 such a plan and at the request of the Indian tribe

14 or tribal organization, such officials shall cooperate

15 with the Indian tribe or tribal organization in the

16 implementation of such plan.

17 ‘‘(3) FUNDING.—The Secretary, acting through

18 the Service, may make funding available to Indian

19 tribes and tribal organizations adopting a resolution

20 pursuant to paragraph (1) to obtain technical assist21 ance for the development of a community behavioral

22 health plan and to provide administrative support in

23 the implementation of such plan.

24 ‘‘(e) COORDINATED PLANNING.—The Secretary, act25 ing through the Service, Indian tribes, tribal organiza-
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1 tions, and urban Indian organizations shall coordinate be2 havioral health planning, to the extent feasible, with other

3 Federal and State agencies, to ensure that comprehensive

4 behavioral health services are available to Indians without

5 regard to their place of residence.

6 ‘‘(f) FACILITIES ASSESSMENT.—Not later than 1

7 year after the date of enactment of this Act, the Secretary,

8 acting through the Service, shall make an assessment of

9 the need for inpatient mental health care among Indians

10 and the availability and cost of inpatient mental health

11 facilities which can meet such need. In making such as12 sessment, the Secretary shall consider the possible conver13 sion of existing, under-utilized service hospital beds into

14 psychiatric units to meet such need.

15 ‘‘SEC. 702. MEMORANDUM OF AGREEMENT WITH THE DE16 PARTMENT OF THE INTERIOR.

17 ‘‘(a) IN GENERAL.—Not later than 1 year after the

18 date of enactment of this Act, the Secretary and the Sec19 retary of the Interior shall develop and enter into a memo20 randum of agreement, or review and update any existing

21 memoranda of agreement as required under section 4205

22 of the Indian Alcohol and Substance Abuse Prevention

23 and Treatment Act of 1986 (25 U.S.C. 2411), and under

24 which the Secretaries address—
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1 ‘‘(1) the scope and nature of mental illness and

2 dysfunctional and self-destructive behavior, including

3 child abuse and family violence, among Indians;

4 ‘‘(2) the existing Federal, tribal, State, local,

5 and private services, resources, and programs avail6 able to provide mental health services for Indians;

7 ‘‘(3) the unmet need for additional services, re8 sources, and programs necessary to meet the needs

9 identified pursuant to paragraph (1);

10 ‘‘(4)(A) the right of Indians, as citizens of the

11 United States and of the States in which they re12 side, to have access to mental health services to

13 which all citizens have access;

14 ‘‘(B) the right of Indians to participate in, and

15 receive the benefit of, such services; and

16 ‘‘(C) the actions necessary to protect the exer17 cise of such right;

18 ‘‘(5) the responsibilities of the Bureau of Indian

19 Affairs and the Service, including mental health

20 identification, prevention, education, referral, and

21 treatment services (including services through multi22 disciplinary resource teams), at the central, area,

23 and agency and service unit levels to address the

24 problems identified in paragraph (1);
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1 ‘‘(6) a strategy for the comprehensive coordina2 tion of the mental health services provided by the

3 Bureau of Indian Affairs and the Service to meet

4 the needs identified pursuant to paragraph (1),

5 including—

6 ‘‘(A) the coordination of alcohol and sub7 stance abuse programs of the Service, the Bu8 reau of Indian Affairs, and the various Indian

9 tribes (developed under the Indian Alcohol and

10 Substance Abuse Prevention and Treatment

11 Act of 1986) with the mental health initiatives

12 pursuant to this Act, particularly with respect

13 to the referral and treatment of dually-diag14 nosed individuals requiring mental health and

15 substance abuse treatment; and

16 ‘‘(B) ensuring that Bureau of Indian Af17 fairs and Service programs and services (includ18 ing multidisciplinary resource teams) address19 ing child abuse and family violence are coordi20 nated with such non-Federal programs and

21 services;

22 ‘‘(7) direct appropriate officials of the Bureau

23 of Indian Affairs and the Service, particularly at the

24 agency and service unit levels, to cooperate fully

25 with tribal requests made pursuant to community
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1 behavioral health plans adopted under section 701(c)

2 and section 4206 of the Indian Alcohol and Sub3 stance Abuse Prevention and Treatment Act of 1986

4 (25 U.S.C. 2412); and

5 ‘‘(8) provide for an annual review of such

6 agreement by the 2 Secretaries and a report which

7 shall be submitted to Congress and made available

8 to the Indian tribes.

9 ‘‘(b) SPECIFIC PROVISIONS.—The memorandum of

10 agreement updated or entered into pursuant to subsection

11 (a) shall include specific provisions pursuant to which the

12 Service shall assume responsibility for—

13 ‘‘(1) the determination of the scope of the prob14 lem of alcohol and substance abuse among Indian

15 people, including the number of Indians within the

16 jurisdiction of the Service who are directly or indi17 rectly affected by alcohol and substance abuse and

18 the financial and human cost;

19 ‘‘(2) an assessment of the existing and needed

20 resources necessary for the prevention of alcohol and

21 substance abuse and the treatment of Indians af22 fected by alcohol and substance abuse; and

23 ‘‘(3) an estimate of the funding necessary to

24 adequately support a program of prevention of alco-
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1 hol and substance abuse and treatment of Indians

2 affected by alcohol and substance abuse.

3 ‘‘(c) CONSULTATION.—The Secretary and the Sec4 retary of the Interior shall, in developing the memoran5 dum of agreement under subsection (a), consult with and

6 solicit the comments of—

7 ‘‘(1) Indian tribes and tribal organizations;

8 ‘‘(2) Indian individuals;

9 ‘‘(3) urban Indian organizations and other In10 dian organizations;

11 ‘‘(4) behavioral health service providers.

12 ‘‘(d) PUBLICATION.—The memorandum of agree13 ment under subsection (a) shall be published in the Fed14 eral Register. At the same time as the publication of such

15 agreement in the Federal Register, the Secretary shall

16 provide a copy of such memorandum to each Indian tribe,

17 tribal organization, and urban Indian organization.

18 ‘‘SEC. 703. COMPREHENSIVE BEHAVIORAL HEALTH PRE19 VENTION AND TREATMENT PROGRAM.

20 ‘‘(a) ESTABLISHMENT.—

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

22 through the Service, Indian tribes and tribal organi23 zations consistent with section 701, shall provide a

24 program of comprehensive behavioral health preven25 tion and treatment and aftercare, including systems
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1 of care and traditional health care practices, which

2 shall include—

3 ‘‘(A) prevention, through educational inter4 vention, in Indian communities;

5 ‘‘(B) acute detoxification or psychiatric

6 hospitalization and treatment (residential and

7 intensive outpatient);

8 ‘‘(C) community-based rehabilitation and

9 aftercare;

10 ‘‘(D) community education and involve11 ment, including extensive training of health

12 care, educational, and community-based person13 nel;

14 ‘‘(E) specialized residential treatment pro15 grams for high risk populations including preg16 nant and post partum women and their chil17 dren;

18 ‘‘(F) diagnostic services utilizing, when ap19 propriate, neuropsychiatric assessments which

20 include the use of the most advances technology

21 available; and

22 ‘‘(G) a telepsychiatry program that uses

23 experts in the field of pediatric psychiatry, and

24 that incorporates assessment, diagnosis and
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1 treatment for children, including those children

2 with concurrent neurological disorders.

3 ‘‘(2) TARGET POPULATIONS.—The target popu4 lation of the program under paragraph (1) shall be

5 members of Indian tribes. Efforts to train and edu6 cate key members of the Indian community shall

7 target employees of health, education, judicial, law

8 enforcement, legal, and social service programs.

9 ‘‘(b) CONTRACT HEALTH SERVICES.—

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

11 through the Service (with the consent of the Indian

12 tribe to be served), Indian tribes and tribal organiza13 tions, may enter into contracts with public or private

14 providers of behavioral health treatment services for

15 the purpose of carrying out the program required

16 under subsection (a).

17 ‘‘(2) PROVISION OF ASSISTANCE.—In carrying

18 out this subsection, the Secretary shall provide as19 sistance to Indian tribes and tribal organizations to

20 develop criteria for the certification of behavioral

21 health service providers and accreditation of service

22 facilities which meet minimum standards for such

23 services and facilities.
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1 ‘‘SEC. 704. MENTAL HEALTH TECHNICIAN PROGRAM.

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

3 of November 2, 1921 (25 U.S.C. 13) (commonly known

4 as the Snyder Act), the Secretary shall establish and

5 maintain a Mental Health Technician program within the

6 Service which—

7 ‘‘(1) provides for the training of Indians as

8 mental health technicians; and

9 ‘‘(2) employs such technicians in the provision

10 of community-based mental health care that includes

11 identification, prevention, education, referral, and

12 treatment services.

13 ‘‘(b) TRAINING.—In carrying out subsection (a)(1),

14 the Secretary shall provide high standard paraprofessional

15 training in mental health care necessary to provide quality

16 care to the Indian communities to be served. Such training

17 shall be based upon a curriculum developed or approved

18 by the Secretary which combines education in the theory

19 of mental health care with supervised practical experience

20 in the provision of such care.

21 ‘‘(c) SUPERVISION AND EVALUATION.—The Sec22 retary shall supervise and evaluate the mental health tech23 nicians in the training program under this section.

24 ‘‘(d) TRADITIONAL CARE.—The Secretary shall en25 sure that the program established pursuant to this section

26 involves the utilization and promotion of the traditional
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1 Indian health care and treatment practices of the Indian

2 tribes to be served.

3 ‘‘SEC. 705. LICENSING REQUIREMENT FOR MENTAL

4 HEALTH CARE WORKERS.

5 ‘‘Subject to section 220, any person employed as a

6 psychologist, social worker, or marriage and family thera7 pist for the purpose of providing mental health care serv8 ices to Indians in a clinical setting under the authority

9 of this Act or through a funding agreement pursuant to

10 the Indian Self-Determination and Education Assistance

11 Act shall—

12 ‘‘(1) in the case of a person employed as a psy13 chologist to provide health care services, be licensed

14 as a clinical or counseling psychologist, or working

15 under the direct supervision of a clinical or counsel16 ing psychologist;

17 ‘‘(2) in the case of a person employed as a so18 cial worker, be licensed as a social worker or work19 ing under the direct supervision of a licensed social

20 worker; or

21 ‘‘(3) in the case of a person employed as a mar22 riage and family therapist, be licensed as a marriage

23 and family therapist or working under the direct su24 pervision of a licensed marriage and family thera25 pist.
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1 ‘‘SEC. 706. INDIAN WOMEN TREATMENT PROGRAMS.

2 ‘‘(a) FUNDING.—The Secretary, consistent with sec3 tion 701, shall make funding available to Indian tribes,

4 tribal organizations and urban Indian organization to de5 velop and implement a comprehensive behavioral health

6 program of prevention, intervention, treatment, and re7 lapse prevention services that specifically addresses the

8 spiritual, cultural, historical, social, and child care needs

9 of Indian women, regardless of age.

10 ‘‘(b) USE OF FUNDS.—Funding provided pursuant to

11 this section may be used to—

12 ‘‘(1) develop and provide community training,

13 education, and prevention programs for Indian

14 women relating to behavioral health issues, including

15 fetal alcohol disorders;

16 ‘‘(2) identify and provide psychological services,

17 counseling, advocacy, support, and relapse preven18 tion to Indian women and their families; and

19 ‘‘(3) develop prevention and intervention models

20 for Indian women which incorporate traditional

21 health care practices, cultural values, and commu22 nity and family involvement.

23 ‘‘(c) CRITERIA.—The Secretary, in consultation with

24 Indian tribes and tribal organizations, shall establish cri25 teria for the review and approval of applications and pro26 posals for funding under this section.
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1 ‘‘(d) EARMARK OF CERTAIN FUNDS.—Twenty per2 cent of the amounts appropriated to carry out this section

3 shall be used to make grants to urban Indian organiza4 tions funded under title V.

5 ‘‘SEC. 707. INDIAN YOUTH PROGRAM.

6 ‘‘(a) DETOXIFICATION AND REHABILITATION.—The

7 Secretary shall, consistent with section 701, develop and

8 implement a program for acute detoxification and treat9 ment for Indian youth that includes behavioral health

10 services. The program shall include regional treatment

11 centers designed to include detoxification and rehabilita12 tion for both sexes on a referral basis and programs devel13 oped and implemented by Indian tribes or tribal organiza14 tions at the local level under the Indian Self-Determina15 tion and Education Assistance Act. Regional centers shall

16 be integrated with the intake and rehabilitation programs

17 based in the referring Indian community.

18 ‘‘(b) ALCOHOL AND SUBSTANCE ABUSE TREATMENT

19 CENTERS OR FACILITIES.—

20 ‘‘(1) ESTABLISHMENT.—

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

22 through the Service, Indian tribes, or tribal or23 ganizations, shall construct, renovate, or, as

24 necessary, purchase, and appropriately staff

25 and operate, at least 1 youth regional treatment
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1 center or treatment network in each area under

2 the jurisdiction of an area office.

3 ‘‘(B) AREA OFFICE IN CALIFORNIA.—For

4 purposes of this subsection, the area office in

5 California shall be considered to be 2 area of6 fices, 1 office whose jurisdiction shall be consid7 ered to encompass the northern area of the

8 State of California, and 1 office whose jurisdic9 tion shall be considered to encompass the re10 mainder of the State of California for the pur11 pose of implementing California treatment net12 works.

13 ‘‘(2) FUNDING.—For the purpose of staffing

14 and operating centers or facilities under this sub15 section, funding shall be made available pursuant to

16 the Act of November 2, 1921 (25 U.S.C. 13) (com17 monly known as the Snyder Act).

18 ‘‘(3) LOCATION.—A youth treatment center

19 constructed or purchased under this subsection shall

20 be constructed or purchased at a location within the

21 area described in paragraph (1) that is agreed upon

22 (by appropriate tribal resolution) by a majority of

23 the tribes to be served by such center.

24 ‘‘(4) SPECIFIC PROVISION OF FUNDS.—
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1 ‘‘(A) IN GENERAL.—Notwithstanding any

2 other provision of this title, the Secretary may,

3 from amounts authorized to be appropriated for

4 the purposes of carrying out this section, make

5 funds available to—

6 ‘‘(i) the Tanana Chiefs Conference,

7 Incorporated, for the purpose of leasing,

8 constructing, renovating, operating and

9 maintaining a residential youth treatment

10 facility in Fairbanks, Alaska;

11 ‘‘(ii) the Southeast Alaska Regional

12 Health Corporation to staff and operate a

13 residential youth treatment facility without

14 regard to the proviso set forth in section

15 4(l) of the Indian Self-Determination and

16 Education Assistance Act (25 U.S.C.

17 450b(l));

18 ‘‘(iii) the Southern Indian Health

19 Council, for the purpose of staffing, oper20 ating, and maintaining a residential youth

21 treatment facility in San Diego County,

22 California; and

23 ‘‘(iv) the Navajo Nation, for the staff24 ing, operation, and maintenance of the

25 Four Corners Regional Adolescent Treat-
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1 ment Center, a residential youth treatment

2 facility in New Mexico.

3 ‘‘(B) PROVISION OF SERVICES TO ELIGI4 BLE YOUTH.—Until additional residential youth

5 treatment facilities are established in Alaska

6 pursuant to this section, the facilities specified

7 in subparagraph (A) shall make every effort to

8 provide services to all eligible Indian youth re9 siding in such State.

10 ‘‘(c) INTERMEDIATE ADOLESCENT BEHAVIORAL

11 HEALTH SERVICES.—

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

13 through the Service, Indian tribes and tribal organi14 zations, may provide intermediate behavioral health

15 services, which may incorporate traditional health

16 care practices, to Indian children and adolescents,

17 including—

18 ‘‘(A) pre-treatment assistance;

19 ‘‘(B) inpatient, outpatient, and after-care

20 services;

21 ‘‘(C) emergency care;

22 ‘‘(D) suicide prevention and crisis interven23 tion; and

24 ‘‘(E) prevention and treatment of mental

25 illness, and dysfunctional and self-destructive
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1 behavior, including child abuse and family vio2 lence.

3 ‘‘(2) USE OF FUNDS.—Funds provided under

4 this subsection may be used—

5 ‘‘(A) to construct or renovate an existing

6 health facility to provide intermediate behav7 ioral health services;

8 ‘‘(B) to hire behavioral health profes9 sionals;

10 ‘‘(C) to staff, operate, and maintain an in11 termediate mental health facility, group home,

12 sober housing, transitional housing or similar

13 facilities, or youth shelter where intermediate

14 behavioral health services are being provided;

15 and

16 ‘‘(D) to make renovations and hire appro17 priate staff to convert existing hospital beds

18 into adolescent psychiatric units; and

19 ‘‘(E) to provide intensive home- and com20 munity-based services, including collaborative

21 systems of care.

22 ‘‘(3) CRITERIA.—The Secretary shall, in con23 sultation with Indian tribes and tribal organizations,

24 establish criteria for the review and approval of ap-
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1 plications or proposals for funding made available

2 pursuant to this subsection.

3 ‘‘(d) FEDERALLY OWNED STRUCTURES.—

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

5 through the Service, shall, in consultation with In6 dian tribes and tribal organizations—

7 ‘‘(A) identify and use, where appropriate,

8 federally owned structures suitable for local res9 idential or regional behavioral health treatment

10 for Indian youth; and

11 ‘‘(B) establish guidelines, in consultation

12 with Indian tribes and tribal organizations, for

13 determining the suitability of any such Feder14 ally owned structure to be used for local resi15 dential or regional behavioral health treatment

16 for Indian youth.

17 ‘‘(2) TERMS AND CONDITIONS FOR USE OF

18 STRUCTURE.—Any structure described in paragraph

19 (1) may be used under such terms and conditions as

20 may be agreed upon by the Secretary and the agency

21 having responsibility for the structure and any In22 dian tribe or tribal organization operating the pro23 gram.

24 ‘‘(e) REHABILITATION AND AFTERCARE SERVICES.—
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1 ‘‘(1) IN GENERAL.—The Secretary, an Indian

2 tribe or tribal organization, in cooperation with the

3 Secretary of the Interior, shall develop and imple4 ment within each service unit, community-based re5 habilitation and follow-up services for Indian youth

6 who have significant behavioral health problems, and

7 require long-term treatment, community reintegra8 tion, and monitoring to support the Indian youth

9 after their return to their home community.

10 ‘‘(2) ADMINISTRATION.—Services under para11 graph (1) shall be administered within each service

12 unit or tribal program by trained staff within the

13 community who can assist the Indian youth in con14 tinuing development of self-image, positive problem15 solving skills, and nonalcohol or substance abusing

16 behaviors. Such staff may include alcohol and sub17 stance abuse counselors, mental health professionals,

18 and other health professionals and paraprofessionals,

19 including community health representatives.

20 ‘‘(f) INCLUSION OF FAMILY IN YOUTH TREATMENT

21 PROGRAM.—In providing the treatment and other services

22 to Indian youth authorized by this section, the Secretary,

23 an Indian tribe or tribal organization shall provide for the

24 inclusion of family members of such youth in the treat25 ment programs or other services as may be appropriate.
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1 Not less than 10 percent of the funds appropriated for

2 the purposes of carrying out subsection (e) shall be used

3 for outpatient care of adult family members related to the

4 treatment of an Indian youth under that subsection.

5 ‘‘(g) MULTIDRUG ABUSE PROGRAM.—The Secretary,

6 acting through the Service, Indian tribes, tribal organiza7 tions and urban Indian organizations, shall provide, con8 sistent with section 701, programs and services to prevent

9 and treat the abuse of multiple forms of substances, in10 cluding alcohol, drugs, inhalants, and tobacco, among In11 dian youth residing in Indian communities, on Indian res12 ervations, and in urban areas and provide appropriate

13 mental health services to address the incidence of mental

14 illness among such youth.

15 ‘‘SEC. 708. INPATIENT AND COMMUNITY-BASED MENTAL

16 HEALTH FACILITIES DESIGN, CONSTRUCTION

17 AND STAFFING ASSESSMENT.

18 ‘‘(a) IN GENERAL.—Not later than 1 year after the

19 date of enactment of this section, the Secretary, acting

20 through the Service, Indian tribes and tribal organiza21 tions, shall provide, in each area of the Service, not less

22 than 1 inpatient mental health care facility, or the equiva23 lent, for Indians with behavioral health problems.

24 ‘‘(b) TREATMENT OF CALIFORNIA.—For purposes of

25 this section, California shall be considered to be 2 areas
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1 of the Service, 1 area whose location shall be considered

2 to encompass the northern area of the State of California

3 and 1 area whose jurisdiction shall be considered to en4 compass the remainder of the State of California.

5 ‘‘(c) CONVERSION OF CERTAIN HOSPITAL BEDS.—

6 The Secretary shall consider the possible conversion of ex7 isting, under-utilized Service hospital beds into psychiatric

8 units to meet needs under this section.

9 ‘‘SEC. 709. TRAINING AND COMMUNITY EDUCATION.

10 ‘‘(a) COMMUNITY EDUCATION.—

11 ‘‘(1) IN GENERAL.—The Secretary, in coopera12 tion with the Secretary of the Interior, shall develop

13 and implement, or provide funding to enable Indian

14 tribes and tribal organization to develop and imple15 ment, within each service unit or tribal program a

16 program of community education and involvement

17 which shall be designed to provide concise and timely

18 information to the community leadership of each

19 tribal community.

20 ‘‘(2) EDUCATION.—A program under paragraph

21 (1) shall include education concerning behavioral

22 health for political leaders, tribal judges, law en23 forcement personnel, members of tribal health and

24 education boards, and other critical members of each

25 tribal community.
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1 ‘‘(3) TRAINING.—Community-based training

2 (oriented toward local capacity development) under a

3 program under paragraph (1) shall include tribal

4 community provider training (designed for adult

5 learners from the communities receiving services for

6 prevention, intervention, treatment and aftercare).

7 ‘‘(b) TRAINING.—The Secretary shall, either directly

8 or through Indian tribes or tribal organization, provide in9 struction in the area of behavioral health issues, including

10 instruction in crisis intervention and family relations in

11 the context of alcohol and substance abuse, child sexual

12 abuse, youth alcohol and substance abuse, and the causes

13 and effects of fetal alcohol disorders, to appropriate em14 ployees of the Bureau of Indian Affairs and the Service,

15 and to personnel in schools or programs operated under

16 any contract with the Bureau of Indian Affairs or the

17 Service, including supervisors of emergency shelters and

18 halfway houses described in section 4213 of the Indian

19 Alcohol and Substance Abuse Prevention and Treatment

20 Act of 1986 (25 U.S.C. 2433).

21 ‘‘(c) COMMUNITY-BASED TRAINING MODELS.—In

22 carrying out the education and training programs required

23 by this section, the Secretary, acting through the Service

24 and in consultation with Indian tribes, tribal organiza25 tions, Indian behavioral health experts, and Indian alcohol
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1 and substance abuse prevention experts, shall develop and

2 provide community-based training models. Such models

3 shall address—

4 ‘‘(1) the elevated risk of alcohol and behavioral

5 health problems faced by children of alcoholics;

6 ‘‘(2) the cultural, spiritual, and

7 multigenerational aspects of behavioral health prob8 lem prevention and recovery; and

9 ‘‘(3) community-based and multidisciplinary

10 strategies for preventing and treating behavioral

11 health problems.

12 ‘‘SEC. 710. BEHAVIORAL HEALTH PROGRAM.

13 ‘‘(a) PROGRAMS FOR INNOVATIVE SERVICES.—The

14 Secretary, acting through the Service, Indian tribes or

15 tribal organizations, consistent with Section 701, may de16 velop, implement, and carry out programs to deliver inno17 vative community-based behavioral health services to Indi18 ans.

19 ‘‘(b) CRITERIA.—The Secretary may award funding

20 for a project under subsection (a) to an Indian tribe or

21 tribal organization and may consider the following criteria:

22 ‘‘(1) Whether the project will address signifi23 cant unmet behavioral health needs among Indians.

24 ‘‘(2) Whether the project will serve a significant

25 number of Indians.
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1 ‘‘(3) Whether the project has the potential to

2 deliver services in an efficient and effective manner.

3 ‘‘(4) Whether the tribe or tribal organization

4 has the administrative and financial capability to ad5 minister the project.

6 ‘‘(5) Whether the project will deliver services in

7 a manner consistent with traditional health care.

8 ‘‘(6) Whether the project is coordinated with,

9 and avoids duplication of, existing services.

10 ‘‘(c) FUNDING AGREEMENTS.—For purposes of this

11 subsection, the Secretary shall, in evaluating applications

12 or proposals for funding for projects to be operated under

13 any funding agreement entered into with the Service

14 under the Indian Self-Determination Act and Education

15 Assistance Act, use the same criteria that the Secretary

16 uses in evaluating any other application or proposal for

17 such funding.

18 ‘‘SEC. 711. FETAL ALCOHOL DISORDER FUNDING.

19 ‘‘(a) ESTABLISHMENT OF PROGRAM.—

20 ‘‘(1) IN GENERAL.—The Secretary, consistent

21 with Section 701, acting through Indian tribes, trib22 al organizations, and urban Indian organizations,

23 shall establish and operate fetal alcohol disorders

24 programs as provided for in this section for the pur-
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1 poses of meeting the health status objective specified

2 in section 3(b).

3 ‘‘(2) USE OF FUNDS.—Funding provided pursu4 ant to this section shall be used to—

5 ‘‘(A) develop and provide community and

6 in-school training, education, and prevention

7 programs relating to fetal alcohol disorders;

8 ‘‘(B) identify and provide behavioral health

9 treatment to high-risk women;

10 ‘‘(C) identify and provide appropriate edu11 cational and vocational support, counseling, ad12 vocacy, and information to fetal alcohol disorder

13 affected persons and their families or care14 takers;

15 ‘‘(D) develop and implement counseling

16 and support programs in schools for fetal alco17 hol disorder affected children;

18 ‘‘(E) develop prevention and intervention

19 models which incorporate traditional practition20 ers, cultural and spiritual values and commu21 nity involvement;

22 ‘‘(F) develop, print, and disseminate edu23 cation and prevention materials on fetal alcohol

24 disorders;
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1 ‘‘(G) develop and implement, through the

2 tribal consultation process, culturally sensitive

3 assessment and diagnostic tools including

4 dysmorphology clinics and multidisciplinary

5 fetal alcohol disorder clinics for use in tribal

6 and urban Indian communities;

7 ‘‘(H) develop early childhood intervention

8 projects from birth on to mitigate the effects of

9 fetal alcohol disorders; and

10 ‘‘(I) develop and fund community-based

11 adult fetal alcohol disorder housing and support

12 services.

13 ‘‘(3) CRITERIA.—The Secretary shall establish

14 criteria for the review and approval of applications

15 for funding under this section.

16 ‘‘(b) PROVISION OF SERVICES.—The Secretary, act17 ing through the Service, Indian tribes, tribal organizations

18 and urban Indian organizations, shall—

19 ‘‘(1) develop and provide services for the pre20 vention, intervention, treatment, and aftercare for

21 those affected by fetal alcohol disorders in Indian

22 communities; and

23 ‘‘(2) provide supportive services, directly or

24 through an Indian tribe, tribal organization or urban

25 Indian organization, including services to meet the
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1 special educational, vocational, school-to-work transi2 tion, and independent living needs of adolescent and

3 adult Indians with fetal alcohol disorders.

4 ‘‘(c) TASK FORCE.—

5 ‘‘(1) IN GENERAL.—The Secretary shall estab6 lish a task force to be known as the Fetal Alcohol

7 Disorders Task Force to advise the Secretary in car8 rying out subsection (b).

9 ‘‘(2) COMPOSITION.—The task force under

10 paragraph (1) shall be composed of representatives

11 from the National Institute on Drug Abuse, the Na12 tional Institute on Alcohol and Alcoholism, the Of13 fice of Substance Abuse Prevention, the National In14 stitute of Mental Health, the Service, the Office of

15 Minority Health of the Department of Health and

16 Human Services, the Administration for Native

17 Americans, the National Institute of Child Health &

18 Human Development, the Centers for Disease Con19 trol and Prevention, the Bureau of Indian Affairs,

20 Indian tribes, tribal organizations, urban Indian

21 communities, and Indian fetal alcohol disorders ex22 perts.

23 ‘‘(d) APPLIED RESEARCH.—The Secretary, acting

24 through the Substance Abuse and Mental Health Services

25 Administration, shall make funding available to Indian
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1 tribes, tribal organizations and urban Indian organizations

2 for applied research projects which propose to elevate the

3 understanding of methods to prevent, intervene, treat, or

4 provide rehabilitation and behavioral health aftercare for

5 Indians and urban Indians affected by fetal alcohol dis6 orders.

7 ‘‘(e) URBAN INDIAN ORGANIZATIONS.—The Sec8 retary shall ensure that 10 percent of the amounts appro9 priated to carry out this section shall be used to make

10 grants to urban Indian organizations funded under title

11 V.

12 ‘‘SEC. 712. CHILD SEXUAL ABUSE AND PREVENTION TREAT13 MENT PROGRAMS.

14 ‘‘(a) ESTABLISHMENT.—The Secretary and the Sec15 retary of the Interior, acting through the Service, Indian

16 tribes and tribal organizations, shall establish, consistent

17 with section 701, in each service area, programs involving

18 treatment for—

19 ‘‘(1) victims of child sexual abuse; and

20 ‘‘(2) perpetrators of child sexual abuse.

21 ‘‘(b) USE OF FUNDS.—Funds provided under this

22 section shall be used to—

23 ‘‘(1) develop and provide community education

24 and prevention programs related to child sexual

25 abuse;
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1 ‘‘(2) identify and provide behavioral health

2 treatment to children who are victims of sexual

3 abuse and to their families who are affected by sex4 ual abuse;

5 ‘‘(3) develop prevention and intervention models

6 which incorporate traditional health care practition7 ers, cultural and spiritual values, and community in8 volvement;

9 ‘‘(4) develop and implement, though the tribal

10 consultation process, culturally sensitive assessment

11 and diagnostic tools for use in tribal and urban In12 dian communities.

13 ‘‘(5) identify and provide behavioral health

14 treatment to perpetrators of child sexual abuse with

15 efforts being made to begin offender and behavioral

16 health treatment while the perpetrator is incarcer17 ated or at the earliest possible date if the perpetra18 tor is not incarcerated, and to provide treatment

19 after release to the community until it is determined

20 that the perpetrator is not a threat to children.

21 ‘‘SEC. 713. BEHAVIORAL MENTAL HEALTH RESEARCH.

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

23 the Service and in consultation with appropriate Federal

24 agencies, shall provide funding to Indian tribes, tribal or25 ganizations and urban Indian organizations or, enter into
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1 contracts with, or make grants to appropriate institutions,

2 for the conduct of research on the incidence and preva3 lence of behavioral health problems among Indians served

4 by the Service, Indian tribes or tribal organizations and

5 among Indians in urban areas. Research priorities under

6 this section shall include—

7 ‘‘(1) the inter-relationship and inter-dependence

8 of behavioral health problems with alcoholism and

9 other substance abuse, suicide, homicides, other in10 juries, and the incidence of family violence; and

11 ‘‘(2) the development of models of prevention

12 techniques.

13 ‘‘(b) SPECIAL EMPHASIS.—The effect of the inter-re14 lationships and interdependencies referred to in subsection

15 (a)(1) on children, and the development of prevention

16 techniques under subsection (a)(2) applicable to children,

17 shall be emphasized.

18 ‘‘SEC. 714. DEFINITIONS.

19 ‘‘In this title:

20 ‘‘(1) ASSESSMENT.—The term ‘assessment’

21 means the systematic collection, analysis and dis22 semination of information on health status, health

23 needs and health problems.

24 ‘‘(2) ALCOHOL RELATED NEURODEVELOP25 MENTAL DISORDERS.—The term ‘alcohol related
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1 neurodevelopmental disorders’ or ‘ARND’ with re2 spect to an individual means the individual has a

3 history of maternal alcohol consumption during

4 pregnancy, central nervous system involvement such

5 as developmental delay, intellectual deficit, or

6 neurologic abnormalities, that behaviorally, there

7 may be problems with irritability, and failure to

8 thrive as infants, and that as children become older

9 there will likely be hyperactivity, attention deficit,

10 language dysfunction and perceptual and judgment

11 problems.

12 ‘‘(3) BEHAVIORAL HEALTH.—The term ‘behav13 ioral health’ means the blending of substances (alco14 hol, drugs, inhalants and tobacco) abuse and mental

15 health prevention and treatment, for the purpose of

16 providing comprehensive services. Such term in17 cludes the joint development of substance abuse and

18 mental health treatment planning and coordinated

19 case management using a multidisciplinary ap20 proach.

21 ‘‘(4) BEHAVIORAL HEALTH AFTERCARE.—

22 ‘‘(A) IN GENERAL.—The term ‘behavioral

23 health aftercare’ includes those activities and

24 resources used to support recovery following in25 patient, residential, intensive substance abuse
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1 or mental health outpatient or outpatient treat2 ment, to help prevent or treat relapse, including

3 the development of an aftercare plan.

4 ‘‘(B) AFTERCARE PLAN.—Prior to the

5 time at which an individual is discharged from

6 a level of care, such as outpatient treatment, an

7 aftercare plan shall have been developed for the

8 individual. Such plan may use such resources as

9 community base therapeutic group care, transi10 tional living, a 12-step sponsor, a local 12-step

11 or other related support group, or other com12 munity based providers (such as mental health

13 professionals, traditional health care practition14 ers, community health aides, community health

15 representatives, mental health technicians, or

16 ministers).

17 ‘‘(5) DUAL DIAGNOSIS.—The term ‘dual diag18 nosis’ means coexisting substance abuse and mental

19 illness conditions or diagnosis. In individual with a

20 dual diagnosis may be referred to as a mentally ill

21 chemical abuser.

22 ‘‘(6) FETAL ALCOHOL DISORDERS.—The term

23 ‘fetal alcohol disorders’ means fetal alcohol syn24 drome, partial fetal alcohol syndrome, or alcohol re25 lated neural developmental disorder.
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1 ‘‘(7) FETAL ALCOHOL SYNDROME.—The term

2 ‘fetal alcohol syndrome’ or ‘FAS’ with respect to an

3 individual means a syndrome in which the individual

4 has a history of maternal alcohol consumption dur5 ing pregnancy, and with respect to which the follow6 ing criteria should be met:

7 ‘‘(A) Central nervous system involvement

8 such as developmental delay, intellectual deficit,

9 microencephaly, or neurologic abnormalities.

10 ‘‘(B) Craniofacial abnormalities with at

11 least 2 of the following: microphthalmia, short

12 palpebral fissures, poorly developed philtrum,

13 thin upper lip, flat nasal bridge, and short

14 upturned nose.

15 ‘‘(C) Prenatal or postnatal growth delay.

16 ‘‘(8) PARTIAL FAS.—The term ‘partial FAS’

17 with respect to an individual means a history of ma18 ternal alcohol consumption during pregnancy having

19 most of the criteria of FAS, though not meeting a

20 minimum of at least 2 of the following: micro-oph21 thalmia, short palpebral fissures, poorly developed

22 philtrum, thin upper lip, flat nasal bridge, short

23 upturned nose.

24 ‘‘(9) REHABILITATION.—The term ‘rehabilita25 tion’ means to restore the ability or capacity to en-
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1 gage in usual and customary life activities through

2 education and therapy.

3 ‘‘(10) SUBSTANCE ABUSE.—The term ‘sub4 stance abuse’ includes inhalant abuse.

5 ‘‘SEC. 715. AUTHORIZATION OF APPROPRIATIONS.

6 ‘‘There is authorized to be appropriated such sums

7 as may be necessary for each fiscal year through fiscal

8 year 2015 to carry out this title.

9 ‘‘TITLE VIII—MISCELLANEOUS

10 ‘‘SEC. 801. REPORTS.

11 ‘‘The President shall, at the time the budget is sub12 mitted under section 1105 of title 31, United States Code,

13 for each fiscal year transmit to the Congress a report

14 containing—

15 ‘‘(1) a report on the progress made in meeting

16 the objectives of this Act, including a review of pro17 grams established or assisted pursuant to this Act

18 and an assessment and recommendations of addi19 tional programs or additional assistance necessary

20 to, at a minimum, provide health services to Indians,

21 and ensure a health status for Indians, which are at

22 a parity with the health services available to and the

23 health status of, the general population, including

24 specific comparisons of appropriations provided and

25 those required for such parity;
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1 ‘‘(2) a report on whether, and to what extent,

2 new national health care programs, benefits, initia3 tives, or financing systems have had an impact on

4 the purposes of this Act and any steps that the Sec5 retary may have taken to consult with Indian tribes

6 to address such impact, including a report on pro7 posed changes in the allocation of funding pursuant

8 to section 808;

9 ‘‘(3) a report on the use of health services by

10 Indians—

11 ‘‘(A) on a national and area or other rel12 evant geographical basis;

13 ‘‘(B) by gender and age;

14 ‘‘(C) by source of payment and type of

15 service;

16 ‘‘(D) comparing such rates of use with

17 rates of use among comparable non-Indian pop18 ulations; and

19 ‘‘(E) on the services provided under fund20 ing agreements pursuant to the Indian Self-De21 termination and Education Assistance Act;

22 ‘‘(4) a report of contractors concerning health

23 care educational loan repayments under section 110;
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1 ‘‘(5) a general audit report on the health care

2 educational loan repayment program as required

3 under section 110(n);

4 ‘‘(6) a separate statement that specifies the

5 amount of funds requested to carry out the provi6 sions of section 201;

7 ‘‘(7) a report on infectious diseases as required

8 under section 212;

9 ‘‘(8) a report on environmental and nuclear

10 health hazards as required under section 214;

11 ‘‘(9) a report on the status of all health care fa12 cilities needs as required under sections 301(c)(2)

13 and 301(d);

14 ‘‘(10) a report on safe water and sanitary waste

15 disposal facilities as required under section

16 302(h)(1);

17 ‘‘(11) a report on the expenditure of non-service

18 funds for renovation as required under sections

19 305(a)(2) and 305(a)(3);

20 ‘‘(12) a report identifying the backlog of main21 tenance and repair required at Service and tribal fa22 cilities as required under section 314(a);

23 ‘‘(13) a report providing an accounting of reim24 bursement funds made available to the Secretary
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1 under titles XVIII and XIX of the Social Security

2 Act as required under section 403(a);

3 ‘‘(14) a report on services sharing of the Serv4 ice, the Department of Veteran’s Affairs, and other

5 Federal agency health programs as required under

6 section 412(c)(2);

7 ‘‘(15) a report on the evaluation and renewal of

8 urban Indian programs as required under section

9 505;

10 ‘‘(16) a report on the findings and conclusions

11 derived from the demonstration project as required

12 under section 512(a)(2);

13 ‘‘(17) a report on the evaluation of programs as

14 required under section 513; and

15 ‘‘(18) a report on alcohol and substance abuse

16 as required under section 701(f).

17 ‘‘SEC. 802. REGULATIONS.

18 ‘‘(a) INITIATION OF RULEMAKING PROCEDURES.—

19 ‘‘(1) IN GENERAL.—Not later than 90 days

20 after the date of enactment of this Act, the Sec21 retary shall initiate procedures under subchapter III

22 of chapter 5 of title 5, United States Code, to nego23 tiate and promulgate such regulations or amend24 ments thereto that are necessary to carry out this

25 Act.
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1 ‘‘(2) PUBLICATION.—Proposed regulations to

2 implement this Act shall be published in the Federal

3 Register by the Secretary not later than 270 days

4 after the date of enactment of this Act and shall

5 have not less than a 120 day comment period.

6 ‘‘(3) EXPIRATION OF AUTHORITY.—The author7 ity to promulgate regulations under this Act shall

8 expire 18 months from the date of enactment of this

9 Act.

10 ‘‘(b) RULEMAKING COMMITTEE.—A negotiated rule11 making committee established pursuant to section 565 of

12 title 5, United States Code, to carry out this section shall

13 have as its members only representatives of the Federal

14 Government and representatives of Indian tribes, and trib15 al organizations, a majority of whom shall be nominated

16 by and be representatives of Indian tribes, tribal organiza17 tions, and urban Indian organizations from each service

18 area.

19 ‘‘(c) ADAPTION OF PROCEDURES.—The Secretary

20 shall adapt the negotiated rulemaking procedures to the

21 unique context of self-governance and the government-to22 government relationship between the United States and

23 Indian tribes.
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1 ‘‘(d) FAILURE TO PROMULGATE REGULATIONS.—

2 The lack of promulgated regulations shall not limit the

3 effect of this Act.

4 ‘‘(e) SUPREMACY OF PROVISIONS.—The provisions of

5 this Act shall supersede any conflicting provisions of law

6 (including any conflicting regulations) in effect on the day

7 before the date of enactment of the Indian Self-Deter8 mination Contract Reform Act of 1994, and the Secretary

9 is authorized to repeal any regulation that is inconsistent

10 with the provisions of this Act.

11 ‘‘SEC. 803. PLAN OF IMPLEMENTATION.

12 ‘‘Not later than 240 days after the date of enactment

13 of this Act, the Secretary, in consultation with Indian

14 tribes, tribal organizations, and urban Indian organiza15 tions, shall prepare and submit to Congress a plan that

16 shall explain the manner and schedule (including a sched17 ule of appropriate requests), by title and section, by which

18 the Secretary will implement the provisions of this Act.

19 ‘‘SEC. 804. AVAILABILITY OF FUNDS.

20 ‘‘Amounts appropriated under this Act shall remain

21 available until expended.

22 ‘‘SEC. 805. LIMITATION ON USE OF FUNDS APPROPRIATED

23 TO THE INDIAN HEALTH SERVICE.

24 ‘‘Any limitation on the use of funds contained in an

25 Act providing appropriations for the Department for a pe-
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1 riod with respect to the performance of abortions shall

2 apply for that period with respect to the performance of

3 abortions using funds contained in an Act providing ap4 propriations for the Service.

5 ‘‘SEC. 806. ELIGIBILITY OF CALIFORNIA INDIANS.

6 ‘‘(a) ELIGIBILITY.—

7 ‘‘(1) IN GENERAL.—Until such time as any

8 subsequent law may otherwise provide, the following

9 California Indians shall be eligible for health services

10 provided by the Service:

11 ‘‘(A) Any member of a federally recognized

12 Indian tribe.

13 ‘‘(B) Any descendant of an Indian who

14 was residing in California on June 1, 1852, but

15 only if such descendant—

16 ‘‘(i) is a member of the Indian com17 munity served by a local program of the

18 Service; and

19 ‘‘(ii) is regarded as an Indian by the

20 community in which such descendant lives.

21 ‘‘(C) Any Indian who holds trust interests

22 in public domain, national forest, or Indian res23 ervation allotments in California.

24 ‘‘(D) Any Indian in California who is listed

25 on the plans for distribution of the assets of
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1 California rancherias and reservations under

2 the Act of August 18, 1958 (72 Stat. 619), and

3 any descendant of such an Indian.

4 ‘‘(b) RULE OF CONSTRUCTION.—Nothing in this sec5 tion may be construed as expanding the eligibility of Cali6 fornia Indians for health services provided by the Service

7 beyond the scope of eligibility for such health services that

8 applied on May 1, 1986.

9 ‘‘SEC. 807. HEALTH SERVICES FOR INELIGIBLE PERSONS.

10 ‘‘(a) INELIGIBLE PERSONS.—

11 ‘‘(1) IN GENERAL.—Any individual who—

12 ‘‘(A) has not attained 19 years of age;

13 ‘‘(B) is the natural or adopted child, step14 child, foster-child, legal ward, or orphan of an

15 eligible Indian; and

16 ‘‘(C) is not otherwise eligible for the health

17 services provided by the Service,

18 shall be eligible for all health services provided by

19 the Service on the same basis and subject to the

20 same rules that apply to eligible Indians until such

21 individual attains 19 years of age. The existing and

22 potential health needs of all such individuals shall be

23 taken into consideration by the Service in determin24 ing the need for, or the allocation of, the health re25 sources of the Service. If such an individual has
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1 been determined to be legally incompetent prior to

2 attaining 19 years of age, such individual shall re3 main eligible for such services until one year after

4 the date such disability has been removed.

5 ‘‘(2) SPOUSES.—Any spouse of an eligible In6 dian who is not an Indian, or who is of Indian de7 scent but not otherwise eligible for the health serv8 ices provided by the Service, shall be eligible for

9 such health services if all of such spouses or spouses

10 who are married to members of the Indian tribe

11 being served are made eligible, as a class, by an ap12 propriate resolution of the governing body of the In13 dian tribe or tribal organization providing such serv14 ices. The health needs of persons made eligible

15 under this paragraph shall not be taken into consid16 eration by the Service in determining the need for,

17 or allocation of, its health resources.

18 ‘‘(b) PROGRAMS AND SERVICES.—

19 ‘‘(1) PROGRAMS.—

20 ‘‘(A) IN GENERAL.—The Secretary may

21 provide health services under this subsection

22 through health programs operated directly by

23 the Service to individuals who reside within the

24 service area of a service unit and who are not

25 eligible for such health services under any other
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1 subsection of this section or under any other

2 provision of law if—

3 ‘‘(i) the Indian tribe (or, in the case

4 of a multi-tribal service area, all the Indian

5 tribes) served by such service unit requests

6 such provision of health services to such

7 individuals; and

8 ‘‘(ii) the Secretary and the Indian

9 tribe or tribes have jointly determined

10 that—

11 ‘‘(I) the provision of such health

12 services will not result in a denial or

13 diminution of health services to eligi14 ble Indians; and

15 ‘‘(II) there is no reasonable alter16 native health program or services,

17 within or without the service area of

18 such service unit, available to meet

19 the health needs of such individuals.

20 ‘‘(B) FUNDING AGREEMENTS.—In the case

21 of health programs operated under a funding

22 agreement entered into under the Indian Self23 Determination and Educational Assistance Act,

24 the governing body of the Indian tribe or tribal

25 organization providing health services under
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1 such funding agreement is authorized to deter2 mine whether health services should be provided

3 under such funding agreement to individuals

4 who are not eligible for such health services

5 under any other subsection of this section or

6 under any other provision of law. In making

7 such determinations, the governing body of the

8 Indian tribe or tribal organization shall take

9 into account the considerations described in

10 subparagraph (A)(ii).

11 ‘‘(2) LIABILITY FOR PAYMENT.—

12 ‘‘(A) IN GENERAL.—Persons receiving

13 health services provided by the Service by rea14 son of this subsection shall be liable for pay15 ment of such health services under a schedule

16 of charges prescribed by the Secretary which, in

17 the judgment of the Secretary, results in reim18 bursement in an amount not less than the ac19 tual cost of providing the health services. Not20 withstanding section 1880 of the Social Secu21 rity Act, section 402(a) of this Act, or any

22 other provision of law, amounts collected under

23 this subsection, including medicare or medicaid

24 reimbursements under titles XVIII and XIX of

25 the Social Security Act, shall be credited to the
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1 account of the program providing the service

2 and shall be used solely for the provision of

3 health services within that program. Amounts

4 collected under this subsection shall be available

5 for expenditure within such program for not to

6 exceed 1 fiscal year after the fiscal year in

7 which collected.

8 ‘‘(B) SERVICES FOR INDIGENT PERSONS.—

9 Health services may be provided by the Sec10 retary through the Service under this sub11 section to an indigent person who would not be

12 eligible for such health services but for the pro13 visions of paragraph (1) only if an agreement

14 has been entered into with a State or local gov15 ernment under which the State or local govern16 ment agrees to reimburse the Service for the

17 expenses incurred by the Service in providing

18 such health services to such indigent person.

19 ‘‘(3) SERVICE AREAS.—

20 ‘‘(A) SERVICE TO ONLY ONE TRIBE.—In

21 the case of a service area which serves only one

22 Indian tribe, the authority of the Secretary to

23 provide health services under paragraph (1)(A)

24 shall terminate at the end of the fiscal year suc25 ceeding the fiscal year in which the governing
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1 body of the Indian tribe revokes its concurrence

2 to the provision of such health services.

3 ‘‘(B) MULTI-TRIBAL AREAS.—In the case

4 of a multi-tribal service area, the authority of

5 the Secretary to provide health services under

6 paragraph (1)(A) shall terminate at the end of

7 the fiscal year succeeding the fiscal year in

8 which at least 51 percent of the number of In9 dian tribes in the service area revoke their con10 currence to the provision of such health serv11 ices.

12 ‘‘(c) PURPOSE FOR PROVIDING SERVICES.—The

13 Service may provide health services under this subsection

14 to individuals who are not eligible for health services pro15 vided by the Service under any other subsection of this

16 section or under any other provision of law in order to—

17 ‘‘(1) achieve stability in a medical emergency;

18 ‘‘(2) prevent the spread of a communicable dis19 ease or otherwise deal with a public health hazard;

20 ‘‘(3) provide care to non-Indian women preg21 nant with an eligible Indian’s child for the duration

22 of the pregnancy through post partum; or

23 ‘‘(4) provide care to immediate family members

24 of an eligible person if such care is directly related

25 to the treatment of the eligible person.
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1 ‘‘(d) HOSPITAL PRIVILEGES.—Hospital privileges in

2 health facilities operated and maintained by the Service

3 or operated under a contract entered into under the Indian

4 Self-Determination Education Assistance Act may be ex5 tended to non-Service health care practitioners who pro6 vide services to persons described in subsection (a) or (b).

7 Such non-Service health care practitioners may be re8 garded as employees of the Federal Government for pur9 poses of section 1346(b) and chapter 171 of title 28,

10 United States Code (relating to Federal tort claims) only

11 with respect to acts or omissions which occur in the course

12 of providing services to eligible persons as a part of the

13 conditions under which such hospital privileges are ex14 tended.

15 ‘‘(e) DEFINITION.—In this section, the term ‘eligible

16 Indian’ means any Indian who is eligible for health serv17 ices provided by the Service without regard to the provi18 sions of this section.

19 ‘‘SEC. 808. REALLOCATION OF BASE RESOURCES.

20 ‘‘(a) REQUIREMENT OF REPORT.—Notwithstanding

21 any other provision of law, any allocation of Service funds

22 for a fiscal year that reduces by 5 percent or more from

23 the previous fiscal year the funding for any recurring pro24 gram, project, or activity of a service unit may be imple25 mented only after the Secretary has submitted to the
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1 President, for inclusion in the report required to be trans2 mitted to the Congress under section 801, a report on the

3 proposed change in allocation of funding, including the

4 reasons for the change and its likely effects.

5 ‘‘(b) NONAPPLICATION OF SECTION.—Subsection (a)

6 shall not apply if the total amount appropriated to the

7 Service for a fiscal year is less than the amount appro8 priated to the Service for previous fiscal year.

9 ‘‘SEC. 809. RESULTS OF DEMONSTRATION PROJECTS.

10 ‘‘The Secretary shall provide for the dissemination to

11 Indian tribes of the findings and results of demonstration

12 projects conducted under this Act.

13 ‘‘SEC. 810. PROVISION OF SERVICES IN MONTANA.

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

15 the Service, shall provide services and benefits for Indians

16 in Montana in a manner consistent with the decision of

17 the United States Court of Appeals for the Ninth Circuit

18 in McNabb for McNabb v. Bowen, 829 F.2d 787 (9th Cr.

19 1987).

20 ‘‘(b) RULE OF CONSTRUCTION.—The provisions of

21 subsection (a) shall not be construed to be an expression

22 of the sense of the Congress on the application of the deci23 sion described in subsection (a) with respect to the provi24 sion of services or benefits for Indians living in any State

25 other than Montana.
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1 ‘‘SEC. 811. MORATORIUM.

2 ‘‘During the period of the moratorium imposed by

3 Public Law 100–446 on implementation of the final rule

4 published in the Federal Register on September 16, 1987,

5 by the Health Resources and Services Administration, re6 lating to eligibility for the health care services of the Serv7 ice, the Service shall provide services pursuant to the cri8 teria for eligibility for such services that were in effect

9 on September 15, 1987, subject to the provisions of sec10 tions 806 and 807 until such time as new criteria govern11 ing eligibility for services are developed in accordance with

12 section 802.

13 ‘‘SEC. 812. TRIBAL EMPLOYMENT.

14 ‘‘For purposes of section 2(2) of the Act of July 5,

15 1935 (49 Stat. 450, Chapter 372), an Indian tribe or trib16 al organization carrying out a funding agreement under

17 the Self-Determination and Education Assistance Act

18 shall not be considered an employer.

19 ‘‘SEC. 813. PRIME VENDOR.

20 ‘‘For purposes of section 4 of Public Law 102–585

21 (38 U.S.C. 812) Indian tribes and tribal organizations

22 carrying out a grant, cooperative agreement, or funding

23 agreement under the Indian Self-Determination and Edu24 cation Assistance Act (25 U.S.C. 450 et seq.) shall be

25 deemed to be an executive agency and part of the Service

26 and, as such, may act as an ordering agent of the Service
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1 and the employees of the tribe or tribal organization may

2 order supplies on behalf thereof on the same basis as em3 ployees of the Service.

4 ‘‘SEC. 814. NATIONAL BI-PARTISAN COMMISSION ON INDIAN

5 HEALTH CARE ENTITLEMENT.

6 ‘‘(a) ESTABLISHMENT.—There is hereby established

7 the National Bi-Partisan Indian Health Care Entitlement

8 Commission (referred to in this Act as the ‘Commission’).

9 ‘‘(b) MEMBERSHIP.—The Commission shall be com10 posed of 25 members, to be appointed as follows:

11 ‘‘(1) Ten members of Congress, of which—

12 ‘‘(A) three members shall be from the

13 House of Representatives and shall be ap14 pointed by the majority leader;

15 ‘‘(B) three members shall be from the

16 House of Representatives and shall be ap17 pointed by the minority leader;

18 ‘‘(C) two members shall be from the Sen19 ate and shall be appointed by the majority lead20 er; and

21 ‘‘(D) two members shall be from the Sen22 ate and shall be appointed by the minority lead23 er;

24 who shall each be members of the committees of

25 Congress that consider legislation affecting the pro-
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1 vision of health care to Indians and who shall elect

2 the chairperson and vice-chairperson of the Commis3 sion.

4 ‘‘(2) Twelve individuals to be appointed by the

5 members of the Commission appointed under para6 graph (1), of which at least 1 shall be from each

7 service area as currently designated by the Director

8 of the Service, to be chosen from among 3 nominees

9 from each such area as selected by the Indian tribes

10 within the area, with due regard being given to the

11 experience and expertise of the nominees in the pro12 vision of health care to Indians and with due regard

13 being given to a reasonable representation on the

14 Commission of members who are familiar with var15 ious health care delivery modes and who represent

16 tribes of various size populations.

17 ‘‘(3) Three individuals shall be appointed by the

18 Director of the Service from among individual who

19 are knowledgeable about the provision of health care

20 to Indians, at least 1 of whom shall be appointed

21 from among 3 nominees from each program that is

22 funded in whole or in part by the Service primarily

23 or exclusively for the benefit of urban Indians.

24 All those persons appointed under paragraphs (2) and (3)

25 shall be members of Federally recognized Indian tribes.
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1 ‘‘(c) TERMS.—

2 ‘‘(1) IN GENERAL.—Members of the Commis3 sion shall serve for the life of the Commission.

4 ‘‘(2) APPOINTMENT OF MEMBERS.—Members of

5 the Commission shall be appointed under subsection

6 (b)(1) not later than 90 days after the date of enact7 ment of this Act, and the remaining members of the

8 Commission shall be appointed not later than 60

9 days after the date on which the members are ap10 pointed under such subsection.

11 ‘‘(3) VACANCY.—A vacancy in the membership

12 of the Commission shall be filled in the manner in

13 which the original appointment was made.

14 ‘‘(d) DUTIES OF THE COMMISSION.—The Commis15 sion shall carry out the following duties and functions:

16 ‘‘(1) Review and analyze the recommendations

17 of the report of the study committee established

18 under paragraph (3) to the Commission.

19 ‘‘(2) Make recommendations to Congress for

20 providing health services for Indian persons as an

21 entitlement, giving due regard to the effects of such

22 a programs on existing health care delivery systems

23 for Indian persons and the effect of such programs

24 on the sovereign status of Indian tribes;
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1 ‘‘(3) Establish a study committee to be com2 posed of those members of the Commission ap3 pointed by the Director of the Service and at least

4 4 additional members of Congress from among the

5 members of the Commission which shall—

6 ‘‘(A) to the extent necessary to carry out

7 its duties, collect and compile data necessary to

8 understand the extent of Indian needs with re9 gard to the provision of health services, regard10 less of the location of Indians, including holding

11 hearings and soliciting the views of Indians, In12 dian tribes, tribal organizations and urban In13 dian organizations, and which may include au14 thorizing and funding feasibility studies of var15 ious models for providing and funding health

16 services for all Indian beneficiaries including

17 those who live outside of a reservation, tempo18 rarily or permanently;

19 ‘‘(B) make recommendations to the Com20 mission for legislation that will provide for the

21 delivery of health services for Indians as an en22 titlement, which shall, at a minimum, address

23 issues of eligibility, benefits to be provided, in24 cluding recommendations regarding from whom

25 such health services are to be provided, and the
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1 cost, including mechanisms for funding of the

2 health services to be provided;

3 ‘‘(C) determine the effect of the enactment

4 of such recommendations on the existing system

5 of the delivery of health services for Indians;

6 ‘‘(D) determine the effect of a health serv7 ices entitlement program for Indian persons on

8 the sovereign status of Indian tribes;

9 ‘‘(E) not later than 12 months after the

10 appointment of all members of the Commission,

11 make a written report of its findings and rec12 ommendations to the Commission, which report

13 shall include a statement of the minority and

14 majority position of the committee and which

15 shall be disseminated, at a minimum, to each

16 federally recognized Indian tribe, tribal organi17 zation and urban Indian organization for com18 ment to the Commission; and

19 ‘‘(F) report regularly to the full Commis20 sion regarding the findings and recommenda21 tions developed by the committee in the course

22 of carrying out its duties under this section.

23 ‘‘(4) Not later than 18 months after the date

24 of appointment of all members of the Commission,

25 submit a written report to Congress containing a
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1 recommendation of policies and legislation to imple2 ment a policy that would establish a health care sys3 tem for Indians based on the delivery of health serv4 ices as an entitlement, together with a determination

5 of the implications of such an entitlement system on

6 existing health care delivery systems for Indians and

7 on the sovereign status of Indian tribes.

8 ‘‘(e) ADMINISTRATIVE PROVISIONS.—

9 ‘‘(1) COMPENSATION AND EXPENSES.—

10 ‘‘(A) CONGRESSIONAL MEMBERS.—Each

11 member of the Commission appointed under

12 subsection (b)(1) shall receive no additional

13 pay, allowances, or benefits by reason of their

14 service on the Commission and shall receive

15 travel expenses and per diem in lieu of subsist16 ence in accordance with sections 5702 and 5703

17 of title 5, United States Code.

18 ‘‘(B) OTHER MEMBERS.—The members of

19 the Commission appointed under paragraphs

20 (2) and (3) of subsection (b), while serving on

21 the business of the Commission (including trav22 el time) shall be entitled to receive compensa23 tion at the per diem equivalent of the rate pro24 vided for level IV of the Executive Schedule

25 under section 5315 of title 5, United States
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1 Code, and while so serving away from home and

2 the member’s regular place of business, be al3 lowed travel expenses, as authorized by the

4 chairperson of the Commission. For purposes of

5 pay (other than pay of members of the Commis6 sion) and employment benefits, rights, and

7 privileges, all personnel of the Commission shall

8 be treated as if they were employees of the

9 United States Senate.

10 ‘‘(2) MEETINGS AND QUORUM.—

11 ‘‘(A) MEETINGS.—The Commission shall

12 meet at the call of the chairperson.

13 ‘‘(B) QUORUM.—A quorum of the Commis14 sion shall consist of not less than 15 members,

15 of which not less than 6 of such members shall

16 be appointees under subsection (b)(1) and not

17 less than 9 of such members shall be Indians.

18 ‘‘(3) DIRECTOR AND STAFF.—

19 ‘‘(A) EXECUTIVE DIRECTOR.—The mem20 bers of the Commission shall appoint an execu21 tive director of the Commission. The executive

22 director shall be paid the rate of basic pay

23 equal to that for level V of the Executive Sched24 ule.
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1 ‘‘(B) STAFF.—With the approval of the

2 Commission, the executive director may appoint

3 such personnel as the executive director deems

4 appropriate.

5 ‘‘(C) APPLICABILITY OF CIVIL SERVICE

6 LAWS.—The staff of the Commission shall be

7 appointed without regard to the provisions of

8 title 5, United States Code, governing appoint9 ments in the competitive service, and shall be

10 paid without regard to the provisions of chapter

11 51 and subchapter III of chapter 53 of such

12 title (relating to classification and General

13 Schedule pay rates).

14 ‘‘(D) EXPERTS AND CONSULTANTS.—With

15 the approval of the Commission, the executive

16 director may procure temporary and intermit17 tent services under section 3109(b) of title 5,

18 United States Code.

19 ‘‘(E) FACILITIES.—The Administrator of

20 the General Services Administration shall locate

21 suitable office space for the operation of the

22 Commission. The facilities shall serve as the

23 headquarters of the Commission and shall in24 clude all necessary equipment and incidentals
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1 required for the proper functioning of the Com2 mission.

3 ‘‘(f) POWERS.—

4 ‘‘(1) HEARINGS AND OTHER ACTIVITIES.—For

5 the purpose of carrying out its duties, the Commis6 sion may hold such hearings and undertake such

7 other activities as the Commission determines to be

8 necessary to carry out its duties, except that at least

9 6 regional hearings shall be held in different areas

10 of the United States in which large numbers of Indi11 ans are present. Such hearings shall be held to so12 licit the views of Indians regarding the delivery of

13 health care services to them. To constitute a hearing

14 under this paragraph, at least 5 members of the

15 Commission, including at least 1 member of Con16 gress, must be present. Hearings held by the study

17 committee established under this section may be

18 counted towards the number of regional hearings re19 quired by this paragraph.

20 ‘‘(2) STUDIES BY GAO.—Upon request of the

21 Commission, the Comptroller General shall conduct

22 such studies or investigations as the Commission de23 termines to be necessary to carry out its duties.

24 ‘‘(3) COST ESTIMATES.—
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1 ‘‘(A) IN GENERAL.—The Director of the

2 Congressional Budget Office or the Chief Actu3 ary of the Health Care Financing Administra4 tion, or both, shall provide to the Commission,

5 upon the request of the Commission, such cost

6 estimates as the Commission determines to be

7 necessary to carry out its duties.

8 ‘‘(B) REIMBURSEMENTS.—The Commis9 sion shall reimburse the Director of the Con10 gressional Budget Office for expenses relating

11 to the employment in the office of the Director

12 of such additional staff as may be necessary for

13 the Director to comply with requests by the

14 Commission under subparagraph (A).

15 ‘‘(4) DETAIL OF FEDERAL EMPLOYEES.—Upon

16 the request of the Commission, the head of any Fed17 eral Agency is authorized to detail, without reim18 bursement, any of the personnel of such agency to

19 the Commission to assist the Commission in carry20 ing out its duties. Any such detail shall not interrupt

21 or otherwise affect the civil service status or privi22 leges of the Federal employee.

23 ‘‘(5) TECHNICAL ASSISTANCE.—Upon the re24 quest of the Commission, the head of a Federal

25 Agency shall provide such technical assistance to the
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1 Commission as the Commission determines to be

2 necessary to carry out its duties.

3 ‘‘(6) USE OF MAILS.—The Commission may use

4 the United States mails in the same manner and

5 under the same conditions as Federal Agencies and

6 shall, for purposes of the frank, be considered a

7 commission of Congress as described in section 3215

8 of title 39, United States Code.

9 ‘‘(7) OBTAINING INFORMATION.—The Commis10 sion may secure directly from the any Federal Agen11 cy information necessary to enable it to carry out its

12 duties, if the information may be disclosed under

13 section 552 of title 4, United States Code. Upon re14 quest of the chairperson of the Commission, the

15 head of such agency shall furnish such information

16 to the Commission.

17 ‘‘(8) SUPPORT SERVICES.—Upon the request of

18 the Commission, the Administrator of General Serv19 ices shall provide to the Commission on a reimburs20 able basis such administrative support services as

21 the Commission may request.

22 ‘‘(9) PRINTING.—For purposes of costs relating

23 to printing and binding, including the cost of per24 sonnel detailed from the Government Printing Of-
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1 fice, the Commission shall be deemed to be a com2 mittee of the Congress.

3 ‘‘(g) AUTHORIZATION OF APPROPRIATIONS.—There

4 is authorized to be appropriated $4,000,000 to carry out

5 this section. The amount appropriated under this sub6 section shall not be deducted from or affect any other ap7 propriation for health care for Indian persons.

8 ‘‘SEC. 815. APPROPRIATIONS; AVAILABILITY.

9 ‘‘Any new spending authority (described in subsection

10 (c)(2)(A) or (B) of section 401 of the Congressional Budg11 et Act of 1974) which is provided under this Act shall

12 be effective for any fiscal year only to such extent or in

13 such amounts as are provided in appropriation Acts.

14 ‘‘SEC. 816. AUTHORIZATION OF APPROPRIATIONS.

15 ‘‘There is authorized to be appropriated such sums

16 as may be necessary for each fiscal year through fiscal

17 year 2015 to carry out this title.’’.

18 TITLE II—CONFORMING AMEND19 MENTS TO THE SOCIAL SECU20 RITY ACT

21 Subtitle A—Medicare

22 SEC. 201. LIMITATIONS ON CHARGES.

23 Section 1866(a)(1) of the Social Security Act (42

24 U.S.C. 1395cc(a)(1)) is amended—
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1 (1) in subparagraph (R), by striking ‘‘and’’ at

2 the end;

3 (2) in subparagraph (S), by striking the period

4 and inserting ‘‘, and’’; and

5 (3) by adding at the end the following:

6 ‘‘(T) in the case of hospitals and critical access

7 hospitals which provide inpatient hospital services

8 for which payment may be made under this title, to

9 accept as payment in full for services that are cov10 ered under and furnished to an individual eligible for

11 the contract health services program operated by the

12 Indian Health Service, by an Indian tribe or tribal

13 organization, or furnished to an urban Indian eligi14 ble for health services purchased by an urban Indian

15 organization (as those terms are defined in section

16 4 of the Indian Health Care Improvement Act), in

17 accordance with such admission practices and such

18 payment methodology and amounts as are prescribed

19 under regulations issued by the Secretary.’’.

20 SEC. 202. QUALIFIED INDIAN HEALTH PROGRAM.

21 Title XVIII of the Social Security Act (42 U.S.C.

22 1395 et seq.) is amended by inserting after section 1880

23 the following:

24 ‘‘QUALIFIED INDIAN HEALTH PROGRAM

25 ‘‘SEC. 1880A. (a) DEFINITION OF QUALIFIED IN26 DIAN HEALTH PROGRAM.—In this section:
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1 ‘‘(1) IN GENERAL.—The term ‘qualified Indian

2 health program’ means a health program operated

3 by—

4 ‘‘(A) the Indian Health Service;

5 ‘‘(B) an Indian tribe or tribal organization

6 or an urban Indian organization (as those

7 terms are defined in section 4 of the Indian

8 Health Care Improvement Act) and which is

9 funded in whole or part by the Indian Health

10 Service under the Indian Self Determination

11 and Education Assistance Act; or

12 ‘‘(C) an urban Indian organization (as so

13 defined) and which is funded in whole or in

14 part under title V of the Indian Health Care

15 Improvement Act.

16 ‘‘(2) INCLUDED PROGRAMS AND ENTITIES.—

17 Such term may include 1 or more hospital, nursing

18 home, home health program, clinic, ambulance serv19 ice or other health program that provides a service

20 for which payments may be made under this title

21 and which is covered in the cost report submitted

22 under this title or title XIX for the qualified Indian

23 health program.

24 ‘‘(b) ELIGIBILITY FOR PAYMENTS.—A qualified In25 dian health program shall be eligible for payments under
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1 this title, notwithstanding sections 1814(c) and 1835(d),

2 if and for so long as the program meets all the conditions

3 and requirements set forth in this section.

4 ‘‘(c) DETERMINATION OF PAYMENTS.—

5 ‘‘(1) IN GENERAL.—Notwithstanding any other

6 provision in the law, a qualified Indian health pro7 gram shall be entitled to receive payment based on

8 an all-inclusive rate which shall be calculated to pro9 vide full cost recovery for the cost of furnishing serv10 ices provided under this section.

11 ‘‘(2) DEFINITION OF FULL COST RECOVERY.—

12 ‘‘(A) IN GENERAL.—Subject to subpara13 graph (B), in this section, the term ‘full cost re14 covery’ means the sum of—

15 ‘‘(i) the direct costs, which are reason16 able, adequate and related to the cost of

17 furnishing such services, taking into ac18 count the unique nature, location, and

19 service population of the qualified Indian

20 health program, and which shall include di21 rect program, administrative, and overhead

22 costs, without regard to the customary or

23 other charge or any fee schedule that

24 would otherwise be applicable; and
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1 ‘‘(ii) indirect costs which, in the case

2 of a qualified Indian health program—

3 ‘‘(I) for which an indirect cost

4 rate (as that term is defined in sec5 tion 4(g) of the Indian Self-Deter6 mination and Education Assistance

7 Act) has been established, shall be not

8 less than an amount determined on

9 the basis of the indirect cost rate; or

10 ‘‘(II) for which no such rate has

11 been established, shall be not less

12 than the administrative costs specifi13 cally associated with the delivery of

14 the services being provided.

15 ‘‘(B) LIMITATION.—Notwithstanding any

16 other provision of law, the amount determined

17 to be payable as full cost recovery may not be

18 reduced for co-insurance, co-payments, or

19 deductibles when the service was provided to an

20 Indian entitled under Federal law to receive the

21 service from the Indian Health Service, an In22 dian tribe or tribal organization, or an urban

23 Indian organization or because of any limita24 tions on payment provided for in any managed

25 care plan.
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1 ‘‘(3) OUTSTATIONING COSTS.—In addition to

2 full cost recovery, a qualified Indian health program

3 shall be entitled to reasonable outstationing costs,

4 which shall include all administrative costs associ5 ated with outreach and acceptance of eligibility ap6 plications for any Federal or State health program

7 including the programs established under this title,

8 title XIX, and XXI.

9 ‘‘(4) DETERMINATION OF ALL-INCLUSIVE EN10 COUNTER OR PER DIEM AMOUNT.—

11 ‘‘(A) IN GENERAL.—Costs identified for

12 services addressed in a cost report submitted by

13 a qualified Indian health program shall be used

14 to determine an all-inclusive encounter or per

15 diem payment amount for such services.

16 ‘‘(B) NO SINGLE REPORT REQUIRE17 MENT.—Not all qualified Indian health pro18 grams provided or administered by the Indian

19 Health Service, an Indian tribe or tribal organi20 zation, or an urban Indian organization need be

21 combined into a single cost report.

22 ‘‘(C) PAYMENT FOR ITEMS NOT COVERED

23 BY A COST REPORT.—A full cost recovery pay24 ment for services not covered by a cost report
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1 shall be made on a fee-for-service, encounter, or

2 per diem basis.

3 ‘‘(5) OPTIONAL DETERMINATION.—The full

4 cost recovery rate provided for in paragraphs (1)

5 through (3) may be determined, at the election of

6 the qualified Indian health program, by the Health

7 Care Financing Administration or by the State

8 agency responsible for administering the State plan

9 under title XIX and shall be valid for reimburse10 ments made under this title, title XIX, and title

11 XXI. The costs described in paragraph (2)(A) shall

12 be calculated under whatever methodology yields the

13 greatest aggregate payment for the cost reporting

14 period, provided that such methodology shall be ad15 justed to include adjustments to such payment to

16 take into account for those qualified Indian health

17 programs that include hospitals—

18 ‘‘(A) a significant decrease in discharges;

19 ‘‘(B) costs for graduate medical education

20 programs;

21 ‘‘(C) additional payment as a dispropor22 tionate share hospital with a payment adjust23 ment factor of 10; and

24 ‘‘(D) payment for outlier cases.
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1 ‘‘(6) ELECTION OF PAYMENT.—A qualified In2 dian health program may elect to receive payment

3 for services provided under this section—

4 ‘‘(A) on the full cost recovery basis pro5 vided in paragraphs (1) through (5);

6 ‘‘(B) on the basis of the inpatient or out7 patient encounter rates established for Indian

8 Health Service facilities and published annually

9 in the Federal Register;

10 ‘‘(C) on the same basis as other providers

11 are reimbursed under this title, provided that

12 the amounts determined under paragraph

13 (c)(2)(B) shall be added to any such amount;

14 ‘‘(D) on the basis of any other rate or

15 methodology applicable to the Indian Health

16 Service or an Indian tribe or tribal organiza17 tion; or

18 ‘‘(E) on the basis of any rate or methodol19 ogy negotiated with the agency responsible for

20 making payment.

21 ‘‘(d) ELECTION OF REIMBURSEMENT FOR OTHER

22 SERVICES.—

23 ‘‘(1) IN GENERAL.—A qualified Indian health

24 program may elect to be reimbursed for any service

25 the Indian Health Service, an Indian tribe or tribal
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1 organization, or an urban Indian organization may

2 be reimbursed for under section 1880 and section

3 1911.

4 ‘‘(2) OPTION TO INCLUDE ADDITIONAL SERV5 ICES.—An election under paragraph (1) may in6 clude, at the election of the qualified Indian health

7 program—

8 ‘‘(A) any service when furnished by an em9 ployee of the qualified Indian health program

10 who is licensed or certified to perform such a

11 service to the same extent that such service

12 would be reimbursable if performed by a physi13 cian and any service or supplies furnished as in14 cident to a physician’s service as would other15 wise be covered if furnished by a physician or

16 as an incident to a physician’s service;

17 ‘‘(B) screening, diagnostic, and therapeutic

18 outpatient services including part-time or inter19 mittent screening, diagnostic, and therapeutic

20 skilled nursing care and related medical sup21 plies (other than drugs and biologicals), fur22 nished by an employee of the qualified Indian

23 health program who is licensed or certified to

24 perform such a service for an individual in the

25 individual’s home or in a community health set-
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1 ting under a written plan of treatment estab2 lished and periodically reviewed by a physician,

3 when furnished to an individual as an out4 patient of a qualified Indian health program;

5 ‘‘(C) preventive primary health services as

6 described under section 330 of the Public

7 Health Service Act, when provided by an em8 ployee of the qualified Indian health program

9 who is licensed or certified to perform such a

10 service, regardless of the location in which the

11 service is provided;

12 ‘‘(D) with respect to services for children,

13 all services specified as part of the State plan

14 under title XIX, the State child health plan

15 under title XXI, and early and periodic screen16 ing, diagnostic, and treatment services as de17 scribed in section 1905(r);

18 ‘‘(E) influenza and pneumococcal immuni19 zations;

20 ‘‘(F) other immunizations for prevention of

21 communicable diseases when targeted; and

22 ‘‘(G) the cost of transportation for provid23 ers or patients necessary to facilitate access for

24 patients.’’.
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1 Subtitle B—Medicaid

2 SEC. 211. STATE CONSULTATION WITH INDIAN HEALTH

3 PROGRAMS.

4 Section 1902(a) of the Social Security Act (42 U.S.C.

5 1396a(a)) is amended—

6 (1) in paragraph (64), by striking ‘‘and’’ at the

7 end:

8 (2) in paragraph (65), by striking the period

9 and inserting ‘‘; and’’; and

10 (3) by inserting after paragraph (65), the fol11 lowing:

12 ‘‘(66) if the Indian Health Service operates or

13 funds health programs in the State or if there are

14 Indian tribes or tribal organizations or urban Indian

15 organizations (as those terms are defined in Section

16 4 of the Indian Health Care Improvement Act)

17 present in the State, provide for meaningful con18 sultation with such entities prior to the submission

19 of, and as a precondition of approval of, any pro20 posed amendment, waiver, demonstration project, or

21 other request that would have the effect of changing

22 any aspect of the State’s administration of the State

23 plan under this title, so long as—

24 ‘‘(A) the term ‘meaningful consultation’ is

25 defined through the negotiated rulemaking
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1 process provided for under section 802 of the

2 Indian Health Care Improvement Act; and

3 ‘‘(B) such consultation is carried out in

4 collaboration with the Indian Medicaid Advisory

5 Committee established under section 415(a)(3)

6 of that Act.’’.

7 SEC. 212. FMAP FOR SERVICES PROVIDED BY INDIAN

8 HEALTH PROGRAMS.

9 The third sentence of Section 1905(b) of the Social

10 Security Act (42 U.S.C. 1396d(b)) is amended to read as

11 follows:

12 ‘‘Notwithstanding the first sentence of this section, the

13 Federal medical assistance percentage shall be 100 per

14 cent with respect to amounts expended as medical assist15 ance for services which are received through the Indian

16 Health Service, an Indian tribe or tribal organization, or

17 an urban Indian organization (as defined in section 4 of

18 the Indian Health Care Improvement Act) under section

19 1911, whether directly, by referral, or under contracts or

20 other arrangements between the Indian Health Service,

21 Indian tribe or tribal organization, or urban Indian orga22 nization and another health provider.’’.

23 SEC. 213. INDIAN HEALTH SERVICE PROGRAMS.

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

25 1396j) is amended to read as follows:
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1 ‘‘INDIAN HEALTH SERVICE PROGRAMS

2 ‘‘SEC. 1911. (a) IN GENERAL.—The Indian Health

3 Service, an Indian tribe or tribal organization, or an urban

4 Indian organization (as those terms are defined in section

5 4 of the Indian Health Care Improvement Act), shall be

6 eligible for reimbursement for medical assistance provided

7 under a State plan by such entities if and for so long as

8 the Service, Indian tribe or tribal organization, or urban

9 Indian organization provides services or provider types of

10 a type otherwise covered under the State plan and meets

11 the conditions and requirements which are applicable gen12 erally to the service for which it seeks reimbursement

13 under this title and for services provided by a qualified

14 Indian health program under section 1880A.

15 ‘‘(b) PERIOD FOR BILLING.—Notwithstanding sub16 section (a), if the Indian Health Service, an Indian tribe

17 or tribal organization, or an urban Indian organization

18 which provides services of a type otherwise covered under

19 the State plan does not meet all of the conditions and re20 quirements of this title which are applicable generally to

21 such services submits to the Secretary within 6 months

22 after the date on which such reimbursement is first sought

23 an acceptable plan for achieving compliance with such con24 ditions and requirements, the Service, an Indian tribe or

25 tribal organization, or urban Indian organization shall be
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1 deemed to meet such conditions and requirements (and to

2 be eligible for reimbursement under this title), without re3 gard to the extent of actual compliance with such condi4 tions and requirements during the first 12 months after

5 the month in which such plan is submitted.

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

7 The Secretary may enter into agreements with the State

8 agency for the purpose of reimbursing such agency for

9 health care and services provided by the Indian Health

10 Service, Indian tribes or tribal organizations, or urban In11 dian organizations, directly, through referral, or under

12 contracts or other arrangements between the Indian

13 Health Service, an Indian tribe or tribal organization, or

14 an urban Indian organization and another health care pro15 vider to Indians who are eligible for medical assistance

16 under the State plan.’’.

17 Subtitle C—State Children’s Health

18 Insurance Program

19 SEC. 221. ENHANCED FMAP FOR STATE CHILDREN’S

20 HEALTH INSURANCE PROGRAM.

21 (a) IN GENERAL.—Section 2105(b) of the Social Se22 curity Act (42 U.S.C. 1397ee(b)) is amended—

23 (1) by striking ‘‘For purposes’’ and inserting

24 the following:
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1 ‘‘(1) IN GENERAL.—Subject to paragraph (2),

2 for purposes’’; and

3 (2) by adding at the end the following:

4 ‘‘(2) SERVICES PROVIDED BY INDIAN PRO5 GRAMS.—Without regard to which option a State

6 chooses under section 2101(a), the ‘enhanced

7 FMAP’ for a State for a fiscal year shall be 100 per

8 cent with respect to expenditures for child health as9 sistance for services provided through a health pro10 gram operated by the Indian Health Service, an In11 dian tribe or tribal organization, or an urban Indian

12 organization (as such terms are defined in section 4

13 of the Indian Health Care Improvement Act).’’.

14 (b) CONFORMING AMENDMENT.—Section

15 2105(c)(6)(B) of such Act (42 U.S.C. 1397ee(c)(6)(B))

16 is amended by inserting ‘‘an Indian tribe or tribal organi17 zation, or an urban Indian organization (as such terms

18 are defined in section 4 of the Indian Health Care Im19 provement Act),’’ after ‘‘Service,’’.

20 SEC. 222. DIRECT FUNDING OF STATE CHILDREN’S HEALTH

21 INSURANCE PROGRAM.

22 Title XXI of Social Security Act (42 U.S.C. 1397aa

23 et seq.) is amended by adding at the end the following:
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1 ‘‘SEC. 2111. DIRECT FUNDING OF INDIAN HEALTH PRO2 GRAMS.

3 ‘‘(a) IN GENERAL.—The Secretary may enter into

4 agreements directly with the Indian Health Service, an In5 dian tribe or tribal organization, or an urban Indian orga6 nization (as such terms are defined in section 4 of the

7 Indian Health Care Improvement Act) for such entities

8 to provide child health assistance to Indians who reside

9 in a service area on or near an Indian reservation. Such

10 agreements may provide for funding under a block grant

11 or such other mechanism as is agreed upon by the Sec12 retary and the Indian Health Service, Indian tribe or trib13 al organization, or urban Indian organization. Such agree14 ments may not be made contingent on the approval of the

15 State in which the Indians to be served reside.

16 ‘‘(b) TRANSFER OF FUNDS.—Notwithstanding any

17 other provision of law, a State may transfer funds to

18 which it is, or would otherwise be, entitled to under this

19 title to the Indian Health Service, an Indian tribe or tribal

20 organization or an urban Indian organization—

21 ‘‘(1) to be administered by such entity to

22 achieve the purposes and objectives of this title

23 under an agreement between the State and the en24 tity; or
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1 ‘‘(2) under an agreement entered into under

2 subsection (a) between the entity and the Sec3 retary.’’.

4 Subtitle D—Authorization of

5 Appropriations

6 SEC. 231. AUTHORIZATION OF APPROPRIATIONS.

7 There is authorized to be appropriated such sums as

8 may be necessary for each of fiscal years 2004 through

9 2015 to carry out this title and the amendments by this

10 title.

11 TITLE III—MISCELLANEOUS

12 PROVISIONS

13 SEC. 301. REPEALS.

14 The following are repealed:

15 (1) Section 506 of Public Law 101–630 (25

16 U.S.C. 1653 note) is repealed.

17 (2) Section 712 of the Indian Health Care

18 Amendments of 1988 is repealed.

19 SEC. 302. SEVERABILITY PROVISIONS.

20 If any provision of this Act, any amendment made

21 by the Act, or the application of such provision or amend22 ment to any person or circumstances is held to be invalid,

23 the remainder of this Act, the remaining amendments

24 made by this Act, and the application of such provisions
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1 to persons or circumstances other than those to which it

2 is held invalid, shall not be affected thereby.

3 SEC. 303. EFFECTIVE DATE.

4 This Act and the amendments made by this Act take

5 effect on October 1, 2003.

Æ
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I

108TH CONGRESS

1ST SESSION H. R. 2440

To improve the implementation of the Federal responsibility for the care

and education of Indian people by improving the services and facilities

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

IN THE HOUSE OF REPRESENTATIVES

JUNE 11, 2003

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

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

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

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

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

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

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

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

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

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

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

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

subsequently determined by the Speaker, in each case for consideration

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

A BILL

To improve the implementation of the Federal responsibility

for the care and education of Indian people by improving

the services and facilities of Federal health programs

for Indians and encouraging maximum participation of

Indians in such programs, and for other purposes.
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2

•HR 2440 IH

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

3 SECTION 1. SHORT TITLE.

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

5 Improvement Act Amendments of 2003’’.

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

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

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

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

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

12 ‘Indian Health Care Improvement Act’.

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

14 for this Act is as follows:

Sec. 1. Short title.

Sec. 2. Indian Health Care Improvement Act amended.

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

‘‘Sec. 2. Findings.

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

‘‘Sec. 4. Definitions.

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

DEVELOPMENT

‘‘Sec. 101. Purpose.

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

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

‘‘Sec. 104. Indian health professions scholarships.

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

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

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

‘‘Sec. 108. Continuing education allowances.

‘‘Sec. 109. Community Health Representative Program.

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

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

‘‘Sec. 112. Recruitment activities.

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

‘‘Sec. 114. Advanced training and research.
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•HR 2440 IH

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

‘‘Sec. 116. Tribal cultural orientation.

‘‘Sec. 117. Inmed program.

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

‘‘Sec. 119. Retention bonus.

‘‘Sec. 120. Nursing residency program.

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

‘‘Sec. 122. Tribal health program administration.

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

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

‘‘Sec. 125. National Health Service Corps.

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

programs.

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

‘‘Sec. 128. Designation of shortage areas.

‘‘Sec. 129. Authorization of appropriations.

‘‘TITLE II—HEALTH SERVICES

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

‘‘Sec. 202. Catastrophic Health Emergency Fund.

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

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

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

‘‘Sec. 206. Health services research.

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

‘‘Sec. 208. Patient travel costs.

‘‘Sec. 209. Epidemiology centers.

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

‘‘Sec. 211. Indian Youth Program.

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

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

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

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

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

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

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

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

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

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

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

‘‘Sec. 221. Licensing.

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

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

‘‘Sec. 224. Liability for payment.

‘‘Sec. 225. Authorization of appropriations.

‘‘TITLE III—FACILITIES

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

‘‘Sec. 302. Sanitation facilities.

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

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

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

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

‘‘Sec. 307. Land transfer.

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

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

‘‘Sec. 310. Tribal leasing.

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

‘‘Sec. 312. Location of facilities.

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

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

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

‘‘Sec. 316. Other funding for facilities.

‘‘Sec. 317. Authorization of appropriations.

‘‘TITLE IV—ACCESS TO HEALTH SERVICES

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

programs.

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

tribes, tribal organizations, and urban Indian organizations.

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

services.

‘‘Sec. 404. Crediting of reimbursements.

‘‘Sec. 405. Purchasing health care coverage.

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

‘‘Sec. 407. Payor of last resort.

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

‘‘Sec. 409. Consultation.

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

‘‘Sec. 411. Social Security Act sanctions.

‘‘Sec. 412. Cost sharing.

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

‘‘Sec. 414. Navajo nation medicaid agency.

‘‘Sec. 415. Authorization of appropriations.

‘‘TITLE V—HEALTH SERVICES FOR URBAN INDIANS

‘‘Sec. 501. Purpose.

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

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

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

care needs.

‘‘Sec. 505. Evaluations; renewals.

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

‘‘Sec. 507. Reports and records.

‘‘Sec. 508. Limitation on contract authority.

‘‘Sec. 509. Facilities.

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

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

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

‘‘Sec. 513. Urban NIAAA transferred programs.

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

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

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

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

‘‘Sec. 519. Community health representatives.

‘‘Sec. 520. Regulations.

‘‘Sec. 521. Eligibility for services.

‘‘Sec. 522. Authorization of appropriations.

‘‘TITLE VI—ORGANIZATIONAL IMPROVEMENTS

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

Public Health Service.

‘‘Sec. 602. Automated management information system.

‘‘Sec. 603. Authorization of appropriations.

‘‘TITLE VII—BEHAVIORAL HEALTH PROGRAMS

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

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

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

‘‘Sec. 704. Mental health technician program.

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

‘‘Sec. 706. Indian women treatment programs.

‘‘Sec. 707. Indian Youth Program.

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

construction, and staffing.

‘‘Sec. 709. Training and community education.

‘‘Sec. 710. Behavioral health program.

‘‘Sec. 711. Fetal alcohol disorder funding.

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

‘‘Sec. 713. Behavioral health research.

‘‘Sec. 714. Definitions.

‘‘Sec. 715. Authorization of appropriations.

‘‘TITLE VIII—MISCELLANEOUS

‘‘Sec. 801. Reports.

‘‘Sec. 802. Regulations.

‘‘Sec. 803. Plan of implementation.

‘‘Sec. 804. Availability of funds.

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

Service.

‘‘Sec. 806. Eligibility of California Indians.

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

‘‘Sec. 808. Reallocation of base resources.

‘‘Sec. 809. Results of demonstration projects.

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

‘‘Sec. 811. Moratorium.

‘‘Sec. 812. Tribal employment.

‘‘Sec. 813. Prime vendor.

‘‘Sec. 814. Severability provisions.

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

Health Care Entitlement.

‘‘Sec. 816. Appropriations; availability.

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

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

Sec. 3. Soboba sanitation facilities.

Sec. 4. Amendments to medicare program.

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

1 ‘‘SEC. 2. FINDINGS.

2 ‘‘Congress finds the following:

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

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

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

9 treaties, Federal statutes and the course of dealings

10 of the United States with Indian Tribes and the

11 United States’ resulting government-to-government

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

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

15 and colonization through the 20th century, policies

16 and practices of the United States caused and/or

17 contributed to the severe health conditions of Indi18 ans.

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

20 acres of land to the United States in exchange for

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

22 Indian Tribes have secured a de facto contract which

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

2 United States.

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

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

5 the need for Federal health care services.

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

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

9 regardless of where they live to be raised to the

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

11 general population and to provide for the maximum

12 participation of Indian Tribes, Tribal Organizations,

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

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

17 of illnesses among, and unnecessary and premature

18 deaths of, Indians.

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

20 needs of Indians remain alarmingly severe and the

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

23 ‘‘(8) The disparity to be addressed is formida24 ble. For example, Indians suffer a death rate for di25 abetes mellitus that is 318 percent higher than the
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1 all races rate for the United States, a pneumonia

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

4 a death rate from alcoholism that is 670 percent

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

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

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

9 Nation, in fulfillment of its special trust responsibilities

10 and legal obligations to Indians—

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

12 for Indians and to provide all resources necessary to

13 effect that policy;

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

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

16 contained within the Healthy People 2010 or succes17 sor objectives;

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

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

22 the health professions and allied and associated

23 health professions awarded to Indians so that the

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

2 the general population;

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

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

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

10 provided to programs and facilities operated directly

11 by the Service.

12 ‘‘SEC. 4. DEFINITIONS.

13 ‘‘For purposes of this Act:

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

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

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

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

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

24 those Indians who are eligible for health services of

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

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

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

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

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

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

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

12 Human Services.

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

14 the Indian Health Service.

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

16 reduction, limitation, and prevention of disease and

17 its complications and reduction in the consequences

18 of disease, including, but not limited to—

19 ‘‘(A) controlling—

20 ‘‘(i) development of diabetes;

21 ‘‘(ii) high blood pressure;

22 ‘‘(iii) infectious agents;

23 ‘‘(iv) injuries;

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

2 and

3 ‘‘(vii) toxic agents; and

4 ‘‘(B) providing—

5 ‘‘(i) fluoridation of water; and

6 ‘‘(ii) immunizations.

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

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

10 means, including Funding Agreements, contracts,

11 memoranda of understanding, contracts pursuant to

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

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

14 otherwise.

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

16 any agreement to transfer funds for the planning,

17 conduct, and administration of programs, services,

18 functions, and activities to Indian Tribes and Tribal

19 Organizations from the Secretary under the Indian

20 Self-Determination and Education Assistance Act.

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

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

24 gynecology, podiatric medicine, nursing, public

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

2 work, marriage and family therapy, chiropractic

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

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

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

9 health, including raising public awareness about

10 health matters and enabling the people to cope

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

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

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

17 ‘‘(D) making available suitable housing,

18 safe water, and sanitary facilities;

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

21 ‘‘(F) promoting adequate opportunity for

22 spiritual, religious, and Traditional Health Care

23 Practices; and

24 ‘‘(G) providing adequate and appropriate

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

2 physical);

3 ‘‘(ii) community health;

4 ‘‘(iii) community safety;

5 ‘‘(iv) consumer health education;

6 ‘‘(v) diet and nutrition;

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

9 HIV/AIDS;

10 ‘‘(vii) environmental health;

11 ‘‘(viii) exercise and physical fitness;

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

14 ‘‘(x) first aid and CPR education;

15 ‘‘(xi) human growth and development;

16 ‘‘(xii) injury prevention and personal

17 safety;

18 ‘‘(xiii) mental health;

19 ‘‘(xiv) personal health and wellness

20 practices;

21 ‘‘(xv) personal capacity building;

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

23 care;

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

2 planning;

3 ‘‘(xix) safe and adequate water;

4 ‘‘(xx) safe housing;

5 ‘‘(xxi) safe work environments;

6 ‘‘(xxii) stress control;

7 ‘‘(xxiii) substance abuse;

8 ‘‘(xxiv) sanitary facilities;

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

11 ‘‘(xxvi) violence prevention; and

12 ‘‘(xxvii) such other activities identified

13 by the Service, a Tribal Health Program,

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

16 described in section 3(2).

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

18 given that term in the Indian Self-Determination

19 and Education Assistance Act.

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

21 the following—

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

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

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

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

5 ‘Buy Indian Act’.

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

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

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

10 has the meaning given to such term by section

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

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

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

15 colony, including former reservations in Oklahoma,

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

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

20 designated, means the Secretary of Health and

21 Human Services.

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

23 Health Service.

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

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

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

9 or in contradistinction to Western healing sciences)

10 which embody the influences or forces of innate

11 Tribal discovery, history, description, explanation

12 and knowledge of the states of wellness and illness

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

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

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

18 shall have the meaning given that term in section

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

20 1059c(b)(3)).

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

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

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

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

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

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

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

9 under title V, as determined by the Secretary.

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

12 meets 1 or more of the following criteria:

13 ‘‘(A) Irrespective of whether the individual

14 lives on or near a reservation, the individual is

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

16 group of Indians, including those tribes, bands,

17 or groups terminated since 1940 and those

18 tribes, bands, or groups that are recognized by

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

21 such member.

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

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

2 Secretary of the Interior to be an Indian for

3 any purpose.

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

5 Indian under regulations promulgated by the

6 Secretary.

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

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

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

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

13 cooperating with other public and private entities for

14 the purpose of performing the activities described in

15 section 503(a).

16 ‘‘TITLE I—INDIAN HEALTH,

17 HUMAN RESOURCES, AND DE18 VELOPMENT

19 ‘‘SEC. 101. PURPOSE.

20 ‘‘The purpose of this title is to increase, to the maxi21 mum extent feasible, the number of Indians entering the

22 health professions and providing health services, and to

23 assure an optimum supply of health professionals to the

24 Indian Health Programs and Urban Indian Organizations

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

2 FOR INDIANS.

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

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

6 to assist such entities in meeting the costs of—

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

8 education or training in the health professions and

9 encouraging and assisting them—

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

11 health professions; or

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

13 any such courses of study, to undertake such

14 postsecondary education or training as may be

15 required to qualify them for enrollment;

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

17 available to Indians enrolled in any course of study

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

19 training necessary to qualify them to enroll in any

20 such course of study; or

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

24 and completion by them of, courses of study referred

25 to in paragraph (1).

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

2 shall require that an application has been submitted

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

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

5 and contain such information, as the Secretary shall

6 by regulation prescribe pursuant to this Act. The

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

9 Organizations.

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

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

13 pursuant to this section may be made in advance or

14 by way of reimbursement, and at such intervals and

15 on such conditions as provided for in regulations

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

18 be for 3 years, as provided in regulations published

19 pursuant to this Act.

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

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

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

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

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

4 acting through the Service, shall provide scholarships to

5 Indians who—

6 ‘‘(1) have successfully completed their high

7 school education or high school equivalency; and

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

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

12 this section shall be for the following purposes:

13 ‘‘(1) Compensatory preprofessional education of

14 any recipient, such scholarship not to exceed 2 years

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

16 thereof, as determined by the Secretary pursuant to

17 regulations issued under this Act).

18 ‘‘(2) Pregraduate education of any recipient

19 leading to a baccalaureate degree in an approved

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

21 health profession, such scholarship not to exceed 4

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

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

2 section—

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

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

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

9 standing at, an accredited institution; and

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

11 applicant’s eligibility for assistance or benefits under

12 any other Federal program.

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

14 ‘‘(a) IN GENERAL.—

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

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

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

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

23 subsection (b) of this section.

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

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

2 a formula developed in consultation with Indian

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

5 resource development needs in each Service Area.

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

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

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

10 enactment of the Indian Health Care Improvement

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

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

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

17 a Funding Agreement.

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

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

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

24 is a recipient of an Indian Health Scholarship, be

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

3 ‘‘(A) In an Indian Health Program.

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

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

9 in a physician or other health professional

10 shortage area and addresses the health care

11 needs of a substantial number of Indians.

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

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

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

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

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

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

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

2 other advanced clinical training shall be counted

3 as satisfying any period of obligated service

4 under this subsection.

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

6 that individual shall commence not later than

7 90 days after the completion of that advanced

8 clinical training (or by a date specified by the

9 Secretary).

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

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

13 (1).

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

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

16 meet the active duty service obligation described

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

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

20 the Indian Tribe in which the recipient is

21 enrolled; or

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

23 the recipient is enrolled.

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

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

2 required to meet the active duty service obligation

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

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

6 health professionals to provide health care services

7 as a result of individuals having breached contracts

8 entered into under this section.

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

11 enrolled part time in an approved course of study—

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

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

14 years, as determined by the Area Office;

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

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

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

18 each year for which the individual was provided

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

21 ‘‘(B) 2 years; and

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

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

3 ‘‘(d) BREACH OF CONTRACT.—

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

5 shall be liable to the United States for the amount

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

7 of the individual, under a contract entered into with

8 the Secretary under this section on or after the date

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

11 individual—

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

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

15 determined by the educational institution under

16 regulations of the Secretary);

17 ‘‘(B) is dismissed from such educational

18 institution for disciplinary reasons;

19 ‘‘(C) voluntarily terminates the training in

20 such an educational institution for which he or

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

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

24 the educational institution in which he or she is

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

2 lieu of any service obligation arising under such

3 contract.

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

5 specified in paragraph (1) an individual breaches a

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

9 United States shall be entitled to recover from the

10 individual an amount determined in accordance with

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

12 in the manner provided for in such subsection.

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

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

17 relates to that scholarship shall be canceled.

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

20 suspension of any obligation of service or payment of

21 a recipient of an Indian Health Scholarship if the

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

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

2 meet that obligation or make that payment;

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

4 obligation or make that payment would result

5 in extreme hardship to the recipient; or

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

7 meet the obligation or make the payment would

8 be unconscionable.

9 ‘‘(5) EXTREME HARDSHIP.—Notwithstanding

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

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

13 the United States to recover funds made available

14 under this section.

15 ‘‘(6) BANKRUPTCY.—Notwithstanding any

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

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

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

21 period beginning on the initial date on which that

22 payment is due, and only if the bankruptcy court

23 finds that the nondischarge of the obligation would

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

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

4 through the Service, shall provide funding grants to at

5 least 3 colleges and universities for the purpose of develop6 ing and maintaining Indian psychology career recruitment

7 programs as a means of encouraging Indians to enter the

8 mental health field. These programs shall be located at

9 various locations throughout the country to maximize their

10 availability to Indian students and new programs shall be

11 established in different locations from time to time.

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

13 Secretary shall provide a grant authorized under sub14 section (a) to develop and maintain a program at the Uni15 versity of North Dakota to be known as the ‘Quentin N.

16 Burdick American Indians Into Psychology Program’.

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

20 Burdick American Indians Into Nursing Program author21 ized under section 115(e), and existing university research

22 and communications networks.

23 ‘‘(c) REGULATIONS.—The Secretary shall issue regu24 lations pursuant to this Act for the competitive awarding

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

2 section shall agree to provide a program which, at a

3 minimum—

4 ‘‘(1) provides outreach and recruitment for

5 health professions to Indian communities including

6 elementary, secondary, and accredited and accessible

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

9 ‘‘(2) incorporates a program advisory board

10 comprised of representatives from the tribes and

11 communities that will be served by the program;

12 ‘‘(3) provides summer enrichment programs to

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

15 activities;

16 ‘‘(4) provides stipends to undergraduate and

17 graduate students to pursue a career in psychology;

18 ‘‘(5) develops affiliation agreements with tribal

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

21 and accessible entities to enhance the education of

22 Indian students;

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

2 qualified Indians in the program.

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

4 active duty service obligation prescribed under section

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

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

9 ‘‘(1) in an Indian Health Program;

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

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

12 determined by the Secretary, in accordance with

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

16 needs of a substantial number of Indians.

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

19 ‘‘(a) IN GENERAL.—

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

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

23 assisting such Tribal Health Programs in educating

24 Indians to serve as health professionals in Indian

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

4 Indian Health Scholarships under section 104.

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

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

8 as consistent with this section.

9 ‘‘(b) REQUIREMENTS.—

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

11 receiving funds under subsection (a) shall provide

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

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

15 any scholarship pursuant to subsection (a)—

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

19 the Tribal Health Program; and

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

21 from any other source of funds.

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

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

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

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

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

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

10 Health Program providing the scholarship is located,

11 for—

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

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

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

16 greater; or

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

19 agree;

20 ‘‘(2) provide that the amount of the

21 scholarship—

22 ‘‘(A) may only be expended for—

23 ‘‘(i) tuition expenses, other reasonable

24 educational expenses, and reasonable living
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1 expenses incurred in attendance at the

2 educational institution; and

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

4 monthly stipend of not more than the

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

6 of the Public Health Service Act (42

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

8 reduced pro rata (as determined by the

9 Secretary) based on the number of hours

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

12 the scholarship is provided, the total

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

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

17 the total amount required for the year for the

18 purposes authorized in subparagraph (A);

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

20 maintain an acceptable level of academic standing as

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

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

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

4 ‘‘(e) BREACH OF CONTRACT.—

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

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

9 the Federal share of the amount which has been

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

11 the contract if that individual—

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

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

15 as determined by the educational institution

16 under regulations of the Secretary);

17 ‘‘(B) is dismissed from such educational

18 institution for disciplinary reasons;

19 ‘‘(C) voluntarily terminates the training in

20 such an educational institution for which he or

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

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

24 the educational institution in which he or she is

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

2 lieu of any service obligation arising under such

3 contract.

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

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

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

9 United States shall be entitled to recover from the

10 individual an amount determined in accordance with

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

12 in the manner provided for in such subsection.

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

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

17 relates to that scholarship shall be canceled.

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

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

21 the basis of information collected through such other

22 means as the Secretary deems appropriate.

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

2 herein—

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

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

9 title XIX or title XXI of such Act; and

10 ‘‘(2) to accept assignment under section

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

12 services for which payment may be made under part

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

14 appropriate agreement with the State agency that

15 administers the State plan for medical assistance

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

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

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

21 shall make payments under this section to a Tribal Health

22 Program for any fiscal year subsequent to the first fiscal

23 year of such payments unless the Secretary determines

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

2 of this section.

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

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

5 who receives a scholarship pursuant to sections 104 or 106

6 shall be given preference for employment in the Service,

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

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

10 the year.

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

12 OBLIGATION.—Periods of employment pursuant to this

13 subsection shall not be counted in determining fulfillment

14 of the service obligation incurred as a condition of the

15 scholarship.

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

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

20 Indian Organization during any nonacademic period of the

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

23 ‘‘(d) NONAPPLICABILITY OF COMPETITIVE PERSON24 NEL SYSTEM.—Any employment pursuant to this section

25 shall be made without regard to any competitive personnel
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1 system or agency personnel limitation and to a position

2 which will enable the individual so employed to receive

3 practical experience in the health profession in which he

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

5 shall receive payment for his or her services comparable

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

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

10 ‘‘SEC. 108. CONTINUING EDUCATION ALLOWANCES.

11 ‘‘In order to encourage health professionals, including

12 community health representatives and emergency medical

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

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

17 through the Service Area, may provide allowances to

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

20 for a period of time each year prescribed by regulation

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

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

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

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

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

7 Program under which Indian Health Programs—

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

10 ‘‘(2) use such community health representatives

11 in the provision of health care, health promotion,

12 and disease prevention services to Indian commu13 nities.

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

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

17 community health representatives to ensure that the

18 community health representatives provide quality

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

21 the Program;

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

23 and maintain a curriculum that—

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

25 health care with supervised practical experience

26 in the provision of health care; and
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1 ‘‘(B) provides instruction and practical ex2 perience in health promotion and disease pre3 vention activities, with appropriate consider4 ation given to lifestyle factors that have an im5 pact on Indian health status, such as alcohol6 ism, family dysfunction, and poverty;

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

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

10 and disease prevention and develop programs that

11 meet the needs for continuing education;

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

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

15 of Community Health Representatives is reviewed

16 and evaluated; and

17 ‘‘(6) promote Traditional Health Care Practices

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

20 promotion, and disease prevention.

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

22 PROGRAM.

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

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

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

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

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

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

9 must—

10 ‘‘(1)(A) be enrolled—

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

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

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

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

16 scheduled to complete such course of study in

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

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

21 ‘‘(B) have—

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

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

2 as a commissioned officer in the Regular or Reserve

3 Corps of the Public Health Service;

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

5 in the Regular or Reserve Corps of the Public

6 Health Service;

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

8 service employment in the Service; or

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

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

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

13 a contract described in subsection (e).

14 ‘‘(c) APPLICATION.—

15 ‘‘(1) INFORMATION TO BE INCLUDED WITH

16 FORMS.—In disseminating application forms and

17 contract forms to individuals desiring to participate

18 in the Loan Repayment Program, the Secretary

19 shall include with such forms a fair summary of the

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

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

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

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

6 to make a decision on an informed basis.

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

8 contract form, and all other information furnished

9 by the Secretary under this section shall be written

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

12 Repayment Program.

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

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

18 that such individuals have adequate time to carefully

19 review and evaluate such forms and information.

20 ‘‘(d) PRIORITIES.—

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

22 Secretary shall annually—

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

24 Health Program or Urban Indian Organization

25 for which there is a need or a vacancy; and
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1 ‘‘(B) rank those positions in order of prior2 ity.

3 ‘‘(2) APPROVALS.—Notwithstanding the prior4 ity determined under paragraph (1), the Secretary,

5 in determining which applications under the Loan

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

8 ‘‘(A) give first priority to applications

9 made by individual Indians; and

10 ‘‘(B) after making determinations on all

11 applications submitted by individual Indians as

12 required under subparagraph (A), give priority

13 to—

14 ‘‘(i) individuals recruited through the

15 efforts of a Tribal Health Program or

16 Urban Indian Organization; and

17 ‘‘(ii) other individuals based on the

18 priority rankings under paragraph (1).

19 ‘‘(e) RECIPIENT CONTRACTS.—

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

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

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

4 ‘‘(A) an agreement under which—

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

6 Secretary agrees—

7 ‘‘(I) to pay loans on behalf of the

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

10 ‘‘(II) to accept (subject to the

11 availability of appropriated funds for

12 carrying out this section) the individ13 ual into the Service or place the indi14 vidual with a Tribal Health Program

15 or Urban Indian Organization as pro16 vided in clause (ii)(III); and

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

18 individual agrees—

19 ‘‘(I) to accept loan payments on

20 behalf of the individual;

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

22 described in subsection (b)(1)—

23 ‘‘(aa) to maintain enrollment

24 in a course of study or training

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

2 course of study or training; and

3 ‘‘(bb) while enrolled in such

4 course of study or training, to

5 maintain an acceptable level of

6 academic standing (as deter7 mined under regulations of the

8 Secretary by the educational in9 stitution offering such course of

10 study or training); and

11 ‘‘(III) to serve for a time period

12 (hereinafter in this section referred to

13 as the ‘period of obligated service’)

14 equal to 2 years or such longer period

15 as the individual may agree to serve

16 in the full-time clinical practice of

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

22 ‘‘(B) a provision permitting the Secretary

23 to extend for such longer additional periods, as

24 the individual may agree to, the period of obli-
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1 gated service agreed to by the individual under

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

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

6 obligation of the individual which is conditioned

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

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

10 the United States is entitled under subsection

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

12 and

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

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

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

17 The Secretary shall provide written notice to an individual

18 within 21 days on—

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

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

23 excess of 4 years; or

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

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

3 for an individual under a written contract under the

4 Loan Repayment Program shall consist of payment,

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

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

8 by the individual regarding the undergraduate or

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

10 loans were made for—

11 ‘‘(A) tuition expenses;

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

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

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

18 service that an individual contracts to serve under

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

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

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

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

24 determination of the amount to pay for a year of

25 such service by an individual, the Secretary shall
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1 consider the extent to which each such

2 determination—

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

4 maximize the number of contracts that can be

5 provided under the Loan Repayment Program

6 from the amounts appropriated for such con7 tracts;

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

11 professionals; and

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

13 the health professional involved remaining in an

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

17 services, after the completion of the period of

18 obligated service under the Loan Repayment

19 Program.

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

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

23 repayments for a year of obligated service shall be

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

25 which the individual completes such year of service.
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1 ‘‘(4) PAYMENT SCHEDULE.—The Secretary

2 may enter into an agreement with the holder of any

3 loan for which payments are made under the Loan

4 Repayment Program to establish a schedule for the

5 making of such payments.

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

7 other provision of law, individuals who have entered into

8 written contracts with the Secretary under this section

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

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

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

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

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

19 to individuals during their period of obligated service

20 under the Loan Repayment Program.

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

22 in assigning individuals to serve in Indian Health Pro23 grams or Urban Indian Organizations pursuant to con24 tracts entered into under this section, shall—
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1 ‘‘(1) ensure that the staffing needs of Tribal

2 Health Programs and Urban Indian Organizations

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

5 and

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

9 provide health care services as a result of individuals

10 having breached contracts entered into under this

11 section.

12 ‘‘(l) BREACH OF CONTRACT.—

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

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

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

17 of any service obligation arising under such contract,

18 to the United States for the amount which has been

19 paid on such individual’s behalf under the contract

20 if that individual—

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

22 course of study and—

23 ‘‘(i) fails to maintain an acceptable

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

3 the Secretary);

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

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

8 such course of study; or

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

12 ‘‘(2) OTHER BREACHES; FORMULA FOR

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

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

15 written contract under this section by failing either

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

18 the United States shall be entitled to recover from

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

21 which—

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

23 is entitled to recover;

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

25 under this section to, or on behalf of, the indi-
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1 vidual and the interest on such amounts which

2 would be payable if, at the time the amounts

3 were paid, they were loans bearing interest at

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

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

7 the individual’s period of obligated service in

8 accordance with subsection (f); and

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

10 period served by such individual in accordance

11 with this section.

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

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

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

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

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

20 the United States within the 1-year period beginning

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

23 Secretary.

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

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

3 the Secretary shall, for the purpose of recover4 ing such damages—

5 ‘‘(i) use collection agencies contracted

6 with by the Administrator of General Serv7 ices; or

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

10 agencies selected by the Secretary.

11 ‘‘(B) REPORT.—Each contract for recover12 ing damages pursuant to this subsection shall

13 provide that the contractor will, not less than

14 once each 6 months, submit to the Secretary a

15 status report on the success of the contractor in

16 collecting such damages. Section 3718 of title

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

18 contract to the extent not inconsistent with this

19 subsection.

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

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

24 an individual under the Loan Repayment Program

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

2 and if enforcement of such obligation with respect to

3 any individual would be unconscionable.

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

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

7 canceled upon the death of the individual.

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

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

10 States to recover amounts under this section in any

11 case of extreme hardship or other good cause shown,

12 as determined by the Secretary.

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

16 bankruptcy under title 11 of the United States Code

17 only if such discharge is granted after the expiration

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

19 payment of such damages is required, and only if

20 the bankruptcy court finds that nondischarge of the

21 obligation would be unconscionable.

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

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

2 the following:

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

4 maintained by Indian Health Programs and Urban

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

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

8 applications filed with respect to each type of health

9 profession.

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

12 health profession.

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

14 this section, in total and by health profession.

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

17 each health profession.

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

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

20 profession.

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

22 that will be needed by Indian Health Programs and

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

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

2 to fill the health professional positions maintained

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

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

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

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

10 Indian Health Scholarship and Loan Repayment Recovery

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

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

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

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

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

17 appropriated, or earned relative to the LRRF shall remain

18 available until expended.

19 ‘‘(b) USE OF FUNDS.—

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

21 may be expended by the Secretary, acting through

22 the Service, to make payments to an Indian Health

23 Program—

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

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

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

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

6 of such recipient or participant having breached

7 the contract entered into under section 104,

8 106, or section 110.

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

10 Health Program receiving payments pursuant to

11 paragraph (1) may expend the payments to provide

12 scholarships or recruit and employ, directly or by

13 contract, health professionals to provide health care

14 services.

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

16 Treasury shall invest such amounts of the LRRF as the

17 Secretary of Health and Human Services determines are

18 not required to meet current withdrawals from the LRRF.

19 Such investments may be made only in interest bearing

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

21 obligations may be acquired on original issue at the issue

22 price, or by purchase of outstanding obligations at the

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

3 Treasury at the market price.

4 ‘‘SEC. 112. RECRUITMENT ACTIVITIES.

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

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

9 student volunteers and individuals considering entering

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

11 actual and reasonable expenses incurred in traveling to

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

13 they may be assigned for the purpose of evaluating such

14 area with respect to such assignment.

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

16 acting through the Service, shall assign one individual in

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

18 recruitment activities.

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

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

22 the Service, shall fund innovative demonstration projects

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

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

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

5 submit an application for funding of a project pursuant

6 to this section.

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

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

9 acting through the Service, shall establish a demonstration

10 project to enable health professionals who have worked in

11 an Indian Health Program or Urban Indian Organization

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

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

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

18 obligation to serve in an Indian Health Program or Urban

19 Indian Organization for a period of obligated service equal

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

21 participates in such program. In the event that the indi22 vidual fails to complete such obligated service, the individ23 ual shall be liable to the United States for the period of

24 service remaining. In such event, with respect to individ25 uals entering the program after the date of the enactment
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1 of the Indian Health Care Improvement Act Amendments

2 of 2003, the United States shall be entitled to recover

3 from such individual an amount to be determined in ac4 cordance with the formula specified in subsection (l) of

5 section 110 in the manner provided for in such subsection.

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

7 Health professionals from Tribal Health Programs and

8 Urban Indian Organizations shall be given an equal oppor9 tunity to participate in the program under subsection (a).

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

11 NURSING PROGRAM.

12 ‘‘(a) GRANTS AUTHORIZED.—For the purpose of in13 creasing the number of nurses, nurse midwives, and nurse

14 practitioners who deliver health care services to Indians,

15 the Secretary, acting through the Service, shall provide

16 grants to the following:

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

18 ‘‘(2) Tribal colleges or universities.

19 ‘‘(3) Nurse midwife programs and advanced

20 practice nurse programs that are provided by any

21 tribal college or university accredited nursing pro22 gram, or in the absence of such, any other public or

23 private institutions.

24 ‘‘(b) USE OF GRANTS.—Grants provided under sub25 section (a) may be used for one or more of the following:
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1 ‘‘(1) To recruit individuals for programs which

2 train individuals to be nurses, nurse midwives, or

3 advanced practice nurses.

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

5 in such programs that may pay the tuition charged

6 for such program and other expenses incurred in

7 connection with such program, including books, fees,

8 room and board, and stipends for living expenses.

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

10 nurses, nurse midwives, and advanced practice

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

12 services to Indians.

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

14 skills of, and provides continuing education to,

15 nurses, nurse midwives, and advanced practice

16 nurses.

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

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

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

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

21 Secretary may require to establish the connection between

22 the program of the applicant and a health care facility

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

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

3 extend a preference to the following:

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

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

8 ‘‘(3) Programs that are interdisciplinary.

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

11 students.

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

13 Secretary shall provide one of the grants authorized under

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

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

16 N. Burdick American Indians Into Nursing Program’.

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

20 N. Burdick American Indians Into Psychology Program

21 established under section 105(b).

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

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

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

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

3 Such obligation shall be met by service—

4 ‘‘(1) in the Service;

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

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

8 with the Bureau of Indian Affairs);

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

10 Act; or

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

14 situated in a physician or other health shortage area

15 and addresses the health care needs of a substantial

16 number of Indians.

17 ‘‘SEC. 116. TRIBAL CULTURAL ORIENTATION.

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

19 Secretary, acting through the Service, shall require that

20 appropriate employees of the Service who serve Indian

21 Tribes in each Service Area receive educational instruction

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

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

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

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

6 Urban Indian Organizations;

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

8 universities;

9 ‘‘(3) include instruction in American Indian

10 studies; and

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

12 Health Care Practices of the Indian Tribes in the

13 Service Area.

14 ‘‘SEC. 117. INMED PROGRAM.

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

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

18 expanding the Indian health careers recruitment program

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

21 of encouraging Indians to enter the health professions.

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

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

2 makes a determination, based upon program reviews, that

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

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

6 Into Psychology Program established under section 105(b)

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

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

10 Act, shall develop regulations to govern grants pursuant

11 to this section.

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

14 which—

15 ‘‘(1) provides outreach and recruitment for

16 health professions to Indian communities including

17 elementary and secondary schools and community

18 colleges located on reservations which will be served

19 by the program;

20 ‘‘(2) incorporates a program advisory board

21 comprised of representatives from the Indian Tribes

22 and Indian communities which will be served by the

23 program;

24 ‘‘(3) provides summer preparatory programs for

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

2 the health professions;

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

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

6 and

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

8 qualified Indians in the program.

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

10 COLLEGES.

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

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

13 through the Service, shall award grants to accredited

14 and accessible community colleges for the purpose of

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

17 health profession leading to a degree or diploma in

18 a health profession for individuals who desire to

19 practice such profession on or near a reservation or

20 in an Indian Health Program.

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

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

24 is provided to the community college shall not exceed

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

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

4 through the Service, shall award grants to accredited

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

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

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

10 made under this section to a community college

11 which—

12 ‘‘(A) is accredited;

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

15 provide training of nurses or health profes16 sionals;

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

18 an accredited college or university medical

19 school, the terms of which—

20 ‘‘(i) provide a program that enhances

21 the transition and recruitment of students

22 into advanced baccalaureate or graduate

23 programs which train health professionals;

24 and
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1 ‘‘(ii) stipulate certifications necessary

2 to approve internship and field placement

3 opportunities at Indian Health Programs;

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

5 appropriate certifications;

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

8 subsection (a)(1); and

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

11 section.

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

13 encourage community colleges described in subsection

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

15 subsection (a)(1) by—

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

18 Service to teach courses of study in such programs;

19 and

20 ‘‘(2) providing technical assistance and support

21 to such colleges.

22 ‘‘(d) ADVANCED TRAINING.—

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

2 health professional who—

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

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

6 reservation or for an Indian Health Program.

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

8 Such courses of study may be offered in conjunction

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

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

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

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

15 where they exist.

16 ‘‘SEC. 119. RETENTION BONUS.

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

18 a retention bonus to any health professional employed by,

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

20 or Urban Indian Organization either as a civilian employee

21 or as a commissioned officer in the Regular or Reserve

22 Corps of the Public Health Service who—

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

24 for which recruitment or retention of personnel is

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

4 ‘‘(3) has—

5 ‘‘(A) completed 3 years of employment

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

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

10 ‘‘(i) any Federal scholarship program;

11 or

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

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

15 Health Program or Urban Indian Organization for

16 continued employment for a period of not less than

17 1 year.

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

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

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

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

23 annum.

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

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

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

3 Government the full amount of the retention bonus for the

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

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

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

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

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

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

15 to Indians.

16 ‘‘SEC. 120. NURSING RESIDENCY PROGRAM.

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

20 licensed vocational nurses, and registered nurses who are

21 working in an Indian Health Program or Urban Indian

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

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

24 shall include a combination of education and work study

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

2 case of a licensed practical nurse or licensed vocational

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

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

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

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

8 obligation to serve in an Indian Health Program or Urban

9 Indian Organization for a period of obligated service equal

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

12 fails to complete such obligated service, the United States

13 shall be entitled to recover from such individual an amount

14 determined in accordance with the formula specified in

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

16 in such subsection.

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

19 ‘‘(a) GENERAL PURPOSES OF PROGRAM.—Under the

20 authority of the Act of November 2, 1921 (25 U.S.C. 13;

21 popularly known as the Snyder Act), the Secretary, acting

22 through the Service, shall develop and operate a Commu23 nity Health Aide Program in Alaska under which the

24 Service—
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1 ‘‘(1) provides for the training of Alaska Natives

2 as health aides or community health practitioners;

3 ‘‘(2) uses such aides or practitioners in the pro4 vision of health care, health promotion, and disease

5 prevention services to Alaska Natives living in vil6 lages in rural Alaska; and

7 ‘‘(3) provides for the establishment of tele8 conferencing capacity in health clinics located in or

9 near such villages for use by community health aides

10 or community health practitioners.

11 ‘‘(b) SPECIFIC PROGRAM REQUIREMENTS.—The Sec12 retary, acting through the Community Health Aide Pro13 gram of the Service, shall—

14 ‘‘(1) using trainers accredited by the Program,

15 provide a high standard of training to community

16 health aides and community health practitioners to

17 ensure that such aides and practitioners provide

18 quality health care, health promotion, and disease

19 prevention services to the villages served by the Pro20 gram;

21 ‘‘(2) in order to provide such training, develop

22 a curriculum that—

23 ‘‘(A) combines education in the theory of

24 health care with supervised practical experience

25 in the provision of health care;
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1 ‘‘(B) provides instruction and practical ex2 perience in the provision of acute care, emer3 gency care, health promotion, disease preven4 tion, and the efficient and effective manage5 ment of clinic pharmacies, supplies, equipment,

6 and facilities; and

7 ‘‘(C) promotes the achievement of the

8 health status objectives specified in section

9 3(2);

10 ‘‘(3) establish and maintain a Community

11 Health Aide Certification Board to certify as com12 munity health aides or community health practition13 ers individuals who have successfully completed the

14 training described in paragraph (1) or can dem15 onstrate equivalent experience;

16 ‘‘(4) develop and maintain a system which iden17 tifies the needs of community health aides and com18 munity health practitioners for continuing education

19 in the provision of health care, including the areas

20 described in paragraph (2)(B), and develop pro21 grams that meet the needs for such continuing edu22 cation;

23 ‘‘(5) develop and maintain a system that pro24 vides close supervision of community health aides

25 and community health practitioners; and
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1 ‘‘(6) develop a system under which the work of

2 community health aides and community health prac3 titioners is reviewed and evaluated to assure the pro4 vision of quality health care, health promotion, and

5 disease prevention services.

6 ‘‘(c) NATIONAL COMMUNITY HEALTH AIDE PRO7 GRAM.—The Secretary, acting through the Service, shall

8 develop and operate a national Community Health Aide

9 Program consistent with the requirements of this section

10 without reducing funds for the Community Health Aide

11 Program for Alaska.

12 ‘‘SEC. 122. TRIBAL HEALTH PROGRAM ADMINISTRATION.

13 ‘‘The Secretary, acting through the Service, shall, by

14 funding agreement or otherwise, provide training for Indi15 ans in the administration and planning of Tribal Health

16 Programs.

17 ‘‘SEC. 123. HEALTH PROFESSIONAL CHRONIC SHORTAGE

18 DEMONSTRATION PROGRAMS.

19 ‘‘(a) DEMONSTRATION PROGRAMS AUTHORIZED.—

20 The Secretary, acting through the Service, may fund dem21 onstration programs for Tribal Health Programs to ad22 dress the chronic shortages of health professionals.

23 ‘‘(b) PURPOSES OF PROGRAMS.—The purposes of

24 demonstration programs funded under subsection (a) shall

25 be—
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1 ‘‘(1) to provide direct clinical and practical ex2 perience at a Service Unit to health profession stu3 dents and residents from medical schools;

4 ‘‘(2) to improve the quality of health care for

5 Indians by assuring access to qualified health care

6 professionals; and

7 ‘‘(3) to provide academic and scholarly opportu8 nities for health professionals serving Indians by

9 identifying all academic and scholarly resources of

10 the region.

11 ‘‘(c) ADVISORY BOARD.—The demonstration pro12 grams established pursuant to subsection (a) shall incor13 porate a program advisory board composed of representa14 tives from the Indian Tribes and Indian communities in

15 the area which will be served by the program.

16 ‘‘SEC. 124. TREATMENT OF SCHOLARSHIPS FOR CERTAIN

17 PURPOSES.

18 ‘‘Scholarships provided to individuals pursuant to

19 this title shall be deemed ‘qualified Scholarships’ for pur20 poses of section 11 of the Internal Revenue Code of 1986.

21 ‘‘SEC. 125. NATIONAL HEALTH SERVICE CORPS.

22 ‘‘(a) NO REDUCTION IN SERVICES.—The Secretary

23 shall not—
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1 ‘‘(1) remove a member of the National Health

2 Service Corps from an Indian Health Program or

3 Urban Indian Organization; or

4 ‘‘(2) withdraw funding used to support such

5 member, unless the Secretary, acting through the

6 Service, Indian Tribes, or Tribal Organizations, has

7 ensured that the Indians receiving services from

8 such member will experience no reduction in serv9 ices.

10 ‘‘(b) EXEMPTION FROM LIMITATIONS.—National

11 Health Service Corps scholars qualifying for the Commis12 sioned Corps in the United States Public Health Service

13 shall be exempt from the full-time equivalent limitations

14 of the National Health Service Corps and the Service

15 when serving as a commissioned corps officer in a Tribal

16 Health Program or an Urban Indian Organization.

17 ‘‘SEC. 126. SUBSTANCE ABUSE COUNSELOR EDUCATIONAL

18 CURRICULA DEMONSTRATION PROGRAMS.

19 ‘‘(a) GRANTS AND CONTRACTS.—The Secretary, act20 ing through the Service, may enter into contracts with,

21 or make grants to, accredited tribal colleges and univer22 sities and eligible accredited and accessible community col23 leges to establish demonstration programs to develop edu24 cational curricula for substance abuse counseling.
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1 ‘‘(b) USE OF FUNDS.—Funds provided under this

2 section shall be used only for developing and providing

3 educational curriculum for substance abuse counseling (in4 cluding paying salaries for instructors). Such curricula

5 may be provided through satellite campus programs.

6 ‘‘(c) TIME PERIOD OF ASSISTANCE; RENEWAL.—A

7 contract entered into or a grant provided under this sec8 tion shall be for a period of 1 year. Such contract or grant

9 may be renewed for an additional 1-year period upon the

10 approval of the Secretary.

11 ‘‘(d) CRITERIA FOR REVIEW AND APPROVAL OF AP12 PLICATIONS.—Not later than 180 days after the date of

13 the enactment of the Indian Health Care Improvement

14 Act Amendments of 2003, the Secretary, after consulta15 tion with Indian Tribes and administrators of tribal col16 leges and universities and eligible accredited and acces17 sible community colleges, shall develop and issue criteria

18 for the review and approval of applications for funding (in19 cluding applications for renewals of funding) under this

20 section. Such criteria shall ensure that demonstration pro21 grams established under this section promote the develop22 ment of the capacity of such entities to educate substance

23 abuse counselors.

24 ‘‘(e) ASSISTANCE.—The Secretary shall provide such

25 technical and other assistance as may be necessary to en-
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1 able grant recipients to comply with the provisions of this

2 section.

3 ‘‘(f) REPORT.—Each fiscal year, the Secretary shall

4 submit to the President, for inclusion in the report which

5 is required to be submitted under section 801 for that fis6 cal year, a report on the findings and conclusions derived

7 from the demonstration programs conducted under this

8 section during that fiscal year.

9 ‘‘(g) DEFINITION.—For the purposes of this section

10 the term ‘educational curriculum’ means 1 or more of the

11 following—

12 ‘‘(1) classroom education;

13 ‘‘(2) clinical work experience; and

14 ‘‘(3) continuing education workshops.

15 ‘‘SEC. 127. MENTAL HEALTH TRAINING AND COMMUNITY

16 EDUCATION PROGRAMS.

17 ‘‘(a) STUDY; LIST.—The Secretary, acting through

18 the Service, and the Secretary of the Interior, in consulta19 tion with Indian Tribes and Tribal Organizations, shall

20 conduct a study and compile a list of the types of staff

21 positions specified in subsection (b) whose qualifications

22 include, or should include, training in the identification,

23 prevention, education, referral, or treatment of mental ill24 ness, or dysfunctional and self destructive behavior.
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1 ‘‘(b) POSITIONS.—The positions referred to in sub2 section (a) are—

3 ‘‘(1) staff positions within the Bureau of Indian

4 Affairs, including existing positions, in the fields

5 of—

6 ‘‘(A) elementary and secondary education;

7 ‘‘(B) social services and family and child

8 welfare;

9 ‘‘(C) law enforcement and judicial services;

10 and

11 ‘‘(D) alcohol and substance abuse;

12 ‘‘(2) staff positions within the Service; and

13 ‘‘(3) staff positions similar to those identified in

14 paragraphs (1) and (2) established and maintained

15 by Indian Tribes, Tribal Organizations, (without re16 gard to the funding source) and Urban Indian Orga17 nizations.

18 ‘‘(c) TRAINING CRITERIA.—

19 ‘‘(1) IN GENERAL.—The appropriate Secretary

20 shall provide training criteria appropriate to each

21 type of position identified in subsection (b)(1) and

22 (b)(2) and ensure that appropriate training has

23 been, or shall be provided to any individual in any

24 such position. With respect to any such individual in

25 a position identified pursuant to subsection (b)(3),
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1 the respective Secretaries shall provide appropriate

2 training to, or provide funds to, an Indian Tribe,

3 Tribal Organization, or Urban Indian Organization

4 for training of appropriate individuals. In the case of

5 positions funded under a funding agreement, the ap6 propriate Secretary shall ensure that funds to cover

7 the costs of such training costs are included in the

8 funding agreement.

9 ‘‘(2) POSITION SPECIFIC TRAINING CRITERIA.—

10 Position specific training criteria shall be culturally

11 relevant to Indians and Indian Tribes and shall en12 sure that appropriate information regarding Tradi13 tional Health Care Practices is provided.

14 ‘‘(d) COMMUNITY EDUCATION ON MENTAL ILL15 NESS.—The Service shall develop and implement, on re16 quest of an Indian Tribe or Tribal Organization, or assist

17 the Indian Tribe or Tribal Organization to develop and

18 implement a program of community education on mental

19 illness. In carrying out this subsection, the Service shall,

20 upon request of an Indian Tribe or Tribal Organization,

21 provide technical assistance to the Indian Tribe or Tribal

22 Organization to obtain and develop community edu23 cational materials on the identification, prevention, refer24 ral, and treatment of mental illness and dysfunctional and

25 self-destructive behavior.
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1 ‘‘(e) PLAN.—Not later than 90 days after the date

2 of the enactment of the Indian Health Care Improvement

3 Act Amendments of 2003, the Secretary shall develop a

4 plan under which the Service will increase the health care

5 staff providing mental health services by at least 500 posi6 tions within 5 years after the date of the enactment of

7 this section, with at least 200 of such positions devoted

8 to child, adolescent, and family services. The plan devel9 oped under this subsection shall be implemented under the

10 Act of November 2, 1921 (25 U.S.C. 13, popularly known

11 as the Snyder Act).

12 ‘‘SEC. 128. DESIGNATION OF SHORTAGE AREAS.

13 ‘‘A Service Area served by an Indian Health Program

14 or Urban Indian Organization shall be designated under

15 the Public Health Services Act (42 U.S.C. 250 et seq.)

16 as a shortage area immediately upon request of an Indian

17 Health Program without further evaluation by the Sec18 retary.

19 ‘‘SEC. 129. AUTHORIZATION OF APPROPRIATIONS.

20 ‘‘There are authorized to be appropriated such sums

21 as may be necessary for each fiscal year through fiscal

22 year 2015 to carry out this title.
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1 ‘‘TITLE II—HEALTH SERVICES

2 ‘‘SEC. 201. INDIAN HEALTH CARE IMPROVEMENT FUND.

3 ‘‘(a) USE OF FUNDS.—The Secretary, acting through

4 the Service, is authorized to expend funds, directly or

5 under the authority of the Indian Self-Determination and

6 Education Assistance Act, which are appropriated under

7 the authority of this section, for the purposes of—

8 ‘‘(1) eliminating the deficiencies in health sta9 tus and health resources of all Indian Tribes;

10 ‘‘(2) eliminating backlogs in the provision of

11 health care services to Indians;

12 ‘‘(3) meeting the health needs of Indians in an

13 efficient and equitable manner;

14 ‘‘(4) eliminating inequities in funding for both

15 direct care and contract health service programs;

16 and

17 ‘‘(5) augmenting the ability of the Service to

18 meet the following health service responsibilities with

19 respect to those Indian Tribes with the highest levels

20 of health status deficiencies and resource defi21 ciencies:

22 ‘‘(A) Clinical care, including, but not lim23 ited to, inpatient care, outpatient care (includ24 ing audiology, clinical eye, and vision care), pri-
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1 mary care, secondary and tertiary care, and

2 long-term care.

3 ‘‘(B) Preventive health, including mam4 mography and other cancer screening in accord5 ance with section 207.

6 ‘‘(C) Dental care.

7 ‘‘(D) Mental health, including community

8 mental health services, inpatient mental health

9 services, dormitory mental health services,

10 therapeutic and residential treatment centers,

11 and training of traditional health care practi12 tioners.

13 ‘‘(E) Emergency medical services.

14 ‘‘(F) Treatment and control of, and reha15 bilitative care related to, alcoholism and drug

16 abuse (including fetal alcohol syndrome) among

17 Indians.

18 ‘‘(G) Accident prevention programs.

19 ‘‘(H) Home health care.

20 ‘‘(I) Community health representatives.

21 ‘‘(J) Maintenance and repair.

22 ‘‘(K) Traditional Health Care Practices.

23 ‘‘(b) NO OFFSET OR LIMITATION.—Any funds appro24 priated under the authority of this section shall not be

25 used to offset or limit any other appropriations made to
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1 the Service under this Act or the Act of November 2, 1921

2 (25 U.S.C. 13, popularly known as the Snyder Act), or

3 any other provision of law.

4 ‘‘(c) ALLOCATION; USE.—

5 ‘‘(1) IN GENERAL.—Funds appropriated under

6 the authority of this section shall be allocated to

7 Service Units, Indian Tribes, or Tribal Organiza8 tions. The funds allocated to each Indian Tribe,

9 Tribal Organization, or Service Unit under this

10 paragraph shall be used by the Indian Tribe, Tribal

11 Organization, or Service Unit under this paragraph

12 to improve the health status and reduce the resource

13 deficiency of each Indian Tribe served by such Serv14 ice Unit, Indian Tribe, or Tribal Organization.

15 ‘‘(2) APPORTIONMENT OF ALLOCATED

16 FUNDS.—The apportionment of funds allocated to a

17 Service Unit, Indian Tribe, or Tribal Organization

18 under paragraph (1) among the health service re19 sponsibilities described in subsection (a)(5) shall be

20 determined by the Service in consultation with, and

21 with the active participation of, the affected Indian

22 Tribes and Tribal Organizations.

23 ‘‘(d) PROVISIONS RELATING TO HEALTH STATUS

24 AND RESOURCE DEFICIENCIES.—For the purposes of this

25 section, the following definitions apply:
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1 ‘‘(1) DEFINITION.—The term ‘health status

2 and resource deficiency’ means the extent to

3 which—

4 ‘‘(A) the health status objectives set forth

5 in section 3(2) are not being achieved; and

6 ‘‘(B) the Indian Tribe or Tribal Organiza7 tion does not have available to it the health re8 sources it needs, taking into account the actual

9 cost of providing health care services given local

10 geographic, climatic, rural, or other cir11 cumstances.

12 ‘‘(2) AVAILABLE RESOURCES.—The health re13 sources available to an Indian Tribe or Tribal Orga14 nization include health resources provided by the

15 Service as well as health resources used by the In16 dian Tribe or Tribal Organization, including services

17 and financing systems provided by any Federal pro18 grams, private insurance, and programs of State or

19 local governments.

20 ‘‘(3) PROCESS FOR REVIEW OF DETERMINA21 TIONS.—The Secretary shall establish procedures

22 which allow any Indian Tribe or Tribal Organization

23 to petition the Secretary for a review of any deter24 mination of the extent of the health status and re-
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1 source deficiency of such Indian Tribe or Tribal Or2 ganization.

3 ‘‘(e) ELIGIBILITY FOR FUNDS.—Tribal Health Pro4 grams shall be eligible for funds appropriated under the

5 authority of this section on an equal basis with programs

6 that are administered directly by the Service.

7 ‘‘(f) REPORT.—By no later than the date that is 3

8 years after the date of the enactment of the Indian Health

9 Care Improvement Act Amendments of 2003, the Sec10 retary shall submit to Congress the current health status

11 and resource deficiency report of the Service for each

12 Service Unit, including newly recognized or acknowledged

13 Indian Tribes. Such report shall set out—

14 ‘‘(1) the methodology then in use by the Service

15 for determining Tribal health status and resource

16 deficiencies, as well as the most recent application of

17 that methodology;

18 ‘‘(2) the extent of the health status and re19 source deficiency of each Indian Tribe served by the

20 Service or a Tribal Health Program;

21 ‘‘(3) the amount of funds necessary to eliminate

22 the health status and resource deficiencies of all In23 dian Tribes served by the Service or a Tribal Health

24 Program; and

25 ‘‘(4) an estimate of—
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1 ‘‘(A) the amount of health service funds

2 appropriated under the authority of this Act, or

3 any other Act, including the amount of any

4 funds transferred to the Service for the preced5 ing fiscal year which is allocated to each Service

6 Unit, Indian Tribe, or Tribal Organization;

7 ‘‘(B) the number of Indians eligible for

8 health services in each Service Unit or Indian

9 Tribe or Tribal Organization; and

10 ‘‘(C) the number of Indians using the

11 Service resources made available to each Service

12 Unit, Indian Tribe or Tribal Organization, and,

13 to the extent available, information on the wait14 ing lists and number of Indians turned away for

15 services due to lack of resources.

16 ‘‘(g) INCLUSION IN BASE BUDGET.—Funds appro17 priated under this section for any fiscal year shall be in18 cluded in the base budget of the Service for the purpose

19 of determining appropriations under this section in subse20 quent fiscal years.

21 ‘‘(h) CLARIFICATION.—Nothing in this section is in22 tended to diminish the primary responsibility of the Serv23 ice to eliminate existing backlogs in unmet health care

24 needs, nor are the provisions of this section intended to

25 discourage the Service from undertaking additional efforts
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1 to achieve equity among Indian Tribes and Tribal Organi2 zations.

3 ‘‘(i) FUNDING DESIGNATION.—Any funds appro4 priated under the authority of this section shall be des5 ignated as the ‘Indian Health Care Improvement Fund’.

6 ‘‘SEC. 202. CATASTROPHIC HEALTH EMERGENCY FUND.

7 ‘‘(a) ESTABLISHMENT.—There is hereby established

8 an Indian Catastrophic Health Emergency Fund (here9 after in this section referred to as the ‘CHEF’) consisting

10 of—

11 ‘‘(1) the amounts deposited under subsection

12 (f); and

13 ‘‘(2) the amounts appropriated to CHEF under

14 this section.

15 ‘‘(b) ADMINISTRATION.—CHEF shall be adminis16 tered by the Secretary, acting through the central office

17 of the Service, solely for the purpose of meeting the ex18 traordinary medical costs associated with the treatment of

19 victims of disasters or catastrophic illnesses who are with20 in the responsibility of the Service.

21 ‘‘(c) CONDITIONS ON USE OF FUND.—No part of

22 CHEF or its administration shall be subject to contract

23 or grant under any law, including the Indian Self-Deter24 mination Act, nor shall CHEF funds be allocated, appor-
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1 tioned, or delegated on an Area Office, Service Unit, or

2 other similar basis.

3 ‘‘(d) REGULATIONS.—The Secretary shall, through

4 the negotiated rulemaking process under title VIII, pro5 mulgate regulations consistent with the provisions of this

6 section to—

7 ‘‘(1) establish a definition of disasters and cata8 strophic illnesses for which the cost of the treatment

9 provided under contract would qualify for payment

10 from CHEF;

11 ‘‘(2) provide that a Service Unit shall not be el12 igible for reimbursement for the cost of treatment

13 from CHEF until its cost of treating any victim of

14 such catastrophic illness or disaster has reached a

15 certain threshold cost which the Secretary shall es16 tablish at—

17 ‘‘(A) the 2000 level of $19,000; and

18 ‘‘(B) for any subsequent year, not less

19 than the threshold cost of the previous year in20 creased by the percentage increase in the medi21 cal care expenditure category of the consumer

22 price index for all urban consumers (United

23 States city average) for the 12-month period

24 ending with December of the previous year; and
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1 ‘‘(3) establish a procedure for the reimburse2 ment of the portion of the costs that exceeds such

3 threshold cost incurred by—

4 ‘‘(A) Service Units; or

5 ‘‘(B) whenever otherwise authorized by the

6 Service, non-Service facilities or providers;

7 ‘‘(4) establish a procedure for payment from

8 CHEF in cases in which the exigencies of the medi9 cal circumstances warrant treatment prior to the au10 thorization of such treatment by the Service; and

11 ‘‘(5) establish a procedure that will ensure that

12 no payment shall be made from CHEF to any pro13 vider of treatment to the extent that such provider

14 is eligible to receive payment for the treatment from

15 any other Federal, State, local, or private source of

16 reimbursement for which the patient is eligible.

17 ‘‘(e) NO OFFSET OR LIMITATION.—Amounts appro18 priated to CHEF under this section shall not be used to

19 offset or limit appropriations made to the Service under

20 the authority of the Act of November 2, 1921 (25 U.S.C.

21 13, popularly known as the Snyder Act), or any other law.

22 ‘‘(f) DEPOSIT OF REIMBURSEMENT FUNDS.—There

23 shall be deposited into CHEF all reimbursements to which

24 the Service is entitled from any Federal, State, local, or

25 private source (including third party insurance) by reason
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1 of treatment rendered to any victim of a disaster or cata2 strophic illness the cost of which was paid from CHEF.

3 ‘‘SEC. 203. HEALTH PROMOTION AND DISEASE PREVENTION

4 SERVICES.

5 ‘‘(a) FINDINGS.—Congress finds that health pro6 motion and disease prevention activities—

7 ‘‘(1) improve the health and well-being of Indi8 ans; and

9 ‘‘(2) reduce the expenses for health care of In10 dians.

11 ‘‘(b) PROVISION OF SERVICES.—The Secretary, act12 ing through the Service and Tribal Health Programs, shall

13 provide health promotion and disease prevention services

14 to Indians to achieve the health status objectives set forth

15 in section 3(2).

16 ‘‘(c) EVALUATION.—The Secretary, after obtaining

17 input from the affected Tribal Health Programs, shall

18 submit to the President for inclusion in each report which

19 is required to be submitted to Congress under section 801

20 an evaluation of—

21 ‘‘(1) the health promotion and disease preven22 tion needs of Indians;

23 ‘‘(2) the health promotion and disease preven24 tion activities which would best meet such needs;
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1 ‘‘(3) the internal capacity of the Service and

2 Tribal Health Programs to meet such needs; and

3 ‘‘(4) the resources which would be required to

4 enable the Service and Tribal Health Programs to

5 undertake the health promotion and disease preven6 tion activities necessary to meet such needs.

7 ‘‘SEC. 204. DIABETES PREVENTION, TREATMENT, AND CON8 TROL.

9 ‘‘(a) DETERMINATIONS REGARDING DIABETES.—

10 The Secretary, acting through the Service, and in con11 sultation with Indian Tribes and Tribal Organizations,

12 shall determine—

13 ‘‘(1) by an Indian Tribe, Tribal Organization,

14 and by Service Unit, the incidence of, and the types

15 of complications resulting from, diabetes among In16 dians; and

17 ‘‘(2) based on the determinations made pursu18 ant to paragraph (1), the measures (including pa19 tient education) each Service Unit should take to re20 duce the incidence of, and prevent, treat, and control

21 the complications resulting from, diabetes among In22 dian Tribes within that Service Unit.

23 ‘‘(b) DIABETES SCREENING.—To the extent medi24 cally indicated and with informed consent, the Secretary

25 shall screen each Indian who receives services from the
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1 Service for diabetes and for conditions which indicate a

2 high risk that the individual will become diabetic. Such

3 screening may be done by a Tribal Health Program.

4 ‘‘(c) FUNDING FOR DIABETES.—The Secretary shall

5 continue to fund each model diabetes project in existence

6 on the date of the enactment of the Indian Health Amend7 ments Care Improvement Act of 2003, any such other dia8 betes programs operated by the Service or Tribal Health

9 Programs, and any additional diabetes projects. Tribal

10 Health Programs shall receive recurring funding for the

11 diabetes projects that they operate pursuant to this sec12 tion, both at the date of enactment of the Indian Health

13 Care Improvement Act Amendments of 2003 and for

14 projects which are added and funded thereafter.

15 ‘‘(d) FUNDING FOR DIALYSIS PROGRAMS.—The Sec16 retary shall provide funding through the Service, Indian

17 Tribes, and Tribal Organizations to establish dialysis pro18 grams, including funding to purchase dialysis equipment

19 and provide necessary staffing.

20 ‘‘(e) OTHER DUTIES OF THE SECRETARY.—The Sec21 retary shall, to the extent funding is available—

22 ‘‘(1) in each Area Office, consult with Indian

23 Tribes and Tribal Organizations regarding programs

24 for the prevention, treatment, and control of diabe25 tes;
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1 ‘‘(2) establish in each Area Office a registry of

2 patients with diabetes to track the incidence of dia3 betes and the complications from diabetes in that

4 area; and

5 ‘‘(3) ensure that data collected in each Area Of6 fice regarding diabetes and related complications

7 among Indians is disseminated to all other Area Of8 fices.

9 ‘‘SEC. 205. SHARED SERVICES FOR LONG-TERM CARE.

10 ‘‘(a) FUNDING AGREEMENTS FOR LONG-TERM

11 CARE.—Notwithstanding any other provisions of law, the

12 Secretary, acting through the Service, is authorized to

13 enter into Funding Agreements or other arrangements

14 with Indian Tribes or Tribal Organizations for the delivery

15 of long-term care and similar services to Indians. Such

16 funding agreements or other arrangements shall provide

17 for the sharing of staff or other services between the Serv18 ice or a Tribal Health Program and a long-term care or

19 other similar facility owned and operated (directly or

20 through a Funding Agreement) by such Indian Tribe or

21 Tribal Organization.

22 ‘‘(b) CONTENTS OF FUNDING AGREEMENTS.—A

23 Funding Agreement or other arrangement entered into

24 pursuant to subsection (a)—
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1 ‘‘(1) may, at the request of the Indian Tribe or

2 Tribal Organization, delegate to such Indian Tribe

3 or Tribal Organization such powers of supervision

4 and control over Service employees as the Secretary

5 deems necessary to carry out the purposes of this

6 section;

7 ‘‘(2) shall provide that expenses (including sala8 ries) relating to services that are shared between the

9 Service and the Tribal Health Program be allocated

10 proportionately between the Service and the Indian

11 Tribe or Tribal Organization; and

12 ‘‘(3) may authorize such Indian Tribe or Tribal

13 Organization to construct, renovate, or expand a

14 long-term care or other similar facility (including the

15 construction of a facility attached to a Service facil16 ity).

17 ‘‘(c) MINIMUM REQUIREMENT.—Any nursing facility

18 provided for under this section shall meet the require19 ments for nursing facilities under section 1919 of the So20 cial Security Act.

21 ‘‘(d) OTHER ASSISTANCE.—The Secretary shall pro22 vide such technical and other assistance as may be nec23 essary to enable applicants to comply with the provisions

24 of this section.
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1 ‘‘(e) USE OF EXISTING OR UNDERUSED FACILI2 TIES.—The Secretary shall encourage the use of existing

3 facilities that are underused or allow the use of swing beds

4 for long-term or similar care.

5 ‘‘SEC. 206. HEALTH SERVICES RESEARCH.

6 ‘‘The Secretary, acting through the Service, shall

7 make funding available for research to further the per8 formance of the health service responsibilities of Indian

9 Health Programs and shall coordinate the activities of

10 other agencies within the Department to address these re11 search needs. The funding shall be divided equitably

12 among the Area Offices. Then each Area Office shall

13 award the funds competitively within that Area. The Sec14 retary shall consult with Indian Tribes and Tribal Organi15 zations in developing the methodology used to allocate

16 these funds among Area Offices for competitive awards.

17 Tribal Health Programs shall be given an equal oppor18 tunity to compete for, and receive, research funds under

19 this section. This funding may be used for both clinical

20 and nonclinical research.

21 ‘‘SEC. 207. MAMMOGRAPHY AND OTHER CANCER SCREEN22 ING.

23 ‘‘The Secretary, acting through the Service or Tribal

24 Health Programs, shall provide for screening as follows:
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1 ‘‘(1) Screening mammography (as defined in

2 section 1861(jj) of the Social Security Act) for In3 dian women at a frequency appropriate to such

4 women under national standards, such as those of

5 the National Cancer Institute for the National Insti6 tutes for Health, and under such terms and condi7 tions as are consistent with standards established by

8 the Secretary to ensure the safety and accuracy of

9 screening mammography under part B of title XVIII

10 of such Act.

11 ‘‘(2) Other cancer screening meeting national

12 standards, such as those of the National Cancer In13 stitute.

14 ‘‘SEC. 208. PATIENT TRAVEL COSTS.

15 ‘‘The Secretary, acting through the Service and Trib16 al Health Programs, shall provide funds for the following

17 patient travel costs, including appropriate and necessary

18 qualified escorts, associated with receiving health care

19 services provided (either through direct or contract care

20 or through Funding Agreements) under this Act—

21 ‘‘(1) emergency air transportation and non22 emergency air transportation where ground trans23 portation is infeasible;

24 ‘‘(2) transportation by private vehicle, specially

25 equipped vehicle, and ambulance; and
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1 ‘‘(3) transportation by such other means as

2 may be available and required when air or motor ve3 hicle transportation is not available.

4 ‘‘SEC. 209. EPIDEMIOLOGY CENTERS.

5 ‘‘(a) ADDITIONAL CENTERS.—In addition to those

6 epidemiology centers already established at the time of en7 actment of this Act, (including those for which funding

8 is currently being provided in Funding Agreements), and

9 without reducing the funding levels for such centers, not

10 later than 180 days after the date of the enactment of

11 the Indian Health Care Improvement Act Amendments of

12 2003, the Secretary, acting through the Service, shall es13 tablish and fund an epidemiology center in each Service

14 Area which does not yet have one to carry out the func15 tions described in subsection (b). Any new centers so es16 tablished may be operated by Tribal Health Programs, but

17 such funding shall not be divisible.

18 ‘‘(b) FUNCTIONS OF CENTERS.—In consultation with

19 and upon the request of Indian Tribes, Tribal Organiza20 tions, and Urban Indian Organizations, each Service Area

21 epidemiology center established under this subsection

22 shall, with respect to such Service Area—

23 ‘‘(1) collect data relating to, and monitor

24 progress made toward meeting, each of the health

25 status objectives of the Service, the Indian Tribes,
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1 Tribal Organizations, and Urban Indian Organiza2 tions in the Service Area;

3 ‘‘(2) evaluate existing delivery systems, data

4 systems, and other systems that impact the improve5 ment of Indian health;

6 ‘‘(3) assist Indian Tribes, Tribal Organizations,

7 and Urban Indian Organizations in identifying their

8 highest priority health status objectives and the

9 services needed to achieve such objectives, based on

10 epidemiological data;

11 ‘‘(4) make recommendations for the targeting

12 of services needed by the populations served;

13 ‘‘(5) make recommendations to improve health

14 care delivery systems for Indians and Urban Indi15 ans;

16 ‘‘(6) provide requested technical assistance to

17 Indian Tribes, Tribal Organizations, and Urban In18 dian Organizations in the development of local

19 health service priorities and incidence and prevalence

20 rates of disease and other illness in the community;

21 and

22 ‘‘(7) provide disease surveillance and assist In23 dian Tribes, Tribal Organizations, and Urban Indian

24 Organizations to promote public health.
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1 ‘‘(c) TECHNICAL ASSISTANCE.—The Director of the

2 Centers for Disease Control and Prevention shall provide

3 technical assistance to the centers in carrying out the re4 quirements of this subsection.

5 ‘‘(d) FUNDING FOR STUDIES.—The Secretary may

6 make funding available to Indian Tribes, Tribal Organiza7 tions, and Urban Indian Organizations to conduct epide8 miological studies of Indian communities.

9 ‘‘SEC. 210. COMPREHENSIVE SCHOOL HEALTH EDUCATION

10 PROGRAMS.

11 ‘‘(a) FUNDING FOR DEVELOPMENT OF PROGRAMS.—

12 The Secretary, acting through the Service, shall provide

13 funding to Indian Tribes, Tribal Organizations, and

14 Urban Indian Organizations to develop comprehensive

15 school health education programs for children from pre16 school through grade 12 in schools for the benefit of In17 dian and Urban Indian children.

18 ‘‘(b) USE OF FUNDS.—Funding provided under this

19 section may be used for purposes which may include, but

20 are not limited to, the following:

21 ‘‘(1) Developing and implementing health edu22 cation curricula both for regular school programs

23 and afterschool programs.

24 ‘‘(2) Training teachers in comprehensive school

25 health education curricula.
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1 ‘‘(3) Integrating school-based, community2 based, and other public and private health promotion

3 efforts.

4 ‘‘(4) Encouraging healthy, tobacco-free school

5 environments.

6 ‘‘(5) Coordinating school-based health programs

7 with existing services and programs available in the

8 community.

9 ‘‘(6) Developing school programs on nutrition

10 education, personal health, oral health, and fitness.

11 ‘‘(7) Developing mental health wellness pro12 grams.

13 ‘‘(8) Developing chronic disease prevention pro14 grams.

15 ‘‘(9) Developing substance abuse prevention

16 programs.

17 ‘‘(10) Developing injury prevention and safety

18 education programs.

19 ‘‘(11) Developing activities for the prevention

20 and control of communicable diseases.

21 ‘‘(12) Developing community and environmental

22 health education programs that include traditional

23 health care practitioners.

24 ‘‘(13) Violence prevention.
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1 ‘‘(14) Such other health issues as are appro2 priate.

3 ‘‘(c) TECHNICAL ASSISTANCE.—Upon request, the

4 Secretary, acting through the Service, shall provide tech5 nical assistance to Indian Tribes, Tribal Organizations,

6 and Urban Indian Organizations in the development of

7 comprehensive health education plans and the dissemina8 tion of comprehensive health education materials and in9 formation on existing health programs and resources.

10 ‘‘(d) CRITERIA FOR REVIEW AND APPROVAL OF AP11 PLICATIONS.—The Secretary, acting through the Service,

12 and in consultation with Indian Tribes, Tribal Organiza13 tions, and Urban Indian Organizations, shall establish cri14 teria for the review and approval of applications for fund15 ing provided pursuant to this section.

16 ‘‘(e) DEVELOPMENT OF PROGRAM FOR BIA FUNDED

17 SCHOOLS.—

18 ‘‘(1) IN GENERAL.—The Secretary of the Inte19 rior, acting through the Bureau of Indian Affairs

20 and in cooperation with the Secretary, acting

21 through the Service, and affected Indian Tribes and

22 Tribal Organizations, shall develop a comprehensive

23 school health education program for children from

24 preschool through grade 12 in schools for which sup25 port is provided by the Bureau of Indian Affairs.
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1 ‘‘(2) REQUIREMENTS FOR PROGRAMS.—Such

2 programs shall include the following—

3 ‘‘(A) school programs on nutrition edu4 cation, personal health, oral health, and fitness;

5 ‘‘(B) mental health wellness programs;

6 ‘‘(C) chronic disease prevention programs;

7 ‘‘(D) substance abuse prevention pro8 grams;

9 ‘‘(E) injury prevention and safety edu10 cation programs; and

11 ‘‘(F) activities for the prevention and con12 trol of communicable diseases.

13 ‘‘(3) DUTIES OF THE SECRETARY.—The Sec14 retary of the Interior shall—

15 ‘‘(A) provide training to teachers in com16 prehensive school health education curricula;

17 ‘‘(B) ensure the integration and coordina18 tion of school-based programs with existing

19 services and health programs available in the

20 community; and

21 ‘‘(C) encourage healthy, tobacco-free school

22 environments.

23 ‘‘SEC. 211. INDIAN YOUTH PROGRAM.

24 ‘‘(a) PROGRAM AUTHORIZED.—The Secretary, acting

25 through the Service, is authorized to establish and admin-
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1 ister a program to provide funding to Indian Tribes, Trib2 al Organizations, and Urban Indian Organizations for in3 novative mental and physical disease prevention and

4 health promotion and treatment programs for Indian and

5 Urban Indian preadolescent and adolescent youths.

6 ‘‘(b) USE OF FUNDS.—

7 ‘‘(1) ALLOWABLE USES.—Funds made available

8 under this section may be used to—

9 ‘‘(A) develop prevention and treatment

10 programs for Indian youth which promote men11 tal and physical health and incorporate cultural

12 values, community and family involvement, and

13 traditional health care practitioners; and

14 ‘‘(B) develop and provide community train15 ing and education.

16 ‘‘(2) PROHIBITED USE.—Funds made available

17 under this section may not be used to provide serv18 ices described in section 707(c).

19 ‘‘(c) DUTIES OF THE SECRETARY.—The Secretary

20 shall—

21 ‘‘(1) disseminate to Indian Tribes, Tribal Orga22 nizations, and Urban Indian Organizations informa23 tion regarding models for the delivery of comprehen24 sive health care services to Indian and Urban Indian

25 adolescents;
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1 ‘‘(2) encourage the implementation of such

2 models; and

3 ‘‘(3) at the request of an Indian Tribe, Tribal

4 Organization, or Urban Indian Organization, provide

5 technical assistance in the implementation of such

6 models.

7 ‘‘(d) CRITERIA FOR REVIEW AND APPROVAL OF AP8 PLICATIONS.—The Secretary, in consultation with Indian

9 Tribes, Tribal Organization, and Urban Indian Organiza10 tions, shall establish criteria for the review and approval

11 of applications or proposals under this section.

12 ‘‘SEC. 212. PREVENTION, CONTROL, AND ELIMINATION OF

13 COMMUNICABLE AND INFECTIOUS DISEASES.

14 ‘‘(a) FUNDING AUTHORIZED.—The Secretary, acting

15 through the Service, and after consultation with Indian

16 Tribes, Tribal Organizations, Urban Indian Organiza17 tions, and the Centers for Disease Control and Prevention,

18 may make funding available to Indian Tribes and Tribal

19 Organizations for the following:

20 ‘‘(1) Projects for the prevention, control, and

21 elimination of communicable and infectious diseases

22 including, but not limited to, tuberculosis, hepatitis,

23 HIV, respiratory syncitial virus, hanta virus, sexu24 ally transmitted diseases, and H. Pylori.
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1 ‘‘(2) Public information and education pro2 grams for the prevention, control, and elimination of

3 communicable and infectious diseases.

4 ‘‘(3) Education, training, and clinical skills im5 provement activities in the prevention, control, and

6 elimination of communicable and infectious diseases

7 for health professionals, including allied health pro8 fessionals.

9 ‘‘(4) Demonstration projects for the screening,

10 treatment, and prevention of hepatitis C virus

11 (HCV).

12 ‘‘(b) APPLICATION REQUIRED.—The Secretary may

13 provide funding under subsection (a) only if an application

14 or proposal for funding is submitted to the Secretary.

15 ‘‘(c) COORDINATION WITH HEALTH AGENCIES.—In16 dian Tribes and Tribal Organizations receiving funding

17 under this section are encouraged to coordinate their ac18 tivities with the Centers for Disease Control and Preven19 tion and State and local health agencies.

20 ‘‘(d) TECHNICAL ASSISTANCE; REPORT.—In carrying

21 out this section, the Secretary—

22 ‘‘(1) may, at the request of an Indian Tribe or

23 Tribal Organization, provide technical assistance;

24 and
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1 ‘‘(2) shall prepare and submit a report to Con2 gress biennially on the use of funds under this sec3 tion and on the progress made toward the preven4 tion, control, and elimination of communicable and

5 infectious diseases among Indians and Urban Indi6 ans.

7 ‘‘SEC. 213. AUTHORITY FOR PROVISION OF OTHER SERV8 ICES.

9 ‘‘(a) FUNDING AUTHORIZED.—The Secretary, acting

10 through the Service, Indian Tribes, and Tribal Organiza11 tions, may provide funding under this Act to meet the ob12 jectives set forth in section 3 through health care-related

13 services and programs not otherwise described in this Act,

14 which shall include, but not be limited to—

15 ‘‘(1) hospice care and assisted living;

16 ‘‘(2) long-term health care;

17 ‘‘(3) home- and community-based services;

18 ‘‘(4) public health functions; and

19 ‘‘(5) Traditional Health Care Practices.

20 ‘‘(b) SERVICES TO OTHERWISE INELIGIBLE PER21 SONS.—At the discretion of the Service, Indian Tribes, or

22 Tribal Organizations, services provided for hospice care,

23 home health care, home- and community-based care, as24 sisted living, and long-term care may be provided (subject

25 to reimbursement of reasonable charges) to persons other-
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1 wise ineligible for the health care benefits of the Service.

2 Any funds received under this subsection shall not be used

3 to offset or limit the funding allocated to an Indian Tribe

4 or Tribal Organization.

5 ‘‘(c) DEFINITIONS.—For the purposes of this section,

6 the following definitions shall apply:

7 ‘‘(1) The term ‘home- and community-based

8 services’ means 1 or more of the following:

9 ‘‘(A) Homemaker/home health aide serv10 ices.

11 ‘‘(B) Chore services.

12 ‘‘(C) Personal care services.

13 ‘‘(D) Nursing care services provided out14 side of a nursing facility by, or under the super15 vision of, a registered nurse.

16 ‘‘(E) Respite care.

17 ‘‘(F) Training for family members.

18 ‘‘(G) Adult day care.

19 ‘‘(H) Such other home- and community20 based services as the Secretary, an Indian

21 Tribe, or Tribal Organization may approve.

22 ‘‘(2) The term ‘hospice care’ means the items

23 and services specified in subparagraphs (A) through

24 (H) of section 1861(dd)(1) of the Social Security

25 Act (42 U.S.C. 1395x(dd)(1)), and such other serv-
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1 ices which an Indian Tribe or Tribal Organization

2 determines are necessary and appropriate to provide

3 in furtherance of this care.

4 ‘‘(3) The term ‘public health functions’ means

5 the provision of public health-related programs,

6 functions, and services including, but not limited to,

7 assessment, assurance, and policy development which

8 Indian Tribes and Tribal Organizations are author9 ized and encouraged, in those circumstances where

10 it meets their needs, to do by forming collaborative

11 relationships with all levels of local, State, and Fed12 eral Government.

13 ‘‘SEC. 214. INDIAN WOMEN’S HEALTH CARE.

14 ‘‘The Secretary, acting through the Service and In15 dian Tribes, Tribal Organizations, and Urban Indian Or16 ganizations, shall provide funding to monitor and improve

17 the quality of health care for Indian women of all ages

18 through the planning and delivery of programs adminis19 tered by the Service, in order to improve and enhance the

20 treatment models of care for Indian women.

21 ‘‘SEC. 215. ENVIRONMENTAL AND NUCLEAR HEALTH HAZ22 ARDS.

23 ‘‘(a) STUDIES AND MONITORING.—The Secretary

24 and the Service shall conduct, in conjunction with other

25 appropriate Federal agencies and in consultation with con-
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1 cerned Indian Tribes and Tribal Organizations, studies

2 and ongoing monitoring programs to determine trends in

3 the health hazards to Indian miners and to Indians on

4 or near reservations and Indian communities as a result

5 of environmental hazards which may result in chronic or

6 life threatening health problems, such as nuclear resource

7 development, petroleum contamination, and contamination

8 of water source and of the food chain. Such studies shall

9 include—

10 ‘‘(1) an evaluation of the nature and extent of

11 health problems caused by environmental hazards

12 currently exhibited among Indians and the causes of

13 such health problems;

14 ‘‘(2) an analysis of the potential effect of ongo15 ing and future environmental resource development

16 on or near reservations and Indian communities, in17 cluding the cumulative effect over time on health;

18 ‘‘(3) an evaluation of the types and nature of

19 activities, practices, and conditions causing or affect20 ing such health problems including, but not limited

21 to, uranium mining and milling, uranium mine tail22 ing deposits, nuclear power plant operation and con23 struction, and nuclear waste disposal; oil and gas

24 production or transportation on or near reservations

25 or Indian communities; and other development that
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1 could affect the health of Indians and their water

2 supply and food chain;

3 ‘‘(4) a summary of any findings and rec4 ommendations provided in Federal and State stud5 ies, reports, investigations, and inspections during

6 the 5 years prior to the date of the enactment of the

7 Indian Health Care Improvement Act Amendments

8 of 2003 that directly or indirectly relate to the ac9 tivities, practices, and conditions affecting the health

10 or safety of such Indians; and

11 ‘‘(5) the efforts that have been made by Federal

12 and State agencies and resource and economic devel13 opment companies to effectively carry out an edu14 cation program for such Indians regarding the

15 health and safety hazards of such development.

16 ‘‘(b) HEALTH CARE PLANS.—Upon completion of

17 such studies, the Secretary and the Service shall take into

18 account the results of such studies and, in consultation

19 with Indian Tribes and Tribal Organizations, develop

20 health care plans to address the health problems studied

21 under subsection (a). The plans shall include—

22 ‘‘(1) methods for diagnosing and treating Indi23 ans currently exhibiting such health problems;

24 ‘‘(2) preventive care and testing for Indians

25 who may be exposed to such health hazards, includ-
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1 ing the monitoring of the health of individuals who

2 have or may have been exposed to excessive amounts

3 of radiation or affected by other activities that have

4 had or could have a serious impact upon the health

5 of such individuals; and

6 ‘‘(3) a program of education for Indians who,

7 by reason of their work or geographic proximity to

8 such nuclear or other development activities, may ex9 perience health problems.

10 ‘‘(c) SUBMISSION OF REPORT AND PLAN TO CON11 GRESS.—The Secretary and the Service shall submit to

12 Congress the study prepared under subsection (a) no later

13 than 18 months after the date of the enactment of the

14 Indian Health Care Improvement Act Amendments of

15 2003. The health care plan prepared under subsection (b)

16 shall be submitted in a report no later than 1 year after

17 the study prepared under subsection (a) is submitted to

18 Congress. Such report shall include recommended activi19 ties for the implementation of the plan, as well as an eval20 uation of any activities previously undertaken by the Serv21 ice to address such health problems.

22 ‘‘(d) INTERGOVERNMENTAL TASK FORCE.—

23 ‘‘(1) ESTABLISHMENT; MEMBERS.—There is es24 tablished an Intergovernmental Task Force to be
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1 composed of the following individuals (or their des2 ignees):

3 ‘‘(A) The Secretary of Energy.

4 ‘‘(B) The Secretary of the Environmental

5 Protection Agency.

6 ‘‘(C) The Director of the Bureau of Mines.

7 ‘‘(D) The Assistant Secretary for Occupa8 tional Safety and Health.

9 ‘‘(E) The Secretary of the Interior.

10 ‘‘(F) The Secretary of Health and Human

11 Services.

12 ‘‘(G) The Director of the Indian Health

13 Service.

14 ‘‘(2) DUTIES.—The Task Force shall—

15 ‘‘(A) identify existing and potential oper16 ations related to nuclear resource development

17 or other environmental hazards that affect or

18 may affect the health of Indians on or near a

19 reservation or in an Indian community; and

20 ‘‘(B) enter into activities to correct exist21 ing health hazards and ensure that current and

22 future health problems resulting from nuclear

23 resource or other development activities are

24 minimized or reduced.
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1 ‘‘(3) CHAIRMAN; MEETINGS.—The Secretary of

2 Health and Human Services shall be the Chairman

3 of the Task Force. The Task Force shall meet at

4 least twice each year.

5 ‘‘(e) HEALTH SERVICES TO CERTAIN EMPLOYEES.—

6 In the case of any Indian who—

7 ‘‘(1) as a result of employment in or near a

8 uranium mine or mill or near any other environ9 mental hazard, suffers from a work-related illness or

10 condition;

11 ‘‘(2) is eligible to receive diagnosis and treat12 ment services from an Indian Health Program; and

13 ‘‘(3) by reason of such Indian’s employment, is

14 entitled to medical care at the expense of such mine

15 or mill operator or entity responsible for the environ16 mental hazard, the Indian Health Program shall, at

17 the request of such Indian, render appropriate medi18 cal care to such Indian for such illness or condition

19 and may be reimbursed for any medical care so ren20 dered to which such Indian is entitled at the expense

21 of such operator or entity from such operator or en22 tity. Nothing in this subsection shall affect the

23 rights of such Indian to recover damages other than

24 such amounts paid to the Indian Health Program
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1 from the employer for providing medical care for

2 such illness or condition.

3 ‘‘SEC. 216. ARIZONA AS A CONTRACT HEALTH SERVICE DE4 LIVERY AREA.

5 ‘‘(a) IN GENERAL.—For fiscal years beginning with

6 the fiscal year ending September 30, 1983, and ending

7 with the fiscal year ending September 30, 2015, the State

8 of Arizona shall be designated as a contract health service

9 delivery area by the Service for the purpose of providing

10 contract health care services to members of federally rec11 ognized Indian Tribes of Arizona.

12 ‘‘(b) MAINTENANCE OF SERVICES.—The Service

13 shall not curtail any health care services provided to Indi14 ans residing on reservations in the State of Arizona if such

15 curtailment is due to the provision of contract services in

16 such State pursuant to the designation of such State as

17 a contract health service delivery area pursuant to sub18 section (a).

19 ‘‘SEC. 216A. NORTH DAKOTA AS A CONTRACT HEALTH

20 SERVICE DELIVERY AREA.

21 ‘‘(a) IN GENERAL.—For fiscal years beginning with

22 the fiscal year ending September 30, 2003, and ending

23 with the fiscal year ending September 30, 2015, the State

24 of North Dakota shall be designated as a contract health

25 service delivery area by the Service for the purpose of pro-
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1 viding contract health care services to members of feder2 ally recognized Indian Tribes of North Dakota.

3 ‘‘(b) LIMITATION.—The Service shall not curtail any

4 health care services provided to Indians residing on res5 ervations in the State of North Dakota if such curtailment

6 is due to the provision of contract services in such State

7 pursuant to the designation of such State as a contract

8 health service delivery area pursuant to subsection (a).

9 ‘‘SEC. 216B. SOUTH DAKOTA AS A CONTRACT HEALTH SERV10 ICE DELIVERY AREA.

11 ‘‘(a) IN GENERAL.—For fiscal years beginning with

12 the fiscal year ending September 30, 2003, and ending

13 with the fiscal year ending on September 30, 2015, the

14 State of South Dakota shall be designated as a contract

15 health service delivery area by the Service for the purpose

16 of providing contract health care services to members of

17 federally recognized Indian Tribes of South Dakota.

18 ‘‘(b) LIMITATION.—The Service shall not curtail any

19 health care services provided to Indians residing on res20 ervations in the State of South Dakota if such curtailment

21 is due to the provision of contract services in such State

22 pursuant to the designation of such State as a contract

23 health service delivery area pursuant to subsection (a).
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1 ‘‘SEC. 217. CALIFORNIA CONTRACT HEALTH SERVICES PRO2 GRAM.

3 ‘‘(a) FUNDING AUTHORIZED.—The Secretary is au4 thorized to fund a program using the California Rural In5 dian Health Board (hereafter in this section referred to

6 as the ‘CRIHB’) as a contract care intermediary to im7 prove the accessibility of health services to California Indi8 ans.

9 ‘‘(b) REIMBURSEMENT CONTRACT.—The Secretary

10 shall enter into an agreement with the CRIHB to reim11 burse the CRIHB for costs (including reasonable adminis12 trative costs) incurred pursuant to this section, in provid13 ing medical treatment under contract to California Indi14 ans described in section 806(a) throughout the California

15 contract health services delivery area described in section

16 218 with respect to high cost contract care cases.

17 ‘‘(c) ADMINISTRATIVE EXPENSES.—Not more than 5

18 percent of the amounts provided to the CRIHB under this

19 section for any fiscal year may be for reimbursement for

20 administrative expenses incurred by the CRIHB during

21 such fiscal year.

22 ‘‘(d) LIMITATION ON PAYMENT.—No payment may

23 be made for treatment provided hereunder to the extent

24 payment may be made for such treatment under the In25 dian Catastrophic Health Emergency Fund described in

26 section 202 or from amounts appropriated or otherwise
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1 made available to the California contract health service de2 livery area for a fiscal year.

3 ‘‘(e) ADVISORY BOARD.—There is hereby established

4 an advisory board which shall advise the CRIHB in carry5 ing out this section. The advisory board shall be composed

6 of representatives, selected by the CRIHB, from not less

7 than 8 Tribal Health Programs serving California Indians

8 covered under this section at least one half of whom of

9 whom are not affiliated with the CRIHB.

10 ‘‘SEC. 218. CALIFORNIA AS A CONTRACT HEALTH SERVICE

11 DELIVERY AREA.

12 ‘‘The State of California, excluding the counties of

13 Alameda, Contra Costa, Los Angeles, Marin, Orange, Sac14 ramento, San Francisco, San Mateo, Santa Clara, Kern,

15 Merced, Monterey, Napa, San Benito, San Joaquin, San

16 Luis Obispo, Santa Cruz, Solano, Stanislaus, and Ven17 tura, shall be designated as a contract health service deliv18 ery area by the Service for the purpose of providing con19 tract health services to California Indians. However, any

20 of the counties listed herein may only be included in the

21 contract health services delivery area if funding is specifi22 cally provided by the Service for such services in those

23 counties.
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1 ‘‘SEC. 219. CONTRACT HEALTH SERVICES FOR THE TREN2 TON SERVICE AREA.

3 ‘‘(a) AUTHORIZATION FOR SERVICES.—The Sec4 retary, acting through the Service, is directed to provide

5 contract health services to members of the Turtle Moun6 tain Band of Chippewa Indians that reside in the Trenton

7 Service Area of Divide, McKenzie, and Williams counties

8 in the State of North Dakota and the adjoining counties

9 of Richland, Roosevelt, and Sheridan in the State of Mon10 tana.

11 ‘‘(b) NO EXPANSION OF ELIGIBILITY.—Nothing in

12 this section may be construed as expanding the eligibility

13 of members of the Turtle Mountain Band of Chippewa In14 dians for health services provided by the Service beyond

15 the scope of eligibility for such health services that applied

16 on May 1, 1986.

17 ‘‘SEC. 220. PROGRAMS OPERATED BY INDIAN TRIBES AND

18 TRIBAL ORGANIZATIONS.

19 ‘‘The Service shall provide funds for health care pro20 grams and facilities operated by Tribal Health Programs

21 on the same basis as such funds are provided to programs

22 and facilities operated directly by the Service.

23 ‘‘SEC. 221. LICENSING.

24 ‘‘Health care professionals employed by a Tribal

25 Health Program shall, if licensed in any State, be exempt

26 from the licensing requirements of the State in which the
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1 Tribal Health Program performs the services described in

2 its Funding Agreement.

3 ‘‘SEC. 222. NOTIFICATION OF PROVISION OF EMERGENCY

4 CONTRACT HEALTH SERVICES.

5 ‘‘With respect to an elderly Indian or an Indian with

6 a disability receiving emergency medical care or services

7 from a non-Service provider or in a non-Service facility

8 under the authority of this Act, the time limitation (as

9 a condition of payment) for notifying the Service of such

10 treatment or admission shall be 30 days.

11 ‘‘SEC. 223. PROMPT ACTION ON PAYMENT OF CLAIMS.

12 ‘‘(a) DEADLINE FOR RESPONSE.—The Service shall

13 respond to a notification of a claim by a provider of a

14 contract care service with either an individual purchase

15 order or a denial of the claim within 5 working days after

16 the receipt of such notification.

17 ‘‘(b) EFFECT OF UNTIMELY RESPONSE.—If the

18 Service fails to respond to a notification of a claim in ac19 cordance with subsection (a), the Service shall accept as

20 valid the claim submitted by the provider of a contract

21 care service.

22 ‘‘(c) DEADLINE FOR PAYMENT OF VALID CLAIM.—

23 The Service shall pay a valid contract care service claim

24 within 30 days after the completion of the claim.
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1 ‘‘SEC. 224. LIABILITY FOR PAYMENT.

2 ‘‘(a) NO PATIENT LIABILITY.—A patient who re3 ceives contract health care services that are authorized by

4 the Service shall not be liable for the payment of any

5 charges or costs associated with the provision of such serv6 ices.

7 ‘‘(b) NOTIFICATION.—The Secretary shall notify a

8 contract care provider and any patient who receives con9 tract health care services authorized by the Service that

10 such patient is not liable for the payment of any charges

11 or costs associated with the provision of such services not

12 later than 5 business days after receipt of a notification

13 of a claim by a provider of contract care services.

14 ‘‘(c) NO RECOURSE.—Following receipt of the notice

15 provided under subsection (b), or, if a claim has been

16 deemed accepted under section 223(b), the provider shall

17 have no further recourse against the patient who received

18 the services.

19 ‘‘SEC. 225. AUTHORIZATION OF APPROPRIATIONS.

20 ‘‘There are authorized to be appropriated such sums

21 as may be necessary for each fiscal year through fiscal

22 year 2015 to carry out this title.
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1 ‘‘TITLE III—FACILITIES

2 ‘‘SEC. 301. CONSULTATION; CONSTRUCTION AND RENOVA3 TION OF FACILITIES; REPORTS.

4 ‘‘(a) PREREQUISITES FOR EXPENDITURE OF

5 FUNDS.—Prior to the expenditure of, or the making of

6 any binding commitment to expend, any funds appro7 priated for the planning, design, construction, or renova8 tion of facilities pursuant to the Act of November 2, 1921

9 (25 U.S.C. 13; popularly known as the Snyder Act), the

10 Secretary, acting through the Service, shall—

11 ‘‘(1) consult with any Indian Tribe that would

12 be significantly affected by such expenditure for the

13 purpose of determining and, whenever practicable,

14 honoring tribal preferences concerning size, location,

15 type, and other characteristics of any facility on

16 which such expenditure is to be made; and

17 ‘‘(2) ensure, whenever practicable and applica18 ble, that such facility meets the construction stand19 ards of any accrediting body recognized by the Sec20 retary for the purposes of the medicare, medicaid,

21 and SCHIP programs under title XVIII, XIX, and

22 XXI of the Social Security Act by not later than 1

23 year after the date on which the construction or ren24 ovation of such facility is completed.

25 ‘‘(b) CLOSURES.—
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1 ‘‘(1) EVALUATION REQUIRED.—Notwithstand2 ing any other provision of law, no facility operated

3 by the Service may be closed if the Secretary has not

4 submitted to Congress at least 1 year prior to the

5 date of the proposed closure an evaluation of the im6 pact of the proposed closure which specifies, in addi7 tion to other considerations the following:

8 ‘‘(A) The accessibility of alternative health

9 care resources for the population served by such

10 facility.

11 ‘‘(B) The cost-effectiveness of such closure.

12 ‘‘(C) The quality of health care to be pro13 vided to the population served by such facility

14 after such closure.

15 ‘‘(D) The availability of contract health

16 care funds to maintain existing levels of service.

17 ‘‘(E) The views of the Indian Tribes served

18 by such facility concerning such closure.

19 ‘‘(F) The level of use of such facility by all

20 eligible Indians.

21 ‘‘(G) The distance between such facility

22 and the nearest operating Service hospital.

23 ‘‘(2) EXCEPTION FOR CERTAIN TEMPORARY

24 CLOSURES.—Paragraph (1) shall not apply to any

25 temporary closure of a facility or any portion of a
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1 facility if such closure is necessary for medical, envi2 ronmental, or construction safety reasons.

3 ‘‘(c) HEALTH CARE FACILITY PRIORITY SYSTEM.—

4 ‘‘(1) IN GENERAL.—

5 ‘‘(A) ESTABLISHMENT.—The Secretary,

6 acting through the Service, shall establish a

7 health care facility priority system, which

8 shall—

9 ‘‘(i) be developed with Indian Tribes

10 and Tribal Organizations through nego11 tiated rulemaking under section 802;

12 ‘‘(ii) give Indian Tribes’ needs the

13 highest priority; and

14 ‘‘(iii) at a minimum, include the lists

15 required in paragraph (2)(B) and the

16 methodology required in paragraph (2)(E).

17 ‘‘(B) PRIORITY OF CERTAIN PROJECTS

18 PROTECTED.—The priority of any project estab19 lished under the construction priority system in

20 effect on the date of the Indian Health Care

21 Improvement Act Amendments of 2003 shall

22 not be affected by any change in the construc23 tion priority system taking place thereafter if

24 the project was identified as 1 of the 10 top25 priority inpatient projects, 1 of the 10 top-pri-
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1 ority outpatient projects, 1 of the 10 top-prior2 ity staff quarters developments, or 1 of the 10

3 top-priority Youth Regional Treatment Centers

4 in the fiscal year 2004 Indian Health Service

5 budget justification, or if the project had com6 pleted both Phase I and Phase II of the con7 struction priority system in effect on the date

8 of the enactment of such Act.

9 ‘‘(2) REPORT; CONTENTS.—The Secretary shall

10 submit to the President, for inclusion in each report

11 required to be transmitted to Congress under section

12 801, a report which sets forth the following:

13 ‘‘(A) A description of the health care facil14 ity priority system of the Service, established

15 under paragraph (1).

16 ‘‘(B) Health care facilities lists, including

17 but not limited to—

18 ‘‘(i) the total health care facilities

19 planning, design, construction, and renova20 tion needs for Indians, identified by na21 tional and Service Area priorities;

22 ‘‘(ii) the 10 top-priority inpatient

23 health care facilities;

24 ‘‘(iii) the 10 top-priority outpatient

25 health care facilities;
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1 ‘‘(iv) the 10 top-priority specialized

2 health care facilities (such as long-term

3 care and alcohol and drug abuse treat4 ment);

5 ‘‘(v) the 10 top-priority staff quarters

6 developments associated with health care

7 facilities; and

8 ‘‘(vi) the 10 top-priority hostels asso9 ciated with health care facilities.

10 ‘‘(C) The justification for such order of

11 priority.

12 ‘‘(D) The projected cost of such projects.

13 ‘‘(E) The methodology adopted by the

14 Service in establishing priorities under its

15 health care facility priority system.

16 ‘‘(3) REQUIREMENTS FOR PREPARATION OF RE17 PORTS.—In preparing each report required under

18 paragraph (2) (other than the initial report), the

19 Secretary shall annually—

20 ‘‘(A) consult with and obtain information

21 on all health care facilities needs from Indian

22 Tribes, Tribal Organizations, and Urban Indian

23 Organizations; and

24 ‘‘(B) review the total unmet needs of all

25 Indian Tribes and Tribal Organizations for
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1 health care facilities (including hostels and staff

2 quarters), including needs for renovation and

3 expansion of existing facilities.

4 ‘‘(4) CRITERIA FOR EVALUATING NEEDS.—For

5 purposes of this subsection, the Secretary shall, in

6 evaluating the needs of facilities operated under any

7 Funding Agreement use the same criteria that the

8 Secretary uses in evaluating the needs of facilities

9 operated directly by the Service.

10 ‘‘(5) NEEDS OF FACILITIES UNDER ISDEAA

11 AGREEMENTS.—The Secretary shall ensure that the

12 planning, design, construction, and renovation needs

13 of Service and non-Service facilities operated under

14 funding agreements in accordance with the Indian

15 Self-Determination and Education Assistance Act

16 are fully and equitably integrated into the health

17 care facility priority system.

18 ‘‘(d) REVIEW OF NEED FOR FACILITIES.—

19 ‘‘(1) INITIAL REPORT.—In the year 2005, the

20 General Accounting Office shall prepare and finalize

21 a report which sets forth the needs of the Service,

22 Indian Tribes, Tribal Organizations, and Urban In23 dian Organizations, for the facilities listed under

24 subsection (c)(2)(B), including the needs for renova25 tion and expansion of existing facilities. The General
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1 Accounting Office shall submit the report to the ap2 propriate authorizing and appropriations committees

3 of the Congress and to the Secretary.

4 ‘‘(2) Beginning in the year 2006, the Secretary

5 shall annually update the report required under

6 paragraph (1).

7 ‘‘(3) The Comptroller General and the Sec8 retary shall consult with Indian Tribes, Tribal Orga9 nizations, and Urban Indian Organizations. In pre10 paring the reports required by paragraphs (1) and

11 (2), the Secretary shall submit the report to the

12 President for inclusion in the report required to be

13 transmitted to the Congress under section 801.

14 ‘‘(4) For purposes of this subsection, the re15 ports shall, regarding the needs of facilities operated

16 under any Funding Agreement be based on the same

17 criteria that the Secretary uses in evaluating the

18 needs of facilities operated directly by the Service.

19 ‘‘(5) The planning, design, construction, and

20 renovation needs of facilities operated under Fund21 ing Agreements shall be fully and equitably inte22 grated into the development of the health facility

23 priority system.

24 ‘‘(6) Beginning in the year 2006 and each fiscal

25 year thereafter, the Secretary shall provide an op-
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1 portunity for nomination of planning, design, and

2 construction projects by the Service, Indian Tribes,

3 and Tribal Organizations for consideration under

4 the health care facility priority system.

5 ‘‘(e) FUNDING CONDITION.—All funds appropriated

6 under the Act of November 2, 1921 (25 U.S.C. 13), for

7 the planning, design, construction, or renovation of health

8 facilities for the benefit of 1 or more Indian Tribes shall

9 be subject to the provisions of the Indian Self-Determina10 tion and Education Assistance Act.

11 ‘‘(f) DEVELOPMENT OF INNOVATIVE APPROACHES.—

12 The Secretary shall consult and cooperate with Indian

13 Tribes, Tribal Organizations, and Urban Indian Organiza14 tions in developing innovative approaches to address all

15 or part of the total unmet need for construction of health

16 facilities, including those provided for in other sections of

17 this title and other approaches.

18 ‘‘SEC. 302. SANITATION FACILITIES.

19 ‘‘(a) FINDINGS.—Congress finds the following:

20 ‘‘(1) The provision of sanitation facilities is pri21 marily a health consideration and function.

22 ‘‘(2) Indian people suffer an inordinately high

23 incidence of disease, injury, and illness directly at24 tributable to the absence or inadequacy of sanitation

25 facilities.
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1 ‘‘(3) The long-term cost to the United States of

2 treating and curing such disease, injury, and illness

3 is substantially greater than the short-term cost of

4 providing sanitation facilities and other preventive

5 health measures.

6 ‘‘(4) Many Indian homes and Indian commu7 nities still lack sanitation facilities.

8 ‘‘(5) It is in the interest of the United States,

9 and it is the policy of the United States, that all In10 dian communities and Indian homes, new and exist11 ing, be provided with sanitation facilities.

12 ‘‘(b) FACILITIES AND SERVICES.—In furtherance of

13 the findings made in subsection (a), Congress reaffirms

14 the primary responsibility and authority of the Service to

15 provide the necessary sanitation facilities and services as

16 provided in section 7 of the Act of August 5, 1954 (42

17 U.S.C. 2004a). Under such authority, the Secretary, act18 ing through the Service, shall provide the following:

19 ‘‘(1) Financial and technical assistance to In20 dian Tribes, Tribal Organizations, and Indian com21 munities in the establishment, training, and equip22 ping of utility organizations to operate and maintain

23 sanitation facilities, including the provision of exist24 ing plans, standard details, and specifications avail25 able in the Department, to be used at the option of
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1 the Indian Tribe, Tribal Organization, or Indian

2 community.

3 ‘‘(2) Ongoing technical assistance and training

4 to Indian Tribes, Tribal Organizations, and Indian

5 communities in the management of utility organiza6 tions which operate and maintain sanitation facili7 ties.

8 ‘‘(3) Priority funding for operation and mainte9 nance assistance for, and emergency repairs to, sani10 tation facilities operated by an Indian Tribe, Tribal

11 Organization or Indian community when necessary

12 to avoid an imminent health threat or to protect the

13 investment in sanitation facilities and the investment

14 in the health benefits gained through the provision

15 of sanitation facilities.

16 ‘‘(c) FUNDING.—Notwithstanding any other provi17 sion of law—

18 ‘‘(1) the Secretary of Housing and Urban De19 velopment is authorized to transfer funds appro20 priated under the Native American Housing Assist21 ance and Self-Determination Act of 1996 to the Sec22 retary of Health and Human Services;

23 ‘‘(2) the Secretary of Health and Human Serv24 ices is authorized to accept and use such funds for

25 the purpose of providing sanitation facilities and
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1 services for Indians under section 7 of the Act of

2 August 5, 1954 (42 U.S.C. 2004a);

3 ‘‘(3) unless specifically authorized otherwise

4 when funds are appropriated, the Secretary of

5 Health and Human Services shall use funds appro6 priated under section 7 of the Act of August 5, 1954

7 (42 U.S.C. 2004a), to provide additional priority of

8 sanitation facilities assistance to eligible new and ex9 isting Indian homes other than the following—

10 ‘‘(A) new homes constructed using housing

11 funds provided by the Department of Housing

12 and Urban Development; and

13 ‘‘(B) existing homes owned or managed by

14 a tribally designated housing entity (as that

15 term is defined in section 4(21) of the Native

16 American Housing Assistance and Self-Deter17 mination Act of 1996 (25 U.S.C. 4103(21))

18 that were constructed using housing funds pro19 vided by the Department of Housing and Urban

20 Development;

21 ‘‘(4) the Secretary of Health and Human Serv22 ices is authorized to accept from any source, includ23 ing Federal and State agencies, funds for the pur24 pose of providing sanitation facilities and services

25 and place these funds into Funding Agreements;
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1 ‘‘(5) funds appropriated under the authority of

2 section 7 of the Act of August 5, 1954 (42 U.S.C.

3 2004a) may be used to fund up to 100 percent of

4 the amount of an Indian Tribe’s loan obtained under

5 any Federal program for new projects to construct

6 eligible sanitation facilities to serve Indian homes;

7 ‘‘(6) funds appropriated under the authority of

8 section 7 of the Act of August 5, 1954 (42 U.S.C.

9 2004a) may be used to meet matching or cost par10 ticipation requirements under other Federal and

11 non-Federal programs for new projects to construct

12 eligible sanitation facilities;

13 ‘‘(7) all Federal agencies are authorized to

14 transfer to the Secretary funds identified, granted,

15 loaned, or appropriated whereby the Department’s

16 applicable policies, rules, and regulations shall apply

17 in the implementation of such projects;

18 ‘‘(8) the Secretary of Health and Human Serv19 ices shall enter into interagency agreements with

20 Federal and State agencies for the purpose of pro21 viding financial assistance for sanitation facilities

22 and services under this Act; and

23 ‘‘(9) the Secretary of Health and Human Serv24 ices shall, by regulation developed through rule25 making under section 802, establish standards appli-
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1 cable to the planning, design, and construction of

2 sanitation facilities funded under this Act.

3 ‘‘(d) FUNDING PLAN.—The Secretary, acting

4 through the Service, and in consultation with Indian

5 Tribes and Tribal Organizations, shall develop and begin

6 implementation of a 10-year funding plan to provide sani7 tation facilities to serve existing Indian homes and Indian

8 communities and new and renovated Indian homes.

9 ‘‘(e) CERTAIN CAPABILITIES NOT PREREQUISITE.—

10 The financial and technical capability of an Indian Tribe,

11 Tribal Organization, or Indian community to safely oper12 ate, manage, and maintain a sanitation facility shall not

13 be a prerequisite to the provision or construction of sanita14 tion facilities by the Secretary.

15 ‘‘(f) FINANCIAL ASSISTANCE.—The Secretary is au16 thorized to provide financial assistance to Indian Tribes,

17 Tribal Organizations, and Indian communities for oper18 ation, management, and maintenance of their sanitation

19 facilities.

20 ‘‘(g) OPERATION, MANAGEMENT, AND MAINTENANCE

21 OF FACILITIES.—The Indian Tribe, Tribal Organization,

22 Indian family, or Indian community has the primary re23 sponsibility to establish, collect, and use reasonable user

24 fees, or otherwise set aside funding, for the purpose of

25 operating, managing, and maintaining sanitation facilities.
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1 If a sanitation facility serving a community that is oper2 ated by an Indian Tribe, Tribal Organization, or Indian

3 community is threatened with imminent failure and such

4 operator lacks capacity to maintain the integrity or the

5 health benefits of the sanitation facility, then the Sec6 retary is authorized to assist the Indian Tribe, Tribal Or7 ganization, or Indian community in the resolution of the

8 problem on a short-term basis through cooperation with

9 the emergency coordinator or by providing operation, man10 agement, and maintenance service.

11 ‘‘(h) ISDEAA PROGRAM FUNDED ON EQUAL

12 BASIS.—Tribal Health Programs shall be eligible (on an

13 equal basis with programs that are administered directly

14 by the Service) for—

15 ‘‘(1) any funds appropriated pursuant to this

16 section; and

17 ‘‘(2) any funds appropriated for the purpose of

18 providing sanitation facilities.

19 ‘‘(i) REPORT.—

20 ‘‘(1) REQUIRED; CONTENTS.—The Secretary

21 shall submit to the President, for inclusion in each

22 report required to be transmitted to Congress under

23 section 801, a report which sets forth—

24 ‘‘(A) the current Indian sanitation facility

25 priority system of the Service;
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1 ‘‘(B) the methodology for determining

2 sanitation deficiencies;

3 ‘‘(C) the level of initial and final sanitation

4 deficiency for each type of sanitation facility for

5 each project of each Indian Tribe or Indian

6 community; and

7 ‘‘(D) the amount of funds necessary to re8 duce the identified sanitation deficiency levels of

9 all Indian Tribes and Indian communities to

10 level I sanitation deficiency as defined in para11 graph (4)(A).

12 ‘‘(2) CONSULTATION.—In preparing each report

13 required under paragraph (1), the Secretary shall

14 consult with Indian Tribes and Tribal Organizations

15 to determine the sanitation facility needs of each In16 dian Tribe. The criteria on which the needs will be

17 evaluated shall be developed through negotiated rule18 making pursuant to section 802.

19 ‘‘(3) UNIFORM METHODOLOGY.—The methodol20 ogy used by the Secretary in determining, preparing

21 cost estimates for, and reporting sanitation defi22 ciencies for purposes of paragraph (1) shall be ap23 plied uniformly to all Indian Tribes and Indian com24 munities.
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1 ‘‘(4) SANITATION DEFICIENCY LEVELS.—For

2 purposes of this subsection, the sanitation deficiency

3 levels for an individual, Indian Tribe or Indian com4 munity sanitation facility to serve Indian homes are

5 determined as follows:

6 ‘‘(A) A level I deficiency exists if a sanita7 tion facility serving an individual, Indian Tribe,

8 or Indian community—

9 ‘‘(i) complies with all applicable water

10 supply, pollution control, and solid waste

11 disposal laws; and

12 ‘‘(ii) deficiencies relate to routine re13 placement, repair, or maintenance needs.

14 ‘‘(B) A level II deficiency exists if a sanita15 tion facility serving an individual, Indian Tribe,

16 or Indian community substantially or recently

17 complied with all applicable water supply, pollu18 tion control, and solid waste laws and any defi19 ciencies relate to—

20 ‘‘(i) small or minor capital improve21 ments needed to bring the facility back

22 into compliance;

23 ‘‘(ii) capital improvements that are

24 necessary to enlarge or improve the facili-
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1 ties in order to meet the current needs for

2 domestic sanitation facilities; or

3 ‘‘(iii) the lack of equipment or train4 ing by an Indian Tribe, Tribal Organiza5 tion, or an Indian community to properly

6 operate and maintain the sanitation facili7 ties.

8 ‘‘(C) A level III deficiency exists if a sani9 tation facility serving an individual, Indian

10 Tribe or Indian community meets one or more

11 of the following conditions—

12 ‘‘(i) water or sewer service in the

13 home is provided by a haul system with

14 holding tanks and interior plumbing;

15 ‘‘(ii) major significant interruptions to

16 water supply or sewage disposal occur fre17 quently, requiring major capital improve18 ments to correct the deficiencies; or

19 ‘‘(iii) there is no access to or no ap20 proved or permitted solid waste facility

21 available.

22 ‘‘(D) A level IV deficiency exists if—

23 ‘‘(i) a sanitation facility of an individ24 ual, Indian Tribe, Tribal Organization, or

25 Indian community has no piped water or
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1 sewer facilities in the home or the facility

2 has become inoperable due to major com3 ponent failure; or

4 ‘‘(ii) where only a washeteria or cen5 tral facility exists in the community.

6 ‘‘(E) A level V deficiency exists in the ab7 sence of a sanitation facility, where individual

8 homes do not have access to safe drinking

9 water or adequate wastewater (including sew10 age) disposal.

11 ‘‘(j) DEFINITIONS.—For purposes of this section, the

12 following terms apply:

13 ‘‘(1) INDIAN COMMUNITY.—The term ‘Indian

14 community’ means a geographic area, a significant

15 proportion of whose inhabitants are Indians and

16 which is served by or capable of being served by a

17 facility described in this section.

18 ‘‘(2) SANITATION FACILITIES.—The terms

19 ‘sanitation facility’ and ‘sanitation facilities’ mean

20 safe and adequate water supply systems, sanitary

21 sewage disposal systems, and sanitary solid waste

22 systems (and all related equipment and support in23 frastructure).
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1 ‘‘SEC. 303. PREFERENCE TO INDIANS AND INDIAN FIRMS.

2 ‘‘(a) BUY INDIAN ACT.—The Secretary, acting

3 through the Service, may use the negotiating authority of

4 section 23 of the Act of June 25, 1910 (25 U.S.C. 47,

5 commonly known as the ‘Buy Indian Act’), to give pref6 erence to any Indian or any enterprise, partnership, cor7 poration, or other type of business organization owned and

8 controlled by an Indian or Indians including former or

9 currently federally recognized Indian Tribes in the State

10 of New York (hereinafter referred to as an ‘Indian firm’)

11 in the construction and renovation of Service facilities pur12 suant to section 301 and in the construction of sanitation

13 facilities pursuant to section 302. Such preference may be

14 accorded by the Secretary unless the Secretary finds, pur15 suant to regulations adopted pursuant to section 802, that

16 the project or function to be contracted for will not be

17 satisfactory or such project or function cannot be properly

18 completed or maintained under the proposed contract. The

19 Secretary, in arriving at such a finding, shall consider

20 whether the Indian or Indian firm will be deficient with

21 respect to—

22 ‘‘(1) ownership and control by Indians;

23 ‘‘(2) equipment;

24 ‘‘(3) bookkeeping and accounting procedures;

25 ‘‘(4) substantive knowledge of the project or

26 function to be contracted for;
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1 ‘‘(5) adequately trained personnel; or

2 ‘‘(6) other necessary components of contract

3 performance.

4 ‘‘(b) LABOR STANDARDS.—

5 ‘‘(1) IN GENERAL.—For the purposes of imple6 menting the provisions of this title, contracts for the

7 construction or renovation of health care facilities,

8 staff quarters, and sanitation facilities, and related

9 support infrastructure, funded in whole or in part

10 with funds made available pursuant to this title,

11 shall contain a provision requiring compliance with

12 the Act of March 3, 1931 (40 U.S.C. 276a—276a–

13 5, known as the Davis-Bacon Act), unless such con14 struction or renovation—

15 ‘‘(A) is performed by a contractor pursu16 ant to a contract with an Indian Tribe or Trib17 al Organization with funds supplied through a

18 contract, compact or funding agreement author19 ized by the Indian Self-Determination and Edu20 cation Assistance Act, or other statutory au21 thority; and

22 ‘‘(B) is subject to prevailing wage rates for

23 similar construction or renovation in the locality

24 as determined by the Indian Tribes or Tribal
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1 Organizations to be served by the construction

2 or renovation.

3 ‘‘(2) EXCEPTION.—This subsection shall not

4 apply to construction or renovation carried out by an

5 Indian Tribe or Tribal Organization with its own

6 employees.

7 ‘‘SEC. 304. EXPENDITURE OF NONSERVICE FUNDS FOR REN8 OVATION.

9 ‘‘(a) IN GENERAL.—Notwithstanding any other pro10 vision of law, if the requirements of subsection (c) are met,

11 the Secretary, acting through the Service, is authorized

12 to accept any major expansion, renovation, or moderniza13 tion by any Indian Tribe or Tribal Organization of any

14 Service facility or of any other Indian health facility oper15 ated pursuant to a Funding Agreement, including—

16 ‘‘(1) any plans or designs for such expansion,

17 renovation, or modernization; and

18 ‘‘(2) any expansion, renovation, or moderniza19 tion for which funds appropriated under any Federal

20 law were lawfully expended.

21 ‘‘(b) PRIORITY LIST.—

22 ‘‘(1) IN GENERAL.—The Secretary shall main23 tain a separate priority list to address the needs for

24 increased operating expenses, personnel, or equip25 ment for such facilities. The methodology for estab-
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1 lishing priorities shall be developed through nego2 tiated rulemaking under section 802. The list of pri3 ority facilities will be revised annually in consulta4 tion with Indian Tribes and Tribal Organizations.

5 ‘‘(2) REPORT.—The Secretary shall submit to

6 the President, for inclusion in each report required

7 to be transmitted to Congress under section 801, the

8 priority list maintained pursuant to paragraph (1).

9 ‘‘(c) REQUIREMENTS.—The requirements of this sub10 section are met with respect to any expansion, renovation,

11 or modernization if—

12 ‘‘(1) the Indian Tribe or Tribal Organization—

13 ‘‘(A) provides notice to the Secretary of its

14 intent to expand, renovate, or modernize; and

15 ‘‘(B) applies to the Secretary to be placed

16 on a separate priority list to address the needs

17 of such new facilities for increased operating ex18 penses, personnel, or equipment; and

19 ‘‘(2) the expansion, renovation, or

20 modernization—

21 ‘‘(A) is approved by the appropriate area

22 director of the Service for Federal facilities; and

23 ‘‘(B) is administered by the Indian Tribe

24 or Tribal Organization in accordance with any

25 applicable regulations prescribed by the Sec-
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1 retary with respect to construction or renova2 tion of Service facilities.

3 ‘‘(d) CLOSURE OR CONVERSION OF FACILITIES.—If

4 any Service facility which has been expanded, renovated,

5 or modernized by an Indian Tribe or Tribal Organization

6 under this section ceases to be used as a Service facility

7 during the 20-year period beginning on the date such ex8 pansion, renovation, or modernization is completed, such

9 Indian Tribe or Tribal Organization shall be entitled to

10 recover from the United States an amount which bears

11 the same ratio to the value of such facility at the time

12 of such cessation as the value of such expansion, renova13 tion, or modernization (less the total amount of any funds

14 provided specifically for such facility under any Federal

15 program that were expended for such expansion, renova16 tion, or modernization) bore to the value of such facility

17 at the time of the completion of such expansion, renova18 tion, or modernization.

19 ‘‘SEC. 305. FUNDING FOR THE CONSTRUCTION, EXPANSION,

20 AND MODERNIZATION OF SMALL AMBULA21 TORY CARE FACILITIES.

22 ‘‘(a) FUNDING.—

23 ‘‘(1) IN GENERAL.—The Secretary, acting

24 through the Service, in consultation with Indian

25 Tribes and Tribal Organizations, shall make funding
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1 available to Indian Tribes and Tribal Organizations

2 for the construction, expansion, or modernization of

3 facilities for the provision of ambulatory care serv4 ices to eligible Indians (and noneligible persons pur5 suant to subsections (b)(2) and (c)(1)(C)). Funding

6 made under this section may cover up to 100 per7 cent of the costs of such construction, expansion, or

8 modernization. For the purposes of this section, the

9 term ‘construction’ includes the replacement of an

10 existing facility.

11 ‘‘(2) FUNDING AGREEMENT REQUIRED.—Fund12 ing under paragraph (1) may only be made available

13 to a Tribal Health Program operating an Indian

14 health facility (other than a facility owned or con15 structed by the Service, including a facility originally

16 owned or constructed by the Service and transferred

17 to an Indian Tribe or Tribal Organization).

18 ‘‘(b) USE OF FUNDS.—

19 ‘‘(1) ALLOWABLE USES.—Funding provided

20 under this section may be used only for debt reduc21 tion or the construction, expansion, or modernization

22 (including the planning and design of such construc23 tion, expansion, or modernization) of an ambulatory

24 care facility—

25 ‘‘(A) located apart from a hospital;
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1 ‘‘(B) not funded under section 301 or sec2 tion 307; and

3 ‘‘(C) which, upon completion of such con4 struction or modernization will—

5 ‘‘(i) have a total capacity appropriate

6 to its projected service population;

7 ‘‘(ii) provide annually no fewer than

8 500 patient visits by eligible Indians and

9 other users who are eligible for services in

10 such facility in accordance with section

11 807(c)(2); and

12 ‘‘(iii) provide ambulatory care in a

13 Service Area (specified in the Funding

14 Agreement) with a population of no fewer

15 than 1,500 eligible Indians and other users

16 who are eligible for services in such facility

17 in accordance with section 807(c)(2).

18 ‘‘(2) USE ONLY FOR CERTAIN PORTION OF

19 COSTS.—Funding provided under this section may

20 be used only for the cost of that portion of a con21 struction, expansion, or modernization project that

22 benefits the Service population identified above in

23 subsection (b)(1)(C)(ii) and (iii). The requirements

24 of clauses (ii) and (iii) of paragraph (1)(C) shall not

25 apply to an Indian Tribe or Tribal Organization ap-
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1 plying for funding under this section whose principal

2 office for health care administration is located on an

3 island or when such office is not located on a road

4 system providing direct access to an inpatient hos5 pital where care is available to the Service popu6 lation.

7 ‘‘(c) FUNDING.—

8 ‘‘(1) APPLICATION.—No funding may be made

9 available under this section unless an application or

10 proposal for such funding has been approved by the

11 Secretary in accordance with applicable regulations

12 and has forth reasonable assurance by the applicant

13 that, at all times after the construction, expansion,

14 or modernization of a facility carried out pursuant

15 to funding received under this section—

16 ‘‘(A) adequate financial support will be

17 available for the provision of services at such

18 facility;

19 ‘‘(B) such facility will be available to eligi20 ble Indians without regard to ability to pay or

21 source of payment; and

22 ‘‘(C) such facility will, as feasible without

23 diminishing the quality or quantity of services

24 provided to eligible Indians, serve noneligible

25 persons on a cost basis.
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1 ‘‘(2) PRIORITY.—In awarding funding under

2 this section, the Secretary shall give priority to In3 dian Tribes and Tribal Organizations that

4 demonstrate—

5 ‘‘(A) a need for increased ambulatory care

6 services; and

7 ‘‘(B) insufficient capacity to deliver such

8 services.

9 ‘‘(3) PEER REVIEW PANELS.—The Secretary

10 may provide for the establishment of peer review

11 panels, as necessary, to review and evaluate applica12 tions and proposals and to advise the Secretary re13 garding such applications using the criteria devel14 oped during consultations pursuant to subsection

15 (a)(1).

16 ‘‘(d) REVERSION OF FACILITIES.—If any facility (or

17 portion thereof) with respect to which funds have been

18 paid under this section, ceases, within 5 years after com19 pletion of the construction, expansion, or modernization

20 carried out with such funds, to be used for the purposes

21 of providing health care services to eligible Indians, all of

22 the right, title, and interest in and to such facility (or por23 tion thereof) shall transfer to the United States unless

24 otherwise negotiated by the Service and the Indian Tribe

25 or Tribal Organization.
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1 ‘‘(e) FUNDING NONRECURRING.—Funding provided

2 under this section shall be nonrecurring and shall not be

3 available for inclusion in any individual Indian Tribe’s

4 tribal share for an award under the Indian Self-Deter5 mination and Education Assistance Act or for reallocation

6 or redesign thereunder.

7 ‘‘SEC. 306. INDIAN HEALTH CARE DELIVERY DEMONSTRA8 TION PROJECT.

9 ‘‘(a) HEALTH CARE DEMONSTRATION PROJECTS.—

10 The Secretary, acting through the Service, and in con11 sultation with Indian Tribes and Tribal Organizations, is

12 authorized to enter into Funding Agreements with, or

13 make grants or loan guarantees to, Indian Tribes or Trib14 al Organizations for the purpose of carrying out a health

15 care delivery demonstration project to test alternative

16 means of delivering health care and services to Indians

17 through facilities, including but not limited to hospice, tra18 ditional Indian health, and child care facilities.

19 ‘‘(b) USE OF FUNDS.—The Secretary, in approving

20 projects pursuant to this section, may authorize funding

21 for the construction and renovation of hospitals, health

22 centers, health stations, and other facilities to deliver

23 health care services and is authorized to—

24 ‘‘(1) waive any leasing prohibition;
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1 ‘‘(2) permit carryover of funds appropriated for

2 the provision of health care services;

3 ‘‘(3) permit the use of other available funds;

4 ‘‘(4) permit the use of funds or property do5 nated from any source for project purposes;

6 ‘‘(5) provide for the reversion of donated real or

7 personal property to the donor; and

8 ‘‘(6) permit the use of Service funds to match

9 other funds, including Federal funds.

10 ‘‘(c) REGULATIONS.—The Secretary shall develop

11 and publish regulations, through rulemaking under section

12 802, for the review and approval of applications submitted

13 under this section.

14 ‘‘(d) CRITERIA.—The Secretary may enter into a con15 tract or Funding Agreement or award a grant under this

16 section for projects which meet the following criteria:

17 ‘‘(1) There is a need for a new facility or pro18 gram or the reorientation of an existing facility or

19 program.

20 ‘‘(2) A significant number of Indians, including

21 those with low health status, will be served by the

22 project.

23 ‘‘(3) The project has the potential to deliver

24 services in an efficient and effective manner.

25 ‘‘(4) The project is economically viable.
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1 ‘‘(5) The Indian Tribe or Tribal Organization

2 has the administrative and financial capability to ad3 minister the project.

4 ‘‘(6) The project is integrated with providers of

5 related health and social services and is coordinated

6 with, and avoids duplication of, existing services.

7 ‘‘(e) PEER REVIEW PANELS.—The Secretary may

8 provide for the establishment of peer review panels, as nec9 essary, to review and evaluate applications using the cri10 teria developed pursuant to subsection (d).

11 ‘‘(f) PRIORITY.—The Secretary shall give priority to

12 applications for demonstration projects in each of the fol13 lowing Service Units to the extent that such applications

14 are timely filed and meet the criteria specified in sub15 section (d):

16 ‘‘(1) Cass Lake, Minnesota.

17 ‘‘(2) Clinton, Oklahoma.

18 ‘‘(3) Harlem, Montana.

19 ‘‘(4) Mescalero, New Mexico.

20 ‘‘(5) Owyhee, Nevada.

21 ‘‘(6) Parker, Arizona.

22 ‘‘(7) Schurz, Nevada.

23 ‘‘(8) Winnebago, Nebraska.

24 ‘‘(9) Ft. Yuma, California.
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1 ‘‘(g) TECHNICAL ASSISTANCE.—The Secretary shall

2 provide such technical and other assistance as may be nec3 essary to enable applicants to comply with the provisions

4 of this section.

5 ‘‘(h) SERVICE TO INELIGIBLE PERSONS.—The au6 thority to provide services to persons otherwise ineligible

7 for the health care benefits of the Service and the author8 ity to extend hospital privileges in Service facilities to non9 Service health practitioners as provided in section 807

10 may be included, subject to the terms of such section, in

11 any demonstration project approved pursuant to this sec12 tion.

13 ‘‘(i) EQUITABLE TREATMENT.—For purposes of sub14 section (d)(1), the Secretary shall, in evaluating facilities

15 operated under any Funding Agreement, use the same cri16 teria that the Secretary uses in evaluating facilities oper17 ated directly by the Service.

18 ‘‘(j) EQUITABLE INTEGRATION OF FACILITIES.—The

19 Secretary shall ensure that the planning, design, construc20 tion, renovation, and expansion needs of Service and non21 Service facilities which are the subject of a Funding

22 Agreement for health services are fully and equitably inte23 grated into the implementation of the health care delivery

24 demonstration projects under this section.
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1 ‘‘SEC. 307. LAND TRANSFER.

2 ‘‘(a) CHEMAWA INDIAN SCHOOL.—The Bureau of In3 dian Affairs is authorized to transfer, at no cost, up to

4 5 acres of land at the Chemawa Indian School, Salem,

5 Oregon, to the Service for the provision of health care

6 services. The land authorized to be transferred by this sec7 tion is that land adjacent to land under the jurisdiction

8 of the Service and occupied by the Chemawa Indian

9 Health Center.

10 ‘‘(b) FEDERAL LAND TO THE SERVICE.—Notwith11 standing any other provision of law, the Bureau of Indian

12 Affairs and all other agencies and departments of the

13 United States are authorized to transfer, at no cost, land

14 and improvements to the Service for the provision of

15 health care services. The Secretary is authorized to accept

16 such land and improvements for such purposes.

17 ‘‘SEC. 308. LEASES, CONTRACTS, AND OTHER AGREEMENTS.

18 ‘‘The Secretary, acting through the Service, may

19 enter into leases, contracts, and other agreements with In20 dian Tribes and Tribal Organizations which hold (1) title

21 to, (2) a leasehold interest in, or (3) a beneficial interest

22 in (when title is held by the United States in trust for

23 the benefit of an Indian Tribe) facilities used or to be used

24 for the administration and delivery of health services by

25 an Indian Health Program. Such leases, contracts, or

26 agreements may include provisions for construction or ren-
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1 ovation and provide for compensation to the Indian Tribe

2 or Tribal Organization of rental and other costs consistent

3 with section 105(l) of the Indian Self-Determination Act

4 and regulations thereunder. Notwithstanding any other

5 provision of law, such leases, contracts, or other agree6 ments shall be considered as operating leases for the pur7 pose of scoring under the Budget Enforcement Act.

8 ‘‘SEC. 309. LOANS, LOAN GUARANTEES, AND LOAN REPAY9 MENT.

10 ‘‘(a) ESTABLISHMENT OF FUND.—There is estab11 lished in the Treasury of the United States a fund to be

12 known as the Health Care Facilities Loan Fund (herein13 after referred to as the ‘HCFLF’) to provide to Indian

14 Tribes and Tribal Organizations direct loans, or guaran15 tees for loans, for construction of health care facilities (in16 cluding but not limited to inpatient facilities, outpatient

17 facilities, staff quarters, hostels, and specialized care fa18 cilities such as behavioral health and elder care facilities).

19 ‘‘(b) REGULATIONS; STANDARDS AND PROCE20 DURES.—The Secretary, acting through the Service, is au21 thorized to issue regulations, developed through rule22 making as set out in section 802, to provide standards

23 and procedures for governing such loans and loan guaran24 tees, subject to the following conditions:
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1 ‘‘(1) The principal amount of a loan or loan

2 guarantee may cover 100 percent of eligible costs,

3 including but not limited to planning, design, financ4 ing, site land development, construction, rehabilita5 tion, renovation, conversion, improvements, medical

6 equipment and furnishings, other facility-related

7 costs and capital purchase (but excluding staffing).

8 ‘‘(2) The cumulative total of the principal of di9 rect loans and loan guarantees, respectively, out10 standing at any one time shall not exceed such limi11 tations as may be specified in appropriation Acts.

12 ‘‘(3) In the discretion of the Secretary, the pro13 gram may be administered by the Service or the

14 Health Resources and Services Administration

15 (which shall be specified by regulation).

16 ‘‘(4) The Secretary may make or guarantee a

17 loan with a term of the useful estimated life of the

18 facility, or 25 years, whichever is shorter.

19 ‘‘(5) The Secretary may allocate up to 100 per20 cent of the funds available for loans or loan guaran21 tees in any year for the purpose of planning and ap22 plying for a loan or loan guarantee.

23 ‘‘(6) The Secretary may accept an assignment

24 of the revenue of an Indian Tribe or Tribal Organi-
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1 zation as security for any direct loan or loan guaran2 tee under this section.

3 ‘‘(7) In the planning and design of health facili4 ties under this section, users eligible under section

5 807(c) may be included in any projection of patient

6 population.

7 ‘‘(8) The Secretary shall not collect loan appli8 cation, processing, or other similar fees from Indian

9 Tribes or Tribal Organizations applying for direct

10 loans or loan guarantees under this section.

11 ‘‘(9) Service funds authorized under loans or

12 loan guarantees in this section shall be eligible for

13 use in matching other Federal funds.

14 ‘‘(c) AMOUNT FOR HCFLF.—

15 ‘‘(1) IN GENERAL.—The HCFLF shall consist

16 of—

17 ‘‘(A) such sums as may be initially appro18 priated to the HCFLF and as may be subse19 quently appropriated to the fund under para20 graph (2);

21 ‘‘(B) such amounts as may be collected

22 from borrowers; and

23 ‘‘(C) all interest earned on amounts in the

24 HCFLF.
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1 ‘‘(2) INITIAL FUNDS.—There are authorized to

2 be appropriated such sums as may be necessary to

3 initiate the HCFLF. For each fiscal year after the

4 initial year in which funds are appropriated to the

5 HCFLF, there is authorized to be appropriated an

6 amount equal to the sum of the amount collected by

7 the HCFLF during the preceding fiscal year and all

8 accrued interest.

9 ‘‘(3) AVAILABLE UNTIL EXPENDED.—All

10 amounts appropriated, collected, or earned relative

11 to the HCFLF shall remain available until ex12 pended.

13 ‘‘(4) INVESTMENTS.—The Secretary of the

14 Treasury shall invest such amounts of the HCFLF

15 as such Secretary determines are not required to

16 meet current withdrawals from the HCFLF. Such

17 investments may be made only in interest-bearing

18 obligations of the United States. For such purpose,

19 such obligations may be acquired on original issue at

20 the issue price or by purchase of outstanding obliga21 tions at the market price. Any obligation acquired by

22 the fund may be sold by the Secretary of the Treas23 ury at the market price.

24 ‘‘(d) LOANS UNDER ISDEAA.—Amounts in the

25 HCFLF and available pursuant to appropriation Acts may
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1 be expended by the Secretary to make loans under this

2 section to a Tribal Health Program.

3 ‘‘(e) GRANTS TO REPAY LOANS.—The Secretary is

4 authorized to establish a program to provide grants to In5 dian Tribes and Tribal Organizations for the purpose of

6 repaying all or part of any loan obtained by an Indian

7 Tribe or Tribal Organization for construction and renova8 tion of health care facilities (including inpatient facilities,

9 outpatient facilities, small ambulatory care, staff quarters,

10 and specialized care facilities). Loans eligible for such re11 payment grants shall include loans that have been ob12 tained under this section or otherwise.

13 ‘‘SEC. 310. TRIBAL LEASING.

14 ‘‘A Tribal Health Program may lease permanent

15 structures for the purpose of providing health care services

16 without obtaining advance approval in appropriation Acts.

17 ‘‘SEC. 311. INDIAN HEALTH SERVICE/TRIBAL FACILITIES

18 JOINT VENTURE PROGRAM.

19 ‘‘(a) IN GENERAL.—The Secretary, acting through

20 the Service, shall make arrangements with Indian Tribes

21 and Tribal Organizations to establish joint venture dem22 onstration projects under which an Indian Tribe or Tribal

23 Organization shall expend tribal, private, or other avail24 able funds, for the acquisition or construction of a health

25 facility for a minimum of 10 years, under a no-cost lease,
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1 in exchange for agreement by the Service to provide the

2 equipment, supplies, and staffing for the operation and

3 maintenance of such a health facility. An Indian Tribe or

4 Tribal Organization may use tribal funds, private sector,

5 or other available resources, including loan guarantees, to

6 fulfill its commitment under a joint venture entered into

7 under this subsection. An Indian Tribe or Tribal Organi8 zation shall be eligible to establish a joint venture project

9 if, when it submits a letter of intent, it—

10 ‘‘(1) has begun but not completed the process

11 of acquisition or construction of a health facility to

12 be used in the joint venture project; or

13 ‘‘(2) has not begun the process of acquisition or

14 construction of a health facility for use in the joint

15 venture project.

16 ‘‘(b) REQUIREMENTS.—The Secretary shall make

17 such an arrangement with an Indian Tribe or Tribal Orga18 nization only if—

19 ‘‘(1) the Secretary first determines that the In20 dian Tribe or Tribal Organization has the adminis21 trative and financial capabilities necessary to com22 plete the timely acquisition or construction of the

23 relevant health facility; and

24 ‘‘(2) the Indian Tribe or Tribal Organization

25 meets the need criteria which shall be developed
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1 through the negotiated rulemaking process provided

2 for under section 802.

3 ‘‘(c) CONTINUED OPERATION.—The Secretary shall

4 negotiate an agreement with the Indian Tribe or Tribal

5 Organization regarding the continued operation of the fa6 cility at the end of the initial 10 year no-cost lease period.

7 ‘‘(d) BREACH OF AGREEMENT.—An Indian Tribe or

8 Tribal Organization that has entered into a written agree9 ment with the Secretary under this section, and that

10 breaches or terminates without cause such agreement,

11 shall be liable to the United States for the amount that

12 has been paid to the Indian Tribe or Tribal Organization,

13 or paid to a third party on the Indian Tribe’s or Tribal

14 Organization’s behalf, under the agreement. The Sec15 retary has the right to recover tangible property (including

16 supplies) and equipment, less depreciation, and any funds

17 expended for operations and maintenance under this sec18 tion. The preceding sentence does not apply to any funds

19 expended for the delivery of health care services, person20 nel, or staffing.

21 ‘‘(e) RECOVERY FOR NONUSE.—An Indian Tribe or

22 Tribal Organization that has entered into a written agree23 ment with the Secretary under this subsection shall be en24 titled to recover from the United States an amount that

25 is proportional to the value of such facility if, at any time
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1 within the 10-year term of the agreement, the Service

2 ceases to use the facility or otherwise breaches the agree3 ment.

4 ‘‘(f) DEFINITION.—For the purposes of this section,

5 the term ‘health facility’ or ‘health facilities’ includes

6 quarters needed to provide housing for staff of the rel7 evant Tribal Health Program.

8 ‘‘SEC. 312. LOCATION OF FACILITIES.

9 ‘‘(a) IN GENERAL.—In all matters involving the reor10 ganization or development of Service facilities or in the

11 establishment of related employment projects to address

12 unemployment conditions in economically depressed areas,

13 the Bureau of Indian Affairs and the Service shall give

14 priority to locating such facilities and projects on Indian

15 lands if requested by the Indian owner and the Indian

16 Tribe with jurisdiction over such lands or other lands

17 owned or leased by the Indian Tribe or Tribal Organiza18 tion. Top priority shall be given to Indian land owned by

19 1 or more Indian Tribes.

20 ‘‘(b) DEFINITION.—For purposes of this section, the

21 term ‘Indian lands’ means—

22 ‘‘(1) all lands within the exterior boundaries of

23 any reservation;

24 ‘‘(2) any lands title to which is held in trust by

25 the United States for the benefit of any Indian
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1 Tribe or individual Indian or held by any Indian

2 Tribe or individual Indian subject to restriction by

3 the United States against alienation and over which

4 an Indian Tribe exercises governmental power; and

5 ‘‘(3) all lands in Alaska owned by any Alaska

6 Native village, or village or regional corporation

7 under the Alaska Native Claims Settlement Act, or

8 any land allotted to any Alaska Native.

9 ‘‘SEC. 313. MAINTENANCE AND IMPROVEMENT OF HEALTH

10 CARE FACILITIES.

11 ‘‘(a) REPORT.—The Secretary shall submit to the

12 President, for inclusion in the report required to be trans13 mitted to Congress under section 801, a report which iden14 tifies the backlog of maintenance and repair work required

15 at both Service and tribal health care facilities, including

16 new health care facilities expected to be in operation in

17 the next fiscal year. The report shall also identify the need

18 for renovation and expansion of existing facilities to sup19 port the growth of health care programs.

20 ‘‘(b) MAINTENANCE OF NEWLY CONSTRUCTED

21 SPACE.—The Secretary, acting through the Service, is au22 thorized to expend maintenance and improvement funds

23 to support maintenance of newly constructed space only

24 if such space falls within the approved supportable space

25 allocation for the Indian Tribe or Tribal Organization.
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1 Supportable space allocation shall be defined through the

2 negotiated rulemaking process provided for under section

3 802.

4 ‘‘(c) REPLACEMENT FACILITIES.—In addition to

5 using maintenance and improvement funds for renovation,

6 modernization, and expansion of facilities, an Indian Tribe

7 or Tribal Organization may use maintenance and improve8 ment funds for construction of a replacement facility if

9 the costs of renovation of such facility would exceed a

10 maximum renovation cost threshold. The maximum ren11 ovation cost threshold shall be determined through the ne12 gotiated rulemaking process provided for under section

13 802.

14 ‘‘SEC. 314. TRIBAL MANAGEMENT OF FEDERALLY OWNED

15 QUARTERS.

16 ‘‘(a) RENTAL RATES.—

17 ‘‘(1) ESTABLISHMENT.—Notwithstanding any

18 other provision of law, a Tribal Health Program

19 which operates a hospital or other health facility and

20 the federally owned quarters associated therewith

21 pursuant to a Funding Agreement shall have the au22 thority to establish the rental rates charged to the

23 occupants of such quarters by providing notice to

24 the Secretary of its election to exercise such author25 ity.
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1 ‘‘(2) OBJECTIVES.—In establishing rental rates

2 pursuant to authority of this subsection, a Tribal

3 Health Program shall endeavor to achieve the follow4 ing objectives:

5 ‘‘(A) To base such rental rates on the rea6 sonable value of the quarters to the occupants

7 thereof.

8 ‘‘(B) To generate sufficient funds to pru9 dently provide for the operation and mainte10 nance of the quarters, and subject to the discre11 tion of the Tribal Health Program, to supply

12 reserve funds for capital repairs and replace13 ment of the quarters.

14 ‘‘(3) EQUITABLE FUNDING.—Any quarters

15 whose rental rates are established by a Tribal

16 Health Program pursuant to this subsection shall

17 remain eligible for quarters improvement and repair

18 funds to the same extent as all federally owned

19 quarters used to house personnel in Services-sup20 ported programs.

21 ‘‘(4) NOTICE OF RATE CHANGE.—A Tribal

22 Health Program which exercises the authority pro23 vided under this subsection shall provide occupants

24 with no less than 60 days notice of any change in

25 rental rates.
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1 ‘‘(b) DIRECT COLLECTION OF RENT.—

2 ‘‘(1) IN GENERAL.—Notwithstanding any other

3 provision of law, and subject to paragraph (2), a

4 Tribal Health Program shall have the authority to

5 collect rents directly from Federal employees who oc6 cupy such quarters in accordance with the following:

7 ‘‘(A) The Tribal Health Program shall no8 tify the Secretary and the subject Federal em9 ployees of its election to exercise its authority

10 to collect rents directly from such Federal em11 ployees.

12 ‘‘(B) Upon receipt of a notice described in

13 subparagraph (A), the Federal employees shall

14 pay rents for occupancy of such quarters di15 rectly to the Tribal Health Program and the

16 Secretary shall have no further authority to col17 lect rents from such employees through payroll

18 deduction or otherwise.

19 ‘‘(C) Such rent payments shall be retained

20 by the Tribal Health Program and shall not be

21 made payable to or otherwise be deposited with

22 the United States.

23 ‘‘(D) Such rent payments shall be depos24 ited into a separate account which shall be used

25 by the Tribal Health Program for the mainte-
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1 nance (including capital repairs and replace2 ment) and operation of the quarters and facili3 ties as the Tribal Health Program shall deter4 mine.

5 ‘‘(2) RETROCESSION OF AUTHORITY.—If a

6 Tribal Health Program which has made an election

7 under paragraph (1) requests retrocession of its au8 thority to directly collect rents from Federal employ9 ees occupying federally owned quarters, such ret10 rocession shall become effective on the earlier of—

11 ‘‘(A) the first day of the month that begins

12 no less than 180 days after the Tribal Health

13 Program notifies the Secretary of its desire to

14 retrocede; or

15 ‘‘(B) such other date as may be mutually

16 agreed by the Secretary and the Tribal Health

17 Program.

18 ‘‘(c) RATES IN ALASKA.—To the extent that a Tribal

19 Health Program, pursuant to authority granted in sub20 section (a), establishes rental rates for federally owned

21 quarters provided to a Federal employee in Alaska, such

22 rents may be based on the cost of comparable private rent23 al housing in the nearest established community with a

24 year-round population of 1,500 or more individuals.
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1 ‘‘SEC. 315. APPLICABILITY OF BUY AMERICAN ACT RE2 QUIREMENT.

3 ‘‘(a) APPLICABILITY.—The Secretary shall ensure

4 that the requirements of the Buy American Act apply to

5 all procurements made with funds provided pursuant to

6 section 317. Indian Tribes and Tribal Organizations shall

7 be exempt from these requirements.

8 ‘‘(b) EFFECT OF VIOLATION.—If it has been finally

9 determined by a court or Federal agency that any person

10 intentionally affixed a label bearing a ‘Made in America’

11 inscription or any inscription with the same meaning, to

12 any product sold in or shipped to the United States that

13 is not made in the United States, such person shall be

14 ineligible to receive any contract or subcontract made with

15 funds provided pursuant to section 317, pursuant to the

16 debarment, suspension, and ineligibility procedures de17 scribed in sections 9.400 through 9.409 of title 48, Code

18 of Federal Regulations.

19 ‘‘(c) DEFINITIONS.—For purposes of this section, the

20 term ‘Buy American Act’ means title III of the Act enti21 tled ‘An Act making appropriations for the Treasury and

22 Post Office Departments for the fiscal year ending June

23 30, 1934, and for other purposes’, approved March 3,

24 1933 (41 U.S.C. 10a et seq.).
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1 ‘‘SEC. 316. OTHER FUNDING FOR FACILITIES.

2 ‘‘(a) AUTHORITY TO ACCEPT FUNDS.—The Sec3 retary is authorized to accept from any source, including

4 Federal and State agencies, funds that are available for

5 the construction of health care facilities and use such

6 funds to plan, design, and construct health care facilities

7 for Indians and to place such funds into Funding Agree8 ments. Receipt of such funds shall have no effect on the

9 priorities established pursuant to section 301.

10 ‘‘(b) INTERAGENCY AGREEMENTS.—The Secretary is

11 authorized to enter into interagency agreements with

12 other Federal agencies or State agencies and other entities

13 and to accept funds from such Federal or State agencies

14 or other sources to provide for the planning, design, and

15 construction of health care facilities to be administered by

16 Indian Health Programs in order to carry out the pur17 poses of this Act and the purposes for which the funds

18 were appropriated or for which the funds were otherwise

19 provided.

20 ‘‘(c) TRANSFERRED FUNDS.—Any Federal agency to

21 which funds for the construction of health care facilities

22 are appropriated is authorized to transfer such funds to

23 the Secretary for the construction of health care facilities

24 to carry out the purposes of this Act as well as the pur25 poses for which such funds are appropriated to such other

26 Federal agency.
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1 ‘‘(d) ESTABLISHMENT OF STANDARDS.—The Sec2 retary, through the Service, shall establish standards by

3 regulation, developed by rulemaking under section 802, for

4 the planning, design, and construction of health care fa5 cilities serving Indians under this Act.

6 ‘‘SEC. 317. AUTHORIZATION OF APPROPRIATIONS.

7 ‘‘There are authorized to be appropriated such sums

8 as may be necessary for each fiscal year through fiscal

9 year 2015 to carry out this title.

10 ‘‘TITLE IV—ACCESS TO HEALTH

11 SERVICES

12 ‘‘SEC. 401. TREATMENT OF PAYMENTS UNDER SOCIAL SE13 CURITY ACT HEALTH CARE PROGRAMS.

14 ‘‘(a) DISREGARD OF MEDICARE, MEDICAID, AND

15 SCHIP PAYMENTS IN DETERMINING APPROPRIATIONS.—

16 Any payments received by an Indian Health Program or

17 by an Urban Indian Organization made under title XVIII,

18 XIX, or XXI of the Social Security Act for services pro19 vided to Indians eligible for benefits under such respective

20 titles shall not be considered in determining appropria21 tions for the provision of health care and services to Indi22 ans.

23 ‘‘(b) NONPREFERENTIAL TREATMENT.—Nothing in

24 this Act authorizes the Secretary to provide services to an

25 Indian with coverage under title XVIII, XIX, or XXI of
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1 the Social Security Act in preference to an Indian without

2 such coverage.

3 ‘‘(c) USE OF FUNDS.—

4 ‘‘(1) SPECIAL FUND.—Notwithstanding any

5 other provision of law, but subject to paragraph (2), pay6 ments to which a facility of the Service is entitled by rea7 son of a provision of the Social Security Act shall be

8 placed in a special fund to be held by the Secretary and

9 first used (to such extent or in such amounts as are pro10 vided in appropriation Acts) for the purpose of making

11 any improvements in the programs of the Service which

12 may be necessary to achieve or maintain compliance with

13 the applicable conditions and requirements of titles

14 XVIII, XIX, and XXI of the Social Security Act. Any

15 amounts to be reimbursed that are in excess of the

16 amount necessary to achieve or maintain such conditions

17 and requirements shall, subject to the consultation with

18 Indian Tribes being served by the Service Unit, be used

19 for reducing the health resource deficiencies of the Indian

20 Tribes. In making payments from such fund, the Sec21 retary shall ensure that each Service Unit of the Service

22 receives 100 percent of the amount to which the facilities

23 of the Service, for which such Service Unit makes collec24 tions, are entitled by reason of a provision of the Social

25 Security Act.
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1 ‘‘(2) DIRECT PAYMENT OPTION.—Paragraph

2 (1) shall not apply upon the election of a Tribal

3 Health Program under subsection (d) to receive pay4 ments directly. No payment may be made out of the

5 special fund described in such paragraph with re6 spect to reimbursement made for services provided

7 during the period of such election.

8 ‘‘(d) DIRECT BILLING.—

9 ‘‘(1) IN GENERAL.—A Tribal Health Program

10 may directly bill for, and receive payment for, health

11 care items and services provided by such Indian

12 tribe or organization for which payment is made

13 under title XVIII, XIX, or XXI of the Social Secu14 rity Act or from any other third party payor.

15 ‘‘(2) DIRECT REIMBURSEMENT.—

16 ‘‘(A) USE OF FUNDS.—Each Tribal Health

17 Program exercising the option described in

18 paragraph (1) with respect to a program under

19 a title of the Social Security Act shall be reim20 bursed directly by that program for items and

21 services furnished without regard to any other

22 provision of law, but all amounts so reimbursed

23 shall be used by the Tribal Health Program for

24 the purpose of making any improvements in

25 Tribal facilities or Tribal Health Programs that
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1 may be necessary to achieve or maintain com2 pliance with the conditions and requirements

3 applicable generally to such items and services

4 under the program under such title and to pro5 vide additional health care services, improve6 ments in health care facilities and Tribal

7 Health Programs, any health care-related pur8 pose, or otherwise to achieve the objectives pro9 vided in section 3 of this Act.

10 ‘‘(B) AUDITS.—The amounts paid to an

11 Indian Tribe or Tribal Organization exercising

12 the option described in paragraph (1) with re13 spect to a program under a title of the Social

14 Security Act shall be subject to all auditing re15 quirements applicable to programs administered

16 by an Indian Health Program.

17 ‘‘(3) EXAMINATION AND IMPLEMENTATION OF

18 CHANGES.—The Secretary, acting through the Serv19 ice and with the assistance of the Administrator of

20 the Centers for Medicare & Medicaid Services, shall

21 examine on an ongoing basis and implement any ad22 ministrative changes that may be necessary to facili23 tate direct billing and reimbursement under the pro24 gram established under this subsection, including

25 any agreements with States that may be necessary
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1 to provide for direct billing under a program under

2 a title of the Social Security Act.

3 ‘‘(4) WITHDRAWAL FROM PROGRAM.—A Tribal

4 Health Program that bills directly under the pro5 gram established under this subsection may with6 draw from participation in the same manner and

7 under the same conditions that an Indian Tribe or

8 Tribal Organization may retrocede a contracted pro9 gram to the Secretary under the authority of the In10 dian Self-Determination and Education Assistance

11 Act (25 U.S.C. 450 et seq.). All cost accounting and

12 billing authority under the program established

13 under this subsection shall be returned to the Sec14 retary upon the Secretary’s acceptance of the with15 drawal of participation in this program.

16 ‘‘SEC. 402. GRANTS TO AND FUNDING AGREEMENTS WITH

17 THE SERVICE, INDIAN TRIBES, TRIBAL ORGA18 NIZATIONS, AND URBAN INDIAN ORGANIZA19 TIONS.

20 ‘‘(a) INDIAN TRIBES AND TRIBAL ORGANIZA21 TIONS.—The Secretary, acting through the Service, shall

22 make grants to or enter into Funding Agreements with

23 Indian Tribes and Tribal Organizations to assist such

24 Tribes and Tribal Organizations in establishing and ad-
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1 ministering programs on or near reservations and trust

2 lands to assist individual Indians—

3 ‘‘(1) to enroll for benefits under title XVIII,

4 XIX, or XXI of the Social Security Act and other

5 health benefits programs; and

6 ‘‘(2) to pay premiums for coverage for such

7 benefits, which may be based on financial need (as

8 determined by the Indian Tribe or Tribes being

9 served based on a schedule of income levels devel10 oped or implemented by such Tribe or Tribes).

11 ‘‘(b) CONDITIONS.—The Secretary, acting through

12 the Service, shall place conditions as deemed necessary to

13 effect the purpose of this section in any grant or Funding

14 Agreement which the Secretary makes with any Indian

15 Tribe or Tribal Organization pursuant to this section.

16 Such conditions shall include requirements that the Indian

17 Tribe or Tribal Organization successfully undertake—

18 ‘‘(1) to determine the population of Indians eli19 gible for the benefits described in subsection (a);

20 ‘‘(2) to educate Indians with respect to the ben21 efits available under the respective programs;

22 ‘‘(3) to provide transportation to such individ23 ual Indians to the appropriate offices for enrollment

24 or applications for such benefits; and
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1 ‘‘(4) to develop and implement methods of im2 proving the participation of Indians in receiving the

3 benefits provided under titles XVIII, XIX, and XXI

4 of the Social Security Act.

5 ‘‘(c) AGREEMENTS RELATING TO IMPROVING EN6 ROLLMENT OF INDIANS UNDER SOCIAL SECURITY ACT

7 PROGRAMS.—

8 ‘‘(1) AGREEMENTS WITH SECRETARY TO IM9 PROVE RECEIPT AND PROCESSING OF APPLICA10 TIONS.—

11 ‘‘(A) AUTHORIZATION.—The Secretary,

12 acting through the Service, may enter into an

13 agreement with an Indian Tribe, Tribal Organi14 zation, or Urban Indian Organization which

15 provides for the receipt and processing of appli16 cations by Indians for assistance under titles

17 XIX and XXI of the Social Security Act, and

18 benefits under title XVIII of such Act, by an

19 Indian Health Program or Urban Indian Orga20 nization.

21 ‘‘(B) REIMBURSEMENT OF COSTS.—Such

22 agreements may provide for reimbursement of

23 costs of outreach, education regarding eligibility

24 and benefits, and translation when such services

25 are provided. The reimbursement may, as ap-
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1 propriate, be added to the applicable rate per

2 encounter or be provided as a separate fee-for3 service payment to the Indian Tribe or Tribal

4 Organization.

5 ‘‘(C) PROCESSING CLARIFIED.—In this

6 paragraph, the term ‘processing’ does not in7 clude a final determination of eligibility.

8 ‘‘(2) AGREEMENTS WITH STATES FOR OUT9 REACH ON OR NEAR RESERVATION.—

10 ‘‘(A) IN GENERAL.—In order to improve

11 the access of Indians residing on or near a res12 ervation to obtain benefits under title XIX or

13 XXI of the Social Security Act, as a condition

14 of continuing approval of a State plan under

15 such title, the State shall take steps as to pro16 vide for enrollment on or near the reservation.

17 Such steps may include outreach efforts such as

18 the outstationing of eligibility workers, entering

19 into agreements with Indian Tribes and Tribal

20 Organizations to provide outreach, education re21 garding eligibility and benefits, enrollment, and

22 translation services when such services are pro23 vided.

24 ‘‘(B) CONSTRUCTION.—Nothing in sub25 paragraph (A) shall be construed as affecting
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1 arrangements entered into between States and

2 Indian Tribes and Tribal Organizations for

3 such Indian Tribes and Tribal Organizations to

4 conduct administrative activities under such ti5 tles.

6 ‘‘(d) FACILITATING COOPERATION.—The Secretary,

7 acting through the Centers for Medicare & Medicaid Serv8 ices, shall take such steps as are necessary to facilitate

9 cooperation with, and agreements between, States and the

10 Service, Indian Tribes, Tribal Organizations, or Urban In11 dian Organizations.

12 ‘‘(e) APPLICATION TO URBAN INDIAN ORGANIZA13 TIONS.—

14 ‘‘(1) IN GENERAL.—The provisions of sub15 section (a) shall apply with respect to grants and

16 other funding to Urban Indian Organizations with

17 respect to populations served by such organizations

18 in the same manner they apply to grants and Fund19 ing Agreements with Indian tribes and Tribal Orga20 nizations with respect to programs on or near res21 ervations.

22 ‘‘(2) REQUIREMENTS.—The Secretary shall in23 clude in the grants or Funding Agreements made or

24 provided under paragraph (1) requirements that

25 are—
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1 ‘‘(A) consistent with the requirements im2 posed by the Secretary under subsection (b);

3 ‘‘(B) appropriate to Urban Indian Organi4 zations and Urban Indians; and

5 ‘‘(C) necessary to effect the purposes of

6 this section.

7 ‘‘SEC. 403. REIMBURSEMENT FROM CERTAIN THIRD PAR8 TIES OF COSTS OF HEALTH SERVICES.

9 ‘‘(a) RIGHT OF RECOVERY.—Except as provided in

10 subsection (f), the United States, an Indian Tribe, or

11 Tribal Organization shall have the right to recover from

12 an insurance company, health maintenance organization,

13 employee benefit plan, third-party tortfeasor, or any other

14 responsible or liable third party (including a political sub15 division or local governmental entity of a State) the rea16 sonable charges billed (or, if charges are not billed, the

17 operational, administrative, and other expenses incurred)

18 by the Secretary, an Indian Tribe, or Tribal Organization

19 in providing health services, through the Service, an In20 dian Tribe, or Tribal Organization to any individual to the

21 same extent that such individual, or any nongovernmental

22 provider of such services, would be eligible to receive dam23 ages, reimbursement, or indemnification for such charges

24 or expenses if—
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1 ‘‘(1) such services had been provided by a non2 governmental provider; and

3 ‘‘(2) such individual had been required to pay

4 such charges or expenses and did pay such charges

5 or expenses.

6 ‘‘(b) LIMITATIONS ON RECOVERIES FROM STATES.—

7 Subsection (a) shall provide a right of recovery against

8 any State, only if the injury, illness, or disability for which

9 health services were provided is covered under—

10 ‘‘(1) workers’ compensation laws; or

11 ‘‘(2) a no-fault automobile accident insurance

12 plan or program.

13 ‘‘(c) NONAPPLICATION OF OTHER LAWS.—No law of

14 any State, or of any political subdivision of a State and

15 no provision of any contract, insurance or health mainte16 nance organization policy, employee benefit plan, self-in17 surance plan, managed care plan, or other health care plan

18 or program entered into or renewed after the date of the

19 enactment of the Indian Health Care Amendments of

20 1988, shall prevent or hinder the right of recovery of the

21 United States, an Indian Tribe, or Tribal Organization

22 under subsection (a).

23 ‘‘(d) NO EFFECT ON PRIVATE RIGHTS OF ACTION.—

24 No action taken by the United States, an Indian Tribe,

25 or Tribal Organization to enforce the right of recovery
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1 provided under subsection (a) shall operate to deny to the

2 injured person the recovery for that portion of the person’s

3 damage not covered hereunder.

4 ‘‘(e) ENFORCEMENT.—

5 ‘‘(1) IN GENERAL.—The United States, an In6 dian Tribe, or Tribal Organization may enforce the

7 right of recovery provided under subsection (a) by—

8 ‘‘(A) intervening or joining in any civil ac9 tion or proceeding brought—

10 ‘‘(i) by the individual for whom health

11 services were provided by the Secretary, an

12 Indian Tribe, or Tribal Organization; or

13 ‘‘(ii) by any representative or heirs of

14 such individual, or

15 ‘‘(B) instituting a civil action, including a

16 civil action for injunctive relief and other relief

17 and including, with respect to a political sub18 division or local governmental entity of a State,

19 such an action against an official thereof.

20 ‘‘(2) NOTICE.—All reasonable efforts shall be

21 made to provide notice of action instituted under

22 paragraph (1)(B) to the individual to whom health

23 services were provided, either before or during the

24 pendency of such action.
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1 ‘‘(f) LIMITATION.—Absent specific written authoriza2 tion by the governing body of an Indian Tribe for the pe3 riod of such authorization (which may not be for a period

4 of more than 1 year and which may be revoked at any

5 time upon written notice by the governing body to the

6 Service), the United States shall not have a right of recov7 ery under this section if the injury, illness, or disability

8 for which health services were provided is covered under

9 a self-insurance plan funded by an Indian Tribe, Tribal

10 Organization, or Urban Indian Organization. Where such

11 authorization is provided, the Service may receive and ex12 pend such amounts for the provision of additional health

13 services consistent with such authorization.

14 ‘‘(g) COSTS AND ATTORNEYS’ FEES.—In any action

15 brought to enforce the provisions of this section, a prevail16 ing plaintiff shall be awarded its reasonable attorneys’ fees

17 and costs of litigation.

18 ‘‘(h) RIGHT OF ACTION AGAINST INSURERS, HMOS,

19 EMPLOYEE BENEFIT PLANS, SELF-INSURANCE PLANS,

20 AND OTHER HEALTH CARE PLANS OR PROGRAMS.—

21 Where an insurance company, health maintenance organi22 zation, employee benefit plan, self-insurance plan, man23 aged care plan, or other health care plan or program fails

24 or refuses to pay the amount due under subsection (a)

25 for services provided to an individual who is a beneficiary,
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1 participant, or insured of such company, organization,

2 plan, or program, the United States, Indian Tribe, or

3 Tribal Organization shall have a right to assert and pur4 sue all the claims and remedies against such company, or5 ganization, plan, or program and against the fiduciaries

6 of such company, organization, plan, or program that the

7 individual could assert or pursue under the terms of the

8 contract, program, or plan or applicable Federal, State,

9 or Tribal law.

10 ‘‘(i) NONAPPLICATION OF CLAIMS FILING REQUIRE11 MENTS.—An insurance company, health maintenance or12 ganization, self-insurance plan, managed care plan, or

13 other health care plan or program (under the Social Secu14 rity Act or otherwise) may not deny a claim for benefits

15 submitted by the Service or by an Indian Tribe or Tribal

16 Organization based on the format in which the claim is

17 submitted if such format complies with the format re18 quired for submission of claims under title XVIII of the

19 Social Security Act or recognized under section 1175 of

20 such Act.

21 ‘‘(j) APPLICATION TO URBAN INDIAN ORGANIZA22 TIONS.—The previous provisions of this section shall apply

23 to Urban Indian Organizations with respect to populations

24 served by such Organizations in the same manner they

25 apply to Indian Tribes and Tribal Organizations with re-
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1 spect to populations served by such Indian Tribes and

2 Tribal Organizations.

3 ‘‘(k) STATUTE OF LIMITATIONS.—The provisions of

4 section 2415 of title 28, United States Code, shall apply

5 to all actions commenced under this section, and the ref6 erences therein to the United States are deemed to include

7 Indian Tribes, Tribal Organizations, and Urban Indian

8 Organizations.

9 ‘‘(l) SAVINGS.—Nothing in this section shall be con10 strued to limit any right of recovery available to the

11 United States, an Indian Tribe, or Tribal Organization

12 under the provisions of any applicable, Federal, State, or

13 Tribal law, including medical lien laws and the Federal

14 Medical Care Recovery Act (42 U.S.C. 2651 et seq.).

15 ‘‘SEC. 404. CREDITING OF REIMBURSEMENTS.

16 ‘‘(a) USE OF AMOUNTS.—

17 ‘‘(1) RETENTION BY PROGRAM.—Except as pro18 vided in section 202(g) (relating to the Catastrophic

19 Health Emergency Fund) and section 807 (relating

20 to health services for ineligible persons), all reim21 bursements received or recovered under any of the

22 programs described in paragraph (2), including

23 under section 807, by reason of the provision of

24 health services by the Service, by an Indian Tribe or

25 Tribal Organization, or by an Urban Indian Organi-
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1 zation, shall be credited to the Service, such Indian

2 Tribe or Tribal Organization, or such Urban Indian

3 Organization, respectively, and may be used as pro4 vided in section 401. In the case of such a service

5 provided by or through a Service Unit, such

6 amounts shall be credited to such unit and used for

7 such purposes.

8 ‘‘(2) PROGRAMS COVERED.—The programs re9 ferred to in paragraph (1) are the following:

10 ‘‘(A) Titles XVIII, XIX, and XXI of the

11 Social Security Act.

12 ‘‘(B) This Act, including section 807.

13 ‘‘(C) Public Law 87–693.

14 ‘‘(D) Any other provision of law.

15 ‘‘(b) NO OFFSET OF AMOUNTS.—The Service may

16 not offset or limit any amount obligated to any Service

17 Unit or entity receiving funding from the Service because

18 of the receipt of reimbursements under subsection (a).

19 ‘‘SEC. 405. PURCHASING HEALTH CARE COVERAGE.

20 ‘‘(a) IN GENERAL.—Insofar as amounts are made

21 available under law (including a provision of the Social

22 Security Act, the Indian Self-Determination and Edu23 cation Assistance Act, or other law, other than under sec24 tion 402) to Indian Tribes, Tribal Organizations, and

25 Urban Indian Organizations for health benefits for Service
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1 beneficiaries, Indian Tribes, Tribal Organizations, and

2 Urban Indian Organizations may use such amounts to

3 purchase health benefits coverage for such beneficiaries in

4 any manner, including through—

5 ‘‘(1) a tribally owned and operated health care

6 plan;

7 ‘‘(2) a State or locally authorized or licensed

8 health care plan;

9 ‘‘(3) a health insurance provider or managed

10 care organization; or

11 ‘‘(4) a self-insured plan.

12 The purchase of such coverage by an Indian Tribe, Tribal

13 Organization, or Urban Indian Organization may be based

14 on the financial needs of such beneficiaries (as determined

15 by the Indian Tribe or Tribes being served based on a

16 schedule of income levels developed or implemented by

17 such Indian Tribe or Tribes).

18 ‘‘(b) EXPENSES FOR SELF-INSURED PLAN.—In the

19 case of a self-insured plan under subsection (a)(4), the

20 amounts may be used for expenses of operating the plan,

21 including administration and insurance to limit the finan22 cial risks to the entity offering the plan.

23 ‘‘(c) CONSTRUCTION.—Nothing in this section shall

24 be construed as affecting the use of any amounts not re25 ferred to in subsection (a).
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1 ‘‘SEC. 406. SHARING ARRANGEMENTS WITH FEDERAL AGEN2 CIES.

3 ‘‘(a) AUTHORITY.—

4 ‘‘(1) IN GENERAL.—The Secretary may enter

5 into (or expand) arrangements for the sharing of

6 medical facilities and services between the Service,

7 Indian Tribes, and Tribal Organizations and the De8 partment of Veterans Affairs and the Department of

9 Defense.

10 ‘‘(2) CONSULTATION BY SECRETARY RE11 QUIRED.—The Secretary may not finalize any ar12 rangement between the Service and a Department

13 described in paragraph (1) without first consulting

14 with the Indian Tribes which will be significantly af15 fected by the arrangement.

16 ‘‘(b) LIMITATIONS.—The Secretary shall not take

17 any action under this section or under subchapter IV of

18 chapter 81 of title 38, United States Code, which would

19 impair—

20 ‘‘(1) the priority access of any Indian to health

21 care services provided through the Service and the

22 eligibility of any Indian to receive health services

23 through the Service;

24 ‘‘(2) the quality of health care services provided

25 to any Indian through the Service;
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1 ‘‘(3) the priority access of any veteran to health

2 care services provided by the Department of Veter3 ans Affairs;

4 ‘‘(4) the quality of health care services provided

5 by the Department of Veterans Affairs or the De6 partment of Defense; or

7 ‘‘(5) the eligibility of any Indian who is a vet8 eran to receive health services through the Depart9 ment of Veterans Affairs.

10 ‘‘(c) REIMBURSEMENT.—The Service, Indian Tribe,

11 or Tribal Organization shall be reimbursed by the Depart12 ment of Veterans Affairs or the Department of Defense

13 (as the case may be) where services are provided through

14 the Service, an Indian Tribe, or a Tribal Organization to

15 beneficiaries eligible for services from either such Depart16 ment, notwithstanding any other provision of law.

17 ‘‘(d) CONSTRUCTION.—Nothing in this section may

18 be construed as creating any right of a non-Indian veteran

19 to obtain health services from the Service.

20 ‘‘SEC. 407. PAYOR OF LAST RESORT.

21 ‘‘Indian Health Programs and health care programs

22 operated by Urban Indian Organizations shall be the

23 payor of last resort for services provided to persons eligible

24 for services from Indian Health Programs and Urban In-
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1 dian Organizations, notwithstanding any Federal, State,

2 or local law to the contrary.

3 ‘‘SEC. 408. NONDISCRIMINATION IN QUALIFICATIONS FOR

4 REIMBURSEMENT FOR SERVICES.

5 ‘‘For purposes of determining the eligibility of an en6 tity that is operated by the Service, an Indian Tribe, Trib7 al Organization, or Urban Indian Organization to receive

8 payment or reimbursement from any federally funded

9 health care program for health care services it furnishes

10 to an Indian, any requirement that the entity be licensed

11 or recognized under State or local law to furnish such

12 services shall be deemed to have been met if the entity

13 meets quality requirements for the furnishing of such serv14 ices recognized by the Secretary.

15 ‘‘SEC. 409. CONSULTATION.

16 ‘‘(a) NATIONAL INDIAN TECHNICAL ADVISORY

17 GROUP (TAG).—

18 ‘‘(1) ESTABLISHMENT AND MEMBERSHIP.—The

19 Secretary shall establish a National Indian Technical

20 Advisory Group (in this subsection referred to as the

21 ‘Advisory Group’) which shall have no fewer than 14

22 members including at least 1 member designated by

23 the Indian Tribes and Tribal Organizations in each

24 Service Area, 1 Urban Indian Organization rep25 resentative, and 1 member representing the Service.
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1 The Secretary may appoint additional members

2 upon the recommendation of the Advisory Group.

3 ‘‘(2) DUTIES.—

4 ‘‘(A) IDENTIFICATION OF ISSUES.—The

5 Advisory Group shall assist the Secretary in

6 identifying and addressing issues regarding the

7 health care programs under the Social Security

8 Act (including medicare, medicaid, and SCHIP)

9 that have implications for Indian Health Pro10 grams or Urban Indian Organizations. The Ad11 visory Group shall provide advice to the Sec12 retary with respect to those issues and with re13 spect to the need for the Secretary to engage in

14 consultation with Indian Tribes, Tribal Organi15 zations, and Urban Indian Organizations.

16 ‘‘(B) CONSTRUCTION.—Nothing in sub17 paragraph (A) shall be construed as affecting

18 any requirement under any applicable Executive

19 order for the Secretary to consult with Indian

20 Tribes in cases of health care policies that have

21 implications for Indian Health Programs or

22 Urban Indian Organizations.

23 ‘‘(3) FUNDING.—The Secretary shall pay the

24 expenses of the Advisory Group using the general
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1 administrative funds of the Centers for Medicare &

2 Medicaid Services.

3 ‘‘(4) NONAPPLICATION OF FEDERAL ADVISORY

4 COMMITTEE ACT.—The Federal Advisory Committee

5 Act (5 U.S.C. App.) shall not apply to the Advisory

6 Group.

7 ‘‘(5) MEETINGS.—The Secretary shall convene

8 meetings of the Advisory Group no less frequently

9 than quarterly.

10 ‘‘(b) SOLICITATION OF MEDICAID ADVICE.—

11 ‘‘(1) IN GENERAL.—As a requirement for pay12 ment under title XIX of the Social Security Act to

13 a State in which the Service operates or funds

14 health care programs or in which 1 or more Indian

15 Health Programs or Urban Indian Organizations

16 provide health care in the State for which medical

17 assistance is available under such title, the State

18 shall establish a process under which the State seeks

19 advice on a regular, ongoing basis (at least on a

20 quarterly basis) from designees of such Indian

21 Health Programs and Urban Indian Organizations

22 on matters relating to the application of such title

23 to such Indian Health Programs and Urban Indian

24 Organizations.
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1 ‘‘(2) MANNER OF ADVICE.—Such process shall

2 be in addition to (and not in lieu of) any consulta3 tion otherwise required by law and shall apply before

4 the submittal of plan amendments, waiver requests,

5 and proposals for demonstration projects. Such proc6 ess may include appointment of an advisory commit7 tee and of a designee of such Indian Health Pro8 grams and Urban Indian Organizations to the medi9 cal care advisory committee advising the State on its

10 medicaid plan.

11 ‘‘(3) PAYMENT OF EXPENSES.—Expenses in

12 carrying out this subsection shall be treated as rea13 sonable administrative expenses for which reimburse14 ment may be made under section 1903(a) of the So15 cial Security Act.

16 ‘‘(c) CONSTRUCTION.—Nothing in this section shall

17 be construed as superseding existing advisory committees,

18 working groups, or other advisory procedures established

19 by the Secretary or by any State.

20 ‘‘SEC. 410. STATE CHILDREN’S HEALTH INSURANCE PRO21 GRAM (SCHIP).

22 ‘‘(a) AUTHORIZATION FOR ARRANGEMENTS.—Not23 withstanding any other provision of law, insofar as the

24 State health plan of a State under title XXI of the Social

25 Security Act may provide (whether through its medicaid
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1 plan under title XIX of such Act or otherwise) child or

2 other health assistance to individuals who are otherwise

3 served by the Service or by an Indian Tribe or Tribal Or4 ganization, the Secretary may enter into an arrangement

5 with the State and with the Service or 1 or more Indian

6 Tribes and Tribal Organizations in the State under which

7 a portion of the funds otherwise made available to the

8 State under such title with respect to such individuals is

9 provided to the Service, Indian Tribe, or Tribal Organiza10 tion, respectively, for the purpose of providing such assist11 ance to such individuals consistent with the purposes of

12 such title.

13 ‘‘(b) ENTERING INTO ARRANGEMENTS.—

14 ‘‘(1) IN GENERAL.—Notwithstanding any other

15 provision of law, in the case of a State which has an

16 unexpended allotment amount described in para17 graph (2) for a fiscal year, before effecting any real18 lotment of such amount to other States, at the re19 quest of the Service or 1 or more Indian Tribes or

20 Tribal Organizations that operate in the State with

21 respect to individuals who are served by such Serv22 ice, Indian Tribes, or Tribal Organizations, the Sec23 retary shall enter into an arrangement with the

24 Service, Indian Tribes, or Tribal Organizations

25 under which the Indian child proportion (as defined
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1 in paragraph (3)) for such Service, Indian Tribes,

2 or Tribal Organizations of such unexpended allot3 ment amount is made available to the Service or

4 such Indian Tribes or Tribal Organizations for the

5 purpose of providing child health or other assistance

6 to individuals who are otherwise served by the Serv7 ice or by such Indian Tribes or Tribal Organizations

8 consistent with the purposes of title XXI of the So9 cial Security Act. Insofar as amounts are made

10 available under the preceding sentence, such

11 amounts shall be treated (for purposes of title XXI

12 of the Social Security Act) as if they had been ex13 pended during the period referred to in paragraph

14 (2).

15 ‘‘(2) UNEXPENDED ALLOTMENT AMOUNT.—For

16 purposes of this subsection, the term ‘unexpended

17 allotment amount’ means, with respect to an allot18 ment to a State under section 2104 of the Social Se19 curity Act for a fiscal year, the portion of such allot20 ment which was not expended by the State during

21 the period in which such allotment is available for

22 expenditure by the State and which would, but for

23 this subsection, be realloted to other States.

24 ‘‘(3) INDIAN CHILD PROPORTION.—For pur25 poses of this subsection, the term ‘Indian child pro-
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1 portion’ means, with respect to an unexpended allot2 ment amount for a State and an arrangement under

3 paragraph (1) with the Service or Indian Tribes or

4 Tribal Organizations, the proportion of targeted low5 income children in the State (as defined in section

6 2110(b) of the Social Security Act) who are Indians

7 who would be served under an arrangement with the

8 Service or such Indian Tribes or Tribal Organiza9 tions under such paragraph, as estimated by the

10 Secretary of Health and Human Services based

11 upon the best available data before a portion of the

12 unexpended allotment amount is made available

13 under this subsection.

14 ‘‘SEC. 411. SOCIAL SECURITY ACT SANCTIONS.

15 ‘‘(a) REQUESTS FOR WAIVER OF SANCTIONS.—For

16 purposes of applying any authority under a provision of

17 title XI, XVIII, XIX, or XXI of the Social Security Act

18 to seek a waiver of a sanction imposed against a health

19 care provider insofar as that provider provides services to

20 individuals through an Indian Health Program, any re21 quirement that a State request such a waiver shall be

22 deemed to be met if such Indian Health Program requests

23 such a waiver.

24 ‘‘(b) SAFE HARBOR FOR TRANSACTIONS BETWEEN

25 AND AMONG INDIAN HEALTH CARE PROGRAMS.—For
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1 purposes of applying section 1128B(b) of the Social Secu2 rity Act, the exchange of anything of value between or

3 among the following shall not be treated as remuneration

4 if the exchange arises from or relates to any of the follow5 ing health programs:

6 ‘‘(1) An exchange between or among the follow7 ing:

8 ‘‘(A) Any Indian Health Program.

9 ‘‘(B) Any Urban Indian Organization.

10 ‘‘(2) An exchange between an Indian Tribe,

11 Tribal Organization, or an Urban Indian Organiza12 tion and any patient served or eligible for service

13 from an Indian Tribe, Tribal Organization, or

14 Urban Indian Organization, including patients

15 served or eligible for service pursuant to section 807,

16 but only if such exchange—

17 ‘‘(A) is for the purpose of transporting the

18 patient for the provision of health care items or

19 services;

20 ‘‘(B) is for the purpose of providing hous21 ing to the patient (including a pregnant pa22 tient) and immediate family members or an es23 cort incidental to assuring the timely provision

24 of health care items and services to the patient;
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1 ‘‘(C) is for the purpose of paying pre2 miums, copayments, deductibles, or other cost3 sharing on behalf of patients; or

4 ‘‘(D) consists of an item or service of small

5 value that is provided as a reasonable incentive

6 to secure timely and necessary preventive and

7 other items and services.

8 ‘‘(3) Such other exchanges involving an Indian

9 Health Program, an Urban Indian Organization, or

10 an Indian Tribe or Tribal Organization as meet such

11 standards as the Secretary of Health and Human

12 Services, in consultation with the Attorney General,

13 determines is appropriate, taking into account the

14 special circumstances of such Indian Health Pro15 grams, Urban Indian Organizations, Indian Tribes,

16 and Tribal Organizations and of patients served by

17 Indian Health Programs, Urban Indian Organiza18 tions, Indian Tribes, and Tribal Organizations.

19 ‘‘SEC. 412. COST SHARING.

20 ‘‘(a) COINSURANCE, COPAYMENTS, AND

21 DEDUCTIBLES.—Notwithstanding any other provision of

22 Federal or State law—

23 ‘‘(1) PROTECTION FOR ELIGIBLE INDIANS

24 UNDER SOCIAL SECURITY ACT HEALTH PRO25 GRAMS.—No Indian who is furnished an item or
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1 service for which payment may be made under title

2 XVIII, XIX, or XXI of the Social Security Act may

3 be charged a deductible, copayment, or coinsurance

4 if the item or service is furnished by, or upon refer5 ral made by, the Service, an Indian Tribe, Tribal

6 Organization, or Urban Indian Organization.

7 ‘‘(2) PROTECTION FOR INDIANS.—No Indian

8 who is furnished an item or service by the Service

9 may be charged a deductible, copayment, or coinsur10 ance.

11 ‘‘(3) NO REDUCTION IN AMOUNT OF PAYMENT

12 TO INDIAN HEALTH PROVIDERS.—The payment or

13 reimbursement due to the Service, Indian Tribe,

14 Tribal Organization, or Urban Indian Organization

15 under title XVIII, XIX, or XXI of the Social Secu16 rity Act may not be reduced by the amount of the

17 deductible, copayment, or coinsurance that would be

18 due from the Indian but for the operation of this

19 section.

20 ‘‘(b) EXEMPTION FROM MEDICAID AND SCHIP PRE21 MIUMS.—Notwithstanding any other provision of Federal

22 or State law, no Indian who is otherwise eligible for serv23 ices under title XIX of the Social Security Act (relating

24 to the medicaid program) or title XXI of such Act (relat25 ing to the State children’s health insurance program) may
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1 be charged a premium as a condition of receiving benefits

2 under the program under the respective title.

3 ‘‘(c) MEDICALLY NEEDY PROGRAM SPEND-DOWN.—

4 For the purposes of determining the eligibility of an In5 dian for medical assistance under any medically needy op6 tion under a State’s medicaid plan under title XIX of the

7 Social Security Act, the cost of providing services to an

8 Indian in a health program of the Service, an Indian

9 Tribe, Tribal Organization, or Urban Indian Organization

10 shall be deemed to have been an expenditure for health

11 care by the Indian.

12 ‘‘(d) LIMITATION ON MEDICAL CHILD SUPPORT RE13 COVERY.—Notwithstanding any other provision of law, a

14 parent (whether or not an Indian) of an Indian child shall

15 not be responsible for reimbursing a State or the Federal

16 Government under title XIX or XXI of the Social Security

17 Act for the cost of medical services relating to the child

18 (including childbirth and including, where such child is a

19 minor parent, any child of such minor parent) under cir20 cumstances in which payment would have been made

21 under the contract health services program of an Indian

22 Health Program but for the child’s (or, in the case of med23 ical services relating to childbirth, mother’s, or grand24 child’s, as the case may be) eligibility under title XIX or

25 XXI of the Social Security Act.
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1 ‘‘(e) TREATMENT OF CERTAIN PROPERTY FOR MED2 ICAID ELIGIBILITY.—Notwithstanding any other provision

3 of Federal or State law, the following property may not

4 be included when determining eligibility for services under

5 title XIX of the Social Security Act:

6 ‘‘(1) Property, including interests in real prop7 erty currently or formerly held in trust by the Fed8 eral Government which is protected under applicable

9 Federal, State, or Tribal law or custom from re10 course and including public domain allotments.

11 ‘‘(2) Property that has unique religious or cul12 tural significance or that supports subsistence or

13 traditional lifestyle according to applicable Tribal

14 law or custom.

15 ‘‘(f) CONTINUATION OF CURRENT LAW PROTEC16 TIONS OF CERTAIN INDIAN PROPERTY FROM MEDICAID

17 ESTATE RECOVERY.—Income, resources, and property

18 that are exempt from medicaid estate recovery under title

19 XIX of the Social Security Act as of April 1, 2003, under

20 manual instructions issued to carry out section 1917(b)(3)

21 of such Act because of Federal responsibility for Indian

22 Tribes and Alaska Native Villages shall remain so exempt.

23 Nothing in this subsection shall be construed as prevent24 ing the Secretary from providing additional medicaid es25 tate recovery exemptions for Indians.
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1 ‘‘SEC. 413. TREATMENT UNDER MEDICAID MANAGED CARE.

2 ‘‘(a) PAYMENT FOR SERVICES FURNISHED TO INDI3 ANS.—In the case of an Indian who is enrolled with a

4 managed care entity under section 1932 of the Social Se5 curity Act (or otherwise under a waiver under title XIX

6 of such Act) and who receives covered services from an

7 Indian Health Program or an Urban Indian Organization,

8 either—

9 ‘‘(1) the entity shall make payment to the In10 dian Health Program or Urban Indian Organization

11 at a rate established by the entity for such services

12 that is not less than the rate for preferred providers

13 (or at such other rate as may be negotiated between

14 the entity and such Indian Health Program or

15 Urban Indian Organization) and shall not require

16 submittal of a claim by the enrollee as a condition

17 of payment to the Indian Health Program or Urban

18 Indian Organization; or

19 ‘‘(2) the State shall provide for payment to the

20 Indian Health Program or Urban Indian Organiza21 tion under its State plan under title XIX of such

22 Act at the rate otherwise applicable and shall pro23 vide for an appropriate adjustment of the capitation

24 payment made to the entity to take into account

25 such payment.

26 ‘‘(b) OFFERING OF MANAGED CARE.—If—
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1 ‘‘(1) a State elects under its State plan under

2 title XIX of the Social Security Act to provide serv3 ices through medicaid managed care organizations

4 or through primary care case managers under sec5 tion 1932 or under a waiver under such title; and

6 ‘‘(2) the Indian Health Program or Urban In7 dian Organization that is funded in whole or in part

8 by the Service, or a consortium thereof, has estab9 lished a medicaid managed care organization or a

10 primary care case manager that meets quality stand11 ards equivalent to those required of such an organi12 zation or manager under such section or waiver,

13 the State shall enter into an agreement under such section

14 with the Service, Indian Tribe, Tribal Organization, or

15 Urban Indian Organization, or such consortium, to serve

16 as a medicaid managed care organization or a primary

17 care case manager, respectively with respect to Indians

18 served by such entity. In carrying out this subsection, the

19 Secretary and the State may waive requirements regard20 ing enrollment, capitalization, and such other matters that

21 might otherwise prevent the application of the previous

22 sentence.

23 ‘‘SEC. 414. NAVAJO NATION MEDICAID AGENCY.

24 ‘‘(a) IN GENERAL.—Notwithstanding any other pro25 vision of law, the Secretary is authorized to treat the Nav-
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1 ajo Nation as a State for the purposes of title XIX of

2 the Social Security Act, to provide services to Indians liv3 ing within the boundaries of the Navajo Nation.

4 ‘‘(b) ASSIGNMENT AND PAYMENT.—Notwithstanding

5 any other provision of law, the Secretary may assign and

6 pay all expenditures for the provision of services to Indi7 ans living within the boundaries of the Navajo Nation

8 under title XIX of the Social Security Act and related ad9 ministrative funds under such title, which are currently

10 paid to or would otherwise be paid to the States of Ari11 zona, New Mexico, and Utah, to an entity established by

12 the Navajo Nation and approved by the Secretary, which

13 shall be denominated the Navajo Nation Medicaid Agency.

14 ‘‘(c) AUTHORITY.—The Navajo Nation Medicaid

15 Agency shall serve Indians living within the boundaries of

16 the Navajo Nation and shall have the same authority and

17 perform the same functions as other single State medicaid

18 agencies responsible for the administration of the State

19 plan under title XIX of the Social Security Act.

20 ‘‘(d) TECHNICAL ASSISTANCE.—The Secretary may

21 directly assist the Navajo Nation in the development and

22 implementation of a Navajo Nation Medicaid Agency for

23 the administration, eligibility, payment, and delivery of

24 medical assistance under title XIX of the Social Security

25 Act (which shall, for purposes of reimbursement to such
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1 Nation, include Western and traditional Navajo healing

2 services) within the Navajo Nation.

3 ‘‘(e) FMAP.—Notwithstanding section 1905(b) of

4 the Social Security Act, the Federal medical assistance

5 percentage shall be 100 per centum with respect to

6 amounts the Navajo Nation Medicaid Agency expends for

7 medical assistance for services and for related administra8 tive costs.

9 ‘‘(f) DEMONSTRATION FUNDING.—The Secretary is

10 further authorized to assist the Navajo Nation by provid11 ing funding including demonstration grant funding for

12 this project.

13 ‘‘(g) WAIVER AUTHORITY.—The Secretary shall have

14 the authority to waive applicable provisions of title XIX

15 of the Social Security Act to establish, develop, and imple16 ment the Navajo Nation Medicaid Agency.

17 ‘‘(h) OPTIONAL APPLICATION TO SCHIP.—In the

18 option of the Navajo Nation, the Secretary is authorized

19 to treat the Navajo Nation as a State for the purposes

20 of title XXI of the Social Security Act (relating to the

21 State children’s health insurance program) under terms

22 equivalent to those described in subsections (a) through

23 (g).
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1 ‘‘SEC. 415. AUTHORIZATION OF APPROPRIATIONS.

2 ‘‘There are authorized to be appropriated such sums

3 as may be necessary for each fiscal year through fiscal

4 year 2015 to carry out this title.

5 ‘‘TITLE V—HEALTH SERVICES

6 FOR URBAN INDIANS

7 ‘‘SEC. 501. PURPOSE.

8 ‘‘The purpose of this title is to establish programs

9 in Urban Centers to make health services more accessible

10 and available to Urban Indians.

11 ‘‘SEC. 502. CONTRACTS WITH, AND GRANTS TO, URBAN IN12 DIAN ORGANIZATIONS.

13 ‘‘Under authority of the Act of November 2, 1921

14 (25 U.S.C. 13; popularly known as the Snyder Act), the

15 Secretary, acting through the Service, shall enter into con16 tracts with, or make grants to, Urban Indian Organiza17 tions to assist such organizations in the establishment and

18 administration, within Urban Centers, of programs which

19 meet the requirements set forth in this title. Subject to

20 section 506, the Secretary, acting through the Service,

21 shall include such conditions as the Secretary considers

22 necessary to effect the purpose of this title in any contract

23 into which the Secretary enters with, or in any grant the

24 Secretary makes to, any Urban Indian Organization pur25 suant to this title.
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1 ‘‘SEC. 503. CONTRACTS AND GRANTS FOR THE PROVISION

2 OF HEALTH CARE AND REFERRAL SERVICES.

3 ‘‘(a) REQUIREMENTS FOR GRANTS AND CON4 TRACTS.—Under authority of the Act of November 2,

5 1921 (25 U.S.C. 13; popularly known as the Snyder Act),

6 the Secretary, acting through the Service, shall enter into

7 contracts with, and make grants to, Urban Indian Organi8 zations for the provision of health care and referral serv9 ices for Urban Indians. Any such contract or grant shall

10 include requirements that the Urban Indian Organization

11 successfully undertake to—

12 ‘‘(1) estimate the population of Urban Indians

13 residing in the Urban Center or centers that the or14 ganization proposes to serve who are or could be re15 cipients of health care or referral services;

16 ‘‘(2) estimate the current health status of

17 Urban Indians residing in such Urban Center or

18 centers;

19 ‘‘(3) estimate the current health care needs of

20 Urban Indians residing in such Urban Center or

21 centers;

22 ‘‘(4) provide basic health education, including

23 health promotion and disease prevention education,

24 to Urban Indians;

25 ‘‘(5) make recommendations to the Secretary

26 and Federal, State, local, and other resource agen-
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1 cies on methods of improving health service pro2 grams to meet the needs of Urban Indians; and

3 ‘‘(6) where necessary, provide, or enter into

4 contracts for the provision of, health care services

5 for Urban Indians.

6 ‘‘(b) CRITERIA.—The Secretary, acting through the

7 Service, shall by regulation adopted pursuant to section

8 520 prescribe the criteria for selecting Urban Indian Or9 ganizations to enter into contracts or receive grants under

10 this section. Such criteria shall, among other factors,

11 include—

12 ‘‘(1) the extent of unmet health care needs of

13 Urban Indians in the Urban Center or centers in14 volved;

15 ‘‘(2) the size of the Urban Indian population in

16 the Urban Center or centers involved;

17 ‘‘(3) the extent, if any, to which the activities

18 set forth in subsection (a) would duplicate any

19 project funded under this title;

20 ‘‘(4) the capability of an Urban Indian Organi21 zation to perform the activities set forth in sub22 section (a) and to enter into a contract with the Sec23 retary or to meet the requirements for receiving a

24 grant under this section;
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1 ‘‘(5) the satisfactory performance and success2 ful completion by an Urban Indian Organization of

3 other contracts with the Secretary under this title;

4 ‘‘(6) the appropriateness and likely effectiveness

5 of conducting the activities set forth in subsection

6 (a) in an Urban Center or centers; and

7 ‘‘(7) the extent of existing or likely future par8 ticipation in the activities set forth in subsection (a)

9 by appropriate health and health-related Federal,

10 State, local, and other agencies.

11 ‘‘(c) ACCESS TO HEALTH PROMOTION AND DISEASE

12 PREVENTION PROGRAMS.—The Secretary, acting through

13 the Service, shall facilitate access to or provide health pro14 motion and disease prevention services for Urban Indians

15 through grants made to Urban Indian Organizations ad16 ministering contracts entered into or receiving grants

17 under subsection (a).

18 ‘‘(d) IMMUNIZATION SERVICES.—

19 ‘‘(1) ACCESS OR SERVICES PROVIDED.—The

20 Secretary, acting through the Service, shall facilitate

21 access to, or provide, immunization services for

22 Urban Indians through grants made to Urban In23 dian Organizations administering contracts entered

24 into or receiving grants under this section.
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1 ‘‘(2) DEFINITION.—For purposes of this sub2 section, the term ‘immunization services’ means

3 services to provide without charge immunizations

4 against vaccine-preventable diseases.

5 ‘‘(e) MENTAL HEALTH SERVICES.—

6 ‘‘(1) ACCESS OR SERVICES PROVIDED.—The

7 Secretary, acting through the Service, shall facilitate

8 access to, or provide, mental health services for

9 Urban Indians through grants made to Urban In10 dian Organizations administering contracts entered

11 into or receiving grants under subsection (a).

12 ‘‘(2) ASSESSMENT REQUIRED.—Except as pro13 vided by paragraph (3)(A), a grant may not be made

14 under this subsection to an Urban Indian Organiza15 tion until that organization has prepared, and the

16 Service has approved, an assessment of the follow17 ing:

18 ‘‘(A) The mental health needs of the

19 Urban Indian population concerned.

20 ‘‘(B) The mental health services and other

21 related resources available to that population.

22 ‘‘(C) The barriers to obtaining those serv23 ices and resources.

24 ‘‘(D) The needs that are unmet by such

25 services and resources.
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1 ‘‘(3) PURPOSES OF GRANTS.—Grants may be

2 made under this subsection for the following:

3 ‘‘(A) To prepare assessments required

4 under paragraph (2).

5 ‘‘(B) To provide outreach, educational, and

6 referral services to Urban Indians regarding the

7 availability of direct behavioral health services,

8 to educate Urban Indians about behavioral

9 health issues and services, and effect coordina10 tion with existing behavioral health providers in

11 order to improve services to Urban Indians.

12 ‘‘(C) To provide outpatient behavioral

13 health services to Urban Indians, including the

14 identification and assessment of illness, thera15 peutic treatments, case management, support

16 groups, family treatment, and other treatment.

17 ‘‘(D) To develop innovative behavioral

18 health service delivery models which incorporate

19 Indian cultural support systems and resources.

20 ‘‘(f) PREVENTION OF CHILD ABUSE.—

21 ‘‘(1) ACCESS OR SERVICES PROVIDED.—The

22 Secretary, acting through the Service, shall facilitate

23 access to or provide services for Urban Indians

24 through grants to Urban Indian Organizations ad25 ministering contracts entered into or receiving
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1 grants under subsection (a) to prevent and treat

2 child abuse (including sexual abuse) among Urban

3 Indians.

4 ‘‘(2) EVALUATION REQUIRED.—Except as pro5 vided by paragraph (3)(A), a grant may not be made

6 under this subsection to an Urban Indian Organiza7 tion until that organization has prepared, and the

8 Service has approved, an assessment that documents

9 the prevalence of child abuse in the Urban Indian

10 population concerned and specifies the services and

11 programs (which may not duplicate existing services

12 and programs) for which the grant is requested.

13 ‘‘(3) PURPOSES OF GRANTS.—Grants may be

14 made under this subsection for the following:

15 ‘‘(A) To prepare assessments required

16 under paragraph (2).

17 ‘‘(B) For the development of prevention,

18 training, and education programs for Urban In19 dians, including child education, parent edu20 cation, provider training on identification and

21 intervention, education on reporting require22 ments, prevention campaigns, and establishing

23 service networks of all those involved in Indian

24 child protection.
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1 ‘‘(C) To provide direct outpatient treat2 ment services (including individual treatment,

3 family treatment, group therapy, and support

4 groups) to Urban Indians who are child victims

5 of abuse (including sexual abuse) or adult sur6 vivors of child sexual abuse, to the families of

7 such child victims, and to Urban Indian per8 petrators of child abuse (including sexual

9 abuse).

10 ‘‘(4) CONSIDERATIONS WHEN MAKING

11 GRANTS.—In making grants to carry out this sub12 section, the Secretary shall take into consideration—

13 ‘‘(A) the support for the Urban Indian Or14 ganization demonstrated by the child protection

15 authorities in the area, including committees or

16 other services funded under the Indian Child

17 Welfare Act of 1978 (25 U.S.C. 1901 et seq.),

18 if any;

19 ‘‘(B) the capability and expertise dem20 onstrated by the Urban Indian Organization to

21 address the complex problem of child sexual

22 abuse in the community; and

23 ‘‘(C) the assessment required under para24 graph (2).
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1 ‘‘(g) OTHER GRANTS.—The Secretary, acting

2 through the Service, may enter into a contract with or

3 make grants to an Urban Indian Organization that pro4 vides or arranges for the provision of health care services

5 (through satellite facilities, provider networks, or other6 wise) to Urban Indians in more than 1 Urban Center.

7 ‘‘SEC. 504. CONTRACTS AND GRANTS FOR THE DETERMINA8 TION OF UNMET HEALTH CARE NEEDS.

9 ‘‘(a) GRANTS AND CONTRACTS AUTHORIZED.—

10 Under authority of the Act of November 2, 1921 (25

11 U.S.C. 13; popularly known as the Snyder Act), the Sec12 retary, acting through the Service, may enter into con13 tracts with or make grants to Urban Indian Organizations

14 situated in Urban Centers for which contracts have not

15 been entered into or grants have not been made under sec16 tion 503.

17 ‘‘(b) PURPOSE.—The purpose of a contract or grant

18 made under this section shall be the determination of the

19 matters described in subsection (c)(1) in order to assist

20 the Secretary in assessing the health status and health

21 care needs of Urban Indians in the Urban Center involved

22 and determining whether the Secretary should enter into

23 a contract or make a grant under section 503 with respect

24 to the Urban Indian Organization which the Secretary has
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1 entered into a contract with, or made a grant to, under

2 this section.

3 ‘‘(c) GRANT AND CONTRACT REQUIREMENTS.—Any

4 contract entered into, or grant made, by the Secretary

5 under this section shall include requirements that—

6 ‘‘(1) the Urban Indian Organization success7 fully undertakes to—

8 ‘‘(A) document the health care status and

9 unmet health care needs of Urban Indians in

10 the Urban Center involved; and

11 ‘‘(B) with respect to Urban Indians in the

12 Urban Center involved, determine the matters

13 described in paragraphs (2), (3), (4), and (7) of

14 section 503(b); and

15 ‘‘(2) the Urban Indian Organization complete

16 performance of the contract, or carry out the re17 quirements of the grant, within 1 year after the date

18 on which the Secretary and such organization enter

19 into such contract, or within 1 year after such orga20 nization receives such grant, whichever is applicable.

21 ‘‘(d) NO RENEWALS.—The Secretary may not renew

22 any contract entered into or grant made under this sec23 tion.
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1 ‘‘SEC. 505. EVALUATIONS; RENEWALS.

2 ‘‘(a) PROCEDURES FOR EVALUATIONS.—The Sec3 retary, acting through the Service, shall develop proce4 dures to evaluate compliance with grant requirements and

5 compliance with and performance of contracts entered into

6 by Urban Indian Organizations under this title. Such pro7 cedures shall include provisions for carrying out the re8 quirements of this section.

9 ‘‘(b) EVALUATIONS.—The Secretary, acting through

10 the Service, shall evaluate the compliance of each Urban

11 Indian Organization which has entered into a contract or

12 received a grant under section 503 with the terms of such

13 contract or grant. For purposes of this evaluation, in de14 termining the capacity of an Urban Indian Organization

15 to deliver quality patient care the Secretary shall, at the

16 option of the organization—

17 ‘‘(1) acting through the Service, conduct an an18 nual onsite evaluation of the organization; or

19 ‘‘(2) accept in lieu of such onsite evaluation evi20 dence of the organization’s provisional or full accred21 itation by a private independent entity recognized by

22 the Secretary for purposes of conducting quality re23 views of providers participating in the Medicare pro24 gram under title XVIII of the Social Security Act.

25 ‘‘(c) NONCOMPLIANCE; UNSATISFACTORY PERFORM26 ANCE.—If, as a result of the evaluations conducted under
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1 this section, the Secretary determines that an Urban In2 dian Organization has not complied with the requirements

3 of a grant or complied with or satisfactorily performed a

4 contract under section 503, the Secretary shall, prior to

5 renewing such contract or grant, attempt to resolve with

6 the organization the areas of noncompliance or unsatisfac7 tory performance and modify the contract or grant to pre8 vent future occurrences of noncompliance or unsatisfac9 tory performance. If the Secretary determines that the

10 noncompliance or unsatisfactory performance cannot be

11 resolved and prevented in the future, the Secretary shall

12 not renew the contract or grant with the organization and

13 is authorized to enter into a contract or make a grant

14 under section 503 with another Urban Indian Organiza15 tion which is situated in the same Urban Center as the

16 Urban Indian Organization whose contract or grant is not

17 renewed under this section.

18 ‘‘(d) CONSIDERATIONS FOR RENEWALS.—In deter19 mining whether to renew a contract or grant with an

20 Urban Indian Organization under section 503 which has

21 completed performance of a contract or grant under sec22 tion 504, the Secretary shall review the records of the

23 Urban Indian Organization, the reports submitted under

24 section 507, and shall consider the results of the onsite

25 evaluations or accreditations under subsection (b).
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1 ‘‘SEC. 506. OTHER CONTRACT AND GRANT REQUIREMENTS.

2 ‘‘(a) PROCUREMENT.—Contracts with Urban Indian

3 Organizations entered into pursuant to this title shall be

4 in accordance with all Federal contracting laws and regu5 lations relating to procurement except that in the discre6 tion of the Secretary, such contracts may be negotiated

7 without advertising and need not conform to the provisions

8 of sections 1304, 3131, and 3133 of title 40, United

9 States Code.

10 ‘‘(b) PAYMENTS UNDER CONTRACTS OR GRANTS.—

11 Payments under any contracts or grants pursuant to this

12 title shall, notwithstanding any term or condition of such

13 contract or grant—

14 ‘‘(1) be made in their entirety by the Secretary

15 to the Urban Indian Organization by no later than

16 the end of the first 30 days of the funding period

17 with respect to which the payments apply, unless the

18 Secretary determines through an evaluation under

19 section 505 that the organization is not capable of

20 administering such payments in their entirety; and

21 ‘‘(2) if any portion thereof is unexpended by the

22 Urban Indian Organization during the funding pe23 riod with respect to which the payments initially

24 apply, shall be carried forward for expenditure with

25 respect to allowable or reimbursable costs incurred

26 by the organization during 1 or more subsequent
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1 funding periods without additional justification or

2 documentation by the organization as a condition of

3 carrying forward the availability for expenditure of

4 such funds.

5 ‘‘(c) REVISION OR AMENDMENT OF CONTRACTS.—

6 Notwithstanding any provision of law to the contrary, the

7 Secretary may, at the request or consent of an Urban In8 dian Organization, revise or amend any contract entered

9 into by the Secretary with such organization under this

10 title as necessary to carry out the purposes of this title.

11 ‘‘(d) FAIR AND UNIFORM SERVICES AND ASSIST12 ANCE.—Contracts with or grants to Urban Indian Organi13 zations and regulations adopted pursuant to this title shall

14 include provisions to assure the fair and uniform provision

15 to Urban Indians of services and assistance under such

16 contracts or grants by such organizations.

17 ‘‘SEC. 507. REPORTS AND RECORDS.

18 ‘‘(a) REPORTS.—For each fiscal year during which

19 an Urban Indian Organization receives or expends funds

20 pursuant to a contract entered into or a grant received

21 pursuant to this title, such Urban Indian Organization

22 shall submit to the Secretary not more frequently than

23 every 6 months, a report that includes the following:
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1 ‘‘(1) In the case of a contract or grant under

2 section 503, recommendations pursuant to section

3 503(a)(5).

4 ‘‘(2) Information on activities conducted by the

5 organization pursuant to the contract or grant.

6 ‘‘(3) An accounting of the amounts and purpose

7 for which Federal funds were expended.

8 ‘‘(4) A minimum set of data, using uniformly

9 defined elements, that is specified by the Secretary

10 in consultation, consistent with section 514, with

11 Urban Indian Organizations.

12 ‘‘(b) AUDIT.—The reports and records of the Urban

13 Indian Organization with respect to a contract or grant

14 under this title shall be subject to audit by the Secretary

15 and the Comptroller General of the United States.

16 ‘‘(c) COSTS OF AUDITS.—The Secretary shall allow

17 as a cost of any contract or grant entered into or awarded

18 under section 502 or 503 the cost of an annual independ19 ent financial audit conducted by—

20 ‘‘(1) a certified public accountant; or

21 ‘‘(2) a certified public accounting firm qualified

22 to conduct Federal compliance audits.

23 ‘‘SEC. 508. LIMITATION ON CONTRACT AUTHORITY.

24 ‘‘The authority of the Secretary to enter into con25 tracts or to award grants under this title shall be to the
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1 extent, and in an amount, provided for in appropriation

2 Acts.

3 ‘‘SEC. 509. FACILITIES.

4 ‘‘(a) GRANTS.—The Secretary, acting through the

5 Service, may make grants to contractors or grant recipi6 ents under this title for the lease, purchase, renovation,

7 construction, or expansion of facilities, including leased fa8 cilities, in order to assist such contractors or grant recipi9 ents in complying with applicable licensure or certification

10 requirements.

11 ‘‘(b) LOANS.—The Secretary, acting through the

12 Service or through the Health Resources and Services Ad13 ministration, may provide to contractors or grant recipi14 ents under this title loans from the Urban Indian Health

15 Care Facilities Revolving Loan Fund described in sub16 section (c), or guarantees for loans, for the construction,

17 renovation, expansion, or purchase of health care facilities,

18 subject to the following requirements:

19 ‘‘(1) The principal amount of a loan or loan

20 guarantee may cover 100 percent of the costs (other

21 than staffing) relating to the facility, including plan22 ning, design, financing, site land development, con23 struction, rehabilitation, renovation, conversion,

24 medical equipment, furnishings, and capital pur25 chase.
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1 ‘‘(2) The total of the principal of loans and loan

2 guarantees, respectively, outstanding at any one

3 time shall not exceed such limitations as may be

4 specified in appropriation Acts.

5 ‘‘(3) The loan or loan guarantee may have a

6 term of the shorter of the estimated useful life of the

7 facility or 25 years.

8 ‘‘(4) An Urban Indian Organization may as9 sign, and the Secretary may accept assignment of,

10 the revenue of the Urban Indian Organization as se11 curity for a loan or loan guarantee under this sub12 section.

13 ‘‘(5) The Secretary shall not collect application,

14 processing, or similar fees from Urban Indian Orga15 nizations applying for loans or loan guarantees

16 under this subsection.

17 ‘‘(c) FUND.—

18 ‘‘(1) ESTABLISHMENT.—There is established in

19 the Treasury of the United States a fund to be

20 known as the Urban Indian Health Care Facilities

21 Revolving Loan Fund (hereafter in this section re22 ferred to as the ‘‘URLF’’). The URLF shall consist

23 of—

24 ‘‘(A) such amounts as may be appropriated

25 to the URLF;
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1 ‘‘(B) amounts received from Urban Indian

2 Organizations in repayment of loans made to

3 such organizations under paragraph (2); and

4 ‘‘(C) interest earned on amounts in the

5 URLF under paragraph (3).

6 ‘‘(2) USE OF AMOUNT IN FUND.—Amounts in

7 the URLF may be expended by the Secretary, acting

8 through the Service or the Health Resources and

9 Services Administration, to make loans available to

10 Urban Indian Organizations receiving grants or con11 tracts under this title for the purposes, and subject

12 to the requirements, described in subsection (b).

13 Amounts appropriated to the URLF, amounts re14 ceived from Urban Indian Organizations in repay15 ment of loans, and interest on amounts in the

16 URLF shall remain available until expended.

17 ‘‘(3) INVESTMENT OF AMOUNTS IN FUND.—The

18 Secretary of the Treasury shall invest such amounts

19 of the URLF as such Secretary determines are not

20 required to meet current withdrawals from the

21 URLF. Such investments may be made only in in22 terest-bearing obligations of the United States. For

23 such purpose, such obligations may be acquired on

24 original issue at the issue price or by purchase of

25 outstanding obligations at the market price. Any ob-
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1 ligation acquired by the URLF may be sold by the

2 Secretary of the Treasury at the market price.

3 ‘‘(4) INITIAL FUNDS.—There are authorized to

4 be appropriated such sums as may be necessary to

5 initiate the URLF. For each fiscal year after the ini6 tial year in which funds are appropriated to the

7 URLF, there is authorized to be appropriated an

8 amount equal to the sum of the amount collected by

9 the URLF during the preceding fiscal year and all

10 accrued interest.

11 ‘‘SEC. 510. OFFICE OF URBAN INDIAN HEALTH.

12 ‘‘There is hereby established within the Service an

13 Office of Urban Indian Health, which shall be responsible

14 for—

15 ‘‘(1) carrying out the provisions of this title;

16 ‘‘(2) providing central oversight of the pro17 grams and services authorized under this title; and

18 ‘‘(3) providing technical assistance to Urban In19 dian Organizations.

20 ‘‘SEC. 511. GRANTS FOR ALCOHOL AND SUBSTANCE ABUSE21 RELATED SERVICES.

22 ‘‘(a) GRANTS AUTHORIZED.—The Secretary, acting

23 through the Service, may make grants for the provision

24 of health-related services in prevention of, treatment of,

25 rehabilitation of, or school- and community-based edu-
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1 cation regarding, alcohol and substance abuse in Urban

2 Centers to those Urban Indian Organizations with which

3 the Secretary has entered into a contract under this title

4 or under section 201.

5 ‘‘(b) GOALS.—Each grant made pursuant to sub6 section (a) shall set forth the goals to be accomplished

7 pursuant to the grant. The goals shall be specific to each

8 grant as agreed to between the Secretary and the grantee.

9 ‘‘(c) CRITERIA.—The Secretary shall establish cri10 teria for the grants made under subsection (a), including

11 criteria relating to the following:

12 ‘‘(1) The size of the Urban Indian population.

13 ‘‘(2) Capability of the organization to ade14 quately perform the activities required under the

15 grant.

16 ‘‘(3) Satisfactory performance standards for the

17 organization in meeting the goals set forth in such

18 grant. The standards shall be negotiated and agreed

19 to between the Secretary and the grantee on a

20 grant-by-grant basis.

21 ‘‘(4) Identification of the need for services.

22 ‘‘(d) ALLOCATION OF GRANTS.—The Secretary shall

23 develop a methodology for allocating grants made pursu24 ant to this section based on the criteria established pursu25 ant to subsection (c).
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1 ‘‘(e) GRANTS SUBJECT TO CRITERIA.—Any funds re2 ceived by an Urban Indian Organization under this Act

3 for substance abuse prevention, treatment, and rehabilita4 tion shall be subject to the criteria set forth in subsection

5 (c).

6 ‘‘SEC. 512. TREATMENT OF CERTAIN DEMONSTRATION

7 PROJECTS.

8 ‘‘Notwithstanding any other provision of law, the

9 Tulsa Clinic and Oklahoma City Clinic demonstration

10 projects shall—

11 ‘‘(1) be permanent programs within the Serv12 ice’s direct care program;

13 ‘‘(2) continue to be treated as Service Units in

14 the allocation of resources and coordination of care;

15 and

16 ‘‘(3) shall be subject to the provisions of the In17 dian Self-Determination and Education Assistance

18 Act, except that the programs shall not be divisible.

19 ‘‘SEC. 513. URBAN NIAAA TRANSFERRED PROGRAMS.

20 ‘‘(a) GRANTS AND CONTRACTS.—The Secretary,

21 through the Office of Urban Indian Health, shall make

22 grants or enter into contracts with Urban Indian Organi23 zations for the administration of Urban Indian alcohol

24 programs that were originally established under the Na25 tional Institute on Alcoholism and Alcohol Abuse (here-
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1 after in this section referred to as ‘NIAAA’) and trans2 ferred to the Service. Such grants and contracts shall be3 come effective no later than September 30, 2004.

4 ‘‘(b) USE OF FUNDS.—Grants provided or contracts

5 entered into under this section shall be used to provide

6 support for the continuation of alcohol prevention and

7 treatment services for Urban Indian populations and such

8 other objectives as are agreed upon between the Service

9 and a recipient of a grant or contract under this section.

10 ‘‘(c) ELIGIBILITY.—Urban Indian Organizations that

11 operate Indian alcohol programs originally funded under

12 the NIAAA and subsequently transferred to the Service

13 are eligible for grants or contracts under this section.

14 ‘‘(d) REPORT.—The Secretary shall evaluate and re15 port to Congress on the activities of programs funded

16 under this section not less than every 5 years.

17 ‘‘SEC. 514. CONSULTATION WITH URBAN INDIAN ORGANIZA18 TIONS.

19 ‘‘(a) IN GENERAL.—The Secretary shall ensure that

20 the Service, the Centers for Medicare & Medicaid Services,

21 and other operating divisions and staff divisions of the De22 partment consult, to the greatest extent practicable, with

23 Urban Indian Organizations prior to taking any action,

24 or approving Federal financial assistance for any action
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1 of a State, that may affect Urban Indians or Urban Indian

2 Organizations.

3 ‘‘(b) DEFINITION OF CONSULTATION.—For purposes

4 of subsection (a), consultation is the open and free ex5 change of information and opinion among Urban Indian

6 Organizations and the operating and staff divisions of the

7 Department which leads to mutual understanding and

8 comprehension and which emphasizes trust, respect, and

9 shared responsibility.

10 ‘‘SEC. 515. FEDERAL TORT CLAIM ACT COVERAGE.

11 ‘‘(a) IN GENERAL.—With respect to claims resulting

12 from the performance of functions during fiscal year 2004

13 and thereafter, or claims asserted after September 30,

14 2003, but resulting from the performance of functions

15 prior to fiscal year 2004, under a contract, grant agree16 ment, or any other agreement authorized under this title,

17 an Urban Indian Organization is deemed hereafter to be

18 part of the Service in the Department of Health and

19 Human Services while carrying out any such contract or

20 agreement and its employees are deemed employees of the

21 Service while acting within the scope of their employment

22 in carrying out the contract or agreement. After Septem23 ber 30, 2003, any civil action or proceeding involving such

24 claims brought hereafter against any Urban Indian Orga25 nization or any employee of such Urban Indian Organiza-
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1 tion covered by this provision shall be deemed to be an

2 action against the United States and will be defended by

3 the Attorney General and be afforded the full protection

4 and coverage of the Federal Tort Claims Act (28 U.S.C.

5 1346(b), 2671 et seq.).

6 ‘‘(b) CLAIMS RESULTING FROM PERFORMANCE OF

7 CONTRACT OR GRANT.—Beginning with the fiscal year

8 ending September 30, 2003, and thereafter, the appro9 priate Secretary shall request through annual appropria10 tions funds sufficient to reimburse the Treasury for any

11 claims paid in the prior fiscal year pursuant to the fore12 going provisions.

13 ‘‘(c) EFFECT ON ISDEAA.—Nothing in this section

14 shall in any way affect the provisions of section 102(d)

15 of the Indian Self-Determination and Education Assist16 ance Act of 1975 (25 U.S.C. 450f(d)).

17 ‘‘SEC. 516. URBAN YOUTH TREATMENT CENTER DEM18 ONSTRATION.

19 ‘‘(a) CONSTRUCTION AND OPERATION.—The Sec20 retary, acting through the Service, through grant or con21 tract, shall make payment for the construction and oper22 ation of at least 2 residential treatment centers in each

23 State described in subsection (b) to demonstrate the provi24 sion of alcohol and substance abuse treatment services to
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1 Urban Indian youth in a culturally competent residential

2 setting.

3 ‘‘(b) DEFINITION OF STATE.—A State described in

4 this subsection is a State in which—

5 ‘‘(1) there resides Urban Indian youth with

6 need for alcohol and substance abuse treatment serv7 ices in a residential setting; and

8 ‘‘(2) there is a significant shortage of culturally

9 competent residential treatment services for Urban

10 Indian youth.

11 ‘‘SEC. 517. USE OF FEDERAL GOVERNMENT FACILITIES AND

12 SOURCES OF SUPPLY.

13 ‘‘(a) AUTHORIZATION FOR USE.—The Secretary, act14 ing through the Service, shall allow an Urban Indian Or15 ganization that has entered into a contract or received a

16 grant pursuant to this title, in carrying out such contract

17 or grant, to use existing facilities and all equipment there18 in or pertaining thereto and other personal property

19 owned by the Federal Government within the Secretary’s

20 jurisdiction under such terms and conditions as may be

21 agreed upon for their use and maintenance.

22 ‘‘(b) DONATIONS.—Subject to subsection (d), the

23 Secretary may donate to an Urban Indian Organization

24 that has entered into a contract or received a grant pursu25 ant to this title any personal or real property determined
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1 to be excess to the needs of the Service or the General

2 Services Administration for purposes of carrying out the

3 contract or grant.

4 ‘‘(c) ACQUISITION OF PROPERTY FOR DONATION.—

5 The Secretary may acquire excess or surplus government

6 personal or real property for donation (subject to sub7 section (d)), to an Urban Indian Organization that has

8 entered into a contract or received a grant pursuant to

9 this title if the Secretary determines that the property is

10 appropriate for use by the Urban Indian Organization for

11 a purpose for which a contract or grant is authorized

12 under this title.

13 ‘‘(d) PRIORITY.—In the event that the Secretary re14 ceives a request for donation of a specific item of personal

15 or real property described in subsection (b) or (c) from

16 both an Urban Indian Organization and from an Indian

17 Tribe or Tribal Organization, the Secretary shall give pri18 ority to the request for donation of the Indian Tribe or

19 Tribal Organization if the Secretary receives the request

20 from the Indian Tribe or Tribal Organization before the

21 date the Secretary transfers title to the property or, if ear22 lier, the date the Secretary transfers the property phys23 ically to the Urban Indian Organization.

24 ‘‘(e) URBAN INDIAN ORGANIZATIONS DEEMED EX25 ECUTIVE AGENCY FOR CERTAIN PURPOSES.—For pur-
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1 poses of section 501 of title 40, United States Code, (relat2 ing to Federal sources of supply, including lodging provid3 ers, airlines, and other transportation providers), an

4 Urban Indian Organization that has entered into a con5 tract or received a grant pursuant to this title shall be

6 deemed an executive agency when carrying out such con7 tract or grant, and the employees of the Urban Indian

8 Organization shall be eligible to have access to such

9 sources of supply on the same basis as employees of an

10 executive agency have such access.

11 ‘‘SEC. 518. GRANTS FOR DIABETES PREVENTION, TREAT12 MENT, AND CONTROL.

13 ‘‘(a) GRANTS AUTHORIZED.—The Secretary may

14 make grants to those Urban Indian Organizations that

15 have entered into a contract or have received a grant

16 under this title for the provision of services for the preven17 tion and treatment of, and control of the complications

18 resulting from, diabetes among Urban Indians.

19 ‘‘(b) GOALS.—Each grant made pursuant to sub20 section (a) shall set forth the goals to be accomplished

21 under the grant. The goals shall be specific to each grant

22 as agreed to between the Secretary and the grantee.

23 ‘‘(c) ESTABLISHMENT OF CRITERIA.—The Secretary

24 shall establish criteria for the grants made under sub25 section (a) relating to the following:
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1 ‘‘(1) The size and location of the Urban Indian

2 population to be served.

3 ‘‘(2) The need for prevention of and treatment

4 of, and control of the complications resulting from,

5 diabetes among the Urban Indian population to be

6 served.

7 ‘‘(3) Performance standards for the organiza8 tion in meeting the goals set forth in such grant

9 that are negotiated and agreed to by the Secretary

10 and the grantee.

11 ‘‘(4) The capability of the organization to ade12 quately perform the activities required under the

13 grant.

14 ‘‘(5) The willingness of the organization to col15 laborate with the registry, if any, established by the

16 Secretary under section 204(e) in the Area Office of

17 the Service in which the organization is located.

18 ‘‘(d) FUNDS SUBJECT TO CRITERIA.—Any funds re19 ceived by an Urban Indian Organization under this Act

20 for the prevention, treatment, and control of diabetes

21 among Urban Indians shall be subject to the criteria devel22 oped by the Secretary under subsection (c).

23 ‘‘SEC. 519. COMMUNITY HEALTH REPRESENTATIVES.

24 ‘‘The Secretary, acting through the Service, may

25 enter into contracts with, and make grants to, Urban In-
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1 dian Organizations for the employment of Indians trained

2 as health service providers through the Community Health

3 Representatives Program under section 109 in the provi4 sion of health care, health promotion, and disease preven5 tion services to Urban Indians.

6 ‘‘SEC. 520. REGULATIONS.

7 ‘‘(a) REQUIREMENTS FOR REGULATIONS.—The Sec8 retary may promulgate regulations to implement the provi9 sions of this title in accordance with the following:

10 ‘‘(1) Proposed regulations to implement this

11 Act shall be published in the Federal Register by the

12 Secretary no later than 9 months after the date of

13 the enactment of this Act and shall have no less

14 than a 4-month comment period.

15 ‘‘(2) The authority to promulgate regulations

16 under this Act shall expire 18 months from the date

17 of the enactment of this Act.

18 ‘‘(b) EFFECTIVE DATE OF TITLE.—The amendments

19 to this title made by the Indian Health Care Improvement

20 Act Amendments of 2003 shall be effective on the date

21 of the enactment of such amendments, regardless of

22 whether the Secretary has promulgated regulations imple23 menting such amendments have been promulgated.
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1 ‘‘SEC. 521. ELIGIBILITY FOR SERVICES.

2 ‘‘Urban Indians shall be eligible for health care or

3 referral services provided pursuant to this title.

4 ‘‘SEC. 522. AUTHORIZATION OF APPROPRIATIONS.

5 ‘‘There are authorized to be appropriated such sums

6 as may be necessary for each fiscal year through fiscal

7 year 2015 to carry out this title.

8 ‘‘TITLE VI—ORGANIZATIONAL

9 IMPROVEMENTS

10 ‘‘SEC. 601. ESTABLISHMENT OF THE INDIAN HEALTH SERV11 ICE AS AN AGENCY OF THE PUBLIC HEALTH

12 SERVICE.

13 ‘‘(a) ESTABLISHMENT.—In order to more effectively

14 and efficiently carry out the responsibilities, authorities,

15 and functions of the United States to provide health care

16 services provided under Federal statute or treaties to Indi17 ans and Indian Tribes, there was established within the

18 Public Health Service of the Department the Indian

19 Health Service.

20 ‘‘(b) DIRECTOR.—The Indian Health Service is an

21 agency within the Public Health Service of the Depart22 ment, and shall not be an office, component, or unit of

23 any other agency of the Department. The Indian Health

24 Service shall be administered by a Director, who shall be

25 appointed by the President, by and with the advice and

26 consent of the Senate. The Director of the Indian Health
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1 Service shall report to the Secretary through the Assistant

2 Secretary for Health of the Department of Health and

3 Human Services. Effective with respect to an individual

4 appointed by the President, by and with the advice and

5 consent of the Senate, after January 1, 1993, the term

6 of service of the Director shall be 4 years. A Director may

7 serve more than 1 term.

8 ‘‘(c) DUTIES.—The Secretary shall carry out through

9 the Director of the Indian Health Service—

10 ‘‘(1) all functions which were, on the day before

11 the date of the enactment of the Indian Health Care

12 Amendments of 1988, carried out by or under the

13 direction of the individual serving as Director of the

14 Indian Health Service on such day;

15 ‘‘(2) all functions of the Secretary relating to

16 the maintenance and operation of hospital and

17 health facilities for Indians and the planning for,

18 and provision and use of, health services for Indians;

19 ‘‘(3) all health programs under which health

20 care is provided to Indians based upon their status

21 as Indians which are administered by the Secretary,

22 including but not limited to programs under—

23 ‘‘(A) this Act;

24 ‘‘(B) the Act of November 2, 1921 (25

25 U.S.C. 13);
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1 ‘‘(C) the Act of August 5, 1954 (42 U.S.C.

2 2001 et seq.);

3 ‘‘(D) the Act of August 16, 1957 (42

4 U.S.C. 2005 et seq.); and

5 ‘‘(E) the Indian Self-Determination and

6 Education Assistance Act (25 U.S.C. 450 et

7 seq.); and

8 ‘‘(4) all scholarship and loan functions carried

9 out under title I.

10 ‘‘(d) AUTHORITIES.—(1) The Director shall have the

11 authority—

12 ‘‘(A) except to the extent provided in paragraph

13 (2), to appoint and compensate employees for the

14 Service in accordance with title 5, United States

15 Code;

16 ‘‘(B) to enter into contracts for the procure17 ment of goods and services to carry out the func18 tions of the Service; and

19 ‘‘(C) to manage, expend, and obligate all funds

20 appropriated for the Service.

21 ‘‘(2) Notwithstanding any other law, the provisions

22 of section 12 of the Act of June 18, 1934 (48 Stat. 986;

23 25 U.S.C. 472), shall apply to all personnel actions taken

24 with respect to new positions created within the Service

25 as a result of its establishment under subsection (a).
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1 ‘‘SEC. 602. AUTOMATED MANAGEMENT INFORMATION SYS2 TEM.

3 ‘‘(a)(1) The Secretary shall establish an automated

4 management information system for the Service.

5 ‘‘(2) The information system established under para6 graph (1) shall include—

7 ‘‘(A) a financial management system;

8 ‘‘(B) a patient care information system for each

9 area served by the Service;

10 ‘‘(C) a privacy component that protects the pri11 vacy of patient information held by, or on behalf of,

12 the Service;

13 ‘‘(D) a services-based cost accounting compo14 nent that provides estimates of the costs associated

15 with the provision of specific medical treatments or

16 services in each Area Office of the Service;

17 ‘‘(E) an interface mechanism for patient billing

18 and accounts receivable system; and

19 ‘‘(F) a training component.

20 ‘‘(b) The Secretary shall provide each Tribal Health

21 Program automated management information systems

22 which—

23 ‘‘(1) meet the management information needs

24 of such Tribal Health Program with respect to the

25 treatment by the Tribal Health Program of patients

26 of the Service; and
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1 ‘‘(2) meet the management information needs

2 of the Service.

3 ‘‘(c) Notwithstanding any other provision of law, each

4 patient shall have reasonable access to the medical or

5 health records of such patient which are held by, or on

6 behalf of, the Service.

7 ‘‘(d) The Director shall have the authority to enter

8 into contracts, agreements, or joint ventures with other

9 Federal agencies, States, private and nonprofit organiza10 tions, for the purpose of enhancing information technology

11 in Indian Health Programs and facilities.

12 ‘‘SEC. 603. AUTHORIZATION OF APPROPRIATIONS.

13 ‘‘There are authorized to be appropriated such sums

14 as may be necessary for each fiscal year through fiscal

15 year 2015 to carry out this title.

16 ‘‘TITLE VII—BEHAVIORAL

17 HEALTH PROGRAMS

18 ‘‘SEC. 701. BEHAVIORAL HEALTH PREVENTION AND TREAT19 MENT SERVICES.

20 ‘‘(a) PURPOSES.—The purposes of this section are as

21 follows:

22 ‘‘(1) To authorize and direct the Secretary, act23 ing through the Service, Indian Tribes, Tribal Orga24 nizations, and Urban Indian Organizations, to de25 velop a comprehensive behavioral health prevention
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1 and treatment program which emphasizes collabora2 tion among alcohol and substance abuse, social serv3 ices, and mental health programs.

4 ‘‘(2) To provide information, direction, and

5 guidance relating to mental illness and dysfunction

6 and self-destructive behavior, including child abuse

7 and family violence, to those Federal, tribal, State,

8 and local agencies responsible for programs in In9 dian communities in areas of health care, education,

10 social services, child and family welfare, alcohol and

11 substance abuse, law enforcement, and judicial serv12 ices.

13 ‘‘(3) To assist Indian Tribes to identify services

14 and resources available to address mental illness and

15 dysfunctional and self-destructive behavior.

16 ‘‘(4) To provide authority and opportunities for

17 Indian Tribes and Tribal Organizations to develop,

18 implement, and coordinate with community-based

19 programs which include identification, prevention,

20 education, referral, and treatment services, including

21 through multidisciplinary resource teams.

22 ‘‘(5) To ensure that Indians, as citizens of the

23 United States and of the States in which they re24 side, have the same access to behavioral health serv25 ices to which all citizens have access.
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1 ‘‘(6) To modify or supplement existing pro2 grams and authorities in the areas identified in

3 paragraph (2).

4 ‘‘(b) PLANS.—

5 ‘‘(1) DEVELOPMENT.—The Secretary, acting

6 through the Service, Indian Tribes, Tribal Organiza7 tions, and Urban Indian Organizations, shall encour8 age Indian Tribes and Tribal Organizations to de9 velop tribal plans, and Urban Indian Organizations

10 to develop local plans, and for all such groups to

11 participate in developing areawide plans for Indian

12 Behavioral Health Services. The plans shall include,

13 to the extent feasible, the following components:

14 ‘‘(A) An assessment of the scope of alcohol

15 or other substance abuse, mental illness, and

16 dysfunctional and self-destructive behavior, in17 cluding suicide, child abuse, and family vio18 lence, among Indians, including—

19 ‘‘(i) the number of Indians served who

20 are directly or indirectly affected by such

21 illness or behavior; or

22 ‘‘(ii) an estimate of the financial and

23 human cost attributable to such illness or

24 behavior.
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1 ‘‘(B) An assessment of the existing and

2 additional resources necessary for the preven3 tion and treatment of such illness and behavior,

4 including an assessment of the progress toward

5 achieving the availability of the full continuum

6 of care described in subsection (c).

7 ‘‘(C) An estimate of the additional funding

8 needed by the Service, Indian Tribes, Tribal

9 Organizations, and Urban Indian Organizations

10 to meet their responsibilities under the plans.

11 ‘‘(2) NATIONAL CLEARINGHOUSE.—The Sec12 retary, acting through the Service, shall establish a

13 national clearinghouse of plans and reports on the

14 outcomes of such plans developed by Indian Tribes,

15 Tribal Organizations, Urban Indian Organizations,

16 and Service Areas relating to behavioral health. The

17 Secretary shall ensure access to these plans and out18 comes by any Indian Tribe, Tribal Organization,

19 Urban Indian Organization, or the Service.

20 ‘‘(3) TECHNICAL ASSISTANCE.—The Secretary

21 shall provide technical assistance to Indian Tribes,

22 Tribal Organizations, and Urban Indian Organiza23 tions in preparation of plans under this section and

24 in developing standards of care that may be used

25 and adopted locally.
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1 ‘‘(c) PROGRAMS.—The Secretary, acting through the

2 Service, Indian Tribes, and Tribal Organizations, shall

3 provide, to the extent feasible and if funding is available,

4 programs including the following:

5 ‘‘(1) COMPREHENSIVE CARE.—A comprehensive

6 continuum of behavioral health care which

7 provides—

8 ‘‘(A) community-based prevention, inter9 vention, outpatient, and behavioral health

10 aftercare;

11 ‘‘(B) detoxification (social and medical);

12 ‘‘(C) acute hospitalization;

13 ‘‘(D) intensive outpatient/day treatment;

14 ‘‘(E) residential treatment;

15 ‘‘(F) transitional living for those needing a

16 temporary, stable living environment that is

17 supportive of treatment and recovery goals;

18 ‘‘(G) emergency shelter;

19 ‘‘(H) intensive case management; and

20 ‘‘(I) Traditional Health Care Practices.

21 ‘‘(2) CHILD CARE.—Behavioral health services

22 for Indians from birth through age 17, including the

23 following:
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1 ‘‘(A) Preschool and school age fetal alcohol

2 disorder services, including assessment and be3 havioral intervention.

4 ‘‘(B) Mental health and substance abuse

5 services (emotional, organic, alcohol, drug, in6 halant, and tobacco).

7 ‘‘(C) Identification and treatment of co-oc8 curring disorders and comorbidity.

9 ‘‘(D) Prevention of alcohol, drug, inhalant,

10 and tobacco use.

11 ‘‘(E) Early intervention, treatment, and

12 aftercare.

13 ‘‘(F) Promotion of healthy choices and life14 style (related to sexually transmitted diseases,

15 domestic violence, sexual abuse, suicide, teen

16 pregnancy, obesity, and other risk/safety

17 issues).

18 ‘‘(G) Identification and treatment of ne19 glect and physical, mental, and sexual abuse.

20 ‘‘(3) ADULT CARE.—Behavioral health services

21 for Indians from age 18 through 55, including the

22 following:

23 ‘‘(A) Early intervention, treatment, and

24 aftercare.
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1 ‘‘(B) Mental health and substance abuse

2 services (emotional, alcohol, drug, inhalant, and

3 tobacco), including gender specific services.

4 ‘‘(C) Identification and treatment of co-oc5 curring disorders (dual diagnosis) and co6 morbidity.

7 ‘‘(D) Promotion of gender specific healthy

8 choices and lifestyle (related to parenting, part9 ners, domestic violence, sexual abuse, suicide,

10 obesity, and other risk-related behavior).

11 ‘‘(E) Treatment services for women at risk

12 of giving birth to a child with a fetal alcohol

13 disorder.

14 ‘‘(F) Gender specific treatment for sexual

15 assault and domestic violence.

16 ‘‘(4) FAMILY CARE.—Behavioral health services

17 for families, including the following:

18 ‘‘(A) Early intervention, treatment, and

19 aftercare for affected families.

20 ‘‘(B) Treatment for sexual assault and do21 mestic violence.

22 ‘‘(C) Promotion of healthy choices and life23 style (related to parenting, partners, domestic

24 violence, and other abuse issues).
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1 ‘‘(5) ELDER CARE.—Behavioral health services

2 for Indians 56 years of age and older, including the

3 following:

4 ‘‘(A) Early intervention, treatment, and

5 aftercare.

6 ‘‘(B) Mental health and substance abuse

7 services (emotional, alcohol, drug, inhalant, and

8 tobacco), including gender specific services.

9 ‘‘(C) Identification and treatment of co-oc10 curring disorders (dual diagnosis) and co11 morbidity.

12 ‘‘(D) Promotion of healthy choices and life13 style (managing conditions related to aging).

14 ‘‘(E) Gender specific treatment for sexual

15 assault, domestic violence, neglect, physical and

16 mental abuse and exploitation.

17 ‘‘(F) Identification and treatment of de18 mentias regardless of cause.

19 ‘‘(d) COMMUNITY BEHAVIORAL HEALTH PLAN.—

20 ‘‘(1) ESTABLISHMENT.—The governing body of

21 any Indian Tribe, Tribal Organization, or Urban In22 dian Organization may adopt a resolution for the es23 tablishment of a community behavioral health plan

24 providing for the identification and coordination of

25 available resources and programs to identify, pre-
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1 vent, or treat substance abuse, mental illness, or

2 dysfunctional and self-destructive behavior, including

3 child abuse and family violence, among its members

4 or its service population. This plan should include

5 behavioral health services, social services, intensive

6 outpatient services, and continuing aftercare.

7 ‘‘(2) TECHNICAL ASSISTANCE.—At the request

8 of an Indian Tribe, Tribal Organization, or Urban

9 Indian Organization, the Bureau of Indian Affairs

10 and the Service shall cooperate with and provide

11 technical assistance to the Indian Tribe, Tribal Or12 ganization, or Urban Indian Organization in the de13 velopment and implementation of such plan.

14 ‘‘(3) FUNDING.—The Secretary, acting through

15 the Service, may make funding available to Indian

16 Tribes and Tribal Organizations which adopt a reso17 lution pursuant to paragraph (1) to obtain technical

18 assistance for the development of a community be19 havioral health plan and to provide administrative

20 support in the implementation of such plan.

21 ‘‘(e) COORDINATION FOR AVAILABILITY OF SERV22 ICES.—The Secretary, acting through the Service, Indian

23 Tribes, Tribal Organizations, and Urban Indian Organiza24 tions, shall coordinate behavioral health planning, to the

25 extent feasible, with other Federal agencies and with State
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1 agencies, to encourage comprehensive behavioral health

2 services for Indians regardless of their place of residence.

3 ‘‘(f) MENTAL HEALTH CARE NEED ASSESSMENT.—

4 Not later than 1 year after the date of the enactment of

5 the Indian Health Care Improvement Act Amendments of

6 2003, the Secretary, acting through the Service, shall

7 make an assessment of the need for inpatient mental

8 health care among Indians and the availability and cost

9 of inpatient mental health facilities which can meet such

10 need. In making such assessment, the Secretary shall con11 sider the possible conversion of existing, underused Service

12 hospital beds into psychiatric units to meet such need.

13 ‘‘SEC. 702. MEMORANDA OF AGREEMENT WITH THE DE14 PARTMENT OF THE INTERIOR.

15 ‘‘(a) CONTENTS.—Not later than 12 months after the

16 date of the enactment of the Indian Health Care Improve17 ment Act Amendments of 2003, the Secretary, acting

18 through the Service, and the Secretary of the Interior shall

19 develop and enter into a memoranda of agreement, or re20 view and update any existing memoranda of agreement,

21 as required by section 4205 of the Indian Alcohol and

22 Substance Abuse Prevention and Treatment Act of 1986

23 (25 U.S.C. 2411) under which the Secretaries address the

24 following:
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1 ‘‘(1) The scope and nature of mental illness and

2 dysfunctional and self-destructive behavior, including

3 child abuse and family violence, among Indians.

4 ‘‘(2) The existing Federal, tribal, State, local,

5 and private services, resources, and programs avail6 able to provide mental health services for Indians.

7 ‘‘(3) The unmet need for additional services, re8 sources, and programs necessary to meet the needs

9 identified pursuant to paragraph (1).

10 ‘‘(4)(A) The right of Indians, as citizens of the

11 United States and of the States in which they re12 side, to have access to mental health services to

13 which all citizens have access.

14 ‘‘(B) The right of Indians to participate in, and

15 receive the benefit of, such services.

16 ‘‘(C) The actions necessary to protect the exer17 cise of such right.

18 ‘‘(5) The responsibilities of the Bureau of In19 dian Affairs and the Service, including mental health

20 identification, prevention, education, referral, and

21 treatment services (including services through multi22 disciplinary resource teams), at the central, area,

23 and agency and Service Unit, Service Area, and

24 headquarters levels to address the problems identi25 fied in paragraph (1).
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1 ‘‘(6) A strategy for the comprehensive coordina2 tion of the mental health services provided by the

3 Bureau of Indian Affairs and the Service to meet

4 the problems identified pursuant to paragraph (1),

5 including—

6 ‘‘(A) the coordination of alcohol and sub7 stance abuse programs of the Service, the Bu8 reau of Indian Affairs, and Indian Tribes and

9 Tribal Organizations (developed under the In10 dian Alcohol and Substance Abuse Prevention

11 and Treatment Act of 1986) with mental health

12 initiatives pursuant to this Act, particularly

13 with respect to the referral and treatment of

14 dually diagnosed individuals requiring mental

15 health and substance abuse treatment; and

16 ‘‘(B) ensuring that the Bureau of Indian

17 Affairs and Service programs and services (in18 cluding multidisciplinary resource teams) ad19 dressing child abuse and family violence are co20 ordinated with such non-Federal programs and

21 services.

22 ‘‘(7) Directing appropriate officials of the Bu23 reau of Indian Affairs and the Service, particularly

24 at the agency and Service Unit levels, to cooperate

25 fully with tribal requests made pursuant to commu-
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1 nity behavioral health plans adopted under section

2 701(c) and section 4206 of the Indian Alcohol and

3 Substance Abuse Prevention and Treatment Act of

4 1986 (25 U.S.C. 2412).

5 ‘‘(8) Providing for an annual review of such

6 agreement by the Secretaries which shall be provided

7 to Congress and Indian Tribes and Tribal Organiza8 tions.

9 ‘‘(b) SPECIFIC PROVISIONS REQUIRED.—The memo10 randa of agreement updated or entered into pursuant to

11 subsection (a) shall include specific provisions pursuant to

12 which the Service shall assume responsibility for—

13 ‘‘(1) the determination of the scope of the prob14 lem of alcohol and substance abuse among Indians,

15 including the number of Indians within the jurisdic16 tion of the Service who are directly or indirectly af17 fected by alcohol and substance abuse and the finan18 cial and human cost;

19 ‘‘(2) an assessment of the existing and needed

20 resources necessary for the prevention of alcohol and

21 substance abuse and the treatment of Indians af22 fected by alcohol and substance abuse; and

23 ‘‘(3) an estimate of the funding necessary to

24 adequately support a program of prevention of alco-
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1 hol and substance abuse and treatment of Indians

2 affected by alcohol and substance abuse.

3 ‘‘(c) CONSULTATION.—The Secretary, acting through

4 the Service, and the Secretary of the Interior shall, in de5 veloping the memoranda of agreement under subsection

6 (a), consult with and solicit the comments from—

7 ‘‘(1) Indian Tribes and Tribal Organizations;

8 ‘‘(2) Indians;

9 ‘‘(3) Urban Indian Organizations and other In10 dian organizations; and

11 ‘‘(4) behavioral health service providers.

12 ‘‘(d) PUBLICATION.—Each memorandum of agree13 ment entered into or renewed (and amendments or modi14 fications thereto) under subsection (a) shall be published

15 in the Federal Register. At the same time as publication

16 in the Federal Register, the Secretary shall provide a copy

17 of such memoranda, amendment, or modification to each

18 Indian Tribe, Tribal Organization, and Urban Indian Or19 ganization.

20 ‘‘SEC. 703. COMPREHENSIVE BEHAVIORAL HEALTH PRE21 VENTION AND TREATMENT PROGRAM.

22 ‘‘(a) ESTABLISHMENT.—

23 ‘‘(1) IN GENERAL.—The Secretary, acting

24 through the Service, Indian Tribes, and Tribal Orga25 nizations, shall provide a program of comprehensive
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1 behavioral health, prevention, treatment, and

2 aftercare, including Traditional Health Care Prac3 tices, which shall include—

4 ‘‘(A) prevention, through educational inter5 vention, in Indian communities;

6 ‘‘(B) acute detoxification, psychiatric hos7 pitalization, and residential and intensive out8 patient treatment;

9 ‘‘(C) community-based rehabilitation and

10 aftercare;

11 ‘‘(D) community education and involve12 ment, including extensive training of health

13 care, educational, and community-based person14 nel; and

15 ‘‘(E) specialized residential treatment pro16 grams for high-risk populations, including but

17 not limited to pregnant and postpartum women

18 and their children.

19 ‘‘(2) TARGET POPULATIONS.—The target popu20 lation of such program shall be members of Indian

21 Tribes. Efforts to train and educate key members of

22 the Indian community shall target employees of

23 health, education, judicial, law enforcement, legal,

24 and social service programs.

25 ‘‘(b) CONTRACT HEALTH SERVICES.—
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1 ‘‘(1) IN GENERAL.—The Secretary, acting

2 through the Service, Indian Tribes, and Tribal Orga3 nizations, may enter into contracts with public or

4 private providers of behavioral health treatment

5 services for the purpose of carrying out the program

6 required under subsection (a).

7 ‘‘(2) PROVISION OF ASSISTANCE.—In carrying

8 out this subsection, the Secretary shall provide as9 sistance to Indian Tribes and Tribal Organizations

10 to develop criteria for the certification of behavioral

11 health service providers and accreditation of service

12 facilities which meet minimum standards for such

13 services and facilities.

14 ‘‘SEC. 704. MENTAL HEALTH TECHNICIAN PROGRAM.

15 ‘‘(a) IN GENERAL.—Under the authority of the Act

16 of November 2, 1921 (25 U.S.C. 13) (commonly known

17 as the Snyder Act), the Secretary shall establish and

18 maintain a mental health technician program within the

19 Service which—

20 ‘‘(1) provides for the training of Indians as

21 mental health technicians; and

22 ‘‘(2) employs such technicians in the provision

23 of community-based mental health care that includes

24 identification, prevention, education, referral, and

25 treatment services.
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1 ‘‘(b) PARAPROFESSIONAL TRAINING.—In carrying

2 out subsection (a), the Secretary, acting through the Serv3 ice, Indian Tribes, and Tribal Organizations, shall provide

4 high-standard paraprofessional training in mental health

5 care necessary to provide quality care to the Indian com6 munities to be served. Such training shall be based upon

7 a curriculum developed or approved by the Secretary

8 which combines education in the theory of mental health

9 care with supervised practical experience in the provision

10 of such care.

11 ‘‘(c) SUPERVISION AND EVALUATION OF TECHNI12 CIANS.—The Secretary, acting through the Service, Indian

13 Tribes, and Tribal Organizations, shall supervise and

14 evaluate the mental health technicians in the training pro15 gram.

16 ‘‘(d) TRADITIONAL HEALTH CARE PRACTICES.—The

17 Secretary, acting through the Service, shall ensure that

18 the program established pursuant to this subsection in19 volves the use and promotion of the Traditional Health

20 Care Practices of the Indian Tribes to be served.

21 ‘‘SEC. 705. LICENSING REQUIREMENT FOR MENTAL

22 HEALTH CARE WORKERS.

23 ‘‘Subject to the provisions of section 221, any person

24 employed as a psychologist, social worker, or marriage and

25 family therapist for the purpose of providing mental health
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1 care services to Indians in a clinical setting under this Act

2 or through a Funding Agreement shall, in the case of a

3 person employed as a psychologist, social worker, or mar4 riage and family therapist, be licensed as a clinical psy5 chologist, social worker, or marriage and family therapist,

6 respectively, or working under the direct supervision of a

7 licensed clinical psychologist, social worker, or marriage

8 and family therapist, respectively.

9 ‘‘SEC. 706. INDIAN WOMEN TREATMENT PROGRAMS.

10 ‘‘(a) FUNDING.—The Secretary, consistent with sec11 tion 701, shall make funds available to Indian Tribes,

12 Tribal Organizations, and Urban Indian Organizations to

13 develop and implement a comprehensive behavioral health

14 program of prevention, intervention, treatment, and re15 lapse prevention services that specifically addresses the

16 spiritual, cultural, historical, social, and child care needs

17 of Indian women, regardless of age.

18 ‘‘(b) USE OF FUNDS.—Funds made available pursu19 ant to this section may be used to—

20 ‘‘(1) develop and provide community training,

21 education, and prevention programs for Indian

22 women relating to behavioral health issues, including

23 fetal alcohol disorders;
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1 ‘‘(2) identify and provide psychological services,

2 counseling, advocacy, support, and relapse preven3 tion to Indian women and their families; and

4 ‘‘(3) develop prevention and intervention models

5 for Indian women which incorporate Traditional

6 Health Care Practices, cultural values, and commu7 nity and family involvement.

8 ‘‘(c) CRITERIA.—The Secretary, in consultation with

9 Indian Tribes and Tribal Organizations, shall establish

10 criteria for the review and approval of applications and

11 proposals for funding under this section.

12 ‘‘(d) EARMARK OF CERTAIN FUNDS.—Twenty per13 cent of the funds appropriated pursuant to this section

14 shall be used to make grants to Urban Indian Organiza15 tions.

16 ‘‘SEC. 707. INDIAN YOUTH PROGRAM.

17 ‘‘(a) DETOXIFICATION AND REHABILITATION.—The

18 Secretary, acting through the Service, consistent with sec19 tion 701, shall develop and implement a program for acute

20 detoxification and treatment for Indian youths, including

21 behavioral health services. The program shall include re22 gional treatment centers designed to include detoxification

23 and rehabilitation for both sexes on a referral basis and

24 programs developed and implemented by Indian Tribes or

25 Tribal Organizations at the local level under the Indian
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1 Self-Determination and Education Assistance Act. Re2 gional centers shall be integrated with the intake and re3 habilitation programs based in the referring Indian com4 munity.

5 ‘‘(b) ALCOHOL AND SUBSTANCE ABUSE TREATMENT

6 CENTERS OR FACILITIES.—

7 ‘‘(1) ESTABLISHMENT.—

8 ‘‘(A) IN GENERAL.—The Secretary, acting

9 through the Service, Indian Tribes, and Tribal

10 Organizations, shall construct, renovate, or, as

11 necessary, purchase, and appropriately staff

12 and operate, at least 1 youth regional treatment

13 center or treatment network in each area under

14 the jurisdiction of an Area Office.

15 ‘‘(B) AREA OFFICE IN CALIFORNIA.—For

16 the purposes of this subsection, the Area Office

17 in California shall be considered to be 2 Area

18 Offices, 1 office whose jurisdiction shall be con19 sidered to encompass the northern area of the

20 State of California, and 1 office whose jurisdic21 tion shall be considered to encompass the re22 mainder of the State of California for the pur23 pose of implementing California treatment net24 works.
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1 ‘‘(2) FUNDING.—For the purpose of staffing

2 and operating such centers or facilities, funding

3 shall be pursuant to the Act of November 2, 1921

4 (25 U.S.C. 13).

5 ‘‘(3) LOCATION.—A youth treatment center

6 constructed or purchased under this subsection shall

7 be constructed or purchased at a location within the

8 area described in paragraph (1) agreed upon (by ap9 propriate tribal resolution) by a majority of the In10 dian Tribes to be served by such center.

11 ‘‘(4) SPECIFIC PROVISION OF FUNDS.—

12 ‘‘(A) IN GENERAL.—Notwithstanding any

13 other provision of this title, the Secretary may,

14 from amounts authorized to be appropriated for

15 the purposes of carrying out this section, make

16 funds available to—

17 ‘‘(i) the Tanana Chiefs Conference,

18 Incorporated, for the purpose of leasing,

19 constructing, renovating, operating, and

20 maintaining a residential youth treatment

21 facility in Fairbanks, Alaska; and

22 ‘‘(ii) the Southeast Alaska Regional

23 Health Corporation to staff and operate a

24 residential youth treatment facility without

25 regard to the proviso set forth in section
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1 4(l) of the Indian Self-Determination and

2 Education Assistance Act (25 U.S.C.

3 450b(l)).

4 ‘‘(B) PROVISION OF SERVICES TO ELIGI5 BLE YOUTHS.—Until additional residential

6 youth treatment facilities are established in

7 Alaska pursuant to this section, the facilities

8 specified in subparagraph (A) shall make every

9 effort to provide services to all eligible Indian

10 youths residing in such State.

11 ‘‘(c) INTERMEDIATE ADOLESCENT BEHAVIORAL

12 HEALTH SERVICES.—

13 ‘‘(1) IN GENERAL.—The Secretary, acting

14 through the Service, Indian Tribes, and Tribal Orga15 nizations, may provide intermediate behavioral

16 health services, which may incorporate Traditional

17 Health Care Practices, to Indian children and ado18 lescents, including—

19 ‘‘(A) pretreatment assistance;

20 ‘‘(B) inpatient, outpatient, and aftercare

21 services;

22 ‘‘(C) emergency care;

23 ‘‘(D) suicide prevention and crisis interven24 tion; and
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1 ‘‘(E) prevention and treatment of mental

2 illness and dysfunctional and self-destructive

3 behavior, including child abuse and family vio4 lence.

5 ‘‘(2) USE OF FUNDS.—Funds provided under

6 this subsection may be used—

7 ‘‘(A) to construct or renovate an existing

8 health facility to provide intermediate behav9 ioral health services;

10 ‘‘(B) to hire behavioral health profes11 sionals;

12 ‘‘(C) to staff, operate, and maintain an in13 termediate mental health facility, group home,

14 sober housing, transitional housing or similar

15 facilities, or youth shelter where intermediate

16 behavioral health services are being provided;

17 ‘‘(D) to make renovations and hire appro18 priate staff to convert existing hospital beds

19 into adolescent psychiatric units; and

20 ‘‘(E) for intensive home- and community21 based services.

22 ‘‘(3) CRITERIA.—The Secretary, acting through

23 the Service, shall, in consultation with Indian Tribes

24 and Tribal Organizations, establish criteria for the
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1 review and approval of applications or proposals for

2 funding made available pursuant to this subsection.

3 ‘‘(d) FEDERALLY OWNED STRUCTURES.—

4 ‘‘(1) IN GENERAL.—The Secretary, in consulta5 tion with Indian Tribes and Tribal Organizations,

6 shall—

7 ‘‘(A) identify and use, where appropriate,

8 federally owned structures suitable for local res9 idential or regional behavioral health treatment

10 for Indian youths; and

11 ‘‘(B) establish guidelines, in consultation

12 with Indian Tribes and Tribal Organizations,

13 for determining the suitability of any such fed14 erally owned structure to be used for local resi15 dential or regional behavioral health treatment

16 for Indian youths.

17 ‘‘(2) TERMS AND CONDITIONS FOR USE OF

18 STRUCTURE.—Any structure described in paragraph

19 (1) may be used under such terms and conditions as

20 may be agreed upon by the Secretary and the agency

21 having responsibility for the structure and any In22 dian Tribe or Tribal Organization operating the pro23 gram.

24 ‘‘(e) REHABILITATION AND AFTERCARE SERVICES.—
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1 ‘‘(1) IN GENERAL.—The Secretary, Indian

2 Tribes, or Tribal Organizations, in cooperation with

3 the Secretary of the Interior, shall develop and im4 plement within each Service Unit, community-based

5 rehabilitation and follow-up services for Indian

6 youths who are having significant behavioral health

7 problems, and require long-term treatment, commu8 nity reintegration, and monitoring to support the In9 dian youths after their return to their home commu10 nity.

11 ‘‘(2) ADMINISTRATION.—Services under para12 graph (1) shall be provided by trained staff within

13 the community who can assist the Indian youths in

14 their continuing development of self-image, positive

15 problem-solving skills, and nonalcohol or substance

16 abusing behaviors. Such staff may include alcohol

17 and substance abuse counselors, mental health pro18 fessionals, and other health professionals and para19 professionals, including community health represent20 atives.

21 ‘‘(f) INCLUSION OF FAMILY IN YOUTH TREATMENT

22 PROGRAM.—In providing the treatment and other services

23 to Indian youths authorized by this section, the Secretary,

24 acting through the Service, Indian Tribes, and Tribal Or25 ganizations, shall provide for the inclusion of family mem-
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1 bers of such youths in the treatment programs or other

2 services as may be appropriate. Not less than 10 percent

3 of the funds appropriated for the purposes of carrying out

4 subsection (e) shall be used for outpatient care of adult

5 family members related to the treatment of an Indian

6 youth under that subsection.

7 ‘‘(g) MULTIDRUG ABUSE PROGRAM.—The Secretary,

8 acting through the Service, Indian Tribes, Tribal Organi9 zations, and Urban Indian Organizations, shall provide,

10 consistent with section 701, programs and services to pre11 vent and treat the abuse of multiple forms of substances,

12 including, but not limited to, alcohol, drugs, inhalants, and

13 tobacco, among Indian youths residing in Indian commu14 nities, on or near reservations, and in urban areas and

15 provide appropriate mental health services to address the

16 incidence of mental illness among such youths.

17 ‘‘SEC. 708. INPATIENT AND COMMUNITY-BASED MENTAL

18 HEALTH FACILITIES DESIGN, CONSTRUC19 TION, AND STAFFING.

20 ‘‘Not later than 1 year after the date of the enact21 ment of the Indian Health Care Improvement Act Amend22 ments of 2003, the Secretary, acting through the Service,

23 Indian Tribes, and Tribal Organizations, shall provide, in

24 each area of the Service, not less than 1 inpatient mental

25 health care facility, or the equivalent, for Indians with be-
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1 havioral health problems. For the purposes of this sub2 section, California shall be considered to be 2 Area Offices,

3 1 office whose location shall be considered to encompass

4 the northern area of the State of California and 1 office

5 whose jurisdiction shall be considered to encompass the

6 remainder of the State of California. The Secretary shall

7 consider the possible conversion of existing, underused

8 Service hospital beds into psychiatric units to meet such

9 need.

10 ‘‘SEC. 709. TRAINING AND COMMUNITY EDUCATION.

11 ‘‘(a) PROGRAM.—The Secretary, in cooperation with

12 the Secretary of the Interior, shall develop and implement

13 or provide funding for Indian Tribes and Tribal Organiza14 tions to develop and implement, within each Service Unit

15 or tribal program, a program of community education and

16 involvement which shall be designed to provide concise and

17 timely information to the community leadership of each

18 tribal community. Such program shall include education

19 about behavioral health issues to political leaders, Tribal

20 judges, law enforcement personnel, members of tribal

21 health and education boards, health care providers includ22 ing traditional practitioners, and other critical members

23 of each tribal community. Community-based training (ori24 ented toward local capacity development) shall also include

25 tribal community provider training (designed for adult
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1 learners from the communities receiving services for pre2 vention, intervention, treatment, and aftercare).

3 ‘‘(b) INSTRUCTION.—The Secretary, acting through

4 the Service, shall, either directly or through Indian Tribes

5 and Tribal Organizations, provide instruction in the area

6 of behavioral health issues, including instruction in crisis

7 intervention and family relations in the context of alcohol

8 and substance abuse, child sexual abuse, youth alcohol and

9 substance abuse, and the causes and effects of fetal alco10 hol disorders to appropriate employees of the Bureau of

11 Indian Affairs and the Service, and to personnel in schools

12 or programs operated under any contract with the Bureau

13 of Indian Affairs or the Service, including supervisors of

14 emergency shelters and halfway houses described in sec15 tion 4213 of the Indian Alcohol and Substance Abuse Pre16 vention and Treatment Act of 1986 (25 U.S.C. 2433).

17 ‘‘(c) TRAINING MODELS.—In carrying out the edu18 cation and training programs required by this section, the

19 Secretary, in consultation with Indian Tribes, Tribal Or20 ganizations, Indian behavioral health experts, and Indian

21 alcohol and substance abuse prevention experts, shall de22 velop and provide community-based training models. Such

23 models shall address—

24 ‘‘(1) the elevated risk of alcohol and behavioral

25 health problems faced by children of alcoholics;
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1 ‘‘(2) the cultural, spiritual, and

2 multigenerational aspects of behavioral health prob3 lem prevention and recovery; and

4 ‘‘(3) community-based and multidisciplinary

5 strategies for preventing and treating behavioral

6 health problems.

7 ‘‘SEC. 710. BEHAVIORAL HEALTH PROGRAM.

8 ‘‘(a) INNOVATIVE PROGRAMS.—The Secretary, acting

9 through the Service, Indian Tribes, and Tribal Organiza10 tions, consistent with section 701, may plan, develop, im11 plement, and carry out programs to deliver innovative

12 community-based behavioral health services to Indians.

13 ‘‘(b) FUNDING; CRITERIA.—The Secretary may

14 award such funding for a project under subsection (a) to

15 an Indian Tribe or Tribal Organization and may consider

16 the following criteria:

17 ‘‘(1) The project will address significant unmet

18 behavioral health needs among Indians.

19 ‘‘(2) The project will serve a significant number

20 of Indians.

21 ‘‘(3) The project has the potential to deliver

22 services in an efficient and effective manner.

23 ‘‘(4) The Indian Tribe or Tribal Organization

24 has the administrative and financial capability to ad25 minister the project.
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1 ‘‘(5) The project may deliver services in a man2 ner consistent with Traditional Health Care Prac3 tices.

4 ‘‘(6) The project is coordinated with, and avoids

5 duplication of, existing services.

6 ‘‘(c) EQUITABLE TREATMENT.—For purposes of this

7 subsection, the Secretary shall, in evaluating applications

8 or proposals for funding for projects to be operated under

9 any Funding Agreement, use the same criteria that the

10 Secretary uses in evaluating any other application or pro11 posal for such funding.

12 ‘‘SEC. 711. FETAL ALCOHOL DISORDER FUNDING.

13 ‘‘(a) PROGRAMS.—

14 ‘‘(1) ESTABLISHMENT.—The Secretary, consist15 ent with section 701, acting through Indian Tribes

16 and Tribal Organizations, shall establish and operate

17 fetal alcohol disorder programs as provided in this

18 section for the purposes of meeting the health status

19 objectives specified in section 3.

20 ‘‘(2) USE OF FUNDS.—Funding provided pursu21 ant to this section shall be used for the following:

22 ‘‘(A) To develop and provide for Indians

23 community and in school training, education,

24 and prevention programs relating to fetal alco25 hol disorders.
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1 ‘‘(B) To identify and provide behavioral

2 health treatment to high-risk Indian women

3 and high-risk women pregnant with an Indian’s

4 child.

5 ‘‘(C) To identify and provide appropriate

6 psychological services, educational and voca7 tional support, counseling, advocacy, and infor8 mation to fetal alcohol disorder affected Indians

9 and their families or caretakers.

10 ‘‘(D) To develop and implement counseling

11 and support programs in schools for fetal alco12 hol disorder affected Indian children.

13 ‘‘(E) To develop prevention and interven14 tion models which incorporate practitioners of

15 Traditional Health Care Practices, cultural and

16 spiritual values, and community involvement.

17 ‘‘(F) To develop, print, and disseminate

18 education and prevention materials on fetal al19 cohol disorder.

20 ‘‘(G) To develop and implement, through

21 the tribal consultation process, culturally sen22 sitive assessment and diagnostic tools including

23 dysmorphology clinics and multidisciplinary

24 fetal alcohol disorder clinics for use in Indian

25 communities and Urban Centers.
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1 ‘‘(H) To develop early childhood interven2 tion projects from birth on to mitigate the ef3 fects of fetal alcohol disorder among Indians.

4 ‘‘(I) To develop and fund community-based

5 adult fetal alcohol disorder housing and support

6 services for Indians and for women pregnant

7 with an Indian’s child.

8 ‘‘(3) CRITERIA FOR APPLICATIONS.—The Sec9 retary shall establish criteria for the review and ap10 proval of applications for funding under this section.

11 ‘‘(b) SERVICES.—The Secretary, acting through the

12 Service and Indian Tribes, Tribal Organizations, and

13 Urban Indian Organizations, shall—

14 ‘‘(1) develop and provide services for the pre15 vention, intervention, treatment, and aftercare for

16 those affected by fetal alcohol disorder in Indian

17 communities; and

18 ‘‘(2) provide supportive services, directly or

19 through an Indian Tribe, Tribal Organization, or

20 Urban Indian Organization, including services to

21 meet the special educational, vocational, school-to22 work transition, and independent living needs of ad23 olescent and adult Indians with fetal alcohol dis24 order.
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1 ‘‘(c) TASK FORCE.—The Secretary shall establish a

2 task force to be known as the Fetal Alcohol Disorder Task

3 Force to advise the Secretary in carrying out subsection

4 (b). Such task force shall be composed of representatives

5 from the following:

6 ‘‘(1) The National Institute on Drug Abuse.

7 ‘‘(2) The National Institute on Alcohol and Al8 coholism.

9 ‘‘(3) The Office of Substance Abuse Prevention.

10 ‘‘(4) The National Institute of Mental Health.

11 ‘‘(5) The Service.

12 ‘‘(6) The Office of Minority Health of the De13 partment of Health and Human Services.

14 ‘‘(7) The Administration for Native Americans.

15 ‘‘(8) The National Institute of Child Health

16 and Human Development (NICHD).

17 ‘‘(9) The Centers for Disease Control and Pre18 vention.

19 ‘‘(10) The Bureau of Indian Affairs.

20 ‘‘(11) Indian Tribes.

21 ‘‘(12) Tribal Organizations.

22 ‘‘(13) Urban Indian Organizations.

23 ‘‘(14) Indian fetal alcohol disorder experts.

24 ‘‘(d) APPLIED RESEARCH PROJECTS.—The Sec25 retary, acting through the Substance Abuse and Mental
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1 Health Services Administration, shall make funding avail2 able to Indian Tribes, Tribal Organizations, and Urban

3 Indian Organizations for applied research projects which

4 propose to elevate the understanding of methods to pre5 vent, intervene, treat, or provide rehabilitation and behav6 ioral health aftercare for Indians and Urban Indians af7 fected by fetal alcohol disorder.

8 ‘‘(e) FUNDING FOR URBAN INDIAN ORGANIZA9 TIONS.—Ten percent of the funds appropriated pursuant

10 to this section shall be used to make grants to Urban In11 dian Organizations funded under title V.

12 ‘‘SEC. 712. CHILD SEXUAL ABUSE AND PREVENTION TREAT13 MENT PROGRAMS.

14 ‘‘(a) ESTABLISHMENT.—The Secretary, acting

15 through the Service, and the Secretary of the Interior, In16 dian Tribes, and Tribal Organizations shall establish, con17 sistent with section 701, in every Service Area, programs

18 involving treatment for—

19 ‘‘(1) victims of sexual abuse who are Indian

20 children or children in an Indian household; and

21 ‘‘(2) perpetrators of child sexual abuse who are

22 Indian or members of an Indian household.

23 ‘‘(b) USE OF FUNDS.—Funding provided pursuant to

24 this section shall be used for the following:
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1 ‘‘(1) To develop and provide community edu2 cation and prevention programs related to sexual

3 abuse of Indian children or children in an Indian

4 household.

5 ‘‘(2) To identify and provide behavioral health

6 treatment to victims of sexual abuse who are Indian

7 children or children in an Indian household, and to

8 their family members who are affected by sexual

9 abuse.

10 ‘‘(3) To develop prevention and intervention

11 models which incorporate Traditional Health Care

12 Practices, cultural and spiritual values, and commu13 nity involvement.

14 ‘‘(4) To develop and implement, through the

15 tribal consultation process, culturally sensitive as16 sessment and diagnostic tools for use in Indian com17 munities and Urban Centers.

18 ‘‘(5) To identify and provide behavioral health

19 treatment to Indian perpetrators and perpetrators

20 who are members of an Indian household—

21 ‘‘(A) making efforts to begin offender and

22 behavioral health treatment while the perpetra23 tor is incarcerated or at the earliest possible

24 date if the perpetrator is not incarcerated; and
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1 ‘‘(B) providing treatment after the per2 petrator is released, until it is determined that

3 the perpetrator is not a threat to children.

4 ‘‘SEC. 713. BEHAVIORAL HEALTH RESEARCH.

5 ‘‘The Secretary, in consultation with appropriate

6 Federal agencies, shall provide funding to Indian Tribes,

7 Tribal Organizations, and Urban Indian Organizations or

8 enter into contracts with, or make grants to appropriate

9 institutions for, the conduct of research on the incidence

10 and prevalence of behavioral health problems among Indi11 ans served by the Service, Indian Tribes, or Tribal Organi12 zations and among Indians in urban areas. Research pri13 orities under this section shall include—

14 ‘‘(1) the interrelationship and interdependence

15 of behavioral health problems with alcoholism and

16 other substance abuse, suicide, homicides, other in17 juries, and the incidence of family violence; and

18 ‘‘(2) the development of models of prevention

19 techniques.

20 The effect of the interrelationships and interdependencies

21 referred to in paragraph (1) on children, and the develop22 ment of prevention techniques under paragraph (2) appli23 cable to children, shall be emphasized.
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1 ‘‘SEC. 714. DEFINITIONS.

2 ‘‘For the purpose of this title, the following defini3 tions shall apply:

4 ‘‘(1) ASSESSMENT.—The term ‘assessment’

5 means the systematic collection, analysis, and dis6 semination of information on health status, health

7 needs, and health problems.

8 ‘‘(2) ALCOHOL-RELATED NEURODEVELOP9 MENTAL DISORDERS OR ARND.—The term ‘alcohol10 related neurodevelopmental disorders’ or ‘ARND’

11 means, with a history of maternal alcohol consump12 tion during pregnancy, central nervous system in13 volvement such as developmental delay, intellectual

14 deficit, or neurologic abnormalities. Behaviorally,

15 there can be problems with irritability, and failure to

16 thrive as infants. As children become older there will

17 likely be hyperactivity, attention deficit, language

18 dysfunction, and perceptual and judgment problems.

19 ‘‘(3) BEHAVIORAL HEALTH.—The term ‘behav20 ioral health’ means the blending of substance (alco21 hol, drugs, inhalants, and tobacco) abuse and mental

22 health prevention and treatment, for the purpose of

23 providing comprehensive services. This can include

24 the joint development of substance abuse and mental

25 health treatment planning and coordinated case

26 management using a multidisciplinary approach.
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1 ‘‘(4) BEHAVIORAL HEALTH AFTERCARE.—The

2 term ‘behavioral health aftercare’ includes those ac3 tivities and resources used to support recovery fol4 lowing inpatient, residential, intensive substance

5 abuse, or mental health outpatient or outpatient

6 treatment. The purpose is to help prevent or deal

7 with relapse by ensuring that by the time a client or

8 patient is discharged from a level of care, such as

9 outpatient treatment, an aftercare plan has been de10 veloped with the client. An aftercare plan may use

11 such resources a as community-based therapeutic

12 group, transitional living facilities, a 12-step spon13 sor, a local 12-step or other related support group,

14 and other community-based providers (mental health

15 professionals, traditional health care practitioners,

16 community health aides, community health rep17 resentatives, mental health technicians, ministers,

18 etc.)

19 ‘‘(5) DUAL DIAGNOSIS.—The term ‘dual diag20 nosis’ means coexisting substance abuse and mental

21 illness conditions or diagnosis. Such clients are

22 sometimes referred to as mentally ill chemical abus23 ers (MICAs).

24 ‘‘(6) FETAL ALCOHOL DISORDERS.—The term

25 ‘fetal alcohol disorders’ means fetal alcohol syn-
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1 drome, partial fetal alcohol syndrome and alcohol re2 lated neurodevelopmental disorder (ARND).

3 ‘‘(7) FETAL ALCOHOL SYNDROME OR FAS.—

4 The term ‘fetal alcohol syndrome’ or ‘FAS’ means a

5 syndrome in which, with a history of maternal alco6 hol consumption during pregnancy, the following cri7 teria are met:

8 ‘‘(A) Central nervous system involvement

9 such as developmental delay, intellectual deficit,

10 microencephaly, or neurologic abnormalities.

11 ‘‘(B) Craniofacial abnormalities with at

12 least 2 of the following: microophthalmia, short

13 palpebral fissures, poorly developed philtrum,

14 thin upper lip, flat nasal bridge, and short

15 upturned nose.

16 ‘‘(C) Prenatal or postnatal growth delay.

17 ‘‘(8) PARTIAL FAS.—The term ‘partial FAS’

18 means, with a history of maternal alcohol consump19 tion during pregnancy, having most of the criteria of

20 FAS, though not meeting a minimum of at least 2

21 of the following: microophthalmia, short palpebral

22 fissures, poorly developed philtrum, thin upper lip,

23 flat nasal bridge, and short upturned nose.

24 ‘‘(9) REHABILITATION.—The term ‘rehabilita25 tion’ means to restore the ability or capacity to en-
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1 gage in usual and customary life activities through

2 education and therapy.

3 ‘‘(10) SUBSTANCE ABUSE.—The term ‘sub4 stance abuse’ includes inhalant abuse.

5 ‘‘SEC. 715. AUTHORIZATION OF APPROPRIATIONS.

6 ‘‘There is authorized to be appropriated such sums

7 as may be necessary for each fiscal year through fiscal

8 year 2015 to carry out the provisions of this title.

9 ‘‘TITLE VIII—MISCELLANEOUS

10 ‘‘SEC. 801. REPORTS.

11 ‘‘The President shall, at the time the budget is sub12 mitted under section 1105 of title 31, United States Code,

13 for each fiscal year transmit to Congress a report contain14 ing the following:

15 ‘‘(1) A report on the progress made in meeting

16 the objectives of this Act, including a review of pro17 grams established or assisted pursuant to this Act

18 and assessments and recommendations of additional

19 programs or additional assistance necessary to, at a

20 minimum, provide health services to Indians and en21 sure a health status for Indians, which are at a par22 ity with the health services available to and the

23 health status of the general population, including

24 specific comparisons of appropriations provided and

25 those required for such parity.
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1 ‘‘(2) A report on whether, and to what extent,

2 new national health care programs, benefits, initia3 tives, or financing systems have had an impact on

4 the purposes of this Act and any steps that the Sec5 retary may have taken to consult with Indian Tribes,

6 Tribal Organizations, and Urban Indian Organiza7 tions to address such impact, including a report on

8 proposed changes in allocation of funding pursuant

9 to section 808.

10 ‘‘(3) A report on the use of health services by

11 Indians—

12 ‘‘(A) on a national and area or other rel13 evant geographical basis;

14 ‘‘(B) by gender and age;

15 ‘‘(C) by source of payment and type of

16 service;

17 ‘‘(D) comparing such rates of use with

18 rates of use among comparable non-Indian pop19 ulations; and

20 ‘‘(E) on the services provided under Fund21 ing Agreements.

22 ‘‘(4) A report of contractors to the Secretary on

23 Health Care Educational Loan Repayments every 6

24 months required by section 110.
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1 ‘‘(5) A general audit report of the Secretary on

2 the Health Care Educational Loan Repayment Pro3 gram as required by section 110(n).

4 ‘‘(6) A report of the findings and conclusions of

5 demonstration programs on development of edu6 cational curricula for substance abuse counseling as

7 required in section 126(f).

8 ‘‘(7) A separate statement which specifies the

9 amount of funds requested to carry out the provi10 sions of section 201.

11 ‘‘(8) A report of the evaluations of health pro12 motion and disease prevention as required in section

13 203(c).

14 ‘‘(9) A biennial report to Congress on infectious

15 diseases as required by section 212.

16 ‘‘(10) A report on environmental and nuclear

17 health hazards as required by section 215.

18 ‘‘(11) An annual report on the status of all

19 health care facilities needs as required by section

20 301(c)(2) and 301(d).

21 ‘‘(12) Reports on safe water and sanitary waste

22 disposal facilities as required by section 302(i).

23 ‘‘(13) An annual report on the expenditure of

24 nonservice funds for renovation as required by sec25 tions 304(b)(2).
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1 ‘‘(14) A report identifying the backlog of main2 tenance and repair required at Service and tribal fa3 cilities required by section 313(a).

4 ‘‘(15) A report providing an accounting of reim5 bursement funds made available to the Secretary

6 under titles XVIII, XIX, and XXI of the Social Se7 curity Act.

8 ‘‘(16) A report on any arrangements for the

9 sharing of medical facilities or services between the

10 Service, Indian Tribes, and Tribal Organizations,

11 and the Department of Veterans Affairs and the De12 partment of Defense, as authorized by section 406.

13 ‘‘(17) A report on evaluation and renewal of

14 Urban Indian programs under section 505.

15 ‘‘(18) A report on the evaluation of programs

16 as required by section 513(d).

17 ‘‘(19) A report on alcohol and substance abuse

18 as required by section 701(f).

19 ‘‘SEC. 802. REGULATIONS.

20 ‘‘(a) DEADLINES.—

21 ‘‘(1) PROCEDURES.—Not later than 90 days

22 after the date of the enactment of the Indian Health

23 Care Improvement Act Amendments of 2003, the

24 Secretary shall initiate procedures under subchapter

25 III of chapter 5 of title 5, United States Code, to
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1 negotiate and promulgate such regulations or

2 amendments thereto that are necessary to carry out

3 titles I, II, III, IV, and VII and section 817. The

4 Secretary may promulgate regulations to carry out

5 sections 105, 115, 117, and title V, using the proce6 dures required by the Administrative Procedures

7 Act. The Secretary shall issue no regulations to

8 carry out titles VI and VIII, except as necessary to

9 carry out section 817.

10 ‘‘(2) PROPOSED REGULATIONS.—Proposed reg11 ulations to implement this Act shall be published in

12 the Federal Register by the Secretary no later than

13 270 days after the date of the enactment of the In14 dian Health Care Improvement Act Amendments of

15 2003 and shall have no less than a 120-day com16 ment period.

17 ‘‘(3) EXPIRATION OF AUTHORITY.—The author18 ity to promulgate regulations under this Act shall

19 expire 18 months from the date of the enactment of

20 this Act.

21 ‘‘(b) COMMITTEE.—A negotiated rulemaking commit22 tee established pursuant to section 565 of title 5, United

23 States Code, to carry out this section shall have as its

24 members only representatives of the Federal Government

25 and representatives of Indian Tribes and Tribal Organiza-
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1 tions, a majority of whom shall be nominated by and be

2 representatives of Indian Tribes, Tribal Organizations,

3 and Urban Indian Organizations from each Service Area.

4 ‘‘(c) ADAPTATION OF PROCEDURES.—The Secretary

5 shall adapt the negotiated rulemaking procedures to the

6 unique context of self-governance and the government-to7 government relationship between the United States and

8 Indian Tribes.

9 ‘‘(d) LACK OF REGULATIONS.—The lack of promul10 gated regulations shall not limit the effect of this Act.

11 ‘‘(e) INCONSISTENT REGULATIONS.—The provisions

12 of this Act shall supersede any conflicting provisions of

13 law (including any conflicting regulations) in effect on the

14 day before the date of the enactment of the Indian Health

15 Care Improvement Act Amendments of 2003, and the Sec16 retary is authorized to repeal any regulation inconsistent

17 with the provisions of this Act.

18 ‘‘SEC. 803. PLAN OF IMPLEMENTATION.

19 ‘‘Not later than 8 months after the date of the enact20 ment of the Indian Health Care Improvement Act Amend21 ments of 2003, the Secretary in consultation with Indian

22 Tribes, Tribal Organizations, and Urban Indian Organiza23 tions, shall submit to Congress a plan explaining the man24 ner and schedule (including a schedule of appropriation
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1 requests), by title and section, by which the Secretary will

2 implement the provisions of this Act.

3 ‘‘SEC. 804. AVAILABILITY OF FUNDS.

4 ‘‘The funds appropriated pursuant to this Act shall

5 remain available until expended.

6 ‘‘SEC. 805. LIMITATION ON USE OF FUNDS APPROPRIATED

7 TO THE INDIAN HEALTH SERVICE.

8 ‘‘Any limitation on the use of funds contained in an

9 Act providing appropriations for the Department for a pe10 riod with respect to the performance of abortions shall

11 apply for that period with respect to the performance of

12 abortions using funds contained in an Act providing ap13 propriations for the Service.

14 ‘‘SEC. 806. ELIGIBILITY OF CALIFORNIA INDIANS.

15 ‘‘(a) IN GENERAL.—The following California Indians

16 shall be eligible for health services provided by the Service:

17 ‘‘(1) Any member of a federally recognized In18 dian Tribe.

19 ‘‘(2) Any descendant of an Indian who was re20 siding in California on June 1, 1852, if such

21 descendant—

22 ‘‘(A) is a member of the Indian community

23 served by a local program of the Service; and

24 ‘‘(B) is regarded as an Indian by the com25 munity in which such descendant lives.
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1 ‘‘(3) Any Indian who holds trust interests in

2 public domain, national forest, or reservation allot3 ments in California.

4 ‘‘(4) Any Indian in California who is listed on

5 the plans for distribution of the assets of California

6 rancherias and reservations under the Act of August

7 18, 1958 (72 Stat. 619), and any descendant of

8 such an Indian.

9 ‘‘(b) CLARIFICATION.—Nothing in this section may

10 be construed as expanding the eligibility of California Indi11 ans for health services provided by the Service beyond the

12 scope of eligibility for such health services that applied on

13 May 1, 1986.

14 ‘‘SEC. 807. HEALTH SERVICES FOR INELIGIBLE PERSONS.

15 ‘‘(a) CHILDREN.—Any individual who—

16 ‘‘(1) has not attained 19 years of age;

17 ‘‘(2) is the natural or adopted child, stepchild,

18 foster child, legal ward, or orphan of an eligible In19 dian; and

20 ‘‘(3) is not otherwise eligible for health services

21 provided by the Service,

22 shall be eligible for all health services provided by the

23 Service on the same basis and subject to the same rules

24 that apply to eligible Indians until such individual attains

25 19 years of age. The existing and potential health needs
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1 of all such individuals shall be taken into consideration

2 by the Service in determining the need for, or the alloca3 tion of, the health resources of the Service. If such an indi4 vidual has been determined to be legally incompetent prior

5 to attaining 19 years of age, such individual shall remain

6 eligible for such services until 1 year after the date of a

7 determination of competency.

8 ‘‘(b) SPOUSES.—Any spouse of an eligible Indian who

9 is not an Indian, or who is of Indian descent but not other10 wise eligible for the health services provided by the Serv11 ice, shall be eligible for such health services if all such

12 spouses or spouses who are married to members of the

13 Indian Tribe(s) being served are made eligible, as a class,

14 by an appropriate resolution of the governing body of the

15 Indian Tribe or Tribal Organization providing such serv16 ices. The health needs of persons made eligible under this

17 paragraph shall not be taken into consideration by the

18 Service in determining the need for, or allocation of, its

19 health resources.

20 ‘‘(c) PROVISION OF SERVICES TO OTHER INDIVID21 UALS.—

22 ‘‘(1) IN GENERAL.—The Secretary is authorized

23 to provide health services under this subsection

24 through health programs operated directly by the

25 Service to individuals who reside within the Service
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1 Unit and who are not otherwise eligible for such

2 health services if—

3 ‘‘(A) the Indian Tribes served by such

4 Service Unit request such provision of health

5 services to such individuals; and

6 ‘‘(B) the Secretary and the served Indian

7 Tribes have jointly determined that—

8 ‘‘(i) the provision of such health serv9 ices will not result in a denial or diminu10 tion of health services to eligible Indians;

11 and

12 ‘‘(ii) there is no reasonable alternative

13 health facilities or services, within or with14 out the Service Unit, available to meet the

15 health needs of such individuals.

16 ‘‘(2) ISDEAA PROGRAMS.—In the case of a

17 Tribal Health Program, the governing body of the

18 Indian Tribe or Tribal Organization providing health

19 services under such Tribal Health Program is au20 thorized to determine whether health services should

21 be provided under its Funding Agreement to individ22 uals who are not otherwise eligible for such services.

23 In making such determination, the governing body

24 shall take into account the considerations described

25 in clauses (i) and (ii) of paragraph (1)(B).
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1 ‘‘(3) PAYMENT FOR SERVICES.—

2 ‘‘(A) IN GENERAL.—Persons receiving

3 health services provided by the Service under of

4 this subsection shall be liable for payment of

5 such health services under a schedule of charges

6 prescribed by the Secretary which, in the judg7 ment of the Secretary, results in reimbursement

8 in an amount not less than the actual cost of

9 providing the health services. Notwithstanding

10 section 1880(c) of the Social Security Act, sec11 tion 404 of this Act, or any other provision of

12 law, amounts collected under this subsection,

13 including medicare, medicaid, or SCHIP reim14 bursements under titles XVIII, XIX, and XXI

15 of the Social Security Act, shall be credited to

16 the account of the program providing the serv17 ice and shall be used for the purposes listed in

18 section 401(d)(2) and amounts collected under

19 this subsection shall be available for expendi20 ture within such program.

21 ‘‘(B) INDIGENT PEOPLE.—Health services

22 may be provided by the Secretary through the

23 Service under this subsection to an indigent in24 dividual who would not be otherwise eligible for

25 such health services but for the provisions of
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1 paragraph (1) only if an agreement has been

2 entered into with a State or local government

3 under which the State or local government

4 agrees to reimburse the Service for the expenses

5 incurred by the Service in providing such health

6 services to such indigent individual.

7 ‘‘(4) REVOCATION OF CONSENT FOR SERV8 ICES.—

9 ‘‘(A) SINGLE TRIBE SERVICE AREA.—In

10 the case of a Service Area which serves only 1

11 Indian Tribe, the authority of the Secretary to

12 provide health services under paragraph (1)

13 shall terminate at the end of the fiscal year suc14 ceeding the fiscal year in which the governing

15 body of the Indian Tribe revokes its concur16 rence to the provision of such health services.

17 ‘‘(B) MULTITRIBAL SERVICE AREA.—In

18 the case of a multitribal Service Area, the au19 thority of the Secretary to provide health serv20 ices under paragraph (1) shall terminate at the

21 end of the fiscal year succeeding the fiscal year

22 in which at least 51 percent of the number of

23 Indian Tribes in the Service Area revoke their

24 concurrence to the provisions of such health

25 services.
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1 ‘‘(d) OTHER SERVICES.—The Service may provide

2 health services under this subsection to individuals who

3 are not eligible for health services provided by the Service

4 under any other provision of law in order to—

5 ‘‘(1) achieve stability in a medical emergency;

6 ‘‘(2) prevent the spread of a communicable dis7 ease or otherwise deal with a public health hazard;

8 ‘‘(3) provide care to non-Indian women preg9 nant with an eligible Indian’s child for the duration

10 of the pregnancy through postpartum; or

11 ‘‘(4) provide care to immediate family members

12 of an eligible person if such care is directly related

13 to the treatment of the eligible individual.

14 ‘‘(e) HOSPITAL PRIVILEGES FOR PRACTITIONERS.—

15 Hospital privileges in health facilities operated and main16 tained by the Service or operated under a Funding Agree17 ment may be extended to non-Service health care practi18 tioners who provide services to individuals described in

19 subsection (a), (b), (c), or (d). Such non-Service health

20 care practitioners may be regarded as employees of the

21 Federal Government for purposes of section 1346(b) and

22 chapter 171 of title 28, United States Code (relating to

23 Federal tort claims) only with respect to acts or omissions

24 which occur in the course of providing services to eligible
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1 persons as a part of the conditions under which such hos2 pital privileges are extended.

3 ‘‘(f) ELIGIBLE INDIAN.—For purposes of this sec4 tion, the term ‘eligible Indian’ means any Indian who is

5 eligible for health services provided by the Service without

6 regard to the provisions of this section.

7 ‘‘SEC. 808. REALLOCATION OF BASE RESOURCES.

8 ‘‘(a) REPORT REQUIRED.—Notwithstanding any

9 other provision of law, any allocation of Service funds for

10 a fiscal year that reduces by 5 percent or more from the

11 previous fiscal year the funding for any recurring pro12 gram, project, or activity of a Service Unit may be imple13 mented only after the Secretary has submitted to the

14 President, for inclusion in the report required to be trans15 mitted to Congress under section 801, a report on the pro16 posed change in allocation of funding, including the rea17 sons for the change and its likely effects.

18 ‘‘(b) EXCEPTION.—Subsection (a) shall not apply if

19 the total amount appropriated to the Service for a fiscal

20 year is at least 5 percent less than the amount appro21 priated to the Service for the previous fiscal year.

22 ‘‘SEC. 809. RESULTS OF DEMONSTRATION PROJECTS.

23 ‘‘The Secretary shall provide for the dissemination to

24 Indian Tribes, Tribal Organizations, and Urban Indian
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1 Organizations of the findings and results of demonstration

2 projects conducted under this Act.

3 ‘‘SEC. 810. PROVISION OF SERVICES IN MONTANA.

4 ‘‘(a) CONSISTENT WITH COURT DECISION.—The

5 Secretary, acting through the Service, shall provide serv6 ices and benefits for Indians in Montana in a manner con7 sistent with the decision of the United States Court of Ap8 peals for the Ninth Circuit in McNabb for McNabb v.

9 Bowen, 829 F.2d 787 (9th Cir. 1987).

10 ‘‘(b) CLARIFICATION.—The provisions of subsection

11 (a) shall not be construed to be an expression of the sense

12 of Congress on the application of the decision described

13 in subsection (a) with respect to the provision of services

14 or benefits for Indians living in any State other than Mon15 tana.

16 ‘‘SEC. 811. MORATORIUM.

17 ‘‘During the period of the moratorium imposed on

18 implementation of the final rule published in the Federal

19 Register on September 16, 1987, by the Health Resources

20 and Services Administration of the Public Health Service,

21 relating to eligibility for the health care services of the

22 Indian Health Service, the Indian Health Service shall

23 provide services pursuant to the criteria for eligibility for

24 such services that were in effect on September 15, 1987,

25 subject to the provisions of sections 806 and 807 until
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1 such time as new criteria governing eligibility for services

2 are developed in accordance with section 802.

3 ‘‘SEC. 812. TRIBAL EMPLOYMENT.

4 ‘‘For purposes of section 2(2) of the Act of July 5,

5 1935 (49 Stat. 450, chapter 372), an Indian Tribe or

6 Tribal Organization carrying out a Funding Agreement

7 shall not be considered an ‘employer’.

8 ‘‘SEC. 813. PRIME VENDOR.

9 ‘‘(a) EXECUTIVE AGENCY STATUS.—For purposes of

10 section 201(a) of the Federal Property and Administrative

11 Services Act (40 U.S.C. 481(a)) (relating to Federal

12 sources of supply, including lodging providers, airlines,

13 and other transportation providers), a Tribal Health Pro14 gram shall be deemed an executive agency when carrying

15 out a contract, grant, cooperative agreement, or Funding

16 Agreement with the Service and shall have access to the

17 Federal Supply Schedule and any other Federal source of

18 supply to which executive agencies have access.

19 ‘‘(b) HHS STATUS.—For purposes of section 4 of

20 Public Law 102–585 (38 U.S.C. 8126), a Tribal Health

21 Program shall have the status of the Indian Health Serv22 ice and shall have direct access to the Veterans Adminis23 tration prime vendor provided for in section 4 of Public

24 Law 102–585.
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1 ‘‘(c) EMPLOYEE STATUS.—The employees of such

2 Tribal Health Programs may order supplies under such

3 respective programs on the same basis as employees of the

4 Service.

5 ‘‘SEC. 814. SEVERABILITY PROVISIONS.

6 ‘‘If any provision of this Act, any amendment made

7 by the Act, or the application of such provision or amend8 ment to any person or circumstances is held to be invalid,

9 the remainder of this Act, the remaining amendments

10 made by this Act, and the application of such provisions

11 to persons or circumstances other than those to which it

12 is held invalid, shall not be affected thereby.

13 ‘‘SEC. 815. ESTABLISHMENT OF NATIONAL BIPARTISAN

14 COMMISSION ON INDIAN HEALTH CARE ENTI15 TLEMENT.

16 ‘‘(a) ESTABLISHMENT.—There is hereby established

17 the National Bipartisan Indian Health Care Entitlement

18 Commission (the ‘Commission’).

19 ‘‘(b) DUTIES OF COMMISSION.—The duties of the

20 Commission are the following:

21 ‘‘(1) To establish a study committee composed

22 of those members of the Commission appointed by

23 the Director and at least 4 members of Congress

24 from among the members of the Commission, the

25 duties of which shall be the following:
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1 ‘‘(A) To the extent necessary to carry out

2 its duties, collect and compile data necessary to

3 understand the extent of Indian needs with re4 gard to the provision of health services, regard5 less of the location of Indians, including holding

6 hearings and soliciting the views of Indians, In7 dian Tribes, Tribal Organizations, and Urban

8 Indian Organizations, which may include au9 thorizing and making funds available for fea10 sibility studies of various models for providing

11 and funding health services for all Indian bene12 ficiaries, including those who live outside of a

13 reservation, temporarily or permanently.

14 ‘‘(B) To make recommendations to the

15 Commission for legislation that will provide for

16 the delivery of health services for Indians as an

17 entitlement, which will address, among other

18 things, issues of eligibility, benefits to be pro19 vided, including recommendations regarding

20 from whom such health services are to be pro21 vided and the cost, including mechanisms for

22 making funds available for the health services

23 to be provided.

24 ‘‘(C) To determine the effect of the enact25 ment of such recommendations on (i) the exist-
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1 ing system of delivery of health services for In2 dians, and (ii) the sovereign status of Indian

3 Tribes.

4 ‘‘(D) Not later than 12 months after the

5 appointment of all members of the Commission,

6 to submit a written report of its findings and

7 recommendations to the full Commission. The

8 report shall include a statement of the minority

9 and majority position of the Committee and

10 shall be disseminated, at a minimum, to every

11 Indian Tribe, Tribal Organization, and Urban

12 Indian Organization for comment to the Com13 mission.

14 ‘‘(E) To report regularly to the full Com15 mission regarding the findings and rec16 ommendations developed by the study commit17 tee in the course of carrying out its duties

18 under this section.

19 ‘‘(2) To review and analyze the recommenda20 tions of the report of the study committee.

21 ‘‘(3) To make recommendations to Congress for

22 providing health services for Indians as an entitle23 ment, giving due regard to the effects of such a pro24 gram on existing health care delivery systems for In-
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1 dians and the effect of such a program on the sov2 ereign status of Indian Tribes.

3 ‘‘(4) Not later than 18 months following the

4 date of appointment of all members of the Commis5 sion, submit a written report to Congress containing

6 a recommendation of policies and legislation to im7 plement a policy that would establish a health care

8 system for Indians based on delivery of health serv9 ices as an entitlement, together with a determination

10 of the implications of such an entitlement system on

11 existing health care delivery systems for Indians and

12 on the sovereign status of Indian Tribes.

13 ‘‘(c) MEMBERS.—

14 ‘‘(1) APPOINTMENT.—The Commission shall be

15 composed of 25 members, appointed as follows:

16 ‘‘(A) Ten members of Congress, including

17 3 from the United States House of Representa18 tives and 2 from the United States Senate, ap19 pointed by their respective majority leaders, and

20 3 from the United States House of Representa21 tives and 2 from the United States Senate, ap22 pointed by their respective minority leaders, and

23 who shall be members of the standing commit24 tees of Congress that consider legislation affect25 ing health care to Indians.
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1 ‘‘(B) Twelve persons chosen by the Con2 gressional members of the Commission, 1 from

3 each Service Area as currently designated by

4 the Director to be chosen from among 3 nomi5 nees from each Service Area put forward by the

6 Indian Tribes within the area, with due regard

7 being given to the experience and expertise of

8 the nominees in the provision of health care to

9 Indians and to a reasonable representation on

10 the commission of members who are familiar

11 with various health care delivery modes and

12 who represent Indian Tribes of various size

13 populations.

14 ‘‘(C) Three persons appointed by the Di15 rector who are knowledgeable about the provi16 sion of health care to Indians, at least one of

17 whom shall be appointed from among 3 nomi18 nees put forward by those programs whose

19 funds are provided in whole or in part by the

20 Service primarily or exclusively for the benefit

21 of Urban Indians.

22 ‘‘(D) All those persons chosen by the Con23 gressional members of the Commission and by

24 the Director shall be members of federally rec25 ognized Indian Tribes.
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1 ‘‘(2) CHAIR; VICE CHAIR.—The Chair and Vice

2 Chair of the Commission shall be selected by the

3 Congressional members of the Commission.

4 ‘‘(3) TERMS.—The terms of members of the

5 Commission shall be for the life of the Commission.

6 ‘‘(4) DEADLINE FOR APPOINTMENTS.—Con7 gressional members of the Commission shall be ap8 pointed not later than 90 days after the date of the

9 enactment of the Indian Health Care Improvement

10 Act Amendments of 2003, and the remaining mem11 bers of the Commission shall be appointed not later

12 than 60 days following the appointment of the Con13 gressional members.

14 ‘‘(5) VACANCY.—A vacancy in the Commission

15 shall be filled in the manner in which the original

16 appointment was made.

17 ‘‘(d) COMPENSATION.—

18 ‘‘(1) CONGRESSIONAL MEMBERS.—Each Con19 gressional member of the Commission shall receive

20 no additional pay, allowances, or benefits by reason

21 of their service on the Commission and shall receive

22 travel expenses and per diem in lieu of subsistence

23 in accordance with sections 5702 and 5703 of title

24 5, United States Code.
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1 ‘‘(2) OTHER MEMBERS.—Remaining members

2 of the Commission, while serving on the business of

3 the Commission (including travel time), shall be en4 titled to receive compensation at the per diem equiv5 alent of the rate provided for level IV of the Execu6 tive Schedule under section 5315 of title 5, United

7 States Code, and while so serving away from home

8 and the member’s regular place of business, a mem9 ber may be allowed travel expenses, as authorized by

10 the Chairman of the Commission. For purpose of

11 pay (other than pay of members of the Commission)

12 and employment benefits, rights, and privileges, all

13 personnel of the Commission shall be treated as if

14 they were employees of the United States Senate.

15 ‘‘(e) MEETINGS.—The Commission shall meet at the

16 call of the Chair.

17 ‘‘(f) QUORUM.—A quorum of the Commission shall

18 consist of not less than 15 members, provided that no less

19 than 6 of the members of Congress who are Commission

20 members are present and no less than 9 of the members

21 who are Indians are present.

22 ‘‘(g) EXECUTIVE DIRECTOR; STAFF; FACILITIES.—

23 ‘‘(1) APPOINTMENT; PAY.—The Commission

24 shall appoint an executive director of the Commis-
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1 sion. The executive director shall be paid the rate of

2 basic pay for level V of the Executive Schedule.

3 ‘‘(2) STAFF APPOINTMENT.—With the approval

4 of the Commission, the executive director may ap5 point such personnel as the executive director deems

6 appropriate.

7 ‘‘(3) STAFF PAY.—The staff of the Commission

8 shall be appointed without regard to the provisions

9 of title 5, United States Code, governing appoint10 ments in the competitive service, and shall be paid

11 without regard to the provisions of chapter 51 and

12 subchapter III of chapter 53 of such title (relating

13 to classification and General Schedule pay rates).

14 ‘‘(4) TEMPORARY SERVICES.—With the ap15 proval of the Commission, the executive director may

16 procure temporary and intermittent services under

17 section 3109(b) of title 5, United States Code.

18 ‘‘(5) FACILITIES.—The Administrator of Gen19 eral Services shall locate suitable office space for the

20 operation of the Commission. The facilities shall

21 serve as the headquarters of the Commission and

22 shall include all necessary equipment and incidentals

23 required for the proper functioning of the Commis24 sion.
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1 ‘‘(h) HEARINGS.—(1) For the purpose of carrying

2 out its duties, the Commission may hold such hearings

3 and undertake such other activities as the Commission de4 termines to be necessary to carry out its duties, provided

5 that at least 6 regional hearings are held in different areas

6 of the United States in which large numbers of Indians

7 are present. Such hearings are to be held to solicit the

8 views of Indians regarding the delivery of health care serv9 ices to them. To constitute a hearing under this sub10 section, at least 5 members of the Commission, including

11 at least 1 member of Congress, must be present. Hearings

12 held by the study committee established in this section

13 may count towards the number of regional hearings re14 quired by this subsection.

15 ‘‘(2) Upon request of the Commission, the Comptrol16 ler General shall conduct such studies or investigations as

17 the Commission determines to be necessary to carry out

18 its duties.

19 ‘‘(3)(A) The Director of the Congressional Budget

20 Office or the Chief Actuary of the Centers for Medicare

21 and Medicaid Services, or both, shall provide to the Com22 mission, upon the request of the Commission, such cost

23 estimates as the Commission determines to be necessary

24 to carry out its duties.
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1 ‘‘(B) The Commission shall reimburse the Director

2 of the Congressional Budget Office for expenses relating

3 to the employment in the office of the Director of such

4 additional staff as may be necessary for the Director to

5 comply with requests by the Commission under subpara6 graph (A).

7 ‘‘(4) Upon the request of the Commission, the head

8 of any Federal agency is authorized to detail, without re9 imbursement, any of the personnel of such agency to the

10 Commission to assist the Commission in carrying out its

11 duties. Any such detail shall not interrupt or otherwise

12 affect the civil service status or privileges of the Federal

13 employee.

14 ‘‘(5) Upon the request of the Commission, the head

15 of a Federal agency shall provide such technical assistance

16 to the Commission as the Commission determines to be

17 necessary to carry out its duties.

18 ‘‘(6) The Commission may use the United States

19 mails in the same manner and under the same conditions

20 as Federal agencies and shall, for purposes of the frank,

21 be considered a commission of Congress as described in

22 section 3215 of title 39, United States Code.

23 ‘‘(7) The Commission may secure directly from any

24 Federal agency information necessary to enable it to carry

25 out its duties, if the information may be disclosed under
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1 section 552 of title 4, United States Code. Upon request

2 of the Chairman of the Commission, the head of such

3 agency shall furnish such information to the Commission.

4 ‘‘(8) Upon the request of the Commission, the Ad5 ministrator of General Services shall provide to the Com6 mission on a reimbursable basis such administrative sup7 port services as the Commission may request.

8 ‘‘(9) For purposes of costs relating to printing and

9 binding, including the cost of personnel detailed from the

10 Government Printing Office, the Commission shall be

11 deemed to be a committee of Congress.

12 ‘‘(i) AUTHORIZATION OF APPROPRIATIONS.—There is

13 authorized to be appropriated $4,000,000 to carry out the

14 provisions of this section, which sum shall not be deducted

15 from or affect any other appropriation for health care for

16 Indian persons.

17 ‘‘(j) FACA.—The Federal Advisory Committee Act

18 (5 U.S.C. App.) shall not apply to the Commission.

19 ‘‘SEC. 816. APPROPRIATIONS; AVAILABILITY.

20 ‘‘Any new spending authority (described in subsection

21 (c)(2)(A) or (B) of section 401 of the Congressional Budg22 et Act of 1974) which is provided under this Act shall

23 be effective for any fiscal year only to such extent or in

24 such amounts as are provided in appropriation Acts.
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1 ‘‘SEC. 817. CONFIDENTIALITY OF MEDICAL QUALITY ASSUR2 ANCE RECORDS: QUALIFIED IMMUNITY FOR

3 PARTICIPANTS.

4 ‘‘(a) CONFIDENTIALITY OF RECORDS.—Medical qual5 ity assurance records created by or for any Indian Health

6 Program or a health program of an Urban Indian Organi7 zation as part of a medical quality assurance program are

8 confidential and privileged. Such records may not be dis9 closed to any person or entity, except as provided in sub10 section (c).

11 ‘‘(b) PROHIBITION ON DISCLOSURE AND TESTI12 MONY.—

13 ‘‘(1) No part of any medical quality assurance

14 record described in subsection (a) may be subject to

15 discovery or admitted into evidence in any judicial or

16 administrative proceeding, except as provided in sub17 section (c).

18 ‘‘(2) A person who reviews or creates medical

19 quality assurance records for any Indian health pro20 gram or who participates in any proceeding that re21 views or creates such records may not be permitted

22 or required to testify in any judicial or administra23 tive proceeding with respect to such records or with

24 respect to any finding, recommendation, evaluation,

25 opinion, or action taken by such person or body in
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1 connection with such records except as provided in

2 this section.

3 ‘‘(c) AUTHORIZED DISCLOSURE AND TESTIMONY.—

4 ‘‘(1) Subject to paragraph (2), a medical qual5 ity assurance record described in subsection (a) may

6 be disclosed, and a person referred to in subsection

7 (b) may give testimony in connection with such a

8 record, only as follows:

9 ‘‘(A) To a Federal executive agency or pri10 vate organization, if such medical quality assur11 ance record or testimony is needed by such

12 agency or organization to perform licensing or

13 accreditation functions related to any Indian

14 Health Program or to a health program of an

15 Urban Indian Organization to perform monitor16 ing, required by law, of such program or orga17 nization.

18 ‘‘(B) To an administrative or judicial pro19 ceeding commenced by a present or former In20 dian Health Program or Urban Indian Organi21 zation provider concerning the termination, sus22 pension, or limitation of clinical privileges of

23 such health care provider.

24 ‘‘(C) To a governmental board or agency

25 or to a professional health care society or orga-
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1 nization, if such medical quality assurance

2 record or testimony is needed by such board,

3 agency, society, or organization to perform li4 censing, credentialing, or the monitoring of pro5 fessional standards with respect to any health

6 care provider who is or was an employee of any

7 Indian Health Program or Urban Indian Orga8 nization.

9 ‘‘(D) To a hospital, medical center, or

10 other institution that provides health care serv11 ices, if such medical quality assurance record or

12 testimony is needed by such institution to as13 sess the professional qualifications of any health

14 care provider who is or was an employee of any

15 Indian Health Program or Urban Indian Orga16 nization and who has applied for or been grant17 ed authority or employment to provide health

18 care services in or on behalf of such program or

19 organization.

20 ‘‘(E) To an officer, employee, or contractor

21 of any Indian Health Program or Urban Indian

22 Organization who has a need for such record or

23 testimony to perform official duties.

24 ‘‘(F) To a criminal or civil law enforce25 ment agency or instrumentality charged under
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1 applicable law with the protection of the public

2 health or safety, if a qualified representative of

3 such agency or instrumentality makes a written

4 request that such record or testimony be pro5 vided for a purpose authorized by law.

6 ‘‘(G) In an administrative or judicial pro7 ceeding commenced by a criminal or civil law

8 enforcement agency or instrumentality referred

9 to in subparagraph (F), but only with respect

10 to the subject of such proceeding.

11 ‘‘(2) With the exception of the subject of a

12 quality assurance action, the identity of any person

13 receiving health care services from any Indian

14 Health Program or Urban Indian Organization or

15 the identity of any other person associated with such

16 program or organization for purposes of a medical

17 quality assurance program that is disclosed in a

18 medical quality assurance record described in sub19 section (a) shall be deleted from that record or docu20 ment before any disclosure of such record is made

21 outside such program or organization. Such require22 ment does not apply to the release of information

23 pursuant to section 552a of title 5.

24 ‘‘(d) DISCLOSURE FOR CERTAIN PURPOSES.—
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1 ‘‘(1) Nothing in this section shall be construed

2 as authorizing or requiring the withholding from any

3 person or entity aggregate statistical information re4 garding the results of any Indian Health Program or

5 Urban Indian Organizations’s medical quality assur6 ance programs.

7 ‘‘(2) Nothing in this section shall be construed

8 as authority to withhold any medical quality assur9 ance record from a committee of either House of

10 Congress, any joint committee of Congress, or the

11 General Accounting Office if such record pertains to

12 any matter within their respective jurisdictions.

13 ‘‘(e) PROHIBITION ON DISCLOSURE OF RECORD OR

14 TESTIMONY.—A person or entity having possession of or

15 access to a record or testimony described by this section

16 may not disclose the contents of such record or testimony

17 in any manner or for any purpose except as provided in

18 this section.

19 ‘‘(f) EXEMPTION FROM FREEDOM OF INFORMATION

20 ACT.—Medical quality assurance records described in sub21 section (a) may not be made available to any person under

22 section 552 of title 5.

23 ‘‘(g) LIMITATION ON CIVIL LIABILITY.—A person

24 who participates in or provides information to a person

25 or body that reviews or creates medical quality assurance
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1 records described in subsection (a) shall not be civilly lia2 ble for such participation or for providing such informa3 tion if the participation or provision of information was

4 in good faith based on prevailing professional standards

5 at the time the medical quality assurance program activity

6 took place.

7 ‘‘(h) APPLICATION TO INFORMATION IN CERTAIN

8 OTHER RECORDS.—Nothing in this section shall be con9 strued as limiting access to the information in a record

10 created and maintained outside a medical quality assur11 ance program, including a patient’s medical records, on

12 the grounds that the information was presented during

13 meetings of a review body that are part of a medical qual14 ity assurance program.

15 ‘‘(i) REGULATIONS.—The Secretary, acting through

16 the Service, shall promulgate regulations pursuant to sec17 tion 802 of this title.

18 ‘‘(j) DEFINITIONS.—In this section:

19 ‘‘(1) The term ‘medical quality assurance pro20 gram’ means any activity carried out before, on, or

21 after the date of enactment of this Act by or for any

22 Indian Health Program or Urban Indian Organiza23 tion to assess the quality of medical care, including

24 activities conducted by individuals, military medical

25 or dental treatment facility committees, or other re-
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1 view bodies responsible for quality assurance, cre2 dentials, infection control, patient care assessment

3 (including treatment procedures, blood, drugs, and

4 therapeutics), medical records, health resources

5 management review and identification and preven6 tion of medical or dental incidents and risks.

7 ‘‘(2) The term ‘medical quality assurance

8 record’ means the proceedings, records, minutes, and

9 reports that emanate from quality assurance pro10 gram activities described in paragraph (1) and are

11 produced or compiled by an Indian Health Program

12 or Urban Indian Organization as part of a medical

13 quality assurance program.

14 ‘‘(3) The term ‘health care provider’ means any

15 health care professional, including community health

16 aides and practitioners certified under section 121,

17 who are granted clinical practice privileges or em18 ployed to provide health care services in an Indian

19 Health Program or health program of an Urban In20 dian Organization, who is licensed or certified to

21 perform health care services by a governmental

22 board or agency or professional health care society

23 or organization.
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1 ‘‘SEC. 818. AUTHORIZATION OF APPROPRIATIONS.

2 ‘‘There are authorized to be appropriated such sums

3 as may be necessary for each fiscal year through fiscal

4 year 2015 to carry out this title.’’.

5 SEC. 3. SOBOBA SANITATION FACILITIES.

6 The Act of December 17, 1970 (84 Stat. 1465), is

7 amended by adding at the end the following new section:

8 ‘‘SEC. 9. Nothing in this Act shall preclude the

9 Soboba Band of Mission Indians and the Soboba Indian

10 Reservation from being provided with sanitation facilities

11 and services under the authority of section 7 of the Act

12 of August 5, 1954 (68 Stat. 674), as amended by the Act

13 of July 31, 1959 (73 Stat. 267).’’.

14 SEC. 4. AMENDMENTS TO MEDICARE PROGRAM.

15 (a) EXPANSION OF MEDICARE PAYMENT FOR ALL

16 COVERED SERVICES FURNISHED BY INDIAN HEALTH

17 PROGRAMS.—

18 (1) EXPANSION TO ALL COVERED SERVICES.—

19 Section 1880 of the Social Security Act (42 U.S.C.

20 1395qq) is amended—

21 (A) by amending the heading to read as

22 follows:

23 ‘‘INDIAN HEALTH PROGRAMS’’;

24 (B) by amending subsection (a) to read as

25 follows:
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1 ‘‘(a) An Indian Health Program (as that term is de2 fined in section 4 of the Indian Health Care Improvement

3 Act) shall be eligible for payments under this title, not4 withstanding sections 1814(c) and 1835(d), with respect

5 to covered items and services it furnishes if (subject to

6 section 408 of such Act) it meets the conditions and re7 quirements for such payments which apply to the furnish8 ing of such items and services under this title.’’; and

9 (C) by striking subsection (e).

10 (2) ELIMINATION OF TEMPORARY DEEMING

11 PROVISION, SEPARATE FUND REQUIREMENT, AND

12 DUPLICATIVE ANNUAL REPORT.—Such section is

13 amended by striking subsections (b) through (d).

14 (3) REFERENCE CORRECTION.—Subsection (f)

15 of such section is redesignated as subsection (b) and

16 is amended by striking ‘‘section 405’’ and inserting

17 ‘‘section 401(d)’’.

18 (b) LIMITATION ON CHARGES FOR HOSPITAL CON19 TRACT HEALTH SERVICES PROVIDED TO INDIANS BY

20 MEDICARE PARTICIPATING HOSPITALS.—

21 (1) IN GENERAL.—Section 1866(a)(1) of the

22 Social Security Act (42 U.S.C. 1395cc(a)(1)) is

23 amended—

24 (A) in subparagraph (R), by striking

25 ‘‘and’’ at the end;
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1 (B) in subparagraph (S), by striking the

2 period and inserting ‘‘, and’’; and

3 (C) by adding at the end the following new

4 subparagraph:

5 ‘‘(T) in the case of hospitals and critical

6 access hospitals which furnish services for

7 which payment may be made under this title to

8 be a participating provider—

9 ‘‘(i) under the contract health services

10 program operated by an Indian Health

11 Program (as those terms are defined in

12 section 4 of the Indian Health Care Im13 provement Act), with respect to items and

14 services that are covered under and fur15 nished to an individual eligible for such

16 program; and

17 ‘‘(ii) under a program funded by the

18 Indian Health Service and operated by an

19 Urban Indian Organization with respect to

20 the purchase of items and services for an

21 eligible Urban Indian (as those terms are

22 defined in section 4 of the Indian Health

23 Care Improvement Act (25 U.S.C. 1603);

24 in accordance with regulations promulgated by

25 the Secretary regarding admission practices,
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1 payment methodology, and rates of payment

2 (including the acceptance of not more than such

3 payment rate as payment in full for such items

4 and services).’’.

5 (2) EFFECTIVE DATE.—The amendments made

6 by paragraph (1) shall apply as of a date specified

7 by the Secretary of Health and Human Services (but

8 in no case later than 6 months after the date of the

9 enactment of this Act) to medicare participation

10 agreements in effect (or entered into) on or after

11 such date.

12 (c) MEDICARE COVERAGE OF SERVICES OF COMMU13 NITY HEALTH AIDES OR PRACTITIONERS.—

14 (1) IN GENERAL.—Section 1861 of such Act

15 (42 U.S.C. 1395x) is amended—

16 (A) in subsection (s)(2)(K)—

17 (i) in clause (ii), by adding ‘‘and’’ at

18 the end; and

19 (ii) by adding at the end the following

20 new clause:

21 ‘‘(iii) services which would be physicians’ serv22 ices if furnished by a physician (as defined in sub23 section (r)(1)) and which are performed by a com24 munity health aide or practitioner which the aide or

25 practitioner is legally authorized to perform, and
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1 such services and supplies furnished as incident to

2 such services as would be covered under subpara3 graph (A) if furnished incident to a physician’s pro4 fessional service but only if no other provider

5 charges or is paid any amounts with respect to the

6 professional fee for furnishing of such services (and,

7 in the case of a telehealth service described in sec8 tion 1834(m), treating services at the originating

9 site and the distant site as separate services);’’; and

10 (B) by adding at the end the following new

11 subsection:

12 ‘‘Community Health Aides or Practitioners

13 ‘‘(ww) The term ‘community health aides or practi14 tioner’ means such an aide or practitioner who has been

15 certified under the provisions of section 121 of the Indian

16 Health Care Improvement Act and who only provides serv17 ices as an employee of the Indian Health Service, an In18 dian Tribe, or Tribal Organization.’’.

19 (2) PAYMENT.—

20 (A) PAYMENT RATE.—Section

21 1833(a)(1)(O) of such Act (42 U.S.C.

22 1395l(a)(1)(O)) is amended—

23 (i) by striking ‘‘or’’ before ‘‘(ii)’’; and

24 (ii) by adding at the end the follow25 ing: ‘‘or (iii) in the case of services of a
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1 community health aide or practitioner, the

2 lesser of the actual charge or 80 percent of

3 the fee schedule amount provided under

4 section 1848,’’.

5 (B) LIMITATION ON BALANCE BILLING.—

6 Section 1842(b)(18)(C) of such Act (42 U.S.C.

7 1395u(b)(18)(C)) is amended by adding at the

8 end the following new clause:

9 ‘‘(vii) A community health aide or practi10 tioner.’’.

11 (3) EFFECTIVE DATE.—The amendments made

12 by this subsection shall apply to services furnished

13 on or after January 1, 2004.

14 (d) CONTINUATION OF SPECIAL TREATMENT FOR

15 COLLABORATIVE ARRANGEMENTS BETWEEN INDIAN

16 HEALTH PROGRAMS AND HOSPITAL OUTPATIENT DE17 PARTMENTS.—Section 1833(t)(13) of the Social Security

18 Act (42 U.S.C. 1395l(t)(13)) is amended by adding at the

19 end the following new subparagraph:

20 ‘‘(B) EXTENSION OF TREATMENT OF CER21 TAIN COLLABORATIVE ARRANGEMENTS.—With

22 respect to the treatment under this subsection

23 of collaborative arrangements between a health

24 program operated by the Indian Health Service,

25 an Indian Tribe, or Tribal Organization and a
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1 hospital operated by such Service or such an

2 Indian Tribe or Tribal Organization, the Sec3 retary shall reinstate treatment (as in effect on

4 January 1, 2000) and extend it to such collabo5 rative arrangements regardless of when they

6 were entered into.’’.

7 (e) COVERAGE OF VISITING NURSE SERVICES OF

8 TRIBAL CLINICS.—

9 (1) IN GENERAL.—Section 1861(aa)(1) of the

10 Social Security Act (42 U.S.C. 1395x(aa)(1)) is

11 amended by adding at the end the following:

12 ‘‘For purposes of applying subparagraph (C) (relating to

13 visiting nurse services), an ambulatory care clinic or other

14 outpatient program of the Indian Health Service or of an

15 Indian Tribe or a Tribal Organization (as such terms are

16 defined in section 4 of the Indian Health Care Improve17 ment Act) shall be treated as if it were a rural health clinic

18 located in an area described in such subparagraph, and

19 nursing care and supplies described in such subparagraph

20 and furnished to an individual as an outpatient of such

21 a tribal clinic or program shall be reimbursable under this

22 title using the methodology specified in section 4(f) of the

23 Indian Health Care Improvement Act Amendments of

24 2003, and, for purposes of this sentence, any reference
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1 in such subparagraph (C) to a licensed practical nurse is

2 also deemed to include a reference to a home health aide.’’.

3 (2) EFFECTIVE DATE.—The amendment made

4 by paragraph (1) shall apply services furnished on or

5 after January 1, 2004.

6 (f) MEDICARE PAYMENT FOR OUTPATIENT CLIN7 ICS.—

8 (1) IN GENERAL.—Notwithstanding any other

9 provision of law, for purposes of determining the

10 rate of reimbursement under title XVIII of the So11 cial Security Act, any outpatient or ambulatory care

12 clinic (whether freestanding or provider-based) oper13 ated by the Indian Health Service, by an Indian

14 Tribe, or by a Tribal Organization (as such terms

15 are defined for purposes of the Indian Health Care

16 Improvement Act) shall, upon the election of such

17 clinic, be reimbursed on the same basis as if such

18 clinic were a hospital outpatient department of the

19 Indian Health Service.

20 (2) EFFECTIVE DATE.—Paragraph (1) shall

21 apply to payment for services furnished on or after

22 January 1, 2004.

23 (g) REVIEW OF MEDICARE AND MEDICAID PAYMENT

24 SYSTEMS.—

25 (1) STUDY.—
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1 (A) IN GENERAL.—The Secretary of

2 Health and Human Services shall conduct a re3 view of the extent to which the payment meth4 odologies applicable under titles XVIII and XIX

5 of the Social Security Act (including under sec6 tion 1880 of such Act, as amended by this sec7 tion, section 1911 of such Act, as amended by

8 section 5(a), and including payment methodolo9 gies in effect at the time the review is under10 taken and payment methodologies effected

11 under this section or section 5) take into ac12 count the unique or special circumstances of the

13 provision of covered services to Indians by the

14 Indian Health Service, Indian Tribes, Tribal

15 Organizations, and Urban Indian Organizations

16 (as such terms are defined in section 4 of the

17 Indian Health Care Improvement Act).

18 (B) MATTERS CONSIDERED.—In particu19 lar, the Secretary shall review the sufficiency of

20 the payment amounts under such methodologies

21 in assuring access to care and payment rates

22 consistent with the payment rates for most fa23 vored providers.

24 (C) CONSULTATION.—In conducting the

25 study, the Secretary shall consult with the In-
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1 dian Health Service, Indian Tribes, Tribal Or2 ganizations, and Urban Indian Organizations.

3 (2) REPORT.—Not later than 2 years after the

4 date of implementation of the amendments made by

5 subsection (a) (or, if later, the date of implementa6 tion of the amendments made by section 5(a)), the

7 Secretary shall submit to Congress a report on the

8 review under paragraph (1). Such report shall in9 clude recommendations for such adjustments to such

10 payment methodologies as may be necessary to as11 sure that payment amounts under the medicare and

12 medicaid programs to such Service, Indian Tribes,

13 Tribal Organizations, and Urban Indian Organiza14 tions are sufficient to provide access to quality care.

15 (3) RETENTION OF CURRENT PAYMENT METH16 ODOLOGY.—Notwithstanding any other provision of

17 law, the Secretary shall retain the all-inclusive pay18 ment methodology for encounter rates for the Indian

19 Health Service, Indian Tribes, and Tribal Organiza20 tions under titles XVIII and XIX of the Social Secu21 rity Act unless the use of such methodology is ex22 pressly prohibited or otherwise superceded by Act of

23 Congress.
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1 SEC. 5. AMENDMENTS TO MEDICAID PROGRAM AND STATE

2 CHILDREN’S HEALTH INSURANCE PROGRAM

3 (SCHIP).

4 (a) EXPANSION OF MEDICAID PAYMENT FOR ALL

5 COVERED SERVICES FURNISHED BY INDIAN HEALTH

6 PROGRAMS.—

7 (1) EXPANSION TO ALL COVERED SERVICES.—

8 Section 1911 of the Social Security Act (42 U.S.C.

9 1396j) is amended—

10 (A) by amending the heading to read as

11 follows:

12 ‘‘INDIAN HEALTH PROGRAMS’’; and

13 (B) by amending subsection (a) to read as

14 follows:

15 ‘‘(a) The Indian Health Service and an Indian Tribe

16 or Tribal Organization (as those terms are defined in sec17 tion 4 of the Indian Health Care Improvement Act) shall

18 be eligible for reimbursement for medical assistance pro19 vided under a State plan with respect to covered items

20 and services it furnishes if it meets all the conditions and

21 requirements which are applicable generally to the furnish22 ing of such items and services under this title.’’.

23 (2) ELIMINATION OF TEMPORARY DEEMING

24 PROVISION—Such section is amended by striking

25 subsection (b).
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1 (3) REVISION OF AUTHORITY TO ENTER INTO

2 AGREEMENTS.—Subsection (c) of such section is re3 designated as subsection (b) and is amended to read

4 as follows:

5 ‘‘(b) The Secretary may enter into agreements with

6 the State agency for the purpose of reimbursing such

7 agency for health care and services provided by the Indian

8 Health Service, Indian Tribes, Tribal Organizations, or

9 Urban Indian Organizations (as such terms are defined

10 in section 4 of the Indian Health Care Improvement Act),

11 directly, through referral, or under contracts or other ar12 rangements between the Indian Health Service, an Indian

13 Tribe or Tribal Organization, or an Urban Indian Organi14 zation and another health care provider to Indians who

15 are eligible for medical assistance under the State plan.’’.

16 (4) REFERENCE CORRECTION.—Subsection (d)

17 of such section is redesignated as subsection (c) and

18 is amended by striking ‘‘section 405’’ and inserting

19 ‘‘section 401(d)’’.

20 (b) SEEKING ADVICE FROM INDIAN HEALTH PRO21 GRAMS.—Section 1902(a) of the Social Security Act (42

22 U.S.C. 1396a(a)) is amended—

23 (1) in paragraph (64), by striking ‘‘and’’ at the

24 end;
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1 (2) in paragraph (65), by striking the period

2 and inserting ‘‘; and’’; and

3 (3) by inserting after paragraph (65), the fol4 lowing new paragraph:

5 ‘‘(66) if the Indian Health Service operates or

6 funds health programs in the State or if there are

7 Indian Tribes, Tribal Organizations, or Urban In8 dian Organizations (as those terms are defined in

9 section 4 of the Indian Health Care Improvement

10 Act) providing health care in the State for which

11 medical assistance is available, provide for the estab12 lishment and maintenance of the advisory process

13 described in section 409(b) of such Act.’’.

14 (c) SCHIP TREATMENT OF INDIAN TRIBES, TRIBAL

15 ORGANIZATIONS, AND URBAN INDIAN ORGANIZATIONS.—

16 Section 2105(c)(6)(B) of such Act (42 U.S.C.

17 1397ee(c)(6)(B)) is amended by inserting ‘‘or by an In18 dian Tribe, Tribal Organization, or Urban Indian Organi19 zation (as such terms are defined in section 4 of the In20 dian Health Care Improvement Act)’’ after ‘‘Service’’.

Æ
671

The CHAIRMAN. Now I would like to turn to our chairman from

the House. Chairman Pombo, do you have an opening statement?

Mr. POMBO. Yes; I do. Thank you, Mr. Chairman.

STATEMENT OF HON. RICHARD W. POMBO, U.S. REPRESENTATIVE FROM WASHINGTON, CHAIRMAN, HOUSE COMMITTEE

ON RESOURCES

Mr. POMBO. I want to thank Senator Campbell for agreeing to

make today’s hearing a joint hearing with the House Resources

Committee. Holding a joint hearing should send a signal that we

can develop a bill to address the health care needs of American Indians and Alaska Natives on a bipartisan basis.

Anyone who has studied the statistical data compiled by the Census Bureau and by health care experts understands there is a profound lack of and access, to quality health care for American Indians and Alaska Natives.

Living conditions for hundreds of thousands of Native Americans

lag far behind the rest of the population, whether they live in a reservation or an urban area. These conditions are unacceptable and

there have to be new approaches that maximize the huge potential

in Indian country to improve health care and disease prevention.

Exploring new ways to raise the quality of health services for

American Indians and Alaska Natives is not an option for Congress. It is a basic obligation.

One way to address health problems for American Indians and

Alaska Natives is to improve basic infrastructure needs such as

safe water, sewer, waste disposal and modern medical facilities.

Unless the bricks and mortar are in place, then we will be reduced

only to responding to outbreaks of health problems, not preventing

them. I am glad today’s witnesses will especially address these

issues.

I look forward to the testimony on these aspects of H.R. 2440 and

S. 556. I thank the chairman for yielding.

The CHAIRMAN. Thank you, Chairman Pombo.

I’m delighted to see some of my old friends from the years I

served in the House. I don’t know if you have opening statements

but why don’t we start with Congressman Kildee. If you have a

statement, go ahead.

Mr. KILDEE. Thank you very much, Mr. Chairman.

STATEMENT OF HON. DALE E. KILDEE, U.S. REPRESENTATIVE

FROM MICHIGAN

Mr. KILDEE. I am happy you and Mr. Pombo are having these

hearings as a member of the House Resources Committee and cochairman of the House Native American Caucus, I think this is

very important. If by chance we are called back for votes, I will

leave Kim TeeHee of my staff who handles all matters of the Native American Caucus to hear all the testimony.

The reauthorization of this act will provide a more comprehensive approach to the delivery of medical care to Native people. The

House bill is based upon the recommendation made by the Indian

health community including tribal leaders, tribal health directors,

health care experts and Native patients themselves. Its primary ob-
672

jective is to improve access to quality medical care for the Native

American population.

I look forward to hearing testimony this morning and would ask

consent that my entire statement be included in the record.

The CHAIRMAN. It will be included in the record.

[Prepared statement of Mr. Kildee appears in appendix.]

The CHAIRMAN. Why don’t we go back and forth? Senator Murkowski, did you have any comments?

STATEMENT OF HON. LISA MURKOWSKI, U.S. SENATOR FROM

ALASKA

Senator MURKOWSKI. Thank you, Mr. Chairman. Good morning

and thank you for the hearing this morning with our House members on a very important issue for us in my State.

I would like to welcome those Alaskans we will be hearing from

this morning, Chief Andrew Jimmie from Minto and Steve Weaver

from Anchorage. I also see some other Alaskans in the audience.

This is our committee’s second hearing on Indian health care reauthorization but it’s the first one that has taken place after the National Steering Committee’s bill was introduced in the other body.

There are many good things in this legislation but what I particularly like about it is that it is not necessarily an Alaskan bill

or a Navajo bill or an urban bill, it is a national bill which was derived through the very diligent work of Native health leaders

throughout Indian country. I hope, Mr. Chairman, that through the

good work of the National Steering Committee, we will form the

nucleus of this bill that we will markup in the Committee on Indian Affairs.

I am very pleased that we will be hearing from Steve Weaver on

the second panel. Oftentimes when you think of Indian health, we

think of the doctors and the nurses. Steve is an engineer, specializing in sanitation and environmental health. His expertise is in preventing disease by focusing on water quality and sanitation. It is

so important that we do focus on these preventative first step

measures, so I am pleased he is here today to help us as we talk

about healthy families and healthy communities.

Mr. Chairman, thank you.

The CHAIRMAN. Thank you.

Mr. Faleomavaega.

Mr. FALEOMAVAEGA. Thank you, Mr. Chairman.

STATEMENT OF HON. ENI F.H. FALEOMAVAEGA, U.S.

DELEGATE, AMERICAN SAMOA

Mr. FALEOMAVAEGA. I would like to echo the sentiments expressed earlier by my colleagues to thank you for the initiative and

your leadership in calling this joint hearing, along with our distinguished chairman, Mr. Pombo from California. I think this effort

certainly demonstrates the urgency of this legislation that has been

on the shelf now for 4 years. Our Indian communities have deliberated and have had so many consultations for many years now

and I sincerely feel this joint hearing gives it a sense of urgency

that we need to pass this legislation as soon as possible. We thank

you for doing this.
673

For those of us on the House side, it’s nice to be here once in a

while to see how glorious and big the chambers are.

The CHAIRMAN. Actually, we’re a pretty friendly crowd. You

didn’t have to sit that far away.

Mr. FALEOMAVAEGA. I don’t know about that, Mr. Chairman. We

kind of felt we were being intimidated by the gloriousness of this

beautiful chamber but as a former colleague and certainly as a

member of our committee, Mr. Chairman, we are delighted to be

here and look forward to hearing from our witnesses this morning.

The CHAIRMAN. Congressman Cole, did you have a statement?

Mr. COLE. Just briefly, Mr. Chairman.

STATEMENT OF HON. TOM COLE, U.S. REPRESENTATIVE FROM

OKLAHOMA

Mr. COLE. I’d like to echo my colleagues’ appreciation for you and

Chairman Pombo having this joint session. It is an extraordinarily

important problem an one that’s been allowed to languish far too

long. I appreciate your initiative. I hope we can develop a bipartisan consensus on this legislation and move ahead. I particularly

hope during the course of the hearing if we have an opportunity

to look at not only the depth of the problem overall but some of the

disparities in funding at the tribal level. Representing a State that

has many, many Native Americans but not much in the way of reservations, we’ve lagged in funding compared to some of the other

tribes.

Certainly we appreciate your initiative and this opportunity to

look at these problems and move ahead.

The CHAIRMAN. Congressman Udall from the great State of Colorado, any comments?

Mr. UDALL. Thank you, Mr. Chairman.

STATEMENT OF HON. MARK UDALL, U.S. REPRESENTATIVE

FROM COLORADO

Mr. UDALL. I too want to associate myself with the remarks of

my Chairman, Mr. Pombo, Mr. Faleomavaega and the rest of the

panel. I want to underline my commitment to proceeding as quickly

as possible. We all know this has been long in arriving and we

need to get this legislation passed and to the President’s desk.

I look forward to working with everybody here to see that we do

that as soon as possible.

Thank you, Mr. Chairman.

The CHAIRMAN. Congressman Grijalva?

Mr. GRIJALVA. Thank you, sir.

STATEMENT OF HON. RAU ́ L M. GRIJALVA, U.S.

REPRESENTATIVE FROM ARIZONA

Mr. GRIJALVA. I also would join with my colleagues in extending

the appreciation to you, Senator, and to our Chairman for having

this hearing. I want to associate myself with the comments made

by my colleagues and look forward to an expedient process and

some quick movement in assuring that access and a health delivery

system is available to our Native American brothers and sisters.

Thank you, sir.

The CHAIRMAN. Thank you.
674

Congressman Pallone, any comments?

Mr. PALLONE. Thank you, Mr. Chairman.

STATEMENT OF HON. FRANK PALLON JR., U.S.

REPRESENTATIVE FROM NEW JERSEY

I just wanted to say that both of you, Senator Campbell, as well

as our House Chairman Pombo, have really highlighted and shown

a tremendous concern over this issue. Senator Campbell obviously

for a number of years and Congressman Pombo over the last couple

months, particularly last week, has shown on the House Resources

side that he is willing to move forward on a number of these initiatives because he realizes how important they are.

I just wanted to say briefly I think there is a tremendous problem, I would call it a crisis, in terms of health care services in Native America primarily because you’ve had an explosion in the Native American population but that the IHS has not been able to

keep up, primarily because of funding. I think lack of funding is

a major issue.

There is also the fact that in Congress, I think we have not paid

enough attention to the lack of money for facilities, for new construction and perhaps the Administration more and more, and I

don’t just mean this Administration but the last 10 years or so,

seems to be relying on the tribes more and more to pay for their

own services, particularly with regard to new facilities and renovation of facilities. I think that is wrong. I really see provision of

health care services for Native Americans as an entitlement, as

something we are required pursuant to the Constitution and treaties over the years to provide. I don’t think we should rely more

and more on their providing their own money. I think we have to

increase the funding.

In addition, there are just so many changes that we haven’t paid

attention to over the last 10 or 20 years, the need for more preventative services, home health care, nursing homes, the changes in the

demographics so that more and more Native Americans are now in

urban areas and that those problems need to be addressed. Although there is a crisis, I think that we can identify what the

needs are. I know that people on this committee, including the

leadership, are very concerned and know what to do.

What we need to do is educate the rest of Congress and try to

move the legislation and get our other colleagues motivated beyond

these two committees to move these measures and realize the crisis

we face, and that it is going to take a lot more money and time

to address this.

I’m very pleased we are having this hearing today. I want to

thank the two Chairmen in particular for their concerns.

The CHAIRMAN. Thank you.

Any comments, Congressman Carson.

Mr. CARSON. Thank you very much, Senator Campbell.

STATEMENT OF HON. BRAD CARSON, U.S. REPRESENTATIVE

FROM OKLAHOMA

Mr. CARSON. I’d like to thank you and Chairman Pombo for holding this hearing too. Of course I have a great interest in this issue

representing the most Native American congressional district in
675

the country, being a member of the Cherokee Nation myself and

the son of a career of Bureau of Indian Affairs employee. I know

how important this legislation is to the many Native Americans

both in Oklahoma and across the country.

I am particularly proud that two Oklahomans will today be testifying before this committee, Carmelita Skeeter who runs a tremendously successful health care center in Tulsa, Oklahoma serving

the Native American population, as well as Dr. Charles Grimm, the

interim director of the IHS. He did a tremendous job in the State

of Oklahoma and I understand his nomination and the hearings on

his confirmation are proceeding nicely and we look forward to this

service to this Administration as the Director of IHS.

Oklahoma has more than 300,000 patients in IHS and there is

only 1.6 million nationwide. You can imagine when you have 20

percent of the IHS population, you are very concerned about what

is going on within the institution.

We appreciate your holding this hearing today. I am proud to be

a cosponsor of H.R. 2440, the House version of the Indian Health

Care Improvement Act reauthorization, and we look forward to

what the panel has to say on this very important matter.

The CHAIRMAN. Thank you.

Congresswoman Christensen.

Ms. CHRISTENSEN. Thank you, Mr. Chairman.

STATEMENT OF HON. DONNA M. CHRISTENSEN, U.S.

DELEGATE FROM VIRGIN ISLANDS

Ms. CHRISTENSEN. I want to join my colleagues in thanking both

you, Chairman Campbell, and Chairman Pombo for holding this

very important meeting and also to say it is very timely as the Minority caucuses in the House are working with members of the

Senate to put all of the initiatives that we have been advocating

over several past Congresses into one comprehensive minority

health bill. Also, to say as chair of the Health Brain Trust of the

Congressional Black Caucus and as a physician, it is my hope that

at the end of this process, we will reauthorize the Indian Health

Care Improvement Act in such a way that we can truly begin to

rectify the deficiencies of past efforts and pass a bill that will bring

the health of Native Americans not just on par with what we consider average for Americans, because if we include the African

American, the Hispanic American, the Asian Pacific Islanders what

is considered American health will be far below what we should be

aspiring to.

Rather, we want to develop a vehicle that will develop the high

level of health attained by those of full and unfettered access to

health services to a bill that provides equal access to culturally

sensitive, comprehensive, easily and universally accessible health

care provided mostly by the increasing cadre of Native American

health providers that will be trained under this bill, with best practices determined by Native American and Alaska Native led and

specific research provided in communities that are environmentally

and socio-economically supportive of good health and developed and

directed by the communities and the tribes themselves fully funded

and supported with technical assistance from the Federal Government and the agencies that can provide such technical assistance.
676

I want to once again thank you for this hearing and I look forward to the testimony of our witnesses.

The CHAIRMAN. Thank you.

We will now start with the first panel which will be Charles

Grim, director, Indian Health Service, accompanied by Gary Hartz,

acting director, Office of Public Health, Indian Health Service;

Richard Olson, acting director, Division of Clinical and Preventive

Services; Mrs. Rae Snyder, acting director, Urban Health Office;

and Steven Nesmith, assistant secretary for Congressional Affairs,

Department of Housing and Urban Development.

We’ll start by telling you that all of your written testimony will

be included in the record. If you would like to abbreviate, that

would be fine. We will start with Mr. Grim first.

STATEMENT OF CHARLES GRIM, DIRECTOR, INDIAN HEALTH

SERVICE, DEPARTMENT OF HEALTH AND HUMAN SERVICES,

ACCOMPANIED BY GARY HARTZ, ACTING DIRECTOR, OFFICE

OF PUBLIC HEALTH, INDIAN HEALTH SERVICE; RICHARD

OLSON, ACTING DIRECTOR, DIVISION OF CLINICAL AND

PREVENTIVE SERVICES, INDIAN HEALTH SERVICE; AND

MRS. RAE SNYDER, ACTING DIRECTOR, URBAN HEALTH OFFICE, INDIAN HEALTH SERVICE

Mr. GRIM. Thank you, Chairman Campbell, Chairman Pombo,

and distinguished members of both committees.

We are very excited too within the Indian Health Service for this

joint hearing to be able to talk about the issues before both the

House and the Senate.

You have introduced the staff I have here. They won’t be making

any opening statements. I will be making the opening statement

for the agency but they are here should we have questions. They

are technical matter experts on a number of these issues today.

We are pleased to have this opportunity to be able to testify on

behalf of Secretary Thompson on both the House and Senate bills

to reauthorize the Indian Health Care Improvement Act. For the

record, I’m submitting my written statement and it contains specific information about the agency including the legislative and

legal history regarding the United States’ commitment to tribal nations and some of the national challenges that we’re facing to improve the health of American Indians and Alaska Natives. My written statement also contains comments on specific aspects of the

proposed legislation that I won’t cover in my oral statement so that

we can conserve time.

As I testified last April, there is no single piece of legislation that

will affect the future health status of American Indians and Alaska

Natives more than the Indian Health Care Improvement Act Reauthorization of 2003. For the past 28 years, the Indian Health Care

Improvement Act has been the basis for extending the life span of

Indian people by 7 years which is still 6 years below that of the

rest of the Nation. It has helped us to address the basic health

needs of a population that was not benefiting from the technological and medical advances of an industrialized nation and it has

also assisted us in identifying current and future health challenges.

To continue to make progress in raising the health status of Indian people to at least the level of the rest of the Nation requires
677

us to modify the Indian Health Care Improvement Act of 1976 to

reflect the health status of the Indian population of 2003 as best

we can and to have it reflect the health status of Indian people as

we project it into the future until the next reauthorization.

The legislation under consideration today reflects the proposed

language developed over a 2-year period by Indian tribes across the

Nation and adopted by both committees of Congress. Our Nation

faces many priorities today, many of which overshadow but do not

diminish the importance of other priorities. As requested by the

committee, I am going to focus my brief remarks on the highlighted

areas of health disparities, health care facilities and urban Indian

health.

My written statement includes some health statistics and the

agency can supply members with more information if requested.

Three simple statements to remember regarding American Indian

and Alaska Native health disparities are: First, Indian people continue to experience disease and illness at greater rates than the

rest of the Nation; second, Indian people continue to prematurely

die at rates greater than the rest of the Nation; and third, Indian

people continue to experience reduced access to health services and

care compared to the rest of the Nation.

It is well publicized and referenced that Indian people continue

to experience health disparities and death rates that are significantly higher than the rest of the United States general population.

Many American Indians and Alaska Natives who receive a diagnosis of diabetes, high blood pressure and high cholesterol levels,

cardiovascular disease, alcoholism and obesity consider it a fatal diagnosis.

The proposed language of the Indian Health Care Improvement

Act can help the Indian health system of the Indian Health Service, tribal health programs and urban Indian health to develop and

implement health promotion and disease prevention strategies so

that healthy behavior choices and lifestyles will begin to significantly reduce the health disparity rates. It also yields an even

more important humanitarian benefit of reducing pain and suffering and prolonging life.

We were successful in working with Indian nations through the

Indian Health Service with infectious diseases and conquering

those and I think we can do it again for chronic diseases with the

help of Congress.

The IHS Health Care Facilities Program, including the tribal

program specifically, are responsible for managing and maintaining

the largest inventory of real property in the Department of Health

and Human Services with over 9 million square feet of space. In

the proposed bill, section 302(B)(3)(c) specifically proposes that IHS

Sanitation Facilities Construction funds will not be used to support

service of sanitation facilities to the Department of Housing and

Urban Development homes. The bill is not clear that homes constructed through HUD should also include the necessary infrastructure to make a home complete including safe water and sewer

and wastewater disposal systems for the home. The IHS and HUD

have cooperated over many decades on the construction of homes

and reservation communities with IHS providing the expertise and
678

development of supporting the sanitation and sewage systems that

the HUD homes would then hook into.

Without clarity in the language, there may come a time when interpretation may result in IHS funds being expended on sanitation

systems of HUD homes which would in turn redirect IHS funds

from providing services to existing homes without water, sewer and

solid waste facilities. Newly constructed HUD homes should be

funded to cover everything including the home itself and to the

street hookup. We request that you consider clarifying this point in

the proposed bill.

Title V of the Indian Health Care Improvement Act provides specific authority focused on the provision of health services for urban

Indian people with funds appropriated to the Indian Health Service. The IHS currently contributes funds toward the operating expenses of 34 independent urban Indian health programs including

programs in Oklahoma City and Tulsa that are demonstration programs. These programs provide a range of services. In 1978, the

entire State of Oklahoma was designated as a contract health service delivery area which means that the Indian beneficiaries could

reside anywhere in the State and maintain their eligibility for both

direct services and contract health services.

The 1992 Congress amended the Health Care Improvement Act

to establish two demonstration projects with Tulsa and Oklahoma

City clinics to be treated as service units in the allocation of resources and the coordination of care. This new and innovative approach to ensuring health services were accessible to all eligible

populations in Oklahoma has resulted in a hybrid system. Each

program maintains its status under the title V as an urban Indian

organization, yet the programs function like other IHS service

units and report on the resources and patient management system

of the Indian Health Service with data utilized for inclusion in the

allocation of resources.

Most service populations and overall utilization of services have

dramatically increased since these programs became demonstration

projects and from the fiscal year 1994 specific congressional line

item funding increases. They have been able to use the best of both

urban and IHS structures to build a community controlled, high

quality health system in a State designated as a contract health

service delivery area.

On the other hand, the hybrid system has raised a few concerns

with some of the Oklahoma tribes that operate their own health

programs under the Indian Self Determination and Education Assistance Act, Public Law 93–638 as amended. The issue in its most

basic terms is that the two urban programs have some aspects of

a service unit but their funding is not subject to transfer to the

tribes under Public Law 93–638 contracts or compacts as our nonhybrid service units are.

With an environment of reduced resources and an increasing

population with greater health needs, it’s expected that the issue

of tribe shares of urban Indian programs, especially the hybrid programs, will receive more attention than they have in the past.

As review of this far-reaching, complex legislation continues, we

may have further comments. However, we wish to reiterate our

strong commitment to reauthorization and improvement of the In-
679

dian Health Care Improvement Act and will be happy to work with

the committees, the National Tribal Steering Committee and other

representatives of the American Indian and Alaska Native communities to develop a bill that is fully acceptable to all stakeholders

in this important program.

Mr. Chairman, that concludes my statement. I want to thank you

for the opportunity to discuss reauthorization of the Indian Health

Care Improvement Act. We will be happy to answer any questions

you may have.

[Prepared statement of Dr. Grim appears in appendix.]

The CHAIRMAN. Thank you, Dr. Grim.

I understand Admiral Hartz, Dr. Olson, and Ms. Snyder are resource people but do not have statements, is that correct?

Mr. GRIM. That is correct.

The CHAIRMAN. Now we will go to Steven Nesmith.

I might tell my colleagues that Mr. Nesmith is really assistant

secretary for Congressional Affairs. I understand your background

is not in Indian health. Is that correct?

Mr. NESMITH. That is correct, sir.

The CHAIRMAN. Hopefully we won’t put you on the spot too much.

Go ahead.

STATEMENT OF STEVEN NESMITH, ASSISTANT SECRETARY

FOR CONGRESSIONAL AND INTERGOVERNMENTAL AFFAIRS,

DEPARTMENT OF HOUSING AND URBAN DEVELOPMENT

Mr. NESMITH. As this is a joint hearing, Chairman Campbell and

Chairman Pombo, Vice Chairman Inouye, and members of both

committees, thank you for inviting me here to provide comments on

S. 556, the Indian Health Care Improvement Act Reauthorization

of 2003.

My name is Steven Nesmith and I am the assistant secretary for

Congressional and Intergovernmental Affairs at HUD.

As you know, the Public and Indian Housing, PIH, is responsible

for the management and operation and oversight of HUD’s Native

American programs. These programs are available to 560 federallyrecognized and a limited number of State-recognized Indian tribes.

We serve these tribes directly or through tribally designated housing entities by providing grants and loan guarantees designated to

support affordable housing community and economic development

activities. Our tribal partners are diverse. They are located on Indian reservations, in Alaska Native villages and other traditional

Indian areas.

In addition to those duties, PIH’s jurisdiction encompasses the

Public Housing Program which aides the Nation’s 3,000 plus public

housing agencies in providing housing and housing related assistance to low income families. It is a pleasure to appear here before

you and I would like to take the opportunity to express my appreciation for all of your continuing efforts to improve the housing conditions of American Indians and Alaska Native peoples.

Much progress has been made and tribes are taking advantage

of new opportunities to improve the housing conditions of the Native American families residing on Indian reservations, on trusts or

restricted Indian lands and in Alaska Native villages. This momen-
680

tum needs to be sustained as we continue to work together toward

creating a better living environment throughout Indian country.

At the outset, let me reaffirm the Department of Housing and

Urban Development’s support for the principle of government to

government relations with Indian tribes. HUD is committed to honoring this fundamental precept in our work with American Indians

and Alaskan Natives. On behalf of Secretary Martinez, thank you

for the opportunity to provide this testimony on S. 556.

The Department agrees that the Indian Health Service, a division of the Department of Health and Human Services, is vital to

the well being of individual Indian families and the Native American community as a whole. Native Americans often have no other

means to receive the health care assistance and related activities

provided by IHS.

HUD’s Office of Native American Programs continues its ongoing

dialogue with IHS representatives to coordinate our activities in a

manner that supports tribal sovereignty, self determination and

self governance. The Department also participates in a Federal

Interagency Task Force on Infrastructure with the IHS, the Environmental Protection Agency, the Bureau of Indian Affairs and the

Department of Agriculture. It is within this perspective that the

following comments are offered on behalf of HUD and this bill.

As you are aware, in 1996, the Native American Housing Assistance and Self Determination Act became law. NAHASDA changed

the way in which housing and housing related assistance is provided to Native American families. Prior to the Act, Indian housing

authorities and Indian tribes applied for a variety of competitive

and categorical grant programs usually with differing program eligibility and reporting requirements.

NAHASDA created the Indian Housing Block Grant Program

which is a non-competitive formula grant made to Indian tribes or

tribally designated housing entities. Under the Indian Housing

Block Grant Program, an Indian tribe or the tribal designated

housing entity submits to HUD a 5-year and a one year housing

plan. The housing plan contains information about how the recipient will use its block grant funds to engage in the six affordable

housing activities authorized by NAHASDA.

Once the Indian housing plan is found to be in compliance with

the statutory and regulatory requirements, the tribe or that designated entity executes a grant agreement to receive the Indian

housing block grant allocation. The Indian housing block grant formula is based on housing needs of each of the tribes and the tribes

designated entity ongoing operation, maintenance needs and for

the dwelling units previously developed under the Indian Housing

Program authorized by the U.S. Housing Act.

The Indian housing block grant formula is calculated by dividing

the total amount appropriated for each fiscal year among the number of eligible grant recipients. Formula components and variables

are weighted to ensure that the complexities and differences among

tribes are taken into consideration. Each tribe’s formula allocation

reflects these factors.

The NAHASDA regulations as described in the Code of Federal

Regulations requires that the Indian housing block grant formula

be reviewed by the calendar year 2003 for possible modification or
681

revision. At present, HUD is engaged in negotiating rulemaking

commonly referred to as NEGREG with a 26-member committee

comprised of a broad cross section of tribal stakeholders. The first

NEGREG session was held in April of this year and additional

monthly meetings are ongoing and are scheduled through September.

Let me turn to the specific comments on S. 556, the Indian

Health Care Improvement Act Reauthorization of 2003. As you

know the Administration is actively reviewing S. 556 and will provide you with specific details of our analysis very shortly. The Administration has not taken a position regarding the transfer of

NAHASDA funds between HUD and HHS. We do, however, have

concerns about transferring NAHASDA funds between Federal

agencies when NAHASDA now provides for the direct distribution

of Indian housing block grant funds to tribes and their housing designated entities based on a formula negotiated between the tribes

and HUD.

An affordable housing activity under the Indian Housing Block

Grant Program is development which includes infrastructure such

as site improvements and the development of utilities and utility

services for housing. The provision of water and sanitation facilities

are included within this category. Tribes and tribal designated

housing entities may currently enter into agreements with IHS to

provide these services or they may choose another service provider.

We believe that this is in keeping with the policy of self deter- mination that is articulated in NAHASDA. Since 1997, nearly $228

million has been transferred to IHS through the tribal designated

housing entities for offsite sanitation facilities. Tribes and their

designated entities continue to make difficult budgetary and management decisions on how to prioritize their Indian housing block

grant dollars which is consistent again with tribal self determination and self government.

Let me assure the committee that we will work with both committees and with our Federal partners in HHS and other Federal

agencies, the tribes and their designees to ensure that the housing

infrastructure needs in the Native American communities are met

in the most efficient manner possible.

We are nevertheless concerned about any provision that might

erode the self determination which we believe is critical in

NAHASDA.

Thank you for the opportunity to express the Department’s

views.

[Prepared statement of Mr. Nesmith appears in appendix.]

The CHAIRMAN. Thank you.

Since our colleagues in the House are going to have further to

walk because there is a vote than we have to in the Senate, I am

going to yield to them for questions first. We will start with Chairman Pombo.

Mr. POMBO. Thank you very much. I appreciate the opportunity.

The House Interior Appropriations bill specifically included committee language which states that IHS sanitation funds should not

be used to provide sanitation facilities for new homes funded by the

housing programs of the Department of Housing and Urban Development. I know, Dr. Grim, that in your opening statement you
682

talked about this issue. Could you expand upon that for me as to

what your level of support or opposition to that particular language

is?

Mr. GRIM. Yes, Mr. Chairman; the way that came about was our

appropriations committees have over the years included that language because HUD funded home projects prior to NAHASDA had

infrastructure funds included for sanitation facilities for newly

funded HUD homes. Once NAHASDA was put in place, it was the

tribes choice of what to use those funds for, whether to build housing infrastructure and so forth.

The IHS program separates and, apart from that, looks at existing homes without adequate sanitation facilities or newly built

homes built with other than HUD funds. We currently have a backlog of those homes as well, so the two programs are separate. So

our committees have wanted to ensure that moneys coming

through the Indian Health Service were used for existing homes

with that need or with newly built homes other than HUD homes.

Mr. POMBO. So you generally in support of that because you want

to keep those two programs separate?

Mr. GRIM. As mentioned by Mr. Nesmith, we’ve worked jointly

with HUD over the years to try to ensure that the two programs

work together but they are two separate programs.

Mr. POMBO. Can you tell me a bit more about what you are currently doing to deal with that backlog? I’ve been told that the backlog is substantial at this point. Can you expand upon that a bit for

me?

Mr. GRIM. The current backlog we have estimated in feasible projects, those able to be completed roughly is around $900 million

right now. We keep records on that and those records do not sometimes include newly built HUD homes that may or may not have

adequate facilities. Once they become existing homes, we try to get

those added to our inventory.

One of the things we try to do on an annual basis, we have cur- rently a $94-million appropriation to deal with new and existing

homes and we have a priority system where we try to prioritize

those in most need. We are trying on an annual basis to work on

those backlogs.

Mr. POMBO. You said something I have a real question on and

that is when a newly constructed HUD home becomes an existing

home, then you can use funding to provide the sanitation services.

Why would you allow a home to be built without the sanitation

services?

Mr. GRIM. I may let Admiral Hartz take a crack at this after I

finish but regarding existing HUD homes, the Indian Health Service staff work in concert with HUD on those homes. However since

the passage of NAHASDA the block grants have now been transferred to tribes. There is extreme pressures out there due to the

backlog and need for housing in Indian country and there are more

and more pressures on tribes to get existing homes in place.

The IHS does not have direct control over any of the NAHASDA

housing projects themselves. We come in as technical assistants

but we do have funds, the $94 million I referenced, to help existing

homes or those that have been built with funds other than HUD

such as State programs or tribal funds and things like that to try
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to get adequate water and sanitation facilities to them. Many

times, in Indian country it’s not like it is in an urban setting like

Washington, DC or Maryland where all you have to do is hook up

to a water main that is a few feet from the house. Sometimes there

are many, many miles to traverse to get to a water or sewer system. So it is not as easy as it sounds sometimes when a home goes

up many, many miles from a location where there is adequate

hookups to sanitation and water. Sometimes that occurs.

The point I would make is the IHS works in tandem with HUD

and with tribes trying to ensure that safe water and sanitation facilities go in but the IHS itself is not the one responsible for the

building programs. We just assist with sanitation and those facilities.

Mr. HARTZ. Mr. Chairman, I can build on that with a couple of

points.

I think historically as pointed out, we have had an excellent relationship with HUD in making sure that the door knob is talking

to the toilet seat as we get these new homes built. I think that’s

been shown going back to when Congress actually started putting

that language in our appropriations bill which dates back to the

early 1980’s. It had to do with some arrangements that were

worked out at that time with OMB and Secretary Pierce I believe

in 1981.

The money started flowing to ensure that the HUD units were

provided sanitation facilities either through an arrangement with

HUD directly or through the Indian Housing Authorities and/or the

Indian tribes depending on how they were set up locally. Those resources contributed from the HUD Indian Housing Program at that

time grew from $5–$6 million to $25 million. That contribution to

the Sanitation Facilities Program of IHS was of tribes’ choosing.

They could do the construction themselves, they could provide it to

IHS. Many times the reason they would provide it to IHS is because you can then do a total community concept in development

of infrastructure as opposed to doing a piecemeal approach where

houses get dropped in a location and you only have dollars to do

just that little piece for infrastructure. Infectious diseases don’t follow those kinds of boundaries when the same children from different places show up in the school system.

It grew in 1994 to almost $25 million, the contribution that was

coming out of the Indian Housing Program from HUD most of the

time, 90 plus percent of the time, the money actually was a decision made by the tribes exercising self determination before that

was even passed through the HUD authorizations to provide those

dollars to IHS to carry it out.

There were lots of arrangements by which that was done. Sometimes the tribes would pool the dollars and the tribes actually did

the construction as on the Navajo Reservation to this day, they do

99 percent of all construction related to infrastructure on water,

sewer, solid waste, et cetera.

It was only after the passage of NAHASDA that the numbers

dramatically dropped. We were down as low as $1.3 million. Last

year in 2002, it was about $4.4 million that was provided. That is

totally a tribe decision. We concur with that.
684

Getting back to your original question about why that language

was put in our appropriation, we are so limited in our resources to

address the sanitation deficiency system that Congress asked us to

identify in that universe of need being at $1.5–$1.6 billion for all

of the existing homes, plus address anything new coming on, we

weren’t in a position, at least the appropriators thought, to pick up

additional responsibility for HUD sponsored units because we have

$94 million we are addressing against the feasible amount of $900

million and of that $94 million, we put about half of it to address

new units every year. In 2002, we had a few hundred units we

weren’t even able to address, about 350 units, where individuals

were financing and paying for their homes themselves that we

couldn’t get to within the priority systems that exist.

That’s a little more background. I hope I haven’t expounded to

far in some of the detail but I’m prepared to expound further as

needed.

Mr. POMBO. Thank you, Mr. Chairman.

The CHAIRMAN. I can look at the clock and see that by the time

we get done with the next panel, we are going to run out of time.

I would ask my colleagues to keep their questions down to 3 or 4

minutes.

Congressman Kildee.

Mr. KILDEE. On the question of sanitation, the Senate bill apparently prohibits the use of IHS funds for sanitation in HUD housing

whereas the House bill does not contain that prohibition. How does

the IHS suggest we clarify the language referring to IHS funding

for sanitation in HUD constructed houses?

Mr. GRIM. As I pointed out earlier, right now the two programs

are really separate programs. We are serving that backlog of existing homes that do not have adequate safe water and sanitation facilities as well as newly built homes that are built with other than

HUD funds. There are a large number of those being built annually.

There are currently two separate programs. The two bills that

have been introduced with differing language, I suspect in conference committee will be dealt with but if our funds were to be

merged with HUD funds, it appears it would be taking two separate programs and merging them into one. We would have a difficult time then perhaps addressing the existing home backlog.

Mr. KILDEE. Perhaps the House and Senate can get together and

try to bring our language to more compatibility to see what we can

do to encourage the IHS. In some very remote parts of Michigan

where I come from where there are no water lines as such and no

sewer lines, they do have septic facilities and there is groundwater

they can use for the operation. I think remoteness alone, there

might be some areas where you don’t have the groundwater, would

not always preclude the possibility. This certainly relates to health,

there is no question about that.

The Saginaw Chippewa Tribe, in my State but not my district,

in 1934 the Federal Government built a number of half houses for

the Indians. Some of those half houses are still there, maybe have

been finished off and changed a bit but I guess the Indians were

grateful to get the half houses but they really were half. I think
685

we certainly should have come a long way since 1934 and a long

way since 1980.

I’m willing to work with you to see what we can do to help the

IHS and HUD work more closely together to provide this. I also believe we should elevate your position to that of assistant secretary.

Mr. GRIM. Thank you, Congressman Kildee. I might point out for

everyone’s information that the language in the Senate bill relative

to the way we work with sanitation facilities is the current practice

that is being carried on.

The CHAIRMAN. Congressman Cole, any questions?

Mr. COLE. No; Mr. Chairman.

The CHAIRMAN. Congressman Faleomavaega.

Mr. FALEOMAVAEGA. Again, I want to thank Dr. Grim for his testimony.

Mr. Grim, I think one of the problems that left this proposed legislation for authorization hanging was the question of scoring. I notice that some estimates come out to $2 billion, $3 billion, $6.9 billion for the 10-year period. It seems we are squeezing blood out of

a turnip. Why is it we are having such a difficult in time in trying

to arrived the best cost estimate when it is so simple to get $70

billion to clean up Saddam Hussein’s mess, so instantly it seems.

We’re asking for a mere $3 billion.

From the statement here, I am concerned that alcoholism, is 770

percent higher than the U.S. population; diabetics, 420 percent

higher; accidents, 280 percent higher; suicide, 190 percent higher;

homicide, 200 percent higher and we can’t even find a common

ground to get the proper money.

The bottomline, Dr. Grim, is funding. What is the Administration’s best estimate of the level of authorization needed for the 10-

year period, because I’m getting all kinds of figures. I’m a little

confused. Can you give us your best estimate of how much authorization is needed to properly fund our Indian Health Care Program?

Mr. GRIM. The current bill, both House and Senate, I don’t currently have available today to be able to tell you. Because of the

variabilities in the two bills, there are some significant variabilities

in title IV for example.

Mr. FALEOMAVAEGA. We can clear that up on our side. I’m asking

the Administration’s position. What is your position on this? How

much should be authorized for of this legislation?

Mr. GRIM. We have a study that’s been done internally that only

looks at the personal health care expenditure needs and doesn’t

look at our public health infrastructure which is also a big need.

We also have a tribal needs based budget the tribes have presented.

Mr. FALEOMAVAEGA. Dr. Grim, you still aren’t understanding my

question. The bottomline, what is the Administration’s recommendation regarding the level of authorization needed to assist

our Indian community for the next 10-year period? If you can’t answer it right now, can you submit that for the record?

Mr. GRIM. Yes, sir; I will submit that for the record. Because of

the variability in the bills, I can’t answer that.

Mr. FALEOMAVAEGA. I really would appreciate that.
686

The second question, I believe the total population of Alaskans

and American Native Indians is over 14 million. Am I correct?

Mr. GRIM. The American Indian and Alaska Natives we serve in

our facilities is about 1.6 million. The most recent census places the

number of American Indians and Alaska Natives in combination

with another race at over 4 million.

Mr. FALEOMAVAEGA. $4 million. I thought it was more than that.

If you could give us exactly what the Administration proposes. I

made the estimate that we have about 14 million American Indians

and Native Alaskans in this country. You are saying the entire

health care system provides services for about one point six million

American Indians and Alaska Native?

Mr. GRIM. Yes, sir.

Mr. FALEOMAVAEGA. For the rest of our Native American community, they are out there on their own, really flat out, just in the

worse situation than any other ethnic group here in our country.

Would you agree with me on that?

Mr. GRIM. I would say a portion of that population we are not

serving has private insurance and is seeking care but that’s a very

small percentage. It is hard for us to place a handle on it since they

don’t access our health care system. The remainder of that group

that is not that small percentage with private insurance or the

ones seeking care from us, many of them are without health care.

Mr. FALEOMAVAEGA. One quick question to Mr. Nesmith. I know

HUD is not part of the Indian health care authorization legislation.

For the last fiscal year, how much monetary assistance did HUD

provide Native Americans for housing?

Mr. NESMITH. The last fiscal year?

Mr. FALEOMAVAEGA. Yes.

Mr. NESMITH. About $650 million.

Mr. FALEOMAVAEGA. How much are you proposing for the coming

fiscal year? I hope it is an increase.

Mr. NESMITH. I’m not sure if it’s level but I can get back to you.

Mr. FALEOMAVAEGA. The $650 million in the last fiscal year provides for how many of our Native American community people?

Mr. NESMITH. We believe that would provide for the numbers you

just mentioned.

Mr. FALEOMAVAEGA. My point is we are totally underserved, even

with the amount of funding that HUD is providing, it is not even

the tip of the iceberg as far as the community housing needs of our

Native American community throughout the country. Would you

agree with me on that?

Mr. NESMITH. Not being able to compare, you said it was $14

million. I would say there needs to be some improvement.

Mr. FALEOMAVAEGA. Thank you, Mr. Chairman.

The CHAIRMAN. Senator Murkowski, did you have any questions?

Senator MURKOWSKI. No; thank you.

The CHAIRMAN. Congresswoman Napolitano.

Ms. NAPOLITANO. I’d like to followup on my colleagues’ questions

and the health disparities issues. I’m wondering how much of the

funding is going into addressing the education or training of Native

Americans to be able to deal with the issues. It is not the first year

that I’ve heard of the high percentages of these individual groups.
687

How are we dealing with the alcoholism, the diabetes, suicide

and homicide? Accidents, that is another issue but all the others

are lumped into an area that has been very prevalent in the American Indian community for many decades. It isn’t the first time.

What are you doing? How much money is being put into programs

that will help these communities be able to deal with those issues?

Mr. GRIM. I will need to submit part of the answer to that question for the record in writing. What I can say is that our current

budget is approaching $3 billion.

Ms. NAPOLITANO. Total budget of what?

Mr. GRIM. Of the Indian Health Service. You initially asked

about education and we do have a scholarship and loan repayment

program that we do work with trying to get American Indian and

Alaska Native Youth into the health professions so they are back

into their own communities. We also have a large portion of that

budget that is in the health care delivery area. Approximately 50

percent of our budget in rough terms is now being administered by

tribes themselves through Public Law 93–638. They are making

their own decisions about the delivery of health care in their communities.

The other locations where the Indian Health Service operates the

programs directly, we work closely with community health boards

and tribal health boards and programs in the communities to determine priorities they want within the communities.

Ms. NAPOLITANO. What has been the result of these health delivery organizations? According to what I see here, the alcoholism is

astounding. Do you have programs to actually help deal with the

alcoholism problem?

Mr. GRIM. Yes; the majority of the programs that are alcohol and

substance abuse programs in Indian country are run and managed

by the tribes themselves. As a rough estimate, I’d say in excess

probably of 95 percent of the programs and the money the Indian

Health Service receives, about $130 million is what we receive in

our line item for alcohol and substance abuse, well over 95 percent

of that is going directly to the tribes themselves to run their programs.

Ms. NAPOLITANO. Is there an issue that what is happening is not

actually being effective in taking another look at how else to approach it, working with the tribes you have authorized the money

for?

Mr. GRIM. I think a large part of it is the complex nature of alcoholism. We have programs directed at both prevention and treatment, although we don’t have enough inpatient treatment facilities

or long term treatment facilities in many of the communities that

need it. However, it is a complex mix of socio-economic factors, isolation issues, lack of adequate jobs, housing and things like that

that all feed into the mix. Many of the diseases we are facing in

Indian country today are behavioral and chronic as opposed to the

infectious diseases we saw early on. So it requires a different mix

of factors and programs that are more than just health programs

alone to try to address them.

Ms. NAPOLITANO. Are those being implemented? That is what I’m

trying to get at, thinking out of the box, doing new, effective methods that are going to break that cycle, that are going to assist fami-
688

lies in being able to be supportive of each other, the tribes to be

able to get to those in alcoholism. My husband died of alcoholism

so I understand it very well.

Thank you.

Mr. GRIM. Yes; I think the programs are ongoing out there, I

think they are effective, I think the tribes are working within the

communities to implement a more whole body wellness approach,

physical, mental. emotional and spiritual. Many of them are involving their traditional ways into the programs and I think we are

seeing progress. The issue is just the overwhelming numbers that

we face right now.

Ms. NAPOLITANO. I’d like to hear more. If you have anything you

can submit to the committee on what is actually being done, I

think it is a great problem and is very hurtful to Native Americans.

I think we need to be able to understand it, to be able to look at

how we as a society can assist in being able to address it and help

them be able to understand how hurtful it is to them and their

communities.

Mr. GRIM. We will submit some information to you for the record

on our programs and the things going on with the tribes. You are

right, there is a huge disparity and a huge need in that arena.

Ms. NAPOLITANO. Thank you, Mr. Chairman.

The CHAIRMAN. Congressman Grijalva, any questions?

Mr. GRIJALVA. Yes; thank you, Mr. Chairman.

In the tribal working group that worked with the Indian Health

Service throughout this process and as a result, much of what

we’re deliberating is a product of that work, did this working group

take a position on the point we spend a lot of time talking about

as to who is going to have the responsibility, HUD or Indian

Health Service for sanitation and sewer?

Mr. GRIM. The group did take a long look at that. There are two

versions as you see before you right now, one in the Senate and one

in the House. I don’t think there is a consensus in Indian country

right now relative to how that issue should be handled, whether

the money should be lumped into one sum or whether these two

existing programs which have separate goals should be kept separate. I just don’t think there is consensus out there in Indian country yet either.

Mr. GRIJALVA. Along the same lines, in reference to the steering

committee you worked with, long and hard, as you see both bills,

the Senate and the House, are there any serious omissions in this

legislation, issues that those of us here should be aware of?

Mr. GRIM. I’ve submitted in my written testimony a number of

things, some of the things this committee asked us to focus on

today. Then there are a couple of overarching issues also in my

written testimony. In the interest of time, I can submit some further issues in writing because it is a complex piece of legislation.

Mr. GRIJALVA. I would appreciate that, sir.

Thank you.

The CHAIRMAN. Congressman Pallone.

Mr. PALLONE. Dr. Grim, I like you personally so I don’t want you

to take offense from anything I say but I just don’t get the sense

of crisis from your testimony. When you go out to Indian country,

you hear stories about people dying because of lack of access to
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health care, you hear about the disparities with diabetes and alcoholism and so many other issues, and the inability to attend to

those problems, and particularly with the facilities. Every time you

go to a tribe, they talk about how they are on a 10- or 15-year waiting list to get a new facility or to renovate their facilities. Then you

get all this stuff about funding. As Mr. Faleomavaega said, we just

hear the funding is so inadequate and even more so that the notion

the Federal Government is relying on the tribes to provide funding,

particularly if they have a little money because they have a casino

or whatever.

I’m trying to look at the larger picture and I guess I could ask

two questions and if you can answer them, fine. If not, get back to

me. Do you see a real crisis because I do and where is that crisis?

Is it in the lack of money for facilities, is it in the diabetes area,

is it an inability to provide funding for nursing home services? I

hear about all these things.

The second question is, the tribes really feel, a lot of them say

to me that the Government is not following through on its commitment to provide the funding federally and that they are now expected to use their own resources to build new diabetes clinics or

new hospitals and almost built into the IHS the notion that the

tribes are going to pay for a significant part of their health care.

That’s not the way it’s supposed to be. Do you see a crisis? Where

is it? Do you assume that they are going to pay a significant portion of their own services or construction?

Mr. GRIM. First, let me say that yes, I see a crisis. The percentage of mortality rates that our population exceeds relative to the

U.S. population is not acceptable to me as the director of the Indian Health Service or as an American Indian.

Is there a funding issue? I think we are starting to see potentially higher rates of inflation in health care than we have in past

years. That impacts our budget significantly. Whenever health care

inflation exceeds the amount of money we receive, we have loss in

buying power. We have stayed relatively static in buying power

over the last decade. We have not seen a large increase in buying

power in the Indian Health Service budget, not withstanding the

increases Congress has appropriated to us.

I think the issue is a very complex one as I said earlier. We certainly need greater access to health care in Indian country. There

are certain services that need higher levels of access than currently

available but the other issue is the complex nature of health. It is

not just being able to access a clinic, it is adequate and safe housing, it is economic opportunities on the reservations.

Mr. PALLONE. What about the backlog in facilities?

Mr. GRIM. We have a large estimated backlog in facilities needs

in Indian country. Right now, the average age of an Indian health

care facility is about 36 years of age. In the private sector, the current age of a facility is about 9 years. About 20 percent of our facilities meet that 9 years or younger average, so we have a large

backlog in facility needs in Indian country.

Regarding the issue of appropriating funds for facilities, Congress has been consistent over the years in trying to keep a number of Indian health facilities projects ongoing but there is a large

backlog of need out there.
690

Mr. PALLONE. Do you assume that a lot of these tribes are going

to take care of their own needs? That is what they tell me. They

say, we have to build our own clinic, we have to build our own hospital, we have to pay for this ourselves. Is there an assumption on

the part of the Federal Government that is going to happen?

Mr. GRIM. No, sir; Congressman Pallone, I do not assume that

and I don’t think the Administration assumes that. One of the

things we have seen over time is sometimes when tribes take over

their own health programs and sometimes when the Federal Government still runs them, tribes have donated tribal funds or placed

tribal funds into programs because of the need in particular sectors

for their communities.

I do hear the same things you hear when I’m out there visiting

Indian country, that they feel we should be doing more.

Mr. PALLONE. Thank you.

The CHAIRMAN. Congresswoman Christensen, did you have questions?

Ms. CHRISTENSEN. Yes; I’ll try to make them short.

I’ve been fortunate to have Native American interns and one of

them is with me, Caryle Begay, and another. I want to ask a question that comes from some of the discussions we have had.

Considering there has been a significant increase of Native

Americans, Alaska Natives into urban areas, away from rural reservation areas where the majority of Indian health services are

provided, what measures are being taken to focus on providing

health services for this growing urban Indian population.

Natalia Arosco, an Indian on the San Pasqual Reservation, lives

in a very small urban tribal reservation. They also have some

unique needs for research data collection, publications and guidance for health care providers. What in this reauthorization addresses that?

Mr. GRIM. You are right in that we have seen a large demographic shift of American Indians and Alaska Natives now in

urban areas. We still have 34 urban Indian programs that we provide grant funding for to operate in some existing locations. Those

funds were put together through title V when Congress adopted

title V of the current Indian Health Care Improvement Act. Those

funds were intended to stimulate some health care services. Some

are just referral and outreach and some provide more comprehensive care for areas where there were large urban Indian populations.

Under the former director, Michael Trujillo, when the Indian

Health Service started consulting with Indian Health Service, tribal and urban programs more, we brought the urban partners to the

table. They now take part in our work groups and policy decisions

within the agency and we are trying to work more closely with

them for their needs.

Ms. CHRISTENSEN. You also say under the negotiated rulemaking

part of the bill that the tribal consultation may not be the most effective way to obtain necessary Indian provider input. As a physician and member of the Small Business Committee and my colleague, Grace Napolitano can attest to this, we spend a fair amount

of time with CMS and their rulemaking as it relates to providers

of all backgrounds.
691

What would be a more effective way because through the Office

of Advocacy and through the Regulatory Flexibility Act we have

been able to improve on their consultation. I think the Native

American and Alaska Native providers deserve the same treatment.

Mr. GRIM. Specifically to the tribal consultation process, the Indian Health Service believes very strongly in that and works with

tribes to that end. One of the comments made in my written testimony was that due to the number of regulations that come out of

CMS, there was concern on behalf of the Administration that tribal

consultation on all of the regulations coming through CMS might

place an undue burden on the agency, on CMS.

Ms. CHRISTENSEN. Maybe they ought to simplify their regulation

and rulemaking.

Mr. GRIM. I’ll take back that information.

The CHAIRMAN. Congressman Udall

Mr. UDALL. First, I want to ask about the reauthorization and

the bill that is before us. In doing that, I compliment Chairman

Campbell. He has introduced a piece of legislation, S. 212, in the

107th Congress; we now have before us in the 108th Congress, S.

556. There has been a great deal of consensus building done on this

bill. Is the Administration at the point of supporting the bill before

this committee now, weighing in and trying to make sure it gets

passed?

Mr. GRIM. The Indian Health Care Improvement Act Reauthorization bill, S. 212?

Mr. UDALL. S. 556 which Chairman Campbell has worked on

very hard. It is a bill that has been around a long time and I don’t

believe you have a reauthorization. You’re just going year by year,

aren’t you?

Mr. GRIM. Currently, that is correct. The reauthorization I don’t

believe has been extended currently but it had been extended in

previous Congresses and we are still operating. I was very excited

to see a joint hearing today between the House and the Senate on

the various versions of the bill.

Again, both bills are complex, very long bills and the Administration has made some comments relative to their issues or concerns

on specific parts of the legislation and we are still doing side by

side comparisons right now, so we don’t have a full analysis.

Mr. UDALL. How soon do you think you will have that?

Mr. GRIM. I would have to submit that for the record, sir, about

the length of time. I’d have to check with our assistant secretary

for Legislation.

Mr. UDALL. Do you think you are going to be in a position in the

next couple months to be able to support this bill?

Mr. GRIM. We work very closely with both committees so that we

can try to do that.

Mr. UDALL. I think that is very important because I think the

approach Chairman Campbell and Don Young have taken in introducing this legislation is looking at the long term and looking at

10 years. It seems to me the more you’re required to go year by

year, you aren’t looking at those big issues that many members of

the panel have been raising. Would you agree with that?
692

Mr. GRIM. I think we have continued to operate our program

with a long term focus, notwithstanding the fact this current bill

has been pending reauthorization for a number of years, but we are

very, very anxious in the Indian Health Service and in the Department of Health and Human Services to see the bill reauthorized.

Mr. UDALL. I’m happy that is the case. I want to ask one other

question on this whole diabetes epidemic. I have a congressional

district that is 22 percent Native American in the State of New

Mexico, 9 percent Native American. I had a very poignant story

told to me by a renal specialist in Santa Fe about diabetes in our

community surrounding Santa Fe which we have a number of

Pueblos.

He told me that 20 to 25 years ago, a gentleman that started a

practice quite a while ago, they did not see very many cases of diabetes in Native American individuals that came into the Indian

Health Service hospital or that were being seen privately. In his

lifetime, he said this has dramatically changed. We truly have an

epidemic.

I’m not a doctor. It is what he described to me but he says a lot

of what is going on here has to do with diet, obesity, sedentary lifestyle, lack of exercise and it seems if this is the key, education and

prevention are the way to go. What are you proposing as to how

to tackle this epidemic and how to move us out of this horrible

cycle we are going into?

Mr. GRIM. I think you have seen the President and the Secretary

have an increased emphasis on health promotion and disease prevention in the last couple of years. Since I’ve been in the Indian

Health Service, I’ve initiated a health promotion disease prevention

initiative within this past year involving tribal leadership and

health expertise from our facilities and clinics to try to reemphasize

or bring to the forefront again health promotion and disease prevention efforts.

I think the Indian Health Service has always been strong over

the years in our health promotion efforts. We run a public health

program in the communities as you have heard today and some of

the testimony is not only the delivery of health care but environmental health and sanitation facility issues as well.

We are trying to focus on those chronic disease issues because

they are not as easily solved as some of the diseases we faced in

the past. As a Nation, we are now starting to address it.

Internally, Congress has been good to devote $100 million over

the last 6 years and an additional $50 million to the huge problem

of diabetes in Indian country. I cannot report to you specific numbers but if you’d like them for the record, we have a large number

of primary prevention programs going on in Indian communities

right now. We have a large number of secondary and some minor

tertiary sorts of initiatives going on with that $100 million Congress appropriated. We are seeing successes out there. We are looking at five to six overall clinical indicators and seeing movement

in the right direction. We think we are staring to make impacts on

the diet issues, the obesity issues, and such things that not only

lead to diabetes but a lot of other chronic diseases like cardiovascular disease. Right now, cardiovascular disease is on the rise

in Indian populations, 25 percent greater than the Nation as a
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whole. A number of years back, we were lower than the rest of the

Nation. The rest of the Nation is seeing reductions in those, we are

seeing some increase. So we are working very hard on the control

of blood pressure and things like that in our population.

I think there is a lot going on out there on issues like this, it is

going to take years before we see significant improvements in the

indicators to show success is coming.

Mr. UDALL. With the Chairman’s permission, could you submit

those for the record, what you are doing, what you anticipate you

need in terms of money to tackle the diabetes epidemic in terms

of prevention and education.

As a final followup, wouldn’t you agree that it is far better to

tackle these at the front end with prevention and education than

dealing at the tail end where you have end stage renal disease and

dialysis and the enormously expensive options that patients have

at that point?

Mr. GRIM. I believe that 100 percent because I think that not

only will it reduce the cost of health care in the long run and allow

us to do more but I also believe it is better for our people, they will

lead longer, healthier lives.

Mr. UDALL. Thank you. Let me compliment Chairman Pombo

and Chairman Campbell for convening this joint hearing. I hope it

will move this legislation along and we can get a 10-year authorization for the Indian Health Service.

The CHAIRMAN. If it moves along as fast as this hearing, it may

be 10 years before we finish the hearing.

I’m going to submit my questions in writing. We have a series

of votes starting at 12:10 p.m. in the Senate and the House will be

voting right after that. We still have six people and I’m dividing

the time to make sure they have equal time at the microphone.

We will thank this panel and move to the second panel which

will be: Rachel Joseph, cochair, National Steering Committee on

the Reauthorization of Indian Health Care Improvement Act from

Lone Pine, CA and Dr. Ben Muneta, president, Association of

American Indian Physicians from Oklahoma City and Steve Weaver, director, Division of Environmental Health and Engineering,

Alaska Native Health Consortium.

As I told the first panel, your complete written testimony will be

included in the record, but in order to give everyone equal time before we have to close it down unless you want to come back later

this afternoon which most don’t, I’d ask you to limit your testimony

to about 5 minutes or less.

Why don’t we ask the third panel to be seated too: Kay

Culbertson, president, Denver Indian Health and Family Services;

Dr. Everett Rhoades, Oklahoma City Urban Indian Health Clinic;

and Carmelita Skeeter, executive director, Indian Health Care Resources Center of Tulsa.

Rachel, would you start. Remember we have about 5 minutes

apiece.
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STATEMENT OF RACHEL JOSEPH, COCHAIR, NATIONAL

STEERING COMMITTEE ON THE REAUTHORIZATION OF THE

INDIAN HEALTH CARE IMPROVEMENT ACT

Ms. JOSEPH. Good morning. My name is Rachel Joseph, chairperson of the Lone Pine Paiute-Shoshone Tribe and cochair of the

National Steering Committee on the Reauthorization of the Indian

Health Care Improvement Act. I’m also chairperson of the Toiyabe

Indian Health Project a consortium of nine tribes serving California’s Inyo and Mono counties.

Thank you for holding this joint hearing providing us an opportunity to state our strong support for S. 556 and H.R. 2440, the Reauthorization of the Indian Health Care Improvement Act. These

bills contain provisions that are necessary to improve the ability of

tribal and urban programs and the Indian Health Service to provide comprehensive, personal and public health services.

In 1976, when Congress found that ‘‘the unmet health needs of

American Indian people are severe and the health status of Indians

is far below that of the general population of the United States,’’

the Indian Health Care Improvement Act was enacted. Federal

health services to Indians and Alaska Natives has resulted in a reduction in prevalence and incidence of some illnesses. For example,

since we delivered our proposed bill, the death rate for pneumonia

and influenza decreased from 71 percent higher than all races in

the United States to 52 percent higher.

However, the unmet health needs of our people remain alarmingly severe and continues to decline. Our health status, as already

stated, is far below that of the general U.S. population. This crisis

and disparity to be addressed is formidable.

The oral health of our patients is poor and we experience approximately three times the amount of tooth decay and periodontal

disease than the U.S. general population. As already stated, the

mortality rate for diabetes, 420 percent greater than the rest of the

Nation, and Type II diabetes is rising faster among our children

and young people than any other population and is 2.6 times the

national average. Our suffering due to diabetic end stage renal disease is 6 times the rate of the national population and amputations

due to diabetes is three and four times the rate.

In my community, diabetes is among the three top chronic diseases. We serve our population with three clinics and just at the

Bishop Clinic, we see an increase of two diabetes patients every

month.

Cardiovascular disease is now the leading cause of mortality

among Indian people with a rate that is almost 2 times that of the

U.S. general population.

The recent fully analyzed and racially adjusted mortality data

[fiscal year 1999] from the National Center for Health Statistics

documents an overall 4.5 percent increase rate for American Indian

and Alaska Native people, from 698.4 per 100,000 population for

the period 1994–96 to 730.1 per 100,000 for the period 1997–99.

In recognition of the conditions just reiterated, tribes engaged in

the consultation with a goal to develop consensus and the NSC

membership acknowledged that all of our constituents included the

‘‘lesser haves’’ the ‘‘least haves’’ and ‘‘have nots’’; thus, we agreed

not to ‘‘take from each other’’. One of our ground rules was that
695

‘‘provisions will not adversely affect or diminish funding which is

available to other Indian programs or the I/T/U system. . . ’’

Now, I will highlight title III of the bills which now provides a

broader approach to address the unmet facilities needs and provides innovative funding options. Language concerning Safe Water

and Sanitary Waste Disposal Facilities in section 302 of S. 556 reiterates a cooperative relationship between HHS and HUD regarding

safe water and sanitary disposal. After consensus was reached on

this issue, reflected in S. 556, there has been an effort by some

housing advocates to amend the language that prohibits the use of

I.H.S. funds for newly constructed HUD homes. Why do it since the

I.H.S. Section 302 funding is already critically under funded for

this ‘‘Safe Water and Sanitary Waste Disposal Facilities’’ program?

Approximately 21,500 American Indians and Alaska Native homes

lack safe water and the current backlog of need for this program

construction is $900 million. Since 1982 Congress has repeatedly

expressed its intent that funds appropriated to the IHS not be used

for sanitation facilities for new HUD homes. This system worked

fairly well until 1996 when NAHASDA was enacted and funding is

now distributed by a formula which does not account for deficiencies or cost of offsite sanitation facilities. One of IHS Government Performance Results Acts [GPRA] indicators for fiscal year

2005 is to increase the proportion of American Indians and Alaska

Natives receiving optimally fluoridated water by 0.5 percent over

2004 levels.

An IHS fiscal year 2002 indicator committed to a 5-percent increase of American Indian and Alaska Natives benefiting from fluoridated drinking water. While the fiscal year 2002 indicator was

not fully achieved, 15 small systems not previously fluoridated became fluoridated adding 20,580 individuals to those receiving the

benefits of fluoridated water. Since fluoridation is one of the most

cost effective public health measures for reducing the prevalence of

dental decay of all ages, we must do what we can to ensure that

these limited funds remain available for these purposes.

If I may share a personal experience. This spring, the Indian

Health Service replaced a water pump, replaced asbestos pipes,

fluoridated our community drinking water and pressurized our system. Before that, my parents had to utilize water that would not

allow for the brushing of teeth at the same time you washed

dishes. My dad did not allow us to wash his dress shirts at home

because our water was tainted with rust color. Now, the 228 young

people in our community will experience the long term benefits of

fluoridated water. The middle-aged and us elders will experience

those benefits as well.

An IHS indicator, No. 35, for fiscal year 2005 is to provide sanitation facilities to 22,300 homes, in 2002, 15,255 homes were

served. I support addressing the need and those tribes that are

next in line to receive these services and I hope the dollars are

there.

A new provision of S. 556, section 310 and section 309 of 2440

authorize a loan guarantee, a revolving loan fund and a grant program for loan repayment. The authorization to appropriate funds

for an Indian health care facility loan program could be tremendous support to those tribes that want to build their own facilities.
696

The joint venture, section 312 of S. 556 and section 311 of H.R.

2440, provides for creative, innovative financing by tribes for construction of health facilities. This joint venture with the Indian

Health Service is a viable option for those tribes that can construct

their own facility. The IHS obligation is for equipment, staffing and

to operate it.

In 2001 and 2002, Congress appropriated dollars for this program which resulted in the construction of four facilities which included two on the IHS priority list. The small ambulatory program,

section 306 of 556 and section 305 of 2440, another popular program with the tribes, authorized in 1992, received its first appropriation in 2001 and 2002 of approximately $10 million which provided for the construction of 17 tribally owned facilities that the

tribes equip, staff and operate. Unfortunately, neither S. 1391 or

H.R. 2691 includes 2004 funds for this small ambulatory program.

Another new provision ‘‘Other Funding’’ provides for alternative financing options.

The CHAIRMAN. Rachel, I apologize, but we are going to run out

of time.

Ms. JOSEPH. The National Steering Committee appreciates this

opportunity. We completed the process of consultation and collaboration with broad support and we want to urge you respectfully to

consider any procedural actions necessary to move this legislation

as quickly as possible.

Thank you for your time.

[Prepared statement of Ms. Joseph appears in appendix.]

The CHAIRMAN. Thank you.

Dr. Muneta.

STATEMENT OF DR. BEN MUNETA, PRESIDENT, ASSOCIATION

OF AMERICAN INDIAN PHYSICIANS

Mr. MUNETA. Good morning.

I am president of the Association of American Indian Physicians.

I would like to add our organization’s support for the reauthorization of the Indian Health Care Improvement Act. I am somewhat

reflective of our membership in that I worked in urban, tribal and

Federal health care facilities and we have all come to the consensus that this Act is for the good of Indian people.

The Indian Health Service is a highly efficient organization. You

can’t find anything in government that is more efficient in the use

of dollars as the IHS. We feel any money that is directed that way

is money well spent by the Government.

I would add that American Indians are living longer but one of

the big problems we see is in several cities American Indians are

going to have the lowest quality of life of any minority group in

this country. The reason is simple. Chronic diseases like diabetes

are going to sap the health of Indian people. Diabetic patients are

4 times more expensive than a non-diabetic patient under usual

medical care. This translates into people being sicker, not having

jobs, and economic loss to the communities. It is a ripple effect

throughout Indian communities, not just in the health care system.

One of the ways we look at these disparities is by training more

Indian doctors, more health professionals who go back to these

communities and provide long term, quality care. This is one of the
697

great success stories that we have, the health scholarships that

IHS operates.

I think that is all I have to say.

[Prepared statement of Mr. Muneta appears in appendix.]

The CHAIRMAN. Thank you.

Mr. Weaver. I might mention Senator Murkowski had to preside

at 12 p.m. She has already left but she did tell me that she particularly wanted to hear your testimony, so I am sure she will read it

with great interest.

STATEMENT OF STEVE WEAVER, DIRECTOR, DIVISION OF ENVIRONMENTAL HEALTH & ENGINEERING, ALASKA NATIVE

TRIBAL HEALTH CONSORTIUM, ACCOMPANIED BY ANDREW

JIMMIE, CHIEF, MINTO TRADITIONAL COUNCIL

Mr. WEAVER. Thank you for the opportunity to testify regarding

S. 556 and H.R. 2440, the Senate and the House bills that would

reauthorize the Indian Health Care Improvement Act.

I am appearing today on behalf of the Alaska Native Tribal

Health Consortium where I serve as Director of the Division of Environmental Health & Engineering. I am accompanied by Chief Andrew Jimmie of the Minto Traditional Council who appears this

morning in his capacity as the vice chair of the Alaska Native

Health Board. Chief Jimmie is also the president of the Tanana

Chiefs Council Conference of Regional Health Boards and recently

received the prestigious Alaska Federation of Natives Health

Award.

Under the leadership of the National Steering Committee, the

language in what has been introduced as H.R. 2440 was developed

in nearly complete consensus by tribal leaders. I am pleased to testify this morning that from a sanitation facilities operations perspective, I recommend to the Senate that it substitute the sanitation and facilities provisions of H.R. 2440 in place of S. 556.

I would particularly like to thank the committee for its long term

support of the SFP program. Sanitation facilities construction is

first and foremost about public health. It has a documented history

of success in raising the health status of American Indians and

Alaska Natives. While much as been accomplished, much remains

to be done.

IHS estimates the current national unmet need both feasible and

infeasible of Indian sanitation unmet need of $1.6 billion. Alaska’s

component is $640 million. Alaska has a unique and demanding

living environment. Suvonga, displayed to your left, is typical of remote Alaska Native communities, accessible by air year round and

in the summer by boat but it is not connected on land by any road

network.

Cooper Bay is also typical of rural Alaska. For the last 40 years,

they have packed in their drinking water and packed out their

human waste in honey buckets. They are not atypical. One-third of

Alaska Native homes still lack piped water and sewer facilities.

Other Indian communities throughout the United States face

similar challenges. Current national funding levels are not nearly

sufficient to make meaningful progress. The Indian Health Service

sanitation deficiencies, unmet needs inventory is increasing at a

rate of $50 million a year in addition to the construction activities.
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The National IHS Priority List for new health facilities has stood

without major addition for some 15 years. Language improvements

in title III of H.R. 2440 represent an opportunity to provide flexibility in how we address this backlog and enhance how we do business. It establishes requirements to set priorities for limited facilities resources. It provides more flexibility of program management

for tribes and the potential for innovation as tribes develop and diversify alternative funding sources. It enhances the ability of IHS

and the tribes to deliver critically needed services as well as clarifying operational authorities.

It also provides the tribes a real opportunity to aggregate funding sources and to utilize those to the best opportunity of the community. The impact of public health is not in the construction of

the facility, it’s in the long term operations and maintenance of

that facility to deliver the lifestyle improvement and the health improvements so badly needed.

In conclusion, I’d like to thank Chairman Campbell and Chairman Pombo and the respective committee members for this opportunity to give an engineer’s perspective as we move forward together building healthy and safe American Indian and Alaska Native communities.

[Prepared statement of Mr. Weaver appears in appendix.]

The CHAIRMAN. Thank you.

Ms. Culbertson.

STATEMENT OF KAY CULBERTSON, PRESIDENT, DENVER

INDIAN HEALTH AND FAMILY SERVICES

Ms. CULBERTSON. Good morning. My name is Kay Culbertson. I

am an enrolled member of the Ft. Peck Assiniboine/Sioux Tribes

from Poplar, MT; the executive director of the Denver Indian

Health and Family Services; and also serve on the board of the National Council of Urban Indian Health.

I am honored today by the presence of my father and I am very

happy he could be here with me.

Let me start by saying I’m not a lawyer or a policy analyst. My

testimony both oral and written are from my heart and reflect a

combination of my brief experience as a program director and my

lifelong experience of growing up between the reservation and the

city. Some of my testimony may sound strong but I find I must

stress these issues or I would not be true to my upbringing and

values I hold as an Indian person and as a wife and as a mother

of three, all of whom are enrolled members of federally recognized

tribes.

It is time that urban Indian health issues are seriously considered and I believe S. 556 is a good beginning. I would like to thank

you for the improvements in the bill. The designation that a major

goal of the United States is to provide the quantity and quality of

health services which will permit the health status of Indians regardless of where they live to be raised to the highest level that

is no less than that of the general population and to provide for the

maximum participation of Indian tribal organizations and urban

Indian organizations in the planning, delivery and management of

those health services.
699

I would also like to point out at this point, the urban Indian

health programs receive not even a full two percent but almost two

percent of the Indian Health Service budget.

Some key points have been very positive for urban Indian health

programs in this legislation, allowing urban programs to receive reimbursement from insurance programs when the urban Indian

health provider is considered to be an out of network provider; the

disregard of payments received through third party revenue and

determining funding appropriations for health care and services to

Indians; the ability of current programs to create satellite clinics to

better address the health needs of the Indian community; the establishment of a self sustaining, revolving loan fund that will be

solely for urban Indian health facilities; and permanency for the

Oklahoma City and Tulsa demonstration projects.

The development and construction of two residential treatment

centers for urban Indian youth in each State where need exists and

where there is a lack of culturally constant residential treatment

services for youth, as mental health and substance abuse needs

continue to grow and State facilities and funding are cut, we must

address these needs for the city youth.

Increased consultation with urban Indian health programs and

Federal Tort Claims Act coverage for urban Indian organizations

who receive funding under this legislation are also items of concern

to me as an urban program director. Urban programs are not eligible to apply for chronic shortage demonstration projects. We experience shortages in personnel all the time through the urban Indian

health clinics.

The sections that address the mental health training and community education programs as well as prevention control and elimination of communicable and infectious disease programs includes

urban Indian programs and studies and consultation processes but

do not include us in the development, technical assistance and

funding of these programs.

Urban Indian health programs are not authorized to benefit from

the Indian Health Care Improvement Fund or the Catastrophic

Health Emergency Fund. Lack of funding authorization for critical

services primarily home and community based services, public

health functions and traditional health care in urban programs, we

do use traditional health care.

Title VIII, which has been very hard for me, addresses the provision of health services to non-eligible persons. This is of great concern to me as a tribal member and all members who live off reservation. I believe it takes away services from legitimate tribal

members regardless of where they live. It appears unfair that tribal members who reside off reservation are subject to minimal care

while non–Indians on the reservation may receive comprehensive

services and possible access to contract health care services.

On behalf of my community and all tribal members who live off

reservation, I’d like to thank you for the opportunity to provide testimony on S. 556. I would like to close with this statement. The

United States continues to have a legal obligation to fulfill with Indian people. Our ancestors, the people that live in the cities, also

signed treaties with this Government that included provision of

health care for their descendants in exchange for this great coun-
700

try. Whether an Indian lives off or on the reservation should not

be an issue. These obligations should follow our people regardless

of where they live.

If all urban Indian people were to return home today or even

one-half of us returned home today, being we have over 60-percent

of the population, and exercised our right to those health benefits,

how would the Federal Government meet the trust and treaty responsibilities to Indian people?

Thank you.

[Prepared statement of Ms. Culbertson appears in appendix.]

The CHAIRMAN. Thank you, Kay.

Let the record reflect that not being a lawyer doesn’t hurt you

in the eyes of the committee.

Ms. CULBERTSON. Thank you.

The CHAIRMAN. We don’t have an objection from Congressman

Udall.

Dr. Rhoades.

STATEMENT OF DR. EVERETT RHOADES, OKLAHOMA CITY

URBAN INDIAN CLINIC

Mr. RHOADES. Chairman Campbell, Chairman Pombo, members

of the joint committees that are considering perhaps the most revolutionary health bill related to Indians that has been passed, my

name is Everett Rhoades. I’m a member of the Kiowa Tribe. I was

one of the incorporators of the original Urban Indian Clinic in

Oklahoma City and I also had the privilege of being one of the outside witnesses that appeared in the deliberations of the original bill

in 1975. I appeared as a predecessor to the imminent Dr. Muneta

on behalf of the Association of American Indian Physicians at that

time where our primary interest was in title I, the Indian manpower provisions as well as in the disparities.

I am here today on behalf of the Oklahoma City Urban Indian

Clinic. Because of the importance of this hearing, I’m accompanied

by our board president, Rufus Cox, a member of the Muskogee

Creek Tribe of Oklahoma; our chief executive officer, Terry Hunter,

a Kiowa from Oklahoma City; and our chief operating officer,

Robyn Sunday, a member of the Cherokee Tribe in Oklahoma City.

Let me make two points in the interest of time. First, there is

a general conception that the basic authorization for provision of

health services to urban Indians, title V of the Indian Health Care

Improvement Act, I do not believe that to be true and many other

individuals do not believe that to be true either.

A reading of the 1921 so-called Snyder Act which really provides

basic authorization for health services simply says at that time the

Commissioner of Indian Affairs should expend such moneys as

Congress should from time to time appropriate for various programs, including interesting language that says conservation of

health and relief of distress and for physicians, for Indians

throughout the United States and does not provide additional guidance.

It is my understanding that the enactment of title V went beyond

simply the authorization of services to urban Indians but it defined

the nature of those services, it defined the nature of the receiving

entity and part of the consideration was to avoid what I would call
701

the intrusion of the Indian Health Services’ program itself into

urban communities recognizing that even by the 1970’s, a dramatic

diaspora of Indians into urban communities would really ultimately

require the entire budget of the Indian Health Service.

As a result of all that, a new entity was created set out in the

definition of paragraph (g) or (h) in section IV that says these programs are to be located in urban areas, to be run by a local urban

Indian board which, in my opinion, distinguishes them from both

Indian Health Service and tribal programs.

In that regard, we would ask that the Congress keep that in

mind in its deliberations in regard to title V and we very strongly

support the Senate language contained in section V.

In 1987, as a result of what I would call the growth and evolution of urban programs in this country, the Congress set two important demonstration programs into being in Oklahoma City and

in Tulsa which further defined urban health care in these two demonstration projects, basically to determine whether or not they

would be more apt to succeed if they received their funding from

the hospitals and clinics account of the Indian Health Service rather than the urban account in title V but the contracts were still executed under title V, so they are hybrid programs with a peculiar

special characteristic that should treat them in many instances as

service units are now operating units.

The second point we feel strongly about in Oklahoma City is that

we respectfully ask the Congress to direct that funds that are received in the Oklahoma area by virtue of the fact the entire State

of Oklahoma is a contract health service delivery area and the populations in both Oklahoma City and Tulsa therefore are counted in

those allocations, unfortunately with the present arrangement of

distribution of those funds, both Tulsa and Oklahoma City receive

a minority of the funds that their own populations generate. We believe the Indian Health Service would welcome direction from the

Congress that the allocations of additional funds, particularly

under Indian Health Care Improvement Act, should be treated as

service units or operating units within themselves.

In closing, I would reiterate in regard to section 512, the Senate

language I think is excellent. It really continues language that has

been in place since 1992 and I would respectfully ask the House

members if they would accede to the language of the Senate where

there may be differences.

Thank you.

[Prepared statement of Dr. Rhoades appears in appendix.]

The CHAIRMAN. Thank you. Your institutional memory is of great

value to the committee.

Ms. Skeeter.

STATEMENT OF CARMELITA WAMEGO SKEETER, EXECUTIVE

DIRECTOR, INDIAN HEALTH CARE RESOURCE CENTER OF

TULSA

Ms. SKEETER. Good morning and thank you for inviting me to

make this presentation today. I am very happy to see that it is a

joint hearing.

I’m the executive director of Indian Health Care Resource Center

in Tulsa and I have been with this organization for 27 years, so it
702

is very dear to my heart. I have I hope a very good story to tell

you on the demonstration programs.

I am citizen Potawotami enrolled in my tribe and very active. Becoming a demonstration project in 1987, we did that with the help

of Indian Health Service, the Urban Directors, coming together and

seeing how we could make sure these two programs existed even

though urban programs nationally were zeroed out of the budget.

Because of IHS and the tribal people seeing our programs were

so vital to the State of Oklahoma, they wanted to make sue we

were able to continue, so we were put into the 01 of the budget,

line item. Since then, we have been able to double our resources

and in some areas, triple our resources. It was like opening a new

door or opening a window to a home that had been very stale and

unsupported. We were able to then start receiving GSA vans to do

transportation for our patients, we were able to start getting health

care providers from IHS, able to start purchasing medications from

the GSA pharmaceutical contract, so it was opening a new door. The program in Tulsa has a $2.5 million Indian Health Service budget. We have been able to turn that budget into over $6.5 million by contracting with other agencies competing with other Federal programs on grants and contracts. We have five contracts with

the State of Oklahoma to provide substance abuse and mental

health services. We are State certified. We are accredited through

the Association of Accreditation for Ambulatory Health Centers.

We have a contract with the Cherokee Nation where they provide

the WIC services in our clinic and have done so since 1979. We

have a contract with seven other tribes in the State of Oklahoma,

a program called BEACH which is through the State health department and CDC working with children on obesity, drugs, physical

fitness, the prevention of diabetes and we are in three Tulsa public

schools with gym teachers working with these children daily.

I believe that we are a very good partner with all the tribes in

Oklahoma. We work very closely with them and our board is a

community elected board, we have elections once a year. Any tribal

member in Tulsa can run for our board. We have in the past had

councilmen from the Creek Nation on our board, councilmen from

the Cherokee Nation on our board. The tribes hold meetings at our

facility. Oklahoma City and Tulsa are the only two urban programs

in the United States that have been able to get new facilities in the

past 25–30 years.

The facility in Tulsa is 27,000 square feet, the facility in Oklahoma City I believe is about 27,000 square feet. We have been able

to do that because we have been able to collect Medicaid at the

OMB rate because we are treated as a service unit. This makes us

different than the other urban programs. We have been able to tap

into this resource of Medicaid reimbursement. That has allowed us

to expand our services.

Tulsa, we do not receive any IHS funds for dental but we are

able to provide dental services by having one dentist because we

are able to collect Medicaid at the OMB rate. We are able to have

an optometry clinic, full-time optometrist because we are able to

fund that with the Medicaid OMB rate.

I feel very proud of what we have been able to do in Oklahoma,

the services we are able to provide. Our service population is
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15,000 active patients at our facility. We have over 6,000 patient

visits a month. I have a staff of 85. I have the largest mental

health outpatient department in the State of Oklahoma for Indian

people. We take referrals from all over the State. I have four clinical psychologists full time, two psychiatrists part time, one for children, one for adults; I have a developmental pediatrician part time

and I have four counselors that work out of our behavioral health

department. I have a full time pediatrician in medical, family practice physician assistant, nurse practitioner, so I have a very large

operation in Tulsa. We work very closely and are very integrated

with the entire health system of the city.

We carry a caseload of 120 to 130 OBs continually. I have a contract with an obstetrician that comes in 1 day a week to see those

OBs and the mothers if they qualify or have third party reimbursement, they are able to deliver in the city. If not, we provide transportation for the mothers to Claremore Indian Hospital which is 30

miles away one way.

We are very entrenched in the community. We are 27 years old.

We try to tap into every resource we possibly can. We work very

closely with the tribes and I do support S. 556. I want to thank the

Senators for honing the language that would protect us from sovereignty. We do not want to get into the sovereignty issue.

We serve over 150 tribes and as an urban program, we want to

continue to serve that 150 tribes. We want to continue operating

as a 501(c)(3) under a community elected board and have the board

set the policies that run the organization.

As I say, I am very passionate about this program. I’ve been

there 27 years. I started out as the resource coordinator, clinic administrator and I’ve been the executive director for the last 14

years. I feel very strongly and would be more than happy to answer

any questions.

[Prepared statement of Ms. Skeeter appears in appendix.]

The CHAIRMAN. Thank you, Ms. Skeeter.

We have managed to keep it within the timeframe. I’m going to

ask our colleagues to submit any questions in writing as I will because we have run out of time but would like to yield to Chairman

Pombo if he has any closing comments.

Mr. POMBO. I want to thank this panel for your testimony. It was

extremely informative and very valuable for the committee as we

move forward with this bill. On behalf of myself and my colleagues

in the House, I want to thank you for taking the time to come here

and share your stories with us.

I do have a number of questions as my colleagues do and we will

be submitting those to you in writing. If you can respond to those

in a timely manner in writing so they can be included as part of

the hearing, we would appreciate it.

Thank you very much.

Mr. PALLONE. Could I just ask a procedural question? I thought

it was very valuable to have this joint hearing today. I don’t want

to suggest to our chairman what he should do on this issue but I

know that the Senate committee is planning to have future hearings. Either we have our own or if not, if we could possibly continue this joint hearing idea, it is certainly a way for the House
704

members to participate and also for us all to continue with investigation of the issues.

The CHAIRMAN. I will have our staff work with Chairman

Pombo’s staff and see if we can’t do that dealing with health care.

We will submit those questions and if you could get those back

to in writing at your earliest convenience, that would be good.

I want to thank all the panels and we will keep the record open

for four weeks on this particular hearing because we will be doing

another on the same subject. Next week we will continue the series

on health care.

This hearing is adjourned.

[Whereupon, at 12:17 p.m., the committees were adjourned, to reconvene at the call of their respective Chairs.]
(705)

APPENDIX

ADDITIONAL MATERIAL SUBMITTED FOR THE RECORD

PREPARED STATEMENT OF MIKE ZACHAROF, CHAIRMAN AND ANDREW JIMMIE, VICE

CHAIRMAN, ALASKA NATIVE HEALTH BOARD

The Alaska Native Health Board [ANHB], established in 1968, is recognized as

the statewide voice of Alaska Natives on health issues. With contributions from its

member tribes and tribal organizations, ANHB has been active for 35 years as an

advocate on behalf of health needs and concerns of all Alaska Natives.

On behalf of 229 tribes within the State of Alaska, and over 119,000 Alaska Natives, the Alaska Native Health Board strongly encourages Congress to support and

enact H.R. 2440, a bill to reauthorize the Indian Health Care Improvement Act.

H.R. 2440 is an update to the 1999 National Steering Committee draft of the Indian Health Care Improvement Act. Over the last year, under the direction of Representative Young, the 1999 National Steering Committee draft reauthorization bill

and the first House and Senate versions of that draft were examined and updated

to respond to concerns expressed by the Administration to provisions contained in

S. 212—the predecessor to S. 556—to resolve differences between the bills before the

Senate and the House in the last session, and to consider tribal concerns that have

arisen since 1999. This work is reflected in H.R. 2440.

We are pleased that Steven Weaver has been invited to testify regarding before

this joint hearing of the Senate Committee on Indian Affairs and House Resources

Committee regarding the provisions of Title M of the Indian Health Care Improvement Act. As Director of the Division of Environmental Health and Engineering for

the Alaska Native Tribal Health Consortium, he brings to you a wealth of experience and technical knowledge. We strongly endorse the recommendations made in

his testimony.

Reauthorization of the Indian Health Care Improvement Act is one of the highest

priorities of the tribes in Alaska. We urge the earliest possible action.

PREPARED STATEMENT OF R. PERRY BEAVER, PRINCIPAL CHIEF, MUSCOGEE [CREEK]

NATION

Chairman Campbell, Vice Chairman Inouye, and members of the committee.

Thank you for this opportunity to share some of my thoughts with you about S.

556, the ‘‘Indian Health Care Improvement Act Reauthorization of 2003.’’ My name

is R. Perry Beaver and I have served as the Principal Chief of the Muscogee [Creek]

Nation for the past 8 years, and as a National Council representative for several

years before that. I request that my written testimony be made part of the hearing

record.

Due to my years of service to the Muscogee Nation and my residence in Tulsa

County for many years, I am familiar with the many health problems faced by Native Americans in Oklahoma, including Creek citizens residing in the Tulsa urban

area. I have also been a part of the development and implementation of Department

of the Interior and Health and Human Services tribal 638 contracts and self-govern-
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ance compacts under the Indian Self-Determination and Education Assistance Act

[‘‘ISDEAA’’] amendments during the past decade. These programs have provided the

Muscogee Nation with a great opportunity to identify the specific needs of its citizens and to administer programs for that purpose, including health programs. The

Muscogee Nation has made significant progress in its development as a government

and in making improvements related to the provision of health care due in part to

the opportunities presented by the ISDEAA.

Unfortunately, S. 556 contains a proposed amendment to the Indian Health Care

Improvement Act that would severely limit the Nation’s ability to exercise self-governance in the area of health care. Section 512(a) would amend the IHCIA to permanently remove the Indian Health Care Resource Center, Inc. in Tulsa, OK

[‘‘Tulsa Clinic’’] from the umbrella of self-governance and make it a permanent direct care program of the Indian Health Service. This would be accomplished by the

following provisions in section 512 (a) of the bill:

Notwithstanding any other provision of law, the Tulsa and Oklahoma City Clinic

demonstration projects shall become permanent programs within the Service’s direct

care program and continue to be treated as service units in the allocation of resources and coordination of care, and shall continue to meet the requirements and

definitions of an urban Indian organization in this title, and as such will not be subject to the provisions of the Indian Self-Determination and Education Assistance

Act.

A large number of the Native American population in Tulsa are citizens of the

Muscogee Nation and the Cherokee Nation. The northern jurisdictional boundary of

a portion of the Muscogee Nation and the southern boundary of a portion of the

Cherokee Nation encompass separate areas in what is now Tulsa County. The Nation has strong roots in Tulsa, which originated as a Creek Tribal Town in the

1830’s. The Nation owns trust lands in Tulsa County and also still owns a one-hundred acre tract of land in Tulsa that has been recognized by Federal courts as ‘‘historic reservation lands.’’ Our capital complex in Okmulgee is only 30 miles from

Tulsa. Although the Muscogee Nation has not fully exercised its self-governance related to its citizens’ health needs in the Tulsa urban area in recent years, it maintains a strong governmental interest in meeting the health needs of Indians within

its service area.

The Tulsa Clinic has been existence for approximately 20 years, many years before Congress amended the ISDEAA to include self-governance programs that would

enable Indian nations to exercise greater control over Federal funds formerly awarded to them under ‘‘638 contracts.’’ During much of that time, the Tulsa Clinic has

been providing health services to Native Americans in Tulsa as a demonstration

project under the IHCIA. The Nation has not made a strong attempt to obtain tribal

control of the provision of health services in Tulsa currently provided by the Tulsa

Clinic for various reasons, including the Nation’s concentration on development of

its existing health programs and its recent conversion to funding through a self-governance compact. I believe that the indefinite continuation of the Tulsa Clinic as a

demonstration project would be in the interests of Native Americans in Tulsa. However, the Muscogee Nation is opposed to making the Clinic a permanent program

and permanently removing it from the authority of the ISDEAA. This would eliminate the Nation’s ability to compact for IHS funding allocated for the needs of Indians in Tulsa. This would infringe on the Nation’s sovereignty within its jurisdictional boundaries in a significant portion of Tulsa County. I believe that at some

point in the not too distant future, the Muscogee Nation will be ready to take an

even stronger role in the provision of health care in Tulsa. The proposed amendment would prevent the Nation from doing so, through what would be, in effect, a

Congressional delegation of the Nation’s governmental authority to the Indian

Health Services and the Tulsa Clinic as its grant recipient. The Board of the Tulsa

Clinic would be in a permanent position to make decisions which are better left to

tribal governments.

I respectfully ask that this committee refrain from approval of S. 556 unless and

until the offending language in section 512(a) is removed or amended. I have reviewed new draft language provided by the Cherokee Nation, and have no strong

objections to use of that language, except to language that would make the Tulsa

Clinic a ‘‘permanent program’’ within the Indian Health Service [‘‘IHS’’] direct care

program. I suggest that the language in section 512(a) be revised to read as follows:
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Sec. 512(a). TULSA AND OKLAHOMA CITY CLINIC—Notwithstanding any

other provision of law, the Tulsa and Oklahoma City Clinic demonstration projects

shall—(1) remain demonstration 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) be subject to the provisions of the Indian Self-Determination

and Education Assistance Act, except that the programs shall not be divisible.

Thank you for this opportunity to provide this testimony to you today.
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