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88–704 PDF 2003

S. HRG. 108–204

REAUTHORIZATION OF THE INDIAN HEALTH CARE

IMPROVEMENT ACT

HEARING

BEFORE THE

COMMITTEE ON INDIAN AFFAIRS

UNITED STATES SENATE

ONE HUNDRED EIGHTH CONGRESS

FIRST SESSION

ON

S. 556

TO AMEND THE INDIAN HEALTH CARE IMPROVEMENT ACT TO REVISE

AND EXTEND THAT ACT

JULY 23, 2003

WASHINGTON, DC

(
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

(II)
(III)

C O N T E N T S

Page

S. 556, text of ........................................................................................................... 2

Statements:

Benjamin, Melanie, chief executive, Mille Lacs Band Assembly, Onamia,

MN ................................................................................................................. 345

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

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

Dixon, Mim, Dixon & Associates, Boulder, CO .............................................. 356

Johnson, Hon. Tim, U.S. Senator from South Dakota .................................. 348

Moose, Samuel, commissioner, Health and Human Services, Mille Lacs

Band Assembly, Onamia, MN ...................................................................... 345

Munson, Myra M., esquire, Sonosky, Chambers, Sachse, Miller, LLP,

Juneau, AK .................................................................................................... 352

Rolin, Buford L., vice chairman, Poarch Band of Creek Indians, Atmore,

AL ................................................................................................................... 349

APPENDIX

Prepared statements:

Benjamin, Melanie ........................................................................................... 363

Dixon, Mim ........................................................................................................ 372

Munson, Myra M. (with attachment) .............................................................. 377

Rolin, Buford L. (with attachment) ................................................................. 366

(1)

REAUTHORIZATION OF THE INDIAN HEALTH

CARE IMPROVEMENT ACT

WEDNESDAY, JULY 23, 2003

U.S. SENATE,

COMMITTEE ON INDIAN AFFAIRS,

Washington, DC.

The Committee met, pursuant to recess, at 10 a.m. in room 485,

Russell Senate Building, Hon. Ben Nighthorse Campbell (chairman

of the committee) presiding.

Present: Senators Campbell, Johnson, and Murkowski.

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

The CHAIRMAN. The Committee on Indian Affairs will be in session.

Welcome to the third hearing in a series held by the Committee

on S. 556, a bill to Reauthorize the Indian Health Care Improvement Act. Today we will hear from tribal leaders and tribal health

care experts on issues related to Indian access to health care and

services. The committee will receive testimony on how Indian access is affected by Medicare, Medicaid, and other Federal health

care programs, and what improvements are needed to increase Indian access.

[Text of S. 556 follows:]
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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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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20

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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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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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30

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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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31

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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

•S 556 IS

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

•S 556 IS

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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•S 556 IS

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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•S 556 IS

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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40

•S 556 IS

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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41

•S 556 IS

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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43

•S 556 IS

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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•S 556 IS

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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•S 556 IS

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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The CHAIRMAN. In the interest of time, we are going to go ahead

and start with our panel which includes Melanie Benjamin, chief

executive, Mille Lacs Band Assembly, Onamia, MN; Buford L.

Rolin, vice chairman, Poarch Band of Cree Indians, Atmore, AL;

Myra M. Munson, Esq., Sonosky, Chambers, Sachse, Miller & Munson, LLP, Juneau, AK; and Mim Dixon, Dixon & Associates, Boulder, CO.

I read all your written testimony this morning. It will all be included in the record. If you would like to abbreviate or diverge from

that written testimony, feel free to do so.

We will start with Ms. Benjamin.

STATEMENT OF MELANIE BENJAMIN, CHIEF EXECUTIVE,

MILLE LACS BAND ASSEMBLY, ONAMIA, MN, ACCOMPANIED

BY SAMUEL MOOSE, COMMISSIONER OF HEALTH AND

HUMAN SERVICES

Ms. BENJAMIN. Good morning, Chairman Campbell, Vice Chairman Inouye, and distinguished members of the Senate Committee

on Indian Affairs. I am Melanie Benjamin. I am the chief executive

of the Mille Lacs Band of Ojibwe. Accompanying me today is Samuel Moose, who is the commissioner of Health and Human Services.

I also brought summer youth as well. This will be their first opportunity to participate in this hearing.

The CHAIRMAN. Are those the young people back here?

Ms. BENJAMIN. Yes.

The CHAIRMAN. We are glad to have them here.

Ms. BENJAMIN. The Mille Lacs Band is a federally-recognized

tribe of 3,570 members located in East Central Minnesota. As an

elected tribal leader, I have an interest in the general direction of

Federal Indian policy. I am greatly concerned with the dismal state

of health across Indian country, and in particular, on the Mille

Lacs Reservation.

My comments to the Senate Committee on Indian Affairs are

provided from this perspective. At the outset, I wish to respectfully

point out that I am not an expert on health care issues, nor on

Medicaid or Medicare. There are individuals on this panel who are

experts and possess the technical knowledge to more adequately

address these subjects.

Today I will briefly discuss three topics as they relate to Medicaid and Medicare under Title IV of the Indian Health Care Improvement Act, sovereignty, the Federal trust responsibility, and

Indian Health disparities. The access to health services under title

IV provisions have a direct connection to the health disparities in

Indian country and must be addressed by Congress.

When the Indian Health Care Improvement Act was first enacted

in 1976, Congress recognized its trust responsibility toward the

tribes to provide adequate health care. Throughout the subsequent

amendments and reauthorizations of the act, one of the major underlying policies has been to provide tribes access to other Federal

health care sources, like Medicaid and Medicare programs that do

not face funding limits like our Indian Health Service programs do.

The intent was and is to improve our health status through that

access. Since then Medicaid and Medicare reimbursement to tribes,
346

including the Mille Lacs Band, have become a significant source of

revenue for our health care programs and operations.

Over the last 15 years, the Mille Lacs Band has actively participated in the formulation of tribal self-governance policy. We were

one of the first 10 self-governance tribes. We participated in the

original demonstration project and the writing of the permanent

acts for BIA and Indian Health Service self-governance. We have

also been on the rulemaking committees for the implementation of

self-governance laws.

Currently, the Mille Lacs Band is an active member of the Tribal

Self-Governance Advisory Committee that advises Federal agencies

on Indian policy matters affecting the self-governance tribes. The

Mille Lacs Band has supported and advocated for self-governance

laws because our philosophy is that we should be free to govern

ourselves and develop our own policies in the administration of our

tribal programs. We should not be entangled by Federal or State

bureaucracy. To us, developing our own policies is an important exercise of sovereignty.

There are three principles that the Mille Lacs Band of Ojibwe

considers when analyzing Federal programs. First, we assert that

our primary relationship is with the Federal Government. Second,

we retain all sovereignty not expressly taken away. Therefore, we

should have the ability to control funds reserved for us under Federal law. Third, we should have equal access to the same funding

avenues as States. This third principle raises the fundamental flaw

of the Medicaid and Medicare programs and the treatment of

tribes.

It is my understanding that the design of the Medicaid and

Medicare programs is a Federal-State collaboration. The problem is

that tribes do not fit into the picture at all. This design flaw makes

it very difficult to meet criteria for receiving reimbursements.

An example is that counties receive an administrative match

from the State for their administrative costs, while tribes cannot.

According to the Mille Lacs Band of Ojibwe’s Commission of Health

and Human Services, our inability to recover the administrative

match demonstrates that tribes do not have equal access to Medicaid and Medicare reimbursements.

The reason is that States determine how their block grants will

be distributed under their own guidelines. As a result, the Mille

Lacs Band and many other tribes lose out on potential and critical

avenues of funding we desperately need. Others on this panel have

addressed this and other legal barriers more specifically, but from

a tribal leader perspective, it is clear that States and managed care

systems have predominance over tribes under Medicaid and Medicare.

Clearly, the establishment of Medicaid and Medicare entitlement

programs happened at a time in history when the Congress did not

focus on tribal sovereignty. However, today tribes are treated as

governments in Federal legislation and tribal sovereignty is recognized. Indian people are provided direct access to Federal programs

and funding.

The Mille Lacs Band of Ojibwe receives direct funding for our

Self-Governance Indian Health Service annual funding agreement.

But when it comes to Medicaid and Medicare programs, it is a dif-
347

ferent situation. The process of devolution, where Federal funds in

the form of block grants are provided to the States who then distribute those funds under their guidelines, has created a framework that leaves the tribes unable to access needed funds.

It is time to change the Medicaid and Medicare provisions under

title IV of the Indian Health Care Improvement Act to reflect the

new enlightened view of tribal sovereignty and provide tribes more

access to health care services as the act was originally intended.

Through our treaties, Federal statutes, executive orders, and court

decisions, a Federal trust responsibility has been established and

recognized over the course of dealings with tribes.

The Mille Lacs Band of Ojibwe signed several treaties with the

United States and the provision of proper health care became an

expectation of the Band and an obligation of the Federal Government. In addition, the Snyder Act of 1921, the Transfer Fact of

1954, the Self-Determination Act of 1975, the Indian Health Care

Improvement of Act of 1976, as well as the enactment of the Indian

Health Service Self-Governance Act, all evidence the trust obligations that flow to the tribes from the Federal Government for the

provision of health care.

In spite of the clear legal duty created by these Federal statutes,

the Federal obligation to provide adequate health care to tribes has

never been properly funded. Historically, this insufficient funding

has interfered with our ability to provide comprehensive health

care to Mille Lacs Band members. According to IHS estimates, the

Mille Lacs Band, and all other tribes in our region, are funded at

approximately 30 percent of need. This means more than twothirds of our need is not being met and explains why the status of

Indian health on the Mille Lacs Band Reservation, and many other

reservations, is so poor.

I am told that the Federal Government spends nearly twice as

much for a prisoner’s health care than it does for Indians. This fact

is an example of why our health status is at the bottom of every

disease category. It seems ironic that Indian health care, through

the Indian Health Service, is not an entitlement for Indian people

when tribes essentially pre-paid for our health care by ceding millions of acres of land to the Federal Government.

It seems more ironic that the tribes have problems accessing the

Federal entitlement programs like Medicaid and Medicare which

were designed for all State citizens. This funding disparity becomes

a matter of fairness and equity because Indian people are also citizens of the States in which we reside. It is only logical that we

should have the same access to the same services as do other nonIndian citizens.

Given that we have been historically under-funded for our health

care needs, and tribes likely will not receive funding for the level

of need in the next appropriations cycle, the Federal trust responsibility needs to be taken seriously and changes made to allow

tribes full participation in the existing entitlement programs of

Medicaid and Medicare. It is fair and it is right.

Finally, I am not going to cite the long and tragic list of statistics

that tell the story of health disparities throughout Indian country.

Instead, I will talk about my own Reservation. Diabetes is a serious problem in the Mille Lacs community. I do not know of one
348

family without diabetes among one of their family members. For

many our Band members, it is not a matter of if they get the disease, but when. Band members are losing their vision. They are

losing their limbs. Many are so close to needing kidney dialysis

treatments.

More alarming is the chronic health conditions occurring in our

children and our youth. They are our future. I have serious concerns for their long-term health and longevity. I do not have answers but I do know that adequate and comprehensive health care

is absolutely critical to preserving our tribal communities. We are

fighting to protect our members’ lives on our reservations and in

our communities.

If Congress makes the necessary changes to Title IV of the Indian Health Care Improvement Act, and provides more access to

Federal health care services and funds, it will at least give us another weapon in the war against health disparities.

Thank you for this opportunity to testify. I would also ask that

my written statement be made part of the record of this hearing.

The CHAIRMAN. Without objection, so ordered.

[Prepared statement of Ms. Benjamin appears in appendix.]

The CHAIRMAN. Thank you, Ms. Benjamin.

Senator Johnson, I do not know how tight your schedule is. Do

you have a statement?

STATEMENT OF HON. TIM JOHNSON, U.S. SENATOR FROM

SOUTH DAKOTA

Senator JOHNSON. Mr. Chairman, I just commend you for holding

this very timely hearing. There are few areas where we have a

greater crisis than in health care as we go about the debate on

Medicare and Medicaid within the context of prescription drug coverage. I think that we have made some real progress on the Senate

side, but it is essential that we continue to be closely consultative

with the tribes. I think you have an excellent panel here.

I am going to have to excuse myself for some conflicting obligations that I have, but I will be examining the testimony closely and

look forward to working with you and other members of the committee to see what we can do. The overall level of funding, of

course, is the first problem. The IHS is funded at roughly half of

what they ought to be funded.

But even beyond that, I think it is proper that we focus on the

role of Medicare-Medicaid third-party payment mechanisms and

what we do to better utilize those resources to live up to our obligations in Indian country.

I thank you very much.

The CHAIRMAN. For the panel’s information, members will be

coming and going. Some will not be here. It does not mean they are

not interested in the issue. Every one of us is over-scheduled with

two or three things to do at the same time. It comes with the territory here. Please understand why some members are not here.

Let us go ahead with Buford Rolin. Thank you for being here.
349

STATEMENT OF BUFORD L. ROLIN, VICE CHAIRMAN, POARCH

BAND OF CREEK INDIANS, ATMORE, AL

Mr. ROLIN. Thank you, Senator Campbell.

Chairman Campbell, Vice Chairman Inouye, and distinguished

members of the Senate Committee on Indian Affairs, I am Buford

Rolin, Vice Chairman of the Poarch Band of Creek Indians from

Atmore, AL. I serve as an elected member of the National Indian

Health Board representing the Nashville area. It is indeed an

honor for me to come before you this morning to offer this testimony on the reauthorization of the Indian Health Care Improvement Act.

As you know, the Indian Health Service’s National Indian Health

Board serves all federally-recognized tribes throughout the Nation.

We have a membership of 12 members that are elected to the

Board by their respective areas. Our goal is to advocate for Indian

people, not only in the budgetary area, but health issues throughout.

I would like to commend the testimony of chief executive officer

Melanie Benjamin and her concerns. She has expressed them well.

I know the other panelists will have equal concerns that they will

talk about.

Given the two previous hearings of the committee that was held

during the 108th Congress, I am going to be brief this morning. I

realize that the members are quite aware, as you have just stated,

about the needs of the health care of the Indian people, the reauthorization, and how important it is in the Indian Health Care Improvement Act. We realize the political realities that are facing

Congress, and we appreciate the fact that you are holding these

hearings this.

Let me talk a little bit about the process of what has taken place

over the years since 1999 with the first bill that we introduced to

reauthorize the Indian Health Care Improvement Act. In 1999, the

National Steering Committee was formed by the Indian Health

Service. It represented tribal leaders throughout the Nation as well

as members from the organizations and urban areas.

Over the last several years, the NSC has worked closely with Indian country, the Administration and Congress, and the Indian

Health Service to develop amendments to the Indian Health Care

Improvement Act. Let me begin first by talking about the Centers

for Medicaid and Medicare services.

At the request of the CMS, we have established a tribal technical

work group that has been representative of Indian people throughout this Nation. The TTAG was formed in 2001 and consists of tribal leaders, area Indian health boards, and designated national tribal organizations.

The activities of the TTAG are coordinated through the Intergovernmental and tribal Affairs Office within CMS. The TTAG has forwarded several recommendations to Congress and CMS regarding

recommended changes to the reimbursement methodologies in

place for the Indian Health Service, tribal health programs, and

urban Indian problems.

The TTAG is very adamant about its position that any reforms

in Medicare, medicaid, or CHIP programs must allow for tribal al-
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location or other direct funding mechanisms that authorize Indian

health program access to CMS.

The TTAG has also worked very closely the NSC to develop the

changes in Title IV of the Indian Health Care Improvement Act,

as reflected in H.R. 2440, which include the most recent NSC recommendation.

As the committee is well aware, the Indian Health Service lags

far behind other segments of the population and has failed to keep

pace with inflation as far as health care is concerned. Current Indian Health Service funding is so inadequate that less than 60 percent of the health care needs of American Indians and Alaska Native people are being met.

In order to address additional health care resources, Title IV of

the Indian Health Care Improvement Act is critical to address the

Medicare-Medicaid and other third party reimbursements, as Chief

Executive Officer Benjamin has stated this morning.

It is one of the most important provisions of the Indian Health

Care Improvement Act. It makes IHS hospitals eligible for Medicare reimbursements and facilities eligible for Medicaid reimbursement. Title IV also makes it possible for Medicare and Medicaid eligible American Indians and Alaska natives to use these benefits.

Since the passage of the Indian Health Care Improvement Act in

1976, Medicare and Medicaid payments have become sources of income for tribal programs, so much so that in fiscal year 2002, $460

million was collected for these services. This amount enhances the

resources available already to hospitals and clinics’ budgets by 30

percent. We are indeed appreciative of that.

But in order to further improve the ability of Indian country as

far as health providers to access third party resources, the NSC

has developed several changes to title IV that was indicated in S.

212 and continues through S. 556. I would like to note that S. 556

introduced to Congress is identical to S. 212. Therefore, many of

the concerns raised in regards to S. 212 remain.

In response to those concerns, however, the National Steering

Committee has revised the recommendations for reauthorization.

The changes are reflected in H.R. 2440. By the way, that bill was

introduced June 11, 2003.

I think it is quite helpful to point out that the Senate Committee

on Indian Affairs and the House Resources Committee’s hearing on

the Indian Health Care Improvement Act last week indicates the

cooperation and the spirit of the two houses to support this reauthorization. H.R. 2440 reflects several changes made to the original

tribal proposal as introduced in 1999. Those changes listed have

come about and we will see that in H.R. 2440.

There are four areas that I would like to quickly talk about that

we have been removed from the previous legislation. One is the

Qualified Indian Health Program. This provision has been removed. We have requested that a provider type with Indian health

programs appear, such as Medicaid, so that we can more fully exercise our statutory rights in that aspect.

Secretary Thompson expressed his concern for that in S. 212. His

concern was that over a 10-year period it would cost in excess of

$3 billion. However, in place of the QIHP proposal, tribes are requesting that the Secretary prepare a program or a report that
351

would, in fact, examine whether these payments under the current

methodologies are sufficient to continue to be applicable as a most

favorable provider under the Social Security Act. The current allinclusive rate certainly is appreciated, and we would hope that in

this process none of that would be discontinued.

Another concern that the Secretary had, of course, was the extension of the 100 percent Federal Medical Assistance Percentage.

Tribal leaders agreed to delete this provision as well. The Centers

for Medicare and Medicaid Services requested that be done. The

States are very supportive of the 100 percent FMAP expansion.

Secretary Thompson’s concern was the cost of $2 billion over a 10-

year period.

A third area of his concern was the waiver of the Medicare late

enrollment penalty as far as Part B of Medicare is concerned and

the barriers that it may create as far as giving Indians the opportunity to enroll late as opposed to other enrollees within the Medicare programs. Tribal leaders reluctantly agreed to remove that

factor as well.

Finally, an area of concern that we had, and the Secretary objected to, was the fact that tribal leaders had asked for, and called

for, regulations in a negotiated rulemaking process. Our concerns

here were relative to the complexity of the Social Security Act and

to having to negotiate a rulemaking process. In response to this

concern again, tribal leaders eliminated the Social Security Act

changes from the bill’s negotiated rulemaking provision.

We believe the changes to the original tribal proposal submitted

in 1999 significantly reduces the bill’s Federal budget impact. S.

212, or its identical bill, S. 556, as it was scored in 2001, has a Federal budget impact of $6.9 billion. With the deletion of QIHP and

the FMAP, the score reflects a 70-percent decrease.

We request, and ask this committee, to submit a request to the

Congressional Budget Office to either score S. 556, without the

above-mentioned provisions, provide a fiscal budget impact on H.R.

2440.

It has been my pleasure to brief this committee on the concerns

that the National Indian Health Board has relative to the Indian

Health Care Improvement Act. As I have been involved, along with

other tribal leaders, including Chief Executive Officer Benjamin

and the other panelists here this morning, we will continue to stay

involved to make sure that this Act hopefully will be passed this

year.

Further, we request that any concerns regarding this legislation

are raised in a timely manner so that passage of the bill will occur

during this session and there are no delays that would jeopardize

the passage of this bill.

I thank you for your time. I would also ask that my written

statement be made part of the record of this hearing.

The CHAIRMAN. Without objection, so ordered.

[Prepared statement of Buford Rolin appears in appendix.]

The CHAIRMAN. Thank you, Mr. Rolin.

Ms. Munson.
352

STATEMENT OF MYRA M. MUNSON, ESQUIRE, SONOSKY,

CHAMBERS, SACHSE, MILLER & MUNSON, LLP, JUNEAU, AK

Ms. MUNSON. Thank you, Mr. Chairman.

The last time I had the privilege of testifying before this committee was in the late 1980’s when I was still commissioner of Health

and Social Services for the State of Alaska. Since joining the law

firm I am a member of now, I have had the opportunity to work

with tribal leaders and tribal health providers on every major

health reform initiative that has been discussed in the Congress,

and since 1998 when the work began on the reauthorization of the

Indian Health Care Improvement Act.

It is fundamental that the United States owes a duty to Indians

to provide them with health care. Everything flows from that. It is

equally fundamental in the decisionmaking that that health care,

in order to be delivered in a responsible way, must be culturally

competent.

That requires not merely that individual Indians have access to

health care, which most do not, at least in any way comparable to

that of other citizens of the United States and the States, but it

is important that the health care they have access to is that operated by their own tribes or the Indian Health Service, carried out

to the extent possible to Indian people, and managed by Indian

people.

Indian people and Indian tribes expected that the duty of the

United States would be satisfied by providing them with direct appropriations to the Indian Health Service and eventually down to

the tribes through the Self-Determination Act. Congress has not

been able to effect the appropriations necessary to meet any level

of health care for Indian people comparable to that, provided even

to Federal employees, let alone to other Americans.

Instead, in 1976 when the Health Care Improvement Act was

first authorized, Congress, realizing it could not meet the needs exclusively through direct appropriations, chose to authorize the Indian Health Service and tribes eventually as they took over the

programs to bill for certain services provided to Medicare or Medicaid eligible Indians, to bill those programs and recover those revenues.

That made a fundamental shift and one which has been very difficult for tribes and for their members to absorb. It essentially

made many Indians into welfare recipients when they had never

been before. It made them apply for benefits through the Medicaid

program in order to have access to the very care they had been

promised and for which they had ceded their lands.

However, time passes and Indian people and Indian tribal leaders are pragmatic. Indian Health Services had to be pragmatic

about this. The resistance to participating in those programs has

had to be overcome simply to make enough money available to try

to begin to provide for the needs for health care.

Tribes and the Indian Health Service have worked to become

competent billers of the Medicare and Medicaid programs and to be

able to participate without losing the integrity of the very special

programs that they offer.

The Indian health system is truly the only system of health care

that exists in the United States. For all the promise of managed
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care, somehow it would bring a preventative focus to care; it would

be a birth-to-death kind of model. In fact, it is as profit-driven as

all other health care in the United States and tends to focus on illness and not on health, on response and not on prevention.

The Indian health system is fundamentally different than that in

that it is truly a birth-to-death program. The people who are running health programs, and many of the programs that I work with,

were born in the hospitals that they now operate and that they

now run. Their children were born in those hospitals. They expect

their great-grandchildren to be born and cared for in a program

that they operate. That is not an expectation that those of us who

rely on the private sector health care system care enjoy. But to

make that real, of course, there must be adequate financing.

The Medicare and Medicaid programs are complex and not the

things that are typically are dealt with by this committee or the

Resources Committee in the House. They are relatively foreign.

You may have experienced this yourself, or you may have talked

with someone who has had to assist an elder parent in applying for

Medicare or making sense of their benefits, or assisted someone in

applying for Medicaid in order that they could be in a nursing

home or get other care that they need—these are difficult programs

to participate in.

In my written testimony, I have described very briefly the basics

of those programs. I think for those of you who are, in fact, familiar

with Indian people, and the way in which they live, when you read

about those programs, you will see the way in which they diverge.

However, the Medicare and Medicaid programs are rife with special exceptions. There is a tendency to believe that it is all one program and it exists in exactly the same way for everyone. Fundamentally not true. There are exceptions built in throughout

Medicare and Medicaid to assure that special populations will get

some level of care to guarantee their access, and that certain kinds

of providers will continue to exist even as the rates get cranked

down in those programs to manage the cost increases.

So there are federally-qualified health centers, rural health centers, and critical access hospitals, children’s hospitals, and cancer

treatment centers. The list goes on and on of various kinds of specific providers, each one of which, if you meet all the finely-tuned

rules, you get a special level of compensation under the program

different than applies to others.

Fundamentally, as we worked on trying to revise the MedicareMedicaid provisions and access by the Indian Health Service and

tribes, we kept that in mind. We recognized that the duty to provide health care to Indians is fundamental. The existence of the Indian Health Service and of tribal health programs is fundamental.

Medicaid and Medicare should recognize those special provider

types.

As Mr. Rolin said, the Steering Committee agreed, reluctantly, to

drop the qualified Indian Health Program as a new and special

provider type in order to try to move this bill forward. Instead,

what we have done is try to tailor very narrow provisions to other

parts of Medicaid where there are special compensation or reimbursement rules or Medicare to permit the kinds of activities that
354

are so essential on reservations and in Indian communities in

which health care is being provided.

For instance, there is a provision that allows visiting nurse services to be reimbursed, provided they are provided through a rural

health center in a setting which is a shortage area for home and

community-based care services. There are lots of rules attached to

that. We ask that the same kind of visiting nurse services be reimbursed when they are provided in any Indian Health Service program without having to go through becoming a rural health center

and proving you are in a shortage area. We know there are those

shortages.

I have provided for the committee comments on H.R. 2440 provisions. Those reflect the best drafting. I can say with some great humility, I wrote much of what is in S. 556 regarding the Social Security Act provisions and the title IV provisions. They were written

conceptually.

I could spend my lifetime and never penetrate to the depths of

the Social Security Act and get an amendment quite right. We

were blessed with the assistance of Representative Young to have

an opportunity to work with House Legislative Counsel who assisted us in turning our concepts into real Social Security Act

amendments. We encourage you to look at those and less at the S.

556 provisions.

There is a side-by-side analysis that has been provided to committee members so that you can track from S. 556 to the House bill

and understand what is left and how it has been redone. There is

also a section-by-section analysis which is attached to my testimony.

I want to mention basically six principles that drive the kinds of

amendments. They are first to improve access to Medicare and

Medicaid enrollment. It is not, as I mentioned earlier, a natural

thought for an Indian elder to seek to apply for Medicare. Many Indian elders are not eligible for Medicare. They are not eligible for

Social Security because they did not work in jobs that participate

in Social Security during their work years.

But for those who are, it is not natural for them to consider enrolling in part B and using up $700 a year of their limited income

to pay part B premiums. Applying for Medicaid is certainly not

something they think about even though they may be living in poverty—because they are used to caring for themselves. They expect

the Indian health programs to provide the health care they need.

Those programs are not accessible because people resist applying

and because in many States services and access by Indian people

to the programs operated by the State is not readily available.

Some of that is a matter of direct policy by States, of where they

locate their services, and some of it is because of the sheer remoteness of where Indian people live in relationship to State services.

Finding ways to involve tribes meaningfully in those activities is

an important feature of the act so that the rights of Indian people

to participate in those programs can be protected.

In addition, reducing co-payments, co-insurance, and deductible

obligations without reducing the reimbursement to the tribal or Indian Health Services program also helps to overcome the barrier to

access to those programs.
355

Second, and I have mentioned this before, Indian health programs should enjoy the same kind of special consideration in the

Social Security Act provisions that other kinds of health care programs, like federally-qualified health centers, or rural health centers, enjoy. You should not be taken in when somebody says, ‘‘Oh,

they are trying to create an exception.’’ There are a thousand exceptions.

The Social Security Act provisions on Medicare and Medicaid are

basically about two general rules. Everything else is an exception

to those rules. We are simply looking for some of the same kinds

of things. Nothing we have asked for is fundamentally different

than is available for some other kind of provider.

Third, we are looking to minimize administrative barriers. Mr.

Rolin spoke to the fact that currently most of the Indian health

programs are reimbursed on an encounter per-day rate. We look to

maintain that rate while a study of reimbursement is carried out

to ensure that any changes in those reimbursement methodologies

are carried out in a way that will minimize administrative burdens

and will control the costs of trying to build new billing systems,

and to respond to the administrative requirements of those programs.

Fourth, we want to encourage cooperation with the States. Medicaid is a partnership with States that cannot be effectively carried

out by tribes without a good relationship with the States. We look

for additional consultation on their part, and in some other provisions to find ways to improve the relationships.

Among those is to reduce the role of the States in licensing tribal

facilities and tribal providers so long as they meet the quality

standards imposed by the Social Security Act. It basically would

put the tribal providers in the same position that the Federal Indian Health Service providers are, vis-a-vis State regulation. We

look to try to achieve that more uniformly.

Finally, we want to improve communication by the formation of

a technical assistance group in which people like myself and Mim

Dixon, along with health care providers from tribal programs and

others can work on behalf of tribal leaders, and in direct interaction with CMS, to work through issues as they arise so that

when the Department of Health and Human Services is making

policy changes, they do so fully aware of the consequences of them.

What happens now all too often is that they make the change and

it is only months down the road that the impact of that change becomes apparent and we all scramble to find a way to fix it.

I join with the others in encouraging that this committee keep

this bill intact, that it endorse these provisions, and that it work

closely with other committees of the Senate and the House who

have jurisdiction over certain of these provisions relating to the Social Security Act to ensure that they will give those requests the

serious attention that they are due. It is easy to lose small changes.

In an environment in which you are trying to make changes as

massive as adopting Medicare prescription drugs, the very tiny nature of what we are asking for should not stop serious consideration of them.

Thank you very much. I would also ask that my written statement be made part of the record of this hearing.
356

The CHAIRMAN. Without objection, so ordered.

[Prepared statement of Ms. Munson appears in appendix.]

The CHAIRMAN. Thank you, Ms. Munson.

By the way, do not worry about not getting things right. We

work year-around here and if you could read our mail, we never get

things right. We just have to keep trying. That is why you never

get rid of us, I guess.

Before I go on, I did not know what Senator Murkowski’s schedule is, particularly since Ms. Munson is from Juneau.

Do you have any opening statement or comments before we go

on? I do not know if you have to leave.

Senator MURKOWSKI. Thank you, Mr. Chairman.

I will be leaving in about 15 minutes, but I did want to hear the

testimony of Ms. Munson and welcome her as a constituent. I also

want to welcome a former constituent, Ms. Dixon. I am looking forward to her testimony. I understand she is from Fairbanks, as I

am. We share a lot there.

I just wanted to listen to the comments this morning and thank

you, Mr. Chairman, for continuing on this very important issue of

the reauthorization of Indian health.

The CHAIRMAN. Thank you.

Ms. Dixon, please proceed.

STATEMENT OF MIM DIXON, DIXON & ASSOCIATES, BOULDER,

CO

Ms. DIXON. Thank you, Chairman Campbell and Senator Murkowski, tribal leaders, and honored guests today.

There has been a lot of talk recently about modernizing Medicare

and, in a way, the proposed Title IV of the Indian Health Care Improvement Act, and the proposed amendments to Medicaid, Medicare, and the Social Security Act, could be considering modernizing

Indian health care. As we know, this is not an appropriations bill

and it will not provide the funding to bring programs and facilities

up to standards.

So when I talk about modernizing Indian health care, I am not

talking about the delivery of services. Rather I am talking about

modernizing the legal and regulatory framework that allows the Indian health programs to bill Medicaid, SCHIP, Medicare, and private insurance, and to be paid for the covered services that are provided to mutual beneficiaries.

Title IV and the Social Security Act amendments are needed to

respond to changes that have occurred in health care delivery in

our country in the past decade. Just a few years ago there was no

Medicaid managed care. There was no SCHIP. There was no Medicare Part C or D or E. In most States, tribes have not been included in the planning for these changes in Medicaid, or to the development of SCHIP programs.

It is difficult for Indian health care to interface with the Medicaid, SCHIP and Medicare of today. Indian health programs are

unique in many ways that make it impossible for many Indian

health facilities and programs to meet the usual requirements to

become providers under managed care programs.

Yet the Indian Health Service beneficiaries who are enrolled in

managed care programs under their Medicaid and SCHIP pro-
357

grams will go off-plan to seek care at their Indian health care facility. It is essential that they have that unrestricted choice and that

the Indian health facility can bill and be paid for the services it

provides.

Provisions in the Indian Health Care Improvement Act also

allow tribes to take advantage of some of the opportunities provided by managed care. For example, they could use funds from the

Indian Health Serve as to purchase managed care plans or other

insurance programs for their beneficiaries. The measures would

also require States to allow Indian health providers to service case

managers for American Indian and Alaska Native Medicaid beneficiaries.

Despite the increasing reliance of Indian health programs on

third-party collections, many American Indians who are eligible for

Medicaid and SCHIP are not enrolled in those programs. To remedy this situation, this bill authorizes funding for tribes for outreach services. The bills would also eliminate financial barriers to

enrollment in Medicaid and SCHIP, such as premiums, deductibles,

and co-pays.

Many of the issues relating to Indian health care financing are

extremely complicated. Tribes have recognized that there is a need

for a national Tribal Technical Advisory Group to work closely with

CMS to resolve problems as they arise. To operate effectively, this

TTAG must be authorized in law. The TTAG will be essential for

helping to implement the provisions in Title IV of the Indian

Health Care Improvement Act, and for all the proposed changes in

Medicare under the proposed prescription drug legislation and proposed Medicaid reform.

In closing, it is important to remember the purpose of this legislation. At the heart of the provisions in title IV is enhancing access

to care for American Indians and Alaska Natives, protecting their

rights to choose their health care providers, and assuring that Indian health care facilities get paid when they provide services

under Medicaid, SCHIP, and Medicare to those beneficiaries.

I have submitted written testimony which provides greater detail

on these points. Thank you. I would also ask that my written statement be made part of the record of this hearing.

The CHAIRMAN. Without objection, so ordered.

[Prepared statement of Ms. Dixon appears in appendix.]

The CHAIRMAN. Thank you, Ms. Dixon.

Let me ask a couple of questions. Let me start with Ms. Benjamin. Thank you for being here.

I have been a big supporter, as you know, for years of self-governance. It seems to me that the tribes, if they have the capability,

should be offered that opportunity. In most cases they do a better

job than the Federal Government could have done.

But with that in mind, I guess there are some things that probably ought to remain with the Agency. Let me just ask you a couple

of things on that. With that thought in mind, what is your view

on Secretarial oversight for the tribal direct billing program?

Ms. BENJAMIN. That’s a hard question.

The CHAIRMAN. Yes; I know. That is why I asked you. [Laughter.]
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Do you think tribes could do that better than can be done

through the Agency?

Ms. BENJAMIN. We know what our need is for our membership.

I think we can address the health disparity issues better than an

outside entity doing that. So I would support that tribes would

have that authority to do that.

The CHAIRMAN. Your testimony also includes a concern that

tribes are usually not consulted in the design of the State Medicaid

programs. It is not unusual, unfortunately. We hear that very often

here in the committee that there is a lack of good in-depth consulting with the tribes before decisions are made.

How do we encourage tribal State collaboration in the design of

health insurance programs so that they are inclusive of Indian people’s needs?

Ms. BENJAMIN. I guess I can look at our example. Currently what

we have for our membership is called a ‘‘Circle of Health.’’ We provide some health care opportunities for all of our members, regardless of where they live in the United States. There is a process that

they have to go through, of course. Our goal is to make sure that

people that may not live on the reservation, that live in different

States, and do not have access, that we are providing a service to

them as well.

The CHAIRMAN. Do you do that through the mail? Do you offer

advice, say, of 500 miles away and cannot get home to the clinic?

Ms. BENJAMIN. We send them applications where they would be

able to get some insurance in their State. We help pay the premiums for that, to get that done. We want to make sure that our

membership is not forgotten, if they live elsewhere beside the reservation.

The CHAIRMAN. That is a great idea. Has that been pretty successful?

Ms. BENJAMIN. It is successful. We still have a lot of folks that

still have not utilized that program. We are continuously trying to

educate them and the opportunities through our mailings or newsletters. We also make sure that they know what services are available.

Also, what we are doing with the State of Minnesota is that we

try to partner in any way we can. Currently we have some discussions with the TANF program to provide services for Indian people

in the Minneapolis-St. Paul area. We also feel that we can show

more compassion to Indian people, to our own tribal members or

whoever, to get them to become more self-sufficient because of our

cultural backgrounds. We can relate to some of those issues, we

feel, in a better way than the State or county agencies that are out

there.

Those are two examples of what we are trying to do. We want

to provide a system that we can hopefully improve lives for membership of our own tribe and other Indian people, even though they

do not live directly on the reservation.

The CHAIRMAN. You mentioned that your tribe has difficulty collecting third-party reimbursements, and the little you do collect

often goes to meeting health care needs of your tribal members.

What are the most serious impediments to preventing the tribe

from collecting third-party reimbursements?
359

Ms. BENJAMIN. I would like to refer that question to Samuel

Moose, the Commissioner of Health and Human Services because

he administers that. Can you assist me, Sam?

Mr. MOOSE. We are always negotiating with the State and

through our State liaison some opportunities within the various

programs. Some of the difficulties that we run into is that the State

delegates some of that authority to the local county agencies where

they were negotiating those rates and opportunities. We have had

difficulties in the past.

The CHAIRMAN. Do they just refuse to negotiate? Do they drag

their feet?

Mr. MOOSE. Yes; they drag their feet. Some of them come to the

table. We really do not make any progress with the issues. There

is always a history. There is always something that comes up that

somehow creates barrier.

The CHAIRMAN. It is called jumping through hoops.

Mr. MOOSE. Yes.

The CHAIRMAN. It is not uncommon, I guess.

Vice Chairman Rolin, you have put a number of years of dedication to improving the health of Indian people. I want to commend

you for that. You have been in here a number of times testifying

on their behalf. I thank you for that.

On the Federal medical assistance percentage, I understand that

the National Steering Committee decided to remove the 100 percent FMAP expansion provision in S. 556 in response to the Administration’s concern that it would be too costly; is that correct?

Mr. ROLIN. That is correct.

The CHAIRMAN. What cost estimates were included in that decision?

Mr. ROLIN. Myra might be able to answer that. She has handled

that technical portion.

The CHAIRMAN. We call that passing the buck around here,

Myra. Go ahead. [Laughter.]

Mr. ROLIN. That has been her area of expertise.

Ms. MUNSON. If Congress would pass the buck, we would have

no problems here. [Laughter.]

The CHAIRMAN. Bucks, plural.

Ms. MUNSON. Many, many bucks. The truth is we really do not

know. What we do know is that they came up with an estimate of

$2.48 billion for the 100 percent FMAP. We believe that that is a

substantial over-estimate of increased costs since we believe that

States that currently claiming 100 percent FMAP for a wide variety of activities that they believe, and I think correctly, are already

authorized as ‘‘through the facility.’’

A significant amount of the FMAP issue arises out of the difference of interpretation of that phrase, ‘‘through the facility,’’ with

tribal health programs and the States interpreting it to mean not

only the things provided in the building, but things which may be

referred out that have to be purchased from other providers. They

should also be entitled to that 100 percent FMAP. We think that

CBO has over-estimated the number, but we do not have the benefit of having any details so we cannot tell you exactly in what

ways.

The CHAIRMAN. I see.
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Mr. ROLIN. Senator, if I might add, you noted in my testimony

also the States support that. They believe this would be a direct

support as far as funding for tribes. They have been most supportive in that aspect.

The CHAIRMAN. We often hear that States deny health care to Indian people by saying it is a Federal responsibility. Is the NSC

aware of cases where States have refused public health insurance

coverage for eligible Indian people because of that concept?

Mr. ROLIN. I do not know of any. Ms. Dixon, are you familiar

with any? I am not aware of any. I know my State has not.

The CHAIRMAN. Ms. Dixon.

Ms. DIXON. I think it is a matter of degree. It is not as black and

white as that. I think that there is a higher level of cooperation

with the State looking for ways to enhance and support the Indian

health system when there is 100 percent FMAP and they are not

trying to conserve State funds and they realize that the Federal are

there.

For those services where there is not 100 percent FMAP, Medicaid directors tend to take the most conservative approach in terms

of allowing tribes to carry out their mission with Medicaid funding.

The CHAIRMAN. Okay.

Ms. Munson.

Ms. MUNSON. If I could, Mr. Chairman, I think the denial plays

out in one other way. I think any Indian person who gets their application in and manages to fill it out completely will be granted

their eligibility if they satisfy all the conditions. The trick is: Will

they ever get the application? Will they understand it? Will they

get it completed? Will they meet the deadlines for personal interviews or whatever other hoops they may have to jump through to

get it considered? Will, in fact, it be returned to them because there

is something missing? Will they have had difficulty getting access?

We believe, and there is pretty good demonstrated evidence of

this, that even in States that cooperate, Indian people are substantially under-represented in the Medicaid rolls compared to the level

of poverty in Indian country. We think there are many barriers;

most of them subtle.

The CHAIRMAN. Including educational problems. Sometimes Indian people do not have the educational opportunities and when

they have to fill out some of these complicated Federal or State

forms, they are already at a disadvantage.

Ms. MUNSON. Absolutely.

The CHAIRMAN. Ms. Dixon, we are dealing with managed care.

You hear it all the time here in Congress, as you probably know.

It seems to be the new rage. It seems to be the way we are going.

But we do get some feedback that one size does not fit all, particularly in the difference between rural America and urban America.

But I think also that might apply to the problems that many Indian people face, and that is cultural differences.

What are your recommendations to try to improve the health

care system from a culturally-sensitive aspect for Indian people?

Ms. DIXON. That is a really good question. First, let me say that

in essence the Indian health system is a culturally-sensitive managed care system. The issue is not so much the cultural sensitivity

within the Indian health system, it is forcing Indian people to en-
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roll in managed care plans that are operated by the State under

Medicaid. And now with the revisions to Medicare that we are talking about, that is a potential there as well. It has not been so much

Medicare up to now, as Medicaid.

Then forcing them to enroll in a Medicaid managed care plan for

which the Indian Health System is not a provider. Then they are

into a health care system that is off the reservation, or outside

their communities, where people have little knowledge of the culture, where there are not people who speak the language, where

people do not understand the living conditions. Often times facilities are very hard to access because they are far away. They are

defaulted to a facility that might require a great deal of transportation to get there. They do not have the vehicles and the transportation.

What we have recommended—and what tribes have been recommending ever since the National Indian Health Board did its

study of the nine State Medicaid programs that have gone into

managed care, that had a significant Indian population in those

States—is that Indian people be exempted from mandatory enrollment, that States keep a carve-out for Indian health that is paid

for on a ‘‘fee-for-service.’’ We call it ‘‘fee- for-service,’’ but it really

is not. It is called the ‘‘encounter rate’’ or the ‘‘all-inclusive rate.’’

Sometimes it is the ‘‘OMB rate’’ or the ‘‘IHS rate.’’ It is not exactly

‘‘fee-for-service,’’ but it is not the capitated managed care payment.

Also, Indian people should be allowed to go to their local Indian

facility, if that is what they choose. If they choose to use another

facility under Medicaid, they should be allowed to do that as well.

But they should not be penalized, and the Indian health facility

should not be penalized if a Medicaid recipient chooses to use their

local tribal or Indian health care facility.

The CHAIRMAN. I agree.

Ms. Benjamin.

Ms. BENJAMIN. I wanted to comment on the cultural sensitive

way of how some of our people deal with the providers. Many of

our elders’ first language would be Ojibwe. There is that communication barrier sometimes with the providers.

What we provide is traditional healers. They then have a comfort

level dealing with someone that can speak and understand their

language. Our issue with the traditional healers is that they are

not recognized. We are not included in the billing process when we

use traditional healing for our membership.

The CHAIRMAN. I think some other tribes have had quite a bit

success with that, too. I think the Navajos do that, not only with

working with the State for health care but such as surgery, for instance. I understand that they have spiritual leaders that understand the traditional healing ways of the Navajos who work with

the doctors. I think that is a terrific idea.

I have often wondered if it creates a liability issue or what is

sometimes called the unintended consequences of doing something.

I wonder if there is something in there that comes around to haunt

you later on why you try to do that. But it seems to me it is the

only way to go, particularly for traditional people. That comfort

level goes up considerably if they know there is a spiritual attachment to healing.
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Mr. Rolin.

Mr. ROLIN. Senator, I have just one more comment regarding the

FMAP. I noticed in the most recent Senate prescription bill that

Native Hawaiian providers were included. However, our providers

were left out. Certainly that is a concern we have as well. We

wanted to share that with you.

The CHAIRMAN. Thank you for bringing that to my attention. I

did not know that. I will make sure that we look into that and find

out why.

Mr. ROLIN. Thank you.

The CHAIRMAN. I have no further questions that I will ask today.

I will put some in writing to you. We have many members who are

not here today. They will be submitting questions in writing, too.

We would appreciate your getting those back to us.

Without objection, so ordered.

We will keep the hearing open for 2 weeks for any additional testimony or letters from anyone in the audience or from our panelists.

I thank you for appearing today.

This committee is adjourned.

[Whereupon, at 11:17 a.m., the committee was adjourned, to reconvene at the call of the Chair.]
(363)

APPENDIX

ADDITIONAL MATERIAL SUBMITTED FOR THE RECORD

PREPARED STATEMENT OF MELANIE BENJAMIN, CHIEF EXECUTIVE, MILLE LACS BAND

OF OJIBWE

Chairman Campbell, Vice Chairman Inouye and distinguished members of the

Senate Committee on Indian Affairs, my name is Melanie Benjamin and I am the

chief executive of the Mille Lacs Band of Ojibwe. The Mille Lacs Band is a federally

recognized tribe of 3,570 members located in East Central Minnesota. We operate

three clinics in three Mille Lacs Band districts on our reservation and serve a user

population of several thousand.

Three topics will be discussed as they relate to Medicaid and Medicare under Title

IV of the Indian Health Care Improvement Act: Sovereignty, the Federal trust responsibility and the health disparities that exist between Indians and the rest of

the American population. The access to health services under title IV have a direct

connection to the health disparities in Indian country and must be addressed by the

Congress. Following the general discussion of the three topics under Medicaid and

Medicare will be the Mille Lacs Band recommendation of the establishment of a

Tribal Leaders Group and Tribal Technical Advisory Group specific to the Centers

for Medicare and Medicaid Services and their work with the Indian Health Service

[IHS]. The statement concludes with one final issue of concern to the Mille Lacs

Band: the Department of Health and Human Services’ ‘‘One’’ HHS Initiative.

When the Indian Health Care Improvement Act was first enacted in 1976, Congress recognized its trust responsibility toward the tribes to provide adequate health

care. Throughout the subsequent amendments and reauthorizations of the Act, one

of the major underlying policies has been to provide tribes access to other Federal

health care sources like Medicare and Medicaid programs. These programs have unlimited funding, as opposed to Indian Health Service programs that have funding

limits each year. The intent was and is to improve our health status through that

access. Since then Medicare and Medicaid reimbursements to tribes, including the

Mille Lacs Band, have become a significant source of revenue for our health care

programs and operations.

Over the last 15 years, the Mille Lacs Band of Ojibwe has actively participated

in the formulation of Tribal Self-Governance policy. We take pride in being one of

the first ten Self-Governance tribes. We participated in the original demonstration

project and the 1 writing of the permanent Acts for BIA and IHS Self-Governance.

The Mille Lacs Band has also been on the rulemaking committees for the implementation of Self-Governance laws. Presently, the Mille Lacs Band of Ojibwe is an active member with the Tribal Self-Governance Advisory Committee that advises Federal agencies on Indian policy matters affecting the Self-Governance tribes.

The Mille Lacs Band has supported and advocated for Self-Governance laws because our philosophy is that we should be free to govern ourselves and develop our

own policies in the administration of our tribal programs. To us, this is an important exercise of sovereignty. In that exercise of sovereignty, we should not be entangled by a Federal or State bureaucracy.
364

There are three principles that the Mille Lacs Band of Ojibwe considers when

analyzing Federal programs. First, we assert that our primary relationship is with

the Federal Government. This tribal-Federal relationship has been established

through treaties with the United States, Executive orders, Federal statutes and numerous court decisions recognizing the same. Second, we retain all sovereignty not

expressly taken away, and therefore we should have the ability to control funds reserved for us under Federal law. Third, we should have equal access to the same

funding avenues as States. This third principle raises the fundamental flaw of the

Medicaid and Medicare programs.

It is the Band’s understanding that the design of the Medicaid and Medicare programs is a Federal—State collaboration. The problem is that tribes do not fit into

the picture at all and this design flaw makes it very difficult to meet the criteria

for receiving reimbursements. An example is that counties receive an administrative

match from the state for their administrative costs while tribes cannot. According

to the Mille Lacs Band of Ojibwe Commissioner of Health and Human Services, our

inability to recover the administrative match demonstrates that tribes do not have

equal access to Medicaid and Medicare reimbursements. The reason is that States

determine how their block grants will be distributed under their own guidelines. As

a result, the Mille Lacs Band and many other tribes lose out on potential and critical avenues of funding we desperately need because Federal funding through the

Indian health service. Others on this panel have addressed this and other legal barriers more specifically, but from a tribal leader perspective it is clear that states and

managed care systems have predominance over tribes under Medicaid and Medicare. Clearly, the establishment of the Medicaid and Medicare entitlement programs

happened at a time in history when the Congress did not focus on tribal sovereignty.

Presently tribes are treated as governments in Federal legislation and tribal sovereignty is recognized. Indian people are provided direct access to Federal programs

and funding. The Mille Lacs Band of Ojibwe receives direct funding through our

Self-Governance Indian Health Service and Bureau of Indian Affairs Annual Funding Agreements. But when it comes to Medicaid and Medicare programs, it is a different situation. It is time to change the Medicaid and Medicare provisions under

Title IV of the Indian Health Care Improvement Act to reflect the new enlightened

view of tribal sovereignty and provide tribes more access to health care services as

the Act was originally intended.

Through our treaties, Federal statutes, Executive orders and court decisions, a

Federal trust responsibility has been established and recognized over the course of

dealings with tribes. The Mille Lacs Band of Ojibwe signed several treaties with the

United States, and the provision of proper health care became an expectation of the

Band and an obligation of the Federal Government. In addition, the Snyder Act of

1921, the Transfer Act of 1954, the Self-Determination Act of 1975, the Indian

Health Care Improvement Act of 1976, as well as the enactment of the IHS SelfGovernance Act, all evidence the trust obligations that flow to the tribes from the

Federal Government for the provision of health care.

In spite of the clear legal duty created by these Federal statutes, the Federal obligation to provide adequate health care to tribes has never been properly funded.

Historically, this insufficient funding has interfered with our ability to provide comprehensive health care to Mille Lacs Band members. According to IRS estimates,

the Mille Lacs Band and all other tribes in the Bemidji are funded at approximately

30 percent of need. This means more than two-thirds of our need is not being met

and explains why the status of Indian health on the Mille Lacs Band Reservation

and almost all other tribal reservations is so poor. We are told that the Federal Government spends nearly twice as much for a prisoner’s health care than it does for

Indians. This fact is an example of why our health status is at the bottom of every

disease category.

It seems ironic that Indian health care through the IHS is not an entitlement for

Indian people when tribes essentially pre-paid for our health care by ceding millions

of acres of land to the Federal Government. It seems even more ironic that tribes

have problems accessing the Federal entitlement programs like Medicaid and Medicare which were designed for all state citizens. This funding disparity becomes a

matter of fairness and equity because Indian people are also citizens of the States

in which we reside. It is only logical that we should have the same access to the

same services as do other non-Indian citizens.

Given that we have been historically under funded for our health care needs and

that tribes likely will not receive funding for the level of need in the next appropriations cycle, the Federal trust responsibility needs to be taken seriously and changes

made to allow tribes full participation in the existing entitlement programs of Medicaid and Medicare. It is fair and it is right.
365

It has been more than 25 years ago since the Indian Health Care Improvement

Act was enacted. The primary purpose of the legislation was to improve the health

status of Indians to a level comparable with the general U.S. population. While

strides have certainly been made in the delivery of Indian health care in that time,

there continue to be health disparities in Indian country that are recited time and

time again. The numbers change slightly, but one constant is that Indians rank

highest in nearly every category of disease incidence than the general American

population. It is plain and simple that Indian health status is not improving and

something must be done.

On the Mille Lacs Band Reservation, diabetes is a very serious problem. There

is not one family without diabetes among one of their family members. For many

of our Band members, it is not a matter of if they get the disease, but when. Band

members are losing their vision due to glaucoma complications, they are losing their

limbs because of circulatory problems and many are close to requiring kidney dialysis treatments. This chronic disease affects our members’ quality of life and it affects the lives of their family members.

More alarming is that diabetes and other long-term chronic health conditions are

now occurring in our children and our youth. We have serious concerns for their

long-term health and longevity. Our children and youth are our future and we must

aggressively confront these health problems to preserve our tribal communities.

There are no answers but it is clear that adequate and comprehensive Indian health

care is a critical part of the solution.

The ability to provide comprehensive health care on our reservations is paramount because frequently our members will use only our tribal health facilities. The

Mille Lacs Band is located in a rural area and other health care facilities are long

distances. Our three clinics attempt to provide the health care our members need,

but resources are quickly used and we make every effort to access outside funding

through Medicaid and Medicare reimbursements within the limitations of existing

law. More often than not, our efforts cannot meet our needs. We are fighting to protect the lives and health of our members on our reservations and in our communities. If Congress makes the necessary changes to Title IV of the Indian Health

Care Improvement Act and provides more access to Federal health care services and

funds, it will at least give us another weapon in this war on health disparities.

Under Executive Order Number 113175, the Tribal Consultation Policy, the Indian Health Service frequently solicits tribal input on health care matters that affect Indian country. The same cannot be said for other agencies within the Federal

Department of Health and Human Services. Two examples that demonstrate the

lack of tribal consultation are the proposed Medicaid and Medicare Reform that will

affect tribal health care programs throughout Indian country.

The Department of Health and Human Services and the Mille Lacs Band of

Ojibwe, along with the other federally recognized tribes throughout the United

States, share the common goal of providing accessible and culturally-appropriate

health care that we believe is best achieved by working together at the earliest

stages of policy development and certainly prior to implementation. The Mille Lacs

Band of Ojibwe endorses and supports the Secretarial appointment of a Tribal Leaders Group [TLG] that would provide policy guidance throughout the Department of

Health and Human Services. The Mille Lacs Band also endorses and supports the

Tribal Technical Advisory Group [TTAG] that would provide technical expertise on

complicated Indian policy matters and issues specifically to the Centers for Medicare

and Medicaid Services.

The Tribal Leaders Group has been sanctioned by the National Indian Health

Board, the National Congress of American Indians and the Tribal Self-Governance

Advisory Committee, and would be comprised of tribal leadership from each of the

Indian Health Service areas. These three organizations are recognized by the Federal Government and the agencies that handle Indian affairs, but on many occasions

Indian policy is overlooked by lawmakers and policymakers during the process of

policy development. The Tribal Leaders Group would provide important policy recommendations to the Department of Health and Human Services on proposed initiatives that affect health care delivery throughout Indian Country, which in turn furthers the government-to-government relationship that fulfills the objectives of the

tribal consultation policy.

On a more specific level, the Tribal Technical Advisory Group [TTAG] would provide the technical expertise and knowledge to the Centers for Medicare and Medicaid Services that is required when dealing with complex issues like Medicaid and

Medicare Reform. The TTAG is also sanctioned by the National Indian Health

Board, the National Congress of American Indians and the Tribal Self-Governance

Advisory Committee. The Centers for Medicare and Medicaid Services has drafted

a charter for the TTAG that provides representation from the three national Indian
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organizations identified above; however, the Mille Lacs Band and the TTAG believe

that the Group should also require the participation of at least three technical advisers that are familiar with health care financing and administration and how proposed changes will affect Indian country.

Through the Secretarial appointment of the Tribal Leaders Group and the Tribal

Technical Advisory Group, tribal involvement from the earliest stages of policy development will ensure that Indian issues will be adequately addressed. Involvement

and consultation also furthers the government-to-government relationship that the

Mille Lacs Band of Ojibwe believes is part of the Federal trust responsibility to

tribes.

The Mille Lacs Band of Ojibwe has a number of concerns with the Secretary of

the Department of Health and Human Services’ One HHS Initiative. First, the Initiative has not involved tribal consultation and that lack of consultation undermines

the government-to-government relationship that tribes enjoy with the Federal Government. One of the underlying policies of Executive Order Number 13175 was and

is to involve tribes at the policymaking level and work with decisionmakers to enhance the government-to-government relationship. The Mille Lacs Band of Ojibwe

and other tribes want to be involved and consulted on health and human service

policy matters that affect Indian country because we know best what our tribal communities need and can provide that knowledge to HHS officials.

Second, tribes’ unique status as sovereign governments who are federally-recognized political entities is overlooked by the One HHS initiative. As a federally-recognized tribe, the Mille Lacs Band of Ojibwe is a sovereign government that has a

government-to-government relationship with the Federal Government and its agencies. Our Self-Governance compacts are an expression of that relationship. As political entities recognized by the Federal Government, the Mille Lacs Band and other

tribes cannot be treated as simply another racial minority group. The U.S. Constitution, our Treaties, Presidential Executive orders, and Federal statutes and court decisions all affirm our political status as sovereign governments that are distinctly

separate from all other racial and minority groups. By engaging in tribal consultation, Federal agencies will support tribes’ government-to-government relationship

expressed in the above mentioned instruments.

Third, implementation of the One HHS Initiative is a departmental reorganization that fails to recognize the Indian Health Services’ unique responsibility to Indian tribes. The restructuring of the HHS does not acknowledge the unique relationship between the Indian Health Service and the federally-recognized tribes. By incorporating Indian health care into public health and minority health programs, the

Indian Health Service may lose its ability to provide direct medical services to tribes

and eventually may see the loss of programs designed specifically for tribes. Inherent in the restructuring is an alteration of the Federal trust responsibility. Indian

Health Service exists to fulfill the Federal trust responsibility of providing health

care to tribes across the United States and attempting to improve the health status

in Indian country. Removing that trust responsibility runs counter to the very purpose of the Indian Health Care Improvement Act.

The Mille Lacs Band of Ojibwe recognizes that improvements have been made in

the delivery of health and human services since the enactment of the Indian Health

Care Improvement Act in 1976. However, we still have significant health disparities

in our communities that have not seen improvement. This tells us there must be

greater efforts to address Indian health disparities. Those efforts must involve tribal

consultation and coordinated discussions for any result to be obtained. It is not too

late to engage tribes and begin working together to move forward and improve Indian health disparities.

Miigwech.

PREPARED STATEMENT OF BUFORD ROLIN, VICE CHAIRMAN, POARCH CREEK OF

INDIANS

Chairman Campbell, Vice Chairman Inouye, and distinguished members of the

Senate Indian Affairs Committee, I am Buford Rolin, member at large of the National Indian Health Board. I am an elected official of the Poarch Creek Band of

Indians, serving as vice chairman. On behalf of the National Indian Health Board,

it is an honor and pleasure to offer my testimony this morning on the Reauthorization of the Indian Health Care Improvement Act.

The NIHB serves nearly all federally recognized American Indian and Alaska Native (AI/AN) tribal governments in advocating for the improvement of health care

delivery to American Indians and Alaska Natives. We strive to advance the level

of health care and the adequacy of funding for health services that are operated by
367

the Indian Health Service, programs operated directly by Tribal Governments, and

other programs. Our Board Members represent each of the 12 areas of IHS and are

elected at-large by the respective Tribal Governmental Officials within their regional area.

I would first like to commend the witnesses that testified before me this morning,

Mim Dixon and Myra Munson, for their tireless work and expertise on American

Indian and Alaska Native issues related to Medicare, Medicaid and the Children’s

Health Insurance Program. I am also much honored to testify this morning alongside Chief Executive Melanie Benjamin of the Mille Lacs Band of Ojibwe.

Given the two previous hearings the committee has held on the Indian Health

Care Improvement Act during the 108th Congress, I’m going to be brief this morning. I realize the members are quite aware of the need and purpose of the reauthorization; therefore I would like to focus on the efforts of tribal leaders to craft legislation that addresses previous concerns raised by the Administration and responds to

the current political realities facing Congress.

The National Steering Committee [NSC] was formed by the Indian Health Service

in 1999 to develop and submit recommendations for changes to the Indian Health

Care Improvement Act. The NSC is comprised of elected tribal representatives

throughout Indian country, and also includes urban health program representation.

The NSC is currently cochaired by Julia Davis-Wheeler, NIHB Chair, and Rachel

Joseph of the Lone Pine Paiute Shoshone Tribe.

Over the last several years, the NSC has worked closely with Indian country, the

Administration, Congress, and the Indian Health Service to develop amendments to

the Indian Health Care Improvement Act. Indian country has proceeded through

this process in a spirit of cooperation and negotiation and the language has gone

through several changes.

At the request of Tribal leaders, the Centers for Medicare and Medicaid Services

[CMS] established the Tribal Technical Advisory Group (TTAG) to advise CMS on

Medicare, Medicaid, and Children’s Health Insurance (CHIP) policy issues related

to American Indians and Alaska Natives. The TTAG was formed in 2001 and consists of Tribal leaders, Area Indian Health Boards, and designated national Tribal

organizations, including the National Indian Health Board. The activities of the

TTAG are coordinated primarily through the Intergovernmental and Tribal Affairs

Office within CMS.

The TTAG has forwarded several recommendations to Congress and CMS regarding recommended changes to the reimbursement methodologies in place for the Indian Health Service, Tribal health programs, and Urban Indian programs. The

TTAG is adamant in its position that any reform or changes in the Medicare, Medicaid, or CHIP programs must allow for Tribal allocation or other direct funding

mechanisms that authorize Indian health programs access to Centers for Medicare

& Medicaid Services (CMS) program funding.

The TTAG has worked closely with the National Steering Committee to develop

the changes to Title IV of the Indian Health Care Improvement Act that are reflected in H.R. 2440, which are the most recent NSC recommendations.

As the committee is well aware, funding for the Indian Health Service lags far

behind other segments of the population and has failed to keep pace with population

increases and inflation. Current Indian Health Service funding is so inadequate that

less than 60 percent of the health care needs of American Indians and Alaska Natives are being met. In order to address the need for additional health care resources, Title IV of the Indian Health Care Improvement Act addresses access to

Medicare, Medicaid and other third party reimbursements. It is one of the most important provisions of the Indian Health Care Improvement Act as it makes IHS hospitals eligible for Medicare reimbursements, and also makes IHS facilities eligible

for Medicaid reimbursements. Title IV makes it possible for Medicare and Medicaid

eligible American Indians and Alaska Natives to utilize these benefits.

Since the passage of the Health Care Improvement Act in 1976, Medicare and

Medicaid payments have become vital sources of revenue for basic tribal hospital

and clinic operations. In fiscal year 2002 alone, IHS and tribally operated hospitals

and clinics collected $460 million for services provided to Indian people enrolled in

these programs. This amount enhances the resources available for the IHS hospitals

and health clinics budget by nearly 30 percent.

In order to further improve the ability of Indian Country health providers to access third party resources, the NSC developed several changes to Title IV that were

included in S. 212 introduced during the 107th Congress. When asked to respond

to the language contained in S. 212, several concerns were raised by Health and

Human Services Secretary Tommy G. Thompson regarding the proposed changes to

title IV. The concerns were primarily related to costs. I would like to note that S.
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556 introduced during this Congress is identical to S. 212 and therefore many of

the concerns raised in regards to S. 212 remain.

In response to those concerns, the National Steering Committee revised their recommendations for the reauthorization and those changes are reflected in H.R. 2440,

which was introduced on June 11, 2003. I think it was,quite helpful to hold the joint

Senate Committee on Indian Affairs and House Resources Committee hearing on

the IHCIA last week as it illustrates the efforts of both houses to pass a bill this

session. Although the bill was introduced in the House, it was developed with input

and involvement from both Senate and House members and staff.

H.R. 2440 reflects several changes made to the original tribal proposal prepared

in 1999 by the National Steering Committee (NSC). The legislation includes revisions to the 1999 proposal in response to the Secretary Thompson’s concerns. Some

of the major changes of the revised Tribal recommendations made ii?- H.R. 2440

that respond to the Administration’s concerns about S. 212.

Qualified Indian Health Program [QIHP]. This provision has been removed.

The NSC designed QIHP as a new provider type through which Indian health programs and urban Indian health programs could more fully exercise their statutory

authority to receive payments under Medicare, Medicaid and SCHIP. Secretary

Thompson expressed concern that QIHP was complex and would be administratively

burdensome. Tribal leaders acknowledged that the CBO score of this provision—in

excess of $3 billion over 10 years—could be a barrier to Congressional acceptance

of QIHP and therefore removed it.

In place of the QIHP proposal, Tribal leaders seek a comprehensive study by the

Department of Health and Human Services [DHHS] of reimbursement methodologies of Medicare and Medicaid for the Indian Health Service [IHS], Tribal health

programs, and health programs of urban Indian organizations. The new provision

found in H.R. 2440 directs the Secretary to perform such a study and report the

findings to Congress. The Secretary is to examine whether payment amounts under

current methodologies are sufficient to assure access to care and whether these

methodologies should be revised consistent with those applicable to the ‘‘most favored’’ providers under the Social Security Act. The current ‘‘all-inclusive’’ rate system through which IHS and tribal hospitals and some clinics now receive Medicare

and Medicaid reimbursements would remain in place until the Secretary’s recommendations are reported to Congress and Congress decides whether to make any

changes.

Extension of 100 percent Federal Medical Assistance Percentage [FMAP].

Tribal leaders also agreed to delete a provision that would have extended the 100

percent FMAP to services provided to Medicaid eligible Indians referred by IHS or

tribal programs to outside providers, such as referrals made through the contract

health services program. Under current interpretation of the Centers for Medicare

and Medicaid Services [CMS], the 100 percent FMAP is made available to States

only for reimbursements for services provided directly in an IHS or tribal facility,

even though the only reason the patient required care outside the IHS or tribal facility was that the facility could not directly provide the service and had to rely on

an outside provider.

While State governments are very supportive of the 100 percent FMAP expansion,

DHHS objected that its cost was too high—more than $2 billion over 10 years—and

that its financial benefits would flow only to the States, not to Indian health programs and their Indian beneficiaries. While the NSC disagrees with the Department’s interpretation of the statute and their conclusions about the effect of the proposed amendment, we agreed to delete the provision from the IHCIA.

Waiver of Medicare Late Enrollment Penalty. The 1999 tribal proposal—and

S. 212 and S. 556—sought to waive the premium penalty for any Medicare-eligible

Indian who did not timely enroll in Medicare Part B because of a number of barriers. The DHHS strongly objected to this provision as it would treat Indians differently than other Medicare-eligible persons who do not timely enroll. The DHHS

asserts that the penalty is needed to encourage eligible persons to enroll and begin

paying Part B premiums when they first become eligible, rather than waiting until

they become ill and need to use their Medicare coverage. Tribal leaders also agreed,

reluctantly, to delete this provision.

Regulations. Secretary Thompson objected to the tribal leaders’ call for all regulations—including Social Security Act regulations affecting Indian health providers—to be prepared through Negotiated Rulemaking with tribal representatives. He

asserted that the large number and complexity of Social Security Act regulations

makes negotiated rulemaking unfeasible. In response to this concern, tribal leaders

eliminated Social Security Act changes from the bill’s negotiated rulemaking provision.
369

We believe the changes to the original tribal proposal submitted in 1999 significantly reduce the bill’s Federal budget impact. S. 212 [identical to S. 556] was

scored in 2001 as having a Federal budget impact of $6.9 billion over 10 years. Deletion of the QIHP and the 100 percent FMAP provisions together reduce the bill’s

score by about 70 percent. We ask that the committee submit a request to the Congressional Budget Office to either score S. 556 without the above mentioned provisions, or provide a fiscal budget impact on H.R. 2440.

Conclusion. On behalf of the National Indian Health Board, I would like to

thank the committee for its consideration of my testimony and for your diligence in

making the health of American Indian and Alaska Native people a high priority of

the 108th Congress. I have been involved with the National Steering Committee

since its inception in 1999 and have seen the hard work and compromises that the

tribal leaders have made. Tribal leaders have come to the table to work out the

more contentious provisions and we urge the committee to act swiftly on this important piece of legislation. Further, we request that any concerns regarding this legislation are raised in a timely manner so that passage of this bill during this session

is not jeopardized.

BUFORD ROLIN, MEMBER AT LARGE, NATIONAL INDIAN HEALTH BOARD, RESPONSES

TO QUESTIONS

On behalf of the National Indian Health Board [NIHB], a non-profit organization

established in 1972 to serve nearly 558 federally recognized tribal governments in

advocating for the improvement of health care delivery for American Indians and

Alaska Natives, I am pleased to respond to your letter dated August 1, 2003 regarding my recent testimony on S. 556, the Indian Health Care Improvement Act Reauthorization.

No. 1. Federal Medical Assistance Program [FMAP]. There appears to be

a concern that a 100-percent FMAP provision is too costly.

Question A—What is the purpose of the 100 percent FMAP and what are

the cost estimates used to determine the provision was too costly?

Response. The discussion of the 100 percent FMAP provision, section 212 of S.

556, has become quite complicated. The National Steering Committee [NSC] endorses passage of a provision of law that will clarify the intent of Congress and require full implementation of what we, and many states, believe is existing law. We

are hopeful that the 100 percent FMAP provision will compel the Centers for Medicare and Medicaid Services [CMS] to do what we think it should already do.

After the Congressional Budget Office [CBO] issued its score on the provision in

S. 212, the predecessor to S. 556, and the Administration expressed its objection to

the provision, the NSC reluctantly determined that the provision was likely to

hinder efforts to reauthorize the Indian Health Care Improvement Act and therefore

agreed to its removal from the bill in favor of free-standing legislation. Current law

states: ‘‘the Federal medical assistance percentage shall be 100 per centum with respect to amounts expended as medical assistance for services which are received

through an Indian Health Service facility whether operated by the Indian Health

Service or by an Indian tribe or tribal organization (as defined in section 1602 of

Title 25).’’

42 U.S.C. § 1396 (d) (b) (emphasis added.). The NSC believes that ‘‘through’’ encompasses all services provided directly by the Indian Health Service [IHS] and

tribes and tribal organizations operating health programs under the Indian Self-Determination and Education Assistance Act [ISDEAA], as well as non-facility based

services—such as home and community-based services—and services that the Indian health program would have paid for from its contract health service program,

but for the patient being Medicaid eligible. CMS has generally interpreted ‘‘through’’

to mean ‘‘in,’’ applying the 100 percent FMAP only for services provided in an IHS

or tribal facility.

Authorization of 100 percent reimbursement for States for services provided

through the IHS reflects Congressional understanding that the obligation to provide

health care to American Indians and Alaska Natives is a Federal obligation deriving

from the Constitution, treaties and laws and paid for by tribes with hundreds of millions of acres of land. Pragmatically, it serves to encourage States to recognize the

importance of IHS and tribal providers to ensuring that Indians have access to culturally appropriate and sensitive health care. Please see the response to question

B for a more thorough discussion of this latter point.

Unfortunately, the NSC is not privy to the CBO scoring methodology or to information that may have been provided to CBO by CMS. We do believe it is highly

probable that the score is inflated substantially. Many States have interpreted the
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current law to permit them to claim exactly what is described in § 212 of S. 556.

Accordingly, they have been claiming, and until recently, often been being reimbursed, at that level. Thus, the expenditures are not new, but part of the current

budget.

Second, we believe it possible that the score includes an estimate of the cost of

all services to Indians by non-IHS providers whether there was a referral from the

IHS or tribal health program or not. This would significantly inflate the score. The

intent of the NSC is only that services provided based on such a referral be included. By limiting it in this way, the continuity of care for Indian patients and the

integrity of the Indian health system are retained.

The score was so high that it also makes us wonder if CBO was relying on census

numbers for estimating the number of Indians instead of the number of active users

in the Indian health system. What is clear to us is that American Indians and Alaska Natives are not receiving the benefit of services in amounts anywhere equivalent

to the CBO estimates and that the Indian health system continues to be dramatically underfunded to carry out its mission. Both should be remedied.

Question B—If FMAP is not enacted, is there a chance that some States

may not extend services to Indians unless the 100-percent FMAP applies?

Response. The relationship between States and tribes varies dramatically from

State to State, administration to administration, issue to issue. It ranges from enmity, to distrust, to indifference with occasional shining lights of cooperation. The

hostilities arise typically from historical and present conflicts over control of resources—land, minerals, water, tax base, to name a few. The indifference arises

from a view that since there is a direct Federal/tribal government-to-government relationship, the State has no role. This is reinforced by the human tendency to set

priorities based on the ‘‘out-of-sight out-of-mind’’ principle under which rural and remote communities suffer, including Indian communities. Increased reimbursement

for Medicaid expenditures won’t cure all of this, but it would be a substantial help.

After the execution of the 1996 Memorandum of Agreement between the Health

Care Financing Administration [HCFA] [now CMS] and IHS, many States demonstrated a significantly higher willingness to work with IHS and tribes to include

them in their Medicaid programs as providers and as programs able to assist Medicaid-eligible Indians to exercise their right to participate in the Medicaid program.

This did not happen overnight and it continues to require diligence and outreach

by IHS and tribes, but gradually it did happen.

We hesitate to say that states will roll back their cooperation if the narrower interpretations by CMS of their right of recovery is not overcome, but in a time when

all states are experiencing financial pressures, particularly centered on their Medicaid programs, it is a high risk. It is a risk we do not believe we should have to take.

No. 2. 1996 MOA between IHS and DHHS: The 1996 Memorandum of

Agreement between IHS and DHHS established a 100-percent FMAP which

applies to certain services provided by IHS and Tribal ‘‘638’’ programs at

their facilities.

Question—Does the MOA apply to tribes who provide programs that are

not contracted such as long-term care and, if not, should it?

Response. In our view the MOA did not change anything substantive about the

coverage. It makes tribal health facilities, health facilities of the IHS, as if there

were a lease between IHS and the tribe, in order to avoid the wasteful exercise of

IHS actually having to enter into such leases. Whether the MCA extends to longterm care, is really a question about whether the IHS and tribes should offer longterm care health services, and whether tribes have the right to do so, even if not

directly funded by IHS to do so. We believe the answer to all these questions is

‘‘yes.’’ Tragically, long-term care wasn’t a priority of the IHS because Indians did

not live long enough to require it. Tragically, long-term care couldn’t be a priority

because IHS was so short-funded it could not meet acute care demand, let alone expand to long-term care. Tragically, Indians who were reluctant to leave their families and communities to receive long-term care simply had to forego that option because there were few, if any, nursing homes on or near reservations and predominantly Indian communities.

Thankfully, life expectancy is increasing and long-term care doesn’t only have to

mean nursing home care, although it is still an important component. Indian tribes

and tribal organizations are exercising their right to assume responsibility for carrying out programs of the IHS under both Title I (self-determination) and Title V (selfgovernance) of the ISDEAA and achieving efficiencies and program improvements

only imagined by the IHS under which they can exercise authority to set priorities

locally and redesign their programs accordingly. Some tribes have even developed

the capability of contributing tribal resources to the mix of funding for health services and this has meant expansion of services, including long-term care. When this
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occurs, the MOA absolutely should cover tribal long-term care. In our view, the better question would be why it shouldn’t cover long-term care.

Most health care expenditures come at the end of life—some of that expense is

due to long-term care. Why should Federal financial participation in delivering

health services to American Indians and Alaska Natives end just at the point the

expense becomes greatest?

No. 3. States Denying Care to Indians. Federal health care to Indians

arises from the special relationship with and obligations of the United

States. But, as U.S. citizens, Indians also have equal access to other public

health programs available to all other U.S. citizens.

Question—Is the National Steering Committee aware of cases where

States have refused public health insurance coverage for eligible Indians

because of the belief that health care is a ‘‘Federal responsibility’’?

Response. The National Steering Committee is not aware of a consistent pattern

of such refusals however, tribal leaders are aware of individual cases where this has

occurred at the application level. Despite the well established Federal responsibility

to provide health services to American Indians and Alaska Natives, tribal members

are often discriminated against and are denied the opportunity to even apply for

other public health programs based on the ‘‘Indians receive free health care,’’ misconception. The result is that tribal members often avoid utilizing such resources

in order to avoid such discrimination and do not utilize those resources that are

available to them.

Another barrier that exists for tribal members in accessing services outside of the

HIS, Tribal, and Urban (I/T/U) system is the eligibility application process. The application process is quite lengthy and arduous, which discourages participation.

Tribal leaders are aware of these problems and are taking steps to address them,

such as working with States to increase participation.
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