I 

114TH CONGRESS 

2D SESSION H. R. 5406 

To amend the Indian Health Care Improvement Act to improve access to 

tribal health care by providing for systemic Indian Health Service workforce and funding allocation reforms, and for other purposes. 

IN THE HOUSE OF REPRESENTATIVES 

JUNE 8, 2016 

Mrs. NOEM (for herself, Mr. ASHFORD, Mr. SMITH of Nebraska, Mr. FORTENBERRY, Mr. CRAMER, and Ms. MCCOLLUM) introduced the following bill; 

which was referred to the Committee on Natural Resources, and in addition to the Committees on Energy and Commerce and Ways and Means, 

for a period to be subsequently determined by the Speaker, in each case 

for consideration of such provisions as fall within the jurisdiction of the 

committee concerned 

A BILL 

To amend the Indian Health Care Improvement Act to improve access to tribal health care by providing for systemic Indian Health Service workforce and funding allocation reforms, and for other purposes. 

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

3 SECTION 1. SHORT TITLE; TABLE OF CONTENTS. 

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

5 ‘‘Helping Ensure Accountability, Leadership, and Trust in 

6 Tribal Healthcare Act’’ or the ‘‘HEALTTH Act’’. 


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

2 this Act is as follows: 

Sec. 1. Short title; table of contents. 

Sec. 2. Findings. 

TITLE I—EXPANDING AUTHORITIES AND IMPROVING ACCESS TO 

CARE 

Sec. 101. Service hospital long-term contract pilot program. 

Sec. 102. Expanded hiring authority for the Indian Health Service. 

Sec. 103. Removal or demotion of employees. 

Sec. 104. Improving timeliness of care. 

TITLE II—INDIAN HEALTH SERVICE RECRUITMENT AND 

WORKFORCE 

Sec. 201. Exclusion from gross income for payments made under Indian Health 

Service Loan Repayment Program. 

Sec. 202. Clarifying that certain degrees qualify individuals for eligibility in the 

Indian Health Service Loan Repayment Program. 

Sec. 203. Cultural competency programs. 

Sec. 204. Relocation reimbursement. 

Sec. 205. Authority to waive Indian preference laws. 

Sec. 206. Streamlining medical volunteer credentialing process. 

TITLE III—PURCHASED/REFERRED CARE PROGRAM REFORMS 

Sec. 301. Codification of limitation on charges for health care professional services and non-hospital-based care source. 

Sec. 302. Allocation of Purchased/Referred Care program funds. 

Sec. 303. Purchased/Referred Care program backlog. 

Sec. 304. Report on financial stability of Service hospitals and facilities. 

3 SEC. 2. FINDINGS. 

4 Congress finds the following: 

5 (1) The United States Government has a treaty 

6 obligation to provide health care to American Indi7 ans and Alaska Natives. 

8 (2) The Indian Health Service is the Federal 

9 agency that is entrusted to carry out this obligation. 

10 (3) Access to high quality health care is critical 

11 for strong and vibrant tribal communities in the 


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1 Great Plains Area and throughout the United 

2 States. 

3 (4) In 2010, the Senate Committee on Indian 

4 Affairs published a report titled ‘‘In Critical Condi5 tion: The Urgent Need to Reform the Indian Health 

6 Service’s Aberdeen Area’’, which detailed defi7 ciencies, abuses, and malfeasance within the Aber8 deen Area of the Indian Health Service, now called 

9 the Great Plains Area. 

10 (5) In 2015 and 2016, the Centers for Medi11 care & Medicaid Services conducted surveys of In12 dian Health Service hospitals in the Great Plains 

13 Area and found serious structural deficiencies that 

14 put patients’ health and safety in immediate jeop15 ardy. 

16 (6) The Indian Health Service’s failures in the 

17 Great Plains Area have resulted in a severe reduc18 tion in access to emergency care, needlessly long 

19 wait times, patient suffering, low quality of life, and 

20 several tragic deaths. 

21 (7) The Indian Health Service is in need of 

22 comprehensive reform that will hold its management 

23 and employees accountable, foster strong and capa24 ble agency leadership, and restore tribal members’ 

25 trust in the care it delivers. 


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1 TITLE I—EXPANDING AUTHORI2 TIES AND IMPROVING AC3 CESS TO CARE 

4 SEC. 101. SERVICE HOSPITAL LONG-TERM CONTRACT 

5 PILOT PROGRAM. 

6 Title VIII of the Indian Health Care Improvement 

7 Act (25 U.S.C. 1671) is amended by adding at the end 

8 the following new section: 

9 ‘‘SEC. 833. SERVICE HOSPITAL LONG-TERM CONTRACT 

10 PILOT PROGRAM. 

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

12 the Service, shall implement a 7-year pilot program to test 

13 the viability and advisability of entering into long-term 

14 contracts for the operation of eligible Service hospitals 

15 with governance structures that include tribal input. 

16 ‘‘(b) ELEMENTS.—Under such pilot program, subject 

17 to subsection (e), the following shall apply: 

18 ‘‘(1) The Secretary shall select three eligible 

19 Service hospitals in rural areas to participate in the 

20 pilot program. 

21 ‘‘(2) For each such participating hospital, the 

22 Secretary shall enter into a long-term contract. 

23 ‘‘(3) At each such participating hospital, the 

24 Secretary, in consultation with the primary Indian 

25 tribes served by the hospital, shall install a govVerDate Sep 11 2014 04:34 Jun 09, 2016 Jkt 059200 PO 00000 Frm 00004 Fmt 6652 Sfmt 6201 E:\BILLS\H5406.IH H5406

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1 erning board described in subsection (d), which shall 

2 be responsible for overseeing the local operation of 

3 the hospital. 

4 ‘‘(c) ELIGIBLE SERVICE HOSPITAL.—For purposes 

5 of this section, the term ‘eligible Service hospital’ means 

6 a Service hospital that furnishes services in a rural area 

7 to direct services tribes and with respect to which the Sec8 retary has obtained the permission of the primary Indian 

9 tribes served by the hospital for the hospital to participate 

10 under the pilot program under this section. 

11 ‘‘(d) GOVERNANCE BOARD DESCRIBED.—For pur12 poses of subsection (b), a governance board described in 

13 this subsection, with respect to a Service hospital partici14 pating in the pilot program, is a board that satisfies the 

15 following criteria: 

16 ‘‘(1) COMPOSITION.— 

17 ‘‘(A) IN GENERAL.—The governance board 

18 is composed, in accordance with the best prac19 tices specified under paragraph (3), of the fol20 lowing individuals: 

21 ‘‘(i) Representatives of the Service, 

22 who shall be selected by the Secretary. 

23 ‘‘(ii) Representatives of the Service 

24 hospital. 


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1 ‘‘(iii) Representatives of each primary 

2 Indian tribe served by the hospital, who 

3 shall be selected by the respective Indian 

4 tribe. 

5 ‘‘(iv) Experts in health care adminis6 tration and delivery, who shall— 

7 ‘‘(I) be selected by the Secretary 

8 and respective Indian tribe; and 

9 ‘‘(II) to the extent possible, lo10 cated in the State in which the hos11 pital is located or otherwise familiar 

12 with such State. 

13 ‘‘(B) VOTING RIGHTS.—In determining the 

14 composition of the board with respect to voting 

15 rights on the board— 

16 ‘‘(i) the number of voting members 

17 representing the Service shall be equal to 

18 the number of voting members rep19 resenting the Indian tribes involved; and 

20 ‘‘(ii) the number of voting members 

21 representing the hospital may not be great22 er than the number of voting members rep23 resenting the Service or the Indian tribes 

24 involved. 


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1 ‘‘(2) DUTIES.—The governance board shall per2 form duties in accordance with the best practices 

3 specified under paragraph (3) and shall include de4 veloping financial and quality metrics and standards 

5 for salaries, recruitment, retention, training, and 

6 dismissal of employees of such hospital. 

7 ‘‘(3) BEST PRACTICES.—The Secretary shall 

8 specify best practices for the governance board de9 scribed in this subsection, including best practices 

10 relating to the number of members of such board, 

11 the authorities of the board, and the duties of the 

12 board. 

13 ‘‘(e) TREATMENT OF ELIGIBLE SERVICE HOSPITALS

14 CURRENTLY UNDER CONTRACT.—In the case of an eligi15 ble Service hospital that is under a current contract with 

16 the Secretary as of the initiation of the selection process 

17 period for the pilot program, in order for such hospital 

18 to participate in the pilot program the Secretary, with the 

19 agreement of the hospital, may— 

20 ‘‘(1) notwithstanding any other provision of 

21 law, modify or terminate such contract and in order 

22 for such hospital to enter into a long-term contract 

23 under the pilot program; or 

24 ‘‘(2) enter into a long-term contract under the 

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1 ning on the date after the last date of such current 

2 contract. 

3 ‘‘(f) LONG-TERM CONTRACT DEFINED.—For pur4 poses of this section, the term ‘long-term contract’ means 

5 a contract for a period of at least 5 years. 

6 ‘‘(g) CLARIFICATION.—Nothing in this section shall 

7 be construed to inhibit a tribe’s authority to enter into 

8 a compact or contract under the Indian Self-Determina9 tion and Education Assistance Act. 

10 ‘‘(h) REPORTS.—For each year of the pilot program, 

11 the Secretary shall submit a report to Congress on the 

12 results of the program demonstrated during the respective 

13 year. Each such report shall include the following: 

14 ‘‘(1) Information related to the financial health 

15 of each eligible hospital participating in the pilot 

16 program. 

17 ‘‘(2) Information on the affect the pilot pro18 gram has on access to care. 

19 ‘‘(3) Information on patient satisfaction with 

20 services provided at such hospitals. 

21 ‘‘(4) The number of readmissions at such hos22 pitals. 

23 ‘‘(5) The number of hospital-acquired condi24 tions at such hospitals. 


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1 ‘‘(6) Recommendations on the viability and ad2 visability of the long-term contracts and hospital 

3 governance structure under such pilot program. 

4 ‘‘(7) Any other information the Secretary con5 siders necessary for a proper analysis of the pilot 

6 program.’’. 

7 SEC. 102. EXPANDED HIRING AUTHORITY FOR THE INDIAN 

8 HEALTH SERVICE. 

9 Section 601(d) of the Indian Health Care Improve10 ment Act (25 U.S.C. 1661(d)) is amended— 

11 (1) in paragraph (1)(A), by inserting ‘‘and sub12 ject to paragraph (4)’’ after ‘‘paragraph (2)’’; and 

13 (2) by adding at the end the following: 

14 ‘‘(4) EMPLOYMENT AUTHORITY.— 

15 ‘‘(A) IN GENERAL.—The Secretary may, 

16 with respect to any employee described in sub17 paragraph (B), provide that one or more provi18 sions of chapter 74 of title 38, United States 

19 Code (other than subchapter V of such chapter 

20 or of regulations promulgated under such chap21 ter other than under such subchapter), shall 

22 apply— 

23 ‘‘(i) in lieu of any provision of title 5 

24 of the United States Code (other than as 

25 applied pursuant to section 834); or 


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1 ‘‘(ii) notwithstanding any lack of spe2 cific authority for a matter with respect to 

3 which title 5 of the United States Code re4 lates. 

5 ‘‘(B) APPLICABILITY TO EMPLOYEES.—Au6 thority under this paragraph may be exercised 

7 with respect to any employee in the Service 

8 holding a position— 

9 ‘‘(i) to which chapter 51 of title 5 of 

10 the United States Code applies, excluding 

11 any senior executive service position; and 

12 ‘‘(ii) which involves health care re13 sponsibilities. 

14 ‘‘(C) DEFINITION.—For purposes of this 

15 paragraph, ‘health care’ means direct patient16 care services or services incident to direct pa17 tient-care services.’’. 

18 SEC. 103. REMOVAL OR DEMOTION OF EMPLOYEES. 

19 (a) IN GENERAL.—Title VIII of the Indian Health 

20 Care Improvement Act (25 U.S.C. 1671 et seq.), as 

21 amended by section 101, is further amended by adding 

22 at the end the following new section: 

23 ‘‘SEC. 834. REMOVAL OR DEMOTION OF EMPLOYEES. 

24 ‘‘(a) IN GENERAL.—The Secretary may remove or 

25 demote an individual who is an employee of the Service 


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1 if the Secretary determines the performance or misconduct 

2 of the individual warrants such removal or demotion. If 

3 the Secretary so removes or demotes such an individual, 

4 the Secretary may— 

5 ‘‘(1) remove the individual from the Service; or 

6 ‘‘(2) demote the individual by means of— 

7 ‘‘(A) a reduction in grade for which the in8 dividual is qualified and that the Secretary de9 termines is appropriate; or 

10 ‘‘(B) a reduction in annual rate of pay 

11 that the Secretary determines is appropriate. 

12 In the case of an individual who is removed under 

13 paragraph (1) or demoted under paragraph (2), the 

14 Secretary may require such individual take unpaid 

15 administrative leave for not longer than 10 consecu16 tive work days. 

17 ‘‘(b) PAY OF CERTAIN DEMOTED INDIVIDUALS.—(1) 

18 Notwithstanding any other provision of law, any individual 

19 subject to a demotion under subsection (a)(2)(A) shall, be20 ginning on the date of such demotion, receive the annual 

21 rate of pay applicable to such grade. 

22 ‘‘(2) An individual so demoted may not be placed on 

23 administrative leave or any other category of paid leave 

24 during the period during which an appeal (if any) under 

25 this section is ongoing, and may only receive pay if the 


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1 individual reports for duty. If an individual so demoted 

2 does not report for duty, such individual shall not receive 

3 pay or other benefits pursuant to subsection (e)(5). 

4 ‘‘(c) NOTICE TO SECRETARY.—Not later than 30 

5 days after removing or demoting an individual under sub6 section (a), the Service shall submit to the Secretary no7 tice in writing of such removal or demotion and the reason 

8 for such removal or demotion. 

9 ‘‘(d) PROCEDURE.—(1) The procedures under section 

10 7513(b) of title 5 and chapter 43 of such title shall not 

11 apply to a removal or demotion under this section. 

12 ‘‘(2)(A) Subject to subparagraph (B) and subsection 

13 (e), any removal or demotion under subsection (a) may 

14 be appealed to the Merit Systems Protection Board under 

15 section 7701 of title 5. 

16 ‘‘(B) An appeal under subparagraph (A) of a removal 

17 or demotion may only be made if such appeal is made not 

18 later than seven days after the date of such removal or 

19 demotion. 

20 ‘‘(e) EXPEDITED REVIEW BY ADMINISTRATIVE

21 JUDGE.—(1) Upon receipt of an appeal under subsection 

22 (d)(2)(A), the Merit Systems Protection Board shall refer 

23 such appeal to an administrative judge pursuant to section 

24 7701(b)(1) of title 5. The administrative judge shall expe25 dite any such appeal under such section and, in any such 


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1 case, shall issue a decision not later than 45 days after 

2 the date of the appeal. 

3 ‘‘(2) Notwithstanding any other provision of law, in4 cluding section 7703 of title 5, the decision of an adminis5 trative judge under paragraph (1) shall be final and shall 

6 not be subject to any further appeal. 

7 ‘‘(3) In any case in which the administrative judge 

8 cannot issue a decision in accordance with the 45-day re9 quirement under paragraph (1), the removal or demotion 

10 is final. In such a case, the Merit Systems Protection 

11 Board shall, within 14 days after the date that such re12 moval or demotion is final, submit to Congress a report 

13 that explains the reasons why a decision was not issued 

14 in accordance with such requirement. 

15 ‘‘(4) The Merit Systems Protection Board or admin16 istrative judge may not stay any removal or demotion 

17 under this section. 

18 ‘‘(5) During the period beginning on the date on 

19 which an individual appeals a removal from the Service 

20 under subsection (d) and ending on the date that the ad21 ministrative judge issues a final decision on such appeal, 

22 such individual may not receive any pay, awards, bonuses, 

23 incentives, allowances, differentials, student loan repay24 ments, special payments, or benefits. 


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1 ‘‘(6) To the maximum extent practicable, the Sec2 retary shall provide to the Merit Systems Protection 

3 Board, and to any administrative judge to whom an appeal 

4 under this section is referred, such information and assist5 ance as may be necessary to ensure an appeal under this 

6 subsection is expedited. 

7 ‘‘(f) TERMINATION OF INVESTIGATIONS BY OFFICE

8 OF SPECIAL COUNSEL.—Notwithstanding any other provi9 sion of law, the Special Counsel (established by section 

10 1211 of title 5) may terminate an investigation of a pro11 hibited personnel practice alleged by an employee or 

12 former employee of the Department after the Special 

13 Counsel provides to the employee or former employee a 

14 written statement of the reasons for the termination of 

15 the investigation. Such statement may not be admissible 

16 as evidence in any judicial or administrative proceeding 

17 without the consent of such employee or former employee. 

18 ‘‘(g) RELATION TO TITLE 5.—The authority provided 

19 by this section is in addition to the authority provided by 

20 subchapter V of chapter 75 of title 5 and chapter 43 of 

21 such title. 

22 ‘‘(h) DEFINITIONS.—In this section: 

23 ‘‘(1) The term ‘individual’ means an individual 

24 occupying a position at the Service but does not in25 clude— 


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1 ‘‘(A) an individual, as that term is defined 

2 in section 713(g)(1); or 

3 ‘‘(B) a political appointee. 

4 ‘‘(2) The term ‘grade’ has the meaning given 

5 such term in section 7511(a) of title 5. 

6 ‘‘(3) The term ‘misconduct’ includes neglect of 

7 duty, malfeasance, or failure to accept a directed re8 assignment or to accompany a position in a transfer 

9 of function. 

10 ‘‘(4) The term ‘political appointee’ means an in11 dividual who is— 

12 ‘‘(A) employed in a position described 

13 under sections 5312 through 5316 of title 5 

14 (relating to the Executive Schedule); 

15 ‘‘(B) a limited term appointee, limited 

16 emergency appointee, or noncareer appointee in 

17 the Senior Executive Service, as defined under 

18 paragraphs (5), (6), and (7), respectively, of 

19 section 3132(a) of title 5; or 

20 ‘‘(C) employed in a position of a confiden21 tial or policy-determining character under 

22 schedule C of subpart C of part 213 of title 5 

23 of the Code of Federal Regulations.’’. 

24 (b) CONFORMING.—Section 4303(f) of title 5, United 

25 States Code, is amended— 


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1 (1) by striking ‘‘or’’ at the end of paragraph 

2 (2); 

3 (2) by striking the period at the end of para4 graph (3) and inserting ‘‘, or’’; and 

5 (3) by adding at the end the following: 

6 ‘‘(4) any removal or demotion under section 

7 834 of the Indian Health Care Improvement Act.’’. 

8 SEC. 104. IMPROVING TIMELINESS OF CARE. 

9 Title III of the Indian Health Care Improvement Act 

10 (25 U.S.C. 1631 et seq.) is amended by adding at the end 

11 the following new section: 

12 ‘‘SEC. 314. STANDARDS TO IMPROVE TIMELINESS OF CARE. 

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

14 the Service, shall— 

15 ‘‘(1) establish, by regulation, standards to 

16 measure the timeliness of the provision of health 

17 care services in Service facilities; and 

18 ‘‘(2) make such standards available to all Serv19 ice areas and Service facilities. 

20 ‘‘(b) DATA COLLECTION.—The Secretary, acting 

21 through the Service, shall develop a process for Service 

22 facilities to submit to the Secretary data with respect to 

23 the standards established under subsection (a).’’. 


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1 TITLE II—INDIAN HEALTH SERV2 ICE RECRUITMENT AND 

3 WORKFORCE 

4 SEC. 201. EXCLUSION FROM GROSS INCOME FOR PAY5 MENTS MADE UNDER INDIAN HEALTH SERV6 ICE LOAN REPAYMENT PROGRAM. 

7 (a) IN GENERAL.—Section 108(f)(4) of the Internal 

8 Revenue Code of 1986 is amended by inserting ‘‘under 

9 section 108 of the Indian Health Care Improvement Act,’’ 

10 after ‘‘338I of such Act,’’. 

11 (b) CLERICAL AMENDMENT.—The heading for sec12 tion 108(f)(4) of such Code is amended by striking ‘‘AND

13 CERTAIN’’ and inserting ‘‘, INDIAN HEALTH SERVICE LOAN

14 REPAYMENT PROGRAM, AND CERTAIN’’. 

15 (c) EFFECTIVE DATE.—The amendments made by 

16 this section shall apply to amounts received after the date 

17 of the enactment of this Act. 

18 SEC. 202. CLARIFYING THAT CERTAIN DEGREES QUALIFY 

19 INDIVIDUALS FOR ELIGIBILITY IN THE IN20 DIAN HEALTH SERVICE LOAN REPAYMENT 

21 PROGRAM. 

22 Section 108 of the Indian Health Care Improvement 

23 Act (25 U.S.C. 1616a) is amended— 

24 (1) in subsection (b)(1)(B)— 


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1 (A) in clause (i), by inserting ‘‘(including 

2 a degree business administration with an em3 phasis in health care management, as defined 

4 by the Secretary, or a degree in health adminis5 tration, hospital administration, or public 

6 health)’’ before the semicolon; and 

7 (B) in clause (ii), by inserting ‘‘or a license 

8 or certification to practice in the field of health 

9 administration, hospital administration, busi10 ness administration, or public health, as appli11 cable, in a State’’ before the semicolon; 

12 (2) in subsection (f)(1)(B)(iii), by striking ‘‘2 

13 years or such longer period as the individual may 

14 agree to serve in the full-time clinical practice of 

15 such individual’s profession’’ and inserting ‘‘2 years 

16 or such longer period as the individual may agree to 

17 serve in the full-time practice of such individual’s 

18 profession (or 4 years or such longer period as the 

19 individual may agree to serve in the half-time prac20 tice of such individual’s profession)’’; and 

21 (3) in subsection (g)(2)(A), in the first sen22 tence— 

23 (A) by inserting ‘‘, in the case of an indi24 vidual agreeing to serve in the full-time practice 


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1 of such individual’s profession,’’ before ‘‘up to 

2 $35,000’’; and 

3 (B) by inserting ‘‘(or, in the case of an in4 dividual agreeing to serve in the half-time prac5 tice of such individual’s profession, up to 

6 $17,500)’’ before ‘‘on behalf of’’. 

7 SEC. 203. CULTURAL COMPETENCY PROGRAMS. 

8 Title I of the Indian Health Care Improvement Act 

9 (25 U.S.C. 1611 et seq.) is amended by adding at the end 

10 the following new section: 

11 ‘‘SEC. 125. CULTURAL COMPETENCY PROGRAMS. 

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

13 the Service, shall, not later than one year after the date 

14 of the enactment of this section and for each Service area, 

15 develop and implement training programs for cultural 

16 competency for employees of the Service, locum tenens 

17 medical providers, and other contracted employees who 

18 work at Service hospitals or other Service facilities and 

19 whose employment requires regular direct patient access. 

20 ‘‘(b) REQUIRED PARTICIPATION.—Notwithstanding 

21 any other provision of law, beginning with years beginning 

22 after (and for contracts entered into on or after) the date 

23 of implementation of the training programs under sub24 section (a), annual participation in such a program shall 

25 be a condition of employment (or of providing services in 


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1 the capacity as a locum tenen medical provider or of the 

2 terms of the contracted employment, as applicable), and 

3 continued employment (or provision of such services in 

4 such capacity or contracted employment, as applicable), 

5 for each employee of the Service, locum tenens medical 

6 provider, and contracted employee described in such sub7 section. For purposes of the previous sentence, an indi8 vidual shall not be considered as participating in such a 

9 program, with respect to a year, unless such individual 

10 satisfies such requirements, including testing, included in 

11 such program for such year, as specified by the Secretary. 

12 ‘‘(c) CONSULTATION.—In developing a training pro13 gram under subsection (a) for a Service area, the Sec14 retary shall consult with representatives of each Indian 

15 tribe served in such area.’’. 

16 SEC. 204. RELOCATION REIMBURSEMENT. 

17 Title I of the Indian Health Care Improvement Act 

18 (25 U.S.C. 1611 et seq.), as amended by section 203, is 

19 further amended by adding at the end the following new 

20 section: 

21 ‘‘SEC. 126. RELOCATION REIMBURSEMENT. 

22 ‘‘(a) IN GENERAL.—In the case of an employee of 

23 the Service who relocates to serve in a different capacity 

24 or position as an employee of the Service, the Secretary 

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1 bursement for reasonable costs associated with such relo2 cation, as determined by the Secretary, incurred by such 

3 employee if— 

4 ‘‘(1) such relocation is to fill a position that— 

5 ‘‘(A) is at a Service facility that is located 

6 in a rural area or medically underserved area; 

7 and 

8 ‘‘(B) had not been filled by a full-time non9 contractor for a period of at least 6 months; or 

10 ‘‘(2) such relocation is to fill a position that is 

11 for hospital management or administration, as deter12 mined by the Secretary. 

13 ‘‘(b) AMOUNT FOR RELOCATION.— 

14 ‘‘(1) IN GENERAL.—The amount of reimburse15 ment to an employee under subsection (a) shall be 

16 in an amount that is at least 50 percent, but not 

17 more than 75 percent, of the specified pay amount 

18 (as described in paragraph (2)) of the employee. 

19 ‘‘(2) SPECIFIED PAY AMOUNT.—For purposes 

20 of paragraph (1), the specified pay amount, with re21 spect to an employee, is the annual rate of basic pay 

22 of the employee in effect at the beginning of the 

23 service period of such employee multiplied by the 

24 number of years (including fractions of a year) in 

25 the service period, not to exceed 4 years. 


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1 ‘‘(c) CLARIFICATION.—Nothing in this section shall 

2 be construed as limiting the authority of the Secretary, 

3 as in existence before the enactment of this section, to 

4 offer reimbursement for travel or relocation.’’. 

5 SEC. 205. AUTHORITY TO WAIVE INDIAN PREFERENCE 

6 LAWS. 

7 Title VI of the Indian Health Care Improvement Act 

8 (25 U.S.C. 1611 et seq.) is amended by adding at the end 

9 the following new section: 

10 ‘‘SEC. 605. AUTHORITY TO WAIVE INDIAN PREFERENCE 

11 LAWS. 

12 ‘‘To enhance recruitment and retention of employees 

13 of the Service, the Secretary may waive the requirements 

14 of the Indian preference laws (as defined in section 2(e) 

15 of Public Law 96–135 (25 U.S.C. 472a(e))) with respect 

16 to a personnel action with respect to a Service unit with 

17 the written request or resolution of an Indian tribe located 

18 within the applicable Service unit— 

19 ‘‘(1) if such personnel action is with respect to 

20 a facility that has a personnel vacancy rate of at 

21 least 20 percent; or 

22 ‘‘(2) in the case such personnel action is with 

23 respect to a former employee of the Service or 

24 former tribal employee who was removed from such 

25 former employment or demoted for misconduct that 


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1 occurred during the five years prior to the date of 

2 such personnel action.’’. 

3 SEC. 206. STREAMLINING MEDICAL VOLUNTEER 

4 CREDENTIALING PROCESS. 

5 Title I of the Indian Health Care Improvement Act 

6 (25 U.S.C. 1611 et seq.), as amended by sections 203 and 

7 204, is further amended by adding at the end the following 

8 new section: 

9 ‘‘SEC. 128. STREAMLINING MEDICAL VOLUNTEER 

10 CREDENTIALING PROCESS. 

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

12 the Service, shall, in accordance with subsection (b), im13 plement a Service-wide centralized credentialing system to 

14 credential licensed health professionals who seek to volun15 teer at a Service facility. 

16 ‘‘(b) REQUIREMENTS.—The credentialing system im17 plemented under subsection (a) shall be in accordance with 

18 the following: 

19 ‘‘(1) Credentialing of licensed health profes20 sionals who seek to volunteer at a Service facility 

21 shall occur at the Service level. 

22 ‘‘(2) Credentialing procedures under such sys23 tem shall be uniform throughout the Service. 

24 ‘‘(3) Under such system, in the case that such 

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1 pleted the credentialing procedures under such sys2 tem, such professional shall be authorized to treat 

3 patients at any Service facility or other facility with4 in a Service area. 

5 ‘‘(c) REGULATIONS.—The Secretary may promulgate 

6 regulations to implement this section. 

7 ‘‘(d) CONSULTATION.—The Secretary may consult 

8 with public and private associations of medical providers 

9 in the development of the credentialing system under this 

10 section. 

11 ‘‘(e) APPLICATION.—The credentialing system under 

12 this section shall apply with respect to licensed health pro13 fessionals seeking to volunteer with respect to— 

14 ‘‘(1) providing direct health care services at a 

15 Service facility; and 

16 ‘‘(2) providing services at facilities operated or 

17 contracted by a tribe, tribal organization, or urban 

18 Indian organization under the Indian Self-Deter19 mination and Education Assistance Act. 

20 ‘‘(f) CLARIFICATION.—Nothing in this section shall 

21 be construed to inhibit a tribe’s authority to enter into 

22 a compact or contract under the Indian Self-Determina23 tion and Education Assistance Act.’’. 


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1 TITLE III—PURCHASED/RE2 FERRED CARE PROGRAM RE3 FORMS 

4 SEC. 301. CODIFICATION OF LIMITATION ON CHARGES FOR 

5 HEALTH CARE PROFESSIONAL SERVICES 

6 AND NON-HOSPITAL-BASED CARE SOURCE. 

7 (a) APPLICABILITY.—The requirements of this sec8 tion shall apply to— 

9 (1) health programs operated by the Indian 

10 Health Service; 

11 (2) health programs operated by an urban In12 dian organization through a contract or grant under 

13 title V of the Indian Health Care Improvement Act, 

14 Public Law 94–437, as amended; and 

15 (3) health programs operated by an Indian 

16 tribe or tribal organization pursuant to a contract or 

17 compact with the Indian Health Service under the 

18 Indian Self-Determination and Education Assistance 

19 Act (25 U.S.C. 450 et seq.), provided that the In20 dian tribe or tribal organization has agreed in such 

21 contract or compact to be bound by this section pur22 suant to section 108 of the Indian Self-Determina23 tion and Education Assistance Act (25 U.S.C. 450l) 

24 and section 517(e) of such Act (25 U.S.C. 458aaa– 

25 16(e)), as applicable. 


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1 (b) DEFINITIONS.—For purposes of this section, the 

2 following definitions apply: 

3 (1) The term ‘‘notification of a claim’’ means, 

4 the submission of a claim, with respect to services 

5 for an individual, that meets the requirements of 

6 section 136.24 of title 42, Code of Federal Regula7 tions, in accordance with the following: 

8 (A) Such claim is submitted within the ap9 plicable period specified under such section 

10 136.24, or if applicable, section 406 of the In11 dian Health Care Improvement Act (25 U.S.C. 

12 1646), and includes information necessary to 

13 determine the relative medical need for the 

14 services and the individual’s eligibility. 

15 (B) The information submitted with the 

16 claim is sufficient to— 

17 (i) identify the individual as eligible 

18 for Indian Health Service services (such as 

19 name, address, home or referring service 

20 unit, tribal affiliation); 

21 (ii) identify the medical care provided 

22 (such as the date of service and description 

23 of services); and 

24 (iii) verify prior authorization by the 

25 Indian Health Service for services provided 


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1 (such as the IHS purchase order number 

2 or medical referral form) or exemption 

3 from prior authorization (such as copies of 

4 pertinent clinical information for emer5 gency care that was not prior-authorized). 

6 (C) To be considered sufficient notification 

7 of a claim, a claim submitted by a provider or 

8 supplier for payment shall be in a format that 

9 complies with the format required for submis10 sion of claims under title XVIII of the Social 

11 Security Act (42 U.S.C. 1395 et seq.) or recog12 nized under section 1175 of such Act (42 

13 U.S.C. 1320d–4). 

14 (2) The term ‘‘provider’’ means a provider of 

15 services not governed by or subject to subpart D of 

16 part 136 of title 42, Code of Federal Regulations, 

17 and may include a skilled nursing facility, com18 prehensive outpatient rehabilitation facility, home 

19 health agency, or hospice program. 

20 (3) The term ‘‘referral’’ means an authorization 

21 for medical care by the appropriate ordering official 

22 in accordance with subpart C of part 136 of title 42, 

23 Code of Federal Regulations. 

24 (4) The term ‘‘repricing agent’’ means an entity 

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1 al organization, or urban Indian organization dis2 counted rates from public and private providers that 

3 are not the Indian Health Service or a tribe, tribal 

4 organization, or urban Indian organization as a re5 sult of existing contracts that the public or private 

6 provider other than the Indian Health Service or a 

7 tribe, tribal organization, or urban Indian organiza8 tion may have within the commercial health care in9 dustry. 

10 (5) The term ‘‘supplier’’ means a physician or 

11 other practitioner, a facility, or other entity (other 

12 than a provider) not already governed by or subject 

13 to subpart D of part 136 of title 42, Code of Fed14 eral Regulations, that furnishes items or services 

15 under this section. 

16 (c) PAYMENT FOR PROVIDER AND SUPPLIER SERV17 ICES PURCHASED BY INDIAN HEALTH PROGRAMS.— 

18 (1) IN GENERAL.—Payment to providers and 

19 suppliers for any level of care authorized under sub20 part C of part 136 of title 42, Code of Federal Reg21 ulations, by a Purchased/Referred Care program of 

22 the Indian Health Service, authorized by a tribe or 

23 tribal organization carrying out such a program of 

24 the Indian Health Service under the Indian Self-De25 termination and Education Assistance Act (25 


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1 U.S.C. 450 et seq.), authorized for purchase under 

2 section 136.31 of such title 42, Code of Federal 

3 Regulations, by an urban Indian organization (as 

4 that term is defined in 25 U.S.C. 1603(h)) (here5 after collectively referred to as the ‘‘I/T/U’’), shall, 

6 subject to subsection (e), be determined based on 

7 one of the methods described in the following sub8 paragraphs, as applicable: 

9 (A) MFC RATE METHOD.— 

10 (i) IN GENERAL.—The method de11 scribed in this subparagraph is that, sub12 ject to clause (ii), in the case a specific 

13 amount for an item or service has been ne14 gotiated with a specific provider or supplier 

15 or its agent by the I/T/U, the I/T/U shall 

16 pay that amount for such item or service. 

17 (ii) LIMITATION.—The amount ap18 plied under clause (i) for an item or service 

19 shall be an amount that is at least the 

20 amount of the provider’s or supplier’s most 

21 favored customer rate, as defined by the 

22 Secretary of Health and Human Services, 

23 for an item or service, as evidenced by 

24 commercial price lists or paid invoices and 

25 other related pricing and discount data to 


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1 ensure that the I/T/U is receiving a fair 

2 and reasonable price. The limitation under 

3 the previous sentence shall not apply with 

4 respect to an item or service if— 

5 (I) the amount offered to the I/ 

6 T/U under the negotiation under 

7 clause (i) is fair and reasonable, as 

8 determined by the I/T/U, even though 

9 comparable discounts were not nego10 tiated; and 

11 (II) the amount is otherwise in 

12 the best interest of the I/T/U, as de13 termined by the I/T/U. 

14 (B) MEDICARE RATES.—The method de15 scribed in this subparagraph is that, in the case 

16 that an amount for an item or service has not 

17 been negotiated in accordance with subpara18 graph (A), the I/T/U will pay the lowest of the 

19 following amounts for the item or service: 

20 (i) The amount that is the applicable 

21 payment amount under the Medicare pro22 gram under title XVIII of the Social Secu23 rity Act for such item or service, including 

24 payment according to a fee schedule, a 

25 prospective payment system or based on 


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1 reasonable cost for the period in which the 

2 service was provided, or in the event of a 

3 Medicare waiver, the payment amount will 

4 be calculated in accordance with such waiv5 er. For purposes of this paragraph, the 

6 amount described in this clause shall be re7 ferred to as the ‘‘Medicare rate’’. 

8 (ii) An amount negotiated by a repric9 ing agent if the provider or supplier is par10 ticipating within the repricing agent’s net11 work and the I/T/U has a pricing arrange12 ment or contract with that repricing agent. 

13 (iii) An amount not to exceed the pro14 vider or supplier’s most favored customer 

15 rate described in subparagraph (A)(ii) for 

16 such item or service, as evidenced by com17 mercial price lists or paid invoices and 

18 other related pricing and discount data to 

19 ensure that the I/T/U is receiving a fair 

20 and reasonable price, but only to the ex21 tent such evidence is reasonably accessible 

22 and available to the I/T/U. 

23 (C) OTHER.—The method described in this 

24 subparagraph is that, in the case that a Medi25 care rate does not exist for an item or service, 


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1 and no other method described in a previous 

2 subparagraph is accessible or available, the 

3 amount shall be deemed to be 65 percent of au4 thorized charges for such item or service. 

5 (2) COORDINATION OF BENEFITS AND LIMITA6 TION ON RECOVERY.—If an I/T/U has authorized 

7 payment for items and services provided to an indi8 vidual who is eligible for benefits under title XVIII 

9 of the Social Security Act, title XIX of such Act, or 

10 another third-party payer, the following shall apply: 

11 (A) The I/T/U shall be the payer of last 

12 resort under section 2901(b) of the Patient 

13 Protection and Affordable Care Act (25 U.S.C. 

14 1623(b)). 

15 (B) If there are any third-party payers, the 

16 I/T/U shall pay the amount for which the pa17 tient is being held responsible after the provider 

18 or supplier of services has coordinated benefits 

19 and all other alternate resources have been con20 sidered and paid, including applicable copay21 ments, deductibles, and coinsurance that are 

22 owed by the patient. 

23 (C) The maximum payment by the I/T/U 

24 shall be only the portion of the payment 


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1 amount determined under this section not cov2 ered by any other payer. 

3 (D) The I/T/U payment may not exceed 

4 the rate calculated in accordance with para5 graph (1) of this section (plus applicable cost 

6 sharing). 

7 (E) In the case payment is made under 

8 such title XIX for an item or service such pay9 ment shall be considered payment in full and 

10 there shall be no additional payment made by 

11 the I/T/U for such item or service. 

12 (3) AUTHORIZED SERVICES.—Payment shall be 

13 made only for those items and services authorized by 

14 an I/T/U consistent with this section or section 

15 503(a) of the Indian Health Care Improvement Act 

16 (25 U.S.C. 1653(a)). 

17 (4) NO ADDITIONAL CHARGES.— 

18 (A) If an amount has not been negotiated 

19 under paragraph (1)(A) for an item or service, 

20 the provider or supplier shall be deemed to have 

21 accepted the applicable payment amount under 

22 paragraph (1)(B) for such item or service as 

23 payment in full if— 

24 (i) the item or service was provided 

25 based on a referral; 


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1 (ii) the provider or supplier submits a 

2 notification of a claim for payment to the 

3 I/T/U; or 

4 (iii) the provider or supplier accepts 

5 payment for the provision of such item or 

6 service from the I/T/U. 

7 (B) A payment made and accepted in ac8 cordance with this section shall constitute pay9 ment in full and the provider or its agent, or 

10 supplier or its agent, may not impose any addi11 tional charge— 

12 (i) on the individual for I/T/U author13 ized items and services; or 

14 (ii) for information requested by the I/ 

15 T/U or its agent or fiscal intermediary for 

16 the purposes of payment determinations or 

17 quality assurance. 

18 (5) NOTIFICATION OF CLAIM.—The Indian 

19 Health Service shall not adjudicate a notification of 

20 a claim that does not contain the information de21 scribed in subsection (b)(1) with an approval or de22 nial, except that the Service may request further in23 formation from the individual, or as applicable, the 

24 provider or supplier, necessary to make a decision. 


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1 A notification of a claim meeting the requirements 

2 specified herein does not guarantee payment. 

3 (6) RATE AUTHORIZED.—No service shall be 

4 authorized and no payment shall be issued under 

5 this section in excess of the rate authorized by this 

6 section. 

7 (d) AUTHORIZATION BY AN URBAN INDIAN ORGANI8 ZATION.—An urban Indian organization may authorize for 

9 purchase items and services for an eligible urban Indian 

10 as those terms are defined in section 4 of the Indian 

11 Health Care Improvement Act (25 U.S.C. 1603) according 

12 to section 503 of such Act (25 U.S.C. 1653) and applica13 ble regulations. Services and items furnished by physicians 

14 and other health care professionals and non-hospital-based 

15 entities shall be subject to the payment methodology set 

16 forth in this section. 

17 (e) EXCEPTION.—In the case of a payment described 

18 in subsection (c) that is with respect to a rare specialty 

19 service, as specified by the Secretary of Health and 

20 Human Services, or a service furnished in highly rural and 

21 medically underserved areas, as specified by the Secretary, 

22 the Indian Health Service or tribe or tribal organization 

23 involved may negotiate an amount for such payment for 

24 such service that is greater than the payment amount that 


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1 would be recognized under title XVIII of the Social Secu2 rity for such service. 

3 (f) REPORT.—Not later than two years after the date 

4 of the enactment of this Act, the Secretary of Health and 

5 Human Services, acting through the Director of the In6 dian Health Service, shall submit to Congress a report on 

7 the impact of this section on access to care under the Pur8 chased/Referred Care program, including recommenda9 tions for such legislative actions as the Secretary deter10 mines appropriate. 

11 SEC. 302. ALLOCATION OF PURCHASED/REFERRED CARE 

12 PROGRAM FUNDS. 

13 (a) IN GENERAL.—Title II of the Indian Health Care 

14 Improvement Act is amended by inserting after section 

15 226 (25 U.S.C. 1621y) the following new section: 

16 ‘‘SEC. 227. PURCHASED/REFERRED CARE PROGRAM DIS17 BURSEMENT FORMULA. 

18 ‘‘(a) IN GENERAL.—The Secretary shall, with respect 

19 to the Purchased/Referred Care program (formerly re20 ferred to as the ‘contract health services program’) funded 

21 by the Indian Health Service and operated by the Indian 

22 Health Service, an Indian tribe, or tribal organization, re23 view the distribution of funds pursuant to the program 

24 and initiate procedures under subchapter III of chapter 

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1 gate regulations to develop and implement a revised dis2 tribution formula in accordance with the subsequent sub3 sections of this section. 

4 ‘‘(b) CONSIDERATIONS.—In developing the revised 

5 distribution formula under subsection (a), the Secretary 

6 shall consider— 

7 ‘‘(1) the extent to which services are available 

8 at a Service hospital or facility of the Service rather 

9 than the mere existence of such a hospital or facility; 

10 ‘‘(2) population growth and the potential for 

11 population growth; 

12 ‘‘(3) the socioeconomic makeup of the popu13 lation of each contract health service delivery area; 

14 ‘‘(4) the geographic makeup of each contract 

15 health service delivery area; 

16 ‘‘(5) the size of the hospital or facility; 

17 ‘‘(6) the relative regional cost of purchasing 

18 services; 

19 ‘‘(7) actual counts of Purchased/Referred Care 

20 users; and 

21 ‘‘(8) accreditation problems at the Service hos22 pital or facility of the Service. 

23 ‘‘(c) IMPLEMENTATION DEADLINE.—The revised dis24 tribution formula under subsection (a) shall be imple25 mented not later than the date that is 3 years after the 


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1 first October 1 following the date of the enactment of this 

2 Act. 

3 ‘‘(d) TRANSITION.— 

4 ‘‘(1) IN GENERAL.—Notwithstanding any other 

5 provision of law, for the period beginning on the 

6 first October 1 following the date of the enactment 

7 of this section and ending the day before the imple8 mentation date of the revised distribution formula 

9 under subsection (a), the Secretary shall provide for 

10 the distribution of funds, with respect to direct 

11 health care services provided by a Service facility, 

12 pursuant to the Purchased/Referred Care program 

13 (and with respect to services provided by any other 

14 facility under such program, at the option of such 

15 facility) be consistent with the following: 

16 ‘‘(A) During any portion of such period for 

17 which a Service area has been designated as a 

18 high IHS level area under paragraph (2)(B), 

19 such area shall not receive any funds pursuant 

20 to such program in addition to the base allot21 ment determined under the distribution formula 

22 under the program for 2016 with respect to 

23 such area. 

24 ‘‘(B) In the case that during such period 

25 the amount of funds made available to the 


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1 Service for such distribution under such pro2 gram is in excess of the total amounts of base 

3 allotments for distribution under such program 

4 for 2016, the Secretary shall distribute such ex5 cess amount, in accordance with a methodology 

6 specified by the Secretary, to Service areas 

7 which for an applicable portion of such period 

8 of excess funding have been designated as a low 

9 IHS level area under paragraph (2)(A). 

10 ‘‘(2) AREA DESIGNATIONS.—For purposes of 

11 paragraph (1), the Secretary shall, with respect to 

12 each contract health service delivery area— 

13 ‘‘(A) review the services provided in the 

14 area to determine the IHS medical priority level 

15 pursuant to section 136.23(e) of title 42, Code 

16 of Federal Regulations, of such services; and 

17 ‘‘(B) in the case majority, as specified by 

18 the Secretary, of the services so provided in the 

19 area were determined to have— 

20 ‘‘(i) such a priority level of a I or II, 

21 designate such area as a low IHS level 

22 area; and 

23 ‘‘(ii) any other priority level, designate 

24 such area as a high IHS level area. 


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1 ‘‘(e) APPLICATION OF REDUCTION CLAUSE.—In the 

2 case of a facility that, as of the date of the enactment 

3 of this section, is under contract with the Secretary with 

4 respect to the Purchased/Referred Care program and such 

5 contract applies to a period to which subsection (d) or the 

6 revised distribution formula under subsection (a) applies, 

7 if application of subsection (d) or the revised distribution 

8 formula results in the distribution of an amount of funds 

9 to such facility during such period that is less than the 

10 amount of funds that would be provided during such pe11 riod to such facility under such contract with respect to 

12 the Purchased/Referred Care program before application 

13 of such subsection (d) or such revised distribution for14 mula, respectively, the Secretary may under section 

15 106(b) of the Indian Self-Determination and Education 

16 Assistance Act (25 U.S.C. 450j–1(b)) reduce such amount 

17 accordingly to be consistent with such subsection (d) or 

18 revised distribution formula, respectively. 

19 ‘‘(f) CLARIFICATION.—Nothing in this section shall 

20 be construed to supersede a Tribe’s self-governance con21 tract under the Indian Self-Determination and Education 

22 Assistance Act. 

23 ‘‘(g) UPDATE.—The Secretary shall periodically, but 

24 not more frequently than once every 3 years and not less 

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1 essary, update the formula implemented under subsection 

2 (a). 

3 ‘‘(h) CONSULTATION.—In developing the formula 

4 under subsection (a) and reviewing and making updates 

5 to such formula under subsection (f), the Secretary shall 

6 consult with Indian tribes, including such tribes consulted 

7 for purposes of carrying out section 226. 

8 ‘‘(i) REPORTS.—Not later than one year after the 

9 date of the enactment of this section, and annually there10 after, the Secretary shall submit to Congress a report on 

11 the implementation of this section. Each such report shall 

12 include information, with respect to the period for such 

13 report, on— 

14 ‘‘(1) the distribution of funds for such period 

15 pursuant to the Purchased/Referred Care program 

16 among the contract health service delivery area, 

17 tribes, tribal organizations, and urban Indian orga18 nizations; 

19 ‘‘(2) whether during such period any contract 

20 health service delivery area, tribe, tribal organiza21 tion, or urban Indian organization had a shortfall in 

22 such funding and, if so, the amount of such short23 fall; and 

24 ‘‘(3) recommendations for such legislative ac25 tion as the Secretary deems appropriate.’’. 


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1 (b) CONFORMING AMENDMENTS.—Section 226 of the 

2 Indian Health Care Improvement Act (25 U.S.C. 1621y) 

3 is amended— 

4 (1) in subsection (a)— 

5 (A) by striking ‘‘As soon as practicable 

6 after the date of enactment of the Indian 

7 Health Care Improvement Reauthorization and 

8 Extension Act of 2009’’ and inserting ‘‘Not 

9 later than 2 years after the date of the enact10 ment of section 227’’; 

11 (B) by striking ‘‘the study’’ and inserting 

12 ‘‘a study’’; and 

13 (C) by striking ‘‘as requested by Congress 

14 in March 2009, or pursuant to section 830’’ 

15 and inserting ‘‘, including as amended pursuant 

16 to section 227’’; 

17 (2) in subsection (b)— 

18 (A) in the matter preceding paragraph (1), 

19 by inserting ‘‘, and submit, not later than one 

20 year after the date of the enactment of section 

21 227 and annually thereafter, to Congress a re22 port on’’ after ‘‘pursuant to the program’’; 

23 (B) in paragraph (3), by striking at the 

24 end ‘‘and’’; 


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1 (C) by redesignating paragraph (4) as 

2 paragraph (5); 

3 (D) by inserting after paragraph (3) the 

4 following new paragraph: 

5 ‘‘(4) to determine whether during the period of 

6 the report any contract health service delivery area, 

7 tribe, tribal organization, or urban Indian organiza8 tion had a shortfall in such funding and, if so, the 

9 amount of such shortfall; and 

10 ‘‘(5) recommendations for such legislative ac11 tion as the Secretary deems appropriate.’’; and 

12 (E) in paragraph (5), as redesignated by 

13 subparagraph (C), by inserting ‘‘, including rec14 ommendations for such legislative actions as the 

15 Secretary determines appropriate’’ before the 

16 period at the end; and 

17 (3) by striking subsection (c). 

18 SEC. 303. PURCHASED/REFERRED CARE PROGRAM BACK19 LOG. 

20 Title II of the Indian Health Care Improvement Act 

21 (25 U.S.C. 1621), as amended by section 302, is further 

22 amended by adding at the end the following new section: 


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1 ‘‘SEC. 228. PURCHASED/REFERRED CARE PROGRAM BACK2 LOG. 

3 ‘‘Not later than one year after the date of the enact4 ment of this section, the Secretary shall develop and im5 plement a system to prioritize any backlog of unpaid bal6 ances under the Purchased/Referred Care program for 

7 each Service area. In developing such system, the Sec8 retary shall consider— 

9 ‘‘(1) the monetary amount of each such unpaid 

10 balance; and 

11 ‘‘(2) how long such balance has remained un12 paid.’’. 

13 SEC. 304. REPORT ON FINANCIAL STABILITY OF SERVICE 

14 HOSPITALS AND FACILITIES. 

15 Not later than one year after the date of the enact16 ment of this Act, the Comptroller General of the United 

17 States shall submit to Congress a report on issues related 

18 to the financial stability of hospitals and facilities of the 

19 Indian Health Service that have experienced sanction or 

20 threat of sanction by the Centers for Medicare & Medicaid 

21 Services. Such report shall focus on the effects of any reve22 nues lost as a result of the sanction or threat of sanction 

23 and shall include recommendations for legislative action. 

Æ 


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