I 

113TH CONGRESS 

2D SESSION H. R. 4843 

To amend title XVIII of the Social Security Act to provide for a limitation 

under the Medicare program on charges for contract health services 

provided to Indians by Medicare providers of services and suppliers. 

IN THE HOUSE OF REPRESENTATIVES 

JUNE 11, 2014 

Ms. MCCOLLUM (for herself, Mr. COLE, Mr. BEN RAY LUJA ́N of New Mexico, 

Mr. ISSA, Mr. GRIJALVA, Mr. KLINE, Mr. PALLONE, Mr. YOUNG of Alaska, Mr. HUFFMAN, and Mr. KIND) introduced the following bill; which 

was referred to the Committee on Energy and Commerce, and in addition 

to the Committees on Ways and Means and Natural Resources, 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 title XVIII of the Social Security Act to provide 

for a limitation under the Medicare program on charges 

for contract health services provided to Indians by Medicare providers of services and suppliers. 

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

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1 SECTION 1. SHORT TITLE. 

2 This Act may be cited as the ‘‘Native Contract and 

3 Rate Expenditure Act of 2014’’ or the ‘‘Native CARE Act 

4 of 2014’’. 

5 SEC. 2. FINDINGS. 

6 Congress makes the following findings: 

7 (1) Federal health services to maintain and im8 prove the health of American Indians and Alaska 

9 Natives are consonant with and required by the Fed10 eral Government’s historical and unique legal rela11 tionship with, and resulting trust responsibility to, 

12 the American Indian and Alaska Native people. 

13 (2) The unmet health needs of American Indi14 ans and Alaska Natives are severe and the health 

15 status of American Indians and Alaska Natives is 

16 far below that of the general population of the 

17 United States, resulting in an average life expect18 ancy for American Indians and Alaska Natives 4.2 

19 years less than that for the all races population of 

20 the United States. 

21 (3) The Indian Health Service and tribal Pur22 chased/Referred Care programs purchase primary 

23 and specialty care services from private health care 

24 providers when those services are not available at In25 dian Health Service or Tribal health facilities. 

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1 (4) Available Purchased/Referred Care funds 

2 have been insufficient to ensure access to care for 

3 American Indians and Alaska Natives, resulting in 

4 rationed care and diagnosis and treatment delays 

5 that lead to the need for more intensive and expen6 sive treatment, further reducing already scarce Pur7 chased/Referred Care funds. 

8 (5) In 2003, Congress amended title XVIII of 

9 the Social Security Act to require Medicare-partici10 pating hospitals to accept patients referred from the 

11 Indian Health Service and Tribal Purchased/Re12 ferred Care programs and to accept payment at no 

13 more than Medicare rates—the Medicare-like rate 

14 cap—for the services provided. 

15 (6) The Medicare-like rate cap only applies to 

16 hospital services, and does not apply to other types 

17 of Medicare-participating providers and suppliers. 

18 (7) Unlike other Federal health care programs, 

19 the Indian Health Service and Tribal Purchased/Re20 ferred Care programs continue to pay full billed 

21 charges for non-hospital services. 

22 (8) Because Purchased/Referred programs con23 tinue to pay full billed charges for non-hospital serv24 ices, in many cases the Indian Health Service may 

25 only treat the most desperate ‘‘Life’’ or ‘‘Limb’’ 

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1 cases, leading to many undesirable health outcomes 

2 for American Indians and Alaska Natives, and ulti3 mately increasing costs to the Purchased/Referred 

4 Care programs. 

5 (9) On April 11, 2013, the Government Ac6 countability Office released a report finding that 

7 capping Purchased/Referred Care reimbursement at 

8 Medicare-like rates for nonhospital services would 

9 enable the Indian Health Service to double the num10 ber of physician services provided by adding an addi11 tional 253,000 patient visits annually. 

12 SEC. 3. LIMITATION ON CHARGES FOR CERTAIN CONTRACT 

13 HEALTH SERVICES PROVIDED TO INDIANS BY 

14 MEDICARE PROVIDERS OF SERVICES AND 

15 SUPPLIERS. 

16 (a) APPLICATION TO ALL PROVIDERS OF SERV17 ICES.— 

18 (1) IN GENERAL.—Section 1866(a)(1)(U) of 

19 the Social Security Act (42 U.S.C. 1395cc(a)(1)(U)) 

20 is amended, in the matter preceding clause (i), by 

21 striking ‘‘in the case of hospitals which furnish inpa22 tient hospital services for which payment may be 

23 made under this title,’’. 

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1 (2) REGULATIONS.—The Secretary of Health 

2 and Human Services shall promulgate regulations to 

3 account for the amendment made by paragraph (1). 

4 (3) EFFECTIVE DATE.—The amendment made 

5 by paragraph (1) shall apply to Medicare participa6 tion agreements in effect (or entered into) on or 

7 after the date that is 90 days after the date of en8 actment of this Act. 

9 (b) APPLICATION TO ALL SUPPLIERS.— 

10 (1) IN GENERAL.—Section 1834 of the Social 

11 Security Act (42 U.S.C. 1395m) is amended by add12 ing at the end the following new subsection: 

13 ‘‘(r) LIMITATION ON CHARGES FOR CERTAIN CON14 TRACT HEALTH SERVICES PROVIDED TO INDIANS BY

15 SUPPLIERS.—No payment may be made under this title 

16 for an item or service furnished by a supplier (as defined 

17 in section 1861(d)) unless the supplier agrees (pursuant 

18 to a process established by the Secretary) to be a partici19 pating provider of medical and other health services 

20 both— 

21 ‘‘(1) under the Purchased/Referred Care pro22 gram (formerly referred to as the ‘contract health 

23 services program’) funded by the Indian Health 

24 Service and operated by the Indian Health Service, 

25 an Indian tribe, or tribal organization (as those 

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1 terms are defined in section 4 of the Indian Health 

2 Care Improvement Act), with respect to items and 

3 services that are covered under such program and 

4 furnished to an individual eligible for such items and 

5 services under such program; and 

6 ‘‘(2) under any program funded by the Indian 

7 Health Service and operated by an urban Indian or8 ganization with respect to the purchase of items and 

9 services for an eligible urban Indian (as those terms 

10 are defined in such section 4), 

11 in accordance with regulations promulgated by the Sec12 retary regarding payment methodology and rates of pay13 ment (including the acceptance of no more than such pay14 ment rate as payment in full for such items and serv15 ices).’’. 

16 (2) EFFECTIVE DATE.—The amendment made 

17 by paragraph (1) shall apply to items and services 

18 furnished on or after the date that is 90 days after 

19 the date of enactment of this Act. 

20 (c) LIMITATION.—There shall be no reduction, offset, 

21 or limitation to any appropriations made to the Indian 

22 Health Service under the Indian Health Care Improve23 ment Act (25 U.S.C. 1621 et seq.), the Act of November 

24 2, 1921 (25 U.S.C. 13) (commonly known as the ‘‘Snyder 

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1 Act’’), or any other provision of law as a result of the 

2 provisions of, including amendments made by, this Act. 

3 (d) STUDIES AND REPORTS.— 

4 (1) STUDY.—The Secretary of Health and 

5 Human Services (in this subsection referred to as 

6 the ‘‘Secretary’’), acting through the Director of the 

7 Indian Health Service, shall conduct a study on the 

8 impact of the amendments made by this section on 

9 access to care under the Purchased/Referred Care 

10 program of the Indian Health Service. 

11 (2) REPORT.—Not later than 2 years after the 

12 date of enactment of this Act, the Secretary shall 

13 submit to Congress a report containing the results 

14 of the study conducted under paragraph (1), includ15 ing recommendations for such legislation and admin16 istrative action as the Secretary determines appro17 priate. 

18 (3) SECTION 219(c) STUDY AND REPORT.—Sec19 tion 219(c) of the Indian Health Care Improvement 

20 Act (25 U.S.C. 1621r(c)) is amended by striking 

21 ‘‘12 months after the date of the enactment of this 

22 section’’ and inserting ‘‘12 months after the date of 

23 the enactment of the Native Contract and Rate Exmstockstill on DSK4VPTVN1PROD with BILLS

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1 penditure Act of 2014, and biennially thereafter 

2 through 2020’’. 

Æ 

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