110TH CONGRESS 

2D SESSION S. 1200

AN ACT

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,
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1 SECTION 1. SHORT TITLE; TABLE OF CONTENTS. 

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

3 ‘‘Indian Health Care Improvement Act Amendments of 

4 2008’’. 

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

6 this Act is as follows:

Sec. 1. Short title; table of contents. 

TITLE I—AMENDMENTS TO INDIAN LAWS 

Sec. 101. Indian Health Care Improvement Act amended. 

Sec. 102. Soboba sanitation facilities. 

Sec. 103. Native American Health and Wellness Foundation. 

Sec. 104. Modification of term. 

Sec. 105. GAO study and report on payments for contract health services. 

Sec. 106. GAO study of membership criteria for federally recognized Indian 

tribes. 

Sec. 107. GAO study of tribal justice systems. 

TITLE II—IMPROVEMENT OF INDIAN HEALTH CARE PROVIDED 

UNDER THE SOCIAL SECURITY ACT 

Sec. 201. Expansion of payments under Medicare, Medicaid, and SCHIP for all 

covered services furnished by Indian Health Programs. 

Sec. 202. Increased outreach to Indians under Medicaid and SCHIP and improved cooperation in the provision of items and services to Indians under Social Security Act health benefit programs. 

Sec. 203. Additional provisions to increase outreach to, and enrollment of, Indians in SCHIP and Medicaid. 

Sec. 204. Premiums and cost sharing protections under Medicaid, eligibility determinations under Medicaid and SCHIP, and protection of 

certain Indian property from Medicaid estate recovery. 

Sec. 205. Nondiscrimination in qualifications for payment for services under 

Federal health care programs. 

Sec. 206. Consultation on Medicaid, SCHIP, and other health care programs 

funded under the Social Security Act involving Indian Health 

Programs and Urban Indian Organizations. 

Sec. 207. Exclusion waiver authority for affected Indian Health Programs and 

safe harbor transactions under the Social Security Act. 

Sec. 208. Rules applicable under Medicaid and SCHIP to managed care entities 

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

Sec. 209. Annual report on Indians served by Social Security Act health benefit 

programs. 

Sec. 210. Development of recommendations to improve interstate coordination 

of Medicaid and SCHIP coverage of Indian children and other 

children who are outside of their State of residency because of 

educational or other needs. 

Sec. 211. Establishment of National Child Welfare Resource Center for Tribes. 
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Sec. 212. Adjustment to the Medicare Advantage stabilization fund. 

Sec. 213. Moratorium on implementation of changes to case management and 

targeted case management payment requirements under Medicaid. 

Sec. 214. Increased civil money penalties and criminal fines for Medicare fraud 

and abuse. 

Sec. 215. Increased sentences for felonies involving Medicare fraud and abuse. 

TITLE III—MISCELLANEOUS 

Sec. 301. Resolution of apology to Native Peoples of United States.

1 TITLE I—AMENDMENTS TO 

2 INDIAN LAWS 

3 SEC. 101. INDIAN HEALTH CARE IMPROVEMENT ACT 

4 AMENDED. 

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

6 1601 et seq.) is amended to read as follows: 

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

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

9 ‘Indian Health Care Improvement Act’. 

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

11 for this Act is as follows:

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

‘‘Sec. 2. Findings. 

‘‘Sec. 3. Declaration of national Indian health policy. 

‘‘Sec. 4. Definitions.

‘‘TITLE I—INDIAN HEALTH, HUMAN RESOURCES, AND 

DEVELOPMENT

‘‘Sec. 101. Purpose. 

‘‘Sec. 102. Health professions recruitment program for Indians. 

‘‘Sec. 103. Health professions preparatory scholarship program for Indians. 

‘‘Sec. 104. Indian health professions scholarships. 

‘‘Sec. 105. American Indians Into Psychology Program. 

‘‘Sec. 106. Scholarship programs for Indian Tribes. 

‘‘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. 
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‘‘Sec. 113. Indian recruitment and retention program. 

‘‘Sec. 114. Advanced training and research. 

‘‘Sec. 115. Quentin N. Burdick American Indians Into Nursing Program. 

‘‘Sec. 116. Tribal cultural orientation. 

‘‘Sec. 117. INMED Program. 

‘‘Sec. 118. Health training programs of community colleges. 

‘‘Sec. 119. Retention bonus. 

‘‘Sec. 120. Nursing residency program. 

‘‘Sec. 121. Community Health Aide Program. 

‘‘Sec. 122. Tribal Health Program administration. 

‘‘Sec. 123. Health professional chronic shortage demonstration programs. 

‘‘Sec. 124. National Health Service Corps. 

‘‘Sec. 125. Substance abuse counselor educational curricula demonstration programs. 

‘‘Sec. 126. Behavioral health training and community education programs. 

‘‘Sec. 127. Authorization of appropriations. 

‘‘TITLE II—HEALTH SERVICES 

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

‘‘Sec. 202. Catastrophic Health Emergency Fund. 

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

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

‘‘Sec. 205. Shared services for long-term care. 

‘‘Sec. 206. Health services research. 

‘‘Sec. 207. Mammography and other cancer screening. 

‘‘Sec. 208. Patient travel costs. 

‘‘Sec. 209. Epidemiology centers. 

‘‘Sec. 210. Comprehensive school health education programs. 

‘‘Sec. 211. Indian youth program. 

‘‘Sec. 212. Prevention, control, and elimination of communicable and infectious 

diseases. 

‘‘Sec. 213. Other authority for provision of 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 and South Dakota as a contract health service delivery area. 

‘‘Sec. 217. California contract health services program. 

‘‘Sec. 218. California as a contract health service delivery area. 

‘‘Sec. 219. Contract health services for the Trenton service area. 

‘‘Sec. 220. Programs operated by Indian Tribes and Tribal Organizations. 

‘‘Sec. 221. Licensing. 

‘‘Sec. 222. Notification of provision of emergency contract health services. 

‘‘Sec. 223. Prompt action on payment of claims. 

‘‘Sec. 224. Liability for payment. 

‘‘Sec. 225. Office of Indian Men’s Health. 

‘‘Sec. 226. Authorization of appropriations. 

‘‘TITLE III—FACILITIES 

‘‘Sec. 301. Consultation; construction and renovation of facilities; reports. 

‘‘Sec. 302. Sanitation facilities. 

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

‘‘Sec. 304. Expenditure of non-Service funds for renovation. 
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‘‘Sec. 305. Funding for the construction, expansion, and modernization of small 

ambulatory care facilities. 

‘‘Sec. 306. Indian health care delivery demonstration projects. 

‘‘Sec. 307. Land transfer. 

‘‘Sec. 308. Leases, contracts, and other agreements. 

‘‘Sec. 309. Study on loans, loan guarantees, and loan repayment. 

‘‘Sec. 310. Tribal leasing. 

‘‘Sec. 311. Indian Health Service/tribal facilities joint venture program. 

‘‘Sec. 312. Location of facilities. 

‘‘Sec. 313. Maintenance and improvement of health care facilities. 

‘‘Sec. 314. Tribal management of Federally-owned quarters. 

‘‘Sec. 315. Applicability of Buy American Act requirement. 

‘‘Sec. 316. Other funding for facilities. 

‘‘Sec. 317. Authorization of appropriations. 

‘‘TITLE IV—ACCESS TO HEALTH SERVICES 

‘‘Sec. 401. Treatment of payments under Social Security Act health benefits 

programs. 

‘‘Sec. 402. Grants to and contracts with the Service, Indian Tribes, Tribal Organizations, and Urban Indian Organizations to facilitate outreach, enrollment, and coverage of Indians under Social Security Act health benefit programs and other health benefits programs. 

‘‘Sec. 403. Reimbursement from certain third parties of costs of health services. 

‘‘Sec. 404. Crediting of reimbursements. 

‘‘Sec. 405. Purchasing health care coverage. 

‘‘Sec. 406. Sharing arrangements with Federal agencies. 

‘‘Sec. 407. Eligible Indian veteran services. 

‘‘Sec. 408. Payor of last resort. 

‘‘Sec. 409. Nondiscrimination under Federal health care programs in qualifications for reimbursement for services. 

‘‘Sec. 410. Consultation. 

‘‘Sec. 411. State Children’s Health Insurance Program (SCHIP). 

‘‘Sec. 412. Exclusion waiver authority for affected Indian Health Programs and 

safe harbor transactions under the Social Security Act. 

‘‘Sec. 413. Premium and cost sharing protections and eligibility determinations 

under Medicaid and SCHIP and protection of certain Indian 

property from Medicaid estate recovery. 

‘‘Sec. 414. Treatment under Medicaid and SCHIP managed care. 

‘‘Sec. 415. Navajo Nation Medicaid Agency feasibility study. 

‘‘Sec. 416. General exceptions. 

‘‘Sec. 417. 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. 
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‘‘Sec. 509. Facilities. 

‘‘Sec. 510. Division 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. Conferring with Urban Indian Organizations. 

‘‘Sec. 515. Urban youth treatment center demonstration. 

‘‘Sec. 516. Grants for diabetes prevention, treatment, and control. 

‘‘Sec. 517. Community Health Representatives. 

‘‘Sec. 518. Effective date. 

‘‘Sec. 519. Eligibility for services. 

‘‘Sec. 520. Authorization of appropriations. 

‘‘TITLE VI—ORGANIZATIONAL IMPROVEMENTS 

‘‘Sec. 601. Establishment of the Indian Health Service as an agency of the 

Public Health Service. 

‘‘Sec. 602. Automated management information system. 

‘‘Sec. 603. Authorization of appropriations. 

‘‘TITLE VII—BEHAVIORAL HEALTH PROGRAMS 

‘‘Sec. 701. Behavioral health prevention and treatment services. 

‘‘Sec. 702. Memoranda of agreement with the Department of the Interior. 

‘‘Sec. 703. Comprehensive behavioral health prevention and treatment program. 

‘‘Sec. 704. Mental health technician program. 

‘‘Sec. 705. Licensing requirement for mental health care workers. 

‘‘Sec. 706. Indian women treatment programs. 

‘‘Sec. 707. Indian youth program. 

‘‘Sec. 708. Indian youth telemental health demonstration project. 

‘‘Sec. 709. Inpatient and community-based mental health facilities design, construction, and staffing. 

‘‘Sec. 710. Training and community education. 

‘‘Sec. 711. Behavioral health program. 

‘‘Sec. 712. Fetal alcohol spectrum disorders programs. 

‘‘Sec. 713. Child sexual abuse and prevention treatment programs. 

‘‘Sec. 714. Domestic and sexual violence prevention and treatment. 

‘‘Sec. 715. Testimony by service employees in cases of rape and sexual assault. 

‘‘Sec. 716. Behavioral health research. 

‘‘Sec. 717. Definitions. 

‘‘Sec. 718. 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 relating to abortion. 

‘‘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. Tribal employment. 

‘‘Sec. 812. Severability provisions. 
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‘‘Sec. 813. Establishment of National Bipartisan Commission on Indian Health 

Care. 

‘‘Sec. 814. Confidentiality of medical quality assurance records; qualified immunity for participants. 

‘‘Sec. 815. Sense of Congress regarding law enforcement and methamphetamine 

issues in Indian Country. 

‘‘Sec. 816. Tribal Health Program option for cost sharing. 

‘‘Sec. 817. Testing for sexually transmitted diseases in cases of sexual violence. 

‘‘Sec. 818. Study on tobacco-related disease and disproportionate health effects 

on tribal populations. 

‘‘Sec. 819. Appropriations; availability. 

‘‘Sec. 820. GAO report on coordination of services. 

‘‘Sec. 821. Authorization of appropriations.

1 ‘‘SEC. 2. FINDINGS. 

2 ‘‘Congress makes the following findings: 

3 ‘‘(1) Federal health services to maintain and 

4 improve the health of the Indians are consonant 

5 with and required by the Federal Government’s his6 torical and unique legal relationship with, and re7 sulting responsibility to, the American Indian people. 

8 ‘‘(2) A major national goal of the United States 

9 is to provide the resources, processes, and structure 

10 that will enable Indian Tribes and tribal members to 

11 obtain the quantity and quality of health care serv12 ices and opportunities that will eradicate the health 

13 disparities between Indians and the general popu14 lation of the United States. 

15 ‘‘(3) A major national goal of the United States 

16 is to provide the quantity and quality of health serv17 ices which will permit the health status of Indians 

18 to be raised to the highest possible level and to en-
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1 courage the maximum participation of Indians in the 

2 planning and management of those services. 

3 ‘‘(4) Federal health services to Indians have re4 sulted in a reduction in the prevalence and incidence 

5 of preventable illnesses among, and unnecessary and 

6 premature deaths of, Indians. 

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

8 needs of the American Indian people are severe and 

9 the health status of the Indians is far below that of 

10 the general population of the United States. 

11 ‘‘SEC. 3. DECLARATION OF NATIONAL INDIAN HEALTH POL12 ICY. 

13 ‘‘Congress declares that it is the policy of this Nation, 

14 in fulfillment of its special trust responsibilities and legal 

15 obligations to Indians—

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

17 for Indians and Urban Indians and to provide all re18 sources necessary to effect that policy; 

19 ‘‘(2) to raise the health status of Indians and 

20 Urban Indians to at least the levels set forth in the 

21 goals contained within the Healthy People 2010 or 

22 successor objectives; 

23 ‘‘(3) to ensure maximum Indian participation in 

24 the direction of health care services so as to render 

25 the persons administering such services and the 
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1 services themselves more responsive to the needs and 

2 desires of Indian communities; 

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

4 the health professions and allied and associated 

5 health professions awarded to Indians so that the 

6 proportion of Indian health professionals in each 

7 Service Area is raised to at least the level of that of 

8 the general population; 

9 ‘‘(5) to require that all actions under this Act 

10 shall be carried out with active and meaningful con11 sultation with Indian Tribes and Tribal Organiza12 tions, and conference with Urban Indian Organiza13 tions, to implement this Act and the national policy 

14 of Indian self-determination; 

15 ‘‘(6) to ensure that the United States and In16 dian Tribes work in a government-to-government re17 lationship to ensure quality health care for all tribal 

18 members; and 

19 ‘‘(7) to provide funding for programs and facili20 ties operated by Indian Tribes and Tribal Organiza21 tions in amounts that are not less than the amounts 

22 provided to programs and facilities operated directly 

23 by the Service. 

24 ‘‘SEC. 4. DEFINITIONS. 

25 ‘‘For purposes of this Act: 
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1 ‘‘(1) The term ‘accredited and accessible’ means 

2 on or near a reservation and accredited by a na3 tional or regional organization with accrediting au4 thority. 

5 ‘‘(2) The term ‘Area Office’ means an adminis6 trative entity, including a program office, within the 

7 Service through which services and funds are pro8 vided to the Service Units within a defined geo9 graphic area. 

10 ‘‘(3)(A) The term ‘behavioral health’ means the 

11 blending of substance (alcohol, drugs, inhalants, and 

12 tobacco) abuse and mental health prevention and 

13 treatment, for the purpose of providing comprehen14 sive services. 

15 ‘‘(B) The term ‘behavioral health’ includes the 

16 joint development of substance abuse and mental 

17 health treatment planning and coordinated case 

18 management using a multidisciplinary approach. 

19 ‘‘(4) The term ‘California Indians’ means those 

20 Indians who are eligible for health services of the 

21 Service pursuant to section 806. 

22 ‘‘(5) The term ‘community college’ means—

23 ‘‘(A) a tribal college or university, or 

24 ‘‘(B) a junior or community college. 
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1 ‘‘(6) The term ‘contract health service’ means 

2 health services provided at the expense of the Serv3 ice or a Tribal Health Program by public or private 

4 medical providers or hospitals, other than the Serv5 ice Unit or the Tribal Health Program at whose ex6 pense the services are provided. 

7 ‘‘(7) The term ‘Department’ means, unless oth8 erwise designated, the Department of Health and 

9 Human Services. 

10 ‘‘(8) The term ‘Director’ means the Director of 

11 the Service. 

12 ‘‘(9) The term ‘disease prevention’ means the 

13 reduction, limitation, and prevention of disease and 

14 its complications and reduction in the consequences 

15 of disease, including—

16 ‘‘(A) controlling—

17 ‘‘(i) the development of diabetes; 

18 ‘‘(ii) high blood pressure; 

19 ‘‘(iii) infectious agents; 

20 ‘‘(iv) injuries; 

21 ‘‘(v) occupational hazards and disabil22 ities; 

23 ‘‘(vi) sexually transmittable diseases; 

24 and 

25 ‘‘(vii) toxic agents; and 
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1 ‘‘(B) providing—

2 ‘‘(i) fluoridation of water; and 

3 ‘‘(ii) immunizations. 

4 ‘‘(10) The term ‘health profession’ means 

5 allopathic medicine, family medicine, internal medi6 cine, pediatrics, geriatric medicine, obstetrics and 

7 gynecology, podiatric medicine, nursing, public 

8 health nursing, dentistry, psychiatry, osteopathy, op9 tometry, pharmacy, psychology, public health, social 

10 work, marriage and family therapy, chiropractic 

11 medicine, environmental health and engineering, al12 lied health professions, and any other health profes13 sion. 

14 ‘‘(11) The term ‘health promotion’ means—

15 ‘‘(A) fostering social, economic, environ16 mental, and personal factors conducive to 

17 health, including raising public awareness about 

18 health matters and enabling the people to cope 

19 with health problems by increasing their knowl20 edge and providing them with valid information; 

21 ‘‘(B) encouraging adequate and appro22 priate diet, exercise, and sleep; 

23 ‘‘(C) promoting education and work in con24 formity with physical and mental capacity; 
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1 ‘‘(D) making available safe water and sani2 tary facilities; 

3 ‘‘(E) improving the physical, economic, cul4 tural, psychological, and social environment; 

5 ‘‘(F) promoting culturally competent care; 

6 and 

7 ‘‘(G) providing adequate and appropriate 

8 programs, which may include—

9 ‘‘(i) abuse prevention (mental and 

10 physical); 

11 ‘‘(ii) community health; 

12 ‘‘(iii) community safety; 

13 ‘‘(iv) consumer health education; 

14 ‘‘(v) diet and nutrition; 

15 ‘‘(vi) immunization and other preven16 tion of communicable diseases, including 

17 HIV/AIDS; 

18 ‘‘(vii) environmental health; 

19 ‘‘(viii) exercise and physical fitness; 

20 ‘‘(ix) avoidance of fetal alcohol spec21 trum disorders; 

22 ‘‘(x) first aid and CPR education; 

23 ‘‘(xi) human growth and development; 

24 ‘‘(xii) injury prevention and personal 

25 safety; 
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1 ‘‘(xiii) behavioral health; 

2 ‘‘(xiv) monitoring of disease indicators 

3 between health care provider visits, 

4 through appropriate means, including 

5 Internet-based health care management 

6 systems; 

7 ‘‘(xv) personal health and wellness 

8 practices; 

9 ‘‘(xvi) personal capacity building; 

10 ‘‘(xvii) prenatal, pregnancy, and in11 fant care; 

12 ‘‘(xviii) psychological well-being; 

13 ‘‘(xix) family planning; 

14 ‘‘(xx) safe and adequate water; 

15 ‘‘(xxi) healthy work environments; 

16 ‘‘(xxii) elimination, reduction, and 

17 prevention of contaminants that create 

18 unhealthy household conditions (including 

19 mold and other allergens); 

20 ‘‘(xxiii) stress control; 

21 ‘‘(xxiv) substance abuse; 

22 ‘‘(xxv) sanitary facilities; 

23 ‘‘(xxvi) sudden infant death syndrome 

24 prevention; 
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1 ‘‘(xxvii) tobacco use cessation and re2 duction; 

3 ‘‘(xxviii) violence prevention; and 

4 ‘‘(xxix) such other activities identified 

5 by the Service, a Tribal Health Program, 

6 or an Urban Indian Organization, to pro7 mote achievement of any of the objectives 

8 described in section 3(2). 

9 ‘‘(12) The term ‘Indian’, unless otherwise des10 ignated, means any person who is a member of an 

11 Indian Tribe or is eligible for health services under 

12 section 806, except that, for the purpose of sections 

13 102 and 103, the term also means any individual 

14 who—

15 ‘‘(A)(i) irrespective of whether the indi16 vidual lives on or near a reservation, is a mem17 ber of a tribe, band, or other organized group 

18 of Indians, including those tribes, bands, or 

19 groups terminated since 1940 and those recog20 nized now or in the future by the State in 

21 which they reside; or 

22 ‘‘(ii) is a descendant, in the first or second 

23 degree, of any such member; 

24 ‘‘(B) is an Eskimo or Aleut or other Alas25 ka Native; 
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1 ‘‘(C) is considered by the Secretary of the 

2 Interior to be an Indian for any purpose; or 

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

4 regulations promulgated by the Secretary. 

5 ‘‘(13) The term ‘Indian Health Program’ 

6 means—

7 ‘‘(A) any health program administered di8 rectly by the Service; 

9 ‘‘(B) any Tribal Health Program; or 

10 ‘‘(C) any Indian Tribe or Tribal Organiza11 tion to which the Secretary provides funding 

12 pursuant to section 23 of the Act of June 25, 

13 1910 (25 U.S.C. 47) (commonly known as the 

14 ‘Buy Indian Act’). 

15 ‘‘(14) The term ‘Indian Tribe’ has the meaning 

16 given the term in the Indian Self-Determination and 

17 Education Assistance Act (25 U.S.C. 450 et seq.). 

18 ‘‘(15) The term ‘junior or community college’ 

19 has the meaning given the term by section 312(e) of 

20 the Higher Education Act of 1965 (20 U.S.C. 

21 1058(e)). 

22 ‘‘(16) The term ‘reservation’ means any feder23 ally recognized Indian Tribe’s reservation, Pueblo, or 

24 colony, including former reservations in Oklahoma, 

25 Indian allotments, and Alaska Native Regions estab-
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1 lished pursuant to the Alaska Native Claims Settle2 ment Act (43 U.S.C. 1601 et seq.). 

3 ‘‘(17) The term ‘Secretary’, unless otherwise 

4 designated, means the Secretary of Health and 

5 Human Services. 

6 ‘‘(18) The term ‘Service’ means the Indian 

7 Health Service. 

8 ‘‘(19) The term ‘Service Area’ means the geo9 graphical area served by each Area Office. 

10 ‘‘(20) The term ‘Service Unit’ means an admin11 istrative entity of the Service, or a Tribal Health 

12 Program through which services are provided, di13 rectly or by contract, to eligible Indians within a de14 fined geographic area. 

15 ‘‘(21) The term ‘telehealth’ has the meaning 

16 given the term in section 330K(a) of the Public 

17 Health Service Act (42 U.S.C. 254c–16(a)). 

18 ‘‘(22) The term ‘telemedicine’ means a tele19 communications link to an end user through the use 

20 of eligible equipment that electronically links health 

21 professionals or patients and health professionals at 

22 separate sites in order to exchange health care infor23 mation in audio, video, graphic, or other format for 

24 the purpose of providing improved health care serv25 ices. 
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1 ‘‘(23) The term ‘tribal college or university’ has 

2 the meaning given the term in section 316(b)(3) of 

3 the Higher Education Act (20 U.S.C. 1059c(b)(3)). 

4 ‘‘(24) The term ‘Tribal Health Program’ means 

5 an Indian Tribe or Tribal Organization that oper6 ates any health program, service, function, activity, 

7 or facility funded, in whole or part, by the Service 

8 through, or provided for in, a contract or compact 

9 with the Service under the Indian Self-Determina10 tion and Education Assistance Act (25 U.S.C. 450 

11 et seq.). 

12 ‘‘(25) The term ‘Tribal Organization’ has the 

13 meaning given the term in the Indian Self-Deter14 mination and Education Assistance Act (25 U.S.C. 

15 450 et seq.). 

16 ‘‘(26) The term ‘Urban Center’ means any com17 munity which has a sufficient Urban Indian popu18 lation with unmet health needs to warrant assistance 

19 under title V of this Act, as determined by the Sec20 retary. 

21 ‘‘(27) The term ‘Urban Indian’ means any indi22 vidual who resides in an Urban Center and who 

23 meets 1 or more of the following criteria: 

24 ‘‘(A) Irrespective of whether the individual 

25 lives on or near a reservation, the individual is 
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1 a member of a tribe, band, or other organized 

2 group of Indians, including those tribes, bands, 

3 or groups terminated since 1940 and those 

4 tribes, bands, or groups that are recognized by 

5 the States in which they reside, or who is a de6 scendant in the first or second degree of any 

7 such member. 

8 ‘‘(B) The individual is an Eskimo, Aleut, 

9 or other Alaska Native. 

10 ‘‘(C) The individual is considered by the 

11 Secretary of the Interior to be an Indian for 

12 any purpose. 

13 ‘‘(D) The individual is determined to be an 

14 Indian under regulations promulgated by the 

15 Secretary. 

16 ‘‘(28) The term ‘Urban Indian Organization’ 

17 means a nonprofit corporate body that (A) is situ18 ated in an Urban Center; (B) is governed by an 

19 Urban Indian-controlled board of directors; (C) pro20 vides for the participation of all interested Indian 

21 groups and individuals; and (D) is capable of legally 

22 cooperating with other public and private entities for 

23 the purpose of performing the activities described in 

24 section 503(a). 
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1 ‘‘TITLE I—INDIAN HEALTH, 

2 HUMAN RESOURCES, AND DE3 VELOPMENT 

4 ‘‘SEC. 101. PURPOSE. 

5 ‘‘The purpose of this title is to increase, to the max6 imum extent feasible, the number of Indians entering the 

7 health professions and providing health services, and to 

8 assure an optimum supply of health professionals to the 

9 Indian Health Programs and Urban Indian Organizations 

10 involved in the provision of health services to Indians. 

11 ‘‘SEC. 102. HEALTH PROFESSIONS RECRUITMENT PROGRAM 

12 FOR INDIANS. 

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

14 the Service, shall make grants to public or nonprofit pri15 vate health or educational entities, Tribal Health Pro16 grams, or Urban Indian Organizations to assist such enti17 ties in meeting the costs of—

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

19 education or training in the health professions and 

20 encouraging and assisting them—

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

22 health professions; or 

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

24 any such courses of study, to undertake such 
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1 postsecondary education or training as may be 

2 required to qualify them for enrollment; 

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

4 available to Indians enrolled in any course of study 

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

6 training necessary to qualify them to enroll in any 

7 such course of study; or 

8 ‘‘(3) establishing other programs which the Sec9 retary determines will enhance and facilitate the en10 rollment of Indians in, and the subsequent pursuit 

11 and completion by them of, courses of study referred 

12 to in paragraph (1). 

13 ‘‘(b) GRANTS.—

14 ‘‘(1) APPLICATION.—The Secretary shall not 

15 make a grant under this section unless an applica16 tion has been submitted to, and approved by, the 

17 Secretary. Such application shall be in such form, 

18 submitted in such manner, and contain such infor19 mation, as the Secretary shall by regulation pre20 scribe pursuant to this Act. The Secretary shall give 

21 a preference to applications submitted by Tribal 

22 Health Programs or Urban Indian Organizations. 

23 ‘‘(2) AMOUNT OF GRANTS; PAYMENT.—The 

24 amount of a grant under this section shall be deter25 mined by the Secretary. Payments pursuant to this 
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1 section may be made in advance or by way of reim2 bursement, and at such intervals and on such condi3 tions as provided for in regulations issued pursuant 

4 to this Act. To the extent not otherwise prohibited 

5 by law, grants shall be for 3 years, as provided in 

6 regulations issued pursuant to this Act. 

7 ‘‘SEC. 103. HEALTH PROFESSIONS PREPARATORY SCHOL8 ARSHIP PROGRAM FOR INDIANS. 

9 ‘‘(a) SCHOLARSHIPS AUTHORIZED.—The Secretary, 

10 acting through the Service, shall provide scholarship 

11 grants to Indians who—

12 ‘‘(1) have successfully completed their high 

13 school education or high school equivalency; and 

14 ‘‘(2) have demonstrated the potential to suc15 cessfully complete courses of study in the health pro16 fessions. 

17 ‘‘(b) PURPOSES.—Scholarship grants provided pursu18 ant to this section shall be for the following purposes: 

19 ‘‘(1) Compensatory preprofessional education of 

20 any recipient, such scholarship not to exceed 2 years 

21 on a full-time basis (or the part-time equivalent 

22 thereof, as determined by the Secretary pursuant to 

23 regulations issued under this Act). 

24 ‘‘(2) Pregraduate education of any recipient 

25 leading to a baccalaureate degree in an approved 
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1 course of study preparatory to a field of study in a 

2 health profession, such scholarship not to exceed 4 

3 years. An extension of up to 2 years (or the part4 time equivalent thereof, as determined by the Sec5 retary pursuant to regulations issued pursuant to 

6 this Act) may be approved. 

7 ‘‘(c) OTHER CONDITIONS.—Scholarships under this 

8 section—

9 ‘‘(1) may cover costs of tuition, books, trans10 portation, board, and other necessary related ex11 penses of a recipient while attending school; 

12 ‘‘(2) shall not be denied solely on the basis of 

13 the applicant’s scholastic achievement if such appli14 cant has been admitted to, or maintained good 

15 standing at, an accredited institution; and 

16 ‘‘(3) shall not be denied solely by reason of such 

17 applicant’s eligibility for assistance or benefits under 

18 any other Federal program. 

19 ‘‘SEC. 104. INDIAN HEALTH PROFESSIONS SCHOLARSHIPS. 

20 ‘‘(a) IN GENERAL.—

21 ‘‘(1) AUTHORITY.—The Secretary, acting 

22 through the Service, shall make scholarship grants 

23 to Indians who are enrolled full or part time in ac24 credited schools pursuing courses of study in the 

25 health professions. Such scholarships shall be des-
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1 ignated Indian Health Scholarships and shall be 

2 made in accordance with section 338A of the Public 

3 Health Services Act (42 U.S.C. 254l), except as pro4 vided in subsection (b) of this section. 

5 ‘‘(2) DETERMINATIONS BY SECRETARY.—The 

6 Secretary, acting through the Service, shall deter7 mine—

8 ‘‘(A) who shall receive scholarship grants 

9 under subsection (a); and 

10 ‘‘(B) the distribution of the scholarships 

11 among health professions on the basis of the 

12 relative needs of Indians for additional service 

13 in the health professions. 

14 ‘‘(3) CERTAIN DELEGATION NOT ALLOWED.—

15 The administration of this section shall be a respon16 sibility of the Director and shall not be delegated in 

17 a contract or compact under the Indian Self-Deter18 mination and Education Assistance Act (25 U.S.C. 

19 450 et seq.). 

20 ‘‘(b) ACTIVE DUTY SERVICE OBLIGATION.—

21 ‘‘(1) OBLIGATION MET.—The active duty serv22 ice obligation under a written contract with the Sec23 retary under this section that an Indian has entered 

24 into shall, if that individual is a recipient of an In25 dian Health Scholarship, be met in full-time practice 
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1 equal to 1 year for each school year for which the 

2 participant receives a scholarship award under this 

3 part, or 2 years, whichever is greater, by service in 

4 1 or more of the following: 

5 ‘‘(A) In an Indian Health Program. 

6 ‘‘(B) In a program assisted under title V 

7 of this Act. 

8 ‘‘(C) In the private practice of the applica9 ble profession if, as determined by the Sec10 retary, in accordance with guidelines promul11 gated by the Secretary, such practice is situated 

12 in a physician or other health professional 

13 shortage area and addresses the health care 

14 needs of a substantial number of Indians. 

15 ‘‘(D) In a teaching capacity in a tribal col16 lege or university nursing program (or a related 

17 health profession program) if, as determined by 

18 the Secretary, the health service provided to In19 dians would not decrease. 

20 ‘‘(2) OBLIGATION DEFERRED.—At the request 

21 of any individual who has entered into a contract re22 ferred to in paragraph (1) and who receives a degree 

23 in medicine (including osteopathic or allopathic med24 icine), dentistry, optometry, podiatry, or pharmacy, 

25 the Secretary shall defer the active duty service obli-
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1 gation of that individual under that contract, in 

2 order that such individual may complete any intern3 ship, residency, or other advanced clinical training 

4 that is required for the practice of that health pro5 fession, for an appropriate period (in years, as deter6 mined by the Secretary), subject to the following 

7 conditions: 

8 ‘‘(A) No period of internship, residency, or 

9 other advanced clinical training shall be counted 

10 as satisfying any period of obligated service 

11 under this subsection. 

12 ‘‘(B) The active duty service obligation of 

13 that individual shall commence not later than 

14 90 days after the completion of that advanced 

15 clinical training (or by a date specified by the 

16 Secretary). 

17 ‘‘(C) The active duty service obligation will 

18 be served in the health profession of that indi19 vidual in a manner consistent with paragraph 

20 (1). 

21 ‘‘(D) A recipient of a scholarship under 

22 this section may, at the election of the recipient, 

23 meet the active duty service obligation described 

24 in paragraph (1) by service in a program speci25 fied under that paragraph that—
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1 ‘‘(i) is located on the reservation of 

2 the Indian Tribe in which the recipient is 

3 enrolled; or 

4 ‘‘(ii) serves the Indian Tribe in which 

5 the recipient is enrolled. 

6 ‘‘(3) PRIORITY WHEN MAKING ASSIGNMENTS.—

7 Subject to paragraph (2), the Secretary, in making 

8 assignments of Indian Health Scholarship recipients 

9 required to meet the active duty service obligation 

10 described in paragraph (1), shall give priority to as11 signing individuals to service in those programs 

12 specified in paragraph (1) that have a need for 

13 health professionals to provide health care services 

14 as a result of individuals having breached contracts 

15 entered into under this section. 

16 ‘‘(c) PART-TIME STUDENTS.—In the case of an indi17 vidual receiving a scholarship under this section who is 

18 enrolled part time in an approved course of study—

19 ‘‘(1) such scholarship shall be for a period of 

20 years not to exceed the part-time equivalent of 4 

21 years, as determined by the Secretary; 

22 ‘‘(2) the period of obligated service described in 

23 subsection (b)(1) shall be equal to the greater of—

24 ‘‘(A) the part-time equivalent of 1 year for 

25 each year for which the individual was provided 
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1 a scholarship (as determined by the Secretary); 

2 or 

3 ‘‘(B) 2 years; and 

4 ‘‘(3) the amount of the monthly stipend speci5 fied in section 338A(g)(1)(B) of the Public Health 

6 Service Act (42 U.S.C. 254l(g)(1)(B)) shall be re7 duced pro rata (as determined by the Secretary) 

8 based on the number of hours such student is en9 rolled. 

10 ‘‘(d) BREACH OF CONTRACT.—

11 ‘‘(1) SPECIFIED BREACHES.—An individual 

12 shall be liable to the United States for the amount 

13 which has been paid to the individual, or on behalf 

14 of the individual, under a contract entered into with 

15 the Secretary under this section on or after the date 

16 of enactment of the Indian Health Care Improve17 ment Act Amendments of 2008 if that individual—

18 ‘‘(A) fails to maintain an acceptable level 

19 of academic standing in the educational institu20 tion in which he or she is enrolled (such level 

21 determined by the educational institution under 

22 regulations of the Secretary); 

23 ‘‘(B) is dismissed from such educational 

24 institution for disciplinary reasons; 
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1 ‘‘(C) voluntarily terminates the training in 

2 such an educational institution for which he or 

3 she is provided a scholarship under such con4 tract before the completion of such training; or 

5 ‘‘(D) fails to accept payment, or instructs 

6 the educational institution in which he or she is 

7 enrolled not to accept payment, in whole or in 

8 part, of a scholarship under such contract, in 

9 lieu of any service obligation arising under such 

10 contract. 

11 ‘‘(2) OTHER BREACHES.—If for any reason not 

12 specified in paragraph (1) an individual breaches a 

13 written contract by failing either to begin such indi14 vidual’s service obligation required under such con15 tract or to complete such service obligation, the 

16 United States shall be entitled to recover from the 

17 individual an amount determined in accordance with 

18 the formula specified in subsection (l) of section 110 

19 in the manner provided for in such subsection. 

20 ‘‘(3) CANCELLATION UPON DEATH OF RECIPI21 ENT.—Upon the death of an individual who receives 

22 an Indian Health Scholarship, any outstanding obli23 gation of that individual for service or payment that 

24 relates to that scholarship shall be canceled. 

25 ‘‘(4) WAIVERS AND SUSPENSIONS.—
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1 ‘‘(A) IN GENERAL.—The Secretary shall 

2 provide for the partial or total waiver or sus3 pension of any obligation of service or payment 

4 of a recipient of an Indian Health Scholarship 

5 if the Secretary determines that—

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

7 to meet that obligation or make that pay8 ment; 

9 ‘‘(ii) requiring that recipient to meet 

10 that obligation or make that payment 

11 would result in extreme hardship to the re12 cipient; or 

13 ‘‘(iii) the enforcement of the require14 ment to meet the obligation or make the 

15 payment would be unconscionable. 

16 ‘‘(B) FACTORS FOR CONSIDERATION.—Be17 fore waiving or suspending an obligation of 

18 service or payment under subparagraph (A), the 

19 Secretary shall consult with the affected Area 

20 Office, Indian Tribes, or Tribal Organizations, 

21 or confer with the affected Urban Indian Orga22 nizations, and may take into consideration 

23 whether the obligation may be satisfied in a 

24 teaching capacity at a tribal college or univer-
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1 sity nursing program under subsection 

2 (b)(1)(D). 

3 ‘‘(5) EXTREME HARDSHIP.—Notwithstanding 

4 any other provision of law, in any case of extreme 

5 hardship or for other good cause shown, the Sec6 retary may waive, in whole or in part, the right of 

7 the United States to recover funds made available 

8 under this section. 

9 ‘‘(6) BANKRUPTCY.—Notwithstanding any 

10 other provision of law, with respect to a recipient of 

11 an Indian Health Scholarship, no obligation for pay12 ment may be released by a discharge in bankruptcy 

13 under title 11, United States Code, unless that dis14 charge is granted after the expiration of the 5-year 

15 period beginning on the initial date on which that 

16 payment is due, and only if the bankruptcy court 

17 finds that the nondischarge of the obligation would 

18 be unconscionable. 

19 ‘‘SEC. 105. AMERICAN INDIANS INTO PSYCHOLOGY PRO20 GRAM. 

21 ‘‘(a) GRANTS AUTHORIZED.—The Secretary, acting 

22 through the Service, shall make grants of not more than 

23 $300,000 to each of 9 colleges and universities for the pur24 pose of developing and maintaining Indian psychology ca25 reer recruitment programs as a means of encouraging In-
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1 dians to enter the behavioral health field. These programs 

2 shall be located at various locations throughout the coun3 try to maximize their availability to Indian students and 

4 new programs shall be established in different locations 

5 from time to time. 

6 ‘‘(b) QUENTIN N. BURDICK PROGRAM GRANT.—The 

7 Secretary shall provide a grant authorized under sub8 section (a) to develop and maintain a program at the Uni9 versity of North Dakota to be known as the ‘Quentin N. 

10 Burdick American Indians Into Psychology Program’. 

11 Such program shall, to the maximum extent feasible, co12 ordinate with the Quentin N. Burdick Indian Health Pro13 grams authorized under section 117(b), the Quentin N. 

14 Burdick American Indians Into Nursing Program author15 ized under section 115(e), and existing university research 

16 and communications networks. 

17 ‘‘(c) REGULATIONS.—The Secretary shall issue regu18 lations pursuant to this Act for the competitive awarding 

19 of grants provided under this section. 

20 ‘‘(d) CONDITIONS OF GRANT.—Applicants under this 

21 section shall agree to provide a program which, at a min22 imum—

23 ‘‘(1) provides outreach and recruitment for 

24 health professions to Indian communities including 

25 elementary, secondary, and accredited and accessible 
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1 community colleges that will be served by the pro2 gram; 

3 ‘‘(2) incorporates a program advisory board 

4 comprised of representatives from the tribes and 

5 communities that will be served by the program; 

6 ‘‘(3) provides summer enrichment programs to 

7 expose Indian students to the various fields of psy8 chology through research, clinical, and experimental 

9 activities; 

10 ‘‘(4) provides stipends to undergraduate and 

11 graduate students to pursue a career in psychology; 

12 ‘‘(5) develops affiliation agreements with tribal 

13 colleges and universities, the Service, university af14 filiated programs, and other appropriate accredited 

15 and accessible entities to enhance the education of 

16 Indian students; 

17 ‘‘(6) to the maximum extent feasible, uses exist18 ing university tutoring, counseling, and student sup19 port services; and 

20 ‘‘(7) to the maximum extent feasible, employs 

21 qualified Indians in the program. 

22 ‘‘(e) ACTIVE DUTY SERVICE REQUIREMENT.—The 

23 active duty service obligation prescribed under section 

24 338C of the Public Health Service Act (42 U.S.C. 254m) 

25 shall be met by each graduate who receives a stipend de-
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1 scribed in subsection (d)(4) that is funded under this sec2 tion. Such obligation shall be met by service—

3 ‘‘(1) in an Indian Health Program; 

4 ‘‘(2) in a program assisted under title V of this 

5 Act; or 

6 ‘‘(3) 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 ‘‘(f) AUTHORIZATION OF APPROPRIATIONS.—There 

13 is authorized to be appropriated to carry out this section 

14 $2,700,000 for each of fiscal years 2008 through 2017. 

15 ‘‘SEC. 106. SCHOLARSHIP PROGRAMS FOR INDIAN TRIBES. 

16 ‘‘(a) IN GENERAL.—

17 ‘‘(1) GRANTS AUTHORIZED.—The Secretary, 

18 acting through the Service, shall make grants to 

19 Tribal Health Programs for the purpose of providing 

20 scholarships for Indians to serve as health profes21 sionals in Indian communities. 

22 ‘‘(2) AMOUNT.—Amounts available under para23 graph (1) for any fiscal year shall not exceed 5 per24 cent of the amounts available for each fiscal year for 

25 Indian Health Scholarships under section 104. 
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1 ‘‘(3) APPLICATION.—An application for a grant 

2 under paragraph (1) shall be in such form and con3 tain such agreements, assurances, and information 

4 as consistent with this section. 

5 ‘‘(b) REQUIREMENTS.—

6 ‘‘(1) IN GENERAL.—A Tribal Health Program 

7 receiving a grant under subsection (a) shall provide 

8 scholarships to Indians in accordance with the re9 quirements of this section. 

10 ‘‘(2) COSTS.—With respect to costs of providing 

11 any scholarship pursuant to subsection (a)—

12 ‘‘(A) 80 percent of the costs of the scholar13 ship shall be paid from the funds made avail14 able pursuant to subsection (a)(1) provided to 

15 the Tribal Health Program; and 

16 ‘‘(B) 20 percent of such costs may be paid 

17 from any other source of funds. 

18 ‘‘(c) COURSE OF STUDY.—A Tribal Health Program 

19 shall provide scholarships under this section only to Indi20 ans enrolled or accepted for enrollment in a course of 

21 study (approved by the Secretary) in 1 of the health pro22 fessions contemplated by this Act. 

23 ‘‘(d) CONTRACT.—

24 ‘‘(1) IN GENERAL.—In providing scholarships 

25 under subsection (b), the Secretary and the Tribal 
36

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1 Health Program shall enter into a written contract 

2 with each recipient of such scholarship. 

3 ‘‘(2) REQUIREMENTS.—Such contract shall—

4 ‘‘(A) obligate such recipient to provide 

5 service in an Indian Health Program or Urban 

6 Indian Organization, in the same Service Area 

7 where the Tribal Health Program providing the 

8 scholarship is located, for—

9 ‘‘(i) a number of years for which the 

10 scholarship is provided (or the part-time 

11 equivalent thereof, as determined by the 

12 Secretary), or for a period of 2 years, 

13 whichever period is greater; or 

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

15 the recipient and the Tribal Health Pro16 gram may agree; 

17 ‘‘(B) provide that the amount of the schol18 arship—

19 ‘‘(i) may only be expended for—

20 ‘‘(I) tuition expenses, other rea21 sonable educational expenses, and rea22 sonable living expenses incurred in at23 tendance at the educational institu24 tion; and 
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1 ‘‘(II) payment to the recipient of 

2 a monthly stipend of not more than 

3 the amount authorized by section 

4 338(g)(1)(B) of the Public Health 

5 Service Act (42 U.S.C. 

6 254m(g)(1)(B)), with such amount to 

7 be reduced pro rata (as determined by 

8 the Secretary) based on the number of 

9 hours such student is enrolled, and 

10 not to exceed, for any year of attend11 ance for which the scholarship is pro12 vided, the total amount required for 

13 the year for the purposes authorized 

14 in this clause; and 

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

16 attendance for which the scholarship is 

17 provided, the total amount required for the 

18 year for the purposes authorized in clause 

19 (i); 

20 ‘‘(C) require the recipient of such scholar21 ship to maintain an acceptable level of academic 

22 standing as determined by the educational insti23 tution in accordance with regulations issued 

24 pursuant to this Act; and 
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1 ‘‘(D) require the recipient of such scholar2 ship to meet the educational and licensure re3 quirements appropriate to each health profes4 sion. 

5 ‘‘(3) SERVICE IN OTHER SERVICE AREAS.—The 

6 contract may allow the recipient to serve in another 

7 Service Area, provided the Tribal Health Program 

8 and Secretary approve and services are not dimin9 ished to Indians in the Service Area where the Trib10 al Health Program providing the scholarship is lo11 cated. 

12 ‘‘(e) BREACH OF CONTRACT.—

13 ‘‘(1) SPECIFIC BREACHES.—An individual who 

14 has entered into a written contract with the Sec15 retary and a Tribal Health Program under sub16 section (d) shall be liable to the United States for 

17 the Federal share of the amount which has been 

18 paid to him or her, or on his or her behalf, under 

19 the contract if that individual—

20 ‘‘(A) fails to maintain an acceptable level 

21 of academic standing in the educational institu22 tion in which he or she is enrolled (such level 

23 as determined by the educational institution 

24 under regulations of the Secretary); 
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1 ‘‘(B) is dismissed from such educational 

2 institution for disciplinary reasons; 

3 ‘‘(C) voluntarily terminates the training in 

4 such an educational institution for which he or 

5 she is provided a scholarship under such con6 tract before the completion of such training; or 

7 ‘‘(D) fails to accept payment, or instructs 

8 the educational institution in which he or she is 

9 enrolled not to accept payment, in whole or in 

10 part, of a scholarship under such contract, in 

11 lieu of any service obligation arising under such 

12 contract. 

13 ‘‘(2) OTHER BREACHES.—If for any reason not 

14 specified in paragraph (1), an individual breaches a 

15 written contract by failing to either begin such indi16 vidual’s service obligation required under such con17 tract or to complete such service obligation, the 

18 United States shall be entitled to recover from the 

19 individual an amount determined in accordance with 

20 the formula specified in subsection (l) of section 110 

21 in the manner provided for in such subsection. 

22 ‘‘(3) CANCELLATION UPON DEATH OF RECIPI23 ENT.—Upon the death of an individual who receives 

24 an Indian Health Scholarship, any outstanding obli-
40

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1 gation of that individual for service or payment that 

2 relates to that scholarship shall be canceled. 

3 ‘‘(4) INFORMATION.—The Secretary may carry 

4 out this subsection on the basis of information re5 ceived from Tribal Health Programs involved or on 

6 the basis of information collected through such other 

7 means as the Secretary deems appropriate. 

8 ‘‘(f) RELATION TO SOCIAL SECURITY ACT.—The re9 cipient of a scholarship under this section shall agree, in 

10 providing health care pursuant to the requirements here11 in—

12 ‘‘(1) not to discriminate against an individual 

13 seeking care on the basis of the ability of the indi14 vidual to pay for such care or on the basis that pay15 ment for such care will be made pursuant to a pro16 gram established in title XVIII of the Social Secu17 rity Act or pursuant to the programs established in 

18 title XIX or title XXI of such Act; and 

19 ‘‘(2) to accept assignment under section 

20 1842(b)(3)(B)(ii) of the Social Security Act for all 

21 services for which payment may be made under part 

22 B of title XVIII of such Act, and to enter into an 

23 appropriate agreement with the State agency that 

24 administers the State plan for medical assistance 

25 under title XIX, or the State child health plan under 
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1 title XXI, of such Act to provide service to individ2 uals entitled to medical assistance or child health as3 sistance, respectively, under the plan. 

4 ‘‘(g) CONTINUANCE OF FUNDING.—The Secretary 

5 shall make payments under this section to a Tribal Health 

6 Program for any fiscal year subsequent to the first fiscal 

7 year of such payments unless the Secretary determines 

8 that, for the immediately preceding fiscal year, the Tribal 

9 Health Program has not complied with the requirements 

10 of this section. 

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

12 ‘‘(a) EMPLOYMENT PREFERENCE.—Any individual 

13 who receives a scholarship pursuant to section 104 or 106 

14 shall be given preference for employment in the Service, 

15 or may be employed by a Tribal Health Program or an 

16 Urban Indian Organization, or other agencies of the De17 partment as available, during any nonacademic period of 

18 the year. 

19 ‘‘(b) NOT COUNTED TOWARD ACTIVE DUTY SERVICE

20 OBLIGATION.—Periods of employment pursuant to this 

21 subsection shall not be counted in determining fulfillment 

22 of the service obligation incurred as a condition of the 

23 scholarship. 

24 ‘‘(c) TIMING; LENGTH OF EMPLOYMENT.—Any indi25 vidual enrolled in a program, including a high school pro-
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1 gram, authorized under section 102(a) may be employed 

2 by the Service or by a Tribal Health Program or an Urban 

3 Indian Organization during any nonacademic period of the 

4 year. Any such employment shall not exceed 120 days dur5 ing any calendar year. 

6 ‘‘(d) NONAPPLICABILITY OF COMPETITIVE PER7 SONNEL SYSTEM.—Any employment pursuant to this sec8 tion shall be made without regard to any competitive per9 sonnel system or agency personnel limitation and to a po10 sition which will enable the individual so employed to re11 ceive practical experience in the health profession in which 

12 he or she is engaged in study. Any individual so employed 

13 shall receive payment for his or her services comparable 

14 to the salary he or she would receive if he or she were 

15 employed in the competitive system. Any individual so em16 ployed shall not be counted against any employment ceil17 ing affecting the Service or the Department. 

18 ‘‘SEC. 108. CONTINUING EDUCATION ALLOWANCES. 

19 ‘‘In order to encourage scholarship and stipend re20 cipients under sections 104, 105, 106, and 115 and health 

21 professionals, including community health representatives 

22 and emergency medical technicians, to join or continue in 

23 an Indian Health Program, in the case of nurses, to obtain 

24 training and certification as sexual assault nurse exam25 iners, and to provide their services in the rural and remote 
43

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1 areas where a significant portion of Indians reside, the 

2 Secretary, acting through the Service, may—

3 ‘‘(1) provide programs or allowances to transi4 tion into an Indian Health Program, including li5 censing, board or certification examination assist6 ance, and technical assistance in fulfilling service ob7 ligations under sections 104, 105, 106, and 115; and 

8 ‘‘(2) provide programs or allowances to health 

9 professionals employed in an Indian Health Program 

10 to enable them for a period of time each year pre11 scribed by regulation of the Secretary to take leave 

12 of their duty stations for professional consultation, 

13 management, leadership, refresher training courses, 

14 and, in the case of nurses, additional clinical sexual 

15 assault nurse examiner experience to maintain com16 petency or certification. 

17 ‘‘SEC. 109. COMMUNITY HEALTH REPRESENTATIVE PRO18 GRAM. 

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

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

21 as the ‘Snyder Act’), the Secretary, acting through the 

22 Service, shall maintain a Community Health Representa23 tive Program under which Indian Health Programs—

24 ‘‘(1) provide for the training of Indians as com25 munity health representatives; and 
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1 ‘‘(2) use such community health representatives 

2 in the provision of health care, health promotion, 

3 and disease prevention services to Indian commu4 nities. 

5 ‘‘(b) DUTIES.—The Community Health Representa6 tive Program of the Service, shall—

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

8 community health representatives to ensure that the 

9 community health representatives provide quality 

10 health care, health promotion, and disease preven11 tion services to the Indian communities served by 

12 the Program; 

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

14 and maintain a curriculum that—

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

16 health care with supervised practical experience 

17 in the provision of health care; and 

18 ‘‘(B) provides instruction and practical ex19 perience in health promotion and disease pre20 vention activities, with appropriate consider21 ation given to lifestyle factors that have an im22 pact on Indian health status, such as alco23 holism, family dysfunction, and poverty; 

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

25 needs of community health representatives for con-
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1 tinuing education in health care, health promotion, 

2 and disease prevention and develop programs that 

3 meet the needs for continuing education; 

4 ‘‘(4) maintain a system that provides close su5 pervision of Community Health Representatives; 

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

7 of Community Health Representatives is reviewed 

8 and evaluated; and 

9 ‘‘(6) promote traditional health care practices 

10 of the Indian Tribes served consistent with the Serv11 ice standards for the provision of health care, health 

12 promotion, and disease prevention. 

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

14 PROGRAM. 

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

16 through the Service, shall establish and administer a pro17 gram to be known as the Service Loan Repayment Pro18 gram (hereinafter referred to as the ‘Loan Repayment 

19 Program’) in order to ensure an adequate supply of 

20 trained health professionals necessary to maintain accredi21 tation of, and provide health care services to Indians 

22 through, Indian Health Programs and Urban Indian Or23 ganizations. 
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1 ‘‘(b) ELIGIBLE INDIVIDUALS.—To be eligible to par2 ticipate in the Loan Repayment Program, an individual 

3 must—

4 ‘‘(1)(A) be enrolled—

5 ‘‘(i) in a course of study or program in an 

6 accredited educational institution (as deter7 mined by the Secretary under section 

8 338B(b)(1)(c)(i) of the Public Health Service 

9 Act (42 U.S.C. 254l–1(b)(1)(c)(i))) and be 

10 scheduled to complete such course of study in 

11 the same year such individual applies to partici12 pate in such program; or 

13 ‘‘(ii) in an approved graduate training pro14 gram in a health profession; or 

15 ‘‘(B) have—

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

17 ‘‘(ii) a license to practice a health profes18 sion; 

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

20 as a commissioned officer in the Regular or Reserve 

21 Corps of the Public Health Service; 

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

23 in the Regular or Reserve Corps of the Public 

24 Health Service; 
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1 ‘‘(C) meet the professional standards for civil 

2 service employment in the Service; or 

3 ‘‘(D) be employed in an Indian Health Program 

4 or Urban Indian Organization without a service obli5 gation; and 

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

7 a contract described in subsection (e). 

8 ‘‘(c) APPLICATION.—

9 ‘‘(1) INFORMATION TO BE INCLUDED WITH

10 FORMS.—In disseminating application forms and 

11 contract forms to individuals desiring to participate 

12 in the Loan Repayment Program, the Secretary 

13 shall include with such forms a fair summary of the 

14 rights and liabilities of an individual whose applica15 tion is approved (and whose contract is accepted) by 

16 the Secretary, including in the summary a clear ex17 planation of the damages to which the United States 

18 is entitled under subsection (l) in the case of the in19 dividual’s breach of contract. The Secretary shall 

20 provide such individuals with sufficient information 

21 regarding the advantages and disadvantages of serv22 ice as a commissioned officer in the Regular or Re23 serve Corps of the Public Health Service or a civil24 ian employee of the Service to enable the individual 

25 to make a decision on an informed basis. 
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1 ‘‘(2) CLEAR LANGUAGE.—The application form, 

2 contract form, and all other information furnished 

3 by the Secretary under this section shall be written 

4 in a manner calculated to be understood by the aver5 age individual applying to participate in the Loan 

6 Repayment Program. 

7 ‘‘(3) TIMELY AVAILABILITY OF FORMS.—The 

8 Secretary shall make such application forms, con9 tract forms, and other information available to indi10 viduals desiring to participate in the Loan Repay11 ment Program on a date sufficiently early to ensure 

12 that such individuals have adequate time to carefully 

13 review and evaluate such forms and information. 

14 ‘‘(d) PRIORITIES.—

15 ‘‘(1) LIST.—Consistent with subsection (k), the 

16 Secretary shall annually—

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

18 Health Program or Urban Indian Organization 

19 for which there is a need or a vacancy; and 

20 ‘‘(B) rank those positions in order of pri21 ority. 

22 ‘‘(2) APPROVALS.—Notwithstanding the pri23 ority determined under paragraph (1), the Secretary, 

24 in determining which applications under the Loan 
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1 Repayment Program to approve (and which con2 tracts to accept), shall—

3 ‘‘(A) give first priority to applications 

4 made by individual Indians; and 

5 ‘‘(B) after making determinations on all 

6 applications submitted by individual Indians as 

7 required under subparagraph (A), give priority 

8 to—

9 ‘‘(i) individuals recruited through the 

10 efforts of an Indian Health Program or 

11 Urban Indian Organization; and 

12 ‘‘(ii) other individuals based on the 

13 priority rankings under paragraph (1). 

14 ‘‘(e) RECIPIENT CONTRACTS.—

15 ‘‘(1) CONTRACT REQUIRED.—An individual be16 comes a participant in the Loan Repayment Pro17 gram only upon the Secretary and the individual en18 tering into a written contract described in paragraph 

19 (2). 

20 ‘‘(2) CONTENTS OF CONTRACT.—The written 

21 contract referred to in this section between the Sec22 retary and an individual shall contain—

23 ‘‘(A) an agreement under which—

24 ‘‘(i) subject to subparagraph (C), the 

25 Secretary agrees—
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1 ‘‘(I) to pay loans on behalf of the 

2 individual in accordance with the pro3 visions of this section; and 

4 ‘‘(II) to accept (subject to the 

5 availability of appropriated funds for 

6 carrying out this section) the indi7 vidual into the Service or place the in8 dividual with a Tribal Health Pro9 gram or Urban Indian Organization 

10 as provided in clause (ii)(III); and 

11 ‘‘(ii) subject to subparagraph (C), the 

12 individual agrees—

13 ‘‘(I) to accept loan payments on 

14 behalf of the individual; 

15 ‘‘(II) in the case of an individual 

16 described in subsection (b)(1)—

17 ‘‘(aa) to maintain enrollment 

18 in a course of study or training 

19 described in subsection (b)(1)(A) 

20 until the individual completes the 

21 course of study or training; and 

22 ‘‘(bb) while enrolled in such 

23 course of study or training, to 

24 maintain an acceptable level of 

25 academic standing (as deter-
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1 mined under regulations of the 

2 Secretary by the educational in3 stitution offering such course of 

4 study or training); and 

5 ‘‘(III) to serve for a time period 

6 (hereinafter in this section referred to 

7 as the ‘period of obligated service’) 

8 equal to 2 years or such longer period 

9 as the individual may agree to serve 

10 in the full-time clinical practice of 

11 such individual’s profession in an In12 dian Health Program or Urban In13 dian Organization to which the indi14 vidual may be assigned by the Sec15 retary; 

16 ‘‘(B) a provision permitting the Secretary 

17 to extend for such longer additional periods, as 

18 the individual may agree to, the period of obli19 gated service agreed to by the individual under 

20 subparagraph (A)(ii)(III); 

21 ‘‘(C) a provision that any financial obliga22 tion of the United States arising out of a con23 tract entered into under this section and any 

24 obligation of the individual which is conditioned 
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1 thereon is contingent upon funds being appro2 priated for loan repayments under this section; 

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

4 the United States is entitled under subsection 

5 (l) for the individual’s breach of the contract; 

6 and 

7 ‘‘(E) such other statements of the rights 

8 and liabilities of the Secretary and of the indi9 vidual, not inconsistent with this section. 

10 ‘‘(f) DEADLINE FOR DECISION ON APPLICATION.—

11 The Secretary shall provide written notice to an individual 

12 within 21 days on—

13 ‘‘(1) the Secretary’s approving, under sub14 section (e)(1), of the individual’s participation in the 

15 Loan Repayment Program, including extensions re16 sulting in an aggregate period of obligated service in 

17 excess of 4 years; or 

18 ‘‘(2) the Secretary’s disapproving an individ19 ual’s participation in such Program. 

20 ‘‘(g) PAYMENTS.—

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

22 for an individual under a written contract under the 

23 Loan Repayment Program shall consist of payment, 

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

25 individual of the principal, interest, and related ex-
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1 penses on government and commercial loans received 

2 by the individual regarding the undergraduate or 

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

4 loans were made for—

5 ‘‘(A) tuition expenses; 

6 ‘‘(B) all other reasonable educational ex7 penses, including fees, books, and laboratory ex8 penses, incurred by the individual; and 

9 ‘‘(C) reasonable living expenses as deter10 mined by the Secretary. 

11 ‘‘(2) AMOUNT.—For each year of obligated 

12 service that an individual contracts to serve under 

13 subsection (e), the Secretary may pay up to $35,000 

14 or an amount equal to the amount specified in sec15 tion 338B(g)(2)(A) of the Public Health Service 

16 Act, whichever is more, on behalf of the individual 

17 for loans described in paragraph (1). In making a 

18 determination of the amount to pay for a year of 

19 such service by an individual, the Secretary shall 

20 consider the extent to which each such determina21 tion—

22 ‘‘(A) affects the ability of the Secretary to 

23 maximize the number of contracts that can be 

24 provided under the Loan Repayment Program 
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1 from the amounts appropriated for such con2 tracts; 

3 ‘‘(B) provides an incentive to serve in In4 dian Health Programs and Urban Indian Orga5 nizations with the greatest shortages of health 

6 professionals; and 

7 ‘‘(C) provides an incentive with respect to 

8 the health professional involved remaining in an 

9 Indian Health Program or Urban Indian Orga10 nization with such a health professional short11 age, and continuing to provide primary health 

12 services, after the completion of the period of 

13 obligated service under the Loan Repayment 

14 Program. 

15 ‘‘(3) TIMING.—Any arrangement made by the 

16 Secretary for the making of loan repayments in ac17 cordance with this subsection shall provide that any 

18 repayments for a year of obligated service shall be 

19 made no later than the end of the fiscal year in 

20 which the individual completes such year of service. 

21 ‘‘(4) REIMBURSEMENTS FOR TAX LIABILITY.—

22 For the purpose of providing reimbursements for tax 

23 liability resulting from a payment under paragraph 

24 (2) on behalf of an individual, the Secretary—
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1 ‘‘(A) in addition to such payments, may 

2 make payments to the individual in an amount 

3 equal to not less than 20 percent and not more 

4 than 39 percent of the total amount of loan re5 payments made for the taxable year involved; 

6 and 

7 ‘‘(B) may make such additional payments 

8 as the Secretary determines to be appropriate 

9 with respect to such purpose. 

10 ‘‘(5) PAYMENT SCHEDULE.—The Secretary 

11 may enter into an agreement with the holder of any 

12 loan for which payments are made under the Loan 

13 Repayment Program to establish a schedule for the 

14 making of such payments. 

15 ‘‘(h) EMPLOYMENT CEILING.—Notwithstanding any 

16 other provision of law, individuals who have entered into 

17 written contracts with the Secretary under this section 

18 shall not be counted against any employment ceiling af19 fecting the Department while those individuals are under20 going academic training. 

21 ‘‘(i) RECRUITMENT.—The Secretary shall conduct re22 cruiting programs for the Loan Repayment Program and 

23 other manpower programs of the Service at educational 

24 institutions training health professionals or specialists 

25 identified in subsection (a). 
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1 ‘‘(j) APPLICABILITY OF LAW.—Section 214 of the 

2 Public Health Service Act (42 U.S.C. 215) shall not apply 

3 to individuals during their period of obligated service 

4 under the Loan Repayment Program. 

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

6 in assigning individuals to serve in Indian Health Pro7 grams or Urban Indian Organizations pursuant to con8 tracts entered into under this section, shall—

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

10 Health Programs and Urban Indian Organizations 

11 receive consideration on an equal basis with pro12 grams that are administered directly by the Service; 

13 and 

14 ‘‘(2) give priority to assigning individuals to In15 dian Health Programs and Urban Indian Organiza16 tions that have a need for health professionals to 

17 provide health care services as a result of individuals 

18 having breached contracts entered into under this 

19 section. 

20 ‘‘(l) BREACH OF CONTRACT.—

21 ‘‘(1) SPECIFIC BREACHES.—An individual who 

22 has entered into a written contract with the Sec23 retary under this section and has not received a 

24 waiver under subsection (m) shall be liable, in lieu 

25 of any service obligation arising under such contract, 
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1 to the United States for the amount which has been 

2 paid on such individual’s behalf under the contract 

3 if that individual—

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

5 course of study and—

6 ‘‘(i) fails to maintain an acceptable 

7 level of academic standing in the edu8 cational institution in which he or she is 

9 enrolled (such level determined by the edu10 cational institution under regulations of 

11 the Secretary); 

12 ‘‘(ii) voluntarily terminates such en13 rollment; or 

14 ‘‘(iii) is dismissed from such edu15 cational institution before completion of 

16 such course of study; or 

17 ‘‘(B) is enrolled in a graduate training pro18 gram and fails to complete such training pro19 gram. 

20 ‘‘(2) OTHER BREACHES; FORMULA FOR

21 AMOUNT OWED.—If, for any reason not specified in 

22 paragraph (1), an individual breaches his or her 

23 written contract under this section by failing either 

24 to begin, or complete, such individual’s period of ob25 ligated service in accordance with subsection (e)(2), 
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1 the United States shall be entitled to recover from 

2 such individual an amount to be determined in ac3 cordance with the following formula: 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 Secretary of the Treasury; 

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 ‘‘(3) DEDUCTIONS IN MEDICARE PAYMENTS.—

21 Amounts not paid within such period shall be sub22 ject to collection through deductions in Medicare 

23 payments pursuant to section 1892 of the Social Se24 curity Act. 
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1 ‘‘(4) TIME PERIOD FOR REPAYMENT.—Any 

2 amount of damages which the United States is enti3 tled to recover under this subsection shall be paid to 

4 the United States within the 1-year period beginning 

5 on the date of the breach or such longer period be6 ginning on such date as shall be specified by the 

7 Secretary. 

8 ‘‘(5) RECOVERY OF DELINQUENCY.—

9 ‘‘(A) IN GENERAL.—If damages described 

10 in paragraph (4) are delinquent for 3 months, 

11 the Secretary shall, for the purpose of recov12 ering such damages—

13 ‘‘(i) use collection agencies contracted 

14 with by the Administrator of General Serv15 ices; or 

16 ‘‘(ii) enter into contracts for the re17 covery of such damages with collection 

18 agencies selected by the Secretary. 

19 ‘‘(B) REPORT.—Each contract for recov20 ering damages pursuant to this subsection shall 

21 provide that the contractor will, not less than 

22 once each 6 months, submit to the Secretary a 

23 status report on the success of the contractor in 

24 collecting such damages. Section 3718 of title 

25 31, United States Code, shall apply to any such 
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1 contract to the extent not inconsistent with this 

2 subsection. 

3 ‘‘(m) WAIVER OR SUSPENSION OF OBLIGATION.—

4 ‘‘(1) IN GENERAL.—The Secretary shall by reg5 ulation provide for the partial or total waiver or sus6 pension of any obligation of service or payment by 

7 an individual under the Loan Repayment Program 

8 whenever compliance by the individual is impossible 

9 or would involve extreme hardship to the individual 

10 and if enforcement of such obligation with respect to 

11 any individual would be unconscionable. 

12 ‘‘(2) CANCELED UPON DEATH.—Any obligation 

13 of an individual under the Loan Repayment Pro14 gram for service or payment of damages shall be 

15 canceled upon the death of the individual. 

16 ‘‘(3) HARDSHIP WAIVER.—The Secretary may 

17 waive, in whole or in part, the rights of the United 

18 States to recover amounts under this section in any 

19 case of extreme hardship or other good cause shown, 

20 as determined by the Secretary. 

21 ‘‘(4) BANKRUPTCY.—Any obligation of an indi22 vidual under the Loan Repayment Program for pay23 ment of damages may be released by a discharge in 

24 bankruptcy under title 11 of the United States Code 

25 only if such discharge is granted after the expiration 
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1 of the 5-year period beginning on the first date that 

2 payment of such damages is required, and only if 

3 the bankruptcy court finds that nondischarge of the 

4 obligation would be unconscionable. 

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

6 President, for inclusion in the report required to be sub7 mitted to Congress under section 801, a report concerning 

8 the previous fiscal year which sets forth by Service Area 

9 the following: 

10 ‘‘(1) A list of the health professional positions 

11 maintained by Indian Health Programs and Urban 

12 Indian Organizations for which recruitment or reten13 tion is difficult. 

14 ‘‘(2) The number of Loan Repayment Program 

15 applications filed with respect to each type of health 

16 profession. 

17 ‘‘(3) The number of contracts described in sub18 section (e) that are entered into with respect to each 

19 health profession. 

20 ‘‘(4) The amount of loan payments made under 

21 this section, in total and by health profession. 

22 ‘‘(5) The number of scholarships that are pro23 vided under sections 104 and 106 with respect to 

24 each health profession. 
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1 ‘‘(6) The amount of scholarship grants provided 

2 under section 104 and 106, in total and by health 

3 profession. 

4 ‘‘(7) The number of providers of health care 

5 that will be needed by Indian Health Programs and 

6 Urban Indian Organizations, by location and profes7 sion, during the 3 fiscal years beginning after the 

8 date the report is filed. 

9 ‘‘(8) The measures the Secretary plans to take 

10 to fill the health professional positions maintained 

11 by Indian Health Programs or Urban Indian Orga12 nizations for which recruitment or retention is dif13 ficult. 

14 ‘‘SEC. 111. SCHOLARSHIP AND LOAN REPAYMENT RECOV15 ERY FUND. 

16 ‘‘(a) ESTABLISHMENT.—There is established in the 

17 Treasury of the United States a fund to be known as the 

18 Indian Health Scholarship and Loan Repayment Recovery 

19 Fund (hereafter in this section referred to as the ‘LRRF’). 

20 The LRRF shall consist of such amounts as may be col21 lected from individuals under section 104(d), section 

22 106(e), and section 110(l) for breach of contract, such 

23 funds as may be appropriated to the LRRF, and interest 

24 earned on amounts in the LRRF. All amounts collected, 
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1 appropriated, or earned relative to the LRRF shall remain 

2 available until expended. 

3 ‘‘(b) USE OF FUNDS.—

4 ‘‘(1) BY SECRETARY.—Amounts in the LRRF 

5 may be expended by the Secretary, acting through 

6 the Service, to make payments to an Indian Health 

7 Program—

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

9 section 104 and 106 or a loan repayment pro10 gram participant under section 110 has been 

11 assigned to meet the obligated service require12 ments pursuant to such sections; and 

13 ‘‘(B) that has a need for a health profes14 sional to provide health care services as a result 

15 of such recipient or participant having breached 

16 the contract entered into under section 104, 

17 106, or section 110. 

18 ‘‘(2) BY TRIBAL HEALTH PROGRAMS.—A Tribal 

19 Health Program receiving payments pursuant to 

20 paragraph (1) may expend the payments to provide 

21 scholarships or recruit and employ, directly or by 

22 contract, health professionals to provide health care 

23 services. 

24 ‘‘(c) INVESTMENT OF FUNDS.—The Secretary of the 

25 Treasury shall invest such amounts of the LRRF as the 
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1 Secretary of Health and Human Services determines are 

2 not required to meet current withdrawals from the LRRF. 

3 Such investments may be made only in interest bearing 

4 obligations of the United States. For such purpose, such 

5 obligations may be acquired on original issue at the issue 

6 price, or by purchase of outstanding obligations at the 

7 market price. 

8 ‘‘(d) SALE OF OBLIGATIONS.—Any obligation ac9 quired by the LRRF may be sold by the Secretary of the 

10 Treasury at the market price. 

11 ‘‘(e) EFFECTIVE DATE.—This section takes effect on 

12 October 1, 2009. 

13 ‘‘SEC. 112. RECRUITMENT ACTIVITIES. 

14 ‘‘(a) REIMBURSEMENT FOR TRAVEL.—The Sec15 retary, acting through the Service, may reimburse health 

16 professionals seeking positions with Indian Health Pro17 grams or Urban Indian Organizations, including individ18 uals considering entering into a contract under section 

19 110 and their spouses, for actual and reasonable expenses 

20 incurred in traveling to and from their places of residence 

21 to an area in which they may be assigned for the purpose 

22 of evaluating such area with respect to such assignment. 

23 ‘‘(b) RECRUITMENT PERSONNEL.—The Secretary, 

24 acting through the Service, shall assign 1 individual in 
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1 each Area Office to be responsible on a full-time basis for 

2 recruitment activities. 

3 ‘‘SEC. 113. INDIAN RECRUITMENT AND RETENTION PRO4 GRAM. 

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

6 the Service, shall fund, on a competitive basis, innovative 

7 demonstration projects for a period not to exceed 3 years 

8 to enable Tribal Health Programs and Urban Indian Or9 ganizations to recruit, place, and retain health profes10 sionals to meet their staffing needs. 

11 ‘‘(b) ELIGIBLE ENTITIES; APPLICATION.—Any Trib12 al Health Program or Urban Indian Organization may 

13 submit an application for funding of a project pursuant 

14 to this section. 

15 ‘‘SEC. 114. ADVANCED TRAINING AND RESEARCH. 

16 ‘‘(a) DEMONSTRATION PROGRAM.—The Secretary, 

17 acting through the Service, shall establish a demonstration 

18 project to enable health professionals who have worked in 

19 an Indian Health Program or Urban Indian Organization 

20 for a substantial period of time to pursue advanced train21 ing or research areas of study for which the Secretary de22 termines a need exists. 

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

25 educational costs are borne by the Service, shall incur an 
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1 obligation to serve in an Indian Health Program or Urban 

2 Indian Organization for a period of obligated service equal 

3 to at least the period of time during which the individual 

4 participates in such program. In the event that the indi5 vidual fails to complete such obligated service, the indi6 vidual shall be liable to the United States for the period 

7 of service remaining. In such event, with respect to indi8 viduals entering the program after the date of enactment 

9 of the Indian Health Care Improvement Act Amendments 

10 of 2008, the United States shall be entitled to recover 

11 from such individual an amount to be determined in ac12 cordance with the formula specified in subsection (l) of 

13 section 110 in the manner provided for in such subsection. 

14 ‘‘(c) EQUAL OPPORTUNITY FOR PARTICIPATION.—

15 Health professionals from Tribal Health Programs and 

16 Urban Indian Organizations shall be given an equal oppor17 tunity to participate in the program under subsection (a). 

18 ‘‘SEC. 115. QUENTIN N. BURDICK AMERICAN INDIANS INTO 

19 NURSING PROGRAM. 

20 ‘‘(a) GRANTS AUTHORIZED.—For the purpose of in21 creasing the number of nurses, nurse midwives, and nurse 

22 practitioners who deliver health care services to Indians, 

23 the Secretary, acting through the Service, shall provide 

24 grants to the following: 

25 ‘‘(1) Public or private schools of nursing. 
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1 ‘‘(2) Tribal colleges or universities. 

2 ‘‘(3) Nurse midwife programs and advanced 

3 practice nurse programs that are provided by any 

4 tribal college or university accredited nursing pro5 gram, or in the absence of such, any other public or 

6 private institutions. 

7 ‘‘(b) USE OF GRANTS.—Grants provided under sub8 section (a) may be used for 1 or more of the following: 

9 ‘‘(1) To recruit individuals for programs which 

10 train individuals to be nurses, nurse midwives, or 

11 advanced practice nurses. 

12 ‘‘(2) To provide scholarships to Indians enrolled 

13 in such programs that may pay the tuition charged 

14 for such program and other expenses incurred in 

15 connection with such program, including books, fees, 

16 room and board, and stipends for living expenses. 

17 ‘‘(3) To provide a program that encourages 

18 nurses, nurse midwives, and advanced practice 

19 nurses to provide, or continue to provide, health care 

20 services to Indians. 

21 ‘‘(4) To provide a program that increases the 

22 skills of, and provides continuing education to, 

23 nurses, nurse midwives, and advanced practice 

24 nurses. 
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1 ‘‘(5) To provide any program that is designed 

2 to achieve the purpose described in subsection (a). 

3 ‘‘(c) APPLICATIONS.—Each application for a grant 

4 under subsection (a) shall include such information as the 

5 Secretary may require to establish the connection between 

6 the program of the applicant and a health care facility 

7 that primarily serves Indians. 

8 ‘‘(d) PREFERENCES FOR GRANT RECIPIENTS.—In 

9 providing grants under subsection (a), the Secretary shall 

10 extend a preference to the following: 

11 ‘‘(1) Programs that provide a preference to In12 dians. 

13 ‘‘(2) Programs that train nurse midwives or ad14 vanced practice nurses. 

15 ‘‘(3) Programs that are interdisciplinary. 

16 ‘‘(4) Programs that are conducted in coopera17 tion with a program for gifted and talented Indian 

18 students. 

19 ‘‘(5) Programs conducted by tribal colleges and 

20 universities. 

21 ‘‘(e) QUENTIN N. BURDICK PROGRAM GRANT.—The 

22 Secretary shall provide 1 of the grants authorized under 

23 subsection (a) to establish and maintain a program at the 

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

25 N. Burdick American Indians Into Nursing Program’. 
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1 Such program shall, to the maximum extent feasible, co2 ordinate with the Quentin N. Burdick Indian Health Pro3 grams established under section 117(b) and the Quentin 

4 N. Burdick American Indians Into Psychology Program 

5 established under section 105(b). 

6 ‘‘(f) ACTIVE DUTY SERVICE OBLIGATION.—The ac7 tive duty service obligation prescribed under section 338C 

8 of the Public Health Service Act (42 U.S.C. 254m) shall 

9 be met by each individual who receives training or assist10 ance described in paragraph (1) or (2) of subsection (b) 

11 that is funded by a grant provided under subsection (a). 

12 Such obligation shall be met by service—

13 ‘‘(1) in the Service; 

14 ‘‘(2) in a program of an Indian Tribe or Tribal 

15 Organization conducted under the Indian Self-Deter16 mination and Education Assistance Act (25 U.S.C. 

17 450 et seq.) (including programs under agreements 

18 with the Bureau of Indian Affairs); 

19 ‘‘(3) in a program assisted under title V of this 

20 Act; 

21 ‘‘(4) in the private practice of nursing if, as de22 termined by the Secretary, in accordance with guide23 lines promulgated by the Secretary, such practice is 

24 situated in a physician or other health shortage area 
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1 and addresses the health care needs of a substantial 

2 number of Indians; or 

3 ‘‘(5) in a teaching capacity in a tribal college or 

4 university nursing program (or a related health pro5 fession program) if, as determined by the Secretary, 

6 health services provided to Indians would not de7 crease. 

8 ‘‘SEC. 116. TRIBAL CULTURAL ORIENTATION. 

9 ‘‘(a) CULTURAL EDUCATION OF EMPLOYEES.—The 

10 Secretary, acting through the Service, shall require that 

11 appropriate employees of the Service who serve Indian 

12 Tribes in each Service Area receive educational instruction 

13 in the history and culture of such Indian Tribes and their 

14 relationship to the Service. 

15 ‘‘(b) PROGRAM.—In carrying out subsection (a), the 

16 Secretary shall establish a program which shall, to the ex17 tent feasible—

18 ‘‘(1) be developed in consultation with the af19 fected Indian Tribes, Tribal Organizations, and 

20 Urban Indian Organizations; 

21 ‘‘(2) be carried out through tribal colleges or 

22 universities; 

23 ‘‘(3) include instruction in American Indian 

24 studies; and 
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1 ‘‘(4) describe the use and place of traditional 

2 health care practices of the Indian Tribes in the 

3 Service Area. 

4 ‘‘SEC. 117. INMED PROGRAM. 

5 ‘‘(a) GRANTS AUTHORIZED.—The Secretary, acting 

6 through the Service, is authorized to provide grants to col7 leges and universities for the purpose of maintaining and 

8 expanding the Indian health careers recruitment program 

9 known as the ‘Indians Into Medicine Program’ (herein10 after in this section referred to as ‘INMED’) as a means 

11 of encouraging Indians to enter the health professions. 

12 ‘‘(b) QUENTIN N. BURDICK GRANT.—The Secretary 

13 shall provide 1 of the grants authorized under subsection 

14 (a) to maintain the INMED program at the University 

15 of North Dakota, to be known as the ‘Quentin N. Burdick 

16 Indian Health Programs’, unless the Secretary makes a 

17 determination, based upon program reviews, that the pro18 gram is not meeting the purposes of this section. Such 

19 program shall, to the maximum extent feasible, coordinate 

20 with the Quentin N. Burdick American Indians Into Psy21 chology Program established under section 105(b) and the 

22 Quentin N. Burdick American Indians Into Nursing Pro23 gram established under section 115. 
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1 ‘‘(c) REGULATIONS.—The Secretary, pursuant to this 

2 Act, shall develop regulations to govern grants pursuant 

3 to this section. 

4 ‘‘(d) REQUIREMENTS.—Applicants for grants pro5 vided under this section shall agree to provide a program 

6 which—

7 ‘‘(1) provides outreach and recruitment for 

8 health professions to Indian communities including 

9 elementary and secondary schools and community 

10 colleges located on reservations which will be served 

11 by the program; 

12 ‘‘(2) incorporates a program advisory board 

13 comprised of representatives from the Indian Tribes 

14 and Indian communities which will be served by the 

15 program; 

16 ‘‘(3) provides summer preparatory programs for 

17 Indian students who need enrichment in the subjects 

18 of math and science in order to pursue training in 

19 the health professions; 

20 ‘‘(4) provides tutoring, counseling, and support 

21 to students who are enrolled in a health career pro22 gram of study at the respective college or university; 

23 and 

24 ‘‘(5) to the maximum extent feasible, employs 

25 qualified Indians in the program. 
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1 ‘‘SEC. 118. HEALTH TRAINING PROGRAMS OF COMMUNITY 

2 COLLEGES. 

3 ‘‘(a) GRANTS TO ESTABLISH PROGRAMS.—

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

5 through the Service, shall award grants to accredited 

6 and accessible community colleges for the purpose of 

7 assisting such community colleges in the establish8 ment of programs which provide education in a 

9 health profession leading to a degree or diploma in 

10 a health profession for individuals who desire to 

11 practice such profession on or near a reservation or 

12 in an Indian Health Program. 

13 ‘‘(2) AMOUNT OF GRANTS.—The amount of any 

14 grant awarded to a community college under para15 graph (1) for the first year in which such a grant 

16 is provided to the community college shall not exceed 

17 $250,000. 

18 ‘‘(b) GRANTS FOR MAINTENANCE AND RECRUIT19 ING.—

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

21 through the Service, shall award grants to accredited 

22 and accessible community colleges that have estab23 lished a program described in subsection (a)(1) for 

24 the purpose of maintaining the program and recruit25 ing students for the program. 
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1 ‘‘(2) REQUIREMENTS.—Grants may only be 

2 made under this section to a community college 

3 which—

4 ‘‘(A) is accredited; 

5 ‘‘(B) has a relationship with a hospital fa6 cility, Service facility, or hospital that could 

7 provide training of nurses or health profes8 sionals; 

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

10 an accredited college or university medical 

11 school, the terms of which—

12 ‘‘(i) provide a program that enhances 

13 the transition and recruitment of students 

14 into advanced baccalaureate or graduate 

15 programs that train health professionals; 

16 and 

17 ‘‘(ii) stipulate certifications necessary 

18 to approve internship and field placement 

19 opportunities at Indian Health Programs; 

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

21 appropriate certifications; 

22 ‘‘(E) is capable of obtaining State or re23 gional accreditation of the program described in 

24 subsection (a)(1); and 
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1 ‘‘(F) agrees to provide for Indian pref2 erence for applicants for programs under this 

3 section. 

4 ‘‘(c) TECHNICAL ASSISTANCE.—The Secretary shall 

5 encourage community colleges described in subsection 

6 (b)(2) to establish and maintain programs described in 

7 subsection (a)(1) by—

8 ‘‘(1) entering into agreements with such col9 leges for the provision of qualified personnel of the 

10 Service to teach courses of study in such programs; 

11 and 

12 ‘‘(2) providing technical assistance and support 

13 to such colleges. 

14 ‘‘(d) ADVANCED TRAINING.—

15 ‘‘(1) REQUIRED.—Any program receiving as16 sistance under this section that is conducted with re17 spect to a health profession shall also offer courses 

18 of study which provide advanced training for any 

19 health professional who—

20 ‘‘(A) has already received a degree or di21 ploma in such health profession; and 

22 ‘‘(B) provides clinical services on or near a 

23 reservation or for an Indian Health Program. 

24 ‘‘(2) MAY BE OFFERED AT ALTERNATE SITE.—

25 Such courses of study may be offered in conjunction 
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1 with the college or university with which the commu2 nity college has entered into the agreement required 

3 under subsection (b)(2)(C). 

4 ‘‘(e) PRIORITY.—Where the requirements of sub5 section (b) are met, grant award priority shall be provided 

6 to tribal colleges and universities in Service Areas where 

7 they exist. 

8 ‘‘SEC. 119. RETENTION BONUS. 

9 ‘‘(a) BONUS AUTHORIZED.—The Secretary may pay 

10 a retention bonus to any health professional employed by, 

11 or assigned to, and serving in, an Indian Health Program 

12 or Urban Indian Organization either as a civilian employee 

13 or as a commissioned officer in the Regular or Reserve 

14 Corps of the Public Health Service who—

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

16 for which recruitment or retention of personnel is 

17 difficult; 

18 ‘‘(2) the Secretary determines is needed by In19 dian Health Programs and Urban Indian Organiza20 tions; 

21 ‘‘(3) has—

22 ‘‘(A) completed 2 years of employment 

23 with an Indian Health Program or Urban In24 dian Organization; or 
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1 ‘‘(B) completed any service obligations in2 curred as a requirement of—

3 ‘‘(i) any Federal scholarship program; 

4 or 

5 ‘‘(ii) any Federal education loan re6 payment program; and 

7 ‘‘(4) enters into an agreement with an Indian 

8 Health Program or Urban Indian Organization for 

9 continued employment for a period of not less than 

10 1 year. 

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

12 the retention bonus which shall provide for a higher an13 nual rate for multiyear agreements than for single year 

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

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

16 annum. 

17 ‘‘(c) DEFAULT OF RETENTION AGREEMENT.—Any 

18 health professional failing to complete the agreed upon 

19 term of service, except where such failure is through no 

20 fault of the individual, shall be obligated to refund to the 

21 Government the full amount of the retention bonus for the 

22 period covered by the agreement, plus interest as deter23 mined by the Secretary in accordance with section 

24 110(l)(2)(B). 
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1 ‘‘(d) OTHER RETENTION BONUS.—The Secretary 

2 may pay a retention bonus to any health professional em3 ployed by a Tribal Health Program if such health profes4 sional is serving in a position which the Secretary deter5 mines is—

6 ‘‘(1) a position for which recruitment or reten7 tion is difficult; and 

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

9 to Indians. 

10 ‘‘SEC. 120. NURSING RESIDENCY PROGRAM. 

11 ‘‘(a) ESTABLISHMENT OF PROGRAM.—The Sec12 retary, acting through the Service, shall establish a pro13 gram to enable Indians who are licensed practical nurses, 

14 licensed vocational nurses, and registered nurses who are 

15 working in an Indian Health Program or Urban Indian 

16 Organization, and have done so for a period of not less 

17 than 1 year, to pursue advanced training. Such program 

18 shall include a combination of education and work study 

19 in an Indian Health Program or Urban Indian Organiza20 tion leading to an associate or bachelor’s degree (in the 

21 case of a licensed practical nurse or licensed vocational 

22 nurse), a bachelor’s degree (in the case of a registered 

23 nurse), or advanced degrees or certifications in nursing 

24 and public health. 
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1 ‘‘(b) SERVICE OBLIGATION.—An individual who par2 ticipates in a program under subsection (a), where the 

3 educational costs are paid by the Service, shall incur an 

4 obligation to serve in an Indian Health Program or Urban 

5 Indian Organization for a period of obligated service equal 

6 to 1 year for every year that nonprofessional employee (li7 censed practical nurses, licensed vocational nurses, nurs8 ing assistants, and various health care technicals), or 2 

9 years for every year that professional nurse (associate de10 gree and bachelor-prepared registered nurses), partici11 pates in such program. In the event that the individual 

12 fails to complete such obligated service, the United States 

13 shall be entitled to recover from such individual an amount 

14 determined in accordance with the formula specified in 

15 subsection (l) of section 110 in the manner provided for 

16 in such subsection. 

17 ‘‘SEC. 121. COMMUNITY HEALTH AIDE PROGRAM. 

18 ‘‘(a) GENERAL PURPOSES OF PROGRAM.—Under the 

19 authority of the Act of November 2, 1921 (25 U.S.C. 13) 

20 (commonly known as the ‘Snyder Act’), the Secretary, act21 ing through the Service, shall develop and operate a Com22 munity Health Aide Program in Alaska under which the 

23 Service—

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

25 as health aides or community health practitioners; 
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1 ‘‘(2) uses such aides or practitioners in the pro2 vision of health care, health promotion, and disease 

3 prevention services to Alaska Natives living in vil4 lages in rural Alaska; and 

5 ‘‘(3) provides for the establishment of tele6 conferencing capacity in health clinics located in or 

7 near such villages for use by community health aides 

8 or community health practitioners. 

9 ‘‘(b) SPECIFIC PROGRAM REQUIREMENTS.—The Sec10 retary, acting through the Community Health Aide Pro11 gram of the Service, shall—

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

13 provide a high standard of training to community 

14 health aides and community health practitioners to 

15 ensure that such aides and practitioners provide 

16 quality health care, health promotion, and disease 

17 prevention services to the villages served by the Pro18 gram; 

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

20 a curriculum that—

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

22 health care with supervised practical experience 

23 in the provision of health care; 

24 ‘‘(B) provides instruction and practical ex25 perience in the provision of acute care, emer-
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1 gency care, health promotion, disease preven2 tion, and the efficient and effective manage3 ment of clinic pharmacies, supplies, equipment, 

4 and facilities; and 

5 ‘‘(C) promotes the achievement of the 

6 health status objectives specified in section 

7 3(2); 

8 ‘‘(3) establish and maintain a Community 

9 Health Aide Certification Board to certify as com10 munity health aides or community health practi11 tioners individuals who have successfully completed 

12 the training described in paragraph (1) or can dem13 onstrate equivalent experience; 

14 ‘‘(4) develop and maintain a system which iden15 tifies the needs of community health aides and com16 munity health practitioners for continuing education 

17 in the provision of health care, including the areas 

18 described in paragraph (2)(B), and develop pro19 grams that meet the needs for such continuing edu20 cation; 

21 ‘‘(5) develop and maintain a system that pro22 vides close supervision of community health aides 

23 and community health practitioners; 

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

25 community health aides and community health prac-
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1 titioners is reviewed and evaluated to assure the pro2 vision of quality health care, health promotion, and 

3 disease prevention services; and 

4 ‘‘(7) ensure that pulpal therapy (not including 

5 pulpotomies on deciduous teeth) or extraction of 

6 adult teeth can be performed by a dental health aide 

7 therapist only after consultation with a licensed den8 tist who determines that the procedure is a medical 

9 emergency that cannot be resolved with palliative 

10 treatment, and further that dental health aide thera11 pists are strictly prohibited from performing all 

12 other oral or jaw surgeries, provided that uncompli13 cated extractions shall not be considered oral sur14 gery under this section. 

15 ‘‘(c) PROGRAM REVIEW.—

16 ‘‘(1) NEUTRAL PANEL.—

17 ‘‘(A) ESTABLISHMENT.—The Secretary, 

18 acting through the Service, shall establish a 

19 neutral panel to carry out the study under 

20 paragraph (2). 

21 ‘‘(B) MEMBERSHIP.—Members of the neu22 tral panel shall be appointed by the Secretary 

23 from among clinicians, economists, community 

24 practitioners, oral epidemiologists, and Alaska 

25 Natives. 
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1 ‘‘(2) STUDY.—

2 ‘‘(A) IN GENERAL.—The neutral panel es3 tablished under paragraph (1) shall conduct a 

4 study of the dental health aide therapist serv5 ices provided by the Community Health Aide 

6 Program under this section to ensure that the 

7 quality of care provided through those services 

8 is adequate and appropriate. 

9 ‘‘(B) PARAMETERS OF STUDY.—The Sec10 retary, in consultation with interested parties, 

11 including professional dental organizations, 

12 shall develop the parameters of the study. 

13 ‘‘(C) INCLUSIONS.—The study shall in14 clude a determination by the neutral panel with 

15 respect to—

16 ‘‘(i) the ability of the dental health 

17 aide therapist services under this section to 

18 address the dental care needs of Alaska 

19 Natives; 

20 ‘‘(ii) the quality of care provided 

21 through those services, including any train22 ing, improvement, or additional oversight 

23 required to improve the quality of care; 

24 and 
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1 ‘‘(iii) whether safer and less costly al2 ternatives to the dental health aide thera3 pist services exist. 

4 ‘‘(D) CONSULTATION.—In carrying out the 

5 study under this paragraph, the neutral panel 

6 shall consult with Alaska Tribal Organizations 

7 with respect to the adequacy and accuracy of 

8 the study. 

9 ‘‘(3) REPORT.—The neutral panel shall submit 

10 to the Secretary, the Committee on Indian Affairs of 

11 the Senate, and the Committee on Natural Re12 sources of the House of Representatives a report de13 scribing the results of the study under paragraph 

14 (2), including a description of—

15 ‘‘(A) any determination of the neutral 

16 panel under paragraph (2)(C); and 

17 ‘‘(B) any comments received from an Alas18 ka Tribal Organization under paragraph 

19 (2)(D). 

20 ‘‘(d) NATIONALIZATION OF PROGRAM.—

21 ‘‘(1) IN GENERAL.—Except as provided in para22 graph (2), the Secretary, acting through the Service, 

23 may establish a national Community Health Aide 

24 Program in accordance with the program under this 
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1 section, as the Secretary determines to be appro2 priate. 

3 ‘‘(2) EXCEPTION.—The national Community 

4 Health Aide Program under paragraph (1) shall not 

5 include dental health aide therapist services. 

6 ‘‘(3) REQUIREMENT.—In establishing a na7 tional program under paragraph (1), the Secretary 

8 shall not reduce the amount of funds provided for 

9 the Community Health Aide Program described in 

10 subsections (a) and (b). 

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

12 ‘‘The Secretary, acting through the Service, shall, by 

13 contract or otherwise, provide training for Indians in the 

14 administration and planning of Tribal Health Programs. 

15 ‘‘SEC. 123. HEALTH PROFESSIONAL CHRONIC SHORTAGE 

16 DEMONSTRATION PROGRAMS. 

17 ‘‘(a) DEMONSTRATION PROGRAMS AUTHORIZED.—

18 The Secretary, acting through the Service, may fund dem19 onstration programs for Tribal Health Programs to ad20 dress the chronic shortages of health professionals. 

21 ‘‘(b) PURPOSES OF PROGRAMS.—The purposes of 

22 demonstration programs funded under subsection (a) shall 

23 be—
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1 ‘‘(1) to provide direct clinical and practical ex2 perience at a Service Unit to health profession stu3 dents and residents from medical schools; 

4 ‘‘(2) to improve the quality of health care for 

5 Indians by assuring access to qualified health care 

6 professionals; and 

7 ‘‘(3) to provide academic and scholarly opportu8 nities for health professionals serving Indians by 

9 identifying all academic and scholarly resources of 

10 the region. 

11 ‘‘(c) ADVISORY BOARD.—The demonstration pro12 grams established pursuant to subsection (a) shall incor13 porate a program advisory board composed of representa14 tives from the Indian Tribes and Indian communities in 

15 the area which will be served by the program. 

16 ‘‘SEC. 124. NATIONAL HEALTH SERVICE CORPS. 

17 ‘‘The Secretary shall not—

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

19 Service Corps from an Indian Health Program or 

20 Urban Indian Organization; or 

21 ‘‘(2) withdraw funding used to support such 

22 member, unless the Secretary, acting through the 

23 Service, has ensured that the Indians receiving serv24 ices from such member will experience no reduction 

25 in services. 
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1 ‘‘SEC. 125. SUBSTANCE ABUSE COUNSELOR EDUCATIONAL 

2 CURRICULA DEMONSTRATION PROGRAMS. 

3 ‘‘(a) CONTRACTS AND GRANTS.—The Secretary, act4 ing through the Service, may enter into contracts with, 

5 or make grants to, accredited tribal colleges and univer6 sities and eligible accredited and accessible community col7 leges to establish demonstration programs to develop edu8 cational curricula for substance abuse counseling. 

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

10 section shall be used only for developing and providing 

11 educational curriculum for substance abuse counseling (in12 cluding paying salaries for instructors). Such curricula 

13 may be provided through satellite campus programs. 

14 ‘‘(c) TIME PERIOD OF ASSISTANCE; RENEWAL.—A 

15 contract entered into or a grant provided under this sec16 tion shall be for a period of 3 years. Such contract or 

17 grant may be renewed for an additional 2-year period 

18 upon the approval of the Secretary. 

19 ‘‘(d) CRITERIA FOR REVIEW AND APPROVAL OF AP20 PLICATIONS.—Not later than 180 days after the date of 

21 enactment of the Indian Health Care Improvement Act 

22 Amendments of 2008, the Secretary, after consultation 

23 with Indian Tribes and administrators of tribal colleges 

24 and universities and eligible accredited and accessible com25 munity colleges, shall develop and issue criteria for the 

26 review and approval of applications for funding (including 
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1 applications for renewals of funding) under this section. 

2 Such criteria shall ensure that demonstration programs 

3 established under this section promote the development of 

4 the capacity of such entities to educate substance abuse 

5 counselors. 

6 ‘‘(e) ASSISTANCE.—The Secretary shall provide such 

7 technical and other assistance as may be necessary to en8 able grant recipients to comply with the provisions of this 

9 section. 

10 ‘‘(f) REPORT.—Each fiscal year, the Secretary shall 

11 submit to the President, for inclusion in the report which 

12 is required to be submitted under section 801 for that fis13 cal year, a report on the findings and conclusions derived 

14 from the demonstration programs conducted under this 

15 section during that fiscal year. 

16 ‘‘(g) DEFINITION.—For the purposes of this section, 

17 the term ‘educational curriculum’ means 1 or more of the 

18 following: 

19 ‘‘(1) Classroom education. 

20 ‘‘(2) Clinical work experience. 

21 ‘‘(3) Continuing education workshops. 

22 ‘‘SEC. 126. BEHAVIORAL HEALTH TRAINING AND COMMU23 NITY EDUCATION PROGRAMS. 

24 ‘‘(a) STUDY; LIST.—The Secretary, acting through 

25 the Service, and the Secretary of the Interior, in consulta-
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1 tion with Indian Tribes and Tribal Organizations, shall 

2 conduct a study and compile a list of the types of staff 

3 positions specified in subsection (b) whose qualifications 

4 include, or should include, training in the identification, 

5 prevention, education, referral, or treatment of mental ill6 ness, or dysfunctional and self destructive behavior. 

7 ‘‘(b) POSITIONS.—The positions referred to in sub8 section (a) are—

9 ‘‘(1) staff positions within the Bureau of Indian 

10 Affairs, including existing positions, in the fields 

11 of—

12 ‘‘(A) elementary and secondary education; 

13 ‘‘(B) social services and family and child 

14 welfare; 

15 ‘‘(C) law enforcement and judicial services; 

16 and 

17 ‘‘(D) alcohol and substance abuse; 

18 ‘‘(2) staff positions within the Service; and 

19 ‘‘(3) staff positions similar to those identified in 

20 paragraphs (1) and (2) established and maintained 

21 by Indian Tribes and Tribal Organizations (without 

22 regard to the funding source). 

23 ‘‘(c) TRAINING CRITERIA.—

24 ‘‘(1) IN GENERAL.—The appropriate Secretary 

25 shall provide training criteria appropriate to each 
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1 type of position identified in subsection (b)(1) and 

2 (b)(2) and ensure that appropriate training has 

3 been, or shall be provided to any individual in any 

4 such position. With respect to any such individual in 

5 a position identified pursuant to subsection (b)(3), 

6 the respective Secretaries shall provide appropriate 

7 training to, or provide funds to, an Indian Tribe or 

8 Tribal Organization for training of appropriate indi9 viduals. In the case of positions funded under a con10 tract or compact under the Indian Self-Determina11 tion and Education Assistance Act (25 U.S.C. 450 

12 et seq.), the appropriate Secretary shall ensure that 

13 such training costs are included in the contract or 

14 compact, as the Secretary determines necessary. 

15 ‘‘(2) POSITION SPECIFIC TRAINING CRITERIA.—

16 Position specific training criteria shall be culturally 

17 relevant to Indians and Indian Tribes and shall en18 sure that appropriate information regarding tradi19 tional health care practices is provided. 

20 ‘‘(d) COMMUNITY EDUCATION ON MENTAL ILL21 NESS.—The Service shall develop and implement, on re22 quest of an Indian Tribe, Tribal Organization, or Urban 

23 Indian Organization, or assist the Indian Tribe, Tribal Or24 ganization, or Urban Indian Organization to develop and 

25 implement, a program of community education on mental 
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1 illness. In carrying out this subsection, the Service shall, 

2 upon request of an Indian Tribe, Tribal Organization, or 

3 Urban Indian Organization, provide technical assistance 

4 to the Indian Tribe, Tribal Organization, or Urban Indian 

5 Organization to obtain and develop community edu6 cational materials on the identification, prevention, refer7 ral, and treatment of mental illness and dysfunctional and 

8 self-destructive behavior. 

9 ‘‘(e) PLAN.—Not later than 90 days after the date 

10 of enactment of the Indian Health Care Improvement Act 

11 Amendments of 2008, the Secretary shall develop a plan 

12 under which the Service will increase the health care staff 

13 providing behavioral health services by at least 500 posi14 tions within 5 years after the date of enactment of this 

15 section, with at least 200 of such positions devoted to 

16 child, adolescent, and family services. The plan developed 

17 under this subsection shall be implemented under the Act 

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

19 as the ‘Snyder Act’). 

20 ‘‘SEC. 127. AUTHORIZATION OF APPROPRIATIONS. 

21 ‘‘There are authorized to be appropriated such sums 

22 as may be necessary for each fiscal year through fiscal 

23 year 2017 to carry out this title. 
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1 ‘‘TITLE II—HEALTH SERVICES 

2 ‘‘SEC. 201. INDIAN HEALTH CARE IMPROVEMENT FUND. 

3 ‘‘(a) USE OF FUNDS.—The Secretary, acting through 

4 the Service, is authorized to expend funds, directly or 

5 under the authority of the Indian Self-Determination and 

6 Education Assistance Act (25 U.S.C. 450 et seq.), which 

7 are appropriated under the authority of this section, for 

8 the purposes of—

9 ‘‘(1) eliminating the deficiencies in health sta10 tus and health resources of all Indian Tribes; 

11 ‘‘(2) eliminating backlogs in the provision of 

12 health care services to Indians; 

13 ‘‘(3) meeting the health needs of Indians in an 

14 efficient and equitable manner, including the use of 

15 telehealth and telemedicine when appropriate; 

16 ‘‘(4) eliminating inequities in funding for both 

17 direct care and contract health service programs; 

18 and 

19 ‘‘(5) augmenting the ability of the Service to 

20 meet the following health service responsibilities with 

21 respect to those Indian Tribes with the highest levels 

22 of health status deficiencies and resource defi23 ciencies: 

24 ‘‘(A) Clinical care, including inpatient care, 

25 outpatient care (including audiology, clinical 
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1 eye, and vision care), primary care, secondary 

2 and tertiary care, and long-term care. 

3 ‘‘(B) Preventive health, including mam4 mography and other cancer screening in accord5 ance with section 207. 

6 ‘‘(C) Dental care. 

7 ‘‘(D) Mental health, including community 

8 mental health services, inpatient mental health 

9 services, dormitory mental health services, 

10 therapeutic and residential treatment centers, 

11 and training of traditional health care practi12 tioners. 

13 ‘‘(E) Emergency medical services. 

14 ‘‘(F) Treatment and control of, and reha15 bilitative care related to, alcoholism and drug 

16 abuse (including fetal alcohol spectrum dis17 orders) among Indians. 

18 ‘‘(G) Injury prevention programs, includ19 ing training. 

20 ‘‘(H) Home health care. 

21 ‘‘(I) Community health representatives. 

22 ‘‘(J) Maintenance and improvement. 

23 ‘‘(b) NO OFFSET OR LIMITATION.—Any funds appro24 priated under the authority of this section shall not be 

25 used to offset or limit any other appropriations made to 
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1 the Service under this Act or the Act of November 2, 1921 

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

3 or any other provision of law. 

4 ‘‘(c) ALLOCATION; USE.—

5 ‘‘(1) IN GENERAL.—Funds appropriated under 

6 the authority of this section shall be allocated to 

7 Service Units, Indian Tribes, or Tribal Organiza8 tions. The funds allocated to each Indian Tribe, 

9 Tribal Organization, or Service Unit under this 

10 paragraph shall be used by the Indian Tribe, Tribal 

11 Organization, or Service Unit under this paragraph 

12 to improve the health status and reduce the resource 

13 deficiency of each Indian Tribe served by such Serv14 ice Unit, Indian Tribe, or Tribal Organization. 

15 ‘‘(2) APPORTIONMENT OF ALLOCATED

16 FUNDS.—The apportionment of funds allocated to a 

17 Service Unit, Indian Tribe, or Tribal Organization 

18 under paragraph (1) among the health service re19 sponsibilities described in subsection (a)(5) shall be 

20 determined by the Service in consultation with, and 

21 with the active participation of, the affected Indian 

22 Tribes and Tribal Organizations. 

23 ‘‘(d) PROVISIONS RELATING TO HEALTH STATUS

24 AND RESOURCE DEFICIENCIES.—For the purposes of this 

25 section, the following definitions apply: 
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1 ‘‘(1) DEFINITION.—The term ‘health status 

2 and resource deficiency’ means the extent to 

3 which—

4 ‘‘(A) the health status objectives set forth 

5 in section 3(2) are not being achieved; and 

6 ‘‘(B) the Indian Tribe or Tribal Organiza7 tion does not have available to it the health re8 sources it needs, taking into account the actual 

9 cost of providing health care services given local 

10 geographic, climatic, rural, or other cir11 cumstances. 

12 ‘‘(2) AVAILABLE RESOURCES.—The health re13 sources available to an Indian Tribe or Tribal Orga14 nization include health resources provided by the 

15 Service as well as health resources used by the In16 dian Tribe or Tribal Organization, including services 

17 and financing systems provided by any Federal pro18 grams, private insurance, and programs of State or 

19 local governments. 

20 ‘‘(3) PROCESS FOR REVIEW OF DETERMINA21 TIONS.—The Secretary shall establish procedures 

22 which allow any Indian Tribe or Tribal Organization 

23 to petition the Secretary for a review of any deter24 mination of the extent of the health status and re-
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1 source deficiency of such Indian Tribe or Tribal Or2 ganization. 

3 ‘‘(e) ELIGIBILITY FOR FUNDS.—Tribal Health Pro4 grams shall be eligible for funds appropriated under the 

5 authority of this section on an equal basis with programs 

6 that are administered directly by the Service. 

7 ‘‘(f) REPORT.—By no later than the date that is 3 

8 years after the date of enactment of the Indian Health 

9 Care Improvement Act Amendments of 2008, the Sec10 retary shall submit to Congress the current health status 

11 and resource deficiency report of the Service for each 

12 Service Unit, including newly recognized or acknowledged 

13 Indian Tribes. Such report shall set out—

14 ‘‘(1) the methodology then in use by the Service 

15 for determining Tribal health status and resource 

16 deficiencies, as well as the most recent application of 

17 that methodology; 

18 ‘‘(2) the extent of the health status and re19 source deficiency of each Indian Tribe served by the 

20 Service or a Tribal Health Program; 

21 ‘‘(3) the amount of funds necessary to eliminate 

22 the health status and resource deficiencies of all In23 dian Tribes served by the Service or a Tribal Health 

24 Program; and 

25 ‘‘(4) an estimate of—
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1 ‘‘(A) the amount of health service funds 

2 appropriated under the authority of this Act, or 

3 any other Act, including the amount of any 

4 funds transferred to the Service for the pre5 ceding fiscal year which is allocated to each 

6 Service Unit, Indian Tribe, or Tribal Organiza7 tion; 

8 ‘‘(B) the number of Indians eligible for 

9 health services in each Service Unit or Indian 

10 Tribe or Tribal Organization; and 

11 ‘‘(C) the number of Indians using the 

12 Service resources made available to each Service 

13 Unit, Indian Tribe or Tribal Organization, and, 

14 to the extent available, information on the wait15 ing lists and number of Indians turned away for 

16 services due to lack of resources. 

17 ‘‘(g) INCLUSION IN BASE BUDGET.—Funds appro18 priated under this section for any fiscal year shall be in19 cluded in the base budget of the Service for the purpose 

20 of determining appropriations under this section in subse21 quent fiscal years. 

22 ‘‘(h) CLARIFICATION.—Nothing in this section is in23 tended to diminish the primary responsibility of the Serv24 ice to eliminate existing backlogs in unmet health care 

25 needs, nor are the provisions of this section intended to 
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1 discourage the Service from undertaking additional efforts 

2 to achieve equity among Indian Tribes and Tribal Organi3 zations. 

4 ‘‘(i) FUNDING DESIGNATION.—Any funds appro5 priated under the authority of this section shall be des6 ignated as the ‘Indian Health Care Improvement Fund’. 

7 ‘‘SEC. 202. CATASTROPHIC HEALTH EMERGENCY FUND. 

8 ‘‘(a) ESTABLISHMENT.—There is established an In9 dian Catastrophic Health Emergency Fund (hereafter in 

10 this section referred to as the ‘CHEF’) consisting of—

11 ‘‘(1) the amounts deposited under subsection 

12 (f); and 

13 ‘‘(2) the amounts appropriated to CHEF under 

14 this section. 

15 ‘‘(b) ADMINISTRATION.—CHEF shall be adminis16 tered by the Secretary, acting through the headquarters 

17 of the Service, solely for the purpose of meeting the ex18 traordinary medical costs associated with the treatment of 

19 victims of disasters or catastrophic illnesses who are with20 in the responsibility of the Service. 

21 ‘‘(c) CONDITIONS ON USE OF FUND.—No part of 

22 CHEF or its administration shall be subject to contract 

23 or grant under any law, including the Indian Self-Deter24 mination and Education Assistance Act (25 U.S.C. 450 

25 et seq.), nor shall CHEF funds be allocated, apportioned, 
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1 or delegated on an Area Office, Service Unit, or other 

2 similar basis. 

3 ‘‘(d) REGULATIONS.—The Secretary shall promul4 gate regulations consistent with the provisions of this sec5 tion to—

6 ‘‘(1) establish a definition of disasters and cata7 strophic illnesses for which the cost of the treatment 

8 provided under contract would qualify for payment 

9 from CHEF; 

10 ‘‘(2) provide that a Service Unit shall not be el11 igible for reimbursement for the cost of treatment 

12 from CHEF until its cost of treating any victim of 

13 such catastrophic illness or disaster has reached a 

14 certain threshold cost which the Secretary shall es15 tablish at—

16 ‘‘(A) the 2000 level of $19,000; and 

17 ‘‘(B) for any subsequent year, not less 

18 than the threshold cost of the previous year in19 creased by the percentage increase in the med20 ical care expenditure category of the consumer 

21 price index for all urban consumers (United 

22 States city average) for the 12-month period 

23 ending with December of the previous year; 
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1 ‘‘(3) establish a procedure for the reimburse2 ment of the portion of the costs that exceeds such 

3 threshold cost incurred by—

4 ‘‘(A) Service Units; or 

5 ‘‘(B) whenever otherwise authorized by the 

6 Service, non-Service facilities or providers; 

7 ‘‘(4) establish a procedure for payment from 

8 CHEF in cases in which the exigencies of the med9 ical circumstances warrant treatment prior to the 

10 authorization of such treatment by the Service; and 

11 ‘‘(5) establish a procedure that will ensure that 

12 no payment shall be made from CHEF to any pro13 vider of treatment to the extent that such provider 

14 is eligible to receive payment for the treatment from 

15 any other Federal, State, local, or private source of 

16 reimbursement for which the patient is eligible. 

17 ‘‘(e) NO OFFSET OR LIMITATION.—Amounts appro18 priated to CHEF under this section shall not be used to 

19 offset or limit appropriations made to the Service under 

20 the authority of the Act of November 2, 1921 (25 U.S.C. 

21 13) (commonly known as the ‘Snyder Act’), or any other 

22 law. 

23 ‘‘(f) DEPOSIT OF REIMBURSEMENT FUNDS.—There 

24 shall be deposited into CHEF all reimbursements to which 

25 the Service is entitled from any Federal, State, local, or 
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1 private source (including third party insurance) by reason 

2 of treatment rendered to any victim of a disaster or cata3 strophic illness the cost of which was paid from CHEF. 

4 ‘‘SEC. 203. HEALTH PROMOTION AND DISEASE PREVENTION 

5 SERVICES. 

6 ‘‘(a) FINDINGS.—Congress finds that health pro7 motion and disease prevention activities—

8 ‘‘(1) improve the health and well-being of Indi9 ans; and 

10 ‘‘(2) reduce the expenses for health care of In11 dians. 

12 ‘‘(b) PROVISION OF SERVICES.—The Secretary, act13 ing through the Service and Tribal Health Programs, shall 

14 provide health promotion and disease prevention services 

15 to Indians to achieve the health status objectives set forth 

16 in section 3(2). 

17 ‘‘(c) EVALUATION.—The Secretary, after obtaining 

18 input from the affected Tribal Health Programs, shall 

19 submit to the President for inclusion in the report which 

20 is required to be submitted to Congress under section 801 

21 an evaluation of—

22 ‘‘(1) the health promotion and disease preven23 tion needs of Indians; 

24 ‘‘(2) the health promotion and disease preven25 tion activities which would best meet such needs; 
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1 ‘‘(3) the internal capacity of the Service and 

2 Tribal Health Programs to meet such needs; and 

3 ‘‘(4) the resources which would be required to 

4 enable the Service and Tribal Health Programs to 

5 undertake the health promotion and disease preven6 tion activities necessary to meet such needs. 

7 ‘‘SEC. 204. DIABETES PREVENTION, TREATMENT, AND CON8 TROL. 

9 ‘‘(a) DETERMINATIONS REGARDING DIABETES.—

10 The Secretary, acting through the Service, and in con11 sultation with Indian Tribes and Tribal Organizations, 

12 shall determine—

13 ‘‘(1) by Indian Tribe and by Service Unit, the 

14 incidence of, and the types of complications resulting 

15 from, diabetes among Indians; and 

16 ‘‘(2) based on the determinations made pursu17 ant to paragraph (1), the measures (including pa18 tient education and effective ongoing monitoring of 

19 disease indicators) each Service Unit should take to 

20 reduce the incidence of, and prevent, treat, and con21 trol the complications resulting from, diabetes 

22 among Indian Tribes within that Service Unit. 

23 ‘‘(b) DIABETES SCREENING.—To the extent medi24 cally indicated and with informed consent, the Secretary 

25 shall screen each Indian who receives services from the 
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1 Service for diabetes and for conditions which indicate a 

2 high risk that the individual will become diabetic and es3 tablish a cost-effective approach to ensure ongoing moni4 toring of disease indicators. Such screening and moni5 toring may be conducted by a Tribal Health Program and 

6 may be conducted through appropriate Internet-based 

7 health care management programs. 

8 ‘‘(c) DIABETES PROJECTS.—The Secretary shall con9 tinue to maintain each model diabetes project in existence 

10 on the date of enactment of the Indian Health Care Im11 provement Act Amendments of 2008, any such other dia12 betes programs operated by the Service or Tribal Health 

13 Programs, and any additional diabetes projects, such as 

14 the Medical Vanguard program provided for in title IV 

15 of Public Law 108–87, as implemented to serve Indian 

16 Tribes. Tribal Health Programs shall receive recurring 

17 funding for the diabetes projects that they operate pursu18 ant to this section, both at the date of enactment of the 

19 Indian Health Care Improvement Act Amendments of 

20 2008 and for projects which are added and funded there21 after. 

22 ‘‘(d) DIALYSIS PROGRAMS.—The Secretary is author23 ized to provide, through the Service, Indian Tribes, and 

24 Tribal Organizations, dialysis programs, including the 
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1 purchase of dialysis equipment and the provision of nec2 essary staffing. 

3 ‘‘(e) OTHER DUTIES OF THE SECRETARY.—

4 ‘‘(1) IN GENERAL.—The Secretary shall, to the 

5 extent funding is available—

6 ‘‘(A) in each Area Office, consult with In7 dian Tribes and Tribal Organizations regarding 

8 programs for the prevention, treatment, and 

9 control of diabetes; 

10 ‘‘(B) establish in each Area Office a reg11 istry of patients with diabetes to track the inci12 dence of diabetes and the complications from 

13 diabetes in that area; and 

14 ‘‘(C) ensure that data collected in each 

15 Area Office regarding diabetes and related com16 plications among Indians are disseminated to 

17 all other Area Offices, subject to applicable pa18 tient privacy laws. 

19 ‘‘(2) DIABETES CONTROL OFFICERS.—

20 ‘‘(A) IN GENERAL.—The Secretary may es21 tablish and maintain in each Area Office a posi22 tion of diabetes control officer to coordinate and 

23 manage any activity of that Area Office relating 

24 to the prevention, treatment, or control of dia25 betes to assist the Secretary in carrying out a 
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1 program under this section or section 330C of 

2 the Public Health Service Act (42 U.S.C. 254c–

3 3). 

4 ‘‘(B) CERTAIN ACTIVITIES.—Any activity 

5 carried out by a diabetes control officer under 

6 subparagraph (A) that is the subject of a con7 tract or compact under the Indian Self-Deter8 mination and Education Assistance Act (25 

9 U.S.C. 450 et seq.), and any funds made avail10 able to carry out such an activity, shall not be 

11 divisible for purposes of that Act. 

12 ‘‘SEC. 205. SHARED SERVICES FOR LONG-TERM CARE. 

13 ‘‘(a) LONG-TERM CARE.—Notwithstanding any other 

14 provision of law, the Secretary, acting through the Service, 

15 is authorized to provide directly, or enter into contracts 

16 or compacts under the Indian Self-Determination and 

17 Education Assistance Act (25 U.S.C. 450 et seq.) with 

18 Indian Tribes or Tribal Organizations for, the delivery of 

19 long-term care (including health care services associated 

20 with long-term care) provided in a facility to Indians. Such 

21 agreements shall provide for the sharing of staff or other 

22 services between the Service or a Tribal Health Program 

23 and a long-term care or related facility owned and oper24 ated (directly or through a contract or compact under the 

25 Indian Self-Determination and Education Assistance Act 
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1 (25 U.S.C. 450 et seq.)) by such Indian Tribe or Tribal 

2 Organization. 

3 ‘‘(b) CONTENTS OF AGREEMENTS.—An agreement 

4 entered into pursuant to subsection (a)—

5 ‘‘(1) may, at the request of the Indian Tribe or 

6 Tribal Organization, delegate to such Indian Tribe 

7 or Tribal Organization such powers of supervision 

8 and control over Service employees as the Secretary 

9 deems necessary to carry out the purposes of this 

10 section; 

11 ‘‘(2) shall provide that expenses (including sala12 ries) relating to services that are shared between the 

13 Service and the Tribal Health Program be allocated 

14 proportionately between the Service and the Indian 

15 Tribe or Tribal Organization; and 

16 ‘‘(3) may authorize such Indian Tribe or Tribal 

17 Organization to construct, renovate, or expand a 

18 long-term care or other similar facility (including the 

19 construction of a facility attached to a Service facil20 ity). 

21 ‘‘(c) MINIMUM REQUIREMENT.—Any nursing facility 

22 provided for under this section shall meet the require23 ments for nursing facilities under section 1919 of the So24 cial Security Act. 
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1 ‘‘(d) OTHER ASSISTANCE.—The Secretary shall pro2 vide such technical and other assistance as may be nec3 essary to enable applicants to comply with the provisions 

4 of this section. 

5 ‘‘(e) USE OF EXISTING OR UNDERUSED FACILI6 TIES.—The Secretary shall encourage the use of existing 

7 facilities that are underused or allow the use of swing beds 

8 for long-term or similar care. 

9 ‘‘SEC. 206. HEALTH SERVICES RESEARCH. 

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

11 the Service, shall make funding available for research to 

12 further the performance of the health service responsibil13 ities of Indian Health Programs. 

14 ‘‘(b) COORDINATION OF RESOURCES AND ACTIVI15 TIES.—The Secretary shall also, to the maximum extent 

16 practicable, coordinate departmental research resources 

17 and activities to address relevant Indian Health Program 

18 research needs. 

19 ‘‘(c) AVAILABILITY.—Tribal Health Programs shall 

20 be given an equal opportunity to compete for, and receive, 

21 research funds under this section. 

22 ‘‘(d) USE OF FUNDS.—This funding may be used for 

23 both clinical and nonclinical research. 

24 ‘‘(e) EVALUATION AND DISSEMINATION.—The Sec25 retary shall periodically—
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1 ‘‘(1) evaluate the impact of research conducted 

2 under this section; and 

3 ‘‘(2) disseminate to Tribal Health Programs in4 formation regarding that research as the Secretary 

5 determines to be appropriate. 

6 ‘‘SEC. 207. MAMMOGRAPHY AND OTHER CANCER SCREEN7 ING. 

8 ‘‘The Secretary, acting through the Service or Tribal 

9 Health Programs, shall provide for screening as follows: 

10 ‘‘(1) Screening mammography (as defined in 

11 section 1861(jj) of the Social Security Act) for In12 dian women at a frequency appropriate to such 

13 women under accepted and appropriate national 

14 standards, and under such terms and conditions as 

15 are consistent with standards established by the Sec16 retary to ensure the safety and accuracy of screen17 ing mammography under part B of title XVIII of 

18 such Act. 

19 ‘‘(2) Other cancer screening that receives an A 

20 or B rating as recommended by the United States 

21 Preventive Services Task Force established under 

22 section 915(a)(1) of the Public Health Service Act 

23 (42 U.S.C. 299b–4(a)(1)). The Secretary shall en24 sure that screening provided for under this para-
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1 graph complies with the recommendations of the 

2 Task Force with respect to—

3 ‘‘(A) frequency; 

4 ‘‘(B) the population to be served; 

5 ‘‘(C) the procedure or technology to be 

6 used; 

7 ‘‘(D) evidence of effectiveness; and 

8 ‘‘(E) other matters that the Secretary de9 termines appropriate. 

10 ‘‘SEC. 208. PATIENT TRAVEL COSTS. 

11 ‘‘(a) DEFINITION OF QUALIFIED ESCORT.—In this 

12 section, the term ‘qualified escort’ means—

13 ‘‘(1) an adult escort (including a parent, guard14 ian, or other family member) who is required be15 cause of the physical or mental condition, or age, of 

16 the applicable patient; 

17 ‘‘(2) a health professional for the purpose of 

18 providing necessary medical care during travel by 

19 the applicable patient; or 

20 ‘‘(3) other escorts, as the Secretary or applica21 ble Indian Health Program determines to be appro22 priate. 

23 ‘‘(b) PROVISION OF FUNDS.—The Secretary, acting 

24 through the Service and Tribal Health Programs, is au25 thorized to provide funds for the following patient travel 
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1 costs, including qualified escorts, associated with receiving 

2 health care services provided (either through direct or con3 tract care or through a contract or compact under the In4 dian Self-Determination and Education Assistance Act 

5 (25 U.S.C. 450 et seq.)) under this Act—

6 ‘‘(1) emergency air transportation and non7 emergency air transportation where ground trans8 portation is infeasible; 

9 ‘‘(2) transportation by private vehicle (where no 

10 other means of transportation is available), specially 

11 equipped vehicle, and ambulance; and 

12 ‘‘(3) transportation by such other means as 

13 may be available and required when air or motor ve14 hicle transportation is not available. 

15 ‘‘SEC. 209. EPIDEMIOLOGY CENTERS. 

16 ‘‘(a) ESTABLISHMENT OF CENTERS.—The Secretary 

17 shall establish an epidemiology center in each Service Area 

18 to carry out the functions described in subsection (b). Any 

19 new center established after the date of enactment of the 

20 Indian Health Care Improvement Act Amendments of 

21 2008 may be operated under a grant authorized by sub22 section (d), but funding under such a grant shall not be 

23 divisible. 

24 ‘‘(b) FUNCTIONS OF CENTERS.—In consultation with 

25 and upon the request of Indian Tribes, Tribal Organiza-
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1 tions, and Urban Indian communities, each Service Area 

2 epidemiology center established under this section shall, 

3 with respect to such Service Area—

4 ‘‘(1) collect data relating to, and monitor 

5 progress made toward meeting, each of the health 

6 status objectives of the Service, the Indian Tribes, 

7 Tribal Organizations, and Urban Indian commu8 nities in the Service Area; 

9 ‘‘(2) evaluate existing delivery systems, data 

10 systems, and other systems that impact the improve11 ment of Indian health; 

12 ‘‘(3) assist Indian Tribes, Tribal Organizations, 

13 and Urban Indian Organizations in identifying their 

14 highest priority health status objectives and the 

15 services needed to achieve such objectives, based on 

16 epidemiological data; 

17 ‘‘(4) make recommendations for the targeting 

18 of services needed by the populations served; 

19 ‘‘(5) make recommendations to improve health 

20 care delivery systems for Indians and Urban Indi21 ans; 

22 ‘‘(6) provide requested technical assistance to 

23 Indian Tribes, Tribal Organizations, and Urban In24 dian Organizations in the development of local 

25 health service priorities and incidence and prevalence 
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1 rates of disease and other illness in the community; 

2 and 

3 ‘‘(7) provide disease surveillance and assist In4 dian Tribes, Tribal Organizations, and Urban Indian 

5 communities to promote public health. 

6 ‘‘(c) TECHNICAL ASSISTANCE.—The Director of the 

7 Centers for Disease Control and Prevention shall provide 

8 technical assistance to the centers in carrying out the re9 quirements of this section. 

10 ‘‘(d) GRANTS FOR STUDIES.—

11 ‘‘(1) IN GENERAL.—The Secretary may make 

12 grants to Indian Tribes, Tribal Organizations, In13 dian organizations, and eligible intertribal consortia 

14 to conduct epidemiological studies of Indian commu15 nities. 

16 ‘‘(2) ELIGIBLE INTERTRIBAL CONSORTIA.—An 

17 intertribal consortium or Indian organization is eligi18 ble to receive a grant under this subsection if—

19 ‘‘(A) the intertribal consortium is incor20 porated for the primary purpose of improving 

21 Indian health; and 

22 ‘‘(B) the intertribal consortium is rep23 resentative of the Indian Tribes or urban In24 dian communities in which the intertribal con25 sortium is located. 
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1 ‘‘(3) APPLICATIONS.—An application for a 

2 grant under this subsection shall be submitted in 

3 such manner and at such time as the Secretary shall 

4 prescribe. 

5 ‘‘(4) REQUIREMENTS.—An applicant for a 

6 grant under this subsection shall—

7 ‘‘(A) demonstrate the technical, adminis8 trative, and financial expertise necessary to 

9 carry out the functions described in paragraph 

10 (5); 

11 ‘‘(B) consult and cooperate with providers 

12 of related health and social services in order to 

13 avoid duplication of existing services; and 

14 ‘‘(C) demonstrate cooperation from Indian 

15 Tribes or Urban Indian Organizations in the 

16 area to be served. 

17 ‘‘(5) USE OF FUNDS.—A grant awarded under 

18 paragraph (1) may be used—

19 ‘‘(A) to carry out the functions described 

20 in subsection (b); 

21 ‘‘(B) to provide information to and consult 

22 with tribal leaders, urban Indian community 

23 leaders, and related health staff on health care 

24 and health service management issues; and 
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1 ‘‘(C) in collaboration with Indian Tribes, 

2 Tribal Organizations, and urban Indian com3 munities, to provide the Service with informa4 tion regarding ways to improve the health sta5 tus of Indians. 

6 ‘‘(e) ACCESS TO INFORMATION.—The Secretary shall 

7 grant epidemiology centers operated by a grantee pursu8 ant to a grant awarded under subsection (d) access to use 

9 of the data, data sets, monitoring systems, delivery sys10 tems, and other protected health information in the pos11 session of the Secretary. Such activities shall be for the 

12 purposes of research and for preventing and controlling 

13 disease, injury, or disability for purposes of the Health 

14 Insurance Portability and Accountability Act of 1996 

15 (Public Law 104–191; 110 Stat. 2033), as such activities 

16 are described in part 164.512 of title 45, Code of Federal 

17 regulations (or a successor regulation). 

18 ‘‘SEC. 210. COMPREHENSIVE SCHOOL HEALTH EDUCATION 

19 PROGRAMS. 

20 ‘‘(a) FUNDING FOR DEVELOPMENT OF PROGRAMS.—

21 In addition to carrying out any other program for health 

22 promotion or disease prevention, the Secretary, acting 

23 through the Service, is authorized to award grants to In24 dian Tribes and Tribal Organizations to develop com25 prehensive school health education programs for children 
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1 from pre-school through grade 12 in schools for the benefit 

2 of Indian and Urban Indian children. 

3 ‘‘(b) USE OF GRANT FUNDS.—A grant awarded 

4 under this section may be used for purposes which may 

5 include, but are not limited to, the following: 

6 ‘‘(1) Developing health education materials both 

7 for regular school programs and afterschool pro8 grams. 

9 ‘‘(2) Training teachers in comprehensive school 

10 health education materials. 

11 ‘‘(3) Integrating school-based, community12 based, and other public and private health promotion 

13 efforts. 

14 ‘‘(4) Encouraging healthy, tobacco-free school 

15 environments. 

16 ‘‘(5) Coordinating school-based health programs 

17 with existing services and programs available in the 

18 community. 

19 ‘‘(6) Developing school programs on nutrition 

20 education, personal health, oral health, and fitness. 

21 ‘‘(7) Developing behavioral health wellness pro22 grams. 

23 ‘‘(8) Developing chronic disease prevention pro24 grams. 
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1 ‘‘(9) Developing substance abuse prevention 

2 programs. 

3 ‘‘(10) Developing injury prevention and safety 

4 education programs. 

5 ‘‘(11) Developing activities for the prevention 

6 and control of communicable diseases. 

7 ‘‘(12) Developing community and environmental 

8 health education programs that include traditional 

9 health care practitioners. 

10 ‘‘(13) Violence prevention. 

11 ‘‘(14) Such other health issues as are appro12 priate. 

13 ‘‘(c) TECHNICAL ASSISTANCE.—Upon request, the 

14 Secretary, acting through the Service, shall provide tech15 nical assistance to Indian Tribes and Tribal Organizations 

16 in the development of comprehensive health education 

17 plans and the dissemination of comprehensive health edu18 cation materials and information on existing health pro19 grams and resources. 

20 ‘‘(d) CRITERIA FOR REVIEW AND APPROVAL OF AP21 PLICATIONS.—The Secretary, acting through the Service, 

22 and in consultation with Indian Tribes and Tribal Organi23 zations, shall establish criteria for the review and approval 

24 of applications for grants awarded under this section. 
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1 ‘‘(e) DEVELOPMENT OF PROGRAM FOR BIA-FUNDED

2 SCHOOLS.—

3 ‘‘(1) IN GENERAL.—The Secretary of the Inte4 rior, acting through the Bureau of Indian Affairs 

5 and in cooperation with the Secretary, acting 

6 through the Service, and affected Indian Tribes and 

7 Tribal Organizations, shall develop a comprehensive 

8 school health education program for children from 

9 preschool through grade 12 in schools for which sup10 port is provided by the Bureau of Indian Affairs. 

11 ‘‘(2) REQUIREMENTS FOR PROGRAMS.—Such 

12 programs shall include—

13 ‘‘(A) school programs on nutrition edu14 cation, personal health, oral health, and fitness; 

15 ‘‘(B) behavioral health wellness programs; 

16 ‘‘(C) chronic disease prevention programs; 

17 ‘‘(D) substance abuse prevention pro18 grams; 

19 ‘‘(E) injury prevention and safety edu20 cation programs; and 

21 ‘‘(F) activities for the prevention and con22 trol of communicable diseases. 

23 ‘‘(3) DUTIES OF THE SECRETARY.—The Sec24 retary of the Interior shall—
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1 ‘‘(A) provide training to teachers in com2 prehensive school health education materials; 

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) PROGRAM AUTHORIZED.—The Secretary, acting 

11 through the Service, is authorized to establish and admin12 ister a program to provide grants to Indian Tribes, Tribal 

13 Organizations, and Urban Indian Organizations for inno14 vative mental and physical disease prevention and health 

15 promotion and treatment programs for Indian preadoles16 cent and adolescent youths. 

17 ‘‘(b) USE OF FUNDS.—

18 ‘‘(1) ALLOWABLE USES.—Funds made available 

19 under this section may be used to—

20 ‘‘(A) develop prevention and treatment 

21 programs for Indian youth which promote men22 tal and physical health and incorporate cultural 

23 values, community and family involvement, and 

24 traditional health care practitioners; and 
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1 ‘‘(B) develop and provide community train2 ing and education. 

3 ‘‘(2) PROHIBITED USE.—Funds made available 

4 under this section may not be used to provide serv5 ices described in section 707(c). 

6 ‘‘(c) DUTIES OF THE SECRETARY.—The Secretary 

7 shall—

8 ‘‘(1) disseminate to Indian Tribes and Tribal 

9 Organizations information regarding models for the 

10 delivery of comprehensive health care services to In11 dian and Urban Indian adolescents; 

12 ‘‘(2) encourage the implementation of such 

13 models; and 

14 ‘‘(3) at the request of an Indian Tribe or Tribal 

15 Organization, provide technical assistance in the im16 plementation of such models. 

17 ‘‘(d) CRITERIA FOR REVIEW AND APPROVAL OF AP18 PLICATIONS.—The Secretary, in consultation with Indian 

19 Tribes and Tribal Organizations, and in conference with 

20 Urban Indian Organizations, shall establish criteria for 

21 the review and approval of applications or proposals under 

22 this section. 
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1 ‘‘SEC. 212. PREVENTION, CONTROL, AND ELIMINATION OF 

2 COMMUNICABLE AND INFECTIOUS DISEASES. 

3 ‘‘(a) GRANTS AUTHORIZED.—The Secretary, acting 

4 through the Service, and after consultation with the Cen5 ters for Disease Control and Prevention, may make grants 

6 available to Indian Tribes and Tribal Organizations for 

7 the following: 

8 ‘‘(1) Projects for the prevention, control, and 

9 elimination of communicable and infectious diseases, 

10 including tuberculosis, hepatitis, HIV, respiratory 

11 syncytial virus, hanta virus, sexually transmitted dis12 eases, and H. Pylori. 

13 ‘‘(2) Public information and education pro14 grams for the prevention, control, and elimination of 

15 communicable and infectious diseases. 

16 ‘‘(3) Education, training, and clinical skills im17 provement activities in the prevention, control, and 

18 elimination of communicable and infectious diseases 

19 for health professionals, including allied health pro20 fessionals. 

21 ‘‘(4) Demonstration projects for the screening, 

22 treatment, and prevention of hepatitis C virus 

23 (HCV). 

24 ‘‘(b) APPLICATION REQUIRED.—The Secretary may 

25 provide funding under subsection (a) only if an application 

26 or proposal for funding is submitted to the Secretary. 
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1 ‘‘(c) COORDINATION WITH HEALTH AGENCIES.—In2 dian Tribes and Tribal Organizations receiving funding 

3 under this section are encouraged to coordinate their ac4 tivities with the Centers for Disease Control and Preven5 tion and State and local health agencies. 

6 ‘‘(d) TECHNICAL ASSISTANCE; REPORT.—In carrying 

7 out this section, the Secretary—

8 ‘‘(1) may, at the request of an Indian Tribe or 

9 Tribal Organization, provide technical assistance; 

10 and 

11 ‘‘(2) shall prepare and submit a report to Con12 gress biennially on the use of funds under this sec13 tion and on the progress made toward the preven14 tion, control, and elimination of communicable and 

15 infectious diseases among Indians and Urban Indi16 ans. 

17 ‘‘SEC. 213. OTHER AUTHORITY FOR PROVISION OF SERV18 ICES. 

19 ‘‘(a) FUNDING AUTHORIZED.—The Secretary, acting 

20 through the Service, Indian Tribes, and Tribal Organiza21 tions, may provide funding under this Act to meet the ob22 jectives set forth in section 3 of this Act through health 

23 care-related services and programs not otherwise described 

24 in this Act for the following services: 

25 ‘‘(1) Hospice care. 
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1 ‘‘(2) Assisted living services. 

2 ‘‘(3) Long-term care services. 

3 ‘‘(4) Home- and community-based services. 

4 ‘‘(b) ELIGIBILITY.—The following individuals shall be 

5 eligible to receive long-term care under this section: 

6 ‘‘(1) Individuals who are unable to perform a 

7 certain number of activities of daily living without 

8 assistance. 

9 ‘‘(2) Individuals with a mental impairment, 

10 such as dementia, Alzheimer’s disease, or another 

11 disabling mental illness, who may be able to perform 

12 activities of daily living under supervision. 

13 ‘‘(3) Such other individuals as an applicable In14 dian Health Program determines to be appropriate. 

15 ‘‘(c) DEFINITIONS.—For the purposes of this section, 

16 the following definitions shall apply: 

17 ‘‘(1) The term ‘assisted living services’ means 

18 any service provided by an assisted living facility (as 

19 defined in section 232(b) of the National Housing 

20 Act (12 U.S.C. 1715w(b))), except that such an as21 sisted living facility—

22 ‘‘(A) shall not be required to obtain a li23 cense; but 

24 ‘‘(B) shall meet all applicable standards 

25 for licensure. 
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1 ‘‘(2) The term ‘home- and community-based 

2 services’ means 1 or more of the services specified 

3 in paragraphs (1) through (9) of section 1929(a) of 

4 the Social Security Act (42 U.S.C. 1396t(a)) 

5 (whether provided by the Service or by an Indian 

6 Tribe or Tribal Organization pursuant to the Indian 

7 Self-Determination and Education Assistance Act 

8 (25 U.S.C. 450 et seq.)) that are or will be provided 

9 in accordance with applicable standards. 

10 ‘‘(3) The term ‘hospice care’ means the items 

11 and services specified in subparagraphs (A) through 

12 (H) of section 1861(dd)(1) of the Social Security 

13 Act (42 U.S.C. 1395x(dd)(1)), and such other serv14 ices which an Indian Tribe or Tribal Organization 

15 determines are necessary and appropriate to provide 

16 in furtherance of this care. 

17 ‘‘(4) The term ‘long-term care services’ has the 

18 meaning given the term ‘qualified long-term care 

19 services’ in section 7702B(c) of the Internal Rev20 enue Code of 1986. 

21 ‘‘(d) AUTHORIZATION OF CONVENIENT CARE SERV22 ICES.—The Secretary, acting through the Service, Indian 

23 Tribes, and Tribal Organizations, may also provide fund24 ing under this Act to meet the objectives set forth in sec-
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1 tion 3 of this Act for convenient care services programs 

2 pursuant to section 306(c)(2)(A). 

3 ‘‘SEC. 214. INDIAN WOMEN’S HEALTH CARE. 

4 ‘‘The Secretary, acting through the Service and In5 dian Tribes, Tribal Organizations, and Urban Indian Or6 ganizations, shall monitor and improve the quality of 

7 health care for Indian women of all ages through the plan8 ning and delivery of programs administered by the Service, 

9 in order to improve and enhance the treatment models of 

10 care for Indian women. 

11 ‘‘SEC. 215. ENVIRONMENTAL AND NUCLEAR HEALTH HAZ12 ARDS. 

13 ‘‘(a) STUDIES AND MONITORING.—The Secretary 

14 and the Service shall conduct, in conjunction with other 

15 appropriate Federal agencies and in consultation with con16 cerned Indian Tribes and Tribal Organizations, studies 

17 and ongoing monitoring programs to determine trends in 

18 the health hazards to Indian miners and to Indians on 

19 or near reservations and Indian communities as a result 

20 of environmental hazards which may result in chronic or 

21 life threatening health problems, such as nuclear resource 

22 development, petroleum contamination, and contamination 

23 of water sources and of the food chain. Such studies shall 

24 include—
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1 ‘‘(1) an evaluation of the nature and extent of 

2 health problems caused by environmental hazards 

3 currently exhibited among Indians and the causes of 

4 such health problems; 

5 ‘‘(2) an analysis of the potential effect of ongo6 ing and future environmental resource development 

7 on or near reservations and Indian communities, in8 cluding the cumulative effect over time on health; 

9 ‘‘(3) an evaluation of the types and nature of 

10 activities, practices, and conditions causing or affect11 ing such health problems, including uranium mining 

12 and milling, uranium mine tailing deposits, nuclear 

13 power plant operation and construction, and nuclear 

14 waste disposal; oil and gas production or transpor15 tation on or near reservations or Indian commu16 nities; and other development that could affect the 

17 health of Indians and their water supply and food 

18 chain; 

19 ‘‘(4) a summary of any findings and rec20 ommendations provided in Federal and State stud21 ies, reports, investigations, and inspections during 

22 the 5 years prior to the date of enactment of the In23 dian Health Care Improvement Act Amendments of 

24 2008 that directly or indirectly relate to the activi-
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1 ties, practices, and conditions affecting the health or 

2 safety of such Indians; and 

3 ‘‘(5) the efforts that have been made by Federal 

4 and State agencies and resource and economic devel5 opment companies to effectively carry out an edu6 cation program for such Indians regarding the 

7 health and safety hazards of such development. 

8 ‘‘(b) HEALTH CARE PLANS.—Upon completion of 

9 such studies, the Secretary and the Service shall take into 

10 account the results of such studies and develop health care 

11 plans to address the health problems studied under sub12 section (a). The plans shall include—

13 ‘‘(1) methods for diagnosing and treating Indi14 ans currently exhibiting such health problems; 

15 ‘‘(2) preventive care and testing for Indians 

16 who may be exposed to such health hazards, includ17 ing the monitoring of the health of individuals who 

18 have or may have been exposed to excessive amounts 

19 of radiation or affected by other activities that have 

20 had or could have a serious impact upon the health 

21 of such individuals; and 

22 ‘‘(3) a program of education for Indians who, 

23 by reason of their work or geographic proximity to 

24 such nuclear or other development activities, may ex25 perience health problems. 
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1 ‘‘(c) SUBMISSION OF REPORT AND PLAN TO CON2 GRESS.—The Secretary and the Service shall submit to 

3 Congress the study prepared under subsection (a) no later 

4 than 18 months after the date of enactment of the Indian 

5 Health Care Improvement Act Amendments of 2008. The 

6 health care plan prepared under subsection (b) shall be 

7 submitted in a report no later than 1 year after the study 

8 prepared under subsection (a) is submitted to Congress. 

9 Such report shall include recommended activities for the 

10 implementation of the plan, as well as an evaluation of 

11 any activities previously undertaken by the Service to ad12 dress such health problems. 

13 ‘‘(d) INTERGOVERNMENTAL TASK FORCE.—

14 ‘‘(1) ESTABLISHMENT; MEMBERS.—There is es15 tablished an Intergovernmental Task Force to be 

16 composed of the following individuals (or their des17 ignees): 

18 ‘‘(A) The Secretary of Energy. 

19 ‘‘(B) The Secretary of the Environmental 

20 Protection Agency. 

21 ‘‘(C) The Director of the Bureau of Mines. 

22 ‘‘(D) The Assistant Secretary for Occupa23 tional Safety and Health. 

24 ‘‘(E) The Secretary of the Interior. 
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1 ‘‘(F) The Secretary of Health and Human 

2 Services. 

3 ‘‘(G) The Director. 

4 ‘‘(2) DUTIES.—The Task Force shall—

5 ‘‘(A) identify existing and potential oper6 ations related to nuclear resource development 

7 or other environmental hazards that affect or 

8 may affect the health of Indians on or near a 

9 reservation or in an Indian community; and 

10 ‘‘(B) enter into activities to correct exist11 ing health hazards and ensure that current and 

12 future health problems resulting from nuclear 

13 resource or other development activities are 

14 minimized or reduced. 

15 ‘‘(3) CHAIRMAN; MEETINGS.—The Secretary of 

16 Health and Human Services shall be the Chairman 

17 of the Task Force. The Task Force shall meet at 

18 least twice each year. 

19 ‘‘(e) HEALTH SERVICES TO CERTAIN EMPLOYEES.—

20 In the case of any Indian who—

21 ‘‘(1) as a result of employment in or near a 

22 uranium mine or mill or near any other environ23 mental hazard, suffers from a work-related illness or 

24 condition; 
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1 ‘‘(2) is eligible to receive diagnosis and treat2 ment services from an Indian Health Program; and 

3 ‘‘(3) by reason of such Indian’s employment, is 

4 entitled to medical care at the expense of such mine 

5 or mill operator or entity responsible for the environ6 mental hazard, the Indian Health Program shall, at 

7 the request of such Indian, render appropriate med8 ical care to such Indian for such illness or condition 

9 and may be reimbursed for any medical care so ren10 dered to which such Indian is entitled at the expense 

11 of such operator or entity from such operator or en12 tity. Nothing in this subsection shall affect the 

13 rights of such Indian to recover damages other than 

14 such amounts paid to the Indian Health Program 

15 from the employer for providing medical care for 

16 such illness or condition. 

17 ‘‘SEC. 216. ARIZONA AS A CONTRACT HEALTH SERVICE DE18 LIVERY AREA. 

19 ‘‘(a) IN GENERAL.—For fiscal years beginning with 

20 the fiscal year ending September 30, 1983, and ending 

21 with the fiscal year ending September 30, 2016, the State 

22 of Arizona shall be designated as a contract health service 

23 delivery area by the Service for the purpose of providing 

24 contract health care services to members of federally rec25 ognized Indian Tribes of Arizona. 
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1 ‘‘(b) MAINTENANCE OF SERVICES.—The Service 

2 shall not curtail any health care services provided to Indi3 ans residing on reservations in the State of Arizona if such 

4 curtailment is due to the provision of contract services in 

5 such State pursuant to the designation of such State as 

6 a contract health service delivery area pursuant to sub7 section (a). 

8 ‘‘SEC. 216A. NORTH DAKOTA AND SOUTH DAKOTA AS A CON9 TRACT HEALTH SERVICE DELIVERY AREA. 

10 ‘‘(a) IN GENERAL.—Beginning in fiscal year 2003, 

11 the States of North Dakota and South Dakota shall be 

12 designated as a contract health service delivery area by 

13 the Service for the purpose of providing contract health 

14 care services to members of federally recognized Indian 

15 Tribes of North Dakota and South Dakota. 

16 ‘‘(b) LIMITATION.—The Service shall not curtail any 

17 health care services provided to Indians residing on any 

18 reservation, or in any county that has a common boundary 

19 with any reservation, in the State of North Dakota or 

20 South Dakota if such curtailment is due to the provision 

21 of contract services in such States pursuant to the des22 ignation of such States as a contract health service deliv23 ery area pursuant to subsection (a). 
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1 ‘‘SEC. 217. CALIFORNIA CONTRACT HEALTH SERVICES PRO2 GRAM. 

3 ‘‘(a) FUNDING AUTHORIZED.—The Secretary is au4 thorized to fund a program using the California Rural In5 dian Health Board (hereafter in this section referred to 

6 as the ‘CRIHB’) as a contract care intermediary to im7 prove the accessibility of health services to California Indi8 ans. 

9 ‘‘(b) REIMBURSEMENT CONTRACT.—The Secretary 

10 shall enter into an agreement with the CRIHB to reim11 burse the CRIHB for costs (including reasonable adminis12 trative costs) incurred pursuant to this section, in pro13 viding medical treatment under contract to California In14 dians described in section 806(a) throughout the Cali15 fornia contract health services delivery area described in 

16 section 218 with respect to high cost contract care cases. 

17 ‘‘(c) ADMINISTRATIVE EXPENSES.—Not more than 5 

18 percent of the amounts provided to the CRIHB under this 

19 section for any fiscal year may be for reimbursement for 

20 administrative expenses incurred by the CRIHB during 

21 such fiscal year. 

22 ‘‘(d) LIMITATION ON PAYMENT.—No payment may 

23 be made for treatment provided hereunder to the extent 

24 payment may be made for such treatment under the In25 dian Catastrophic Health Emergency Fund described in 

26 section 202 or from amounts appropriated or otherwise 
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1 made available to the California contract health service de2 livery area for a fiscal year. 

3 ‘‘(e) ADVISORY BOARD.—There is established an ad4 visory board which shall advise the CRIHB in carrying 

5 out this section. The advisory board shall be composed of 

6 representatives, selected by the CRIHB, from not less 

7 than 8 Tribal Health Programs serving California Indians 

covered under this section at least 1 8 ⁄2 of whom of whom 

9 are not affiliated with the CRIHB. 

10 ‘‘SEC. 218. CALIFORNIA AS A CONTRACT HEALTH SERVICE 

11 DELIVERY AREA. 

12 ‘‘The State of California, excluding the counties of 

13 Alameda, Contra Costa, Los Angeles, Marin, Orange, Sac14 ramento, San Francisco, San Mateo, Santa Clara, Kern, 

15 Merced, Monterey, Napa, San Benito, San Joaquin, San 

16 Luis Obispo, Santa Cruz, Solano, Stanislaus, and Ven17 tura, shall be designated as a contract health service deliv18 ery area by the Service for the purpose of providing con19 tract health services to California Indians. However, any 

20 of the counties listed herein may only be included in the 

21 contract health services delivery area if funding is specifi22 cally provided by the Service for such services in those 

23 counties. 
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1 ‘‘SEC. 219. CONTRACT HEALTH SERVICES FOR THE TREN2 TON SERVICE AREA. 

3 ‘‘(a) AUTHORIZATION FOR SERVICES.—The Sec4 retary, acting through the Service, is directed to provide 

5 contract health services to members of the Turtle Moun6 tain Band of Chippewa Indians that reside in the Trenton 

7 Service Area of Divide, McKenzie, and Williams counties 

8 in the State of North Dakota and the adjoining counties 

9 of Richland, Roosevelt, and Sheridan in the State of Mon10 tana. 

11 ‘‘(b) NO EXPANSION OF ELIGIBILITY.—Nothing in 

12 this section may be construed as expanding the eligibility 

13 of members of the Turtle Mountain Band of Chippewa In14 dians for health services provided by the Service beyond 

15 the scope of eligibility for such health services that applied 

16 on May 1, 1986. 

17 ‘‘SEC. 220. PROGRAMS OPERATED BY INDIAN TRIBES AND 

18 TRIBAL ORGANIZATIONS. 

19 ‘‘The Service shall provide funds for health care pro20 grams and facilities operated by Tribal Health Programs 

21 on the same basis as such funds are provided to programs 

22 and facilities operated directly by the Service. 

23 ‘‘SEC. 221. LICENSING. 

24 ‘‘Health care professionals employed by a Tribal 

25 Health Program shall, if licensed in any State, be exempt 

26 from the licensing requirements of the State in which the 
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1 Tribal Health Program performs the services described in 

2 its contract or compact under the Indian Self-Determina3 tion and Education Assistance Act (25 U.S.C. 450 et 

4 seq.). 

5 ‘‘SEC. 222. NOTIFICATION OF PROVISION OF EMERGENCY 

6 CONTRACT HEALTH SERVICES. 

7 ‘‘With respect to an elderly Indian or an Indian with 

8 a disability receiving emergency medical care or services 

9 from a non-Service provider or in a non-Service facility 

10 under the authority of this Act, the time limitation (as 

11 a condition of payment) for notifying the Service of such 

12 treatment or admission shall be 30 days. 

13 ‘‘SEC. 223. PROMPT ACTION ON PAYMENT OF CLAIMS. 

14 ‘‘(a) DEADLINE FOR RESPONSE.—The Service shall 

15 respond to a notification of a claim by a provider of a 

16 contract care service with either an individual purchase 

17 order or a denial of the claim within 5 working days after 

18 the receipt of such notification. 

19 ‘‘(b) EFFECT OF UNTIMELY RESPONSE.—If the 

20 Service fails to respond to a notification of a claim in ac21 cordance with subsection (a), the Service shall accept as 

22 valid the claim submitted by the provider of a contract 

23 care service. 
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1 ‘‘(c) DEADLINE FOR PAYMENT OF VALID CLAIM.—

2 The Service shall pay a valid contract care service claim 

3 within 30 days after the completion of the claim. 

4 ‘‘SEC. 224. LIABILITY FOR PAYMENT. 

5 ‘‘(a) NO PATIENT LIABILITY.—A patient who re6 ceives contract health care services that are authorized by 

7 the Service shall not be liable for the payment of any 

8 charges or costs associated with the provision of such serv9 ices. 

10 ‘‘(b) NOTIFICATION.—The Secretary shall notify a 

11 contract care provider and any patient who receives con12 tract health care services authorized by the Service that 

13 such patient is not liable for the payment of any charges 

14 or costs associated with the provision of such services not 

15 later than 5 business days after receipt of a notification 

16 of a claim by a provider of contract care services. 

17 ‘‘(c) NO RECOURSE.—Following receipt of the notice 

18 provided under subsection (b), or, if a claim has been 

19 deemed accepted under section 223(b), the provider shall 

20 have no further recourse against the patient who received 

21 the services. 

22 ‘‘SEC. 225. OFFICE OF INDIAN MEN’S HEALTH. 

23 ‘‘(a) ESTABLISHMENT.—The Secretary may establish 

24 within the Service an office to be known as the ‘Office 
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1 of Indian Men’s Health’ (referred to in this section as the 

2 ‘Office’). 

3 ‘‘(b) DIRECTOR.—

4 ‘‘(1) IN GENERAL.—The Office shall be headed 

5 by a director, to be appointed by the Secretary. 

6 ‘‘(2) DUTIES.—The director shall coordinate 

7 and promote the status of the health of Indian men 

8 in the United States. 

9 ‘‘(c) REPORT.—Not later than 2 years after the date 

10 of enactment of the Indian Health Care Improvement Act 

11 Amendments of 2008, the Secretary, acting through the 

12 director of the Office, shall submit to Congress a report 

13 describing—

14 ‘‘(1) any activity carried out by the director as 

15 of the date on which the report is prepared; and 

16 ‘‘(2) any finding of the director with respect to 

17 the health of Indian men. 

18 ‘‘SEC. 226. AUTHORIZATION OF APPROPRIATIONS. 

19 ‘‘There are authorized to be appropriated such sums 

20 as may be necessary for each fiscal year through fiscal 

21 year 2017 to carry out this title. 
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1 ‘‘TITLE III—FACILITIES 

2 ‘‘SEC. 301. CONSULTATION; CONSTRUCTION AND RENOVA3 TION OF FACILITIES; REPORTS. 

4 ‘‘(a) PREREQUISITES FOR EXPENDITURE OF

5 FUNDS.—Prior to the expenditure of, or the making of 

6 any binding commitment to expend, any funds appro7 priated for the planning, design, construction, or renova8 tion of facilities pursuant to the Act of November 2, 1921 

9 (25 U.S.C. 13) (commonly known as the ‘Snyder Act’), 

10 the Secretary, acting through the Service, shall—

11 ‘‘(1) consult with any Indian Tribe that would 

12 be significantly affected by such expenditure for the 

13 purpose of determining and, whenever practicable, 

14 honoring tribal preferences concerning size, location, 

15 type, and other characteristics of any facility on 

16 which such expenditure is to be made; and 

17 ‘‘(2) ensure, whenever practicable and applica18 ble, that such facility meets the construction stand19 ards of any accrediting body recognized by the Sec20 retary for the purposes of the Medicare, Medicaid, 

21 and SCHIP programs under titles XVIII, XIX, and 

22 XXI of the Social Security Act by not later than 1 

23 year after the date on which the construction or ren24 ovation of such facility is completed. 
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1 ‘‘(b) CLOSURES AND REDUCTIONS IN HOURS OF

2 SERVICE.—

3 ‘‘(1) EVALUATION REQUIRED.—Notwith4 standing any other provision of law, no facility oper5 ated by the Service, or any portion of such facility, 

6 may be closed or have the hours of service of the fa7 cility reduced if the Secretary has not submitted to 

8 Congress not less than 1 year, and not more than 

9 2 years, before the date of the proposed closure or 

10 reduction in hours of service an evaluation, com11 pleted not more than 2 years before the submission, 

12 of the impact of the proposed closure or reduction 

13 in hours of service that specifies, in addition to other 

14 considerations—

15 ‘‘(A) the accessibility of alternative health 

16 care resources for the population served by such 

17 facility; 

18 ‘‘(B) the cost-effectiveness of such closure 

19 or reduction in hours of service; 

20 ‘‘(C) the quality of health care to be pro21 vided to the population served by such facility 

22 after such closure or reduction in hours of serv23 ice; 

24 ‘‘(D) the availability of contract health 

25 care funds to maintain existing levels of service; 
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1 ‘‘(E) the views of the Indian Tribes served 

2 by such facility concerning such closure or re3 duction in hours of service; 

4 ‘‘(F) the level of use of such facility by all 

5 eligible Indians; and 

6 ‘‘(G) the distance between such facility and 

7 the nearest operating Service hospital. 

8 ‘‘(2) EXCEPTION FOR CERTAIN TEMPORARY

9 CLOSURES AND REDUCTIONS.—Paragraph (1) shall 

10 not apply to any temporary closure or reduction in 

11 hours of service of a facility or any portion of a fa12 cility if such closure or reduction in hours of service 

13 is necessary for medical, environmental, or construc14 tion safety reasons. 

15 ‘‘(c) HEALTH CARE FACILITY PRIORITY SYSTEM.—

16 ‘‘(1) IN GENERAL.—

17 ‘‘(A) PRIORITY SYSTEM.—The Secretary, 

18 acting through the Service, shall maintain a 

19 health care facility priority system, which—

20 ‘‘(i) shall be developed in consultation 

21 with Indian Tribes and Tribal Organiza22 tions; 

23 ‘‘(ii) shall give Indian Tribes’ needs 

24 the highest priority; 
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1 ‘‘(iii)(I) may include the lists required 

2 in paragraph (2)(B)(ii); and 

3 ‘‘(II) shall include the methodology re4 quired in paragraph (2)(B)(v); and 

5 ‘‘(III) may include such health care 

6 facilities, and such renovation or expansion 

7 needs of any health care facility, as the 

8 Service may identify; and 

9 ‘‘(iv) shall provide an opportunity for 

10 the nomination of planning, design, and 

11 construction projects by the Service, In12 dian Tribes, and Tribal Organizations for 

13 consideration under the priority system at 

14 least once every 3 years, or more fre15 quently as the Secretary determines to be 

16 appropriate. 

17 ‘‘(B) NEEDS OF FACILITIES UNDER

18 ISDEAA AGREEMENTS.—The Secretary shall en19 sure that the planning, design, construction, 

20 renovation, and expansion needs of Service and 

21 non-Service facilities operated under contracts 

22 or compacts in accordance with the Indian Self23 Determination and Education Assistance Act 

24 (25 U.S.C. 450 et seq.) are fully and equitably 
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1 integrated into the health care facility priority 

2 system. 

3 ‘‘(C) CRITERIA FOR EVALUATING

4 NEEDS.—For purposes of this subsection, the 

5 Secretary, in evaluating the needs of facilities 

6 operated under a contract or compact under the 

7 Indian Self-Determination and Education As8 sistance Act (25 U.S.C. 450 et seq.), shall use 

9 the criteria used by the Secretary in evaluating 

10 the needs of facilities operated directly by the 

11 Service. 

12 ‘‘(D) PRIORITY OF CERTAIN PROJECTS

13 PROTECTED.—The priority of any project estab14 lished under the construction priority system in 

15 effect on the date of enactment of the Indian 

16 Health Care Improvement Act Amendments of 

17 2008 shall not be affected by any change in the 

18 construction priority system taking place after 

19 that date if the project—

20 ‘‘(i) was identified in the fiscal year 

21 2008 Service budget justification as—

22 ‘‘(I) 1 of the 10 top-priority inpa23 tient projects; 

24 ‘‘(II) 1 of the 10 top-priority out25 patient projects; 
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1 ‘‘(III) 1 of the 10 top-priority 

2 staff quarters developments; or 

3 ‘‘(IV) 1 of the 10 top-priority 

4 Youth Regional Treatment Centers; 

5 ‘‘(ii) had completed both Phase I and 

6 Phase II of the construction priority sys7 tem in effect on the date of enactment of 

8 such Act; or 

9 ‘‘(iii) is not included in clause (i) or 

10 (ii) and is selected, as determined by the 

11 Secretary—

12 ‘‘(I) on the initiative of the Sec13 retary; or 

14 ‘‘(II) pursuant to a request of an 

15 Indian Tribe or Tribal Organization. 

16 ‘‘(2) REPORT; CONTENTS.—

17 ‘‘(A) INITIAL COMPREHENSIVE REPORT.—

18 ‘‘(i) DEFINITIONS.—In this subpara19 graph: 

20 ‘‘(I) FACILITIES APPROPRIATION

21 ADVISORY BOARD.—The term ‘Facili22 ties Appropriation Advisory Board’ 

23 means the advisory board, comprised 

24 of 12 members representing Indian 

25 tribes and 2 members representing 
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1 the Service, established at the discre2 tion of the Director—

3 ‘‘(aa) to provide advice and 

4 recommendations for policies and 

5 procedures of the programs fund6 ed pursuant to facilities appro7 priations; and 

8 ‘‘(bb) to address other facili9 ties issues. 

10 ‘‘(II) FACILITIES NEEDS ASSESS11 MENT WORKGROUP.—The term ‘Fa12 cilities Needs Assessment Workgroup’ 

13 means the workgroup established at 

14 the discretion of the Director—

15 ‘‘(aa) to review the health 

16 care facilities construction pri17 ority system; and 

18 ‘‘(bb) to make recommenda19 tions to the Facilities Appropria20 tion Advisory Board for revising 

21 the priority system. 

22 ‘‘(ii) INITIAL REPORT.—

23 ‘‘(I) IN GENERAL.—Not later 

24 than 1 year after the date of enact25 ment of the Indian Health Care Im-
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1 provement Act Amendments of 2008, 

2 the Secretary shall submit to the 

3 Committee on Indian Affairs of the 

4 Senate and the Committee on Natural 

5 Resources of the House of Represent6 atives a report that describes the com7 prehensive, national, ranked list of all 

8 health care facilities needs for the 

9 Service, Indian Tribes, and Tribal Or10 ganizations (including inpatient health 

11 care facilities, outpatient health care 

12 facilities, specialized health care facili13 ties (such as for long-term care and 

14 alcohol and drug abuse treatment), 

15 wellness centers, and staff quarters, 

16 and the renovation and expansion 

17 needs, if any, of such facilities) devel18 oped by the Service, Indian Tribes, 

19 and Tribal Organizations for the Fa20 cilities Needs Assessment Workgroup 

21 and the Facilities Appropriation Advi22 sory Board. 

23 ‘‘(II) INCLUSIONS.—The initial 

24 report shall include—
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1 ‘‘(aa) the methodology and 

2 criteria used by the Service in de3 termining the needs and estab4 lishing the ranking of the facili5 ties needs; and 

6 ‘‘(bb) such other information 

7 as the Secretary determines to be 

8 appropriate. 

9 ‘‘(iii) UPDATES OF REPORT.—Begin10 ning in calendar year 2011, the Secretary 

11 shall—

12 ‘‘(I) update the report under 

13 clause (ii) not less frequently that 

14 once every 5 years; and 

15 ‘‘(II) include the updated report 

16 in the appropriate annual report 

17 under subparagraph (B) for submis18 sion to Congress under section 801. 

19 ‘‘(B) ANNUAL REPORTS.—The Secretary 

20 shall submit to the President, for inclusion in 

21 the report required to be transmitted to Con22 gress under section 801, a report which sets 

23 forth the following: 
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1 ‘‘(i) A description of the health care 

2 facility priority system of the Service es3 tablished under paragraph (1). 

4 ‘‘(ii) Health care facilities lists, which 

5 may include—

6 ‘‘(I) the 10 top-priority inpatient 

7 health care facilities; 

8 ‘‘(II) the 10 top-priority out9 patient health care facilities; 

10 ‘‘(III) the 10 top-priority special11 ized health care facilities (such as 

12 long-term care and alcohol and drug 

13 abuse treatment); and 

14 ‘‘(IV) the 10 top-priority staff 

15 quarters developments associated with 

16 health care facilities. 

17 ‘‘(iii) The justification for such order 

18 of priority. 

19 ‘‘(iv) The projected cost of such 

20 projects. 

21 ‘‘(v) The methodology adopted by the 

22 Service in establishing priorities under its 

23 health care facility priority system. 
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1 ‘‘(3) REQUIREMENTS FOR PREPARATION OF RE2 PORTS.—In preparing the report required under 

3 paragraph (2), the Secretary shall—

4 ‘‘(A) consult with and obtain information 

5 on all health care facilities needs from Indian 

6 Tribes and Tribal Organizations; and 

7 ‘‘(B) review the total unmet needs of all 

8 Indian Tribes and Tribal Organizations for 

9 health care facilities (including staff quarters), 

10 including needs for renovation and expansion of 

11 existing facilities. 

12 ‘‘(d) REVIEW OF METHODOLOGY USED FOR HEALTH

13 FACILITIES CONSTRUCTION PRIORITY SYSTEM.—

14 ‘‘(1) IN GENERAL.—Not later than 1 year after 

15 the establishment of the priority system under sub16 section (c)(1)(A), the Comptroller General of the 

17 United States shall prepare and finalize a report re18 viewing the methodologies applied, and the processes 

19 followed, by the Service in making each assessment 

20 of needs for the list under subsection (c)(2)(A)(ii) 

21 and developing the priority system under subsection 

22 (c)(1), including a review of—

23 ‘‘(A) the recommendations of the Facilities 

24 Appropriation Advisory Board and the Facili25 ties Needs Assessment Workgroup (as those 
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1 terms are defined in subsection (c)(2)(A)(i)); 

2 and 

3 ‘‘(B) the relevant criteria used in ranking 

4 or prioritizing facilities other than hospitals or 

5 clinics. 

6 ‘‘(2) SUBMISSION TO CONGRESS.—The Comp7 troller General of the United States shall submit the 

8 report under paragraph (1) to—

9 ‘‘(A) the Committees on Indian Affairs and 

10 Appropriations of the Senate; 

11 ‘‘(B) the Committees on Natural Re12 sources and Appropriations of the House of 

13 Representatives; and 

14 ‘‘(C) the Secretary. 

15 ‘‘(e) FUNDING CONDITION.—All funds appropriated 

16 under the Act of November 2, 1921 (25 U.S.C. 13) (com17 monly known as the ‘Snyder Act’), for the planning, de18 sign, construction, or renovation of health facilities for the 

19 benefit of 1 or more Indian Tribes shall be subject to the 

20 provisions of section 102 of the Indian Self-Determination 

21 and Education Assistance Act (25 U.S.C. 450f) or sec22 tions 504 and 505 of that Act (25 U.S.C. 458aaa–3, 

23 458aaa–4). 

24 ‘‘(f) DEVELOPMENT OF INNOVATIVE APPROACHES.—

25 The Secretary shall consult and cooperate with Indian 
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1 Tribes and Tribal Organizations, and confer with Urban 

2 Indian Organizations, in developing innovative approaches 

3 to address all or part of the total unmet need for construc4 tion of health facilities, that may include—

5 ‘‘(1) the establishment of an area distribution 

6 fund in which a portion of health facility construc7 tion funding could be devoted to all Service Areas; 

8 ‘‘(2) approaches provided for in other provisions 

9 of this title; and 

10 ‘‘(3) other approaches, as the Secretary deter11 mines to be appropriate. 

12 ‘‘SEC. 302. SANITATION FACILITIES. 

13 ‘‘(a) FINDINGS.—Congress finds the following: 

14 ‘‘(1) The provision of sanitation facilities is pri15 marily a health consideration and function. 

16 ‘‘(2) Indian people suffer an inordinately high 

17 incidence of disease, injury, and illness directly at18 tributable to the absence or inadequacy of sanitation 

19 facilities. 

20 ‘‘(3) The long-term cost to the United States of 

21 treating and curing such disease, injury, and illness 

22 is substantially greater than the short-term cost of 

23 providing sanitation facilities and other preventive 

24 health measures. 
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1 ‘‘(4) Many Indian homes and Indian commu2 nities still lack sanitation facilities. 

3 ‘‘(5) It is in the interest of the United States, 

4 and it is the policy of the United States, that all In5 dian communities and Indian homes, new and exist6 ing, be provided with sanitation facilities. 

7 ‘‘(b) FACILITIES AND SERVICES.—In furtherance of 

8 the findings made in subsection (a), Congress reaffirms 

9 the primary responsibility and authority of the Service to 

10 provide the necessary sanitation facilities and services as 

11 provided in section 7 of the Act of August 5, 1954 (42 

12 U.S.C. 2004a). Under such authority, the Secretary, act13 ing through the Service, is authorized to provide the fol14 lowing: 

15 ‘‘(1) Financial and technical assistance to In16 dian Tribes, Tribal Organizations, and Indian com17 munities in the establishment, training, and equip18 ping of utility organizations to operate and maintain 

19 sanitation facilities, including the provision of exist20 ing plans, standard details, and specifications avail21 able in the Department, to be used at the option of 

22 the Indian Tribe, Tribal Organization, or Indian 

23 community. 

24 ‘‘(2) Ongoing technical assistance and training 

25 to Indian Tribes, Tribal Organizations, and Indian 
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1 communities in the management of utility organiza2 tions which operate and maintain sanitation facili3 ties. 

4 ‘‘(3) Priority funding for operation and mainte5 nance assistance for, and emergency repairs to, sani6 tation facilities operated by an Indian Tribe, Tribal 

7 Organization or Indian community when necessary 

8 to avoid an imminent health threat or to protect the 

9 investment in sanitation facilities and the investment 

10 in the health benefits gained through the provision 

11 of sanitation facilities. 

12 ‘‘(c) FUNDING.—Notwithstanding any other provi13 sion of law—

14 ‘‘(1) the Secretary of Housing and Urban De15 velopment is authorized to transfer funds appro16 priated under the Native American Housing Assist17 ance and Self-Determination Act of 1996 (25 U.S.C. 

18 4101 et seq.) to the Secretary of Health and Human 

19 Services; 

20 ‘‘(2) the Secretary of Health and Human Serv21 ices is authorized to accept and use such funds for 

22 the purpose of providing sanitation facilities and 

23 services for Indians under section 7 of the Act of 

24 August 5, 1954 (42 U.S.C. 2004a); 
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1 ‘‘(3) unless specifically authorized when funds 

2 are appropriated, the Secretary shall not use funds 

3 appropriated under section 7 of the Act of August 

4 5, 1954 (42 U.S.C. 2004a), to provide sanitation fa5 cilities to new homes constructed using funds pro6 vided by the Department of Housing and Urban De7 velopment; 

8 ‘‘(4) the Secretary of Health and Human Serv9 ices is authorized to accept from any source, includ10 ing Federal and State agencies, funds for the pur11 pose of providing sanitation facilities and services 

12 and place these funds into contracts or compacts 

13 under the Indian Self-Determination and Education 

14 Assistance Act (25 U.S.C. 450 et seq.); 

15 ‘‘(5) the Secretary is authorized to establish a 

16 program under which the Secretary may, in accord17 ance with this subsection and with paragraphs (2), 

18 (3), (4), and (5) of section 330(d) of the Public 

19 Health Service Act (42 U.S.C. 254b(d)) related to a 

20 loan guarantee program, guarantee the principal and 

21 interest on loans made by lenders to Indian Tribes 

22 for new projects to construct eligible sanitation fa23 cilities to serve Indian homes, but only to the extent 

24 that appropriations are provided in advance specifi25 cally for such program, and without reducing funds 
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1 made available for the provision of domestic and 

2 community sanitation facilities for Indians, as au3 thorized by section 7 of the Act of August 5, 1954 

4 (42 U.S.C. 2004a), the Indian Self-Determination 

5 and Education Assistance Act (25 U.S.C. 450 et 

6 seq.), and this Act; 

7 ‘‘(6) except as otherwise prohibited by this sec8 tion, the Secretary may use funds appropriated 

9 under the authority of section 7 of the Act of Au10 gust 5, 1954 (42 U.S.C. 2004a) to meet matching 

11 or cost participation requirements under other Fed12 eral and non-Federal programs for new projects to 

13 construct eligible sanitation facilities; 

14 ‘‘(7) all Federal agencies are authorized to 

15 transfer to the Secretary funds identified, granted, 

16 loaned, or appropriated whereby the Department’s 

17 applicable policies, rules, and regulations shall apply 

18 in the implementation of such projects; 

19 ‘‘(8) the Secretary of Health and Human Serv20 ices shall enter into interagency agreements with 

21 Federal and State agencies for the purpose of pro22 viding financial assistance for sanitation facilities 

23 and services under this Act; 

24 ‘‘(9) the Secretary of Health and Human Serv25 ices shall, by regulation, establish standards applica-
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1 ble to the planning, design, and construction of sani2 tation facilities funded under this Act; and 

3 ‘‘(10) the Secretary of Health and Human 

4 Services is authorized to accept payments for goods 

5 and services furnished by the Service from appro6 priate public authorities, nonprofit organizations or 

7 agencies, or Indian Tribes, as contributions by that 

8 authority, organization, agency, or tribe to agree9 ments made under section 7 of the Act of August 5, 

10 1954 (42 U.S.C. 2004a), and such payments shall 

11 be credited to the same or subsequent appropriation 

12 account as funds appropriated under the authority 

13 of section 7 of the Act of August 5, 1954 (42 U.S.C. 

14 2004a). 

15 ‘‘(d) CERTAIN CAPABILITIES NOT PREREQUISITE.—

16 The financial and technical capability of an Indian Tribe, 

17 Tribal Organization, or Indian community to safely oper18 ate, manage, and maintain a sanitation facility shall not 

19 be a prerequisite to the provision or construction of sanita20 tion facilities by the Secretary. 

21 ‘‘(e) FINANCIAL ASSISTANCE.—The Secretary is au22 thorized to provide financial assistance to Indian Tribes, 

23 Tribal Organizations, and Indian communities for oper24 ation, management, and maintenance of their sanitation 

25 facilities. 
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1 ‘‘(f) OPERATION, MANAGEMENT, AND MAINTENANCE

2 OF FACILITIES.—The Indian Tribe has the primary re3 sponsibility to establish, collect, and use reasonable user 

4 fees, or otherwise set aside funding, for the purpose of 

5 operating, managing, and maintaining sanitation facilities. 

6 If a sanitation facility serving a community that is oper7 ated by an Indian Tribe or Tribal Organization is threat8 ened with imminent failure and such operator lacks capac9 ity to maintain the integrity or the health benefits of the 

10 sanitation facility, then the Secretary is authorized to as11 sist the Indian Tribe, Tribal Organization, or Indian com12 munity in the resolution of the problem on a short-term 

13 basis through cooperation with the emergency coordinator 

14 or by providing operation, management, and maintenance 

15 service. 

16 ‘‘(g) ISDEAA PROGRAM FUNDED ON EQUAL

17 BASIS.—Tribal Health Programs shall be eligible (on an 

18 equal basis with programs that are administered directly 

19 by the Service) for—

20 ‘‘(1) any funds appropriated pursuant to this 

21 section; and 

22 ‘‘(2) any funds appropriated for the purpose of 

23 providing sanitation facilities. 

24 ‘‘(h) REPORT.—
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1 ‘‘(1) REQUIRED CONTENTS.—The Secretary, in 

2 consultation with the Secretary of Housing and 

3 Urban Development, Indian Tribes, Tribal Organiza4 tions, and tribally designated housing entities (as de5 fined in section 4 of the Native American Housing 

6 Assistance and Self-Determination Act of 1996 (25 

7 U.S.C. 4103)) shall submit to the President, for in8 clusion in the report required to be transmitted to 

9 Congress under section 801, a report which sets 

10 forth—

11 ‘‘(A) the current Indian sanitation facility 

12 priority system of the Service; 

13 ‘‘(B) the methodology for determining 

14 sanitation deficiencies and needs; 

15 ‘‘(C) the criteria on which the deficiencies 

16 and needs will be evaluated; 

17 ‘‘(D) the level of initial and final sanitation 

18 deficiency for each type of sanitation facility for 

19 each project of each Indian Tribe or Indian 

20 community; 

21 ‘‘(E) the amount and most effective use of 

22 funds, derived from whatever source, necessary 

23 to accommodate the sanitation facilities needs 

24 of new homes assisted with funds under the 

25 Native American Housing Assistance and Self-
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1 Determination Act (25 U.S.C. 4101 et seq.), 

2 and to reduce the identified sanitation defi3 ciency levels of all Indian Tribes and Indian 

4 communities to level I sanitation deficiency as 

5 defined in paragraph (3)(A); and 

6 ‘‘(F) a 10-year plan to provide sanitation 

7 facilities to serve existing Indian homes and In8 dian communities and new and renovated In9 dian homes. 

10 ‘‘(2) UNIFORM METHODOLOGY.—The method11 ology used by the Secretary in determining, pre12 paring cost estimates for, and reporting sanitation 

13 deficiencies for purposes of paragraph (1) shall be 

14 applied uniformly to all Indian Tribes and Indian 

15 communities. 

16 ‘‘(3) SANITATION DEFICIENCY LEVELS.—For 

17 purposes of this subsection, the sanitation deficiency 

18 levels for an individual, Indian Tribe, or Indian com19 munity sanitation facility to serve Indian homes are 

20 determined as follows: 

21 ‘‘(A) A level I deficiency exists if a sanita22 tion facility serving an individual, Indian Tribe, 

23 or Indian community—
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1 ‘‘(i) complies with all applicable water 

2 supply, pollution control, and solid waste 

3 disposal laws; and 

4 ‘‘(ii) deficiencies relate to routine re5 placement, repair, or maintenance needs. 

6 ‘‘(B) A level II deficiency exists if a sanita7 tion facility serving an individual, Indian Tribe, 

8 or Indian community substantially or recently 

9 complied with all applicable water supply, pollu10 tion control, and solid waste laws and any defi11 ciencies relate to—

12 ‘‘(i) small or minor capital improve13 ments needed to bring the facility back 

14 into compliance; 

15 ‘‘(ii) capital improvements that are 

16 necessary to enlarge or improve the facili17 ties in order to meet the current needs for 

18 domestic sanitation facilities; or 

19 ‘‘(iii) the lack of equipment or train20 ing by an Indian Tribe, Tribal Organiza21 tion, or an Indian community to properly 

22 operate and maintain the sanitation facili23 ties. 

24 ‘‘(C) A level III deficiency exists if a sani25 tation facility serving an individual, Indian 
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1 Tribe or Indian community meets 1 or more of 

2 the following conditions—

3 ‘‘(i) water or sewer service in the 

4 home is provided by a haul system with 

5 holding tanks and interior plumbing; 

6 ‘‘(ii) major significant interruptions to 

7 water supply or sewage disposal occur fre8 quently, requiring major capital improve9 ments to correct the deficiencies; or 

10 ‘‘(iii) there is no access to or no ap11 proved or permitted solid waste facility 

12 available. 

13 ‘‘(D) A level IV deficiency exists—

14 ‘‘(i) if a sanitation facility for an indi15 vidual home, an Indian Tribe, or an Indian 

16 community exists but—

17 ‘‘(I) lacks—

18 ‘‘(aa) a safe water supply 

19 system; or 

20 ‘‘(bb) a waste disposal sys21 tem; 

22 ‘‘(II) contains no piped water or 

23 sewer facilities; or 

24 ‘‘(III) has become inoperable due 

25 to a major component failure; or 
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1 ‘‘(ii) if only a washeteria or central fa2 cility exists in the community. 

3 ‘‘(E) A level V deficiency exists in the ab4 sence of a sanitation facility, where individual 

5 homes do not have access to safe drinking 

6 water or adequate wastewater (including sew7 age) disposal. 

8 ‘‘(i) DEFINITIONS.—For purposes of this section, the 

9 following terms apply: 

10 ‘‘(1) 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 ‘‘(2) SANITATION FACILITIES.—The terms 

16 ‘sanitation facility’ and ‘sanitation facilities’ mean 

17 safe and adequate water supply systems, sanitary 

18 sewage disposal systems, and sanitary solid waste 

19 systems (and all related equipment and support in20 frastructure). 

21 ‘‘SEC. 303. PREFERENCE TO INDIANS AND INDIAN FIRMS. 

22 ‘‘(a) DISCRETIONARY AUTHORITY; COVERED ACTIVI23 TIES.—The Secretary, acting through the Service, may 

24 utilize the negotiating authority of section 23 of the Act 

25 of June 25, 1910 (25 U.S.C. 47), to give preference to 
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1 any Indian or any enterprise, partnership, corporation, or 

2 other type of business organization owned and controlled 

3 by an Indian or Indians including former or currently fed4 erally recognized Indian Tribes in the State of New York 

5 (hereinafter referred to as an ‘Indian firm’) in the con6 struction and renovation of Service facilities pursuant to 

7 section 301 and in the construction of safe water and sani8 tary waste disposal facilities pursuant to section 302. Such 

9 preference may be accorded by the Secretary unless the 

10 Secretary finds, pursuant to rules and regulations promul11 gated by the Secretary, that the project or function to be 

12 contracted for will not be satisfactory or that the project 

13 or function cannot be properly completed or maintained 

14 under the proposed contract. The Secretary, in arriving 

15 at such a finding, shall consider whether the Indian or 

16 Indian firm will be deficient with respect to—

17 ‘‘(1) ownership and control by Indians; 

18 ‘‘(2) equipment; 

19 ‘‘(3) bookkeeping and accounting procedures; 

20 ‘‘(4) substantive knowledge of the project or 

21 function to be contracted for; 

22 ‘‘(5) adequately trained personnel; or 

23 ‘‘(6) other necessary components of contract 

24 performance. 
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1 ‘‘(b) PAY RATES.—For the purpose of implementing 

2 the provisions of this title, the Secretary shall assure that 

3 the rates of pay for personnel engaged in the construction 

4 or renovation of facilities constructed or renovated in 

5 whole or in part by funds made available pursuant to this 

6 title are not less than the prevailing local wage rates for 

7 similar work as determined in accordance with sections 

8 3141 through 3144, 3146, and 3147 of title 40, United 

9 States Code. 

10 ‘‘SEC. 304. EXPENDITURE OF NON-SERVICE FUNDS FOR 

11 RENOVATION. 

12 ‘‘(a) IN GENERAL.—Notwithstanding any other pro13 vision of law, if the requirements of subsection (c) are met, 

14 the Secretary, acting through the Service, is authorized 

15 to accept any major expansion, renovation, or moderniza16 tion by any Indian Tribe or Tribal Organization of any 

17 Service facility or of any other Indian health facility oper18 ated pursuant to a contract or compact under the Indian 

19 Self-Determination and Education Assistance Act (25 

20 U.S.C. 450 et seq.), including—

21 ‘‘(1) any plans or designs for such expansion, 

22 renovation, or modernization; and 

23 ‘‘(2) any expansion, renovation, or moderniza24 tion for which funds appropriated under any Federal 

25 law were lawfully expended. 
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1 ‘‘(b) PRIORITY LIST.—

2 ‘‘(1) IN GENERAL.—The Secretary shall main3 tain a separate priority list to address the needs for 

4 increased operating expenses, personnel, or equip5 ment for such facilities. The methodology for estab6 lishing priorities shall be developed through regula7 tions. The list of priority facilities will be revised an8 nually in consultation with Indian Tribes and Tribal 

9 Organizations. 

10 ‘‘(2) REPORT.—The Secretary shall submit to 

11 the President, for inclusion in the report required to 

12 be transmitted to Congress under section 801, the 

13 priority list maintained pursuant to paragraph (1). 

14 ‘‘(c) REQUIREMENTS.—The requirements of this sub15 section are met with respect to any expansion, renovation, 

16 or modernization if—

17 ‘‘(1) the Indian Tribe or Tribal Organization—

18 ‘‘(A) provides notice to the Secretary of its 

19 intent to expand, renovate, or modernize; and 

20 ‘‘(B) applies to the Secretary to be placed 

21 on a separate priority list to address the needs 

22 of such new facilities for increased operating ex23 penses, personnel, or equipment; and 

24 ‘‘(2) the expansion, renovation, or moderniza25 tion—
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1 ‘‘(A) is approved by the appropriate area 

2 Director for Federal facilities; and 

3 ‘‘(B) is administered by the Indian Tribe 

4 or Tribal Organization in accordance with any 

5 applicable regulations prescribed by the Sec6 retary with respect to construction or renova7 tion of Service facilities. 

8 ‘‘(d) ADDITIONAL REQUIREMENT FOR EXPANSION.—

9 In addition to the requirements under subsection (c), for 

10 any expansion, the Indian Tribe or Tribal Organization 

11 shall provide to the Secretary additional information pur12 suant to regulations, including additional staffing, equip13 ment, and other costs associated with the expansion. 

14 ‘‘(e) CLOSURE OR CONVERSION OF FACILITIES.—If 

15 any Service facility which has been expanded, renovated, 

16 or modernized by an Indian Tribe or Tribal Organization 

17 under this section ceases to be used as a Service facility 

18 during the 20-year period beginning on the date such ex19 pansion, renovation, or modernization is completed, such 

20 Indian Tribe or Tribal Organization shall be entitled to 

21 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. 305. FUNDING FOR THE CONSTRUCTION, EXPANSION, 

6 AND MODERNIZATION OF SMALL AMBULA7 TORY CARE FACILITIES. 

8 ‘‘(a) GRANTS.—

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

10 through the Service, shall make grants to Indian 

11 Tribes and Tribal Organizations for the construc12 tion, expansion, or modernization of facilities for the 

13 provision of ambulatory care services to eligible Indi14 ans (and noneligible persons pursuant to subsections 

15 (b)(2) and (c)(1)(C)). A grant made under this sec16 tion may cover up to 100 percent of the costs of 

17 such construction, expansion, or modernization. For 

18 the purposes of this section, the term ‘construction’ 

19 includes the replacement of an existing facility. 

20 ‘‘(2) GRANT AGREEMENT REQUIRED.—A grant 

21 under paragraph (1) may only be made available to 

22 a Tribal Health Program operating an Indian health 

23 facility (other than a facility owned or constructed 

24 by the Service, including a facility originally owned 
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1 or constructed by the Service and transferred to an 

2 Indian Tribe or Tribal Organization). 

3 ‘‘(b) USE OF GRANT FUNDS.—

4 ‘‘(1) ALLOWABLE USES.—A grant awarded 

5 under this section may be used for the construction, 

6 expansion, or modernization (including the planning 

7 and design of such construction, expansion, or mod8 ernization) of an ambulatory care facility—

9 ‘‘(A) located apart from a hospital; 

10 ‘‘(B) not funded under section 301 or sec11 tion 306; and 

12 ‘‘(C) which, upon completion of such con13 struction or modernization will—

14 ‘‘(i) have a total capacity appropriate 

15 to its projected service population; 

16 ‘‘(ii) provide annually no fewer than 

17 150 patient visits by eligible Indians and 

18 other users who are eligible for services in 

19 such facility in accordance with section 

20 807(c)(2); and 

21 ‘‘(iii) provide ambulatory care in a 

22 Service Area (specified in the contract or 

23 compact under the Indian Self-Determina24 tion and Education Assistance Act (25 

25 U.S.C. 450 et seq.)) with a population of 
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1 no fewer than 1,500 eligible Indians and 

2 other users who are eligible for services in 

3 such facility in accordance with section 

4 807(c)(2). 

5 ‘‘(2) ADDITIONAL ALLOWABLE USE.—The Sec6 retary may also reserve a portion of the funding pro7 vided under this section and use those reserved 

8 funds to reduce an outstanding debt incurred by In9 dian Tribes or Tribal Organizations for the con10 struction, expansion, or modernization of an ambula11 tory care facility that meets the requirements under 

12 paragraph (1). The provisions of this section shall 

13 apply, except that such applications for funding 

14 under this paragraph shall be considered separately 

15 from applications for funding under paragraph (1). 

16 ‘‘(3) USE ONLY FOR CERTAIN PORTION OF

17 COSTS.—A grant provided under this section may be 

18 used only for the cost of that portion of a construc19 tion, expansion, or modernization project that bene20 fits the Service population identified above in sub21 section (b)(1)(C) (ii) and (iii). The requirements of 

22 clauses (ii) and (iii) of paragraph (1)(C) shall not 

23 apply to an Indian Tribe or Tribal Organization ap24 plying for a grant under this section for a health 

25 care facility located or to be constructed on an is-
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1 land or when such facility is not located on a road 

2 system providing direct access to an inpatient hos3 pital where care is available to the Service popu4 lation. 

5 ‘‘(c) GRANTS.—

6 ‘‘(1) APPLICATION.—No grant may be made 

7 under this section unless an application or proposal 

8 for the grant has been approved by the Secretary in 

9 accordance with applicable regulations and has set 

10 forth reasonable assurance by the applicant that, at 

11 all times after the construction, expansion, or mod12 ernization of a facility carried out using a grant re13 ceived under this section—

14 ‘‘(A) adequate financial support will be 

15 available for the provision of services at such 

16 facility; 

17 ‘‘(B) such facility will be available to eligi18 ble Indians without regard to ability to pay or 

19 source of payment; and 

20 ‘‘(C) such facility will, as feasible without 

21 diminishing the quality or quantity of services 

22 provided to eligible Indians, serve noneligible 

23 persons on a cost basis. 
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1 ‘‘(2) PRIORITY.—In awarding grants under this 

2 section, the Secretary shall give priority to Indian 

3 Tribes and Tribal Organizations that demonstrate—

4 ‘‘(A) a need for increased ambulatory care 

5 services; and 

6 ‘‘(B) insufficient capacity to deliver such 

7 services. 

8 ‘‘(3) PEER REVIEW PANELS.—The Secretary 

9 may provide for the establishment of peer review 

10 panels, as necessary, to review and evaluate applica11 tions and proposals and to advise the Secretary re12 garding such applications using the criteria devel13 oped pursuant to subsection (a)(1). 

14 ‘‘(d) REVERSION OF FACILITIES.—If any facility (or 

15 portion thereof) with respect to which funds have been 

16 paid under this section, ceases, at any time after comple17 tion of the construction, expansion, or modernization car18 ried out with such funds, to be used for the purposes of 

19 providing health care services to eligible Indians, all of the 

20 right, title, and interest in and to such facility (or portion 

21 thereof) shall transfer to the United States unless other22 wise negotiated by the Service and the Indian Tribe or 

23 Tribal Organization. 

24 ‘‘(e) FUNDING NONRECURRING.—Funding provided 

25 under this section shall be nonrecurring and shall not be 
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1 available for inclusion in any individual Indian Tribe’s 

2 tribal share for an award under the Indian Self-Deter3 mination and Education Assistance Act (25 U.S.C. 450 

4 et seq.) or for reallocation or redesign thereunder. 

5 ‘‘SEC. 306. INDIAN HEALTH CARE DELIVERY DEMONSTRA6 TION PROJECTS. 

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

8 the Service, is authorized to carry out, or to enter into 

9 construction agreements under the Indian Self-Determina10 tion and Education Assistance Act (25 U.S.C. 450 et seq.) 

11 with Indian Tribes or Tribal Organizations to carry out, 

12 a health care delivery demonstration project to test alter13 native means of delivering health care and services to Indi14 ans through facilities. 

15 ‘‘(b) USE OF FUNDS.—The Secretary, in approving 

16 projects pursuant to this section, may authorize such con17 struction agreements for the construction and renovation 

18 of hospitals, health centers, health stations, and other fa19 cilities to deliver health care services and is authorized 

20 to—

21 ‘‘(1) waive any leasing prohibition; 

22 ‘‘(2) permit carryover of funds appropriated for 

23 the provision of health care services; 

24 ‘‘(3) permit the use of other available funds; 
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1 ‘‘(4) permit the use of funds or property do2 nated from any source for project purposes; 

3 ‘‘(5) provide for the reversion of donated real or 

4 personal property to the donor; and 

5 ‘‘(6) permit the use of Service funds to match 

6 other funds, including Federal funds. 

7 ‘‘(c) HEALTH CARE DEMONSTRATION PROJECTS.—

8 ‘‘(1) GENERAL PROJECTS.—

9 ‘‘(A) CRITERIA.—The Secretary may ap10 prove under this section demonstration projects 

11 that meet the following criteria: 

12 ‘‘(i) There is a need for a new facility 

13 or program, such as a program for conven14 ient care services, or the reorientation of 

15 an existing facility or program. 

16 ‘‘(ii) A significant number of Indians, 

17 including Indians with low health status, 

18 will be served by the project. 

19 ‘‘(iii) The project has the potential to 

20 deliver services in an efficient and effective 

21 manner. 

22 ‘‘(iv) The project is economically via23 ble. 

24 ‘‘(v) For projects carried out by an 

25 Indian Tribe or Tribal Organization, the 
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1 Indian Tribe or Tribal Organization has 

2 the administrative and financial capability 

3 to administer the project. 

4 ‘‘(vi) The project is integrated with 

5 providers of related health and social serv6 ices and is coordinated with, and avoids 

7 duplication of, existing services in order to 

8 expand the availability of services. 

9 ‘‘(B) PRIORITY.—In approving demonstra10 tion projects under this paragraph, the Sec11 retary shall give priority to demonstration 

12 projects, to the extent the projects meet the cri13 teria described in subparagraph (A), located in 

14 any of the following Service Units: 

15 ‘‘(i) Cass Lake, Minnesota. 

16 ‘‘(ii) Mescalero, New Mexico. 

17 ‘‘(iii) Owyhee, Nevada. 

18 ‘‘(iv) Schurz, Nevada. 

19 ‘‘(v) Ft. Yuma, California. 

20 ‘‘(2) CONVENIENT CARE SERVICE PROJECTS.—

21 ‘‘(A) DEFINITION OF CONVENIENT CARE

22 SERVICE.—In this paragraph, the term ‘conven23 ient care service’ means any primary health 

24 care service, such as urgent care services, non25 emergent care services, prevention services and 
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1 screenings, and any service authorized by sec2 tions 203 or 213(d), that is—

3 ‘‘(i) provided outside the regular 

4 hours of operation of a health care facility; 

5 or 

6 ‘‘(ii) offered at an alternative setting, 

7 including through telehealth. 

8 ‘‘(B) APPROVAL.—In addition to projects 

9 described in paragraph (1), in any fiscal year, 

10 the Secretary is authorized to approve not more 

11 than 10 applications for health care delivery 

12 demonstration projects that—

13 ‘‘(i) include a convenient care services 

14 program as an alternative means of deliv15 ering health care services to Indians; and 

16 ‘‘(ii) meet the criteria described in 

17 subparagraph (C). 

18 ‘‘(C) CRITERIA.—The Secretary shall ap19 prove under subparagraph (B) demonstration 

20 projects that meet all of the following criteria: 

21 ‘‘(i) The criteria set forth in para22 graph (1)(A). 

23 ‘‘(ii) There is a lack of access to 

24 health care services at existing health care 

25 facilities, which may be due to limited 
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1 hours of operation at those facilities or 

2 other factors. 

3 ‘‘(iii) The project—

4 ‘‘(I) expands the availability of 

5 services; or 

6 ‘‘(II) reduces—

7 ‘‘(aa) the burden on Con8 tract Health Services; or 

9 ‘‘(bb) the need for emer10 gency room visits. 

11 ‘‘(d) PEER REVIEW PANELS.—The Secretary may 

12 provide for the establishment of peer review panels, as nec13 essary, to review and evaluate applications using the cri14 teria described in paragraphs (1)(A) and (2)(C) of sub15 section (c). 

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

17 provide such technical and other assistance as may be nec18 essary to enable applicants to comply with this section. 

19 ‘‘(f) SERVICE TO INELIGIBLE PERSONS.—Subject to 

20 section 807, the authority to provide services to persons 

21 otherwise ineligible for the health care benefits of the 

22 Service, and the authority to extend hospital privileges in 

23 Service facilities to non-Service health practitioners as 

24 provided in section 807, may be included, subject to the 
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1 terms of that section, in any demonstration project ap2 proved pursuant to this section. 

3 ‘‘(g) EQUITABLE TREATMENT.—For purposes of 

4 subsection (c), the Secretary, in evaluating facilities oper5 ated under any contract or compact under the Indian Self6 Determination and Education Assistance Act (25 U.S.C. 

7 450 et seq.), shall use the same criteria that the Secretary 

8 uses in evaluating facilities operated directly by the Serv9 ice. 

10 ‘‘(h) EQUITABLE INTEGRATION OF FACILITIES.—

11 The Secretary shall ensure that the planning, design, con12 struction, renovation, and expansion needs of Service and 

13 non-Service facilities that are the subject of a contract or 

14 compact under the Indian Self-Determination and Edu15 cation Assistance Act (25 U.S.C. 450 et seq.) for health 

16 services are fully and equitably integrated into the imple17 mentation of the health care delivery demonstration 

18 projects under this section. 

19 ‘‘SEC. 307. LAND TRANSFER. 

20 ‘‘Notwithstanding any other provision of law, the Bu21 reau of Indian Affairs and all other agencies and depart22 ments of the United States are authorized to transfer, at 

23 no cost, land and improvements to the Service for the pro24 vision of health care services. The Secretary is authorized 

25 to accept such land and improvements for such purposes. 
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1 ‘‘SEC. 308. LEASES, CONTRACTS, AND OTHER AGREEMENTS. 

2 ‘‘The Secretary, acting through the Service, may 

3 enter into leases, contracts, and other agreements with In4 dian Tribes and Tribal Organizations which hold (1) title 

5 to, (2) a leasehold interest in, or (3) a beneficial interest 

6 in (when title is held by the United States in trust for 

7 the benefit of an Indian Tribe) facilities used or to be used 

8 for the administration and delivery of health services by 

9 an Indian Health Program. Such leases, contracts, or 

10 agreements may include provisions for construction or ren11 ovation and provide for compensation to the Indian Tribe 

12 or Tribal Organization of rental and other costs consistent 

13 with section 105(l) of the Indian Self-Determination and 

14 Education Assistance Act (25 U.S.C. 450j(l)) and regula15 tions thereunder. 

16 ‘‘SEC. 309. STUDY ON LOANS, LOAN GUARANTEES, AND 

17 LOAN REPAYMENT. 

18 ‘‘(a) IN GENERAL.—The Secretary, in consultation 

19 with the Secretary of the Treasury, Indian Tribes, and 

20 Tribal Organizations, shall carry out a study to determine 

21 the feasibility of establishing a loan fund to provide to In22 dian Tribes and Tribal Organizations direct loans or guar23 antees for loans for the construction of health care facili24 ties, including—

25 ‘‘(1) inpatient facilities; 

26 ‘‘(2) outpatient facilities; 
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1 ‘‘(3) staff quarters; and 

2 ‘‘(4) specialized care facilities, such as behav3 ioral health and elder care facilities. 

4 ‘‘(b) DETERMINATIONS.—In carrying out the study 

5 under subsection (a), the Secretary shall determine—

6 ‘‘(1) the maximum principal amount of a loan 

7 or loan guarantee that should be offered to a recipi8 ent from the loan fund; 

9 ‘‘(2) the percentage of eligible costs, not to ex10 ceed 100 percent, that may be covered by a loan or 

11 loan guarantee from the loan fund (including costs 

12 relating to planning, design, financing, site land de13 velopment, construction, rehabilitation, renovation, 

14 conversion, improvements, medical equipment and 

15 furnishings, and other facility-related costs and cap16 ital purchase (but excluding staffing)); 

17 ‘‘(3) the cumulative total of the principal of di18 rect loans and loan guarantees, respectively, that 

19 may be outstanding at any 1 time; 

20 ‘‘(4) the maximum term of a loan or loan guar21 antee that may be made for a facility from the loan 

22 fund; 

23 ‘‘(5) the maximum percentage of funds from 

24 the loan fund that should be allocated for payment 
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1 of costs associated with planning and applying for a 

2 loan or loan guarantee; 

3 ‘‘(6) whether acceptance by the Secretary of an 

4 assignment of the revenue of an Indian Tribe or 

5 Tribal Organization as security for any direct loan 

6 or loan guarantee from the loan fund would be ap7 propriate; 

8 ‘‘(7) whether, in the planning and design of 

9 health facilities under this section, users eligible 

10 under section 807(c) may be included in any projec11 tion of patient population; 

12 ‘‘(8) whether funds of the Service provided 

13 through loans or loan guarantees from the loan fund 

14 should be eligible for use in matching other Federal 

15 funds under other programs; 

16 ‘‘(9) the appropriateness of, and best methods 

17 for, coordinating the loan fund with the health care 

18 priority system of the Service under section 301; and 

19 ‘‘(10) any legislative or regulatory changes re20 quired to implement recommendations of the Sec21 retary based on results of the study. 

22 ‘‘(c) REPORT.—Not later than September 30, 2009, 

23 the Secretary shall submit to the Committee on Indian Af24 fairs of the Senate and the Committee on Natural Re-
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1 sources and the Committee on Energy and Commerce of 

2 the House of Representatives a report that describes—

3 ‘‘(1) the manner of consultation made as re4 quired by subsection (a); and 

5 ‘‘(2) the results of the study, including any rec6 ommendations of the Secretary based on results of 

7 the study. 

8 ‘‘SEC. 310. TRIBAL LEASING. 

9 ‘‘A Tribal Health Program may lease permanent 

10 structures for the purpose of providing health care services 

11 without obtaining advance approval in appropriation Acts. 

12 ‘‘SEC. 311. INDIAN HEALTH SERVICE/TRIBAL FACILITIES 

13 JOINT VENTURE PROGRAM. 

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

15 the Service, shall make arrangements with Indian Tribes 

16 and Tribal Organizations to establish joint venture dem17 onstration projects under which an Indian Tribe or Tribal 

18 Organization shall expend tribal, private, or other avail19 able funds, for the acquisition or construction of a health 

20 facility for a minimum of 10 years, under a no-cost lease, 

21 in exchange for agreement by the Service to provide the 

22 equipment, supplies, and staffing for the operation and 

23 maintenance of such a health facility. An Indian Tribe or 

24 Tribal Organization may use tribal funds, private sector, 

25 or other available resources, including loan guarantees, to 
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1 fulfill its commitment under a joint venture entered into 

2 under this subsection. An Indian Tribe or Tribal Organi3 zation shall be eligible to establish a joint venture project 

4 if, when it submits a letter of intent, it—

5 ‘‘(1) has begun but not completed the process 

6 of acquisition or construction of a health facility to 

7 be used in the joint venture project; or 

8 ‘‘(2) has not begun the process of acquisition or 

9 construction of a health facility for use in the joint 

10 venture project. 

11 ‘‘(b) REQUIREMENTS.—The Secretary shall make 

12 such an arrangement with an Indian Tribe or Tribal Orga13 nization only if—

14 ‘‘(1) the Secretary first determines that the In15 dian Tribe or Tribal Organization has the adminis16 trative and financial capabilities necessary to com17 plete the timely acquisition or construction of the 

18 relevant health facility; and 

19 ‘‘(2) the Indian Tribe or Tribal Organization 

20 meets the need criteria determined using the criteria 

21 developed under the health care facility priority sys22 tem under section 301, unless the Secretary deter23 mines, pursuant to regulations, that other criteria 

24 will result in a more cost-effective and efficient 
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1 method of facilitating and completing construction of 

2 health care facilities. 

3 ‘‘(c) CONTINUED OPERATION.—The Secretary shall 

4 negotiate an agreement with the Indian Tribe or Tribal 

5 Organization regarding the continued operation of the fa6 cility at the end of the initial 10 year no-cost lease period. 

7 ‘‘(d) BREACH OF AGREEMENT.—An Indian Tribe or 

8 Tribal Organization that has entered into a written agree9 ment with the Secretary under this section, and that 

10 breaches or terminates without cause such agreement, 

11 shall be liable to the United States for the amount that 

12 has been paid to the Indian Tribe or Tribal Organization, 

13 or paid to a third party on the Indian Tribe’s or Tribal 

14 Organization’s behalf, under the agreement. The Sec15 retary has the right to recover tangible property (including 

16 supplies) and equipment, less depreciation, and any funds 

17 expended for operations and maintenance under this sec18 tion. The preceding sentence does not apply to any funds 

19 expended for the delivery of health care services, per20 sonnel, or staffing. 

21 ‘‘(e) RECOVERY FOR NONUSE.—An Indian Tribe or 

22 Tribal Organization that has entered into a written agree23 ment with the Secretary under this subsection shall be en24 titled to recover from the United States an amount that 

25 is proportional to the value of such facility if, at any time 
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1 within the 10-year term of the agreement, the Service 

2 ceases to use the facility or otherwise breaches the agree3 ment. 

4 ‘‘(f) DEFINITION.—For the purposes of this section, 

5 the term ‘health facility’ or ‘health facilities’ includes 

6 quarters needed to provide housing for staff of the rel7 evant Tribal Health Program. 

8 ‘‘SEC. 312. LOCATION OF FACILITIES. 

9 ‘‘(a) IN GENERAL.—In all matters involving the reor10 ganization or development of Service facilities or in the 

11 establishment of related employment projects to address 

12 unemployment conditions in economically depressed areas, 

13 the Bureau of Indian Affairs and the Service shall give 

14 priority to locating such facilities and projects on Indian 

15 lands, or lands in Alaska owned by any Alaska Native vil16 lage, or village or regional corporation under the Alaska 

17 Native Claims Settlement Act (43 U.S.C. 1601 et seq.), 

18 or any land allotted to any Alaska Native, if requested 

19 by the Indian owner and the Indian Tribe with jurisdiction 

20 over such lands or other lands owned or leased by the In21 dian Tribe or Tribal Organization. Top priority shall be 

22 given to Indian land owned by 1 or more Indian Tribes. 

23 ‘‘(b) DEFINITION.—For purposes of this section, the 

24 term ‘Indian lands’ means—
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1 ‘‘(1) all lands within the exterior boundaries of 

2 any reservation; and 

3 ‘‘(2) any lands title to which is held in trust by 

4 the United States for the benefit of any Indian 

5 Tribe or individual Indian or held by any Indian 

6 Tribe or individual Indian subject to restriction by 

7 the United States against alienation. 

8 ‘‘SEC. 313. MAINTENANCE AND IMPROVEMENT OF HEALTH 

9 CARE FACILITIES. 

10 ‘‘(a) REPORT.—The Secretary shall submit to the 

11 President, for inclusion in the report required to be trans12 mitted to Congress under section 801, a report which iden13 tifies the backlog of maintenance and repair work required 

14 at both Service and tribal health care facilities, including 

15 new health care facilities expected to be in operation in 

16 the next fiscal year. The report shall also identify the need 

17 for renovation and expansion of existing facilities to sup18 port the growth of health care programs. 

19 ‘‘(b) MAINTENANCE OF NEWLY CONSTRUCTED

20 SPACE.—The Secretary, acting through the Service, is au21 thorized to expend maintenance and improvement funds 

22 to support maintenance of newly constructed space only 

23 if such space falls within the approved supportable space 

24 allocation for the Indian Tribe or Tribal Organization. 
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1 Supportable space allocation shall be defined through the 

2 health care facility priority system under section 301(c). 

3 ‘‘(c) REPLACEMENT FACILITIES.—In addition to 

4 using maintenance and improvement funds for renovation, 

5 modernization, and expansion of facilities, an Indian Tribe 

6 or Tribal Organization may use maintenance and improve7 ment funds for construction of a replacement facility if 

8 the costs of renovation of such facility would exceed a 

9 maximum renovation cost threshold. The maximum ren10 ovation cost threshold shall be determined through the ne11 gotiated rulemaking process provided for under section 

12 802. 

13 ‘‘SEC. 314. TRIBAL MANAGEMENT OF FEDERALLY-OWNED 

14 QUARTERS. 

15 ‘‘(a) RENTAL RATES.—

16 ‘‘(1) ESTABLISHMENT.—Notwithstanding any 

17 other provision of law, a Tribal Health Program 

18 which operates a hospital or other health facility and 

19 the federally-owned quarters associated therewith 

20 pursuant to a contract or compact under the Indian 

21 Self-Determination and Education Assistance Act 

22 (25 U.S.C. 450 et seq.) shall have the authority to 

23 establish the rental rates charged to the occupants 

24 of such quarters by providing notice to the Secretary 

25 of its election to exercise such authority. 
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1 ‘‘(2) OBJECTIVES.—In establishing rental rates 

2 pursuant to authority of this subsection, a Tribal 

3 Health Program shall endeavor to achieve the fol4 lowing objectives: 

5 ‘‘(A) To base such rental rates on the rea6 sonable value of the quarters to the occupants 

7 thereof. 

8 ‘‘(B) To generate sufficient funds to pru9 dently provide for the operation and mainte10 nance of the quarters, and subject to the discre11 tion of the Tribal Health Program, to supply 

12 reserve funds for capital repairs and replace13 ment of the quarters. 

14 ‘‘(3) EQUITABLE FUNDING.—Any quarters 

15 whose rental rates are established by a Tribal 

16 Health Program pursuant to this subsection shall 

17 remain eligible for quarters improvement and repair 

18 funds to the same extent as all federally-owned quar19 ters used to house personnel in Services-supported 

20 programs. 

21 ‘‘(4) NOTICE OF RATE CHANGE.—A Tribal 

22 Health Program which exercises the authority pro23 vided under this subsection shall provide occupants 

24 with no less than 60 days notice of any change in 

25 rental rates. 
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1 ‘‘(b) DIRECT COLLECTION OF RENT.—

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

3 provision of law, and subject to paragraph (2), a 

4 Tribal Health Program shall have the authority to 

5 collect rents directly from Federal employees who oc6 cupy such quarters in accordance with the following: 

7 ‘‘(A) The Tribal Health Program shall no8 tify the Secretary and the subject Federal em9 ployees of its election to exercise its authority 

10 to collect rents directly from such Federal em11 ployees. 

12 ‘‘(B) Upon receipt of a notice described in 

13 subparagraph (A), the Federal employees shall 

14 pay rents for occupancy of such quarters di15 rectly to the Tribal Health Program and the 

16 Secretary shall have no further authority to col17 lect rents from such employees through payroll 

18 deduction or otherwise. 

19 ‘‘(C) Such rent payments shall be retained 

20 by the Tribal Health Program and shall not be 

21 made payable to or otherwise be deposited with 

22 the United States. 

23 ‘‘(D) Such rent payments shall be depos24 ited into a separate account which shall be used 

25 by the Tribal Health Program for the mainte-
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1 nance (including capital repairs and replace2 ment) and operation of the quarters and facili3 ties as the Tribal Health Program shall deter4 mine. 

5 ‘‘(2) RETROCESSION OF AUTHORITY.—If a 

6 Tribal Health Program which has made an election 

7 under paragraph (1) requests retrocession of its au8 thority to directly collect rents from Federal employ9 ees occupying federally-owned quarters, such ret10 rocession shall become effective on the earlier of—

11 ‘‘(A) the first day of the month that begins 

12 no less than 180 days after the Tribal Health 

13 Program notifies the Secretary of its desire to 

14 retrocede; or 

15 ‘‘(B) such other date as may be mutually 

16 agreed by the Secretary and the Tribal Health 

17 Program. 

18 ‘‘(c) RATES IN ALASKA.—To the extent that a Tribal 

19 Health Program, pursuant to authority granted in sub20 section (a), establishes rental rates for federally-owned 

21 quarters provided to a Federal employee in Alaska, such 

22 rents may be based on the cost of comparable private rent23 al housing in the nearest established community with a 

24 year-round population of 1,500 or more individuals. 
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1 ‘‘SEC. 315. APPLICABILITY OF BUY AMERICAN ACT RE2 QUIREMENT. 

3 ‘‘(a) APPLICABILITY.—The Secretary shall ensure 

4 that the requirements of the Buy American Act apply to 

5 all procurements made with funds provided pursuant to 

6 section 317. Indian Tribes and Tribal Organizations shall 

7 be exempt from these requirements. 

8 ‘‘(b) EFFECT OF VIOLATION.—If it has been finally 

9 determined by a court or Federal agency that any person 

10 intentionally affixed a label bearing a ‘Made in America’ 

11 inscription or any inscription with the same meaning, to 

12 any product sold in or shipped to the United States that 

13 is not made in the United States, such person shall be 

14 ineligible to receive any contract or subcontract made with 

15 funds provided pursuant to section 317, pursuant to the 

16 debarment, suspension, and ineligibility procedures de17 scribed in sections 9.400 through 9.409 of title 48, Code 

18 of Federal Regulations. 

19 ‘‘(c) DEFINITIONS.—For purposes of this section, the 

20 term ‘Buy American Act’ means title III of the Act enti21 tled ‘An Act making appropriations for the Treasury and 

22 Post Office Departments for the fiscal year ending June 

23 30, 1934, and for other purposes’, approved March 3, 

24 1933 (41 U.S.C. 10a et seq.). 
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1 ‘‘SEC. 316. OTHER FUNDING FOR FACILITIES. 

2 ‘‘(a) AUTHORITY TO ACCEPT FUNDS.—The Sec3 retary is authorized to accept from any source, including 

4 Federal and State agencies, funds that are available for 

5 the construction of health care facilities and use such 

6 funds to plan, design, and construct health care facilities 

7 for Indians and to place such funds into a contract or com8 pact under the Indian Self-Determination and Education 

9 Assistance Act (25 U.S.C. 450 et seq.). Receipt of such 

10 funds shall have no effect on the priorities established pur11 suant to section 301. 

12 ‘‘(b) INTERAGENCY AGREEMENTS.—The Secretary is 

13 authorized to enter into interagency agreements with 

14 other Federal agencies or State agencies and other entities 

15 and to accept funds from such Federal or State agencies 

16 or other sources to provide for the planning, design, and 

17 construction of health care facilities to be administered by 

18 Indian Health Programs in order to carry out the pur19 poses of this Act and the purposes for which the funds 

20 were appropriated or for which the funds were otherwise 

21 provided. 

22 ‘‘(c) ESTABLISHMENT OF STANDARDS.—The Sec23 retary, through the Service, shall establish standards by 

24 regulation for the planning, design, and construction of 

25 health care facilities serving Indians under this Act. 
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1 ‘‘SEC. 317. AUTHORIZATION OF APPROPRIATIONS. 

2 ‘‘There are authorized to be appropriated such sums 

3 as may be necessary for each fiscal year through fiscal 

4 year 2017 to carry out this title. 

5 ‘‘TITLE IV—ACCESS TO HEALTH 

6 SERVICES 

7 ‘‘SEC. 401. TREATMENT OF PAYMENTS UNDER SOCIAL SE8 CURITY ACT HEALTH BENEFITS PROGRAMS. 

9 ‘‘(a) DISREGARD OF MEDICARE, MEDICAID, AND

10 SCHIP PAYMENTS IN DETERMINING APPROPRIATIONS.—

11 Any payments received by an Indian Health Program or 

12 by an Urban Indian Organization under title XVIII, XIX, 

13 or XXI of the Social Security Act for services provided 

14 to Indians eligible for benefits under such respective titles 

15 shall not be considered in determining appropriations for 

16 the provision of health care and services to Indians. 

17 ‘‘(b) NONPREFERENTIAL TREATMENT.—Nothing in 

18 this Act authorizes the Secretary to provide services to an 

19 Indian with coverage under title XVIII, XIX, or XXI of 

20 the Social Security Act in preference to an Indian without 

21 such coverage. 

22 ‘‘(c) USE OF FUNDS.—

23 ‘‘(1) SPECIAL FUND.—

24 ‘‘(A) 100 PERCENT PASS-THROUGH OF

25 PAYMENTS DUE TO FACILITIES.—Notwith26 standing any other provision of law, but subject 
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1 to paragraph (2), payments to which a facility 

2 of the Service is entitled by reason of a provi3 sion of the Social Security Act shall be placed 

4 in a special fund to be held by the Secretary. 

5 In making payments from such fund, the Sec6 retary shall ensure that each Service Unit of 

7 the Service receives 100 percent of the amount 

8 to which the facilities of the Service, for which 

9 such Service Unit makes collections, are enti10 tled by reason of a provision of the Social Secu11 rity Act. 

12 ‘‘(B) USE OF FUNDS.—Amounts received 

13 by a facility of the Service under subparagraph 

14 (A) shall first be used (to such extent or in 

15 such amounts as are provided in appropriation 

16 Acts) for the purpose of making any improve17 ments in the programs of the Service operated 

18 by or through such facility which may be nec19 essary to achieve or maintain compliance with 

20 the applicable conditions and requirements of 

21 titles XVIII and XIX of the Social Security 

22 Act. Any amounts so received that are in excess 

23 of the amount necessary to achieve or maintain 

24 such conditions and requirements shall, subject 

25 to consultation with the Indian Tribes being 
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1 served by the Service Unit, be used for reducing 

2 the health resource deficiencies (as determined 

3 under section 201(d)) of such Indian Tribes. 

4 ‘‘(2) DIRECT PAYMENT OPTION.—Paragraph 

5 (1) shall not apply to a Tribal Health Program upon 

6 the election of such Program under subsection (d) to 

7 receive payments directly. No payment may be made 

8 out of the special fund described in such paragraph 

9 with respect to reimbursement made for services 

10 provided by such Program during the period of such 

11 election. 

12 ‘‘(d) DIRECT BILLING.—

13 ‘‘(1) IN GENERAL.—Subject to complying with 

14 the requirements of paragraph (2), a Tribal Health 

15 Program may elect to directly bill for, and receive 

16 payment for, health care items and services provided 

17 by such Program for which payment is made under 

18 title XVIII or XIX of the Social Security Act or 

19 from any other third party payor. 

20 ‘‘(2) DIRECT REIMBURSEMENT.—

21 ‘‘(A) USE OF FUNDS.—Each Tribal Health 

22 Program making the election described in para23 graph (1) with respect to a program under a 

24 title of the Social Security Act shall be reim25 bursed directly by that program for items and 
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1 services furnished without regard to subsection 

2 (c)(1), but all amounts so reimbursed shall be 

3 used by the Tribal Health Program for the pur4 pose of making any improvements in facilities 

5 of the Tribal Health Program that may be nec6 essary to achieve or maintain compliance with 

7 the conditions and requirements applicable gen8 erally to such items and services under the pro9 gram under such title and to provide additional 

10 health care services, improvements in health 

11 care facilities and Tribal Health Programs, any 

12 health care related purpose, or otherwise to 

13 achieve the objectives provided in section 3 of 

14 this Act. 

15 ‘‘(B) AUDITS.—The amounts paid to a 

16 Tribal Health Program making the election de17 scribed in paragraph (1) with respect to a pro18 gram under a title of the Social Security Act 

19 shall be subject to all auditing requirements ap20 plicable to the program under such title, as well 

21 as all auditing requirements applicable to pro22 grams administered by an Indian Health Pro23 gram. Nothing in the preceding sentence shall 

24 be construed as limiting the application of au25 diting requirements applicable to amounts paid 
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1 under title XVIII, XIX, or XXI of the Social 

2 Security Act. 

3 ‘‘(C) IDENTIFICATION OF SOURCE OF PAY4 MENTS.—Any Tribal Health Program that re5 ceives reimbursements or payments under title 

6 XVIII, XIX, or XXI of the Social Security Act, 

7 shall provide to the Service a list of each pro8 vider enrollment number (or other identifier) 

9 under which such Program receives such reim10 bursements or payments. 

11 ‘‘(3) EXAMINATION AND IMPLEMENTATION OF

12 CHANGES.—

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

14 through the Service and with the assistance of 

15 the Administrator of the Centers for Medicare 

16 & Medicaid Services, shall examine on an ongo17 ing basis and implement any administrative 

18 changes that may be necessary to facilitate di19 rect billing and reimbursement under the pro20 gram established under this subsection, includ21 ing any agreements with States that may be 

22 necessary to provide for direct billing under a 

23 program under a title of the Social Security 

24 Act. 
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1 ‘‘(B) COORDINATION OF INFORMATION.—

2 The Service shall provide the Administrator of 

3 the Centers for Medicare & Medicaid Services 

4 with copies of the lists submitted to the Service 

5 under paragraph (2)(C), enrollment data re6 garding patients served by the Service (and by 

7 Tribal Health Programs, to the extent such 

8 data is available to the Service), and such other 

9 information as the Administrator may require 

10 for purposes of administering title XVIII, XIX, 

11 or XXI of the Social Security Act. 

12 ‘‘(4) WITHDRAWAL FROM PROGRAM.—A Tribal 

13 Health Program that bills directly under the pro14 gram established under this subsection may with15 draw from participation in the same manner and 

16 under the same conditions that an Indian Tribe or 

17 Tribal Organization may retrocede a contracted pro18 gram to the Secretary under the authority of the In19 dian Self-Determination and Education Assistance 

20 Act (25 U.S.C. 450 et seq.). All cost accounting and 

21 billing authority under the program established 

22 under this subsection shall be returned to the Sec23 retary upon the Secretary’s acceptance of the with24 drawal of participation in this program. 
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1 ‘‘(5) TERMINATION FOR FAILURE TO COMPLY

2 WITH REQUIREMENTS.—The Secretary may termi3 nate the participation of a Tribal Health Program or 

4 in the direct billing program established under this 

5 subsection if the Secretary determines that the Pro6 gram has failed to comply with the requirements of 

7 paragraph (2). The Secretary shall provide a Tribal 

8 Health Program with notice of a determination that 

9 the Program has failed to comply with any such re10 quirement and a reasonable opportunity to correct 

11 such noncompliance prior to terminating the Pro12 gram’s participation in the direct billing program es13 tablished under this subsection. 

14 ‘‘(e) RELATED PROVISIONS UNDER THE SOCIAL SE15 CURITY ACT.—For provisions related to subsections (c) 

16 and (d), see sections 1880, 1911, and 2107(e)(1)(D) of 

17 the Social Security Act. 
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1 ‘‘SEC. 402. GRANTS TO AND CONTRACTS WITH THE SERV2 ICE, INDIAN TRIBES, TRIBAL ORGANIZA3 TIONS, AND URBAN INDIAN ORGANIZATIONS 

4 TO FACILITATE OUTREACH, ENROLLMENT, 

5 AND COVERAGE OF INDIANS UNDER SOCIAL 

6 SECURITY ACT HEALTH BENEFIT PROGRAMS 

7 AND OTHER HEALTH BENEFITS PROGRAMS. 

8 ‘‘(a) INDIAN TRIBES AND TRIBAL ORGANIZA9 TIONS.—From funds appropriated to carry out this title 

10 in accordance with section 417, the Secretary, acting 

11 through the Service, shall make grants to or enter into 

12 contracts with Indian Tribes and Tribal Organizations to 

13 assist such Tribes and Tribal Organizations in estab14 lishing and administering programs on or near reserva15 tions and trust lands, including programs to provide out16 reach and enrollment through video, electronic delivery 

17 methods, or telecommunication devices that allow real18 time or time-delayed communication between individual 

19 Indians and the benefit program, to assist individual Indi20 ans—

21 ‘‘(1) to enroll for benefits under a program es22 tablished under title XVIII, XIX, or XXI of the So23 cial Security Act and other health benefits pro24 grams; and 

25 ‘‘(2) with respect to such programs for which 

26 the charging of premiums and cost sharing is not 
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1 prohibited under such programs, to pay premiums or 

2 cost sharing for coverage for such benefits, which 

3 may be based on financial need (as determined by 

4 the Indian Tribe or Tribes or Tribal Organizations 

5 being served based on a schedule of income levels de6 veloped or implemented by such Tribe, Tribes, or 

7 Tribal Organizations). 

8 ‘‘(b) CONDITIONS.—The Secretary, acting through 

9 the Service, shall place conditions as deemed necessary to 

10 effect the purpose of this section in any grant or contract 

11 which the Secretary makes with any Indian Tribe or Trib12 al Organization pursuant to this section. Such conditions 

13 shall include requirements that the Indian Tribe or Tribal 

14 Organization successfully undertake—

15 ‘‘(1) to determine the population of Indians eli16 gible for the benefits described in subsection (a); 

17 ‘‘(2) to educate Indians with respect to the ben18 efits available under the respective programs; 

19 ‘‘(3) to provide transportation for such indi20 vidual Indians to the appropriate offices for enroll21 ment or applications for such benefits; and 

22 ‘‘(4) to develop and implement methods of im23 proving the participation of Indians in receiving ben24 efits under such programs. 
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1 ‘‘(c) APPLICATION TO URBAN INDIAN ORGANIZA2 TIONS.—

3 ‘‘(1) IN GENERAL.—The provisions of sub4 section (a) shall apply with respect to grants and 

5 other funding to Urban Indian Organizations with 

6 respect to populations served by such organizations 

7 in the same manner they apply to grants and con8 tracts with Indian Tribes and Tribal Organizations 

9 with respect to programs on or near reservations. 

10 ‘‘(2) REQUIREMENTS.—The Secretary shall in11 clude in the grants or contracts made or provided 

12 under paragraph (1) requirements that are—

13 ‘‘(A) consistent with the requirements im14 posed by the Secretary under subsection (b); 

15 ‘‘(B) appropriate to Urban Indian Organi16 zations and Urban Indians; and 

17 ‘‘(C) necessary to effect the purposes of 

18 this section. 

19 ‘‘(d) FACILITATING COOPERATION.—The Secretary, 

20 acting through the Centers for Medicare & Medicaid Serv21 ices, shall develop and disseminate best practices that will 

22 serve to facilitate cooperation with, and agreements be23 tween, States and the Service, Indian Tribes, Tribal Orga24 nizations, or Urban Indian Organizations with respect to 

25 the provision of health care items and services to Indians 
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1 under the programs established under title XVIII, XIX, 

2 or XXI of the Social Security Act. 

3 ‘‘(e) AGREEMENTS RELATING TO IMPROVING EN4 ROLLMENT OF INDIANS UNDER SOCIAL SECURITY ACT

5 HEALTH BENEFITS PROGRAMS.—For provisions relating 

6 to agreements between the Secretary, acting through the 

7 Service, and Indian Tribes, Tribal Organizations, and 

8 Urban Indian Organizations for the collection, prepara9 tion, and submission of applications by Indians for assist10 ance under the Medicaid and State children’s health insur11 ance programs established under titles XIX and XXI of 

12 the Social Security Act, and benefits under the Medicare 

13 program established under title XVIII of such Act, see 

14 subsections (a) and (b) of section 1139 of the Social Secu15 rity Act. 

16 ‘‘(f) DEFINITION OF PREMIUMS AND COST SHAR17 ING.—In this section: 

18 ‘‘(1) PREMIUM.—The term ‘premium’ includes 

19 any enrollment fee or similar charge. 

20 ‘‘(2) COST SHARING.—The term ‘cost sharing’ 

21 includes any deduction, deductible, copayment, coin22 surance, or similar charge. 
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1 ‘‘SEC. 403. REIMBURSEMENT FROM CERTAIN THIRD PAR2 TIES OF COSTS OF HEALTH SERVICES. 

3 ‘‘(a) RIGHT OF RECOVERY.—Except as provided in 

4 subsection (f), the United States, an Indian Tribe, or 

5 Tribal Organization shall have the right to recover from 

6 an insurance company, health maintenance organization, 

7 employee benefit plan, third-party tortfeasor, or any other 

8 responsible or liable third party (including a political sub9 division or local governmental entity of a State) the rea10 sonable charges billed by the Secretary, an Indian Tribe, 

11 or Tribal Organization in providing health services 

12 through the Service, an Indian Tribe, or Tribal Organiza13 tion to any individual to the same extent that such indi14 vidual, or any nongovernmental provider of such services, 

15 would be eligible to receive damages, reimbursement, or 

16 indemnification for such charges or expenses if—

17 ‘‘(1) such services had been provided by a non18 governmental provider; and 

19 ‘‘(2) such individual had been required to pay 

20 such charges or expenses and did pay such charges 

21 or expenses. 

22 ‘‘(b) LIMITATIONS ON RECOVERIES FROM STATES.—

23 Subsection (a) shall provide a right of recovery against 

24 any State, only if the injury, illness, or disability for which 

25 health services were provided is covered under—

26 ‘‘(1) workers’ compensation laws; or 
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1 ‘‘(2) a no-fault automobile accident insurance 

2 plan or program. 

3 ‘‘(c) NONAPPLICATION OF OTHER LAWS.—No law of 

4 any State, or of any political subdivision of a State and 

5 no provision of any contract, insurance or health mainte6 nance organization policy, employee benefit plan, self-in7 surance plan, managed care plan, or other health care plan 

8 or program entered into or renewed after the date of the 

9 enactment of the Indian Health Care Amendments of 

10 1988, shall prevent or hinder the right of recovery of the 

11 United States, an Indian Tribe, or Tribal Organization 

12 under subsection (a). 

13 ‘‘(d) NO EFFECT ON PRIVATE RIGHTS OF ACTION.—

14 No action taken by the United States, an Indian Tribe, 

15 or Tribal Organization to enforce the right of recovery 

16 provided under this section shall operate to deny to the 

17 injured person the recovery for that portion of the person’s 

18 damage not covered hereunder. 

19 ‘‘(e) ENFORCEMENT.—

20 ‘‘(1) IN GENERAL.—The United States, an In21 dian Tribe, or Tribal Organization may enforce the 

22 right of recovery provided under subsection (a) by—

23 ‘‘(A) intervening or joining in any civil ac24 tion or proceeding brought—
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1 ‘‘(i) by the individual for whom health 

2 services were provided by the Secretary, an 

3 Indian Tribe, or Tribal Organization; or 

4 ‘‘(ii) by any representative or heirs of 

5 such individual, or 

6 ‘‘(B) instituting a civil action, including a 

7 civil action for injunctive relief and other relief 

8 and including, with respect to a political sub9 division or local governmental entity of a State, 

10 such an action against an official thereof. 

11 ‘‘(2) NOTICE.—All reasonable efforts shall be 

12 made to provide notice of action instituted under 

13 paragraph (1)(B) to the individual to whom health 

14 services were provided, either before or during the 

15 pendency of such action. 

16 ‘‘(3) RECOVERY FROM TORTFEASORS.—

17 ‘‘(A) IN GENERAL.—In any case in which 

18 an Indian Tribe or Tribal Organization that is 

19 authorized or required under a compact or con20 tract issued pursuant to the Indian Self-Deter21 mination and Education Assistance Act (25 

22 U.S.C. 450 et seq.) to furnish or pay for health 

23 services to a person who is injured or suffers a 

24 disease on or after the date of enactment of the 

25 Indian Health Care Improvement Act Amend-
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1 ments of 2008 under circumstances that estab2 lish grounds for a claim of liability against the 

3 tortfeasor with respect to the injury or disease, 

4 the Indian Tribe or Tribal Organization shall 

5 have a right to recover from the tortfeasor (or 

6 an insurer of the tortfeasor) the reasonable 

7 value of the health services so furnished, paid 

8 for, or to be paid for, in accordance with the 

9 Federal Medical Care Recovery Act (42 U.S.C. 

10 2651 et seq.), to the same extent and under the 

11 same circumstances as the United States may 

12 recover under that Act. 

13 ‘‘(B) TREATMENT.—The right of an In14 dian Tribe or Tribal Organization to recover 

15 under subparagraph (A) shall be independent of 

16 the rights of the injured or diseased person 

17 served by the Indian Tribe or Tribal Organiza18 tion. 

19 ‘‘(f) LIMITATION.—Absent specific written authoriza20 tion by the governing body of an Indian Tribe for the pe21 riod of such authorization (which may not be for a period 

22 of more than 1 year and which may be revoked at any 

23 time upon written notice by the governing body to the 

24 Service), the United States shall not have a right of recov25 ery under this section if the injury, illness, or disability 
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1 for which health services were provided is covered under 

2 a self-insurance plan funded by an Indian Tribe, Tribal 

3 Organization, or Urban Indian Organization. Where such 

4 authorization is provided, the Service may receive and ex5 pend such amounts for the provision of additional health 

6 services consistent with such authorization. 

7 ‘‘(g) COSTS AND ATTORNEYS’ FEES.—In any action 

8 brought to enforce the provisions of this section, a pre9 vailing plaintiff shall be awarded its reasonable attorneys’ 

10 fees and costs of litigation. 

11 ‘‘(h) NONAPPLICATION OF CLAIMS FILING REQUIRE12 MENTS.—An insurance company, health maintenance or13 ganization, self-insurance plan, managed care plan, or 

14 other health care plan or program (under the Social Secu15 rity Act or otherwise) may not deny a claim for benefits 

16 submitted by the Service or by an Indian Tribe or Tribal 

17 Organization based on the format in which the claim is 

18 submitted if such format complies with the format re19 quired for submission of claims under title XVIII of the 

20 Social Security Act or recognized under section 1175 of 

21 such Act. 

22 ‘‘(i) APPLICATION TO URBAN INDIAN ORGANIZA23 TIONS.—The previous provisions of this section shall apply 

24 to Urban Indian Organizations with respect to populations 

25 served by such Organizations in the same manner they 
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1 apply to Indian Tribes and Tribal Organizations with re2 spect to populations served by such Indian Tribes and 

3 Tribal Organizations. 

4 ‘‘(j) STATUTE OF LIMITATIONS.—The provisions of 

5 section 2415 of title 28, United States Code, shall apply 

6 to all actions commenced under this section, and the ref7 erences therein to the United States are deemed to include 

8 Indian Tribes, Tribal Organizations, and Urban Indian 

9 Organizations. 

10 ‘‘(k) SAVINGS.—Nothing in this section shall be con11 strued to limit any right of recovery available to the 

12 United States, an Indian Tribe, or Tribal Organization 

13 under the provisions of any applicable, Federal, State, or 

14 Tribal law, including medical lien laws. 

15 ‘‘SEC. 404. CREDITING OF REIMBURSEMENTS. 

16 ‘‘(a) USE OF AMOUNTS.—

17 ‘‘(1) RETENTION BY PROGRAM.—Except as pro18 vided in section 202(f) (relating to the Catastrophic 

19 Health Emergency Fund) and section 807 (relating 

20 to health services for ineligible persons), all reim21 bursements received or recovered under any of the 

22 programs described in paragraph (2), including 

23 under section 807, by reason of the provision of 

24 health services by the Service, by an Indian Tribe or 

25 Tribal Organization, or by an Urban Indian Organi-
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1 zation, shall be credited to the Service, such Indian 

2 Tribe or Tribal Organization, or such Urban Indian 

3 Organization, respectively, and may be used as pro4 vided in section 401. In the case of such a service 

5 provided by or through a Service Unit, such 

6 amounts shall be credited to such unit and used for 

7 such purposes. 

8 ‘‘(2) PROGRAMS COVERED.—The programs re9 ferred to in paragraph (1) are the following: 

10 ‘‘(A) Titles XVIII, XIX, and XXI of the 

11 Social Security Act. 

12 ‘‘(B) This Act, including section 807. 

13 ‘‘(C) Public Law 87–693. 

14 ‘‘(D) Any other provision of law. 

15 ‘‘(b) NO OFFSET OF AMOUNTS.—The Service may 

16 not offset or limit any amount obligated to any Service 

17 Unit or entity receiving funding from the Service because 

18 of the receipt of reimbursements under subsection (a). 

19 ‘‘SEC. 405. PURCHASING HEALTH CARE COVERAGE. 

20 ‘‘(a) IN GENERAL.—Insofar as amounts are made 

21 available under law (including a provision of the Social 

22 Security Act, the Indian Self-Determination and Edu23 cation Assistance Act (25 U.S.C. 450 et seq.), or other 

24 law, other than under section 402) to Indian Tribes, Trib25 al Organizations, and Urban Indian Organizations for 
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1 health benefits for Service beneficiaries, Indian Tribes, 

2 Tribal Organizations, and Urban Indian Organizations 

3 may use such amounts to purchase health benefits cov4 erage for such beneficiaries in any manner, including 

5 through—

6 ‘‘(1) a tribally owned and operated health care 

7 plan; 

8 ‘‘(2) a State or locally authorized or licensed 

9 health care plan; 

10 ‘‘(3) a health insurance provider or managed 

11 care organization; 

12 ‘‘(4) a self-insured plan; or 

13 ‘‘(5) a high deductible or health savings account 

14 plan. 

15 The purchase of such coverage by an Indian Tribe, Tribal 

16 Organization, or Urban Indian Organization may be based 

17 on the financial needs of such beneficiaries (as determined 

18 by the Indian Tribe or Tribes being served based on a 

19 schedule of income levels developed or implemented by 

20 such Indian Tribe or Tribes). 

21 ‘‘(b) EXPENSES FOR SELF-INSURED PLAN.—In the 

22 case of a self-insured plan under subsection (a)(4), the 

23 amounts may be used for expenses of operating the plan, 

24 including administration and insurance to limit the finan25 cial risks to the entity offering the plan. 
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1 ‘‘(c) CONSTRUCTION.—Nothing in this section shall 

2 be construed as affecting the use of any amounts not re3 ferred to in subsection (a). 

4 ‘‘SEC. 406. SHARING ARRANGEMENTS WITH FEDERAL AGEN5 CIES. 

6 ‘‘(a) AUTHORITY.—

7 ‘‘(1) IN GENERAL.—The Secretary may enter 

8 into (or expand) arrangements for the sharing of 

9 medical facilities and services between the Service, 

10 Indian Tribes, and Tribal Organizations and the De11 partment of Veterans Affairs and the Department of 

12 Defense. 

13 ‘‘(2) CONSULTATION BY SECRETARY RE14 QUIRED.—The Secretary may not finalize any ar15 rangement between the Service and a Department 

16 described in paragraph (1) without first consulting 

17 with the Indian Tribes which will be significantly af18 fected by the arrangement. 

19 ‘‘(b) LIMITATIONS.—The Secretary shall not take 

20 any action under this section or under subchapter IV of 

21 chapter 81 of title 38, United States Code, which would 

22 impair—

23 ‘‘(1) the priority access of any Indian to health 

24 care services provided through the Service and the 
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1 eligibility of any Indian to receive health services 

2 through the Service; 

3 ‘‘(2) the quality of health care services provided 

4 to any Indian through the Service; 

5 ‘‘(3) the priority access of any veteran to health 

6 care services provided by the Department of Vet7 erans Affairs; 

8 ‘‘(4) the quality of health care services provided 

9 by the Department of Veterans Affairs or the De10 partment of Defense; or 

11 ‘‘(5) the eligibility of any Indian who is a vet12 eran to receive health services through the Depart13 ment of Veterans Affairs. 

14 ‘‘(c) REIMBURSEMENT.—The Service, Indian Tribe, 

15 or Tribal Organization shall be reimbursed by the Depart16 ment of Veterans Affairs or the Department of Defense 

17 (as the case may be) where services are provided through 

18 the Service, an Indian Tribe, or a Tribal Organization to 

19 beneficiaries eligible for services from either such Depart20 ment, notwithstanding any other provision of law. 

21 ‘‘(d) CONSTRUCTION.—Nothing in this section may 

22 be construed as creating any right of a non-Indian veteran 

23 to obtain health services from the Service. 

24 ‘‘SEC. 407. ELIGIBLE INDIAN VETERAN SERVICES. 

25 ‘‘(a) FINDINGS; PURPOSE.—
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1 ‘‘(1) FINDINGS.—Congress finds that—

2 ‘‘(A) collaborations between the Secretary 

3 and the Secretary of Veterans Affairs regarding 

4 the treatment of Indian veterans at facilities of 

5 the Service should be encouraged to the max6 imum extent practicable; and 

7 ‘‘(B) increased enrollment for services of 

8 the Department of Veterans Affairs by veterans 

9 who are members of Indian tribes should be en10 couraged to the maximum extent practicable. 

11 ‘‘(2) PURPOSE.—The purpose of this section is 

12 to reaffirm the goals stated in the document entitled 

13 ‘Memorandum of Understanding Between the VA/

14 Veterans Health Administration And HHS/Indian 

15 Health Service’ and dated February 25, 2003 (relat16 ing to cooperation and resource sharing between the 

17 Veterans Health Administration and Service). 

18 ‘‘(b) DEFINITIONS.—In this section: 

19 ‘‘(1) ELIGIBLE INDIAN VETERAN.—The term 

20 ‘eligible Indian veteran’ means an Indian or Alaska 

21 Native veteran who receives any medical service that 

22 is—

23 ‘‘(A) authorized under the laws adminis24 tered by the Secretary of Veterans Affairs; and 
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1 ‘‘(B) administered at a facility of the Serv2 ice (including a facility operated by an Indian 

3 tribe or tribal organization through a contract 

4 or compact with the Service under the Indian 

5 Self-Determination and Education Assistance 

6 Act (25 U.S.C. 450 et seq.)) pursuant to a local 

7 memorandum of understanding. 

8 ‘‘(2) LOCAL MEMORANDUM OF UNDER9 STANDING.—The term ‘local memorandum of under10 standing’ means a memorandum of understanding 

11 between the Secretary (or a designee, including the 

12 director of any Area Office of the Service) and the 

13 Secretary of Veterans Affairs (or a designee) to im14 plement the document entitled ‘Memorandum of Un15 derstanding Between the VA/Veterans Health Ad16 ministration And HHS/Indian Health Service’ and 

17 dated February 25, 2003 (relating to cooperation 

18 and resource sharing between the Veterans Health 

19 Administration and Indian Health Service). 

20 ‘‘(c) ELIGIBLE INDIAN VETERANS’ EXPENSES.—

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

22 provision of law, the Secretary shall provide for vet23 eran-related expenses incurred by eligible Indian vet24 erans as described in subsection (b)(1)(B). 
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1 ‘‘(2) METHOD OF PAYMENT.—The Secretary 

2 shall establish such guidelines as the Secretary de3 termines to be appropriate regarding the method of 

4 payments to the Secretary of Veterans Affairs under 

5 paragraph (1). 

6 ‘‘(d) TRIBAL APPROVAL OF MEMORANDA.—In nego7 tiating a local memorandum of understanding with the 

8 Secretary of Veterans Affairs regarding the provision of 

9 services to eligible Indian veterans, the Secretary shall 

10 consult with each Indian tribe that would be affected by 

11 the local memorandum of understanding. 

12 ‘‘(e) FUNDING.—

13 ‘‘(1) TREATMENT.—Expenses incurred by the 

14 Secretary in carrying out subsection (c)(1) shall not 

15 be considered to be Contract Health Service ex16 penses. 

17 ‘‘(2) USE OF FUNDS.—Of funds made available 

18 to the Secretary in appropriations Acts for the Serv19 ice (excluding funds made available for facilities, 

20 Contract Health Services, or contract support costs), 

21 the Secretary shall use such sums as are necessary 

22 to carry out this section. 

23 ‘‘SEC. 408. PAYOR OF LAST RESORT. 

24 ‘‘Indian Health Programs and health care programs 

25 operated by Urban Indian Organizations shall be the 
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1 payor of last resort for services provided to persons eligible 

2 for services from Indian Health Programs and Urban In3 dian Organizations, notwithstanding any Federal, State, 

4 or local law to the contrary. 

5 ‘‘SEC. 409. NONDISCRIMINATION UNDER FEDERAL HEALTH 

6 CARE PROGRAMS IN QUALIFICATIONS FOR 

7 REIMBURSEMENT FOR SERVICES. 

8 ‘‘(a) REQUIREMENT TO SATISFY GENERALLY APPLI9 CABLE PARTICIPATION REQUIREMENTS.—

10 ‘‘(1) IN GENERAL.—A Federal health care pro11 gram must accept an entity that is operated by the 

12 Service, an Indian Tribe, Tribal Organization, or 

13 Urban Indian Organization as a provider eligible to 

14 receive payment under the program for health care 

15 services furnished to an Indian on the same basis as 

16 any other provider qualified to participate as a pro17 vider of health care services under the program if 

18 the entity meets generally applicable State or other 

19 requirements for participation as a provider of 

20 health care services under the program. 

21 ‘‘(2) SATISFACTION OF STATE OR LOCAL LICEN22 SURE OR RECOGNITION REQUIREMENTS.—Any re23 quirement for participation as a provider of health 

24 care services under a Federal health care program 

25 that an entity be licensed or recognized under the 
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1 State or local law where the entity is located to fur2 nish health care services shall be deemed to have 

3 been met in the case of an entity operated by the 

4 Service, an Indian Tribe, Tribal Organization, or 

5 Urban Indian Organization if the entity meets all 

6 the applicable standards for such licensure or rec7 ognition, regardless of whether the entity obtains a 

8 license or other documentation under such State or 

9 local law. In accordance with section 221, the ab10 sence of the licensure of a health care professional 

11 employed by such an entity under the State or local 

12 law where the entity is located shall not be taken 

13 into account for purposes of determining whether 

14 the entity meets such standards, if the professional 

15 is licensed in another State. 

16 ‘‘(b) APPLICATION OF EXCLUSION FROM PARTICIPA17 TION IN FEDERAL HEALTH CARE PROGRAMS.—

18 ‘‘(1) EXCLUDED ENTITIES.—No entity operated 

19 by the Service, an Indian Tribe, Tribal Organiza20 tion, or Urban Indian Organization that has been 

21 excluded from participation in any Federal health 

22 care program or for which a license is under suspen23 sion or has been revoked by the State where the en24 tity is located shall be eligible to receive payment or 
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1 reimbursement under any such program for health 

2 care services furnished to an Indian. 

3 ‘‘(2) EXCLUDED INDIVIDUALS.—No individual 

4 who has been excluded from participation in any 

5 Federal health care program or whose State license 

6 is under suspension shall be eligible to receive pay7 ment or reimbursement under any such program for 

8 health care services furnished by that individual, di9 rectly or through an entity that is otherwise eligible 

10 to receive payment for health care services, to an In11 dian. 

12 ‘‘(3) FEDERAL HEALTH CARE PROGRAM DE13 FINED.—In this subsection, the term, ‘Federal 

14 health care program’ has the meaning given that 

15 term in section 1128B(f) of the Social Security Act 

16 (42 U.S.C. 1320a–7b(f)), except that, for purposes 

17 of this subsection, such term shall include the health 

18 insurance program under chapter 89 of title 5, 

19 United States Code. 

20 ‘‘(c) RELATED PROVISIONS.—For provisions related 

21 to nondiscrimination against providers operated by the 

22 Service, an Indian Tribe, Tribal Organization, or Urban 

23 Indian Organization, see section 1139(c) of the Social Se24 curity Act (42 U.S.C. 1320b–9(c)). 
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1 ‘‘SEC. 410. CONSULTATION. 

2 ‘‘For provisions related to consultation with rep3 resentatives of Indian Health Programs and Urban Indian 

4 Organizations with respect to the health care programs 

5 established under titles XVIII, XIX, and XXI of the Social 

6 Security Act, see section 1139(d) of the Social Security 

7 Act (42 U.S.C. 1320b–9(d)). 

8 ‘‘SEC. 411. STATE CHILDREN’S HEALTH INSURANCE PRO9 GRAM (SCHIP). 

10 ‘‘For provisions relating to—

11 ‘‘(1) outreach to families of Indian children 

12 likely to be eligible for child health assistance under 

13 the State children’s health insurance program estab14 lished under title XXI of the Social Security Act, see 

15 sections 2105(c)(2)(C) and 1139(a) of such Act (42 

16 U.S.C. 1397ee(c)(2), 1320b–9); and 

17 ‘‘(2) ensuring that child health assistance is 

18 provided under such program to targeted low-income 

19 children who are Indians and that payments are 

20 made under such program to Indian Health Pro21 grams and Urban Indian Organizations operating in 

22 the State that provide such assistance, see sections 

23 2102(b)(3)(D) and 2105(c)(6)(B) of such Act (42 

24 U.S.C. 1397bb(b)(3)(D), 1397ee(c)(6)(B)). 
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1 ‘‘SEC. 412. EXCLUSION WAIVER AUTHORITY FOR AFFECTED 

2 INDIAN HEALTH PROGRAMS AND SAFE HAR3 BOR TRANSACTIONS UNDER THE SOCIAL SE4 CURITY ACT. 

5 ‘‘For provisions relating to—

6 ‘‘(1) exclusion waiver authority for affected In7 dian Health Programs under the Social Security 

8 Act, see section 1128(k) of the Social Security Act 

9 (42 U.S.C. 1320a–7(k)); and 

10 ‘‘(2) certain transactions involving Indian 

11 Health Programs deemed to be in safe harbors 

12 under that Act, see section 1128B(b)(4) of the So13 cial Security Act (42 U.S.C. 1320a–7b(b)(4)). 

14 ‘‘SEC. 413. PREMIUM AND COST SHARING PROTECTIONS 

15 AND ELIGIBILITY DETERMINATIONS UNDER 

16 MEDICAID AND SCHIP AND PROTECTION OF 

17 CERTAIN INDIAN PROPERTY FROM MEDICAID 

18 ESTATE RECOVERY. 

19 ‘‘For provisions relating to—

20 ‘‘(1) premiums or cost sharing protections for 

21 Indians furnished items or services directly by In22 dian Health Programs or through referral under the 

23 contract health service under the Medicaid program 

24 established under title XIX of the Social Security 

25 Act, see sections 1916(j) and 1916A(a)(1) of the So-
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1 cial Security Act (42 U.S.C. 1396o(j), 1396o–

2 1(a)(1)); 

3 ‘‘(2) rules regarding the treatment of certain 

4 property for purposes of determining eligibility 

5 under such programs, see sections 1902(e)(13) and 

6 2107(e)(1)(B) of such Act (42 U.S.C. 1396a(e)(13), 

7 1397gg(e)(1)(B)); and 

8 ‘‘(3) the protection of certain property from es9 tate recovery provisions under the Medicaid pro10 gram, see section 1917(b)(3)(B) of such Act (42 

11 U.S.C. 1396p(b)(3)(B)). 

12 ‘‘SEC. 414. TREATMENT UNDER MEDICAID AND SCHIP MAN13 AGED CARE. 

14 ‘‘For provisions relating to the treatment of Indians 

15 enrolled in a managed care entity under the Medicaid pro16 gram under title XIX of the Social Security Act and In17 dian Health Programs and Urban Indian Organizations 

18 that are providers of items or services to such Indian en19 rollees, see sections 1932(h) and 2107(e)(1)(H) of the So20 cial Security Act (42 U.S.C. 1396u–2(h), 

21 1397gg(e)(1)(H)). 

22 ‘‘SEC. 415. NAVAJO NATION MEDICAID AGENCY FEASI23 BILITY STUDY. 

24 ‘‘(a) STUDY.—The Secretary shall conduct a study 

25 to determine the feasibility of treating the Navajo Nation 
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1 as a State for the purposes of title XIX of the Social Secu2 rity Act, to provide services to Indians living within the 

3 boundaries of the Navajo Nation through an entity estab4 lished having the same authority and performing the same 

5 functions as single-State medicaid agencies responsible for 

6 the administration of the State plan under title XIX of 

7 the Social Security Act. 

8 ‘‘(b) CONSIDERATIONS.—In conducting the study, 

9 the Secretary shall consider the feasibility of—

10 ‘‘(1) assigning and paying all expenditures for 

11 the provision of services and related administration 

12 funds, under title XIX of the Social Security Act, to 

13 Indians living within the boundaries of the Navajo 

14 Nation that are currently paid to or would otherwise 

15 be paid to the State of Arizona, New Mexico, or 

16 Utah; 

17 ‘‘(2) providing assistance to the Navajo Nation 

18 in the development and implementation of such enti19 ty for the administration, eligibility, payment, and 

20 delivery of medical assistance under title XIX of the 

21 Social Security Act; 

22 ‘‘(3) providing an appropriate level of matching 

23 funds for Federal medical assistance with respect to 

24 amounts such entity expends for medical assistance 

25 for services and related administrative costs; and 
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1 ‘‘(4) authorizing the Secretary, at the option of 

2 the Navajo Nation, to treat the Navajo Nation as a 

3 State for the purposes of title XIX of the Social Se4 curity Act (relating to the State children’s health in5 surance program) under terms equivalent to those 

6 described in paragraphs (2) through (4). 

7 ‘‘(c) REPORT.—Not later then 3 years after the date 

8 of enactment of the Indian Health Care Improvement Act 

9 Amendments of 2008, the Secretary shall submit to the 

10 Committee on Indian Affairs and Committee on Finance 

11 of the Senate and the Committee on Natural Resources 

12 and Committee on Energy and Commerce of the House 

13 of Representatives a report that includes—

14 ‘‘(1) the results of the study under this section; 

15 ‘‘(2) a summary of any consultation that oc16 curred between the Secretary and the Navajo Na17 tion, other Indian Tribes, the States of Arizona, 

18 New Mexico, and Utah, counties which include Nav19 ajo Lands, and other interested parties, in con20 ducting this study; 

21 ‘‘(3) projected costs or savings associated with 

22 establishment of such entity, and any estimated im23 pact on services provided as described in this section 

24 in relation to probable costs or savings; and 
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1 ‘‘(4) legislative actions that would be required 

2 to authorize the establishment of such entity if such 

3 entity is determined by the Secretary to be feasible. 

4 ‘‘SEC. 416. GENERAL EXCEPTIONS. 

5 ‘‘The requirements of this title shall not apply to any 

6 excepted benefits described in paragraph (1)(A) or (3) of 

7 section 2791(c) of the Public Health Service Act (42 

8 U.S.C. 300gg–91). 

9 ‘‘SEC. 417. AUTHORIZATION OF APPROPRIATIONS. 

10 ‘‘There are authorized to be appropriated such sums 

11 as may be necessary for each fiscal year through fiscal 

12 year 2017 to carry out this title. 

13 ‘‘TITLE V—HEALTH SERVICES 

14 FOR URBAN INDIANS 

15 ‘‘SEC. 501. PURPOSE. 

16 ‘‘The purpose of this title is to establish and maintain 

17 programs in Urban Centers to make health services more 

18 accessible and available to Urban Indians. 

19 ‘‘SEC. 502. CONTRACTS WITH, AND GRANTS TO, URBAN IN20 DIAN ORGANIZATIONS. 

21 ‘‘Under authority of the Act of November 2, 1921 

22 (25 U.S.C. 13) (commonly known as the ‘Snyder Act’), 

23 the Secretary, acting through the Service, shall enter into 

24 contracts with, or make grants to, Urban Indian Organi25 zations to assist such organizations in the establishment 
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1 and administration, within Urban Centers, of programs 

2 which meet the requirements set forth in this title. Subject 

3 to section 506, the Secretary, acting through the Service, 

4 shall include such conditions as the Secretary considers 

5 necessary to effect the purpose of this title in any contract 

6 into which the Secretary enters with, or in any grant the 

7 Secretary makes to, any Urban Indian Organization pur8 suant to this title. 

9 ‘‘SEC. 503. CONTRACTS AND GRANTS FOR THE PROVISION 

10 OF HEALTH CARE AND REFERRAL SERVICES. 

11 ‘‘(a) REQUIREMENTS FOR GRANTS AND CON12 TRACTS.—Under authority of the Act of November 2, 

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

14 Act’), the Secretary, acting through the Service, shall 

15 enter into contracts with, and make grants to, Urban In16 dian Organizations for the provision of health care and 

17 referral services for Urban Indians. Any such contract or 

18 grant shall include requirements that the Urban Indian 

19 Organization successfully undertake to—

20 ‘‘(1) estimate the population of Urban Indians 

21 residing in the Urban Center or centers that the or22 ganization proposes to serve who are or could be re23 cipients of health care or referral services; 
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1 ‘‘(2) estimate the current health status of 

2 Urban Indians residing in such Urban Center or 

3 centers; 

4 ‘‘(3) estimate the current health care needs of 

5 Urban Indians residing in such Urban Center or 

6 centers; 

7 ‘‘(4) provide basic health education, including 

8 health promotion and disease prevention education, 

9 to Urban Indians; 

10 ‘‘(5) make recommendations to the Secretary 

11 and Federal, State, local, and other resource agen12 cies on methods of improving health service pro13 grams to meet the needs of Urban Indians; and 

14 ‘‘(6) where necessary, provide, or enter into 

15 contracts for the provision of, health care services 

16 for Urban Indians. 

17 ‘‘(b) CRITERIA.—The Secretary, acting through the 

18 Service, shall, by regulation, prescribe the criteria for se19 lecting Urban Indian Organizations to enter into contracts 

20 or receive grants under this section. Such criteria shall, 

21 among other factors, include—

22 ‘‘(1) the extent of unmet health care needs of 

23 Urban Indians in the Urban Center or centers in24 volved; 
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1 ‘‘(2) the size of the Urban Indian population in 

2 the Urban Center or centers involved; 

3 ‘‘(3) the extent, if any, to which the activities 

4 set forth in subsection (a) would duplicate any 

5 project funded under this title, or under any current 

6 public health service project funded in a manner 

7 other than pursuant to this title; 

8 ‘‘(4) the capability of an Urban Indian Organi9 zation to perform the activities set forth in sub10 section (a) and to enter into a contract with the Sec11 retary or to meet the requirements for receiving a 

12 grant under this section; 

13 ‘‘(5) the satisfactory performance and success14 ful completion by an Urban Indian Organization of 

15 other contracts with the Secretary under this title; 

16 ‘‘(6) the appropriateness and likely effectiveness 

17 of conducting the activities set forth in subsection 

18 (a) in an Urban Center or centers; and 

19 ‘‘(7) the extent of existing or likely future par20 ticipation in the activities set forth in subsection (a) 

21 by appropriate health and health-related Federal, 

22 State, local, and other agencies. 

23 ‘‘(c) ACCESS TO HEALTH PROMOTION AND DISEASE

24 PREVENTION PROGRAMS.—The Secretary, acting through 

25 the Service, shall facilitate access to or provide health pro-
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1 motion and disease prevention services for Urban Indians 

2 through grants made to Urban Indian Organizations ad3 ministering contracts entered into or receiving grants 

4 under subsection (a). 

5 ‘‘(d) IMMUNIZATION SERVICES.—

6 ‘‘(1) ACCESS OR SERVICES PROVIDED.—The 

7 Secretary, acting through the Service, shall facilitate 

8 access to, or provide, immunization services for 

9 Urban Indians through grants made to Urban In10 dian Organizations administering contracts entered 

11 into or receiving grants under this section. 

12 ‘‘(2) DEFINITION.—For purposes of this sub13 section, the term ‘immunization services’ means 

14 services to provide without charge immunizations 

15 against vaccine-preventable diseases. 

16 ‘‘(e) BEHAVIORAL HEALTH SERVICES.—

17 ‘‘(1) ACCESS OR SERVICES PROVIDED.—The 

18 Secretary, acting through the Service, shall facilitate 

19 access to, or provide, behavioral health services for 

20 Urban Indians through grants made to Urban In21 dian Organizations administering contracts entered 

22 into or receiving grants under subsection (a). 

23 ‘‘(2) ASSESSMENT REQUIRED.—Except as pro24 vided by paragraph (3)(A), a grant may not be made 

25 under this subsection to an Urban Indian Organiza-
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1 tion until that organization has prepared, and the 

2 Service has approved, an assessment of the fol3 lowing: 

4 ‘‘(A) The behavioral health needs of the 

5 Urban Indian population concerned. 

6 ‘‘(B) The behavioral health services and 

7 other related resources available to that popu8 lation. 

9 ‘‘(C) The barriers to obtaining those serv10 ices and resources. 

11 ‘‘(D) The needs that are unmet by such 

12 services and resources. 

13 ‘‘(3) PURPOSES OF GRANTS.—Grants may be 

14 made under this subsection for the following: 

15 ‘‘(A) To prepare assessments required 

16 under paragraph (2). 

17 ‘‘(B) To provide outreach, educational, and 

18 referral services to Urban Indians regarding the 

19 availability of direct behavioral health services, 

20 to educate Urban Indians about behavioral 

21 health issues and services, and effect coordina22 tion with existing behavioral health providers in 

23 order to improve services to Urban Indians. 

24 ‘‘(C) To provide outpatient behavioral 

25 health services to Urban Indians, including the 
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1 identification and assessment of illness, thera2 peutic treatments, case management, support 

3 groups, family treatment, and other treatment. 

4 ‘‘(D) To develop innovative behavioral 

5 health service delivery models which incorporate 

6 Indian cultural support systems and resources. 

7 ‘‘(f) PREVENTION OF CHILD ABUSE.—

8 ‘‘(1) ACCESS OR SERVICES PROVIDED.—The 

9 Secretary, acting through the Service, shall facilitate 

10 access to or provide services for Urban Indians 

11 through grants to Urban Indian Organizations ad12 ministering contracts entered into or receiving 

13 grants under subsection (a) to prevent and treat 

14 child abuse (including sexual abuse) among Urban 

15 Indians. 

16 ‘‘(2) EVALUATION REQUIRED.—Except as pro17 vided by paragraph (3)(A), a grant may not be made 

18 under this subsection to an Urban Indian Organiza19 tion until that organization has prepared, and the 

20 Service has approved, an assessment that documents 

21 the prevalence of child abuse in the Urban Indian 

22 population concerned and specifies the services and 

23 programs (which may not duplicate existing services 

24 and programs) for which the grant is requested. 
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1 ‘‘(3) PURPOSES OF GRANTS.—Grants may be 

2 made under this subsection for the following: 

3 ‘‘(A) To prepare assessments required 

4 under paragraph (2). 

5 ‘‘(B) For the development of prevention, 

6 training, and education programs for Urban In7 dians, including child education, parent edu8 cation, provider training on identification and 

9 intervention, education on reporting require10 ments, prevention campaigns, and establishing 

11 service networks of all those involved in Indian 

12 child protection. 

13 ‘‘(C) To provide direct outpatient treat14 ment services (including individual treatment, 

15 family treatment, group therapy, and support 

16 groups) to Urban Indians who are child victims 

17 of abuse (including sexual abuse) or adult sur18 vivors of child sexual abuse, to the families of 

19 such child victims, and to Urban Indian per20 petrators of child abuse (including sexual 

21 abuse). 

22 ‘‘(4) CONSIDERATIONS WHEN MAKING

23 GRANTS.—In making grants to carry out this sub24 section, the Secretary shall take into consideration—
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1 ‘‘(A) the support for the Urban Indian Or2 ganization demonstrated by the child protection 

3 authorities in the area, including committees or 

4 other services funded under the Indian Child 

5 Welfare Act of 1978 (25 U.S.C. 1901 et seq.), 

6 if any; 

7 ‘‘(B) the capability and expertise dem8 onstrated by the Urban Indian Organization to 

9 address the complex problem of child sexual 

10 abuse in the community; and 

11 ‘‘(C) the assessment required under para12 graph (2). 

13 ‘‘(g) OTHER GRANTS.—The Secretary, acting 

14 through the Service, may enter into a contract with or 

15 make grants to an Urban Indian Organization that pro16 vides or arranges for the provision of health care services 

17 (through satellite facilities, provider networks, or other18 wise) to Urban Indians in more than 1 Urban Center. 

19 ‘‘SEC. 504. CONTRACTS AND GRANTS FOR THE DETERMINA20 TION OF UNMET HEALTH CARE NEEDS. 

21 ‘‘(a) GRANTS AND CONTRACTS AUTHORIZED.—

22 Under authority of the Act of November 2, 1921 (25 

23 U.S.C. 13) (commonly known as the ‘Snyder Act’), the 

24 Secretary, acting through the Service, may enter into con25 tracts with or make grants to Urban Indian Organizations 
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1 situated in Urban Centers for which contracts have not 

2 been entered into or grants have not been made under sec3 tion 503. 

4 ‘‘(b) PURPOSE.—The purpose of a contract or grant 

5 made under this section shall be the determination of the 

6 matters described in subsection (c)(1) in order to assist 

7 the Secretary in assessing the health status and health 

8 care needs of Urban Indians in the Urban Center involved 

9 and determining whether the Secretary should enter into 

10 a contract or make a grant under section 503 with respect 

11 to the Urban Indian Organization which the Secretary has 

12 entered into a contract with, or made a grant to, under 

13 this section. 

14 ‘‘(c) GRANT AND CONTRACT REQUIREMENTS.—Any 

15 contract entered into, or grant made, by the Secretary 

16 under this section shall include requirements that—

17 ‘‘(1) the Urban Indian Organization success18 fully undertakes to—

19 ‘‘(A) document the health care status and 

20 unmet health care needs of Urban Indians in 

21 the Urban Center involved; and 

22 ‘‘(B) with respect to Urban Indians in the 

23 Urban Center involved, determine the matters 

24 described in paragraphs (2), (3), (4), and (7) of 

25 section 503(b); and 
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1 ‘‘(2) the Urban Indian Organization complete 

2 performance of the contract, or carry out the re3 quirements of the grant, within 1 year after the date 

4 on which the Secretary and such organization enter 

5 into such contract, or within 1 year after such orga6 nization receives such grant, whichever is applicable. 

7 ‘‘(d) NO RENEWALS.—The Secretary may not renew 

8 any contract entered into or grant made under this sec9 tion. 

10 ‘‘SEC. 505. EVALUATIONS; RENEWALS. 

11 ‘‘(a) PROCEDURES FOR EVALUATIONS.—The Sec12 retary, acting through the Service, shall develop proce13 dures to evaluate compliance with grant requirements and 

14 compliance with and performance of contracts entered into 

15 by Urban Indian Organizations under this title. Such pro16 cedures shall include provisions for carrying out the re17 quirements of this section. 

18 ‘‘(b) EVALUATIONS.—The Secretary, acting through 

19 the Service, shall evaluate the compliance of each Urban 

20 Indian Organization which has entered into a contract or 

21 received a grant under section 503 with the terms of such 

22 contract or grant. For purposes of this evaluation, the 

23 Secretary shall—

24 ‘‘(1) acting through the Service, conduct an an25 nual onsite evaluation of the organization; or 
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1 ‘‘(2) accept in lieu of such onsite evaluation evi2 dence of the organization’s provisional or full accred3 itation by a private independent entity recognized by 

4 the Secretary for purposes of conducting quality re5 views of providers participating in the Medicare pro6 gram under title XVIII of the Social Security Act. 

7 ‘‘(c) NONCOMPLIANCE; UNSATISFACTORY PERFORM8 ANCE.—If, as a result of the evaluations conducted under 

9 this section, the Secretary determines that an Urban In10 dian Organization has not complied with the requirements 

11 of a grant or complied with or satisfactorily performed a 

12 contract under section 503, the Secretary shall, prior to 

13 renewing such contract or grant, attempt to resolve with 

14 the organization the areas of noncompliance or unsatisfac15 tory performance and modify the contract or grant to pre16 vent future occurrences of noncompliance or unsatisfac17 tory performance. If the Secretary determines that the 

18 noncompliance or unsatisfactory performance cannot be 

19 resolved and prevented in the future, the Secretary shall 

20 not renew the contract or grant with the organization and 

21 is authorized to enter into a contract or make a grant 

22 under section 503 with another Urban Indian Organiza23 tion which is situated in the same Urban Center as the 

24 Urban Indian Organization whose contract or grant is not 

25 renewed under this section. 
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1 ‘‘(d) CONSIDERATIONS FOR RENEWALS.—In deter2 mining whether to renew a contract or grant with an 

3 Urban Indian Organization under section 503 which has 

4 completed performance of a contract or grant under sec5 tion 504, the Secretary shall review the records of the 

6 Urban Indian Organization, the reports submitted under 

7 section 507, and shall consider the results of the onsite 

8 evaluations or accreditations under subsection (b). 

9 ‘‘SEC. 506. OTHER CONTRACT AND GRANT REQUIREMENTS. 

10 ‘‘(a) PROCUREMENT.—Contracts with Urban Indian 

11 Organizations entered into pursuant to this title shall be 

12 in accordance with all Federal contracting laws and regu13 lations relating to procurement except that in the discre14 tion of the Secretary, such contracts may be negotiated 

15 without advertising and need not conform to the provisions 

16 of sections 1304 and 3131 through 3133 of title 40, 

17 United States Code. 

18 ‘‘(b) PAYMENTS UNDER CONTRACTS OR GRANTS.—

19 ‘‘(1) IN GENERAL.—Payments under any con20 tracts or grants pursuant to this title, notwith21 standing any term or condition of such contract or 

22 grant—

23 ‘‘(A) may be made in a single advance pay24 ment by the Secretary to the Urban Indian Or25 ganization by no later than the end of the first 
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1 30 days of the funding period with respect to 

2 which the payments apply, unless the Secretary 

3 determines through an evaluation under section 

4 505 that the organization is not capable of ad5 ministering such a single advance payment; and 

6 ‘‘(B) if any portion thereof is unexpended 

7 by the Urban Indian Organization during the 

8 funding period with respect to which the pay9 ments initially apply, shall be carried forward 

10 for expenditure with respect to allowable or re11 imbursable costs incurred by the organization 

12 during 1 or more subsequent funding periods 

13 without additional justification or documenta14 tion by the organization as a condition of car15 rying forward the availability for expenditure of 

16 such funds. 

17 ‘‘(2) SEMIANNUAL AND QUARTERLY PAYMENTS

18 AND REIMBURSEMENTS.—If the Secretary deter19 mines under paragraph (1)(A) that an Urban Indian 

20 Organization is not capable of administering an en21 tire single advance payment, on request of the 

22 Urban Indian Organization, the payments may be 

23 made—

24 ‘‘(A) in semiannual or quarterly payments 

25 by not later than 30 days after the date on 
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1 which the funding period with respect to which 

2 the payments apply begins; or 

3 ‘‘(B) by way of reimbursement. 

4 ‘‘(c) REVISION OR AMENDMENT OF CONTRACTS.—

5 Notwithstanding any provision of law to the contrary, the 

6 Secretary may, at the request and consent of an Urban 

7 Indian Organization, revise or amend any contract entered 

8 into by the Secretary with such organization under this 

9 title as necessary to carry out the purposes of this title. 

10 ‘‘(d) FAIR AND UNIFORM SERVICES AND ASSIST11 ANCE.—Contracts with or grants to Urban Indian Organi12 zations and regulations adopted pursuant to this title shall 

13 include provisions to assure the fair and uniform provision 

14 to Urban Indians of services and assistance under such 

15 contracts or grants by such organizations. 

16 ‘‘SEC. 507. REPORTS AND RECORDS. 

17 ‘‘(a) REPORTS.—

18 ‘‘(1) IN GENERAL.—For each fiscal year during 

19 which an Urban Indian Organization receives or ex20 pends funds pursuant to a contract entered into or 

21 a grant received pursuant to this title, such Urban 

22 Indian Organization shall submit to the Secretary 

23 not more frequently than every 6 months, a report 

24 that includes the following: 
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1 ‘‘(A) In the case of a contract or grant 

2 under section 503, recommendations pursuant 

3 to section 503(a)(5). 

4 ‘‘(B) Information on activities conducted 

5 by the organization pursuant to the contract or 

6 grant. 

7 ‘‘(C) An accounting of the amounts and 

8 purpose for which Federal funds were ex9 pended. 

10 ‘‘(D) A minimum set of data, using uni11 formly defined elements, as specified by the 

12 Secretary after consultation with Urban Indian 

13 Organizations. 

14 ‘‘(2) HEALTH STATUS AND SERVICES.—

15 ‘‘(A) IN GENERAL.—Not later than 18 

16 months after the date of enactment of the In17 dian Health Care Improvement Act Amend18 ments of 2008, the Secretary, acting through 

19 the Service and working with a national mem20 bership-based consortium of Urban Indian Or21 ganizations, shall submit to Congress a report 

22 evaluating—

23 ‘‘(i) the health status of Urban Indi24 ans; 
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1 ‘‘(ii) the services provided to Indians 

2 pursuant to this title; and 

3 ‘‘(iii) areas of unmet needs in the de4 livery of health services to Urban Indians, 

5 including unmet health care facilities 

6 needs. 

7 ‘‘(B) CONSULTATION AND CONTRACTS.—

8 In preparing the report under paragraph (1), 

9 the Secretary—

10 ‘‘(i) shall confer with Urban Indian 

11 Organizations; and 

12 ‘‘(ii) may enter into a contract with a 

13 national organization representing Urban 

14 Indian Organizations to conduct any as15 pect of the report. 

16 ‘‘(b) AUDIT.—The reports and records of the Urban 

17 Indian Organization with respect to a contract or grant 

18 under this title shall be subject to audit by the Secretary 

19 and the Comptroller General of the United States. 

20 ‘‘(c) COSTS OF AUDITS.—The Secretary shall allow 

21 as a cost of any contract or grant entered into or awarded 

22 under section 502 or 503 the cost of an annual inde23 pendent financial audit conducted by—

24 ‘‘(1) a certified public accountant; or 
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1 ‘‘(2) a certified public accounting firm qualified 

2 to conduct Federal compliance audits. 

3 ‘‘SEC. 508. LIMITATION ON CONTRACT AUTHORITY. 

4 ‘‘The authority of the Secretary to enter into con5 tracts or to award grants under this title shall be to the 

6 extent, and in an amount, provided for in appropriation 

7 Acts. 

8 ‘‘SEC. 509. FACILITIES. 

9 ‘‘(a) GRANTS.—The Secretary, acting through the 

10 Service, may make grants to contractors or grant recipi11 ents under this title for the lease, purchase, renovation, 

12 construction, or expansion of facilities, including leased fa13 cilities, in order to assist such contractors or grant recipi14 ents in complying with applicable licensure or certification 

15 requirements. 

16 ‘‘(b) LOAN FUND STUDY.—The Secretary, acting 

17 through the Service, may carry out a study to determine 

18 the feasibility of establishing a loan fund to provide to 

19 Urban Indian Organizations direct loans or guarantees for 

20 loans for the construction of health care facilities in a 

21 manner consistent with section 309, including by submit22 ting a report in accordance with subsection (c) of that sec23 tion. 
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1 ‘‘SEC. 510. DIVISION OF URBAN INDIAN HEALTH. 

2 ‘‘There is established within the Service a Division 

3 of Urban Indian Health, which shall be responsible for—

4 ‘‘(1) carrying out the provisions of this title; 

5 ‘‘(2) providing central oversight of the pro6 grams and services authorized under this title; and 

7 ‘‘(3) providing technical assistance to Urban In8 dian Organizations working with a national member9 ship-based consortium of Urban Indian Organiza10 tions. 

11 ‘‘SEC. 511. GRANTS FOR ALCOHOL AND SUBSTANCE ABUSE12 RELATED SERVICES. 

13 ‘‘(a) GRANTS AUTHORIZED.—The Secretary, acting 

14 through the Service, may make grants for the provision 

15 of health-related services in prevention of, treatment of, 

16 rehabilitation of, or school- and community-based edu17 cation regarding, alcohol and substance abuse, including 

18 fetal alcohol spectrum disorders, in Urban Centers to 

19 those Urban Indian Organizations with which the Sec20 retary has entered into a contract under this title or under 

21 section 201. 

22 ‘‘(b) GOALS.—Each grant made pursuant to sub23 section (a) shall set forth the goals to be accomplished 

24 pursuant to the grant. The goals shall be specific to each 

25 grant as agreed to between the Secretary and the grantee. 
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1 ‘‘(c) CRITERIA.—The Secretary shall establish cri2 teria for the grants made under subsection (a), including 

3 criteria relating to the following: 

4 ‘‘(1) The size of the Urban Indian population. 

5 ‘‘(2) Capability of the organization to ade6 quately perform the activities required under the 

7 grant. 

8 ‘‘(3) Satisfactory performance standards for the 

9 organization in meeting the goals set forth in such 

10 grant. The standards shall be negotiated and agreed 

11 to between the Secretary and the grantee on a 

12 grant-by-grant basis. 

13 ‘‘(4) Identification of the need for services. 

14 ‘‘(d) ALLOCATION OF GRANTS.—The Secretary shall 

15 develop a methodology for allocating grants made pursu16 ant to this section based on the criteria established pursu17 ant to subsection (c). 

18 ‘‘(e) GRANTS SUBJECT TO CRITERIA.—Any grant re19 ceived by an Urban Indian Organization under this Act 

20 for substance abuse prevention, treatment, and rehabilita21 tion shall be subject to the criteria set forth in subsection 

22 (c). 
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1 ‘‘SEC. 512. TREATMENT OF CERTAIN DEMONSTRATION 

2 PROJECTS. 

3 ‘‘Notwithstanding any other provision of law, the 

4 Tulsa Clinic and Oklahoma City Clinic demonstration 

5 projects shall—

6 ‘‘(1) be permanent programs within the Serv7 ice’s direct care program; 

8 ‘‘(2) continue to be treated as Service Units 

9 and Operating Units in the allocation of resources 

10 and coordination of care; and 

11 ‘‘(3) continue to meet the requirements and 

12 definitions of an Urban Indian Organization in this 

13 Act, and shall not be subject to the provisions of the 

14 Indian Self-Determination and Education Assistance 

15 Act (25 U.S.C. 450 et seq.). 

16 ‘‘SEC. 513. URBAN NIAAA TRANSFERRED PROGRAMS. 

17 ‘‘(a) GRANTS AND CONTRACTS.—The Secretary, 

18 through the Division of Urban Indian Health, shall make 

19 grants to, or enter into contracts with, Urban Indian Or20 ganizations, to take effect not later than September 30, 

21 2010, for the administration of Urban Indian alcohol pro22 grams that were originally established under the National 

23 Institute on Alcoholism and Alcohol Abuse (hereafter in 

24 this section referred to as ‘NIAAA’) and transferred to 

25 the Service. 
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1 ‘‘(b) USE OF FUNDS.—Grants provided or contracts 

2 entered into under this section shall be used to provide 

3 support for the continuation of alcohol prevention and 

4 treatment services for Urban Indian populations and such 

5 other objectives as are agreed upon between the Service 

6 and a recipient of a grant or contract under this section. 

7 ‘‘(c) ELIGIBILITY.—Urban Indian Organizations that 

8 operate Indian alcohol programs originally funded under 

9 the NIAAA and subsequently transferred to the Service 

10 are eligible for grants or contracts under this section. 

11 ‘‘(d) REPORT.—The Secretary shall evaluate and re12 port to Congress on the activities of programs funded 

13 under this section not less than every 5 years. 

14 ‘‘SEC. 514. CONFERRING WITH URBAN INDIAN ORGANIZA15 TIONS. 

16 ‘‘(a) IN GENERAL.—The Secretary shall ensure that 

17 the Service confers or conferences, to the greatest extent 

18 practicable, with Urban Indian Organizations. 

19 ‘‘(b) DEFINITION OF CONFER; CONFERENCE.—In 

20 this section, the terms ‘confer’ and ‘conference’ mean an 

21 open and free exchange of information and opinions 

22 that—

23 ‘‘(1) leads to mutual understanding and com24 prehension; and 
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1 ‘‘(2) emphasizes trust, respect, and shared re2 sponsibility. 

3 ‘‘SEC. 515. URBAN YOUTH TREATMENT CENTER DEM4 ONSTRATION. 

5 ‘‘(a) CONSTRUCTION AND OPERATION.—

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

7 through the Service, through grant or contract, shall 

8 fund the construction and operation of at least 1 

9 residential treatment center in each Service Area 

10 that meets the eligibility requirements set forth in 

11 subsection (b) to demonstrate the provision of alco12 hol and substance abuse treatment services to Urban 

13 Indian youth in a culturally competent residential 

14 setting. 

15 ‘‘(2) TREATMENT.—Each residential treatment 

16 center described in paragraph (1) shall be in addi17 tion to any facilities constructed under section 

18 707(b). 

19 ‘‘(b) ELIGIBILITY REQUIREMENTS.—To be eligible to 

20 obtain a facility under subsection (a)(1), a Service Area 

21 shall meet the following requirements: 

22 ‘‘(1) There is an Urban Indian Organization in 

23 the Service Area. 
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1 ‘‘(2) There reside in the Service Area Urban In2 dian youth with need for alcohol and substance 

3 abuse treatment services in a residential setting. 

4 ‘‘(3) There is a significant shortage of cul5 turally competent residential treatment services for 

6 Urban Indian youth in the Service Area. 

7 ‘‘SEC. 516. GRANTS FOR DIABETES PREVENTION, TREAT8 MENT, AND CONTROL. 

9 ‘‘(a) GRANTS AUTHORIZED.—The Secretary may 

10 make grants to those Urban Indian Organizations that 

11 have entered into a contract or have received a grant 

12 under this title for the provision of services for the preven13 tion and treatment of, and control of the complications 

14 resulting from, diabetes among Urban Indians. 

15 ‘‘(b) GOALS.—Each grant made pursuant to sub16 section (a) shall set forth the goals to be accomplished 

17 under the grant. The goals shall be specific to each grant 

18 as agreed to between the Secretary and the grantee. 

19 ‘‘(c) ESTABLISHMENT OF CRITERIA.—The Secretary 

20 shall establish criteria for the grants made under sub21 section (a) relating to—

22 ‘‘(1) the size and location of the Urban Indian 

23 population to be served; 

24 ‘‘(2) the need for prevention of and treatment 

25 of, and control of the complications resulting from, 
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1 diabetes among the Urban Indian population to be 

2 served; 

3 ‘‘(3) performance standards for the organiza4 tion in meeting the goals set forth in such grant 

5 that are negotiated and agreed to by the Secretary 

6 and the grantee; 

7 ‘‘(4) the capability of the organization to ade8 quately perform the activities required under the 

9 grant; and 

10 ‘‘(5) the willingness of the organization to col11 laborate with the registry, if any, established by the 

12 Secretary under section 204(e) in the Area Office of 

13 the Service in which the organization is located. 

14 ‘‘(d) FUNDS SUBJECT TO CRITERIA.—Any funds re15 ceived by an Urban Indian Organization under this Act 

16 for the prevention, treatment, and control of diabetes 

17 among Urban Indians shall be subject to the criteria devel18 oped by the Secretary under subsection (c). 

19 ‘‘SEC. 517. COMMUNITY HEALTH REPRESENTATIVES. 

20 ‘‘The Secretary, acting through the Service, may 

21 enter into contracts with, and make grants to, Urban In22 dian Organizations for the employment of Indians trained 

23 as health service providers through the Community Health 

24 Representatives Program under section 109 in the provi-
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1 sion of health care, health promotion, and disease preven2 tion services to Urban Indians. 

3 ‘‘SEC. 518. EFFECTIVE DATE. 

4 ‘‘The amendments made by the Indian Health Care 

5 Improvement Act Amendments of 2008 to this title shall 

6 take effect beginning on the date of enactment of that Act, 

7 regardless of whether the Secretary has promulgated regu8 lations implementing such amendments. 

9 ‘‘SEC. 519. ELIGIBILITY FOR SERVICES. 

10 ‘‘Urban Indians shall be eligible for, and the ultimate 

11 beneficiaries of, health care or referral services provided 

12 pursuant to this title. 

13 ‘‘SEC. 520. AUTHORIZATION OF APPROPRIATIONS. 

14 ‘‘There are authorized to be appropriated such sums 

15 as may be necessary for each fiscal year through fiscal 

16 year 2017 to carry out this title. 

17 ‘‘TITLE VI—ORGANIZATIONAL 

18 IMPROVEMENTS 

19 ‘‘SEC. 601. ESTABLISHMENT OF THE INDIAN HEALTH SERV20 ICE AS AN AGENCY OF THE PUBLIC HEALTH 

21 SERVICE. 

22 ‘‘(a) ESTABLISHMENT.—

23 ‘‘(1) IN GENERAL.—In order to more effectively 

24 and efficiently carry out the responsibilities, authori25 ties, and functions of the United States to provide 
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1 health care services to Indians and Indian Tribes, as 

2 are or may be hereafter provided by Federal statute 

3 or treaties, there is established within the Public 

4 Health Service of the Department the Indian Health 

5 Service. 

6 ‘‘(2) DIRECTOR.—The Service shall be adminis7 tered by a Director, who shall be appointed by the 

8 President, by and with the advice and consent of the 

9 Senate. The Director shall report to the Secretary. 

10 Effective with respect to an individual appointed by 

11 the President, by and with the advice and consent 

12 of the Senate, after January 1, 2008, the term of 

13 service of the Director shall be 4 years. A Director 

14 may serve more than 1 term. 

15 ‘‘(3) INCUMBENT.—The individual serving in 

16 the position of Director of the Service on the day be17 fore the date of enactment of the Indian Health 

18 Care Improvement Act Amendments of 2008 shall 

19 serve as Director. 

20 ‘‘(4) ADVOCACY AND CONSULTATION.—The po21 sition of Director is established to, in a manner con22 sistent with the government-to-government relation23 ship between the United States and Indian Tribes—

24 ‘‘(A) facilitate advocacy for the develop25 ment of appropriate Indian health policy; and 
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1 ‘‘(B) promote consultation on matters re2 lating to Indian health. 

3 ‘‘(b) AGENCY.—The Service shall be an agency within 

4 the Public Health Service of the Department, and shall 

5 not be an office, component, or unit of any other agency 

6 of the Department. 

7 ‘‘(c) DUTIES.—The Director shall—

8 ‘‘(1) perform all functions that were, on the day 

9 before the date of enactment of the Indian Health 

10 Care Improvement Act Amendments of 2008, car11 ried out by or under the direction of the individual 

12 serving as Director of the Service on that day; 

13 ‘‘(2) perform all functions of the Secretary re14 lating to the maintenance and operation of hospital 

15 and health facilities for Indians and the planning 

16 for, and provision and utilization of, health services 

17 for Indians; 

18 ‘‘(3) administer all health programs under 

19 which health care is provided to Indians based upon 

20 their status as Indians which are administered by 

21 the Secretary, including programs under—

22 ‘‘(A) this Act; 

23 ‘‘(B) the Act of November 2, 1921 (25 

24 U.S.C. 13); 
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1 ‘‘(C) the Act of August 5, 1954 (42 U.S.C. 

2 2001 et seq.); 

3 ‘‘(D) the Act of August 16, 1957 (42 

4 U.S.C. 2005 et seq.); and 

5 ‘‘(E) the Indian Self-Determination and 

6 Education Assistance Act (25 U.S.C. 450 et 

7 seq.); 

8 ‘‘(4) administer all scholarship and loan func9 tions carried out under title I; 

10 ‘‘(5) directly advise the Secretary concerning 

11 the development of all policy- and budget-related 

12 matters affecting Indian health; 

13 ‘‘(6) collaborate with the Assistant Secretary 

14 for Health concerning appropriate matters of Indian 

15 health that affect the agencies of the Public Health 

16 Service; 

17 ‘‘(7) advise each Assistant Secretary of the De18 partment concerning matters of Indian health with 

19 respect to which that Assistant Secretary has au20 thority and responsibility; 

21 ‘‘(8) advise the heads of other agencies and pro22 grams of the Department concerning matters of In23 dian health with respect to which those heads have 

24 authority and responsibility; 
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1 ‘‘(9) coordinate the activities of the Department 

2 concerning matters of Indian health; and 

3 ‘‘(10) perform such other functions as the Sec4 retary may designate. 

5 ‘‘(d) AUTHORITY.—

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

7 through the Director, shall have the authority—

8 ‘‘(A) except to the extent provided for in 

9 paragraph (2), to appoint and compensate em10 ployees for the Service in accordance with title 

11 5, United States Code; 

12 ‘‘(B) to enter into contracts for the pro13 curement of goods and services to carry out the 

14 functions of the Service; and 

15 ‘‘(C) to manage, expend, and obligate all 

16 funds appropriated for the Service. 

17 ‘‘(2) PERSONNEL ACTIONS.—Notwithstanding 

18 any other provision of law, the provisions of section 

19 12 of the Act of June 18, 1934 (48 Stat. 986; 25 

20 U.S.C. 472), shall apply to all personnel actions 

21 taken with respect to new positions created within 

22 the Service as a result of its establishment under 

23 subsection (a). 
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1 ‘‘SEC. 602. AUTOMATED MANAGEMENT INFORMATION SYS2 TEM. 

3 ‘‘(a) ESTABLISHMENT.—

4 ‘‘(1) IN GENERAL.—The Secretary shall estab5 lish an automated management information system 

6 for the Service. 

7 ‘‘(2) REQUIREMENTS OF SYSTEM.—The infor8 mation system established under paragraph (1) shall 

9 include—

10 ‘‘(A) a financial management system; 

11 ‘‘(B) a patient care information system for 

12 each area served by the Service; 

13 ‘‘(C) a privacy component that protects the 

14 privacy of patient information held by, or on be15 half of, the Service; 

16 ‘‘(D) a services-based cost accounting com17 ponent that provides estimates of the costs as18 sociated with the provision of specific medical 

19 treatments or services in each Area office of the 

20 Service; 

21 ‘‘(E) an interface mechanism for patient 

22 billing and accounts receivable system; and 

23 ‘‘(F) a training component. 

24 ‘‘(b) PROVISION OF SYSTEMS TO TRIBES AND ORGA25 NIZATIONS.—The Secretary shall provide each Tribal 
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1 Health Program automated management information sys2 tems which—

3 ‘‘(1) meet the management information needs 

4 of such Tribal Health Program with respect to the 

5 treatment by the Tribal Health Program of patients 

6 of the Service; and 

7 ‘‘(2) meet the management information needs 

8 of the Service. 

9 ‘‘(c) ACCESS TO RECORDS.—Notwithstanding any 

10 other provision of law, each patient shall have reasonable 

11 access to the medical or health records of such patient 

12 which are held by, or on behalf of, the Service. 

13 ‘‘(d) AUTHORITY TO ENHANCE INFORMATION TECH14 NOLOGY.—The Secretary, acting through the Director, 

15 shall have the authority to enter into contracts, agree16 ments, or joint ventures with other Federal agencies, 

17 States, private and nonprofit organizations, for the pur18 pose of enhancing information technology in Indian 

19 Health Programs and facilities. 

20 ‘‘SEC. 603. AUTHORIZATION OF APPROPRIATIONS. 

21 ‘‘There is authorized to be appropriated such sums 

22 as may be necessary for each fiscal year through fiscal 

23 year 2017 to carry out this title. 
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1 ‘‘TITLE VII—BEHAVIORAL 

2 HEALTH PROGRAMS 

3 ‘‘SEC. 701. BEHAVIORAL HEALTH PREVENTION AND TREAT4 MENT SERVICES. 

5 ‘‘(a) PURPOSES.—The purposes of this section are as 

6 follows: 

7 ‘‘(1) To authorize and direct the Secretary, act8 ing through the Service, Indian Tribes and Tribal 

9 Organizations to develop a comprehensive behavioral 

10 health prevention and treatment program which em11 phasizes collaboration among alcohol and substance 

12 abuse, social services, and mental health programs. 

13 ‘‘(2) To provide information, direction, and 

14 guidance relating to mental illness and dysfunction 

15 and self-destructive behavior, including child abuse 

16 and family violence, to those Federal, tribal, State, 

17 and local agencies responsible for programs in In18 dian communities in areas of health care, education, 

19 social services, child and family welfare, alcohol and 

20 substance abuse, law enforcement, and judicial serv21 ices. 

22 ‘‘(3) To assist Indian Tribes to identify services 

23 and resources available to address mental illness and 

24 dysfunctional and self-destructive behavior. 
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1 ‘‘(4) To provide authority and opportunities for 

2 Indian Tribes and Tribal Organizations to develop, 

3 implement, and coordinate with community-based 

4 programs which include identification, prevention, 

5 education, referral, and treatment services, including 

6 through multidisciplinary resource teams. 

7 ‘‘(5) To ensure that Indians, as citizens of the 

8 United States and of the States in which they re9 side, have the same access to behavioral health serv10 ices to which all citizens have access. 

11 ‘‘(6) To modify or supplement existing pro12 grams and authorities in the areas identified in 

13 paragraph (2). 

14 ‘‘(b) PLANS.—

15 ‘‘(1) DEVELOPMENT.—The Secretary, acting 

16 through the Service, Indian Tribes, and Tribal Orga17 nizations, shall encourage Indian Tribes and Tribal 

18 Organizations to develop tribal plans and to partici19 pate in developing areawide plans for Indian Behav20 ioral Health Services. The plans shall include, to the 

21 extent feasible, the following components: 

22 ‘‘(A) An assessment of the scope of alcohol 

23 or other substance abuse, mental illness, and 

24 dysfunctional and self-destructive behavior, in-
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1 cluding suicide, child abuse, and family vio2 lence, among Indians, including—

3 ‘‘(i) the number of Indians served who 

4 are directly or indirectly affected by such 

5 illness or behavior; or 

6 ‘‘(ii) an estimate of the financial and 

7 human cost attributable to such illness or 

8 behavior. 

9 ‘‘(B) An assessment of the existing and 

10 additional resources necessary for the preven11 tion and treatment of such illness and behavior, 

12 including an assessment of the progress toward 

13 achieving the availability of the full continuum 

14 of care described in subsection (c). 

15 ‘‘(C) An estimate of the additional funding 

16 needed by the Service, Indian Tribes, and Trib17 al Organizations to meet their responsibilities 

18 under the plans. 

19 ‘‘(2) COORDINATION WITH NATIONAL CLEAR20 INGHOUSES AND INFORMATION CENTERS.—The Sec21 retary, acting through the Service, shall coordinate 

22 with existing national clearinghouses and informa23 tion centers to include at the clearinghouses and 

24 centers plans and reports on the outcomes of such 

25 plans developed by Indian Tribes, Tribal Organiza-
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1 tions, and Service Areas relating to behavioral 

2 health. The Secretary shall ensure access to these 

3 plans and outcomes by any Indian Tribe, Tribal Or4 ganization, or the Service. 

5 ‘‘(3) TECHNICAL ASSISTANCE.—The Secretary 

6 shall provide technical assistance to Indian Tribes 

7 and Tribal Organizations in preparation of plans 

8 under this section and in developing standards of 

9 care that may be used and adopted locally. 

10 ‘‘(c) PROGRAMS.—The Secretary, acting through the 

11 Service, Indian Tribes, and Tribal Organizations, shall 

12 provide, to the extent feasible and if funding is available, 

13 programs including the following: 

14 ‘‘(1) COMPREHENSIVE CARE.—A comprehensive 

15 continuum of behavioral health care which pro16 vides—

17 ‘‘(A) community-based prevention, inter18 vention, outpatient, and behavioral health 

19 aftercare; 

20 ‘‘(B) detoxification (social and medical); 

21 ‘‘(C) acute hospitalization; 

22 ‘‘(D) intensive outpatient/day treatment; 

23 ‘‘(E) residential treatment; 
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1 ‘‘(F) transitional living for those needing a 

2 temporary, stable living environment that is 

3 supportive of treatment and recovery goals; 

4 ‘‘(G) emergency shelter; 

5 ‘‘(H) intensive case management; 

6 ‘‘(I) diagnostic services; and 

7 ‘‘(J) promotion of healthy approaches to 

8 risk and safety issues, including injury preven9 tion. 

10 ‘‘(2) CHILD CARE.—Behavioral health services 

11 for Indians from birth through age 17, including—

12 ‘‘(A) preschool and school age fetal alcohol 

13 spectrum disorder services, including assess14 ment and behavioral intervention; 

15 ‘‘(B) mental health and substance abuse 

16 services (emotional, organic, alcohol, drug, in17 halant, and tobacco); 

18 ‘‘(C) identification and treatment of co-oc19 curring disorders and comorbidity; 

20 ‘‘(D) prevention of alcohol, drug, inhalant, 

21 and tobacco use; 

22 ‘‘(E) early intervention, treatment, and 

23 aftercare; and 

24 ‘‘(F) identification and treatment of ne25 glect and physical, mental, and sexual abuse. 
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1 ‘‘(3) ADULT CARE.—Behavioral health services 

2 for Indians from age 18 through 55, including—

3 ‘‘(A) early intervention, treatment, and 

4 aftercare; 

5 ‘‘(B) mental health and substance abuse 

6 services (emotional, alcohol, drug, inhalant, and 

7 tobacco), including sex specific services; 

8 ‘‘(C) identification and treatment of co-oc9 curring disorders (dual diagnosis) and comor10 bidity; 

11 ‘‘(D) promotion of healthy approaches for 

12 risk-related behavior; 

13 ‘‘(E) treatment services for women at risk 

14 of a fetal alcohol-exposed pregnancy; and 

15 ‘‘(F) sex specific treatment for sexual as16 sault and domestic violence. 

17 ‘‘(4) FAMILY CARE.—Behavioral health services 

18 for families, including—

19 ‘‘(A) early intervention, treatment, and 

20 aftercare for affected families; 

21 ‘‘(B) treatment for sexual assault and do22 mestic violence; and 

23 ‘‘(C) promotion of healthy approaches re24 lating to parenting, domestic violence, and other 

25 abuse issues. 
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1 ‘‘(5) ELDER CARE.—Behavioral health services 

2 for Indians 56 years of age and older, including—

3 ‘‘(A) early intervention, treatment, and 

4 aftercare; 

5 ‘‘(B) mental health and substance abuse 

6 services (emotional, alcohol, drug, inhalant, and 

7 tobacco), including sex specific services; 

8 ‘‘(C) identification and treatment of co-oc9 curring disorders (dual diagnosis) and comor10 bidity; 

11 ‘‘(D) promotion of healthy approaches to 

12 managing conditions related to aging; 

13 ‘‘(E) sex specific treatment for sexual as14 sault, domestic violence, neglect, physical and 

15 mental abuse and exploitation; and 

16 ‘‘(F) identification and treatment of de17 mentias regardless of cause. 

18 ‘‘(d) COMMUNITY BEHAVIORAL HEALTH PLAN.—

19 ‘‘(1) ESTABLISHMENT.—The governing body of 

20 any Indian Tribe or Tribal Organization may adopt 

21 a resolution for the establishment of a community 

22 behavioral health plan providing for the identifica23 tion and coordination of available resources and pro24 grams to identify, prevent, or treat substance abuse, 

25 mental illness, or dysfunctional and self-destructive 
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1 behavior, including child abuse and family violence, 

2 among its members or its service population. This 

3 plan should include behavioral health services, social 

4 services, intensive outpatient services, and con5 tinuing aftercare. 

6 ‘‘(2) TECHNICAL ASSISTANCE.—At the request 

7 of an Indian Tribe or Tribal Organization, the Bu8 reau of Indian Affairs and the Service shall cooper9 ate with and provide technical assistance to the In10 dian Tribe or Tribal Organization in the develop11 ment and implementation of such plan. 

12 ‘‘(3) FUNDING.—The Secretary, acting through 

13 the Service, may make funding available to Indian 

14 Tribes and Tribal Organizations which adopt a reso15 lution pursuant to paragraph (1) to obtain technical 

16 assistance for the development of a community be17 havioral health plan and to provide administrative 

18 support in the implementation of such plan. 

19 ‘‘(e) COORDINATION FOR AVAILABILITY OF SERV20 ICES.—The Secretary, acting through the Service, Indian 

21 Tribes, and Tribal Organizations, shall coordinate behav22 ioral health planning, to the extent feasible, with other 

23 Federal agencies and with State agencies, to encourage 

24 comprehensive behavioral health services for Indians re25 gardless of their place of residence. 
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1 ‘‘(f) MENTAL HEALTH CARE NEED ASSESSMENT.—

2 Not later than 1 year after the date of enactment of the 

3 Indian Health Care Improvement Act Amendments of 

4 2008, the Secretary, acting through the Service, shall 

5 make an assessment of the need for inpatient mental 

6 health care among Indians and the availability and cost 

7 of inpatient mental health facilities which can meet such 

8 need. In making such assessment, the Secretary shall con9 sider the possible conversion of existing, underused Service 

10 hospital beds into psychiatric units to meet such need. 

11 ‘‘SEC. 702. MEMORANDA OF AGREEMENT WITH THE DE12 PARTMENT OF THE INTERIOR. 

13 ‘‘(a) CONTENTS.—Not later than 12 months after the 

14 date of enactment of the Indian Health Care Improvement 

15 Act Amendments of 2008, the Secretary, acting through 

16 the Service, and the Secretary of the Interior shall develop 

17 and enter into a memoranda of agreement, or review and 

18 update any existing memoranda of agreement, as required 

19 by section 4205 of the Indian Alcohol and Substance 

20 Abuse Prevention and Treatment Act of 1986 (25 U.S.C. 

21 2411) under which the Secretaries address the following: 

22 ‘‘(1) The scope and nature of mental illness and 

23 dysfunctional and self-destructive behavior, including 

24 child abuse and family violence, among Indians. 
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1 ‘‘(2) The existing Federal, tribal, State, local, 

2 and private services, resources, and programs avail3 able to provide behavioral health services for Indi4 ans. 

5 ‘‘(3) The unmet need for additional services, re6 sources, and programs necessary to meet the needs 

7 identified pursuant to paragraph (1). 

8 ‘‘(4)(A) The right of Indians, as citizens of the 

9 United States and of the States in which they re10 side, to have access to behavioral health services to 

11 which all citizens have access. 

12 ‘‘(B) The right of Indians to participate in, and 

13 receive the benefit of, such services. 

14 ‘‘(C) The actions necessary to protect the exer15 cise of such right. 

16 ‘‘(5) The responsibilities of the Bureau of In17 dian Affairs and the Service, including mental illness 

18 identification, prevention, education, referral, and 

19 treatment services (including services through multi20 disciplinary resource teams), at the central, area, 

21 and agency and Service Unit, Service Area, and 

22 headquarters levels to address the problems identi23 fied in paragraph (1). 

24 ‘‘(6) A strategy for the comprehensive coordina25 tion of the behavioral health services provided by the 
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1 Bureau of Indian Affairs and the Service to meet 

2 the problems identified pursuant to paragraph (1), 

3 including—

4 ‘‘(A) the coordination of alcohol and sub5 stance abuse programs of the Service, the Bu6 reau of Indian Affairs, and Indian Tribes and 

7 Tribal Organizations (developed under the In8 dian Alcohol and Substance Abuse Prevention 

9 and Treatment Act of 1986 (25 U.S.C. 2401 et 

10 seq.)) with behavioral health initiatives pursu11 ant to this Act, particularly with respect to the 

12 referral and treatment of dually diagnosed indi13 viduals requiring behavioral health and sub14 stance abuse treatment; and 

15 ‘‘(B) ensuring that the Bureau of Indian 

16 Affairs and Service programs and services (in17 cluding multidisciplinary resource teams) ad18 dressing child abuse and family violence are co19 ordinated with such non-Federal programs and 

20 services. 

21 ‘‘(7) Directing appropriate officials of the Bu22 reau of Indian Affairs and the Service, particularly 

23 at the agency and Service Unit levels, to cooperate 

24 fully with tribal requests made pursuant to commu25 nity behavioral health plans adopted under section 
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1 701(c) and section 4206 of the Indian Alcohol and 

2 Substance Abuse Prevention and Treatment Act of 

3 1986 (25 U.S.C. 2412). 

4 ‘‘(8) Providing for an annual review of such 

5 agreement by the Secretaries which shall be provided 

6 to Congress and Indian Tribes and Tribal Organiza7 tions. 

8 ‘‘(b) SPECIFIC PROVISIONS REQUIRED.—The memo9 randa of agreement updated or entered into pursuant to 

10 subsection (a) shall include specific provisions pursuant to 

11 which the Service shall assume responsibility for—

12 ‘‘(1) the determination of the scope of the prob13 lem of alcohol and substance abuse among Indians, 

14 including the number of Indians within the jurisdic15 tion of the Service who are directly or indirectly af16 fected by alcohol and substance abuse and the finan17 cial and human cost; 

18 ‘‘(2) an assessment of the existing and needed 

19 resources necessary for the prevention of alcohol and 

20 substance abuse and the treatment of Indians af21 fected by alcohol and substance abuse; and 

22 ‘‘(3) an estimate of the funding necessary to 

23 adequately support a program of prevention of alco24 hol and substance abuse and treatment of Indians 

25 affected by alcohol and substance abuse. 
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1 ‘‘(c) PUBLICATION.—Each memorandum of agree2 ment entered into or renewed (and amendments or modi3 fications thereto) under subsection (a) shall be published 

4 in the Federal Register. At the same time as publication 

5 in the Federal Register, the Secretary shall provide a copy 

6 of such memoranda, amendment, or modification to each 

7 Indian Tribe, Tribal Organization, and Urban Indian Or8 ganization. 

9 ‘‘SEC. 703. COMPREHENSIVE BEHAVIORAL HEALTH PRE10 VENTION AND TREATMENT PROGRAM. 

11 ‘‘(a) ESTABLISHMENT.—

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

13 through the Service, Indian Tribes, and Tribal Orga14 nizations, shall provide a program of comprehensive 

15 behavioral health, prevention, treatment, and 

16 aftercare, which shall include—

17 ‘‘(A) prevention, through educational inter18 vention, in Indian communities; 

19 ‘‘(B) acute detoxification, psychiatric hos20 pitalization, residential, and intensive outpatient 

21 treatment; 

22 ‘‘(C) community-based rehabilitation and 

23 aftercare; 

24 ‘‘(D) community education and involve25 ment, including extensive training of health 
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1 care, educational, and community-based per2 sonnel; 

3 ‘‘(E) specialized residential treatment pro4 grams for high-risk populations, including preg5 nant and postpartum women and their children; 

6 and 

7 ‘‘(F) diagnostic services. 

8 ‘‘(2) TARGET POPULATIONS.—The target popu9 lation of such programs shall be members of Indian 

10 Tribes. Efforts to train and educate key members of 

11 the Indian community shall also target employees of 

12 health, education, judicial, law enforcement, legal, 

13 and social service programs. 

14 ‘‘(b) CONTRACT HEALTH SERVICES.—

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

16 through the Service, Indian Tribes, and Tribal Orga17 nizations, may enter into contracts with public or 

18 private providers of behavioral health treatment 

19 services for the purpose of carrying out the program 

20 required under subsection (a). 

21 ‘‘(2) PROVISION OF ASSISTANCE.—In carrying 

22 out this subsection, the Secretary shall provide as23 sistance to Indian Tribes and Tribal Organizations 

24 to develop criteria for the certification of behavioral 

25 health service providers and accreditation of service 
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1 facilities which meet minimum standards for such 

2 services and facilities. 

3 ‘‘SEC. 704. MENTAL HEALTH TECHNICIAN PROGRAM. 

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

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

6 as the ‘Snyder Act’), the Secretary shall establish and 

7 maintain a mental health technician program within the 

8 Service which—

9 ‘‘(1) provides for the training of Indians as 

10 mental health technicians; and 

11 ‘‘(2) employs such technicians in the provision 

12 of community-based mental health care that includes 

13 identification, prevention, education, referral, and 

14 treatment services. 

15 ‘‘(b) PARAPROFESSIONAL TRAINING.—In carrying 

16 out subsection (a), the Secretary, acting through the Serv17 ice, Indian Tribes, and Tribal Organizations, shall provide 

18 high-standard paraprofessional training in mental health 

19 care necessary to provide quality care to the Indian com20 munities to be served. Such training shall be based upon 

21 a curriculum developed or approved by the Secretary 

22 which combines education in the theory of mental health 

23 care with supervised practical experience in the provision 

24 of such care. 
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1 ‘‘(c) SUPERVISION AND EVALUATION OF TECHNI2 CIANS.—The Secretary, acting through the Service, Indian 

3 Tribes, and Tribal Organizations, shall supervise and 

4 evaluate the mental health technicians in the training pro5 gram. 

6 ‘‘(d) TRADITIONAL HEALTH CARE PRACTICES.—The 

7 Secretary, acting through the Service, shall ensure that 

8 the program established pursuant to this subsection in9 volves the use and promotion of the traditional health care 

10 practices of the Indian Tribes to be served. 

11 ‘‘SEC. 705. LICENSING REQUIREMENT FOR MENTAL 

12 HEALTH CARE WORKERS. 

13 ‘‘(a) IN GENERAL.—Subject to the provisions of sec14 tion 221, and except as provided in subsection (b), any 

15 individual employed as a psychologist, social worker, or 

16 marriage and family therapist for the purpose of providing 

17 mental health care services to Indians in a clinical setting 

18 under this Act is required to be licensed as a psychologist, 

19 social worker, or marriage and family therapist, respec20 tively. 

21 ‘‘(b) TRAINEES.—An individual may be employed as 

22 a trainee in psychology, social work, or marriage and fam23 ily therapy to provide mental health care services de24 scribed in subsection (a) if such individual—
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1 ‘‘(1) works under the direct supervision of a li2 censed psychologist, social worker, or marriage and 

3 family therapist, respectively; 

4 ‘‘(2) is enrolled in or has completed at least 2 

5 years of course work at a post-secondary, accredited 

6 education program for psychology, social work, mar7 riage and family therapy, or counseling; and 

8 ‘‘(3) meets such other training, supervision, and 

9 quality review requirements as the Secretary may es10 tablish. 

11 ‘‘SEC. 706. INDIAN WOMEN TREATMENT PROGRAMS. 

12 ‘‘(a) GRANTS.—The Secretary, consistent with sec13 tion 701, may make grants to Indian Tribes, Tribal Orga14 nizations, and Urban Indian Organizations to develop and 

15 implement a comprehensive behavioral health program of 

16 prevention, intervention, treatment, and relapse preven17 tion services that specifically addresses the cultural, his18 torical, social, and child care needs of Indian women, re19 gardless of age. 

20 ‘‘(b) USE OF GRANT FUNDS.—A grant made pursu21 ant to this section may be used to—

22 ‘‘(1) develop and provide community training, 

23 education, and prevention programs for Indian 

24 women relating to behavioral health issues, including 

25 fetal alcohol spectrum disorders; 
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1 ‘‘(2) identify and provide psychological services, 

2 counseling, advocacy, support, and relapse preven3 tion to Indian women and their families; and 

4 ‘‘(3) develop prevention and intervention models 

5 for Indian women which incorporate traditional 

6 health care practices, cultural values, and commu7 nity and family involvement. 

8 ‘‘(c) CRITERIA.—The Secretary, in consultation with 

9 Indian Tribes and Tribal Organizations, shall establish 

10 criteria for the review and approval of applications and 

11 proposals for funding under this section. 

12 ‘‘(d) ALLOCATION OF CERTAIN FUNDS.—Twenty 

13 percent of the funds appropriated pursuant to this section 

14 shall be used to make grants to Urban Indian Organiza15 tions. 

16 ‘‘SEC. 707. INDIAN YOUTH PROGRAM. 

17 ‘‘(a) DETOXIFICATION AND REHABILITATION.—The 

18 Secretary, acting through the Service, consistent with sec19 tion 701, shall develop and implement a program for acute 

20 detoxification and treatment for Indian youths, including 

21 behavioral health services. The program shall include re22 gional treatment centers designed to include detoxification 

23 and rehabilitation for both sexes on a referral basis and 

24 programs developed and implemented by Indian Tribes or 

25 Tribal Organizations at the local level under the Indian 
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1 Self-Determination and Education Assistance Act (25 

2 U.S.C. 450 et seq.). Regional centers shall be integrated 

3 with the intake and rehabilitation programs based in the 

4 referring Indian community. 

5 ‘‘(b) ALCOHOL AND SUBSTANCE ABUSE TREATMENT

6 CENTERS OR FACILITIES.—

7 ‘‘(1) ESTABLISHMENT.—

8 ‘‘(A) IN GENERAL.—The Secretary, acting 

9 through the Service, Indian Tribes, and Tribal 

10 Organizations, shall construct, renovate, or, as 

11 necessary, purchase, and appropriately staff 

12 and operate, at least 1 youth regional treatment 

13 center or treatment network in each area under 

14 the jurisdiction of an Area Office. 

15 ‘‘(B) AREA OFFICE IN CALIFORNIA.—For 

16 the purposes of this subsection, the Area Office 

17 in California shall be considered to be 2 Area 

18 Offices, 1 office whose jurisdiction shall be con19 sidered to encompass the northern area of the 

20 State of California, and 1 office whose jurisdic21 tion shall be considered to encompass the re22 mainder of the State of California for the pur23 pose of implementing California treatment net24 works. 
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1 ‘‘(2) FUNDING.—For the purpose of staffing 

2 and operating such centers or facilities, funding 

3 shall be pursuant to the Act of November 2, 1921 

4 (25 U.S.C. 13). 

5 ‘‘(3) LOCATION.—A youth treatment center 

6 constructed or purchased under this subsection shall 

7 be constructed or purchased at a location within the 

8 area described in paragraph (1) agreed upon (by ap9 propriate tribal resolution) by a majority of the In10 dian Tribes to be served by such center. 

11 ‘‘(4) SPECIFIC PROVISION OF FUNDS.—

12 ‘‘(A) IN GENERAL.—Notwithstanding any 

13 other provision of this title, the Secretary may, 

14 from amounts authorized to be appropriated for 

15 the purposes of carrying out this section, make 

16 funds available to—

17 ‘‘(i) the Tanana Chiefs Conference, 

18 Incorporated, for the purpose of leasing, 

19 constructing, renovating, operating, and 

20 maintaining a residential youth treatment 

21 facility in Fairbanks, Alaska; and 

22 ‘‘(ii) the Southeast Alaska Regional 

23 Health Corporation to staff and operate a 

24 residential youth treatment facility without 

25 regard to the proviso set forth in section 
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1 4(l) of the Indian Self-Determination and 

2 Education Assistance Act (25 U.S.C. 

3 450b(l)). 

4 ‘‘(B) PROVISION OF SERVICES TO ELIGI5 BLE YOUTHS.—Until additional residential 

6 youth treatment facilities are established in 

7 Alaska pursuant to this section, the facilities 

8 specified in subparagraph (A) shall make every 

9 effort to provide services to all eligible Indian 

10 youths residing in Alaska. 

11 ‘‘(c) INTERMEDIATE ADOLESCENT BEHAVIORAL

12 HEALTH SERVICES.—

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

14 through the Service, Indian Tribes, and Tribal Orga15 nizations, may provide intermediate behavioral 

16 health services to Indian children and adolescents, 

17 including—

18 ‘‘(A) pretreatment assistance; 

19 ‘‘(B) inpatient, outpatient, and aftercare 

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 ‘‘(D) to make renovations and hire appro16 priate staff to convert existing hospital beds 

17 into adolescent psychiatric units; and 

18 ‘‘(E) for intensive home- and community19 based services. 

20 ‘‘(3) CRITERIA.—The Secretary, acting through 

21 the Service, shall, in consultation with Indian Tribes 

22 and Tribal Organizations, establish criteria for the 

23 review and approval of applications or proposals for 

24 funding made available pursuant to this subsection. 

25 ‘‘(d) FEDERALLY-OWNED STRUCTURES.—
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1 ‘‘(1) IN GENERAL.—The Secretary, in consulta2 tion with Indian Tribes and Tribal Organizations, 

3 shall—

4 ‘‘(A) identify and use, where appropriate, 

5 federally-owned structures suitable for local res6 idential or regional behavioral health treatment 

7 for Indian youths; and 

8 ‘‘(B) establish guidelines for determining 

9 the suitability of any such federally-owned 

10 structure to be used for local residential or re11 gional behavioral health treatment for Indian 

12 youths. 

13 ‘‘(2) TERMS AND CONDITIONS FOR USE OF

14 STRUCTURE.—Any structure described in paragraph 

15 (1) may be used under such terms and conditions as 

16 may be agreed upon by the Secretary and the agency 

17 having responsibility for the structure and any In18 dian Tribe or Tribal Organization operating the pro19 gram. 

20 ‘‘(e) REHABILITATION AND AFTERCARE SERVICES.—

21 ‘‘(1) IN GENERAL.—The Secretary, Indian 

22 Tribes, or Tribal Organizations, in cooperation with 

23 the Secretary of the Interior, shall develop and im24 plement within each Service Unit, community-based 

25 rehabilitation and follow-up services for Indian 
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1 youths who are having significant behavioral health 

2 problems, and require long-term treatment, commu3 nity reintegration, and monitoring to support the In4 dian youths after their return to their home commu5 nity. 

6 ‘‘(2) ADMINISTRATION.—Services under para7 graph (1) shall be provided by trained staff within 

8 the community who can assist the Indian youths in 

9 their continuing development of self-image, positive 

10 problem-solving skills, and nonalcohol or substance 

11 abusing behaviors. Such staff may include alcohol 

12 and substance abuse counselors, mental health pro13 fessionals, and other health professionals and para14 professionals, including community health represent15 atives. 

16 ‘‘(f) INCLUSION OF FAMILY IN YOUTH TREATMENT

17 PROGRAM.—In providing the treatment and other services 

18 to Indian youths authorized by this section, the Secretary, 

19 acting through the Service, Indian Tribes, and Tribal Or20 ganizations, shall provide for the inclusion of family mem21 bers of such youths in the treatment programs or other 

22 services as may be appropriate. Not less than 10 percent 

23 of the funds appropriated for the purposes of carrying out 

24 subsection (e) shall be used for outpatient care of adult 
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1 family members related to the treatment of an Indian 

2 youth under that subsection. 

3 ‘‘(g) MULTIDRUG ABUSE PROGRAM.—The Secretary, 

4 acting through the Service, Indian Tribes, and Tribal Or5 ganizations, shall provide, consistent with section 701, 

6 programs and services to prevent and treat the abuse of 

7 multiple forms of substances, including alcohol, drugs, 

8 inhalants, and tobacco, among Indian youths residing in 

9 Indian communities, on or near reservations, and in urban 

10 areas and provide appropriate mental health services to 

11 address the incidence of mental illness among such youths. 

12 ‘‘(h) INDIAN YOUTH MENTAL HEALTH.—The Sec13 retary, acting through the Service, shall collect data for 

14 the report under section 801 with respect to—

15 ‘‘(1) the number of Indian youth who are being 

16 provided mental health services through the Service 

17 and Tribal Health Programs; 

18 ‘‘(2) a description of, and costs associated with, 

19 the mental health services provided for Indian youth 

20 through the Service and Tribal Health Programs; 

21 ‘‘(3) the number of youth referred to the Serv22 ice or Tribal Health Programs for mental health 

23 services; 

24 ‘‘(4) the number of Indian youth provided resi25 dential treatment for mental health and behavioral 
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1 problems through the Service and Tribal Health 

2 Programs, reported separately for on- and off-res3 ervation facilities; and 

4 ‘‘(5) the costs of the services described in para5 graph (4). 

6 ‘‘SEC. 708. INDIAN YOUTH TELEMENTAL HEALTH DEM7 ONSTRATION PROJECT. 

8 ‘‘(a) PURPOSE.—The purpose of this section is to au9 thorize the Secretary to carry out a demonstration project 

10 to test the use of telemental health services in suicide pre11 vention, intervention and treatment of Indian youth, in12 cluding through—

13 ‘‘(1) the use of psychotherapy, psychiatric as14 sessments, diagnostic interviews, therapies for men15 tal health conditions predisposing to suicide, and al16 cohol and substance abuse treatment; 

17 ‘‘(2) the provision of clinical expertise to, con18 sultation services with, and medical advice and train19 ing for frontline health care providers working with 

20 Indian youth; 

21 ‘‘(3) training and related support for commu22 nity leaders, family members and health and edu23 cation workers who work with Indian youth; 

24 ‘‘(4) the development of culturally-relevant edu25 cational materials on suicide; and 
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1 ‘‘(5) data collection and reporting. 

2 ‘‘(b) DEFINITIONS.—For the purpose of this section, 

3 the following definitions shall apply: 

4 ‘‘(1) DEMONSTRATION PROJECT.—The term 

5 ‘demonstration project’ means the Indian youth tele6 mental health demonstration project authorized 

7 under subsection (c). 

8 ‘‘(2) TELEMENTAL HEALTH.—The term ‘tele9 mental health’ means the use of electronic informa10 tion and telecommunications technologies to support 

11 long distance mental health care, patient and profes12 sional-related education, public health, and health 

13 administration. 

14 ‘‘(c) AUTHORIZATION.—

15 ‘‘(1) IN GENERAL.—The Secretary is authorized 

16 to award grants under the demonstration project for 

17 the provision of telemental health services to Indian 

18 youth who—

19 ‘‘(A) have expressed suicidal ideas; 

20 ‘‘(B) have attempted suicide; or 

21 ‘‘(C) have mental health conditions that in22 crease or could increase the risk of suicide. 

23 ‘‘(2) ELIGIBILITY FOR GRANTS.—Such grants 

24 shall be awarded to Indian Tribes and Tribal Orga25 nizations that operate 1 or more facilities—
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1 ‘‘(A) located in Alaska and part of the 

2 Alaska Federal Health Care Access Network; 

3 ‘‘(B) reporting active clinical telehealth ca4 pabilities; or 

5 ‘‘(C) offering school-based telemental 

6 health services relating to psychiatry to Indian 

7 youth. 

8 ‘‘(3) GRANT PERIOD.—The Secretary shall 

9 award grants under this section for a period of up 

10 to 4 years. 

11 ‘‘(4) AWARDING OF GRANTS.—Not more than 5 

12 grants shall be provided under paragraph (1), with 

13 priority consideration given to Indian Tribes and 

14 Tribal Organizations that—

15 ‘‘(A) serve a particular community or geo16 graphic area where there is a demonstrated 

17 need to address Indian youth suicide; 

18 ‘‘(B) enter in to collaborative partnerships 

19 with Indian Health Service or Tribal Health 

20 Programs or facilities to provide services under 

21 this demonstration project; 

22 ‘‘(C) serve an isolated community or geo23 graphic area which has limited or no access to 

24 behavioral health services; or 
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1 ‘‘(D) operate a detention facility at which 

2 Indian youth are detained. 

3 ‘‘(d) USE OF FUNDS.—

4 ‘‘(1) IN GENERAL.—An Indian Tribe or Tribal 

5 Organization shall use a grant received under sub6 section (c) for the following purposes: 

7 ‘‘(A) To provide telemental health services 

8 to Indian youth, including the provision of—

9 ‘‘(i) psychotherapy; 

10 ‘‘(ii) psychiatric assessments and di11 agnostic interviews, therapies for mental 

12 health conditions predisposing to suicide, 

13 and treatment; and 

14 ‘‘(iii) alcohol and substance abuse 

15 treatment. 

16 ‘‘(B) To provide clinician-interactive med17 ical advice, guidance and training, assistance in 

18 diagnosis and interpretation, crisis counseling 

19 and intervention, and related assistance to 

20 Service, tribal, or urban clinicians and health 

21 services providers working with youth being 

22 served under this demonstration project. 

23 ‘‘(C) To assist, educate and train commu24 nity leaders, health education professionals and 

25 paraprofessionals, tribal outreach workers, and 
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1 family members who work with the youth re2 ceiving telemental health services under this 

3 demonstration project, including with identifica4 tion of suicidal tendencies, crisis intervention 

5 and suicide prevention, emergency skill develop6 ment, and building and expanding networks 

7 among these individuals and with State and 

8 local health services providers. 

9 ‘‘(D) To develop and distribute culturally 

10 appropriate community educational materials 

11 on—

12 ‘‘(i) suicide prevention; 

13 ‘‘(ii) suicide education; 

14 ‘‘(iii) suicide screening; 

15 ‘‘(iv) suicide intervention; and 

16 ‘‘(v) ways to mobilize communities 

17 with respect to the identification of risk 

18 factors for suicide. 

19 ‘‘(E) For data collection and reporting re20 lated to Indian youth suicide prevention efforts. 

21 ‘‘(2) TRADITIONAL HEALTH CARE PRAC22 TICES.—In carrying out the purposes described in 

23 paragraph (1), an Indian Tribe or Tribal Organiza24 tion may use and promote the traditional health care 
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1 practices of the Indian Tribes of the youth to be 

2 served. 

3 ‘‘(e) APPLICATIONS.—To be eligible to receive a grant 

4 under subsection (c), an Indian Tribe or Tribal Organiza5 tion shall prepare and submit to the Secretary an applica6 tion, at such time, in such manner, and containing such 

7 information as the Secretary may require, including—

8 ‘‘(1) a description of the project that the Indian 

9 Tribe or Tribal Organization will carry out using the 

10 funds provided under the grant; 

11 ‘‘(2) a description of the manner in which the 

12 project funded under the grant would—

13 ‘‘(A) meet the telemental health care needs 

14 of the Indian youth population to be served by 

15 the project; or 

16 ‘‘(B) improve the access of the Indian 

17 youth population to be served to suicide preven18 tion and treatment services; 

19 ‘‘(3) evidence of support for the project from 

20 the local community to be served by the project; 

21 ‘‘(4) a description of how the families and lead22 ership of the communities or populations to be 

23 served by the project would be involved in the devel24 opment and ongoing operations of the project; 
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1 ‘‘(5) a plan to involve the tribal community of 

2 the youth who are provided services by the project 

3 in planning and evaluating the mental health care 

4 and suicide prevention efforts provided, in order to 

5 ensure the integration of community, clinical, envi6 ronmental, and cultural components of the treat7 ment; and 

8 ‘‘(6) a plan for sustaining the project after Fed9 eral assistance for the demonstration project has ter10 minated. 

11 ‘‘(f) COLLABORATION; REPORTING TO NATIONAL

12 CLEARINGHOUSE.—

13 ‘‘(1) COLLABORATION.—The Secretary, acting 

14 through the Service, shall encourage Indian Tribes 

15 and Tribal Organizations receiving grants under this 

16 section to collaborate to enable comparisons about 

17 best practices across projects. 

18 ‘‘(2) REPORTING TO NATIONAL CLEARING19 HOUSE.—The Secretary, acting through the Service, 

20 shall also encourage Indian Tribes and Tribal Orga21 nizations receiving grants under this section to sub22 mit relevant, declassified project information to the 

23 national clearinghouse authorized under section 

24 701(b)(2) in order to better facilitate program per-
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1 formance and improve suicide prevention, interven2 tion, and treatment services. 

3 ‘‘(g) ANNUAL REPORT.—Each grant recipient shall 

4 submit to the Secretary an annual report that—

5 ‘‘(1) describes the number of telemental health 

6 services provided; and 

7 ‘‘(2) includes any other information that the 

8 Secretary may require. 

9 ‘‘(h) REPORT TO CONGRESS.—Not later than 270 

10 days after the termination of the demonstration project, 

11 the Secretary shall submit to the Committee on Indian Af12 fairs of the Senate and the Committee on Natural Re13 sources and Committee on Energy and Commerce of the 

14 House of Representatives a final report, based on the an15 nual reports provided by grant recipients under subsection 

16 (h), that—

17 ‘‘(1) describes the results of the projects funded 

18 by grants awarded under this section, including any 

19 data available which indicates the number of at20 tempted suicides; 

21 ‘‘(2) evaluates the impact of the telemental 

22 health services funded by the grants in reducing the 

23 number of completed suicides among Indian youth; 

24 ‘‘(3) evaluates whether the demonstration 

25 project should be—
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1 ‘‘(A) expanded to provide more than 5 

2 grants; and 

3 ‘‘(B) designated a permanent program; 

4 and 

5 ‘‘(4) evaluates the benefits of expanding the 

6 demonstration project to include Urban Indian Or7 ganizations. 

8 ‘‘(i) AUTHORIZATION OF APPROPRIATIONS.—There is 

9 authorized to be appropriated to carry out this section 

10 $1,500,000 for each of fiscal years 2008 through 2011. 

11 ‘‘SEC. 709. INPATIENT AND COMMUNITY-BASED MENTAL 

12 HEALTH FACILITIES DESIGN, CONSTRUC13 TION, AND STAFFING. 

14 ‘‘Not later than 1 year after the date of enactment 

15 of the Indian Health Care Improvement Act Amendments 

16 of 2008, the Secretary, acting through the Service, Indian 

17 Tribes, and Tribal Organizations, may provide, in each 

18 area of the Service, not less than 1 inpatient mental health 

19 care facility, or the equivalent, for Indians with behavioral 

20 health problems. For the purposes of this subsection, Cali21 fornia shall be considered to be 2 Area Offices, 1 office 

22 whose location shall be considered to encompass the north23 ern area of the State of California and 1 office whose ju24 risdiction shall be considered to encompass the remainder 

25 of the State of California. The Secretary shall consider 
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1 the possible conversion of existing, underused Service hos2 pital beds into psychiatric units to meet such need. 

3 ‘‘SEC. 710. TRAINING AND COMMUNITY EDUCATION. 

4 ‘‘(a) PROGRAM.—The Secretary, in cooperation with 

5 the Secretary of the Interior, shall develop and implement 

6 or assist Indian Tribes and Tribal Organizations to de7 velop and implement, within each Service Unit or tribal 

8 program, a program of community education and involve9 ment which shall be designed to provide concise and timely 

10 information to the community leadership of each tribal 

11 community. Such program shall include education about 

12 behavioral health issues to political leaders, Tribal judges, 

13 law enforcement personnel, members of tribal health and 

14 education boards, health care providers including tradi15 tional practitioners, and other critical members of each 

16 tribal community. Such program may also include commu17 nity-based training to develop local capacity and tribal 

18 community provider training for prevention, intervention, 

19 treatment, and aftercare. 

20 ‘‘(b) INSTRUCTION.—The Secretary, acting through 

21 the Service, shall, either directly or through Indian Tribes 

22 and Tribal Organizations, provide instruction in the area 

23 of behavioral health issues, including instruction in crisis 

24 intervention and family relations in the context of alcohol 

25 and substance abuse, child sexual abuse, youth alcohol and 
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1 substance abuse, and the causes and effects of fetal alco2 hol spectrum disorders to appropriate employees of the 

3 Bureau of Indian Affairs and the Service, and to personnel 

4 in schools or programs operated under any contract with 

5 the Bureau of Indian Affairs or the Service, including su6 pervisors of emergency shelters and halfway houses de7 scribed in section 4213 of the Indian Alcohol and Sub8 stance Abuse Prevention and Treatment Act of 1986 (25 

9 U.S.C. 2433). 

10 ‘‘(c) TRAINING MODELS.—In carrying out the edu11 cation and training programs required by this section, the 

12 Secretary, in consultation with Indian Tribes, Tribal Or13 ganizations, Indian behavioral health experts, and Indian 

14 alcohol and substance abuse prevention experts, shall de15 velop and provide community-based training models. Such 

16 models shall address—

17 ‘‘(1) the elevated risk of alcohol and behavioral 

18 health problems faced by children of alcoholics; 

19 ‘‘(2) the cultural, spiritual, and 

20 multigenerational aspects of behavioral health prob21 lem prevention and recovery; and 

22 ‘‘(3) community-based and multidisciplinary 

23 strategies for preventing and treating behavioral 

24 health problems. 
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1 ‘‘SEC. 711. BEHAVIORAL HEALTH PROGRAM. 

2 ‘‘(a) INNOVATIVE PROGRAMS.—The Secretary, acting 

3 through the Service, Indian Tribes, and Tribal Organiza4 tions, consistent with section 701, may plan, develop, im5 plement, and carry out programs to deliver innovative 

6 community-based behavioral health services to Indians. 

7 ‘‘(b) AWARDS; CRITERIA.—The Secretary may award 

8 a grant for a project under subsection (a) to an Indian 

9 Tribe or Tribal Organization and may consider the fol10 lowing criteria: 

11 ‘‘(1) The project will address significant unmet 

12 behavioral health needs among Indians. 

13 ‘‘(2) The project will serve a significant number 

14 of Indians. 

15 ‘‘(3) The project has the potential to deliver 

16 services in an efficient and effective manner. 

17 ‘‘(4) The Indian Tribe or Tribal Organization 

18 has the administrative and financial capability to ad19 minister the project. 

20 ‘‘(5) The project may deliver services in a man21 ner consistent with traditional health care practices. 

22 ‘‘(6) The project is coordinated with, and avoids 

23 duplication of, existing services. 

24 ‘‘(c) EQUITABLE TREATMENT.—For purposes of this 

25 subsection, the Secretary shall, in evaluating project appli26 cations or proposals, use the same criteria that the Sec-
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1 retary uses in evaluating any other application or proposal 

2 for such funding. 

3 ‘‘SEC. 712. FETAL ALCOHOL SPECTRUM DISORDERS PRO4 GRAMS. 

5 ‘‘(a) PROGRAMS.—

6 ‘‘(1) ESTABLISHMENT.—The Secretary, con7 sistent with section 701, acting through the Service, 

8 Indian Tribes, and Tribal Organizations, is author9 ized to establish and operate fetal alcohol spectrum 

10 disorders programs as provided in this section for 

11 the purposes of meeting the health status objectives 

12 specified in section 3. 

13 ‘‘(2) USE OF FUNDS.—

14 ‘‘(A) IN GENERAL.—Funding provided 

15 pursuant to this section shall be used for the 

16 following: 

17 ‘‘(i) To develop and provide for Indi18 ans community and in-school training, edu19 cation, and prevention programs relating 

20 to fetal alcohol spectrum disorders. 

21 ‘‘(ii) To identify and provide behav22 ioral health treatment to high-risk Indian 

23 women and high-risk women pregnant with 

24 an Indian’s child. 
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1 ‘‘(iii) To identify and provide appro2 priate psychological services, educational 

3 and vocational support, counseling, advo4 cacy, and information to fetal alcohol spec5 trum disorders-affected Indians and their 

6 families or caretakers. 

7 ‘‘(iv) To develop and implement coun8 seling and support programs in schools for 

9 fetal alcohol spectrum disorders-affected 

10 Indian children. 

11 ‘‘(v) To develop prevention and inter12 vention models which incorporate practi13 tioners of traditional health care practices, 

14 cultural values, and community involve15 ment. 

16 ‘‘(vi) To develop, print, and dissemi17 nate education and prevention materials on 

18 fetal alcohol spectrum disorders. 

19 ‘‘(vii) To develop and implement, in 

20 consultation with Indian Tribes and Tribal 

21 Organizations, and in conference with 

22 Urban Indian Organizations, culturally 

23 sensitive assessment and diagnostic tools 

24 including dysmorphology clinics and multi25 disciplinary fetal alcohol spectrum dis-
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1 orders clinics for use in Indian commu2 nities and Urban Centers. 

3 ‘‘(B) ADDITIONAL USES.—In addition to 

4 any purpose under subparagraph (A), funding 

5 provided pursuant to this section may be used 

6 for 1 or more of the following: 

7 ‘‘(i) Early childhood intervention 

8 projects from birth on to mitigate the ef9 fects of fetal alcohol spectrum disorders 

10 among Indians. 

11 ‘‘(ii) Community-based support serv12 ices for Indians and women pregnant with 

13 Indian children. 

14 ‘‘(iii) Community-based housing for 

15 adult Indians with fetal alcohol spectrum 

16 disorders. 

17 ‘‘(3) CRITERIA FOR APPLICATIONS.—The Sec18 retary shall establish criteria for the review and ap19 proval of applications for funding under this section. 

20 ‘‘(b) SERVICES.—The Secretary, acting through the 

21 Service, Indian Tribes, and Tribal Organizations, shall—

22 ‘‘(1) develop and provide services for the pre23 vention, intervention, treatment, and aftercare for 

24 those affected by fetal alcohol spectrum disorders in 

25 Indian communities; and 
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1 ‘‘(2) provide supportive services, including serv2 ices to meet the special educational, vocational, 

3 school-to-work transition, and independent living 

4 needs of adolescent and adult Indians with fetal al5 cohol spectrum disorders. 

6 ‘‘(c) TASK FORCE.—The Secretary shall establish a 

7 task force to be known as the Fetal Alcohol Spectrum Dis8 orders Task Force to advise the Secretary in carrying out 

9 subsection (b). Such task force shall be composed of rep10 resentatives from the following: 

11 ‘‘(1) The National Institute on Drug Abuse. 

12 ‘‘(2) The National Institute on Alcohol and Al13 coholism. 

14 ‘‘(3) The Office of Substance Abuse Prevention. 

15 ‘‘(4) The National Institute of Mental Health. 

16 ‘‘(5) The Service. 

17 ‘‘(6) The Office of Minority Health of the De18 partment of Health and Human Services. 

19 ‘‘(7) The Administration for Native Americans. 

20 ‘‘(8) The National Institute of Child Health 

21 and Human Development (NICHD). 

22 ‘‘(9) The Centers for Disease Control and Pre23 vention. 

24 ‘‘(10) The Bureau of Indian Affairs. 

25 ‘‘(11) Indian Tribes. 
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1 ‘‘(12) Tribal Organizations. 

2 ‘‘(13) Urban Indian communities. 

3 ‘‘(14) Indian fetal alcohol spectrum disorders 

4 experts. 

5 ‘‘(d) APPLIED RESEARCH PROJECTS.—The Sec6 retary, acting through the Substance Abuse and Mental 

7 Health Services Administration, shall make grants to In8 dian Tribes, Tribal Organizations, and Urban Indian Or9 ganizations for applied research projects which propose to 

10 elevate the understanding of methods to prevent, inter11 vene, treat, or provide rehabilitation and behavioral health 

12 aftercare for Indians and Urban Indians affected by fetal 

13 alcohol spectrum disorders. 

14 ‘‘(e) FUNDING FOR URBAN INDIAN ORGANIZA15 TIONS.—Ten percent of the funds appropriated pursuant 

16 to this section shall be used to make grants to Urban In17 dian Organizations funded under title V. 

18 ‘‘SEC. 713. CHILD SEXUAL ABUSE PREVENTION AND TREAT19 MENT PROGRAMS. 

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

21 through the Service, and the Secretary of the Interior, In22 dian Tribes, and Tribal Organizations, shall establish, 

23 consistent with section 701, in every Service Area, pro24 grams involving treatment for victims of sexual abuse who 

25 are Indian children or children in an Indian household. 
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1 ‘‘(b) USE OF FUNDS.—Funding provided pursuant to 

2 this section shall be used for the following: 

3 ‘‘(1) To develop and provide community edu4 cation and prevention programs related to sexual 

5 abuse of Indian children or children in an Indian 

6 household. 

7 ‘‘(2) To identify and provide behavioral health 

8 treatment to victims of sexual abuse who are Indian 

9 children or children in an Indian household, and to 

10 their family members who are affected by sexual 

11 abuse. 

12 ‘‘(3) To develop prevention and intervention 

13 models which incorporate traditional health care 

14 practices, cultural values, and community involve15 ment. 

16 ‘‘(4) To develop and implement culturally sen17 sitive assessment and diagnostic tools for use in In18 dian communities and Urban Centers. 

19 ‘‘(5) To identify and provide behavioral health 

20 treatment to Indian perpetrators and perpetrators 

21 who are members of an Indian household—

22 ‘‘(A) making efforts to begin offender and 

23 behavioral health treatment while the perpe24 trator is incarcerated or at the earliest possible 

25 date if the perpetrator is not incarcerated; and 
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1 ‘‘(B) providing treatment after the perpe2 trator is released, until it is determined that the 

3 perpetrator is not a threat to children. 

4 ‘‘(c) COORDINATION.—The programs established 

5 under subsection (a) shall be carried out in coordination 

6 with programs and services authorized under the Indian 

7 Child Protection and Family Violence Prevention Act (25 

8 U.S.C. 3201 et seq.). 

9 ‘‘SEC. 714. DOMESTIC AND SEXUAL VIOLENCE PREVENTION 

10 AND TREATMENT. 

11 ‘‘(a) IN GENERAL.—The Secretary, in accordance 

12 with section 701, is authorized to establish in each Service 

13 Area programs involving the prevention and treatment 

14 of—

15 ‘‘(1) Indian victims of domestic violence or sex16 ual abuse; and 

17 ‘‘(2) perpetrators of domestic violence or sexual 

18 abuse who are Indian or members of an Indian 

19 household. 

20 ‘‘(b) USE OF FUNDS.—Funds made available to carry 

21 out this section shall be used—

22 ‘‘(1) to develop and implement prevention pro23 grams and community education programs relating 

24 to domestic violence and sexual abuse; 
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1 ‘‘(2) to provide behavioral health services, in2 cluding victim support services, and medical treat3 ment (including examinations performed by sexual 

4 assault nurse examiners) to Indian victims of domes5 tic violence or sexual abuse; 

6 ‘‘(3) to purchase rape kits, 

7 ‘‘(4) to develop prevention and intervention 

8 models, which may incorporate traditional health 

9 care practices; and 

10 ‘‘(5) to identify and provide behavioral health 

11 treatment to perpetrators who are Indian or mem12 bers of an Indian household. 

13 ‘‘(c) TRAINING AND CERTIFICATION.—

14 ‘‘(1) IN GENERAL.—Not later than 1 year after 

15 the date of enactment of the Indian Health Care Im16 provement Act Amendments of 2008, the Secretary 

17 shall establish appropriate protocols, policies, proce18 dures, standards of practice, and, if not available 

19 elsewhere, training curricula and training and cer20 tification requirements for services for victims of do21 mestic violence and sexual abuse. 

22 ‘‘(2) REPORT.—Not later than 18 months after 

23 the date of enactment of the Indian Health Care Im24 provement Act Amendments of 2008, the Secretary 

25 shall submit to the Committee on Indian Affairs of 
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1 the Senate and the Committee on Natural Resources 

2 of the House of Representatives a report that de3 scribes the means and extent to which the Secretary 

4 has carried out paragraph (1). 

5 ‘‘(d) COORDINATION.—

6 ‘‘(1) IN GENERAL.—The Secretary, in coordina7 tion with the Attorney General, Federal and tribal 

8 law enforcement agencies, Indian Health Programs, 

9 and domestic violence or sexual assault victim orga10 nizations, shall develop appropriate victim services 

11 and victim advocate training programs—

12 ‘‘(A) to improve domestic violence or sex13 ual abuse responses; 

14 ‘‘(B) to improve forensic examinations and 

15 collection; 

16 ‘‘(C) to identify problems or obstacles in 

17 the prosecution of domestic violence or sexual 

18 abuse; and 

19 ‘‘(D) to meet other needs or carry out 

20 other activities required to prevent, treat, and 

21 improve prosecutions of domestic violence and 

22 sexual abuse. 

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

24 date of enactment of the Indian Health Care Im25 provement Act Amendments of 2008, the Secretary 
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1 shall submit to the Committee on Indian Affairs of 

2 the Senate and the Committee on Natural Resources 

3 of the House of Representatives a report that de4 scribes, with respect to the matters described in 

5 paragraph (1), the improvements made and needed, 

6 problems or obstacles identified, and costs necessary 

7 to address the problems or obstacles, and any other 

8 recommendations that the Secretary determines to 

9 be appropriate. 

10 ‘‘SEC. 715. TESTIMONY BY SERVICE EMPLOYEES IN CASES 

11 OF RAPE AND SEXUAL ASSAULT. 

12 ‘‘(a) APPROVAL BY DIRECTOR.—

13 ‘‘(1) IN GENERAL.—The Director shall approve 

14 or disapprove, in writing, any request or subpoena 

15 for a sexual assault nurse examiner employed by the 

16 Service to provide testimony in a deposition, trial, or 

17 other similar proceeding regarding information ob18 tained in carrying out the official duties of the nurse 

19 examiner. 

20 ‘‘(2) REQUIREMENT.—The Director shall ap21 prove a request or subpoena under paragraph (1) if 

22 the request or subpoena does not violate the policy 

23 of the Department to maintain strict impartiality 

24 with respect to private causes of action. 
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1 ‘‘(3) TREATMENT.—If the Director fails to ap2 prove or disapprove a request or subpoena by the 

3 date that is 30 days after the date of receipt of the 

4 request or subpoena, the request or subpoena shall 

5 be considered to be approved for purposes of this 

6 subsection. 

7 ‘‘(b) POLICIES AND PROTOCOL.—The Director, in co8 ordination with the Director of the Office on Violence 

9 Against Women of the Department of Justice, in consulta10 tion with Indian Tribes and Tribal Organizations, and in 

11 conference with Urban Indian Organizations, shall develop 

12 standardized sexual assault policies and protocol for the 

13 facilities of the Service. 

14 ‘‘SEC. 716. BEHAVIORAL HEALTH RESEARCH. 

15 ‘‘The Secretary, in consultation with appropriate 

16 Federal agencies, shall make grants to, or enter into con17 tracts with, Indian Tribes, Tribal Organizations, and 

18 Urban Indian Organizations or enter into contracts with, 

19 or make grants to appropriate institutions for, the conduct 

20 of research on the incidence and prevalence of behavioral 

21 health problems among Indians served by the Service, In22 dian Tribes, or Tribal Organizations and among Indians 

23 in urban areas. Research priorities under this section shall 

24 include—
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1 ‘‘(1) the multifactorial causes of Indian youth 

2 suicide, including—

3 ‘‘(A) protective and risk factors and sci4 entific data that identifies those factors; and 

5 ‘‘(B) the effects of loss of cultural identity 

6 and the development of scientific data on those 

7 effects; 

8 ‘‘(2) the interrelationship and interdependence 

9 of behavioral health problems with alcoholism and 

10 other substance abuse, suicide, homicides, other in11 juries, and the incidence of family violence; and 

12 ‘‘(3) the development of models of prevention 

13 techniques. 

14 The effect of the interrelationships and interdependencies 

15 referred to in paragraph (2) on children, and the develop16 ment of prevention techniques under paragraph (3) appli17 cable to children, shall be emphasized. 

18 ‘‘SEC. 717. DEFINITIONS. 

19 ‘‘For the purpose of this title, the following defini20 tions shall apply: 

21 ‘‘(1) ASSESSMENT.—The term ‘assessment’ 

22 means the systematic collection, analysis, and dis23 semination of information on health status, health 

24 needs, and health problems. 
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1 ‘‘(2) ALCOHOL-RELATED

2 NEURODEVELOPMENTAL DISORDERS OR ARND.—The 

3 term ‘alcohol-related neurodevelopmental disorders’ 

4 or ‘ARND’ means any 1 of a spectrum of effects 

5 that—

6 ‘‘(A) may occur when a woman drinks al7 cohol during pregnancy; and 

8 ‘‘(B) involves a central nervous system ab9 normality that may be structural, neurological, 

10 or functional. 

11 ‘‘(3) BEHAVIORAL HEALTH AFTERCARE.—The 

12 term ‘behavioral health aftercare’ includes those ac13 tivities and resources used to support recovery fol14 lowing inpatient, residential, intensive substance 

15 abuse, or mental health outpatient or outpatient 

16 treatment. The purpose is to help prevent or deal 

17 with relapse by ensuring that by the time a client or 

18 patient is discharged from a level of care, such as 

19 outpatient treatment, an aftercare plan has been de20 veloped with the client. An aftercare plan may use 

21 such resources as a community-based therapeutic 

22 group, transitional living facilities, a 12-step spon23 sor, a local 12-step or other related support group, 

24 and other community-based providers. 
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1 ‘‘(4) DUAL DIAGNOSIS.—The term ‘dual diag2 nosis’ means coexisting substance abuse and mental 

3 illness conditions or diagnosis. Such clients are 

4 sometimes referred to as mentally ill chemical abus5 ers (MICAs). 

6 ‘‘(5) FETAL ALCOHOL SPECTRUM DIS7 ORDERS.—

8 ‘‘(A) IN GENERAL.—The term ‘fetal alco9 hol spectrum disorders’ includes a range of ef10 fects that can occur in an individual whose 

11 mother drank alcohol during pregnancy, includ12 ing physical, mental, behavioral, and/or learning 

13 disabilities with possible lifelong implications. 

14 ‘‘(B) INCLUSIONS.—The term ‘fetal alcohol 

15 spectrum disorders’ may include—

16 ‘‘(i) fetal alcohol syndrome (FAS); 

17 ‘‘(ii) fetal alcohol effect (FAE); 

18 ‘‘(iii) alcohol-related birth defects; and 

19 ‘‘(iv) alcohol-related 

20 neurodevelopmental disorders (ARND). 

21 ‘‘(6) FETAL ALCOHOL SYNDROME OR FAS.—

22 The term ‘fetal alcohol syndrome’ or ‘FAS’ means 

23 any 1 of a spectrum of effects that may occur when 

24 a woman drinks alcohol during pregnancy, the diag-
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1 nosis of which involves the confirmed presence of the 

2 following 3 criteria: 

3 ‘‘(A) Craniofacial abnormalities. 

4 ‘‘(B) Growth deficits. 

5 ‘‘(C) Central nervous system abnormalities. 

6 ‘‘(7) REHABILITATION.—The term ‘rehabilita7 tion’ means to restore the ability or capacity to en8 gage in usual and customary life activities through 

9 education and therapy. 

10 ‘‘(8) SUBSTANCE ABUSE.—The term ‘substance 

11 abuse’ includes inhalant abuse. 

12 ‘‘SEC. 718. AUTHORIZATION OF APPROPRIATIONS. 

13 ‘‘There is authorized to be appropriated such sums 

14 as may be necessary for each fiscal year through fiscal 

15 year 2017 to carry out the provisions of this title. 

16 ‘‘TITLE VIII—MISCELLANEOUS 

17 ‘‘SEC. 801. REPORTS. 

18 ‘‘For each fiscal year following the date of enactment 

19 of the Indian Health Care Improvement Act Amendments 

20 of 2008, the Secretary shall transmit to Congress a report 

21 containing the following: 

22 ‘‘(1) A report on the progress made in meeting 

23 the objectives of this Act, including a review of pro24 grams established or assisted pursuant to this Act 

25 and assessments and recommendations of additional 
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1 programs or additional assistance necessary to, at a 

2 minimum, provide health services to Indians and en3 sure a health status for Indians, which are at a par4 ity with the health services available to and the 

5 health status of the general population. 

6 ‘‘(2) A report on whether, and to what extent, 

7 new national health care programs, benefits, initia8 tives, or financing systems have had an impact on 

9 the purposes of this Act and any steps that the Sec10 retary may have taken to consult with Indian Tribes, 

11 Tribal Organizations, and Urban Indian Organiza12 tions to address such impact, including a report on 

13 proposed changes in allocation of funding pursuant 

14 to section 808. 

15 ‘‘(3) A report on the use of health services by 

16 Indians—

17 ‘‘(A) on a national and area or other rel18 evant geographical basis; 

19 ‘‘(B) by gender and age; 

20 ‘‘(C) by source of payment and type of 

21 service; 

22 ‘‘(D) comparing such rates of use with 

23 rates of use among comparable non-Indian pop24 ulations; and 

25 ‘‘(E) provided under contracts. 
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1 ‘‘(4) A report of contractors to the Secretary on 

2 Health Care Educational Loan Repayments every 6 

3 months required by section 110. 

4 ‘‘(5) A general audit report of the Secretary on 

5 the Health Care Educational Loan Repayment Pro6 gram as required by section 110(n). 

7 ‘‘(6) A report of the findings and conclusions of 

8 demonstration programs on development of edu9 cational curricula for substance abuse counseling as 

10 required in section 125(f). 

11 ‘‘(7) A separate statement which specifies the 

12 amount of funds requested to carry out the provi13 sions of section 201. 

14 ‘‘(8) A report of the evaluations of health pro15 motion and disease prevention as required in section 

16 203(c). 

17 ‘‘(9) A biennial report to Congress on infectious 

18 diseases as required by section 212. 

19 ‘‘(10) A report on environmental and nuclear 

20 health hazards as required by section 215. 

21 ‘‘(11) An annual report on the status of all 

22 health care facilities needs as required by section 

23 301(c)(2)(B) and 301(d). 

24 ‘‘(12) Reports on safe water and sanitary waste 

25 disposal facilities as required by section 302(h). 
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1 ‘‘(13) An annual report on the expenditure of 

2 non-Service funds for renovation as required by sec3 tions 304(b)(2). 

4 ‘‘(14) A report identifying the backlog of main5 tenance and repair required at Service and tribal fa6 cilities required by section 313(a). 

7 ‘‘(15) A report providing an accounting of reim8 bursement funds made available to the Secretary 

9 under titles XVIII, XIX, and XXI of the Social Se10 curity Act. 

11 ‘‘(16) A report on any arrangements for the 

12 sharing of medical facilities or services, as author13 ized by section 406. 

14 ‘‘(17) A report on evaluation and renewal of 

15 Urban Indian programs under section 505. 

16 ‘‘(18) A report on the evaluation of programs 

17 as required by section 513(d). 

18 ‘‘(19) A report on alcohol and substance abuse 

19 as required by section 701(f). 

20 ‘‘(20) A report on Indian youth mental health 

21 services as required by section 707(h). 

22 ‘‘(21) A report on the reallocation of base re23 sources if required by section 808. 

24 ‘‘SEC. 802. REGULATIONS. 

25 ‘‘(a) DEADLINES.—
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1 ‘‘(1) PROCEDURES.—Not later than 90 days 

2 after the date of enactment of the Indian Health 

3 Care Improvement Act Amendments of 2008, the 

4 Secretary shall initiate procedures under subchapter 

5 III of chapter 5 of title 5, United States Code, to 

6 negotiate and promulgate such regulations or 

7 amendments thereto that are necessary to carry out 

8 titles II (except section 202) and VII, the sections 

9 of title III for which negotiated rulemaking is spe10 cifically required, and section 807. Unless otherwise 

11 required, the Secretary may promulgate regulations 

12 to carry out titles I, III, IV, and V, and section 202, 

13 using the procedures required by chapter V of title 

14 5, United States Code (commonly known as the ‘Ad15 ministrative Procedure Act’). 

16 ‘‘(2) PROPOSED REGULATIONS.—Proposed reg17 ulations to implement this Act shall be published in 

18 the Federal Register by the Secretary no later than 

19 2 years after the date of enactment of the Indian 

20 Health Care Improvement Act Amendments of 2008 

21 and shall have no less than a 120-day comment pe22 riod. 

23 ‘‘(3) FINAL REGULATIONS.—The Secretary 

24 shall publish in the Federal Register final regula25 tions to implement this Act by not later than 3 years 
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1 after the date of enactment of the Indian Health 

2 Care Improvement Act Amendments of 2008. 

3 ‘‘(b) COMMITTEE.—A negotiated rulemaking com4 mittee established pursuant to section 565 of title 5, 

5 United States Code, to carry out this section shall have 

6 as its members only representatives of the Federal Gov7 ernment and representatives of Indian Tribes, and Tribal 

8 Organizations, a majority of whom shall be nominated by 

9 and be representatives of Indian Tribes and Tribal Orga10 nizations from each Service Area. 

11 ‘‘(c) ADAPTATION OF PROCEDURES.—The Secretary 

12 shall adapt the negotiated rulemaking procedures to the 

13 unique context of self-governance and the government-to14 government relationship between the United States and 

15 Indian Tribes. 

16 ‘‘(d) LACK OF REGULATIONS.—The lack of promul17 gated regulations shall not limit the effect of this Act. 

18 ‘‘(e) INCONSISTENT REGULATIONS.—The provisions 

19 of this Act shall supersede any conflicting provisions of 

20 law in effect on the day before the date of enactment of 

21 the Indian Health Care Improvement Act Amendments of 

22 2008, and the Secretary is authorized to repeal any regu23 lation inconsistent with the provisions of this Act. 
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1 ‘‘SEC. 803. PLAN OF IMPLEMENTATION. 

2 ‘‘Not later than 9 months after the date of enactment 

3 of the Indian Health Care Improvement Act Amendments 

4 of 2008, the Secretary, in consultation with Indian Tribes 

5 and Tribal Organizations, and in conference with Urban 

6 Indian Organizations, shall submit to Congress a plan ex7 plaining the manner and schedule, by title and section, 

8 by which the Secretary will implement the provisions of 

9 this Act. This consultation may be conducted jointly with 

10 the annual budget consultation pursuant to the Indian 

11 Self-Determination and Education Assistance Act (25 

12 U.S.C. 450 et seq). 

13 ‘‘SEC. 804. AVAILABILITY OF FUNDS. 

14 ‘‘The funds appropriated pursuant to this Act shall 

15 remain available until expended. 

16 ‘‘SEC. 805. LIMITATION RELATING TO ABORTION. 

17 ‘‘(a) DEFINITION OF HEALTH BENEFITS COV18 ERAGE.—In this section, the term ‘health benefits cov19 erage’ means a health-related service or group of services 

20 provided pursuant to a contract, compact, grant, or other 

21 agreement. 

22 ‘‘(b) LIMITATION.—

23 ‘‘(1) IN GENERAL.—Except as provided in para24 graph (2), no funds or facilities of the Service may 

25 be used—

26 ‘‘(A) to provide any abortion; or 
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1 ‘‘(B) to provide, or pay any administrative 

2 cost of, any health benefits coverage that in3 cludes coverage of an abortion. 

4 ‘‘(2) EXCEPTIONS.—The limitation described in 

5 paragraph (1) shall not apply in any case in which—

6 ‘‘(A) a pregnancy is the result of an act of 

7 rape, or an act of incest against a minor; or 

8 ‘‘(B) the woman suffers from a physical 

9 disorder, physical injury, or physical illness 

10 that, as certified by a physician, would place 

11 the woman in danger of death unless an abor12 tion is performed, including a life-endangering 

13 physical condition caused by or arising from the 

14 pregnancy itself. 

15 ‘‘(c) TRADITIONAL HEALTH CARE PRACTICES.—Al16 though the Secretary may promote traditional health care 

17 practices, consistent with the Service standards for the 

18 provision of health care, health promotion, and disease 

19 prevention under this Act, the United States is not liable 

20 for any provision of traditional health care practices pur21 suant to this Act that results in damage, injury, or death 

22 to a patient. Nothing in this subsection shall be construed 

23 to alter any liability or other obligation that the United 

24 States may otherwise have under the Indian Self-Deter-
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1 mination and Education Assistance Act (25 U.S.C. 450 

2 et seq.) or this Act. 

3 ‘‘(d) FIREARM PROGRAMS.—None of the funds made 

4 available to carry out this Act may be used to carry out 

5 any antifirearm program, gun buy-back program, or pro6 gram to discourage or stigmatize the private ownership of 

7 firearms for collecting, hunting, or self-defense purposes. 

8 ‘‘SEC. 806. ELIGIBILITY OF CALIFORNIA INDIANS. 

9 ‘‘(a) IN GENERAL.—The following California Indians 

10 shall be eligible for health services provided by the Service: 

11 ‘‘(1) Any member of a federally recognized In12 dian Tribe. 

13 ‘‘(2) Any descendant of an Indian who was re14 siding in California on June 1, 1852, if such de15 scendant—

16 ‘‘(A) is a member of the Indian community 

17 served by a local program of the Service; and 

18 ‘‘(B) is regarded as an Indian by the com19 munity in which such descendant lives. 

20 ‘‘(3) Any Indian who holds trust interests in 

21 public domain, national forest, or reservation allot22 ments in California. 

23 ‘‘(4) Any Indian in California who is listed on 

24 the plans for distribution of the assets of rancherias 

25 and reservations located within the State of Cali-
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1 fornia under the Act of August 18, 1958 (72 Stat. 

2 619), and any descendant of such an Indian. 

3 ‘‘(b) CLARIFICATION.—Nothing in this section may 

4 be construed as expanding the eligibility of California Indi5 ans for health services provided by the Service beyond the 

6 scope of eligibility for such health services that applied on 

7 May 1, 1986. 

8 ‘‘SEC. 807. HEALTH SERVICES FOR INELIGIBLE PERSONS. 

9 ‘‘(a) CHILDREN.—Any individual who—

10 ‘‘(1) has not attained 19 years of age; 

11 ‘‘(2) is the natural or adopted child, stepchild, 

12 foster child, legal ward, or orphan of an eligible In13 dian; and 

14 ‘‘(3) is not otherwise eligible for health services 

15 provided by the Service, 

16 shall be eligible for all health services provided by the 

17 Service on the same basis and subject to the same rules 

18 that apply to eligible Indians until such individual attains 

19 19 years of age. The existing and potential health needs 

20 of all such individuals shall be taken into consideration 

21 by the Service in determining the need for, or the alloca22 tion of, the health resources of the Service. If such an indi23 vidual has been determined to be legally incompetent prior 

24 to attaining 19 years of age, such individual shall remain 
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1 eligible for such services until 1 year after the date of a 

2 determination of competency. 

3 ‘‘(b) SPOUSES.—Any spouse of an eligible Indian who 

4 is not an Indian, or who is of Indian descent but is not 

5 otherwise eligible for the health services provided by the 

6 Service, shall be eligible for such health services if all such 

7 spouses or spouses who are married to members of each 

8 Indian Tribe being served are made eligible, as a class, 

9 by an appropriate resolution of the governing body of the 

10 Indian Tribe or Tribal Organization providing such serv11 ices. The health needs of persons made eligible under this 

12 paragraph shall not be taken into consideration by the 

13 Service in determining the need for, or allocation of, its 

14 health resources. 

15 ‘‘(c) PROVISION OF SERVICES TO OTHER INDIVID16 UALS.—

17 ‘‘(1) IN GENERAL.—The Secretary is authorized 

18 to provide health services under this subsection 

19 through health programs operated directly by the 

20 Service to individuals who reside within the Service 

21 Unit and who are not otherwise eligible for such 

22 health services if—

23 ‘‘(A) the Indian Tribes served by such 

24 Service Unit request such provision of health 

25 services to such individuals; and 
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1 ‘‘(B) the Secretary and the served Indian 

2 Tribes have jointly determined that—

3 ‘‘(i) the provision of such health serv4 ices will not result in a denial or diminu5 tion of health services to eligible Indians; 

6 and 

7 ‘‘(ii) there is no reasonable alternative 

8 health facilities or services, within or with9 out the Service Unit, available to meet the 

10 health needs of such individuals. 

11 ‘‘(2) ISDEAA PROGRAMS.—In the case of 

12 health programs and facilities operated under a con13 tract or compact entered into under the Indian Self14 Determination and Education Assistance Act (25 

15 U.S.C. 450 et seq.), the governing body of the In16 dian Tribe or Tribal Organization providing health 

17 services under such contract or compact is author18 ized to determine whether health services should be 

19 provided under such contract to individuals who are 

20 not eligible for such health services under any other 

21 subsection of this section or under any other provi22 sion of law. In making such determinations, the gov23 erning body of the Indian Tribe or Tribal Organiza24 tion shall take into account the considerations de25 scribed in paragraph (1)(B). 
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1 ‘‘(3) PAYMENT FOR SERVICES.—

2 ‘‘(A) IN GENERAL.—Persons receiving 

3 health services provided by the Service under 

4 this subsection shall be liable for payment of 

5 such health services under a schedule of charges 

6 prescribed by the Secretary which, in the judg7 ment of the Secretary, results in reimbursement 

8 in an amount not less than the actual cost of 

9 providing the health services. Notwithstanding 

10 section 404 of this Act or any other provision 

11 of law, amounts collected under this subsection, 

12 including Medicare, Medicaid, or SCHIP reim13 bursements under titles XVIII, XIX, and XXI 

14 of the Social Security Act, shall be credited to 

15 the account of the program providing the serv16 ice and shall be used for the purposes listed in 

17 section 401(d)(2) and amounts collected under 

18 this subsection shall be available for expendi19 ture within such program. 

20 ‘‘(B) INDIGENT PEOPLE.—Health services 

21 may be provided by the Secretary through the 

22 Service under this subsection to an indigent in23 dividual who would not be otherwise eligible for 

24 such health services but for the provisions of 

25 paragraph (1) only if an agreement has been 
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1 entered into with a State or local government 

2 under which the State or local government 

3 agrees to reimburse the Service for the expenses 

4 incurred by the Service in providing such health 

5 services to such indigent individual. 

6 ‘‘(4) REVOCATION OF CONSENT FOR SERV7 ICES.—

8 ‘‘(A) SINGLE TRIBE SERVICE AREA.—In 

9 the case of a Service Area which serves only 1 

10 Indian Tribe, the authority of the Secretary to 

11 provide health services under paragraph (1) 

12 shall terminate at the end of the fiscal year suc13 ceeding the fiscal year in which the governing 

14 body of the Indian Tribe revokes its concur15 rence to the provision of such health services. 

16 ‘‘(B) MULTITRIBAL SERVICE AREA.—In 

17 the case of a multitribal Service Area, the au18 thority of the Secretary to provide health serv19 ices under paragraph (1) shall terminate at the 

20 end of the fiscal year succeeding the fiscal year 

21 in which at least 51 percent of the number of 

22 Indian Tribes in the Service Area revoke their 

23 concurrence to the provisions of such health 

24 services. 
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1 ‘‘(d) OTHER SERVICES.—The Service may provide 

2 health services under this subsection to individuals who 

3 are not eligible for health services provided by the Service 

4 under any other provision of law in order to—

5 ‘‘(1) achieve stability in a medical emergency; 

6 ‘‘(2) prevent the spread of a communicable dis7 ease or otherwise deal with a public health hazard; 

8 ‘‘(3) provide care to non-Indian women preg9 nant with an eligible Indian’s child for the duration 

10 of the pregnancy through postpartum; or 

11 ‘‘(4) provide care to immediate family members 

12 of an eligible individual if such care is directly re13 lated to the treatment of the eligible individual. 

14 ‘‘(e) HOSPITAL PRIVILEGES FOR PRACTITIONERS.—

15 Hospital privileges in health facilities operated and main16 tained by the Service or operated under a contract or com17 pact pursuant to the Indian Self-Determination and Edu18 cation Assistance Act (25 U.S.C. 450 et seq.) may be ex19 tended to non-Service health care practitioners who pro20 vide services to individuals described in subsection (a), (b), 

21 (c), or (d). Such non-Service health care practitioners 

22 may, as part of the privileging process, be designated as 

23 employees of the Federal Government for purposes of sec24 tion 1346(b) and chapter 171 of title 28, United States 

25 Code (relating to Federal tort claims) only with respect 
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1 to acts or omissions which occur in the course of providing 

2 services to eligible individuals as a part of the conditions 

3 under which such hospital privileges are extended. 

4 ‘‘(f) ELIGIBLE INDIAN.—For purposes of this sec5 tion, the term ‘eligible Indian’ means any Indian who is 

6 eligible for health services provided by the Service without 

7 regard to the provisions of this section. 

8 ‘‘SEC. 808. REALLOCATION OF BASE RESOURCES. 

9 ‘‘(a) REPORT REQUIRED.—Notwithstanding any 

10 other provision of law, any allocation of Service funds for 

11 a fiscal year that reduces by 5 percent or more from the 

12 previous fiscal year the funding for any recurring pro13 gram, project, or activity of a Service Unit may be imple14 mented only after the Secretary has submitted to Con15 gress, under section 801, a report on the proposed change 

16 in allocation of funding, including the reasons for the 

17 change and its likely effects. 

18 ‘‘(b) EXCEPTION.—Subsection (a) shall not apply if 

19 the total amount appropriated to the Service for a fiscal 

20 year is at least 5 percent less than the amount appro21 priated to the Service for the previous fiscal year. 

22 ‘‘SEC. 809. RESULTS OF DEMONSTRATION PROJECTS. 

23 ‘‘The Secretary shall provide for the dissemination to 

24 Indian Tribes, Tribal Organizations, and Urban Indian 
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1 Organizations of the findings and results of demonstration 

2 projects conducted under this Act. 

3 ‘‘SEC. 810. PROVISION OF SERVICES IN MONTANA. 

4 ‘‘(a) CONSISTENT WITH COURT DECISION.—The 

5 Secretary, acting through the Service, shall provide serv6 ices and benefits for Indians in Montana in a manner con7 sistent with the decision of the United States Court of Ap8 peals for the Ninth Circuit in McNabb for McNabb v. 

9 Bowen, 829 F.2d 787 (9th Cir. 1987). 

10 ‘‘(b) CLARIFICATION.—The provisions of subsection 

11 (a) shall not be construed to be an expression of the sense 

12 of Congress on the application of the decision described 

13 in subsection (a) with respect to the provision of services 

14 or benefits for Indians living in any State other than Mon15 tana. 

16 ‘‘SEC. 811. TRIBAL EMPLOYMENT. 

17 ‘‘For purposes of section 2(2) of the Act of July 5, 

18 1935 (49 Stat. 450, chapter 372), an Indian Tribe or 

19 Tribal Organization carrying out a contract or compact 

20 pursuant to the Indian Self-Determination and Education 

21 Assistance Act (25 U.S.C. 450 et seq.) shall not be consid22 ered an ‘employer’. 

23 ‘‘SEC. 812. SEVERABILITY PROVISIONS. 

24 ‘‘If any provision of this Act, any amendment made 

25 by the Act, or the application of such provision or amend-
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1 ment to any person or circumstances is held to be invalid, 

2 the remainder of this Act, the remaining amendments 

3 made by this Act, and the application of such provisions 

4 to persons or circumstances other than those to which it 

5 is held invalid, shall not be affected thereby. 

6 ‘‘SEC. 813. ESTABLISHMENT OF NATIONAL BIPARTISAN 

7 COMMISSION ON INDIAN HEALTH CARE. 

8 ‘‘(a) ESTABLISHMENT.—There is established the Na9 tional Bipartisan Indian Health Care Commission (the 

10 ‘Commission’). 

11 ‘‘(b) DUTIES OF COMMISSION.—The duties of the 

12 Commission are the following: 

13 ‘‘(1) To establish a study committee composed 

14 of those members of the Commission appointed by 

15 the Director and at least 4 members of Congress 

16 from among the members of the Commission, the 

17 duties of which shall be the following: 

18 ‘‘(A) To the extent necessary to carry out 

19 its duties, collect and compile data necessary to 

20 understand the extent of Indian needs with re21 gard to the provision of health services, regard22 less of the location of Indians, including holding 

23 hearings and soliciting the views of Indians, In24 dian Tribes, Tribal Organizations, and Urban 

25 Indian Organizations, which may include au-
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1 thorizing and making funds available for feasi2 bility studies of various models for providing 

3 and funding health services for all Indian bene4 ficiaries, including those who live outside of a 

5 reservation, temporarily or permanently. 

6 ‘‘(B) To make legislative recommendations 

7 to the Commission regarding the delivery of 

8 Federal health care services to Indians. Such 

9 recommendations shall include those related to 

10 issues of eligibility, benefits, the range of serv11 ice providers, the cost of such services, financ12 ing such services, and the optimal manner in 

13 which to provide such services. 

14 ‘‘(C) To determine the effect of the enact15 ment of such recommendations on (i) the exist16 ing system of delivery of health services for In17 dians, and (ii) the sovereign status of Indian 

18 Tribes. 

19 ‘‘(D) Not later than 12 months after the 

20 appointment of all members of the Commission, 

21 to submit a written report of its findings and 

22 recommendations to the full Commission. The 

23 report shall include a statement of the minority 

24 and majority position of the Committee and 

25 shall be disseminated, at a minimum, to every 
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1 Indian Tribe, Tribal Organization, and Urban 

2 Indian Organization for comment to the Com3 mission. 

4 ‘‘(E) To report regularly to the full Com5 mission regarding the findings and rec6 ommendations developed by the study com7 mittee in the course of carrying out its duties 

8 under this section. 

9 ‘‘(2) To review and analyze the recommenda10 tions of the report of the study committee. 

11 ‘‘(3) To make legislative recommendations to 

12 Congress regarding the delivery of Federal health 

13 care services to Indians. Such recommendations 

14 shall include those related to issues of eligibility, 

15 benefits, the range of service providers, the cost of 

16 such services, financing such services, and the opti17 mal manner in which to provide such services. 

18 ‘‘(4) Not later than 18 months following the 

19 date of appointment of all members of the Commis20 sion, submit a written report to Congress regarding 

21 the delivery of Federal health care services to Indi22 ans. Such recommendations shall include those re23 lated to issues of eligibility, benefits, the range of 

24 service providers, the cost of such services, financing 
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1 such services, and the optimal manner in which to 

2 provide such services. 

3 ‘‘(c) MEMBERS.—

4 ‘‘(1) APPOINTMENT.—The Commission shall be 

5 composed of 25 members, appointed as follows: 

6 ‘‘(A) Ten members of Congress, including 

7 3 from the House of Representatives and 2 

8 from the Senate, appointed by their respective 

9 majority leaders, and 3 from the House of Rep10 resentatives and 2 from the Senate, appointed 

11 by their respective minority leaders, and who 

12 shall be members of the standing committees of 

13 Congress that consider legislation affecting 

14 health care to Indians. 

15 ‘‘(B) Twelve persons chosen by the con16 gressional members of the Commission, 1 from 

17 each Service Area as currently designated by 

18 the Director to be chosen from among 3 nomi19 nees from each Service Area put forward by the 

20 Indian Tribes within the area, with due regard 

21 being given to the experience and expertise of 

22 the nominees in the provision of health care to 

23 Indians and to a reasonable representation on 

24 the commission of members who are familiar 

25 with various health care delivery modes and 
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1 who represent Indian Tribes of various size 

2 populations. 

3 ‘‘(C) Three persons appointed by the Di4 rector who are knowledgeable about the provi5 sion of health care to Indians, at least 1 of 

6 whom shall be appointed from among 3 nomi7 nees put forward by those programs whose 

8 funds are provided in whole or in part by the 

9 Service primarily or exclusively for the benefit 

10 of Urban Indians. 

11 ‘‘(D) All those persons chosen by the con12 gressional members of the Commission and by 

13 the Director shall be members of federally rec14 ognized Indian Tribes. 

15 ‘‘(2) CHAIR; VICE CHAIR.—The Chair and Vice 

16 Chair of the Commission shall be selected by the 

17 congressional members of the Commission. 

18 ‘‘(3) TERMS.—The terms of members of the 

19 Commission shall be for the life of the Commission. 

20 ‘‘(4) DEADLINE FOR APPOINTMENTS.—Con21 gressional members of the Commission shall be ap22 pointed not later than 180 days after the date of en23 actment of the Indian Health Care Improvement Act 

24 Amendments of 2008, and the remaining members 

25 of the Commission shall be appointed not later than 
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1 60 days following the appointment of the congres2 sional members. 

3 ‘‘(5) VACANCY.—A vacancy in the Commission 

4 shall be filled in the manner in which the original 

5 appointment was made. 

6 ‘‘(d) COMPENSATION.—

7 ‘‘(1) CONGRESSIONAL MEMBERS.—Each con8 gressional member of the Commission shall receive 

9 no additional pay, allowances, or benefits by reason 

10 of their service on the Commission and shall receive 

11 travel expenses and per diem in lieu of subsistence 

12 in accordance with sections 5702 and 5703 of title 

13 5, United States Code. 

14 ‘‘(2) OTHER MEMBERS.—Remaining members 

15 of the Commission, while serving on the business of 

16 the Commission (including travel time), shall be en17 titled to receive compensation at the per diem equiv18 alent of the rate provided for level IV of the Execu19 tive Schedule under section 5315 of title 5, United 

20 States Code, and while so serving away from home 

21 and the member’s regular place of business, a mem22 ber may be allowed travel expenses, as authorized by 

23 the Chairman of the Commission. For purpose of 

24 pay (other than pay of members of the Commission) 

25 and employment benefits, rights, and privileges, all 
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1 personnel of the Commission shall be treated as if 

2 they were employees of the United States Senate. 

3 ‘‘(e) MEETINGS.—The Commission shall meet at the 

4 call of the Chair. 

5 ‘‘(f) QUORUM.—A quorum of the Commission shall 

6 consist of not less than 15 members, provided that no less 

7 than 6 of the members of Congress who are Commission 

8 members are present and no less than 9 of the members 

9 who are Indians are present. 

10 ‘‘(g) EXECUTIVE DIRECTOR; STAFF; FACILITIES.—

11 ‘‘(1) APPOINTMENT; PAY.—The Commission 

12 shall appoint an executive director of the Commis13 sion. The executive director shall be paid the rate of 

14 basic pay for level V of the Executive Schedule. 

15 ‘‘(2) STAFF APPOINTMENT.—With the approval 

16 of the Commission, the executive director may ap17 point such personnel as the executive director deems 

18 appropriate. 

19 ‘‘(3) STAFF PAY.—The staff of the Commission 

20 shall be appointed without regard to the provisions 

21 of title 5, United States Code, governing appoint22 ments in the competitive service, and shall be paid 

23 without regard to the provisions of chapter 51 and 

24 subchapter III of chapter 53 of such title (relating 

25 to classification and General Schedule pay rates). 
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1 ‘‘(4) TEMPORARY SERVICES.—With the ap2 proval of the Commission, the executive director may 

3 procure temporary and intermittent services under 

4 section 3109(b) of title 5, United States Code. 

5 ‘‘(5) FACILITIES.—The Administrator of Gen6 eral Services shall locate suitable office space for the 

7 operation of the Commission. The facilities shall 

8 serve as the headquarters of the Commission and 

9 shall include all necessary equipment and incidentals 

10 required for the proper functioning of the Commis11 sion. 

12 ‘‘(h) HEARINGS.—(1) For the purpose of carrying 

13 out its duties, the Commission may hold such hearings 

14 and undertake such other activities as the Commission de15 termines to be necessary to carry out its duties, provided 

16 that at least 6 regional hearings are held in different areas 

17 of the United States in which large numbers of Indians 

18 are present. Such hearings are to be held to solicit the 

19 views of Indians regarding the delivery of health care serv20 ices to them. To constitute a hearing under this sub21 section, at least 5 members of the Commission, including 

22 at least 1 member of Congress, must be present. Hearings 

23 held by the study committee established in this section 

24 may count toward the number of regional hearings re25 quired by this subsection. 
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1 ‘‘(2)(A) The Director of the Congressional Budget 

2 Office or the Chief Actuary of the Centers for Medicare 

3 & Medicaid Services, or both, shall provide to the Commis4 sion, upon the request of the Commission, such cost esti5 mates as the Commission determines to be necessary to 

6 carry out its duties. 

7 ‘‘(B) The Commission shall reimburse the Director 

8 of the Congressional Budget Office for expenses relating 

9 to the employment in the office of that Director of such 

10 additional staff as may be necessary for the Director to 

11 comply with requests by the Commission under subpara12 graph (A). 

13 ‘‘(3) Upon the request of the Commission, the head 

14 of any Federal agency is authorized to detail, without re15 imbursement, any of the personnel of such agency to the 

16 Commission to assist the Commission in carrying out its 

17 duties. Any such detail shall not interrupt or otherwise 

18 affect the civil service status or privileges of the Federal 

19 employee. 

20 ‘‘(4) Upon the request of the Commission, the head 

21 of a Federal agency shall provide such technical assistance 

22 to the Commission as the Commission determines to be 

23 necessary to carry out its duties. 

24 ‘‘(5) The Commission may use the United States 

25 mails in the same manner and under the same conditions 
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1 as Federal agencies and shall, for purposes of the frank, 

2 be considered a commission of Congress as described in 

3 section 3215 of title 39, United States Code. 

4 ‘‘(6) The Commission may secure directly from any 

5 Federal agency information necessary to enable it to carry 

6 out its duties, if the information may be disclosed under 

7 section 552 of title 4, United States Code. Upon request 

8 of the Chairman of the Commission, the head of such 

9 agency shall furnish such information to the Commission. 

10 ‘‘(7) Upon the request of the Commission, the Ad11 ministrator of General Services shall provide to the Com12 mission on a reimbursable basis such administrative sup13 port services as the Commission may request. 

14 ‘‘(8) For purposes of costs relating to printing and 

15 binding, including the cost of personnel detailed from the 

16 Government Printing Office, the Commission shall be 

17 deemed to be a committee of Congress. 

18 ‘‘(i) AUTHORIZATION OF APPROPRIATIONS.—There is 

19 authorized to be appropriated $4,000,000 to carry out the 

20 provisions of this section, which sum shall not be deducted 

21 from or affect any other appropriation for health care for 

22 Indian persons. 

23 ‘‘(j) NONAPPLICABILITY OF FACA.—The Federal 

24 Advisory Committee Act (5 U.S.C. App.) shall not apply 

25 to the Commission. 
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1 ‘‘SEC. 814. CONFIDENTIALITY OF MEDICAL QUALITY ASSUR2 ANCE RECORDS; QUALIFIED IMMUNITY FOR 

3 PARTICIPANTS. 

4 ‘‘(a) CONFIDENTIALITY OF RECORDS.—Medical qual5 ity assurance records created by or for any Indian Health 

6 Program or a health program of an Urban Indian Organi7 zation as part of a medical quality assurance program are 

8 confidential and privileged. Such records may not be dis9 closed to any person or entity, except as provided in sub10 section (c). 

11 ‘‘(b) PROHIBITION ON DISCLOSURE AND TESTI12 MONY.—

13 ‘‘(1) IN GENERAL.—No part of any medical 

14 quality assurance record described in subsection (a) 

15 may be subject to discovery or admitted into evi16 dence in any judicial or administrative proceeding, 

17 except as provided in subsection (c). 

18 ‘‘(2) TESTIMONY.—A person who reviews or 

19 creates medical quality assurance records for any In20 dian Health Program or Urban Indian Organization 

21 who participates in any proceeding that reviews or 

22 creates such records may not be permitted or re23 quired to testify in any judicial or administrative 

24 proceeding with respect to such records or with re25 spect to any finding, recommendation, evaluation, 

26 opinion, or action taken by such person or body in 
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1 connection with such records except as provided in 

2 this section. 

3 ‘‘(c) AUTHORIZED DISCLOSURE AND TESTIMONY.—

4 ‘‘(1) IN GENERAL.—Subject to paragraph (2), a 

5 medical quality assurance record described in sub6 section (a) may be disclosed, and a person referred 

7 to in subsection (b) may give testimony in connec8 tion with such a record, only as follows: 

9 ‘‘(A) To a Federal executive agency or pri10 vate organization, if such medical quality assur11 ance record or testimony is needed by such 

12 agency or organization to perform licensing or 

13 accreditation functions related to any Indian 

14 Health Program or to a health program of an 

15 Urban Indian Organization to perform moni16 toring, required by law, of such program or or17 ganization. 

18 ‘‘(B) To an administrative or judicial pro19 ceeding commenced by a present or former In20 dian Health Program or Urban Indian Organi21 zation provider concerning the termination, sus22 pension, or limitation of clinical privileges of 

23 such health care provider. 

24 ‘‘(C) To a governmental board or agency 

25 or to a professional health care society or orga-
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1 nization, if such medical quality assurance 

2 record or testimony is needed by such board, 

3 agency, society, or organization to perform li4 censing, credentialing, or the monitoring of pro5 fessional standards with respect to any health 

6 care provider who is or was an employee of any 

7 Indian Health Program or Urban Indian Orga8 nization. 

9 ‘‘(D) To a hospital, medical center, or 

10 other institution that provides health care serv11 ices, if such medical quality assurance record or 

12 testimony is needed by such institution to as13 sess the professional qualifications of any health 

14 care provider who is or was an employee of any 

15 Indian Health Program or Urban Indian Orga16 nization and who has applied for or been grant17 ed authority or employment to provide health 

18 care services in or on behalf of such program or 

19 organization. 

20 ‘‘(E) To an officer, employee, or contractor 

21 of the Indian Health Program or Urban Indian 

22 Organization that created the records or for 

23 which the records were created. If that officer, 

24 employee, or contractor has a need for such 

25 record or testimony to perform official duties. 
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1 ‘‘(F) To a criminal or civil law enforce2 ment agency or instrumentality charged under 

3 applicable law with the protection of the public 

4 health or safety, if a qualified representative of 

5 such agency or instrumentality makes a written 

6 request that such record or testimony be pro7 vided for a purpose authorized by law. 

8 ‘‘(G) In an administrative or judicial pro9 ceeding commenced by a criminal or civil law 

10 enforcement agency or instrumentality referred 

11 to in subparagraph (F), but only with respect 

12 to the subject of such proceeding. 

13 ‘‘(2) IDENTITY OF PARTICIPANTS.—With the 

14 exception of the subject of a quality assurance ac15 tion, the identity of any person receiving health care 

16 services from any Indian Health Program or Urban 

17 Indian Organization or the identity of any other per18 son associated with such program or organization 

19 for purposes of a medical quality assurance program 

20 that is disclosed in a medical quality assurance 

21 record described in subsection (a) shall be deleted 

22 from that record or document before any disclosure 

23 of such record is made outside such program or or24 ganization. 

25 ‘‘(d) DISCLOSURE FOR CERTAIN PURPOSES.—
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1 ‘‘(1) IN GENERAL.—Nothing in this section 

2 shall be construed as authorizing or requiring the 

3 withholding from any person or entity aggregate sta4 tistical information regarding the results of any In5 dian Health Program’s or Urban Indian Organiza6 tion’s medical quality assurance programs. 

7 ‘‘(2) WITHHOLDING FROM CONGRESS.—Noth8 ing in this section shall be construed as authority to 

9 withhold any medical quality assurance record from 

10 a committee of either House of Congress, any joint 

11 committee of Congress, or the Government Account12 ability Office if such record pertains to any matter 

13 within their respective jurisdictions. 

14 ‘‘(e) PROHIBITION ON DISCLOSURE OF RECORD OR

15 TESTIMONY.—A person or entity having possession of or 

16 access to a record or testimony described by this section 

17 may not disclose the contents of such record or testimony 

18 in any manner or for any purpose except as provided in 

19 this section. 

20 ‘‘(f) EXEMPTION FROM FREEDOM OF INFORMATION

21 ACT.—Medical quality assurance records described in sub22 section (a) may not be made available to any person under 

23 section 552 of title 5. 

24 ‘‘(g) LIMITATION ON CIVIL LIABILITY.—A person 

25 who participates in or provides information to a person 
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1 or body that reviews or creates medical quality assurance 

2 records described in subsection (a) shall not be civilly lia3 ble for such participation or for providing such informa4 tion if the participation or provision of information was 

5 in good faith based on prevailing professional standards 

6 at the time the medical quality assurance program activity 

7 took place. 

8 ‘‘(h) APPLICATION TO INFORMATION IN CERTAIN

9 OTHER RECORDS.—Nothing in this section shall be con10 strued as limiting access to the information in a record 

11 created and maintained outside a medical quality assur12 ance program, including a patient’s medical records, on 

13 the grounds that the information was presented during 

14 meetings of a review body that are part of a medical qual15 ity assurance program. 

16 ‘‘(i) REGULATIONS.—The Secretary, acting through 

17 the Service, is authorized to promulgate regulations pursu18 ant to section 802. 

19 ‘‘(j) DEFINITIONS.—In this section: 

20 ‘‘(1) The term ‘health care provider’ means any 

21 health care professional, including community health 

22 aides and practitioners certified under section 121, 

23 who are granted clinical practice privileges or em24 ployed to provide health care services in an Indian 

25 Health Program or health program of an Urban In-
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1 dian Organization, who is licensed or certified to 

2 perform health care services by a governmental 

3 board or agency or professional health care society 

4 or organization. 

5 ‘‘(2) The term ‘medical quality assurance pro6 gram’ means any activity carried out before, on, or 

7 after the date of enactment of this Act by or for any 

8 Indian Health Program or Urban Indian Organiza9 tion to assess the quality of medical care, including 

10 activities conducted by or on behalf of individuals, 

11 Indian Health Program or Urban Indian Organiza12 tion medical or dental treatment review committees, 

13 or other review bodies responsible for review of ad14 verse incidents, claims, quality assurance, creden15 tials, infection control, patient safety, patient care 

16 assessment (including treatment procedures, blood, 

17 drugs, and therapeutics), medical records, health re18 sources management review and identification and 

19 prevention of medical or dental incidents and risks. 

20 ‘‘(3) The term ‘medical quality assurance 

21 record’ means the proceedings, records, minutes, and 

22 reports that emanate from quality assurance pro23 gram activities described in paragraph (2) and are 

24 produced or compiled by or for an Indian Health 
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1 Program or Urban Indian Organization as part of a 

2 medical quality assurance program. 

3 ‘‘(k) RELATIONSHIP TO OTHER LAW.—This section 

4 shall continue in force and effect, except as otherwise spe5 cifically provided in any Federal law enacted after the date 

6 of enactment of the Indian Health Care Improvement Act 

7 Amendments of 2008. 

8 ‘‘SEC. 815. SENSE OF CONGRESS REGARDING LAW EN9 FORCEMENT AND METHAMPHETAMINE 

10 ISSUES IN INDIAN COUNTRY. 

11 ‘‘It is the sense of Congress that Congress encourages 

12 State, local, and Indian tribal law enforcement agencies 

13 to enter into memoranda of agreement between and 

14 among those agencies for purposes of streamlining law en15 forcement activities and maximizing the use of limited re16 sources—

17 ‘‘(1) to improve law enforcement services pro18 vided to Indian tribal communities; and 

19 ‘‘(2) to increase the effectiveness of measures to 

20 address problems relating to methamphetamine use 

21 in Indian Country (as defined in section 1151 of 

22 title 18, United States Code). 
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1 ‘‘SEC. 816. TRIBAL HEALTH PROGRAM OPTION FOR COST 

2 SHARING. 

3 ‘‘(a) IN GENERAL.—Nothing in this Act limits the 

4 ability of a Tribal Health Program operating any health 

5 program, service, function, activity, or facility funded, in 

6 whole or part, by the Service through, or provided for in, 

7 a compact with the Service pursuant to title V of the In8 dian Self-Determination and Education Assistance Act 

9 (25 U.S.C. 458aaa et seq.) to charge an Indian for serv10 ices provided by the Tribal Health Program. 

11 ‘‘(b) SERVICE.—Nothing in this Act authorizes the 

12 Service—

13 ‘‘(1) to charge an Indian for services; or 

14 ‘‘(2) to require any Tribal Health Program to 

15 charge an Indian for services. 

16 ‘‘SEC. 817. TESTING FOR SEXUALLY TRANSMITTED DIS17 EASES IN CASES OF SEXUAL VIOLENCE. 

18 ‘‘The Attorney General shall ensure that, with respect 

19 to any Federal criminal action involving a sexual assault, 

20 rape, or other incident of sexual violence against an In21 dian—

22 ‘‘(1)(A) at the request of the victim, a defend23 ant is tested for the human immunodeficiency virus 

24 (HIV) and such other sexually transmitted diseases 

25 as are requested by the victim not later than 48 
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1 hours after the date on which the applicable infor2 mation or indictment is presented; 

3 ‘‘(B) a notification of the test results is pro4 vided to the victim or the parent or guardian of the 

5 victim and the defendant as soon as practicable after 

6 the results are generated; and 

7 ‘‘(C) such follow-up tests for HIV and other 

8 sexually transmitted diseases are provided as are 

9 medically appropriate, with the test results made 

10 available in accordance with subparagraph (B); and 

11 ‘‘(2) pursuant to section 714(a), HIV and other 

12 sexually transmitted disease testing, treatment, and 

13 counseling is provided for victims of sexual abuse. 

14 ‘‘SEC. 818. STUDY ON TOBACCO-RELATED DISEASE AND DIS15 PROPORTIONATE HEALTH EFFECTS ON TRIB16 AL POPULATIONS. 

17 ‘‘Not later than 180 days after the date of enactment 

18 of the Indian Health Care Improvement Act Amendments 

19 of 2008, the Secretary, in consultation with appropriate 

20 Federal departments and agencies and acting through the 

21 epidemiology centers established under section 209, shall 

22 solicit from independent organizations bids to conduct, 

23 and shall submit to Congress no later than 5 years after 

24 enactment a report describing the results of, a study to 
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1 determine possible causes for the high prevalence of to2 bacco use among Indians. 

3 ‘‘SEC. 819. APPROPRIATIONS; AVAILABILITY. 

4 ‘‘Any new spending authority (described in subpara5 graph (A) or (B) of section 401(c)(2) of the Congressional 

6 Budget Act of 1974 (Public Law 93–344; 88 Stat. 317)) 

7 which is provided under this Act shall be effective for any 

8 fiscal year only to such extent or in such amounts as are 

9 provided in appropriation Acts. 

10 ‘‘SEC. 820. GAO REPORT ON COORDINATION OF SERVICES. 

11 ‘‘(a) STUDY AND EVALUATION.—The Comptroller 

12 General of the United States shall conduct a study, and 

13 evaluate the effectiveness, of coordination of health care 

14 services provided to Indians—

15 ‘‘(1) through Medicare, Medicaid, or SCHIP; 

16 ‘‘(2) by the Service; or 

17 ‘‘(3) using funds provided by—

18 ‘‘(A) State or local governments; or 

19 ‘‘(B) Indian Tribes. 

20 ‘‘(b) REPORT.—Not later than 18 months after the 

21 date of enactment of the Indian Health Care Improvement 

22 Act Amendments of 2007, the Comptroller General shall 

23 submit to Congress a report—

24 ‘‘(1) describing the results of the evaluation 

25 under subsection (a); and 
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1 ‘‘(2) containing recommendations of the Comp2 troller General regarding measures to support and 

3 increase coordination of the provision of health care 

4 services to Indians as described in subsection (a). 

5 ‘‘SEC. 821. AUTHORIZATION OF APPROPRIATIONS. 

6 ‘‘There are authorized to be appropriated such sums 

7 as may be necessary for each fiscal year through fiscal 

8 year 2017 to carry out this title.’’. 

9 SEC. 102. SOBOBA SANITATION FACILITIES. 

10 The Act of December 17, 1970 (84 Stat. 1465), is 

11 amended by adding at the end the following: 

12 ‘‘SEC. 9. Nothing in this Act shall preclude the 

13 Soboba Band of Mission Indians and the Soboba Indian 

14 Reservation from being provided with sanitation facilities 

15 and services under the authority of section 7 of the Act 

16 of August 5, 1954 (68 Stat. 674), as amended by the Act 

17 of July 31, 1959 (73 Stat. 267).’’. 

18 SEC. 103. NATIVE AMERICAN HEALTH AND WELLNESS 

19 FOUNDATION. 

20 (a) IN GENERAL.—The Indian Self-Determination 

21 and Education Assistance Act (25 U.S.C. 450 et seq.) is 

22 amended by adding at the end the following: 
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1 ‘‘TITLE VIII—NATIVE AMERICAN 

2 HEALTH AND WELLNESS 

3 FOUNDATION 

4 ‘‘SEC. 801. DEFINITIONS. 

5 ‘‘In this title: 

6 ‘‘(1) BOARD.—The term ‘Board’ means the 

7 Board of Directors of the Foundation. 

8 ‘‘(2) COMMITTEE.—The term ‘Committee’ 

9 means the Committee for the Establishment of Na10 tive American Health and Wellness Foundation es11 tablished under section 802(f). 

12 ‘‘(3) FOUNDATION.—The term ‘Foundation’ 

13 means the Native American Health and Wellness 

14 Foundation established under section 802. 

15 ‘‘(4) SECRETARY.—The term ‘Secretary’ means 

16 the Secretary of Health and Human Services. 

17 ‘‘(5) SERVICE.—The term ‘Service’ means the 

18 Indian Health Service of the Department of Health 

19 and Human Services. 

20 ‘‘SEC. 802. NATIVE AMERICAN HEALTH AND WELLNESS 

21 FOUNDATION. 

22 ‘‘(a) ESTABLISHMENT.—

23 ‘‘(1) IN GENERAL.—As soon as practicable 

24 after the date of enactment of this title, the Sec25 retary shall establish, under the laws of the District 
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1 of Columbia and in accordance with this title, the 

2 Native American Health and Wellness Foundation. 

3 ‘‘(2) FUNDING DETERMINATIONS.—No funds, 

4 gift, property, or other item of value (including any 

5 interest accrued on such an item) acquired by the 

6 Foundation shall—

7 ‘‘(A) be taken into consideration for pur8 poses of determining Federal appropriations re9 lating to the provision of health care and serv10 ices to Indians; or 

11 ‘‘(B) otherwise limit, diminish, or affect 

12 the Federal responsibility for the provision of 

13 health care and services to Indians. 

14 ‘‘(b) PERPETUAL EXISTENCE.—The Foundation 

15 shall have perpetual existence. 

16 ‘‘(c) NATURE OF CORPORATION.—The Foundation—

17 ‘‘(1) shall be a charitable and nonprofit feder18 ally chartered corporation; and 

19 ‘‘(2) shall not be an agency or instrumentality 

20 of the United States. 

21 ‘‘(d) PLACE OF INCORPORATION AND DOMICILE.—

22 The Foundation shall be incorporated and domiciled in the 

23 District of Columbia. 

24 ‘‘(e) DUTIES.—The Foundation shall—
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1 ‘‘(1) encourage, accept, and administer private 

2 gifts of real and personal property, and any income 

3 from or interest in such gifts, for the benefit of, or 

4 in support of, the mission of the Service; 

5 ‘‘(2) undertake and conduct such other activi6 ties as will further the health and wellness activities 

7 and opportunities of Native Americans; and 

8 ‘‘(3) participate with and assist Federal, State, 

9 and tribal governments, agencies, entities, and indi10 viduals in undertaking and conducting activities that 

11 will further the health and wellness activities and op12 portunities of Native Americans. 

13 ‘‘(f) COMMITTEE FOR THE ESTABLISHMENT OF NA14 TIVE AMERICAN HEALTH AND WELLNESS FOUNDA15 TION.—

16 ‘‘(1) IN GENERAL.—The Secretary shall estab17 lish the Committee for the Establishment of Native 

18 American Health and Wellness Foundation to assist 

19 the Secretary in establishing the Foundation. 

20 ‘‘(2) DUTIES.—Not later than 180 days after 

21 the date of enactment of this section, the Committee 

22 shall—

23 ‘‘(A) carry out such activities as are nec24 essary to incorporate the Foundation under the 
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1 laws of the District of Columbia, including act2 ing as incorporators of the Foundation; 

3 ‘‘(B) ensure that the Foundation qualifies 

4 for and maintains the status required to carry 

5 out this section, until the Board is established; 

6 ‘‘(C) establish the constitution and initial 

7 bylaws of the Foundation; 

8 ‘‘(D) provide for the initial operation of 

9 the Foundation, including providing for tem10 porary or interim quarters, equipment, and 

11 staff; and 

12 ‘‘(E) appoint the initial members of the 

13 Board in accordance with the constitution and 

14 initial bylaws of the Foundation. 

15 ‘‘(g) BOARD OF DIRECTORS.—

16 ‘‘(1) IN GENERAL.—The Board of Directors 

17 shall be the governing body of the Foundation. 

18 ‘‘(2) POWERS.—The Board may exercise, or 

19 provide for the exercise of, the powers of the Foun20 dation. 

21 ‘‘(3) SELECTION.—

22 ‘‘(A) IN GENERAL.—Subject to subpara23 graph (B), the number of members of the 

24 Board, the manner of selection of the members 

25 (including the filling of vacancies), and the 
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1 terms of office of the members shall be as pro2 vided in the constitution and bylaws of the 

3 Foundation. 

4 ‘‘(B) REQUIREMENTS.—

5 ‘‘(i) NUMBER OF MEMBERS.—The 

6 Board shall have at least 11 members, who 

7 shall have staggered terms. 

8 ‘‘(ii) INITIAL VOTING MEMBERS.—The 

9 initial voting members of the Board—

10 ‘‘(I) shall be appointed by the 

11 Committee not later than 180 days 

12 after the date on which the Founda13 tion is established; and 

14 ‘‘(II) shall have staggered terms. 

15 ‘‘(iii) QUALIFICATION.—The members 

16 of the Board shall be United States citi17 zens who are knowledgeable or experienced 

18 in Native American health care and related 

19 matters. 

20 ‘‘(C) COMPENSATION.—A member of the 

21 Board shall not receive compensation for service 

22 as a member, but shall be reimbursed for actual 

23 and necessary travel and subsistence expenses 

24 incurred in the performance of the duties of the 

25 Foundation. 
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1 ‘‘(h) OFFICERS.—

2 ‘‘(1) IN GENERAL.—The officers of the Founda3 tion shall be—

4 ‘‘(A) a secretary, elected from among the 

5 members of the Board; and 

6 ‘‘(B) any other officers provided for in the 

7 constitution and bylaws of the Foundation. 

8 ‘‘(2) CHIEF OPERATING OFFICER.—The sec9 retary of the Foundation may serve, at the direction 

10 of the Board, as the chief operating officer of the 

11 Foundation, or the Board may appoint a chief oper12 ating officer, who shall serve at the direction of the 

13 Board. 

14 ‘‘(3) ELECTION.—The manner of election, term 

15 of office, and duties of the officers of the Founda16 tion shall be as provided in the constitution and by17 laws of the Foundation. 

18 ‘‘(i) POWERS.—The Foundation—

19 ‘‘(1) shall adopt a constitution and bylaws for 

20 the management of the property of the Foundation 

21 and the regulation of the affairs of the Foundation; 

22 ‘‘(2) may adopt and alter a corporate seal; 

23 ‘‘(3) may enter into contracts; 

24 ‘‘(4) may acquire (through a gift or otherwise), 

25 own, lease, encumber, and transfer real or personal 
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1 property as necessary or convenient to carry out the 

2 purposes of the Foundation; 

3 ‘‘(5) may sue and be sued; and 

4 ‘‘(6) may perform any other act necessary and 

5 proper to carry out the purposes of the Foundation. 

6 ‘‘(j) PRINCIPAL OFFICE.—

7 ‘‘(1) IN GENERAL.—The principal office of the 

8 Foundation shall be in the District of Columbia. 

9 ‘‘(2) ACTIVITIES; OFFICES.—The activities of 

10 the Foundation may be conducted, and offices may 

11 be maintained, throughout the United States in ac12 cordance with the constitution and bylaws of the 

13 Foundation. 

14 ‘‘(k) SERVICE OF PROCESS.—The Foundation shall 

15 comply with the law on service of process of each State 

16 in which the Foundation is incorporated and of each State 

17 in which the Foundation carries on activities. 

18 ‘‘(l) LIABILITY OF OFFICERS, EMPLOYEES, AND

19 AGENTS.—

20 ‘‘(1) IN GENERAL.—The Foundation shall be 

21 liable for the acts of the officers, employees, and 

22 agents of the Foundation acting within the scope of 

23 their authority. 

24 ‘‘(2) PERSONAL LIABILITY.—A member of the 

25 Board shall be personally liable only for gross neg-
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1 ligence in the performance of the duties of the mem2 ber. 

3 ‘‘(m) RESTRICTIONS.—

4 ‘‘(1) LIMITATION ON SPENDING.—Beginning 

5 with the fiscal year following the first full fiscal year 

6 during which the Foundation is in operation, the ad7 ministrative costs of the Foundation shall not exceed 

8 the percentage described in paragraph (2) of the 

9 sum of—

10 ‘‘(A) the amounts transferred to the Foun11 dation under subsection (o) during the pre12 ceding fiscal year; and 

13 ‘‘(B) donations received from private 

14 sources during the preceding fiscal year. 

15 ‘‘(2) PERCENTAGES.—The percentages referred 

16 to in paragraph (1) are—

17 ‘‘(A) for the first fiscal year described in 

18 that paragraph, 20 percent; 

19 ‘‘(B) for the following fiscal year, 15 per20 cent; and 

21 ‘‘(C) for each fiscal year thereafter, 10 

22 percent. 

23 ‘‘(3) APPOINTMENT AND HIRING.—The ap24 pointment of officers and employees of the Founda25 tion shall be subject to the availability of funds. 
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1 ‘‘(4) STATUS.—A member of the Board or offi2 cer, employee, or agent of the Foundation shall not 

3 by reason of association with the Foundation be con4 sidered to be an officer, employee, or agent of the 

5 United States. 

6 ‘‘(n) AUDITS.—The Foundation shall comply with 

7 section 10101 of title 36, United States Code, as if the 

8 Foundation were a corporation under part B of subtitle 

9 II of that title. 

10 ‘‘(o) FUNDING.—

11 ‘‘(1) AUTHORIZATION OF APPROPRIATIONS.—

12 There is authorized to be appropriated to carry out 

13 subsection (e)(1) $500,000 for each fiscal year, as 

14 adjusted to reflect changes in the Consumer Price 

15 Index for all-urban consumers published by the De16 partment of Labor. 

17 ‘‘(2) TRANSFER OF DONATED FUNDS.—The 

18 Secretary shall transfer to the Foundation funds 

19 held by the Department of Health and Human Serv20 ices under the Act of August 5, 1954 (42 U.S.C. 

21 2001 et seq.), if the transfer or use of the funds is 

22 not prohibited by any term under which the funds 

23 were donated. 
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1 ‘‘SEC. 803. ADMINISTRATIVE SERVICES AND SUPPORT. 

2 ‘‘(a) PROVISION OF SUPPORT BY SECRETARY.—Sub3 ject to subsection (b), during the 5-year period beginning 

4 on the date on which the Foundation is established, the 

5 Secretary—

6 ‘‘(1) may provide personnel, facilities, and other 

7 administrative support services to the Foundation; 

8 ‘‘(2) may provide funds for initial operating 

9 costs and to reimburse the travel expenses of the 

10 members of the Board; and 

11 ‘‘(3) shall require and accept reimbursements 

12 from the Foundation for—

13 ‘‘(A) services provided under paragraph 

14 (1); and 

15 ‘‘(B) funds provided under paragraph (2). 

16 ‘‘(b) REIMBURSEMENT.—Reimbursements accepted 

17 under subsection (a)(3)—

18 ‘‘(1) shall be deposited in the Treasury of the 

19 United States to the credit of the applicable appro20 priations account; and 

21 ‘‘(2) shall be chargeable for the cost of pro22 viding services described in subsection (a)(1) and 

23 travel expenses described in subsection (a)(2). 

24 ‘‘(c) CONTINUATION OF CERTAIN SERVICES.—The 

25 Secretary may continue to provide facilities and necessary 

26 support services to the Foundation after the termination 
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1 of the 5-year period specified in subsection (a) if the facili2 ties and services—

3 ‘‘(1) are available; and 

4 ‘‘(2) are provided on reimbursable cost basis.’’. 

5 (b) TECHNICAL AMENDMENTS.—The Indian Self-De6 termination and Education Assistance Act is amended—

7 (1) by redesignating title V (25 U.S.C. 458bbb 

8 et seq.) as title VII; 

9 (2) by redesignating sections 501, 502, and 503 

10 (25 U.S.C. 458bbb, 458bbb–1, 458bbb–2) as sec11 tions 701, 702, and 703, respectively; and 

12 (3) in subsection (a)(2) of section 702 and 

13 paragraph (2) of section 703 (as redesignated by 

14 paragraph (2)), by striking ‘‘section 501’’ and in15 serting ‘‘section 701’’. 

16 SEC. 104. MODIFICATION OF TERM. 

17 (a) IN GENERAL.—Except as provided in subsection 

18 (b), the Indian Health Care Improvement Act (as amend19 ed by section 101) and each provision of the Social Secu20 rity Act amended by title II are amended (as applicable)—

21 (1) by striking ‘‘Urban Indian Organizations’’ 

22 each place it appears and inserting ‘‘urban Indian 

23 organizations’’; 
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1 (2) by striking ‘‘Urban Indian Organization’’ 

2 each place it appears and inserting ‘‘urban Indian 

3 organization’’; 

4 (3) by striking ‘‘Urban Indians’’ each place it 

5 appears and inserting ‘‘urban Indians’’; 

6 (4) by striking ‘‘Urban Indian’’ each place it 

7 appears and inserting ‘‘urban Indian’’; 

8 (5) by striking ‘‘Urban Centers’’ each place it 

9 appears and inserting ‘‘urban centers’’; and 

10 (6) by striking ‘‘Urban Center’’ each place it 

11 appears and inserting ‘‘urban center’’. 

12 (b) EXCEPTION.—The amendments made by sub13 section (a) shall not apply with respect to—

14 (1) the matter preceding paragraph (1) of sec15 tion 510 of the Indian Health Care Improvement 

16 Act (as amended by section 101); and 

17 (2) ‘‘Urban Indian’’ the first place it appears in 

18 section 513(a) of the Indian Health Care Improve19 ment Act (as amended by section 101). 

20 (c) MODIFICATION OF DEFINITION.—Section 4 of the 

21 Indian Health Care Improvement Act (as amended by sec22 tion 101) is amended by striking paragraph (27) and in23 serting the following: 

24 ‘‘(27) The term ‘urban Indian’ means any indi25 vidual who resides in an urban center and who 
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1 meets 1 or more of the 4 criteria in subparagraphs 

2 (A) through (D) of paragraph (12).’’. 

3 SEC. 105. GAO STUDY AND REPORT ON PAYMENTS FOR 

4 CONTRACT HEALTH SERVICES. 

5 (a) STUDY.—

6 (1) IN GENERAL.—The Comptroller General of 

7 the United States (in this section referred to as the 

8 ‘‘Comptroller General’’) shall conduct a study on the 

9 utilization of health care furnished by health care 

10 providers under the contract health services program 

11 funded by the Indian Health Service and operated 

12 by the Indian Health Service, an Indian Tribe, or a 

13 Tribal Organization (as those terms are defined in 

14 section 4 of the Indian Health Care Improvement 

15 Act). 

16 (2) ANALYSIS.—The study conducted under 

17 paragraph (1) shall include an analysis of—

18 (A) the amounts reimbursed under the 

19 contract health services program described in 

20 paragraph (1) for health care furnished by enti21 ties, individual providers, and suppliers, includ22 ing a comparison of reimbursement for such 

23 health care through other public programs and 

24 in the private sector; 
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1 (B) barriers to accessing care under such 

2 contract health services program, including, but 

3 not limited to, barriers relating to travel dis4 tances, cultural differences, and public and pri5 vate sector reluctance to furnish care to pa6 tients under such program; 

7 (C) the adequacy of existing Federal fund8 ing for health care under such contract health 

9 services program; and 

10 (D) any other items determined appro11 priate by the Comptroller General. 

12 (b) REPORT.—Not later than 18 months after the 

13 date of enactment of this Act, the Comptroller General 

14 shall submit to Congress a report on the study conducted 

15 under subsection (a), together with recommendations re16 garding—

17 (1) the appropriate level of Federal funding 

18 that should be established for health care under the 

19 contract health services program described in sub20 section (a)(1); and 

21 (2) how to most efficiently utilize such funding. 

22 (c) CONSULTATION.—In conducting the study under 

23 subsection (a) and preparing the report under subsection 

24 (b), the Comptroller General shall consult with the Indian 

25 Health Service, Indian Tribes, and Tribal Organizations. 
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1 SEC. 106. GAO STUDY OF MEMBERSHIP CRITERIA FOR FED2 ERALLY RECOGNIZED INDIAN TRIBES. 

3 Not later than 1 year after the date of enactment 

4 of this Act, the Comptroller General of the United States 

5 shall conduct a study of membership criteria for federally 

6 recognized Indian tribes, including—

7 (1) the number of federally recognized Indian 

8 tribes in existence on the date on which the study 

9 is conducted; 

10 (2) the number of those Indian tribes that use 

11 blood quantum as a criterion for membership in the 

12 Indian tribe and the importance assigned to that cri13 terion; 

14 (3) the percentage of members of federally rec15 ognized Indian tribes that possesses degrees of In16 dian blood of—

(A) 1 17 ⁄4; 

(B) 1 18 ⁄8; and 

(C) 1 19 ⁄16; and 

20 (4) the variance in wait times and rationing of 

21 health care services within the Service between fed22 erally recognized Indian Tribes that use blood quan23 tum as a criterion for membership and those Indian 

24 Tribes that do not use blood quantum as such a cri25 terion. 
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1 SEC. 107. GAO STUDY OF TRIBAL JUSTICE SYSTEMS. 

2 (a) IN GENERAL.—Not later than 1 year after the 

3 date of enactment of this Act, the Comptroller General 

4 of the United States shall conduct, and submit to Con5 gress a report describing the results of, a study of the 

6 tribal justice systems of Indian tribes located in the States 

7 of North Dakota and South Dakota. 

8 (b) INCLUSIONS.—The study under subsection (a) 

9 shall include, with respect to the tribal system of each In10 dian tribe described in subsection (a) and the tribal justice 

11 system as a whole—

12 (1)(A) a description of how the tribal justice 

13 systems function, or are supposed to function; and 

14 (B) a description of the components of the trib15 al justice systems, such as tribal trial courts, courts 

16 of appeal, applicable tribal law, judges, qualifications 

17 of judges, the selection and removal of judges, turn18 over of judges, the creation of precedent, the record19 ing of precedent, the jurisdictional authority of the 

20 tribal court system, and the separation of powers be21 tween the tribal court system, the tribal council, and 

22 the head of the tribal government; 

23 (2) a review of the origins of the tribal justice 

24 systems, such as the development of the systems 

25 pursuant to the Act of June 18, 1934 (25 U.S.C. 

26 461 et seq.) (commonly known as the ‘‘Indian Reor-
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1 ganization Act’’), which promoted tribal constitu2 tions and addressed the tribal court system; 

3 (3) an analysis of the weaknesses of the tribal 

4 justice systems, including the adequacy of law en5 forcement personnel and detention facilities, in par6 ticular in relation to crime rates; and 

7 (4) an analysis of the measures that tribal offi8 cials suggest could be carried out to improve the 

9 tribal justice systems, including an analysis of how 

10 Federal law could improve and stabilize the tribal 

11 court system. 

12 TITLE II—IMPROVEMENT OF IN13 DIAN HEALTH CARE PRO14 VIDED UNDER THE SOCIAL 

15 SECURITY ACT 

16 SEC. 201. EXPANSION OF PAYMENTS UNDER MEDICARE, 

17 MEDICAID, AND SCHIP FOR ALL COVERED 

18 SERVICES FURNISHED BY INDIAN HEALTH 

19 PROGRAMS. 

20 (a) MEDICAID.—

21 (1) EXPANSION TO ALL COVERED SERVICES.—

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

23 1396j) is amended—

24 (A) by amending the heading to read as 

25 follows: 
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1 ‘‘SEC. 1911. INDIAN HEALTH PROGRAMS.’’; 

2 and 

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

4 follows: 

5 ‘‘(a) ELIGIBILITY FOR PAYMENT FOR MEDICAL AS6 SISTANCE.—The Indian Health Service and an Indian 

7 Tribe, Tribal Organization, or an Urban Indian Organiza8 tion shall be eligible for payment for medical assistance 

9 provided under a State plan or under waiver authority 

10 with respect to items and services furnished by the Indian 

11 Health Service, Indian Tribe, Tribal Organization, or 

12 Urban Indian Organization if the furnishing of such serv13 ices meets all the conditions and requirements which are 

14 applicable generally to the furnishing of items and services 

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

16 (2) COMPLIANCE WITH CONDITIONS AND RE17 QUIREMENTS.—Subsection (b) of such section is 

18 amended to read as follows: 

19 ‘‘(b) COMPLIANCE WITH CONDITIONS AND REQUIRE20 MENTS.—A facility of the Indian Health Service or an In21 dian Tribe, Tribal Organization, or an Urban Indian Or22 ganization which is eligible for payment under subsection 

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

24 but which does not meet all of the conditions and require25 ments of this title and under a State plan or waiver au26 thority which are applicable generally to such facility, shall 
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1 make such improvements as are necessary to achieve or 

2 maintain compliance with such conditions and require3 ments in accordance with a plan submitted to and accept4 ed by the Secretary for achieving or maintaining compli5 ance with such conditions and requirements, and shall be 

6 deemed to meet such conditions and requirements (and to 

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

8 to the extent of its actual compliance with such conditions 

9 and requirements, during the first 12 months after the 

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

11 (3) REVISION OF AUTHORITY TO ENTER INTO

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

13 amended to read as follows: 

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

15 The Secretary may enter into an agreement with a State 

16 for the purpose of reimbursing the State for medical as17 sistance provided by the Indian Health Service, an Indian 

18 Tribe, Tribal Organization, or an Urban Indian Organiza19 tion (as so defined), directly, through referral, or under 

20 contracts or other arrangements between the Indian 

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

22 an Urban Indian Organization and another health care 

23 provider to Indians who are eligible for medical assistance 

24 under the State plan or under waiver authority.’’. 
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1 (4) CROSS-REFERENCES TO SPECIAL FUND FOR

2 IMPROVEMENT OF IHS FACILITIES; DIRECT BILLING

3 OPTION; DEFINITIONS.—Such section is further 

4 amended by striking subsection (d) and adding at 

5 the end the following new subsections: 

6 ‘‘(d) SPECIAL FUND FOR IMPROVEMENT OF IHS FA7 CILITIES.—For provisions relating to the authority of the 

8 Secretary to place payments to which a facility of the In9 dian Health Service is eligible for payment under this title 

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

11 the Indian Health Care Improvement Act, and the require12 ment to use amounts paid from such fund for making im13 provements in accordance with subsection (b), see sub14 paragraphs (A) and (B) of section 401(c)(1) of such Act. 

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

16 the authority of a Tribal Health Program or an Urban 

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

18 payment for, health care items and services provided by 

19 such Program or Organization for which payment is made 

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

21 Care Improvement Act. 

22 ‘‘(f) DEFINITIONS.—In this section, the terms ‘In23 dian Health Program’, ‘Indian Tribe’,‘Tribal Health Pro24 gram’, ‘Tribal Organization’, and ‘Urban Indian Organi-
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1 zation’ have the meanings given those terms in section 4 

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

3 (b) MEDICARE.—

4 (1) EXPANSION TO ALL COVERED SERVICES.—

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

6 amended—

7 (A) by amending the heading to read as 

8 follows: 

9 ‘‘SEC. 1880. INDIAN HEALTH PROGRAMS.’’; 

10 and 

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

12 follows: 

13 ‘‘(a) ELIGIBILITY FOR PAYMENTS.—Subject to sub14 section (e), the Indian Health Service and an Indian 

15 Tribe, Tribal Organization, or an Urban Indian Organiza16 tion shall be eligible for payments under this title with 

17 respect to items and services furnished by the Indian 

18 Health Service, Indian Tribe, Tribal Organization, or 

19 Urban Indian Organization if the furnishing of such serv20 ices meets all the conditions and requirements which are 

21 applicable generally to the furnishing of items and services 

22 under this title.’’. 

23 (2) COMPLIANCE WITH CONDITIONS AND RE24 QUIREMENTS.—Subsection (b) of such section is 

25 amended to read as follows: 
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1 ‘‘(b) COMPLIANCE WITH CONDITIONS AND REQUIRE2 MENTS.—Subject to subsection (e), a facility of the Indian 

3 Health Service or an Indian Tribe, Tribal Organization, 

4 or an Urban Indian Organization which is eligible for pay5 ment under subsection (a) with respect to the furnishing 

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

7 conditions and requirements of this title which are applica8 ble generally to such facility, shall make such improve9 ments as are necessary to achieve or maintain compliance 

10 with such conditions and requirements in accordance with 

11 a plan submitted to and accepted by the Secretary for 

12 achieving or maintaining compliance with such conditions 

13 and requirements, and shall be deemed to meet such con14 ditions and requirements (and to be eligible for payment 

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

16 compliance with such conditions and requirements, during 

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

18 is submitted.’’. 

19 (3) CROSS-REFERENCES TO SPECIAL FUND FOR

20 IMPROVEMENT OF IHS FACILITIES; DIRECT BILLING

21 OPTION; DEFINITIONS.—

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

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

24 and inserting the following new subsections: 
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1 ‘‘(c) SPECIAL FUND FOR IMPROVEMENT OF IHS FA2 CILITIES.—For provisions relating to the authority of the 

3 Secretary to place payments to which a facility of the In4 dian Health Service is eligible for payment under this title 

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

6 the Indian Health Care Improvement Act, and the require7 ment to use amounts paid from such fund for making im8 provements in accordance with subsection (b), see sub9 paragraphs (A) and (B) of section 401(c)(1) of such Act. 

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

11 the authority of a Tribal Health Program or an Urban 

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

13 payment for, health care items and services provided by 

14 such Program or Organization for which payment is made 

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

16 Care Improvement Act.’’. 

17 (B) CONFORMING AMENDMENT.—Para18 graph (3) of section 1880(e) of such Act (42 

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

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

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

22 (4) DEFINITIONS.—Such section is further 

23 amended by amending subsection (f) to read as fol24 lows: 
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1 ‘‘(f) DEFINITIONS.—In this section, the terms ‘In2 dian Health Program’, ‘Indian Tribe’, ‘Service Unit’, 

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

4 ‘Urban Indian Organization’ have the meanings given 

5 those terms in section 4 of the Indian Health Care Im6 provement Act.’’. 

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

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

9 amended—

10 (1) by redesignating subparagraph (D) as sub11 paragraph (E); and 

12 (2) by inserting after subparagraph (C), the fol13 lowing new subparagraph: 

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

15 Health Programs, other than subsection (d) of 

16 such section).’’. 

17 SEC. 202. INCREASED OUTREACH TO INDIANS UNDER MED18 ICAID AND SCHIP AND IMPROVED COOPERA19 TION IN THE PROVISION OF ITEMS AND 

20 SERVICES TO INDIANS UNDER SOCIAL SECU21 RITY ACT HEALTH BENEFIT PROGRAMS. 

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

23 1320b–9) is amended to read as follows: 
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1 ‘‘SEC. 1139. IMPROVED ACCESS TO, AND DELIVERY OF, 

2 HEALTH CARE FOR INDIANS UNDER TITLES 

3 XVIII, XIX, AND XXI. 

4 ‘‘(a) AGREEMENTS WITH STATES FOR MEDICAID

5 AND SCHIP OUTREACH ON OR NEAR RESERVATIONS TO

6 INCREASE THE ENROLLMENT OF INDIANS IN THOSE

7 PROGRAMS.—

8 ‘‘(1) IN GENERAL.—In order to improve the ac9 cess of Indians residing on or near a reservation to 

10 obtain benefits under the Medicaid and State chil11 dren’s health insurance programs established under 

12 titles XIX and XXI, the Secretary shall encourage 

13 the State to take steps to provide for enrollment on 

14 or near the reservation. Such steps may include out15 reach efforts such as the outstationing of eligibility 

16 workers, entering into agreements with the Indian 

17 Health Service, Indian Tribes, Tribal Organizations, 

18 and Urban Indian Organizations to provide out19 reach, education regarding eligibility and benefits, 

20 enrollment, and translation services when such serv21 ices are appropriate. 

22 ‘‘(2) CONSTRUCTION.—Nothing in subpara23 graph (A) shall be construed as affecting arrange24 ments entered into between States and the Indian 

25 Health Service, Indian Tribes, Tribal Organizations, 

26 or Urban Indian Organizations for such Service, 
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1 Tribes, or Organizations to conduct administrative 

2 activities under such titles. 

3 ‘‘(b) REQUIREMENT TO FACILITATE COOPERA4 TION.—The Secretary, acting through the Centers for 

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

6 necessary to facilitate cooperation with, and agreements 

7 between, States and the Indian Health Service, Indian 

8 Tribes, Tribal Organizations, or Urban Indian Organiza9 tions with respect to the provision of health care items 

10 and services to Indians under the programs established 

11 under title XVIII, XIX, or XXI. 

12 ‘‘(c) DEFINITION OF INDIAN; INDIAN TRIBE; INDIAN

13 HEALTH PROGRAM; TRIBAL ORGANIZATION; URBAN IN14 DIAN ORGANIZATION.—In this section, the terms ‘Indian’, 

15 ‘Indian Tribe’, ‘Indian Health Program’, ‘Tribal Organi16 zation’, and ‘Urban Indian Organization’ have the mean17 ings given those terms in section 4 of the Indian Health 

18 Care Improvement Act.’’. 

19 SEC. 203. ADDITIONAL PROVISIONS TO INCREASE OUT20 REACH TO, AND ENROLLMENT OF, INDIANS 

21 IN SCHIP AND MEDICAID. 

22 (a) NONAPPLICATION OF 10 PERCENT LIMIT ON

23 OUTREACH AND CERTAIN OTHER EXPENDITURES.—Sec24 tion 2105(c)(2) of the Social Security Act (42 U.S.C. 
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1 1397ee(c)(2)) is amended by adding at the end the fol2 lowing new subparagraph: 

3 ‘‘(C) NONAPPLICATION TO EXPENDITURES

4 FOR OUTREACH TO INCREASE THE ENROLL5 MENT OF INDIAN CHILDREN UNDER THIS TITLE

6 AND TITLE XIX.—The limitation under sub7 paragraph (A) on expenditures for items de8 scribed in subsection (a)(1)(D) shall not apply 

9 in the case of expenditures for outreach activi10 ties to families of Indian children likely to be el11 igible for child health assistance under the plan 

12 or medical assistance under the State plan 

13 under title XIX (or under a waiver of such 

14 plan), to inform such families of the availability 

15 of, and to assist them in enrolling their children 

16 in, such plans, including such activities con17 ducted under grants, contracts, or agreements 

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

19 (b) ASSURANCE OF PAYMENTS TO INDIAN HEALTH

20 CARE PROVIDERS FOR CHILD HEALTH ASSISTANCE.—

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

22 1397bb(b)(3)(D)) is amended by striking ‘‘(as defined in 

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

24 25 U.S.C. 1603(c))’’ and inserting ‘‘, including how the 

25 State will ensure that payments are made to Indian 
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1 Health Programs and Urban Indian Organizations oper2 ating in the State for the provision of such assistance’’. 

3 (c) INCLUSION OF OTHER INDIAN FINANCED

4 HEALTH CARE PROGRAMS IN EXEMPTION FROM PROHI5 BITION ON CERTAIN PAYMENTS.—Section 2105(c)(6)(B) 

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

7 striking ‘‘insurance program, other than an insurance pro8 gram operated or financed by the Indian Health Service’’ 

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

10 operated or financed by the Indian Health Service or by 

11 an Indian Tribe, Tribal Organization, or Urban Indian 

12 Organization’’. 

13 (d) SATISFACTION OF MEDICAID DOCUMENTATION

14 REQUIREMENTS.—Section 1903(x)(3)(B) of the Social Se15 curity Act (42 U.S.C. 1396b(x)(3)(B)) is amended—

16 (1) by redesignating clause (v) as clause (vii); 

17 and 

18 (2) by inserting after clause (iv), the following 

19 new clauses: 

20 ‘‘(v) Except as provided in clause (vi), a docu21 ment issued by a federally recognized Indian tribe 

22 evidencing membership or enrollment in, or affili23 ation with, such tribe (such as a tribal enrollment 

24 card or certificate of degree of Indian blood). 
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1 ‘‘(vi)(I) With respect to those federally recog2 nized Indian tribes located within States having an 

3 international border whose membership includes in4 dividuals who are not citizens of the United States 

5 documentation (including tribal documentation, if 

6 appropriate) that the Secretary determines to be sat7 isfactory documentary evidence of United States citi8 zenship or nationality under the regulations adopted 

9 pursuant to subclause (II). 

10 ‘‘(II) Not later than 90 days after the date of 

11 enactment of this subclause, the Secretary, in con12 sultation with the tribes referred to in subclause (I), 

13 shall promulgate interim final regulations specifying 

14 the forms of documentation (including tribal docu15 mentation, if appropriate) deemed to be satisfactory 

16 evidence of the United States citizenship or nation17 ality of a member of any such Indian tribe for pur18 poses of satisfying the requirements of this sub19 section. 

20 ‘‘(III) During the period that begins on the 

21 date of enactment of this clause and ends on the ef22 fective date of the interim final regulations promul23 gated under subclause (II), a document issued by a 

24 federally recognized Indian tribe referred to in sub25 clause (I) evidencing membership or enrollment in, 
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1 or affiliation with, such tribe (such as a tribal enroll2 ment card or certificate of degree of Indian blood) 

3 accompanied by a signed attestation that the indi4 vidual is a citizen of the United States and a certifi5 cation by the appropriate officer or agent of the In6 dian tribe that the membership or other records 

7 maintained by the Indian tribe indicate that the in8 dividual was born in the United States is deemed to 

9 be a document described in this subparagraph for 

10 purposes of satisfying the requirements of this sub11 section.’’. 

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

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

14 following new paragraph: 

15 ‘‘(9) INDIAN; INDIAN HEALTH PROGRAM; IN16 DIAN TRIBE; ETC.—The terms ‘Indian’, ‘Indian 

17 Health Program’, ‘Indian Tribe’, ‘Tribal Organiza18 tion’, and ‘Urban Indian Organization’ have the 

19 meanings given those terms in section 4 of the In20 dian Health Care Improvement Act.’’. 
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1 SEC. 204. PREMIUMS AND COST SHARING PROTECTIONS 

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

4 PROTECTION OF CERTAIN INDIAN PROPERTY 

5 FROM MEDICAID ESTATE RECOVERY. 

6 (a) PREMIUMS AND COST SHARING PROTECTION

7 UNDER MEDICAID.—

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

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

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

12 inserting ‘‘, (i), and (j)’’; and 

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

14 subsection: 

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

16 FURNISHED ITEMS OR SERVICES DIRECTLY BY INDIAN

17 HEALTH PROGRAMS OR THROUGH REFERRAL UNDER

18 THE CONTRACT HEALTH SERVICE.—

19 ‘‘(1) NO COST SHARING FOR INDIANS FUR20 NISHED ITEMS OR SERVICES DIRECTLY BY OR

21 THROUGH INDIAN HEALTH PROGRAMS.—

22 ‘‘(A) NO ENROLLMENT FEES, PREMIUMS, 

23 OR COPAYMENTS.—

24 ‘‘(i) IN GENERAL.—No enrollment fee, 

25 premium, or similar charge, and no deduc26 tion, copayment, cost sharing, or similar 
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1 charge shall be imposed against an Indian 

2 who is furnished an item or service directly 

3 by the Indian Health Service, an Indian 

4 Tribe, a Tribal Organization, or an urban 

5 Indian organization, or by a health care 

6 provider through referral under the con7 tract health service for which payment may 

8 be made under this title. 

9 ‘‘(ii) EXCEPTION.—Clause (i) shall 

10 not apply to an individual only eligible for 

11 the programs or services under sections 

12 102 and 103 or title V of the Indian 

13 Health Care Improvement Act. 

14 ‘‘(B) NO REDUCTION IN AMOUNT OF PAY15 MENT TO INDIAN HEALTH PROVIDERS.—Pay16 ment due under this title to the Indian Health 

17 Service, an Indian Tribe, Tribal Organization, 

18 or Urban Indian Organization, or a health care 

19 provider through referral under the contract 

20 health service for the furnishing of an item or 

21 service to an Indian who is eligible for assist22 ance under such title, may not be reduced by 

23 the amount of any enrollment fee, premium, or 

24 similar charge, or any deduction, copayment, 

25 cost sharing, or similar charge that would be 
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1 due from the Indian but for the operation of 

2 subparagraph (A). 

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

4 this subsection shall be construed as restricting the 

5 application of any other limitations on the imposi6 tion of premiums or cost sharing that may apply to 

7 an individual receiving medical assistance under this 

8 title who is an Indian. 

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

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

11 Tribe’, ‘Tribal Organization’, and ‘Urban Indian Or12 ganization’ have the meanings given those terms in 

13 section 4 of the Indian Health Care Improvement 

14 Act.’’. 

15 (2) CONFORMING AMENDMENT.—Section 

16 1916A(a)(1) of such Act (42 U.S.C. 1396o–1(a)(1)) 

17 is amended by striking ‘‘section 1916(g)’’ and in18 serting ‘‘subsections (g), (i), or (j) of section 1916’’. 

19 (3) EFFECTIVE DATE.—The amendments made 

20 by this subsection take effect on October 1, 2009. 

21 (b) TREATMENT OF CERTAIN PROPERTY FOR MED22 ICAID AND SCHIP ELIGIBILITY.—

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

24 Security Act (42 U.S.C. 1396a) is amended by add25 ing at the end the following new paragraph: 
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1 ‘‘(13) Notwithstanding any other requirement 

2 of this title or any other provision of Federal or 

3 State law, a State shall disregard the following prop4 erty for purposes of determining the eligibility of an 

5 individual who is an Indian (as defined in section 4 

6 of the Indian Health Care Improvement Act) for 

7 medical assistance under this title: 

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

9 improvements, that is held in trust, subject to 

10 Federal restrictions, or otherwise under the su11 pervision of the Secretary of the Interior, lo12 cated on a reservation, including any federally 

13 recognized Indian Tribe’s reservation, pueblo, 

14 or colony, including former reservations in 

15 Oklahoma, Alaska Native regions established by 

16 the Alaska Native Claims Settlement Act, and 

17 Indian allotments on or near a reservation as 

18 designated and approved by the Bureau of In19 dian Affairs of the Department of the Interior. 

20 ‘‘(B) For any federally recognized Tribe 

21 not described in subparagraph (A), property lo22 cated within the most recent boundaries of a 

23 prior Federal reservation. 

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

25 royalties, or usage rights related to natural re-
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1 sources (including extraction of natural re2 sources or harvesting of timber, other plants 

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

4 resulting from the exercise of federally pro5 tected rights. 

6 ‘‘(D) Ownership interests in or usage 

7 rights to items not covered by subparagraphs 

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

9 spiritual, traditional, or cultural significance or 

10 rights that support subsistence or a traditional 

11 lifestyle according to applicable tribal law or 

12 custom.’’. 

13 (2) APPLICATION TO SCHIP.—Section 

14 2107(e)(1) of such Act (42 U.S.C. 1397gg(e)(1)) is 

15 amended—

16 (A) by redesignating subparagraphs (B) 

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

18 (F), respectively; and 

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

20 the following new subparagraph: 

21 ‘‘(B) Section 1902(e)(13) (relating to dis22 regard of certain property for purposes of mak23 ing eligibility determinations).’’. 

24 (c) CONTINUATION OF CURRENT LAW PROTECTIONS

25 OF CERTAIN INDIAN PROPERTY FROM MEDICAID ESTATE
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1 RECOVERY.—Section 1917(b)(3) of the Social Security 

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

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

4 (2) by adding at the end the following new sub5 paragraph: 

6 ‘‘(B) The standards specified by the Sec7 retary under subparagraph (A) shall require 

8 that the procedures established by the State 

9 agency under subparagraph (A) exempt income, 

10 resources, and property that are exempt from 

11 the application of this subsection as of April 1, 

12 2003, under manual instructions issued to carry 

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

14 because of the Federal responsibility for Indian 

15 Tribes and Alaska Native Villages. Nothing in 

16 this subparagraph shall be construed as pre17 venting the Secretary from providing additional 

18 estate recovery exemptions under this title for 

19 Indians.’’. 

20 SEC. 205. NONDISCRIMINATION IN QUALIFICATIONS FOR 

21 PAYMENT FOR SERVICES UNDER FEDERAL 

22 HEALTH CARE PROGRAMS. 

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

24 1320b–9), as amended by section 202, is amended by re-
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1 designating subsection (c) as subsection (d), and inserting 

2 after subsection (b) the following new subsection: 

3 ‘‘(c) NONDISCRIMINATION IN QUALIFICATIONS FOR

4 PAYMENT FOR SERVICES UNDER FEDERAL HEALTH

5 CARE PROGRAMS.—

6 ‘‘(1) REQUIREMENT TO SATISFY GENERALLY

7 APPLICABLE PARTICIPATION REQUIREMENTS.—

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

9 program must accept an entity that is operated 

10 by the Indian Health Service, an Indian Tribe, 

11 Tribal Organization, or Urban Indian Organiza12 tion as a provider eligible to receive payment 

13 under the program for health care services fur14 nished to an Indian on the same basis as any 

15 other provider qualified to participate as a pro16 vider of health care services under the program 

17 if the entity meets generally applicable State or 

18 other requirements for participation as a pro19 vider of health care services under the program. 

20 ‘‘(B) SATISFACTION OF STATE OR LOCAL

21 LICENSURE OR RECOGNITION REQUIRE22 MENTS.—Any requirement for participation as 

23 a provider of health care services under a Fed24 eral health care program that an entity be li25 censed or recognized under the State or local 
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1 law where the entity is located to furnish health 

2 care services shall be deemed to have been met 

3 in the case of an entity operated by the Indian 

4 Health Service, an Indian Tribe, Tribal Organi5 zation, or Urban Indian Organization if the en6 tity meets all the applicable standards for such 

7 licensure or recognition, regardless of whether 

8 the entity obtains a license or other documenta9 tion under such State or local law. In accord10 ance with section 221 of the Indian Health 

11 Care Improvement Act, the absence of the licen12 sure of a health care professional employed by 

13 such an entity under the State or local law 

14 where the entity is located shall not be taken 

15 into account for purposes of determining wheth16 er the entity meets such standards, if the pro17 fessional is licensed in another State. 

18 ‘‘(2) PROHIBITION ON FEDERAL PAYMENTS TO

19 ENTITIES OR INDIVIDUALS EXCLUDED FROM PAR20 TICIPATION IN FEDERAL HEALTH CARE PROGRAMS

21 OR WHOSE STATE LICENSES ARE UNDER SUSPEN22 SION OR HAVE BEEN REVOKED.—

23 ‘‘(A) EXCLUDED ENTITIES.—No entity op24 erated by the Indian Health Service, an Indian 

25 Tribe, Tribal Organization, or Urban Indian 
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1 Organization that has been excluded from par2 ticipation in any Federal health care program 

3 or for which a license is under suspension or 

4 has been revoked by the State where the entity 

5 is located shall be eligible to receive payment 

6 under any such program for health care serv7 ices furnished to an Indian. 

8 ‘‘(B) EXCLUDED INDIVIDUALS.—No indi9 vidual who has been excluded from participation 

10 in any Federal health care program or whose 

11 State license is under suspension or has been 

12 revoked shall be eligible to receive payment 

13 under any such program for health care serv14 ices furnished by that individual, directly or 

15 through an entity that is otherwise eligible to 

16 receive payment for health care services, to an 

17 Indian. 

18 ‘‘(C) FEDERAL HEALTH CARE PROGRAM

19 DEFINED.—In this subsection, the term, ‘Fed20 eral health care program’ has the meaning 

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

22 that, for purposes of this subsection, such term 

23 shall include the health insurance program 

24 under chapter 89 of title 5, United States 

25 Code.’’. 
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1 SEC. 206. CONSULTATION ON MEDICAID, SCHIP, AND 

2 OTHER HEALTH CARE PROGRAMS FUNDED 

3 UNDER THE SOCIAL SECURITY ACT INVOLV4 ING INDIAN HEALTH PROGRAMS AND URBAN 

5 INDIAN ORGANIZATIONS. 

6 (a) IN GENERAL.—Section 1139 of the Social Secu7 rity Act (42 U.S.C. 1320b–9), as amended by sections 202 

8 and 205, is amended by redesignating subsection (d) as 

9 subsection (e), and inserting after subsection (c) the fol10 lowing new subsection: 

11 ‘‘(d) CONSULTATION WITH TRIBAL TECHNICAL AD12 VISORY GROUP (TTAG).—The Secretary shall maintain 

13 within the Centers for Medicaid & Medicare Services 

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

15 accordance with requirements of the charter dated Sep16 tember 30, 2003, and in such group shall include a rep17 resentative of the Urban Indian Organizations and the 

18 Service. The representative of the Urban Indian Organiza19 tion shall be deemed to be an elected officer of a tribal 

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

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

22 1534(b)).’’. 

23 (b) SOLICITATION OF ADVICE UNDER MEDICAID AND

24 SCHIP.—
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1 (1) MEDICAID STATE PLAN AMENDMENT.—Sec2 tion 1902(a) of the Social Security Act (42 U.S.C. 

3 1396a(a)) is amended—

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

5 at the end; 

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

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

8 and 

9 (C) by inserting after paragraph 

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

11 ‘‘(71) in the case of any State in which the In12 dian Health Service operates or funds health care 

13 programs, or in which 1 or more Indian Health Pro14 grams or Urban Indian Organizations (as such 

15 terms are defined in section 4 of the Indian Health 

16 Care Improvement Act) provide health care in the 

17 State for which medical assistance is available under 

18 such title, provide for a process under which the 

19 State seeks advice on a regular, ongoing basis from 

20 designees of such Indian Health Programs and 

21 Urban Indian Organizations on matters relating to 

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

23 direct effect on such Indian Health Programs and 

24 Urban Indian Organizations and that—
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1 ‘‘(A) shall include solicitation of advice 

2 prior to submission of any plan amendments, 

3 waiver requests, and proposals for demonstra4 tion projects likely to have a direct effect on In5 dians, Indian Health Programs, or Urban In6 dian Organizations; and 

7 ‘‘(B) may include appointment of an advi8 sory committee and of a designee of such In9 dian Health Programs and Urban Indian Orga10 nizations to the medical care advisory com11 mittee advising the State on its State plan 

12 under this title.’’. 

13 (2) APPLICATION TO SCHIP.—Section 

14 2107(e)(1) of such Act (42 U.S.C. 1397gg(e)(1)), as 

15 amended by section 204(b)(2), is amended—

16 (A) by redesignating subparagraphs (B) 

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

18 respectively; and 

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

20 the following new subparagraph: 

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

22 option of certain States to seek advice from 

23 designees of Indian Health Programs and 

24 Urban Indian Organizations).’’. 
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1 (c) RULE OF CONSTRUCTION.—Nothing in the 

2 amendments made by this section shall be construed as 

3 superseding existing advisory committees, working groups, 

4 guidance, or other advisory procedures established by the 

5 Secretary of Health and Human Services or by any State 

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

7 (d) EFFECTIVE DATE.—This section and the amend8 ments made by this section take effect on October 1, 2009. 

9 SEC. 207. EXCLUSION WAIVER AUTHORITY FOR AFFECTED 

10 INDIAN HEALTH PROGRAMS AND SAFE HAR11 BOR TRANSACTIONS UNDER THE SOCIAL SE12 CURITY ACT. 

13 (a) EXCLUSION WAIVER AUTHORITY.—Section 1128 

14 of the Social Security Act (42 U.S.C. 1320a–7) is amend15 ed by adding at the end the following new subsection: 

16 ‘‘(k) ADDITIONAL EXCLUSION WAIVER AUTHORITY

17 FOR AFFECTED INDIAN HEALTH PROGRAMS.—In addi18 tion to the authority granted the Secretary under sub19 sections (c)(3)(B) and (d)(3)(B) to waive an exclusion 

20 under subsection (a)(1), (a)(3), (a)(4), or (b), the Sec21 retary may, in the case of an Indian Health Program, 

22 waive such an exclusion upon the request of the adminis23 trator of an affected Indian Health Program (as defined 

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

25 who determines that the exclusion would impose a hard-
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1 ship on individuals entitled to benefits under or enrolled 

2 in a Federal health care program.’’. 

3 (b) CERTAIN TRANSACTIONS INVOLVING INDIAN

4 HEALTH CARE PROGRAMS DEEMED TO BE IN SAFE HAR5 BORS.—Section 1128B(b) of the Social Security Act (42 

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

7 following new paragraph: 

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

9 promulgate from time to time as necessary to prevent 

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

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

12 treated as remuneration: 

13 ‘‘(A) TRANSFERS BETWEEN INDIAN HEALTH

14 PROGRAMS, INDIAN TRIBES, TRIBAL ORGANIZATIONS, 

15 AND URBAN INDIAN ORGANIZATIONS.—Transfers of 

16 anything of value between or among an Indian 

17 Health Program, Indian Tribe, Tribal Organization, 

18 or Urban Indian Organization, that are made for the 

19 purpose of providing necessary health care items and 

20 services to any patient served by such Program, 

21 Tribe, or Organization and that consist of—

22 ‘‘(i) services in connection with the collec23 tion, transport, analysis, or interpretation of di24 agnostic specimens or test data; 

25 ‘‘(ii) inventory or supplies; 
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1 ‘‘(iii) staff; or 

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

3 or cost sharing. 

4 ‘‘(B) TRANSFERS BETWEEN INDIAN HEALTH

5 PROGRAMS, INDIAN TRIBES, TRIBAL ORGANIZATIONS, 

6 OR URBAN INDIAN ORGANIZATIONS AND PA7 TIENTS.—Transfers of anything of value between an 

8 Indian Health Program, Indian Tribe, Tribal Orga9 nization, or Urban Indian Organization and any pa10 tient served or eligible for service from an Indian 

11 Health Program, Indian Tribe, Tribal Organization, 

12 or Urban Indian Organization, including any patient 

13 served or eligible for service pursuant to section 807 

14 of the Indian Health Care Improvement Act, but 

15 only if such transfers—

16 ‘‘(i) consist of expenditures related to pro17 viding transportation for the patient for the 

18 provision of necessary health care items or serv19 ices, provided that the provision of such trans20 portation is not advertised, nor an incentive of 

21 which the value is disproportionately large in 

22 relationship to the value of the health care item 

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

24 or service itself or, for preventative items or 
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1 services, the future health care costs reasonably 

2 expected to be avoided); 

3 ‘‘(ii) consist of expenditures related to pro4 viding housing to the patient (including a preg5 nant patient) and immediate family members or 

6 an escort necessary to assuring the timely pro7 vision of health care items and services to the 

8 patient, provided that the provision of such 

9 housing is not advertised nor an incentive of 

10 which the value is disproportionately large in 

11 relationship to the value of the health care item 

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

13 or service itself or, for preventative items or 

14 services, the future health care costs reasonably 

15 expected to be avoided); or 

16 ‘‘(iii) are for the purpose of paying pre17 miums or cost sharing on behalf of such a pa18 tient, provided that the making of such pay19 ment is not subject to conditions other than 

20 conditions agreed to under a contract for the 

21 delivery of contract health services. 

22 ‘‘(C) CONTRACT HEALTH SERVICES.—A trans23 fer of anything of value negotiated as part of a con24 tract entered into between an Indian Health Pro25 gram, Indian Tribe, Tribal Organization, Urban In-
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1 dian Organization, or the Indian Health Service and 

2 a contract care provider for the delivery of contract 

3 health services authorized by the Indian Health 

4 Service, provided that—

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

6 or value of referrals or other business generated 

7 by the parties; and 

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

9 market value of the health care items or serv10 ices provided or, in the case of a transfer of 

11 items or services related to preventative care, 

12 the value of the future health care costs reason13 ably expected to be avoided. 

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

15 of anything of value involving an Indian Health Pro16 gram, Indian Tribe, Tribal Organization, or Urban 

17 Indian Organization, or a patient served or eligible 

18 for service from an Indian Health Program, Indian 

19 Tribe, Tribal Organization, or Urban Indian Organi20 zation, that the Secretary, in consultation with the 

21 Attorney General, determines is appropriate, taking 

22 into account the special circumstances of such In23 dian Health Programs, Indian Tribes, Tribal Orga24 nizations, and Urban Indian Organizations, and of 
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1 patients served by such Programs, Tribes, and Orga2 nizations.’’. 

3 SEC. 208. RULES APPLICABLE UNDER MEDICAID AND 

4 SCHIP TO MANAGED CARE ENTITIES WITH 

5 RESPECT TO INDIAN ENROLLEES AND IN6 DIAN HEALTH CARE PROVIDERS AND INDIAN 

7 MANAGED CARE ENTITIES. 

8 (a) IN GENERAL.—Section 1932 of the Social Secu9 rity Act (42 U.S.C. 1396u–2) is amended by adding at 

10 the end the following new subsection: 

11 ‘‘(h) SPECIAL RULES WITH RESPECT TO INDIAN EN12 ROLLEES, INDIAN HEALTH CARE PROVIDERS, AND IN13 DIAN MANAGED CARE ENTITIES.—

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

15 HEALTH CARE PROVIDER AS PRIMARY CARE PRO16 VIDER.—In the case of a non-Indian Medicaid man17 aged care entity that—

18 ‘‘(A) has an Indian enrolled with the enti19 ty; and 

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

21 that is participating as a primary care provider 

22 within the network of the entity, 

23 insofar as the Indian is otherwise eligible to receive 

24 services from such Indian health care provider and 

25 the Indian health care provider has the capacity to 
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1 provide primary care services to such Indian, the 

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

3 under section 1905(t)(3) shall require, as a condi4 tion of receiving payment under such contract, that 

5 the Indian shall be allowed to choose such Indian 

6 health care provider as the Indian’s primary care 

7 provider under the entity. 

8 ‘‘(2) ASSURANCE OF PAYMENT TO INDIAN

9 HEALTH CARE PROVIDERS FOR PROVISION OF COV10 ERED SERVICES.—Each contract with a managed 

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

12 1905(t)(3) shall require any such entity that has a 

13 significant percentage of Indian enrollees (as deter14 mined by the Secretary), as a condition of receiving 

15 payment under such contract to satisfy the following 

16 requirements: 

17 ‘‘(A) DEMONSTRATION OF PARTICIPATING

18 INDIAN HEALTH CARE PROVIDERS OR APPLICA19 TION OF ALTERNATIVE PAYMENT ARRANGE20 MENTS.—Subject to subparagraph (E), to—

21 ‘‘(i) demonstrate that the number of 

22 Indian health care providers that are par23 ticipating providers with respect to such 

24 entity are sufficient to ensure timely access 

25 to covered Medicaid managed care services 
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1 for those enrollees who are eligible to re2 ceive services from such providers; or 

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

4 providers who are not participating pro5 viders with the entity for covered Medicaid 

6 managed care services provided to those 

7 enrollees who are eligible to receive services 

8 from such providers at a rate equal to the 

9 rate negotiated between such entity and 

10 the provider involved or, if such a rate has 

11 not been negotiated, at a rate that is not 

12 less than the level and amount of payment 

13 which the entity would make for the serv14 ices if the services were furnished by a par15 ticipating provider which is not an Indian 

16 health care provider. 

17 ‘‘(B) PROMPT PAYMENT.—To agree to 

18 make prompt payment (in accordance with 

19 rules applicable to managed care entities) to In20 dian health care providers that are participating 

21 providers with respect to such entity or, in the 

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

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

24 in accordance with that subparagraph. 
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1 ‘‘(C) SATISFACTION OF CLAIM REQUIRE2 MENT.—To deem any requirement for the sub3 mission of a claim or other documentation for 

4 services covered under subparagraph (A) by the 

5 enrollee to be satisfied through the submission 

6 of a claim or other documentation by an Indian 

7 health care provider that is consistent with sec8 tion 403(h) of the Indian Health Care Improve9 ment Act. 

10 ‘‘(D) COMPLIANCE WITH GENERALLY AP11 PLICABLE REQUIREMENTS.—

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

13 (ii), as a condition of payment under sub14 paragraph (A), an Indian health care pro15 vider shall comply with the generally appli16 cable requirements of this title, the State 

17 plan, and such entity with respect to cov18 ered Medicaid managed care services pro19 vided by the Indian health care provider to 

20 the same extent that non-Indian providers 

21 participating with the entity must comply 

22 with such requirements. 

23 ‘‘(ii) LIMITATIONS ON COMPLIANCE

24 WITH MANAGED CARE ENTITY GENERALLY
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1 APPLICABLE REQUIREMENTS.—An Indian 

2 health care provider—

3 ‘‘(I) shall not be required to com4 ply with a generally applicable re5 quirement of a managed care entity 

6 described in clause (i) as a condition 

7 of payment under subparagraph (A) if 

8 such compliance would conflict with 

9 any other statutory or regulatory re10 quirements applicable to the Indian 

11 health care provider; and 

12 ‘‘(II) shall only need to comply 

13 with those generally applicable re14 quirements of a managed care entity 

15 described in clause (i) as a condition 

16 of payment under subparagraph (A) 

17 that are necessary for the entity’s 

18 compliance with the State plan, such 

19 as those related to care management, 

20 quality assurance, and utilization 

21 management. 

22 ‘‘(E) APPLICATION OF SPECIAL PAYMENT

23 REQUIREMENTS FOR FEDERALLY-QUALIFIED

24 HEALTH CENTERS AND ENCOUNTER RATE FOR
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1 SERVICES PROVIDED BY CERTAIN INDIAN

2 HEALTH CARE PROVIDERS.—

3 ‘‘(i) FEDERALLY-QUALIFIED HEALTH

4 CENTERS.—

5 ‘‘(I) MANAGED CARE ENTITY

6 PAYMENT REQUIREMENT.—To agree 

7 to pay any Indian health care provider 

8 that is a Federally-qualified health 

9 center but not a participating provider 

10 with respect to the entity, for the pro11 vision of covered Medicaid managed 

12 care services by such provider to an 

13 Indian enrollee of the entity at a rate 

14 equal to the amount of payment that 

15 the entity would pay a Federally16 qualified health center that is a par17 ticipating provider with respect to the 

18 entity but is not an Indian health care 

19 provider for such services. 

20 ‘‘(II) CONTINUED APPLICATION

21 OF STATE REQUIREMENT TO MAKE

22 SUPPLEMENTAL PAYMENT.—Nothing 

23 in subclause (I) or subparagraph (A) 

24 or (B) shall be construed as waiving 

25 the application of section 1902(bb)(5) 
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1 regarding the State plan requirement 

2 to make any supplemental payment 

3 due under such section to a Federally4 qualified health center for services 

5 furnished by such center to an en6 rollee of a managed care entity (re7 gardless of whether the Federally8 qualified health center is or is not a 

9 participating provider with the entity). 

10 ‘‘(ii) CONTINUED APPLICATION OF

11 ENCOUNTER RATE FOR SERVICES PRO12 VIDED BY CERTAIN INDIAN HEALTH CARE

13 PROVIDERS.—If the amount paid by a 

14 managed care entity to an Indian health 

15 care provider that is not a Federally-quali16 fied health center and that has elected to 

17 receive payment under this title as an In18 dian Health Service provider under the 

19 July 11, 1996, Memorandum of Agreement 

20 between the Health Care Financing Ad21 ministration (now the Centers for Medicare 

22 & Medicaid Services) and the Indian 

23 Health Service for services provided by 

24 such provider to an Indian enrollee with 

25 the managed care entity is less than the 
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1 encounter rate that applies to the provision 

2 of such services under such memorandum, 

3 the State plan shall provide for payment to 

4 the Indian health care provider of the dif5 ference between the applicable encounter 

6 rate under such memorandum and the 

7 amount paid by the managed care entity to 

8 the provider for such services. 

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

10 paragraph shall be construed as waiving the ap11 plication of section 1902(a)(30)(A) (relating to 

12 application of standards to assure that pay13 ments are consistent with efficiency, economy, 

14 and quality of care). 

15 ‘‘(3) OFFERING OF MANAGED CARE THROUGH

16 INDIAN MEDICAID MANAGED CARE ENTITIES.—If—

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

18 through Medicaid managed care entities under 

19 its Medicaid managed care program; and 

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

21 funded in whole or in part by the Indian Health 

22 Service, or a consortium composed of 1 or more 

23 Tribes, Tribal Organizations, or Urban Indian 

24 Organizations, and which also may include the 

25 Indian Health Service, has established an In-
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1 dian Medicaid managed care entity in the State 

2 that meets generally applicable standards re3 quired of such an entity under such Medicaid 

4 managed care program, 

5 the State shall offer to enter into an agreement with 

6 the entity to serve as a Medicaid managed care enti7 ty with respect to eligible Indians served by such en8 tity under such program. 

9 ‘‘(4) SPECIAL RULES FOR INDIAN MANAGED

10 CARE ENTITIES.—The following are special rules re11 garding the application of a Medicaid managed care 

12 program to Indian Medicaid managed care entities: 

13 ‘‘(A) ENROLLMENT.—

14 ‘‘(i) LIMITATION TO INDIANS.—An In15 dian Medicaid managed care entity may re16 strict enrollment under such program to 

17 Indians and to members of specific Tribes 

18 in the same manner as Indian Health Pro19 grams may restrict the delivery of services 

20 to such Indians and tribal members. 

21 ‘‘(ii) NO LESS CHOICE OF PLANS.—

22 Under such program the State may not 

23 limit the choice of an Indian among Med24 icaid managed care entities only to Indian 

25 Medicaid managed care entities or to be 
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1 more restrictive than the choice of man2 aged care entities offered to individuals 

3 who are not Indians. 

4 ‘‘(iii) DEFAULT ENROLLMENT.—

5 ‘‘(I) IN GENERAL.—If such pro6 gram of a State requires the enroll7 ment of Indians in a Medicaid man8 aged care entity in order to receive 

9 benefits, the State, taking into consid10 eration the criteria specified in sub11 section (a)(4)(D)(ii)(I), shall provide 

12 for the enrollment of Indians de13 scribed in subclause (II) who are not 

14 otherwise enrolled with such an entity 

15 in an Indian Medicaid managed care 

16 entity described in such clause. 

17 ‘‘(II) INDIAN DESCRIBED.—An 

18 Indian described in this subclause, 

19 with respect to an Indian Medicaid 

20 managed care entity, is an Indian 

21 who, based upon the service area and 

22 capacity of the entity, is eligible to be 

23 enrolled with the entity consistent 

24 with subparagraph (A). 
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1 ‘‘(iv) EXCEPTION TO STATE LOCK2 IN.—A request by an Indian who is en3 rolled under such program with a non-In4 dian Medicaid managed care entity to 

5 change enrollment with that entity to en6 rollment with an Indian Medicaid managed 

7 care entity shall be considered cause for 

8 granting such request under procedures 

9 specified by the Secretary. 

10 ‘‘(B) FLEXIBILITY IN APPLICATION OF

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

12 an Indian Medicaid managed care entity—

13 ‘‘(i) any reference to a ‘State’ in sub14 paragraph (A)(ii) of that section shall be 

15 deemed to be a reference to the ‘Sec16 retary’; and 

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

18 a public entity described in subparagraph 

19 (C)(ii) of that section. 

20 ‘‘(C) EXCEPTIONS TO ADVANCE DIREC21 TIVES.—The Secretary may modify or waive the 

22 requirements of section 1902(w) (relating to 

23 provision of written materials on advance direc24 tives) insofar as the Secretary finds that the re25 quirements otherwise imposed are not an appro-
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1 priate or effective way of communicating the in2 formation to Indians. 

3 ‘‘(D) FLEXIBILITY IN INFORMATION AND

4 MARKETING.—

5 ‘‘(i) MATERIALS.—The Secretary may 

6 modify requirements under subsection 

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

8 in that subsection is provided to enrollees 

9 and potential enrollees of Indian Medicaid 

10 managed care entities in a culturally ap11 propriate and understandable manner that 

12 clearly communicates to such enrollees and 

13 potential enrollees their rights, protections, 

14 and benefits. 

15 ‘‘(ii) DISTRIBUTION OF MARKETING

16 MATERIALS.—The provisions of subsection 

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

18 marketing materials to an entire service 

19 area shall be deemed satisfied in the case 

20 of an Indian Medicaid managed care entity 

21 that distributes appropriate materials only 

22 to those Indians who are potentially eligi23 ble to enroll with the entity in the service 

24 area. 
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1 ‘‘(5) MALPRACTICE INSURANCE.—Insofar as, 

2 under a Medicaid managed care program, a health 

3 care provider is required to have medical malpractice 

4 insurance coverage as a condition of contracting as 

5 a provider with a Medicaid managed care entity, an 

6 Indian health care provider that is—

7 ‘‘(A) a Federally-qualified health center 

8 that is covered under the Federal Tort Claims 

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

10 ‘‘(B) providing health care services pursu11 ant to a contract or compact under the Indian 

12 Self-Determination and Education Assistance 

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

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

15 1346(b), 2671 et seq.); or 

16 ‘‘(C) the Indian Health Service providing 

17 health care services that are covered under the 

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

19 2671 et seq.); 

20 are deemed to satisfy such requirement. 

21 ‘‘(6) DEFINITIONS.—For purposes of this sub22 section: 

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

24 The term ‘Indian health care provider’ means 
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1 an Indian Health Program or an Urban Indian 

2 Organization. 

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

4 SERVICE; TRIBE; TRIBAL ORGANIZATION; URBAN

5 INDIAN ORGANIZATION.—The terms ‘Indian’, 

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

7 ‘tribal organization’, ‘Urban Indian Organiza8 tion’ have the meanings given such terms in 

9 section 4 of the Indian Health Care Improve10 ment Act. 

11 ‘‘(C) INDIAN MEDICAID MANAGED CARE

12 ENTITY.—The term ‘Indian Medicaid managed 

13 care entity’ means a managed care entity that 

14 is controlled (within the meaning of the last 

15 sentence of section 1903(m)(1)(C)) by the In16 dian Health Service, a Tribe, Tribal Organiza17 tion, or Urban Indian Organization, or a con18 sortium, which may be composed of 1 or more 

19 Tribes, Tribal Organizations, or Urban Indian 

20 Organizations, and which also may include the 

21 Service. 

22 ‘‘(D) NON-INDIAN MEDICAID MANAGED

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

24 managed care entity’ means a managed care en-
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1 tity that is not an Indian Medicaid managed 

2 care entity. 

3 ‘‘(E) COVERED MEDICAID MANAGED CARE

4 SERVICES.—The term ‘covered Medicaid man5 aged care services’ means, with respect to an 

6 individual enrolled with a managed care entity, 

7 items and services that are within the scope of 

8 items and services for which benefits are avail9 able with respect to the individual under the 

10 contract between the entity and the State in11 volved. 

12 ‘‘(F) MEDICAID MANAGED CARE PRO13 GRAM.—The term ‘Medicaid managed care pro14 gram’ means a program under sections 

15 1903(m) and 1932 and includes a managed 

16 care program operating under a waiver under 

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

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

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

20 206(b)(2), is amended by adding at the end the following 

21 new subparagraph: 

22 ‘‘(H) Subsections (a)(2)(C) and (h) of sec23 tion 1932.’’. 

24 (c) EFFECTIVE DATE.—This section and the amend25 ments made by this section take effect on October 1, 2009. 
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1 SEC. 209. ANNUAL REPORT ON INDIANS SERVED BY SOCIAL 

2 SECURITY ACT HEALTH BENEFIT PROGRAMS. 

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

4 1320b–9), as amended by the sections 202, 205, and 206, 

5 is amended by redesignating subsection (e) as subsection 

6 (f), and inserting after subsection (d) the following new 

7 subsection: 

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

9 HEALTH BENEFIT PROGRAMS FUNDED UNDER THIS

10 ACT.—Beginning January 1, 2008, and annually there11 after, the Secretary, acting through the Administrator of 

12 the Centers for Medicare & Medicaid Services and the Di13 rector of the Indian Health Service, shall submit a report 

14 to Congress regarding the enrollment and health status 

15 of Indians receiving items or services under health benefit 

16 programs funded under this Act during the preceding 

17 year. Each such report shall include the following: 

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

19 receiving items or services under, such programs, 

20 disaggregated with respect to each such program. 

21 ‘‘(2) The number of Indians described in para22 graph (1) that also received health benefits under 

23 programs funded by the Indian Health Service. 

24 ‘‘(3) General information regarding the health 

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

26 disaggregated with respect to specific diseases or 
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1 conditions and presented in a manner that is con2 sistent with protections for privacy of individually 

3 identifiable health information under section 264(c) 

4 of the Health Insurance Portability and Account5 ability Act of 1996. 

6 ‘‘(4) A detailed statement of the status of facili7 ties of the Indian Health Service or an Indian Tribe, 

8 Tribal Organization, or an Urban Indian Organiza9 tion with respect to such facilities’ compliance with 

10 the applicable conditions and requirements of titles 

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

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

13 under waiver authority, and of the progress being 

14 made by such facilities (under plans submitted 

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

16 the achievement and maintenance of such compli17 ance. 

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

19 determines is appropriate.’’. 
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1 SEC. 210. DEVELOPMENT OF RECOMMENDATIONS TO IM2 PROVE INTERSTATE COORDINATION OF MED3 ICAID AND SCHIP COVERAGE OF INDIAN 

4 CHILDREN AND OTHER CHILDREN WHO ARE 

5 OUTSIDE OF THEIR STATE OF RESIDENCY BE6 CAUSE OF EDUCATIONAL OR OTHER NEEDS. 

7 (a) STUDY.—The Secretary shall conduct a study to 

8 identify barriers to interstate coordination of enrollment 

9 and coverage under the Medicaid program under title XIX 

10 of the Social Security Act and the State Children’s Health 

11 Insurance Program under title XXI of such Act of chil12 dren who are eligible for medical assistance or child health 

13 assistance under such programs and who, because of edu14 cational needs, migration of families, emergency evacu15 ations, or otherwise, frequently change their State of resi16 dency or otherwise are temporarily present outside of the 

17 State of their residency. Such study shall include an exam18 ination of the enrollment and coverage coordination issues 

19 faced by Indian children who are eligible for medical as20 sistance or child health assistance under such programs 

21 in their State of residence and who temporarily reside in 

22 an out-of-State boarding school or peripheral dormitory 

23 funded by the Bureau of Indian Affairs. 

24 (b) REPORT.—Not later than 18 months after the 

25 date of enactment of this Act, the Secretary, in consulta26 tion with directors of State Medicaid programs under title 
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1 XIX of the Social Security Act and directors of State Chil2 dren’s Health Insurance Programs under title XXI of such 

3 Act, shall submit a report to Congress that contains rec4 ommendations for such legislative and administrative ac5 tions as the Secretary determines appropriate to address 

6 the enrollment and coverage coordination barriers identi7 fied through the study required under subsection (a). 

8 SEC. 211. ESTABLISHMENT OF NATIONAL CHILD WELFARE 

9 RESOURCE CENTER FOR TRIBES. 

10 (a) ESTABLISHMENT.—The Secretary of Health and 

11 Human Services shall establish a National Child Welfare 

12 Resource Center for Tribes that is—

13 (1) specifically and exclusively dedicated to 

14 meeting the needs of Indian tribes and tribal organi15 zations through the provision of assistance described 

16 in subsection (b); and 

17 (2) not part of any existing national child wel18 fare resource center. 

19 (b) ASSISTANCE PROVIDED.—

20 (1) IN GENERAL.—The National Child Welfare 

21 Resource Center for Tribes shall provide informa22 tion, advice, educational materials, and technical as23 sistance to Indian tribes and tribal organizations 

24 with respect to the types of services, administrative 

25 functions, data collection, program management, 
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1 and reporting that are provided for under State 

2 plans under parts B and E of title IV of the Social 

3 Security Act. 

4 (2) IMPLEMENTATION AUTHORITY.—The Sec5 retary may provide the assistance described in para6 graph (1) either directly or through grant or con7 tract with public or private organizations knowledge8 able and experienced in the field of Indian tribal af9 fairs and child welfare. 

10 (c) APPROPRIATIONS.—There is appropriated to the 

11 Secretary of Health and Human Services, out of any 

12 money in the Treasury of the United States not otherwise 

13 appropriated, $1,000,000 for each of fiscal years 2009 

14 through 2013 to carry out the purposes of this section. 

15 SEC. 212. ADJUSTMENT TO THE MEDICARE ADVANTAGE 

16 STABILIZATION FUND. 

17 Section 1858(e)(2)(A)(i) of the Social Security Act 

18 (42 U.S.C. 1395w–27a(e)(2)(A)(i)), as amended by sec19 tion 110 of the Medicare, Medicaid, and SCHIP Extension 

20 Act of 2007 (Public Law 110–173), is amended by strik21 ing ‘‘$1,790,000,000’’ and inserting ‘‘$1,657,000,000’’. 
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1 SEC. 213. MORATORIUM ON IMPLEMENTATION OF 

2 CHANGES TO CASE MANAGEMENT AND TAR3 GETED CASE MANAGEMENT PAYMENT RE4 QUIREMENTS UNDER MEDICAID. 

5 (a) MORATORIUM.—

6 (1) DELAYED IMPLEMENTATION OF DECEMBER

7 4, 2007, INTERIM FINAL RULE.—The interim final 

8 rule published on December 4, 2007, at pages 

9 68,077 through 68,093 of volume 72 of the Federal 

10 Register (relating to parts 431, 440, and 441 of title 

11 42 of the Code of Federal Regulations) shall not 

12 take effect before April 1, 2009. 

13 (2) CONTINUATION OF 2007 PAYMENT POLICIES

14 AND PRACTICES.—Notwithstanding any other provi15 sion of law, the Secretary of Health and Human 

16 Services shall not, prior to April 1, 2009, take any 

17 action (through promulgation of regulation, issuance 

18 of regulatory guidance, use of Federal payment 

19 audit procedures, or other administrative action, pol20 icy or practice, including a Medical Assistance Man21 ual transmittal or issuance of a letter to State Med22 icaid directors) to restrict coverage or payment 

23 under title XIX of the Social Security Act for case 

24 management and targeted case management services 

25 if such action is more restrictive than the adminis26 trative action, policy, or practice that applies to cov-
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1 erage of, or payment for, such services under title 

2 XIX of the Social Security Act on December 3, 

3 2007. Any such action taken by the Secretary of 

4 Health and Human Services during the period that 

5 begins on December 4, 2007, and ends on March 31, 

6 2009, that is based in whole or in part on the in7 terim final rule described in subsection (a) is null 

8 and void. 

9 (b) INCLUSION OF MEDICARE PROVIDERS AND SUP10 PLIERS IN FEDERAL PAYMENT LEVY AND ADMINISTRA11 TIVE OFFSET PROGRAM.—

12 (1) IN GENERAL.—Section 1874 of the Social 

13 Security Act (42 U.S.C. 1395kk) is amended by 

14 adding at the end the following new subsection: 

15 ‘‘(d) INCLUSION OF MEDICARE PROVIDER AND SUP16 PLIER PAYMENTS IN FEDERAL PAYMENT LEVY PRO17 GRAM.—

18 ‘‘(1) IN GENERAL.—The Centers for Medicare 

19 & Medicaid Services shall take all necessary steps to 

20 participate in the Federal Payment Levy Program 

21 under section 6331(h) of the Internal Revenue Code 

22 of 1986 as soon as possible and shall ensure that—

23 ‘‘(A) at least 50 percent of all payments 

24 under parts A and B are processed through 
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1 such program beginning within 1 year after the 

2 date of the enactment of this section; 

3 ‘‘(B) at least 75 percent of all payments 

4 under parts A and B are processed through 

5 such program beginning within 2 years after 

6 such date; and 

7 ‘‘(C) all payments under parts A and B 

8 are processed through such program beginning 

9 not later than September 30, 2011. 

10 ‘‘(2) ASSISTANCE.—The Financial Management 

11 Service and the Internal Revenue Service shall pro12 vide assistance to the Centers for Medicare & Med13 icaid Services to ensure that all payments described 

14 in paragraph (1) are included in the Federal Pay15 ment Levy Program by the deadlines specified in 

16 that subsection.’’. 

17 (2) APPLICATION OF ADMINISTRATIVE OFFSET

18 PROVISIONS TO MEDICARE PROVIDER OR SUPPLIER

19 PAYMENTS.—Section 3716 of title 31, United States 

20 Code, is amended—

21 (A) by inserting ‘‘the Department of 

22 Health and Human Services,’’ after ‘‘United 

23 States Postal Service,’’ in subsection (c)(1)(A); 

24 and 
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1 (B) by adding at the end of subsection 

2 (c)(3) the following new subparagraph: 

3 ‘‘(D) This section shall apply to payments 

4 made after the date which is 90 days after the 

5 enactment of this subparagraph (or such earlier 

6 date as designated by the Secretary of Health 

7 and Human Services) with respect to claims or 

8 debts, and to amounts payable, under title 

9 XVIII of the Social Security Act.’’. 

10 (3) EFFECTIVE DATE.—The amendments made 

11 by this subsection shall take effect on the date of the 

12 enactment of this Act. 

13 SEC. 214. INCREASED CIVIL MONEY PENALTIES AND CRIMI14 NAL FINES FOR MEDICARE FRAUD AND 

15 ABUSE. 

16 (a) INCREASED CIVIL MONEY PENALTIES.—Section 

17 1128A of the Social Security Act (42 U.S.C. 1320a–7a) 

18 is amended—

19 (1) in subsection (a), in the flush matter fol20 lowing paragraph (7)—

21 (A) by striking ‘‘$10,000’’ each place it 

22 appears and inserting ‘‘$20,000’’; 

23 (B) by striking ‘‘$15,000’’ and inserting 

24 ‘‘$30,000’’; and 
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1 (C) by striking ‘‘$50,000’’ and inserting 

2 ‘‘$100,000’’; and 

3 (2) in subsection (b)—

4 (A) in paragraph (1), in the flush matter 

5 following subparagraph (B), by striking 

6 ‘‘$2,000’’ and inserting ‘‘$4,000’’; 

7 (B) in paragraph (2), by striking ‘‘$2,000’’ 

8 and inserting ‘‘$4,000’’; and 

9 (C) in paragraph (3)(A)(i), by striking 

10 ‘‘$5,000’’ and inserting ‘‘$10,000’’. 

11 (b) INCREASED CRIMINAL FINES.—Section 1128B of 

12 the Social Security Act (42 U.S.C. 1320a–7b) is amend13 ed—

14 (1) in subsection (a), in the flush matter fol15 lowing paragraph (6)—

16 (A) by striking ‘‘$25,000’’ and inserting 

17 ‘‘$100,000’’; and 

18 (B) by striking ‘‘$10,000’’ and inserting 

19 ‘‘$20,000’’; 

20 (2) in subsection (b)—

21 (A) in paragraph (1), in the flush matter 

22 following subparagraph (B), by striking 

23 ‘‘$25,000’’ and inserting ‘‘$100,000’’; and 
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1 (B) in paragraph (2), in the flush matter 

2 following subparagraph (B), by striking 

3 ‘‘$25,000’’ and inserting ‘‘$100,000’’; 

4 (3) in subsection (c), by striking ‘‘$25,000’’ and 

5 inserting ‘‘$100,000’’; 

6 (4) in subsection (d), in the second flush matter 

7 following subparagraph (B), by striking ‘‘$25,000’’ 

8 and inserting ‘‘$100,000’’; and 

9 (5) in subsection (e), by striking ‘‘$2,000’’ and 

10 inserting ‘‘$4,000’’. 

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

12 this section shall apply to civil money penalties and fines 

13 imposed for actions taken on or after the date of enact14 ment of this Act. 

15 SEC. 215. INCREASED SENTENCES FOR FELONIES INVOLV16 ING MEDICARE FRAUD AND ABUSE. 

17 (a) FALSE STATEMENTS AND REPRESENTATIONS.—

18 Section 1128B(a) of the Social Security Act (42 U.S.C. 

19 1320a–7b(a)) is amended, in clause (i) of the flush matter 

20 following paragraph (6), by striking ‘‘not more than 5 

21 years’’ and inserting ‘‘not more than 10 years’’. 

22 (b) ANTI-KICKBACK.—Section 1128B(b) of the So23 cial Security Act (42 U.S.C. 1320a–7b(b)) is amended—

24 (1) in paragraph (1), in the flush matter fol25 lowing subparagraph (B), by striking ‘‘not more 
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1 than 5 years’’ and inserting ‘‘not more than 10 

2 years’’; and 

3 (2) in paragraph (2), in the flush matter fol4 lowing subparagraph (B), by striking ‘‘not more 

5 than 5 years’’ and inserting ‘‘not more than 10 

6 years’’. 

7 (c) FALSE STATEMENT OR REPRESENTATION WITH

8 RESPECT TO CONDITIONS OR OPERATIONS OF FACILI9 TIES.—Section 1128B(c) of the Social Security Act (42 

10 U.S.C. 1320a–7b(c)) is amended by striking ‘‘not more 

11 than 5 years’’ and inserting ‘‘not more than 10 years’’. 

12 (d) EXCESS CHARGES.—Section 1128B(d) of the So13 cial Security Act (42 U.S.C. 1320a–7b(d)) is amended, in 

14 the second flush matter following subparagraph (B), by 

15 striking ‘‘not more than 5 years’’ and inserting ‘‘not more 

16 than 10 years’’. 

17 (e) EFFECTIVE DATE.—The amendments made by 

18 this section shall apply to criminal penalties imposed for 

19 actions taken on or after the date of enactment of this 

20 Act. 

21 TITLE III—MISCELLANEOUS 

22 SEC. 301. RESOLUTION OF APOLOGY TO NATIVE PEOPLES 

23 OF UNITED STATES. 

24 (a) FINDINGS.—Congress finds that—
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1 (1) the ancestors of today’s Native Peoples in2 habited the land of the present-day United States 

3 since time immemorial and for thousands of years 

4 before the arrival of people of European descent; 

5 (2) for millennia, Native Peoples have honored, 

6 protected, and stewarded this land we cherish; 

7 (3) Native Peoples are spiritual people with a 

8 deep and abiding belief in the Creator, and for mil9 lennia Native Peoples have maintained a powerful 

10 spiritual connection to this land, as evidenced by 

11 their customs and legends; 

12 (4) the arrival of Europeans in North America 

13 opened a new chapter in the history of Native Peo14 ples; 

15 (5) while establishment of permanent European 

16 settlements in North America did stir conflict with 

17 nearby Indian tribes, peaceful and mutually bene18 ficial interactions also took place; 

19 (6) the foundational English settlements in 

20 Jamestown, Virginia, and Plymouth, Massachusetts, 

21 owed their survival in large measure to the compas22 sion and aid of Native Peoples in the vicinities of the 

23 settlements; 

24 (7) in the infancy of the United States, the 

25 founders of the Republic expressed their desire for 
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1 a just relationship with the Indian tribes, as evi2 denced by the Northwest Ordinance enacted by Con3 gress in 1787, which begins with the phrase, ‘‘The 

4 utmost good faith shall always be observed toward 

5 the Indians’’; 

6 (8) Indian tribes provided great assistance to 

7 the fledgling Republic as it strengthened and grew, 

8 including invaluable help to Meriwether Lewis and 

9 William Clark on their epic journey from St. Louis, 

10 Missouri, to the Pacific Coast; 

11 (9) Native Peoples and non-Native settlers en12 gaged in numerous armed conflicts in which unfortu13 nately, both took innocent lives, including those of 

14 women and children; 

15 (10) the Federal Government violated many of 

16 the treaties ratified by Congress and other diplo17 matic agreements with Indian tribes; 

18 (11) the United States forced Indian tribes and 

19 their citizens to move away from their traditional 

20 homelands and onto federally established and con21 trolled reservations, in accordance with such Acts as 

22 the Act of May 28, 1830 (4 Stat. 411, chapter 148) 

23 (commonly known as the ‘‘Indian Removal Act’’); 

24 (12) many Native Peoples suffered and per25 ished—
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1 (A) during the execution of the official 

2 Federal Government policy of forced removal, 

3 including the infamous Trail of Tears and Long 

4 Walk; 

5 (B) during bloody armed confrontations 

6 and massacres, such as the Sand Creek Mas7 sacre in 1864 and the Wounded Knee Massacre 

8 in 1890; and 

9 (C) on numerous Indian reservations; 

10 (13) the Federal Government condemned the 

11 traditions, beliefs, and customs of Native Peoples 

12 and endeavored to assimilate them by such policies 

13 as the redistribution of land under the Act of Feb14 ruary 8, 1887 (25 U.S.C. 331; 24 Stat. 388, chapter 

15 119) (commonly known as the ‘‘General Allotment 

16 Act’’), and the forcible removal of Native children 

17 from their families to faraway boarding schools 

18 where their Native practices and languages were de19 graded and forbidden; 

20 (14) officials of the Federal Government and 

21 private United States citizens harmed Native Peo22 ples by the unlawful acquisition of recognized tribal 

23 land and the theft of tribal resources and assets 

24 from recognized tribal land; 
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1 (15) the policies of the Federal Government to2 ward Indian tribes and the breaking of covenants 

3 with Indian tribes have contributed to the severe so4 cial ills and economic troubles in many Native com5 munities today; 

6 (16) despite the wrongs committed against Na7 tive Peoples by the United States, Native Peoples 

8 have remained committed to the protection of this 

9 great land, as evidenced by the fact that, on a per 

10 capita basis, more Native Peoples have served in the 

11 United States Armed Forces and placed themselves 

12 in harm’s way in defense of the United States in 

13 every major military conflict than any other ethnic 

14 group; 

15 (17) Indian tribes have actively influenced the 

16 public life of the United States by continued co17 operation with Congress and the Department of the 

18 Interior, through the involvement of Native individ19 uals in official Federal Government positions, and by 

20 leadership of their own sovereign Indian tribes; 

21 (18) Indian tribes are resilient and determined 

22 to preserve, develop, and transmit to future genera23 tions their unique cultural identities; 

24 (19) the National Museum of the American In25 dian was established within the Smithsonian Institu-
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1 tion as a living memorial to Native Peoples and their 

2 traditions; and 

3 (20) Native Peoples are endowed by their Cre4 ator with certain unalienable rights, and among 

5 those are life, liberty, and the pursuit of happiness. 

6 (b) ACKNOWLEDGMENT AND APOLOGY.—The United 

7 States, acting through Congress—

8 (1) recognizes the special legal and political re9 lationship Indian tribes have with the United States 

10 and the solemn covenant with the land we share; 

11 (2) commends and honors Native Peoples for 

12 the thousands of years that they have stewarded and 

13 protected this land; 

14 (3) recognizes that there have been years of of15 ficial depredations, ill-conceived policies, and the 

16 breaking of covenants by the Federal Government 

17 regarding Indian tribes; 

18 (4) apologizes on behalf of the people of the 

19 United States to all Native Peoples for the many in20 stances of violence, maltreatment, and neglect in21 flicted on Native Peoples by citizens of the United 

22 States; 

23 (5) expresses its regret for the ramifications of 

24 former wrongs and its commitment to build on the 

25 positive relationships of the past and present to 
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1 move toward a brighter future where all the people 

2 of this land live reconciled as brothers and sisters, 

3 and harmoniously steward and protect this land to4 gether; 

5 (6) urges the President to acknowledge the 

6 wrongs of the United States against Indian tribes in 

7 the history of the United States in order to bring 

8 healing to this land; and 

9 (7) commends the State governments that have 

10 begun reconciliation efforts with recognized Indian 

11 tribes located in their boundaries and encourages all 

12 State governments similarly to work toward recon13 ciling relationships with Indian tribes within their 

14 boundaries. 

15 (c) DISCLAIMER.—Nothing in this section—

16 (1) authorizes or supports any claim against 

17 the United States; or 

18 (2) serves as a settlement of any claim against 

19 the United States. 

Passed the Senate February 26, 2008. 

Attest:

Secretary. 
110TH CONGRESS 

2D SESSION S. 1200

AN ACT

To amend the Indian Health Care Improvement 

Act to revise and extend that Act.