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in the health benefits gained through the provision 
of sanitation facilities. 
‘‘(c) FUNDING.—Notwithstanding any other provi-
sion of law— 
‘‘(1) the Secretary of Housing and Urban De-
velopment is authorized to transfer funds appro-
priated under the Native American Housing Assist-
ance and Self-Determination Act of 1996 (25 U.S.C. 
4101 et seq.) to the Secretary of Health and Human 
Services; 
‘‘(2) the Secretary of Health and Human Serv-
ices is authorized to accept and use such funds for 
the purpose of providing sanitation facilities and 
services for Indians under section 7 of the Act of 
August 5, 1954 (42 U.S.C. 2004a); 
‘‘(3) unless specifically authorized when funds 
are appropriated, the Secretary shall not use funds 
appropriated under section 7 of the Act of August 
5, 1954 (42 U.S.C. 2004a), to provide sanitation fa-
cilities to new homes constructed using funds pro-
vided by the Department of Housing and Urban De-
velopment; 
‘‘(4) the Secretary of Health and Human Serv-
ices is authorized to accept from any source, includ-
ing Federal and State agencies, funds for the pur-
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pose of providing sanitation facilities and services 
and place these funds into contracts or compacts 
under the Indian Self-Determination and Education 
Assistance Act (25 U.S.C. 450 et seq.); 
‘‘(5) except as otherwise prohibited by this sec-
tion, the Secretary may use funds appropriated 
under the authority of section 7 of the Act of Au-
gust 5, 1954 (42 U.S.C. 2004a), to fund up to 100 
percent of the amount of an Indian Tribe’s loan ob-
tained under any Federal program for new projects 
to construct eligible sanitation facilities to serve In-
dian homes; 
‘‘(6) except as otherwise prohibited by this sec-
tion, the Secretary may use funds appropriated 
under the authority of section 7 of the Act of Au-
gust 5, 1954 (42 U.S.C. 2004a), to meet matching 
or cost participation requirements under other Fed-
eral and non-Federal programs for new projects to 
construct eligible sanitation facilities; 
‘‘(7) all Federal agencies are authorized to 
transfer to the Secretary funds identified, granted, 
loaned, or appropriated whereby the Department’s 
applicable policies, rules, and regulations shall apply 
in the implementation of such projects; 
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‘‘(8) the Secretary of Health and Human Serv-
ices shall enter into interagency agreements with 
Federal and State agencies for the purpose of pro-
viding financial assistance for sanitation facilities 
and services under this Act; 
‘‘(9) the Secretary of Health and Human Serv-
ices shall, by regulation, establish standards applica-
ble to the planning, design, and construction of sani-
tation facilities funded under this Act; and 
‘‘(10) the Secretary of Health and Human 
Services is authorized to accept payments for goods 
and services furnished by the Service from appro-
priate public authorities, nonprofit organizations or 
agencies, or Indian Tribes, as contributions by that 
authority, organization, agency, or tribe to agree-
ments made under section 7 of the Act of August 5, 
1954 (42 U.S.C. 2004a), and such payments shall 
be credited to the same or subsequent appropriation 
account as funds appropriated under the authority 
of section 7 of the Act of August 5, 1954 (42 U.S.C. 
2004a). 
‘‘(d) CERTAIN CAPABILITIES NOT PREREQUISITE.— 
The financial and technical capability of an Indian Tribe, 
Tribal Organization, or Indian community to safely oper-
ate, manage, and maintain a sanitation facility shall not 
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be a prerequisite to the provision or construction of sanita-
tion facilities by the Secretary. 
‘‘(e) FINANCIAL ASSISTANCE.—The Secretary is au-
thorized to provide financial assistance to Indian Tribes, 
Tribal Organizations, and Indian communities in an 
amount equal to the Federal share of the costs of oper-
ating, managing, and maintaining the facilities provided 
under the plan described in subsection (h)(1)(F). 
‘‘(f) OPERATION, MANAGEMENT, AND MAINTENANCE 
OF FACILITIES.—The Indian Tribe has the primary re-
sponsibility to establish, collect, and use reasonable user 
fees, or otherwise set aside funding, for the purpose of 
operating, managing, and maintaining sanitation facilities. 
If a sanitation facility serving a community that is oper-
ated by an Indian Tribe or Tribal Organization is threat-
ened with imminent failure and such operator lacks capac-
ity to maintain the integrity or the health benefits of the 
sanitation facility, then the Secretary is authorized to as-
sist the Indian Tribe, Tribal Organization, or Indian com-
munity in the resolution of the problem on a short-term 
basis through cooperation with the emergency coordinator 
or by providing operation, management, and maintenance 
service. 
‘‘(g) ISDEAA PROGRAM
FUNDED
ON
EQUAL 
BASIS.—Tribal Health Programs shall be eligible (on an 
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equal basis with programs that are administered directly 
by the Service) for— 
‘‘(1) any funds appropriated pursuant to this 
section; and 
‘‘(2) any funds appropriated for the purpose of 
providing sanitation facilities. 
‘‘(h) REPORT.— 
‘‘(1) REQUIRED; CONTENTS.—The Secretary, in 
consultation with the Secretary of Housing and 
Urban Development, Indian Tribes, Tribal Organiza-
tions, and tribally designated housing entities (as de-
fined in section 4 of the Native American Housing 
Assistance and Self-Determination Act of 1996 (25 
U.S.C. 4103)) shall submit to the President, for in-
clusion in the report required to be transmitted to 
Congress under section 801, a report which sets 
forth— 
‘‘(A) the current Indian sanitation facility 
priority system of the Service; 
‘‘(B) the methodology for determining 
sanitation deficiencies and needs; 
‘‘(C) the criteria on which the deficiencies 
and needs will be evaluated; 
‘‘(D) the level of initial and final sanitation 
deficiency for each type of sanitation facility for 
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each project of each Indian Tribe or Indian 
community; 
‘‘(E) the amount and most effective use of 
funds, derived from whatever source, necessary 
to accommodate the sanitation facilities needs 
of new homes assisted with funds under the 
Native American Housing Assistance and Self- 
Determination Act (25 U.S.C. 4101 et seq.), 
and to reduce the identified sanitation defi-
ciency levels of all Indian Tribes and Indian 
communities to level I sanitation deficiency as 
defined in paragraph (3)(A); and 
‘‘(F) a 10-year plan to provide sanitation 
facilities to serve existing Indian homes and In-
dian communities and new and renovated In-
dian homes. 
‘‘(2) UNIFORM METHODOLOGY.—The method-
ology used by the Secretary in determining, pre-
paring cost estimates for, and reporting sanitation 
deficiencies for purposes of paragraph (1) shall be 
applied uniformly to all Indian Tribes and Indian 
communities. 
‘‘(3) SANITATION
DEFICIENCY
LEVELS.—For 
purposes of this subsection, the sanitation deficiency 
levels for an individual, Indian Tribe, or Indian com-
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tion, or an Indian community to properly 
operate and maintain the sanitation facili-
ties. 
‘‘(C) A level III deficiency exists if a sani-
tation facility serving an individual, Indian 
Tribe or Indian community meets 1 or more of 
the following conditions— 
‘‘(i) water or sewer service in the 
home is provided by a haul system with 
holding tanks and interior plumbing; 
‘‘(ii) major significant interruptions to 
water supply or sewage disposal occur fre-
quently, requiring major capital improve-
ments to correct the deficiencies; or 
‘‘(iii) there is no access to or no ap-
proved or permitted solid waste facility 
available. 
‘‘(D) A level IV deficiency exists— 
‘‘(i) if a sanitation facility for an indi-
vidual home, an Indian Tribe, or an Indian 
community exists but— 
‘‘(I) lacks— 
‘‘(aa) a safe water supply 
system; or 
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‘‘(bb) a waste disposal sys-
tem; 
‘‘(II) contains no piped water or 
sewer facilities; or 
‘‘(III) has become inoperable due 
to a major component failure; or 
‘‘(ii) if only a washeteria or central fa-
cility exists in the community. 
‘‘(E) A level V deficiency exists in the ab-
sence of a sanitation facility, where individual 
homes do not have access to safe drinking 
water or adequate wastewater (including sew-
age) disposal. 
‘‘(i) DEFINITIONS.—For purposes of this section, the 
following terms apply: 
‘‘(1) INDIAN
COMMUNITY.—The term ‘Indian 
community’ means a geographic area, a significant 
proportion of whose inhabitants are Indians and 
which is served by or capable of being served by a 
facility described in this section. 
‘‘(2) 
SANITATION
FACILITIES.—The 
terms 
‘sanitation facility’ and ‘sanitation facilities’ mean 
safe and adequate water supply systems, sanitary 
sewage disposal systems, and sanitary solid waste 
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systems (and all related equipment and support in-
frastructure). 
‘‘SEC. 303. PREFERENCE TO INDIANS AND INDIAN FIRMS. 
‘‘(a) BUY
INDIAN
ACT.—The Secretary, acting 
through the Service, may use the negotiating authority of 
section 23 of the Act of June 25, 1910 (25 U.S.C. 47, 
commonly known as the ‘Buy Indian Act’), to give pref-
erence to any Indian or any enterprise, partnership, cor-
poration, or other type of business organization owned and 
controlled by an Indian or Indians including former or 
currently federally recognized Indian Tribes in the State 
of New York (hereinafter referred to as an ‘Indian firm’) 
in the construction and renovation of Service facilities pur-
suant to section 301 and in the construction of sanitation 
facilities pursuant to section 302. Such preference may be 
accorded by the Secretary unless the Secretary finds, pur-
suant to regulations, that the project or function to be 
contracted for will not be satisfactory or such project or 
function cannot be properly completed or maintained 
under the proposed contract. The Secretary, in arriving 
at such a finding, shall consider whether the Indian or 
Indian firm will be deficient with respect to— 
‘‘(1) ownership and control by Indians; 
‘‘(2) equipment; 
‘‘(3) bookkeeping and accounting procedures; 
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‘‘(4) substantive knowledge of the project or 
function to be contracted for; 
‘‘(5) adequately trained personnel; or 
‘‘(6) other necessary components of contract 
performance. 
‘‘(b) PAY RATES.—For the purposes of implementing 
the provisions of this title, the Secretary shall assure that 
the rates of pay for personnel engaged in the construction 
or renovation of facilities constructed or renovated in 
whole or in part by funds made available pursuant to this 
title are not less than the prevailing local wage rates for 
similar work as determined in accordance with the Act of 
March 3, 1931 (40 U.S.C. 276a–276a–5, known as the 
Davis-Bacon Act). 
‘‘(c) LABOR STANDARDS.—For the purposes of im-
plementing the provisions of this title, contracts for the 
construction or renovation of health care facilities, staff 
quarters, and sanitation facilities, and related support in-
frastructure, funded in whole or in part with funds made 
available pursuant to this title, shall contain a provision 
requiring compliance with subchapter IV of chapter 31 of 
title 40, United States Code (commonly known as the 
‘Davis-Bacon Act’). 
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‘‘SEC. 304. EXPENDITURE OF NON-SERVICE FUNDS FOR 
RENOVATION. 
‘‘(a) IN GENERAL.—Notwithstanding any other pro-
vision of law, if the requirements of subsection (c) are met, 
the Secretary, acting through the Service, is authorized 
to accept any major expansion, renovation, or moderniza-
tion by any Indian Tribe or Tribal Organization of any 
Service facility or of any other Indian health facility oper-
ated pursuant to a contract or compact under the Indian 
Self-Determination and Education Assistance Act (25 
U.S.C. 450 et seq.), including— 
‘‘(1) any plans or designs for such expansion, 
renovation, or modernization; and 
‘‘(2) any expansion, renovation, or moderniza-
tion for which funds appropriated under any Federal 
law were lawfully expended. 
‘‘(b) PRIORITY LIST.— 
‘‘(1) IN GENERAL.—The Secretary shall main-
tain a separate priority list to address the needs for 
increased operating expenses, personnel, or equip-
ment for such facilities. The methodology for estab-
lishing priorities shall be developed through regula-
tions. The list of priority facilities will be revised an-
nually in consultation with Indian Tribes and Tribal 
Organizations. 
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‘‘(2) REPORT.—The Secretary shall submit to 
the President, for inclusion in the report required to 
be transmitted to Congress under section 801, the 
priority list maintained pursuant to paragraph (1). 
‘‘(c) REQUIREMENTS.—The requirements of this sub-
section are met with respect to any expansion, renovation, 
or modernization if— 
‘‘(1) the Indian Tribe or Tribal Organization— 
‘‘(A) provides notice to the Secretary of its 
intent to expand, renovate, or modernize; and 
‘‘(B) applies to the Secretary to be placed 
on a separate priority list to address the needs 
of such new facilities for increased operating ex-
penses, personnel, or equipment; and 
‘‘(2) the expansion, renovation, or moderniza-
tion— 
‘‘(A) is approved by the appropriate area 
director of the Service for Federal facilities; and 
‘‘(B) is administered by the Indian Tribe 
or Tribal Organization in accordance with any 
applicable regulations prescribed by the Sec-
retary with respect to construction or renova-
tion of Service facilities. 
‘‘(d) ADDITIONAL REQUIREMENT FOR EXPANSION.— 
In addition to the requirements under subsection (c), for 
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any expansion, the Indian Tribe or Tribal Organization 
shall provide to the Secretary additional information pur-
suant to regulations, including additional staffing, equip-
ment, and other costs associated with the expansion. 
‘‘(e) CLOSURE OR CONVERSION OF FACILITIES.—If 
any Service facility which has been expanded, renovated, 
or modernized by an Indian Tribe or Tribal Organization 
under this section ceases to be used as a Service facility 
during the 20-year period beginning on the date such ex-
pansion, renovation, or modernization is completed, such 
Indian Tribe or Tribal Organization shall be entitled to 
recover from the United States an amount which bears 
the same ratio to the value of such facility at the time 
of such cessation as the value of such expansion, renova-
tion, or modernization (less the total amount of any funds 
provided specifically for such facility under any Federal 
program that were expended for such expansion, renova-
tion, or modernization) bore to the value of such facility 
at the time of the completion of such expansion, renova-
tion, or modernization. 
‘‘SEC. 305. FUNDING FOR THE CONSTRUCTION, EXPANSION, 
AND MODERNIZATION OF SMALL AMBULA-
TORY CARE FACILITIES. 
‘‘(a) GRANTS.— 
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‘‘(1) IN
GENERAL.—The Secretary, acting 
through the Service, shall make grants to Indian 
Tribes and Tribal Organizations for the construc-
tion, expansion, or modernization of facilities for the 
provision of ambulatory care services to eligible Indi-
ans (and noneligible persons pursuant to subsections 
(b)(2) and (c)(1)(C)). A grant made under this sec-
tion may cover up to 100 percent of the costs of 
such construction, expansion, or modernization. For 
the purposes of this section, the term ‘construction’ 
includes the replacement of an existing facility. 
‘‘(2) GRANT AGREEMENT REQUIRED.—A grant 
under paragraph (1) may only be made available to 
a Tribal Health Program operating an Indian health 
facility (other than a facility owned or constructed 
by the Service, including a facility originally owned 
or constructed by the Service and transferred to an 
Indian Tribe or Tribal Organization). 
‘‘(b) USE OF GRANT FUNDS.— 
‘‘(1) ALLOWABLE
USES.—A grant awarded 
under this section may be used for the construction, 
expansion, or modernization (including the planning 
and design of such construction, expansion, or mod-
ernization) of an ambulatory care facility— 
‘‘(A) located apart from a hospital; 
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‘‘(B) not funded under section 301 or sec-
tion 306; and 
‘‘(C) which, upon completion of such con-
struction or modernization will— 
‘‘(i) have a total capacity appropriate 
to its projected service population; 
‘‘(ii) provide annually no fewer than 
150 patient visits by eligible Indians and 
other users who are eligible for services in 
such facility in accordance with section 
806(c)(2); and 
‘‘(iii) provide ambulatory care in a 
Service Area (specified in the contract or 
compact under the Indian Self-Determina-
tion and Education Assistance Act (25 
U.S.C. 450 et seq.)) with a population of 
no fewer than 1,500 eligible Indians and 
other users who are eligible for services in 
such facility in accordance with section 
806(c)(2). 
‘‘(2) ADDITIONAL ALLOWABLE USE.—The Sec-
retary may also reserve a portion of the funding pro-
vided under this section and use those reserved 
funds to reduce an outstanding debt incurred by In-
dian Tribes or Tribal Organizations for the con-
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struction, expansion, or modernization of an ambula-
tory care facility that meets the requirements under 
paragraph (1). The provisions of this section shall 
apply, except that such applications for funding 
under this paragraph shall be considered separately 
from applications for funding under paragraph (1). 
‘‘(3) USE
ONLY
FOR
CERTAIN
PORTION
OF 
COSTS.—A grant provided under this section may be 
used only for the cost of that portion of a construc-
tion, expansion, or modernization project that bene-
fits the Service population identified above in sub-
section (b)(1)(C) (ii) and (iii). The requirements of 
clauses (ii) and (iii) of paragraph (1)(C) shall not 
apply to an Indian Tribe or Tribal Organization ap-
plying for a grant under this section for a health 
care facility located or to be constructed on an is-
land or when such facility is not located on a road 
system providing direct access to an inpatient hos-
pital where care is available to the Service popu-
lation. 
‘‘(c) GRANTS.— 
‘‘(1) APPLICATION.—No grant may be made 
under this section unless an application or proposal 
for the grant has been approved by the Secretary in 
accordance with applicable regulations and has set 
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forth reasonable assurance by the applicant that, at 
all times after the construction, expansion, or mod-
ernization of a facility carried out using a grant re-
ceived under this section— 
‘‘(A) adequate financial support will be 
available for the provision of services at such 
facility; 
‘‘(B) such facility will be available to eligi-
ble Indians without regard to ability to pay or 
source of payment; and 
‘‘(C) such facility will, as feasible without 
diminishing the quality or quantity of services 
provided to eligible Indians, serve noneligible 
persons on a cost basis. 
‘‘(2) PRIORITY.—In awarding grants under this 
section, the Secretary shall give priority to Indian 
Tribes and Tribal Organizations that demonstrate— 
‘‘(A) a need for increased ambulatory care 
services; and 
‘‘(B) insufficient capacity to deliver such 
services. 
‘‘(3) PEER
REVIEW
PANELS.—The Secretary 
may provide for the establishment of peer review 
panels, as necessary, to review and evaluate applica-
tions and proposals and to advise the Secretary re-
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garding such applications using the criteria devel-
oped pursuant to subsection (a)(1). 
‘‘(d) REVERSION OF FACILITIES.—If any facility (or 
portion thereof) with respect to which funds have been 
paid under this section, ceases, at any time after comple-
tion of the construction, expansion, or modernization car-
ried out with such funds, to be used for the purposes of 
providing health care services to eligible Indians, all of the 
right, title, and interest in and to such facility (or portion 
thereof) shall transfer to the United States unless other-
wise negotiated by the Service and the Indian Tribe or 
Tribal Organization. 
‘‘(e) FUNDING NONRECURRING.—Funding provided 
under this section shall be nonrecurring and shall not be 
available for inclusion in any individual Indian Tribe’s 
tribal share for an award under the Indian Self-Deter-
mination and Education Assistance Act (25 U.S.C. 450 
et seq.) or for reallocation or redesign thereunder. 
‘‘SEC. 306. INDIAN HEALTH CARE DELIVERY DEMONSTRA-
TION PROJECT. 
‘‘(a) HEALTH CARE DEMONSTRATION PROJECTS.— 
The Secretary, acting through the Service, is authorized 
to make grants to, and enter into construction contracts 
or construction project agreements with, Indian Tribes or 
Tribal Organizations under the Indian Self-Determination 
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and Education Assistance Act (25 U.S.C. 450 et seq.) for 
the purpose of carrying out a health care delivery dem-
onstration project to test alternative means of delivering 
health care and services to Indians through facilities. 
‘‘(b) USE OF FUNDS.—The Secretary, in approving 
projects pursuant to this section, may authorize such con-
tracts for the construction and renovation of hospitals, 
health centers, health stations, and other facilities to de-
liver health care services and is authorized to— 
‘‘(1) waive any leasing prohibition; 
‘‘(2) permit carryover of funds appropriated for 
the provision of health care services; 
‘‘(3) permit the use of other available funds; 
‘‘(4) permit the use of funds or property do-
nated from any source for project purposes; 
‘‘(5) provide for the reversion of donated real or 
personal property to the donor; and 
‘‘(6) permit the use of Service funds to match 
other funds, including Federal funds. 
‘‘(c) REGULATIONS.—The Secretary shall develop 
and promulgate regulations, not later than 1 year after 
the date of enactment of the Indian Health Care Improve-
ment Act Amendments of 2009, for the review and ap-
proval of applications submitted under this section. 
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‘‘(d) CRITERIA.—The Secretary may approve projects 
that meet the following criteria: 
‘‘(1) There is a need for a new facility or pro-
gram or the reorientation of an existing facility or 
program. 
‘‘(2) A significant number of Indians, including 
those with low health status, will be served by the 
project. 
‘‘(3) The project has the potential to deliver 
services in an efficient and effective manner. 
‘‘(4) The project is economically viable. 
‘‘(5) The Indian Tribe or Tribal Organization 
has the administrative and financial capability to ad-
minister the project. 
‘‘(6) The project is integrated with providers of 
related health and social services and is coordinated 
with, and avoids duplication of, existing services. 
‘‘(e) PEER REVIEW PANELS.—The Secretary may 
provide for the establishment of peer review panels, as nec-
essary, to review and evaluate applications using the cri-
teria developed pursuant to subsection (d). 
‘‘(f) PRIORITY.—The Secretary shall give priority to 
applications for demonstration projects in each of the fol-
lowing Service Units to the extent that such applications 
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are timely filed and meet the criteria specified in sub-
section (d): 
‘‘(1) Cass Lake, Minnesota. 
‘‘(2) Mescalero, New Mexico. 
‘‘(3) Owyhee, Nevada. 
‘‘(4) Schurz, Nevada. 
‘‘(5) Ft. Yuma, California. 
‘‘(g) TECHNICAL ASSISTANCE.—The Secretary shall 
provide such technical and other assistance as may be nec-
essary to enable applicants to comply with the provisions 
of this section. 
‘‘(h) SERVICE TO INELIGIBLE PERSONS.—Subject to 
section 806, the authority to provide services to persons 
otherwise ineligible for the health care benefits of the 
Service and the authority to extend hospital privileges in 
Service facilities to non-Service health practitioners as 
provided in section 806 may be included, subject to the 
terms of such section, in any demonstration project ap-
proved pursuant to this section. 
‘‘(i) EQUITABLE TREATMENT.—For purposes of sub-
section (d)(1), the Secretary shall, in evaluating facilities 
operated under any contract or compact under the Indian 
Self-Determination and Education Assistance Act (25 
U.S.C. 450 et seq.), use the same criteria that the Sec-
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retary uses in evaluating facilities operated directly by the 
Service. 
‘‘(j) EQUITABLE INTEGRATION OF FACILITIES.—The 
Secretary shall ensure that the planning, design, construc-
tion, renovation, and expansion needs of Service and non- 
Service facilities which are the subject of a contract or 
compact under the Indian Self-Determination and Edu-
cation Assistance Act (25 U.S.C. 450 et seq.) for health 
services are fully and equitably integrated into the imple-
mentation of the health care delivery demonstration 
projects under this section. 
‘‘SEC. 307. LAND TRANSFER. 
‘‘Notwithstanding any other provision of law, the Bu-
reau of Indian Affairs and all other agencies and depart-
ments of the United States are authorized to transfer, at 
no cost, land and improvements to the Service for the pro-
vision of health care services. The Secretary is authorized 
to accept such land and improvements for such purposes. 
‘‘SEC. 308. LEASES, CONTRACTS, AND OTHER AGREEMENTS. 
‘‘The Secretary, acting through the Service, may 
enter into leases, contracts, and other agreements with In-
dian Tribes and Tribal Organizations which hold (1) title 
to, (2) a leasehold interest in, or (3) a beneficial interest 
in (when title is held by the United States in trust for 
the benefit of an Indian Tribe) facilities used or to be used 
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for the administration and delivery of health services by 
an Indian Health Program. Such leases, contracts, or 
agreements may include provisions for construction or ren-
ovation and provide for compensation to the Indian Tribe 
or Tribal Organization of rental and other costs consistent 
with section 105(l) of the Indian Self-Determination and 
Education Assistance Act (25 U.S.C. 450j(l)) and regula-
tions thereunder. 
‘‘SEC. 309. STUDY ON LOANS, LOAN GUARANTEES, AND 
LOAN REPAYMENT. 
‘‘(a) IN GENERAL.—The Secretary, in consultation 
with the Secretary of the Treasury, Indian Tribes, and 
Tribal Organizations, shall carry out a study to determine 
the feasibility of establishing a loan fund to provide to In-
dian Tribes and Tribal Organizations direct loans or guar-
antees for loans for the construction of health care facili-
ties, including— 
‘‘(1) inpatient facilities; 
‘‘(2) outpatient facilities; 
‘‘(3) staff quarters; 
‘‘(4) hostels; and 
‘‘(5) specialized care facilities, such as behav-
ioral health and elder care facilities. 
‘‘(b) DETERMINATIONS.—In carrying out the study 
under subsection (a), the Secretary shall determine— 
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‘‘(1) the maximum principal amount of a loan 
or loan guarantee that should be offered to a recipi-
ent from the loan fund; 
‘‘(2) the percentage of eligible costs, not to ex-
ceed 100 percent, that may be covered by a loan or 
loan guarantee from the loan fund (including costs 
relating to planning, design, financing, site land de-
velopment, construction, rehabilitation, renovation, 
conversion, improvements, medical equipment and 
furnishings, and other facility-related costs and cap-
ital purchase (but excluding staffing)); 
‘‘(3) the cumulative total of the principal of di-
rect loans and loan guarantees, respectively, that 
may be outstanding at any 1 time; 
‘‘(4) the maximum term of a loan or loan guar-
antee that may be made for a facility from the loan 
fund; 
‘‘(5) the maximum percentage of funds from 
the loan fund that should be allocated for payment 
of costs associated with planning and applying for a 
loan or loan guarantee; 
‘‘(6) whether acceptance by the Secretary of an 
assignment of the revenue of an Indian Tribe or 
Tribal Organization as security for any direct loan 
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or loan guarantee from the loan fund would be ap-
propriate; 
‘‘(7) whether, in the planning and design of 
health facilities under this section, users eligible 
under section 806(c) may be included in any projec-
tion of patient population; 
‘‘(8) whether funds of the Service provided 
through loans or loan guarantees from the loan fund 
should be eligible for use in matching other Federal 
funds under other programs; 
‘‘(9) the appropriateness of, and best methods 
for, coordinating the loan fund with the health care 
priority system of the Service under section 301; and 
‘‘(10) any legislative or regulatory changes re-
quired to implement recommendations of the Sec-
retary based on results of the study. 
‘‘(c) REPORT.—Not later than September 30, 2010, 
the Secretary shall submit to the Committee on Indian Af-
fairs of the Senate and the Committee on Natural Re-
sources and the Committee on Energy and Commerce of 
the House of Representatives a report that describes— 
‘‘(1) the manner of consultation made as re-
quired by subsection (a); and 
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‘‘(2) the results of the study, including any rec-
ommendations of the Secretary based on results of 
the study. 
‘‘SEC. 310. TRIBAL LEASING. 
‘‘A Tribal Health Program may lease permanent 
structures for the purpose of providing health care services 
without obtaining advance approval in appropriation Acts. 
‘‘SEC. 311. INDIAN HEALTH SERVICE/TRIBAL FACILITIES 
JOINT VENTURE PROGRAM. 
‘‘(a) IN GENERAL.—The Secretary, acting through 
the Service, shall make arrangements with Indian Tribes 
and Tribal Organizations to establish joint venture dem-
onstration projects under which an Indian Tribe or Tribal 
Organization shall expend tribal, private, or other avail-
able funds, for the acquisition or construction of a health 
facility for a minimum of 10 years, under a no-cost lease, 
in exchange for agreement by the Service to provide the 
equipment, supplies, and staffing for the operation and 
maintenance of such a health facility. An Indian Tribe or 
Tribal Organization may use tribal funds, private sector, 
or other available resources, including loan guarantees, to 
fulfill its commitment under a joint venture entered into 
under this subsection. An Indian Tribe or Tribal Organi-
zation shall be eligible to establish a joint venture project 
if, when it submits a letter of intent, it— 
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‘‘(1) has begun but not completed the process 
of acquisition or construction of a health facility to 
be used in the joint venture project; 
‘‘(2) has not begun the process of acquisition or 
construction of a health facility for use in the joint 
venture project; or 
‘‘(3) in its application for a joint venture agree-
ment, agrees— 
‘‘(A) to construct a facility for the joint 
venture which complies with the size and space 
criteria established by the Service; or 
‘‘(B) if the facility it proposes for the joint 
venture is already in existence or under con-
struction, that only the portion of such facility 
which complies with the size and space criteria 
of the Service will be eligible for the joint ven-
ture agreement. 
‘‘(b) REQUIREMENTS.—The Secretary shall make 
such an arrangement with an Indian Tribe or Tribal Orga-
nization only if— 
‘‘(1) the Secretary first determines that the In-
dian Tribe or Tribal Organization has the adminis-
trative and financial capabilities necessary to com-
plete the timely acquisition or construction of the 
relevant health facility; and 
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‘‘(2) the Indian Tribe or Tribal Organization 
meets the need criteria determined using the criteria 
developed under the health care facility priority sys-
tem under section 301, unless the Secretary deter-
mines, pursuant to regulations, that other criteria 
will result in a more cost-effective and efficient 
method of facilitating and completing construction of 
health care facilities. 
‘‘(c) CONTINUED OPERATION.—The Secretary shall 
negotiate an agreement with the Indian Tribe or Tribal 
Organization regarding the continued operation of the fa-
cility at the end of the initial 10 year no-cost lease period. 
‘‘(d) BREACH OF AGREEMENT.—An Indian Tribe or 
Tribal Organization that has entered into a written agree-
ment with the Secretary under this section, and that 
breaches or terminates without cause such agreement, 
shall be liable to the United States for the amount that 
has been paid to the Indian Tribe or Tribal Organization, 
or paid to a third party on the Indian Tribe’s or Tribal 
Organization’s behalf, under the agreement. The Sec-
retary has the right to recover tangible property (including 
supplies) and equipment, less depreciation, and any funds 
expended for operations and maintenance under this sec-
tion. The preceding sentence does not apply to any funds 
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expended for the delivery of health care services, per-
sonnel, or staffing. 
‘‘(e) RECOVERY FOR NONUSE.—An Indian Tribe or 
Tribal Organization that has entered into a written agree-
ment with the Secretary under this subsection shall be en-
titled to recover from the United States an amount that 
is proportional to the value of such facility if, at any time 
within the 10-year term of the agreement, the Service 
ceases to use the facility or otherwise breaches the agree-
ment. 
‘‘(f) DEFINITION.—For the purposes of this section, 
the term ‘health facility’ or ‘health facilities’ includes 
quarters needed to provide housing for staff of the rel-
evant Tribal Health Program. 
‘‘SEC. 312. LOCATION OF FACILITIES. 
‘‘(a) IN GENERAL.—In all matters involving the reor-
ganization or development of Service facilities or in the 
establishment of related employment projects to address 
unemployment conditions in economically depressed areas, 
the Bureau of Indian Affairs and the Service shall give 
priority to locating such facilities and projects on Indian 
lands, or lands in Alaska owned by any Alaska Native vil-
lage, or village or regional corporation under the Alaska 
Native Claims Settlement Act (43 U.S.C. 1601 et seq.), 
or any land allotted to any Alaska Native, if requested 
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by the Indian owner and the Indian Tribe with jurisdiction 
over such lands or other lands owned or leased by the In-
dian Tribe or Tribal Organization. Top priority shall be 
given to Indian land owned by 1 or more Indian Tribes. 
‘‘(b) DEFINITION.—For purposes of this section, the 
term ‘Indian lands’ means— 
‘‘(1) all lands within the exterior boundaries of 
any reservation; and 
‘‘(2) any lands title to which is held in trust by 
the United States for the benefit of any Indian 
Tribe or individual Indian or held by any Indian 
Tribe or individual Indian subject to restriction by 
the United States against alienation. 
‘‘SEC. 313. MAINTENANCE AND IMPROVEMENT OF HEALTH 
CARE FACILITIES. 
‘‘(a) REPORT.—The Secretary shall submit to the 
President, for inclusion in the report required to be trans-
mitted to Congress under section 801, a report which iden-
tifies the backlog of maintenance and repair work required 
at both Service and tribal health care facilities, including 
new health care facilities expected to be in operation in 
the next fiscal year. The report shall also identify the need 
for renovation and expansion of existing facilities to sup-
port the growth of health care programs. 
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‘‘(b) MAINTENANCE
OF
NEWLY
CONSTRUCTED 
SPACE.—The Secretary, acting through the Service, is au-
thorized to expend maintenance and improvement funds 
to support maintenance of newly constructed space only 
if such space falls within the approved supportable space 
allocation for the Indian Tribe or Tribal Organization. 
Supportable space allocation shall be defined through the 
health care facility priority system under section 301(c). 
‘‘(c) REPLACEMENT FACILITIES.—In addition to 
using maintenance and improvement funds for renovation, 
modernization, and expansion of facilities, an Indian Tribe 
or Tribal Organization may use maintenance and improve-
ment funds for construction of a replacement facility if 
the costs of renovation of such facility would exceed a 
maximum renovation cost threshold. The Secretary shall 
consult with Indian Tribes and Tribal Organizations in de-
termining the maximum renovation cost threshold. 
‘‘SEC. 314. TRIBAL MANAGEMENT OF FEDERALLY OWNED 
QUARTERS. 
‘‘(a) RENTAL RATES.— 
‘‘(1) ESTABLISHMENT.—Notwithstanding any 
other provision of law, a Tribal Health Program 
which operates a hospital or other health facility and 
the federally owned quarters associated therewith 
pursuant to a contract or compact under the Indian 
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Self-Determination and Education Assistance Act 
(25 U.S.C. 450 et seq.) shall have the authority to 
establish the rental rates charged to the occupants 
of such quarters by providing notice to the Secretary 
of its election to exercise such authority. 
‘‘(2) OBJECTIVES.—In establishing rental rates 
pursuant to authority of this subsection, a Tribal 
Health Program shall endeavor to achieve the fol-
lowing objectives: 
‘‘(A) To base such rental rates on the rea-
sonable value of the quarters to the occupants 
thereof. 
‘‘(B) To generate sufficient funds to pru-
dently provide for the operation and mainte-
nance of the quarters, and subject to the discre-
tion of the Tribal Health Program, to supply 
reserve funds for capital repairs and replace-
ment of the quarters. 
‘‘(3) 
EQUITABLE
FUNDING.—Any 
quarters 
whose rental rates are established by a Tribal 
Health Program pursuant to this subsection shall 
remain eligible for quarters improvement and repair 
funds to the same extent as all federally owned 
quarters used to house personnel in Services-sup-
ported programs. 
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‘‘(4) NOTICE
OF
RATE
CHANGE.—A Tribal 
Health Program which exercises the authority pro-
vided under this subsection shall provide occupants 
with no less than 60 days notice of any change in 
rental rates. 
‘‘(b) DIRECT COLLECTION OF RENT.— 
‘‘(1) IN GENERAL.—Notwithstanding any other 
provision of law, and subject to paragraph (2), a 
Tribal Health Program shall have the authority to 
collect rents directly from Federal employees who oc-
cupy such quarters in accordance with the following: 
‘‘(A) The Tribal Health Program shall no-
tify the Secretary and the subject Federal em-
ployees of its election to exercise its authority 
to collect rents directly from such Federal em-
ployees. 
‘‘(B) Upon receipt of a notice described in 
subparagraph (A), the Federal employees shall 
pay rents for occupancy of such quarters di-
rectly to the Tribal Health Program and the 
Secretary shall have no further authority to col-
lect rents from such employees through payroll 
deduction or otherwise. 
‘‘(C) Such rent payments shall be retained 
by the Tribal Health Program and shall not be 
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made payable to or otherwise be deposited with 
the United States. 
‘‘(D) Such rent payments shall be depos-
ited into a separate account which shall be used 
by the Tribal Health Program for the mainte-
nance (including capital repairs and replace-
ment) and operation of the quarters and facili-
ties as the Tribal Health Program shall deter-
mine. 
‘‘(2) RETROCESSION
OF
AUTHORITY.—If a 
Tribal Health Program which has made an election 
under paragraph (1) requests retrocession of its au-
thority to directly collect rents from Federal employ-
ees occupying federally owned quarters, such ret-
rocession shall become effective on the earlier of— 
‘‘(A) the first day of the month that begins 
no less than 180 days after the Tribal Health 
Program notifies the Secretary of its desire to 
retrocede; or 
‘‘(B) such other date as may be mutually 
agreed by the Secretary and the Tribal Health 
Program. 
‘‘(c) RATES IN ALASKA.—To the extent that a Tribal 
Health Program, pursuant to authority granted in sub-
section (a), establishes rental rates for federally owned 
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quarters provided to a Federal employee in Alaska, such 
rents may be based on the cost of comparable private rent-
al housing in the nearest established community with a 
year-round population of 1,500 or more individuals. 
‘‘SEC. 315. APPLICABILITY OF BUY AMERICAN ACT RE-
QUIREMENT. 
‘‘(a) APPLICABILITY.—The Secretary shall ensure 
that the requirements of the Buy American Act apply to 
all procurements made with funds provided pursuant to 
section 317. Indian Tribes and Tribal Organizations shall 
be exempt from these requirements. 
‘‘(b) EFFECT OF VIOLATION.—If it has been finally 
determined by a court or Federal agency that any person 
intentionally affixed a label bearing a ‘Made in America’ 
inscription or any inscription with the same meaning, to 
any product sold in or shipped to the United States that 
is not made in the United States, such person shall be 
ineligible to receive any contract or subcontract made with 
funds provided pursuant to section 317, pursuant to the 
debarment, suspension, and ineligibility procedures de-
scribed in sections 9.400 through 9.409 of title 48, Code 
of Federal Regulations. 
‘‘(c) DEFINITIONS.—For purposes of this section, the 
term ‘Buy American Act’ means title III of the Act enti-
tled ‘An Act making appropriations for the Treasury and 
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Post Office Departments for the fiscal year ending June 
30, 1934, and for other purposes’, approved March 3, 
1933 (41 U.S.C. 10a et seq.). 
‘‘SEC. 316. OTHER FUNDING FOR FACILITIES. 
‘‘(a) AUTHORITY TO ACCEPT FUNDS.—The Sec-
retary is authorized to accept from any source, including 
Federal and State agencies, funds that are available for 
the construction of health care facilities and use such 
funds to plan, design, and construct health care facilities 
for Indians and to place such funds into a contract or com-
pact under the Indian Self-Determination and Education 
Assistance Act (25 U.S.C. 450 et seq.). Receipt of such 
funds shall have no effect on the priorities established pur-
suant to section 301. 
‘‘(b) INTERAGENCY AGREEMENTS.—The Secretary is 
authorized to enter into interagency agreements with 
other Federal agencies or State agencies and other entities 
and to accept funds from such Federal or State agencies 
or other sources to provide for the planning, design, and 
construction of health care facilities to be administered by 
Indian Health Programs in order to carry out the pur-
poses of this Act and the purposes for which the funds 
were appropriated or for which the funds were otherwise 
provided. 
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‘‘(c) TRANSFERRED FUNDS.—Any Federal agency to 
which funds for the construction of health care facilities 
are appropriated is authorized to transfer such funds to 
the Secretary for the construction of health care facilities 
to carry out the purposes of this Act as well as the pur-
poses for which such funds are appropriated to such other 
Federal agency. 
‘‘(d) ESTABLISHMENT
OF STANDARDS.—The Sec-
retary, through the Service, shall establish standards by 
regulation for the planning, design, and construction of 
health care facilities serving Indians under this Act. 
‘‘SEC. 317. AUTHORIZATION OF APPROPRIATIONS. 
‘‘There are authorized to be appropriated such sums 
as may be necessary to carry out this title. 
‘‘TITLE IV—ACCESS TO HEALTH 
SERVICES 
‘‘SEC. 401. TREATMENT OF PAYMENTS UNDER SOCIAL SE-
CURITY ACT HEALTH BENEFITS PROGRAMS. 
‘‘(a) DISREGARD
OF MEDICARE, MEDICAID, AND 
SCHIP PAYMENTS IN DETERMINING APPROPRIATIONS.— 
Any payments received by an Indian Health Program or 
by an urban Indian organization under title XVIII, XIX, 
or XXI of the Social Security Act for services provided 
to Indians eligible for benefits under such respective titles 
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shall not be considered in determining appropriations for 
the provision of health care and services to Indians. 
‘‘(b) NONPREFERENTIAL TREATMENT.—Nothing in 
this Act authorizes the Secretary to provide services to an 
Indian with coverage under title XVIII, XIX, or XXI of 
the Social Security Act in preference to an Indian without 
such coverage. 
‘‘(c) USE OF FUNDS.— 
‘‘(1) SPECIAL FUND.— 
‘‘(A) 100 PERCENT
PASS-THROUGH
OF 
PAYMENTS
DUE
TO
FACILITIES.—Notwith-
standing any other provision of law, but subject 
to paragraph (2), payments to which a facility 
of the Service is entitled by reason of a provi-
sion of title XVIII or XIX of the Social Secu-
rity Act shall be placed in a special fund to be 
held by the Secretary. In making payments 
from such fund, the Secretary shall ensure that 
each Service Unit of the Service receives 100 
percent of the amount to which the facilities of 
the Service, for which such Service Unit makes 
collections, are entitled by reason of a provision 
of either such title. 
‘‘(B) USE OF FUNDS.—Amounts received 
by a facility of the Service under subparagraph 
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(A) by reason of a provision of title XVIII or 
XIX of the Social Security Act shall first be 
used (to such extent or in such amounts as are 
provided in appropriation Acts) for the purpose 
of making any improvements in the programs 
of the Service operated by or through such fa-
cility which may be necessary to achieve or 
maintain compliance with the applicable condi-
tions and requirements of such respective title. 
Any amounts so received that are in excess of 
the amount necessary to achieve or maintain 
such conditions and requirements shall, subject 
to consultation with the Indian Tribes being 
served by the Service Unit, be used for increas-
ing the facility’s capacity to provide, or improv-
ing the quality or accessibility of, services. 
‘‘(2) DIRECT
PAYMENT
OPTION.—Paragraph 
(1) shall not apply to a Tribal Health Program upon 
the election of such Program under subsection (d) to 
receive payments directly. No payment may be made 
out of the special fund described in such paragraph 
with respect to reimbursement made for services 
provided by such Program during the period of such 
election. 
‘‘(d) DIRECT BILLING.— 
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‘‘(1) IN GENERAL.—Subject to complying with 
the requirements of paragraph (2), a Tribal Health 
Program may elect to directly bill for, and receive 
payment for, health care items and services provided 
by such Program for which payment is made under 
title XVIII, XIX, or XXI of the Social Security Act. 
‘‘(2) DIRECT REIMBURSEMENT.— 
‘‘(A) USE OF FUNDS.—Each Tribal Health 
Program making the election described in para-
graph (1) with respect to a program under title 
XVIII, XIX, or XXI of the Social Security Act 
shall be reimbursed directly by that program 
for items and services furnished without regard 
to subsection (c)(1), but all amounts so reim-
bursed shall be used by the Tribal Health Pro-
gram for the same purposes with respect to 
such Program for which payment under sub-
paragraph (A) of subsection (c)(1) to a facility 
of the Service may be used pursuant to sub-
paragraph (B) of such subsection with respect 
to the Service. 
‘‘(B) AUDITS.—The amounts paid to a 
Tribal Health Program making the election de-
scribed in paragraph (1) with respect to a pro-
gram under title XVIII, XIX, or XXI of the So-
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cial Security Act shall be subject to all auditing 
requirements applicable to the program under 
such title, as well as all auditing requirements 
applicable to programs administered by an In-
dian Health Program. Nothing in the preceding 
sentence shall be construed as limiting the ap-
plication of auditing requirements applicable to 
amounts paid under title XVIII, XIX, or XXI 
of the Social Security Act. 
‘‘(C) IDENTIFICATION OF SOURCE OF PAY-
MENTS.—Any Tribal Health Program that re-
ceives reimbursements or payments under title 
XVIII, XIX, or XXI of the Social Security Act 
shall provide to the Service a list of each pro-
vider enrollment number (or other identifier) 
under which such Program receives such reim-
bursements or payments. 
‘‘(3) EXAMINATION AND IMPLEMENTATION OF 
CHANGES.— 
‘‘(A) IN GENERAL.—The Secretary, acting 
through the Service and with the assistance of 
the Administrator of the Centers for Medicare 
& Medicaid Services, shall examine on an ongo-
ing basis and implement any administrative 
changes that may be necessary to facilitate di-
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rect billing and reimbursement under the pro-
gram established under this subsection, includ-
ing any agreements with States that may be 
necessary to provide for direct billing under a 
program under title XIX or XXI of the Social 
Security Act. 
‘‘(B) COORDINATION OF INFORMATION.— 
The Service shall provide the Administrator of 
the Centers for Medicare & Medicaid Services 
with copies of the lists submitted to the Service 
under paragraph (2)(C), enrollment data re-
garding patients served by the Service (and by 
Tribal Health Programs, to the extent such 
data is available to the Service), and such other 
information as the Administrator may require 
for purposes of administering title XVIII, XIX, 
or XXI of the Social Security Act. 
‘‘(4) WITHDRAWAL FROM PROGRAM.—A Tribal 
Health Program that bills directly under the pro-
gram established under this subsection may with-
draw from participation in the same manner and 
under the same conditions that an Indian Tribe or 
Tribal Organization may retrocede a contracted pro-
gram to the Secretary under the authority of the In-
dian Self-Determination and Education Assistance 
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Act (25 U.S.C. 450 et seq.). All cost accounting and 
billing authority under the program established 
under this subsection shall be returned to the Sec-
retary upon the Secretary’s acceptance of the with-
drawal of participation in this program. 
‘‘(5) TERMINATION FOR FAILURE TO COMPLY 
WITH REQUIREMENTS.—The Secretary may termi-
nate the participation of a Tribal Health Program or 
in the direct billing program established under this 
subsection if the Secretary determines that the Pro-
gram has failed to comply with the requirements of 
paragraph (2). The Secretary shall provide a Tribal 
Health Program with notice of a determination that 
the Program has failed to comply with any such re-
quirement and a reasonable opportunity to correct 
such noncompliance prior to terminating the Pro-
gram’s participation in the direct billing program es-
tablished under this subsection. 
‘‘(e) RELATED PROVISIONS UNDER THE SOCIAL SE-
CURITY ACT.—For provisions related to subsections (c) 
and (d), see sections 1880, 1911, and 2107(e)(1)(D) of 
the Social Security Act. 
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‘‘SEC. 402. GRANTS TO AND CONTRACTS WITH THE SERV-
ICE, 
INDIAN 
TRIBES, 
TRIBAL 
ORGANIZA-
TIONS, AND URBAN INDIAN ORGANIZATIONS 
TO FACILITATE OUTREACH, ENROLLMENT, 
AND COVERAGE OF INDIANS UNDER SOCIAL 
SECURITY ACT HEALTH BENEFIT PROGRAMS. 
‘‘(a) INDIAN
TRIBES
AND
TRIBAL
ORGANIZA-
TIONS.—The Secretary, acting through the Service, shall 
make grants to or enter into contracts with Indian Tribes 
and Tribal Organizations to assist such Tribes and Tribal 
Organizations in establishing and administering programs 
on or near reservations, trust lands, and Alaska Native 
Villages, including programs to provide outreach and en-
rollment through video, electronic delivery methods, or 
telecommunication devices that allow real-time or time-de-
layed communication between individual Indians and the 
benefit program, to assist individual Indians— 
‘‘(1) to enroll for benefits under a program es-
tablished under title XVIII, XIX, or XXI of the So-
cial Security Act; and 
‘‘(2) with respect to such programs for which 
the charging of premiums and cost sharing is not 
prohibited under such programs, to pay premiums or 
cost sharing for coverage for such benefits, which 
may be based on financial need (as determined by 
the Indian Tribe or Tribes or Tribal Organizations 
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being served based on a schedule of income levels de-
veloped or implemented by such Tribe, Tribes, or 
Tribal Organizations). 
‘‘(b) CONDITIONS.—The Secretary, acting through 
the Service, shall place conditions as deemed necessary to 
effect the purpose of this section in any grant or contract 
which the Secretary makes with any Indian Tribe or Trib-
al Organization pursuant to this section. Such conditions 
shall include requirements that the Indian Tribe or Tribal 
Organization successfully undertake— 
‘‘(1) to determine the population of Indians eli-
gible for the benefits described in subsection (a); 
‘‘(2) to educate Indians with respect to the ben-
efits available under the respective programs; 
‘‘(3) to provide transportation for such indi-
vidual Indians to the appropriate offices for enroll-
ment or applications for such benefits; and 
‘‘(4) to develop and implement methods of im-
proving the participation of Indians in receiving ben-
efits under such programs. 
‘‘(c) APPLICATION
TO URBAN INDIAN ORGANIZA-
TIONS.— 
‘‘(1) IN
GENERAL.—The provisions of sub-
section (a) shall apply with respect to grants and 
other funding to urban Indian organizations with re-
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spect to populations served by such organizations in 
the same manner they apply to grants and contracts 
with Indian Tribes and Tribal Organizations with 
respect to programs on or near reservations. 
‘‘(2) REQUIREMENTS.—The Secretary shall in-
clude in the grants or contracts made or provided 
under paragraph (1) requirements that are— 
‘‘(A) consistent with the requirements im-
posed by the Secretary under subsection (b); 
‘‘(B) appropriate to urban Indian organi-
zations and urban Indians; and 
‘‘(C) necessary to effect the purposes of 
this section. 
‘‘(d) FACILITATING COOPERATION IN ENROLLMENT 
AND RETENTION.—The Secretary, acting through the 
Centers for Medicare & Medicaid Services, shall consult 
with States, the Service, Indian Tribes, Tribal Organiza-
tions, and urban Indian organizations to develop and dis-
seminate best practices with respect to facilitating agree-
ments between the States and Indian Tribes, Tribal Orga-
nizations, and urban Indian organizations relating to en-
rollment and retention of Indians in programs established 
under titles XVIII, XIX, and XXI of the Social Security 
Act. 
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‘‘(e) AGREEMENTS TO IMPROVE ENROLLMENT OF 
INDIANS UNDER SOCIAL SECURITY ACT HEALTH BENE-
FITS PROGRAMS.—For provisions relating to agreements 
between the Secretary and the Service, Indian Tribes, 
Tribal Organizations, and urban Indian organizations for 
the collection, preparation, and submission of applications 
by Indians for assistance under the Medicaid and chil-
dren’s health insurance programs established under titles 
XIX and XXI of the Social Security Act, and benefits 
under the Medicare program established under title XVIII 
of such Act, see subsections (a) and (b) of section 1139 
of the Social Security Act. 
‘‘(f) DEFINITIONS.—In this section: 
‘‘(1) PREMIUM.—The term ‘premium’ includes 
any enrollment fee or similar charge. 
‘‘(2) COST SHARING.—The term ‘cost sharing’ 
includes any deduction, deductible, copayment, coin-
surance, or similar charge. 
‘‘(3) BENEFITS.—The term ‘benefits’ means, 
with respect to— 
‘‘(A) title XVIII of the Social Security Act, 
benefits under such title; 
‘‘(B) title XIX of such Act, medical assist-
ance under such title; and 
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‘‘(C) title XXI of such Act, assistance 
under such title. 
‘‘SEC. 403. REIMBURSEMENT FROM CERTAIN THIRD PAR-
TIES OF COSTS OF HEALTH SERVICES. 
‘‘(a) RIGHT OF RECOVERY.—Except as provided in 
subsection (f), the United States, an Indian Tribe, or 
Tribal Organization shall have the right to recover from 
an insurance company, health maintenance organization, 
employee benefit plan, third-party tortfeasor, or any other 
responsible or liable third party (including a political sub-
division or local governmental entity of a State) the rea-
sonable charges incurred by the Secretary, an Indian 
Tribe, or Tribal Organization, or, if higher, the highest 
amount the third party would pay for care and services 
furnished by providers other than governmental entities, 
in providing health services through the Service, an Indian 
Tribe, or Tribal Organization to any individual to the 
same extent that such individual, or any nongovernmental 
provider of such services, would be eligible to receive dam-
ages, reimbursement, or indemnification for such charges 
if— 
‘‘(1) such services had been provided by a non-
governmental provider; and 
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‘‘(2) such individual had been required to pay 
such charges or expenses and did pay such charges 
or expenses. 
‘‘(b) LIMITATIONS ON RECOVERIES FROM STATES.— 
Subsection (a) shall provide a right of recovery against 
any State, only if the injury, illness, or disability for which 
health services were provided is covered under— 
‘‘(1) workers’ compensation laws; or 
‘‘(2) a no-fault automobile accident insurance 
plan or program. 
‘‘(c) NONAPPLICATION OF OTHER LAWS.—No law of 
any State, or of any political subdivision of a State and 
no provision of any contract, insurance or health mainte-
nance organization policy, employee benefit plan, self-in-
surance plan, managed care plan, or other health care plan 
or program entered into or renewed after the date of the 
enactment of the Indian Health Care Amendments of 
1988, shall prevent or hinder the right of recovery of the 
United States, an Indian Tribe, or Tribal Organization 
under subsection (a). 
‘‘(d) NO EFFECT ON PRIVATE RIGHTS OF ACTION.— 
No action taken by the United States, an Indian Tribe, 
or Tribal Organization to enforce the right of recovery 
provided under this section shall operate to deny to the 
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injured person the recovery for that portion of the person’s 
damage not covered hereunder. 
‘‘(e) ENFORCEMENT.— 
‘‘(1) IN GENERAL.—The United States, an In-
dian Tribe, or Tribal Organization may enforce the 
right of recovery provided under subsection (a) by— 
‘‘(A) intervening or joining in any civil ac-
tion or proceeding brought— 
‘‘(i) by the individual for whom health 
services were provided by the Secretary, an 
Indian Tribe, or Tribal Organization; or 
‘‘(ii) by any representative or heirs of 
such individual, or 
‘‘(B) instituting a civil action, including a 
civil action for injunctive relief and other relief 
and including, with respect to a political sub-
division or local governmental entity of a State, 
such an action against an official thereof. 
‘‘(2) NOTICE.—All reasonable efforts shall be 
made to provide notice of action instituted under 
paragraph (1)(B) to the individual to whom health 
services were provided, either before or during the 
pendency of such action. 
‘‘(3) RECOVERY FROM TORTFEASORS.— 
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‘‘(A) IN GENERAL.—In any case in which 
an Indian Tribe or Tribal Organization that is 
authorized or required under a compact or con-
tract issued pursuant to the Indian Self-Deter-
mination and Education Assistance Act (25 
U.S.C. 450 et seq.) to furnish or pay for health 
services to a person who is injured or suffers a 
disease on or after the date of enactment of the 
Indian Health Care Improvement Act Amend-
ments of 2009 under circumstances that estab-
lish grounds for a claim of liability against the 
tortfeasor with respect to the injury or disease, 
the Indian Tribe or Tribal Organization shall 
have a right to recover from the tortfeasor (or 
an insurer of the tortfeasor) the reasonable 
value of the health services so furnished, paid 
for, or to be paid for, in accordance with the 
Federal Medical Care Recovery Act (42 U.S.C. 
2651 et seq.), to the same extent and under the 
same circumstances as the United States may 
recover under that Act. 
‘‘(B) TREATMENT.—The right of an In-
dian Tribe or Tribal Organization to recover 
under subparagraph (A) shall be independent of 
the rights of the injured or diseased person 
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served by the Indian Tribe or Tribal Organiza-
tion. 
‘‘(f) LIMITATION.—Absent specific written authoriza-
tion by the governing body of an Indian Tribe for the pe-
riod of such authorization (which may not be for a period 
of more than 1 year and which may be revoked at any 
time upon written notice by the governing body to the 
Service), the United States shall not have a right of recov-
ery under this section if the injury, illness, or disability 
for which health services were provided is covered under 
a self-insurance plan funded by an Indian Tribe, Tribal 
Organization, or urban Indian organization. Where such 
authorization is provided, the Service may receive and ex-
pend such amounts for the provision of additional health 
services consistent with such authorization. 
‘‘(g) COSTS AND ATTORNEYS’ FEES.—In any action 
brought to enforce the provisions of this section, a pre-
vailing plaintiff shall be awarded its reasonable attorneys’ 
fees and costs of litigation. 
‘‘(h) NONAPPLICATION OF CLAIMS FILING REQUIRE-
MENTS.—An insurance company, health maintenance or-
ganization, self-insurance plan, managed care plan, or 
other health care plan or program (under the Social Secu-
rity Act or otherwise) may not deny a claim for benefits 
submitted by the Service or by an Indian Tribe or Tribal 
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Organization based on the format in which the claim is 
submitted if such format complies with the format re-
quired for submission of claims under title XVIII of the 
Social Security Act or recognized under section 1175 of 
such Act. 
‘‘(i) APPLICATION
TO URBAN INDIAN ORGANIZA-
TIONS.—The previous provisions of this section shall apply 
to urban Indian organizations with respect to populations 
served by such Organizations in the same manner they 
apply to Indian Tribes and Tribal Organizations with re-
spect to populations served by such Indian Tribes and 
Tribal Organizations. 
‘‘(j) STATUTE OF LIMITATIONS.—The provisions of 
section 2415 of title 28, United States Code, shall apply 
to all actions commenced under this section, and the ref-
erences therein to the United States are deemed to include 
Indian Tribes, Tribal Organizations, and urban Indian or-
ganizations. 
‘‘(k) SAVINGS.—Nothing in this section shall be con-
strued to limit any right of recovery available to the 
United States, an Indian Tribe, or Tribal Organization 
under the provisions of any applicable, Federal, State, or 
Tribal law, including medical lien laws. 
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‘‘SEC. 404. CREDITING OF REIMBURSEMENTS. 
‘‘(a) RETENTION OF AMOUNTS FOR USE BY PRO-
GRAM.—Except as provided in section 202(f) (relating to 
the Catastrophic Health Emergency Fund) and section 
806 (relating to health services for ineligible persons), all 
reimbursements received or recovered, including under 
section 806, by reason of the provision of health services 
by the Service, by an Indian Tribe or Tribal Organization, 
or by an urban Indian organization, shall be credited to 
the Service, such Indian Tribe or Tribal Organization, or 
such urban Indian organization, respectively, and may be 
used as provided in section 401. In the case of such a 
service provided by or through a Service Unit, such 
amounts shall be credited to such unit and used for such 
purposes. 
‘‘(b) NO OFFSET OF AMOUNTS.—The Service may 
not offset or limit any amount obligated to any Service 
Unit or entity receiving funding from the Service because 
of the receipt of reimbursements under subsection (a). 
‘‘SEC. 405. PURCHASING HEALTH CARE COVERAGE. 
‘‘(a) PURCHASING COVERAGE.— 
‘‘(1) IN
GENERAL.—Insofar as amounts are 
made available under law (including a provision of 
the Social Security Act, the Indian Self-Determina-
tion and Education Assistance Act (25 U.S.C. 450 
et seq.), or other law, other than under section 402) 
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to Indian Tribes, Tribal Organizations, and urban 
Indian organizations for health benefits for Service 
beneficiaries, Indian Tribes, Tribal Organizations, 
and urban Indian organizations may use such 
amounts to purchase health benefits coverage that 
qualifies as creditable coverage under section 
2701(c)(1) of the Public Health Service Act for such 
beneficiaries, including, subject to paragraph (2), 
through— 
‘‘(A) a tribally owned and operated health 
care plan; 
‘‘(B) a State or locally authorized or li-
censed health care plan; 
‘‘(C) a health insurance provider or man-
aged care organization; or 
‘‘(D) a self-insured plan. 
‘‘(2) 
EXCEPTION.—The 
coverage 
provided 
under paragraph (1) may not include coverage con-
sisting of— 
‘‘(A) benefits provided under a health flexi-
ble spending arrangement (as defined in section 
106(c)(2) of the Internal Revenue Code of 
1986); or 
‘‘(B) a high deductible health plan (as de-
fined in section 223(c)(2) of such Code), with-
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out regard to whether the plan is purchased in 
conjunction with a health savings account (as 
defined under section 223(d) of such Code). 
‘‘(3) PERMITTING
PURCHASE
OF
COVERAGE 
BASED ON FINANCIAL NEED.—The purchase of cov-
erage by an Indian Tribe, Tribal Organization, or 
urban Indian organization under this subsection may 
be based on the financial needs of beneficiaries (as 
determined by the Indian Tribe or Tribes being 
served based on a schedule of income levels devel-
oped or implemented by such Indian Tribe or 
Tribes). 
‘‘(b) EXPENSES FOR SELF-INSURED PLAN.—In the 
case of a self-insured plan under subsection (a)(4), the 
amounts may be used for expenses of operating the plan, 
including administration and insurance to limit the finan-
cial risks to the entity offering the plan. 
‘‘(c) CONSTRUCTION.—Nothing in this section shall 
be construed as affecting the use of any amounts not re-
ferred to in subsection (a). 
‘‘SEC. 406. SHARING ARRANGEMENTS WITH FEDERAL AGEN-
CIES. 
‘‘(a) AUTHORITY.— 
‘‘(1) IN GENERAL.—The Secretary may enter 
into (or expand) arrangements for the sharing of 
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‘‘(4) the quality of health care services provided 
by the Department of Veterans Affairs or the De-
partment of Defense; or 
‘‘(5) the eligibility of any Indian who is a vet-
eran to receive health services through the Depart-
ment of Veterans Affairs. 
‘‘(c) REIMBURSEMENT.—The Service, Indian Tribe, 
or Tribal Organization shall be reimbursed by the Depart-
ment of Veterans Affairs or the Department of Defense 
(as the case may be) where services are provided through 
the Service, an Indian Tribe, or a Tribal Organization to 
beneficiaries eligible for services from either such Depart-
ment, notwithstanding any other provision of law. 
‘‘(d) CONSTRUCTION.—Nothing in this section may 
be construed as creating any right of a non-Indian veteran 
to obtain health services from the Service. 
‘‘SEC. 407. ELIGIBLE INDIAN VETERAN SERVICES. 
‘‘(a) FINDINGS; PURPOSE.— 
‘‘(1) FINDINGS.—Congress finds that— 
‘‘(A) collaborations between the Secretary 
and the Secretary of Veterans Affairs regarding 
the treatment of Indian veterans at facilities of 
the Service should be encouraged to the max-
imum extent practicable; and 
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‘‘(B) increased enrollment for services of 
the Department of Veterans Affairs by veterans 
who are members of Indian tribes should be en-
couraged to the maximum extent practicable. 
‘‘(2) PURPOSE.—The purpose of this section is 
to reaffirm the goals stated in the document entitled 
‘Memorandum of Understanding Between the VA/ 
Veterans Health Administration And HHS/Indian 
Health Service’ and dated February 25, 2003 (relat-
ing to cooperation and resource sharing between the 
Veterans Health Administration and Service). 
‘‘(b) DEFINITIONS.—In this section: 
‘‘(1) ELIGIBLE
INDIAN
VETERAN.—The term 
‘eligible Indian veteran’ means an Indian or Alaska 
Native veteran who receives any medical service that 
is— 
‘‘(A) authorized under the laws adminis-
tered by the Secretary of Veterans Affairs; and 
‘‘(B) administered at a facility of the Serv-
ice (including a facility operated by an Indian 
tribe or tribal organization through a contract 
or compact with the Service under the Indian 
Self-Determination and Education Assistance 
Act (25 U.S.C. 450 et seq.)) pursuant to a local 
memorandum of understanding. 
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‘‘(2) 
LOCAL
MEMORANDUM
OF
UNDER-
STANDING.—The term ‘local memorandum of under-
standing’ means a memorandum of understanding 
between the Secretary (or a designee, including the 
director of any Area Office of the Service) and the 
Secretary of Veterans Affairs (or a designee) to im-
plement the document entitled ‘Memorandum of Un-
derstanding Between the VA/Veterans Health Ad-
ministration And HHS/Indian Health Service’ and 
dated February 25, 2003 (relating to cooperation 
and resource sharing between the Veterans Health 
Administration and Indian Health Service). 
‘‘(c) ELIGIBLE INDIAN VETERANS’ EXPENSES.— 
‘‘(1) IN GENERAL.—Notwithstanding any other 
provision of law, the Secretary shall provide for vet-
eran-related expenses incurred by eligible Indian vet-
erans as described in subsection (b)(1)(B). 
‘‘(2) METHOD
OF
PAYMENT.—The Secretary 
shall establish such guidelines as the Secretary de-
termines to be appropriate regarding the method of 
payments to the Secretary of Veterans Affairs under 
paragraph (1). 
‘‘(d) TRIBAL APPROVAL OF MEMORANDA.—In nego-
tiating a local memorandum of understanding with the 
Secretary of Veterans Affairs regarding the provision of 
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services to eligible Indian veterans, the Secretary shall 
consult with each Indian tribe that would be affected by 
the local memorandum of understanding. 
‘‘(e) FUNDING.— 
‘‘(1) TREATMENT.—Expenses incurred by the 
Secretary in carrying out subsection (c)(1) shall not 
be considered to be Contract Health Service ex-
penses. 
‘‘(2) USE OF FUNDS.—Of funds made available 
to the Secretary in appropriations Acts for the Serv-
ice (excluding funds made available for facilities, 
Contract Health Services, or contract support costs), 
the Secretary shall use such sums as are necessary 
to carry out this section. 
‘‘SEC. 408. PAYOR OF LAST RESORT. 
‘‘Indian Health Programs and health care programs 
operated by Urban Indian Organizations shall be the 
payor of last resort for services provided to persons eligible 
for services from Indian Health Programs and Urban In-
dian Organizations, notwithstanding any Federal, State, 
or local law to the contrary. 
‘‘SEC. 409. CONSULTATION. 
‘‘For provisions related to consultation with rep-
resentatives of Indian Health Programs and urban Indian 
organizations with respect to the health care programs es-
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tablished under titles XVIII, XIX, and XXI of the Social 
Security Act, see section 1139(d) of the Social Security 
Act (42 U.S.C. 1320b–9(d)). 
‘‘SEC. 410. STATE CHILDREN’S HEALTH INSURANCE PRO-
GRAM (SCHIP). 
‘‘For provisions relating to— 
‘‘(1) outreach to families of Indian children 
likely to be eligible for child health assistance under 
the State children’s health insurance program estab-
lished under title XXI of the Social Security Act, see 
sections 2105(c)(2)(C) and 1139(a) of such Act (42 
U.S.C. 1397ee(c)(2), 1320b–9); and 
‘‘(2) ensuring that child health assistance is 
provided under such program to targeted low-income 
children who are Indians and that payments are 
made under such program to Indian Health Pro-
grams and urban Indian organizations operating in 
the State that provide such assistance, see sections 
2102(b)(3)(D) and 2105(c)(6)(B) of such Act (42 
U.S.C. 1397bb(b)(3)(D), 1397ee(c)(6)(B)). 
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‘‘SEC. 411. PREMIUM AND COST SHARING PROTECTIONS 
AND ELIGIBILITY DETERMINATIONS UNDER 
MEDICAID AND SCHIP AND PROTECTION OF 
CERTAIN INDIAN PROPERTY FROM MEDICAID 
ESTATE RECOVERY. 
‘‘For provisions relating to— 
‘‘(1) premiums or cost sharing protections for 
Indians furnished items or services directly by In-
dian Health Programs or through referral under the 
contract health service under the Medicaid program 
established under title XIX of the Social Security 
Act, see sections 1916(j) and 1916A(a)(1) of the So-
cial Security Act (42 U.S.C. 1396o(j), 1396o– 
1(a)(1)); 
‘‘(2) rules regarding the treatment of certain 
property for purposes of determining eligibility 
under such programs, see sections 1902(e)(13) and 
2107(e)(1)(B) of such Act (42 U.S.C. 1396a(e)(13), 
1397gg(e)(1)(B)); and 
‘‘(3) the protection of certain property from es-
tate recovery provisions under the Medicaid pro-
gram, see section 1917(b)(3)(B) of such Act (42 
U.S.C. 1396p(b)(3)(B)). 
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