110
‘‘(2) Public information and education pro-
grams for the prevention, control, and elimination of 
communicable and infectious diseases. 
‘‘(3) Education, training, and clinical skills im-
provement activities in the prevention, control, and 
elimination of communicable and infectious diseases 
for health professionals, including allied health pro-
fessionals. 
‘‘(4) Demonstration projects for the screening, 
treatment, and prevention of hepatitis C virus 
(HCV). 
‘‘(b) APPLICATION REQUIRED.—The Secretary may 
provide funding under subsection (a) only if an application 
or proposal for funding is submitted to the Secretary. 
‘‘(c) COORDINATION WITH HEALTH AGENCIES.—In-
dian Tribes and Tribal Organizations receiving funding 
under this section are encouraged to coordinate their ac-
tivities with the Centers for Disease Control and Preven-
tion and State and local health agencies. 
‘‘(d) TECHNICAL ASSISTANCE; REPORT.—In carrying 
out this section, the Secretary—
‘‘(1) may, at the request of an Indian Tribe or 
Tribal Organization, provide technical assistance; 
and
111
‘‘(2) shall prepare and submit a report to Con-
gress biennially on the use of funds under this sec-
tion and on the progress made toward the preven-
tion, control, and elimination of communicable and 
infectious diseases among Indians and Urban Indi-
ans. 
‘‘SEC. 213. AUTHORITY FOR PROVISION OF OTHER SERV-
ICES. 
‘‘(a) FUNDING AUTHORIZED.—The Secretary, acting 
through the Service, Indian Tribes, and Tribal Organiza-
tions, may provide funding under this Act to meet the ob-
jectives set forth in section 3 through health care-related 
services and programs not otherwise described in this Act, 
which shall include, but not be limited to—
‘‘(1) hospice care and assisted living; 
‘‘(2) long-term health care; 
‘‘(3) home- and community-based services; 
‘‘(4) public health functions; and 
‘‘(5) Traditional Health Care Practices. 
‘‘(b) SERVICES
TO OTHERWISE INELIGIBLE PER-
SONS.—At the discretion of the Service, Indian Tribes, or 
Tribal Organizations, services provided for hospice care, 
home health care, home- and community-based care, as-
sisted living, and long-term care may be provided (subject 
to reimbursement of reasonable charges) to persons other-
112
wise ineligible for the health care benefits of the Service. 
Any funds received under this subsection shall not be used 
to offset or limit the funding allocated to an Indian Tribe 
or Tribal Organization. 
‘‘(c) DEFINITIONS.—For the purposes of this section, 
the following definitions shall apply: 
‘‘(1) The term ‘home- and community-based 
services’ means 1 or more of the following: 
‘‘(A) Homemaker/home health aide serv-
ices. 
‘‘(B) Chore services. 
‘‘(C) Personal care services. 
‘‘(D) Nursing care services provided out-
side of a nursing facility by, or under the super-
vision of, a registered nurse. 
‘‘(E) Respite care. 
‘‘(F) Training for family members. 
‘‘(G) Adult day care. 
‘‘(H) Such other home- and community-
based services as the Secretary, an Indian 
Tribe, or Tribal Organization may approve. 
‘‘(2) The term ‘hospice care’ means the items 
and services specified in subparagraphs (A) through 
(H) of section 1861(dd)(1) of the Social Security 
Act (42 U.S.C. 1395x(dd)(1)), and such other serv-
113
ices which an Indian Tribe or Tribal Organization 
determines are necessary and appropriate to provide 
in furtherance of this care. 
‘‘(3) The term ‘public health functions’ means 
the provision of public health-related programs, 
functions, and services including, but not limited to, 
assessment, assurance, and policy development which 
Indian Tribes and Tribal Organizations are author-
ized and encouraged, in those circumstances where 
it meets their needs, to do by forming collaborative 
relationships with all levels of local, State, and Fed-
eral Government. 
‘‘SEC. 214. INDIAN WOMEN’S HEALTH CARE. 
‘‘The Secretary, acting through the Service and In-
dian Tribes, Tribal Organizations, and Urban Indian Or-
ganizations, shall provide funding to monitor and improve 
the quality of health care for Indian women of all ages 
through the planning and delivery of programs adminis-
tered by the Service, in order to improve and enhance the 
treatment models of care for Indian women. 
‘‘SEC. 215. ENVIRONMENTAL AND NUCLEAR HEALTH HAZ-
ARDS. 
‘‘(a) STUDIES
AND MONITORING.—The Secretary 
and the Service shall conduct, in conjunction with other 
appropriate Federal agencies and in consultation with con-
114
cerned Indian Tribes and Tribal Organizations, studies 
and ongoing monitoring programs to determine trends in 
the health hazards to Indian miners and to Indians on 
or near reservations and Indian communities as a result 
of environmental hazards which may result in chronic or 
life threatening health problems, such as nuclear resource 
development, petroleum contamination, and contamination 
of water source and of the food chain. Such studies shall 
include—
‘‘(1) an evaluation of the nature and extent of 
health problems caused by environmental hazards 
currently exhibited among Indians and the causes of 
such health problems; 
‘‘(2) an analysis of the potential effect of ongo-
ing and future environmental resource development 
on or near reservations and Indian communities, in-
cluding the cumulative effect over time on health; 
‘‘(3) an evaluation of the types and nature of 
activities, practices, and conditions causing or affect-
ing such health problems including, but not limited 
to, uranium mining and milling, uranium mine tail-
ing deposits, nuclear power plant operation and con-
struction, and nuclear waste disposal; oil and gas 
production or transportation on or near reservations 
or Indian communities; and other development that
115
could affect the health of Indians and their water 
supply and food chain; 
‘‘(4) a summary of any findings and rec-
ommendations provided in Federal and State stud-
ies, reports, investigations, and inspections during 
the 5 years prior to the date of the enactment of the 
Indian Health Care Improvement Act Amendments 
of 2003 that directly or indirectly relate to the ac-
tivities, practices, and conditions affecting the health 
or safety of such Indians; and 
‘‘(5) the efforts that have been made by Federal 
and State agencies and resource and economic devel-
opment companies to effectively carry out an edu-
cation program for such Indians regarding the 
health and safety hazards of such development. 
‘‘(b) HEALTH CARE PLANS.—Upon completion of 
such studies, the Secretary and the Service shall take into 
account the results of such studies and, in consultation 
with Indian Tribes and Tribal Organizations, develop 
health care plans to address the health problems studied 
under subsection (a). The plans shall include—
‘‘(1) methods for diagnosing and treating Indi-
ans currently exhibiting such health problems; 
‘‘(2) preventive care and testing for Indians 
who may be exposed to such health hazards, includ-
116
ing the monitoring of the health of individuals who 
have or may have been exposed to excessive amounts 
of radiation or affected by other activities that have 
had or could have a serious impact upon the health 
of such individuals; and 
‘‘(3) a program of education for Indians who, 
by reason of their work or geographic proximity to 
such nuclear or other development activities, may ex-
perience health problems. 
‘‘(c) SUBMISSION OF REPORT AND PLAN TO CON-
GRESS.—The Secretary and the Service shall submit to 
Congress the study prepared under subsection (a) no later 
than 18 months after the date of the enactment of the 
Indian Health Care Improvement Act Amendments of 
2003. The health care plan prepared under subsection (b) 
shall be submitted in a report no later than 1 year after 
the study prepared under subsection (a) is submitted to 
Congress. Such report shall include recommended activi-
ties for the implementation of the plan, as well as an eval-
uation of any activities previously undertaken by the Serv-
ice to address such health problems. 
‘‘(d) INTERGOVERNMENTAL TASK FORCE.—
‘‘(1) ESTABLISHMENT; MEMBERS.—There is es-
tablished an Intergovernmental Task Force to be
117
composed of the following individuals (or their des-
ignees): 
‘‘(A) The Secretary of Energy. 
‘‘(B) The Secretary of the Environmental 
Protection Agency. 
‘‘(C) The Director of the Bureau of Mines. 
‘‘(D) The Assistant Secretary for Occupa-
tional Safety and Health. 
‘‘(E) The Secretary of the Interior. 
‘‘(F) The Secretary of Health and Human 
Services. 
‘‘(G) The Director of the Indian Health 
Service. 
‘‘(2) DUTIES.—The Task Force shall—
‘‘(A) identify existing and potential oper-
ations related to nuclear resource development 
or other environmental hazards that affect or 
may affect the health of Indians on or near a 
reservation or in an Indian community; and 
‘‘(B) enter into activities to correct exist-
ing health hazards and ensure that current and 
future health problems resulting from nuclear 
resource or other development activities are 
minimized or reduced.
118
‘‘(3) CHAIRMAN; MEETINGS.—The Secretary of 
Health and Human Services shall be the Chairman 
of the Task Force. The Task Force shall meet at 
least twice each year. 
‘‘(e) HEALTH SERVICES TO CERTAIN EMPLOYEES.—
In the case of any Indian who—
‘‘(1) as a result of employment in or near a 
uranium mine or mill or near any other environ-
mental hazard, suffers from a work-related illness or 
condition; 
‘‘(2) is eligible to receive diagnosis and treat-
ment services from an Indian Health Program; and 
‘‘(3) by reason of such Indian’s employment, is 
entitled to medical care at the expense of such mine 
or mill operator or entity responsible for the environ-
mental hazard, the Indian Health Program shall, at 
the request of such Indian, render appropriate med-
ical care to such Indian for such illness or condition 
and may be reimbursed for any medical care so ren-
dered to which such Indian is entitled at the expense 
of such operator or entity from such operator or en-
tity. Nothing in this subsection shall affect the 
rights of such Indian to recover damages other than 
such amounts paid to the Indian Health Program
119
from the employer for providing medical care for 
such illness or condition. 
‘‘SEC. 216. ARIZONA AS A CONTRACT HEALTH SERVICE DE-
LIVERY AREA. 
‘‘(a) IN GENERAL.—For fiscal years beginning with 
the fiscal year ending September 30, 1983, and ending 
with the fiscal year ending September 30, 2015, the State 
of Arizona shall be designated as a contract health service 
delivery area by the Service for the purpose of providing 
contract health care services to members of federally rec-
ognized Indian Tribes of Arizona. 
‘‘(b) MAINTENANCE
OF
SERVICES.—The Service 
shall not curtail any health care services provided to Indi-
ans residing on reservations in the State of Arizona if such 
curtailment is due to the provision of contract services in 
such State pursuant to the designation of such State as 
a contract health service delivery area pursuant to sub-
section (a).
‘‘SEC. 216A. NORTH DAKOTA AS A CONTRACT HEALTH 
SERVICE DELIVERY AREA. 
‘‘(a) IN GENERAL.—For fiscal years beginning with 
the fiscal year ending September 30, 2003, and ending 
with the fiscal year ending September 30, 2015, the State 
of North Dakota shall be designated as a contract health 
service delivery area by the Service for the purpose of pro-
120
viding contract health care services to members of feder-
ally recognized Indian Tribes of North Dakota. 
‘‘(b) LIMITATION.—The Service shall not curtail any 
health care services provided to Indians residing on res-
ervations in the State of North Dakota if such curtailment 
is due to the provision of contract services in such State 
pursuant to the designation of such State as a contract 
health service delivery area pursuant to subsection (a). 
‘‘SEC. 216B. SOUTH DAKOTA AS A CONTRACT HEALTH SERV-
ICE DELIVERY AREA. 
‘‘(a) IN GENERAL.—For fiscal years beginning with 
the fiscal year ending September 30, 2003, and ending 
with the fiscal year ending on September 30, 2015, the 
State of South Dakota shall be designated as a contract 
health service delivery area by the Service for the purpose 
of providing contract health care services to members of 
federally recognized Indian Tribes of South Dakota. 
‘‘(b) LIMITATION.—The Service shall not curtail any 
health care services provided to Indians residing on res-
ervations in the State of South Dakota if such curtailment 
is due to the provision of contract services in such State 
pursuant to the designation of such State as a contract 
health service delivery area pursuant to subsection (a).
121
‘‘SEC. 217. CALIFORNIA CONTRACT HEALTH SERVICES PRO-
GRAM. 
‘‘(a) FUNDING AUTHORIZED.—The Secretary is au-
thorized to fund a program using the California Rural In-
dian Health Board (hereafter in this section referred to 
as the ‘CRIHB’) as a contract care intermediary to im-
prove the accessibility of health services to California Indi-
ans. 
‘‘(b) REIMBURSEMENT CONTRACT.—The Secretary 
shall enter into an agreement with the CRIHB to reim-
burse the CRIHB for costs (including reasonable adminis-
trative costs) incurred pursuant to this section, in pro-
viding medical treatment under contract to California In-
dians described in section 806(a) throughout the Cali-
fornia contract health services delivery area described in 
section 218 with respect to high cost contract care cases. 
‘‘(c) ADMINISTRATIVE EXPENSES.—Not more than 5 
percent of the amounts provided to the CRIHB under this 
section for any fiscal year may be for reimbursement for 
administrative expenses incurred by the CRIHB during 
such fiscal year. 
‘‘(d) LIMITATION ON PAYMENT.—No payment may 
be made for treatment provided hereunder to the extent 
payment may be made for such treatment under the In-
dian Catastrophic Health Emergency Fund described in 
section 202 or from amounts appropriated or otherwise
122
made available to the California contract health service de-
livery area for a fiscal year. 
‘‘(e) ADVISORY BOARD.—There is hereby established 
an advisory board which shall advise the CRIHB in car-
rying out this section. The advisory board shall be com-
posed of representatives, selected by the CRIHB, from not 
less than 8 Tribal Health Programs serving California In-
dians covered under this section at least one half of whom 
of whom are not affiliated with the CRIHB. 
‘‘SEC. 218. CALIFORNIA AS A CONTRACT HEALTH SERVICE 
DELIVERY AREA. 
‘‘The State of California, excluding the counties of 
Alameda, Contra Costa, Los Angeles, Marin, Orange, Sac-
ramento, San Francisco, San Mateo, Santa Clara, Kern, 
Merced, Monterey, Napa, San Benito, San Joaquin, San 
Luis Obispo, Santa Cruz, Solano, Stanislaus, and Ven-
tura, shall be designated as a contract health service deliv-
ery area by the Service for the purpose of providing con-
tract health services to California Indians. However, any 
of the counties listed herein may only be included in the 
contract health services delivery area if funding is specifi-
cally provided by the Service for such services in those 
counties.
123
‘‘SEC. 219. CONTRACT HEALTH SERVICES FOR THE TREN-
TON SERVICE AREA. 
‘‘(a) AUTHORIZATION
FOR SERVICES.—The Sec-
retary, acting through the Service, is directed to provide 
contract health services to members of the Turtle Moun-
tain Band of Chippewa Indians that reside in the Trenton 
Service Area of Divide, McKenzie, and Williams counties 
in the State of North Dakota and the adjoining counties 
of Richland, Roosevelt, and Sheridan in the State of Mon-
tana. 
‘‘(b) NO EXPANSION OF ELIGIBILITY.—Nothing in 
this section may be construed as expanding the eligibility 
of members of the Turtle Mountain Band of Chippewa In-
dians for health services provided by the Service beyond 
the scope of eligibility for such health services that applied 
on May 1, 1986. 
‘‘SEC. 220. PROGRAMS OPERATED BY INDIAN TRIBES AND 
TRIBAL ORGANIZATIONS. 
‘‘The Service shall provide funds for health care pro-
grams and facilities operated by Tribal Health Programs 
on the same basis as such funds are provided to programs 
and facilities operated directly by the Service. 
‘‘SEC. 221. LICENSING. 
‘‘Health care professionals employed by a Tribal 
Health Program shall, if licensed in any State, be exempt 
from the licensing requirements of the State in which the
124
Tribal Health Program performs the services described in 
its Funding Agreement. 
‘‘SEC. 222. NOTIFICATION OF PROVISION OF EMERGENCY 
CONTRACT HEALTH SERVICES. 
‘‘With respect to an elderly Indian or an Indian with 
a disability receiving emergency medical care or services 
from a non-Service provider or in a non-Service facility 
under the authority of this Act, the time limitation (as 
a condition of payment) for notifying the Service of such 
treatment or admission shall be 30 days. 
‘‘SEC. 223. PROMPT ACTION ON PAYMENT OF CLAIMS. 
‘‘(a) DEADLINE FOR RESPONSE.—The Service shall 
respond to a notification of a claim by a provider of a 
contract care service with either an individual purchase 
order or a denial of the claim within 5 working days after 
the receipt of such notification. 
‘‘(b) EFFECT
OF UNTIMELY RESPONSE.—If the 
Service fails to respond to a notification of a claim in ac-
cordance with subsection (a), the Service shall accept as 
valid the claim submitted by the provider of a contract 
care service. 
‘‘(c) DEADLINE FOR PAYMENT OF VALID CLAIM.—
The Service shall pay a valid contract care service claim 
within 30 days after the completion of the claim.
125
‘‘SEC. 224. LIABILITY FOR PAYMENT. 
‘‘(a) NO PATIENT LIABILITY.—A patient who re-
ceives contract health care services that are authorized by 
the Service shall not be liable for the payment of any 
charges or costs associated with the provision of such serv-
ices. 
‘‘(b) NOTIFICATION.—The Secretary shall notify a 
contract care provider and any patient who receives con-
tract health care services authorized by the Service that 
such patient is not liable for the payment of any charges 
or costs associated with the provision of such services not 
later than 5 business days after receipt of a notification 
of a claim by a provider of contract care services. 
‘‘(c) NO RECOURSE.—Following receipt of the notice 
provided under subsection (b), or, if a claim has been 
deemed accepted under section 223(b), the provider shall 
have no further recourse against the patient who received 
the services. 
‘‘SEC. 225. AUTHORIZATION OF APPROPRIATIONS. 
‘‘There are authorized to be appropriated such sums 
as may be necessary for each fiscal year through fiscal 
year 2015 to carry out this title.
126
‘‘TITLE III—FACILITIES 
‘‘SEC. 301. CONSULTATION; CONSTRUCTION AND RENOVA-
TION OF FACILITIES; REPORTS. 
‘‘(a) 
PREREQUISITES
FOR
EXPENDITURE
OF 
FUNDS.—Prior to the expenditure of, or the making of 
any binding commitment to expend, any funds appro-
priated for the planning, design, construction, or renova-
tion of facilities pursuant to the Act of November 2, 1921 
(25 U.S.C. 13; popularly known as the Snyder Act), the 
Secretary, acting through the Service, shall—
‘‘(1) consult with any Indian Tribe that would 
be significantly affected by such expenditure for the 
purpose of determining and, whenever practicable, 
honoring tribal preferences concerning size, location, 
type, and other characteristics of any facility on 
which such expenditure is to be made; and 
‘‘(2) ensure, whenever practicable and applica-
ble, that such facility meets the construction stand-
ards of any accrediting body recognized by the Sec-
retary for the purposes of the medicare, medicaid, 
and SCHIP programs under title XVIII, XIX, and 
XXI of the Social Security Act by not later than 1 
year after the date on which the construction or ren-
ovation of such facility is completed. 
‘‘(b) CLOSURES.—
127
‘‘(1) 
EVALUATION
REQUIRED.—Notwith-
standing any other provision of law, no facility oper-
ated by the Service may be closed if the Secretary 
has not submitted to Congress at least 1 year prior 
to the date of the proposed closure an evaluation of 
the impact of the proposed closure which specifies, 
in addition to other considerations the following: 
‘‘(A) The accessibility of alternative health 
care resources for the population served by such 
facility. 
‘‘(B) The cost-effectiveness of such closure. 
‘‘(C) The quality of health care to be pro-
vided to the population served by such facility 
after such closure. 
‘‘(D) The availability of contract health 
care funds to maintain existing levels of service. 
‘‘(E) The views of the Indian Tribes served 
by such facility concerning such closure. 
‘‘(F) The level of use of such facility by all 
eligible Indians. 
‘‘(G) The distance between such facility 
and the nearest operating Service hospital. 
‘‘(2) EXCEPTION
FOR
CERTAIN
TEMPORARY 
CLOSURES.—Paragraph (1) shall not apply to any 
temporary closure of a facility or any portion of a
128
facility if such closure is necessary for medical, envi-
ronmental, or construction safety reasons. 
‘‘(c) HEALTH CARE FACILITY PRIORITY SYSTEM.—
‘‘(1) IN GENERAL.—
‘‘(A) ESTABLISHMENT.—The Secretary, 
acting through the Service, shall establish a 
health care facility priority system, which 
shall—
‘‘(i) be developed with Indian Tribes 
and Tribal Organizations through nego-
tiated rulemaking under section 802; 
‘‘(ii) give Indian Tribes’ needs the 
highest priority; and 
‘‘(iii) at a minimum, include the lists 
required in paragraph (2)(B) and the 
methodology required in paragraph (2)(E). 
‘‘(B) PRIORITY
OF
CERTAIN
PROJECTS 
PROTECTED.—The priority of any project estab-
lished under the construction priority system in 
effect on the date of the Indian Health Care 
Improvement Act Amendments of 2003 shall 
not be affected by any change in the construc-
tion priority system taking place thereafter if 
the project was identified as 1 of the 10 top-
priority inpatient projects, 1 of the 10 top-pri-
129
ority outpatient projects, 1 of the 10 top-pri-
ority staff quarters developments, or 1 of the 
10 top-priority Youth Regional Treatment Cen-
ters in the fiscal year 2004 Indian Health Serv-
ice budget justification, or if the project had 
completed both Phase I and Phase II of the 
construction priority system in effect on the 
date of the enactment of such Act. 
‘‘(2) REPORT; CONTENTS.—The Secretary shall 
submit to the President, for inclusion in each report 
required to be transmitted to Congress under section 
801, a report which sets forth the following: 
‘‘(A) A description of the health care facil-
ity priority system of the Service, established 
under paragraph (1). 
‘‘(B) Health care facilities lists, including 
but not limited to—
‘‘(i) the total health care facilities 
planning, design, construction, and renova-
tion needs for Indians, identified by na-
tional and Service Area priorities; 
‘‘(ii) the 10 top-priority inpatient 
health care facilities; 
‘‘(iii) the 10 top-priority outpatient 
health care facilities;
130
‘‘(iv) the 10 top-priority specialized 
health care facilities (such as long-term 
care and alcohol and drug abuse treat-
ment); 
‘‘(v) the 10 top-priority staff quarters 
developments associated with health care 
facilities; and 
‘‘(vi) the 10 top-priority hostels asso-
ciated with health care facilities. 
‘‘(C) The justification for such order of 
priority. 
‘‘(D) The projected cost of such projects. 
‘‘(E) The methodology adopted by the 
Service in establishing priorities under its 
health care facility priority system. 
‘‘(3) REQUIREMENTS FOR PREPARATION OF RE-
PORTS.—In preparing each report required under 
paragraph (2) (other than the initial report), the 
Secretary shall annually—
‘‘(A) consult with and obtain information 
on all health care facilities needs from Indian 
Tribes, Tribal Organizations, and Urban Indian 
Organizations; and 
‘‘(B) review the total unmet needs of all 
Indian Tribes and Tribal Organizations for
131
health care facilities (including hostels and staff 
quarters), including needs for renovation and 
expansion of existing facilities. 
‘‘(4) CRITERIA FOR EVALUATING NEEDS.—For 
purposes of this subsection, the Secretary shall, in 
evaluating the needs of facilities operated under any 
Funding Agreement use the same criteria that the 
Secretary uses in evaluating the needs of facilities 
operated directly by the Service. 
‘‘(5) NEEDS
OF
FACILITIES
UNDER
ISDEAA 
AGREEMENTS.—The Secretary shall ensure that the 
planning, design, construction, and renovation needs 
of Service and non-Service facilities operated under 
funding agreements in accordance with the Indian 
Self-Determination and Education Assistance Act 
are fully and equitably integrated into the health 
care facility priority system. 
‘‘(d) REVIEW OF NEED FOR FACILITIES.—
‘‘(1) INITIAL REPORT.—In the year 2005, the 
General Accounting Office shall prepare and finalize 
a report which sets forth the needs of the Service, 
Indian Tribes, Tribal Organizations, and Urban In-
dian Organizations, for the facilities listed under 
subsection (c)(2)(B), including the needs for renova-
tion and expansion of existing facilities. The General
132
Accounting Office shall submit the report to the ap-
propriate authorizing and appropriations committees 
of the Congress and to the Secretary. 
‘‘(2) Beginning in the year 2006, the Secretary 
shall annually update the report required under 
paragraph (1). 
‘‘(3) The Comptroller General and the Sec-
retary shall consult with Indian Tribes, Tribal Orga-
nizations, and Urban Indian Organizations. In pre-
paring the reports required by paragraphs (1) and 
(2), the Secretary shall submit the report to the 
President for inclusion in the report required to be 
transmitted to the Congress under section 801. 
‘‘(4) For purposes of this subsection, the re-
ports shall, regarding the needs of facilities operated 
under any Funding Agreement be based on the same 
criteria that the Secretary uses in evaluating the 
needs of facilities operated directly by the Service. 
‘‘(5) The planning, design, construction, and 
renovation needs of facilities operated under Fund-
ing Agreements shall be fully and equitably inte-
grated into the development of the health facility 
priority system. 
‘‘(6) Beginning in the year 2006 and each fiscal 
year thereafter, the Secretary shall provide an op-
133
portunity for nomination of planning, design, and 
construction projects by the Service, Indian Tribes, 
and Tribal Organizations for consideration under 
the health care facility priority system. 
‘‘(e) FUNDING CONDITION.—All funds appropriated 
under the Act of November 2, 1921 (25 U.S.C. 13), for 
the planning, design, construction, or renovation of health 
facilities for the benefit of 1 or more Indian Tribes shall 
be subject to the provisions of the Indian Self-Determina-
tion and Education Assistance Act. 
‘‘(f) DEVELOPMENT OF INNOVATIVE APPROACHES.—
The Secretary shall consult and cooperate with Indian 
Tribes, Tribal Organizations, and Urban Indian Organiza-
tions in developing innovative approaches to address all 
or part of the total unmet need for construction of health 
facilities, including those provided for in other sections of 
this title and other approaches. 
‘‘SEC. 302. SANITATION FACILITIES. 
‘‘(a) FINDINGS.—Congress finds the following: 
‘‘(1) The provision of sanitation facilities is pri-
marily a health consideration and function. 
‘‘(2) Indian people suffer an inordinately high 
incidence of disease, injury, and illness directly at-
tributable to the absence or inadequacy of sanitation 
facilities.
134
‘‘(3) The long-term cost to the United States of 
treating and curing such disease, injury, and illness 
is substantially greater than the short-term cost of 
providing sanitation facilities and other preventive 
health measures. 
‘‘(4) Many Indian homes and Indian commu-
nities still lack sanitation facilities. 
‘‘(5) It is in the interest of the United States, 
and it is the policy of the United States, that all In-
dian communities and Indian homes, new and exist-
ing, be provided with sanitation facilities. 
‘‘(b) FACILITIES AND SERVICES.—In furtherance of 
the findings made in subsection (a), Congress reaffirms 
the primary responsibility and authority of the Service to 
provide the necessary sanitation facilities and services as 
provided in section 7 of the Act of August 5, 1954 (42 
U.S.C. 2004a). Under such authority, the Secretary, act-
ing through the Service, shall provide the following: 
‘‘(1) Financial and technical assistance to In-
dian Tribes, Tribal Organizations, and Indian com-
munities in the establishment, training, and equip-
ping of utility organizations to operate and maintain 
sanitation facilities, including the provision of exist-
ing plans, standard details, and specifications avail-
able in the Department, to be used at the option of
135
the Indian Tribe, Tribal Organization, or Indian 
community. 
‘‘(2) Ongoing technical assistance and training 
to Indian Tribes, Tribal Organizations, and Indian 
communities in the management of utility organiza-
tions which operate and maintain sanitation facili-
ties. 
‘‘(3) Priority funding for operation and mainte-
nance assistance for, and emergency repairs to, sani-
tation facilities operated by an Indian Tribe, Tribal 
Organization or Indian community when necessary 
to avoid an imminent health threat or to protect the 
investment in sanitation facilities and the investment 
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 to the Sec-
retary 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
136
services for Indians under section 7 of the Act of 
August 5, 1954 (42 U.S.C. 2004a); 
‘‘(3) unless specifically authorized otherwise 
when funds are appropriated, the Secretary of 
Health and Human Services shall use funds appro-
priated under section 7 of the Act of August 5, 1954 
(42 U.S.C. 2004a), to provide additional priority of 
sanitation facilities assistance to eligible new and ex-
isting Indian homes other than the following—
‘‘(A) new homes constructed using housing 
funds provided by the Department of Housing 
and Urban Development; and 
‘‘(B) existing homes owned or managed by 
a tribally designated housing entity (as that 
term is defined in section 4(21) of the Native 
American Housing Assistance and Self-Deter-
mination Act of 1996 (25 U.S.C. 4103(21)) 
that were constructed using housing funds pro-
vided by the Department of Housing and Urban 
Development; 
‘‘(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-
pose of providing sanitation facilities and services 
and place these funds into Funding Agreements;
137
‘‘(5) funds appropriated under the authority of 
section 7 of the Act of August 5, 1954 (42 U.S.C. 
2004a) may be used to fund up to 100 percent of 
the amount of an Indian Tribe’s loan obtained under 
any Federal program for new projects to construct 
eligible sanitation facilities to serve Indian homes; 
‘‘(6) funds appropriated under the authority of 
section 7 of the Act of August 5, 1954 (42 U.S.C. 
2004a) may be used to meet matching or cost par-
ticipation requirements under other Federal 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; 
‘‘(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; and 
‘‘(9) the Secretary of Health and Human Serv-
ices shall, by regulation developed through rule-
making under section 802, establish standards appli-
138
cable to the planning, design, and construction of 
sanitation facilities funded under this Act. 
‘‘(d) 
FUNDING
PLAN.—The 
Secretary, 
acting 
through the Service, and in consultation with Indian 
Tribes and Tribal Organizations, shall develop and begin 
implementation of a 10-year funding plan to provide sani-
tation facilities to serve existing Indian homes and Indian 
communities and new and renovated Indian homes. 
‘‘(e) 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 
be a prerequisite to the provision or construction of sanita-
tion facilities by the Secretary. 
‘‘(f) FINANCIAL ASSISTANCE.—The Secretary is au-
thorized to provide financial assistance to Indian Tribes, 
Tribal Organizations, and Indian communities for oper-
ation, management, and maintenance of their sanitation 
facilities. 
‘‘(g) OPERATION, MANAGEMENT, AND MAINTENANCE 
OF FACILITIES.—The Indian Tribe, Tribal Organization, 
Indian family, or Indian community 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.
139
If a sanitation facility serving a community that is oper-
ated by an Indian Tribe, Tribal Organization, or Indian 
community is threatened with imminent failure and such 
operator lacks capacity to maintain the integrity or the 
health benefits of the sanitation facility, then the Sec-
retary is authorized to assist the Indian Tribe, Tribal Or-
ganization, or Indian community in the resolution of the 
problem on a short-term basis through cooperation with 
the emergency coordinator or by providing operation, man-
agement, and maintenance service. 
‘‘(h) ISDEAA PROGRAM
FUNDED
ON
EQUAL 
BASIS.—Tribal Health Programs shall be eligible (on an 
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. 
‘‘(i) REPORT.—
‘‘(1) REQUIRED; CONTENTS.—The Secretary 
shall submit to the President, for inclusion in each 
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;
140
‘‘(B) the methodology for determining 
sanitation deficiencies; 
‘‘(C) the level of initial and final sanitation 
deficiency for each type of sanitation facility for 
each project of each Indian Tribe or Indian 
community; and 
‘‘(D) the amount of funds necessary to re-
duce the identified sanitation deficiency levels of 
all Indian Tribes and Indian communities to 
level I sanitation deficiency as defined in para-
graph (4)(A). 
‘‘(2) CONSULTATION.—In preparing each report 
required under paragraph (1), the Secretary shall 
consult with Indian Tribes and Tribal Organizations 
to determine the sanitation facility needs of each In-
dian Tribe. The criteria on which the needs will be 
evaluated shall be developed through negotiated rule-
making pursuant to section 802. 
‘‘(3) 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.
141
‘‘(4) SANITATION
DEFICIENCY
LEVELS.—For 
purposes of this subsection, the sanitation deficiency 
levels for an individual, Indian Tribe or Indian com-
munity sanitation facility to serve Indian homes are 
determined as follows: 
‘‘(A) A level I deficiency exists if a sanita-
tion facility serving an individual, Indian Tribe, 
or Indian community—
‘‘(i) complies with all applicable water 
supply, pollution control, and solid waste 
disposal laws; and 
‘‘(ii) deficiencies relate to routine re-
placement, repair, or maintenance needs. 
‘‘(B) A level II deficiency exists if a sanita-
tion facility serving an individual, Indian Tribe, 
or Indian community substantially or recently 
complied with all applicable water supply, pollu-
tion control, and solid waste laws and any defi-
ciencies relate to—
‘‘(i) small or minor capital improve-
ments needed to bring the facility back 
into compliance; 
‘‘(ii) capital improvements that are 
necessary to enlarge or improve the facili-
142
ties in order to meet the current needs for 
domestic sanitation facilities; or 
‘‘(iii) the lack of equipment or train-
ing by an Indian Tribe, Tribal Organiza-
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 one 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 if—
‘‘(i) a sanitation facility of an indi-
vidual, Indian Tribe, Tribal Organization, 
or Indian community has no piped water
143
or sewer facilities in the home or the facil-
ity has become inoperable due to major 
component failure; or 
‘‘(ii) where only a washeteria or cen-
tral facility 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. 
‘‘(j) 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 
systems (and all related equipment and support in-
frastructure).
144
‘‘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 adopted pursuant to section 802, 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; 
‘‘(4) substantive knowledge of the project or 
function to be contracted for;
145
‘‘(5) adequately trained personnel; or 
‘‘(6) other necessary components of contract 
performance. 
‘‘(b) LABOR STANDARDS.—
‘‘(1) IN GENERAL.—For the purposes of imple-
menting the provisions of this title, contracts for the 
construction or renovation of health care facilities, 
staff quarters, and sanitation facilities, and related 
support infrastructure, funded in whole or in part 
with funds made available pursuant to this title, 
shall contain a provision requiring compliance with 
the Act of March 3, 1931 (40 U.S.C. 276a—276a–
5, known as the Davis-Bacon Act), unless such con-
struction or renovation—
‘‘(A) is performed by a contractor pursu-
ant to a contract with an Indian Tribe or Trib-
al Organization with funds supplied through a 
contract, compact or funding agreement author-
ized by the Indian Self-Determination and Edu-
cation Assistance Act, or other statutory au-
thority; and 
‘‘(B) is subject to prevailing wage rates for 
similar construction or renovation in the locality 
as determined by the Indian Tribes or Tribal
146
Organizations to be served by the construction 
or renovation. 
‘‘(2) EXCEPTION.—This subsection shall not 
apply to construction or renovation carried out by an 
Indian Tribe or Tribal Organization with its own 
employees. 
‘‘SEC. 304. EXPENDITURE OF NONSERVICE FUNDS FOR REN-
OVATION. 
‘‘(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 Funding Agreement, 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-
147
lishing priorities shall be developed through nego-
tiated rulemaking under section 802. The list of pri-
ority facilities will be revised annually in consulta-
tion with Indian Tribes and Tribal Organizations. 
‘‘(2) REPORT.—The Secretary shall submit to 
the President, for inclusion in each 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-
148
retary with respect to construction or renova-
tion of Service facilities. 
‘‘(d) 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) FUNDING.—
‘‘(1) IN
GENERAL.—The Secretary, acting 
through the Service, in consultation with Indian 
Tribes and Tribal Organizations, shall make funding
149
available to Indian Tribes and Tribal Organizations 
for the construction, expansion, or modernization of 
facilities for the provision of ambulatory care serv-
ices to eligible Indians (and noneligible persons pur-
suant to subsections (b)(2) and (c)(1)(C)). Funding 
made under this section may cover up to 100 per-
cent 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) FUNDING AGREEMENT REQUIRED.—Fund-
ing under paragraph (1) may only be made available 
to a Tribal Health Program operating an Indian 
health facility (other than a facility owned or con-
structed 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 FUNDS.—
‘‘(1) ALLOWABLE
USES.—Funding provided 
under this section may be used only for debt reduc-
tion or the construction, expansion, or modernization 
(including the planning and design of such construc-
tion, expansion, or modernization) of an ambulatory 
care facility—
‘‘(A) located apart from a hospital;
150
‘‘(B) not funded under section 301 or sec-
tion 307; 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 
500 patient visits by eligible Indians and 
other users who are eligible for services in 
such facility in accordance with section 
807(c)(2); and 
‘‘(iii) provide ambulatory care in a 
Service Area (specified in the Funding 
Agreement) 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 807(c)(2). 
‘‘(2) USE
ONLY
FOR
CERTAIN
PORTION
OF 
COSTS.—Funding provided under this section may 
be used only for the cost of that portion of a con-
struction, expansion, or modernization project that 
benefits the Service population identified above in 
subsection (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-
151
plying for funding under this section whose principal 
office for health care administration is located on an 
island or when such office 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) FUNDING.—
‘‘(1) APPLICATION.—No funding may be made 
available under this section unless an application or 
proposal for such funding has been approved by the 
Secretary in accordance with applicable regulations 
and has forth reasonable assurance by the applicant 
that, at all times after the construction, expansion, 
or modernization of a facility carried out pursuant 
to funding received 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.
152
‘‘(2) PRIORITY.—In awarding funding under 
this section, the Secretary shall give priority to In-
dian Tribes and Tribal Organizations that dem-
onstrate—
‘‘(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-
garding such applications using the criteria devel-
oped during consultations 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, within 5 years after com-
pletion of the construction, expansion, or modernization 
carried 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 por-
tion thereof) shall transfer to the United States unless 
otherwise negotiated by the Service and the Indian Tribe 
or Tribal Organization.
153
‘‘(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 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, and in con-
sultation with Indian Tribes and Tribal Organizations, is 
authorized to enter into Funding Agreements with, or 
make grants or loan guarantees to, Indian Tribes or Trib-
al Organizations for the purpose of carrying out a health 
care delivery demonstration project to test alternative 
means of delivering health care and services to Indians 
through facilities, including but not limited to hospice, tra-
ditional Indian health, and child care facilities. 
‘‘(b) USE OF FUNDS.—The Secretary, in approving 
projects pursuant to this section, may authorize funding 
for the construction and renovation of hospitals, health 
centers, health stations, and other facilities to deliver 
health care services and is authorized to—
‘‘(1) waive any leasing prohibition;
154
‘‘(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 publish regulations, through rulemaking under section 
802, for the review and approval of applications submitted 
under this section. 
‘‘(d) CRITERIA.—The Secretary may enter into a con-
tract or Funding Agreement or award a grant under this 
section for projects which 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.
155
‘‘(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 
are timely filed and meet the criteria specified in sub-
section (d): 
‘‘(1) Cass Lake, Minnesota. 
‘‘(2) Clinton, Oklahoma. 
‘‘(3) Harlem, Montana. 
‘‘(4) Mescalero, New Mexico. 
‘‘(5) Owyhee, Nevada. 
‘‘(6) Parker, Arizona. 
‘‘(7) Schurz, Nevada. 
‘‘(8) Winnebago, Nebraska. 
‘‘(9) Ft. Yuma, California.
156
‘‘(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.—The au-
thority to provide services to persons otherwise ineligible 
for the health care benefits of the Service and the author-
ity to extend hospital privileges in Service facilities to non-
Service health practitioners as provided in section 807 
may be included, subject to the terms of such section, in 
any demonstration project approved pursuant to this sec-
tion. 
‘‘(i) EQUITABLE TREATMENT.—For purposes of sub-
section (d)(1), the Secretary shall, in evaluating facilities 
operated under any Funding Agreement, use the same cri-
teria that the Secretary uses in evaluating facilities oper-
ated 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 Funding 
Agreement for health services are fully and equitably inte-
grated into the implementation of the health care delivery 
demonstration projects under this section.
157
‘‘SEC. 307. LAND TRANSFER. 
‘‘(a) CHEMAWA INDIAN SCHOOL.—The Bureau of In-
dian Affairs is authorized to transfer, at no cost, up to 
5 acres of land at the Chemawa Indian School, Salem, 
Oregon, to the Service for the provision of health care 
services. The land authorized to be transferred by this sec-
tion is that land adjacent to land under the jurisdiction 
of the Service and occupied by the Chemawa Indian 
Health Center. 
‘‘(b) FEDERAL LAND TO THE SERVICE.—Notwith-
standing any other provision of law, the Bureau of Indian 
Affairs and all other agencies and departments of the 
United States are authorized to transfer, at no cost, land 
and improvements to the Service for the provision 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 
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-
158
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 Act 
and regulations thereunder. Notwithstanding any other 
provision of law, such leases, contracts, or other agree-
ments shall be considered as operating leases for the pur-
pose of scoring under the Budget Enforcement Act. 
‘‘SEC. 309. LOANS, LOAN GUARANTEES, AND LOAN REPAY-
MENT. 
‘‘(a) ESTABLISHMENT OF FUND.—There is estab-
lished in the Treasury of the United States a fund to be 
known as the Health Care Facilities Loan Fund (herein-
after referred to as the ‘HCFLF’) to provide to Indian 
Tribes and Tribal Organizations direct loans, or guaran-
tees for loans, for construction of health care facilities (in-
cluding but not limited to inpatient facilities, outpatient 
facilities, staff quarters, hostels, and specialized care fa-
cilities such as behavioral health and elder care facilities). 
‘‘(b) 
REGULATIONS; 
STANDARDS
AND
PROCE-
DURES.—The Secretary, acting through the Service, is au-
thorized to issue regulations, developed through rule-
making as set out in section 802, to provide standards 
and procedures for governing such loans and loan guaran-
tees, subject to the following conditions:
159
‘‘(1) The principal amount of a loan or loan 
guarantee may cover 100 percent of eligible costs, 
including but not limited to planning, design, financ-
ing, site land development, construction, rehabilita-
tion, renovation, conversion, improvements, medical 
equipment and furnishings, other facility-related 
costs and capital purchase (but excluding staffing). 
‘‘(2) The cumulative total of the principal of di-
rect loans and loan guarantees, respectively, out-
standing at any one time shall not exceed such limi-
tations as may be specified in appropriation Acts. 
‘‘(3) In the discretion of the Secretary, the pro-
gram may be administered by the Service or the 
Health Resources and Services Administration 
(which shall be specified by regulation). 
‘‘(4) The Secretary may make or guarantee a 
loan with a term of the useful estimated life of the 
facility, or 25 years, whichever is shorter. 
‘‘(5) The Secretary may allocate up to 100 per-
cent of the funds available for loans or loan guaran-
tees in any year for the purpose of planning and ap-
plying for a loan or loan guarantee. 
‘‘(6) The Secretary may accept an assignment 
of the revenue of an Indian Tribe or Tribal Organi-
160
zation as security for any direct loan or loan guar-
antee under this section. 
‘‘(7) In the planning and design of health facili-
ties under this section, users eligible under section 
807(c) may be included in any projection of patient 
population. 
‘‘(8) The Secretary shall not collect loan appli-
cation, processing, or other similar fees from Indian 
Tribes or Tribal Organizations applying for direct 
loans or loan guarantees under this section. 
‘‘(9) Service funds authorized under loans or 
loan guarantees in this section shall be eligible for 
use in matching other Federal funds. 
‘‘(c) AMOUNT FOR HCFLF.—
‘‘(1) IN GENERAL.—The HCFLF shall consist 
of—
‘‘(A) such sums as may be initially appro-
priated to the HCFLF and as may be subse-
quently appropriated to the fund under para-
graph (2); 
‘‘(B) such amounts as may be collected 
from borrowers; and 
‘‘(C) all interest earned on amounts in the 
HCFLF.
161
‘‘(2) INITIAL FUNDS.—There are authorized to 
be appropriated such sums as may be necessary to 
initiate the HCFLF. For each fiscal year after the 
initial year in which funds are appropriated to the 
HCFLF, there is authorized to be appropriated an 
amount equal to the sum of the amount collected by 
the HCFLF during the preceding fiscal year and all 
accrued interest. 
‘‘(3) 
AVAILABLE
UNTIL
EXPENDED.—All 
amounts appropriated, collected, or earned relative 
to the HCFLF shall remain available until ex-
pended. 
‘‘(4) INVESTMENTS.—The Secretary of the 
Treasury shall invest such amounts of the HCFLF 
as such Secretary determines are not required to 
meet current withdrawals from the HCFLF. Such 
investments may be made only in interest-bearing 
obligations of the United States. For such purpose, 
such obligations may be acquired on original issue at 
the issue price or by purchase of outstanding obliga-
tions at the market price. Any obligation acquired by 
the fund may be sold by the Secretary of the Treas-
ury at the market price. 
‘‘(d) LOANS UNDER ISDEAA.—Amounts in the 
HCFLF and available pursuant to appropriation Acts may
162
be expended by the Secretary to make loans under this 
section to a Tribal Health Program. 
‘‘(e) GRANTS TO REPAY LOANS.—The Secretary is 
authorized to establish a program to provide grants to In-
dian Tribes and Tribal Organizations for the purpose of 
repaying all or part of any loan obtained by an Indian 
Tribe or Tribal Organization for construction and renova-
tion of health care facilities (including inpatient facilities, 
outpatient facilities, small ambulatory care, staff quarters, 
and specialized care facilities). Loans eligible for such re-
payment grants shall include loans that have been ob-
tained under this section or otherwise. 
‘‘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,
163
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—
‘‘(1) has begun but not completed the process 
of acquisition or construction of a health facility to 
be used in the joint venture project; or 
‘‘(2) has not begun the process of acquisition or 
construction of a health facility for use in the joint 
venture project. 
‘‘(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 
‘‘(2) the Indian Tribe or Tribal Organization 
meets the need criteria which shall be developed
164
through the negotiated rulemaking process provided 
for under section 802. 
‘‘(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 
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
165
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 if requested by the Indian owner and the Indian 
Tribe with jurisdiction over such lands or other lands 
owned or leased by the Indian Tribe or Tribal Organiza-
tion. 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; 
‘‘(2) any lands title to which is held in trust by 
the United States for the benefit of any Indian
166
Tribe or individual Indian or held by any Indian 
Tribe or individual Indian subject to restriction by 
the United States against alienation and over which 
an Indian Tribe exercises governmental power; and 
‘‘(3) all lands in Alaska owned by any Alaska 
Native village, or village or regional corporation 
under the Alaska Native Claims Settlement Act, or 
any land allotted to any Alaska Native. 
‘‘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. 
‘‘(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.
167
Supportable space allocation shall be defined through the 
negotiated rulemaking process provided for under section 
802. 
‘‘(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 maximum ren-
ovation cost threshold shall be determined through the ne-
gotiated rulemaking process provided for under section 
802. 
‘‘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 Funding Agreement shall have the au-
thority to establish the rental rates charged to the 
occupants of such quarters by providing notice to 
the Secretary of its election to exercise such author-
ity.
168
‘‘(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. 
‘‘(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.
169
‘‘(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 
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-
170
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 
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.
171
‘‘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 
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.).
172
‘‘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 Funding Agree-
ments. Receipt of such funds shall have no effect on the 
priorities established pursuant 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. 
‘‘(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.
173
‘‘(d) ESTABLISHMENT
OF STANDARDS.—The Sec-
retary, through the Service, shall establish standards by 
regulation, developed by rulemaking under section 802, for 
the planning, design, and construction of health care fa-
cilities serving Indians under this Act. 
‘‘SEC. 317. AUTHORIZATION OF APPROPRIATIONS. 
‘‘There are authorized to be appropriated such sums 
as may be necessary for each fiscal year through fiscal 
year 2015 to carry out this title.
‘‘TITLE IV—ACCESS TO HEALTH 
SERVICES
‘‘SEC. 401. TREATMENT OF PAYMENTS UNDER SOCIAL SE-
CURITY ACT HEALTH CARE 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 made under title XVIII, 
XIX, or XXI of the Social Security Act for services pro-
vided to Indians eligible for benefits under such respective 
titles shall not be considered in determining appropria-
tions for the provision of health care and services to Indi-
ans. 
‘‘(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
174
the Social Security Act in preference to an Indian without 
such coverage. 
‘‘(c) USE OF FUNDS.—
‘‘(1) SPECIAL
FUND.—Notwithstanding any 
other provision of law, but subject to paragraph (2), pay-
ments to which a facility of the Service is entitled by rea-
son of a provision of the Social Security Act shall be 
placed in a special fund to be held by the Secretary and 
first used (to such extent or in such amounts as are pro-
vided in appropriation Acts) for the purpose of making 
any improvements in the programs of the Service which 
may be necessary to achieve or maintain compliance with 
the applicable conditions and requirements of titles 
XVIII, XIX, and XXI of the Social Security Act. Any 
amounts to be reimbursed that are in excess of the 
amount necessary to achieve or maintain such conditions 
and requirements shall, subject to the consultation with 
Indian Tribes being served by the Service Unit, be used 
for reducing the health resource deficiencies of the Indian 
Tribes. In making payments from such fund, the Sec-
retary 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 collec-
tions, are entitled by reason of a provision of the Social 
Security Act.
175
‘‘(2) DIRECT
PAYMENT
OPTION.—Paragraph 
(1) shall not apply upon the election of a Tribal 
Health Program under subsection (d) to receive pay-
ments directly. No payment may be made out of the 
special fund described in such paragraph with re-
spect to reimbursement made for services provided 
during the period of such election. 
‘‘(d) DIRECT BILLING.—
‘‘(1) IN GENERAL.—A Tribal Health Program 
may directly bill for, and receive payment for, health 
care items and services provided by such Indian 
tribe or organization for which payment is made 
under title XVIII, XIX, or XXI of the Social Secu-
rity Act or from any other third party payor. 
‘‘(2) DIRECT REIMBURSEMENT.—
‘‘(A) USE OF FUNDS.—Each Tribal Health 
Program exercising the option described in 
paragraph (1) with respect to a program under 
a title of the Social Security Act shall be reim-
bursed directly by that program for items and 
services furnished without regard to any other 
provision of law, but all amounts so reimbursed 
shall be used by the Tribal Health Program for 
the purpose of making any improvements in 
Tribal facilities or Tribal Health Programs that
176
may be necessary to achieve or maintain com-
pliance with the conditions and requirements 
applicable generally to such items and services 
under the program under such title and to pro-
vide additional health care services, improve-
ments in health care facilities and Tribal 
Health Programs, any health care-related pur-
pose, or otherwise to achieve the objectives pro-
vided in section 3 of this Act. 
‘‘(B) AUDITS.—The amounts paid to an 
Indian Tribe or Tribal Organization exercising 
the option described in paragraph (1) with re-
spect to a program under a title of the Social 
Security Act shall be subject to all auditing re-
quirements applicable to programs administered 
by an Indian Health Program. 
‘‘(3) EXAMINATION AND IMPLEMENTATION OF 
CHANGES.—The Secretary, acting through the Serv-
ice and with the assistance of the Administrator of 
the Centers for Medicare & Medicaid Services, shall 
examine on an ongoing basis and implement any ad-
ministrative changes that may be necessary to facili-
tate direct billing and reimbursement under the pro-
gram established under this subsection, including 
any agreements with States that may be necessary
177
to provide for direct billing under a program under 
a title 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 
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.
‘‘SEC. 402. GRANTS TO AND FUNDING AGREEMENTS WITH 
THE SERVICE, INDIAN TRIBES, TRIBAL ORGA-
NIZATIONS, AND URBAN INDIAN ORGANIZA-
TIONS. 
‘‘(a) INDIAN
TRIBES
AND
TRIBAL
ORGANIZA-
TIONS.—The Secretary, acting through the Service, shall 
make grants to or enter into Funding Agreements with 
Indian Tribes and Tribal Organizations to assist such 
Tribes and Tribal Organizations in establishing and ad-
178
ministering programs on or near reservations and trust 
lands to assist individual Indians—
‘‘(1) to enroll for benefits under title XVIII, 
XIX, or XXI of the Social Security Act and other 
health benefits programs; and 
‘‘(2) to pay premiums for coverage for such 
benefits, which may be based on financial need (as 
determined by the Indian Tribe or Tribes being 
served based on a schedule of income levels devel-
oped or implemented by such Tribe or Tribes). 
‘‘(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 Funding 
Agreement which the Secretary makes with any Indian 
Tribe or Tribal 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 to such indi-
vidual Indians to the appropriate offices for enroll-
ment or applications for such benefits; and
179
‘‘(4) to develop and implement methods of im-
proving the participation of Indians in receiving the 
benefits provided under titles XVIII, XIX, and XXI 
of the Social Security Act. 
‘‘(c) AGREEMENTS RELATING TO IMPROVING EN-
ROLLMENT OF INDIANS UNDER SOCIAL SECURITY ACT 
PROGRAMS.—
‘‘(1) AGREEMENTS
WITH
SECRETARY
TO
IM-
PROVE
RECEIPT
AND
PROCESSING
OF
APPLICA-
TIONS.—
‘‘(A) 
AUTHORIZATION.—The 
Secretary, 
acting through the Service, may enter into an 
agreement with an Indian Tribe, Tribal Organi-
zation, or Urban Indian Organization which 
provides for the receipt and processing of appli-
cations by Indians for assistance under titles 
XIX and XXI of the Social Security Act, and 
benefits under title XVIII of such Act, by an 
Indian Health Program or Urban Indian Orga-
nization. 
‘‘(B) REIMBURSEMENT OF COSTS.—Such 
agreements may provide for reimbursement of 
costs of outreach, education regarding eligibility 
and benefits, and translation when such services 
are provided. The reimbursement may, as ap-
180
propriate, be added to the applicable rate per 
encounter or be provided as a separate fee-for-
service payment to the Indian Tribe or Tribal 
Organization. 
‘‘(C) PROCESSING
CLARIFIED.—In this 
paragraph, the term ‘processing’ does not in-
clude a final determination of eligibility. 
‘‘(2) AGREEMENTS
WITH
STATES
FOR
OUT-
REACH ON OR NEAR RESERVATION.—
‘‘(A) IN GENERAL.—In order to improve 
the access of Indians residing on or near a res-
ervation to obtain benefits under title XIX or 
XXI of the Social Security Act, as a condition 
of continuing approval of a State plan under 
such title, the State shall take steps as to pro-
vide for enrollment on or near the reservation. 
Such steps may include outreach efforts such as 
the outstationing of eligibility workers, entering 
into agreements with Indian Tribes and Tribal 
Organizations to provide outreach, education re-
garding eligibility and benefits, enrollment, and 
translation services when such services are pro-
vided. 
‘‘(B) CONSTRUCTION.—Nothing in sub-
paragraph (A) shall be construed as affecting
181
arrangements entered into between States and 
Indian Tribes and Tribal Organizations for 
such Indian Tribes and Tribal Organizations to 
conduct administrative activities under such ti-
tles.
‘‘(d) FACILITATING COOPERATION.—The Secretary, 
acting through the Centers for Medicare & Medicaid Serv-
ices, shall take such steps as are necessary to facilitate 
cooperation with, and agreements between, States and the 
Service, Indian Tribes, Tribal Organizations, or Urban In-
dian Organizations. 
‘‘(e) 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 
respect to populations served by such organizations 
in the same manner they apply to grants and Fund-
ing Agreements with Indian tribes and Tribal Orga-
nizations with respect to programs on or near res-
ervations. 
‘‘(2) REQUIREMENTS.—The Secretary shall in-
clude in the grants or Funding Agreements made or 
provided under paragraph (1) requirements that 
are—
182
‘‘(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.
‘‘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 billed (or, if charges are not billed, the 
operational, administrative, and other expenses incurred) 
by the Secretary, an Indian Tribe, or Tribal Organization 
in providing health services, through the Service, an In-
dian 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 
or expenses if—
183
‘‘(1) such services had been provided by a non-
governmental provider; and 
‘‘(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
184
provided under subsection (a) shall operate to deny to the 
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.
185
‘‘(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) RIGHT OF ACTION AGAINST INSURERS, HMOS, 
EMPLOYEE BENEFIT PLANS, SELF-INSURANCE PLANS, 
AND OTHER HEALTH CARE PLANS
OR PROGRAMS.—
Where an insurance company, health maintenance organi-
zation, employee benefit plan, self-insurance plan, man-
aged care plan, or other health care plan or program fails 
or refuses to pay the amount due under subsection (a) 
for services provided to an individual who is a beneficiary,
186
participant, or insured of such company, organization, 
plan, or program, the United States, Indian Tribe, or 
Tribal Organization shall have a right to assert and pur-
sue all the claims and remedies against such company, or-
ganization, plan, or program and against the fiduciaries 
of such company, organization, plan, or program that the 
individual could assert or pursue under the terms of the 
contract, program, or plan or applicable Federal, State, 
or Tribal law. 
‘‘(i) 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 
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. 
‘‘(j) 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-
187
spect to populations served by such Indian Tribes and 
Tribal Organizations. 
‘‘(k) 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 
Organizations. 
‘‘(l) 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 and the Federal 
Medical Care Recovery Act (42 U.S.C. 2651 et seq.). 
‘‘SEC. 404. CREDITING OF REIMBURSEMENTS. 
‘‘(a) USE OF AMOUNTS.—
‘‘(1) RETENTION BY PROGRAM.—Except as pro-
vided in section 202(g) (relating to the Catastrophic 
Health Emergency Fund) and section 807 (relating 
to health services for ineligible persons), all reim-
bursements received or recovered under any of the 
programs described in paragraph (2), including 
under section 807, by reason of the provision of 
health services by the Service, by an Indian Tribe or 
Tribal Organization, or by an Urban Indian Organi-
188
zation, shall be credited to the Service, such Indian 
Tribe or Tribal Organization, or such Urban Indian 
Organization, respectively, and may be used as pro-
vided 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. 
‘‘(2) PROGRAMS COVERED.—The programs re-
ferred to in paragraph (1) are the following: 
‘‘(A) Titles XVIII, XIX, and XXI of the 
Social Security Act. 
‘‘(B) This Act, including section 807. 
‘‘(C) Public Law 87–693. 
‘‘(D) Any other provision of law. 
‘‘(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) IN GENERAL.—Insofar as amounts are made 
available under law (including a provision of the Social 
Security Act, the Indian Self-Determination and Edu-
cation Assistance Act, or other law, other than under sec-
tion 402) to Indian Tribes, Tribal Organizations, and 
Urban Indian Organizations for health benefits for Service
189
beneficiaries, Indian Tribes, Tribal Organizations, and 
Urban Indian Organizations may use such amounts to 
purchase health benefits coverage for such beneficiaries in 
any manner, including through—
‘‘(1) a tribally owned and operated health care 
plan; 
‘‘(2) a State or locally authorized or licensed 
health care plan; 
‘‘(3) a health insurance provider or managed 
care organization; or 
‘‘(4) a self-insured plan. 
The purchase of such coverage by an Indian Tribe, Tribal 
Organization, or Urban Indian Organization may be based 
on the financial needs of such beneficiaries (as determined 
by the Indian Tribe or Tribes being served based on a 
schedule of income levels developed 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).
190
‘‘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 
medical facilities and services between the Service, 
Indian Tribes, and Tribal Organizations and the De-
partment of Veterans Affairs and the Department of 
Defense. 
‘‘(2) 
CONSULTATION
BY
SECRETARY
RE-
QUIRED.—The Secretary may not finalize any ar-
rangement between the Service and a Department 
described in paragraph (1) without first consulting 
with the Indian Tribes which will be significantly af-
fected by the arrangement. 
‘‘(b) LIMITATIONS.—The Secretary shall not take 
any action under this section or under subchapter IV of 
chapter 81 of title 38, United States Code, which would 
impair—
‘‘(1) the priority access of any Indian to health 
care services provided through the Service and the 
eligibility of any Indian to receive health services 
through the Service; 
‘‘(2) the quality of health care services provided 
to any Indian through the Service;
191
‘‘(3) the priority access of any veteran to health 
care services provided by the Department of Vet-
erans Affairs; 
‘‘(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. 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-
192
dian Organizations, notwithstanding any Federal, State, 
or local law to the contrary. 
‘‘SEC. 408. NONDISCRIMINATION IN QUALIFICATIONS FOR 
REIMBURSEMENT FOR SERVICES. 
‘‘For purposes of determining the eligibility of an en-
tity that is operated by the Service, an Indian Tribe, Trib-
al Organization, or Urban Indian Organization to receive 
payment or reimbursement from any federally funded 
health care program for health care services it furnishes 
to an Indian, any requirement that the entity be licensed 
or recognized under State or local law to furnish such 
services shall be deemed to have been met if the entity 
meets quality requirements for the furnishing of such serv-
ices recognized by the Secretary. 
‘‘SEC. 409. CONSULTATION. 
‘‘(a) NATIONAL
INDIAN
TECHNICAL
ADVISORY 
GROUP (TAG).—
‘‘(1) ESTABLISHMENT AND MEMBERSHIP.—The 
Secretary shall establish a National Indian Technical 
Advisory Group (in this subsection referred to as the 
‘Advisory Group’) which shall have no fewer than 14 
members including at least 1 member designated by 
the Indian Tribes and Tribal Organizations in each 
Service Area, 1 Urban Indian Organization rep-
resentative, and 1 member representing the Service.
193
The Secretary may appoint additional members 
upon the recommendation of the Advisory Group. 
‘‘(2) DUTIES.—
‘‘(A) IDENTIFICATION
OF
ISSUES.—The 
Advisory Group shall assist the Secretary in 
identifying and addressing issues regarding the 
health care programs under the Social Security 
Act (including medicare, medicaid, and SCHIP) 
that have implications for Indian Health Pro-
grams or Urban Indian Organizations. The Ad-
visory Group shall provide advice to the Sec-
retary with respect to those issues and with re-
spect to the need for the Secretary to engage in 
consultation with Indian Tribes, Tribal Organi-
zations, and Urban Indian Organizations. 
‘‘(B) CONSTRUCTION.—Nothing in sub-
paragraph (A) shall be construed as affecting 
any requirement under any applicable Executive 
order for the Secretary to consult with Indian 
Tribes in cases of health care policies that have 
implications for Indian Health Programs or 
Urban Indian Organizations. 
‘‘(3) FUNDING.—The Secretary shall pay the 
expenses of the Advisory Group using the general
194
administrative funds of the Centers for Medicare & 
Medicaid Services. 
‘‘(4) NONAPPLICATION OF FEDERAL ADVISORY 
COMMITTEE ACT.—The Federal Advisory Committee 
Act (5 U.S.C. App.) shall not apply to the Advisory 
Group. 
‘‘(5) MEETINGS.—The Secretary shall convene 
meetings of the Advisory Group no less frequently 
than quarterly. 
‘‘(b) SOLICITATION OF MEDICAID ADVICE.—
‘‘(1) IN GENERAL.—As a requirement for pay-
ment under title XIX of the Social Security Act to 
a State in which the Service operates or funds 
health care programs or in which 1 or more Indian 
Health Programs or Urban Indian Organizations 
provide health care in the State for which medical 
assistance is available under such title, the State 
shall establish a process under which the State seeks 
advice on a regular, ongoing basis (at least on a 
quarterly basis) from designees of such Indian 
Health Programs and Urban Indian Organizations 
on matters relating to the application of such title 
to such Indian Health Programs and Urban Indian 
Organizations.
195
‘‘(2) MANNER OF ADVICE.—Such process shall 
be in addition to (and not in lieu of) any consulta-
tion otherwise required by law and shall apply before 
the submittal of plan amendments, waiver requests, 
and proposals for demonstration projects. Such proc-
ess may include appointment of an advisory com-
mittee and of a designee of such Indian Health Pro-
grams and Urban Indian Organizations to the med-
ical care advisory committee advising the State on 
its medicaid plan. 
‘‘(3) PAYMENT
OF
EXPENSES.—Expenses in 
carrying out this subsection shall be treated as rea-
sonable administrative expenses for which reimburse-
ment may be made under section 1903(a) of the So-
cial Security Act. 
‘‘(c) CONSTRUCTION.—Nothing in this section shall 
be construed as superseding existing advisory committees, 
working groups, or other advisory procedures established 
by the Secretary or by any State. 
‘‘SEC. 410. STATE CHILDREN’S HEALTH INSURANCE PRO-
GRAM (SCHIP).
‘‘(a) AUTHORIZATION
FOR ARRANGEMENTS.—Not-
withstanding any other provision of law, insofar as the 
State health plan of a State under title XXI of the Social 
Security Act may provide (whether through its medicaid
196
plan under title XIX of such Act or otherwise) child or 
other health assistance to individuals who are otherwise 
served by the Service or by an Indian Tribe or Tribal Or-
ganization, the Secretary may enter into an arrangement 
with the State and with the Service or 1 or more Indian 
Tribes and Tribal Organizations in the State under which 
a portion of the funds otherwise made available to the 
State under such title with respect to such individuals is 
provided to the Service, Indian Tribe, or Tribal Organiza-
tion, respectively, for the purpose of providing such assist-
ance to such individuals consistent with the purposes of 
such title. 
‘‘(b) ENTERING INTO ARRANGEMENTS.—
‘‘(1) IN GENERAL.—Notwithstanding any other 
provision of law, in the case of a State which has an 
unexpended allotment amount described in para-
graph (2) for a fiscal year, before effecting any real-
lotment of such amount to other States, at the re-
quest of the Service or 1 or more Indian Tribes or 
Tribal Organizations that operate in the State with 
respect to individuals who are served by such Serv-
ice, Indian Tribes, or Tribal Organizations, the Sec-
retary shall enter into an arrangement with the 
Service, Indian Tribes, or Tribal Organizations 
under which the Indian child proportion (as defined
197
in paragraph (3)) for such Service, Indian Tribes, 
or Tribal Organizations of such unexpended allot-
ment amount is made available to the Service or 
such Indian Tribes or Tribal Organizations for the 
purpose of providing child health or other assistance 
to individuals who are otherwise served by the Serv-
ice or by such Indian Tribes or Tribal Organizations 
consistent with the purposes of title XXI of the So-
cial Security Act. Insofar as amounts are made 
available 
under 
the 
preceding 
sentence, 
such 
amounts shall be treated (for purposes of title XXI 
of the Social Security Act) as if they had been ex-
pended during the period referred to in paragraph 
(2). 
‘‘(2) UNEXPENDED ALLOTMENT AMOUNT.—For 
purposes of this subsection, the term ‘unexpended 
allotment amount’ means, with respect to an allot-
ment to a State under section 2104 of the Social Se-
curity Act for a fiscal year, the portion of such allot-
ment which was not expended by the State during 
the period in which such allotment is available for 
expenditure by the State and which would, but for 
this subsection, be realloted to other States. 
‘‘(3) INDIAN
CHILD
PROPORTION.—For pur-
poses of this subsection, the term ‘Indian child pro-
198
portion’ means, with respect to an unexpended allot-
ment amount for a State and an arrangement under 
paragraph (1) with the Service or Indian Tribes or 
Tribal Organizations, the proportion of targeted low-
income children in the State (as defined in section 
2110(b) of the Social Security Act) who are Indians 
who would be served under an arrangement with the 
Service or such Indian Tribes or Tribal Organiza-
tions under such paragraph, as estimated by the 
Secretary of Health and Human Services based 
upon the best available data before a portion of the 
unexpended allotment amount is made available 
under this subsection. 
‘‘SEC. 411. SOCIAL SECURITY ACT SANCTIONS. 
‘‘(a) REQUESTS FOR WAIVER OF SANCTIONS.—For 
purposes of applying any authority under a provision of 
title XI, XVIII, XIX, or XXI of the Social Security Act 
to seek a waiver of a sanction imposed against a health 
care provider insofar as that provider provides services to 
individuals through an Indian Health Program, any re-
quirement that a State request such a waiver shall be 
deemed to be met if such Indian Health Program requests 
such a waiver. 
‘‘(b) SAFE HARBOR FOR TRANSACTIONS BETWEEN 
AND AMONG INDIAN HEALTH CARE PROGRAMS.—For
199
purposes of applying section 1128B(b) of the Social Secu-
rity Act, the exchange of anything of value between or 
among the following shall not be treated as remuneration 
if the exchange arises from or relates to any of the fol-
lowing health programs: 
‘‘(1) An exchange between or among the fol-
lowing: 
‘‘(A) Any Indian Health Program. 
‘‘(B) Any Urban Indian Organization. 
‘‘(2) An exchange between an Indian Tribe, 
Tribal Organization, or an Urban Indian Organiza-
tion and any patient served or eligible for service 
from an Indian Tribe, Tribal Organization, or 
Urban Indian Organization, including patients 
served or eligible for service pursuant to section 807, 
but only if such exchange—
‘‘(A) is for the purpose of transporting the 
patient for the provision of health care items or 
services; 
‘‘(B) is for the purpose of providing hous-
ing to the patient (including a pregnant pa-
tient) and immediate family members or an es-
cort incidental to assuring the timely provision 
of health care items and services to the patient;
200
‘‘(C) is for the purpose of paying pre-
miums, copayments, deductibles, or other cost-
sharing on behalf of patients; or 
‘‘(D) consists of an item or service of small 
value that is provided as a reasonable incentive 
to secure timely and necessary preventive and 
other items and services. 
‘‘(3) Such other exchanges involving an Indian 
Health Program, an Urban Indian Organization, or 
an Indian Tribe or Tribal Organization as meet such 
standards as the Secretary of Health and Human 
Services, in consultation with the Attorney General, 
determines is appropriate, taking into account the 
special circumstances of such Indian Health Pro-
grams, Urban Indian Organizations, Indian Tribes, 
and Tribal Organizations and of patients served by 
Indian Health Programs, Urban Indian Organiza-
tions, Indian Tribes, and Tribal Organizations. 
‘‘SEC. 412. COST SHARING. 
‘‘(a) 
COINSURANCE, 
COPAYMENTS, 
AND 
DEDUCTIBLES.—Notwithstanding any other provision of 
Federal or State law—
‘‘(1) PROTECTION
FOR
ELIGIBLE
INDIANS 
UNDER
SOCIAL
SECURITY
ACT
HEALTH
PRO-
GRAMS.—No Indian who is furnished an item or
201
service for which payment may be made under title 
XVIII, XIX, or XXI of the Social Security Act may 
be charged a deductible, copayment, or coinsurance 
if the item or service is furnished by, or upon refer-
ral made by, the Service, an Indian Tribe, Tribal 
Organization, or Urban Indian Organization. 
‘‘(2) PROTECTION
FOR
INDIANS.—No Indian 
who is furnished an item or service by the Service 
may be charged a deductible, copayment, or coinsur-
ance. 
‘‘(3) NO REDUCTION IN AMOUNT OF PAYMENT 
TO INDIAN HEALTH PROVIDERS.—The payment or 
reimbursement due to the Service, Indian Tribe, 
Tribal Organization, or Urban Indian Organization 
under title XVIII, XIX, or XXI of the Social Secu-
rity Act may not be reduced by the amount of the 
deductible, copayment, or coinsurance that would be 
due from the Indian but for the operation of this 
section. 
‘‘(b) EXEMPTION FROM MEDICAID AND SCHIP PRE-
MIUMS.—Notwithstanding any other provision of Federal 
or State law, no Indian who is otherwise eligible for serv-
ices under title XIX of the Social Security Act (relating 
to the medicaid program) or title XXI of such Act (relat-
ing to the State children’s health insurance program) may
202
be charged a premium as a condition of receiving benefits 
under the program under the respective title.
‘‘(c) MEDICALLY NEEDY PROGRAM SPEND-DOWN.—
For the purposes of determining the eligibility of an In-
dian for medical assistance under any medically needy op-
tion under a State’s medicaid plan under title XIX of the 
Social Security Act, the cost of providing services to an 
Indian in a health program of the Service, an Indian 
Tribe, Tribal Organization, or Urban Indian Organization 
shall be deemed to have been an expenditure for health 
care by the Indian. 
‘‘(d) LIMITATION ON MEDICAL CHILD SUPPORT RE-
COVERY.—Notwithstanding any other provision of law, a 
parent (whether or not an Indian) of an Indian child shall 
not be responsible for reimbursing a State or the Federal 
Government under title XIX or XXI of the Social Security 
Act for the cost of medical services relating to the child 
(including childbirth and including, where such child is a 
minor parent, any child of such minor parent) under cir-
cumstances in which payment would have been made 
under the contract health services program of an Indian 
Health Program but for the child’s (or, in the case of med-
ical services relating to childbirth, mother’s, or grand-
child’s, as the case may be) eligibility under title XIX or 
XXI of the Social Security Act.
203
‘‘(e) TREATMENT OF CERTAIN PROPERTY FOR MED-
ICAID ELIGIBILITY.—Notwithstanding any other provision 
of Federal or State law, the following property may not 
be included when determining eligibility for services under 
title XIX of the Social Security Act: 
‘‘(1) Property, including interests in real prop-
erty currently or formerly held in trust by the Fed-
eral Government which is protected under applicable 
Federal, State, or Tribal law or custom from re-
course and including public domain allotments. 
‘‘(2) Property that has unique religious or cul-
tural significance or that supports subsistence or 
traditional lifestyle according to applicable Tribal 
law or custom. 
‘‘(f) CONTINUATION
OF CURRENT LAW PROTEC-
TIONS OF CERTAIN INDIAN PROPERTY FROM MEDICAID 
ESTATE RECOVERY.—Income, resources, and property 
that are exempt from medicaid estate recovery under title 
XIX of the Social Security Act as of April 1, 2003, under 
manual instructions issued to carry out section 1917(b)(3) 
of such Act because of Federal responsibility for Indian 
Tribes and Alaska Native Villages shall remain so exempt. 
Nothing in this subsection shall be construed as pre-
venting the Secretary from providing additional medicaid 
estate recovery exemptions for Indians.
204
‘‘SEC. 413. TREATMENT UNDER MEDICAID MANAGED CARE.
‘‘(a) PAYMENT FOR SERVICES FURNISHED TO INDI-
ANS.—In the case of an Indian who is enrolled with a 
managed care entity under section 1932 of the Social Se-
curity Act (or otherwise under a waiver under title XIX 
of such Act) and who receives covered services from an 
Indian Health Program or an Urban Indian Organization, 
either—
‘‘(1) the entity shall make payment to the In-
dian Health Program or Urban Indian Organization 
at a rate established by the entity for such services 
that is not less than the rate for preferred providers 
(or at such other rate as may be negotiated between 
the entity and such Indian Health Program or 
Urban Indian Organization) and shall not require 
submittal of a claim by the enrollee as a condition 
of payment to the Indian Health Program or Urban 
Indian Organization; or 
‘‘(2) the State shall provide for payment to the 
Indian Health Program or Urban Indian Organiza-
tion under its State plan under title XIX of such 
Act at the rate otherwise applicable and shall pro-
vide for an appropriate adjustment of the capitation 
payment made to the entity to take into account 
such payment. 
‘‘(b) OFFERING OF MANAGED CARE.—If—
205
‘‘(1) a State elects under its State plan under 
title XIX of the Social Security Act to provide serv-
ices through medicaid managed care organizations 
or through primary care case managers under sec-
tion 1932 or under a waiver under such title; and 
‘‘(2) the Indian Health Program or Urban In-
dian Organization that is funded in whole or in part 
by the Service, or a consortium thereof, has estab-
lished a medicaid managed care organization or a 
primary care case manager that meets quality stand-
ards equivalent to those required of such an organi-
zation or manager under such section or waiver, 
the State shall enter into an agreement under such section 
with the Service, Indian Tribe, Tribal Organization, or 
Urban Indian Organization, or such consortium, to serve 
as a medicaid managed care organization or a primary 
care case manager, respectively with respect to Indians 
served by such entity. In carrying out this subsection, the 
Secretary and the State may waive requirements regard-
ing enrollment, capitalization, and such other matters that 
might otherwise prevent the application of the previous 
sentence. 
‘‘SEC. 414. NAVAJO NATION MEDICAID AGENCY. 
‘‘(a) IN GENERAL.—Notwithstanding any other pro-
vision of law, the Secretary is authorized to treat the Nav-
206
ajo Nation as a State for the purposes of title XIX of 
the Social Security Act, to provide services to Indians liv-
ing within the boundaries of the Navajo Nation. 
‘‘(b) ASSIGNMENT AND PAYMENT.—Notwithstanding 
any other provision of law, the Secretary may assign and 
pay all expenditures for the provision of services to Indi-
ans living within the boundaries of the Navajo Nation 
under title XIX of the Social Security Act and related ad-
ministrative funds under such title, which are currently 
paid to or would otherwise be paid to the States of Ari-
zona, New Mexico, and Utah, to an entity established by 
the Navajo Nation and approved by the Secretary, which 
shall be denominated the Navajo Nation Medicaid Agency. 
‘‘(c) AUTHORITY.—The Navajo Nation Medicaid 
Agency shall serve Indians living within the boundaries of 
the Navajo Nation and shall have the same authority and 
perform the same functions as other single State medicaid 
agencies responsible for the administration of the State 
plan under title XIX of the Social Security Act. 
‘‘(d) TECHNICAL ASSISTANCE.—The Secretary may 
directly assist the Navajo Nation in the development and 
implementation of a Navajo Nation Medicaid Agency for 
the administration, eligibility, payment, and delivery of 
medical assistance under title XIX of the Social Security 
Act (which shall, for purposes of reimbursement to such
207
Nation, include Western and traditional Navajo healing 
services) within the Navajo Nation. 
‘‘(e) FMAP.—Notwithstanding section 1905(b) of 
the Social Security Act, the Federal medical assistance 
percentage shall be 100 per centum with respect to 
amounts the Navajo Nation Medicaid Agency expends for 
medical assistance for services and for related administra-
tive costs. 
‘‘(f) DEMONSTRATION FUNDING.—The Secretary is 
further authorized to assist the Navajo Nation by pro-
viding funding including demonstration grant funding for 
this project. 
‘‘(g) WAIVER AUTHORITY.—The Secretary shall have 
the authority to waive applicable provisions of title XIX 
of the Social Security Act to establish, develop, and imple-
ment the Navajo Nation Medicaid Agency. 
‘‘(h) OPTIONAL APPLICATION TO SCHIP.—In the 
option of the Navajo Nation, the Secretary is authorized 
to treat the Navajo Nation as a State for the purposes 
of title XXI of the Social Security Act (relating to the 
State children’s health insurance program) under terms 
equivalent to those described in subsections (a) through 
(g).
208
‘‘SEC. 415. AUTHORIZATION OF APPROPRIATIONS. 
‘‘There are authorized to be appropriated such sums 
as may be necessary for each fiscal year through fiscal 
year 2015 to carry out this title.
‘‘TITLE V—HEALTH SERVICES 
FOR URBAN INDIANS 
‘‘SEC. 501. PURPOSE. 
‘‘The purpose of this title is to establish programs 
in Urban Centers to make health services more accessible 
and available to Urban Indians. 
‘‘SEC. 502. CONTRACTS WITH, AND GRANTS TO, URBAN IN-
DIAN ORGANIZATIONS. 
‘‘Under authority of the Act of November 2, 1921 
(25 U.S.C. 13; popularly known as the Snyder Act), the 
Secretary, acting through the Service, shall enter into con-
tracts with, or make grants to, Urban Indian Organiza-
tions to assist such organizations in the establishment and 
administration, within Urban Centers, of programs which 
meet the requirements set forth in this title. Subject to 
section 506, the Secretary, acting through the Service, 
shall include such conditions as the Secretary considers 
necessary to effect the purpose of this title in any contract 
into which the Secretary enters with, or in any grant the 
Secretary makes to, any Urban Indian Organization pur-
suant to this title.
209
‘‘SEC. 503. CONTRACTS AND GRANTS FOR THE PROVISION 
OF HEALTH CARE AND REFERRAL SERVICES. 
‘‘(a) REQUIREMENTS
FOR
GRANTS
AND
CON-
TRACTS.—Under authority of the Act of November 2, 
1921 (25 U.S.C. 13; popularly known as the Snyder Act), 
the Secretary, acting through the Service, shall enter into 
contracts with, and make grants to, Urban Indian Organi-
zations for the provision of health care and referral serv-
ices for Urban Indians. Any such contract or grant shall 
include requirements that the Urban Indian Organization 
successfully undertake to—
‘‘(1) estimate the population of Urban Indians 
residing in the Urban Center or centers that the or-
ganization proposes to serve who are or could be re-
cipients of health care or referral services; 
‘‘(2) estimate the current health status of 
Urban Indians residing in such Urban Center or 
centers; 
‘‘(3) estimate the current health care needs of 
Urban Indians residing in such Urban Center or 
centers; 
‘‘(4) provide basic health education, including 
health promotion and disease prevention education, 
to Urban Indians; 
‘‘(5) make recommendations to the Secretary 
and Federal, State, local, and other resource agen-
210
cies on methods of improving health service pro-
grams to meet the needs of Urban Indians; and 
‘‘(6) where necessary, provide, or enter into 
contracts for the provision of, health care services 
for Urban Indians. 
‘‘(b) CRITERIA.—The Secretary, acting through the 
Service, shall by regulation adopted pursuant to section 
520 prescribe the criteria for selecting Urban Indian Or-
ganizations to enter into contracts or receive grants under 
this section. Such criteria shall, among other factors, in-
clude—
‘‘(1) the extent of unmet health care needs of 
Urban Indians in the Urban Center or centers in-
volved; 
‘‘(2) the size of the Urban Indian population in 
the Urban Center or centers involved; 
‘‘(3) the extent, if any, to which the activities 
set forth in subsection (a) would duplicate any 
project funded under this title; 
‘‘(4) the capability of an Urban Indian Organi-
zation to perform the activities set forth in sub-
section (a) and to enter into a contract with the Sec-
retary or to meet the requirements for receiving a 
grant under this section;
211
‘‘(5) the satisfactory performance and success-
ful completion by an Urban Indian Organization of 
other contracts with the Secretary under this title; 
‘‘(6) the appropriateness and likely effectiveness 
of conducting the activities set forth in subsection 
(a) in an Urban Center or centers; and 
‘‘(7) the extent of existing or likely future par-
ticipation in the activities set forth in subsection (a) 
by appropriate health and health-related Federal, 
State, local, and other agencies. 
‘‘(c) ACCESS TO HEALTH PROMOTION AND DISEASE 
PREVENTION PROGRAMS.—The Secretary, acting through 
the Service, shall facilitate access to or provide health pro-
motion and disease prevention services for Urban Indians 
through grants made to Urban Indian Organizations ad-
ministering contracts entered into or receiving grants 
under subsection (a). 
‘‘(d) IMMUNIZATION SERVICES.—
‘‘(1) ACCESS
OR
SERVICES
PROVIDED.—The 
Secretary, acting through the Service, shall facilitate 
access to, or provide, immunization services for 
Urban Indians through grants made to Urban In-
dian Organizations administering contracts entered 
into or receiving grants under this section.
212
‘‘(2) DEFINITION.—For purposes of this sub-
section, the term ‘immunization services’ means 
services to provide without charge immunizations 
against vaccine-preventable diseases. 
‘‘(e) MENTAL HEALTH SERVICES.—
‘‘(1) ACCESS
OR
SERVICES
PROVIDED.—The 
Secretary, acting through the Service, shall facilitate 
access to, or provide, mental health services for 
Urban Indians through grants made to Urban In-
dian Organizations administering contracts entered 
into or receiving grants under subsection (a). 
‘‘(2) ASSESSMENT REQUIRED.—Except as pro-
vided by paragraph (3)(A), a grant may not be made 
under this subsection to an Urban Indian Organiza-
tion until that organization has prepared, and the 
Service has approved, an assessment of the fol-
lowing: 
‘‘(A) The mental health needs of the 
Urban Indian population concerned. 
‘‘(B) The mental health services and other 
related resources available to that population. 
‘‘(C) The barriers to obtaining those serv-
ices and resources. 
‘‘(D) The needs that are unmet by such 
services and resources.
213
‘‘(3) PURPOSES OF GRANTS.—Grants may be 
made under this subsection for the following: 
‘‘(A) To prepare assessments required 
under paragraph (2). 
‘‘(B) To provide outreach, educational, and 
referral services to Urban Indians regarding the 
availability of direct behavioral health services, 
to educate Urban Indians about behavioral 
health issues and services, and effect coordina-
tion with existing behavioral health providers in 
order to improve services to Urban Indians. 
‘‘(C) To provide outpatient behavioral 
health services to Urban Indians, including the 
identification and assessment of illness, thera-
peutic treatments, case management, support 
groups, family treatment, and other treatment. 
‘‘(D) To develop innovative behavioral 
health service delivery models which incorporate 
Indian cultural support systems and resources. 
‘‘(f) PREVENTION OF CHILD ABUSE.—
‘‘(1) ACCESS
OR
SERVICES
PROVIDED.—The 
Secretary, acting through the Service, shall facilitate 
access to or provide services for Urban Indians 
through grants to Urban Indian Organizations ad-
ministering contracts entered into or receiving
214
grants under subsection (a) to prevent and treat 
child abuse (including sexual abuse) among Urban 
Indians. 
‘‘(2) EVALUATION REQUIRED.—Except as pro-
vided by paragraph (3)(A), a grant may not be made 
under this subsection to an Urban Indian Organiza-
tion until that organization has prepared, and the 
Service has approved, an assessment that documents 
the prevalence of child abuse in the Urban Indian 
population concerned and specifies the services and 
programs (which may not duplicate existing services 
and programs) for which the grant is requested. 
‘‘(3) PURPOSES OF GRANTS.—Grants may be 
made under this subsection for the following: 
‘‘(A) To prepare assessments required 
under paragraph (2). 
‘‘(B) For the development of prevention, 
training, and education programs for Urban In-
dians, including child education, parent edu-
cation, provider training on identification and 
intervention, education on reporting require-
ments, prevention campaigns, and establishing 
service networks of all those involved in Indian 
child protection.
215
‘‘(C) To provide direct outpatient treat-
ment services (including individual treatment, 
family treatment, group therapy, and support 
groups) to Urban Indians who are child victims 
of abuse (including sexual abuse) or adult sur-
vivors of child sexual abuse, to the families of 
such child victims, and to Urban Indian per-
petrators of child abuse (including sexual 
abuse). 
‘‘(4) 
CONSIDERATIONS
WHEN
MAKING 
GRANTS.—In making grants to carry out this sub-
section, the Secretary shall take into consideration—
‘‘(A) the support for the Urban Indian Or-
ganization demonstrated by the child protection 
authorities in the area, including committees or 
other services funded under the Indian Child 
Welfare Act of 1978 (25 U.S.C. 1901 et seq.), 
if any; 
‘‘(B) the capability and expertise dem-
onstrated by the Urban Indian Organization to 
address the complex problem of child sexual 
abuse in the community; and 
‘‘(C) the assessment required under para-
graph (2).
216
‘‘(g) 
OTHER
GRANTS.—The 
Secretary, 
acting 
through the Service, may enter into a contract with or 
make grants to an Urban Indian Organization that pro-
vides or arranges for the provision of health care services 
(through satellite facilities, provider networks, or other-
wise) to Urban Indians in more than 1 Urban Center. 
‘‘SEC. 504. CONTRACTS AND GRANTS FOR THE DETERMINA-
TION OF UNMET HEALTH CARE NEEDS. 
‘‘(a) GRANTS
AND
CONTRACTS
AUTHORIZED.—
Under authority of the Act of November 2, 1921 (25 
U.S.C. 13; popularly known as the Snyder Act), the Sec-
retary, acting through the Service, may enter into con-
tracts with or make grants to Urban Indian Organizations 
situated in Urban Centers for which contracts have not 
been entered into or grants have not been made under sec-
tion 503. 
‘‘(b) PURPOSE.—The purpose of a contract or grant 
made under this section shall be the determination of the 
matters described in subsection (c)(1) in order to assist 
the Secretary in assessing the health status and health 
care needs of Urban Indians in the Urban Center involved 
and determining whether the Secretary should enter into 
a contract or make a grant under section 503 with respect 
to the Urban Indian Organization which the Secretary has
217
entered into a contract with, or made a grant to, under 
this section. 
‘‘(c) GRANT AND CONTRACT REQUIREMENTS.—Any 
contract entered into, or grant made, by the Secretary 
under this section shall include requirements that—
‘‘(1) the Urban Indian Organization success-
fully undertakes to—
‘‘(A) document the health care status and 
unmet health care needs of Urban Indians in 
the Urban Center involved; and 
‘‘(B) with respect to Urban Indians in the 
Urban Center involved, determine the matters 
described in paragraphs (2), (3), (4), and (7) of 
section 503(b); and 
‘‘(2) the Urban Indian Organization complete 
performance of the contract, or carry out the re-
quirements of the grant, within 1 year after the date 
on which the Secretary and such organization enter 
into such contract, or within 1 year after such orga-
nization receives such grant, whichever is applicable. 
‘‘(d) NO RENEWALS.—The Secretary may not renew 
any contract entered into or grant made under this sec-
tion.
218
‘‘SEC. 505. EVALUATIONS; RENEWALS. 
‘‘(a) PROCEDURES
FOR EVALUATIONS.—The Sec-
retary, acting through the Service, shall develop proce-
dures to evaluate compliance with grant requirements and 
compliance with and performance of contracts entered into 
by Urban Indian Organizations under this title. Such pro-
cedures shall include provisions for carrying out the re-
quirements of this section. 
‘‘(b) EVALUATIONS.—The Secretary, acting through 
the Service, shall evaluate the compliance of each Urban 
Indian Organization which has entered into a contract or 
received a grant under section 503 with the terms of such 
contract or grant. For purposes of this evaluation, in de-
termining the capacity of an Urban Indian Organization 
to deliver quality patient care the Secretary shall, at the 
option of the organization—
‘‘(1) acting through the Service, conduct an an-
nual onsite evaluation of the organization; or 
‘‘(2) accept in lieu of such onsite evaluation evi-
dence of the organization’s provisional or full accred-
itation by a private independent entity recognized by 
the Secretary for purposes of conducting quality re-
views of providers participating in the Medicare pro-
gram under title XVIII of the Social Security Act. 
‘‘(c) NONCOMPLIANCE; UNSATISFACTORY PERFORM-
ANCE.—If, as a result of the evaluations conducted under
219
this section, the Secretary determines that an Urban In-
dian Organization has not complied with the requirements 
of a grant or complied with or satisfactorily performed a 
contract under section 503, the Secretary shall, prior to 
renewing such contract or grant, attempt to resolve with 
the organization the areas of noncompliance or unsatisfac-
tory performance and modify the contract or grant to pre-
vent future occurrences of noncompliance or unsatisfac-
tory performance. If the Secretary determines that the 
noncompliance or unsatisfactory performance cannot be 
resolved and prevented in the future, the Secretary shall 
not renew the contract or grant with the organization and 
is authorized to enter into a contract or make a grant 
under section 503 with another Urban Indian Organiza-
tion which is situated in the same Urban Center as the 
Urban Indian Organization whose contract or grant is not 
renewed under this section. 
‘‘(d) CONSIDERATIONS FOR RENEWALS.—In deter-
mining whether to renew a contract or grant with an 
Urban Indian Organization under section 503 which has 
completed performance of a contract or grant under sec-
tion 504, the Secretary shall review the records of the 
Urban Indian Organization, the reports submitted under 
section 507, and shall consider the results of the onsite 
evaluations or accreditations under subsection (b).
220
‘‘SEC. 506. OTHER CONTRACT AND GRANT REQUIREMENTS. 
‘‘(a) PROCUREMENT.—Contracts with Urban Indian 
Organizations entered into pursuant to this title shall be 
in accordance with all Federal contracting laws and regu-
lations relating to procurement except that in the discre-
tion of the Secretary, such contracts may be negotiated 
without advertising and need not conform to the provisions 
of sections 1304, 3131, and 3133 of title 40, United 
States Code. 
‘‘(b) PAYMENTS UNDER CONTRACTS OR GRANTS.—
Payments under any contracts or grants pursuant to this 
title shall, notwithstanding any term or condition of such 
contract or grant—
‘‘(1) be made in their entirety by the Secretary 
to the Urban Indian Organization by no later than 
the end of the first 30 days of the funding period 
with respect to which the payments apply, unless the 
Secretary determines through an evaluation under 
section 505 that the organization is not capable of 
administering such payments in their entirety; and 
‘‘(2) if any portion thereof is unexpended by the 
Urban Indian Organization during the funding pe-
riod with respect to which the payments initially 
apply, shall be carried forward for expenditure with 
respect to allowable or reimbursable costs incurred 
by the organization during 1 or more subsequent
221
funding periods without additional justification or 
documentation by the organization as a condition of 
carrying forward the availability for expenditure of 
such funds. 
‘‘(c) REVISION OR AMENDMENT OF CONTRACTS.—
Notwithstanding any provision of law to the contrary, the 
Secretary may, at the request or consent of an Urban In-
dian Organization, revise or amend any contract entered 
into by the Secretary with such organization under this 
title as necessary to carry out the purposes of this title. 
‘‘(d) FAIR AND UNIFORM SERVICES AND ASSIST-
ANCE.—Contracts with or grants to Urban Indian Organi-
zations and regulations adopted pursuant to this title shall 
include provisions to assure the fair and uniform provision 
to Urban Indians of services and assistance under such 
contracts or grants by such organizations. 
‘‘SEC. 507. REPORTS AND RECORDS. 
‘‘(a) REPORTS.—For each fiscal year during which 
an Urban Indian Organization receives or expends funds 
pursuant to a contract entered into or a grant received 
pursuant to this title, such Urban Indian Organization 
shall submit to the Secretary not more frequently than 
every 6 months, a report that includes the following:
222
‘‘(1) In the case of a contract or grant under 
section 503, recommendations pursuant to section 
503(a)(5). 
‘‘(2) Information on activities conducted by the 
organization pursuant to the contract or grant. 
‘‘(3) An accounting of the amounts and purpose 
for which Federal funds were expended. 
‘‘(4) A minimum set of data, using uniformly 
defined elements, that is specified by the Secretary 
in consultation, consistent with section 514, with 
Urban Indian Organizations. 
‘‘(b) AUDIT.—The reports and records of the Urban 
Indian Organization with respect to a contract or grant 
under this title shall be subject to audit by the Secretary 
and the Comptroller General of the United States. 
‘‘(c) COSTS OF AUDITS.—The Secretary shall allow 
as a cost of any contract or grant entered into or awarded 
under section 502 or 503 the cost of an annual inde-
pendent financial audit conducted by—
‘‘(1) a certified public accountant; or 
‘‘(2) a certified public accounting firm qualified 
to conduct Federal compliance audits. 
‘‘SEC. 508. LIMITATION ON CONTRACT AUTHORITY. 
‘‘The authority of the Secretary to enter into con-
tracts or to award grants under this title shall be to the
223
extent, and in an amount, provided for in appropriation 
Acts. 
‘‘SEC. 509. FACILITIES. 
‘‘(a) GRANTS.—The Secretary, acting through the 
Service, may make grants to contractors or grant recipi-
ents under this title for the lease, purchase, renovation, 
construction, or expansion of facilities, including leased fa-
cilities, in order to assist such contractors or grant recipi-
ents in complying with applicable licensure or certification 
requirements. 
‘‘(b) LOANS.—The Secretary, acting through the 
Service or through the Health Resources and Services Ad-
ministration, may provide to contractors or grant recipi-
ents under this title loans from the Urban Indian Health 
Care Facilities Revolving Loan Fund described in sub-
section (c), or guarantees for loans, for the construction, 
renovation, expansion, or purchase of health care facilities, 
subject to the following requirements: 
‘‘(1) The principal amount of a loan or loan 
guarantee may cover 100 percent of the costs (other 
than staffing) relating to the facility, including plan-
ning, design, financing, site land development, con-
struction, 
rehabilitation, 
renovation, 
conversion, 
medical equipment, furnishings, and capital pur-
chase.
224
‘‘(2) The total of the principal of loans and loan 
guarantees, respectively, outstanding at any one 
time shall not exceed such limitations as may be 
specified in appropriation Acts. 
‘‘(3) The loan or loan guarantee may have a 
term of the shorter of the estimated useful life of the 
facility or 25 years. 
‘‘(4) An Urban Indian Organization may as-
sign, and the Secretary may accept assignment of, 
the revenue of the Urban Indian Organization as se-
curity for a loan or loan guarantee under this sub-
section. 
‘‘(5) The Secretary shall not collect application, 
processing, or similar fees from Urban Indian Orga-
nizations applying for loans or loan guarantees 
under this subsection. 
‘‘(c) FUND.—
‘‘(1) ESTABLISHMENT.—There is established in 
the Treasury of the United States a fund to be 
known as the Urban Indian Health Care Facilities 
Revolving Loan Fund (hereafter in this section re-
ferred to as the ‘‘URLF’’). The URLF shall consist 
of—
‘‘(A) such amounts as may be appropriated 
to the URLF;
225
‘‘(B) amounts received from Urban Indian 
Organizations in repayment of loans made to 
such organizations under paragraph (2); and 
‘‘(C) interest earned on amounts in the 
URLF under paragraph (3). 
‘‘(2) USE OF AMOUNT IN FUND.—Amounts in 
the URLF may be expended by the Secretary, acting 
through the Service or the Health Resources and 
Services Administration, to make loans available to 
Urban Indian Organizations receiving grants or con-
tracts under this title for the purposes, and subject 
to the requirements, described in subsection (b). 
Amounts appropriated to the URLF, amounts re-
ceived from Urban Indian Organizations in repay-
ment of loans, and interest on amounts in the 
URLF shall remain available until expended. 
‘‘(3) INVESTMENT OF AMOUNTS IN FUND.—The 
Secretary of the Treasury shall invest such amounts 
of the URLF as such Secretary determines are not 
required to meet current withdrawals from the 
URLF. Such investments may be made only in in-
terest-bearing obligations of the United States. For 
such purpose, such obligations may be acquired on 
original issue at the issue price or by purchase of 
outstanding obligations at the market price. Any ob-
226
ligation acquired by the URLF may be sold by the 
Secretary of the Treasury at the market price. 
‘‘(4) INITIAL FUNDS.—There are authorized to 
be appropriated such sums as may be necessary to 
initiate the URLF. For each fiscal year after the ini-
tial year in which funds are appropriated to the 
URLF, there is authorized to be appropriated an 
amount equal to the sum of the amount collected by 
the URLF during the preceding fiscal year and all 
accrued interest. 
‘‘SEC. 510. OFFICE OF URBAN INDIAN HEALTH. 
‘‘There is hereby established within the Service an 
Office of Urban Indian Health, which shall be responsible 
for—
‘‘(1) carrying out the provisions of this title; 
‘‘(2) providing central oversight of the pro-
grams and services authorized under this title; and 
‘‘(3) providing technical assistance to Urban In-
dian Organizations. 
‘‘SEC. 511. GRANTS FOR ALCOHOL AND SUBSTANCE ABUSE-
RELATED SERVICES. 
‘‘(a) GRANTS AUTHORIZED.—The Secretary, acting 
through the Service, may make grants for the provision 
of health-related services in prevention of, treatment of, 
rehabilitation of, or school- and community-based edu-
227
cation regarding, alcohol and substance abuse in Urban 
Centers to those Urban Indian Organizations with which 
the Secretary has entered into a contract under this title 
or under section 201. 
‘‘(b) GOALS.—Each grant made pursuant to sub-
section (a) shall set forth the goals to be accomplished 
pursuant to the grant. The goals shall be specific to each 
grant as agreed to between the Secretary and the grantee. 
‘‘(c) CRITERIA.—The Secretary shall establish cri-
teria for the grants made under subsection (a), including 
criteria relating to the following: 
‘‘(1) The size of the Urban Indian population. 
‘‘(2) Capability of the organization to ade-
quately perform the activities required under the 
grant. 
‘‘(3) Satisfactory performance standards for the 
organization in meeting the goals set forth in such 
grant. The standards shall be negotiated and agreed 
to between the Secretary and the grantee on a 
grant-by-grant basis. 
‘‘(4) Identification of the need for services. 
‘‘(d) ALLOCATION OF GRANTS.—The Secretary shall 
develop a methodology for allocating grants made pursu-
ant to this section based on the criteria established pursu-
ant to subsection (c).
228
‘‘(e) GRANTS SUBJECT TO CRITERIA.—Any funds re-
ceived by an Urban Indian Organization under this Act 
for substance abuse prevention, treatment, and rehabilita-
tion shall be subject to the criteria set forth in subsection 
(c). 
‘‘SEC. 512. TREATMENT OF CERTAIN DEMONSTRATION 
PROJECTS. 
‘‘Notwithstanding any other provision of law, the 
Tulsa Clinic and Oklahoma City Clinic demonstration 
projects shall—
‘‘(1) be permanent programs within the Serv-
ice’s direct care program; 
‘‘(2) continue to be treated as Service Units in 
the allocation of resources and coordination of care; 
and 
‘‘(3) shall be subject to the provisions of the In-
dian Self-Determination and Education Assistance 
Act, except that the programs shall not be divisible. 
‘‘SEC. 513. URBAN NIAAA TRANSFERRED PROGRAMS. 
‘‘(a) GRANTS
AND
CONTRACTS.—The Secretary, 
through the Office of Urban Indian Health, shall make 
grants or enter into contracts with Urban Indian Organi-
zations for the administration of Urban Indian alcohol 
programs that were originally established under the Na-
tional Institute on Alcoholism and Alcohol Abuse (here-
229
after in this section referred to as ‘NIAAA’) and trans-
ferred to the Service. Such grants and contracts shall be-
come effective no later than September 30, 2004. 
‘‘(b) USE OF FUNDS.—Grants provided or contracts 
entered into under this section shall be used to provide 
support for the continuation of alcohol prevention and 
treatment services for Urban Indian populations and such 
other objectives as are agreed upon between the Service 
and a recipient of a grant or contract under this section. 
‘‘(c) ELIGIBILITY.—Urban Indian Organizations that 
operate Indian alcohol programs originally funded under 
the NIAAA and subsequently transferred to the Service 
are eligible for grants or contracts under this section. 
‘‘(d) REPORT.—The Secretary shall evaluate and re-
port to Congress on the activities of programs funded 
under this section not less than every 5 years. 
‘‘SEC. 514. CONSULTATION WITH URBAN INDIAN ORGANIZA-
TIONS. 
‘‘(a) IN GENERAL.—The Secretary shall ensure that 
the Service, the Centers for Medicare & Medicaid Services, 
and other operating divisions and staff divisions of the De-
partment consult, to the greatest extent practicable, with 
Urban Indian Organizations prior to taking any action, 
or approving Federal financial assistance for any action
230
of a State, that may affect Urban Indians or Urban Indian 
Organizations. 
‘‘(b) DEFINITION OF CONSULTATION.—For purposes 
of subsection (a), consultation is the open and free ex-
change of information and opinion among Urban Indian 
Organizations and the operating and staff divisions of the 
Department which leads to mutual understanding and 
comprehension and which emphasizes trust, respect, and 
shared responsibility. 
‘‘SEC. 515. FEDERAL TORT CLAIM ACT COVERAGE. 
‘‘(a) IN GENERAL.—With respect to claims resulting 
from the performance of functions during fiscal year 2004 
and thereafter, or claims asserted after September 30, 
2003, but resulting from the performance of functions 
prior to fiscal year 2004, under a contract, grant agree-
ment, or any other agreement authorized under this title, 
an Urban Indian Organization is deemed hereafter to be 
part of the Service in the Department of Health and 
Human Services while carrying out any such contract or 
agreement and its employees are deemed employees of the 
Service while acting within the scope of their employment 
in carrying out the contract or agreement. After Sep-
tember 30, 2003, any civil action or proceeding involving 
such claims brought hereafter against any Urban Indian 
Organization or any employee of such Urban Indian Orga-
231
nization covered by this provision shall be deemed to be 
an action against the United States and will be defended 
by the Attorney General and be afforded the full protec-
tion and coverage of the Federal Tort Claims Act (28 
U.S.C. 1346(b), 2671 et seq.). 
‘‘(b) CLAIMS RESULTING FROM PERFORMANCE OF 
CONTRACT OR GRANT.—Beginning with the fiscal year 
ending September 30, 2003, and thereafter, the appro-
priate Secretary shall request through annual appropria-
tions funds sufficient to reimburse the Treasury for any 
claims paid in the prior fiscal year pursuant to the fore-
going provisions. 
‘‘(c) EFFECT ON ISDEAA.—Nothing in this section 
shall in any way affect the provisions of section 102(d) 
of the Indian Self-Determination and Education Assist-
ance Act of 1975 (25 U.S.C. 450f(d)). 
‘‘SEC. 516. URBAN YOUTH TREATMENT CENTER DEM-
ONSTRATION. 
‘‘(a) CONSTRUCTION
AND OPERATION.—The Sec-
retary, acting through the Service, through grant or con-
tract, shall make payment for the construction and oper-
ation of at least 2 residential treatment centers in each 
State described in subsection (b) to demonstrate the provi-
sion of alcohol and substance abuse treatment services to
232
Urban Indian youth in a culturally competent residential 
setting. 
‘‘(b) DEFINITION OF STATE.—A State described in 
this subsection is a State in which—
‘‘(1) there resides Urban Indian youth with 
need for alcohol and substance abuse treatment serv-
ices in a residential setting; and 
‘‘(2) there is a significant shortage of culturally 
competent residential treatment services for Urban 
Indian youth. 
‘‘SEC. 517. USE OF FEDERAL GOVERNMENT FACILITIES AND 
SOURCES OF SUPPLY. 
‘‘(a) AUTHORIZATION FOR USE.—The Secretary, act-
ing through the Service, shall allow an Urban Indian Or-
ganization that has entered into a contract or received a 
grant pursuant to this title, in carrying out such contract 
or grant, to use existing facilities and all equipment there-
in or pertaining thereto and other personal property 
owned by the Federal Government within the Secretary’s 
jurisdiction under such terms and conditions as may be 
agreed upon for their use and maintenance. 
‘‘(b) DONATIONS.—Subject to subsection (d), the 
Secretary may donate to an Urban Indian Organization 
that has entered into a contract or received a grant pursu-
ant to this title any personal or real property determined
233
to be excess to the needs of the Service or the General 
Services Administration for purposes of carrying out the 
contract or grant. 
‘‘(c) ACQUISITION OF PROPERTY FOR DONATION.—
The Secretary may acquire excess or surplus government 
personal or real property for donation (subject to sub-
section (d)), to an Urban Indian Organization that has 
entered into a contract or received a grant pursuant to 
this title if the Secretary determines that the property is 
appropriate for use by the Urban Indian Organization for 
a purpose for which a contract or grant is authorized 
under this title. 
‘‘(d) PRIORITY.—In the event that the Secretary re-
ceives a request for donation of a specific item of personal 
or real property described in subsection (b) or (c) from 
both an Urban Indian Organization and from an Indian 
Tribe or Tribal Organization, the Secretary shall give pri-
ority to the request for donation of the Indian Tribe or 
Tribal Organization if the Secretary receives the request 
from the Indian Tribe or Tribal Organization before the 
date the Secretary transfers title to the property or, if ear-
lier, the date the Secretary transfers the property phys-
ically to the Urban Indian Organization. 
‘‘(e) URBAN INDIAN ORGANIZATIONS DEEMED EX-
ECUTIVE AGENCY FOR CERTAIN PURPOSES.—For pur-
234
poses of section 501 of title 40, United States Code, (relat-
ing to Federal sources of supply, including lodging pro-
viders, airlines, and other transportation providers), an 
Urban Indian Organization that has entered into a con-
tract or received a grant pursuant to this title shall be 
deemed an executive agency when carrying out such con-
tract or grant, and the employees of the Urban Indian 
Organization shall be eligible to have access to such 
sources of supply on the same basis as employees of an 
executive agency have such access. 
‘‘SEC. 518. GRANTS FOR DIABETES PREVENTION, TREAT-
MENT, AND CONTROL. 
‘‘(a) GRANTS AUTHORIZED.—The Secretary may 
make grants to those Urban Indian Organizations that 
have entered into a contract or have received a grant 
under this title for the provision of services for the preven-
tion and treatment of, and control of the complications 
resulting from, diabetes among Urban Indians. 
‘‘(b) GOALS.—Each grant made pursuant to sub-
section (a) shall set forth the goals to be accomplished 
under the grant. The goals shall be specific to each grant 
as agreed to between the Secretary and the grantee. 
‘‘(c) ESTABLISHMENT OF CRITERIA.—The Secretary 
shall establish criteria for the grants made under sub-
section (a) relating to the following:
235
‘‘(1) The size and location of the Urban Indian 
population to be served. 
‘‘(2) The need for prevention of and treatment 
of, and control of the complications resulting from, 
diabetes among the Urban Indian population to be 
served. 
‘‘(3) Performance standards for the organiza-
tion in meeting the goals set forth in such grant 
that are negotiated and agreed to by the Secretary 
and the grantee. 
‘‘(4) The capability of the organization to ade-
quately perform the activities required under the 
grant. 
‘‘(5) The willingness of the organization to col-
laborate with the registry, if any, established by the 
Secretary under section 204(e) in the Area Office of 
the Service in which the organization is located. 
‘‘(d) FUNDS SUBJECT TO CRITERIA.—Any funds re-
ceived by an Urban Indian Organization under this Act 
for the prevention, treatment, and control of diabetes 
among Urban Indians shall be subject to the criteria devel-
oped by the Secretary under subsection (c). 
‘‘SEC. 519. COMMUNITY HEALTH REPRESENTATIVES. 
‘‘The Secretary, acting through the Service, may 
enter into contracts with, and make grants to, Urban In-
236
dian Organizations for the employment of Indians trained 
as health service providers through the Community Health 
Representatives Program under section 109 in the provi-
sion of health care, health promotion, and disease preven-
tion services to Urban Indians. 
‘‘SEC. 520. REGULATIONS. 
‘‘(a) REQUIREMENTS FOR REGULATIONS.—The Sec-
retary may promulgate regulations to implement the provi-
sions of this title in accordance with the following: 
‘‘(1) Proposed regulations to implement this 
Act shall be published in the Federal Register by the 
Secretary no later than 9 months after the date of 
the enactment of this Act and shall have no less 
than a 4-month comment period. 
‘‘(2) The authority to promulgate regulations 
under this Act shall expire 18 months from the date 
of the enactment of this Act. 
‘‘(b) EFFECTIVE DATE OF TITLE.—The amendments 
to this title made by the Indian Health Care Improvement 
Act Amendments of 2003 shall be effective on the date 
of the enactment of such amendments, regardless of 
whether the Secretary has promulgated regulations imple-
menting such amendments have been promulgated.
237
‘‘SEC. 521. ELIGIBILITY FOR SERVICES. 
‘‘Urban Indians shall be eligible for health care or 
referral services provided pursuant to this title. 
‘‘SEC. 522. AUTHORIZATION OF APPROPRIATIONS. 
‘‘There are authorized to be appropriated such sums 
as may be necessary for each fiscal year through fiscal 
year 2015 to carry out this title. 
‘‘TITLE VI—ORGANIZATIONAL 
IMPROVEMENTS 
‘‘SEC. 601. ESTABLISHMENT OF THE INDIAN HEALTH SERV-
ICE AS AN AGENCY OF THE PUBLIC HEALTH 
SERVICE.
‘‘(a) ESTABLISHMENT.—In order to more effectively 
and efficiently carry out the responsibilities, authorities, 
and functions of the United States to provide health care 
services provided under Federal statute or treaties to Indi-
ans and Indian Tribes, there was established within the 
Public Health Service of the Department the Indian 
Health Service. 
‘‘(b) DIRECTOR.—The Indian Health Service is an 
agency within the Public Health Service of the Depart-
ment, and shall not be an office, component, or unit of 
any other agency of the Department. The Indian Health 
Service shall be administered by a Director, who shall be 
appointed by the President, by and with the advice and 
consent of the Senate. The Director of the Indian Health
238
Service shall report to the Secretary through the Assistant 
Secretary for Health of the Department of Health and 
Human Services. Effective with respect to an individual 
appointed by the President, by and with the advice and 
consent of the Senate, after January 1, 1993, the term 
of service of the Director shall be 4 years. A Director may 
serve more than 1 term. 
‘‘(c) DUTIES.—The Secretary shall carry out through 
the Director of the Indian Health Service—
‘‘(1) all functions which were, on the day before 
the date of the enactment of the Indian Health Care 
Amendments of 1988, carried out by or under the 
direction of the individual serving as Director of the 
Indian Health Service on such day; 
‘‘(2) all functions of the Secretary relating to 
the maintenance and operation of hospital and 
health facilities for Indians and the planning for, 
and provision and use of, health services for Indians; 
‘‘(3) all health programs under which health 
care is provided to Indians based upon their status 
as Indians which are administered by the Secretary, 
including but not limited to programs under—
‘‘(A) this Act; 
‘‘(B) the Act of November 2, 1921 (25 
U.S.C. 13);
239
‘‘(C) the Act of August 5, 1954 (42 U.S.C. 
2001 et seq.); 
‘‘(D) the Act of August 16, 1957 (42 
U.S.C. 2005 et seq.); and 
‘‘(E) the Indian Self-Determination and 
Education Assistance Act (25 U.S.C. 450 et 
seq.); and 
‘‘(4) all scholarship and loan functions carried 
out under title I. 
‘‘(d) AUTHORITIES.—(1) The Director shall have the 
authority—
‘‘(A) except to the extent provided in paragraph 
(2), to appoint and compensate employees for the 
Service in accordance with title 5, United States 
Code; 
‘‘(B) to enter into contracts for the procure-
ment of goods and services to carry out the func-
tions of the Service; and 
‘‘(C) to manage, expend, and obligate all funds 
appropriated for the Service. 
‘‘(2) Notwithstanding any other law, the provisions 
of section 12 of the Act of June 18, 1934 (48 Stat. 986; 
25 U.S.C. 472), shall apply to all personnel actions taken 
with respect to new positions created within the Service 
as a result of its establishment under subsection (a).
240
‘‘SEC. 602. AUTOMATED MANAGEMENT INFORMATION SYS-
TEM. 
‘‘(a)(1) The Secretary shall establish an automated 
management information system for the Service. 
‘‘(2) The information system established under para-
graph (1) shall include—
‘‘(A) a financial management system; 
‘‘(B) a patient care information system for each 
area served by the Service; 
‘‘(C) a privacy component that protects the pri-
vacy of patient information held by, or on behalf of, 
the Service; 
‘‘(D) a services-based cost accounting compo-
nent that provides estimates of the costs associated 
with the provision of specific medical treatments or 
services in each Area Office of the Service; 
‘‘(E) an interface mechanism for patient billing 
and accounts receivable system; and 
‘‘(F) a training component. 
‘‘(b) The Secretary shall provide each Tribal Health 
Program automated management information systems 
which—
‘‘(1) meet the management information needs 
of such Tribal Health Program with respect to the 
treatment by the Tribal Health Program of patients 
of the Service; and
241
‘‘(2) meet the management information needs 
of the Service. 
‘‘(c) Notwithstanding any other provision of law, each 
patient shall have reasonable access to the medical or 
health records of such patient which are held by, or on 
behalf of, the Service. 
‘‘(d) The Director shall have the authority to enter 
into contracts, agreements, or joint ventures with other 
Federal agencies, States, private and nonprofit organiza-
tions, for the purpose of enhancing information technology 
in Indian Health Programs and facilities. 
‘‘SEC. 603. AUTHORIZATION OF APPROPRIATIONS. 
‘‘There are authorized to be appropriated such sums 
as may be necessary for each fiscal year through fiscal 
year 2015 to carry out this title.
‘‘TITLE VII—BEHAVIORAL 
HEALTH PROGRAMS 
‘‘SEC. 701. BEHAVIORAL HEALTH PREVENTION AND TREAT-
MENT SERVICES. 
‘‘(a) PURPOSES.—The purposes of this section are as 
follows: 
‘‘(1) To authorize and direct the Secretary, act-
ing through the Service, Indian Tribes, Tribal Orga-
nizations, and Urban Indian Organizations, to de-
velop a comprehensive behavioral health prevention
242
and treatment program which emphasizes collabora-
tion among alcohol and substance abuse, social serv-
ices, and mental health programs. 
‘‘(2) To provide information, direction, and 
guidance relating to mental illness and dysfunction 
and self-destructive behavior, including child abuse 
and family violence, to those Federal, tribal, State, 
and local agencies responsible for programs in In-
dian communities in areas of health care, education, 
social services, child and family welfare, alcohol and 
substance abuse, law enforcement, and judicial serv-
ices. 
‘‘(3) To assist Indian Tribes to identify services 
and resources available to address mental illness and 
dysfunctional and self-destructive behavior. 
‘‘(4) To provide authority and opportunities for 
Indian Tribes and Tribal Organizations to develop, 
implement, and coordinate with community-based 
programs which include identification, prevention, 
education, referral, and treatment services, including 
through multidisciplinary resource teams. 
‘‘(5) To ensure that Indians, as citizens of the 
United States and of the States in which they re-
side, have the same access to behavioral health serv-
ices to which all citizens have access.
243
‘‘(6) To modify or supplement existing pro-
grams and authorities in the areas identified in 
paragraph (2). 
‘‘(b) PLANS.—
‘‘(1) DEVELOPMENT.—The Secretary, acting 
through the Service, Indian Tribes, Tribal Organiza-
tions, and Urban Indian Organizations, shall encour-
age Indian Tribes and Tribal Organizations to de-
velop tribal plans, and Urban Indian Organizations 
to develop local plans, and for all such groups to 
participate in developing areawide plans for Indian 
Behavioral Health Services. The plans shall include, 
to the extent feasible, the following components: 
‘‘(A) An assessment of the scope of alcohol 
or other substance abuse, mental illness, and 
dysfunctional and self-destructive behavior, in-
cluding suicide, child abuse, and family vio-
lence, among Indians, including—
‘‘(i) the number of Indians served who 
are directly or indirectly affected by such 
illness or behavior; or 
‘‘(ii) an estimate of the financial and 
human cost attributable to such illness or 
behavior.
244
‘‘(B) An assessment of the existing and 
additional resources necessary for the preven-
tion and treatment of such illness and behavior, 
including an assessment of the progress toward 
achieving the availability of the full continuum 
of care described in subsection (c). 
‘‘(C) An estimate of the additional funding 
needed by the Service, Indian Tribes, Tribal 
Organizations, and Urban Indian Organizations 
to meet their responsibilities under the plans. 
‘‘(2) NATIONAL
CLEARINGHOUSE.—The Sec-
retary, acting through the Service, shall establish a 
national clearinghouse of plans and reports on the 
outcomes of such plans developed by Indian Tribes, 
Tribal Organizations, Urban Indian Organizations, 
and Service Areas relating to behavioral health. The 
Secretary shall ensure access to these plans and out-
comes by any Indian Tribe, Tribal Organization, 
Urban Indian Organization, or the Service. 
‘‘(3) TECHNICAL ASSISTANCE.—The Secretary 
shall provide technical assistance to Indian Tribes, 
Tribal Organizations, and Urban Indian Organiza-
tions in preparation of plans under this section and 
in developing standards of care that may be used 
and adopted locally.
245
‘‘(c) PROGRAMS.—The Secretary, acting through the 
Service, Indian Tribes, and Tribal Organizations, shall 
provide, to the extent feasible and if funding is available, 
programs including the following: 
‘‘(1) COMPREHENSIVE CARE.—A comprehensive 
continuum of behavioral health care which pro-
vides—
‘‘(A) community-based prevention, inter-
vention, outpatient, and behavioral health 
aftercare; 
‘‘(B) detoxification (social and medical); 
‘‘(C) acute hospitalization; 
‘‘(D) intensive outpatient/day treatment; 
‘‘(E) residential treatment; 
‘‘(F) transitional living for those needing a 
temporary, stable living environment that is 
supportive of treatment and recovery goals; 
‘‘(G) emergency shelter; 
‘‘(H) intensive case management; and 
‘‘(I) Traditional Health Care Practices. 
‘‘(2) CHILD CARE.—Behavioral health services 
for Indians from birth through age 17, including the 
following:
246
‘‘(A) Preschool and school age fetal alcohol 
disorder services, including assessment and be-
havioral intervention. 
‘‘(B) Mental health and substance abuse 
services (emotional, organic, alcohol, drug, in-
halant, and tobacco). 
‘‘(C) Identification and treatment of co-oc-
curring disorders and comorbidity. 
‘‘(D) Prevention of alcohol, drug, inhalant, 
and tobacco use. 
‘‘(E) Early intervention, treatment, and 
aftercare. 
‘‘(F) Promotion of healthy choices and life-
style (related to sexually transmitted diseases, 
domestic violence, sexual abuse, suicide, teen 
pregnancy, 
obesity, 
and 
other 
risk/safety 
issues). 
‘‘(G) Identification and treatment of ne-
glect and physical, mental, and sexual abuse. 
‘‘(3) ADULT CARE.—Behavioral health services 
for Indians from age 18 through 55, including the 
following: 
‘‘(A) Early intervention, treatment, and 
aftercare.
247
‘‘(B) Mental health and substance abuse 
services (emotional, alcohol, drug, inhalant, and 
tobacco), including gender specific services. 
‘‘(C) Identification and treatment of co-oc-
curring disorders (dual diagnosis) and comor-
bidity. 
‘‘(D) Promotion of gender specific healthy 
choices and lifestyle (related to parenting, part-
ners, domestic violence, sexual abuse, suicide, 
obesity, and other risk-related behavior). 
‘‘(E) Treatment services for women at risk 
of giving birth to a child with a fetal alcohol 
disorder. 
‘‘(F) Gender specific treatment for sexual 
assault and domestic violence. 
‘‘(4) FAMILY CARE.—Behavioral health services 
for families, including the following: 
‘‘(A) Early intervention, treatment, and 
aftercare for affected families. 
‘‘(B) Treatment for sexual assault and do-
mestic violence. 
‘‘(C) Promotion of healthy choices and life-
style (related to parenting, partners, domestic 
violence, and other abuse issues).
248
‘‘(5) ELDER CARE.—Behavioral health services 
for Indians 56 years of age and older, including the 
following: 
‘‘(A) Early intervention, treatment, and 
aftercare. 
‘‘(B) Mental health and substance abuse 
services (emotional, alcohol, drug, inhalant, and 
tobacco), including gender specific services. 
‘‘(C) Identification and treatment of co-oc-
curring disorders (dual diagnosis) and comor-
bidity. 
‘‘(D) Promotion of healthy choices and life-
style (managing conditions related to aging). 
‘‘(E) Gender specific treatment for sexual 
assault, domestic violence, neglect, physical and 
mental abuse and exploitation. 
‘‘(F) Identification and treatment of de-
mentias regardless of cause. 
‘‘(d) COMMUNITY BEHAVIORAL HEALTH PLAN.—
‘‘(1) ESTABLISHMENT.—The governing body of 
any Indian Tribe, Tribal Organization, or Urban In-
dian Organization may adopt a resolution for the es-
tablishment of a community behavioral health plan 
providing for the identification and coordination of 
available resources and programs to identify, pre-
249
vent, or treat substance abuse, mental illness, or 
dysfunctional and self-destructive behavior, including 
child abuse and family violence, among its members 
or its service population. This plan should include 
behavioral health services, social services, intensive 
outpatient services, and continuing aftercare. 
‘‘(2) TECHNICAL ASSISTANCE.—At the request 
of an Indian Tribe, Tribal Organization, or Urban 
Indian Organization, the Bureau of Indian Affairs 
and the Service shall cooperate with and provide 
technical assistance to the Indian Tribe, Tribal Or-
ganization, or Urban Indian Organization in the de-
velopment and implementation of such plan. 
‘‘(3) FUNDING.—The Secretary, acting through 
the Service, may make funding available to Indian 
Tribes and Tribal Organizations which adopt a reso-
lution pursuant to paragraph (1) to obtain technical 
assistance for the development of a community be-
havioral health plan and to provide administrative 
support in the implementation of such plan. 
‘‘(e) COORDINATION FOR AVAILABILITY OF SERV-
ICES.—The Secretary, acting through the Service, Indian 
Tribes, Tribal Organizations, and Urban Indian Organiza-
tions, shall coordinate behavioral health planning, to the 
extent feasible, with other Federal agencies and with State
250
agencies, to encourage comprehensive behavioral health 
services for Indians regardless of their place of residence. 
‘‘(f) MENTAL HEALTH CARE NEED ASSESSMENT.—
Not later than 1 year after the date of the enactment of 
the Indian Health Care Improvement Act Amendments of 
2003, the Secretary, acting through the Service, shall 
make an assessment of the need for inpatient mental 
health care among Indians and the availability and cost 
of inpatient mental health facilities which can meet such 
need. In making such assessment, the Secretary shall con-
sider the possible conversion of existing, underused Service 
hospital beds into psychiatric units to meet such need. 
‘‘SEC. 702. MEMORANDA OF AGREEMENT WITH THE DE-
PARTMENT OF THE INTERIOR. 
‘‘(a) CONTENTS.—Not later than 12 months after the 
date of the enactment of the Indian Health Care Improve-
ment Act Amendments of 2003, the Secretary, acting 
through the Service, and the Secretary of the Interior shall 
develop and enter into a memoranda of agreement, or re-
view and update any existing memoranda of agreement, 
as required by section 4205 of the Indian Alcohol and 
Substance Abuse Prevention and Treatment Act of 1986 
(25 U.S.C. 2411) under which the Secretaries address the 
following:
251
‘‘(1) The scope and nature of mental illness and 
dysfunctional and self-destructive behavior, including 
child abuse and family violence, among Indians. 
‘‘(2) The existing Federal, tribal, State, local, 
and private services, resources, and programs avail-
able to provide mental health services for Indians. 
‘‘(3) The unmet need for additional services, re-
sources, and programs necessary to meet the needs 
identified pursuant to paragraph (1). 
‘‘(4)(A) The right of Indians, as citizens of the 
United States and of the States in which they re-
side, to have access to mental health services to 
which all citizens have access. 
‘‘(B) The right of Indians to participate in, and 
receive the benefit of, such services. 
‘‘(C) The actions necessary to protect the exer-
cise of such right. 
‘‘(5) The responsibilities of the Bureau of In-
dian Affairs and the Service, including mental health 
identification, prevention, education, referral, and 
treatment services (including services through multi-
disciplinary resource teams), at the central, area, 
and agency and Service Unit, Service Area, and 
headquarters levels to address the problems identi-
fied in paragraph (1).
252
‘‘(6) A strategy for the comprehensive coordina-
tion of the mental health services provided by the 
Bureau of Indian Affairs and the Service to meet 
the problems identified pursuant to paragraph (1), 
including—
‘‘(A) the coordination of alcohol and sub-
stance abuse programs of the Service, the Bu-
reau of Indian Affairs, and Indian Tribes and 
Tribal Organizations (developed under the In-
dian Alcohol and Substance Abuse Prevention 
and Treatment Act of 1986) with mental health 
initiatives pursuant to this Act, particularly 
with respect to the referral and treatment of 
dually diagnosed individuals requiring mental 
health and substance abuse treatment; and 
‘‘(B) ensuring that the Bureau of Indian 
Affairs and Service programs and services (in-
cluding multidisciplinary resource teams) ad-
dressing child abuse and family violence are co-
ordinated with such non-Federal programs and 
services. 
‘‘(7) Directing appropriate officials of the Bu-
reau of Indian Affairs and the Service, particularly 
at the agency and Service Unit levels, to cooperate 
fully with tribal requests made pursuant to commu-
253
nity behavioral health plans adopted under section 
701(c) and section 4206 of the Indian Alcohol and 
Substance Abuse Prevention and Treatment Act of 
1986 (25 U.S.C. 2412). 
‘‘(8) Providing for an annual review of such 
agreement by the Secretaries which shall be provided 
to Congress and Indian Tribes and Tribal Organiza-
tions. 
‘‘(b) SPECIFIC PROVISIONS REQUIRED.—The memo-
randa of agreement updated or entered into pursuant to 
subsection (a) shall include specific provisions pursuant to 
which the Service shall assume responsibility for—
‘‘(1) the determination of the scope of the prob-
lem of alcohol and substance abuse among Indians, 
including the number of Indians within the jurisdic-
tion of the Service who are directly or indirectly af-
fected by alcohol and substance abuse and the finan-
cial and human cost; 
‘‘(2) an assessment of the existing and needed 
resources necessary for the prevention of alcohol and 
substance abuse and the treatment of Indians af-
fected by alcohol and substance abuse; and 
‘‘(3) an estimate of the funding necessary to 
adequately support a program of prevention of alco-
254
hol and substance abuse and treatment of Indians 
affected by alcohol and substance abuse. 
‘‘(c) CONSULTATION.—The Secretary, acting through 
the Service, and the Secretary of the Interior shall, in de-
veloping the memoranda of agreement under subsection 
(a), consult with and solicit the comments from—
‘‘(1) Indian Tribes and Tribal Organizations; 
‘‘(2) Indians; 
‘‘(3) Urban Indian Organizations and other In-
dian organizations; and 
‘‘(4) behavioral health service providers. 
‘‘(d) PUBLICATION.—Each memorandum of agree-
ment entered into or renewed (and amendments or modi-
fications thereto) under subsection (a) shall be published 
in the Federal Register. At the same time as publication 
in the Federal Register, the Secretary shall provide a copy 
of such memoranda, amendment, or modification to each 
Indian Tribe, Tribal Organization, and Urban Indian Or-
ganization. 
‘‘SEC. 703. COMPREHENSIVE BEHAVIORAL HEALTH PRE-
VENTION AND TREATMENT PROGRAM. 
‘‘(a) ESTABLISHMENT.—
‘‘(1) IN
GENERAL.—The Secretary, acting 
through the Service, Indian Tribes, and Tribal Orga-
nizations, shall provide a program of comprehensive
255
behavioral 
health, 
prevention, 
treatment, 
and 
aftercare, including Traditional Health Care Prac-
tices, which shall include—
‘‘(A) prevention, through educational inter-
vention, in Indian communities; 
‘‘(B) acute detoxification, psychiatric hos-
pitalization, and residential and intensive out-
patient treatment; 
‘‘(C) community-based rehabilitation and 
aftercare; 
‘‘(D) community education and involve-
ment, including extensive training of health 
care, educational, and community-based per-
sonnel; and 
‘‘(E) specialized residential treatment pro-
grams for high-risk populations, including but 
not limited to pregnant and postpartum women 
and their children. 
‘‘(2) TARGET POPULATIONS.—The target popu-
lation of such program shall be members of Indian 
Tribes. Efforts to train and educate key members of 
the Indian community shall target employees of 
health, education, judicial, law enforcement, legal, 
and social service programs. 
‘‘(b) CONTRACT HEALTH SERVICES.—
256
‘‘(1) IN
GENERAL.—The Secretary, acting 
through the Service, Indian Tribes, and Tribal Orga-
nizations, may enter into contracts with public or 
private providers of behavioral health treatment 
services for the purpose of carrying out the program 
required under subsection (a). 
‘‘(2) PROVISION OF ASSISTANCE.—In carrying 
out this subsection, the Secretary shall provide as-
sistance to Indian Tribes and Tribal Organizations 
to develop criteria for the certification of behavioral 
health service providers and accreditation of service 
facilities which meet minimum standards for such 
services and facilities. 
‘‘SEC. 704. MENTAL HEALTH TECHNICIAN PROGRAM. 
‘‘(a) IN GENERAL.—Under the authority of the Act 
of November 2, 1921 (25 U.S.C. 13) (commonly known 
as the Snyder Act), the Secretary shall establish and 
maintain a mental health technician program within the 
Service which—
‘‘(1) provides for the training of Indians as 
mental health technicians; and 
‘‘(2) employs such technicians in the provision 
of community-based mental health care that includes 
identification, prevention, education, referral, and 
treatment services.
257
‘‘(b) PARAPROFESSIONAL TRAINING.—In carrying 
out subsection (a), the Secretary, acting through the Serv-
ice, Indian Tribes, and Tribal Organizations, shall provide 
high-standard paraprofessional training in mental health 
care necessary to provide quality care to the Indian com-
munities to be served. Such training shall be based upon 
a curriculum developed or approved by the Secretary 
which combines education in the theory of mental health 
care with supervised practical experience in the provision 
of such care. 
‘‘(c) SUPERVISION AND EVALUATION OF TECHNI-
CIANS.—The Secretary, acting through the Service, Indian 
Tribes, and Tribal Organizations, shall supervise and 
evaluate the mental health technicians in the training pro-
gram. 
‘‘(d) TRADITIONAL HEALTH CARE PRACTICES.—The 
Secretary, acting through the Service, shall ensure that 
the program established pursuant to this subsection in-
volves the use and promotion of the Traditional Health 
Care Practices of the Indian Tribes to be served. 
‘‘SEC. 
705. 
LICENSING 
REQUIREMENT 
FOR 
MENTAL 
HEALTH CARE WORKERS. 
‘‘Subject to the provisions of section 221, any person 
employed as a psychologist, social worker, or marriage and 
family therapist for the purpose of providing mental health
258
care services to Indians in a clinical setting under this Act 
or through a Funding Agreement shall, in the case of a 
person employed as a psychologist, social worker, or mar-
riage and family therapist, be licensed as a clinical psy-
chologist, social worker, or marriage and family therapist, 
respectively, or working under the direct supervision of a 
licensed clinical psychologist, social worker, or marriage 
and family therapist, respectively. 
‘‘SEC. 706. INDIAN WOMEN TREATMENT PROGRAMS. 
‘‘(a) FUNDING.—The Secretary, consistent with sec-
tion 701, shall make funds available to Indian Tribes, 
Tribal Organizations, and Urban Indian Organizations to 
develop and implement a comprehensive behavioral health 
program of prevention, intervention, treatment, and re-
lapse prevention services that specifically addresses the 
spiritual, cultural, historical, social, and child care needs 
of Indian women, regardless of age. 
‘‘(b) USE OF FUNDS.—Funds made available pursu-
ant to this section may be used to—
‘‘(1) develop and provide community training, 
education, and prevention programs for Indian 
women relating to behavioral health issues, including 
fetal alcohol disorders;
259
‘‘(2) identify and provide psychological services, 
counseling, advocacy, support, and relapse preven-
tion to Indian women and their families; and 
‘‘(3) develop prevention and intervention models 
for Indian women which incorporate Traditional 
Health Care Practices, cultural values, and commu-
nity and family involvement. 
‘‘(c) CRITERIA.—The Secretary, in consultation with 
Indian Tribes and Tribal Organizations, shall establish 
criteria for the review and approval of applications and 
proposals for funding under this section. 
‘‘(d) EARMARK OF CERTAIN FUNDS.—Twenty per-
cent of the funds appropriated pursuant to this section 
shall be used to make grants to Urban Indian Organiza-
tions. 
‘‘SEC. 707. INDIAN YOUTH PROGRAM. 
‘‘(a) DETOXIFICATION AND REHABILITATION.—The 
Secretary, acting through the Service, consistent with sec-
tion 701, shall develop and implement a program for acute 
detoxification and treatment for Indian youths, including 
behavioral health services. The program shall include re-
gional treatment centers designed to include detoxification 
and rehabilitation for both sexes on a referral basis and 
programs developed and implemented by Indian Tribes or 
Tribal Organizations at the local level under the Indian
260
Self-Determination and Education Assistance Act. Re-
gional centers shall be integrated with the intake and re-
habilitation programs based in the referring Indian com-
munity. 
‘‘(b) ALCOHOL AND SUBSTANCE ABUSE TREATMENT 
CENTERS OR FACILITIES.—
‘‘(1) ESTABLISHMENT.—
‘‘(A) IN GENERAL.—The Secretary, acting 
through the Service, Indian Tribes, and Tribal 
Organizations, shall construct, renovate, or, as 
necessary, purchase, and appropriately staff 
and operate, at least 1 youth regional treatment 
center or treatment network in each area under 
the jurisdiction of an Area Office. 
‘‘(B) AREA OFFICE IN CALIFORNIA.—For 
the purposes of this subsection, the Area Office 
in California shall be considered to be 2 Area 
Offices, 1 office whose jurisdiction shall be con-
sidered to encompass the northern area of the 
State of California, and 1 office whose jurisdic-
tion shall be considered to encompass the re-
mainder of the State of California for the pur-
pose of implementing California treatment net-
works.
261
‘‘(2) FUNDING.—For the purpose of staffing 
and operating such centers or facilities, funding 
shall be pursuant to the Act of November 2, 1921 
(25 U.S.C. 13). 
‘‘(3) LOCATION.—A youth treatment center 
constructed or purchased under this subsection shall 
be constructed or purchased at a location within the 
area described in paragraph (1) agreed upon (by ap-
propriate tribal resolution) by a majority of the In-
dian Tribes to be served by such center. 
‘‘(4) SPECIFIC PROVISION OF FUNDS.—
‘‘(A) IN GENERAL.—Notwithstanding any 
other provision of this title, the Secretary may, 
from amounts authorized to be appropriated for 
the purposes of carrying out this section, make 
funds available to—
‘‘(i) the Tanana Chiefs Conference, 
Incorporated, for the purpose of leasing, 
constructing, renovating, operating, and 
maintaining a residential youth treatment 
facility in Fairbanks, Alaska; and 
‘‘(ii) the Southeast Alaska Regional 
Health Corporation to staff and operate a 
residential youth treatment facility without 
regard to the proviso set forth in section
262
4(l) of the Indian Self-Determination and 
Education Assistance Act (25 U.S.C. 
450b(l)). 
‘‘(B) PROVISION OF SERVICES TO ELIGI-
BLE
YOUTHS.—Until 
additional 
residential 
youth treatment facilities are established in 
Alaska pursuant to this section, the facilities 
specified in subparagraph (A) shall make every 
effort to provide services to all eligible Indian 
youths residing in such State. 
‘‘(c) INTERMEDIATE
ADOLESCENT
BEHAVIORAL 
HEALTH SERVICES.—
‘‘(1) IN
GENERAL.—The Secretary, acting 
through the Service, Indian Tribes, and Tribal Orga-
nizations, may provide intermediate behavioral 
health services, which may incorporate Traditional 
Health Care Practices, to Indian children and ado-
lescents, including—
‘‘(A) pretreatment assistance; 
‘‘(B) inpatient, outpatient, and aftercare 
services; 
‘‘(C) emergency care; 
‘‘(D) suicide prevention and crisis interven-
tion; and
263
‘‘(E) prevention and treatment of mental 
illness and dysfunctional and self-destructive 
behavior, including child abuse and family vio-
lence. 
‘‘(2) USE OF FUNDS.—Funds provided under 
this subsection may be used—
‘‘(A) to construct or renovate an existing 
health facility to provide intermediate behav-
ioral health services; 
‘‘(B) to hire behavioral health profes-
sionals; 
‘‘(C) to staff, operate, and maintain an in-
termediate mental health facility, group home, 
sober housing, transitional housing or similar 
facilities, or youth shelter where intermediate 
behavioral health services are being provided; 
‘‘(D) to make renovations and hire appro-
priate staff to convert existing hospital beds 
into adolescent psychiatric units; and 
‘‘(E) for intensive home- and community-
based services. 
‘‘(3) CRITERIA.—The Secretary, acting through 
the Service, shall, in consultation with Indian Tribes 
and Tribal Organizations, establish criteria for the
264
review and approval of applications or proposals for 
funding made available pursuant to this subsection. 
‘‘(d) FEDERALLY OWNED STRUCTURES.—
‘‘(1) IN GENERAL.—The Secretary, in consulta-
tion with Indian Tribes and Tribal Organizations, 
shall—
‘‘(A) identify and use, where appropriate, 
federally owned structures suitable for local res-
idential or regional behavioral health treatment 
for Indian youths; and 
‘‘(B) establish guidelines, in consultation 
with Indian Tribes and Tribal Organizations, 
for determining the suitability of any such fed-
erally owned structure to be used for local resi-
dential or regional behavioral health treatment 
for Indian youths. 
‘‘(2) TERMS
AND
CONDITIONS
FOR
USE
OF 
STRUCTURE.—Any structure described in paragraph 
(1) may be used under such terms and conditions as 
may be agreed upon by the Secretary and the agency 
having responsibility for the structure and any In-
dian Tribe or Tribal Organization operating the pro-
gram. 
‘‘(e) REHABILITATION AND AFTERCARE SERVICES.—
265
‘‘(1) IN
GENERAL.—The Secretary, Indian 
Tribes, or Tribal Organizations, in cooperation with 
the Secretary of the Interior, shall develop and im-
plement within each Service Unit, community-based 
rehabilitation and follow-up services for Indian 
youths who are having significant behavioral health 
problems, and require long-term treatment, commu-
nity reintegration, and monitoring to support the In-
dian youths after their return to their home commu-
nity. 
‘‘(2) ADMINISTRATION.—Services under para-
graph (1) shall be provided by trained staff within 
the community who can assist the Indian youths in 
their continuing development of self-image, positive 
problem-solving skills, and nonalcohol or substance 
abusing behaviors. Such staff may include alcohol 
and substance abuse counselors, mental health pro-
fessionals, and other health professionals and para-
professionals, including community health represent-
atives. 
‘‘(f) INCLUSION OF FAMILY IN YOUTH TREATMENT 
PROGRAM.—In providing the treatment and other services 
to Indian youths authorized by this section, the Secretary, 
acting through the Service, Indian Tribes, and Tribal Or-
ganizations, shall provide for the inclusion of family mem-
266
bers of such youths in the treatment programs or other 
services as may be appropriate. Not less than 10 percent 
of the funds appropriated for the purposes of carrying out 
subsection (e) shall be used for outpatient care of adult 
family members related to the treatment of an Indian 
youth under that subsection. 
‘‘(g) MULTIDRUG ABUSE PROGRAM.—The Secretary, 
acting through the Service, Indian Tribes, Tribal Organi-
zations, and Urban Indian Organizations, shall provide, 
consistent with section 701, programs and services to pre-
vent and treat the abuse of multiple forms of substances, 
including, but not limited to, alcohol, drugs, inhalants, and 
tobacco, among Indian youths residing in Indian commu-
nities, on or near reservations, and in urban areas and 
provide appropriate mental health services to address the 
incidence of mental illness among such youths. 
‘‘SEC. 708. INPATIENT AND COMMUNITY-BASED MENTAL 
HEALTH 
FACILITIES 
DESIGN, 
CONSTRUC-
TION, AND STAFFING. 
‘‘Not later than 1 year after the date of the enact-
ment of the Indian Health Care Improvement Act Amend-
ments of 2003, the Secretary, acting through the Service, 
Indian Tribes, and Tribal Organizations, shall provide, in 
each area of the Service, not less than 1 inpatient mental 
health care facility, or the equivalent, for Indians with be-
267
havioral health problems. For the purposes of this sub-
section, California shall be considered to be 2 Area Offices, 
1 office whose location shall be considered to encompass 
the northern area of the State of California and 1 office 
whose jurisdiction shall be considered to encompass the 
remainder of the State of California. The Secretary shall 
consider the possible conversion of existing, underused 
Service hospital beds into psychiatric units to meet such 
need. 
‘‘SEC. 709. TRAINING AND COMMUNITY EDUCATION. 
‘‘(a) PROGRAM.—The Secretary, in cooperation with 
the Secretary of the Interior, shall develop and implement 
or provide funding for Indian Tribes and Tribal Organiza-
tions to develop and implement, within each Service Unit 
or tribal program, a program of community education and 
involvement which shall be designed to provide concise and 
timely information to the community leadership of each 
tribal community. Such program shall include education 
about behavioral health issues to political leaders, Tribal 
judges, law enforcement personnel, members of tribal 
health and education boards, health care providers includ-
ing traditional practitioners, and other critical members 
of each tribal community. Community-based training (ori-
ented toward local capacity development) shall also include 
tribal community provider training (designed for adult
268
learners from the communities receiving services for pre-
vention, intervention, treatment, and aftercare). 
‘‘(b) INSTRUCTION.—The Secretary, acting through 
the Service, shall, either directly or through Indian Tribes 
and Tribal Organizations, provide instruction in the area 
of behavioral health issues, including instruction in crisis 
intervention and family relations in the context of alcohol 
and substance abuse, child sexual abuse, youth alcohol and 
substance abuse, and the causes and effects of fetal alco-
hol disorders to appropriate employees of the Bureau of 
Indian Affairs and the Service, and to personnel in schools 
or programs operated under any contract with the Bureau 
of Indian Affairs or the Service, including supervisors of 
emergency shelters and halfway houses described in sec-
tion 4213 of the Indian Alcohol and Substance Abuse Pre-
vention and Treatment Act of 1986 (25 U.S.C. 2433). 
‘‘(c) TRAINING MODELS.—In carrying out the edu-
cation and training programs required by this section, the 
Secretary, in consultation with Indian Tribes, Tribal Or-
ganizations, Indian behavioral health experts, and Indian 
alcohol and substance abuse prevention experts, shall de-
velop and provide community-based training models. Such 
models shall address—
‘‘(1) the elevated risk of alcohol and behavioral 
health problems faced by children of alcoholics;
269
‘‘(2) 
the 
cultural, 
spiritual, 
and 
multigenerational aspects of behavioral health prob-
lem prevention and recovery; and 
‘‘(3) community-based and multidisciplinary 
strategies for preventing and treating behavioral 
health problems. 
‘‘SEC. 710. BEHAVIORAL HEALTH PROGRAM. 
‘‘(a) INNOVATIVE PROGRAMS.—The Secretary, acting 
through the Service, Indian Tribes, and Tribal Organiza-
tions, consistent with section 701, may plan, develop, im-
plement, and carry out programs to deliver innovative 
community-based behavioral health services to Indians. 
‘‘(b) FUNDING; CRITERIA.—The Secretary may 
award such funding for a project under subsection (a) to 
an Indian Tribe or Tribal Organization and may consider 
the following criteria: 
‘‘(1) The project will address significant unmet 
behavioral health needs among Indians. 
‘‘(2) The project will serve a significant number 
of Indians. 
‘‘(3) The project has the potential to deliver 
services in an efficient and effective manner. 
‘‘(4) The Indian Tribe or Tribal Organization 
has the administrative and financial capability to ad-
minister the project.
270
‘‘(5) The project may deliver services in a man-
ner consistent with Traditional Health Care Prac-
tices. 
‘‘(6) The project is coordinated with, and avoids 
duplication of, existing services. 
‘‘(c) EQUITABLE TREATMENT.—For purposes of this 
subsection, the Secretary shall, in evaluating applications 
or proposals for funding for projects to be operated under 
any Funding Agreement, use the same criteria that the 
Secretary uses in evaluating any other application or pro-
posal for such funding. 
‘‘SEC. 711. FETAL ALCOHOL DISORDER FUNDING. 
‘‘(a) PROGRAMS.—
‘‘(1) ESTABLISHMENT.—The Secretary, con-
sistent with section 701, acting through Indian 
Tribes and Tribal Organizations, shall establish and 
operate fetal alcohol disorder programs as provided 
in this section for the purposes of meeting the health 
status objectives specified in section 3. 
‘‘(2) USE OF FUNDS.—Funding provided pursu-
ant to this section shall be used for the following: 
‘‘(A) To develop and provide for Indians 
community and in school training, education, 
and prevention programs relating to fetal alco-
hol disorders.
271
‘‘(B) To identify and provide behavioral 
health treatment to high-risk Indian women 
and high-risk women pregnant with an Indian’s 
child. 
‘‘(C) To identify and provide appropriate 
psychological services, educational and voca-
tional support, counseling, advocacy, and infor-
mation to fetal alcohol disorder affected Indians 
and their families or caretakers. 
‘‘(D) To develop and implement counseling 
and support programs in schools for fetal alco-
hol disorder affected Indian children. 
‘‘(E) To develop prevention and interven-
tion models which incorporate practitioners of 
Traditional Health Care Practices, cultural and 
spiritual values, and community involvement. 
‘‘(F) To develop, print, and disseminate 
education and prevention materials on fetal al-
cohol disorder. 
‘‘(G) To develop and implement, through 
the tribal consultation process, culturally sen-
sitive assessment and diagnostic tools including 
dysmorphology clinics and multidisciplinary 
fetal alcohol disorder clinics for use in Indian 
communities and Urban Centers.
272
‘‘(H) To develop early childhood interven-
tion projects from birth on to mitigate the ef-
fects of fetal alcohol disorder among Indians. 
‘‘(I) To develop and fund community-based 
adult fetal alcohol disorder housing and support 
services for Indians and for women pregnant 
with an Indian’s child. 
‘‘(3) CRITERIA FOR APPLICATIONS.—The Sec-
retary shall establish criteria for the review and ap-
proval of applications for funding under this section. 
‘‘(b) SERVICES.—The Secretary, acting through the 
Service and Indian Tribes, Tribal Organizations, and 
Urban Indian Organizations, shall—
‘‘(1) develop and provide services for the pre-
vention, intervention, treatment, and aftercare for 
those affected by fetal alcohol disorder in Indian 
communities; and 
‘‘(2) provide supportive services, directly or 
through an Indian Tribe, Tribal Organization, or 
Urban Indian Organization, including services to 
meet the special educational, vocational, school-to-
work transition, and independent living needs of ad-
olescent and adult Indians with fetal alcohol dis-
order.
273
‘‘(c) TASK FORCE.—The Secretary shall establish a 
task force to be known as the Fetal Alcohol Disorder Task 
Force to advise the Secretary in carrying out subsection 
(b). Such task force shall be composed of representatives 
from the following: 
‘‘(1) The National Institute on Drug Abuse. 
‘‘(2) The National Institute on Alcohol and Al-
coholism. 
‘‘(3) The Office of Substance Abuse Prevention. 
‘‘(4) The National Institute of Mental Health. 
‘‘(5) The Service. 
‘‘(6) The Office of Minority Health of the De-
partment of Health and Human Services. 
‘‘(7) The Administration for Native Americans. 
‘‘(8) The National Institute of Child Health 
and Human Development (NICHD). 
‘‘(9) The Centers for Disease Control and Pre-
vention. 
‘‘(10) The Bureau of Indian Affairs. 
‘‘(11) Indian Tribes. 
‘‘(12) Tribal Organizations. 
‘‘(13) Urban Indian Organizations. 
‘‘(14) Indian fetal alcohol disorder experts. 
‘‘(d) APPLIED
RESEARCH
PROJECTS.—The Sec-
retary, acting through the Substance Abuse and Mental
274
Health Services Administration, shall make funding avail-
able to Indian Tribes, Tribal Organizations, and Urban 
Indian Organizations for applied research projects which 
propose to elevate the understanding of methods to pre-
vent, intervene, treat, or provide rehabilitation and behav-
ioral health aftercare for Indians and Urban Indians af-
fected by fetal alcohol disorder. 
‘‘(e) FUNDING
FOR
URBAN
INDIAN
ORGANIZA-
TIONS.—Ten percent of the funds appropriated pursuant 
to this section shall be used to make grants to Urban In-
dian Organizations funded under title V. 
‘‘SEC. 712. CHILD SEXUAL ABUSE AND PREVENTION TREAT-
MENT PROGRAMS. 
‘‘(a) 
ESTABLISHMENT.—The 
Secretary, 
acting 
through the Service, and the Secretary of the Interior, In-
dian Tribes, and Tribal Organizations shall establish, con-
sistent with section 701, in every Service Area, programs 
involving treatment for—
‘‘(1) victims of sexual abuse who are Indian 
children or children in an Indian household; and 
‘‘(2) perpetrators of child sexual abuse who are 
Indian or members of an Indian household. 
‘‘(b) USE OF FUNDS.—Funding provided pursuant to 
this section shall be used for the following:
275
‘‘(1) To develop and provide community edu-
cation and prevention programs related to sexual 
abuse of Indian children or children in an Indian 
household. 
‘‘(2) To identify and provide behavioral health 
treatment to victims of sexual abuse who are Indian 
children or children in an Indian household, and to 
their family members who are affected by sexual 
abuse. 
‘‘(3) To develop prevention and intervention 
models which incorporate Traditional Health Care 
Practices, cultural and spiritual values, and commu-
nity involvement. 
‘‘(4) To develop and implement, through the 
tribal consultation process, culturally sensitive as-
sessment and diagnostic tools for use in Indian com-
munities and Urban Centers. 
‘‘(5) To identify and provide behavioral health 
treatment to Indian perpetrators and perpetrators 
who are members of an Indian household—
‘‘(A) making efforts to begin offender and 
behavioral health treatment while the perpe-
trator is incarcerated or at the earliest possible 
date if the perpetrator is not incarcerated; and
276
‘‘(B) providing treatment after the perpe-
trator is released, until it is determined that the 
perpetrator is not a threat to children. 
‘‘SEC. 713. BEHAVIORAL HEALTH RESEARCH. 
‘‘The Secretary, in consultation with appropriate 
Federal agencies, shall provide funding to Indian Tribes, 
Tribal Organizations, and Urban Indian Organizations or 
enter into contracts with, or make grants to appropriate 
institutions for, the conduct of research on the incidence 
and prevalence of behavioral health problems among Indi-
ans served by the Service, Indian Tribes, or Tribal Organi-
zations and among Indians in urban areas. Research pri-
orities under this section shall include—
‘‘(1) the interrelationship and interdependence 
of behavioral health problems with alcoholism and 
other substance abuse, suicide, homicides, other in-
juries, and the incidence of family violence; and 
‘‘(2) the development of models of prevention 
techniques. 
The effect of the interrelationships and interdependencies 
referred to in paragraph (1) on children, and the develop-
ment of prevention techniques under paragraph (2) appli-
cable to children, shall be emphasized.
277
‘‘SEC. 714. DEFINITIONS. 
‘‘For the purpose of this title, the following defini-
tions shall apply: 
‘‘(1) ASSESSMENT.—The term ‘assessment’ 
means the systematic collection, analysis, and dis-
semination of information on health status, health 
needs, and health problems. 
‘‘(2) 
ALCOHOL-RELATED
NEURODEVELOP-
MENTAL DISORDERS OR ARND.—The term ‘alcohol-
related neurodevelopmental disorders’ or ‘ARND’ 
means, with a history of maternal alcohol consump-
tion during pregnancy, central nervous system in-
volvement such as developmental delay, intellectual 
deficit, or neurologic abnormalities. Behaviorally, 
there can be problems with irritability, and failure to 
thrive as infants. As children become older there will 
likely be hyperactivity, attention deficit, language 
dysfunction, and perceptual and judgment problems. 
‘‘(3) BEHAVIORAL HEALTH.—The term ‘behav-
ioral health’ means the blending of substance (alco-
hol, drugs, inhalants, and tobacco) abuse and mental 
health prevention and treatment, for the purpose of 
providing comprehensive services. This can include 
the joint development of substance abuse and mental 
health treatment planning and coordinated case 
management using a multidisciplinary approach.
278
‘‘(4) BEHAVIORAL HEALTH AFTERCARE.—The 
term ‘behavioral health aftercare’ includes those ac-
tivities and resources used to support recovery fol-
lowing inpatient, residential, intensive substance 
abuse, or mental health outpatient or outpatient 
treatment. The purpose is to help prevent or deal 
with relapse by ensuring that by the time a client or 
patient is discharged from a level of care, such as 
outpatient treatment, an aftercare plan has been de-
veloped with the client. An aftercare plan may use 
such resources a as community-based therapeutic 
group, transitional living facilities, a 12-step spon-
sor, a local 12-step or other related support group, 
and other community-based providers (mental health 
professionals, traditional health care practitioners, 
community health aides, community health rep-
resentatives, mental health technicians, ministers, 
etc.) 
‘‘(5) DUAL DIAGNOSIS.—The term ‘dual diag-
nosis’ means coexisting substance abuse and mental 
illness conditions or diagnosis. Such clients are 
sometimes referred to as mentally ill chemical abus-
ers (MICAs). 
‘‘(6) FETAL ALCOHOL DISORDERS.—The term 
‘fetal alcohol disorders’ means fetal alcohol syn-
279
drome, partial fetal alcohol syndrome and alcohol re-
lated neurodevelopmental disorder (ARND). 
‘‘(7) FETAL
ALCOHOL
SYNDROME
OR
FAS.—
The term ‘fetal alcohol syndrome’ or ‘FAS’ means a 
syndrome in which, with a history of maternal alco-
hol consumption during pregnancy, the following cri-
teria are met: 
‘‘(A) Central nervous system involvement 
such as developmental delay, intellectual deficit, 
microencephaly, or neurologic abnormalities. 
‘‘(B) Craniofacial abnormalities with at 
least 2 of the following: microophthalmia, short 
palpebral fissures, poorly developed philtrum, 
thin upper lip, flat nasal bridge, and short 
upturned nose. 
‘‘(C) Prenatal or postnatal growth delay. 
‘‘(8) PARTIAL
FAS.—The term ‘partial FAS’ 
means, with a history of maternal alcohol consump-
tion during pregnancy, having most of the criteria of 
FAS, though not meeting a minimum of at least 2 
of the following: microophthalmia, short palpebral 
fissures, poorly developed philtrum, thin upper lip, 
flat nasal bridge, and short upturned nose.
‘‘(9) REHABILITATION.—The term ‘rehabilita-
tion’ means to restore the ability or capacity to en-
280
gage in usual and customary life activities through 
education and therapy. 
‘‘(10) SUBSTANCE
ABUSE.—The term ‘sub-
stance abuse’ includes inhalant abuse. 
‘‘SEC. 715. AUTHORIZATION OF APPROPRIATIONS. 
‘‘There is authorized to be appropriated such sums 
as may be necessary for each fiscal year through fiscal 
year 2015 to carry out the provisions of this title.
‘‘TITLE VIII—MISCELLANEOUS 
‘‘SEC. 801. REPORTS. 
‘‘The President shall, at the time the budget is sub-
mitted under section 1105 of title 31, United States Code, 
for each fiscal year transmit to Congress a report con-
taining the following: 
‘‘(1) A report on the progress made in meeting 
the objectives of this Act, including a review of pro-
grams established or assisted pursuant to this Act 
and assessments and recommendations of additional 
programs or additional assistance necessary to, at a 
minimum, provide health services to Indians and en-
sure a health status for Indians, which are at a par-
ity with the health services available to and the 
health status of the general population, including 
specific comparisons of appropriations provided and 
those required for such parity.
281
‘‘(2) A report on whether, and to what extent, 
new national health care programs, benefits, initia-
tives, or financing systems have had an impact on 
the purposes of this Act and any steps that the Sec-
retary may have taken to consult with Indian Tribes, 
Tribal Organizations, and Urban Indian Organiza-
tions to address such impact, including a report on 
proposed changes in allocation of funding pursuant 
to section 808. 
‘‘(3) A report on the use of health services by 
Indians—
‘‘(A) on a national and area or other rel-
evant geographical basis; 
‘‘(B) by gender and age; 
‘‘(C) by source of payment and type of 
service; 
‘‘(D) comparing such rates of use with 
rates of use among comparable non-Indian pop-
ulations; and 
‘‘(E) on the services provided under Fund-
ing Agreements. 
‘‘(4) A report of contractors to the Secretary on 
Health Care Educational Loan Repayments every 6 
months required by section 110.