160 
any expansion, the Indian Tribe or Tribal Organization 
shall provide to the Secretary additional information pur-
suant to regulations, including additional staffing, equip-
ment, and other costs associated with the expansion. 
‘‘(e) CLOSURE OR CONVERSION OF FACILITIES.—If 
any Service facility which has been expanded, renovated, 
or modernized by an Indian Tribe or Tribal Organization 
under this section ceases to be used as a Service facility 
during the 20-year period beginning on the date such ex-
pansion, renovation, or modernization is completed, such 
Indian Tribe or Tribal Organization shall be entitled to 
recover from the United States an amount which bears the 
same ratio to the value of such facility at the time of such 
cessation as the value of such expansion, renovation, or 
modernization (less the total amount of any funds provided 
specifically for such facility under any Federal program 
that were expended for such expansion, renovation, or mod-
ernization) bore to the value of such facility at the time 
of the completion of such expansion, renovation, or mod-
ernization. 
‘‘SEC. 305. FUNDING FOR THE CONSTRUCTION, EXPANSION, 
AND MODERNIZATION OF SMALL AMBULA-
TORY CARE FACILITIES. 
‘‘(a) GRANTS.— 
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‘‘(1) 
IN
GENERAL.—The 
Secretary, 
acting 
through the Service, shall make grants to Indian 
Tribes and Tribal Organizations for the construction, 
expansion, or modernization of facilities for the provi-
sion of ambulatory care services to eligible Indians 
(and noneligible persons pursuant to subsections 
(b)(2) and (c)(1)(C)). A grant made under this sec-
tion may cover up to 100 percent of the costs of such 
construction, expansion, or modernization. For the 
purposes of this section, the term ‘construction’ in-
cludes the replacement of an existing facility. 
‘‘(2) GRANT AGREEMENT REQUIRED.—A grant 
under paragraph (1) may only be made available to 
a Tribal Health Program operating an Indian health 
facility (other than a facility owned or constructed by 
the Service, including a facility originally owned or 
constructed by the Service and transferred to an In-
dian Tribe or Tribal Organization). 
‘‘(b) USE OF GRANT FUNDS.— 
‘‘(1) ALLOWABLE
USES.—A grant awarded 
under this section may be used for the construction, 
expansion, or modernization (including the planning 
and design of such construction, expansion, or mod-
ernization) of an ambulatory care facility— 
‘‘(A) located apart from a hospital; 
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‘‘(B) not funded under section 301 or sec-
tion 306; and 
‘‘(C) which, upon completion of such con-
struction or modernization will— 
‘‘(i) have a total capacity appropriate 
to its projected service population; 
‘‘(ii) provide annually no fewer than 
150 patient visits by eligible Indians and 
other users who are eligible for services in 
such facility in accordance with section 
807(c)(2); and 
‘‘(iii) provide ambulatory care in a 
Service Area (specified in the contract or 
compact under the Indian Self-Determina-
tion and Education Assistance Act (25 
U.S.C. 450 et seq.)) with a population of no 
fewer than 1,500 eligible Indians and other 
users who are eligible for services in such 
facility 
in 
accordance 
with 
section 
807(c)(2). 
‘‘(2) ADDITIONAL
ALLOWABLE
USE.—The Sec-
retary may also reserve a portion of the funding pro-
vided under this section and use those reserved funds 
to reduce an outstanding debt incurred by Indian 
Tribes or Tribal Organizations for the construction, 
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expansion, or modernization of an ambulatory care 
facility that meets the requirements under paragraph 
(1). The provisions of this section shall apply, except 
that such applications for funding under this para-
graph shall be considered separately from applica-
tions for funding under paragraph (1). 
‘‘(3) USE
ONLY
FOR
CERTAIN
PORTION
OF 
COSTS.—A grant provided under this section may be 
used only for the cost of that portion of a construc-
tion, expansion, or modernization project that 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 applying for 
a grant under this section for a health care facility 
located or to be constructed on an island or when such 
facility is not located on a road system providing di-
rect access to an inpatient hospital where care is 
available to the Service population. 
‘‘(c) GRANTS.— 
‘‘(1) APPLICATION.—No grant may be made 
under this section unless an application or proposal 
for the grant has been approved by the Secretary in 
accordance with applicable regulations and has set 
forth reasonable assurance by the applicant that, at 
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164 
all times after the construction, expansion, or mod-
ernization of a facility carried out using a grant re-
ceived under this section— 
‘‘(A) adequate financial support will be 
available for the provision of services at such fa-
cility; 
‘‘(B) such facility will be available to eligi-
ble Indians without regard to ability to pay or 
source of payment; and 
‘‘(C) such facility will, as feasible without 
diminishing the quality or quantity of services 
provided to eligible Indians, serve noneligible 
persons on a cost basis. 
‘‘(2) PRIORITY.—In awarding grants under this 
section, the Secretary shall give priority to Indian 
Tribes and Tribal Organizations that demonstrate— 
‘‘(A) a need for increased ambulatory care 
services; and 
‘‘(B) insufficient capacity to deliver such 
services. 
‘‘(3) PEER REVIEW PANELS.—The Secretary may 
provide for the establishment of peer review panels, as 
necessary, to review and evaluate applications and 
proposals and to advise the Secretary regarding such 
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165 
applications using the criteria developed pursuant to 
subsection (a)(1). 
‘‘(d) REVERSION OF FACILITIES.—If any facility (or 
portion thereof) with respect to which funds have been paid 
under this section, ceases, at any time after completion 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 portion thereof) shall 
transfer to the United States unless otherwise negotiated by 
the Service and the Indian Tribe or Tribal Organization. 
‘‘(e) FUNDING NONRECURRING.—Funding provided 
under this section shall be nonrecurring and shall not be 
available for inclusion in any individual Indian Tribe’s 
tribal share for an award under the Indian Self-Determina-
tion and Education Assistance Act (25 U.S.C. 450 et seq.) 
or for reallocation or redesign thereunder. 
‘‘SEC. 306. INDIAN HEALTH CARE DELIVERY DEMONSTRA-
TION PROJECT. 
‘‘(a) HEALTH CARE DEMONSTRATION PROJECTS.— 
The Secretary, acting through the Service, is authorized to 
enter into contracts under the Indian Self-Determination 
and Education Assistance Act (25 U.S.C. 450 et seq.) with 
Indian Tribes or Tribal Organizations for the purpose of 
carrying out a health care delivery demonstration project 
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166 
to test alternative means of delivering health care and serv-
ices to Indians through facilities. 
‘‘(b) USE OF FUNDS.—The Secretary, in approving 
projects pursuant to this section, may authorize such con-
tracts for the construction and renovation of hospitals, 
health centers, health stations, and other facilities to deliver 
health care services and is authorized to— 
‘‘(1) waive any leasing prohibition; 
‘‘(2) permit carryover of funds appropriated for 
the provision of health care services; 
‘‘(3) permit the use of other available funds; 
‘‘(4) permit the use of funds or property donated 
from any source for project purposes; 
‘‘(5) provide for the reversion of donated real or 
personal property to the donor; and 
‘‘(6) permit the use of Service funds to match 
other funds, including Federal funds. 
‘‘(c) REGULATIONS.—The Secretary shall develop and 
promulgate regulations, not later than 1 year after the date 
of enactment of the Indian Health Care Improvement Act 
Amendments of 2007, for the review and approval of appli-
cations submitted under this section. 
‘‘(d) CRITERIA.—The Secretary may approve projects 
that meet the following criteria: 
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167 
‘‘(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 serv-
ices in an efficient and effective manner. 
‘‘(4) The project is economically viable. 
‘‘(5) The Indian Tribe or Tribal Organization 
has the administrative and financial capability to 
administer 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 pro-
vide 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 subsection 
(d): 
‘‘(1) Cass Lake, Minnesota. 
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‘‘(2) Mescalero, New Mexico. 
‘‘(3) Owyhee, Nevada. 
‘‘(4) Schurz, Nevada. 
‘‘(5) Ft. Yuma, California. 
‘‘(g) TECHNICAL ASSISTANCE.—The Secretary shall 
provide such technical and other assistance as may be nec-
essary to enable applicants to comply with the provisions 
of this section. 
‘‘(h) SERVICE TO INELIGIBLE PERSONS.—Subject to 
section 807, the authority to provide services to persons oth-
erwise ineligible for the health care benefits of the Service 
and the authority to extend hospital privileges in Service 
facilities to non-Service health practitioners as provided in 
section 807 may be included, subject to the terms of such 
section, in any demonstration project approved pursuant 
to this section. 
‘‘(i) EQUITABLE TREATMENT.—For purposes of sub-
section (d)(1), the Secretary shall, in evaluating facilities 
operated under any contract or compact under the Indian 
Self-Determination and Education Assistance Act (25 
U.S.C. 450 et seq.), use the same criteria that the Secretary 
uses in evaluating facilities operated directly by the Service. 
‘‘(j) EQUITABLE INTEGRATION OF FACILITIES.—The 
Secretary shall ensure that the planning, design, construc-
tion, renovation, and expansion needs of Service and non- 
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Service facilities which are the subject of a contract or com-
pact under the Indian Self-Determination and Education 
Assistance Act (25 U.S.C. 450 et seq.) for health services 
are fully and equitably integrated into the implementation 
of the health care delivery demonstration projects under this 
section. 
‘‘SEC. 307. LAND TRANSFER. 
‘‘Notwithstanding any other provision of law, the Bu-
reau of Indian Affairs and all other agencies and depart-
ments of the United States are authorized to transfer, at 
no cost, land and improvements to the Service for the provi-
sion 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 Indian 
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 ad-
ministration and delivery of health services by an Indian 
Health Program. Such leases, contracts, or agreements may 
include provisions for construction or renovation and pro-
vide for compensation to the Indian Tribe or Tribal Orga-
nization of rental and other costs consistent with section 
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105(l) of the Indian Self-Determination and Education As-
sistance Act (25 U.S.C. 450j(l)) and regulations thereunder. 
‘‘SEC. 309. STUDY ON LOANS, LOAN GUARANTEES, AND 
LOAN REPAYMENT. 
‘‘(a) IN GENERAL.—The Secretary, in consultation 
with the Secretary of the Treasury, Indian Tribes, and 
Tribal Organizations, shall carry out a study to determine 
the feasibility of establishing a loan fund to provide to In-
dian Tribes and Tribal Organizations direct loans or guar-
antees for loans for the construction of health care facilities, 
including— 
‘‘(1) inpatient facilities; 
‘‘(2) outpatient facilities; 
‘‘(3) staff quarters; 
‘‘(4) hostels; and 
‘‘(5) specialized care facilities, such as behavioral 
health and elder care facilities. 
‘‘(b) DETERMINATIONS.—In carrying out the study 
under subsection (a), the Secretary shall determine— 
‘‘(1) the maximum principal amount of a loan 
or loan guarantee that should be offered to a recipient 
from the loan fund; 
‘‘(2) the percentage of eligible costs, not to exceed 
100 percent, that may be covered by a loan or loan 
guarantee from the loan fund (including costs relating 
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171 
to planning, design, financing, site land development, 
construction, rehabilitation, renovation, conversion, 
improvements, medical equipment and furnishings, 
and other facility-related costs and capital purchase 
(but excluding staffing)); 
‘‘(3) the cumulative total of the principal of di-
rect loans and loan guarantees, respectively, that may 
be outstanding at any 1 time; 
‘‘(4) the maximum term of a loan or loan guar-
antee that may be made for a facility from the loan 
fund; 
‘‘(5) the maximum percentage of funds from the 
loan fund that should be allocated for payment of 
costs associated with planning and applying for a 
loan or loan guarantee; 
‘‘(6) whether acceptance by the Secretary of an 
assignment of the revenue of an Indian Tribe or Trib-
al Organization as security for any direct loan or 
loan guarantee from the loan fund would be appro-
priate; 
‘‘(7) whether, in the planning and design of 
health facilities under this section, users eligible 
under section 807(c) may be included in any projec-
tion of patient population; 
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‘‘(8) whether funds of the Service provided 
through loans or loan guarantees from the loan fund 
should be eligible for use in matching other Federal 
funds under other programs; 
‘‘(9) the appropriateness of, and best methods 
for, coordinating the loan fund with the health care 
priority system of the Service under section 301; and 
‘‘(10) any legislative or regulatory changes re-
quired to implement recommendations of the Sec-
retary based on results of the study. 
‘‘(c) REPORT.—Not later than September 30, 2009, the 
Secretary shall submit to the Committee on Indian Affairs 
of the Senate and the Committee on Natural Resources and 
the Committee on Energy and Commerce of the House of 
Representatives a report that describes— 
‘‘(1) the manner of consultation made as re-
quired by subsection (a); and 
‘‘(2) the results of the study, including any rec-
ommendations of the Secretary based on results of the 
study. 
‘‘SEC. 310. TRIBAL LEASING. 
‘‘A Tribal Health Program may lease permanent 
structures for the purpose of providing health care services 
without obtaining advance approval in appropriation Acts. 
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‘‘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 demonstra-
tion projects under which an Indian Tribe or Tribal Orga-
nization shall expend tribal, private, or other available 
funds, for the acquisition or construction of a health facility 
for a minimum of 10 years, under a no-cost lease, in ex-
change for agreement by the Service to provide the equip-
ment, supplies, and staffing for the operation and mainte-
nance 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 Organization 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. 
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‘‘(b) REQUIREMENTS.—The Secretary shall make such 
an arrangement with an Indian Tribe or Tribal Organiza-
tion 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 rel-
evant health facility; and 
‘‘(2) the Indian Tribe or Tribal Organization 
meets the need criteria determined using the criteria 
developed under the health care facility priority sys-
tem under section 301, unless the Secretary deter-
mines, pursuant to regulations, that other criteria 
will result in a more cost-effective and efficient meth-
od of facilitating and completing construction of 
health care facilities. 
‘‘(c) CONTINUED OPERATION.—The Secretary shall ne-
gotiate an agreement with the Indian Tribe or Tribal Orga-
nization regarding the continued operation of the facility 
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 
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paid to the Indian Tribe or Tribal Organization, or paid 
to a third party on the Indian Tribe’s or Tribal Organiza-
tion’s behalf, under the agreement. The Secretary has the 
right to recover tangible property (including supplies) and 
equipment, less depreciation, and any funds expended for 
operations and maintenance under this section. The pre-
ceding sentence does not apply to any funds expended for 
the delivery of health care services, personnel, 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 enti-
tled to recover from the United States an amount that is 
proportional to the value of such facility if, at any time 
within the 10-year term of the agreement, the Service ceases 
to use the facility or otherwise breaches the agreement. 
‘‘(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 relevant 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 es-
tablishment of related employment projects to address un-
employment conditions in economically depressed areas, the 
Bureau of Indian Affairs and the Service shall give priority 
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to locating such facilities and projects on Indian lands, or 
lands in Alaska owned by any Alaska Native village, or 
village or regional corporation under the Alaska Native 
Claims Settlement Act (43 U.S.C. 1601 et seq.), or any land 
allotted to any Alaska Native, if requested 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 Organization. Top priority shall be given to In-
dian land owned by 1 or more Indian Tribes. 
‘‘(b) DEFINITION.—For purposes of this section, the 
term ‘Indian lands’ means— 
‘‘(1) all lands within the exterior boundaries of 
any reservation; and 
‘‘(2) any lands title to which is held in trust by 
the United States for the benefit of any Indian Tribe 
or individual Indian or held by any Indian Tribe or 
individual Indian subject to restriction by the United 
States against alienation. 
‘‘SEC. 313. MAINTENANCE AND IMPROVEMENT OF HEALTH 
CARE FACILITIES. 
‘‘(a) REPORT.—The Secretary shall submit to the 
President, for inclusion in the report required to be trans-
mitted to Congress under section 801, a report which identi-
fies the backlog of maintenance and repair work required 
at both Service and tribal health care facilities, including 
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177 
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 support 
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 allo-
cation for the Indian Tribe or Tribal Organization. Sup-
portable space allocation shall be defined through the health 
care facility priority system under section 301(c). 
‘‘(c) REPLACEMENT FACILITIES.—In addition to using 
maintenance and improvement funds for renovation, mod-
ernization, 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 renovation cost 
threshold shall be determined through the negotiated rule-
making process provided for under section 802. 
‘‘SEC. 314. TRIBAL MANAGEMENT OF FEDERALLY-OWNED 
QUARTERS. 
‘‘(a) RENTAL RATES.— 
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‘‘(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 pur-
suant to a contract or compact under the Indian Self- 
Determination and Education Assistance Act (25 
U.S.C. 450 et seq.) shall have the authority to estab-
lish the rental rates charged to the occupants of such 
quarters by providing notice to the Secretary of its 
election to exercise such authority. 
‘‘(2) OBJECTIVES.—In establishing rental rates 
pursuant to authority of this subsection, a Tribal 
Health Program shall endeavor to achieve the fol-
lowing objectives: 
‘‘(A) To base such rental rates on the rea-
sonable value of the quarters to the occupants 
thereof. 
‘‘(B) To generate sufficient funds to pru-
dently provide for the operation and mainte-
nance of the quarters, and subject to the discre-
tion of the Tribal Health Program, to supply re-
serve funds for capital repairs and replacement 
of the quarters. 
‘‘(3) EQUITABLE FUNDING.—Any quarters whose 
rental rates are established by a Tribal Health Pro-
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in subparagraph (A) shall make every effort to 
provide services to all eligible Indian youths re-
siding in Alaska. 
‘‘(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 to Indian children and adolescents, includ-
ing— 
‘‘(A) pretreatment assistance; 
‘‘(B) inpatient, outpatient, and aftercare 
services; 
‘‘(C) emergency care; 
‘‘(D) suicide prevention and crisis interven-
tion; and 
‘‘(E) prevention and treatment of mental 
illness and dysfunctional and self-destructive be-
havior, 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 behavioral 
health services; 
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