I 
108TH CONGRESS 
1ST SESSION H. R. 2440
To improve the implementation of the Federal responsibility for the care 
and education of Indian people by improving the services and facilities 
of Federal health programs for Indians and encouraging maximum par-
ticipation of Indians in such programs, and for other purposes. 
IN THE HOUSE OF REPRESENTATIVES 
JUNE 11, 2003
Mr. YOUNG of Alaska (for himself, Mr. HAYWORTH, Mr. RENZI, Mr. COLE, 
Mr. HUNTER, Mr. MCKEON, Mr. PALLONE, Mr. RAHALL, Mr. GEORGE 
MILLER of California, Mr. KILDEE, Mr. DINGELL, Mr. WAXMAN, Mr. 
RANGEL, 
Mr. 
CONYERS, 
Mr. 
OBERSTAR, 
Mr. 
GRIJALVA, 
Ms. 
MILLENDER-MCDONALD, Mr. FROST, Mr. KENNEDY of Rhode Island, 
Mr. FRANK of Massachusetts, Mr. FILNER, Mr. HONDA, Mr. CARSON of 
Oklahoma, Mr. ALLEN, Mr. ABERCROMBIE, Ms. LEE, Mrs. NAPOLITANO, 
Mr. FALEOMAVAEGA, Ms. MCCOLLUM, Mr. TOWNS, Mr. UDALL of New 
Mexico, Mr. UDALL of Colorado, Mr. KIND, Mr. LANTOS, Mr. INSLEE, 
Mr. STUPAK, Mr. BACA, Ms. KILPATRICK, Mrs. CHRISTENSEN, Mr. 
BLUMENAUER, and Ms. NORTON) introduced the following bill; which was 
referred to the Committee on Resources, and in addition to the Commit-
tees on Energy and Commerce, and Ways and Means, for a period to be 
subsequently determined by the Speaker, in each case for consideration 
of such provisions as fall within the jurisdiction of the committee con-
cerned 
A BILL 
To improve the implementation of the Federal responsibility 
for the care and education of Indian people by improving 
the services and facilities of Federal health programs 
for Indians and encouraging maximum participation of 
Indians in such programs, and for other purposes.
Be it enacted by the Senate and House of Representa-
tives of the United States of America in Congress assembled, 
SECTION 1. SHORT TITLE. 
This Act may be cited as the ‘‘Indian Health Care 
Improvement Act Amendments of 2003’’. 
SEC. 2. INDIAN HEALTH CARE IMPROVEMENT ACT AMEND-
ED. 
The Indian Health Care Improvement Act (25 U.S.C. 
1601 et seq.) is amended to read as follows: 
‘‘SECTION 1. SHORT TITLE; TABLE OF CONTENTS. 
‘‘(a) SHORT TITLE.—This Act may be cited as the 
‘Indian Health Care Improvement Act’. 
‘‘(b) TABLE OF CONTENTS.—The table of contents 
for this Act is as follows:
Sec. 1. Short title. 
Sec. 2. Indian Health Care Improvement Act amended. 
‘‘Sec. 1. Short title; table of contents. 
‘‘Sec. 2. Findings. 
‘‘Sec. 3. Declaration of National Indian health policy. 
‘‘Sec. 4. Definitions. 
‘‘TITLE I—INDIAN HEALTH, HUMAN RESOURCES, AND 
DEVELOPMENT 
‘‘Sec. 101. Purpose. 
‘‘Sec. 102. Health Professions Recruitment Program for Indians. 
‘‘Sec. 103. Health Professions Preparatory Scholarship Program for Indi-
ans. 
‘‘Sec. 104. Indian health professions scholarships. 
‘‘Sec. 105. American Indians into psychology program. 
‘‘Sec. 106. Funding for tribes for scholarship programs. 
‘‘Sec. 107. Indian Health Service extern programs. 
‘‘Sec. 108. Continuing education allowances. 
‘‘Sec. 109. Community Health Representative Program. 
‘‘Sec. 110. Indian Health Service Loan Repayment Program. 
‘‘Sec. 111. Scholarship and loan repayment recovery fund. 
‘‘Sec. 112. Recruitment activities. 
‘‘Sec. 113. Indian recruitment and retention program. 
‘‘Sec. 114. Advanced training and research.
‘‘Sec. 115. Quentin N. Burdick American Indians into nursing program. 
‘‘Sec. 116. Tribal cultural orientation. 
‘‘Sec. 117. Inmed program. 
‘‘Sec. 118. Health training programs of community colleges. 
‘‘Sec. 119. Retention bonus. 
‘‘Sec. 120. Nursing residency program. 
‘‘Sec. 121. Community Health Aide Program for Alaska. 
‘‘Sec. 122. Tribal health program administration. 
‘‘Sec. 123. Health professional chronic shortage demonstration programs. 
‘‘Sec. 124. Treatment of scholarships for certain purposes. 
‘‘Sec. 125. National Health Service Corps. 
‘‘Sec. 126. Substance abuse counselor educational curricula demonstration 
programs. 
‘‘Sec. 127. Mental health training and community education programs. 
‘‘Sec. 128. Designation of shortage areas. 
‘‘Sec. 129. Authorization of appropriations. 
‘‘TITLE II—HEALTH SERVICES 
‘‘Sec. 201. Indian Health Care Improvement Fund. 
‘‘Sec. 202. Catastrophic Health Emergency Fund. 
‘‘Sec. 203. Health promotion and disease prevention services. 
‘‘Sec. 204. Diabetes prevention, treatment, and control. 
‘‘Sec. 205. Shared services for long-term care. 
‘‘Sec. 206. Health services research. 
‘‘Sec. 207. Mammography and other cancer screening. 
‘‘Sec. 208. Patient travel costs. 
‘‘Sec. 209. Epidemiology centers. 
‘‘Sec. 210. Comprehensive school health education programs. 
‘‘Sec. 211. Indian Youth Program. 
‘‘Sec. 212. Prevention, control, and elimination of communicable and infec-
tious diseases. 
‘‘Sec. 213. Authority for provision of other services. 
‘‘Sec. 214. Indian women’s health care. 
‘‘Sec. 215. Environmental and nuclear health hazards. 
‘‘Sec. 216. Arizona as a contract health service delivery area. 
‘‘Sec. 216A. North Dakota as a contract health service delivery area. 
‘‘Sec. 216B. South Dakota as a contract health service delivery area. 
‘‘Sec. 217. California contract health services program. 
‘‘Sec. 218. California as a contract health service delivery area. 
‘‘Sec. 219. Contract health services for the Trenton Service Area. 
‘‘Sec. 220. Programs operated by Indian tribes and tribal organizations. 
‘‘Sec. 221. Licensing. 
‘‘Sec. 222. Notification of provision of emergency contract health services. 
‘‘Sec. 223. Prompt action on payment of claims. 
‘‘Sec. 224. Liability for payment. 
‘‘Sec. 225. Authorization of appropriations. 
‘‘TITLE III—FACILITIES 
‘‘Sec. 301. Consultation; construction and renovation of facilities; reports. 
‘‘Sec. 302. Sanitation facilities. 
‘‘Sec. 303. Preference to Indians and Indian firms. 
‘‘Sec. 304. Expenditure of nonservice funds for renovation. 
‘‘Sec. 305. Funding for the construction, expansion, and modernization of 
small ambulatory care facilities.
‘‘Sec. 306. Indian Health Care Delivery Demonstration Project. 
‘‘Sec. 307. Land transfer. 
‘‘Sec. 308. Leases, contracts, and other agreements. 
‘‘Sec. 309. Loans, loan guarantees, and loan repayment. 
‘‘Sec. 310. Tribal leasing. 
‘‘Sec. 311. Indian Health Service/tribal facilities joint venture program. 
‘‘Sec. 312. Location of facilities. 
‘‘Sec. 313. Maintenance and improvement of health care facilities. 
‘‘Sec. 314. Tribal management of federally owned quarters. 
‘‘Sec. 315. Applicability of Buy American Act requirement. 
‘‘Sec. 316. Other funding for facilities. 
‘‘Sec. 317. Authorization of appropriations. 
‘‘TITLE IV—ACCESS TO HEALTH SERVICES 
‘‘Sec. 401. Treatment of payments under Social Security Act health care 
programs. 
‘‘Sec. 402. Grants to and funding agreements with the Service, Indian 
tribes, tribal organizations, and urban Indian organiza-
tions. 
‘‘Sec. 403. Reimbursement from certain third parties of costs of health 
services. 
‘‘Sec. 404. Crediting of reimbursements. 
‘‘Sec. 405. Purchasing health care coverage. 
‘‘Sec. 406. Sharing arrangements with Federal agencies. 
‘‘Sec. 407. Payor of last resort. 
‘‘Sec. 408. Nondiscrimination in qualifications for reimbursement for serv-
ices. 
‘‘Sec. 409. Consultation. 
‘‘Sec. 410. State children’s health insurance program (SCHIP). 
‘‘Sec. 411. Social Security Act sanctions. 
‘‘Sec. 412. Cost sharing. 
‘‘Sec. 413. Treatment under medicaid managed care. 
‘‘Sec. 414. Navajo nation medicaid agency. 
‘‘Sec. 415. Authorization of appropriations. 
‘‘TITLE V—HEALTH SERVICES FOR URBAN INDIANS 
‘‘Sec. 501. Purpose. 
‘‘Sec. 502. Contracts with, and grants to, urban Indian organizations. 
‘‘Sec. 503. Contracts and grants for the provision of health care and refer-
ral services. 
‘‘Sec. 504. Contracts and grants for the determination of unmet health 
care needs. 
‘‘Sec. 505. Evaluations; renewals. 
‘‘Sec. 506. Other contract and grant requirements. 
‘‘Sec. 507. Reports and records. 
‘‘Sec. 508. Limitation on contract authority. 
‘‘Sec. 509. Facilities. 
‘‘Sec. 510. Office of Urban Indian Health. 
‘‘Sec. 511. Grants for alcohol and substance abuse-related services. 
‘‘Sec. 512. Treatment of certain demonstration projects. 
‘‘Sec. 513. Urban NIAAA transferred programs. 
‘‘Sec. 514. Consultation with urban Indian organizations. 
‘‘Sec. 515. Federal Tort Claims Act coverage. 
‘‘Sec. 516. Urban youth treatment center demonstration.
‘‘Sec. 818. Authorization of appropriations. 
Sec. 3. Soboba sanitation facilities. 
Sec. 4. Amendments to medicare program. 
Sec. 5. Amendments to medicaid program and State Children’s Health Insur-
ance Program (SCHIP).
‘‘SEC. 2. FINDINGS. 
‘‘Congress finds the following: 
‘‘(1) Federal delivery of health services and 
funding of Indian and Urban Indian Health Pro-
grams to maintain and improve the health of Indi-
ans are consonant with and required by the Federal 
Government’s historical and unique legal relation-
ship with Indians, as reflected in the Constitution, 
treaties, Federal statutes and the course of dealings 
of the United States with Indian Tribes and the 
United States’ resulting government-to-government 
relationship with Indian Tribes and trust respon-
sibilities and obligations to Indians. 
‘‘(2) From the time of European occupation 
and colonization through the 20th century, policies 
and practices of the United States caused and/or 
contributed to the severe health conditions of Indi-
ans. 
‘‘(3) Through the cession of over 400,000,000 
acres of land to the United States in exchange for 
promises, often reflected in treaties, of health care, 
Indian Tribes have secured a de facto contract which 
entitles Indians to health care in perpetuity, based
all races rate for the United States, a pneumonia 
and influenza death rate 52 percent greater, a tuber-
culosis death rate that is 650 percent greater, and 
a death rate from alcoholism that is 670 percent 
higher than that of the all races United States rate. 
‘‘SEC. 3. DECLARATION OF NATIONAL INDIAN HEALTH POL-
ICY. 
‘‘Congress hereby declares that it is the policy of this 
Nation, in fulfillment of its special trust responsibilities 
and legal obligations to Indians— 
‘‘(1) to assure the highest possible health status 
for Indians and to provide all resources necessary to 
effect that policy; 
‘‘(2) to raise the health status of Indians by the 
year 2010 to at least the levels set forth in the goals 
contained within the Healthy People 2010 or suc-
cessor objectives; 
‘‘(3) to the greatest extent possible, to allow In-
dians to set their own health care priorities and es-
tablish goals that reflect their unmet needs; 
‘‘(4) to increase the proportion of all degrees in 
the health professions and allied and associated 
health professions awarded to Indians so that the 
proportion of Indian health professionals in each
Service Area is raised to at least the level of that of 
the general population; 
‘‘(5) to require meaningful consultation with In-
dian Tribes, Tribal Organizations, and Urban Indian 
Organizations to implement this Act and the na-
tional policy of Indian self-determination; and 
‘‘(6) to provide funding for programs and facili-
ties operated by Indian Tribes and Tribal Organiza-
tions in amounts that are not less than the amounts 
provided to programs and facilities operated directly 
by the Service. 
‘‘SEC. 4. DEFINITIONS. 
‘‘For purposes of this Act: 
‘‘(1) The term ‘accredited and accessible’ means 
on or near a reservation and accredited by a na-
tional or regional organization with accrediting au-
thority. 
‘‘(2) The term ‘Area Office’ means an adminis-
trative entity including a program office, within the 
Service through which services and funds are pro-
vided to the Service Units within a defined geo-
graphic area. 
‘‘(3) The term ‘California Indians’ shall mean 
those Indians who are eligible for health services of 
the Service pursuant to section 806.
‘‘(4) The term ‘community college’ means—
‘‘(A) a tribal college or university, or 
‘‘(B) a junior or community college. 
‘‘(5) The term ‘contract health service’ means 
health services provided at the expense of the Serv-
ice or a Tribal Health Program by public or private 
medical providers or hospitals, other than the Serv-
ice Unit or the Tribal Health Program at whose ex-
pense the services are provided. 
‘‘(6) The term ‘Department’ means, unless oth-
erwise designated, the Department of Health and 
Human Services. 
‘‘(7) The term ‘Director’ means the Director of 
the Indian Health Service. 
‘‘(8) The term ‘disease prevention’ means the 
reduction, limitation, and prevention of disease and 
its complications and reduction in the consequences 
of disease, including, but not limited to—
‘‘(A) controlling—
‘‘(i) development of diabetes; 
‘‘(ii) high blood pressure; 
‘‘(iii) infectious agents; 
‘‘(iv) injuries; 
‘‘(v) occupational hazards and disabil-
ities;
‘‘(vi) sexually transmittable diseases; 
and 
‘‘(vii) toxic agents; and 
‘‘(B) providing—
‘‘(i) fluoridation of water; and 
‘‘(ii) immunizations. 
‘‘(9) The term ‘fund’ or ‘funding’ means the 
transfer of moneys from the Department to any eli-
gible entity or individual under this Act by any legal 
means, including Funding Agreements, contracts, 
memoranda of understanding, contracts pursuant to 
section 23 of the Act of April 20, 1908 (25 U.S.C. 
47; popularly known as the ‘Buy Indian Act’), or 
otherwise. 
‘‘(10) The term ‘Funding Agreement’ means 
any agreement to transfer funds for the planning, 
conduct, and administration of programs, services, 
functions, and activities to Indian Tribes and Tribal 
Organizations from the Secretary under the Indian 
Self-Determination and Education Assistance Act. 
‘‘(11) The term ‘health profession’ means 
allopathic medicine, family medicine, internal medi-
cine, pediatrics, geriatric medicine, obstetrics and 
gynecology, podiatric medicine, nursing, public 
health nursing, dentistry, psychiatry, osteopathy, op-
tometry, pharmacy, psychology, public health, social 
work, marriage and family therapy, chiropractic 
medicine, environmental health and engineering, al-
lied health professions, and any other health profes-
sion. 
‘‘(12) The term ‘health promotion’ means—
‘‘(A) fostering social, economic, environ-
mental, and personal factors conducive to 
health, including raising public awareness about 
health matters and enabling the people to cope 
with health problems by increasing their knowl-
edge and providing them with valid information; 
‘‘(B) encouraging adequate and appro-
priate diet, exercise, and sleep; 
‘‘(C) promoting education and work in con-
formity with physical and mental capacity; 
‘‘(D) making available suitable housing, 
safe water, and sanitary facilities; 
‘‘(E) improving the physical, economic, cul-
tural, psychological, and social environment; 
‘‘(F) promoting adequate opportunity for 
spiritual, religious, and Traditional Health Care 
Practices; and 
‘‘(G) providing adequate and appropriate 
programs, including, but not limited to—
‘‘(i) abuse prevention (mental and 
physical); 
‘‘(ii) community health; 
‘‘(iii) community safety; 
‘‘(iv) consumer health education; 
‘‘(v) diet and nutrition; 
‘‘(vi) immunization and other preven-
tion of communicable diseases, including 
HIV/AIDS; 
‘‘(vii) environmental health; 
‘‘(viii) exercise and physical fitness; 
‘‘(ix) avoidance of fetal alcohol dis-
orders; 
‘‘(x) first aid and CPR education; 
‘‘(xi) human growth and development; 
‘‘(xii) injury prevention and personal 
safety; 
‘‘(xiii) mental health; 
‘‘(xiv) personal health and wellness 
practices; 
‘‘(xv) personal capacity building; 
‘‘(xvi) prenatal, pregnancy, and infant 
care; 
‘‘(xvii) psychological well-being;
‘‘(xviii) reproductive health and family 
planning; 
‘‘(xix) safe and adequate water; 
‘‘(xx) safe housing; 
‘‘(xxi) safe work environments; 
‘‘(xxii) stress control; 
‘‘(xxiii) substance abuse; 
‘‘(xxiv) sanitary facilities; 
‘‘(xxv) tobacco use cessation and re-
duction; 
‘‘(xxvi) violence prevention; and 
‘‘(xxvii) such other activities identified 
by the Service, a Tribal Health Program, 
or an Urban Indian Organization, to pro-
mote achievement of any of the objectives 
described in section 3(2). 
‘‘(13) The term ‘Indian’ shall have the meaning 
given that term in the Indian Self-Determination 
and Education Assistance Act. 
‘‘(14) The term ‘Indian Health Program’ means 
the following—
‘‘(A) any health program administered di-
rectly by the Service; 
‘‘(B) any Tribal Health Program; or
‘‘(C) any Indian Tribe or Tribal Organiza-
tion to which the Secretary provides funding 
pursuant to section 23 of the Act of April 30, 
1908 (25 U.S.C. 47), popularly known as the 
‘Buy Indian Act’. 
‘‘(15) The term ‘Indian Tribe’ shall have the 
meaning given that term in the Indian Self-Deter-
mination and Education Assistance Act. 
‘‘(16) The term ‘junior or community college’ 
has the meaning given to such term by section 
312(e) of the Higher Education Act of 1965 (20 
U.S.C. 1058(e)). 
‘‘(17) The term ‘reservation’ means any feder-
ally recognized Indian Tribe’s reservation, Pueblo, or 
colony, including former reservations in Oklahoma, 
Indian allotments, and Alaska Native Regions estab-
lished pursuant to the Alaska Native Claims Settle-
ment Act (25 U.S.C. 1601 et seq.). 
‘‘(18) The term ‘Secretary’, unless otherwise 
designated, means the Secretary of Health and 
Human Services. 
‘‘(19) The term ‘Service’ means the Indian 
Health Service. 
‘‘(20) The term ‘Service Area’ means the geo-
graphical area served by each Area Office.
‘‘(21) The term ‘Service Unit’ means an admin-
istrative entity of the Service, or a Tribal Health 
Program through which services are provided, di-
rectly or by contract, to eligible Indians within a de-
fined geographic area. 
‘‘(22) The term ‘Traditional Health Care Prac-
tices’ means the application by Native healing prac-
titioners of the Native healing sciences (as opposed 
or in contradistinction to Western healing sciences) 
which embody the influences or forces of innate 
Tribal discovery, history, description, explanation 
and knowledge of the states of wellness and illness 
and which call upon these influences or forces, in-
cluding physical, mental, and spiritual forces in the 
promotion, restoration, preservation, and mainte-
nance of health, well-being, and life’s harmony. 
‘‘(23) The term ‘tribal college or university’ 
shall have the meaning given that term in section 
316(b)(3) of the Higher Education Act (20 U.S.C. 
1059c(b)(3)). 
‘‘(24) The term ‘Tribal Health Program’ means 
an Indian Tribe or Tribal Organization that oper-
ates any health program, service, function, activity, 
or facility funded, in whole or part, by the Service 
through, or provided for in, a Funding Agreement
with the Service under the Indian Self-Determina-
tion and Education Assistance Act. 
‘‘(25) The term ‘Tribal Organization’ shall have 
the meaning given that term in the Indian Self-De-
termination and Education Assistance Act. 
‘‘(26) The term ‘Urban Center’ means any com-
munity which has a sufficient Urban Indian popu-
lation with unmet health needs to warrant assistance 
under title V, as determined by the Secretary. 
‘‘(27) The term ‘Urban Indian’ means any indi-
vidual who resides in an Urban Center and who 
meets 1 or more of the following criteria: 
‘‘(A) Irrespective of whether the individual 
lives on or near a reservation, the individual is 
a member of a tribe, band, or other organized 
group of Indians, including those tribes, bands, 
or groups terminated since 1940 and those 
tribes, bands, or groups that are recognized by 
the States in which they reside, or who is a de-
scendant in the first or second degree of any 
such member. 
‘‘(B) The individual is an Eskimo, Aleut, 
or other Alaskan Native.
‘‘(C) The individual is considered by the 
Secretary of the Interior to be an Indian for 
any purpose. 
‘‘(D) The individual is determined to be an 
Indian under regulations promulgated by the 
Secretary. 
‘‘(28) The term ‘Urban Indian Organization’ 
means a nonprofit corporate body that (A) is situ-
ated in an Urban Center; (B) is governed by an 
Urban Indian-controlled board of directors; (C) pro-
vides for the participation of all interested Indian 
groups and individuals; and (D) is capable of legally 
cooperating with other public and private entities for 
the purpose of performing the activities described in 
section 503(a).
‘‘TITLE 
I—INDIAN 
HEALTH, 
HUMAN RESOURCES, AND DE-
VELOPMENT 
‘‘SEC. 101. PURPOSE. 
‘‘The purpose of this title is to increase, to the max-
imum extent feasible, the number of Indians entering the 
health professions and providing health services, and to 
assure an optimum supply of health professionals to the 
Indian Health Programs and Urban Indian Organizations 
involved in the provision of health services to Indians.
‘‘SEC. 102. HEALTH PROFESSIONS RECRUITMENT PROGRAM 
FOR INDIANS. 
‘‘(a) IN GENERAL.—The Secretary, acting through 
the Service, shall make funds available to public or non-
profit private health entities or Tribal Health Programs 
to assist such entities in meeting the costs of—
‘‘(1) identifying Indians with a potential for 
education or training in the health professions and 
encouraging and assisting them—
‘‘(A) to enroll in courses of study in such 
health professions; or 
‘‘(B) if they are not qualified to enroll in 
any such courses of study, to undertake such 
postsecondary education or training as may be 
required to qualify them for enrollment; 
‘‘(2) publicizing existing sources of financial aid 
available to Indians enrolled in any course of study 
referred to in paragraph (1) or who are undertaking 
training necessary to qualify them to enroll in any 
such course of study; or 
‘‘(3) establishing other programs which the Sec-
retary determines will enhance and facilitate the en-
rollment of Indians in, and the subsequent pursuit 
and completion by them of, courses of study referred 
to in paragraph (1). 
‘‘(b) FUNDING.—
‘‘(1) APPLICATION.—Funds under this section 
shall require that an application has been submitted 
to, and approved by, the Secretary. Such application 
shall be in such form, submitted in such manner, 
and contain such information, as the Secretary shall 
by regulation prescribe pursuant to this Act. The 
Secretary shall give a preference to applications sub-
mitted by Tribal Health Programs or Urban Indian 
Organizations. 
‘‘(2) AMOUNT
OF
FUNDS; 
PAYMENT.—The 
amount of funds provided to entities under this sec-
tion shall be determined by the Secretary. Payments 
pursuant to this section may be made in advance or 
by way of reimbursement, and at such intervals and 
on such conditions as provided for in regulations 
issued pursuant to this Act. To the extent not other-
wise prohibited by law, funding commitments shall 
be for 3 years, as provided in regulations published 
pursuant to this Act. 
‘‘(c) DEFINITION OF INDIAN.—For purposes of this 
section and sections 103 and 104, the term ‘Indian’ shall, 
in addition to the meaning given that term in section 4, 
also mean any individual who is an Urban Indian.
‘‘(c) OTHER CONDITIONS.—Scholarships under this 
section—
‘‘(1) may cover costs of tuition, books, trans-
portation, board, and other necessary related ex-
penses of a recipient while attending school; 
‘‘(2) shall not be denied solely on the basis of 
the applicant’s scholastic achievement if such appli-
cant has been admitted to, or maintained good 
standing at, an accredited institution; and 
‘‘(3) shall not be denied solely by reason of such 
applicant’s eligibility for assistance or benefits under 
any other Federal program. 
‘‘SEC. 104. INDIAN HEALTH PROFESSIONS SCHOLARSHIPS. 
‘‘(a) IN GENERAL.—
‘‘(1) 
AUTHORITY.—The 
Secretary, 
acting 
through the Service, shall make scholarships to Indi-
ans who are enrolled full or part time in accredited 
schools pursuing courses of study in the health pro-
fessions. Such scholarships shall be designated In-
dian Health Scholarships and shall be made in ac-
cordance with section 338A of the Public Health 
Services Act (42 U.S.C. 2541), except as provided in 
subsection (b) of this section. 
‘‘(2) ALLOCATION
BY
FORMULA.—Except as 
provided in paragraph (3), the funding authorized
by this section shall be allocated by Service Area by 
a formula developed in consultation with Indian 
Tribes, Tribal Organizations, and Urban Indian Or-
ganizations. Such formula shall consider the human 
resource development needs in each Service Area. 
‘‘(3) CONTINUITY OF PRIOR SCHOLARSHIPS.—
Paragraph (2) shall not apply with respect to indi-
vidual recipients of scholarships provided under this 
section (as in effect 1 day prior to the date of the 
enactment of the Indian Health Care Improvement 
Act Amendments of 2003) until such time as the in-
dividual completes the course of study that is sup-
ported through such scholarship. 
‘‘(4) CERTAIN DELEGATION NOT ALLOWED.—
The administration of this section shall be a respon-
sibility of the Director and shall not be delegated in 
a Funding Agreement. 
‘‘(b) ACTIVE DUTY SERVICE OBLIGATION.—
‘‘(1) OBLIGATION MET.—The active duty serv-
ice obligation under a written contract with the Sec-
retary under section 338A of the Public Health 
Service Act (42 U.S.C. 254l) that an Indian has en-
tered into under that section shall, if that individual 
is a recipient of an Indian Health Scholarship, be 
met in full-time practice on an equivalent year-for-
year obligation, by service in one or more of the fol-
lowing: 
‘‘(A) In an Indian Health Program. 
‘‘(B) In a program assisted under title V. 
‘‘(C) In the private practice of the applica-
ble profession if, as determined by the Sec-
retary, in accordance with guidelines promul-
gated by the Secretary, such practice is situated 
in a physician or other health professional 
shortage area and addresses the health care 
needs of a substantial number of Indians. 
‘‘(2) OBLIGATION DEFERRED.—At the request 
of any individual who has entered into a contract re-
ferred to in paragraph (1) and who receives a degree 
in medicine (including osteopathic or allopathic med-
icine), dentistry, optometry, podiatry, or pharmacy, 
the Secretary shall defer the active duty service obli-
gation of that individual under that contract, in 
order that such individual may complete any intern-
ship, residency, or other advanced clinical training 
that is required for the practice of that health pro-
fession, for an appropriate period (in years, as deter-
mined by the Secretary), subject to the following 
conditions:
‘‘(A) No period of internship, residency, or 
other advanced clinical training shall be counted 
as satisfying any period of obligated service 
under this subsection. 
‘‘(B) The active duty service obligation of 
that individual shall commence not later than 
90 days after the completion of that advanced 
clinical training (or by a date specified by the 
Secretary). 
‘‘(C) The active duty service obligation will 
be served in the health profession of that indi-
vidual in a manner consistent with paragraph 
(1). 
‘‘(D) A recipient of a scholarship under 
this section may, at the election of the recipient, 
meet the active duty service obligation described 
in paragraph (1) by service in a program speci-
fied under that paragraph that—
‘‘(i) is located on the reservation of 
the Indian Tribe in which the recipient is 
enrolled; or 
‘‘(ii) serves the Indian Tribe in which 
the recipient is enrolled. 
‘‘(3) PRIORITY WHEN MAKING ASSIGNMENTS.—
Subject to paragraph (2), the Secretary, in making
assignments of Indian Health Scholarship recipients 
required to meet the active duty service obligation 
described in paragraph (1), shall give priority to as-
signing individuals to service in those programs 
specified in paragraph (1) that have a need for 
health professionals to provide health care services 
as a result of individuals having breached contracts 
entered into under this section. 
‘‘(c) PART-TIME STUDENTS.—In the case of an indi-
vidual receiving a scholarship under this section who is 
enrolled part time in an approved course of study—
‘‘(1) such scholarship shall be for a period of 
years not to exceed the part-time equivalent of 4 
years, as determined by the Area Office; 
‘‘(2) the period of obligated service described in 
subsection (b)(1) shall be equal to the greater of—
‘‘(A) the part-time equivalent of 1 year for 
each year for which the individual was provided 
a scholarship (as determined by the Area Of-
fice); or 
‘‘(B) 2 years; and 
‘‘(3) the amount of the monthly stipend speci-
fied in section 338A(g)(1)(B) of the Public Health 
Service Act (42 U.S.C. 254l(g)(1)(B)) shall be re-
duced pro rata (as determined by the Secretary)
based on the number of hours such student is en-
rolled. 
‘‘(d) BREACH OF CONTRACT.—
‘‘(1) SPECIFIED
BREACHES.—An individual 
shall be liable to the United States for the amount 
which has been paid to the individual, or on behalf 
of the individual, under a contract entered into with 
the Secretary under this section on or after the date 
of the enactment of the Indian Health Care Im-
provement Act Amendments of 2003 if that indi-
vidual—
‘‘(A) fails to maintain an acceptable level 
of academic standing in the educational institu-
tion in which he or she is enrolled (such level 
determined by the educational institution under 
regulations of the Secretary); 
‘‘(B) is dismissed from such educational 
institution for disciplinary reasons; 
‘‘(C) voluntarily terminates the training in 
such an educational institution for which he or 
she is provided a scholarship under such con-
tract before the completion of such training; or 
‘‘(D) fails to accept payment, or instructs 
the educational institution in which he or she is 
enrolled not to accept payment, in whole or in
part, of a scholarship under such contract, in 
lieu of any service obligation arising under such 
contract. 
‘‘(2) OTHER BREACHES.—If for any reason not 
specified in paragraph (1) an individual breaches a 
written contract by failing either to begin such indi-
vidual’s service obligation required under such con-
tract or to complete such service obligation, the 
United States shall be entitled to recover from the 
individual an amount determined in accordance with 
the formula specified in subsection (l) of section 110 
in the manner provided for in such subsection. 
‘‘(3) CANCELLATION UPON DEATH OF RECIPI-
ENT.—Upon the death of an individual who receives 
an Indian Health Scholarship, any outstanding obli-
gation of that individual for service or payment that 
relates to that scholarship shall be canceled. 
‘‘(4) WAIVERS
AND
SUSPENSIONS.—The Sec-
retary shall provide for the partial or total waiver or 
suspension of any obligation of service or payment of 
a recipient of an Indian Health Scholarship if the 
Secretary, in consultation with the Area Office, In-
dian Tribes, Tribal Organizations, and Urban Indian 
Organizations, determines that—
‘‘(A) it is not possible for the recipient to 
meet that obligation or make that payment; 
‘‘(B) requiring that recipient to meet that 
obligation or make that payment would result 
in extreme hardship to the recipient; or 
‘‘(C) the enforcement of the requirement to 
meet the obligation or make the payment would 
be unconscionable. 
‘‘(5) EXTREME
HARDSHIP.—Notwithstanding 
any other provision of law, in any case of extreme 
hardship or for other good cause shown, the Sec-
retary may waive, in whole or in part, the right of 
the United States to recover funds made available 
under this section. 
‘‘(6) 
BANKRUPTCY.—Notwithstanding 
any 
other provision of law, with respect to a recipient of 
an Indian Health Scholarship, no obligation for pay-
ment may be released by a discharge in bankruptcy 
under title 11, United States Code, unless that dis-
charge is granted after the expiration of the 5-year 
period beginning on the initial date on which that 
payment is due, and only if the bankruptcy court 
finds that the nondischarge of the obligation would 
be unconscionable.
‘‘SEC. 105. AMERICAN INDIANS INTO PSYCHOLOGY PRO-
GRAM. 
‘‘(a) GRANTS AUTHORIZED.—The Secretary, acting 
through the Service, shall provide funding grants to at 
least 3 colleges and universities for the purpose of devel-
oping and maintaining Indian psychology career recruit-
ment programs as a means of encouraging Indians to 
enter the mental health field. These programs shall be lo-
cated at various locations throughout the country to maxi-
mize their availability to Indian students and new pro-
grams shall be established in different locations from time 
to time. 
‘‘(b) QUENTIN N. BURDICK PROGRAM GRANT.—The 
Secretary shall provide a grant authorized under sub-
section (a) to develop and maintain a program at the Uni-
versity of North Dakota to be known as the ‘Quentin N. 
Burdick American Indians Into Psychology Program’. 
Such program shall, to the maximum extent feasible, co-
ordinate with the Quentin N. Burdick Indian Health Pro-
grams authorized under section 117(b), the Quentin N. 
Burdick American Indians Into Nursing Program author-
ized under section 115(e), and existing university research 
and communications networks. 
‘‘(c) REGULATIONS.—The Secretary shall issue regu-
lations pursuant to this Act for the competitive awarding 
of funds provided under this section.
‘‘(d) CONDITIONS OF GRANT.—Applicants under this 
section shall agree to provide a program which, at a min-
imum—
‘‘(1) provides outreach and recruitment for 
health professions to Indian communities including 
elementary, secondary, and accredited and accessible 
community colleges that will be served by the pro-
gram; 
‘‘(2) incorporates a program advisory board 
comprised of representatives from the tribes and 
communities that will be served by the program; 
‘‘(3) provides summer enrichment programs to 
expose Indian students to the various fields of psy-
chology through research, clinical, and experimental 
activities; 
‘‘(4) provides stipends to undergraduate and 
graduate students to pursue a career in psychology; 
‘‘(5) develops affiliation agreements with tribal 
colleges and universities, the Service, university af-
filiated programs, and other appropriate accredited 
and accessible entities to enhance the education of 
Indian students; 
‘‘(6) to the maximum extent feasible, uses exist-
ing university tutoring, counseling, and student sup-
port services; and
‘‘(7) to the maximum extent feasible, employs 
qualified Indians in the program. 
‘‘(e) ACTIVE DUTY SERVICE REQUIREMENT.—The 
active duty service obligation prescribed under section 
338C of the Public Health Service Act (42 U.S.C. 254m) 
shall be met by each graduate who receives a stipend de-
scribed in subsection (d)(4) that is funded under this sec-
tion. Such obligation shall be met by service—
‘‘(1) in an Indian Health Program; 
‘‘(2) in a program assisted under title V; or 
‘‘(3) in the private practice of psychology if, as 
determined by the Secretary, in accordance with 
guidelines promulgated by the Secretary, such prac-
tice is situated in a physician or other health profes-
sional shortage area and addresses the health care 
needs of a substantial number of Indians. 
‘‘SEC. 106. FUNDING FOR TRIBES FOR SCHOLARSHIP PRO-
GRAMS. 
‘‘(a) IN GENERAL.—
‘‘(1) FUNDING
AUTHORIZED.—The Secretary, 
acting through the Service, shall make funds avail-
able to Tribal Health Programs for the purpose of 
assisting such Tribal Health Programs in educating 
Indians to serve as health professionals in Indian 
communities.
‘‘(2) AMOUNT.—Amounts available under para-
graph (1) for any fiscal year shall not exceed 5 per-
cent of the amounts available for each fiscal year for 
Indian Health Scholarships under section 104. 
‘‘(3) APPLICATION.—An application for funds 
under paragraph (1) shall be in such form and con-
tain such agreements, assurances, and information 
as consistent with this section. 
‘‘(b) REQUIREMENTS.—
‘‘(1) IN GENERAL.—A Tribal Health Program 
receiving funds under subsection (a) shall provide 
scholarships to Indians in accordance with the re-
quirements of this section. 
‘‘(2) COSTS.—With respect to costs of providing 
any scholarship pursuant to subsection (a)—
‘‘(A) 80 percent of the costs of the scholar-
ship shall be paid from the funds made avail-
able pursuant to subsection (a)(1) provided to 
the Tribal Health Program; and 
‘‘(B) 20 percent of such costs may be paid 
from any other source of funds. 
‘‘(c) COURSE OF STUDY.—A Tribal Health Program 
shall provide scholarships under this section only to Indi-
ans enrolled or accepted for enrollment in a course of
study (approved by the Secretary) in one of the health pro-
fessions contemplated by this Act. 
‘‘(d) CONTRACT.—In providing scholarships under 
subsection (b), the Secretary and the Tribal Health Pro-
gram shall enter into a written contract with each recipi-
ent of such scholarship. Such contract shall—
‘‘(1) obligate such recipient to provide service in 
an Indian Health Program or Urban Indian Organi-
zation, in the same Service Area where the Tribal 
Health Program providing the scholarship is located, 
for—
‘‘(A) a number of years for which the 
scholarship is provided (or the part-time equiva-
lent thereof, as determined by the Secretary), 
or for a period of 2 years, whichever period is 
greater; or 
‘‘(B) such greater period of time as the re-
cipient and the Tribal Health Program may 
agree; 
‘‘(2) provide that the amount of the scholar-
ship—
‘‘(A) may only be expended for—
‘‘(i) tuition expenses, other reasonable 
educational expenses, and reasonable living
expenses incurred in attendance at the 
educational institution; and 
‘‘(ii) payment to the recipient of a 
monthly stipend of not more than the 
amount authorized by section 338(g)(1)(B) 
of the Public Health Service Act (42 
U.S.C. 254m(g)(1)(B)), such amount to be 
reduced pro rata (as determined by the 
Secretary) based on the number of hours 
such student is enrolled; and may not ex-
ceed, for any year of attendance for which 
the scholarship is provided, the total 
amount required for the year for the pur-
poses authorized in this clause; and 
‘‘(B) may not exceed, for any year of at-
tendance for which the scholarship is provided, 
the total amount required for the year for the 
purposes authorized in subparagraph (A); 
‘‘(3) require the recipient of such scholarship to 
maintain an acceptable level of academic standing as 
determined by the educational institution in accord-
ance with regulations issued pursuant to this Act; 
and
‘‘(4) require the recipient of such scholarship to 
meet the educational and licensure requirements ap-
propriate to each health profession. 
‘‘(e) BREACH OF CONTRACT.—
‘‘(1) SPECIFIC BREACHES.—An individual who 
has entered into a written contract with the Sec-
retary and a Tribal Health Program under sub-
section (d) shall be liable to the United States for 
the Federal share of the amount which has been 
paid to him or her, or on his or her behalf, under 
the contract if that individual—
‘‘(A) fails to maintain an acceptable level 
of academic standing in the educational institu-
tion in which he or she is enrolled (such level 
as determined by the educational institution 
under regulations of the Secretary); 
‘‘(B) is dismissed from such educational 
institution for disciplinary reasons; 
‘‘(C) voluntarily terminates the training in 
such an educational institution for which he or 
she is provided a scholarship under such con-
tract before the completion of such training; or 
‘‘(D) fails to accept payment, or instructs 
the educational institution in which he or she is 
enrolled not to accept payment, in whole or in
part, of a scholarship under such contract, in 
lieu of any service obligation arising under such 
contract. 
‘‘(2) OTHER BREACHES.—If for any reason not 
specified in paragraph (1), an individual breaches a 
written contract by failing to either begin such indi-
vidual’s service obligation required under such con-
tract or to complete such service obligation, the 
United States shall be entitled to recover from the 
individual an amount determined in accordance with 
the formula specified in subsection (l) of section 110 
in the manner provided for in such subsection. 
‘‘(3) CANCELLATION UPON DEATH OF RECIPI-
ENT.—Upon the death of an individual who receives 
an Indian Health Scholarship, any outstanding obli-
gation of that individual for service or payment that 
relates to that scholarship shall be canceled. 
‘‘(4) INFORMATION.—The Secretary may carry 
out this subsection on the basis of information re-
ceived from Tribal Health Programs involved or on 
the basis of information collected through such other 
means as the Secretary deems appropriate. 
‘‘(f) RELATION TO SOCIAL SECURITY ACT.—The re-
cipient of a scholarship under this section shall agree, in
providing health care pursuant to the requirements here-
in—
‘‘(1) not to discriminate against an individual 
seeking care on the basis of the ability of the indi-
vidual to pay for such care or on the basis that pay-
ment for such care will be made pursuant to a pro-
gram established in title XVIII of the Social Secu-
rity Act or pursuant to the programs established in 
title XIX or title XXI of such Act; and 
‘‘(2) to accept assignment under section 
1842(b)(3)(B)(ii) of the Social Security Act for all 
services for which payment may be made under part 
B of title XVIII of such Act, and to enter into an 
appropriate agreement with the State agency that 
administers the State plan for medical assistance 
under title XIX, or the State child health plan under 
title XXI, of such Act to provide service to individ-
uals entitled to medical assistance or child health as-
sistance, respectively, under the plan. 
‘‘(g) CONTINUANCE OF FUNDING.—The Secretary 
shall make payments under this section to a Tribal Health 
Program for any fiscal year subsequent to the first fiscal 
year of such payments unless the Secretary determines 
that, for the immediately preceding fiscal year, the Tribal
Health Program has not complied with the requirements 
of this section. 
‘‘SEC. 107. INDIAN HEALTH SERVICE EXTERN PROGRAMS. 
‘‘(a) EMPLOYMENT PREFERENCE.—Any individual 
who receives a scholarship pursuant to sections 104 or 106 
shall be given preference for employment in the Service, 
or may be employed by a Tribal Health Program or an 
Urban Indian Organization, or other agencies of the De-
partment as available, during any nonacademic period of 
the year. 
‘‘(b) NOT COUNTED TOWARD ACTIVE DUTY SERVICE 
OBLIGATION.—Periods of employment pursuant to this 
subsection shall not be counted in determining fulfillment 
of the service obligation incurred as a condition of the 
scholarship. 
‘‘(c) TIMING; LENGTH OF EMPLOYMENT.—Any indi-
vidual enrolled in a program, including a high school pro-
gram, authorized under section 102(a) may be employed 
by the Service or by a Tribal Health Program or an Urban 
Indian Organization during any nonacademic period of the 
year. Any such employment shall not exceed 120 days dur-
ing any calendar year. 
‘‘(d) NONAPPLICABILITY
OF
COMPETITIVE
PER-
SONNEL SYSTEM.—Any employment pursuant to this sec-
tion shall be made without regard to any competitive per-
sonnel system or agency personnel limitation and to a po-
sition which will enable the individual so employed to re-
ceive practical experience in the health profession in which 
he or she is engaged in study. Any individual so employed 
shall receive payment for his or her services comparable 
to the salary he or she would receive if he or she were 
employed in the competitive system. Any individual so em-
ployed shall not be counted against any employment ceil-
ing affecting the Service or the Department. 
‘‘SEC. 108. CONTINUING EDUCATION ALLOWANCES. 
‘‘In order to encourage health professionals, including 
community health representatives and emergency medical 
technicians, to join or continue in an Indian Health Pro-
gram or an Urban Indian Organization and to provide 
their services in the rural and remote areas where a sig-
nificant portion of Indians reside, the Secretary, acting 
through the Service Area, may provide allowances to 
health professionals employed in an Indian Health Pro-
gram or an Urban Indian Organization to enable them 
for a period of time each year prescribed by regulation 
of the Secretary to take leave of their duty stations for 
professional consultation and refresher training courses.
‘‘SEC. 109. COMMUNITY HEALTH REPRESENTATIVE PRO-
GRAM. 
‘‘(a) IN GENERAL.—Under the authority of the Act 
of November 2, 1921 (25 U.S.C. 13; popularly known as 
the Snyder Act), the Secretary, acting through the Serv-
ice, shall maintain a Community Health Representative 
Program under which Indian Health Programs—
‘‘(1) provide for the training of Indians as com-
munity health representatives; and 
‘‘(2) use such community health representatives 
in the provision of health care, health promotion, 
and disease prevention services to Indian commu-
nities. 
‘‘(b) DUTIES.—The Community Health Representa-
tive Program of the Service, shall—
‘‘(1) provide a high standard of training for 
community health representatives to ensure that the 
community health representatives provide quality 
health care, health promotion, and disease preven-
tion services to the Indian communities served by 
the Program; 
‘‘(2) in order to provide such training, develop 
and maintain a curriculum that—
‘‘(A) combines education in the theory of 
health care with supervised practical experience 
in the provision of health care; and
‘‘(B) provides instruction and practical ex-
perience in health promotion and disease pre-
vention activities, with appropriate consider-
ation given to lifestyle factors that have an im-
pact on Indian health status, such as alco-
holism, family dysfunction, and poverty; 
‘‘(3) maintain a system which identifies the 
needs of community health representatives for con-
tinuing education in health care, health promotion, 
and disease prevention and develop programs that 
meet the needs for continuing education; 
‘‘(4) maintain a system that provides close su-
pervision of Community Health Representatives; 
‘‘(5) maintain a system under which the work 
of Community Health Representatives is reviewed 
and evaluated; and 
‘‘(6) promote Traditional Health Care Practices 
of the Indian Tribes served consistent with the Serv-
ice standards for the provision of health care, health 
promotion, and disease prevention. 
‘‘SEC. 110. INDIAN HEALTH SERVICE LOAN REPAYMENT 
PROGRAM. 
‘‘(a) 
ESTABLISHMENT.—The 
Secretary, 
acting 
through the Service, shall establish and administer a pro-
gram to be known as the Service Loan Repayment Pro-
gram (hereinafter referred to as the ‘Loan Repayment 
Program’) in order to ensure an adequate supply of 
trained health professionals necessary to maintain accredi-
tation of, and provide health care services to Indians 
through, Indian Health Programs and Urban Indian Or-
ganizations. 
‘‘(b) ELIGIBLE INDIVIDUALS.—To be eligible to par-
ticipate in the Loan Repayment Program, an individual 
must—
‘‘(1)(A) be enrolled—
‘‘(i) in a course of study or program in an 
accredited educational institution (as deter-
mined 
by 
the 
Secretary 
under 
section 
338B(b)(1)(c)(i) of the Public Health Service 
Act (42 U.S.C. 254l–1(b)(1)(c)(i))) and be 
scheduled to complete such course of study in 
the same year such individual applies to partici-
pate in such program; or 
‘‘(ii) in an approved graduate training pro-
gram in a health profession; or 
‘‘(B) have—
‘‘(i) a degree in a health profession; and 
‘‘(ii) a license to practice a health profes-
sion;
‘‘(2)(A) be eligible for, or hold, an appointment 
as a commissioned officer in the Regular or Reserve 
Corps of the Public Health Service; 
‘‘(B) be eligible for selection for civilian service 
in the Regular or Reserve Corps of the Public 
Health Service; 
‘‘(C) meet the professional standards for civil 
service employment in the Service; or 
‘‘(D) be employed in an Indian Health Program 
or Urban Indian Organization without a service obli-
gation; and 
‘‘(3) submit to the Secretary an application for 
a contract described in subsection (e). 
‘‘(c) APPLICATION.—
‘‘(1) INFORMATION
TO
BE
INCLUDED
WITH 
FORMS.—In disseminating application forms and 
contract forms to individuals desiring to participate 
in the Loan Repayment Program, the Secretary 
shall include with such forms a fair summary of the 
rights and liabilities of an individual whose applica-
tion is approved (and whose contract is accepted) by 
the Secretary, including in the summary a clear ex-
planation of the damages to which the United States 
is entitled under subsection (l) in the case of the in-
dividual’s breach of contract. The Secretary shall
provide such individuals with sufficient information 
regarding the advantages and disadvantages of serv-
ice as a commissioned officer in the Regular or Re-
serve Corps of the Public Health Service or a civil-
ian employee of the Service to enable the individual 
to make a decision on an informed basis. 
‘‘(2) CLEAR LANGUAGE.—The application form, 
contract form, and all other information furnished 
by the Secretary under this section shall be written 
in a manner calculated to be understood by the aver-
age individual applying to participate in the Loan 
Repayment Program. 
‘‘(3) TIMELY
AVAILABILITY
OF
FORMS.—The 
Secretary shall make such application forms, con-
tract forms, and other information available to indi-
viduals desiring to participate in the Loan Repay-
ment Program on a date sufficiently early to ensure 
that such individuals have adequate time to carefully 
review and evaluate such forms and information. 
‘‘(d) PRIORITIES.—
‘‘(1) LIST.—Consistent with subsection (k), the 
Secretary shall annually—
‘‘(A) identify the positions in each Indian 
Health Program or Urban Indian Organization 
for which there is a need or a vacancy; and
‘‘(B) rank those positions in order of pri-
ority. 
‘‘(2) APPROVALS.—Notwithstanding the pri-
ority determined under paragraph (1), the Secretary, 
in determining which applications under the Loan 
Repayment Program to approve (and which con-
tracts to accept), shall—
‘‘(A) give first priority to applications 
made by individual Indians; and 
‘‘(B) after making determinations on all 
applications submitted by individual Indians as 
required under subparagraph (A), give priority 
to—
‘‘(i) individuals recruited through the 
efforts of a Tribal Health Program or 
Urban Indian Organization; and 
‘‘(ii) other individuals based on the 
priority rankings under paragraph (1). 
‘‘(e) RECIPIENT CONTRACTS.—
‘‘(1) CONTRACT REQUIRED.—An individual be-
comes a participant in the Loan Repayment Pro-
gram only upon the Secretary and the individual en-
tering into a written contract described in paragraph 
(2).
‘‘(2) CONTENTS
OF
CONTRACT.—The written 
contract referred to in this section between the Sec-
retary and an individual shall contain—
‘‘(A) an agreement under which—
‘‘(i) subject to subparagraph (C), the 
Secretary agrees—
‘‘(I) to pay loans on behalf of the 
individual in accordance with the pro-
visions of this section; and 
‘‘(II) to accept (subject to the 
availability of appropriated funds for 
carrying out this section) the indi-
vidual into the Service or place the in-
dividual with a Tribal Health Pro-
gram or Urban Indian Organization 
as provided in clause (ii)(III); and 
‘‘(ii) subject to subparagraph (C), the 
individual agrees—
‘‘(I) to accept loan payments on 
behalf of the individual; 
‘‘(II) in the case of an individual 
described in subsection (b)(1)—
‘‘(aa) to maintain enrollment 
in a course of study or training 
described in subsection (b)(1)(A)
until the individual completes the 
course of study or training; and 
‘‘(bb) while enrolled in such 
course of study or training, to 
maintain an acceptable level of 
academic standing (as deter-
mined under regulations of the 
Secretary by the educational in-
stitution offering such course of 
study or training); and 
‘‘(III) to serve for a time period 
(hereinafter in this section referred to 
as the ‘period of obligated service’) 
equal to 2 years or such longer period 
as the individual may agree to serve 
in the full-time clinical practice of 
such individual’s profession in an In-
dian Health Program or Urban In-
dian Organization to which the indi-
vidual may be assigned by the Sec-
retary; 
‘‘(B) a provision permitting the Secretary 
to extend for such longer additional periods, as 
the individual may agree to, the period of obli-
gated service agreed to by the individual under 
subparagraph (A)(ii)(III); 
‘‘(C) a provision that any financial obliga-
tion of the United States arising out of a con-
tract entered into under this section and any 
obligation of the individual which is conditioned 
thereon is contingent upon funds being appro-
priated for loan repayments under this section; 
‘‘(D) a statement of the damages to which 
the United States is entitled under subsection 
(l) for the individual’s breach of the contract; 
and 
‘‘(E) such other statements of the rights 
and liabilities of the Secretary and of the indi-
vidual, not inconsistent with this section. 
‘‘(f) DEADLINE FOR DECISION ON APPLICATION.—
The Secretary shall provide written notice to an individual 
within 21 days on—
‘‘(1) the Secretary’s approving, under sub-
section (e)(1), of the individual’s participation in the 
Loan Repayment Program, including extensions re-
sulting in an aggregate period of obligated service in 
excess of 4 years; or 
‘‘(2) the Secretary’s disapproving an individ-
ual’s participation in such Program.
‘‘(g) PAYMENTS.—
‘‘(1) IN GENERAL.—A loan repayment provided 
for an individual under a written contract under the 
Loan Repayment Program shall consist of payment, 
in accordance with paragraph (2), on behalf of the 
individual of the principal, interest, and related ex-
penses on government and commercial loans received 
by the individual regarding the undergraduate or 
graduate education of the individual (or both), which 
loans were made for—
‘‘(A) tuition expenses; 
‘‘(B) all other reasonable educational ex-
penses, including fees, books, and laboratory ex-
penses, incurred by the individual; and 
‘‘(C) reasonable living expenses as deter-
mined by the Secretary. 
‘‘(2) AMOUNT.—For each year of obligated 
service that an individual contracts to serve under 
subsection (e), the Secretary may pay up to $35,000 
or an amount equal to the amount specified in sec-
tion 338B(g)(2)(A) of the Public Health Service 
Act, whichever is more, on behalf of the individual 
for loans described in paragraph (1). In making a 
determination of the amount to pay for a year of 
such service by an individual, the Secretary shall
consider the extent to which each such determina-
tion—
‘‘(A) affects the ability of the Secretary to 
maximize the number of contracts that can be 
provided under the Loan Repayment Program 
from the amounts appropriated for such con-
tracts; 
‘‘(B) provides an incentive to serve in In-
dian Health Programs and Urban Indian Orga-
nizations with the greatest shortages of health 
professionals; and 
‘‘(C) provides an incentive with respect to 
the health professional involved remaining in an 
Indian Health Program or Urban Indian Orga-
nization with such a health professional short-
age, and continuing to provide primary health 
services, after the completion of the period of 
obligated service under the Loan Repayment 
Program. 
‘‘(3) TIMING.—Any arrangement made by the 
Secretary for the making of loan repayments in ac-
cordance with this subsection shall provide that any 
repayments for a year of obligated service shall be 
made no later than the end of the fiscal year in 
which the individual completes such year of service.
‘‘(4) PAYMENT
SCHEDULE.—The Secretary 
may enter into an agreement with the holder of any 
loan for which payments are made under the Loan 
Repayment Program to establish a schedule for the 
making of such payments. 
‘‘(h) EMPLOYMENT CEILING.—Notwithstanding any 
other provision of law, individuals who have entered into 
written contracts with the Secretary under this section 
shall not be counted against any employment ceiling af-
fecting the Department while those individuals are under-
going academic training. 
‘‘(i) RECRUITMENT.—The Secretary shall conduct re-
cruiting programs for the Loan Repayment Program and 
other Service manpower programs of the Service at edu-
cational institutions training health professionals or spe-
cialists identified in subsection (a). 
‘‘(j) APPLICABILITY OF LAW.—Section 214 of the 
Public Health Service Act (42 U.S.C. 215) shall not apply 
to individuals during their period of obligated service 
under the Loan Repayment Program. 
‘‘(k) ASSIGNMENT OF INDIVIDUALS.—The Secretary, 
in assigning individuals to serve in Indian Health Pro-
grams or Urban Indian Organizations pursuant to con-
tracts entered into under this section, shall—
‘‘(1) ensure that the staffing needs of Tribal 
Health Programs and Urban Indian Organizations 
receive consideration on an equal basis with pro-
grams that are administered directly by the Service; 
and 
‘‘(2) give priority to assigning individuals to In-
dian Health Programs and Urban Indian Organiza-
tions that have a need for health professionals to 
provide health care services as a result of individuals 
having breached contracts entered into under this 
section. 
‘‘(l) BREACH OF CONTRACT.—
‘‘(1) SPECIFIC BREACHES.—An individual who 
has entered into a written contract with the Sec-
retary under this section and has not received a 
waiver under subsection (m) shall be liable, in lieu 
of any service obligation arising under such contract, 
to the United States for the amount which has been 
paid on such individual’s behalf under the contract 
if that individual—
‘‘(A) is enrolled in the final year of a 
course of study and—
‘‘(i) fails to maintain an acceptable 
level of academic standing in the edu-
cational institution in which he or she is
enrolled (such level determined by the edu-
cational institution under regulations of 
the Secretary); 
‘‘(ii) voluntarily terminates such en-
rollment; or 
‘‘(iii) is dismissed from such edu-
cational institution before completion of 
such course of study; or 
‘‘(B) is enrolled in a graduate training pro-
gram and fails to complete such training pro-
gram. 
‘‘(2) 
OTHER
BREACHES; 
FORMULA
FOR 
AMOUNT OWED.—If, for any reason not specified in 
paragraph (1), an individual breaches his or her 
written contract under this section by failing either 
to begin, or complete, such individual’s period of ob-
ligated service in accordance with subsection (e)(2), 
the United States shall be entitled to recover from 
such individual an amount to be determined in ac-
cordance with the following formula: A=3Z(t-s/t) in 
which—
‘‘(A) ‘A’ is the amount the United States 
is entitled to recover; 
‘‘(B) ‘Z’ is the sum of the amounts paid 
under this section to, or on behalf of, the indi-
vidual and the interest on such amounts which 
would be payable if, at the time the amounts 
were paid, they were loans bearing interest at 
the maximum legal prevailing rate, as deter-
mined by the Secretary of the Treasury; 
‘‘(C) ‘t’ is the total number of months in 
the individual’s period of obligated service in 
accordance with subsection (f); and 
‘‘(D) ‘s’ is the number of months of such 
period served by such individual in accordance 
with this section. 
‘‘(3) DEDUCTIONS IN MEDICARE PAYMENTS.—
Amounts not paid within such period shall be sub-
ject to collection through deductions in medicare 
payments pursuant to section 1892 of the Social Se-
curity Act. 
‘‘(4) TIME
PERIOD
FOR
REPAYMENT.—Any 
amount of damages which the United States is enti-
tled to recover under this subsection shall be paid to 
the United States within the 1-year period beginning 
on the date of the breach or such longer period be-
ginning on such date as shall be specified by the 
Secretary. 
‘‘(5) RECOVERY OF DELINQUENCY.—
‘‘(A) IN GENERAL.—If damages described 
in paragraph (4) are delinquent for 3 months, 
the Secretary shall, for the purpose of recov-
ering such damages—
‘‘(i) use collection agencies contracted 
with by the Administrator of General Serv-
ices; or 
‘‘(ii) enter into contracts for the re-
covery of such damages with collection 
agencies selected by the Secretary. 
‘‘(B) REPORT.—Each contract for recov-
ering damages pursuant to this subsection shall 
provide that the contractor will, not less than 
once each 6 months, submit to the Secretary a 
status report on the success of the contractor in 
collecting such damages. Section 3718 of title 
31, United States Code, shall apply to any such 
contract to the extent not inconsistent with this 
subsection. 
‘‘(m) WAIVER OR SUSPENSION OF OBLIGATION.—
‘‘(1) IN GENERAL.—The Secretary shall by reg-
ulation provide for the partial or total waiver or sus-
pension of any obligation of service or payment by 
an individual under the Loan Repayment Program 
whenever compliance by the individual is impossible
or would involve extreme hardship to the individual 
and if enforcement of such obligation with respect to 
any individual would be unconscionable. 
‘‘(2) CANCELED UPON DEATH.—Any obligation 
of an individual under the Loan Repayment Pro-
gram for service or payment of damages shall be 
canceled upon the death of the individual. 
‘‘(3) HARDSHIP WAIVER.—The Secretary may 
waive, in whole or in part, the rights of the United 
States to recover amounts under this section in any 
case of extreme hardship or other good cause shown, 
as determined by the Secretary. 
‘‘(4) BANKRUPTCY.—Any obligation of an indi-
vidual under the Loan Repayment Program for pay-
ment of damages may be released by a discharge in 
bankruptcy under title 11 of the United States Code 
only if such discharge is granted after the expiration 
of the 5-year period beginning on the first date that 
payment of such damages is required, and only if 
the bankruptcy court finds that nondischarge of the 
obligation would be unconscionable. 
‘‘(n) REPORT.—The Secretary shall submit to the 
President, for inclusion in each report required to be sub-
mitted to Congress under section 801, a report concerning
the previous fiscal year which sets forth by Service Area 
the following: 
‘‘(1) A list of the health professional positions 
maintained by Indian Health Programs and Urban 
Indian Organizations for which recruitment or reten-
tion is difficult. 
‘‘(2) The number of Loan Repayment Program 
applications filed with respect to each type of health 
profession. 
‘‘(3) The number of contracts described in sub-
section (e) that are entered into with respect to each 
health profession. 
‘‘(4) The amount of loan payments made under 
this section, in total and by health profession. 
‘‘(5) The number of scholarships that are pro-
vided under section 104 and 106 with respect to 
each health profession. 
‘‘(6) The amount of scholarship grants provided 
under section 104 and 106, in total and by health 
profession. 
‘‘(7) The number of providers of health care 
that will be needed by Indian Health Programs and 
Urban Indian Organizations, by location and profes-
sion, during the 3 fiscal years beginning after the 
date the report is filed.
‘‘(8) The measures the Secretary plans to take 
to fill the health professional positions maintained 
by Indian Health Programs or Urban Indian Orga-
nizations for which recruitment or retention is dif-
ficult. 
‘‘SEC. 111. SCHOLARSHIP AND LOAN REPAYMENT RECOV-
ERY FUND. 
‘‘(a) ESTABLISHMENT.—There is established in the 
Treasury of the United States a fund to be known as the 
Indian Health Scholarship and Loan Repayment Recovery 
Fund (hereafter in this section referred to as the ‘LRRF’). 
The LRRF shall consist of such amounts as may be col-
lected from individuals under section 104(d), section 
106(e), and section 110(l) for breach of contract, such 
funds as may be appropriated to the LRRF, and interest 
earned on amounts in the LRRF. All amounts collected, 
appropriated, or earned relative to the LRRF shall remain 
available until expended. 
‘‘(b) USE OF FUNDS.—
‘‘(1) BY SECRETARY.—Amounts in the LRRF 
may be expended by the Secretary, acting through 
the Service, to make payments to an Indian Health 
Program—
‘‘(A) to which a scholarship recipient under 
section 104 and 106 or a loan repayment pro-
gram participant under section 110 has been 
assigned to meet the obligated service require-
ments pursuant to such sections; and 
‘‘(B) that has a need for a health profes-
sional to provide health care services as a result 
of such recipient or participant having breached 
the contract entered into under section 104, 
106, or section 110. 
‘‘(2) BY TRIBAL HEALTH PROGRAMS.—A Tribal 
Health Program receiving payments pursuant to 
paragraph (1) may expend the payments to provide 
scholarships or recruit and employ, directly or by 
contract, health professionals to provide health care 
services. 
‘‘(c) INVESTMENT OF FUNDS.—The Secretary of the 
Treasury shall invest such amounts of the LRRF as the 
Secretary of Health and Human Services determines are 
not required to meet current withdrawals from the LRRF. 
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 obligations at the 
market price.
‘‘(d) SALE
OF OBLIGATIONS.—Any obligation ac-
quired by the LRRF may be sold by the Secretary of the 
Treasury at the market price. 
‘‘SEC. 112. RECRUITMENT ACTIVITIES. 
‘‘(a) REIMBURSEMENT
FOR
TRAVEL.—The Sec-
retary, acting through the Service, may reimburse health 
professionals seeking positions with Indian Health Pro-
grams or Urban Indian Organizations, including unpaid 
student volunteers and individuals considering entering 
into a contract under section 110, and their spouses, for 
actual and reasonable expenses incurred in traveling to 
and from their places of residence to an area in which 
they may be assigned for the purpose of evaluating such 
area with respect to such assignment. 
‘‘(b) RECRUITMENT PERSONNEL.—The Secretary, 
acting through the Service, shall assign one individual in 
each Area Office to be responsible on a full-time basis for 
recruitment activities. 
‘‘SEC. 113. INDIAN RECRUITMENT AND RETENTION PRO-
GRAM. 
‘‘(a) IN GENERAL.—The Secretary, acting through 
the Service, shall fund innovative demonstration projects 
for a period not to exceed 3 years to enable Tribal Health 
Programs and Urban Indian Organizations to recruit,
place, and retain health professionals to meet their staff-
ing needs. 
‘‘(b) ELIGIBLE ENTITIES; APPLICATION.—Any Trib-
al Health Program or Urban Indian Organization may 
submit an application for funding of a project pursuant 
to this section. 
‘‘SEC. 114. ADVANCED TRAINING AND RESEARCH. 
‘‘(a) DEMONSTRATION PROGRAM.—The Secretary, 
acting through the Service, shall establish a demonstration 
project to enable health professionals who have worked in 
an Indian Health Program or Urban Indian Organization 
for a substantial period of time to pursue advanced train-
ing or research areas of study for which the Secretary de-
termines a need exists. 
‘‘(b) SERVICE OBLIGATION.—An individual who par-
ticipates in a program under subsection (a), where the 
educational costs are borne by the Service, shall incur an 
obligation to serve in an Indian Health Program or Urban 
Indian Organization for a period of obligated service equal 
to at least the period of time during which the individual 
participates in such program. In the event that the indi-
vidual fails to complete such obligated service, the indi-
vidual shall be liable to the United States for the period 
of service remaining. In such event, with respect to indi-
viduals entering the program after the date of the enact-
ment of the Indian Health Care Improvement Act Amend-
ments of 2003, the United States shall be entitled to re-
cover from such individual an amount to be determined 
in accordance with the formula specified in subsection (l) 
of section 110 in the manner provided for in such sub-
section. 
‘‘(c) EQUAL OPPORTUNITY FOR PARTICIPATION.—
Health professionals from Tribal Health Programs and 
Urban Indian Organizations shall be given an equal oppor-
tunity to participate in the program under subsection (a). 
‘‘SEC. 115. QUENTIN N. BURDICK AMERICAN INDIANS INTO 
NURSING PROGRAM. 
‘‘(a) GRANTS AUTHORIZED.—For the purpose of in-
creasing the number of nurses, nurse midwives, and nurse 
practitioners who deliver health care services to Indians, 
the Secretary, acting through the Service, shall provide 
grants to the following: 
‘‘(1) Public or private schools of nursing. 
‘‘(2) Tribal colleges or universities.
‘‘(3) Nurse midwife programs and advanced 
practice nurse programs that are provided by any 
tribal college or university accredited nursing pro-
gram, or in the absence of such, any other public or 
private institutions.
‘‘(b) USE OF GRANTS.—Grants provided under sub-
section (a) may be used for one or more of the following: 
‘‘(1) To recruit individuals for programs which 
train individuals to be nurses, nurse midwives, or 
advanced practice nurses. 
‘‘(2) To provide scholarships to Indians enrolled 
in such programs that may pay the tuition charged 
for such program and other expenses incurred in 
connection with such program, including books, fees, 
room and board, and stipends for living expenses. 
‘‘(3) To provide a program that encourages 
nurses, nurse midwives, and advanced practice 
nurses to provide, or continue to provide, health care 
services to Indians. 
‘‘(4) To provide a program that increases the 
skills of, and provides continuing education to, 
nurses, nurse midwives, and advanced practice 
nurses. 
‘‘(5) To provide any program that is designed 
to achieve the purpose described in subsection (a). 
‘‘(c) APPLICATIONS.—Each application for funding 
under subsection (a) shall include such information as the 
Secretary may require to establish the connection between 
the program of the applicant and a health care facility 
that primarily serves Indians.
‘‘(d) PREFERENCES FOR GRANT RECIPIENTS.—In 
providing grants under subsection (a), the Secretary shall 
extend a preference to the following: 
‘‘(1) Programs that provide a preference to In-
dians. 
‘‘(2) Programs that train nurse midwives or ad-
vanced practice nurses. 
‘‘(3) Programs that are interdisciplinary. 
‘‘(4) Programs that are conducted in coopera-
tion with a program for gifted and talented Indian 
students. 
‘‘(e) QUENTIN N. BURDICK PROGRAM GRANT.—The 
Secretary shall provide one of the grants authorized under 
subsection (a) to establish and maintain a program at the 
University of North Dakota to be known as the ‘Quentin 
N. Burdick American Indians Into Nursing Program’. 
Such program shall, to the maximum extent feasible, co-
ordinate with the Quentin N. Burdick Indian Health Pro-
grams established under section 117(b) and the Quentin 
N. Burdick American Indians Into Psychology Program 
established under section 105(b). 
‘‘(f) ACTIVE DUTY SERVICE OBLIGATION.—The ac-
tive duty service obligation prescribed under section 338C 
of the Public Health Service Act (42 U.S.C. 254m) shall 
be met by each individual who receives training or assist-
ance described in paragraph (1) or (2) of subsection (b) 
that is funded by a grant provided under subsection (a). 
Such obligation shall be met by service—
‘‘(1) in the Service; 
‘‘(2) in a program of an Indian Tribe or Tribal 
Organization conducted under the Indian Self-Deter-
mination Act (including programs under agreements 
with the Bureau of Indian Affairs); 
‘‘(3) in a program assisted under title V of this 
Act; or 
‘‘(4) in the private practice of nursing if, as de-
termined by the Secretary, in accordance with guide-
lines promulgated by the Secretary, such practice is 
situated in a physician or other health shortage area 
and addresses the health care needs of a substantial 
number of Indians. 
‘‘SEC. 116. TRIBAL CULTURAL ORIENTATION. 
‘‘(a) CULTURAL EDUCATION OF EMPLOYEES.—The 
Secretary, acting through the Service, shall require that 
appropriate employees of the Service who serve Indian 
Tribes in each Service Area receive educational instruction 
in the history and culture of such Indian Tribes and their 
relationship to the Service.
‘‘(b) PROGRAM.—In carrying out subsection (a), the 
Secretary shall establish a program which shall, to the ex-
tent feasible—
‘‘(1) be developed in consultation with the af-
fected Indian Tribes, Tribal Organizations, and 
Urban Indian Organizations; 
‘‘(2) be carried out through tribal colleges or 
universities; 
‘‘(3) include instruction in American Indian 
studies; and 
‘‘(4) describe the use and place of Traditional 
Health Care Practices of the Indian Tribes in the 
Service Area. 
‘‘SEC. 117. INMED PROGRAM. 
‘‘(a) GRANTS AUTHORIZED.—The Secretary, acting 
through the Service, is authorized to provide grants to col-
leges and universities for the purpose of maintaining and 
expanding the Indian health careers recruitment program 
known as the ‘Indians Into Medicine Program’ (herein-
after in this section referred to as ‘INMED’) as a means 
of encouraging Indians to enter the health professions. 
‘‘(b) QUENTIN N. BURDICK GRANT.—The Secretary 
shall provide one of the grants authorized under sub-
section (a) to maintain the INMED program at the Uni-
versity of North Dakota, to be known as the ‘Quentin N.
Burdick Indian Health Programs’, unless the Secretary 
makes a determination, based upon program reviews, that 
the program is not meeting the purposes of this section. 
Such program shall, to the maximum extent feasible, co-
ordinate with the Quentin N. Burdick American Indians 
Into Psychology Program established under section 105(b) 
and the Quentin N. Burdick American Indians Into Nurs-
ing Program established under section 115. 
‘‘(c) REGULATIONS.—The Secretary, pursuant to this 
Act, shall develop regulations to govern grants pursuant 
to this section. 
‘‘(d) REQUIREMENTS.—Applicants for grants pro-
vided under this section shall agree to provide a program 
which—
‘‘(1) provides outreach and recruitment for 
health professions to Indian communities including 
elementary and secondary schools and community 
colleges located on reservations which will be served 
by the program; 
‘‘(2) incorporates a program advisory board 
comprised of representatives from the Indian Tribes 
and Indian communities which will be served by the 
program; 
‘‘(3) provides summer preparatory programs for 
Indian students who need enrichment in the subjects
of math and science in order to pursue training in 
the health professions; 
‘‘(4) provides tutoring, counseling, and support 
to students who are enrolled in a health career pro-
gram of study at the respective college or university; 
and 
‘‘(5) to the maximum extent feasible, employs 
qualified Indians in the program. 
‘‘SEC. 118. HEALTH TRAINING PROGRAMS OF COMMUNITY 
COLLEGES. 
‘‘(a) GRANTS TO ESTABLISH PROGRAMS.—
‘‘(1) IN
GENERAL.—The Secretary, acting 
through the Service, shall award grants to accredited 
and accessible community colleges for the purpose of 
assisting such community colleges in the establish-
ment of programs which provide education in a 
health profession leading to a degree or diploma in 
a health profession for individuals who desire to 
practice such profession on or near a reservation or 
in an Indian Health Program. 
‘‘(2) AMOUNT OF GRANTS.—The amount of any 
grant awarded to a community college under para-
graph (1) for the first year in which such a grant 
is provided to the community college shall not exceed 
$100,000.
‘‘(b) GRANTS
FOR MAINTENANCE
AND RECRUIT-
ING.—
‘‘(1) IN
GENERAL.—The Secretary, acting 
through the Service, shall award grants to accredited 
and accessible community colleges that have estab-
lished a program described in subsection (a)(1) for 
the purpose of maintaining the program and recruit-
ing students for the program. 
‘‘(2) REQUIREMENTS.—Grants may only be 
made under this section to a community college 
which—
‘‘(A) is accredited; 
‘‘(B) has a relationship with a hospital fa-
cility, Service facility, or hospital that could 
provide training of nurses or health profes-
sionals; 
‘‘(C) has entered into an agreement with 
an accredited college or university medical 
school, the terms of which—
‘‘(i) provide a program that enhances 
the transition and recruitment of students 
into advanced baccalaureate or graduate 
programs which train health professionals; 
and
‘‘(ii) stipulate certifications necessary 
to approve internship and field placement 
opportunities at Indian Health Programs; 
‘‘(D) has a qualified staff which has the 
appropriate certifications; 
‘‘(E) is capable of obtaining State or re-
gional accreditation of the program described in 
subsection (a)(1); and 
‘‘(F) agrees to provide for Indian pref-
erence for applicants for programs under this 
section. 
‘‘(c) TECHNICAL ASSISTANCE.—The Secretary shall 
encourage community colleges described in subsection 
(b)(2) to establish and maintain programs described in 
subsection (a)(1) by—
‘‘(1) entering into agreements with such col-
leges for the provision of qualified personnel of the 
Service to teach courses of study in such programs; 
and 
‘‘(2) providing technical assistance and support 
to such colleges. 
‘‘(d) ADVANCED TRAINING.—
‘‘(1) REQUIRED.—Any program receiving as-
sistance under this section that is conducted with re-
spect to a health profession shall also offer courses
of study which provide advanced training for any 
health professional who—
‘‘(A) has already received a degree or di-
ploma in such health profession; and 
‘‘(B) provides clinical services on or near a 
reservation or for an Indian Health Program. 
‘‘(2) MAY BE OFFERED AT ALTERNATE SITE.—
Such courses of study may be offered in conjunction 
with the college or university with which the commu-
nity college has entered into the agreement required 
under subsection (b)(2)(C). 
‘‘(e) FUNDING PRIORITY.—Where the requirements 
of subsection (b) are met, funding priority shall be pro-
vided to tribal colleges and universities in Service Areas 
where they exist. 
‘‘SEC. 119. RETENTION BONUS. 
‘‘(a) BONUS AUTHORIZED.—The Secretary may pay 
a retention bonus to any health professional employed by, 
or assigned to, and serving in, an Indian Health Program 
or Urban Indian Organization either as a civilian employee 
or as a commissioned officer in the Regular or Reserve 
Corps of the Public Health Service who—
‘‘(1) is assigned to, and serving in, a position 
for which recruitment or retention of personnel is 
difficult;
‘‘(2) the Secretary determines is needed by In-
dian Health Programs and Urban Indian Organiza-
tions; 
‘‘(3) has—
‘‘(A) completed 3 years of employment 
with an Indian Health Program or Urban In-
dian Organization; or 
‘‘(B) completed any service obligations in-
curred as a requirement of—
‘‘(i) any Federal scholarship program; 
or 
‘‘(ii) any Federal education loan re-
payment program; and 
‘‘(4) enters into an agreement with an Indian 
Health Program or Urban Indian Organization for 
continued employment for a period of not less than 
1 year. 
‘‘(b) RATES.—The Secretary may establish rates for 
the retention bonus which shall provide for a higher an-
nual rate for multiyear agreements than for single year 
agreements referred to in subsection (a)(4), but in no 
event shall the annual rate be more than $25,000 per 
annum. 
‘‘(c) DEFAULT OF RETENTION AGREEMENT.—Any 
health professional failing to complete the agreed upon
term of service, except where such failure is through no 
fault of the individual, shall be obligated to refund to the 
Government the full amount of the retention bonus for the 
period covered by the agreement, plus interest as deter-
mined by the Secretary in accordance with section 
110(l)(2)(B). 
‘‘(d) OTHER RETENTION BONUS.—The Secretary 
may pay a retention bonus to any health professional em-
ployed by a Tribal Health Program if such health profes-
sional is serving in a position which the Secretary deter-
mines is—
‘‘(1) a position for which recruitment or reten-
tion is difficult; and 
‘‘(2) necessary for providing health care services 
to Indians. 
‘‘SEC. 120. NURSING RESIDENCY PROGRAM. 
‘‘(a) ESTABLISHMENT
OF
PROGRAM.—The Sec-
retary, acting through the Service, shall establish a pro-
gram to enable Indians who are licensed practical nurses, 
licensed vocational nurses, and registered nurses who are 
working in an Indian Health Program or Urban Indian 
Organization, and have done so for a period of not less 
than 1 year, to pursue advanced training. Such program 
shall include a combination of education and work study 
in an Indian Health Program or Urban Indian Organiza-
tion leading to an associate or bachelor’s degree (in the 
case of a licensed practical nurse or licensed vocational 
nurse), a bachelor’s degree (in the case of a registered 
nurse), or advanced degrees in nursing and public health. 
‘‘(b) SERVICE OBLIGATION.—An individual who par-
ticipates in a program under subsection (a), where the 
educational costs are paid by the Service, shall incur an 
obligation to serve in an Indian Health Program or Urban 
Indian Organization for a period of obligated service equal 
to the amount of time during which the individual partici-
pates in such program. In the event that the individual 
fails to complete such obligated service, the United States 
shall be entitled to recover from such individual an amount 
determined in accordance with the formula specified in 
subsection (l) of section 110 in the manner provided for 
in such subsection. 
‘‘SEC. 121. COMMUNITY HEALTH AIDE PROGRAM FOR ALAS-
KA. 
‘‘(a) GENERAL PURPOSES OF PROGRAM.—Under the 
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 develop and operate a Commu-
nity Health Aide Program in Alaska under which the 
Service—
‘‘(1) provides for the training of Alaska Natives 
as health aides or community health practitioners; 
‘‘(2) uses such aides or practitioners in the pro-
vision of health care, health promotion, and disease 
prevention services to Alaska Natives living in vil-
lages in rural Alaska; and 
‘‘(3) provides for the establishment of tele-
conferencing capacity in health clinics located in or 
near such villages for use by community health aides 
or community health practitioners. 
‘‘(b) SPECIFIC PROGRAM REQUIREMENTS.—The Sec-
retary, acting through the Community Health Aide Pro-
gram of the Service, shall—
‘‘(1) using trainers accredited by the Program, 
provide a high standard of training to community 
health aides and community health practitioners to 
ensure that such aides and practitioners provide 
quality health care, health promotion, and disease 
prevention services to the villages served by the Pro-
gram; 
‘‘(2) in order to provide such training, develop 
a curriculum that—
‘‘(A) combines education in the theory of 
health care with supervised practical experience 
in the provision of health care;
‘‘(B) provides instruction and practical ex-
perience in the provision of acute care, emer-
gency care, health promotion, disease preven-
tion, and the efficient and effective manage-
ment of clinic pharmacies, supplies, equipment, 
and facilities; and 
‘‘(C) promotes the achievement of the 
health status objectives specified in section 
3(2); 
‘‘(3) establish and maintain a Community 
Health Aide Certification Board to certify as com-
munity health aides or community health practi-
tioners individuals who have successfully completed 
the training described in paragraph (1) or can dem-
onstrate equivalent experience; 
‘‘(4) develop and maintain a system which iden-
tifies the needs of community health aides and com-
munity health practitioners for continuing education 
in the provision of health care, including the areas 
described in paragraph (2)(B), and develop pro-
grams that meet the needs for such continuing edu-
cation; 
‘‘(5) develop and maintain a system that pro-
vides close supervision of community health aides 
and community health practitioners; and
‘‘(6) develop a system under which the work of 
community health aides and community health prac-
titioners is reviewed and evaluated to assure the pro-
vision of quality health care, health promotion, and 
disease prevention services. 
‘‘(c) NATIONAL COMMUNITY HEALTH AIDE PRO-
GRAM.—The Secretary, acting through the Service, shall 
develop and operate a national Community Health Aide 
Program consistent with the requirements of this section 
without reducing funds for the Community Health Aide 
Program for Alaska. 
‘‘SEC. 122. TRIBAL HEALTH PROGRAM ADMINISTRATION. 
‘‘The Secretary, acting through the Service, shall, by 
funding agreement or otherwise, provide training for Indi-
ans in the administration and planning of Tribal Health 
Programs. 
‘‘SEC. 123. HEALTH PROFESSIONAL CHRONIC SHORTAGE 
DEMONSTRATION PROGRAMS. 
‘‘(a) DEMONSTRATION PROGRAMS AUTHORIZED.— 
The Secretary, acting through the Service, may fund dem-
onstration programs for Tribal Health Programs to ad-
dress the chronic shortages of health professionals. 
‘‘(b) PURPOSES OF PROGRAMS.—The purposes of 
demonstration programs funded under subsection (a) shall 
be—
‘‘(1) to provide direct clinical and practical ex-
perience at a Service Unit to health profession stu-
dents and residents from medical schools; 
‘‘(2) to improve the quality of health care for 
Indians by assuring access to qualified health care 
professionals; and 
‘‘(3) to provide academic and scholarly opportu-
nities for health professionals serving Indians by 
identifying all academic and scholarly resources of 
the region. 
‘‘(c) ADVISORY BOARD.—The demonstration pro-
grams established pursuant to subsection (a) shall incor-
porate a program advisory board composed of representa-
tives from the Indian Tribes and Indian communities in 
the area which will be served by the program. 
‘‘SEC. 124. TREATMENT OF SCHOLARSHIPS FOR CERTAIN 
PURPOSES. 
‘‘Scholarships provided to individuals pursuant to 
this title shall be deemed ‘qualified Scholarships’ for pur-
poses of section 11 of the Internal Revenue Code of 1986. 
‘‘SEC. 125. NATIONAL HEALTH SERVICE CORPS. 
‘‘(a) NO REDUCTION IN SERVICES.—The Secretary 
shall not—
‘‘(1) remove a member of the National Health 
Service Corps from an Indian Health Program or 
Urban Indian Organization; or 
‘‘(2) withdraw funding used to support such 
member, unless the Secretary, acting through the 
Service, Indian Tribes, or Tribal Organizations, has 
ensured that the Indians receiving services from 
such member will experience no reduction in serv-
ices. 
‘‘(b) EXEMPTION
FROM
LIMITATIONS.—National 
Health Service Corps scholars qualifying for the Commis-
sioned Corps in the United States Public Health Service 
shall be exempt from the full-time equivalent limitations 
of the National Health Service Corps and the Service 
when serving as a commissioned corps officer in a Tribal 
Health Program or an Urban Indian Organization. 
‘‘SEC. 126. SUBSTANCE ABUSE COUNSELOR EDUCATIONAL 
CURRICULA DEMONSTRATION PROGRAMS. 
‘‘(a) GRANTS AND CONTRACTS.—The Secretary, act-
ing through the Service, may enter into contracts with, 
or make grants to, accredited tribal colleges and univer-
sities and eligible accredited and accessible community col-
leges to establish demonstration programs to develop edu-
cational curricula for substance abuse counseling.
‘‘(b) USE OF FUNDS.—Funds provided under this 
section shall be used only for developing and providing 
educational curriculum for substance abuse counseling (in-
cluding paying salaries for instructors). Such curricula 
may be provided through satellite campus programs. 
‘‘(c) TIME PERIOD OF ASSISTANCE; RENEWAL.—A 
contract entered into or a grant provided under this sec-
tion shall be for a period of 1 year. Such contract or grant 
may be renewed for an additional 1-year period upon the 
approval of the Secretary. 
‘‘(d) CRITERIA FOR REVIEW AND APPROVAL OF AP-
PLICATIONS.—Not later than 180 days after the date of 
the enactment of the Indian Health Care Improvement 
Act Amendments of 2003, the Secretary, after consulta-
tion with Indian Tribes and administrators of tribal col-
leges and universities and eligible accredited and acces-
sible community colleges, shall develop and issue criteria 
for the review and approval of applications for funding (in-
cluding applications for renewals of funding) under this 
section. Such criteria shall ensure that demonstration pro-
grams established under this section promote the develop-
ment of the capacity of such entities to educate substance 
abuse counselors. 
‘‘(e) ASSISTANCE.—The Secretary shall provide such 
technical and other assistance as may be necessary to en-
able grant recipients to comply with the provisions of this 
section. 
‘‘(f) REPORT.—Each fiscal year, the Secretary shall 
submit to the President, for inclusion in the report which 
is required to be submitted under section 801 for that fis-
cal year, a report on the findings and conclusions derived 
from the demonstration programs conducted under this 
section during that fiscal year. 
‘‘(g) DEFINITION.—For the purposes of this section 
the term ‘educational curriculum’ means 1 or more of the 
following—
‘‘(1) classroom education; 
‘‘(2) clinical work experience; and 
‘‘(3) continuing education workshops. 
‘‘SEC. 127. MENTAL HEALTH TRAINING AND COMMUNITY 
EDUCATION PROGRAMS. 
‘‘(a) STUDY; LIST.—The Secretary, acting through 
the Service, and the Secretary of the Interior, in consulta-
tion with Indian Tribes and Tribal Organizations, shall 
conduct a study and compile a list of the types of staff 
positions specified in subsection (b) whose qualifications 
include, or should include, training in the identification, 
prevention, education, referral, or treatment of mental ill-
ness, or dysfunctional and self destructive behavior.
‘‘(b) POSITIONS.—The positions referred to in sub-
section (a) are—
‘‘(1) staff positions within the Bureau of Indian 
Affairs, including existing positions, in the fields 
of—
‘‘(A) elementary and secondary education; 
‘‘(B) social services and family and child 
welfare; 
‘‘(C) law enforcement and judicial services; 
and 
‘‘(D) alcohol and substance abuse; 
‘‘(2) staff positions within the Service; and 
‘‘(3) staff positions similar to those identified in 
paragraphs (1) and (2) established and maintained 
by Indian Tribes, Tribal Organizations, (without re-
gard to the funding source) and Urban Indian Orga-
nizations. 
‘‘(c) TRAINING CRITERIA.—
‘‘(1) IN GENERAL.—The appropriate Secretary 
shall provide training criteria appropriate to each 
type of position identified in subsection (b)(1) and 
(b)(2) and ensure that appropriate training has 
been, or shall be provided to any individual in any 
such position. With respect to any such individual in 
a position identified pursuant to subsection (b)(3),
the respective Secretaries shall provide appropriate 
training to, or provide funds to, an Indian Tribe, 
Tribal Organization, or Urban Indian Organization 
for training of appropriate individuals. In the case of 
positions funded under a funding agreement, the ap-
propriate Secretary shall ensure that funds to cover 
the costs of such training costs are included in the 
funding agreement. 
‘‘(2) POSITION SPECIFIC TRAINING CRITERIA.—
Position specific training criteria shall be culturally 
relevant to Indians and Indian Tribes and shall en-
sure that appropriate information regarding Tradi-
tional Health Care Practices is provided. 
‘‘(d) COMMUNITY EDUCATION
ON MENTAL ILL-
NESS.—The Service shall develop and implement, on re-
quest of an Indian Tribe or Tribal Organization, or assist 
the Indian Tribe or Tribal Organization to develop and 
implement a program of community education on mental 
illness. In carrying out this subsection, the Service shall, 
upon request of an Indian Tribe or Tribal Organization, 
provide technical assistance to the Indian Tribe or Tribal 
Organization to obtain and develop community edu-
cational materials on the identification, prevention, refer-
ral, and treatment of mental illness and dysfunctional and 
self-destructive behavior.
‘‘(e) PLAN.—Not later than 90 days after the date 
of the enactment of the Indian Health Care Improvement 
Act Amendments of 2003, the Secretary shall develop a 
plan under which the Service will increase the health care 
staff providing mental health services by at least 500 posi-
tions within 5 years after the date of the enactment of 
this section, with at least 200 of such positions devoted 
to child, adolescent, and family services. The plan devel-
oped under this subsection shall be implemented under the 
Act of November 2, 1921 (25 U.S.C. 13, popularly known 
as the Snyder Act). 
‘‘SEC. 128. DESIGNATION OF SHORTAGE AREAS. 
‘‘A Service Area served by an Indian Health Program 
or Urban Indian Organization shall be designated under 
the Public Health Services Act (42 U.S.C. 250 et seq.) 
as a shortage area immediately upon request of an Indian 
Health Program without further evaluation by the Sec-
retary. 
‘‘SEC. 129. 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 II—HEALTH SERVICES 
‘‘SEC. 201. INDIAN HEALTH CARE IMPROVEMENT FUND. 
‘‘(a) USE OF FUNDS.—The Secretary, acting through 
the Service, is authorized to expend funds, directly or 
under the authority of the Indian Self-Determination and 
Education Assistance Act, which are appropriated under 
the authority of this section, for the purposes of—
‘‘(1) eliminating the deficiencies in health sta-
tus and health resources of all Indian Tribes; 
‘‘(2) eliminating backlogs in the provision of 
health care services to Indians; 
‘‘(3) meeting the health needs of Indians in an 
efficient and equitable manner; 
‘‘(4) eliminating inequities in funding for both 
direct care and contract health service programs; 
and 
‘‘(5) augmenting the ability of the Service to 
meet the following health service responsibilities with 
respect to those Indian Tribes with the highest levels 
of health status deficiencies and resource defi-
ciencies: 
‘‘(A) Clinical care, including, but not lim-
ited to, inpatient care, outpatient care (includ-
ing audiology, clinical eye, and vision care), pri-
mary care, secondary and tertiary care, and 
long-term care. 
‘‘(B) Preventive health, including mam-
mography and other cancer screening in accord-
ance with section 207. 
‘‘(C) Dental care. 
‘‘(D) Mental health, including community 
mental health services, inpatient mental health 
services, dormitory mental health services, 
therapeutic and residential treatment centers, 
and training of traditional health care practi-
tioners. 
‘‘(E) Emergency medical services. 
‘‘(F) Treatment and control of, and reha-
bilitative care related to, alcoholism and drug 
abuse (including fetal alcohol syndrome) among 
Indians. 
‘‘(G) Accident prevention programs. 
‘‘(H) Home health care. 
‘‘(I) Community health representatives. 
‘‘(J) Maintenance and repair. 
‘‘(K) Traditional Health Care Practices. 
‘‘(b) NO OFFSET OR LIMITATION.—Any funds appro-
priated under the authority of this section shall not be 
used to offset or limit any other appropriations made to
the Service under this Act or the Act of November 2, 1921 
(25 U.S.C. 13, popularly known as the Snyder Act), or 
any other provision of law. 
‘‘(c) ALLOCATION; USE.—
‘‘(1) IN GENERAL.—Funds appropriated under 
the authority of this section shall be allocated to 
Service Units, Indian Tribes, or Tribal Organiza-
tions. The funds allocated to each Indian Tribe, 
Tribal Organization, or Service Unit under this 
paragraph shall be used by the Indian Tribe, Tribal 
Organization, or Service Unit under this paragraph 
to improve the health status and reduce the resource 
deficiency of each Indian Tribe served by such Serv-
ice Unit, Indian Tribe, or Tribal Organization. 
‘‘(2) 
APPORTIONMENT
OF
ALLOCATED 
FUNDS.—The apportionment of funds allocated to a 
Service Unit, Indian Tribe, or Tribal Organization 
under paragraph (1) among the health service re-
sponsibilities described in subsection (a)(5) shall be 
determined by the Service in consultation with, and 
with the active participation of, the affected Indian 
Tribes and Tribal Organizations. 
‘‘(d) PROVISIONS RELATING
TO HEALTH STATUS 
AND RESOURCE DEFICIENCIES.—For the purposes of this 
section, the following definitions apply:
‘‘(1) DEFINITION.—The term ‘health status 
and resource deficiency’ means the extent to 
which—
‘‘(A) the health status objectives set forth 
in section 3(2) are not being achieved; and 
‘‘(B) the Indian Tribe or Tribal Organiza-
tion does not have available to it the health re-
sources it needs, taking into account the actual 
cost of providing health care services given local 
geographic, climatic, rural, or other cir-
cumstances. 
‘‘(2) AVAILABLE RESOURCES.—The health re-
sources available to an Indian Tribe or Tribal Orga-
nization include health resources provided by the 
Service as well as health resources used by the In-
dian Tribe or Tribal Organization, including services 
and financing systems provided by any Federal pro-
grams, private insurance, and programs of State or 
local governments. 
‘‘(3) PROCESS
FOR
REVIEW
OF
DETERMINA-
TIONS.—The Secretary shall establish procedures 
which allow any Indian Tribe or Tribal Organization 
to petition the Secretary for a review of any deter-
mination of the extent of the health status and re-
source deficiency of such Indian Tribe or Tribal Or-
ganization. 
‘‘(e) ELIGIBILITY FOR FUNDS.—Tribal Health Pro-
grams shall be eligible for funds appropriated under the 
authority of this section on an equal basis with programs 
that are administered directly by the Service. 
‘‘(f) REPORT.—By no later than the date that is 3 
years after the date of the enactment of the Indian Health 
Care Improvement Act Amendments of 2003, the Sec-
retary shall submit to Congress the current health status 
and resource deficiency report of the Service for each 
Service Unit, including newly recognized or acknowledged 
Indian Tribes. Such report shall set out—
‘‘(1) the methodology then in use by the Service 
for determining Tribal health status and resource 
deficiencies, as well as the most recent application of 
that methodology; 
‘‘(2) the extent of the health status and re-
source deficiency of each Indian Tribe served by the 
Service or a Tribal Health Program; 
‘‘(3) the amount of funds necessary to eliminate 
the health status and resource deficiencies of all In-
dian Tribes served by the Service or a Tribal Health 
Program; and 
‘‘(4) an estimate of—
‘‘(A) the amount of health service funds 
appropriated under the authority of this Act, or 
any other Act, including the amount of any 
funds transferred to the Service for the pre-
ceding fiscal year which is allocated to each 
Service Unit, Indian Tribe, or Tribal Organiza-
tion; 
‘‘(B) the number of Indians eligible for 
health services in each Service Unit or Indian 
Tribe or Tribal Organization; and 
‘‘(C) the number of Indians using the 
Service resources made available to each Service 
Unit, Indian Tribe or Tribal Organization, and, 
to the extent available, information on the wait-
ing lists and number of Indians turned away for 
services due to lack of resources. 
‘‘(g) INCLUSION IN BASE BUDGET.—Funds appro-
priated under this section for any fiscal year shall be in-
cluded in the base budget of the Service for the purpose 
of determining appropriations under this section in subse-
quent fiscal years. 
‘‘(h) CLARIFICATION.—Nothing in this section is in-
tended to diminish the primary responsibility of the Serv-
ice to eliminate existing backlogs in unmet health care 
needs, nor are the provisions of this section intended to
discourage the Service from undertaking additional efforts 
to achieve equity among Indian Tribes and Tribal Organi-
zations. 
‘‘(i) FUNDING DESIGNATION.—Any funds appro-
priated under the authority of this section shall be des-
ignated as the ‘Indian Health Care Improvement Fund’. 
‘‘SEC. 202. CATASTROPHIC HEALTH EMERGENCY FUND. 
‘‘(a) ESTABLISHMENT.—There is hereby established 
an Indian Catastrophic Health Emergency Fund (here-
after in this section referred to as the ‘CHEF’) consisting 
of—
‘‘(1) the amounts deposited under subsection 
(f); and 
‘‘(2) the amounts appropriated to CHEF under 
this section. 
‘‘(b) ADMINISTRATION.—CHEF shall be adminis-
tered by the Secretary, acting through the central office 
of the Service, solely for the purpose of meeting the ex-
traordinary medical costs associated with the treatment of 
victims of disasters or catastrophic illnesses who are with-
in the responsibility of the Service. 
‘‘(c) CONDITIONS ON USE OF FUND.—No part of 
CHEF or its administration shall be subject to contract 
or grant under any law, including the Indian Self-Deter-
mination Act, nor shall CHEF funds be allocated, appor-
tioned, or delegated on an Area Office, Service Unit, or 
other similar basis. 
‘‘(d) REGULATIONS.—The Secretary shall, through 
the negotiated rulemaking process under title VIII, pro-
mulgate regulations consistent with the provisions of this 
section to—
‘‘(1) establish a definition of disasters and cata-
strophic illnesses for which the cost of the treatment 
provided under contract would qualify for payment 
from CHEF; 
‘‘(2) provide that a Service Unit shall not be el-
igible for reimbursement for the cost of treatment 
from CHEF until its cost of treating any victim of 
such catastrophic illness or disaster has reached a 
certain threshold cost which the Secretary shall es-
tablish at—
‘‘(A) the 2000 level of $19,000; and 
‘‘(B) for any subsequent year, not less 
than the threshold cost of the previous year in-
creased by the percentage increase in the med-
ical care expenditure category of the consumer 
price index for all urban consumers (United 
States city average) for the 12-month period 
ending with December of the previous year; and
‘‘(3) establish a procedure for the reimburse-
ment of the portion of the costs that exceeds such 
threshold cost incurred by—
‘‘(A) Service Units; or 
‘‘(B) whenever otherwise authorized by the 
Service, non-Service facilities or providers; 
‘‘(4) establish a procedure for payment from 
CHEF in cases in which the exigencies of the med-
ical circumstances warrant treatment prior to the 
authorization of such treatment by the Service; and 
‘‘(5) establish a procedure that will ensure that 
no payment shall be made from CHEF to any pro-
vider of treatment to the extent that such provider 
is eligible to receive payment for the treatment from 
any other Federal, State, local, or private source of 
reimbursement for which the patient is eligible. 
‘‘(e) NO OFFSET OR LIMITATION.—Amounts appro-
priated to CHEF under this section shall not be used to 
offset or limit appropriations made to the Service under 
the authority of the Act of November 2, 1921 (25 U.S.C. 
13, popularly known as the Snyder Act), or any other law. 
‘‘(f) DEPOSIT OF REIMBURSEMENT FUNDS.—There 
shall be deposited into CHEF all reimbursements to which 
the Service is entitled from any Federal, State, local, or 
private source (including third party insurance) by reason
of treatment rendered to any victim of a disaster or cata-
strophic illness the cost of which was paid from CHEF. 
‘‘SEC. 203. HEALTH PROMOTION AND DISEASE PREVENTION 
SERVICES. 
‘‘(a) FINDINGS.—Congress finds that health pro-
motion and disease prevention activities—
‘‘(1) improve the health and well-being of Indi-
ans; and 
‘‘(2) reduce the expenses for health care of In-
dians. 
‘‘(b) PROVISION OF SERVICES.—The Secretary, act-
ing through the Service and Tribal Health Programs, shall 
provide health promotion and disease prevention services 
to Indians to achieve the health status objectives set forth 
in section 3(2). 
‘‘(c) EVALUATION.—The Secretary, after obtaining 
input from the affected Tribal Health Programs, shall 
submit to the President for inclusion in each report which 
is required to be submitted to Congress under section 801 
an evaluation of—
‘‘(1) the health promotion and disease preven-
tion needs of Indians; 
‘‘(2) the health promotion and disease preven-
tion activities which would best meet such needs;
‘‘(3) the internal capacity of the Service and 
Tribal Health Programs to meet such needs; and 
‘‘(4) the resources which would be required to 
enable the Service and Tribal Health Programs to 
undertake the health promotion and disease preven-
tion activities necessary to meet such needs. 
‘‘SEC. 204. DIABETES PREVENTION, TREATMENT, AND CON-
TROL. 
‘‘(a) DETERMINATIONS REGARDING DIABETES.—
The Secretary, acting through the Service, and in con-
sultation with Indian Tribes and Tribal Organizations, 
shall determine—
‘‘(1) by an Indian Tribe, Tribal Organization, 
and by Service Unit, the incidence of, and the types 
of complications resulting from, diabetes among In-
dians; and 
‘‘(2) based on the determinations made pursu-
ant to paragraph (1), the measures (including pa-
tient education) each Service Unit should take to re-
duce the incidence of, and prevent, treat, and control 
the complications resulting from, diabetes among In-
dian Tribes within that Service Unit. 
‘‘(b) DIABETES SCREENING.—To the extent medi-
cally indicated and with informed consent, the Secretary 
shall screen each Indian who receives services from the
Service for diabetes and for conditions which indicate a 
high risk that the individual will become diabetic. Such 
screening may be done by a Tribal Health Program. 
‘‘(c) FUNDING FOR DIABETES.—The Secretary shall 
continue to fund each model diabetes project in existence 
on the date of the enactment of the Indian Health Amend-
ments Care Improvement Act of 2003, any such other dia-
betes programs operated by the Service or Tribal Health 
Programs, and any additional diabetes projects. Tribal 
Health Programs shall receive recurring funding for the 
diabetes projects that they operate pursuant to this sec-
tion, both at the date of enactment of the Indian Health 
Care Improvement Act Amendments of 2003 and for 
projects which are added and funded thereafter. 
‘‘(d) FUNDING FOR DIALYSIS PROGRAMS.—The Sec-
retary shall provide funding through the Service, Indian 
Tribes, and Tribal Organizations to establish dialysis pro-
grams, including funding to purchase dialysis equipment 
and provide necessary staffing. 
‘‘(e) OTHER DUTIES OF THE SECRETARY.—The Sec-
retary shall, to the extent funding is available—
‘‘(1) in each Area Office, consult with Indian 
Tribes and Tribal Organizations regarding programs 
for the prevention, treatment, and control of diabe-
tes;
‘‘(2) establish in each Area Office a registry of 
patients with diabetes to track the incidence of dia-
betes and the complications from diabetes in that 
area; and 
‘‘(3) ensure that data collected in each Area Of-
fice regarding diabetes and related complications 
among Indians is disseminated to all other Area Of-
fices. 
‘‘SEC. 205. SHARED SERVICES FOR LONG-TERM CARE. 
‘‘(a) FUNDING
AGREEMENTS
FOR
LONG-TERM 
CARE.—Notwithstanding any other provisions of law, the 
Secretary, acting through the Service, is authorized to 
enter into Funding Agreements or other arrangements 
with Indian Tribes or Tribal Organizations for the delivery 
of long-term care and similar services to Indians. Such 
funding agreements or other arrangements shall provide 
for the sharing of staff or other services between the Serv-
ice or a Tribal Health Program and a long-term care or 
other similar facility owned and operated (directly or 
through a Funding Agreement) by such Indian Tribe or 
Tribal Organization. 
‘‘(b) CONTENTS
OF FUNDING AGREEMENTS.—A 
Funding Agreement or other arrangement entered into 
pursuant to subsection (a)—
‘‘(1) may, at the request of the Indian Tribe or 
Tribal Organization, delegate to such Indian Tribe 
or Tribal Organization such powers of supervision 
and control over Service employees as the Secretary 
deems necessary to carry out the purposes of this 
section; 
‘‘(2) shall provide that expenses (including sala-
ries) relating to services that are shared between the 
Service and the Tribal Health Program be allocated 
proportionately between the Service and the Indian 
Tribe or Tribal Organization; and 
‘‘(3) may authorize such Indian Tribe or Tribal 
Organization to construct, renovate, or expand a 
long-term care or other similar facility (including the 
construction of a facility attached to a Service facil-
ity). 
‘‘(c) MINIMUM REQUIREMENT.—Any nursing facility 
provided for under this section shall meet the require-
ments for nursing facilities under section 1919 of the So-
cial Security Act. 
‘‘(d) OTHER ASSISTANCE.—The Secretary shall pro-
vide such technical and other assistance as may be nec-
essary to enable applicants to comply with the provisions 
of this section.
100
‘‘(e) USE
OF EXISTING
OR UNDERUSED FACILI-
TIES.—The Secretary shall encourage the use of existing 
facilities that are underused or allow the use of swing beds 
for long-term or similar care. 
‘‘SEC. 206. HEALTH SERVICES RESEARCH. 
‘‘The Secretary, acting through the Service, shall 
make funding available for research to further the per-
formance of the health service responsibilities of Indian 
Health Programs and shall coordinate the activities of 
other agencies within the Department to address these re-
search needs. The funding shall be divided equitably 
among the Area Offices. Then each Area Office shall 
award the funds competitively within that Area. The Sec-
retary shall consult with Indian Tribes and Tribal Organi-
zations in developing the methodology used to allocate 
these funds among Area Offices for competitive awards. 
Tribal Health Programs shall be given an equal oppor-
tunity to compete for, and receive, research funds under 
this section. This funding may be used for both clinical 
and nonclinical research. 
‘‘SEC. 207. MAMMOGRAPHY AND OTHER CANCER SCREEN-
ING. 
‘‘The Secretary, acting through the Service or Tribal 
Health Programs, shall provide for screening as follows:
101
‘‘(1) Screening mammography (as defined in 
section 1861(jj) of the Social Security Act) for In-
dian women at a frequency appropriate to such 
women under national standards, such as those of 
the National Cancer Institute for the National Insti-
tutes for Health, and under such terms and condi-
tions as are consistent with standards established by 
the Secretary to ensure the safety and accuracy of 
screening mammography under part B of title XVIII 
of such Act. 
‘‘(2) Other cancer screening meeting national 
standards, such as those of the National Cancer In-
stitute. 
‘‘SEC. 208. PATIENT TRAVEL COSTS. 
‘‘The Secretary, acting through the Service and Trib-
al Health Programs, shall provide funds for the following 
patient travel costs, including appropriate and necessary 
qualified escorts, associated with receiving health care 
services provided (either through direct or contract care 
or through Funding Agreements) under this Act—
‘‘(1) emergency air transportation and non-
emergency air transportation where ground trans-
portation is infeasible; 
‘‘(2) transportation by private vehicle, specially 
equipped vehicle, and ambulance; and
102
‘‘(3) transportation by such other means as 
may be available and required when air or motor ve-
hicle transportation is not available. 
‘‘SEC. 209. EPIDEMIOLOGY CENTERS. 
‘‘(a) ADDITIONAL CENTERS.—In addition to those 
epidemiology centers already established at the time of en-
actment of this Act, (including those for which funding 
is currently being provided in Funding Agreements), and 
without reducing the funding levels for such centers, not 
later than 180 days after the date of the enactment of 
the Indian Health Care Improvement Act Amendments of 
2003, the Secretary, acting through the Service, shall es-
tablish and fund an epidemiology center in each Service 
Area which does not yet have one to carry out the func-
tions described in subsection (b). Any new centers so es-
tablished may be operated by Tribal Health Programs, but 
such funding shall not be divisible. 
‘‘(b) FUNCTIONS OF CENTERS.—In consultation with 
and upon the request of Indian Tribes, Tribal Organiza-
tions, and Urban Indian Organizations, each Service Area 
epidemiology center established under this subsection 
shall, with respect to such Service Area—
‘‘(1) collect data relating to, and monitor 
progress made toward meeting, each of the health 
status objectives of the Service, the Indian Tribes,
103
Tribal Organizations, and Urban Indian Organiza-
tions in the Service Area; 
‘‘(2) evaluate existing delivery systems, data 
systems, and other systems that impact the improve-
ment of Indian health; 
‘‘(3) assist Indian Tribes, Tribal Organizations, 
and Urban Indian Organizations in identifying their 
highest priority health status objectives and the 
services needed to achieve such objectives, based on 
epidemiological data; 
‘‘(4) make recommendations for the targeting 
of services needed by the populations served; 
‘‘(5) make recommendations to improve health 
care delivery systems for Indians and Urban Indi-
ans; 
‘‘(6) provide requested technical assistance to 
Indian Tribes, Tribal Organizations, and Urban In-
dian Organizations in the development of local 
health service priorities and incidence and prevalence 
rates of disease and other illness in the community; 
and 
‘‘(7) provide disease surveillance and assist In-
dian Tribes, Tribal Organizations, and Urban Indian 
Organizations to promote public health.
104
‘‘(c) TECHNICAL ASSISTANCE.—The Director of the 
Centers for Disease Control and Prevention shall provide 
technical assistance to the centers in carrying out the re-
quirements of this subsection. 
‘‘(d) FUNDING FOR STUDIES.—The Secretary may 
make funding available to Indian Tribes, Tribal Organiza-
tions, and Urban Indian Organizations to conduct epide-
miological studies of Indian communities. 
‘‘SEC. 210. COMPREHENSIVE SCHOOL HEALTH EDUCATION 
PROGRAMS. 
‘‘(a) FUNDING FOR DEVELOPMENT OF PROGRAMS.—
The Secretary, acting through the Service, shall provide 
funding to Indian Tribes, Tribal Organizations, and 
Urban Indian Organizations to develop comprehensive 
school health education programs for children from pre-
school through grade 12 in schools for the benefit of In-
dian and Urban Indian children. 
‘‘(b) USE OF FUNDS.—Funding provided under this 
section may be used for purposes which may include, but 
are not limited to, the following: 
‘‘(1) Developing and implementing health edu-
cation curricula both for regular school programs 
and afterschool programs. 
‘‘(2) Training teachers in comprehensive school 
health education curricula.
105
‘‘(3) 
Integrating 
school-based, 
community-
based, and other public and private health promotion 
efforts. 
‘‘(4) Encouraging healthy, tobacco-free school 
environments. 
‘‘(5) Coordinating school-based health programs 
with existing services and programs available in the 
community. 
‘‘(6) Developing school programs on nutrition 
education, personal health, oral health, and fitness. 
‘‘(7) Developing mental health wellness pro-
grams. 
‘‘(8) Developing chronic disease prevention pro-
grams. 
‘‘(9) Developing substance abuse prevention 
programs. 
‘‘(10) Developing injury prevention and safety 
education programs. 
‘‘(11) Developing activities for the prevention 
and control of communicable diseases. 
‘‘(12) Developing community and environmental 
health education programs that include traditional 
health care practitioners. 
‘‘(13) Violence prevention.
106
‘‘(14) Such other health issues as are appro-
priate. 
‘‘(c) TECHNICAL ASSISTANCE.—Upon request, the 
Secretary, acting through the Service, shall provide tech-
nical assistance to Indian Tribes, Tribal Organizations, 
and Urban Indian Organizations in the development of 
comprehensive health education plans and the dissemina-
tion of comprehensive health education materials and in-
formation on existing health programs and resources. 
‘‘(d) CRITERIA FOR REVIEW AND APPROVAL OF AP-
PLICATIONS.—The Secretary, acting through the Service, 
and in consultation with Indian Tribes, Tribal Organiza-
tions, and Urban Indian Organizations, shall establish cri-
teria for the review and approval of applications for fund-
ing provided pursuant to this section. 
‘‘(e) DEVELOPMENT OF PROGRAM FOR BIA FUNDED 
SCHOOLS.—
‘‘(1) IN GENERAL.—The Secretary of the Inte-
rior, acting through the Bureau of Indian Affairs 
and in cooperation with the Secretary, acting 
through the Service, and affected Indian Tribes and 
Tribal Organizations, shall develop a comprehensive 
school health education program for children from 
preschool through grade 12 in schools for which sup-
port is provided by the Bureau of Indian Affairs.
107
‘‘(2) REQUIREMENTS
FOR
PROGRAMS.—Such 
programs shall include the following—
‘‘(A) school programs on nutrition edu-
cation, personal health, oral health, and fitness; 
‘‘(B) mental health wellness programs; 
‘‘(C) chronic disease prevention programs; 
‘‘(D) substance abuse prevention pro-
grams; 
‘‘(E) injury prevention and safety edu-
cation programs; and 
‘‘(F) activities for the prevention and con-
trol of communicable diseases. 
‘‘(3) DUTIES OF THE SECRETARY.—The Sec-
retary of the Interior shall—
‘‘(A) provide training to teachers in com-
prehensive school health education curricula; 
‘‘(B) ensure the integration and coordina-
tion of school-based programs with existing 
services and health programs available in the 
community; and 
‘‘(C) encourage healthy, tobacco-free school 
environments. 
‘‘SEC. 211. INDIAN YOUTH PROGRAM. 
‘‘(a) PROGRAM AUTHORIZED.—The Secretary, acting 
through the Service, is authorized to establish and admin-
108
ister a program to provide funding to Indian Tribes, Trib-
al Organizations, and Urban Indian Organizations for in-
novative mental and physical disease prevention and 
health promotion and treatment programs for Indian and 
Urban Indian preadolescent and adolescent youths. 
‘‘(b) USE OF FUNDS.—
‘‘(1) ALLOWABLE USES.—Funds made available 
under this section may be used to—
‘‘(A) develop prevention and treatment 
programs for Indian youth which promote men-
tal and physical health and incorporate cultural 
values, community and family involvement, and 
traditional health care practitioners; and 
‘‘(B) develop and provide community train-
ing and education. 
‘‘(2) PROHIBITED USE.—Funds made available 
under this section may not be used to provide serv-
ices described in section 707(c). 
‘‘(c) DUTIES OF THE SECRETARY.—The Secretary 
shall—
‘‘(1) disseminate to Indian Tribes, Tribal Orga-
nizations, and Urban Indian Organizations informa-
tion regarding models for the delivery of comprehen-
sive health care services to Indian and Urban Indian 
adolescents;
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‘‘(2) encourage the implementation of such 
models; and 
‘‘(3) at the request of an Indian Tribe, Tribal 
Organization, or Urban Indian Organization, provide 
technical assistance in the implementation of such 
models. 
‘‘(d) CRITERIA FOR REVIEW AND APPROVAL OF AP-
PLICATIONS.—The Secretary, in consultation with Indian 
Tribes, Tribal Organization, and Urban Indian Organiza-
tions, shall establish criteria for the review and approval 
of applications or proposals under this section. 
‘‘SEC. 212. PREVENTION, CONTROL, AND ELIMINATION OF 
COMMUNICABLE AND INFECTIOUS DISEASES. 
‘‘(a) FUNDING AUTHORIZED.—The Secretary, acting 
through the Service, and after consultation with Indian 
Tribes, Tribal Organizations, Urban Indian Organiza-
tions, and the Centers for Disease Control and Prevention, 
may make funding available to Indian Tribes and Tribal 
Organizations for the following: 
‘‘(1) Projects for the prevention, control, and 
elimination of communicable and infectious diseases 
including, but not limited to, tuberculosis, hepatitis, 
HIV, respiratory syncitial virus, hanta virus, sexu-
ally transmitted diseases, and H. Pylori.