206 
‘‘(1) Property, including real property and im-
provements, located on a reservation, including any 
federally recognized Indian Tribe’s reservation, 
Pueblo, or Colony, including former reservations in 
Oklahoma, Alaska Native regions established by the 
Alaska Native Claims Settlement Act and Indian al-
lotments on or near a reservation as designated and 
approved by the Bureau of Indian Affairs of the De-
partment of the Interior. 
‘‘(2) For any federally recognized Tribe not de-
scribed in paragraph (1), property located within the 
most recent boundaries of a prior Federal reserva-
tion. 
‘‘(3) Ownership interests in rents, leases, royal-
ties, or usage rights related to natural resources (in-
cluding extraction of natural resources or harvesting 
of timber, other plants and plant products, animals, 
fish, and shellfish) resulting from the exercise of fed-
erally protected rights. 
‘‘(4) Ownership interests in or usage rights to 
items not covered by paragraphs (1) through (3) 
that have unique religious, spiritual, traditional, or 
cultural significance or rights that support subsist-
ence or a traditional life style according to applicable 
tribal law or custom. 
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CCOLEMAN on PROD1PC71 with BILLS
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‘‘(d) CONTINUATION
OF CURRENT LAW PROTEC-
TIONS OF CERTAIN INDIAN PROPERTY FROM MEDICAID 
ESTATE RECOVERY.—Income, resources, and property 
that are exempt from medicaid estate recovery under title 
XIX of the Social Security Act as of April 1, 2003, under 
manual instructions issued to carry out section 1917(b)(3) 
of such Act because of Federal responsibility for Indian 
Tribes and Alaska Native Villages shall remain so exempt. 
Nothing in this subsection shall be construed as pre-
venting the Secretary from providing additional medicaid 
estate recovery exemptions for Indians. 
‘‘SEC. 413. TREATMENT UNDER MEDICAID MANAGED CARE. 
‘‘(a) PROVISION OF SERVICES, TO ENROLLEES WITH 
NON-INDIAN MEDICAID MANAGED CARE ENTITIES, BY 
INDIAN HEALTH PROGRAMS AND URBAN INDIAN ORGANI-
ZATIONS.— 
‘‘(1) PAYMENT RULES.— 
‘‘(A) IN
GENERAL.—Subject to subpara-
graph (B), in the case of an Indian who is en-
rolled with a non-Indian medicaid managed care 
entity (as defined in subsection (c)) and who re-
ceives covered medicaid managed care services 
from an Indian Health Program or an Urban 
Indian Organization, whether or not it is a par-
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CCOLEMAN on PROD1PC71 with BILLS
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ticipating provider with respect to such entity, 
the following rules apply: 
‘‘(i) DIRECT
PAYMENT.—The entity 
shall make prompt payment (in accordance 
with rules applicable to medicaid managed 
care entities under title XIX of the Social 
Security Act) to the Indian Health Pro-
gram or Urban Indian Organization at a 
rate established by the entity for such serv-
ices that is equal to the rate negotiated be-
tween such entity and the Program or Or-
ganization involved or, if such a rate has 
not been negotiated, a rate that is not less 
than the level and amount of payment 
which the entity would make for the serv-
ices if the services were furnished by a pro-
vider which is not such a Program or Or-
ganization. 
‘‘(ii) PAYMENT THROUGH STATE.—If 
there is no arrangement for direct payment 
under clause (i) or if a State provides for 
this clause to apply in lieu of clause (i), 
the State shall provide for payment to the 
Indian Health Program or Urban Indian 
Organization under its State program 
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CCOLEMAN on PROD1PC71 with BILLS
209 
under title XIX of such Act at the rate 
that would be otherwise applicable for such 
services under such program and shall pro-
vide for an appropriate adjustment of the 
capitation payment made to the entity to 
take into account such payment. 
‘‘(B) COMPLIANCE WITH GENERALLY AP-
PLICABLE REQUIREMENTS.— 
‘‘(i) IN GENERAL.—Except as other-
wise provided, as a condition of payment 
under 
subparagraph 
(A), 
the 
Indian 
Health Program or Urban Indian Organi-
zation shall comply with the generally ap-
plicable requirements of title XIX of the 
Social Security Act with respect to covered 
services. 
‘‘(ii) SATISFACTION
OF
CLAIM
RE-
QUIREMENT.—Any requirement for the 
submission of a claim or other documenta-
tion for services covered under subpara-
graph (A) by the enrollee is deemed to be 
satisfied through the submission of a claim 
or other documentation by the Indian 
Health Program or Urban Indian Organi-
zation consistent with section 403(h). 
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CCOLEMAN on PROD1PC71 with BILLS
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‘‘(C) CONSTRUCTION.—Nothing in this 
subsection shall be construed as waiving the ap-
plication of section 1902(a)(30)(A) of the Social 
Security Act (relating to application of stand-
ards to assure that payments are consistent 
with efficiency, economy, and quality of care). 
‘‘(2) ENROLLEE OPTION TO SELECT AN INDIAN 
HEALTH PROGRAM OR URBAN INDIAN ORGANIZATION 
AS PRIMARY CARE PROVIDER.—In the case of a non- 
Indian medicaid managed care entity that— 
‘‘(A) has an Indian enrolled with the enti-
ty; and 
‘‘(B) has an Indian Health Program or 
Urban Indian Organization that is participating 
as a primary care provider within the network 
of the entity, 
insofar as the Indian is otherwise eligible to receive 
services from such Program or Organization and the 
Program or Organization has the capacity to provide 
primary care services to such Indian, the Indian 
shall be allowed to choose such Program or Organi-
zation as the Indian’s primary care provider under 
the entity. 
‘‘(b) OFFERING OF MANAGED CARE THROUGH IN-
DIAN MEDICAID MANAGED CARE ENTITIES.—If— 
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CCOLEMAN on PROD1PC71 with BILLS
211 
‘‘(1) a State elects to provide services through 
medicaid managed care entities under its medicaid 
managed care program; and 
‘‘(2) an Indian Health Program or Urban In-
dian Organization that is funded in whole or in part 
by the Service, or a consortium thereof, has estab-
lished an Indian medicaid managed care entity in 
the State that meets generally applicable standards 
required of such an entity under such medicaid man-
aged care program, 
the State shall offer to enter into an agreement with the 
entity to serve as a medicaid managed care entity with 
respect to eligible Indians served by such entity under 
such program. 
‘‘(c) SPECIAL RULES FOR INDIAN MANAGED CARE 
ENTITIES.—The following are special rules regarding the 
application of a medicaid managed care program to Indian 
medicaid managed care entities: 
‘‘(1) ENROLLMENT.— 
‘‘(A) LIMITATION TO INDIANS.—An Indian 
medicaid managed care entity may restrict en-
rollment under such program to Indians and to 
members of specific Tribes in the same manner 
as Indian Health Programs may restrict the de-
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CCOLEMAN on PROD1PC71 with BILLS
212 
livery of services to such Indians and tribal 
members. 
‘‘(B) NO LESS CHOICE OF PLANS.—Under 
such program the State may not limit the 
choice of an Indian among medicaid managed 
care entities only to Indian medicaid managed 
care entities or to be more restrictive than the 
choice of managed care entities offered to indi-
viduals who are not Indians. 
‘‘(C) DEFAULT ENROLLMENT.— 
‘‘(i) IN GENERAL.—If such program 
of a State requires the enrollment of Indi-
ans in a medicaid managed care entity in 
order to receive benefits, the State shall 
provide for the enrollment of Indians de-
scribed in clause (ii) who are not otherwise 
enrolled with such an entity in an Indian 
medicaid managed care entity described in 
such clause. 
‘‘(ii) INDIAN DESCRIBED.—An Indian 
described in this clause, with respect to an 
Indian medicaid managed care entity, is an 
Indian who, based upon the service area 
and capacity of the entity, is eligible to be 
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CCOLEMAN on PROD1PC71 with BILLS
213 
enrolled with the entity consistent with 
subparagraph (A). 
‘‘(D) EXCEPTION TO STATE LOCK-IN.—A 
request by an Indian who is enrolled under such 
program with a non-Indian medicaid managed 
care entity to change enrollment with that enti-
ty to enrollment with an Indian medicaid man-
aged care entity shall be considered cause for 
granting such request under procedures speci-
fied by the Secretary. 
‘‘(2) FLEXIBILITY
IN
APPLICATION
OF
SOL-
VENCY.—In applying section 1903(m)(1) of the So-
cial Security Act to an Indian medicaid managed 
care entity— 
‘‘(A) any reference to a ‘State’ in subpara-
graph (A)(ii) of that section shall be deemed to 
be a reference to the ‘Secretary’; and 
‘‘(B) the entity shall be deemed to be a 
public entity described in subparagraph (C)(ii) 
of that section. 
‘‘(3) EXCEPTIONS TO ADVANCE DIRECTIVES.— 
The Secretary may modify or waive the require-
ments of section 1902(w) of the Social Security Act 
(relating to provision of written materials on ad-
vance directives) insofar as the Secretary finds that 
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CCOLEMAN on PROD1PC71 with BILLS
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the requirements otherwise imposed are not an ap-
propriate or effective way of communicating the in-
formation to Indians. 
‘‘(4) FLEXIBILITY IN INFORMATION AND MAR-
KETING.— 
‘‘(A) MATERIALS.—The Secretary may 
modify requirements under section 1932(a)(5) 
of the Social Security Act in a manner that im-
proves the materials to take into account the 
special circumstances of such entities and their 
enrollees while maintaining and clearly commu-
nicating to potential enrollees their rights, pro-
tections, and benefits. 
‘‘(B) DISTRIBUTION OF MARKETING MATE-
RIALS.—The 
provisions 
of 
section 
1932(d)(2)(B) of the Social Security Act re-
quiring the distribution of marketing materials 
to an entire service area shall be deemed satis-
fied in the case of an Indian medicaid managed 
care entity that distributes appropriate mate-
rials only to those Indians who are potentially 
eligible to enroll with the entity in the service 
area. 
‘‘(d) MALPRACTICE INSURANCE.—Insofar as, under 
a medicaid managed care program, a health care provider 
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CCOLEMAN on PROD1PC71 with BILLS
215 
is required to have medical malpractice insurance coverage 
as a condition of contracting as a provider with a medicaid 
managed care entity, an Indian Health Program, or an 
Urban Indian Organization that is a Federally-qualified 
health center under title XIX of the Social Security Act, 
that is covered under the Federal Tort Claims Act (28 
U.S.C. 1346(b), 2671 et seq.) is deemed to satisfy such 
requirement. 
‘‘(e) DEFINITIONS.—For purposes of this section: 
‘‘(1) MEDICAID MANAGED CARE ENTITY.—The 
term ‘medicaid managed care entity’ means a man-
aged care entity (whether a managed care organiza-
tion or a primary care case manager) under title 
XIX of the Social Security Act, whether pursuant to 
section 1903(m) or section 1932 of such Act, a waiv-
er under section 1115 or 1915(b) of such Act, or 
otherwise. 
‘‘(2) INDIAN MEDICAID MANAGED CARE ENTI-
TY.—The term ‘Indian medicaid managed care enti-
ty’ means a managed care entity that is controlled 
(within the meaning of the last sentence of section 
1903(m)(1)(C) of the Social Security Act) by the In-
dian Health Service, a Tribe, Tribal Organization, or 
Urban Indian Organization (as such terms are de-
fined in section 4), or a consortium, which may be 
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CCOLEMAN on PROD1PC71 with BILLS
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composed of 1 or more Tribes, Tribal Organizations, 
or Urban Indian Organizations, and which also may 
include the Service. 
‘‘(3) NON-INDIAN
MEDICAID
MANAGED
CARE 
ENTITY.—The term ‘non-Indian medicaid managed 
care entity’ means a medicaid managed care entity 
that is not an Indian medicaid managed care entity. 
‘‘(4) COVERED
MEDICAID
MANAGED
CARE 
SERVICES.—The term ‘covered medicaid managed 
care services’ means, with respect to an individual 
enrolled with a medicaid managed care entity, items 
and services that are within the scope of items and 
services for which benefits are available with respect 
to the individual under the contract between the en-
tity and the State involved. 
‘‘(5) MEDICAID
MANAGED
CARE
PROGRAM.— 
The term ‘medicaid managed care program’ means 
a program under sections 1903(m) and 1932 of the 
Social Security Act and includes a managed care 
program operating under a waiver under section 
1915(b) or 1115 of such Act or otherwise. 
‘‘SEC. 414. NAVAJO NATION MEDICAID AGENCY FEASI-
BILITY STUDY. 
‘‘(a) STUDY.—The Secretary shall conduct a study 
to determine the feasibility of treating the Navajo Nation 
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CCOLEMAN on PROD1PC71 with BILLS
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as a State for the purposes of title XIX of the Social Secu-
rity Act, to provide services to Indians living within the 
boundaries of the Navajo Nation through an entity estab-
lished having the same authority and performing the same 
functions as single-State medicaid agencies responsible for 
the administration of the State plan under title XIX of 
the Social Security Act. 
‘‘(b) CONSIDERATIONS.—In conducting the study, 
the Secretary shall consider the feasibility of— 
‘‘(1) assigning and paying all expenditures for 
the provision of services and related administration 
funds, under title XIX of the Social Security Act, to 
Indians living within the boundaries of the Navajo 
Nation that are currently paid to or would otherwise 
be paid to the State of Arizona, New Mexico, or 
Utah; 
‘‘(2) providing assistance to the Navajo Nation 
in the development and implementation of such enti-
ty for the administration, eligibility, payment, and 
delivery of medical assistance under title XIX of the 
Social Security Act; 
‘‘(3) providing an appropriate level of matching 
funds for Federal medical assistance with respect to 
amounts such entity expends for medical assistance 
for services and related administrative costs; and 
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