282
‘‘(5) A general audit report of the Secretary on 
the Health Care Educational Loan Repayment Pro-
gram as required by section 110(n). 
‘‘(6) A report of the findings and conclusions of 
demonstration programs on development of edu-
cational curricula for substance abuse counseling as 
required in section 126(f). 
‘‘(7) A separate statement which specifies the 
amount of funds requested to carry out the provi-
sions of section 201. 
‘‘(8) A report of the evaluations of health pro-
motion and disease prevention as required in section 
203(c). 
‘‘(9) A biennial report to Congress on infectious 
diseases as required by section 212. 
‘‘(10) A report on environmental and nuclear 
health hazards as required by section 215. 
‘‘(11) An annual report on the status of all 
health care facilities needs as required by section 
301(c)(2) and 301(d). 
‘‘(12) Reports on safe water and sanitary waste 
disposal facilities as required by section 302(i). 
‘‘(13) An annual report on the expenditure of 
nonservice funds for renovation as required by sec-
tions 304(b)(2).
283
‘‘(14) A report identifying the backlog of main-
tenance and repair required at Service and tribal fa-
cilities required by section 313(a). 
‘‘(15) A report providing an accounting of reim-
bursement funds made available to the Secretary 
under titles XVIII, XIX, and XXI of the Social Se-
curity Act. 
‘‘(16) A report on any arrangements for the 
sharing of medical facilities or services between the 
Service, Indian Tribes, and Tribal Organizations, 
and the Department of Veterans Affairs and the De-
partment of Defense, as authorized by section 406. 
‘‘(17) A report on evaluation and renewal of 
Urban Indian programs under section 505. 
‘‘(18) A report on the evaluation of programs 
as required by section 513(d). 
‘‘(19) A report on alcohol and substance abuse 
as required by section 701(f). 
‘‘SEC. 802. REGULATIONS. 
‘‘(a) DEADLINES.—
‘‘(1) PROCEDURES.—Not later than 90 days 
after the date of the enactment of the Indian Health 
Care Improvement Act Amendments of 2003, the 
Secretary shall initiate procedures under subchapter 
III of chapter 5 of title 5, United States Code, to
284
negotiate and promulgate such regulations or 
amendments thereto that are necessary to carry out 
titles I, II, III, IV, and VII and section 817. The 
Secretary may promulgate regulations to carry out 
sections 105, 115, 117, and title V, using the proce-
dures required by the Administrative Procedures 
Act. The Secretary shall issue no regulations to 
carry out titles VI and VIII, except as necessary to 
carry out section 817. 
‘‘(2) PROPOSED REGULATIONS.—Proposed reg-
ulations to implement this Act shall be published in 
the Federal Register by the Secretary no later than 
270 days after the date of the enactment of the In-
dian Health Care Improvement Act Amendments of 
2003 and shall have no less than a 120-day com-
ment period. 
‘‘(3) EXPIRATION OF AUTHORITY.—The author-
ity to promulgate regulations under this Act shall 
expire 18 months from the date of the enactment of 
this Act. 
‘‘(b) COMMITTEE.—A negotiated rulemaking com-
mittee established pursuant to section 565 of title 5,
United States Code, to carry out this section shall have 
as its members only representatives of the Federal Gov-
ernment and representatives of Indian Tribes and Tribal
285
Organizations, a majority of whom shall be nominated by 
and be representatives of Indian Tribes, Tribal Organiza-
tions, and Urban Indian Organizations from each Service 
Area. 
‘‘(c) ADAPTATION OF PROCEDURES.—The Secretary 
shall adapt the negotiated rulemaking procedures to the 
unique context of self-governance and the government-to-
government relationship between the United States and 
Indian Tribes. 
‘‘(d) LACK OF REGULATIONS.—The lack of promul-
gated regulations shall not limit the effect of this Act. 
‘‘(e) INCONSISTENT REGULATIONS.—The provisions 
of this Act shall supersede any conflicting provisions of 
law (including any conflicting regulations) in effect on the 
day before the date of the enactment of the Indian Health 
Care Improvement Act Amendments of 2003, and the Sec-
retary is authorized to repeal any regulation inconsistent 
with the provisions of this Act. 
‘‘SEC. 803. PLAN OF IMPLEMENTATION. 
‘‘Not later than 8 months after the date of the enact-
ment of the Indian Health Care Improvement Act Amend-
ments of 2003, the Secretary in consultation with Indian 
Tribes, Tribal Organizations, and Urban Indian Organiza-
tions, shall submit to Congress a plan explaining the man-
ner and schedule (including a schedule of appropriation
286
requests), by title and section, by which the Secretary will 
implement the provisions of this Act. 
‘‘SEC. 804. AVAILABILITY OF FUNDS. 
‘‘The funds appropriated pursuant to this Act shall 
remain available until expended. 
‘‘SEC. 805. LIMITATION ON USE OF FUNDS APPROPRIATED 
TO THE INDIAN HEALTH SERVICE. 
‘‘Any limitation on the use of funds contained in an 
Act providing appropriations for the Department for a pe-
riod with respect to the performance of abortions shall 
apply for that period with respect to the performance of 
abortions using funds contained in an Act providing ap-
propriations for the Service. 
‘‘SEC. 806. ELIGIBILITY OF CALIFORNIA INDIANS. 
‘‘(a) IN GENERAL.—The following California Indians 
shall be eligible for health services provided by the Service: 
‘‘(1) Any member of a federally recognized In-
dian Tribe. 
‘‘(2) Any descendant of an Indian who was re-
siding in California on June 1, 1852, if such de-
scendant—
‘‘(A) is a member of the Indian community 
served by a local program of the Service; and 
‘‘(B) is regarded as an Indian by the com-
munity in which such descendant lives.
287
‘‘(3) Any Indian who holds trust interests in 
public domain, national forest, or reservation allot-
ments in California. 
‘‘(4) Any Indian in California who is listed on 
the plans for distribution of the assets of California 
rancherias and reservations under the Act of August 
18, 1958 (72 Stat. 619), and any descendant of 
such an Indian. 
‘‘(b) CLARIFICATION.—Nothing in this section may 
be construed as expanding the eligibility of California Indi-
ans for health services provided by the Service beyond the 
scope of eligibility for such health services that applied on 
May 1, 1986. 
‘‘SEC. 807. HEALTH SERVICES FOR INELIGIBLE PERSONS. 
‘‘(a) CHILDREN.—Any individual who—
‘‘(1) has not attained 19 years of age; 
‘‘(2) is the natural or adopted child, stepchild, 
foster child, legal ward, or orphan of an eligible In-
dian; and 
‘‘(3) is not otherwise eligible for health services 
provided by the Service, 
shall be eligible for all health services provided by the 
Service on the same basis and subject to the same rules 
that apply to eligible Indians until such individual attains 
19 years of age. The existing and potential health needs
288
of all such individuals shall be taken into consideration 
by the Service in determining the need for, or the alloca-
tion of, the health resources of the Service. If such an indi-
vidual has been determined to be legally incompetent prior 
to attaining 19 years of age, such individual shall remain 
eligible for such services until 1 year after the date of a 
determination of competency. 
‘‘(b) SPOUSES.—Any spouse of an eligible Indian who 
is not an Indian, or who is of Indian descent but not other-
wise eligible for the health services provided by the Serv-
ice, shall be eligible for such health services if all such 
spouses or spouses who are married to members of the 
Indian Tribe(s) being served are made eligible, as a class, 
by an appropriate resolution of the governing body of the 
Indian Tribe or Tribal Organization providing such serv-
ices. The health needs of persons made eligible under this 
paragraph shall not be taken into consideration by the 
Service in determining the need for, or allocation of, its 
health resources. 
‘‘(c) PROVISION OF SERVICES TO OTHER INDIVID-
UALS.—
‘‘(1) IN GENERAL.—The Secretary is authorized 
to provide health services under this subsection 
through health programs operated directly by the 
Service to individuals who reside within the Service
289
Unit and who are not otherwise eligible for such 
health services if—
‘‘(A) the Indian Tribes served by such 
Service Unit request such provision of health 
services to such individuals; and 
‘‘(B) the Secretary and the served Indian 
Tribes have jointly determined that—
‘‘(i) the provision of such health serv-
ices will not result in a denial or diminu-
tion of health services to eligible Indians; 
and 
‘‘(ii) there is no reasonable alternative 
health facilities or services, within or with-
out the Service Unit, available to meet the 
health needs of such individuals. 
‘‘(2) ISDEAA PROGRAMS.—In the case of a 
Tribal Health Program, the governing body of the 
Indian Tribe or Tribal Organization providing health 
services under such Tribal Health Program is au-
thorized to determine whether health services should 
be provided under its Funding Agreement to individ-
uals who are not otherwise eligible for such services. 
In making such determination, the governing body 
shall take into account the considerations described 
in clauses (i) and (ii) of paragraph (1)(B).
290
‘‘(3) PAYMENT FOR SERVICES.—
‘‘(A) IN
GENERAL.—Persons receiving 
health services provided by the Service under of 
this subsection shall be liable for payment of 
such health services under a schedule of charges 
prescribed by the Secretary which, in the judg-
ment of the Secretary, results in reimbursement 
in an amount not less than the actual cost of 
providing the health services. Notwithstanding 
section 1880(c) of the Social Security Act, sec-
tion 404 of this Act, or any other provision of 
law, amounts collected under this subsection, 
including medicare, medicaid, or SCHIP reim-
bursements under titles XVIII, XIX, and XXI 
of the Social Security Act, shall be credited to 
the account of the program providing the serv-
ice and shall be used for the purposes listed in 
section 401(d)(2) and amounts collected under 
this subsection shall be available for expendi-
ture within such program. 
‘‘(B) INDIGENT PEOPLE.—Health services 
may be provided by the Secretary through the 
Service under this subsection to an indigent in-
dividual who would not be otherwise eligible for 
such health services but for the provisions of
291
paragraph (1) only if an agreement has been 
entered into with a State or local government 
under which the State or local government 
agrees to reimburse the Service for the expenses 
incurred by the Service in providing such health 
services to such indigent individual. 
‘‘(4) REVOCATION
OF
CONSENT
FOR
SERV-
ICES.—
‘‘(A) SINGLE
TRIBE
SERVICE
AREA.—In 
the case of a Service Area which serves only 1 
Indian Tribe, the authority of the Secretary to 
provide health services under paragraph (1) 
shall terminate at the end of the fiscal year suc-
ceeding the fiscal year in which the governing 
body of the Indian Tribe revokes its concur-
rence to the provision of such health services. 
‘‘(B) MULTITRIBAL
SERVICE
AREA.—In 
the case of a multitribal Service Area, the au-
thority of the Secretary to provide health serv-
ices under paragraph (1) shall terminate at the 
end of the fiscal year succeeding the fiscal year 
in which at least 51 percent of the number of 
Indian Tribes in the Service Area revoke their 
concurrence to the provisions of such health 
services.
292
‘‘(d) OTHER SERVICES.—The Service may provide 
health services under this subsection to individuals who 
are not eligible for health services provided by the Service 
under any other provision of law in order to—
‘‘(1) achieve stability in a medical emergency; 
‘‘(2) prevent the spread of a communicable dis-
ease or otherwise deal with a public health hazard; 
‘‘(3) provide care to non-Indian women preg-
nant with an eligible Indian’s child for the duration 
of the pregnancy through postpartum; or 
‘‘(4) provide care to immediate family members 
of an eligible person if such care is directly related 
to the treatment of the eligible individual. 
‘‘(e) HOSPITAL PRIVILEGES FOR PRACTITIONERS.—
Hospital privileges in health facilities operated and main-
tained by the Service or operated under a Funding Agree-
ment may be extended to non-Service health care practi-
tioners who provide services to individuals described in 
subsection (a), (b), (c), or (d). Such non-Service health 
care practitioners may be regarded as employees of the 
Federal Government for purposes of section 1346(b) and 
chapter 171 of title 28, United States Code (relating to 
Federal tort claims) only with respect to acts or omissions 
which occur in the course of providing services to eligible
293
persons as a part of the conditions under which such hos-
pital privileges are extended. 
‘‘(f) ELIGIBLE INDIAN.—For purposes of this sec-
tion, the term ‘eligible Indian’ means any Indian who is 
eligible for health services provided by the Service without 
regard to the provisions of this section. 
‘‘SEC. 808. REALLOCATION OF BASE RESOURCES. 
‘‘(a) REPORT
REQUIRED.—Notwithstanding any 
other provision of law, any allocation of Service funds for 
a fiscal year that reduces by 5 percent or more from the 
previous fiscal year the funding for any recurring pro-
gram, project, or activity of a Service Unit may be imple-
mented only after the Secretary has submitted to the 
President, for inclusion in the report required to be trans-
mitted to Congress under section 801, a report on the pro-
posed change in allocation of funding, including the rea-
sons for the change and its likely effects. 
‘‘(b) EXCEPTION.—Subsection (a) shall not apply if 
the total amount appropriated to the Service for a fiscal 
year is at least 5 percent less than the amount appro-
priated to the Service for the previous fiscal year.
‘‘SEC. 809. RESULTS OF DEMONSTRATION PROJECTS. 
‘‘The Secretary shall provide for the dissemination to 
Indian Tribes, Tribal Organizations, and Urban Indian
294
Organizations of the findings and results of demonstration 
projects conducted under this Act. 
‘‘SEC. 810. PROVISION OF SERVICES IN MONTANA. 
‘‘(a) CONSISTENT WITH COURT DECISION.—The 
Secretary, acting through the Service, shall provide serv-
ices and benefits for Indians in Montana in a manner con-
sistent with the decision of the United States Court of Ap-
peals for the Ninth Circuit in McNabb for McNabb v. 
Bowen, 829 F.2d 787 (9th Cir. 1987). 
‘‘(b) CLARIFICATION.—The provisions of subsection 
(a) shall not be construed to be an expression of the sense 
of Congress on the application of the decision described 
in subsection (a) with respect to the provision of services 
or benefits for Indians living in any State other than Mon-
tana. 
‘‘SEC. 811. MORATORIUM. 
‘‘During the period of the moratorium imposed on 
implementation of the final rule published in the Federal 
Register on September 16, 1987, by the Health Resources 
and Services Administration of the Public Health Service, 
relating to eligibility for the health care services of the 
Indian Health Service, the Indian Health Service shall 
provide services pursuant to the criteria for eligibility for 
such services that were in effect on September 15, 1987, 
subject to the provisions of sections 806 and 807 until
295
such time as new criteria governing eligibility for services 
are developed in accordance with section 802. 
‘‘SEC. 812. TRIBAL EMPLOYMENT. 
‘‘For purposes of section 2(2) of the Act of July 5, 
1935 (49 Stat. 450, chapter 372), an Indian Tribe or 
Tribal Organization carrying out a Funding Agreement 
shall not be considered an ‘employer’. 
‘‘SEC. 813. PRIME VENDOR. 
‘‘(a) EXECUTIVE AGENCY STATUS.—For purposes of 
section 201(a) of the Federal Property and Administrative 
Services Act (40 U.S.C. 481(a)) (relating to Federal 
sources of supply, including lodging providers, airlines, 
and other transportation providers), a Tribal Health Pro-
gram shall be deemed an executive agency when carrying 
out a contract, grant, cooperative agreement, or Funding 
Agreement with the Service and shall have access to the 
Federal Supply Schedule and any other Federal source of 
supply to which executive agencies have access. 
‘‘(b) HHS STATUS.—For purposes of section 4 of 
Public Law 102–585 (38 U.S.C. 8126), a Tribal Health 
Program shall have the status of the Indian Health Serv-
ice and shall have direct access to the Veterans Adminis-
tration prime vendor provided for in section 4 of Public 
Law 102–585.
296
‘‘(c) EMPLOYEE STATUS.—The employees of such 
Tribal Health Programs may order supplies under such 
respective programs on the same basis as employees of the 
Service. 
‘‘SEC. 814. SEVERABILITY PROVISIONS. 
‘‘If any provision of this Act, any amendment made 
by the Act, or the application of such provision or amend-
ment to any person or circumstances is held to be invalid, 
the remainder of this Act, the remaining amendments 
made by this Act, and the application of such provisions 
to persons or circumstances other than those to which it 
is held invalid, shall not be affected thereby. 
‘‘SEC. 815. ESTABLISHMENT OF NATIONAL BIPARTISAN 
COMMISSION ON INDIAN HEALTH CARE ENTI-
TLEMENT. 
‘‘(a) ESTABLISHMENT.—There is hereby established 
the National Bipartisan Indian Health Care Entitlement 
Commission (the ‘Commission’). 
‘‘(b) DUTIES OF COMMISSION.—The duties of the 
Commission are the following: 
‘‘(1) To establish a study committee composed 
of those members of the Commission appointed by 
the Director and at least 4 members of Congress 
from among the members of the Commission, the 
duties of which shall be the following:
297
‘‘(A) To the extent necessary to carry out 
its duties, collect and compile data necessary to 
understand the extent of Indian needs with re-
gard to the provision of health services, regard-
less of the location of Indians, including holding 
hearings and soliciting the views of Indians, In-
dian Tribes, Tribal Organizations, and Urban 
Indian Organizations, which may include au-
thorizing and making funds available for feasi-
bility studies of various models for providing 
and funding health services for all Indian bene-
ficiaries, including those who live outside of a 
reservation, temporarily or permanently. 
‘‘(B) To make recommendations to the 
Commission for legislation that will provide for 
the delivery of health services for Indians as an 
entitlement, which will address, among other 
things, issues of eligibility, benefits to be pro-
vided, including recommendations regarding 
from whom such health services are to be pro-
vided and the cost, including mechanisms for 
making funds available for the health services 
to be provided.
‘‘(C) To determine the effect of the enact-
ment of such recommendations on (i) the exist-
298
ing system of delivery of health services for In-
dians, and (ii) the sovereign status of Indian 
Tribes. 
‘‘(D) Not later than 12 months after the 
appointment of all members of the Commission, 
to submit a written report of its findings and 
recommendations to the full Commission. The 
report shall include a statement of the minority 
and majority position of the Committee and 
shall be disseminated, at a minimum, to every 
Indian Tribe, Tribal Organization, and Urban 
Indian Organization for comment to the Com-
mission. 
‘‘(E) To report regularly to the full Com-
mission 
regarding 
the 
findings 
and 
rec-
ommendations developed by the study com-
mittee in the course of carrying out its duties 
under this section. 
‘‘(2) To review and analyze the recommenda-
tions of the report of the study committee. 
‘‘(3) To make recommendations to Congress for 
providing health services for Indians as an entitle-
ment, giving due regard to the effects of such a pro-
gram on existing health care delivery systems for In-
299
dians and the effect of such a program on the sov-
ereign status of Indian Tribes. 
‘‘(4) Not later than 18 months following the 
date of appointment of all members of the Commis-
sion, submit a written report to Congress containing 
a recommendation of policies and legislation to im-
plement a policy that would establish a health care 
system for Indians based on delivery of health serv-
ices as an entitlement, together with a determination 
of the implications of such an entitlement system on 
existing health care delivery systems for Indians and 
on the sovereign status of Indian Tribes. 
‘‘(c) MEMBERS.—
‘‘(1) APPOINTMENT.—The Commission shall be 
composed of 25 members, appointed as follows: 
‘‘(A) Ten members of Congress, including 
3 from the United States House of Representa-
tives and 2 from the United States Senate, ap-
pointed by their respective majority leaders, and 
3 from the United States House of Representa-
tives and 2 from the United States Senate, ap-
pointed by their respective minority leaders, and 
who shall be members of the standing commit-
tees of Congress that consider legislation affect-
ing health care to Indians.
300
‘‘(B) Twelve persons chosen by the Con-
gressional members of the Commission, 1 from 
each Service Area as currently designated by 
the Director to be chosen from among 3 nomi-
nees from each Service Area put forward by the 
Indian Tribes within the area, with due regard 
being given to the experience and expertise of 
the nominees in the provision of health care to 
Indians and to a reasonable representation on 
the commission of members who are familiar 
with various health care delivery modes and 
who represent Indian Tribes of various size 
populations. 
‘‘(C) Three persons appointed by the Di-
rector who are knowledgeable about the provi-
sion of health care to Indians, at least one of 
whom shall be appointed from among 3 nomi-
nees put forward by those programs whose 
funds are provided in whole or in part by the 
Service primarily or exclusively for the benefit 
of Urban Indians. 
‘‘(D) All those persons chosen by the Con-
gressional members of the Commission and by 
the Director shall be members of federally rec-
ognized Indian Tribes.
301
‘‘(2) CHAIR; VICE CHAIR.—The Chair and Vice 
Chair of the Commission shall be selected by the 
Congressional members of the Commission. 
‘‘(3) TERMS.—The terms of members of the 
Commission shall be for the life of the Commission. 
‘‘(4) DEADLINE
FOR
APPOINTMENTS.—Con-
gressional members of the Commission shall be ap-
pointed not later than 90 days after the date of the 
enactment of the Indian Health Care Improvement 
Act Amendments of 2003, and the remaining mem-
bers of the Commission shall be appointed not later 
than 60 days following the appointment of the Con-
gressional members. 
‘‘(5) VACANCY.—A vacancy in the Commission 
shall be filled in the manner in which the original 
appointment was made. 
‘‘(d) COMPENSATION.—
‘‘(1) CONGRESSIONAL
MEMBERS.—Each Con-
gressional member of the Commission shall receive 
no additional pay, allowances, or benefits by reason 
of their service on the Commission and shall receive 
travel expenses and per diem in lieu of subsistence 
in accordance with sections 5702 and 5703 of title 
5, United States Code.
302
‘‘(2) OTHER
MEMBERS.—Remaining members 
of the Commission, while serving on the business of 
the Commission (including travel time), shall be en-
titled to receive compensation at the per diem equiv-
alent of the rate provided for level IV of the Execu-
tive Schedule under section 5315 of title 5, United 
States Code, and while so serving away from home 
and the member’s regular place of business, a mem-
ber may be allowed travel expenses, as authorized by 
the Chairman of the Commission. For purpose of 
pay (other than pay of members of the Commission) 
and employment benefits, rights, and privileges, all 
personnel of the Commission shall be treated as if 
they were employees of the United States Senate. 
‘‘(e) MEETINGS.—The Commission shall meet at the 
call of the Chair. 
‘‘(f) QUORUM.—A quorum of the Commission shall 
consist of not less than 15 members, provided that no less 
than 6 of the members of Congress who are Commission 
members are present and no less than 9 of the members 
who are Indians are present. 
‘‘(g) EXECUTIVE DIRECTOR; STAFF; FACILITIES.—
‘‘(1) APPOINTMENT; PAY.—The Commission 
shall appoint an executive director of the Commis-
303
sion. The executive director shall be paid the rate of 
basic pay for level V of the Executive Schedule. 
‘‘(2) STAFF APPOINTMENT.—With the approval 
of the Commission, the executive director may ap-
point such personnel as the executive director deems 
appropriate. 
‘‘(3) STAFF PAY.—The staff of the Commission 
shall be appointed without regard to the provisions 
of title 5, United States Code, governing appoint-
ments in the competitive service, and shall be paid 
without regard to the provisions of chapter 51 and 
subchapter III of chapter 53 of such title (relating 
to classification and General Schedule pay rates). 
‘‘(4) TEMPORARY
SERVICES.—With the ap-
proval of the Commission, the executive director may 
procure temporary and intermittent services under 
section 3109(b) of title 5, United States Code. 
‘‘(5) FACILITIES.—The Administrator of Gen-
eral Services shall locate suitable office space for the 
operation of the Commission. The facilities shall 
serve as the headquarters of the Commission and 
shall include all necessary equipment and incidentals 
required for the proper functioning of the Commis-
sion.
304
‘‘(h) HEARINGS.—(1) For the purpose of carrying 
out its duties, the Commission may hold such hearings 
and undertake such other activities as the Commission de-
termines to be necessary to carry out its duties, provided 
that at least 6 regional hearings are held in different areas 
of the United States in which large numbers of Indians 
are present. Such hearings are to be held to solicit the 
views of Indians regarding the delivery of health care serv-
ices to them. To constitute a hearing under this sub-
section, at least 5 members of the Commission, including 
at least 1 member of Congress, must be present. Hearings 
held by the study committee established in this section 
may count towards the number of regional hearings re-
quired by this subsection. 
‘‘(2) Upon request of the Commission, the Comp-
troller General shall conduct such studies or investigations 
as the Commission determines to be necessary to carry 
out its duties. 
‘‘(3)(A) The Director of the Congressional Budget 
Office or the Chief Actuary of the Centers for Medicare 
and Medicaid Services, or both, shall provide to the Com-
mission, upon the request of the Commission, such cost 
estimates as the Commission determines to be necessary 
to carry out its duties.
305
‘‘(B) The Commission shall reimburse the Director 
of the Congressional Budget Office for expenses relating 
to the employment in the office of the Director of such 
additional staff as may be necessary for the Director to 
comply with requests by the Commission under subpara-
graph (A). 
‘‘(4) Upon the request of the Commission, the head 
of any Federal agency is authorized to detail, without re-
imbursement, any of the personnel of such agency to the 
Commission to assist the Commission in carrying out its 
duties. Any such detail shall not interrupt or otherwise 
affect the civil service status or privileges of the Federal 
employee. 
‘‘(5) Upon the request of the Commission, the head 
of a Federal agency shall provide such technical assistance 
to the Commission as the Commission determines to be 
necessary to carry out its duties. 
‘‘(6) The Commission may use the United States 
mails in the same manner and under the same conditions 
as Federal agencies and shall, for purposes of the frank, 
be considered a commission of Congress as described in 
section 3215 of title 39, United States Code. 
‘‘(7) The Commission may secure directly from any 
Federal agency information necessary to enable it to carry 
out its duties, if the information may be disclosed under
306
section 552 of title 4, United States Code. Upon request 
of the Chairman of the Commission, the head of such 
agency shall furnish such information to the Commission. 
‘‘(8) Upon the request of the Commission, the Ad-
ministrator of General Services shall provide to the Com-
mission on a reimbursable basis such administrative sup-
port services as the Commission may request. 
‘‘(9) For purposes of costs relating to printing and 
binding, including the cost of personnel detailed from the 
Government Printing Office, the Commission shall be 
deemed to be a committee of Congress. 
‘‘(i) AUTHORIZATION OF APPROPRIATIONS.—There is 
authorized to be appropriated $4,000,000 to carry out the 
provisions of this section, which sum shall not be deducted 
from or affect any other appropriation for health care for 
Indian persons. 
‘‘(j) FACA.—The Federal Advisory Committee Act 
(5 U.S.C. App.) shall not apply to the Commission. 
‘‘SEC. 816. APPROPRIATIONS; AVAILABILITY. 
‘‘Any new spending authority (described in subsection 
(c)(2)(A) or (B) of section 401 of the Congressional Budg-
et Act of 1974) which is provided under this Act shall 
be effective for any fiscal year only to such extent or in 
such amounts as are provided in appropriation Acts.
307
‘‘SEC. 817. CONFIDENTIALITY OF MEDICAL QUALITY ASSUR-
ANCE RECORDS: QUALIFIED IMMUNITY FOR 
PARTICIPANTS. 
‘‘(a) CONFIDENTIALITY OF RECORDS.—Medical qual-
ity assurance records created by or for any Indian Health 
Program or a health program of an Urban Indian Organi-
zation as part of a medical quality assurance program are 
confidential and privileged. Such records may not be dis-
closed to any person or entity, except as provided in sub-
section (c). 
‘‘(b) PROHIBITION
ON DISCLOSURE
AND TESTI-
MONY.—
‘‘(1) No part of any medical quality assurance 
record described in subsection (a) may be subject to 
discovery or admitted into evidence in any judicial or 
administrative proceeding, except as provided in sub-
section (c). 
‘‘(2) A person who reviews or creates medical 
quality assurance records for any Indian health pro-
gram or who participates in any proceeding that re-
views or creates such records may not be permitted 
or required to testify in any judicial or administra-
tive proceeding with respect to such records or with
respect to any finding, recommendation, evaluation, 
opinion, or action taken by such person or body in
308
connection with such records except as provided in 
this section. 
‘‘(c) AUTHORIZED DISCLOSURE AND TESTIMONY.—
‘‘(1) Subject to paragraph (2), a medical qual-
ity assurance record described in subsection (a) may 
be disclosed, and a person referred to in subsection 
(b) may give testimony in connection with such a 
record, only as follows: 
‘‘(A) To a Federal executive agency or pri-
vate organization, if such medical quality assur-
ance record or testimony is needed by such 
agency or organization to perform licensing or 
accreditation functions related to any Indian 
Health Program or to a health program of an 
Urban Indian Organization to perform moni-
toring, required by law, of such program or or-
ganization. 
‘‘(B) To an administrative or judicial pro-
ceeding commenced by a present or former In-
dian Health Program or Urban Indian Organi-
zation provider concerning the termination, sus-
pension, or limitation of clinical privileges of 
such health care provider. 
‘‘(C) To a governmental board or agency 
or to a professional health care society or orga-
310
applicable law with the protection of the public 
health or safety, if a qualified representative of 
such agency or instrumentality makes a written 
request that such record or testimony be pro-
vided for a purpose authorized by law. 
‘‘(G) In an administrative or judicial pro-
ceeding commenced by a criminal or civil law 
enforcement agency or instrumentality referred 
to in subparagraph (F), but only with respect 
to the subject of such proceeding. 
‘‘(2) With the exception of the subject of a 
quality assurance action, the identity of any person 
receiving health care services from any Indian 
Health Program or Urban Indian Organization or 
the identity of any other person associated with such 
program or organization for purposes of a medical 
quality assurance program that is disclosed in a 
medical quality assurance record described in sub-
section (a) shall be deleted from that record or docu-
ment before any disclosure of such record is made 
outside such program or organization. Such require-
ment does not apply to the release of information 
pursuant to section 552a of title 5. 
‘‘(d) DISCLOSURE FOR CERTAIN PURPOSES.—
311
‘‘(1) Nothing in this section shall be construed 
as authorizing or requiring the withholding from any 
person or entity aggregate statistical information re-
garding the results of any Indian Health Program or 
Urban Indian Organizations’s medical quality assur-
ance programs. 
‘‘(2) Nothing in this section shall be construed 
as authority to withhold any medical quality assur-
ance record from a committee of either House of 
Congress, any joint committee of Congress, or the 
General Accounting Office if such record pertains to 
any matter within their respective jurisdictions. 
‘‘(e) PROHIBITION ON DISCLOSURE OF RECORD OR 
TESTIMONY.—A person or entity having possession of or 
access to a record or testimony described by this section 
may not disclose the contents of such record or testimony 
in any manner or for any purpose except as provided in 
this section. 
‘‘(f) EXEMPTION FROM FREEDOM OF INFORMATION 
ACT.—Medical quality assurance records described in sub-
section (a) may not be made available to any person under 
section 552 of title 5. 
‘‘(g) LIMITATION ON CIVIL LIABILITY.—A person 
who participates in or provides information to a person 
or body that reviews or creates medical quality assurance
312
records described in subsection (a) shall not be civilly lia-
ble for such participation or for providing such informa-
tion if the participation or provision of information was 
in good faith based on prevailing professional standards 
at the time the medical quality assurance program activity 
took place. 
‘‘(h) APPLICATION
TO INFORMATION
IN CERTAIN 
OTHER RECORDS.—Nothing in this section shall be con-
strued as limiting access to the information in a record 
created and maintained outside a medical quality assur-
ance program, including a patient’s medical records, on 
the grounds that the information was presented during 
meetings of a review body that are part of a medical qual-
ity assurance program. 
‘‘(i) REGULATIONS.—The Secretary, acting through 
the Service, shall promulgate regulations pursuant to sec-
tion 802 of this title. 
‘‘(j) DEFINITIONS.—In this section: 
‘‘(1) The term ‘medical quality assurance pro-
gram’ means any activity carried out before, on, or 
after the date of enactment of this Act by or for any 
Indian Health Program or Urban Indian Organiza-
tion to assess the quality of medical care, including
activities conducted by individuals, military medical 
or dental treatment facility committees, or other re-
313
view bodies responsible for quality assurance, cre-
dentials, infection control, patient care assessment 
(including treatment procedures, blood, drugs, and 
therapeutics), medical records, health resources 
management review and identification and preven-
tion of medical or dental incidents and risks. 
‘‘(2) The term ‘medical quality assurance 
record’ means the proceedings, records, minutes, and 
reports that emanate from quality assurance pro-
gram activities described in paragraph (1) and are 
produced or compiled by an Indian Health Program 
or Urban Indian Organization as part of a medical 
quality assurance program. 
‘‘(3) The term ‘health care provider’ means any 
health care professional, including community health 
aides and practitioners certified under section 121, 
who are granted clinical practice privileges or em-
ployed to provide health care services in an Indian 
Health Program or health program of an Urban In-
dian Organization, who is licensed or certified to 
perform health care services by a governmental 
board or agency or professional health care society 
or organization.
314
‘‘SEC. 818. 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.’’. 
SEC. 3. SOBOBA SANITATION FACILITIES. 
The Act of December 17, 1970 (84 Stat. 1465), is 
amended by adding at the end the following new section: 
‘‘SEC. 9. Nothing in this Act shall preclude the 
Soboba Band of Mission Indians and the Soboba Indian 
Reservation from being provided with sanitation facilities 
and services under the authority of section 7 of the Act 
of August 5, 1954 (68 Stat. 674), as amended by the Act 
of July 31, 1959 (73 Stat. 267).’’.
SEC. 4. AMENDMENTS TO MEDICARE PROGRAM. 
(a) EXPANSION OF MEDICARE PAYMENT FOR ALL 
COVERED SERVICES FURNISHED
BY INDIAN HEALTH 
PROGRAMS.—
(1) EXPANSION TO ALL COVERED SERVICES.—
Section 1880 of the Social Security Act (42 U.S.C. 
1395qq) is amended—
(A) by amending the heading to read as 
follows: 
‘‘INDIAN HEALTH PROGRAMS’’; 
(B) by amending subsection (a) to read as 
follows:
315
‘‘(a) An Indian Health Program (as that term is de-
fined in section 4 of the Indian Health Care Improvement 
Act) shall be eligible for payments under this title, not-
withstanding sections 1814(c) and 1835(d), with respect 
to covered items and services it furnishes if (subject to 
section 408 of such Act) it meets the conditions and re-
quirements for such payments which apply to the fur-
nishing of such items and services under this title.’’; and 
(C) by striking subsection (e). 
(2) ELIMINATION
OF
TEMPORARY
DEEMING 
PROVISION, SEPARATE
FUND
REQUIREMENT, AND 
DUPLICATIVE
ANNUAL
REPORT.—Such section is 
amended by striking subsections (b) through (d). 
(3) REFERENCE CORRECTION.—Subsection (f) 
of such section is redesignated as subsection (b) and 
is amended by striking ‘‘section 405’’ and inserting 
‘‘section 401(d)’’. 
(b) LIMITATION ON CHARGES FOR HOSPITAL CON-
TRACT HEALTH SERVICES PROVIDED
TO INDIANS
BY 
MEDICARE PARTICIPATING HOSPITALS.—
(1) IN GENERAL.—Section 1866(a)(1) of the 
Social Security Act (42 U.S.C. 1395cc(a)(1)) is 
amended—
(A) in subparagraph (R), by striking 
‘‘and’’ at the end;
316
(B) in subparagraph (S), by striking the 
period and inserting ‘‘, and’’; and 
(C) by adding at the end the following new 
subparagraph: 
‘‘(T) in the case of hospitals and critical 
access hospitals which furnish services for 
which payment may be made under this title to 
be a participating provider—
‘‘(i) under the contract health services 
program operated by an Indian Health 
Program (as those terms are defined in 
section 4 of the Indian Health Care Im-
provement Act), with respect to items and 
services that are covered under and fur-
nished to an individual eligible for such 
program; and 
‘‘(ii) under a program funded by the 
Indian Health Service and operated by an 
Urban Indian Organization with respect to 
the purchase of items and services for an 
eligible Urban Indian (as those terms are 
defined in section 4 of the Indian Health 
Care Improvement Act (25 U.S.C. 1603); 
in accordance with regulations promulgated by 
the Secretary regarding admission practices,
317
payment methodology, and rates of payment 
(including the acceptance of not more than such 
payment rate as payment in full for such items 
and services).’’. 
(2) EFFECTIVE DATE.—The amendments made 
by paragraph (1) shall apply as of a date specified 
by the Secretary of Health and Human Services (but 
in no case later than 6 months after the date of the 
enactment of this Act) to medicare participation 
agreements in effect (or entered into) on or after 
such date. 
(c) MEDICARE COVERAGE OF SERVICES OF COMMU-
NITY HEALTH AIDES OR PRACTITIONERS.—
(1) IN GENERAL.—Section 1861 of such Act 
(42 U.S.C. 1395x) is amended—
(A) in subsection (s)(2)(K)—
(i) in clause (ii), by adding ‘‘and’’ at 
the end; and 
(ii) by adding at the end the following 
new clause: 
‘‘(iii) services which would be physicians’ serv-
ices if furnished by a physician (as defined in sub-
section (r)(1)) and which are performed by a com-
munity health aide or practitioner which the aide or 
practitioner is legally authorized to perform, and
318
such services and supplies furnished as incident to 
such services as would be covered under subpara-
graph (A) if furnished incident to a physician’s pro-
fessional service but only if no other provider 
charges or is paid any amounts with respect to the 
professional fee for furnishing of such services (and, 
in the case of a telehealth service described in sec-
tion 1834(m), treating services at the originating 
site and the distant site as separate services);’’; and 
(B) by adding at the end the following new 
subsection: 
‘‘Community Health Aides or Practitioners 
‘‘(ww) The term ‘community health aides or practi-
tioner’ means such an aide or practitioner who has been 
certified under the provisions of section 121 of the Indian 
Health Care Improvement Act and who only provides serv-
ices as an employee of the Indian Health Service, an In-
dian Tribe, or Tribal Organization.’’. 
(2) PAYMENT.—
(A) 
PAYMENT
RATE.—Section 
1833(a)(1)(O) 
of 
such 
Act 
(42 
U.S.C. 
1395l(a)(1)(O)) is amended—
(i) by striking ‘‘or’’ before ‘‘(ii)’’; and 
(ii) by adding at the end the fol-
lowing: ‘‘or (iii) in the case of services of
319
a community health aide or practitioner, 
the lesser of the actual charge or 80 per-
cent of the fee schedule amount provided 
under section 1848,’’. 
(B) LIMITATION ON BALANCE BILLING.—
Section 1842(b)(18)(C) of such Act (42 U.S.C. 
1395u(b)(18)(C)) is amended by adding at the 
end the following new clause: 
‘‘(vii) A community health aide or practi-
tioner.’’. 
(3) EFFECTIVE DATE.—The amendments made 
by this subsection shall apply to services furnished 
on or after January 1, 2004. 
(d) CONTINUATION OF SPECIAL TREATMENT FOR 
COLLABORATIVE
ARRANGEMENTS
BETWEEN
INDIAN 
HEALTH PROGRAMS AND HOSPITAL OUTPATIENT DE-
PARTMENTS.—Section 1833(t)(13) of the Social Security 
Act (42 U.S.C. 1395l(t)(13)) is amended by adding at the 
end the following new subparagraph: 
‘‘(B) EXTENSION OF TREATMENT OF CER-
TAIN
COLLABORATIVE
ARRANGEMENTS.—With 
respect to the treatment under this subsection 
of collaborative arrangements between a health 
program operated by the Indian Health Service, 
an Indian Tribe, or Tribal Organization and a
320
hospital operated by such Service or such an 
Indian Tribe or Tribal Organization, the Sec-
retary shall reinstate treatment (as in effect on 
January 1, 2000) and extend it to such collabo-
rative arrangements regardless of when they 
were entered into.’’. 
(e) COVERAGE OF VISITING NURSE SERVICES OF 
TRIBAL CLINICS.—
(1) IN GENERAL.—Section 1861(aa)(1) of the 
Social Security Act (42 U.S.C. 1395x(aa)(1)) is 
amended by adding at the end the following: 
‘‘For purposes of applying subparagraph (C) (relating to 
visiting nurse services), an ambulatory care clinic or other 
outpatient program of the Indian Health Service or of an 
Indian Tribe or a Tribal Organization (as such terms are 
defined in section 4 of the Indian Health Care Improve-
ment Act) shall be treated as if it were a rural health clinic 
located in an area described in such subparagraph, and 
nursing care and supplies described in such subparagraph 
and furnished to an individual as an outpatient of such 
a tribal clinic or program shall be reimbursable under this 
title using the methodology specified in section 4(f) of the 
Indian Health Care Improvement Act Amendments of 
2003, and, for purposes of this sentence, any reference
321
in such subparagraph (C) to a licensed practical nurse is 
also deemed to include a reference to a home health aide.’’. 
(2) EFFECTIVE DATE.—The amendment made 
by paragraph (1) shall apply services furnished on or 
after January 1, 2004. 
(f) MEDICARE PAYMENT FOR OUTPATIENT CLIN-
ICS.—
(1) IN GENERAL.—Notwithstanding any other 
provision of law, for purposes of determining the 
rate of reimbursement under title XVIII of the So-
cial Security Act, any outpatient or ambulatory care 
clinic (whether freestanding or provider-based) oper-
ated by the Indian Health Service, by an Indian 
Tribe, or by a Tribal Organization (as such terms 
are defined for purposes of the Indian Health Care 
Improvement Act) shall, upon the election of such 
clinic, be reimbursed on the same basis as if such 
clinic were a hospital outpatient department of the 
Indian Health Service. 
(2) EFFECTIVE
DATE.—Paragraph (1) shall 
apply to payment for services furnished on or after 
January 1, 2004. 
(g) REVIEW OF MEDICARE AND MEDICAID PAYMENT 
SYSTEMS.—
(1) STUDY.—
322
(A) 
IN
GENERAL.—The 
Secretary 
of 
Health and Human Services shall conduct a re-
view of the extent to which the payment meth-
odologies applicable under titles XVIII and XIX 
of the Social Security Act (including under sec-
tion 1880 of such Act, as amended by this sec-
tion, section 1911 of such Act, as amended by 
section 5(a), and including payment methodolo-
gies in effect at the time the review is under-
taken and payment methodologies effected 
under this section or section 5) take into ac-
count the unique or special circumstances of the 
provision of covered services to Indians by the 
Indian Health Service, Indian Tribes, Tribal 
Organizations, and Urban Indian Organizations 
(as such terms are defined in section 4 of the 
Indian Health Care Improvement Act). 
(B) 
MATTERS
CONSIDERED.—In 
par-
ticular, the Secretary shall review the suffi-
ciency of the payment amounts under such 
methodologies in assuring access to care and 
payment rates consistent with the payment 
rates for most favored providers. 
(C) CONSULTATION.—In conducting the 
study, the Secretary shall consult with the In-
323
dian Health Service, Indian Tribes, Tribal Or-
ganizations, and Urban Indian Organizations. 
(2) REPORT.—Not later than 2 years after the 
date of implementation of the amendments made by 
subsection (a) (or, if later, the date of implementa-
tion of the amendments made by section 5(a)), the 
Secretary shall submit to Congress a report on the 
review under paragraph (1). Such report shall in-
clude recommendations for such adjustments to such 
payment methodologies as may be necessary to as-
sure that payment amounts under the medicare and 
medicaid programs to such Service, Indian Tribes, 
Tribal Organizations, and Urban Indian Organiza-
tions are sufficient to provide access to quality care. 
(3) RETENTION OF CURRENT PAYMENT METH-
ODOLOGY.—Notwithstanding any other provision of 
law, the Secretary shall retain the all-inclusive pay-
ment methodology for encounter rates for the Indian 
Health Service, Indian Tribes, and Tribal Organiza-
tions under titles XVIII and XIX of the Social Secu-
rity Act unless the use of such methodology is ex-
pressly prohibited or otherwise superceded by Act of 
Congress.
324
SEC. 5. AMENDMENTS TO MEDICAID PROGRAM AND STATE 
CHILDREN’S HEALTH INSURANCE PROGRAM 
(SCHIP). 
(a) EXPANSION OF MEDICAID PAYMENT FOR ALL 
COVERED SERVICES FURNISHED
BY INDIAN HEALTH 
PROGRAMS.—
(1) EXPANSION TO ALL COVERED SERVICES.—
Section 1911 of the Social Security Act (42 U.S.C. 
1396j) is amended—
(A) by amending the heading to read as 
follows: 
‘‘INDIAN HEALTH PROGRAMS’’; and 
(B) by amending subsection (a) to read as 
follows: 
‘‘(a) The Indian Health Service and an Indian Tribe 
or Tribal Organization (as those terms are defined in sec-
tion 4 of the Indian Health Care Improvement Act) shall 
be eligible for reimbursement for medical assistance pro-
vided under a State plan with respect to covered items 
and services it furnishes if it meets all the conditions and 
requirements which are applicable generally to the fur-
nishing of such items and services under this title.’’. 
(2) ELIMINATION
OF
TEMPORARY
DEEMING 
PROVISION—Such section is amended by striking 
subsection (b).
325
(3) REVISION OF AUTHORITY TO ENTER INTO 
AGREEMENTS.—Subsection (c) of such section is re-
designated as subsection (b) and is amended to read 
as follows: 
‘‘(b) The Secretary may enter into agreements with 
the State agency for the purpose of reimbursing such 
agency for health care and services provided by the Indian 
Health Service, Indian Tribes, Tribal Organizations, or 
Urban Indian Organizations (as such terms are defined 
in section 4 of the Indian Health Care Improvement Act), 
directly, through referral, or under contracts or other ar-
rangements between the Indian Health Service, an Indian 
Tribe or Tribal Organization, or an Urban Indian Organi-
zation and another health care provider to Indians who 
are eligible for medical assistance under the State plan.’’. 
(4) REFERENCE CORRECTION.—Subsection (d) 
of such section is redesignated as subsection (c) and 
is amended by striking ‘‘section 405’’ and inserting 
‘‘section 401(d)’’. 
(b) SEEKING ADVICE FROM INDIAN HEALTH PRO-
GRAMS.—Section 1902(a) of the Social Security Act (42 
U.S.C. 1396a(a)) is amended—
(1) in paragraph (64), by striking ‘‘and’’ at the 
end;
326
(2) in paragraph (65), by striking the period 
and inserting ‘‘; and’’; and 
(3) by inserting after paragraph (65), the fol-
lowing new paragraph: 
‘‘(66) if the Indian Health Service operates or 
funds health programs in the State or if there are 
Indian Tribes, Tribal Organizations, or Urban In-
dian Organizations (as those terms are defined in 
section 4 of the Indian Health Care Improvement 
Act) providing health care in the State for which 
medical assistance is available, provide for the estab-
lishment and maintenance of the advisory process 
described in section 409(b) of such Act.’’. 
(c) SCHIP TREATMENT OF INDIAN TRIBES, TRIBAL 
ORGANIZATIONS, AND URBAN INDIAN ORGANIZATIONS.—
Section 
2105(c)(6)(B) 
of 
such 
Act 
(42 
U.S.C. 
1397ee(c)(6)(B)) is amended by inserting ‘‘or by an In-
dian Tribe, Tribal Organization, or Urban Indian Organi-
zation (as such terms are defined in section 4 of the In-
dian Health Care Improvement Act)’’ after ‘‘Service’’.
Æ