I 
113TH CONGRESS 
2D SESSION 
H. R. 4843 
To amend title XVIII of the Social Security Act to provide for a limitation 
under the Medicare program on charges for contract health services 
provided to Indians by Medicare providers of services and suppliers. 
IN THE HOUSE OF REPRESENTATIVES 
JUNE 11, 2014 
Ms. MCCOLLUM (for herself, Mr. COLE, Mr. BEN RAY LUJA´N of New Mexico, 
Mr. ISSA, Mr. GRIJALVA, Mr. KLINE, Mr. PALLONE, Mr. YOUNG of Alas-
ka, Mr. HUFFMAN, and Mr. KIND) introduced the following bill; which 
was referred to the Committee on Energy and Commerce, and in addition 
to the Committees on Ways and Means and Natural Resources, for a pe-
riod to be subsequently determined by the Speaker, in each case for con-
sideration of such provisions as fall within the jurisdiction of the com-
mittee concerned 
A BILL 
To amend title XVIII of the Social Security Act to provide 
for a limitation under the Medicare program on charges 
for contract health services provided to Indians by Medi-
care providers of services and suppliers. 
Be it enacted by the Senate and House of Representa-
tives of the United States of America in Congress assembled, 
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SECTION 1. SHORT TITLE. 
This Act may be cited as the ‘‘Native Contract and 
Rate Expenditure Act of 2014’’ or the ‘‘Native CARE Act 
of 2014’’. 
SEC. 2. FINDINGS. 
Congress makes the following findings: 
(1) Federal health services to maintain and im-
prove the health of American Indians and Alaska 
Natives are consonant with and required by the Fed-
eral Government’s historical and unique legal rela-
tionship with, and resulting trust responsibility to, 
the American Indian and Alaska Native people. 
(2) The unmet health needs of American Indi-
ans and Alaska Natives are severe and the health 
status of American Indians and Alaska Natives is 
far below that of the general population of the 
United States, resulting in an average life expect-
ancy for American Indians and Alaska Natives 4.2 
years less than that for the all races population of 
the United States. 
(3) The Indian Health Service and tribal Pur-
chased/Referred Care programs purchase primary 
and specialty care services from private health care 
providers when those services are not available at In-
dian Health Service or Tribal health facilities. 
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(4) Available Purchased/Referred Care funds 
have been insufficient to ensure access to care for 
American Indians and Alaska Natives, resulting in 
rationed care and diagnosis and treatment delays 
that lead to the need for more intensive and expen-
sive treatment, further reducing already scarce Pur-
chased/Referred Care funds. 
(5) In 2003, Congress amended title XVIII of 
the Social Security Act to require Medicare-partici-
pating hospitals to accept patients referred from the 
Indian Health Service and Tribal Purchased/Re-
ferred Care programs and to accept payment at no 
more than Medicare rates—the Medicare-like rate 
cap—for the services provided. 
(6) The Medicare-like rate cap only applies to 
hospital services, and does not apply to other types 
of Medicare-participating providers and suppliers. 
(7) Unlike other Federal health care programs, 
the Indian Health Service and Tribal Purchased/Re-
ferred Care programs continue to pay full billed 
charges for non-hospital services. 
(8) Because Purchased/Referred programs con-
tinue to pay full billed charges for non-hospital serv-
ices, in many cases the Indian Health Service may 
only treat the most desperate ‘‘Life’’ or ‘‘Limb’’ 
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cases, leading to many undesirable health outcomes 
for American Indians and Alaska Natives, and ulti-
mately increasing costs to the Purchased/Referred 
Care programs. 
(9) On April 11, 2013, the Government Ac-
countability Office released a report finding that 
capping Purchased/Referred Care reimbursement at 
Medicare-like rates for nonhospital services would 
enable the Indian Health Service to double the num-
ber of physician services provided by adding an addi-
tional 253,000 patient visits annually. 
SEC. 3. LIMITATION ON CHARGES FOR CERTAIN CONTRACT 
HEALTH SERVICES PROVIDED TO INDIANS BY 
MEDICARE PROVIDERS OF SERVICES AND 
SUPPLIERS. 
(a) APPLICATION
TO ALL PROVIDERS
OF SERV-
ICES.— 
(1) IN
GENERAL.—Section 1866(a)(1)(U) of 
the Social Security Act (42 U.S.C. 1395cc(a)(1)(U)) 
is amended, in the matter preceding clause (i), by 
striking ‘‘in the case of hospitals which furnish inpa-
tient hospital services for which payment may be 
made under this title,’’. 
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(2) REGULATIONS.—The Secretary of Health 
and Human Services shall promulgate regulations to 
account for the amendment made by paragraph (1). 
(3) EFFECTIVE DATE.—The amendment made 
by paragraph (1) shall apply to Medicare participa-
tion agreements in effect (or entered into) on or 
after the date that is 90 days after the date of en-
actment of this Act. 
(b) APPLICATION TO ALL SUPPLIERS.— 
(1) IN GENERAL.—Section 1834 of the Social 
Security Act (42 U.S.C. 1395m) is amended by add-
ing at the end the following new subsection: 
‘‘(r) LIMITATION ON CHARGES FOR CERTAIN CON-
TRACT HEALTH SERVICES PROVIDED
TO INDIANS
BY 
SUPPLIERS.—No payment may be made under this title 
for an item or service furnished by a supplier (as defined 
in section 1861(d)) unless the supplier agrees (pursuant 
to a process established by the Secretary) to be a partici-
pating provider of medical and other health services 
both— 
‘‘(1) under the Purchased/Referred Care pro-
gram (formerly referred to as the ‘contract health 
services program’) funded by the Indian Health 
Service and operated by the Indian Health Service, 
an Indian tribe, or tribal organization (as those 
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terms are defined in section 4 of the Indian Health 
Care Improvement Act), with respect to items and 
services that are covered under such program and 
furnished to an individual eligible for such items and 
services under such program; and 
‘‘(2) under any program funded by the Indian 
Health Service and operated by an urban Indian or-
ganization with respect to the purchase of items and 
services for an eligible urban Indian (as those terms 
are defined in such section 4), 
in accordance with regulations promulgated by the Sec-
retary regarding payment methodology and rates of pay-
ment (including the acceptance of no more than such pay-
ment rate as payment in full for such items and serv-
ices).’’. 
(2) EFFECTIVE DATE.—The amendment made 
by paragraph (1) shall apply to items and services 
furnished on or after the date that is 90 days after 
the date of enactment of this Act. 
(c) LIMITATION.—There shall be no reduction, offset, 
or limitation to any appropriations made to the Indian 
Health Service under the Indian Health Care Improve-
ment Act (25 U.S.C. 1621 et seq.), the Act of November 
2, 1921 (25 U.S.C. 13) (commonly known as the ‘‘Snyder 
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Act’’), or any other provision of law as a result of the 
provisions of, including amendments made by, this Act. 
(d) STUDIES AND REPORTS.— 
(1) STUDY.—The Secretary of Health and 
Human Services (in this subsection referred to as 
the ‘‘Secretary’’), acting through the Director of the 
Indian Health Service, shall conduct a study on the 
impact of the amendments made by this section on 
access to care under the Purchased/Referred Care 
program of the Indian Health Service. 
(2) REPORT.—Not later than 2 years after the 
date of enactment of this Act, the Secretary shall 
submit to Congress a report containing the results 
of the study conducted under paragraph (1), includ-
ing recommendations for such legislation and admin-
istrative action as the Secretary determines appro-
priate. 
(3) SECTION 219(c) STUDY AND REPORT.—Sec-
tion 219(c) of the Indian Health Care Improvement 
Act (25 U.S.C. 1621r(c)) is amended by striking 
‘‘12 months after the date of the enactment of this 
section’’ and inserting ‘‘12 months after the date of 
the enactment of the Native Contract and Rate Ex-
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penditure Act of 2014, and biennially thereafter 
through 2020’’. 
Æ 
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