137 
‘‘(II) 1 of the 10 top-priority out-
patient projects; 
‘‘(III) 1 of the 10 top-priority 
staff quarters developments; or 
‘‘(IV) 1 of the 10 top-priority 
Youth Regional Treatment Centers; 
‘‘(ii) had completed both Phase I and 
Phase II of the construction priority sys-
tem in effect on the date of enactment of 
such Act; or 
‘‘(iii) is not included in clause (i) or 
(ii) and is selected, as determined by the 
Secretary— 
‘‘(I) on the initiative of the Sec-
retary; or 
‘‘(II) pursuant to a request of an 
Indian Tribe or Tribal Organization. 
‘‘(2) REPORT; CONTENTS.— 
‘‘(A) INITIAL COMPREHENSIVE REPORT.— 
‘‘(i) DEFINITIONS.—In this subpara-
graph: 
‘‘(I) FACILITIES APPROPRIATION 
ADVISORY BOARD.—The term ‘Facili-
ties Appropriation Advisory Board’ 
means the advisory board, comprised 
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138 
of 12 members representing Indian 
tribes and 2 members representing 
the Service, established at the discre-
tion of the Assistant Secretary— 
‘‘(aa) to provide advice and 
recommendations for policies and 
procedures of the programs fund-
ed pursuant to facilities appro-
priations; and 
‘‘(bb) to address other facili-
ties issues. 
‘‘(II) FACILITIES NEEDS ASSESS-
MENT
WORKGROUP.—The term ‘Fa-
cilities Needs Assessment Workgroup’ 
means the workgroup established at 
the discretion of the Assistant Sec-
retary— 
‘‘(aa) to review the health 
care facilities construction pri-
ority system; and 
‘‘(bb) to make recommenda-
tions to the Facilities Appropria-
tion Advisory Board for revising 
the priority system. 
‘‘(ii) INITIAL REPORT.— 
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139 
‘‘(I) IN
GENERAL.—Not later 
than 1 year after the date of enact-
ment of the Indian Health Care Im-
provement Act Amendments of 2009, 
the Secretary shall submit to the 
Committee on Indian Affairs of the 
Senate and the Committee on Natural 
Resources of the House of Represent-
atives a report that describes the com-
prehensive, national, ranked list of all 
health care facilities needs for the 
Service, Indian Tribes, and Tribal Or-
ganizations (including inpatient health 
care facilities, outpatient health care 
facilities, specialized health care facili-
ties (such as for long-term care and 
alcohol and drug abuse treatment), 
wellness centers, staff quarters and 
hostels associated with health care fa-
cilities, and the renovation and expan-
sion needs, if any, of such facilities) 
developed by the Service, Indian 
Tribes, and Tribal Organizations for 
the 
Facilities 
Needs 
Assessment 
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140 
Workgroup and the Facilities Appro-
priation Advisory Board. 
‘‘(II) INCLUSIONS.—The initial 
report shall include— 
‘‘(aa) the methodology and 
criteria used by the Service in de-
termining the needs and estab-
lishing the ranking of the facili-
ties needs; and 
‘‘(bb) such other information 
as the Secretary determines to be 
appropriate. 
‘‘(iii) UPDATES OF REPORT.—Begin-
ning in calendar year 2011, the Secretary 
shall— 
‘‘(I) update the report under 
clause (ii) not less frequently that 
once every 5 years; and 
‘‘(II) include the updated report 
in the appropriate annual report 
under subparagraph (B) for submis-
sion to Congress under section 801. 
‘‘(B) ANNUAL
REPORTS.—The Secretary 
shall submit to the President, for inclusion in 
the report required to be transmitted to Con-
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141 
gress under section 801, a report which sets 
forth the following: 
‘‘(i) A description of the health care 
facility priority system of the Service es-
tablished under paragraph (1). 
‘‘(ii) Health care facilities lists, which 
may include— 
‘‘(I) the 10 top-priority inpatient 
health care facilities; 
‘‘(II) the 10 top-priority out-
patient health care facilities; 
‘‘(III) the 10 top-priority special-
ized health care facilities (such as 
long-term care and alcohol and drug 
abuse treatment); 
‘‘(IV) the 10 top-priority staff 
quarters developments associated with 
health care facilities; and 
‘‘(V) the 10 top-priority hostels 
associated with health care facilities. 
‘‘(iii) The justification for such order 
of priority. 
‘‘(iv) The projected cost of such 
projects. 
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142 
‘‘(v) The methodology adopted by the 
Service in establishing priorities under its 
health care facility priority system. 
‘‘(3) REQUIREMENTS FOR PREPARATION OF RE-
PORTS.—In preparing the report required under 
paragraph (2), the Secretary shall— 
‘‘(A) consult with and obtain information 
on all health care facilities needs from Indian 
Tribes, Tribal Organizations, and urban Indian 
organizations; and 
‘‘(B) review the total unmet needs of all 
Indian Tribes, Tribal Organizations, and urban 
Indian organizations for health care facilities 
(including hostels and staff quarters), including 
needs for renovation and expansion of existing 
facilities. 
‘‘(d) REVIEW OF METHODOLOGY USED FOR HEALTH 
FACILITIES CONSTRUCTION PRIORITY SYSTEM.— 
‘‘(1) IN GENERAL.—Not later than 1 year after 
the establishment of the priority system under sub-
section (c)(1)(A), the Comptroller General of the 
United States shall prepare and finalize a report re-
viewing the methodologies applied, and the processes 
followed, by the Service in making each assessment 
of needs for the list under subsection (c)(2)(A)(ii) 
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143 
and developing the priority system under subsection 
(c)(1), including a review of— 
‘‘(A) the recommendations of the Facilities 
Appropriation Advisory Board and the Facili-
ties Needs Assessment Workgroup (as those 
terms are defined in subsection (c)(2)(A)(i)); 
and 
‘‘(B) the relevant criteria used in ranking 
or prioritizing facilities other than hospitals or 
clinics. 
‘‘(2) SUBMISSION TO CONGRESS.—The Comp-
troller General of the United States shall submit the 
report under paragraph (1) to— 
‘‘(A) the Committees on Indian Affairs and 
Appropriations of the Senate; 
‘‘(B) the Committees on Natural Re-
sources and Appropriations of the House of 
Representatives; and 
‘‘(C) the Secretary. 
‘‘(e) FUNDING CONDITION.—All funds appropriated 
under the Act of November 2, 1921 (25 U.S.C. 13) (com-
monly known as the ‘Snyder Act’), for the planning, de-
sign, construction, or renovation of health facilities for the 
benefit of 1 or more Indian Tribes shall be subject to the 
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144 
provisions of the Indian Self-Determination and Edu-
cation Assistance Act (25 U.S.C. 450 et seq.). 
‘‘(f) DEVELOPMENT OF INNOVATIVE APPROACHES.— 
The Secretary shall consult and cooperate with Indian 
Tribes, Tribal Organizations, and urban Indian organiza-
tions in developing innovative approaches to address all 
or part of the total unmet need for construction of health 
facilities, including those provided for in other sections of 
this title and other approaches. 
‘‘SEC. 302. SANITATION FACILITIES. 
‘‘(a) FINDINGS.—Congress finds the following: 
‘‘(1) The provision of sanitation facilities is pri-
marily a health consideration and function. 
‘‘(2) Indian people suffer an inordinately high 
incidence of disease, injury, and illness directly at-
tributable to the absence or inadequacy of sanitation 
facilities. 
‘‘(3) The long-term cost to the United States of 
treating and curing such disease, injury, and illness 
is substantially greater than the short-term cost of 
providing sanitation facilities and other preventive 
health measures. 
‘‘(4) Many Indian homes and Indian commu-
nities still lack sanitation facilities. 
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145 
‘‘(5) It is in the interest of the United States, 
and it is the policy of the United States, that all In-
dian communities and Indian homes, new and exist-
ing, be provided with sanitation facilities. 
‘‘(b) FACILITIES AND SERVICES.—In furtherance of 
the findings made in subsection (a), Congress reaffirms 
the primary responsibility and authority of the Service to 
provide the necessary sanitation facilities and services as 
provided in section 7 of the Act of August 5, 1954 (42 
U.S.C. 2004a). Under such authority, the Secretary, act-
ing through the Service, is authorized to provide the fol-
lowing: 
‘‘(1) Financial and technical assistance to In-
dian Tribes, Tribal Organizations, and Indian com-
munities in the establishment, training, and equip-
ping of utility organizations to operate and maintain 
sanitation facilities, including the provision of exist-
ing plans, standard details, and specifications avail-
able in the Department, to be used at the option of 
the Indian Tribe, Tribal Organization, or Indian 
community. 
‘‘(2) Ongoing technical assistance and training 
to Indian Tribes, Tribal Organizations, and Indian 
communities in the management of utility organiza-
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146 
tions which operate and maintain sanitation facili-
ties. 
‘‘(3) Priority funding for operation and mainte-
nance assistance for, and emergency repairs to, sani-
tation facilities operated by an Indian Tribe, Tribal 
Organization or Indian community when necessary 
to avoid an imminent health threat or to protect the 
investment in sanitation facilities and the investment 
in the health benefits gained through the provision 
of sanitation facilities. 
‘‘(c) FUNDING.—Notwithstanding any other provi-
sion of law— 
‘‘(1) the Secretary of Housing and Urban De-
velopment is authorized to transfer funds appro-
priated under the Native American Housing Assist-
ance and Self-Determination Act of 1996 (25 U.S.C. 
4101 et seq.) to the Secretary of Health and Human 
Services; 
‘‘(2) the Secretary of Health and Human Serv-
ices is authorized to accept and use such funds for 
the purpose of providing sanitation facilities and 
services for Indians under section 7 of the Act of 
August 5, 1954 (42 U.S.C. 2004a); 
‘‘(3) unless specifically authorized when funds 
are appropriated, the Secretary shall not use funds 
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147 
appropriated under section 7 of the Act of August 
5, 1954 (42 U.S.C. 2004a), to provide sanitation fa-
cilities to new homes constructed using funds pro-
vided by the Department of Housing and Urban De-
velopment; 
‘‘(4) the Secretary of Health and Human Serv-
ices is authorized to accept from any source, includ-
ing Federal and State agencies, funds for the pur-
pose of providing sanitation facilities and services 
and place these funds into contracts or compacts 
under the Indian Self-Determination and Education 
Assistance Act (25 U.S.C. 450 et seq.); 
‘‘(5) except as otherwise prohibited by this sec-
tion, the Secretary may use funds appropriated 
under the authority of section 7 of the Act of Au-
gust 5, 1954 (42 U.S.C. 2004a), to fund up to 100 
percent of the amount of an Indian Tribe’s loan ob-
tained under any Federal program for new projects 
to construct eligible sanitation facilities to serve In-
dian homes; 
‘‘(6) except as otherwise prohibited by this sec-
tion, the Secretary may use funds appropriated 
under the authority of section 7 of the Act of Au-
gust 5, 1954 (42 U.S.C. 2004a), to meet matching 
or cost participation requirements under other Fed-
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148 
eral and non-Federal programs for new projects to 
construct eligible sanitation facilities; 
‘‘(7) all Federal agencies are authorized to 
transfer to the Secretary funds identified, granted, 
loaned, or appropriated whereby the Department’s 
applicable policies, rules, and regulations shall apply 
in the implementation of such projects; 
‘‘(8) the Secretary of Health and Human Serv-
ices shall enter into interagency agreements with 
Federal and State agencies for the purpose of pro-
viding financial assistance for sanitation facilities 
and services under this Act; 
‘‘(9) the Secretary of Health and Human Serv-
ices shall, by regulation, establish standards applica-
ble to the planning, design, and construction of sani-
tation facilities funded under this Act; and 
‘‘(10) the Secretary of Health and Human 
Services is authorized to accept payments for goods 
and services furnished by the Service from appro-
priate public authorities, nonprofit organizations or 
agencies, or Indian Tribes, as contributions by that 
authority, organization, agency, or tribe to agree-
ments made under section 7 of the Act of August 5, 
1954 (42 U.S.C. 2004a), and such payments shall 
be credited to the same or subsequent appropriation 
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149 
account as funds appropriated under the authority 
of section 7 of the Act of August 5, 1954 (42 U.S.C. 
2004a). 
‘‘(d) CERTAIN CAPABILITIES NOT PREREQUISITE.— 
The financial and technical capability of an Indian Tribe, 
Tribal Organization, or Indian community to safely oper-
ate, manage, and maintain a sanitation facility shall not 
be a prerequisite to the provision or construction of sanita-
tion facilities by the Secretary. 
‘‘(e) FINANCIAL ASSISTANCE.—The Secretary is au-
thorized to provide financial assistance to Indian Tribes, 
Tribal Organizations, and Indian communities in an 
amount equal to the Federal share of the costs of oper-
ating, managing, and maintaining the facilities provided 
under the plan described in subsection (h)(1)(F). 
‘‘(f) OPERATION, MANAGEMENT, AND MAINTENANCE 
OF FACILITIES.—The Indian Tribe has the primary re-
sponsibility to establish, collect, and use reasonable user 
fees, or otherwise set aside funding, for the purpose of 
operating, managing, and maintaining sanitation facilities. 
If a sanitation facility serving a community that is oper-
ated by an Indian Tribe or Tribal Organization is threat-
ened with imminent failure and such operator lacks capac-
ity to maintain the integrity or the health benefits of the 
sanitation facility, then the Secretary is authorized to as-
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150 
sist the Indian Tribe, Tribal Organization, or Indian com-
munity in the resolution of the problem on a short-term 
basis through cooperation with the emergency coordinator 
or by providing operation, management, and maintenance 
service. 
‘‘(g) ISDEAA PROGRAM
FUNDED
ON
EQUAL 
BASIS.—Tribal Health Programs shall be eligible (on an 
equal basis with programs that are administered directly 
by the Service) for— 
‘‘(1) any funds appropriated pursuant to this 
section; and 
‘‘(2) any funds appropriated for the purpose of 
providing sanitation facilities. 
‘‘(h) REPORT.— 
‘‘(1) REQUIRED; CONTENTS.—The Secretary, in 
consultation with the Secretary of Housing and 
Urban Development, Indian Tribes, Tribal Organiza-
tions, and tribally designated housing entities (as de-
fined in section 4 of the Native American Housing 
Assistance and Self-Determination Act of 1996 (25 
U.S.C. 4103)) shall submit to the President, for in-
clusion in the report required to be transmitted to 
Congress under section 801, a report which sets 
forth— 
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151 
‘‘(A) the current Indian sanitation facility 
priority system of the Service; 
‘‘(B) the methodology for determining 
sanitation deficiencies and needs; 
‘‘(C) the criteria on which the deficiencies 
and needs will be evaluated; 
‘‘(D) the level of initial and final sanitation 
deficiency for each type of sanitation facility for 
each project of each Indian Tribe or Indian 
community; 
‘‘(E) the amount and most effective use of 
funds, derived from whatever source, necessary 
to accommodate the sanitation facilities needs 
of new homes assisted with funds under the 
Native American Housing Assistance and Self- 
Determination Act (25 U.S.C. 4101 et seq.), 
and to reduce the identified sanitation defi-
ciency levels of all Indian Tribes and Indian 
communities to level I sanitation deficiency as 
defined in paragraph (3)(A); and 
‘‘(F) a 10-year plan to provide sanitation 
facilities to serve existing Indian homes and In-
dian communities and new and renovated In-
dian homes. 
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152 
‘‘(2) UNIFORM METHODOLOGY.—The method-
ology used by the Secretary in determining, pre-
paring cost estimates for, and reporting sanitation 
deficiencies for purposes of paragraph (1) shall be 
applied uniformly to all Indian Tribes and Indian 
communities. 
‘‘(3) SANITATION
DEFICIENCY
LEVELS.—For 
purposes of this subsection, the sanitation deficiency 
levels for an individual, Indian Tribe, or Indian com-
munity sanitation facility to serve Indian homes are 
determined as follows: 
‘‘(A) A level I deficiency exists if a sanita-
tion facility serving an individual, Indian Tribe, 
or Indian community— 
‘‘(i) complies with all applicable water 
supply, pollution control, and solid waste 
disposal laws; and 
‘‘(ii) deficiencies relate to routine re-
placement, repair, or maintenance needs. 
‘‘(B) A level II deficiency exists if a sanita-
tion facility serving an individual, Indian Tribe, 
or Indian community substantially or recently 
complied with all applicable water supply, pollu-
tion control, and solid waste laws and any defi-
ciencies relate to— 
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153 
‘‘(i) small or minor capital improve-
ments needed to bring the facility back 
into compliance; 
‘‘(ii) capital improvements that are 
necessary to enlarge or improve the facili-
ties in order to meet the current needs for 
domestic sanitation facilities; or 
‘‘(iii) the lack of equipment or train-
ing by an Indian Tribe, Tribal Organiza-
tion, or an Indian community to properly 
operate and maintain the sanitation facili-
ties. 
‘‘(C) A level III deficiency exists if a sani-
tation facility serving an individual, Indian 
Tribe or Indian community meets 1 or more of 
the following conditions— 
‘‘(i) water or sewer service in the 
home is provided by a haul system with 
holding tanks and interior plumbing; 
‘‘(ii) major significant interruptions to 
water supply or sewage disposal occur fre-
quently, requiring major capital improve-
ments to correct the deficiencies; or 
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154 
‘‘(iii) there is no access to or no ap-
proved or permitted solid waste facility 
available. 
‘‘(D) A level IV deficiency exists— 
‘‘(i) if a sanitation facility for an indi-
vidual home, an Indian Tribe, or an Indian 
community exists but— 
‘‘(I) lacks— 
‘‘(aa) a safe water supply 
system; or 
‘‘(bb) a waste disposal sys-
tem; 
‘‘(II) contains no piped water or 
sewer facilities; or 
‘‘(III) has become inoperable due 
to a major component failure; or 
‘‘(ii) if only a washeteria or central fa-
cility exists in the community. 
‘‘(E) A level V deficiency exists in the ab-
sence of a sanitation facility, where individual 
homes do not have access to safe drinking 
water or adequate wastewater (including sew-
age) disposal. 
‘‘(i) DEFINITIONS.—For purposes of this section, the 
following terms apply: 
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155 
‘‘(1) INDIAN
COMMUNITY.—The term ‘Indian 
community’ means a geographic area, a significant 
proportion of whose inhabitants are Indians and 
which is served by or capable of being served by a 
facility described in this section. 
‘‘(2) 
SANITATION
FACILITIES.—The 
terms 
‘sanitation facility’ and ‘sanitation facilities’ mean 
safe and adequate water supply systems, sanitary 
sewage disposal systems, and sanitary solid waste 
systems (and all related equipment and support in-
frastructure). 
‘‘SEC. 303. PREFERENCE TO INDIANS AND INDIAN FIRMS. 
‘‘(a) BUY
INDIAN
ACT.—The Secretary, acting 
through the Service, may use the negotiating authority of 
section 23 of the Act of June 25, 1910 (25 U.S.C. 47, 
commonly known as the ‘Buy Indian Act’), to give pref-
erence to any Indian or any enterprise, partnership, cor-
poration, or other type of business organization owned and 
controlled by an Indian or Indians including former or 
currently federally recognized Indian Tribes in the State 
of New York (hereinafter referred to as an ‘Indian firm’) 
in the construction and renovation of Service facilities pur-
suant to section 301 and in the construction of sanitation 
facilities pursuant to section 302. Such preference may be 
accorded by the Secretary unless the Secretary finds, pur-
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156 
suant to regulations, that the project or function to be 
contracted for will not be satisfactory or such project or 
function cannot be properly completed or maintained 
under the proposed contract. The Secretary, in arriving 
at such a finding, shall consider whether the Indian or 
Indian firm will be deficient with respect to— 
‘‘(1) ownership and control by Indians; 
‘‘(2) equipment; 
‘‘(3) bookkeeping and accounting procedures; 
‘‘(4) substantive knowledge of the project or 
function to be contracted for; 
‘‘(5) adequately trained personnel; or 
‘‘(6) other necessary components of contract 
performance. 
‘‘(b) PAY RATES.—For the purposes of implementing 
the provisions of this title, the Secretary shall assure that 
the rates of pay for personnel engaged in the construction 
or renovation of facilities constructed or renovated in 
whole or in part by funds made available pursuant to this 
title are not less than the prevailing local wage rates for 
similar work as determined in accordance with the Act of 
March 3, 1931 (40 U.S.C. 276a–276a-5, known as the 
Davis-Bacon Act). 
‘‘(c) LABOR STANDARDS.—For the purposes of im-
plementing the provisions of this title, contracts for the 
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157 
construction or renovation of health care facilities, staff 
quarters, and sanitation facilities, and related support in-
frastructure, funded in whole or in part with funds made 
available pursuant to this title, shall contain a provision 
requiring compliance with subchapter IV of chapter 31 of 
title 40, United States Code (commonly known as the 
‘Davis-Bacon Act’). 
‘‘SEC. 304. EXPENDITURE OF NON-SERVICE FUNDS FOR 
RENOVATION. 
‘‘(a) IN GENERAL.—Notwithstanding any other pro-
vision of law, if the requirements of subsection (c) are met, 
the Secretary, acting through the Service, is authorized 
to accept any major expansion, renovation, or moderniza-
tion by any Indian Tribe or Tribal Organization of any 
Service facility or of any other Indian health facility oper-
ated pursuant to a contract or compact under the Indian 
Self-Determination and Education Assistance Act (25 
U.S.C. 450 et seq.), including— 
‘‘(1) any plans or designs for such expansion, 
renovation, or modernization; and 
‘‘(2) any expansion, renovation, or moderniza-
tion for which funds appropriated under any Federal 
law were lawfully expended. 
‘‘(b) PRIORITY LIST.— 
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158 
‘‘(1) IN GENERAL.—The Secretary shall main-
tain a separate priority list to address the needs for 
increased operating expenses, personnel, or equip-
ment for such facilities. The methodology for estab-
lishing priorities shall be developed through regula-
tions. The list of priority facilities will be revised an-
nually in consultation with Indian Tribes and Tribal 
Organizations. 
‘‘(2) REPORT.—The Secretary shall submit to 
the President, for inclusion in the report required to 
be transmitted to Congress under section 801, the 
priority list maintained pursuant to paragraph (1). 
‘‘(c) REQUIREMENTS.—The requirements of this sub-
section are met with respect to any expansion, renovation, 
or modernization if— 
‘‘(1) the Indian Tribe or Tribal Organization— 
‘‘(A) provides notice to the Secretary of its 
intent to expand, renovate, or modernize; and 
‘‘(B) applies to the Secretary to be placed 
on a separate priority list to address the needs 
of such new facilities for increased operating ex-
penses, personnel, or equipment; and 
‘‘(2) the expansion, renovation, or moderniza-
tion— 
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‘‘(A) is approved by the appropriate area 
director of the Service for Federal facilities; and 
‘‘(B) is administered by the Indian Tribe 
or Tribal Organization in accordance with any 
applicable regulations prescribed by the Sec-
retary with respect to construction or renova-
tion of Service facilities. 
‘‘(d) ADDITIONAL REQUIREMENT FOR EXPANSION.— 
In addition to the requirements under subsection (c), for 
any expansion, the Indian Tribe or Tribal Organization 
shall provide to the Secretary additional information pur-
suant to regulations, including additional staffing, equip-
ment, and other costs associated with the expansion. 
‘‘(e) CLOSURE OR CONVERSION OF FACILITIES.—If 
any Service facility which has been expanded, renovated, 
or modernized by an Indian Tribe or Tribal Organization 
under this section ceases to be used as a Service facility 
during the 20-year period beginning on the date such ex-
pansion, renovation, or modernization is completed, such 
Indian Tribe or Tribal Organization shall be entitled to 
recover from the United States an amount which bears 
the same ratio to the value of such facility at the time 
of such cessation as the value of such expansion, renova-
tion, or modernization (less the total amount of any funds 
provided specifically for such facility under any Federal 
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program that were expended for such expansion, renova-
tion, or modernization) bore to the value of such facility 
at the time of the completion of such expansion, renova-
tion, or modernization. 
‘‘SEC. 305. FUNDING FOR THE CONSTRUCTION, EXPANSION, 
AND MODERNIZATION OF SMALL AMBULA-
TORY CARE FACILITIES. 
‘‘(a) GRANTS.— 
‘‘(1) IN
GENERAL.—The Secretary, acting 
through the Service, shall make grants to Indian 
Tribes and Tribal Organizations for the construc-
tion, expansion, or modernization of facilities for the 
provision of ambulatory care services to eligible Indi-
ans (and noneligible persons pursuant to subsections 
(b)(2) and (c)(1)(C)). A grant made under this sec-
tion may cover up to 100 percent of the costs of 
such construction, expansion, or modernization. For 
the purposes of this section, the term ‘construction’ 
includes the replacement of an existing facility. 
‘‘(2) GRANT AGREEMENT REQUIRED.—A grant 
under paragraph (1) may only be made available to 
a Tribal Health Program operating an Indian health 
facility (other than a facility owned or constructed 
by the Service, including a facility originally owned 
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or constructed by the Service and transferred to an 
Indian Tribe or Tribal Organization). 
‘‘(b) USE OF GRANT FUNDS.— 
‘‘(1) ALLOWABLE
USES.—A grant awarded 
under this section may be used for the construction, 
expansion, or modernization (including the planning 
and design of such construction, expansion, or mod-
ernization) of an ambulatory care facility— 
‘‘(A) located apart from a hospital; 
‘‘(B) not funded under section 301 or sec-
tion 306; and 
‘‘(C) which, upon completion of such con-
struction or modernization will— 
‘‘(i) have a total capacity appropriate 
to its projected service population; 
‘‘(ii) provide annually no fewer than 
150 patient visits by eligible Indians and 
other users who are eligible for services in 
such facility in accordance with section 
807(c)(2); and 
‘‘(iii) provide ambulatory care in a 
Service Area (specified in the contract or 
compact under the Indian Self-Determina-
tion and Education Assistance Act (25 
U.S.C. 450 et seq.)) with a population of 
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no fewer than 1,500 eligible Indians and 
other users who are eligible for services in 
such facility in accordance with section 
807(c)(2). 
‘‘(2) ADDITIONAL ALLOWABLE USE.—The Sec-
retary may also reserve a portion of the funding pro-
vided under this section and use those reserved 
funds to reduce an outstanding debt incurred by In-
dian Tribes or Tribal Organizations for the con-
struction, expansion, or modernization of an ambula-
tory care facility that meets the requirements under 
paragraph (1). The provisions of this section shall 
apply, except that such applications for funding 
under this paragraph shall be considered separately 
from applications for funding under paragraph (1). 
‘‘(3) USE
ONLY
FOR
CERTAIN
PORTION
OF 
COSTS.—A grant provided under this section may be 
used only for the cost of that portion of a construc-
tion, expansion, or modernization project that bene-
fits the Service population identified above in sub-
section (b)(1)(C) (ii) and (iii). The requirements of 
clauses (ii) and (iii) of paragraph (1)(C) shall not 
apply to an Indian Tribe or Tribal Organization ap-
plying for a grant under this section for a health 
care facility located or to be constructed on an is-
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land or when such facility is not located on a road 
system providing direct access to an inpatient hos-
pital where care is available to the Service popu-
lation. 
‘‘(c) GRANTS.— 
‘‘(1) APPLICATION.—No grant may be made 
under this section unless an application or proposal 
for the grant has been approved by the Secretary in 
accordance with applicable regulations and has set 
forth reasonable assurance by the applicant that, at 
all times after the construction, expansion, or mod-
ernization of a facility carried out using a grant re-
ceived under this section— 
‘‘(A) adequate financial support will be 
available for the provision of services at such 
facility; 
‘‘(B) such facility will be available to eligi-
ble Indians without regard to ability to pay or 
source of payment; and 
‘‘(C) such facility will, as feasible without 
diminishing the quality or quantity of services 
provided to eligible Indians, serve noneligible 
persons on a cost basis. 
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‘‘(2) PRIORITY.—In awarding grants under this 
section, the Secretary shall give priority to Indian 
Tribes and Tribal Organizations that demonstrate— 
‘‘(A) a need for increased ambulatory care 
services; and 
‘‘(B) insufficient capacity to deliver such 
services. 
‘‘(3) PEER
REVIEW
PANELS.—The Secretary 
may provide for the establishment of peer review 
panels, as necessary, to review and evaluate applica-
tions and proposals and to advise the Secretary re-
garding such applications using the criteria devel-
oped pursuant to subsection (a)(1). 
‘‘(d) REVERSION OF FACILITIES.—If any facility (or 
portion thereof) with respect to which funds have been 
paid under this section, ceases, at any time after comple-
tion of the construction, expansion, or modernization car-
ried out with such funds, to be used for the purposes of 
providing health care services to eligible Indians, all of the 
right, title, and interest in and to such facility (or portion 
thereof) shall transfer to the United States unless other-
wise negotiated by the Service and the Indian Tribe or 
Tribal Organization. 
‘‘(e) FUNDING NONRECURRING.—Funding provided 
under this section shall be nonrecurring and shall not be 
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available for inclusion in any individual Indian Tribe’s 
tribal share for an award under the Indian Self-Deter-
mination and Education Assistance Act (25 U.S.C. 450 
et seq.) or for reallocation or redesign thereunder. 
‘‘SEC. 306. INDIAN HEALTH CARE DELIVERY DEMONSTRA-
TION PROJECT. 
‘‘(a) HEALTH CARE DEMONSTRATION PROJECTS.— 
The Secretary, acting through the Service, is authorized 
to make grants to, and enter into construction contracts 
or construction project agreements with, Indian Tribes or 
Tribal Organizations under the Indian Self-Determination 
and Education Assistance Act (25 U.S.C. 450 et seq.) for 
the purpose of carrying out a health care delivery dem-
onstration project to test alternative means of delivering 
health care and services to Indians through facilities. 
‘‘(b) USE OF FUNDS.—The Secretary, in approving 
projects pursuant to this section, may authorize such con-
tracts for the construction and renovation of hospitals, 
health centers, health stations, and other facilities to de-
liver health care services and is authorized to— 
‘‘(1) waive any leasing prohibition; 
‘‘(2) permit carryover of funds appropriated for 
the provision of health care services; 
‘‘(3) permit the use of other available funds; 
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‘‘(4) permit the use of funds or property do-
nated from any source for project purposes; 
‘‘(5) provide for the reversion of donated real or 
personal property to the donor; and 
‘‘(6) permit the use of Service funds to match 
other funds, including Federal funds. 
‘‘(c) REGULATIONS.—The Secretary shall develop 
and promulgate regulations, not later than 1 year after 
the date of enactment of the Indian Health Care Improve-
ment Act Amendments of 2009, for the review and ap-
proval of applications submitted under this section. 
‘‘(d) CRITERIA.—The Secretary may approve projects 
that meet the following criteria: 
‘‘(1) There is a need for a new facility or pro-
gram or the reorientation of an existing facility or 
program. 
‘‘(2) A significant number of Indians, including 
those with low health status, will be served by the 
project. 
‘‘(3) The project has the potential to deliver 
services in an efficient and effective manner. 
‘‘(4) The project is economically viable. 
‘‘(5) The Indian Tribe or Tribal Organization 
has the administrative and financial capability to ad-
minister the project. 
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‘‘(6) The project is integrated with providers of 
related health and social services and is coordinated 
with, and avoids duplication of, existing services. 
‘‘(e) PEER REVIEW PANELS.—The Secretary may 
provide for the establishment of peer review panels, as nec-
essary, to review and evaluate applications using the cri-
teria developed pursuant to subsection (d). 
‘‘(f) PRIORITY.—The Secretary shall give priority to 
applications for demonstration projects in each of the fol-
lowing Service Units to the extent that such applications 
are timely filed and meet the criteria specified in sub-
section (d): 
‘‘(1) Cass Lake, Minnesota. 
‘‘(2) Mescalero, New Mexico. 
‘‘(3) Owyhee, Nevada. 
‘‘(4) Schurz, Nevada. 
‘‘(5) Ft. Yuma, California. 
‘‘(g) TECHNICAL ASSISTANCE.—The Secretary shall 
provide such technical and other assistance as may be nec-
essary to enable applicants to comply with the provisions 
of this section. 
‘‘(h) SERVICE TO INELIGIBLE PERSONS.—Subject to 
section 806, the authority to provide services to persons 
otherwise ineligible for the health care benefits of the 
Service and the authority to extend hospital privileges in 
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Service facilities to non-Service health practitioners as 
provided in section 806 may be included, subject to the 
terms of such section, in any demonstration project ap-
proved pursuant to this section. 
‘‘(i) EQUITABLE TREATMENT.—For purposes of sub-
section (d)(1), the Secretary shall, in evaluating facilities 
operated under any contract or compact under the Indian 
Self-Determination and Education Assistance Act (25 
U.S.C. 450 et seq.), use the same criteria that the Sec-
retary uses in evaluating facilities operated directly by the 
Service. 
‘‘(j) EQUITABLE INTEGRATION OF FACILITIES.—The 
Secretary shall ensure that the planning, design, construc-
tion, renovation, and expansion needs of Service and non- 
Service facilities which are the subject of a contract or 
compact under the Indian Self-Determination and Edu-
cation Assistance Act (25 U.S.C. 450 et seq.) for health 
services are fully and equitably integrated into the imple-
mentation of the health care delivery demonstration 
projects under this section. 
‘‘SEC. 307. LAND TRANSFER. 
‘‘Notwithstanding any other provision of law, the Bu-
reau of Indian Affairs and all other agencies and depart-
ments of the United States are authorized to transfer, at 
no cost, land and improvements to the Service for the pro-
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vision of health care services. The Secretary is authorized 
to accept such land and improvements for such purposes. 
‘‘SEC. 308. LEASES, CONTRACTS, AND OTHER AGREEMENTS. 
‘‘The Secretary, acting through the Service, may 
enter into leases, contracts, and other agreements with In-
dian Tribes and Tribal Organizations which hold (1) title 
to, (2) a leasehold interest in, or (3) a beneficial interest 
in (when title is held by the United States in trust for 
the benefit of an Indian Tribe) facilities used or to be used 
for the administration and delivery of health services by 
an Indian Health Program. Such leases, contracts, or 
agreements may include provisions for construction or ren-
ovation and provide for compensation to the Indian Tribe 
or Tribal Organization of rental and other costs consistent 
with section 105(l) of the Indian Self-Determination and 
Education Assistance Act (25 U.S.C. 450j(l)) and regula-
tions thereunder. 
‘‘SEC. 309. STUDY ON LOANS, LOAN GUARANTEES, AND 
LOAN REPAYMENT. 
‘‘(a) IN GENERAL.—The Secretary, in consultation 
with the Secretary of the Treasury, Indian Tribes, and 
Tribal Organizations, shall carry out a study to determine 
the feasibility of establishing a loan fund to provide to In-
dian Tribes and Tribal Organizations direct loans or guar-
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antees for loans for the construction of health care facili-
ties, including— 
‘‘(1) inpatient facilities; 
‘‘(2) outpatient facilities; 
‘‘(3) staff quarters; 
‘‘(4) hostels; and 
‘‘(5) specialized care facilities, such as behav-
ioral health and elder care facilities. 
‘‘(b) DETERMINATIONS.—In carrying out the study 
under subsection (a), the Secretary shall determine— 
‘‘(1) the maximum principal amount of a loan 
or loan guarantee that should be offered to a recipi-
ent from the loan fund; 
‘‘(2) the percentage of eligible costs, not to ex-
ceed 100 percent, that may be covered by a loan or 
loan guarantee from the loan fund (including costs 
relating to planning, design, financing, site land de-
velopment, construction, rehabilitation, renovation, 
conversion, improvements, medical equipment and 
furnishings, and other facility-related costs and cap-
ital purchase (but excluding staffing)); 
‘‘(3) the cumulative total of the principal of di-
rect loans and loan guarantees, respectively, that 
may be outstanding at any 1 time; 
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‘‘(10) any legislative or regulatory changes re-
quired to implement recommendations of the Sec-
retary based on results of the study. 
‘‘(c) REPORT.—Not later than September 30, 2010, 
the Secretary shall submit to the Committee on Indian Af-
fairs of the Senate and the Committee on Natural Re-
sources and the Committee on Energy and Commerce of 
the House of Representatives a report that describes— 
‘‘(1) the manner of consultation made as re-
quired by subsection (a); and 
‘‘(2) the results of the study, including any rec-
ommendations of the Secretary based on results of 
the study. 
‘‘SEC. 310. TRIBAL LEASING. 
‘‘A Tribal Health Program may lease permanent 
structures for the purpose of providing health care services 
without obtaining advance approval in appropriation Acts. 
‘‘SEC. 311. INDIAN HEALTH SERVICE/TRIBAL FACILITIES 
JOINT VENTURE PROGRAM. 
‘‘(a) IN GENERAL.—The Secretary, acting through 
the Service, shall make arrangements with Indian Tribes 
and Tribal Organizations to establish joint venture dem-
onstration projects under which an Indian Tribe or Tribal 
Organization shall expend tribal, private, or other avail-
able funds, for the acquisition or construction of a health 
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facility for a minimum of 10 years, under a no-cost lease, 
in exchange for agreement by the Service to provide the 
equipment, supplies, and staffing for the operation and 
maintenance of such a health facility. An Indian Tribe or 
Tribal Organization may use tribal funds, private sector, 
or other available resources, including loan guarantees, to 
fulfill its commitment under a joint venture entered into 
under this subsection. An Indian Tribe or Tribal Organi-
zation shall be eligible to establish a joint venture project 
if, when it submits a letter of intent, it— 
‘‘(1) has begun but not completed the process 
of acquisition or construction of a health facility to 
be used in the joint venture project; 
‘‘(2) has not begun the process of acquisition or 
construction of a health facility for use in the joint 
venture project; or 
‘‘(3) in its application for a joint venture agree-
ment, agrees— 
‘‘(A) to construct a facility for the joint 
venture which complies with the size and space 
criteria established by the Service; or 
‘‘(B) if the facility it proposes for the joint 
venture is already in existence or under con-
struction, that only the portion of such facility 
which complies with the size and space criteria 
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of the Service will be eligible for the joint ven-
ture agreement. 
‘‘(b) REQUIREMENTS.—The Secretary shall make 
such an arrangement with an Indian Tribe or Tribal Orga-
nization only if— 
‘‘(1) the Secretary first determines that the In-
dian Tribe or Tribal Organization has the adminis-
trative and financial capabilities necessary to com-
plete the timely acquisition or construction of the 
relevant health facility; and 
‘‘(2) the Indian Tribe or Tribal Organization 
meets the need criteria determined using the criteria 
developed under the health care facility priority sys-
tem under section 301, unless the Secretary deter-
mines, pursuant to regulations, that other criteria 
will result in a more cost-effective and efficient 
method of facilitating and completing construction of 
health care facilities. 
‘‘(c) CONTINUED OPERATION.—The Secretary shall 
negotiate an agreement with the Indian Tribe or Tribal 
Organization regarding the continued operation of the fa-
cility at the end of the initial 10 year no-cost lease period. 
‘‘(d) BREACH OF AGREEMENT.—An Indian Tribe or 
Tribal Organization that has entered into a written agree-
ment with the Secretary under this section, and that 
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breaches or terminates without cause such agreement, 
shall be liable to the United States for the amount that 
has been paid to the Indian Tribe or Tribal Organization, 
or paid to a third party on the Indian Tribe’s or Tribal 
Organization’s behalf, under the agreement. The Sec-
retary has the right to recover tangible property (including 
supplies) and equipment, less depreciation, and any funds 
expended for operations and maintenance under this sec-
tion. The preceding sentence does not apply to any funds 
expended for the delivery of health care services, per-
sonnel, or staffing. 
‘‘(e) RECOVERY FOR NONUSE.—An Indian Tribe or 
Tribal Organization that has entered into a written agree-
ment with the Secretary under this subsection shall be en-
titled to recover from the United States an amount that 
is proportional to the value of such facility if, at any time 
within the 10-year term of the agreement, the Service 
ceases to use the facility or otherwise breaches the agree-
ment. 
‘‘(f) DEFINITION.—For the purposes of this section, 
the term ‘health facility’ or ‘health facilities’ includes 
quarters needed to provide housing for staff of the rel-
evant Tribal Health Program. 
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‘‘SEC. 312. LOCATION OF FACILITIES. 
‘‘(a) IN GENERAL.—In all matters involving the reor-
ganization or development of Service facilities or in the 
establishment of related employment projects to address 
unemployment conditions in economically depressed areas, 
the Bureau of Indian Affairs and the Service shall give 
priority to locating such facilities and projects on Indian 
lands, or lands in Alaska owned by any Alaska Native vil-
lage, or village or regional corporation under the Alaska 
Native Claims Settlement Act (43 U.S.C. 1601 et seq.), 
or any land allotted to any Alaska Native, if requested 
by the Indian owner and the Indian Tribe with jurisdiction 
over such lands or other lands owned or leased by the In-
dian Tribe or Tribal Organization. Top priority shall be 
given to Indian land owned by 1 or more Indian Tribes. 
‘‘(b) DEFINITION.—For purposes of this section, the 
term ‘Indian lands’ means— 
‘‘(1) all lands within the exterior boundaries of 
any reservation; and 
‘‘(2) any lands title to which is held in trust by 
the United States for the benefit of any Indian 
Tribe or individual Indian or held by any Indian 
Tribe or individual Indian subject to restriction by 
the United States against alienation. 
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‘‘SEC. 313. MAINTENANCE AND IMPROVEMENT OF HEALTH 
CARE FACILITIES. 
‘‘(a) REPORT.—The Secretary shall submit to the 
President, for inclusion in the report required to be trans-
mitted to Congress under section 801, a report which iden-
tifies the backlog of maintenance and repair work required 
at both Service and tribal health care facilities, including 
new health care facilities expected to be in operation in 
the next fiscal year. The report shall also identify the need 
for renovation and expansion of existing facilities to sup-
port the growth of health care programs. 
‘‘(b) MAINTENANCE
OF
NEWLY
CONSTRUCTED 
SPACE.—The Secretary, acting through the Service, is au-
thorized to expend maintenance and improvement funds 
to support maintenance of newly constructed space only 
if such space falls within the approved supportable space 
allocation for the Indian Tribe or Tribal Organization. 
Supportable space allocation shall be defined through the 
health care facility priority system under section 301(c). 
‘‘(c) REPLACEMENT FACILITIES.—In addition to 
using maintenance and improvement funds for renovation, 
modernization, and expansion of facilities, an Indian Tribe 
or Tribal Organization may use maintenance and improve-
ment funds for construction of a replacement facility if 
the costs of renovation of such facility would exceed a 
maximum renovation cost threshold. The Secretary shall 
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consult with Indian Tribes and Tribal Organizations in de-
termining the maximum renovation cost threshold. 
‘‘SEC. 314. TRIBAL MANAGEMENT OF FEDERALLY OWNED 
QUARTERS. 
‘‘(a) RENTAL RATES.— 
‘‘(1) ESTABLISHMENT.—Notwithstanding any 
other provision of law, a Tribal Health Program 
which operates a hospital or other health facility and 
the federally owned quarters associated therewith 
pursuant to a contract or compact under the Indian 
Self-Determination and Education Assistance Act 
(25 U.S.C. 450 et seq.) shall have the authority to 
establish the rental rates charged to the occupants 
of such quarters by providing notice to the Secretary 
of its election to exercise such authority. 
‘‘(2) OBJECTIVES.—In establishing rental rates 
pursuant to authority of this subsection, a Tribal 
Health Program shall endeavor to achieve the fol-
lowing objectives: 
‘‘(A) To base such rental rates on the rea-
sonable value of the quarters to the occupants 
thereof. 
‘‘(B) To generate sufficient funds to pru-
dently provide for the operation and mainte-
nance of the quarters, and subject to the discre-
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tion of the Tribal Health Program, to supply 
reserve funds for capital repairs and replace-
ment of the quarters. 
‘‘(3) 
EQUITABLE
FUNDING.—Any 
quarters 
whose rental rates are established by a Tribal 
Health Program pursuant to this subsection shall 
remain eligible for quarters improvement and repair 
funds to the same extent as all federally owned 
quarters used to house personnel in Services-sup-
ported programs. 
‘‘(4) NOTICE
OF
RATE
CHANGE.—A Tribal 
Health Program which exercises the authority pro-
vided under this subsection shall provide occupants 
with no less than 60 days notice of any change in 
rental rates. 
‘‘(b) DIRECT COLLECTION OF RENT.— 
‘‘(1) IN GENERAL.—Notwithstanding any other 
provision of law, and subject to paragraph (2), a 
Tribal Health Program shall have the authority to 
collect rents directly from Federal employees who oc-
cupy such quarters in accordance with the following: 
‘‘(A) The Tribal Health Program shall no-
tify the Secretary and the subject Federal em-
ployees of its election to exercise its authority 
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to collect rents directly from such Federal em-
ployees. 
‘‘(B) Upon receipt of a notice described in 
subparagraph (A), the Federal employees shall 
pay rents for occupancy of such quarters di-
rectly to the Tribal Health Program and the 
Secretary shall have no further authority to col-
lect rents from such employees through payroll 
deduction or otherwise. 
‘‘(C) Such rent payments shall be retained 
by the Tribal Health Program and shall not be 
made payable to or otherwise be deposited with 
the United States. 
‘‘(D) Such rent payments shall be depos-
ited into a separate account which shall be used 
by the Tribal Health Program for the mainte-
nance (including capital repairs and replace-
ment) and operation of the quarters and facili-
ties as the Tribal Health Program shall deter-
mine. 
‘‘(2) RETROCESSION
OF
AUTHORITY.—If a 
Tribal Health Program which has made an election 
under paragraph (1) requests retrocession of its au-
thority to directly collect rents from Federal employ-
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ees occupying federally owned quarters, such ret-
rocession shall become effective on the earlier of— 
‘‘(A) the first day of the month that begins 
no less than 180 days after the Tribal Health 
Program notifies the Secretary of its desire to 
retrocede; or 
‘‘(B) such other date as may be mutually 
agreed by the Secretary and the Tribal Health 
Program. 
‘‘(c) RATES IN ALASKA.—To the extent that a Tribal 
Health Program, pursuant to authority granted in sub-
section (a), establishes rental rates for federally owned 
quarters provided to a Federal employee in Alaska, such 
rents may be based on the cost of comparable private rent-
al housing in the nearest established community with a 
year-round population of 1,500 or more individuals. 
‘‘SEC. 315. APPLICABILITY OF BUY AMERICAN ACT RE-
QUIREMENT. 
‘‘(a) APPLICABILITY.—The Secretary shall ensure 
that the requirements of the Buy American Act apply to 
all procurements made with funds provided pursuant to 
section 317. Indian Tribes and Tribal Organizations shall 
be exempt from these requirements. 
‘‘(b) EFFECT OF VIOLATION.—If it has been finally 
determined by a court or Federal agency that any person 
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intentionally affixed a label bearing a ‘Made in America’ 
inscription or any inscription with the same meaning, to 
any product sold in or shipped to the United States that 
is not made in the United States, such person shall be 
ineligible to receive any contract or subcontract made with 
funds provided pursuant to section 317, pursuant to the 
debarment, suspension, and ineligibility procedures de-
scribed in sections 9.400 through 9.409 of title 48, Code 
of Federal Regulations. 
‘‘(c) DEFINITIONS.—For purposes of this section, the 
term ‘Buy American Act’ means title III of the Act enti-
tled ‘An Act making appropriations for the Treasury and 
Post Office Departments for the fiscal year ending June 
30, 1934, and for other purposes’, approved March 3, 
1933 (41 U.S.C. 10a et seq.). 
‘‘SEC. 316. OTHER FUNDING FOR FACILITIES. 
‘‘(a) AUTHORITY TO ACCEPT FUNDS.—The Sec-
retary is authorized to accept from any source, including 
Federal and State agencies, funds that are available for 
the construction of health care facilities and use such 
funds to plan, design, and construct health care facilities 
for Indians and to place such funds into a contract or com-
pact under the Indian Self-Determination and Education 
Assistance Act (25 U.S.C. 450 et seq.). Receipt of such 
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183 
funds shall have no effect on the priorities established pur-
suant to section 301. 
‘‘(b) INTERAGENCY AGREEMENTS.—The Secretary is 
authorized to enter into interagency agreements with 
other Federal agencies or State agencies and other entities 
and to accept funds from such Federal or State agencies 
or other sources to provide for the planning, design, and 
construction of health care facilities to be administered by 
Indian Health Programs in order to carry out the pur-
poses of this Act and the purposes for which the funds 
were appropriated or for which the funds were otherwise 
provided. 
‘‘(c) TRANSFERRED FUNDS.—Any Federal agency to 
which funds for the construction of health care facilities 
are appropriated is authorized to transfer such funds to 
the Secretary for the construction of health care facilities 
to carry out the purposes of this Act as well as the pur-
poses for which such funds are appropriated to such other 
Federal agency. 
‘‘(d) ESTABLISHMENT
OF STANDARDS.—The Sec-
retary, through the Service, shall establish standards by 
regulation for the planning, design, and construction of 
health care facilities serving Indians under this Act. 
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184 
‘‘SEC. 317. AUTHORIZATION OF APPROPRIATIONS. 
‘‘There are authorized to be appropriated such sums 
as may be necessary for each fiscal year through fiscal 
year 2025 to carry out this title. 
‘‘TITLE IV—ACCESS TO HEALTH 
SERVICES 
‘‘SEC. 401. TREATMENT OF PAYMENTS UNDER SOCIAL SE-
CURITY ACT HEALTH BENEFITS PROGRAMS. 
‘‘(a) DISREGARD
OF MEDICARE, MEDICAID, AND 
SCHIP PAYMENTS IN DETERMINING APPROPRIATIONS.— 
Any payments received by an Indian Health Program or 
by an urban Indian organization under title XVIII, XIX, 
or XXI of the Social Security Act for services provided 
to Indians eligible for benefits under such respective titles 
shall not be considered in determining appropriations for 
the provision of health care and services to Indians. 
‘‘(b) NONPREFERENTIAL TREATMENT.—Nothing in 
this Act authorizes the Secretary to provide services to an 
Indian with coverage under title XVIII, XIX, or XXI of 
the Social Security Act in preference to an Indian without 
such coverage. 
‘‘(c) USE OF FUNDS.— 
‘‘(1) SPECIAL FUND.— 
‘‘(A) 100 PERCENT
PASS-THROUGH
OF 
PAYMENTS
DUE
TO
FACILITIES.—Notwith-
standing any other provision of law, but subject 
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185 
to paragraph (2), payments to which a facility 
of the Service is entitled by reason of a provi-
sion of title XVIII or XIX of the Social Secu-
rity Act shall be placed in a special fund to be 
held by the Secretary. In making payments 
from such fund, the Secretary shall ensure that 
each Service Unit of the Service receives 100 
percent of the amount to which the facilities of 
the Service, for which such Service Unit makes 
collections, are entitled by reason of a provision 
of either such title. 
‘‘(B) USE OF FUNDS.—Amounts received 
by a facility of the Service under subparagraph 
(A) by reason of a provision of title XVIII or 
XIX of the Social Security Act shall first be 
used (to such extent or in such amounts as are 
provided in appropriation Acts) for the purpose 
of making any improvements in the programs 
of the Service operated by or through such fa-
cility which may be necessary to achieve or 
maintain compliance with the applicable condi-
tions and requirements of such respective title. 
Any amounts so received that are in excess of 
the amount necessary to achieve or maintain 
such conditions and requirements shall, subject 
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186 
to consultation with the Indian Tribes being 
served by the Service Unit, be used for increas-
ing the facility’s capacity to provide, or improv-
ing the quality or accessibility of, services. 
‘‘(2) DIRECT
PAYMENT
OPTION.—Paragraph 
(1) shall not apply to a Tribal Health Program upon 
the election of such Program under subsection (d) to 
receive payments directly. No payment may be made 
out of the special fund described in such paragraph 
with respect to reimbursement made for services 
provided by such Program during the period of such 
election. 
‘‘(d) DIRECT BILLING.— 
‘‘(1) IN GENERAL.—Subject to complying with 
the requirements of paragraph (2), a Tribal Health 
Program may elect to directly bill for, and receive 
payment for, health care items and services provided 
by such Program for which payment is made under 
title XVIII, XIX, or XXI of the Social Security Act. 
‘‘(2) DIRECT REIMBURSEMENT.— 
‘‘(A) USE OF FUNDS.—Each Tribal Health 
Program making the election described in para-
graph (1) with respect to a program under title 
XVIII, XIX, or XXI of the Social Security Act 
shall be reimbursed directly by that program 
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for items and services furnished without regard 
to subsection (c)(1), but all amounts so reim-
bursed shall be used by the Tribal Health Pro-
gram for the same purposes with respect to 
such Program for which payment under sub-
paragraph (A) of subsection (c)(1) to a facility 
of the Service may be used pursuant to sub-
paragraph (B) of such subsection with respect 
to the Service. 
‘‘(B) AUDITS.—The amounts paid to a 
Tribal Health Program making the election de-
scribed in paragraph (1) with respect to a pro-
gram under title XVIII, XIX, or XXI of the So-
cial Security Act shall be subject to all auditing 
requirements applicable to the program under 
such title, as well as all auditing requirements 
applicable to programs administered by an In-
dian Health Program. Nothing in the preceding 
sentence shall be construed as limiting the ap-
plication of auditing requirements applicable to 
amounts paid under title XVIII, XIX, or XXI 
of the Social Security Act. 
‘‘(C) IDENTIFICATION OF SOURCE OF PAY-
MENTS.—Any Tribal Health Program that re-
ceives reimbursements or payments under title 
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188 
XVIII, XIX, or XXI of the Social Security Act 
shall provide to the Service a list of each pro-
vider enrollment number (or other identifier) 
under which such Program receives such reim-
bursements or payments. 
‘‘(3) EXAMINATION AND IMPLEMENTATION OF 
CHANGES.— 
‘‘(A) IN GENERAL.—The Secretary, acting 
through the Service and with the assistance of 
the Administrator of the Centers for Medicare 
& Medicaid Services, shall examine on an ongo-
ing basis and implement any administrative 
changes that may be necessary to facilitate di-
rect billing and reimbursement under the pro-
gram established under this subsection, includ-
ing any agreements with States that may be 
necessary to provide for direct billing under a 
program under title XIX or XXI of the Social 
Security Act. 
‘‘(B) COORDINATION OF INFORMATION.— 
The Service shall provide the Administrator of 
the Centers for Medicare & Medicaid Services 
with copies of the lists submitted to the Service 
under paragraph (2)(C), enrollment data re-
garding patients served by the Service (and by 
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Tribal Health Programs, to the extent such 
data is available to the Service), and such other 
information as the Administrator may require 
for purposes of administering title XVIII, XIX, 
or XXI of the Social Security Act. 
‘‘(4) WITHDRAWAL FROM PROGRAM.—A Tribal 
Health Program that bills directly under the pro-
gram established under this subsection may with-
draw from participation in the same manner and 
under the same conditions that an Indian Tribe or 
Tribal Organization may retrocede a contracted pro-
gram to the Secretary under the authority of the In-
dian Self-Determination and Education Assistance 
Act (25 U.S.C. 450 et seq.). All cost accounting and 
billing authority under the program established 
under this subsection shall be returned to the Sec-
retary upon the Secretary’s acceptance of the with-
drawal of participation in this program. 
‘‘(5) TERMINATION FOR FAILURE TO COMPLY 
WITH REQUIREMENTS.—The Secretary may termi-
nate the participation of a Tribal Health Program or 
in the direct billing program established under this 
subsection if the Secretary determines that the Pro-
gram has failed to comply with the requirements of 
paragraph (2). The Secretary shall provide a Tribal 
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190 
Health Program with notice of a determination that 
the Program has failed to comply with any such re-
quirement and a reasonable opportunity to correct 
such noncompliance prior to terminating the Pro-
gram’s participation in the direct billing program es-
tablished under this subsection. 
‘‘(e) RELATED PROVISIONS UNDER THE SOCIAL SE-
CURITY ACT.—For provisions related to subsections (c) 
and (d), see sections 1880, 1911, and 2107(e)(1)(D) of 
the Social Security Act. 
‘‘SEC. 402. GRANTS TO AND CONTRACTS WITH THE SERV-
ICE, 
INDIAN 
TRIBES, 
TRIBAL 
ORGANIZA-
TIONS, AND URBAN INDIAN ORGANIZATIONS 
TO FACILITATE OUTREACH, ENROLLMENT, 
AND COVERAGE OF INDIANS UNDER SOCIAL 
SECURITY ACT HEALTH BENEFIT PROGRAMS. 
‘‘(a) INDIAN
TRIBES
AND
TRIBAL
ORGANIZA-
TIONS.—From funds appropriated to carry out this title 
in accordance with section 414, the Secretary, acting 
through the Service, shall make grants to or enter into 
contracts with Indian Tribes and Tribal Organizations to 
assist such Tribes and Tribal Organizations in estab-
lishing and administering programs on or near reserva-
tions and trust lands, including programs to provide out-
reach and enrollment through video, electronic delivery 
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191 
methods, or telecommunication devices that allow real- 
time or time-delayed communication between individual 
Indians and the benefit program, to assist individual Indi-
ans— 
‘‘(1) to enroll for benefits under a program es-
tablished under title XVIII, XIX, or XXI of the So-
cial Security Act; and 
‘‘(2) with respect to such programs for which 
the charging of premiums and cost sharing is not 
prohibited under such programs, to pay premiums or 
cost sharing for coverage for such benefits, which 
may be based on financial need (as determined by 
the Indian Tribe or Tribes or Tribal Organizations 
being served based on a schedule of income levels de-
veloped or implemented by such Tribe, Tribes, or 
Tribal Organizations). 
‘‘(b) CONDITIONS.—The Secretary, acting through 
the Service, shall place conditions as deemed necessary to 
effect the purpose of this section in any grant or contract 
which the Secretary makes with any Indian Tribe or Trib-
al Organization pursuant to this section. Such conditions 
shall include requirements that the Indian Tribe or Tribal 
Organization successfully undertake— 
‘‘(1) to determine the population of Indians eli-
gible for the benefits described in subsection (a); 
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‘‘(2) to educate Indians with respect to the ben-
efits available under the respective programs; 
‘‘(3) to provide transportation for such indi-
vidual Indians to the appropriate offices for enroll-
ment or applications for such benefits; and 
‘‘(4) to develop and implement methods of im-
proving the participation of Indians in receiving ben-
efits under such programs. 
‘‘(c) APPLICATION
TO URBAN INDIAN ORGANIZA-
TIONS.— 
‘‘(1) IN
GENERAL.—The provisions of sub-
section (a) shall apply with respect to grants and 
other funding to urban Indian organizations with re-
spect to populations served by such organizations in 
the same manner they apply to grants and contracts 
with Indian Tribes and Tribal Organizations with 
respect to programs on or near reservations. 
‘‘(2) REQUIREMENTS.—The Secretary shall in-
clude in the grants or contracts made or provided 
under paragraph (1) requirements that are— 
‘‘(A) consistent with the requirements im-
posed by the Secretary under subsection (b); 
‘‘(B) appropriate to urban Indian organi-
zations and urban Indians; and 
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‘‘(C) necessary to effect the purposes of 
this section. 
‘‘(d) FACILITATING COOPERATION IN ENROLLMENT 
AND RETENTION.—The Secretary, acting through the 
Centers for Medicare & Medicaid Services, shall consult 
with States, the Service, Indian Tribes, Tribal Organiza-
tions, and urban Indian organizations to develop and dis-
seminate best practices with respect to facilitating agree-
ments between the States and Indian Tribes, Tribal Orga-
nizations, and urban Indian organizations relating to en-
rollment and retention of Indians in programs established 
under titles XVIII, XIX, and XXI of the Social Security 
Act. 
‘‘(e) AGREEMENTS TO IMPROVE ENROLLMENT OF 
INDIANS UNDER SOCIAL SECURITY ACT HEALTH BENE-
FITS PROGRAMS.—For provisions relating to agreements 
between the Secretary and the Service, Indian Tribes, 
Tribal Organizations, and urban Indian organizations for 
the collection, preparation, and submission of applications 
by Indians for assistance under the Medicaid and chil-
dren’s health insurance programs established under titles 
XIX and XXI of the Social Security Act, and benefits 
under the Medicare program established under title XVIII 
of such Act, see subsections (a) and (b) of section 1139 
of the Social Security Act. 
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‘‘(f) DEFINITIONS.—In this section: 
‘‘(1) PREMIUM.—The term ‘premium’ includes 
any enrollment fee or similar charge. 
‘‘(2) COST SHARING.—The term ‘cost sharing’ 
includes any deduction, deductible, copayment, coin-
surance, or similar charge. 
‘‘(3) BENEFITS.—The term ‘benefits’ means, 
with respect to— 
‘‘(A) title XVIII of the Social Security Act, 
benefits under such title; 
‘‘(B) title XIX of such Act, medical assist-
ance under such title; and 
‘‘(C) title XXI of such Act, assistance 
under such title. 
‘‘SEC. 403. REIMBURSEMENT FROM CERTAIN THIRD PAR-
TIES OF COSTS OF HEALTH SERVICES. 
‘‘(a) RIGHT OF RECOVERY.—Except as provided in 
subsection (f), the United States, an Indian Tribe, or 
Tribal Organization shall have the right to recover from 
an insurance company, health maintenance organization, 
employee benefit plan, third-party tortfeasor, or any other 
responsible or liable third party (including a political sub-
division or local governmental entity of a State) the rea-
sonable charges billed by the Secretary, an Indian Tribe, 
or Tribal Organization, or, if higher, the highest amount 
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the third party would pay for care and services furnished 
by providers other than governmental entities, in providing 
health services through the Service, an Indian Tribe, or 
Tribal Organization to any individual to the same extent 
that such individual, or any nongovernmental provider of 
such services, would be eligible to receive damages, reim-
bursement, or indemnification for such charges if— 
‘‘(1) such services had been provided by a non-
governmental provider; and 
‘‘(2) such individual had been required to pay 
such charges or expenses and did pay such charges 
or expenses. 
‘‘(b) LIMITATIONS ON RECOVERIES FROM STATES.— 
Subsection (a) shall provide a right of recovery against 
any State, only if the injury, illness, or disability for which 
health services were provided is covered under— 
‘‘(1) workers’ compensation laws; or 
‘‘(2) a no-fault automobile accident insurance 
plan or program. 
‘‘(c) NONAPPLICATION OF OTHER LAWS.—No law of 
any State, or of any political subdivision of a State and 
no provision of any contract, insurance or health mainte-
nance organization policy, employee benefit plan, self-in-
surance plan, managed care plan, or other health care plan 
or program entered into or renewed after the date of the 
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enactment of the Indian Health Care Amendments of 
1988, shall prevent or hinder the right of recovery of the 
United States, an Indian Tribe, or Tribal Organization 
under subsection (a). 
‘‘(d) NO EFFECT ON PRIVATE RIGHTS OF ACTION.— 
No action taken by the United States, an Indian Tribe, 
or Tribal Organization to enforce the right of recovery 
provided under this section shall operate to deny to the 
injured person the recovery for that portion of the person’s 
damage not covered hereunder. 
‘‘(e) ENFORCEMENT.— 
‘‘(1) IN GENERAL.—The United States, an In-
dian Tribe, or Tribal Organization may enforce the 
right of recovery provided under subsection (a) by— 
‘‘(A) intervening or joining in any civil ac-
tion or proceeding brought— 
‘‘(i) by the individual for whom health 
services were provided by the Secretary, an 
Indian Tribe, or Tribal Organization; or 
‘‘(ii) by any representative or heirs of 
such individual, or 
‘‘(B) instituting a civil action, including a 
civil action for injunctive relief and other relief 
and including, with respect to a political sub-
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197 
division or local governmental entity of a State, 
such an action against an official thereof. 
‘‘(2) NOTICE.—All reasonable efforts shall be 
made to provide notice of action instituted under 
paragraph (1)(B) to the individual to whom health 
services were provided, either before or during the 
pendency of such action. 
‘‘(3) RECOVERY FROM TORTFEASORS.— 
‘‘(A) IN GENERAL.—In any case in which 
an Indian Tribe or Tribal Organization that is 
authorized or required under a compact or con-
tract issued pursuant to the Indian Self-Deter-
mination and Education Assistance Act (25 
U.S.C. 450 et seq.) to furnish or pay for health 
services to a person who is injured or suffers a 
disease on or after the date of enactment of the 
Indian Health Care Improvement Act Amend-
ments of 2009 under circumstances that estab-
lish grounds for a claim of liability against the 
tortfeasor with respect to the injury or disease, 
the Indian Tribe or Tribal Organization shall 
have a right to recover from the tortfeasor (or 
an insurer of the tortfeasor) the reasonable 
value of the health services so furnished, paid 
for, or to be paid for, in accordance with the 
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Federal Medical Care Recovery Act (42 U.S.C. 
2651 et seq.), to the same extent and under the 
same circumstances as the United States may 
recover under that Act. 
‘‘(B) TREATMENT.—The right of an In-
dian Tribe or Tribal Organization to recover 
under subparagraph (A) shall be independent of 
the rights of the injured or diseased person 
served by the Indian Tribe or Tribal Organiza-
tion. 
‘‘(f) LIMITATION.—Absent specific written authoriza-
tion by the governing body of an Indian Tribe for the pe-
riod of such authorization (which may not be for a period 
of more than 1 year and which may be revoked at any 
time upon written notice by the governing body to the 
Service), the United States shall not have a right of recov-
ery under this section if the injury, illness, or disability 
for which health services were provided is covered under 
a self-insurance plan funded by an Indian Tribe, Tribal 
Organization, or urban Indian organization. Where such 
authorization is provided, the Service may receive and ex-
pend such amounts for the provision of additional health 
services consistent with such authorization. 
‘‘(g) COSTS AND ATTORNEYS’ FEES.—In any action 
brought to enforce the provisions of this section, a pre-
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vailing plaintiff shall be awarded its reasonable attorneys’ 
fees and costs of litigation. 
‘‘(h) NONAPPLICATION OF CLAIMS FILING REQUIRE-
MENTS.—An insurance company, health maintenance or-
ganization, self-insurance plan, managed care plan, or 
other health care plan or program (under the Social Secu-
rity Act or otherwise) may not deny a claim for benefits 
submitted by the Service or by an Indian Tribe or Tribal 
Organization based on the format in which the claim is 
submitted if such format complies with the format re-
quired for submission of claims under title XVIII of the 
Social Security Act or recognized under section 1175 of 
such Act. 
‘‘(i) APPLICATION
TO URBAN INDIAN ORGANIZA-
TIONS.—The previous provisions of this section shall apply 
to urban Indian organizations with respect to populations 
served by such Organizations in the same manner they 
apply to Indian Tribes and Tribal Organizations with re-
spect to populations served by such Indian Tribes and 
Tribal Organizations. 
‘‘(j) STATUTE OF LIMITATIONS.—The provisions of 
section 2415 of title 28, United States Code, shall apply 
to all actions commenced under this section, and the ref-
erences therein to the United States are deemed to include 
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Indian Tribes, Tribal Organizations, and urban Indian or-
ganizations. 
‘‘(k) SAVINGS.—Nothing in this section shall be con-
strued to limit any right of recovery available to the 
United States, an Indian Tribe, or Tribal Organization 
under the provisions of any applicable, Federal, State, or 
Tribal law, including medical lien laws. 
‘‘SEC. 404. CREDITING OF REIMBURSEMENTS. 
‘‘(a) RETENTION OF AMOUNTS FOR USE BY PRO-
GRAM.—Except as provided in section 202(f) (relating to 
the Catastrophic Health Emergency Fund) and section 
806 (relating to health services for ineligible persons), all 
reimbursements received or recovered, including under 
section 806, by reason of the provision of health services 
by the Service, by an Indian Tribe or Tribal Organization, 
or by an urban Indian organization, shall be credited to 
the Service, such Indian Tribe or Tribal Organization, or 
such urban Indian organization, respectively, and may be 
used as provided in section 401. In the case of such a 
service provided by or through a Service Unit, such 
amounts shall be credited to such unit and used for such 
purposes. 
‘‘(b) NO OFFSET OF AMOUNTS.—The Service may 
not offset or limit any amount obligated to any Service 
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Unit or entity receiving funding from the Service because 
of the receipt of reimbursements under subsection (a). 
‘‘SEC. 405. PURCHASING HEALTH CARE COVERAGE. 
‘‘(a) PURCHASING COVERAGE.— 
‘‘(1) IN
GENERAL.—Insofar as amounts are 
made available under law (including a provision of 
the Social Security Act, the Indian Self-Determina-
tion and Education Assistance Act (25 U.S.C. 450 
et seq.), or other law, other than under section 402) 
to Indian Tribes, Tribal Organizations, and urban 
Indian organizations for health benefits for Service 
beneficiaries, Indian Tribes, Tribal Organizations, 
and urban Indian organizations may use such 
amounts to purchase health benefits coverage that 
qualifies as creditable coverage under section 
2701(c)(1) of the Public Health Service Act for such 
beneficiaries, including, subject to paragraph (2), 
through— 
‘‘(A) a tribally owned and operated health 
care plan; 
‘‘(B) a State or locally authorized or li-
censed health care plan; 
‘‘(C) a health insurance provider or man-
aged care organization; or 
‘‘(D) a self-insured plan. 
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202 
‘‘(2) 
EXCEPTION.—The 
coverage 
provided 
under paragraph (1) may not include coverage con-
sisting of— 
‘‘(A) benefits provided under a health flexi-
ble spending arrangement (as defined in section 
106(c)(2) of the Internal Revenue Code of 
1986); or 
‘‘(B) a high deductible health plan (as de-
fined in section 223(c)(2) of such Code), with-
out regard to whether the plan is purchased in 
conjunction with a health savings account (as 
defined under section 223(d) of such Code). 
‘‘(3) PERMITTING
PURCHASE
OF
COVERAGE 
BASED ON FINANCIAL NEED.—The purchase of cov-
erage by an Indian Tribe, Tribal Organization, or 
urban Indian organization under this subsection may 
be based on the financial needs of beneficiaries (as 
determined by the Indian Tribe or Tribes being 
served based on a schedule of income levels devel-
oped or implemented by such Indian Tribe or 
Tribes). 
‘‘(b) EXPENSES FOR SELF-INSURED PLAN.—In the 
case of a self-insured plan under subsection (a)(4), the 
amounts may be used for expenses of operating the plan, 
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203 
including administration and insurance to limit the finan-
cial risks to the entity offering the plan. 
‘‘(c) CONSTRUCTION.—Nothing in this section shall 
be construed as affecting the use of any amounts not re-
ferred to in subsection (a). 
‘‘SEC. 406. SHARING ARRANGEMENTS WITH FEDERAL AGEN-
CIES. 
‘‘(a) AUTHORITY.— 
‘‘(1) IN GENERAL.—The Secretary may enter 
into (or expand) arrangements for the sharing of 
medical facilities and services between the Service, 
Indian Tribes, and Tribal Organizations and the De-
partment of Veterans Affairs and the Department of 
Defense. 
‘‘(2) 
CONSULTATION
BY
SECRETARY
RE-
QUIRED.—The Secretary may not finalize any ar-
rangement between the Service and a Department 
described in paragraph (1) without first consulting 
with the Indian Tribes which will be significantly af-
fected by the arrangement. 
‘‘(b) LIMITATIONS.—The Secretary shall not take 
any action under this section or under subchapter IV of 
chapter 81 of title 38, United States Code, which would 
impair— 
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204 
‘‘(1) the priority access of any Indian to health 
care services provided through the Service and the 
eligibility of any Indian to receive health services 
through the Service; 
‘‘(2) the quality of health care services provided 
to any Indian through the Service; 
‘‘(3) the priority access of any veteran to health 
care services provided by the Department of Vet-
erans Affairs; 
‘‘(4) the quality of health care services provided 
by the Department of Veterans Affairs or the De-
partment of Defense; or 
‘‘(5) the eligibility of any Indian who is a vet-
eran to receive health services through the Depart-
ment of Veterans Affairs. 
‘‘(c) REIMBURSEMENT.—The Service, Indian Tribe, 
or Tribal Organization shall be reimbursed by the Depart-
ment of Veterans Affairs or the Department of Defense 
(as the case may be) where services are provided through 
the Service, an Indian Tribe, or a Tribal Organization to 
beneficiaries eligible for services from either such Depart-
ment, notwithstanding any other provision of law. 
‘‘(d) CONSTRUCTION.—Nothing in this section may 
be construed as creating any right of a non-Indian veteran 
to obtain health services from the Service. 
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205 
‘‘SEC. 407. ELIGIBLE INDIAN VETERAN SERVICES. 
‘‘(a) FINDINGS; PURPOSE.— 
‘‘(1) FINDINGS.—Congress finds that— 
‘‘(A) collaborations between the Secretary 
and the Secretary of Veterans Affairs regarding 
the treatment of Indian veterans at facilities of 
the Service should be encouraged to the max-
imum extent practicable; and 
‘‘(B) increased enrollment for services of 
the Department of Veterans Affairs by veterans 
who are members of Indian tribes should be en-
couraged to the maximum extent practicable. 
‘‘(2) PURPOSE.—The purpose of this section is 
to reaffirm the goals stated in the document entitled 
‘Memorandum of Understanding Between the VA/ 
Veterans Health Administration And HHS/Indian 
Health Service’ and dated February 25, 2003 (relat-
ing to cooperation and resource sharing between the 
Veterans Health Administration and Service). 
‘‘(b) DEFINITIONS.—In this section: 
‘‘(1) ELIGIBLE
INDIAN
VETERAN.—The term 
‘eligible Indian veteran’ means an Indian or Alaska 
Native veteran who receives any medical service that 
is— 
‘‘(A) authorized under the laws adminis-
tered by the Secretary of Veterans Affairs; and 
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206 
‘‘(B) administered at a facility of the Serv-
ice (including a facility operated by an Indian 
tribe or tribal organization through a contract 
or compact with the Service under the Indian 
Self-Determination and Education Assistance 
Act (25 U.S.C. 450 et seq.)) pursuant to a local 
memorandum of understanding. 
‘‘(2) 
LOCAL
MEMORANDUM
OF
UNDER-
STANDING.—The term ‘local memorandum of under-
standing’ means a memorandum of understanding 
between the Secretary (or a designee, including the 
director of any Area Office of the Service) and the 
Secretary of Veterans Affairs (or a designee) to im-
plement the document entitled ‘Memorandum of Un-
derstanding Between the VA/Veterans Health Ad-
ministration And HHS/Indian Health Service’ and 
dated February 25, 2003 (relating to cooperation 
and resource sharing between the Veterans Health 
Administration and Indian Health Service). 
‘‘(c) ELIGIBLE INDIAN VETERANS’ EXPENSES.— 
‘‘(1) IN GENERAL.—Notwithstanding any other 
provision of law, the Secretary shall provide for vet-
eran-related expenses incurred by eligible Indian vet-
erans as described in subsection (b)(1)(B). 
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207 
‘‘(2) METHOD
OF
PAYMENT.—The Secretary 
shall establish such guidelines as the Secretary de-
termines to be appropriate regarding the method of 
payments to the Secretary of Veterans Affairs under 
paragraph (1). 
‘‘(d) TRIBAL APPROVAL OF MEMORANDA.—In nego-
tiating a local memorandum of understanding with the 
Secretary of Veterans Affairs regarding the provision of 
services to eligible Indian veterans, the Secretary shall 
consult with each Indian tribe that would be affected by 
the local memorandum of understanding. 
‘‘(e) FUNDING.— 
‘‘(1) TREATMENT.—Expenses incurred by the 
Secretary in carrying out subsection (c)(1) shall not 
be considered to be Contract Health Service ex-
penses. 
‘‘(2) USE OF FUNDS.—Of funds made available 
to the Secretary in appropriations Acts for the Serv-
ice (excluding funds made available for facilities, 
Contract Health Services, or contract support costs), 
the Secretary shall use such sums as are necessary 
to carry out this section. 
‘‘SEC. 408. PAYOR OF LAST RESORT. 
‘‘Indian Health Programs and health care programs 
operated by Urban Indian Organizations shall be the 
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208 
payor of last resort for services provided to persons eligible 
for services from Indian Health Programs and Urban In-
dian Organizations, notwithstanding any Federal, State, 
or local law to the contrary. 
‘‘SEC. 409. NONDISCRIMINATION UNDER FEDERAL HEALTH 
CARE PROGRAMS IN QUALIFICATIONS FOR 
REIMBURSEMENT FOR SERVICES. 
‘‘(a) REQUIREMENT TO SATISFY GENERALLY APPLI-
CABLE PARTICIPATION REQUIREMENTS.— 
‘‘(1) IN GENERAL.—A Federal health care pro-
gram must accept an entity that is operated by the 
Service, an Indian Tribe, Tribal Organization, or 
Urban Indian Organization as a provider eligible to 
receive payment under the program for health care 
services furnished to an Indian on the same basis as 
any other provider qualified to participate as a pro-
vider of health care services under the program if 
the entity meets generally applicable State or other 
requirements for participation as a provider of 
health care services under the program. 
‘‘(2) SATISFACTION OF STATE OR LOCAL LICEN-
SURE
OR
RECOGNITION
REQUIREMENTS.—Any re-
quirement for participation as a provider of health 
care services under a Federal health care program 
that an entity be licensed or recognized under the 
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209 
State or local law where the entity is located to fur-
nish health care services shall be deemed to have 
been met in the case of an entity operated by the 
Service, an Indian Tribe, Tribal Organization, or 
Urban Indian Organization if the entity meets all 
the applicable standards for such licensure or rec-
ognition, regardless of whether the entity obtains a 
license or other documentation under such State or 
local law. In accordance with section 221, the ab-
sence of the licensure of a health care professional 
employed by such an entity under the State or local 
law where the entity is located shall not be taken 
into account for purposes of determining whether 
the entity meets such standards, if the professional 
is licensed in another State. 
‘‘(b) APPLICATION OF EXCLUSION FROM PARTICIPA-
TION IN FEDERAL HEALTH CARE PROGRAMS.— 
‘‘(1) EXCLUDED ENTITIES.—No entity operated 
by the Service, an Indian Tribe, Tribal Organiza-
tion, or Urban Indian Organization that has been 
excluded from participation in any Federal health 
care program or for which a license is under suspen-
sion or has been revoked by the State where the en-
tity is located shall be eligible to receive payment or 
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210 
reimbursement under any such program for health 
care services furnished to an Indian. 
‘‘(2) EXCLUDED INDIVIDUALS.—No individual 
who has been excluded from participation in any 
Federal health care program or whose State license 
is under suspension shall be eligible to receive pay-
ment or reimbursement under any such program for 
health care services furnished by that individual, di-
rectly or through an entity that is otherwise eligible 
to receive payment for health care services, to an In-
dian. 
‘‘(3) FEDERAL
HEALTH
CARE
PROGRAM
DE-
FINED.—In this subsection, the term, ‘Federal 
health care program’ has the meaning given that 
term in section 1128B(f) of the Social Security Act 
(42 U.S.C. 1320a–7b(f)), except that, for purposes 
of this subsection, such term shall include the health 
insurance program under chapter 89 of title 5, 
United States Code. 
‘‘(c) RELATED PROVISIONS.—For provisions related 
to nondiscrimination against providers operated by the 
Service, an Indian Tribe, Tribal Organization, or Urban 
Indian Organization, see section 1139(c) of the Social Se-
curity Act (42 U.S.C. 1320b–9(c)). 
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211 
‘‘SEC. 410. CONSULTATION. 
‘‘For provisions related to consultation with rep-
resentatives of Indian Health Programs and urban Indian 
organizations with respect to the health care programs es-
tablished under titles XVIII, XIX, and XXI of the Social 
Security Act, see section 1139(d) of the Social Security 
Act (42 U.S.C. 1320b–9(d)). 
‘‘SEC. 411. STATE CHILDREN’S HEALTH INSURANCE PRO-
GRAM (SCHIP). 
‘‘For provisions relating to— 
‘‘(1) outreach to families of Indian children 
likely to be eligible for child health assistance under 
the State children’s health insurance program estab-
lished under title XXI of the Social Security Act, see 
sections 2105(c)(2)(C) and 1139(a) of such Act (42 
U.S.C. 1397ee(c)(2), 1320b–9); and 
‘‘(2) ensuring that child health assistance is 
provided under such program to targeted low-income 
children who are Indians and that payments are 
made under such program to Indian Health Pro-
grams and urban Indian organizations operating in 
the State that provide such assistance, see sections 
2102(b)(3)(D) and 2105(c)(6)(B) of such Act (42 
U.S.C. 1397bb(b)(3)(D), 1397ee(c)(6)(B)). 
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212 
‘‘SEC. 412. EXCLUSION WAIVER AUTHORITY FOR AFFECTED 
INDIAN HEALTH PROGRAMS AND SAFE HAR-
BOR TRANSACTIONS UNDER THE SOCIAL SE-
CURITY ACT. 
‘‘For provisions relating to— 
‘‘(1) exclusion waiver authority for affected In-
dian Health Programs under the Social Security 
Act, see section 1128(k) of the Social Security Act 
(42 U.S.C. 1320a–7(k)); and 
‘‘(2) certain transactions involving Indian 
Health Programs deemed to be in safe harbors 
under that Act, see section 1128B(b)(4) of the So-
cial Security Act (42 U.S.C. 1320a–7b(b)(4)). 
‘‘SEC. 413. PREMIUM AND COST SHARING PROTECTIONS 
AND ELIGIBILITY DETERMINATIONS UNDER 
MEDICAID AND SCHIP AND PROTECTION OF 
CERTAIN INDIAN PROPERTY FROM MEDICAID 
ESTATE RECOVERY. 
‘‘For provisions relating to— 
‘‘(1) premiums or cost sharing protections for 
Indians furnished items or services directly by In-
dian Health Programs or through referral under the 
contract health service under the Medicaid program 
established under title XIX of the Social Security 
Act, see sections 1916(j) and 1916A(a)(1) of the So-
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213 
cial Security Act (42 U.S.C. 1396o(j), 1396o– 
1(a)(1)); 
‘‘(2) rules regarding the treatment of certain 
property for purposes of determining eligibility 
under such programs, see sections 1902(e)(13) and 
2107(e)(1)(B) of such Act (42 U.S.C. 1396a(e)(13), 
1397gg(e)(1)(B)); and 
‘‘(3) the protection of certain property from es-
tate recovery provisions under the Medicaid pro-
gram, see section 1917(b)(3)(B) of such Act (42 
U.S.C. 1396p(b)(3)(B)). 
‘‘SEC. 414. TREATMENT UNDER MEDICAID AND SCHIP MAN-
AGED CARE. 
‘‘For provisions relating to the treatment of Indians 
enrolled in a managed care entity under the Medicaid pro-
gram under title XIX of the Social Security Act and In-
dian Health Programs and urban Indian organizations 
that are providers of items or services to such Indian en-
rollees, see sections 1932(h) and 2107(e)(1)(H) of the So-
cial 
Security 
Act 
(42 
U.S.C. 
1396u–2(h), 
1397gg(e)(1)(H)). 
‘‘SEC. 415. 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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214 
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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215 
‘‘(4) authorizing the Secretary, at the option of 
the Navajo Nation, to treat the Navajo Nation as a 
State for the purposes of title XIX of the Social Se-
curity Act (relating to the State children’s health in-
surance program) under terms equivalent to those 
described in paragraphs (2) through (4). 
‘‘(c) REPORT.—Not later than 3 years after the date 
of enactment of the Indian Health Care Improvement Act 
Amendments of 2009, the Secretary shall submit to the 
Committee on Indian Affairs and Committee on Finance 
of the Senate and the Committee on Natural Resources 
and Committee on Energy and Commerce of the House 
of Representatives a report that includes— 
‘‘(1) the results of the study under this section; 
‘‘(2) a summary of any consultation that oc-
curred between the Secretary and the Navajo Na-
tion, other Indian Tribes, the States of Arizona, 
New Mexico, and Utah, counties which include Nav-
ajo Lands, and other interested parties, in con-
ducting this study; 
‘‘(3) projected costs or savings associated with 
establishment of such entity, and any estimated im-
pact on services provided as described in this section 
in relation to probable costs or savings; and 
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216 
‘‘(4) legislative actions that would be required 
to authorize the establishment of such entity if such 
entity is determined by the Secretary to be feasible. 
‘‘SEC. 416. EXCEPTION FOR EXCEPTED BENEFITS. 
‘‘The previous provisions of this title shall not apply 
to the provision of excepted benefits described in para-
graph (1)(A) or (3) of section 2791(c) of the Public 
Health Service Act (42 U.S.C. 300gg–91(c)). 
‘‘SEC. 417. AUTHORIZATION OF APPROPRIATIONS. 
‘‘There are authorized to be appropriated such sums 
as may be necessary to carry out this title. 
‘‘TITLE V—HEALTH SERVICES 
FOR URBAN INDIANS 
‘‘SEC. 501. PURPOSE. 
‘‘The purpose of this title is to establish and maintain 
programs in Urban Centers to make health services more 
accessible and available to Urban Indians. 
‘‘SEC. 502. CONTRACTS WITH, AND GRANTS TO, URBAN IN-
DIAN ORGANIZATIONS. 
‘‘Under authority of the Act of November 2, 1921 
(25 U.S.C. 13) (commonly known as the ‘Snyder Act’), 
the Secretary, acting through the Service, shall enter into 
contracts with, or make grants to, urban Indian organiza-
tions to assist such organizations in the establishment and 
administration, within Urban Centers, of programs which 
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217 
meet the requirements set forth in this title. Subject to 
section 506, the Secretary, acting through the Service, 
shall include such conditions as the Secretary considers 
necessary to effect the purpose of this title in any contract 
into which the Secretary enters with, or in any grant the 
Secretary makes to, any urban Indian organization pursu-
ant to this title. 
‘‘SEC. 503. CONTRACTS AND GRANTS FOR THE PROVISION 
OF HEALTH CARE AND REFERRAL SERVICES. 
‘‘(a) REQUIREMENTS
FOR
GRANTS
AND
CON-
TRACTS.—Under authority of the Act of November 2, 
1921 (25 U.S.C. 13) (commonly known as the ‘Snyder 
Act’), the Secretary, acting through the Service, shall 
enter into contracts with, and make grants to, urban In-
dian organizations for the provision of health care and re-
ferral services for Urban Indians. Any such contract or 
grant shall include requirements that the urban Indian or-
ganization successfully undertake to— 
‘‘(1) estimate the population of Urban Indians 
residing in the Urban Center or centers that the or-
ganization proposes to serve who are or could be re-
cipients of health care or referral services; 
‘‘(2) estimate the current health status of 
Urban Indians residing in such Urban Center or 
centers; 
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218 
‘‘(3) estimate the current health care needs of 
Urban Indians residing in such Urban Center or 
centers; 
‘‘(4) provide basic health education, including 
health promotion and disease prevention education, 
to Urban Indians; 
‘‘(5) make recommendations to the Secretary 
and Federal, State, local, and other resource agen-
cies on methods of improving health service pro-
grams to meet the needs of Urban Indians; and 
‘‘(6) where necessary, provide, or enter into 
contracts for the provision of, health care services 
for Urban Indians. 
‘‘(b) CRITERIA.—The Secretary, acting through the 
Service, shall, by regulation, prescribe the criteria for se-
lecting urban Indian organizations to enter into contracts 
or receive grants under this section. Such criteria shall, 
among other factors, include— 
‘‘(1) the extent of unmet health care needs of 
Urban Indians in the Urban Center or centers in-
volved; 
‘‘(2) the size of the urban Indian population in 
the Urban Center or centers involved; 
‘‘(3) the extent, if any, to which the activities 
set forth in subsection (a) would duplicate any 
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project funded under this title, or under any current 
public health service project funded in a manner 
other than pursuant to this title; 
‘‘(4) the capability of an urban Indian organiza-
tion to perform the activities set forth in subsection 
(a) and to enter into a contract with the Secretary 
or to meet the requirements for receiving a grant 
under this section; 
‘‘(5) the satisfactory performance and success-
ful completion by an urban Indian organization of 
other contracts with the Secretary under this title; 
‘‘(6) the appropriateness and likely effectiveness 
of conducting the activities set forth in subsection 
(a) in an Urban Center or centers; and 
‘‘(7) the extent of existing or likely future par-
ticipation in the activities set forth in subsection (a) 
by appropriate health and health-related Federal, 
State, local, and other agencies. 
‘‘(c) ACCESS TO HEALTH PROMOTION AND DISEASE 
PREVENTION PROGRAMS.—The Secretary, acting through 
the Service, shall facilitate access to or provide health pro-
motion and disease prevention services for Urban Indians 
through grants made to urban Indian organizations ad-
ministering contracts entered into or receiving grants 
under subsection (a). 
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220 
‘‘(d) IMMUNIZATION SERVICES.— 
‘‘(1) ACCESS
OR
SERVICES
PROVIDED.—The 
Secretary, acting through the Service, shall facilitate 
access to, or provide, immunization services for 
Urban Indians through grants made to urban Indian 
organizations administering contracts entered into or 
receiving grants under this section. 
‘‘(2) DEFINITION.—For purposes of this sub-
section, the term ‘immunization services’ means 
services to provide without charge immunizations 
against vaccine-preventable diseases. 
‘‘(e) BEHAVIORAL HEALTH SERVICES.— 
‘‘(1) ACCESS
OR
SERVICES
PROVIDED.—The 
Secretary, acting through the Service, shall facilitate 
access to, or provide, behavioral health services for 
Urban Indians through grants made to urban Indian 
organizations administering contracts entered into or 
receiving grants under subsection (a). 
‘‘(2) ASSESSMENT REQUIRED.—Except as pro-
vided by paragraph (3)(A), a grant may not be made 
under this subsection to an urban Indian organiza-
tion until that organization has prepared, and the 
Service has approved, an assessment of the fol-
lowing: 
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221 
‘‘(A) The behavioral health needs of the 
urban Indian population concerned. 
‘‘(B) The behavioral health services and 
other related resources available to that popu-
lation. 
‘‘(C) The barriers to obtaining those serv-
ices and resources. 
‘‘(D) The needs that are unmet by such 
services and resources. 
‘‘(3) PURPOSES OF GRANTS.—Grants may be 
made under this subsection for the following: 
‘‘(A) To prepare assessments required 
under paragraph (2). 
‘‘(B) To provide outreach, educational, and 
referral services to Urban Indians regarding the 
availability of direct behavioral health services, 
to educate Urban Indians about behavioral 
health issues and services, and effect coordina-
tion with existing behavioral health providers in 
order to improve services to Urban Indians. 
‘‘(C) To provide outpatient behavioral 
health services to Urban Indians, including the 
identification and assessment of illness, thera-
peutic treatments, case management, support 
groups, family treatment, and other treatment. 
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‘‘(D) To develop innovative behavioral 
health service delivery models which incorporate 
Indian cultural support systems and resources. 
‘‘(f) PREVENTION OF CHILD ABUSE.— 
‘‘(1) ACCESS
OR
SERVICES
PROVIDED.—The 
Secretary, acting through the Service, shall facilitate 
access to or provide services for Urban Indians 
through grants to urban Indian organizations ad-
ministering contracts entered into or receiving 
grants under subsection (a) to prevent and treat 
child abuse (including sexual abuse) among Urban 
Indians. 
‘‘(2) EVALUATION REQUIRED.—Except as pro-
vided by paragraph (3)(A), a grant may not be made 
under this subsection to an urban Indian organiza-
tion until that organization has prepared, and the 
Service has approved, an assessment that documents 
the prevalence of child abuse in the urban Indian 
population concerned and specifies the services and 
programs (which may not duplicate existing services 
and programs) for which the grant is requested. 
‘‘(3) PURPOSES OF GRANTS.—Grants may be 
made under this subsection for the following: 
‘‘(A) To prepare assessments required 
under paragraph (2). 
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‘‘(B) For the development of prevention, 
training, and education programs for Urban In-
dians, including child education, parent edu-
cation, provider training on identification and 
intervention, education on reporting require-
ments, prevention campaigns, and establishing 
service networks of all those involved in Indian 
child protection. 
‘‘(C) To provide direct outpatient treat-
ment services (including individual treatment, 
family treatment, group therapy, and support 
groups) to Urban Indians who are child victims 
of abuse (including sexual abuse) or adult sur-
vivors of child sexual abuse, to the families of 
such child victims, and to urban Indian per-
petrators of child abuse (including sexual 
abuse). 
‘‘(4) 
CONSIDERATIONS
WHEN
MAKING 
GRANTS.—In making grants to carry out this sub-
section, the Secretary shall take into consideration— 
‘‘(A) the support for the urban Indian or-
ganization demonstrated by the child protection 
authorities in the area, including committees or 
other services funded under the Indian Child 
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Welfare Act of 1978 (25 U.S.C. 1901 et seq.), 
if any; 
‘‘(B) the capability and expertise dem-
onstrated by the urban Indian organization to 
address the complex problem of child sexual 
abuse in the community; and 
‘‘(C) the assessment required under para-
graph (2). 
‘‘(g) 
OTHER
GRANTS.—The 
Secretary, 
acting 
through the Service, may enter into a contract with or 
make grants to an urban Indian organization that pro-
vides or arranges for the provision of health care services 
(through satellite facilities, provider networks, or other-
wise) to Urban Indians in more than 1 Urban Center. 
‘‘SEC. 504. USE OF FEDERAL GOVERNMENT FACILITIES AND 
SOURCES OF SUPPLY. 
‘‘(a) IN GENERAL.—The Secretary may permit an 
urban Indian organization that has entered into a contract 
or received a grant pursuant to this title, in carrying out 
such contract or grant, to use existing facilities and all 
equipment therein or pertaining thereto and other per-
sonal property owned by the Federal Government within 
the Secretary’s jurisdiction under such terms and condi-
tions as may be agreed upon for their use and mainte-
nance. 
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‘‘(b) DONATIONS.—Subject to subsection (d), the 
Secretary may donate to an urban Indian organization 
that has entered into a contract or received a grant pursu-
ant to this title any personal or real property determined 
to be excess to the needs of the Indian Health Service or 
the General Services Administration for the purposes of 
carrying out the contract or grant. 
‘‘(c) ACQUISITION
OF PROPERTY.—The Secretary 
may acquire excess or surplus government personal or real 
property for donation, subject to subsection (d) to an 
urban Indian organization that has entered into a contract 
or received a grant pursuant to this title if the Secretary 
determines that the property is appropriate for use by the 
urban Indian organization for a purpose for which a con-
tract or grant is authorized under this title. 
‘‘(d) PRIORITY.—In the event that the Secretary re-
ceives a request for a specific item of personal or real 
property described in subsections (b) or (c) from an urban 
Indian organization and from an Indian Tribe or Tribal 
Organization, the Secretary shall give priority to the re-
quest for donation to the Indian Tribe or Tribal Organiza-
tion if the Secretary receives the request from the Indian 
Tribe or Tribal Organization before the date the Secretary 
transfers title to the property or, if earlier, the date the 
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Secretary transfers the property physically, to the urban 
Indian organization. 
‘‘(e) EXECUTIVE AGENCY STATUS.—For purposes of 
section 201(a) of the Federal Property and Administrative 
Services Act of 1949 (40 U.S.C 481(a)) (relating to Fed-
eral sources of supply), an urban Indian organization that 
has entered into a contract or received a grant pursuant 
to this title may be deemed to be an executive agency when 
carrying out such contract or grant. 
‘‘SEC. 505. CONTRACTS AND GRANTS FOR THE DETERMINA-
TION OF UNMET HEALTH CARE NEEDS. 
‘‘(a) GRANTS
AND
CONTRACTS
AUTHORIZED.— 
Under authority of the Act of November 2, 1921 (25 
U.S.C. 13) (commonly known as the ‘Snyder Act’), the 
Secretary, acting through the Service, may enter into con-
tracts with or make grants to urban Indian organizations 
situated in Urban Centers for which contracts have not 
been entered into or grants have not been made under sec-
tion 503. 
‘‘(b) PURPOSE.—The purpose of a contract or grant 
made under this section shall be the determination of the 
matters described in subsection (c)(1) in order to assist 
the Secretary in assessing the health status and health 
care needs of Urban Indians in the Urban Center involved 
and determining whether the Secretary should enter into 
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a contract or make a grant under section 503 with respect 
to the urban Indian organization which the Secretary has 
entered into a contract with, or made a grant to, under 
this section. 
‘‘(c) GRANT AND CONTRACT REQUIREMENTS.—Any 
contract entered into, or grant made, by the Secretary 
under this section shall include requirements that— 
‘‘(1) the urban Indian organization successfully 
undertakes to— 
‘‘(A) document the health care status and 
unmet health care needs of urban Indians in 
the Urban Center involved; and 
‘‘(B) with respect to urban Indians in the 
Urban Center involved, determine the matters 
described in paragraphs (2), (3), (4), and (7) of 
section 503(b); and 
‘‘(2) the urban Indian organization complete 
performance of the contract, or carry out the re-
quirements of the grant, within 1 year after the date 
on which the Secretary and such organization enter 
into such contract, or within 1 year after such orga-
nization receives such grant, whichever is applicable. 
‘‘(d) NO RENEWALS.—The Secretary may not renew 
any contract entered into or grant made under this sec-
tion. 
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‘‘SEC. 506. EVALUATIONS; RENEWALS. 
‘‘(a) PROCEDURES
FOR EVALUATIONS.—The Sec-
retary, acting through the Service, shall develop proce-
dures to evaluate compliance with grant requirements and 
compliance with and performance of contracts entered into 
by urban Indian organizations under this title. Such pro-
cedures shall include provisions for carrying out the re-
quirements of this section. 
‘‘(b) EVALUATIONS.—The Secretary, acting through 
the Service, shall evaluate the compliance of each Urban 
Indian Organization which has entered into a contract or 
received a grant under section 503 with the terms of such 
contract or grant. For purposes of this evaluation, the 
Secretary shall— 
‘‘(1) acting through the Service, conduct an an-
nual onsite evaluation of the organization; or 
‘‘(2) accept in lieu of such onsite evaluation evi-
dence of the organization’s provisional or full accred-
itation by a private independent entity recognized by 
the Secretary for purposes of conducting quality re-
views of providers participating in the Medicare pro-
gram under title XVIII of the Social Security Act. 
‘‘(c) NONCOMPLIANCE; UNSATISFACTORY PERFORM-
ANCE.—If, as a result of the evaluations conducted under 
this section, the Secretary determines that an urban In-
dian organization has not complied with the requirements 
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of a grant or complied with or satisfactorily performed a 
contract under section 503, the Secretary shall, prior to 
renewing such contract or grant, attempt to resolve with 
the organization the areas of noncompliance or unsatisfac-
tory performance and modify the contract or grant to pre-
vent future occurrences of noncompliance or unsatisfac-
tory performance. If the Secretary determines that the 
noncompliance or unsatisfactory performance cannot be 
resolved and prevented in the future, the Secretary shall 
not renew the contract or grant with the organization and 
is authorized to enter into a contract or make a grant 
under section 503 with another urban Indian organization 
which is situated in the same Urban Center as the urban 
Indian organization whose contract or grant is not re-
newed under this section. 
‘‘(d) CONSIDERATIONS FOR RENEWALS.—In deter-
mining whether to renew a contract or grant with an 
urban Indian organization under section 503 which has 
completed performance of a contract or grant under sec-
tion 504, the Secretary shall review the records of the 
urban Indian organization, the reports submitted under 
section 507, and shall consider the results of the onsite 
evaluations or accreditations under subsection (b). 
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‘‘SEC. 507. OTHER CONTRACT AND GRANT REQUIREMENTS. 
‘‘(a) PROCUREMENT.—Contracts with urban Indian 
organizations entered into pursuant to this title shall be 
in accordance with all Federal contracting laws and regu-
lations relating to procurement except that in the discre-
tion of the Secretary, such contracts may be negotiated 
without advertising and need not conform to the provisions 
of sections 1304 and 3131 through 3133 of title 40, 
United States Code. 
‘‘(b) PAYMENTS UNDER CONTRACTS OR GRANTS.— 
‘‘(1) IN GENERAL.—Payments under any con-
tracts or grants pursuant to this title, notwith-
standing any term or condition of such contract or 
grant— 
‘‘(A) may be made in a single advance pay-
ment by the Secretary to the urban Indian or-
ganization by no later than the end of the first 
30 days of the funding period with respect to 
which the payments apply, unless the Secretary 
determines through an evaluation under section 
505 that the organization is not capable of ad-
ministering such a single advance payment; and 
‘‘(B) if any portion thereof is unexpended 
by the urban Indian organization during the 
funding period with respect to which the pay-
ments initially apply, shall be carried forward 
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for expenditure with respect to allowable or re-
imbursable costs incurred by the organization 
during 1 or more subsequent funding periods 
without additional justification or documenta-
tion by the organization as a condition of car-
rying forward the availability for expenditure of 
such funds. 
‘‘(2) SEMIANNUAL AND QUARTERLY PAYMENTS 
AND
REIMBURSEMENTS.—If the Secretary deter-
mines under paragraph (1)(A) that an urban Indian 
organization is not capable of administering an en-
tire single advance payment, on request of the urban 
Indian organization, the payments may be made— 
‘‘(A) in semiannual or quarterly payments 
by not later than 30 days after the date on 
which the funding period with respect to which 
the payments apply begins; or 
‘‘(B) by way of reimbursement. 
‘‘(c) REVISION OR AMENDMENT OF CONTRACTS.— 
Notwithstanding any provision of law to the contrary, the 
Secretary may, at the request and consent of an urban 
Indian organization, revise or amend any contract entered 
into by the Secretary with such organization under this 
title as necessary to carry out the purposes of this title. 
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232 
‘‘(d) FAIR AND UNIFORM SERVICES AND ASSIST-
ANCE.—Contracts with or grants to urban Indian organi-
zations and regulations adopted pursuant to this title shall 
include provisions to assure the fair and uniform provision 
to urban Indians of services and assistance under such 
contracts or grants by such organizations. 
‘‘SEC. 508. REPORTS AND RECORDS. 
‘‘(a) REPORTS.— 
‘‘(1) IN GENERAL.—For each fiscal year during 
which an urban Indian organization receives or ex-
pends funds pursuant to a contract entered into or 
a grant received pursuant to this title, such urban 
Indian organization shall submit to the Secretary 
not more frequently than every 6 months, a report 
that includes the following: 
‘‘(A) In the case of a contract or grant 
under section 503, recommendations pursuant 
to section 503(a)(5). 
‘‘(B) Information on activities conducted 
by the organization pursuant to the contract or 
grant. 
‘‘(C) An accounting of the amounts and 
purpose for which Federal funds were ex-
pended. 
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‘‘(D) A minimum set of data, using uni-
formly defined elements, as specified by the 
Secretary after consultation with urban Indian 
organizations. 
‘‘(2) HEALTH STATUS AND SERVICES.— 
‘‘(A) IN
GENERAL.—Not later than 18 
months after the date of enactment of the In-
dian Health Care Improvement Act Amend-
ments of 2009, the Secretary, acting through 
the Service, shall submit to Congress a report 
evaluating— 
‘‘(i) the health status of urban Indi-
ans; 
‘‘(ii) the services provided to Indians 
pursuant to this title; and 
‘‘(iii) areas of unmet needs in the de-
livery of health services to urban Indians. 
‘‘(B) CONSULTATION
AND
CONTRACTS.— 
In preparing the report under paragraph (1), 
the Secretary— 
‘‘(i) shall consult with urban Indian 
organizations; and 
‘‘(ii) may enter into a contract with a 
national organization representing urban 
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234 
Indian organizations to conduct any aspect 
of the report. 
‘‘(b) AUDIT.—The reports and records of the urban 
Indian organization with respect to a contract or grant 
under this title shall be subject to audit by the Secretary 
and the Comptroller General of the United States. 
‘‘(c) COSTS OF AUDITS.—The Secretary shall allow 
as a cost of any contract or grant entered into or awarded 
under section 502 or 503 the cost of an annual inde-
pendent financial audit conducted by— 
‘‘(1) a certified public accountant; or 
‘‘(2) a certified public accounting firm qualified 
to conduct Federal compliance audits. 
‘‘SEC. 509. LIMITATION ON CONTRACT AUTHORITY. 
‘‘The authority of the Secretary to enter into con-
tracts or to award grants under this title shall be to the 
extent, and in an amount, provided for in appropriation 
Acts. 
‘‘SEC. 510. FACILITIES. 
‘‘(a) GRANTS.—The Secretary, acting through the 
Service, may make grants to contractors or grant recipi-
ents under this title for the lease, purchase, renovation, 
construction, or expansion of facilities, including leased fa-
cilities, in order to assist such contractors or grant recipi-
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ents in complying with applicable licensure or certification 
requirements. 
‘‘(b) LOAN FUND STUDY.—The Secretary, acting 
through the Service, may carry out a study to determine 
the feasibility of establishing a loan fund to provide to 
urban Indian organizations direct loans or guarantees for 
loans for the construction of health care facilities in a 
manner consistent with section 309, including by submit-
ting a report in accordance with subsection (c) of that sec-
tion. 
‘‘SEC. 511. DIVISION OF URBAN INDIAN HEALTH. 
‘‘There is established within the Service a Division 
of Urban Indian Health, which shall be responsible for— 
‘‘(1) carrying out the provisions of this title; 
‘‘(2) providing central oversight of the pro-
grams and services authorized under this title; and 
‘‘(3) providing technical assistance to urban In-
dian organizations. 
‘‘SEC. 512. GRANTS FOR ALCOHOL AND SUBSTANCE ABUSE- 
RELATED SERVICES. 
‘‘(a) GRANTS AUTHORIZED.—The Secretary, acting 
through the Service, may make grants for the provision 
of health-related services in prevention of, treatment of, 
rehabilitation of, or school- and community-based edu-
cation regarding, alcohol and substance abuse in Urban 
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Centers to those urban Indian organizations with which 
the Secretary has entered into a contract under this title 
or under section 201. 
‘‘(b) GOALS.—Each grant made pursuant to sub-
section (a) shall set forth the goals to be accomplished 
pursuant to the grant. The goals shall be specific to each 
grant as agreed to between the Secretary and the grantee. 
‘‘(c) CRITERIA.—The Secretary shall establish cri-
teria for the grants made under subsection (a), including 
criteria relating to the following: 
‘‘(1) The size of the urban Indian population. 
‘‘(2) Capability of the organization to ade-
quately perform the activities required under the 
grant. 
‘‘(3) Satisfactory performance standards for the 
organization in meeting the goals set forth in such 
grant. The standards shall be negotiated and agreed 
to between the Secretary and the grantee on a 
grant-by-grant basis. 
‘‘(4) Identification of the need for services. 
‘‘(d) ALLOCATION OF GRANTS.—The Secretary shall 
develop a methodology for allocating grants made pursu-
ant to this section based on the criteria established pursu-
ant to subsection (c). 
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‘‘(e) GRANTS SUBJECT TO CRITERIA.—Any grant re-
ceived by an urban Indian organization under this Act for 
substance abuse prevention, treatment, and rehabilitation 
shall be subject to the criteria set forth in subsection (c). 
‘‘SEC. 513. TREATMENT OF CERTAIN DEMONSTRATION 
PROJECTS. 
‘‘Notwithstanding any other provision of law, the 
Tulsa Clinic and Oklahoma City Clinic demonstration 
projects shall— 
‘‘(1) be permanent programs within the Serv-
ice’s direct care program; 
‘‘(2) continue to be treated as Service Units 
and Operating Units in the allocation of resources 
and coordination of care; and 
‘‘(3) continue to meet the requirements and 
definitions of an urban Indian organization in this 
Act, and shall not be subject to the provisions of the 
Indian Self-Determination and Education Assistance 
Act (25 U.S.C. 450 et seq.). 
‘‘SEC. 514. URBAN NIAAA TRANSFERRED PROGRAMS. 
‘‘(a) GRANTS
AND
CONTRACTS.—The Secretary, 
through the Division of Urban Indian Health, shall make 
grants or enter into contracts with urban Indian organiza-
tions, to take effect not later than September 30, 2010, 
for the administration of urban Indian alcohol programs 
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that were originally established under the National Insti-
tute on Alcoholism and Alcohol Abuse (hereafter in this 
section referred to as ‘NIAAA’) and transferred to the 
Service. 
‘‘(b) USE OF FUNDS.—Grants provided or contracts 
entered into under this section shall be used to provide 
support for the continuation of alcohol prevention and 
treatment services for urban Indian populations and such 
other objectives as are agreed upon between the Service 
and a recipient of a grant or contract under this section. 
‘‘(c) ELIGIBILITY.—Urban Indian organizations that 
operate Indian alcohol programs originally funded under 
the NIAAA and subsequently transferred to the Service 
are eligible for grants or contracts under this section. 
‘‘(d) REPORT.—The Secretary shall evaluate and re-
port to Congress on the activities of programs funded 
under this section not less than every 5 years. 
‘‘SEC. 515. CONFERRING WITH URBAN INDIAN ORGANIZA-
TIONS. 
‘‘(a) IN GENERAL.—The Secretary shall ensure that 
the Service confers or conferences, to the greatest extent 
practicable, with Urban Indian Organizations. 
‘‘(b) DEFINITION
OF CONFER; CONFERENCE.—In 
this section, the terms ‘confer’ and ‘conference’ mean an 
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open and free exchange of information and opinions 
that— 
‘‘(1) leads to mutual understanding and com-
prehension; and 
‘‘(2) emphasizes trust, respect, and shared re-
sponsibility. 
‘‘SEC. 516. URBAN YOUTH TREATMENT CENTER DEM-
ONSTRATION. 
‘‘(a) CONSTRUCTION AND OPERATION.— 
‘‘(1) IN
GENERAL.—The Secretary, acting 
through the Service, through grant or contract, shall 
fund the construction and operation of at least 1 
residential treatment center in each Service Area 
that meets the eligibility requirements set forth in 
subsection (b) to demonstrate the provision of alco-
hol and substance abuse treatment services to Urban 
Indian youth in a culturally competent residential 
setting. 
‘‘(2) TREATMENT.—Each residential treatment 
center described in paragraph (1) shall be in addi-
tion to any facilities constructed under section 
707(b). 
‘‘(b) ELIGIBILITY REQUIREMENTS.—To be eligible to 
obtain a facility under subsection (a)(1), a Service Area 
shall meet the following requirements: 
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‘‘(1) There is an Urban Indian Organization in 
the Service Area. 
‘‘(2) There reside in the Service Area Urban In-
dian youth with need for alcohol and substance 
abuse treatment services in a residential setting. 
‘‘(3) There is a significant shortage of cul-
turally competent residential treatment services for 
Urban Indian youth in the Service Area. 
‘‘SEC. 517. GRANTS FOR DIABETES PREVENTION, TREAT-
MENT, AND CONTROL. 
‘‘(a) GRANTS AUTHORIZED.—The Secretary may 
make grants to those urban Indian organizations that 
have entered into a contract or have received a grant 
under this title for the provision of services for the preven-
tion and treatment of, and control of the complications 
resulting from, diabetes among urban Indians. 
‘‘(b) GOALS.—Each grant made pursuant to sub-
section (a) shall set forth the goals to be accomplished 
under the grant. The goals shall be specific to each grant 
as agreed to between the Secretary and the grantee. 
‘‘(c) ESTABLISHMENT OF CRITERIA.—The Secretary 
shall establish criteria for the grants made under sub-
section (a) relating to— 
‘‘(1) the size and location of the urban Indian 
population to be served; 
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‘‘(2) the need for prevention of and treatment 
of, and control of the complications resulting from, 
diabetes among the urban Indian population to be 
served; 
‘‘(3) performance standards for the organiza-
tion in meeting the goals set forth in such grant 
that are negotiated and agreed to by the Secretary 
and the grantee; 
‘‘(4) the capability of the organization to ade-
quately perform the activities required under the 
grant; and 
‘‘(5) the willingness of the organization to col-
laborate with the registry, if any, established by the 
Secretary under section 204(e) in the Area Office of 
the Service in which the organization is located. 
‘‘(d) FUNDS SUBJECT TO CRITERIA.—Any funds re-
ceived by an urban Indian organization under this Act for 
the prevention, treatment, and control of diabetes among 
urban Indians shall be subject to the criteria developed 
by the Secretary under subsection (c). 
‘‘SEC. 518. COMMUNITY HEALTH REPRESENTATIVES. 
‘‘The Secretary, acting through the Service, may 
enter into contracts with, and make grants to, urban In-
dian organizations for the employment of Indians trained 
as health service providers through the Community Health 
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Representatives Program under section 109 in the provi-
sion of health care, health promotion, and disease preven-
tion services to urban Indians. 
‘‘SEC. 519. EFFECTIVE DATE. 
‘‘The amendments made by the Indian Health Care 
Improvement Act Amendments of 2009 to this title shall 
take effect beginning on the date of enactment of that Act, 
regardless of whether the Secretary has promulgated regu-
lations implementing such amendments. 
‘‘SEC. 520. ELIGIBILITY FOR SERVICES. 
‘‘Urban Indians shall be eligible for, and the ultimate 
beneficiaries of, health care or referral services provided 
pursuant to this title. 
‘‘SEC. 521. AUTHORIZATION OF APPROPRIATIONS. 
‘‘(a) IN GENERAL.—There are authorized to be ap-
propriated such sums as may be necessary for each fiscal 
year through fiscal year 2025 to carry out this title. 
‘‘(b) URBAN INDIAN ORGANIZATIONS.—The Sec-
retary, acting through the Service, is authorized to estab-
lish programs, including programs for the awarding of 
grants, for urban Indian organizations that are identical 
to any programs established pursuant to section 126 (be-
havioral health training), section 210 (school health edu-
cation), section 212 (prevention of communicable dis-
eases), section 701 (behavioral health prevention and 
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treatment services), and section 707(g) (multidrug abuse 
program). 
‘‘SEC. 522. HEALTH INFORMATION TECHNOLOGY. 
‘‘The Secretary, acting through the Service, may 
make grants to urban Indian organizations under this title 
for the development, adoption, and implementation of 
health information technology (as defined in section 
3000(5) of the American Recovery and Reinvestment Act), 
telemedicine services development, and related infrastruc-
ture. 
‘‘TITLE VI—ORGANIZATIONAL 
IMPROVEMENTS 
‘‘SEC. 601. ESTABLISHMENT OF THE INDIAN HEALTH SERV-
ICE AS AN AGENCY OF THE PUBLIC HEALTH 
SERVICE. 
‘‘(a) ESTABLISHMENT.— 
‘‘(1) IN GENERAL.—In order to more effectively 
and efficiently carry out the responsibilities, authori-
ties, and functions of the United States to provide 
health care services to Indians and Indian Tribes, as 
are or may be hereafter provided by Federal statute 
or treaties, there is established within the Public 
Health Service of the Department the Indian Health 
Service. 
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244 
‘‘(2) 
ASSISTANT
SECRETARY
OF
INDIAN 
HEALTH.—The Service shall be administered by an 
Assistant Secretary of Indian Health, who shall be 
appointed by the President, by and with the advice 
and consent of the Senate. The Assistant Secretary 
shall report to the Secretary. Effective with respect 
to an individual appointed by the President, by and 
with the advice and consent of the Senate, after 
January 1, 2010, the term of service of the Assist-
ant Secretary shall be 4 years. An Assistant Sec-
retary may serve more than 1 term. 
‘‘(3) INCUMBENT.—The individual serving in 
the position of Director of the Service on the day be-
fore the date of enactment of the Indian Health 
Care Improvement Act Amendments of 2009 shall 
serve as Assistant Secretary. 
‘‘(4) ADVOCACY AND CONSULTATION.—The po-
sition of Assistant Secretary is established to, in a 
manner consistent with the government-to-govern-
ment relationship between the United States and In-
dian Tribes— 
‘‘(A) facilitate advocacy for the develop-
ment of appropriate Indian health policy; and 
‘‘(B) promote consultation on matters re-
lating to Indian health. 
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‘‘(b) AGENCY.—The Service shall be an agency within 
the Public Health Service of the Department, and shall 
not be an office, component, or unit of any other agency 
of the Department. 
‘‘(c) DUTIES.—The Assistant Secretary shall— 
‘‘(1) perform all functions that were, on the day 
before the date of enactment of the Indian Health 
Care Improvement Act Amendments of 2009, car-
ried out by or under the direction of the individual 
serving as Director of the Service on that day; 
‘‘(2) perform all functions of the Secretary re-
lating to the maintenance and operation of hospital 
and health facilities for Indians and the planning 
for, and provision and utilization of, health services 
for Indians; 
‘‘(3) administer all health programs under 
which health care is provided to Indians based upon 
their status as Indians which are administered by 
the Secretary, including programs under— 
‘‘(A) this Act; 
‘‘(B) the Act of November 2, 1921 (25 
U.S.C. 13); 
‘‘(C) the Act of August 5, 1954 (42 U.S.C. 
2001 et seq.); 
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‘‘(D) the Act of August 16, 1957 (42 
U.S.C. 2005 et seq.); and 
‘‘(E) the Indian Self-Determination and 
Education Assistance Act (25 U.S.C. 450 et 
seq.); 
‘‘(4) administer all scholarship and loan func-
tions carried out under title I; 
‘‘(5) report directly to the Secretary concerning 
all policy- and budget-related matters affecting In-
dian health; 
‘‘(6) collaborate with the Assistant Secretary 
for Health concerning appropriate matters of Indian 
health that affect the agencies of the Public Health 
Service; 
‘‘(7) advise each Assistant Secretary of the De-
partment concerning matters of Indian health with 
respect to which that Assistant Secretary has au-
thority and responsibility; 
‘‘(8) advise the heads of other agencies and pro-
grams of the Department concerning matters of In-
dian health with respect to which those heads have 
authority and responsibility; 
‘‘(9) coordinate the activities of the Department 
concerning matters of Indian health; and 
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247 
‘‘(10) perform such other functions as the Sec-
retary may designate. 
‘‘(d) AUTHORITY.— 
‘‘(1) IN
GENERAL.—The Secretary, acting 
through the Assistant Secretary, shall have the au-
thority— 
‘‘(A) except to the extent provided for in 
paragraph (2), to appoint and compensate em-
ployees for the Service in accordance with title 
5, United States Code; 
‘‘(B) to enter into contracts for the pro-
curement of goods and services to carry out the 
functions of the Service; and 
‘‘(C) to manage, expend, and obligate all 
funds appropriated for the Service. 
‘‘(2) PERSONNEL
ACTIONS.—Notwithstanding 
any other provision of law, the provisions of section 
12 of the Act of June 18, 1934 (48 Stat. 986; 25 
U.S.C. 472), shall apply to all personnel actions 
taken with respect to new positions created within 
the Service as a result of its establishment under 
subsection (a). 
‘‘(e) REFERENCES.—Any reference to the Director of 
the Indian Health Service in any other Federal law, Exec-
utive order, rule, regulation, or delegation of authority, or 
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in any document of or relating to the Director of the In-
dian Health Service, shall be deemed to refer to the Assist-
ant Secretary. 
‘‘SEC. 602. AUTOMATED MANAGEMENT INFORMATION SYS-
TEM. 
‘‘(a) ESTABLISHMENT.— 
‘‘(1) IN GENERAL.—The Secretary shall estab-
lish an automated management information system 
for the Service. 
‘‘(2) REQUIREMENTS OF SYSTEM.—The infor-
mation system established under paragraph (1) shall 
include— 
‘‘(A) a financial management system; 
‘‘(B) a patient care information system for 
each area served by the Service; 
‘‘(C) privacy protections consistent with 
the regulations promulgated under section 
264(c) of the Health Insurance Portability and 
Accountability Act of 1996 or, to the extent 
consistent with such regulations, other Federal 
rules applicable to privacy of automated man-
agement information systems of a Federal 
agency; 
‘‘(D) a services-based cost accounting com-
ponent that provides estimates of the costs as-
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sociated with the provision of specific medical 
treatments or services in each Area office of the 
Service; 
‘‘(E) an interface mechanism for patient 
billing and accounts receivable system; and 
‘‘(F) a training component. 
‘‘(b) PROVISION OF SYSTEMS TO TRIBES AND ORGA-
NIZATIONS.—The Secretary shall provide each Tribal 
Health Program automated management information sys-
tems which— 
‘‘(1) meet the management information needs 
of such Tribal Health Program with respect to the 
treatment by the Tribal Health Program of patients 
of the Service; and 
‘‘(2) meet the management information needs 
of the Service. 
‘‘(c) ACCESS TO RECORDS.—The Service shall pro-
vide access of patients to their medical or health records 
which are held by, or on behalf of, the Service in accord-
ance with the regulations promulgated under section 
264(c) of the Health Insurance Portability and Account-
ability Act of 1996 or, to the extent consistent with such 
regulations, other Federal rules applicable to access to 
health care records. 
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‘‘(d) AUTHORITY TO ENHANCE INFORMATION TECH-
NOLOGY.—The Secretary, acting through the Assistant 
Secretary, shall have the authority to enter into contracts, 
agreements, or joint ventures with other Federal agencies, 
States, private and nonprofit organizations, for the pur-
pose of enhancing information technology in Indian 
Health Programs and facilities. 
‘‘SEC. 603. AUTHORIZATION OF APPROPRIATIONS. 
‘‘There is authorized to be appropriated such sums 
as may be necessary for each fiscal year through fiscal 
year 2025 to carry out this title. 
‘‘TITLE VII—BEHAVIORAL 
HEALTH PROGRAMS 
‘‘SEC. 701. BEHAVIORAL HEALTH PREVENTION AND TREAT-
MENT SERVICES. 
‘‘(a) PURPOSES.—The purposes of this section are as 
follows: 
‘‘(1) To authorize and direct the Secretary, act-
ing through the Service, to develop a comprehensive 
behavioral health prevention and treatment program 
which emphasizes collaboration among alcohol and 
substance abuse, social services, and mental health 
programs. 
‘‘(2) To provide information, direction, and 
guidance relating to mental illness and dysfunction 
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251 
and self-destructive behavior, including child abuse 
and family violence, to those Federal, tribal, State, 
and local agencies responsible for programs in In-
dian communities in areas of health care, education, 
social services, child and family welfare, alcohol and 
substance abuse, law enforcement, and judicial serv-
ices. 
‘‘(3) To assist Indian Tribes to identify services 
and resources available to address mental illness and 
dysfunctional and self-destructive behavior. 
‘‘(4) To provide authority and opportunities for 
Indian Tribes and Tribal Organizations to develop, 
implement, and coordinate with community-based 
programs which include identification, prevention, 
education, referral, and treatment services, including 
through multidisciplinary resource teams. 
‘‘(5) To ensure that Indians, as citizens of the 
United States and of the States in which they re-
side, have the same access to behavioral health serv-
ices to which all citizens have access. 
‘‘(6) To modify or supplement existing pro-
grams and authorities in the areas identified in 
paragraph (2). 
‘‘(b) PLANS.— 
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252 
‘‘(1) DEVELOPMENT.—The Secretary, acting 
through the Service, shall encourage Indian Tribes 
and Tribal Organizations to develop tribal plans, 
and urban Indian organizations to develop local 
plans, and for all such groups to participate in de-
veloping areawide plans for Indian Behavioral 
Health Services. The plans shall include, to the ex-
tent feasible, the following components: 
‘‘(A) An assessment of the scope of alcohol 
or other substance abuse, mental illness, and 
dysfunctional and self-destructive behavior, in-
cluding suicide, child abuse, and family vio-
lence, among Indians, including— 
‘‘(i) the number of Indians served who 
are directly or indirectly affected by such 
illness or behavior; or 
‘‘(ii) an estimate of the financial and 
human cost attributable to such illness or 
behavior. 
‘‘(B) An assessment of the existing and 
additional resources necessary for the preven-
tion and treatment of such illness and behavior, 
including an assessment of the progress toward 
achieving the availability of the full continuum 
of care described in subsection (c). 
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253 
‘‘(C) An estimate of the additional funding 
needed by the Service, Indian Tribes, Tribal 
Organizations, and urban Indian organizations 
to meet their responsibilities under the plans. 
‘‘(2) NATIONAL
CLEARINGHOUSE.—The Sec-
retary, acting through the Service, shall coordinate 
with existing national clearinghouses and informa-
tion centers to include at the clearinghouses and 
centers plans and reports on the outcomes of such 
plans developed by Indian Tribes, Tribal Organiza-
tions, urban Indian organizations, and Service Areas 
relating to behavioral health. The Secretary shall en-
sure access to these plans and outcomes by any In-
dian Tribe, Tribal Organization, urban Indian orga-
nization, or the Service. 
‘‘(3) TECHNICAL ASSISTANCE.—The Secretary 
shall provide technical assistance to Indian Tribes, 
Tribal Organizations, and urban Indian organiza-
tions in preparation of plans under this section and 
in developing standards of care that may be used 
and adopted locally. 
‘‘(c) PROGRAMS.—The Secretary, acting through the 
Service, shall provide, to the extent feasible and if funding 
is available, programs including the following: 
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254 
‘‘(1) COMPREHENSIVE CARE.—A comprehensive 
continuum of behavioral health care which pro-
vides— 
‘‘(A) community-based prevention, inter-
vention, outpatient, and behavioral health 
aftercare; 
‘‘(B) detoxification (social and medical); 
‘‘(C) acute hospitalization; 
‘‘(D) intensive outpatient/day treatment; 
‘‘(E) residential treatment; 
‘‘(F) transitional living for those needing a 
temporary, stable living environment that is 
supportive of treatment and recovery goals; 
‘‘(G) emergency shelter; 
‘‘(H) intensive case management; and 
‘‘(I) diagnostic services. 
‘‘(2) CHILD CARE.—Behavioral health services 
for Indians from birth through age 17, including— 
‘‘(A) preschool and school age fetal alcohol 
disorder services, including assessment and be-
havioral intervention; 
‘‘(B) mental health and substance abuse 
services (emotional, organic, alcohol, drug, in-
halant, and tobacco); 
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‘‘(C) identification and treatment of co-oc-
curring disorders and comorbidity; 
‘‘(D) prevention of alcohol, drug, inhalant, 
and tobacco use; 
‘‘(E) early intervention, treatment, and 
aftercare; 
‘‘(F) promotion of healthy approaches to 
risk and safety issues; and 
‘‘(G) identification and treatment of ne-
glect and physical, mental, and sexual abuse. 
‘‘(3) ADULT CARE.—Behavioral health services 
for Indians from age 18 through 55, including— 
‘‘(A) early intervention, treatment, and 
aftercare; 
‘‘(B) mental health and substance abuse 
services (emotional, alcohol, drug, inhalant, and 
tobacco), including sex specific services; 
‘‘(C) identification and treatment of co-oc-
curring disorders (dual diagnosis) and comor-
bidity; 
‘‘(D) promotion of healthy approaches for 
risk-related behavior; 
‘‘(E) treatment services for women at risk 
of giving birth to a child with a fetal alcohol 
disorder; and 
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‘‘(F) sex specific treatment for sexual as-
sault and domestic violence. 
‘‘(4) FAMILY CARE.—Behavioral health services 
for families, including— 
‘‘(A) early intervention, treatment, and 
aftercare for affected families; 
‘‘(B) treatment for sexual assault and do-
mestic violence; and 
‘‘(C) promotion of healthy approaches re-
lating to parenting, domestic violence, and other 
abuse issues. 
‘‘(5) ELDER CARE.—Behavioral health services 
for Indians 56 years of age and older, including— 
‘‘(A) early intervention, treatment, and 
aftercare; 
‘‘(B) mental health and substance abuse 
services (emotional, alcohol, drug, inhalant, and 
tobacco), including sex specific services; 
‘‘(C) identification and treatment of co-oc-
curring disorders (dual diagnosis) and comor-
bidity; 
‘‘(D) promotion of healthy approaches to 
managing conditions related to aging; 
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257 
‘‘(E) sex specific treatment for sexual as-
sault, domestic violence, neglect, physical and 
mental abuse and exploitation; and 
‘‘(F) identification and treatment of de-
mentias regardless of cause. 
‘‘(d) COMMUNITY BEHAVIORAL HEALTH PLAN.— 
‘‘(1) ESTABLISHMENT.—The governing body of 
any Indian Tribe, Tribal Organization, or urban In-
dian organization may adopt a resolution for the es-
tablishment of a community behavioral health plan 
providing for the identification and coordination of 
available resources and programs to identify, pre-
vent, or treat substance abuse, mental illness, or 
dysfunctional and self-destructive behavior, including 
child abuse and family violence, among its members 
or its service population. This plan should include 
behavioral health services, social services, intensive 
outpatient services, and continuing aftercare. 
‘‘(2) TECHNICAL ASSISTANCE.—At the request 
of an Indian Tribe, Tribal Organization, or urban 
Indian organization, the Bureau of Indian Affairs 
and the Service shall cooperate with and provide 
technical assistance to the Indian Tribe, Tribal Or-
ganization, or urban Indian organization in the de-
velopment and implementation of such plan. 
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258 
‘‘(3) FUNDING.—The Secretary, acting through 
the Service, may make funding available to Indian 
Tribes and Tribal Organizations which adopt a reso-
lution pursuant to paragraph (1) to obtain technical 
assistance for the development of a community be-
havioral health plan and to provide administrative 
support in the implementation of such plan. 
‘‘(e) COORDINATION FOR AVAILABILITY OF SERV-
ICES.—The Secretary, acting through the Service, shall 
coordinate behavioral health planning, to the extent fea-
sible, with other Federal agencies and with State agencies, 
to encourage comprehensive behavioral health services for 
Indians regardless of their place of residence. 
‘‘(f) MENTAL HEALTH CARE NEED ASSESSMENT.— 
Not later than 1 year after the date of enactment of the 
Indian Health Care Improvement Act Amendments of 
2009, the Secretary, acting through the Service, shall 
make an assessment of the need for inpatient mental 
health care among Indians and the availability and cost 
of inpatient mental health facilities which can meet such 
need. In making such assessment, the Secretary shall con-
sider the possible conversion of existing, underused Service 
hospital beds into psychiatric units to meet such need. 
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259 
‘‘SEC. 702. MEMORANDA OF AGREEMENT WITH THE DE-
PARTMENT OF THE INTERIOR. 
‘‘(a) CONTENTS.—Not later than 12 months after the 
date of enactment of the Indian Health Care Improvement 
Act Amendments of 2009, the Secretary, acting through 
the Service, and the Secretary of the Interior shall develop 
and enter into a memoranda of agreement, or review and 
update any existing memoranda of agreement, as required 
by section 4205 of the Indian Alcohol and Substance 
Abuse Prevention and Treatment Act of 1986 (25 U.S.C. 
2411) under which the Secretaries address the following: 
‘‘(1) The scope and nature of mental illness and 
dysfunctional and self-destructive behavior, including 
child abuse and family violence, among Indians. 
‘‘(2) The existing Federal, tribal, State, local, 
and private services, resources, and programs avail-
able to provide behavioral health services for Indi-
ans. 
‘‘(3) The unmet need for additional services, re-
sources, and programs necessary to meet the needs 
identified pursuant to paragraph (1). 
‘‘(4)(A) The right of Indians, as citizens of the 
United States and of the States in which they re-
side, to have access to behavioral health services to 
which all citizens have access. 
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260 
‘‘(B) The right of Indians to participate in, and 
receive the benefit of, such services. 
‘‘(C) The actions necessary to protect the exer-
cise of such right. 
‘‘(5) The responsibilities of the Bureau of In-
dian Affairs and the Service, including mental illness 
identification, prevention, education, referral, and 
treatment services (including services through multi-
disciplinary resource teams), at the central, area, 
and agency and Service Unit, Service Area, and 
headquarters levels to address the problems identi-
fied in paragraph (1). 
‘‘(6) A strategy for the comprehensive coordina-
tion of the behavioral health services provided by the 
Bureau of Indian Affairs and the Service to meet 
the problems identified pursuant to paragraph (1), 
including— 
‘‘(A) the coordination of alcohol and sub-
stance abuse programs of the Service, the Bu-
reau of Indian Affairs, and Indian Tribes and 
Tribal Organizations (developed under the In-
dian Alcohol and Substance Abuse Prevention 
and Treatment Act of 1986 (25 U.S.C. 2401 et 
seq.)) with behavioral health initiatives pursu-
ant to this Act, particularly with respect to the 
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261 
referral and treatment of dually diagnosed indi-
viduals requiring behavioral health and sub-
stance abuse treatment; and 
‘‘(B) ensuring that the Bureau of Indian 
Affairs and Service programs and services (in-
cluding multidisciplinary resource teams) ad-
dressing child abuse and family violence are co-
ordinated with such non-Federal programs and 
services. 
‘‘(7) Directing appropriate officials of the Bu-
reau of Indian Affairs and the Service, particularly 
at the agency and Service Unit levels, to cooperate 
fully with tribal requests made pursuant to commu-
nity behavioral health plans adopted under section 
701(c) and section 4206 of the Indian Alcohol and 
Substance Abuse Prevention and Treatment Act of 
1986 (25 U.S.C. 2412). 
‘‘(8) Providing for an annual review of such 
agreement by the Secretaries which shall be provided 
to Congress and Indian Tribes and Tribal Organiza-
tions. 
‘‘(b) SPECIFIC PROVISIONS REQUIRED.—The memo-
randa of agreement updated or entered into pursuant to 
subsection (a) shall include specific provisions pursuant to 
which the Service shall assume responsibility for— 
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‘‘(1) the determination of the scope of the prob-
lem of alcohol and substance abuse among Indians, 
including the number of Indians within the jurisdic-
tion of the Service who are directly or indirectly af-
fected by alcohol and substance abuse and the finan-
cial and human cost; 
‘‘(2) an assessment of the existing and needed 
resources necessary for the prevention of alcohol and 
substance abuse and the treatment of Indians af-
fected by alcohol and substance abuse; and 
‘‘(3) an estimate of the funding necessary to 
adequately support a program of prevention of alco-
hol and substance abuse and treatment of Indians 
affected by alcohol and substance abuse. 
‘‘(c) PUBLICATION.—Each memorandum of agree-
ment entered into or renewed (and amendments or modi-
fications thereto) under subsection (a) shall be published 
in the Federal Register. At the same time as publication 
in the Federal Register, the Secretary shall provide a copy 
of such memoranda, amendment, or modification to each 
Indian Tribe, Tribal Organization, and urban Indian orga-
nization. 
‘‘SEC. 703. COMPREHENSIVE BEHAVIORAL HEALTH PRE-
VENTION AND TREATMENT PROGRAM. 
‘‘(a) ESTABLISHMENT.— 
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263 
‘‘(1) IN
GENERAL.—The Secretary, acting 
through the Service, shall provide a program of com-
prehensive behavioral health, prevention, treatment, 
and aftercare, including Systems of Care, which 
shall include— 
‘‘(A) prevention, through educational inter-
vention, in Indian communities; 
‘‘(B) acute detoxification, psychiatric hos-
pitalization, residential, and intensive outpatient 
treatment; 
‘‘(C) community-based rehabilitation and 
aftercare; 
‘‘(D) community education and involve-
ment, including extensive training of health 
care, educational, and community-based per-
sonnel; 
‘‘(E) specialized residential treatment pro-
grams for high-risk populations, including preg-
nant and postpartum women and their children; 
and 
‘‘(F) diagnostic services. 
‘‘(2) TARGET POPULATIONS.—The target popu-
lation of such programs shall be members of Indian 
Tribes. Efforts to train and educate key members of 
the Indian community shall also target employees of 
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264 
health, education, judicial, law enforcement, legal, 
and social service programs. 
‘‘(b) CONTRACT HEALTH SERVICES.— 
‘‘(1) IN
GENERAL.—The Secretary, acting 
through the Service, may enter into contracts with 
public or private providers of behavioral health treat-
ment services for the purpose of carrying out the 
program required under subsection (a). 
‘‘(2) PROVISION OF ASSISTANCE.—In carrying 
out this subsection, the Secretary shall provide as-
sistance to Indian Tribes and Tribal Organizations 
to develop criteria for the certification of behavioral 
health service providers and accreditation of service 
facilities which meet minimum standards for such 
services and facilities. 
‘‘SEC. 704. MENTAL HEALTH TECHNICIAN PROGRAM. 
‘‘(a) IN GENERAL.—Under the authority of the Act 
of November 2, 1921 (25 U.S.C. 13) (commonly known 
as the ‘Snyder Act’), the Secretary shall establish and 
maintain a mental health technician program within the 
Service which— 
‘‘(1) provides for the training of Indians as 
mental health technicians; and 
‘‘(2) employs such technicians in the provision 
of community-based mental health care that includes 
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identification, prevention, education, referral, and 
treatment services. 
‘‘(b) PARAPROFESSIONAL TRAINING.—In carrying 
out subsection (a), the Secretary, acting through the Serv-
ice, shall provide high-standard paraprofessional training 
in mental health care necessary to provide quality care to 
the Indian communities to be served. Such training shall 
be based upon a curriculum developed or approved by the 
Secretary which combines education in the theory of men-
tal health care with supervised practical experience in the 
provision of such care. 
‘‘(c) SUPERVISION AND EVALUATION OF TECHNI-
CIANS.—The Secretary, acting through the Service, shall 
supervise and evaluate the mental health technicians in 
the training program. 
‘‘(d) TRADITIONAL HEALTH CARE PRACTICES.—The 
Secretary, acting through the Service, shall ensure that 
the program established pursuant to this subsection in-
volves the use and promotion of the traditional health care 
practices of the Indian Tribes to be served. 
‘‘SEC. 
705. 
LICENSING 
REQUIREMENT 
FOR 
MENTAL 
HEALTH CARE WORKERS. 
‘‘(a) IN GENERAL.—Subject to the provisions of sec-
tion 221, and except as provided in subsection (b), any 
individual employed as a psychologist, social worker, or 
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marriage and family therapist for the purpose of providing 
mental health care services to Indians in a clinical setting 
under this Act is required to be licensed as a psychologist, 
social worker, or marriage and family therapist, respec-
tively. 
‘‘(b) TRAINEES.—An individual may be employed as 
a trainee in psychology, social work, or marriage and fam-
ily therapy to provide mental health care services de-
scribed in subsection (a) if such individual— 
‘‘(1) works under the direct supervision of a li-
censed psychologist, social worker, or marriage and 
family therapist, respectively; 
‘‘(2) is enrolled in or has completed at least 2 
years of course work at a post-secondary, accredited 
education program for psychology, social work, mar-
riage and family therapy, or counseling; and 
‘‘(3) meets such other training, supervision, and 
quality review requirements as the Secretary may es-
tablish. 
‘‘SEC. 706. INDIAN WOMEN TREATMENT PROGRAMS. 
‘‘(a) GRANTS.—The Secretary, consistent with sec-
tion 701, may make grants to Indian Tribes, Tribal Orga-
nizations, and urban Indian organizations to develop and 
implement a comprehensive behavioral health program of 
prevention, intervention, treatment, and relapse preven-
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tion services that specifically addresses the cultural, his-
torical, social, and child care needs of Indian women, re-
gardless of age. 
‘‘(b) USE OF GRANT FUNDS.—A grant made pursu-
ant to this section may be used to— 
‘‘(1) develop and provide community training, 
education, and prevention programs for Indian 
women relating to behavioral health issues, including 
fetal alcohol disorders; 
‘‘(2) identify and provide psychological services, 
counseling, advocacy, support, and relapse preven-
tion to Indian women and their families; and 
‘‘(3) develop prevention and intervention models 
for Indian women which incorporate traditional 
health care practices, cultural values, and commu-
nity and family involvement. 
‘‘(c) CRITERIA.—The Secretary, in consultation with 
Indian Tribes and Tribal Organizations, shall establish 
criteria for the review and approval of applications and 
proposals for funding under this section. 
‘‘(d) ALLOCATION OF FUNDS FOR URBAN INDIAN 
ORGANIZATIONS.—Twenty percent of the funds appro-
priated pursuant to this section shall be used to make 
grants to urban Indian organizations. 
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‘‘SEC. 707. INDIAN YOUTH PROGRAM. 
‘‘(a) DETOXIFICATION AND REHABILITATION.—The 
Secretary, acting through the Service, consistent with sec-
tion 701, shall develop and implement a program for acute 
detoxification and treatment for Indian youths, including 
behavioral health services. The program shall include re-
gional treatment centers designed to include detoxification 
and rehabilitation for both sexes on a referral basis and 
programs developed and implemented by Indian Tribes or 
Tribal Organizations at the local level under the Indian 
Self-Determination and Education Assistance Act (25 
U.S.C. 450 et seq.). Regional centers shall be integrated 
with the intake and rehabilitation programs based in the 
referring Indian community. 
‘‘(b) ALCOHOL AND SUBSTANCE ABUSE TREATMENT 
CENTERS OR FACILITIES.— 
‘‘(1) ESTABLISHMENT.— 
‘‘(A) IN GENERAL.—The Secretary, acting 
through the Service, shall construct, renovate, 
or, as necessary, purchase, and appropriately 
staff and operate, at least 1 youth regional 
treatment center or treatment network in each 
area under the jurisdiction of an Area Office. 
‘‘(B) AREA OFFICE IN CALIFORNIA.—For 
the purposes of this subsection, the Area Office 
in California shall be considered to be 2 Area 
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Offices, 1 office whose jurisdiction shall be con-
sidered to encompass the northern area of the 
State of California, and 1 office whose jurisdic-
tion shall be considered to encompass the re-
mainder of the State of California for the pur-
pose of implementing California treatment net-
works. 
‘‘(2) FUNDING.—For the purpose of staffing 
and operating such centers or facilities, funding 
shall be pursuant to the Act of November 2, 1921 
(25 U.S.C. 13). 
‘‘(3) LOCATION.—A youth treatment center 
constructed or purchased under this subsection shall 
be constructed or purchased at a location within the 
area described in paragraph (1) agreed upon (by ap-
propriate tribal resolution) by a majority of the In-
dian Tribes to be served by such center. 
‘‘(4) SPECIFIC PROVISION OF FUNDS.— 
‘‘(A) IN GENERAL.—Notwithstanding any 
other provision of this title, the Secretary may, 
from amounts authorized to be appropriated for 
the purposes of carrying out this section, make 
funds available to— 
‘‘(i) the Tanana Chiefs Conference, 
Incorporated, for the purpose of leasing, 
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constructing, renovating, operating, and 
maintaining a residential youth treatment 
facility in Fairbanks, Alaska; and 
‘‘(ii) the Southeast Alaska Regional 
Health Corporation to staff and operate a 
residential youth treatment facility without 
regard to the proviso set forth in section 
4(l) of the Indian Self-Determination and 
Education Assistance Act (25 U.S.C. 
450b(l)). 
‘‘(B) PROVISION OF SERVICES TO ELIGI-
BLE
YOUTHS.—Until 
additional 
residential 
youth treatment facilities are established in 
Alaska pursuant to this section, the facilities 
specified in subparagraph (A) shall make every 
effort to provide services to all eligible Indian 
youths residing in Alaska. 
‘‘(c) INTERMEDIATE
ADOLESCENT
BEHAVIORAL 
HEALTH SERVICES.— 
‘‘(1) IN
GENERAL.—The Secretary, acting 
through the Service, may provide intermediate be-
havioral health services, which may incorporate Sys-
tems of Care, to Indian children and adolescents, in-
cluding— 
‘‘(A) pretreatment assistance; 
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‘‘(B) inpatient, outpatient, and aftercare 
services; 
‘‘(C) emergency care; 
‘‘(D) suicide prevention and crisis interven-
tion; and 
‘‘(E) prevention and treatment of mental 
illness and dysfunctional and self-destructive 
behavior, including child abuse and family vio-
lence. 
‘‘(2) USE OF FUNDS.—Funds provided under 
this subsection may be used— 
‘‘(A) to construct or renovate an existing 
health facility to provide intermediate behav-
ioral health services; 
‘‘(B) to hire behavioral health profes-
sionals; 
‘‘(C) to staff, operate, and maintain an in-
termediate mental health facility, group home, 
sober housing, transitional housing or similar 
facilities, or youth shelter where intermediate 
behavioral health services are being provided; 
‘‘(D) to make renovations and hire appro-
priate staff to convert existing hospital beds 
into adolescent psychiatric units; and 
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‘‘(E) for intensive home- and community- 
based services. 
‘‘(3) CRITERIA.—The Secretary, acting through 
the Service, shall, in consultation with Indian Tribes 
and Tribal Organizations, establish criteria for the 
review and approval of applications or proposals for 
funding made available pursuant to this subsection. 
‘‘(d) FEDERALLY OWNED STRUCTURES.— 
‘‘(1) IN GENERAL.—The Secretary, in consulta-
tion with Indian Tribes and Tribal Organizations, 
shall— 
‘‘(A) identify and use, where appropriate, 
federally owned structures suitable for local res-
idential or regional behavioral health treatment 
for Indian youths; and 
‘‘(B) establish guidelines for determining 
the suitability of any such federally owned 
structure to be used for local residential or re-
gional behavioral health treatment for Indian 
youths. 
‘‘(2) TERMS
AND
CONDITIONS
FOR
USE
OF 
STRUCTURE.—Any structure described in paragraph 
(1) may be used under such terms and conditions as 
may be agreed upon by the Secretary and the agency 
having responsibility for the structure and any In-
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273 
dian Tribe or Tribal Organization operating the pro-
gram. 
‘‘(e) REHABILITATION AND AFTERCARE SERVICES.— 
‘‘(1) IN
GENERAL.—The Secretary, Indian 
Tribes, or Tribal Organizations, in cooperation with 
the Secretary of the Interior, shall develop and im-
plement within each Service Unit, community-based 
rehabilitation and follow-up services for Indian 
youths who are having significant behavioral health 
problems, and require long-term treatment, commu-
nity reintegration, and monitoring to support the In-
dian youths after their return to their home commu-
nity. 
‘‘(2) ADMINISTRATION.—Services under para-
graph (1) shall be provided by trained staff within 
the community who can assist the Indian youths in 
their continuing development of self-image, positive 
problem-solving skills, and nonalcohol or substance 
abusing behaviors. Such staff may include alcohol 
and substance abuse counselors, mental health pro-
fessionals, and other health professionals and para-
professionals, including community health represent-
atives. 
‘‘(f) INCLUSION OF FAMILY IN YOUTH TREATMENT 
PROGRAM.—In providing the treatment and other services 
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to Indian youths authorized by this section, the Secretary, 
acting through the Service, shall provide for the inclusion 
of family members of such youths in the treatment pro-
grams or other services as may be appropriate. Not less 
than 10 percent of the funds appropriated for the pur-
poses of carrying out subsection (e) shall be used for out-
patient care of adult family members related to the treat-
ment of an Indian youth under that subsection. 
‘‘(g) MULTIDRUG ABUSE PROGRAM.—The Secretary, 
acting through the Service, shall provide, consistent with 
section 701, programs and services to prevent and treat 
the abuse of multiple forms of substances, including alco-
hol, drugs, inhalants, and tobacco, among Indian youths 
residing in Indian communities, on or near reservations, 
and in urban areas and provide appropriate mental health 
services to address the incidence of mental illness among 
such youths. 
‘‘(h) INDIAN YOUTH MENTAL HEALTH.—The Sec-
retary, acting through the Service, shall collect data for 
the report under section 801 with respect to— 
‘‘(1) the number of Indian youth who are being 
provided mental health services through the Service 
and Tribal Health Programs; 
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‘‘(2) a description of, and costs associated with, 
the mental health services provided for Indian youth 
through the Service and Tribal Health Programs; 
‘‘(3) the number of youth referred to the Serv-
ice or Tribal Health Programs for mental health 
services; 
‘‘(4) the number of Indian youth provided resi-
dential treatment for mental health and behavioral 
problems through the Service and Tribal Health 
Programs, reported separately for on- and off-res-
ervation facilities; and 
‘‘(5) the costs of the services described in para-
graph (4). 
‘‘SEC. 708. INDIAN YOUTH TELEMENTAL HEALTH DEM-
ONSTRATION PROJECT. 
‘‘(a) PURPOSE.—The purpose of this section is to au-
thorize the Secretary to carry out a demonstration project 
to test the use of telemental health services in suicide pre-
vention, intervention and treatment of Indian youth, in-
cluding through— 
‘‘(1) the use of psychotherapy, psychiatric as-
sessments, diagnostic interviews, therapies for men-
tal health conditions predisposing to suicide, and al-
cohol and substance abuse treatment; 
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‘‘(2) the provision of clinical expertise to, con-
sultation services with, and medical advice and train-
ing for frontline health care providers working with 
Indian youth; 
‘‘(3) training and related support for commu-
nity leaders, family members and health and edu-
cation workers who work with Indian youth; 
‘‘(4) the development of culturally relevant edu-
cational materials on suicide; and 
‘‘(5) data collection and reporting. 
‘‘(b) DEFINITIONS.—For the purpose of this section, 
the following definitions shall apply: 
‘‘(1) DEMONSTRATION
PROJECT.—The term 
‘demonstration project’ means the Indian youth tele-
mental health demonstration project authorized 
under subsection (c). 
‘‘(2) TELEMENTAL HEALTH.—The term ‘tele-
mental health’ means the use of electronic informa-
tion and telecommunications technologies to support 
long distance mental health care, patient and profes-
sional-related education, public health, and health 
administration. 
‘‘(c) AUTHORIZATION.— 
‘‘(1) IN GENERAL.—The Secretary is authorized 
to award grants under the demonstration project for 
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the provision of telemental health services to Indian 
youth who— 
‘‘(A) have expressed suicidal ideas; 
‘‘(B) have attempted suicide; or 
‘‘(C) have mental health conditions that in-
crease or could increase the risk of suicide. 
‘‘(2) ELIGIBILITY FOR GRANTS.—Such grants 
shall be awarded to Indian Tribes and Tribal Orga-
nizations that operate 1 or more facilities— 
‘‘(A) located in Alaska and part of the 
Alaska Federal Health Care Access Network; 
‘‘(B) reporting active clinical telehealth ca-
pabilities; or 
‘‘(C) 
offering 
school-based 
telemental 
health services relating to psychiatry to Indian 
youth. 
‘‘(3) GRANT
PERIOD.—The Secretary shall 
award grants under this section for a period of up 
to 4 years. 
‘‘(4) AWARDING OF GRANTS.—Not more than 5 
grants shall be provided under paragraph (1), with 
priority consideration given to Indian Tribes and 
Tribal Organizations that— 
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‘‘(A) serve a particular community or geo-
graphic area where there is a demonstrated 
need to address Indian youth suicide; 
‘‘(B) enter in to collaborative partnerships 
with Indian Health Service or Tribal Health 
Programs or facilities to provide services under 
this demonstration project; 
‘‘(C) serve an isolated community or geo-
graphic area which has limited or no access to 
behavioral health services; or 
‘‘(D) operate a detention facility at which 
Indian youth are detained. 
‘‘(d) USE OF FUNDS.— 
‘‘(1) IN GENERAL.—An Indian Tribe or Tribal 
Organization shall use a grant received under sub-
section (c) for the following purposes: 
‘‘(A) To provide telemental health services 
to Indian youth, including the provision of— 
‘‘(i) psychotherapy; 
‘‘(ii) psychiatric assessments and di-
agnostic interviews, therapies for mental 
health conditions predisposing to suicide, 
and treatment; and 
‘‘(iii) alcohol and substance abuse 
treatment. 
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‘‘(B) To provide clinician-interactive med-
ical advice, guidance and training, assistance in 
diagnosis and interpretation, crisis counseling 
and intervention, and related assistance to 
Service, tribal, or urban clinicians and health 
services providers working with youth being 
served under this demonstration project. 
‘‘(C) To assist, educate and train commu-
nity leaders, health education professionals and 
paraprofessionals, tribal outreach workers, and 
family members who work with the youth re-
ceiving telemental health services under this 
demonstration project, including with identifica-
tion of suicidal tendencies, crisis intervention 
and suicide prevention, emergency skill develop-
ment, and building and expanding networks 
among these individuals and with State and 
local health services providers. 
‘‘(D) To develop and distribute culturally 
appropriate community educational materials 
on— 
‘‘(i) suicide prevention; 
‘‘(ii) suicide education; 
‘‘(iii) suicide screening; 
‘‘(iv) suicide intervention; and 
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280 
‘‘(v) ways to mobilize communities 
with respect to the identification of risk 
factors for suicide. 
‘‘(E) For data collection and reporting re-
lated to Indian youth suicide prevention efforts. 
‘‘(2) 
TRADITIONAL
HEALTH
CARE
PRAC-
TICES.—In carrying out the purposes described in 
paragraph (1), an Indian Tribe or Tribal Organiza-
tion may use and promote the traditional health care 
practices of the Indian Tribes of the youth to be 
served. 
‘‘(e) APPLICATIONS.—To be eligible to receive a grant 
under subsection (c), an Indian Tribe or Tribal Organiza-
tion shall prepare and submit to the Secretary an applica-
tion, at such time, in such manner, and containing such 
information as the Secretary may require, including— 
‘‘(1) a description of the project that the Indian 
Tribe or Tribal Organization will carry out using the 
funds provided under the grant; 
‘‘(2) a description of the manner in which the 
project funded under the grant would— 
‘‘(A) meet the telemental health care needs 
of the Indian youth population to be served by 
the project; or 
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‘‘(B) improve the access of the Indian 
youth population to be served to suicide preven-
tion and treatment services; 
‘‘(3) evidence of support for the project from 
the local community to be served by the project; 
‘‘(4) a description of how the families and lead-
ership of the communities or populations to be 
served by the project would be involved in the devel-
opment and ongoing operations of the project; 
‘‘(5) a plan to involve the tribal community of 
the youth who are provided services by the project 
in planning and evaluating the mental health care 
and suicide prevention efforts provided, in order to 
ensure the integration of community, clinical, envi-
ronmental, and cultural components of the treat-
ment; and 
‘‘(6) a plan for sustaining the project after Fed-
eral assistance for the demonstration project has ter-
minated. 
‘‘(f) COLLABORATION; REPORTING
TO NATIONAL 
CLEARINGHOUSE.— 
‘‘(1) COLLABORATION.—The Secretary, acting 
through the Service, shall encourage Indian Tribes 
and Tribal Organizations receiving grants under this 
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282 
section to collaborate to enable comparisons about 
best practices across projects. 
‘‘(2) REPORTING
TO
NATIONAL
CLEARING-
HOUSE.—The Secretary, acting through the Service, 
shall also encourage Indian Tribes and Tribal Orga-
nizations receiving grants under this section to sub-
mit relevant, declassified project information to the 
national clearinghouse authorized under section 
701(b)(2) in order to better facilitate program per-
formance and improve suicide prevention, interven-
tion, and treatment services. 
‘‘(g) ANNUAL REPORT.—Each grant recipient shall 
submit to the Secretary an annual report that— 
‘‘(1) describes the number of telemental health 
services provided; and 
‘‘(2) includes any other information that the 
Secretary may require. 
‘‘(h) REPORT TO CONGRESS.—Not later than 270 
days after the termination of the demonstration project, 
the Secretary shall submit to the Committee on Indian Af-
fairs of the Senate and the Committee on Natural Re-
sources and Committee on Energy and Commerce of the 
House of Representatives a final report, based on the an-
nual reports provided by grant recipients under subsection 
(h), that— 
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283 
‘‘(1) describes the results of the projects funded 
by grants awarded under this section, including any 
data available which indicates the number of at-
tempted suicides; 
‘‘(2) evaluates the impact of the telemental 
health services funded by the grants in reducing the 
number of completed suicides among Indian youth; 
‘‘(3) evaluates whether the demonstration 
project should be— 
‘‘(A) expanded to provide more than 5 
grants; and 
‘‘(B) designated a permanent program; 
and 
‘‘(4) evaluates the benefits of expanding the 
demonstration project to include urban Indian orga-
nizations. 
‘‘(i) AUTHORIZATION OF APPROPRIATIONS.—There is 
authorized to be appropriated to carry out this section 
$1,500,000 for each of fiscal years 2010 through 2025. 
‘‘SEC. 709. INPATIENT AND COMMUNITY-BASED MENTAL 
HEALTH 
FACILITIES 
DESIGN, 
CONSTRUC-
TION, AND STAFFING. 
‘‘Not later than 1 year after the date of enactment 
of the Indian Health Care Improvement Act Amendments 
of 2009, the Secretary, acting through the Service, may 
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provide, in each area of the Service, not less than 1 inpa-
tient mental health care facility, or the equivalent, for In-
dians with behavioral health problems. For the purposes 
of this subsection, California shall be considered to be 2 
Area Offices, 1 office whose location shall be considered 
to encompass the northern area of the State of California 
and 1 office whose jurisdiction shall be considered to en-
compass the remainder of the State of California. The Sec-
retary shall consider the possible conversion of existing, 
underused Service hospital beds into psychiatric units to 
meet such need. 
‘‘SEC. 710. TRAINING AND COMMUNITY EDUCATION. 
‘‘(a) PROGRAM.—The Secretary, in cooperation with 
the Secretary of the Interior, shall develop and implement 
or assist Indian Tribes and Tribal Organizations to de-
velop and implement, within each Service Unit or tribal 
program, a program of community education and involve-
ment which shall be designed to provide concise and timely 
information to the community leadership of each tribal 
community. Such program shall include education about 
behavioral health issues to political leaders, Tribal judges, 
law enforcement personnel, members of tribal health and 
education boards, health care providers including tradi-
tional practitioners, and other critical members of each 
tribal community. Such program may also include commu-
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285 
nity-based training to develop local capacity and tribal 
community provider training for prevention, intervention, 
treatment, and aftercare. 
‘‘(b) INSTRUCTION.—The Secretary, acting through 
the Service, shall provide instruction in the area of behav-
ioral health issues, including instruction in crisis interven-
tion and family relations in the context of alcohol and sub-
stance abuse, child sexual abuse, youth alcohol and sub-
stance abuse, and the causes and effects of fetal alcohol 
disorders to appropriate employees of the Bureau of In-
dian Affairs and the Service, and to personnel in schools 
or programs operated under any contract with the Bureau 
of Indian Affairs or the Service, including supervisors of 
emergency shelters and halfway houses described in sec-
tion 4213 of the Indian Alcohol and Substance Abuse Pre-
vention and Treatment Act of 1986 (25 U.S.C. 2433). 
‘‘(c) TRAINING MODELS.—In carrying out the edu-
cation and training programs required by this section, the 
Secretary, in consultation with Indian Tribes, Tribal Or-
ganizations, Indian behavioral health experts, and Indian 
alcohol and substance abuse prevention experts, shall de-
velop and provide community-based training models. Such 
models shall address— 
‘‘(1) the elevated risk of alcohol and behavioral 
health problems faced by children of alcoholics; 
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286 
‘‘(2) 
the 
cultural, 
spiritual, 
and 
multigenerational aspects of behavioral health prob-
lem prevention and recovery; and 
‘‘(3) community-based and multidisciplinary 
strategies, including Systems of Care, for preventing 
and treating behavioral health problems. 
‘‘SEC. 711. BEHAVIORAL HEALTH PROGRAM. 
‘‘(a) INNOVATIVE PROGRAMS.—The Secretary, acting 
through the Service, consistent with section 701, may 
plan, develop, implement, and carry out programs to de-
liver innovative community-based behavioral health serv-
ices to Indians. 
‘‘(b) AWARDS; CRITERIA.—The Secretary may award 
a grant for a project under subsection (a) to an Indian 
Tribe or Tribal Organization and may consider the fol-
lowing criteria: 
‘‘(1) The project will address significant unmet 
behavioral health needs among Indians. 
‘‘(2) The project will serve a significant number 
of Indians. 
‘‘(3) The project has the potential to deliver 
services in an efficient and effective manner. 
‘‘(4) The Indian Tribe or Tribal Organization 
has the administrative and financial capability to ad-
minister the project. 
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‘‘(5) The project may deliver services in a man-
ner consistent with traditional health care practices. 
‘‘(6) The project is coordinated with, and avoids 
duplication of, existing services. 
‘‘(c) EQUITABLE TREATMENT.—For purposes of this 
subsection, the Secretary shall, in evaluating project appli-
cations or proposals, use the same criteria that the Sec-
retary uses in evaluating any other application or proposal 
for such funding. 
‘‘SEC. 712. FETAL ALCOHOL DISORDER PROGRAMS. 
‘‘(a) PROGRAMS.— 
‘‘(1) ESTABLISHMENT.—The Secretary, con-
sistent with section 701 and acting through the 
Service, is authorized to establish and operate fetal 
alcohol disorder programs as provided in this section 
for the purposes of meeting the health status objec-
tives specified in section 3. 
‘‘(2) USE OF FUNDS.— 
‘‘(A) IN
GENERAL.—Funding provided 
pursuant to this section shall be used for the 
following: 
‘‘(i) To develop and provide for Indi-
ans community and in-school training, edu-
cation, and prevention programs relating 
to fetal alcohol disorders. 
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‘‘(ii) To identify and provide behav-
ioral health treatment to high-risk Indian 
women and high-risk women pregnant with 
an Indian’s child. 
‘‘(iii) To identify and provide appro-
priate psychological services, educational 
and vocational support, counseling, advo-
cacy, and information to fetal alcohol dis-
order affected Indians and their families or 
caretakers. 
‘‘(iv) To develop and implement coun-
seling and support programs in schools for 
fetal alcohol disorder affected Indian chil-
dren. 
‘‘(v) To develop prevention and inter-
vention models which incorporate practi-
tioners of traditional health care practices, 
cultural values, and community involve-
ment. 
‘‘(vi) To develop, print, and dissemi-
nate education and prevention materials on 
fetal alcohol disorder. 
‘‘(vii) To develop and implement, in 
consultation with Indian Tribes, Tribal Or-
ganizations, and urban Indian organiza-
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tions, culturally sensitive assessment and 
diagnostic tools including dysmorphology 
clinics and multidisciplinary fetal alcohol 
disorder clinics for use in Indian commu-
nities and Urban Centers. 
‘‘(B) ADDITIONAL USES.—In addition to 
any purpose under subparagraph (A), funding 
provided pursuant to this section may be used 
for 1 or more of the following: 
‘‘(i) 
Early 
childhood 
intervention 
projects from birth on to mitigate the ef-
fects of fetal alcohol disorder among Indi-
ans. 
‘‘(ii) Community-based support serv-
ices for Indians and women pregnant with 
Indian children. 
‘‘(iii) Community-based housing for 
adult Indians with fetal alcohol disorder. 
‘‘(3) CRITERIA FOR APPLICATIONS.—The Sec-
retary shall establish criteria for the review and ap-
proval of applications for funding under this section. 
‘‘(b) SERVICES.—The Secretary, acting through the 
Service, shall— 
‘‘(1) develop and provide services for the pre-
vention, intervention, treatment, and aftercare for 
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those affected by fetal alcohol disorder in Indian 
communities; and 
‘‘(2) provide supportive services, including serv-
ices to meet the special educational, vocational, 
school-to-work transition, and independent living 
needs of adolescent and adult Indians with fetal al-
cohol disorder. 
‘‘(c) TASK FORCE.—The Secretary shall establish a 
task force to be known as the Fetal Alcohol Disorder Task 
Force to advise the Secretary in carrying out subsection 
(b). Such task force shall be composed of representatives 
from the following: 
‘‘(1) The National Institute on Drug Abuse. 
‘‘(2) The National Institute on Alcohol and Al-
coholism. 
‘‘(3) The Office of Substance Abuse Prevention. 
‘‘(4) The National Institute of Mental Health. 
‘‘(5) The Service. 
‘‘(6) The Office of Minority Health of the De-
partment of Health and Human Services. 
‘‘(7) The Administration for Native Americans. 
‘‘(8) The National Institute of Child Health 
and Human Development (NICHD). 
‘‘(9) The Centers for Disease Control and Pre-
vention. 
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‘‘(10) The Bureau of Indian Affairs. 
‘‘(11) Indian Tribes. 
‘‘(12) Tribal Organizations. 
‘‘(13) urban Indian organizations. 
‘‘(14) Indian fetal alcohol spectrum disorders 
experts. 
‘‘(d) APPLIED
RESEARCH
PROJECTS.—The Sec-
retary, acting through the Substance Abuse and Mental 
Health Services Administration, shall make grants to In-
dian Tribes, Tribal Organizations, and urban Indian orga-
nizations for applied research projects which propose to 
elevate the understanding of methods to prevent, inter-
vene, treat, or provide rehabilitation and behavioral health 
aftercare for Indians and urban Indians affected by fetal 
alcohol spectrum disorders. 
‘‘(e) FUNDING
FOR
URBAN
INDIAN
ORGANIZA-
TIONS.—Ten percent of the funds appropriated pursuant 
to this section shall be used to make grants to urban In-
dian organizations funded under title V. 
‘‘SEC. 713. CHILD SEXUAL ABUSE AND PREVENTION TREAT-
MENT PROGRAMS. 
‘‘(a) 
ESTABLISHMENT.—The 
Secretary, 
acting 
through the Service, shall establish, consistent with section 
701, in every Service Area, programs involving treatment 
for— 
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‘‘(1) victims of sexual abuse who are Indian 
children or children in an Indian household; and 
‘‘(2) perpetrators of child sexual abuse who are 
Indian or members of an Indian household. 
‘‘(b) USE OF FUNDS.—Funding provided pursuant to 
this section shall be used for the following: 
‘‘(1) To develop and provide community edu-
cation and prevention programs related to sexual 
abuse of Indian children or children in an Indian 
household. 
‘‘(2) To identify and provide behavioral health 
treatment to victims of sexual abuse who are Indian 
children or children in an Indian household, and to 
their family members who are affected by sexual 
abuse. 
‘‘(3) To develop prevention and intervention 
models which incorporate traditional health care 
practices, cultural values, and community involve-
ment. 
‘‘(4) To develop and implement culturally sen-
sitive assessment and diagnostic tools for use in In-
dian communities and Urban Centers. 
‘‘(5) To identify and provide behavioral health 
treatment to Indian perpetrators and perpetrators 
who are members of an Indian household— 
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‘‘(A) making efforts to begin offender and 
behavioral health treatment while the perpe-
trator is incarcerated or at the earliest possible 
date if the perpetrator is not incarcerated; and 
‘‘(B) providing treatment after the perpe-
trator is released, until it is determined that the 
perpetrator is not a threat to children. 
‘‘(c) COORDINATION.—The programs established 
under subsection (a) shall be carried out in coordination 
with programs and services authorized under the Indian 
Child Protection and Family Violence Prevention Act (25 
U.S.C. 3201 et seq.). 
‘‘SEC. 714. DOMESTIC AND SEXUAL VIOLENCE PREVENTION 
AND TREATMENT. 
‘‘(a) IN GENERAL.—The Secretary, in accordance 
with section 701, is authorized to establish in each Service 
Area programs involving the prevention and treatment 
of— 
‘‘(1) Indian victims of domestic violence or sex-
ual abuse; and 
‘‘(2) perpetrators of domestic violence or sexual 
abuse who are Indian or members of an Indian 
household. 
‘‘(b) USE OF FUNDS.—Funds made available to carry 
out this section shall be used— 
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‘‘(1) to develop and implement prevention pro-
grams and community education programs relating 
to domestic violence and sexual abuse; 
‘‘(2) to provide behavioral health services, in-
cluding victim support services, and medical treat-
ment (including examinations performed by sexual 
assault nurse examiners) to Indian victims of domes-
tic violence or sexual abuse; 
‘‘(3) to purchase rape kits; 
‘‘(4) to develop prevention and intervention 
models, which may incorporate traditional health 
care practices; and 
‘‘(5) to identify and provide behavioral health 
treatment to perpetrators who are Indian or mem-
bers of an Indian household. 
‘‘(c) TRAINING AND CERTIFICATION.— 
‘‘(1) IN GENERAL.—Not later than 1 year after 
the date of enactment of the Indian Health Care Im-
provement Act Amendments of 2009, the Secretary 
shall establish appropriate protocols, policies, proce-
dures, standards of practice, and, if not available 
elsewhere, training curricula and training and cer-
tification requirements for services for victims of do-
mestic violence and sexual abuse. 
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