Subtitle C—Optional Coverage of 
Legal Immigrants Under the 
Medicaid 
Program 
and 
Title 
XXI, and to Extend Eligibility to 
Certain Legal Residents 
SEC. 131. EQUAL ACCESS TO HEALTH COVERAGE FOR 
LEGAL IMMIGRANTS. 
(a) IN GENERAL.—Section 401(b)(1) of the Personal 
Responsibility and Work Opportunity Reconciliation Act 
of 1996 (8 U.S.C. 1611(b)(1)) is amended— 
(1) by striking subparagraph (A) and inserting 
the following: 
‘‘(A) Medical assistance under title XIX of 
the Social Security Act.’’; and 
(2) by adding at the end the following: 
‘‘(F) Child health assistance under title 
XXI of the Social Security Act.’’. 
(b) CONFORMING AMENDMENTS.— 
(1) Section 402(b) of the Personal Responsi-
bility and Work Opportunity Reconciliation Act of 
1996 (8 U.S.C. 1612(b)) is amended— 
(A) in paragraph (2)— 
(i) in subparagraph (A)— 
(I) by striking clause (i);
(II) by redesignating clause (ii) 
as subparagraph (A) and realigning 
the margins accordingly; and 
(III) by redesignating subclauses 
(I) through (V) of subparagraph (A), 
as so redesignated, as clauses (i) 
through (v), respectively and realign-
ing the margins accordingly; and 
(ii) by striking subparagraphs (E) and 
(F); and 
(B) in paragraph (3), by striking subpara-
graph (C). 
(2) Section 403 of the Personal Responsibility 
and Work Opportunity Reconciliation Act of 1996 (8 
U.S.C. 1613)) is amended— 
(A) in subsection (c), by adding at the end 
the following: 
‘‘(M) Child health assistance provided 
under title XXI of the Social Security Act.’’; 
and 
(B) in subsection (d)(1), by striking ‘‘pro-
grams specified in subsections (a)(3) and 
(b)(3)(C)’’ and inserting ‘‘program specified in 
subsection (a)(3)’’.
(3) Section 421 of the Personal Responsibility 
and Work Opportunity Reconciliation Act of 1996 (8 
U.S.C. 1631)) is amended by adding at the end the 
following: 
‘‘(g) EXCEPTIONS.—This section shall not apply to— 
‘‘(1) medical assistance provided under a State 
plan approved under title XIX of the Social Security 
Act; and 
‘‘(2) child health assistance provided under title 
XXI of the Social Security Act.’’. 
(4) Section 423(d) of the Personal Responsi-
bility and Work Opportunity Reconciliation Act of 
1996 is amended by adding at the end the following: 
‘‘(12) Child health assistance provided under 
title XXI of the Social Security Act.’’. 
(c) EFFECTIVE DATE.— 
(1) IN GENERAL.—Except as provided in para-
graph (2), the amendments made by this section 
take effect on the date of enactment of this Act and 
apply to medical assistance provided under title XIX 
of the Social Security Act and child health assist-
ance provided under title XXI of the Social Security 
Act on or after that date. 
(2) REQUIREMENTS FOR SPONSOR’S AFFIDAVIT 
OF SUPPORT.—Section 423(d) of the Personal Re-
sponsibility and Work Opportunity Reconciliation 
Act of 1996 shall be applied as if the amendments 
made by this Act were enacted on December 1, 
2002. 
SEC. 132. EXCEPTION FOR CITIZENS OF FREELY ASSOCI-
ATED STATES. 
(a) IN GENERAL.—Section 402(a)(2) of the Personal 
Responsibility and Work Opportunity Reconciliation Act 
of 1996 (8 U.S.C. 1612(a)(2)) is amended by adding at 
the end the following: 
‘‘(M) EXCEPTION FOR CITIZENS OF FREE-
LY ASSOCIATED STATES.—With respect to eligi-
bility for benefits for the specified Federal pro-
grams described in paragraph (3), paragraph 
(1) shall not apply to any individual who law-
fully resides in the United States (including ter-
ritories and possessions of the United States) in 
accordance with— 
‘‘(i) section 141 of the Compact of 
Free Association between the Government 
of the United States and the Government 
of the Federated States of Micronesia, ap-
proved by Congress in the Compact of 
Free Association Amendments Act of 
2003;
‘‘(ii) section 141 of the Compact of 
Free Association between the Government 
of the United States and the Government 
of the Republic of the Marshall Islands, 
approved by Congress in the Compact of 
Free Association Amendments Act of 
2003; or 
‘‘(iii) section 141 of the Compact of 
Free Association between the Government 
of the United States and the Government 
of Palau, approved by Congress in Public 
Law 99–658 (100 Stat. 3672).’’. 
(b) MEDICAID EXCEPTION.—Section 402(b)(2) of the 
Personal Responsibility and Work Opportunity Reconcili-
ation Act of 1996 (8 U.S.C. 1612(b)(2)) is amended by 
adding at the end the following: 
‘‘(G) MEDICAID
EXCEPTIONS
FOR
CITI-
ZENS OF FREELY ASSOCIATED STATES.—With 
respect to eligibility for benefits for the pro-
grams defined in subparagraphs (A) and (C) of 
paragraph (3) (relating to medicaid), paragraph 
(1) shall not apply to any individual who law-
fully resides in the United States (including ter-
ritories and possessions of the United States) in
accordance with a Compact of Free Association 
referred to in subsection (a)(2)(M).’’. 
(c) QUALIFIED ALIEN.—Section 431(b) of the Per-
sonal Responsibility and Work Opportunity Reconciliation 
Act of 1996 (8 U.S.C. 1641(b)) is amended— 
(1) in paragraph (6), by striking ‘‘or’’ at the 
end; 
(2) in paragraph (7), by striking the period at 
the end and inserting ‘‘; or’’; and 
(3) by adding at the end the following: 
‘‘(8) an individual who lawfully resides in the 
United States (including territories and possessions 
of the United States) in accordance with a Compact 
of 
Free 
Association 
referred 
to 
in 
section 
402(a)(2)(M).’’. 
(d) FINANCIAL TREATMENT UNDER MEDICAID.— 
Section 1108 of the Social Security Act (42 U.S.C. 1308) 
is amended— 
(1) in subsection (f), by striking ‘‘subsection 
(g)’’ and inserting ‘‘subsections (g) and (h)’’; and 
(2) by adding at the end the following new sub-
section: 
‘‘(h) The limitations of subsections (f) and (g) shall 
not apply with respect to medical assistance provided to 
an individual described in section 431(b)(8) of the Per-
sonal Responsibility and Work Opportunity Reconciliation 
Act of 1996.’’. 
Subtitle D—Indian Healthcare 
Funding 
CHAPTER 1—GUARANTEED FUNDING 
SEC. 141. GUARANTEED ADEQUATE FUNDING FOR INDIAN 
HEALTHCARE. 
Section 825 of the Indian Health Care Improvement 
Act (25 U.S.C. 1680o) is amended to read as follows: 
‘‘SEC. 825. FUNDING. 
‘‘(a) IN GENERAL.—Notwithstanding any other pro-
vision of law, not later than 30 days after the date of en-
actment of this section, on October 1, 2007, and on each 
October 1 thereafter, out of any funds in the Treasury 
not otherwise appropriated, the Secretary of the Treasury 
shall transfer to the Secretary to carry out this title the 
amount determined under subsection (d). 
‘‘(b) USE AND AVAILABILITY.— 
‘‘(1) IN
GENERAL.—An amount transferred 
under subsection (a)— 
‘‘(A) shall remain available until expended; 
and 
‘‘(B) shall be used to carry out any pro-
grams, functions, and activities relating to clin-
ical services (as defined in paragraph (2)) of 
the Service and Service units. 
‘‘(2) CLINICAL SERVICES DEFINED.—For pur-
poses of paragraph (1)(B), the term ‘clinical serv-
ices’ includes all programs of the Indian Health 
Service which are funded directly or under the au-
thority of the Indian Self-Determination and Edu-
cation Assistance Act, for the purposes of— 
‘‘(A) clinical care, including inpatient care, 
outpatient care (including audiology, clinical eye 
and vision care), primary care, secondary and 
tertiary care, and long term care; 
‘‘(B) preventive health, including mam-
mography and other cancer screening; 
‘‘(C) dental care; 
‘‘(D) mental and behavioral health, includ-
ing community mental and behavioral health 
services, inpatient mental and behavioral health 
services, dormitory mental and behavioral 
health services, therapeutic and residential 
treatment centers; 
‘‘(E) emergency medical services; 
‘‘(F) treatment and control of, and reha-
bilitative care related to, alcoholism and drug
abuse (including fetal alcohol syndrome) among 
Indians; 
‘‘(G) accident prevention programs; 
‘‘(H) home healthcare; 
‘‘(I) community health representatives; 
‘‘(J) maintenance and repair; and 
‘‘(K) traditional healthcare practices and 
training of traditional healthcare practitioners. 
‘‘(c) RECEIPT
AND ACCEPTANCE.—The Secretary 
shall be entitled to receive, shall accept, and shall use to 
carry out this title the funds transferred under subsection 
(a), without further appropriation. 
‘‘(d) AMOUNT.—The amount referred to in sub-
section (a) is— 
‘‘(1) for fiscal year 2006, the amount equal to 
390 percent of the amount obligated by the Service 
during fiscal year 2002 for the purposes described in 
subsection (b)(2); and 
‘‘(2) for fiscal year 2007 and each fiscal year 
thereafter, the amount equal to the product obtained 
by multiplying— 
‘‘(A) the number of Indians served by the 
Service as of September 30 of the preceding the 
fiscal year; and
‘‘(B) the per capita baseline amount, as 
determined under subsection (e). 
‘‘(e) PER CAPITA BASELINE AMOUNT.— 
‘‘(1) IN GENERAL.—For the purpose of sub-
section (d)(2)(B), the per capita baseline amount 
shall be equal to the sum of— 
‘‘(A) the quotient obtained by dividing— 
‘‘(i) the amount specified in sub-
section (d)(1); by 
‘‘(ii) the number of Indians served by 
the Service as of September 30, 2002; and 
‘‘(B) any applicable increase under para-
graph (2). 
‘‘(2) INCREASE.—For each fiscal year, the Sec-
retary shall provide a percentage increase (rounded 
to the nearest dollar) in the per capita baseline 
amount equal to the percentage by which— 
‘‘(A) the Consumer Price Index for all 
Urban Consumers published by the Department 
of Labor (relating to the United States city av-
erage for medical care and not seasonally ad-
justed) for the 1-year period ending on the 
June 30 of the fiscal year preceding the fiscal 
year for which the increase is made; exceeds
‘‘(B) that Consumer Price Index for the 1- 
year period preceding the 1-year period de-
scribed in subparagraph (A).’’. 
CHAPTER 2—INDIAN HEALTHCARE 
PROGRAMS 
SEC. 145. PROGRAMS OPERATED BY INDIAN TRIBES AND 
TRIBAL ORGANIZATIONS. 
The Service shall provide funds for healthcare pro-
grams and facilities operated by Indian tribes and tribal 
organizations under funding agreements with the Service 
entered into under the Indian Self-Determination and 
Education Assistance Act on the same basis as such funds 
are provided to programs and facilities operated directly 
by the Service. 
SEC. 146. LICENSING. 
Healthcare professionals employed by Indian tribes 
and tribal organizations to carry out agreements under the 
Indian Self-Determination and Education Assistance Act, 
shall, if licensed in any State, be exempt from the licensing 
requirements of the State in which the agreement is per-
formed. 
SEC. 147. AUTHORIZATION FOR EMERGENCY CONTRACT 
HEALTH SERVICES. 
With respect to an elderly Indian or an Indian with 
a disability receiving emergency medical care or services
from a non-Service provider or in a non-Service facility 
under the authority of the Indian Health Care Improve-
ment Act, the time limitation (as a condition of payment) 
for notifying the Service of such treatment or admission 
shall be 30 days. 
SEC. 148. PROMPT ACTION ON PAYMENT OF CLAIMS. 
(a) REQUIREMENT.—The Service shall respond to a 
notification of a claim by a provider of a contract care 
service with either an individual purchase order or a denial 
of the claim within 5 working days after the receipt of 
such notification. 
(b) FAILURE TO RESPOND.—If the Service fails to 
respond to a notification of a claim in accordance with 
subsection (a), the Service shall accept as valid the claim 
submitted by the provider of a contract care service. 
(c) PAYMENT.—The Service shall pay a valid contract 
care service claim within 30 days after the completion of 
the claim. 
SEC. 149. LIABILITY FOR PAYMENT. 
(a) NO LIABILITY.—A patient who receives contract 
healthcare services that are authorized by the Service shall 
not be liable for the payment of any charges or costs asso-
ciated with the provision of such services. 
(b) NOTIFICATION.—The Secretary shall notify a 
contract care provider and any patient who receives con-
tract healthcare services authorized by the Service that 
such patient is not liable for the payment of any charges 
or costs associated with the provision of such services. 
(c) LIMITATION.—Following receipt of the notice pro-
vided under subsection (b), or, if a claim has been deemed 
accepted under section 154(b), the provider shall have no 
further recourse against the patient who received the serv-
ices involved. 
SEC. 150. HEALTH SERVICES FOR INELIGIBLE PERSONS. 
(a) INELIGIBLE PERSONS.— 
(1) IN GENERAL.—Any individual who— 
(A) has not attained 19 years of age; 
(B) is the natural or adopted child, step- 
child, foster-child, legal ward, or orphan of an 
eligible Indian; and 
(C) is not otherwise eligible for the health 
services provided by the Service, shall be eligible 
for all health services provided by the Service 
on the same basis and subject to the same rules 
that apply to eligible Indians until such indi-
vidual attains 19 years of age. The existing and 
potential health needs of all such individuals 
shall be taken into consideration by the Service 
in determining the need for, or the allocation 
of, the health resources of the Service. If such
an individual has been determined to be legally 
incompetent prior to attaining 19 years of age, 
such individual shall remain eligible for such 
services until one year after the date such dis-
ability has been removed. 
(2) SPOUSES.—Any spouse of an eligible Indian 
who is not an Indian, or who is of Indian descent 
but not otherwise eligible for the health services pro-
vided by the Service, shall be eligible for such health 
services if all of such spouses or spouses who are 
married to members of the Indian tribe being served 
are made eligible, as a class, by an appropriate reso-
lution of the governing body of the Indian tribe or 
tribal organization providing such services. The 
health needs of persons made eligible under this 
paragraph shall not be taken into consideration by 
the Service in determining the need for, or allocation 
of, its health resources. 
(b) PROGRAMS AND SERVICES.— 
(1) PROGRAMS.— 
(A) IN
GENERAL.—The Secretary may 
provide health services under this subsection 
through health programs operated directly by 
the Service to individuals who reside within the 
service area of a service unit and who are not
eligible for such health services under any other 
subsection of this section or under any other 
provision of law if— 
(i) the Indian tribe (or, in the case of 
a multi-tribal service area, all the Indian 
tribes) served by such service unit requests 
such provision of health services to such 
individuals; and 
(ii) the Secretary and the Indian tribe 
or tribes have jointly determined that— 
(I) the provision of such health 
services will not result in a denial or 
diminution of health services to eligi-
ble Indians; and 
(II) there is no reasonable alter-
native health program or services, 
within or without the service area of 
such service unit, available to meet 
the health needs of such individuals. 
(B) FUNDING AGREEMENTS.—In the case 
of health programs operated under a funding 
agreement entered into under the Indian Self- 
Determination and Educational Assistance Act, 
the governing body of the Indian tribe or tribal 
organization providing health services under
such funding agreement is authorized to deter-
mine whether health services should be provided 
under such funding agreement to individuals 
who are not eligible for such health services 
under any other subsection of this section or 
under any other provision of law. In making 
such determinations, the governing body of the 
Indian tribe or tribal organization shall take 
into account the considerations described in 
subparagraph (A)(ii). 
(2) LIABILITY FOR PAYMENT.— 
(A) 
IN
GENERAL.—Persons 
receiving 
health services provided by the Service by rea-
son of this subsection shall be liable for pay-
ment of such health services under a schedule 
of charges prescribed by the Secretary which, in 
the judgment of the Secretary, results in reim-
bursement in an amount not less than the ac-
tual cost of providing the health services. Not-
withstanding section 1880 of the Social Secu-
rity Act or any other provision of law, amounts 
collected under this subsection, including medi-
care or medicaid reimbursements under titles 
XVIII and XIX of the Social Security Act, shall 
be credited to the account of the program pro-
viding the service and shall be used solely for 
the provision of health services within that pro-
gram. Amounts collected under this subsection 
shall be available for expenditure within such 
program for not to exceed 1 fiscal year after 
the fiscal year in which collected. 
(B) SERVICES FOR INDIGENT PERSONS.— 
Health services may be provided by the Sec-
retary through the Service under this sub-
section to an indigent person who would not be 
eligible for such health services but for the pro-
visions of paragraph (1) only if an agreement 
has been entered into with a State or local gov-
ernment under which the State or local govern-
ment agrees to reimburse the Service for the 
expenses incurred by the Service in providing 
such health services to such indigent person. 
(3) SERVICE AREAS.— 
(A) SERVICE TO ONLY ONE TRIBE.—In the 
case of a service area which serves only one In-
dian tribe, the authority of the Secretary to 
provide health services under paragraph (1)(A) 
shall terminate at the end of the fiscal year suc-
ceeding the fiscal year in which the governing
body of the Indian tribe revokes its concurrence 
to the provision of such health services. 
(B) MULTI-TRIBAL AREAS.—In the case of 
a multi-tribal service area, the authority of the 
Secretary to provide health services under para-
graph (1)(A) shall terminate at the end of the 
fiscal year succeeding the fiscal year in which at 
least 51 percent of the number of Indian tribes 
in the service area revoke their concurrence to 
the provision of such health services. 
(c) PURPOSE FOR PROVIDING SERVICES.—The Serv-
ice may provide health services under this subsection to 
individuals who are not eligible for health services provided 
by the Service under any other subsection of this section 
or under any other provision of law in order to— 
(1) achieve stability in a medical emergency; 
(2) prevent the spread of a communicable dis-
ease or otherwise deal with a public health hazard; 
(3) provide care to non-Indian women pregnant 
with an eligible Indian’s child for the duration of the 
pregnancy through post partum; or 
(4) provide care to immediate family members 
of an eligible person if such care is directly related 
to the treatment of the eligible person.