I
107TH CONGRESS
1ST SESSION
H. R. 1662
To improve the implementation of the Federal responsibility for the care
and education of Indian people by improving the services and facilities
of Federal Indian health programs and encouraging maximum participa-
tion of Indians in such programs, and for other purposes.
IN THE HOUSE OF REPRESENTATIVES
MAY 1, 2001
Mr. GEORGE MILLER of California (for himself, Mr. PALLONE, Mr. RAHALL,
Mr. KILDEE, Mr. HAYWORTH, Mr. WAXMAN, Mr. OBERSTAR, Mr. FIL-
NER, Mr. BONIOR, Mrs. MINK of Hawaii, Mr. CARSON of Oklahoma, Mr.
LARSEN of Washington, Mr. MCDERMOTT, Ms. LEE, Ms. MILLENDER-
MCDONALD, Mr. BACA, Mr. ABERCROMBIE, Mrs. BONO, Mr. KIND, Mr.
FRANK, Mr. STUPAK, Mr. FROST, Mr. KENNEDY of Rhode Island, Mr.
UDALL of New Mexico, Mr. INSLEE, Mr. NETHERCUTT, Mr. BALDACCI,
Mr. FALEOMAVAEGA, Mr. BLUMENAUER, Ms. LOFGREN, Mr. LANTOS,
Mr. JEFFERSON, Mr. CANNON, Mr. CONDIT, Mr. TOWNS, Mr.
BLAGOJEVICH, Mr. TAYLOR of North Carolina, Mr. WATKINS, Mr.
ALLEN, Mrs. NAPOLITANO, Mr. HINCHEY, Ms. MCCOLLUM, Mr. UDALL
of Colorado, Mr. LUCAS of Oklahoma, Mr. CAMP, Ms. KILPATRICK, and
Mr. HONDA) introduced the following bill; which was referred to the Com-
mittee on Resources, and in addition to the Committees on Energy and
Commerce, Ways and Means, and Government Reform, for a period to
be subsequently determined by the Speaker, in each case for consider-
ation of such provisions as fall within the jurisdiction of the committee
concerned
A BILL
To improve the implementation of the Federal responsibility
for the care and education of Indian people by improving
the services and facilities of Federal Indian health pro-
‘‘Sec. 114. Advanced training and research.
‘‘Sec. 115. Quentin B. Burdick American Indians into Nursing Program.
‘‘Sec. 116. Tribal cultural orientation.
‘‘Sec. 117. INMED program.
‘‘Sec. 118. Health training programs of community colleges.
‘‘Sec. 119. Retention bonus.
‘‘Sec. 120. Nursing residency program.
‘‘Sec. 121. Community health aide program for Alaska.
‘‘Sec. 122. Tribal health program administration.
‘‘Sec. 123. Health professional chronic shortage demonstration project.
‘‘Sec. 124. Treatment of scholarships for certain purposes.
‘‘Sec. 125. National health service corps.
‘‘Sec. 126. Substance abuse counselor education demonstration project.
‘‘Sec. 127. Mental health training and community education programs.
‘‘Sec. 128. Authorization of appropriations.
‘‘TITLE II—HEALTH SERVICES
‘‘Sec. 201. Indian health care improvement fund.
‘‘Sec. 202. Catastrophic health emergency fund.
‘‘Sec. 203. Health promotion and disease prevention services.
‘‘Sec. 204. Diabetes prevention, treatment, and control.
‘‘Sec. 205. Shared services.
‘‘Sec. 206. Health services research.
‘‘Sec. 207. Mammography and other cancer screening.
‘‘Sec. 208. Patient travel costs.
‘‘Sec. 209. Epidemiology centers.
‘‘Sec. 210. Comprehensive school health education programs.
‘‘Sec. 211. Indian youth program.
‘‘Sec. 212. Prevention, control, and elimination of communicable and infectious
diseases.
‘‘Sec. 213. Authority for provision of other services.
‘‘Sec. 214. Indian women’s health care.
‘‘Sec. 215. Environmental and nuclear health hazards.
‘‘Sec. 216. Arizona as a contract health service delivery area.
‘‘Sec. 217. California contract health services program.
‘‘Sec. 218. California as a contract health service delivery area.
‘‘Sec. 219. Contract health services for the Trenton service area.
‘‘Sec. 220. Programs operated by Indian tribes and tribal organizations.
‘‘Sec. 221. Licensing.
‘‘Sec. 222. Authorization for emergency contract health services.
‘‘Sec. 223. Prompt action on payment of claims.
‘‘Sec. 224. Liability for payment.
‘‘Sec. 225. Authorization of appropriations.
‘‘TITLE III—FACILITIES
‘‘Sec. 301. Consultation; construction and renovation of facilities; reports.
‘‘Sec. 302. Safe water and sanitary waste disposal facilities.
‘‘Sec. 303. Preference to Indians and Indian firms.
‘‘Sec. 304. Expenditure of nonservice funds for renovation.
‘‘Sec. 305. Funding for the construction, expansion, and modernization of small
ambulatory care facilities.
‘‘Sec. 306. Indian health care delivery demonstration project.
‘‘Sec. 307. Land transfer.
‘‘Sec. 308. Leases.
‘‘Sec. 309. Loans, loan guarantees, and loan repayment.
‘‘Sec. 310. Tribal leasing.
‘‘Sec. 311. Indian health service/tribal facilities joint venture program.
‘‘Sec. 312. Location of facilities.
‘‘Sec. 313. Maintenance and improvement of health care facilities.
‘‘Sec. 314. Tribal management of federally owned quarters.
‘‘Sec. 315. Applicability of buy American requirement.
‘‘Sec. 316. Other funding for facilities.
‘‘Sec. 317. Authorization of appropriations.
‘‘TITLE IV—ACCESS TO HEALTH SERVICES
‘‘Sec. 401. Treatment of payments under medicare program.
‘‘Sec. 402. Treatment of payments under medicaid program.
‘‘Sec. 403. Report.
‘‘Sec. 404. Grants to and funding agreements with the service, Indian tribes,
tribal organizations, and urban Indian organizations.
‘‘Sec. 405. Direct billing and reimbursement of medicare, medicaid, and other
third-party payors.
‘‘Sec. 406. Reimbursement from certain third parties of costs of health services.
‘‘Sec. 407. Crediting of reimbursements.
‘‘Sec. 408. Purchasing health care coverage.
‘‘Sec. 409. Indian health service, department of veterans affairs, and other Fed-
eral agency health facilities and services sharing.
‘‘Sec. 410. Payor of last resort.
‘‘Sec. 411. Payment or reimbursement for services.
‘‘Sec. 412. Tuba city demonstration project.
‘‘Sec. 413. Access to Federal insurance.
‘‘Sec. 414. Consultation and rulemaking.
‘‘Sec. 415. Limitation on secretary’s waiver authority.
‘‘Sec. 416. Children’s health insurance program funds.
‘‘Sec. 417. Waiver of medicare and medicaid sanctions.
‘‘Sec. 418. Safe harbor.
‘‘Sec. 419. Cost sharing.
‘‘Sec. 420. Managed care.
‘‘Sec. 421. Navajo nation medicaid agency.
‘‘Sec. 422. Indian advisory committees.
‘‘Sec. 423. Limitation on charges.
‘‘Sec. 424. Authorization of appropriations.
‘‘TITLE V—HEALTH SERVICES FOR URBAN INDIANS
‘‘Sec. 501. Purpose.
‘‘Sec. 502. Contracts with, and grants to, urban Indian organizations.
‘‘Sec. 503. Contracts and grants for the provision of health care and referral
services.
‘‘Sec. 504. Contracts and grants for the determination of unmet health care
needs.
‘‘Sec. 505. Evaluations; renewals.
‘‘Sec. 506. Other contract and grant requirements.
‘‘Sec. 507. Reports and records.
‘‘Sec. 508. Limitation on contract authority.
‘‘Sec. 509. Facilities.
‘‘Sec. 510. Office of urban Indian health.
‘‘Sec. 511. Grants for alcohol and substance abuse related services.
‘‘Sec. 512. Treatment of certain demonstration projects.
‘‘Sec. 513. Urban NIAAA transferred programs.
‘‘Sec. 514. Consultation with urban Indian organizations.
‘‘Sec. 515. Federal tort claims act coverage.
‘‘Sec. 516. Urban youth treatment center demonstration.
‘‘Sec. 517. Use of Federal government facilities and sources of supply.
‘‘Sec. 518. Grants for diabetes prevention, treatment, and control.
‘‘Sec. 519. Community health representatives.
‘‘Sec. 520. Regulations.
‘‘Sec. 521. Authorization of appropriations.
‘‘TITLE VI—ORGANIZATIONAL IMPROVEMENTS
‘‘Sec. 601. Establishment of the Indian health service as an agency of the pub-
lic health service.
‘‘Sec. 602. Automated management information system.
‘‘Sec. 603. Authorization of appropriations.
‘‘TITLE VII—BEHAVIORAL HEALTH PROGRAMS
‘‘Sec. 701. Behavioral health prevention and treatment services.
‘‘Sec. 702. Memoranda of agreement with the department of the interior.
‘‘Sec. 703. Comprehensive behavioral health prevention and treatment program.
‘‘Sec. 704. Mental health technician program.
‘‘Sec. 705. Licensing requirement for mental health care workers.
‘‘Sec. 706. Indian women treatment programs.
‘‘Sec. 707. Indian youth program.
‘‘Sec. 708. Inpatient and community-based mental health facilities design, con-
struction, and staffing.
‘‘Sec. 709. Training and community education.
‘‘Sec. 710. Behavioral health program.
‘‘Sec. 711. Fetal alcohol disorder funding.
‘‘Sec. 712. Child sexual abuse and prevention treatment programs.
‘‘Sec. 713. Behavioral health research.
‘‘Sec. 714. Definitions.
‘‘Sec. 715. Authorization of appropriations.
‘‘TITLE VIII—MISCELLANEOUS
‘‘Sec. 801. Reports.
‘‘Sec. 802. Regulations.
‘‘Sec. 803. Plan of implementation.
‘‘Sec. 804. Availability of funds.
‘‘Sec. 805. Limitation on use of funds appropriated to the Indian health serv-
ice.
‘‘Sec. 806. Eligibility of California Indians.
‘‘Sec. 807. Health services for ineligible persons.
‘‘Sec. 808. Reallocation of base resources.
‘‘Sec. 809. Results of demonstration projects.
‘‘Sec. 810. Provision of services in Montana.
‘‘Sec. 811. Moratorium.
‘‘Sec. 812. Tribal employment.
‘‘Sec. 813. Prime vendor.
‘‘Sec. 814. Severability provisions.
‘‘Sec. 815. Establishment of national bipartisan commission on Indian health
care entitlement.
‘‘Sec. 816. Appropriations; availability.
‘‘Sec. 817. Authorization of appropriations.
‘‘SEC. 2. FINDINGS.
‘‘The Congress finds the following:
‘‘(1) Federal delivery of health services and
funding of tribal and urban Indian health programs
to maintain and improve the health of the Indians
are consonant with and required by the Federal Gov-
ernment’s historical and unique legal relationship, as
reflected in the Constitution, treaties, Federal stat-
utes and the course of dealings of the United States
with Indian tribes and the United States resulting
Government to Government and trust responsibility
and obligations to the American Indian people.
‘‘(2) From the time of European occupation
and colonization through the 20th century policies
and practices of the United States caused and/or
contributed to the severe health conditions of Indi-
ans.
‘‘(3) Indian tribes, have, through the cession of
over 400,000,000 acres of land, to the United States
in exchange for promises, often reflected in treaties,
of health care secured a de facto contract which en-
titles Indians to health care in perpetuity, based on
the moral legal and historic obligation of the United
States.
‘‘(4) The population growth of the Indian peo-
ple that began in the later part of the 20th century
increases the need for Federal health care services.
‘‘(5) A major national goal of the United States
is to provide the quantity and quality of health serv-
ices which will permit the health status of Indians
regardless of where they live to be raised to the
highest possible level that is no less than that of the
general population and to provide for the maximum
participation of Indian tribes, tribal organizations,
and urban Indian organizations in the planning, de-
livery and management of those services.
‘‘(6) Federal health services to Indians have re-
sulted in a reduction in the prevalence and incidence
of illnesses among, and unnecessary and premature
deaths of, Indians.
‘‘(7) Despite such services, the unmet health
needs of the American Indian people remain alarm-
ingly severe, and even continue to decline, and the
health status of Indians is far below the health sta-
tus of the general population of the United States.
‘‘(8) The disparity to be addressed is formi-
dable. In death rates, for example, Indian people
suffer a death rate for diabetes mellitus that is 249
percent higher than the all races rate for the United
States, a pneumonia and influenza death rate 71
percent greater, a tuberculosis death rate that is
533 percent greater, and a death rate from alco-
holism that is 627 percent higher than that of the
all races United States rate.
‘‘SEC. 3. DECLARATION OF HEALTH OBJECTIVES.
‘‘(a) The Congress hereby declares that it is the pol-
icy of this Nation, in fulfillment of its special trust respon-
sibilities and legal obligations to the American Indian
people—
‘‘(1) to assure the highest possible health status
for Indians and to provide all resources necessary to
effect that policy;
‘‘(2) to raise the health status of Indians by the
year 2011 to at least the levels set forth in the goals
contained within the Healthy People 2000 or suc-
cessor standards;
‘‘(3) to the greatest extent possible, to allow In-
dian people to set their own health care priorities
and establish goals that reflect their unmet needs;
‘‘(4) to increase the proportion of all degrees in
the health professions and allied and associated
health professions awarded to Indians so that the
proportion of Indian health professionals in each ge-
ographic service area is raised to at least the level
of that of the general population;
‘‘(5) to require meaningful consultation with In-
dian tribes, Indian organizations, and urban Indian
organizations to implement this Act and the national
policy of Indian self-determination; and
‘‘(6) to provide for health care programs and
facilities operated by Tribes and tribal organizations
in amounts that are not less funds than are provided
to programs and facilities operated directly by the
Service.
‘‘SEC. 4. DEFINITIONS.
‘‘For purposes of this Act:
‘‘(1) The term ‘accredited and accessible’ means
a community college or other appropriate entity on
or near a Reservation and accredited by a national
or regional organization with accrediting authority.
‘‘(2) The term ‘Area Office’ mean an adminis-
trative entity including a program office, within the
Indian Health Service through which services and
funds are provided to the service units within a de-
fined geographic area.
‘‘(3) The term ‘contract health service’ means
health services provided at the expense of the Serv-
ice, Indian tribe or tribal organization from public or
private medical providers or hospitals, other than
those funded under the Indian Self-Determination
and Education Assistance Act.
‘‘(4) The term ‘Department’ means, unless oth-
erwise designated, the Department of Health and
Human Services.
‘‘(5) The term ‘Director’ means the Director of
the Indian Health Service.
‘‘(6) The term ‘disease prevention’ is the reduc-
tion, limitation, and prevention of disease and its
complications and reduction in the consequences of
such diseases including, but not limited to—
‘‘(A) controlling—
‘‘(i) development of diabetes;
‘‘(ii) high blood pressure;
‘‘(iii) infectious agents;
‘‘(iv) injuries;
‘‘(v) occupational hazards and disabil-
ities;
‘‘(vi) sexually transmittable diseases;
and
‘‘(vii) toxic agents; and
‘‘(B) providing—
‘‘(i) fluoridation of water; and
‘‘(ii) immunizations.
‘‘(7) The term ‘fund’ or ‘funding’ means the
transfer of moneys from the Department to any eli-
gible entity or individual under this Act by any legal
means, including funding agreements, contracts,
memoranda of understanding, Buy Indian Act con-
tracts or otherwise.
‘‘(8) The term ‘funding agreement’ means any
agreement to transfer funds for the planning, con-
duct, and administration of programs, functions,
services and activities to Tribes and tribal organiza-
tions from the Secretary under the Indian Self-De-
termination and Education Assistance Act.
‘‘(9) The term ‘health profession’ means
allopathic medicine, family medicine, internal medi-
cine, pediatrics, geriatric medicine, obstetrics and
gynecology, podiatric medicine, nursing, public
health nursing, dentistry, psychiatry, osteopathy, op-
tometry, pharmacy, psychology, public health, social
work, marriage and family therapy, chiropractic
medicine, environmental health and engineering, and
allied health professions, or any other health profes-
sion.
‘‘(10) The ‘health promotion’ means fostering
social, economic, environmental, and personal factors
conducive to health, including raising people’s
awareness about health matters and enabling them
to cope with health problems by increasing their
knowledge and providing them with valid informa-
tion; encouraging adequate and appropriate diet, ex-
ercise, and enough sleep; promoting education and
work in conformity with physical and mental capac-
ity; making available suitable housing, safe water,
and sanitary facilities; improving the physical, eco-
nomic, cultural, psychological, and social environ-
ment; and promoting adequate opportunity for spir-
itual, religious, and traditional practices; and ade-
quate and appropriate programs including, but not
limited to—
‘‘(A) abuse prevention (mental and phys-
ical);
‘‘(B) community health;
‘‘(C) community safety;
‘‘(D) consumer health education;
‘‘(E) diet and nutrition;
‘‘(F) disease prevention (communicable,
immunizations, HIV/AIDS);
‘‘(G) environmental health;
‘‘(H) exercise and physical fitness;
‘‘(I) fetal alcohol disorders;
‘‘(J) first aid and CPR education;
‘‘(K) human growth and development;
‘‘(L) injury prevention and personal safety;
‘‘(M) mental health (emotional, self-worth);
‘‘(N) personal health and wellness prac-
tices;
‘‘(O) personal capacity building;
‘‘(P) prenatal, pregnancy, and infant care;
‘‘(Q) psychological well-being;
‘‘(R) reproductive health (family planning);
‘‘(S) safe and adequate water;
‘‘(T) safe housing;
‘‘(U) safe work environments;
‘‘(V) stress control;
‘‘(W) substance abuse;
‘‘(X) sanitary facilities;
‘‘(Y) tobacco use cessation and reduction;
‘‘(Z) violence prevention; and
‘‘(AA) such other activities identified by
the Indian Health Service, or an Indian tribe or
tribal organization, to promote achievement of
any of the objectives described in section 3(b).
‘‘(11) The term ‘Indians’ or ‘Indian’ shall have
the same meaning as provided in the Indian Self-De-
termination and Education Assistance Act.
‘‘(12) The term ‘Indian health program’ means
any health program or facility funded, in whole or
part, by the Service for the benefit of Indians and
administered—
‘‘(i) directly by the Service;
‘‘(ii) by any Indian tribe or tribal organiza-
tion pursuant to a funding agreement under—
‘‘(I) the Indian Self-Determination
and Educational Assistance Act; or
‘‘(II) section 23 of the Act of April
30, 1908 (25 U.S.C. 47), popularly known
as the ‘Buy-Indian Act’’; or
‘‘(iii) by an urban Indian organization pur-
suant to title V of this Act.
‘‘(13) The term ‘Indian tribe’ shall have the
same meaning as provided in the Indian Self-Deter-
mination and Education Assistance Act.
‘‘(14) The term ‘reservation’ means any feder-
ally recognized Indian tribe’s reservation, Pueblo or
colony, including former reservations in Oklahoma,
Alaska Native Regions established pursuant to the
Alaska Native Claims Settlement Act, and Indian al-
lotments.
‘‘(15) The term ‘Secretary’, unless otherwise
designated, means the Secretary of Health and
Human Services.
‘‘(16) The term ‘Service’ means the Indian
Health Service.
‘‘(17) The term ‘service area’ means the geo-
graphical area served by each Area Office.
‘‘(18) The term ‘Service Unit’ means—
‘‘(A) an administrative entity within the
Indian Health Service, or
‘‘(B) a Tribe or tribal organization oper-
ating health care programs or facilities with
funds from the Service under the Indian Self-
Determination and Education Assistance Act,
through which services are provided, directly or
by contract, to the eligible Indian population
within a defined geographic area.
‘‘(19) The term ‘traditional health care prac-
tices’ means the application by Native healing prac-
titioners of the Native healing sciences (as opposed
or in contradistinction to Western Healing Sciences)
which embodies the influences or forces of innate
tribal discovery, history, description, explanation and
knowledge of the states of wellness and illness and
which calls upon these influences or forces, including
physical, mental, and spiritual forces in the pro-
motion, restoration, preservation and maintenance of
health, well-being, and life’s harmony.
‘‘(20) The term ‘tribal organization’ shall have
the same meaning as provided in the Indian Self-De-
termination and Education Assistance Act.
‘‘(21) The term ‘tribally controlled community
college’ has the meaning given such term in section
2(a)(4) of the Tribally Controlled Community Col-
lege Assistance Act of 1978 (25 U.S.C. 1801(a)(4))
and the definition contained in the Indian Land
Grant Status Act (7 U.S.C. 301 note).
‘‘(22) The term ‘urban center’ means any com-
munity which has a sufficient urban Indian popu-
lation with unmet health needs to warrant assistance
under title V, as determined by the Secretary.
‘‘(23) The term ‘urban Indian’ means any indi-
vidual who resides in an urban center and who
meets one or more of the following criteria:
‘‘(A) Irrespective of whether the individual
lives on or near a reservation, the individual is
a member of a Tribe, band, or other organized
group of Indians, including those Tribes, bands,
or groups terminated since 1940.
‘‘(B) The individual is an Eskimo or Aleut
or other Alaskan Native.
‘‘(C) The individual is considered by the
Secretary of the Interior to be an Indian for
any purpose.
‘‘(D) The individual is determined to be an
Indian under regulations promulgated by the
Secretary.
‘‘(24) The term ‘urban Indian organization’
means a nonprofit corporate body situated in an
urban center, governed by an urban Indian con-
trolled board of directors, and providing for the par-
ticipation of all interested Indian groups and individ-
uals, which body is capable of legally cooperating
with other public and private entities for the purpose
of performing the activities described in section
503(a).
‘‘TITLE 
I—INDIAN 
HEALTH,
HUMAN RESOURCES, AND DE-
VELOPMENT
‘‘SEC. 101. PURPOSE.
‘‘The purpose of this title is to increase to the max-
imum feasible extent the number of Indians entering the
health professions and providing health services, and to
assure an optimum supply of health professionals to the
Service, Indian tribes, tribal organizations, and urban In-
dian organizations involved in the provision of health serv-
ices to Indian people.
‘‘SEC. 102. GENERAL REQUIREMENTS.
‘‘(a) SERVICE AREA PRIORITIES.—(1) Unless other-
wise specified, the funding for each program authorized
by this title shall be allocated by service area by formula
developed in consultation with Indian tribes, tribal organi-
zations, and urban Indian organizations. Such formula
shall consider the human resource and development needs
in each service area.
‘‘(2) Each Area Office shall undertake active and
continuing consultation with representatives of Indian
tribes, tribal organizations, and urban Indian organiza-
tions to prioritize the use of funds authorized and provided
under this title within the service area.
‘‘(3) Unless otherwise prohibited, the Area Office is
authorized to reallocate the funds available to it pursuant
to this title among the programs authorized by this title,
excepted that scholarship and loan repayment funds may
not be used for administrative functions.
‘‘(b) All individual recipients of scholarships, loans,
or other funding authorized by this title that exist on Sep-
tember 30, 1976 shall be excluded from operation of this
subsection through to the completion of the individual’s
course of study supported by funds appropriated to carry
out this title.
‘‘SEC. 103. HEALTH PROFESSIONS RECRUITMENT PROGRAM
FOR INDIANS.
‘‘(a) Subject to the requirements of section 102, the
Secretary shall make funds available to public or nonprofit
private health entities or Indian tribes or tribal organiza-
tions to assist such entities in meeting the costs of—
‘‘(1) identifying Indians with a potential for
education or training in the health professions and
encouraging and assisting them—
‘‘(A) to enroll in courses of study in such
health professions; or
‘‘(B) if they are not qualified to enroll in
any such courses of study, to undertake such
postsecondary education or training as may be
required to qualify them for enrollment;
‘‘(2) publicizing existing sources of financial aid
available to Indians enrolled in any course of study
referred to in paragraph (1) or who are undertaking
training necessary to qualify them to enroll in any
such course of study; or
‘‘(3) establishing other programs which the
Area Office determines will enhance and facilitate
the enrollment of Indians in, and the subsequent
pursuit and completion by them of, courses of study
referred to in paragraph (1).
‘‘(b)(1) Funds under this section shall require that
an application has been submitted to, and approved by,
the Secretary through the Area Office. Such application
shall be in such form, submitted in such manner, and con-
tain such information, as the Secretary shall by regulation
prescribe pursuant to this Act. The Area Office shall give
a preference to applications submitted by Indian tribes,
tribal organizations, or urban Indian organizations.
‘‘(2) The amount of funds provided to entities author-
ized under this section shall be determined by the Area
Office. Payments pursuant to this section may be made
in advance or by way of reimbursement, and at such inter-
vals and on such conditions as provided for in regulations
issued pursuant to this Act. To the extent not otherwise
prohibited by law, funding commitments shall be for 3
years, as provided for in regulations published pursuant
to this Act.
‘‘(c) For purposes of this section and sections 104
and 105, the term ‘Indian’ or ‘Indians’ shall, in addition
to the meaning contained in section 4, also mean any per-
son who—
‘‘(1) irrespective of whether he or she lives on
or near a reservation, is a member of a Tribe, band,
or other organized group of Indians, including those
Tribes, bands, or groups terminated since 1940;
‘‘(2) is an Eskimo or Aleut or other Alaska Na-
tive;
‘‘(3) is considered by the Secretary of the Inte-
rior to be an Indian for any purpose; or
‘‘(4) is determined to be an Indian under regu-
lations promulgated by the Secretary.
‘‘SEC. 104. HEALTH PROFESSIONS PREPARATORY SCHOL-
ARSHIP PROGRAM FOR INDIANS.
‘‘(a) Subject to the requirements of section 102, the
Secretary shall provide scholarships to Indians who—
‘‘(1) have successfully completed their high
school education or high school equivalency; and
‘‘(2) have demonstrated the potential to suc-
cessfully complete courses of study in the health pro-
fessions.
‘‘(b) Scholarships provided pursuant to this section
shall be for the following purposes:
‘‘(1) Compensatory preprofessional education of
any recipient, such scholarship not to exceed 2 years
on a full-time basis (or the part-time equivalent
thereof, as determined by the Area Office pursuant
to regulations issued under this Act).
‘‘(2) Pregraduate education of any recipient
leading to a baccalaureate degree in an approved
course of study preparatory to a field of study in a
health profession, such scholarship not to exceed 4
years. An extension of up to 2-years (or the part-
time equivalent thereof, as determined by the Area
Office pursuant to regulations issued pursuant to
this Act) may be approved.
‘‘(c) Scholarships under this section—
‘‘(1) may cover costs of tuition, books, trans-
portation, board, and other necessary related ex-
penses of a recipient while attending school;
‘‘(2) shall not be denied solely on the basis of
the applicant’s scholastic achievement if such appli-
cant has been admitted to, or maintained good
standing at, an accredited institution; and
‘‘(3) shall not be denied solely by reason of such
applicant’s eligibility for assistance or benefits under
any other Federal program.
‘‘SEC. 105. INDIAN HEALTH PROFESSIONS SCHOLARSHIPS.
‘‘(a) In order to meet the need for health profes-
sionals serving Indians, Indian tribes, tribal organizations,
and urban Indian organizations, subject to the require-
ments of section 102. The administration of this section
shall be a responsibility of the Director and shall not be
delegated in a funding agreement pursuant to the Indian
Self-Determination and Education Assistance Act. The
Secretary shall make scholarships to Indians who are en-
rolled full or part time in accredited schools and pursuing
courses of study in the health professions. Such scholar-
ships shall be designated Indian Health Scholarships and
shall be made in accordance with section 338A of the Pub-
lic Health Service Act (42 U.S.C. 254l), except as pro-
vided in subsection (b) of this section.
‘‘(b)(1) An Indian shall be eligible for a scholarship
under subsection (a) in any year in which such individual
is enrolled full or part time in a course of study referred
to in subsection (a).
‘‘(2)(A) The active duty service obligation under a
written contract with the Secretary under section 338A
of the Public Health Service Act (42 U.S.C. 254l) that
an Indian has entered into under that section shall, if that
individual is a recipient of an Indian Health Scholarship,
be met in full-time practice on an equivalent year for year
obligation, by service—
‘‘(i) in the Indian Health Service;
‘‘(ii) in a program conducted under a funding
agreement entered into under the Indian Self-Deter-
mination and Education Assistance Act;
‘‘(iii) in a program assisted under title V of this
Act; or
‘‘(iv) in the private practice of the applicable
profession if, as determined by the Secretary, in ac-
cordance with guidelines promulgated by the Sec-
retary, such practice is situated in a physician or
other health professional shortage area and address-
es the health care needs of a substantial number of
Indians.
‘‘(B) At the request of any individual who has entered
into a contract referred to in subparagraph (A) and who
receives a degree in medicine (including osteopathic or
allopathic medicine), dentistry, optometry, podiatry, or
pharmacy, the Secretary shall defer the active duty service
obligation of that individual under that contract, in order
that such individual may complete any internship, resi-
dency, or other advanced clinical training that is required
for the practice of that health profession, for an appro-
priate period (in years, as determined by the Secretary),
subject to the following conditions:
‘‘(i) No period of internship, residency, or other
advanced clinical training shall be counted as satis-
fying any period of obligated service that is required
under this section.
‘‘(ii) The active duty service obligation of that
individual shall commence not later than 90 days
after the completion of that advanced clinical train-
ing (or by a date specified by the Secretary).
‘‘(iii) The active duty service obligation will be
served in the health profession of that individual, or
in a field or specialty where a need is determined to
exist by the appropriate service area, in a manner
consistent with clauses (i) through (iv) of subpara-
graph (A).
‘‘(C) All new recipients of Indian Health Scholarships
awarded after 2002 shall meet the active duty service obli-
gation within the service area from which the scholarship
was awarded. Priority shall be given to a program that
funded the recipient. Under special circumstances, a re-
cipient may be placed in a different service area by agree-
ment between Areas or programs.
‘‘(D) Subject to subparagraph (C), the Area Office,
in making assignments of Indian Health Scholarship re-
cipients required to meet the active duty service obligation
described in subparagraph (A), shall give priority to as-
signing individuals to service in those programs specified
in subparagraph (A) that have a need for health profes-
sionals to provide health care services as a result of indi-
viduals having breached contracts entered into under this
section.
‘‘(3) In the case of an individual receiving a scholar-
ship under this section who is enrolled part time in an
approved course of study—
‘‘(A) such scholarship shall be for a period of
years not to exceed the part-time equivalent of 4
years, as determined by the Area Office;
‘‘(B) the period of obligated service described in
paragraph (2)(A) shall be equal to the greater of—
‘‘(i) the part-time equivalent of one year
for each year for which the individual was pro-
vided a scholarship (as determined by the Area
Office); or
‘‘(ii) 2 years; and
‘‘(C) the amount of the monthly stipend speci-
fied in section 338A(g)(1)(B) of the Public Health
Service Act (42 U.S.C. 254l(g)(1)(B)) shall be re-
duced pro rata (as determined by the Secretary)
based on the number of hours such student is en-
rolled.
‘‘(4)(A) An individual who has, on or after the date
of the enactment of this paragraph, entered into a written
contract with the Secretary under this section and who—
‘‘(i) fails to maintain an acceptable level of aca-
demic standing in the educational institution in
which he is enrolled (such level determined by the
educational institution under regulations of the Sec-
retary),
‘‘(ii) is dismissed from such educational institu-
tion for disciplinary reasons,
‘‘(iii) voluntarily terminates the training in such
an educational institution for which he is provided a
scholarship under such contract before the comple-
tion of such training, or
‘‘(iv) fails to accept payment, or instructs the
educational institution in which he is enrolled not to
accept payment, in whole or in part, of a scholarship
under such contract, in lieu of any service obligation
arising under such contract, shall be liable to the
United States for the amount which has been paid
to him, or on his behalf, under the contract.
‘‘(B) If for any reason not specified in subparagraph
(A) an individual breaches a written contract by failing
either to begin such individual’s service obligation under
this section or to complete such service obligation, the
United States shall be entitled to recover from the indi-
vidual an amount determined in accordance with the for-
mula specified in subsection (l) of section 108 in the man-
ner provided for in such subsection.
‘‘(C) Upon the death of an individual who receives
an Indian Health Scholarship, any obligation of that indi-
vidual for service or payment that relates to that scholar-
ship shall be canceled.
‘‘(D) The Secretary shall provide for the partial or
total waiver or suspension of any obligation of service or
payment of a recipient of an Indian Health Scholarship
if the Secretary, in consultation with the Area Office, In-
dian tribes, tribal organizations, and urban Indian organi-
zations, determines that—
‘‘(i) it is not possible for the recipient to meet
that obligation or make that payment;
‘‘(ii) requiring that recipient to meet that obli-
gation or make that payment would result in ex-
treme hardship to the recipient; or
‘‘(iii) the enforcement of the requirement to
meet the obligation or make the payment would be
unconscionable.
‘‘(E) Notwithstanding any other provision of law, in
any case of extreme hardship or for other good cause
shown, the Secretary may waive, in whole or in part, the
right of the United States to recover funds made available
under this section.
‘‘(F) Notwithstanding any other provision of law,
with respect to a recipient of an Indian Health Scholar-
ship, no obligation for payment may be released by a dis-
charge in bankruptcy under title 11, United States Code,
unless that discharge is granted after the expiration of the
5-year period beginning on the initial date on which that
payment is due, and only if the bankruptcy court finds
that the nondischarge of the obligation would be uncon-
scionable.
‘‘(c) FUNDING FOR TRIBES FOR SCHOLARSHIP PRO-
GRAMS.—(1)(A) Subject to section 102, the Secretary
shall make funds available to Indian tribes and tribal or-
ganizations for the purpose of assisting such tribes and
tribal organizations in educating Indians to serve as health
professionals in Indian communities.
‘‘(B) Amounts available under subparagraph (A) for
any fiscal year shall not exceed 5 percent of the amounts
available for each fiscal year for Indian Health Scholar-
ships under this section.
‘‘(C) An application for funds under subparagraph
(A) shall be in such form and contain such agreements,
assurances, and information as consistent with this sec-
tion.
‘‘(2)(A) An Indian tribe or tribal organization receiv-
ing funds under paragraph (1) shall provide scholarships
to Indians in accordance with the requirements of this
subsection.
‘‘(B) With respect to costs of providing any scholar-
ship pursuant to subparagraph (A)—
‘‘(i) 80 percent of the costs of the scholarship
shall be paid from the funds pursuant to subsection
(c)(1) provided to the Indian tribe or tribal organi-
zation; and
‘‘(ii) 20 percent of such costs may be paid from
any other source of funds.
‘‘(3) An Indian tribe or tribal organization shall pro-
vide scholarships under subsection (c) only to Indians en-
rolled or accepted for enrollment in a course of study (ap-
proved by the Secretary) in one of the health professions
contemplated by this Act.
‘‘(4) In providing scholarships under paragraph (2),
the Secretary and the Indian tribe or tribal organization
shall enter into a written contract with each recipient of
such scholarship. Such contract shall—
‘‘(A) obligate such recipient to provide service
in an Indian health program (as defined in section
109(a)(2)(A)), in the same service area where the
Indian tribe or tribal organization providing the
scholarship is located, for—
‘‘(i) a number of years for which the schol-
arship is provided (or the part-time equivalent
thereof, as determined by the Secretary), or for
a period of 2 years, whichever period is greater;
or
‘‘(ii) such greater period of time as the re-
cipient and the Indian tribe or tribal organiza-
tion may agree;
‘‘(B) 
provide 
that 
the 
amount 
of 
the
scholarship—
‘‘(i) may only be expended for—
‘‘(I) tuition expenses, other reasonable
educational expenses, and reasonable living
expenses incurred in attendance at the
educational institution; and
‘‘(II) payment to the recipient of a
monthly stipend of not more than the
amount authorized by section 338(g)(1)(B)
of the Public Health Service Act (42
U.S.C. 254m(g)(1)(B), such amount to be
reduced pro rata (as determined by the
Secretary) based on the number of hours
such student is enrolled; and may not ex-
ceed, for any year of attendance for which
the scholarship is provided, the total
amount required for the year for the pur-
poses authorized in this clause; and
‘‘(ii) may not exceed, for any year of at-
tendance for which the scholarship is provided,
the total amount required for the year for the
purposes authorized in clause (i);
‘‘(C) require the recipient of such scholarship to
maintain an acceptable level of academic standing as
determined by the educational institution in accord-
ance with regulations issued pursuant to this Act;
and
‘‘(D) require the recipient of such scholarship
to meet the educational and licensure requirements
appropriate to each health profession.
‘‘(5)(A) An individual who has entered into a written
contract with the Secretary and an Indian tribe or tribal
organization under this paragraph and who—
‘‘(i) fails to maintain an acceptable level of aca-
demic standing in the educational institution in
which he is enrolled (such level determined by the
educational institution under regulations of the Sec-
retary);
‘‘(ii) is dismissed from such educational institu-
tion for disciplinary reasons;
‘‘(iii) voluntarily terminates the training in such
an educational institution for which he or she is pro-
vided a scholarship under such contract before the
completion of such training; or
‘‘(iv) fails to accept payment, or instructs the
educational institution in which he or she is enrolled
not to accept payment, in whole or in part, of a
scholarship under such contract, in lieu of any serv-
ice obligation arising under such contract,
shall be liable to the United States for the Federal share
of the amount which has been paid to him or her, or on
his or her behalf, under the contract.
‘‘(B) If for any reason not specified in subparagraph
(A), an individual breaches his or her written contract by
failing to either begin such individual’s service obligation
required under such contract or to complete such service
obligation, the United States shall be entitled to recover
from the individual an amount determined in accordance
with the formula specified in subsection (l) of section 110
in the manner provided for in such subsection.
‘‘(C) The Secretary may carry out this subsection on
the basis of information received from Indian tribes or
tribal organizations involved, or on the basis of informa-
tion collected through such other means as the Secretary
deems appropriate.
‘‘(6) The recipient of a scholarship under paragraph
(1) shall agree, in providing health care pursuant to the
requirements herein—
‘‘(A) not to discriminate against an individual
seeking care on the basis of the ability of the indi-
vidual to pay for such care or on the basis that pay-
ment for such care will be made pursuant to the
program established in title XVIII of the Social Se-
curity Act or pursuant to the programs established
in title XIX of such Act; and
‘‘(B) to accept assignment under section
1842(b)(3)(B)(ii) of the Social Security Act for all
services for which payment may be made under part
B of title XVIII of such Act, and to enter into an
appropriate agreement with the State agency that
administers the State plan for medical assistance
under title XIX of such Act to provide service to in-
dividuals entitled to medical assistance under the
plan.
‘‘(7) The Secretary shall make payments under this
paragraph to an Indian tribe or tribal organization for any
fiscal year subsequent to the first fiscal year of such pay-
ments unless the Secretary determines that, for the imme-
diately preceding fiscal year, the Indian tribe or tribal or-
ganization has not complied with the requirements of this
subsection.
‘‘SEC. 106. AMERICAN INDIANS INTO PSYCHOLOGY PRO-
GRAM.
‘‘(a) Notwithstanding section 102, the Secretary shall
provide funding grants to at least 3 colleges and univer-
sities for the purpose of developing and maintaining Amer-
ican Indian psychology career recruitment programs as a
means of encouraging Indians to enter the mental health
field. These programs shall be located at various locations
throughout the country to maximize their availability to
Indian students and new programs shall be established in
different locations from time to time.
‘‘(b) The Secretary shall provide one of the grants
authorized under subsection (a) to develop and maintain
a program at the University of North Dakota to be known
as the ‘Quentin N. Burdick American Indians Into Psy-
chology Program’. Such program shall, to the maximum
extent feasible, coordinate with the Quentin N. Burdick
Indian Health Programs authorized under section 117(b),
the Quentin N. Burdick American Indians Into Nursing
Program authorized under section 115(e), and existing
university research and communications networks.
‘‘(c)(1) The Secretary shall issue regulations pursu-
ant to this Act for the competitive awarding of funds pro-
vided under this section.
‘‘(2) Applicants under this section shall agree to pro-
vide a program which, at a minimum—
‘‘(A) provides outreach and recruitment for
health professions to Indian communities including
elementary, secondary, and accredited and accessible
community colleges that will be served by the pro-
gram;
‘‘(B) incorporates a program advisory board
comprised of representatives from the tribes and
communities that will be served by the program;
‘‘(C) provides stipends to undergraduate and
graduate students to pursue a career in psychology;
‘‘(D) develops affiliation agreements with tribal
community colleges, the Service, university affiliated
programs, and other appropriate accredited and ac-
cessible entities to enhance the education of Indian
students;
‘‘(E) to the maximum extent feasible, uses ex-
isting university tutoring, counseling, and student
support services; and
‘‘(F) to the maximum extent feasible, employs
qualified Indians in the program.
‘‘(d) The active duty service obligation prescribed
under section 338C of the Public Health Service Act (42
U.S.C. 254m) shall be met by each graduate who receives
a stipend described in subsection (c)(2)(D) that is funded
under this section. Such obligation shall be met by
service—
‘‘(1) in the Indian Health Service;
‘‘(2) in a program conducted under a funding
agreement entered into under the Indian Self-Deter-
mination and Education Assistance Act;
‘‘(3) in a program assisted under title V of this
Act; or
‘‘(4) in the private practice of psychology if, as
determined by the Secretary, in accordance with
guidelines promulgated by the Secretary, such prac-
tice is situated in a physician or other health profes-
sional shortage area and addresses the health care
needs of a substantial number of Indians.
‘‘SEC. 107. INDIAN HEALTH SERVICE EXTERN PROGRAMS.
‘‘(a) Any individual who receives a scholarship pursu-
ant to section 105 shall be given preference for employ-
ment in the Service, or may be employed by a program
of an Indian tribe, tribal organization, or urban Indian
organization, or other agencies of the Department as
available, during any nonacademic period of the year. Pe-
‘‘SEC. 108. CONTINUING EDUCATION ALLOWANCES.
‘‘In order to encourage health professionals, including
for purposes of this section, community health representa-
tives and emergency medical technicians, to join or con-
tinue in the Service or program of an Indian tribe, tribal
organization, or urban Indian organization and to provide
their services in the rural and remote areas where a sig-
nificant portion of the Indian people reside, the Secretary,
subject to section 102, acting through the service area,
may provide allowances to health professionals employed
in the Service or program of an Indian tribe, tribal organi-
zation, or urban Indian organization to enable them for
a period of time each year prescribed by regulation of the
Secretary to take leave of their duty stations for profes-
sional consultation and refresher training courses.
‘‘SEC. 109. COMMUNITY HEALTH REPRESENTATIVE PRO-
GRAM.
‘‘(a) Under the authority of the Act of November 2,
1921 (25 U.S.C. 13), popularly known as the Snyder Act,
the Secretary shall maintain a Community Health Rep-
resentative Program under which the Service, Indian
tribes, and tribal organizations—
‘‘(1) provide for the training of Indians as com-
munity health representatives; and
‘‘(2) use such community health representatives
in the provision of health care, health promotion,
and disease prevention services to Indian commu-
nities.
‘‘(b) The Secretary, acting through the Community
Health Representative Program of the Service, shall—
‘‘(1) provide a high standard of training for
community health representatives to ensure that the
community health representatives provide quality
health care, health promotion, and disease preven-
tion services to the Indian communities served by
such Program;
‘‘(2) in order to provide such training, develop
and maintain a curriculum that—
‘‘(A) combines education in the theory of
health care with supervised practical experience
in the provision of health care; and
‘‘(B) provides instruction and practical ex-
perience in health promotion and disease pre-
vention activities, with appropriate consider-
ation given to lifestyle factors that have an im-
pact on Indian health status, such as alco-
holism, family dysfunction, and poverty;
‘‘(3) maintain a system which identifies the
needs of community health representatives for con-
tinuing education in health care, health promotion,
and disease prevention and develop programs that
meet the needs for continuing education;
‘‘(4) maintain a system that provides close su-
pervision of Community Health Representatives;
‘‘(5) maintain a system under which the work
of the Community Health Representatives is re-
viewed and evaluated; and
‘‘(6) promote traditional health care practices
of the Indian tribes served consistent with the Serv-
ice standards for the provision of health care, health
promotion, and disease prevention.
‘‘SEC. 110. INDIAN HEALTH SERVICE LOAN REPAYMENT
PROGRAM.
‘‘(a)(1) Subject to section 102, the Secretary shall es-
tablish a program to be known as the Indian Health Serv-
ice Loan Repayment Program (hereinafter referred to as
the ‘Loan Repayment Program’) in order to ensure an
adequate supply of trained health professionals necessary
to maintain accreditation of, and provide health care serv-
ices to Indians through, Indian health programs.
‘‘(2) For the purposes of this section the term ‘State’
has the same meaning given such term in section 331(i)(4)
of the Public Health Service Act.
‘‘(b) To be eligible to participate in the Loan Repay-
ment Program, an individual must—
‘‘(1)(A) be enrolled—
‘‘(i) in a course of study or program in an
accredited institution, as determined by the
Secretary, within any State and be scheduled to
complete such course of study in the same year
such individual applies to participate in such
program; or
‘‘(ii) in an approved graduate training pro-
gram in a health profession; or
‘‘(B) have—
‘‘(i) a degree in a health profession; and
‘‘(ii) a license to practice a health profes-
sion;
‘‘(2)(A) be eligible for, or hold, an appointment
as a commissioned officer in the Regular or Reserve
Corps of the Public Health Service;
‘‘(B) be eligible for selection for civilian service
in the Regular or Reserve Corps of the Public
Health Service;
‘‘(C) meet the professional standards for civil
service employment in the Indian Health Service; or
‘‘(D) be employed in an Indian health program
without a service obligation; and
‘‘(3) submit to the Secretary an application for
a contract described in subsection (f).
‘‘(c)(1) In disseminating application forms and con-
tract forms to individuals desiring to participate in the
Loan Repayment Program, the Secretary shall include
with such forms a fair summary of the rights and liabil-
ities of an individual whose application is approved (and
whose contract is accepted) by the Secretary, including in
the summary a clear explanation of the damages to which
the United States is entitled under subsection (l) in the
case of the individual’s breach of contract. The Secretary
shall provide such individuals with sufficient information
regarding the advantages and disadvantages of service as
a commissioned officer in the Regular or Reserve Corps
of the Public Health Service or a civilian employee of the
Indian Health Service to enable the individual to make
a decision on an informed basis.
‘‘(2) The application form, contract form, and all
other information furnished by the Secretary under this
section shall be written in a manner calculated to be un-
derstood by the average individual applying to participate
in the Loan Repayment Program.
‘‘(3) The Secretary shall make such application
forms, contract forms, and other information available to
individuals desiring to participate in the Loan Repayment
Program on a date sufficiently early to ensure that such
individuals have adequate time to carefully review and
evaluate such forms and information.
‘‘(d)(1) Consistent with section 102 and subsection
(k), the Secretary shall annually—
‘‘(A) identify the positions in each Indian
health program for which there is a need or a va-
cancy; and
‘‘(B) rank those positions in order of priority.
‘‘(2) Consistent with the priority determined under
paragraph (1), the Secretary, in determining which appli-
cations under the Loan Repayment Program to approve
(and which contracts to accept), shall give priority to ap-
plications made by—
‘‘(A) Indians; and
‘‘(B) individuals recruited through the efforts of
an Indian tribe, tribal organization, or urban Indian
organization.
‘‘(e)(1) An individual becomes a participant in the
Loan Repayment Program only upon the Secretary and
the individual entering into a written contract described
in subsection (f).
‘‘(2) The Secretary shall provide written notice to an
individual within 21 days on—
‘‘(A) the Secretary’s approving, under para-
graph (1), of the individual’s participation in the
Loan Repayment Program, including extensions re-
sulting in an aggregate period of obligated service in
excess of 4 years; or
‘‘(B) the Secretary’s disapproving an individ-
ual’s participation in such Program.
‘‘(f) The written contract referred to in this section
between the Secretary and an individual shall contain—
‘‘(1) an agreement under which—
‘‘(A) subject to paragraph (3), the Sec-
retary agrees—
‘‘(i) to pay loans on behalf of the indi-
vidual in accordance with the provisions of
this section; and
‘‘(ii) to accept (subject to the avail-
ability of appropriated funds for carrying
out this section) the individual into the
Service or place the individual with a tribe,
tribal organization, or urban Indian orga-
nization as provided in subparagraph
(B)(iii); and
‘‘(B) subject to paragraph (3), the indi-
vidual agrees—
‘‘(i) to accept loan payments on behalf
of the individual;
‘‘(ii) in the case of an individual de-
scribed in subsection (b)(1)—
‘‘(I) to maintain enrollment in a
course of study or training described
in subsection (b)(1)(A) until the indi-
vidual completes the course of study
or training, and
‘‘(II) while enrolled in such
course of study or training, to main-
tain an acceptable level of academic
standing (as determined under regula-
tions of the Secretary by the edu-
cational 
institution 
offering 
such
course of study or training); and
‘‘(iii) to serve for a time period (here-
inafter in this section referred to as the
‘period of obligated service’) equal to 2
years or such longer period as the indi-
vidual may agree to serve in the full-time
clinical practice of such individual’s profes-
sion in an Indian health program to which
the individual may be assigned by the Sec-
retary;
‘‘(2) a provision permitting the Secretary to ex-
tend for such longer additional periods, as the indi-
vidual may agree to, the period of obligated service
agreed to by the individual under paragraph
(1)(B)(iii);
‘‘(3) a provision that any financial obligation of
the United States arising out of a contract entered
into under this section and any obligation of the in-
dividual which is conditioned thereon is contingent
upon funds being appropriated for loan repayments
under this section;
‘‘(4) a statement of the damages to which the
United States is entitled under subsection (l) for the
individual’s breach of the contract; and
‘‘(5) such other statements of the rights and li-
abilities of the Secretary and of the individual, not
inconsistent with this section.
‘‘(g)(1) A loan repayment provided for an individual
under a written contract under the Loan Repayment Pro-
gram shall consist of payment, in accordance with para-
graph (2), on behalf of the individual of the principal, in-
terest, and related expenses on government and commer-
cial loans received by the individual regarding the under-
graduate or graduate education of the individual (or both),
which loans were made for—
‘‘(A) tuition expenses;
‘‘(B) all other reasonable educational expenses,
including fees, books, and laboratory expenses, in-
curred by the individual; and
‘‘(C) reasonable living expenses as determined
by the Secretary.
‘‘(2)(A) For each year of obligated service that an
individual contracts to serve under subsection (f) the Sec-
retary may pay up to $35,000 or an amount equal to the
amount specified in section 338B(g)(2)(A) of the Public
Health Service Act, whichever is more, on behalf of the
individual for loans described in paragraph (1). In making
a determination of the amount to pay for a year of such
service by an individual, the Secretary shall consider the
extent to which each such determination—
‘‘(i) affects the ability of the Secretary to maxi-
mize the number of contracts that can be provided
under the Loan Repayment Program from the
amounts appropriated for such contracts;
‘‘(ii) provides an incentive to serve in Indian
health programs with the greatest shortages of
health professionals; and
‘‘(iii) provides an incentive with respect to the
health professional involved remaining in an Indian
health program with such a health professional
shortage, and continuing to provide primary health
services, after the completion of the period of obli-
gated service under the Loan Repayment Program.
‘‘(B) Any arrangement made by the Secretary for the
making of loan repayments in accordance with this sub-
section shall provide that any repayments for a year of
obligated service shall be made no later than the end of
the fiscal year in which the individual completes such year
of service.
‘‘(3) The Secretary may enter into an agreement with
the holder of any loan for which payments are made under
the Loan Repayment Program to establish a schedule for
the making of such payments.
‘‘(h) Notwithstanding any other provision of law, in-
dividuals who have entered into written contracts with the
Secretary under this section, while undergoing academic
training, shall not be counted against any employment
ceiling affecting the Department.
‘‘(i) The Secretary shall conduct recruiting programs
for the Loan Repayment Program and other Service man-
power programs of the Service at educational institutions
training health professionals or specialists identified in
subsection (a).
‘‘(j) Section 214 of the Public Health Service Act (42
U.S.C. 215) shall not apply to individuals during their pe-
riod of obligated service under the Loan Repayment Pro-
gram.
‘‘(k) The Secretary, in assigning individuals to serve
in Indian health programs pursuant to contracts entered
into under this section, shall—
‘‘(1) ensure that the staffing needs of Indian
health programs administered by an Indian tribe or
tribal organization receive consideration on an equal
basis with programs that are administered directly
by the Service; and
‘‘(2) give priority to assigning individuals to In-
dian health programs that have a need for health
professionals to provide health care services as a re-
sult of individuals having breached contracts entered
into under this section.
‘‘(l)(1) An individual who has entered into a written
contract with the Secretary under this section and who—
(A) is enrolled in the final year of a course of
study and who—
‘‘(i) fails to maintain an acceptable level of
academic standing in the educational institution
in which he is enrolled (such level determined
by the educational institution under regulations
of the Secretary);
‘‘(ii) voluntarily terminates such enroll-
ment; or
‘‘(iii) is dismissed from such educational
institution before completion of such course of
study; or
‘‘(B) is enrolled in a graduate training pro-
gram, fails to complete such training program, and
does not receive a waiver from the Secretary under
subsection (b)(1)(B)(ii),
shall be liable, in lieu of any service obligation arising
under such contract, to the United States for the amount
which has been paid on such individual’s behalf under the
contract.
‘‘(2) If, for any reason not specified in paragraph (1),
an individual breaches his written contract under this sec-
tion by failing either to begin, or complete, such individ-
ual’s period of obligated service in accordance with sub-
section (f), the United States shall be entitled to recover
from such individual an amount to be determined in ac-
cordance with the following formula:
‘‘A=3Z(t-s/t)
in which—
‘‘(A) ‘A’ is the amount the United States is en-
titled to recover;
‘‘(B) ‘Z’ is the sum of the amounts paid under
this section to, or on behalf of, the individual and
the interest on such amounts which would be pay-
able if, at the time the amounts were paid, they were
loans bearing interest at the maximum legal pre-
vailing rate, as determined by the Secretary of the
Treasury;
‘‘(C) ‘t’ is the total number of months in the in-
dividual’s period of obligated service in accordance
with subsection (f); and
‘‘(D) ‘s’ is the number of months of such period
served by such individual in accordance with this
section.
Amounts not paid within such period shall be subject to
collection through deductions in medicare payments pur-
suant to section 1892 of the Social Security Act.
‘‘(3)(A) Any amount of damages which the United
States is entitled to recover under this subsection shall be
paid to the United States within the 1-year period begin-
ning on the date of the breach or such longer period begin-
ning on such date as shall be specified by the Secretary.
‘‘(B) If damages described in subparagraph (A) are
delinquent for 3 months, the Secretary shall, for the pur-
pose of recovering such damages—
‘‘(i) use collection agencies contracted with by
the Administrator of General Services; or
‘‘(ii) enter into contracts for the recovery of
such damages with collection agencies selected by
the Secretary.
‘‘(C) Each contract for recovering damages pursuant
to this subsection shall provide that the contractor will,
not less than once each 6 months, submit to the Secretary
a status report on the success of the contractor in col-
lecting such damages. Section 3718 of title 31, United
States Code, shall apply to any such contract to the extent
not inconsistent with this subsection.
‘‘(m)(1) Any obligation of an individual under the
Loan Repayment Program for service or payment of dam-
ages shall be canceled upon the death of the individual.
‘‘(2) The Secretary shall by regulation provide for the
partial or total waiver or suspension of any obligation of
service or payment by an individual under the Loan Re-
payment Program whenever compliance by the individual
is impossible or would involve extreme hardship to the in-
dividual and if enforcement of such obligation with respect
to any individual would be unconscionable.
‘‘(3) The Secretary may waive, in whole or in part,
the rights of the United States to recover amounts under
this section in any case of extreme hardship or other good
cause shown, as determined by the Secretary.
‘‘(4) Any obligation of an individual under the Loan
Repayment Program for payment of damages may be re-
leased by a discharge in bankruptcy under title 11 of the
United States Code only if such discharge is granted after
the expiration of the 5-year period beginning on the first
date that payment of such damages is required, and only
if the bankruptcy court finds that nondischarge of the ob-
ligation would be unconscionable.
‘‘(n) The Secretary shall submit to the President, for
inclusion in each report required to be submitted to the
Congress under section 801, a report concerning the pre-
vious fiscal year which sets forth by service area—
‘‘(1) the health professional positions main-
tained by the Service or by tribal or Indian organi-
zations for which recruitment or retention is dif-
ficult;
‘‘(2) the number of Loan Repayment Program
applications filed with respect to each type of health
profession;
‘‘(3) the number of contracts described in sub-
section (f) that are entered into with respect to each
health profession;
‘‘(4) the amount of loan payments made under
this section, in total and by health profession;
‘‘(5) the number of scholarships that are pro-
vided under section 105 with respect to each health
profession;
‘‘(6) the amount of scholarship grants provided
under section 105, in total and by health profession;
‘‘(7) the number of providers of health care
that will be needed by Indian health programs, by
location and profession, during the 3 fiscal years be-
ginning after the date the report is filed; and
‘‘(8) the measures the Secretary plans to take
to fill the health professional positions maintained
by the Service or by tribes or tribal organizations,
or urban Indian organization for which recruitment
or retention is difficult.
‘‘SEC. 111. SCHOLARSHIP AND LOAN REPAYMENT RECOV-
ERY FUND.
‘‘(a) Notwithstanding section 102 of this title, there
is established in the Treasury of the United States a fund
to be known as the Indian Health Scholarship and Loan
Repayment Recovery Fund (hereafter in this section re-
ferred to as the ‘LRRF’). The LRRF shall consist of such
amounts as may be collected from individuals under sec-
tions 105(b)(4)(A) and (B) and 110(1) for breach of con-
tract, such funds as may be appropriated to the LRRF,
and such interest earned on amounts in the LRRF, and
all amounts collected, appropriated, or earned relative to
the LRRF shall remain available until expended.
‘‘(b)(1) Amounts in the LRRF may be expended by
the Secretary, subject to the provisions of section 102, to
make payments to the Service or to an Indian tribe or
tribal organization administering a health care program
pursuant to a funding agreement entered into under the
Indian Self-Determination and Education Assistance
Act—
‘‘(A) to which a scholarship recipient under sec-
tion 105 or a loan repayment program participant
under section 110 has been assigned to meet the ob-
ligated service requirements pursuant to such sec-
tions; and
‘‘(B) that has a need for a health professional
to provide health care services as a result of such re-
cipient or participant having breached the contract
entered into under section 105 or section 110.
‘‘(2) An Indian tribe or tribal organization receiving
payments pursuant to paragraph (1) may expend the pay-
ments to provide scholarships or recruit and employ, di-
rectly or by contract, health professionals to provide health
care services.
‘‘(c)(1) The Secretary of the Treasury shall invest
such amounts of the LRRF as the Secretary determines
are not required to meet current withdrawals from the
LRRF. Such investments may be made only in interest-
bearing obligations of the United States. For such pur-
pose, such obligations may be acquired on original issue
at the issue price, or by purchase of outstanding obliga-
tions at the market price.
‘‘(2) Any obligation acquired by the LRRF may be
sold by the Secretary of the Treasury at the market price.
‘‘SEC. 112. RECRUITMENT ACTIVITIES.
‘‘(a) The Secretary may reimburse health profes-
sionals seeking positions with the Service, Indian tribes,
tribal organizations, or urban Indian organizations, in-
cluding unpaid student volunteers and individuals consid-
ering entering into a contract under section 110, and their
spouses, for actual and reasonable expenses incurred in
traveling to and from their places of residence to an area
in which they may be assigned for the purpose of evalu-
ating such area with respect to such assignment.
‘‘(b) The Secretary shall assign one individual in each
Area Office to be responsible on a full-time basis for re-
cruitment activities.
‘‘SEC. 113. TRIBAL RECRUITMENT AND RETENTION PRO-
GRAM.
‘‘(a) Subject to section 102, the Secretary shall fund
innovative demonstration projects for a period not to ex-
ceed 3 years to enable Indian tribes, tribal organizations,
and urban Indian organizations to recruit, place, and re-
tain health professionals to meet the staffing needs of In-
dian health programs (as defined in section 110(a)(2)(A)).
‘‘(b) Any Indian tribe, tribal organization, or urban
Indian organization may submit an application for funding
of a project pursuant to this section.
‘‘SEC. 114. ADVANCED TRAINING AND RESEARCH.
‘‘(a) The Secretary shall establish a demonstration
project to enable health professionals who have worked in
an Indian health program (as defined in section 110 for
a substantial period of time to pursue advanced training
or research areas of study for which the Secretary deter-
mines a need exists.
‘‘(b) An individual who participates in a program
under subsection (a), where the educational costs are
borne by the Service, shall incur an obligation to serve
in an Indian health program for a period of obligated serv-
ice equal to at least the period of time during which the
individual participates in such program. In the event that
the individual fails to complete such obligated service, the
individual shall be liable to the United States for the pe-
riod of service remaining. In such event, with respect to
individuals entering the program after the date of the en-
actment of the Indian Health Care Improvement Act
Amendments of 2001, the United States shall be entitled
to recover from such individual an amount to be deter-
mined in accordance with the formula specified in sub-
section (l) of section 110 in the manner provided for in
such subsection.
‘‘(c) Health professionals from Indian tribes and trib-
al organizations under the authority of the Indian Self-
Determination and Education Assistance Act, and urban
Indian organizations shall be given an equal opportunity
to participate in the program under subsection (a).
‘‘SEC. 115. QUENTIN B. BURDICK AMERICAN INDIANS INTO
NURSING PROGRAM.
‘‘(a) Notwithstanding section 102, the Secretary shall
provide grants to—
‘‘(1) public or private schools of nursing,
‘‘(2) tribally controlled community colleges and
tribally controlled postsecondary vocational institu-
tions (as defined in section 390(2) of the Tribally
Controlled Vocational Institutions Support Act of
1990 (20 U.S.C. 2397h(2)), and
‘‘(3) nurse midwife programs, and advance
practice nurse programs, that are provided by any
tribal college accredited nursing program, in the ab-
sence of such, any other public or private institu-
tions,
for the purpose of increasing the number of nurses, nurse
midwives, and nurse practitioners who deliver health care
services to Indians.
‘‘(b) Grants provided under subsection (a) may be
used to—
‘‘(1) recruit individuals for programs which
train individuals to be nurses, nurse midwives, or
advanced practice nurses,
‘‘(2) provide scholarships to Indian individuals
enrolled in such programs that may pay the tuition
charged for such program and other expenses in-
curred in connection with such program, including
books, fees, room and board, and stipends for living
expenses,
‘‘(3) provide a program that encourages nurses,
nurse midwives, and advanced practice nurses to
provide, or continue to provide, health care services
to Indians,
‘‘(4) provide a program that increases the skills
of, and provides continuing education to, nurses,
nurse midwives, and advanced practice nurses, or
‘‘(5) provide any program that is designed to
achieve the purpose described in subsection (a).
‘‘(c) Each application for funding under subsection
(a) shall include such information as the Secretary may
require to establish the connection between the program
of the applicant and a health care facility that primarily
serves Indians.
‘‘(d) In providing grants under subsection (a), the
Secretary shall extend a preference to—
‘‘(1) programs that provide a preference to In-
dians,
‘‘(2) programs that train nurse midwives or ad-
vanced practice nurses,
‘‘(3) programs that are interdisciplinary, and
‘‘(4) programs that are conducted in coopera-
tion with a center for gifted and talented Indian stu-
dents established under section 5324(a) of the In-
dian Education Act of 1988.
‘‘(e) The Secretary shall provide one of the grants
authorized under subsection (a) to establish and maintain
a program at the University of North Dakota to be known
as the ‘Quentin N. Burdick American Indians Into Nurs-
ing Program’. Such program shall, to the maximum extent
feasible, coordinate with the Quentin N. Burdick Indian
Health Programs established under section 117(b) and the
Quentin N. Burdick American Indians Into Psychology
Program established under section 106(b).
‘‘(f) The active duty service obligation prescribed
under section 338C of the Public Health Service Act (42
U.S.C. 254m) shall be met by each individual who receives
training or assistance described in paragraph (1) or (2)
of subsection (b) that is funded by a grant provided under
subsection (a). Such obligation shall be met by service—
‘‘(A) in the Indian Health Service;
‘‘(B) in a program conducted under a contract
entered into under the Indian Self-Determination
Act;
‘‘(C) in a program assisted under title V of this
Act; or
‘‘(D) in the private practice of nursing if, as de-
termined by the Secretary, in accordance with guide-
lines promulgated by the Secretary, such practice is
situated in a physician or other health professional
shortage area and addresses the health care needs of
a substantial number of Indians.
‘‘SEC. 116. TRIBAL CULTURAL ORIENTATION.
‘‘(a) The Secretary, pursuant to the requirements of
section 102, shall require that appropriate employees of
the Service who serve Indian tribes in each service area
receive educational instruction in the history and culture
of such Tribes and their relationship to the Service.
‘‘(b) To the extent feasible, the program established
under subsection (a) shall—
‘‘(1) be developed in consultation with the af-
fected tribal governments, tribal organizations, and
urban Indian organizations,
‘‘(2) be carried out through tribally controlled
community colleges (within the meaning of section
2(4) of the Tribally Controlled Community College
Assistance Act of 1978) and tribally controlled post-
secondary vocational institutions (as defined in sec-
tion 390(2) of the Tribally Controlled Vocational In-
stitutions 
Support 
Act 
of 
1990 
(20 
U.S.C.
2397h(2)),
‘‘(3) include instruction in American Indian
studies, and
‘‘(4) the use and place of traditional health care
practices in the tribe.
‘‘SEC. 117. INMED PROGRAM.
‘‘(a) The Secretary is authorized to provide grants
to colleges and universities for the purpose of maintaining
and expanding the Native American health careers recruit-
ment program known as the ‘Indians into Medicine Pro-
gram’ (hereinafter in this section referred to as ‘INMED’)
as a means of encouraging Indians to enter the health pro-
fessions.
‘‘(b) The Secretary shall provide one of the grants
authorized under subsection (a) to maintain the INMED
program at the University of North Dakota, to be known
as the ‘Quentin N. Burdick Indian Health Programs’, un-
less the Secretary makes a determination, based upon pro-
gram reviews, that the program is not meeting the pur-
poses of this section. Such program shall, to the maximum
extent feasible, coordinate with the Quentin N. Burdick
American Indians Into Psychology Program established
under section 106(b) and the Quentin N. Burdick Amer-
ican Indians Into Nursing Program established under sec-
tion 115.
‘‘(c)(1) The Secretary, pursuant to this Act, shall de-
velop regulations to govern grants pursuant to this sec-
tion.
‘‘(2) Applicants for grants provided under this section
shall agree to provide a program which—
‘‘(A) provides outreach and recruitment for
health professions to Indian communities including
elementary, secondary, and community colleges lo-
cated on Indian reservations which will be served by
the program,
‘‘(B) incorporates a program advisory board
comprised of representatives from the tribes and
communities which will be served by the program,
‘‘(C) provides summer preparatory programs
for Indian students who need enrichment in the sub-
jects of math and science in order to pursue training
in the health professions,
‘‘(D) provides tutoring, counseling, and support
to students who are enrolled in a health career pro-
gram of study at the respective college or university,
and
‘‘(E) to the maximum extent feasible, employs
qualified Indians in the program.
‘‘SEC. 118. HEALTH TRAINING PROGRAMS OF COMMUNITY
COLLEGES.
‘‘(a)(1) Subject to the requirements of section 102,
the Secretary shall award grants to accredited and acces-
sible community colleges for the purpose of assisting such
community colleges in the establishment of programs
which provide education in a health profession leading to
a degree or diploma in a health profession for individuals
who desire to practice such profession on an Indian res-
ervation, in the Service, or in a tribal health program.
‘‘(2) The amount of any grant awarded to a commu-
nity college under paragraph (1) for the first year in which
such a grant is provided to the community college shall
not exceed $100,000.
‘‘(b)(1) The Secretary shall award grants to accred-
ited and accessible community colleges that have estab-
lished a program described in subsection (a)(1) for the
purpose of maintaining the program and recruiting stu-
dents for the program.
‘‘(2) Grants may only be made under this section to
a community college which—
‘‘(A) is accredited,
‘‘(B) has a relationship with a hospital facility,
Service facility, or hospital that could provide train-
ing of nurses or health professionals,
‘‘(C) has entered into an agreement with an ac-
credited college or university medical school, the
terms of which—
‘‘(i) provide a program that enhances the
transition and recruitment of students into ad-
vanced baccalaureate or graduate programs
which train health professionals, and
‘‘(ii) stipulate certifications necessary to
approve internship and field placement opportu-
nities at health programs of the Service or trib-
al health programs,
‘‘(D) has a qualified staff which has the appro-
priate certifications,
‘‘(E) is capable of obtaining State or regional
accreditation of the program described in subsection
(a)(1), and
‘‘(F) agrees to provide for Indian preference for
applicants for programs under this section.
‘‘(c) The Secretary shall encourage community col-
leges described in subsection (b)(2) to establish and main-
tain programs described in subsection (a)(1) by—
‘‘(1) entering into agreements with such col-
leges for the provision of qualified personnel of the
Service to teach courses of study in such programs,
and
‘‘(2) providing technical assistance and support
to such colleges.
‘‘(d) Any program receiving assistance under this sec-
tion that is conducted with respect to a health profession
shall also offer courses of study which provide advanced
training for any health professional who—
‘‘(1) has already received a degree or diploma
in such health profession, and
‘‘(2) provides clinical services on an Indian res-
ervation, at a Service facility, or at a tribal clinic.
Such courses of study may be offered in conjunction with
the college or university with which the community college
has entered into the agreement required under subsection
(b)(2)(C).
‘‘(e) For purposes of this section:
‘‘(1) The term ‘community college’ means—
‘‘(A) a tribally controlled college, or
‘‘(B) a junior or community college.
‘‘(2) The term ‘tribally controlled college’ has
the meaning given to ‘tribally controlled community
college’ by section 2(4) of the Tribally Controlled
Community College Assistance Act of 1978.
‘‘(3) The term ‘junior or community college’
has the meaning given to such term by section
312(e) of the Higher Education Act of 1965 (20
U.S.C. 1058(e)).
‘‘(4) Where the requirements of subsection (b)
are met, funding priority shall be provided to tribally
controlled colleges in service areas where they exist.
‘‘SEC. 119. RETENTION BONUS.
‘‘(a) The Secretary may pay a retention bonus to any
health professional employed by, or assigned to, and serv-
ing in, the Service and Indian tribes, tribal organizations,
or urban Indian organizations either as a civilian employee
or as a commissioned officer in the Regular or Reserve
Corps of the Public Health Service who—
‘‘(1) is assigned to, and serving in, a position
for which recruitment or retention of personnel is
difficult,
‘‘(2) the Secretary determines is needed by the
Service, tribes, tribal organizations, and urban In-
dian organizations,
‘‘(3) has—
‘‘(A) completed 3 years of employment
with the Service, or Indian tribe, or tribal orga-
nization, or urban Indian organization, or
‘‘(B) completed any service obligations in-
curred as a requirement of—
‘‘(i) any Federal scholarship program,
or
‘‘(ii) any Federal education loan re-
payment program, and
‘‘(4) enters into an agreement with the Service,
or Indian tribe, or tribal organization, or urban In-
dian organization for continued employment for a
period of not less than 1 year.
‘‘(b) The Secretary may establish rates for the reten-
tion bonus which shall provide for a higher annual rate
for multiyear agreements than for single year agreements
referred to in subsection (a)(4), but in no event shall the
annual rate be more than $25,000 per annum.
‘‘(c) Any health professional failing to complete the
agreed upon term of service, except where such failure is
through no fault of the individual, shall be obligated to
refund to the Government the full amount of the retention
bonus for the period covered by the agreement, plus inter-
est as determined by the Secretary in accordance with sec-
tion 110(l)(2)(B).
‘‘(d) The Secretary may pay a retention bonus to any
health professional employed by an organization providing
health care services to Indians pursuant to a funding
agreement under the Indian Self-Determination and Edu-
cation Assistance Act if such health professional is serving
in a position which the Secretary determines is—
‘‘(1) a position for which recruitment or reten-
tion is difficult; and
‘‘(2) necessary for providing health care services
to Indians.
‘‘SEC. 120. NURSING RESIDENCY PROGRAM.
‘‘(a) The Secretary shall establish a program to en-
able Indians who are licensed practical nurses, licensed vo-
cational nurses, and registered nurses who are working in
an Indian health program (as defined in section
110(a)(2)(A)), and have done so for a period of not less
than one year, to pursue advanced training.
‘‘(b) Such program shall include a combination of
education and work study in an Indian health program
(as defined in section 110(a)(2)(A)) leading to an asso-
ciate or bachelor’s degree (in the case of a licensed prac-
tical nurse or licensed vocational nurse) or a bachelor’s
degree (in the case of a registered nurse), or advanced
degrees in nursing and public health.
‘‘(c) An individual who participates in a program
under subsection (a), where the educational costs are paid
by the Service, shall incur an obligation to serve in an
Indian health program for a period of obligated service
equal to the amount of time during which the individual
participates in such program. In the event that the indi-
vidual fails to complete such obligated service, the United
States shall be entitled to recover from such individual an
amount determined in accordance with the formula speci-
fied in subsection (l) of section 110 in the manner pro-
vided for in such subsection.
‘‘SEC. 121. COMMUNITY HEALTH AIDE PROGRAM FOR
ALASKA.
‘‘(a) Under the authority of the Act of November 2,
1921 (25 U.S.C. 13; popularly known as the Snyder Act),
the Secretary shall maintain a Community Health Aide
Program in Alaska under which the Service—
‘‘(1) provides for the training of Alaska Natives
as health aides or community health practitioners;
‘‘(2) uses such aides or practitioners in the pro-
vision of health care, health promotion, and disease
prevention services to Alaska Natives living in vil-
lages in rural Alaska; and
‘‘(3) provides for the establishment of tele-
conferencing capacity in health clinics located in or
near such villages for use by community health aides
or community health practitioners.
‘‘(b) The Secretary, acting through the Community
Health Aide Program of the Service, shall—
‘‘(1) using trainers accredited by the Program,
provide a high standard of training to community
health aides and community health practitioners to
ensure that such aides and practitioners provide
quality health care, health promotion, and disease
prevention services to the villages served by the Pro-
gram;
‘‘(2) in order to provide such training, develop
a curriculum that—
‘‘(A) combines education in the theory of
health care with supervised practical experience
in the provision of health care;
‘‘(B) provides instruction and practical ex-
perience in the provision of acute care, emer-
gency care, health promotion, disease preven-
tion, and the efficient and effective manage-
ment of clinic pharmacies, supplies, equipment,
and facilities; and
‘‘(C) promotes the achievement of the
health status objectives specified in section
3(b);
‘‘(3) establish and maintain a Community
Health Aide Certification Board to certify as com-
munity health aides or community health practi-
tioners individuals who have successfully completed
the training described in paragraph (1) or can dem-
onstrate equivalent experience;
‘‘(4) develop and maintain a system which iden-
tifies the needs of community health aides and com-
munity health practitioners for continuing education
in the provision of health care, including the areas
described in paragraph (2)(B), and develop pro-
grams that meet the needs for such continuing edu-
cation;
‘‘(5) develop and maintain a system that pro-
vides close supervision of community health aides
and community health practitioners; and
‘‘(6) develop a system under which the work of
community health aides and community health prac-
titioners is reviewed and evaluated to assure the pro-
vision of quality health care, health promotion, and
disease prevention services.
‘‘(c) Subject to section 102, the Secretary shall de-
velop and operate a National Community Health Aide
Program based on the elements contained in this section.
‘‘SEC. 122. TRIBAL HEALTH PROGRAM ADMINISTRATION.
‘‘Subject to section 102, the Secretary shall, by fund-
ing agreement or otherwise, provide training for Indians
in the administration and planning of tribal health pro-
grams.
‘‘SEC. 123. HEALTH PROFESSIONAL CHRONIC SHORTAGE
DEMONSTRATION PROJECT.
‘‘(a) Subject to section 102, the Secretary may fund
pilot programs for tribes and tribal organizations to ad-
dress the chronic shortages of health professionals.
‘‘(b) The purposes of the health profession dem-
onstration program established herein are—
‘‘(1) to provide direct clinical and practical ex-
perience at a service unit to health profession stu-
dents and residents from medical schools;
‘‘(2) to improve the quality of health care for
Indians by assuring access to qualified health care
professionals; and
‘‘(3) to provide academic and scholarly opportu-
nities for health professionals serving Indian people
by identifying and using all academic and scholarly
resources of the region.
‘‘(c) The demonstration programs established pursu-
ant to subsection (a) shall incorporate a program advisory
board composed of representatives from the tribes and
communities in the area which will be served by the pro-
gram.
‘‘SEC. 124. TREATMENT OF SCHOLARSHIPS FOR CERTAIN
PURPOSES.
‘‘Scholarships provided to individuals pursuant to
this title shall be deemed ‘qualified Scholarships’ for pur-
poses of section 117 of the Internal Revenue Code of
1986.
‘‘SEC. 125. NATIONAL HEALTH SERVICE CORPS.
‘‘(a) The Secretary shall not—
‘‘(1) remove a member of the National Health
Service Corps from a health program operated by
‘‘SEC. 126. SUBSTANCE ABUSE COUNSELOR EDUCATION
DEMONSTRATION PROJECT.
‘‘(a) The Secretary may enter into contracts with, or
make grants to, accredited tribally controlled community
colleges, tribally controlled postsecondary vocational insti-
tutions, and eligible accredited and accessible community
colleges to establish demonstration projects to develop
educational curricula for substance abuse counseling.
‘‘(b) Funds provided under this section shall be used
only for developing and providing educational curriculum
for substance abuse counseling (including paying salaries
for instructors). Such curricula may be provided through
satellite campus programs.
‘‘(c) A contract entered into or a grant provided
under this section shall be for a period of one year. Such
contract or grant may be renewed for an additional one-
year period upon the approval of the Secretary.
‘‘(d) Not later than 180 days after the date of the
enactment of this section, the Secretary, after consultation
with Indian tribes and administrators of accredited trib-
ally controlled community colleges, tribally controlled post-
secondary vocational institutions, and eligible accredited
and accessible community colleges, shall develop and issue
criteria for the review and approval of applications for
funding (including applications for renewals of funding)
under this section. Such criteria shall ensure that dem-
onstration projects established under this section promote
the development of the capacity of such entities to educate
substance abuse counselors.
‘‘(e) The Secretary shall provide such technical and
other assistance as may be necessary to enable grant re-
cipients to comply with the provisions of this section.
‘‘(f) The Secretary shall submit to the President, for
inclusion in the report which is required to be submitted
under section 801 for fiscal year 2000 a report on the
findings and conclusions derived from the demonstration
projects conducted under this section.
‘‘(g) For the purposes of this section, the following
definitions apply:
‘‘(1) The term ‘educational curriculum’ means
one or more of the following:
‘‘(A) Classroom education.
‘‘(B) Clinical work experience.
‘‘(C) Continuing education workshops.
‘‘(2) The term ‘tribally controlled postsecondary
vocational institution’ has the meaning given such
term in section 390(2) of the Tribally Controlled Vo-
cational Institutions Support Act of 1990 (20 U.S.C.
2397h(2)).
‘‘SEC. 127. MENTAL HEALTH TRAINING AND COMMUNITY
EDUCATION PROGRAMS.
‘‘(a)(1) The Secretary and the Secretary of the Inte-
rior, in consultation with Indian tribes and tribal organi-
zations, shall conduct a study and compile a list of the
types of staff positions specified in subsection (b) whose
qualifications include, or should include, training in the
identification, prevention, education, referral, or treatment
of mental illness, or dysfunctional and self-destructive be-
havior.
‘‘(2) The positions referred to in subsection (a) are—
‘‘(A) staff positions within the Bureau of In-
dian Affairs, including existing positions, in the
fields of—
‘‘(i) elementary and secondary education;
‘‘(ii) social services and family and child
welfare;
‘‘(iii) law enforcement and judicial services;
and
‘‘(iv) alcohol and substance abuse;
‘‘(B) staff positions within the Service; and
‘‘(C) staff positions similar to those identified
in subsection (b) established and maintained by In-
dian tribes, tribal organizations, and urban Indian
organizations, including positions established pursu-
ant to funding agreements pursuant to the Indian
Self-Determination and Education Assistance Act,
and this Act.
‘‘(3) The appropriate Secretary shall provide training
criteria appropriate to each type of position identified in
subsection (b)(1) and ensure that appropriate training has
been, or shall be provided to any individual in any such
position. With respect to any such individual in a position
identified pursuant to subsection (b)(3), the respective
Secretaries shall provide appropriate training to, or pro-
vide funds to an Indian tribe, tribal organization, or urban
Indian organization for training of appropriate individ-
uals. In the case of a funding agreement, the appropriate
Secretary shall ensure that such training costs are in-
cluded in the funding agreement, if necessary.
‘‘(4) Position-specific training criteria shall be cul-
turally relevant to Indians and Indian tribes and shall en-
sure that appropriate information regarding traditional
health care practices is provided.
‘‘(5) The Service shall develop and implement, or on
request of an Indian tribe or tribal organization, assist
an Indian tribe or tribal organization, to develop and im-
plement, a program of community education on mental ill-
ness. In carrying out this subsection, the Service shall,
upon request of an Indian tribe or tribal organization, pro-
vide technical assistance to an Indian tribe or tribal orga-
nization to obtain and develop community educational ma-
terials on the identification, technical assistance to the In-
dian tribe or tribal organization to obtain or develop mate-
rials on the identification, prevention, referral, and treat-
ment of mental illness, dysfunctional, and self-destructive
behavior.
‘‘(b)(1) Within 90 days after the date of the enact-
ment of the Indian Health Care Improvement Act Amend-
ments of 2001, the Secretary shall develop a plan under
which the Service will increase the health care staff pro-
viding mental health services by at least 500 positions
within 5 years after the date of enactment of this section,
with at least 200 of such positions devoted to child, adoles-
cent, and family services. The allocation of such positions
shall be subject to the provisions of section 102(a).
‘‘(2) The plan developed under paragraph (1) shall
be implemented under the Act of November 2, 1921 (25
U.S.C. 13), popularly known as the Snyder Act.
‘‘SEC. 128. AUTHORIZATION OF APPROPRIATIONS.
‘‘There are authorized to be appropriated such sums
as may be necessary for each fiscal year through fiscal
year 2013 to carry out this title.
‘‘TITLE II—HEALTH SERVICES
‘‘SEC. 201. INDIAN HEALTH CARE IMPROVEMENT FUND.
‘‘(a) The Secretary is authorized to expend funds, di-
rectly or under the authority of the Indian Self-Deter-
mination and Education Assistance Act, which are appro-
priated under the authority of this section, for the purpose
of—
‘‘(1) eliminating the deficiencies in health sta-
tus and resources of all Indian tribes,
‘‘(2) eliminating backlogs in the provision of
health care services to Indians,
‘‘(3) meeting the health needs of Indians in an
efficient and equitable manner,
‘‘(4) eliminating inequities in funding for both
direct care and contract health service programs,
and
‘‘(5) augmenting the ability of the Service to
meet the following health service responsibilities,
with respect to those Indian tribes with the highest
levels of health status deficiencies and resource defi-
ciencies:
‘‘(A) Clinical care, including, but not lim-
ited to, inpatient care, outpatient care (includ-
ing audiology, clinical eye and vision care), pri-
mary care, secondary and tertiary care, and
long-term care.
‘‘(B) Preventive health, including mam-
mography and other cancer screening in accord-
ance with section 207.
‘‘(C) Dental care.
‘‘(D) Mental Health, including community
mental health services, inpatient mental health
services, dormitory mental health services,
therapeutic and residential treatment centers,
and training of traditional health care practi-
tioners.
‘‘(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 health care.
‘‘(I) Community health representatives.
‘‘(J) Maintenance and repair.
‘‘(K) Traditional health care practices.
‘‘(b)(1) Any funds appropriated under the authority
of this section shall not be used to offset or limit any other
appropriations made to the Service under this Act or the
Act of November 2, 1921 (25 U.S.C. 13), popularly known
as the Snyder Act, or any other provision of law.
‘‘(2)(A) Funds appropriated under the authority of
this section shall be allocated to service units or Indian
tribes or tribal organizations. The funds allocated to each
Tribe, tribal organization, or service unit under this sub-
paragraph shall be used by the Tribe, tribal organization,
or service unit under this subparagraph to improve the
health status and reduce the resource deficiency of each
Tribe served by such service unit, Tribe, or tribal organi-
zation.
‘‘(B) The apportionment of funds allocated to a serv-
ice unit, Tribe, or tribal organization under subparagraph
(A) among the health service responsibilities described in
subsection (a)(4) shall be determined by the Service in
consultation with, and with the active participation of, the
affected Indian tribes in accordance with the provisions
of this section and such rulemaking as is permitted under
title VIII of this Act.
‘‘(c) For purposes of this section:
‘‘(1) The term ‘health status and resource defi-
ciency’ means the extent to which—
‘‘(A) the health status objectives set forth
in section 3(b) are not being achieved; and
‘‘SEC. 202. CATASTROPHIC HEALTH EMERGENCY FUND.
‘‘(a)(1) There is hereby established an Indian Cata-
strophic Health Emergency Fund (hereafter in this sec-
tion referred to as the ‘CHEF’) consisting of—
‘‘(A) the amounts deposited under subsection
(d), and
‘‘(B) the amounts appropriated under sub-
section (e) to CHEF under this section.
‘‘(2) CHEF shall be administered by the Secretary,
solely for the purpose of meeting the extraordinary med-
ical costs associated with the treatment of victims of disas-
ters or catastrophic illnesses who are within the responsi-
bility of the Service.
‘‘(3) CHEF shall be equitably allocated, apportioned,
or delegated on a service unit or Area Office basis, based
upon a formula developed in consultation with the Indian
tribes and tribal organizations through negotiated rule-
making under title VIII of this Act, which formula shall
take into account the added needs of service areas which
are contract health-service dependent.
‘‘(4) No part of CHEF or its administration shall be
subject to contract or grant under any law, including the
Indian Self-Determination Act, and shall be administered
by the Area Offices based upon priorities determined by
the Indian tribes and tribal organizations within each Area
including consideration of the needs of Indian tribes and
tribal organizations which are contract health service-de-
pendent.
‘‘(b) The Secretary shall, through the negotiated rule-
making process under title VIII of this Act, promulgate
regulations consistent with the provisions of this section—
‘‘(1) establish a definition of disasters and cata-
strophic illnesses for which the cost of the treatment
provided under contract would qualify for payment
from the Fund;
‘‘(2) provide that a service unit, Indian tribe, or
tribal organization shall not be eligible for reim-
bursement for the cost of treatment from CHEF
until its cost of treating any victim of such cata-
strophic illness or disaster has reached a certain
threshold cost which the Secretary shall establish
at—
‘‘(A) the 2000 level of $19,000; and
‘‘(B) for any subsequent year, not less
than the threshold cost of the previous year in-
creased by the percentage increase in the med-
ical care expenditure category of the consumer
price index for all urban consumers (United
States city average) for the 12-month period
ending with December of the previous year; and
‘‘(3) establish a procedure for the reimburse-
ment of the portion of the costs incurred by—
‘‘(A) service units, Indian tribes or tribal
organizations, or facilities of the Service, or
‘‘(B) whenever otherwise authorized by the
Service, non-Service facilities or providers,
in rendering treatment that exceeds such threshold
cost;
‘‘(4) establish a procedure for payment from
CHEF in cases in which the exigencies of the med-
ical circumstances warrant treatment prior to the
authorization of such treatment by the Service; and
‘‘(5) establish a procedure that will ensure that
no payment shall be made from CHEF to any pro-
vider of treatment to the extent that such provider
is eligible to receive payment for the treatment from
any other Federal, State, local, or private source of
reimbursement for which the patient is eligible.
‘‘(c) Amounts appropriated to CHEF under this sec-
tion shall not be used to offset or limit appropriations
made to the Service under the authority of the Act of No-
vember 2, 1921 (25 U.S.C. 13), popularly known as the
Snyder Act, or any other law.
‘‘(d) There shall be deposited into CHEF all reim-
bursements to which the Service is entitled from any Fed-
eral, State, local, or private source (including third-party
insurance) by reason of treatment rendered to any victim
of a disaster or catastrophic illness the cost of which was
paid from CHEF.
‘‘SEC. 203. HEALTH PROMOTION AND DISEASE PREVENTION
SERVICES.
‘‘(a) The Congress finds that health promotion and
disease prevention activities will—
‘‘(1) improve the health and well-being of Indi-
ans, and
‘‘(2) reduce the expenses for health care of In-
dians.
‘‘(b) The Secretary, acting through the Service, and
through willing Indian tribes and tribal organizations,
shall provide health promotion and disease prevention
services to Indians so as to achieve the health status objec-
tives set forth in section 3(b).
‘‘(c) The Secretary, after obtaining input from the
affected Indian tribes and tribal organizations, shall sub-
mit to the President for inclusion in each statement which
is required to be submitted to the Congress under section
801 an evaluation of—
‘‘(1) the health promotion and disease preven-
tion needs of Indians;
‘‘(2) the health promotion and disease preven-
tion activities which would best meet such needs;
‘‘(3) the internal capacity of the Service to meet
such needs; and
‘‘(4) the resources which would be required to
enable the Service to undertake the health promotion
and disease prevention activities necessary to meet
such needs.
‘‘SEC. 204. DIABETES PREVENTION, TREATMENT, AND CON-
TROL.
‘‘(a) The Secretary, in consultation with the Indian
tribes and tribal organizations, shall determine—
‘‘(1) by tribe, tribal organization, and by Serv-
ice unit of the Service, the incidence of, and the
types of complications resulting from, diabetes
among Indians; and
‘‘(2) based on paragraph (1), the measures (in-
cluding patient education) each Service unit should
take to reduce the incidence of, and prevent, treat,
and control the complications resulting from, diabe-
tes among Indian tribes within that Service unit.
‘‘(b) The Secretary shall screen each Indian who re-
ceives services from the Service for diabetes and for condi-
tions which indicate a high risk that the individual will
become diabetic. Such screening may be done by a tribe
or tribal organization operating health care programs or
facilities with funds from the Service under the Indian
Self-Determination and Education Assistance Act.
‘‘(c) The Secretary shall continue to fund through fis-
cal year 2013 each model diabetes project in existence on
the date of the enactment of the Indian Health Amend-
ments of 2001 and any such other diabetes programs op-
erated by the Secretary or Indian tribes and tribal organi-
zations and any additional programs added to meet exist-
ing needs. Indian tribes and tribal organizations shall re-
ceive recurring funding for the diabetes programs which
they operate pursuant to this section.
‘‘(d) The Secretary shall provide funding through the
Service, Indian tribes, and tribal organizations to establish
dialysis programs, including funding to purchase dialysis
equipment and provide necessary staffing.
‘‘(e) The Secretary shall, to the extent funding is
available—
‘‘(1) in each Area Office of the Service, consult
with Indian tribes and tribal organizations regarding
programs for the prevention, treatment, and control
of diabetes;
‘‘(2) establish in each Area Office of the Service
a registry of patients with diabetes to track the inci-
dence of diabetes and the complications from diabe-
tes in that area; and
‘‘(3) ensure that data collected in each Area Of-
fice regarding diabetes and related complications
among Indians is disseminated to all other Area Of-
fices.
‘‘SEC. 205. SHARED SERVICES.
‘‘(a) The Secretary is authorized to enter into fund-
ing agreements or other arrangements with Indian tribes
or tribal organizations for the delivery of long-term care
and similar services to Indians. Such projects shall provide
for the sharing of staff or other services between a Service
or tribal facility and a long-term care or other similar fa-
cility owned and operated (directly or through funding
agreement) by such Indian tribe or tribal organization.
‘‘(b) A funding agreement or other arrangement en-
tered into pursuant to subsection (a)—
‘‘(1) may, at the request of the Indian tribe or
tribal organization, delegate to such tribe or tribal
organization such powers of supervision and control
over Service employees as the Secretary deems nec-
essary to carry out the purposes of this section;
‘‘(2) shall provide that expenses (including sala-
ries) relating to services that are shared between the
Service and the tribal facility be allocated propor-
tionately between the Service and the tribe or tribal
organization; and
‘‘(3) may authorize such tribe or tribal organi-
zation to construct, renovate, or expand a long-term
care or other similar facility (including the construc-
tion of a facility attached to a Service facility).
‘‘(c) The Secretary shall provide such technical and
other assistance as may be necessary to enable applicants
to comply with the provisions of this section.
‘‘(d) The Secretary shall encourage the use for long-
term or similar care of existing facilities that are
underused or allow the use of swing beds for such pur-
poses.
‘‘SEC. 206. HEALTH SERVICES RESEARCH.
‘‘The Secretary shall make funding available for re-
search to further the performance of the health service re-
sponsibilities of the Service, Indian tribes, and tribal orga-
nizations and shall coordinate the activities of other agen-
cies within the Department of Health and Human Services
to address these research needs. The funding shall be di-
vided equitably among the Area Offices and then each
Area Office shall award the funds competitively within
that Area. Indian tribes and tribal organizations receiving
funding from the Service under the authority of the Indian
Self-Determination and Education Assistance Act shall be
given an equal opportunity to compete for, and receive,
research funds under this section. This funding may be
used for both clinical and nonclinical research by Indian
tribes and tribal organizations and shall be distributed to
the Area Offices which may make grants from these funds
within each Area.
‘‘SEC. 207. MAMMOGRAPHY AND OTHER CANCER SCREEN-
ING.
‘‘The Secretary, through the Service or through In-
dian tribes or tribal organizations, shall provide for screen-
ing, as follows:
‘‘(1) Mammography (as defined in section
1861(jj) of the Social Security Act) for Indian
women at a frequency appropriate to such women
under national standards, and under such terms and
conditions as are consistent with standards estab-
lished by the Secretary to ensure the safety and ac-
curacy of screening mammography under part B of
title XVIII of the Social Security Act.
‘‘(2) Other cancer screening meeting national
standards.
‘‘SEC. 208. PATIENT TRAVEL COSTS.
‘‘The Secretary, acting through the Service and will-
ing Indian tribes and tribal organizations, shall provide
funds for the following patient travel costs, including ap-
propriate and necessary qualified escorts, associated with
receiving health care services provided (either through di-
rect or contract care or through funding agreements en-
tered into pursuant to the Indian Self-Determination and
Education Assistance Act) under this Act—
‘‘(1) 
emergency 
air 
transportation 
non-
emergency air transportation where ground trans-
portation is infeasible;
‘‘(2) transportation by private vehicle, specially
equipped vehicle and ambulance; and
‘‘(3) transportation by such other means as
may be available and required when air or motor ve-
hicle transportation is not available.
‘‘SEC. 209. EPIDEMIOLOGY CENTERS.
‘‘(a)(1) In addition to those centers already estab-
lished at the time of enactment of this Act (including those
for which funding is currently being provided in funding
agreements under the Indian Self-Determination and
Education Assistance Act), within 180 days of enactment
of the Indian Health Care Improvement Act Amendments
of 2001, the Secretary shall establish and fund an epide-
miology center in each service area which does not yet
have one to carry out the functions described in paragraph
(2). Any new centers so established may be operated by
Indian tribes or tribal organizations pursuant to funding
agreements under the Indian Self-Determination and
Education Assistance Act, but such funding may not be
divisible.
‘‘(2) In consultation with and upon the request of In-
dian tribes, tribal organizations, and urban Indian organi-
zations, each area epidemiology center established under
this subsection shall, with respect to such area carry out—
‘‘(A) collect data relating to, and monitor
progress made toward meeting, each of the health
status objectives of the Indian Health Service, the
Indian tribes, tribal organizations, and urban Indian
organizations in the Area;
‘‘(B) evaluate existing delivery systems, data
systems, and other systems that impact the improve-
ment of Indian health;
‘‘(C) assist Indian tribes, tribal organizations,
and urban Indian organizations in identifying their
highest priority health status objectives and the
services needed to achieve such objectives, based on
epidemiological data;
‘‘(D) make recommendations for the targeting
of services needed by tribal, urban, and other Indian
communities;
‘‘(E) make recommendations to improve health
care delivery systems for Indians and urban Indians;
‘‘(F) provide requested technical assistance to
Indian tribes and urban Indian organizations in the
development of local health service priorities and in-
cidence and prevalence rates of disease and other ill-
ness in the community; and
‘‘(G) provide disease surveillance and assist In-
dian tribes, tribal organizations, and urban Indian
organizations to promote public health.
‘‘(3) The Director of the Centers for Disease Control
and Prevention shall provide technical assistance to the
centers in carrying out the requirements of this sub-
section.
‘‘(b) The Secretary may make funding available to
Indian tribes, tribal organizations, and urban Indian orga-
nizations to conduct epidemiological studies of Indian
communities.
‘‘SEC. 210. COMPREHENSIVE SCHOOL HEALTH EDUCATION
PROGRAMS.
‘‘(a) The Secretary shall provide funding to Indian
tribes, tribal organizations and urban Indian organizations
to develop comprehensive school health education pro-
grams for children from preschool through grade 12 in
schools for the benefit of Indian and urban Indian chil-
dren.
100
‘‘(b) Funding provided under this section may be
used for purposes which may include, but are not limited
to the following:
‘‘(1) Developing and implementing health edu-
cation curricula both for regular school programs
and after-school programs.
‘‘(2) Training teachers in comprehensive school
health education curricula.
‘‘(3) 
Integrating 
school-based, 
community-
based, and other public and private health promotion
efforts.
‘‘(4) Encouraging healthy, tobacco-free school
environments.
‘‘(5) Coordinating school-based health programs
with existing services and programs available in the
community.
‘‘(6) Developing school programs on nutrition
education, personal health, oral health, and fitness.
‘‘(7) Developing mental health wellness pro-
grams.
‘‘(8) Developing chronic disease prevention pro-
grams.
‘‘(9) Developing substance abuse prevention
programs.
101
‘‘(10) Developing injury prevention and safety
education programs.
‘‘(11) Developing activities for the prevention
and control of communicable diseases.
‘‘(12) Developing community and environmental
health education programs that include traditional
health care practitioners.
‘‘(13) Violence prevention.
‘‘(14) Such other health issues as are appro-
priate.
‘‘(c) Upon request, the Secretary shall provide tech-
nical assistance to Indian tribes, tribal organizations, and
urban Indian organizations in the development of com-
prehensive health education plans, and the dissemination
of comprehensive health education materials and informa-
tion on existing health programs and resources.
‘‘(d) The Secretary, in consultation with Indian
tribes, tribal organizations, and urban Indian organiza-
tions, shall establish criteria for the review and approval
of applications for funding provided pursuant to this sec-
tion.
‘‘(e)(1) The Secretary of the Interior, acting through
the Bureau of Indian Affairs and in cooperation with the
Secretary and the affected Indian tribes and tribal organi-
zations, shall develop a comprehensive school health edu-
102
cation program for children from preschool through grade
12 in schools operated by the Bureau of Indian Affairs.
‘‘(2) Such programs shall include—
‘‘(A) school programs on nutrition education,
personal health, oral health, and fitness;
‘‘(B) mental health wellness programs;
‘‘(C) chronic disease prevention programs;
‘‘(D) substance abuse prevention programs;
‘‘(E) injury prevention and safety education
programs; and
‘‘(F) activities for the prevention and control of
communicable diseases.
‘‘(3) The Secretary of the Interior shall—
‘‘(A) provide training to teachers in comprehen-
sive school health education curricula;
‘‘(B) ensure the integration and coordination of
school-based programs with existing services and
health programs available in the community; and
‘‘(C) encourage healthy, tobacco-free school en-
vironments.
‘‘SEC. 211. INDIAN YOUTH PROGRAM.
‘‘(a) The Secretary is authorized to provide funding
to Indian tribes, tribal organizations, and urban Indian
organizations for innovative mental and physical disease
prevention and health promotion and treatment programs
103
for Indian and urban Indian preadolescent and adolescent
youths.
‘‘(b)(1) Funds made available under this section may
be used to—
‘‘(A) develop prevention and treatment pro-
grams for Indian youth which promote mental and
physical health and incorporate cultural values, com-
munity and family involvement, and traditional
health care practitioners; and
‘‘(B) develop and provide community training
and education.
‘‘(2) Funds made available under this section may
not be used to provide services described in section 707(c).
‘‘(c) The Secretary shall—
‘‘(1) disseminate to Indian tribes, tribal organi-
zations, and urban Indian organizations information
regarding models for the delivery of comprehensive
health care services to Indian and urban Indian ado-
lescents;
‘‘(2) encourage the implementation of such
models; and
‘‘(3) at the request of an Indian tribe, tribal or-
ganization, or urban Indian organization, provide
technical assistance in the implementation of such
models.
104
‘‘(d) The Secretary, in consultation with Indian
tribes, tribal organizations, and urban Indian organiza-
tions, shall establish criteria for the review and approval
of applications or proposals under this section.
‘‘SEC. 212. PREVENTION, CONTROL, AND ELIMINATION OF
COMMUNICABLE AND INFECTIOUS DISEASES.
‘‘(a) The Secretary, after consultation with Indian
tribes, tribal organizations, and urban Indian organiza-
tions, and the Centers for Disease Control and Prevention,
may make funding available to Indian tribes and tribal
organizations for—
‘‘(1) projects for the prevention, control, and
elimination of communicable and infectious diseases
including, but not limited to, tuberculosis, hepatitis,
HIV, respiratory syncitial virus, hanta virus, sexu-
ally transmitted diseases, and H. Pylori;
‘‘(2) public information and education programs
for the prevention, control, and elimination of com-
municable and infectious diseases; and
‘‘(3) education, training, and clinical skills im-
provement activities in the prevention, control, and
elimination of communicable and infectious diseases
for health professionals, including allied health pro-
fessionals.
105
‘‘(b) The Secretary may provide funding under sub-
section (a) only if an application or proposal for funding
is submitted to the Secretary.
‘‘(c) Indian tribes and tribal organizations receiving
funding under this section are encouraged to coordinate
their activities with the Centers for Disease Control and
Prevention and State and local health agencies.
‘‘(d) In carrying out this section, the Secretary—
‘‘(1) may, at the request of an Indian tribe or
tribal organization, provide technical assistance; and
‘‘(2) shall prepare and submit a report to the
Congress biennially on the use of funds under this
section and on the progress made toward the preven-
tion, control, and elimination of communicable and
infectious diseases among Indians and urban Indi-
ans.
‘‘SEC. 213. AUTHORITY FOR PROVISION OF OTHER SERV-
ICES.
‘‘(a) The Secretary, acting through the Service and
willing tribes and tribal organizations, may provide fund-
ing under this Act to meet the objectives set forth in sec-
tion 3 of this Act through health care related services and
programs not otherwise described in this Act, which shall
include, but not be limited to—
‘‘(1) hospice care and assisted living;
106
‘‘(2) long-term health care;
‘‘(3) home- and community-based services;
‘‘(4) public health functions; and
‘‘(5) traditional health care practices.
‘‘(b) At the discretion of the Service, Indian tribes,
or tribal organizations, services provided for hospice care,
home health care (under section 201 of this Act), home-
and community-based care, assisted living, and long-term
care may be provided (on a cost basis) to persons other-
wise ineligible for the health care benefits of the Service.
Any funds received under this subsection shall not be used
to offset or limit the funding allocated to a tribe or tribal
organization.
‘‘(c) For the purposes of this section, the following
definitions shall apply:
‘‘(1) The term ‘hospice care’ means the items
and services specified in subparagraphs (A) through
(H) of section 1861(dd)(1) of the Social Security
Act (42 U.S.C. 1395x(dd)(1)), and such other serv-
ices which a tribe or tribal organization determines
are necessary and appropriate to provide in further-
ance of this care.
‘‘(2) The term ‘home- and community-based
services’ means 1 or more of the following:
107
‘‘(A) Homemaker/home health aide serv-
ices.
‘‘(B) Chore services.
‘‘(C) Personal care services.
‘‘(D) Nursing care services provided out-
side of a nursing facility by, or under the super-
vision of, a registered nurse.
‘‘(E) Training for family members.
‘‘(F) Adult day care.
‘‘(G) Such other home- and community-
based services as the Secretary or a tribe or
tribal organization may approve.
‘‘(3) The term ‘public health functions’ means
the provision of public health related programs,
functions, and services including, but not limited to,
assessment, assurance, and policy development which
Indian tribes and tribal organizations are authorized
and encouraged, in those circumstances where it
meets their needs, to do by forming collaborative re-
lationships with all levels of local, State, and Federal
Government.
‘‘SEC. 214. INDIAN WOMEN’S HEALTH CARE.
‘‘The Secretary, acting through the Service and will-
ing Indian tribes, tribal organizations, and urban Indian
organizations, shall provide funding to monitor and im-
108
prove the quality of health care for Indian women of all
ages through the planning and delivery of programs ad-
ministered by the Service, in order to improve and enhance
the treatment models of care for Indian women.
‘‘SEC. 215. ENVIRONMENTAL AND NUCLEAR HEALTH HAZ-
ARDS.
‘‘(a) The Secretary and the Service shall conduct, in
conjunction with other appropriate Federal agencies and
in consultation with concerned Indian tribes and tribal or-
ganizations, studies and ongoing monitoring programs to
determine trends in the health hazards to Indian miners
and to Indians on or near Indian reservations and in In-
dian communities as a result of environmental hazards
which may result in chronic or life-threatening health
problems, such as nuclear resource development, petro-
leum contamination, and contamination of water source
and of the food chain. Such study shall include—
‘‘(1) an evaluation of the nature and extent of
health problems caused by environmental hazards
currently exhibited among Indians and the causes of
such health problems;
‘‘(2) an analysis of the potential effect of ongo-
ing and future environmental resource development
on or near Indian reservations and communities in-
cluding the cumulative effect over time on health;
109
‘‘(3) an evaluation of the types and nature of
activities, practices, and conditions causing or affect-
ing such health problems including, but not limited
to, uranium mining and milling, uranium mine tail-
ing deposits, nuclear power plant operation and con-
struction, and nuclear waste disposal; oil and gas
production or transportation on or near Indian res-
ervations or communities; and other development
that could affect the health of Indians and their
water supply and food chain;
‘‘(4) a summary of any findings and rec-
ommendations provided in Federal and State stud-
ies, reports, investigations, and inspections during
the 5 years prior to the date of the enactment of
this section that directly or indirectly relate to the
activities, practices, and conditions affecting the
health or safety of such Indians; and
‘‘(5) the efforts that have been made by Federal
and State agencies and resource and economic devel-
opment companies to effectively carry out an edu-
cation program for such Indians regarding the
health and safety hazards of such development.
‘‘(b) Upon completion of such study the Secretary
and the Service shall take into account the results of such
study and, in consultation with Indian tribes and tribal
110
organizations, develop health care plans to address the
health problems studied under subsection (a). The plans
shall include—
‘‘(1) methods for diagnosing and treating Indi-
ans currently exhibiting such health problems;
‘‘(2) preventive care and testing for Indians
who may be exposed to such health hazards, includ-
ing the monitoring of the health of individuals who
have or may have been exposed to excessive amounts
of radiation, or affected by other activities that have
had or could have a serious impact upon the health
of such individuals; and
‘‘(3) a program of education for Indians who,
by reason of their work or geographic proximity to
such nuclear or other development activities, may ex-
perience health problems.
‘‘(c) The Secretary and the Service shall submit to
Congress the study prepared under subsection (a) no later
than the date 18 months after the date of enactment of
this section. The health care plan prepared under sub-
section (b) shall be submitted in a report no later than
the date 1 year after the date that the study prepared
under subsection (a) is submitted to Congress. Such re-
port shall include recommended activities for the imple-
mentation of the plan, as well as an evaluation of any ac-
111
tivities previously undertaken by the Service to address
such health problems.
‘‘(d)(1) There is established an Intergovernmental
Task Force to be composed of the following individuals
(or their designees): The Secretary of Energy, the Admin-
istrator of the Environmental Protection Agency, the Di-
rector of the Bureau of Mines, the Assistant Secretary for
Occupational Safety and Health, and the Secretary of the
Interior.
‘‘(2) The Task Force shall identify existing and po-
tential operations related to nuclear resource development
or other environmental hazards that affect or may affect
the health of Indians on or near an Indian reservation or
in an Indian community and enter into activities to correct
existing health hazards and ensure that current and future
health problems resulting from nuclear resource or other
development activities are minimized or reduced.
‘‘(3) The Secretary shall be Chairman of the Task
Force. The Task Force shall meet at least twice each year.
Each member of the Task Force shall furnish necessary
assistance to the Task Force.
‘‘(e) In the case of any Indian who—
‘‘(1) as a result of employment in or near a
uranium mine or mill or near any other environ-
112
mental hazard, suffers from a work related illness or
condition;
‘‘(2) is eligible to receive diagnosis and treat-
ment services from a Service facility; and
‘‘(3) by reason of such Indian’s employment, is
entitled to medical care at the expense of such mine
or mill operator or entity responsible for the environ-
mental hazard,
the Service shall, at the request of such Indian, render
appropriate medical care to such Indian for such illness
or condition and may recover the costs of any medical care
so rendered to which such Indian is entitled at the expense
of such operator or entity from such operator or entity.
Nothing in this subsection shall affect the rights of such
Indian to recover damages other than such costs paid to
the Service from the employer for such illness or condition.
‘‘SEC. 216. ARIZONA AS A CONTRACT HEALTH SERVICE DE-
LIVERY AREA.
‘‘(a) For fiscal years beginning with the fiscal year
ending September 30, 1983, and ending with the fiscal
year ending September 30, 2013, the State of Arizona
shall be designated as a contract health service delivery
area by the Service for the purpose of providing contract
health care services to members of federally recognized In-
dian tribes of Arizona.
113
‘‘(b) The Service shall not curtail any health care
services provided to Indians residing on Federal reserva-
tions in the State of Arizona if such curtailment is due
to the provision of contract services in such State pursu-
ant to the designation of such State as a contract health
service delivery area pursuant to subsection (a).
‘‘SEC. 217. CALIFORNIA CONTRACT HEALTH SERVICES PRO-
GRAM.
‘‘(a) The Secretary is authorized to fund a program
using California Rural Indian Health Board as a contract
care intermediary to improve the accessibility of health
services to California Indians.
‘‘(b)(1) The Secretary shall enter into an agreement
with the California Rural Indian Health Board to reim-
burse the Board for costs (including reasonable adminis-
trative costs) incurred pursuant to this section, in pro-
viding medical treatment under contract to California In-
dians described in section 809(b) throughout the Cali-
fornia contract health services delivery area described in
section 218 with respect to high-cost contract care cases.
‘‘(2) Not more than 5 percent of the amounts pro-
vided to the Board under this section for any fiscal year
may be for reimbursement for administrative expenses in-
curred by the Board during such fiscal year.
114
‘‘(3) No payment may be made for treatment pro-
vided hereunder to the extent payment may be made for
such treatment under the Catastrophic Health Emergency
Fund described in section 202 or from amounts appro-
priated or otherwise made available to the California con-
tract health service delivery area for a fiscal year.
‘‘(c) There is hereby established an advisory board
which shall advise the California Rural Indian Health
Board in carrying out the demonstration pursuant to this
section. The advisory board shall be composed of rep-
resentatives, selected by the California Rural Indian
Health Board, from not less than 8 tribal health programs
serving California Indians covered under such demonstra-
tion, at least one-half of whom are not affiliated with the
California Rural Indian Health Board.
‘‘SEC. 218. CALIFORNIA AS A CONTRACT HEALTH SERVICE
DELIVERY AREA.
‘‘The State of California, excluding the Counties of
Alameda, Contra Costa, Los Angeles, Marin, Orange, Sac-
ramento, San Francisco, San Mateo, Santa Clara, Kern,
Merced, Monterey, Napa, San Benito, San Joaquin, San
Luis Obispo, Santa Cruz, Solano, Stanislaus, and Ven-
tura, shall be designated as a contract health service deliv-
ery area by the Service for the purpose of providing con-
tract health services to Indians in such State. However,
115
any of the counties herein may be included in the contract
health services delivery area if funding is specifically pro-
vided by the Service for such services in those counties.
‘‘SEC. 219. CONTRACT HEALTH SERVICES FOR THE TREN-
TON SERVICE AREA.
‘‘(a) The Secretary is directed to provide contract
health services to members of the Turtle Mountain Band
of Chippewa Indians that reside in the Trenton Service
Area of Divide, McKenzie, and Williams Counties in the
State of North Dakota and the adjoining Counties of
Richland, Roosevelt, and Sheridan in the State of Mon-
tana.
‘‘(b) Nothing in this section may be construed as ex-
panding the eligibility of members of the Turtle Mountain
Band of Chippewa Indians for health services provided by
the Service beyond the scope of eligibility for such health
services that applied on May 1, 1986.
‘‘SEC. 220. PROGRAMS OPERATED BY INDIAN TRIBES AND
TRIBAL ORGANIZATIONS.
‘‘The Service shall provide funds for health care 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
116
are provided to programs and facilities operated directly
by the Service.
‘‘SEC. 221. LICENSING.
‘‘Health care 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 other State, be exempt from the
licensing requirements of the State in which the agreement
is performed.
‘‘SEC. 222. 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 this Act, the time limitation (as
a condition of payment) for notifying the Service of such
treatment or admission shall be 30 days.
‘‘SEC. 223. PROMPT ACTION ON PAYMENT OF CLAIMS.
‘‘(a) 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 with-
in 5 working days after the receipt of such notification.
‘‘(b) If the Service fails to respond to a notification
of a claim in accordance with subsection (a), the Service
117
shall accept as valid the claim submitted by the provider
of a contract care service.
‘‘(c) The Service shall pay a valid contract care serv-
ice claim within 30 days after completion of the claim.
‘‘SEC. 224. LIABILITY FOR PAYMENT.
‘‘(a) A patient who receives contract health care serv-
ices that are authorized by the Service shall not be liable
for the payment of any charges or costs associated with
the provision of such services.
‘‘(b) The Secretary shall notify a contract care pro-
vider and any patient who receives contract health care
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) Following receipt of the notice provided by sub-
section (a) of this section, or, if a claim has been deemed
accepted under section 223(b), the provider shall have no
further recourse against the patient who received the serv-
ices.
‘‘SEC. 225. AUTHORIZATION OF APPROPRIATIONS.
‘‘There are authorized to be appropriated such sums
as may be necessary for each fiscal year through fiscal
year 2013 to carry out this title.
118
‘‘TITLE III—FACILITIES
‘‘SEC. 301. CONSULTATION; CONSTRUCTION AND RENOVA-
TION OF FACILITIES; REPORTS.
‘‘(a) Prior to the expenditure of, or the making of
any binding commitment to expend, any funds appro-
priated for the planning, design, construction, or renova-
tion of facilities pursuant to the Act of November 2, 1921
(25 U.S.C. 13), popularly known as the Snyder Act, the
Secretary shall—
‘‘(1) consult with any Indian tribe that would
be significantly affected by such expenditure for the
purpose of determining and, whenever practicable,
honoring tribal preferences concerning size, location,
type, and other characteristics of any facility on
which such expenditure is to be made, and
‘‘(2) ensure, whenever practicable, that such fa-
cility meets the construction standards of any na-
tionally recognized accrediting body by not later
than 1 year after the date on which the construction
or renovation of such facility is completed.
‘‘(b)(1) Notwithstanding any provision of law other
than this subsection, no Service hospital or outpatient
health care facility or any inpatient service or special care
facility operated by the Service may be closed if the Sec-
retary has not submitted to the Congress at least 1 year
119
prior to the date of such proposed closure an evaluation
of the impact of such proposed closure which specifies, in
addition to other considerations—
‘‘(A) the accessibility of alternative health care
resources for the population served by such hospital
or facility;
‘‘(B) the cost-effectiveness of such closure;
‘‘(C) the quality of health care to be provided
to the population served by such hospital or facility
after such closure;
‘‘(D) the availability of contract health care
funds to maintain existing levels of service;
‘‘(E) the views of the Indian tribes served by
such hospital or facility concerning such closure;
‘‘(F) the level of use of such hospital or facility
by all eligible Indians; and
‘‘(G) the distance between such hospital or fa-
cility and the nearest operating Service hospital.
‘‘(2) Paragraph (1) shall not apply to any temporary
closure of a facility or any portion of a facility if such
closure is necessary for medical, environmental, or con-
struction safety reasons.
‘‘(c)(1)(A) The Secretary shall establish a health care
facility priority system, which shall—
120
‘‘(i) be developed with Indian tribes and tribal
organizations by negotiated rulemaking under sec-
tion 802;
‘‘(ii) give Indian tribes’ needs the highest pri-
ority; and
‘‘(iii) at a minimum, include the lists required
in paragraph (2)(B) and the methodology required
in paragraph (2)(E) of this subsection.
‘‘(B) The priority of any project established under the
construction priority system in effect on the date of the
Indian Health Care Improvement Act Amendments of
2001 shall not be affected by any change in the construc-
tion priority system taking place thereafter if the project
was identified as one of the top ten priority inpatient
projects or one of the top ten outpatient projects in the
fiscal year 2001 Indian Health Service budget justifica-
tion, or if the project had completed both Phase I and
Phase II of the construction priority system in effect on
the date of the enactment of such Act.
‘‘(2) The Secretary shall submit to the President, for
inclusion in each report required to be transmitted to the
Congress under section 801, a report which sets forth—
‘‘(A) a description of the health care facility
priority system of the Service, established under
paragraph (1) of this subsection;
122
organizations operating health programs or facilities
under any funding agreement entered into with the
Service under the Indian Self-Determination and
Education Assistance Act; and
‘‘(B) review the total unmet needs of all tribes
and tribal organizations for health care facilities (in-
cluding staff quarters), including needs for renova-
tion and expansion of existing facilities.
‘‘(4) For purposes of this subsection, the Secretary
shall, in evaluating the needs of facilities operated under
any funding agreement entered into with the Service
under the Indian Self-Determination and Education As-
sistance Act, use the same criteria that the Secretary uses
in evaluating the needs of facilities operated directly by
the Service.
‘‘(5) The Secretary shall ensure that the planning,
design, construction, and renovation needs of Service and
non-Service facilities, operated under funding agreements
in accordance with the Indian Self-Determination and
Education Assistance Act, are fully and equitably inte-
grated into the health care facility priority system.
‘‘(d) REVIEW OF NEED FOR FACILITIES.—
‘‘(1) Beginning in the year 2001, the Secretary
shall annually submit to the President, for inclusion
in the report required to be transmitted to the Con-
123
gress under section 801 of this Act, a report which
sets forth the needs of the Indian Health Service
and all Indian tribes and tribal organizations, in-
cluding urban Indian organizations, for inpatient,
outpatient, and specialized care facilities, including
the needs for renovation and expansion of existing
facilities .
‘‘(2) In preparing each report required under
paragraph (1) (other than the initial report), the
Secretary shall consult with Indian tribes and tribal
organizations including those Tribes or tribal organi-
zations operating health programs or facilities under
any funding agreement entered into with the Service
under the Indian Self-Determination and Education
Assistance Act (25 U.S.C. 450f et seq.), and with
urban Indian organizations.
‘‘(3) For purposes of this subsection, the Sec-
retary shall, in evaluating the needs of facilities op-
erated under any funding agreement entered into
with the Service under the Indian Self-Determina-
tion and Education Assistance Act, use the same cri-
teria that the Secretary uses in evaluating the needs
of facilities operated directly by the Service.
‘‘(4) The Secretary shall ensure that the plan-
ning, design, construction, and renovation needs of
124
facilities operated under funding agreements, in ac-
cordance with the Indian Self-Determination and
Education Assistance Act, are fully and equitably in-
tegrated into the development of the health facility
priority system.
‘‘(5) Each fiscal year, the Secretary shall pro-
vide an opportunity for nomination of planning, de-
sign, and construction projects by the Indian Health
Service and all tribes and tribal organizations for
consideration under the health care facility priority
system.
‘‘(e) All funds appropriated under the Act of Novem-
ber 2, 1921 (25 U.S.C. 13), for the planning, design, con-
struction, or renovation of health facilities for the benefit
of an Indian tribe or Tribes shall be subject to the provi-
sions of section 102 of the Indian Self-Determination and
Education Assistance Act.
‘‘(f) The Secretary shall consult and cooperate with
Indian tribes, tribal organizations, and urban Indian orga-
nizations 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 sec-
tions of this title and other approaches.
125
‘‘SEC. 302. SAFE WATER AND SANITARY WASTE DISPOSAL
FACILITIES.
‘‘(a) The Congress hereby finds and declares that—
‘‘(1) the provision of safe water supply facilities
and sanitary sewage and solid waste disposal facili-
ties is primarily 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 such fa-
cilities;
‘‘(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 such facilities and other preventive health
measures;
‘‘(4) many Indian homes and communities still
lack safe water supply facilities and sanitary sewage
and solid waste disposal facilities; and
‘‘(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 safe and adequate water sup-
ply facilities and sanitary sewage waste disposal fa-
cilities.
‘‘(b)(1) In furtherance of the findings and declara-
tions made in subsection (a), Congress reaffirms the pri-
126
mary 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).
‘‘(2) The Secretary is authorized to provide under
section 7 of the Act of August 5, 1954 (42 U.S.C.
2004a)—
‘‘(A) financial and technical assistance to In-
dian tribes, tribal organizations, and Indian commu-
nities in the establishment, training, and equipping
of utility organizations to operate and maintain In-
dian sanitation facilities, including the provision of
existing plans, standard details, and specifications
available in the department, to be used at the option
of the tribe or tribal organization;
‘‘(B) ongoing technical assistance and training
in the management of utility organizations which op-
erate and maintain sanitation facilities; and
‘‘(C) priority funding for operation and mainte-
nance assistance for, and emergency repairs to, trib-
al sanitation facilities 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 sani-
tation facilities.
127
‘‘(3) Notwithstanding any other provision of law—
‘‘(A) 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 to the Sec-
retary of Health and Human Services,
‘‘(B) 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),
‘‘(C) unless specifically authorized when funds
are appropriated, the Secretary of Health and
Human Services shall not use funds appropriated
under section 7 of the Act of August 5, 1954 (42
U.S.C. 2004a) to provide sanitation facilities to new
homes constructed using funds provided by the De-
partment of Housing and Urban Development,
‘‘(D) the Secretary of Health and Human Serv-
ices is authorized to accept all Federal funds that
are for the purpose of providing sanitation facilities
and related services and place those funds into fund-
ing agreements, authorized under the Indian Self-
Determination and Education Assistance Act (25
128
U.S.C. 450f et seq.), between the Secretary and In-
dian tribes and tribal organizations,
‘‘(E) the Secretary may allow funds appro-
priated under the authority of section 7 of the Act
of August 5, 1954 (42 U.S.C. 2004a), to be used to
fund up to 100 percent of the amount of a tribe’s
loan obtained under any Federal program for new
projects to construct eligible sanitation facilities to
serve Indian homes,
‘‘(F) the Secretary may allow funds appro-
priated under the authority of section 7 of the Act
of August 5, 1954 (42 U.S.C. 2004a), to be used to
meet matching or cost participation requirements
under other Federal and non-Federal programs for
new projects to construct eligible sanitation facilities,
‘‘(G) 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,
‘‘(H) The Secretary of Health and Human
Services shall enter into interagency agreements
with the Bureau of Indian Affairs, the Department
of Housing and Urban Development, the Depart-
ment of Agriculture, the Environmental Protection
129
Agency, and other appropriate Federal agencies, for
the purpose of providing financial assistance for safe
water supply and sanitary sewage disposal facilities
under this Act, and
‘‘(I) the Secretary of Health and Human Serv-
ices shall, by regulation developed through rule-
making under section 802, establish standards appli-
cable to the planning, design, and construction of
water supply and sanitary sewage and solid waste
disposal facilities funded under this Act.
‘‘(c) The Secretary, in consultation with Indian tribes
and tribal organizations, shall develop and begin imple-
mentation of a 10-year funding plan to provide safe water
supply and sanitary sewage and solid waste disposal facili-
ties serving existing Indian homes and communities and
new and renovated Indian homes.
‘‘(d) The financial and technical capability of an In-
dian tribe or community to safely operate and maintain
a sanitation facility shall not be a prerequisite to the provi-
sion or construction of sanitation facilities by the Sec-
retary.
‘‘(e) The Secretary is authorized to provide financial
assistance to Indian tribes, tribal organizations, and com-
munities for operation, management, and maintenance of
their sanitation facilities.
130
‘‘(f) The Indian family, community, or Tribe has the
primary responsibility to establish, collect, and use reason-
able user fees, or otherwise set aside funding, for the pur-
pose of operating and maintaining sanitation facilities. If
a community facility is threatened with imminent failure
and there is a lack of tribal capacity to maintain the integ-
rity or the health benefits of the facility, then the Sec-
retary is authorized to assist the Tribe in the resolution
of the problem on a short-term basis through cooperation
with the emergency coordinator or by providing operation
and maintenance service.
‘‘(g) Programs administered by Indian tribes or tribal
organizations under the authority of the Indian Self-De-
termination and Education Assistance Act shall be eligible
for—
‘‘(1) any funds appropriated pursuant to this
section, and
‘‘(2) any funds appropriated for the purpose of
providing water supply, sewage disposal, or solid
waste facilities,
on an equal basis with programs that are administered
directly by the Service.
‘‘(h)(1) The Secretary shall submit to the President,
for inclusion in each report required to be transmitted to
131
the Congress under section 801, a report which sets
forth—
‘‘(A) the current Indian sanitation facility pri-
ority system of the Service;
‘‘(B) the methodology for determining sanita-
tion deficiencies;
‘‘(C) the level of initial and final sanitation defi-
ciency for each type of sanitation facility for each
project of each Indian tribe or community; and
‘‘(D) the amount of funds necessary to reduce
the identified sanitation deficiency levels of all In-
dian tribes and communities to level I sanitation de-
ficiency as defined in subsection (h)(4)(A) of this
section.
‘‘(2) In preparing each report required under para-
graph (1), the Secretary shall consult with Indian tribes
and tribal organizations (including those tribes or tribal
organizations operating health care programs or facilities
under any funding agreement entered into with the Serv-
ice under the Indian Self-Determination and Education
Assistance Act) to determine the sanitation needs of each
tribe and in developing the criteria on which the needs
will be evaluated through a process of negotiated rule-
making.
132
‘‘(3) The methodology used by the Secretary in deter-
mining, preparing cost estimates for and reporting sanita-
tion deficiencies for purposes of paragraph (1) shall be ap-
plied uniformly to all Indian tribes and communities.
‘‘(4) For purposes of this subsection, the sanitation
deficiency levels for an individual or community sanitation
facility serving Indian homes are as follows:
‘‘(A) A level I deficiency is a sanitation facility
serving an individual or community—
‘‘(i) which complies with all applicable
water supply, pollution control, and solid waste
disposal laws, and
‘‘(ii) in which the deficiencies relate to rou-
tine replacement, repair, or maintenance needs.
‘‘(B) A level II deficiency is a sanitation facility
serving an individual or community—
‘‘(i) which substantially or recently com-
plied with all applicable water supply, pollution
control, and solid waste laws, in which the defi-
ciencies relate to small or minor capital im-
provements needed to bring the facility back
into compliance;
‘‘(ii) in which the deficiencies relate to cap-
ital improvements that are necessary to enlarge
or improve the facilities in order to meet the
133
current needs for domestic sanitation facilities;
or
‘‘(iii) in which the deficiencies relate to the
lack of equipment or training by an Indian tribe
or community to properly operate and maintain
the sanitation facilities.
‘‘(C) A level III deficiency is an individual or
community facility with water or sewer service in the
home, piped services, or a haul system with holding
tanks and interior plumbing, or where major signifi-
cant interruptions to water supply or sewage dis-
posal occur frequently, requiring major capital im-
provements to correct the deficiencies. There is no
access to or no approved or permitted solid waste fa-
cility available.
‘‘(D) A level IV deficiency is an individual or
community facility where there is no piped water or
sewer facilities in the home or the facility has be-
come inoperable due to major component failure or
where only a washeteria or central facility exists.
‘‘(E) A level V deficiency is the absence of a
sanitation facility, where individual homes do not
have access to safe drinking water or adequate
wastewater disposal.
‘‘(i) For purposes of this section—
134
‘‘(1) the terms ‘facility’ and ‘facilities’ have the
same meanings as the terms ‘system’ and ‘systems’
unless the context requires otherwise; and
‘‘(2) the term ‘Indian community’ means a geo-
graphic area, a significant proportion of whose in-
habitants are Indians and which is served by or ca-
pable of being served by a facility described in this
section.
‘‘SEC. 303. PREFERENCE TO INDIANS AND INDIAN FIRMS.
‘‘(a) The Secretary may use the negotiating authority
of the Act of June 25, 1910 (25 U.S.C. 47), 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 safe water
and sanitary waste disposal facilities pursuant to section
302. Such preference may be accorded by the Secretary
unless he finds, pursuant to rules and regulations promul-
gated by him, that the project or function to be contracted
for will not be satisfactory or such project or function can-
not be properly completed or maintained under the pro-
posed contract. The Secretary, in arriving at his finding,
135
shall consider whether the Indian or Indian firm will be
deficient with respect to (1) ownership and control by In-
dians, (2) equipment, (3) bookkeeping and accounting pro-
cedures, (4) substantive knowledge of the project or func-
tion to be contracted for, (5) adequately trained personnel,
or (6) other necessary components of contract perform-
ance.
‘‘(b) For the purpose of implementing the provisions
of this title, construction or renovation of facilities con-
structed or renovated in whole or in part by funds made
available pursuant to this title are exempt from the Act
of March 3, 1931 (40 U.S.C. 276a–276a–5, known as the
Davis-Bacon Act.) For all health facilities, staff quarters,
and sanitation facilities, construction and renovation sub-
contractors shall be paid wage rates not less than the pre-
vailing wages on similar construction in the locality, as
determined by the Indian tribe, Tribes, or tribal organiza-
tions served by such facilities.
‘‘SEC. 304. EXPENDITURE OF NONSERVICE FUNDS FOR REN-
OVATION.
‘‘(a)(1) Notwithstanding any other provision of law,
the Secretary is authorized to accept any major expansion,
renovation, or modernization by any Indian tribe of any
Service facility, or of any other Indian health facility oper-
ated pursuant to a funding agreement entered into under
136
the Indian Self-Determination and Education Assistance
Act, including—
‘‘(A) any plans or designs for such expansion,
renovation, or modernization; and
‘‘(B) any expansion, renovation, or moderniza-
tion for which funds appropriated under any Federal
law were lawfully expended,
but only if the requirements of subsection (b) are met.
‘‘(2) The Secretary shall maintain a separate priority
list to address the needs for increased operating expenses,
personnel, or equipment for such facilities. The method-
ology for establishing priorities shall be developed by nego-
tiated rulemaking under section 802. The list of priority
facilities will be revised annually in consultation with In-
dian tribes and tribal organizations.
‘‘(3) The Secretary shall submit to the President, for
inclusion in each report required to be transmitted to the
Congress under section 801, the priority list maintained
pursuant to paragraph (2).
‘‘(b) The requirements of this subsection are met with
respect to any expansion, renovation, or modernization
if—
‘‘(1) the tribe or tribal organization—
‘‘(A) provides notice to the Secretary of its
intent to expand, renovate, or modernize; and
137
‘‘(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
modernization—
‘‘(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 ap-
plicable regulations prescribed by the Secretary
with respect to construction or renovation of
Service facilities.
‘‘(c) If any Service facility which has been expanded,
renovated, or modernized by an Indian tribe under this
section ceases to be used as a Service facility during the
20-year period beginning on the date such expansion, ren-
ovation, or modernization is completed, such Indian tribe
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, renovation, or modernization (less the total
amount of any funds provided specifically for such facility
under any Federal program that were expended for such
expansion, renovation, or modernization) bore to the value
138
of such facility at the time of the completion of such ex-
pansion, renovation, or modernization.
‘‘SEC. 305. FUNDING FOR THE CONSTRUCTION, EXPANSION,
AND MODERNIZATION OF SMALL AMBULA-
TORY CARE FACILITIES.
‘‘(a)(1) The Secretary, in consultation with Indian
tribes and tribal organizations, shall make funding avail-
able to Tribes and tribal organizations for the construc-
tion, expansion, or modernization of facilities for the provi-
sion of ambulatory care services to eligible Indians (and
noneligible persons as provided in subsections (c)(1)(C)
and (b)(2) of this section). Funding made under this sec-
tion may cover up to 100 percent of the costs of such con-
struction, expansion, or modernization. For the purposes
of this section, the term ‘construction’ includes the re-
placement of an existing facility.
‘‘(2) Funding under paragraph (1) may only be made
available to an Indian tribe or tribal organization oper-
ating an Indian health facility (other than a facility owned
or constructed by the Service, including a facility origi-
nally owned or constructed by the Service and transferred
to an Indian tribe or tribal organization) pursuant to a
funding agreement entered into under the Indian Self-De-
termination and Education Assistance Act.
139
‘‘(b)(1) Funding provided under this section may be
used only for the construction, expansion, or moderniza-
tion (including the planning and design of such construc-
tion, expansion, or modernization) of an ambulatory care
facility—
‘‘(A) located apart from a hospital;
‘‘(B) not funded under section 301 or section
307; and
‘‘(C) which, upon completion of such construc-
tion or modernization will—
‘‘(i) have a total capacity appropriate to its
projected service population;
‘‘(ii) provide annually no less than 500 pa-
tient visits by eligible Indians and other users
who are eligible for services in such facility in
accordance with section 807(b)(1)(B); and
‘‘(iii) provide ambulatory care in a service
area (specified in the funding agreement en-
tered into under the Indian Self-Determination
and Education Assistance Act) with a popu-
lation of no fewer than 1,500 eligible Indians
and other users who are eligible for services in
such 
facility 
in 
accordance 
with 
section
807(b)(1)(B).
140
‘‘(2) Funding provided under this section may be
used only for the cost of that portion of a construction,
expansion, or modernization project that benefits the serv-
ice population identified above in subsection (b)(1)(C)(ii)
and (iii). The requirements of clauses (ii) and (iii) of para-
graph (1)(C) shall not apply to a Tribe or tribal organiza-
tion applying for funding under this section whose prin-
cipal office for health care administration is located on an
island or when such office is not located on a road system
providing direct access to an inpatient hospital where care
is available to the service population.
‘‘(c)(1) No funding may be made available under this
section unless an application or proposal for such funding
has been submitted to and approved by the Secretary. An
application or proposal for funding under this section shall
be submitted in accordance with applicable regulations
and shall set forth reasonable assurance by the applicant
that, at all times after the construction, expansion, or
modernization of a facility carried out pursuant to funding
received under this section—
‘‘(A) adequate financial support will be avail-
able for the provision of services at such facility;
‘‘(B) such facility will be available to eligible In-
dians without regard to ability to pay or source of
payment; and
141
‘‘(C) such facility will, as feasible without di-
minishing the quality or quantity of services pro-
vided to eligible Indians, serve noneligible persons on
a cost basis.
‘‘(2) In awarding funding under this section, the Sec-
retary shall give priority to tribes and tribal organizations
that demonstrate—
‘‘(A) a need for increased ambulatory care serv-
ices; and
‘‘(B) insufficient capacity to deliver such serv-
ices.
‘‘(3) The Secretary may provide for the establishment
of peer review panels, as necessary, to review and evaluate
applications and proposals and to advise the Secretary re-
garding such applications using the criteria developed pur-
suant to paragraph (1).
‘‘(d) If any facility (or portion thereof) with respect
to which funds have been paid under this section, ceases,
within 5 years after completion of the construction, expan-
sion, or modernization carried 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 otherwise negotiated by the Service
and the Indian tribe or tribal organization.
142
‘‘(e) Funding provided to Indian tribes and tribal or-
ganizations under this section shall be nonrecurring and
shall not be available for inclusion in any individual
Tribe’s tribal share for an award under the Indian Self-
Determination and Education Assistance Act or for re-
allocation or redesign thereunder.
‘‘SEC. 306. INDIAN HEALTH CARE DELIVERY DEMONSTRA-
TION PROJECT.
‘‘(a) HEALTH CARE DEMONSTRATION PROJECTS.—
The Secretary, in consultation with Indian tribes and trib-
al organizations, is authorized to enter into funding agree-
ments with, or make grants or loan guarantees to, Indian
tribes or tribal organizations for the purpose of carrying
out a health care delivery demonstration project to test
alternative means of delivering health care and services
through facilities, including but not limited to hospice, tra-
ditional Indian health, and child care facilities to Indians.
‘‘(b) USE OF FUNDS.—The Secretary, in approving
projects pursuant to this section, may authorize funding
for the construction and renovation of hospitals, health
centers, health stations, and other facilities to deliver
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;
143
‘‘(3) permit the use of other available funds;
‘‘(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) CRITERIA.—(1) The Secretary shall develop and
publish regulations, through rulemaking under section
802, for the review and approval of applications submitted
under this section. The Secretary may enter into a con-
tract or funding agreement or award a grant under this
section for projects which meet the following criteria:
‘‘(A) There is a need for a new facility or pro-
gram or the reorientation of an existing facility or
program.
‘‘(B) A significant number of Indians, including
those with low health status, will be served by the
project.
‘‘(C) The project has the potential to deliver
services in an efficient and effective manner.
‘‘(D) The project is economically viable.
‘‘(E) The Indian tribe or tribal organization has
the administrative and financial capability to admin-
ister the project.
144
‘‘(F) The project is integrated with providers of
related health and social services and is coordinated
with, and avoids duplication of, existing services.
‘‘(2) The Secretary may provide for the establishment
of peer review panels, as necessary, to review and evaluate
applications and using the criteria developed pursuant to
paragraph (1).
‘‘(3) The Secretary shall give priority to applications
for demonstration projects in each of the following service
units to the extent that such applications are timely filed
and meet the criteria specified in paragraph (1):
‘‘(i) Cass Lake, Minnesota.
‘‘(ii) Clinton, Oklahoma.
‘‘(iii) Harlem, Montana.
‘‘(iv) Mescalero, New Mexico.
‘‘(v) Owyhee, Nevada.
‘‘(vi) Parker, Arizona.
‘‘(vii) Schurz, Nevada.
‘‘(viii) Winnebago, Nebraska.
‘‘(ix) Ft. Yuma, California.
‘‘(d) 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.
145
‘‘(e) SERVICE TO INELIGIBLE PERSONS.—The au-
thority to provide services to persons otherwise ineligible
for the health care benefits of the Service and the author-
ity to extend hospital privileges in Service facilities to non-
Service health practitioners as provided in section 807
may be included, subject to the terms of such section, in
any demonstration project approved pursuant to this sec-
tion.
‘‘(f) EQUITABLE TREATMENT.—For purposes of sub-
section (c)(1)(A), the Secretary shall, in evaluating facili-
ties operated under any funding agreement entered into
with the Service under the Indian Self-Determination and
Education Assistance Act, use the same criteria that the
Secretary uses in evaluating facilities operated directly by
the Service.
‘‘(g) EQUITABLE INTEGRATION
OF FACILITIES.—
The Secretary shall ensure that the planning, design, con-
struction, renovation, and expansion needs of Service and
non-Service facilities which are the subject of a funding
agreement for health services entered into with the Service
under the Indian Self-Determination and Education As-
sistance Act, are fully and equitably integrated into the
implementation of the health care delivery demonstration
projects under this section.
146
‘‘SEC. 307. LAND TRANSFER.
‘‘(a) The Bureau of Indian Affairs is authorized to
transfer, at no cost, up to 5 acres of land at the Chemawa
Indian School, Salem, Oregon, to the Service for the provi-
sion of health care services. The land authorized to be
transferred by this section is that land adjacent to land
under the jurisdiction of the Service and occupied by the
Chemawa Indian Health Center.
‘‘(b) Notwithstanding any other provision of law, the
Bureau of Indian Affairs and all other agencies and de-
partments of the United States are authorized to transfer,
at no cost, land and improvements to the Service for the
provision of health care services. The Secretary is author-
ized to accept such land and improvements for such pur-
poses.
‘‘SEC. 308. LEASES.
‘‘(a) Notwithstanding any other provision of law, the
Secretary is authorized, in carrying out the purposes of
this Act, to enter into leases with Indian tribes and tribal
organizations for periods not in excess of 20 years. Prop-
erty leased by the Secretary from an Indian tribe or tribal
organization may be reconstructed or renovated by the
Secretary pursuant to an agreement with such Indian
tribe or tribal organization.
147
‘‘(b) The Secretary may enter into leases, contracts,
and other legal agreements with Indian tribes or tribal or-
ganizations which hold title to—
‘‘(1) a leasehold interest in; or
‘‘(2) a beneficial interest in (where title is held
by the United States in trust for the benefit of a
Tribe); facilities used for the administration and de-
livery of health services by the Service or by pro-
grams operated by Indian tribes or tribal organiza-
tions to compensate such Indian tribes or tribal or-
ganizations for costs associated with the use of such
facilities for such purposes, and such leases shall be
considered as operating leases for the purposes of
scoring under the Budget Enforcement Act of 1990,
notwithstanding any other provision of law. Such
costs include rent, depreciation based on the useful
life of the building, principal and interest paid or ac-
crued, operation and maintenance expenses, and
other expenses determined by regulation to be allow-
able pursuant to regulations under section 105(l) of
the Indian Self-Determination and Education Assist-
ance Act.
148
‘‘SEC. 309. LOANS, LOAN GUARANTEES, AND LOAN REPAY-
MENT.
‘‘(a) There is established in the Treasury of the
United States a fund to be known as the Health Care Fa-
cilities Loan Fund (hereinafter referred to as the
‘HCFLF’) to provide to Indian tribes and tribal organiza-
tions direct loans, or guarantees for loans, for construction
of health care facilities (including but not limited to inpa-
tient facilities, outpatient facilities, associated staff quar-
ters and specialized care facilities such as behavioral
health and elder care facilities).
‘‘(b) The Secretary is authorized to issue regulations,
developed through rulemaking as set out in section 802,
to provide standards and procedures for governing such
loans and loan guarantees, subject to the following condi-
tions:
‘‘(1) The principal amount of a loan or loan
guarantee may cover 100 percent of eligible costs,
including but not limited to planning, design, financ-
ing, site land development, construction, rehabilita-
tion, renovation, conversion, improvements, medical
equipment and furnishings, other facility-related
costs and capital purchase (but excluding staffing).
‘‘(2) The cumulative total of the principal of di-
rect loans and loan guarantees, respectively, out-
149
standing at any one time shall not exceed such limi-
tations as may be specified in appropriation Acts.
‘‘(3) In the discretion of the Secretary, the pro-
gram may be administered by the Service or the
Health Resources and Services Administration
(which shall be specified by regulation).
‘‘(4) The Secretary may make or guarantee a
loan with a term of the useful estimated life of the
facility, or 25 years, whichever is shorter.
‘‘(5) The Secretary may allocate up to 100 per-
cent of the funds available for loans or loan guaran-
tees in any year for the purpose of planning and ap-
plying for a loan or loan guarantee.
‘‘(6) The Secretary may accept an assignment
of the revenue of an Indian tribe or tribal organiza-
tion as security for any direct loan or loan guarantee
under this section.
‘‘(7) In the planning and design of health facili-
ties under this section, users eligible under section
807(b) may be included in any projection of patient
population.
‘‘(8) The Secretary shall not collect loan appli-
cation, processing, or other similar fees from Indian
tribes or tribal organizations applying for direct
loans or loan guarantees under this section.
150
‘‘(9) Service funds authorized under loans or
loan guarantees in this section shall be eligible for
use in matching other Federal funds.
‘‘(c)(1) The HCFLF shall consist of—
‘‘(A) such sums as may be initially appropriated
to the HCFLF and as may be subsequently appro-
priated to the fund under paragraph (2);
‘‘(B) such amounts as may be collected from
borrowers; and
‘‘(C) all interest earned on amounts in the
HCFLF.
‘‘(2) There are authorized to be appropriated such
sums as may be necessary to initiate the HCFLF. For
each fiscal year after the initial year in which funds are
appropriated to the HCFLF, there is authorized to be ap-
propriated an amount equal to the sum of the amount col-
lected by the HCFLF during the preceding fiscal year,
and all accrued interest.
‘‘(3) All amounts appropriated, collected, or earned
relative to the HCFLF shall remain available until ex-
pended.
‘‘(d) Amounts in the HCFLF and available pursuant
to appropriation Acts may be expended by the Secretary
to make loans under this section to an Indian tribe or trib-
al organization pursuant to a funding agreement entered
151
into under the Indian Self-Determination and Education
Assistance Act.
‘‘(e) The Secretary of the Treasury shall invest such
amounts of the HCFLF as such Secretary determines are
not required to meet current withdrawals from the
HCFLF. Such investments may be made only in interest-
bearing obligations of the United States. For such pur-
pose, such obligations may be acquired on original issue
at the issue price, or by purchase of outstanding obliga-
tions at the market price. Any obligation acquired by the
fund may be sold by the Secretary of the Treasury at the
market price.
‘‘(f) The Secretary is authorized to establish a pro-
gram to provide grants to Indian tribes and tribal organi-
zations for the purpose of repaying all or part of any loan
obtained by an Indian tribe or tribal organization for con-
struction and renovation of health care facilities (including
inpatient facilities, outpatient facilities, associated staff
quarters and specialized care facilities). Loans eligible for
such repayment grants shall include loans that have been
obtained under this section or otherwise.
‘‘SEC. 310. TRIBAL LEASING.
‘‘Indian tribes and tribal organizations providing
health care services pursuant to a funding agreement en-
tered into under the Indian Self-Determination and Edu-
152
cation Assistance Act may lease permanent structures for
the purpose of providing such health care services without
obtaining advance approval in appropriation Acts.
‘‘SEC. 311. INDIAN HEALTH SERVICE/TRIBAL FACILITIES
JOINT VENTURE PROGRAM.
‘‘(a) The Secretary shall make arrangements with In-
dian tribes and tribal organizations to establish joint ven-
ture demonstration projects under which an Indian tribe
or tribal organization shall expend tribal, private, or other
available funds, for the acquisition or construction of a
health 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 oper-
ation and maintenance of such a health facility. A Tribe
or tribal organization may use tribal funds, private sector,
or other available resources, including loan guarantees, to
fulfill its commitment under this subsection. A Tribe that
has begun and substantially completed the process of ac-
quisition or construction of a health facility shall be eligi-
ble to establish a joint venture project with the Service
using such health facility.
‘‘(b)(1) The Secretary shall make such an arrange-
ment with an Indian tribe or tribal organization only if—
‘‘(A) the Secretary first determines that the In-
dian tribe or tribal organization has the administra-
153
tive and financial capabilities necessary to complete
the timely acquisition or construction of the health
facility described in paragraph (1), and
‘‘(B) the Indian tribe or tribal organization
meets the need criteria which shall be developed
through the negotiated rulemaking process provided
for under section 802.
‘‘(2) The Secretary shall negotiate an agreement with
the Indian tribe or tribal organization regarding the con-
tinued operation of the facility at the end of the initial
10 year no-cost lease period.
‘‘(c) An Indian tribe or tribal organization that has
entered into a written agreement with the Secretary under
this subsection, and that breaches or terminates without
cause such agreement, shall be liable to the United States
for the amount that has been paid to the Tribe or tribal
organization, or paid to a third party on the Tribe’s or
tribal organization’s behalf, under the agreement. The
Secretary has the right to recover tangible property (in-
cluding supplies), and equipment, less depreciation, and
any funds expended for operations and maintenance under
this section. The preceding sentence does not apply to any
funds expended for the delivery of health care services, or
for personnel or staffing.
154
‘‘(d) 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 should at any
time within 10 years the Service ceases to use the facility
or otherwise breaches the agreement.
‘‘(e) Wherever ‘health facility’ or ‘health facilities’ is
used in this section, they may include quarters needed to
provide housing for staff of the tribal health program.
‘‘SEC. 312. LOCATION OF FACILITIES.
‘‘(a) The Bureau of Indian Affairs and the Service
shall, in all matters involving the reorganization or devel-
opment of Service facilities, or in the establishment of re-
lated employment projects to address unemployment con-
ditions in economically depressed areas, give priority to
locating such facilities and projects on Indian lands if re-
quested by the Indian owner and the Indian tribe with
jurisdiction over such lands or other lands owned or leased
by the Indian tribe or tribal organization, provided that
priority shall be given to Indian land owned by an Indian
tribe or Tribes.
‘‘(b) For purposes of this section, the term ‘Indian
lands’ means—
155
‘‘(1) all lands within the exterior boundaries of
any Indian reservation;
‘‘(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 and over which an Indian
tribe exercises governmental power; and
‘‘(3) all lands in Alaska owned by any Alaska
Native village, or village or regional corporation
under the Alaska Native Claims Settlement Act, or
any land allotted to any Alaska Native.
‘‘SEC. 313. MAINTENANCE AND IMPROVEMENT OF HEALTH
CARE FACILITIES.
‘‘(a) The Secretary shall submit to the President, for
inclusion in the report required to be transmitted to the
Congress under section 801, a report which identifies the
backlog of maintenance and repair work required at both
Service and tribal facilities, including new facilities ex-
pected to be in operation in the next fiscal year. The re-
port shall also identify the need for renovation and expan-
sion of existing facilities to support the growth of health
care programs.
‘‘(b) The Secretary is authorized to expend mainte-
nance and improvement funds to support maintenance of
156
newly constructed space only if such space falls within the
approved supportable space allocation for the Tribe or
tribal organization. ‘Supportable space allocation’ shall be
defined through the negotiated rulemaking process pro-
vided for under section 802.
‘‘(c) In addition to using maintenance and improve-
ment funds for renovation, modernization, and expansion
of facilities, an Indian tribe or tribal organization may use
maintenance and improvement funds for construction of
a replacement facility if the costs of renovation of such
facility would exceed a maximum renovation cost thresh-
old. The ‘maximum renovation cost threshold’ shall be de-
termined through the negotiated rulemaking process pro-
vided for under section 802.
‘‘SEC. 314. TRIBAL MANAGEMENT OF FEDERALLY OWNED
QUARTERS.
‘‘(a)(1) Notwithstanding any other provision of law,
an Indian tribe or tribal organization which operates a
hospital or other health facility and the federally owned
quarters associated therewith pursuant to a funding
agreement under the Indian Self-Determination and Edu-
cation Assistance Act 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 exer-
cise such authority.
157
‘‘(2) In establishing rental rates pursuant to author-
ity of this subsection, an Indian tribe or tribal organiza-
tion shall endeavor to achieve the following objectives:
‘‘(A) To base such rental rates on the reason-
able value of the quarters to the occupants thereof.
‘‘(B) To generate sufficient funds to prudently
provide for the operation and maintenance of the
quarters, and, subject to the discretion of the Indian
tribe or tribal organization, to supply reserve funds
for capital repairs and replacement of the quarters.
‘‘(3) Any quarters whose rental rates are established
by an Indian tribe or tribal organization pursuant to au-
thority of 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 In-
dian Health Services-supported programs;
‘‘(4) An Indian tribe or tribal organization which ex-
ercises the authority provided under this subsection shall
provide occupants with no less than 60 days notice of any
change in rental rates.
‘‘(b)(1) Notwithstanding any other provision of law,
and subject to paragraph (2) hereof, an Indian tribe or
a tribal organization which operates federally owned quar-
ters pursuant to a funding agreement under the Indian
Self-Determination and Education Assistance Act shall
158
have the authority to collect rents directly from Federal
employees who occupy such quarters in accordance with
the following:
‘‘(A) The Indian tribe or tribal organization
shall notify the Secretary and the subject Federal
employees of its election to exercise its authority to
collect rents directly from such Federal employees.
‘‘(B) Upon receipt of a notice described in sub-
paragraph (A), the Federal employees shall pay
rents for occupancy of such quarters directly to the
Indian tribe or tribal organization and the Secretary
shall have no further authority to collect rents from
such employees through payroll deduction or other-
wise.
‘‘(C) Such rent payments shall be retained by
the Indian tribe or tribal organization and shall not
be made payable to or otherwise be deposited with
the United States.
‘‘(D) Such rent payments shall be deposited
into a separate account which shall be used by the
Indian tribe or tribal organization for the mainte-
nance (including capital repairs and replacement)
and operation of the quarters and facilities as the
Indian tribe or tribal organization shall determine.
159
‘‘(2) If an Indian tribe or tribal organization which
has made an election under paragraph (1) hereof requests
retrocession of its authority to directly collect rents from
Federal employees occupying federally owned quarters,
such retrocession shall become effective on the earlier of—
‘‘(A) the first day of the month that begins no
less than 180 days after the Indian tribe or tribal
organization notifies the Secretary of its desire to
retrocede; or
‘‘(B) such other date as may be mutually
agreed by the Secretary and the Indian tribe or trib-
al organization.
‘‘(c) To the extent that an Indian tribe or tribal orga-
nization, pursuant to authority granted in subsection (a)
hereof, establishes rental rates for federally owned quar-
ters provided to a Federal employee in Alaska, such rents
may be based on the cost of comparable private rental
housing in the nearest established community with a year-
round population of 1,500 or more individuals.
‘‘SEC. 315. APPLICABILITY OF BUY AMERICAN REQUIRE-
MENT.
‘‘(a) The Secretary shall ensure that the require-
ments of the Buy American Act apply to all procurements
made with funds provided pursuant to the authorization
contained in section 318, provided that Indian tribes and
160
tribal organizations shall be exempt from these require-
ments.
‘‘(b) If it has been finally determined by a court or
Federal agency that any person intentionally affixed a
label bearing a ‘Made in America’ inscription, or any in-
scription 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 the authorization contained in section 309,
pursuant to the debarment, suspension, and ineligibility
procedures described in sections 9.400 through 9.409 of
title 48, Code of Federal Regulations.
‘‘(c) For purposes of this section, the term ‘Buy
American Act’ means title III of the Act entitled ‘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.
‘‘Notwithstanding any other provision of law—
‘‘(1) the Secretary 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, de-
161
sign, and construct health care facilities for Indians
and to place such funds into funding agreements au-
thorized under the Indian Self-Determination and
Education Assistance Act (25 U.S.C. 450f et seq.)
between the Secretary and an Indian tribe or tribal
organization, provided that receipt of such funds
shall have not an effect on the priorities established
pursuant to section 301;
‘‘(2) 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 con-
struction of health care facilities to be administered
by the Service or by Indian tribes or tribal organiza-
tions under the Indian Self-Determination and Edu-
cation Assistance Act in order to carry out the pur-
poses of this Act, together with the purposes for
which such funds are appropriated to such other
Federal department or State agency or for which the
funds were otherwise provided;
‘‘(3) 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
162
out the purposes of this Act as well as the purposes
for which such funds are appropriated to such other
Federal agency; and
‘‘(4) the Secretary, through the Service, shall
establish standards by regulation, developed by rule-
making under section 802, for the planning, design,
and construction of health care facilities serving In-
dians under this Act.
‘‘SEC. 317. AUTHORIZATION OF APPROPRIATIONS.
‘‘There are authorized to be appropriated such sums
as may be necessary for each fiscal year through fiscal
year 2013 to carry out this title.
‘‘TITLE IV—ACCESS TO HEALTH
SERVICES
‘‘SEC. 401. TREATMENT OF PAYMENTS UNDER MEDICARE
PROGRAM.
‘‘(a) Any payments received by the Service or by an
Indian tribe or tribal organization pursuant to a funding
agreement under the Indian Self-Determination and Edu-
cation Assistance Act or by an urban Indian organization
pursuant to title V of this Act for services provided to
Indians eligible for benefits under title XVIII of the Social
Security Act shall not be considered in determining appro-
priations for health care and services to Indians.
163
‘‘(b) Nothing in this Act authorizes the Secretary to
provide services to an Indian beneficiary with coverage
under title XVIII of the Social Security Act, as amended,
in preference to an Indian beneficiary without such cov-
erage.
‘‘(c) Notwithstanding any other provision of this title
or of title XVIII of the Social Security Act, payments to
which facility of the Service is entitled by reason of this
section shall be placed in a special fund to be held by the
Secretary and first 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 which may be necessary to achieve or maintain
compliance with the applicable conditions and require-
ments of this title and of title XVIII of the Social Security
Act. Any funds to be reimbursed which are in excess of
the amount necessary to achieve or maintain such condi-
tions and requirements shall, subject to the consultation
with Tribes being served by the service unit, be used for
reducing the health resource deficiencies of the Indian
tribes. This paragraph shall not apply upon the election
of an Indian tribe or tribal organization under section 405
of the Indian Health Care Improvement Act to receive
payments directly.
164
‘‘SEC. 402. TREATMENT OF PAYMENTS UNDER MEDICAID
PROGRAM.
‘‘(a) Notwithstanding any other provision of law, pay-
ments to which any facility of the Service (including a hos-
pital, nursing facility, intermediate care facility for the
mentally retarded, or any other type of facility which pro-
vides services for which payment is available under title
XIX of the Social Security Act) is entitled under a State
plan by reason of section 1911 of such Act shall be placed
in a special fund to be held by the Secretary and first
used (to such extent or in such amounts as are provided
in appropriation Acts) for the purpose of making any im-
provements in the facilities of such Service which may be
necessary to achieve or maintain compliance with the ap-
plicable conditions and requirements of such title. Any
payments which are in excess of the amount necessary to
achieve or maintain such conditions and requirements
shall, subject to the consultation with Tribes being served
by the service unit, be used for reducing the health re-
source deficiencies of the Indian tribes. In making pay-
ments from such fund, the Secretary shall ensure that
each service unit of the Service receives 100 percent of
the amounts to which the facilities of the Service, for
which such service unit makes collections, are entitled by
reason of section 1911 of the Social Security Act. This
subsection shall not apply to Indian tribes and tribal orga-
165
nizations that elect under section 405 to receive payments
directly.
‘‘(b) Any payments received under section 1911 of
the Social Security Act for services provided to Indians
eligible for benefits under title XIX of the Social Security
Act shall not be considered in determining appropriations
for the provision of health care and services to Indians.
‘‘(c) For provisions relating to the authority of cer-
tain Indian tribes and tribal organizations to elect to di-
rectly bill for, and receive payment for, health care services
provided by a hospital or clinic of such Tribes or tribal
organizations and for which payment may be made under
this title, see section 405 of the Indian Health Care Im-
provement Act.
‘‘SEC. 403. REPORT.
‘‘(a) The Secretary shall submit to the President, for
inclusion in the report required to be transmitted to the
Congress under section 801, an accounting on the amount
and use of funds made available to the Service pursuant
to this title as a result of reimbursements through titles
XVIII and XIX of the Social Security Act, as amended.
‘‘(b) If an Indian tribe or tribal organization receives
funding from the Service under the Indian Self-Deter-
mination and Education Assistance Act or an urban In-
dian organization receives funding from the Indian Health
166
Service under title V of the Indian Health Care Improve-
ment Act receives reimbursements or payments under title
XVIII (medicare), title XIX (medicaid), or title XXI (chil-
dren’s health insurance program) of the Social Security
Act, such Indian tribe, tribal organization, or urban In-
dian organization shall provide to the Service a list of each
provider enrollment number (or other identifier) under
which it receives payments.
‘‘SEC. 404. GRANTS TO AND FUNDING AGREEMENTS WITH
THE SERVICE, INDIAN TRIBES, TRIBAL ORGA-
NIZATIONS, AND URBAN INDIAN ORGANIZA-
TIONS.
‘‘(a) The Secretary shall make grants to or enter into
funding agreements with Indian tribes and tribal organi-
zations to assist such organizations in establishing and ad-
ministering programs on or near Federal Indian reserva-
tions and trust areas and in or near Alaska Native villages
to assist individual Indians to—
‘‘(1) enroll under section 1818 of part A and
sections 1836 and 1837 of part B of title XVIII of
the Social Security Act;
‘‘(2) pay premiums for coverage; and
‘‘(3) apply for medical assistance provided pur-
suant to title XIX (medicaid) and XXI (children’s
167
health insurance program) of the Social Security
Act.
‘‘(b) The Secretary shall place conditions as deemed
necessary to effect the purpose of this section in any fund-
ing agreement or grant which the Secretary makes with
any Indian tribe or tribal organization pursuant to this
section. Such conditions shall include, but are not limited
to, requirements that the organization successfully under-
take to—
‘‘(1) determine the population of Indians to be
served that are or could be recipients of benefits
under titles XVIII, XIX, and XXI of the Social Se-
curity Act;
‘‘(2) assist individual Indians in becoming fa-
miliar with and using such benefits;
‘‘(3) provide transportation to such individual
Indians to the appropriate offices for enrollment or
applications for medical assistance; and
‘‘(4) develop and implement—
‘‘(A) a schedule of income levels to deter-
mine the extent of payments of premiums by
such organizations for coverage of needy indi-
viduals; and
‘‘(B) methods of improving the participa-
tion of Indians in receiving the benefits pro-
168
vided under titles XVIII, XIX, and XXI of the
Social Security Act.
‘‘(c) The Secretary may enter into an agreement with
an Indian tribe, tribal organization, or urban Indian orga-
nization which provides for the receipt and processing of
applications for medical assistance under title XIX of the
Social Security Act and benefits under titles XVIII and
XXI of the Social Security Act by a Service facility or
a health care program administered by such Indian tribe,
tribal organization, or urban Indian organization pursuant
to a funding agreement under the Indian Self-Determina-
tion and Education Assistance Act or a grant or contract
entered into with an urban Indian organization under title
V of this Act. Notwithstanding any other provision of law,
such agreements shall provide for reimbursement of the
cost of outreach, education regarding eligibility and bene-
fits, and translation when such services are provided. The
reimbursement may be included in an encounter rate or
be made on a fee for service basis as appropriate for the
provider. When necessary to carry out the terms of this
section, the Secretary, acting through the Health Care Fi-
nancing Administration or the Service, may enter into
agreements with a State (or political subdivision thereof)
to facilitate cooperation between the State and the Service,
Indian tribe, or tribal organization.
169
‘‘(d)(1) The Secretary shall make grants or enter into
contracts with urban Indian organizations to assist such
organizations in establishing and administering programs
to assist individual urban Indians to—
‘‘(A) enroll under section 1818 of part A and
sections 1836 and 1837 of part B of title XVIII
(medicare) of the Social Security Act;
‘‘(B) pay premiums on behalf of such individ-
uals for coverage under title XVIII of the Social Se-
curity Act; and
‘‘(C) apply for medical assistance provided
under title XIX (medicaid) of the Social Security
Act and for child health assistance under title XXI
(child health insurance program) of the Social Secu-
rity Act.
‘‘(2) The Secretary shall include in the grants or con-
tracts made or entered into under paragraph (1) require-
ments that are—
‘‘(A) consistent with the requirements imposed
by the Secretary under subsection (b);
‘‘(B) appropriate to urban Indian organizations
and urban Indians; and
‘‘(C) necessary to effect the purposes of this
section.
170
‘‘SEC. 405. DIRECT BILLING AND REIMBURSEMENT OF
MEDICARE, MEDICAID, AND OTHER THIRD-
PARTY PAYORS.
‘‘(a)(1) An Indian tribe or tribal organization may
directly bill for, and receive payment for, health care serv-
ices provided by such health program for which payment
is made under title XVIII of the Social Security Act (42
U.S.C. 1395 et seq.) (medicare), under a State plan for
medical assistance approved under title XIX of the Social
Security Act (42 U.S.C. 1396 et seq.) (medicaid), under
a State’s children’s health insurance plan approved under
title XXI of the Social Security Act (42 U.S.C. 1397aa
et seq.) or from any other third-party payor.
‘‘(2) The third sentence of section 1905(b) of the So-
cial Security Act (42 U.S.C. 1396d(b)) and the second
sentence of section 2101(c) of the Social Security Act (42
U.S.C. 1397aa(c)) shall apply for purposes of reimburse-
ment under the medicaid or children’s health insurance
program for health care services directly billed under the
program established under this section.
‘‘(b)(1) Each Indian tribe or tribal organization exer-
cising the option described in subsection (a) of this section
shall be reimbursed directly under the medicare, medicaid,
and children’s health insurance programs for services fur-
nished, without regard to the provisions of section 1880(c)
of the Social Security Act (42 U.S.C. 1395qq(c)) and sec-
171
tion 402(a) of this title, but all funds so reimbursed shall
first be used by the health program for the purpose of
making any improvements in the facility or health pro-
grams that may be necessary to achieve or maintain com-
pliance with the conditions and requirements applicable
generally to such health services under the medicare, med-
icaid, or children’s health insurance program. Any funds
so reimbursed which are in excess of the amount necessary
to achieve or maintain such conditions or requirements
shall be used to provide additional health services, im-
provements in its health care facilities, or otherwise to
achieve the health objectives provided for under section 3
of this Act.
‘‘(2) The amounts paid to the health programs exer-
cising the option described in subsection (a) of this section
shall be subject to all auditing requirements applicable to
programs administered directly by the Service and to fa-
cilities participating in the medicare, medicaid, and chil-
dren’s health insurance programs.
‘‘(3) Notwithstanding section 1880(c) of the Social
Security Act (42 U.S.C. 1395qq(c)) or section 402(a) of
this title, no payment may be made out of the special fund
described in section 1880(c) of the Social Security Act (42
U.S.C. 1395qq(c)), or section 402(a) of this title, for the
benefit of any health program exercising the option de-
172
scribed in subsection (a) of this section during the period
of such participation.
‘‘(c) The Secretary, and with the assistance of the
Administrator of the Health Care Financing Administra-
tion, shall examine on an ongoing basis and implement
any administrative changes that may be necessary to fa-
cilitate direct billing and reimbursement under the pro-
gram established under this section, including any agree-
ments with States that may be necessary to provide for
direct billing under the medicaid or children’s health in-
surance program.
‘‘(d) A participant in the program established under
this section may withdraw from participation in the same
manner and under the same conditions that an Indian
tribe or tribal organization may retrocede a contracted
program to the Secretary under authority of the Indian
Self-Determination and Education Assistance Act (25
U.S.C. 450 et seq.). All cost accounting and billing author-
ity under the program established under this section shall
be returned to the Secretary upon the Secretary’s accept-
ance of the withdrawal of participation in this program.
‘‘SEC. 406. REIMBURSEMENT FROM CERTAIN THIRD PAR-
TIES OF COSTS OF HEALTH SERVICES.
‘‘(a) Except as provided in subsection (g), the United
States, an Indian tribe, or tribal organization shall have
173
the right to recover the reasonable charges billed or ex-
penses incurred by the Secretary, an Indian tribe, or tribal
organization in providing health services, through the
Service, an Indian tribe, or tribal organization to any indi-
vidual to the same extent that such individual, or any non-
governmental provider of such services, would be eligible
to receive reimbursement or indemnification for such
charges or expenses 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 expenses.
‘‘(b) Except as provided in subsection (g), an urban
Indian organization shall have the right to recover the rea-
sonable charges billed or expenses incurred by the organi-
zation in providing health services to any individual to the
same extent that such individual, or any other nongovern-
mental provider of such services, would be eligible to re-
ceive reimbursement or indemnification for such charges
or expenses if such individual had been required to pay
such charges or expenses and did pay such charges or ex-
penses.
‘‘(c) Subsections (a) and (b) shall provide a right of
recovery against any State, only if the injury, illness, or
174
disability for which health services were provided is cov-
ered under—
‘‘(1) workers’ compensation laws, or
‘‘(2) a no-fault automobile accident insurance
plan or program.
‘‘(d) No law of any State, or of any political subdivi-
sion of a State and no provision of any contract entered
into or renewed after the date of 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) or an urban
Indian organization under subsection (b).
‘‘(e) No action taken by the United States, an Indian
tribe, or tribal organization to enforce the right of recovery
provided under subsection (a), or by an urban Indian or-
ganization to enforce the right of recovery provided under
subsection (b), shall affect the right of any person to any
damages (other than damages for the cost of health serv-
ices provided by the Secretary through the Service).
‘‘(f) The United States, an Indian tribe, or tribal or-
ganization may enforce the right of recovery provided
under subsection (a), and an urban Indian organization
may enforce the right of recovery provided under sub-
section (b), by—
175
‘‘(1) intervening or joining in any civil action or
proceeding brought—
‘‘(A) by the individual for whom health
services were provided by the Secretary, an In-
dian tribe, tribal organization, or urban Indian
organization; or
‘‘(B) by any representative or heirs of such
individual, or
‘‘(2) instituting a civil action.
All reasonable efforts shall be made to provide notice of
such action to the individual to whom health services were
provided, either before or during the pendency of such ac-
tion.
‘‘(g) Absent specific written authorization by the gov-
erning body of an Indian tribe for the period of such au-
thorization which may not be for a period of more than
one 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 recovery 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. However, where such tribal au-
thorization is provided, the Service may receive and ex-