351 
scribed in subsection (a)(1)(D) shall not apply 
in the case of expenditures for outreach activi-
ties to families of Indian children likely to be el-
igible for child health assistance under the plan 
or medical assistance under the State plan 
under title XIX (or under a waiver of such 
plan), to inform such families of the availability 
of, and to assist them in enrolling their children 
in, such plans, including such activities con-
ducted under grants, contracts, or agreements 
entered into under section 1139(a).’’. 
(b) ASSURANCE OF PAYMENTS TO INDIAN HEALTH 
CARE PROVIDERS FOR CHILD HEALTH ASSISTANCE.— 
Section 
2102(b)(3)(D) 
of 
such 
Act 
(42 
U.S.C. 
1397bb(b)(3)(D)) is amended by striking ‘‘(as defined in 
section 4(c) of the Indian Health Care Improvement Act, 
25 U.S.C. 1603(c))’’ and inserting ‘‘, including how the 
State will ensure that payments are made to Indian 
Health Programs and Urban Indian Organizations oper-
ating in the State for the provision of such assistance’’. 
(c) INCLUSION
OF
OTHER
INDIAN
FINANCED 
HEALTH CARE PROGRAMS IN EXEMPTION FROM PROHI-
BITION ON CERTAIN PAYMENTS.—Section 2105(c)(6)(B) 
of such Act (42 U.S.C. 1397ee(c)(6)(B)) is amended by 
striking ‘‘insurance program, other than an insurance pro-
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352 
gram operated or financed by the Indian Health Service’’ 
and inserting ‘‘program, other than a health care program 
operated or financed by the Indian Health Service or by 
an Indian Tribe, Tribal Organization, or Urban Indian 
Organization’’. 
(d) SATISFACTION OF MEDICAID DOCUMENTATION 
REQUIREMENTS.— 
(1) IN GENERAL.—Section 1903(x)(3)(B) of the 
Social Security Act (42 U.S.C. 1396b(x)(3)(B)) is 
amended— 
(A) by redesignating clause (v) as clause 
(vi); and 
(B) by inserting after clause (iv), the fol-
lowing new clause: 
‘‘(v)(I) Except as provided in subclause (II), a 
document issued by a federally-recognized Indian 
tribe evidencing membership or enrollment in, or af-
filiation with, such tribe. 
‘‘(II) With respect to those federally-recognized 
Indian tribes located within States having an inter-
national border whose membership includes individ-
uals who are not citizens of the United States, the 
Secretary shall, after consulting with such tribes, 
issue regulations authorizing the presentation of 
such other forms of documentation (including tribal 
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353 
documentation, if appropriate) that the Secretary 
determines to be satisfactory documentary evidence 
of citizenship or nationality for purposes of satis-
fying the requirement of this subsection.’’. 
(2) TRANSITION RULE.—During the period that 
begins on July 1, 2006, and ends on the effective 
date of final regulations issued under subclause (II) 
of section 1903(x)(3)(B)(v) of the Social Security 
Act (42 U.S.C. 1396b(x)(3)(B)(v)) (as added by 
paragraph (1)), an individual who is a member of a 
federally-recognized Indian tribe described in sub-
clause (II) of that section who presents a document 
described in subclause (I) of such section that is 
issued by such Indian tribe, shall be deemed to have 
presented satisfactory evidence of citizenship or na-
tionality for purposes of satisfying the requirement 
of subsection (x) of section 1903 of such Act. 
(e) DEFINITIONS.—Section 2110(c) of such Act (42 
U.S.C. 1397jj(c)) is amended by adding at the end the 
following new paragraph: 
‘‘(9) INDIAN; INDIAN
HEALTH
PROGRAM; IN-
DIAN
TRIBE; ETC.—The terms ‘Indian’, ‘Indian 
Health Program’, ‘Indian Tribe’, ‘Tribal Organiza-
tion’, and ‘Urban Indian Organization’ have the 
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354 
meanings given those terms in section 4 of the In-
dian Health Care Improvement Act.’’. 
SEC. 204. PREMIUMS AND COST SHARING PROTECTIONS 
UNDER MEDICAID, ELIGIBILITY DETERMINA-
TIONS UNDER MEDICAID AND SCHIP, AND 
PROTECTION OF CERTAIN INDIAN PROPERTY 
FROM MEDICAID ESTATE RECOVERY. 
(a) PREMIUMS
AND COST SHARING PROTECTION 
UNDER MEDICAID.— 
(1) IN GENERAL.—Section 1916 of the Social 
Security Act (42 U.S.C. 1396o) is amended— 
(A) in subsection (a), in the matter pre-
ceding paragraph (1), by striking ‘‘and (i)’’ and 
inserting ‘‘, (i), and (j)’’; and 
(B) by adding at the end the following new 
subsection: 
‘‘(j) NO PREMIUMS OR COST SHARING FOR INDIANS 
FURNISHED ITEMS OR SERVICES DIRECTLY BY INDIAN 
HEALTH PROGRAMS OR THROUGH REFERRAL UNDER 
THE CONTRACT HEALTH SERVICE.— 
‘‘(1) NO COST SHARING FOR ITEMS OR SERV-
ICES
FURNISHED
TO
INDIANS
THROUGH
INDIAN 
HEALTH PROGRAMS.— 
‘‘(A) IN
GENERAL.—No enrollment fee, 
premium, or similar charge, and no deduction, 
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355 
copayment, cost sharing, or similar charge shall 
be imposed against an Indian who is furnished 
an item or service directly by the Indian Health 
Service, an Indian Tribe, Tribal Organization, 
or Urban Indian Organization or through refer-
ral under the contract health service for which 
payment may be made under this title. 
‘‘(B) NO REDUCTION IN AMOUNT OF PAY-
MENT TO INDIAN HEALTH PROVIDERS.—Pay-
ment due under this title to the Indian Health 
Service, an Indian Tribe, Tribal Organization, 
or Urban Indian Organization, or a health care 
provider through referral under the contract 
health service for the furnishing of an item or 
service to an Indian who is eligible for assist-
ance under such title, may not be reduced by 
the amount of any enrollment fee, premium, or 
similar charge, or any deduction, copayment, 
cost sharing, or similar charge that would be 
due from the Indian but for the operation of 
subparagraph (A). 
‘‘(2) RULE
OF
CONSTRUCTION.—Nothing in 
this subsection shall be construed as restricting the 
application of any other limitations on the imposi-
tion of premiums or cost sharing that may apply to 
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356 
an individual receiving medical assistance under this 
title who is an Indian. 
‘‘(3) DEFINITIONS.—In this subsection, the 
terms ‘contract health service’, ‘Indian’, ‘Indian 
Tribe’, ‘Tribal Organization’, and ‘Urban Indian Or-
ganization’ have the meanings given those terms in 
section 4 of the Indian Health Care Improvement 
Act.’’. 
(2) 
CONFORMING
AMENDMENT.—Section 
1916A (a)(1) of such Act (42 U.S.C. 1396o–1(a)(1)) 
is amended by striking ‘‘section 1916(g)’’ and in-
serting ‘‘subsections (g), (i), or (j) of section 1916’’. 
(b) TREATMENT OF CERTAIN PROPERTY FOR MED-
ICAID AND SCHIP ELIGIBILITY.— 
(1) MEDICAID.—Section 1902(e) of the Social 
Security Act (42 U.S.C. 1396a) is amended by add-
ing at the end the following new paragraph: 
‘‘(13) Notwithstanding any other requirement 
of this title or any other provision of Federal or 
State law, a State shall disregard the following prop-
erty for purposes of determining the eligibility of an 
individual who is an Indian (as defined in section 4 
of the Indian Health Care Improvement Act) for 
medical assistance under this title: 
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357 
‘‘(A) Property, including real property and 
improvements, that is held in trust, subject to 
Federal restrictions, or otherwise under the su-
pervision of the Secretary of the Interior, lo-
cated on a reservation, including any federally 
recognized Indian Tribe’s reservation, pueblo, 
or colony, including former reservations in 
Oklahoma, Alaska Native regions established by 
the Alaska Native Claims Settlement Act, and 
Indian allotments on or near a reservation as 
designated and approved by the Bureau of In-
dian Affairs of the Department of the Interior. 
‘‘(B) For any federally recognized Tribe 
not described in subparagraph (A), property lo-
cated within the most recent boundaries of a 
prior Federal reservation. 
‘‘(C) Ownership interests in rents, leases, 
royalties, or usage rights related to natural re-
sources (including extraction of natural re-
sources or harvesting of timber, other plants 
and plant products, animals, fish, and shellfish) 
resulting from the exercise of federally pro-
tected rights. 
‘‘(D) Ownership interests in or usage 
rights to items not covered by subparagraphs 
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358 
(A) through (C) that have unique religious, 
spiritual, traditional, or cultural significance or 
rights that support subsistence or a traditional 
lifestyle according to applicable tribal law or 
custom.’’. 
(2) 
APPLICATION
TO
SCHIP.—Section 
2107(e)(1) of such Act (42 U.S.C. 1397gg(e)(1)) is 
amended— 
(A) by redesignating subparagraphs (B) 
through (E), as subparagraphs (C) through 
(F), respectively; and 
(B) by inserting after subparagraph (A), 
the following new subparagraph: 
‘‘(B) Section 1902(e)(13) (relating to dis-
regard of certain property for purposes of mak-
ing eligibility determinations).’’. 
(c) CONTINUATION OF CURRENT LAW PROTECTIONS 
OF CERTAIN INDIAN PROPERTY FROM MEDICAID ESTATE 
RECOVERY.—Section 1917(b)(3) of the Social Security 
Act (42 U.S.C. 1396p(b)(3)) is amended— 
(1) by inserting ‘‘(A)’’ after ‘‘(3)’’; and 
(2) by adding at the end the following new sub-
paragraph: 
‘‘(B) The standards specified by the Sec-
retary under subparagraph (A) shall require 
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359 
that the procedures established by the State 
agency under subparagraph (A) exempt income, 
resources, and property that are exempt from 
the application of this subsection as of April 1, 
2003, under manual instructions issued to carry 
out this subsection (as in effect on such date) 
because of the Federal responsibility for Indian 
Tribes and Alaska Native Villages. Nothing in 
this subparagraph shall be construed as pre-
venting the Secretary from providing additional 
estate recovery exemptions under this title for 
Indians.’’. 
SEC. 205. NONDISCRIMINATION IN QUALIFICATIONS FOR 
PAYMENT FOR SERVICES UNDER FEDERAL 
HEALTH CARE PROGRAMS. 
Section 1139 of the Social Security Act (42 U.S.C. 
1320b–9), as amended by section 202, is amended by re-
designating subsection (c) as subsection (d), and inserting 
after subsection (b) the following new subsection: 
‘‘(c) NONDISCRIMINATION IN QUALIFICATIONS FOR 
PAYMENT
FOR SERVICES UNDER FEDERAL HEALTH 
CARE PROGRAMS.— 
‘‘(1) REQUIREMENT
TO
SATISFY
GENERALLY 
APPLICABLE PARTICIPATION REQUIREMENTS.— 
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360 
‘‘(A) IN GENERAL.—A Federal health care 
program must accept an entity that is operated 
by the Indian Health Service, an Indian Tribe, 
Tribal Organization, or Urban Indian Organiza-
tion as a provider eligible to receive payment 
under the program for health care services fur-
nished to an Indian on the same basis as any 
other provider qualified to participate as a pro-
vider of health care services under the program 
if the entity meets generally applicable State or 
other requirements for participation as a pro-
vider of health care services under the program. 
‘‘(B) SATISFACTION OF STATE OR LOCAL 
LICENSURE
OR
RECOGNITION
REQUIRE-
MENTS.—Any requirement for participation as 
a provider of health care services under a Fed-
eral health care program that an entity be li-
censed or recognized under the State or local 
law where the entity is located to furnish health 
care services shall be deemed to have been met 
in the case of an entity operated by the Indian 
Health Service, an Indian Tribe, Tribal Organi-
zation, or Urban Indian Organization if the en-
tity meets all the applicable standards for such 
licensure or recognition, regardless of whether 
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361 
the entity obtains a license or other documenta-
tion under such State or local law. In accord-
ance with section 221 of the Indian Health 
Care Improvement Act, the absence of the licen-
sure of a health care professional employed by 
such an entity under the State or local law 
where the entity is located shall not be taken 
into account for purposes of determining wheth-
er the entity meets such standards, if the pro-
fessional is licensed in another State. 
‘‘(2) PROHIBITION ON FEDERAL PAYMENTS TO 
ENTITIES OR INDIVIDUALS EXCLUDED FROM PAR-
TICIPATION IN FEDERAL HEALTH CARE PROGRAMS 
OR WHOSE STATE LICENSES ARE UNDER SUSPEN-
SION OR HAVE BEEN REVOKED.— 
‘‘(A) EXCLUDED ENTITIES.—No entity op-
erated by the Indian Health Service, an Indian 
Tribe, Tribal Organization, or Urban Indian 
Organization that has been excluded from par-
ticipation in any Federal health care program 
or for which a license is under suspension or 
has been revoked by the State where the entity 
is located shall be eligible to receive payment 
under any such program for health care serv-
ices furnished to an Indian. 
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362 
‘‘(B) EXCLUDED INDIVIDUALS.—No indi-
vidual who has been excluded from participation 
in any Federal health care program or whose 
State license is under suspension or has been 
revoked shall be eligible to receive payment 
under any such program for health care serv-
ices furnished by that individual, directly or 
through an entity that is otherwise eligible to 
receive payment for health care services, to an 
Indian. 
‘‘(C) FEDERAL
HEALTH
CARE
PROGRAM 
DEFINED.—In this subsection, the term, ‘Fed-
eral health care program’ has the meaning 
given that term in section 1128B(f), except 
that, for purposes of this subsection, such term 
shall include the health insurance program 
under chapter 89 of title 5, United States 
Code.’’. 
SEC. 206. CONSULTATION ON MEDICAID, SCHIP, AND 
OTHER HEALTH CARE PROGRAMS FUNDED 
UNDER THE SOCIAL SECURITY ACT INVOLV-
ING INDIAN HEALTH PROGRAMS AND URBAN 
INDIAN ORGANIZATIONS. 
(a) IN GENERAL.—Section 1139 of the Social Secu-
rity Act (42 U.S.C. 1320b–9), as amended by sections 202 
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363 
and 205, is amended by redesignating subsection (d) as 
subsection (e), and inserting after subsection (c) the fol-
lowing new subsection: 
‘‘(d) CONSULTATION WITH TRIBAL TECHNICAL AD-
VISORY GROUP (TTAG).—The Secretary shall maintain 
within the Centers for Medicaid & Medicare Services 
(CMS) a Tribal Technical Advisory Group, established in 
accordance with requirements of the charter dated Sep-
tember 30, 2003, and in such group shall include a rep-
resentative of the Urban Indian Organizations and the 
Service. The representative of the Urban Indian Organiza-
tion shall be deemed to be an elected officer of a tribal 
government for purposes of applying section 204(b) of the 
Unfunded Mandates Reform Act of 1995 (2 U.S.C. 
1534(b)).’’. 
(b) SOLICITATION OF ADVICE UNDER MEDICAID AND 
SCHIP.— 
(1) MEDICAID STATE PLAN AMENDMENT.—Sec-
tion 1902(a) of the Social Security Act (42 U.S.C. 
1396a(a)) is amended— 
(A) in paragraph (69), by striking ‘‘and’’ 
at the end; 
(B) in paragraph (70)(B)(iv), by striking 
the period at the end and inserting ‘‘; and’’; 
and 
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364 
(C) 
by 
inserting 
after 
paragraph 
(70)(B)(iv), the following new paragraph: 
‘‘(71) in the case of any State in which the In-
dian Health Service operates or funds health care 
programs, or in which 1 or more Indian Health Pro-
grams or Urban Indian Organizations (as such 
terms are defined in section 4 of the Indian Health 
Care Improvement Act) provide health care in the 
State for which medical assistance is available under 
such title, provide for a process under which the 
State seeks advice on a regular, ongoing basis from 
designees of such Indian Health Programs and 
Urban Indian Organizations on matters relating to 
the application of this title that are likely to have a 
direct effect on such Indian Health Programs and 
Urban Indian Organizations and that— 
‘‘(A) shall include solicitation of advice 
prior to submission of any plan amendments, 
waiver requests, and proposals for demonstra-
tion projects likely to have a direct effect on In-
dians, Indian Health Programs, or Urban In-
dian Organizations; and 
‘‘(B) may include appointment of an advi-
sory committee and of a designee of such In-
dian Health Programs and Urban Indian Orga-
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365 
nizations to the medical care advisory com-
mittee advising the State on its State plan 
under this title.’’. 
(2) 
APPLICATION
TO
SCHIP.—Section 
2107(e)(1) of such Act (42 U.S.C. 1397gg(e)(1)), as 
amended by section 204(b)(2), is amended— 
(A) by redesignating subparagraphs (B) 
through (F) as subparagraphs (C) through (G), 
respectively; and 
(B) by inserting after subparagraph (A), 
the following new subparagraph: 
‘‘(B) Section 1902(a)(71) (relating to the 
option of certain States to seek advice from 
designees of Indian Health Programs and 
Urban Indian Organizations).’’. 
(c) RULE
OF
CONSTRUCTION.—Nothing in the 
amendments made by this section shall be construed as 
superseding existing advisory committees, working groups, 
guidance, or other advisory procedures established by the 
Secretary of Health and Human Services or by any State 
with respect to the provision of health care to Indians. 
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366 
SEC. 207. EXCLUSION WAIVER AUTHORITY FOR AFFECTED 
INDIAN HEALTH PROGRAMS AND SAFE HAR-
BOR TRANSACTIONS UNDER THE SOCIAL SE-
CURITY ACT. 
(a) EXCLUSION WAIVER AUTHORITY.—Section 1128 
of the Social Security Act (42 U.S.C. 1320a–7) is amend-
ed by adding at the end the following new subsection: 
‘‘(k) ADDITIONAL EXCLUSION WAIVER AUTHORITY 
FOR AFFECTED INDIAN HEALTH PROGRAMS.—In addi-
tion to the authority granted the Secretary under sub-
sections (c)(3)(B) and (d)(3)(B) to waive an exclusion 
under subsection (a)(1), (a)(3), (a)(4), or (b), the Sec-
retary may, in the case of an Indian Health Program, 
waive such an exclusion upon the request of the adminis-
trator of an affected Indian Health Program (as defined 
in section 4 of the Indian Health Care Improvement Act) 
who determines that the exclusion would impose a hard-
ship on individuals entitled to benefits under or enrolled 
in a Federal health care program.’’. 
(b) CERTAIN
TRANSACTIONS
INVOLVING
INDIAN 
HEALTH CARE PROGRAMS DEEMED TO BE IN SAFE HAR-
BORS.—Section 1128B(b) of the Social Security Act (42 
U.S.C. 1320a–7b(b)) is amended by adding at the end the 
following new paragraph: 
‘‘(4) Subject to such conditions as the Secretary may 
promulgate from time to time as necessary to prevent 
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367 
fraud and abuse, for purposes of paragraphs (1) and (2) 
and section 1128A(a), the following transfers shall not be 
treated as remuneration: 
‘‘(A) TRANSFERS
BETWEEN
INDIAN
HEALTH 
PROGRAMS, INDIAN TRIBES, TRIBAL ORGANIZATIONS, 
AND URBAN INDIAN ORGANIZATIONS.—Transfers of 
anything of value between or among an Indian 
Health Program, Indian Tribe, Tribal Organization, 
or Urban Indian Organization, that are made for the 
purpose of providing necessary health care items and 
services to any patient served by such Program, 
Tribe, or Organization and that consist of— 
‘‘(i) services in connection with the collec-
tion, transport, analysis, or interpretation of di-
agnostic specimens or test data; 
‘‘(ii) inventory or supplies; 
‘‘(iii) staff; or 
‘‘(iv) a waiver of all or part of premiums 
or cost sharing. 
‘‘(B) TRANSFERS
BETWEEN
INDIAN
HEALTH 
PROGRAMS, INDIAN TRIBES, TRIBAL ORGANIZATIONS, 
OR
URBAN
INDIAN
ORGANIZATIONS
AND
PA-
TIENTS.—Transfers of anything of value between an 
Indian Health Program, Indian Tribe, Tribal Orga-
nization, or Urban Indian Organization and any pa-
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368 
tient served or eligible for service from an Indian 
Health Program, Indian Tribe, Tribal Organization, 
or Urban Indian Organization, including any patient 
served or eligible for service pursuant to section 807 
of the Indian Health Care Improvement Act, but 
only if such transfers— 
‘‘(i) consist of expenditures related to pro-
viding transportation for the patient for the 
provision of necessary health care items or serv-
ices, provided that the provision of such trans-
portation is not advertised, nor an incentive of 
which the value is disproportionately large in 
relationship to the value of the health care item 
or service (with respect to the value of the item 
or service itself or, for preventative items or 
services, the future health care costs reasonably 
expected to be avoided); 
‘‘(ii) consist of expenditures related to pro-
viding housing to the patient (including a preg-
nant patient) and immediate family members or 
an escort necessary to assuring the timely pro-
vision of health care items and services to the 
patient, provided that the provision of such 
housing is not advertised nor an incentive of 
which the value is disproportionately large in 
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369 
relationship to the value of the health care item 
or service (with respect to the value of the item 
or service itself or, for preventative items or 
services, the future health care costs reasonably 
expected to be avoided); or 
‘‘(iii) are for the purpose of paying pre-
miums or cost sharing on behalf of such a pa-
tient, provided that the making of such pay-
ment is not subject to conditions other than 
conditions agreed to under a contract for the 
delivery of contract health services. 
‘‘(C) CONTRACT HEALTH SERVICES.—A trans-
fer of anything of value negotiated as part of a con-
tract entered into between an Indian Health Pro-
gram, Indian Tribe, Tribal Organization, Urban In-
dian Organization, or the Indian Health Service and 
a contract care provider for the delivery of contract 
health services authorized by the Indian Health 
Service, provided that— 
‘‘(i) such a transfer is not tied to volume 
or value of referrals or other business generated 
by the parties; and 
‘‘(ii) any such transfer is limited to the fair 
market value of the health care items or serv-
ices provided or, in the case of a transfer of 
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370 
items or services related to preventative care, 
the value of the future health care costs reason-
ably expected to be avoided. 
‘‘(D) OTHER TRANSFERS.—Any other transfer 
of anything of value involving an Indian Health Pro-
gram, Indian Tribe, Tribal Organization, or Urban 
Indian Organization, or a patient served or eligible 
for service from an Indian Health Program, Indian 
Tribe, Tribal Organization, or Urban Indian Organi-
zation, that the Secretary, in consultation with the 
Attorney General, determines is appropriate, taking 
into account the special circumstances of such In-
dian Health Programs, Indian Tribes, Tribal Orga-
nizations, and Urban Indian Organizations, and of 
patients served by such Programs, Tribes, and Orga-
nizations.’’. 
SEC. 208. RULES APPLICABLE UNDER MEDICAID AND 
SCHIP TO MANAGED CARE ENTITIES WITH 
RESPECT TO INDIAN ENROLLEES AND IN-
DIAN HEALTH CARE PROVIDERS AND INDIAN 
MANAGED CARE ENTITIES. 
(a) IN GENERAL.—Section 1932 of the Social Secu-
rity Act (42 U.S.C. 1396u–2) is amended by adding at 
the end the following new subsection: 
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371 
‘‘(h) SPECIAL RULES WITH RESPECT TO INDIAN EN-
ROLLEES, INDIAN HEALTH CARE PROVIDERS, AND IN-
DIAN MANAGED CARE ENTITIES.— 
‘‘(1) ENROLLEE OPTION TO SELECT AN INDIAN 
HEALTH CARE PROVIDER AS PRIMARY CARE PRO-
VIDER.—In the case of a non-Indian Medicaid man-
aged care entity that— 
‘‘(A) has an Indian enrolled with the enti-
ty; and 
‘‘(B) has an Indian health care provider 
that is participating as a primary care provider 
within the network of the entity, 
insofar as the Indian is otherwise eligible to receive 
services from such Indian health care provider and 
the Indian health care provider has the capacity to 
provide primary care services to such Indian, the 
contract with the entity under section 1903(m) or 
under section 1905(t)(3) shall require, as a condi-
tion of receiving payment under such contract, that 
the Indian shall be allowed to choose such Indian 
health care provider as the Indian’s primary care 
provider under the entity. 
‘‘(2) ASSURANCE
OF
PAYMENT
TO
INDIAN 
HEALTH CARE PROVIDERS FOR PROVISION OF COV-
ERED
SERVICES.—Each contract with a managed 
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372 
care entity under section 1903(m) or under section 
1905(t)(3) shall require any such entity that has a 
significant percentage of Indian enrollees (as deter-
mined by the Secretary), as a condition of receiving 
payment under such contract to satisfy the following 
requirements: 
‘‘(A) DEMONSTRATION OF PARTICIPATING 
INDIAN HEALTH CARE PROVIDERS OR APPLICA-
TION
OF
ALTERNATIVE
PAYMENT
ARRANGE-
MENTS.—Subject to subparagraph (E), to— 
‘‘(i) demonstrate that the number of 
Indian health care providers that are par-
ticipating providers with respect to such 
entity are sufficient to ensure timely access 
to covered Medicaid managed care services 
for those enrollees who are eligible to re-
ceive services from such providers; or 
‘‘(ii) agree to pay Indian health care 
providers who are not participating pro-
viders with the entity for covered Medicaid 
managed care services provided to those 
enrollees who are eligible to receive services 
from such providers at a rate equal to the 
rate negotiated between such entity and 
the provider involved or, if such a rate has 
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373 
not been negotiated, at a rate that is not 
less than the level and amount of payment 
which the entity would make for the serv-
ices if the services were furnished by a par-
ticipating provider which is not an Indian 
health care provider. 
‘‘(B) PROMPT
PAYMENT.—To agree to 
make prompt payment (in accordance with 
rules applicable to managed care entities) to In-
dian health care providers that are participating 
providers with respect to such entity or, in the 
case of an entity to which subparagraph (A)(ii) 
or (E) applies, that the entity is required to pay 
in accordance with that subparagraph. 
‘‘(C) SATISFACTION
OF
CLAIM
REQUIRE-
MENT.—To deem any requirement for the sub-
mission of a claim or other documentation for 
services covered under subparagraph (A) by the 
enrollee to be satisfied through the submission 
of a claim or other documentation by an Indian 
health care provider that is consistent with sec-
tion 403(h) of the Indian Health Care Improve-
ment Act. 
‘‘(D) COMPLIANCE WITH GENERALLY AP-
PLICABLE REQUIREMENTS.— 
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374 
‘‘(i) IN GENERAL.—Subject to clause 
(ii), as a condition of payment under sub-
paragraph (A), an Indian health care pro-
vider shall comply with the generally appli-
cable requirements of this title, the State 
plan, and such entity with respect to cov-
ered Medicaid managed care services pro-
vided by the Indian health care provider to 
the same extent that non-Indian providers 
participating with the entity must comply 
with such requirements. 
‘‘(ii) LIMITATIONS
ON
COMPLIANCE 
WITH MANAGED CARE ENTITY GENERALLY 
APPLICABLE
REQUIREMENTS.—An Indian 
health care provider— 
‘‘(I) shall not be required to com-
ply with a generally applicable re-
quirement of a managed care entity 
described in clause (i) as a condition 
of payment under subparagraph (A) if 
such compliance would conflict with 
any other statutory or regulatory re-
quirements applicable to the Indian 
health care provider; and 
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375 
‘‘(II) shall only need to comply 
with those generally applicable re-
quirements of a managed care entity 
described in clause (i) as a condition 
of payment under subparagraph (A) 
that are necessary for the entity’s 
compliance with the State plan, such 
as those related to care management, 
quality 
assurance, 
and 
utilization 
management. 
‘‘(E) APPLICATION OF SPECIAL PAYMENT 
REQUIREMENTS
FOR
FEDERALLY-QUALIFIED 
HEALTH CENTERS AND ENCOUNTER RATE FOR 
SERVICES
PROVIDED
BY
CERTAIN
INDIAN 
HEALTH CARE PROVIDERS.— 
‘‘(i) FEDERALLY-QUALIFIED HEALTH 
CENTERS.— 
‘‘(I) MANAGED
CARE
ENTITY 
PAYMENT
REQUIREMENT.—To agree 
to pay any Indian health care provider 
that is a federally-qualified health 
center but not a participating provider 
with respect to the entity, for the pro-
vision of covered Medicaid managed 
care services by such provider to an 
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376 
Indian enrollee of the entity at a rate 
equal to the amount of payment that 
the entity would pay a federally-quali-
fied health center that is a partici-
pating provider with respect to the en-
tity but is not an Indian health care 
provider for such services. 
‘‘(II) CONTINUED
APPLICATION 
OF
STATE
REQUIREMENT
TO
MAKE 
SUPPLEMENTAL
PAYMENT.—Nothing 
in subclause (I) or subparagraph (A) 
or (B) shall be construed as waiving 
the application of section 1902(bb)(5) 
regarding the State plan requirement 
to make any supplemental payment 
due under such section to a federally- 
qualified health center for services 
furnished by such center to an en-
rollee of a managed care entity (re-
gardless of whether the federally- 
qualified health center is or is not a 
participating provider with the entity). 
‘‘(ii) CONTINUED
APPLICATION
OF 
ENCOUNTER
RATE
FOR
SERVICES
PRO-
VIDED BY CERTAIN INDIAN HEALTH CARE 
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377 
PROVIDERS.—If the amount paid by a 
managed care entity to an Indian health 
care provider that is not a federally-quali-
fied health center and that has elected to 
receive payment under this title as an In-
dian Health Service provider under the 
July 11, 1996, Memorandum of Agreement 
between the Health Care Financing Ad-
ministration (now the Centers for Medicare 
& Medicaid Services) and the Indian 
Health Service for services provided by 
such provider to an Indian enrollee with 
the managed care entity is less than the 
encounter rate that applies to the provision 
of such services under such memorandum, 
the State plan shall provide for payment to 
the Indian health care provider of the dif-
ference between the applicable encounter 
rate under such memorandum and the 
amount paid by the managed care entity to 
the provider for such services. 
‘‘(F) CONSTRUCTION.—Nothing in this 
paragraph shall be construed as waiving the ap-
plication of section 1902(a)(30)(A) (relating to 
application of standards to assure that pay-
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378 
ments are consistent with efficiency, economy, 
and quality of care). 
‘‘(3) OFFERING OF MANAGED CARE THROUGH 
INDIAN MEDICAID MANAGED CARE ENTITIES.—If— 
‘‘(A) a State elects to provide services 
through Medicaid managed care entities under 
its Medicaid managed care program; and 
‘‘(B) an Indian health care provider that is 
funded in whole or in part by the Indian Health 
Service, or a consortium composed of 1 or more 
Tribes, Tribal Organizations, or Urban Indian 
Organizations, and which also may include the 
Indian Health Service, has established an In-
dian Medicaid managed care entity in the State 
that meets generally applicable standards re-
quired of such an entity under such Medicaid 
managed care program, 
the State shall offer to enter into an agreement with 
the entity to serve as a Medicaid managed care enti-
ty with respect to eligible Indians served by such en-
tity under such program. 
‘‘(4) SPECIAL
RULES
FOR
INDIAN
MANAGED 
CARE ENTITIES.—The following are special rules re-
garding the application of a Medicaid managed care 
program to Indian Medicaid managed care entities: 
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379 
‘‘(A) ENROLLMENT.— 
‘‘(i) LIMITATION TO INDIANS.—An In-
dian Medicaid managed care entity may re-
strict enrollment under such program to 
Indians and to members of specific Tribes 
in the same manner as Indian Health Pro-
grams may restrict the delivery of services 
to such Indians and tribal members. 
‘‘(ii) NO LESS CHOICE OF PLANS.— 
Under such program the State may not 
limit the choice of an Indian among Med-
icaid managed care entities only to Indian 
Medicaid managed care entities or to be 
more restrictive than the choice of man-
aged care entities offered to individuals 
who are not Indians. 
‘‘(iii) DEFAULT ENROLLMENT.— 
‘‘(I) IN GENERAL.—If such pro-
gram of a State requires the enroll-
ment of Indians in a Medicaid man-
aged care entity in order to receive 
benefits, the State, taking into consid-
eration the criteria specified in sub-
section (a)(4)(D)(ii)(I), shall provide 
for the enrollment of Indians de-
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380 
scribed in subclause (II) who are not 
otherwise enrolled with such an entity 
in an Indian Medicaid managed care 
entity described in such clause. 
‘‘(II) INDIAN
DESCRIBED.—An 
Indian described in this subclause, 
with respect to an Indian Medicaid 
managed care entity, is an Indian 
who, based upon the service area and 
capacity of the entity, is eligible to be 
enrolled with the entity consistent 
with subparagraph (A). 
‘‘(iv) EXCEPTION
TO
STATE
LOCK- 
IN.—A request by an Indian who is en-
rolled under such program with a non-In-
dian Medicaid managed care entity to 
change enrollment with that entity to en-
rollment with an Indian Medicaid managed 
care entity shall be considered cause for 
granting such request under procedures 
specified by the Secretary. 
‘‘(B) FLEXIBILITY
IN
APPLICATION
OF 
SOLVENCY.—In applying section 1903(m)(1) to 
an Indian Medicaid managed care entity— 
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381 
‘‘(i) any reference to a ‘State’ in sub-
paragraph (A)(ii) of that section shall be 
deemed to be a reference to the ‘Sec-
retary’; and 
‘‘(ii) the entity shall be deemed to be 
a public entity described in subparagraph 
(C)(ii) of that section. 
‘‘(C) EXCEPTIONS
TO
ADVANCE
DIREC-
TIVES.—The Secretary may modify or waive the 
requirements of section 1902(w) (relating to 
provision of written materials on advance direc-
tives) insofar as the Secretary finds that the re-
quirements otherwise imposed are not an appro-
priate or effective way of communicating the in-
formation to Indians. 
‘‘(D) FLEXIBILITY IN INFORMATION AND 
MARKETING.— 
‘‘(i) MATERIALS.—The Secretary may 
modify 
requirements 
under 
subsection 
(a)(5) to ensure that information described 
in that subsection is provided to enrollees 
and potential enrollees of Indian Medicaid 
managed care entities in a culturally ap-
propriate and understandable manner that 
clearly communicates to such enrollees and 
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382 
potential enrollees their rights, protections, 
and benefits. 
‘‘(ii) DISTRIBUTION
OF
MARKETING 
MATERIALS.—The provisions of subsection 
(d)(2)(B) requiring the distribution of 
marketing materials to an entire service 
area shall be deemed satisfied in the case 
of an Indian Medicaid managed care entity 
that distributes appropriate materials only 
to those Indians who are potentially eligi-
ble to enroll with the entity in the service 
area. 
‘‘(5) MALPRACTICE
INSURANCE.—Insofar as, 
under a Medicaid managed care program, a health 
care provider is required to have medical malpractice 
insurance coverage as a condition of contracting as 
a provider with a Medicaid managed care entity, an 
Indian health care provider that is— 
‘‘(A) a federally-qualified health center 
that is covered under the Federal Tort Claims 
Act (28 U.S.C. 1346(b), 2671 et seq.); 
‘‘(B) providing health care services pursu-
ant to a contract or compact under the Indian 
Self-Determination and Education Assistance 
Act (25 U.S.C. 450 et seq.) that are covered 
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383 
under the Federal Tort Claims Act (28 U.S.C. 
1346(b), 2671 et seq.); or 
‘‘(C) the Indian Health Service providing 
health care services that are covered under the 
Federal Tort Claims Act (28 U.S.C. 1346(b), 
2671 et seq.); 
are deemed to satisfy such requirement. 
‘‘(6) DEFINITIONS.—For purposes of this sub-
section: 
‘‘(A) INDIAN HEALTH CARE PROVIDER.— 
The term ‘Indian health care provider’ means 
an Indian Health Program or an Urban Indian 
Organization. 
‘‘(B) INDIAN; INDIAN HEALTH PROGRAM; 
SERVICE; TRIBE; TRIBAL ORGANIZATION; URBAN 
INDIAN
ORGANIZATION.—The terms ‘Indian’, 
‘Indian Health Program’, ‘Service’, ‘Tribe’, 
‘tribal organization’, ‘Urban Indian Organiza-
tion’ have the meanings given such terms in 
section 4 of the Indian Health Care Improve-
ment Act. 
‘‘(C) INDIAN
MEDICAID
MANAGED
CARE 
ENTITY.—The term ‘Indian Medicaid managed 
care entity’ means a managed care entity that 
is controlled (within the meaning of the last 
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384 
sentence of section 1903(m)(1)(C)) by the In-
dian Health Service, a Tribe, Tribal Organiza-
tion, or Urban Indian Organization, or a con-
sortium, which may be composed of 1 or more 
Tribes, Tribal Organizations, or Urban Indian 
Organizations, and which also may include the 
Service. 
‘‘(D) NON-INDIAN
MEDICAID
MANAGED 
CARE ENTITY.—The term ‘non-Indian Medicaid 
managed care entity’ means a managed care en-
tity that is not an Indian Medicaid managed 
care entity. 
‘‘(E) COVERED MEDICAID MANAGED CARE 
SERVICES.—The term ‘covered Medicaid man-
aged care services’ means, with respect to an 
individual enrolled with a managed care entity, 
items and services that are within the scope of 
items and services for which benefits are avail-
able with respect to the individual under the 
contract between the entity and the State in-
volved. 
‘‘(F) MEDICAID
MANAGED
CARE
PRO-
GRAM.—The term ‘Medicaid managed care pro-
gram’ 
means 
a 
program 
under 
sections 
1903(m) and 1932 and includes a managed 
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385 
care program operating under a waiver under 
section 1915(b) or 1115 or otherwise.’’. 
(b) APPLICATION TO SCHIP.—Section 2107(e)(1) of 
such Act (42 U.S.C. 1397gg(1)), as amended by section 
206(b)(2), is amended by adding at the end the following 
new subparagraph: 
‘‘(H) Subsections (a)(2)(C) and (h) of sec-
tion 1932.’’. 
SEC. 209. ANNUAL REPORT ON INDIANS SERVED BY SOCIAL 
SECURITY ACT HEALTH BENEFIT PROGRAMS. 
Section 1139 of the Social Security Act (42 U.S.C. 
1320b–9), as amended by the sections 202, 205, and 206, 
is amended by redesignating subsection (e) as subsection 
(f), and inserting after subsection (d) the following new 
subsection: 
‘‘(e) ANNUAL REPORT
ON INDIANS SERVED
BY 
HEALTH BENEFIT PROGRAMS FUNDED UNDER THIS 
ACT.—Beginning January 1, 2007, and annually there-
after, the Secretary, acting through the Administrator of 
the Centers for Medicare & Medicaid Services and the Di-
rector of the Indian Health Service, shall submit a report 
to Congress regarding the enrollment and health status 
of Indians receiving items or services under health benefit 
programs funded under this Act during the preceding 
year. Each such report shall include the following: 
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386 
‘‘(1) The total number of Indians enrolled in, or 
receiving items or services under, such programs, 
disaggregated with respect to each such program. 
‘‘(2) The number of Indians described in para-
graph (1) that also received health benefits under 
programs funded by the Indian Health Service. 
‘‘(3) General information regarding the health 
status of the Indians described in paragraph (1), 
disaggregated with respect to specific diseases or 
conditions and presented in a manner that is con-
sistent with protections for privacy of individually 
identifiable health information under section 264(c) 
of the Health Insurance Portability and Account-
ability Act of 1996. 
‘‘(4) A detailed statement of the status of facili-
ties of the Indian Health Service or an Indian Tribe, 
Tribal Organization, or an Urban Indian Organiza-
tion with respect to such facilities’ compliance with 
the applicable conditions and requirements of titles 
XVIII, XIX, and XXI, and, in the case of title XIX 
or XXI, under a State plan under such title or 
under waiver authority, and of the progress being 
made by such facilities (under plans submitted 
under section 1880(b), 1911(b) or otherwise) toward 
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387 
the achievement and maintenance of such compli-
ance. 
‘‘(5) Such other information as the Secretary 
determines is appropriate.’’. 
Æ 
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