109
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
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
110
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-
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
111
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-
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
112
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
DELIVERY AREA.
‘‘(a) For fiscal years beginning with the fiscal year
ending September 30, 1983, and ending with the fiscal
year ending September 30, 2012, 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.
‘‘(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
PROGRAM.
‘‘(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-
113
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.
‘‘(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.
114
‘‘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,
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
115
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
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
116
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
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
117
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 2012 to carry out this title.
‘‘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
118
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
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.
119
‘‘(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—
‘‘(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
2000 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 2000 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.
120
‘‘(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;
‘‘(B) health care facilities lists, including but
not limited to—
‘‘(i) the total health care facilities plan-
ning, design, construction, and renovation needs
for Indians;
‘‘(ii) the 10 top-priority inpatient care fa-
cilities;
‘‘(iii) the 10 top-priority outpatient care
facilities;
‘‘(iv) the 10 top-priority specialized care
facilities (such as long-term care and alcohol
and drug abuse treatment);
‘‘(v) any staff quarters associated with
such prioritized facilities;
‘‘(C) the justification for such order of priority;
‘‘(D) the projected cost of such projects; and
‘‘(E) the methodology adopted by the Service in
establishing priorities under its health care facility
priority system.
121
‘‘(3) In preparing each report required under para-
graph (2) (other than the initial report), the Secretary
shall annually—
‘‘(A) consult with and obtain information on all
health care facilities needs from Indian tribes and
tribal organizations, including those tribes or tribal
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
122
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 2000, the Secretary
shall annually submit to the President, for inclusion
in the report required to be transmitted to the Con-
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
123
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
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-
124
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.
‘‘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-
125
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-
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-
126
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.
‘‘(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
127
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
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,
128
‘‘(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
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-
129
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.
‘‘(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
130
‘‘(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
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
131
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.
‘‘(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-
132
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
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-
133
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—
‘‘(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
134
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,
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.
135
‘‘SEC. 304. EXPENDITURE OF NONSERVICE FUNDS FOR
RENOVATION.
‘‘(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
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).
136
‘‘(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
‘‘(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
137
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
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
138
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.
‘‘(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-
139
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).
‘‘(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—
140
‘‘(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
‘‘(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
141
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.
‘‘(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
142
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;
‘‘(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.
143
‘‘(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.
‘‘(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.
144
‘‘(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.
‘‘(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
145
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.
‘‘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
146
organization may be reconstructed or renovated by the
Secretary pursuant to an agreement with such Indian
tribe or tribal organization.
‘‘(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.
147
‘‘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-
148
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.
149
‘‘(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
150
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-
151
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-
152
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.
153
‘‘(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—
154
‘‘(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
155
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.
156
‘‘(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
157
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.
158
‘‘(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
159
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-
160
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
161
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 2012 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.
162
‘‘(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.
163
‘‘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-
164
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
165
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
166
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-
167
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.
168
‘‘(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.
169
‘‘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-
170
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-
171
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
172
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
173
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—
174
‘‘(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-
175
pend such funds for the provision of additional health
services.
‘‘(h) In any action brought to enforce the provisions
of this section, a prevailing plaintiff shall be awarded its
reasonable attorneys fees and costs of litigation.
‘‘(i) Where an insurance company or employee benefit
plan fails or refuses to pay the amount due under sub-
section (a) of this section for services provided to an indi-
vidual who is a beneficiary, participant, or insured of such
company or plan, the United States, Indian tribe, or tribal
organization shall have a right to assert and pursue all
the claims and remedies against such company or plan,
and against the fiduciaries of such company or plan, that
the individual could assert or pursue under applicable
Federal, State, or tribal law.
‘‘(j) Where an insurance company or employee benefit
plan fails or refuses to pay the amounts due under sub-
section (b) for health services provided to an individual
who is a beneficiary, participant, or insured of such com-
pany or plan, the urban Indian organization shall have a
right to assert and pursue all the claims and remedies
against such company or plan, and against the fiduciaries
of such company or plan, that the individual could assert
or pursue under applicable Federal or State law.
176
‘‘(k) Notwithstanding any other provision in law, the
Service, an Indian tribe, tribal organization, or an urban
Indian organization shall have a right of recovery for any
otherwise reimbursable claim filed on a current HCFA–
1500 or UB–92 form, or the current electronic format,
or their successors. No health plan shall deny payment
because a claim has not been submitted in a unique format
that differs from such forms.
‘‘SEC. 407. CREDITING OF REIMBURSEMENTS.
‘‘(a) Except as provided in section 202(d), this title,
and section 807, all reimbursements received or recovered,
under authority of this Act, Public Law 87–693 (42
U.S.C. 2651 et seq.), or any other provision of law, by
reason of the provision of health services by the Service
or by an Indian tribe or tribal organization under a fund-
ing agreement pursuant to the Indian Self-Determination
and Education Assistance Act or by an urban Indian orga-
nization funded under title V shall be retained by the Serv-
ice or that Tribe or tribal organization and shall be avail-
able for the facilities, and to carry out the programs, of
the Service or that Tribe or tribal organization to provide
health care services to Indians.
‘‘(b) The Service may not offset or limit the amount
of funds obligated to any service unit or entity receiving
177
funding from the Service because of the receipt of reim-
bursements under subsection (a).
‘‘SEC. 408. PURCHASING HEALTH CARE COVERAGE.
‘‘Tribes, tribal organizations, and urban Indian orga-
nizations are authorized to use funding from the Secretary
under this Act to purchase managed care coverage for In-
dian Health Services beneficiaries (including authority to
purchase insurance to limit the financial risks of such enti-
ties) from—
‘‘(1) a tribally owned and operated managed
care plan;
‘‘(2) a State or locally authorized or licensed
managed care plan; or
‘‘(3) a health insurance provider.
‘‘SEC. 409. INDIAN HEALTH SERVICE, DEPARTMENT OF VET-
ERANS AFFAIRS, AND OTHER FEDERAL AGEN-
CY HEALTH FACILITIES AND SERVICES SHAR-
ING.
‘‘(a) The Secretary shall examine the feasibility of en-
tering into arrangements or expanding existing arrange-
ments for the sharing of medical facilities and services be-
tween the Indian Health Service and the Veterans Admin-
istration, and other appropriate Federal agencies, includ-
ing those within the Department, and shall, in accordance
with subsection (b), prepare a report on the feasibility of
178
such an arrangement and submit such report to the Con-
gress by no later than September 30, 2000, provided that
the Secretary may not finalize any such agreement with-
out first consulting with the affected Indian tribes.
‘‘(b) The Secretary shall not take any action under
this section or under subchapter IV of chapter 81 of title
38, United States Code, which would impair—
‘‘(1) the priority access of any Indian to health
care services provided through the Indian Health
Service;
‘‘(2) the quality of health care services provided
to any Indian through the Indian Health Service;
‘‘(3) the priority access of any veteran to health
care services provided by the Veterans Administra-
tion;
‘‘(4) the quality of health care services provided
to any veteran by the Veterans Administration;
‘‘(5) the eligibility of any Indian to receive
health services through the Indian Health Service;
or
‘‘(6) the eligibility of any Indian who is a vet-
eran to receive health services through the Veterans
Administration (provided that the Service, the In-
dian tribe or tribal organization shall be reimbursed
by the Veterans Administration where services are
179
provided through the Service, Indian tribes or tribal
organizations to beneficiaries eligible for services
from the Veterans Administration, notwithstanding
any other provision of law).
‘‘(c) The Director is authorized to enter into agree-
ments with other Federal agencies to assist in achieving
parity in services for Indians. Nothing in this section may
be construed as creating any right of a veteran to obtain
health services from the Indian Health Service.
‘‘SEC. 410. PAYOR OF LAST RESORT.
‘‘The Indian Health Service, and programs operated
by Tribes, tribal organizations, or urban Indian organiza-
tions shall be the payor of last resort for services provided
to persons eligible for services from these programs, not-
withstanding any Federal, State, or local law to the con-
trary, unless such law explicitly provides otherwise.
‘‘SEC. 411. PAYMENT OR REIMBURSEMENT FOR SERVICES.
‘‘Notwithstanding any other provision of law, the In-
dian Health Service, Indian Tribes, tribal organizations,
and urban Indian organizations (notwithstanding limita-
tions on who is eligible to receive services from such enti-
ty) shall be eligible to receive payment or reimbursement
for services provided by such entities from any federally
funded health care program, unless there is an explicit
180
prohibition on such payments in the applicable authorizing
statute.
‘‘SEC. 412. TUBA CITY DEMONSTRATION PROJECT.
‘‘Notwithstanding any other provision of law, includ-
ing the Anti-Deficiency Act, provided the Indian tribes to
be served approve, the Service in the Tuba City Service
Unit is authorized to enter into a demonstration project
with the State of Arizona under which the Service would
provide certain specified medicaid services to Indian
Health Services/medicaid eligibles in return for payment
on a capitated basis from the State of Arizona and is au-
thorized to purchase insurance to limit its financial risks
under this project. This project may be extended to other
service units in Arizona, subject to the approval of the In-
dian tribes to be served in such service units, the Service,
and the State of Arizona.
‘‘SEC. 413. ACCESS TO FEDERAL INSURANCE.
‘‘Notwithstanding the provisions of title 5, United
States Code, executive order, or administrative regulation,
an Indian tribe or tribal organization carrying out pro-
grams under the Indian Self-Determination and Edu-
cation Assistance Act or an urban Indian organization car-
rying out programs under title V of this Act shall be enti-
tled to purchase coverage, rights, and benefits for the em-
ployees of such Indian tribe, tribal organization, or urban
181
Indian organization under chapter 89 of title 5, United
States Code, (relating to health insurance) and chapter
87 of title 5, United States Code, (relating to life insur-
ance) if necessary employee deductions and agency con-
tributions in payment for the coverage, rights, and bene-
fits for the period of employment with such Indian tribe,
tribal organization, or urban Indian organization are cur-
rently deposited in the applicable Employee’s Fund under
title 5, United States Code.
‘‘SEC. 414. CONSULTATION AND RULEMAKING.
‘‘(a) CONSULTATION.—Prior to the adoption of any
policy or regulation by the Health Care Financing Admin-
istration, the Secretary shall—
‘‘(1) identify the impact such policy or regula-
tion may have on the Service, Indian tribes, tribal
organizations, and urban Indian organizations;
‘‘(2) provide to the Service, Indian tribes, tribal
organizations, and urban Indian organizations the
information described in paragraph (1); and
‘‘(3) engage in consultation with the Service,
Indian tribes, tribal organizations, and urban Indian
organizations prior to enacting any such policy or
regulation. Such consultation shall be consistent
with the requirements of Executive Order 13084 of
May 14, 1998.
182
‘‘(b) RULEMAKING.—The Health Care Financing Ad-
ministration shall participate in the negotiated rulemaking
provided for under title VIII of this Act with regard to
any regulations necessary to implement the provisions of
this title that relate to the Social Security Act.’’.
‘‘SEC. 415. LIMITATION ON SECRETARY’S WAIVER AUTHOR-
ITY.
‘‘Notwithstanding any other provision of law, the Sec-
retary may not waive the application of section
1902(a)(13)(D) to any State Plan under title XIX of the
Social Security Act.
‘‘SEC. 416. CHILDREN’S HEALTH INSURANCE PROGRAM
FUNDS.
‘‘(a) DIRECT FUNDING.—The Secretary is authorized
to enter into agreements directly with the Indian Health
Service and Indian tribes and tribal organizations under
which such entities will provide children’s health insurance
program-like services to Indians who reside in a service
area on or near an Indian reservation. Such agreements
may provide for funding under a block grant or such other
mechanism as is agreed upon by the Secretary and the
Indian Health Service, Indian tribe, or tribal organization.
Such agreements may not be made contingent on the ap-
proval of the State in which the Indians to be served re-
side.
183
‘‘(b) TRANSFER.—Notwithstanding any other provi-
sion of law, a State may transfer funds to which it is,
or would otherwise be, entitled under title XXI of the So-
cial Security Act to the Indian Health Service, Indian
tribes, and tribal organizations to be administered to
achieve the purposes and objectives of such title under
agreements between the State and recipient entity or
under an agreement directly between the recipient entity
and the Health Care Financing Administration.
‘‘SEC. 417. WAIVER OF MEDICARE AND MEDICAID SANC-
TIONS.
‘‘Notwithstanding any other provision of law, the In-
dian Health Service or an Indian tribe or tribal organiza-
tion operating a health program under the Indian Self-
Determination and Education Assistance Act shall be enti-
tled to seek a waiver of sanctions imposed under title
XVIII, XIX, or XXI of the Social Security Act as if it
were directly responsible for administering the State
health care program.
‘‘SEC. 418. SAFE HARBOR.
‘‘(a) The term ‘remuneration’ as used in sections
1128A and 1128B of the Social Security Act (42 U.S.C.
1320a–7a and 1320a–7b) shall not include any exchange
of anything of value between or among—
184
‘‘(1) any Indian tribe or tribal organization that
administers health programs under the authority of
the Indian Self-Determination and Education Assist-
ance Act (25 U.S.C. 450 et seq.);
‘‘(2) any such Indian tribe or tribal organiza-
tion and the Indian Health Service;
‘‘(3) any such Indian tribe or tribal organiza-
tion and any patient served or eligible for service
under such programs, including patients served or
eligible for service pursuant to section 813 of Public
Law 94–437 (25 U.S.C. 1680c); or
‘‘(4) any such Indian tribe or tribal organiza-
tion and any third party required by contract, sec-
tion 206 or 207 of Public Law 94–437 (42 U.S.C.
1621e or 1621f), or other applicable law, to pay or
reimburse the reasonable health care costs incurred
by the United States or any such Indian tribe or
tribal organization;
if the exchange arises from or relates to such health pro-
grams.
‘‘(b) An Indian tribe, tribal organization, or urban
Indian organization that administers health programs
under the authority of the Indian Self-Determination and
Education Assistance Act (25 U.S.C. 450 et seq.) or title
V of the Indian Health Care Improvement Act shall be
185
deemed to be an agency of the United States and immune
from liability under the Sherman Act (15 U.S.C. 1 et
seq.), the Clayton Act (15 U.S.C. 12 et seq.), the Robin-
son-Patman Act, the Federal Trade Commission Act (15
U.S.C. 41 et seq.), and any other Federal, State, or local
antitrust laws, with regard to any transaction, agreement,
or conduct that relates to such programs.
‘‘SEC. 419. COST SHARING.
‘‘(a) 
COINSURANCE, 
COPAYMENTS, 
AND
DEDUCTIBLES.—Notwithstanding any other provision of
Federal or State law, no Indian who is eligible for services
under title XVIII, XIX, or XXI of the Social Security Act,
or any other federally funded health programs may be
charged a deductible, copayment, or coinsurance for any
service provided by or through the Indian Health Service,
an Indian tribe, tribal organization, or urban Indian orga-
nization, nor may the payment or reimbursement due to
the Indian Health Service or an Indian tribe, tribal organi-
zation, or urban Indian organization be reduced by the
amount of the deductible, copayment, or coinsurance that
would be due from the Indian but for the operation of
this section. For the purposes of this section, ‘through’
shall include services provided directly, by referral, or
under contracts or other arrangements between the Indian
186
Health Service, Indian tribe, tribal organization, or urban
Indian organization and another health provider.
‘‘(b) PREMIUMS.—
‘‘(1) MEDICAID
AND
CHILD
HEALTH
INSUR-
ANCE PROGRAM.—Notwithstanding any other provi-
sion of Federal or State law, no Indian who is other-
wise eligible for services under title XIX (medicaid)
or title XXI (children’s health insurance program) of
the Social Security Act may be charged a premium
as a condition of receiving benefits from the pro-
gram.
‘‘(2) MEDICARE ENROLLMENT PREMIUM PEN-
ALTIES.—Notwithstanding any other provision of
Federal or State law, no Indian (as that term is de-
fined in section 4 of the Indian Health Care Im-
provement Act) who is eligible for Medicare, but for
the payment of premiums, shall be charged a penalty
for enrolling in Medicare at a time later than the
person might otherwise have been eligible. This pro-
hibition applies whether the Indian pays for the pre-
miums directly or the premiums are paid by another
person or entity, including a State, the Indian
Health Service, an Indian tribe, tribal organization,
or an urban Indian organization.
187
‘‘(c) MEDICALLY NEEDY PROGRAM SPEND-DOWN.—
For the purposes of any medically needy option under a
State’s Medicaid plan under title XIX of the Social Secu-
rity Act, the cost of providing services to an Indian in a
health program of the Indian Health Service, an Indian
tribe, tribal organization, or urban Indian organization
shall be deemed to have been an expenditure for health
care by the person applying for Medicaid.
‘‘(d) ESTATE
RECOVERY.—Notwithstanding any
other provision of Federal or State law, the following prop-
erty may not be included when determining eligibility for
services or implementing estate recovery rights under title
XVIII, XIX, or XXI of the Social Security Act, or other
health care programs funded in whole or part with Federal
moneys—
‘‘(1) income derived from rents, leases, or royal-
ties of property held in trust for individuals by the
Federal Government;
‘‘(2) income derived from rents, leases, royal-
ties, or natural resources (including timber and fish-
ing activities) resulting from the exercise of federally
protected rights, whether collected by an individual
or tribal group, and distributed to individuals;
‘‘(3) property, including interests in real prop-
erty currently or formerly held in trust by the Fed-
188
eral Government which is protected under applicable
Federal, State or tribal law or custom from recourse
and including public domain allotments; and
‘‘(4) property that has unique religious or cul-
tural significance or that supports subsistence or
traditional lifestyle according to applicable tribal law
or custom.
‘‘(e) MEDICAL CHILD SUPPORT RECOVERY.—Not-
withstanding any other provision of law, a parent shall not
be responsible for reimbursing a State or the Federal Gov-
ernment for the cost of medical services provided to a child
by or through the Indian Health Service, an Indian tribe,
tribal organization, or urban Indian organization. For the
purposes of this subsection, ‘through’ shall include services
provided directly, by referral, or under contracts or other
arrangements between the Indian Health Service, Indian
tribe, tribal organization or urban Indian organization and
another health provider.
‘‘SEC. 420. MANAGED CARE.
‘‘(a) RECOVERY FROM MANAGED CARE PLANS.—(1)
Notwithstanding any other provision in law, the Indian
Health Service, an Indian tribe, tribal organization, or
urban Indian organization shall have a right of recovery
under section 408 of this title from all private and public
health plans, including medicare, medicaid, children’s
189
health insurance, and privately managed care plans for the
reasonable costs of delivering health services to Indians
entitled to receive services from the Service, an Indian
tribe, tribal organization, or urban Indian organization.
‘‘(2) No provision of a contract, regulation or statute
may be relied upon or interpreted to deny or reduce pay-
ments otherwise due under this section, except to the ex-
tent the Service, Indian tribe, tribal organization, or urban
Indian organization has entered into an agreement with
the managed care plan regarding services to be provided
or rates to be paid, provided that such an agreement may
not be made a prerequisite for such payments to be made.
‘‘(3) Payments due under this section may not be less
than those paid to a ‘preferred provider’ under the man-
aged care plan or, in the event there is no such rate, the
usual and customary fee for equivalent services.
‘‘(4) A managed care plan may not deny payment
under this section because the insured or covered bene-
ficiary of the plan has not submitted a claim.
‘‘(5) Notwithstanding paragraphs (1) through (4) of
this section, the Indian Health Service, an Indian tribe,
tribal organization, or urban Indian organization that pro-
vides a health service to an Indian entitled under title XIX
(medicaid) or enrolled under title XXI (children’s health
insurance program) of the Social Security Act to receive
190
such services shall have the right to be paid directly by
the State’s Medicaid or children’s health insurance pro-
gram notwithstanding any agreements the State may have
entered into with managed care organizations or pro-
viders.
‘‘(6) A managed care organization that is enrolled in
a State Medicaid program must as a condition of such
enrollment offer a contract to health programs adminis-
tered by the Indian Health Service, an Indian tribe, tribal
organization, or urban Indian organization that provides
health services in the geographic area served by the man-
aged care organization and such contract (or other pro-
vider participation agreement) shall contain terms and
conditions of participation and payment no more restric-
tive or onerous than those provided for in this section.
‘‘(b) PROHIBIT
AUTO- 
AND
DEFAULT
ASSIGN-
MENT.—Notwithstanding any other provision of law or
any waiver granted by the Secretary, no Indian may be
assigned automatically or by default under any managed
care plan paid under title XIX (medicaid) or title XXI
(children’s health insurance program) of the Social Secu-
rity Act unless the person had the option of enrolling in
a managed care plan or health program administered by
the Service, an Indian tribe, tribal organization, or urban
Indian organization in which case an Indian may be as-
191
signed only to such a managed care plan or health pro-
gram.
‘‘(c) INDIAN
MANAGED
CARE
PLANS.—Notwith-
standing any other provision of law, any State entering
into agreements with one or more managed care organiza-
tions to provide services under title XIX or title XXI of
the Social Security Act must enter into such an agreement
with the Service, an Indian tribe, tribal organization, or
urban Indian organization that can provide services to In-
dians who may be eligible or required to enroll in such
a managed care plan similar to those to be offered by
other managed care organizations. The Secretary and the
State are hereby authorized to waive requirements regard-
ing discrimination, capitalization, and other matters that
might otherwise prevent the Indian managed care organi-
zation or health program from meeting Federal or State
standards applicable to such organizations, provided such
Indian managed care organization or health program must
be able to offer its Indian enrollees services of an equiva-
lent quality to that required of other managed care organi-
zations.
‘‘(d) ADVERTISING.—A managed care organization
entering into contracts to provide services to Indians on
or near an Indian reservation shall provide a certificate
of coverage or similar type of document that is written
192
in the Indian language of the majority of the Indian popu-
lation residing on such reservation.
‘‘SEC. 421. NAVAJO NATION MEDICAID AGENCY.
‘‘(a) Notwithstanding any other provision of law, the
Secretary is authorized to treat the Navajo Nation as a
State for the purposes of title XIX of the Social Security
Act, to provide services to Indians living within the bound-
aries of the Navajo Nation.
‘‘(b) Notwithstanding any other provision of law, the
Secretary shall have the authority to assign and pay all
funds for the provision of services to Indians living within
the boundaries of the Navajo Nation under title XIX of
the Social Security Act and related administrative funds
under title XIX (medicaid) of the Social Security Act,
which are currently paid to or would otherwise be paid
to the States of Arizona, New Mexico, and Utah, to an
entity established by the Navajo Nation and approved by
the Secretary, which shall be denominated the Navajo Na-
tion Medicaid Agency.
‘‘(c) The Navajo Nation Medicaid Agency shall serve
Indians living within the boundaries of the Navajo Nation
and shall have the same authority and perform the same
functions as other single State medicaid agencies.
‘‘(d) The Secretary is authorized to directly assist the
Navajo Nation in the development and implementation of
193
a Navajo Nation Medicaid Agency for the administration,
eligibility, payment, and delivery of Medicaid eligible serv-
ices, including western and traditional Navajo healing
services, within the Navajo Nation.
‘‘(e) Notwithstanding section 1905(b) of the Social
Security Act, the Federal medical assistance percentage
shall be 100 per centum with respect to amounts the Nav-
ajo Nation Medicaid Agency expends for medical assist-
ance for services and for related administrative costs.
‘‘(f) The Secretary is further authorized to assist the
Navajo Nation by providing funding including demonstra-
tion grant funding for this project.
‘‘(g) The Secretary shall have the authority to waive
applicable provisions of title XIX of the Social Security
Act to establish, develop, and implement the Navajo Na-
tion Medicaid Agency.
‘‘(h) In the option of the Navajo Nation, the Sec-
retary is authorized to treat the Navajo Nation as a State
for the purposes of title XXI (children’s health insurance
program) under terms equivalent to those described in
subsections (a) through (g) of this section.
‘‘SEC. 422. INDIAN ADVISORY COMMITTEES.
‘‘(a) NATIONAL
INDIAN
TECHNICAL
ADVISORY
GROUP.—The Health Care Financing Administration
shall establish and fund the expenses of a National Indian
194
Technical Advisory Group which shall have no fewer than
14 members including at least 1 member designated by
the Indian tribes and tribal organizations in each service
area, 1 urban Indian organization representative, and 1
member representing the Indian Health Service. The
scope of the activities of such group shall be established
under section 802. Such scope shall include providing com-
ment on and advice regarding the programs funded under
titles XVIII, XIX, and XXI of the Social Security Act or
any other health care program funded (in whole or part)
by the Health Care Financing Administration.
‘‘(b) INDIAN MEDICAID ADVISORY COMMITTEES.—
The Health Care Financing Administration shall establish
and provide funding for an Indian Medicaid Advisory
Committee made up of designees of the Indian Health
Service, Indian tribes, tribal organizations, and urban In-
dian organizations in each State in which the Indian
Health Service directly operates a health program or in
which there is 1 or more Indian tribe, tribal organization,
or urban Indian organization.
‘‘SEC. 423. LIMITATIONS ON CHARGES.
‘‘No provider of health services that is eligible to re-
ceive payments or reimbursements from under title XVIII,
XIX, or XXI of the Social Security Act or from any feder-
195
ally funded (whether in whole or part) health care pro-
gram may seek to recover payment for services—
‘‘(1) that are covered under and furnished to an
individual eligible for the contract health services
program operated by the Indian Health Service, by
an Indian tribe or tribal organization or furnished to
an urban Indian eligible for health services pur-
chased by an urban Indian organization (as those
terms are defined in section 4 of the Indian Health
Care Improvement Act), an amount in excess of the
lowest amount paid by any other payor for com-
parable services; or
‘‘(2) for examinations or other diagnostic proce-
dures that are not medically necessary if such proce-
dures have already been performed by the referring
Indian health program and reported to the provider.
‘‘SEC. 424. AUTHORIZATION OF APPROPRIATIONS.
‘‘There are authorized to be appropriated such sums
as may be necessary for each fiscal year through fiscal
year 2012 to carry out this title.
196
‘‘TITLE V—HEALTH SERVICES
FOR URBAN INDIANS
‘‘SEC. 501. PURPOSE.
‘‘The purpose of this title is to establish programs
in urban centers to make health services more accessible
and available to urban Indians.
‘‘SEC. 502. CONTRACTS WITH, AND GRANTS TO, URBAN IN-
DIAN ORGANIZATIONS.
‘‘Under authority of the Act of November 2, 1921
(25 U.S.C. 13), popularly known as the Snyder Act, the
Secretary, through the Service, shall enter into contracts
with, or make grants to, urban Indian organizations to
assist such organizations in the establishment and admin-
istration, within urban centers, of programs which meet
the requirements set forth in this title. The Secretary,
through the Service, subject to subsection 506, shall in-
clude such conditions as the Secretary considers necessary
to effect the purpose of this title in any contract which
the Secretary enters into with, or in any grant the Sec-
retary makes to, any urban Indian organization pursuant
to this title.
‘‘SEC. 503. CONTRACTS AND GRANTS FOR THE PROVISION
OF HEALTH CARE AND REFERRAL SERVICES.
‘‘(a) Under authority of the Act of November 2, 1921
(25 U.S.C. 13), popularly known as the Snyder Act, the
197
Secretary, through the Service, shall enter into contracts
with, and make grants to, urban Indian organizations for
the provision of health care and referral services for urban
Indians. Any such contract or grant shall include require-
ments that the urban Indian organization successfully un-
dertake to—
‘‘(1) estimate the population of urban Indians
residing in the urban center or centers that the or-
ganization proposes to serve who are or could be re-
cipients of health care or referral services;
‘‘(2) estimate the current health status of
urban Indians residing in such urban center or cen-
ters;
‘‘(3) estimate the current health care needs of
urban Indians residing in such urban center or cen-
ters;
‘‘(4) provide basic health education, including
health promotion and disease prevention education,
to urban Indians;
‘‘(5) make recommendations to the Secretary
and Federal, State, local, and other resource agen-
cies on methods of improving health service pro-
grams to meet the needs of urban Indians; and
198
‘‘(6) where necessary, provide, or enter into
contracts for the provision of, health care services
for urban Indians.
‘‘(b) The Secretary, through the Service, shall by reg-
ulation adopted pursuant to section 520 prescribe the cri-
teria for selecting urban Indian organizations to enter into
contracts or receive grants under this section. Such cri-
teria shall, among other factors, include—
‘‘(1) the extent of unmet health care needs of
urban Indians in the urban center or centers in-
volved;
‘‘(2) the size of the urban Indian population in
the urban center or centers involved;
‘‘(3) the extent, if any, to which the activities
set forth in subsection (a) would duplicate any
project funded under this title;
‘‘(4) the capability of an urban Indian organiza-
tion to perform the activities set forth in subsection
(a) and to enter into a contract with the Secretary
or to meet the requirements for receiving a grant
under this section;
‘‘(5) the satisfactory performance and success-
ful completion by an urban Indian organization of
other contracts with the Secretary under this title;
201
‘‘(D) to develop innovative behavioral health
service delivery models which incorporate Indian cul-
tural support systems and resources.
‘‘(f)(1) The Secretary shall facilitate access to, or
provide, services for urban Indians through grants to
urban Indian organizations administering contracts en-
tered into pursuant to this section or receiving grants
under subsection (a) to prevent and treat child abuse (in-
cluding sexual abuse) among urban Indians.
‘‘(2) A grant may not be made under this subsection
to an urban Indian organization until that organization
has prepared, and the Service has approved, an assess-
ment that documents the prevalence of child abuse in the
urban Indian population concerned and specifies the serv-
ices and programs (which may not duplicate existing serv-
ices and programs) for which the grant is requested.
‘‘(3) Grants may be made under this subsection—
‘‘(A) to prepare assessments required under
paragraph (2);
‘‘(B) for the development of prevention, train-
ing, and education programs for urban Indian popu-
lations, including child education, parent education,
provider training on identification and intervention,
education on reporting requirements, prevention
202
campaigns, and establishing service networks of all
those involved in Indian child protection; and
‘‘(C) to provide direct outpatient treatment
services (including individual treatment, family
treatment, group therapy, and support groups) to
urban Indians who are child victims of abuse (in-
cluding sexual abuse) or adult survivors of child sex-
ual abuse, to the families of such child victims, and
to urban Indian perpetrators of child abuse (includ-
ing sexual abuse).
‘‘(4) In making grants to carry out this subsection,
the Secretary shall take into consideration—
‘‘(A) the support for the urban Indian organiza-
tion demonstrated by the child protection authorities
in the area, including committees or other services
funded under the Indian Child Welfare Act of 1978
(25 U.S.C. 1901 et seq.), if any;
‘‘(B) the capability and expertise demonstrated
by the urban Indian organization to address the
complex problem of child sexual abuse in the com-
munity; and
‘‘(C) the assessment required under paragraph
(2).
‘‘(g) The Secretary, through the Service, may enter
into a contract with, or make grants to, an urban Indian
203
organization that provides or arranges for the provision
of health care services (through satellite facilities, provider
networks, or otherwise) to urban Indians in more than 1
urban center.
‘‘SEC. 504. CONTRACTS AND GRANTS FOR THE DETERMINA-
TION OF UNMET HEALTH CARE NEEDS.
‘‘(a) Under authority of the Act of November 2, 1921
(25 U.S.C. 13), popularly known as the Snyder Act, the
Secretary, through the Service, may enter into contracts
with, or make grants to, urban Indian organizations situ-
ated in urban centers for which contracts have not been
entered into, or grants have not been made, under section
503. The purpose of a contract or grant made under this
section shall be the determination of the matters described
in subsection (b)(1) in order to assist the Secretary in as-
sessing the health status and health care needs of urban
Indians in the urban center involved and determining
whether the Secretary should enter into a contract or
make a grant under section 503 with respect to the urban
Indian organization which the Secretary has entered into
a contract with, or made a grant to, under this section.
‘‘(b) Any contract entered into, or grant made, by
the Secretary under this section shall include requirements
that—
204
‘‘(1) the urban Indian organization successfully
undertakes to—
‘‘(A) document the health care status and
unmet health care needs of urban Indians in
the urban center involved; and
‘‘(B) with respect to urban Indians in the
urban center involved, determine the matters
described in paragraphs (2), (3), (4), and (7) of
section 503(b); and
‘‘(2) the urban Indian organization complete
performance of the contract, or carry out the re-
quirements of the grant, within 1 year after the date
on which the Secretary and such organization enter
into such contract, or within 1 year after such orga-
nization receives such grant, whichever is applicable.
‘‘(c) The Secretary may not renew any contract en-
tered into, or grant made, under this section.
‘‘SEC. 505. EVALUATIONS; RENEWALS.
‘‘(a) The Secretary shall develop procedures to evalu-
ate compliance with grant requirements under this title
and compliance with, and performance of contracts en-
tered into by urban Indian organizations under this title.
Such procedures shall include provisions for carrying out
the requirements of this section.
205
‘‘(b) The Secretary shall evaluate the compliance of
each urban Indian organization which has entered into a
contract or received a grant under section 503 with the
terms of such contract or grant. For purposes of this eval-
uation, the Secretary, in determining the capacity of an
urban Indian organization to deliver quality patient care
shall, at the option of the organization—
‘‘(1) through the Service conduct an annual on-
site evaluation of the organization; or
‘‘(2) accept in lieu of such onsite evaluation evi-
dence of the organization’s provisional or full accred-
itation by a private independent entity recognized by
the Secretary for purposes of conducting quality re-
views or providers participating in the Medicare pro-
gram under title XVIII of the Social Security Act.
‘‘(c) If, as a result of the evaluations conducted under
this section, the Secretary determines that an urban In-
dian organization has not complied with the requirements
of a grant or complied with or satisfactorily performed a
contract under section 503, the Secretary shall, prior to
renewing such contract or grant, attempt to resolve with
such organization the areas of noncompliance or unsatis-
factory performance and modify such contract or grant to
prevent future occurrences of such noncompliance or un-
satisfactory performance. If the Secretary determines that
206
such noncompliance or unsatisfactory performance cannot
be resolved and prevented in the future, the Secretary
shall not renew such contract or grant with such organiza-
tion and is authorized to enter into a contract or make
a grant under section 503 with another urban Indian or-
ganization which is situated in the same urban center as
the urban Indian organization whose contract or grant is
not renewed under this section.
‘‘(d) In determining whether to renew a contract or
grant with an urban Indian organization under section
503 which has completed performance of a contract or
grant under section 504, the Secretary shall review the
records of the urban Indian organization, the reports sub-
mitted under section 507, and, in the case of a renewal
of a contract or grant under section 503, shall consider
the results of the onsite evaluations or accreditations
under subsection (b).
‘‘SEC. 506. OTHER CONTRACT AND GRANT REQUIREMENTS.
‘‘(a) Contracts with urban Indian organizations en-
tered into pursuant to this title shall be in accordance with
all Federal contracting laws and regulations relating to
procurement except that in the discretion of the Secretary,
such contracts may be negotiated without advertising and
need not conform to the provisions of the Act of August
24, 1935 (40 U.S.C. 270a et seq.).
207
‘‘(b) Payments under any contracts or grants pursu-
ant to this title shall, notwithstanding any term or condi-
tion of such contract or grant—
‘‘(1) be made in their entirety by the Secretary
to the urban Indian organization by no later than
the end of the first 30 days of the funding period
with respect to which the payments apply, unless the
Secretary determines through an evaluation under
section 505 that the organization is not capable of
administering such payments in their entirety; and
‘‘(2) if unexpended by the urban Indian organi-
zation during the funding period with respect to
which the payments initially apply, shall be carried
forward for expenditure with respect to allowable or
reimbursable costs incurred by the organization dur-
ing one or more subsequent funding periods without
additional justification or documentation by the or-
ganization as a condition of carrying forward the ex-
penditure of such funds.
‘‘(c) Notwithstanding any provision of law to the con-
trary, the Secretary may, at the request or consent of an
urban Indian organization, revise or amend any contract
entered into by the Secretary with such organization under
this title as necessary to carry out the purposes of this
title.
208
‘‘(d) Contracts with or grants to urban Indian organi-
zations and regulations adopted pursuant to this title shall
include provisions to assure the fair and uniform provision
to urban Indians of services and assistance under such
contracts or grants by such organizations.
‘‘(e) Urban Indians, as defined under section 4(t) of
this Act, shall be eligible for health care or referral serv-
ices provided pursuant to this title.
‘‘SEC. 507. REPORTS AND RECORDS.
‘‘(a) For each fiscal year during which an urban In-
dian organization receives or expends funds pursuant to
a contract entered into, or a grant received, pursuant to
this title, such organization shall submit to the Secretary
on a basis no more frequent than every 6 months,
including—
‘‘(1) in the case of a contract or grant under
section 503, information gathered pursuant to para-
graph (5) of subsection (a) of such section;
‘‘(2) information on activities conducted by the
organization pursuant to the contract or grant;
‘‘(3) an accounting of the amounts and purpose
for which Federal funds were expended; and
‘‘(4) a minimum set of data, using uniformly
defined elements, that is specified by the Secretary
209
in consultation consistent with section 514, with
urban Indian organizations.
‘‘(b) The reports and records of the urban Indian or-
ganization with respect to a contract or grant under this
title shall be subject to audit by the Secretary and the
Comptroller General of the United States.
‘‘(c) The Secretary shall allow as a cost of any con-
tract or grant entered into or awarded under section 502
or 503 the cost of an annual independent financial audit
conducted by—
‘‘(1) a certified public accountant; or
‘‘(2) a certified public accounting firm qualified
to conduct Federal compliance audits.
‘‘SEC. 508. LIMITATION ON CONTRACT AUTHORITY.
‘‘The authority of the Secretary to enter into con-
tracts or to award grants under this title shall be to the
extent, and in an amount, provided for in appropriation
Acts.
‘‘SEC. 509. FACILITIES.
‘‘(a) The Secretary may make grants to contractors
or grant recipients under this title for the lease, purchase,
renovation, construction, or expansion of facilities, includ-
ing leased facilities, in order to assist such contractors or
grant recipients in complying with applicable licensure or
certification requirements.
210
‘‘(b) The Secretary, acting through the Service or
through the Health Resources and Services Administra-
tion, may provide to contractors or grant recipients under
this title loans from the Urban Indian Health Care Facili-
ties Revolving Loan Fund (hereinafter in this section re-
ferred to as the ‘URLF’) described in subsection (c), or
guarantees for loans, for the construction, renovation, ex-
pansion, or purchase of health care facilities, subject to
the following requirements:
‘‘(1) The principal amount of a loan or loan
guarantee may cover 100 percent of the costs (other
than staffing) relating to the facility, including plan-
ning, design, financing, site land development, con-
struction, 
rehabilitation, 
renovation, 
conversion,
medical equipment, furnishings, and capital pur-
chase.
‘‘(2) The total of the principal of loans and loan
guarantees, respectively, outstanding at any one
time shall not exceed such limitations as may be
specified in appropriation Acts.
‘‘(3) The loan or loan guarantee may have a
term of the shorter of the estimated useful life of the
facility, or 25 years.
‘‘(4) An urban Indian organization may assign,
and the Secretary may accept assignment of, the
211
revenue of the organization as security for a loan or
loan guarantee under this subsection.
‘‘(5) The Secretary shall not collect application,
processing, or similar fees from urban Indian organi-
zations applying for loans or loan guarantees under
this subsection.
‘‘(c)(1) There is established in the Treasury of the
United States a fund to be known as the Urban Indian
Health Care Facilities Revolving Loan Fund. The URLF
shall consist of—
‘‘(A) such amounts as may be appropriated to
the URLF;
‘‘(B) amounts received from urban Indian orga-
nizations in repayment of loans made to such orga-
nizations under paragraph (2); and
‘‘(C) interest earned on amounts in the URLF
under paragraph (3).
‘‘(2) Amounts in the URLF may be expended by the
Secretary, acting through the Service or the Health Re-
sources and Services Administration, to make loans avail-
able to urban Indian organizations receiving grants or con-
tracts under this title for the purposes, and subject to the
requirements, described in subsection (b). Amounts appro-
priated to the URLF, amounts received from urban In-
dian organizations in repayment of loans, and interest on
212
amounts in the URLF shall remain available until ex-
pended.
‘‘(3) The Secretary of the Treasury shall invest such
amounts of the URLF as such Secretary determines are
not required to meet current withdrawals from the URLF.
Such investments may be made only in interest-bearing
obligations of the United States. For such purpose, such
obligations may be acquired on original issue at the issue
price, or by purchase of outstanding obligations at the
market price. Any obligation acquired by the URLF may
be sold by the Secretary of the Treasury at the market
price.
‘‘SEC. 510. OFFICE OF URBAN INDIAN HEALTH.
‘‘There is hereby established within the Service an
Office of Urban Indian Health, which shall be responsible
for—
‘‘(1) carrying out the provisions of this title;
‘‘(2) providing central oversight of the pro-
grams and services authorized under this title; and
‘‘(3) providing technical assistance to urban In-
dian organizations.
‘‘SEC. 511. GRANTS FOR ALCOHOL AND SUBSTANCE ABUSE
RELATED SERVICES.
‘‘(a) The Secretary may make grants for the provi-
sion of health-related services in prevention of, treatment
213
of, rehabilitation of, or school and community-based edu-
cation in, alcohol and substance abuse in urban centers
to those urban Indian organizations with which the Sec-
retary has entered into a contract under this title or under
section 201.
‘‘(b) Each grant made pursuant to subsection (a)
shall set forth the goals to be accomplished pursuant to
the grant. The goals shall be specific to each grant as
agreed to between the Secretary and the grantee.
‘‘(c) The Secretary shall establish criteria for the
grants made under subsection (a), including criteria relat-
ing to the—
‘‘(1) size of the urban Indian population;
‘‘(2) capability of the organization to adequately
perform the activities required under the grant;
‘‘(3) satisfactory performance standards for the
organization in meeting the goals set forth in such
grant, which standards shall be negotiated and
agreed to between the Secretary and the grantee on
a grant-by-grant basis; and
‘‘(4) identification of need for services.
The Secretary shall develop a methodology for allocating
grants made pursuant to this section based on such cri-
teria.
214
‘‘(d) Any funds received by an urban Indian organiza-
tion under this Act for substance abuse prevention, treat-
ment, and rehabilitation shall be subject to the criteria set
forth in subsection (c).
‘‘SEC. 512. TREATMENT OF CERTAIN DEMONSTRATION
PROJECTS.
‘‘(a)(1) Notwithstanding any other provision of law,
the Oklahoma City Clinic demonstration project shall be
treated as a service unit in the allocation of resources and
coordination of care and shall not be subject to the provi-
sions of the Indian Self-Determination and Education As-
sistance Act for the term of such project. The Secretary
shall provide assistance to such project in the development
of resources and equipment and facility needs.
‘‘(2) The Secretary shall submit to the President, for
inclusion in the report required to be submitted to the
Congress under section 801 for fiscal year 1999, a report
on the findings and conclusions derived from the dem-
onstration project specified in paragraph (1).
‘‘(b) Notwithstanding any other provision of law, the
Tulsa Clinic demonstration project shall become perma-
nent programs within the Service’s direct care program
and continue to be treated as service units in the allocation
of resources and coordination of care, and shall continue
to meet the requirements and definitions of an urban In-
215
dian organization in this title, and as such will not be sub-
ject to the provisions of the Indian Self-Determination and
Education Assistance Act.
‘‘SEC. 513. URBAN NIAAA TRANSFERRED PROGRAMS.
‘‘(a) The Secretary shall, through the Office of Urban
Indian Health of the Service, make grants or enter into
contracts effective no later than September 30, 2001, with
urban Indian organizations for the administration of
urban Indian alcohol programs that were originally estab-
lished under the National Institute on Alcoholism and Al-
cohol Abuse (hereafter in this section referred to as
‘NIAAA’) and transferred to the Service.
‘‘(b) Grants provided or contracts entered into under
this section shall be used to provide support for the con-
tinuation of alcohol prevention and treatment services for
urban Indian populations and such other objectives as are
agreed upon between the Service and a recipient of a grant
or contract under this section.
‘‘(c) Urban Indian organizations that operate Indian
alcohol programs originally funded under the NIAAA and
subsequently transferred to the Service are eligible for
grants or contracts under this section.
‘‘(d) The Secretary shall evaluate and report to the
Congress on the activities of programs funded under this
section at least every 5 years.
216
‘‘SEC. 514. CONSULTATION WITH URBAN INDIAN ORGANIZA-
TIONS.
‘‘(a) The Secretary shall ensure that the Service, the
Health Care Financing Administration, and other oper-
ating divisions and staff divisions of the Department con-
sult, to the greatest extent practicable, with urban Indian
organizations (as defined in section 4(w)) prior to taking
any action, or approving Federal financial assistance for
any action of a State, that may affect urban Indians or
urban Indian organizations.
‘‘(b) For purposes of subsection (a), consultation is
the open and free exchange of information and opinion
among urban Indian organizations and the operating and
staff divisions of the Department which leads to mutual
understanding and comprehension and which emphasizes
trust, respect, and shared responsibility.
‘‘SEC. 515. FEDERAL TORT CLAIMS ACT COVERAGE.
‘‘For purposes of section 224 of the Public Health
Service Act of July 1, 1944 (42 U.S.C. 233(a)) with re-
spect to claims by any person, initially filed on or after
October 1, 1999, whether or not such person is an Indian
or Alaska Native or is served on a fee basis or under other
circumstances as permitted by Federal law or regulations,
for personal injury, including death, resulting from the
performance prior to, including, or after October 1, 1999,
of medical, surgical, dental, or related functions, including
217
the conduct of clinical studies or investigations, or for pur-
poses of section 2679 of title 28, United States Code, with
respect to claims by any such person, on or after October
1, 1999, for personal injury, including death, resulting
from the operation of an emergency motor vehicle, an
urban Indian organization that has entered into a contract
or received a grant pursuant to this title is deemed to be
part of the Public Health Service in the Department of
Health and Human Services while carrying out any such
contract or grant and its employees (including those act-
ing on behalf of the organization as provided in section
2671 of title 28, United States Code, and including an
individual who provides health care services pursuant to
a personal services contract with an urban Indian organi-
zation for the provision of services in any facility owned,
operated, or constructed under the jurisdiction of the In-
dian Health Service) are deemed employees of the Service
while acting within the scope of their employment in car-
rying out the contract or grant. Such employees shall be
deemed to be acting within the scope of their employment
in carrying out the contract or grant when they are re-
quired, by reason of their employment, to perform medical,
surgical, dental, or related functions at a facility other
than a facility operated by the urban Indian organization
pursuant to such contract or grant, but only if such em-
218
ployees are not compensated for the performance of such
functions by a person or entity other than the urban In-
dian organization.
‘‘SEC. 516. URBAN YOUTH TREATMENT CENTER DEM-
ONSTRATION.
‘‘(a) The Secretary shall, through grant or contract,
make payment for the construction and operation of at
least 2 residential treatment centers in each State de-
scribed in subsection (b) to demonstrate the provision of
alcohol and substance abuse treatment services to urban
Indian youth in a culturally competent residential setting.
‘‘(b) A State described in this subsection is a State
in which—
‘‘(1) there reside urban Indian youth with need
for alcohol and substance abuse treatment services
in a residential setting; and
‘‘(2) there is a significant shortage of culturally
competent residential treatment services for urban
Indian youth.
‘‘SEC. 517. USE OF FEDERAL GOVERNMENT FACILITIES AND
SOURCES OF SUPPLY.
‘‘(a) The Secretary shall permit an urban Indian or-
ganization that has entered into a contract or received a
grant pursuant to this title, in carrying out such contract
or grant, to use existing facilities and all equipment there-
219
in or pertaining thereto and other personal property
owned by the Federal Government within the Secretary’s
jurisdiction under such terms and conditions as may be
agreed upon for their use and maintenance.
‘‘(b) Subject to subsection (d), the Secretary may do-
nate to an urban Indian organization that has entered into
a contract or received a grant pursuant to this title any
personal or real property determined to be excess to the
needs of the Indian Health Service or the General Services
Administration for purposes of carrying out the contract
or grant.
‘‘(c) The Secretary may acquire excess or surplus
government personal or real property for donation, subject
to subsection (d), to an urban Indian organization that
has entered into a contract or received a grant pursuant
to this title if the Secretary determines that the property
is appropriate for use by the urban Indian organization
for a purpose for which a contract or grant is authorized
under this title.
‘‘(d) In the event that the Secretary receives a re-
quest for a specific item of personal or real property de-
scribed in subsection (b) or (c) from an urban Indian orga-
nization and from an Indian tribe or tribal organization,
the Secretary shall give priority to the request for dona-
tion of the Indian tribe or tribal organization if the Sec-
220
retary receives the request from the Indian tribe or tribal
organization before the date the Secretary transfers title
to the property or, if earlier, the date the Secretary trans-
fers the property physically, to the urban Indian organiza-
tion.
‘‘(e) For purposes of section 201(a) of the Federal
Property and Administrative Services Act of 1949 (40
U.S.C. 481(a)) (relating to Federal sources of supply, in-
cluding lodging providers, airlines, and other transpor-
tation providers), an urban Indian organization that has
entered into a contract or received a grant pursuant to
this title shall be deemed an executive agency when car-
rying out such contract or grant, and the employees of
the urban Indian organization shall be eligible to have ac-
cess to such sources of supply on the same basis as em-
ployees of an executive agency have such access.
‘‘SEC. 518. GRANTS FOR DIABETES PREVENTION, TREAT-
MENT, AND CONTROL.
‘‘(a) The Secretary may make grants to those urban
Indian organizations that have entered into a contract or
have received a grant under this title for the provision of
services for the prevention, treatment, and control of the
complications resulting from, diabetes among urban Indi-
ans.
221
‘‘(b) Each grant made pursuant to subsection (a)
shall set forth the goals to be accomplished under the
grant. The goals shall be specific to each grant as agreed
to between the Secretary and the grantee.
‘‘(c) The Secretary shall establish criteria for the
grants made under subsection (a) relating to—
‘‘(1) the size and location of the urban Indian
population to be served;
‘‘(2) the need for prevention of, treatment of,
and control of the complications resulting from dia-
betes among the urban Indian population to be
served;
‘‘(3) performance standards for the organiza-
tion in meeting the goals set forth in such grant
that are negotiated and agreed to by the Secretary
and the grantee;
‘‘(4) the capability of the organization to ade-
quately perform the activities required under the
grant; and
‘‘(5) the willingness of the organization to col-
laborate with the registry, if any, established by the
Secretary under section 204(e) in the Area Office of
the Service in which the organization is located.
‘‘(d) Any funds received by an urban Indian organiza-
tion under this Act for the prevention, treatment, and con-
222
trol of diabetes among urban Indians shall be subject to
the criteria developed by the Secretary under subsection
(c).
‘‘SEC. 519. COMMUNITY HEALTH REPRESENTATIVES.
‘‘The Secretary, through the Service, may enter into
contracts with, and make grants to, urban Indian organi-
zations for the use of Indians trained as health service
providers through the Community Health Representatives
Program under section 107(b) in the provision of health
care, health promotion, and disease prevention services to
urban Indians.
‘‘SEC. 520. REGULATIONS.
‘‘(a) The amendments to this title made by the Indian
Health Care Improvement Act Amendments of 2000 shall
be effective on the date of enactment of such amendments,
regardless of whether the Secretary has promulgated regu-
lations implementing such amendments have been promul-
gated.
‘‘(b) The Secretary may promulgate regulations to
implement the provisions of this title.
‘‘(1) Proposed regulations to implement this
Act shall be published in the Federal Register by the
Secretary no later than 270 days after the date of
enactment of this Act and shall have no less than a
120-day comment period.
223
‘‘(2) The authority to promulgate regulations
under this Act shall expire 18 months from the date
of enactment of this Act.
‘‘(c) The negotiated rulemaking committee described
in this section shall be established pursuant to section 565
of title 5, United States Code, and shall have as the major-
ity of its members representatives of urban Indian organi-
zations from each service area in addition to Federal rep-
resentatives.
‘‘(d) The Secretary shall adapt the negotiated rule-
making procedures to the unique context of this Act.
‘‘SEC. 521. AUTHORIZATION OF APPROPRIATIONS.
‘‘There are authorized to be appropriated such sums
as may be necessary for each fiscal year through fiscal
year 2012 to carry out this title.
‘‘TITLE VI—ORGANIZATIONAL
IMPROVEMENTS
‘‘SEC. 601. ESTABLISHMENT OF THE INDIAN HEALTH SERV-
ICE AS AN AGENCY OF THE PUBLIC HEALTH
SERVICE.
‘‘(a) In order to more effectively and efficiently carry
out the responsibilities, authorities, and functions of the
United States to provide health care services to Indians
and Indian tribes, as are or may be hereafter provided
by Federal statute or treaties, there is established within
224
the Public Health Service of the Department of Health
and Human Services the Indian Health Service. The In-
dian Health Service shall be administered by a Director,
who shall be appointed by the President, by and with the
advice and consent of the Senate. The Director of the In-
dian Health Service shall report to the Secretary through
the Assistant Secretary for Health of the Department of
Health and Human Services. Effective with respect to an
individual appointed by the President, by and with the ad-
vice and consent of the Senate, after January 1, 1993,
the term of service of the Director shall be 4 years. A
Director may serve more than 1 term.
‘‘(b) The Indian Health Service shall be an agency
within the Public Health Service of the Department of
Health and Human Services, and shall not be an office,
component, or unit of any other agency of the Depart-
ment.
‘‘(c) The Secretary shall carry out through the Direc-
tor of the Indian Health Service—
‘‘(1) all functions which were, on the day before
the date of enactment of the Indian Health Care
Amendments of 1988, carried out by or under the
direction of the individual serving as Director of the
Indian Health Service on such day;
225
‘‘(2) all functions of the Secretary relating to
the maintenance and operation of hospital and
health facilities for Indians and the planning for,
and provision and use of, health services for Indians;
‘‘(3) all health programs under which health
care is provided to Indians based upon their status
as Indians which are administered by the Secretary,
including but not limited to programs under—
‘‘(A) this Act;
‘‘(B) the Act of November 2, 1921 (25
U.S.C. 13);
‘‘(C) the Act of August 5, 1954 (42 U.S.C.
2001 et seq.);
‘‘(D) the Act of August 16, 1957 (42
U.S.C. 2005 et seq.); and
‘‘(E) the Indian Self-Determination and
Education Assistance Act (25 U.S.C. 450f et
seq.); and
‘‘(4) all scholarship and loan functions carried
out under title I.
‘‘(d)(1) The Director shall have the authority—
‘‘(A) except to the extent provided in paragraph
(2), to appoint and compensate employees for the
Service in accordance with title 5, United States
Code;
226
‘‘(B) to enter into contracts for the procure-
ment of goods and services to carry out the func-
tions of the Service; and
‘‘(C) to manage, expend, and obligate all funds
appropriated for the Service.
‘‘(2) Notwithstanding any other law, the provisions
of section 12 of the Act of June 18, 1934 (48 Stat. 986;
25 U.S.C. 472), shall apply to all personnel actions taken
with respect to new positions created within the Service
as a result of its establishment under subsection (a).
‘‘(e) All personnel, records, equipment, facilities, and
interests in property that are administered by the Indian
Health Service shall be the transferred to the Indian
Health Service established by the amendment made by
subsection (a) of this section. All transfers must be accom-
plished within 9 months of the date of enactment of this
section. The Secretary is authorize to waive the Indian
preference laws on a case-by-case basis for temporary
transfers involved in implementing this section during
such 9-month period.
‘‘(f)(1) Except as provided in paragraph (2), section
601 of the Indian Health Care Improvement Act shall take
effect 9 months from the date of the enactment of this
section.
227
‘‘(2) Notwithstanding subsections (e) and (f)(1), any
action which carries out such section 601 that is taken
by the Secretary before the effective date of such section
601 shall be effective beginning on the date such action
was taken.
‘‘SEC. 602. AUTOMATED MANAGEMENT INFORMATION SYS-
TEM.
‘‘(a)(1) The Secretary shall establish an automated
management information system for the Service.
‘‘(2) The information system established under para-
graph (1) shall include—
‘‘(A) a financial management system;
‘‘(B) a patient care information system for each
area served by the Service;
‘‘(C) a privacy component that protects the pri-
vacy of patient information held by, or on behalf of,
the Service;
‘‘(D) a services-based cost accounting compo-
nent that provides estimates of the costs associated
with the provision of specific medical treatments or
services in each Area Office of the Service;
‘‘(E) an interface mechanism for patient billing
and accounts receivable system; and
‘‘(F) a training component.
228
‘‘(b) The Secretary shall provide each Indian tribe
and tribal organization that provides health services under
a contract entered into with the Service under the Indian
Self-Determination and Education Assistance Act auto-
mated management information systems which—
‘‘(1) meet the management information needs
of such Indian tribe or tribal organization with re-
spect to the treatment by the Indian tribe or tribal
organization of patients of the Service; and
‘‘(2) meet the management information needs
of the Service.
‘‘(c) Notwithstanding any other provision of law, each
patient shall have reasonable access to the medical or
health records of such patient which are held by, or on
behalf of, the Service.
‘‘(d) The Director shall have the authority to enter
into contracts, agreements, or joint ventures with other
Federal agencies, States, private and nonprofit organiza-
tions, for the purpose of enhancing information technology
in Indian health programs and facilities.
‘‘SEC. 603. AUTHORIZATION OF APPROPRIATIONS.
‘‘There are authorized to be appropriated such sums
as may be necessary for each fiscal year through fiscal
year 2012 to carry out this title.
229
‘‘TITLE VII—BEHAVIORAL
HEALTH PROGRAMS
‘‘SEC. 701. BEHAVIORAL HEALTH PREVENTION AND TREAT-
MENT SERVICES.
‘‘(a) The purposes of this section are to—
‘‘(1) authorize and direct the Secretary, acting
through the Indian Health Service, and willing In-
dian tribes, tribal organizations, and urban Indian
organizations, to develop a comprehensive behavioral
health prevention and treatment program which em-
phasizes collaboration among alcohol and substance
abuse, social services, and mental health programs;
‘‘(2) provide information, direction, and guid-
ance relating to mental illness and dysfunction and
self-destructive behavior, including child abuse and
family violence, to those Federal, tribal, State, and
local agencies responsible for programs in Indian
communities in areas of health care, education, so-
cial services, child and family welfare, alcohol and
substance abuse, law enforcement, and judicial serv-
ices;
‘‘(3) assist Indian tribes to identify services and
resources available to address mental illness and
dysfunctional and self-destructive behavior;
230
‘‘(4) provide authority and opportunities for In-
dian tribes to develop and implement, and coordinate
with, community-based programs which include iden-
tification, prevention, education, referral, and treat-
ment services, including through multidisciplinary
resource teams;
‘‘(5) ensure that Indians, as citizens of the
United States and of the States in which they re-
side, have the same access to behavioral health serv-
ices to which all citizens have access; and
‘‘(6) modify or supplement existing programs
and authorities in the areas identified in paragraph
(2).
‘‘(b)(1) The Secretary, acting through the Service,
and willing Indian tribes, tribal organizations, and urban
Indian organizations, shall encourage Indian tribes and
tribal organizations to develop tribal plans, and urban In-
dian organizations to develop local plans, and for all such
groups to participate in developing area-wide plans for In-
dian Behavioral Health Services. The plans shall include,
to the extent feasible, the following components:
‘‘(A) An assessment of the scope of the problem
of alcohol or other substance abuse, mental illness,
and dysfunctional and self-destructive behavior, in-
231
cluding suicide, child abuse, and family violence,
among Indians, including—
‘‘(i) the number of Indians served who are
directly or indirectly affected by such illness or
behavior, and
‘‘(ii) an estimate of the financial and
human cost attributable to such illness or be-
havior.
‘‘(B) An assessment of the existing and addi-
tional resources necessary for the prevention and
treatment of such illness and behavior, including an
assessment of the progress toward achieving the
availability of the full continuum of care described in
subsection (c).
‘‘(C) An estimate of the additional funding
needed by the Service, Indian tribes, tribal organiza-
tions, and urban Indian organizations to meet their
responsibilities under the plans.
‘‘(2) The Secretary shall establish a national clearing-
house of plans and reports on the outcomes of such plans
developed by Indian tribes, tribal organizations, and by
Areas relating to Behavioral Health. The Secretary shall
ensure access to these plans and outcomes by any Indian
tribe, tribal organization, urban organization, or the Serv-
ice.
232
‘‘(3) The Secretary shall provide technical assistance
to Indian tribes, tribal organizations, and urban Indian
organizations in preparation of their plans and in devel-
oping standards of care that may be used and adopted
locally.
‘‘(c) The Secretary, acting through the Service and
willing Indian tribes and tribal organizations, shall pro-
vide, to the extent feasible and funding is available, pro-
grams including, but not limited to, the following:
‘‘(1) A comprehensive continuum of behavioral
health care which provides—
‘‘(A) community-based prevention, inter-
vention, outpatient, and behavioral health
aftercare;
‘‘(B) detoxification (social and medical);
‘‘(C) acute hospitalization;
‘‘(D) intensive outpatient/day treatment;
‘‘(E) residential treatment;
‘‘(F) transitional living for those needing a
temporary stable living environment that is sup-
portive of treatment/recovery goals;
‘‘(G) emergency shelter;
‘‘(H) intensive case management; and
‘‘(I) traditional health care practices.
233
‘‘(2) Behavioral health services by the following
services and populations:
‘‘(A) Child Behavioral Health Services for
persons from birth through age 17, including—
‘‘(i) preschool and school age fetal al-
cohol disorder services, including assess-
ment and behavioral intervention;
‘‘(ii) mental health/substance abuse
services (emotional, organic, alcohol, drug,
inhalant and, tobacco);
‘‘(iii) co-occurring disorders (multiple
diagnosis);
‘‘(iv) prevention focused on ages 5
through 10 (alcohol, drug, inhalant, and
tobacco);
‘‘(v) early intervention, treatment and
aftercare focused on ages 11–17;
‘‘(vi) healthy choices/lifestyle (related
to sexually transmitted diseases, domestic
violence, sexual abuse; suicide, teen preg-
nancy, 
obesity, 
and 
other 
risk/safety
issues); and
‘‘(vii) co-morbidity.
‘‘(B) Adult Behavioral Health Services
(ages 18 through 55):
234
‘‘(i) Early intervention, treatment,
and aftercare.
‘‘(ii) Mental health/substance abuse
services (emotional, alcohol, drug, inhalant
and tobacco).
‘‘(iii) Co-occurring disorders (dual di-
agnosis) and co-morbidity.
‘‘(iv) Healthy choices/lifestyle (related
to parenting, partners, domestic violence,
sexual abuse, suicide, obesity, and other
risk-related behavior).
‘‘(v)(I) Treatment services for women
at risk of giving birth to a child with a
fetal alcohol disorder.
‘‘(II) Treatment for substance abuse
requiring gender-specific services.
‘‘(III) Treatment for sexual assault
and domestic violence.
‘‘(IV) Healthy choices/lifestyle (par-
enting, partners, obesity, suicide, and other
related behavioral risk).
‘‘(vi) Men-specific:
‘‘(I) Treatment for substance
abuse requiring gender-specific serv-
ices.
235
‘‘(II) Treatment for sexual as-
sault and domestic violence.
‘‘(III) Healthy choices/lifestyle
(parenting, partners, obesity, suicide,
and other risk-related behavior).
‘‘(C) Family Behavioral Health Services:
‘‘(i) Early intervention, treatment,
and aftercare for affected families.
‘‘(ii) Treatment for sexual assault and
domestic violence.
‘‘(iii) Healthy choices/lifestyle (related
to parenting, partners, domestic violence,
and other abuse issues).
‘‘(D) Elder Behavioral Health Services
(age 56 and above):
‘‘(i) Early intervention, treatment,
and aftercare.
‘‘(I) 
Mental 
health/substance
abuse services (emotional, alcohol,
drug, inhalant, and tobacco).
‘‘(II) 
Co-occurring 
disorders
(dual diagnosis) and co-morbidity.
‘‘(III) Healthy choices/lifestyle
(managing 
conditions 
related 
to
aging).
236
‘‘(ii) Elder women-specific:
‘‘(I) Treatment for substance
abuse requiring gender-specific serv-
ices.
‘‘(II) Treatment for sexual as-
sault, domestic violence, and neglect.
‘‘(iii) Elder men-specific:
‘‘(I) Treatment for substance
abuse requiring gender-specific serv-
ices.
‘‘(II) Treatment for sexual as-
sault, domestic violence, and neglect.
‘‘(iv) Dimentias regardless of cause.
‘‘(d)(1) The governing body of any Indian tribe, or
tribal organization, or urban Indian organization may, at
its discretion, adopt a resolution for the establishment of
a community behavioral health plan providing for the iden-
tification and coordination of available resources and pro-
grams to identify, prevent, or treat alcohol and other sub-
stance abuse, mental illness, or dysfunctional and self-de-
structive behavior, including child abuse and family vio-
lence, among its members or its service population. This
plan should include, but not be limited to, behavioral
health services, social services, intensive outpatient serv-
ices, and continuing after care.
237
‘‘(2) In furtherance of a plan established pursuant
to paragraph (1) and at the request of a Tribe, the appro-
priate agency, service unit, or other officials of the Bureau
of Indian Affairs and the Service shall cooperate with, and
provide technical assistance to, the Indian tribe or tribal
organization in the development of such plan. Upon the
establishment of such a plan and at the request of the
Indian tribe or tribal organization, such officials shall co-
operate with the Indian tribe or tribal organization in the
implementation of such plan.
‘‘(3) The Secretary may make funding available to
Indian tribes and tribal organizations adopting a resolu-
tion pursuant to paragraph (1) to obtain technical assist-
ance for the development of a community mental health
plan and to provide administrative support in the imple-
mentation of such plan.
‘‘(e) The Secretary, acting through the Service and
willing Indian tribes, tribal organizations, and urban In-
dian organizations, shall coordinate behavioral health
planning, to the extent feasible, with other Federal agen-
cies and with State agencies, to encourage comprehensive
behavioral health services are available to Indians without
regard to their place of residence.
‘‘(f) Within 1 year after the date of the enactment
of the Indian Health Care Improvement Act Amendments
238
of 2000, the Secretary shall make an assessment of the
need for inpatient mental health care among Indians and
the availability and cost of inpatient mental health facili-
ties which can meet such need. In making such assess-
ment, the Secretary shall consider the possible conversion
of existing, underused service hospital beds into psy-
chiatric units to meet such need.
‘‘SEC. 702. MEMORANDA OF AGREEMENT WITH THE DE-
PARTMENT OF THE INTERIOR.
‘‘(a) Not later than 12 months after the date of the
enactment of the Indian Health Care Improvement Act
Amendments of 2000, the Secretary and the Secretary of
the Interior shall develop and enter into memoranda of
agreement, or review and update any existing memoranda
of agreement, as required by section 4205 of the Indian
Alcohol and Substance Abuse Prevention and Treatment
Act of 1986 (25 U.S.C. 2411) and under which the Secre-
taries address—
‘‘(1) the scope and nature of mental illness and
dysfunctional and self-destructive behavior, including
child abuse and family violence, among Indians;
‘‘(2) the existing Federal, tribal, State, local,
and private services, resources, and programs avail-
able to provide mental health services for Indians;
239
‘‘(3) the unmet need for additional services, re-
sources, and programs necessary to meet the needs
identified pursuant to paragraph (1);
‘‘(4)(A) the right of Indians, as citizens of the
United States and of the States in which they re-
side, to have access to mental health services to
which all citizens have access;
‘‘(B) the right of Indians to participate in, and
receive the benefit of, such services; and
‘‘(C) take actions necessary to protect the exer-
cise of such right;
‘‘(5) the responsibilities of the Bureau of Indian
Affairs and the Service, including mental health
identification, prevention, education, referral, and
treatment services (including services through multi-
disciplinary resource teams), at the central, area,
and agency and service unit levels to address the
problems identified in paragraph (1);
‘‘(6) a strategy for the comprehensive coordina-
tion of the mental health services provided by the
Bureau of Indian Affairs and the Service to meet
the needs identified pursuant to paragraph (1),
including—
‘‘(A) the coordination of alcohol and sub-
stance abuse programs of the Service, the Bu-
240
reau of Indian Affairs, and the various Indian
tribes (developed under the Indian Alcohol and
Substance Abuse Prevention and Treatment
Act of 1986) with the mental health initiatives
pursuant to this Act, particularly with respect
to the referral and treatment of dually diag-
nosed individuals requiring mental health and
substance abuse treatment; and
‘‘(B) ensuring that the Bureau of Indian
Affairs and Service programs and services (in-
cluding multi-disciplinary resource teams) ad-
dressing child abuse and family violence are co-
ordinated with such non-Federal programs and
services;
‘‘(7) direct appropriate officials of the Bureau
of Indian Affairs and the Service, particularly at the
agency and service unit levels, to cooperate fully
with tribal requests made pursuant to community
behavioral health plans adopted under section 701(c)
and section 4206 of the Indian Alcohol and Sub-
stance Abuse Prevention and Treatment Act of 1986
(25 U.S.C. 2412); and
‘‘(8) provide for an annual review of such
agreement by the 2 Secretaries which shall be pro-
vided to Congress and the Indian tribes.
242
‘‘(3) urban Indian organizations and other In-
dian organizations; and
‘‘(4) behavioral health service providers.
‘‘(d) The memoranda of agreement under subsection
(a) of this section shall be published in the Federal Reg-
ister. At the same time as publication in the Federal Reg-
ister, the Secretary shall provide a copy of such memo-
randa to each Indian tribe, tribal organization, and urban
Indian organization.
‘‘SEC. 703. COMPREHENSIVE BEHAVIORAL HEALTH PRE-
VENTION AND TREATMENT PROGRAM.
‘‘(a)(1) The Secretary, acting through the Service
and willing Indian tribes, and tribal organizations, con-
sistent with section 701, shall provide a program of com-
prehensive behavioral health, prevention, treatment, and
aftercare, including traditional health care practices,
which shall include—
‘‘(A) prevention, through educational interven-
tion, in Indian communities;
‘‘(B) acute detoxification and psychiatric hos-
pitalization and treatment (residential and intensive
outpatient);
‘‘(C) 
community-based 
rehabilitation 
and
aftercare;
243
‘‘(D) community education and involvement, in-
cluding extensive training of health care, edu-
cational, and community-based personnel; and
‘‘(E) specialized residential treatment programs
for high-risk populations, including but not limited
to pregnant and post partum women and their chil-
dren.
‘‘(2) The target population of such program shall be
members of Indian tribes. Efforts to train and educate key
members of the Indian community shall target employees
of health, education, judicial, law enforcement, legal, and
social service programs.
‘‘(b)(1) The Secretary, acting through the Service
and willing Indian tribes and tribal organizations, may,
enter into contracts with public or private providers of be-
havioral health treatment services for the purpose of car-
rying out the program required under subsection (a).
‘‘(2) In carrying out this subsection, the Secretary
shall provide assistance to Indian tribes and tribal organi-
zations to develop criteria for the certification of behav-
ioral health service providers and accreditation of service
facilities which meet minimum standards for such services
and facilities.
244
‘‘SEC. 704. MENTAL HEALTH TECHNICIAN PROGRAM.
‘‘(a) Under the authority of the Snyder Act of No-
vember 2, 1921 (25 U.S.C. 13), the Secretary shall estab-
lish and maintain a mental health technician program
within the Service which—
‘‘(1) provides for the training of Indians as
mental health technicians; and
‘‘(2) employs such technicians in the provision
of community-based mental health care that includes
identification, prevention, education, referral, and
treatment services.
‘‘(b) In carrying out subsection (a), the Secretary
shall provide high-standard paraprofessional training in
mental health care necessary to provide quality care to the
Indian communities to be served. Such training shall be
based upon a curriculum developed or approved by the
Secretary which combines education in the theory of men-
tal health care with supervised practical experience in the
provision of such care.
‘‘(c) The Secretary shall supervise and evaluate the
mental health technicians in the training program.
‘‘(d) The Secretary shall ensure that the program es-
tablished pursuant to this subsection involves the use and
promotion of the traditional health care practices of the
Indian tribes to be served.
245
‘‘SEC. 
705. 
LICENSING 
REQUIREMENT 
FOR 
MENTAL
HEALTH CARE WORKERS.
‘‘Subject to the provisions of section 220, any person
employed as a psychologist, social worker, or marriage and
family therapist for the purpose of providing mental health
care services to Indians in a clinical setting under the au-
thority of this Act or through a funding agreement pursu-
ant to the Indian Self-Determination and Education As-
sistance Act shall—
‘‘(1) in the case of a person employed as a psy-
chologist, be licensed as a clinical psychologist or
working under the direct supervision of a licensed
clinical psychologist;
‘‘(2) in the case of a person employed as a so-
cial worker, be licensed as a social worker or work-
ing under the direct supervision of a licensed social
worker; or
‘‘(3) in the case of a person employed as a mar-
riage and family therapist, be licensed as a marriage
and family therapist or working under the direct su-
pervision of a licensed marriage and family thera-
pist.
‘‘SEC. 706. INDIAN WOMEN TREATMENT PROGRAMS.
‘‘(a) The Secretary, consistent with section 701, shall
make funding available to Indian tribes, tribal organiza-
tions, and urban Indian organizations to develop and im-
246
plement a comprehensive behavioral health program of
prevention, intervention, treatment, and relapse preven-
tion services that specifically addresses the spiritual, cul-
tural, historical, social, and child care needs of Indian
women, regardless of age.
‘‘(b) Funding made available pursuant to this section
may be used to—
‘‘(1) develop and provide community training,
education, and prevention programs for Indian
women relating to behavioral health issues, including
fetal alcohol disorders;
‘‘(2) identify and provide psychological services,
counseling, advocacy, support, and relapse preven-
tion to Indian women and their families; and
‘‘(3) develop prevention and intervention models
for Indian women which incorporate traditional
health care practices, cultural values, and commu-
nity and family involvement.
‘‘(c) The Secretary, in consultation with Indian tribes
and tribal organizations, shall establish criteria for the re-
view and approval of applications and proposals for fund-
ing under this section.
‘‘(d) Twenty percent of the funds appropriated pursu-
ant to this section shall be used to make grants to urban
Indian organizations funded under title V.
247
‘‘SEC. 707. INDIAN YOUTH PROGRAM.
‘‘(a) The Secretary, consistent with section 701, shall
develop and implement a program for acute detoxification
and treatment for Indian youth, including behavioral
health services. The program shall include regional treat-
ment centers designed to include detoxification and reha-
bilitation for both sexes on a referral basis and programs
developed and implemented by Indian tribes or tribal orga-
nizations at the local level under the Indian Self-Deter-
mination and Education Assistance Act. Regional centers
shall be integrated with the intake and rehabilitation pro-
grams based in the referring Indian community.
‘‘(b)(1) The Secretary, acting through the Service or
willing Indian tribes, or tribal organizations, shall con-
struct, renovate, or, as necessary, purchase, and appro-
priately staff and operate, at least 1 youth regional treat-
ment center or treatment network in each area under the
jurisdiction of an Area Office. For the purposes of this
subsection, the Area Office in California shall be consid-
ered to be 2 Area Offices, 1 office whose jurisdiction shall
be considered to encompass the northern area of the State
of California, and 1 office whose jurisdiction shall be con-
sidered to encompass the remainder of the State of Cali-
fornia for the purpose of implementing California treat-
ment networks.
248
‘‘(2) For the purpose of staffing and operating such
centers or facilities, funding shall be pursuant to the Act
of November 2, 1921 (25 U.S.C. 13).
‘‘(3) A youth treatment center constructed or pur-
chased under this subsection shall be constructed or pur-
chased at a location within the area described in para-
graph (1) agreed upon (by appropriate tribal resolution)
by a majority of the Indian tribes to be served by such
center.
‘‘(4)(A) Notwithstanding any other provision of this
title, the Secretary may, from amounts authorized to be
appropriated for the purposes of carrying out this section,
make funds available to—
‘‘(i) the Tanana Chiefs Conference, Incor-
porated, for the purpose of leasing, constructing,
renovating, operating, and maintaining a residential
youth treatment facility in Fairbanks, Alaska; and
‘‘(ii) the Southeast Alaska Regional Health
Corporation to staff and operate a residential youth
treatment facility without regard to the proviso set
forth in section 4(l) of the Indian Self-Determina-
tion and Education Assistance Act (25 U.S.C.
450b(l)).
‘‘(B) Until additional residential youth treatment fa-
cilities are established in Alaska pursuant to this section,
249
the facilities specified in subparagraph (A) shall make
every effort to provide services to all eligible Indian youth
residing in such State.
‘‘(c)(1) The Secretary, acting through the Service
and willing Indian tribes and tribal organizations, may
provide intermediate behavioral health services, which may
incorporate traditional health care practices, to Indian
children and adolescents, including—
‘‘(A) pretreatment assistance;
‘‘(B) inpatient, outpatient, and after-care serv-
ices;
‘‘(C) emergency care;
‘‘(D) suicide prevention and crisis intervention;
and
‘‘(E) prevention and treatment of mental illness
and dysfunctional and self-destructive behavior, in-
cluding child abuse and family violence.
‘‘(2) Funds provided under this subsection may be
used—
‘‘(A) to construct or renovate an existing health
facility to provide intermediate behavioral health
services;
‘‘(B) to hire behavioral health professionals;
‘‘(C) to staff, operate, and maintain an inter-
mediate mental health facility, group home, sober
250
housing, transitional housing or similar facilities, or
youth shelter where intermediate behavioral health
services are being provided;
‘‘(D) to make renovations and hire appropriate
staff to convert existing hospital beds into adolescent
psychiatric units; and
‘‘(E) for intensive home- and community-based
services.
‘‘(3) The Secretary shall, in consultation with Indian
tribes and tribal organizations, establish criteria for the
review and approval of applications or proposals for fund-
ing made available pursuant to this subsection.
‘‘(d)(1) The Secretary, in consultation with Indian
tribes and tribal organizations, shall—
‘‘(A) identify and use, where appropriate, feder-
ally owned structures suitable for local residential or
regional behavioral health treatment for Indian
youth; and
‘‘(B) establish guidelines, in consultation with
Indian tribes and tribal organizations, for deter-
mining the suitability of any such federally owned
structure to be used for local residential or regional
behavioral health treatment for Indian youth.
‘‘(2) Any structure described in paragraph (1) may
be used under such terms and conditions as may be agreed
251
upon by the Secretary and the agency having responsi-
bility for the structure and any Tribe or tribal organiza-
tion operating the program.
‘‘(e)(1) The Secretary, Indian tribes or tribal organi-
zations, in cooperation with the Secretary of the Interior,
shall develop and implement within each service unit, com-
munity-based rehabilitation and follow-up services for In-
dian youth who are having significant behavioral health
problems, and require long-term treatment, community re-
integration, and monitoring to support the Indian youth
after their return to their home community.
‘‘(2) Services under paragraph (1) shall be adminis-
tered within each service unit or tribal program by trained
staff within the community who can assist the Indian
youth in continuing development of self-image, positive
problem-solving skills, and nonalcohol or substance abus-
ing behaviors. Such staff may include alcohol and sub-
stance abuse counselors, mental health professionals, and
other health professionals and paraprofessionals, including
community health representatives.
‘‘(f) In providing the treatment and other services to
Indian youth authorized by this section, the Secretary, In-
dian tribes, and tribal organizations shall provide for the
inclusion of family members of such youth in the treat-
ment programs or other services as may be appropriate.
252
Not less than 10 percent of the funds appropriated for
the purposes of carrying out subsection (e) shall be used
for outpatient care of adult family members related to the
treatment of an Indian youth under that subsection.
‘‘(g) The Secretary, acting through the Service and
willing Indian tribes, tribal organizations, and urban In-
dian organizations, shall provide, consistent with section
701, programs and services to prevent and treat the abuse
of multiple forms of substances, including, but not limited
to, alcohol, drugs, inhalants, and tobacco, among Indian
youth residing in Indian communities, on Indian reserva-
tions, and in urban areas and provide appropriate mental
health services to address the incidence of mental illness
among such youth.
‘‘SEC. 708. INPATIENT AND COMMUNITY-BASED MENTAL
HEALTH 
FACILITIES 
DESIGN, 
CONSTRUC-
TION, AND STAFFING.
‘‘Within 1 year after the date of enactment of the
Indian Health Care Improvement Act Amendments of
2000, the Secretary, acting through the Service and will-
ing Indian tribes and tribal organizations, shall provide,
in each area of the Service, not less than 1 inpatient men-
tal health care facility, or the equivalent, for Indians with
behavioral health problems. For the purposes of this sub-
section, California shall be considered to be 2 Area Offices,
253
1 office whose location shall be considered to encompass
the northern area of the State of California and 1 office
whose jurisdiction shall be considered to encompass the
remainder of the State of California. The Secretary shall
consider the possible conversion of existing, underused
service hospital beds into psychiatric units to meet such
need.
‘‘SEC. 709. TRAINING AND COMMUNITY EDUCATION.
‘‘(a) The Secretary, in cooperation with the Secretary
of the Interior, shall develop and implement or provide
funding for Indian tribes and tribal organizations to de-
velop and implement within each service unit or tribal pro-
gram a program of community education and involvement
which shall be designed to provide concise and timely in-
formation to the community leadership of each tribal com-
munity. Such program shall include education about be-
havioral health issues to political leaders, tribal judges,
law enforcement personnel, members of tribal health and
education boards, health care providers including tradi-
tional practitioners, and other critical members of each
tribal community. Community-based training (oriented to-
ward local capacity development) shall also include tribal
community provider training (designed for adult learners
from the communities receiving services for prevention,
intervention, treatment and aftercare).
254
‘‘(b) The Secretary shall, either directly or through
Indian tribes and tribal organizations, provide instruction
in the area of behavioral health issues, including instruc-
tion in crisis intervention and family relations in the con-
text of alcohol and substance abuse, child sexual abuse,
youth alcohol and substance abuse, and the causes and
effects of fetal alcohol disorders to appropriate employees
of the Bureau of Indian Affairs and the Service, and to
personnel in schools or programs operated under any con-
tract with the Bureau of Indian Affairs or the Service,
including supervisors of emergency shelters and halfway
houses described in section 4213 of the Indian Alcohol and
Substance Abuse Prevention and Treatment Act of 1986
(25 U.S.C. 2433).
‘‘(c) In carrying out the education and training pro-
grams required by this section, the Secretary, in consulta-
tion with Indian tribes, tribal organizations, Indian behav-
ioral health experts, and Indian alcohol and substance
abuse prevention experts, shall develop and provide com-
munity-based 
training 
models. 
Such 
models 
shall
address—
‘‘(1) the elevated risk of alcohol and behavioral
health problems faced by children of alcoholics;
255
‘‘(2) 
the 
cultural, 
spiritual 
and
multigenerational aspects of behavioral health prob-
lem prevention and recovery; and
‘‘(3) community-based and multidisciplinary
strategies for preventing and treating behavioral
health problems.
‘‘SEC. 710. BEHAVIORAL HEALTH PROGRAM.
‘‘(a) The Secretary, acting through the Service or
willing Indian tribes or tribal organizations, consistent
with section 701, may plan, develop, implement, and carry
out programs to deliver innovative community-based be-
havioral health services to Indians.
‘‘(b) The Secretary may award such funding for a
project under subsection (a) to an Indian tribe or tribal
organization and may consider the following criteria:
‘‘(1) The project will address significant unmet
behavioral health needs among Indians.
‘‘(2) The project will serve a significant number
of Indians.
‘‘(3) The project has the potential to deliver
services in an efficient and effective manner.
‘‘(4) The Tribe or tribal organization has the
administrative and financial capability to administer
the project.
256
‘‘(5) The project may deliver services in a man-
ner consistent with traditional health care practices.
‘‘(6) The project is coordinated with, and avoids
duplication of, existing services.
‘‘(c) For purposes of this subsection, the Secretary
shall, in evaluating applications or proposals for funding
for projects to be operated under any funding agreement
entered into with the Service under the Indian Self-Deter-
mination and Education Assistance Act, use the same cri-
teria that the Secretary uses in evaluating any other appli-
cation or proposal for such funding.
‘‘SEC. 711. FETAL ALCOHOL DISORDER FUNDING.
‘‘(a)(1) The Secretary, consistent with section 701,
acting through willing Indian tribes, tribal organizations,
and urban Indian organizations, shall establish and oper-
ate fetal alcohol disorders programs as provided in this
section for the purposes of meeting the health status ob-
jectives specified in section 3(b).
‘‘(2) Funding provided pursuant to this section shall
be used to—
‘‘(A) develop and provide community and in-
school training, education, and prevention programs
relating to fetal alcohol disorders;
‘‘(B) identify and provide behavioral health
treatment to high-risk women;
257
‘‘(C) identify and provide appropriate psycho-
logical services, educational and vocational support,
counseling, advocacy, and information to fetal alco-
hol disorder affected persons and their families or
caretakers;
‘‘(D) develop and implement counseling and
support programs in schools for fetal alcohol dis-
order affected children;
‘‘(E) develop prevention and intervention mod-
els which incorporate traditional practitioners, cul-
tural and spiritual values, and community involve-
ment;
‘‘(F) develop, print, and disseminate education
and prevention materials on fetal alcohol disorders;
‘‘(G) develop and implement, through the tribal
consultation process, culturally sensitive assessment
and diagnostic tools including dysmorphology clinics
and multidisciplinary fetal alcohol disorder clinics
for use in tribal and urban Indian communities;
‘‘(H) develop early childhood intervention
projects from birth on to mitigate the effects of fetal
alcohol disorders; and
‘‘(I) develop and fund community-based adult
fetal alcohol disorder housing and support services.
258
‘‘(3) The Secretary shall establish criteria for the re-
view and approval of applications for funding under this
section.
‘‘(b) The Secretary, acting through the Service and
willing Indian tribes, tribal organizations, and urban In-
dian organizations, shall—
‘‘(1) develop and provide services for the pre-
vention, intervention, treatment, and aftercare for
those affected by fetal alcohol disorders in Indian
communities; and
‘‘(2) provide supportive services, directly or
through an Indian tribe, tribal organization, or
urban Indian organization, including, which services
shall include but not be limited to, meeting the spe-
cial educational, vocational, school-to-work transi-
tion, and independent living needs of adolescent and
adult Indians with fetal alcohol disorders.
‘‘(c) The Secretary shall establish a task force to be
known as the Fetal Alcohol Disorders Task Force to ad-
vise the Secretary in carrying out subsection (b). Such
task force shall be composed of representatives from the
National Institute on Drug Abuse, the National Institute
on Alcohol and Alcoholism, the Office of Substance Abuse
Prevention, the National Institute of Mental Health, the
Service, the Office of Minority Health of the Department
259
of Health and Human Services, the Administration for
Native Americans, the National Institute of Child Health
and Human Development (NICHD), the Centers for Dis-
ease Control and Prevention, the Bureau of Indian Af-
fairs, Indian tribes, tribal organizations, urban Indian
communities, and Indian fetal alcohol disorders experts.
‘‘(d) The Secretary, acting through the Substance
Abuse and Mental Health Services Administration, shall
make funding available to Indian tribes, tribal organiza-
tions, and urban Indian organizations for applied research
projects which propose to elevate the understanding of
methods to prevent, intervene, treat, or provide rehabilita-
tion and behavioral health aftercare for Indians and urban
Indians affected by fetal alcohol disorders.
‘‘(e) Ten percent of the funds appropriated pursuant
to this section shall be used to make grants to urban In-
dian organizations funded under title V.
‘‘SEC. 712. CHILD SEXUAL ABUSE AND PREVENTION TREAT-
MENT PROGRAMS.
‘‘(a) The Secretary and the Secretary of the Interior,
acting through the Service and willing Indian tribes and
tribal organizations, shall establish, consistent with section
701, in every service area, programs involving treatment
for—
‘‘(1) victims of child sexual abuse; and
260
‘‘(2) perpetrators of child sexual abuse.
‘‘(b) Funding provided pursuant to this section shall
be used to—
‘‘(1) develop and provide community education
and prevention programs related to child sexual
abuse;
‘‘(2) identify and provide behavioral health
treatment to children who are victims of sexual
abuse and to their families who are affected by sex-
ual abuse;
‘‘(3) develop prevention and intervention models
which incorporate traditional health care practi-
tioners, cultural and spiritual values, and community
involvement;
‘‘(4) develop and implement, though the tribal
consultation process, culturally sensitive assessment
and diagnostic tools for use in tribal and urban In-
dian communities; and
‘‘(5) identify and provide behavioral health
treatment to perpetrators—
‘‘(A) efforts will be made to begin offender
and behavioral health treatment while the per-
petrator is incarcerated or at the earliest pos-
sible date if the perpetrator is not incarcerated;
and
261
‘‘(B) treatment should be provided after
release to the community, until it is determined
that the perpetrator is not a threat to children.
‘‘SEC. 713. BEHAVIORAL HEALTH RESEARCH.
‘‘The Secretary, in consultation with appropriate
Federal agencies, shall provide funding to Indian tribes,
tribal organizations, and urban Indian organizations or,
enter into contracts with, or make grants to appropriate
institutions for the conduct of research on the incidence
and prevalence of behavioral health problems among Indi-
ans served by the Service, Indian tribes, or tribal organiza-
tions and among Indians in urban areas. Research prior-
ities under this section shall include—
‘‘(1) the interrelationship and interdependence
of behavioral health problems with alcoholism and
other substance abuse, suicide, homicides, other in-
juries, and the incidence of family violence; and
‘‘(2) the development of models of prevention
techniques.
The effect of the interrelationships and interdependencies
referred to in paragraph (1) on children, and the develop-
ment of prevention techniques under paragraph (2) appli-
cable to children, shall be emphasized.
262
‘‘SEC. 714. DEFINITIONS.
‘‘For the purpose of this title, the following defini-
tions shall apply:
‘‘(1) ‘Assessment’ means the systematic collec-
tion, analysis, and dissemination of information on
health status, health needs, and health problems.
‘‘(2) ‘Alcohol related neurodevelopmental dis-
orders’ or ‘ARND’ means with a history of maternal
alcohol consumption during pregnancy, central nerv-
ous system involvement such as developmental delay,
intellectual deficit, or neurologic abnormalities. Be-
haviorally, there can be problems with irritability,
and failure to thrive as infants. As children become
older there will likely be hyperactivity, attention def-
icit, language dysfunction, and perceptual and judg-
ment problems.
‘‘(3) ‘Behavioral health’ means the blending of
substances (alcohol, drugs, inhalants, and tobacco)
abuse and mental health prevention and treatment,
for the purpose of providing comprehensive services.
This can include the joint development of substance
abuse and mental health treatment planning and co-
ordinated case management using a multidisci-
plinary approach.
‘‘(4) ‘Behavioral health aftercare’ includes those
activities and resources used to support recovery fol-
263
lowing inpatient, residential, intensive substance
abuse, or mental health outpatient or outpatient
treatment. The purpose is to help prevent or deal
with relapse by ensuring that by the time a client or
patient is discharged from a level of care, such as
outpatient treatment, an aftercare plan has been de-
veloped with the client. An aftercare plan may use
such resources as community-based therapeutic
group, transitional living, a 12-step sponsor, a local
12-step or other related support group, and other
community-based providers (mental health profes-
sionals, traditional health care practitioners, commu-
nity health aides, community health representatives,
mental health technicians, ministers, etc.)
‘‘(5) ‘Dual diagnosis’ means coexisting sub-
stance abuse and mental illness conditions or diag-
nosis. Patients/clients are sometimes referred to as
mentally ill chemical abusers (MICAs).
‘‘(6) ‘Fetal alcohol disorders’ means fetal alco-
hol syndrome, partial fetal alcohol syndrome and al-
cohol 
related 
neural 
developmental 
disorder
(ARNDD).
‘‘(7) ‘Fetal alcohol syndrome’ or ‘FAS’ means
a syndrome in which with a history of maternal alco-
264
hol consumption during pregnancy, the following cri-
teria should be met:
‘‘(A) Central nervous system involvement
such as developmental delay, intellectual deficit,
microcephaly, or neurologic abnormalities.
‘‘(B) Craniofacial abnormalities with at
least 2 of the following: microphthalmia, short
palpebral fissures, poorly developed philtrum,
thin upper lip, flat nasal bridge, and short
upturned nose.
‘‘(C) Prenatal or postnatal growth delay.
‘‘(8) ‘Partial FAS’ means with a history of ma-
ternal alcohol consumption during pregnancy having
most of the criteria of FAS, though not meeting a
minimum of at least 2 of the following: microoph-
thalmia, short palpebral fissures, poorly developed
philtrum, thin upper lip, flat nasal bridge, short
upturned nose.
‘‘(9) ‘Rehabilitation’ means to restore the abil-
ity or capacity to engage in usual and customary life
activities through education and therapy.
‘‘(10) ‘Substance abuse’ includes inhalant
abuse.
265
‘‘SEC. 715. AUTHORIZATION OF APPROPRIATIONS.
‘‘There are authorized to be appropriated such sums
as may be necessary for each fiscal year through fiscal
year 2012 to carry out the provisions of this title.
‘‘TITLE VIII—MISCELLANEOUS
‘‘SEC. 801. REPORTS.
‘‘The President shall, at the time the budget is sub-
mitted under section 1105 of title 31, United States Code,
for each fiscal year transmit to the Congress a report
containing—
‘‘(1) a report on the progress made in meeting
the objectives of this Act, including a review of pro-
grams established or assisted pursuant to this Act
and an assessment and recommendations of addi-
tional programs or additional assistance necessary
to, at a minimum, provide health services to Indians,
and ensure a health status for Indians, which are at
a parity with the health services available to and the
health status of, the general population including
specific comparisons of appropriations provided and
those required for such parity;
‘‘(2) a report on whether, and to what extent,
new national health care programs, benefits, initia-
tives, or financing systems have had an impact on
the purposes of this Act and any steps that the Sec-
retary may have taken to consult with Indian tribes,
266
tribal organizations, and urban Indian organizations
to address such impact, including a report on pro-
posed changes in allocation of funding pursuant to
section 808;
‘‘(3) a report on the use of health services by
Indians—
‘‘(A) on a national and area or other rel-
evant geographical basis;
‘‘(B) by gender and age;
‘‘(C) by source of payment and type of
service;
‘‘(D) comparing such rates of use with
rates of use among comparable non-Indian pop-
ulations; and
‘‘(E) on the services provided under fund-
ing agreements pursuant to the Indian Self-De-
termination and Education Assistance Act;
‘‘(4) a report of contractors to the Secretary on
Health Care Educational Loan Repayments every 6
months required by section 110;
‘‘(5) a General Audit Report of the Secretary
on the Health Care Educational Loan Repayment
Program as required by section 110(n);
267
‘‘(6) a separate statement which specifies the
amount of funds requested to carry out the provi-
sions of section 201;
‘‘(7) a biennial report to Congress on infectious
diseases as required by section 212;
‘‘(8) a report on environmental and nuclear
health hazards as required by section 214;
‘‘(9) an annual report on the status of all
health care facilities needs as required by section
301(c)(2) and 301(d);
‘‘(10) reports on safe water and sanitary waste
disposal facilities as required by section 302(h)(1);
‘‘(11) an annual report on the expenditure of
nonservice funds for renovation as required by sec-
tions 305(a)(2) and 305(a)(3);
‘‘(12) a report identifying the backlog of main-
tenance and repair required at Service and tribal fa-
cilities required by section 314(a);
‘‘(13) a report providing an accounting of reim-
bursement funds made available to the Secretary
under titles XVIII and XIX of the Social Security
Act required by section 403(a);
‘‘(14) a report on services sharing of Indian
Health Service, Veterans Affairs, and other Federal
268
agency health programs as required by section
412(c)(2);
‘‘(15) a report on evaluation and renewal of
urban Indian programs as required by section 505;
‘‘(16) a report on the findings and conclusions
derived from the demonstration project as required
by section 512(a)(2);
‘‘(17) a report on the evaluation of programs as
required by section 513; and
‘‘(18) a report on alcohol and substance abuse
as required by section 701(f).
‘‘SEC. 802. REGULATIONS.
‘‘(a)(1) Not later than 90 days after the date of en-
actment of this Act, the Secretary shall initiate procedures
under subchapter III of chapter 5 of title 5, United States
Code, to negotiate and promulgate such regulations or
amendments thereto that are necessary to carry out the
Indian Health Care Improvement Act, as amended.
‘‘(2) Proposed regulations to implement this Act shall
be published in the Federal Register by the Secretary no
later than 270 days after the date of enactment of this
Act and shall have no less than a 120-day comment pe-
riod.
269
‘‘(3) The authority to promulgate regulations under
this Act shall expire 18 months from the date of enact-
ment of this Act.
‘‘(b) COMMITTEE.—A negotiated rulemaking com-
mittee established pursuant to section 565 of title 5,
United States Code, to carry out this section shall have
as its members only representatives of the Federal Gov-
ernment and representatives of Indian tribes, and tribal
organizations, a majority of whom shall be nominated by
and be representatives of Indian tribes, tribal organiza-
tions, and urban Indian organizations from each service
area.
‘‘(c) ADAPTATION OF PROCEDURES.—The Secretary
shall adapt the negotiated rulemaking procedures to the
unique context of self-governance and the government-to-
government relationship between the United States and
Indian tribes.
‘‘(d) The lack of promulgated regulations shall not
limit the effect of this Act.
‘‘(e) The provisions of this Act shall supersede any
conflicting provisions of law (including any conflicting reg-
ulations) in effect on the day before the date of enactment
of the Indian Self-Determination Contract Reform Act of
1994, and the Secretary is authorized to repeal any regu-
lation inconsistent with the provisions of this Act.
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‘‘SEC. 803. PLAN OF IMPLEMENTATION.
‘‘Within 240 days after the date of the enactment of
the Indian Health Care Improvement Act Amendments of
2000, a plan will be prepared by the Secretary in consulta-
tion with Indian tribes, tribal organizations, and urban In-
dian organizations, and will be submitted to the Congress.
The plan will explain the manner and schedule (including
a schedule of appropriation requests), by title and section,
by which the Secretary will implement the provisions of
this Act.
‘‘SEC. 804. AVAILABILITY OF FUNDS.
‘‘The funds appropriated pursuant to this Act shall
remain available until expended.
‘‘SEC. 805. LIMITATION ON USE OF FUNDS APPROPRIATED
TO THE INDIAN HEALTH SERVICE.
‘‘Any limitation on the use of funds contained in an
Act providing appropriations for the Department for a pe-
riod with respect to the performance of abortions shall
apply for that period with respect to the performance of
abortions using funds contained in an Act providing ap-
propriations for the Indian Health Service.
‘‘SEC. 806. ELIGIBILITY OF CALIFORNIA INDIANS.
‘‘(a) Until such time as any subsequent law may oth-
erwise provide, the following California Indians shall be
eligible for health services provided by the Service:
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‘‘(1) Any member of a federally recognized In-
dian tribe.
‘‘(2) Any descendant of an Indian who was re-
siding in California on June 1, 1852, but only if
such descendant—
‘‘(A) is a member of the Indian community
served by a local program of the Service; and
‘‘(B) is regarded as an Indian by the com-
munity in which such descendant lives.
‘‘(3) Any Indian who holds trust interests in
public domain, national forest, or Indian reservation
allotments in California.
‘‘(4) Any Indian in California who is listed on
the plans for distribution of the assets of California
rancherias and reservations under the Act of August
18, 1958 (72 Stat. 619), and any descendant of
such an Indian.
‘‘(b) Nothing in this section may be construed as ex-
panding the eligibility of California Indians for health
services provided by the Service beyond the scope of eligi-
bility for such health services that applied on May 1, 1986.
‘‘SEC. 807. HEALTH SERVICES FOR INELIGIBLE PERSONS.
‘‘(a)(1) Any individual who—
‘‘(A) has not attained 19 years of age;
272
‘‘(B) is the natural or adopted child, step-child,
foster-child, legal ward, or orphan of an eligible In-
dian; and
‘‘(C) is not otherwise eligible for health services
provided by the Service,
shall be eligible for all health services provided by the
Service on the same basis and subject to the same rules
that apply to eligible Indians until such individual attains
19 years of age. The existing and potential health needs
of all such individuals shall be taken into consideration
by the Service in determining the need for, or the alloca-
tion of, the health resources of the service. If such an indi-
vidual has been determined to be legally incompetent prior
to attaining 19 years of age, such individual shall remain
eligible for such services until 1 year after the date of a
determination of competency.
‘‘(2) Any spouse of an eligible Indian who is not an
Indian, or who is of Indian descent but not otherwise eligi-
ble for the health services provided by the Service, shall
be eligible for such health services if all such spouses or
spouses who are married to members of the Indian tribe(s)
being served are made eligible, as a class, by an appro-
priate resolution of the governing body of the Indian tribe
or tribal organization providing such services. The health
needs of persons made eligible under this paragraph shall
273
not be taken into consideration by the Service in deter-
mining the need for, or allocation of, its health resources.
‘‘(b)(1)(A) The Secretary is authorized to provide
health services under this subsection through health pro-
grams operated directly by the Service to individuals who
reside within the service area of a service unit and who
are not eligible for such health services under any other
subsection of this section or under any other provision of
law if—
‘‘(i) the Indian tribe (or, in the case of a multi-
tribal service area, all the Indian tribes) served by
such service unit requests such provision of health
services to such individuals; and
‘‘(ii) the Secretary and the Indian tribe or
tribes have jointly determined that—
‘‘(I) the provision of such health services
will not result in a denial or diminution of
health services to eligible Indians; and
‘‘(II) there is no reasonable alternative
health program, within or without the service
area of such service unit, available to meet the
health needs of such individuals.
‘‘(B) In the case of health programs operated under
a contract entered into under the Indian Self-Determina-
tion and Education Assistance Act, the governing body of
274
the Indian tribe or tribal organization providing health
services under such contract is authorized to determine
whether health services should be provided under such
funding agreement to individuals who are not eligible for
such health services under any other subsection in this
section or under any other provision of law. In making
such determinations, the governing body of the Indian
tribe or tribal organization shall take into account the con-
siderations described in subparagraph (A)(ii).
‘‘(2)(A) Persons receiving health services provided by
the Service by reason of this subsection shall be liable for
payment of such health services under a schedule of
charges prescribed by the Secretary which, in the judg-
ment of the Secretary, results in reimbursement in an
amount not less than the actual cost of providing the
health services. Notwithstanding section 1880(c) of the
Social Security Act, section 402(a) of this Act, or any
other provision of law, amounts collected under this sub-
section, including medicare or medicaid reimbursements
under titles XVIII and XIX of the Social Security Act,
shall be credited to the account of the program providing
the service and shall be used solely for the provision of
health services within that program. Amounts collected
under this subsection shall be available for expenditure
within such program.
275
‘‘(B) Health services may be provided by the Sec-
retary through the Service under this subsection to an in-
digent person who would not be eligible for such health
services but for the provisions of paragraph (1) only if
an agreement has been entered into with a State or local
government under which the State or local government
agrees to reimburse the Service for the expenses incurred
by the Service in providing such health services to such
indigent person.
‘‘(3)(A) In the case of a service area which serves
only one Indian tribe, the authority of the Secretary to
provide health services under paragraph (1)(A) shall ter-
minate at the end of the fiscal year succeeding the fiscal
year in which the governing body of the Indian tribe re-
vokes its concurrence to the provision of such health serv-
ices.
‘‘(B) In the case of a multi-tribal service area, the
authority of the Secretary to provide health services under
paragraph (1)(A) shall terminate at the end of the fiscal
year succeeding the fiscal year in which at least 51 percent
of the number of Indian tribes in the service area revoke
their concurrence to the provisions of such health services.
‘‘(c) The Service may provide health services under
this subsection to individuals who are not eligible for
health services provided by the Service under any other
276
subsection of this section or under any other provision of
law in order to—
‘‘(1) achieve stability in a medical emergency;
‘‘(2) prevent the spread of a communicable dis-
ease or otherwise deal with a public health hazard;
‘‘(3) provide care to non-Indian women preg-
nant with an eligible Indian’s child for the duration
of the pregnancy through post partum; or
‘‘(4) provide care to immediate family members
of an eligible person if such care is directly related
to the treatment of the eligible person.
‘‘(d) Hospital privileges in health facilities operated
and maintained by the Service or operated under a con-
tract entered into under the Indian Self-Determination
and Education Assistance Act may be extended to non-
Service health care practitioners who provide services to
persons described in subsection (a) or (b). Such non-Serv-
ice health care practitioners may be regarded as employees
of the Federal Government for purposes of section
1346(b) and chapter 171 of title 28, United States Code
(relating to Federal tort claims) only with respect to acts
or omissions which occur in the course of providing serv-
ices to eligible persons as a part of the conditions under
which such hospital privileges are extended.
277
‘‘(e) For purposes of this section, the term ‘eligible
Indian’ means any Indian who is eligible for health serv-
ices provided by the Service without regard to the provi-
sions of this section.
‘‘SEC. 808. REALLOCATION OF BASE RESOURCES.
‘‘(a) Notwithstanding any other provision of law, any
allocation of Service funds for a fiscal year that reduces
by 5 percent or more from the previous fiscal year the
funding for any recurring program, project, or activity of
a service unit may be implemented only after the Secretary
has submitted to the President, for inclusion in the report
required to be transmitted to the Congress under section
801, a report on the proposed change in allocation of fund-
ing, including the reasons for the change and its likely
effects.
‘‘(b) Subsection (a) shall not apply if the total
amount appropriated to the Service for a fiscal year is less
than the amount appropriated to the Service for the pre-
vious fiscal year.
‘‘SEC. 809. RESULTS OF DEMONSTRATION PROJECTS.
‘‘The Secretary shall provide for the dissemination to
Indian tribes of the findings and results of demonstration
projects conducted under this Act.