I 113th CONGRESS 2d Session H. R. 4843 IN THE HOUSE OF REPRESENTATIVES June 11, 2014 Ms. McCollum (for herself, Mr. Cole , Mr. Ben Ray Luján of New Mexico , Mr. Issa , Mr. Grijalva , Mr. Kline , Mr. Pallone , Mr. Young of Alaska , Mr. Huffman , and Mr. Kind ) introduced the following bill; which was referred to the Committee on Energy and Commerce , and in addition to the Committees on Ways and Means and Natural Resources , for a period to be subsequently determined by the Speaker, in each case for consideration of such provisions as fall within the jurisdiction of the committee concerned A BILL To amend title XVIII of the Social Security Act to provide for a limitation under the Medicare program on charges for contract health services provided to Indians by Medicare providers of services and suppliers.

1. Short title This Act may be cited as the Native Contract and Rate Expenditure Act of 2014 or the Native CARE Act of 2014 . 2. Findings Congress makes the following findings: (1) Federal health services to maintain and improve the health of American Indians and Alaska Natives are consonant with and required by the Federal Government’s historical and unique legal relationship with, and resulting trust responsibility to, the American Indian and Alaska Native people. (2) The unmet health needs of American Indians and Alaska Natives are severe and the health status of American Indians and Alaska Natives is far below that of the general population of the United States, resulting in an average life expectancy for American Indians and Alaska Natives 4.2 years less than that for the all races population of the United States. (3) The Indian Health Service and tribal Purchased/Referred Care programs purchase primary and specialty care services from private health care providers when those services are not available at Indian Health Service or Tribal health facilities. (4) Available Purchased/Referred Care funds have been insufficient to ensure access to care for American Indians and Alaska Natives, resulting in rationed care and diagnosis and treatment delays that lead to the need for more intensive and expensive treatment, further reducing already scarce Purchased/Referred Care funds. (5) In 2003, Congress amended title XVIII of the Social Security Act to require Medicare-participating hospitals to accept patients referred from the Indian Health Service and Tribal Purchased/Referred Care programs and to accept payment at no more than Medicare rates—the Medicare-like rate cap—for the services provided. (6) The Medicare-like rate cap only applies to hospital services, and does not apply to other types of Medicare-participating providers and suppliers. (7) Unlike other Federal health care programs, the Indian Health Service and Tribal Purchased/Referred Care programs continue to pay full billed charges for non-hospital services. (8) Because Purchased/Referred programs continue to pay full billed charges for non-hospital services, in many cases the Indian Health Service may only treat the most desperate Life or Limb cases, leading to many undesirable health outcomes for American Indians and Alaska Natives, and ultimately increasing costs to the Purchased/Referred Care programs. (9) On April 11, 2013, the Government Accountability Office released a report finding that capping Purchased/Referred Care reimbursement at Medicare-like rates for nonhospital services would enable the Indian Health Service to double the number of physician services provided by adding an additional 253,000 patient visits annually. 3. Limitation on charges for certain contract health services provided to Indians by Medicare providers of services and suppliers (a) Application to all providers of services (1) In general Section 1866(a)(1)(U) of the Social Security Act ( 42 U.S.C. 1395cc(a)(1)(U) ) is amended, in the matter preceding clause (i), by striking in the case of hospitals which furnish inpatient hospital services for which payment may be made under this title, . (2) Regulations The Secretary of Health and Human Services shall promulgate regulations to account for the amendment made by paragraph (1). (3) Effective date The amendment made by paragraph (1) shall apply to Medicare participation agreements in effect (or entered into) on or after the date that is 90 days after the date of enactment of this Act. (b) Application to all suppliers (1) In general Section 1834 of the Social Security Act ( 42 U.S.C. 1395m ) is amended by adding at the end the following new subsection: (r) Limitation on charges for certain contract health services provided to Indians by suppliers No payment may be made under this title for an item or service furnished by a supplier (as defined in section 1861(d)) unless the supplier agrees (pursuant to a process established by the Secretary) to be a participating provider of medical and other health services both— (1) under the Purchased/Referred Care program (formerly referred to as the contract health services program ) funded by the Indian Health Service and operated by the Indian Health Service, an Indian tribe, or tribal organization (as those terms are defined in section 4 of the Indian Health Care Improvement Act), with respect to items and services that are covered under such program and furnished to an individual eligible for such items and services under such program; and (2) under any program funded by the Indian Health Service and operated by an urban Indian organization with respect to the purchase of items and services for an eligible urban Indian (as those terms are defined in such section 4), in accordance with regulations promulgated by the Secretary regarding payment methodology and rates of payment (including the acceptance of no more than such payment rate as payment in full for such items and services). . (2) Effective date The amendment made by paragraph (1) shall apply to items and services furnished on or after the date that is 90 days after the date of enactment of this Act. (c) Limitation There shall be no reduction, offset, or limitation to any appropriations made to the Indian Health Service under the Indian Health Care Improvement Act (25 U.S.C. 1621 et seq.), the Act of November 2, 1921 ( 25 U.S.C. 13 ) (commonly known as the Snyder Act ), or any other provision of law as a result of the provisions of, including amendments made by, this Act. (d) Studies and reports (1) Study The Secretary of Health and Human Services (in this subsection referred to as the Secretary ), acting through the Director of the Indian Health Service, shall conduct a study on the impact of the amendments made by this section on access to care under the Purchased/Referred Care program of the Indian Health Service. (2) Report Not later than 2 years after the date of enactment of this Act, the Secretary shall submit to Congress a report containing the results of the study conducted under paragraph (1), including recommendations for such legislation and administrative action as the Secretary determines appropriate. (3) Section 219(c) study and report Section 219(c) of the Indian Health Care Improvement Act ( 25 U.S.C. 1621r(c) ) is amended by striking 12 months after the date of the enactment of this section and inserting 12 months after the date of the enactment of the Native Contract and Rate Expenditure Act of 2014, and biennially thereafter through 2020 .