II 119th CONGRESS 1st Session S. 699 IN THE SENATE OF THE UNITED STATES February 24, 2025 Mr. Rounds (for himself, Ms. Cantwell , Mr. Thune , and Mrs. Murray ) introduced the following bill; which was read twice and referred to the Committee on Indian Affairs A BILL To amend the Indian Health Care Improvement Act to address liability for payment of charges or costs associated with the provision of purchased/referred care services, and for other purposes.

1. Short title This Act may be cited as the Purchased and Referred Care Improvement Act of 2025 . 2. Changes to liability for payment (a) In general Section 222 of the Indian Health Care Improvement Act ( 25 U.S.C. 1621u ) is amended— (1) in subsection (a)— (A) by striking A patient who receives contract health care services and inserting Notwithstanding any other provision of law or any agreement, form, or other written or electronic document signed by a patient, a patient who receives purchased/referred care ; and (B) by striking such services and inserting the purchased/referred care ; (2) by striking subsection (b) and inserting the following: (b) Notification The Secretary shall notify a purchased/referred care provider and any patient who receives purchased/referred care authorized by the Service that, notwithstanding any other provision of law or any agreement, form, or other written or electronic document signed by the patient, the patient is not liable to any provider, debt collector, or any other person for the payment of any charges or costs associated with the provision of the purchased/referred care not later than 5 business days after receipt of a notification of a claim by a provider of the purchased/referred care. ; (3) in subsection (c)— (A) by inserting , debt collector, or any other person, as applicable, after the provider ; and (B) by striking the services and inserting the purchased/referred care ; and (4) by adding at the end the following: (d) Reimbursement (1) Establishment of procedures (A) In general Not later than 120 days after the date of enactment of the Purchased and Referred Care Improvement Act of 2025 , in consultation with Indian tribes, and except as provided in paragraph (2), the Secretary shall establish and implement procedures to allow a patient that paid out-of-pocket for purchased/referred care authorized by the Service under this Act to be reimbursed by the Service for that payment not later than 30 days after the date on which the patient submits documentation to the Service in accordance with subparagraph (B). (B) Submitting documentation The Secretary shall accept documentation from a patient seeking reimbursement under paragraph (1) that was submitted— (i) electronically; or (ii) in-person at a Service facility. (2) Limitation Paragraph (1) shall not apply to purchased/referred care furnished under a purchased/referred care services program operated by an Indian tribe under a contract or compact entered into under the Indian Self-Determination and Education Assistance Act ( 25 U.S.C. 5301 et seq. ) unless expressly agreed to by the Indian tribe. (e) Updating authorities Not later than 180 days after the date of enactment of the Purchased and Referred Care Improvement Act of 2025 , the Secretary, in consultation with Indian tribes, shall update applicable provisions of and exhibits to the Indian Health Manual, contracts with providers, and other relevant documents and administrative authorities to incorporate the provisions of this section. . (b) Application The amendments made by subsection (a) shall apply to purchased/referred care (as defined in section 4 of the Indian Health Care Improvement Act ( 25 U.S.C. 1603 )) authorized by the Indian Health Service furnished on, before, or after the date of enactment of this Act. 3. Technical and conforming amendments (a) Definitions Section 4 of the Indian Health Care Improvement Act ( 25 U.S.C. 1603 ) is amended— (1) by striking paragraph (5); (2) by redesignating paragraphs (6) through (15) as paragraph (5) through (14), respectively; (3) in paragraph (12) (as so redesignated), in the matter preceding subparagraph (A), by striking , as defined in subsection (d) hereof, ; (4) by inserting after paragraph (14) (as so redesignated) the following: (15) Purchased/referred care The term purchased/referred care means any health service that is— (A) delivered based on a referral by, or at the expense of, an Indian health program; and (B) provided by a public or private medical provider or hospital that is not a provider or hospital of the Indian health program. ; (5) in paragraph (25), by striking ( 25 U.S.C. 450 et seq. ) and inserting ( 25 U.S.C. 5301 et seq. ) ; (6) in paragraph (26), by striking ( 25 U.S.C. 450b ) and inserting ( 25 U.S.C. 5304 ) ; and (7) in paragraph (28)— (A) by striking , as defined in subsection (g) hereof, ; and (B) by striking subsection (c)(1) through (4) of this section and inserting subparagraphs (A) through (D) of paragraph (12) . (b) Technical and conforming amendments (1) The Indian Health Care Improvement Act ( 25 U.S.C. 1601 et seq. ) is amended— (A) by striking contract health service each place it appears and inserting purchased/referred care ; (B) by striking contract health services each place it appears and inserting purchased/referred care ; (C) by striking Contract Health Service each place it appears and inserting purchased/referred care ; (D) by striking Contract Health Services each place it appears and inserting purchased/referred care ; and (E) by striking contract care each place it appears and inserting purchased/referred care . (2) Section 211 of the Indian Health Care Improvement Act ( 25 U.S.C. 1621j ) is amended by striking the section heading and designation and all that follows through (a) The Secretary and inserting the following: 211. California purchased/referred care demonstration program (a) The Secretary . (3) Section 219 of the Indian Health Care Improvement Act ( 25 U.S.C. 1621r ) is amended by striking the section heading and designation and all that follows through (a) The Secretary and inserting the following: 219. Purchased/referred care payment study (a) The Secretary . (4) Section 226 of the Indian Health Care Improvement Act ( 25 U.S.C. 1621y ) is amended, in the section heading, by striking Contract health service and inserting Purchased/referred care . (5) Section 406 of the Indian Health Care Improvement Act ( 25 U.S.C. 1646 ) is amended by striking the section heading and designation and all that follows through With respect and inserting the following: 406. Authorization for emergency purchased/referred care With respect . (6) Section 506(f) of the Indian Health Care Improvement Act ( 25 U.S.C. 1656(f) ) is amended by striking , as defined in section 4(f) of this Act, . (7) Section 704(b) of the Indian Health Care Improvement Act ( 25 U.S.C. 1665c(b) ) is amended, in the subsection heading, by striking Contract Health Services and inserting Purchased/referred care . (8) Section 808 of the Indian Health Care Improvement Act ( 25 U.S.C. 1678 ) is amended, in the section heading, by striking contract health service and inserting purchased/referred care . (9) Section 808A of the Indian Health Care Improvement Act ( 25 U.S.C. 1678a ) is amended, in the section heading, by striking contract health service and inserting purchased/referred care . (10) Section 810 of the Indian Health Care Improvement Act ( 25 U.S.C. 1680 ) is amended by striking the section heading and designation and all that follows through The State and inserting the following: 810. California as a purchased/referred care delivery area The State . (11) Section 815 of the Indian Health Care Improvement Act ( 25 U.S.C. 1680e ) is amended by striking the section heading and designation and all that follows through (a) The Secretary and inserting the following: 815. Purchased/referred care for the Trenton service area (a) The Secretary . (12) Section 830(b) of the Indian Health Care Improvement Act ( 25 U.S.C. 1680t(b) ) is amended, in the subsection heading, by striking contract health services and inserting purchased/referred care . (13) Section 506A(a) of the Public Health Service Act (42 U.S.C. 290aa–5a(a)) is amended— (A) in paragraph (2), by striking Tribal health program the second place it appears and inserting tribal health program ; and (B) in paragraph (3)— (i) by striking health program administered by the Service and inserting health program administered directly by the Service ; and (ii) by striking section 4(12)(A) of the Indian Health Care Improvement Act and inserting paragraph (11)(A) of section 4 of the Indian Health Care Improvement Act ( 25 U.S.C. 1603 ) . (c) Updating authorities The Secretary of Health and Human Services is directed to ensure that the Indian Health Manual and all other relevant rules, guidance, manuals, and other materials are revised such that contract health service each place it appears (regardless of casing and typeface and including in the headings) is revised to read purchased/referred care (with appropriate casing and typeface).