Indian Health Care Amendments of 1988
PL 100-713 (H.R.5261), enacted 11/23/1988

102 STAT. 4784 
PUBLIC LAW 100-713—NOV. 23, 1988 
Public Law 100-713 
100th Congress 
An Act 
Nov. 23, 1988 
[H.R. 5261] 
Indian Health 
Care 
Amendments of 
1988. 
Appropriation 
authorizations. 
25 u s e 1601 
note. 
To reauthorize and amend the Indian Health Care Improvement Act, and for other 
purposes. 
Be it enacted by the Senate and House of Representatives of the 
United States of America in Congress assembled, 
mORT TITLE 
SECTION 1. This Act may be cited as the "Indian Health Care 
Amendments of 1988". 
TABLE OF CONTENTS 
SEC. 2. Table of contents. 
Sec. 1. Short title. 
Sec. 2. Table of contents. 
Sec. 3. References. 
Sec. 4. Appropriation; availability. 
TITLE I—INDIAN HEALTH MANPOWER 
Sec. 101. Health professions recruitment program for Indians. 
Sec. 102. Health professions preparatory scholarship program. 
Sec. 103. Indian Health Service extern programs. 
Sec. 104. Indian health professions scholarship program. 
Sec. 105. Continuing education allowances. 
Sec. 106. Native Hawaiian health professions scholarship program. 
Sec. 107. Community health representatives. 
Sec. 108. Indian health service clinical staffing. 
Sec. 109. Other recruitment and retention provisions. 
Sec. 110. Report on recruitment and retention. 
TITLE n—HEALTH SERVICES 
Sec. 201. Improvement of Indian health status. 
Sec. 202. Catastrophic health program. 
Sec. 203. Health promotion and disease prevention. 
Sec. 204. Reimbursement of certain expenses; research. 
TITLE ra—HEALTH FACILITIES 
Sec. 301. Consultation; closure of facilities; reports. 
Sec. 302. Safe water and sanitary waste disposal facilities. 
Sec. 303. Use of non-Service funds for renovation. 
Sec. 304. Bethel, Alaska, hospital. 
TITLE IV—ACCESS TO HEALTH SERVICES 
Sec. 401. Medicare provisions. 
Sec. 402. Demonstration program. 
TITLE V—URBAN INDIAN HEALTH SERVICES 
Sec. 501. Revision of program. 
Sec. 502. Urban Indian organization. 
TITLE VI—ORGANIZATIONAL IMPROVEMENTS 
Sec. 601. Establishment of the Indian Health Service as an agency of the Public 
Health Service. 
PUBLIC LAW 100-713—NOV. 23, 1988 
102 STAT. 4785 
TITLE Vn—MISCELLANEOUS PROVISIONS 
Sec. 701. Leasing and other contracts. 
Sec. 702. Arizona as a contract health service delivery area. 
Sec. 703. Eligibility of California Indians. 
Sec. 704. California as a contract health service delivery area. 
Sec. 705. Contract health facilities. 
Sec. 706. National Health Service Corps. 
Sec. 707. Health services for ineligible persons. 
Sec. 708. Infant and maternal mortality; fetal edcohol sjrndrome. 
Sec. 709. Contract health services for the Trenton Service Area. 
Sec. 710. Indian health service and Vetertuis' Administration health facilities and 
services sharing. 
Sec. 711. Reallocation of base resources. 
Sec. 712. Provision of services in Montfuia. 
Sec. 713. Demonstration projects for tribal management of health care services. 
Sec. 714. Health care for rural areas. 
Sec. 715. Child sexual abuse treatment progr£un. 
Sec. 716. Pueblo substance abuse treatment project for San Juan Pueblo, New 
Mexico. 
Sec. 717. Study with respect to nuclear resource development health hazards. 
Sec. 718. Limitation on use of funds appropriated to the Indian Health Service. 
Sec. 719. Eligibility for services. 
TITLE Vra—SEVERABILITY PROVISION 
Sec. 801. Severability. 
REFERENCES 
SEC. 3. Except as otherwise specifically provided, whenever in this 
Act an amendment or repeal is expressed in terms of an amendment 
to, or a repeal of, a section or other provision, the reference shall be 
considered to be made to a section or other provision of the Indian 
Health Care Improvement Act (25 U.S.C. 1601, et seqq.). 
APPROPRIATION; AVAILABILITY 
SEC. 4. Any new spending authority (described in subsection (cX2) 25 USC 1601 
(A) or (B) of section 401 of the Congressional Budget Act of 1974) 
"°*^ 
which is provided under this Act shall be effective for any fiscal year 
only to such extent or in such amounts as are provided in appropria-
tion Acts. 
TITLE I—INDIAN HEALTH MANPOWER 
HEALTH PROFESSIONS RECRUITMENT PROGRAM FOR INDIANS 
SEC. 101. Subsection (c) of section 102 (25 U.S.C. 1612 (c)) is 
amended to read as follows: 
"(c) There are authorized to be appropriated for the purpose of 
carrying out the provisions of this section— 
"(1) $600,000 for fiscal year 1989, 
"(2) $650,000 for fiscal year 1990, 
"(3) $700,000 for fiscal year 1991, and 
"(4) $750,000 for fiscal year 1992.". 
HEALTH PROFESSIONS PREPARATORY SCHOLARSHIP PROGRAM 
SEC. 102. (a) Section 103 (25 U.S.C. 1613) is amended by striking 
out subsection (d) and inserting in lieu thereof the following: 
"(d) The Secretary shall not deny scholarship assistance to an 
eligible applicant under this section solely on the basis of the 
applicant's scholastic achievement if such applicant has been admit-
ted to, or maintained good standing at, an accredited institution. 
102 STAT. 4786 
PUBLIC LAW 100-713—NOV. 23, 1988 
"(e) There are authorized to be appropriated for the purpose of 
canying out the provisions of this section-
ed) $3,000,000 for fiscal year 1989, 
"(2) $3,700,000 for fiscal year 1990, 
"(3) $4,400,000 for fiscal year 1991, and 
"(4) $5,100,000 for fiscal year 1992.". 
25 use 1613. 
(b) Subsection (c) of section 103 is amended by striking out 
"expenses" and inserting in lieu thereof "expenses of a grantee while 
attending school fiill time". 
INDIAN HEALTH SERVICE EXTERN PROGRAMS 
SEC. 103. Subsection (d) of section 105 (25 U.S.C. 1614) is amended 
to read as follows: 
"(d) There are authorized to be appropriated for the purpose of 
canying out the provisions of this section— 
"(1) $300,000 for fiscal year 1989, 
"(2) $350,000 for fiscal year 1990, 
"(3) $400,000 for fiscal year 1991, and 
"(4) $450,000 for fiscal year 1992.". 
INDIAN HEALTH PROFESSIONS SCHOLARSHIP PROGRAM 
25 use 1613a. 
SBC. 104- (a) Section 104 is amended to read as follows: 
"INDIAN HEALTH PROFESSIONS SCHOLARSHIPS 
"SBC. 104. (a) In order to provide health professionals to Indian 
communities, the Secretary, acting through the Service and in 
accordance with this section, shall make scholarship grants to In-
dians who are enrolled fiill time in appropriately accredited schools 
of medicine, osteopathy, podiatry, psychol<^y, dentistry, environ-
mental health and engineering, nursing, optometry, public health, 
allied health professions, and social work. Such scholarships shall be 
designated Indian Health Scholarships and shall be made in accord-
ance with section 338A of the Public Health Service Act (42 U.S.C. 
2541), except as provided in subsection (b) of this section. 
"(bXD The Secretary, acting through the Service, shall determine 
who shall receive scholarships under subsection (a) and shall deter-
mine the distribution of such scholarships among such health 
professions on the basis of the relative needs of Indians for addi-
tional service in such health professions. 
"(2) An individual shall be eligible for a scholarship under subsec-
tion (a) in any year in which such individual is enrolled full time in 
a health profession school referred to in subsection (a). 
"(3) The active duty service obligation prescribed under section 
338C of the PubUc Health Service Act (42 US.C. 254m) shall be met 
by a recipient of an Indian Health Scholarship by service— 
"(A) in the Indian Health Service; 
"(B) in a program conducted under a contract entered into 
under the Indian Self-Determination Act; 
"(C) in a program assisted under title V of this Act; or 
"(D) in the private prsurtice of the appUcable profession if, as 
determined by the Secretary, in accordance with guidelines 
promulgated by the Secretary, such practice is situated in a 
physician or other health professional shortage area and 
addresses the healtJi care needs of a substantial number of 
Indians. 
PUBLIC LAW 100-713—NOV. 23, 1988 
102 STAT. 4787 
"(c) For purposes of this section, the term 'Indian' has the same 
meaning given that term by subsection (c) of section 4 of this Act, 
including all individuals described in clauses (1) through (4) of that 
subsection. 
"(d) There are authorized to be appropriated for the purpose of 
carrying out the provisions of this section— 
"(1) $5,100,000 for fiscal year 1989, 
"(2) $6,000,000 for fiscal year 1990, 
"(3) $7,100,000 for fiscal year 1991, and 
"(4) $8,234,000 for fiscal year 1992.". 
(bXD Section 3381 of the Public Health Service Act (42 U.S.C. 254r) 
is repealed. 
(2) Scholarships that have been provided under section 3381 of the 
42 use 254r 
Public Health Service Act (42 U.S.C. 254r) on or before the date of 
"°*^ 
enactment of this Act— 
(A) shall continue to be provided under the provisions of such 
section that were in effect on the day before the date of enact-
ment of this Act, 
(B) shall be subject to the same terms and conditions to which 
such scholarships were subject on the day before the date of 
enactment of this Act, and 
(C) shall be funded from funds appropriated to carry out 
section 104 of the Indian Health Care Improvement Act, as 
amended by this Act. 
CONTINUING EDUCATION ALLOWANCES 
SEC. 105. Subsection (b) of section 106 (25 U.S.C. 1615(b)) is 
amended to read as follows: 
"(b) There are authorized to be appropriated for the purpose of 
carrying out the provisions of this section— 
"(1) $500,000 for fiscal year 1989, 
"(2) $526,300 for fiscal year 1990, 
"(3) $553,800 for fiscal year 1991, and 
"(4) $582,500 for fiscal year 1992.". 
NATIVE HAWAIIAN HEALTH PROFESSIONS SCHOLARSHIP PROGRAM 
SEC. 106. Subpart III of part D of title III of the Public Health 
Service Act (42 U.S.C. 254b, et seq.) is amended by adding at the 
end thereof the following new section: 
"SEC. 338J. NATIVE HAWAIIAN HEALTH SCHOLARSHIPS. 
I 
42 USC 254s. 
"(a) Subject to the availability of funds appropriated under the 
authority of subsection (d), the Secretary shall provide scholarship 
assistance, pursuant to a contract with the Kamehameha Schools/ 
Bishop Estate, to students who— 
"(1) meet the requirements of section 338A(b), and 
"(2) are Native Hawaiians. 
"(bXD The scholarship assistance provided under subsection (a) 
shall be provided under the same terms and subject to the same 
conditions, regulations, and rules that apply to scholarship assist-
ance provided under section 338A. 
"(2) The Native Hawaiian Health Scholarship program shall not 
be administered by or through the Indian Health Service. 
"(c) For purposes of this section, the term 'Native Hawaiian' 
means any individual who is— 
"(1) a citizen of the United States, 
102 STAT. 4788 
PUBLIC LAW 100-713—NOV. 23, 1988 
"(2) a resident of the State of Hawaii, and 
''(3) a descendant of the aboriginal people, who prior to 1778, 
occupied and exercised sovereignly in the area lliat now con-
stitutes the State of Hawaii, as evidenced by— 
"(A) genealogical records, 
"(B) Kupuna (elders) or Kama'aina Gong-term community 
residents) verification, or 
"(Q birth records of the State of Hawaii. 
"(d) There are authorized to be appropriated $1,800,000 for each of 
the fiscal years 1990, 1991, and 1992 for the purpose of funding the 
scholarship assistance provided under subsection (a).''. 
CiOMMUNITT HEALTH REFBESENTATIVES 
SBC. 107. Title I is amended by adding at the end thereof the 
following new section: 
"OOMBCUNTTT HEALTH REPRESENTATIVE PROGRAM 
25 use 1616. 
"SEC. 107. (a) Under the authority of the Act of November 2,1921 
(25 UJS.C. 13), popularly known as the Snyder Act, the Secretary 
shall maintain a Community Health Representative Program under 
which the Service— 
"(1) provides for the training of Indians as health paraprof^-
sionals,and 
"(2) uses such paraprofessionals in the provision of health 
care, health promotion, and disease prevention services to 
Indian communities. 
"(b) The Secretary, acting through the Community Health Rep-
resentative Program of the Service, shall— 
"(1) provide a high standard of training for paraprofessionals 
to Community Health Representatives to ensure that the 
Community Health Representatives provide quality health care, 
health promotion, and disease prevention services to the Indian 
communities served by such Program, 
"(2) in order to provide such training, develop a curriculum 
that— 
"(A) combines education in the theory of health care with 
supervised practical experience in the provision of health 
care, and 
"(B) provides instruction and practical experience in 
health promotion and disease prevention activities, 
"(3) develop a sjrstem which identifies the needs of Commu-
nity Health Representatives for continuing education in health 
care, health promotion, and disease prevention and develop 
programs that meet the needs for such continuing education, 
"(4) develop and maintain a system that provides close super-
vision of Community Health Representatives, 
"(5) develop a system under which the work of (Community 
Health Representatives is reviewed and evaluated, and 
"(6) promote traditional health care practices of the Indian 
tribes served consistent with the Service standards for the 
provision of health care, health promotion, and disease 
prevention.". 
PUBLIC LAW 100-713—NOV. 23, 1988 
102 STAT. 4789 
INDIAN HEALTH SERVICE CLINICAL STAFFING 
SEC. 108. Title I, as amended by section 107 of this Act, is further 
amended by adding at the end thereof the following new sections: 
"INDIAN HEALTH SERVICE LOAN REPAYMENT PROGRAM 
"SEC. 108. (aXD The Secretary, acting through the Service, shall 
25 use I6l6a. 
establish a program to be known as the Indian Health Service Loan 
Repayment Program (hereinafter referred to as the 'Loan Repay-
ment Program') in order to assure an adequate supply of trained 
physicians, dentists, nurses, nurse practitioners, physician assist-
ants, clinical and counseling psychologists, graduates of schools of 
public health, graduates of schools of social work, and other health 
professionals necessary to maintain accreditation of, and provide 
health care services to Indians through, Indian health programs. 
"(2) For the purposes of this section— 
"(A) the term 'Indian health program' means any health 
program or facility funded, in whole or part, by the Service for 
the benefit of Indians and administered— 
"(i) directly by the Service; 
"(ii) by any Indian tribe or tribal or Indian organization 
pursuant to a contract imder— 
"(I) the Indian Self-Determination Act, or 
"(II) section 23 of the Act of April 30,1908 (25 U.S.C. 
47), popularly known as the 'Buy-Indian' Act; or 
"(iii) by an urban Indian organization pursuant to title V 
of this Act; and 
"(B) the term 'State' has the same meaning given such term 
in section 331(iX4) of the Public Health Service Act. 
"(b) To be eligible to participate in the Loan Repajmaent Program, 
an individual must— 
"(1)(A) be enrolled— 
"(i) as a full-time student in the final year of a course of 
study or program in an accredited institution, as deter-
mined by the Secretary, within any State; or 
"(ii) in an approved graduate training program in medi-
cine, osteopathy, dentistry, or other health profession; or 
"(B) have— 
"(i) a degree in medicine, osteopathy, dentistry, or other 
health profession; 
"(ii) completed an approved graduate training program in 
medicine, osteopathy, dentistry, or other health profession 
in a State, except that the Secretary may waive the comple-
tion requirement of this clause for good cause; and 
"(iii) a license to practice medicine, osteopathy, dentistry, 
or other health profession in a State; 
"(2XA) be eligible for, or hold, an appointment as a commis-
sioned officer in the Regular or Reserve Corps of the Public 
Health Service; 
"(B) be eligible for selection for civilian service in the Regular 
or Reserve Corps of the Public Health Service; 
"(C) meet the professional standards for civil service employ-
ment in the Indian Health Service; or 
"(D) be employed in an Indian health program without a 
service obligation; 
102 STAT. 4790 
PUBLIC LAW 100-713—NOV. 23, 1988 
Contracts. 
Contracts. 
Contracts. 
Contracts. 
"(3) submit an application to participate in the Loan Repay-
ment Program; and 
"(4) sign and submit to the Secretary, at the time of submis-
sion of such appUcation, a written contract (described in subsec-
tion (f)) to accept repayment of educational loans and to serve 
(in accordance with this section) for the applicable period of 
obligated service in an Indian health program. 
"(cXD In disseminating application forms and contract forms to 
individuals desiring to participate in the Loan Repayment Program, 
the Secretary shall include with such forms a fair summary of the 
rights and liabilities of an individual whose application is approved 
(and whose contract is accepted) by the Secretary, including in the 
summary a clear explanation of the damages to which the United 
States is entitled under subsection (1) in the case of the individual's 
breach of the contract. The Secretary shall provide such individuals 
with sufficient information regarding the advantages and disadvan-
tages of service as a commissioned officer in the Regular or Reserve 
Corps of the Public Health Service or a civilian employee of the 
Indian Health Service to enable the individual to make a decision on 
£in informed basis. 
"(2) The application form, contract form, and all other informa-
tion furnished by the Secretary under this section shall be written 
in a manner calculated to be understood by the average individual 
applying to participate in the Loan Repayment Program. 
"(3) The Secretary shall make such application forms, contract 
forms, and other information available to individuals desiring to 
participate in the Loan Repayment Program on a date sufficiently 
early to ensure that such individuals have adequate time to care-
fully review and evaluate such forms and information. 
"(dXD The Secretary, acting through the Service and in accord-
ance with subsection (k), shall annually— 
"(A) identify the positions in each Indian Health program for 
which there is a need or a vacancy, and 
"(B) rank those positions in order of priority. 
"(2) Consistent with the priority determined under paragraph (1), 
the Secretary, in determining which applications under the Loan 
Repayment Program to approve (and which contracts to accept), 
shall give priority to applications made by— 
"(A) Indians; and 
"(B) individuals recruited through the efforts of Indian tribes 
or tribal or Indian organizations. 
"(eXD An individual becomes a participant in the Loan Repay-
ment Program only on the Secretary's approved of the individual's 
application submitted under subsection (bX3) and the Secretary's 
acceptance of the contract submitted by the individual under subsec-
tion (bX4). 
"(2) The Secretary shall provide written notice to an individual 
promptly on— 
"(A) the Secretary's approving, under pareigraph (1), of the 
individual's participation in the Loan Repajnnent Program; or 
"(B) the Secretary's disapproving an individual's participation 
in such Program. 
"(f) The written contract referred to in this section between the 
Secretary and an individual shall contain— 
"(1) an agreement under which— 
"(A) subject to paragraph (3), the Secretary agrees— 
PUBLIC LAW 100-713—NOV. 23, 1988 
102 STAT. 4791 
"(i) to pay loans on behalf of the individual in accord-
ance with uie provisions of this section, and 
"(ii) to accept (subject to the availability of appro-
priated funds for carrying out this section) the individ-
ual into the Service or place the individual with a tribe 
or Lidian organization as provided in subparagraph 
(BXiii), and 
"(B) subject to paragraph (3), the individual agrees— 
"(i) to accept loan payments on beludf of the 
individual; 
"(ii) in tiie case of an individual described in subsec-
tion (bXD— 
"(D to maintain enrollment in a course of study 
or training described in subsection (bXlXA) until 
the individual completes the course of study or 
training, and 
"(ID while enrolled in such course of study or 
training, to maintain an acceptable level of aca-
demic standing (as determined under r^ulations 
of the Secretary by the educational institution 
offering such course of study or training); 
"(iii) to serve for a time period (hereinafter in this 
section referred to as the 'period of obligated service') 
equal to 2 years or such longer period as the individual 
may agree to serve in the full-time clinical practice of 
sudb individual's profession in an Indian health pro-
gram to which the individual may be assigned by the 
Secretary; 
"(2) a provision permitting the Secretary to extend for such 
longer additional periods, as the individual may agree to, the 
period of obligated service agreed to by the individual under 
paragraph (l)(BXiii); 
"(3) a provision that any financial obligation of the United 
States arising out of a contract entered into under this section 
and any obligation of the individual which is conditioned 
thereon is contingent upon funds being appropriated for loan 
repayments under this section; 
(4) a statement of the damages to which the United States is 
entitied under subsection (1) for the individual's breach of the 
contract^ and 
"(5) such other statements of the rights and liabilities of the 
Secretary and of tiie individual, not inconsistent with tiiis 
section. 
"(gXD A loan repayment provided for an individual under a 
written contract under the Loan Repayment Program shall consist 
of payment, in accordance with paragraph (2), on behalf of the 
individual of the principal, interest, and related expenses on govern-
ment and commercial loans received by the individual for— 
"(A) tuition expenses; 
"(B) all other reasonable educational expenses, including fees, 
books, and laboratory expenses, incurred by the individual; and 
*'iO reasonable living expenses as determined by tiie 
Secretary. 
"(2XA) Ebccept as provided in subparagraph (B) and paragraph (3), 
for each year of obligated service for which an individual contracts 
to serve under subsection (f), the Secretary may pay up to $25,000 on 
behalf of tiie individual for loans described in paragraph (1) 
102 STAT. 4792 
PUBLIC LAW 100-713—NOV. 23, 1988 
Taxes. 
Employment 
and 
unemployment. 
Discrimination, 
prohibition. 
Contracts. 
"(B) Any arrangement made by the Secretary for the iwalring of 
loan repayments in accordance with this subsection shall provide 
that any repayments for a year of obligated service shall be made no 
later than the end of the fiscal year in which the individual com-
pletes such year of service. 
"(3) In addition to payments made under paragraph (2), in any 
case in which payments on behalf of an individual under the Loan 
Repayment Program result in an increase in Federal, State, or local 
income tax liability for such individual, the Secretary may, on the 
request of such individual, make payments to such individual in a 
reasonable amount, as determined by the Secretary, to reimburse 
such individual for all or part of the increased tax liability of the 
individual. 
"(4) The Secretary may enter into an agreement with the holder of 
any loan for which payments are made under the Loan Repayment 
Program to establish a schedule for the making of such payments. 
**Qi) Notwithstanding any other provision of law, individuals who 
have entered into written contracts with the Secretary under this 
section, while undergoing academic training, shall not be counted 
against any employment ceiling affecting the Department of Health 
and Human Services. 
"(i) The Secretary shall conduct recruiting programs for the Loan 
Repayment Program and other Service manpower programs at 
educational institutions training health professionals or specialists 
identified in subsection (a). 
"0) Section 214 of the PubUc Health Service Act (42 U.S.C. 215) 
shall not apply to individuals during their period of obligated service 
under the Losm Repayment Program. 
"(k) The Secretary shall ensure that the staffing needs of Indian 
health programs administered by any Indian tribe or tribal or 
Indian organization receive consideration on an equal basis with 
programs that are administered directly by the Service. 
"GXD An individual who has entered into a written contract with 
the Secretary under this section and who— 
"(A) is enrolled in the final year of a course of study and 
who— 
"(i) fails to maintain an acceptable level of academic 
standing in the educational institution in which he is en-
rolled (such level determined by the educational institution 
under r^ulations of the Secretary); 
'Xii) voluntarily terminates such enrollment; or 
"(iii) is dismissed froia such educational institution before 
completion of such course of study; or 
"(B) is enrolled in a graduate training pn^ram, fails to 
complete such training program, and does not receive a waiver 
firom the Secretary under subsection (bXl)(BXii), 
shall be liable, in lieu of any service obligation arising under such 
contract, to the United States for the amount which has been paid 
on such individual's behalf under the contract. 
"(2) If, for any reason not specified in paragraph (1), an individual 
breaches his written contract under this section by failing either to 
b ^ ^ , or complete, such individual's period of obligated service in 
accordance with subsection (f), the United States shadl be entitled to 
recover from such individual an amount to be determined in accord-
ance with the following formula: 
A=3Z(t-s/t) 
PUBLIC LAW 100-713—NOV. 23, 1988 
102 STAT. 4793 
in which— 
"(A) 'A' is the amount the United States is entitled to recover; 
"(B) 'Z' is the sum of the amounts paid under this section to, 
or on behalf of, the individual and the interest on such amounts 
which would be payable if, at the time the amounts were paid, 
they were loans bearing interest at the maximum legal prevail-
ing rate, as determined by the Treasurer of the United States; 
"(C) 't' is the total number of months in the individual's 
period of obligated service in accordance with subsection (f); and 
"(D) 's' is the number of months of such period served by such 
individual in accordance with this section. 
Amounts not paid within such period shall be subject to collection 
through deductions in Medicare payments pursuant to section 1892 
of the Social Security Act. 
"(3XA) Any amount of damages which the United States is enti-
tled to recover under this subsection shall be paid to the United 
States within the 1-year period beginning on the date of the breach 
or such longer period beginning on such date £is shall be specified by 
the Secretary. 
"(B) If damages described in subparagraph (A) are delinquent for 3 
months, the Secretary shall, for the purpose of recovering such 
damages— 
"(i) utilize collection agencies contracted with by the Adminis-
trator of the General Services Administration; or 
"(ii) enter into contracts for the recovery of such damages 
with collection agencies selected by the Secretary. 
"(C) Each contract for recovering damages pursuant to this 
subsection shall provide that the contractor will, not less than once 
each 6 months, submit to the Secretary a status report on the 
success of the contractor in collecting such damages. Section 3718 of 
title 31, United States Code, shall apply to any such contract to the 
extent not inconsistent with this subsection. 
"(mXD Any obligation of an individual under the Loan Repay-
ment Program for service or pajmient of damages shall be canceled 
upon the death of the individual. 
"(2) The Secretary shall by regulation provide for the partial or 
total waiver or suspension of any obligation of service or payment by 
an individual under the Loan Repa5nnent Program whenever 
compliance by the individual is impossible or would involve extreme 
hardship to the individual and if enforcement of such obligation 
with respect to any individual would be unconscionable. 
"(3) The Secretary may waive, in whole or in part, the rights of 
the United States to recover amounts under this section in any case 
of extreme hardship or other good cause shown, as determined by 
the Secretary. 
"(4) Any obligation of an individual under the Loan Repayment 
Program for pajnnent of damages may be released by a discharge in 
bankruptcy under title 11 of the United States Code only if such 
discharge is granted after the expiration of the 5-year period begin-
ning on the first date that pajrment of such damages is required, and 
only if the bankruptcy court finds that nondischarge of the obliga-
tion would be unconscionable. 
"(nXD By not later than the first of March of each year, the 
Secretary shall, beginning vnih fiscal year 1990, submit to the 
Congress an annual report for the preceding fiscal year setting out— 
Contracts. 
Reports. 
Regulations. 
Reports. 
102 STAT. 4794 
PUBLIC LAW 100-713—NOV. 23, 1988 
25 use 1616b. 
"(A) the number of such applications filed with respect to 
each type of health profession; 
"(B) the health professional positions maintained by the Serv-
ice or by tribal or Indian organizations for which recruitment or 
retention is difficult; 
"(C) the number of contracts described in subsection (f) that 
are entered into with respect to each health profession; and 
"(D) the amount of loan payments made in total and by 
health profession. 
"(2) Not later than the first of July of each year, beginning in 
1989, the Secretary shsdl submit to Congress a report on— 
"(A) the number of providers of health care that will be 
needed by Indian health programs by location and profession, 
during the three fiscal years beginning after the date the report 
is filed; and 
"(B) the measures the Secretary plans to take to fill the 
hesQth professional positions maintained by the Service or by 
tribes or tribal or Indian organizations for which recruitment or 
retention is difficult. 
"(o) There are authorized to be appropriated such sums as may be 
necessary for each fiscal year to carry out the provisions of this 
section. 
"TRAVEL EXPENSES FOR RECRUITMENT 
"SEC. 109. (a) The Secretary may reimburse health professionals 
seeking positions in the Service, including individuals considering 
entering into a contract under section 108, and their spouses, for 
actual and reasonable expenses incurred in traveling to and from 
their places of residence to an area in which they may be assigned 
for the purpose of evaluating such area with respect to such 
assignment. 
"(b) There are authorized to be appropriated $100,000 for each of 
the fiscal years 1990, 1991, and 1992, for the purpose of carrying out 
the provisions of this section. 
TRIBAL RECRUITMENT AND RETENTION PROGRAM 
25 use 1616c. 
"SEC. 110. (a) The Secretary, acting through the Service, shall 
fund, on a competitive basis, projects to enable Indian tribes and 
tribal and Indian organizations to recruit, place, and retain health 
professionals to meet the staffing needs of Indian health programs 
(as defined in section 108(aX2)). 
"(bXD Any Indian tribe or tribal or Indian organization may 
submit an application for funding of a project pursuant to th^ 
section. 
"(2) Indian tribes and tribal and Indian organizations under the 
authority of the Indian Self-Determination Act shall be given an 
equal opportunity with programs that are administered directly by 
the Service to compete for, and receive, grants under subsection (a) 
for such projects. 
"(c) There are authorized to be appropriated $1,000,000 for each of 
the fiscal years 1990, 1991, and 1992, for the purpose of carrying out 
the provisions of this section. 
PUBLIC LAW 100-713—NOV. 23, 1988 
102 STAT. 4795 
ADVANCED TRAINING AND RESEARCH 
"SEC. 111. (a) The Secretary, acting through the Service, shall 
establish a program to enable health professionals who have worked 
in an Indian health program (as defined in section 108(a)(2)) for a 
substantial period of time to pursue advanced training or research 
in areas of study for which the Secretary determines a need exists. 
"Ot)) An individual who participates in a program under subsection 
(a), where the educational costs are borne by the Service, shall incur 
an obligation to serve in an Indian health program for a period of 
obligated service equal to at least the period of time during which 
the individual participates in such progrsmi. In the event that the 
individual fails to complete such obligated service, the individual 
shall be liable to the United States for the period of service remain-
ing. The Secretary shall develop stamdards for 
appropriate 
recoupment for such remaining service. 
"(c) Health professionals from Indian tribes and tribal and Indian 
organizations under the authority of the Indian Self-Determination 
Act shall be given an equal opportunity to participate in the pro-
gram under subsection (a). 
"(d) REGULATIONS.—The Secretary shall prescribe such regula-
tions as may be necessary to carry out the provisions of this section. 
25 u s e 1616d. 
NURSING PROGRAM 
"SEC. 112. (a) The Secretary, acting through the Service, shall 
provide grants to— 
"(1) public or private schools of nursing, 
"(2) tribally controlled community colleges, and 
"(3) nurse midwife programs, and nurse practitioner pro-
grams, that are provided by any public or private institution, 
for the purpose of increasing the number of nurses, nurse midwives, 
and nurse practitioners who deliver health care services to Indians. 
"(b) Grants provided under subsection (a) may be used to— 
"(1) recruit individuals for programs which train individuals 
to be nurses, nurse midwives, or nurse practitioners, 
"(2) provide scholarships to individuals enrolled in such pro-
grams that may pay the tuition charged for such program and 
other expenses incurred in connection with such program, 
including books, fees, room and board, and stipends for living 
expenses, 
"(3) provide a program that encourages nurses, nurse mid-
wives, and nurse practitioners to provide, or continue to 
provide, health care services to Indians, 
"(4) provide a program that increases the skills of, and pro-
vides continuing education to, nurses, nurse midwives, and 
nurse practitioners, or 
"(5) provide any program that is designed to achieve the 
purpose described in subsection (a). 
"(c) Each application for a grant under subsection (a) shall include 
such information as the Secretary may require to establish the 
connection between the program of the applicant and a health care 
facility that primarily serves Indians. 
"(d) In providing grants under subsection (a), the Secretary shall 
extend a preference to— 
"(1) programs that provide a preference to Indians, 
Grants. 
25 u s e 1616e. 
102 STAT. 4796 
PUBLIC LAW 100-713—NOV. 23, 1988 
"(2) programs 
that 
train 
nurse 
midwives 
or 
nurse 
practitioners, 
"(3) programs that are interdisciplinary, and 
"(4) programs that are conducted in cooperation with a center 
for gifted and talented Indian students established under sec-
tion 5324(a) of the Indian Education Act of 1988. 
"(e) The active duty service obligation prescribed under section 
338C of the Public Health Service Act (42 U.S.C. 254m) shall be met 
by each individual who receives training or assistance described in 
paragraph (1) or (2) of subsection (b) that is funded by a grant 
provided under subsection (a). Such obligation shall be met by 
service— 
"(A) in the Indian Health Service; 
"(B) in a program conducted under a contract entered into 
under the Indian Self-Determination Act; 
"(C) in a program assisted under title V of this Act; or 
"(D) in the private practice of nursing if, as determined by the 
Secretary, in accordance with guidelines promulgated by the 
Secretary, such practice is situated in a physician or other 
health professional shortage area and addresses the health care 
needs of a substantial number of Indians. 
"(fXD There are authorized to be appropriated for each of the 
fiscal years 1990, 1991, and 1992, $5,000,000 for the purpose of 
carrying out the provisions of this section. 
"(2) Of the amounts appropriated under the authority of para-
graph (1) for each fiscal year, the Secretary shall use at least 
ll,000,()00 to provide grants under subsection (a) for the training of 
nurse midwives.". 
OTHER RECRUITMENT AND RETENTION PROVISIONS 
Ssa 109. Title I, as amended by section 108 of this Act, is further 
amended by adding at the end tiiereof the following new sections: 
Education. 
25 u s e 1616f. 
Grants. 
Schools and 
colleges. 
25 u s e 1616g. 
TRIBAL CULTURE AND HISTORY 
"SEC. 113. (a) The Secretary, acting through the Service, shall 
establish a program under which appropriate employees of the 
Service who serve particular Indian tribes shall receive educational 
instruction in the history and culture of such tribes and in the 
history of the Service. 
"(b) To the extent feasible, the program established under subsec-
tion (a) shall— 
"(1) be carried out through tribally-controUed community 
collies (within the meaning of section 2(4) of the Tribally 
Controlled Ck>mmunity Collie Assistance Act of 1978), 
"(2) be developed m consultation with the affected tribal 
government, and 
"(3) include instruction in Native American studies. 
"(c) There are authorized to be appropriated for each of the fiscal 
years 1990, 1991, and 1992, $1,000,000 to carry out the provisions of 
this section. 
"INMED PROGRAM 
"SEC. 114. (a) The Secretary is authorized to provide grants to at 
least 3 collies and universities for the purpose of maintaining and 
expanding the Native American health careers recruitment pro-
PUBLIC LAW 100-713—NOV. 23, 1988 
102 STAT. 4797 
gram known as the Indians into Medicine Program' (hereinafter in 
this section referred to as 'INMED') as a means of encouraging 
Indians to enter the health professions. 
"(b) The Secretary shall provide one of the grants authorized 
under subsection (a) to maintain the INMED program at the Univer-
sity of North Dakota, unless the Secretary makes a determination, 
based upon program reviews, that the program is not meeting the 
purposes of this section. 
"(cXD The Secretary shall develop regulations for the competitive 
awarding of the grants provided under this section. 
"(2) Applicants for grants provided under this section shall agree 
to provide a program which— 
"(A) provides outreach and recruitment for health professions 
to Indian communities including elementary, secondary and 
community colleges located on Indian reservations which will 
be served by the program, 
"(B) incorporates a program advisory board comprised of 
representatives from the tribes and communities which will be 
served by the program, 
"(C) provides summer preparatory programs for Indian stu-
dents who need enrichment in the subjects of math and science 
in order to pursue training in the health professions, 
"(D) provides tutoring, counseling and support to students 
who are enrolled in a health career program of study at the 
respective college or university, and 
(E) to the maximum extent feasible, employs qualified In-
dians in the program. 
"(d) By no later than the date that is 3 years after the date of 
enactment of the Indian Health Care Amendments of 1988, the 
Secretary shall submit a report to the Congress on the program 
established under this section including recommendations for 
expansion or changes to the program. 
(e) There are authorized to be appropriated for each of the fiscal 
years 1990, 1991, and 1992, $1,000,000 to carry out the provisions of 
this section. 
North Dakota. 
Regulations. 
Reports. 
HEALTH TRAINING PROGRAMS OF COMMUNITY COLLEGES 
"SEC. 115. (aXD The Secretary, acting through the Service, shall 
award grants to community colleges for the purpose of assisting the 
community college in the establishment of programs which provide 
education in a health profession leading to a degree or diploma in a 
health profession for individuals who desire to practice such profes-
sion on an Indian reservation or in a tribal clinic. 
"(2) The amount of any grant awarded to a community college 
under paragraph (1) for the first year in which such a grant is 
provided to the community college shall not exceed $100,000. 
"(bXD The Secretary, acting through the Service, shall award 
grants to community colleges that have established a program 
described in subsection (aXl) for the purpose of maintaining the 
program and recruiting students for the program. 
"(2) Grants may only be made under this section to a community 
college which— 
"(A) is accredited, 
"(B) has access to a hospital facility. Service facility, or 
hospital that could provide training of nurses or health 
professionals, 
Grants. 
25 u s e 1616h. 
102 STAT. 4798 
PUBLIC LAW 100-713—NOV. 23, 1988 
"(C) has entered into an agreement with an accredited college 
or university medical school, the terms of which— 
"(i) provide a progreun that enhances the transition and 
recruitment of students into advanced baccalaureate or 
graduate programs which train health professionals, and 
"(ii) stipulate certifications necessary to approve intern-
ship £md field placement opportunities at service unit facili-
ties of the Service or at tribal health facilities, 
"(D) has a qualified staff which has the appropriate certifi-
cations, and 
"(E) is capable of obtaining State or regional accreditation of 
the program described in subsection (aXl). 
"(c) The Secretary shall encourage community colleges described 
in subsection (bX2) to establish and maintain programs described in 
subsection (aXD by— 
Contracts. 
"(1) entering into agreements with such colleges for the provi-
sion of qualified personnel of the Service to teach courses of 
study in such programs, and 
"(2) providing technical assistance and support to such 
colleges. 
"(d) Any program receiving assistance under this section that is 
conducted with respect to a health profession shall also offer courses 
of study which provide advanced trsdning for any health profes-
sional who— 
"(1) has already received a degree or diploma in such health 
profession, and 
"(2) provides clinical services on an Indian reservation, at a 
Service facility, or at a tribal clinic. 
Such courses of study may be offered in conjunction with the collie 
or university with which the community college has entered into the 
agreement required under subsection (bX2XC). 
"(e) For purposes of this section— 
"(1) The term 'community college' means— 
"(A) a tribally controlled community college, or 
"(B) a junior or community college. 
"(2) The term 'tribally controlled community college' has the 
meaning given to such term by section 2(4) of the Tribally 
Controlled Community (DoUege Assistance Act of 1978. 
"(3) The term 'junior or community college' has the meaning 
given to such term by section 312(e) of the Higher Education Act 
of 1965 (20 U.S.C. 1058(e)). 
"(f) There are authorized to be appropriated for each of the fiscal 
years 1990, 1991, and 1992, $1,500,000 to carry out the provisions of 
this section. 
"ADDITIONAL INCENTIVES FOR HEALTH PROFESSIONALS 
Wages. 
"SEC. 116. (a) The Secretary may provide the incentive special pay 
25 use 16161. 
authorized under section 3020)) of title 37, United States Code, to 
civilian medical officers of the Indian Health Service who are 
assigned to, and serving in, positions included in the list established 
under subsection (bXD for which recruitment or retention of person-
nel is difficult. 
"(bXD The Secretary shall establish and update on an annual 
basis a list of positions of health care professionals employed by, or 
assigned to, the Service for which recruitment or retention is 
difficult. 
PUBLIC LAW 100-713—NOV. 23, 1988 
102 STAT. 4799 
"(2XA) The Secretary may pay a bonus to any commissioned 
officer or civil service employee, other than a commissioned medical 
officer, dental officer, optometrist, and veterinarian, who is 
employed in or assigned to, and serving in, a position in the 
Service included in the list established by the Secretary under 
paragraph (1). 
"(B) TTie total amount of bonus payments made by the Secretary 
under this paragraph to any employee during any 1-year period 
shall not exceed $2,000. 
"(c) The Secretary may establish programs to allow the use of 
flexible work schedules, and compressed work schedules, in accord-
ance with the provisions of subchapter II of chapter 61 of title 5, 
United States Code, for health professionals employed by, or 
assigned to, the Service. 
"(d) By no later than the date that is 6 months after the date of 
Reports, 
enactment of the Indian Health Care Amendments of 1988, the 
Secretary shall submit a report to the Congress on the limitation 
imposed on amounts of premium pay for overtime to any individual 
employed by, or assigned to, the Service. The report shall include an 
explanation of existing overtime pay policy, an estimate of the 
budget impact of removing limitations on overtime pay, a summary 
of problems associated with overtime pay limitations, and rec-
ommendations for changes to the overtime pay policy. 
"(e) There are authorized to be appropriated $600,000 for each of 
the fiscal years 1990, 1991, and 1992 to carry out the provisions of 
this section. 
"RETENTION BONUS 
"SEC. 117. (a) The Secretary may pay a retention bonus to any 
Wages. 
physician or nurse employed by, or assigned to, and serving in, the 
^5 use I6i6j. 
Service either as a civilian employee or as a commissioned officer in 
the Regular or Reserve Corps of the Public Health Service who— 
(1) is assigned to, and serving in, a position included in the 
list established under section 116(bXl) for which recruitment or 
retention of personnel is difficult, 
"(2) the Secretary determines is needed by the Service, 
"(3)has— 
"(A) completed 3 years of emplojmient with the Service, 
or 
"(B) completed any service obligations incurred as a 
requirement of— 
"(i) any Federal scholarship program, or 
"(ii) any Federal education loan repajnnent program, 
and 
"(4) enters into an agreement with the Service for continued 
Contracts. 
emplojonent for a period of not less than 1 year. 
"(b) The Secretary may establish rates for the retention bonus 
which shall provide for a higher annual rate for multiyear agree-
ments than for single year agreements referred to in subsection 
(aX4), but in no event shall the annual rate be more than $25,000 per 
annum. 
"(c) The retention bonus for the entire period covered by the 
agreement described in subsection (aX4) shall be paid at the begin-
ning of the agreed upon term of service. 
"(d) Any physician or nurse failing to complete the agreed upon 
term of service, except where such feulure is through no fault of the 
individual, shall be obligated to refund to the Government the full 
102 STAT. 4800 
PUBLIC LAW 100-713—NOV. 23, 1988 
amount of the retention bonus for the period covered by the agree-
ment, plus interest as determined by the Secretary in acconkince 
with section 108aX2XB). 
"(e) There are authorized to be appropriated $3,200,000 for each of 
the fiscal years 1990, 1991, and 1992 to carry out the provisions of 
this section.". 
REFOBT ON RECRUITMENT AND RETENTION 
25 use 1611 
SEC. 110. (a) The Secretary of Health and Human Services shall 
note. 
establish an advisory panel composed of— 
(1) 10 physicians or ouier health professionals who are 
employees o^ or assigned to, the Indian Health Service, 
(2) 3 representatives of tribal health boards, and 
(3) 1 representative of an urban health care organization. 
0
1
>
) The advisory panel established under subsection (a) shall 
conduct an investigation o
f
— 
(1) the administrative policies and r^ulatory procedures 
which impede the recruitment or retention of physicians and 
other health professionals by the Indian Health Service, and 
(2) the regulatory changes necessary to establish pay grades 
for health professionals employed by, or assigned to, the Service 
that correspond to the pay grades established for positions 
provided under sections 4103 and 4104 of title 38, United States 
Code, and the costs associated with establishing such pay 
grades. 
(c) By no later than the date that is 18 months after the date of 
enactment of this Act, the advisory panel established under subsec-
tion (a) shall submit to the Congress a report on the investigation 
conducted under subsection 0
1
>
)
, tc^ether with any recommendations 
for administrative or legislative changes in existing law, practices, 
or procedures. 
TITLE n—HEALTH SERVICES 
IMPROVEBfENT OF INDIAN HEALTH STATUS 
SEC. 201. (a) Section 201 (25 U.S.C. 1621) is amended to read as 
follows: 
"IMPROVEBCENT OF INDIAN HEALTH STATUS 
"SEC. 201. (a) The Secretary is authorized to expend funds which 
are appropriated under the authority of subsection (h), through the 
Service, for the purposes of— 
"(1) raising the health status of Indians to zero deficiency, 
"(2) eliminating backlogs in the provision of health care 
services to Indians, 
"(3) meeting the health needs of Indians in an efficient and 
equitable manner, and 
"(4) augmenting the ability of the Service to meet the follow-
ing health service responsibiUties with respect to those Indian 
tribes with the high^ levels of health resources deficiency: 
"(A) clinical care (direct and indirect) including clinical 
eye and vision care; 
"(B) preventive health; 
"(C) dental care (direct and indirect); 
"(D) mental health, including community mental health 
services, inpatient mental health services, dormitory 
mental health services, therapeutic and residential 
PUBLIC LAW 100-713—NOV. 23, 1988 
102 STAT. 4801 
treatment centers, and training of traditional Indian 
practitioners; 
"(E) emergency medical services; 
"(F) treatment and control of, and rehabilitative care 
related to, alcoholism and drug abuse (including fetal alco-
hol syndrome) among Indians; 
"((j) accident prevention programs; 
"(H) home health care; 
"(I) community health representatives; and 
"(J) maintenance and repair. 
"(bXD Any funds appropriated under the authority of subsection 
(h) shall not be used to offset or limit any appropriations made to 
the Service under the Act of November 2, 1921 (25 U.S.C. 13), 
popularly known as the Snyder Act, or any other provision of law. 
(2) Funds which are appropriated under the authority of subsec-
tion (h) may be allocated to, or used for the benefit of, any Indian 
tribe which has a health resources deficiency level at level I or II 
only if a sufficient amount of funds have been appropriated under 
the authority of subsection (h) to raise all Indian tribes to health 
resources deficiency level 11. 
"(3XA) Funds appropriated under the authority of subsection (h) 
may be allocated on a service unit basis but such allocation shall be 
made in a manner which ensures that the requirement of paragraph 
(2) is met. The funds allocated to each service unit under this 
subparagraph shall be used by the service imit (in accordance with 
paragraph (2)) to raise the deficiency level of each tribe served by 
such service unit. 
"(B) The apportionment of funds allocated to a service unit under 
subp£u*agraph (A) among the health service responsibilities de-
scribed in subsection (aX4) shall be determined by the Service in 
consultation with the aJffected Indian tribes. 
"(c) For purposes of this section— 
"(1) The health resources deficiency levels of an Indism tribe 
are as follows: 
"(A) level I—0 to 20 percent health resources deficiency; 
"(B) level n—21 to 40 percent health resources deficiency; 
"(C) level in—41 to 60 percent health resources 
deficiency; 
"(D) level IV—61 to 80 percent health resources 
deficiency; and 
"(E) level V—81 to 100 percent health resources 
deficiency. 
"(2) The term 'health resources deficiency' means a percent-
age determined by dividing— 
"(A) the excess, if any, of— 
"(i) the value of the health resources that the Indian 
tribe needs, over 
"(ii) the vedue of the health resources available to the 
Indian tribe, by 
"(B) the value of the health resources that the Indian 
tribe needs. 
"(3) The health resources available to an Indian tribe include 
health resources provided by the Service as well as health 
resources used by the Indian tribe, including services and 
financing systems provided by any Federal progrcuns, private 
insurance, and programs of State or local governments. 
102 STAT. 4802 
PUBLIC LAW 100-713—NOV. 23, 1988 
"(4) Under r^ulations, the Secretary shall establish proce-
dures which allow any Indian tribe to petition the Secretary for 
a review of any determination of the health resources deficiency 
level of such tribe. 
"(dXD Programs administered by any Indian tribe or tribal 
organization under the authority of the Indian Self-Determination 
Act shall be eligible for funds appropriated under the authority of 
subsection (h) on an equal basis with programs that are adminis-
tered directly by the Service. 
"(2) If any funds allocated to a tribe or service unit under the 
authori^ of this section are used for a contract entered into under 
the Indian Self-Determination Act, a reasonable portion of such 
funds may be used for health planning, training, technical assist-
ance, and other administrative support fiinctions. 
Reports. 
"(e) By no later than the date that is 60 dajrs after the date of 
enactment of the Indian Health Care Amendments of 1988, the 
Secretary shall submit to the Congress the current health services 
priority i^rstem report of the Service for each Indian tribe or service 
unit, including newly recognized or acknowledged tribes. Such 
report shall set out— 
"(1) the methodology then in use by the Service for determin-
ing tribal health resources deficiencies, as well as the most 
recent application of that methodology; 
"(2) the level of health resources deficiency for each Indian 
tribe served by the Service; 
"&) the amount of funds necessary to raise all Indian tribes 
served by the Service below health resources deficiency level 11 
to health resources deficiency level 11; 
"(4) the amount of funds necessary to raise all tribes served by 
the Service below health resources deficiency level I to health 
resources deficiency level I; 
"(5) the amount of funds necessary to raise all tribes served by 
the Service to zero health resources deficiency; and 
"(6) an estimate of— 
"(A) the amount of health service funds appropriated 
under the authority of this Act, or any other Act, including 
the amount of any funds transferred to the Service, for the 
preceding fiscal year which is allocated to each service unit, 
Indian tribe, or comparable e n t i ^ 
"(B) the number of Indians eligible for health services in 
each service unit or Indian tribe; and 
"
(
C
O the number of Indians using the Service resources 
made available to each service unit or Indian tribe. 
President of us. 
"(fXD The President shall include with the budget submitted to 
the Congress under section 1105 of title 31, United States Code, for 
each fiscal year a separate statement which specifies the amount of 
funds requested to carry out the provisions of this section for such 
fiscal year. 
"(2) Funds appropriated under authority of this section for any 
fiscal year shall be included in the base budget of the Service for the 
purpose of determining appropriations under this section in subse-
quent fiscal years. 
"(g) Nothing in this section is intended to diminish the primary 
responsibility of the Service to eliminate existing backl(^ in unmet 
hesdth care needs, nor are the provisions of this section intended to 
discourage the Service from undertaking additional efforts to 
achieve parity among Indian tribes. 
PUBLIC LAW 100-713—NOV. 23, 1988 
102 STAT. 4803 
"(h) There are authorized to be appropriated for the purpose of 
carrying out the provisions of this section— 
"(1) $19,000,000 for fiscal year 1990, 
"(2) $19,000,000 for fiscal year 1991, and 
"(3) $20,000,000 for fiscal year 1992. 
Any fiinds appropriated under the authority of this subsection shall 
be designated as the 'Indian Health Care Improvement Fund'.". 
O
i
>
) Section 4 (25 U.S.C. 1603) is amended by striking out subsec-
tions (i), (j), and (k), and by inserting in lieu thereof the following 
new subsections: 
"(i) 'Area office' means an administrative entity including a pro-
gram office, within the Indian Health Service through which serv-
ices and funds are provided to the service units within a defined 
geographic area, 
"(j) 'Service unit' means— 
"(1) an administrative entity within the Indian Health Serv-
ice, or 
"(2) a tnbe or tribal organization operating health care pro-
grams or facilities with funds 
fix>m 
the Service under the Indian 
Self-Determination Act, 
through which services are provided, directly or by contract, to the 
eligible Indian population within a defined geographic area.". 
CATASTHOPmC HEALTH PROGRAM 
SEC. 202. IHtle II is amended by adding at the end thereof the 
following new section: 
"CATASTROPHIC HEALTH EMERGENCY FUNS 
"SEC. 202. (aXD There is hereby established an Indian Cata- 
25 USC I62la 
strophic Health Ehnergency Fund (hereafter in this section referred 
to as the 'Fund') consisting of^ 
"(A) the amounts deposited under subsection (d), and 
"(B) the amounts appropriated under subsection (e). 
"(2) 'The Fund shall be administered by the Secretary, acting 
through the central office of the Service, solely for the purpose of 
meeting the extraordinary medical costs associated with the treat-
ment of victims of disasters or catastrophic illnesses who are within 
tiie responsibility of the Service. 
"(3) The Fund shall not be allocated, apportioned, or del^ated on 
a service unit, area office, or any other basis. 
"(4) No part of the Fund or its administration shall be subject to 
contract or grant under any law, including the Indian Self-
Determination Act. 
"(b) The Secretary shall, through the promulgation of r^ulations 
Regulations. 
consistent with the provisions of this section— 
"(1) establish a definition of disasters and catastrophic ill-
nesses for which the cost of treatment provided under contract 
would qualify for payment from the Fund; 
"(2) provide that a service unit shall not be eligible for 
reimbursement for the cost of treatment from the Fund until its 
cost of treating any victim of such catastrophic illness or disas-
ter has reached a certain threshold cost which the Secretary 
shall establish at not less than $10,000 or not more than $20,000; 
"(3) establish a procedure for the reimbursement of the por-
tion of the costs incurred by— 
102 STAT. 4804 
PUBLIC LAW 100-713—NOV. 23, 1988 
"(A) service units or facilities of the Service, or 
"(B) whenever otherwise authorized by the Service, non-
Service facilities or providers, 
in rendering treatment that exceeds such threshold cost; 
"(4) establish a procedure for payment from the Fund in cases 
in which the exigencies of the medical circumstances warrant 
treatment prior to the authorization of such treatment by the 
Service; and 
"(5) establish a procedure that will ensure that no payment 
shall be made from the Fund to any provider of treatment to the 
extent that such provider is eligible to receive payment for the 
treatment from any other Federal, State, local, or private 
source of reimbursement for which the patient is eligible. 
"(c) Funds appropriated imder subsection (e) shall not be used to 
ofiGset or limit appropriations made to the Service under authority of 
the Act of November 2,1921 (25 U.S.C. 13), popularly known as the 
Snyder Act, or any other law. 
"(d) There shall be deposited into the Fund all reimbursements to 
which the Service is entitled frx)m any Federal, State, local, or 
private source (including third party insurance) by reason of treat-
ment rendered to any victim of a disaster or catas^phic illness the 
cost of which was paid from the Fund. 
"(e) There are authorized to be appropriated for the purpose of 
carrying out the provisions of this section— 
"(1) $12,000,000 for fiscal year 1989, and 
"(2) for each of the fiscal years 1990, 1991, and 1992, such 
sums as may be necessary to restore the Fund to a level of 
$12,000,000 for such fiscal year. 
Funds appropriated imder the authority of this subsection shall 
remain available until expended.". 
HEALTH PROMOTION AND DISEASE PREVENTION 
25 use 1621b 
SBC. 203. (a) The Congress finds that health promotion and disease 
"°*^- 
prevention activities wQl— 
(1) improve the health and well being of Indians, and 
(2) reduce the expenses for medical care of Indians. 
0
1
>
) Section 4 (25 U.S.C. 1603), as amended by section 201(b) of this 
Act, is further amended by adding at the end thereof the following 
new subsections: 
"(10 'Health promotion' includes— 
"(1) cessation of tobacco smoking, 
"(2) reduction in the misuse of sdcohol and drugs, 
"(3) improvement of nutrition, 
"(4) improvement in physical fitness, 
"(5) family planning, 
"(6) control of stress, and 
"(7) pr^nancy and infant care (including prevention of fetal 
alcohol syndrome). 
"(1) 'Disease prevention' includes— 
"(1) immunizations, 
"(2) control of high blood pressure, 
"(3) control of sexually transmittsJble diseases, 
"(4) prevention and control of diabetes, 
"(5) control of toxic agents, 
"(6) occupational safety and health, 
"(7) accident prevention. 
<>?C,-r. 
PUBLIC LAW 100-713—NOV. 23, 1988 
102 STAT. 4805 
"(8) fluoridation of water, and 
"(9) control of infectious agents.", 
(c) Title II (25 U.S.C. 1621, et seq.), as amended by section 202 of 
this Act, is further amended by adding at the end thereof the 
following new sections: 
"HEALTH PROMOTION AND DISEASE PREVENTION SERVICES 
"SEC. 203. (a) The Secretary, acting through the Service, shall 
25 USC I62lb. 
provide health promotion and disease prevention services to Indians. 
"QD) The Secretary shall submit to the President for inclusion in 
each statement which is required to be submitted to the Congress 
under section 201(f) an evaluation of— 
"(1) the health promotion and disease prevention needs of 
Indians, 
"(2) the health promotion and disease prevention activities 
which would best meet such needs, 
"(3) the internal capacity of the Service to meet such needs, 
and 
"(4) the resources which would be required to enable the 
Service to undertake the health promotion and disease preven-
tion activities necessary to meet such needs. 
"(c)(1) The Secretary shall establish at least 1 demonstration 
project (but no more than 4 demonstration projects) to determine the 
most effective and cost-efficient means of— 
"(A) providing health promotion and disease prevention serv-
ices, 
"(B) encouraging Indians to adopt good health habits, 
"(C) reducing health risks to Indians, particularly the risks of 
heart disease, cancer, stroke, diabetes, anxiety, depression, and 
lifestyle-related accidents, 
"(D) reducing medical expenses of Indians through health 
promotion and disease prevention activities, 
"(E) establishing a program— 
"(i) which trains Indians in the provision of health pro-
motion and disease prevention services to members of their 
tribe, and 
"(ii) under which such Indians are available on a contract 
basis to provide such services to other tribes, and 
"(F) providing traming and continuing education to employ-
ees of the Service, and to paraprofessionals participating in the 
Community Health Representative Program, in the delivery of 
health promotion and disease prevention services. 
"(2) The demonstration project described in paragraph (1) shall 
include an analysis of the cost effectiveness of organizational struc-
tures and of social and educational programs that may be useful in 
achieving the objectives described in paragraph (1). 
"(3)(A) The demonstration project described in paragraph (1) shall 
be conducted in association with at leeist one— 
"(i) health profession school, 
"(ii) allied health profession or nurse training institution, or 
"(iii) public or private entity that provides health care. 
"(B) The Secretary is authorized to enter into contracts with, or 
make grants to, any school of medicine or school of osteopathy for 
the purpose of carrying out the demonstration project described in 
paragraph (1). 
102 STAT. 4806 
PUBLIC LAW 100-713—NOV. 23, 1988 
"(C) Far purposes of this paragraph, the term 'school of medicine' 
and 'school of osteopathy* have tihe respective meaning given to such 
terms by section 701(4) of the Public Health Service Act (42 U.S.C. 
292a(4)). 
Sports. 
"(4) The Secretary shall submit to Congress a final report on the 
demonstration project described in paragraph (1) within 60 days 
after the termination of such project. 
"(JS) The demonstration project described in paragraph (1) shall be 
established by no later than the date that is 12 months after the 
date of enactment of the Indian Health Care Amendments of 1988 
and shall terminate on the date that is 30 montlis after the date of 
enactment of such amendments. 
"(6) There are authorized to be appropriated $5()0,000 for the 
purpose of carrying out the provisions of this subsection, such sum 
to remain available without fiscal year limitation. 
"DIABETES FSEVENnON, TREATMENT, AND CONTROL 
25 use 1621c. 
"SEC. 204. (aXD The Secretary, in consultation with the tribes, 
shall determine— 
"(A) by tribe and by Service unit of the Service, the incidence 
of, and the t3rpes of complications resulting from, diabetes 
among Indians; and 
"(B) based on subparagraph (A), the measures (including 
patient education) each Service unit should take to reduce the 
incidence of, and prevent, treat, and control the complications 
resulting 
fix>in, 
diabetes among tribes within that Service unit. 
Reports. 
"(2) Within 18 months after the date of enactment of the Indian 
Health Care Amendments of 1988, the Secretary shall prepare and 
transmit to the President and the Congress a report describing the 
determinations made and measures taken under paragraph (1) and 
making recommendations for additional fimding to prevent, treat, 
and control diabetes among Indians. 
"(b) The Secretary shall screen each Indian who receives services 
bom the Service for diabetes and for conditions which indicate a 
h i ^ risk that the individual will become diabetic. Such screening 
may be done by a tribe or tribal oiganization operating health care 
programs or facilities with 
fiinds 
fi:t>m 
the Service under the Indian 
Self-Determination Act. 
State listing. 
"(cXD The Secretary shall continue to maintain during fiscal 
years 1988 throu^ 1991 each of the following model diabetes 
projects which are in existence on the date of enactment of the 
Lidian Heallli Care Amendments of 1988: 
"(A) CLaremore Indian Hospital in Oklahoma; 
"(B) Fort Totten Health Center in North Dakota; 
"(C) Sacaton Indian Hospital in Arizona; 
"(D) Winnebago Indian Hospital in Nebraska; 
"(E) Albuquerque Indian Hospital in New Mexico; 
"(F) Perry, Princeton, and Old Town Health Centers in 
Maine; and 
"(G) Bellingham Health CJenter in Washington. 
State listing. 
«(2) The Secretary shall establish in fiscal year 1989, and maintain 
during fiscal years 1989 through 1991, a model diabetes project in 
each of the following locations: 
"(A) Fort Berthold Reservation; 
"(B) the Navsgo Reservation; 
"(C) the Papago Reservation; 
PUBLIC LAW 100-713—NOV. 23, 1988 
102 STAT. 4807 
"(D) the Zuni Reservation; and 
''(E) the States of Alaska, California, Minnesota, Montana, 
Qre^n, and Utah. 
"(d) The Secretary shall— 
"(1) employ in each area office of the Service at least one 
diabetes control officer who shall coordinate and manage on a 
fidl-time basis activities within that area office for the preven-
tion, treatment, and control of diabetes; 
"(2) establish in each area office of the Service a registry of 
patients with diabetes to track the incidence of diabetes and the 
complications 
from 
diabetes in that area; and 
"(3) ensure that data collected in each area office r^arding 
diabetes and related complications among Indians is dissemi-
nated to all other area offices. 
"(e) There are authorized to be appropriated such sums as may be 
necessary to carry out the provisions of this section. Funds appro-
priated under subsection (c) in any fiscal year shall be in addition to 
base resources appropriated to the Service for that year. 
" N A T I V E HAWAIIAN HEALTH PBOMOTION AND DISEASE PREVENTION 
Contracts. 
"Ssa 205. (aXl) The Secretary shaU, acting through the Public 2
5 use I62id 
Health Service, establish in the State of Hawaii, as a demonstration 
project, a Native Hawaiian Program for Health Promotion and 
Disi^ffie Prevention for the purpose of exploring ways to meet the 
unique health care needs of Native Hawaiians. 
"(2) The demoiistitition program that is to be established under 
paragraph (1) shall— 
"(A) provide necessary preventive-oriented health services, 
induding health education and mental health care, 
"(B) develop innovative training and research projects, 
"(Q establish cooperative relationships with the leadership of 
the Native Hawaiian community, 
"(D) ensure that a continuous effort is made to establish 
programs which can be of direct benefit to other Native Amer-
ican people, and 
"(]^ assure a comprehensive effort to reduce the incidence of 
diabetes among Native Hawaiians. 
"(3) The Secretary is authorized to enter into contracts with 
Native Hawaiian oiganizations for the purpose of assisting the 
Secretary in meeting the objectives of the demonstration program 
that is to be established under paragraph (1). 
"(bXD In fuUBllment of the objective set forth in subsection 
(aX2)(E!), the Secretary shall enter into a contract with a Native 
"' 
Hawaiian organization to conduct a study to determine— 
"(A) the incidence of 
diabetes among Native Hawaiians: 
"(B) activities which should be undertaken— 
"(i) to reduce the incidence of diabetes among Native 
Hawaiians, 
"(ii) to provide Native Hawaiians with guidance in the 
prevention, treatment, and control of diabetes, 
"(iii) to provide early diagnosis of diabetes among Native 
Hawaiians, and 
"(iv) to ensure that proper continuing health care is 
provided to Native Hawaiians who are diagnosed as 
diabetic. 
10 1Q4 r» 
Q1 
X>ari ! 
102 STAT. 4808 
PUBLIC LAW 100-713—NOV. 23, 1988 
"(2) The Secretary shall enter into a contract with a Native 
Hawaiian organization for the purpose of preparing an inventory of 
all health care programs (public and private) within the State of 
Hawaii that are available for the treatment, prevention, or control 
of diabetes among Native Hawaiians. 
Reports. 
"(3) By no later than the date that is two years after the date of 
enactment of this section, the Native Hawaiian organization with 
whom the Secretary has entered into a contract, shall prepare and 
transmit to the Secretary a report describing the determinations 
made under paragraph (1), containing the inventory prepared under 
paragraph (2), and describing the research activities conducted 
under this subsection. The Secretary shall submit the report to the 
Congress and the President. 
"(cXD By no later than the date that is three years after the date 
of enactment of this section, the Secretary shall enter into a con-
tract with a Native Hawaiian organization for the purpose of 
implementing a program designed— 
"(A) to establish a diabetes control program; 
"(B) to screen those Native Hawaiian individuals that have 
been identified as having a high risk of becoming diabetic; 
"(C) to effectively treat— 
"(i) individuals diagnosed as diabetics in order to reduce 
further complications from diabetes, 
"(ii) individuals who have a high risk of becoming dia-
betic in order to reduce the incidence of diabetes, and 
"(iii) short- and long-term complications of diabetes; 
"(D) to conduct for Federal, State, and other Native Hawaiian 
health care providers (including Native Hawaiian community 
health outreach workers), training programs concerning cur-
rent methods of prevention, diagnosis, and treatment of 
diabetes and related complications among Native Hawaiians; 
"(E) to determine the appropriate delivery to Native Hawai-
ians of health care services relating to diabetes; 
"(F) to develop and present health education information to 
Native Hawaiian communities and schools concerning the 
prevention, treatment, and control of diabetes; and 
"(G) to ensure that proper continuing health care is provided 
to Native Hawaiians who are diagnosed as being diabetic. 
"(2) The Secretary shall enter into a contract with a Native 
Hawaiian organization for the purpose of— 
"(A) promoting coordination and cooperation between all 
health care providers in the delivery of diabetes related services 
to Native Hawaiians; and 
** 
"(B) encouraging and funding joint projects between Federal 
programs, State health care facilities, community health cen-
ters, and Native Hawaiian communities for the prevention and 
treatment of diabetes. 
"(3)(A) The Secretary shall enter into a contract with a Native 
Hawaiian organization for the purpose of establishing a model 
diabetes program to serve Native Hawaiians in the State of Hawaii. 
"(B) The Secretary shall enter into a contract with a Native 
Hawaiian organization for the purpose of developing and im-
plementing an outreach program to ensure that the achievements 
and benefits derived from the activities of the model diabetes pro-
gram established under subparagraph (A) are applied in Native 
Hawaiian communities to assure the diagnosis, prevention, and 
treatment of diabetes among Native Hawaiians. 
PUBLIC LAW 100-713—NOV. 23, 1988 
102 STAT. 4809 
"(4) The Secretary shall submit to the Congress an annual report 
outlining the activities, achievements, needs, and goals of the Native 
Hawaiian diabetes care program established under this paragraph. 
"(d) The Secretary shall enter into a contract with a Native 
Hawaiian organization, for the purpose of developing a standardized 
system to collect, analyze, and report data regarding diabetes and 
related complications among Native Hawaiians. Such system shall 
be designed to facilitate dissemination of the best available informa-
tion on diabetes to Native Hawaiian communities and health care 
professionals. 
"(e) The Secretary shall enter into a contract with a Native 
Hawaiian organization for the purpose of— 
"(1) conducting research concerning the causes, diagnosis, 
treatment, and prevention of diabetes and related complications 
among Native Hawaiians, and 
"(2) coordinating such research with all other relevant agen-
cies and units of the government of the State of Hawaii and the 
Department of Health and Human Services which conduct 
research relating to diabetes and related complications. 
*\f) The Secretary shall submit to the Congress an annual report 
on the status and accomplishments of the progress established 
under this section during each of the fiscal years 1990, 1991, and 
1992. 
"(gXD The Secretary shall include in any contract which the 
Secretary enters into with any Native Hawaiian organization under 
this subsection such conditions as the Secretary considers necessary 
to ensure that the objectives of such contract are achieved. 
"(2) The Secretary shall develop procedures to evaluate compli-
ance with, and performance of, contracts entered into by Native 
Hawaiian organizations under this subsection. 
"(3) The Secretary shall conduct an evaluation of each Native 
Hawaiian organization which has entered into a contract under this 
subsection for purposes of determining the compliance of such 
organization with, and evaluating the performance of such organiza-
tion under, such contract. 
"(4) If, as a result of the evaluations conducted under paragraph 
(3), the Secretary determines that a Native Hawaiian organization 
has not complied with or satisfactorily performed a contract entered 
into under this subsection, the Secretary shall, prior to renewing 
such contract, attempt to resolve the areas of noncompliance or 
unsatisfactory performance and modify such contract to prevent 
future occurrences of such noncompliance or unsatisfactory 
performance. If the Secretary determines that such noncompliance 
or unsatisfactory performance cannot be resolved and prevented in 
the future, the Secretary shall not renew such contract with such 
organization and is authorized to enter into a contract imder this 
subsection with another Native Hawaiian organization that serves 
the same population of Native Hawaiians which is served by the 
Native Hawaiian organization whose contract is not renewed by 
reason of this subparagraph. 
"(5) In determining whether to renew a contract entered into with 
a Native Hawaiian organization under this subsection, the Sec-
retary shall— 
"(A) review the records of the Native Hawaiian organization, 
and 
"(B) shall consider the results of the onsite evaluations con-
ducted under paragraph (3). 
Reports. 
Public 
information. 
Reports. 
102 STAT. 4810 
PUBLIC LAW 100-713—NOV. 23, 1988 
"(6) All contracts entered into by the Secretary under this subsec-
tion shall be in accordance with all Federal contracting laws and 
regulations except that, in the discretion of the Secretary, such 
contracts may be negotiated without advertising and need not con-
form to the provision of the Act of August 24, 1935 (40 U.S.C. 270a, 
et seq.). 
"(7) Pajonents made under any contract entered into under this 
subsection may be made in advance, by means of reimbursement, or 
in installments and shall be made on such conditions as the Sec-
retary deems necessary to carry out the purposes of this subsection. 
"(8) Notwithstanding any other provision of law, the Secretary 
may, at the request or consent of a Native Hawaiian organization, 
revise or amend any contract entered into by the Secretary with 
such organization under this subsection as necessary to carry out 
the purposes of this subsection. 
Reports. 
"(9XA) For each fiscal year during which a Native Hawaiian 
organization receives or expends funds pursuant to a contract en-
tered into under this subsection, such organization shall submit to 
the Secretary a quarterly report on— 
"(i) activities conducted by the organization under the 
contract, 
"(ii) the amounts and purposes for which Federal funds were 
expended, 
and 
"(iii) such other information as the Secretary may request. 
"(B) The reports and records of any Native Hawaiian organization 
which concern any contract entered into under this subsection shall 
be subject to audit by the Secretary and the Comptroller General of 
the United States. 
"(10) The Secretary shall allow as a cost of any contract entered 
into under this subsection the cost of an annual private audit 
conducted by a certified public accountant. 
"(11) The authority of the Secretary to enter into contracts under 
this subsection shall be to the extent, and in amounts, provided for 
in appropriation Acts. 
"(h) For purposes of this subsection— 
"(1) The term 'Native Hawaiian' means any individual who— 
"(A) is a citizen of the United States, 
"(B) is a resident of the State of Hawaii, and 
"(C) is a descendant of the aboriginal people who, prior to 
1778, occupied and exercised sovereignty in the area that 
now constitutes the State of Hawaii, as evidenced by— 
"(i) genealogical records, 
"(ii) Kupuna (elders) or Kama'aina (long-term 
community residents) verification, or 
"(iii) birth records of the State of Hawaii. 
"(2) The term 'Native HawaiiEui organization' means any 
organization— 
"(A) which serves and represents the interests of Native 
Hawaiians, 
"(B) which is recognized by the Department of Health of 
the State of Hawaii, the Office of Hawaiian Affairs of the 
State of Hawaii, and E Ola Mau for the purpose of plan-
ning, conducting, or administering programs (or portion of 
programs) authorized under this Act for Native Hawaiians, 
and 
PUBLIC LAW 100-713—NOV. 23, 1988 
102 STAT. 4811 
"(C) in which Native Hawaiian health professionals 
significantly participate in the planning, mansigement, 
monitoring, and evaluation of health services. 
"(i) There are authorized to be appropriated $750,000 for each of 
the fiscal years 1990, 1991, 1992, and 1993, for the purpose of 
carrying out the provisions of this subsection. 
"(j) The programs and services established by this section shall not 
be administered by or through the Indian Health Service nor shall 
any funds appropriated to the Indian Health Service be used to 
supplement funding of such programs and services.". 
REIMBURSEMENT OF CERTAIN EXPENSES; RESEARCH 
SEC. 204. Title II, as amended by section 203(c), is further amended 
by adding at the end thereof the following new sections: 
"REIMBURSEMENT FROM CERTAIN THIRD PARTIES OF COSTS OF HEALTH 
SERVICES 
"SEC. 206. (a) The United States shall have the right to recover the 
25 use I62ie. 
re£isonable expenses incurred by the Secretary in providing health 
services, through the Service, to any individual to the same extent 
that such individual, or any nongovernmental provider of such 
services, would be eligible to receive reimbursement or indemnifica-
tion for such expenses i
f
— 
"(1) such services had been provided by a nongovernmental 
provider, and 
"(2) such individual had been required to pay such expenses 
and did pay such expenses. 
"(b) Subsection (a) shall provide a right of recovery against any 
State, or any political subdivision of a State, only if the injury, 
illness, or disability for which health services were provided is 
covered under— 
"(1) workers' compensation laws, or 
"(2) a no-fault automobile accident insurance plan or 
program. 
"(c) No law of any State, or of any political subdivision 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 
under subsection (a). 
"(d) No action taken by the United States to enforce the right of 
recovery provided under subsection (a) shall affect the right of any 
person to any damages (other th£ui damages for the cost of health 
services provided by the Secretary through the Service). 
"(e) The United States may enforce the right of recovery provided 
under subsection (a) by— 
"(1) intervening or joining in any civil action or proceeding 
brought— 
"(A) by the individual for whom health services were 
provided by the Secretary, or 
"(B) by any representative or heirs of such individual, or 
"(2) instituting a separate civil action, after providing to such 
individual, or to the representative or heirs of such individual, 
notice of the intention of the United States to institute a 
separate civil action. 
102 STAT. 4812 
PUBLIC LAW 100-713—NOV. 23, 1988 
"CREDITING OF REIMBUBSEMENTO 
25 use I62if 
"SEC 207. (a) Except as provided in section 202(d), titie IV, and 
section 713 of tiiis Act, 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 tiie Service or by a tribe or tribal organization 
under a contract pursuant to the Indian Self-Determination Act 
shall be retained by the Service or that tribe or tribal oiganization 
and shall be available for the facilities, and to carry out the pro-
grams, of the Service or that tribe or tribal organization to provide 
heedth care services to Indians. 
"(b) The Service may not ofibet or limit the amount of funds 
obl^ted to any service unit or any entity under contract with the 
Service because of the receipt of reimbursements under sub-
section (a). 
"HEALTH SERVICES RESEARCH 
25 use I62ig 
"ggc. 208. Of the amounts appropriated for the Service in any 
fiscal year, other than amounts made available for the Indian 
Health Care Improvement Fund, not less than $200,000 shall be 
available only for research to further the performance of the health 
service responsibilities of the Service. Indian tribes and tribal 
organizations contracting with the Service under the authority of 
the Indian Self-Determination Act shall be given an equal oppor-
tunity to compete for, and receive, research funds under this 
section.". 
TITLE in—HEALTH FAdLTTIES 
CONSULTATION; CLOSURE OF FACILITIES; REPORTS 
SEC. 301. Section 301 (25 U.S.C. 1631) is amended to read as 
follows: 
"CONSULTATION; CLOSURE OF FACUJTIES; REPORTS 
"Ssa 301. (a) Prior to the expenditure of, or the making of any 
firm commitment to expend^ any funds appropriated for ti^e plan-
ning, design, construction, or renovation of facilities pursuant to the 
Act of November 2, 1921 (25 U.S.C. 13), popularly known as the 
Snyder Act, the Secretary, acting through the Service, shall— 
"(1) consult with any Indian tribe that would be significantiy 
affected by such expendituro for the purpose of determining 
and, whenever practicable, honoring tribal preferences concern-
ing size, location, type, and other characteristics of any facility 
on whidi such expenditure is to be made, and 
"(2) ensure, whenever practicable, that such facility meets the 
standards of the Joint (>ommission on Accreditation of Hos-
pitals by not later than 1 year after the date on which the 
construction or renovation of such facility is completed. 
"(bXD Notwithstanding any provision of law other than this 
subsection, no Service hospital or other outpatient health care 
facility of the Service, or any portion of such a hospital or facility, 
may be closed if the Secretary has not submitted to the Ck>ngress at 
least 1 year prior to the date such hospital or facility (or portion 
thereof) is proposed to be closed an evaluation of the impact of such 
PUBLIC LAW 100-713—NOV. 23, 1988 
102 STAT. 4813 
proposed closure which specifies, in addition to other consider-
ations— 
"(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 i)opu-
lation served by such hospital or facility after such closure; 
"(D) the availability of contract health care funds to maintain 
existing levels of service; and 
"(E) the views of the Indian tribes served by such hospital or 
facility concerning such closure. 
"(2) Paragraph (1) shall not apply to any temporary closure of a 
facility or of any portion of a faolity if such closure is necessary for 
medical, environmental, or safety reasons. 
"(c) The President shall include with the budget submitted under 
section 1105 of title 31, United States Code, for each of the fiscal 
years 1990,1991, and 1992, program information documents for the 
construction of 10 Indian health facilities which— 
"(1) comply with applicable construction standards, and 
"(2) have been approved by the Secretary. 
"(dXD The Secretary shall submit to the Congress an annual 
report which sets forth— 
"(A) the current health facility priority system of the Service, 
"(B) the planning, design, construction, and renovation needs 
for the 10 top-priority inpatient care facilities and the 10 top-
priority ambulatory care facilities (together vdth required staff 
quarters), 
"(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 facility priority system. 
"(2) The first report required under paragraph (1) shall be submit-
ted by no later than the date that is 180 days after the date of 
enactment of the Indian Health Care Amendbnents of 1988 and, 
b^inning in 1990, each subsequent annual report shall be submitted 
by the date that is 60 days after the date on which the President 
submits the budget to the Congress under section 1105 of title 31, 
United States Code. 
"(3) In preparing each report required imder paragraph (1) (other 
than the initial report), the Secretary shall— 
"(A) consult with Indian tribes and tribal organizations 
including those tribes or tribal organizations operating healtJi 
programs or facilities under any contract entered into with tiie 
Service under the Indian Self-Determination Act, and 
"(B) review the needs of such tribes and tribal oiganizations 
for inpatient and outpatient facilities, including their needs for 
renovation and expansion of costing facilities. 
"(4) For purposes of this subsection, the Secretary shall, in 
evaluating tiie needs of facilities operated under any contract en-
tered into with the Service under the Indian Self-Determination 
Act, use the same criteria that the Secretary uses in evaluating the 
needs of facilities operated directly by the Service. 
"(5) Tlie Secretary shall ensure that the planning, design, 
construction, and renovation needs of Service and non-Service facili-
ties which are the subject of a contract for health services entered 
into with the Service under the Indian Self-Determination Act are 
President of U.S. 
Reports. 
102 STAT. 4814 
PUBLIC LAW 100-713—NOV. 23, 1988 
fully and equitably integrated into the development of the health 
facility priority system. 
"(e) All fund^ appropriated under the Act of November 2,1921 (25 
U.S.C. 13), for the planning, design, construction, or renovation of 
health facilities for the benefit of an Indian tribe or tribes shall be 
subject to the provisions of sections 102 and 103(b) of the Indian Self-
Determination Act.". 
SAFE WATER AND SANITARY WASTE DISPOSAL FACILITIES 
SEC. 302. Section 302 (25 U.S.C. 1632) is amended to read as 
follows: 
"SAFE WATER AND SANITARY WASTE DISPOSAL FACILITIES 
"SEC. 302. (a) The Congress hereby finds and declares that— 
"(1) the provision of safe water supply systems and sanitary 
sewage and solid waste disposal systems is primarily a health 
consideration and function; 
"(2) Indian people suffer an inordinately high incidence of 
disease, injury, and illness directly attributable to the absence 
or inadequacy of such systems; 
"(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 systems £md other 
preventive health measures; 
"(4) many Indian homes and communities still lack safe water 
supply systems and sanitary sewage and solid waste disposal 
systems; and 
"(5) it is in the interest of the United States, and it is the 
policy of the United States, that all Indian communities and 
Indian homes, new and existing, be provided with safe and 
adequate water supply systems and sanitary sewage w£iste dis-
posal systems as soon as possible. 
"(bXD In furtherance of the findings and declarations made in 
subsection (a), Congress reaffirms the primary 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, acting through the Service, is authorized to 
provide under section 7 of the Act of August 5, 1954 (42 U.S.C. 
2004a)— 
"(A) financial and technical assistcuice to Indian tribes and 
communities in the establishment, training, and equipping of 
utility oi^anizations to operate and maintain Indian sanitation 
facilities; 
"(B) ongoing technical assistance and training in the manage-
ment of utility organizations which operate and maintain sani-
tation facilities; and 
"(C) operation and maintenance assistance for, and emer-
gency repairs to, tribal sanitation facilities when necessary to 
avoid a health hazard or to protect the Federal investment in 
sanitation facilities. 
"(3) Notwithstanding any other provision of law— 
"(A) the Secretary of Housing and Urban Affairs is authorized 
to transfer funds appropriated under the Housing and Commu-
PUBLIC LAW 100-713—NOV. 23, 1988 
102 STAT. 4815 
nity Development Act of 1974 (42 U.S.C. 5301, et seq.) to the 
Secretary of Health and Human Services, and 
ij r 
"(B) the Secretary of Health and Human Services 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) Beginning in fiscsd year 1990, the Secretary, acting through 
the Service, shall develop and begin implementation of a 10-year 
plan to provide safe water supply and sanitation sewage and solid 
waste disposal facilities to existing Indian homes and communities 
and to new and renovated Indian homes. 
"(d) The financial and technical capability of an Indian tribe or 
community to safely operate and maintain a sanitation facility shall 
not be a prerequisite to the provision or construction of sanitation 
facilities by the Secretary. 
"(e) The provisions of this section shall not diminish the primary 
responsibility of the Indian family, community, or tribe to establish, 
collect, and utilize reasonable user fees, or otherwise set aside 
funding, for the purpose of operating and maintaining sanitation 
facilities. 
"(f) Programs administered by Indian tribes or tribal orgemiza-
tions under the authority of the Indiem Self-Determination Act shall 
be eligible for— 
"(1) any funds appropriated pursuant to subsection (h), and 
"(2) any funds appropriated for the purpose of providing 
water supply or sewage disposal services, 
on an equal basis with programs that are administered directly by 
the Service. 
"(gXD The Secretary shall submit to the Congress an annual 
Reports. 
report which sets forth— 
"(A) the current Indian sanitation facility priority system of 
the Service; 
"(B) the methodology for determining sanitation deficiencies; 
"(C) the level of sanitation deficiency for each sanitation 
facilities project of each Indian tribe or community; 
"(D) the amount of funds necessary to raise all Indian tribes 
and communities to a level I sanitation deficiency; and 
"(E) the amount of funds necessary to raise all Indian tribes 
and communities to zero sanitation deficiency. 
"(2) The first report required under paragraph (1) shall be submit-
ted by no later than the date that is 180 days after the date of 
enactment of the Indian Health Care Amendments of 1988 and, 
beginning in 1990, each subsequent annual report shall be submitted 
by the date that is 60 days «rfter the date on which the President 
submits the budget to the Congress under section 1105 of title 31, 
United States Ckxie. 
"(3) 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 
organizations operating health care programs or facilities under any 
contract entered into with the Service under the Indian Self-Deter-
mination Act) to determine the sanitation needs of each tribe. 
"(4) The methodology used by the Secretary in determining sanita-
tion deficiencies for purposes of paragraph (1) shall be applied 
uniformly to all Indian tribes and communities. 
"(5) For purposes of this subsection, the sanitation deficiency 
levels for an Indian tribe or community are as follows: 
102 STAT. 4816 
PUBLIC LAW 100-713—NOV. 23, 1988 
"(A) level I is an Indian tribe or community with a sanitation 
system— 
"(i) which complies with all applicable water supply and 
pollution control laws, and 
"(ii) in which the deficiencies relate to routine replace-
ment, repair, or maintenance needs; 
"(B) level II is an Indian tribe or community with a semitation 
system— 
"(i) which complies with all applicable water supply and 
pollution control laws, and 
"(ii) in which the deficiencies relate to capital improve-
ments that are necessary to improve the facilities in order 
to meet the needs of such tribe or community for domestic 
sanitation facilities; 
"(C) level III is an Indian tribe or community with a sanita-
tion system which— 
"(i) has an inadequate or partial water supply and a 
sewage disposal facility that does not comply with ap-
plicable water supply and pollution control laws, or 
"(ii) has no solid waste disposal facility; 
"(D) level IV is an Indian tribe or community with a sanita-
tion system which lacks either a safe water supply system or a 
sewage disposal system; and 
"(E) level V is an Indian tribe or community that lacks a safe 
water supply and a sewage disposal system. 
"(6) For purposes of this subsection, any Indian tribe or commu-
nity that lacks the operation and maintenance capability to enable 
its sanitation system to meet pollution control laws may not be 
treated as having a level I or II sanitation deficiency. 
"(hXl) There are authorized to be appropriated for each of the 
fiscal years 1990, 1991, and 1992, $3,000,000 for the purpose of 
providing funds necessary to implement the responsibilities of the 
Service described in subsection (bX2). 
"(2) In addition to the amount authorized under paragraph (1), 
there are authorized to be appropriated for each of the fiscal years 
1990, 1991, and 1992, $850,000 for the sanitation service account of 
the Service which shall be used to carry out the responsibilities of 
the Service described in subsection (bX2).". 
USE OF NON-SERVICE FUNDS FOR RENOVATION 
SEC. 303. (a) Section 305 (25 U.S.C. 1634) is amended to read as 
follows: 
"EXPENDITURE OF NON-SERVICE FUNDS FOR RENOVATION 
"SEC. 305. (a) Notwithstanding any other provision of law, the 
Secretary is authorized to accept any major renovation or mod-
ernization by any Indian tribe of any Service facility, or of any other 
Indian health facility operated pursuant to a contract entered into 
under the Indiem Self-Determination Act, including— 
"(1) any plans or designs for such renovation or moderniza-
tion, and 
"(2) any renovation or modernization for which funds appro-
priated under any Federed law were lawfully expended, 
but only if the requirements of subsection (b) are met. 
PUBLIC LAW 100-713—NOV. 23, 1988 
102 STAT. 4817 
"(b) The requirements of this subsection are met with respect to 
any renovation or modernization if the renovation or moderniza-
tion— 
"(1) does not require or obligate the Secretary to provide any 
additional employees or equipment, 
"(2) is approved by the appropriate area director of the Serv-
ice, and 
"(3) is administered by the Indian tribe in accordance with 
the rules and r^ulations prescribed by the Secretary with 
respect to construction or renovation of Service facilities. 
"(c) A renovation or modernization shall not be authorized by this 
section if such renovation or modernization would require the diver-
sion of funds appropriated to the Service from any project which has 
a higher priority under the health facility priority system of the 
Service. 
"(d) If any Service facility which has been renovated or modern-
ized by an Indian tribe under this section ceases to be used as a 
Service facility during the 20-year period b^inning on the date such 
renovation or modernization is completed, such Indian tribe shall be 
entitled to recover from the United States an amount which bears 
the same ratio to the value of such facility at the time of such 
cessation as the value of such renovation or modernization Gess the 
total amount of any funds provided specifically for such facility 
under any Federal program tliat were expended for such renovation 
or modernization) bore to the value of such facility at the time of the 
completion of such renovation or modernization.". 
(b) The paragraph relating to administrative provisions of the 
Health Services Administration under the heading "Department of 
Health and Human Services" in title n of the matter contained in 
section 101(c) of PubUc Law 98-473 (98 Stat. 1864) is amended by 
25 use 1635. 
striking out tiie sixth proviso. 
BETHEL, ALASKA, HOSPITAL 
SEC. 304. Title m is amended by adding at the end thereof the 
following new section: 
"BETHEL, ALASKA, HOSPITAL 
"SEC. 306. (a) If a final administrative ruling by the Department of Reaij)roperty 
the Interior holds that the Bethel Native Corporation is entitled to 
conveyance under the Alaska Native Claims Settlement Act of the 
title to the real property described in subsection (dXD, such ruling 
shall be sul^ect to judicial review. 
"(b) The Secretary is authorized to enter into an agreement with 
Bethel Native Corporation for an exchange of the real property 
descxibed in subsection (dXD for— 
"(1) the lands described in subsection (dX2), or 
"(2) any other Federal property which Bethel Native Corpora-
tion woi^d have been able to select under the Alaska Native 
Claims Settlement Act 
"(c) If an agreement for the exchange of land is not entered into 
under subsection (b) before the date that is 90 days after t^e date on 
which a ruling described in subsection (a) becomes final and is no 
longer appealable, the Secretary shall, subject to the availability of 
funds provided by Appropriations Acts, purchase the lands de-
scribed in subsection (d)(1) at fair market value. 
25 u s e 1636. 
102 STAT. 4818 
PUBLIC LAW 100-713—NOV. 23, 1988 
"(dXD The real property referred to in subsection (a) is United 
States Survey Numbered 4000, other than the lands described in 
paragraph (2). 
"(2) The lands referred to in subsection 0)X1) are the lands identi-
fied as tracts A and B in the determination AA-18959 of the Bureau 
of Land Management issued on September 30,1983, pursuant to the 
Alaska Native Claims Settlement Act.". 
TITLE IV—ACCESS TO HEALTH SERVICES 
42 u s e 1396J 
note. 
42 u s e 1396J 
note. 
Health care 
facilities. 
42 u s e 1395qq 
note. 
MEDICAID PROVISIONS 
SEC. 401. (a) Subsection (c) of section 402 (42 U.S.C. 1396j, note) is 
amended— 
(1) by striking out "or skilled nuraing facility" and inserting 
in lieu thereof "skilled nursing facility, or any other t3T)e of 
facility which provides services of a type otherwise covered 
under a State plan for medical assistance approved under title 
XIX of the Social Security Act", 
(2) by striking out "a State plan approved under title XIX of 
the Social Security Act" and inserting in lieu thereof "such a 
State plan", and 
(3) by striking out "The preceding sentence shall" and insert-
ing in lieu thereof "In making pajnnents from such fund, the 
Secreta^ shall ensure that each service unit of the Indian 
Health Service receives at least 50 percent of the amounts to 
which the facilities of the Indian Health Service, for which such 
service unit makes collections, are entitled by reason of section 
1911 of the Social Security Act, if such amount is necessary for 
the purpose of making improvements in such facilities in order 
to achieve compliance with the conditions and requirements of 
title XIX of the Social Security Act. This subsection shall". 
(b) Subsection (b) of section 402 (42 U.S.C. 1396j, note) is repealed. 
(c) The amendments made by this section shall applv to services 
performed on or after the date of the enactment of this Act. 
DEMONSTRATION PROGRAM 
SEC. 402. Title IV is amended by adding at the end thereof the 
following new section: 
"DEMONSTRATION PROGRAM FOR DIRECT BIIXING OF MEDICARE, 
MEDICAID, AND OTHER THIRD PARTY PAYORS 
"SEC. 405. (a) The Secretary shall establish a demonstration pro-
gram under which Indian tribes, tribal organizations, and Alaska 
Native health organizations, which are contracting the entire oper-
ation of an entire hospital or clinic of the Service under the author-
ity of the Indian Self-Determination Act, shall directly bill for, and 
receive pajmient for, health care services provided by such hospital 
or clinic for which payment is made under title XVIII of the Social 
Security Act (medicare), under a State plan for medical assistance 
approved under title XIX of the Social Security Act (medicaid), or 
from any other third-party payor. The last sentence of section 
1905(b) of the Social Security Act shall apply for purposes of the 
demonstration program. 
"(bXD Each hospital or clinic participating in the demonstration 
program described in subsection (a) shall be reimbursed directly 
PUBLIC LAW 100-713—NOV. 23, 1988 
102 STAT. 4819 
under the medicare and medicaid pr(^ams for services furnished, 
without r^ard to the provisions of section 1880(c) of the Social 
Security Act and sections 402(c) and 713(bX2XA) of this Act, but all 
funds so reimbursed shall first be used by the hospital or clinic for 
the purpose of making any improvements in the hospital or clinic 
that may be necessary to achieve or maintain compliance with the 
conditions and requirements applicable generally to facilities of 
such type under the medicare or medicaid program. Any funds so 
reimbursed which are in excess of the amount necessary to achieve 
or maintain such conditions or requirements shall be used— 
"(A) solely for improving the health resources deficiency level 
of the Indian tribe, and 
"(B) in accordance with the r^ulations of the Service 
appUcable to funds provided by the Service under any contract 
entered into under the Indian Self-Determination Act. 
"(2) The amounts paid to the hospitals and clinics participating in 
the demonstration program desmbed in subsection (a) shall be 
subject to all auditing requirements applicable to programs adminis-
tered directly by the Service and to facilities participating in the 
medicare and medicaid programs. 
"(3) The Secretary shall monitor the performance of hospitals and 
clinics participating in the demonstration program described in 
subsection (a), and shall require such hospitals and clinics to submit 
reports on the pr(^ram to the Secretary on a quarterly basis (or 
more frequently if the Secretary deems it to be necessary). 
"(4) Notwithstanding section 1880(c) of the Social Security Act or 
section 402(c) of this Act, no payment may be made out of the special 
fiind described in section 188(Kc) of the Social Security Act, or 
section 402(c) of this Act, for the benefit of any hospital or clinic 
participatii^ in the demonstration pn^ram described in subsection 
(a) during the period of such participation. 
"(cXD In order to be considered for participation in the demonstra-
tion program described in subsection (a), a hospital or clinic must 
submit an application to the Secretary which establishes to the 
satisfaction of the Secretary that— 
"(A) the Indian tribe, tribal organization, or Alaska Native 
health organization contracts the entire operation of the Service 
facility; 
"(B) the facility is eligible to participate in the medicare and 
medicaid programs under sections 1880 and 1911 of the Social 
Security Act; 
"(Q the fadlity meets any requirements which apply to pro-
grams operated directly by tlie Service; and 
"(D) tiie facility is acoredited by the Joint Commission on 
Accreditation of Hospitals, or has submitted a plan, which has 
been approved by the Seoretary, for achieving such accredita-
tion prior to October 1,1990. 
"(2) From among the qualified applicants, the Secretary shall, 
prior to October 1, 1989, select no more than 4 facilities to partici-
pate in the demonstration program described in subsection (a). The 
demonstration program described in subsection (a) shall b^in by no 
later than October 1,1991, and end on September 30,1995. 
"(dXl) Upon the enactment of the Indian Health d^are Amend-
ments of 1988, the Secretary, acting through the Service, shall 
commence an examination of— 
"(A) any administrative changes which may be necessary to 
allow direct billing and reimbursement under the demonstra-
102 STAT. 4820 
PUBLIC LAW 100-713—NOV. 23, 1988 
Reports. 
Contracts. 
tion program described in subsection (a), including any agree-
ments with States which may be necessary to provide for such 
direct billing under the medicaid program; and 
"
C
B
) any changes which may be necessary to enable partici-
pants in such damonstration program to provide to the Service 
medical records information on patiente served under such 
demonstration program which is consistent with the medical 
records information system of the Service. 
"(2) Prior to the commencement of the demonstration program 
described in subsection (a), the Secretary shall implement all 
changes required as a resiilt of the examinations conducted under 
paragraph (1). 
"(3) F^or to October 1, 1990, the Secretary shall determine any 
accounting information which a participant in the demonstration 
program described in subsection (a) would be required to r^wrt. 
"(e) The Secretary shall submit a final report at the end of fiscal 
year 1995, on the activities carried out under the demonstration 
program described in subsection (a) which shall include an evalua-
tion of whether such activities have fulfilled the objectives of such 
program. In such report the Secretary shall provide a recommenda-
tion, based upon the results of such demonstration pn^ram, as to 
whether direct billing of, and reimbursement by, the medicare and 
medicaid programs and other third-party payors should be 
authorized for all Indian tribes and Alaska Native health oiganiza-
tions which are contracting the entire operation of a facility of the 
Service. 
"(0 The Secretary shall provide for the retrocession of any con-
tract entered into between a participant in the demonstration pro-
gram described in subsection (a) and the Service under the authority 
of the Indian Self-Determination Act All cost accounting and billing 
autii<nrity shall be retroceded to the Secretary upon the Secretary's 
acceptance of a retroceded contract". 
TITLE V—URBAN INDIAN HEALTH SERVICES 
REVISION OF PROGRAM 
SEC. 501. Titie V (25 UJS.C. 1651, et seq.) is amended to read as 
follows: 
'TTTLE V—HEALTH SERVICES FOR URBAN INDIANS 
PURP08K 
25 use 1651. 
"SBC. 501. The purpose of this title is to establish programs in 
urban centers to make health services more accessible to urban 
Indians. 
''CONTRACTS W I T H U R R A N INDIAN ORGANIZATIONS 
25 use 1652. 
**SBC. 502. Under authority of the Act of November 2, 1921 (25 
U.S.C. 13), popularly known as the Snyder Act, the Secretary, 
thzou^ the Service, shall enter into contracts with urban Indian 
organizations to assist such organizations in the establishment and 
administration, within the urban centers in which such organiza-
tions are situated, of programs which meet the requirements set 
forth in this titie. The Secretary, through the Service, shall include 
such conditions as the Secretary considers necessary to effect the 
PUBLIC LAW 100-713—NOV. 23, 1988 
102 STAT. 4821 
purpose of this title in any contract which the Secretary enters into 
with any urban Indian organization pursuant to this title. 
"CONTRACTS FOR THE PROVISION OF HEALTH CARE AND REFERRAL 
SERVICES 
"SEC. 503. (a) Under authority of the Act of November 2, 1921 (25 25 use 1653. 
U.S.C. 13), popularly known as the Snyder Act, the Secretary, 
through the Service, shall enter into contracts with urban Indian 
organizations for the provision of health care and referral services 
for urban Indians residing in the urban centers in which such 
organizations are situated. Any such contract shall include require-
ments that the urban Indian organization successfully undertake 
to— 
"(1) estimate the population of urban Indians residing in the 
urban center in which such organization is situated who are or 
could be recipients of health care or referral services; 
"(2) estimate the current health status of urbsm Indians 
residing in such urban center; 
"(3) estimate the current health care needs of urban Indieins 
residing in such urban center; 
"(4) identify all public and private health services resources 
within such urban center which are or may be available to 
urban Indians; 
"(5) determine the use of public and private health services 
resources by the urban Indians residing in such urban center; 
"(6) assist such health services resources in providing services 
to urban Indians; 
"(7) assist urban Indians in becoming familiar with and utiliz-
ing such health services resources; 
"(8) provide basic health education, including health pro-
motion and disease prevention education, to urban Indians; 
"(9) establish and implement training programs to accomplish 
the referral and education tasks set forth in paragraphs (6) 
through (8) of this subsection; 
"(10) identify gaps between unmet health needs of urban 
Indians and the resources available to meet such needs; 
"(11) make recommendations to the Secretary and Federal, 
State, local, and other resource agencies on methods of improv-
ing health service programs to meet the needs of urban Indisms; 
and 
"(12) 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 regulation pre- Regulations. 
scribe the criteria for selecting urban Indian organizations to enter 
into contracts under this section. Such criteria shall, among other 
factors, include— 
"(1) the extent of unmet health care needs of urban Indians in 
the urban center involved; 
"(2) the size of the urban Indian population in the urban 
center involved; 
"(3) the accessibility to, and utilization of, health care services 
(other than services provided under this title) by urban Indians 
in the urban center involved; 
"(4) the extent, if any, to which the activities set forth in 
subsection (a) woiild duplicate— 
102 STAT. 4822 
PUBLIC LAW 100-713—NOV. 23, 1988 " 
"(A) any previous or current public or private health 
services project in an urbcin center that was or is funded in 
a manner other than pursuant to this title; or 
"(B) any project funded under this title; 
"(5) the capability of an urban Indian organization to perform 
the activities set forth in subsection (a) and to enter into a 
contract with the Secretary under this section; 
"(6) the satisfactory performance and successful completion 
by an urban Indian organization of other contracts with the 
Secretary under this title; 
"(7) the appropriateness and likely effectiveness of conducting 
the activities set forth in subsection (a) in an urban center; and 
"(8) the extent of existing or likely future participation in the 
activities set forth in subsection (a) by appropriate health and 
health-related Federal, State, local, and other agencies. 
"CONTRACTS FOR THE DETERMINATION OF UNMET HEALTH CARE NEEDS 
25 use 1654. 
"SEC. 504. (a) Under authority of the Act of November 2,1921 (25 
U.S.C. 13), popularly known as the Snyder Act, the Secretsuy, 
through the Service, may enter into contracts with urban Indian 
organizations situated in urban centers for which contracts have not 
been entered into under section 503. The purpose of a contract under 
this section shall be the determination of the matters described in 
subsection (bXD in order to assist the Secretary in assessing 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 under section 503 with the urban Indian 
organization with which the Secretary has entered into a contract 
under this section. 
"(b) Any contract entered into by the Secretary under this section 
shall include requirements that— 
"(1) the urban Indian organization successfully undertake 
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 clauses (2), (3), 
(4), and (8) of section 503(b); and 
"(2) the urban Indian organization complete performance of 
the contract within one year after the date on which the 
Secretary and such organization enter into such contract. 
"(c) The Secretary may not renew any contract entered into under 
this section. 
"EVALUATIONS; CONTRACT RENEWALS 
25 use 1655. 
"SEC. 505. (a) The Secretary, through the Service, shall develop 
procedures to evaluate compliance with, and performance of con-
tracts entered into by urban Indian organizations under this title. 
Such procedures shall include provisions for carrying out the 
requirements of this section. 
Q
>
) The Secretary, through the Service, shall conduct an annual 
onsite evaluation of each urban Indian organization which has 
entered into a contract under section 503 for purposes of determin-
ing the compliance of such organization with, and evaluating the 
performance of such organization under, such contract. 
PUBLIC LAW 100-713—NOV. 23, 1988 
102 STAT. 4823 
"(c) If, as a result of the evaluations conducted under this section, 
the Secretary determines that an urban Indian organization hsis not 
complied with or satisfactorily performed a contract under section 
503, the Secretary shall, prior to renewing such contract, attempt to 
resolve with such organization the areas of noncompliance or 
unsatisfactory performance and modify such contract to prevent 
future 
occurrences of such noncompliance or 
unsatisfactory 
performance. If the Secretary determines that such noncompliance 
or unsatisfactory performance cannot be resolved and prevented in 
the future, the Secretary shall not renew such contract with such 
organization and is authorized to enter into a contract under section 
503 with another urban Indian organization which is situated in the 
same urban center as the urban Indian organization whose contract 
is not renewed under this section. 
"(d) In determining whether to renew a contract with an urban 
Indian organization under section 503 which has completed perform-
ance of a contract under section 504, the Secretary shall review the 
records of the urban Indian organization, the reports submitted 
under section 507, and, in the case of a renewal of a contract under 
section 503, shall consider the results of the onsite evaluations 
conducted under subsection (b). 
"OTHER CONTRACT REQUIREMENTS 
"SEC. 506. (a) Contracts with urban Indian organizations entered 
25 use 1656. 
into pursuant to this title shall be in accordance with all Federal 
contracting laws and regulations 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.). 
"(b) Payments under any contracts pursuant to this title may be 
made in advance or by way of reimbursement and in such install-
ments and on such conditions as the Secretary deems necessary to 
carry out the purposes of this title. 
"(c) Notwithstanding any provision of law to the contrary, 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. 
"(d) In connection with any contract entered into pursuant to this 
title, the Secretary may permit an urban Indian organization to 
utilize, in carr3dng out such contract, existing facilities owned by the 
Federal Government within the Secretary's jurisdiction under such 
terms and conditions as may be agreed upon for the use and 
maintenance of such facilities. 
"(e) Contracts with urban Indian organizations and regulations 
adopted pursusmt to this title shall include provisions to assure the 
fair and uniform provision to urban Indians of services and assist-
ance under such contracts by such organizations. 
"(f) Urban Indians, as defined in section 4(f) of this Act, shall be 
eligible for health care or referral services provided pursuant to this 
title. 
"REPORTS AND RECORDS 
"SEC. 507. (a) For each fiscal year during which an urban Indian 
25 USC 1657. 
organization receives or expends funds pursuaiit to a contract 
102 STAT. 4824 
PUBLIC LAW 100-713—NOV. 23, 1988 
entered into pursueint to this title, such organization shall submit to 
the Secretary a quarterly report including— 
"(1) in the case of a contract under section 503, information 
gathered pursuant to clauses (10) and (11) of subsection (a) of 
such section; 
"(2) information on activities conducted by the organization 
pursuant to the contract; 
"(3) an accounting of the eimounts and purposes for which 
Federal funds were expended; and 
"(4) such other information as the Secretary may request. 
"(b) The reports and records of the urban Indian organization with 
respect to a contract 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 contract entered 
into under section 503 the cost of an annual private audit conducted 
by a certified public accountant. 
"LIMITATION ON CONTRACT AUTHORITY 
25 use 1658. 
"SEC. 508. The authority of the Secretary to enter into contracts 
under this title shall be to the extent, and in an amount, provided 
for in appropriation Acts.". 
U R B A N INDIAN ORGANIZATION 
SEC. 502. Subsection (h) of section 4 (25 U.S.C. 1603(h)) is amended 
by inserting "urban" after "governed by an". 
TITLE VI—ORGANIZATIONAL IMPROVEMENTS 
ESTABLISHMENT OF THE INDIAN HEALTH SERVICE AS AN AGENCY OF 
THE PUBUC HEALTH SERVICE 
SEC. 601. (a) Title VI (25 U.S.C. 1661) is amended to read as 
follows: 
"TITLE VI—ORGANIZATIONAL IMPROVEMENTS 
"ESTABLISHMENT OF THE INDIAN HEALTH SERVICE AS AN AGENCY OF 
THE PUBUC HEALTH SERVICE 
25 use 1661. 
"SEC. 601. (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 the Public Health Service of the Department of 
Health and Human Services the Indian Health Service. The Indian 
Reports. 
Health Service shall be administered by a Director, who shall be 
appointed by the Secretary. The Director of the Indian Health 
Service shall report to the Secretary through the Assistant Sec-
retary for Health of the Department of Health and Human Services. 
"(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 Department. 
"(c) The Secretary shall carry out through the Director of the 
Indian Health Service— 
PUBLIC LAW 100-713—NOV. 23, 1988 
102 STAT. 4825 
"(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 tiie Indian Health Service on such day; 
"(2) all functions of the Secretary relating to the maintenance 
and operation of hospital and hcialth facilities for Indians and 
the planning for, and provision and utilization of, health serv-
ices for Indians^ and 
"(3) all health programs under which health care is provided 
to Indians based upon their status as Indians which are 
administered by the Secretaxy, including (but not limited to) 
programs under— 
"(A) thia 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 (25 U.S.C. 2005, et seq.); 
and 
"
(
E
D the Indian Self-Determmation Act (25 U.S.C. 450f, 
et seq.). 
"(dXD The Secretary, acting through the Director of the Indian 
Health Service, 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; 
"(B) to enter into contracts for the procurement of goods and 
services to carry out the functions of the Service; and 
"(Q to manage, expend, and obligate all funds appropriate 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 sub-
section (a). 
"AITTOMATED MANAGEMENT INFORMATION SYSTEM 
"SBC. 602. (aXD The Secretary shall establish an automated 25 use 1662. 
management information system for the Service. 
"(2) The information system established under paragraph (1) shall 
include— 
"(A) a financial management system, 
"(B) a patient care information system for each area served by 
the Service, 
"(Q a privacy component that protects the privacy of patient 
information held by, or on behalf of, the Service, and 
"(D) a services4>ased cost accounting component that provides 
estimates of the costs associated with the provision of specific 
medical treatments or services in each area office of the Service. 
"(3) By no later than September 30, 1989, the Secretary shall Reports. 
submit a report to Congress setting forth— 
"(A) the activities which have been undertaken to establish 
an autmnated management information system, 
"(B) the activities, if any, which remain to be undertaken to 
complete the implementation of an automated management 
information system, and 
102 STAT. 4826 
PUBLIC LAW 100-713—NOV. 23, 1988 
California. 
25 u s e 1661 
note. 
Effective date. 
25 u s e 1661 
note. 
"(C) the amount of funds which will be needed to complete the 
implementation of a memagement information system in the 
succeeding fiscal years. 
"(bXD The Secretary shall provide each Indian tribe and tribal 
organization that provides headth services under a contract entered 
into with the Service under the Indian Self-Determination Act 
automated management information systems which— 
"(A) meet the management information needs of such Indian 
tribe or tribal organization with respect to the treatment by the 
Indian tribe or tribal organization of patients of the Service, and 
"(B) meet the management information needs of the Service. 
"(2) The Secretary shall reimburse each Indian tribe or tribal 
organization for the part of the cost of the operation of a system 
provided under paragraph (1) which is attributable to the treatment 
by such Indian tribe or tribal organization of patients of the Service. 
"(3) The Secretary shall provide sjrstems under paragraph (1) to 
Indian tribes and tribal organizations providing health services in 
California by no later than September 30,1990. 
"(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.". 
(b) All personnel, records, equipment, facilities, and interests in 
property that are administered by the Indian Health Service on the 
day before the date on which the amendments made l^ this section 
take effect shall be transferred to the Indian Health Service estab-
lished by the amendment made by subsection (a) of this section. All 
transfers must be accomplished within 9 months of the date of 
enactment of this section. The Secretary is authorized to waive the 
Indian preference laws on a case-by-case basis for temporary trans-
fers involved in implementing this section during such 9-month 
period. 
(cXD Except as provided in paragraph (2), section 601 of the Indian 
Health Care Improvement Act added by subsection (a) of this section 
shall take effect 9 months from the date of the enactment of this 
section. 
(2) Notwithstanding subsections (b) and (cXD, 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. 
(d) Section 5316 of title 5, United States Code, is amended by 
adding at the end thereof the following: 
"Director, Indian Health Service, Department of Health and 
Human Services.". 
TITLE Vn—MISCELLANEOUS PROVISIONS 
LEASING AND OTHER CONTRACTS 
SEC. 701. Section 704 (25 U.S.C. 1674) is amended— 
(1) by striking out "Notwithstanding", and inserting in lieu 
thereof "(a) Notwithstanding", and 
(2) by adding at the end thereof the following new subsection: 
"0)) Tlie Secretary may enter into leases, contracts, and other 
legal agreements with Indian tribes or tribal organizations which 
hold— 
"(1) title to; 
"(2) a leasehold interest in; or 
PUBLIC LAW 100-713—NOV. 23, 1988 
102 STAT. 4827 
"(3) 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 delivery of health services 
by the Service or by pn^ams operated by Indian tribes or tribal 
organizations to compensate such Indian tribes or tribal organiza-
tions^ for costs associated with the use of such facilities for such 
purposes. Such costs include rent, depreciation based on the useful 
life of the building, principal and interest paid or accrued, operation 
and maintenance expenses, and other expenses determined by r^u-
lation to be allowable.". 
ARIZONA AS A CONTRACT HEALTH SERVICE DEIIVERT AREA 
SEC. 702. (a) Subsection (a) of section 708 (25 U.S.C. 1678(a)) is 
amended— 
.(1) by striking out "1984" and inserting in lieu thereof "1991", 
and 
(2) by striking out "Indians in such State" and inserting in 
Heu thereof "members of federally recognized Indian tribes of 
Arizona", 
(b) Section 708 (25 U.S.C. 1678(c)) is amended by striking out 
sulxsection (c). 
EUGIBnJTT OF CALIFORNIA INDIANS 
SEC. 703. Section 709 (25 U.S.C. 1679) is amended to read as 
follows: 
"EUGiBiLrry O F CALIFORNIA I N D I A N S 
"SEC. 709. (aXD In order to provide the (Ik)ngress with sufficient 
Reports. 
data to determine which Indians in the State of CJalifomia should be 
eligible for health services provided by the Service, the Secretary 
shsdl, by no later than the date that is 3 years after the date of 
enactment of the Indian Health Care Amendments of 1988, prepare 
and submit to the Congress a report which sets forth— 
"(A) a determination by the Secretary of the number of 
Indians described in subsection (bX2), and the number of Indians 
described in subsection (bX3), who are not members of an Indian 
tribe recognized by the F^eral Covemment, 
"(B) the geographic location of such Indians, 
"
(
C
O the Indian tribes of which such Indians are members, 
"(D) an assessment of the current health status, and health 
care needs, of such Indians, and 
"(E) an assessment of the actual availability and accessibility 
of alternative resources for the health care of such Indians that 
such Indians would have to rely on if the Service did not provide 
for the health care of such Indians. 
"(2) The report required under paragraph (1) shall be prepared by 
the Secretary— 
"(A) in consultation with the Secretary of the Interior, and 
"(B) with the assistance of the tribal health programs provid-
ing services to the Indians described in paragraph (2) or (3) of 
subsection (b) who are not members of any Indian tribe recog-
nized by the Federal Government. 
"(b) Until such time as any subsequent law may otherwise pro-
vide, the following California Indians shall be eligible for health 
services provided by the Service: 
"(1) Any member of a federally recognized Indian tribe. 
102 STAT. 4828 
PUBLIC LAW 100-713—NOV. 23, 1988 
"(2) Any descendant of an Indian who was residing in Califor-
nia on June 1,1852, but only if such descendant— 
"(A) is living in California, 
"(B) is a member of the Indian community served by a 
local program of the Service, and 
"(C) is regarded as an Indian by the community 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 Indi£m in California who is listed on the plans for 
distribution of the assets of California rancherias and reserva-
tions under the Act of August 18, 1958 (72 Stat. 619), and any 
descendant of such an Indian. 
"(c) Nothing in this section may be construed as expanding the 
eligibility of California Indians for health services provided by the 
Service beyond the scope of eligibility for such health services that 
applied on May 1,1986.^'. 
CALIFORNIA AS A CONTRACT HEALTH SERVICE DELIVERY AREA 
SEC. 704. Section 710 (25 U.S.C. 1680) is amended to read as 
follows: 
"CAUPORNIA AS A CONTRACT HEALTH SERVICE DELIVERY AREA 
"SEC. 710. The State of California, excluding the counties of 
Alameda, Contra Costa, Los Angeles, Marin, Orange, Sacramento, 
San Francisco, San Mateo, Santa Clara, Kern, Merced, Monterey, 
Napa, San Benito, San Joaquin, San Luis Obispo, Santa Cruz, 
Solano, Stanislaus, and Ventura shall be designated as a contract 
health service delivery area by the Service for the purpose of 
providing contract health services to Indians in such State.". 
CONTRACT HEALTH FACILITIES 
SEC. 705. Title VII is amended by adding at the end thereof the 
following new section: 
"CONTRACT HEALTH FACILITIES 
25 use 1680a. 
"SEC. 711. The Service shall provide funds for health care pro-
grams and facilities operated by tribes and tribal organizations 
under contracts with the Service entered into under the Indian Self-
Determination Act— 
"(1) for the maintenance and repair of clinics owned or leased 
by such tribes or tribal organizations, 
"(2) for employee training, 
"(3) for cost-of-living increases for employees, and 
"(4) for any other expenses relating to the provision of health 
services, 
on the same basis as such funds are provided to programs and 
facilities operated directly by the Service.'. 
NATIONAL HEALTH SERVICE CORPS 
SEC. 706. Title VII, as amended by section 705 of this Act, is 
further amended by adding at the end thereof the following new 
section: 
PUBLIC LAW 100-713—NOV. 23, 1988 
102 STAT. 4829 
Children and 
youth. 
25 u s e 1680c. 
NATIONAL HEALTH SERVICE CORPS 
"SEC. 712. The Secretary of Health and Human Services shall 
25 use I680b. 
not— 
"(1) remove a member of the National Health Service Corps 
from a health facility operated by the Indian Health Service or 
by a tribe or tribal organization under contract with the Indian 
Health Service under the Indian Self-Determination Act, or 
"(2) withdraw funding used to support such member, 
unless the Secretary, acting through the Service, has ensured that 
the Indians receiving services from such member will experience no 
reduction in services.". 
HEALTH SERVICES FOR INEUGIBLE PERSONS 
SEC. 707. (a) Title Vn, as amended by section 706 of this Act, is 
further amended by adding at the end thereof the following new 
section: 
"HEALTH SERVICES FOR INELIGIBLE PERSONS 
"SEC. 713. (aXD Any individual who— 
"(A) has not attained 19 years of age, 
"(B) is the natural or adopted cMld, step-child, foster-child, 
l^al ward, or orphan of an eligible Indian, and 
"(Q is not otherwise eligible for the 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 
allocation of, the health resources of the Service. If such an individ-
ual has been determined to be l^ally incompetent prior to attaining 
19 years of age, such individual shall remain eligible for such 
services until one year after the date such disability has been 
removed. 
"(2) Any spouse of an eligible Indian who is not an Indian, or who 
is of Indian descent but not otherwise eligible for the health services 
provided by the Service, shall be eligible for such health services if 
all of such spouses are made eligible, as a class, by an appropriate 
resolution of the governing body of the Indian tribe of the eligible 
Indian. The health needs of persons made eligible under this para-
graph shall not be taken into consideration by the Service in 
determining the need for, or allocation of, its health resources. 
"01>X1XA) The Secretary is authorized to provide health services 
under this subsection through health facilities 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— 
102 STAT. 4830 
PUBLIC LAW 100-713—NOV. 23, 1988 
"(D the provision of such health services will not result in 
a denial or diminution of health services to eligible Indians, 
and 
"(0) there is no reasonable alternative health facility or 
services, within or without the service area of such service 
unit, available to meet the health needs of such individuals. 
Contracts. 
"(B) In the case of health facilities operated under a contract 
entered into under the Indian Self-Determination Act, the govern-
ing body of the Indian tribe or tribal organization providing health 
services imder such contract is authorized to determine whether 
health services should be provided under such contract to individ-
uals who are not eligible for such health services under any other 
subsection of 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 considerations 
described in subparagraph (AXii)-
"(2XA) 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 Sec-
retary which, in the judgment of the Secretary, results in reimburse-
ment in an amount not less than the actual cost of providing the 
health services. Notwithstanding section 1880(c) of the Social Secu-
rity Act, section 402(c) of this Act, or any other provision of law, 
amounts collected under this subsection, including medicare or 
medicaid reimbursements under titles XVIII and XIX of the Social 
Security Act, shall be credited to the account of the faciUty provid-
ing the service and shall be used solely for the provision of health 
services within that facility. Amounts collected under this subsec-
tion shall be available for expenditure within such facility for not to 
exceed one fiscal year after the fiscal year in which collected. 
"(B) Health services may be provided by the Secretary through 
the Service under this subsection to an indigent person who woiHd 
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 govern-
ment agrees to reimburse the Service for the expenses incurred by 
the Service in providing such health services to such indigent 
person. 
"(3XA) In the case of a service area which serves only one Indian 
tribe, tiie authority of the Secretary to provide health services under 
paragraph (IXA) shall terminate at the end of the fiscal year 
succeeding the fiscal year in which the governing body of the Indian 
tribe revokes its concurrence to the provision of such health 
services. 
"(B) In the case of a multi-tribal service area, the authority of the 
Secretary to provide health services under paragraph (IXA) 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 provision 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 subsection of this section or under any 
other provision of law in order to— 
"(1) achieve stability in a medical emergency. 
Diseases. 
"(2) prevent the spread of a communicable disease or other-
Safety. 
ynsQ d ^ with a public health hazard. 
Contracts. 
State and local 
governments. 
PUBLIC LAW 100-713—NOV. 23, 1988 
102 STAT. 4831 
"(3) provide care to non-Indian women pregnant with an 
Women. 
eligible Indian's child for the duration of the pregnancy through 
post partum, or 
"(4) provide care to immediate family members of £m eligible 
person if such care is directly related to the treatment of the 
eligible person. 
"(d) Hospital privileges in health facilities operated and main-
tained by the Service or operated under a contract entered into 
under the Indian Self-Determination Act may be extended to non-
Service health care practitioners who provide services to persons 
described in subsection (a) or (b). Such non-Service health care 
practitioners may be regarded as employees of the Federal Govern-
ment 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 
services to eligible persons as a part of the conditions under which 
such hospital privileges are extended. 
"(e) For purposes of this section, the term 'eligible Indian' means 
any Indian who is eligible for health services provided by the 
Service without regard to the provisions of this section.". 
INFANT AND MATERNAL MORTALITY; FETAL ALCOHOL SYNDROME 
SEC. 708. Title VII, as amended by section 707 of this Act, is 
further amended by adding at the end thereof the following new 
section: 
INFANT AND MATERNAL MORTALITY; FETAL ALCOHOL SYNDROME 
"SEC. 714. (a) By no later than January 1,1990, the Secretary shall 
25 USC I680d. 
develop and begin implementation of a plan to achieve the following 
objectives by January 1,1994: 
"(1) reduction of the rate of Indian infant mortality in each 
area office of the Service to the lower of— 
"(A) twelve deaths per one thousand live births, or 
"(B) the rate of infant mortality applicable to the United 
States population as a whole; 
"(2) reduction of the rate of maternal mortality in each area 
office of the Service to the lower of— 
"(A) five deaths per one hundred thousand live births, or 
"(B) the rate of maternal mortality applicable to the 
United Stetes population as a whole; and 
"(3) reduction of the rate of fetal alcohol sjmdrome among 
Indians served by, or on behalf of, the Service to one per one 
thousand live births. 
"0)) The President shall include with the budget submitted under 
President of U.S. 
section 1105 of title 31, United Stetes (Dode, for each fiscal year a 
separate stetement which specifies the total amount obligated or 
expended in the most recently completed fiscal year to achieve each 
of the objectives described in subsection (a).". 
CONTRACT HEALTH SERVICES FOR THE TRENTON SERVICE AREA 
SEC. 709. Title VII, as amended by section 708 of this Act, is 
further amended by adding at the end thereof the following new 
section: 
102 STAT. 4832 
PUBLIC LAW 100-713—NOV. 23, 1988 
North Dakota. 
Montana. 
25 u s e 1680e. 
CONTRACT HEALTH SERVICES FOR THE TRENTON SERVICE AREA 
"SEC. 715. (a) The Secretary, acting through the Service, is di-
rected 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 Montana. 
"(b) Nothing in this section may be construed as expanding the 
eligibility of members of the Turtle Mountain Band of Chippewa 
Indians for health services provided by the Service beyond the scope 
of eligibility for such health services that applied on May 1, 1986.". 
INDIAN HEALTH SERVICE AND VETERANS* ADMINISTRATION HEALTH 
FACILITIES AND SERVICES SHARING 
SEC. 710. Title VII, as amended by section 709 of this Act, is 
further amended by adding at the end thereof the following new 
section: 
Reports. 
25 u s e 1680f. 
Utah. 
Reports. 
INDIAN HEALTH SERVICE AND VETERANS ADMINISTRATION HEALTH 
FACILITIES AND SERVICES SHARING 
"SEC 716. (a) The Secretary shall examine the feasibility of enter-
ing into an arrangement for the sharing of medical facilities and 
services between the Indian Health Service and the Veterans' 
Administration and shall, in accordance with subsection db), prepare 
a report on the feasibility of such an arrangement and submit such 
report to the Congress by no later than September 30,1990. 
0)) 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' Administration; 
"(4) the quality of health care services provided to any vet-
eran by the Veterans' Administration; 
"(5) the eligibility of any Indian to receive health services 
through the Indiem Health Service; or 
"(6) the eligibility of any Indian who is a veteran to receive 
health services through the Veterans' Administration. 
"(cXl) Within 30 days after the date of enactment of this section, 
the Director of the Indian Health Service and the Administrator of 
Veterans' Affairs are authorized and directed to implement an 
agreement under which— 
"(A) individuals in the vicinity of Roosevelt, Utah, who are 
eligible for health care from the Veterans' Administration could 
o b ^ n health care services at the facilities of the Indian Health 
Service located at Fort Duchesne, Utah; and 
"(B) individuals eligible for health care from the Indian 
Health Service at Fort Duchesne, Utah, could obtain health 
care services at the Veterans' Administration medical center 
located in Salt Lake City, Utah. 
"(2) Not later than 2 years after the date of enactment of this 
section, the Secretary and the Administrator of Veterans' Affairs 
PUBLIC LAW 100-713—NOV. 23, 1988 
102 STAT. 4833 
shall jointly submit a report to the Congress on the health care 
services provided as a result of paragraph (1). 
"(d) Nothing in this section may be construed as creating any 
right of a veteran to obtain health services from the Indian Health 
Service except as provided in an agreement under subsection (c).". 
REALLOCATION 
OF 
BASE 
RESOUBCES 
SEC. 711. Title Vn, as amended by section 710 of this Act, is 
further amended by adding at the end thereof the following new 
section: 
"BEALLOCATION OF BASE BESOUBCES 
"SEC. 717. (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 Congress a report on 
the proposed change in allocation of funding, including the reasons 
for tiie change and its likely effects. 
"
O
i
>
) Subs^ion (a) shall not apply if the total amount appro-
priated to the Service for a fiscal year is less than the amount 
appropriated to the Service for previous fiscal year.". 
PBOVISION OF SERVICES IN MONTANA 
SEC. 712. (a) The Secretary of Health and Human Services, acting 
through the Lidian Health Service, shall provide services and bene-
fits for Indians in Montana in a manner consistent with the decision 
of the United States Court of Appeals for the Ninth Circuit in 
McNabb for McNabb v. Bowen, 829 F.2d 787 (9th Cir. 1987). 
(b) The provisions of subsection (a) shall not be construed to be an 
expression of the sense of the Congress on the application of the 
decision described in subsection (a) with respect to the provision of 
services or benefits for Indians living in any State other than 
Montana. 
DEMONSTRATION PROJECTS FOR TRIBAL MANAGEMENT OF HEALTH CABE 
SEBVICES 
SEC. 713. Title Vn, as amended by section 711 of this Act, is 
amended by adding at the end thereof the following new section: 
Reports. 
25 u s e 1680g. 
DEMONSTRATION PROJECTS FOR TRIBAL MANAGEMENT OF HEALTH 
CABE SEBVICES 
"SEC. 718. (aXD The Secretary, acting through the Service, shall 
make grants to Indian tribes to establish demonstration projects 
under which the Indian tribe will develop and test a phased 
approach to assumption by the Indian tribe of the heall^ care 
delivery system of the Service for members of the Indian tribe living 
on or near the reservations of the Indian tribe through the use of 
Service, tribal, and private sector resources. 
"(2) A grant may be awarded to an Indian tribe under paragraph 
(1) only IJL the Secretary determines that the Indian tribe has the 
administrative and financial capabilities necessary to conduct a 
demonstration project described in paragraph (1). 
Grants. 
25 u s e 1680h. 
102 STAT. 4834 
PUBLIC LAW 100-713—NOV. 23, 1988 
"(b) During the period in which a demonstration project estab-
lished under subsection (a) is being conducted by an Indian tribe, the 
Secretary shall award all health care contracts, including commu-
nity, behavioral, and preventive health care contracts, to the Indian 
tribe in the form of a single grant to which the regulations pre-
scribed under part A of title XIX of the Public Health Service Act 
(as modified as necessary by any agreement entered into between 
the Secretary and the Indian tribe to achieve the purposes of the 
demonstration project established under subsection (a)) shall apply. 
"(c) The Secretary may waive such provisions of Federal procure-
ment law as are necessary to enable any Indian tribe to develop and 
test administrative systems under the demonstration project estab-
lished under subsection (a), but only if such waiver does not dimin-
ish or endanger the delivery of health care services to Indians. 
Termination 
"(dXD The demonstration project established under subsection (a) 
date. 
shall terminate on September 30,1993. 
Reports. 
"(2) By no later than September 30, 1994, the Secretary shall 
evaluate the performance of each Indian tribe that has participated 
in a demonstration project established under subsection (a) and shall 
submit to the CJongress a report on such evaluations and demonstra-
tion projects. 
"(e) There are authorized to be appropriated such sums as may be 
necessary to carry out the purposes of this section.". 
HEALTH 
CARE 
FOR 
RURAL 
AREAS 
SEC. 714. Title VII of the Public Health Service Act is amended by 
adding at the end thereof the following: 
"PART I—HEALTH CARE FOR RURAL AREAS 
HEALTH CARE FOR RURAL AREAS 
Grants. 
"SEC. 799A. (a) The Secretary is authorized to make grants to, or 
Contracts. 
enter into contracts with, any eligible applicant to help such 
42 use 295j. 
applicant fund authorized activities under an application and 
approved under subsection (d). 
(bXl) Amounts provided under subsection (a) shall be used by the 
recipients to fund interdisciplinary projects designed to use new and 
innovative methods and models to— 
"(A) train health care practitioners to provide services in 
rural areas; 
"(B) provide access to cost-effective, comprehensive health 
care to individuals residing in rural areas; 
"(C) enhance the amount of research conducted concerning 
health care delivery in rural areas; and 
"(D) increase the recruitment and retention of health care 
practitioners in rural areas and make rural practice a more 
attractive career choice for health care practitioners. 
"(2) A recipient of funds under subsection (a) may use various 
methods in carrying out the projects described in paragraph (1), 
including— 
"(A) the distribution of stipends to students of eligible 
applicants; 
(B) the establishment of a post-graduate fellowship program; 
"(C) the training of faculty in the economic and logistical 
problems confronting rural health care delivery systems; or 
PUBLIC LAW 100-713—NOV. 23, 1988 
102 STAT. 4835 
"(D) the purchase or rental of transportation and tele-
communication equipment where the need for such equipment 
due to unique characteristics of the rural area is demonstrated 
by the recipient. 
"(3XA) An applicant shall not use more than 10 percent of the 
funds made available to such applicant under subsection (a) for 
administrative expenses. 
"(B) Not more than 10 percent of the individuals receiving train-
ing with funds made available to an appUcant under subsection (a) 
shall be trained as doctors of medicine or doctors of osteopathy. 
"(c) AppUcants eligible to obtain funds under subsection (a) shall 
include nonprofit organizations and public or nonprofit collies, 
universities, or schools of, or programs that specialize in, nursing, 
psychology, social work, optometry, public health, dentistry, osteop-
athy, physicians assistants, phannacy, podiatry, medicine, chiix)-
practic, and allied health professions if such applicants submit 
applications approved by the Secretary under sulxsection (d). Ap-
plicants eligible to obtain funds under subsection (a) shall not 
include for-profit entities, either directly or through a subcontract 
or subgrant. 
"(dXD In order to receive a grant or contract under subsection (a) 
an entity shall submit an application to the Secretary. 
"(2) An application submitted under this subsection shall be in 
such form, be submitted by such date, and contain such information 
as the Secretary shall require. 
"(3) Applications submitted under this subsection shall— 
"(A) be jointly submitted by at least two eligible applicants 
with the express purpose of assisting individuals in academic 
institutions in establishing long-term collaborative relation-
ships with health care providers in rural areas; 
(B) designate a rural health care agency or agencies for 
clini(^ treatment or training, including hospitals, community 
health centers, migrant health centers, rural health clinics, 
community mental health centers, long-term care facilities, 
facilities operated by the Indian Health Service or an Indian 
tribe or tribal organization or Indian organization under a 
contract with the Indian Health Service under the Indian Self-
Determination Act, or Native Hawaiian health centers; and 
"(C) provide any additional information required by the 
Secretary. 
"(eXD The Secretary shall enter into a contract to conduct a study 
of manpower training needs in rural areas, with attention focused 
on the supply of health professionals and whether such supply is 
adequate to meet the demands for health care services in rural 
communities. 
"(2XA) The study conducted imder paragraph (1) shall include 
statistics and projections on— 
"(i) the supply of health care practitioners in rural areas; and 
Health care 
"(ii) suggested methods of improving access to health care 
professionals. 
services in rural areas. 
^^^^ P«"'°"^ 
The study shall pay particular attention to the needs of the elderly 
in rural areas. 
"(B) The study conducted under paragraph (1) shall evaluate 
existing models for health care training and service delivery and 
propose innovative alternative models to enhance the quality and 
availability of health care services in rural areas and to increase the 
retention of health professionals in rural areas. 
102 STAT. 4836 
PUBLIC LAW 100-713—NOV. 23, 1988 
Reports. 
Termination 
date. 
"(3) The Secretary shall evaluate the effectiveness of the health 
care trainmg and service delivery models developed with funds 
made available under this section and compare such models with 
programs designed to increase the availability of health care provid-
ers in rural areas, including the National Health Service Corps 
program authorized by subpart II of part D of the Public Health 
Service Act (42 U.S.C. 254d et seq.) and the area health education 
center program authorized under section 781 of such Act (42 U.S.C. 
295g-l). 
"(4) Not later than 18 months after the date of the signing of the 
contract for the health care study under paragraph (1), the Sec-
retary shall submit to the appropriate committees of the (Jongress a 
report that describes the results of the study conducted under 
paragraph (1). 
"(CKD Each application for a grant or contract under this section 
shedl be submitted to a peer review group for an evaluation of the 
merits of the proposals made in the application. 
"(2) The Secretary shall establish such peer review groups as may 
be necessary to carry out paragraph (1). The Secretary shall make 
appointments to the peer review groups from among appropriately 
qualitied persons who are not officers or employees of the United 
States. 
"(3) With respect to applications referred to in paragraph (1), a 
peer review group established pursuant to paragraph (2) shsdl report 
its findings and recommendations to the Secretary. The Secretary 
may not approve such an application unless a peer review group has 
recommended the application for approval. 
"(4) This paragraph shall be carried out by the Secretary, acting 
through Health Resources and Services Administration. 
"(g) For the purposes of this section, the term 'rural area' includes 
a frontier area, which is an area in which the population density is 
less than 7 individuals per square mile. 
"(hXD There are authorized to be appropriated to carry out the 
provisions of this section, other than subsection (e), $5,000,000 for 
fiscal year 1989. 
"(2) There are authorized to be appropriated $1,000,000 for fiscal 
year 1989 to carry out subsection (e). 
"(g) This section shall cease to be effective on October 1, 1989.". 
CHILD SEXUAL ABUSE TREATMENT PROGRAMS 
SEC. 715. Title VII, as amended by section 713 of this Act, is 
amended by adding at the end thereof the following new section: 
CHILD SEXUAL ABUSE TREATMENT PROGRAMS 
25 use I680i. 
"SEC. 719. (a) The Secretary and the Secretary of the Interior 
shall, for each of the fiscal years 1989, 1990, and 1991, continue to 
provide through the Hopi Tribe and the Asiniboine and Sioux Tribes 
of the Fort Peck Reservation the demonstration programs involving 
treatment for child sexual abuse that were conducted during fiscal 
year 1988 through such tribes. 
"(b) There are authorized to be appropriated for each of the fiscal 
years 1989, 1990, and 1991 such sums as may be necessary to carry 
out the provisions of this section.". 
PUBLIC LAW 100-713—NOV. 23, 1988 
102 STAT. 4837 
PUEBLO SUBSTANCE ABUSE TREATMENT PROJECT FOR SAN JUAN 
PUEBLO, NEW MEXICO 
SEC. 716. Title VII, as amended by section 715, is further amended 
by adding at the end thereof the following new section: 
"PUEBLO SUBSTANCE ABUSE TREATMENT PROJECT FOR SAN JUAN 
PUEBLO, NEW MEXICO 
"SEC 720. (a) The Secretary, through the Service, shall make 
grants to the Eight Northern Indian Pueblos Council, San Juan 
Pueblo, New Mexico, for the purpose of providing substance abuse 
treatment services to Indians in need of such services. 
"(b) There are authorized to be appropriated to carry out this 
section $250,000 for each of the fiscal years 1990 and 1991.". 
STUDY WITH RESPECT TO NUCLEAR RESOURCE DEVELOPMENT HEALTH 
HAZARDS 
SEC. 717. (a) The Secretary of Health and Human Services (acting 
through the Indian Health Service), the Secretary of the Interior 
(acting through the Bureau of Indian Affairs), and the Secretary of 
Energy shall jointly conduct a study for 
the purpose of 
determining— 
(1) the number of active nuclear resource development sites 
on Indian lands in the United States; 
(2) the Federal agencies that carry out Federal responsibilities 
with respect to each such site; 
(3) the health hazards that exist as a result of such sites; 
(4) the remedial actions which have been undertaken with 
respect to such health hazards; 
(5) remedial actions that are needed with respect to such 
health hazards; and 
(6) the amount of funds that would be necessary each year to 
implement and maintain such needed remedial actions and the 
date by which the remedial actions would be implemented if 
sufficient funds were to provide for the remedial actions. 
(b) By no later than the date that is 2 years after the date of 
enactment of this Act, a report shall be submitted to the Congress 
describing the findings and conclusions made as a result of canying 
out the study required in subsection (a). 
UMITATION ON USE OF FUNDS APPROPRIATED TO THE INDIAN HEALTH 
SERVICE 
SEC. 718. Section 706 (25 U.S.C. 1676) is amended to read as 
follows: 
Grants. 
25 u s e 1680J. 
25 u s e 1677 
note. 
Reports. 
LIMITATION ON USE OF FUNDS APPROPRIATED TO THE INDIAN HEALTH 
SERVICE 
"SEC. 706. Any limitation on the use of funds contained in an Act 
providing appropriations for the Department of Health and Human 
Services for a period 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 appropriations 
for the Indian Health Service.". 
Abortion. 
102 STAT. 4838 
PUBLIC LAW 100-713—NOV. 23, 1988 
Contracts. 
Reports. 
SEC. 719. (a) Duiing the period of the moratorium imposed by 
Public Law 100-446 on implementation of the final rule published in 
the Federal Register on September 16, 1987, by the Health 
Resources and Services Administration of the Public Health Service, 
relating to eligibility for the health care services of the Indian 
Health Service, the Indian Health Service shall provide services 
pursuant to the criteria for eligibility for such services that were in 
effect on September 15,1987, subject to the provisions of section 709 
of the Indian Health Care Improvement Act, as amended by this 
Act 
G
>
) The Secretary of Health and Human Services, acting through 
the Indian Health Service, shall, by contract or any other means, 
conduct a study to determine the impact of the final rule described 
in subsection (a) and of any other proposed rules which would 
change the eligibility criteria for medical services provided by the 
Indian Health Service. 
(c) The study conducted under subsection (b) shall include— 
(1) fiill participation and consultation with Indian and Alas-
kan Native tribal governments and representatives of urban 
Indian health care programs; 
(2) statistics for each of the service areas of the Indian Health 
Service on the number of Indians who are currently eligible for 
the services of the Indian Health Service; 
(3) statistics for each of the service areas of the Indian Health 
Service on the number of Indians who would be eligible for such 
services if the final rule described in subsection (a), or any 
alternative rule changing eligibility, were implemented; 
(4) consideration of the financial impact of such final rule or 
any other proposed rule on the contract health care budget and 
on the clinical services budget of the Indian Health Service; 
(5) consideration of the health status, cultural, social, and 
economic impact on Indian reservations and urban Indian popu-
lations of such final rule or any other rule changing the eligi-
bility criteria; 
(6) consideration of the alternatives, if any, that would be 
available to those Indians who would not be eligible for such 
services by reason of any such final rule; and 
(7) consideration of the program changes that the Indian 
Health Service would be required to make if the eligibility 
requirements for such services that were in efiect on 
September 15,1987, were modified. 
(d) The Secretary of Health and Human Services shall submit to 
the Congress a report on the study required under subsection (b). 
(e) Before submitting to Congress the report on the study required 
under subsection (b), the Secretary of Health and Human Services 
shall provide Indian tribes, Alaska Native villages and urban Indian 
health care programs an opportunity to comment on the report and 
shall incorporate the comments of such Indian groups into the 
report. 
(0 There are hereby authorized to be appropriated such sums as 
are necessary to carry out the provisions of this section. 
PUBLIC LAW 100-713—NOV. 23, 1988 
102 STAT. 4839 
TITLE Vra—SEVERABILITY PROVISION 
SEC. 801. If any provision of this Act, any amendment made by 
25 use I60i 
this Act, or the application of such provision or amendment to ai^ ^°^-
person or circumstances is held to be invalid, the remainder of thk 
Act, the remaining amendments made by this Act, and the applica-
tion of such provision or amendment to persons or circumstances 
other than those to which it is held invsdid, shall not be affected 
thereby. 
Approved November 23, 1988. 
LEGISLATIVE HISTORY—H.R. 5261 (S. 129): 
HOUSE REPORTS: No. 100-1075 (Comm. of Conference). 
SENATE REPORTS: No. 100-508 accompanying S. 129 (Select Comm. on Indian 
Affairs). 
CONGRESSIONAL RECORD, Vol. 134 (1988): 
Sept. 13, considered and passed House. 
Sept. 28, considered and passed Senate, amended. 
Oct. 12, House agreed to conference report. 
^ 
Oct. 14, Senate agreed to conference report. 
^ 
19-194 O—91—PMt 6 
27 : QL 3