[Senate Report 109-222]
[From the U.S. Government Publishing Office]
Calendar No. 375
109th Congress Report
SENATE
2d Session 109-222
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INDIAN HEALTH CARE IMPROVEMENT ACT AMENDMENTS OF 2005
_______
March 16 (legislative day, March 15), 2006.--Ordered to be printed
_______
Mr. McCain, from the Committee on Indian Affairs, submitted the
following
R E P O R T
[To accompany S. 1057]
The Senate Committee on Indian Affairs, to which was
referred the bill (S. 1057), to amend the Indian Health Care
Improvement Act to revise and extend that Act, having
considered the same, reports favorably thereon with an
amendment in the nature of a substitute and recommends that the
bill, as amended, do pass.
Purpose
The purpose of the Indian Health Care Improvement Act
Amendments of 2005 (S. 1057) is to reauthorize the Act and
improve the Indian health care delivery system. This
legislation is intended to raise the health status of American
Indians and Alaska Natives to the highest possible level in
accordance with Healthy People 2010.\1\
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\1\ Healthy People 2010 is the major health agenda for the Nation.
``It is a statement of national health objectives designed to identify
the most significant preventable threats to health and to establish
national goals to reduce those threats.'' U.S. Department of Health and
Human Services, www.healthypeople.gov (last reviewed November 8, 2005).
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S. 1057 sets forth policies, programs and procedures
designed to address health care deficiencies in native and
urban Indian communities and streamline service delivery to
those communities. In addition, S. 1057 addresses the health
problems and associated socio-economic conditions in native
communities by authorizing the Indian Health Service (IHS) and
tribes to adopt current health industry ``best practices''.
Background
Enacted in 1976, the Act established the first
comprehensive framework for the delivery of health care
services for native people, including various health programs,
projects, and facilities. The Act was last reauthorized in
1992.
The Reauthorization Process
The work on the latest reauthorization began in 1999. Bills
have been introduced since the 106th Congress \2\ to enact a
series of improvements and updates to current law, most of
which are contained in S. 1057.
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\2\ S. 2526 (106th Congress), S. 212 (107th Congress), S. 556
(108th Congress).
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NATIONAL STEERING COMMITTEE (NSC)
In June, 1999, the Director of the IHS convened the NSC
comprised of tribal leaders and representatives from Indian
health organizations to facilitate the reauthorization. The NSC
held a series of meetings in 1999 during which extensive
discussions were held between the NSC and Department of Health
and Human Services (DHHS) officials. The NSC also received
technical assistance from the DHHS officials during these
meetings.
The NSC set out to craft a comprehensive legislative
proposal that would reflect a consensus of the Indian tribes.
With over 560 federally-recognized Indian tribes, each with
unique histories, cultures, locations and needs, the NSC faced
serious challenges. Despite the many differences, they
coalesced around a draft document which formed the basis of the
bills introduced, S. 2526 (106th Congress) and S. 212 (107th
Congress). Neither bill was enacted, but S. 212 did receive
significant attention from the Administration.
By letter dated September 27, 2001, the Administration
provided its views on S. 212 to the Committee. During 2002,
tribal officials and Committee staff reconvened to address the
Administration's concerns. The legislation was not passed by
Congress that year, and S. 556 was introduced in the next
Congress.
During the 108th Congress, the Committee, the NSC and the
Administration engaged in extensive negotiations over the
reauthorization, but a final bill was not concluded before the
108th Congress ended. Several recommendations developed during
these negotiations were incorporated into S. 1057.
Overview of Indian Health Care History
The history of the Federal responsibility for Indian health
care is quite extensive and well-documented in numerous
sources, including past Senate Reports on prior legislation.
See e.g., Senate Report Nos. 94-133, 102-392 and 108-411. The
underlying responsibility to provide health care did not
originate with the Act; rather, the Act was passed after
Congress recognized that a sea-change in administration was
needed to ensure improvements were achieved in Indian health
status and services.
The administration of Indian health had initially been
managed in a piecemeal approach, then ultimately coalesced
within the IHS, an agency of the DHHS.\3\
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\3\ The responsibility for Indian health first fell to the War
Department in 1803, then to the Interior Department in 1849, before
finally being transferred to the Department of Health, Education and
Welfare (DHEW), the predecessor of the DHHS, in 1955. The Division of
Indian Health within DHEW had initial responsibility for Indian health
before eventually being renamed the Indian Health Service. See Task
Force on Indian Health in the Final Report to the American Indian
Policy Review Commission (Final Report) at 32.
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Based on that history and in fulfillment of the special
obligation to Indian people,\4\ Congress passed the Act to
provide coordinated programs and meaningful direction in Indian
health care administration.
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\4\ Based on the U.S. Constitution, treaties, statutes and the
historical, political and legal relationship with the Indian tribes,
the United States has assumed responsibility for the provision of
health care to Indian people. Those laws and relationships serve as the
backdrop for the government-to-government relationship.
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THE PRE-IHCIA INDIAN HEALTH SYSTEM
At the time of passage of the Act in 1976, the information
on Indian health painted a stark portrait of existence in
Indian communities. The Senate Report accompanying S. 522, the
Indian Health Care Improvement Act, which was signed into law
as Public Law No. 94-437, indicated that the ``vast majority of
Indians still live in an environment characterized by
inadequate and understaffed health facilities, improper or
nonexistent waste disposal and water supply systems, and
continuing dangers of deadly or disabling diseases.'' \5\
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\5\ S. Rep. No. 94-133, at 36 (1976).
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Health status. These conclusions were based upon the
statistics at the time. For example, the ``incidence of
tuberculosis for Indians and Alaska Natives [was] 7.3 times
higher than the rate for all citizens of the United States. * *
* [T]he suicide rate * * * [was] approximately twice as high as
in the total U.S. population.'' \6\ Also troubling was the
infant mortality rate for Indian babies which was significantly
higher than the national average.\7\
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\6\ Id.
\7\ Id.
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Health professionals. Compounding the low health status
were the difficulties in recruiting and retaining qualified
health professionals--Indian health professionals, in
particular--to work in the Indian communities. The available
information indicated that out of 500 doctors in the Indian
Health Service, only 3 were Indian.\8\ Overall, ``in 1975,
there were only 72 American Indian physicians.'' \9\ Likewise,
only half of the number of pharmacists needed were employed in
these Indian communities.\10\
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\8\ Id., at 55.
\9\ Headlands Indian Health Careers, Program History, available at
http://www.headlands. ouhsc.edu/history.asp (Last reviewed December 14,
2005).
\10\ S. Rep. No. 94-133, at 42 (1976).
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Health facilities. The conditions and availability of
health facilities did not fare any better. A significant number
of the existing facilities were over twenty years old. Many
others were ``old one-story, wooden buildings with inadequate
electricity, ventilation, insulation and fire protection
systems, and of such insufficient size as to jeopardize the
health and safety of their occupants.'' \11\ The Joint
Committee on Accreditation of Hospitals (JCAHO) found that
``only 24 of the 51 existing IHS hospitals'' met accreditation
standards and ``two-thirds [were] obsolete and that 22 need[ed]
complete replacement.'' \12\
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\11\ S. Rep. No. 94-133, at 36-37 (1976).
\12\ Id., at 37.
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Funding. The funding situation also revealed significant
disparities. For example, ``[p]er capita expenditures for
Indian health purposes [were] 25 percent below per capita
expenditures for health care in the average American
community.'' \13\
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\13\ Id.
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Thus, the goals of the Act, by improving funding, direction
in programs, and access to other programs such as Medicare and
Medicaid, held great promise for the advancement of Indian
health.
CURRENT INDIAN HEALTH SYSTEM
Since 1976, significant improvements have been made in the
programs and funding levels for Indian health through the Act
and the amendments thereto. Yet, a comparison of historic
statistics with current status indicators show that, while real
progress has been made, significant disparities still persist.
Indian health status. Indian mortality rates from
tuberculosis were 400% greater than other U.S. populations.\14\
Despite a decrease of 64% over a period spanning 1972 to 1999,
Indian infant mortality rates still remained 24% higher than
other U.S. populations.\15\ Other Indian mortality rates far
exceeded the mortality rates of other U.S. populations for
causes including alcoholism (638%), diabetes mellitus (291%),
unintentional injuries (215%), pneumonia and influenza (67%),
gastrointestinal disease (38-40%) and heart disease (20%).
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\14\ U.S. Department of Health and Human Services, Indian Health
Service, 2000-2001 Trends in Indian Health, at 7.
\15\ U.S. Department of Health and Human Services, Indian Health
Service, 2000-2001 Trends in Indian Health, at 49.
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Even during the short period of 1997 to 2001, the overall
``prevalence of diabetes increased by 33% in all major regions
served by the Indian Health Service.'' The most alarming
increase, however, occurred among the Indian youth ages 15-19,
for whom diabetes increased by 106% from 1990-2002.\16\
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\16\ U.S. Department of Health and Human Services, Indian Health
Service, Fiscal Year 2006, Justification of Estimates for
Appropriations Committees, at IHS-81.
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Recent information on suicide indicates that these rates
are also astonishing. In 2005, the Committee held two hearings
on the issue of Indian youth suicide. A field hearing was held
in Bismarck, N.D. on May 2, 2005, and an oversight hearing was
held in Washington, D.C. on June 15, 2005.
According to national data for 2002, suicide was the second
leading cause of death for Indians of both sexes in the 15-34
year age range, and the fourth leading cause of death for both
sexes in the 10-14 year age range. On the reservations of the
Northern Great Plains (States of North and South Dakota, Iowa,
Minnesota and Nebraska), the rate of Indian youth suicide is up
to 10 times higher than it is elsewhere in the country.
Yet, in terms of services at several Indian health
facilities, the demand for mental health care outstripped their
capacity.\17\ In at least one facility, the mental health
services would be cut by 20% in FY 2005 because funding had
been depleted.\18\
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\17\ United States Government Accountability Office, Report to the
Committee on Indian Affairs, U.S. Senate, Indian Health Service: Health
Care Services Are Not Always Available to Native Americans, GAO Report
No. GAO-05-789, (August, 2005) at 18.
\18\ GAO Report No. GAO-05-789, at 18.
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Another alarming and growing problem arising in Indian
communities is the use of methamphetamines. According to the
National Survey on Drug Use and Health, the use rate during a
2002-2004 survey period among Indians, aged 12 and older, is
higher than nearly every other population.\19\
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\19\ U.S. Department of Health and Human Services, Substance Abuse
and Mental Health Services Administration, Office of Applied Studies,
The NSDUH Report, September 16, 2005, http://oas.samhsa.gov/2k5/meth/
meth.htm, (Last reviewed on December 2, 2005).
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Health facilities. According to the most recent data, 413
facilities exist within the Indian health system with an
average age of 30 years.\20\ Approximately 49 of those
facilities are hospitals ranging in capacity from 4 to 156
beds, but only 19 of the hospitals have operating rooms.\21\
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\20\ U.S. Department of Health and Human Services, Indian Health
Service, Fiscal Year 2006, Justification of Estimates for
Appropriations Committees, at IHS-5.
\21\ GAO Report No. GAO-05-789, at 9.
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Besides hospitals, ``there were 231 health centers * * *
offering primary care and some ancillary services such as
pharmacy, laboratory and X-ray''.\22\ Also, the 133 health
stations in the Indian health system provided primary
services.\23\
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\22\ Id.
\23\ Id.
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According to the IHS Health Facilities Construction
Priority System, the estimated unfunded total cost to meet the
need was nearly $1.5 billion as of FY 2005.\24\ In addition,
the backlog for the maintenance and improvement needs of
current facilities was estimated at $482,956,000.\25\ However,
on the bright side, ``[f]ully 100 percent of IHS hospitals and
health clinics met accreditation standards in FY 2004.'' \26\
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\24\ U.S. Department of Health and Human Services, Indian Health
Service, Health Care Facilities FY 2007 Planned Construction Budget
(February 11, 2005).
\25\ U.S. Department of Health and Human Services, Indian Health
Service, Fiscal Year 2006, Justification of Estimates for
Appropriations Committees, at IHF-4.
\26\ Id., at IHS-5.
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In addition, since the Indian Sanitation Facilities and
Services Act, Public Law 86-121, codified at 42 U.S.C. 2004,
was passed in 1959, ``over 265,000 Indian homes have been
provided sanitation facilities'' which served to reduce ``[t]he
gastroenteric and post-neonatal death rates among the Indian
people * * * primarily because of the increased prevalence of
safe drinking water supplies and sanitary waste disposal
systems.'' \27\
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\27\ U.S. Department of Health and Human Services, Indian Health
Service. The Sanitation Facilities Construction Program of the Indian
Health Service, Public Law 86-121, Annual Report for 2004, at 1.
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The IHS noted that ``in 1955, more than 80% of American
Indians and Alaska Natives were living in homes without
essential sanitation facilities.'' \28\ The gastrointestinal
death rate was ``15.4 per 100,000 population, * * * 4.3 times
higher than that for all other races in the United States.''
\29\ But by 1995, that death rate was reduced to 1.7 per
100,000, although it is still 38-40% higher than the rate for
all races in the United States.\30\
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\28\ Id., at 20.
\29\ Id.
\30\ Id.
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In FY 2004, approximately $139 million was available for
sanitation facilities construction, of which nearly $93 million
came from Indian Health Service funds and more than $46.5
million came from other Federal agencies and non-Federal
sources.\31\ The Indian Health Service estimated that in FY
2004 sanitation facilities were provided to a total of 24,928
homes.\32\ However, the total estimated costs to address the
sanitation deficiencies in existing homes was nearly $1.9
billion, with nearly 150,000 Indian homes still needing
sanitation facilities, 36,000 of which did not have potable
water.\33\
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\31\ U.S. Department of Health and Human Services, Indian Health
Service. The sanitation Facilities Construction Program of the Indian
Health Service, Public Law 86-121, Annual Report for 2004, at 5.
\32\ Id.
\33\ U.S. Department of Health and Human Services, Indian Health
Service, Justification of Estimates for Appropriations Committees for
Fiscal Year 2006, p. IHF-9 and U.S. Department of Health and Human
Services, Indian Health Service, The Sanitation Facilities Construction
Program of the Indian Health Service, Public Law 86-121, Annual Report
for 2003.
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Health professionals. The number of Indian health
professionals has increased since the Act was signed into law.
According to the latest Census information, there were over
1,300 Indian physicians and surgeons and over 10,000 Indian
registered nurses.\34\ These numbers suggest that the
incentives in the Act have assisted in increasing these
numbers.
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\34\ U.S. Census Bureau, American FactFinder, Census 2000 Summary
File 4, Table PCT86. The numbers are for individuals reporting only the
American Indian and Alaska Native race.
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However, vacancy rates for key health professionals
indicate that a substantial need still exists for qualified
health professionals in the Indian health system. The vacancy
rates for health professions with the greatest shortfalls
consist of Dentists (24%), Certified Registered Nurse
Anesthetists (33%), Medical Imaging (including x-rays,
ultrasounds, CT scans etc.) (20%), Nurses (14%) Pharmacists and
Physicians (both 11%).\35\
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\35\ Hearings on Interior, Environment and Related Agencies
Appropriations for 2006 Before the U.S. House of Representatives,
Committee on Appropriations, 109th Cong., 1st Sess., April 14, 2005, at
278-279.
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Types and level of services. The IHS and tribal and urban
Indian health programs provide an array of basic medical,
dental and vision services. For example, the personal health
services including inpatient care, and routine and emergency
ambulatory care; and medical support services including
laboratory, pharmacy, nutrition, diagnostic imaging, medical
records, physical therapy, etc.\36\
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\36\ U.S. Department of Health and Human Services, Indian Health
Service, Fiscal Year 2006, Justification of Estimates for
Appropriations Committees, at IHS-3.
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Even though basic services may be available, access to
those services is not assured. In its study on the availability
of health services to Indians, the Government Accountability
Office (GAO) found that Indian patients often had to wait more
than 30 days--in some cases 2 to 6 months--between setting the
appointment for services and receiving the services, a time
frame ``in excess of standards and goals identified in other
federally operated health service delivery systems.'' \37\
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\37\ GAO Report No. GAO-05-789, at 15.
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Moreover, ``[t]he most frequent gaps were for services
aimed at the diagnosis and treatment of medical conditions that
caused discomfort, pain, or some degree of disability but that
were not emergent or acutely urgent.'' \38\ For example, in
some cases, adult Indian patients ``could wait as long as 120
days to get approval for eyeglasses.'' \39\
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\38\ Id., at 19.
\39\ Id.
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According to one tribal official interviewed by the GAO,
these situations create an environment in which Indian patients
become demoralized and may wait until their condition becomes
``an emergency that required a higher level of treatment.''
\40\ The GAO also noted that gaps in care were common.
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\40\ Id., at 16.
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The Committee is deeply concerned with the GAO's findings
and its conclusions that the disturbing result of these gaps
are ``diagnosis or treatment delays that exacerbate[ ] the
severity of a patient's condition and create[ ] a need for more
intensive treatment.'' \41\ The Committee is further concerned
that these gaps are increasing health care costs and
diminishing the potential for prevention efforts.
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\41\ GAO Report No. GAO-05-789, at 21.
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The Committee appreciates the Administration's efforts in
promoting prevention as a key to reducing health care costs,
but believes greater effort is needed to reduce gaps in health
services to Indians. Improvements are needed in all areas of
the Indian health care system to ameliorate problems and delays
in service delivery. The improvements outlined in S. 1057 for
programs and policies, the Bi-partisan Commission study on
health service delivery, and other new provisions in S. 1057
are designed to help address these problems.
The Indian Health Care Improvement Act
In passing the Act, Congress set forth ambitious goals for
improving the health of Indians, including encouraging their
participation in ``the planning and management'' of health
services. 25 U.S.C. 1601(b). The Act ``would provide the
direction and financial resources to overcome the inadequacies
in the existing Federal Indian health care program.'' Senate
Report No. 94-133, at 13.
These goals built upon the foundation laid in President
Nixon's 1970 ``Special Message to the Congress on Indian
Affairs''.\42\ In his Special Message, President Nixon declared
that ``[t]he time ha[d] come to break decisively with the past
and to create the conditions for a new era in which the Indian
future is determined by Indians acts and Indian decisions.''
\43\
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\42\ President's Special Message to Congress on Indian Affairs, 213
Pub. Papers 564 (July 8, 1970).
\43\ Id., at 565.
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Breaking decisively with the past meant a radical change in
health care delivery, beginning with the administration of the
programs and policy-making. Placing administrative and
decision-making authority in the hands of Indian tribes, rather
than solely in the agency's hands, was a fundamental and
logical approach in health care delivery. Such a modification
took several years to overcome difficulties in achieving tribal
participation in the administration of these programs.\44\
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\44\ See e.g., U.S. General Accounting Office, now, U.S. Government
Accountability Office, Report to the Chairman, Select Committee on
Indian Affairs, U.S. Senate, Indian Health Service, Contracting under
the Indian Self-Determination Act, GAO Report No. GAO/HRD-86-99,
September, 1986.
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Today, nearly half of the IHS budget is administered
through tribal contracts or compacts under the Indian Self-
Determination and Education Assistance Act of 1976 (ISDEAA),
U.S.C. 450 et seq. This not only reflects Congressional policy
of promoting tribal self-determination, but generates a higher
level of cooperation between the Indian health providers.\45\
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\45\ U.S. Department of Health and Human Services, Indian Health
Service, Fiscal Year 2006, Justification of Estimates for
Appropriations Committees.
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GENERAL PRINCIPLES IN THE REAUTHORIZATION
During the reauthorization process, a critical assessment
of the Act was undertaken by the Committee and the Indian
health community and several basic principles evolved. As a
general matter, the history of Indian health and the interplay
between the ISDEAA and the Act must be kept in mind when
developing Indian health policy.
Self-determination. Since self-determination was declared
to be the new direction in Federal Indian policy, tribal
participation has significantly contributed to improving
services for Indian people.\46\ Meaningful participation by
tribes in administering programs through contracting or
compacting has been a principal means of implementing the self-
determination policy.
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\46\ See e.g., National Indian Health Board, Tribal Perspectives on
Indian Self-Determination and Self-Governance in Health Care
Management, 1998.
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However, simply administering a program designed and handed
down by the agency does not accomplish the vision embodied in
self-determination. Indian participation is critical in the
development of the framework of these programs and services.
Tribal self-determination involves tribes initiating programs,
and the ideas, concepts and methodology of how those programs
or services should be delivered to their own communities.
Such involvement means appreciable engagement between the
agency and Indian tribes. Numerous tools have successfully
increased that involvement. For example, negotiated rulemaking
has been found to be useful in several initiatives such as
education, housing and self-governance.\47\
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\47\ See e.g., No Child Left Behind Act, Pub. L. 107-110, 25 U.S.C.
2001, et seq.; Native American Housing Assistance and Self-
Determination Act, Pub. L. 104-330, 25 U.S.C. 4116; Indian Self-
Determination and Education Assistance Act, Pub. L. 106-477, 25 U.S.C.
458aa-16.
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The Committee has received testimony from tribal
participants in negotiated rulemaking that ``true understanding
among Tribes and with IHS is achieved'' \48\ through that
process. That true understanding is consistent with the
Committee's desire to foster consensus-building and reduce
obstacles that negatively impact service delivery.
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\48\ The Indian Health Care Improvement Act Amendments of 2005:
Hearings on S. 1057 Before the Senate Comm. on Indian Affairs and
Senate Comm. on Health, Education, Labor and Pensions, 109th Cong., 1st
Session, S. Hrg. 109-162 at 725 (July 14, 2005) (statement of Don
Kashaveroff, President, Seldovia Village Tribe).
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The Administration has expressed concerns about the time
and resource constraints involved in negotiated rulemaking. The
Committee strongly supports fiscal accountability, but believes
that the long-term benefits of negotiated rulemaking exceed the
short-term costs.
The Committee believes that the Indian tribal and urban
health providers--as first responders in the health system--
should be directly involved in developing health programs and
the regulations that govern them. Tribal involvement in
rulemaking not only leads to a more informed rule, but it
fosters tribal support. Negotiated rulemaking can save costs to
all parties in the long run. By building a higher level of
consensus in the regulations, the IHS lowers the potential for
legal challenges to the rules and associated litigation costs.
The Committee favors consensus-building over litigation and
encourages this long-term view.
Besides negotiated rulemaking, the Committee has favored
consultation with tribes as another tool to increase tribal
participation, but has generally left the manner or method of
consultation to the discretion of the Secretary.
For example, the ISDEAA simply requires an annual
consultation on the budget. However, the Secretary has in the
past implemented a rigorous regional and national schedule for
budget consultation.\49\
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\49\ See e.g., http://www.hhs.gov/iga/tribal/
0506_budget_session_transcript.doc, (Last reviewed December 12, 2005),
and http://www.hhs.gov/iga/tribal/9707.html, (Last reviewed December 9,
2005), but see http://www.npaihb.org/legis/IHS%20Budget/
Budget_Intro_Page.htm, (Last reviewed December 9, 2005).
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The Committee recognizes that the Administration has made
efforts to involve Indian tribes in decision-making through the
consultation policy issued by the DHHS.\50\ The Committee
recognizes that the Department's policy has attempted to
address a wide variety of matters affecting Indian communities.
However, the Committee is concerned that the scope of the
Department policy may not fully encompass all critical matters
for which the Committee believes consultation should be used.
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\50\ U.S. Department of Health and Human Services, Department
Tribal Consultation Policy, January, 2005, available at http://
www.hhs.gov/ofta/docs/FnlCnsltPlcywl.pdf. (Last reviewed December 15,
2005).
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Such matters involve the development of program eligibility
or criteria, or relate to specific tribes, Indian population
groups (e.g., women) or to special tribal history, customs, or
practices. Consequently, the Committee has provided for robust
consultation in several key areas, leaving the manner of
consultation to Secretarial discretion, and it remains
committed to promoting tribal input by institutionalizing
consultation.
Flexibility. In addition, the Committee believes that less
bureaucracy and more flexibility are needed to tailor programs
or services to address local community health needs.\51\ The
Committee is pleased that the Administration has joined in
supporting flexibility, new approaches to health care, and
expanding the range of options of health services.\52\
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\51\ Flexibility also eliminates the need to identify each and
every program that may be administered by IHS, the tribal or urban
programs (e.g., the definition of ``health professions'' does not
identify every profession that may be authorized). Many of the
decisions or priorities are left to the Indian health providers to
determine to implement as needed. The Committee is aware that the IHS,
Indian tribes and urban programs engage in extensive budget
consultations involving which programs and professions to implement,
sometimes two years in advance of implementation.
\52\ S. Hrg. 109-162 at 589 (statement of Dr. Grim, Director, U.S.
Department of Health and Human Services, Indian Health Service).
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However, in the course of negotiating this legislation, the
Administration has indicated its preference to change mandatory
programs to discretionary ones to meet budgetary constraints
and to give the Secretary maximum flexibility.\53\ The
Committee has accommodated these principles based on the
understanding that Indian tribes would also be accorded the
same flexibility under the Act and the ISDEAA.
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\53\ Id., at 596.
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The Committee understands that, in the past, the Indian
tribes had been foreclosed from implementing programs that the
agency did not actually implement either under the Act or the
Snyder Act, 25 U.S.C. 13. Simple program authorizations under
the Act and the Snyder Act were deemed insufficient to allow
the Indian tribes to administer the programs even under the
redesign provisions of the ISDEAA.
It is the Committee's intent, however, that simple
authorizations are sufficient to enable tribes to implement
programs, even if the Federal agency chooses not to, provided
all other applicable provisions of the Act, the Snyder Act and
the ISDEAA are met. The Committee believes that this
interpretation is necessary to enable Indian tribes to meet the
needs of their communities and required if the Secretary is to
experience the flexibility desired.
In the past, the Committee has been apprehensive about
eliminating certain mandates such as those requiring studies.
In reviewing the studies conducted and annual reporting
information, it appears that quite a few studies mandated by
the Act were not completed. These studies were intended to
provide insight into the accomplishments and challenges in
Indian health and assist the Committee in seeking new
approaches to service delivery. The Committee is troubled that
the health status of Indians reflects many of the same problems
it did in 1976 and that several mandates in current law have
been disregarded.
Consequently, the Committee has included in S. 1057, a Bi-
partisan Commission to thoroughly review opportunities for
improvement. During the 108th Congress, the bill to reauthorize
the Act, S. 556, contained provisions wherein the Bi-partisan
Commission would study the potential of funding Indian health
as an entitlement. Based on the Administration's
recommendations offered during the 108th Congress, the
Committee modified the Commission's objectives in S. 1057.
In addition, the Committee has included the Native American
Health and Wellness Foundation provisions to promote the
mission of IHS in improving Indian health. This Foundation is
not a substitute for the federal obligation to Indian health,
but is intended to complement the federal obligation in ways in
which the United States has fallen short.
Oversight and Reporting. While much discretion and
flexibility is provided, the Committee must preserve the
necessary mechanisms to fulfill its oversight function. The
primary means is through active reporting requirements by the
Secretary. Congress simply cannot leave unfettered the
operations of these important programs without appropriate
assurances that Indian people are being served consistent with
Congressional intent and priorities. Moreover, Congress should
be informed of how and when these programs meet--or fall short
of meeting--the basic health needs of Indian people.
KEY PROVISIONS
Several key improvements and provisions of S. 1057 are
particularly noteworthy:
Non-Eligibles. Congress has recognized that ``without a
proper health status, the Indian people will be unable to fully
avail themselves of the many economic, educational, and social
programs already directed to them. * * *'' Senate Report No.
94-133, at 23. Providing services to Indian people improves the
health of Indians in a direct manner.
However, protecting the health of Indians requires
attention to issues other than direct services to Indians. In
the 1800s, services such as vaccinations were provided to
Indians located near forts to protect the health of
soldiers.\54\ Now the tables are turned. Individuals not
otherwise eligible for Indian health care may receive a limited
scope of health services under the Act to protect the health of
Indians.
---------------------------------------------------------------------------
\54\ See American Indian Policy Review Commission, Task Force Six,
Final Report to the Commission, Vol. 6.
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Serving non-eligibles for these purposes comports with the
Administration's goals of promoting healthy ``Indian * * *
communities'' and ``including new approaches to delivering
care''.\55\ Serving non-eligibles has been a policy of the Act
for many years and it reflects a logical and reasonable
approach to protect Indian health.
---------------------------------------------------------------------------
\55\ S. Hrg 109-162, at 589 (statement of Dr. Grim, Director, U.S.
Department of Health and Human Services, Indian Health Service).
---------------------------------------------------------------------------
For example, the Act provides that services may be provided
to a non-eligible pregnant woman carrying an Indian's child. 25
U.S.C. 1680c(c)(3) (Section 807(d)(3) of S. 1057). In addition,
services may be provided to prevent the outbreak of
communicable diseases such as tuberculosis. 25 U.S.C.
1680c(c)(2) (Section 807(d)(2) of S. 1057).
In including these ``non-eligible individuals'' in the
service delivery, Congress has set forth considerations for the
IHS and Indian tribes to address prior to providing the
services--the ``two-part determination''. This two-part
determination consists of determining that
(i) the provision of such health services will not
result in a denial or diminution of health services to
eligible Indians; and
(ii) there is no reasonable alternative health
facility or services, within or without the service
area of such service unit, available to meet the health
needs of such individuals. 25 U.S.C. 1680c(b)(1)(A).
However, the Committee is aware that questions have arisen
regarding how the two-part determination applies to Indian
tribes with contracts or compacts under ISDEAA.
Where services are directly provided by the IHS (direct
services), the Indian tribe(s) served by the Service Unit and
the IHS jointly make the two-part determination. 25 U.S.C.
1680c(b)(1)(A). Section 807 of S. 1057 provides that, for
programs administered by an Indian tribe pursuant to a contract
or compact under the ISDEAA, the Indian tribe is authorized to
provide services to non-eligibles, but ``shall take into
account'' the two-part determination.
Congress has made it clear that the determination shall be
made in both instances: in the case of direct services it is
made by both IHS and the Indian tribes and, in the case of
ISDEAA contracts or compacts, by Indian tribes. Congress did
not provide in the Act express substantive or procedural
provisions governing how the determinations should be made,
given the innumerable variances in circumstances for the Indian
communities.
However, Section 807 does provide some guidance on how the
parties may determine whether there will be no diminution of
services. For example, the non-eligibles receiving services
``shall be liable for payment of such health services under a
schedule of charges prescribed by the Secretary. * * *'' 25
U.S.C. 1680c(b)(2)(A).
In addition, health services may be provided to indigent
non-eligibles if there is a reimbursement agreement with the
State or local governments. These provisions, however, do not
limit the ability of either the IHS or Indian tribes to include
additional considerations in determining whether services would
be decreased. Other budgetary factors, delays in services,
appointment waiting times,\56\ etc. are all other
considerations that may be appropriate, depending on the
particular circumstances.
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\56\ See GAO Report No. GAO-05-789.
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Likewise, when assessing reasonable alternatives, the IHS
and Indian tribes may be confronted by factors such as remote
locations, distances to other health facilities and other
unique difficulties, which render other health care
alternatives unavailable. Questions surrounding what is
available should be placed in the context of the following
policy considerations. First, services under this Act are for
the ultimate protection of Indian health. Second, the IHS and
tribal health programs are the payors of last resort which
means, in this situation, that all other avenues of obtaining
health services should be exhausted prior to seeking assistance
from either IHS or the tribal health programs.
The Committee has been informed that some health providers
may refuse to serve Medicaid beneficiaries, thus making any
other health service alternative unavailable. If all entities
have made good faith efforts to obtain services and all avenues
have been exhausted, it appears that there may be an arguable
case of unavailability.
When making these determinations, Indian tribal leaders are
placed in a difficult situation. On the one hand, the federal
obligation for Indian health--which the Indian tribe is
administering--is secured for the benefit of Indians. It may
also be politically disastrous for tribal leaders to authorize
services for non-eligibles, so the determinations are not made
lightly by Indian tribal leaders. On the other hand,
withholding services from these non-eligibles under the limited
circumstances enumerated in this Act may serve to do harm to
Indian people by not eliminating general health hazards.
Evaluations were left in S. 1057 to the IHS and Indian
tribes based on their individual circumstances and, if
appropriate, could be developed more fully through negotiated
rule-making or consultation.
Third Party Reimbursements. Funding from sources other than
IHS was identified as a factor which affected the availability
of health care services for Indians.\57\ Those funding sources
include third-party reimbursements from Medicaid and Medicare.
In some cases, these reimbursements constitute up to 50% of the
medical care budget for a particular Indian health program.\58\
---------------------------------------------------------------------------
\57\ GAO Report No. GAO-05-789, at 4.
\58\ Id., at 5.
---------------------------------------------------------------------------
With more resources, the Indian health care system could
provide more services and the Committee strongly encourages IHS
and the Indian tribes to seek additional resources to
supplement the appropriated sums provided annually.\59\ The GAO
noted that ``[f]acilities with higher reimbursements had
additional funds with which they could hire staff, purchase
equipment and supplies, and renovate their buildings.'' \60\ In
one case, 31 percent of a facility's clinical providers and
other staff was funded by third party reimbursements.\61\
---------------------------------------------------------------------------
\59\ S. 1057 adds amendments to the ISDEAA which authorize the
Native American Health and Wellness Foundation to promote the mission
of IHS through such means as receiving donations which supplement, not
offset, appropriations. Offsetting in Indian health care programs is
generally prohibited by law. See 25 USC Sec. 1641(a).
\60\ GAO Report No. GAO-05-789, at 26.
\61\ Id.
---------------------------------------------------------------------------
S. 1057 provides for an increase in access to Medicaid by
removing barriers through waivers of premiums and cost-sharing
at Indian health facilities and by codifying agency regulations
or practices which recognize the unique nature of and special
circumstances applying to Indian property, particularly trust
and restricted property.\62\ Likewise, S. 1057 provides other
means of removing barriers to obtaining third-party
reimbursements, such as the process for seeking waivers of
sanctions, which promotes favorable state-tribal relations.
---------------------------------------------------------------------------
\62\ As a general rule, these special types of property are not
included in eligibility calculations for income taxes or federal
benefits.
---------------------------------------------------------------------------
Health Professions. Difficulties in recruiting and
retaining qualified health professionals have long been
recognized as a significant factor impairing Indians' access to
health care services.\63\ Noting that many Indian communities
are often in remote locations and lack adequate housing and
educational and recreational opportunities for employees and
their families,\64\ the GAO reported that some critical
positions such as for pharmacists and dentists remained vacant
for several years in some locations.\65\
---------------------------------------------------------------------------
\63\ See also GAO Report No. GAO-05-789, at 4.
\64\ Id.
\65\ Id.
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The provisions in Title I address the health professional
shortage in Indian communities. Congress specifically included
these provisions in 1976 because the existing programs to
improve manpower capabilities were woefully inadequate or
completely unsuitable for Indian health providers and
communities.\66\
---------------------------------------------------------------------------
\66\ Senate Report No. 94-133, at 55-57.
---------------------------------------------------------------------------
The programs existing in 1976 did ``not link the recipients
[of scholarships] directly to the Indian Health Service,'' were
``not designed to recruit and support Indians,'' and were too
limited in the ``category of health professionals'' supported
by these programs.\67\
---------------------------------------------------------------------------
\67\ Id., at 55-56.
---------------------------------------------------------------------------
Consequently, Congress developed a new approach and the IHS
scholarship program was born. Fears of duplication were quickly
disproven by the obvious need for and success of these programs
in filling vacancies and returning Indian health professionals
to the Indian communities. Today, the program has expanded to
include a wide variety of health professions as determined by
the priorities set by the IHS and the Indian tribes. The
program also now includes, besides the scholarships, loan
repayments, a tribal scholarship program, and bonus incentive
payments.
These programs specifically target the needs of the Indian
health system. For example, the scholarship priorities are
developed through a year-long consultation process wherein the
IHS sends the program information and request for priority to
each tribal leader and the tribal education and health
programs. The comprehensive list is developed based on the IHS
and tribal health professional projected needs, vacancies and
available positions. By focusing on the specific needs of
Indian communities, the Committee believes that this approach
has significantly improved Indian health.
Just as targeting the specific needs of the Indian health
system became the hallmark of the health professional policy, a
holistic approach also became a key policy component in
increasing the number of Indian health professionals. The
Committee strongly encourages the Secretary to evaluate all
opportunities to improve the chances of success for Indian
health professionals, including obtaining the licenses or
certifications necessary for providing health care services.
The Committee has been made aware of the need to increase the
number of licensed health professionals in the Indian health
system and included provisions in S. 1057 to address that need.
S. 1057 provides for portability of current licenses for tribal
health professionals consistent with other Federal health
licensing provisions. In addition, S. 1057 authorizes programs
to enhance and facilitate enrollment in and completion of
courses of study in health professions.
The Committee believes that the Title I programs should
fully equip the individuals with the tools needed to transition
into the health profession, including successfully completing
all courses of study and passing the required licensing or
board examinations. In addition, the Committee expects that the
IHS would also ensure that scholarship recipients are provided
every opportunity to fulfill their service obligations,
including technical assistance in understanding their
obligations.
The remedial programs, scholarships, grants, externships,
service obligations and advanced training established in Title
I are all designed to provide seamless opportunities for
successfully transitioning Indians into health professions. As
part of the long-term view of Indian health professions, the
Committee believes continuity is appropriate in administering
the Title I programs.
The incentives fostered by scholarships, loan repayments,
and bonuses are multiplied when combined with professional
development programs for health professionals which the
Committee believes to be essential components of recruitment
and retention programs in the Indian health system. S. 1057
establishes several professional development programs in Title
I such as opportunities for advanced training and research,
tribal cultural orientation, training in the administration and
planning of tribal health programs and tribal demonstration
projects for innovative recruitment, placement and retention
programs, which may include professional development programs.
Such additional training for health professionals is
particularly important in developing leadership and
collaboration skills and ensuring that a culturally-competent
workforce exists within the Indian health system. The Committee
strongly encourages the Secretary and tribal and urban Indian
health providers to develop innovative programs or take
advantage of existing models for such professional development
to increase and maintain the number of Indian health
professionals in the Indian health system.
In addition, the Committee took a long-term view of health
professions in S. 1057. The most dire placement needs are in
the direct care positions, such as doctors, nurses, and
pharmacists. In the long-term, Indian health professionals are
also needed in educational positions to bolster recruitment and
improve the new Indian health professionals' chances of
success.
The Committee has been informed that an appreciable need
exists at the tribal colleges and universities to increase the
number of Indian instructors in the nursing programs.\68\ The
Committee recognizes that Indian instructors often have
personal knowledge of the health disparities in Indian
communities and a deep commitment to serve these communities
for the long-term. Indian educators increase the likelihood of
success for Indian students and bring to the classroom the
unique cultural competence required in the Indian health field.
---------------------------------------------------------------------------
\68\ Joseph F. McDonald, Ed.D., President, Salish-Kootnai College,
Letter to Chairman John McCain, U.S. Senate Committee on Indian
Affairs, September 22, 2005.
---------------------------------------------------------------------------
With that in mind, the Committee included provisions in
Title I of S. 1057 wherein a scholarship recipient may fulfill
his or her service obligation (required in exchange for the
scholarship) by teaching in a tribal college or university
nursing or other health related program, provided the Secretary
determines that the health services to Indians will not be
decreased. In addition, the Secretary may, prior to waiving any
service obligation or repayment of a scholarship, consider
placement of a scholarship recipient in a teaching capacity in
a tribal college or university nursing or related health
program. Other provisions for nursing grants were added to
extend a preference in grant awards to tribal college and
university nursing programs.
Prior to including these provisions, the Committee
considered the likelihood that inexperienced, new graduates
might be placed in teaching positions. One tribal college
President indicated that ``these are clinically seasoned,
mature [Bachelor of Science-Nursing] prepared nurses returning
to school for educational and career mobility.'' \69\ Teaching
positions available for these individuals would include lab
coordinators and clinical instructors. This tribal college
President also indicated that ``new [Registered Nurse]
graduates of associate or generic baccalaureate programs would
not be qualified to teach. * * *'' \70\
---------------------------------------------------------------------------
\69\ Joseph F. McDonald, Ed.D., President, Salish-Kootenai College,
Letter to Honorable Don Young, U.S. House of Representatives, November
1, 2005.
\70\ Id.
---------------------------------------------------------------------------
The Committee believes these positions should be filledby
experienced faculty and expects that the Secretary and the tribal
colleges or universities would be selective in placing these
individuals to avoid compromising the quality of education and
accreditation.
The Committee strongly encourages the Secretary to examine
the Title I programs with targeted, holistic, long-term
approaches in mind and to develop more opportunities to
increase the number of Indians in the health professions. The
Committee believes that in the long-run, improving health
educational opportunities at every level will also contribute
to improving the health of Indian communities.
Home Health Care. Current law authorized a feasibility
study to be conducted on hospice care services. However, the
IHS never conducted that study and now, thirteen years later,
to conduct such a study would greatly delay what have already
been demonstrated to be much needed services.
The Committee has been informed that some Indian tribes and
tribal organizations, through pilot projects, have provided
this type of service or other services such as home-health care
with great success. The Committee is concerned that not
authorizing through the Indian health care system these
services and other long-term or home health care services that
have been an accepted part of the national health care system
and Medicare since 1983 will prevent IHS and tribes from
utilizing a proven, effective health delivery vehicle.
Currently, home health care, long-term care and hospice
care are not readily available to most Native communities.
Indians must travel long distances only to be placed in
facilities that are far from home, culturally unfamiliar, and
not conducive to their well-being. Having culturally-
appropriate facilities close to Indian communities will not
only promote the patient's well-being, but will enable family
members to more easily visit the patient.
Section 213 of S. 1057 authorizes the Secretary to fund
other services which meet the policy objectives set forth in
section 3 of the legislation. A partial list of such other
services includes hospice care, assisted living, long-term
health care, home- and community-based services, public health
functions, and traditional health care practices.
Concerns have been raised regarding the economic
feasibility of facilities providing these types of services, if
access is limited to just Indians. Therefore, subject to the
``two-part determination'' under Section 807 of the bill, the
IHS, Indian tribes, or tribal organizations may provide the
types of care authorized in Section 213 to persons otherwise
ineligible for the health care benefits of the IHS, provided
that such persons furnish reimbursement of reasonable charges
for such services. The inclusion of these individuals may be
necessary in some circumstances to achieve the minimum patient
base needed to make the venture economically feasible and to
realize the cost efficiencies of providing these services.
With regard to the services authorized by Section 213, the
Department of Justice informally expressed concerns with a
subset of the home- and community-based services, specifically
``chore services''. These concerns primarily focus on potential
liability for the Federal government that may arise under the
Federal Tort Claims Act from: (1) services provided in a
setting other than an IHS or tribal facility that are not
directly associated with the medical condition being treated,
(2) whether the providers will be adequately trained, and (3)
family members' support being included as a standard service.
To address these concerns the Committee struck the words
``homemaker'' and ``chore services'' from the definitions in
the substitute amendment adopted in Committee. The substitute
amendment further clarified the ``Personal care services''
definition to specify that ancillary tasks, when performed,
must be associated with support services related to activities
of daily living. Last, the substitute amendment makes clear
that home- and community-based services do not include services
provided by an individual who is legally responsible for the
provision of such services, such as a family member or legal
guardian.
Traditional Health Care. The 1928 Merriam Report \71\
generated several initiatives to improve health conditions for
Native Americans. One reform was the active solicitation of
traditional Indian healers to participate in federal health
services to Indians--an abrupt change from the prior
assimilationist policies promoted by the Federal Government.
---------------------------------------------------------------------------
\71\ Merriam, Lewis (ed.), Institute for Government Research, The
Problem of Indian Administration (1928) (commonly referred to as the
``Merriam Report'').
---------------------------------------------------------------------------
Several provisions in the Act reflected those reforms as
well.\72\ In particular, the Community Health Representatives
in the Act were required to ``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.'' 25 U.S.C. 1616(b)(6).
---------------------------------------------------------------------------
\72\ Other federal agencies also appear to be consider the value of
traditional healing in assisting Indian people recover from various
maladies such as post-traumatic stress disorders. See e.g.,
www.helenair.com/articles/2005/11/30/montana/a06113005_01.txt, (Last
reviewed November 30, 2005).
---------------------------------------------------------------------------
The Committee is aware that Indian tribes have long sought
to promote traditional healing in the framework of the Indian
health system, but that concerns have been raised regarding
inclusion of traditional healing in the IHCIA.
One concern involves the possible legal liability to the
Federal Government in connection with the traditional
practices. Under the ISDEAA, Federal Tort Claim Act (FTCA)
coverage applies when Indian tribes or tribal organizations
administer programs or services pursuant to a contract or
compact. If traditional health practices were services provided
under an ISDEAA contract or compact, such practices would be
covered by the FTCA.
Other concerns have been raised regarding whether the
Federal Government or courts should be scrutinizing tribal
traditions in the defense against claims arising under the
FTCA. To address these concerns, the Committee encourages the
Secretary and Indian tribes to thoroughly examine the
traditional healing provisions through the implementation plan
under Section 803 of S. 1057, or through consultation,
particularly on how the traditional practices and healers fit
within the FTCA framework.
Behavioral Health. S. 1057 has a strong focus on behavioral
health. Title VII takes a comprehensive and integrative
approach to behavioral health, providing both prevention and
treatment programs for Indian children, youth, women and
elders. The bill also emphasizes the interconnectedness of
services related to alcohol and substance abuse, child welfare,
suicide prevention and social services. Particular programs are
authorized for Indian youth, Indian women, those affected by
fetal alcohol disorder in Indian communities, and both the
victims and perpetrators of child sexual abuse in Indian
households.
In addition to a comprehensive approach to addressing
behavioral health services, the Committee recognizes and
affirms the importance of providing care within the context of
an individual's family, community and particular tribal
culture, such as is used by the systems of care model.
Indian Youth Suicide Prevention. The alarming suicide rates
among Indian youth indicate a great need for improved,
comprehensive behavioral health care services.
The nation was shocked in March, 2005, when a troubled 16-
year old member of the Red Lake Band of Chippewa Indians in
Minnesota shot and killed his grandfather, his grandfather's
partner, five fellow high school students, a high school
teacher and a security guard and seriously wounded several
others at Red Lake High School on the reservation before
killing himself. Several other young people subsequently took
their own lives.
The publicity around the nation's second-most deadly school
shooting on the Red Lake reservation brought attention to the
fact that in Indian Country, suicide is characterized by higher
rates among a younger group than is experienced in the rest of
the country. The suicide rate for Indian and Alaska Native
youth, aged 15-24, is two and one-half times higher than the
national average. Youth suicide ``clusters'' have also occurred
on reservations in North and South Dakota, New Mexico and
Arizona and in Nativecommunities in Alaska.
In response to this tragedy, a number of resources were
provided to the Red Lake reservation, including services by
such Federal agencies as the IHS, SAMHSA and Office of Juvenile
Justice and Delinquency Prevention, as well as by state and
tribal agencies.
The Committee held two hearings specifically on the issue
of Indian youth suicide, one in Bismarck, North Dakota on May
2, 2005, and the other in Washington, DC, on June 15, 2005, to
discuss the kinds of resources and services being provided to
Indian youth who have expressed suicidal thoughts or attempted
suicide, and to explore what more might be done.
Based on the information developed through hearings, the
Committee added provisions to Title VII of S. 1057 which
address youth suicide as part of the behavioral health program
provisions. Other provisions added in Title I encourage more
Indian people to enter into the psychology profession by
increasing the number of grants for the program commonly
referred to as In-Psych (Indians into the Psychology) from 3 to
9 and by authorizing a specific level of funding.
The provisions also add a significant cultural component to
the suicide programs. They authorize the Secretary to award
grants for telemental health demonstration projects to provide
counseling to Indian youth and health providers, training for
Indian community leaders, and the development of culturally-
relevant materials.
The Committee is aware that suicide prevention for Indian
youth is a long-term effort that must address many multi-
factorial causes. Questions such as whether the loss of
cultural identity contributes to the youth suicide problem
remain unanswered. Consequently, S. 1057 makes suicide a
priority for the IHS research agenda, particularly the
identification of various factors that either protect the
tribal community or make that community at risk for suicides,
and the role the loss of tribal identity plays in suicidal
behavior.
Urban Indians. Providing for urban Indian health has been a
part of Federal policy for nearly 40 years. Congress began
funding urban Indian clinics in 1967 when $321,000 was provided
for an Indian clinic in Rapid City, South Dakota.\73\
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\73\ Senate Report No. 94-133, pg 136. In 1972, Congress added
funding to the IHS appropriations for a pilot program in Minneapolis.
Others followed in 1973 in Oklahoma City, Seattle and California (which
covered nine urban Indian organizations).
---------------------------------------------------------------------------
Congress specifically included urban Indian health programs
as part of the Indian health care system in the Act in 1976,
recognizing that the Federal obligation for health care
extended to these individuals, to correct disparities in health
levels for Indians living in urban areas first as pilot
programs and then permanently in the Indian health care system.
See Senate Report Nos. 94-133, 100-508 and 108-411.
The policies and status of Indians and Indian tribes under
Federal laws, treaties and judicial decisions provide ample
support for continuing and improving programs for urban
Indians. Under this varied history, the Federal government had
dealt with Indian tribes in a variety of ways: some by treaty,
others not by treaty. For some Indian tribes, the Federal
Government had ignored completely. Some Indian tribes were
legislatively blocked from some administrative programs, yet
were allowed to exercise treaty rights. Some Indian tribes were
``terminated'', yet later ``restored''.
Courts have long held with great favor that Congress has
the broad power to legislate for the benefit of Indians, even
if located off the reservation, and to define who is an Indian,
even if they may not be an enrolled member of a federally-
recognized Indian tribe, and for what purposes they may be
provided services.\74\
---------------------------------------------------------------------------
\74\ U.S. Const., Art. I Sec. 8, cl. 3. See also Cohen, Felix.
Handbook of Federal Indian Law, at 23. 1982 ed.; U.S. v. Holliday, 70
U.S. 407, 417 (1865) (the broad power also includes Congress' dealings
with individual Indians). As the courts suggest, federal policy for
Indians cannot be confined to reservation boundaries. (``The overriding
duty of our Federal Government to deal fairly with Indians wherever
located has been recognized by this Court on many occasions.'' Morton
v. Ruiz, 415 U.S. 199 (1974) (citing Seminole Nation v. U.S., 316 U.S.
286, 296 (1942); (``Patterns of cross or circular migration on and off
the reservations make it misleading to suggest that reservations and
urban Indians are two well-defined groups.'' U.S. v. Raszkiewicz, 169
F.3d 459, 465 (7th Cir. 1999).
---------------------------------------------------------------------------
For example, Congress has enacted laws which define Indians
in different ways for different purposes. See e.g., Indian Arts
and Crafts Act, Pub.L. 101-644, 25 USC 305; No Child Left
Behind Act, Pub.L. 107-110, 25 USC 7491; and the American
Indian Probate Reform Act of 2004, Pub.L. 108-374. Even the
criminal statutes under Title 18 of the U.S. Code regarding
crimes on Indian reservations do not define who is an Indian.
In other cases, Congress did not define Indians, nor place
geographical limitations on the service areas in which they may
be served. The Snyder Act, 25 USC 13, authorizes permanent
funding for health care for ``the Indians throughout the United
States''. This statute does not confine the services to Indians
who are members of current Federally-recognized tribes or to
those living only on reservations. The Snyder Act has never
been repealed nor otherwise limited in this respect.
Under this Act, Congress has provided a more inclusive
definition of urban Indian than mere membership in a federally-
recognized Indian tribe, including members of ``terminated''
tribes, that is, groups that once had a political government
relationship with the United States.
Termination was another failed Federal Indian policy
designed to end the government-to-government relationship with
Indian tribes and assimilate their members into the larger
society. However in remedying the devastating effect of
termination, Congress saw fit to continue the health services
in the Act to those individuals. See Menominee Tribe v. U.S.,
391 U.S. 404 (1968). Likewise, by including members of state-
recognized tribes, Congress recognized that several Indian
tribes had treaty relations with individual states before the
Federal government was established, often referred to as
``state-recognized tribes''.
Congress did not in this Act recognize either the
``terminated tribes'' or the state-recognized tribes on the
same basis or for the same purposes as the federally-recognized
tribes under this Act. However, the U.S. Supreme Court has
found that extending Federal protection for limited purposes,
such as in this Act, is within Congressional power.
Further, in adopting S. 1057, the Committee is of the
opinion that the Congress was on firm constitutional footing
based on long-standing precedent. Indeed, the U.S. Supreme
Court has held that ``it is not meant * * * that Congress may
bring a community or body of people within the range of this
power by arbitrarily calling them an Indian tribe, but only
that in respect of distinctly Indian communities the questions,
whether, to what extent and for what time they shall be
recognized and dealt with as dependent tribes requiring the
guardianship and protection of the United States are to be
determined by Congress, and not by the courts.'' U.S. v.
Sandoval, 231 U.S. 28, 46 (1913) (emphasis added). Accordingly,
the Act extends health benefits to members of these groups
(terminated tribes and state-recognized tribes) without
extending Federal recognition to them for all purposes.
In enacting this Act, the Committee has found ample
justification for extending health services to the Indians who
ended up in these urban areas because of several major
developments:
First, Indians were provided an opportunity to work
and share in the Nation's prosperity in industries
prior to and during World War II; second, thousands of
Indian men and women served in the Armed Forces away
from their reservation, traditional communities or
Alaska Native villages; third, formal government
relocation programs moved many Indian families from low
employment, rural areas to urban areas where
``employment opportunities'' were considered more
readily available; and fourth, countless numbers of
Indians attempting to escape depressed conditions on
their reservations voluntarily relocated.\75\
---------------------------------------------------------------------------
\75\ Senate Report 94-133, page 131.
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The comprehensive approach of this Act is needed to more
fully implement the federal responsibility for Indian health
care and, even more so today, to address health disparities
facing the Indians that had moved from the reservations as a
result of the relocation policies. Relocating Indians from
reservations to urban areas is the Federal policy and program
first begun in 1931.\76\ ``Relocation complemented other
termination programs designed to promote rapid assimilation.
Once relocated, Indians were cut off from the special federal
services that had been available to them as reservation
residents.'' \77\
---------------------------------------------------------------------------
\76\ Felix Cohen, Handbook of Federal Indian Law (1982 ed.), at
169.
\77\ Id.
---------------------------------------------------------------------------
Congress has previously recognized that the establishment
of urban Indian health programs was necessary to rectify the
errors of failed Federal Indian policies such as relocation.
See Senate Report No. 94-133 at 138. The Committee further
found that Title V ``represent[ed] a Federal policy commitment
to provide the essential authorities and financial resources to
permit urban Indian organizations to develop needed health
services and to strengthen relationships with existing
community health and medical care programs.'' Senate Report No.
94-133 at 140.
The justifications for that policy are still valid today.
The most recent statistics indicate that urban Indians suffer
health disparities as do Indians located on reservations. For
example, the mortality rates are higher due to accidents (38%
higher than other populations), chronic liver disease and
cirrhosis (126% higher), diabetes (54% higher), alcoholism
(178% higher), and sudden infant death syndrome (157%
higher).\78\
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\78\ The Health Status of Urban American Indians and Alaska
Natives, Urban Indian Health Institute, March 16, 2004, available at
www.uihi.org (Last reviewed March 16, 2006).
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The Committee believes that continuation of services to
urban Indians, recognized by S. 1057, makes sense from both
policy and fiscal perspectives. The Committee has received
testimony that these urban Indian health programs improve
health services for Indians located in the urban centers in a
highly cost-effective manner.
In addition, the Committee has received testimony that
without the urban Indian health programs, urban Indians would
not seek care or could delay seeking proper medical attention
until their health problems erupt into emergency situations or
reach advanced stages when treatment is costlier and the rate
of survival is much lower.
By being located closer to the urban Indians than the
tribal health programs on the reservations, urban Indian health
programs reduce the number of emergency room visits by
providing early disease prevention services.
For example, the South Dakota Urban Indian Health Center
operates 3 clinics and experiences over 17,500 patient
encounters per year under the Title V program. This center
provides such services as a foot care home visit program
whereby Community Health Representatives conduct home visits to
assess diabetic patients (or those at risk for diabetes). These
home visits are a critical part of chronic disease management,
particularly in avoiding amputations due to diabetes.
The First Nations Community HealthSource in Albuquerque,
New Mexico provides dental, primary, and behavioral health care
for approximately 45,000 urban Indians and handles
approximately 12,700 patient encounters per year under the
Title V program.
The Native Americans for Community Action in Flagstaff,
Arizona provides immunizations, mental health and youth
substance abuse prevention services among several other primary
care services for urban Indians. The Committee has received
testimony suggesting that the patients at this urban Indian
health center would either have to travel 100 or more miles to
visit an IHS clinic on the reservation or wait two or three
weeks for an appointment at the local Community Health Center.
Either alternative would impose significantly more burdens on
the patient, and the testimony further suggests that most
patients would simply avoid the care altogether.
The Tucson Indian Center in Tucson, Arizona also provides
important disease prevention services such as substance abuse
prevention, wellness programs and immunizations. This Center
provides services for over 2,500 patient encounters under the
Title V programs.
The health program operated by the Nevada Urban Indians,
Inc. in Reno, Nevada provides, among other things, immunization
and diabetes education programs and experienced over 9,000
patient encounters in 2005. The Native American Rehabilitation
Association of the Northwest, Inc. in Portland, Oregon
experiences nearly 9,300 patient encounters per year, including
1,040 for mental health care and 3,400 for alcohol and drug
treatment. The N.A.T.I.V.E. Project in Spokane, Washington
provides a community wellness program and community outreach
services for diabetes screening and health education for a
community of approximately 12,000 urban Indians.
These programs, particularly the wellness, diabetes, and
behavioral health programs are critical to preventing the
development of diseases which may require long-term disease
management such as for diabetes and alcohol or drug addictions.
In addition, the outreach, screening and home-based care
programs are a vital component in ensuring the patients receive
early intervention and care rather than waiting until they need
emergency services which cost far more than intervention
services.
Urban Indian health programs provide culturally-appropriate
health care for Indians. The Committee has received testimony
that Indians may avoid non-Indian (or ``mainstream'') health
providers who are unfamiliar with or insensitive to Indian
culture. The urban Indians have confidence in the urban Indian
health programs and are more likely to seek care when the
provider recognizes and respects culturally-appropriate care.
Urban Indian health programs also address continuity of
care for Indians migrating between the urban areas and
reservations. Even though the disavowed policy of relocation no
longer forces such migration, moving from the reservation to
urban areas is not uncommon for these individuals, and neither
is their return to the reservation. For example, the urban
Indians may travel to the reservation for traditional
ceremonies, tribal political (elections) or cultural events
(e.g., pow-wows, festivals), clan or family events, and so on.
On the other hand, Indians may move to the urban areas for job
or educational opportunities--and carry with them the need for
continuity of care. The Committee has received testimony that
these programs recognize the migration and account for it in
their patient care, particularly for quality follow-up care.
The urban Indian health programs provide services for the
uninsured Indians who might not be able to obtain care
elsewhere. With poverty rates of urban Indians hovering at 25%
(compared to 14% for the general population), and nearly half
living below 200% of the Federal poverty level (compared to 30%
for the general population) \79\, it is no surprise that many
urban Indians are uninsured. The Committee has received
testimony that in Boston, Massachusetts, 87% of the Boston
Indian Center's clients have no health insurance and nearly two
out of three urban Indians in Arizona have no insurance.
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\79\ The Health Status of Urban American Indians and Alaska
Natives, Urban Indian Health Institute, March 16, 2004.
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The Committee believes that the urban Indian health
programs are a crucial component in the overall Federal effort
to reduce the health disparities for the urban Indians. Without
such services by the Title V health programs, it is quite
likely that the health disparities among the urban Indians will
increase. This result would contradict the Congressional policy
embodied in this Act and other statutes of increasing access to
health care and of remedying health disparities resulting from
the past failed Federal Indian policies.
Dental health aides. Decades of inadequate access to dental
care, along with other factors that contribute to the generally
worse health condition of Indians as compared to the general
population, have led to a true epidemic of dental disease in
Indian communities and for Alaska Natives in particular.
According to Oral Health in America: A Report of the
Surgeon General, the incidence rates for periodontal disease
among Indians is 2\1/2\ times that of the general public.\80\
In Alaska Native communities, it is not uncommon for the
children to require extraction of all of their baby teeth due
to pervasive caries. Nor is it uncommon for the nutritional
status of Alaska Native elders to be compromised by their
inability to consume healthy foods due to dental pain or
missing teeth.
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\80\ U.S. Department of Health and Human Services, U.S. Public
Health Service, National Institute of Dental and Craniofacial Research,
National Institutes of Health, Oral Health in America: A Report of the
Surgeon General (2000) at 77.
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This situation is exacerbated by a chronic shortage of
dentists. Alaska Tribal health programs are currently
experiencing a persistent 25 percent vacancy rate among
dentists, with an annual 30 percent turnover rate.\81\ Even if
the number of dentists in the IHS/tribal system were doubled,
it would take 10 years to address the unmet need for dental
services.\82\ A recent independent evaluation of the DHAT
Program in Alaska reports that ``five full-time paid dentist
positions in the Yukon-Kuskokwim Delta have remained vacant for
six years despite a salary/benefits package starting at
$177,000.'' \83\
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\81\ Indian Health, Hearing Before the Senate Comm. on Indian
Affairs, 109th Cong., 1st Sess., S. Hrg. 109-26, at 168 (April 13,
2005) (statement of Sally H. Smith, Chairman, National Indian Health
Board).
\82\ S. Hrg. 109-162, at 784 (statement of Dr. Mary Willard, Yukon-
Kuskokwim Health Corporation).
\83\ Fiset, Louis. ``A Report on Quality Assessment of Primary Care
Provided by Dental Therapists to Alaska Natives.'' August, 2005.
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At its joint hearing on S. 1057 on July 14, 2005, with the
Senate Health, Education, Labor and Pensions Committee, the
Committee examined issues surrounding the Dental Health Aide
Therapist (DHAT) program currently operated under the Community
Health Aide/Practitioner (CHAP) program in Alaska Native
communities. The Committee received testimony regarding the
crisis in oral health care in Alaska Native communities and how
the DHAT program was a result of Alaska Native leaders and
health providers searching for a means of addressing it. The
Committee believes that the use of Alaska Natives trained
through the DHAT program to serve as dental health aide
therapists in Alaska is a necessary response to this access to
care crisis.\84\
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\84\ Because no U.S. dental school provides mid-level dental
training, DHATs are trained at the University of Otago, New Zealand,
under a two-year program. The Committee has been informed that the DHAT
Program is operated with wide success in Canada and 40 other countries.
See World Oral Health Country/Area Profile Programme, World Health
Organization Collaborating Center.
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At the July 14 joint hearing, Dr. Willard, who serves as a
dentist for the Yukon-Kuskokwim Health Corporation in Bethel,
Alaska, testified before the Committee that the CHAP program
has been used in Alaska for 30 years and that the dental health
aides are part of the often-remote Native communities.\85\ She
further testified that DHATs must meet the same dental
standards and quality assessments that IHS uses for dentists,
and that their skills are equal.
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\85\ S. Hrg. 109-162, at 363-363 (statement of Dr. Mary Willard,
Yukon-Kuskokwim Health Corporation).
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The DHAT program in Alaska has been part of the CHAP
program since 2002, and DHATs provide a wide range of oral
health care promotion and disease prevention services. For the
most part, the DHAT program is supported and applauded for its
efforts in reducing the extraordinary dental crisis in Alaska
Native communities. However, some activities have generated
controversy because they require the performance of certain
irreversible procedures, specifically, the treatment of dental
caries, pulpotomies and extractions of teeth.
Despite strong concerns expressed by the American Dental
Association about the quality of care that would be provided by
the DHATs, the Committee has received letters indicating strong
support of the DHAT Program in Alaska from the State of
Alaska's Department of Health and Human Services, the Alaska
Native Health Board, the Alaska Native Tribal Health
Consortium, the American Dental Hygienists' Association, and
others.\86\
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\86\ See also Id., at 716 et seq. (statement of Don Kashaveroff,
President, Seldovia Village Tribe).
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The Committee wants to ensure that Alaska Natives receive
the best feasible care and appreciates the concerns for patient
safety regarding the use of DHATs to perform surgical dental
procedures (extractions, pulpotomies and diagnosis and
treatment of caries). However, the difficult policy decisions
lie in balancing perceived risks to patient safety against the
alternative reality of their receiving no care at all.
Consequently, the Committee has determined to limit the
DHAT program to Alaska and require a study of the program. The
study will be conducted by a panel of neutral experts,
including clinicians with experience in providing care to
remote populations and clinicians who can measure and evaluate
oral and medical complications, community practitioners from
Alaska, economists with experience in dental delivery, oral
epidemiologists, and Alaskan Natives with experience in the
health delivery system.
In developing the study parameters, the Secretary must
consult with appropriate professional organizations, among
other parties. The Committee expects that the American Dental
Association will be specifically included in that consultation
given their concerns and expertise in these matters.
Furthermore, the Committee believes that the study should
compare the care provided by the DHATs with care provided by
other dental delivery systems, such as the ``Integrated Dental
Health Program for Alaska Native Populations'' model developed
by Drs. Howard Bailit, Tryfon Beazoglou, Amid Ismail, and
Thomas Kovaleski. During the term of this study, the Secretary
should engage in appropriate oversight and take actions
necessary to ensure that patient health and safety is not
compromised.
Section-by-Section Analysis
A significant portion of current law has been carried
forward by S. 1057 and reorganized in the various titles
according to subject matter. S. 1057 also adds several new
provisions to current law which may (1) amend current law, such
as turning a demonstration project into a permanent program,
(2) simply clarify or make small additions, such as including
tribal organizations in various sections, or (3) introduce
brand new programs to the Indian health care system, such as
hospice care.
The following section-by-section analysis will, where
relevant, identify whether current law has been changed
followed by an explanation of the current law to be
reauthorized by S. 1057. In addition, the codified section in
current law will also be noted to provide ease of reference.
Section 1. Short title. This Act may be cited as the
``Indian Health Care Improvement Act Amendments of 2005''.
Section 2(a). Indian Health Care Improvement Act Amended.
This section begins the provisions of the Act ending with
Section 816. The following section numbers of this analysis
will reflect the section numbers of the Act.
Section 1. Short title; table of contents
This Act may be cited as the ``Indian Health Care
Improvement Act''. Section 1 also contains the table of
contents.
Section 2. Findings
This section maintains current law.
Current law: Section 1601 of current law (25 U.S.C. 1601)
sets out Congressional findings for the Act which indicate that
the health levels of Indians are below that of the rest of the
U.S. population and that the provision of health care is
consonant with the Federal relationship and responsibility to
Indian people.
Section 3. Declaration of national Indian health policy
This section amends current law by (1) replacing the
enumerated list of health level objectives with the goals
contained in the Healthy People 2010 national health agenda;
and (2) adding new language to (a) add trust to the
responsibilities being fulfilled by the national policy, (b)
allow Indians to set their priorities according to their needs,
(c) increase the health profession degrees awarded to Indians
so the levels of Indian health professionals in each Service
Area is at least the level of the general population, (4)
require consultation consistent with Indian self-determination,
and (5) provide funding to Indian tribal programs and
facilities consistent with levels of IHS programs and
facilities.
Current law: In Section 1602, Congress declares that the
national policy, in fulfillment of special responsibilities and
legal obligation to Indians, is to assure the highest possible
health status for Indians and urban Indians and to provide all
resources necessary to effect the policy. In addition, the
policy is to meet an enumerated list of health status
objectives for Indians such as reducing coronary heart disease
to no more than 100 per 100,000. It is also the intent of
Congress that the proportion of degrees awarded in the health
professions to Indians be increased to 0.6 percent. The
Secretary is also required to report on the progress made in
each objective annually.
Section 4. Definitions
This section (Section 1603 in current law) maintains
current law and adds several new definitions to reflect current
practices, significant updates and coordination in health
services to Indians, as follows: accredited and accessible,
Area Office, Assistant Secretary, behavioral health, community
college, contract health service, Department, Indian health
program, junior or community college, reservation, telehealth,
telemedicine, Traditional Health Care Practices, tribal college
or university, and Tribal Health Program.
TITLE I--INDIAN HEALTH, HUMAN RESOURCES, AND DEVELOPMENT
Section 101. Purpose
This section maintains current law and adds language
indicating Congressional intent to maximize the number, and
assure an optimum (not merely adequate) supply, of health
professionals in the Indian health system.
Current law: Under Section 1611, the purpose of Title I is
to increase the number of Indian health professionals and to
assure an adequate supply of health professionals to provide
health services to Indians.
Section 102. Health professions recruitment program for Indians
This section maintains current law.
Current law: Section 1612 authorizes funding for
recruitment programs, to include identifying Indians with
potential for entering health professions, publicizing funding
sources, and establishing programs to facilitate enrollment in
applicable courses of study. This section also addresses
funding applications and amount of funding to be provided, as
well as outlining the eligibility for these programs.
Section 103. Health professions preparatory scholarship program for
Indians
This section maintains current law and adds new provisions
authorizing extensions of pregraduate scholarship award terms
up to 2 years according to Secretarial regulations and
authorizing regulations for determining part-time equivalents
for the compensatory preprofessional scholarships.
Current law. Section 1613 authorizes scholarships to
Indians for compensatory preprofessional education as well as
pregraduate education leading to a baccalaureate degree in a
preparatory field for a health profession. The compensatory
preprofessions scholarships are awarded for up to two years on
a full or part-time basis and pregraduate scholarships are for
up to four years (S. 1057 adds 2-year extensions). This section
specifies certain conditions on these scholarships which
include the types of costs that may be covered and prohibits
denial of a scholarship based solely on scholastic achievement
if the applicant has already been admitted or maintains good
standing at an accredited institution or if the applicant is
eligible for assistance under another Federal program.
Section 104. Indian Health Professions Scholarships
This section maintains current law and adds new provisions
that (1) require a year-for-year service obligation for
scholarship recipients, (2) require Secretarial guidelines for
fulfilling the service obligation in private practice, and (3)
allow a recipient to fulfill the service obligation by teaching
in a tribal college or university nursing program if health
services to Indians are not diminished.
Current law. Section 1613a authorizes scholarships,
designated as Indian Health Scholarships, to Indians who are
enrolled full or part time in accredited schools pursuing
courses of study in the health professions. Scholarship
recipients are then required to fulfill a service obligation by
either working for an IHS, tribal or urban Indian health
program or in private practice located in a health professional
shortage area with the length not specified in statute. The
section further sets forth how the funding for these
scholarships is to be allocated and addresses all the
requirements of the active duty service obligation incurred as
a result of the scholarship, including breach of contract
situations.
Section 105. American Indians Into Psychology Program
This section maintains current law and adds new language
which (1) sets the number of colleges or universities that may
receive grants from at least 3 to 9 and (2) establishes a
maximum grant amount of $300,000, for a total of $2.7 million
for each of FY 2006 through 2015.
Current law: Section 1621p authorizes grants to at least 3
colleges and universities for developing and maintaining Indian
psychology career recruitment programs, including one to
develop and maintain the Quentin N. Burdick American Indians
Into Psychology Program at the University of North Dakota. This
section directs the Secretary to issue regulations for
competitive funding and specifies conditions of the grants and
active duty service requirements.
Section 106. Scholarship programs for Indian tribes
This section maintains current law and adds new language
which (1) amends the source of funds for the scholarship costs
by allowing 20% to be from any source instead of only non-
federal sources, (2) requires that licensing and educational
requirements for all health professions, instead of only
thedoctor and nursing professions, be met, and (3) adds Title XXI of
the Social Security Act to the non-discriminatory provisions.
Current law: Section 1616m authorizes the Secretary to make
funds available to Tribal Health Programs for the purpose of
educating Indians to serve as health professionals in Indian
communities. This section specifies the requirements for
receiving such funds; the course of study; contract conditions;
specific parameters for a breach of contract; the relationship
of a scholarship under this section to the Social Security Act;
and conditions of continuance of funding are all specified in
this section. The recipient cannot discriminate against
patients who receive assistance under Titles XVIII and XIX of
the Social Security Act. The recipients shall be required to
fulfill service obligations and use the scholarship for tuition
and reasonable education or living expenses.
Section 107. Indian health service extern programs
This section maintains current law and adds provisions (1)
extending the extern program to tribal or urban Indian health
providers (on a discretionary basis) or other DHHS agencies (as
available) instead of only the IHS, (2) instead of entitling
the externs to employment, gives them a preference for
employment with the IHS, and allowing an extern program for
high school programs.
Current law: Section 1614 gives preference for employment
in the Service (and as added by S. 1057, a Tribal Health
Program, Urban Indian Organization or other agencies within the
Department), to any recipient of a scholarship pursuant to
section 1613a or 1616m. The section specifies that such
employment does not count toward any active duty service
obligation. It specifies the timing and length of employment
and exempts the program from any competitive personnel system
or agency personnel limitation.
Section 108. Continuing education allowances
This section maintains current law, except for the deletion
of the set-aside for postdoctoral training, and adds language
which extends the continuing education allowances to tribal and
urban Indian health providers, not just the IHS, and includes
all health professionals.
Current law: To encourage health professionals to join the
IHS and continue working in rural or remote areas where
significant numbers of Indians reside, Section 1615 permits the
Secretary to provide allowances to health professionals
employed by the IHS to enable them to take leave of their duty
stations for a period of time each year for professional
consultation and refresher training courses. Section 108 also
authorizes a set-aside of not more than $1 million for
postdoctoral training programs.
Section 109. Community Health Representative Program
This section maintains current law and adds language which
formally identifies the health paraprofessionals as Community
Health Representatives (CHRs) and extends the use of CHRs to
tribal and urban Indian health programs.
Current law: Section 1616 authorizes the CHR Program for
training and using Indians as CHRs. This section specifies the
duties of the Service regarding this program, including
providing supervision, an evaluation system and a high standard
of training for CHRs to ensure that they provide quality health
services to Indian communities served by this program. This
program may also promote traditional health care practices
consistent with IHS standards for health care.
Section 110. Indian Health Service Loan Repayment Program
This section maintains current law and (1) eliminates the
obsolete set asides during FY 1993-1995 for nursing and mental
health professions, (2) establishes priorities among
applications rather than requiring the priorities be subject to
the list of positions established by the Secretary, and sets a
21-day notice requirement instead of merely prompt notice.
Current law: Section 1616a establishes the Indian Health
Service Loan Repayment Program in order to ensure an adequate
supply of trained health professionals needed to maintain
accreditation and provide health care services to Indians. The
section specifies eligibility for the program which includes
individuals with a degree or license in a health profession, in
graduate training or about to complete an approved course of
study. The application information must clearly explain rights
and obligations and be available very early so individuals can
timely complete the applications. This section outlines how the
priorities for program participants will be established.
Recipient contracts are required which set forth the rights and
obligations. This section establishes deadlines for decisions
on applications (21 days under S. 1057). The loan repayment
program includes payment of principal, interest and related
expenses of school loans up to $35,000 for each year of
obligated service and, in addition to this payment, may include
an amount to cover tax liability incurred for this payment.
This section also includes a waiver from any employment
ceiling; recruitment programs; non-applicability of Section 215
of the Public Health Service Act; assignment of individuals;
breach of contract; waiver or suspension of obligation; and the
requirement of an annual report to Congress.
Section 111. Scholarship and Loan Repayment Recovery Fund
This section maintains current law and adds provisions
expanding the source of funds for this Recovery Fund, in
addition to appropriations, to include collections from
contract breaches for the scholarships or loan repayment
programs and interest. Tribal health programs may also use
payments received to provide scholarships, in addition to the
current uses of recruitment and employment of health care
professionals. The Secretary of DHHS may now determine what
amounts are not required to meet withdrawals for the Fund,
rather than the Secretary of the Treasury.
Current law: Section 1616a-1 establishes an Indian Health
Scholarship and Loan Repayment Recovery Fund within the
Treasury of the United States wherein funds collected for
breaches of contractual obligations under the IHS or tribal
scholarships or under loan repayment programs. The section
specifies the use of these funds which includes employment or
recruitment of health professionals, the investment of the
funds, and the sale of obligations by the Secretary of the
Treasury. The Secretary of the Treasury may also invest funds
in this Fund which are not necessary to meet withdrawals for
the uses specified in this Section.
Section 112. Recruitment activities
This section maintains current law and adds language to
allow reimbursement for health professionals seeking positions
with tribal and urban Indian health programs, in addition to
the IHS.
Current law: Section 1616b permits the Secretary to
reimburse certain travel expenses to health professionals
seeking positions with the IHS. Potential candidates for
contracts under section 110 and their spouses are all eligible
for such reimbursement of travel. In addition, this section
requires the Secretary to assign one individual in each Area
Office to have full-time responsibility for recruitment
activities.
Section 113. Indian Recruitment and Retention Program
This section maintains current law and adds language which
(1) sets a time limit of three years for demonstration projects
funded under this section instead of an open-ended timeframe
under current law and (2) clarifies that the Indian
organizations eligible to compete are urban Indian
organizations.
Current law: Section 1616c requires the Secretary to fund
innovative demonstration projects (under S. 1057 for up to 3
years) to enable Indian tribes, tribal and Indian organizations
to recruit, place, and retain health professionals to meet the
staffing needs of Indian health programs. The section also
specifies that any Indian tribe, tribal or Indian organization
is eligible to apply for these funds and compete on the same
basis as IHS programs which receive grants under this section.
Section 114. Advanced training and research
This section maintains current law and adds language which
limits the advanced training or research opportunities to
health professionals who have worked for the IHS, tribal or
urban Indian health programs for a substantial period of time,
instead of merely being employed by one of these programs at
the time of application.
Current law: Section 1616d establishes a demonstration
project to enable health professionals who are employed in an
Indian Health Program or Urban Indian Organization at the time
of application to pursue advanced training or research areas of
study, where a need exists. The section also imposes a service
obligation for the recipients and requires equal opportunity
for participating in the program.
Section 115. Quentin N. Burdick American Indians into Nursing Program
This section maintains current law and adds language which
(1) includes advanced practice nurse programs in addition to
nurse practitioners, (2) authorizes grants for midwife or
nursing programs at tribal colleges and universities or, in
their absence, other colleges and universities, instead of only
at the other public or private institutions, (3) includes
tribal colleges and universities in the preferences among grant
applicants.
Current law: Section 1616e authorizes the Quentin N.
Burdick American Indians into Nursing Program for the purpose
of increasing the number of nurses, nurse midwives, and nurse
practitioners who deliver health care services to Indians. The
section specifies potential grant recipients and requires that
one of them be for the program at the University of North
Dakota; how grants may be used; information which must be
included in applications for the grant; preferences for grant
recipients; establishment and maintenance of a program at the
University of North Dakota; and an active duty service
obligation.
Section 116. Tribal cultural orientation
This section maintains current law and adds language which
(1) ensures that employees in each Service Area obtain cultural
orientation, rather than merely establishing a program for
cultural orientation, (2) requires the program to include
instruction on the relationship of the Indian tribes with the
IHS, rather than simply a history of the IHS, and a description
of the traditional health care practices of the Indian tribes
in the Service Area and (3) requires consultation with affected
tribal and urban Indian organizations.
Current law: Section 1616f requires appropriate employees
of the Service who serve particular Indian Tribes to receive
instruction in the history and culture of the tribes they serve
and in the history of the IHS. The section requires the
Secretary to develop such a program in consultation with the
affected Indian tribes, which shall, to the extent feasible, be
implemented through tribal colleges or universities and include
instruction in NativeAmerican studies.
Section 117. INMED Program
This section maintains current law and adds language which
(1) authorizes grants to an unspecified number of colleges or
universities instead of the previous mandate of at least 3
schools, (2) clarifies that the regulations govern the grants,
including substantive provisions such as criteria and
application requirements, rather than only the competitive
award process, and (3) eliminates an old 1988 requirement of a
report to Congress on the program and recommendations for
changes.
Current law: Section 1616g authorizes the Secretary to
provide grants to at least 3 colleges and universities to
maintain and expand the Indian health careers recruitment
program (Indians Into Medicine Program). The Quentin N. Burdick
Indian Health Programs at the University of North Dakota is to
be one of the authorized grants. This section also specifies
requirements for institutional applicants for these grants.
Section 118. Health training programs of community colleges
This section maintains current law and adds language which
(1) recognizes accredited and accessible community colleges as
eligible recipients of grants, (2) requires the colleges to
have a relationship with a hospital, rather than merely having
access to a hospital, (3) requires Indian preference for
program participants, (4) increases the ceiling amount of the
grant from $100,000 to $250,000, and (5) establishes priority
for tribally-controlled colleges in Service Areas where they
exist if other requirements in the section are met.
Current law: Section 1616h requires the Secretary to award
grants to (under S. 1057, accredited, accessible) community
colleges to assist in establishing health profession education
leading to a degree or diploma for individuals who desire to
practice such profession on or near a reservation or in a
tribal clinic. The Secretary is also required to award grants
to the colleges that already have these programs. The Secretary
must provide technical assistance to encourage community
colleges to establish and maintain such programs. Finally, any
program receiving assistance under this section is required to
provide advanced training for health professionals.
Section 119. Retention bonus
This section maintains current law and adds language
expanding the bonuses (1) to any health professional, rather
than only doctors and nurses, so funding set-asides between
these 2 professions have been deleted, (2) to health
professionals employed by the tribal or urban health programs,
rather than employed only by the Service, and eliminates the
requirement that the retention bonus be paid at the beginning
of the term of service.
Current law: Section 1616j permits the Secretary to provide
retention bonuses for health professions where recruitment or
retention is difficult if the individual has completed 3 years
of employment and any service obligation from federal
scholarships or loan repayment programs. Rates for retention
bonuses may cover multiple years, but not exceed an annual rate
of $25,000. Refunds shall be required if the health
professional does not complete the term of service under any
retention agreement, unless the default is not the fault of the
individual.
Section 120. Nursing residency program
This section maintains current law and adds language which
establishes this program for Indian nurses and includes
advanced degrees or certifications in nursing or public health
as eligible programs, besides a Master's degree as appropriate
post-baccalaureate training.
Current law: Section 1616k establishes a program to enable
nurses working for an Indian Health Program or Urban Indian
Organization to pursue advanced training. The participants are
required to enter a service obligation. The program shall
include a combination of education and work study leading to
either an associate or bachelor's degree in nursing degrees or
a Master's degree.
Section 121. Community health aide program
This section maintains current law and adds provisions
which (1) require the Secretary to establish a neutral panel,
whose membership is also set forth in this section, to study
the dental health aide therapist program in Alaska Native
communities and to submit a report on the study to appropriate
Congressional Committees and (2) authorizes the expansion of
the Community Health Aide Program, except for the dental health
aide therapist program, to Indian communities in the lower 48
states.
Current law: Section 1616e directs the Secretary to develop
and operate a Community Health Aide Program in Alaska.
Requirements are specified for the Alaska program including the
(1) development of training and curriculum combining theory and
practical experience, (2) instruction in acute care, health
promotion, (3) establishment of a certification Board, and (4)
development of systems for continuing education and
supervision.
Section 122 Tribal health program administration
This section maintains current law and adds language which
specifies that the training shall be for Indian individuals.
Current law: Section 1616n requires the Secretary to
provide training in the administration and planning of Tribal
Health Programs.
Section 123. Health professional chronic shortage demonstration
programs
This section amends current law by changing a lone pilot
program to address health professional shortages into a
national demonstration project.
Current law: Section 1616o authorizes the Secretary to make
a grant to the School of Medicine at the University of South
Dakota to fund a pilot program on an Indian reservation at one
or more service units in South Dakota to address the chronic
manpower shortages in the Aberdeen Area of the IHS. The pilot
program shall incorporate a program advisory board composed of
representatives from the tribes and Indian communities which
are served by the program.
Section 124. National health service corps
This section maintains current law and adds urban Indian
health programs within the protections against removal of any
member of the Corps working in the programs. The section also
exempts National Health Service Corps scholars qualifying for
the Commissioned Corps in the United States Public Health
Service from full-time equivalent limitations when serving as a
commissioned corps officer in a Tribal Health Program or an
Urban Indian Organization.
Current law: Section 1680b prohibits the Secretary from
removing a member of this Corps from an Indian health program
or withdrawing funding to support such member, unless the
Secretary ensures that Indians will experience no reduction in
services.
Section 125. Substance abuse counselor educational curricula
demonstration programs
This section maintains current law and adds language
including accredited and accessible qualifications for the
community colleges eligible for these programs and extending
the initial grant period from one year to three years and the
renewal periods from one year to two years.
Current law: Section 1665j allows the Secretary to enter
into contracts with or make grants to colleges and universities
(including tribal) to establish demonstration programs
developing curricula for substance abuse counseling. Duration
and renewal of the grant are both for periods of one year each.
The section also states the criteria for review and approval of
the applications, requires the Secretary to provide technical
and other assistance to grant recipients, requires the
Secretary to submit an annual report to the President for
inclusion in the annual report to Congress and defines the term
``educational curriculum'' and ``eligible community college''.
Section 126. Behavioral health training and community education
programs
This section maintains current law and (1) adds tribal
organizations and urban Indian organizations as participants in
the program, (2) clarifies that the tribal and urban Indian
organizations are part of the consultation process, (3) changes
the focus from solely on mental health to behavioral health and
(4) eliminates the requirement that the staff be assigned
primarily to the IHS Service Units.
Current law: Section 1621h(d) requires the Secretary, with
the Secretary of the Interior and in consultation with
representatives of the Indian Tribes, to conduct a study and
compile a list of certain types of staff positions within the
Bureau of Indian Affairs, the Service and Indian Tribes,which
should include training in any aspect of mental illness, dysfunction,
or self-destructive behavior. The Secretary is then required to provide
training criteria appropriate for each type of position and ensure that
this training is provided. On request of the appropriate Indian entity,
the Secretary is required to develop and implement a program of
community education on mental illness, as well as technical assistance
to tribal entities to obtain and develop community education materials.
Within 90 days of enactment of this Act, the Secretary is required to
develop a plan to increase mental health services by at least 500 staff
positions within 5 years, with at least 200 of such positions devoted
to child, adolescent, and family services. Such staff would be assigned
primarily to the IHS service unit levels.
Section 127. Authorization of appropriations
Section 127 authorizes appropriations as are necessary to
carry out this title for each fiscal year through 2015.
TITLE II--HEALTH SERVICES
Section 201. Indian Health Care Improvement Fund
This section maintains current law and adds provisions
clarifying that the Secretary may expend funds either directly
or through contracts or compacts under the Indian Self-
Determination and Education Assistance Act, as well as
provisions regarding the use of telemedicine and Traditional
Health Care Practices.
Current law: Section 1621 authorizes the use of funds,
designated as the ``Indian Health Care Improvement Fund'', for
the purposes of eliminating the deficiencies in health status
and resources for tribes; eliminating backlogs and meeting the
needs in health care services; eliminating the inequities in
funding for direct care and contract health service programs;
and augmenting the ability of the Indian Health Service to meet
its various responsibilities. Funding authorized by this
section may not be used to offset appropriated funds and must
be used to improve the health status and reduce the resource
deficiencies of tribes. This section also defines ``health
status and resource deficiency'' and requires that Tribal
Health Programs be equally eligible for funds as the IHS. A
report is required to be submitted to Congress 3 years after
enactment which addresses the current health status and
resource deficiency for each Service Unit. Funds appropriated
under this section are to be included in the base budget of the
IHS for determining appropriations in subsequent years.
Finally, nothing in this section is intended to diminish the
primary responsibility of the IHS to eliminate backlogs in
unmet health care, or to discourage additional efforts of IHS
to achieve parity among Tribes.
Section 202. Catastrophic Health Emergency Fund
This section maintains current law and adds language which
requires the use of negotiated rulemaking for promulgation of
regulations issued for this section.
Current law: Section 1621a establishes the Catastrophic
Health Emergency Fund (CHEF) to be administered by the
Secretary through the central office of the Indian Health
Service in order to meet the extraordinary medical costs
associated with the treatment of victims of disasters or
catastrophic illnesses. No part of the CHEF or the
administration thereof is to be subject to contract or grant,
nor shall these funds be apportioned on an Area Office, Service
Unit, or other similar basis. The Secretary is required to
promulgate regulations for the administration of these funds.
This section prohibits funds appropriated to CHEF from being
used to offset or limit other appropriations made to the Indian
Health Service. It also requires that all reimbursements to
which the Service is entitled from any source by reason of
treatment rendered to any victim of a disaster or catastrophic
illness the cost of which was paid from CHEF be deposited into
CHEF.
Section 203. Health promotion and disease prevention services
This section maintains current law, but moves the
definition of health promotion and disease prevention to the
definitions section and adds Congressional findings.
Current law: Section 1621b directs the Secretary to provide
health promotion and disease prevention services to Indians in
order to meet the Act's health status objectives. An evaluation
statement of the resources required to undertake these health
promotion and disease prevention activities would be included
in a required report to Congress.
Section 204. Diabetes prevention, treatment, and control
This section maintains current law and (1) adds (a) tribal
organizations as eligible participants in these programs, (b)
effective ongoing monitoring of disease indicators, (c) the
requirement that screening shall be to the extent medically
indicated and with informed consent, (d) funding for dialysis
programs, (e) consultation requirements; (2) changes the model
diabetes projects into permanent programs to be continued along
with any new programs developed with recurring funding; and (3)
still allows employment of diabetes control officers, but if
these positions and activities are administered by the Tribes
or Tribal Organizations, then the funding and activities would
not be divisible under the Indian Self-Determination and
Education Assistance Act.
Current law: Section 1621c requires the Secretary to
determine the incidence of this disease and its complications
among Indians and the measures needed to prevent, treat and
control it. The Secretary is also required to screen Indians
for diabetes and for conditions which indicate a high risk for
diabetes. The Secretary is required to continue to fund model
diabetes projects (and under S. 1057, dialysis programs). To
the extent that funding is available, the Secretary is required
to work with each Area Office to establish patient registries
in Area Offices and ensure that data collected are disseminated
to other Area Offices, subject to privacy laws. The Secretary
is also allowed to maintain diabetes control officers in each
Area.
Section 205. Shared services for long-term care
This section amends current law by changing a demonstration
project into a permanent program and adding new provisions
which (1) authorize other services similar in nature to long-
term care and construction for facilities for the similar
services and (2) encourage the use of existing underused
facilities or allow the use of swing beds for long-term or
similar care.
Current law: Section 1680l allows the Secretary to enter
contracts for 6 demonstration projects to deliver long-term
care services to Indians which may also authorize sharing of
staff, construction and proportionate allocation of funding
between the tribes and IHS. Any nursing facility funded under
this section must meet the requirements for such facilities
under section 1919 of the Social Security Act. In addition, the
Secretary is required to provide necessary technical and other
assistance to enable applicants to comply with the provisions
of this section.
Section 206. Health services research
This section amends current law by (1) eliminating the
specific set-aside of $200,000 for research and replacing it
with general authority to fund research for Indian health
programs, instead of only the IHS, (2) requiring the Secretary
to coordinate, to the extent practical, the resources and
activities for Indian health research needs, and (3)
authorizing the funding for both clinical and nonclinical
research.
Current law: Section 1621g authorizes funding for research
to further the performance of the health service
responsibilities of the IHS. Indian tribes and tribal
organizations contracting under the Indian Self-Determination
and Education Assistance Act are to be given equal opportunity
to compete for these research funds.
Section 207. Mammography and other cancer screening
This section amends current law by authorizing other cancer
screening, eliminating the minimum age requirement of 35 for
Indian women and opening the mammography screening to all
Indian women, at a frequency under appropriate national
standards.
Current law: Section 1621k requires the Secretary to
provide for mammography for Indian women 35 years or older at a
frequency determined by the Secretary in consultation with the
National Cancer Institute and consistent with appropriate
standards to ensure the safety and accuracy of the mammogram
under the Social Security Act.
Section 208. Patient travel costs
This section maintains current law and adds language which
allows the use of appropriate and necessary qualified escorts
and transportation by private vehicle where no other
transportation is available, specially equipped vehicle,
ambulance or by other means required when air or motor vehicle
transport is not available.
Current law: Section 1631l requires the Secretary to
provide funds for the travel costs of patients, for emergency
and non-emergency air transport where ground transport is not
feasible, associated with receiving health care services.
Section 209. Epidemiology centers
This section amends current law by (1) maintaining the
centers in existence on the date of passage of this Act, but
still requiring the establishment of centers in the remaining
Areas without reducing funds for the existing centers, (2)
allowing the funding for any new centers to be administered,
but not divisible, by tribes and tribal organizations under the
Indian Self-Determination and Education Assistance Act, but no
longer by tribal consortia and (3) eliminating the requirements
that the Secretary establish the data and formats for reporting
and establish the system for monitoring progress toward the
health objectives.
Current law: Section 1621m requires the Secretary establish
epidemiology centers in each Service Area. Newly established
centers may be operated by Tribal Health Programs. The
functions of these centers are delineated in this section. The
Director of the Centers for Disease Control and Prevention is
required to provide technical assistance to the centers and the
Secretary is authorized to provide funding to Tribes and Tribal
Organizations to conduct epidemiological studies of Indian
communities.
Section 210. Comprehensive school health education programs
This section maintains current law and adds language which
(1) clarifies the types of purposes for which the funds may be
used such as for both regular school and after school programs,
for the benefit of Indian and urban Indian children, for oral
health programs, for violence prevention and for other health
issues as appropriate, (2) includes tribal organizations and
urban Indian health organizations as eligible for funding, (3)
consolidates the reporting requirements into the application
criteria which is now subject to consultation between the
Secretary and the Indian tribes, tribal organizations and urban
Indian organizations.
Current law: Section 1621n allows the Secretary to provide
grants to Indian Tribes for the development of comprehensive
school health education programs for children from pre-school
through grade 12. The specific purposes for which funds may be
used are delineated. Upon request, the Secretary is required to
provide technical assistance in the development and
dissemination of comprehensive health education plans,
materials and information. The Secretary shall establish
criteria for review and approval of applications for this
funding. For Bureau of Indian Affairs funded schools, the
Secretary of the Interior shall develop similar programs.
Section 211. Indian Youth Program
This section maintains current law and adds tribal
organizations and urban Indian organizations as participants in
the program and consultation and includes urban Indian youth as
beneficiaries of program services.
Current law: Section 1621o allows the Secretary to
establish and administer programs for innovative mental and
physical disease prevention and health promotion and treatment
for Indian preadolescent and adolescent youths. Allowable and
prohibited uses of the funds authorized by this section are
delineated. The Secretary is required to disseminate
information regarding models for delivery of comprehensive
health care services to Indian youth; to encourage the
implementation of these models; and to provide technical
assistance upon request. The Secretary will establish criteria
for review and approval of applications under this section.
Section 212. Prevention, control, and elimination of communicable and
infectious diseases.
This section amends current law by expanding the
communicable diseases from simply tuberculosis to other
communicable and infectious diseases, by encouraging the Indian
tribes to coordinate with the Centers for Disease Control, by
eliminating superfluous provisions which reduce the grant
amount for expenses incurred by the federal government or for
supplies or equipment furnished to the grant recipient.
Current law: Section 1621q authorizes the Secretary to fund
projects specifically for the purpose of preventing,
controlling and eliminating tuberculosis. Funding is also
authorized for public information and education programs, and
skills improvement activities. Funding under this section
requires an application or proposal for funding. Entities which
receive funding under this section must provide assurances they
will coordinate their activities with the Centers for Disease
Control and Prevention as well as State and local health
agencies. Finally, in carrying out this section, the Secretary
may provide technical assistance upon request and shall submit
a report to Congress on the use of the funds and the progress
made toward prevention, control, and elimination of
tuberculosis among Indians.
Section 213. Authority for provision of other services
This section amends current law by making permanent a
demonstration project for home- and community-based care. The
new provisions also (1) add special requirements for the home-
and community-based care, (2) add several definitions, and (3)
eliminate the exclusion of cash payments, room and board,
construction and nursing facility services.
Current law: Section 1680k authorizes the Secretary to
establish not more than 24 demonstration projects for home- and
community-based care, excluding cash payments, room and board,
construction and nursing facility services, for functionally
disabled Indians. Discretion is provided to the Indian Health
Service, Indian Tribes, or Tribal Organizations to provide such
care to persons otherwise ineligible for the health care
benefits of the Indian Health Service (on a cost basis). The
Secretary is required to submit to the President for inclusion
in a report to Congress the findings of these projects. ``Home-
and community-based services'' and ``functionally disabled''
are defined.
Section 214. Indian women's health care
This section amends current law by eliminating the Office
of Indian Women's Health and, instead, requiring the Secretary
to monitor and improve the quality of Indian women's health
through the various programs administered by IHS.
Current law: Section 1621v establishes an Office of Indian
women's health to oversee efforts of the IHS to monitor and
improve health care for Indian women of all ages.
Section 215. Environmental and nuclear health hazards
This section maintains current law and adds language which
(1) requires ongoing monitoring of trends in health hazards to
Indians and other environmental hazards to Indian communities,
(2) provides additional considerations for the studies
conducted under this section and (3) requires consultation with
Indian tribes and tribal organizations in developing plans for
addressing the health problems.
Current law: Section 1677 requires the Secretary, in
conjunction with other Federal agencies, to conduct studies to
determine trends in the health hazards to Indian miners and
other Indians as a result of nuclear resource development. Upon
completion of such studies, the Secretary shall develop health
plans to address the health problems studied. The Secretary is
required to submit the study to Congress 18 months after the
date of enactment and a report no later than 1 year after the
study which includes recommendations for the implementation of
the plan and evaluation activities. This section establishes an
Intergovernmental Task Force to identify environmental hazards
and to take corrective action. The Secretary is to chair this
task force, which shall meet at least twice yearly. If an
Indian, who is employed in or around any environmental hazard,
suffers from a work-related condition, the Indian Health
Program which treats him may be reimbursed by the Indian's
employer.
Section 216. Arizona as a contract health service delivery area
This section maintains current law and extends the date to
2015, instead of 2000, for the designation as a contract health
service delivery area.
Current law: Under Section 1678, the State of Arizona is
designated as a contract health service delivery area for the
purpose of providing contract health care services to members
of federally recognized Indian Tribes of Arizona effective
fiscal years 1984 to 2000. The Indian Health Service will not
curtail any services as a result of this provision.
Section 216A. North Dakota and South Dakota as a contract health
service delivery area
This section is new.
New provisions: The States of North Dakota and South Dakota
are designated as one contract health service delivery area for
the purpose of providing contract health care services to
members of federally recognized Indian Tribes in North and
South Dakota. The Indian Health Service will not curtail any
services as a result of this provision.
Section 217. California Contract Health Services Program
This section amends current law by turning the
demonstration project for the California Indians into a
permanent program.
Current law: Section 1621j requires the Secretary to
establish a demonstration project using the California Rural
Indian Health Board (CRIHB) to serve as the contract care
intermediary to improve the accessibility of health services to
California Indians. The Secretary will reimburse CRIHB for
costs incurred pursuant to this section. Not more than 5
percent of the amounts provided under this section may be for
administrative expenses. No payment may be made for treatment
under this section to the extent payment may be made under the
Indian Catastrophic Health Emergency Fund or from amounts
appropriated or otherwise made available to the California
contract health service delivery area. This section also
establishes an Advisory Board, comprised of representatives
from not less than 8 Tribal Health Programs serving California
Indians covered under this section and at least one-half of
whom are not affiliated with the CRIHB. The Advisory Board will
advise the CRIHB in carrying out this section. The CRIHB is
also required to report to the Secretary on the demonstration
project findings.
Section 218. California as a contract health service delivery area
This section maintains current law, but allows the excluded
counties to become a part of the contract service delivery area
if funding is specifically provided for those counties.
Current law: Section 1680 designates the State of
California, excluding certain specified counties, as a contract
health service delivery area for providing contract health care
services to California Indians.
Section 219. Contract health services for the Trenton service area
This section maintains current law.
Current law: Section 1680e directs the Secretary 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 North Dakota and the
counties of Richland, Roosevelt, and Sheridan in Montana. This
section does not expand 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
these services that applied on May 1, 1986.
Section 220. Programs operated by Indian tribes and tribal
organizations
This section maintains current law, but eliminates language
which limits the particular use of funds for which the Indian
tribes and tribal organizations can receive funding on the same
basis as the IHS.
Current law: Section 1680a requires the Indian Health
Service to provide funds to Tribal Health Programs for health
care programs and facilities to (1) maintain and repair
clinics, (2) train employees, (3) provide cost-of-living
expenses, and (4) provide for other expenses related to health
services on the same basis as funds are provided to these
programs operated directly by the Indian Health Service.
Section 221. Licensing
This section is new.
New provision: Section 221 requires that health care
professionals employed by a Tribal Health Program shall, if
licensed in any State, be exempt from the licensing
requirements of the State in which the Tribal Health Program
provides the services.
Section 222. Notification of provision of emergency contract health
services
This section maintains current law.
Current law: Section 1646 allows 30 days (as a condition of
payment) for an elderly or disabled Indian to notify the
Service of any emergency care or health services received from
a non-Service provider or in a non-Service facility.
Section 223. Prompt action on payment of claims
This section maintains current law, but changes the
requirement of a completed claim to a valid claim.
Current law: Section 1621s provides a deadline for the
Service to respond to notification of a claim by a provider of
a contract care service. The section also provides that if the
Service fails to respond within the required time, the Service
shall accept the claim as valid. The IHS shall pay a completed
claim within 30 days after completion of the claim.
Section 224. Liability for payment
This section maintains current law and adds language which
limits the recourse against the patient if the claim has been
deemed accepted under Section 223.
Current law: Section 1621u provides that a patient who
receives authorized contract health care services will not be
held liable for any charges or costs associated with those
authorized services. In addition, the Secretary is required to
notify the provider of such services and the patient who
receives them of the same, within a specified time.
Section 225. Office of Indian Men's Health
This section is new.
New provision: Section 225 directs the Secretary to
establish the Office of Indian Men's Health, which shall be
headed by a Director, to coordinate and promote the health
status of Indian men. The Secretary is also required to submit
a report to Congress within two years of enactment, describing
any activity and finding of the Director.
Section 226. Authorization of appropriations
This section maintains current law, but extends the
authorization to 2015 and eliminates the references to specific
sections which had a separate authorization period.
Current law: Section 226 authorizes appropriations as
necessary to carry out this title, for each fiscal year through
2000, except for certain specific sections.
TITLE III--FACILITIES
Section 301. Consultation; construction and renovation of facilities;
reports
This section maintains current law and adds language which
(1) expands the accrediting bodies whose standards may be met
for construction, (2) requires an evaluation of the impact of a
proposed closure prior to closing, (3) requires the Secretary
to establish a health care facility priority system developed
through negotiated rule-making which prioritizes certain types
of facilities such as outpatient, specialized care facilities,
(4) adds specific requirements for the report to be submitted
to Congress such as the types of facilities to be included, the
method for evaluating the needs, the opportunity for nomination
of facilities and consultation, (5) requires the Secretary to
consult and cooperate with Indian tribes in finding innovative
approaches to meet the facilities needs; and (6) requires a GAO
study of the baseline facility needs and requires the Secretary
to update this report every 5 years.
Current law: Section 1631 requires consultation with Indian
tribes prior to expending construction funds. In addition, it
sets forth requirements to be met prior to closing any
facility. This section also establishes and defines criteria
for closure of health care facilities and sets forth reporting
requirements.
Section 302. Sanitation Facilities
This section maintains current law and adds language which
(1) establishes priority funding for emergency repairs and
operation or maintenance to avoid imminent health threats or to
protect the investment in health benefits gained through the
sanitation facilities, (2) prohibits the use of IHS funding for
new homes constructed using Department of Housing and Urban
Development funds, (3) allows the Secretary to accept funds
from all federal sources and may place those funds in ISDEAA
agreements for sanitation facilities construction, (4)
authorizes the Secretary to allows certain funding to be used
to fund tribal loans or matching or cost participation
requirements to construct sanitation facilities, (5) requires
the Secretary enter into interagency agreements for financial
assistance, (6) requires standards for planning, design and
construction of sanitation facilities to be developed through
negotiated rule-making, (7) requires consultation with Indian
tribes in developing the 10-year plan for sanitation
facilities, (8) establishes an Indian tribe's primary
responsibility for collecting user fees and the Secretary's
responsibility in assisting tribes when the facility is
threatened with imminent failure, (9) clarifies the information
required to be in the annual report and, (10) sets forth the
definitions of the different levels of deficiencies.
Current law: Section 1632 provides the findings, certain
duties for sanitation, authorized uses of sanitation funding
and facilities, and reporting requirements, and establishes the
deficiency levels for those facilities. This section requires
training or technical assistance in the operation and
maintenance of sanitation facilities. The Secretary is also
required to submit a report to Congress on the status of
sanitation facilities backlog and a 10-year plan for addressing
it.
Section 303. Preference to Indians and Indian firms
This section maintains current law and adds new language to
clarify rates of pay requirements and other wage requirements
similar to local rates as determined by the Indian tribes.
Current law: Section 1633 authorizes the Secretary to use
Indian preference for certain construction activities.
Section 304. Expenditure of nonservice funds for renovation
This section maintains current law and adds language which
(1) includes major expansion as an authorized use of funds, in
addition to renovation and modernization, but requires the
Indian Tribes or Tribal Organizations to provide certain
information to the Secretary regarding staffing, equipment and
other costs associated with the expansion, and (2) requires the
methodology for determining priorities to be developed through
negotiated rule-making with annual revisions developed through
consultation.
Current law: Section 1634 authorizes the Secretary to
accept any expansion or renovation funded with non-Service
funds in accordance with certain criteria. The Secretary is
required to maintain a separate priority list for these
facilities.
Section 305. Funding for the construction, expansion and modernization
of small ambulatory care facilities
This section maintains current law and adds language which
requires the funding to be used for the portion of costs which
benefits the eligible population, but exempts from the specific
eligibility requirements applicants whose principal health
administration offices are located where there is no road
system providing direct access to inpatient hospitals.
Current law: Section 1636 establishes criteria for small
ambulatory care facilities, including use of funds, grant
application requirement priorities, and conditions for
reversion of facilities.
Section 306. Indian health care delivery demonstration project
This section maintains current law and adds language which
(1) requires consultation, (2) permits the use of IHS funds to
match other funds, and (3) authorizes regulations to be
developed through negotiated rule-making.
Current law: Section 1637 authorizes the Secretary to
establish demonstration projects to test alternative health
care delivery systems through the construction and renovation
of hospitals, health centers, health stations and other
facilities. Section 1637 establishes criteria for the projects
such as the need for such facility, number of Indians to be
served, the economic viability of the project, and the
administrative and financial capability of Indian tribes or
Tribal Organizations to administer the project. This section
also requires technical assistance and use of the same criteria
in evaluating tribal and IHS facilities.
Section 307. Land transfer
This section amends current law by changing a specific
authorization into a general authorization whereby Federal
agencies may transfer, at nocost, land and improvements to the
IHS for the provision of health care services, and the Secretary is
authorized to accept the land.
Current law: Section 1638 provides specific authorization
for transferring 5 acres of land at the Chemawa Indian School
to the IHS.
Section 308. Leases, contracts and other agreements
This section maintains current law and adds tribal
organizations as eligible lessors.
Current law: Section 1674 authorizes the Secretary to enter
into leases, contracts or other agreements with Indian Tribes
for the delivery of health services at those facilities. The
leases may also include provisions for construction, renovation
and compensation.
Section 309. Study for loans, loan guarantees and loan repayment
This section is new.
New provisions: Section 309 authorizes a study, using
consultation, to determine the feasibility of a loan or loan
guarantee fund for Indian health care facilities construction.
A number of study requirements are delineated such as the
maximum principal amount and term of the loan that should be
offered, amount attributable for planning, appropriate security
for the loan, and legislative or regulatory changes needed.
Section 310. Tribal leasing
This section is new.
New provision: Section 310 authorizes a tribal health
program to lease permanent structures without prior approval in
appropriation Acts.
Section 311. Indian Health Service/Tribal Facilities Joint Venture
Program
This section maintains current law and adds (1) tribal
organizations to the eligible participants and those tribes
that have begun, but not completed the process of acquisition
or construction of a health care facility, (2) requires the
criteria to be developed through negotiated rule-making, (3)
requires negotiation for the continued operation of the
facility at the end of the 10-year lease, (4) authorizes
recovery in a proportional amount from the IHS if the IHS
ceases to use the facility within the 10-year lease period, and
(5) includes staff quarters in the definition of the health
facilities under this section.
Current law: Section 1680h(e) authorizes the Secretary to
enter joint ventures with Indian Tribes, and provide staffing,
equipment and supplies for the operation of the facility under
a no-cost 10-year lease with the Indian Tribes in exchange for
the tribal construction of the facility, in accordance with
certain criteria.
Section 312. Location of facilities
This section maintains current law and adds language which
(1) allows an Indian owner to request that the IHS locate
facilities on his or her lands within tribal jurisdiction,
subject to the priority for location being given to the Indian
tribe and (2) adds, as part of the Indian lands for
consideration under this section, all lands in Alaska owned by
any Alaska Native village, or regional corporation under the
Alaska Native Claims Settlement Act, or land allotted to an
Alaska Native.
Current law: Section 1680n sets forth certain priorities in
locating health care facilities on Indian lands to address
unemployment conditions in the economically depressed Indian
communities, if requested by the Indian tribe with jurisdiction
over the Indian lands. Section 1680n also defines ``Indian
lands''.
Section 313. Maintenance and improvement of health care facilities
This section is new.
New provisions: Section 313 requires reporting of backlogs
in maintenance and improvements for facilities and authorizes
the use of funds to construct a replacement facility if the
costs of renovation would exceed a maximum threshold cost to be
developed through negotiated rule-making.
Section 314. Tribal management of federally-owned quarters
This section is new.
New provisions: Section 314 authorizes Tribal Health
Programs operating a health care facility and federally-owned
quarters pursuant to a contract or compact under the Indian
Self-Determination and Education Assistance Act to establish
reasonable rental rates for the federally-owned quarters and
directly collect the rent. These quarters shall remain eligible
for improvement and repair funds as other federally-owned
quarters. The Tribal Health Programs operating the quarters are
required to provide at least 60 days notice before changing the
rental rate.
Section 315. Applicability of Buy American Act requirement
This section maintains current law, but exempts Indian
tribes and tribal organizations from the requirements of the
Buy American Act and eliminates a reporting requirement for
purchases from FY 1993 to FY 1994.
Current law: Section 1638b requires application of the Buy
American Act for all procurement.
Section 316. Other funding for facilities
This section is new.
New provisions: Section 316 authorizes the Secretary to
accept funding from other sources for the construction of
health care facilities and to transfer such funds to Indian
tribes. The Secretary may also enter into interagency
agreements for the planning, design and construction of health
care facilities.
Section 317. Authorization of appropriations
This section maintains current law (found in Section
1638a), but extends the authorization for appropriations
through fiscal year 2015.
TITLE IV--ACCESS TO HEALTH SERVICES
Section 401. Treatment of payments under Social Security Act health
care programs
This section maintains current law and adds (1) tribal
organizations and urban Indian organizations, in addition to
tribes and the IHS for whom reimbursements would not be
considered in determining appropriations, and (2) expands the
authorized uses of the reimbursements from improvements only to
hospitals or skilled facilities to also include programs and
the excess used to reduce health deficiencies, subject to
consultation by the Indian tribes. However, this provision
authorizing the Secretary to determine the uses shall not apply
when the Indian tribes elect to receive reimbursements
directly.
Current law: Sections 1641 and 1642 require that any
Medicare or Medicaid payments received by the IHS or Indian
tribes shall not be considered in determining appropriations
for health care services, and that Indians without Medicare or
Medicaid are given equal consideration as those Indians are who
are covered by these programs. Section 1645 established a
program under which tribes could elect to directly bill and be
reimbursed health care services provided under Medicare,
Medicaid or other third parties. Specifications are made as to
how funds collected from Medicare or Medicaid are to be used.
Section 402. Grants to and contracts with the service, Indian tribes,
tribal organizations, and urban Indian organizations
This section maintains current law and adds provisions
which outline the agreements between the Secretary and the
tribes, tribal or urban Indian organizations to improve the
enrollment of Indians in the Social Security Act programs.
Current law: Section 402 requires the Secretary to make
grants or enter into contracts with Tribes and Tribal
Organizations to improve enrollment and participation in
Medicare, Medicaid or SCHIP programs, such as paying premiums.
In doing so, the Secretary shall place conditions as deemed
necessary to effect the purpose of such funding. Additional
agreements may be made in order to improve the receipt and
processing of applications for enrollment of Indians under
Social Security Act programs and to facilitate cooperation
between States, the Service, Indian Tribes, Tribal
Organizations, or Urban Indian Organizations.
Section 403. Reimbursement from certain third parties of costs of
health services
This section maintains current law and adds language (1) to
enable urban Indian organizations to seek recovery from third
parties, (2) to require reasonable efforts be taken to provide
notice to the patient either before or during the pendency of
the action, (3) to limit the IHS right of recovery against a
tribal self-insured plan absent written consent from the tribe,
(4) to include awards of reasonable attorneys fees and costs of
litigation, (5) to prohibit denial of reimbursement on the basis of a
different format or form.
Current law: Section 403 allows an Indian Tribe or Tribal
Organization to recover payment from third parties for health
services provided to the same extent that an individual, or any
nongovernmental provider of health services, would be eligible
to receive damages, reimbursement, or indemnification. This
right of recovery is extended against any State under certain
conditions. Certain State or local laws are deemed
nonapplicable to prevent or hinder this right of recovery. This
section has no effect on private rights of action. Enforcement
measures for the right of recovery are all specified in this
section.
Section 404. Crediting of reimbursements
This section maintains current law and adds language which
identifies which programs are included in the reimbursements.
Current law: Section 404 authorizes the retention of the
reimbursements received from third parties and specifies the
use of those amounts collected. This section also disallows any
offset or limitation of amount obligated to any Service Unit,
Indian Tribe or Tribal or Urban Indian Organization because of
the receipt of reimbursements under this section.
Section 405. Purchasing health care coverage
This section is new.
New provisions: Section 405 allows funding to be used for
purchasing health insurance for Indians or to be used for a
tribal self-insurance plan and eliminates the study previously
required to determine the feasibility of allowing Indian tribes
to purchase managed care coverage for their members and the
report to Congress on the study.
Section 406. Sharing arrangements with Federal agencies
This section amends current law by (1) authorizing the
Secretary to enter agreements for sharing of medical facilities
with the Departments of Veterans Affairs and Defense, instead
of merely examining the feasibility of entering the agreements,
(2) requiring consultation with Indian tribes prior to entering
the agreements, (3) require reimbursement to the IHS, tribes,
or tribal organizations by the VA where VA eligible
beneficiaries receive care from the IHS, tribes or tribal
organizations, (4) eliminating the specific cross-utilization
of services in Utah only (expanding it generally), and (5)
authorizing the Director of IHS to enter into interagency
agreements to assist in achieving parity in services for
Indians.
Current law: Section 406 authorizes the Secretary to
examine the feasibility of entering agreements to share medical
facilities and services with the Departments of Veterans
Affairs and Defense. The Secretary shall not take action which
would impair priority access to or quality of care for Indians
at IHS or priority of veterans to care by the Veterans'
Administration.
Section 407. Payor of last resort
This section is new.
New provision: Section 407 codifies long-standing policy
and specifies that Indian Health Programs and health care
programs operated by Urban Indian Organizations shall be the
payor of last resort for services provided to eligible persons.
Section 408. Nondiscrimination in qualifications for reimbursement for
services
This section is new.
New provision: Section 408 codifies regulations under Title
42 of the Code of Federal Regulations and deems entities that
are operated by the Service, an Indian Tribe, Tribal
Organization, or Urban Indian Organization to be licensed or
recognized under State or local law to furnish such services,
for purposes of receiving payment or reimbursement from any
federally funded health care program so long as these entities
meet all applicable standards for licensure.
Section 409. Consultation
This section is new.
New provision: Section 409 codifies the Centers for
Medicaid and Medicare Services charter which recognized the
Tribal Technical Advisory Group established to assist the
Secretary in identifying and addressing issues affecting
Indians in health care programs under the Social Security Act.
It also encourages a State to establish a process to seek
advice on a regular basis from designees of Indian Health
Programs and Urban Indian Organizations.
Section 410. State Children's Health Insurance Program (SCHIP)
This section is new.
New provision: Section 410 allows the Secretary to enter
arrangements with individual States to allow SCHIP funds for
Indians to be provided to Indian Health Programs for providing
child health assistance to targeted low-income Indian children,
consistent with the purposes of SCHIP.
Section 411. Social Security Act sanctions
This section is new.
New provision: Section 411 allows Indian Health Programs to
request a waiver of a sanction imposed against a health care
provider in the event the State does not act upon a tribal
request to the State to seek the waiver. A safe harbor clause
from anti-kickback sanctions is included in this section for
referrals, transactions or exchanges between and among Indian
Health Care Programs.
Section 412. Cost sharing
This section is new.
New provisions: Section 412 addresses coinsurance,
copayments, and deductibles, and exempts Indians from such cost
sharing. Section 412 provides an exemption from premium
payments for Indians eligible for Medicaid and SCHIP programs.
Section 412 also excludes certain trust, restricted, cultural
or subsistence Indian property from the Medicaid eligibility
determinations or Medicaid estate recovery.
Section 413. Treatment under Medicaid managed care
This section is new.
New provisions: Section 413 specifies actions to be taken
for payment for services furnished to Indians in Medicaid
managed care programs. This section also allows Medicaid
managed care programs to be offered by Indian Health Programs
and provides the requirements for these programs.
Section 414. Navajo Nation Medicaid Agency feasibility study
This section is new.
New provisions: Section 414 requires the Secretary to
conduct a study to determine the feasibility of treating the
Navajo Nation as a State for Medicaid purposes. Considerations
for and a report of the results of the study are described in
this section.
Section 415. Authorization of appropriations
This section maintains current law and extends the
authorization for appropriations to fiscal year 2015.
Current law: Section 415 authorizes appropriations of such
sums as may be necessary for each fiscal year through fiscal
year 2000 to carry out this title.
TITLE V--HEALTH SERVICES FOR URBAN INDIANS
Section 501. Purpose
This section maintains current law and adds language to
maintain and make health services available, in addition to
being accessible to urban Indians.
Current law: Section 1651 sets forth the purpose of the
title which is to establish programs in urban center to make
health care accessible to urban Indians.
Section 502. Contracts with, and grants to, urban Indian organizations
This section maintains current law.
Current law: Section 1652 sets forth the authority of the
Secretary to enter contracts with or make grants to Urban
Indian Organizations including prescribing the criteria for
selecting urban Indian organizations and making recommendations
for improving health programs for urban Indians.
Section 503. Contracts and grants for the provision of health care and
referral services
This section maintainscurrent law.
Current law: Section 1653 sets forth the standards,
criteria and uses of funds for contracts and grants for health
care services. The grants require that the urban Indian
organization estimate the service population, health care needs
and status of the urban Indians, provide basic health education
and make recommendations for improving health programs. The
grants may be made to provide outreach, educational, outpatient
behavioral health services, develop innovative service delivery
models, health promotion and immunization services.
Section 504. Contracts and grants for the determination of unmet health
care needs
This section maintains current law.
Current law: Section 1654 authorizes the Secretary to enter
into contracts under the Snyder Act, 25 U.S.C. 13, to urban
Indian organizations who does not have a contract under section
1654. Section 1654 sets forth the standards, criteria and uses
of funds for contracts and grants to determine unmet health
care needs of urban Indians.
Section 505. Evaluations; renewals
This section maintains current law and adds a provision
which would allow the Secretary to evaluate the urban Indian
organization through acceptance of evidence of the
organization's accreditation as an alternative to the onsite
annual evaluation.
Current law: Section 1655 authorizes the Secretary to
develop evaluation and renewal standards for the various
contracts and grants. The Secretary shall also evaluate the
urban Indian programs through onsite annual evaluations.
Section 506. Other contract and grant requirements
This section maintains current law and adds provisions
which would allow lump sum payments unless the urban Indian
organization is not capable of administering the payments in
their entirety and allows the funding to be carried forward.
Current law: Section 1656 sets forth other specific
contract and grant requirements such as payment methods,
procurement and amendments.
Section 507. Reports and records
This section maintains current law and (1) adds language
which extends the reporting period to semi-annual, rather than
quarterly, (2) adds the requirement of a minimum set of data
using uniform elements and that the audits may also be
conducted by a certified public accounting firm and (3) deletes
the requirement that IHS and the Department of Interior report
to Congress by March 31, 1992, on the health status, unmet
needs and welfare of urban Indian children.
Current law: Section 1657 sets forth certain reporting and
recordkeeping requirements for Urban Indian Organizations.
Section 508. Limitation on contract authority
This section maintains current law and adds language which
includes authority to award grants.
Current law: Section 1658 limits contracts to the amount of
appropriations.
Section 509. Facilities
This section maintains current law and adds provisions
which would allow for leasing, purchasing, renovating,
constructing and expanding, in addition to repairing,
facilities and authorizes a study for a revolving loan fund to
construct facilities.
Current law: Section 1659 sets forth the various
requirements governing the funding for urban health care
facilities and authorizes the Secretary to make funds available
to contractors or grant recipients to make minor renovations to
the urban health facilities to meet or maintain compliance with
the requirements of the Joint Commission on Accrediting Health
Care Organizations.
Section 510. Division of urban Indian health
This section maintains current law, but changes the Branch
of Urban Indian programs into an Office within the IHS.
Current law: Section 1660 establishes a Branch of Urban
Indian Health within the IHS.
Section 511. Grants for alcohol and substance abuse related services
This section maintains current law.
Current law: Section 1660a authorizes the Secretary to make
grants for alcohol and substance abuse services to urban Indian
organizations. Section 511 also establishes criteria for
alcohol and substance abuse grants.
Section 512. Treatment of certain demonstration projects
This section maintains provisions which makes permanent
certain demonstration projects in Oklahoma and requires them to
meet the requirements of Title V, but will be treated as
service units, and the funding shall not be subject to the
ISDEAA.
Section 513. Urban NIAAA transferred programs
This section maintains current law, but changes the date of
the transfer from September 30, 2001 to September 30, 2008.
Current law: Section 1660c authorizes the Secretary to
transfer to Urban Indian Organizations alcohol programs that
had been previously transferred to the Secretary.
Section 514. Consultation with urban Indian organizations
This section is new.
New provision: Section 514 establishes consultation
requirements with Urban Indian Organizations including a
definition of consultation.
Section 515. Federal Tort Claim Act coverage
This section is new.
New provision: Section 515 authorizes Urban Indian
Organizations to be deemed an executive agency for Federal Tort
Claim Act coverage.
Section 516. Urban youth treatment center demonstration
This section is new.
New provision: Section 516 authorizes the Secretary to fund
at least 2 Indian youth treatment centers in certain states
where urban centers are located.
Section 517. Use of Federal Government facilities and sources of supply
This section is new.
New provisions: Section 517 authorizes the Urban Indian
Organizations to receive donations of Federal excess property
and, for purposes of 40 CFR 501, and deems them to be executive
agencies for access to the Federal sources of supply.
Section 518. Grants for diabetes prevention, treatment and control
This section is new.
New provisions: Section 518 authorizes the Secretary to
make grants for diabetes prevention, treatment and control.
Section 518 sets forth requirements and criteria for diabetes
grants, such as the size and location of the urban Indian
population, the need and performance standards.
Section 519. Community health representatives
This section is new.
New provision: Section 519 authorizes the Secretary to
contract with the urban Indian organizations to provide
community health representatives.
Section 520. Effective date
This section is new.
New provision: Section 520 establishes that the effective
date for the amendments made by this Act begins on the date of
enactment regardless of whether the Secretary has issued
regulations.
Section 521. Eligibility for services
This section is new.
New provision: Section 521 establishes that urban Indians
are the ultimate beneficiaries of the services under this
title.
Section 522. Authorization of appropriations
This section maintains current law and extends the
authorization to fiscal year 2015.
Current law: Section 522 authorizes appropriations through
fiscal year 2015.
TITLE VI--ORGANIZATIONAL IMPROVEMENTS
Section 601. Establishment of the Indian Health Service as an agency of
the Public Health Service
This section amends current law by changing the position of
the Director into an Assistant Secretary.
Current law: Section 1661 establishes the Indian Health
Service within the Public Health Service of the Department, and
the position of Director of the Indian Health Service who shall
be confirmed by the Senate with a term of four years. The
Director shall administer the Indian Health Service and the
Director's duties and responsibilities are outlined in this
section, including managing funds, entering contracts, all
functions relating to the management of hospitals and
facilities.
Section 602. Automated management information system
This section maintains current law and adds Secretarial
authority to enter contracts or joint ventures to enhance
information technology in Indian health programs.
Current law: Section 1662 requires the Secretary to
establish an automated management information system for the
Service and each Tribal Health Program. It requires that
patients have access to their own health records.
Section 603. Authorization of appropriations
This section maintains current law and extends the
authorization to fiscal year 2015.
Current law: Section 1663 authorizes appropriated funds in
sums that may be necessary to carry out this title, for each
fiscal year through fiscal year 2000.
TITLE VII--BEHAVIORAL HEALTH PROGRAMS
Section 701. Behavioral health prevention and treatment services
This section maintains current law and adds language which
(1) authorizes the Secretary, Indian tribes, tribal
organizations, and urban Indian organizations to develop
programs which emphasize collaboration for behavioral health,
(2) requires technical assistance to Indian tribes, tribal and
urban Indian organizations, (3) requires a continuum of care
for behavioral health to the extent feasible including acute
hospitalization, detoxification, and emergency shelter.
Current law: Section 1621h and Section 1665 state the
purposes of the section; requires the Secretary to encourage
the development of plans for delivery of Indian mental Health
Services; directs the Secretary to provide comprehensive mental
health care programs; facilitates the governing body of any
Indian Tribe, Tribal Organization, or Urban Indian Organization
to establish community mental health plans; requires the
Secretary to coordinate mental health planning; and directs the
Secretary to assess the need, availability and cost for
inpatient mental health care for Indians.
Section 702. Memoranda of agreement with the Department of the Interior
This section maintains current law and adds language which
requires the Secretary to update existing Memoranda of
Agreement and adds tribal organizations and to consult with
Indian tribes, tribal and urban Indian organizations in
developing the Memoranda which shall be published in the
Federal Register.
Current law: Section 1621h(b) requires the Secretary to
develop and enter memoranda of agreement with the Secretary of
the Interior to, among other things, make a comprehensive
assessment, coordination, and annual review of all the
behavioral health care needs and services available or
unavailable to Indians. Specific provisions that are required
in this memorandum are delineated.
Section 703. Comprehensive Behavioral Health Prevention and Treatment
Program
This section amends current law by changing the alcohol and
substance abuse focus to comprehensive behavioral health and
adds more specific types of treatment such as residential and
intensive outpatient treatment and by requiring consent of
Indian tribes to be served before the Secretary enters
contracts with private or other public health providers to
provide the services under this section.
Current law: Section 1665a requires the Secretary to
provide a program of comprehensive behavioral health,
prevention, treatment, and aftercare. The Secretary may provide
these services through Contract Health Services.
Section 704. Mental Health Technician Program
This section maintains current law and adds the use and
promotion of traditional health care practices.
Current law: Section 1621h(g) establishes a mental health
technician program within the Service, requiring high-standard
paraprofessional training in mental health care, supervision
and evaluation of technicians.
Section 705. Licensing requirement for mental health care workers
This section maintains current law.
Current law: Section 1621h(l) requires that any person
employed as a psychologist, social worker, or marriage and
family therapist, be licensed to provide those services or be
supervised by one who is licensed.
Section 706. Indian women treatment programs
This section maintains current law and adds language which
requires the implementation of this section to be consistent
with section 701, recognizes the behavioral health focus and
requires consultation with Indian tribes and tribal
organizations in establishing criteria for applications.
Current law: Section 1665b authorizes funding to develop
and implement a program of prevention, intervention, treatment,
and relapse prevention services for alcohol and substance
abuse, specifically addressing the cultural, historical,
social, and childcare needs of Indian women. How funds are to
be used is specified in this section, including the development
of community training, counseling and prevention models.
Section 707. Indian Youth Program
This section maintains current law and adds language which
(1) requires implementation of this section to be consistent
with section 701, (2) recognizes the behavioral health focus,
(3) includes programs developed at the local tribal level, (4)
includes treatment networks in addition to treatment programs,
(5) includes sober or transitional housing in the intermediate
adolescent services, (6) requires community reintegration as
part of the rehabilitation and aftercare services, (7)
establishes a program to prevent and treat multi-drug abuse and
(8) requires the Secretary to collect data for an Indian youth
mental health report.
Current law: Section 1665c requires the development and
implementation of a program for detoxification and
rehabilitation of Indian youth. It also establishes alcohol and
substance abuse treatment centers or facilities for Indian
youth. Additional provisions addressed in this section are:
intermediate adolescent behavioral health services; use of
Federally owned structures; rehabilitation and aftercare
services; inclusion of family in youth treatment programs; and
a study for the feasibility of multi-drug abuse programs.
Section 708. Indian Youth Telemental Health Demonstration Project
This section is new.
New provisions: This section authorizes the Secretary to
carry out a four-year demonstration project under which five
Tribes, Tribal Organizations or Urban Indian Organizations with
telehealth capabilities could use telemental health services in
youth suicide prevention and treatment. In awarding the grants,
the Secretary would give priority to Tribes, Tribal
Organizations or Urban Indian Organizations serving a
particular tribal community where there is a demonstrated need
to address Indian youth suicide or which is isolated and has
limited access to mental health services; entering into
collaborative partnership to provide the services; or operating
a detention facility at which youth are detained. The
demonstration project would permit the use of telemedicine for
psychotherapy, psychiatric assessments and diagnostic
interviews of Indian youth; the provision of clinical expertise
and other medical advice to frontline health care providers
working with Indian youth; training and related support for
community leaders, family members and health and education
workers who work with Indian youth; the development of
culturally relevant educational materials on suicide prevention
and intervention; and data collection and reporting.
Section 709. Inpatient and community-based mental health facilities
design, construction, and staffing
This section amends current law by requiring the
establishment in each Area at least one inpatient mental health
facility and determining that California shall be considered
two Areas.
Current law: Section 1621h(i) states within one year after
enactment, the Secretary shall make an assessment of the need
for inpatient mental health care facilities, including the
conversion of under utilized hospital beds into psychiatric
units to meet the needs.
Section 710. Training and community education
This section maintains current law and adds language which
authorizes the Indian tribes and tribal organizations to
develop training and community education programs, defines
community based training, adds child sexual abuse to the types
of training authorized and recognizes the behavioral health
focus.
Current law: Section 1621h(d) requires that the Secretary,
in cooperation with the Secretary of the Interior, provide
either directly or through funding, a program of community
education in the area of behavioral health. Specifics of
instruction are delineated. This section also requires the
Secretary to develop and provide community-based training
models.
Section 711. Behavioral Health Program
This section maintains current law and adds the tribal
organizations as eligible recipients for funding under this
section.
Current law: Section 1621h allows for the development of
innovative community-based behavioral health programs; suggests
criteria to be used for funding such programs; and requires
that the same criteria as used in evaluating other funding
proposals be used for programs under this section.
Section 712. Fetal alcohol disorder programs
This section maintains current law and adds language (1)
requiring these programs to be implemented consistent with
section 701, (2)consolidating fetal alcohol syndrome and fetal
alcohol effects into fetal alcohol disorders (FAD), (3) authorizing
appropriate psychological services, the development of early childhood
intervention projects, supportive services, (4) including the National
Institute for Child Health and Human Development and the Centers for
Disease Control and Prevention in the national task force on FAD.
Current law: Section 1665g authorizes the Secretary to
establish fetal alcohol syndrome and effects programs, to
include the development and provision of services for the
prevention, intervention, treatment, and aftercare for those
affected by fetal alcohol disorders in Indian communities. In
addition a Fetal Alcohol Task Force is established to advise
the Secretary. Funding is to be made available for applied
research projects which propose to elevate the understanding of
methods to prevent, intervene, treat or provide rehabilitation
and aftercare for Indians affected by this disorder. Urban
Indians are included and 10% of the funding is set aside for
urban programs.
Section 713. Child sexual abuse and prevention treatment programs
This section amends current law by (1) turning two specific
demonstration projects into permanent programs, (2) authorizing
services for Indian child victims of sexual abuse and
perpetrators of child sexual abuse who are members of an Indian
household, and (3) including authorized uses of funds such as
developing community education, identifying and providing
treatment to victims, developing culturally-sensitive
prevention models and diagnostic tools, providing treatment to
the perpetrators.
Current law: Section 1680i establishes demonstration
projects for Child Sexual Abuse and Prevention Treatment
Programs through the Hopi Tribe and Sioux Tribes of the Fort
Peck Reservation. The Secretary may establish other
demonstration projects, but must have an equal number of
projects for the Areas.
Section 714. Behavioral health research
This section maintains current law and adds language which
emphasizes the focus on behavioral health instead of only
mental health problems.
Current law: Section 1621h provides for funding for
research on the incidence and prevalence of behavioral health
problems among Indians. Research priorities are specified such
as the interrelationship of mental disorders with alcoholism,
suicide, homicide, and the incidence of family violence.
Section 715. Definitions
This section is new.
New provisions: Section 715 provides definitions for the
following terms used in this title: assessment; alcohol-related
neurodevelopmental disorders or ARND; behavioral health
aftercare; dual diagnosis; fetal alcohol disorders; fetal
alcohol syndrome or FAS; partial FAS; rehabilitation; and
substance abuse.
Section 716. Authorization of appropriations
This section maintains current law and extends the
authorization to fiscal year 2015 and eliminates the exceptions
for sections that had specific terms of authorization.
Current law: Section 1621w authorizes such sums as may be
necessary to carry out this section, for each fiscal year
through fiscal year 2000, except for section 703, 706, 708, 710
and 711.
TITLE VIII--MISCELLANEOUS
Section 801. Reports
This section maintains current law and adds provisions
which either establish new reporting requirements or
consolidates the information required in other sections in one
organized list such as (1) requiring as part of the annual
reports to Congress (a) comparisons of appropriations provided
and required for parity in health services, (b) services
provided under ISDEAA agreements, (c) information on the loan
repayments, infectious diseases, environmental hazards, status
of health care and sanitation facilities, sharing of services
between the IHS and other federal agencies, and urban Indian
programs.
Current law: Section 1671 requires annual reports which
outline the progress made in meeting health objectives, whether
new national programs are needed, steps taken to consult with
Indian tribes, separate statements for funding requested and
obligated and other reporting requirements under this Act.
Section 802. Regulations
This section is new.
New provision: Section 802 sets forth the various
requirements for regulations, including negotiated rule-making,
for certain titles under this Act. Proposed regulations are
required to be published in the Federal Register no later than
270 days after enactment. This section authorizes a negotiated
rule-making committee consisting of Indian tribes, tribal and
urban Indian organizations.
Section 803. Plan of implementation
This new section requires a plan of implementation of this
Act to be submitted to Congress.
Section 804. Availability of funds
This section maintains current law.
Current law: Section 1675 authorizes funding to remain
available until expended.
Section 805. Limitation on use of funds appropriated to the Indian
Health Service
This section maintains current law.
Current law: Section 1676 recognizes that any limitation
contained in DHHS appropriations on the use of federal funds
for abortions shall apply for that period with respect to use
of IHS funds.
Section 806. Eligibility of California Indians
This section maintains current law, but eliminates the
Secretarial report developing data on the Indians located in
California, health status and needs and other information.
Current law: Section 1679 requires that until other federal
law provides otherwise, Indians located in California shall be
eligible for health services from under this Act, including
members of federally-recognized tribes, descendants of Indians
residing in California as of June 1, 1852, Indians holding
trust interests in certain types of land, and Indians listed on
the plans for asset distribution in California.
Section 807. Health services for ineligible persons
This section maintains current law and adds language to
include compacts, in addition to contracts, under the ISDEAA.
Current law: Section 1680c authorizes services for certain
ineligible persons under limited circumstances, including
spouses or children of eligible Indians, non-Indian women
carrying Indian babies, persons in need of emergency
stabilization or prevention of communicable diseases, and
outlines criteria for providing services such as requiring
reimbursement and tribal approval.
Section 808. Reallocation of base services
This section maintains current law.
Current law: Section 1680g limits the reallocation of base
funding upon certain requirements, such as reporting to
Congress on the proposed changes and likely effects, the
Secretary must fulfill.
Section 809. Results of demonstration projects
This section maintains current law.
Current law: Section 1680m requires that results of
demonstration projects be made available to Indian tribes.
Section 810. Provision of services in Montana
This section is new.
Current law: Section 810 requires that services and
benefits for Indians in Montana be provided consistent with the
court decision McNabb v. Bowen, 829 F.2d 787 (9th Cir. 1987),
but that this requirement shall not be construed as the sense
of the Congress for Indians in any other state.
Section 811. Moratorium
This section authorizes the Service to provide certain
services according to eligibility criteria in effect on a
certain date.
Section 812. Tribal employment
This section is new.
New provision: Section 812 recognizes the governmental
purposes of health care by treating Indian tribes or tribal
organizations not as an employer for certain purposes.
Section 813. Severability provisions
This section retains remaining provisions if others are
stricken by any court.
Section 814. Establishment of national bipartisan commission on Indian
health care
This section is new.
New provisions: Section 814 establishes a bi-partisan
commission to study the delivery of health care services to
Indians and sets forth (1) duties, such as holding hearings,
consulting with Indian tribes, making recommendations and
findings which have evaluated the needs, services available,
costs and mechanisms for funding, (2) membership made up of 25
members, 10 from Congress, 12 chosen by Congressional Members
from each IHS Area and shall be members of federally-recognized
tribes, 3 chosen by the Assistant Secretary for Indian Health,
and (3) reporting requirements. This section (1) authorizes
appointment of a Director and staff for the Commission, (2)
establishes their compensation, and (3) authorizes details of
federal employees, use of mails, technical assistance and
administrative support services. This section authorizes $4
million for the Commission.
Section 815. Appropriations; availability
This section maintains current law subjects new spending
authority to the availability of appropriations.
Section 816. Authorization of appropriations.
This section maintains current law and extends the
authorization to fiscal year 2015.
Current law: Section 1680o authorizes appropriations
through fiscal year 2000.
OTHER SECTIONS OF THE BILL
Section 2(b). Indian Health Care Improvement Act amended.
Section 2 of the bill is new.
New provision: Section 2(b) also includes provisions
amending other laws for the references to the ``Director of
Indian Health Service'' which would be changed to ``Assistant
Secretary for Indian Health''.
Section 3. Soboba sanitation facilities. Section 3 of the
bill retains current law.
Current law: Section 3 authorizes sanitation facilities to
the Soboba Band of Mission Indians, pursuant to the Act of
December 17, 1970 (84 Stat. 1465).
Section 4. Amendments to the Medicaid and State Children's
Health Insurance Programs. Section 4 of the bill sets forth
conforming amendments to the Social Security Act for Medicaid
and State Children's Health Insurance Programs which authorize
reimbursement to Indian Health Programs for medical assistance
provided.
Section 5. Native American Health and Wellness Foundation.
Section 5 is new and sets forth amendments to the Indian Self-
Determination and Education Assistance Act to establish a
Native American Health and Wellness Foundation in the following
sections 801 to 803.
Section 801. Definitions
This section sets forth definitions for the Foundation, the
Foundation Board of Directors and establishment Committee.
Section 802. Native American Health and Wellness Foundation
This section establishes the perpetual existence of the
Foundation, the nature and duties of the Foundation and the
place of incorporation. This section also authorizes the
Secretary to establish an initial Committee to assist in
establishing the Foundation. Section 802 establishes the
authority of the Board of Directors, including their terms, the
officers (including the extent of their liabilities) and the
powers of the Foundation. This section also establishes limits
on the administrative costs, audit requirements, and authorizes
$500,000 for the fiscal years.
Section 803. Administrative services and support
This section authorizes the Secretary to provide
administrative support to the Foundation and initial operating
funds on a reimbursement basis for up to five years.
Legislative History
LEGISLATIVE ACTION
During the 109th Congress,\87\ Senator McCain introduced S.
1057, the Indian Health Care Improvement Act Amendments of
2005, on May 17, 2005, for himself and Senator Dorgan. The bill
was referred to the Committee on Indian Affairs and reported
favorably with amendments on October 27, 2005.
---------------------------------------------------------------------------
\87\ Senate Report No. 108-411 provides a detailed chronology of
the legislative activity that has occurred since the 106th Congress.
---------------------------------------------------------------------------
On June 7, 2005, Senator Johnson was added as a cosponsor.
On July 14, 2005, Senators Kennedy and Bingaman were added as
cosponsors. On October 24, 2005, Senators Cantwell and Murray
were added as cosponsors.
LEGISLATIVE HEARINGS
The Committee has held nine hearings since the 106th
Congress on the reauthorization of the Act.
During the 109th Congress, on July 14, 2005, the Committee
held a joint hearing with the Senate Committee on Health,
Education, Labor and Pensions to reauthorize the IHCIA. The
hearing addressed the need for reauthorization and several key
issues, including negotiated rulemaking, Federal Tort Claim Act
coverage and the DHAT program. The witnesses included DHHS,
members of the National Steering Committee, tribal leaders and
health providers and the American Dental Association.
Committee Recommendation and Tabulation of Votes
In an open business session on October 27, 2005, the
Committee considered a substitute amendment proposed by Senator
McCain and other amendments offered by Senators Dorgan, Crapo,
Coburn, and McCain. The Committee adopted the amendment offered
by Senator McCain by unanimous consent.
The Committee adopted by voice vote the amendments offered
by Senators Dorgan and Crapo. The Committee, by roll call vote,
rejected the amendment offered by Senator Coburn. Then, by a
unanimous vote, the Committee ordered the substitute amendment,
as amended, favorably reported to the full Senate with the
recommendation that the bill do pass.
Regulatory and Paperwork Impact Statement
Paragraph 11(b) of rule XXVI of the Standing Rules of the
Senate requires that each report accompanying a bill to
evaluate the regulatory and paperwork impact that would be
incurred in carrying out the bill. The Committee has concluded
that S. 1057 will not require the promulgation of regulations
so the regulatory and paperwork impact should be minimal.
Executive Communications
The Committee has not received any formal communication on
S. 1057 from the Administration other than the written
testimony from the Department of Health and Human Services
submitted at the Joint Hearing on S. 1057 on July 14, 2005,
which is attached hereto as an Exhibit.
Statement of Dr. Charles W. Grim, Director, Indian Health Service,
Department of Health and Human Services
Mr. Chairmen and Members of the Committees:
I am honored to testify before you today on the important
issue of reauthorization of the Indian Health Care Improvement
Act (IHCIA). Accompanying me today are Robert McSwain, Deputy
Directory, Craig Vanderwagen, M.D., Acting Chief Medical
Officer, and Gary Hartz, Director, Office of Environmental
Health and Engineering.
This landmark legislation forms the backbone of the system
through which Federal health programs serve American Indians/
Alaska Natives and encourages participation of eligible
American Indians/Alaska Natives in these and other programs.
The IHS has the responsibility for the delivery of health
services to more than 1.8 million Federally-recognized American
Indians/Alaska Natives through a system of IHS, tribal, and
urban (I/T/U) health programs based on judicial decisions and
statutes. The mission of the agency is to raise the physical,
mental, social, and spiritual health of American Indians/Alaska
Natives to the highest levels, in partnership with the
population we serve. The agency goal is to assure that
comprehensive, culturally acceptable personal and public health
services are available and accessible to the service
population. Our foundation is to uphold the Federal
government's responsibility to promote healthy American Indian
and Alaska Native people, communities, and cultures and to
honor and protect the inherent sovereign rights of Tribes.
Two major statutes are at the core of the Federal
government's responsibility for meeting the health needs of
American Indians/Alaska Natives: The Snyder Act of 1921, P.L.
67-85, and the Indian Health Care Improvement Act (IHCIA), P.L.
94-437, as amended. The Snyder Act authorized regular
appropriations for ``the relief of distress and conservation of
health'' of American Indians/Alaska Natives. The IHCIA was
enacted ``to implement the Federal responsibility for the care
and education of the Indian people by improving the services
and facilities of Federal Indian health programs and
encouraging maximum participation of Indians in such
programs.'' Like the Snyder Act, the IHCIA provides the
authority for the Federal government programs that deliver
health services to Indian people, but it also provides
additional guidance in several areas. The IHCIA contains
specific language addressing the recruitment and retention of
health professionals serving Indian communities; the provision
of health services; the construction, replacement, and repair
of health care facilities; access to health services; and, the
provision of health services for urban Indian people.
DHHS ACTIVITIES
Since enactment of the IHCIA in 1976, statutory authority
has substantially expanded programs and activities to keep pace
with changes in healthcare services and administration. Federal
funding for the IHCIA has contributed billions of dollars to
improve the health status of American Indians/Alaska Natives.
And, much progress has been made, particularly in the areas of
infant and maternal mortality.
The Department under this Administration's leadership
reactivated the Intradepartmental Council on Native American
Affairs (ICNAA) to provide for a consistent HHS policy when
working with the more than 560 Federally recognized Tribes.
This Council gives the IHS Director a highly visible role
within the Department on Indian policy, where he serves as vice
chairperson of the Council.
The Department has also recently completed work ushering
through a revised HHS Tribal consultation policy and involving
Tribal leaders in the process. This new policy further
emphasizes the unique government-to-government relationship
between Indian Tribes and the Federal government and assists in
improving services to the Indian community through better
communications. Consultation may take place at many different
levels. To ensure the active participation of Tribes in the
development of its budget request, an HHS-wide budget
consultation session is held annually. This meeting provides
Tribes with an opportunity to meet directly with leadership
from all Department agencies and identify their priorities for
upcoming program requests. Last year, Tribes identified
inflation and population growth as their top budget priorities
and IHS's FY 2006 budget request included an increase of $80
million for these items. Both the House and the Senate have
included these increases in FY 2006 appropriations action, and
we appreciate their efforts in this regard.
Through the Centers for Medicare & Medicaid Services (CMS),
a Technical Tribal Advisory Group was established which
provides Tribes with a vehicle for communicating concerns and
comments to CMS on Medicare, Medicaid and SCHIP policies
impacting their members. And, the IHS has been vigilant about
improving outcomes of Indian children and families with
diabetes by increasing education and physical activity programs
aimed at preventing and addressing the needs of those
susceptible to, or struggling with, this potentially disabling
disease.
It is clear the Department has not been a passive observer
of the health needs of eligible American Indians/Alaska
Natives. Yet, we recognize that health disparities among this
population do exist and are among some of the highest in the
Nation for certain diseases (e.g., alcoholism, tuberculosis,
diabetes, and injuries), and that improvements in access to IHS
and other Federal and private sector programs will result in
improved health status for Indian people.
The IHCIA was enacted to provide basic primary and
preventive services in recognition of the Federal government's
unique relationship with members of Federally recognized
Tribes. Members of Federally recognized Tribes are also
eligible for other Federal health programs (such as Medicare,
Medicaid and SCHIP), on the same basis as other Americans, and
many also receive health care through employer-sponsored or
other healthcare coverage.
It is within the context of current law and programs, that
we turn our attention to S. 1057.
S. 1057
We are here today to discuss reauthorization of the IHCIA,
and its impact on programs and services provided for in current
law. Improving access to healthcare for all eligible American
Indians and Alaska Natives is critical to the Department and a
priority for all of those involved in the administration of
these important programs. We, therefore, commend your interest
and will note positive provisions in S. 1057. However, we will
also note concern on provisions which may negatively impact our
ability to provide needed access to services by establishing
program mandates and burdensome requirements that may divert
resources from important services. We hope to work with you to
address these issues.
The Department brings a keen awareness of the health care
needs of Indian country and is supportive of reauthorization of
the IHCIA. We support provisions that increase the flexibility
of the Department to work with Tribes, to increase the
availability of health care, including new approaches to
delivering care, and to expand the range of options of health
services available to eligible American Indians and Alaska
Natives. Accordingly, I commend Congress for including in S.
1057 various changes that respond to concerns raised in
previous proposals. Some of these changes go a long way toward
improving the ability of the Secretary to effectively manage
the program within current budgetary resources.
Moreover, I would like to note our particular interest in
other provisions of S. 1057.
In the area of behavioral health, title VII of S. 1057
provides for the needs of Indian women and youth and expands
behavioral health services to include a much needed child
sexual abuse and prevention treatment program. The Department
supports this effort, but opposes language in Sections 704,
706, 711(b) and 712 that requires the establishment or
expansion of specific additional services. The Department
should be given the flexibility to provide for all Behavioral
Health Programs in a manner that supports the local control and
priorities of Tribes, and to address their specific needs
within IHS overall budgetary levels.
PROVISIONS RELATED TO MEDICARE AND MEDICAID
In general, we believe the provisions of the bill that
relate to the Medicaid and State Children's Health Insurance
(SCHIP) programs should be considered by the authorizing
committees and in a framework consistent with the FY 2006
Budget Resolution and the Reconciliation process. As part of
the larger Resolution and Reconciliation process, a Medicaid
Commission was established to examine many aspects of that
program. The Commission is charged with advising the Secretary
on ways to modernize the Medicaid program so that it can
provide high-quality health care to its beneficiaries in a
financially sustainable way. Tribes are represented on the
Commission through Secretary Leavitt's recent appointment of
the Chair of the Centers for Medicaid and Medicaid Services
Tribal Technical Advisory Group.
REPORTING REQUIREMENTS
S. 1057 includes new requirements for reporting to Congress
within the President's Budget. The IHS and HHS will work with
Congress to provide the most complete and relevant information
on IHS programs, activities, and performance. However, we
recommend striking language that provides additional
specificity about what should be included in the President's
budget request.
INDIAN HEALTH PROFESSIONS SCHOLARSHIPS
Currently, the scholarship program regularly consults with
the I/T/U's to determine the priorities. Each year, the program
sends letters to all tribal chairmen, tribal health directors,
urban program directors, IHS clinical directors, and IHS
headquarters offices. Through this communication, scholarship
program staff will update the relevant parties regarding the
health professions for which awards were made in the current
year and ask for their recommendations for the professions for
which awards should be made in the coming year. Recommendations
are aggregated and reviewed with the Office of Public Health
and the Office of Management Support to determine which
professions will be funded for the coming year.
New section 104(a)(2) proposes to allocate the program
funding by formula to the twelve IHS areas. If allocation by
formula is authorized Indian, students will not be given an
opportunity to apply for a scholarship if their area does not
receive adequate allocation and if their profession is not
considered a priority in their area; e.g., dental hygienist,
physical therapist, medical technology. This would even impact
a medical student who has identified general surgery or general
psychiatry as a specialty. They will not receive the
scholarship, because it is not a priority or there are no
positions available for these disciplines/specialties.
We are concerned that the large areas will receive the
greatest amount of appropriated funds, leaving the smaller
areas with amounts sufficient to fund only a small portion of
their health professional needs. If an area chooses to allocate
the funds among the tribes within the area, funds available to
many will be insufficient to support even one student.
We recommend retaining the provision in current law which
would maintain the national focus of the scholarship program to
more appropriately meet the health professions needs of Indian
country.
DIABETES EVALUATION AND COORDINATION
The bill has eliminated the current requirement for an
evaluation of the 20 model diabetes programs for effectiveness
and for each Area to employ at least one diabetes control
officer, commonly now known as the Area Diabetes Consultant/
Coordinator, to coordinate and manage on a full-time basis
activities within the Area Office for the prevention,
treatment, and control of diabetes. Area Diabetes Consultants/
Coordinators are critical to the ability of the Service to
provide support to the local Indian health programs as they
implement the Special Diabetes for Indians Program formula and
competitive grants programs. The evaluation provision for the
model diabetes programs also is important to ensure that this
program's effectiveness is assessed to make sure it maintains a
productive role in the context of the implementation of the
Special Diabetes for Indians Program at the local level. Both
the National Diabetes Program and the Tribal Leaders Diabetes
Committee (TLDC) have advocated for Area Diabetes Consultant/
Coordinators.
We recommend that the requirement to employ at least one
diabetes control officer in each of the 12 areas, as well as
the requirement to evaluate the effectiveness of services
provided through model diabetes projects established under this
section, be retained.
HEALTH CARE FACILITIES
Sanitation facilities construction is conducted in 38
States with Federally recognized Tribes who take ownership of
the facilities to operate and maintain them once completed.
There are 49 hospitals, 247 health centers, 5 school health
centers, over 2000 units of staff housing, and 309 health
stations, satellite clinics, and Alaska village clinics
supporting the delivery of health care to Indian people.
HEALTH CARE FACILITIES NEEDS ASSESSMENT AND REPORT
New section 301(d)91) authorizes Government Accountability
Office (GAO) to complete a report, after consultation with
Tribes, on the needs for health care facilities construction,
including renovation and expansion needs. However, efforts are
currently underway to develop a complete description of need
similar to what would be required by the bill. The plan is to
base our future facilities construction priority system
methodology application on a more complete listing of tribal
and Federal facilities needs for delivery of health care
services funded through the IHS. We will continue to explore
with the Tribes less resource intensive means for acquiring and
updating the information that would be required in these
reports.
We recommend the deletion of the reference to the
Government Accountability Office undertaking the report because
it would be redundant of and a setback for IHS's current
efforts to develop an improved facilities construction
methodology. This would allow the IHS to complete its new
priority construction methodology which will address the future
federal and tribal health facility needs.
RETROACTIVE FUNDING OF JOINT VENTURE CONSTRUCTION PROJECTS
New section 311(a)(1) would permit a tribe that has ``begun
or substantially completed'' the process of acquisition of a
facility to participate in the Joint Venture Program,
regardless of government involvement or lack thereof in the
facility acquisition. An agreement implies that all parties
have participated in the development of a plan and have arrived
at some kind of consensus regarding the actions to be taken. By
permitting a tribe that has ``begun or substantially
completed'' the process of acquisition or construction, the
proposed provisions could force IHS to commit the government to
support already completed actions that have not included the
government in the review and approval process. We are concerned
that this language could put the government in the position of
accepting space that is inefficient or ineffective to operate
and recommend that it be deleted.
SANITATION FACILITIES DEFICIENCY DEFINITIONS
New section 302(h)(4) provides definitions of the
sanitation deficiencies used to identify and prioritize water
and sewer projects in Indian country, which are ambiguous. As
proposed deficiency level III could be interpreted to mean all
methods of service delivery (including methods where water and
sewer service is provided by hauling rather than through piping
systems directly into the home) are adequate to meet the level
III requirements and only the operating condition, such as
frequent service interruptions, makes that facility deficient.
This description assumes that water haul delivery systems and
piped systems provide a similar level of service. We believe it
is important to distinguish between the two.
In addition, the definition for deficiency level V and
deficiency level IV, through phrased differently, have
essentially the same meaning. Level IV should refer to an
individual home or community lacking either water or wastewater
facilities, whereas, level V should refer to an individual home
or community lacking both water and wastewater facilities.
We recommend retaining current law as more appropriate for
distinguishing the various levels of deficiencies which
determine the allocation of existing resources.
THRESHOLD CRITERIA FOR SMALL AMBULATORY PROGRAM
New Section 305(b)(1) amends current law to set two minimum
thresholds--one for number of patient visits and another for
the number of eligible Indians. In order to be eligible under
the criteria of S. 1057, a facility must provide at least 150
patient visits annually in a service area with no fewer than
1500 eligible Indians. Aside from the fact that these are both
minimum thresholds and so somewhat contradictory, the new makes
implementation difficult. First, the IHS cannot validate
patient visits unless the applicant participates in the
Resource Patient Management System (RPNS). Since some tribes do
not participate in the RPMS, it is difficult to ensure a fair
evaluation of all applicants. Second, the term ``eligible
Indians'' refers to the census population figures, which cannot
be verified, since they are based on the individual's statement
regarding ethnicity. In order to make the language clear and
equitable, the provision should provide one minimum threshold
that can be validated.
NEW NEGOTIATED RULEMAKING AND CONSULTATION REQUIREMENTS
We are concerned about the remaining requirements for
negotiated rulemaking and increased requirements for
consultation in the bill because of the high cost and staff
time associated with this approach. We are committed to our on-
going consultation with Tribes and urban Indian organizations
under current Executive Orders, as well as promulgating
regulations where necessary to carry out IHCIA using the
procedures required by Chapter V of title 6, United States Code
(commonly known as the Administrative Procedures Act).
We have other objections to S. 1057, including, for
example: new requirements using ``shall'' instead of ``may'' in
provisions that will create budget pressures on current program
activity; expansion of the scope of Federal Torts Claim
Coverage for service provided to otherwise ineligible non-
Indians; expansion of authorities for Urban Indian
Organizations; elimination of the term ``grant'' and
replacement with the term ``funding''; and new provisions that
contemplate the Secretary exercising authority through the
Service, Tribes and Tribal Organizations which is not tied to
agreements entered into under the Indian Self-Determination and
Education Assistance Act (ISDEAA). The Administration may also
have additional views on this legislation.
I reiterate our commitment to working with you to
reauthorize of the Indian Health Care Improvement Act, and the
strengthening of Indian health care programs. I hope to work
with this Committee and other Committees of the Congress, the
National Tribal Steering Committee, and other representatives
of Indian country to develop a bill that all stakeholders in
these important programs can support. Again, I appreciate the
opportunity to appear before you today to discuss this
important legislative proposal. I will be pleased to try to
answer any questions that you may have. Thank you.
Cost Estimates
The Committee has not yet received the final cost estimate
from the Congressional Budget Office.
Changes in Existing Law
In compliance with subsection 12 of rule XXVI of the
Standing Rules of the Senate, the Committee states that the
enactment of S. 1057 will result in the following changes in
existing law (existing law proposed to be omitted enclosed in
black brackets, new language to be added in italic, and
existing law in which no change is proposed shown in roman):
UNITED STATES CODE ANNOTATED
TITLE 25. INDIANS
CHAPTER 18--INDIAN HEALTH CARE
GENERAL PROVISIONS
Sec.
1. Short title; table of contents
1601. [Congressional f]Findings.
1602. Declaration of National Indian health [objectives] policy.
1603. Definitions.
[SUBCHAPTER] TITLE I--INDIAN HEALTH, HUMAN RESOURCES, AND DEVELOPMENT
[PROFESSIONAL PERSONNEL]
1611. [Congressional statement of p]Purpose.
1612. Health [p]Professions [r]Recruitment [p]Program for Indians.
1613. Health [p]Professions [p]Preparatory [s]Scholarship [p]Program for
Indians.
1613a. Indian health professions scholarships.
105. American Indians into Psychology program.
106. Scholarship programs for Indian Tribes.
1614. Indian health service extern programs.
1615. Continuing education allowances.
1616. Community Health Representative Program.
1616a. Indian Health Service Loan Repayment Program.
1616a-1. Scholarship and [L]loan [R]repayment [R]recovery [F]fund.
1616b. Recruitment activities.
1616c. [Tribal] Indian recruitment and retention program.
1616d. Advanced training and research.
1616e. Quentin N. Burdick American Indians into [N]nursing program.
[1616e-1. Nursing school clinics.]
1616f. Tribal cultural orientation [culture and history.]
1616g. INMED Program.
1616h. Health training programs of community colleges.
[1616i. Additional incentives for health professionals.]
1616j. Retention bonus.
1616k. Nursing residency program.
1616l. Community Health Aide Program.
[1616m. Matching grants to tribes for scholarship programs.]
1616n. Tribal health program administration.
123. Health professional chronic shortage demonstration programs.
124. National Health Service Corps.
125. Substance abuse counselor education curricula demonstration
programs.
126. Behavioral health training and community education programs.
[1616o. University of South Dakota pilot program.]
1616p. Authorization of appropriations.
[SUBCHAPTER] TITLE II--HEALTH SERVICES
1621. Indian Health Care Improvement Fund.
1621a. Catastrophic [h]Health [e]Emergency [f]Fund.
1621b. Health promotion and disease prevention services.
1621c. Diabetes prevention, treatment, and control.
205. Shared services for long-term care.
[1621d. Hospice care feasibility study.]
[1621e. Reimbursement from certain third parties of costs of health
services.]
[1621f. Crediting of reimbursements.]
1621g. Health services research.
207. Mammography and other cancer screening.
[1621h. Mental health prevention and treatment services.]
[1621i. Managed care feasibility study.]
[1621j. California contract health services demonstration program.]
[1621k. Coverage of screening mammography.]
1621l. Patient travel costs.
1621m. Epidemiology centers.
1621n. Comprehensive [school] health education programs.
1621o. Indian [y]Youth [grant] [p]Program.
[1621p. American Indians Into Psychology Program.]
1621q. Prevention, control, and elimination of [tuberculosis]
communicable and infectious diseases.
213. Authority for provision of other services.
214. Indian women's health care.
215. Environmental and nuclear health hazards.
216. Arizona as a contract health service delivery area.
216A. North Dakota and South Dakota as a contract health service
delivery area.
217. California contract health services program.
218. California as a contract health service delivery area.
219. Contract health services for the Trenton Service Area.
220. Programs operated by Indian Tribes and Tribal Organizations.
221. Licensing.
222. Notification of provision of emergency contract health services.
223. Prompt action on payment of claims.
[1621r. Contract health services payment study.]
[1621s. Prompt action on payment of claims.]
[1621t. Demonstration of electronic claims processing.]
1621u. Liability for payment.
[1621v. Office of Indian Women's Health Care.]
225. Office of Indian Men's Health.
1621w. Authorization of appropriations.
[1621x. Limitation on use of funds.]
[1622. Transferred.]
[SUBCHAPTER] TITLE III--[HEALTH] FACILITIES
1631. Consultation; [closure] construction and renovation of facilities;
reports.
1632. [Safe water and sanitary waste disposal] Sanitation facilities.
1633. Preference to Indians and Indian firms.
1634. Expenditure of [non-Service] nonservice funds for renovation.
[1635. Repealed.]
1636. [Grant program] Funding for the construction, expansion, and
modernization of small ambulatory care facilities.
1637. Indian [h]Health [c]Care [d]Delivery [d]Demonstration [p]Project.
1638. Land transfer.
308. Leases, contracts, and other agreements.
309. Study on loans, loan guarantees, and loan repayment.
310. Tribal leasing.
311. Indian Health Service/tribal facilities joint venture program.
312. Location of facilities.
313. Maintenance and improvement of health care facilities.
314. Tribal management of Federally owned quarters.
[1638a. Authorization of appropriations.]
1638b. Applicability of Buy American requirement.
316. Other funding for facilities.
317. Authorization of appropriations.
[1638c. Contracts for personal services in Indian Health Service
facilities.]
[1638d. Credit to appropriations of money collected for meals at Indian
Health Service facilities.]
[SUBCHAPTER III-A] TITLE IV--ACCESS TO HEALTH SERVICES
1641. Treatment of payments under [medicare program] Social Security Act
health care programs.
[1642. Treatment of payments under medicaid program.]
[1643. Amount and use of funds reimbursed through medicare and medicaid
available to Indian Health Service.]
1644. Grants to and contracts with the Service, Indian Tribes, [t]Tribal
[o]Organizations, and Urban Indian Organizations.
403. Reimbursement from certain third parties of costs of health
services.
404. Crediting of reimbursements.
405. Purchasing health care coverage.
406. Sharing arrangements with Federal agencies.
407. Payor of last resort.
408. Nondiscrimination in qualifications for reimbursement for services.
409. Consultation.
410. State children's health insurance program (SCHIP).
411. Social Security Act sanctions.
412. Cost sharing.
413. Treatment under medicaid managed care.
414. Navajo nation medicaid agency feasibility study.
[1645. Direct billing of Medicare, Medicaid, and other third party
payors.]
[1646. Authorization for emergency contract health services.]
1647. Authorization of appropriations.
[SUBCHAPTER IV] TITLE V--HEALTH SERVICES FOR URBAN INDIANS
1651. Purpose.
1652. Contracts with, and grants to, [u]Urban Indian [o]Organizations.
1653. Contracts and grants for the provision of health care and referral
services.
1654. Contracts and grants for the determination of unmet health care
needs.
1655. Evaluations; renewals.
1656. Other contract and grant requirements.
1657. Reports and records.
1658. Limitation on contract authority.
1659. Facilities [renovation].
1660. Division of Urban Indian Health [Programs Branch].
1660a. Grants for alcohol and substance abuse-related services.
1660b. Treatment of certain demonstration projects.
1660c. Urban NIAAA transferred programs.
514. Consultation with Urban Indian Organizations.
515. Federal Tort Claim Act coverage.
516. Urban youth treatment center demonstration.
517. Use of Federal government facilities and sources of supply.
518. Grants for diabetes prevention, treatment, and control.
519. Community health representatives.
520. Effective date.
521. Eligibility for services.
1660d. Authorization of appropriations.
[SUBCHAPTER V] TITLE VI--ORGANIZATIONAL IMPROVEMENTS
1661. Establishment of the Indian Health Service as an agency of the
Public Health Service.
1662. Automated management information system.
1663. Authorization of appropriations.
[SUBCHAPTER V--A--SUBSTANCE ABUSE] TITLE VII_BEHAVIORAL HEALTH PROGRAMS
[1665. Indian Health Service responsibilities.]
[1665a. Indian Health Service program.]
701. Behavioral health prevention and treatment services.
702. Memoranda of agreement with the Department of the Interior.
703. Comprehensive behavioral health prevention and treatment program.
704. Mental health technician program.
705. Licensing requirement for mental health care workers.
1665b. Indian women treatment programs.
1665c. Indian [Health Service y]Youth [p]Program.
708. Indian youth telemental health demonstration project.
709. Inpatient and community-based mental health facilities design,
construction, and staffing.
1665d. Training and community education.
[1665e. Gallup alcohol and substance abuse treatment center.]
[1665f. Reports.]
711. Behavioral health program.
1665g. Fetal alcohol [syndrome and fetal alcohol effect grants] disorder
programs.
[1665h. Pueblo substance abuse treatment project for San Juan Pueblo,
New Mexico.]
[1665i. Thunder Child Treatment Center.]
[1665j. Substance abuse counselor education demonstration project.]
[1665k. Gila River alcohol and substance abuse treatment facility.]
[1665l. Alaska Native drug and alcohol abuse demonstration project.]
713. Child sexual abuse and prevention treatment programs.
714. Behavioral health research.
715. Definitions.
1665m. Authorization of appropriations.
[SUBCHAPTER VI] TITLE VIII--MISCELLANEOUS
1671. Reports.
1672. Regulations.
[1673. Repealed.]
[1674. Leases with Indian tribes.]
803. Plan of implementation.
1675. Availability of funds.
1676. Limitation on use of funds appropriated to the Indian Health
Service.
[1677. Nuclear resource development health hazards.]
[1678. Arizona as a contract health service delivery area.]
1679. Eligibility of California Indians.
[1680. California as a contract health service delivery area.]
[1680a. Contract health facilities.]
[1680b. National Health Service Corps.]
1680c. Health services for ineligible persons.
[1680d. Infant and maternal mortality; fetal alcohol syndrome.]
[1680e. Contract health services for the Trenton Service Area.]
[1680f. Indian Health Service and Department of Veterans Affairs health
facilities and services sharing.]
1680g. Reallocation of base resources.
[1680h. Demonstration projects for tribal management of health care
services.]
[1680i. Child sexual abuse treatment programs.]
[1680j. Tribal leasing.]
[1680k. Home- and community-based care demonstration project.]
[1680l. Shared services demonstration project.]
1680m. Results of demonstration projects.
810. Provision of services in Montana.
811. Moratorium.
812. Tribal employment.
813. Severability provisions.
814. Establishment of National Bipartisan Commission on Indian Health
Care.
815. Appropriations; availability.
[1680n. Priority for Indian reservations.]
1680o. Authorization of appropriations.
[1681. Omitted.]
[1682. Subrogation of claims by Indian Health Service.]
[1683. Indian Catastrophic Health Emergency Fund.]
GENERAL PROVISIONS
Sec. 1601. [Congressional f]Findings
[The] Congress makes the following findings:
[(a)] (1) Federal health services to maintain and
improve the health of the Indians are consonant with
and required by the Federal Government's historical and
unique legal relationship with, and resulting
responsibility to the American Indian people.
[(b)] (2) A major national goal of the United States
is to provide the quantity and quality of health
services which will permit the health status of Indians
to be raised to the highest possible level and to
encourage the maximum participation of Indians in the
planning and management of those services.
[(c)] (3) Federal health services to Indians have
resulted in a reduction in the prevalence and incidence
of preventable illnesses among, and unnecessary and
premature deaths of, Indians.
[(d)] (4) Despite such services, the unmet health
needs of [the American] Indians [people] are severe and
the health status of the Indians is far below that of
the general population of the United States.
Sec. 1602. Declaration of [health objectives] National Indian Health
Policy
[(a) The] Congress [hereby] declares that it is the policy
of this Nation, in fulfillment of its special trust
responsibilities and legal obligations to [the American]
Indians.--[people,]
(1) to assure the highest possible health status for
Indians [and urban Indians] and to provide all
resources necessary to effect that policy[.];
[(b) It is the intent of the Congress that the Nation meet
the following health status objectives with respect to Indians
and urban Indians by the year 2000:]
[(1) Reduce coronary heart disease deaths to a level
of no more than 100 per 100,000.]
[(2) Reduce the prevalence of overweight individuals
to no more than 30 percent.]
[(3) Reduce the prevalence of anemia to less than 10
percent among children aged 1 through 5.]
[(4) Reduce the level of cancer deaths to a rate of
no more than 130 per 100,000.]
[(5) Reduce the level of lung cancer deaths to a rate
of no more than 42 per 100,000.]
[(6) Reduce the level of chronic obstructive
pulmonary disease related deaths to a rate of no more
than 25 per 100,000.]
[(7) Reduce deaths among men caused by alcohol-
related motor vehicle crashes to no more than 44.8 per
100,000.]
[(8) Reduce cirrhosis deaths to no more than 13 per
100,000.]
[(9) Reduce drug-related deaths to no more than 3 per
100,000.]
[(10) Reduce pregnancies among girls aged 17 and
younger to no more than 50 per 1,000 adolescents.]
[(11) Reduce suicide among men to no more than 12.8
per 100,000.]
[(12) Reduce by 15 percent the incidence of injurious
suicide attempts among adolescents aged 14 through 17.]
[(13) Reduce to less than 10 percent the prevalence
of mental disorders among children and adolescents.]
[(14) Reduce the incidence of child abuse or neglect
to less than 25.2 per 1,000 children under age 18.]
[(15) Reduce physical abuse directed at women by male
partners to no more than 27 per 1,000 couples.]
[(16) Increase years of healthy life to at least 65
years.]
[(17) Reduce deaths caused by unintentional injuries
to no more than 66.1 per 100,000.]
[(18) Reduce deaths caused by motor vehicle crashes
to no more than 39.2 per 100,000.]
[(19) Among children aged 6 months through 5 years,
reduce the prevalence of blood lead levels exceeding 15
ug/dl and reduce to zero the prevalence of blood lead
levels exceeding 25 ug/dl.]
[(20) Reduce dental caries (cavities) so that the
proportion of children with one or more caries (in
permanent or primary teeth) is no more than 45 percent
among children aged 6 through 8 and no more than 60
percent among adolescents aged 15.]
[(21) Reduce untreated dental caries so that the
proportion of children with untreated caries (in
permanent or primary teeth) is no more than 20 percent
among children aged 6 through 8 and no more than 40
percent among adolescents aged 15.]
[(22) Reduce to no more than 20 percent the
proportion of individuals aged 65 and older who have
lost all of their natural teeth.]
[(23) Increase to at least 45 percent the proportion
of individuals aged 35 to 44 who have never lost a
permanent tooth due to dental caries or periodontal
disease.]
[(24) Reduce destructive periodontal disease to a
prevalence of no more than 15 percent among individuals
aged 35 to 44.]
[(25) Increase to at least 50 percent the proportion
of children who have received protective sealants on
the occlusal (chewing) surfaces of permanent molar
teeth.]
[(26) Reduce the prevalence of gingivitis among
individuals aged 35 to 44 to no more than 50 percent.]
[(27) Reduce the infant mortality rate to no more
than 8.5 per 1,000 live births.]
[(28) Reduce the fetal death rate (20 or more weeks
of gestation) to no more than 4 per 1,000 live births
plus fetal deaths.]
[(29) Reduce the maternal mortality rate to no more
than 3.3 per 100,000 live births.]
[(30) Reduce the incidence of fetal alcohol syndrome
to no more than 2 per 1,000 live births.]
[(31) Reduce stroke deaths to no more than 20 per
100,000.]
[(32) Reverse the increase in end-stage renal disease
(requiring maintenance dialysis or transplantation) to
attain an incidence of no more than 13 per 100,000.]
[(33) Reduce breast cancer deaths to no more than
20.6 per 100,000 women.]
[(34) Reduce deaths from cancer of the uterine cervix
to no more than 1.3 per 100,000 women.]
[(35) Reduce colorectal cancer death to no more than
13.2 per 100,000.]
[(36) Reduce to no more than 11 percent the
proportion of individuals who experience a limitation
in major activity due to chronic conditions.]
[(37) Reduce significant hearing impairment to a
prevalence of no more than 82 per 1,000.]
[(38) Reduce significant visual impairment to a
prevalence of no more than 30 per 1,000.]
[(39) Reduce diabetes-related deaths to no more than
48 per 100,000.]
[(40) Reduce diabetes to an incidence of no more than
2.5 per 1,000 and a prevalence of no more than 62 per
1,000.]
[(41) Reduce the most severe complications of
diabetes as follows:]
[(A) End-stage renal disease, 1.9 per 1,000.]
[(B) Blindness, 1.4 per 1,000.]
[(C) Lower extremity amputation, 4.9 per
1,000.]
[(D) Perinatal mortality, 2 percent.]
[(E) Major congenital malformations, 4
percent.]
[(42) Confine annual incidence of diagnosed AIDS
cases to no more than 1,000 cases.]
[(43) Confine the prevalence of HIV infection to no
more than 100 per 100,000.]
[(44) Reduce gonorrhea to an incidence of no more
than 225 cases per 100,000.]
[(45) Reduce chlamydia trachomatis infections, as
measured by a decrease in the incidence of
nongonococcal urethritis to no more than 170 cases per
100,000.]
[(46) Reduce primary and secondary syphilis to an
incidence to no more than 10 cases per 100,000.]
[(47) Reduce the incidence of pelvic inflammatory
disease, as measured by a reduction in hospitalization
for pelvic inflammatory disease to no more than 250 per
100,000 women aged 15 through 44.]
[(48) Reduce viral hepatitis B infection to no more
than 40 per 100,000 cases.]
[(49) Reduce indigenous cases of vaccine-preventable
diseases as follows:]
[(A) Diphtheria among individuals aged 25 and
younger, 0.]
[(B) Tetanus among individuals aged 25 and
younger, 0.]
[(C) Polio (wild-type virus), 0.]
[(D) Measles, 0.]
[(E) Rubella, 0.]
[(F) Congenital Rubella Syndrome, 0.]
[(G) Mumps, 500.]
[(H) Pertussis, 1,000.]
[(50) Reduce epidemic-related pneumonia and influenza
deaths among individuals aged 65 and older to no more
than 7.3 per 100,000.]
[(51) Reduce the number of new carriers of viral
hepatitis B among Alaska Natives to no more than 1
case.]
[(52) Reduce tuberculosis to an incidence of no more
than 5 cases per 100,000.]
[(53) Reduce bacterial meningitis to no more than 8
cases per 100,000.]
[(54) Reduce infectious diarrhea by at least 25
percent among children.]
[(55) Reduce acute middle ear infections among
children aged 4 and younger, as measured by days of
restricted activity or school absenteeism, to no more
than 105 days per 100 children.]
[(56) Reduce cigarette smoking to a prevalence of no
more than 20 percent.]
[(57) Reduce smokeless tobacco use by youth to a
prevalence of no more than 10 percent.]
[(58) Increase to at least 65 percent the proportion
of parents and caregivers who use feeding practices
that prevent baby bottle tooth decay.]
[(59) Increase to at least 75 percent the proportion
of mothers who breast feed their babies in the early
postSE 1)partum period, and to at least 50 percent the
proportion who continue breast feeding until their
babies are 5 to 6 months old.]
[(60) Increase to at least 90 percent the proportion
of pregnant women who receive prenatal care in the
first trimester of pregnancy.]
[(61) Increase to at least 70 percent the proportion
of individuals who have received, as a minimum within
the appropriate interval, all of the screening and
immunization services and at least one of the
counseling services appropriate for their age and
gender as recommended by the United States Preventive
Services Task Force.]
[(c) It is the intent of the Congress that the Nation
increase the proportion of all degrees in the health
professions and allied and associated health profession fields
awarded to Indians to 0.6 percent.]
[(d) The Secretary shall submit to the President, for
inclusion in each report required to be transmitted to the
Congress under section 1671 of this title, a report on the
progress made in each area of the Service toward meeting each
of the objectives described in subsection (b) of this section.]
(2) to raise the health status of Indians by the year
2010 to at least the levels set forth in the goals
contained within the Healthy People 2010 or successor
objectives;
(3) to the greatest extent possible, to allow Indians
to set their own health care priorities and establish
goals that reflect their unmet needs;
(4) to increase the proportion of all degrees in the
health professions and allied and associated health
professions awarded to Indians so that the proportion
of Indian health professionals in each Service Area is
raised to at least the level of that of the general
population;
(5) to require meaningful consultation with Indian
Tribes, Tribal Organizations, and Urban Indian
Organizations to implement this Act and the national
policy of Indian self-determination; and
(6) to provide funding for programs and facilities
operated by Indian Tribes and Tribal Organizations in
amounts that are not less than the amounts provided to
programs and facilities operated directly by the
Service.
Sec. 1603. Definitions
For purposes of this [chapter] Act[--]:
(1) The term `accredited and accessible' means on or
near a reservation and accredited by a national or
regional organization with accrediting authority.
(2) The term `Area Office' means an administrative
entity including a program office, within the Service
through which services and funds are provided to the
Service Units within a defined geographic area.
(3) The term `Assistant Secretary' means the
Assistant Secretary of Indian Health.
(4) The term `behavioral health' means the blending
of substance (alcohol, drugs, inhalants, and tobacco)
abuse and mental health prevention and treatment, for
the purpose of providing comprehensive services. This
definition can include the joint development of
substance abuse and mental health treatment planning
and coordinated case management using a
multidisciplinary approach.
(5) The term `California Indians' means those Indians
who are eligible for health services of the Service
pursuant to section 806.
(6) The term `community college' means--
(A) a tribal college or university, or
(B) a junior or community college.
(7) The term `contract health service' means health
services provided at the expense of the Service or a
Tribal Health Program by public or private medical
providers or hospitals, other than the Service Unit or
the Tribal Health Program at whose expense the services
are provided.
(8) The term `Department' means, unless otherwise
designated, the Department of Health and Human
Services.
(9) The term `disease prevention' means the
reduction, limitation, and prevention of disease and
its complications and reduction in the consequences of
disease, including--
(A) controlling--
(i) development of diabetes;
(ii) high blood pressure;
(iii) infectious agents;
(iv) injuries;
(v) occupational hazards and
disabilities;
(vi) sexually transmittable diseases;
and
(vii) toxic agents; and
(B) providing--
(i) fluoridation of water; and
(ii) immunizations.
(10) The term `health profession' means allopathic
medicine, family medicine, internal medicine,
pediatrics, geriatric medicine, obstetrics and
gynecology, podiatric medicine, nursing, public health
nursing, dentistry, psychiatry, osteopathy, optometry,
pharmacy, psychology, public health, social work,
marriage and family therapy, chiropractic medicine,
environmental health and engineering, allied health
professions, and any other health profession.
(11) The term `health promotion' means--
(A) fostering social, economic,
environmental, and personal factors conducive
to health, including raising public awareness
about health matters and enabling the people to
cope with health problems by increasing their
knowledge and providing them with valid
information;
(B) encouraging adequate and appropriate
diet, exercise, and sleep;
(C) promoting education and work in
conformity with physical and mental capacity;
(D) making available suitable housing, safe
water, and sanitary facilities;
(E) improving the physical, economic,
cultural, psychological, and social
environment;
(F) promoting adequate opportunity for
spiritual, religious, and Traditional Health
Care Practices; and
(G) providing adequate and appropriate
programs, including--
(i) abuse prevention (mental and
physical);
(ii) community health;
(iii) community safety;
(iv) consumer health education;
(v) diet and nutrition;
(vi) immunization and other
prevention of communicable diseases,
including HIV/AIDS;
(vii) environmental health;
(viii) exercise and physical fitness;
(ix) avoidance of fetal alcohol
disorders;
(x) first aid and CPR education;
(xi) human growth and development;
(xii) injury prevention and personal
safety;
(xiii) behavioral health;
(xiv) monitoring of disease
indicators between health care provider
visits, through appropriate means,
including Internet-based health care
management systems;
(xv) personal health and wellness
practices;
(xvi) personal capacity building;
(xvii) prenatal, pregnancy, and
infant care;
(xviii) psychological well-being;
(xix) reproductive health and family
planning;
(xx) safe and adequate water;
(xxi) safe housing relating to the
elimination, reduction, and prevention
of contaminants that create unhealthy
housing conditions;
(xxii) safe work environments;
(xxiii) stress control;
(xxiv) substance abuse;
(xxv) sanitary facilities;
(xxvi) sudden infant death syndrome
prevention;
(xxvii) tobacco use cessation and
reduction;
(xxviii) violence prevention; and
(xxix) such other activities
identified by the Service, a Tribal
Health Program, or an Urban Indian
Organization, to promote achievement of
any of the objectives described in
section 3(2).
(12) The term `Indian', unless otherwise designated,
means any person who is a member of an Indian Tribe or
is eligible for health services under section 806,
except that, for the purpose of section 102 and 104,
the term also means any individual who--
(A)(i) irrespective of whether the individual
lives on or near a reservation, is a member of
a tribe, band, or other organized group of
Indians, including those tribes, bands, or
groups terminated since 1940 and those
recognized now or in the future by the State in
which they reside; or
(ii) is a descendant, in the first or second
degree, or any such member;
(B) is an Eskimo or Aleut or other Alaska
Native;
(C) is considered by the Secretary of the
Interior to be an Indian for any purpose; or
(D) is determined to be an Indian under
regulations promulgated by the Secretary.
(13) The term `Indian Health Program' means--
(A) any health program administered directly
by the Service;
(B) any Tribal Health Program; or
(C) any Indian Tribe or Tribal Organization
to which the Secretary provides funding
pursuant to section 23 of the Act of June 25,
1910 (25 U.S.C. 47), (commonly known as the
`Buy Indian Act').
(14) The term `Indian Tribe' has the meaning given
the term in the Indian Self-Determination and Education
Assistance Act (25 U.S.C. 450 et seq.).
(15) The term `junior or community college' has the
meaning given the term by section 312(e) of the Higher
Education Act of 1965 (20 U.S.C. 1058(e)).
(16) The term `reservation' means any federally
recognized Indian Tribe's reservation, Pueblo, or
colony, including former reservations in Oklahoma,
Indian allotments, and Alaska Native Regions
established pursuant to the Alaska Native Claims
Settlement Act (25 U.S.C. 1601 et seq.).
[(a)](17) The term [``]`Secretary['']' , unless otherwise
designated, means the Secretary of Health and Human Services.
[(b)](18) The term [``]`Service['']' means the Indian
Health Service.
[(c) ``Indians'' or ``Indian'', unless otherwise
designated, means any person who is a member of an Indian
tribe, as defined in subsection (d) of this section, except
that, for the purpose of sections 1612 and 1613 of this title,
such terms shall mean any individual who (1), irrespective of
whether he or she lives on or near a reservation, is a member
of a tribe, band, or other organized group of Indians,
including those tribes, bands, or groups terminated since 1940
and those recognized now or in the future by the State in which
they reside, or who is a descendant, in the first or second
degree, of any such member, or (2) is an Eskimo or Aleut or
other Alaska Native, or (3) is considered by the Secretary of
the Interior to be an Indian for any purpose, or (4) is
determined to be an Indian under regulations promulgated by the
Secretary.]
[(d) ``Indian tribe'' means any Indian tribe, band, nation,
or other organized group or community, including any Alaska
Native village or group or regional or village corporation as
defined in or established pursuant to the Alaska Native Claims
Settlement Act (85 Stat. 688) [43 U.S.C.A. Sec. 1601 et seq.],
which is recognized as eligible for the special programs and
services provided by the United States to Indians because of
their status as Indians.]
[(e) ``Tribal organization'' means the elected governing
body of any Indian tribe or any legally established
organization of Indians which is controlled by one or more such
bodies or by a board of directors elected or selected by one or
more such bodies (or elected by the Indian population to be
served by such organization) and which includes the maximum
participation of Indians in all phases of its activities.]
(19) The term `Service Area' means the geographical
area served by each Area Office.
(20) The term `Service Unit' means an administrative
entity of the Service, or a Tribal Health Program
through which services are provided, directly or by
contract, to eligible Indians within a defined
geographic area.
(21) The term `telehealth' has the meaning given the
term in section 330K(a) of the Public Health Service
Act (42 U.S.C. 254c-16(a)).
(22) The term `telemedicine' means a
telecommunications link to an end user through the use
of eligible equipment that electronically links health
professionals or patients and health professionals at
separate sites in order to exchange health care
information in audio, video, graphic, or other format
for the purpose of providing improved health care
services.
(23) The term `Traditional Health Care Practices'
means the application by Native healing practitioners
of the Native healing sciences (as opposed or in
contradistinction to Western healing sciences) which
embody the influences or forces of innate Tribal
discovery, history, description, explanation and
knowledge of the states of wellness and illness and
which call upon these influences or forces in the
promotion, restoration, preservation, and maintenance
of health, well-being, and life's harmony.
(24) The term `tribal college or university' has the
meaning given the term in section 316(b)(3) of the
Higher Education Act (20 U.S.C. 1059c(b)(3)).
(25) The term `Tribal Health Program' means an Indian
Tribe or Tribal Organization that operates any health
program, service, function, activity, or facility
funded, in whole or part, by the Service through, or
provided for in, a contract or compact with the Service
under the Indian Self-Determination and Education
Assistance Act (25 U.S.C. 450 et seq.).
(26) The term `Tribal Organization' has the meaning
given the term in the Indian Self-Determination and
Education Assistance Act (25 U.S.C. 450 et seq.).
(27) The term `Urban Center' means any community
which has a sufficient Urban Indian population with
unmet health needs to warrant assistance under title V
of this Act, as determined by the Secretary.
[(f) ``] (28) The term `Urban Indian['']' means any
individual who resides in an [u]Urban [c]Center [, as
defined in subsection (g) of this section,] and who
meets [one] 1 or more of the [four] following criteria:
[in subsection (c)(1) through (4) of this section.]
(A) Irrespective of whether the individual
lives on or near a reservation, the individual
is a member of a tribe, band, or other
organized group of Indians, including those
tribes, bands, or groups terminated since 1940
and those tribes, bands, or groups that are
recognized by the States in which they reside,
or who is a descendant in the first or second
degree of any such member.
(B) The individual is an Eskimo, Aleut, or
other Alaska Native.
(C) The individual is considered by the
Secretary of the Interior to be an Indian for
any purpose.
(D) The individual is determined to be an
Indian under regulations promulgated by the
Secretary.
(29) The term `Urban Indian Organization' means a
nonprofit corporate body that (A) is situated in an
Urban Center; (B) is governed by an Urban Indian-
controlled board of directors; (C) provides for the
participation of all interested Indian groups and
individuals; and (D) is capable of legally cooperating
with other public and private entities for the purpose
of performing the activities described in section
503(a).
[(g) ``Urban center'' means any community which has a
sufficient urban Indian population with unmet health needs to
warrant assistance under subchapter IV of this chapter, as
determined by the Secretary.]
[(h) ``Urban Indian organization'' means a nonprofit
corporate body situated in an urban center, governed by an
urban Indian controlled board of directors, and providing for
the maximum participation of all interested Indian groups and
individuals, which body is capable of legally cooperating with
other public and private entities for the purpose of performing
the activities described in section 1653(a) of this title.]
[(i) ``Area office'' means an administrative entity
including a program office, within the Indian Health Service
through which services 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 Service, or]
[(2) a tribe or tribal organization operating health
care programs or facilities with funds from the Service
under the Indian Self-Determination Act [25 U.S.C.A.
Sec. 450f et seq.],]
[through which services are provided, directly or by contract,
to the eligible Indian population within a defined geographic
area.]
[(k) ``Health promotion'' includes--]
[(1) cessation of tobacco smoking,]
[(2) reduction in the misuse of alcohol and drugs,]
[(3) improvement of nutrition,]
[(4) improvement in physical fitness,]
[(5) family planning,]
[(6) control of stress, and]
[(7) pregnancy and infant care (including prevention
of fetal alcohol syndrome).]
[(l) ``Disease prevention'' includes--]
[(1) immunizations,]
[(2) control of high blood pressure,]
[(3) control of sexually transmittable diseases,]
[(4) prevention and control of diabetes,]
[(5) control of toxic agents,]
[(6) occupational safety and health,]
[(7) accident prevention,]
[(8) fluoridation of water, and]
[(9) control of infectious agents.]
[(m) ``Service area'' means the geographical area served by
each area office.]
[(n) ``Health profession'' means allopathic medicine,
family medicine, internal medicine, pediatrics, geriatric
medicine, obstetrics and gynecology, podiatric medicine,
nursing, public health nursing, dentistry, psychiatry,
osteopathy, optometry, pharmacy, psychology, public health,
social work, marriage and family therapy, chiropractic
medicine, environmental health and engineering, an allied
health profession, or any other health profession.]
[(o) ``Substance abuse'' includes inhalant abuse.]
[(p) ``FAE'' means fetal alcohol effect.]
[(q) ``FAS'' means fetal alcohol syndrome.]
[SUBCHAPTER] TITLE I--INDIAN HEALTH, HUMAN RESOURCES, AND DEVELOPMENT
[PROFESSIONAL PERSONNEL]
Sec. 1611. [Congressional statement of p]Purpose
The purpose of this [subchapter] title is to increase, to
the maximum extent feasible, the number of Indians entering the
health professions and providing health services, and to assure
an [adequate] optimum supply of health professionals to the
Indian Health Programs [Service, Indian tribes, tribal
organizations,] and [u]Urban Indian [o]Organizations involved
in the provision of health care to Indians [people].
Sec. 1612. Health P[p]rofessions R[r]ecruitment P[p]rogram for Indians
(a) [Grants for education and training] In General.--The
Secretary, acting through the Service, shall make grants to
public or nonprofit private health or educational entities,
Tribal Health Programs, or Urban Indian Organizations [or
Indian tribes or tribal organizations] to assist such entities
in meeting the costs of--
(1) identifying Indians with a potential for
education or training in the health professions and
encouraging and assisting them--
(A) to enroll in courses of study in such
health professions; or
(B) if they are not qualified to enroll in
any such courses of study, to undertake such
postsecondary education or training as may be
required to qualify them for enrollment;
(2) publicizing existing sources of financial aid
available to Indians enrolled in any course of study
referred to in paragraph (1) [of this subsection] or
who are undertaking training necessary to qualify them
to enroll in any such course of study; or
(3) establishing other programs which the Secretary
determines will enhance and facilitate the enrollment
of Indians in, and the subsequent pursuit and
completion by them of, courses of study referred to in
paragraph (1) [of this subsection].
(b) [Application for grant; submittal and approval;
preference; payment] Funding._
(1) Application._The Secretary shall not make a grant
under this section [No grant may be made under this
section] unless an application [therefor] has been
submitted to, and approved by, the Secretary. Such
application shall be in such form, submitted in such
manner, and contain such information, as the Secretary
shall by regulation prescribe pursuant to this Act. The
Secretary shall give a preference to applications
submitted by Tribal Health Programs or Urban Indian
Organizations [Indian tribes or tribal organizations].
(2) Amount of grants; payment.--The amount of a [any]
grant under this section shall be determined by the
Secretary. Payments pursuant to [grants under] this
section may be made in advance or by way of
reimbursement, and at such intervals and on such
conditions as [the Secretary finds necessary.] provided
for in regulations issued pursuant to this Act. To the
extentnot otherwise prohibited by law, funding
commitments shall be for 3 years, as provided in regulations issued
pursuant to this Act.
Sec. 1613. Health P[p]rofessions Pp]reparatory Ss]cholarship
Pp]rogram for Indians
(a) [Requirements] Scholarships Authorized.--The Secretary,
acting through the Service, shall provide scholarship [make
scholarship] grants to Indians who--
(1) have successfully completed their high school
education or high school equivalency; and
(2) have demonstrated the potential [capability] to
successfully complete courses of study in the health
professions.
(b) Purposes.--[and duration of grants; preprofessional and
pregraduate education] Scholarship grants provided [grants
made] pursuant to this section shall be for the following
purposes:
(1) Compensatory preprofessional education of any
recipient [grantee], such scholarship not to exceed
[two] 2 years on a full-time basis (or the part-time
equivalent thereof, as determined by the Secretary
pursuant to regulations issued under this Act).
(2) Pregraduate education of any recipient [grantee]
leading to a baccalaureate degree in an approved course
of study preparatory to a field of study in a health
profession, such scholarship not to exceed 4 years [(or
the part-time equivalent thereof, as determined by the
Secretary)]. An extension of up to 2 years (or the
part-time equivalent thereof, as determined by the
Secretary pursuant to regulations issued pursuant to
this Act) may be approved.
(c) [Covered expenses] Other Conditions.--Scholarships
[grants made] under this section--
(1) may cover costs of tuition, books,
transportation, board, and other necessary related
expenses of a recipient [grantee] while attending
school[.];
(2) shall not be denied solely on the basis of the
applicant's scholastic achievement if such applicant
has been admitted to, or maintained good standing at,
an accredited institution; and
(3) shall not be denied solely by reason of such
applicant's eligibility for assistance or benefits
under any other Federal program.
[(d) Basis for denial of assistance]
[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 admitted to, or maintained good standing at, an accredited
institution.]
[(e) Eligibility for assistance under other Federal
programs]
[The Secretary shall not deny scholarship assistance to an
eligible applicant under this section solely by reason of such
applicant's eligibility for assistance or benefits under any
other Federal program.]
Sec. 1613a. Indian H[h]ealth Pp]rofessions Ss]cholarships
(a) In General.-- [authority]
(1) Authority.--[In order to provide health
professionals to Indians, Indian tribes, tribal
organizations, and urban Indian organizations, t]The
Secretary, acting through the Service [and in
accordance with this section], shall make scholarship
grants to Indians who are enrolled full or part time in
[appropriately] accredited schools [and] pursuing
courses of study in the health professions. Such
scholarships shall be designated Indian Health
Scholarships and shall be made in accordance with
section 338A of the Public Health Services Act (42
U.S.C. 254l) [of Title 42], except as provided in
subsection (b) of this section.
(2) Determinations by secretary.--The Secretary,
acting through the Service, shall determine--
(A) who shall receive scholarship grants
under subsection (a); and
(B) the distribution of the scholarships
among health professionals on the basis of the
relative needs of Indians for additional
service in the health professions.
(3) Certain delegation not allowed.--The
administration of this section shall be a
responsibility of the Assistant Secretary and shall not
be delegated in a contract or compact under the Indian
Self-Determination and Education Assistance Act (25
U.S.C. 450 et seq.).
(b) [Recipients; a]Active D[d]uty S[s]ervice
O[o]bligation.--
[(1) The Secretary, acting through the Service, shall
determine who shall receive scholarships under
subsection (a) of this section and shall determine the
distribution of such scholarships among such health
professions on the basis of the relative needs of
Indians for additional service in such health
professions.]
[(2) An individual shall be eligible for a
scholarship under subsection (a) of this section in any
year in which such individual is enrolled full or part
time in a course of study referred to in subsection (a)
of this section.]
(1)[(3)(A)] Obligation met.--The [A]active duty
service obligation under a written contract with the
Secretary under this section [of Title 42] that an
[individual] Indian has entered into [under that
section] shall, if that individual is a recipient of an
Indian Health Scholarship, be met in full-time practice
on an equivalent year-for-year obligation, by service
in 1 or more of the following:[--]
(A)[(i) i]In an [the] Indian Health Program.
[Service;]
[(ii) in a program conducted under a contract
entered into under the Indian Self-
Determination Act [25 U.S.C.A. Sec. 450f et
seq.];]
(B)[(iii) i]In a program assisted under title
V [subchapter IV] of this Act. [chapter;]
(C)[(iv) i]In the private practice of the
applicable 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
health care needs of a substantial number of
Indians.[; or]
(D) In a teaching capacity in a tribal
college or university nursing program (or a
related health profession program) if, as
determined by the Secretary, the health service
provided to Indians would not decrease.
(2)[(B)] Obligation deferred.--At the request of any
individual who has entered into a contract referred to
in paragraph (1) [subparagraph (A)] and who receives a
degree in medicine (including osteopathic or allopathic
medicine), dentistry, optometry, podiatry, or pharmacy,
the Secretary shall defer the active duty service
obligation of that individual under that contract, in
order that such individual may complete any internship,
residency, or other advanced clinical training that is
required for the practice of that health profession,
for an appropriate period (in years, as determined by
the Secretary), subject to the following conditions:
(A)[(i)] No period of internship, residency,
or other advanced clinical training shall be
counted as satisfying any period of obligated
service [that is required] under this
subsection.
(B)[(ii)] The active duty service obligation
of that individual shall commence not later
than 90 days after the completion of that
advanced clinical training (or by a date
specified by the Secretary).
(C)[(iii)] The active duty service obligation
will be served in the health profession of that
individual[,] in a manner consistent with
paragraph (1) [clauses (i) through (v) of
subparagraph (A)].
(D)[(C)] A recipient of a[n Indian Health
S]scholarship under this section may, at the
election of the recipient, meet the active duty
service obligation described in paragraph (1)
[subparagraph (A)] by service in a program
specified under [in] that paragraph
[subparagraph] that--
(i) is located on the reservation of
the Indian T[t]ribe in which the
recipient is enrolled; or
(ii) serves the Indian T[t]ribe in
which the recipient is enrolled.
(3)[(D)] Priority when making assignments.--Subject
to paragraph (2) [subparagraph (C)], the Secretary, in
making assignments of Indian Health Scholarship
recipients required to meet the active duty service
obligation described in paragraph (1) [subparagraph
(A)], shall give priority to assigning individuals to
service in those programs specified in paragraph (1)
[subparagraph (A)] that have a need for health
professionals to provide health care services as a
result of individuals having breached contracts entered
into under this section.
(c)[(4)] Part-Time Students.--In the case of an individual
receiving a scholarship under this section who is enrolled part
time in an approved course of study--
(1)[(A)] such scholarship shall be for a period of
years not to exceed the part-time equivalent of 4
years, as determined by the Area Office [Secretary];
(2)[(B)] the period of obligated service described in
subsection (b)(1) [paragraph (3)(A)] shall be equal to
the greater of--
(A)[(i)] the part-time equivalent of 1[one]
year for each year for which the individual was
provided a scholarship (as determined by the
Area Office [Secretary]); or
(B)[(ii) two] 2 years; and
(3)[(C)] the amount of the monthly stipend specified
in section 338A(g)(1)(B) of the Public Health Service
Act (42 U.S.C. 254l(g)(1)(B)) [of Title 42] shall be
reduced pro rata (as determined by the Secretary) based
on the number of hours such student is enrolled.
(d) Breach of Contract.--
(1) Specified Breaches.--An individual shall be
liable to the United States for the amount which has
been paid to the individual, or on behalf of the
individual, under a contract entered into with the
Secretary under this section on or after the date of
the enactment of the Indian Health Care Improvement Act
Amendments of 2005 if that individual--
[(5)(A) An individual who has, on or after October
29, 1992, entered into a written contract with the
Secretary under this section and who--]
(A)[(i)] fails to maintain an acceptable
level of academic standing in the educational
institution in which he or she is enrolled
(such level determined by the educational
institution under regulations of the
Secretary)[,];
(B)[(ii)] is dismissed from such educational
institution for disciplinary reasons[,];
(C)[(iii)] voluntarily terminates the
training in such an educational institution for
which he or she is provided a scholarship under
such contract before the completion of such
training[,]; or
(D)[(iv)] fails to accept payment, or
instructs the educational institution in which
he or she is enrolled not to accept payment, in
whole or in part, of a scholarship under such
contract, in lieu of any service obligation
arising under such contract[, shall be liable
to the United States for the amount which has
been paid to him, on his behalf, under the
contract].
(2)[(B)] Other breaches.--If for any reason not
specified in paragraph (1) [subparagraph (A)] an
individual breaches a [his] written contract by failing
either to begin such individual's service obligation
required under such contract [this section] or to
complete such service obligation, the United States
shall be entitled to recover from the individual an
amount determined in accordance with the formula
specified in subsection (l) of section 110 [1616a of
this title] in the manner provided for in such
subsection.
(3)[(C)] Cancellation upon death of recipient.--Upon
the death of an individual who receives an Indian
Health Scholarship, any obligation of that individual
for service or payment that relates to that scholarship
shall be canceled.
(4)[(D)] Waivers and suspensions._
(A) In general.--The Secretary shall provide
for the partial or total waiver or suspension
of any obligation of service or payment of a
recipient of an Indian Health Scholarship if
the Secretary, in consultation with the
affected Area Office, Indian Tribes, Tribal
Organizations, and Urban Indian Organizations,
determines that--
(i) it is not possible for the
recipient to meet that obligation or
make that payment;
(ii) requiring that recipient to meet
that obligation or make that payment
would result in extreme hardship to the
recipient; or
(iii) the enforcement of the
requirement to meet the obligation or
make the payment would be
unconscionable.
(B) Factors for consideration.--Before
waiving or suspending an obligation of service
or payment under subparagraph (A), the
Secretary may take into consideration whether
the obligation may be satisfied in a teaching
capacity at a tribal college or university
nursing program under subsection (b)(1)(D).
(5)[(E)] Extreme hardship.--Notwithstanding any other
provision of law, in any case of extreme hardship or
for other good cause shown, the Secretary may waive, in
whole or in part, the right of the United States to
recover funds made available under this section.
(6)[(F)] Bankruptcy.--Notwithstanding any other
provision of law, with respect to a recipient of an
Indian Health Scholarship, no obligation for payment
may be released by a discharge in bankruptcy under
[T]title 11, United States Code, unless that discharge
is granted after the expiration of the 5-year period
beginning on the initial date on which that payment is
due, and only if the bankruptcy court finds that the
nondischarge of the obligation would be unconscionable.
[(c) Placement Office]
[The Secretary shall, acting through the Service, establish
a Placement Office to develop and implement a national policy
for the placement, to available vacancies within the Service,
of Indian Health Scholarship recipients required to meet the
active duty service obligation prescribed under section 254m of
Title 42 without regard to any competitive personnel system,
agency personnel limitation, or Indian preference policy.]
Sec. 105. American Indians into Psychology Program
(a) Grants Authorized.--The Secretary, acting through the
Service, shall make grants of not more than $300,000 to each of
9 colleges and universities for the purpose of developing and
maintaining Indian psychology career recruitment programs as a
means of encouraging Indians to enter the behavioral health
field. These programs shall be located at various locations
throughout the country to maximize their availability to Indian
students and new programs shall be established in different
locations from time to time.
(b) Quentin N. Burdick Program Grant.--The Secretary shall
provide a grant authorized under subsection (a) to develop and
maintain a program at the University of North Dakota to be
known as the `Quentin N. Burdick American Indians Into
Psychology Program'. Such program shall, to the maximum extent
feasible, coordinate with the Quentin N. Burdick Indian Health
Programs authorized under section 117(b), the Quentin N.
Burdick American Indians Into Nursing Program authorized under
section 115(e), and existing university research and
communications networks.
(c) Regulations.--The Secretary shall issue regulations
pursuant to this Act for the competitive awarding of grants
provided under this section.
(d) Conditions of Grant.--Applicants under this section
shall agree to provide a program which, at a minimum--
(1) provides outreach and recruitment for the health
professions to Indian communities including elementary,
secondary, and accredited and accessible community
colleges that will be served by the program;
(2) incorporates a program advisory board comprised
of representatives from the tribes and communities that
will be served by the program;
(3) provides summer enrichment programs to expose
Indian students to the various fields of psychology
through research, clinical, and experimental
activities;
(4) provides stipends to undergraduate and graduate
students to pursue a career in psychology;
(5) develops affiliation agreements with tribal
colleges and universities, the Service, university
affiliated programs, and other appropriate accredited
and accessible entities to enhance the education of
Indian students;
(6) to the maximum extent feasible, uses existing
university tutoring, counseling, and student support
services; and
(7) to the maximum extent feasible, employs qualified
Indians in the program.
(e) Active Duty Service Requirement.--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
graduate who receives a stipend described in subsection (d)(4)
that is funded under this section. Such obligation shall be met
by service--
(1) in an Indian Health Program;
(2) in a program assisted under title V of this Act;
or
(3) in the private practice of psychology 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.
(f) Authorization of Appropriations.--There is authorized
to be appropriated to carry out this section $2,700,000 for
each of fiscal years 2006 through 2015.
Sec. 106. Scholarship programs for Indian tribes
(a) In General.--
(1) Grants authorized.--The Secretary, acting through
the Service, shall make grants available to Tribal
Health Programs for the purpose of providing
scholarships for Indians to serve as health
professionals in Indian communities.
(2) Amount.--Amounts available under paragraph (1)
for any fiscal year shall not exceed 5 percent of the
amounts available for each fiscal year for Indian
Health Scholarships under section 104.
(3) Application.--An application for a grant under
paragraph (1) shall be in such form and contain such
agreements, assurances, and information as consistent
with this section.
(b) Requirements.--
(1) In general.--A Tribal Health Program receiving a
grant under subsection (a) shall provide scholarships
to Indians in accordance with the requirements of this
section.
(2) Costs.--With respect to costs of providing any
scholarship pursuant to subsection (a)--
(A) 80 percent of the costs of the
scholarship shall be paid from the funds made
available pursuant to subsection (a)(1)
provided to the Tribal Health Program; and
(B) 20 percent of such costs may be paid from
any other source of funds.
(c) Course of Study.--A Tribal Health Program shall provide
scholarships under this section only to Indians enrolled or
accepted for enrollment in a course of study (approved by the
Secretary) in 1 of the health professions contemplated by this
Act.
(d) Contract.--In providing scholarships under subsection
(b), the Secretary and the Tribal Health Program shall enter
into a written contract with each recipient of such
scholarship. Such contract shall--
(1) obligate such recipient to provide service in an
Indian Health Program or Urban Indian Organization, in
the same Service Area where the Tribal Health Program
providing the scholarship is located, for--
(A) a number of years for which the
scholarship is provided (or the part-time
equivalent thereof, as determined by the
Secretary), or for a period of 2 years,
whichever period is greater; or
(B) such greater period of time as the
recipient and the Tribal Health Program may
agree;
(2) provide that the amount of the scholarship--
(A) may only be expended for--
(i) tuition expenses, other
reasonable educational expenses, and
reasonable living expenses incurred in
attendance at the educational
institution; and
(ii) payment to the recipient of a
monthly stipend of not more than the
amount authorized by section
338(g)(1)(B) of the Public Health
Service Act (42 U.S.C. 254m(g)(1)(B)),
with such amount to be reduced pro rata
(as determined by the Secretary) based
on the number of hours such student is
enrolled; and not to exceed, for any
year of attendance for which the
scholarship is provided, the total
amount required for the year for the
purposes authorized in this clause; and
(B) may not exceed, for any year of
attendance for which the scholarship is
provided, the total amount required for the
year for the purposes authorized in
subparagraph (A);
(3) require the recipient of such scholarship to
maintain an acceptable level of academic standing as
determined by the educational institution in accordance
with regulations issued pursuant to this Act; and
(4) require the recipient of such scholarship to meet
the educational and licensure requirements appropriate
to each health profession.
(e) Breach of Contract.--
(1) Specific breaches.--An individual who has entered
into a written contract with the Secretary and a Tribal
Health Program under subsection (d) shall be liable to
the United States for the Federal share of the amount
which has been paid to him or her, or on his or her
behalf, under the contract if that individual--
(A) fails to maintain an acceptable level of
academic standing in the educational
institution in which he or she is enrolled
(such level as determined by the educational
institution under regulations of the
Secretary);
(B) is dismissed from such educational
institution for disciplinary reasons;
(C) voluntarily terminates the training in
such an educational institution for which he or
she is provided a scholarship under such
contract before the completion of such
training; or
(D) fails to accept payment, or instructs the
educational institution in which he or she is
enrolled not to accept payment, in whole or in
part, of a scholarship under such contract, in
lieu of any service obligation arising under
such contract.
(2) Other breaches.--If for any reason not specified
in paragraph (1), an individual breaches a written
contract by failing to either begin such individual's
service obligation required under such contract or to
complete such service obligation, the United States
shall be entitled to recover from the individual an
amount determined in accordance with the formula
specified in subsection (l) of section 110 in the
manner provided for in such subsection.
(3) Cancellation upon death of recipient.--Upon the
death of an individual who receives an Indian Health
Scholarship, any outstanding obligation of that
individual for service or payment that relates to that
scholarship shall be canceled.
(4) Information.--The Secretary may carry out this
subsection on the basis of informationreceived from
Tribal Health Programs involved or on the basis of information
collected through such other means as the Secretary deems appropriate.
(f) Relation to Social Security Act.--The recipient of a
scholarship under this section shall agree, in providing health
care pursuant to the requirements herein--
(1) not to discriminate against an individual seeking
care on the basis of the ability of the individual to
pay for such care or on the basis that payment for such
care will be made pursuant to a program established in
title XVIII of the Social Security Act or pursuant to
the programs established in title XIX or title XXI of
such Act; and
(2) to accept assignment under section
1842(b)(3)(B)(ii) of the Social Security Act for all
services for which payment may be made under part B of
title XVIII of such Act, and to enter into an
appropriate agreement with the State agency that
administers the State plan for medical assistance under
title XIX, or the State child health plan under title
XXI, of such Act to provide service to individuals
entitled to medical assistance or child health
assistance, respectively, under the plan.
(g) Continuance of Funding.--The Secretary shall make
payments under this section to a Tribal Health Program for any
fiscal year subsequent to the first fiscal year of such
payments unless the Secretary determines that, for the
immediately preceding fiscal year, the Tribal Health Program
has not complied with the requirements of this section.
Sec. 1614. Indian H[h]ealth S[s]ervice E[e]xtern P[p]rograms
(a) Employment Preference.--[of scholarship grantees during
nonacademic periods] Any individual who receives a scholarship
pursuant to section 104 or 106 shall be given preference for
employment in the Service, or may be employed by a Tribal
Health Program or an Urban Indian Organization, or other
agencies of the Department as available, during any nonacademic
period of the year.
(b) Not Counted Toward Active Duty Service Obligation._
[Any individual who receives a scholarship grant pursuant
to section 1613a of this title shall be entitled to employment
in the Service during any nonacademic period of the year.]
Periods of employment pursuant to this subsection shall not be
counted in determining [the] fulfillment of the service
obligation incurred as a condition of the scholarship [grant].
(c) Timing; Length of Employment._
[(b) Employment of medical and other students during
nonacademic periods]
Any individual enrolled in a program, including a high
school program, authorized under section 102(a) [course of
study in the health professions] may be employed by the Service
or by a Tribal Health Program or an Urban Indian Organization
during any nonacademic period of the year. Any such employment
shall not exceed [120] [one hundred and twenty] days during any
calendar year.
(d) Nonapplicability of Competitive Personnel System._
[(c) Employment without regard to competitive personnel
system or agency personnel limitation; compensation]
Any employment pursuant to this section shall be made
without regard to any competitive personnel system or agency
personnel limitation and to a position which will enable the
individual so employed to receive practical experience in the
health profession in which he or she is engaged in study. Any
individual so employed shall receive payment for his or her
services comparable to the salary he or she would receive if he
or she were employed in the competitive system. Any individual
so employed shall not be counted against any employment ceiling
affecting the Service or the Department [of Health and Human
Services].
Sec. 1615. Continuing E[e]ducation A[a]llowances
[(a) Discretionary authority; scope of activities]
In order to encourage health professionals, including
community health representatives and emergency medical
technicians, [physicians, dentists, nurses, and other health
professionals] to join or continue in an Indian Health Program
or an Urban Indian Organization [the Service] and to provide
their services in the rural and remote areas where a
significant portion of [the] Indians [people] reside[s], the
Secretary, acting through the Service, may provide allowances
to health professionals employed in an Indian Health Program or
an Urban Indian Organization [the Service] to enable them for a
period of time each year prescribed by regulation of the
Secretary to take leave of their duty stations for professional
consultation and refresher training courses.
[(b) Limitation]
[Of amounts appropriated under the authority of this
subchapter for each fiscal year to be used to carry out this
section, not more than $1,000,000 may be used to establish
postdoctoral training programs for health professionals.]
Sec. 1616. Community Health Representative Program
(a) In General.--Under the authority of the Act of November
2, 1921 (25 U.S.C. 13) (commonly[, popularly] known as the
(Snyder Act), the Secretary, acting through the Service, shall
maintain a Community Health Representative Program under which
Indian Health Programs [the Service]--
(1) provide[s] for the training of Indians as
community health representatives; [health
paraprofessionals,] and
(2) use[s] such community health representatives
[paraprofessionals] in the provision of health care,
health promotion, and disease prevention services to
Indian communities.
(b) Duties.--The [Secretary, acting through the] Community
Health Representative Program of the Service, shall--
(1) provide a high standard of training for
[paraprofessionals to C]community [H]health
[R]representatives to ensure that the [C]community
[H]health [R]representatives provide quality health
care, health promotion, and disease prevention services
to the Indian communities served by [such] the
Program[,];
(2) in order to provide such training, develop and
maintain 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, with appropriate
consideration given to lifestyle factors that
have an impact on Indian health status, such as
alcoholism, family dysfunction, and poverty[,];
(3) maintain a system which identifies the needs of
[C]community [H]health [R]representatives for
continuing education in health care, health promotion,
and disease prevention, and develop [maintain] programs
that meet the needs for [such] continuing education[,];
(4) maintain a system that provides close supervision
of Community Health Representatives[,];
(5) maintain a system under which the work of
Community Health Representatives is reviewed and
evaluated[,]; and
(6) promote [t]Traditional [h]Health [c]Care
[p]Practices of the Indian [t]Tribes served consistent
with the Service standards for the provision of health
care, health promotion, and disease prevention.
Sec. 1616a. Indian Health Service Loan Repayment Program
(a) Establishment.--
[(1)] The Secretary, acting through the Service,
shall establish and administer a program to be known as
the [Indian Health] Service Loan Repayment Program
(hereinafter referred to as the ``Loan Repayment
Program'') in order to ensure [assure] an adequate
supply of trained health professionals necessary to
maintain accreditation of, and provide health care
services to Indians through, Indian [h]Health
[p]Programs and Urban Indian Organizations.
[(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 under--]
[(I) the Indian Self-
Determination Act [25 U.S.C.A.
Sec. 450f et seq.], 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 subchapter IV
of this chapter; and]
[(B) the term ``State'' has the same meaning
given such term in section 254d(i)(4) of Title
42.]
(b) Eligible Individuals.--[Eligibility]
To be eligible to participate in the Loan Repayment
Program, an individual must--
(1)(A) be enrolled--
(i) in a course of study or program in an
accredited institution[,] (as determined by the
Secretary under section 338B(b)(1)(c)(i) of the
Public Health Service Act (42 U.S.C. 254l-
1(b)(1)(c)(i)) [, within any State] and be
scheduled to complete such course of study in
the same year such individual applies to
participate in such program; or
(ii) in an approved graduate training program
in a health profession; or
(B) have--
(i) a degree in a health profession; and
(ii) a license to practice a health
profession [in a State];
(2)(A) be eligible for, or hold, an appointment as a
commissioned 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
employment in the [Indian Health] Service; or
(D) be employed in an Indian [h]Health [p]Program or
Urban Indian Organization without a service obligation;
and
(3) submit to the Secretary an application for a
contract described in subsection (e) [(f) of this
section].
(c) Application [and contract forms].--
(1) Information to be included with forms.--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
(l) [of this section] in the case of the individual's
breach of the contract. The Secretary shall provide
such individuals with sufficient information regarding
the advantages and disadvantages 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 an informed basis.
(2) Clear language.--The application form, contract
form, and all other information 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) Timely availability of forms.--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 carefully review and evaluate such
forms and information.
(d) Priorities.--[Vacancies; priority]
(1) List.--Consistent with subsection (k) [paragraph
(3)], the Secretary[, acting through the Service and in
accordance with subsection (k), of this section,] shall
annually--
(A) identify the positions in each Indian
[h]Health [p]Program or Urban Indian
Organization for which there is a need or a
vacancy[,]; and
(B) rank those positions in order of
priority.
(2) Approvals.--Notwithstanding [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--
(A) give first priority to applications made
by individual Indians; and
(B) after making determinations on all
applications submitted by individual Indians as
required under subparagraph (A), give priority
to--
(i) individuals recruited through the
efforts of an Indian Health Program or
Urban Indian Organization; and [tribes
or tribal or Indian organizations.]
(ii) other individuals based on the
priority rankings under paragraph (1).
[(3)(A) Subject to subparagraph (B), of the total
amounts appropriated for each of the fiscal years 1993,
1994, and 1995 for loan repayment contracts under this
section, the Secretary shall provide that--]
[(i) not less than 25 percent be provided to
applicants who are nurses, nurse practitioners,
or nurse midwives; and]
[(ii) not less than 10 percent be provided to
applicants who are mental health professionals
(other than applicants described in clause
(i)).]
[(B) The requirements specified in clause (i) or
clause (ii) of subparagraph (A) shall not apply if the
Secretary does not receive the number of applications
from the individuals described in clause (i) or clause
(ii), respectively, necessary to meet such
requirements.]
(e) Recipient Contracts.--[Approval]
(1) Contract Required.--An individual becomes a
participant in the Loan Repayment Program only upon the
Secretary and the individual entering into a written
contract described in paragraph (2) [subsection (f) of
this section].
(2) Contents of Contract.--[The Secretary shall
provide written notice to an individual promptly on--]
[(A) the Secretary's approving, under
paragraph (1), of the individual's
participation in the Loan Repayment Program,
including extensions resulting in an aggregate
period of obligated service in excess of 4
years; or]
[(B) the Secretary's disapproving an
individual's participation in such Program.]
[(f) Contract terms]
The written contract referred to in this section
between the Secretary and an individual shall contain--
(A)[(1)] an agreement under which--
(i)[(A)] subject to subparagraph
(C)[(3)], the Secretary agrees--
(I)[(i)] to pay loans on
behalf of the individual in
accordance with the provisions
of this section[,]; and
(II)[(ii)] to accept (subject
to the availability of
appropriated funds for carrying
out this section) the
individual into the Service or
place the individual with a
Tribal Health Program or Urban
Indian Organization [tribe or
Indian organization] as
provided in clause (ii)(III);
[subparagraph (B)(iii),] and
(ii)[(B)] subject to subparagraph
(C)[(3)], the individual agrees--
(I)[(i)] to accept loan
payments on behalf of the
individual;
(II)[(ii)] in the case of an
individual described in
subsection (b)(1)--
(aa)[(I)] to maintain
enrollment in a course
of study or training
described in subsection
(b)(1)(A) [of this
section] until the
individual completes
the course of study or
training[,]; and
(bb)[(II)] while
enrolled in such course
of study or training,
to maintain an
acceptable level of
academic standing (as
determined under
regulations of the
Secretary by the
educational institution
offering such course of
study or training); and
(III)[(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 such individual's
profession in an Indian
[h]Health [p]Program or Urban
Indian Organization to which
the individual may be assigned
by the Secretary;
(B)[(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 subparagraph (A)(ii)(III) [paragraph
(1)(B)(iii)];
(C)[(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;
(D)[(4)] a statement of the damages to which
the United States is entitled under subsection
(l) [of this section] for the individual's
breach of the contract; and
(E)[(5)] such other statements of the rights
and liabilities of the Secretary and of the
individual, not inconsistent with this section.
(f) Deadline for Decision on Application._The Secretary
shall provide written notice to an individual within 21 days
on--
(1) the Secretary's approving, under subsection
(e)(1), of the individual's participation in the Loan
Repayment Program, including extensions resulting in an
aggregate period of obligated service in excess of 4
years; or
(2) the Secretary's disapproving an individual's
participation in such Program.
(g) Payments.--[Loan repayment purposes; maximum amount;
tax liability reimbursement; schedule of payments]
(1) In general.--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 government and commercial loans received by
the individual regarding the undergraduate or graduate
education of the individual (or both), which loans were
made for--
(A) tuition expenses;
(B) all other reasonable educational
expenses, including fees, books, and laboratory
expenses, incurred by the individual; and
(C) reasonable living expenses as determined
by the Secretary.
(2)[(A)] Amount.--For each year of obligated service
that an individual contracts to serve under subsection
(e),[(f) of this section] the Secretary may pay up to
$35,000 [(]or an amount equal to the amount specified
in section 338B(g)(2)(A) of the Public Health Service
Act, whichever is more, [254l-1(g)(2)(A) of Title 42)]
on behalf of the individual for loans described in
paragraph (1). In making a determination of the amount
to pay for a year of such service by an individual, the
Secretary shall consider the extent to which each such
determination--
(A)[(i)] affects the ability of the Secretary
to maximize the number of contracts that can be
provided under the Loan Repayment Program from
the amounts appropriated for such contracts;
(B)[(ii)] provides an incentive to serve in
Indian [h]Health [p]Programs and Urban Indian
Organizations with the greatest shortages of
health professionals; and
(C)[(iii)] provides an incentive with respect
to the health professional involved remaining
in an Indian [h]Health [p]Program or Urban
Indian Organization with such a health
professional shortage, and continuing to
provide primary health services, after the
completion of the period of obligated service
under the Loan Repayment Program.
(3)[(B)]Timing.--Any arrangement made by the
Secretary for the making 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 completes such year of service.
(4)[(3)] Reimbursements for tax liability.--For the
purpose of providing reimbursements for tax liability
resulting from a payment under paragraph (2) on behalf
of an individual, the Secretary--
(A) in addition to such payments, may make
payments to the individual in an amount equal
to not less than 20 percent and not more than
39 percent of the total amount of loan
repayments made for the taxable year involved;
and
(B) may make such additional payments as the
Secretary determines to be appropriate with
respect to such purpose.
(5)[(4)] Payment schedule.--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.
(h) Employment Ceiling.--[Effect on employment ceiling of
Department of Health and Human Services] 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] while those individuals are undergoing academic
training.
(i) Recruitment.--[Recruiting programs] The Secretary shall
conduct recruiting programs for the Loan Repayment Program and
other [health professional programs of the] manpower programs
of the Service at educational institutions training health
professionals or specialists identified in subsection (a) [of
this section].
(j) Applicability of Law.--[Prohibition of assignment to
other government departments] Section 214 of the Public Health
Service Act (42 U.S.C. 215) [215 of Title 42] shall not apply
to individuals during their period of obligated service under
the Loan Repayment Program.
(k) Assignment of Individuals.--[Staff needs of health
programs administered by Indian tribes] The Secretary, in
assigning individuals to serve in Indian [h]Health [p]Programs
or Urban Indian Organizations pursuant to contracts entered
into under this section, shall--
(1) ensure that the staffing needs of Tribal [Indian
h]Health [p]Programs and Urban Indian Organizations
[administered by an Indian tribe or tribal or health
organization] receive consideration on an equal basis
with programs that are administered directly by the
Service; and
(2) give priority to assigning individuals to Indian
[h]Health [p]Programs and Urban Indian Organizations
that have a need for health professionals to provide
health care services as a result of individuals having
breached contracts entered into under this section.
(l) Breach of Contract.--[Voluntary termination of study or
dismissal from educational institution; collection of damages]
(1) Specific breaches.--An individual who has entered
into a written contract with the Secretary under this
section and has not received a waiver under subsection
(m) 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 if that individual [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 or
she is enrolled (such level determined
by the educational institution under
regulations of the Secretary);
(ii) voluntarily terminates such
enrollment; or
(iii) is dismissed from such
educational institution before
completion of such course of study; or
(B) is enrolled in a graduate training
program[,] and fails to complete such training
program[, and does not receive a waiver from
the Secretary under subsection (b)(1)(B)(ii) of
this section,].
[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) Other breaches; formula for amount owed.--If, for
any reason not specified in paragraph (1), an
individual breaches his or her written contract under
this section by failing either to begin, or complete,
such individual's period of obligated service in
accordance with subsection (e)(2) [(f) of this
section], the United States shall be entitled to
recover from such individual an amount to be determined
in accordance with the following formula: A=3Z(t-s/t)
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 prevailing 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) [of this section]; and
(D) [``]`s'[''] is the number of months of
such period served by such individual in
accordance with this section.
(3) Deductions in medicare payments.--Amounts not
paid within such period shall be subject to collection
through deductions in [M]medicare payments pursuant to
section 1892 of the Social Security Act [1395ccc of
Title 42].
(4)[(3)(A)] Time period for repayment.--Any amount of
damages which the United States is entitled 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 as shall be specified by the Secretary.
(5) Recovery of delinquency._
(A)[(B)] In general.--If damages described in
paragraph (4) [subparagraph (A)] are delinquent
for 3 months, the Secretary shall, for the
purpose of recovering such damages--
(i) use [utilize] collection agencies
contracted with by the Administrator of
[the] General Services
[Administration]; or
(ii) enter into contracts for the
recovery of such damages with
collection agencies selected by the
Secretary.
(B)[(C)] Report.--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 [T]title 31, United States Code, shall
apply to any such contract to the extent not
inconsistent with this subsection.
(m) Waiver or Suspension of Obligation.--[Cancellation or
waiver of obligations; bankruptcy discharge]
[(1) Any obligation of an individual under the Loan
Repayment program for service or payment of damages
shall be canceled upon the death of the individual.]
(1)[(2)] In general.--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 Repayment 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.
(2) Canceled upon death.--Any obligation of an
individual under the Loan Repayment Program for service
or payment of damages shall be canceled upon the death
of the individual.
(3) Hardship waiver.--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) Bankruptcy.--Any obligation of an individual
under the Loan Repayment Program for payment of damages
may be released by a discharge in bankruptcy under
[T]title 11 of the United States Code only if such
discharge is granted after the expiration of the 5-year
period beginning on the first date that payment of such
damages is required, and only if the bankruptcy court
finds that nondischarge of the obligation would be
unconscionable.
(n) [Annual r]Report.--The Secretary shall submit to the
President, for inclusion in the [each] report required to be
submitted to [the] Congress under section 801 [1671 of this
title], a report concerning the previous fiscal year which sets
forth by Service Area the following:[--]
(1) A list of the health professional positions
maintained by Indian Health Programs and Urban Indian
Organizations [the Service or by tribal or Indian
organizations] for which recruitment or retention is
difficult[;].
(2) [t]The number of Loan Repayment Program
applications filed with respect to each type of health
profession[;].
(3) [t]The number of contracts described in
subsection (e) [(f) of this section] that are entered
into with respect to each health profession[;].
(4) [t]The amount of loan payments made under this
section, in total and by health profession[;].
(5) [t]The number of scholarships [grants] that are
provided under sections 104 and 106 [1613a of this
title] with respect to each health profession[;].
(6) [t]The amount of scholarships [grants] provided
under section 104 and 106 [1613a of this title], in
total and by health profession[;].
(7) [t]The number of providers of health care that
will be needed by Indian [h]Health [p]Programs and
Urban Indian Organizations, by location and profession,
during the 3 [three] fiscal years beginning after the
date the report is filed[; and].
(8) [t]The measures the Secretary plans to take to
fill the health professional positions maintained by
Indian Health Programs or Urban Indian Organizations
[the Service or by tribes or tribal or Indian
organizations] for which recruitment or retention is
difficult.
Sec. 1616a-1. Scholarship and Loan Repayment Recovery Fund
(a) Establishment.--There is established in the Treasury of
the United States a fund to be known as theIndian Health
Scholarship and Loan Repayment Recovery Fund (hereinafter in this
section referred to as the `LRRF' [``Fund'']). The LRRF [Fund] shall
consist of such amounts as may be collected from individuals
[appropriated to the Fund] under section 104(d), section 106(e), and
section 110(l) for breach of contract, such funds as may be
appropriated to the LRRF, and interest earned on amounts in the LRRF
[subsection (b) of this section]. All [A]amounts collected,
appropriated, or earned relative to the LRRF [for the Fund] shall
remain available until expended.
[(b) Authorization of appropriations]
[For each fiscal year, there is authorized to be
appropriated to the Fund an amount equal to the sum of--]
[(1) the amount collected during the preceding fiscal
year by the Federal Government pursuant to--]
[(A) the liability of individuals under
subparagraph (A) or (B) of section 1613a(b)(5)
of this title for the breach of contracts
entered into under section 1613a of this title;
and]
[(B) the liability of individuals under
section 1616a(l) of this title for the breach
of contracts entered into under section 1616a
of this title; and]
[(2) the aggregate amount of interest accruing during
the preceding fiscal year on obligations held in the
Fund pursuant to subsection (d) of this section and the
amount of proceeds from the sale or redemption of such
obligations during such fiscal year.]
(b) [(c)] Use of Funds.--
(1) By secretary.--Amounts in the LRRF [Fund and
available pursuant to appropriation Acts] may be
expended by the Secretary, acting through the Service,
to make payments to an Indian Health Program--[tribe or
tribal organization administering a health care program
pursuant to a contract entered into under the Indian
Self-Determination Act [25 U.S.C.A. Sec. 450f et
seq.]--]
(A) to which a scholarship recipient under
section 104 and 106 [1613a of this title] or a
loan repayment program participant under
section 110 [1616a of this title] has been
assigned to meet the obligated service
requirements pursuant to such sections; and
(B) that has a need for a health professional
to provide health care services as a result of
such recipient or participant having breached
the contract entered into under section 104,
106, or 110. [1613a of this title or section
1616a of this title.]
(2) By Tribal health programs.--A Tribal Health
Program [An Indian tribe or tribal organization]
receiving payments pursuant to paragraph (1) may expend
the payments to provide scholarships or recruit and
employ, directly or by contract, health professionals
to provide health care services.
(c) [(d)] Investment of [excess f]Funds.--
[(1)] The Secretary of the Treasury shall invest such
amounts of the LRRF, [Fund as such] as the Secretary of
Health and Human Services determines are not required
to meet current withdrawals from the LRRF [Fund]. Such
investments may be made only in interest[-] bearing
obligations of the United States. For such purpose,
such obligations may be acquired on original issue at
the issue price, or by purchase of outstanding
obligations at the market price.
(d) Sale of Obligations.--[(2)] Any obligation acquired by
the LRRF [Fund] may be sold by the Secretary of the Treasury at
the market price.
Sec. 1616b. Recruitment A[a]ctivities
(a) Reimbursement for Travel.--The Secretary, acting
through the Service, may reimburse health professionals seeking
positions with Indian Health Programs or Urban Indian
Organizations [in the Service], including individuals
considering entering into a contract under section 110 [1616a
of this title], 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) Recruitment Personnel.--The Secretary, acting through
the Service, shall assign 1 individual in each [a] Area [o]
Office to be responsible on a full-time basis for recruitment
activities.
Sec. 1616c. Indian [Tribal r]Recruitment and R[r]etention P[p]rogram
(a) In General.--[Projects funded on competitive basis] The
Secretary, acting through the Service, shall fund, on a
competitive basis, innovative demonstration projects for a
period not to exceed 3 years to enable Tribal Health Programs
and Urban Indian Organizations to recruit, place, and retain
health professionals to meet their staffing needs. [, on a
competitive basis, projects to enable Indian tribes and tribal
and Indian organization to recruit, place, and retain health
professionals to meet the staffing needs of Indian health
programs (as defined in section 1616a(a)(2) of this title).]
(b) Eligible Entities; Application.--[Eligibility] [(1)]
Any Tribal Health Program or Urban Indian Organization [Indian
tribe or tribal or Indian organization] may submit an
application for funding of a project pursuant to this section.
[(2) Indian tribes and tribal and Indian organizations
under the authority of the Indian Self-Determination Act [25
U.S.C.A. Sec. 450f et seq.] shall be given an equal opportunity
with programs that are administered directly by the Service to
compete for, and receive, grants under subsection (a) of this
section for such projects.]
Sec. 1616d. Advanced T[t]raining and R[r]esearch
(a) Demonstration [Establishment of p]Program.--The
Secretary, acting through the Service, shall establish a
demonstration project [program] to enable health professionals
who have worked in an Indian Health Program or Urban Indian
Organization for a substantial period of time to pursue
advanced training or research in areas of study for which the
Secretary determines a need exists. [In selecting participants
for a program established under this subsection, the Secretary,
acting through the Service, shall give priority to applicants
who are employed by the Indian Health Service, Indian tribes,
tribal organization, and urban Indian organizations, at the
time of the submission of the applications.]
(b) Service Obligation.--[Obligated service]An individual
who participates in a program under subsection (a) [of this
section], where the educational costs are borne by the Service,
shall incur an obligation to serve in an Indian [h]Health
[p]Program or Urban Indian Organization [(as defined in section
1616a(a)(2) of this title)] for a period of obligated service
equal to at least the period of time during which the
individual participates in such program. 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 remaining. In such event, with respect to
individuals entering the program after the date of the
enactment of the Indian Health Care Improvement Act Amendments
of 2005, [October 29, 1992,] the United States shall be
entitled to recover from such individual an amount to be
determined in accordance with the formula specified in
subsection (l) of section 110 [1616a of this title] in the
manner provided for in such subsection.
(c) Equal Opportunity for Participation.--[Eligibility]
Health professionals from Tribal Health Programs and Urban
Indian Organizations [Indian tribes and tribal and Indian
organizations under the authority of the Indian Self-
Determination Act [25 U.S.C.A. Sec. 450f et seq.]] shall be
given an equal opportunity to participate in the program under
subsection (a) [of this section].
[Sec. 1616e. Nursing program]
[(a) Grants]
[The Secretary, acting through the Service, shall provide
grants to--]
[(1) public or private schools of nursing,]
[(2) tribally controlled community colleges and
tribally controlled postsecondary vocational
institutions (as defined in section 2397h(2) of Title
20), and]
[(3) nurse midwife programs, and nurse practitioner
programs, 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) Purposes]
[Grants provided under subsection (a) of this section 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 programs 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
midwives, and nurse practitioners to provide, or
continue to provide, health care services to Indians,]
[(4) provide a program that increases the skills of,
and provides 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) of this
section.]
[(c) Application]
[Each application for a grant under subsection (a) of this
section 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) Preference]
[In providing grants under subsection (a) of this section,
the Secretary shall extend a preference to--]
[(1) programs that provide a preference to Indians,]
[(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 section 2624(a) of this title.]
Sec. 115. [(e)] Quentin N. Burdick American Indians Into Nursing
Program
(a) Grants Authorized.--For the purpose of increasing the
number of nurses, nurse midwives, and nurse practitioners who
deliver health care services to Indians, the Secretary, acting
through the Service, shall provide grants to the following:
(1) Public or private schools of nursing.
(2) Tribal colleges or universities.
(3) Nurse midwife programs and advanced practice
nurse programs that are provided by any tribal college
or university accredited nursing program, or in the
absence of such, any other public or private
institutions.
(b) Use of Grants.--Grants provided under subsection (a)
may be used for one or more of the following:
(1) To recruit individuals for programs which train
individuals to be nurses, nurse midwives, or advanced
practice nurses.
(2) To provide scholarships to Indians enrolled in
such programs 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) To provide a program that encourages nurses,
nurse midwives, and advanced practice nurses to
provide, or continue to provide, health care services
to Indians.
(4) To provide a program that increases the skills
of, and provides continuing education to, nurses, nurse
midwives, and advanced practice nurses.
(5) To provide any program that is designed to
achieve the purpose described in subsection (a).
(c) Applications.--Each application for funding 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) Preferences for Grant Recipients.--In providing grants
under subsection (a), the Secretary shall extend a preference
to the following:
(1) Programs that provide a preference to Indians.
(2) Programs that train nurse midwives or advanced
practice nurses.
(3) Programs that are interdisciplinary.
(4) Programs that are conducted in cooperation with a
program for gifted and talented Indian students.
(e) Quentin N. Burdick Program Grant.--The Secretary shall
provide 1 of the grants authorized under subsection (a) [of
this section] to establish and maintain a program at the
University of North Dakota to be known as the [``]`Quentin N.
Burdick American Indians Into Nursing Program'['']. Such
program shall, to the maximum extent feasible, coordinate with
the Quentin N. Burdick Indian Health Programs established under
section 117(b) [1616g(b) of this title] and the Quentin N.
Burdick American Indians Into Psychology Program established
under section 105(b) [1621p(b) of this title].
(f) Active Duty Service O[o]bligation.--The active duty
service obligation prescribed under section 338C of the Public
Health Service Act (42 U.S.C. 254m) [of Title 42] shall be met
by each individual who receives training or assistance
described in paragraph (1) or (2) of subsection (b) [of this
section] that is funded by a grant provided under subsection
(a) [of this section]. Such obligation shall be met by
service--
(1)[(A)] in the [Indian Health] Service;
(2)[(B)] in a program of an Indian Tribe or Tribal
Organization conducted under the Indian Self-
Determination and Education Assistance Act (25 U.S.C.
450 et seq.) (including programs under agreements with
the Bureau of Indian Affairs) [a contract entered into
under the Indian Self-Determination Act [25 U.S.C.A.
Sec. 450f et seq.]];
(3)[(C)] in a program assisted under title V
[subchapter IV] of this Act [chapter]; or
(4)[(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.
(5) in a teaching capacity in a tribal college or
university nursing program (or a related health
profession program) if, as determined by the Secretary,
health services provided to Indians would not decrease.
[(g) Authorization of appropriations]
[Beginning with fiscal year 1993, of the amounts
appropriated under the authority of this subchapter for each
fiscal year to be used to carry out this section, not less than
$1,000,000 shall be used to provide grants under subsection (a)
of this section for the training of nurse midwives, nurse
anesthetists, and nurse practitioners.]
[Sec. 1616e-1. Nursing school clinics]
[(a) Grants]
[In addition to the authority of the Secretary under
section 1616e(a)(1) of this title, the Secretary, acting
through the Service, is authorized to provide grants to public
or private schools of nursing for the purpose of establishing,
developing, operating, and administering clinics to address the
health care needs of Indians, and to provide primary health
care services to Indians who reside on or within 50 miles of
Indian country, as defined in section 1151 of Title 18.]
[(b) Purposes]
[Grants provided under subsection (a) of this section may
be used to--]
[(1) establish clinics, to be run and staffed by the
faculty and students of a grantee school, to provide
primary care services in areas in or within 50 miles of
Indian country (as defined in section 1151 of Title
18);]
[(2) provide clinical training, program development,
faculty enhancement, and student scholarships in a
manner that would benefit such clinics; and]
[(3) carry out any other activities determined
appropriate by the Secretary.]
[(c) Amount and conditions]
[The Secretary may award grants under this section in such
amounts and subject to such conditions as the Secretary deems
appropriate.]
[(d) Design]
[The clinics established under this section shall be
designed to provide nursing students with a structured clinical
experience that is similar in nature to that provided by
residency training programs for physicians.]
[(e) Regulations]
[The Secretary shall prescribe such regulations as may be
necessary to carry out the provisions of this section.]
[(f) Authorization to use amounts]
[Out of amounts appropriated to carry out this subchapter
for each of the fiscal years 1993 through 2000 not more than
$5,000,000 may be used to carry out this section.]
Sec. 1616f. Tribal Cultural Orientation [culture and history]
(a) Cultural Education of Employees.--[Program established]
The Secretary, acting through the Service, shall require that
[establish a program under which] appropriate employees of the
Service who serve [particular] Indian [t]Tribes in each Service
Area [shall] receive educational instruction in the history and
culture of such Indian T[t]ribes and their relationship to [in
the history of] the Service.
(b) Program.--[Tribally-controlled community colleges] In
carrying out subsection (a), the Secretary shall establish a
program which shall, to the extent feasible--
[To the extent feasible, the program established under
subsection (a) of this section shall--]
(1) be developed in consultation with the affected
Indian Tribes, Tribal Organizations, and Urban Indian
Organizations; [be carried out through tribally-
controlled community colleges (within the meaning of
section 1801(4) of this title) and tribally controlled
postsecondary vocational institutions (as defined in
section 2397h(2) of Title 20),]
(2) be carried out through tribal colleges or
universities; [be developed in consultation with the
affected tribal government, and]
(3) include instruction in American Indian [Native
American] studies; and[.]
(4) describe the use and place of Traditional Health
Care Practices of the Indian Tribes in the Service
Area.
Sec. 1616g. INMED Program
(a) Grants Authorized._The Secretary, acting through the
Service, is authorized to provide grants to [at least 3]
colleges and universities for the purpose of maintaining and
expanding the Indian [Native American] health careers
recruitment program 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) Quentin N. Burdick Grant.--[University of North Dakota]
The Secretary shall provide one of the grants authorized under
subsection (a) [of this section] to maintain the INMED program
at the University of North Dakota, to be known as the `Quentin
N. Burdick Indian Health Programs', unless the Secretary makes
a determination, based upon program reviews, that the program
is not meeting the purposes of this section. Such program
shall, to the maximum extent feasible, coordinate with the
Quentin N. Burdick American Indians Into Psychology Program
established under section 105(b) [1621p(b) of this title] and
the Quentin N. Burdick American Indians Into Nursing Program
established under section 115 [1616e of this title].
(c) Regulations.--[; contents of recruitment program]
[(1)] The Secretary, pursuant to this Act, shall
develop regulations to govern [for the competitive
awarding of the] grants pursuant to [provided under]
this section.
(d) Requirements.--[(2)] Applicants for grants provided
under this section shall agree to provide a program which--
(1) [(A)] provides outreach and recruitment for
health professions to Indian communities, including
elementary[,] and secondary schools and community
colleges located on [Indian] reservations, which will
be served by the program[,];
(2) [(B)] incorporates a program advisory board
comprised of representatives from the Indian tribes and
Indian communities which will be served by the
program[,];
(3) [(C)] provides summer preparatory programs for
Indian students who need enrichment in the subjects of
math and science in order to pursue training in the
health professions[,];
(4) [(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
(5) [(E)] to the maximum extent feasible, employs
qualified Indians in the program.
[(d) Report to Congress]
[By no later than the date that is 3 years after November
23, 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.]
Sec. 1616h. Health [t]Training [p]Programs of [c]Community [c]Colleges
(a) Grants To Establish Programs._
(1) In general.--The Secretary, acting through the
Service, shall award grants to accredited and
accessible community colleges for the purpose of
assisting such [the] community colleges 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 profession on or near a [an Indian]
reservation or in an Indian Health Program [a tribal
clinic].
(2) Amount of grants._T[t]he 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 $250,000.
(b) Grants for Maintenance and Recruiting.--[Eligibility]
(1) In general.--The Secretary, acting through the
Service, shall award grants to accredited and
accessible community colleges that have established a
program described in subsection (a)(1) [of this
section] for the purpose of maintaining the program and
recruiting students for the program.
(2) Requirements.--Grants may only be made under this
section to a community college which--
(A) is accredited[,];
(B) has a relationship with [access to] a
hospital facility, Service facility, or
hospital that could provide training of nurses
or health professionals[,];
(C) has entered into an agreement with an
accredited college or university medical
school, the terms of which--
(i) provide a program that enhances
the transition and recruitment of
students into advanced baccalaureate or
graduate programs that train health
professionals[,]; and
(ii) stipulate certifications
necessary to approved internship and
field placement opportunities at Indian
Health Programs; [service unit
facilities of the Service or at tribal
health facilities,]
(D) has a qualified staff which has the
appropriate certifications[, and];
(E) is capable of obtaining State or regional
accreditation of the program described in
subsection (a)(1) [of this section.]; and
(F) agrees to provide for Indian preference
for applicants for programs under this section.
(c) [Agreements and t]Technical [a]Assistance.--The
Secretary shall encourage community colleges described in
subsection (b)(2) [of this section] to establish and maintain
programs described in subsection (a)(1) [of this section] by--
(1) entering into agreements with such colleges for
the provision 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) Advanced Training.--
(1) Required.--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 training for any health professional
who--
(A)[(1)] has already received a degree or
diploma in such health profession[,]; and
(B)[(2)] provides clinical services on or
near a [an Indian] reservation or for an Indian
Health Program[, at a Service facility, or at a
tribal clinic].
(2) May be offered at alternate site.--Such courses
of study may be offered in conjunction with the college
or university with which the community college has
entered into the agreement required under subsection
(b)(2)(C) [of this section].
(e) Funding Priority.--Where the requirements of subsection
(b) are met, funding priority shall be provided to tribal
colleges and universities in Service Areas where they exist.
[(e) Definitions]
[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
1801(4) of this title.]
[(3) The term ``junior or community college'' has the
meaning given to such term by section 1058(e) of Title
20.]
[Sec. 1616i. Additional incentives for health professionals]
[(a) Incentive special pay]
[The Secretary may provide the incentive special pay
authorized under section 302(b) of Title 37, to civilian
medical officers of the Indian Health Service who are assigned
to, and serving in, positions included in the list established
under subsection (b)(1) of this section for which recruitment
or retention of personnel is difficult.]
[(b) List of positions; bonus pay]
[(1) 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.]
[(2)(A) 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) The 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) Work schedules]
[The Secretary may establish programs to allow the use of
flexible work schedules, and compressed work schedules, in
accordance with the provisions of subchapter II of chapter 61
of Title 5, for health professionals employed by, or assigned
to, the Service.]
Sec. 1616j. Retention bonus
(a) Bonus Authorized.--[Eligibility]The Secretary may pay a
retention bonus to any health professional [physician or nurse]
employed by, or assigned to, and serving in, an Indian Health
Program or Urban Indian Organization [the 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
1616i(b)(1) of this title] for which recruitment or
retention of personnel is difficult[,];
(2) the Secretary determines is needed by Indian
Health Programs and Urban Indian Organizations; [the
Service,]
(3) has--
(A) completed 3 years of employment with an
Indian Health Program or Urban Indian
Organization; [the Service,] or
(B) completed any service obligations
incurred as a requirement of--
(i) any Federal scholarship
program[,]; or
(ii) any Federal education loan
repayment program[,]; and
(4) enters into an agreement with an Indian Health
Program or Urban Indian Organization [the Service] for
continued employment for a period of not less than 1
year.
[(b) Minimum award percentage to nurses]
[Beginning with fiscal year 1993, not less than 25 percent
of the retention bonuses awarded each year under subsection (a)
of the section shall be awarded to nurses.]
(b)[(c)] Rates.--[; maximum rate]The Secretary may
establish rates for the retention bonus which shall provide for
a higher annual rate for multiyear agreements than for single
year agreements referred to in subsection (a)(4) [of this
section], but in no event shall the annual rate be more than
$25,000 per annum.
[(d) Time of payment]
[The retention bonus for the entire period covered by the
agreement described in subsection (a)(4) of this section shall
be paid at the beginning of the agreed upon term of service.]
[(e) Refund; interest]
(c) Default of Retention Agreement._Any health professional
[physician or nurse] failing to complete the agreed upon term
of service, except where such failure is through no fault of
the individual, shall be obligated to refund to the Government
the full amount of the retention bonus for the period covered
by the agreement, plus interest as determined by the Secretary
in accordance with section 110(l)(2)(B) [1616a(l)(2)(B) of this
title].
(d) Other Retention Bonus._
[(f) Physicians and nurses employed under indian self-
determination act]
The Secretary may pay a retention bonus to any health
professional [physician or nurse] employed by a Tribal Health
Program [an organization providing health care services to
Indians pursuant to a contract under the Indian Self-
Determination Act [25 U.S.C.A. Sec. 450f et. seq.]] if such
health professional [physician or nurse] is serving in a
position which the Secretary determines is--
(1) a position for which recruitment or retention is
difficult; and
(2) necessary for providing health care services to
Indians.
Sec. 1616k. Nursing residency program
(a) Establishment of Program._The Secretary, acting through
the Service, shall establish a program to enable Indians who
are licensed practical nurses, licensed vocational nurses, and
registered nurses who are working in an Indian H[h]ealth
P[p]rogram or Urban Indian Organization [(as defined in section
1616a(a)(2)(A) of this title)], and have done so for a period
of not less than 1 [one] year, to pursue advanced training.
[(b) Program components]
Such program shall include a combination of education and
work study in an Indian H[h]ealth P[p]rogram or Urban Indian
Organization [(as defined in section 1616a(a)(2)(A) of this
title)] leading to an associate or bachelor's degree (in the
case of a licensed practical nurse or licensed vocational
nurse), [or] a bachelor's degree (in the case of a registered
nurse) or advanced degrees or certification in nursing and
public health [a Master's degree].
(b)[(c)] Service O[o]bligation.--[of program participant]
An individual who participates in a program under subsection
(a) [of this section], where the educational costs are paid by
the Service, shall incur an obligation to serve in an Indian
H[h]ealth P[p]rogram or Urban Indian Organization for a period
of obligated service equal to the amount of [at least three
times the period of the] time during which the individual
participates in such program. In the event that the individual
fails to complete such obligated service, the United States
shall be entitled to recover from such individual an amount
determined in accordance with the formula specified in
subsection (l) of section 110 [1616a of this title] in the
manner provided for in such subsection.
Sec. 1616l. Community Health Aide Program
(a) General Purposes [Maintenance] of Program.--Under the
authority of the Act of November 2, 1921 (25 U.S.C. 13)
(commonly known as the `Snyder Act') [section 13 of this
title], the Secretary, acting through the Service, shall
develop and operate [maintain] a Community Health Aide Program
in Alaska under which the Service--
(1) provides for the training of Alaska Natives as
health aides or community health practitioners;
(2) uses such aides or practitioners in the provision
of health care, health promotion, and disease
prevention services to Alaska Natives living in
villages in rural Alaska; and
(3) provides for the establishment of
teleconferencing capacity in health clinics located in
or near such villages for use by community health aides
or community health practitioners.
(b) Specific Program Requirements.--[Training; curriculum;
certification board]The Secretary, acting through the Community
Health Aide Program of the Service, shall--
(1) using trainers accredited by the Program, provide
a high standard of training to community health aides
and community health practitioners to ensure that such
aides and practitioners provide quality health care,
health promotion, and disease prevention services to
the villages served by the 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;
(B) provides instruction and practical
experience in the provision of acute care,
emergency care, health promotion, disease
prevention, and the efficient and effective
management of clinic pharmacies, supplies,
equipment, and facilities; and
(C) promotes the achievement of the health
status objectives specified in section 3(2)
[1602(b) of this title];
(3) establish and maintain a Community Health Aide
Certification Board to certify as community health
aides or community health practitioners individuals who
have successfully completed the training described in
paragraph (1) or can demonstrate equivalent experience;
(4) develop and maintain a system which identifies
the needs of community health aides and community
health practitioners for continuing education in the
provision of health care, including the areas described
in paragraph (2)(B), and develop programs that meet the
needs for such continuing education;
(5) develop and maintain a system that provides close
supervision of community health aides and community
health practitioners; and
(6) develop a system under which the work of
community health aides and community health
practitioners is reviewed and evaluated to assure the
provision of quality health care, health promotion, and
disease prevention services.
(c) Program Review.--
(1) Neutral panel.--
(A) Establishment.--The Secretary, acting
through the Service, shall establish a neutral
panel to carry out the study under paragraph
(2).
(B) Membership.--Members of the neutral panel
shall be appointed by the Secretary from among
clinicians, economists, community
practitioners, oral epidemiologists, and Alaska
Natives.
(2) study.--
(A) In general.--The neutral panel
established under paragraph (1) shall conduct a
study of the dental health aide therapist
services provided by the Community Health Aide
Program under this section to ensure that the
quality of care provided through thoseservices
is adequate and appropriate.
(B) Parameters of study.--The Secretary, in
consultation with interested parties, including
professional dental organizations, shall
develop the parameters of the study.
(C) Inclusions.--The study shall include a
determination by the neutral panel with respect
to--
(i) the ability of the dental health
aide services under this section to
address the dental care needs of Alaska
Natives;
(ii) the quality of care provided
through those services, including any
training, improvement, or additional
oversight required to improve the
quality of care; and
(iii) whether safer and less costly
alternatives to the dental health aide
therapist services exist.
(D) Consultation.--In carrying out the study
under this paragraph, the neutral panel shall
consult with Alaska Tribal Organizations with
respect to the adequacy and accuracy of the
study.
(3) Report.--The neutral panel shall submit to the
Secretary, the Committee on Indian Affairs of the
Senate, and the Committee on Resources of the House of
Representatives a report describing the results of the
study under paragraph (2), including a description of--
(A) any determination of the neutral panel
under paragraph (2)(C); and
(B) any comments received from an Alaska
Tribal Organization under paragraph (2)(D).
(d) Nationalization of Program.--
(1) In general.--Except as provided in paragraph (2),
the Secretary, acting through the Service, may
establish a national Community Health Aide Program in
accordance with the program under this section, as the
Secretary determines to be appropriate.
(2) Exception.--The national Community Health Aide
Program under paragraph (10) shall not include dental
health aide therapist services.
(3) Requirement.--In establishing a national program
under paragraph (1), the Secretary shall not reduce the
amount of funds provided for the Community Health Aide
Program described in subsections (a) and (b).
[Sec. 1616m. Matching grants to tribes for scholarship programs]
[(a) In general]
[(1) The Secretary shall make grants to Indian tribes
and tribal organizations for the purpose of assisting
such tribes and tribal organizations in educating
Indians to serve as health professionals in Indian
communities.]
[(2) Amounts available for grants under paragraph (1)
for any fiscal year shall not exceed 5 percent of
amounts available for such fiscal year for Indian
Health Scholarships under section 1613a of this title.]
[(3) An application for a grant under paragraph (1)
shall be in such form and contain such agreements,
assurances, and information as the Secretary determines
are necessary to carry out this section.]
[(b) Compliance with requirements]
[(1) An Indian tribe or tribal organization receiving
a grant under subsection (a) of this section shall
agree to provide scholarships to Indians pursuing
education in the health professions in accordance with
the requirements of this section.]
[(2) With respect to the costs of providing any
scholarship pursuant to paragraph (1)--]
[(A) 80 percent of the costs of the
scholarship shall be paid from the grant made
under subsection (a) of this section to the
Indian tribe or tribal organization; and]
[(B) 20 percent of such costs shall be paid
from non-Federal contributions by the Indian
tribe or tribal organization through which the
scholarship is provided.]
[(3) In determining the amount of non-Federal
contributions that have been provided for purposes of
subparagraph (B) of paragraph (2), any amounts provided
by the Federal Government to the Indian tribe or tribal
organization involved or to any other entity shall not
be included.]
[(4) Non-Federal contributions required by
subparagraph (B) of paragraph (2) may be provided
directly by the Indian tribe or tribal organization
involved or through donations from public and private
entities.]
[(c) Course of study in health professions]
[An Indian tribe or tribal organization shall provide
scholarships under subsection (b) of this section only to
Indians enrolled or accepted for enrollment in the course of
study (approved by the Secretary) in one of the health
professions described in section 1613a(a) of this title.]
[(d) Contract requirements]
[In providing scholarships under subsection (b) of this
section, the Secretary and the Indian tribe or tribal
organization shall enter into a written contract with each
recipient of such scholarship. Such contract shall--]
[(1) obligate such recipient to provide service in an
Indian health program (as defined in section
1616a(a)(2)(A) of this title), in the same service area
where the Indian tribe or tribal organization providing
the scholarship is located, for--]
[(A) a number of years equal to the number of
years for which the scholarship is provided (or
the part-time equivalent thereof, as determined
by the Secretary), or for a period of 2 years,
whichever period is greater; or]
[(B) such greater period of time as the
recipient and the Indian tribe or tribal
organization may agree;]
[(2) provide that the amount of such scholarship--]
[(A) may be expended only for--]
[(i) tuition expenses, other
reasonable educational expenses, and
reasonable living expenses incurred in
attendance at the educational
institution; and]
[(ii) payment to the recipient of a
monthly stipend of not more than the
amount authorized by section
254l(g)(1)(B) of Title 42, such amount
to be reduced pro rata (as determined
by the Secretary) based on the number
of hours such student is enrolled; and]
[(B) may not exceed, for any year of
attendance for which the scholarship is
provided, the total amount required for the
year for the purposes authorized in
subparagraph (A);]
[(3) require the recipient of such scholarship to
maintain an acceptable level of academic standing (as
determined by the educational institution in accordance
with regulations issued by the Secretary); and]
[(4) require the recipient of such scholarship to
meet the educational and licensure requirements
necessary to be a physician, certified nurse
practitioner, certified nurse midwife, or physician
assistant.]
[(e) Breach of contract]
[(1) an individual who has entered into a written
contract with the Secretary and an Indian tribe or
tribal organization under subsection (d) of this
section and who--]
[(A) fails to maintain an acceptable level of
academic standing in the educational
institution in which he is enrolled (such level
determined by the educational institution under
regulations of the Secretary),]
[(B) is dismissed from such educational
institution for disciplinary reasons,]
[(C) voluntarily terminates the training in
such an educational institution for which he is
provided a scholarship under such contract
before the completion of such training, or]
[(D) fails to accept payment, or instructs
the educational institution in which he is
enrolled not to accept payment,]
[in whole or in part, of a scholarship under such contract, in
lieu of any service obligation arising under such contract,
shall be liable to the United States for the Federal share of
the amount which has been paid to him, or on his behalf, under
the contract.]
[(2) If for any reason not specified in paragraph
(1), an individual breaches his written contract by
failing either to begin such individual's service
obligation required under such contract or to complete
such service obligation, the United States shall be
entitled to recover from the individual an amount
determined in accordance with the formula specified in
subsection (l) of section 1616a of this title in the
manner provided for in such subsection.]
[(3) The Secretary may carry out this subsection on
the basis of information submitted by the tribes or
tribal organization involved, or on the basis of
information collected through such other means as the
Secretary determines to be appropriate.]
[(f) Nondiscriminatory practice]
[The recipient of a scholarship under subsection (b) of
this section shall agree, in providing health care pursuant to
the requirements of subsection (d)(1) of this section--]
[(1) not to discriminate against an individual
seeking such care on the basis of the ability of the
individual to pay for such care or on the basis that
payment for such care will be made pursuant to the
program established in title XVIII of the Social
Security Act [42 U.S.C.A. Sec. 1395 et. Seq.] or
pursuant to the program established in title XIX of
such Act [42 U.S.C.A. Sec. 1396 et. seq.]; and]
[(2) to accept assignment under section
1842(b)(3)(B)(ii) of the Social Security Act [42
U.S.C.A. Sec. 1395u(b)(3)(B)(ii)] for all services for
which payment may be made under part B of title XVIII
of such Act 42 U.S.C.A. Sec. 1395j et. seq., and to
enter into an appropriate agreement with the State
agency that administers the State plan for medical
assistance under title XIX of such Act 42 U.S.C.A.
Sec. 1396 et. seq. to provide service to individuals
entitled to medical assistance under the plan.]
[(g) Payments for subsequent fiscal years]
[The Secretary may not make any payments under subsection
(a) of this section to an Indian tribe or tribal organization
for any fiscal year subsequent to the first fiscal year of such
payments unless the Secretary determines that, for the
immediately preceding fiscal year, the Indian tribe or tribal
organization has complied with requirements of this section.]
Sec. 1616n. Tribal H[h]ealth P[p]rogram A[a]dministration
The Secretary, acting through the Service, shall, by
contract or otherwise, provide training for Indians
[individuals] in the administration and planning of T[t]ribal
H[h]ealth P[p]rograms
Sec. 123. Health Professional Chronic Shortage Demonstration Programs
(a) Demonstration Programs Authorized.--The Secretary,
acting through the Service, may fund demonstration programs for
Tribal Health Programs to address the chronic shortages of
health professionals.
(b) Purposes of Programs.--The purposes of demonstration
programs funded under subsection (a) shall be--
(1) to provide direct clinical and practical
experience at a Service Unit to health profession
students and residents from medical schools;
(2) to improve the quality of health care for Indians
by assuring access to qualified health care
professionals; and
(3) to provide academic and scholarly opportunities
for health professionals serving Indians by identifying
all academic and scholarly resources of the region.
(c) Advisory Board.--The demonstration programs established
pursuant to subsection (a) shall incorporate a program advisory
board composed of representatives from the Indian Tribes and
Indian communities in the area which will be served by the
program.
Sec. 124. National Health Service Corps
(a) No Reduction in Services.--The Secretary shall not--
(1) remove a member of the National Health Service
Corps from an Indian Health Program or Urban Indian
Organization; or
(2) withdraw funding used to support such member,
unless the Secretary, acting through the Service,
Indian Tribes, or Tribal Organizations, has ensured
that the Indians receiving services from such member
will experience no reduction in services.
(b) Exemption From Limitations.--National Health Service
Corps scholars qualifying for the Commissioned Corps in the
United States Public Health Service shall be exempt from the
full-time equivalent limitations of the National Health Service
Corps and the Service when serving as a commissioned corps
officer in a Tribal Health Program or an Urban Indian
Organization.
Sec. 125. Substance abuse counselor educational curricula demonstration
programs
(a) Grants and Contracts.--The Secretary, acting through
the Service, may enter into contracts with, or make grants to,
accredited tribal colleges and universities and eligible
accredited and accessible community colleges to establish
demonstration programs to develop educational curricula for
substance abuse counseling.
(b) Use of Funds.--Funds provided under this section shall
be used only for developing and providing educational
curriculum for substance abuse counseling (including paying
salaries for instructors). Such curricula may be provided
through satellite campus programs.
(c) Time Period of Assistance; Renewal.--A contract entered
into or a grant provided under this section shall be for a
period of 3 years. Such contract or grant may be renewed for an
additional 2-year period upon the approval of the Secretary.
(d) Criteria for Review and Approval of Applications.--Not
later than 180 days after the date of the enactment of the
Indian Health Care Improvement Act Amendments of 2005, the
Secretary, after consultation with Indian Tribes and
administrators of tribal colleges and universities and eligible
accredited and accessible community colleges, shall develop and
issue criteria for the review and approval of applications for
funding (including applications for renewals of funding) under
this section. Such criteria shall ensure that demonstration
programs established under this section promote the development
of the capacity of such entities to educate substance abuse
counselors.
(e) Assistance.--The Secretary shall provide such technical
and other assistance as may be necessary to enable grant
recipients to comply with the provisions of this section.
(f) Report.--Each fiscal year, the Secretary shall submit
to the President, for inclusion in the report which is required
to be submitted under section 801 for that fiscal year, a
report on the findings and conclusions derived from the
demonstration programs conducted under this section during that
fiscal year.
(g) Definition.--For the purposes of this section, the term
`educational curriculum' means 1 or more of the following:
(1) Classroom education.
(2) Clinical work experience.
(3) Continuing education workshops.
Sec. 126. Behavioral health training and community education programs
(a) Study; List.--The Secretary, acting through the
Service, and the Secretary of the Interior, in consultation
with Indian Tribes and Tribal Organizations, shall conduct a
study and compile a list of the types of staff positions
specified in subsection (b) whose qualifications include, or
should include, training in the identification, prevention,
education, referral, or treatment of mental illness, or
dysfunctional and self destructive behavior.
(b) Positions.--The positions referred to in subsection (a)
are--
(1) staff positions within the Bureau of Indian
Affairs, including existing positions, in the fields
of--
(A) elementary and secondary education;
(B) social services and family and child
welfare;
(C) law enforcement and judicial services;
and
(D) alcohol and substance abuse;
(2) staff positions within the Service; and
(3) staff positions similar to those identified in
paragraphs (1) and (2) established and maintained by
Indian Tribes, Tribal Organizations, (without regard to
the funding source) and Urban Indian Organizations.
(c) Training Criteria.--
(1) In general.--The appropriate Secretary shall
provide training criteria appropriate to each type of
position identified in subsection (b)(1) and (b)(2) and
ensure that appropriate training has been, or shall be
provided to any individual in any such position. With
respect to any such individual in a position identified
pursuant to subsection (b)(3), the respective
Secretaries shall provide appropriate training to, or
provide funds to, an Indian Tribe, Tribal Organization,
or Urban Indian Organization for training of
appropriate individuals. In the case of positions
funded under a contract or compact under the Indian
Self-Determination and Education Assistance Act (25
U.S.C. 450 et seq.), the appropriate Secretary shall
ensure that such training costs are included in the
contract or compact, as the Secretary determines
necessary.
(2) Position specific training criteria.--Position
specific training criteria shall be culturally relevant
to Indians and Indian Tribes and shall ensure that
appropriate information regarding Traditional Health
Care Practices is provided.
(d) Community Education on Mental Illness.--The Service
shall develop and implement, on request of an Indian Tribe,
Tribal Organization, or Urban Indian Organization, or assist
the Indian Tribe, Tribal Organization, or Urban Indian
Organization to develop and implement, a program of community
education on mental illness. In carrying out this subsection,
the Service shall, upon request of an Indian Tribe, Tribal
Organization, or Urban Indian Organization, provide technical
assistance to the Indian Tribe, Tribal Organization, or Urban
Indian Organization to obtain and develop community educational
materials on the identification, prevention, referral, and
treatment of mental illness and dysfunctional and self-
destructive behavior.
(e) Plan.--Not later than 90 days after the date of the
enactment of the Indian Health Care Improvement Act Amendments
of 2005, the Secretary shall develop a plan under which the
Service will increase the health care staff providing
behavioral health services by at least 500 positions within 5
years after the date of the enactment of this section, with at
least 200 of such positions devoted to child, adolescent, and
family services. The plan developed under this subsection shall
be implemented under the Act of November 2, 1921 (25 U.S.C. 13)
(commonly known as the `Snyder Act').
[Sec. 1616o. University of South Dakota pilot program]
[(a) Establishment]
[The Secretary may make a grant to the School of Medicine
of the University of South Dakota (hereafter in this section
referred to as ``USDSM'') to establish a pilot program on an
Indian reservation at one or more service units in South Dakota
to address the chronic manpower shortage in the Aberdeen Area
of the Service.]
[(b) Purposes]
[The purposes of the program established pursuant to a
grant provided under subsection (a) of this section are--]
[(1) to provide direct clinical and practical
experience at the service unit to medical students and
residents from USDSM and other medical schools;]
[(2) to improve the quality of health care for
Indians by assuring access to qualified health care
professionals; and]
[(3) to provide academic and scholarly opportunities
for physicians, physician assistants, nurse
practitioners, nurse and other allied health
professionals serving Indian people by identifying and
utilizing all academic and scholarly resources of the
region.]
[(c) Composition; designation]
[The pilot program established pursuant to a grant provided
under subsection (a) of this section shall--]
[(1) incorporate a program advisory board composed of
representatives from the tribes and communities in the
area which will be served by the program; and]
[(2) shall be designated as an extension of the USDSM
campus and program participants shall be under the
direct supervision and instruction of qualified medical
staff serving at the service unit who shall be members
of the USDSM faculty.]
[(d) Coordination with other schools]
[The USDSM shall coordinate the program established
pursuant to a grant provided under subsection (a) of this
section with other medical schools in the region, nursing
schools, tribal community colleges, and other health
professional schools.]
[(e) Development of additional professional opportunities]
[The USDSM, in cooperation with the Service, shall develop
additional professional opportunities for program participants
on Indian reservations in order to improve the recruitment and
retention of qualified health professionals in the Aberdeen
Area of the Service.]
Sec. 1616p. Authorization of [a]Appropriations
There are authorized to be appropriated such sums as may be
necessary for each fiscal year through fiscal year 2015 [2000]
to carry out this title [subchapter].
TITLE [SUBCHAPTER] II--HEALTH SERVICES
Sec. 1621. Indian Health Care Improvement Fund
(a) Use of Funds._[Approved expenditures]
The Secretary, acting through the Service, is authorized to
expend funds, directly or under the authority of the Indian
Self-Determination and Education Assistance Act (25 U.S.C. 450
et seq.), which are appropriated under the authority of this
section, [through the Service,] for the purposes of--
(1) eliminating the deficiencies in health status and
health resources of all Indian [t]Tribes[,];
(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, including the use of
telehealth and telemedicine when appropriate; [and]
(4) eliminating inequities in funding for both direct
care and contract health service programs; and
(5) [(4)] augmenting the ability of the Service to
meet the following health service responsibilities[,
either through direct or contract care or through
contracts entered into pursuant to the Indian Self-
Determination Act [25 U.S.C.A. Sec. 450f et seq.],]
with respect to those Indian [t]Tribes with the highest
levels of health status deficiencies and resource
deficiencies:
(A) [c]Clinical care, [(direct and indirect)]
including inpatient care, outpatient care
(including audiology, clinical eye and vision
care), primary care, secondary and tertiary
care, and long-term care.[;]
(B) [p]Preventive health, including
[screening] mammography and other cancer
screening in accordance with section 207.
[1621k of this title;]
(C) [d]Dental care. [(direct and indirect);]
(D) [m]Mental health, including community
mental health services, inpatient mental health
services, dormitory mental health services,
therapeutic and residential treatment centers,
and training of traditional health care
[Indian] practitioners.[;]
(E) [e]Emergency medical services.[;]
(F) [t]Treatment and control of, and
rehabilitative care related to, alcoholism and
drug abuse (including fetal alcohol syndrome)
among Indians.[;]
(G) [a]Accident prevention programs.[;]
(H) [h]Home health care.[;]
(I) [c]Community health representatives.[;
and]
(J) [m]Maintenance and repair.
(K) Traditional Health Care Practices.
(b) No Offset or Limitation.--[Effect on other
appropriations; allocation to service units]
[(1)] Any funds appropriated under the authority of
this section shall not be used to offset or limit any
other appropriations made to the Service under this Act
or the Act of November 2, 1921 (25 U.S.C. 13) (commonly
known as the `Snyder Act'), [section 13 of this title,]
or any other provision of law.
(c) Allocation; Use.--[(2)(A)]
(1) In general.--Funds appropriated under the
authority of this section shall [may] be allocated to
Service Units, Indian Tribes, or Tribal Organizations
[on a service unit basis]. The funds allocated to each
Indian Tribe, Tribal Organization, or S[s]ervice
U[u]nit under this [sub]paragraph shall be used by the
Indian Tribe, Tribal Organization, or S[s]ervice
U[u]nit under this paragraph to improve [reduce] the
health status and reduce the resource deficiency of
each Indian Tribe served by such S[s]ervice U[u]nit,
Indian Tribe, or Tribal Organization.
(2) [(B)] Apportionment of allocated funds.--The
apportionment of funds allocated to a S[s]ervice
U[u]nit, Indian Tribe, or Tribal Organization under
[sub]paragraph (1) [(A)] among the health service
responsibilities described in subsection (a)(5) [(4) of
this section] shall be determined by the Service in
consultation with, and with the active participation
of, the affectedIndian Tribes and Tribal Organizations.
(d) [(c)] Provisions Relating to Health Status and
R[r]esource[s d]Deficiencyies [levels]
For purposes of this section, the following definitions
apply:[--]
(1) Definition.--The term [``]`health status and
resource deficiency'[''] means the extent to which--
(A) the health status objectives set forth in
section 3(2)[1602(b) of this title] are not
being achieved; and
(B) the Indian [t]Tribe or Tribal
Organization does not have available to it the
health resources it needs, taking into account
the actual cost of providing health care
services given local geographic, climatic,
rural, or other circumstances.
(2) Available resources.--The health resources
available to an Indian [t]Tribe or Tribal Organization
include health resources provided by the Service as
well as health resources used by the Indian [t]Tribe or
Tribal Organization, including services and financing
systems provided by any Federal programs, private
insurance, and programs of State or local governments.
(3) Process for review of determinations.--The
Secretary shall establish procedures which allow any
Indian [t]Tribe or Tribal Organization to petition the
Secretary for a review of any determination of the
extent of the health status and resource deficiency of
such Indian T[t]ribe or Tribal Organization.
(e) [(d)] Eligibility for Funds._[Programs administered by
Indian tribe]
[(1)] Tribal Health 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 this
section on an equal basis with programs that are
administered directly by the Service.
[(2) If any funds allocated to a tribe or service
unit under the authority of this section are used for a
contract entered into under the Indian Self-
Determination Act [25 U.S.C.A. Sec. 450f et seq.], a
reasonable portion of such funds may be used for health
planning, training, technical assistance, and other
administrative support functions.]
(f) [(e)] Report [to Congress].--
By no later than the date that is 3 years after the date of
the enactment of the Indian Health Care Improvement Act
Amendments of 2005 [October 29, 1992], the Secretary shall
submit to [the] Congress the current health status and resource
deficiency report of the Service for each [Indian tribe or
s]Service [u]Unit, including newly recognized or acknowledged
Indian T[t]ribes. Such report shall set out--
(1) the methodology then in use by the Service for
determining [t]Tribal health status and resource
deficiencies, as well as the most recent application of
that methodology;
(2) the extent of the health status and resource
deficiency of each Indian tribe served by the Service
or a Tribal Health Program;
(3) the amount of funds necessary to eliminate the
health status and resource deficiencies of all Indian
tribes served by the Service or a Tribal Health
Program; and
(4) an estimate of--
(A) the amount of health service funds
appropriated under the authority of this Act
[chapter], or any other Act, including the
amount of any funds transferred to the
Service[,] for the preceding fiscal year which
is allocated to each S[s]ervice U[u]nit, Indian
[t]Tribe, or Tribal Organization [comparable
entity];
(B) the number of Indians eligible for health
services in each [s]Service [u]Unit or Indian
[t]Tribe or Tribal Organization; and
(C) the number of Indians using the Service
resources made available to each [s]Service
[u]Unit, [or] Indian [t]Tribe or Tribal
Organization, and, to the extent available,
information on the waiting lists and number of
Indians turned away for services due to lack of
resources.
(g) [(f)] Inclusion [Appropriated funds included] in
[b]Base [b]Budget [of Service].--
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 subsequent fiscal years.
(h)[(g)] Clarification._[Continuation of Service
responsibilities for backlogs and parity]
Nothing in this section is intended to diminish the primary
responsibility of the Service to eliminate existing backlogs in
unmet health care needs, nor are the provisions of this section
intended to discourage the Service from undertaking additional
efforts to achieve equity [parity] among Indian[s t]Tribes and
Tribal Organizations.
(i)[(h)] Funding Designation.-- [Authorization of
appropriations]
Any funds appropriated under the authority of this section
shall be designated as the [``]`Indian Health Care Improvement
Fund'[''].
Sec. 1621a. Catastrophic [h]Health [e]Emergency [f]Fund.
(a) Establishment.--[; administration; purpose]
[(1)] There is established an Indian Catastrophic Health
Emergency Fund (hereafter in this section referred to as the
`CHEF' [``Fund'']) consisting of--
(1)[(A)] the amounts deposited under subsection
(f)[(d) of this section,]; and
(2)[(B)] the amounts appropriated to CHEF [the Fund]
under this section.
(b) Administration.--[(2) The Fund] CHEF 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 treatment of
victims of disasters or catastrophic illnesses who are within
the responsibility of the Service.
[(3) The Fund shall not be allocated, apportioned, or
delegated on a service unit, area office, or any other
basis.]
(c) Conditions on Use of Fund.--[(4)] No part of CHEF
[the Fund] or its administration shall be subject to contract
or grant under any law, including the Indian Self-Determination
and Education Assistance Act (25 U.S.C. 450 et seq.), [[25
U.S.C.A. Sec. 450f et seq.].] nor shall CHEF funds be
allocated, apportioned, or delegated on an Areaffice, Service
Unit, or other similar basis.
(d)[(b)] Regulations.--[; procedures for payment]
The Secretary shall, through the negotiated rulemaking
process under title VIII, promulgate [promulgation of]
regulations consistent with the provisions of this section to--
(1) establish a definition of disasters and
catastrophic illnesses for which the cost of the
treatment provided under contract would qualify for
payment from CHEF [the Fund];
(2) provide that a [s]Service [u]Unit shall not be
eligible for reimbursement for the cost of treatment
from CHEF [the Fund] until its cost of treating any
victim of such catastrophic illness or disaster has
reached a certain threshold cost which the Secretary
shall establish at--
(A) the 2000 level of $19,000 [for 1993, not
less than $15,000 or not more than $25,000];
and
(B) for any subsequent year, not less than
the threshold cost of the previous year
increased by the percentage increase in the
medical care expenditure category of the
consumer price index for all urban consumers
(United States city average) for the 12-month
period ending with December of the previous
year;
(3) establish a procedure for the reimbursement of
the portion of the costs that exceeds such threshold
cost incurred by--
(A) [s]Service [u]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 CHEF [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 CHEF [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.
(e) No Offset or Limitation.--[(c) Effect on other
appropriations]
Amounts appropriated to CHEF [the Fund] under this section
shall not be used to offset or limit appropriations made to the
Service under authority of the Act of November 2, 1921 (25
U.S.C. 13) (commonly known as the `Snyder Act') [section 13 of
this title], or any other law.
(f)[(d)] Deposit of Reimbursement[s to] Funds.--
There shall be deposited into CHEF [the Fund] all
reimbursements to which the Service is entitled from any
Federal, State, local, or private source (including third party
insurance) by reason of treatment rendered to any victim of a
disaster or catastrophic illness the cost of which was paid
from CHEF [the Fund].
Sec. 1621b. Health [p]Promotion and [d]Disease [p]Prevention
[s]Services
(a) Findings.--Congress finds that health promotion and
disease prevention activities--
(1) improve the health and well-being of Indians; and
(2) reduce the expenses for health care of Indians.
[(a) Authorization]
(b) Provision of Services._
The Secretary, acting through the Service and Tribal Health
Programs, shall provide health promotion and disease prevention
services to Indians [so as] to achieve the health status
objectives set forth in section 3(2)[1602(b) of this title].
(c)[(b)] Evaluation.--[statement for Presidential Budget]
The Secretary, after obtaining input from the affected
Tribal Health Programs, shall submit to the President for
inclusion in the report [each statement] which is required to
be submitted to [the] Congress under section 801[1671 of this
title] 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 and Tribal
Health Programs to meet such needs[,]; and
(4) the resources which would be required to enable
the Service and Tribal Health Programs to undertake the
health promotion and disease prevention activities
necessary to meet such needs.
Sec. 1621c. Diabetes [p]Prevention, [t]Treatment, and [c]Control
(a) Determinations Regarding Diabetes.--[Incidence and
complications]
The Secretary, acting through the Service, and in
consultation with [the] Indian T[t]ribes and Tribal
Organizations, shall determine--
(1) by Indian T[t]ribe and by Service [u]Unit [of the
Service], the incidence of, and the types of
complications resulting from, diabetes among Indians;
and
(2) based on the determinations made pursuant to
paragraph (1), the measures (including patient
education and effective ongoing monitoring of disease
indicators) each Service [u]Unit should take to reduce
the incidence of, and prevent, treat, and control the
complications resulting from, diabetes among Indian
T[t]ribes within that Service unit.
(b) Diabetes Screening.--
To the extent medically indicated and with informed
consent, t[T]he Secretary shall screen each Indian who receives
services from the Service for diabetes and for conditions which
indicate a high risk that the individual will become diabetic
and, in consultation with Indian Tribes, Urban Indian
Organizations, and appropriate health care providers, establish
a cost-effective approach to ensure ongoing monitoring of
disease indicators. Such screening and monitoring may be
conducted [done] by a Tribal Health Program and may be
conducted through appropriate Internet-based health care
management programs. [tribe or tribal organization operating
health care programs or facilities with funds from the Service
under the Indian Self-Determination Act [25 U.S.C.A. Sec. 450f
et seq.].]
(c) Funding for Diabetes.--The Secretary shall
continue to maintain each model diabetes project in
existence on the date of the enactment of the Indian
Health Care Improvement Act Amendments of 2005, any
such other diabetes programs operated by the Service or
Tribal Health Programs, and any additional diabetes
projects, such as the Medical Vanguard program provided
for in title IV of Public Law 108-87, as implemented to
serve Indian Tribes. Tribal Health Programs shall
receive recurring funding for the diabetes projects
that they operate pursuant to this section, both at the
date of enactment of the Indian Health Care Improvement
Act Amendments of 2005 and for projects which are added
and funded thereafter.
[(c) Model diabetes projects]
[(1) The Secretary shall continue to maintain through
fiscal year 2000 each model diabetes project in
existence October 29, 1992 and located--]
[(A) at the Claremore Indian Hospital in
Oklahoma;]
[(B) at the Fort Totten Health Center in
North Dakota;]
[(C) at the Sacaton Indian Hospital in
Arizona;]
[(D) at the Winnebago Indian Hospital in
Nebraska;]
[(E) at the Albuquerque Indian Hospital in
New Mexico;]
[(F) at the Perry, Princeton, and Old Town
Health Centers in Maine;]
[(G) at the Bellingham Health Center in
Washington;]
[(H) at the Fort Berthold Reservation;]
[(I) at the Navajo Reservation;]
[(J) at the Papago Reservation;]
[(K) at the Zuni Reservation; or]
[(L) in the States of Alaska, California,
Minnesota, Montana, Oregon, or Utah.]
[(2) The Secretary may establish new model diabetes
projects under this section taking into consideration
applications received under this section from all
service areas, except that the Secretary may not
establish a greater number of such projects in one
service area than in any other service area until there
is an equal number of such projects established with
respect to all service areas from which the Secretary
receives qualified applications during the application
period (as determined by the Secretary).]
(d) Funding for Dialysis Programs.--The Secretary is
authorized to provide funding through the Service, Indian
Tribes, and Tribal Organizations to establish dialysis
programs, including funding to purchase dialysis equipment and
provide necessary staffing.
[(d) Control officer; registry of patients]
[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 full-time basis activities within that
area office for the prevention, 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;]
[(3) ensure that data collected in each area office
regarding diabetes and related complications among
Indians is disseminated to all other area offices; and]
[(4) evaluate the effectiveness of services provided
through model diabetes projects established under this
section.]
(e) Other Duties of the Secretary.--
(1) In general.--The Secretary shall, to the extent
funding is available--
(A) in each Area Office, consult with Indian
Tribes and Tribal Organizations regarding
programs for the prevention, treatment, and
control of diabetes;
(B) establish in each Area Office a registry
of patients with diabetes to track the
incidence of diabetes and the complications
from diabetes in that area; and
(C) ensure that data collected in each Area
Office regarding diabetes and related
complications among Indians are disseminated to
all other Area Offices, subject to applicable
patient privacy laws.
(2) Diabetes control officers.--
(A) In general.--The Secretary may establish
and maintain in each Area Office a position of
diabetes control officer to coordinate and
manage any activity of that Area office
relating to the prevention, treatment, or
control of diabetes to assist the Secretary in
carrying out a program under this section or
section 330C of the Public Health Service Act
(42 U.S.C. 254c-3).
(B) Certain activities.--Any Activity carried
out by a diabetes control officer under
subparagraph (A) that is the subject of a
contract or compact under the Indian Self-
Determination and Education Assistance Act (25
U.S.C. 450 et seq.), and any funds made
available to carry out such an activity, shall
not be divisible for purposes of that Act.
[(e) Authorization of appropriations]
[Funds appropriated under this section in any fiscal year
shall be in addition to base resources appropriated to the
Service for that year.]
Sec. 205. Shared services for long-term care
(a) Long-Term Care.--Notwithstanding any other provision of
law, the Secretary, acting through the Service, is authorized
to provide directly, or enter into contracts or compacts under
the Indian Self-Determination and Education Act (25 U.S.C. 450
et seq.) with Indian Tribes or Tribal Organizations for, the
delivery of long-term care and similar services to Indians.
Such agreements shall provide for the sharing of staff or other
services between the Service or a Tribal Health Program and a
long-term care or other similar facility owned and operated
(directly or through a contract or compact under the Indian
Self-Determination and Education Act) (25 U.S.C. 450 et seq.))
by such Indian Tribe or Tribal Organization.
(b) Contents of Agreements.--An agreement or other
arrangement entered into pursuant to subsection (a)--
(1) may, at the request of the Indian Tribe or Tribal
Organization, delegate to such Indian Tribe or Tribal
Organization such powers of supervision and control
over Service employees as the Secretary deems necessary
to carry out the purposes of this section;
(2) shall provide that expenses (including salaries)
relating to services that are shared between the
Service and the Tribal Health Program be allocated
proportionately between the Service and the Indian
Tribe or Tribal Organization; and
(3) may authorize such Indian Tribe or Tribal
Organization to construct, renovate, or expand a long-
term care or other similar facility (including the
construction of a facility attached to a Service
facility).
(c) Minimum Requirement.--Any nursing facility provided for
under this section shall meet the requirements for nursing
facilities under section 1919 of the Social Security Act.
(d) Other Assistance.--The Secretary shall provide such
technical and other assistance as may be necessary to enable
applicants to comply with the provisions of this section.
(e) Use of Existing or Underused Facilities.--The Secretary
shall encourage the use of existing facilities that are
underused or allow the use of swing beds for long-term or
similar care.
[Sec. 1621d. Hospice care feasibility study]
[(a) Duty of Secretary]
[The Secretary, acting through the Service and in
consultation with representatives of Indian tribes, tribal
organizations, Indian Health Service personnel, and hospice
providers, shall conduct a study--]
[(1) to assess the feasibility and desirability of
furnishing hospice care to terminally ill Indians; and]
[(2) to determine the most efficient and effective
means of furnishing such care.]
[(b) Functions of study]
[Such study shall--]
[(1) assess the impact of Indian culture and beliefs
concerning death and dying on the provision of hospice
care to Indians;]
[(2) estimate the number of Indians for whom hospice
care may be appropriate and determine the geographic
distribution of such individuals;]
[(3) determine the most appropriate means to
facilitate the participation of Indian tribes and
tribal organizations in providing hospice care;]
[(4) identify and evaluate various means for
providing hospice care, including--]
[(A) the provision of such care by the
personnel of a Service hospital pursuant to a
hospice program established by the Secretary at
such hospital; and]
[(B) the provision of such care by a
community-based hospice program under contract
to the Service; and]
[(5) identify and assess any difficulties in
furnishing such care and the actions needed to resolve
such difficulties.]
[(c) Report to Congress]
[Not later than the date which is 12 months after October
29, 1992, the Secretary shall transmit to the Congress a report
containing--]
[(1) a detailed description of the study conducted
pursuant to this section; and]
[(2) a discussion of the findings and conclusions of
such study.]
[(d) Definitions]
[For the purposes of this section--]
[(1) the term ``terminally ill'' means any Indian who
has a medical prognosis (as certified by a physician)
of a life expectancy of six months or less; and]
[(2) the term ``hospice program'' means any program
which satisfies the requirements of section
1395x(dd)(2) of Title 42; and]
[(3) the term ``hospice care'' means the items and
services specified in subparagraphs (A) through (H) of
section 1395x(dd)(1) of Title 42.]
Sec. 206. Health services research
The Secretary, acting through the Service, shall make
funding available for research to further the performance of
the health service responsibilities of Indian Health Programs.
The Secretary shall also, to the maximum extent practicable,
coordinate departmental research resources and activities to
address relevant Indian Health Program research needs. Tribal
Health Programs shall be given an equal opportunity to compete
for, and receive, research funds under this section. This
funding may be used for both clinical and nonclinical research.
[Sec. 1621e. Reimbursement from certain third parties of costs of
health services]
[(a) Right of recovery]
[Except as provided in subsection (f) of this section, the
United States, an Indian tribe, or a tribal organization shall
have the right to recover the reasonable expenses incurred by
the Secretary, an Indian tribe, or a tribal organization in
providing health services, through the Service, an Indian
tribe, or tribal organization, to any individual to the same
extent that such individual, or any nongovernmental provider of
such services, would be eligible to receive reimbursement or
indemnification for such expenses if--]
[(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) Recovery against State with workers' compensation laws
or no-fault automobile accident insurance program]
[Subsection (a) of this section shall provide a right of
recovery against any 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) Prohibition of State law or contract provision
impeding right of recovery]
[No law of any State, or of any political subdivision of a
State, and no provision of any contract entered into or renewed
after November 23, 1988, shall prevent or hinder the right of
recovery of the United States, an Indian tribe, or a tribal
organization under subsection (a) of this section.]
[(d) Right to damages]
[No action taken by the United States, an Indian tribe, or
a tribal organization to enforce the right of recovery provided
under subsection (a) of this section shall affect the right of
any person to any damages (other than damages for the cost of
health services provided by the Secretary through the
Service).]
[(e) Intervention or separate civil action]
[The United States, an Indian tribe, or a tribal
organization may enforce the right of recovery provided under
subsection (a) of this section 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, an
Indian tribe, or a tribal organization, 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, an Indian tribe, or a tribal
organization to institute a separate civil action.]
[(f) Right of recovery for services when self-insurance
plan provides coverage]
[The United States shall not have a right of recovery under
this section if the injury, illness, or disability for which
health services were provided is covered under a self-insurance
plan funded by an Indian tribe or tribal organization.]
Sec. 207. Mammography and other cancer screening
The Secretary, acting through the Service or Tribal Health
Programs, shall provide for screening as follows:
(1) Screening mammography (as defined in section
1861(jj) of the Social Security Act) for Indian women
at a frequency appropriate to such women under accepted
and appropriate national standards, and under such
terms and conditions as are consistent with standards
established by the Secretary to ensure the safety and
accuracy of screening mammography under part B of title
XVIII of such Act.
(2) Other cancer screening meeting accepted and
appropriate national standards.
[Sec. 1621f. Crediting of reimbursements]
[(a) Except as provided in section 1621a(d) of this title,
subchapter III-A of this chapter, and section 1680c of this
title, all reimbursements received or recovered, under
authority of this chapter, Public Law 87-693 (42 U.S.C. 2651,
et seq.), or any other provision of law, by reason of the
provision of health services by the Service or by a tribe or
tribal organization under a contract pursuant to the Indian
Self-Determination Act [25 U.S.C.A. Sec. 450f et seq.] shall be
retained by the Service or that tribe or tribal organization
and shall be available for the facilities, and to carry out the
programs, of the Service or that tribe or tribal organization
to provide healthcare services to Indians.]
[(b) The Service may not offset or limit the amount of
funds obligated to any service unit or any entity under
contract with the Service because of the receipt of
reimbursements under subsection (a) of this section.]
Sec. 208. Patient travel costs
The Secretary, acting through the Service and Tribal Health
Programs, is authorized to provide funds for the following
patient travel costs, including appropriate and necessary
qualified escorts, associated with receiving health care
services provided (either through direct or contract care or
through a contract or compact under the Indian Self-
Determination and Education Act (25 U.S.C. 450 et seq.)) under
this Act--
(1) emergency air transportation and non-emergency
air transportation where ground transportation is
infeasible;
(2) transportation by private vehicle (where no other
means of transportation is available), specially
equipped vehicle, and ambulance; and
(3) transportation by such other means as may be
available and required when air or motor vehicle
transportation is not available.
[Sec. 1621g. Health services research]
[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 [25 U.S.C.A.
Sec. 450f et seq.] shall be given an equal opportunity to
compete for, and receive, research funds under this section.]
Sec. 209. Epidemiology centers
(a) Additional Centers.--In addition to those epidemiology
centers already established as of the date of enactment of this
Act, and without reducing the funding levels for such centers,
not later than 180 days after the date of the enactment of the
Indian Health Care Improvement Act Amendments of 2005, the
Secretary, acting through the Service, shall establish an
epidemiology center in each Service Area which does not yet
have one to carry out the functions described in subsection
(b). Any new centers so established may be operated by Tribal
Health Programs, but such funding shall not be divisible.
(b) Functions of Centers.--In consultation with and upon
the request of Indian Tribes, Tribal Organizations, and Urban
Indian Organizations, each Service Area epidemiology center
established under this subsection shall, with respect to such
Service Area--
(1) collect data relating to, and monitor progress
made toward meeting, each of the health status
objectives of the Service, the Indian Tribes, Tribal
Organizations, and Urban Indian Organizations in the
Service Area;
(2) evaluate existing delivery systems, data systems,
and other systems that impact the improvement of Indian
health;
(3) assist Indian Tribes, Tribal Organizations, and
Urban Indian Organizations in identifying their highest
priority health status objectives and the services
needed to achieve such objectives, based on
epidemiological data;
(4) make recommendations for the targeting of
services needed by the populations served;
(5) make recommendations to improve health care
delivery systems for Indians and Urban Indians;
(6) provide requested technical assistance to Indian
Tribes, Tribal Organizations, and Urban Indian
Organizations in the development of local health
service priorities and incidence and prevalence rates
of disease and other illness in the community; and
(7) provide disease surveillance and assist Indian
Tribes, Tribal Organizations, and Urban Indian
Organizations to promote public health.
(c) Technical Assistance.--The Director of the Centers for
Disease Control and Prevention shall provide technical
assistance to the centers in carrying out the requirements of
this subsection.
(d) Funding for Studies.--The Secretary may make funding
available to Indian Tribes, Tribal Organizations, and Urban
Indian Organizations to conduct epidemiological studies of
Indian communities.
[Sec. 1621h. Mental health prevention and treatment services]
[(a) National plan for Indian Mental Health Services]
[(1) Not later than 120 days after November 28, 1990,
the Secretary, acting through the Service, shall
develop and publish in the Federal Register a final
national plan for Indian Mental Health Services. The
plan shall include--]
[(A) an assessment of the scope of the
problem of mental illness and dysfunctional and
self-destructive behavior, including child
abuse and family violence, among Indians,
including--]
[(i) the number of Indians served by
the Service who are directly or
indirectly affected by such illness or
behavior, and]
[(ii) an estimate of the financial
and human cost attributable to such
illness or behavior;]
[(B) an assessment of the existing and
additional resources necessary for the
prevention and treatment of such illness and
behavior; and]
[(C) an estimate of the additional funding
needed by the Service to meet its
responsibilities under the plan].
[(2) The Secretary shall submit a copy of the
national plan to the Congress.]
[(b) Memorandum of agreement]
[Not later than 180 days after November 28, 1990, the
Secretary and the Secretary of the Interior shall develop and
enter into a memorandum of agreement under which the
Secretaries shall, among other things--]
[(1) determine and define the scope and nature of
mental illness and dysfunctional and self-destructive
behavior, including child abuse and family violence,
among Indians;]
[(2) make an assessment of the existing Federal,
tribal, State, local, and private services, resources,
and programs available to provide mental health
services for Indians;]
[(3) make an initial determination of the unmet need
for additional services, resources, and programs
necessary to meet the needs identified pursuant to
paragraph (1);]
[(4)(A) ensure that Indians, as citizens of the
United States and of the States in which they reside,
have access to mental health services to which all
citizens have access;]
[(B) determine the right of Indians to participate
in, and receive the benefit of, such services; and]
[(C) take actions necessary to protect the exercise
of such right;]
[(5) delineate the responsibilities of the Bureau of
Indian Affairs and the Service, including mental health
identification, prevention, education, referral, and
treatment services (including services through
multidisciplinary resource teams), at the central,
area, and agency and service unit levels to address the
problems identified in paragraph (1);]
[(6) provide a strategy for the comprehensive
coordination of the mental health services provided by
the Bureau of Indian Affairs and the Service to meet
the needs identified pursuant to paragraph (1),
including--]
[(A) the coordination of alcohol and
substance abuse programs of the Service, the
Bureau of Indian Affairs, and the various
tribes (developed under the Indian Alcohol and
Substance Abuse Prevention and Treatment Act of
1986) [25 U.S.C.A. Sec. 2401 et seq.] with the
mental health initiatives pursuant to this
chapter, particularly with respect to the
referral and treatment of dually-diagnosed
individuals requiring mental health and
substance abuse treatment; and]
[(B) ensuring that Bureau of Indian Affairs
and Service programs and services (including
multidisciplinary resource teams) addressing
child abuse and family violence are coordinated
with such non-Federal programs and services;]
[(7) direct appropriate officials of the Bureau of
Indian Affairs and the Service, particularly at the
agency and service unit levels, to cooperate fully with
tribal requests made pursuant to subsection (d) of this
section; and]
[(8) provide for an annual review of such agreement
by the two Secretaries.]
[(c) Community mental health plan]
[(1) The governing body of any Indian tribe may, at
its discretion, adopt a resolution for the
establishment of a community mental health plan
providing for the identification and coordination of
available resources and programs to identify, prevent,
or treat mental illness or dysfunctional and self-
destructive behavior, including child abuse and family
violence, among its members.]
[(2) In furtherance of a plan established pursuant to
paragraph (1) and at the request of a tribe, the
appropriate agency, service unit, or other officials of
the Bureau of Indian Affairs and the Service shall
cooperate with, and provide technical assistance to,
the tribe in the development of such plan. Upon the
establishment of such a plan and at the request of the
tribe, such officials, as directed by the memorandum of
agreement developed pursuant to subsection (c), of this
section, shall cooperate with the tribe in the
implementation of such plan.]
[(3) Two or more Indian tribes may form a coalition
for the adoption of resolutions and the establishment
and development of a joint community mental health plan
under this subsection.]
[(4) The Secretary, acting through the Service, may
make grants to Indian tribes adopting a resolution
pursuant to paragraph (1) to obtain technical
assistance for the development of a community mental
health plan and to provide administrative support in
the implementation of such plan.]
[(d) Mental health training and community education
programs]
[(1) The Secretary and the Secretary of the Interior,
in consultation with representatives of Indian tribes,
shall conduct a study and compile a list, of the types
of staff positions specified in paragraph (2) whose
qualifications include, or should include, training in
the identification, prevention, education, referral, or
treatment of mental illness or dysfunctional and self-
destructive behavior.]
[(2) The positions referred to in paragraph (1) are--]
[(A) staff positions within the Bureau of
Indian Affairs, including existing positions,
in the fields of--]
[(i) elementary and secondary
education;]
[(ii) social services and family and
child welfare;]
[(iii) law enforcement and judicial
services; and]
[(iv) alcohol and substance abuse;]
[(B) staff positions with the Service; and]
[(C) staff positions similar to those
identified in subparagraphs (A) and (B)
established and maintained by Indian tribes,
including positions established in contracts
entered into under the Indian Self-
Determination Act [25 U.S.C.A. Sec. 450f et
seq.].]
[(3)(A) The appropriate Secretary shall provide
training criteria appropriate to each type of position
identified in paragraph (2)(A) and ensure that
appropriate training has been, or will be, provided to
any individual in any such position. With respect to
any such individual in a position identified pursuant
to paragraph (2)(C), the respective Secretaries shall
provide appropriate training to, or provide funds to an
Indian tribe for the training of, such individual. In
the case of positions funded under a contract entered
into under the Indian Self-Determination Act [25
U.S.C.A. Sec. 450f et seq.], the appropriate Secretary
shall ensure that such training costs are included in
the contract, if necessary.]
[(B) Funds authorized to be appropriated pursuant to
this section may be used to provide training authorized
by this paragraph for community education programs
described in paragraph (5) if a plan adopted pursuant
to subsection (d) of this section identifies
individuals or employment categories, other than those
identified pursuant to paragraph (1), for which such
training or community education is deemed necessary or
desirable.]
[(4) Position-specific training criteria described in
paragraph (3) shall be culturally relevant to Indians
and Indian tribes and shall ensure that appropriate
information regarding traditional Indian healing and
treatment practices is provided.]
[(5) The Service shall develop and implement or, upon
the request of an Indian tribe, assist such tribe to
develop and implement, a program of community education
on mental illness and dysfunctional and self-
destructive behavior for individuals, as determined in
a plan adopted pursuant to subsection (d) of this
section. In carrying out this paragraph, the Service
shall provide, upon the request of an Indian tribe,
technical assistance to the Indian tribe to obtain or
develop community education and training materials on
the identification, prevention, referral, and treatment
of mental illness and dysfunctional and self-
destructive behavior.]
[(e) Staffing]
[(1) Within 90 days after November 28, 1990, the
Secretary shall develop a plan under which the Service
will increase the health care staff providing mental
health services by at least 500 positions within five
years after November 28, 1990, with at least 200 of
such positions devoted to child, adolescent, and family
services. Such additional staff shall be primarily
assigned to the service unit level for services which
shall include outpatient, emergency, aftercare and
follow-up, and prevention and education services.]
[(2) The plan developed under paragraph (1) shall be
implemented under section 13 of this title.]
[(f) Staff recruitment and retention]
[(1) The Secretary shall provide for the recruitment
of the additional personnel required by subsection (f)
of this section and the retention of all Service
personnel providing mental health services. In carrying
out this subsection, the Secretary shall give priority
to practitioners providing mental health services to
children and adolescents with mental health problems.]
[(2) In carrying out paragraph (1), the Secretary
shall develop a program providing for--]
[(A) the payment of bonuses (which shall not
be more favorable than those provided for under
section 1616i and 1616j of this title) for
service in hardship posts;]
[(B) the repayment of loans (for which the
provisions of repayment contracts shall not be
more favorable than the repayment contracts
under section 1616a of this title) for health
professions education as a recruitment
incentive; and]
[(C) a system of postgraduate rotations as a
retention incentive.]
[(3) This subsection shall be carried out in
coordination with the recruitment and retention
programs under subchapter I of this chapter.]
[(g) Mental Health Technician program]
[(1) Under the authority of section 13 of this title,
the Secretary shall establish and maintain a Mental
Health Technician program within the Service which--]
[(A) provides for the training of Indians as
mental health technicians; and]
[(B) employs such technicians in the
provision of community-based mental health care
that includes identification, prevention,
education, referral, and treatment services.]
[(2) In carrying out paragraph (1)(A), the Secretary
shall provide high standard paraprofessional training
in mental health care necessary to provide quality care
to the Indian communities to be served. Such training
shall be based upon a curriculum developed or approved
by the Secretary which combines education in the theory
of mental health care with supervised practical
experience in the provision of such care.]
[(3) The Secretary shall supervise and evaluate the
mental health technicians in the training program.]
[(4) The Secretary shall ensure that the program
established pursuant to this subsection involves the
utilization and promotion of the traditional Indian
health care and treatment practices of the Indian
tribes to be served.]
[(h) Mental health research]
[The Secretary, acting through the Service and in
consultation with the National Institute of Mental Health,
shall enter into contracts with, or make grants to, appropriate
institutions for the conduct of research on the incidence and
prevalence of mental disorders among Indians on Indian
reservations and in urban areas. Research priorities under this
subsection shall include--]
[(1) the inter-relationship and inter-dependence of
mental disorders with alcoholism, suicide, homicides,
accidents, and the incidence of family violence, and]
[(2) the development of models of prevention
techniques.]
[The effect of the inter-relationships and
interdependencies referred to in paragraph (1) on children, and
the development of prevention techniques under paragraph (2)
applicable to children, shall be emphasized.]
[(i) Facilities assessment]
[Within one year after November 28, 1990, the Secretary,
acting through the Service, shall make an assessment of the
need for inpatient mental health care among Indians and the
availability and cost of inpatient mental health facilities
which can meet such need. In making such assessment, the
Secretary shall consider the possible conversion of existing,
under-utilized service hospital beds into psychiatric units to
meet such need.]
[(j) Annual report]
[The Service shall develop methods for analyzing and
evaluating the overall status of mental health programs and
services for Indians and shall submit to the President, for
inclusion in each report required to be transmitted to the
Congress under section 1671 of this title, a report on the
mental health status of Indians which shall describe the
progress being made to address mental health problems of Indian
communities.]
[(k) Mental health demonstration grant program]
[(1) The Secretary, acting through the Service, is
authorized to make grants to Indian tribes and inter-
tribal consortia to pay 75 percent of the cost of
planning, developing, andimplementing programs to
deliver innovative community-based mental health services to Indians.
The 25 percent tribal share of such cost may be provided in cash or
through the provision of property or services.]
[(2) The Secretary may award a grant for a project
under paragraph (1) to an Indian tribe or inter-tribal
consortium which meets the following criteria:]
[(A) The project will address significant
unmet mental health needs among Indians.]
[(B) The project will serve a significant
number of Indians.]
[(C) The project has the potential to deliver
services in an efficient and effective manner.]
[(D) The tribe or consortium has the
administrative and financial capability to
administer the project.]
[(E) The project will deliver services in a
manner consistent with traditional Indian
healing and treatment practices.]
[(F) The project is coordinated with, and
avoids duplication of, existing services.]
[(3) For purposes of this subsection, the Secretary
shall, in evaluating applications for grants for
projects to be operated under any contract entered into
with the Service under the Indian Self-Determination
Act [25 U.S.C.A. Sec. 450f et seq.], use the same
criteria that the Secretary uses in evaluating any
other application for such a grant.]
[(4) The Secretary may only award one grant under
this subsection with respect to a service area until
the Secretary has awarded grants for all service areas
with respect to which the Secretary receives
applications during the application period, as
determined by the Secretary, which meet the criteria
specified in paragraph (2).]
[(5) Not later than 180 days after the close of the
term of the last grant awarded pursuant to this
subsection, the Secretary shall submit to the Congress
a report evaluating the effectiveness of the innovative
community-based projects demonstrated pursuant to this
subsection. Such report shall include findings and
recommendations, if any, relating to the reorganization
of the programs of the Service for delivery of mental
services to Indians.]
[(6) Grants made pursuant to this section may be
expended over a period of three years and no grant may
exceed $1,000,000 for the fiscal years involved.]
[(l) Licensing requirement for mental health care workers]
[Any person employed as a psychologist, social worker, or
marriage and family therapist for the purpose of providing
mental health care services to Indians in a clinical setting
under the authority of this chapter or through a contract
pursuant to the Indian Self-Determination Act [25 U.S.C.A.
Sec. 450f et. seq.] shall--]
[(1) in the case of a person employed as a
psychologist, be licensed as a clinical psychologist or
working under the direct supervision of a licensed
clinical psychologist;]
[(2) in the case of a person employed as a social
worker, be licensed as a social worker or working under
the direct supervision of a licensed social worker; or]
[(3) in the case of a person employed as a marriage
and family therapist, be licensed as a marriage and
family therapist or working under the direct
supervision of a licensed marriage and family
therapist.]
[(m) Intermediate adolescent mental health services]
[(1) The Secretary, acting through the Service, may
make grants to Indian tribes and tribal organizations
to provide intermediate mental health services to
Indian children and adolescents, including--]
[(A) inpatient and outpatient services;]
[(B) emergency care;]
[(C) suicide prevention and crisis
intervention; and]
[(D) prevention and treatment of mental
illness, and dysfunctional and self-destructive
behavior, including child abuse and family
violence.]
[(2) Funds provided under this subsection may be
used--]
[(A) to construct or renovate an existing
health facility to provide intermediate mental
health services;]
[(B) to hire mental health professionals;]
[(C) to staff, operate, and maintain an
intermediate mental health facility, group
home, or youth shelter where intermediate
mental health services are being provided; and]
[(D) to make renovations and hire appropriate
staff to convert existing hospital beds into
adolescent psychiatric units.]
[(3) Funds provided under this subsection may not be
used for the purposes described in section 1621o(b)(1)
of this title.]
[(4) An Indian tribe or tribal organization receiving
a grant under this subsection shall ensure that
intermediate adolescent mental health services are
coordinated with other tribal, Service, and Bureau of
Indian Affairs mental health, alcohol and substance
abuse, and social services programs on the reservation
of such tribe or tribal organization.]
[(5) The Secretary shall establish criteria for the
review and approval of applications for grants made
pursuant to this subsection.]
[(6) There are authorized to be appropriated to carry
out this section $10,000,000 for fiscal year 1993 and
such sums as may be necessary for each of the fiscal
year 1993 and such sums as may be necessary for each of
the fiscal years 1994, 1995, 1996, 1997, 1998, 1999,
and 2000.]
Sec. 210. Comprehensive school health education programs
(a) Funding for Development of Programs.--In addition to
carrying out any other program for health promotion or disease
prevention, the Secretary, acting through the Service, is
authorized to award grants to Indian Tribes, Tribal
Organizations, and Urban Indian Organizations to develop
comprehensive school health education programs for children
from pre-school through grade 12 in schools for the benefit of
Indian and Urban Indian children.
(b) Use of Grant Funds.--A grant awarded under this section
may be used for purposes which may include, but are not limited
to, the following:
(1) Developing and implementing health education
curricula both for regular school programs and
afterschool programs.
(2) Training teachers in comprehensive school health
education curricula.
(3) Integrating school-based, community-based, and
other public and private health promotion efforts.
(4) Encouraging healthy, tobacco-free school
environments.
(5) Coordinating school-based health programs with
existing services and programs available in the
community.
(6) Developing school programs on nutrition
education, personal health, oral health, and fitness.
(7) Developing behavioral health wellness programs.
(8) Developing chronic disease prevention programs.
(9) Developing substance abuse prevention programs.
(10) Developing injury prevention and safety
education programs.
(11) Developing activities for the prevention and
control of communicable diseases.
(12) Developing community and environmental health
education programs that include traditional health care
practitioners.
(13) Violence prevention.
(14) Such other health issues as are appropriate.
(c) Technical Assistance.--Upon request, the Secretary,
acting through the Service, shall provide technical assistance
to Indian Tribes, Tribal Organizations, and Urban Indian
Organizations in the development of comprehensive health
education plans and the dissemination of comprehensive health
education materials and information on existing health programs
and resources.
(d) Criteria for Review and Approval of Applications.--The
Secretary, acting through the Service, and in consultation with
Indian Tribes, Tribal Organizations, and Urban Indian
Organizations, shall establish criteria for the review and
approval of applications for funding provided pursuant to this
section.
(e) Development of Program for BIA Funded Schools.--
(1) In general.--The Secretary of the Interior,
acting through the Bureau of Indian Affairs and in
cooperation with the Secretary, acting through the
Service, and affected Indian Tribes and Tribal
Organizations, shall develop a comprehensive school
health education program for children from preschool
through grade 12 in schools for which support is
provided by the Bureau of Indian Affairs.
(2) Requirements for programs.--Such programs shall
include--
(A) school programs on nutrition education,
personal health, oral health, and fitness;
(B) behavioral health wellness programs;
(C) chronic disease prevention programs;
(D) substance abuse prevention programs;
(E) injury prevention and safety education
programs; and
(F) activities for the prevention and control
of communicable diseases.
(3) Duties of the secretary.--The Secretary of the
Interior shall--
(A) provide training to teachers in
comprehensive school health education
curricula;
(B) ensure the integration and coordination
of school-based programs with existing services
and health programs available in the community;
and
(C) encourage healthy, tobacco-free school
environments.
[Sec. 1621i. Managed care feasibility study]
[(a) The Secretary, acting through the Service, shall
conduct a study to assess the feasibility of allowing an Indian
tribe to purchase, directly or through the Service, managed
care coverage for all members of the tribe from--]
[(1) a tribally owned and operated managed care plan;
or]
[(2) a State licensed managed care plan.]
[(b) Not later than the date which is 12 months after
October 29, 1992, the Secretary shall transmit to the Congress
a report containing--]
[(1) a detailed description of the study conducted
pursuant to this section; and]
[(2) a discussion of the findings and conclusions of
such study.]
Sec. 211. Indian Youth Program
(a) Program Authorized.--The Secretary, acting through the
Service, is authorized to establish and administer a program to
provide funding to Indian Tribes, Tribal Organizations, and
Urban Indian Organizations for innovative mental and physical
disease prevention and health promotion and treatment programs
for Indian and Urban Indian preadolescent and adolescent
youths.
(b) Use of Funds.--
(1) Allowable uses.--Funds made available under this
section may be used to--
(A) develop prevention and treatment programs
for Indian youth which promote mental and
physical health and incorporate cultural
values, community and family involvement, and
traditional health care practitioners; and
(B) develop and provide community training
and education.
(2) Prohibited use.--Funds made available under this
section may not be used to provide services described
in section 707(c).
(c) Duties of the Secretary.--The Secretary shall--
(1) disseminate to Indian Tribes, Tribal
Organizations, and Urban Indian Organizations
information regarding models for the delivery of
comprehensive health care services to Indian and Urban
Indian adolescents;
(2) encourage the implementation of such models; and
(3) at the request of an Indian Tribe, Tribal
Organization, or Urban Indian Organization, provide
technical assistance in the implementation of such
models.
(d) Criteria for Review and Approval of Applications.--The
Secretary, in consultation with Indian Tribes, Tribal
Organizations, and Urban Indian Organizations, shall establish
criteria for the review and approval of applications or
proposals under this section.
[Sec. 1621j. California contract health services demonstration program]
[(a) Establishment]
[The Secretary shall establish a demonstration program to
evaluate the use of a contract care intermediary to improve the
accessibility of health services to California Indians.]
[(b) Agreement with California Rural Indian Health Board]
[(1) In establishing such program, the Secretary
shall enter into an agreement with the California Rural
Indian Health Board to reimburse the Board for costs
(including reasonable administrative costs) incurred,
during the period of the demonstration program, in
providing medical treatment under contract to
California Indians described in section 1679(b) of this
title throughout the California contract health
services delivery area described in section 1680 of
this title with respect to high-cost contract care
cases.]
[(2) Not more than 5 percent of the amounts provided
to the Board under this section for any fiscal year may
be for reimbursement for administrative expenses
incurred by the Board during such fiscal year.]
[(3) No payment may be made for treatment provided
under the demonstration program to the extent payment
may be made for such treatment under the Catastrophic
Health Emergency Fund described in section 1621a of
this title or from amounts appropriated or otherwise
made available to the California contract health
service delivery area for a fiscal year.]
[(c) Advisory board]
[There is hereby established an advisory board which shall
advise the California Rural Indian Health Board in carrying out
the demonstration pursuant to this section. The advisory board
shall be composed of representatives, selected by the
California Rural Indian Health Board, from not less than 8
tribal health programs serving California Indians covered under
such demonstration, at least one half of whom are not
affiliated with the California Rural Indian Health Board.]
[(d) Commencement and termination dates]
[The demonstration program described in this section shall
begin on January 1, 1993, and shall terminate on September 30,
1997.]
[(e) Report]
[Not later than July 1, 1998, the California Rural Indian
Health Board shall submit to the Secretary a report on the
demonstration program carried out under this section, including
a statement of its findings regarding the impact of using a
contract care intermediary on--]
[(1) access to needed health services;]
[(2) waiting periods for receiving such services;
and]
[(3) the efficient management of high-cost contract
care cases.]
[(f) ``High-cost contract care cases'' defined]
[For the purposes of this section, the term ``high-cost
contract care cases'' means those cases in which the cost of
the medical treatment provided to an individual--]
[(1) would otherwise be eligible for reimbursement
from the Catastrophic Health Emergency Fund established
under section 1621a of this title, except that the cost
of such treatment does not meet the threshold cost
requirement established pursuant to section 1621a(b)(2)
of this title; and]
[(2) exceeds $1,000.]
[(g) Authorization of appropriations]
[There are authorized to be appropriated for each of the
fiscal years 1996 through 2000 such sums as may be necessary to
carry out the purposes of this section.]
Sec. 212. Prevention, control, and elimination of communicable and
infectious diseases
(a) Funding Authorized.--The Secretary, acting through the
Service, and after consultation with Indian Tribes, Tribal
Organizations, Urban Indian Organizations, and the Centers for
Disease Control and Prevention, may make funding available to
Indian Tribes, Tribal Organizations, and Urban Indian
Organizations for the following:
(1) Projects for the prevention, control, and
elimination of communicable and infectious diseases,
including tuberculosis, hepatitis, HIV, respiratory
syncytial virus, hanta virus, sexually transmitted
diseases, and H. Pylori.
(2) Public information and education programs for the
prevention, control, and elimination of communicable
and infectious diseases.
(3) Education, training, and clinical skills
improvement activities in the prevention, control, and
elimination of communicable and infectious diseases for
health professionals, including allied health
professionals.
(4) Demonstration projects for the screening,
treatment, and prevention of hepatitis C virus (HCV).
(b) Application Required.--The Secretary may provide
funding under subsection (a) only if an application or proposal
for funding is submitted to the Secretary.
(c) Coordination with Health Agencies.--Indian Tribes,
Tribal Organizations, and Urban Indian Organizations receiving
funding under this section are encouraged to coordinate their
activities with the Centers for Disease Control and Prevention
and State and local health agencies.
(d) Technical Assistance; Report.--In carrying out this
section, the Secretary--
(1) may, at the request of an Indian Tribe, Tribal
Organization, or Urban Indian Organization, provide
technical assistance; and
(2) shall prepare and submit a report to Congress
biennially on the use of funds under this section and
on the progress made toward the prevention, control,
and elimination of communicable and infectious diseases
among Indians and Urban Indians.
[Sec. 1621k. Coverage of screening mammography]
[The Secretary, through the Service, shall provide for
screening mammography (as defined in section 1861(jj) of the
Social Security Act [42 U.S.C.A. Sec. 1395x9JJ0]) for Indian
and urban Indian women 35 years of age or older at a frequency,
determined by the Secretary (in consultation with the Director
of the National Cancer Institute), appropriate to such women,
and under such terms and conditions as are consistent with
standards established by the Secretary to assure the safety and
accuracy of screening mammography under part B of title XVIII
of the Social Security Act [42 U.S.C.A. Sec. 1395j et. seq.].]
Sec. 213. Authority for provision of other services
(a) Funding Authorized.--The Secretary, acting through the
Service, Indian Tribes, and Tribal Organizations, may provide
funding under this Act to meet the objectives set forth in
section 3 through health care-related services and programs not
otherwise described in this Act, including--
(1) hospice care;
(2) assisted living;
(3) long-term health care;
(4) home- and community-based services, in accordance
with subsection (d); and
(5) public health functions.
(b) Services to Otherwise Ineligible Persons.--Subject to
section 807, at the discretion of the Service, Indian Tribes,
or Tribal Organizations, services provided for hospice care,
home- and community-based care, assisted living, and long-term
care may be provided (subject to reimbursement) to persons
otherwise ineligible for the health care benefits of the
Service. Any funds received under this subsection shall not be
used to offset or limit the funding allocated to the Service or
an Indian Tribe or Tribal Organization.
(c) Terms and Conditions.--The Secretary shall require that
any service provided under this section shall be in accordance
with such terms and conditions as the Secretary determines to
be consistent with accepted and appropriate standards relating
to the service, including any licensing term or condition under
this Act.
(d) Definitions.--For the purposes of this section, the
following definitions shall apply:
(1)(A) The term `home- and community-based services'
means 1 or more of the following:
(i) Home health aide services.
(ii) Personal care services.
(iii) Nursing care services provided outside
of a nursing facility by, or under the
supervision of, a registered nurse.
(iv) Respite care.
(v) Training for family members.
(vi) Adult day care.
(vii) Such other home- and community-based
services as the Secretary, an Indian Tribe, or
a Tribal Organization may approve.
(B) The term `home- and community-based services'
does not include a service provided by an individual
that is legally responsible for providing the service.
(2) The term `hospice care' means the items and
services specified in subparagraphs (A) through (H) of
section 1861(dd)(1) of the Social Security Act (42
U.S.C. 1395x(dd)(1)), and such other services which an
Indian Tribe or Tribal Organization determines are
necessary and appropriate to provide in furtherance of
this care.
(3)(A) The term `personal care services' means
services relating to assistance in carrying out
activities of daily living.
(B) The term `personal care services' does not
include a service solely relating to assistance in
carrying out an ancillary activity, such as
housekeeping or household chores, as determined by the
Secretary.
(4) The term `public health functions' means the
provision of public health-related programs, functions,
and services including assessment, assurance, and
policy development which Indian Tribes and Tribal
Organizations are authorized and encouraged, in those
circumstances where it meets their needs, to do by
forming collaborative relationships with all levels of
local, State, and Federal Government.
[Sec. 1621l. Patient travel costs]
[(a) The Secretary, acting through the Service, shall
provide funds for the following patient travel costs associated
with receiving health care services provided (either through
direct or contract care or through contracts entered into
pursuant to the Indian Self-Determination Act [25 U.S.C.A.
Sec. 450f et seq.]) under this chapter--]
[(1) emergency air transportation; and]
[(2) nonemergency air transportation where ground
transportation is infeasible.]
[(b) There are authorized to be appropriated to carry out
this section $15,000,000 for fiscal year 1993 and such sums as
may be necessary for each of the fiscal years 1994, 1995, 1996,
1997, 1998, 1999, and 2000.]
Sec. 214. Indian women's health care
The Secretary, acting through the Service and Indian
Tribes, Tribal Organizations, and Urban Indian Organizations,
shall monitor and improve the quality of health care for Indian
women of all ages through the planning and delivery of programs
administered by the Service, in order to improve and enhance
the treatment models of care for Indian women.
[Sec. 1621m. Epidemiology centers]
[(a)(1) The Secretary shall establish an epidemiology
center in each Service area to carry out the functions
described in paragraph (3).]
[(2) To assist such centers in carrying out such functions,
the Secretary shall perform the following:]
[(A) In consultation with the Centers for Disease
Control and Indian tribes, develop sets of data (which
to the extent practicable, shall be consistent with the
uniform data sets used by the States with respect to
the year 2000 health objectives) for uniformly
defininghealth status for purposes of the objectives specified in
section 1602(b) of this title. Such sets shall consist of one or more
categories of information. The Secretary shall develop formats for the
uniform collecting and reporting of information on such categories.]
[(B) Establish and maintain a system for monitoring
the progress made toward meeting each of the health
status objectives described in section 1602(b) of this
title.]
[(3) In consultation with Indian tribes and urban Indian
communities, each area epidemiology center established under
this subsection shall, with respect to such area--]
[(A) collect data relating to, and monitor progress
made toward meeting, each of the health status
objectives described in section 1602(b) of this title
using the data sets and monitoring system developed by
the Secretary pursuant to paragraph (2);]
[(B) evaluate existing delivery systems, data
systems, and other systems that impact the improvement
of Indian health;]
[(C) assist tribes and urban Indian communities in
identifying their highest priority health status
objectives and the services needed to achieve such
objectives, based on epidemiological data;]
[(D) make recommendations for the targeting of
services needed by tribal, urban, and other Indian
communities;]
[(E) make recommendations to improve health care
delivery systems for Indians and urban Indians;]
[(F) work cooperatively with tribal providers of
health and social services in order to avoid
duplication of existing services; and]
[(G) provide technical assistance to Indian tribes
and urban Indian organizations in the development of
local health service priorities and incidence and
prevalence rates of disease and other illness in the
community.]
[(4) Epidemiology centers established under this subsection
shall be subject to the provisions of the Indian Self-
Determination Act (25 U.S.C. 450f et seq.).]
[(5) The director of the Centers for Disease Control shall
provide technical assistance to the centers in carrying out the
requirements of this subsection.]
[(6) The Service shall assign one epidemiologist from each
of its area offices to each area epidemiology center to provide
such center with technical assistance necessary to carry out
this subsection.]
[(b)(1) The Secretary may make grants to Indian tribes,
tribal organizations, and eligible intertribal consortia or
Indian organization to conduct epidemiological studies of
Indian communities.]
[(2) An intertribal consortia or Indian organization is
eligible to receive a grant under this subsection if--]
[(A) it is incorporated for the primary purpose of
improving Indian health; and]
[(B) it is representative of the tribes or urban
Indian communities in which it is located.]
[(3) An application for a grant under this subsection shall
be submitted in such manner and at such time as the Secretary
shall prescribe.]
[(4) Applicants for grants under this subsection shall--]
[(A) demonstrate the technical, administrative, and
financial expertise necessary to carry out the
functions described in paragraph (5);]
[(B) consult and cooperate with providers of related
health and social services in order to avoid
duplication of existing services; and]
[(C) demonstrate cooperation from Indian tribes or
urban Indian organizations in the area to be served.]
[(5) A grant awarded under paragraph (1) may be used to--]
[(A) carry out the functions described in subsection
(a)(3) of this section;]
[(B) provide information to and consult with tribal
leaders, urban Indian community leaders, and related
health staff, on health care and health services
management issues; and]
[(C) provide, in collaboration with tribes and urban
Indian communities, the Service with information
regarding ways to improve the health status of Indian
people.]
[(6) There are authorized to be appropriated to carry out
the purposes of this subsection not more that $12,000,000 for
fiscal year 1993 and such sums as may be necessary for each of
the fiscal years 1994, 1995, 1996, 1997, 1998, 1999, and 2000.]
Sec. 215. Environmental and nuclear health hazards
(a) Studies and Monitoring. The Secretary and the Service
shall conduct, in conjunction with other appropriate Federal
agencies and in consultation with concerned Indian Tribes and
Tribal Organizations, studies and ongoing monitoring programs
to determine trends in the health hazards to Indian miners and
to Indians on or near reservations and Indian communities as a
result of environmental hazards which may result in chronic or
life threatening health problems, such as nuclear resource
development, petroleum contamination, and contamination of
water source and of the food chain. Such studies shall
include--
(1) an evaluation of the nature and extent of health
problems caused by environmental hazards currently
exhibited among Indians and the causes of such health
problems;
(2) an analysis of the potential effect of ongoing
and future environmental resource development on or
near reservations and Indian communities, including the
cumulative effect over time on health;
(3) and evaluation of the types and nature of
activities, practices, and conditions causing or
affecting such health problems including uranium mining
and milling, uranium mining tailing deposits, nuclear
power plant operation and construction, and nuclear
waste disposal; oil and gas production or
transportation on or near reservations or Indian
communities; and other development that could affect
the health of Indians and their water supply and food
chain;
(4) a summary of any findings and recommendations
provided in Federal and State studies, reports,
investigations, and inspections during the 5 years
prior to the date of the enactment of the Indian Health
Care Improvement Act Amendments of 2005 that directly
or indirectly relate to the activities, practices, and
conditions affecting the health or safety of such
Indians; and
(5) the efforts that have been made by Federal and
State agencies and resource and economic development
companies to effectively carry out an education program
for such Indians regarding the health and safety
hazards of such development.
(b) Health Care Plans.--Upon completion of such studies,
the Secretary and the Service shall take into account the
results of such studies and, in consultation with Indian Tribes
and Tribal Organizations, develop health care plans to address
the health problems studied under subsection (a). The plans
shall include--
(1) methods for diagnosing and treating Indians
currently exhibiting such health problems;
(2) preventive care and testing for Indians who may
be exposed to such health hazards, including the
monitoring of the health of individuals who have or may
have been exposed to excessive amounts of radiation or
affected by other activities that have had or could
have a serious impact upon the health of such
individuals; and
(3) a program of education for Indians who, by reason
of their work or geographic proximity to such nuclear
or other development activities, may experience health
problems.
(c) Submission of Report and Plan to Congress.--The
Secretary and the Service shall submit to Congress the study
prepared under subsection (a) no later than 18 months after the
date of the enactment of the Indian Health Care Improvement Act
Amendments of 2005. The health care plan prepared under
subsection (b) shall be submitted in a report no later than 1
year after thestudy prepared under subsection (a) is submitted
to Congress. Such report shall include recommended activities for the
implementation of the plan, as well as an evaluation of any activities
previously undertaken by the Service to address such health problems.
(d) Intergovernmental Task Force.--
(1) Establishment; members.--There is established an
Intergovernmental Task Force to be composed of the
following individuals (or their designees):
(A) The Secretary of Energy.
(B) The Secretary of the Environmental
Protection Agency.
(C) The Director of the Bureau of Mines.
(D) The Assistant Secretary for Occupational
Safety and Health.
(E) The Secretary of the Interior.
(F) The Secretary of Health and Human
Services.
(G) The Director of the Indian Health
Service.
(2) Duties.--The Task Force shall--
(A) identify existing and potential
operations related to nuclear resource
development or other environmental hazards that
affect or may affect the health of Indians on
or near a reservation or in an Indian
community; and
(B) enter into activities to correct existing
health hazards and ensure that current and
future health problems resulting from nuclear
resource or other development activities are
minimized or reduced.
(3) Chairman; meetings.--The Secretary of Health and
Human Services shall be the Chairman of the Task Force.
The Task Force shall meet at least twice each year.
(e) Health Services to Certain Employees.--In the case of
any Indian who--
(1) as a result of employment in or near a uranium
mine or mill or near any other environmental hazard,
suffers from a work-related illness or condition;
(2) is eligible to receive diagnosis and treatment
services from an Indian Health Program; and
(3) by reason of such Indian's employment, is
entitled to medical care at the expense of such mine or
mill operator or entity responsible for the
environmental hazard, the Indian Health Program shall,
at the request of such Indian, render appropriate
medical care to such Indian for such illness or
condition and may be reimbursed for any medical care so
rendered to which such Indian is entitled at the
expense of such operator or entity from such operator
or entity. Nothing in this subsection shall affect the
rights of such Indian to recover damages other than
such amounts paid to the Indian Health Program from the
employer for providing medical care for such illness or
condition.
[Sec. 1621n. Comprehensive school health education programs]
[(a) Award of grants]
[The Secretary, acting through the Service and in
consultation with the Secretary of the Interior, may award
grants to Indian tribes to develop comprehensive school health
education programs for children from preschool through grade 12
in schools located on Indian reservations.]
[(b) Use of grants]
[Grants awarded under this section may be used to--]
[(1) develop health education curricula;]
[(2) train teachers in comprehensive school health
education curricula;]
[(3) integrate school-based, community-based, and
other public and private health promotion efforts;]
[(4) encourage healthy, tobacco-free school
environments;]
[(5) coordinate school-based health programs with
existing services and programs available in the
community;]
[(6) develop school programs on nutrition education,
personal health, and fitness;]
[(7) develop mental health wellness programs;]
[(8) develop chronic disease prevention programs;]
[(9) develop substance abuse prevention programs;]
[(10) develop accident prevention and safety
education programs;]
[(11) develop activities for the prevention and
control of communicable diseases; and]
[(12) develop community and environmental health
education programs.]
[(c) Assistance]
[The Secretary shall provide technical assistance to Indian
tribes in the development of health education plans, and the
dissemination of health education materials and information on
existing health programs and resources.]
[(d) Criteria for review and approval of applications]
[The Secretary shall establish criteria for the review and
approval of applications for grants made pursuant to this
section.]
[(e) Report of recipient]
[Recipients of grants under this section shall submit to
the Secretary an annual report on activities undertaken with
funds provided under this section. Such reports shall include a
statement of--]
[(1) the number of preschools, elementary schools,
and secondary schools served;]
[(2) the number of students served;]
[(3) any new curricula established with funds
provided under this section;]
[(4) the number of teachers trained in the health
curricula; and]
[(5) the involvement of parents, members of the
community, and community health workers in programs
established with funds provided under this section.]
[(f) Program development]
[(1) The Secretary of the Interior, acting through
the Bureau of Indian Affairs and in cooperation with
the Secretary, shall develop a comprehensive school
health education program for children from preschool
through grade 12 in schools operated by the Bureau of
Indian Affairs.]
[(2) Such program shall include--]
[(A) school programs on nutrition education,
personal health, and fitness;]
[(B) mental health wellness programs;]
[(C) chronic disease prevention programs;]
[(D) substance abuse prevention programs;]
[(E) accident prevention and safety education
programs; and]
[(F) activities for the prevention and
control of communicable diseases.]
[(3) The Secretary of the Interior shall--]
[(A) provide training to teachers in
comprehensive school health education
curricula;]
[(B) ensure the integration and coordination
of school-based programs with existing services
and health programs available in the community;
and]
[(C) encourage healthy, tobacco-free school
environments.]
[(g) Authorization of appropriations]
[There are authorized to be appropriated to carry out this
section $15,000,000 for the fiscal year 1993 and such sums as
may be necessary for each of the fiscal years 1994, 1995, 1996,
1997, 1998, 1999, and 2000.]
Sec. 216. Arizona as a contract health service delivery area
(a) In General.--For fiscal years beginning with the fiscal
year ending September 30, 1983, and ending with the fiscal year
ending September 30, 2015, the State of Arizona shall be
designated as a contract health service delivery area by the
Service for the purpose of providing contract health care
services to members of federally recognized Indian Tribes of
Arizona.
(b) Maintenance of Services.--The Service shall not curtail
any health care services provided to Indians residing on
reservations in the State of Arizona if such curtailment is due
to the provision of contract services in such State pursuant to
the designation of such State as a contract health service
delivery area pursuant to subsection (a).
Sec. 216A. North Dakota and South Dakota as contract health service
delivery area
(a) In General.--Beginning in fiscal year 2003, the States
of North Dakota and South Dakota shall be designated as a
contract health service delivery area by the Service for the
purpose of providing contract health care services to members
of federally recognized Indian Tribes of North Dakota and South
Dakota.
(b) Limitation.--The Service shall not curtail any health
care services provided to Indians residing on any reservation,
or in any county that has a common boundary with any
reservation, in the State of North Dakota or South Dakota if
such curtailment is due to the provision of contract services
in such States pursuant to the designation of such States as a
contract health service delivery area pursuant to subsection
(a).
[Sec. 1621o. Indian youth grant program]
[(a) Grants]
[The Secretary, acting through the Service, is authorized
to make grants to Indian tribes, tribal organizations, and
urban Indian organizations for innovative mental and physical
disease prevention and health promotion and treatment programs
for Indian preadolescent and adolescent youths.]
[(b) Use of funds]
[(1) Funds made available under this section may be
used to--]
[(A) develop prevention and treatment
programs for Indian youth which promote mental
and physical health and incorporate cultural
values, community and family involvement, and
traditional healers; and]
[(B) develop and provide community training
and education.]
[(2) Funds made available under this section may not
be used to provide services described in section
1621h(m) of this title.]
[(c) Models for delivery of comprehensive health care
services]
[The Secretary shall--]
[(1) disseminate to Indian tribes information
regarding models for the delivery of comprehensive
health care services to Indian and urban Indian
adolescents;]
[(2) encourage the implementation of such models;
and]
[(3) at the request of an Indian tribe, provide
technical assistance in the implementation of such
models.]
[(d) Criteria for review and approval of applications]
[The Secretary shall establish criteria for the review and
approval of applications under this section.]
[(e) Authorization of appropriations]
[There are authorized to be appropriated to carry out this
section $5,000,000 for fiscal year 1993 and such sums as may be
necessary for each of the fiscal years 1994, 1995, 1996, 1997,
1998, 1999, and 2000.]
Sec. 217. California contract health services program
(a) Funding Authorized.--The Secretary is authorized to
fund a program using the California Rural Indian Health Board
(hereafter in this section referred to as the `CRIHB') as a
contract care intermediary to improve the accessibility of
health services to California Indians.
(b) Reimbursement Contract.--The Secretary shall enter into
an agreement with the CRIHB to reimburse the CRIHB for costs
(including reasonable administrative costs) incurred pursuant
to this section, in providing medical treatment under contract
to California Indians described in section 806(a) throughout
the California contract health services delivery area described
in section 218 with respect to high cost contract care cases.
(c) Administrative Expenses.--Not more than 5 percent of
the amounts provided to the CRIHB under this section for any
fiscal year may be for reimbursement for administrative
expenses incurred by the CRIHB during such fiscal year.
(d) Limitation on Payment.--No payment may be made for
treatment provided hereunder to the extent payment may be made
for such treatment under the Indian Catastrophic Health
Emergency Fund described in section 202 or from amounts
appropriated or otherwise made available to the California
contract health service delivery area for a fiscal year.
(e) Advisory Board.--There is established an advisory board
which shall advise the CRIHB in carrying out this section. The
advisory board shall be composed of representatives, selected
by the CRIHB, from not less than 8 Tribal Health Programs
serving California Indians covered under this section at least
one half of whom are not affiliated with the CRIHB.
Sec. 218. California as a contract health service delivery area
The State of California, excluding the counties of Alameda,
Contra Costa, Los Angeles, Marin, Orange, 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 California
Indians. However, any of the counties listed herein may only be
included in the contract health services delivery area if
funding is specifically provided by the Service for such
services in those counties.
Sec. 219. Contract health services for the Trenton Service Area
(a) Authorization for Services.--The Secretary, acting
through the Service, is directed to provide contract health
services to members of the Turtle Mountain Band of Chippewa
Indians that reside in the Trenton Service Area of Divide,
McKenzie, and Williams counties in the State of North Dakota
and the adjoining counties of Richland, Roosevelt, and Sheridan
in the State of Montana.
(b) No Expansion of Eligibility.--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.
[Sec. 1621p. American Indians Into Psychology Program]
[(a) Grants]
[The Secretary may provide grants to at least 3 colleges
and universities for the purpose of developing and maintaining
American Indian psychology career recruitment programs as a
means of encouraging Indians to enter the mental health field.]
[(b) Quentin N. Burdick American Indians Into Psychology
Program]
[The Secretary shall provide one of the grants authorized
under subsection (a) of this section to develop and maintain a
program at the University of North Dakota to be known as the
``Quentin N. Burdick American Indians Into Psychology
Program''. Such program shall, to the maximum extent feasible,
coordinate with the Quentin N. Burdick Indian Health Programs
authorized under section 1616g(b) of this title, the Quentin N.
Burdick American Indians Into Nursing Program authorized under
section 1616e(e) of this title, and existing university
research and communications networks.]
[(c) Issuance of regulations]
[(1) The Secretary shall issue regulations for the
competitive awarding of the grants provided under this
section.]
[(2) Applicants for grants under this section shall
agree to provide a program which, at a minimum--]
[(A) provides outreach and recruitment for
health professions to Indian communities
including elementary, secondary and community
colleges located on Indian reservations that
will be served by the program;]
[(B) incorporates a program advisory board
comprised of representatives from the tribes
and communities that will be served by the
program;]
[(C) provides summer enrichment programs to
expose Indian students to the varied fields of
psychology through research, clinical, and
experiential activities;]
[(D) provides stipends to undergraduate and
graduate students to pursue a career in
psychology;]
[(E) develops affiliation agreements with
tribal community colleges, the Service,
university affiliated programs, and other
appropriate entities to enhance the education
of Indian students;]
[(F) to the maximum extent feasible, utilizes
existing university tutoring, counseling and
student support services; and]
[(G) to the maximum extent feasible, employs
qualified Indians in the program.]
[(d) Active duty service obligation]
[The active duty service obligation prescribed under
section 254m of Title 42 shall be met by each graduate student
who receives a stipend described in subsection (c)(2)(D) of
this section that is funded by a grant provided under this
section. Such obligation shall be met by service--]
[(1) in the Indian Health Service;]
[(2) in a program conducted under a contract entered
into under the Indian Self-Determination Act [25
U.S.C.A. Sec. 450f et seq.],]
[(3) in a program assisted under subchapter IV of
this chapter; or]
[(4) in the private practice of psychology 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.]
[Sec. 1621q. Prevention, control, and elimination of tuberculosis]
[(a) Grants]
[The Secretary, acting through the Service after
consultation with the Centers for Disease Control, may make
grants to Indian tribes and tribal organizations for--]
[(1) projects for the prevention, control, and
elimination of tuberculosis;]
[(2) public information and education programs for
the prevention, control, and elimination of
tuberculosis; and]
[(3) education, training, and clinical skills
improvement activities in the prevention, control, and
elimination of tuberculosis for health professionals,
including allied health professionals.]
[(b) Application for grant]
[The Secretary may make a grant under subsection (a) of
this section only if an application for the grant is submitted
to the Secretary and the application is in such form, is made
in such manner, and contains the assurances required by
subsection (c) of this section and such other agreements,
assurances, and information as the Secretary may require.]
[(c) Eligibility for grant]
[To be eligible for a grant under subsection (a) of this
section, an applicant must provide assurances satisfactory to
the Secretary that--]
[(1) the applicant will coordinate its activities for
the prevention, control, and elimination of
tuberculosis with activities of the Centers for Disease
Control, and State and local health agencies; and]
[(2) the applicant will submit to the Secretary an
annual report on its activities for the prevention,
control, and elimination of tuberculosis.]
[(d) Duties of Secretary]
[In carrying out this section, the Secretary--]
[(1) shall establish criteria for the review and
approval of applications for grants under subsection
(a) of this section, including requirement of public
health qualifications of applicants;]
[(2) shall, subject to available appropriations, make
at least one grant under subsection (a) of this section
within each area office;]
[(3) may, at the request of an Indian tribe or tribal
organization, provide technical assistance; and]
[(4) shall prepare and submit a report to the
Committee on Energy and Commerce and the Committee on
Natural Resources of the House and the Committee on
Indian Affairs of the Senate not later than February 1,
1994, and biennially thereafter, on the use of funds
under this section and on the progress made toward the
prevention, control, and elimination of tuberculosis
among Indian tribes and tribal organizations.]
[(e) Reduction of amount of grant]
[The Secretary may, at the request of a recipient of a
grant under subsection (a) of this section, reduce the amount
of such grant by--]
[(1) the fair market value of any supplies or
equipment furnished the grant recipient; and]
[(2) the amount of the pay, allowances, and travel
expenses of any officer or employee of the Government
when detailed to the grant recipient and the amount of
any other costs incurred in connection with the detail
of such officer or employee,]
[when the furnishing of such supplies or equipment or the
detail of such an officer or employee is for the convenience of
and at the request of such grant recipient and for the purpose
of carrying out a program with respect to which the grant under
subsection (a) of this section is made. The amount by which any
such grant is so reduced shall be available for payment by the
Secretary of the costs incurred in furnishing the supplies or
equipment, or in detailing the personnel, on which the
reduction of such grant is based, and such amount shall be
deemed as part of the grant and shall be deemed to have been
paid to the grant recipient.]
[Sec. 1621r. Contract health services payment study]
[(a) Duty of Secretary]
[The Secretary, acting through the Service and in
consultation with representatives of Indian tribes and tribal
organizations operating contract health care programs under the
Indian Self-Determination Act (25 U.S.C. 450f et seq.) or under
self-governance compacts, Service personnel, private contract
health services providers, the Indian Health Service Fiscal
Intermediary, and other appropriate experts, shall conduct a
study--]
[(1) to assess and identify administrative barriers
that hinder the timely payment for services delivered
by private contract health services providers to
individual Indians by the Service and the Indian Health
Service Fiscal Intermediary;]
[(2) to assess and identify the impact of such
delayed payments upon the personal credit histories of
individual Indians who have been treated by such
providers; and]
[(3) to determine the most efficient and effective
means of improving the Service's contract health
services payment system and ensuring the development of
appropriate consumer protection policies to protect
individual Indians who receive authorized services from
private contract health services providers from billing
and collection practices, including the development of
materials and programs explaining patients' rights and
responsibilities.]
[(b) Functions of study]
[The study required by subsection (a) of this section
shall--]
[(1) assess the impact of the existing contract
health services regulations and policies upon the
ability of the Service and the Indian Health Service
Fiscal Intermediary to process, on a timely and
efficient basis, the payment of bills submitted by
private contract health services providers;]
[(2) assess the financial and any other burdens
imposed upon individual Indians and private contract
health services providers by delayed payments;]
[(3) survey the policies and practices of collection
agencies used by contract health services providers to
collect payments for services rendered to individual
Indians;]
[(4) identify appropriate changes in Federal
policies, administrative procedures, and regulations,
to eliminate the problems experienced by private
contract health services providers and individual
Indians as a result of delayed payments; and]
[(5) compare the Service's payment processing
requirements with private insurance claims processing
requirement to evaluate the systemic differences or
similarities employed by the Service and private
insurers.]
[(c) Report to Congress]
[Not later than 12 months after October 29, 1992, the
Secretary shall transmit to the Congress a report that
includes--]
[(1) a detailed description of the study conducted
pursuant to this section; and]
[(2) a discussion of the findings and conclusions of
such study.]
[Sec. 1621s. Prompt action on payment of claims]
[(a) Time of response]
[The Service shall respond to a notification of a claim by
a provider of a contract care service with either an individual
purchase order or a denial of the claim within 5 working days
after the receipt of such notification.]
[(b) Failure to timely respond]
[If the Service fails to respond to a notification of a
claim in accordance with subsection (a) of this section, the
Service shall accept as valid the claim submitted by the
provider of a contract care service.]
[(c) Time of payment]
[The Service shall pay a completed contract care service
claim within 30 days after completion of the claim.]
[Sec. 1621t. Demonstration of electronic claims processing]
[(a) Not later than June 15, 1993, the Secretary shall
develop and implement, directly or by contract, 2 projects to
demonstrate in a pilot setting the use of claims processing
technology to improve the accuracy and timeliness of the
billing for, and payment of, contract health services.]
[(b) The Secretary shall conduct one of the projects
authorized in subsection (a) of this section in the Service
area served by the area office located in Phoenix, Arizona.]
[Sec. 1621u. Liability for payment]
[(a) A patient who receives contract health care services
that are authorized by the Service shall not be liable for the
payment of any charges or costs associated with the provision
of such services.]
[(b) The Secretary shall notify a contract care provider
and any patient who receives contract health care services
authorized by the Service that such patient is not liable for
the payment of any charges or costs associated with the
provision of such services.]
[Sec. 1621v. Office of Indian Women's Health Care]
[There is established within the Service an Office of
Indian Women's Health Care to oversee efforts of the Service to
monitor and improve the quality of health care for Indian women
of all ages through the planning and delivery of programs
administered by the Service, in order to improve and enhance
the treatment models of care for Indian women.]
Sec. 220. Programs operated by Indian tribes and tribal organizations
The Service shall provide funds for health care programs
and facilities operated by Tribal Health Programs on the same
basis as such funds are provided to programs and facilities
operated directly by the Service.
Sec. 221. Licensing
Health care professionals employed by a Tribal Health
Program shall, if licensed or certified in any State, be exempt
from the licensing requirements of the State in which the
Tribal Health Program performs the services described in its
contract or compact under the Indian Self-Determination and
Education Assistance Act (25 U.S.C. 450 et seq.).
Sec. 222. Notification of provision of emergency contract health
services
With respect to an elderly Indian or an Indian with a
disability receiving emergency medical care or services from a
non-Service provider or in a non-Service facility under the
authority of this Act, the time limitation (as a condition of
payment) for notifying the Service of such treatment or
admission shall be 30 days.
Sec. 223. Prompt action on payment of claims
(a) Deadline for Response.--The Service shall respond to a
notification of a claim by a provider of a contract care
service with either an individual purchase order or a denial of
the claim within 5 working days after the receipt of such
notification.
(b) Effect of Untimely Response.--If the Service fails to
respond to a notification of a claim in accordance with
subsection (a), the Service shall accept as valid the claim
submitted by the provider of a contract care service.
(c) Deadline for Payment of Valid Claim.--The Service shall
pay a valid contract care service claim within 30 days after
the completion of the claim.
Sec. 224. Liability for payment
(a) No Patient Liability.--A patient who receives contract
health care services that are authorized by the Service shall
not be liable for the payment of any charges or costs
associated with the provision of such services.
(b) Notification.--The Secretary shall notify a contract
care provider and any patient who receives contract health care
services authorized by the Service that such patient is not
liable for the payment of any charges or costs associated with
the provision of such services not later than 5 business days
after receipt of a notification of a claim by a provider of
contract care services.
(c) No Recourse.--Following receipt of the notice provided
under subsection (b), or, if a claim has been deemed accepted
under section 233(b), the provider shall have no further
recourse against the patient who received the services.
Sec. 225. Office of Indian men's health
(a) Establishment.--The Secretary shall establish within
the Service an office to be known as the `Office of Indian
Men's Health' (referred to in this section as the `Office').
(b) Director.--
(1) In general.--The Office shall be headed by a
Director, to be appointed by the Secretary.
(2) Duties.--The Director shall coordinate and
promote the status of the health of Indian men in the
United States.
(c) Report.--Not later than 2 years after the date of
enactment of the Indian Health Care Improvement Act Amendments
of 2005, the Secretary, acting through the Director of the
Office, shall submit to Congress a report describing--
(1) any activity carried out by the Director as of
the date on which the report is prepared; and
(2) any finding of the Director with respect to the
health of Indian men.
Sec. 1621w. Authorization of appropriations
[Except as provided in sections 1621h(m), 1621j, 1621l,
1621m(b)(5), 1621n, and 1621o of this title, t] There are
authorized to be appropriated such sums as may be necessary for
each fiscal year through fiscal year 2015 [2000] to carry out
this title [subchapter].
[Sec. 1621x. Limitation on use of funds]
[Amounts appropriated to carry out this subchapter may not
be used in a manner inconsistent with the Assisted Suicide
Funding Restriction Act of 1997 [42 U.S.C.A. Sec. 14401 et
seq.].
[Sec. 1622. Transferred]
TITLE [SUBCHAPTER] III--[HEALTH] FACILITIES
Sec. 1631. Consultation; Construction and Renovation of Facilities;
[closure of facilities; r]Reports
(a) Prerequisites for Expenditure of Funds.--[Consultation;
standards for accreditation]
Prior to the expenditure of, or the making of any binding
[firm] commitment to expend, any funds appropriated for the
planning, design, construction, or renovation of facilities
pursuant to the Act of November 2, 1921 (25 U.S.C. 13)
(commonly known as the `Snyder Act') [section 13 of this title,
popularly known as the Snyder Act], the Secretary, acting
through the Service, shall--
(1) consult with any Indian [t] Tribe that would be
significantly affected by such expenditure for the
purpose of determining and, whenever practicable,
honoring tribal preferences concerning size, location,
type, and other characteristics of any facility on
which such expenditure is to be made[,]; and
(2) ensure, whenever practicable and applicable, that
such facility meets the construction standards of any
accrediting body recognized by the Secretary for the
purposes of the medicare, medicaid, and SCHIP programs
under titles XVIII, XIX, and XXI of the Social Security
Act [the Joint Commission on Accreditation of Health
Care Organizations] by not later than 1 year after the
date on which the construction or renovation of such
facility is completed.
(b) Closures.--[; report on proposed closure]
(1) Evaluation Required.--Notwithstanding any other
provision of law, no facility operated by the Service
[other than this subsection, no Service hospital or
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] Congress at
least 1 year prior to the date of the proposed closure
[such hospital or facility (or portion thereof) is
proposed to be closed] an evaluation of the impact of
the [such] proposed closure which specifies, in
addition to other considerations--
(A) the accessibility of alternative health
care resources for the population served by
such [hospital or] facility;
(B) the cost-effectiveness of such closure;
(C) the quality of health care to be provided
to the population served by such [hospital or]
facility after such closure;
(D) the availability of contract health care
funds to maintain existing levels of service;
(E) the views of the Indian [t] Tribes served
by such [hospital or] facility concerning such
closure;
(F) the level of use of such [utilization of
such hospital or] facility by all eligible
Indians; and
(G) the distance between such [hospital or]
facility and the nearest operating Service
hospital.
(2) Exception for certain temporary closures.--
Paragraph (1) shall not apply to any temporary closure
of a facility or [of] any portion of a facility if such
closure is necessary for medical, environmental, or
construction safety reasons.
(c) Health Care Facility Priority System.--[Annual report
on health facility priority system]
(1) In general.--
(A) Establishment.--The Secretary, acting
through the Service, shall establish a health
care facility priority system, which shall--
(i) be developed with Indian Tribes
and Tribal Organizations through
negotiated rulemaking under section
802;
(ii) give Indian Tribes' needs the
highest priority; and
(iii) at a minimum, include the lists
required in paragraph (2)(B) and the
methodology required in paragraph
(2)(E).
(B) Priority of certain projects protected.--
The priority of any project established under
the construction priority system in effect on
the date of the Indian Health Care Improvement
Act Amendments of 2005 shall not be affected by
any change in the construction priority system
taking place thereafter if the project was
identified as 1 of the 10 top-priority
inpatient projects, 1 of the 10 top-priority
outpatient projects, 1 of the 10 top-priority
staff quarters developments, or 1 of the 10
top-priority Youth Regional Treatment Centers
in the fiscal year 2005 Indian Health Service
budget justification, or if the project had
completed both Phase I and Phase II of the
construction priority system in effect on the
date of the enactment of such Act.
(2) [(1)] Report; contents.--The Secretary shall
submit to the President, for inclusion in [each] the
report required to be transmitted to [the] Congress
under section 801 [1671 of this title], a report which
sets forth the following:[--]
(A) A description of the [current] health
care facility priority system of the Service,
established under paragraph (1).
(B) Health care facilities lists, including--
[the planning, design, construction,and
renovation needs for the 10 top-priority inpatient care facilities and
the 10 top-priority ambulatory care facilities (together with required
staff quarters),]
(i) the 10 top-priority inpatient
health care facilities;
(ii) the 10 top-priority outpatient
health care facilities;
(iii) the 10 top-priority specialized
health care facilities (such as long-
term care and alcohol and drug abuse
treatment);
(iv) the 10 top-priority staff
quarters developments associated with
health care facilities; and
(v) the 10 top-priority hostels
associated with health care facilities.
(C) [t]The justification for such order of
priority[,].
(D) [t]The projected cost of such projects.[,
and]
(E) [t]The methodology adopted by the Service
in establishing priorities under its health
facility priority system.
(3)[(2)] Requirements for preparation of reports.--In
preparing each report required under paragraph (2)
[(1)] (other than the initial report), the Secretary
shall annually--
(A) consult with and obtain information on
all health care facilities needs from Indian
[t]Tribes, Tribal Organizations, and Urban
Indian Organizations; [and tribal organizations
including those tribes or tribal organizations
operating health programs or facilities under
any contract entered into with the Service
under the Indian Self-Determination Act [25
U.S.C.A. Sec. 450f et seq.],] and
(B) review the total unmet needs of all
Indian [such t]Tribes, Tribal Organizations,
and Urban Indian Organizations [and tribal
organizations] for health care [inpatient and
outpatient] facilities (including hostels and
staff quarters), including [their] needs for
renovation and expansion of existing
facilities.
(4)[(3)] Criteria for evaluating needs.--For purposes
of this subsection, the Secretary shall, in evaluating
the needs of facilities operated under any contract or
compact [entered into with the Service] under the
Indian Self-Determination and Education Act (25 U.S.C.
450 et seq.) [25 U.S.C. Sec. 450f et seq],] use the
same criteria that the Secretary uses in evaluating the
needs of facilities operated directly by the Service.
(5)[(4)] Needs of facilities under isdeaa
agreements.--The Secretary shall ensure that the
planning, design, construction, and renovation needs of
Service and non-Service facilities operated under
contracts or compacts in accordance with the [which are
the subject of a contract for health services entered
into with the Service under the] Indian Self-
Determination and Education Assistance Act (25 U.S.C.
450 et seq.) [25 U.S.C. Sec. 450f et seq] are fully and
equitably integrated into [the development of] the
health care facility priority system.
(d) Review of Need for Facilities
(1) Initial report.--In the year 2006, the Government
Accountability Office shall prepare and finalize a
report which sets forth the needs of the Service,
Indian Tribes, Tribal Organizations, and Urban Indian
Organizations, for the facilities listed under
subsection (c)(2)(B), including the needs for
renovation and expansion of existing facilities. The
Government Accountability Office shall submit the
report to the appropriate authorizing and
appropriations committees of Congress and to the
Secretary.
(2) Beginning in the year 2006, the Secretary shall
update the report required under paragraph (1) every 5
years.
(3) In preparing an updated report under paragraph
(2), the Secretary shall consult with Indian Tribes,
Tribal Organizations, and Urban Indian Organizations.
The Secretary shall submit the report under paragraph
(2) for inclusion in the report required to be
transmitted to Congress under section 801.
(4) For purposes of this subsection, the reports
shall, regarding the needs of facilities operated under
any contracts or compacts under the Indian Self-
Determination and Education Assistance Act (25 U.S.C.
450 et seq.), be based on the same criteria that the
Secretary uses in evaluating the needs of facilities
operated directly by the Service.
(5) The planning, design, construction, and
renovation needs of facilities operated under contracts
or compacts under the Indian Self-Determination and
Education Assistance Act (25 U.S.C. 450 et seq.) shall
be fully and equitably integrated into the development
of the health facility priority system.
(6) Beginning in the year 2007 and each fiscal year
thereafter, the Secretary shall provide an opportunity
for nomination of planning, design, and construction
projects by the Service, Indian Tribes, and Tribal
Organizations for consideration under the health care
facility priority system.
(e) Funding Condition.--[(d) Funds appropriated subject to
section 450f of this title]
All funds appropriated under the Act of November 2, 1921
(25 U.S.C. 13) (commonly known as the `Snyder Act'), [section
13 of this title,] for the planning, design, construction, or
renovation of health facilities for the benefit of 1 or more
[an] Indian [tribe or t]Tribes shall be subject to the
provisions of [section 102 of] the Indian Self-Determination
and Education Assistance Act (25 U.S.C. 450 et seq.).
(f) Development of Innovative Approaches.--The Secretary
shall consult and cooperate with Indian Tribes, Tribal
Organizations, and Urban Indian Organizations in developing
innovative approaches to address all or part of the total unmet
need for construction of health facilities, including those
provided for in other sections of this title and other
approaches.
Sec. 1632. Sanitation [Safe water and sanitary waste disposal
f]Facilities
(a) [Congressional f]Findings.--
[The] Congress [hereby] finds the following: [and declares
that--]
(1) [t]The provision of sanitation facilities [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 sanitation
facilities. [such systems;]
(3) [t]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 sanitation facilities [such systems] and
other preventive health measures[;].
(4) [m]Many Indian homes and Indian communities still
lack sanitation facilities. [safe water supply systems
and sanitary sewage and solid waste disposal systems;
and]
(5) [i]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 sanitation facilities. [safe and
adequate water supply systems and sanitary sewage waste
disposal systems as soon as possible.]
(b) Facilities and Services._[Authority; assistance;
transfer of funds]
[(1)] In furtherance of the findings [and declarations]
made in subsection (a) [of this section], 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.A.
2004a) [2004a of Title 42]. Under such authority, [(2) T]the
Secretary, acting through the Service, is authorized to provide
the following: [under section 2004a of Title 42.]
(1)[(A) f]Financial and technical assistance to
Indian [t]Tribes, Tribal Organizations, and Indian
communities in the establishment, training, and
equipping of utility organizations to operate and
maintain [Indian] sanitation facilities[;], including
the provision of existing plans, standard details, and
specifications available in the Department, to be used
at the option of the Indian Tribe, Tribal Organization,
or Indian community.
(2)[(B) o]Ongoing technical assistance and training
to Indian Tribes, Tribal Organizations, and Indian
communities in the management of utility organizations
which operate and maintain sanitation facilities.[;
and]
(3)[(C)] Priority funding for operation and
maintenance assistance for, and emergency repairs to,
[tribal] sanitation facilities operated by an Indian
Tribe, Tribal Organization orIndian community when
necessary to avoid an imminent [a] health threat [hazard] or to protect
the [Federal] investment in sanitation facilities and the investment in
the health benefits gained through the provision of sanitation
facilities.
(c) Funding.--[(3)] Notwithstanding any other provision of
law--
(1)[(A)] the Secretary of Housing and Urban
Development [Affairs] is authorized to transfer funds
appropriated under the Native American Housing
Assistance and Self-Determination [Community
Development] Act of 1996 [1974 (42 U.S.C. 5301 et
seq.)] to the Secretary of Health and Human Services;[,
and]
(2)[(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); [2004a of Title 42.]
(3) unless specifically authorized when funds are
appropriated, the Secretary shall not use funds
appropriated under section 7 of the Act of August 5,
1954 (42 U.S.C. 2004a), to provide sanitation
facilities to new homes constructed using funds
provided by the Department of Housing and Urban
Development;
(4) the Secretary of Health and Human Services is
authorized to accept from any source, including Federal
and State agencies, funds for the purposes of providing
sanitation facilities and services and place these
funds into contracts or compacts under the Indian Self-
Determination and Education Act (25 U.S.C. 450 et
seq.);
(5) except as otherwise prohibited by this section,
the Secretary may use funds appropriated under the
authority of section 7 of the Act of August 5, 1954 (42
U.S.C. 2004a) to fund up to 100 percent of the amount
of an Indian Tribe's loan obtained under any Federal
program for new projects to construct eligible
sanitation facilities to serve Indian homes;
(6) except as otherwise prohibited by this section,
the Secretary may use funds appropriated under the
authority of section 7 of the Act of August 5, 1954 (42
U.S.C. 2004a) to meet matching or cost participation
requirements under other Federal and non-Federal
programs for new projects to construct eligible
sanitation facilities;
(7) all Federal agencies are authorized to transfer
to the Secretary funds identified, granted, loaned, or
appropriated whereby the Department's applicable
policies, rules, and regulations shall apply in the
implementation of such projects;
(8) the Secretary of Health and Human Services shall
enter into interagency agreements with Federal and
State agencies for the purpose of providing financial
assistance for sanitation facilities and services under
this Act; and
(9) the Secretary of Health and Human Services shall,
by regulation developed through rulemaking under
section 802, establish standards applicable to the
planning, design, and construction of sanitation
facilities funded under this Act.
[(c) 10-Year Plan]
[Beginning in fiscal 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) Certain Capabilities Not Prerequisite._[Tribal
capability]
The financial and technical capability of an Indian
[t]Tribe, Tribal Organization, or Indian community to safely
operate, manage, and maintain a sanitation facility shall not
be a prerequisite to the provision or construction of
sanitation facilities by the Secretary.
(e) Financial [Amount of a]Assistance.--
[(1)] The Secretary is authorized to provide
financial assistance to Indian [t]Tribes, Tribal
Organizations and Indian communities for operation,
management, and maintenance of their sanitation
facilities. [in an amount equal to the Federal share of
the costs of operating, managing, and maintaining the
facilities provided under the plan described in
subsection (c) of this section.]
[(2) For the purposes of paragraph (1), the term
``Federal share'' means 80 percent of the costs
described in paragraph (1).]
[(3) With respect to Indian tribes with fewer than
1,000 enrolled members, the non-Federal portion of the
costs of operating, managing, and maintaining such
facilities may be provided, in part, through cash
donations or in kind property, fairly evaluated.]
(f) Operation, Management, and Maintenance of Facilities.--
The Indian Tribe has the primary responsibility to establish,
collect, and use reasonable user fees, or otherwise set aside
funding, for the purpose of operating, managing, and
maintaining sanitation facilities. If a sanitation facility
serving a community that is operated by an Indian Tribe or
Tribal Organization is threatened with imminent failure and
such operator lacks capacity to maintain the integrity or the
health benefits of the sanitation facility, then the Secretary
is authorized to assist the Indian Tribe, Tribal Organization,
or Indian community in the resolution of the problem on a
short-term basis through cooperation with the emergency
coordinator or by providing operation, management, and
maintenance service.
(g) ISDEAA Program Funded on Equal Basis.--Tribal Health
Programs shall be eligible (on an equal basis with programs
that are administered directly by the Service) for--
(1) any funds appropriated pursuant to this section;
and
(2) any funds appropriated for the purpose of
providing sanitation facilities.
[(f) Eligibility of programs administered by Indian tribes]
[Programs administered by Indian tribes or tribal
organizations under the authority of the Indian Self-
Determination Act [25 U.S.C.A. Sec. 450f et seq.] shall be
eligible for--]
[(1) any funds appropriated pursuant to this section,
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.]
(h) Report.--[(g) Annual report; sanitation deficiency
levels]
(1) Required; contents.--The Secretary, in
consultation with the Secretary of Housing and Urban
Development, Indian Tribes, Tribal Organizations, and
tribally designated housing entities (as defined in
section 4 of the Native American Housing Assistance and
Self-Determination Act of 1996 (25 U.S.C. 4103)) shall
submit to the President, for inclusion in [each] the
report required to be transmitted to [the] Congress
under section 801[1671 of this title], a report which
sets forth--
(A) the current Indian sanitation facility
priority system of the Service;
(B) the methodology for determining
sanitation deficiencies and needs;
(C) the level of initial and final sanitation
deficiency for each type of sanitation facility
[facilities] for each type of project of each
Indian [t]Tribe or Indian community;
(D) the amount and most effective use of
funds, derived from whatever source, necessary
to accommodate the sanitation facilities needs
of new homes assisted with funds under the
Native American Housing Assistance and Self-
Determination Act, and to reduce the identified
sanitation deficiency levels of [raise] all
Indian [t]Tribes and Indian communities to [a]
level I sanitation deficiency as defined in
paragraph (4)(A); and
(E) a 10-year plan to provide sanitation
facilities to serve existing Indian homes and
Indian communities and new and renovated Indian
homes. [the amount of funds necessary to raise
all Indian tribes and communities to zero
sanitation deficiency.]
(2) Criteria.--The criteria on which the deficiencies and
needs will be evaluated shall be developed through negotiated
rulemaking pursuant to section 802.
[(2) In preparing each report required under
paragraph (1) (other than the initial report), the
Secretary shall consult with Indian tribes and tribal
organizations (including those tribes or tribal
organizations operating health care programs or
facilities under any contract entered into with the
Service under the Indian Self-Determination Act [25
U.S.C.A. Sec. 450f et seq.]) to determine the
sanitation needs of each tribe.]
(3) Uniform methodology.--The methodology used by the
Secretary in determining, preparing cost estimates for,
and reporting sanitation deficiencies for purposes of
paragraph (1) shall be applied uniformly to all Indian
[t]Tribes and Indian communities.
(4) Sanitation deficiency levels.--For purposes of
this subsection, the sanitation deficiency levels for
an individual, Indian [t]Tribe or Indian community
sanitation facility to serve Indian homes are
determined as follows:
(A) A level I deficiency exists if a
sanitation facility serving [is] an individual,
Indian [t]Tribe or Indian community [with a
sanitation system]--
(i) [which] complies with all
applicable water supply, [and]
pollution control, and solid waste
disposal laws[,]; and
(ii) [in which the] deficiencies
relate to routine replacement, repair,
or maintenance needs[;].
(B) A level II deficiency exists if a
sanitation facility serving an individual, [is
an] Indian [t]Tribe, or Indian community
substantially or recently complied with all
applicable water supply, pollution control, and
solid waste laws and any deficiencies relate to
[with a sanitation system]--
(i) small or minor capital
improvements needed to bring the
facility back into compliance; [which
complies with all applicable water
supply and pollution control laws, and]
(ii) [in which the deficiencies
relate to] capital improvements that
are necessary to enlarge or improve the
facilities in order to meet the current
needs [of such tribe or community] for
domestic sanitation facilities; or
(iii) the lack of equipment or
training by an Indian Tribe, Tribal
Organization, or an Indian community to
properly operate and maintain the
sanitation facilities.
(C) A level III deficiency exists if a
sanitation facility serving an individual, [is
an] Indian [t]Tribe or Indian community meets
one or more of the following conditions [with a
sanitation system which]--
(i) water or sewer service in the
home is provided by a haul system with
holding tanks and interior plumbing;
[has an inadequate or partial water
supply and a sewage disposal facility
that does not comply with applicable
water supply and pollution control
laws, or]
(ii) major significant interruptions
to water supply or sewage disposal
occur frequently, requiring major
capital improvements to correct the
deficiencies; or [has no solid waste
disposal facility;]
(iii) there is no access to or no
approved or permitted solid waste
facility available.
(D) A level iv deficiency exists.--[(IV) is
an Indian tribe or community with a sanitary
system which lacks either a safe water supply
system or a sewage disposal system: and]
(i) if a sanitation facility of an
individual home, an Indian Tribe, or an
Indian community exists but--
(I) lacks--
(aa) a safe water
supply system; or
(bb) a waste disposal
system;
(II) contains no piped water
or sewer facilities; or
(III) has become inoperable
due to a major component
failure; or
(ii) if only a washeteria or central
facility exists in the community.
(E) A level V deficiency exists in the
absence of a sanitation facility, where
individual homes do not have access to safe
drinking water or adequate wastewater
(including sewage) disposal. [(V) is an Indian
tribe or community that lacks a safe water
supply and a sewage disposal system.]
(i) Definitions.--For purposes of this section, the
following terms apply:
(1) Indian community.--The term `Indian community'
means a geographic area, a significant proportion of
whose inhabitants are Indians and which is served by or
capable of being served by a facility described in this
section.
(2) Sanitation facilities.--The terms `sanitation
facility' and `sanitation facilities' mean safe and
adequate water supply systems, sanitary sewage disposal
systems, and sanitary solid waste systems (and all
related equipment and support infrastructure).
[(5) For purposes of this subsection, any Indian
tribe or community 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.]
Sec. 1633. Preference to Indians and Indian firms
(a) Buy Indian Act._[Discretionary authority; covered
activities]
The Secretary, acting through the Service, may use
[utilize] the negotiating authority of section 23 [47] of the
Act of June 25, 1910 (25 U.S.C. 47, commonly known as the `Buy
Indian Act') [this title], to give preference to any Indian or
any enterprise, partnership, corporation, or other type of
business organization owned and controlled by an Indian or
Indians including former or currently federally recognized
Indian [t]Tribes in the State of New York (hereinafter referred
to as an [``] `Indian firm' ['']) in the construction and
renovation of Service facilities pursuant to section 301 [1631
of this title] and in the construction of sanitation [safe
water and sanitary waste disposal] facilities pursuant to
section 302 [1632 of this title]. Such preference may be
accorded by the Secretary unless the Secretary [he] finds,
pursuant to [rules and] regulations [promulgated] adopted
pursuant to section 802 [by him], that the project or function
to be contracted for will not be satisfactory or such project
or function cannot be properly completed or maintained under
the proposed contract. The Secretary, in arriving at such a
[his] finding, shall consider whether the Indian or Indian firm
will be deficient with respect to--
(1) ownership and control by Indians[,];
(2) equipment[,];
(3) bookkeeping and accounting procedures[,];
(4) substantive knowledge of the project or function
to be contracted for[,];
(5) adequately trained personnel[,]; or
(6) other necessary components of contract
performance.
(b) Labor Standards._[Pay rates]
(1) In general.--For the purpose of implementing the
provisions of this title [subchapter], contracts for
the construction or renovation of health care
facilities, staff quarters, and sanitation facilities,
and related support infrastructure, funded in whole or
in part with funds made available pursuant to this
title, shall contain a provision requiring compliance
with subchapter IV of chapter 31 of title 40, United
States Code (commonly known as the `Davis-Bacon Act'),
unless such construction or renovation--[the secretary
shall assure that the rates of pay for personnel
engaged in the construction or renovation of facilities
constructed or renovated in whole or in part by funds
made available pursuant to this subchapter are not less
than the prevailing local wage rates for similar work
as determined in accordance with sections 3141 to 3144,
3146, 3147 of Title 40.]
(A) is performed by a contractor pursuant to
a contract with an Indian Tribe or Tribal
Organization with funds supplied through a
contract or compact authorized by the Indian
Self-Determination and Education Assistance Act
(25 U.S.C. 450 et seq.), or other statutory
authority; and
(B) is subject to prevailing wage rates for
similar construction or renovation in the
locality as determined by the Indian Tribes or
Tribal Organizations to be served by the
construction or renovation.
(2) Exception.--This subsection shall not apply to
construction or renovation carried out by an Indian
Tribe or Tribal Organization with its own employees.
Sec. 1634. Expenditure of [n]Non[-S]service [f]Funds for [r]Renovation
(a) In General.--[Authority of Secretary] [(1)]
Notwithstanding any other provision of law, if the requirements
of subsection (c) are met, the Secretary, acting through the
Service, is authorized to accept any major expansion,
renovation or modernization by any Indian [t]Tribe or Tribal
Organization of any Service facility or of any other Indian
health facility operated pursuant to a contract or compact
[entered into] under the Indian Self-Determination Act and
Education Assistance Act (25 U.S.C. 450 et seq.), [25 U.S.C.A.
Sec. 450f et seq.] including--
(1)[(A)] any plans or designs for such expansion,
renovation or modernization; and
(2)[(B)] any expansion, renovation or modernization
for which funds appropriated under any Federal law were
lawfully expended. [, but only if the requirements of
subsection (b) of this section are met.]
(b) Priority List._
(1)[(2)] In general.--The Secretary shall maintain a
separate priority list to address the needs for
increased operating expenses, [of such facilities for]
personnel, or equipment for such facilities. The
methodology for establishing priorities shall be
developed through negotiated rulemaking under section
802. The list of priority facilities will be revised
annually in consultation with Indian Tribes and Tribal
Organizations.
(2)[(3)] Report.--The Secretary shall submit to the
President, for inclusion in [each] the report required
to be transmitted to [the] Congress under section 801
[1671 of this section], the priority list maintained
pursuant to paragraph (1)[(2)].
(c)[(b)] Requirements--The requirements of this subsection
are met with respect to any expansion, renovation or
modernization if--
(1) the Indian T[t]ribe or [t]Tribal
[o]Organization--
(A) provides notice to the Secretary of its
intent to expand, renovate or modernize; and
(B) applies to the Secretary to be placed on
a separate priority list to address the needs
of such new facilities for increased operating
expenses, personnel or equipment; and
(2) the expansion, renovation or modernization--
(A) is approved by the appropriate area
director of the Service for Federal facilities;
and
(B) is administered by the Indian T[t]ribe or
Tribal Organization in accordance with any
applicable [the rules and] regulations
prescribed by the Secretary with respect to
construction or renovation of Service
facilities.
(d) Additional Requirement for Expansion.--In addition to
the requirements in subsection (c), for any expansion, the
Indian Tribe or Tribal Organization shall provide to the
Secretary additional information developed through negotiated
rulemaking under section 802, including additional staffing,
equipment, and other costs associated with the expansion.
(e) Closure or Conversion of Facilities._[(c) Recovery for
non-use as Service facility]
If any Service facility which has been expanded, renovated
or modernized by an Indian [t]Tribe or Tribal Organization
under this section ceases to be used as a Service facility
during the 20-year period beginning on the date such expansion,
renovation or modernization is completed, such Indian [t]Tribe
or Tribal Organization 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 expansion, renovation or modernization (less the total
amount of any funds provided specifically for such facility
under any Federal program that were expended for such
expansion, renovation or modernization) bore to the value of
such facility at the time of the completion of such expansion,
renovation or modernization.
[Sec. 1635. Repealed. Pub. L. 100-713, Title III, Sec. 303(b), Nov. 23,
1988, 102 Stat. 4817]
Sec. 1636. Funding [Grant program] for the [c]Construction,
[e]Expansion, and [m]Modernization of [s]Small
[a]Ambulatory [c]Care [f]Facilities
(a) Funding._[Authorization]
(1) In general.--The Secretary, acting through the
Service, shall make grants to Indian T[t]ribes and
[t]Tribal [o]Organizations for the construction,
expansion, or modernization of facilities for the
provision of ambulatory care services to eligible
Indians (and noneligible persons pursuant to
subsections (b)(2) and (c)(1)(C) [as provided in
subsection (c)(1)(C) of this section)]. A grant made
under this section may cover up to 100 percent of the
costs of such construction, expansion, or
modernization. For the purposes of this section, the
term [``]`construction'[''] includes the replacement of
an existing facility.
(2) Grant agreement required._A grant under paragraph
(1) may only be available [made] to a Tribal Health
Program [tribe or tribal organization] operating an
Indian health facility (other than a facility owned or
constructed by the Service, including a facility
originally owned or constructed by the Service and
transferred to a Indian T[t]ribe or [t]Tribal
[o]Organization) [pursuant to a contract entered into
under the Indian Self-Determination Act [25 U.S.C.A.
Sec. 450f et seq.]].
(b) Use of [g] Grant Funds
(1) Allowable uses._A grant provided under this
section may be used [only] for the construction,
expansion, or modernization (including the planning and
design of such construction, expansion, or
modernization) of an ambulatory care facility--
(A) located apart from a hospital;
(B) not funded under section 301[1631] or
section 307[1637 of this title]; and
(C) which, upon completion of such
construction, expansion, or modernization
will--
(i) have a total capacity appropriate
to its projected service population;
(ii) provide annually no fewer than
150 patient visits by eligible Indians
and other users who are eligible for
services in such facility in accordance
with section 807(c)(2) [serve no less
than 500 eligible Indians annually];
and
(iii) provide ambulatory care in a
[s]Service [a]Area (specified in the
contract or compact [entered into]
under the Indian Self-Determination and
Education Assistance Act (25 U.S.C. 450
et seq.)[25 U.S.C.A. Sec. 450f et
seq.]]) with a population of no fewer
than 1,500 [not less than 2,000]
eligible Indians and other users who
are eligible for services in such
facility in accordance with section
807(c)(2).
(2) Additional allowable use.--The Secretary may also
reserve a portion of the funding provided under this
section and use those reserved funds to reduce an
outstanding debt incurred by Indian Tribes or Tribal
Organizations for the construction, expansion, or
modernization of an ambulatory care facility that meets
the requirements under paragraph (1). The provisions of
this section shall apply, except that such applications
for funding under this paragraph shall be considered
separately from applications for funding under
paragraph (1).
(3) Use only for certain portion of costs.--A grant
provided under this section may be used only for the
cost of that portion of a construction, expansion, or
modernization project that benefits the Service
population identified above in subsection (b)(1)(C)(ii)
and (iii). [(2)] The requirements of clauses (ii) and
(iii) of paragraph (1)(C) shall not apply to an Indian
Tribe [a tribe] or [t]Tribal [o]Organization applying
for a grant under this section for a health care
facility [whose tribal government offices are] located
or to be constructed on an island or when such facility
is not located on a road system providing direct access
to an inpatient hospital where care is available to the
Service population.
(c) [Application for g]Grants.--
(1) Application._No grant may be made available under
this section unless an application or proposal for
[the] a grant has been [submitted to and] approved by
the Secretary in accordance with applicable regulations
and has forth reasonable assurance by the applicant
that, at all times after the construction, expansion,
or modernization of a facility carried out pursuant to
funding received under this section--[. An application
for a grant under this section shall be submitted in
such form and manner as the Secretary shall by
regulation prescribe and shall set forth reasonable
assurance by the applicant that, at all times after the
construction, expansion, or modernization of a facility
carried out pursuant to a grant received under this
section--]
(A) adequate financial support will be
available for the provision of services at such
facility;
(B) such facility will be available to
eligible Indians without regard to ability to
pay or source of payment; and
(C) such facility will, as feasible without
diminishing the quality or quantity of services
provided to eligible Indians, serve noneligible
persons on a cost basis.
(2) Priority.--In awarding grants under this section,
the Secretary shall give priority to Indian T[t]ribes
and [t]Tribal [o]Organizations that demonstrate--
(A) a need for increased ambulatory care
services; and
(B) insufficient capacity to deliver such
services.
(3) Peer review panels.--The Secretary may provide
for the establishment of peer review panels, as
necessary, to review and evaluate applications and
proposals and to advise the Secretary regarding such
applications using the criteria developed during
consultations pursuant to subsection (a)(1).
(d) Reversion of Facilities._[Transfer of interest to
United States upon cessation of facility] If any facility (or
portion thereof) with respect to which funds have been paid
under this section, ceases, within 5 years [at any time] after
completion of the construction, expansion, or modernization
carried out with such funds, to be used [utilized] for the
purposes of providing health [ambulatory] care services to
eligible Indians, all of the right, title, and interest in and
to such facility (or portion thereof) shall transfer to the
United States unless otherwise negotiated by the Service and
the Indian Tribe or Tribal Organization.
(e) Funding Nonrecurring.--Funding provided under this
section shall be nonrecurring and shall not be available for
inclusion in any individual Indian Tribe's tribal share for an
award under the Indian Self-Determination and Education
Assistance Act (25 U.S.C. 450 et seq.) or for reallocation or
redesign thereunder.
Sec. 1637. Indian [h]Health [c]Care [d]Delivery [d]Demonstration
[p]Project
(a) Health [c]Care [delivery d]Demonstration [p]Projects.--
The Secretary, acting through the Service, and in consultation
with Indian Tribes and Tribal Organizations, is authorized to
enter into construction agreements under the Indian Self-
Determination and Education Assistance Act (25 U.S.C. 450 et
seq.) with[, or make grants to,] Indian [t]Tribes or [t]Tribal
[o]Organizations for the purpose of carrying out a health care
delivery demonstration project to test alternative means of
delivering health care and services through [health] facilities
[to Indians].
(b) Use of [f]Funds.--The Secretary, in approving projects
pursuant to this section, may authorize funding for the
construction and renovation of hospitals, health centers,
health stations, and other facilities to deliver health care
services and is authorized to--
(1) waive any leasing prohibition;
(2) permit carryover of funds appropriated for the
provision of health care services;
(3) permit the use of other available [non-Service
Federal funds and non-Federal] funds;
(4) permit the use of funds or property donated from
any source for project purposes; [and]
(5) provide for the reversion of donated real or
personal property to the donor[.]; and
(6) permit the use of Service funds to match other
funds, including Federal funds.
(c) Regulations._Criteria]
[(1) Within 180 days after November 28, 1990, t]The
Secretary[, after consultation with Indian tribes and
tribal organizations,] shall develop and promulgate
regulations not later than 1 year after the enactment
of the Indian Health Care Improvement Act Amendments of
2005. If the Secretary has not promulgated regulations
by that date, the Secretary shall develop and publish
regulations, through rulemaking under 802, [in the
Federal Register criteria] for the review and approval
of applications submitted under this section.
(d) Criteria._The Secretary may approve [enter into a
contract or award a grant under this section for] projects that
[which] meet the following criteria:
(1)[(A)] There is a need for a new facility or
program or the reorientation of an existing facility or
program.
(2)[(B)] A significant number of Indians, including
those with low health status, will be served by the
project.
[(C) The project has the potential to address the
health needs of Indians in an innovative manner.]
(3)[(D)] The project has the potential to deliver
services in an efficient and effective manner.
(4)[(E)] The project is economically viable.
(5)[(F)] The Indian [t]Tribe or [t]Tribal
[o]Organization has the administrative and financial
capability to administer the project.
(6)[(G)] The project is integrated with providers of
related health and social services and is coordinated
with, and avoids duplication of, existing services.
(e) Peer Review Panels._[(2)] The Secretary may provide for
the establishment of peer review panels, as necessary, to
review and evaluate applications [and to advise the Secretary
regarding such applications] using the criteria developed
pursuant to subsection (d) [paragraph (1)].
(f) Priority._The Secretary shall give priority to
applications for demonstration projects [(3)(A) On or before
September 30, 1995, the Secretary shall enter into contracts or
award grants under this section for a demonstration project] in
each of the following [s]Service [u]Units to the extent that
such applications are timely filed and meet the criteria
specified in subsection (d): [which meets the criteria
specified in paragraph (1) and for which a completed
application has been received by the Secretary:]
(1)[(i)] Cass Lake, Minnesota.
(2)[(ii)] Clinton, Oklahoma.
(3)[(iii)] Harlem, Montana.
(4)[(iv)] Mescalero, New Mexico.
(5)[(v)] Owyhee, Nevada.
(6)[(vi)] Parker, Arizona.
(7)[(vii)] Schurz, Nevada.
(8)[(viii)] Winnebago, Nebraska.
(9)[(ix)] Ft. Yuma, California.
[(B) The Secretary may also enter into
contracts or award grants under this section
taking into consideration applications received
under this section from all service areas. The
Secretary may not award a greater number of
such contracts or grants in one service area
than in any other service area until there is
an equal number of such contracts or grants
awarded with respect to all service areas from
which the Secretary receives applications
during the application period (as determined by
the Secretary) which meet the criteria
specified in paragraph (1).]
(g)[(d)] Technical [a]Assistance.--The Secretary shall
provide such technical and other assistance as may be necessary
to enable applicants to comply with the provisions of this
section.
(h)[(e)] Service to [i]Ineligible [p]Persons.--Subject to
section 807, [T]the authority to provide services to persons
otherwise ineligible for the health care benefits of the
Service and the authority to extend hospital privileges in
[s]Service facilities to non-Service health care practitioners
as provided in section 807[1680c of this title] may be
included, subject to the terms of such section, in any
demonstration project approved pursuant to this section.
(i)[(f)] Equitable [t]Treatment.--For purposes of
subsection (d)(1)[(c)(1)(A) of this section], the Secretary
shall, in evaluating facilities operated under any contract or
compact entered into with the Service under the Indian Self-
Determination and Education Assistance Act (25 U.S.C. 450 et
seq.) [25 U.S.C.A. Sec. 450f et seq.], use the same criteria
that the Secretary uses in evaluating facilities operated
directly by the Service.
(j)[(g)] Equitable [i]Integration of [f]Facilities.--The
Secretary shall ensure that the planning, design, construction,
[and] renovation, and expansion needs of Service and non-
Service facilities which are the subject of a contract or
compact [entered into with the Service] under the Indian Self-
Determination and Education Assistance Act (25 U.S.C. 450 et
seq.) (25 U.S.C. 450 et seq.) [25 U.S.C.A. 450f et seq.],] for
health services are fully and equitably integrated into the
implementation of the health care delivery demonstration
projects under this section.
[(h) Report to Congress]
[(1) The Secretary shall submit to the President, for
inclusion in the report which is required to be
submitted to the Congress under section 1671 of this
title for fiscal year 1997, an interim report on the
findings and conclusions derived from the demonstration
projects established under this section.]
[(2) The Secretary shall submit to the President, for
inclusion in the report which is required to be
submitted to the Congress under section 1671 of this
title for fiscal year 1999, a final report on the
findings and conclusions derived from the demonstration
projects established under this section, together with
legislative recommendations.]
Sec. 1638. Land [t]Transfer
Notwithstanding any other provision of law, [T]the Bureau
of Indian Affairs and all other agencies and departments of the
United States are [is] authorized to transfer, at no cost, land
and improvements to the Service for the provision of health
care services. The Secretary is authorized to accept such land
and improvements for such purposes. [up to 5 acres of land at
the Chemawa Indian School, Salem, Oregon, to the Service for
the provision of health care services. The land authorized to
be transferred by this section is that land adjacent to land
under the jurisdiction of the Service and occupied by the
Chemawa Indian Health Center.]
Sec. 308. Leases, contracts, and other agreements
The Secretary, acting through the Service, may enter into
leases, contracts, and other agreements with Indian Tribes and
Tribal Organization which hold (1) title to, (2) a leasehold
interest in, or (3) a beneficial interest in (when title is
held by the United States in trust for the benefit of an Indian
Tribe) facilities used or to be used for the administration and
delivery of health services by an Indian Health Program. Such
leases, contracts, or agreements may include provisions for
construction or renovation and provide for compensation to the
Indian Tribe or Tribal Organization of rental and other costs
consistent with section 105(l) of the Indian Self-Determination
and Education Assistance Act (25 U.S.C. 450j(l)) and
regulations thereunder.
Sec. 309. Study on loans, loan guarantees, and loan repayment
(a) In General.--The Secretary, in consultation with the
Secretary of the Treasury, Indian Tribes, and Tribal
Organizations, shall carry out a study to determine the
feasibility of establishing a loan fund to provide to Indian
Tribes and Tribal Organizations direct loans or guarantees for
loans for the construction of health care facilities,
including--
(1) inpatient facilities;
(2) outpatient facilities;
(3) staff quarters;
(4) hostels; and
(5) specialized care facilities, such as behavioral
health and elder care facilities.
(b) Determinations.--In carrying out the study under
subsection (a), the Secretary shall determine--
(1) the maximum principal amount of a loan or loan
guarantee that should be offered to a recipient from
the loan fund;
(2) the percentage of eligible costs, not to exceed
100 percent, that may be covered by a loan or loan
guarantee from the loan fund (including costs relating
to planning, design, financing, site land development,
construction, rehabilitation, renovation, conversion,
improvements, medical equipment and furnishings, and
other facility-related costs and capital purchase (but
excluding staffing));
(3) the cumulative total of the principal of direct
loans and loan guarantees, respectively, that may be
outstanding at any 1 time;
(4) the maximum term of a loan or loan guarantee that
may be made for a facility from the loan fund;
(5) the maximum percentage of funds from the loan
fund that should be allocated for payment of costs
associated with planning and applying for a loan or
loan guarantee;
(6) whether acceptance by the Secretary of an
assignment of the revenue of an Indian Tribe or Tribal
Organization as security for any direct loan or loan
guarantee from the loan fund would be appropriate;
(7) whether, in the planning and design of health
facilities under this section, users eligible under
section 807(c) may be included in any projection of
patient population;
(8) whether funds of the Service provided through
loans or loan guarantees from the loan fund should be
eligible for use in matching other Federal funds under
other programs;
(9) the appropriateness of, and best methods for,
coordinating the loan fund with the health care
priority system of the Service under section 301; and
(10) any legislative or regulatory changes required
to implement recommendations of the Secretary based on
results of the study.
(c) Report.--Not later than September 30, 2007, the
Secretary shall submit to the Committee on Indian Affairs of
the Senate and the Committee on Resources and the Committee on
Energy and Commerce of the House of Representatives a report
that describes--
(1) the manner of consultation made as required by
subsection (a); and
(2) the results of the study, including any
recommendations of the Secretary based on results of
the study.
Sec. 310. Tribal leasing
A Tribal Health Program may lease permanent structures for
the purpose of providing health care services without obtaining
advance approval in appropriation Acts.
Sec. 311. Indian health service/tribal facilities joint venture program
(a) In General.--The Secretary, acting through the Service,
shall make arrangements with Indian Tribes and Tribal
Organizations to establish joint venture demonstration projects
under which an Indian Tribe or Tribal Organization shall expend
tribal, private, or other available funds, for the acquisition
or construction of a health facility for a minimum of 10 years,
under a no-cost lease, in exchange for agreement by the Service
to provide the equipment, supplies, and staffing for the
operation and maintenance of such a health facility. An Indian
Tribe or Tribal Organization may use tribal funds, private
sector, or other available resources, including loan
guarantees, to fulfill its commitment under a joint venture
entered into under this subsection. An Indian Tribe or Tribal
Organization shall be eligible to establish a joint venture
project if, when it submits a letter of intent, it--
(1) has begun but not completed the process of
acquisition or construction of a health facility to be
used in the joint venture project; or
(2) has not begun the process of acquisition or
construction of a health facility for use in the joint
venture project.
(b) Requirements.--The Secretary shall make such an
arrangement with an Indian Tribe or Tribal Organization only
if--
(1) the Secretary first determines that the Indian
Tribe or Tribal Organization has the administrative and
financial capabilities necessary to complete the timely
acquisition or construction of the relevant health
facility; and
(2) the Indian Tribe or Tribal Organization meets the
need criteria which shall be developed through the
negotiated rulemaking process provided for under
section 802.
(c) Continued Operation.--The Secretary shall negotiate an
agreement with the Indian Tribe or Tribal Organization
regarding the continued operation of the facility at the end of
the initial 10 year no-cost lease period.
(d) Breach of Agreement.--An Indian Tribe or Tribal
Organization that has entered into a written agreement with the
Secretary under this section, and that breaches or terminates
without cause such agreement, shall be liable to the United
States for the amount that has been paid to the Indian Tribe or
Tribal Organization, or paid to a third party on the Indian
Tribe's or Tribal Organization's behalf, under the agreement.
The Secretary has the right to recover tangible property
(including supplies) and equipment, less depreciation, and any
funds expended for operations and maintenance under this
section. The preceding sentence does not apply to any funds
expended for the delivery of health care services, personnel,
or staffing.
(e) Recovery for Nonuse.--An Indian Tribe or Tribal
Organization that has entered into a written agreement with the
Secretary under this subsection shall be entitled to recover
from the United States an amount that is proportional to the
value of such facility if, at any time within the 10-year term
of the agreement, the Service ceases to use the facility or
otherwise breaches the agreement.
(f) Definition.--For the purposes of this section, the term
`health facility' or `health facilities' includes quarters
needed to provide housing for staff of the relevant Tribal
Health Program.
Sec. 312. Location of facilities
(a) In General.--In all matters involving the
reorganization or development of Service facilities or in the
establishment of related employment projects to address
unemployment conditions in economically depressed areas, the
Bureau of Indian Affairs and the Service shall give priority to
locating such facilities and projects on Indian lands, or lands
owned by any Alaska Native village, or village or regional
corporation under the Alaska Native Claims Settlement Act, or
any lands allotted to any Alaska Native, if requested by the
Indian owner and the Indian Tribe with jurisdiction over such
lands or other lands owned or leased by the Indian Tribe or
Tribal Organization. Top priority shall be given to Indian land
owned by 1 or more Indian Tribes.
(b) Definition.--For purposes of this section, the term
`Indian lands' means--
(1) all lands within the exterior boundaries of any
reservation;
(2) any lands title to which is held in trust by the
United States for the benefit of any Indian Tribe or
individual Indian or held by any Indian Tribe or
individual Indian subject to restriction by the United
States against alienation.
Sec. 313. Maintenance and improvement of health care facilities
(a) Report.--The Secretary shall submit to the President,
for inclusion in the report required to be transmitted to
Congress under section 801, a report which identifies the
backlog of maintenance and repair work required at both Service
and tribal health care facilities, including new health care
facilities expected to be in operation in the next fiscal year.
The report shall also identify the need for renovation and
expansion of existing facilities to support the growth of
health care programs.
(b) Maintenance of Newly Constructed Space.--The Secretary,
acting through the Service, is authorized to expend maintenance
and improvement funds to support maintenance of newly
constructed space only if such space falls within the approved
supportable space allocation for the Indian Tribe or Tribal
Organization. Supportable space allocation shall be defined
through the negotiated rulemaking process provided for under
section 802.
(c) Replacement Facilities.--In addition to using
maintenance and improvement funds for renovation,
modernization, and expansion of facilities, an Indian Tribe or
Tribal Organization may use maintenance and improvement funds
for construction of a replacement facility if the costs of
renovation of such facility would exceed a maximum renovation
cost threshold. The maximum renovation cost threshold shall be
determined through the negotiated rulemaking process provided
for under section 802.
Sec. 314. Tribal management of federally owned quarters
(a) Rental Rates.--
(1) Establishment.--Notwithstanding any other
provision of law, a Tribal Health Program which
operates a hospital or other health facility and the
federally owned quarters associated therewith pursuant
to a contract or compact under the Indian Self-
Determination and Education Assistance Act (25 U.S.C.
450 et seq.) shall have the authority to establish the
rental rates charged to the occupants of such quarters
by providing notice to the Secretary of its election to
exercise such authority.
(2) Objectives.--In establishing rental rates
pursuant to authority of this subsection, a Tribal
Health Program shall endeavor to achieve the following
objections:
(A) To base such rental rates on the
reasonable value of the quarters to the
occupants thereof.
(B) To generate sufficient funds to prudently
provide for the operation and maintenance of
the quarters, and subject to the discretion of
the Tribal Health Program, to supply reserve
funds for capital repairs and replacement of
the quarters.
(3) Equitable funding.--Any quarters whose rental
rates are established by a Tribal Health Program
pursuant to this subsection shall remain eligible for
quarters improvement and repair funds to the same
extent as all federally owned quarters used to house
personnel in Services-supported programs.
(4) Notice of rate change.--A Tribal Health Program
which exercises the authority provided under this
subsection shall provide occupants with no less than 60
days notice of any change in rental rates.
(b) Direct Collection of Rent.--
(1) In general.--Notwithstanding any other provision
of law, and subject to paragraph (2), a Tribal Health
Program shall have the authority to collect rents
directly from Federal employees who occupy such
quarters in accordance with the following:
(A) The Tribal Health Program shall notify
the Secretary and the subject Federal employees
of its election to exercise its authority to
collect rents directly from such Federal
employees.
(B) Upon receipt of a notice described in
subparagraph (A), the Federal employees shall
pay rents for occupancy of such quarters
directly to the Tribal Health Program and the
Secretary shall have no further authority to
collect rents from such employees through
payroll deduction or otherwise.
(C) Such rent payments shall be retained by
the Tribal Health Program and shall not be made
payable to or otherwise be deposited with the
United States.
(D) Such rent payments shall be deposited
into a separate account which shall be used by
the Tribal Health Program for the maintenance
(including capital repairs and replacement) and
operation of the quarters and facilities as the
Tribal Health Program shall determine.
(2) Retrocession of authority.--If a Tribal Health
Program which has made an election under paragraph (1)
requests retrocession of its authority to directly
collect rents from Federal employees occupying
federally owned quarters, such retrocession shall
become effective on the earlier of--
(A) the first day of the month that begins no
less than 180 days after the Tribal Health
Program notifies the Secretary of its desire to
retrocede; or
(B) such other date as may be mutually agreed
by the Secretary and the Tribal Health Program.
(c) Rates in Alaska.--To the extent that a Tribal Health
Program, pursuant to authority granted in subsection (a),
establishes rental rates for federally owned quarters provided
to a Federal employee in Alaska, such rents may be based on the
cost of comparable private rental housing in the nearest
established community with a year-round population of 1,500 or
more individuals.
[Sec. 1638a. Authorization of appropriations]
[There are authorized to be appropriated such sums as may
be necessary for each fiscal year through fiscal year 2000 to
carry out this subchapter.]
Sec. 1638b. Applicability of Buy American Act Rr]equirement
(a) Applicability.--[Duty of Secretary]
The Secretary shall ensure that the requirements of the Buy
American Act [[41 U.S.C.A. Sec. 10a et seq.]] apply to all
procurements made with funds provided pursuant to [the
authorization contained in] section 317[1638a of this title].
Indian Tribes and Tribal Organizations shall be exempt from
these requirements.
[(b) Report to Congress]
[The Secretary shall submit to the Congress a report on the
amount of procurements from foreign entities made in fiscal
years 1993 and 1994 with funds provided pursuant to the
authorization contained in section 1638a of this title. Such
report shall separately indicate the dollar value of items
procured with such funds for which the Buy American Act [41
U.S.C.A. Sec. 10a et seq.] was waived pursuant to the Trade
Agreement Act of 1979 [19 U.S.C.A. Sec. 2501 et seq.] or any
international agreement to which the United States is a party.]
(b)[(c)] Effect of Violation.--[Fraudulent use of Made-in-
America label] If it has been finally determined by a court or
Federal agency that any person intentionally affixed a label
bearing a [``]`Made in America'[''] inscription[,] or any
inscription with the same meaning, to any product sold in or
shipped to the United States that is not made in the United
States, such person shall be ineligible to receive any contract
or subcontract made with funds provided pursuant to [the
authorization contained in] section 317 [1638a of this title],
pursuant to the debarment, suspension, and ineligibility
procedures described in sections 9.400 through 9.409 of title
48, Code of Federal Regulations.
(c)[(d)] Definitions._[``Buy American Act'' defined] For
purposes of this section, the term [``]`Buy American Act'['']
means title III of the Act entitled ``An Act making
appropriations for the Treasury and Post Office Departments for
the fiscal year ending June 30, 1934, and for other purposes'',
approved March 3, 1933 (41 U.S.C. 10a et seq.).
Sec. 316. Other funding for facilities
(a) Authority to Accept Funds.--The Secretary is authorized
to accept from any source, including Federal and State
agencies, funds that are available for the construction of
health care facilities and use such funds to plan, design, and
construct health care facilities for Indians and to place such
funds into a contract or compact under the Indian Self-
Determination and Education Assistance Act (25 U.S.C. 450 et
seq.). Receipt of such funds shall have no effect on the
priorities established pursuant to section 301.
(b) Interagency Agreements.--The Secretary is authorized to
enter into interagency agreements with other Federal agencies
or State agencies and other entities and to accept funds from
such Federal or State agencies or other sources to provide for
the planning, design, and construction of health care
facilities to be administered by Indian Health Programs in
order to carry out the purposes of this Act and the purposes
for which the funds were appropriated or for which the funds
were otherwise provided.
(c) Transferred Funds.--Any Federal agency to which funds
for the construction of health care facilities are appropriated
is authorized to transfer such funds to the Secretary for the
construction of health care facilities to carry out the
purposes of this Act as well as the purposes for which such
funds are appropriated to such other Federal agency.
(d) Establishment of Standards.--The Secretary, through the
Service, shall establish standards by regulation, developed by
rulemaking under section 802, for the planning, design, and
construction of health care facilities serving Indians under
this Act.
Sec. 317. Authorization of appropriations
There are authorized to be appropriated such sums as may be
necessary for each fiscal year through fiscal year 2015 to
carry out this title.
[Sec. 1638c. Contracts for personal services in Indian Health Service
facilities]
[In fiscal year 1995 and thereafter--]
[(a) In general]
[The Secretary may enter into personal services contracts
with entities, either individuals or organizations, for the
provision of services in facilities owned, operated or
constructed under the jurisdiction of the Indian Health
Service.]
[(b) Exemption from competitive contracting requirements]
[The Secretary may exempt such a contract from competitive
contracting requirements upon adequate notice of contracting
opportunities to individuals and organizations residing in the
geographic vicinity of the health facility.]
[(c) Consideration of individuals and organizations]
[Consideration of individuals and organizations shall be
based solely on the qualifications established for the contract
and the proposed contract price.]
[(d) Liability]
[Individuals providing health care services pursuant to
these contracts are covered by the Federal Tort Claims Act.]
[Sec. 1638d. Credit to appropriations of money collected for meals at
Indian Health Service facilities]
[Money before, on, and after September 30, 1994, collected
for meals served at Indian Health Service facilities will be
credited to the appropriations from which the services were
furnished and shall be credited to the appropriation when
received.]
TITLE IV [SUBCHAPTER III-A]--ACCESS TO HEALTH SERVICES
Sec. 1641. Treatment of [p]Payments [u]Under Social Security Act Health
Care [medicare] P[programs
(a) Disregard of Medicare, Medicaid, and SCHIP Payments in
Determining Appropriations [Determination of appropriations]
Any payments received by an Indian Health Program or by an
Urban Indian Organization made under title XVIII, XIX, or XXI
of the Social Security Act [a hospital or skilled nursing
facility of the Service (whether operated by the Service or by
an Indian tribe or tribal organization pursuant to a contract
under the Indian Self-Determination Act [25 U.S.C.A.Sec. 450f
et seq.])] for services provided to Indians eligible for
benefits under such respective titles [Title XVIII of the
Social Security Act [42 U.S.C.A. Sec. 1395 et seq.]] shall not
be considered in determining appropriations for the provision
of health care and services to Indians.
(b) Nonpreferential Treatment._[Preferences] Nothing in
this Act [chapter] authorizes the Secretary to provide services
to an Indian [beneficiary] with coverage under title XVIII,
XIX, or XXI of the Social Security Act [[42 U.S.C.A. Sec. 1395
et seq.], as amended,] in preference to an Indian [beneficiary]
without such coverage.
[Sec. 1642. Treatment of payments under medicaid program]
(c)[(a)] Use of Funds._[Payments to special fund]
(1) Special fund._Notwithstanding any other provision
of law, but subject to paragraph (2), payments to which
a[ny] facility of the Service [(including a hospital,
nursing facility, intermediate care facility for the
mentally retarded, or any other type of facility which
provides services for which payment is available under
Title XIX of the Social Security Act [42 U.S.C.A.
Sec. 1396 et seq.])] is entitled [under a State plan]
by reason of a provision of the Social Security Act
[section 1911 of such Act [42 U.S.C.A.Sec. 1396j]]
shall be placed in a special fund to be held by the
Secretary and first used [by him] (to such extent or in
such amounts as are provided in appropriation Acts)
[exclusively] for the purpose of making any
improvements in the programs [facilities] of the [such]
Service which may be necessary to achieve or maintain
compliance with the applicable conditions and
requirements of [such] titles XVIII, XIX, and XXI of
the Social Security Act. Any amounts to be reimbursed
that are in excess of the amount necessary to achieve
or maintain such conditions and requirements shall,
subject to the consultation with Indian Tribes being
served by the Service Unit, be used for reducing the
health resource deficiencies of the Indian Tribes. In
making payments from such fund, the Secretary shall
ensure that each [s]Service [u]Unit of the Service
receives 100 [at least 80] percent of the amount[s] to
which the facilities of the Service, for which such
[s]Service [u]Unit makes collections, are entitled by
reason of a provision [section 1911] of the Social
Security Act [[42 U.S.C.A. Sec. 1396j]].
(2) Direct payment option.--Paragraph (1) shall not
apply upon the election of a Tribal Health Program
under subsection (d) to receive payments directly. No
payment may be made out of the special fund described
in such paragraph with respect to reimbursement made
for services provided during the period of such
election.
(d) Direct Billing.--
(1) In general.--A Tribal Health Program may directly
bill for, and receive payment for, health care items
and services provided by such Indian Tribe or Tribal
organization for which payment is made under title
XVIII, XIX, or XXI of the Social Security Act or from
any other third party payor.
(2) Direct reimbursement.--
(A) Use of funds.--Each Tribal Health Program
exercising the option described in paragraph
(1) with respect to a program under a title of
the Social Security Act shall be reimbursed
directly by that program for items and services
furnished without regard to section 401(c), but
all amounts so reimbursed shall be used by the
Tribal Health Program for the purpose of making
any improvements in Tribal facilities or Tribal
Health Programs that may be necessary to
achieve or maintain compliance with the
conditions and requirements applicable
generally to such items and services under the
program under such title and to provide
additional health care services, improvements
in health care facilities and Tribal Health
Programs, any health care-related purpose, or
otherwise to achieve the objectives provided in
section 3 of this Act.
(B) Audits.--The amounts paid to an Indian
Tribe or Tribal Organization exercising the
option described in paragraph (1) with respect
to a program under a title of the Social
Security Act shall be subject to all auditing
requirements applicable to programs
administered by an Indian Health Program.
(C) Identification of source of payments.--If
an Indian Tribe or Tribal Organization receives
funding from the Service under the Indian Self-
Determination and Education Assistance Act (25
U.S.C. 450 et seq.) or an Urban Indian
Organization receives funding from the Service
under title V of this Act and receives
reimbursements or payments under title XVIII,
XIX, or XXI of the Social Security Act, such
Indian Tribe or Tribal Organization, or Urban
Indian Organization, shall provide to the
Service a list of each provider enrollment
number (or other identifier) under which it
receives such reimbursements or payments.
(3) Examination and implementation of changes.--The
Secretary, acting through the Service and with the
assistance of the Administrator of the Centers for
Medicare & Medicaid Services, shall examine on an
ongoing basis and implement any administrative changes
that may be necessary to facilitate direct billing and
reimbursement under the program established under this
subsection, including any agreements with States that
may be necessary to provide for direct billing under a
program under a title of the Social Security Act.
(4) Withdrawal from program.--A Tribal Health Program
that bills directly under the program established under
this subsection may withdraw from participation in the
same manner and under the same conditions that an
Indian Tribe or Tribal Organization may retrocede a
contracted program to the Secretary under the authority
of the Indian Self-Determination and Education
Assistance Act (25 U.S.C. 450 et seq.). All cost
accounting and billing authority under the program
established under this subsection shall be returned to
the Secretary upon the Secretary's acceptance of the
withdrawal of participation in this program.
[(b) Determination of appropriations]
[Any payments received by such facility for services
provided to Indians eligible for benefits under title XIX of
the Social Security Act [42 U.S.C.A. Sec. 1396 et seq.] shall
not be considered in determining appropriations for the
provision of health care and services to Indians.]
[Sec. 1643. Amount and use of funds reimbursed through medicare and
medicaid available to Indian Health Service]
[The Secretary shall submit to the President, for inclusion
in the report required to be transmitted to the Congress under
section 1671 of this title, an accounting on the amount and use
of funds made available to the Service pursuant to this
subchapter as a result of reimbursements through Titles XVIII
and XIX of the Social Security Act [42 U.S.C.A. Sec. Sec. 1395
et seq., 1396 et seq.], as amended.]
Sec. 1644. Grants to and C[c]ontracts with the Service, Indian Tribes,
T [t]ribal [o]Organizations, and Urban Indian
Organizations
(a) Indian Tribes and Tribal Organizations._[Access to
health services] The Secretary, acting through the Service,
shall make grants to or enter into contracts with Indian Tribes
and T [t]ribal O[o]rganizations to assist such Tribes and
Tribal O[o]rganizations in establishing and administering
programs on or near [Federal Indian] reservations and trust
areas [and in or near Alaska Native villages] to assist
individual Indians [to]--
(1) to enroll for benefits under title XVIII, XIX, or
XXI [section 1818 of part A and sections 1836 and 1837
of part B of Title XVIII] of the Social Security Act
and other health benefits programs [42 U.S.C.A.
Sec. Sec. 1395i-2, 1395o, 1395p]; and
(2) to pay [monthly] premiums for coverage for such
benefits, which may be based on financial need (as
determined by the Indian Tribe or Tribes being served
based on a schedule of income levels developed or
implemented by such Tribe or Tribes). [due to financial
need of such individual; and]
[(3) apply for medical assistance provided pursuant
to Title XIX of the Social Security Act [42 U.S.C.A.
Sec. 1396 et seq.].]
(b) [Terms and c]Conditions.--The Secretary, acting through
the Service, shall place conditions as deemed necessary to
effect the purpose of this section in any [contract or] grant
or contract which the Secretary makes with any Indian Tribe or
T[t]ribal O[o]rganization pursuant to this section. Such
conditions shall include[, by are not limited to,] requirements
that the Indian Tribe or Tribal O[o]rganization successfully
undertake [to]--
(1) to determine the population of Indians eligible
for the [to be served that are or could be recipients
of] benefits described in subsection (a) [under Titles
XVIII and XIX of the Social Security Act [42 U.S.C.A.
Sec. Sec. 1395 et seq., 1396 et seq.]];
(2) to educate [assist individual] Indians with
respect to the benefits available under the respective
programs [in becoming familiar with and utilizing such
benefits];
(3) to provide transportation for [to] such
individual Indians to the appropriate offices for
enrollment or applications for such benefits [medical
assistance]; and
(4) to develop and implement[--]
[(A) a schedule of income levels to determine
the extent of payments of premiums by such
organizations for coverage of needy
individuals; and]
[(B)] methods of improving the participation
of Indians in receiving the benefits provided
under titles XVIII, [and] XIX, and XXI of the
Social Security Act [[42 U.S.C.A.
Sec. Sec. 1395 et seq. And 1396 et seq.]].
(c) Agreements Relating To Improving Enrollment of Indians
Under Social Security Act Programs._[Application for medical
assistance]
(1) Agreements with secretary to improve receipt and
processing of applications._
(A) Authorization._The Secretary, acting
through the Service, may enter into an
agreement with an Indian [t]Tribe, [t]Tribal
[o]Organization, or [u]Urban Indian
[o]Organization which provides for the receipt
and processing of applications by Indians for
[medical] assistance under titles XIX and XXI
of the Social Security Act, [[42 U.S.C.A.
Sec. 1396 et seq.]] and benefits under title
XVIII of such [the Social Security] Act, by an
Indian Health Program or Urban Indian
Organization. [[42 U.S.C.A. Sec. 1395 et seq.]
at a Service facility or a health care facility
administered by such tribe or organization
pursuant to a contract under the Indian Self-
Determination Act [25 U.S.C.A. Sec. 450f et
seq.].]
(B) Reimbursement of costs.--Such agreements
may provide for reimbursement of costs of
outreach, education regarding eligibility and
benefits, and translation when such services
are provided. The reimbursement may, as
appropriate, be added to the applicable rate
per encounter or be provided as a separate fee-
for-service payment to the Indian Tribe or
Tribal Organization.
(C) Processing clarified.--In this paragraph,
the term `processing' does not include a final
determination of eligibility.
(2) Agreements with states for outreach on or near
reservation.--
(A) In general.--In order to improve the
access of Indians residing on or near a
reservation to obtain benefits under title XIX
or XXI of the Social Security Act, the
Secretary shall encourage the State to take
steps to provide for enrollment on or near the
reservation. Such steps may include outreach
efforts such as the outstationing of
eligibility workers, entering into agreements
with Indian Tribes and Tribal Organizations to
provide outreach, education regarding
eligibility and benefits, enrollment, and
translation services when such services are
provided.
(B) Construction.--Nothing in subparagraph
(A) shall be construed as affecting
arrangements entered into between States and
Indian Tribes and Tribal Organizations for such
Indian Tribes and Tribal Organizations to
conduct administrative activities under such
titles.
(d) Facilitating Cooperation.--The Secretary, acting
through the Centers for Medicare & Medicaid Services, shall
take such steps as are necessary to facilitate cooperation
with, and agreements between, States and the Service, Indian
Tribes, Tribal Organizations, or Urban Indian Organizations.
(e) Application to Urban Indian Organizations.--
(1) In general.--The provisions of subsection (a)
shall apply with respect to grants and other funding to
Urban Indian Organizations with respect to populations
served by such organizations in the same manner they
apply to grants and contracts with Indian Tribes and
Tribal Organizations with respect to programs on or
near reservations.
(2) Requirements.--The Secretary shall include in the
grants or contracts made or provided under paragraph
(1) requirements that are--
(A) consistent with the requirements imposed
by the Secretary under subsection (b);
(B) appropriate to Urban Indian Organizations
and Urban Indians; and
(C) necessary to effect the purposes of this
section.
[Sec. 1645. Direct billing of Medicare, Medicaid, and other third party
payors]
[(a) Establishment of direct billing program]
[(1) In general]
[The Secretary shall establish a program under which Indian
tribes, tribal organizations, and Alaska Native health
organizations that contract or compact for the operation of a
hospital or clinic of the Service under the Indian Self-
Determination and Education Assistance Act (25 U.S.C. 450 et
seq.) may elect to directly bill for, and receive payment for,
health care services provided by such hospital or clinic for
which payment is made under title XVIII of the Social Security
Act (42 U.S.C. 1395 et seq.) (In this section referred to as
the ``medicare program''), under a State plan for medical
assistance approved under title XIX of the Social Security Act
(42 U.S.C. 1396 et seq.) (In this section referred to as the
``medicaid program''), or from any other third party payor.]
[(2) Application of 100 percent FMAP]
[The third sentence of section 1396d(b) of Title 42 shall
apply for purposes of reimbursement under the medicaid program
for health care services directly billed under the program
established under this section.]
[(b) Direct reimbursement]
[(1) Use of funds]
[Each hospital or clinic participating in the program
described in subsection (a) of this section shall be reimbursed
directly under the medicare and medicaid programs for services
furnished, without regard to the provisions of section 1880(c)
of the Social Security Act (42 U.S.C. 1395qq(c)) and sections
1642(a) and 1680c(b)(2)(A) of this title, 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
programs. Any funds so reimbursed which are in excess of the
amount necessary to achieve or maintain such conditions shall
be used--]
[(A) solely for improving the health
resources deficiency level of the Indian tribe;
and]
[(B) in accordance with the regulations of
the Service applicable to funds provided by the
Service under any contract entered into under
the Indian Self-Determination Act (25 U.S.C.
450f et seq.).]
[(2) Audits]
[The amounts paid to the hospitals and clinics
participating in the program established under this section
shall be subject to all auditing requirements applicable to
programs administered directly by the Service and to facilities
participating in the medicare and medicaid programs.]
[(3) Secretarial oversight]
[The Secretary shall monitor the performance of hospitals
and clinics participating in the program established under this
section, and shall require such hospitals and clinics to submit
reports on the program to the Secretary on an annual basis.]
[(4) No payments from special funds]
[Notwithstanding section 1880(c) of the Social Security Act
(42 U.S.C.A. Sec. 1395qq(c)) or section 1642(a) of this title,
no payment may be made out of the special funds described in
such sections for the benefit of any hospital or clinic during
the period that the hospital or clinic participates in the
program established under this section.]
[(c) Requirements for participation]
[(1) Application]
[Except as provided in paragraph (2)(B), in order to be
eligible for participation in the program established under
this section, an Indian tribe, tribal organization, or Alaska
Native health organization shall submit an application to the
Secretary that establishes to the satisfaction of the Secretary
that--]
[(A) the Indian tribe, tribal organization,
or Alaska Native health organization contracts
or compacts for the operation of a facility of
the Service;]
[(B) the facility is eligible to participate
in the medicare or medicaid programs under
section 1395qq or 1396j of Title 42;]
[(C) the facility meets the requirements that
apply to programs operated directly by the
Service; and]
[(D) the facility--]
[(i) is accredited by an accrediting
body as eligible for reimbursement
under the medicare or medicaid
programs; or]
[(ii) has submitted a plan, which has
been approved by the Secretary, for
achieving such accreditation.]
[(2) Approval]
[(A) In general]
[The Secretary shall review and approve a qualified
application not later than 90 days after the date that
application is submitted to the Secretary unless the Secretary
determines that any of the criteria set forth in paragraph (1)
are not met.]
[(B) Grandfather of demonstration program
participants]
[Any participant in the demonstration program authorized
under this section as in effect on November 1, 2000, shall be
deemed approved for participation in the program established
under this section and shall not be required to submit an
application in order to participate in the program.]
[(C) Duration]
[An approval by the Secretary of a qualified application
under subparagraph (A), or a deemed approval of a demonstration
program under subparagraph (B), shall continue in effect as
long as the approved applicant or the deemed approved
demonstration program meets the requirements of this section.]
[(d) Examination and implementation of changes]
[(1) In general]
[The Secretary, acting through the Service, and with the
assistance of the Administrator of the Centers for Medicare &
Medicaid Services, shall examine on an ongoing basis and
implement--]
[(A) any administrative changes that may be
necessary to facilitate direct bill and
reimbursement under the program established
under this section, including any agreements
with States that may be necessary to provide
for direct billing under the medicaid program;
and]
[(B) any changes that may be necessary to
enable participants in the program established
under this section to provide to the Service
medical records information on patients served
under the program that is consistent with the
medical records information system of the
Service.]
[(2) Accounting information]
[The accounting information that a participant in the
program established under this section shall be required to
report shall be the same as the information required to be
reported by participants in the demonstration program
authorized under this section as in effect on the day before
November 1, 2000. The Secretary may from time to time, after
consultation with the program participants, change the
accounting information submission requirements.]
[(e) Withdrawal from program]
[A participant in the program established under this
section may withdraw from participation in the same manner and
under the same conditions that a tribe or tribal organization
may retrocede a contracted program to the Secretary under
authority of the Indian Self-Determination Act [25 U.S.C.A.
Sec. 450f et seq.]. All cost accounting and billing authority
under the program established under this section shall be
returned to the Secretary upon the Secretary's acceptance of
the withdrawal of participation in this program.]
Sec. 403. Reimbursement from certain third parties of costs of health
services
(a) Right of Recovery.--Except as provided in subsection
(f), the United States, an Indian Tribe, or Tribal Organization
shall have the right to recover from an insurance company,
health maintenance organization, employee benefit plan, third-
party tortfeasor, or any other responsible or liable third
party (including a political subdivision or local governmental
entity of a State) the reasonable charges as determined by the
Secretary, and billed by the Secretary, an Indian Tribe, or
Tribal Organization in providing health services, through the
Service, an Indian Tribe, or Tribal Organization to any
individual to the same extent that such individual, or any
nongovernmental provider of such services, would be eligible to
receive damages, reimbursement, or indemnification for such
charges or expenses if--
(1) such services had been provided by a
nongovernmental provider; and
(2) such individual had been required to pay such
charges or expenses and did pay such charges or
expenses.
(b) Limitations on Recoveries From States.--Subsection (a)
shall provide a right of recovery against any 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) Nonapplication of Other Laws.--No law of any State, or
of any political subdivision of a State and no provision of any
contract, insurance or health maintenance organization policy,
employee benefit plan, self-insurance plan, managed care plan,
or other health care plan or program entered into or renewed
after the date of the enactment of the Indian Health Care
Amendments of 1988, shall prevent or hinder the right of
recovery of the United States, an Indian Tribe, or Tribal
Organization under subsection (a).
(d) No Effect on Private Rights of Action.--No action taken
by the United States, an Indian Tribe, or Tribal Organization
to enforce the right of recovery provided under this section
shall operate to deny to the injured person the recovery for
that portion of the person's damage not covered hereunder.
(e) Enforcement.--
(1) In general.--The United States, an Indian Tribe, or
Tribal Organization may enforce the right of recovery
provided under subsection (a) by--
(A) intervening or joining in any civil
action or proceeding brought--
(i) by the individual for whom health
services were provided by the
Secretary, an Indian Tribe, or Tribal
Organization; or
(ii) by any representative or heirs
of such individual, or
(B) instituting a civil action, including a
civil action for injunctive relief and other
relief and including, with respect to a
political subdivision or local governmental
entity of a State, such an action against an
official thereof.
(2) Notice.--All reasonable efforts shall be made to
provide notice of action instituted under paragraph
(1)(B) to the individual to whom health services were
provided, either before or during the pendency of such
action.
(f) Limitation.--Absent specific written authorization by
the governing body of an Indian Tribe for the period of such
authorization (which may not be for a period of more than 1
year and which may be revoked at any time upon written notice
by the governing body to the Service), the United States shall
not have a right of recovery under this section if the injury,
illness, or disability for which health services were provided
is covered under a self-insurance plan funded by an Indian
Tribe, Tribal Organization, or Urban Indian Organization. Where
suchauthorization is provided, the Service may receive and
expend such amounts for the provision of additional health services
consistent with such authorization.
(g) Costs and Attorneys' Fees.--In any action brought to
enforce the provisions of this section, a prevailing plaintiff
shall be awarded its reasonable attorneys' fees and costs of
litigation.
(h) Nonapplication of Claims Filing Requirements.--An
insurance company, health maintenance organization, self-
insurance plan, managed care plan, or other health care plan or
program (under the Social Security Act or otherwise) may not
deny a claim for benefits submitted by the Service or by an
Indian Tribe or Tribal Organization based on the format in
which the claim is submitted if such format complies with the
format required for submission of claims under title XVIII of
the Social Security Act or recognized under section 1175 of
such Act.
(i) Application to Urban Indian Organizations.--The
previous provisions of this section shall apply to Urban Indian
Organizations with respect to populations served by such
Organizations in the same manner they apply to Indian Tribes
and Tribal Organizations with respect to populations served by
such Indian Tribes and Tribal Organizations.
(j) Statute of Limitations.--The provisions of section 2415
of title 28, United States Code, shall apply to all actions
commenced under this section, and the references therein to the
United States are deemed to include Indian Tribes, Tribal
Organizations, and Urban Indian Organizations.
(k) Savings.--Nothing in this section shall be construed to
limit any right of recovery available to the United States, an
Indian Tribe, or Tribal Organization under the provisions of
any applicable, Federal, State, or Tribal law, including
medical lien laws and the Federal Medical Care Recovery Act (42
U.S.C. 2651 et seq.).
Sec. 404. Crediting of reimbursements
(a) Use of Amounts.--
(1) Retention by program.--Except as provided in
section 202(g) (relating to the Catastrophic Health
Emergency Fund) and section 807 (relating to health
services for ineligible persons), all reimbursements
received or recovered under any of the programs
described in paragraph (2), including under section
807, by reason of the provision of health services by
the Service, by an Indian Tribe or Tribal Organization,
or by an Urban Indian Organization, shall be credited
to the Service, such Indian Tribe or Tribal
Organization, or such Urban Indian Organization,
respectively, and may be used as provided in section
401. In the case of such a service provided by or
through a Service Unit, such amounts shall be credited
to such unit and used for such purposes.
(2) Programs covered.--The programs referred to in
paragraph (1) are the following:
(A) Titles XVIII, XIX, and XXI of the Social
Security Act.
(B) This Act, including section 807.
(C) Public Law 87-693.
(D) Any other provision of law.
(b) No Offset of Amounts.--The Service may not offset or
limit any amount obligated to any Service Unit or entity
receiving funding from the Service because of the receipt of
reimbursements under subsection (a).
Sec. 405. Purchasing health care coverage
(a) In General.--Insofar as amounts are made available
under law (including a provision of the Social Security Act,
the Indian Self-Determination and Education Assistance Act (25
U.S.C. 450 et seq.), or other law, other than under section
402) to Indian Tribes, Tribal Organizations, and Urban Indian
Organizations for health benefits for Service beneficiaries,
Indian Tribes, Tribal Organizations, and Urban Indian
Organizations may use such amounts to purchase health benefits
coverage for such beneficiaries in any manner, including
through--
(1) a tribally owned and operated health care plan;
(2) a State or locally authorized or licensed health
care plan;
(3) a health insurance provider or managed care
organization; or
(4) a self-insured plan.
The purchase of such coverage by an Indian Tribe, Tribal
Organization, or Urban Indian Organization may be based on the
financial needs of such beneficiaries (as determined by the
Indian Tribe or Tribes being served based on a schedule of
income levels developed or implemented by such Indian Tribe or
Tribes).
(b) Expenses for Self-Insured Plan.--In the case of a self-
insured plan under subsection (a)(4), the amounts may be used
for expenses of operating the plan, including administration
and insurance to limit the financial risks to the entity
offering the plan.
(c) Construction.--Nothing in this section shall be
construed as affecting the use of any amounts not referred to
in subsection (a).
Sec. 406. Sharing arrangements with Federal agencies
(a) Authority.--
(1) In general.--The Secretary may enter into (or
expand) arrangements for the sharing of medical
facilities and services between the Service, Indian
Tribes, and Tribal Organizations and the Department of
Veterans Affairs and the Department of Defense.
(2) Consultation by secretary required.--The
Secretary may not finalize any arrangement between the
Service and a Department described in paragraph (1)
without first consulting with the Indian Tribes which
will be significantly affected by the arrangement.
(b) Limitations.--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 Service and the
eligibility of any Indian to receive health services
through the Service;
(2) the quality of health care services provided to
any Indian through the Service;
(3) the priority access of any veteran to health care
services provided by the Department of Veterans
Affairs;
(4) the quality of health care services provided by
the Department of Veterans Affairs or the Department of
Defense; or
(5) the eligibility of any Indian who is a veteran to
receive health services through the Department of
Veterans Affairs.
(c) Reimbursement.--The Service, Indian Tribe, or Tribal
Organization shall be reimbursed by the Department of Veterans
Affairs or the Department of Defense (as the case may be) where
services are provided through the Service, an Indian Tribe, or
a Tribal Organization to beneficiaries eligible for services
from either such Department, notwithstanding any other
provision of law.
(d) Construction.--Nothing in this section may be construed
as creating any right of a non-Indian veteran to obtain health
services from the Service.
Sec. 407. Payor of last resort
Indian Health Programs and health care programs operated by
Urban Indian Organizations shall be the payor of last resort
for services provided to persons eligible for services from
Indian Health Programs and Urban Indian Organizations,
notwithstanding any Federal, State, or local law to the
contrary.
Sec. 408. Nondiscrimination in qualifications for reimbursement for
services
For purposes of determining the eligibility of an entity
that is operated by the Service, an Indian Tribe, Tribal
Organization, or Urban Indian Organization to receive payment
or reimbursement from any federally funded health care program
for health care services it furnishes to an Indian, such
program must provide that such entity, meeting generally
applicable State or other requirements applicable for
participation, must be accepted as a provider on the same basis
as any other qualified provider, except that any requirement
that the entity be licensed or recognized under State or local
law to furnish such services shall be deemed to have been met
if the entity meets all the applicable standards for such
licensure, but the entity need not obtain a license or other
documentation. In determining whether the entity meets such
standards, the absence of licensure of any staff member of the
entity may not be taken into account.
Sec. 409. Consultation
(a) Tribal Indian Technical Advisory Group (TTAG).--The
Secretary shall maintain within the Centers for Medicare &
Medicaid Services (CMS) a Tribal Indian Technical Advisory
Group, established in accordance with requirements of the
charter dated September 30, 2003, and in such group shall
include a representative of the Urban Indian Organizations and
the Service. The representative of the Urban Indian
Organization shall be deemed to be an elected officer of a
tribal government for purposes of applying section 204(b) of
the Unfunded Mandates Reform Act of 1995 (2 U.S.C. 1534(b)).
(b) Solicitation of Medicaid Advice.--
(1) In general.--As part of its plan for payment
under title XIX of the Social Security Act, a State in
which the Service operates or funds health care
programs or in which 1 or more Indian Health Programs
or Urban Indian Organizations provide health care in
the State for which medical assistance is available
under such title, may establish a process under which
the State seeks advice on a regular, ongoing basis from
designees of such Indian Health Programs and Urban
Indian Organizations on matters relating to the
application of such title to and likely to have a
direct effect on such Indian Health Programs and Urban
Indian Organizations.
(2) Manner of advice.--The process described in
paragraph (1) should include solicitation of advice
prior to submission of any plan amendments, waiver
requests, and proposals for demonstration projects
likely to have a direct effect on Indians, Indian
Health Programs, or Urban Indian Organizations. Such
process may include appointment of an advisory
committee and of a designee of such Indian Health
Programs and Urban Indian Organizations to the medical
care advisory committee advising the State on its
medicaid plan.
(3) Payment of expenses.--The reasonable expenses of
carrying out this subsection shall be eligible for
reimbursement under section 1903(a) of the Social
Security Act.
(c) Construction.--Nothing in this section shall be
construed as superseding existing advisory committees, working
groups, or other advisory procedures established by the
Secretary or by any State.
Sec. 410. State Children's Health Insurance Program (SCHIP)
(a) Optional Use of Funds for Indian Health Payments.--
Subject to the succeeding provisions of this section, a State
may provide under its State child health plan under title XXI
of the Social Security Act (regardless of whether such plan is
implemented under such title, title XIX of such Act, or both)
for payments under this section to Indian Health Programs and
Urban Indian Organizations operating in the State. Such payment
shall be treated under title XXI of the Social Security Act as
expenditures described in section 2105(a)(1)(A) of such Act.
(b) Use of Funds.--Payments under this section may be used
only for expenditures described in clauses (i) through (iii) of
section 2105 (a)(1)(D) of the Social Security Act for targeted
low-income children or other low-income children (as defined in
2110 of such Act) who are--
(1) Indians; or
(2) otherwise eligible for health services from the
Indian Health Program involved.
(c) Special Restrictions.--The following conditions apply
to a State electing to provide payments under this section:
(1) No limitation on other schip participation of, or
provider payments to, indian health programs.--The
State may not exclude or limit participation of
otherwise eligible Indian Health Programs in its State
child health program under title XXI of the Social
Security Act or its medicaid program under title XIX of
such Act or pay such Programs less then they otherwise
would as participating providers on the basis that
payments are made to such Programs under this section.
(2) No limitation on other schip eligibility of
indians.--The State may not exclude or limit
participation of otherwise eligible Indian children in
such State child health or medicaid program on the
basis that payments are made for assistance for such
children under this section.
(3) Limitation on acceptance of contributions.--
(A) In general.--The State may not accept
contributions or condition making of payments
under this section upon contribution of funds
from an Indian Health Program to meet the
State's non-Federal matching fund requirements
under titles XIX and XXI of the Social Security
Act.
(B) Contribution defined.--For purposes of
subparagraph (A), the term `contribution'
includes any tax, donation, fee, or other
payment made, whether made voluntarily or
involuntarily.
(d) Application of Separate 10 Percent Limitation.--Payment
may be made under section 2105(a) of the Social Security Act to
a State for a fiscal year for payments under this section up to
an amount equal to 10 percent of the total amount available
under title XXI of such Act (including allotments and
reallotments available from previous fiscal years) to the State
with respect to the fiscal year.
(e) General Terms.--A payment under this section shall only
be made upon application to the State from the Indian Health
Program involved and under such terms and conditions, and in a
form and manner, as the Secretary determines appropriate.
Sec. 411. Social Security Act sanctions
(a) Requests for Waiver of Sanctions.--
(1) In general.--For purposes of applying any
authority under a provision of title XI, XVIII, XIX, or
XXI of the Social Security Act to seek a waiver of a
sanction imposed against a health care provider insofar
as that provider provides services to individuals
through an Indian Health Program, the Indian Health
Program shall request the State to seek such waiver,
and if such State has not sought the waiver within 60
days of the Indian Health Program request, the Indian
Health Program itself may petition the Secretary for
such waiver.
(2) Procedure.--In seeking a waiver under paragraph
(1), the Indian Health Program much provide notice an a
copy of the request, including the reasons for the
waiver sought, to the State. The Secretary may consider
the State's views in the determination of the waiver
request, but may not withhold or delay a determination
based on the lack of the State's views.
(b) Safe Harbor for Transactions Between and Among Indian
Health Care Programs.--For purposes of applying section
1128B(b) of the Social Security Act, the exchange of anything
of value between or among the following shall not be treated as
remuneration if the exchange arises from or relates to any of
the following health programs:
(1) An exchange between or among the following:
(A) Any Indian Health Program.
(B) Any Urban Indian Organization.
(2) An exchange between an Indian Tribe, Tribal
Organization, or an Urban Indian Organization and any
patient served or eligible for service from an Indian
Tribe, Tribal Organization, or Urban Indian
Organization, including patients served or eligible for
service pursuant to section 807, but only if such
exchange--
(A) is for the purpose of transporting the
patient for the provision of health care items
or services;
(B) is for the purpose of providing housing
to the patient (including a pregnant patient)
and immediate family members or an escort
incidental to assuring the timely provision of
health care items and services to the patient;
(C) is for the purpose of paying premiums,
copayments, deductibles, or other cost-sharing
on behalf of patients; or
(D) consists of an item or service of small
value that is provided as a reasonable
incentive to secure timely and necessary
preventive and other items and services.
(3) Other exchanges involving an Indian Health
Program, an Urban Indian Organization, or an Indian
Tribe or Tribal Organization that meet such standards
as the Secretary of Health and Human Services, in
consultation with the Attorney General, determines is
appropriate, taking into account the special
circumstances of such Indian Health Programs, Urban
Indian Organizations, Indian Tribes, and Tribal
Organizations and of patients served by Indian Health
Programs, Urban Indian Organizations, Indian Tribes,
and Tribal Organizations.
Sec. 412. Cost sharing
(a) Coinsurance, Copayments, and Deductibles.--
Notwithstanding any other provision of Federal or State law--
(1) Protection for eligible indians under social
security act health programs.--No Indian who is
furnished an item or service for which payment may be
made under title XIX or XXI of the Social Security Act
may be charged a deductible, copayment, or coinsurance.
(2) Protection for indians.--No Indian who is
furnished an item or service by the Service may be
charged a deductible, copayment, or coinsurance.
(3) No reduction in amount of payment to indian
health providers.--The payment or reimbursement due to
the Service, Indian Tribe, Tribal Organization, or
Urban Indian Organization under title XIX or XXI of the
Social Security Act may not be reduced by the amount of
the deductible, copayment, or coinsurance that would be
due from the Indian but for the operation of this
section.
(b) Exemption From Medicaid and SCHIP Premiums.--
Notwithstanding any other provision of Federal or State law, no
Indian who is otherwise eligible for services under title XIX
of the Social Security Act (relating to the medicaid program)
or title XXI of such Act (relating to the State children's
health insurance program) may be charged a premium as a
condition of receiving benefits under the program under the
respective title.
(c) Treatment of Certain Property for Medicaid
Eligibility.--Notwithstanding any other provision of Federal or
State law, the following property may not be included when
determining eligibility for services under title XIX of the
Social Security Act:
(1) Property, including real property and
improvements, located on the reservation, including any
federally recognized Indian Tribe's reservation,
Pueblo, or Colony, including former reservations in
Oklahoma, Alaska Native regions established by the
Alaska Native Claims Settlement Act and Indian
allotments on or near the reservation as designated and
approved by the Bureau of Indian Affairs of the
Department of the Interior.
(2) For any federally recognized Tribe not described
in paragraph (1), property located within the most
recent boundaries of a prior Federal reservation.
(3) Ownership interests in rents, leases, royalties,
or usage rights related to natural resources (including
extraction of natural resources or harvesting of
timber, or other plants and plant products, animals,
fish, and shellfish) resulting from the exercise of
federally protected rights.
(4) Ownership interests in or usage rights to items
not covered by paragraphs (1) through (3) that have
unique religious, spiritual, traditional, or cultural
significance or rights that support subsistence or a
traditional life style according to applicable tribal
law and custom.
(d) Continuation of Current Law Protections of Certain
Indian Property From Medicaid Estate Recovery.--Income,
resources, and property that are exempt from medicaid estate
recovery under title XIX of the Social Security Act as of April
1, 2003, under manual instructions issued to carry out section
1917 (b)(3) of such Act because of Federal responsibility for
Indian Tribes and Alaska Native Villages shall remain so
exempt. Nothing in this subsection shall be construed as
preventing the Secretary from providing additional medicaid
estate recovery exemptions for Indians.
Sec. 413. Treatment under Medicaid Managed Care
(a) Provision of Services, to Enrollees With Non-Indian
Medicaid Managed Care Entities, by Indian Health Programs and
Urban Indian Organizations.--
(1) Payment rules.--
(A) In general.--Subject to subparagraph (B),
in the case of an Indian who is enrolled with a
non-Indian medicaid managed care entity (as
defined in subsection (c)) and who receives
covered medicaid managed care services from an
Indian Health Program or an Urban Indian
Organization, whether or not it is a
participating provider with respect to such
entity, the following rules apply:
(i) Direct payment.--The entity shall
make prompt payment (in accordance with
rules applicable to medicaid managed
care entities under title XIX of the
Social Security Act) to the Indian
Health Program or Urban Indian
Organization at a rate established by
the entity for such services that is
equal to the rate negotiated between
such entity and the Program or
Organization involved or, if such a
rate has not been negotiated, a rate
that is not less than the level and
amount of payment which the entity
would make for the services if the
services were furnished by a provider
which is not a Program or Organization.
(ii) Payment through state.--If there
is no arrangement for direct payment
under clause (i) or if the State
provides for this clause to apply in
lieu of clause (i), the State shall
provide for payment to the Indian
Health Program or Urban Indian
Organization under its State program
under title XIX of such Act at the rate
that would be otherwise applicable for
such services under such program and
shall provide for an appropriate
adjustment of the capitation payment
made to the entity to take into account
such payment.
(B) Compliance with generally applicable
requirements.--
(i) In general.--Except as otherwise
provided, as a condition of payment
under subparagraph (A), the Indian
Health Program or Urban Indian
Organization shall comply with the
generally applicable requirements of
title XIX of the Social Security Act
with respect to covered services.
(ii) Satisfaction of claim
requirement.--Any requirement for the
submission of a claim or other
documentation for services covered
under subparagraph (A) by the enrollee
is deemed to be satisfied through the
submission of a claim or other
documentation by the Indian Health
Program or Urban Indian Organization
consistent with section 403(h).
(C) Construction.--Nothing in this subsection
shall be construed as waiving the application
of section 1902(a)(30)(A) of the Social
Security Act (relating to application of
standards to assure that payments are
consistent with efficiency, economy, and
quality of care).
(2) Enrollee option to select an indian health
program or urban indian organization as primary care
provider.--In the case of a non-Indian medicaid managed
care entity that--
(A) has an Indian enrolled with the entity;
and
(B) has an Indian Health Program or Urban
Indian Organization that is participating as a
primary care provider within the network of the
entity, insofar as the Indian is otherwise
eligible to receive services from such Program
or Organization and the Program or Organization
has the capacity to provide primary care
services to such Indian, the Indian shall be
allowed to choose such Program or Organization
as the Indian's primary care provider under the
entity.
(b) Offering of Managed Care Through Indian Medicaid
Managed Care Entities.--if--
(1) a State elects to provide services through
medicaid managed care entities under its medicaid
managed care program; and
(2) an Indian Health Program or Urban Indian
Organization that is funded in whole or in part by the
Service, or a consortium thereof, has established an
Indian medicaid managed care entity in the State that
meets generally applicable standards required of such
an entity under such medicaid managed care program, the
State shall offer to enter into an agreement with the
entity to serve as a medicaid managed care entity with
respect to eligible Indians served by such entity under
such program.
(c) Special Rules for Indian Managed Care Entities.--The
following are special rules regarding the application of a
medicaid managed care program to Indian medicaid managed care
entities:
(1) Enrollment.--
(A) Limitation to indians.--An Indian
medicaid managed care entity may restrict
enrollment under such program to Indians and to
members of specific Tribes in the same manner
as Indian Health Programs may restrict the
delivery of services to such Indians and tribal
members.
(B) No less choice of plans.--Under such
program the State may not limit the choice of
an Indian among medicaid managed care entities
only to Indian medicaid managed care entities
or to be more restrictive than the choice of
managed care entities offered to individual who
are not Indians.
(C) Default enrollment.--
(i) In general.--If such program of a
State required the enrollment of
Indians in a medicaid managed care
entity in order to receive benefits,
the State shall provide for the
enrollment of Indians described in
clause (ii) who are not otherwise
enrolled with such an entity in an
Indian medicaid managed care entity
described in such clause.
(ii) Indian described.--An Indian
described in this clause, with respect
to an Indian medicaid managed care
entity, is an Indian who, based upon
the service area and capacity of the
entity, is eligible to be enrolled with
the entity consistent with subparagraph
(A).
(D) Exception to state lock-in.--A request by
an Indian who is enrolled under such program
with a non-Indian medicaid managed care entity
to change enrollment with that entity to
enrollment with an Indian medicaid managed care
entity shall be considered cause for granting
such request under procedures specified by the
Secretary.
(2) Flexibility in application of solvency.--In
applying section 1903(m)(1) of the Social Security Act
to an Indian medicaid managed care entity--
(A) any reference to a 'State' in
subparagraph (A)(ii) of that section shall be
deemed to be a reference to the 'Secretary';
and
(B) the entity shall be deemed to be a public
entity described in subparagraph (C)(ii) of
that section.
(3) Exceptions to advance directives.--The Secretary
may modify or waive the requirement of section 1902(w)
of the Social Security Act (relating to provision of
written materials of advance directives) insofar as the
Secretary finds that the requirements otherwise imposed
are not an appropriate or effective way of
communicating the information to Indians.
(4) Flexibility in information and marketing.--
(A) Materials.--The Secretary may modify
requirements under section 1932(a)(5) of the
Social Security Act in a manner that improves
the materials to take into account the special
circumstances of such entities and their
enrollees while maintaining and clearly
communicating to potential enrollees their
rights, protections, and benefits.
(B) Distribution of marketing materials.--The
provisions of section 1931(d)(2)(B) of the
Social Security Act requiring the distribution
of marketing materials to an entire service
areashall be deemed satisfied in the case of an
Indian medicaid managed care entity that distributes appropriate
materials only to those Indians who are potentially eligible to enroll
with the entity in the service area.
(d) Malpractice Insurance.--Insofar as, under a medicaid
managed care program, a health care provider is required to
have a medical malpractice insurance coverage as a condition of
contracting as a provider with a medicaid managed care entity,
an Indian Health Program, or an Urban Indian Organization that
is a Federally-qualified health center under title XIX of the
Social Security Act, that is covered under the Federal Tort
Claims Act 28 U.S.C. 1346(b), 2671 et seq.) is deemed to
satisfy such requirement.
(e) Definitions.--For purposes of this section:
(1) Medicaid managed care entity.--The term `medicaid
managed care entity' means a managed care entity
(whether a managed care organization or a primary care
case manager) under title XIX of the Social Security
Act, whether pursuant to section 1903(m) or section
1932 of such Act, a waiver under section 1115 or
1915(b) of such Act, or otherwise.
(2) Indian medicaid managed care entity.--The term
`Indian medicaid managed care entity' means a managed
care entity that is controlled (within the meaning of
the last sentence of section 1903(m)(1)(C) of the
Social Security Act) by the Indian Health Service, a
Tribe, Tribal Organization, or Urban Indian
Organization (as such terms are defined in section 4),
or a consortium, which may be composed of 1 or more
Tribes, Tribal Organizations, or Urban Indian
Organizations, and which also may include the Service.
(3) Non-indian medicaid managed care entity.--The
term `non-Indian medicaid managed care entity' means a
medicaid managed care entity that is not an Indian
medicaid managed care entity.
(4) Covered medicaid managed care services.--The term
`covered medicaid managed care services' means, with
respect to an individual enrolled with a medicaid
managed care entity, items and services that are within
the scope of items and services for which benefits are
available with respect to the individual under the
contract between the entity and the State involved.
(5) Medicaid managed care program.--The term
`medicaid managed care program' means a program under
sections 1903(m) and 1932 of the Social Security Act
and includes a managed care program operating under a
waiver under section 1915(b) or 1115 of such Act or
otherwise.
Sec. 414. Navajo Nation Medicaid Agency Feasibility Study
(a) Study.--The Secretary shall conduct a study to
determine the feasibility of treating the Navajo Nation as a
State for the purposes of title XIX of the Social Security Act,
to provide services to Indians living within the boundaries of
the Navajo Nation through an entity established having the same
authority and performing the same functions as single-State
medicaid agencies responsible for the administration of the
State plan under title XIX of the Social Security Act.
(b) Considerations.--In conducting the study, the Secretary
shall consider the feasibility of--
(1) assigning and paying all expenditures for the
provision of services and related administration funds,
under title XIX of the Social Security Act, to Indians
living within the boundaries of the Navajo Nation that
are currently paid to or would otherwise be paid to the
State of Arizona, New Mexico, or Utah;
(2) providing assistance to the Navajo Nation in the
development and implementation of such entity for the
administration, eligibility, payment, and delivery of
medical assistance under title XIX of the Social
Security Act;
(3) providing an appropriate level of matching funds
for Federal medical assistance with respect to amounts
such entity expends for medical assistance for services
and related administrative costs; and
(4) authorizing the Secretary, at the option of the
Navajo Nation, to treat the Navajo Nation as a State
for the purposes of title XIX of the Social Security
Act (relating to the State children's health insurance
program) under terms equivalent to those described in
paragraphs (2) through (4).
(c) Report.--Not later then 3 years after the date of
enactment of the Indian Health Act Improvement Act Amendments
of 2005, the Secretary shall submit to the Committee on Indian
Affairs and Committee on Finance of the Senate and the
Committee on Resources and Committee on Energy and Commerce of
the House of Representatives a report that includes--
(1) the results of the study under this section;
(2) a summary of any consultation that occurred
between the Secretary and the Navajo Nation, other
Indian Tribes, the States of Arizona, New Mexico, and
Utah, counties which include Navajo Lands, and other
interested parties, in conducting this study;
(3) projected costs or savings associated with
establishment of such entity, and any estimated impact
on services provided as described in this section in
relation to probable costs or savings; and
(4) legislative actions that would be required to
authorize the establishment of such entity if such
entity is determined by the Secretary to be feasible.
[Sec. 1646. Authorization for emergency contract health services]
[With respect to an elderly or disabled Indian receiving
emergency medical care or services from a non-Service provider
or in a non-Service facility under the authority of this
chapter, the time limitation (as a condition of payment) for
notifying the Service of suchtreatment or admission shall be 30
days.]
Sec. 1647. Authorization of [a]Appropriations
There are authorized to be appropriated such sums as may be
necessary for each fiscal year through fiscal year 2015 [2000]
to carry out this title [subchapter].
TITLE V [SUBCHAPTER IV]--HEALTH SERVICES FOR URBAN INDIANS
Sec. 1651. Purpose
The purpose of this title [subchapter] is to establish and
maintain programs in [u]Urban [c]Centers to make health
services more accessible and available to [u]Urban Indians.
Sec. 1652. Contracts [w]With, and [g]Grants to, [u]Urban Indian
[o]Organizations
Under authority of the Act of November 2, 1921 (25 U.S.C.
13), (commonly [popularly] known as the `Snyder Act'), the
Secretary, acting through the Service, shall enter into
contracts with, or make grants to, [u]Urban Indian
[o]Organizations to assist such organizations in the
establishment and administration, within [the u]Urban
[c]Centers [in which such organizations are situated], of
programs which meet the requirements set forth in this title
[subchapter]. Subject to section 506, t[T]he Secretary, acting
through the Service, shall include such conditions as the
Secretary considers necessary to effect the purpose of this
title [subchapter] in any contract into which the Secretary
enters [into] with, or in any grant the Secretary makes to, any
U[u]rban Indian O[o]rganization pursuant to this title
[subchapter].
Sec. 1653. Contracts and G[g]rants for the P[p]rovision of H[h]ealth
C[c]are and R[r]eferral S[s]ervices
(a) Requirements for Grants and Contracts.--Under authority
of the Act of November 2, 1921 (25 U.S.C. 13)[, popularly]
(commonly known as the `Snyder Act'), the Secretary, acting
through the Service, shall enter into contracts with, and make
grants to, [u]Urban Indian [o]Organizations for the provision
of health care and referral services for [u]Urban Indians
[residing in the urban centers in which such organizations are
situated]. Any such contract or grant shall include
requirements that the [u]Urban Indian [o]Organization
successfully undertake to--
(1) estimate the population of [u]Urban Indians
residing in the [u]Urban [c]Center or centers that the
organization proposes to serve [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 [u]Urban
Indians residing in such [u]Urban [c]Center or centers;
(3) estimate the current health care needs of
[u]Urban Indians residing in such [u]Urban [c]Center or
centers;
(4) provide basic health education, including health
promotion and disease prevention education, to Urban
Indians [identify all public and private health
services resources within such urban center which are
or may be available to urban Indians];
(5) make recommendations to the Secretary and
Federal, State, local, and other resource agencies on
methods of improving health service programs to meet
the needs of Urban Indians [determine the use of public
and private health services resources by the urban
Indians residing in such urban center]; and
(6) where necessary, provide, or enter into contracts
for the provision of, health care services for Urban
Indians. [assist such health services resources in
providing services to urban Indians;]
[(7) assist urban Indians in becoming familiar with
and utilizing such health services resources;]
[(8) provide basic health education, including health
promotion 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 improving health service programs to meet
the needs of urban Indians; and]
[(12) where necessary, provide, or enter into
contracts for the provision of, health care services
for urban Indians.]
(b) Criteria [for selection of organizations to enter
into contracts or receive grants].--The Secretary,
acting through the Service, shall, by regulation,
prescribe the criteria for selecting [u]Urban Indian
[o]Organizations to enter into contracts or receive
grants under this section. Such criteria shall, among
other factors, include--
(1) the extent of unmet health care needs of [u]Urban
Indians in the [u]Urban [c]Center or centers involved;
(2) the size of the [u]Urban Indian population in the
[u]Urban [c]Center or centers involved;
[(3) the accessibility to, and utilization of, health
care services (other than services provided under this
subchapter) by urban Indians in the urban center
involved;]
(3)[(4)] the extent, if any, to which the activities
set forth in subsection (a) [of this section] would
duplicate any project funded under this title;[--]
[(A) any previous or current public or
private health services project in an urban
center that was or is funded in a manner other
than pursuant to this subchapter; or]
[(B) any project funded under this
subchapter;]
(4)[(5)] the capability of an [u]Urban Indian
[o]Organization to perform the activities set forth in
subsection (a) [of this section] and to enter into a
contract with the Secretary or to meet the requirements
for receiving a grant under this section;
(5)[(6)] the satisfactory performance and successful
completion by an [u]Urban Indian [o]Organization of
other contracts with the Secretary under this title
[subchapter];
(6)[(7)] the appropriateness and likely effectiveness
of conducting the activities set forth in subsection
(a) [of this section] in an [u]Urban [c]Center or
centers; and
(7)[(8)] the extent of existing or likely future
participation in the activities set forth in subsection
(a) [of this section] by appropriate health and health-
related Federal, State, local, and other agencies.
(c) Access to Health Promotion and Disease Prevention
Programs.--[Grants for health promotion and disease prevention
services] The Secretary, acting through the Service, shall
facilitate access to[,] or provide[,] health promotion and
disease prevention services for [u]Urban Indians through grants
made to [u]Urban Indian [o]Organizations administering
contracts entered into [pursuant to this section] or receiving
grants under subsection (a) [of this section].
(d) [Grants for i]Immunization [s]Services
(1) Access or services provided.--The Secretary,
acting through the Service, shall facilitate access to,
or provide, immunization services for [u]Urban Indians
through grants made to [u]Urban Indian [o]Organizations
administering contracts entered into [pursuant to this
section] or receiving grants under [subsection (a) of]
this section.
(2) Definition.--For purposes of this subsection, the
term `immunization services' means services to provide
without charge immunizations against vaccine-
preventable diseases.
[(2) In making any grant to carry out this
subsection, the Secretary shall take into
consideration--]
[(A) the size of the urban Indian population
to be served;]
[(B) the immunization levels of the urban
Indian population, particularly the
immunization levels of infants, children, and
the elderly;]
[(C) the utilization by the urban Indians of
alternative resources from State and local
governments for no-cost or low-cost
immunization services to the general
population; and]
[(D) the capability of the urban Indian
organization to carry out services pursuant to
this subsection.]
[(3) For purposes of this subsection, the term
``immunization services'' means services to provide
without charge immunizations against vaccine-
preventable diseases.]
(e) Behavioral [Grants for provision of mental h]Health
[s]Services.--
(1) Access or services provided.--The Secretary,
acting through the Service, shall facilitate access to,
or provide, behavioral [mental] health services for
[u]Urban Indians through grants made to [u]Urban Indian
[o]Organizations administering contracts entered into
[pursuant to this section] or receiving grants under
subsection (a) [of this section].
(2) Assessment required.--Except as provided by
paragraph (3)(A), a [A] grant may not be made under
this subsection to an [u]Urban Indian [o]Organization
until that organization has prepared, and the Service
has approved, an assessment of the following: [mental
health needs of the urban Indian population concerned,
the mental health services and other related resources
available to that population, the barriers to obtaining
those services and resources, and the needs that are
unmet by such services and resources.]
(A) The behavioral health needs of the Urban
Indian population concerned.
(B) The behavioral health services and other
related resources available to that population.
(C) The barriers to obtaining those services
and resources.
(D) The needs that are unmet by such services
and resources.
(3) Purposes of grants.--Grants may be made under
this subsection[--] for the following:
(A) [t]To prepare assessments required under
paragraph (2)[;].
(B) [t]To provide outreach, educational, and
referral services to [u]Urban Indians regarding
the availability of direct behavioral [mental]
health services, to educate [u]Urban Indians
about behavioral [mental] health issues and
services, and effect coordination with existing
behavioral [mental] health providers in order
to improve services to [u]Urban Indians[;].
(C) [t]To provide outpatient behavioral
[mental] health services to [u]Urban Indians,
including the identification and assessment of
illness, therapeutic treatments, case
management, support groups, family treatment,
and other treatment.[; and]
(D) [t]To develop innovative behavioral
[mental] health service delivery models which
incorporate Indian cultural support systems and
resources.
(f) [Grants for p]Prevention [and treatment] of [c]Child
[a]Abuse
(1) Access or services provided.--The Secretary,
acting through the Service, shall facilitate access
to[,] or provide[,] services for [u]Urban Indians
through grants to [u]Urban Indian [o]Organizations
administering contracts entered into [pursuant to this
section] or receiving grants under subsection (a) [of
this section] to prevent and treat child abuse
(including sexual abuse) among [u]Urban Indians.
(2) Evaluation required.--Except as provided by
paragraph (3)(A), a [A] grant may not be made under
this subsection to an [u]Urban Indian [o]Organization
until that organization has prepared, and the Service
has approved, an assessment that documents the
prevalence of child abuse in the [u]Urban Indian
population concerned and specifies the services and
programs (which may not duplicate existing services and
programs) for which the grant is requested.
(3) Purposes of grants.--Grants may be made under
this subsection[--] for the following:
(A) [t]To prepare assessments required under
paragraph (2)[;].
(B) [f]For the development of prevention,
training, and education programs for [u]Urban
Indians [populations], including child
education, parent education, provider training
on identification and intervention, education
on reporting requirements, prevention
campaigns, and establishing service networks of
all those involved in Indian child
protection.[; and]
(C) [t]To provide direct outpatient treatment
services (including individual treatment,
family treatment, group therapy, and support
groups) to [u]Urban Indians who are child
victims of abuse (including sexual abuse) or
adult survivors of child sexual abuse, to the
families of such child victims, and to [u]Urban
Indian perpetrators of child abuse (including
sexual abuse).
(4) Considerations when making grants.--In making
grants to carry out this subsection, the Secretary
shall take into consideration--
(A) the support for the [u]Urban Indian
[o]Organization demonstrated by the child
protection authorities in the area, including
committees or other services funded under the
Indian Child Welfare Act of 1978 (25 U.S.C.
1901 et seq.), if any;
(B) the capability and expertise demonstrated
by the [u]Urban Indian [o]Organization to
address the complex problem of child sexual
abuse in the community; and (C) the assessment
required under paragraph (2).
(C) the assessment required under paragraph
(2).
(g) Other Grants.--The Secretary, acting through the
Service, may enter into a contract with or make grants to an
Urban Indian Organization that provides or arranges for the
provision of health care services (through satellite
facilities, provider networks, or otherwise) to Urban Indians
in more than 1 Urban Center.
Sec. 1654. Contracts and [g]Grants for the [d]Determination of [u]Unmet
[h]Health [c]Care [n]Needs
(a) Grants and Contracts Authorized.--[Authority] Under
authority of the Act of November 2, 1921 (25 U.S.C. 13)[,
popularly] (commonly known as the `Snyder Act'), the Secretary,
acting through the Service, may enter into contracts with[,] or
make grants to[, u]Urban Indian [o]Organizations situated in
[u]Urban [c]Centers for which contracts have not been entered
into[,] or grants have not been made[,] under section 503 [1653
of this title].
(b) Purpose._The purpose of a contract or grant made under
this section shall be the determination of the matters
described in subsection (c)[(b)](1) [of this section] in order
to assist the Secretary in assessing the health status and
health care needs of [u]Urban Indians in the [u]Urban [c]Center
involved and determining whether the Secretary should enter
into a contract or make a grant under section 503[1653 of this
title] with respect to the [u]Urban Indian [o]Organization
which the Secretary has entered into a contract with, or made a
grant to, under this section.
(c)[(b)] Grant and Contract Requirements.--Any contract
entered into, or grant made, by the Secretary under this
section shall include requirements that--
(1) the [u]Urban Indian [o]Organization successfully
undertakes to--
(A) document the health care status and unmet
health care needs of [u]Urban Indians in the
[u]Urban [c]Center involved; and
(B) with respect to [u]Urban Indians in the
[u]Urban [c]Center involved, determine the
matters described in paragraphs [clauses] (2),
(3), (4), and (7)[(8)] of section
503(b)[1653(b) of this title]; and
(2) the [u]Urban Indian [o]Organization complete
performance of the contract, or carry out the
requirements of the grant, within 1[one] year after the
date on which the Secretary and such organization enter
into such contract, or within 1[one] year after such
organization receives such grant, whichever is
applicable.
(d)[(c)] No Renewals.--The Secretary may not renew any
contract entered into [,] or grant made [,] under this section.
Sec. 1655. Evaluations; [r]Renewals
(a) Procedures for Evaluations.--[Contract compliance and
performance] The Secretary, acting through the Service, shall
develop procedures to evaluate compliance with grant
requirements [under this subchapter] and compliance with[,] and
performance of contracts entered into by [u]Urban Indian
[o]Organizations under this title [subchapter]. Such procedures
shall include provisions for carrying out the requirements of
this section.
(b) [Annual onsite e]Evaluations.--The Secretary, acting
through the Service, shall evaluate the compliance [conduct an
annual onsite evaluation] of each [u]Urban Indian
[o]Organization which has entered into a contract or received a
grant under section 503 with the terms of [1653 of this title
for purposes of determining the compliance of such organization
with, and evaluating the performance of such organization
under, such contract or the terms of] such contract or grant.
For purposes of this evaluation, in determining the capacity of
an Urban Indian Organization to deliver quality patient care
the Secretary shall--
(1) acting through the Service, conduct an annual
onsite evaluation of the organization; or
(2) accept in lieu of such onsite evaluation evidence
of the organization's provisional or full accreditation
by a private independent entity recognized by the
Secretary for purposes of conducting quality reviews of
providers participating in the Medicare program under
title XVIII of the Social Security Act.
(c) Noncompliance; [or u]Unsatisfactory [p]Performance.--
If, as a result of the evaluations conducted under this
section, the Secretary determines that an [u]Urban Indian
[o]Organization has not complied with the requirements of a
grant or complied with or satisfactorily performed a contract
under section 503 [1653 of this title], the Secretary shall,
prior to renewing such contract or grant, attempt to resolve
with the [such] organization the areas of noncompliance or
unsatisfactory performance and modify the [such] contract or
grant to prevent future occurrences of [such] noncompliance or
unsatisfactory performance. If the Secretary determines that
the [such] noncompliance or unsatisfactory performance cannot
be resolved and prevented in the future, the Secretary shall
not renew the [such] contract or grant with the [such]
organization and is authorized to enter into a contract or make
a grant under section 503 [1653 of this title] with another
[u]Urban Indian [o]Organization which is situated in the same
[u]Urban [c]Center as the [u]Urban Indian [o]Organization whose
contract or grant is not renewed under this section.
(d) Considerations for Contract and grant r]Renewals.-- In
determining whether to renew a contract or grant with an
[u]Urban Indian [o]Organization under section 503 [1653 of this
title] which has completed performance of a contract or grant
under section 504 [1654 of this title], the Secretary shall
review the records of the [u]Urban Indian [o]Organization, the
reports submitted under section 507 [1657 of this title, and,
in the case of a renewal of a contract or grant under section
1653 of this title], and shall consider the results of the
onsite evaluations or accreditations [conducted] under
subsection (b) [of this section].
Sec. 1656. Other [c]Contract and [g]Grant [r]Requirements
(a) Procurement._Federal regulations; exceptions]
Contracts with [u]Urban Indian [o]Organizations entered into
pursuant to this title [subchapter] shall be in accordance with
all Federal contracting laws and regulations relating to
procurement except that[,] in the discretion of the Secretary,
such contracts may be negotiated without advertising and need
not conform to the provisions of sections 1304 and 3131 through
[3131 to] 3133 of [T]title 40, United States Code.
(b) Payment Under Contracts or Grants._Payments under any
contracts or grants pursuant to this title shall,
notwithstanding any term or condition of such contract or
grant--[subchapter may be made in advance or by way of
reimbursement and in such installments and on such conditions
as the Secretary deems necessary to carry out the purposes of
this subchapter.]
(1) be made in their entirety by the Secretary to the
Urban Indian Organization by no later than the end of
the first 30 days of the funding period with respect to
which the payments apply, unless the Secretary
determines through an evaluation under section 505 that
the organization is not capable of administering such
payments in their entirety; and
(2) if any portion thereof is unexpended by the Urban
Indian Organization during the funding period with
respect to which the payments initially apply, shall be
carried forward for expenditure with respect to
allowable or reimbursable costs incurred by the
organization during 1 or more subsequent funding
periods without additional justification or
documentation by the organization as a condition of
carrying forward the availability for expenditure of
such funds.
(c) Revision or [a]Amendment of Contracts._Notwithstanding
any provision of law to the contrary, the Secretary may, at the
request and consent of an [u]Urban Indian [o]Organization,
revise or amend any contract entered into by the Secretary with
such organization under this title [subchapter] as necessary to
carry out thepurposes of this title [subchapter].
[(d) Existing Government facilities]
[In connection with any contract or grant entered into
pursuant to this subchapter, the Secretary may permit an urban
Indian organization to utilize, in carrying out such contract
or grant, 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.]
(d) Fair and (e)] Uniform [provision of s]Services and
[a]Assistance.--Contracts with[,] or grants to[, u]Urban Indian
[o]Organizations and regulations adopted pursuant to this title
[subchapter] shall include provisions to assure the fair and
uniform provision to [u]Urban Indians of services and
assistance under such contracts or grants by such
organizations.
[(f) Eligibility for health care or referral services]
[Urban Indians, as defined in section 1603(f) of this
title, shall be eligible for health care or referral services
provided pursuant to this subchapter.]
Sec. 1657. Reports and [r]Records
(a) [Quarterly r]Reports.--For each fiscal year during
which an [u]Urban Indian [o]Organization receives or expends
funds pursuant to a contract entered into[,] or a grant
received[,] pursuant to this title [subchapter], such Urban
Indian O[o]rganization shall submit to the Secretary not more
frequently than every 6 months, a [quarterly] report that
includes the following: [including--]
(1) [i]In the case of a contract or grant under
section 503, recommendations pursuant to section
503(a)(5). [1653 of this title, information gathered
pursuant to clauses (10) and (11) of this subsection
(a) of such section;]
(2) [i]Information on activities conducted by the
organization pursuant to the contract or grant[;].
(3) [a]An accounting of the amounts and purpose[s]
for which Federal funds were expended.[; and]
(4) A minimum set of data, using uniformly defined
elements, as specified by the Secretary after
consultation with Urban Indian Organizations. [such
other information as the Secretary may request.]
(b) Audit [by Secretary and Comptroller General].--
The reports and records of the [u]Urban Indian
[o]Organization with respect to a contract or grant under this
title [subchapter] shall be subject to audit by the Secretary
and the Comptroller General of the United States.
(c) Cost of [annual private a]Audits.--The Secretary shall
allow as a cost of any contract or grant entered into or
awarded under section 502 or 503 [1653 of this title] the cost
of an annual independent financial [private] audit conducted
by--
(1) a certified public accountant[.]; or
(2) a certified public accounting firm qualified to
conduct Federal compliance audits.
[(d) Health status, services, and areas of unmet needs;
child welfare]
[(1) The Secretary, acting through the Service, shall
submit a report to the Congress not later than March
31, 1992, evaluating--]
[(A) the health status of urban Indians;]
[(B) The services provided to Indians through
this subchapter;]
[(C) areas of unmet needs in urban areas
served under this subchapter; and]
[(D) areas of unmet needs in urban areas not
served under this subchapter.]
[(2) In preparing the report under paragraph (1), the
Secretary shall consult with urban Indian health
providers and may contract with a national organization
representing urban Indian health concerns to conduct
any aspect of the report.]
[(3) The Secretary and the Secretary of the Interior
shall--]
[(A) assess the status of the welfare of
urban Indian children, including the volume of
child protection cases, the prevalence of child
sexual abuse, and the extent of urban Indian
coordination with tribal authorities with
respect to child sexual abuse; and]
[(B) submit a report on the assessment
required under subparagraph (A), together with
recommended legislation to improve Indian child
protection in urban Indian populations, to the
Congress no later than March 31, 1992.]
Sec. 1658. Limitation on [c]Contract [a]Authority
The authority of the Secretary to enter into contracts or
to award grants under this title [subchapter] shall be to the
extent, and in an amount, provided for in appropriation Acts.
Sec. 1659. Facilities [renovation]
(a) Grants.--The Secretary, acting through the Service, may
make grants [funds available] to contractors or grant
recipients under this title [subchapter] for the lease,
purchase, renovation, construction, or expansion of [minor
renovations to] facilities, including leased facilities, in
order to assist such contractors or grant recipients in
complying with applicable licensure or certification
requirements [meeting or maintaining the Joint Commission for
Accreditation of Health Care Organizations (JCAHO) standards].
(b) Loan Fund Study.--The Secretary, acting through the
Services, may carry out a study to determine the feasibility of
establishing a loan fund to provide to Urban Indian
Organizations direct loans or guarantees for loans for the
construction of health care facilities in a manner consistent
with Section 309.
Sec. 1660. Division of Urban Indian Health [Programs Branch]
[(a) Establishment]
There is established within the Service a Division [a
Branch] of Urban Indian Health, [Programs] which shall be
responsible for--
(1) carrying out the provisions of this title;
[subchapter and for]
(2) providing central oversight of the programs and
services authorized under this title; and [subchapter.]
(3) providing technical assistance to Urban Indian
Organizations.
[(b) Staff, services, and equipment]
[The Secretary shall appoint such employees to work in the
branch, including a program director, and shall provide such
services and equipment, as may be necessary for it to carry out
its responsibilities. The Secretary shall also analyze the need
to provide at least one urban health program analyst for each
area office of the Indian Health Service and shall submit his
findings to the Congress as a part of the Department's fiscal
year 1993 budget request.]
Sec. 1660a. Grants for [a]Alcohol and [s]Substance [a]Abuse rRelated
[s]Services
(a) Grants Authorized._The Secretary, acting through the
Service, may make grants for the provision of health-related
services in prevention of, treatment of, rehabilitation of, or
school and community-based education regarding [in], alcohol
and substance abuse in [u]Urban [c]Centers to those [u]Urban
Indian [o]Organizations with which [whom] the Secretary has
entered into a contract under this title [subchapter] or under
section 201[1621 of this title].
(b) Goals [of grant].--Each grant made pursuant to
subsection (a) [of this section] shall set forth the goals to
be accomplished pursuant to the grant. The goals shall be
specific to each grant as agreed to between the Secretary and
the grantee.
(c) Criteria.--The Secretary shall establish criteria for
the grants made under subsection (a) [of this section],
including criteria relating to the following:[--]
(1) The size of the [u]Urban Indian population[;].
[(2) accessibility to, and utilization of, other
health resources available to such population;]
[(3) duplication of existing Service or other Federal
grants or contracts;]
(2) [(4) c]Capability of the organization to
adequately perform the activities required under the
grant[;].
(3)[(5) s]Satisfactory performance standards for the
organization in meeting the goals set forth in such
grant.[, which] The standards shall be negotiated and
agreed to between the Secretary and the grantee on a
grant-by-grant basis.[; and]
(4)[(6) i]Identification of need for services.
(d) Allocation of Grants.--The Secretary shall develop a
methodology for allocating grants made pursuant to this section
based on the [such] criteria established pursuant to subsection
(c).
(e)[(d)] Grants Subject to Criteria.--[Treatment of funds
received by urban Indian organizations] Any funds received by
an [u]Urban Indian [o]Organization under this Act [chapter] for
substance abuse prevention, treatment, and rehabilitation shall
be subject to the criteria set forth in subsection (c) [of this
section].
Sec. 1660b. Treatment of [c]Certain [d]Demonstration [p]Projects
[(a)] Notwithstanding any other provision of law, the Tulsa
Clinic and Oklahoma City Clinic demonstration projects shall--
[and the Tulsa Clinic demonstration project shall be treated as
service units in the allocation of resources and coordination
of care and shall not be subject to the provisions of the
Indian Self-Determination Act [25 U.S.C.A. Sec. 450f et seq.]
for the term of such projects. The Secretary shall provide
assistance to such projects in the development of resources and
equipment and facility needs.]
(1) be permanent programs within the Service's direct
care program;
(2) continue to be treated as Service Units in the
allocation of resources and coordination of care; and
(3) continue to meet the requirements and definitions
of an Urban Indian Organization in this Act, and shall
not be subject to the provisions of the Indian Self-
Determination and Education Assistance Act (25 U.S.C.
450 et seq.).
[(b) The Secretary shall submit to the President, for
inclusion in the report required to be submitted to the
Congress under section 1671 of this title for fiscal year 1999,
a report on the findings and conclusions derived from the
demonstration projects specified in subsection (a) of this
section.]
[(c) In addition to the amounts made available under
section 1660d of this title to carry out this section through
fiscal year 2000, there are authorized to be appropriated such
sums as may be necessary to carry out this section for each of
fiscal years 2001 and 2002.]
Sec. 1660c. Urban NIAAA [t]Transferred [p]Programs
(a) Grants and Contracts.--[Duty of Secretary] The
Secretary, through the Division [shall, within the Branch] of
Urban Indian Health, shall [Programs of the Service,] make
grants or enter into contracts with Urban Indian Organizations,
to take effect not later than September 30, 2008, for the
administration of [u]Urban Indian alcohol programs that were
originally established under the National Institute on
Alcoholism and Alcohol Abuse (hereafter in this section
referred to as [``] `NIAAA' ['']) and transferred to the
Service.
(b) Use of Funds.--[grants] Grants provided or contracts
entered into under this section shall be used to provide
support for the continuation of alcohol prevention and
treatment services for [u]Urban Indian populations and such
other objectives as are agreed upon between the Service and a
recipient of a grant or contract under this section.
(c) Eligibility.--[for grants] Urban Indian
[o]Organizations that operate Indian alcohol programs
originally funded under the NIAAA and subsequently transferred
to the Service are eligible for grants or contracts under this
section.
[(d) Combination of funds]
[For the purpose of carrying out this section, the
Secretary may combine NIAAA alcohol funds with other substance
abuse funds currently administered through the Branch of
UrbanHealth Programs of the Service.]
(d)[(e) Evaluation and r]Report.--[to Congress] The
Secretary shall evaluate and report to [the] Congress on the
activities of programs funded under this section not less than
[at least] every 5 years.
Sec. 514. Consultation with Urban Indian Organizations
(a) In General.--The Secretary shall ensure that the
Service consults, to the greatest extent practicable, with
Urban Indian Organizations.
(b) Definition of Consultation.--For purposes of subsection
(a), consultation is the open and free exchange of information
and opinions which leads to mutual understanding and
comprehension and which emphasizes trust, respect, and shared
responsibility.
Sec. 515. Federal Tort Claim Act Coverage
(a) In General.--With respect to claims resulting from the
performance of functions during fiscal year 2005 and
thereafter, or claims asserted after September 30, 2004, but
resulting from the performance of functions prior to fiscal
year 2005, under a contract, grant agreement, or any other
agreement authorized under this title, an Urban Indian
Organization is deemed hereafter to be part of the Service in
the Department of Health and Human Services while carrying out
any such contract or agreement and its employees are deemed
employees of the Service while acting within the scope of their
employment in carrying out the contract or agreement. After
September 30, 2003, any civil action or proceeding involving
such claims brought hereafter against any Urban Indian
Organization or any employee of such Urban Indian Organization
covered by this provision shall be deemed to be an action
against the United States and will be defended by the Attorney
General and be afforded the full protection and coverage of the
Federal Tort Claims Act (28 U.S.C. 1346(b), 2671 et seq.).
Future coverage under that Act shall be contingent on
cooperation of the Urban Indian Organization with the Attorney
General in prosecuting past claims.
(b) Claims Resulting From Performance of Contract or
Grant.--Beginning for fiscal year 2005 and thereafter, the
Secretary shall request through annual appropriations funds
sufficient to reimburse the Treasury for any claims paid in the
prior fiscal year pursuant to the foregoing provisions.
Sec. 516. Urban Youth Treatment Center Demonstration
(a) Construction and Operation.--The Secretary, acting
through the Service, through grant or contract, is authorized
to fund the construction and operation of at least 2
residential treatment centers in each State described in
subsection (b) to demonstrate the provision of alcohol and
substance abuse treatment services to Urban Indian youth in a
culturally competent residential setting.
(b) Definition of State.--A State described in this
subsection is a State in which--
(1) there resides Urban Indian youth with need for
alcohol and substance abuse treatment services in a
residential setting; and
(2) there is a significant shortage of culturally
competent residential treatment services for Urban
Indian youth.
Sec. 517. Use of Federal Government Facilities and Sources of Supply
(a) Authorization for Use.--The Secretary, acting through
the Service, shall allow an Urban Indian Organization that has
entered into a contract or received a grant pursuant to this
title, in carrying out such contract or grant, to use existing
facilities and all equipment therein or pertaining thereto and
other personal property owned by the Federal Government within
the Secretary's jurisdiction under such terms and conditions as
may be agreed upon for their use and maintenance.
(b) Donations.--Subject to subsection (d), the Secretary
may donate to an Urban Indian Organization that has entered
into a contract or received a grant pursuant to this title any
personal or real property determined to be excess to the needs
of the Service or the General Services Administration for
purposes of carrying out the contract or grant.
(c) Acquisition of Property for Donation.--The Secretary
may acquire excess or surplus government personal or real
property for donation (subject to subsection (d)), to an Urban
Indian Organization that has entered into a contract or
received a grant pursuant to this title if the Secretary
determines that the property is appropriate for use by the
Urban Indian Organization for a purpose for which a contract or
grant is authorized under this title.
(d) Priority.--In the event that the Secretary receives a
request for donation of a specific item of personal or real
property described in subsection (b) or (c) from both an Urban
Indian Organization and from an Indian Tribe or Tribal
Organization, the Secretary shall give priority to the request
for donation of the Indian Tribe or Tribal Organization if the
Secretary receives the request from the Indian Tribe or Tribal
Organization before the date the Secretary transfers title to
the property or, if earlier, the date the Secretary transfers
the property physically to the Urban Indian Organization.
(e) Urban Indian Organizations Deemed Executive Agency for
Certain Purposes.--For purposes of section 501 of title 40,
United States Code, (relating to Federal sources of supply,
including lodging providers, airlines, and other transportation
providers), an Urban Indian Organization that has entered into
a contract or received a grant pursuant to this title shall be
deemed an executive agency when carrying out such contract or
grant.
Sec. 518. Grants for Diabetes Prevention, Treatment, and Control
(a) Grants Authorized.--The Secretary may make grants to
those Urban Indian Organizations that have entered into a
contract or have received a grant under this title for the
provision ofservices for the prevention and treatment of, and
control of the complications resulting from, diabetes among Urban
Indians.
(b) Goals.--Each grant made pursuant to subsection (a)
shall set forth the goals to be accomplished under the grant.
The goals shall be specific to each grant as agreed to between
the Secretary and the grantee.
(c) Establishment of Criteria.--The Secretary shall
establish criteria for the grants made under subsection (a)
relating to--
(1) the size and location of the Urban Indian
population to be served;
(2) the need for prevention of and treatment of, and
control of the complications resulting from, diabetes
among the Urban Indian population to be served;
(3) performance standards for the organization in
meeting the goals set forth in such grant that are
negotiated and agreed to by the Secretary and the
grantee;
(4) the capability of the organization to adequately
perform the activities required under the grant; and
(5) the willingness of the organization to
collaborate with the registry, if any, established by
the Secretary under section 204(e) in the Area Office
of the Service in which the organization is located.
(d) Funds Subject to Criteria.--Any funds received by an
Urban Indian Organization under this Act for the prevention,
treatment, and control of diabetes among Urban Indians shall be
subject to the criteria developed by the Secretary under
subsection (c).
Sec. 519. Community Health Representatives
The Secretary, acting through the Service, may enter into
contracts with, and make grants to, Urban Indian Organizations
for the employment of Indians trained as health service
providers through the Community Health Representatives Program
under section 109 in the provision of health care, health
promotion, and disease prevention services to Urban Indians.
Sec. 520. Effective Date
The amendments made by the Indian Health Care Improvement
Act Amendments of 2005 to this title shall take effect
beginning on the date of enactment of that Act, regardless of
whether the Secretary has promulgated regulations implementing
such amendments.
Sec. 521. Eligibility for Services
Urban Indians shall be eligible and the ultimate
beneficiaries for health care or referral services provided
pursuant to this title.
Sec. 1660d. Authorization of [a]Appropriations
There are authorized to be appropriated such sums as may be
necessary for each fiscal year through fiscal year 2015 [2000]
to carry out this title [subchapter].
TITLE VI [SUBCHAPTER V]--ORGANIZATIONAL IMPROVEMENTS
Sec. 1661. Establishment of the Indian Health Service as an A agency
of the Public Health Service
(a) Establishment.--
(1) In general.--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
[t]Tribes, as are or may be hereafter [on and after
November 23,1988,] 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.
(2) Assistant secretary of indian health.--The
[Indian Health] Service shall be administered by an
Assistant Secretary of Indian Health [a Director], who
shall be appointed by the President, by and with the
advice and consent of the Senate. The Assistant
Secretary [Director of the Indian Health Service] shall
report to the Secretary. [through the Assistant
Secretary for Health of the Department of Health and
Human Services.] Effective with respect to an
individual appointed by the President, by and with the
advice and consent of the Senate, after January 1,
2005[1993], the term of service of the Assistant
Secretary [Director] shall be 4 years. An Assistant
Secretary [A Director] may serve more that 1 term.
(3) Incumbent.--The individual serving in the
position of Director of the Indian Health Service on
the day before the date of enactment of the Indian
Health Care Improvement Act Amendments of 2005 shall
serve as Assistant Secretary.
(4) Advocacy and consultation--The position of
Assistant Secretary is established to, in a manner
consistent with the government-to-government
relationship between the United States and Indian
Tribes--
(A) facilitate advocacy for the development
of appropriate Indian health policy; and
(B) promote consultation on matters relating
to Indian health.
(b) Agency.--[status] 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) Duties.--The Assistant Secretary [shall carry out
through the Director] of [the] Indian Health [Service] shall--
(1) perform all functions that [which] were, on the
day before the date of enactment of the Indian Health
Care Improvement Act Amendments of 2005, [November 23,
1988,] carried out by or under the direction of the
individual serving as Director of the Indian Health
Service on that [such] day;
(2) perform all functions of the Secretary relating
to the maintenance and operation of hospital and health
facilities for Indians and the planning for, and
provision and utilization of, health services for
Indians;
(3) administer all health programs under which health
care is provided to Indians based upon their status as
Indians which are administered by the Secretary,
including [(but not limited to)] programs under--
(A) this Act [chapter];
(B) the Act of November 2, 1921 (25 U.S.C.
13);
(C) the Act of August 5, 1954 (42 U.S.C. 2001
et seq.);
(D) the Act of August 16, 1957 (42 U.S.C.
2005 et seq.); and
(E) the Indian Self-Determination and
Education Assistance Act (25 U.S.C. 450[f] et
seq.); [and]
(4) administer all scholarship and loan functions
carried out under title [subchapter] I [of this
chapter.];
(5) report directly to the Secretary concerning all
policy- and budget-related matters affecting Indian
health;
(6) collaborate with the Assistant Secretary for
Health concerning appropriate matters of Indian health
that affect the agencies of the Public Health Service;
(7) advise each Assistant Secretary of the Department
concerning matters of Indian health with respect to
which that Assistant Secretary has authority and
responsibility;
(8) advise the heads of other agencies and programs
of the Department concerning matters of Indian health
with respect to which those heads have authority and
responsibility;
(9) coordinate the activities of the Department
concerning matters of Indian health; and
(10) perform such other functions as the Secretary
may designate.
(d) Authority.--[of Secretary]
(1) In general.--The Secretary, acting through the
Assistant Secretary [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
[T]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
(C) to manage, expend, and obligate all funds
appropriated for the Service.
(2) Personnel actions.--Notwithstanding any other
provisions of law, the provisions of section 12 [472]
of the Act of June 18, 1934 (48 Stat. 986; 25 U.S.C.
472) [this title], shall apply to all personnel actions
taken with respect to new positions created within the
Service as a result of its establishment under
subsection (a) [of this section].
(e) References.--Any reference to the Director of the
Indian Health Service in any other Federal law, Executive
order, rule, regulation, or delegation of authority, or in any
document of or relating to the Director of the Indian Health
Service, shall be deemed to refer to the Assistant Secretary.
Sec. 1662. Automated [m]Management [i]Information [s]System
(a) Establishment.--
(1) In general.--The Secretary shall establish an
automated management information system for the
Service.
(2) Requirements of system.--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 [s]Service[,];
(C) a privacy component that protects the
privacy of patient information held by, or on
behalf of, the Service[, and];
(D) a services-based cost accounting
component that provides estimates of the costs
associated with the provision of specific
medical treatments or services in each [a]Area
office of the Service[.];
(E) an interface mechanism for patient
billing and accounts receivable system; and
(F) a training component.
(b) Provision of Systems to [Indian t]Tribes and
[o]Organizations.--[; reimbursement] [(1)] The Secretary shall
provide each Tribal Health Program [Indian tribe and tribal
organization] that provides health services under a contract
entered into with the Service under the Indian Self-
Determination Act [25 U.S.C.A. Sec. 450f et seq.]] automated
management information systems which--
(1)[(A)] meet the management information needs of
such Tribal Health Program [Indian tribe or tribal
organization] with respect to the treatment by the
Tribal Health Program [Indian tribe or tribal
organization] of patients of the Service[,]; and
(2)[(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 systems under
paragraph (1) to Indian tribes and tribal organizations
providing health services in California by no later
than September 30, 1990.]
(c) Access to Records.--Notwithstanding any other provision
of law, each patient shall have reasonable access to the
medical or health records of such patient which are held by, or
on behalf of, the Service.
(d) Authority to Enhance Information Technology.--The
Secretary, acting through the Assistant Secretary, shall have
the authority to enter into contracts, agreements, or joint
ventures with other Federal agencies, States, private and
nonprofit organizations, for the purpose of enhancing
information technology in Indian health programs and
facilities.
Sec. 603. Authorization of Appropriations
There is authorized to be appropriated such sums as may be
necessary for each fiscal year through fiscal year 2015 to
carry out this title.
TITLE VII--BEHAVIORAL HEALTH SUBCHAPTER V--A--SUBSTANCE ABUSE
PROGRAMS
Sec. 701. Behavioral Health Prevention and Treatment Services
(a) Purposes.--The purposes of this section are as follows:
(1) To authorize and direct the Secretary, acting
through the Service, Indian Tribes, Tribal
Organizations, and Urban Indian Organizations, to
develop a comprehensive behavior health prevention and
treatment program which emphasizes collaboration among
alcohol and substance abuse, social services, and
mental health programs.
(2) To provide information, direction, and guidance
relating to mental illness and dysfunction and self-
destructive behavior, including child abuse and family
violence, to those Federal, tribal, State, and local
agencies responsible for programs in Indian communities
in areas of health care, education, social services,
child and family welfare, alcohol and substance abuse,
law enforcement, and judicial services.
(3) To assist Indian Tribes to identify services and
resources available to address mental illness and
dysfunctional and self-destructive behavior.
(4) To provide authority and opportunities for Indian
Tribes and Tribal Organizations to develop, implement,
and coordinate with community-based programs which
include identification, prevention, education,
referral, and treatment services, including through
multidisciplinary resource teams.
(5) To ensure that Indians, as citizens of the United
States and of the States in which they reside, have the
same access to behavioral health services to which all
citizens have access.
(6) To modify or supplement existing programs and
authorities in the areas identified in paragraph (2).
(b) Plans.--
(1) Development.--The Secretary, acting through the
Service, Indian Tribes, Tribal Organizations, and Urban
Indian Organizations, shall encourage Indian Tribes and
Tribal Organizations to develop tribal plans, and Urban
Indian Organizations to develop local plans, and for
all such groups to participate in developing areawide
plans for Indian Behavioral Health Services. The plans
shall include, to the extent feasible, the following
components:
(A) An assessment of the scope of alcohol or
other substance abuse, mental illness, and
dysfunctional and self-destructive behavior,
including suicide, child abuse, and family
violence, among Indians, including--
(i) the number of Indians served who
are directly or indirectly affected by
such illness or behavior; or
(ii) an estimate of the financial and
human cost attributable to such illness
or behavior.
(B) An assessment of the existing and
additional resources necessary for the
prevention and treatment of such illness and
behavior, including an assessment of the
progresstoward achieving the availability of
the full continuum of care described in subsection (c).
(C) An estimate of the additional funding
needed by the Service, Indian Tribes, Tribal
Organizations, and Urban Indian Organizations
to meet their responsibilities under the plans.
(2) National clearinghouse.--The Secretary, acting
through the Service, shall establish a national
clearinghouse of plans and reports on the outcomes of
such plans developed by Indian Tribes, Tribal
Organizations, Urban Indian Organizations, and Service
Areas relating to behavioral health. The Secretary
shall ensure access to these plans and outcomes by any
Indian Tribe, Tribal Organization, Urban Indian
Organization, or the Service.
(3) Technical assistance.--The Secretary shall
provide technical assistance to Indian Tribes, Tribal
Organizations, and Urban Indian Organizations in
preparation of plans under this section and in
developing standards of care that may be used and
adopted locally.
(c) Programs.--The Secretary, acting through the Service,
Indian Tribes, and Tribal Organizations, shall provide, to the
extent feasible and if funding is available, programs including
the following:
(1) Comprehensive care.--A comprehensive continuum of
behavioral health care which provides--
(A) community-based prevention, intervention,
outpatient, and behavioral health aftercare;
(B) detoxification (social and medical);
(C) acute hospitalization;
(D) intensive outpatient/day treatment;
(E) residential treatment;
(F) transitional living for those needing a
temporary, stable living environment that is
supportive of treatment and recovery goals;
(G) emergency shelter;
(H) intensive case management;
(I) Traditional Health Care Practices; and
(J) diagnostic services.
(2) Child care.--Behavioral health services for
Indians from birth through age 17, including--
(A) preschool and school age fetal alcohol
disorder services, including assessment and
behavioral intervention;
(B) mental health and substance abuse
services (emotional, organic, alcohol, drug,
inhalant, and tobacco);
(C) identification and treatment of co-
occurring disorders and comorbidity;
(D) prevention of alcohol, drug, inhalant,
and tobacco use;
(E) early intervention, treatment, and
aftercare;
(F) promotion of healthy approaches to risk
and safety issues; and
(G) identification and treatment of neglect
and physical, mental, and sexual abuse.
(3) Adult care.--Behavioral health services for
Indians from age 18 through 55, including--
(A) early intervention, treatment, and
aftercare;
(B) mental health and substance abuse
services (emotional, alcohol, drug, inhalant,
and tobacco), including sex specific services;
(C) identification and treatment of co-
occurring disorders (dual diagnosis) and
comorbidity;
(D) promotion of healthy approached to risk-
related behaviors;
(E) treatment services for women at risk of
giving birth to a child with a fetal alcohol
disorder; and
(F) sex specific treatment for sexual assault
and domestic violence.
(4) Family care.--Behavioral health services for
families, including--
(A) early intervention, treatment, and
aftercare for affected families;
(B) treatment for sexual assault and domestic
violence; and
(C) promotion of healthy approaches relating
to parenting, domestic violence, and other
abuse issues.
(5) Elder care.--Behavioral health services for
Indians 56 years of age and older, including--
(A) early intervention, treatment, and
aftercare;
(B) mental health and substance abuse
services (emotional, alcohol, drug, inhalant,
and tobacco), including sex specific services;
(C) identification and treatment of co-
occurring disorders (dual diagnosis) and
comorbidity;
(D) promotion of healthy approaches to
managing conditions related to aging;
(E) sex specific treatment for sexual
assault, domestic violence, neglect, physical
and mental abuse and exploitation; and
(F) identification and treatment of dementias
regardless of cause.
(d) Community Behavioral Health Plan.--
(1) Establishment.--The governing body of any Indian
Tribe, Tribal Organization, or Urban Indian
Organization may adopt a resolution for the
establishment of a community behavioral health plan
providing for the identification and coordination of
available resources and programs to identify, prevent,
or treat substance abuse, mental illness, or
dysfunctional and self-destructive behavior, including
child abuse and family violence, among its members or
its service population. This plan should include
behavioral health services, social services, intensive
outpatient services, and continuing aftercare.
(2) Technical assistance.--At the request of an
Indian Tribe, Tribal Organization, or Urban Indian
Organization, the Bureau of Indian Affairs and the
Service shall cooperate with and provide technical
assistance to the Indian Tribe, Tribal Organization, or
Urban Indian Organization in the development and
implementation of such plan.
(3) Funding.--The Secretary, acting through the
Service, may make funding available to Indian Tribes
and Tribal Organizations which adopt a resolution
pursuant to paragraph (1) to obtain technical
assistance for the development of a community
behavioral health plan and to provide administrative
support in the implementation of such plan.
(e) Coordination for Availability of Services.--The
Secretary, acting through the Service, Indian Tribes, Tribal
Organizations, and Urban Indian Organizations, shall coordinate
behavioral health planning, to the extent feasible, with other
Federal agencies and with State agencies, to encourage
comprehensive behavioral health services for Indians regardless
of their place of residence.
(f) Mental Health Care Need Assessment.--Not later than 1
year after the date of the enactment of the Indian Health Care
Improvement Act Amendments of 2005, the Secretary, acting
through the Service, shall make an assessment of the need for
inpatient mental health care among Indians and the availability
and cost of inpatient mental health facilities which can meet
such need. In making such assessment, the Secretary shall
consider the possible conversion of existing, underused Service
hospital beds into psychiatric units to meet such need.
Sec. 702. Memoranda of Agreement with the Department of the Interior
[Sec. 1665. Indian Health Service responsibilities]
(a) Contents.--Not later than 12 months after the date of
the enactment of the Indian Health Care Improvement Act
Amendments of 2005, the Secretary, acting through the Service,
and the Secretary of the Interior shall develop and enter into
a memoranda of agreement, or review and update any existing
memoranda of agreement, as required by section 4205 of the
Indian Alcohol and Substance Abuse Prevention and Treatment Act
of 1986 (25 U.S.C. 2411) under which the Secretaries address
the following:
(1) The scope and nature of mental illness and
dysfunctional and self-destructive behavior, including
child abuse and family violence, among Indians.
(2) The existing Federal, tribal, State, local, and
private services, resources, and programs available to
provide behavioral health services for Indians.
(3) The unmet need for additional services,
resources, and programs necessary to meet the needs
identified pursuant to paragraph (1).
(4)(A) The right of Indians, as citizens of the
United States and of the States in which they reside,
to have access to behavioral health services to which
all citizens have access.
(B) The right of Indians to participate in, and
receive the benefit of, such services.
(C) The actions necessary to protect the exercise of
such right.
(5) The responsibilities of the Bureau of Indian
Affairs and the Service, including mental illness
identification, prevention, education, referral, and
treatment services (including services through
multidisciplinary resource teams), at the central,
area, and agency and Service Unit, Service Area, and
headquarters levels to address the problems identified
in paragraph (1).
(6) A strategy for the comprehensive coordination of
the behavioral health services provided by the Bureau
of Indian Affairs and the Service to meet the problems
identified pursuant to paragraph (1), including--
(A) the coordination of alcohol and substance
abuse programs of the Service, the Bureau of
Indian Affairs, and Indian Tribes and Tribal
Organizations (developed under the Indian
Alcohol and Substance Abuse Prevention and
Treatment Act of 1986) with behavioral health
initiatives pursuant to this Act, particularly
with respect to the referral and treatment
ofdually diagnosed individuals requiring behavioral health and
substance abuse treatment; and
(B) ensuring that the Bureau of Indian
Affairs and Service programs and services
(including multidisciplinary resource teams)
addressing child abuse and family violence are
coordinated with such non-Federal programs and
services.
(7) Directing appropriate officials of the Bureau of
Indian Affairs and the Service, particularly at the
agency and Service Unit levels, to cooperate fully with
tribal requests made pursuant to community behavioral
health plans adopted under section 701(c) and section
4206 of the Indian Alcohol and Substance Abuse
Prevention and Treatment Act of 1986 (25 U.S.C. 2412).
(8) Providing for an annual review of such agreement
by the Secretaries which shall be provided to Congress
and Indian Tribes and Tribal Organizations.
(b) Specific Provisions Required.--The [Memorandum]
memoranda of [A]agreement updated or entered into pursuant to
subsection (a) [section 2411 of this title] shall include
specific provisions pursuant to which the Service shall assue
responsibility for--
(1) the determination of the scope of the problem of
alcohol and substance abuse among Indians [people],
including the number of Indians within the jurisdiction
of the Service who are directly or indirectly affected
by alcohol and substance abuse and the financial and
human cost;
(2) an assessment of the existing and needed
resources necessary for the prevention of alcohol and
substance abuse and the treatment of Indians affected
by alcohol and substance abuse; and
(3) an estimate of the funding necessary to
adequately support a program of prevention of alcohol
and substance abuse and treatment of Indians affected
by alcohol and substance abuse.
(c) Consultation.--The Secretary, acting through the
Service, and the Secretary of the Interior shall, in developing
the memoranda of agreement under subsection (a), consult with
and solicit the comments from--
(1) Indian Tribes and Tribal Organizations;
(2) Indians;
(3) Urban Indian Organizations and other Indian
organizations; and
(4) behavioral health service providers.
(d) Publication.--Each memorandum of agreement entered into
or renewed (and amendments or modifications thereof) under
subsection (a) shall be published in the Federal Register. At
the same time as publication in the Federal Register, the
Secretary shall provide a copy of such memoranda, amendment, or
modification to each Indian Tribe, Tribal Organization, and
Urban Indian Organization.
[Sec. 1665a. Indian Health Service program]
Sec. 703. [(a)] Comprehensive Behavioral Health [p] Prevention and
[t]Treatment [p]Program
(a) Establishment.--
(1) In general.--The Secretary, acting through the
Service, Indian Tribes, and Tribal Organizations, shall
provide a program of comprehensive behavioral health,
[alcohol and substance abuse] prevention, [and]
treatment, and aftercare, including Traditional Health
Care Practices, which shall include--
(A) prevention, through educational
intervention, in Indian communities;
(B) acute detoxification, psychiatric
hospitalization, residential, and intensive
outpatient [and] treatment;
(C) community-based rehabilitation and
aftercare;
(D) community education and involvement,
including extensive training of health care,
educational, and community-based personnel;
[and]
(E) specialized residential treatment
programs for high-risk populations, including
pregnant and postpartum [post partum] women and
their children[.]; and
(F) diagnostic services.
(2) Target populations.--The target population of
such programs shall be members of Indian [t]Tribes.
Efforts to train and educate key members of the Indian
community shall also target employees of health,
education, judicial, law enforcement, legal, and social
service programs.
(b) Contract [h]Health [s]Services.--
(1) In general.--The Secretary, acting through the
Service, Indian Tribes, and Tribal Organizations, may
enter into contracts with public or private providers
of behavioral health [alcohol and substance abuse]
treatment services for the purpose of [assisting the
Service in] carrying out the program required under
subsection (a) [of this section].
(2) Provision of assistance.--In carrying out this
subsection, the Secretary shall provide assistance to
Indian [t]Tribes and Tribal Organizations to develop
criteria for the certification of behavioral health
[alcohol and substance abuse] service providers and
accreditation of service facilities which meet minimum
standards for such services and facilities [as may be
determined pursuant to section 2411(a)(3) of this
title].
Sec. 704. Mental Health Technician Program
(a) In General.--Under the authority of the Act of November
2, 1921 (25 U.S.C. 13) (commonly known as the `Snyder Act'),
the Secretary shall establish and maintain a mental health
technician program within the Service which--
(1) provides for the training of Indians as mental
health technicians; and
(2) employs such technicians in the provision of
community-based mental health care that includes
identification, prevention, education, referral, and
treatment services.
(b) Paraprofessional Training.--In carrying out subsection
(a), the Secretary, acting through the Service, Indian Tribes,
and Tribal Organizations, shall provide high-standard
paraprofessional training in mental health care necessary to
provide quality care to the Indian communities to be served.
Such training shall be based upon a curriculum developed or
approved by the Secretary which combines education in the
theory of mental health care with supervised practical
experience in the provision of such care.
(c) Supervision and Evaluation of Technicians.--The
Secretary, acting through the Service, Indian Tribes, and
Tribal Organizations, shall supervise and evaluate the mental
health technicians in the training program.
(d) Traditional Health Care Practices.--The Secretary,
acting through the Service, shall ensure that the program
established pursuant to this subsection involves the use and
promotion of the Traditional Health Care Practices of the
Indian Tribes to be served.
[(c) Grants for model program]
[(1) The Secretary, acting through the Service shall
make a grant to the Standing Rock Sioux Tribe to
develop a community-based demonstration project to
reduce drug and alcohol abuse on the Standing Rock
Sioux Reservation and to rehabilitate Indian families
afflicted by such abuse.]
[(2) Funds shall be used by the Tribe to--]
[(A) develop and coordinate community-based
alcohol and substance abuse prevention and
treatment services for Indian families;]
[(B) develop prevention and intervention
models for Indian families;]
[(C) conduct community education on alcohol
and substance abuse; and]
[(D) coordinate with existing Federal, State,
and tribal services on the reservation to
develop a comprehensive alcohol and substance
abuse program that assists in the
rehabilitation of Indian families that have
been or are afflicted by alcoholism.]
[(3) The Secretary shall submit to the President for
inclusion in the report to be transmitted to the
Congress under section 1671 of this title for fiscal
year 1995 an evaluation of the demonstration project
established under paragraph (1).]
Sec. 705. Licensing Requirement for Mental Health Care Workers
Subject to the provisions of section 221, any person
employed as a psychologist, social worker, or marriage and
family therapist for the purpose of providing mental health
care services to Indians in a clinical setting under this Act
is required to be licensed as a clinical psychologist, social
worker, or marriage and family therapist, respectively, or
working under the direct supervision of a licensed clinical
psychologist, social worker, or marriage and family therapist,
respectively.
Sec. 1665b. Indian [w]Women [t]Treatment [p]Programs
(a) Grants.--The Secretary, consistent with section 701,
may make grants to Indian [t]Tribes, [and t]Tribal
[o]Organizations, and Urban Indian Organizations to develop and
implement a comprehensive behavioral health [alcohol and
substance abuse] program of prevention, intervention,
treatment, and relapse prevention services that specifically
addresses the spiritual, cultural, historical, social, and
child care needs of Indian women, regardless of age.
(b) Use of Grant[s] Funds._A grant made pursuant to this
section may be used to--
(1) develop and provide community training,
education, and prevention programs for Indian women
relating to behavioral health [alcohol and substance
abuse] issues, including fetal alcohol disorders
[syndrome and fetal alcohol effect];
(2) identify and provide psychological services,
[appropriate] counseling, advocacy, support, and
relapse prevention to Indian women and their families;
and
(3) develop prevention and intervention models for
Indian women which incorporate [t]Traditional Health
Care Practices [healers], cultural values, and
community and family involvement.
(c) Criteria.--[for review and approval of grant
applications]The Secretary, in consultation with Indian Tribes
and Tribal Organizations, shall establish criteria for the
review and approval of applications and proposals for funding
[grants] under this section.
(d) Earmark of Certain Funds.--Twenty percent of the funds
appropriated pursuant to this section shall be used to make
grants to Urban Indian Organizations.
[(d) Authorization of appropriations]
[(1) There are authorized to be appropriated to carry
out this section $10,000,000 for fiscal year 1993 and
such sums as are necessary for each of the fiscal years
1994, 1995, 1996, 1997, 1998, 1999, and 2000.]
[(2) Twenty percent of the funds appropriated
pursuant to this subsection shall be used to make
grants to urban Indian organizations funded under
subchapter IV of this chapter.]
Sec. 1665c. Indian [Health Service y]Youth [p]Program
(a) Detoxification and [r]Rehabilitation.--The Secretary,
acting through the Service, consistent with section 701, shall
develop and implement a program for acute detoxification and
treatment for Indian youths, including behavioral health
services [who are alcohol and substance abusers]. The program
shall include regional treatment centers designed to include
detoxification and rehabilitation for both sexes on a referral
basis and programs developed and implemented by Indian Tribes
or Tribal Organizations at the local level under the Indian
Self-Determination and Education Assistance Act (25 U.S.C. 450
et seq.). [These r]Regional centers shall be integrated with
the intake and rehabilitation programs based in the referring
Indian community.
(b) Alcohol and Substance Abuse Treatment [c]Centers or
[f]Facilities
(1) Establishment._
[(1)](A) In general.--The Secretary, acting
through the Service, Indian Tribes, and Tribal
Organizations, shall construct, renovate, or,
as necessary, purchase, and appropriately staff
and operate, at least 1[a] youth regional
treatment center or treatment network in each
area under the jurisdiction of an [a]Area
[o]Office.
(B) Area office in California.--For the
purposes of this subsection, the [area offices
of the Service in Tucson and Phoenix, Arizona,
shall be considered one area office and the
a]Area [o]Office in California shall be
considered to be 2 [two a]Area [o]Offices,
1[one] office whose jurisdiction shall be
considered to encompass the northern area of
the State of California, and 1[one] office
whose jurisdiction shall be considered to
encompass the remainder of the State of
California for the purpose of implementing
California treatment networks.
(2) Funding.--For the purpose of staffing and
operating such centers or facilities, funding shall be
pursuant to the Act of November 2, 1921 (25 U.S.C. 13).
(3) Location.--A youth treatment center constructed
or purchased under this subsection shall be constructed
or purchased at a location within the area described in
paragraph (1) agreed upon (by appropriate tribal
resolution) by a majority of the Indian T[t]ribes to be
served by such center.
(4) Specific Provision of Funds._
(A) In general.--Notwithstanding any other
provision of this title [subchapter], the
Secretary may, from amounts authorized to be
appropriated for the purposes of carrying out
this section, make funds available to--
(i) The Tanana Chiefs Conference,
Incorporated, for the purpose of
leasing, constructing, renovating,
operating and maintaining a residential
youth treatment facility in Fairbanks,
Alaska; and
(ii) the Southeast Alaska Regional
Health Corporation to staff and operate
a residential youth treatment facility
without regard to the proviso set forth
in section 4[50b](l) of the Indian
Self-Determination and Education
Assistance Act (25 U.S.C. 450b(l))
[this title].
(B) Provision of services to eligible
youths.--Until additional residential youth
treatment facilities are established in Alaska
pursuant to this section, the facilities
specified in subparagraph (A) shall make every
effort to provide services to all eligible
Indian youths residing in Alaska [such State].
(c) Intermediate Adolescent Behavioral Health Services.--
(1) In general.--The Secretary, acting through the
Service, Indian Tribes, and Tribal Organizations, may
provide intermediate behavioral health services, which
may incorporate Traditional Health Care Practices, to
Indian children and adolescents, including--
(A) pretreatment assistance;
(B) inpatient, outpatient, and aftercare
services;
(C) emergency care;
(D) suicide prevention and crisis
intervention; and
(E) prevention and treatment of mental
illness and dysfunctional and self-destructive
behavior, including child abuse and family
violence.
(2) Use of funds.--Funds provided under this
subsection may be used--
(A) to construct or renovate an existing
health facility to provide intermediate
behavioral health services;
(B) to hire behavioral health professionals;
(C) to staff, operate, and maintain an
intermediate mental health facility, group
home, sober housing, transitional housing or
similar facilities, or youth shelter where
intermediate behavioral health services are
being provided;
(D) to make renovations and hire appropriate
staff to convert existing hospital beds into
adolescent psychiatric units; and
(E) for intensive home- and community-based
services.
(3) Criteria.--The Secretary, acting through the
Service, shall, in consultation with Indian Tribes and
Tribal Organizations, establish criteria for the review
and approval of applications or proposals for funding
made available pursuant to this subsection.
(d)[(c)] Federally [o]Owned [s]Structures.--
(1) In general.--The Secretary, [acting through the
Service, shall,] in consultation with Indian [t]Tribes
and Tribal Organizations, shall--
(A) identify and use, where appropriate,
federally owned structures suitable for [as]
local residential or regional behavioral health
[alcohol and substance abuse] treatment
[centers] for Indian youths; and
(B) establish guidelines, in consultation
with Indian Tribes and Tribal Organizations,
for determining the suitability of any such
federally owned structure to be used for [as a]
local residential or regional behavioral health
[alcohol and substance abuse] treatment
[center] for Indian youths.
(2) Terms and conditions for use of structure.--Any
structure described in paragraph (1) may be used under
such terms and conditions as may be agreed upon by the
Secretary and the agency having responsibility for the
structure and any Indian Tribe or Tribal Organization
operating the program.
(e)[(d)] Rehabilitation and [a]Aftercare [s]Services.--
(1) In general.--The Secretary, Indian Tribes, or
Tribal Organizations, in cooperation with the Secretary
of the Interior, shall develop and implement within
each Service [service u]Unit, community-based
rehabilitation and follow-up services for Indian youths
who are having significant behavioral health problems
and require [alcohol or substance abusers which are
designed to integrate] long-term treatment, community
reintegration, and monitoring to [monitor and] support
the Indian youths after their return to their home
community.
(2) Administration.--Services under paragraph (1)
shall be provided [administered within each service
unit] by trained staff within the community who can
assist the Indian youths in their continuing
development of self-image, positive problem-solving
skills, and nonalcohol or substance abusing behaviors.
Such staff may [shall] include alcohol and substance
abuse counselors, mental health professionals, and
other health professionals and paraprofessionals,
including community health representatives.
(f)[(e)] Inclusion of [f]Family in [y]Youth [t]Treatment
[p]Program.--In providing the treatment and other services to
Indian youths authorized by this section, the Secretary, acting
through the Service, Indian Tribes, and Tribal Organizations,
shall provide for the inclusion of family members of such
youths in the treatment programs or other services as may be
appropriate. Not less than 10 percent of the funds appropriated
for the purposes of carrying out subsection (e)[(d) of this
section] shall be used for outpatient care of adult family
members related to the treatment of an Indian youth under that
subsection.
(g)[(f)] Multidrug [a]Abuse Program.--[study]
[(1)] The Secretary, acting through the Service,
Indian Tribes, Tribal Organizations, and Urban Indian
Organizations, shall provide, consistent with section
701, programs and services to prevent and treat
[conduct a study to determine the incidence and
prevalence of] the abuse of multiple forms of
substances [drugs], including alcohol, drugs,
inhalants, and tobacco, among Indian youths residing in
Indian communities, on or near [Indian] reservations,
and in urban areas and provide appropriate mental
health services to address [the interrelationship of
such abuse with] the incidence of mental illness among
such youths.
[(2) The Secretary shall submit a report detailing
the findings of such study, together with
recommendations based on such findings, to the Congress
no later than two years after October 29, 1992.]
(h) Indian Youth Mental Health.--The Secretary, acting
through the Service, shall collect data from the report under
section 801 with respect to--
(1) the number of Indian youth who are being provided
mental health services through the Service and Tribal
Health Programs;
(2) a description of, and costs associated with, the
mental health services provided for Indian youth
through the Service and Tribal Health Programs;
(3) the number of youth referred to the Service or
Tribal Health Programs for mental health services;
(4) the number of Indian youth provided residential
treatment for mental health and behavioral problems
through the Service and Tribal Health Programs,
reported separately for on-and off-reservation
facilities; and
(5) the cost of the services described in paragraph
(4).
Sec. 708. Indian Youth Telemental Health Demonstration Project
(a) Purpose.--The purpose of this section is to authorize
the Secretary to carry out a demonstration project to test the
use of telemental health services in suicide prevention,
intervention and treatment of Indian youth, including through--
(1) the use of psychotherapy, psychiatric
assessments, diagnostic interviews, therapies for
mental health conditions predisposing to suicide, and
alcohol and substance abuse treatment;
(2) the provision of clinical expertise to,
consultation services with, and medical advice and
training for frontline health care providers working
with Indian youth;
(3) training and related support for community
leaders, family members and health and education
workers who work with Indian youth;
(4) the development of culturally-relevant
educational materials on suicide; and
(5) data collection and reporting.
(b) Definitions.--For the purpose of this section, the
following definitions shall apply:
(1) Demonstration project.--The term `demonstration
project' means the Indian youth telemental health
demonstration project authorized under subsection (c).
(2) Telemental health.--The term `telemental health'
means the use of electronic information and
telecommunications technologies to support long
distance mental health care, patient and professional-
related education, public health, and health
administration.
(c) Authorization.--
(1) In general.--The Secretary is authorized to award
grants under the demonstration project for the
provision of telemental health services to Indian youth
who--
(A) have expressed suicidal ideas;
(B) have attempted suicide; or
(C) have mental health conditions that
increase or could increase the risk of suicide.
(2) Eligibility for grants.--Such grants shall be
awarded to Indian Tribes, Tribal Organizations, and
Urban Indian Organizations that operate 1 or more
facilities--
(A) located in Alaska and part of the Alaska
Federal Health Care Access Network;
(B) reporting active clinical telehealth
capabilities; or
(C) offering school-based telemental health
services relating to psychiatry to Indian
youth.
(3) Grant period.--The Secretary shall award grants
under this section for a period of up to 4 years.
(4) Awarding of grants.--Not more than 5 grants shall
be provided under paragraph (1), with priority
consideration given to Indian Tribes, Tribal
Organizations, and Urban Indian Organizations that--
(A) serve a particular community or
geographic area where there is a demonstrated
need to address Indian youth suicide;
(B) enter into collaborative partnerships
with Indian Health Service or other Tribal
Health Programs or facilities to provide
services under this demonstration project;
(C) serve an isolated community or geographic
area which has limited or no access to
behavioral health services; or
(D) operate a detention facility at which
youth are detained.
(d) Use of Funds.--An Indian Tribe, Tribal Organization, or
Urban Indian Organization shall use a grant received under
subsection (c) for the following purposes:
(1) To provide telemental health services to Indian
youth, including the provision of--
(A) psychotherapy;
(B) psychiatric assessments and diagnostic
interviews, therapies for mental health
conditions predisposing to suicide, and
treatment; and
(C) alcohol and substance abuse treatment.
(2) To provide clinician-interactive medical advice,
guidance and training, assistance in diagnosis and
interpretation, crisis counseling and intervention, and
related assistance to Service, tribal, or urban
clinicians and health services providers working with
youth being served under this demonstration project.
(3) To assist, educate and train community leaders,
health education professionals and paraprofessionals,
tribal outreach workers, and family members who work
with the youth receiving telemental health services
under this demonstration project, including with
identification of suicidal tendencies, crisis
intervention and suicide prevention, emergency skill
development, and building and expanding networks among
these individuals and with State and local health
services providers.
(4) To develop and distribute culturally appropriate
community educational materials on--
(A) suicide prevention;
(B) suicide education;
(C) suicide screening;
(D) suicide intervention; and
(E) ways to mobilize communities with respect
to the identification of risk factors for
suicide.
(5) For data collection and reporting related to
Indian youth suicide prevention efforts.
(e) Applications.--To be eligible to receive a grant under
subsection (c), an Indian Tribe, Tribal Organization, or Urban
Indian Organization shall prepare and submit to the Secretary
an application, at such time, in such manner, and containing
such information as the Secretary may require, including--
(1) a description of the project that the Indian
Tribe, Tribal Organization, or Urban Indian
Organization will carry out using the funds provided
under the grant;
(2) a description of the manner in which the project
funded under the grant would--
(A) meet the telemental health care needs of
the Indian youth population to be served by the
project; or
(B) improve the access of the Indian youth
population to be served to suicide prevention
and treatment services;
(3) evidence of support for the project from the
local community to be served by the project;
(4) a description of how the families and leadership
of the communities or populations to be served by the
project would be involved in the development and
ongoing operations of the project;
(5) a plan to involve the tribal community of the
youth who are provided services by the project in
planning and evaluating the mental health care and
suicide prevention efforts provided, in order to ensure
the integration of community, clinical, environmental,
and cultural components of the treatment; and
(6) a plan for sustaining the project after Federal
assistance for the demonstration project has
terminated.
(f) Traditional Health Care Practices.--The Secretary,
acting through the Service, shall ensure that the demonstration
project established pursuant to this section involves the use
and promotion of the Traditional Health Care Practices of the
Indian Tribes of the youth to be served.
(g) Collaboration; Reporting to National Clearinghouse.--
(1) Collaboration.--The Secretary, acting through the
Service, shall encourage Indian Tribes, Tribal
Organizations, and Urban Indian Organizations receiving
grants under this section to collaborate to enable
comparisons about best practices across projects.
(2) Reporting to national clearinghouse.--The
Secretary, acting through the Service, shall also
encourage Indian Tribes, Tribal Organizations, and
Urban Indian Organizations receiving grants under this
section to submit relevant, declassified project
information to the national clearinghouse authorized
under section 701(b)(2) in order to better facilitate
program performance and improve suicide prevention,
intervention, and treatment services.
(h) Annual Report.--Each grant recipient shall submit to
the Secretary an annual report that--
(1) describes the number of telemental health
services provided; and
(2) includes any other information that the Secretary
may require.
(i) Report to Congress.--Not later than 270 days after the
termination of the demonstration project, the Secretary shall
submit to the Committee on Indian Affairs of the Senate and the
Committee on Resources and Committee on Energy and Commerce of
the House of Representatives a final report, based on the
annual reports provided by grant recipients under subsection
(h), that--
(1) describes the results of the projects funded by
grants awarded under this section, including any data
available which indicates the number of attempted
suicides; and
(2) evaluates the impact of the telemental health
services funded by the grants in reducing the number of
completed suicides among Indian youth.
(j) Authorization of Appropriations.--There is authorized
to be appropriated to carry out this section $1,500,000 for
each of fiscal years 2006 through 2009.''
Sec. 709. Inpatient and Community-Based Mental Health Facilities
Design, Construction, and Staffing
Not later than 1 year after the date of enactment of the
Indian Health Care Improvement Act Amendments of 2005, the
Secretary, acting through the Service, Indian Tribes, and
Tribal Organizations, may provide, in each area of the Service,
not less than 1 inpatient mental health care facility, or the
equivalent, for Indians with behavioral health problems. For
the purposes of this subsection, California shall be considered
to encompass the northern area of the State of California and 1
office whose jurisdiction shall be considered to encompass the
remainder of the State of California. The Secretary shall
consider the possible conversion of existing, underused Service
hospital beds into psychiatric units to meet such need.
Sec. 1665d. Training and [c]Community [e]Education
(a) Program._[Community education] The Secretary, in
cooperation with the Secretary of the Interior, shall develop
and implement or provide funding for Indian Tribes and Tribal
Organizations to develop and implement, within each [s]Service
[u]Unit or tribal program, a program of community education and
involvement which shall be designed to provide concise and
timely information to the community leadership of each tribal
community. Such program shall include education about
behavioral health issues [in alcohol and substance abuse] to
political leaders, [t]Tribal judges, law enforcement personnel,
members of tribal health and education boards, health care
providers including traditional practitioners, and other
critical members of each tribal community. Community-based
training (oriented toward local capacity development) shall
also include tribal community provider training (designed for
adult learners from the communities receiving services for
prevention, intervention, treatment, and aftercare.)
(b) Instruction._[Training] The Secretary, acting through
the Service, shall, either directly or through Indian Tribes
and Tribal Organizations [by contract], provide instruction in
the area of behavioral health issues [alcohol and substance
abuse], including instruction in crisis intervention and family
relations in the context of alcohol and substance abuse, child
sexual abuse, youth alcohol and substance abuse, and the causes
and effects of fetal alcohol disorders [syndrome] to
appropriate employees of the Bureau of Indian Affairs and the
Service, and to personnel in schools or programs operated under
any contract with the Bureau of Indian Affairs or the Service,
including supervisors of emergency shelters and halfway houses
described in section 4213 of the Indian Alcohol and Substance
Abuse Prevention and Treatment Act of 1986 (25 U.S.C. 2433)
[2433 of this title].
(c) Training [Community-based training m]Models.-- In
carrying out the education and training programs required by
this section, the Secretary, [acting through the Service and]
in consultation with Indian T[t]ribes, Tribal Organizations,
Indian behavioral health experts, and Indian alcohol and
substance abuse prevention experts, shall develop and provide
community-based training models. Such models shall address--
(1) the elevated risk of alcohol and behavioral
health problems [substance abuse] faced by children of
alcoholics;
(2) the cultural, spiritual, and multigenerational
aspects of behavioral health problem [alcohol and
substance abuse] prevention and recovery; and
(3) community-based and multidisciplinary strategies
for preventing and treatingbehavioral health problems
[alcohol and substance abuse].
Sec. 711. Behavioral Health Program
(a) Innovative Programs.--The Secretary, acting through the
Service, Indian Tribes, and Tribal Organizations, consistent
with section 701, may plan, develop, implement, and carry out
programs to deliver innovative community-based behavioral
health services to Indians.
(b) Funding; Criteria.--The Secretary may award such
funding for a project under subsection (a) to an Indian Tribe
or Tribal Organization and may consider the following criteria:
(1) The project will address significant unmet
behavioral health needs among Indians.
(2) The project will serve a significant number of
Indians.
(3) The project has the potential to deliver services
in an efficient and effective manner.
(4) The Indian Tribe or Tribal Organization has the
administrative and financial capability to administer
the project.
(5) The project may deliver services in a manner
consistent with Traditional Health Care Practices.
(6) The project is coordinated with, and avoids
duplication of, existing services.
(c) Equitable Treatment.--For purposes of this subsection,
the Secretary shall, in evaluating project applications or
proposals, use the same criteria that the Secretary uses in
evaluating any other application or proposal for such funding.
[Sec. 1665e. Gallup alcohol and substance abuse treatment center]
[(a) Grants for residential treatment]
[The Secretary shall make grants to the Navajo Nation for
the purpose of providing residential treatment for alcohol and
substance abuse for adult and adolescent members of the Navajo
Nation and neighboring tribes.]
[(b) Purposes of grants]
[Grants made pursuant to this section shall (to the extent
appropriations are made available) be used to--]
[(1) provide at least 15 residential beds each year
for adult long-term treatment, including beds for
specialized services such as polydrug abusers, dual
diagnosis, and specialized services for women with
fetal alcohol syndrome children;]
[(2) establish clinical assessment teams consisting
of a clinical psychologist, a part-time
addictionologist, a master's level assessment
counselor, and a certified medical records technician
which shall be responsible for conducting individual
assessments and matching Indian clients with the
appropriate available treatment;]
[(3) provide at least 12 beds for an adolescent
shelterbed program in the city of Gallup, New Mexico,
which shall serve as a satellite facility to the Acoma/
Canoncito/Laguna Hospital and the adolescent center
located in Shiprock, New Mexico, for emergency crisis
services, assessment, and family intervention;]
[(4) develop a relapse program for the purposes of
identifying sources of job training and job opportunity
in the Gallup area and providing vocational training,
job placement, and job retention services to recovering
substance abusers; and]
[(5) provide continuing education and training of
treatment staff in the areas of intensive outpatient
services, development of family support systems, and
case management in cooperation with regional colleges,
community colleges, and universities.]
[(c) Contract for residential treatment]
[The Navajo Nation, in carrying out the purposes of this
section, shall enter into a contract with an institution in the
Gallup, New Mexico area which is accredited by the Joint
Commission of the Accreditation of Health Care Organizations to
provide comprehensive alcohol and drug treatment as authorized
in subsection (b) of this section.]
[(d) Authorization of appropriations]
[There are authorized to be appropriated, for each of
fiscal years 1996 through 2000, such sums as may be necessary
to carry out subsection (b) of this section.]
[Sec. 1665f. Reports]
[(a) Compilation of data]
[The Secretary, with respect to the administration of any
health program by a service unit, directly or through contract,
including a contract under the Indian Self-Determination Act
[25 U.S.C.A. Sec. 450f et seq.], shall require the compilation
of data relating to the number of cases or incidents in which
any Service personnel or services were involved and which were
related, either directly or indirectly, to alcohol or substance
abuse. Such report shall include the type of assistance
provided and the disposition of these cases.]
[(b) Referral of data]
[The data compiled under subsection (a) of this section
shall be provided annually to the affected Indian tribe and
Tribal Coordinating Committee to assist them in developing or
modifying a Tribal Action Plan under section 2412 of this
title.]
[(c) Comprehensive report]
[Each service unit director shall be responsible for
assembling the data compiled under this section and section
2434 of this title into an annual tribal comprehensive report.
Such report shall be provided to the affected tribe and to the
Director of the Service who shall develop and publish a
biennial national report based on such tribal comprehensive
reports.]
Sec. 1665g. Fetal [a]Alcohol Disorder Programs._ [syndrome and fetal
alcohol effect grants]
(a) Programs._[Award; use; review criteria]
(1) Establishment.--The Secretary, consistent with
section 701, acting through the Service, Indian Tribes,
and Tribal Organizations, is authorized to establish
and operate fetal alcohol disorder [syndrome and fetal
alcohol effect] programs as provided in this section
for the purposes of meeting the health status
objectives specified in section 3[1602(b) of this
title].
(2) Use of funds._Funding provided [Grants made]
pursuant to this section shall be used for the
following:[ to--]
(A) To develop and provide for Indians
community and in[-]school training, education,
and prevention programs relating to fetal
alcohol disorders. [FAS and FAE;]
(B) To identify and provide behavioral health
[alcohol and substance abuse] treatment to
high-risk Indian women and high-risk women
pregnant with an Indian's child.[;]
(C) To identify and provide appropriate
psychological services, educational and
vocational support, counseling, advocacy, and
information to fetal alcohol disorder [FAS and
FAE] affected Indians [persons] and their
families or caretakers[;].
(D) To develop and implement counseling and
support programs in schools for fetal alcohol
disorder [FAS and FAE] affected Indian
children[;].
(E) To develop prevention and intervention
models which incorporate practitioners of
T[t]raditional Health Care Practices [healers],
cultural and spiritual values, and community
involvement[;].
(F) To develop, print, and disseminate
education and prevention materials on fetal
alcohol disorder. [FAS and FAE; and]
(G) To develop and implement, through the
tribal consultation with Indian Tribes, Tribal
Organizations, and Urban Indian Organizations,
culturally sensitive assessment and diagnostic
tools including dysmorphology clinics and
multidisciplinary fetal alcohol and disorder
clinics for use in [tribal and urban] Indian
communities and Urban Centers.
(H) To develop early childhood intervention
projects from birth on to mitigate the effects
of fetal alcohol disorder among Indians.
(I) To develop--
(i) community-based support service
for Indians and for women pregnant with
Indian children; and
(ii) to the extent funding is
available, community-based housing for
adult Indians with fetal alcohol
disorder.
(3) Criteria for applications.--The Secretary shall
establish criteria for the review and approval of
applications for funding [grants] under this section.
(b) Services.--[Plan; study; national clearinghouse] The
Secretary, acting through the Service and Indian Tribes, Tribal
Organizations, and Urban Indian Organizations, shall--
(1) develop and provide services [an annual plan] for
the prevention, intervention, treatment, and aftercare
for those affected by fetal alcohol disorder [FAS and
FAE] in Indian communities; and
(2) provide supportive services, directly or through
an Indian Tribe, Tribal Organization, or Urban Indian
Organization, including services to meet [conduct a
study, directly or by contract with any organization,
entity, or institution of higher education with
significant knowledge of FAS and FAE and Indian
communities, of] the special educational, vocational,
school-to-work transition, and independent living needs
of adolescent and adult Indians with fetal alcohol
disorder. [and Alaska Natives with FAS or FAE; and]
[(3) establish a national clearinghouse for
prevention and educational materials and other
information of FAS and FAE effect in Indian and Alaska
Native communities and ensure access to clearinghouse
materials by any Indian tribe or urban Indian
organization.]
(c) Task [f]Force.--The Secretary shall establish a task
force to be known as the Fetal Alcohol Disorder [FAS/FAE] Task
Force to advise the Secretary in carrying out subsection (b)
[of this section]. Such task force shall be composed of
representatives from the following:
(1) The National Institute on Drug Abuse.[,]
(2) T[t]he National Institute on Alcohol and
Alcoholism.[,]
(3) T[t]he Office of Substance Abuse Prevention.[,]
(4) T[t]he National Institute of Mental Health.[,]
(5) T[t]he Service.[,]
(6) T[t]he Office of Minority Health of the
Department of Health and Human Services.[,]
(7) T[t]he Administration for Native Americans.[,]
(8) The National Institute of Child Health and Human
Development (NICHD).
(9) The Centers for Disease Control and Prevention.
(10) T[t]he Bureau of Indian Affairs.[,]
(11) Indian T[t]ribes.[,]
(12) T[t]ribal O[o]rganizations.[,]
(13) U[u]rban Indian Organizations. [communities,
and]
(14) Indian fetal alcohol disorder [FAS/FAE] experts.
(d) [Cooperative projects;] Applied R[r]esearch
P[p]rojects.--The Secretary, acting through the Substance Abuse
and Mental Health Services Administration, shall make grants to
Indian T[t]ribes, T[t]ribal O[o]rganizations, and Urban Indian
Organizations [universities working with Indian tribes on
cooperative projects, and urban Indian organizations] for
applied research projects which propose to elevate the
understanding of methods to prevent, intervene, treat, or
provide rehabilitation and behavioral health aftercare for
Indians and U[u]rban Indians affected by fetal alcohol disorder
[FAS or FAE].
[(e) Report]
[(1) The Secretary shall submit to the President, for
inclusion in each report required to be transmitted to
the Congress under section 1671 of this title, a report
on the status of FAS and FAE in the Indian population.
Such report shall include, in addition to the
information required under section 1602(d) of this
title with respect to the health status objective
specified in section 1602(b)(27) of this title, the
following:]
[(A) The progress of implementing a uniform
assessment and diagnostic methodology in
Service and tribally based service delivery
systems.]
[(B) The incidence of FAS and FAE babies born
for all births by reservation and urban-based
sites.]
[(C) The prevalence of FAS and FAE affected
Indian persons in Indian communities, their
primary means of support, and recommendations
to improve the support system for these
individuals and their families or caretakers.]
[(D) The level of support received from the
entities specified in subsection (c) of this
section in the area of FAS and FAE.]
[(E) The number of inpatient and outpatient
substance abuse treatment resources which are
specifically designed to meet the unique needs
of Indian women, and the volume of care
provided to Indian women through these means.]
[(F) Recommendations regarding the
prevention, intervention, and appropriate
vocational, educational and other support
services for FAS and FAE affected individuals
in Indian communities.]
[(2) The Secretary may contract the production of
this report to a national organization specifically
addressing FAS and FAE in Indian communities.]
[(f) Authorization of appropriations]
[(1) There are authorized to be appropriated to carry
out this section $22,000,000 for fiscal year 1993 and
such sums as may be necessary for each of the fiscal
years 1994, 1995, 1996, 1997, 1998, 1999, and 2000.]
(e) Funding for Urban Indian Organizations.--[(2)] Ten
percent of the funds appropriated pursuant to this section
shall be used to make grants to U[u]rban Indian
O[o]rganizations funded under title V [subchapter IV of this
chapter].
[Sec. 1665h. Pueblo substance abuse treatment project for San Juan
Pueblo, New Mexico]
[The Secretary, acting through the Service, shall continue
to make grants, through fiscal year 1995, to the 8 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.]
[Sec. 1665i. Thunder Child Treatment Center]
[(a) The Secretary, acting through the Service, shall make
a grant to the Intertribal Addictions Recovery Organization,
Inc. (commonly known as the Thunder Child Treatment Center) at
Sheridan, Wyoming, for the completion of construction of a
multiple approach substance abuse treatment center which
specializes in the treatment of alcohol and drug abuse of
Indians.]
[(b) For the purposes of carrying out subsection (a) of
this section, there are authorized to be appropriated
$2,000,000 for fiscal years 1993 and 1994. No funding shall be
available for staffing or operation of this facility. None of
the funding appropriated to carry out subsection (a) of this
section shall be used for administrative purposes.]
[Sec. 1665j. Substance abuse counselor education demonstration project]
[(a) Contracts and grants]
[The Secretary, acting through the Service, may enter into
contracts with, or make grants to, accredited tribally
controlled community colleges, tribally controlled
postsecondary vocational institutions, and eligible community
colleges to establish demonstration projects to develop
educational curricula for substance abuse counseling.]
[(b) Use of funds]
[Funds provided under this section shall be used only for
developing and providing educational curricula for substance
abuse counseling (including paying salaries for instructors).
Such curricula may be provided through satellite campus
programs.]
[(c) Effective period of contract or grant; renewal]
[A contract entered into or a grant provided under this
section shall be for a period of one year. Such contract or
grant may be renewed for an additional one year period upon the
approval of the Secretary.]
[(d) Criteria for review and approval of applications]
[Not later than 180 days after October 29, 1992, the
Secretary, after consultation with Indian tribes and
administrators of accredited tribally controlled community
colleges, tribally controlled postsecondary vocational
institutions, and eligible community colleges, shall develop
and issue criteria for the review and approval of applications
for funding (including applications for renewals of funding)
under this section. Such criteria shall ensure that
demonstration projects established under this section promote
the development of the capacity of such entities to education
substance abuse counselors.]
[(e) Assistance to recipients]
[The Secretary shall provide such technical and other
assistance as may be necessary to enable grant recipients to
comply with the provisions of this section.]
[(f) Report]
[The Secretary shall submit to the President, for inclusion
in the report which is required to be submitted under section
1671 of this title for fiscal year 1999, a report on the
findings and conclusions derived from the demonstration
projects conducted under this section.]
Sec. 713. Child Sexual Abuse and Prevention Treatment Programs
(a) Establishment.--The Secretary, acting through the
Service, and the Secretary of the Interior, Indian Tribes, and
Tribal Organizations shall establish, consistent with section
701, in every Service Area, programs involving treatment for--
(1) victims of sexual abuse who are Indian children
or children in an Indian household; and
(2) perpetrators of child sexual abuse who are Indian
or members of an Indian household.
(b) Use of Funds.--Funding provided pursuant to this
section shall be used for the following:
(1) To develop and provide community education and
prevention programs related to sexual abuse of Indian
children or children in an Indian household.
(2) To identify and provide behavioral health
treatment to victims of sexual abuse who are Indian
children or children in an Indian household, and to
their family members who are affected by sexual abuse.
(3) To develop prevention and intervention models
which incorporate Traditional Health Care Practices,
cultural and spiritual values, and community
involvement.
(4) To develop and implement, in consultation with
Indian Tribes, Tribal Organizations, and Urban Indian
Organizations, cultural sensitive assessment and
diagnostic tools for use in Indian communities and
Urban Centers.
(5) To identify and provide behavioral health
treatment to Indian perpetrators and perpetrators who
are members of an Indian household--
(A) making efforts to begin offender and
behavioral health treatment while the
perpetrator is incarcerated or at the earliest
possible date if the perpetrator is not
incarcerated; and
(B) providing treatment after the perpetrator
is released, until it is determined that the
perpetrator is not a threat to children.
Sec. 714. Behavioral Health Research
The Secretary, in consultation with appropriate Federal
agencies, shall provide grants to, or enter into contracts
with, Indian Tribes, Tribal Organizations, and Urban Indian
Organizations or make grants to appropriate institutions for,
the conduct of research on the incidence and prevalence of
behavioral health problems among Indians served by the Service,
Indian Tribes, or Tribal Organizations and among Indians in
urban areas. Research priorities under this section shall
include--
(1) the multifactorial causes of Indian youth
suicide, including--
(A) protective and risk factors and
scientific data that identifies those factors;
and
(B) the effects of loss of cultural identity
and the development of scientific data on those
effects;
(2) the interrelationship and interdependence of
behavioral health problems with alcoholism and other
substance abuse, suicide, homicides, other injuries,
and the incidence of family violence; and
(3) the development of models of prevention
techniques.
The effect of the interrelationships and interdependencies
referred to in paragraph (2) on children, and the development
of prevention techniques under paragraph (3) applicable to
children, shall be emphasized.
Sec. 715. [(g)] Definitions
For the purposes of this title [section], the following
definitions shall apply:
(1) Assessment._The term `assessment' means the
systematic collection, analysis, and dissemination of
information on health status, health needs, and health
problems. [The term ``educational curriculum'' means
one or more of the following:]
[(A) Classroom education.]
[(B) Clinical work experience.]
[(C) Continuing education workshops.]
(2) Alcohol-related neurodevelopmental disorders or
arnd.--The term `alcohol-related neurodevelopmental
disorders' or `ARND' means, with a history of maternal
alcohol consumption during pregnancy, central nervous
system involvement such as developmental delay,
intellectual, deficit, or neurologic abnormalities.
Behaviorally, there can be problems with irritability,
and failure to thrive as infants. As children become
older there will likely be hyperactivity, attention
deficit, language dysfunction, and perceptual and
judgment problems.
(3) Behavioral health aftercare.--The term
`behavioral health aftercare' includes those activities
and resources used to support recovery following
inpatient, residential, intensive substance abuse, or
mental health outpatient or outpatient treatment. The
purpose is to help prevent or deal with relapse by
ensuring that by the time a client or patient is
discharged from a level of care, such as outpatient
treatment, an aftercare plan has been developed with
the client. An aftercare plan may use such resources as
a community-based therapeutic group, transitional
living facilities, a 12-step sponsor, a local 12-step
or other related support group, and other community-
based providers (mental health professionals,
traditional health care practitioners, community health
aides, community health representatives, mental health
technicians, ministers, etc.)
[(3) The term ``tribally controlled community
college'' has the meaning given such term in section
1801(a)(4) of this title.]
(4) Dual diagnosis.--The term `dual diagnosis' means
coexisting substance abuse andmental illness conditions
or diagnosis. Such clients are sometimes referred to as mentally ill
chemical abusers (MICAs).
[(4) The term ``tribally controlled postsecondary
vocational institution'' has the meaning given such
term in section 2397h(2) of Title 20.]
(5) Fetal alcohol disorders.--The term `fetal alcohol
disorders' means fetal alcohol syndrome, partial fetal
alcohol syndrome and alcohol related neurodevelopmental
disorder (ARND).
(6) Fetal alcohol syndrome or fas.--The term `fetal
alcohol syndrome' or `FAS' means a syndrome in which,
with a history of maternal alcohol consumption during
pregnancy, the following criteria are met:
(A) Central nervous system involvement such
as developmental delay, intellectual deficit,
microencephaly, or neurologic abnormalities.
(B) Craniofacial abnormalities with at least
2 of the following: microophthalmia, short
palpebral fissures, poorly developed philtrum,
thin upper lip, flat nasal bridge, and short
upturned nose.
(C) Prenatal or postnatal growth delay.
(7) Partial fas.--The term `partial FAS' means, with
a history of maternal alcohol consumption during
pregnancy, having most of the criteria of FAS, though
not meeting a minimum of at least 2 of the following:
microophthalmia, short palpebral fissures, poorly
developed philtrum, thin upper lip, flat nasal bridge,
and short upturned nose.
(8) Rehabilitation.--The term `rehabilitation' means
to restore the ability or capacity to engage in usual
and customary life activities through education and
therapy.
(9) Substance abuse.--The term `substance abuse'
includes inhalant abuse.
Sec. 716. [(h)] Authorization of A[a]ppropriations
There is [are] authorized to be appropriated [for each of
fiscal years 1996 through 2000,] such sums as may be necessary
for each fiscal year through fiscal year 2015 to carry out the
provisions [purposes] of this title [section]. [Such sums shall
remain available until expended.]
[Sec. 1665k. Gila River alcohol and substance abuse treatment facility]
[(a) Regional center]
[The Secretary, acting through the Service, shall establish
a regional youth alcohol and substance abuse prevention and
treatment center in Sacaton, Arizona, on the Gila River Indian
Reservation. The center shall be established within facilities
leased, with the consent of the Gila River Indian Community, by
the Service from such Community.]
[(b) Name of regional center]
[The center established pursuant to this section shall be
known as the ``Regional Youth Alcohol and Substance Abuse
Prevention and Treatment Center''.]
[(c) Unit of regional center]
[The Secretary, acting through the Service, shall
establish, as a unit of the regional center, a youth alcohol
and substance abuse prevention and treatment facility in
Fallon, Nevada.]
[Sec. 1665l. Alaska Native drug and alcohol abuse demonstration
project]
[(a) The Secretary, acting through the Service, shall make
grants to the Alaska Native Health Board for the conduct of a
two-part community-based demonstration project to reduce drug
and alcohol abuse in Alaska Native villages and to rehabilitate
families afflicted by such abuse. Sixty percent of such grant
funds shall be used by the Health Board to stimulate
coordinated community development programs in villages seeking
to organize to combat alcohol and drug use. Forty percent of
such grant funds shall be transferred to a qualified nonprofit
corporation providing alcohol recovery services in the village
of St. Mary's, Alaska, to enlarge and strengthen a family life
demonstration program of rehabilitation for families that have
been or are afflicted by alcoholism.]
[(b) The Secretary shall submit to the President for
inclusion in the report required to be submitted to the
Congress under section 1671 of this title for fiscal year 1995
an evaluation of the demonstration project established under
subsection (a) of this section.]
[Sec. 1665m. Authorization of appropriations]
[Except as provided in sections 1665b, 1665e, 1665g, 1665i,
and 1665j of this title, there are authorized to be
appropriated such sums as may be necessary for each fiscal year
through fiscal year 2000 to carry out the provisions of this
subchapter.]
TITLE VIII [SUBCHAPTER VI]--MISCELLANEOUS
Sec. 1671. Reports
For each fiscal year following the date of enactment of the
Indian Health Care Improvement Act Amendments of 2005, the
Secretary shall transmit to Congress a report containing the
following:
[The President shall, at the time the budget is submitted
under section 1105 of Title 31, for each fiscal year transmit
to the Congress a report containing--]
(1) A[a] report on the progress made in meeting the
objectives of this Act [chapter], including a review of
programs established or assisted pursuant to this Act
[chapter] and [an] assessments and recommendations of
additional programs or additional assistance necessary
to, at a minimum, provide health services to Indians[,]
and ensure a health status for Indians, which are at a
parity with the health services available to and the
health status of[,] the general population, including
specific comparisons of appropriations provided and
those required for such parity.[;]
(2) A[a] report on whether, and to what extent, new
national health care programs, benefits, initiatives,
or financing systems have had an impact on the purposes
of this Act [chapter] and any steps that the Secretary
may have taken to consult with Indian [t]Tribes, Tribal
Organizations, and Urban Indian Organizations to
address such impact, including a report on proposed
changes in allocation of funding pursuant to section
808.[;]
(3) A[a] report on the use of health services by
Indians--
(A) on a national and area or other relevant
geographical basis;
(B) by gender and age;
(C) by source of payment and type of service;
[and]
(D) comparing such rates of use with rates of
use among comparable non-Indian populations[.];
and
(E) provided under contracts.
(4) A report of contractors to the Secretary on
Health Care Educational Loan Repayments every 6 months
required by section 110.
(5) A general audit report of the Secretary on the
Health Care Educational Loan Repayment Program as
required by section 110(n).
(6) A report of the findings and conclusions of
demonstration programs on development of educational
curricula for substance abuse counseling as required in
section 125(f).
(7)[(4) a]A separate statement which specifies the
amount of funds requested to carry out the provisions
of section 201. [1621 of this title;]
(8) A report of the evaluations of health promotion
and disease prevention as required in section 203(c).
(9) A biennial report to Congress on infectious
diseases as required by section 212.
(10) A report on environmental and nuclear health
hazards as required by section 215.
(11) An annual report on the status of all health
care facilities needs as required by section 301(c)(2)
and 301(d).
(12) Reports on safe water and sanitary waste
disposal facilities as required by section 302(h).
(13) An annual report on the expenditure of
nonservice funds for renovation as required by sections
304(b)(2).
(14) A report identifying the backlog of maintenance
and repair required at Service and tribal facilities
required by section 313(a).
(15) A report providing an accounting of
reimbursement funds made available to the Secretary
under titles XVIII, XIX, and XXI of the Social Security
Act.
(16) A report on any arrangements for the sharing of
medical facilities or services as authorized by section
406.
(17) A report on evaluation and renewal of Urban
Indian programs under section 505.
(18) A report on the evaluation of programs as
required by section 513(d).
(19) A report on alcohol and substance abuse as
required by section 701(f).
(20) A report on Indian youth mental health services
are required by section 707(h).
[(5) a separate statement of the total amount
obligated or expended in the most recently completed
fiscal year to achieve each of the objectives described
in section 1680d of this title, relating to infant and
maternal mortality and fetal alcohol syndrome;]
[(6) the reports required by the sections 1602(d),
1616a(n), 1621b(b), 1621h(j), 1631(c), 1632(g),
1634(a)(3), 1643, 1665g(e), and 1680g(a), and 1680l(f)
of this title;]
[(7) for fiscal year 1995, the report required by
sections 1665a(c)(3) and 1665l(b) of this title;]
[(8) for fiscal year 1997, the interim report
required by section 1637(h)(1) of this title; and]
[(9) for fiscal year 1999, the reports required by
sections 1637(h)(2), 1660b(b), 1665j(f), and 1680k(g)
of this title.]
Sec. 1672. Regulations
(a) Deadlines.--
(1) Procedures.--Not later than 90 days after the
date of the enactment of the IndianHealth Care
Improvement Act Amendments of 2005, the Secretary shall initiate
procedures under subchapter III of chapter 5 of title 5, United States
Code, to negotiate and promulgate such regulations or amendments
thereto that are necessary to carry out titles I (except section 105,
115 and 117), II, III, and VII. The Secretary may promulgate
regulations to carry out sections 105,115, 117, and titles IV and V,
using the procedures required by chapter V of title 5, United States
Code (commonly known as the `Administrative Procedure Act'). The
Secretary shall issue no regulations to carry out titles VI and VIII.
(2) Proposed regulations.--Proposed regulations to
implement this Act shall be published in the Federal
Register by the Secretary no later than 1 year after
the date of the enactment of the Indian Health Care
Improvement Act Amendments of 2005 and shall have no
less than a 120-day comment period.
(3) Expiration of authority.--The authority to
promulgate regulations under this Act shall expire 24
months from the date of the enactment of this Act.
(b) Committee.--A negotiated rulemaking committee
established pursuant to section 565 of title 5, United State
Code, to carry out this section shall have as its members only
representatives of the Federal Government and representatives
of Indian Tribes and Tribal Organizations, a majority of whom
shall be nominated by and be representatives of Indian Tribes,
Tribal Organizations, and Urban Indian Organizations from each
Service Area. The representative of the Urban Indian
Organizations shall be deemed to be an elected officer of a
tribal government for purposes fo applying section 204(b) of
the Unfunded Mandates Reform Act of 1995 (2 U.S.C. 1534(b).
(c) Adaptation of Procedures.--The Secretary shall adapt
the negotiated rulemaking procedures to the unique context of
self-governance and the government-to-government relationship
between the United States and Indian Tribes.
(d) Lack of Regulations.--The lack of promulgated
regulations shall not limit the effect of this Act.
(e) Inconsistent Regulations.--The provisions of this Act
shall supersede any conflicting provisions of law in effect on
the day before the date of the enactment of the Indian Health
Care Improvement Act Amendments of 2005, and the Secretary is
authorized to repeal any regulation inconsistent with the
provisions of this Act.
[Prior to any revision of or amendment to rules or
regulations promulgated pursuant to this chapter, the Secretary
shall consult with Indian tribes and appropriate national or
regional Indian organizations and shall publish any proposed
revision or amendment in the Federal Register not less than
sixty days prior to the effective date of such revision or
amendment in order to provide adequate notice to, and receive
comments from, other interested parties.]
[Sec. 1673. Repealed.]
[Sec. 1674. Leases with Indian tribes]
[(a) Notwithstanding any other provision of law, the
Secretary is authorized, in carrying out the purposes of this
chapter, to enter into leases with Indian tribes for periods
not in excess of twenty years. Property leased by the Secretary
from an Indian tribe may be reconstructed or renovated by the
Secretary pursuant to an agreement with such Indian tribe.]
[(b) The 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]
[(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 programs operated by Indian
tribes or tribal organizations to compensate such Indian tribes
or tribal organizations 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
regulation to be allowable.]
Sec. 803. Plan of Implementation.
Not later than 9 months after the date of the enactment of
the Indian Health Care Improvement Act Amendments of 2005, the
Secretary in consultation with Indian Tribes, Tribal
Organizations, and Urban Indian Organizations, shall submit to
Congress a plan explaining the manner and schedule (including a
schedule of appropriation requests), by title and section, by
which the Secretary will implement the provisions of this Act.
Sec. 1675. Availability of Ff]unds
The funds appropriated pursuant to this Act [chapter] shall
remain available until expended.
Sec. 1676. Limitation on Uu]se of Ff]unds Aa]ppropriated to the
Indian Health Service
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.
[Sec. 1677. Nuclear resource development health hazards]
[(a) Study]
[The Secretary and the Service shall conduct, in
conjunction with other appropriate Federal agencies and in
consultation with concerned Indian tribes and organizations, a
study of the health hazards to Indian miners and Indians on or
near Indian reservations and in Indian communities as a result
of nuclear resource development. Such study shall include--]
[(1) an evaluation of the nature and extent of
nuclear resource development related health problems
currently exhibited among Indians and the causes of
such health problems;]
[(2) an analysis of the potential effect of ongoing
and future nuclear resource development on or near
Indian reservations and communities;]
[(3) an evaluation of the types and nature of
activities, practices, and conditions causing or
affecting such health problems, including uranium
mining and milling, uranium mine tailing deposits,
nuclear power plant operation and construction, and
nuclear waste disposal;]
[(4) a summary of any findings and recommendations
provided in Federal and State studies, reports,
investigations, and inspections during the five years
prior to December 17, 1980, that directly or indirectly
relate to the activities, practices, and conditions
affecting the health or safety of such Indians; and]
[(5) the efforts that have been made by Federal and
State agencies and mining and milling companies to
effectively carry out an education program for such
Indians regarding the health and safety hazards of such
nuclear resource development.]
[(b) Health care plan; development]
[Upon completion of such study the Secretary and the
Service shall take into account the results of such study and
develop a health care plan to address the health problems
studied under subsection (a) of this section. The plan shall
include--]
[(1) methods for diagnosing and treating Indians
currently exhibiting such health problems;]
[(2) preventive care for Indians who may be exposed
to such health hazards, including the monitoring of the
health of individuals who have or may have been exposed
to excessive amounts of radiation, or affected by other
nuclear development activities that have had or could
have a serious impact upon the health of such
individuals; and]
[(3) a program of education for Indians who, by
reason of their work or geographic proximity to such
nuclear development activities, may experience health
problems.]
[(c) Reports to Congress]
[The Secretary and the Service shall submit to Congress the
study prepared under subsection (a) of this section no later
than the date eighteen months after December 17, 1980. The
health care plan prepared under subsection (b) of this section
shall be submitted in a report no later than the date one year
after the date that the study prepared under subsection (a) of
this section is submitted to Congress. Such report shall
include recommended activities for the implementation of the
plan, as well as an evaluation of any activities previously
undertaken by the Service to address such health problems.]
[(d) Intergovernmental Task Force; establishment and
functions]
[(1) There is established an Intergovernmental Task
Force to be composed of the following individuals (or
their designees): the Secretary of Energy, the
Administrator of the Environmental Protection Agency,
the Director of the United States Bureau of Mines, the
Assistant Secretary for Occupational Safety and Health,
and the Secretary of the Interior.]
[(2) The Task Force shall identify existing and
potential operations related to nuclear resource
development that affect or may affect the health of
Indians on or near an Indian reservation or in an
Indian community and enter into activities to correct
existing health hazards and insure that current and
future health problems resulting from nuclear resource
development activities are minimized or reduced.]
[(3) The Secretary shall be Chairman of the Task
Force. The Task Force shall meet at least twice each
year. Each member of the Task Force shall furnish
necessary assistance to the Task Force.]
[(e) Medical care]
[In the case of any Indian who--]
[(1) as a result of employment in or near a uranium
mine or mill, suffers from a work related illness or
condition;]
[(2) is eligible to receive diagnosis and treatment
services from a Service facility; and]
[(3) by reason of such Indian's employment, is
entitled to medical care at the expense of such mine or
mill operator;]
[the Service shall, at the request of such Indian, render
appropriate medical care to such Indian for such illness or
condition and may recover the costs of any medical care so
rendered to which such Indian is entitled at the expense of
such operator from such operator. Nothing in this subsection
shall affect the rights of such Indian to recover damages other
than such costs paid to the Service from the employer for such
illness or condition.]
[Sec. 1678. Arizona as a contract health service delivery area]
[(a) Designation]
[For the fiscal years beginning with the fiscal year ending
September 30, 1982, and ending with the fiscal year ending
September 30, 2000, the State of Arizona shall be designatedas
a contract health service delivery area by the Service for the purpose
of providing contract health care services to members of federally
recognized Indian tribes of Arizona.]
[(b) Curtailment of health services prohibited]
[The Service shall not curtail any health care services
provided to Indians residing on Federal reservations in the
State of Arizona if such curtailment is due to the provision of
contract services in such State pursuant to the designation of
such State as a contract health service delivery area pursuant
to subsection (a) of this section.]
Sec. 1679. Eligibility of California Indians
(a) In General._[Report to Congress] The following
California Indians shall be eligible for health services
provided by the Service:
[(1) In order to provide the Congress with sufficient
data to determine which Indians in the State of
California should be eligible for health services
provided by the Service, the Secretary shall, by no
later than the date that is 3 years after November 23,
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
(b)(2) of this section, and the number of
Indians described in subsection (b)(3) of this
section, who are not members of an Indian tribe
recognized by the Federal Government,]
[(B) the geographic location of such
Indians,]
[(C) 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 providing services to the Indians
described in paragraph (2) or (3) of subsection
(b) of this section who are not members of any
Indian tribe recognized by the Federal
Government.]
[(b) Eligible Indians]
[Until such time as any subsequent law may otherwise
provide, the following California Indians shall be eligible for
health services provided by the Service:]
(1) Any member of a federally recognized Indian
T[t]ribe.
(2) Any descendant of an Indian who was residing in
California on June 1, 1852, [but only] if such
descendant--
[(A) is living in California,]
(A)[(B)] is a member of the Indian community
served by a local program of the Service[,];
and
(B)[(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 Indian in California who is listed on the
plans for distribution of the assets of [California]
rancherias and reservations located within the State of
California under the Act of August 18, 1958 (72 Stat.
619), and any descendant of such an Indian.
(b)[(c)] Clarification.--[Scope of eligibility] 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.
[Sec. 1680. California as a contract health service delivery area]
[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, Sant 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.]
[Sec. 1680a. Contract health facilities]
[The Service shall provide funds for health care programs
and facilities operated by tribes and tribal organizations
under contracts with the Service entered into under the Indian
Self-Determination Act [25 U.S.C.A. Sec. 450f et seq.]--]
[(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.]
[Sec. 1680b. National Health Service Corps]
[The Secretary of Health and Human Services shall 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 [25 U.S.C.A. Sec. 450f et
seq.], 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.]
Sec. 1680c. Health S[s]ervices for I[i]neligible P[p]ersons
(a) Children.--[Individuals not otherwise eligible]
[(1)] Any individual who--
(1)[(A)] has not attained 19 years of age[,];
(2)[(B)] is the natural or adopted child, step[-
]child,
foster[-]child, legal ward, or orphan of an eligible
Indian[,]; and
(3)[(C)] 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 individual has been
determined to be legally incompetent prior to attaining 19
years of age, such individual shall remain eligible for such
services until 1[one] year after the date of a determination of
competency [such disability has been removed].
(b) Spouses.--[(2)] Any spouse of an eligible Indian who is
not an Indian, or who is of Indian descent but is not otherwise
eligible for the health services provided by the Service, shall
be eligible for such health services if all of such spouses or
spouses who are married to membersof each Indian Tribe served
are made eligible, as a class, by an appropriate resolution of the
governing body of the Indian tribe or Tribal Organization providing
such services [of the eligible Indian]. The health needs of persons
made eligible under this paragraph shall not be taken into
consideration by the Service in determining the need for, or allocation
of, its health resources.
(c)[(b)] Provision of Services to Other Individuals._
[Health facilities providing health service]
(1)[(A)] In general.--The Secretary is authorized to
provide health services under this subsection through
health programs [facilities] operated directly by the
Service to individuals who reside within the [service
area of a s]Service [u]Unit and who are not otherwise
eligible for such health services [under any other
subsection of this section or under any other provision
of law] if--
(A)[(i)] the Indian T[t]ribes [(or, in the
case of a multi-tribal service are, all the
Indian tribes)] served by such [s]Service
[u]Unit request[s] such provision of health
services to such individuals[,]; and
(B)[(ii)] the Secretary and the served Indian
[tribe or t]Tribes have jointly determined
that--
(i)[(I)] the provision of such health
services will not result in a denial or
diminution of health services to
eligible Indians[,]; and
(ii)[(II)] there is no reasonable
alternative health facilit[y]ies or
services, within or without the
[service area of such s]Service
[u]Unit, available to meet the health
needs of such individuals.
(2)[(B)] ISDEAA programs.--In the case of health
programs and facilities operated under a contract or
compact entered into under the Indian Self-
Determination and Education Assistance Act (25 U.S.C.
450 et seq.), [[25 U.S.C.A. Sec. 450f et seq.],] the
governing body of the Indian [t]Tribe or T[t]ribal
O[o]rganization providing health services under such
contract or compact is authorized to determine whether
health services should be provided under such contract
or compact to individuals who are not otherwise
eligible for such [health] services under any other
subsection of this section or under any other provision
of law. In making such determination[s], the governing
body of the Indian [t]Tribe or [t]Tribal
[o]Organization shall take into account the
considerations described in clauses (i) and (ii) of
paragraph (1)(B) [subparagraph (A)(ii)].
(3)[(2)] Payment for services._
(A) In general.--Persons receiving health
services provided by the Service under [by
reason of] this subsection shall be liable for
payment of such health services under a
schedule of charges prescribed by the Secretary
which, in the judgment of the Secretary,
results in reimbursement in an amount not less
than the actual cost of providing the health
services. Notwithstanding section 404[1880(c)]
of this [the Social Security] Act [[42 U.S.C.A.
Sec. 1395qq(c)], section 1642(a) of this
title,] or any other provision of law, amounts
collected under this subsection, including
medicare, [or] medicaid or SCHIP reimbursements
under titles XVIII, [and] XIX, and XXI of the
Social Security Act [[42 U.S.C.A.
Sec. Sec. 1395 et seq., 1396 et seq.]], shall
be credited to the account of the program
[facility] providing the service and shall be
used [solely] for the purposes listed in
section 401(d)(2) and [provision of health
services within that facility. A]amounts
collected under this subsection shall be
available for expenditure within such program
[facility for not to exceed one fiscal year
after the fiscal year in which collected].
(B) Indigent people.--Health services may be
provided by the Secretary through the Service
under this subsection to an indigent individual
[person] who would not be otherwise eligible
for such health services but for the provisions
of paragraph (1) only if an agreement has been
entered into with a State or local government
under which the State or local government
agrees to reimburse the Service for the
expenses incurred by the Service in providing
such health services to such indigent
individual [person].
(4)[(3)] Revocation of consent for services._
(A) Single tribe service area.--In the case
of a S[s]ervice A[a]rea which serves only
1[one] Indian T[t]ribe, the authority of the
Secretary to provide health services under
paragraph (1)[(A)] shall terminate at the end
of the fiscal year succeeding the fiscal year
in which the governing body of the Indian
T[t]ribe revokes its concurrence to the
provision of such health services.
(B) Multitribal service area.--In the case of
a
multi[-]tribal S[s]ervice A[a]rea, the
authority of the Secretary to provide health
services under paragraph (1)[(A)] shall
terminate at the end of the fiscal year
succeeding the fiscal year in which at least 51
percent of the number of Indian T[t]ribes in
the S[s]ervice A[a]rea revoke their concurrence
to the provision of such health services.
(d)[(c)] Other Services.--[Purposes served in providing
health services to otherwise ineligible individuals] 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[,];
(2) prevent the spread of a communicable disease or
otherwise deal with a public health hazard[,];
(3) provide care to non-Indian women pregnant with an
eligible Indian's child for the duration of the
pregnancy through post[ ]partum[,]; or
(4) provide care to immediate family members of an
eligible individual [person] if suchcare is directly
related to the treatment of the eligible individual [person].
(e)[(d) Extension of h]Hospital [p]Privileges for [to non-
Service health care p]Practitioners.--Hospital privileges in
health facilities operated and maintained by the Service or
operated under a contract or compact [entered into under]
pursuant to the Indian Self-Determination and Education
Assistance Act (25 U.S.C. 450 et seq.) [[25 U.S.C.A. Sec. 450f
et seq.]] may be extended to non-Service health care
practitioners who provide services to individuals [persons]
described in subsection (a), [or] (b), (c), or (d) [of this
section]. Such non-Service health care practitioners may, as
part of the privileging process, be designated [regarded] as
employees of the Federal Government for purposes of section
1346(b) and chapter 171 of Title 28, United States Code
(relating to Federal tort claims) only with respect to acts or
omissions which occur in the course of providing services to
eligible individuals [persons] as a part of the conditions
under which such hospital privileges are extended.
(f)[(e) ``]Eligible Indian['' ``defined].--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.
[Sec. 1680d. Infant and maternal mortality; fetal alcohol syndrome]
[By no later than January 1, 1990, the Secretary shall
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 States population as a
whole; and]
[(3) reduction of the rate of fetal alcohol syndrome
among Indians served by, or on behalf of, the Service
to one per one thousand births.]
[Sec. 1680e. Contract health services for the Trenton Service Area]
[(a) Service to Turtle Mountain Band]
[The Secretary, acting through the Service, is directed to
provide contract health services to members of the Turtle
Mountain Band of Chippewa Indians that reside in the Trenton
Service Area of Divide, McKenzie, and Williams counties in the
State of North Dakota and the adjoining counties of Richland,
Roosevelt, and Sheridan in the State of Montana.]
[(b) Band member eligibility not expanded]
[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.]
[Sec. 1680f. Indian Health Service and Department of Veterans Affairs
health facilities and services sharing]
[(a) Feasibility study and report]
[The Secretary shall examine the feasibility of entering
into an arrangement for the sharing of medical facilities and
services between the Indian Health Service and the Department
of Veterans Affairs and shall, in accordance with subsection
(b) of this section, prepare a report on the feasibility of
such an arrangement and submit such report to the Congress by
no later than September 30, 1990.]
[(b) Nonimpairment of service quality, eligibility, or
priority of access]
[The Secretary shall not take any action under this section
or under subchapter IV of chapter 81 of Title 38 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 Department of Veterans
Affairs;]
[(4) the quality of health care services provided to
any veteran by the Department of Veterans Affairs;]
[(5) the eligibility of any Indian to receive health
services through the Indian Health Service; or]
[(6) the eligibility of any Indian who is a veteran
to receive health services through the Department of
Veterans Affairs.]
[(c) Cross utilization of services]
[(1) Not later than December 23, 1988, the Director
of the Indian Health Service and the Secretary of
Veterans Affairs shall implement an agreement under
which--]
[(A) individuals in the vicinity of
Roosevelt, Utah, who are eligible for health
care from the Department of Veterans Affairs
could obtain 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 George E. Wahlen Department of
Veterans Affairs Medical Center located in Salt
Lake City, Utah.]
[(2) Not later than November 23, 1990, the Secretary
and the Secretary of Veterans Affairs shall jointly
submit a report to the Congress on the health care
services provided as a result of paragraph (1).]
[(d) Right to health services]
[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) of this section.]
Sec. 1680g. Reallocation of B[b]aseR[r]esources
(a) Report Required.--[to Congress] 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 S[s]ervice U[u]nit may be implemented only after
the Secretary has submitted to the President, for inclusion in
the report required to be transmitted to [the] Congress under
section 801[1671 of this title], a report on the proposed
change in allocation of funding, including the reasons for the
change and its likely effects.
(b) Exception.--[Appropriated amounts] Subsection (a) [of
this section] shall not apply if the total amount appropriated
to the Service for a fiscal year is at least 5 percent less
than the amount appropriated to the Service for the previous
fiscal year.
[Sec. 1680h. Demonstration projects for tribal management of health
care services]
[(a) Establishment; grants]
[(1) 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 health 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 if the Secretary determines that the
Indian tribe has the administrative and financial
capabilities necessary to conduct a demonstration
project described in paragraph (1).]
[(b) Health care contracts]
[During the period in which a demonstration project
established under subsection (a) of this section is being
conducted by an Indian tribe, the Secretary shall award all
health care contracts, including community, behavioral, and
preventive health care contracts, to the Indian tribe in the
form of a single grant to which the regulations prescribed
under part A of title XIX of the Public Health Service Act [42
U.S.C.A. Sec. 300w et seq.] (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) of this section) shall apply.]
[(c) Waiver of procurement laws]
[The Secretary may waive such provisions of Federal
procurement law as are necessary to enable any Indian tribe to
develop and test administrative systems under the demonstration
project established under subsection (a) of this section, but
only if such waiver does not diminish or endanger the delivery
of health care services to Indians.]
[(d) Termination; evaluation and report]
[(1) The demonstration project established under
subsection (a) of this section shall terminate on
September 30, 1993, or, in the case of a demonstration
project for which a grant is made after September 30,
1990, three years after the date on which such grant is
made.]
[(2) By no later than September 30, 1996, the
Secretary shall evaluate the performance of each Indian
tribe that has participated in a demonstration project
established under subsection (a) of this section and
shall submit to the Congress a report on such
evaluations and demonstration projects.]
[(e) Joint venture demonstration projects]
[(1) The Secretary, acting through the Service, shall
make arrangements with Indian tribes to establish joint
venture demonstrative projects under which an Indian
tribe shall expend tribal, private, or other available
nontribal funds, for the acquisition or construction of
a health facility for a minimum of 20 years, under a
no-cost lease, in exchange for agreement by the Service
to provide the equipment, supplies, and staffing for
the operation and maintenance of such a health
facility. A tribe may utilize tribal funds, private
sector, or other available resources, including loan
guarantees, to fulfill its commitment under this
subsection.]
[(2) The Secretary shall make such an arrangement
with an Indian tribe only if the Secretary first
determines that the Indian tribe has the administrative
and financial capabilities necessary to complete the
timely acquisition or construction of the health
facility described in paragraph (1).]
[(3) An Indian tribe or tribal organization that has
entered into a written agreement with the Secretary
under this subsection, and that breaches or terminates
without cause such agreement, shall be liable to the
United States for the amount that has been paid to the
tribe, or paid to a third party on the tribe's behalf,
under the agreement. The Secretary has the right to
recover tangible property (including supplies), and
equipment, less depreciation, and any funds expended
for operations and maintenance under this section. The
preceding sentence does not apply to any funds expended
for the delivery of health care services, or for
personnel or staffing, shall be recoverable.]
[Sec. 1680i. Child sexual abuse treatment programs]
[(a) Continuation of existing demonstration programs]
[The Secretary and the Secretary of the Interior shall, for
each fiscal year through fiscal year 1995, continue the
demonstration programs involving treatment for child sexual
abuse provided through the Hopi Tribe and the Assiniboine and
Sioux Tribes of the Fort Peck Reservation.]
[(b) Establishment of new demonstration programs]
[Beginning October 1, 1995, the Secretary and the Secretary
of the Interior may establish, in any service area,
demonstration programs involving treatment for child sexual
abuse, except that the Secretaries may not establish a greater
number of such programs in one service area than in any other
service area until there is an equal number of such programs
established with respect to all service areas from which the
Secretary receives qualified applications during the
application period (as determined by the Secretary).]
[Sec. 1680j. Tribal leasing]
[Indian tribes providing health care services pursuant to a
contract entered into under the Indian Self-Determination Act
[25 U.S.C.A. Sec. 450f et seq.] may lease permanent structures
for the purpose of providing such health care services without
obtaining advance approval in appropriation Acts.]
[Sec. 1680k. Home- and community-based care demonstration project]
[(a) Authority of Secretary]
[The Secretary, acting through the Service, is authorized
to enter into contracts with, or make grants to, Indian tribes
or tribal organizations providing health care services pursuant
to a contract entered into under the Indian Self-Determination
Act [25 U.S.C.A. Sec. 450f et seq.], to establish demonstration
projects for the delivery of home- and community-based services
to functionally disabled Indians.]
[(b) Use of funds]
[(1) Funds provided for a demonstration project under
this section shall be used only for the delivery of
home- and community-based services (including
transportation services) to functionally disabled
Indians.]
[(2) Such funds may not by used--]
[(A) to make cash payments to functionally
disabled Indians;]
[(B) to provide room and board for
functionally disabled Indians;]
[(C) for the construction or renovation of
facilities or the purchase of medical
equipment; or]
[(D) for the provision of nursing facility
services.]
[(c) Criteria for approval of applications]
[Not later than 180 days after October 29, 1992, the
Secretary, after consultation with Indian tribes and tribal
organizations, shall develop and issue criteria for the
approval of applications submitted under this section. Such
criteria shall ensure that demonstration projects established
under this section promote the development of the capacity of
tribes and tribal organizations to deliver, or arrange for the
delivery of, high quality, culturally appropriate home- and
community-based services to functionally disabled Indians;]
[(d) Assistance to applicants]
[The Secretary shall provide such technical and other
assistance as may be necessary to enable applicants to comply
with the provisions of this section.]
[(e) Services to ineligible persons]
[At the discretion of the tribe or tribal organization,
services provided under a demonstration project established
under this section may be provided (on a cost basis) to persons
otherwise ineligible for the health care benefits of the
Service.]
[(f) Maximum number of demonstration projects]
[The Secretary shall establish not more than 24
demonstration projects under this section. The Secretary may
not establish a greater number of demonstration projects under
this section in one service area than in any other service area
until there is an equal number of such demonstration projects
established with respect to all service areas from which the
Secretary receives applications during the application period
(as determined by the Secretary) which meet the criteria issued
pursuant to subsection (c) of this section.]
[(g) Report]
[The Secretary shall submit to the President, for inclusion
in the report which is required to be submitted under section
1671 of this title for fiscal year 1999, a report on the
findings and conclusions derived from the demonstration
projects conducted under this section, together with
legislative recommendations.]
[(h) Definitions]
[For the purposes of this section, the following
definitions shall apply:]
[(1) The term ``home- and community-based services''
means one or more of the following:]
[(A) Homemaker/home health aide services.]
[(B) Chore services.]
[(C) Personal care services.]
[(D) Nursing care services provided outside
of a nursing facility by, or under the
supervision of, a registered nurse.]
[(E) Respite care.]
[(F) Training for family members in managing
a functionally disabled individual.]
[(G) Adult day care.]
[(H) Such other home- and community-based
services as the Secretary may approve.]
[(2) The term ``functionally disabled'' means an
individual who is determined to require home- and
community-based services based on an assessment that
uses criteria (including, at the discretion of the
tribe or tribal organization, activities of daily
living) developed by the tribe or tribal organization.]
[(i) Authorization of appropriations]
[There are authorized to be appropriated for each of the
fiscal years 1996 through 2000 such sums as may be necessary to
carry out this section. Such sums shall remain available until
expended.]
[Sec. 1680l. Shared services demonstration project]
[(a) Authority of Secretary]
[The Secretary, acting through the Service and
notwithstanding any other provision of law, is authorized to
enter into contracts with Indian tribes or tribal organizations
to establish not more than 6 shared services demonstration
projects for the delivery of long-term care to Indians. Such
projects shall provide for the sharing of staff or other
services between a Service facility and a nursing facility
owned and operated (directly or by contract) by such Indian
tribe or tribal organization.]
[(b) Contract requirements]
[A contract entered into pursuant to subsection (a) of this
section--]
[(1) may, at the request of the Indian tribe or
tribal organization, delegate to such tribe or tribal
organization such powers of supervision and control
over Service employees as the Secretary deems necessary
to carry out the purposes of this section;]
[(2) shall provide that expenses (including salaries)
relating to services that are shared between the
Service facility and the tribal facility be allocated
proportionately between the Service and the tribe or
tribal organization; and]
[(3) may authorize such tribe or tribal organization
to construct, renovate, or expand a nursing facility
(including the construction of a facility attached to a
Service facility), except that no funds appropriated
for the Service shall be obligated or expended for such
purpose.]
[(c) Eligibility]
[To be eligible for a contract under this section, a tribe
or tribal organization, shall, as of October 29, 1992--]
[(1) own and operate (directly or by contract) a
nursing facility;]
[(2) have entered into an agreement with a consultant
to develop a plan for meeting the long-term needs of
the tribe or tribal organization; or]
[(3) have adopted a tribal resolution providing for
the construction of a nursing facility.]
[(d) Nursing facilities]
[Any nursing facility for which a contract is entered into
under this section shall meet the requirements for nursing
facilities under section 1396r or Title 42.]
[(e) Assistance to applicants]
[The Secretary shall provide such technical and other
assistance as may be necessary to enable applicants to comply
with the provisions of this section.]
[(f) Report]
[The Secretary shall submit to the President, for inclusion
in each report required to be transmitted to the Congress under
section 1671 of this title, a report on the findings and
conclusions derived from the demonstration projects conducted
under this section.]
Sec. 1680m. Results of [d]Demonstration [p]Projects
The Secretary shall provide for the dissemination to Indian
T[t]ribes, Tribal Organizations, and Urban Indian Organizations
of the findings and results of demonstration projects conducted
under this Act [chapter].
[Sec. 1680n. Priority for Indian reservations]
[(a) Facilities and projects]
[Beginning on October 29, 1992, the Bureau of Indian
Affairs and the Service shall, in all matters involving the
reorganization or development of service facilities, or in the
establishment of related employment projects to address
unemployment conditions in economically depressed areas, give
priority to locating such facilities and projects on Indian
lands if requested by the Indian tribe with jurisdiction over
such lands.]
[(b) ``Indian lands'' defined]
[For purposes of this section, the term ``Indian lands''
means--]
[(1) all lands within the limits of any Indian
reservation; and]
[(2) any lands title which is held in trust by the
United States for the benefit of any Indian tribe or
individual Indian, or held by any Indian tribe or
individual Indian subject to restriction by the United
States against alienation and over which an Indian
tribe exercises governmental power.]
Sec. 810. Provision of Services in Montana
(a) Consistent With Court Decision.--The Secretary, acting
through the Service, shall provide services and benefits 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) Clarification.--The provisions of subsection (a) shall
not be construed to be an expression of the sense of 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.
[Sec. 1680o. Authorization of appropriations]
[Except as provided in section 1680k of this title, there
are authorized to be appropriated such sums as may be necessary
for each fiscal year through fiscal year 2000 to carry out this
subchapter.]
Sec. 811. Moratorium
During the period of the moratorium imposed 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 sections 806 and 807 until such time as new
criteria governing eligibility for services are developed in
accordance with section 802.
[Sec. 1681. Omitted]
Sec. 812. Tribal Employment
For purposes of section 2(2) of the Act of July 5, 1935 (49
Stat. 450, chapter 372), an Indian Tribe or Tribal Organization
carrying out a contract or compact pursuant to the Indian Self-
Determination and Education Assistance Act (25 U.S.C. 450 et
seq.) shall not be considered an `employer'.
[Sec. 1682. Subrogation of claims by Indian Health Service]
[On and after October 18, 1986, the Indian Health Service
may seek subrogation of claims including but not limited to
auto accident claims, including no-fault claims, personal
injury, disease, or disability claims, and worker's
compensation claims, the proceeds of which shall be credited to
the funds established by sections 401 and 402 of the Indian
Health Care Improvement Act.]
[Sec. 1683. Indian Catastrophic Health Emergency Fund]
[$10,000,000 shall remain available until expended, for the
establishment of an Indian Catastrophic Health Emergency Fund
(hereinafter referred to as the ``Fund''). On and after October
18, 1986, the Fund is to cover the Indian Health Service
portion of the medical expenses of catastrophic illness falling
within the responsibility of the Service and shall be
administered by the Secretary of Health and Human Services,
acting through the central office of the Indian Health Service.
No part of the Fund or its administration shall be subject to
contract or grant under the Indian Self-Determination and
Education Assistance Act (Public Law 93-638) [25 U.S.C.A.
Sec. 450 et seq.]. There shall be deposited into the Fund all
amounts recovered under the authority of the Federal Medical
Care Recovery Act (42 U.S.C. 2651 et seq.), which shall become
available for obligation upon receipt and which shall remain
available for obligation until expended. The Fund shall not be
used to pay for health services provided to eligible Indians to
the extent that alternate Federal, State, local, or private
insurance resources for payment: (1) are available and
accessible to the beneficiary; or (2) would be available and
accessible if the beneficiary were to apply for them; or (3)
would be available and accessible to other citizens similarly
situated under Federal, State, or local law or regulation or
private insurance program notwithstanding Indian Health Service
eligibility or residency on or off a Federal Indian
reservation.]
Sec. 813. Severability Provisions
If any provision of this Act, any amendment made by the
Act, or the application of such provision or amendment to any
person or circumstances is held to be invalid, the remainder of
this Act, the remaining amendments made by this Act, and the
application of such provisions to persons or circumstances
other than those to which it is held invalid, shall not be
affected thereby.
Sec. 814. Establishment of National Bipartisan Commission on Indian
Health Care
(a) Establishment.--There is established the National
Bipartisan Indian Health Care Commission (the `Commission').
(b) Duties of Commission.--The duties of the Commission are
the following:
(1) To establish a study committee composed of those
members of the Commission appointed by the Director and
at least 4 members of Congress from among the members
of the Commission, the duties of which shall be the
following:
(A) To the extent necessary to carry out its
duties, collect and compile data necessary to
understand the extent of Indian needs with
regard to the provision of health services,
regardless of the location of Indians,
including holding hearings and soliciting the
views of Indians, Indian Tribes, Tribal
Organizations, and Urban Indian Organizations,
which may include authorizing and making funds
available for feasibility studies of various
models for providing and funding health
services for all Indian beneficiaries,
including those who live outside of a
reservation, temporarily or permanently.
(B) To make legislative recommendations to
the Commission regarding the delivery of
Federal health services to Indians. Such
recommendations shall include those related to
issues of eligibility, benefits, the range of
service providers, the cost of such services,
financing such services, and the optimal manner
in which to provide such services.
(C) To determine the effect of the enactment
of such recommendations on (i) the existing
system of delivery of health services for
Indians, and (ii) the sovereign status of
Indian Tribes.
(D) Not later than 12 months after the
appointment of all members of the Commission,
to submit a written report of its findings and
recommendations to the full Commission. The
report shall include a statement of the
minority and majority position of the Committee
and shall be disseminated, at a minimum, to
every Indian Tribe, Tribal Organization, and
Urban Indian Organization for comment to the
Commission.
(E) To report regularly to the full
Commission regarding the findings and
recommendations developed by the study
committee in the course of carrying out its
duties under this section.
(2) To review and analyze the recommendations of the
report of the study committee.
(3) To make legislative recommendations to Congress
regarding the delivery of health care services to
Indians. Such recommendation shall include those
related to issues of eligibility, benefits, the range
of service providers, the cost of such services,
financing such services, and the optimal manner in
which to provide such services.
(4) Not later than 18 months following the date of
appointment of all members of the Commission, submit a
written report to Congress regarding the delivery of
Federal health care services to Indians. Such
recommendation shall include those related to issues of
eligibility, benefits, the range of service providers,
the cost of such services, financing such services, and
the optimal manner in which to provide such services.
(c) Members.--
(1) Appointment.--The Commission shall be composed of
25 members, appointed as follows:
(A) Ten members of Congress, including 3 from
the House of Representatives and 2 from the
Senate, appointed by their respective majority
leaders, and 3 from the House of
Representatives and 2 from the Senate,
appointed by their respective minority leaders,
and who shall be members of the standing
committees of Congress that consider
legislation affecting health care to Indians.
(B) Twelve persons chosen by the
congressional members of the Commission, 1 from
each Service Area as currently designated by
the Director to be chosen from among 3 nominees
from each Service Area put forward by the
Indian Tribes within the area, with due regard
being given to the experience and expertise of
the nominees in the provision of health care to
Indians and to a reasonable representation on
the commission of members who are familiar with
various health care delivery modes and who
represent Indian Tribes of various size
populations.
(C) Three persons appointed by the Director
who are knowledgeable about the provision of
health care to Indians, at least 1 of whom
shall be appointed from among 3 nominees put
forward by those programs whose funds are
provided in whole or in part by the Service
primarily or exclusively for the benefit of
Urban Indians.
(D) All those persons chosen by the
congressional members of the Commission and by
the Director shall be members of federally
recognized Indian Tribes.
(2) Chair; vice chair.--The Chair and Vice Chair of
the Commission shall be selected by the congressional
members of the Commission.
(3) Terms.--The terms of members of the Commission
shall be for the life of the Commission.
(4) Deadline for appointments.--Congressional members
of the Commission shall be appointed not later than 180
days after the date of the enactment of the Indian
Health Care Improvement Act Amendments of 2005, and the
remaining members of the Commission shall be appointed
not later than 60 days following the appointment of the
congressional members.
(5) Vacancy.--A vacancy in the Commission shall be
filled in the manner in which the original appointment
was made.
(d) Compensation.--
(1) Congressional members.--Each congressional member
of the Commission shall receive no additional pay,
allowances, or benefits by reason of their service on
the Commission and shall receive travel expenses and
per diem in lieu of subsistence in accordance with
sections 5702 and 5703 of title 5, United States Code.
(2) Other members.--Remaining members of the
Commission, while serving on the business of the
Commission (including travel time), shall be entitled
to receive compensation at the per diem equivalent of
the rate provided for level IV of the Executive
Schedule under section 5315 of title 5, United States
Code, and while so serving away from home and the
member's regular place of business, a member may be
allowed travel expenses, as authorized by the Chairman
of the Commission. For purpose of pay (other than pay
of members of the Commission) and employment benefits,
rights, and privileges, all personnel of the Commission
shall be treated as if they were employees of the
United States Senate.
(e) Meetings.--The Commission shall meet at the call of the
Chair.
(f) Quorum.--A quorum of the Commission shall consist of
not less than 15 members, provided that no less than 6 of the
members of Congress who are Commission members are present and
no less than 9 of the members who are Indians are present.
(g) Executive Director; Staff; Facilities.--
(1) Appointment; pay.--The Commission shall appoint
an executive director of the Commission. The executive
director shall be paid the rate of basic pay for level
V of the Executive Schedule.
(2) Staff appointment.--With the approval of the
Commission, the executive director may appoint such
personnel as the executive director deems appropriate.
(3) Staff pay.--The staff of the Commission shall be
appointed without regard to the provisions of title 5,
United States Code, governing appointments in the
competitive service, and shall be paid without regard
to the provisions of chapter 51 and subchapter III of
chapter 53 of such title (relating to classification
and General Schedule pay rates).
(4) Temporary services.--With the approval of the
Commission, the executive director may procure
temporary and intermittent services under section
3109(b) of title 5, United States Code.
(5) Facilities.--The Administrator of General
Services shall locate suitable office space for the
operation of the Commission. The facilities shall serve
as the headquarters of the Commission and shall include
all necessary equipment and incidentals required for
the proper functioning of the Commission.
(h) Hearings.--
(1) For the purpose of carrying out its duties, the
Commission may hold such hearings and undertake such
other activities as the Commission determines to be
necessary to carry out its duties, provided that at
least 6 regional hearings are held in different areas
of the United States in which large numbers of Indians
are present. Such hearings are to be held to solicit
the views of Indians regarding the delivery of health
care services to them. To constitute a hearing under
this subsection, at least 5 members of the Commission,
including at least 1 member of Congress, must be
present. Hearings held by the study committee
established in this section may count toward the number
of regional hearings required by this subsection.
(2) Upon request of the Commission, the Comptroller
General shall conduct such studies or investigations as
the Commission determines to be necessary to carry out
its duties.
(3)(A) The Director of the Congressional Budget
Office or the Chief Actuary of the Centers for Medicare
& Medicaid Services, or both, shall provide to the
Commission, upon the request of the Commission, such
cost estimates as the Commission determines to be
necessary to carry out its duties.
(B) The Commission shall reimburse the Director of
the Congressional Budget Office for expenses relating
to the employment in the office of the Director of such
additional staff as may be necessary for the Director
to comply with requests by the Commission under
subparagraph (A).
(4) Upon the request of the Commission, the head of
any Federal agency is authorized to detail, without
reimbursement, any of the personnel of such agency to
the Commission to assist the Commission in carrying out
its duties. Any such detail shall not interrupt or
otherwise affect the civil service status or privileges
of the Federal employee.
(5) Upon the request of the Commission, the head of a
Federal agency shall provide such technical assistance
to the Commission as the Commission determines to be
necessary to carry out its duties.
(6) The Commission may use the United States mails in
the same manner and under the same conditions as
Federal agencies and shall, for purposes of the frank,
be considered a commission of Congress as described in
section 3215 of title 39, United States Code.
(7) The Commission may secure directly from any
Federal agency information necessary to enable it to
carry out its duties, if the information may be
disclosed under section 552 of title 4, United States
Code. Upon request of the Chairman of the Commission,
the head of such agency shall furnish such information
to the Commission.
(8) Upon the request of the Commission, the
Administrator of General Services shall provide to the
Commission on a reimbursable basis such administrative
support services as the Commission may request.
(9) For purposes of costs relating to printing and
binding, including the cost of personnel detailed from
the Government Printing Office, the Commission shall be
deemed to be a committee of Congress.
(i) Authorization of Appropriations.--There is authorized
to be appropriated $4,000,000 to carry out the provisions of
this section, which sum shall not be deducted from or affect
any other appropriations for health care for Indian persons.
(j) FACA.--The Federal Advisory Committee Act (5 U.S.C.
App.) shall not apply to the Commission.
Sec. 815. Appropriations; Availability
Any new spending authority (described in subsection
(c)(2)(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 appropriation Acts.
Sec. 816. Authorization of Appropriations
(a) In General.--There are authorized to be appropriated
such sums as may be necessary for each fiscal year through
fiscal year 2015 to carry out this title.
(b) Rate of Pay.--
(1) Positions at level iv.--Section 5315 of title 5,
United States Code, is amended by striking ``Assistant
Secretaries of Health and Human Services (6).'' and
inserting ``Assistant Secretaries of Health and Human
Services (7)''.
(2) Positions at level v.--Section 5316 of title 5,
United States Code, is amended by striking ``Director,
Indian Health Service, Department of Health and Human
Services''.
(c) Amendments to Other Provisions of Law._
(1) Section 3307(b)(1)(C) of the Children's Health
Act of 2000 (25 U.S.C. 1671 note; Public Law 106-310)
is amended by striking ``Director of the Indian Health
Service'' and inserting ``Assistant Secretary for
Indian Health''.
(2) The Indian Lands Open Dump Cleanup Act of 1994 is
amended--
(A) in section 3 (25 U.S.C. 3902)--
(i) by striking paragraph (2);
(ii) by redesignating paragraphs (1),
(3), (4), (5), and (6) as paragraphs
(4), (5), (2), (6), and (1),
respectively, and moving those
paragraphs so as to appear in numerical
order; and
(iii) by inserting before paragraph
(4) (as redesignated by subclause (II))
the following:
``(3) Assistant secretary.--The term `Assistant
Secretary' means the Assistant Secretary for Indian
Health.'';
(B) in section 5 (25 U.S.C. 3904), by
striking the section heading and inserting the
following:
``SEC. 5. AUTHORITY OF ASSISTANT SECRETARY FOR INDIAN HEALTH.'';
(C) in section 6(a) (25 U.S.C. 3905(a)), in
the subsection heading, by striking
``Director'' and inserting ``Assistant
Secretary'';
(D) in section 9(a) (25 U.S.C. 3908(a)), in
the subsection heading, by striking
``Director'' and inserting ``Assistant
Secretary''; and
(E) by striking ``Director'' each place it
appears and inserting ``Assistant Secretary''.
(3) Section 5504(d)(2) of the Augustus F. Hawkins-
Robert T. Stafford Elementary and Secondary School
Improvement Amendments of 1988 (25 U.S.C. 2001 note;
Public Law 100-297) is amended by striking ``Director
of the Indian Health Service'' and inserting
``Assistant Secretary for Indian Health''.
(4) Section 203(a)(1) of the Rehabilitation Act of
1973 (29 U.S.C. 763(a)(1)) is amended by striking
``Director of the Indian Health Service'' and inserting
``Assistant Secretary for Indian Health''.
(5) Subsections (b) and (e) of section 518 of the
Federal Water Pollution Control Act (33 U.S.C. 1377)
are amended by striking ``Director of the Indian Health
Service'' each place it appears and inserting
``Assistant Secretary for Indian Health''.
(6) Section 317M(b) of the Public Health Service Act
(42 U.S.C. 247b-14(b)) is amended--
(A) by striking ``Director of the Indian
Health Service'' each place it appears and
inserting ``Assistant Secretary for Indian
Health''; and
(B) in paragraph (2)(A), by striking ``the
Directors referred to in such paragraph'' and
inserting ``the Director of the Centers for
Disease Control and Prevention and the
Assistant Secretary for Indian Health''.
(7) Section 417C(b) of the Public Health Service Act
(42 U.S.C. 285-9(b)) is amended by striking ``Director
of the Indian Health Service'' and inserting
``Assistant Secretary for Indian Health''.
(8) Section 1452(i) of the Safe Drinking Water Act
(42 U.S.C. 300j-12(i)) is amended by striking
``Director of the Indian Health Service'' each place it
appears and inserting ``Assistant Secretary for Indian
Health''.
(9) Section 803B(d)(1) of the Native American
Programs Act of 1974 (42 U.S.C. 2991b-2(d)(1)) is
amended in the last sentence by striking ``Director of
the Indian Health Service'' and inserting ``Assistant
Secretary for Indian Health''.
(10) Section 203(b) of the Michigan Indian Land
Claims Settlement Act (Public Law 105-143; 111 Stat.
2666) is amended by striking ``Director of the Indian
Health Service'' and inserting ``Assistant Secretary
for Indian Health''.
SEC. 3. SOBOBA SANITATION FACILITIES.
The Act of December 17, 1970 (84 Stat. 1465), is amended by
adding at the end the following new section:
``Sec. 9. Nothing in this Act shall preclude the Soboba
Band of Mission Indians and the Soboba Indian Reservation from
being provided with sanitation facilities and services under
the authority of section 7 of the Act of August 5, 1954 (68
Stat. 674), as amended by the Act of July 31, 1959 (73 Stat.
267).''.
SEC. 4. AMENDMENTS TO THE MEDICAID AND STATE CHILDREN'S HEALTH
INSURANCE PROGRAMS.
(a) Expansion of Medicaid Payment for All Covered Services
Furnished by Indian Health Programs.--
(1) Expansion to all covered services.--Section 1911
of the Social Security Act (42 U.S.C. 1396j) is
amended--
(A) by amending the heading to read as
follows:
``SEC. 1911. INDIAN HEALTH PROGRAMS.''; AND
(B) by amending subsection (a) to read as
follows:
``(a) Eligibility for Reimbursement for Medical
Assistance._The Indian Health Service and an Indian Tribe,
Tribal Organization, or an Urban Indian Organization (as such
terms are defined in section 4 of the Indian Health Care
Improvement Act) shall be eligible for reimbursement for
medical assistance provided under a State plan or under waiver
authority with respect to items and services furnished by the
Indian Health Service, Indian Tribe, Tribal Organization, or
Urban Indian Organization if the furnishing of such services
meets all the conditions and requirements which are applicable
generally to the furnishing of items and services under this
title and under such plan or waiver authority.''.
(2) Elimination of temporary deeming provision.--Such
section is amended by striking subsection (b).
(3) Revision of authority to enter into agreements.--
Subsection (c) of such section is redesignated as
subsection (b) and is amended to read as follows:
``(b) Authority To Enter Into Agreements._The Secretary may
enter into an agreement with a State for the purpose of
reimbursing the State for medical assistance provided by the
Indian Health Service, an Indian Tribe, Tribal Organizations,
or an Urban Indian Organization (as so defined), directly,
through referral, or under contracts or other arrangements
between the Indian Health Service, an Indian Tribe, Tribal
Organization, or an Urban Indian Organization and another
health care provider to Indians who are eligible for medical
assistance under the State plan or under waiver authority.''.
(4) Reference correction.--Subsection (d) of such
section is redesignated as subsection (c) and is
amended--
(A) by striking ``For'' and inserting
``DIRECT BILLING.--For''; and
(B) by striking ``section 405'' and inserting
``section 401(d)''.
(b) Special Rules for Indians, Indian Health Care
Providers, and Indian Managed Care Entities.--
(1) In general.--Section 1932 of the Social Security
Act (42 U.S.C. 1396u-2) is amended by adding at the end
the following new subsection:
``(h) Special Rules for Indians, Indian Health Care
Providers, and Indian Managed Care Entities.--A State shall
comply with the provisions of section 413 of the Indian Health
Care Improvement Act (relating to the treatment of Indians,
Indian health care providers, and Indian managed care entities
under a medicaid managed care program).''.
(2) Application to schip.--Section 2107(e)(1) of the
Social Security Act (42 U.S.C. 1397gg(1)) is amended by
adding at the end the following:
``(E) Subsections (a)(2)(C) and (h) of
section 1932.''.
(c) SCHIP Treatment of Indian Tribes, Tribal Organizations,
and Urban Indian Organizations.--Section 2105(c) of the Social
Security Act (42 U.S.C. 1397ee(c)) is amended--
(1) in paragraph (2), by adding at the end the
following:
``(C) Indian health program payments.--For
provisions relating to authorizing use of
allotments under this title for payments to
Indian Health Programs and Urban Indian
Organizations, see section 410 of the Indian
Health Care Improvement Act.''; and
(2) in paragraph (6)(B), by inserting ``or by an
Indian Tribe, Tribal Organization, or Urban Indian
Organization (as such terms are defined in section 4 of
the Indian Health Care Improvement Act)'' after
``Service''.
SEC. 5. NATIVE AMERICAN HEALTH AND WELLNESS FOUNDATION.
(a) In General.--The Indian Self-Determination and
Education Assistance Act (25 U.S.C. 450 et seq.) is amended by
adding at the end the following:
``TITLE VIII--NATIVE AMERICAN HEALTH AND WELLNESS FOUNDATION
``SEC. 801. DEFINITIONS.
``In this title:
``(1) Board.--The term `Board' means the Board of
Directors of the Foundation.
``(2) Committee.--The term `Committee' means the
Committee for the Establishment of Native American
Health and Wellness Foundation established under
section 802(f).
``(3) Foundation.--The term `Foundation' means the
Native American Health and Wellness Foundation
established under section 802.
``(4) Secretary.--The term `Secretary' means the
Secretary of Health and Human Services.
``(5) Service.--The term `Service' means the Indian
Health Service of the Department of Health and Human
Services.
``SEC. 802. NATIVE AMERICAN HEALTH AND WELLNESS FOUNDATION.
``(a) Establishment.--
``(1) In general.--As soon as practicable after the
date of enactment of this title, the Secretary shall
establish, under the laws of the District of Columbia
and in accordance with this title, the Native American
Health and Wellness Foundation.
``(2) Funding determinations.--No funds, gift,
property, or other item of value (including any
interest accrued on such an item) acquired by the
Foundation shall--
``(A) be taken into consideration for
purposes of determining Federal appropriations
relating to the provision of health care and
services to Indians; or
``(B) otherwise limit, diminish, or affect
the Federal responsibility for the provision of
health care and services to Indians.
``(b) Perpetual Existence.--The Foundation shall have
perpetual existence.
``(c) Nature of Corporation.--The Foundation--
``(1) shall be a charitable and nonprofit federally
chartered corporation; and
``(2) shall not be an agency or instrumentality of
the United States.
``(d) Place of Incorporation and Domicile.--The Foundation
shall be incorporated and domiciled in the District of
Columbia.
``(e) Duties.--The Foundation shall--
``(1) encourage, accept, and administer private gifts
of real and personal property, and any income from or
interest in such gifts, for the benefit of, or in
support of, the mission of the Service;
``(2) undertake and conduct such other activities as
will further the health and wellness activities and
opportunities of Native Americans; and
``(3) participate with and assist Federal, State, and
tribal governments, agencies, entities, and individuals
in undertaking and conducting activities that will
further the health and wellness activities and
opportunities of Native Americans.
``(f) Committee for the Establishment of Native American
Health and Wellness Foundation.--
``(1) In general.--The Secretary shall establish the
Committee for the Establishment of Native American
Health and Wellness Foundation to assist the Secretary
in establishing the Foundation.
``(2) Duties.--Not later than 180 days after the date
of enactment of this section, the Committee shall--
``(A) carry out such activities as are
necessary to incorporate the Foundation under
the laws of the District of Columbia, including
acting as incorporators of the Foundation;
``(B) ensure that the Foundation qualifies
for and maintains the status required to carry
out this section, until the Board is
established;
``(C) establish the constitution and initial
bylaws of the Foundation;
``(D) provide for the initial operation of
the Foundation, including providing for
temporary or interim quarters, equipment, and
staff; and
``(E) appoint the initial members of the
Board in accordance with the constitution and
initial bylaws of the Foundation.
``(g) Board of Directors.--
``(1) In general.--The Board of Directors shall be
the governing body of the Foundation.
``(2) Powers.--The Board may exercise, or provide for
the exercise of, the powers of the Foundation.
``(3) Selection.--
``(A) In general.--Subject to subparagraph
(B), the number of members of the Board, the
manner of selection of the members (including
the filling of vacancies), and the terms of
office of the members shall be as provided in
the constitution and bylaws of the Foundation.
``(B) Requirements.--
``(i) Number of members.--The Board
shall have at least 11 members, who
shall have staggered terms.
``(ii) Initial voting members.--The
initial voting members of the Board--
``(I) shall be appointed by
the Committee not later than
180 days after the date on
which the Foundation is
established; and
``(II) shall have staggered
terms.
``(iii) Qualification.--The members
of the Board shall be United States
citizens who are knowledgeable or
experienced in Native American health
care and related matters.
``(C) Compensation.--A member of the Board
shall not receive compensation for service as a
member, but shall be reimbursed for actual and
necessary travel and subsistence expenses
incurred in the performance of the duties of
the Foundation.
``(h) Officers.--
``(1) In general.--The officers of the Foundation
shall be--
``(A) a secretary, elected from among the
members of the Board; and
``(B) any other officers provided for in the
constitution and bylaws of the Foundation.
``(2) Secretary.--The secretary of the Foundation
shall serve, at the direction of the Board, as the
chief operating officer of the Foundation.
``(3) Election.--The manner of election, term of
office, and duties of the officers of the Foundation
shall be as provided in the constitution and bylaws of
the Foundation.
``(i) Powers.--The Foundation--
``(1) shall adopt a constitution and bylaws for the
management of the property of the Foundation and the
regulation of the affairs of the Foundation;
``(2) may adopt and alter a corporate seal;
``(3) may enter into contracts;
``(4) may acquire (through a gift or otherwise), own,
lease, encumber, and transfer real or personal property
as necessary or convenient to carry out the purposes of
the Foundation;
``(5) may sue and be sued; and
``(6) may perform any other act necessary and proper
to carry out the purposes of the Foundation.
``(j) Principal Office.--
``(1) In general.--The principal office of the
Foundation shall be in the District of Columbia.
``(2) Activities; offices.--The activities of the
Foundation may be conducted, and offices may be
maintained, throughout the United States in accordance
with the constitution and bylaws of the Foundation.
``(k) Service of Process.--The Foundation shall comply with
the law on service of process of each State in which the
Foundation is incorporated and of each State in which the
Foundation carries on activities.
``(l) Liability of Officers, Employees, and Agents.--
``(1) In general.--The Foundation shall be liable for
the acts of the officers, employees, and agents of the
Foundation acting within the scope of their authority.
``(2) Personal liability.--A member of the Board
shall be personally liable only for gross negligence in
the performance of the duties of the member.
``(m) Restrictions.--
``(1) Limitation on spending.--Beginning with the
fiscal year following the first full fiscal year during
which the Foundation is in operation, the
administrative costs of the Foundation shall not exceed
10 percent of the sum of--
``(A) the amounts transferred to the
Foundation under subsection (o) during the
preceding fiscal year; and
``(B) donations received from private sources
during the preceding fiscal year.
``(2) Appointment and hiring.--The appointment of
officers and employees of the Foundation shall be
subject to the availability of funds.
``(3) Status.--A member of the Board or officer,
employee, or agent of the Foundation shall not by
reason of association with the Foundation be considered
to be an officer, employee, or agent of the United
States.
``(n) Audits.--The Foundation shall comply with section
10101 of title 36, United States Code, as if the Foundation
were a corporation under part B of subtitle II of that title.
``(o) Funding.--
``(1) Authorization of appropriations.--There is
authorized to be appropriated to carry out subsection
(e)(1) $500,000 for each fiscal year, as adjusted to
reflect changes in the Consumer Price Index for all-
urban consumers published by the Department of Labor.
``(2) Transfer of donated funds.--The Secretary shall
transfer to the Foundation funds held by the Department
of Health and Human Services under the Act of August 5,
1954 (42 U.S.C. 2001 et seq.), if the transfer or use
of the funds is not prohibited by any term under which
the funds were donated.
``SEC. 803. ADMINISTRATIVE SERVICES AND SUPPORT.
``(a) Provision of Support by Secretary.--Subject to
subsection (b), during the 5-year period beginning on the date
on which the Foundation is established, the Secretary--
``(1) may provide personnel, facilities, and other
administrative support services to the Foundation;
``(2) may provide funds for initial operating costs
and to reimburse the travel expenses of the members of
the Board; and
``(3) shall require and accept reimbursements from
the Foundation for--
``(A) services provided under paragraph (1);
and
``(B) funds provided under paragraph (2).
``(b) Reimbursement.--Reimbursements accepted under
subsection (a)(3)--
``(1) shall be deposited in the Treasury of the
United States to the credit of the applicable
appropriations account; and
``(2) shall be chargeable for the cost of providing
services described in subsection (a)(1) and travel
expenses described in subsection (a)(2).
``(c) Continuation of Certain Services.--The Secretary may
continue to provide facilities and necessary support services
to the Foundation after the termination of the 5-year period
specified in subsection (a) if the facilities and services--
``(1) are available; and
``(2) are provided on reimbursable cost basis.''.
(b) Technical Amendments.--The Indian Self-Determination
and Education Assistance Act (25 U.S.C. 450 et seq.) is
amended--
(1) by redesignating title V (25 U.S.C. 458bbb et
seq.) as title VII;
(2) by redesignating sections 501, 502, and 503 (25
U.S.C. 458bbb, 458bbb-1, 458bbb-2) as sections 701,
702, and 703, respectively; and
(3) in subsection (a)(2) of section 702 and paragraph
(2) of section 703 (as redesignated by paragraph (2)),
by striking ``section 501'' and inserting ``section
701''.