[Senate Report 110-197]
[From the U.S. Government Publishing Office]
Calendar No. 421
110th Congress Report
SENATE
1st Session 110-197
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INDIAN HEALTH CARE IMPROVEMENT ACT AMENDMENTS OF 2007
_______
October 16, 2007.--Ordered to be printed
_______
Mr. Dorgan, from the Committee on Indian Affairs, submitted the
following
R E P O R T
[To accompany S. 1200]
The Committee on Indian Affairs, to which was referred the
bill (S. 1200) to amend the Indian Health Care Improvement Act
to revise and extend that Act, having considered the same,
reports favorably thereon without amendment and recommends that
the bill do pass.
Purpose
The purpose of the Indian Health Care Improvement Act
Amendments of 2007 (S. 1200) is to reauthorize the Act to
maintain and improve the Indian health care delivery system.
This legislation is intended to raise the health status of
American Indians and Alaska Natives\1\ to the highest possible
level in accordance with Healthy People 2010.\2\
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\1\The original Act defines the term ``Indian'' to include Indians
and Alaska Natives.
\2\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 these threats.'' U.S. Department of Health and
Human Services, www.healthypeople.gov.
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S. 1200 builds upon current law to set forth policies,
programs and procedures designed to address health care
deficiencies in Indian and urban Indian communities, and to
streamline service delivery to those communities. In addition,
S. 1200 addresses the health problems and associated socio-
economic conditions in Native American 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, and authorized funding for various programs through
Fiscal Year 2000. Public Law 106-568 included a simple
extension of the Act's authority through FY 2001. Congress has
continued to fund programs under the Act through the general
permanent authority under the Snyder Act (25 U.S.C. 13).
THE REAUTHORIZATION PROCESS
The work on the latest reauthorization of the Indian Health
Care Improvement Act began in 1999. Bills have been introduced
since the 106th Congress\3\ to provide numerous improvements
and updates to current law, many of which are contained in S.
1200.
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\3\S. 2526 (106th Congress), S. 212 (107th Congress), S. 556 (108th
Congress), S. 1200 and S. 4122 (109th Congress).
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In June, 1999, the Director of the IHS convened a National
Tribal Steering Committee on the Reauthorization of the Indian
Health Care Improvement Act (NSC), which was comprised of
tribal leaders and representatives from Indian health
organizations to facilitate the Act's 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 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.
During the 108th Congress, the Committee, the NSC and the
Administration engaged in extensive negotiations over
reauthorization issues, but action on a final version of that
Congress' bill, S. 556, did not occur before the conclusion of
the 108th Congress. Several recommendations developed during
these negotiations were incorporated into S. 1057, which was
introduced in the 109th Congress.
In the first session of the 109th Congress, the Indian
Affairs Committee favorably reported an amendment in the nature
of a substitute to S. 1057. In the ensuing months, the
Committee engaged in discussions with the Administration--not
only DHHS, but also the Department of Justice. Changes based on
these discussions were made in an amendment in the nature of a
substitute to S. 1057. In addition, the Committee worked
extensively with the Senate Finance Committee on provisions in
the jurisdiction of that committee, which were separately
reported out by the Finance Committee on June 8, 2006, as S.
3524, and incorporated in to the amendment in the nature of a
substitute to S. 1057. Comments were also received from the
Senate Health, Education, Labor and Pensions Committee, on
provisions over which that Committee maintains an interest, and
many were incorporated. A new bill, based on the amendment in
the nature of a substitute, was introduced as S. 4122 on
December 8, 2006, the last day of the second session of the
109th Congress. No further consideration of that measure
occurred.
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 accompanying prior
legislation, (see, e.g., Senate Report Nos. 94-133, 102-392,
108-411 and 109-222).
Based on the U.S. Constitution, treaties, statutes and the
historical, political and legal relationship with the Indian
tribes, the United States has assumed a trust responsibility
for the provision of health care to Indian people. Those laws
and relationships serve as the backdrop for the government-to-
government relationship.
Extensive research indicates that the health of Indians
deteriorated after contact with the European colonists, as the
aboriginal inhabitants had no natural immunities to the
diseases carried by the new arrivals. Decades later, when
Federal policy forced the Indians to relocate from their
homelands and settle on reservations and, in many cases,
prohibited the conduct of traditional practices--including
traditional healing--the health of Indians continued to
plummet. Thus, health care became a particularly significant
element of the treaties and other agreements between the Indian
tribes and the United States.
During the early 1800s, the health care provided was little
more than vaccinations for the Indians around federal military
posts in order to protect the soldiers and non-Indians from the
possibility that Indians might spread diseases. During the late
1800s, physicians and hospitals were added to the reservations
and other outposts. Mention of the provision of health care was
included in treaties. For example, the Treaty with the
Chippewa, Red Lake and Pembina Bands, of 1864, stated in
Article 4,
The United States also agree[s] to furnish said bands
of Indians, for the period of fifteen years, one
blacksmith, one physician, one miller, and one farmer;
and will also furnish them annually, during the same
period, with fifteen hundred dollars' worth of iron,
steel, and other articles for blacksmithing purposes,
and one thousand dollars for carpentering, and other
purposes (emphasis added).\4\
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\4\Charles J. Kappler, Indian Affairs: Laws & Treaties, Vol. II, at
861.
With respect to federal agencies overseeing the
responsibility for Indian health, the task was first assigned
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.\5\
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\5\Report on Indian Health by Task Force Six: Indian Health in the
Final Report to the American Indian Policy Review Commission (Final
Report) at 32.
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In 1921, Congress enacted the Snyder Act (25 U.S.C. 13), to
provide for permanent appropriations authority for Indian
health programs and services. However, the Snyder Act did not
provide meaningful standards by which to measure progress in
Indian health status or other improvements in services.
The lack of standards in the Snyder Act and other organized
efforts led the American Indian Policy Review Commission to
conclude in 1976 that
there [was] no clear overall direction or policy for
implementation of the various programs. As a result,
the Indian Health Services operates primarily an
emergency and crisis oriented service. . . . This has
resulted in increased prevalence of certain health
deficiencies which are virtually unknown in the general
population.\6\
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\6\Id. at 12.
Shortly after the responsibility for Indian health was
transferred to DHEW, Congress passed the Indian Sanitation
Facilities and Services Act, 42 U.S.C. 2004, which authorized
the IHS to provide sanitation facilities to Indian communities.
These sanitation facilities were critical to eliminating many
health maladies associated with the lack of proper sanitation,
such as dysentery and infectious hepatitis.
The administration of Indian health had initially been
managed in a piecemeal approach, then ultimately was placed
within the IHS, an agency of the DHHS. Based on that history
and in fulfillment of the special trust obligation to Indian
people, Congress passed the Indian Health Care Improvement Act
to provide coordinated programs and meaningful direction in
Indian health care administration. 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 and management was needed
to ensure improvements were achieved in Indian health status
and services.
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. Senate Report No. 94-133 accompanying S.
522, the Indian Health Care Improvement Act of 1976, which was
signed into law as Public Law 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.''\7\
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\7\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.''\8\ Also troubling was the
infant mortality rate for Indian babies, which was
significantly higher than the national average.\9\
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\8\Id.
\9\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.\10\ Overall, ``in 1975,
there were only 72 American Indian physicians to serve the
needs of 1,000,000 American Indians, most of whom lived on
Reservations.''\11\ Likewise, only half of the number of
pharmacists needed was employed in these Indian
communities.\12\
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\10\Id., at 55.
\11\Headlands Indian Health Careers, Program History, available at
http://www.headlands.ouhsc.edu/history.asp.
\12\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.''\13\ 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.''\14\
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\13\Id. at 36-37.
\14\Id., at 37.
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Funding. The funding available for the provision of health
services to Indians 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.''\15\
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\15\Id.
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Accordingly, the goals of the Act held great promise for
the advancement of Indian health by improving the direction in
programs and access to other programs, such as Medicare and
Medicaid.
CURRENT INDIAN HEALTH SYSTEM
Since 1976, significant improvements have been made in the
programs and funding levels authorized for Indian health
through the Act and the amendments thereto. Yet, a comparison
of historic statistics with current status indicators shows
that, while real progress has been made, significant
disparities still persist.
Indian Health Status. The Indian Health Service report
2000-2001 Trends in Indian Health indicates the age-adjusted
death rates for American Indians and Alaska Natives for 1996-
1998 was five times the rate for U.S. all-races in 1997.\16\
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.\17\ 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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\16\U.S. Department of Health and Human Services, Indian Health
Service, 2000-2001 Trends in Indian Health, at 68.
\17\U.S. Department of Health and Human Services, Indian Health
Service, 2000-2001 Trends in Indian Health, at 162.
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Even during the short period of 1997 to 2004, the
``prevalence of diagnosed diabetes increased by 47 percent in
all major regions (all ages) served by the Indian Health
Service.'' The most alarming increase, however, has occurred
among younger American Indians and Alaska Natives, with a 160
percent increase from 1990-2004 for young adults aged 25-34
years, and a 128 percent increase for adolescents aged 15-19
years from 1990-2004.\18\
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\18\U.S. Department of Health and Human Services, Indian Health
Service, Fiscal Year 2008, Justification of Estimates for
Appropriations Committees, at CJ-147.
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Recent information also indicates that suicide rates among
youth in Indian Country are predominately higher than for non-
Indian youth. 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. During the second
session of the 109th Congress, on May 17, 2006, the Committee
held an oversight hearing on suicide prevention programs and
their application in Indian Country.
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. At
several Indian health facilities, the demand for mental health
care outstripped capacity.\19\ In at least one facility, the
mental health services were to be cut by 20% in FY 2005 because
funding had been depleted.\20\
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\19\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.
\20\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. The Committee held
an oversight hearing on the problem of methamphetamine in
Indian Country on April 5, 2006. According to the National
Survey on Drug Use and Health, the past-year use rate during a
2002-2004 survey period among American Indians and Alaska
Natives aged 12 and older is higher than every other population
except Native Hawaiians or other Pacific Islanders and youth
reporting two or more races.\21\
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\21\U.S. Department of Health and Human Services, Substance Abuse
and Mental Health Services Administration, Office of Applied Studies,
National Survey on Drug Use and Health, The NSDUH Report, September 16,
2005, http://oas.samhsa.gov/2k5/meth/meth.htm.
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Health Facilities. According to the Indian Health Service's
FY 2008 budget request, the IHS health care facilities system
is made up of 163 Service Units (63 IHS, 100 tribal); 48
Hospitals (33 IHS, 15 tribal); and 603 Ambulatory Care Centers
(92 IHS and 511 tribal) (consisting of Health Centers, School
Health Centers, Health Stations and Alaska Village
Clinics).\22\
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\22\U.S. Department of Health and Human Services, Indian Health
Service, Fiscal Year 2008, Justification of Estimates for
Appropriations Committees, at CJ-251.
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According to the IHS Health Facilities Construction
Priority System, the estimated unfunded total cost to meet the
need was nearly $3.5 billion as of FY 2008.\23\ In addition,
the backlog for the maintenance and improvement needs of
current facilities was estimated at $408,956,000.\24\
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\23\U.S. Department of Health and Human Services, Indian Health
Service, chart of Health Care Facilities FY 2009 Planned Construction
Budget (March 30, 2007).
\24\U.S. Department of Health and Human Services, Indian Health
Service, Fiscal Year 2008, Justification of Estimates for
Appropriations Committees, at CJ-164.
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However, on the positive side, ``All IHS and Tribally-
operated hospitals are accredited by the Joint Commission on
Accreditation of Healthcare Organizations (JCAHO) or certified
by the Centers for Medicare and Medicaid Services (CMS).''\25\
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\25\Id., at CJ-167.
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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 270,000 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.''\26\ The IHS noted that ``[i]n 1955, more than 80
percent of American Indians and Alaska Natives were living in
homes without essential sanitation facilities.''\27\ The age-
adjusted gastrointestinal death rate was ``15.4 per 100,000
population. . . . 4.3 times higher than that for all other
races in the United States.''\28\ But by 1995, that death rate
was reduced to 1.7 per 100,000, although that 1995 rate is
still 40% higher than the rate for all races in the United
States.\29\
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\26\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 2005, at 1.
\27\Id., at 21.
\28\Id.
\29\Id.
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In FY 2005, approximately $132 million was appropriated for
sanitation facilities construction, of which $91.7 million was
appropriated to the Indian Health Service and more than $40.4
million came from other Federal agencies and non-Federal
sources such as tribes and state agencies.\30\ IHS estimated
that in FY 2005, the Sanitation Construction Program provided
sanitation facilities to a total of 24,072 homes.\31\ However,
the total estimated costs needed to address the sanitation
deficiencies in existing homes as of the end of FY 2006 totaled
over $2.2 billion, with projects considered economically
feasible totaling $1 billion. There were more than 155,000
Indian and Alaska Native homes in need of sanitation
facilities, including more than 38,000 which are without
potable water.\32\
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\30\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 2005, at 5.
\31\Id.
\32\U.S. Department of Health and Human Services, Indian Health
Service, Justification of Estimates for Appropriations Committees for
Fiscal Year 2008, at CJ-170.
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Health Professionals. The number of Indian health
professionals has increased since the Act was first 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.\33\ These numbers suggest that the
incentives in the Act have assisted in increasing these
numbers. However, vacancy rates for key health professionals
indicate that a substantial need still exists for qualified
health professionals in the Indian health system. The December,
2006, vacancy rates for health professions with the greatest
shortfalls consist of Dentists (32%), Optometrists (12%),
Nurses (17%), and Pharmacists and Physicians (both 12%).\34\
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\33\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.
\34\U.S. Department of Health and Human Services, Indian Health
Service, Justification of Estimates for Appropriations Committees for
Fiscal Year 2008, at CJ-125.
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Types and Level of Services. The IHS, tribal and urban
Indian health programs provide an array of basic medical,
dental and vision 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.,\35\ as well
as other preventive, clinical and environmental health
services. When these services are not available at their
facilities, IHS, tribal and urban programs purchase medical
care and urgent care services through the Contract Health
Services program.
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\35\U.S. Department of Health and Human Services, Indian Health
Service, Fiscal Year 2008, Justification of Estimates for
Appropriations Committees, at CJ-71.
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Even though basic services may be available at an Indian
health facility, access to these services is not assured. In
its study on the availability of health services to Indians in
August, 2005, the Government Accountability Office (GAO) found
that Indian patients often had to wait more than 30 days--in
some cases two to six 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.''\36\ 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.''\37\ For example, in some
cases, adult Indian patients ``could wait as long as 120 days
to get approval for eyeglasses.''\38\ 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.''\39\
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\36\GAO Report No. GAO-05-789, at 15.
\37\Id., at 19.
\38\Id.
\39\GAO Report No. GAO-05-789, 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.''\40\ The Committee is further concerned
that these gaps increase the costs of health care and diminish
the potential for prevention efforts.
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\40\Id., 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 a much 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.
1200 for programs and policies, provisions in S. 1200 which
would be new to the Act, including services for home- and
community-based care, youth suicide prevention and convenient
care services, and the National Bipartisan Commission on Indian
Health Care study on the delivery of federal health care
services to Indians are all designed to help address these
problems.
THE INDIAN HEALTH CARE IMPROVEMENT ACT
In passing the Indian Health Care Improvement Act of 1976,
Congress set forth ambitious goals for improving the health of
Indians, including encouraging Indian 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.''\41\ 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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\41\Senate Report No. 94-133, at 13.
\42\President's Special Message to Congress on Indian Affairs, 213
Pub. Papers 564 (July 8, 1970).
\43\President's Special Message to Congress on Indian Affairs, 213
Pub. Papers 565 (July 8, 1970).
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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 tribal
governments, rather than solely in the agency's hands, was both
a fundamental and logical change in the approach in health care
delivery. Reconfirming the tribes' authority to administer
health programs, however, took several years to achieve.\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), 25
U.S.C. 450 et seq. Title I contracts and Title V compacts total
more than $1.6 billion. The IHS currently administers contracts
and Annual Funding Agreements with 245 tribes or tribal
organizations, and 72 compacts and 93 funding agreements with
322 tribes.\45\ These numbers not only reflect congressional
policy of promoting tribal self-determination, but generate a
higher level of cooperation among Indian health providers.
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\45\U.S. Department of Health and Human Services, Indian Health
Service, Fiscal Year 2008, Justification of Estimates for
Appropriations Committees, at CJ-258.
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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 emerged. The
history of Indian health and the interplay between the ISDEAA
and the Act are key considerations in the development of sound
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 both
health and other 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 and Alaska Native participation is
critical in the development of the framework of these programs
and services. Tribal self-determination involves tribes
designing or modifying programs, as well as formulating new
ideas, concepts and methodologies of how those programs or
services should be delivered to their own communities.
Negotiated Rulemaking and Consultation. Such participation
means appreciable engagement between the agency and Indian
tribes, and numerous tools have successfully increased that
involvement. For example, negotiated rulemaking under the
Administrative Procedures Act 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 health care service delivery,
as well as to carry out the government-to-government
relationship between Indian tribes and the federal government.
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\48\Indian Health Care Improvement Act Amendments of 2005: Joint
Hearing on S. 1057 Before the Senate Committee on Indian Affairs and
Senate Committee 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 and decreased
bureaucracy, but believes that the long-term benefits of
negotiated rulemaking more than justify the costs which may be
required in the short-term.
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 affect their service populations. Tribal
involvement in rulemaking not only leads to a more informed
rule, but it fosters tribal support. In addition, 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.
The concerns are further abated by the limited number of
program criteria or requirements under the Act which are
subject to negotiated rulemaking. Section 802 outlines the
scope for negotiated rulemaking which is limited to Titles II
(except for section 202) and VII, a few sections in Title III,
and section 807.
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, holding the 9th Annual HHS Tribal Budget
Formulation and Policy Consultation Session in Washington, DC,
March 28 and 29, 2007.\49\
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\49\See www.hhs.gov/iga/tribal.
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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 also
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,
or that comments received are fully considered.
---------------------------------------------------------------------------
\50\U.S. Department of Health and Human Services, Department Tribal
Consultation Policy, January, 2005, available at www.hhs.gov/ofta/docs/
FnlCnsltPlcywl.pdf.
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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, remaining committed to promoting
tribal input by institutionalizing consultation, the Committee
has provided for robust consultation requirements in several
key areas, while leaving the manner of consultation to
Secretarial discretion.
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 and 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, sometimes two years
in advance of implementation, where programs and professions to
emphasize for scholarships is discussed.
\52\S. Hrg. 109-162 at 589 (statement of Dr. Grim, Director, U.S.
Department of Health and Human Services, Indian Health Service).
---------------------------------------------------------------------------
However, in the course of negotiating this legislation, the
Administration has repeatedly 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.
---------------------------------------------------------------------------
\53\Id., at 596, and S. Hrg. 110-53 at 38 (March 8, 2007)
(statement of Admiral John Agwunobi).
---------------------------------------------------------------------------
The Committee has been informed 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.
Oversight and Reporting. In the past, the Committee has
been reluctant to eliminate certain mandates, such as those
requiring studies. For example, many studies and reports
mandated by the 1976 Act have never been completed. These
studies were intended to provide insight into the
accomplishments and challenges in Indian health and to assist
the Congress 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 mandated studies, reports and programs in current law
have been disregarded.
Consequently, the Committee has included in S. 1200
provisions which will establish a National Bipartisan
Commission on Indian Health Care to thoroughly review
opportunities for improvement of the Indian health care system.
During the 108th Congress, the bill to reauthorize the Act, S.
556, contained provisions requiring the Bipartisan Commission
to 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 to what is now included in S. 1200.
In addition, the Committee has included authorization of
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
provide health services to Indians, but is intended to
complement the federal obligation in ways in which the United
States has fallen short.
While much discretion and flexibility is provided to the
IHS throughout S. 1200, 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 to the Act contained in S. 1200
are particularly noteworthy:
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.\54\ Noting that many Indian communities
are often in remote locations and lack adequate housing and
educational and recreational opportunities for employees and
their families,\55\ the GAO reported that some critical
positions such as for pharmacists and dentists remained vacant
for several years in some locations.\56\
---------------------------------------------------------------------------
\54\See also GAO Report No. GAO-05-789, at 4.
\55\GAO Report No. GAO-05-789, at 4.
\56\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.\57\
---------------------------------------------------------------------------
\57\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.\58\
---------------------------------------------------------------------------
\58\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. Besides
the scholarships, the program also now includes 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 Indian tribe 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.
Targeting the specific needs of the Indian health system
has become the hallmark of the Indian health professional
policy. Likewise, a continuous and seamless transitional
approach also is 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. 1200 to address that need. S. 1200 provides
for portability of current licenses for tribal health
professionals consistent with other Federal health licensing
provisions. In addition, S. 1200 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 Indian student trainees 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 recruiting and training Indians for health
professions. As part of the long-term view of Indian health
professions, the Committee believes continuity is necessary 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. 1200
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 takes a long-term view of health
professions in S. 1200. The most urgent placement needs are in
the direct care positions, such as dentists, doctors, nurses,
and pharmacists. In the long-term, Indian health professionals
are also needed in educational positions to bolster recruitment
levels and improve the new Indian health professionals' chances
of success.
The Committee has been informed that significant need
exists at the tribal colleges and universities to increase the
number of Indian instructors in the nursing programs.\59\ 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.
---------------------------------------------------------------------------
\59\Joseph F. McDonald, Ed.D., President, Salish-Kootenai 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. 1200 allowing a scholarship recipient to 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 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 [instructors] are clinically
seasoned, mature [Bachelor of Science--Nursing] prepared nurses
returning to school for educational and career mobility.''\60\
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.''\61\
---------------------------------------------------------------------------
\60\Joseph F. McDonald, Ed.D., President, Salish-Kootenai College,
Letter to Honorable Don Young, U.S. House of Representatives, November
1, 2005.
\61\Joseph F. McDonald, Ed.D., President, Salish-Kootenai College,
Letter to Honorable Don Young, U.S. House of Representatives, November
1, 2005.
---------------------------------------------------------------------------
The Committee believes these positions should be filled by
experienced faculty and expects that the Secretary and the
tribal colleges or universities would coordinate these
opportunities and 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 authorizes a feasibility
study to be conducted on hospice care services. However, the
IHS has never conducted that study and, now, 14 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 these and other long-term or home health care
services through the Indian health care system--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. Many
Indians must travel long distances, only to be placed in
facilities that are far from home, culturally unfamiliar, and
not conducive to their overall well-being. Home health care is
crucial for these individuals. Having culturally-appropriate
facilities close to Indian communities not only promotes the
patient's well-being, but enables family members to more easily
visit the patient.
Section 213 of S. 1200 authorizes services such as home
health care, long-term care and hospice care, which are a
standard part of the health care industry. If the Indian health
system is to advance into the 21st Century, then Indian health
programs must be authorized to make these services available
for their Indian patients, if circumstances warrant.
However, the Department of Justice has indicated that it
has concerns regarding the provision of services for which no
standards exist.\62\ To address those concerns, S. 4122 in the
109th Congress included language that required standards to be
in place from either the Secretary or the state in which the
Indian health program was located. This type of requirement has
been a part of the Indian health system as required in the
Indian Self-Determination and Education Assistance Act.\63\
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\62\S. Hrg. 110-53 at 41 (March 8, 2007) (statement of C. Frederick
Beckner III, Deputy Assistant Attorney General, Civil Division,
Department of Justice).
\63\See 25 U.S.C. 450f(a)(2). ``The contractor shall include in the
proposal of the contractor the standards under which the tribal
organization will operate the contracted program, service, function, or
activity. . . .''
---------------------------------------------------------------------------
Indian tribes want to ensure that the services authorized
in Section 213 are consistent with those services reimbursable
by Medicaid and, in particular, those services already
authorized in compacts or contracts entered into by the tribes
or tribal organizations and the IHS pursuant to the ISDEAA.
To that end, S. 1200 authorizes the Secretary to promulgate
standards to govern any service in the absence of state
standards. It is the intent of the Committee that those
services already authorized in compacts or contracts will
remain so authorized and that the Secretary is authorized to
issue interim standards in the absence of either state
standards or final Secretarial standards. The Committee expects
the Secretary to act promptly to promulgate these standards, so
that services to Indian patients are not disrupted or denied.
Convenient Care Services. Section 213 also authorizes the
Secretary to provide funding to meet the health status
objectives of the Act for convenient care services programs
pursuant to section 306(c)(2)(A). Section 213 further
authorizes health care delivery demonstration projects that
include a ``convenient care services'' program as an
alternative means of delivering health care services to
Indians.
In including this new provision, the Committee seeks to
address the lack of access to health care services that exists
in so many tribal communities, which may be due to limited
hours of operation at existing health care facilities, lack of
staff, or other factors. It is the Committee's hope that these
convenient care services projects may expand the availability
of health care, as well as decrease the need for more-costly
emergency room visits, thereby reducing the over-stressed
Contract Health Services budget.
Traditional Health Care Practices. For much of America's
history, the federal government's policy of assimilation and
termination sought to destroy Indian cultures and religions, as
well as tribal legal, political and economic institutions.
Indian people were denied the exercise of traditional practices
or punished, should those ceremonies be practiced, as well as
were punished for speaking their own languages and observing
other traditional ways.
However, federal policy toward Native people has run the
gamut, with the policy of one period often contradicting that
of another. An example of such a policy shift occurred
following the 1928 Merriam Report, which generated several
initiatives to improve health conditions for Native
Americans.\64\ One reform was the active solicitation of
traditional Indian healers to participate in federal health
services to Indians.
---------------------------------------------------------------------------
\64\Merriam, Lewis (ed.), Institute for Government Research, The
Problem of Indian Administration (1928) (commonly referred to as the
``Merriam Report'').
---------------------------------------------------------------------------
The Indian Health Care Improvement Act currently contains
provisions to promote long-practiced traditional health care
practices of the Indian tribes served by IHS, tribal and urban
Indian health programs, consistent with the standards for the
provision of health care, health promotion, and disease
prevention. Authority also exists for culturally appropriate
health care with respect to specific programs (the Community
Health Representative Program), specific elements of the Indian
population (Indian youth and Indian women), and specific
services and training (mental health). These practices
encourage respect for and affirmation of concepts of Indian and
Alaska Native cultural values, beliefs and traditions that
Indian people define for themselves as a complement to western
medical practices in promoting good health and curing illness.
Former IHS Director Dr. Emery A. Johnson, in ``Policy and
Procedures in reference to P.L. 95-341,'' the American Indian
Religious Freedom Act of 1978, stated the Service's views as
follows:
The Indian Health Service has continued to recognize
the value and efficacy to [sic] traditional beliefs,
ceremonies, and practices of the healing of body, mind
and spirit. . . . It is, therefore, the policy of the
Indian Health Service to encourage a climate of respect
and acceptance in which an individual's private
traditional beliefs become a part of the healing and
harmonizing force within his/her life.
More recently, in 1994, IHS Director Michael H. Trujillo
issued a ``Traditional Cultural Advocacy Program Policy
Statement'' which states:
The Indian Health Service (IHS) recognizes the value
of traditional beliefs, ceremonies, and practices in
the healing of body, mind, and spirit. The IHS
encourages a climate of respect and acceptance in which
traditional beliefs are honored as a healing and
harmonizing force with individual lives, a vital
support for purposeful living, and an integral
component of the healing process. It is the policy of
the IHS to facilitate [sic] right of American Indian
and Alaska Native people to their beliefs and health
practices as defined by the tribe's or village's
traditional culture. This policy is meant to complement
and support previously stated IHS policy for
implementing the American Indian Religious Freedom Act
of 1978 (Public Law 95-341, as amended).
The Department of Veterans Affairs' National Center for
Post- Traumatic Stress Disorder is adding traditional healing
methods, such as talking circles and healing herbs, to modern
medical treatments for American Indian and Alaska Native
veterans and service personnel returning from active duty in
the Middle East and suffering from post-traumatic stress
disorder problems.\65\ The American Cancer Society (Society)
includes Native American healing in a section on its website
concerning treatment decisions.\66\ The Society, in connection
with work at Montana State University, is providing funding to
a group of Indian women health care workers on the Crow
Reservation in Montana to help IHS providers understand
traditional Crow healing practices and customs.
---------------------------------------------------------------------------
\65\See Department of Veterans Affairs' National Center for
Posttraumatic Stress Disorder website, www.ncptsd.va.gov/ncmain/
index.jsp, and, e.g., www.adn.com/front/v-printer/story/9137819p-
9054019c.html.
\66\www.cancer.org/docroot/ETO/content/
ETO_5_3X_Native_American_Healing.asp?sitearea=ETO.
---------------------------------------------------------------------------
The Committee believes that health care treatment should be
relevant to and effective for the population to be served, and
thus regards traditional health care practices as an important
part of culturally appropriate care for Indian people. These
practices have been a part of the IHS, tribal and urban Indian
health care system for years, are provided only at the request
of the patient or family members, and are within the
traditional culture of that individual. It is the Committee's
understanding, based on Department of Justice testimony to the
Committee on March 8, 2007, that no medical malpractice suit
has ever been filed arising from a traditional health care
practice.\67\ Thus, the risk for the United States in terms of
liability appears to be insignificant, compared to the benefits
of allowing Indian patients to obtain this care. DOJ's concerns
are unfounded in light of the fact that traditional health care
practices are based in Native healing sciences. The bill has
the legislative purpose of providing for the highest possible
health status for Indians without intruding on Indian self-
determination.
---------------------------------------------------------------------------
\67\S. Hrg. 110-53 at 14 (March 8, 2007) (statement of C. Frederick
Beckner III, Deputy Assistant Attorney General, Civil Division,
Department of Justice). See also S. Hrg. 110-53 at 104, testimony of
Duke McCloud.
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Behavioral Health. S. 1200 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 from that
reservation subsequently took their own lives.
The publicity around the Red Lake incident, which was then
the nation's second-most deadly school shooting, brought
attention to the fact that, in Indian Country, suicide impacts
a younger population than 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 Native
communities in Alaska.
During the 109th Congress, the Committee held three
hearings specifically on the issue of Indian youth suicide: one
in Bismarck, North Dakota on May 2, 2005, and two oversight
hearings in Washington, DC (on June 15, 2005, and on May 17,
2006), to discuss the kinds of resources and services being
provided to Indian youth who have expressed suicidal thoughts
or attempted suicide.
Based on the information developed through hearings, the
Committee has included provisions in S. 1200 which address
youth suicide as part of the behavioral health program
provisions and in a culturally-appropriate manner. Section 708
authorizes 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 recognizes 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.
Therefore, S. 1200 also 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. Finally, provisions
included 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 three to nine and by authorizing a
specific level of funding.
Urban Indians. Providing health care services to urban
Indians 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.\68\
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\68\Senate Report No. 94-133, at 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. These provisions sought to
correct disparities in health levels for Indians living in
urban areas, first as pilot programs and later permanently in
the Indian health care system.\69\
---------------------------------------------------------------------------
\69\See Senate Report Nos. 94-133, 100-508 and 108-411.
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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. The Federal Government had ignored some
Indian tribes completely. Other Indian tribes were
legislatively excluded from receiving services under some
administrative programs, yet were allowed to exercise treaty
rights. Some Indian tribes were ``terminated,'' yet later
``restored'' to a government-to-government relationship with
the United States.
Courts have long held that Congress has the broad power to
legislate for the benefit of Indians, even if located off of
the reservation, and to define who is an Indian and for what
purposes they may be provided services, even if they may not be
an enrolled member of a federally-recognized Indian tribe.\70\
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\70\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).)
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For example, Congress has enacted laws which define Indians
in different ways for different purposes.\71\ 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, or place geographical
limitations on the service areas in which they may be served.
The Snyder Act, 25 U.S.C. 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 which was ended under the ``termination''
policy of Federal-Indian relations.
---------------------------------------------------------------------------
\71\See, e.g., Indian Arts and Crafts Act, Pub.L. 101-644, 25
U.S.C. 305; No Child Left Behind Act, Pub. L. 107-110, 25 U.S.C. 7491;
and the American Indian Probate Reform Act of 2004, Pub. L. 108-374, 25
U.S.C. 2201.
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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. When that policy gave way to self-determination,
however, and Congress sought to try to remedy the devastating
effects 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.
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 for services provided in this Act, is within Congress'
power.
Further, in adopting S. 1200, 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.\72\
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\72\Senate Report 94-133, at 131.
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 who had moved from the reservations as a
result of the relocation policies. Relocating Indians from
reservations to urban areas was the Federal policy and program
first begun in 1931.\73\ ``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.''\74\
---------------------------------------------------------------------------
\73\Felix Cohen, Handbook of Federal Indian Law (1982 ed.), at 169.
\74\Id.
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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.\75\ The Committee further found that Title V of the
original Act ``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.''\76\
---------------------------------------------------------------------------
\75\Senate Report No. 94-133, at 138.
\76\Id., at 140.
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The justifications for this policy are still valid today.
Recent statistics indicate that urban Indians suffer health
disparities, as do Indians living 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).\77\
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\77\The Health Status of Urban American Indians and Alaska Natives,
Urban Indian Health Institute, March 16, 2004, at v. Available at
www.uihi.org. See also American Journal of Public Health, August 2006,
Vol. 96, No. 8, ``A Nationwide Population-Based Study Identifying
Health Disparities Between American Indians/Alaska Natives and the
General Populations Living in Select Urban Counties.''
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The Committee believes that continuation of services to
urban Indians, recognized in the original Act and affirmed by
S. 1200, 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 three clinics with more than 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 Health Source 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 vital 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
(such as pow-wows), 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),\78\ it is no surprise that many
urban Indians are uninsured. The Committee has received
testimony that in Boston, MA, 87% of the Boston Indian Center's
clients have no health insurance. In Arizona, nearly two out of
three urban Indians have no insurance.
---------------------------------------------------------------------------
\78\The Health Status of Urban American Indians and Alaska Natives,
Urban Indian Health Institute, at v.
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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
set forth in this Act and in other statutes of increasing
access to health care and of remedying health disparities that
result from the past failed Federal Indian policies.
Dental Health Aide Therapists. 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 in Alaska Native
communities, in particular.
During the 108th and 109th Congresses, there was
considerable discussion surrounding the Dental Health Aide
Therapists (DHAT) 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.
The DHAT program in Alaska has been part of the Community
Health Aide 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.
In January, 2006, the American Dental Association (ADA),
the Alaska Dental Society (ADS) and several individual dentists
filed a lawsuit in Alaska Superior Court, seeking to stop the
practice of dentistry and dental surgery by non-dentists by
asking the court to declare the Alaska Native Tribal Health
Consortium and its Dental Health Aide Therapists program in
violation of state dental licensing laws. On June 27, 2007, the
Alaska Superior Court dismissed the case, noting in its
decision that DHAT is part of the Community Health Aide
Practitioner Program and Congress clearly intended the
utilization of paraprofessionals in providing care through both
CHAP and DHAT.
When the House Resources Committee marked up its version of
the Indian health reauthorization in the second session of the
109th Congress, the Committee agreed to an amendment offered by
Representative Young (R-AK) regarding the Dental Health Aide
Therapist program in Alaska. The language, which the Committee
has been informed was agreed to by the American Dental
Association and the Alaska Native Health Board, prohibits
dental health aide therapists from performing all oral and jaw
surgeries except pulpal therapy or extraction of adult teeth
after consultation with a licensed dentist in a dental
emergency. That agreed-upon bill language is carried forward
and included in S. 1200.
National Bipartisan Commission on Indian Health Care. The
Committee intends that S. 1200 will provide many much-needed
improvements to the Indian health system. However, adequate
funding levels remain a significant factor in achieving those
improvements.
For several years, the Committee has received testimony
regarding the substantial funding needs for Indian health.\79\
Federal appropriations have increased over time, but, as
evident in the IHS Level of Need Funded Study, have not reached
optimal levels.\80\ While the reimbursements from Medicaid and
Medicare have been beneficial in adding additional resources,
they are not a complete solution to the funding deficiencies.
---------------------------------------------------------------------------
\79\See Hearing on the President's Fiscal Year 2008 Budget Request
for Indian Programs Before the Senate Comm. on Indian Affairs, 110th
Cong., 1st Sess., February 15, 2007, S. Hrg. 110-48; Hearings on the
President's Fiscal Year 2007 Budget Request for Indian Programs Before
the Senate Comm. on Indian Affairs, 109th Cong., 2nd Sess., February
14, 2006, S. Hrg. 109-396, Pt. 1 and February 23, 2006, S. Hrg. 109-
396, Pt. 2; Hearing on the President's Fiscal Year 2006 Budget Request
for Indian Programs Before the Senate Comm. on Indian Affairs, 109th
Cong., 1st Sess., February 16, 2005, S. Hrg. 109-9; Hearings on the
President's Fiscal Year 2005 Budget Request for Indian Programs Before
the Senate Comm. on Indian Affairs, 108th Cong., 2nd Sess., February 11
and 25, 2004, S. Hrg. 108-420; Hearing on the President's Fiscal Year
2004 Budget Request for Indian Programs Before the Senate Comm. on
Indian Affairs, 108th Cong., 1st Sess., February 26, 2003, S. Hrg. 108-
60; Hearings on the President's Fiscal Year 2003 Budget Request for
Indian Programs Before the Senate Comm. on Indian Affairs, 107th Cong.,
2nd Sess., March 5, 7, and 14, 2002, S. Hrg. 107-360.
\80\See, e.g., ``LNF Primer,'' U.S. Department of Health and Human
Services, Indian Health Service, located at http://www.ihs.gov/
NonMedicalPrograms/Lnf/docs2003/Primer.pdf.
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The Committee has concluded that an overarching assessment
of need and financing mechanisms is warranted to address the
health disparities and financing for Indian health care.
Accordingly, section 814 establishes the National Bipartisan
Commission on Indian Health Care to study the optimal manner in
which to provide and finance health care services to Indians.
This Commission will have broad authority to conduct
hearings and other activities needed to provide Congress with
comprehensive and thoughtful recommendations regarding the
optimal means of delivering health care services to Indians.
The Committee intends that this Commission will also serve as
an appropriate forum for addressing outstanding questions
relative to financing, including, among others, balancing
concerns about overutilization and deficiencies.
Indian Health Care Facilities Construction. During the
109th Congress, much discussion between the National Steering
Committee and the Committee centered around section 301, which
directs the Secretary to maintain a health care facility
priority system for construction.
Background: Development of the Priority System. In the
early 1980's, the IHS developed a health care facilities
priority system (Priority System) for construction of various
types of health care facilities in Indian communities. In 1988,
pursuant to Public Law 100-713 (as amended by Public Law 102-
573), Congress required the IHS to provide an annual report
which set forth (1) the current priority system; (2) the
planning, design, construction and renovation needs of the top-
10 priority inpatient and outpatient facilities (including
staff quarters); (3) the justification and projected costs of
these projects; and (4) the methodology for establishing the
priorities.
In this Priority System, construction projects for
hospitals, health centers, staff quarters and youth regional
treatment centers go through three key phases, wherein the IHS
solicits proposals for health facility construction and ranks
the proposals according to their relative need for
construction.\81\
---------------------------------------------------------------------------
\81\For a detailed discussion on the Priority System and the three
phases, see U.S. Department of Health and Human Services, Indian Health
Service, ``Healthcare Facilities Construction Priority System
Methodology,'' June 3, 2004, located at http://www.ihs.gov/
TribalLeaders/triballetters/2004_Letters/06-28-2004_Enclosure.pdf; and
``Health Care and Related Facilities,'' located at http://www.ihs.gov/
NonMedicalPrograms/DFEE/InfoSheets/infosheet.PDF.
---------------------------------------------------------------------------
The projects are selected for inclusion on a ``Priority
List'' after completion of Phases I and II, then move up the
Priority List as Phase III is completed and appropriations for
the projects are provided.
Congressional Directive To Revise the Priority List. In
1999, in the conference report accompanying the FY 2000
Interior Appropriations Act (House Report 106-406), Congress
directed the IHS, working closely with Indian tribes, to review
and revise the Priority System. In recognizing the ``extreme
need for new and replacement hospitals and clinics,'' Congress
noted that ``there should be a base funding amount, which
serves as a minimum annual amount in the budget request.''
Congress further noted that several issues needed to be
considered in revising the Priority System and that ``a more
flexible and responsive program can be developed that will more
readily accommodate the wide variances in tribal needs and
capabilities.''\82\
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\82\House Report 106-406, at 138-139.
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In response to this directive, the IHS Director convened a
Facilities Appropriations Advisory Board (FAAB) and a
Facilities Needs Assessment Workgroup to review the Priority
System and make recommendations for revision. According to the
IHS, the FAAB was comprised of 12 members representing Indian
tribes and two members representing the IHS, and the Workgroup
was established by the IHS Director to make recommendations to
the FAAB. The Committee has been informed that, earlier this
year, the FAAB submitted final recommendations to the IHS
Director, but no final decision has been made on these
recommendations.
Meanwhile, in 1999, the National Steering Committee
developed language regarding the Priority System contained in
section 301 of the various iterations of bills introduced for
the reauthorization of the Act. The language in section 301
remained primarily the same until 2006, when the Committee
refined certain provisions and included an additional protected
category in section 301(c)(1)(D), referred to as the
``grandfather'' provision, in S. 4122, introduced at the end of
the 109th Congress.
Grandfather Provision. The ``grandfather'' provision of
section 301(c)(1)(D) protects the priority status of health
care facilities (in certain categories) on the Priority List
from being affected by changes to the Priority System being
contemplated by the IHS, pursuant to the 1999 Interior
Appropriations Conference Report instruction. These projects
have been on the Priority List since at least 1991.
Under the ``grandfather'' provision, the protected
categories include:
(1) Top 10 Projects. Projects in the FY 2008 IHS budget
justification for the 10 top-priority inpatient, outpatient,
staff quarters and Youth Regional Treatment Centers (YRTC)
projects. Currently, those projects include:
Inpatient: Phoenix and Whiteriver, AZ; Barrow and Nome, AK.
Outpatient: Ft. Yuma, Red Mesa, Kayenta, San Carlos and
Winslow-Dilkon, AZ; St. Paul, AK; Sisseton, Eagle Butte and
Rapid City, SD.
YRTC: Wadsworth, NV; Central-Southern and Northern
California.
(2) Phase I and II. Projects that have completed Phases I
and II of the Priority System in effect on the date of
enactment of the Indian Health Care Improvement Act Amendments.
Currently, these projects include: Ft. Belknap, MT; Wagner, SD;
Sells and Bodaway-Coppermine, AZ; Gallup, Alamo, Albuquerque,
Pueblo Pintado, Crownpoint and Shiprock, NM.
During the 109th Congress, a third category was added:
(3) Secretarial Discretion. Projects not in the other two
protected categories and selected on the initiative of the
Secretary or at the request of an Indian tribe or tribal
organization.
During the 109th Congress, the IHS, FAAB and Workgroup
began finalizing their recommendations and draft revisions to
the Priority System. The Committee had been informed that these
drafts purported to revise what would constitute Phases I and
II of the Priority System. These proposed changes could then
have affected what projects would be ``grandfathered'' under
section 301(c)(1)(D) and thus change the priority of several
projects which have been waiting on the Priority List for many
years.
Due to the uncertainty of when the IHS will approve the
final changes (before or after the Act is reauthorized) and
what those changes will consist of, the third category was
added to ensure that the Secretary still has authority to
prioritize projects which might no longer qualify under the
other two protected categories.
Innovative Approaches. Currently, construction funding
generally has been applied to the projects on the Priority
List. The Committee has been informed that the total cost of
the current Priority List is in excess of $200 million as of FY
2008, with other unmet needs in the billions of dollars. At the
time of the congressional directive in 1999, the construction
appropriations was over $41 million and even reached over $94
million in FY 2004. The amount of appropriations increased
slightly until FY 2006, after which it has decreased quite
significantly.
Ideally, with a continuation of the level of funding
appropriated following the conference report directive in FY
2000, the current Priority List should have been nearing
completion by the time revisions to the Priority System were
finalized. Unfortunately, significant unforeseen national
events occurred since the Appropriations Committee's directive,
which affected the amount of available appropriations for
closing out the current Priority List and allowing other
projects to be added to the List and built. Thus, the current
Priority List has not been completed, whereas the revisions to
the Prriority System are nearing completion.
The Committee has been informed that while projects have
been on the Priority List for a number of years, many other
needed projects have never been on the Priority List. The
Committee had been requested to include an alternative approach
in S. 1200 to address the remaining unmet needs through the
concept of an Area Distribution Fund. Under an Area
Distribution Fund, a portion of construction funding could be
devoted to IHS Area priorities. This localized approach would
allow other smaller projects to be completed, instead of
waiting until the entire current Priority List is completed.
In light of the facilities backlog, section 301(f) of S.
1200 encourages the Secretary to seek innovative approaches to
address unmet needs for health care facility construction, and
requires the Secretary to consult and cooperate with Indian
tribes in developing these innovative approaches. The Committee
recognizes that the Secretary has engaged in considerable work
revising the Priority System thus far. These proposed revisions
may also be useful in developing innovative approaches.
However, the Committee encourages the Secretary, prior to
finalizing the revisions, to take into consideration the fiscal
circumstances under which the 1999 congressional directive
occurred, relative to those experienced today, and how
innovative approaches to financing construction may be
implemented in such a manner which is fair and equitable to
those Indian tribes to be served by the projects on the current
Priority List and those Indian tribes which have not had the
opportunity to have their projects placed on the list.
The Committee expects the IHS to work with Indian tribes in
developing the types of innovative approaches to pursue, as
well the contours of those approaches. The Secretary has used
broad authority to develop and maintain the Priority System
since the 1980s, and section 301(f) also provides broad
authority to implement innovative approaches, such as an Area
Distribution Fund, if, after consultation with the Indian
tribes, it is determined that this is an appropriate system to
address the health facility needs of Indian communities. The
Committee also expects the IHS to work with Indian tribes and
to submit a minimum budget request consistent with the
congressional directive which will accommodate both the current
Priority List and any innovative approaches.
Elevation of the IHS Director. Section 601 of S. 1200
elevates the Director of the IHS to the position of Assistant
Secretary for Indian Health within the Department of Health and
Human Services. The purpose of this elevation is to foster the
government-to-government relationship between Indian tribes and
the United States, facilitate advocacy for Indian health
policy, and promote consultation on Indian health matters.
Presently, the Director of the Indian Health Service is
appointed by the President and confirmed by the Senate pursuant
to 25 U.S.C. 1661(a). The Director reports to the DHHS
Secretary through the Assistant Secretary for Health.
During the 109th Congress, the provisions elevating the
Director to the Assistant Secretary were included in the
introduced bill, S. 1057, but not in the final iteration, S.
4122, due to objections by the Administration. The Committee
has continued to receive testimony in strong support of
elevation from the Indian tribes.\83\ The testimony received by
the Committee and consultation with Indian tribes during the
110th Congress have counseled in favor of including the
provisions in S. 1200 as part of the IHCIA reauthorization.
---------------------------------------------------------------------------
\83\Indian Health Care Improvement Act: Hearing of the Senate
Indian Affairs Committee, 110th Cong., 1st Session, S. Hrg. 110-53 at
74 (March 8, 2007) (statement of Rachel Joseph).
---------------------------------------------------------------------------
Previous bills establishing this position in the Department
have either been favorably approved by the Committee or passed
the Senate: S. 558 (108th Congress, passed by the Senate), S.
214 (107th Congress, ordered reported by the Committee), S. 299
(106th Congress, passed by the Senate), S. 1770 (105th
Congress, passed by the Senate), S. 311 (104th Congress,
ordered reported by the Committee), and S. 2067 (103rd
Congress, passed by the Senate).
Like these legislative predecessors, S. 1200 facilitates
the government-to-government relationship between the United
States and Indian tribes by providing the necessary leadership
within the Administration on Indian health issues to bring
focus, priority and national attention to the health care
status and needs of Indians. Section 601 is intended to enhance
the Federal capacity to respond to the ongoing health crisis in
Indian Country and the continuing frustration of Indian tribes
and patients that their needs and concerns are not adequately
addressed under the current administrative policy and budgetary
processes.
Previous Senate reports further elaborate upon the
evolution of the IHS and the need and purposes for establishing
this position. (See Senate Report Nos. 108-76, 107-170, 106-
148, 105-319, and 103-327.) Nevertheless, an abbreviated
discourse is necessary to inform the continuing need for
elevating the Director to the Assistant Secretary for Indian
Health.
Budgetary Improvement. The IHS operates a comprehensive
health care delivery system nationwide through a variety of
health care facilities and services and through contracts and
compacts with Indian tribes under the Indian Self-Determination
and Education Assistance Act, with Urban Indian Organizations,
or with private health care providers through the contract
health services program.
Efforts to address Indian health care needs have been
tempered by the steady decline in purchasing power of the IHS
budget. Indeed, the IHS 2004 study on Level of Need Funding
indicated that the funding fell short of meeting the health
care needs of Indian people and was operating at approximately
a 40% deficiency.
The Committee has not seen appreciable decreases to this
deficiency to convince it that elevation is not necessary. One
of the principal justifications for the elevation has been past
Administrations' failure to incorporate tribal recommendations
in the final budget request, despite tribal participation
throughout the budget process.
For example, the Committee received testimony estimating
health care needs in excess of $19.7 billion to achieve parity
for Indian people.\84\ Past budgets have reflected marginal
increases, even in the era of tight budgets, but these
increases have not closed the gap on the ``level of need''
funding deficiency.
---------------------------------------------------------------------------
\84\S. Hrg. 110-48 at 184 (testimony of H. Sally Smith).
---------------------------------------------------------------------------
In addition, the Committee has also received testimony that
Indian tribes requested continued funding for the Urban Indian
Organizations during the annual budget formulation
sessions.\85\ However, the FY 2007 and FY 2008 President's
Budget Requests zeroed out funding for the Urban Indian
Organizations.\86\ These decreases are disturbing in light of
the alarming disparities that exist between the health status
of the Indian population and other populations in the United
States. These disparities have been well-documented in past
Committee reports, legislation and testimony before the
Committee.\87\
---------------------------------------------------------------------------
\85\Id.
\86\U.S. Department of Health and Human Services, Indian Health
Service, Fiscal Year 2007, Justification of Estimates for
Appropriations Committees, at IHS-49, and U.S. Department of Health and
Human Services, Indian Health Service, Fiscal Year 2008, Justification
of Estimates for Appropriations Committees, at CJ-121.
\87\See, for example, footnotes 46 and 76, above.
---------------------------------------------------------------------------
Although the Committee has received testimony that the
Director has access and policy input within the DHHS, the
health care status of Indians remains at such levels which
necessitate a modified level of leadership and advocacy. The
establishment of the Assistant Secretary for Indian Health will
facilitate advocacy within DHHS and the Office of Management
and Budget for the funding resources and policies that are
necessary to effectively and efficiently address the health
care needs and concerns of the Indian people.
Regulatory and Administrative Improvement. The Indian
health care system presents cross-cutting issues which involve
DHHS agencies other than the IHS. The Committee recognizes the
current attention given to Indian health issues as well as the
revitalization of the Intra-departmental Council on Native
American Affairs within the DHHS which would address matters in
DHHS agencies affecting Indian health.
Despite this revitalization, concerns have been raised with
the Committee that broad administrative and regulatory matters
within DHHS affecting Indian health have not been addressed
either properly or timely. The Committee intends that this
position would create an opportunity for the Assistant
Secretary for Indian Health to be involved in the formulation
of policy and regulatory authority on these larger issues which
affect Indian health rather than simply addressing matters
which are solely Indian in nature.
As stated in previous Committee reports, the Committee
continues to believe that the institutionalization of a senior
policy official responsible for Indian health within the DHHS
is necessary to bring parity and reduce deficiencies in the
delivery of Indian health care services. This
institutionalization is also important to ensure that the
advocacy and the knowledge of the United States legal and moral
obligations for Indian health and the mission of the IHS is
carried forward in future Administrations.
Third Party Reimbursements. Funding from sources other than
IHS appropriations has been identified as a factor affecting
the availability of health care services for Indians.\88\ 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.\89\
---------------------------------------------------------------------------
\88\GAO Report No. GAO-05-789, at 4.
\89\Id., at 5.
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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.\90\ 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.''\91\ In
one case, 31 percent of a facility's clinical providers and
other staff was funded by third party reimbursements.\92\
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\90\S. 1200 includes 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 U.S.C. Sec. 1641(a).
\91\GAO Report No. GAO-05-789, at 26.
\92\Id.
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S. 1200 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.\93\ Likewise, S. 1200 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.
---------------------------------------------------------------------------
\93\As a general rule, these special types of property are not
included in eligibility calculations for income taxes or federal
benefits.
---------------------------------------------------------------------------
Waiver of Medicaid Co-Pays. One fundamental purpose of the
Indian Health Care Improvement Act is to improve access to
health care for Indian people. Removing barriers to such access
is a critical aspect in accomplishing that purpose. To that
end, section 204 of Title II of S. 1200 prohibits cost-sharing
under Medicaid.\94\
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\94\This provision is modeled after the current Centers for
Medicare and Medicaid Services State Children's Health Insurance
Program regulation prohibiting cost-sharing for Indian children (42
C.F.R. Section 457.535).
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Indian tribes have strongly advocated that this policy
waiving Medicaid co-pays reflects the federal trust obligation
for Indian health wherein the health care has been ``pre-
paid''--for example, by the treaty agreements exchanging tribal
lands for health care. As additional justification, the Indian
tribes contend that this policy is not unusual to the Medicaid
system, since other Medicaid policies reflect that federal
obligation. An example of this is the 100% FMAP or Federal
Matching Assistance Percentage, wherein the federal government
provides 100% of the reimbursement to states of Medicaid
reimbursements for services provided by the IHS or tribal
health programs.
Moreover, Indian tribes contend that the waiver of the co-
pay is necessary to create incentives to enroll in Medicaid.
Recognizing the federal obligation for Indian health care, the
IHS, tribal and urban health programs do not charge the Indian
patients cost-sharing for participating in the Indian health
system to which Medicaid provides reimbursements. Charging the
Indian patient a Medicaid co-pay will create a disincentive to
enroll, essentially barring that Indian patient's access to
Medicaid; as a result, the overall Indian health budget, along
with the ability to provide additional services, may suffer. On
the other hand, waiver of the co-pay will continue to encourage
Indian patients to enroll in Medicaid programs, thus
``stretching'' IHS appropriated dollars.
The Committee is aware of concerns that cost sharing
discourages overutilization of health care services, which
should be of particular concern to a system which is
overburdened already. However, this concern may be addressed in
several ways.
Cost-sharing would not achieve the intended purpose of
modifying behavior to avoid overutilization within the Indian
health system. Overutilization assumes that there are otherwise
adequate levels of services available to a population of non-
overutilizers. Punitive or disincentive measures will not work
if the service is not available or delayed. Services being
unavailable or delayed have been documented by the GAO
study,\95\ and the IHS Level of Need Funded (LNF) Study. The
data in the GAO study reported that many Indian people are not
seeking health care services until it is too late. There was no
evidence in this GAO report that overutilization of the health
care services occurred at the Indian health programs.
---------------------------------------------------------------------------
\95\GAO Report No. GAO-05-789, (August, 2005).
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The data in the LNF Study also suggests that many Indian
patients may have to delay seeking health care because services
are rationed, rather than available for every health care need.
In other words, Indian patients are not running to the clinic
for every sniffle, but may wait until their health care needs
become emergent problems. Thus, it is unlikely that
overutilization occurs, so there is no problem that the cost-
sharing would obviate. Imposing cost-sharing, on the other
hand, may serve to further exacerbate the problem of delaying
health care by requiring a co-pay by Indian patients who can
ill afford it.
Removing barriers to enrollment will enable Indian patients
to enroll in Medicaid, and the ensuing Medicaid reimbursements
will assist the Indian health program in providing more
services, thereby diminishing the potential of overburdening
the system. Cost-sharing is, in reality, cost-shifting. If
Indian patients are eligible and qualify for Medicaid, then the
patient should take advantage of the available program. By not
enrolling, the cost that should be borne by Medicaid continues
to strain the IHS budget, which has been documented to be
insufficient to meet the needs of Indian communities.
Consequently, S. 1200 continues the policy and provisions
regarding Medicaid co-pays that were reported favorably by the
Senate Finance Committee in S. 3524 during the 109th Congress.
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.''\96\ Providing services to
Indian people improves the health of Indians in a direct
manner.
---------------------------------------------------------------------------
\96\Senate Report 94-133, at 23.
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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.\97\ Now the tables are turned. Under certain
circumstances, 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.
---------------------------------------------------------------------------
\97\See American Indian Policy Review Commission, Task Force Six,
Final Report to the Commission, Vol. 6, at 28.
---------------------------------------------------------------------------
Serving ``non-eligibles'' for these purposes comports with
the Administration's goals of promoting ``healthy Indian . . .
communities''\98\ and ``including new approaches to delivering
care.''\99\ 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.
---------------------------------------------------------------------------
\98\S. Hrg. 109-162, at 585 (statement of Dr. Grim, Director, U.S.
Department of Health and Human Services, Indian Health Service).
\99\Id. at 589.
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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. 1200). 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. 1200).
In including these ``non-eligible individuals'' in the
service delivery system, Congress has set forth considerations
for the IHS and Indian tribes to address prior to providing the
services--the ``two-part determination'' contained at 25 U.S.C.
1680c(b)(1)(A):
(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.
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, 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. 1200 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 variations 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 other words, no diminution may be
experienced if the funded used to serve these people is
replaced by other funding.
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, and
appointment waiting times,\100\ are all other considerations
that may be appropriate, depending on the particular
circumstances.
---------------------------------------------------------------------------
\100\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 by the non- eligible
individual 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 alternatives unavailable. In those
situations, if good faith efforts have been made 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.
Authorizing services for non-eligibles is a determination 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. 1200 to the IHS and Indian
tribes based on their particular circumstances and, if
appropriate, could be developed more fully through negotiated
rulemaking or consultation.
Section-by-Section Analysis
A significant portion of current law has been carried
forward by S. 1200 and reorganized in the various titles
according to subject matter. S. 1200 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) 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 Indian youth
suicide prevention, intervention and treatment through the use
of telemedicine, and convenient care services.
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. 1200. In addition, the codified section in
current law is also noted to provide ease of reference.
Section 1. Short title; table of contents
Section 1 provides that this Act may be cited as the
``Indian Health Care Improvement Act Amendments of 2007,'' and
contains the table of contents.
TITLE I--AMENDMENTS TO INDIAN LAWS
The provisions of Title I are within the jurisdiction of
the Senate Indian Affairs Committee.
Section 101. Indian Health Care Improvement Act amended
This section sets forth a host of provisions which
incorporate provisions of current law and make amendments to
the Act.
Section 1. Short title; table of contents
This Act may be cited as the ``Indian Health Care
Improvement Act.'' Section 1 also sets for the table of
contents for Title I.
Section 2. Findings
Section 2 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.
Amendments: This section maintains current law.
Current Law: This section is Section 1601 of current law.
Section 3. Declaration of national Indian health policy
This section declares national policy, in fulfillment of
the special trust responsibilities and legal obligations to
Indians, to assure the highest possible health status for and
raise the health status of Indians and Urban Indians through
the provision of health services.
Amendments: 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, (d)
require consultation with Indian Tribes, Tribal Organizations
and Urban Indian Organizations, consistent with the policy of
Indian self-determination, and (e) provide funding to Indian
tribal programs and facilities consistent with levels of IHS
programs and facilities.
Current Law: This section is Section 1602 of current law.
Section 4. Definitions
Section 4 provides definitions for terms used throughout
the Act.
Amendments: This section maintains current law and adds
several new definitions. Assistant Secretary, behavioral
health, tribal college or university, telehealth, contract
health service, and telemedicine are examples of new
definitions not now in current law.
Current Law: Section 1603 of current law provides
definitions for terms used throughout the Act.
TITLE I--INDIAN HEALTH, HUMAN RESOURCES, AND DEVELOPMENT
Section 101. Purpose
This section states the purpose of this title, which is to
increase the number of Indians entering health professions and
providing health services, and to assure an optimum supply of
health professionals to provide health services to Indians.
Amendments: 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: Section 1611 of current law states the purpose
of increasing the number of Indian health professionals and
assuring an adequate supply of health professionals to provide
health services to Indians.
Section 102. Health professions recruitment program for Indians
This section authorizes grants for recruitment programs,
including identifying Indians with potential for entering
health professions, publicizing sources of financial aid, 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.
Amendments: This section maintains current law.
Current Law: This section is Section 1612 of current law.
Section 103. Health professions preparatory scholarship program for
Indians
Section 103 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. This section specifies certain
conditions on these scholarships which include costs which may
be covered by the scholarships, and prohibits denial of a
scholarship based solely on scholastic achievement if 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.
Amendments: 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: This section is Section 1613 in current law.
Section 104. Indian health professions scholarships
Section 104 authorizes scholarships to Indians who are
enrolled full- or part-time in accredited schools, pursuing
courses of study in the health professions. Such scholarships
are designated as Indian Health Scholarships. 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.
Amendments: 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: This section is Section 1613a of current law.
Section 105. American Indians into psychology program
This section authorizes grants of not more than $300,000 to
each of 9 colleges and universities for developing and
maintaining Indian psychology career recruitment programs,
including a Quentin N. Burdick Program Grant 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. $2.7
million is authorized for each of FY 2008 through 2017.
Amendments: 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 2008 through 2017.
Current Law: The section is Section 1621p of current law.
Section 106. Scholarship programs for Indian tribes
Section 106 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. The requirements for receiving such funds; the
course of study; contract requirements; 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 is required to fulfill service obligations and use
the scholarship for tuition and reasonable education or living
expenses. The recipient cannot discriminate against patients
who receive assistance under Titles XVIII and XIX of the Social
Security Act.
Amendments: 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 be met for all health professions, not
only for the doctor and nursing professions; (3) provides that
the scholarship may allow the recipient to serve in another
Service Area, provided the Tribal Health Program and Secretary
approve and services are not diminished to Indians in the
Service Area where the Tribal Health Program providing the
scholarship is located; and (4) adds Title XXI of the Social
Security Act to the non- discriminatory provisions.
Current Law: This section is Section 1616m of current law.
Section 107. Indian Health Service extern programs
Section 107 gives preference for employment with the
Service, a Tribal Health Program, Urban Indian Organization or
other agencies within the Department, to any recipient of a
scholarship pursuant to section 104 or 106. 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. The section
further specifies that an individual employed under this
section will receive practical experience in the health
profession in which he or she is engaged in study.
Amendments: This section maintains current law and adds the
following new provisions: (1) extends the extern program to
Tribal Health Programs, Urban Indian Organizations or urban
Indian health providers (on a discretionary basis) or other
Department agencies, instead of only the IHS; and (2) gives the
extern, including an extern in a high school program, a
preference for employment with the IHS, instead of entitling
them to employment.
Current Law: This section is Section 1614 of current law.
Section 108. Continuing education allowances
This section permits the Secretary to provide programs or
allowances to (a) transition in to an Indian Health Program,
including licensing, board or certification examination and
technical assistance, in fulfilling service obligations, and
(b) health professionals employed in an Indian Health Program
to enable them to take leave of their duty stations for a
period of time each year for professional consultation and
refresher training courses.
Amendments: This section maintains current law, but also
deletes the set-aside of not more than $1 million for
postdoctoral training contained in current law, and adds
language which extends the continuing education allowances to
Tribal Health Programs and Urban Indian Organizations, in
addition to the IHS, and includes all health professionals,
rather than specified select health professionals.
Current Law: This section is Section 1615 of current law.
Section 109. Community Health Representative Program
Section 109 authorizes the Community Health Representative
Program for training and using Indians as community health
representatives. The section specifies the duties of the
Service regarding this program, including providing a high
standard of training for Community Health Representatives to
ensure that these representatives 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.
Amendments: 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 Health Programs and Urban Indian
Organizations as well as IHS programs.
Current Law: The section is Section 1616 of current law.
Section 110. Indian Health Service Loan Repayment Program
This section directs the Secretary to establish and
administer the Service Loan Repayment Program in order to
ensure an adequate supply of trained health professionals
needed to maintain accreditation of, and provide health care
services to Indians through, Indian Health Programs and Urban
Indian Organizations. The section includes provisions
addressing eligibility for the program; application
information; priorities; recipient contracts; deadlines for
decisions on applications; a loan repayment program; a waiver
from any employment ceiling; a recruitment program; non-
applicability of Section 214 of the Public Health Service Act
(which concerns employees or officers being assigned to other
agencies) during the period of obligated service; assignment of
individuals; breach of contract; waiver or suspension of
obligation; and the requirement of an annual report to Congress
under Section 801.
Amendments: This section maintains current law. In
addition, it (1) eliminates the set-asides during FY 1993-1995
for nursing and mental health professions; and (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: This section is Section 1616a of current law.
Section 111. Scholarship and Loan Repayment Recovery Fund
Section 111 establishes an Indian Health Scholarship and
Loan Repayment Recovery Fund within the Treasury of the United
States. The section specifies the use of these funds, the
investment of the funds, and the sale of obligations by the
Secretary of the Treasury.
Amendments: This section maintains current law, and adds
provisions expanding the source of funds for this Recovery Fund
to include funds collected from individuals for breach of
contract under the scholarship or loan repayment programs and
interest, in addition to appropriations. 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 Health and Human
Services may now determine what amounts are not required to
meet current withdrawals from the Fund, rather than the
Secretary of the Treasury, as in current law.
Current Law: This section is Section 1616a-1 of current
law. It 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 loan
repayment programs are placed.
Section 112. Recruitment activities
Section 112 permits the Secretary to reimburse certain
travel expenses to health professionals seeking positions with
Indian Health Programs or Urban Indian Organizations. 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.
Amendments: 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: This section is Section 1616b of current law.
Section 113. Indian recruitment and retention program
Section 113 requires the Secretary to fund innovative
demonstration projects to enable Tribal Health Programs and
Urban Indian Organizations to recruit, place, and retain health
professionals to meet their staffing needs. The section also
specifies that any Tribal Health Program or Urban Indian
Organization is eligible to apply for these funds.
Amendments: 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 entities eligible to compete are Tribal Health Programs and
Urban Indian Organizations.
Current Law: This section is Section 1616c of current law.
Section 114. Advanced training and research
This section establishes a demonstration project 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 areas of study,
where a need exists. Each individual who participates shall
incur a service obligation. The section also specifies equal
opportunity for participating in the program.
Amendments: 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: This section is Section 1616d of current law.
Section 115. Quentin N. Burdick American Indians into Nursing Program
Section 115 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; 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.
Amendments: 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; and (3)
includes tribal colleges and universities in the preferences
among grant applicants.
Current Law: This section is Section 1616e of current law.
Section 116. Tribal cultural orientation
This section requires certain employees of the Service who
serve Indian Tribes in each Service Area to receive instruction
in the history and culture of the Indian Tribes they serve. The
section requires that the program be developed in consultation
with the affected Indian entities, be implemented through
tribal colleges or universities, include instruction in
American Indian studies, and describe the use and place of
traditional health care practices of the Indian Tribes in the
Service Area.
Amendments: 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 Tribes, Tribal Organizations and
Urban Indian Organizations.
Current Law: This section is Section 1616f of current law.
Section 117. INMED Program
Section 117 authorizes the Secretary to provide grants to
colleges and universities to maintain and expand the Indian
health careers recruitment program known as the Indians Into
Medicine Program (INMED). The Quentin N. Burdick Grant 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.
Amendments: 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 govern 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: This section is Section 1616g of current law.
Section 118. Health training programs of community colleges
This section requires the Secretary to award grants to
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 an Indian Health Program. The
Secretary is also required to award grants to accredited,
accessible community colleges that already have these programs.
The Secretary must provide technical assistance to encourage
community colleges to establish and maintain such programs. Any
program receiving assistance under this section is required to
provide advanced training for health professionals. Grant award
priority is provided to tribal colleges and universities in
Service Areas where they exist.
Amendments: 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: This section is Section 1616h of current law.
Section 119. Retention bonus
Section 119 permits the Secretary to provide retention
bonuses to any health professional where recruitment or
retention is difficult or is needed by Indian Health Programs
and Urban Indian Organizations, if the individual has completed
2 years of employment with an Indian Health Program or Urban
Indian Organization or any service obligation from federal
scholarships or loan repayment programs, and enters into an
agreement with an Indian Health Program or Urban Indian
Organization for continued employment for a period of not less
than 1 year. 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.
Amendments: This section maintains current law and adds
language expanding the bonuses (1) to any health professional,
rather than only doctors and nurses, so language specifying
funding set-asides between these 2 professions has been
deleted; and (2) to health professionals employed by the tribal
or urban health programs, rather than employed only by the
Service. Language also eliminates the current requirement that
the retention bonus be paid at the beginning of the term of
service.
Current Law: This section is Section 1616j in current law.
Section 120. Nursing residency program
This section establishes a program to enable Indians who
are nurses working for an Indian Health Program or Urban Indian
Organization to pursue advanced training. The participants are
required to enter a service obligation to serve in an Indian
Health Program or Urban Indian Organization. The program shall
include a combination of education and work study leading to
either an associate or bachelor's degree or advanced degrees or
certifications.
Amendments: 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, instead of a Master's
degree, as appropriate post-baccalaureate training.
Current Law: This section is Section 1616k of current law.
Section 121. Community Health Aide Program
Section 121 directs the Secretary to develop and operate a
Community Health Aide Program in Alaska. Requirements are
specified for the Alaska program. Dental Health Aide Therapists
under the Program would be prohibited from performing all oral
and jaw surgeries except pulpal therapy or extraction of adult
teeth after consultation with a licensed dentist in a dental
emergency. In addition, the Secretary is directed to establish
a neutral panel to conduct a study of the dental health aide
therapist services provided by the Community Health Aide
Program. Specifications of the study, which will lead to a
report to Congress, are delineated. This section also allows
the Secretary to establish a national Community Health Aide
Program, which shall not include dental health aide therapist
services, and shall not reduce funds for the Alaska program.
Amendments: 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: This section is Section 1616l of current law.
Section 122. Tribal Health Program administration
This section requires the Secretary to provide training for
Indians in the administration and planning of Tribal Health
Programs.
Amendments: This section maintains current law and adds
language which specifies that the training shall be for
individuals who are Indian.
Current Law: This section is Section 1616n of current law.
Section 123. Health professional chronic shortage demonstration
programs
This section permits the Secretary to fund demonstration
programs for Tribal Health Programs to address the chronic
shortages of health professionals. Each demonstration program
shall incorporate a program advisory board, which is to be
composed of representatives from the Indian Tribes and Indian
communities which are served by the program.
Amendments: This section amends current law by changing a
single pilot program at the School of Medicine at the
University of South Dakota to address health professional
shortages into a national demonstration project.
Current Law: This section is Section 1616o in current law.
Current law 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.
Section 124. National Health Service Corps
This section prohibits the Secretary from removing a member
of the National Health Service Corps from an Indian Health
Program or Urban Indian Organization or withdrawing funding
used to support such member, unless the Secretary ensures that
Indians will experience no reduction in services. The section
also exempts 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.
Amendments: This section maintains current law and adds
Urban Indian organizations. Language which 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 is new to current law.
Current Law: This section is Section 1680b of current law.
Section 125. Substance abuse counselor educational curricula
demonstration programs
Section 125 allows the Secretary to enter into contracts
with or make grants to accredited colleges and universities
(including tribal) to establish demonstration programs
developing curricula for substance abuse counseling. Duration
and renewal of the grants is specified. 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 under section 801; and
defines the term ``educational curriculum.''
Amendments: 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: This section is Section 1665j of current law.
Section 126. Behavioral health training and community education
programs
This section requires the Secretary, with the Secretary of
the Interior and in consultation with Indian Tribes and Tribal
Organizations, to conduct a study and compile a list of certain
types of staff positions within the Bureau of Indian Affairs,
the Service, Indian Tribes, Tribal Organizations and Urban
Indian Organizations, 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. Upon 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 to
provide 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 behavioral health
services by at least 500 staff positions within 5 years, with
at least 200 of such positions being devoted to child,
adolescent, and family services.
Amendments: This section maintains current law and (1) adds
Tribal Organizations and Urban Indian Organizations as
participants in the program; (2) clarifies that Tribal
Organizations are to be 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: This section is Section 1621h(d) of current
law.
Section 127. Authorization of appropriations
Section 127 authorizes to be appropriated such sums as may
be necessary to carry out this title for each fiscal year
through 2017.
Amendments: The section updates the authorization period
through fiscal year 2017, instead of fiscal year 2000.
Current Law: This section is Section 1616p of current law.
TITLE II--HEALTH SERVICES
Section 201. Indian Health Care Improvement Fund
This section authorizes the use of funds 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 programs administered by the
Indian Health Service. 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 Indian Health Service for determining
appropriations in subsequent years.
Nothing in this section is intended to diminish the primary
responsibility of the Indian Health Service to eliminate
backlogs in unmet health care, or to discourage additional
efforts of the Service to achieve equity among Tribes and
Tribal Organizations.
Funds appropriated under this section are to be designated
as the ``Indian Health Care Improvement Fund.''
Amendments: 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 telehealth and telemedicine.
Language has been added specifying the kinds of injury
prevention programs that may be offered.
Current Law: This section is Section 1621 of current law.
Section 202. Catastrophic Health Emergency Fund
Section 202 establishes the Catastrophic Health Emergency
Fund (CHEF), which is to be administered by the Secretary
through the headquarters 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 shall be deposited into CHEF.
Amendments: This section maintains current law.
Current Law: This section is Section 1621a in current law.
Section 203. Health promotion and disease prevention services
This section finds that health promotion and disease
prevention activities improve health and well-being and reduce
the expenses for health care. It requires the Secretary to
provide these services and, with input from the affected Tribal
Health Programs, to report to Congress on an evaluation
statement of the status, capacity and resources needed to
promote health and prevent disease.
Amendments: 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: This section is Section 1621b of current law.
Section 204. Diabetes prevention, treatment, and control
Section 204 requires the Secretary to determine the
incidence of diabetes and its complications among Indians and
the measures needed to prevent, treat and control this disease.
The Secretary is also required, when medically indicated and
with informed consent, 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 dialysis programs. To the extent that
funding is available, the Secretary is required to work with
each Area Office to consult with Tribes and Tribal
Organizations regarding diabetes programs; 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, 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.
Amendments: 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, and (d)
funding for dialysis programs; (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 for diabetes control officers in each Area Office, but
provides that 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: This section is Section 1621c of current law.
Section 205. Shared services for long-term care
This section allows the Secretary to enter into funding
agreements with Tribes and Tribal Organizations for the
delivery of long-term care services to Indians. Contents of
these funding agreements are specified. 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. The Secretary shall
encourage the use of existing underused facilities or allow the
use of swing beds for long-term or similar care.
Amendments: This section amends current law by changing a
demonstration project into a permanent program and adding new
provisions which (1) include health care services associated
with long- term care provided in a facility for Indians; and
(2) encourage the use of existing underused facilities or allow
the use of swing beds for long-term or similar care.
Current Law: This section is Section 1680l of current law.
Section 206. Health services research
This section requires the Secretary to make funding
available for both clinical and nonclinical research to further
the delivery of Indian health services, and to coordinate the
activities of other agencies within the Department to address
this need. Tribal Health Programs are to be given equal
opportunity to compete for these research funds. The Secretary
shall also periodically evaluate the impact of research
conducted under this section, and disseminate to Tribal Health
Programs information regarding that research.
Amendments: 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; (3)
authorizing funding for both clinical and nonclinical research;
and (4) providing for a periodic evaluation and dissemination
of the research to Tribal Health Programs.
Current Law: This section is Section 1621g of current law.
Section 207. Mammography and other cancer screening
This section requires the Secretary to provide for
mammography and other cancer screening, consistent with the
screening recommendations of the United States Preventive
Services Task Force.
Amendments: This section amends current law by authorizing
other cancer screening, and 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: This section is Section 1621k of current law.
Section 208. Patient travel costs
Section 208 requires the Secretary to provide funds for the
travel costs of patients and their qualified escorts,
associated with receiving health care services. A definition of
``qualified escort'' for purposes of accompanying a patient who
is traveling to receive health care services is provided.
Amendments: This section maintains current law and adds
language which allows the use of 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: This section is Section 1621l of current law.
Section 209. Epidemiology centers
This section directs the Secretary to establish an
epidemiology center in each Service Area. The functions of
these centers are delineated. The Director of the Centers for
Disease Control and Prevention is required to provide technical
assistance to the centers. The Secretary is also authorized to
make grants to Tribes, Tribal Organizations, Urban Indian
Organizations and eligible intertribal consortia to conduct
epidemiological studies of Indian communities. Eligibility
requirements for consortia, application requirements and use of
grant funds are specified. This section also authorizes the
Secretary to provide access to information in the possession of
the Secretary to an epidemiology center operated by a grantee
pursuant to a grant awarded under this section.
Amendments: 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; (2) allowing new centers to be operated
under a grant under this section, but the funding under such a
grant shall not be divisible; (3) eliminating the requirements
in current law that the Secretary establish the data and
formats for reporting and establish the system for monitoring
progress toward the health objectives; and (4) providing that
an epidemiology center operated under this section shall be
treated as a public health authority for purposes of the Health
Insurance Portability and Accountability Act of 1996 and
directing the Secretary to grant grantees access to and use of
data and other protected health information in the possession
of the Secretary.
Current Law: This section is Section 1621m of current law.
Section 210. Comprehensive school health education programs
Section 210 allows the Secretary to provide 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.
The specific purposes for which grant funds may be used are
delineated. Upon request, the Secretary shall provide technical
assistance in the development and dissemination of
comprehensive health education plans, materials and
information. The Secretary, through the Service and in
consultation with Tribes, Tribal Organizations and Urban Indian
Organizations, 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 a
similar school health education program.
Amendments: 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)
expands the grants to include Tribal Organizations and Urban
Indian Health Organizations as eligible for funding, as well as
Tribes; (3) deletes the reporting requirements of current law;
and (4) requires that the application criteria be established
in consultation with Indian Tribes, Tribal Organizations and
Urban Indian Organizations.
Current Law: This section is Section 1621n of current law.
Section 211. Indian youth program
This section authorizes the Secretary to establish and
administer a program for innovative mental and physical disease
prevention and health promotion and treatment for Indian and
Urban 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 in
consultation with Tribes, Tribal Organizations and Urban Indian
Organizations.
Amendments: 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. The
specific authorization of this program in current law is
deleted.
Current Law: This section is Section 1621o of current law.
Section 212. Prevention, control, and elimination of communicable and
infectious diseases
Section 212 authorizes the Secretary to make grants
available to projects specifically for the purpose of
preventing, controlling and eliminating communicable and
infectious diseases. Funding is also authorized for public
information and education programs; education, training and
clinical skills improvement activities for health
professionals; and demonstration projects for the screening,
treatment and prevention of the hepatitis C virus. Funding
under this section requires an application or proposal to be
submitted. Entities which receive funding under this section
are encouraged to coordinate their activities with the Centers
for Disease Control and Prevention, as well as with state and
local health agencies. Finally, in carrying out this section,
the Secretary may provide technical assistance, upon request,
and shall submit a biennial report to Congress on the use of
the funds and the progress made toward prevention, control, and
elimination of communicable and infectious diseases among
Indians and Urban Indians.
Amendments: This section amends current law by (1)
including Urban Indian Organizations; (2) expanding the
communicable diseases from simply tuberculosis to other
communicable and infectious diseases; (3) by encouraging,
rather than requiring, that entities funded under this section
coordinate with the Centers for Disease Control and state and
local health agencies; and (4) by eliminating provisions of
current law which would reduce the grant amount for expenses
incurred by the federal government or for supplies or equipment
furnished to the grant recipient.
Current Law: This section is Section 1621q of current law.
Section 213. Other authority for provision of services
This section authorizes the Secretary to fund other
activities which meet the objectives set forth in Section 3 of
this Act through health care-related services and programs not
otherwise described in the Act, including hospice care,
assisted living, long-term health care, and home- and
community-based services. Services are to be in provided in
accordance with accepted and appropriate standards relating to
the service, including any licensing term or condition. The
Secretary is authorized to establish standards, by regulation,
for a service provided under this section, provided that those
standards are not more stringent than the standards required by
the state in which the service is provided. If the Secretary
does not establish standards by regulation, state standards
shall apply. If a service under this section is provided by an
Indian Tribe or Tribal Organization pursuant to the Indian
Self-Determination and Education Assistance Act, the
verification by the Secretary that the service meets any
standards required by the state in which the service is or will
be provided shall be considered to meet the terms and
conditions required. The individuals who are eligible to
receive long-term care under this section are specified, and
the terms ``home- and community-based services'' and ``hospice
care'' are defined. This section also authorizes the Secretary
to provide funding to meet the objectives set forth in Section
3 of this Act for convenient care services programs pursuant to
section 306(c)(2)(A).
Amendments: This section amends current law by making
permanent a demonstration project for home- and community-based
care. New provisions also (1) add standards; (2) add several
definitions and deletes the definition of ``functionally
disabled'' found in current law; and (3) eliminates the
exclusion of cash payments, room and board, construction and
nursing facility services. The provision authorizing the
Secretary to provide funding to meet the objectives set forth
in Section 3 of this Act for convenient care services programs
is new.
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 requires the Secretary, acting through the
Service, Indian Tribes, Tribal Organizations and Urban Indian
Organizations, to monitor and improve health care for Indian
women of all ages through the planning and delivery of programs
administered by the Service.
Amendments: 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 Care 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
Section 215 requires the Secretary, in conjunction with
other Federal agencies and in consultation with concerned
Tribes and Tribal Organizations, to conduct studies and ongoing
monitoring programs to determine trends in the health hazards
to Indian miners and other Indians as a result of environmental
hazards, such as nuclear resource development, petroleum
contamination, and contamination of water sources and the food
chain. Upon completion of such studies, the Secretary shall
develop health care plans to address these health problems. 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 shall include recommendations for the
implementation of the health care 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.
Amendments: 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; and (2) provides additional elements of the
studies conducted under this section.
Current Law: This section is Section 1677 of current law.
Section 216. Arizona as a contract health service delivery area
This section designates the State of Arizona as a contract
health service delivery area for providing contract health care
services to members of federally recognized Indian Tribes of
Arizona. The Indian Health Service is not to curtail any
services as a result of this provision.
Amendments: This section maintains current law and extends
the date to 2017, instead of 2000, for the designation as a
contract health service delivery area.
Current Law: This section is Section 1678 of current law.
Section 216A. North Dakota and South Dakota as contract health service
delivery area
This section designates the States of North Dakota and
South Dakota as one contract health service delivery area for
providing contract health care services to members of federally
recognized Indian Tribes in North and South Dakota. The Indian
Health Service is not to curtail any services as a result of
this provision.
Amendments: This section is new to the Act and is not
contained in current law.
Section 217. California contract health services program
This section authorizes the Secretary to fund a program
using the California Rural Indian Health Board (CRIHB) as a
contract care intermediary to improve the accessibility of
health services to California Indians. The Secretary will
reimburse the CRIHB for costs incurred pursuant to this
section. Not more than 5 percent of the amounts provided under
this section to the CRIHB in any fiscal year 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 to advise the CRIHB in carrying
out this section. The Advisory Board shall be 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.
Amendments: This section amends current law by turning the
demonstration project for the California Indians into a
permanent program.
Current Law: This section is Section 1621j of current law.
Section 218. California as a contract health service delivery area
This section designates the State of California, excluding
certain specified counties, as a contract health service
delivery area for the purpose of providing contract health care
services to California Indians. The excluded counties may be
included only if funding is specifically provided by the Indian
Health Service for such services in those counties.
Amendments: 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 such
services in those counties.
Current Law: This section is Section 1680 of current law.
Section 219. Contract health services for the Trenton service area
This section directs the Secretary to provide contract
health services to members of the Turtle Mountain Band of
Chippewa Indians who 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.
Nothing in this section is to 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 these services that applied on May 1,
1986.
Amendments: This section maintains current law.
Current Law: This section is Section 1680e of current law.
Section 220. Programs operated by Indian tribes and tribal
organizations
This section requires the Indian Health Service to provide
funds to Tribal Health Programs for health care programs and
facilities on the same basis as funds are provided to these
programs operated directly by the Indian Health Service.
Amendments: This section maintains current law, but
eliminates language which specifies 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 tribes and tribal organizations
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
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.
Amendments: This section is new to the Act and is not
contained in current law.
Section 222. Notification of provision of emergency contract health
services
This section allows 30 days (as a condition of payment) for
an elderly or disabled Indian to notify the Service of any
emergency medical care or services received from a non-Service
provider or in a non-Service facility.
Amendments: This section maintains current law.
Current Law: This section is Section 1646 of current law.
Section 223. Prompt action on payment of claims
Section 223 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 submitted by the provider as valid. The IHS shall pay a
valid claim within 30 days after the completion of the claim.
Amendments: This section maintains current law, but changes
the requirement of a completed claim to a valid claim.
Current Law: This section is Section 1621s of current law.
Section 224. Liability for payment
This section 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. The Secretary is required to notify the
contract care provider and the patient who receives such
services that the patient is not liable within a specified
time. Following receipt of this notice or an acceptable claim
under the previous section, the provider shall have no further
recourse against the patient who received the health care.
Amendments: 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: This section is Section 1621u of current law.
Section 225. Office of Indian Men's Health
This section provides that the Secretary may establish the
Office of Indian Men's Health to coordinate and promote the
health status of Indian men. The Office will be headed by a
director, who is to be appointed by the Secretary. The
Secretary is also required to submit a report to Congress
within two years of enactment, describing any activity and
finding about the health of Indian men of the director.
Amendments: This section is new to the Act and is not
contained in current law.
Section 226. Authorization of appropriations
This section authorizes to be appropriated such sums as may
be necessary to carry out this title for each fiscal year
through fiscal year 2017.
Amendments: This section maintains current law, but extends
the authorization from fiscal year 2000 to fiscal year 2017 and
eliminates the references to specific sections which had a
separate authorization period.
Current Law: This section is Section 1621w of current law.
TITLE III--FACILITIES
Section 301. Consultation; Construction and renovation of facilities;
Reports
This section requires that prior to expending construction
funds, the Secretary shall consult with impacted Indian Tribes,
and ensure that facilities built pursuant to this section meet
certain construction standards within one year after the date
on which the construction or renovation of such facility is
completed. In addition, Section 301 sets forth requirements to
be met prior to closing any facility.
This section also directs the Secretary to maintain a
health care facility priority system which shall be developed
in consultation with Indian Tribes and Tribal Organizations and
meet other requirements. The priority of any project
established under the construction priority system in effect on
the date of enactment, if the project meets certain criteria,
is protected. Not later than 1 year after the date of enactment
of the Indian Health Care Improvement Act Amendments of 2007,
the Secretary shall submit to Congress a report that describes
the comprehensive, national, ranked list of all health care
facilities needs for the Service, Indian Tribes, and Tribal
Organizations. Beginning in calendar year 2011, the Secretary
shall update this report not less frequently than once every 5
years. Annual reports are also required under this section.
Not later than 1 year after the establishment of the health
care facilities construction priority system under this
section, the Comptroller General of the United States shall
prepare and finalize a report to Congress, that reviews the
methodologies applied, and the processes followed, by the
Service in making each assessment of needs for the priority
system. This section also directs the Secretary to 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.
Amendments: This section maintains current law and builds
on it substantially. Language is added which (1) requires an
evaluation of the impact of a proposed closure prior to
closing; (2) requires the Secretary to maintain a health care
facility priority system developed through consultation, which
prioritizes certain facilities; (3) adds specific requirements
for the initial, comprehensive report to Congress and
subsequent annual reports; (4) requires the Secretary to
consult and cooperate with Indian Tribes, Tribal Organizations,
and Urban Indian Organizations in developing innovative
approaches to meet facilities needs; and (5) requires the
Comptroller General to prepare a report to Congress which
reviews the methodology used for the health facilities
construction priority list.
Current Law: This section is Section 1631 of current law.
Section 302. Sanitation facilities
This section provides findings, certain responsibilities of
the Service 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, and
priority funding for operation and maintenance or emergency
repairs.
Section 302 authorizes the Secretary to accept funds from
any source, including funds appropriated under the Native
American Housing Assistance and Self-Determination Act, for
construction of sanitation facilities. The Secretary, after
consulting with the Secretary of Housing and Urban Development
and Indian Tribes, Tribal Organizations and tribally designated
housing entities, is also required to submit a report to
Congress on the sanitation facilities priority system and a 10-
year plan to provide sanitation facilities to new and renovated
Indian homes. Deficiency levels for sanitation facilities are
defined.
Amendments: 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 to provide sanitation facilities to new homes
constructed using Department of Housing and Urban Development
funds; (3) allows the Secretary to accept funds from any
source, including federal and state agencies, for sanitation
facilities and services, and to place those funds into
contracts or compacts under the Indian Self-Determination and
Education Assistance Act; (4) authorizes the Secretary to allow
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 consultation
in preparation of the report to Congress, and clarifies the
information required to be in the annual report; and (7)
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.
Current Law: This section is Section 1632 of current law.
Section 303. Preference to Indians and Indian firms
This section authorizes the Secretary to give preference to
Indians or Indian or tribal enterprises or other businesses in
the construction and renovation of Service facilities pursuant
to section 301, and in the construction of sanitation
facilities pursuant to section 302. Compliance with certain
labor standards is required.
Amendments: 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 or Tribal Organizations to be served by the
construction.
Current Law: This section is Section 1633 of current law.
Section 304. Expenditure of non-service funds for renovation
This section authorizes the Secretary to accept any
expansion, renovation or modernization of any Service or tribal
health facility funded with non-Service funds in accordance
with certain criteria. The Secretary is required to maintain a
separate priority list for these facilities, which shall be
submitted to Congress as part of the annual report to Congress.
Indian Tribes or Tribal Organizations are required to meet
certain requirements for expansions, renovations or
modernizations. This section also provides that if any Service
facility which has been expanded, renovated, or modernized
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 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 bore to the value
of such facility at the time of the completion of such
expansion, renovation, or modernization.
Amendments: 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 regulations.
Current Law: This section is Section 1634 of current law.
Section 305. Funding for the construction, expansion and modernization
of small ambulatory care facilities
This section authorizes the Secretary to make grants to
Indian Tribes and Tribal Organizations for the construction,
expansion, or modernization of facilities for the provision of
ambulatory care services. Use of funds, grant application
requirements, priorities, and conditions for reversion of
facilities are set forth.
Amendments: This section maintains current law and adds
language which (1) 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; (2) adds additional capacity requirements for a
facility constructed with a grant under this section; (3) makes
reduction of an outstanding debt for construction, expansion or
modernization an additional allowable use of funds; and (4)
authorizes peer review panels to be established to evaluate
applications and proposals.
Current Law: This section is Section 1636 of current law.
Section 306. Indian health care delivery demonstration projects
This section authorizes the Secretary to establish a health
care delivery demonstration project to test alternative means
of delivering health care and services to Indians through
facilities. There would be two kinds of demonstration projects.
General projects would be authorized, with priority given to
projects located in specific Service Areas, if they meet the
specified criteria, 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.
Health care delivery demonstration projects would also be
authorized that include a convenient care services program as
an alternative means of delivering health care services to
Indians. This section also requires technical assistance and
use of the same criteria in evaluating tribal and IHS
facilities.
Amendments: This section maintains current law and adds
language which (1) permits the use of IHS funds to match other
funds; (2) authorizes the convenient care services
demonstration projects; and (3) authorizes peer review panels
to be established to review and evaluate applications. Language
of current law authorizing reports to Congress on the findings
and conclusions of the demonstration projects has been deleted.
Current Law: This section is Section 1637 of current law.
Section 307. Land transfer
This section authorizes the Secretary to accept any land
and improvements transferred, at no cost, from the Bureau of
Indian Affairs or other federal agencies for the provision of
health care services.
Amendments: This section amends current law by changing a
specific authorization into a general authorization whereby
federal agencies may transfer land and improvements to the IHS
for the provision of health care services.
Current Law: Section 1638 provides specific authorization
for transferring 5 acres of land at the Chemawa Indian School
in Salem, OR, to the IHS.
Section 308. Leases, contracts and other agreements
This section authorizes the Secretary to enter into leases,
contracts and other agreements with Indian Tribes and Tribal
Organizations which have facilities for the delivery of health
services at those facilities. The agreements may also include
provisions for construction, renovation and compensation.
Amendments: This section essentially maintains current law.
The provision of current law authorizing the Secretary to enter
into 20-year leases with Tribes that may specify reconstruction
or renovation of property has been deleted.
Current Law: This section is Section 1674 of current law.
Section 309. Study for loans, loan guarantees and loan repayment
This section directs the Secretary to conduct a study to
determine the feasibility of establishing a loan fund to
provide Indian Tribes and Tribal Organizations direct loans or
loan guarantees for health care facilities construction. A
number of study requirements are delineated. The results of the
study shall be reported to Congress.
Amendments: This section is new and is not now contained in
current law.
Section 310. Tribal leasing
This section authorizes a tribal health program to lease
permanent structures for the purpose of providing health care
services without obtaining prior approval in appropriation
Acts.
Amendments: This section maintains current law, and expands
the program to include Tribal Organizations.
Current Law: This section is Section 1680j of current law.
Section 311. Indian Health Service/Tribal Facilities Joint Venture
Program.
This section authorizes the Secretary to make arrangements
with Indian Tribes and Tribal Organizations to establish joint
venture demonstration projects, under which an Indian Tribe or
Tribal Organization would 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, the Service will agree to provide the equipment,
supplies, and staffing for the operation and maintenance of
such a health facility. Certain capabilities and other
requirements are set forth. There are provisions for breach of
agreement by either the Tribe or Tribal Organization or the
IHS.
Amendments: 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 negotiation for the continued operation of the
facility at the end of the 10-year lease; (3) authorizes
recovery in a proportional amount from the IHS if the IHS
ceases to use the facility within the 10-year lease period; and
(4) includes staff quarters in the definition of the health
facilities under this section.
Current Law: This section is Section 1680h(e) of current
law.
Section 312. Location of facilities
This section directs the Bureau of Indian Affairs and the
Service to give priority to locating health care facilities and
employment projects in economically depressed areas to Indian
and Alaska Native lands, if requested by the Indian owner and
Indian Tribe with jurisdiction over such lands.
Amendments: This section maintains current law and adds
language to (1) include lands in Alaska owned by any Alaska
Native village, or village or regional corporation under the
Alaska Native Claims Settlement Act, or any land allotted to
any Alaska Native; and (2) gives top priority to Indian land
owned by 1 or more Indian Tribes. The definition of ``Indian
lands'' is modified from current law.
Current Law: This section is Section 1680n of current law.
Section 313. Maintenance and improvement of health care facilities
This section requires the Secretary to report to Congress
on the backlog of maintenance and repair work required at both
Service and tribal health care facilities. This section also
authorizes an Indian Tribe or Tribal Organization to use
maintenance and improvement funds for construction of a
replacement facility, as well as for renovation, modernization,
and expansion of facilities, under certain circumstances.
Amendments: This section is new and is not now contained in
current law.
Section 314. Tribal management of federally-owned quarters
This section 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 to collect the rent
directly from federal employees who occupy such quarters. These
quarters shall remain eligible for improvement and repair funds
as other federally-owned quarters. The Tribal Health Program
operating the quarters is required to provide at least 60 days
notice before changing the rental rate.
Amendments: This section is new and is not now contained in
current law.
Section 315. Applicability of Buy American Act requirement
This section requires application of the Buy American Act
for all procurements under this title. Indian Tribes and Tribal
Organizations are exempt from this requirement.
Amendments: This section maintains current law, but exempts
Indian Tribes and Tribal Organizations from the requirements of
the Buy American Act, and eliminates the reporting requirement
contained in current law.
Current Law: This section is Section 1638b of current law.
Section 316. Other funding for facilities
This section authorizes the Secretary to accept funds from
other sources for the construction of health care facilities
and to place such funds into a contract or compact under the
Indian Self-Determination and Education Assistance Act. The
Secretary is also authorized to enter into interagency
agreements with other federal or state agencies for the
planning, design and construction of health care facilities to
be administered by Indian Health Programs.
Amendments: This section is new and is not now contained in
current law.
Section 317. Authorization of appropriations
This section authorizes to be appropriated such sums as may
be necessary for each fiscal year through fiscal year 2017 to
carry out this title.
Amendments: This section maintains current law but extends
the authorization for appropriations beyond fiscal year 2000
through fiscal year 2017.
Current Law: This section is Section 1638a of current law.
TITLE IV--ACCESS TO HEALTH SERVICES
Section 401. Treatment of payments under Social Security Act health
care benefits programs
This section requires that any Medicare, Medicaid, or State
Children's Health Insurance Program (SCHIP) payments received
by an Indian Health Program or Urban Indian Organization for
services provided to eligible Indians shall not be considered
in determining appropriations for the provision of health care
and services. Indians without Medicare, Medicaid or SCHIP
coverage are to be given equal consideration as Indians who are
covered by these Social Security Act health benefit programs.
Payments to which a facility of the Service is entitled by
reason of a provision of the Social Security Act are to be
placed in a special fund to be held by the Secretary. In making
payments from such fund, the Secretary is to ensure that each
Service Unit receives 100% of the amount to which the facility
of the Service, for which such Service Unit makes collections,
is entitled. How funds collected from Medicare, Medicaid, or
SCHIP are to be used is specified. This section also allows
Tribal Health Programs to elect to directly bill for, and
receive payment for, health care items and services provided by
that Tribal Health Program for which payment is made under
Medicare, Medicaid, SCHIP, or third party payors.
Amendments: This section maintains current law and (1) adds
Tribal Organizations and Urban Indian Organizations, in
addition to Tribes and the IHS, for whom reimbursements would
not be considered in determining appropriations; (2) authorizes
the 100% pass-through of payments due to Service facilities
from the special fund; and (3) 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 served. 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 address treatment of
payments under Medicare or Medicaid. Section 1645 established a
program under which tribes could elect to directly bill and be
reimbursed for health care services provided under Medicare,
Medicaid or other third parties.
Section 402. Grants to and contracts with the service, Indian tribes,
tribal organizations, and urban Indian organizations to
facilitate outreach, enrollment, and coverage of Indians under
Social Security Act health benefit programs and other health
benefits programs
This section directs the Secretary to make grants to or
enter into contracts with Tribes and Tribal Organizations to
improve enrollment and participation in Medicare, Medicaid or
SCHIP programs, including paying premiums or cost sharing
(which terms are defined in this section). In doing so, the
Secretary shall place such conditions as are deemed necessary
to affect the purpose of this section, including certain
requirements of the Indian Tribe or Tribal Organization.
Specifications for applying this section to Urban Indian
Organizations are included. This section also directs the
Secretary, acting through the Centers for Medicare and Medicaid
Services, to 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 with respect to the provision of health care
items and services to Indians and to improving the enrollment
of Indians under Social Security Act health benefits programs.
This section also provides a cross-reference to the relevant
section of the Social Security Act for provisions related to
agreements between the Secretary and Indian Tribes, Tribal
Organizations, and Urban Indian Organizations for the
collection, preparation, and submission of applications by
Indians for assistance under Medicare, Medicaid and SCHIP.
Amendments: 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 Social Security Act programs.
Current Law: This section is Section 1644 of current law.
Section 403. Reimbursement from certain third parties of costs of
health services
Section 403 provides that the United States, an Indian
Tribe, or Tribal Organization has the right to recover from an
insurance company, health maintenance organization, employee
benefit plan, or any third party the reasonable charges billed
by the Secretary, an Indian Tribe, or Tribal Organization in
providing health services 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. 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, notice,
costs and attorneys' fees are all specified in this section.
Section 403 limits the Indian Health Service right of recovery
against a tribal self-insured plan absent written consent from
the Tribe. Other items covered in this section include
nonapplication of claims filing requirements; application to
Urban Indian Organizations; statute of limitations; and a
savings clause.
This section adds a new provision which would extend to
Tribes and Tribal Organizations the same authority the U.S. has
under the Federal Medical Care Recovery Act (FMCRA) to recover
the costs of medical care from a tortfeasor whose action caused
an injury or disease to a patient whom a federal health care
provider is obliged to treat. While the Department of Justice
brings such suits against tortfeasors for federal health care
providers such as the IHS, it does not currently do so for
Tribes which operate IHS-funded health programs.
Amendments: 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; (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; and
(6) to extend to Tribes and Tribal Organizations the same
authority the U.S. has under the Federal Medical Care Recovery
Act (FMCRA) to recover the costs of medical care from a
tortfeasor.
Current Law: This section is Section 1621e of current law.
Section 404. Crediting of reimbursements
This section authorizes the retention of the reimbursements
received or recovered under this Act, Medicare, Medicaid or
SCHIP and other provisions of law, from third parties and
specifies the use of those reimbursements. 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.
Amendments: This section maintains current law and adds
language which specifies which programs are included in the
reimbursements.
Current Law: This section is Section 1621f of current law.
Section 405. Purchasing health care coverage
Section 405 allows Tribes, Tribal Organizations and Urban
Indian Organizations to use funding for health benefits for
Indians to be used to purchase health benefits coverage for
Service beneficiaries in any manner (including through a
tribally owned and operated health care plan, a state or
locally authorized or licensed health care plan, a health
insurance provider or managed care organization, or a self-
insured plan), based on the financial needs of such
beneficiaries.
Amendments: This section replaces a provision of current
law which authorized a managed care feasibility study.
Current Law: Section 1621i of current law authorized the
Secretary to conduct a study to assess the feasibility of
allowing an Indian Tribe to purchase managed care coverage for
tribal members from a tribally owned and operated managed care
plan or a state or licensed managed care plan.
Section 406. Sharing arrangements with Federal agencies
This section allows the Secretary to enter into or expand
arrangements to share medical facilities and services with the
Departments of Veterans Affairs and Defense, with certain
limitations. If health care services are provided to
beneficiaries eligible for services from either the Department
of Veterans Affairs or the Department of Defense, then the
Service, Indian Tribe, or Tribal Organization providing the
service shall be reimbursed from the appropriate Department.
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 VA.
Amendments: This section amends current law by (1)
authorizing the Secretary to enter agreements for sharing of
medical facilities with the Departments of Veterans Affairs
(VA) and Defense, instead of merely examining the feasibility
of entering agreements with the VA; (2) requiring consultation
with the affected Indian Tribes prior to entering the
agreements; (3) requiring reimbursement to the IHS, Tribes, or
Tribal Organizations; and (4) eliminating the specific cross-
utilization of services in Utah only (expanding it, generally).
Current Law: Section 1680f of current law authorizes the
Secretary to examine the feasibility of entering agreements to
share medical facilities and services with the Department of
Veterans Affairs, with a specific agreement for Utah.
Section 407. Payor of last resort
This section 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.
Amendments: This section is new and is not contained in
current law.
Section 408. Nondiscrimination under Federal health care programs in
qualifications for reimbursement for services
Section 408 provides that a federal health care program
must accept an entity that is operated by the Service, an
Indian Tribe, Tribal Organization, or Urban Indian Organization
as a provider eligible to receive payment under the program for
health care services furnished to an Indian on the same basis
as any other provider qualified to participate as a provider of
health care services under the program if the entity meets
generally applicable state or other requirements for
participation as a provider of health care services under the
program. This section also provides that state or local
licensure or recognition requirements by a provider of health
care services shall be deemed to have been met in the case of
an entity operated by the Service, an Indian Tribe, Tribal
Organization, or Urban Indian Organization, if the entity meets
all the applicable standards for such licensure or recognition,
regardless of whether the entity obtains a license or other
documentation under such state or local law. Certain entities
operated by the Service, an Indian Tribe, Tribal Organization,
or Urban Indian Organization, or individuals who have been
excluded from participation in any federal health care program
or for which a license is under suspension or has been revoked
by the state where the entity or individual is located, shall
not be eligible to receive payment or reimbursement under any
such program for health care services furnished to an Indian.
Amendments: This section is new and is not contained in
current law.
Section 409. Consultation
This section provides a cross-reference to the relevant
section of the Social Security Act for provisions related to
consultation with representatives of Indian Health Programs and
Urban Indian Organizations with respect to the health care
programs established under Medicare, Medicaid and SCHIP.
Amendments: This section is new and is not contained in
current law.
Section 410. State Children's Health Insurance Program (SCHIP)
This section provides cross-references to relevant sections
of the Social Security Act for provisions relating to outreach
to families of Indian children likely to be eligible for child
health assistance under SCHIP, and ensuring that child health
assistance is provided under such program to targeted low-
income children who are Indians and that payments are made
under that program.
Amendments: This section is new and is not contained in
current law.
Section 411. Exclusion waiver authority for affected Indian health
programs and safe harbor transactions under the Social Security
Act
This section provides cross-references to relevant sections
of the Social Security Act for provisions relating to exclusion
waiver authority for affected Indian Health Programs, and
certain transactions involving Indian Health Programs deemed to
be in safe harbors under the Social Security Act.
Amendments: This section is new and is not contained in
current law.
Section 412. Premium and cost sharing protections and eligibility
determinations under Medicaid and SCHIP and protection of
certain Indian property from Medicaid estate recovery
This section provides cross-references to relevant sections
of the Social Security Act for provisions relating to premiums
or cost sharing protections for Indians furnished items or
services directly by Indian Health Programs or through referral
under the contract health service under Medicaid; rules
regarding the treatment of certain property for purposes of
determining eligibility under Social Security Act programs; and
the protection of certain property from estate recovery
provisions under Medicaid.
Amendments: This section is new and is not contained in
current law.
Section 413. Treatment under Medicaid and SCHIP managed care
Section 413 provides cross-references to relevant sections
of the Social Security Act for provisions relating to the
treatment of Indians enrolled in a managed care entity under
Medicaid, and Indian Health Programs and Urban Indian
Organizations that are providers of items or services to such
Indian enrollees.
Amendments: This section is new and is not contained in
current law.
Section 414. Navajo Nation Medicaid Agency feasibility study
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 a report to
Congress on the results of the study are described in this
section.
Amendments: This section is new and is not contained in
current law.
Section 415. General exceptions
Section 415 provides that the requirements of this title
shall not apply to any excepted benefits described in paragraph
(1)(A) or (3) of section 2791(c) of the Public Health Service
Act, which relates to supplemental insurance products.
Amendments: This is a new provision and is not contained in
current law.
Section 416. Authorization of appropriations
Section 416 authorizes to be appropriated such sums as may
be necessary for each fiscal year through fiscal year 2017 to
carry out this title.
Amendments: This section extends the authorization beyond
FY fiscal year 2000 to fiscal year 2017.
Current Law: The authorization of appropriations section
for the Access to Health Services title of current law is
Section 1647, and extends through fiscal year 2000.
TITLE V--HEALTH SERVICES FOR URBAN INDIANS
Section 501. Purpose
This section sets forth the purpose of the title as
establishing and maintaining programs in Urban Centers to make
health services more accessible and available to Urban Indians.
Amendments: This section maintains current law and adds
language to maintain the programs and make health services
available, in addition to being accessible, to Urban Indians.
Current Law: This section is Section 1651 of current law.
Section 502. Contracts with, and grants to, urban Indian organizations
This section provides that the Secretary shall enter into
contracts with, or make grants to, Urban Indian Organizations
to assist such organizations in the establishment and
administration, within Urban Centers, of programs which meet
the requirements set forth in this title.
Amendments: This section maintains current law.
Current Law: This section is Section 1652 of current law.
Section 503. Contracts and grants for the provision of health care and
referral services
This section sets forth the authority of the Secretary to
enter into contracts with or make grants to Urban Indian
Organizations to establish and administer programs under this
title, which shall meet certain requirements. This section
prescribes the criteria for selecting Urban Indian
Organizations for contracts or grants. Such contracts or grants
shall facilitate access to or provide services for health
promotion and disease prevention, immunization services,
behavioral health services, prevention of child abuse, and
other services to Urban Indians.
Amendments: This section maintains current law, generally,
while (1) modifying contract and grant requirements and
criteria; and (2) deleting factors to be considered for
immunization services contracts or grants that are set forth in
current law.
Current Law: This section is Section 1653 of current law.
Section 504. Contracts and grants for the determination of unmet health
care needs
This section authorizes the Secretary to enter into
contracts with or make grants to Urban Indian Organizations for
which contracts or grants have not been entered into under the
prior section. The purpose of these contracts/grants would be
to determine unmet health care needs of urban Indians. Grant
and contract requirements are set forth.
Amendments: This section maintains current law.
Current Law: This section is Section 1654 of current law.
Section 505. Evaluations; renewals
This section authorizes the Secretary to develop evaluation
and renewal procedures and standards for the various contracts
and grants entered into by Urban Indian Organizations under
this title, including considerations for renewals of contracts/
grants. The Secretary shall also evaluate the urban Indian
programs through onsite annual evaluations.
Amendments: 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: This section is Section 1655 of current law.
Section 506. Other contract and grant requirements
This section sets forth other specific contract and grant
requirements, such as payment methods, revisions and amendments
to contracts, and assurance of the fair and uniform provision
of services to Urban Indians.
Amendments: This section maintains current law and adds
provisions which (1) would allow a single advance payment,
unless the urban Indian organization is not capable of
administering the payments in their entirety and allows the
funding to be carried forward; and (2) would allow payments to
be made in semiannual or quarterly payments or by way of
reimbursement. This section deletes provisions of current law
allowing an Urban Indian Organization to use existing federal
facilities.
Current Law: This section is Section 1656 of current law.
Section 507. Reports and records
This section sets forth certain reporting and recordkeeping
requirements for Urban Indian Organizations. This section also
provides that not later than 18 months after the date of
enactment, the Secretary, in consultation with Urban Indian
Organizations, shall submit to Congress a report evaluating the
health status of Urban Indians; the services provided to
Indians pursuant to this title; and areas of unmet needs in the
delivery of health services to Urban Indians. This section also
provides that reports and records of the Urban Indian
Organization shall be subject to audit by the Secretary and the
Comptroller General of the United States.
Amendments: 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; (3) adds that the audits
may also be conducted by a certified public accounting firm;
and (4) deletes the requirement that IHS and the Department of
the Interior report to Congress by March 31, 1992, on the
health status, unmet needs and welfare of urban Indian
children.
Current Law: This section is Section 1657 of current law.
Section 508. Limitation on contract authority
This section limits the authority of the Secretary to enter
into contracts or to award grants under this title to the
extent and amount provided for in appropriations Acts.
Amendments: This section maintains current law and adds
language which includes the Secretary's authority to award
grants under this title.
Current Law: This section is Section 1658 of current law.
Section 509. Facilities
This section provides that the Secretary, acting through
the Service, may make grants for the lease, purchase,
renovation, construction, or expansion of facilities. This
section also allows the Secretary to carry out a study to
determine the feasibility of establishing a loan fund to
provide direct loans or guarantees for loans to Urban Indian
Organizations for the construction of health care facilities.
Amendments: This section replaces current law by adding
provisions which would allow for leasing, purchasing,
renovating, constructing and expanding, in addition to
repairing, facilities. The provision regarding the feasibility
study of a loan fund to construct facilities is new.
Current Law: Section 1659 of current law 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 establishes a Division of Urban Indian Health
within the Service to carry out the provisions of this title,
provide oversight of the programs, and provide technical
assistance to Urban Indian Organizations.
Amendments: This section maintains current law, but (1)
changes the Branch of Urban Indian programs into an Office
within the IHS; (2) adds technical assistance; and (3) deletes
provisions of current law regarding staffing, services and
equipment.
Current Law: This section is Section 1660 of current law.
Section 511. Grants for alcohol and substance abuse-related services
This section provides that the Secretary may make grants to
Urban Indian Organizations for the provision of health-related
services in prevention of, treatment of, rehabilitation of, or
school- and community-based education regarding, alcohol and
substance abuse in Urban Centers. Goals and criteria are set
forth.
Amendments: This section essentially maintains current law.
Current Law: This section is Section 1660a of current law.
Section 512. Treatment of certain demonstration projects
This section makes permanent the Tulsa Clinic and Oklahoma
City Clinic demonstration projects in Oklahoma and parallels
the language of the Interior Appropriations Act which first
contained this provision (Public Law 108-447).
Amendments: This section maintains provisions which make
permanent certain demonstration projects in Oklahoma, but
modifies the language of current law of this Act to parallel
the language of the Interior Appropriations Act which first
contained this provision (Public Law 108-447).
Current Law: This section is Section 1660b of current law.
Section 513. Urban NIAAA transferred programs
This section authorizes the Secretary, through the Division
of Urban Indian Health, to make grants to or enter into
contracts with Urban Indian Organizations, to take effect not
later than September 30, 2010, for the administration of Urban
Indian alcohol programs that were originally established under
the National Institute on Alcoholism and Alcohol Abuse (NIAAA).
Use of funds, eligibility and reporting requirements are set
forth.
Amendments: This section maintains current law, but (1)
changes references to the Branch of Urban Indian Health to the
Division; and (2) deletes the provision of current law allowing
the Secretary to combine NIAAA alcohol funds with other
substance abuse funds.
Current Law: This section is Section 1660c of current law.
Section 514. Consultation with urban Indian organizations
This section provides that the Secretary shall ensure that
the Service consults, to the greatest extent practicable, with
Urban Indian Organizations, and defines ``consultation.''
Amendments: This section is new and is not contained in
current law.
Section 515. Urban youth treatment center demonstration
This section authorizes the Secretary to fund the
construction and operation of at least 2 Indian youth
residential treatment centers in certain states to demonstrate
the provision of alcohol and substance abuse treatment services
to Urban Indian youth in a culturally competent residential
setting.
Amendments: This section is new and is not contained in
current law.
Section 516. Grants for diabetes prevention, treatment, and control
This section authorizes the Secretary to make grants to
Urban Indian Organizations to provide services for the
prevention and treatment of, and control of the complications
resulting from, diabetes among Urban Indians, based on certain
grant criteria that are set forth.
Amendments: This section is new and is not contained in
current law.
Section 517. Community health representatives
This section authorizes the Secretary to make grants to or
enter into contracts with Urban Indian Organizations for the
employment of Indians trained as health service providers
through the Community Health Representatives Program.
Amendments: This section is new and is not contained in
current law.
Section 518. Effective date
This section establishes that the amendments made by the
Act to this title shall take effect on the date of enactment,
regardless of whether the Secretary has promulgated regulations
implementing these amendments.
Amendments: This section is new and is not contained in
current law.
Section 519. Eligibility for services
This section provides that Urban Indians shall be eligible
for, and the ultimate beneficiaries of, health care or referral
services provided pursuant to this title.
Amendments: This section is new and is not contained in
current law.
Section 520. Authorization of appropriations
This section authorizes to be appropriated such sums as may
be necessary for each fiscal year through fiscal year 2017 to
carry out this title.
Amendments: This section maintains current law and extends
the authorization from fiscal year 2000 to fiscal year 2017.
Current Law: This section is Section 1660d of current law.
TITLE VI--ORGANIZATIONAL IMPROVEMENTS
Section 601. Establishment of the Indian Health Service as an agency of
the Public Health Service
This section establishes the Indian Health Service within
the Public Health Service of the Department, and elevates the
position of Director of the Indian Health Service to that of
the Assistant Secretary for Indian Health. The Assistant
Secretary for Indian Health shall be confirmed by the Senate
with a term of four years, and shall administer the Indian
Health Service. This section also specifies the duties and
responsibilities of the Assistant Secretary and deems that any
reference to the Director of the Indian Health Service in any
Federal law, Executive order, rule, regulation, or delegation
of authority, is deemed to refer to the Assistant Secretary.
Amendments: This section amends current law to (1) change
the position of the Director into an Assistant Secretary; (2)
provide that the individual serving in the position of Director
of the Service on the day before the date of enactment shall
serve as Assistant Secretary; (3) provide that the position of
Assistant Secretary is established to facilitate advocacy and
promote consultation on matters relating to Indian health; (4)
give the Assistant Secretary additional duties; and (5) deem
current law or regulatory references to the Director to refer
to the Assistant Secretary.
Current Law: This section is Section 1661 of current law.
Section 602. Automated management information system
Section 602 requires the Secretary to establish automated
management information systems for the Service and each Tribal
Health Program which meets certain requirements. This section
also requires that patients have access to their own health
records, and authorizes the Secretary to enter in to 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.
Amendments: 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: This section is Section 1662 of current law.
Section 603. Authorization of appropriations
This section authorizes to be appropriated such sums as may
be necessary to carry out this title, for each fiscal year
through fiscal year 2017.
Amendments: This section maintains current law and extends
the authorization from fiscal year 2000 to fiscal year 2017.
Current Law: This section is Section 1663 of current law.
TITLE VII--BEHAVIORAL HEALTH PROGRAMS
Section 701. Behavioral health prevention and treatment services
Section 701 states the purposes of the section, including
directing the Secretary, acting through the Service, Indian
Tribes, Tribal Organizations, and Urban Indian Organizations,
to develop a comprehensive behavioral health prevention and
treatment program which emphasizes collaboration among alcohol
and substance abuse, social services, and mental health
programs. This section also requires the Secretary to encourage
the development of plans for areawide Indian Behavioral Health
Services; directs the Secretary to coordinate with existing
national clearinghouses and information centers to include
plans and reports of outcomes of such behavioral health plans
developed by Indian Tribes, Tribal Organizations, Urban Indian
Organizations, and Service Areas; directs the Secretary to
provide comprehensive behavioral health care programs;
facilitates the governing body of any Indian Tribe, Tribal
Organization, or Urban Indian Organization to establish
community behavioral health plans; requires the Secretary to
coordinate behavioral health planning with other federal and
state agencies; and directs the Secretary to assess the need,
availability and cost for inpatient mental health care for
Indians within 1 year.
Amendments: 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
Organizations and Urban Indian Organizations; and (3) requires
a continuum of care for behavioral health to the extent
feasible, including acute hospitalization, detoxification, and
emergency shelter.
Current Law: This section is Section 1621h and Section 1665
of current law.
Section 702. Memoranda of agreement with the Department of the Interior
This section requires the Secretary and the Secretary of
the Interior to develop and enter, or review and update, within
1 year, memoranda of agreement 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. Each memorandum of agreement
under this section shall be published in the Federal Register.
This section also directs the Secretaries to address a strategy
for the comprehensive coordination of the behavioral health
services provided by the Bureau of Indian Affairs and the
Service, including the coordination of alcohol and substance
abuse programs of the Service, the BIA, 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.
Amendments: This section maintains current law and adds
language which (1) requires the Secretary to update existing
memoranda of agreement; and (2) includes Tribal Organizations.
Current Law: This section is Section 1621h(b) of current
law.
Section 703. Comprehensive behavioral health prevention and treatment
program
Section 703 requires the Secretary to provide a program of
comprehensive behavioral health, prevention, treatment, and
aftercare. Elements to be included in this program and target
populations are specified. The Secretary may provide these
services through Contract Health Services.
Amendments: This section amends current law by (1)
expanding beyond the alcohol and substance abuse focus to
comprehensive behavioral health; and (2) adding more specific
types of treatment. Language of current law, authorizing a
grant to the Standing Rock Sioux Tribe to develop a community-
based demonstration project, has been deleted.
Current Law: This section is Section 1665a of current law.
Section 704. Mental health technician program
This section directs the Secretary to establish and
maintain a mental health technician program within the Service
to train and employ Indians as mental health technicians. The
Secretary is to provide high-standard paraprofessional training
in mental health care, supervise and evaluate the technicians,
and ensure that the program involves the use and promotion of
traditional health care practices of the Indian Tribes to be
served.
Amendments: This section maintains current law.
Current Law: This section is Section 1621h(g) of current
law.
Section 705. Licensing requirement for mental health care workers
This section requires that any individual 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 to be licensed to
provide these services. This section also sets forth
requirements for individuals who may be employed as trainees in
psychology, social work, or marriage and family therapy to
provide mental health care services.
Amendments: This section maintains current law.
Current Law: This section is Section 1621h(l) of current
law.
Section 706. Indian women treatment programs
This section authorizes the Secretary, consistent with
section 701, to make grants to Tribes, Tribal Organizations and
Urban Indian Organizations to develop and implement a
comprehensive behavioral health program of prevention,
intervention, treatment, and relapse prevention services that
specifically address the cultural, historical, social, and
child care needs of Indian women. Use of grant funds, criteria
for applications for funding, and a specified amount of funding
for grants to Urban Indian Organizations are also specified.
Amendments: This section maintains current law and (1) adds
language which requires the implementation of this section to
be consistent with section 701; (2) recognizes the behavioral
health focus, beyond just alcohol and substance abuse; and (3)
requires consultation with Indian Tribes and Tribal
Organizations in establishing criteria for the review and
approval of applications.
Current Law: This section is Section 1665b of current law.
Section 707. Indian youth program
This section requires the Secretary to develop and
implement, consistent with section 701, a program for acute
detoxification and treatment for Indian youth. The construction
and staffing of alcohol and substance abuse treatment centers
or facilities for Indian youths, including behavioral health
services, is authorized. Additional provisions addressed in
this section are: Construction and staffing of at least 1 youth
regional treatment center in each IHS Area; the provision of
intermediate adolescent behavioral health services; use of
federally-owned structures for local residential or regional
behavioral health treatment for Indian youths; the development
and implementation of community-based rehabilitation and
aftercare services; inclusion of family in youth treatment
programs; programs and services to prevent and treat the abuse
of multiple forms of substances among Indian youth; and data
collection and a report to Congress concerning Indian youth and
mental health services.
Amendments: 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, beyond alcohol and substance abuse; (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: This section is Section 1665c of current law.
Section 708. Indian youth telemental health demonstration project
This section authorizes the Secretary to carry out a four-
year demonstration project under which five Tribes or Tribal
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 and Tribal 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
partnerships to provide the services; or operating a detention
facility at which Indian 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.
Amendments: This section is new and is not contained in
current law.
Section 709. Inpatient and community-based mental health facilities
design, construction, and staffing
This section allows the Secretary, not later than 1 year
after the date of enactment, to provide, in each IHS Area, not
less than 1 inpatient mental health care facility, or the
equivalent, for Indians with behavioral health problems. The
Secretary shall consider the possible conversion of existing
underutilized hospital beds into psychiatric units to meet the
needs.
Amendments: This section amends current law by (1)
requiring the establishment in each Area of at least 1
inpatient mental health facility, rather than an assessment of
the need; and (2) providing that California shall be considered
two Area Offices.
Current Law: Section 1621h(i) of current law provides that
within one year after enactment, the Secretary shall make an
assessment of the need for inpatient mental health care
facilities.
Section 710. Training and community education
Section 710 requires that the Secretary, in cooperation
with the Secretary of the Interior, develop and implement, or
assist Indian Tribes and Tribal Organizations to develop and
implement, a program of community education and involvement in
the area of behavioral health. This section also addresses
specifics of instruction and the development of community-based
training models.
Amendments: This section maintains current law and (1) adds
language which authorizes the Indian Tribes and Tribal
Organizations to develop training and community education
programs; (2) adds child sexual abuse to the types of training
authorized; and (3) recognizes the behavioral health focus of
the program.
Current Law: This section is Section 1621h(d) of current
law.
Section 711. Behavioral health program
This section allows the Secretary, consistent with section
701, to plan, develop, implement, and carry out programs to
deliver innovative community-based behavioral health services
to Indians. The section sets forth criteria to be used for
grant awards for such programs, and requires that the same
criteria as are used in evaluating other funding proposals be
used for programs under this section.
Amendments: This section maintains current law and adds
Tribal Organizations as eligible recipients for funding under
this section.
Current Law: This section is Section 1621h of current law.
Section 712. Fetal alcohol disorder programs
Section 712 authorizes the Secretary, consistent with
section 701, to establish and operate fetal alcohol disorder
programs, to include the development and provision of services
for the prevention, intervention, treatment, and aftercare for
those affected by fetal alcohol disorder in Indian communities.
Use of funds and criteria for applications are specified. In
addition, the Secretary is directed to establish a Fetal
Alcohol Disorder Task Force to advise the Secretary. This
section also authorizes funding 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 to receive a certain amount of funds appropriated for this
program.
Amendments: 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,
early childhood intervention projects, community-based support
services and housing as allowable uses of funding under this
section; and (4) including the National Institute for Child
Health and Human Development and the Centers for Disease
Control and Prevention in the national Fetal Alcohol Disorder
Task Force. Provisions of current law establishing a national
clearinghouse for prevention and educational materials and
other information on FAS and FAE effect in Indian and Alaska
Native communities, and requirements for a report to Congress
contained in current law have been deleted.
Current Law: This section is Section 1665g of current law.
Section 713. Child sexual abuse and prevention treatment programs
This section directs the Secretary to establish, consistent
with section 701, treatment programs in every IHS Area for both
Indian victims of child sexual abuse and Indian perpetrators of
child sexual abuse. This section specifies the use of funds for
these programs, and directs that they be carried out in
coordination with programs and services authorized under the
Indian Child Protection and Family Violence Prevention Act (25
U.S.C. 3201 et seq.).
Amendments: This section amends current law by (1) turning
two specific demonstration projects into permanent programs;
(2) making the establishment of these programs consistent with
section 701; (3) authorizing services for Indian child victims
of sexual abuse and perpetrators of child sexual abuse who are
members of an Indian household; (4) including authorized uses
of funds such as developing community education, identifying
and providing treatment to victims, developing culturally-
sensitive prevention models and diagnostic tools, and providing
treatment to the perpetrators; and (5) providing that these
programs are carried out in coordination with programs and
services authorized under the Indian Child Protection and
Family Violence Prevention Act.
Current Law: Section 1680i of current law establishes
demonstration programs involving treatment for child sexual
abuse through the Hopi Tribe and the Assiniboine 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 IHS Areas.
Section 714. Behavioral health research
Section 714 authorizes the Secretary to make grants to, or
enter into contracts with, Indian Tribes, Tribal Organizations,
and Urban Indian Organizations or enter into contracts with, or
make grants to appropriate institutions for, the conduct of
research on the incidence and prevalence of behavioral health
problems among Indians. Research priorities are specified,
including youth suicide, the interrelationship of mental
disorders with alcoholism, suicide, homicide, and the incidence
of family violence, and prevention models.
Amendments: This section maintains current law and adds
language which emphasizes the focus on behavioral health
instead of only mental health problems.
Current Law: This section is Section 1621h of current law.
Section 715. Definitions
This section 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.
Amendments: This section is new and is not contained in
current law.
Section 716. Authorization of appropriations
This section authorizes to be appropriated such sums as may
be necessary for each fiscal year through fiscal year 2017 to
carry out this title.
Amendments: This section maintains current law and extends
the authorization from fiscal year 2000 to fiscal year 2017 and
eliminates the exceptions for sections that had specific terms
of authorization.
Current Law: This section is Section 1621w of current law.
TITLE VIII--MISCELLANEOUS
Section 801. Reports
This section outlines requirements under this Act for
various reports (and their contents) and audits which shall be
submitted to Congress.
Amendments: This section maintains current law and adds
provisions which either establish new reporting requirements or
consolidate the information required in other sections in one
organized list, such as requiring as part of the annual reports
to Congress information on services provided under Indian Self-
Determination Act agreements, loan repayment programs,
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: This section is Section 1671 of current law.
Section 802. Regulations
This section sets forth the various requirements for
regulations, including regulations developed through negotiated
rulemaking, for selected titles and sections, and timelines for
issuance of regulations under this Act. The membership of the
negotiated rulemaking committee and its procedures are
delineated.
Amendments: This section is new and is not contained in
current law.
Section 803. Plan of implementation
This section requires the Secretary, in consultation with
Indian Tribes, Tribal Organizations, and Urban Indian
Organizations, to submit to Congress a plan of implementation
of this Act within 9 months.
Amendments: This section is new and is not contained in
current law.
Section 804. Availability of funds
This section authorizes funds appropriated pursuant to this
Act to remain available until expended.
Amendments: This section maintains current law.
Current Law: This section is Section 1675 of current law.
Section 805. Limitation on use of funds appropriated to Indian Health
Service
This section provides that any limitation on the use of
funds contained in an Act that provides appropriations for the
Department of Health and Human Services with respect to the
performance of abortions shall apply for that fiscal year to
the performance of abortions using funds contained in an Act
providing appropriations for the Service.
Amendments: This section maintains current law.
Current Law: This section is Section 1676 of current law.
Section 806. Eligibility of California Indians
This section clarifies the eligibility of California
Indians for health services provided by the Service to include
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 assets distribution in California.
Amendments: This section maintains current law, but
eliminates the report to Congress developing data on the
Indians located in California, health status and needs and
other information.
Current Law: This section is Section 1679 of current law.
Section 807. Health services for ineligible persons
This section authorizes services for certain persons (such
as children and spouses) and other individuals otherwise
ineligible for health services provided by the Service under
limited circumstances, and outlines criteria for providing and
paying for those services.
Amendments: This section maintains current law and adds
compacts, in addition to contracts, entered in to under the
Indian Self-Determination Act.
Current Law: This section is Section 1680c of current law.
Section 808. Reallocation of base services
This section requires the Secretary to submit a report to
Congress on any allocation of Service funds for a fiscal year
that reduces by 5% or more from the previous fiscal year the
funding for any recurring program, project, or activity of a
Service Unit.
Amendments: This section maintains current law.
Current Law: This section is Section 1680g of current law.
Section 809. Results of demonstration projects
This section requires the Secretary to disseminate to
Indian Tribes, Tribal Organizations, and Urban Indian
Organizations the findings and results of demonstration
projects conducted under this Act.
Amendments: This section maintains current law, and adds
Tribal Organizations and Urban Indian Organizations.
Current Law: This section is Section 1680m of current law.
Section 810. Provision of services in Montana
This section recognizes a court decision governing the
provision of services and benefits for certain Indians in
Montana.
Amendments: This section is new and is not contained in
current law.
Section 811. Moratorium
This section authorizes the Service to provide certain
health care services according to eligibility criteria in
effect on a certain date until the Service submits to Congress
and the Congress enacts an appropriations Act that reflects the
increased costs associated with the Department's proposed final
rule, implementing other eligibility criteria.
Amendments: This section is new and is not contained in the
current Indian health law. However, similar language has
appeared for several years in Interior Appropriations Acts.
Section 812. Tribal employment
This section provides that an Indian Tribe or Tribal
Organization carrying out a contract or compact pursuant to the
Indian Self-Determination and Education Assistance Act shall
not be considered an ``employer.''
Amendments: This section is new and is not contained in
current law.
Section 813. Severability provisions
This section retains remaining provisions of the Act if
other provisions are stricken by any court.
Amendments: This section is new and is not contained in
current law.
Section 814. Establishment of national bipartisan commission on Indian
health care
This section establishes a Commission to study the delivery
of health care services to Indians, and sets forth the duties,
membership, compensation, and meeting, hearing and reporting
requirements. This section also authorizes the appointment of a
Director and staff for the Commission; establishes their
compensation; and authorizes details of federal employees,
hearings, use of mails, technical assistance and administrative
support services. $4 million is authorized for the Commission.
Amendments: This section is new and is not contained in
current law.
Section 815. Confidentiality of medical quality assurance records;
qualified immunity for participants
This section would establish requirements for quality
assurance such as confidentiality, privacy, disclosure and
liability. Section 815 also sets forth the limits of such
disclosure.
Amendments: This section is new and is not contained in
current law.
Section 816. Appropriations; availability
This section subjects new spending authority to amounts
provided in appropriations Acts.
Amendments: This section is new and is not contained in
current law.
Section 817. Authorization of appropriations
This section authorizes to be appropriated such sums as may
be necessary for each fiscal year through fiscal year 2017 to
carry out this title.
Amendments: This section maintains current law and extends
the authorization through fiscal year 2017.
Current Law: Section 1680o authorizes appropriations
through fiscal year 2000.
Section 101(b). Indian Health Care Improvement Act amended
Section 101(b) 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''.
Amendments: This section is new and is not contained in
current law.
Section 102. Soboba sanitation facilities
Section 102 authorizes sanitation facilities and services
to be provided to the Soboba Band of Mission Indians and the
Soboba Indian Reservation.
Amendments: This section is new and is not contained in
current law.
Section 103. Native American Health and Wellness Foundation
Section 103 amends the Indian Self-Determination and
Education Assistance Act to include a new Title VIII under
which a Native American Health and Wellness Foundation would be
established, in the following sections:
Section 801. Definitions
This section includes definitions for the Board, Committee,
Foundation, and other terms used in this section.
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.
Amendments: This section is new and is not contained in
current law.
Title II
Title II of the bill is amendments to the Social Security
Act that is under the jurisdiction of the Senate Finance
Committee. These provisions include waivers of cost-sharing and
premiums for Medicaid for Indians receiving services at IHS,
tribal or urban Indian health programs, Medicaid managed care
provisions, and safe harbor protections from the anti-kickback
statutes.
Section 201. Expansion of payments under Medicare, Medicaid and SCHIP
for all covered services furnished by Indian health programs
Section 201 authorizes IHS, tribal and urban Indian health
programs to be reimbursed for Medicaid, if the services meet
the conditions and requirements generally applicable to the
delivery of such care. In addition, this section requires IHS,
tribal or urban Indian health facilities to make improvements
to achieve or maintain compliance. The Secretary is also
authorized to enter into an agreement with a State to reimburse
the State for Medicaid services provided by the IHS, tribal or
urban Indian health programs. This section cross-references the
special fund to which Medicaid reimbursements are placed for
IHS and direct billing requirements for the IHS and tribal
health programs under the Act. This section also authorizes
Medicare payments to IHS, tribal and urban Indian health
programs so long as they are compliant with Medicare
requirements. The section cross-references the Act's provisions
under which Medicare payments made are placed in a special fund
for the purpose of making improvements to maintain compliance.
Section 202. Increased outreach to Indians under Medicaid and SCHIP and
improved cooperation in the provision of items and services to
Indians under Social Security Act health benefit programs
Section 202 authorizes the Secretary to encourage States to
take steps to increase enrollment and outreach for Indian
children in the State Children's Health Insurance Program and
requires the Secretary to facilitate cooperation between States
and the IHS, tribal and urban Indian health programs.
Section 203. Additional provisions to increase outreach to, and
enrollment of, Indians in SCHIP and Medicaid for outreach
Section 203 excludes certain activities, such as outreach
activities for families of Indian children likely to be
eligible for SCHIP and enrollment assistance activities, from
the current 10% cap on certain SCHIP payments.
Section 204. Premiums and cost sharing protections under Medicaid,
eligibility determinations under Medicaid and SCHIP, and
protection of certain Indian property from Medicaid estate
recovery
Section 204 prohibits the imposition of enrollment fees,
premiums and cost-sharing on Indians served at the IHS, tribal
or urban Indian health programs or through the referrals to
contract health and the reduction of the reimbursement to the
IHS, tribal or urban Indian health program for the fees or
cost-sharing. In addition, this section exempts certain Indian
property, such as trust land, from being included in
determining eligibility of an individual who is an Indian for
Medicaid, and continues protections of certain Indian property
from Medicaid estate recovery.
Section 205. Nondiscrimination in qualifications for payment for
services under Federal health care programs
Section 205 allows the IHS, Tribal or urban Indian health
programs to be accepted on the same basis as any other provider
eligible for reimbursement, if the program meets generally
applicable participation requirements. The provision would
prohibit payments if the program was excluded from any other
Federal health care program and if any State licenses were
suspended or revoked.
Section 206. Consultation on Medicaid, SCHIP, and other health care
programs funded under the Social Security Act involving Indian
health programs and urban Indian organizations
Section 206 maintains the Tribal Technical Advisory Group
established to provide technical assistance or advice to the
Centers for Medicare and Medicaid Services. This section also
requires the States to establish a process for consultation
with the tribal or urban Indian health programs on matters
relating to Medicaid which are likely to have a direct effect
on Indians or Indian health programs.
Section 207. Exclusion waiver authority for affected Indian health
programs and safe harbor transactions under the Social Security
Act
Section 207 establishes a process whereby the administrator
of an Indian Health Program may request a waiver of sanctions
imposed on a health provider. This section also specifies that
certain transactions not be considered remuneration under
Section 1128B(b) of the Social Security Act for certain
transfers between the Indian health programs or patient for the
purpose of providing necessary health care services to the
patient.
Section 208. Rules applicable under Medicaid and SCHIP to managed care
entities with respect to Indian enrollees and Indian health
care providers and Indian managed care entities
Section 208 allows Indians, enrolled in a non-Indian
Medicaid managed care entity (MCE) with an Indian health
program participating in the network, to choose the Indian
health program as the primary care provider. It also requires
MCEs with significant Indian enrollees to meet other
requirements. The Indian health programs would also be required
to comply with all generally applicable Medicaid requirements
to the extent the requirements do not conflict with other
Federal statutes applicable to the Indian health programs. This
section also sets forth special rules applicable to Indian
MCEs, such as the ability to restrict enrollment to Indians and
other enrollment rules. In regard to a Medicaid managed care
program, if a health care provider is required to have medical
malpractice insurance as a condition of contracting with a
Medicaid MCE, an Indian health care provider would be deemed to
satisfy such a requirement if it is an FQHC covered under the
Federal Tort Claims Act, a provider that delivers services
pursuant to a contract under the Indian Self-Determination and
Education Assistance Act, or the Indian Health Service, which
is covered under the Federal Tort Claims Act.
Section 209. Annual report on Indians served by Social Security Act
health benefit programs
Section 209 requires annual reports to Congress regarding
the enrollment and health status of Indians receiving items or
services under the health benefit programs.
Legislative History
On April 24, 2007, Senators Dorgan, Thomas, Boxer, Reid,
Cantwell, Johnson, Tester, Inouye, Domenici, Bingaman, Baucus,
Klobuchar, Obama and Murkowski introduced S. 1200, the Indian
Health Care Improvement Act Amendments of 2007. Senators
Cochran and Murray were added as cosponsors on April 26, 2007;
Senator Clinton on May 3, 2007; and Senators Brown and Stevens
on May 21, 2007. Senator Stabenow was added as a cosponsor on
September 4, 2007.
The Committee held a hearing on the Indian Health Care
Improvement Act on March 8, 2007. This was the tenth hearing
since the 106th Congress on the reauthorization of the Act.
On May 10, 2007, the Committee on Indian Affairs convened a
business meeting to consider S. 1200 and other measures that
had been referred to it, and ordered the bill favorably
reported.
Committee Recommendation and Tabulation of Vote
On May 10, 2007, the Committee on Indian Affairs convened a
business meeting to consider S. 1200 and other measures, and
voted to have the bill favorably reported to the full Senate,
without amendment, 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 evaluate
the regulatory and paperwork impact that would be incurred in
carrying out the bill. The Committee has concluded that S. 1200
will not require the promulgation of regulations so the
regulatory and paperwork impact should be minimal.
Executive Communications
On May 1, 2007, Chairman Dorgan sent letters to both
Secretary Michael Leavitt and Attorney General Gonzales, asking
the Department of Health and Human Services and the Department
of Justice to provide the Committee with their views on S.
1200.
The Department of Justice submitted a letter of comments on
June 13, 2007, which is attached, below.
Department of Justice,
Office of Legislative Affairs,
Washington, DC, June 13, 2007.
Hon. Byron L. Dorgan,
Chairman, Committee on Indian Affairs,
U.S. Senate, Washington, DC.
Dear Mr. Chairman: Thank you for the opportunity to comment
upon S. 1200, the Indian Health Care Improvement Act Amendments
of 2007. The Department of Justice fully supports the purposes
of this legislation--improving access to health care for
American Indians and Alaska natives. The Department has worked
with the Committee on Indian Affairs on previous versions of
this legislation and believes that most of its prior concerns
have been addressed by S. 1200. The Department does, however,
continue to have a few concerns with the legislation that we
have noted in the past. As explained below, the Department
believes that these concerns can be addressed with relatively
modest changes to bill language that would not detract from the
overall goal of improving health care for Native Americans but
would, in the Department's view, benefit both the Native
American community specifically and taxpayers generally.
1. The legislation authorizes funding and encourages the
use of traditional health care practices. The Department does
not oppose the provision of traditional health care practices
as an adjunct to ``Western'' medical practices. We note that on
March 8, 2007, Ms. Rachel Joseph, Co-Chairperson of the
National Steering Committee for the Reauthorization of the
Indian Health Care Improvement Act, testified that
``[t]raditional health care practices are usually provided as
complementary services to Western medical practices at the
request of family members.'' Ms. Joseph also testified that
``[i]n most cases, the traditional health care practitioners
are not employees of the IHS or tribes so FTCA coverage would
not apply in the event that a malpractice claim was ever
filed.''
A prior version of this legislation contained language
clarifying that traditional health care practitioners are not
covered by the Federal Tort Claims Act (``FTCA''), and we
recommend that this language be added back to S. 1200.
Specifically, we recommend the following provision as an
addition to section 805:
(b) No Liability.--Although the Secretary may promote
traditional health care practices, consistent with the Service
standards for the provision of health care, health promotion,
and disease prevention under this Act, the United States is not
liable for the acts or omissions of any person in providing
traditional health care practices under this Act that result in
damage, injury, death, or any outcome to any patient.
This language is intended to confirm existing law that
there is no valid cause of action under the FTCA for injuries
resulting from traditional tribal healing practices provided
pursuant to self determination contracts because state law
generally does not make private parties liable for
``malpractice'' involving traditional tribal healing practices.
See 28 U.S.C. Sec. 2674. Thus, this provision would ensure that
the United States would not face potential tort liability for
the provision of treatment through traditional health care
practices for which no state standard of care exists and would
prevent costly litigation about whether the United States could
be held liable under the FTCA for such practices. Moreover, it
would preclude intrusive discovery regarding the nature and
purpose of traditional health care practices. Such litigation
would almost certainly raise questions as to the advisability
of Tribal health practices and potentially create unnecessary
conflict between these practices and Western medical standards.
Additionally, we believe the proposed language would ameliorate
any Tribal sovereignty concerns that would arise in FTCA
litigation regarding inquiry into traditional health care
practices. At the same time, this language would not scale back
in any way the current liability protections that the Tribes
enjoy in carrying out self-determination contracts.
We also have concerns regarding changes made to section 213
of the legislation. The current version of section 213(b)(1)
was modified to provide:
(b) Terms and Conditions.--
(1) In general.--Any service provided under this section
shall be in accordance with such terms and conditions as are
consistent with accepted and appropriate standards relating to
the service, including any licensing term or condition required
under this Act.
The previous version of the legislation, unlike S. 1200,
made explicit that the Secretary ``shall require'' that any
service provided be in accordance with terms and conditions
that the Secretary determined to be consistent with accepted
and appropriate standards relating to the service. We think S.
1200 is unclear in this regard, as it fails to explicitly
specify who is responsible for requiring that any services
provided are in accordance ``with such terms and conditions as
are consistent with the accepted and appropriate standards
relating to the service.'' We suggest revising subsection
213(b)(1) to provide:
(1) In general.--The Secretary shall require that any
service provided pursuant to this Act is in compliance with the
accepted and appropriate standards relating to the service,
including any licensing term or condition under this Act.
Relatedly, S. 1200 made changes to the prior language of
subsection 213(b)(2). That subsection now reads:
(b)(2)(A) Standards.--
In general.--The Secretary may establish, by regulation,
the standards for a service provided under this section,
provided that such standards shall not be more stringent than
the standards required by the State in which the service is
provided.
We have concerns about this language. For the purposes of
tort liability under the FTCA, state law provides the standards
governing the conduct at issue. If the Secretary, by
regulation, establishes standards that fall below the standards
required by the State, there is a risk the United States could
be held liable under the FTCA, even if the care complied with
the standards promulgated by the Secretary. Moreover, and more
likely troublesome, if the Secretary approves services for
which there are no applicable state standards, subsection
(b)(2), by its plain language, would appear to prevent the
Secretary from establishing any appropriate standards because
those standards would, by their very existence, be more
stringent than what is required by the State. Where no state
standards are applicable, it is in the interests of both the
United States and the Tribes to whom such services might be
provided to have some applicable and appropriate standards of
care set by the Secretary. Thus, along with the Department of
Health and Human Services, we propose working with the
Committee to revise subsection (b)(2)(A) to address this
concern.
Finally, S. 1200 also includes this new provision to
section 213:
(b)(2)(B) Use of State Standards.--
If the Secretary does not, by regulation, establish
standards for a service provided under this section, the
standards required by the State in which the service is or will
be provided shall apply to such service.
We agree that state standards should be applicable, since
liability under the FTCA would be measured by those standards.
Again, however, if there is no applicable state standard, the
Secretary should be permitted to set some meaningful and
appropriate standard of care, which is arguably not possible
given the limitation of subsection (b)(2)(A).
2. The Department believes that the legislation continues
to raise a constitutional concern to the extent that it
provides government benefits to individuals who are not members
of, or closely affiliated with, a Federally recognized Indian
tribe. As the Department has noted in the past, the Supreme
Court has held that classifications based on affiliation with a
Federally recognized tribe are ``political rather than
racial,'' and therefore will be upheld as long as there is a
rational basis for them. To the extent, however, that programs
benefiting ``Urban Indians'' under this legislation could be
viewed as authorizing the award of grants and other Government
benefits on the basis of racial or ethnic criteria, rather than
tribal affiliation, these programs would be subject to strict
scrutiny under the equal protection component of the Due
Process Clause. Both this bill and the current statute broadly
define ``Urban Indian'' to include individuals who are not
necessarily affiliated with a federally recognized Indian
tribe. Under the Supreme Court's decisions, there is a
substantial likelihood that legislation providing special
benefits to individuals of Indian or Alaska Native descent who
do not have a clear and close affiliation with a federally
recognized tribe would be regarded by the courts as creating a
racial preference subject to strict constitutional scrutiny,
rather than a political preference subject to rational basis
review. In the event the legislation is regarded as awarding
Government benefits based on a racial classification, it would
be constitutional only if the bill is supported by a factual
record demonstrating that its use of race-based criteria to
award the benefits at issue is ``narrowly tailored'' to serve a
``compelling'' Government interest.
The bill's extension of benefits to members of State-
recognized tribes raise the same concern. As a threshold
matter, it is not clear whether the courts would agree that
Congress can constitutionally delegate its tribal recognition
authority to the States and, even if Congress can do so as a
general matter, the delegation in this bill would allow States
to designate as ``tribal members'' eligible for Federal
benefits individuals who: (i) do not belong to a ``distinctly
Indian community'' or other group that conforms to the Supreme
Court's definitions of ``the Indian tribes'' referenced in the
Commerce Clause, but instead are considered a member of a State
``tribe'' solely on the basis of race or affiliation with a
group that lacks the sovereign attributes the Supreme Court has
identified as important to classification as an ``Indian
tribe'' for purposes of Commerce Clause legislation; and/or
(ii) are otherwise outside the class of beneficiaries that
Congress intended to reach with this bill. In this regard, as
you may know, the American Indian Heritage Support Center
(``AIHSC''), in a March 29, 2007, letter to the Department,
with copies to Members of Congress, voiced concerns about the
extension of benefits under this legislation to ``state
recognized tribes'' because, according to the AIHSC, some of
these ``tribes'' ``have no historical background past the last
10 to 20 years'' and simply seek ``tribal'' recognition to take
advantage of certain recent Government benefits such as gaming
privileges.
The Department recommends that, consistent with the settled
practice of avoiding unnecessary constitutional issues,
Congress revise the bill to extend benefits only to individuals
who, in addition to satisfying whatever other criteria Congress
may wish to impose, qualify as ``members of, or individuals
having a clear and close affiliation with, a federally-
recognized tribe.'' Such a revision would avoid the
constitutional concerns outlined above in a way that the
Department believes would not detract from the overall goal of
improving health care for Native Americans, and might actually
better ensure that benefits under the bill would extend only to
the class of beneficiaries contemplated by Congress and the
Constitution.
Thank you for the opportunity to comment upon this very
important legislation. We are committed to working with the
Committee to have this legislation passed. The Office of
Management and Budget has advised us that there is no objection
to this letter from the perspective of the Administration's
program.
Sincerely,
Richard A. Hertling,
Principal Deputy Assistant Attorney General.
The Committee has not received any formal communication on
S. 1200 from the Department of Health and Human Services other
than the testimony presented to the Committee at the hearing on
reauthorization of the Indian Health Care Improvement Act on
March 8, 2007, which is also attached, below.
Statement of Admiral John O. Agwunobi, MD, MBA, MPH, Assistant
Secretary for Health, U.S. Department of Health and Human Services
Mr. Chairman and Members of the Committee: My name is John
Agwunobi and I am the Assistant Secretary for Health for the
U.S. Department of Health and Human Services (HHS). As the
Assistant Secretary, I serve as the Secretary's primary advisor
on matters involving the nation's public health. I also oversee
the U.S. Public Health Service and its Commissioned Corps for
the Secretary.
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 governed by judicial decisions
and statutes. The mission of the agency is to raise the
physical, mental, social, and spiritual health of American
Indian/Alaska Natives to the highest level, 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 duty 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, Congress has
substantially expanded the statutory authority for programs and
activities in order 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's vice chairperson is the IHS Director, giving him
a highly visible role within the Department on Indian policy.
In January of 2005 the Department completed work ushering
through a revised HHS Tribal consultation policy and involving
Tribal leaders in the process. This 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 the
Department's 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. For FY 2008, Tribes identified population
growth and increases in the cost of providing health care as
their top budget priorities and IHS's FY 2008 budget request
included an increase of $88 million for these items.
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 for 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. In addition, a Tribal Leaders Diabetes Committee
continues to meet several times a year at the direction of the
IHS Director to review information on the progress of the
Special Diabetes Program for Indians activities and to provide
general recommendations to IHS.
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, cardiovascular
disease, 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 primary and preventive
services in recognition of the Federal government's unique
relationship with members of Federally recognized Tribes.
Members of Federally recognized Tribes and their descendants
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 reauthorization of the ``Indian Health
Care Improvement Act.''
reauthorization
We are here today to discuss reauthorization of the IHCIA,
and its impact on programs and services provided for in current
law. In December of 2006, the Department submitted to this
Committee comments on proposed legislation that the 109th
Congress was considering. These comments are the basis for our
testimony today, and any changes introduced by the bill under
review in the 110th Congress will be considered once we have
had an opportunity to review newly introduced legislation.
Improving access to healthcare for all eligible American
Indians and Alaska Natives is a priority for all those involved
in the administration of the IHS program. We have worked
closely with this Committee in the past and we have made
progress in moving toward a program supportive of existing
authority while maintaining the Secretary's flexibility to
effectively manage the IHS program. However, in the last bill,
S. 1057, there continued to be provisions which could
negatively impact our ability to provide needed access to
services. Such provisions established program mandates and
burdensome requirements that could, or would, divert resources
from important services. To the extent that those provisions
are included in the new legislation, we hope to work with you
to continue to address these concerns.
The Department is supportive of reauthorization of the
IHCIA and supports provisions that maintain or increase the
Secretary's flexibility to work with Tribes, and to increase
the availability of health care. Committee leadership
previously responded to some concerns raised about certain
provisions and some of the changes went a long way toward
improving the Secretary's ability to effectively manage the
program within current budgetary resources.
I would like to note for you today our particular interest
in provisions previously reported out of this Committee.
overarching concerns
We have a number of general objections to previous
language, including, expanded requirements for negotiated
rulemaking and consultation; new requirements using ``shall''
instead of ``may''; use of the term ``funding'' in place of
``grant''; expansion of authorities for Urban Indian
Organizations; new permissive authorities; provisions governing
traditional health care practices; new reporting requirements;
establishment of the Bipartisan Commission on Indian Health
Care; 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). In addition, we noted concerns in previous
language about modifying current law with respect to Medicaid
and the State Children's Health Insurance Program (SCHIP) and,
in some cases, we believe maintaining the current structure of
Medicaid and the State Children's Health Insurance Program
(SCHIP) preserves access, delivery, efficiency, and quality of
services to American Indians.
We also have some more specific comments on proposals we
have previously reviewed for comment.
In the area of behavioral health, proposed title VII
provisions provided 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.
reporting requirements
The last version of S. 1057 that we reviewed contained
various new requirements for reporting to Congress, including
requirements for specific information to be included within the
President's Budget and a new annual report to Congress by the
Centers for Medicare & Medicaid Services and the IHS on Indians
served by Social Security Act health benefit programs. The IHS,
CMS, and HHS will work with Congress to provide the most
complete and relevant information on IHS programs, activities,
and performance and other Indian health matters. However, we
recommend striking language that requires additional
specificity about what should be included in the President's
budget request and new requirements for annual reports.
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. IHS
and Tribes operate 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 & report
One provision in last year's bill, section 301(d)(1),
required 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
have been required by the bill. The IHS 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.
retroactive funding of joint venture construction projects
In last year's bill, 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. A Joint Venture Program 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. We, therefore, would oppose such a
provision.
sanitation facilities deficiency definitions
Another section 302(h)(4) would provide ambiguous
definitions of the sanitation deficiencies used to identify and
prioritize water and sewer projects in Indian country. As
previously 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, though 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 to distinguish the
various levels of deficiencies which determine the allocation
of existing resources.
threshold criteria for small ambulatory program
Yet another Section 305(b)(1) would amend current law to
set two minimum thresholds for the Small Ambulatory Program--
one for number of patient visits and another for the number of
eligible Indians. In order to be eligible for the Small
Ambulatory Program under the previously proposed criteria, a
facility must provide at least 150 patient visits annually in a
service area with no fewer than 1,500 eligible Indians. Aside
from the fact that these are both minimum thresholds and so
somewhat contradictory, the proposed provisions would make
implementation difficult. First, the IHS cannot validate
patient visits unless the applicant participates in the
Resource Patient Management System (RPMS). 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.
new negotiated rulemaking and consultation requirements
In addition, we are concerned about the 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 under current Executive Orders,
as well as using the authority of Chapter V of title 5, United
States Code (commonly known as the Administrative Procedures
Act) to promulgate regulations where necessary to carry out
IHCIA.
The comments expressed today in this testimony do not
represent a comprehensive list of our current concerns. And, we
will be reviewing legislation introduced in this Congress for
any provisions that might be addressed in the future.
I reiterate our commitment to working with you to
reauthorize the Indian Health Care Improvement Act, and the
strengthening of Indian health care programs. And we will
continue to work with the Committee, other Committees of
Congress, and 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 reauthorization of the ``Indian Health
Care Improvement Act'' and I will answer any questions that you
may have at this time. Thank you.
Cost Estimates
The Congressional Budget Office prepared a cost estimate
for S. 1200, dated June 8, 2007. However, an error was made in
that estimate, so a revised estimate was sent to the Committee
on September 11, 2007, which follows.
S. 1200--Indian Health Care Improvement Act Amendments of 2007
Summary: S. 1200 would authorize the appropriation of such
sums as are necessary through 2017 for activities under the
Indian Health Care Improvement Act, the primary authorizing
legislation for the Indian Health Service (IHS). The bill also
contains specific authorizations for a program to encourage
Indians to pursue careers related to behavioral health, a
demonstration project to provide suicide prevention services, a
commission on Indian health care, and administrative costs for
a new nonprofit corporation. Enacting the bill also would
affect direct spending, primarily through provisions affecting
the Medicaid program.
CBO estimates that implementing S. 1200 would have
discretionary costs of $2.7 billion in 2008, about $16 billion
over the 2008-2012 period, and about $35 billion over the 2008-
2017 period, assuming appropriation of the necessary amounts.
We also estimate that enacting the bill would increase direct
spending by $9 million in 2008, $53 million over the 2008-2012
period, and $129 million over the 2008-2017 period.
S. 1200 would preempt state licensing laws in certain
cases, and this preemption would be an intergovernmental
mandate as defined in the Unfunded Mandates Reform Act (UMRA);
however, CBO estimates that the costs of that mandate would be
small and would not approach the threshold established in UMRA
($66 million in 2007, adjusted annually for inflation). The
bill also would place new requirements on Medicaid that would
result in additional spending of about $80 million over the
2008-2017 period. Those requirements, however, would not be
intergovernmental mandates as defined by UMRA. Other provisions
of the bill would benefit tribal governments by establishing
new or expanding existing programs for Indian health care. This
bill contains no private-sector mandates as defined in UMRA.
Estimated cost to the Federal Government: The estimated
budgetary impact of S. 1200 is summarized in Table 1. The costs
of this legislation fall within budget function 550 (health).
TABLE 1.--ESTIMATED BUDGETARY EFFECTS OF S. 1200
----------------------------------------------------------------------------------------------------------------
By fiscal year, in millions of dollars--
--------------------------------------------
2008 2009 2010 2011 2012
----------------------------------------------------------------------------------------------------------------
CHANGES IN SPENDING SUBJECT TO APPROPRIATION
Estimated Authorization Level...................................... 3,257 3,326 3,402 3,481 3,558
Estimated Outlays.................................................. 2,682 3,141 3,310 3,449 3,534
CHANGES IN DIRECT SPENDINGa
Estmated Budget Authority.......................................... 9 10 11 12 12
Estimated Outlays.................................................. 9 10 11 12 12
----------------------------------------------------------------------------------------------------------------
aDirect spending changes through 2017 are shown in Table 3.
Basis of estimate: For the purpose of this estimate, CBO
assumes that S. 1200 will be enacted near the start of fiscal
year 2008 and that the necessary amounts will be appropriated
for each year.
Spending subject to appropriation
The estimated effects of S. 1200 on spending subject to
appropriation for the next five years are detailed in Table 2.
Implementing the legislation would result in discretionary
costs of about $16 billion over the 2008-2012 period. Because
the bill would authorize funding through 2017, such
discretionary cost would continue, with an estimated cost of
about $35 billion over the 2008-2017 period.
TABLE 2.--ESTIMATED EFFECTS OF S. 1200 ON DISCRETIONARY SPENDING
----------------------------------------------------------------------------------------------------------------
By fiscal year, in millions of dollars--
-----------------------------------------------------
2007 2008 2009 2010 2011 2012
----------------------------------------------------------------------------------------------------------------
SPENDING SUBJECT TO APPROPRIATION
IHS Spending Under Current Lawa
Budget Authority...................................... 3,169 0 0 0 0 0
Estimated Outlays..................................... 3,203 553 164 72 12 2
Proposed Changes:
Existing Indian Health Service Activities:
Estimated Authorization Level..................... 0 3,247 3,320 3,396 3,475 3,554
Estimated Outlays................................. 0 2,679 3,134 3,303 3,443 3,529
Recruitment Program for Behavioral Health Careers:
Authorization Level............................... 0 3 3 3 3 3
Estimated Outlays................................. 0 2 3 3 3 3
Mental Health Demonstration Project:
Authorization Level............................... 0 2 2 2 2 0
Estimated Outlays................................. 0 * 1 2 2 1
Commission on Indian Health Care:
Authorization Level............................... 0 4 0 0 0 0
Estimated Outlays................................. 0 1 2 1 0 0
Native American Health and Wellness Foundation:
Authorization Level............................... 0 1 1 1 1 1
Estimated Outlays................................. 0 * 1 1 1 1
Total Changes:
Estimated Authorization Level................. 0 3,257 3,326 3,402 3,481 3,558
Estimated Outlays............................. 0 2,682 3,141 3,310 3,449 3,534
Spending Under S. 1200
Estimated Authorization Levela........................ 3,169 3,257 3,326 3,402 3,481 3,558
Estimated Outlays..................................... 3,203 3,235 3,305 3,382 3,461 3,536
----------------------------------------------------------------------------------------------------------------
a.The 2007 level is the amount appropriated for that year for IHS.
*Note: *=less than $500,000.
Existing Indian Health Service Activities. S. 1200 would
authorize the appropriation of such sums as are necessary for
the Indian Health Service through 2017. The agency's
responsibilities under the bill would be broadly similar to
those in current law. In 2007, the agency received an
appropriation of $3.2 billion. CBO's estimate of the authorized
level for IHS programs is the appropriated amount for 2007
adjusted for inflation in later years. (That level would grow
to nearly $4 billion by 2017.) The estimated outlays reflect
historical spending patterns for IHS activities.
Recruitment Program for Behavioral Health Careers. Section
105 of the bill would authorize the appropriation of $2.7
million annually through 2017 for grants to develop and
maintain programs that encourage Indians to pursue careers in a
field related to behavioral health. Assuming the appropriation
of the authorized amounts, CBO estimates that implementing this
provision would cost $2 million in 2008, $13 million over the
2008-2012 period, and $26 million over the 2008-2017 period.
Mental Health Demonstration Project. Section 708 would
authorize the appropriation of $1.5 million annually for fiscal
years 2008 through 2011 for grants to examine the feasibility
of using telecommunication technology to provide suicide
prevention services to Indians. Assuming the appropriation of
the authorized amounts, CBO estimates that implementing this
provision would cost less than $500,000 in 2008 and about $6
million over the 2008-2012 period.
Commission on Indian Health Care. Section 814 would
authorize the appropriation of $4 million for a commission that
would examine how the federal government provides health care
services to Indians. The members of the commission would have
to be appointed within eight months of the bill's enactment and
would be required to submit a final report to the Congress no
later than 18 months after that. Assuming the appropriation of
the authorized amount, CBO estimates that implementing this
provision would cost $1 million in 2008, $2 million in 2009,
and $1 million in 2010.
Native American Health and Wellness Foundation. S. 1200
would establish a charitable and nonprofit corporation called
the Native American Health and Wellness Foundation to assist
federal, state, tribal, and other entities in efforts to
further health and wellness activities and opportunities for
Indians. The bill would authorize the appropriation of $500,000
annually for the foundation's administrative expenses; this
amount would be adjusted in later years for inflation. Assuming
the appropriation of the authorized amounts, CBO estimates that
implementing this provision would cost less than $500,000 in
2008 and about $2 million over the 2008-2012 period.
Direct spending
S. 1200 contains several provisions, primarily related to
the Medicaid program, that would affect direct spending. The
bill's estimated effects on direct spending are shown in Table
3. Overall, CBO estimates that enacting the bill would increase
direct spending by $9 million in 2008 and $129 million over the
2008-2017 period.
TABLE 3.--ESTIMATED EFFECTS OF S. 1200 ON DIRECT SPENDING
--------------------------------------------------------------------------------------------------------------------------------------------------------
By fiscal year, in millions of dollars--
-----------------------------------------------------------------------------------------------------
2008 2009 201O 2011 2012 2013 2014 2015 2016 2017 2008-2012 2008-2017
--------------------------------------------------------------------------------------------------------------------------------------------------------
CHANGES IN DIRECT SPENDING
Exemption from Medicaid Cost Sharing and Premiums:
Estimated Budget Authority.................... 5 6 6 7 7 8 8 9 9 10 31 74
Estimated Outlays............................. 5 6 6 7 7 8 8 9 9 10 31 74
Consultation with Indian Health Programs:
Estimated Budget Authority.................... * * 1 1 1 1 1 1 1 1 3 7
Estimated Outlays............................. * * 1 1 1 1 1 1 1 1 3 7
Medicaid Managed Care Provisions:
Estimated Budget Authority.................... 3 3 4 4 4 5 5 5 6 6 18 45
Estimated Outlays............................. 3 3 4 4 4 5 5 5 6 6 18 45
Scholarship and Loan Repayment Recovery Fund:
Estimated Budget Authority.................... * * * * * * * * * * 2 4
Estimated Outlays............................. * * * * * * * * * * 2 4
Total Changes:
Estimated Budget Authority.................... 9 10 11 12 12 14 14 15 16 17 53 129
Estimated Outlays............................. 9 10 11 12 12 14 14 15 16 17 53 129
--------------------------------------------------------------------------------------------------------------------------------------------------------
* = costs savings of less than $500,000.
Notes: Components may not sum to totals because of rounding.
IHS-funded health programs are commonly divided into three
groups: those operated directly by the Indian Health Service,
those operated by tribes and tribal organizations under self-
governance agreements, and those operated by urban Indian
organizations. For this estimate, they are referred to
collectively as Indian health programs.
Exemption from Medicaid Cost Sharing and Premiums. Section
204 would prohibit Medicaid programs from charging premiums or
other cost-sharing payments to Indians for services that are
provided directly or upon referral by Indian health programs.
The provision also would prohibit states from reducing payments
to providers for those services by the amount of cost sharing
that Indians otherwise would pay.
CBO anticipates that this provision's budgetary effect
would stem largely from eliminating cost sharing for referral
services. Current law already prohibits Indian health programs
from charging cost sharing to Indians who use their services.
In addition, Medicaid pays almost all facilities operated by
IHS and tribes based on an all-inclusive rate that is not
reduced to account for any cost sharing that Indians would
otherwise have to pay. Finally, very few states charge premiums
to their Medicaid enrollees.
Using Medicaid administrative data, CBO estimates that
about 280,000 Indians are Medicaid recipients who also use IHS,
and that federal Medicaid spending on affected services would
be about $225 per person annually in 2008. The amount of
affected spending would be relatively low because Medicaid
already prohibits cost sharing in many instances, such as long-
term care services, emergency services, and services for many
children and pregnant women. For the affected spending, CBO
assumes that cost-sharing payments by individuals equal 2
percent of total spending--Medicaid law limits the extent to
which states can impose cost sharing and that eliminating cost
sharing would increase total spending by about 5 percent as
individuals consume more services. Overall, CBO estimates that
the provision would increase federal Medicaid spending by $5
million in 2008 and by $74 million over the 2008-2017 period.
Consultation with Indian Health Programs. Section 206 would
encourage state Medicaid programs to consult regularly with
Indian health programs on outstanding Medicaid issues by
allowing states to receive federal matching funds for the cost
of those consultations. Those costs would be treated as an
administrative expense under Medicaid and divided equally
between the federal government and the states. CBO anticipates
that a small number of states would take advantage of this
provision, increasing federal Medicaid spending by less than
$500,000 in 2008 and by $7 million over the 2008-2017 period.
Medicaid Managed Care Provisions. Section 208 would make
several changes to improve the ability of Indian health
programs to receive payments for Indians who receive Medicaid
benefits through managed care arrangements. Those changes
include:
Managed care organizations (MCOs) would have to
pay Indian health programs at least the rates used for non-
preferred providers. States also would have the option of
making those payments directly to Indian health programs.
MCOs would have to accept claims submitted by
Indian health programs instead of requiring enrollees to submit
claims personally.
Some requirements that MCOs must now meet to
participate in Medicaid would be waived or modified for Indian
health programs that seek to operate as MCOs. (For example,
MCOs run by Indian health programs would be able to limit
enrollment to Indians only.)
States would be required to offer contracts to
Indian health programs seeking to operate their own MCOs.
Based on administrative data on Medicaid enrollment and
spending for Indians who receive benefits via managed care, CBO
estimates that those provisions would increase federal Medicaid
spending by $3 million in 2008 and $45 million over the 2008-
2017 period. We anticipate that the additional costs would be
relatively modest because some states already use similar rules
in their Medicaid managed care programs and Indian health
programs would have a limited interest in participating as
MCOs.
Scholarship and Loan Repayment Recovery Fund. S. 1200 would
allow the Secretary of Health and Human Services to spend
amounts collected for breach of contract from recipients of
certain IHS scholarships. Under current law, those funds are
deposited in the Treasury and not spent. Because the
Secretary's ability to spend those funds would not be subject
to appropriation, the provision would increase direct spending.
Based on historical information from IHS, CBO estimates that
the provision would increase spending by less than $500,000 a
year, but would total about $4 million over the 2008-2017
period.
Estimated impact on state, local, and tribal governments:
Intergovernmental mandates
S. 1200 would preempt state licensing laws in cases where a
health care professional is licensed in one state but is
performing services in another state under a contract or
compact with a tribal health program. This preemption would be
an intergovernmental mandate as defined in the UMRA; however,
CBO estimates that the loss of any licensing fees resulting
from the mandate would be small and would not approach the
threshold established in UMRA ($66 million in 2007, adjusted
annually for inflation).
Other impacts
S. 1200 would reauthorize and expand grant and assistance
programs available to Indian tribes, tribal organizations, and
urban Indian organizations for a range of health care programs,
including prevention, treatment, and ongoing care. The bill
also would allow IHS and tribal entities to share facilities,
and it would authorize joint ventures between IHS and Indian
tribes or tribal organizations for the construction and
operation of health facilities. The bill would authorize
funding for a variety of health services including hospice
care, long-term care, public health services, and home and
community-based services.
The bill would prohibit states from charging cost sharing
or premiums in the Medicaid program to Indians who receive
services or benefits through an Indian health program. CBO
estimates that the new requirements in the bill would result in
additional spending by states of about $80 million over the
2008-2017 period. Those requirements, however, would not be
intergovernmental mandates as defined by UMRA because Medicaid
provides states with significant flexibility to make
programmatic adjustments to accommodate the changes. Some
tribal entities, particularly those operating managed care
systems, may realize some savings as a result of these
provisions.
Estimated impact on the private sector: This bill contains
no private-sector mandates as defined in UMRA.
Previous CBO estimate: This estimate supersedes the cost
estimate for S. 1200 that CBO transmitted on June 8, 2007. Our
June 8 cost estimate erroneously indicated that section 204 of
the bill (exempting Indians from paying certain types of cost
sharing and premiums) would apply to both Medicaid and the
State Children's Health Insurance Program. The provision would
apply only to Medicaid, and we have lowered our estimate of the
bill's impact on direct spending by $4 million over the 2008-
2012 period and by $8 million over the 2008-2017 period as a
result.
On September 11, 2007, CBO also issued a revised estimate
for H.R. 1328, the Indian Health Care Improvement Act
Amendments of 2007, as ordered reported by the House Committee
on Natural Resources on April 25, 2007. There are only minor
differences between the two bills, and CBO's revised estimates
for them are identical.
Estimate prepared by: Federal Costs: Eric Rollins; Impact
on State, Local, and Tribal Governments: Lisa Ramirez-Branum;
Impact on the Private Sector: Paige Shevlin.
Estimate approved by: Peter H. Fontaine, Assistant Director
for Budget Analysis.
Changes in Existing Law
In accordance with subsection 12 of rule XXVI of the
Standing Rules of the Senate, changes in existing law made by
the bill S. 1200, as ordered reported, are shown as follows
(existing law proposed to be omitted is enclosed in black
brackets, new language to be added in italic, existing law to
which no change is proposed is shown in roman):
UNITED STATES CODE ANNOTATED
TITLE 25. INDIANS
CHAPTER 18--INDIAN HEALTH CARE
[Sec. 1601. Congressional]
S 1200 IS
110th CONGRESS
1st Session
S. 1200
To amend the Indian Health Care Improvement Act to revise and
extend that Act.
IN THE SENATE OF THE UNITED STATES
April 24, 2007
Mr. DORGAN (for himself, Mrs. Boxer, Mr. Reid, Ms. Cantwell,
Mr. Johnson, Mr. Tester, Mr. Inouye, Mr. Domenici, Mr.
Bingaman, Mr. Baucus, Ms. Klobuchar, Mr. Thomas, Mr. Obama, and
Ms. Murkowski) introduced the following bill; which was read
twice and referred to the Committee on Indian Affairs
A BILL
To amend the Indian Health Care Improvement Act to revise and
extend that Act.
Be it enacted by the Senate and House of Representatives of
the United States of America in Congress assembled,
SECTION 1. SHORT TITLE; TABLE OF CONTENTS.
(a) Short Title.--This Act may be cited as the ``Indian
Health Care Improvement Act Amendments of 2007''.
(b) Table of Contents.--The table of contents of this Act
is as follows:
Sec. 1. Short title; table of contents.
TITLE I--AMENDMENTS TO INDIAN LAWS
Sec. 101. Indian Health Care Improvement Act amended.
Sec. 102. Soboba sanitation facilities.
Sec. 103. Native American Health and Wellness Foundation.
TITLE II--IMPROVEMENT OF INDIAN HEALTH CARE PROVIDED UNDER THE SOCIAL
SECURITY ACT
Sec. 201. Expansion of payments under Medicare, Medicaid, and SCHIP for
all covered services furnished by Indian Health Programs.
Sec. 202. Increased outreach to Indians under Medicaid and SCHIP and
improved cooperation in the provision of items and services to
Indians under Social Security Act health benefit programs.
Sec. 203. Additional provisions to increase outreach to, and enrollment
of, Indians in SCHIP and Medicaid.
Sec. 204. Premiums and cost sharing protections under Medicaid,
eligibility determinations under Medicaid and SCHIP, and
protection of certain Indian property from Medicaid estate
recovery.
Sec. 205. Nondiscrimination in qualifications for payment for services
under Federal health care programs.
Sec. 206. Consultation on Medicaid, SCHIP, and other health care
programs funded under the Social Security Act involving Indian
Health Programs and Urban Indian Organizations.
Sec. 207. Exclusion waiver authority for affected Indian Health Programs
and safe harbor transactions under the Social Security Act.
Sec. 208. Rules applicable under Medicaid and SCHIP to managed care
entities with respect to Indian enrollees and Indian health
care providers and Indian managed care entities.
Sec. 209. Annual report on Indians served by Social Security Act health
benefit programs.
TITLE I--AMENDMENTS TO INDIAN LAWS
SEC. 101. INDIAN HEALTH CARE IMPROVEMENT ACT AMENDED.
(a) In General.--The Indian Health Care Improvement Act (25
U.S.C. 1601 et seq.) is amended to read as follows:
SECTION 1. SHORT TITLE; TABLE OF CONTENTS.
(a) Short Title.--This Act may be cited as the ``Indian
Health Care Improvement Act''.
(b) Table of Contents.--The table of contents for this Act
is as follows:
Sec. 1. Short title; table of contents.
Sec. 2. Findings.
Sec. 3. Declaration of national Indian health policy.
Sec. 4. Definitions.
TITLE I--INDIAN HEALTH, HUMAN RESOURCES, AND DEVELOPMENT
Sec. 101. Purpose.
Sec. 102. Health professions recruitment program for Indians.
Sec. 103. Health professions preparatory scholarship program for
Indians.
Sec. 104. Indian health professions scholarships.
Sec. 105. American Indians Into Psychology Program.
Sec. 106. Scholarship programs for Indian Tribes.
Sec. 107. Indian Health Service extern programs.
Sec. 108. Continuing education allowances.
Sec. 109. Community Health Representative Program.
Sec. 110. Indian Health Service Loan Repayment Program.
Sec. 111. Scholarship and Loan Repayment Recovery Fund.
Sec. 112. Recruitment activities.
Sec. 113. Indian recruitment and retention program.
Sec. 114. Advanced training and research.
Sec. 115. Quentin N. Burdick American Indians Into Nursing Program.
Sec. 116. Tribal cultural orientation.
Sec. 117. INMED Program.
Sec. 118. Health training programs of community colleges.
Sec. 119. Retention bonus.
Sec. 120. Nursing residency program.
Sec. 121. Community Health Aide Program.
Sec. 122. Tribal Health Program administration.
Sec. 123. Health professional chronic shortage demonstration programs.
Sec. 124. National Health Service Corps.
Sec. 125. Substance abuse counselor educational curricula demonstration
programs.
Sec. 126. Behavioral health training and community education programs.
Sec. 127. Authorization of appropriations.
TITLE II--HEALTH SERVICES
Sec. 201. Indian Health Care Improvement Fund.
Sec. 202. Catastrophic Health Emergency Fund.
Sec. 203. Health promotion and disease prevention services.
Sec. 204. Diabetes prevention, treatment, and control.
Sec. 205. Shared services for long-term care.
Sec. 206. Health services research.
Sec. 207. Mammography and other cancer screening.
Sec. 208. Patient travel costs.
Sec. 209. Epidemiology centers.
Sec. 210. Comprehensive school health education programs.
Sec. 211. Indian youth program.
Sec. 212. Prevention, control, and elimination of communicable and
infectious diseases.
Sec. 213. Other authority for provision of services.
Sec. 214. Indian women's health care.
Sec. 215. Environmental and nuclear health hazards.
Sec. 216. Arizona as a contract health service delivery area.
Sec. 216A. North Dakota and South Dakota as contract health service
delivery area.
Sec. 217. California contract health services program.
Sec. 218. California as a contract health service delivery area.
Sec. 219. Contract health services for the Trenton service area.
Sec. 220. Programs operated by Indian Tribes and Tribal Organizations.
Sec. 221. Licensing.
Sec. 222. Notification of provision of emergency contract health
services.
Sec. 223. Prompt action on payment of claims.
Sec. 224. Liability for payment.
Sec. 225. Office of Indian Men's Health.
Sec. 226. Authorization of appropriations.
TITLE III--FACILITIES
Sec. 301. Consultation; construction and renovation of facilities;
reports.
Sec. 302. Sanitation facilities.
Sec. 303. Preference to Indians and Indian firms.
Sec. 304. Expenditure of non-Service funds for renovation.
Sec. 305. Funding for the construction, expansion, and modernization of
small ambulatory care facilities.
Sec. 306. Indian health care delivery demonstration projects.
Sec. 307. Land transfer.
Sec. 308. Leases, contracts, and other agreements.
Sec. 309. Study on loans, loan guarantees, and loan repayment.
Sec. 310. Tribal leasing.
Sec. 311. Indian Health Service/tribal facilities joint venture program.
Sec. 312. Location of facilities.
Sec. 313. Maintenance and improvement of health care facilities.
Sec. 314. Tribal management of Federally-owned quarters.
Sec. 315. Applicability of Buy American Act requirement.
Sec. 316. Other funding for facilities.
Sec. 317. Authorization of appropriations.
TITLE IV--ACCESS TO HEALTH SERVICES
Sec. 401. Treatment of payments under Social Security Act health
benefits programs.
Sec. 402. Grants to and contracts with the Service, Indian Tribes,
Tribal Organizations, and Urban Indian Organizations to
facilitate outreach, enrollment, and coverage of Indians under
Social Security Act health benefit programs and other health
benefits programs.
Sec. 403. Reimbursement from certain third parties of costs of health
services.
Sec. 404. Crediting of reimbursements.
Sec. 405. Purchasing health care coverage.
Sec. 406. Sharing arrangements with Federal agencies.
Sec. 407. Payor of last resort.
Sec. 408. Nondiscrimination under Federal health care programs in
qualifications for reimbursement for services.
Sec. 409. Consultation.
Sec. 410. State Children's Health Insurance Program (SCHIP).
Sec. 411. Exclusion waiver authority for affected Indian Health Programs
and safe harbor transactions under the Social Security Act.
Sec. 412. Premium and cost sharing protections and eligibility
determinations under Medicaid and SCHIP and protection of
certain Indian property from Medicaid estate recovery.
Sec. 413. Treatment under Medicaid and SCHIP managed care.
Sec. 414. Navajo Nation Medicaid Agency feasibility study.
Sec. 415. General exceptions.
Sec. 416. Authorization of appropriations.
TITLE V--HEALTH SERVICES FOR URBAN INDIANS
Sec. 501. Purpose.
Sec. 502. Contracts with, and grants to, Urban Indian Organizations.
Sec. 503. Contracts and grants for the provision of health care and
referral services.
Sec. 504. Contracts and grants for the determination of unmet health
care needs.
Sec. 505. Evaluations; renewals.
Sec. 506. Other contract and grant requirements.
Sec. 507. Reports and records.
Sec. 508. Limitation on contract authority.
Sec. 509. Facilities.
Sec. 510. Division of Urban Indian Health.
Sec. 511. Grants for alcohol and substance abuse-related services.
Sec. 512. Treatment of certain demonstration projects.
Sec. 513. Urban NIAAA transferred programs.
Sec. 514. Consultation with Urban Indian Organizations.
Sec. 515. Urban youth treatment center demonstration.
Sec. 516. Grants for diabetes prevention, treatment, and control.
Sec. 517. Community Health Representatives.
Sec. 518. Effective date.
Sec. 519. Eligibility for services.
Sec. 520. Authorization of appropriations.
TITLE VI--ORGANIZATIONAL IMPROVEMENTS
Sec. 601. Establishment of the Indian Health Service as an agency of the
Public Health Service.
Sec. 602. Automated management information system.
Sec. 603. Authorization of appropriations.
TITLE VII--BEHAVIORAL HEALTH PROGRAMS
Sec. 701. Behavioral health prevention and treatment services.
Sec. 702. Memoranda of agreement with the Department of the Interior.
Sec. 703. Comprehensive behavioral health prevention and treatment
program.
Sec. 704. Mental health technician program.
Sec. 705. Licensing requirement for mental health care workers.
Sec. 706. Indian women treatment programs.
Sec. 707. Indian youth program.
Sec. 708. Indian youth telemental health demonstration project.
Sec. 709. Inpatient and community-based mental health facilities design,
construction, and staffing.
Sec. 710. Training and community education.
Sec. 711. Behavioral health program.
Sec. 712. Fetal alcohol disorder programs.
Sec. 713. Child sexual abuse and prevention treatment programs.
Sec. 714. Behavioral health research.
Sec. 715. Definitions.
Sec. 716. Authorization of appropriations.
TITLE VIII--MISCELLANEOUS
Sec. 801. Reports.
Sec. 802. Regulations.
Sec. 803. Plan of implementation.
Sec. 804. Availability of funds.
Sec. 805. Limitation on use of funds appropriated to Indian Health
Service.
Sec. 806. Eligibility of California Indians.
Sec. 807. Health services for ineligible persons.
Sec. 808. Reallocation of base resources.
Sec. 809. Results of demonstration projects.
Sec. 810. Provision of services in Montana.
Sec. 811. Moratorium.
Sec. 812. Tribal employment.
Sec. 813. Severability provisions.
Sec. 814. Establishment of National Bipartisan Commission on Indian
Health Care.
Sec. 815. Confidentiality of medical quality assurance records;
qualified immunity for participants.
Sec. 816. Appropriations; availability.
Sec. 817. Authorization of appropriations.
SEC. 2. FINDINGS.
Congress makes the following findings:
[The Congress finds the following:
[(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 Indian 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]
SEC. 3. DECLARATION OF 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 [obligation to the American Indian
people,] obligations to Indians--
(1) to assure the highest possible health status for
Indians and [urban]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
15ug/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 deaths 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 of 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
postpartum 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.]
(2) to raise the health status of Indians and Urban
Indians 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;
[(c) It is the intent of the Congress that the
Nation] (4) to increase the proportion of all degrees
in the health professions and allied and associated
health [profession fields awarded to Indians to 0.6
percent.]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;
[(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.]
(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
[Sec. 1603. Definitions]
(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. 4. 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 for Indian Health.
(4)(A) 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.
(B) The term ``behavioral health'' includes 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.
[(a) ``Secretary''] (8) The term ``Department''
means, unless otherwise designated, [means the
Secretary]the Department of Health and Human Services.
[(b) ``Service'' means the Indian Health Service.]
(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) the 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 safe water and sanitary
facilities;
(E) improving the physical, economic,
cultural, psychological, and social
environment;
(F) promoting culturally competent care; and
(G) providing adequate and appropriate
programs, which may include--
(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) healthy work environments;
(xxii) elimination, reduction, and
prevention of contaminants that create
unhealthy household conditions
(including mold and other allergens);
(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).
[(c) ``Indians'' or] (12) The term ``Indian'', unless
otherwise designated, means any person who is a member
of an Indian [tribe, as defined in subsection (d) of
this section,] Tribe or is eligible for health services
under section 806, except that, for the purpose of
sections [1612 and 1613 of this title, such terms shall
mean] 102 and 103, the term also means any individual
who [(1),]--
(A)(i) irrespective of whether [he or she]
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 [who]
(ii) is a descendant, in the first or second
degree, of any such member[, or (2)];
(B) is an Eskimo or Aleut or other Alaska
Native[, or (3)];
(C) is considered by the Secretary of the
Interior to be an Indian for any purpose[, or
(4)]; 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)).
[(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] (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
([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.] 1601 et seq.).
[(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.
[(f) ``Urban Indian'' means any individual who resides in
an urban center, as defined in subsection (g) hereof, and who
meets one or more of the four criteria in subsection (c)(1)
through (4) of this section.]
(17) The term ``Secretary'', unless otherwise
designated, means the Secretary of Health and Human
Services.
(18) The term ``Service'' means the Indian Health
Service.
(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 ``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)).
(24) 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.).
(25) 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.).
[(g)] (26) [``]The term ``Urban [center''] Center''
means any community which has a sufficient [urban]
Urban Indian population with unmet health needs to
warrant assistance under [subchapter IV] title V of
this [chapter] Act, as determined by the Secretary.
(27) The term ``Urban Indian'' means any individual
who resides in an Urban Center and who meets 1 or more
of the following criteria:
(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.
[(h)] (28) The term ``Urban Indian [organization'']
Organization'' means a nonprofit corporate body that
(A) is situated in an [urban center,] Urban Center; (B)
is governed by an [urban] Urban Indian-controlled board
of directors[, and providing]; (C) provides for the
[maximum] participation of all interested Indian groups
and individuals[, which body]; and (D) is capable of
legally cooperating with other public and private
entities for the purpose of performing the activities
described in section [1653] 503(a).
TITLE I--INDIAN HEALTH, HUMAN RESOURCES, AND DEVELOPMENT
SEC. 101. PURPOSE.
The purpose 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.
[Sec. 1611. Congressional statement of purpose The purpose
of this subchapter] 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 [Service, Indian
tribes, tribal organizations, and urban Indian organizations]
Indian Health Programs and Urban Indian Organizations involved
in the provision of health [care] services to [Indian people]
Indians.
[Sec. 1612. Health professions recruitment program for Indians]
SEC. 102. HEALTH PROFESSIONS RECRUITMENT PROGRAM FOR INDIANS.
[(a) Grants for education and training]
(a) 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
[tribes or tribal organizations] 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]
(b) Grants.--
[(1) No] (1) Application.--The Secretary shall not
make a 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 [Indian
tribes or tribal organizations] Tribal Health Programs
or Urban Indian Organizations.
(2) Amount of grants; payment.--The amount of [any] a
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
extent not otherwise prohibited by law, grants shall be
for 3 years, as provided in regulations issued pursuant
to this Act.
[Sec. 1613. Health professions preparatory scholarship program for
Indians]
SEC. 103. HEALTH PROFESSIONS PREPARATORY SCHOLARSHIP PROGRAM FOR
INDIANS.
[(a) Requirements]
(a) Scholarships Authorized._The Secretary, acting through
the Service, shall [make] provide scholarship grants to Indians
who--
(1) have successfully completed their high school
education or high school equivalency; and
(2) have demonstrated the [capability] potential to
successfully complete courses of study in the health
professions.
(b) Purposes. [and duration of grants; preprofessional and
pregraduate education]--Scholarship grants [made] provided
pursuant to this section shall be for the following purposes:
(1) Compensatory preprofessional education of any
[grantee] recipient, 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 [grantee] recipient
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. 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]
[Scholarship grants made] (c) Other Conditions.--
Scholarships under this section--
(1) may cover costs of tuition, books,
transportation, board, and other necessary related
expenses of a [grantee] recipient while attending
school[.];
[(d) Basis for Denial of Assistance]
[The Secretary] (2) shall not [deny scholarship
assistance to an eligible applicant under this section]
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
[(e) Eligibility for Assistance Under Other Federal
Programs]
[The Secretary] (3) shall not [deny scholarship
assistance to an eligible applicant under this section]
be denied solely by reason of such applicant's
eligibility for assistance or benefits under any other
Federal program.
[Sec. 1613a. Indian health professions scholarships]
SEC. 104. INDIAN HEALTH PROFESSIONS SCHOLARSHIPS.
[(a) General Authority] (a) In General.--
[In order to provide health professionals to Indians,
Indian tribes, tribal organizations, and urban Indian
organizations, the] (1) Authority.--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 [254l of Title 42,] 338A of
the Public Health Services Act (42 U.S.C. 254l), except
as provided in subsection (b) of this section.
[(b) Recipients; active duty service obligation]
[(1)] (2) Determinations by secretary.--The
Secretary, acting through the Service, shall
determine--
(A) who shall receive [scholarships]
scholarship grants under subsection (a); and
[shall determine]
(B) the distribution of [such] the
scholarships among [such] health professions on
the basis of the relative needs of Indians for
additional service in [such] the 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.]
(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) Active Duty Service Obligation_
[(3)(A)] (1) Obligation met.--The active duty service
obligation under a written contract with the Secretary
under this section [254l 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[, by service--] equal to 1 year for each
school year for which the participant receives a
scholarship award under this part, or 2 years,
whichever is greater, by service in 1 or more of the
following:
[(i) in the Indian Health 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.];]
(A) In an Indian Health Program.
[(iii)] (B) [in] In a program assisted under
[subchapter IV of this chapter;] title V of
this Act.
[(iv)] (C) [in]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.
[(B)] (2) Obligation deferred.--At the request of any
individual who has entered into a contract referred to
in [subparagraph (A]paragraph (1) 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:
[(i)] (A) 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
[section]subsection.
[(ii)] (B) 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).
[(iii)] (C) The active duty service
obligation will be served in the health
profession of that individual, in a manner
consistent with [clauses (i) through (v) of
subparagraph (A)] paragraph (1).
[(C)] (D) A recipient of [an Indian Health
Scholarship]a scholarship under this section
may, at the election of the recipient, meet the
active duty service obligation described in
[subparagraph (A)] paragraph (1) by service in
a program specified [in] under that
[subparagraph] paragraph that--
(i) is located on the reservation of
the [tribe] Indian Tribe in which the
recipient is enrolled; or
(ii) serves the [tribe] Indian Tribe
in which the recipient is enrolled.
[(D)] (3) Priority when making assignments.--Subject
to [subparagraph (C] paragraph (2), the Secretary, in
making assignments of Indian Health Scholarship
recipients required to meet the active duty service
obligation described in [subparagraph (A)] paragraph
(1), shall give priority to assigning individuals to
service in those programs specified in [subparagraph
(A)] paragraph (1) 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.
[(4)] (c) 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--
[(A)] (1) such scholarship shall be for a period of
years not to exceed the part-time equivalent of 4
years, as determined by the Secretary;
[(B)] (2) the period of obligated service described
in [paragraph (3)(A)] subsection (b)(1) shall be equal
to the greater of--
[(i)] (A) the part-time equivalent of [one] 1
year for each year for which the individual was
provided a scholarship (as determined by the
Secretary); or
[(ii)] (B) [two] 2 years; and
[(C)] (3) 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.
[(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--]
(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
enactment of the Indian Health Care Improvement Act
Amendments of 2007 if that individual--
[(i)] (A) 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)] (B) is dismissed from such educational
institution for disciplinary reasons[,];
[(iii)] (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
[(iv)] (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[, shall be liable
to the United States for the amount which has
been paid to him, or on his behalf, under the
contract].
[(B)] (2) Other breaches.--If for any reason not
specified in [subparagraph (A)] paragraph (1) an
individual breaches [his] a written contract by failing
either to begin such individual's service obligation
required under [this section] 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(l) of
this title] 110 in the manner provided for in such
subsection.
[(C)] (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) Waivers and suspensions.--
[(D)] (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 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 shall consult with the affected Area
Office, Indian Tribes, Tribal Organizations, or
Urban Indian Organizations, and 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).
[(E)] (5) 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.
[(F)] (6) 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
[Title] 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]
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 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.
[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.]
(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 2008 through 2017.
SEC. 106. SCHOLARSHIP PROGRAMS FOR INDIAN TRIBES.
(a) In General.--
(1) Grants authorized.--The Secretary, acting through
the Service, shall make grants 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.--
(1) In general.--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.
(2) Requirements.--Such contract shall--
(A) 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--
(i) 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
(ii) such greater period of time as
the recipient and the Tribal Health
Program may agree;
(B) provide that the amount of the
scholarship--
(i) 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
(ii) 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
clause (i);
(C) 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
(D) require the recipient of such scholarship
to meet the educational and licensure
requirements appropriate to each health
profession.
(3) Service in other service areas.--The contract may
allow the recipient to serve in another Service Area,
provided the Tribal Health Program and Secretary
approve and services are not diminished to Indians in
the Service Area where the Tribal Health Program
providing the scholarship is located.
(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 information received 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 Health Service extern programs]
SEC. 107. INDIAN HEALTH SERVICE EXTERN PROGRAMS.
(a) Employment [of scholarship grantees during nonacademic
periods] Preference.--Any individual who receives a scholarship
[grant] pursuant to section [1613a of this title] 104 or 106
shall be [entitled to] given preference for employment in the
Service [during any nonacademic period of the year.], 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.--
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].
[(b)](c) Timing; Length of Employment [of medical and other
students during nonacademic periods].--Any individual enrolled
in a [course of study in the health professions] program,
including a high school program, authorized under section
102(a) 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 [one
hundred and twenty] 120 days during any calendar year.
[(c) Employment without regard to competitive personnel
system or agency personnel limitation; compensation] (d)
Nonapplicability of Competitive Personnel System.--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 education allowances]
SEC. 108. CONTINUING EDUCATION ALLOWANCES.
[(a) Discretionary authority; scope of activities]
In order to encourage [physicians, dentists, nurses, and
other] scholarship and stipend recipients under sections 104,
105, 106, and 115 and health professionals, including community
health representatives and emergency medical technicians, to
join or continue in [the Service] an Indian Health Program and
to provide their services in the rural and remote areas where a
significant portion of [the Indian people resides] Indians
reside, the Secretary, acting through the Service, may
[provide]--
(1) provide programs or allowances to transition into
an Indian Health Program, including licensing, board or
certification examination assistance, and technical
assistance in fulfilling service obligations under
sections 104, 105, 106, and 115; and
(2) provide programs or allowances to health
professionals employed in [the Service] an Indian
Health Program 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, management, leadership, 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]
SEC. 109. COMMUNITY HEALTH REPRESENTATIVE PROGRAM.
(a) In General.--Under the 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 maintain a Community Health Representative Program under
which [the Service]Indian Health Programs--
(1) [provides] provide for the training of Indians as
[health paraprofessionals, and] community health
representatives; and
[(2) uses such paraprofessionals] (2) use such
community health representatives in the provision of
health care, health promotion, and disease prevention
services to Indian communities.
[(b) The Secretary, acting through the Community Health
Representative Program of the Service, shall--]
(b) Duties.--The Community Health Representative Program of
the Service, shall--
(1) provide a high standard of training for
[paraprofessionals to Community Health Representatives]
community health representatives to ensure that the
[Community Health Representatives] community health
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
[Community Health Representatives] community health
representatives for continuing education in health
care, health promotion, and disease prevention and
develop programs that meet the needs for [such]
continuing education[,];
(4) 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 traditional health care practices of the
Indian [tribes] 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]
SEC. 110. 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 [assure] ensure an adequate supply of
trained health professionals necessary to maintain
accreditation of, and provide health care services to Indians
through, Indian [health programs] Health 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 of Title 42.]
[(b) Eligibility] (b) Eligible Individuals.--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 educational institution[,] (as
determined by the Secretary[, within any State]
under section 338B(b)(1)(c)(i) of the Public
Health Service Act (42 U.S.C. 254l-
1(b)(1)(c)(i))) 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 [health program] Health
Program or Urban Indian Organization without a service
obligation; and
(3) submit to the Secretary an application for a
contract described in subsection [(f) of this section]
(e).
(c) Application [and Contract Forms].--
[(1)] (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
[(1)] (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)] (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) Vacancies; priority]
(d) Priorities.--
(1) List.--Consistent [with paragraph (3), the
Secretary, acting through the Service and in
accordance] with subsection (k) [of this section], the
Secretary shall annually--
(A) identify the positions in each Indian
[health program] Health Program or Urban Indian
Organization for which there is a need or a
vacancy[,]; and
(B) rank those positions in order of
priority.
(2) [Consistent with] Approvals.--Notwithstanding 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[-- (A)] individual Indians; and
(B) after making determinations on all
applications submitted by individual Indians as
required under subparagraph (A), give priority
to--
[(B)] (i) individuals recruited
through the efforts of an Indian
[tribes or tribal or Indian
organizations.]
[(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]
Health Program or Urban Indian
Organization; 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) Approval]
(ii) other individuals based on the
priority rankings under paragraph (1).
(e) Recipient Contracts._
(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 [subsection (f) of this section.]
paragraph (2).
[(2) 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]
(2) Contents of contract.--The written contract
referred to in this section between the Secretary and
an individual shall contain--
[(1)] (A) an agreement under which--
[(A)] (i) subject to [paragraph (3)]
subparagraph (C), 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
[tribe] Tribal Health Program
or Urban Indian [organization]
Organization as provided in
[subparagraph (B)(iii),] clause
(ii)(III); and
[(B] (ii) subject to [paragraph (3]
subparagraph (C), 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)--
[(I)] (aa) 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
[(II)] (bb) 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 [health
program] Health Program or
Urban Indian Organization to
which the individual may be
assigned by the Secretary;
[(2)] (B) a provision permitting the
Secretary to extend for such longer
additional periods, as the individual
may agree to, the period of obligated
service agreed to by the individual
under [paragraph (1)(B)(iii)]
subparagraph (A)(ii)(III);
[(3)] (C) a provision that any
financial obligation of the United
States arising out of a contract
entered into under this section and any
obligation of the individual which is
conditioned thereon is contingent upon
funds being appropriated for loan
repayments under this section;
[(4)] (D) a statement of the damages
to which the United States is entitled
under subsection ([1]l) [of this
section] for the individual's breach of
the contract; and
[(5)] (E) such other statements of
the rights and liabilities of the
Secretary and of the individual, not
inconsistent with this section.
[(g) Loan repayment purposes; maximum amount; tax liability
reimbursement; schedule of payments]
(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.--
[(1)] (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
([f]e), the Secretary may pay up to $35,000 [(]or an
amount equal to the amount specified in section [254l-
l]338B(g)(2)(A) of [Title 42] the Public Health Service
Act, whichever is more, 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--
[(i)] (A) 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;
[(ii)] (B) provides an incentive to serve in
Indian [health programs]Health Programs and
Urban Indian Organizations with the greatest
shortages of health professionals; and
[(iii)] (C) provides an incentive with
respect to the health professional involved
remaining in an Indian [health program] Health
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.
[(B)] (3) 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.
[(3)] (4) Reimbursements for tax liability.--For the
purpose of providing reimbursements for tax liability
resulting from [payments] 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.
[(4)] (5) 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) Effect on Employment Ceiling of Department of Health
and Human Services]
(h) Employment Ceiling.--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) [Recruiting programs] Recruitment.--The Secretary shall
conduct recruiting programs for the Loan Repayment Program and
other [health professional] manpower programs of the Service at
educational institutions training health professionals or
specialists identified in subsection (a)[of this section].
(j) [Prohibition of assignment to other government
departments.--Section 215 of Title 42] Applicability of Law.--
Section 214 of the Public Health Service Act (42 U.S.C. 215)
shall not apply to individuals during their period of obligated
service under the Loan Repayment Program.
[(k) Staff needs of health programs administered by Indian
tribes] (k) Assignment of Individuals.--The Secretary, in
assigning individuals to serve in Indian [health programs]
Health Programs or Urban Indian Organizations pursuant to
contracts entered into under this section, shall--
(1) ensure that the staffing needs of [Indian health
programs administered by an Indian tribe or tribal or
health organization] Tribal Health Programs and Urban
Indian Organizations receive consideration on an equal
basis with programs that are administered directly by
the Service; and
(2) give priority to assigning individuals to Indian
[health programs] Health 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) Voluntarily termination of study or dismissal from
educational institution; collection of damages]
(l) Breach of Contract.--
(1) Specific breaches.--An individual who has entered
into a written contract with the Secretary under this
section and [who--] 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--
(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),
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)] (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 [(f) of this section]
(e)(2), 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] Secretary of
the [United States] Treasury;
(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 Medicare payments pursuant to
section [1395ccc of Title 42.] 1892 of the Social
Security Act.
[(3)(A)] (4) 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.--
[(B)] (A) In general.--If damages described
in [subparagraph (A)] paragraph (4) are
delinquent for 3 months, the Secretary shall,
for the purpose of recovering such damages--
(i) [utilize] use 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.
[(C)] (B) 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 [Title 31] title 31, United States
Code, shall apply to any such contract to the
extent not inconsistent with this subsection.
[(m) 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.]
(m) Waiver or Suspension of Obligation._
[(2)](1) 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
[Title] 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 report] Report.--The Secretary shall submit to
the President, for inclusion in [each] the report required to
be submitted to [the] Congress under section [1671 of this
title,] 801, 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 [the Service or by tribal or Indian
organizations] Indian Health Programs and Urban Indian
Organizations for which recruitment or retention is
difficult[;].
(2) [the] The number of Loan Repayment Program
applications filed with respect to each type of health
profession[;].
(3) [the] The number of contracts described in
subsection [(f) of this section] (e) that are entered
into with respect to each health profession[;].
(4) [the] The amount of loan payments made under this
section, in total and by health profession[;].
(5) [the] The number of [scholarship grants]
scholarships that are provided under [section 1613a of
this title] sections 104 and 106 with respect to each
health profession[;].
(6) [the] The amount of scholarship grants provided
under section [1613a of this title,] 104 and 106, in
total and by health profession[;].
(7) [the] The number of providers of health care that
will be needed by Indian [health programs] Health
Programs and Urban Indian Organizations, by location
and profession, during the [three] 3 fiscal years
beginning after the date the report is filed[; and].
(8) [the] The measures the Secretary plans to take to
fill the health professional positions maintained by
[the Service or by tribes or tribal or Indian
organizations] Indian Health Programs or Urban Indian
Organizations for which recruitment or retention is
difficult.
[Sec. 1616a-1. Scholarship and Loan Repayment Recovery Fund]
SEC. 111. SCHOLARSHIP AND LOAN REPAYMENT RECOVERY FUND.
(a) Establishment.--There is established in the Treasury of
the United States a fund to be known as the Indian Health
Scholarship and Loan Repayment Recovery Fund (hereafter in this
section referred to as the [``Fund''] ``LRRF''). The [Fund]
LRRF shall consist of such amounts as may be [appropriated to
the Fund under subsection (b) of this section. Amounts
appropriated for the Fund] collected from individuals 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. All amounts collected,
appropriated, or earned relative to the LRRF 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 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.
[(c)] (b) Use of [funds] Funds.--
(1) By secretary.--Amounts in the [Fund and available
pursuant to appropriation Acts] LRRF may be expended by
the Secretary, acting through the Service, to make
payments to an Indian [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.]--]
Health Program--
(A) to which a scholarship recipient under
section [1613a of this title] 104 and 106 or a
loan repayment program participant under
section [1616a of this title] 110 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 [1613a
of this title, or section 1616a of this title.]
104, 106, or section 110.
[(2) An Indian tribe or tribal organization] (2) By
tribal health programs.--A Tribal Health Program
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.
[(d)] (c) Investment of [excess funds (1)] Funds.--The
Secretary of the Treasury shall invest such amounts of the
[Fund] LRRF as [such] the Secretary of Health and Human
Services determines are not required to meet current
withdrawals from the [Fund] LRRF. 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.
[(2)] (d) Sale of Obligations.--Any obligation acquired by
the [Fund] LRRF may be sold by the Secretary of the Treasury at
the market price.
[Sec. 1616b. Recruitment activities]
SEC. 112. RECRUITMENT ACTIVITIES.
(a) Reimbursement for Travel.--The Secretary, acting
through the Service, may reimburse health professionals seeking
positions [in the Service] with Indian Health Programs or Urban
Indian Organizations, including individuals considering
entering into a contract under section [1616a of this title,]
110 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)] (b) Recruitment Personnel.--The Secretary, acting
through the Service, shall assign [one] 1 individual in each
[area office] Area Office to be responsible on a full-time
basis for recruitment activities.
[Sec. 1616c. Tribal recruitment and retention program]
SEC. 113. INDIAN RECRUITMENT AND RETENTION PROGRAM.
[(a) Projects funded on competitive basis]
(a) In General.--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 [Indian
tribes and tribal and Indian organizations] Tribal Health
Programs and Urban Indian Organizations to recruit, place, and
retain health professionals to meet [the] their staffing needs
[of Indian health programs (as defined in section 1616a(a)(2)
of this title)].
[(b) Eligibility]
[(1) Any Indian tribe or tribal or Indian organization](b)
Eligible Entities; Application.--Any Tribal Health Program or
Urban 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 training and research]
SEC. 114. ADVANCED TRAINING AND RESEARCH
[(a) Establishment of program]
(a) Demonstration Program.--The Secretary, acting through
the Service, shall establish a [program] demonstration project
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 determinates 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 organizations,
and urban Indian organizations, at the time of the submission
of the applications.]
[(b) Obligated service]
(b) Service Obligation.--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 [health program (as defined in
section 1616a(a)(2) of this title)] Health Program or Urban
Indian Organization 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 [October 29, 1992,] the date of enactment of
the Indian Health Care Improvement Act Amendments of 2007, the
United States shall be entitled to recover from such individual
an amount to be determined in accordance with the formula
specified in subsection (1) of section [1616a of this title]
110 in the manner provided for in such subsection.
[(c) Eligibility]
(c) Equal Opportunity for Participation.--Health
professionals from [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.] Tribal Health
Programs and Urban Indian Organizations shall be given an equal
opportunity to participate in the program under subsection
(a)[of this section].
[Sec. 1616e. Nursing program]
SEC. 115. QUENTIN N. BURDICK AMERICAN INDIANS INTO 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] 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) [Purposes] Use of Grants._Grants provided under
subsection (a) [of this section] may be used [to--] for 1 or
more of the following:
(1) To recruit individuals for programs which train
individuals to be nurses, nurse midwives, or [nurse
practitioners,] advanced practice nurses.
(2) To provide scholarships to [individuals] 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 [nurse practitioners] 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 [nurse practitioners, or] advanced
practice nurses.
(5) To provide any program that is designed to
achieve the purpose described in subsection (a) [of
this section].
(c) [Application] Applications._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]
(d) Preferences for Grant Recipients._In providing grants
under subsection (a) [of this section], the Secretary shall
extend a preference to[--] the following:
(1) [programs] Programs that provide a preference to
Indians[,].
(2) [programs] Programs that train nurse midwives or
[nurse practitioners,] advanced practice nurses.
(3) [programs] Programs that are interdisciplinary[,
and].
(4) [programs] Programs that are conducted in
cooperation with a [center] program for gifted and
talented Indian students [established under section
2624(a) of this title].
(5) Programs conducted by tribal colleges and
universities.
(e) Quentin N. Burdick [American Indians Into Nursing]
Program Grant._The Secretary shall provide [one] 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 [1616g] 117(b) [of
this title] and the Quentin N. Burdick American Indians Into
Psychology Program established under section [1621p] 105(b) [of
this title].
(f) Active Duty Service [obligation] Obligation._The active
duty service obligation prescribed under section [254m of this
title] 338C of the Public Health Service Act (42 U.S.C. 254m)
shall be met by each individual who receives training or
assistance described in paragraph (1) or (2) of subsection (b)
[of this section] that is funded by a grant provided under
subsection (a) [of this section]. Such obligation shall be met
by service--
[(A)] (1) in the [Indian Health] Service;
[(B)] (2) in a program of an Indian Tribe or Tribal
Organization conducted under [a contract entered into
under] the Indian Self-Determination and Education
Assistance Act [[](25 U.S.C.[A. Sec. ] 450[f et seq.];
(C] et seq.) (including programs under agreements with
the Bureau of Indian Affairs);
(3) in a program assisted under [subchapter IV] title
V of this [chapter; or] Act;
[(D)](4) 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[.]; or
[(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.]
(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.
[Sec. 1616f. Tribal culture and history]
SEC. 116. TRIBAL CULTURAL ORIENTATION.
[(a) Program established]
(a) Cultural Education of Employees.--The Secretary, acting
through the Service, shall [establish a program under
which]require that appropriate employees of the Service who
serve [particular] Indian [tribes shall]Tribes in each Service
Area receive educational instruction in the history and culture
of such [tribes and in the history of]Indian Tribes and their
relationship to the Service.
(b) [Tribally-controlled community collegesTo the extent
feasible, the program established under subsection (a) of this
section shall] Program.--In carrying out subsection (a), the
Secretary shall establish a program which shall, to the extent
feasible--
[(1) 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 developed in consultation with the affected
tribal government, and]
(1) be developed in consultation with the affected
Indian Tribes, Tribal Organizations, and Urban Indian
Organizations;
(2) be carried out through tribal colleges or
universities;
(3) include instruction in Native American Indian
studies; and
(4) describe the use and place of traditional health
care practices of the Indian Tribes in the Service
Area.
[Sec. 1616g.]
SEC. 117. INMED [PROGRAM] 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 [Native American] Indian health careers
recruitment program known as the [``]`Indians [into] Into
Medicine Program''' (hereinafter in this section referred to as
```INMED''') as a means of encouraging Indians to enter the
health professions.
[(b) University of North Dakota]
(b) Quentin N. Burdick Grant.--The Secretary shall provide
one1 of the grants authorized under subsection (a) 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 [1621p] 105(b) [of this title] and the Quentin N.
Burdick American Indians Into Nursing Program established under
section [1616e(e) of this title.] 115.
(c) Regulations[; contents of recruitment program (1)].--
The Secretary, pursuant to this Act, shall develop regulations
[for the competitive awarding of the] to govern grants
[provided under] pursuant to this section.
[(2)] (d) Requirements.--Applicants for grants provided
under this section shall agree to provide a program which--
[(A)] (1) 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[,];
[(B)] (2) incorporates a program advisory board
comprised of representatives from the [tribes] Indian
Tribes and Indian communities which will be served by
the program[,];
[(C)] (3) 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[,];
[(D)] (4) provides tutoring, counseling, and support
to students who are enrolled in a health career program
of study at the respective college or university[,];
and
[(E)] (5) 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 training programs of community colleges]
SEC. 118. HEALTH TRAINING PROGRAMS OF COMMUNITY 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 [the community college] such 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 [an Indian] or
near a reservation or in [a tribal clinic] an Indian
Health Program.
(2) Amount of grants.--The amount of any grant
awarded to a community college under paragraph (1) for
the first year in which such a grant is provided to the
community college shall not exceed $[100,000.] 250,000.
[(b) Eligibility]
(b) Grants for Maintenance and Recruiting.--
[(1)] (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 [access to] a relationship with 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 [which] that train
health professionals[,]; and
(ii) stipulate certifications
necessary to approve internship and
field placement opportunities at
[service unit facilities of the Service
or at tribal health facilities,] Indian
Health Programs;
(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]; and
(F) agrees to provide for Indian preference
for applicants for programs under this section.
[(c) Agreements and technical assistance]
(c) Technical 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] 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--
[(1)] (A) has already received a degree or
diploma in such health profession[,]; and
[(2)] (B) provides clinical services on [an
Indian] or near a reservation[, at a Service
facility, or at a tribal clinic] or for an
Indian Health Program.
(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) 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.]
(e) Priority.--Where the requirements of subsection (b) are
met, grant award priority shall be provided to tribal colleges
and universities in Service Areas where they exist.
[Sec. 1616i. Additional incentives for health professionals]
SEC. 119. RETENTION BONUS.
[(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] (a) Bonus Authorized.--The Secretary may
pay a retention bonus to any health professional
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) Eligibility.--The Secretary may pay a retention bonus
to any physician or nurse employed by, or assigned to, and
serving in, the Service] and serving in, an Indian Health
Program or Urban Indian Organization 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 [the
Service,] Indian Health Programs and Urban Indian
Organizations;
(3) has--
(A) completed [3] 2 years of employment with
[the Service, or] an Indian Health Program or
Urban Indian Organization; 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 [the Service] an
Indian Health Program or Urban Indian Organization 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 this section shall be awarded to nurses.
[(c)] (b) 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
[Any physician or nurse] (c) Default of Retention
Agreement.--Any health professional 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 [1616a]
110(l)(2)(B)[of this title].
[(f) Physicians and nurses employed under Indian Self-
Determination Act] (d) Other Retention Bonus.--The Secretary
may pay a retention bonus to any [physician or nurse employed
by 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 physician or nurse]
health professional employed by a Tribal Health Program if such
health professional 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]
SEC. 120. 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
[health program (as defined in section 1616a(a)(2)(A) of this
title] Health Program or Urban Indian Organization, and have
done so for a period of not less than [one] 1 year, to pursue
advanced training.
[(b) Program components]Such program shall include a
combination of education and work study in an Indian [health
program (as defined in section 1616a(a)(2)(A) of this title)]
Health Program or Urban Indian Organization 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 a Master's
degree], or advanced degrees or certifications in nursing and
public health.
[(c)] (b) Service [obligation of program
participant]Obligation.-- 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 [health program] Health
Program or Urban Indian Organization for a period of obligated
service equal to [at least three times the period of time
during which the individual] 1 year for every year that
nonprofessional employee (licensed practical nurses, licensed
vocational nurses, nursing assistants, and various health care
technicals), or 2 years for every year that professional nurse
(associate degree and bachelor-prepared registered nurses),
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 [1616a of this title] 110 in the
manner provided for in such subsection.
[Sec. 1616l. Community Health Aide Program for Alaska]
SEC. 121. COMMUNITY HEALTH AIDE PROGRAM.
[(a) Maintenance of program]
(a) General Purposes of Program.--Under the authority of
[section 13 of this title] the Act of November 2, 1921 (25
U.S.C. 13) (commonly known as the ``Snyder Act'', the
Secretary, acting through the Service, shall [maintain] develop
and operate 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) Training; curriculum; Certification Board]
(b) Specific Program Requirements.--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 [1602(b)
of this title] 3(2);
(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[.]; and
(7) ensure that pulpal therapy (not including
pulpotomies on deciduous teeth) or extraction of adult
teeth can be performed by a dental health aide
therapist only after consultation with a licensed
dentist who determines that the procedure is a medical
emergency that cannot be resolved with palliative
treatment, and further that dental health aide
therapists are strictly prohibited from performing all
other oral or jaw surgeries, provided that
uncomplicated extractions shall not be considered oral
surgery under this section.
(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 those services
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 therapist 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 Natural 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.
[Sec. 1616m. Matching grants to tribes for scholarship programs]
(2) Exception.--The national Community Health Aide
Program under paragraph (1) shall not include dental
health aide therapist services.
[(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 carryout 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 a 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
254m(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(l) of this title in the
manner provided for in such subsection.
[(3) The Secretary may carryout this subsection on
the basis of information submitted by the tribes or
tribal organizations 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.]
(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. 1616n. Tribal health program administration]
SEC. 122. TRIBAL HEALTH PROGRAM ADMINISTRATION.
[The Secretary] The Secretary, acting through the Service,
shall, by contract or otherwise, provide training for
[individuals] Indians in the administration and planning of
[tribal health programs] Tribal Health Programs.
SEC. 123. HEALTH PROFESSIONAL CHRONIC SHORTAGE DEMONSTRATION PROGRAMS.
[Sec. 1616o. University of South Dakota pilot program]
(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.
[(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 of Programs._The purposes of [the program
established pursuant to a grant provided] demonstration
programs funded under subsection (a) [are] shall be--
(1) to provide direct clinical and practical
experience at a [service unit to medical] Service Unit
to health profession 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, nurses, and other allied] health
professionals serving [Indian people] Indians by
identifying [and utilizing] all academic and scholarly
resources of the region.
[(c) Composition; designation
[The pilot program] (c) Advisory Board._The demonstration
programs established pursuant to a [grant provided under]
subsection (a) shall[--(1)] incorporate a program advisory
board composed of representatives from the [tribes] Indian
Tribes and Indian 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. 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, 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
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) Contracts and Grants.--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 enactment of the Indian
Health Care Improvement Act Amendments of 2007, 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.
[Sec. 1616p. Authorization of appropriations]
(e) Plan.--Not later than 90 days after the date of
enactment of the Indian Health Care Improvement Act Amendments
of 2007, 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 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. 127. AUTHORIZATION OF APPROPRIATIONS.
There are authorized to be appropriated such sums as may be
necessary for each fiscal year through fiscal year [2000] 2017
to carry out this [subchapter] title.
TITLE II--HEALTH SERVICES
[Sec. 1621. Indian Health Care Improvement Fund]
SEC. 201. INDIAN HEALTH CARE IMPROVEMENT FUND.
[(a) Approved expenditures]
(a) Use of Funds.--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 [tribes,] 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, [and] including the use
of telehealth and telemedicine when appropriate;
(4) eliminating inequities in funding for both direct
care and contract health service programs; and
[(4)] (5) 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 [tribes] Tribes with the
highest levels of health status deficiencies and
resource deficiencies:
(A) [clinical] 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) [preventive] Preventive health, including
[screening] mammography and other cancer
screening in accordance with section [1621k of
this title;] 207.
[(C) dental care (direct and indirect);] (C)
Dental care.
(D) [mental] Mental health, including
community mental health services, inpatient
mental health services, dormitory mental health
services, therapeutic and residential treatment
centers, and training of traditional [Indian]
health care practitioners[;].
(E) [emergency] Emergency medical
services[;].
(F) [treatment] Treatment and control of, and
rehabilitative care related to, alcoholism and
drug abuse (including fetal alcohol syndrome)
among Indians[;].
(G) [accident] Injury prevention programs[;],
including data collection and evaluation,
demonstration projects, training, and capacity
building.
(H) [home] Home health care[;].
(I) [community] Community health
representatives[; and].
[(J) maintenance and repair.]
[(b) Effect of other appropriations; allocation to service
units]
(J) Maintenance and improvement.
[(1)] (b) No Offset or Limitation._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
[section 13 of this title] this Act or the Act of November 2,
1921 (25 U.S.C. 13) (commonly known as the ``Snyder Act''), or
any other provision of law.
(c) Allocation; Use.--
[(2)] (1)[(A)] In general._Funds appropriated under
the authority of this section [may] shall be allocated
[on a service unit basis] to Service Units, Indian
Tribes, or Tribal Organizations. The funds allocated to
each [service unit] Indian Tribe, Tribal Organization,
or Service Unit under this [subparagraph] paragraph
shall be used by the [service unit to reduce] Indian
Tribe, Tribal Organization, or Service Unit under this
paragraph to improve the health status and reduce the
resource deficiency of each [tribe] Indian Tribe served
by such [service unit] Service Unit, Indian Tribe, or
Tribal Organization.
[B] (2) Apportionment of allocated funds._The
apportionment of funds allocated to a [service unit
under subparagraph (A)] Service Unit, Indian Tribe, or
Tribal Organization under paragraph (1) among the
health service responsibilities described in subsection
(a)[(4) of this section] (5) shall be determined by the
Service in consultation with, and with the active
participation of, the affected Indian [tribes] Tribes
and Tribal Organizations.
[(c) Health Resources Deficiency Levels.--For] (d)
Provisions Relating to Health Status and Resource
Deficiencies._For the 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 [1602(b) of this title] 3(2) are not
being achieved; and
(B) the Indian [tribe] 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 [tribe] Tribe or Tribal
Organization include health resources provided by the
Service as well as health resources used by the Indian
[tribe] 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 [tribe] 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 [tribe] Indian Tribe or Tribal Organization.
[(d) Programs administered by Indian tribe]
[(1) Programs administered by any Indian tribe or
tribal organization under the authority of the Indian
Self-Determination Act] (e) Eligibility for Funds._
Tribal Health Programs 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.]
[(e)] (f) Report [to Congress].--By no later than the date
that is 3 years after [October 29, 1992,] the date of enactment
of the Indian Health Care Improvement Act Amendments of 2007,
the Secretary shall submit to the Congress the current health
status and resource deficiency report of the Service for each
[Indian tribe or service unit] Service Unit, including newly
recognized or acknowledged [tribes] Indian Tribes. Such report
shall set out--
(1) the methodology then in use by the Service for
determining [tribal] 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] 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] 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
[chapter] Act, or any other Act, including the
amount of any funds transferred to the
Service[,] for the preceding fiscal year which
is allocated to each [service unit] Service
Unit, Indian [tribe] Tribe, or [comparable
entity] Tribal Organization;
(B) the number of Indians eligible for health
services in each [service unit] Service Unit or
Indian [tribe; and] Tribe or Tribal
Organization; and
(C) the number of Indians using the Service
resources made available to each [service unit
or Indian tribe.] Service Unit, Indian 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.
[(f) Appropriated funds included in base budget of Service]
(g) Inclusion in Base Budget._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.
[(g) Continuation of Service responsibilities for backlogs
and parity ]
(h) Clarification._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 [parity] equity
among Indian [tribes.] Tribes and Tribal Organizations.
[(h) Authorization of appropriations]
(i) Funding Designation._Any funds appropriated under the
authority of this section shall be designated as the
[``]`Indian Health Care Improvement Fund.['']'
[Sec. 1621a. Catastrophic Health Emergency Fund]
SEC. 202. CATASTROPHIC HEALTH EMERGENCY FUND.
(a) Establishment[; administration; purpose (1)].--There is
[hereby] established an Indian Catastrophic Health Emergency
Fund (hereafter in this section referred to as the [``Fund'']
``CHEF'') consisting of--
[(A)] (1) the amounts deposited under subsection [(d)
of this section,] (f); and
[(B)] (2)) the amounts appropriated to [the Fund]
CHEF under this section.
[(2) The Fund](b) Administration._CHEF shall be
administered by the Secretary, acting through the
[central office] headquarters 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] (c) Conditions on Use of
Fund._No part of CHEF 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.), nor shall CHEF funds be
allocated, apportioned, or delegated on [a service
unit, area office, or any other] an Area Office,
Service Unit, or other similar basis.
[(4) No part of the Fund or its administration shall
be subject to contract or grant under any law,
including the Indian Self-Determination Act [25
U.S.C.A. Sec. 450f et seq.].]
[(b) Regulations; procedures for payment]
(d) Regulations._The Secretary shall[, through the
promulgation of] promulgate 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 [the Fund] CHEF;
(2) provide that a [service unit] Service Unit shall
not be eligible for reimbursement for the cost of
treatment from [the Fund] CHEF 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) for 1993, not less than $15,000 or not
more than $25,000; and]
(A) the 2000 level of $19,000; 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) service units or facilities of the
Service, or]
(A) Service Units; or
(B) whenever otherwise authorized by the
Service, non-Service facilities or providers[,
in rendering treatment that exceeds such
threshold cost];
(4) establish a procedure for payment from [the Fund]
CHEF in cases in which the exigencies of the medical
circumstances warrant treatment prior to the
authorization of such treatment by the Service; and
(5) establish a procedure that will ensure that no
payment shall be made from [the Fund] CHEF to any
provider of treatment to the extent that such provider
is eligible to receive payment for the treatment from
any other Federal, State, local, or private source of
reimbursement for which the patient is eligible.
[(c) Effect on other appropriations]
(e) No Offset or Limitation._Amounts appropriated to [the
Fund] CHEF under this section shall not be used to offset or
limit appropriations made to the Service under the authority of
[section 13 of this title] the Act of November 2, 1921 (25
U.S.C. 13) (commonly known as the ``Snyder Act''), or any other
law.
[(d) Reimbursements to fund]
(f) Deposit of Reimbursement Funds._There shall be
deposited into [the Fund] CHEF 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 [the Fund] CHEF.
SEC. 203. HEALTH PROMOTION AND DISEASE PREVENTION SERVICES.
(a) Findings.--Congress finds that health promotion and
disease prevention activities--
(1) improve the health and well-being of Indians; and
[Sec. 1621b. Health promotion and disease prevention services]
(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
[1602(b) of this title]3(2).
[(b)](c) Evaluation [statement for Presidential budget].--
The Secretary, after obtaining input from the affected Tribal
Health Programs, shall submit to the President for inclusion in
[each statement] the report which is required to be submitted
to [the] Congress under section [1671 of this title] 801 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 prevention, treatment, and control]
SEC. 204. DIABETES PREVENTION, TREATMENT, AND CONTROL.
[(a) Incidence and complications]
(a) Determinations Regarding Diabetes.--The Secretary,
acting through the Service, and in consultation with [the
tribes] Indian Tribes and Tribal Organizations, shall
determine--
(1) by [tribe] Indian Tribe and by Service [unit of
the Service] Unit, 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 [unit] Unit should take to
reduce the incidence of, and prevent, treat, and
control the complications resulting from, diabetes
among [tribes] Indian Tribes within that Service [unit]
Unit.
(b) Diabetes Screening.--[The]To the extent medically
indicated and with informed consent, the 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 establish a cost-effective
approach to ensure ongoing monitoring of disease indicators.
Such screening [may be done by 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.].] and monitoring may be conducted
by a Tribal Health Program and may be conducted through
appropriate Internet-based health care management programs.
[(c) Model diabetes projects]
[(1)] (c) Diabetes projects.--The Secretary shall continue
to maintain through [fiscal year 2000] each model diabetes
project in existence on [October 29, 1992 and located--] the
date of enactment of the Indian Health Care Improvement Act
Amendments of 2007, 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 2007 and for
projects which are added and funded thereafter.
[(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) Control officer; registry of patients
[The Secretary shall--]
(d) Dialysis Programs.--The Secretary is authorized to
provide, through the Service, Indian Tribes, and Tribal
Organizations, dialysis programs, including the purchase of
dialysis equipment and the provision of necessary staffing.
(e) Other Duties of the Secretary.--
(1) In general.--The Secretary shall, to the extent
funding is available--
[(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] (A) in each Area Office, consult with
Indian Tribes and Tribal Organizations regarding
programs for the prevention, treatment, and control of
diabetes;
[(2) establish in each area office of the Service]
(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
[(3)](C) ensure that data collected in each [area
office] Area Office regarding diabetes and related
complications among Indians [is] are disseminated to
all other [area offices; and (4) evaluate the
effectiveness of services provided through model
diabetes projects established under this section] Area
Offices, subject to applicable patient privacy laws.
[(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.]
(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.
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 Assistance Act (25
U.S.C. 450 et seq.) with Indian Tribes or Tribal Organizations
for, the delivery of long-term care (including health care
services associated with long-term care) provided in a facility
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 related facility owned and
operated (directly or through a contract or compact under the
Indian Self-Determination and Education Assistance Act (25
U.S.C. 450 et seq.)) by such Indian Tribe or Tribal
Organization.
(b) Contents of Agreements.--An agreement entered into
pursuant to subsection (a)--
[Sec. 1621d. Hospice care feasibility study]
(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;
[(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.]
(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
[Sec. 1621e. Reimbursement from certain third parties of costs of
health services]
(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).
[(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 a 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.]
(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.
[Sec. 1621f. Crediting of reimbursements]
(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.
[(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 health care 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.]
(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. 1621g. Health services research]
SEC. 206. HEALTH SERVICES RESEARCH.
[Of the amounts appropriated for]
(a) In General.--The Secretary, acting through 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], shall make funding available 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.]] Indian Health Programs.
(b) Coordination of Resources and Activities.--The
Secretary shall also, to the maximum extent practicable,
coordinate departmental research resources and activities to
address relevant Indian Health Program research needs.
(c) Availability.--Tribal Health Programs shall be given an
equal opportunity to compete for, and receive, research funds
under this section.
[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 Act,
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 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
sections 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, and implementing 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
health 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 1625o(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
years 1994, 1995, 1996, 1997, 1998, 1999, and 2000.
(d) Use of Funds.--This funding may be used for both
clinical and nonclinical research.
[Sec. 1621i. Managed care feasibility study]
(e) Evaluation and Dissemination.--The Secretary shall
periodically--
[(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.
(1) evaluate the impact of research conducted under
this section; and
[Sec. 1621j. California contract health services demonstration program]
(2) disseminate to Tribal Health Programs information
regarding that research as the Secretary determines to
be appropriate.
[(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. 207. MAMMOGRAPHY AND OTHER CANCER SCREENING.
[Sec. 1621k. Coverage of screening mammography]
The Secretary, acting through the Service or Tribal Health
Programs, shall provide for screening as follows:
[The Secretary, through the Service, shall provide
for screening] (1) Screening mammography (as defined in
section 1861(jj) of the Social Security Act [[42
U.S.C.A. Sec. 1395x(jj)]]) 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),] 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 [assure] ensure 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.].] such Act.
(2) Other cancer screening that receives an A or B
rating as recommended by the United States Preventive
Services Task Force established under section 915(a)(1)
of the Public Health Service Act (42 U.S.C. 299b-
4(a)(1)). The Secretary shall ensure that screening
provided for under this paragraph complies with the
recommendations of the Task Force with respect to--
(A) frequency;
(B) the population to be served;
(C) the procedure or technology to be used;
(D) evidence of effectiveness; and
(E) other matters that the Secretary
determines appropriate.
SEC. 208. PATIENT TRAVEL COSTS.
(a) Definition of Qualified Escort.--In this section, the
term `qualified escort' means--
(1) an adult escort (including a parent, guardian, or
other family member) who is required because of the
physical or mental condition, or age, of the applicable
patient;
(2) a health professional for the purpose of
providing necessary medical care during travel by the
applicable patient; or
[Sec. 1621l. Patient travel costs]
(3) other escorts, as the Secretary or applicable
Indian Health Program determines to be appropriate.
[(a) The Secretary, acting through the Service, shall
provide funds for the following patient travel costs] (b)
Provision of Funds.--The Secretary, acting through the Service
and Tribal Health Programs, is authorized to provide funds for
the following patient travel costs, including qualified
escorts, 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
Act--] a contract or compact under the Indian Self-
Determination and Education Assistance Act (25 U.S.C. 450 et
seq.)) under this Act--
(1) emergency air transportation[;] and [(2)
nonemergency] non-emergency 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.]
(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. 1621m. Epidemiology centers]
SEC. 209. EPIDEMIOLOGY CENTERS.
(a)[(1)] Establishment of Centers.--The Secretary shall
establish an epidemiology center in each Service [area] Area to
carry out the functions described in [paragraph (3).]
subsection (b). Any new center established after the date of
enactment of the Indian Health Care Improvement Act Amendments
of 2007 may be operated under a grant authorized by subsection
(d), but funding under such a grant shall not be divisible.
[(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 defining
health 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--
(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 section shall, with respect to such
Service Area--
[A] (1) 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);] of the
Service, the Indian Tribes, Tribal Organizations, and
Urban Indian Organizations in the Service Area;
[(B)](2) evaluate existing delivery systems, data
systems, and other systems that impact the improvement
of Indian health;
[(C)](3) assist [tribes and urban Indian communities]
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;
[(D)](4) make recommendations for the targeting of
services needed by [tribal, urban, and other Indian
communities] the populations served;
[(E)](5) make recommendations to improve health care
delivery systems for Indians and [urban] Urban Indians;
[(F) work cooperatively with tribal providers of
health and social services in order to avoid
duplication of existing services; and]
[(G)] (6) provide requested technical assistance to
Indian [tribes and urban Indian organizations] 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
[(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.).]
(7) provide disease surveillance and assist Indian
Tribes, Tribal Organizations, and Urban Indian
Organizations to promote public health.
[(5)] (c) Technical Assistance.--The [director] Director of
the Centers for Disease Control and Prevention shall provide
technical assistance to the centers in carrying out the
requirements of this [subsection] section.
[(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.]
(d) Grants for Studies.--
[(b)] (1) In general.--The Secretary may make grants
to Indian [tribes, tribal organizations] Tribes, Tribal
Organizations, Urban Indian Organizations, and eligible
intertribal consortia [or Indian organizations] to
conduct epidemiological studies of Indian communities.
[(2)] (2) Eligible intertribal consortia.--An
intertribal [consortia or Indian organization]
consortium is eligible to receive a grant under this
subsection if--
[(A) it] (A) the intertribal consortium is
incorporated for the primary purpose of
improving Indian health; and
[(B) it] (B) the intertribal consortium is
representative of the [tribes] Indian Tribes or
urban Indian communities in which [it] the
intertribal consortium is located.
(3) Applications.--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] (4) Requirements.--An
applicant for a grant 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] Tribes or [urban] Urban Indian
[organizations] Organizations in the area to be
served.
(5) Use of funds.--A grant awarded under paragraph
(1) may be used [to]--
(A) to carry out the functions described in
subsection ([a]b);
[(3) of this section;] (B) to provide
information to and consult with tribal leaders,
urban Indian community leaders, and related
health staff[,] on health care and health
[services]service management issues; and
(C) [provide,] in collaboration with [tribes]
Indian Tribes, Tribal Organizations, and urban
Indian communities, to provide the Service with
information regarding ways to improve the
health status of [Indian people] Indians.
[(6) There are authorized to be appropriated to carry
out the purposes of this subsection not more than
$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.]
(e) Access to Information.--An epidemiology center operated
by a grantee pursuant to a grant awarded under subsection (d)
shall be treated as a public health authority for purposes of
the Health Insurance Portability and Accountability Act of 1996
(Public Law 104-191; 110 Stat. 2033), as such entities are
defined in part 164.501 of title 45, Code of Federal
Regulations (or a successor regulation). The Secretary shall
grant such grantees access to and use of data, data sets,
monitoring systems, delivery systems, and other protected
health information in the possession of the Secretary.
[Sec. 1621n. Comprehensive school health education programs]
SEC. 210. COMPREHENSIVE SCHOOL HEALTH EDUCATION PROGRAMS.
[(a) Award of grants
[The] (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
[and in consultation with the Secretary of the Interior, may],
is authorized to award grants to Indian [tribes] Tribes, Tribal
Organizations, and Urban Indian Organizations to develop
comprehensive school health education programs for children
from [preschool] pre-school through grade 12 in schools
[located on] for the benefit of Indian [reservations.] and
Urban Indian children.
(b) Use of [grantsGrants] Grant Funds.--A grant awarded
under this section may be used [to--] for purposes which may
include, but are not limited to, the following:
[(1) develop health education curricula;]
(1) Developing health education materials both for
regular school programs and afterschool programs.
(2) [train] Training teachers in comprehensive school
health education [curricula;] materials.
(3) [integrate] Integrating school-based, community-
based, and other public and private health promotion
efforts[;].
(4) [encourage] Encouraging healthy, tobacco-free
school environments[;].
(5) [coordinate] Coordinating school-based health
programs with existing services and programs available
in the community[;].
(6) [develop] Developing school programs on nutrition
education, personal health, oral health, and
fitness[;].
[(7) develop mental] (7) Developing behavioral health
wellness programs[;].
(8) [develop] Developing chronic disease prevention
programs[;].
(9) [develop] Developing substance abuse prevention
programs[;].
(10) [develop accident] Developing injury prevention
and safety education programs[;].
(11) [develop] Developing activities for the
prevention and control of communicable diseases[; and].
(12) [develop] 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 [The].--Upon request, the
Secretary, acting through the Service, shall provide technical
assistance to Indian [tribes] 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] 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 grants [made pursuant to this section.]
awarded under this section.
(e) [Report] Development 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] 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 [operated] for which
support is provided by the Bureau of Indian Affairs.
[(2) Such program shall include--]
(2) Requirements for programs._Such programs shall
include--
(A) school programs on nutrition education,
personal health, oral health, and fitness;
(B) [mental] behavioral health wellness
programs;
(C) chronic disease prevention programs;
(D) substance abuse prevention programs;
(E) [accident] injury prevention and safety
education programs; and
(F) activities for the prevention and control
of communicable diseases.
[(3) The Secretary of the Interior shall--]
(3) Duties of the secretary._The Secretary of the
Interior shall--
[(A) provide training to teachers in
comprehensive school health education
[curricula;] materials;
(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 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. 1621o. Indian youth grant program]
SEC. 211. INDIAN YOUTH PROGRAM.
[(a) Grants]
(a) Program Authorized._The Secretary, acting through the
Service, is authorized to [make] establish and administer a
program to provide grants to Indian [tribes, tribal
organizations, and urban Indian organizations] 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] 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 [healers] 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 [1621h(m) of this title.] 707(c).
[(c) Models for delivery of comprehensive health care
services
[The]
(c) Duties of the Secretary[shall].--The Secretary shall--
(1) disseminate to Indian [tribes] Tribes, Tribal
Organizations, and Urban Indian Organizations
information regarding models for the delivery of
comprehensive health care services to Indian and
[urban] Urban Indian adolescents;
(2) encourage the implementation of such models; and
(3) at the request of an Indian [tribe] Tribe, Tribal
Organization, or Urban Indian Organization, provide
technical assistance in the implementation of such
models.
(d) Criteria for [the review and approval of applications]
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.
[(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. 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
SEC. 212. PREVENTION, CONTROL, AND ELIMINATION OF COMMUNICABLE AND
INFECTIOUS DISEASES.
[(a) Grants]
(a) Grants Authorized.--The Secretary, acting through the
Service, and after consultation with the Centers for Disease
Control and Prevention, may make grants [to Indian tribes and
tribal organizations for--] available to Indian Tribes, Tribal
Organizations, and Urban Indian Organizations for the
following:
[(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]
(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] Education, training, and clinical
skills improvement activities in the prevention,
control, and elimination of [tuberculosis] 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 [for grant] Required.--The Secretary may
[make a grant] provide funding under subsection (a) [of this
section] only if an application [for the grant] or proposal for
funding 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] (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[; and].
[(2) the applicant will submit to the Secretary an
annual report on its activities for the prevention,
control, and elimination of tuberculosis.
[(d) Duty of Secretary]
(d) Technical Assistance; Report._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] (1) may, at the request of an Indian [tribe or
tribal organization] Tribe, Tribal Organization, or
Urban Indian Organization, provide technical
assistance; and
[(4] (2) 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,] Congress biennially
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.] communicable and infectious
diseases among Indians and Urban Indians.
[(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. 213. OTHER AUTHORITY FOR PROVISION OF 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 of this Act through health care-related services and
programs not otherwise described in this Act, including--
(1) hospice care;
(2) assisted living;
(3) long-term care; and
(4) home- and community-based services.
(b) Terms and Conditions.--
(1) In general.--Any service provided under this
section shall be in accordance with such terms and
conditions as are consistent with accepted and
appropriate standards relating to the service,
including any licensing term or condition under this
Act.
(2) Standards.--
(A) In general.--The Secretary may establish,
by regulation, the standards for a service
provided under this section, provided that such
standards shall not be more stringent than the
standards required by the State in which the
service is provided.
(B) Use of state standards.--If the Secretary
does not, by regulation, establish standards
for a service provided under this section, the
standards required by the State in which the
service is or will be provided shall apply to
such service.
(C) Indian tribes.--If a service under this
section is provided by an Indian Tribe or
Tribal Organization pursuant to the Indian
Self-Determination and Education Assistance Act
(25 U.S.C. 450 et seq.), the verification by
the Secretary that the service meets any
standards required by the State in which the
service is or will be provided shall be
considered to meet the terms and conditions
required under this subsection.
(3) Eligibility.--The following individuals shall be
eligible to receive long-term care under this section:
(A) Individuals who are unable to perform a
certain number of activities of daily living
without assistance.
(B) Individuals with a mental impairment,
such as dementia, Alzheimer's disease, or
another disabling mental illness, who may be
able to perform activities of daily living
under supervision.
(C) Such other individuals as an applicable
Indian Health Program determines to be
appropriate.
(c) Definitions.--For the purposes of this section, the
following definitions shall apply:
(1) The term ``home- and community-based services''
means 1 or more of the services specified in paragraphs
(1) through (9) of section 1929(a) of the Social
Security Act (42 U.S.C. 1396t(a)) (whether provided by
the Service or by an Indian Tribe or Tribal
Organization pursuant to the Indian Self-Determination
and Education Assistance Act (25 U.S.C. 450 et seq.))
that are or will be provided in accordance with the
standards described in subsection (b).
(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.
(d) Authorization of Convenient Care Services.--The
Secretary, acting through the Service, Indian Tribes, and
Tribal Organizations, may also provide funding under this Act
to meet the objectives set forth in section 3 of this Act for
convenient care services programs pursuant to section
306(c)(2)(A).
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. 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) 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; 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 enactment of the Indian Health
Care Improvement Act Amendments of 2007 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 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 enactment of the Indian Health Care Improvement Act
Amendments of 2007. The health care plan prepared under
subsection (b) shall be submitted in a report no later than 1
year after the study 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 Assistant Secretary.
(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. 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, 2016, 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. 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
\1/2\ of whom 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. 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 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. 1621r. Contract health services payment study]
SEC. 222. NOTIFICATION OF PROVISION OF EMERGENCY CONTRACT HEALTH
SERVICES.
[(a) Duties 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
requirements 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.]
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. 1621s. Prompt action on payment of claims]
SEC. 223. PROMPT ACTION ON PAYMENT OF CLAIMS.
[(a) Time of response]
(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) Failure to timely respond]
(b) Effect of Untimely Response._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]
(c) Deadline for Payment of Valid Claim._The Service shall
pay a [completed] valid contract care service claim within 30
days after the 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. 224. LIABILITY FOR PAYMENT.
[Sec. 1621u.]
(a) No Patient 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) 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 223(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 may 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 2007, the Secretary, acting through the director of the
Office, shall submit to Congress a report describing--
[Sec. 1621v. Office of Indian Women's Health Care]
(1) any activity carried out by the director as of
the date on which the report is prepared; and
[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.]
(2) any finding of the director with respect to the
health of Indian men.
[Sec. 1621w. Authorization of appropriations]
SEC. 226. AUTHORIZATION OF APPROPRIATIONS.
[Except as provided in sections 1621h(m), 1621j, 1621l,
1621m(b)(5), 1621n, and 1621o of this title, there] 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] 2017 to carry out this title.
[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.].]
TITLE III--FACILITIES
[Sec. 1631. Consultation; closure of facilities; reports]
SEC. 301. CONSULTATION; CONSTRUCTION AND RENOVATION OF FACILITIES;
REPORTS.
[(a) Consultation; standards for accreditation]
(a) Prerequisites for Expenditure of Funds._Prior to the
expenditure of, or the making of any [firm] binding 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)[,] [popularly] (commonly
known as the ``Snyder Act''), the Secretary, acting through the
Service, shall--
(1) consult with any Indian [tribe] 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 [the
Joint Commission on Accreditation of Health Care
Organizations] 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 by not later than 1 year after
the date on which the construction or renovation of
such facility is completed.
[(b) Closure; report on proposed closure]
(b) Closures.--
(1) Evaluation required._Notwithstanding any other
provision of law [other than this subsection], no
facility operated by the 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 such hospital or
facility (or portion thereof) is proposed to be closed
on evaluation of the impact of such proposed closure
which] Congress not less than 1 year, and not more than
2 years, before the date of the proposed closure an
evaluation, completed not more than 2 years before the
submission, of the impact of the proposed closure that
specifies, in addition to other considerations--
(A) the accessibility of alternative health
care resources for the population served by
such [hospital or] facility;
(B) the cost-effectiveness of such closure;
(C) the quality of health care to be provided
to the population served by such [hospital or]
facility after such closure;
(D) the availability of contract health care
funds to maintain existing levels of service;
(E) the views of the Indian [tribes] Tribes
served by such [hospital or] facility
concerning such closure;
(F) the level of [utilization] use 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) Annual report on health facility priority system
[(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
which sets forth--
[(A) the current health facility priority
system of the Service,
[(B) the planning, design, construction, and
renovation needs for the 10 top-priority
inpatient care facilities and the 10 top-
priority ambulatory care facilities (together
with required staff quarters),
[(C) the justification for such order of
priority,
[(D) the projected cost of such projects, and
[(E) the methodology adopted by the Service
in establishing priorities under its health
facility priority system.
[(2) In preparing each report required under
paragraph (1) (other than the initial report), the
Secretary shall--
[(A) consult with Indian tribes and tribal
organizations including those tribes or tribal
organizations operating 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 needs of such tribes and
tribal organizations for inpatient and
outpatient facilities, including their needs
for renovation and expansion of existing
facilities.
[(3) For purposes of this subsection, the Secretary
shall, in evaluating the needs of facilities 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 the needs of facilities
operated directly by the Service.]
(c) Health Care Facility Priority System.--
(1) In general.--
(A) Priority system.--The Secretary, acting
through the Service, shall maintain a health
care facility priority system, which--
(i) shall be developed in
consultation with Indian Tribes and
Tribal Organizations;
(ii) shall give Indian Tribes' needs
the highest priority;
(iii)(I) may include the lists
required in paragraph (2)(B)(ii); and
(II) shall include the methodology
required in paragraph (2)(B)(v); and
(III) may include such other
facilities, and such renovation or
expansion needs of any health care
facility, as the Service, Indian
Tribes, and Tribal Organizations may
identify; and
(iv) shall provide an opportunity for
the nomination of planning, design, and
construction projects by the Service,
Indian Tribes, and Tribal Organizations
for consideration under the priority
system at least once every 3 years, or
more frequently as the Secretary
determines to be appropriate.
[(4)] (B) Needs of facilities under ISDEAA
agreements.--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 for health services entered into
with the Service under] operated under
contracts or compacts in accordance with the
Indian Self-Determination and Education
Assistance Act [[](25 U.S.C.[A. Sec. 450f] 450
et seq.[]])are fully and equitably integrated
into the [development of the] health care
facility priority system.
[(d) Funds appropriated subject to section 450f of this
title]
(C) Criteria for evaluating needs.--For
purposes of this subsection, the Secretary, in
evaluating the needs of facilities operated
under a contract or compact under the Indian
Self-Determination and Education Assistance Act
(25 U.S.C. 450 et seq.), shall use the criteria
used by the Secretary in evaluating the needs
of facilities operated directly by the Service.
(D) Priority of certain projects protected.--
The priority of any project established under
the construction priority system in effect on
the date of enactment of the Indian Health Care
Improvement Act Amendments of 2007 shall not be
affected by any change in the construction
priority system taking place after that date if
the project--
(i) was identified in the fiscal year
2008 Service budget justification as--
(I) 1 of the 10 top-priority
inpatient projects;
(II) 1 of the 10 top-priority
outpatient projects;
(III) 1 of the 10 top-
priority staff quarters
developments; or
(IV) 1 of the 10 top-priority
Youth Regional Treatment
Centers;
(ii) had completed both Phase I and
Phase II of the construction priority
system in effect on the date of
enactment of such Act; or
(iii) is not included in clause (i)
or (ii) and is selected, as determined
by the Secretary--
(I) on the initiative of the
Secretary; or
(II) pursuant to a request of
an Indian Tribe or Tribal
Organization.
(2) Report; contents.--
(A) Initial comprehensive report.--
(i) Definitions.--In this
subparagraph:
(I) Facilities appropriation
advisory board.--The term
``Facilities Appropriation
Advisory Board'' means the
advisory board, comprised of 12
members representing Indian
tribes and 2 members
representing the Service,
established at the discretion
of the Assistant Secretary--
(aa) to provide
advice and
recommendations for
policies and procedures
of the programs funded
pursuant to facilities
appropriations; and
(bb) to address other
facilities issues.
(II) Facilities needs
assessment workgroup.--The term
``Facilities Needs Assessment
Workgroup'' means the workgroup
established at the discretion
of the Assistant Secretary--
(aa) to review the
health care facilities
construction priority
system; and
(bb) to make
recommendations to the
Facilities
Appropriation Advisory
Board for revising the
priority system.
(ii) Initial report.--
(I) In general.--Not later
than 1 year after the date of
enactment of the Indian Health
Care Improvement Act Amendments
of 2007, the Secretary shall
submit to the Committee on
Indian Affairs of the Senate
and the Committee on Natural
Resources of the House of
Representatives a report that
describes the comprehensive,
national, ranked list of all
health care facilities needs
for the Service, Indian Tribes,
and Tribal Organizations
(including inpatient health
care facilities, outpatient
health care facilities,
specialized health care
facilities (such as for long-
term care and alcohol and drug
abuse treatment), wellness
centers, staff quarters and
hostels associated with health
care facilities, and the
renovation and expansion needs,
if any, of such facilities)
developed by the Service,
Indian Tribes, and Tribal
Organizations for the
Facilities Needs Assessment
Workgroup and the Facilities
Appropriation Advisory Board.
(II) Inclusions.--The initial
report shall include--
(aa) the methodology
and criteria used by
the Service in
determining the needs
and establishing the
ranking of the
facilities needs; and
(bb) such other
information as the
Secretary determines to
be appropriate.
(iii) Updates of report.--Beginning
in calendar year 2011, the Secretary
shall--
(I) update the report under
clause (ii) not less frequently
than once every 5 years; and
(II) include the updated
report in the appropriate
annual report under
subparagraph (B) for submission
to Congress under section 801.
(B) Annual reports.--The Secretary shall
submit to the President, for inclusion in the
report required to be transmitted to Congress
under section 801, a report which sets forth
the following:
(i) A description of the health care
facility priority system of the Service
established under paragraph (1).
(ii) Health care facilities lists,
which may include--
(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.
(iii) The justification for such
order of priority.
(iv) The projected cost of such
projects.
(v) The methodology adopted by the
Service in establishing priorities
under its health care facility priority
system.
(3) Requirements for preparation of reports.--In
preparing the report required under paragraph (2), the
Secretary shall--
(A) consult with and obtain information on
all health care facilities needs from Indian
Tribes, Tribal Organizations, and Urban Indian
Organizations; and
(B) review the total unmet needs of all
Indian Tribes, Tribal Organizations, and Urban
Indian Organizations for health care facilities
(including hostels and staff quarters),
including needs for renovation and expansion of
existing facilities.
(d) Review of Methodology Used for Health Facilities
Construction Priority System.--
(1) In general.--Not later than 1 year after the
establishment of the priority system under subsection
(c)(1)(A), the Comptroller General of the United States
shall prepare and finalize a report reviewing the
methodologies applied, and the processes followed, by
the Service in making each assessment of needs for the
list under subsection (c)(2)(A)(ii) and developing the
priority system under subsection (c)(1), including a
review of--
(A) the recommendations of the Facilities
Appropriation Advisory Board and the Facilities
Needs Assessment Workgroup (as those terms are
defined in subsection (c)(2)(A)(i)); and
(B) the relevant criteria used in ranking or
prioritizing facilities other than hospitals or
clinics.
(2) Submission to congress.--The Comptroller General
of the United States shall submit the report under
paragraph (1) to--
(A) the Committees on Indian Affairs and
Appropriations of the Senate;
(B) the Committees on Natural Resources and
Appropriations of the House of Representatives;
and
(C) the Secretary.
(e) Funding Condition._ All funds appropriated under the
Act of November 2, 1921 (25 U.S.C. 13) (commonly known as the
``Snyder Act''), for the planning, design, construction, or
renovation of health facilities for the benefit of [an] 1 or
more Indian [tribe or tribes] Tribes shall be subject to the
provisions of [section 102 of] the Indian Self-Determination
and Education Assistance Act [(25 U.S.C.[A. Sec. 450f].] 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. Safe water and sanitary waste disposal facilities]
SEC. 302. SANITATION FACILITIES.
[(a) Congressional findings
[The] (a) Findings._Congress [hereby] finds [and declares
that--] the following:
(1) [the]The provision of [safe water supply systems
and sanitary sewage and solid waste disposal
systems]sanitation facilities is primarily a health
consideration and function[;].
(2) Indian people suffer an inordinately high
incidence of disease, injury, and illness directly
attributable to the absence or inadequacy of [such
systems;]sanitation facilities.
(3) [the]The long-term cost to the United States of
treating and curing such disease, injury, and illness
is substantially greater than the short-term cost of
providing [such systems]sanitation facilities and other
preventive health measures[;].
(4) [many]Many Indian homes and Indian communities
still lack [safe water supply systems and sanitary
sewage and solid waste disposal systems; and]sanitation
facilities.
(5) [it]It is in the interest of the United States,
and it is the policy of the United States, that all
Indian communities and Indian homes, new and existing,
be provided with [safe and adequate water supply
systems and sanitary sewage waste disposal systems as
soon as possible]sanitation facilities.
[(b) Authority; assistance; transfer of funds]
[(1)](b) Facilities and Services.--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 [2004a of Title
42. (2) The] 7 of the Act of August 5, 1954 (42 U.S.C. 2004a).
Under such authority, the Secretary, acting through the
Service, is authorized to provide [under section 2004a of Title
42--] the following:
[(A) financial](1) Financial and technical assistance
to Indian [tribes and]Tribes, Tribal Organizations, and
Indian communities in the establishment, training, and
equipping of utility organizations to operate and
maintain [Indian sanitation facilities;]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.
[(B)] (2) [ongoing]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].
[(C)](3) Priority funding for operation and
maintenance assistance for, and emergency repairs to,
[tribal] sanitation facilities operated by an Indian
Tribe, Tribal Organization or Indian community when
necessary to avoid [a] an imminent health [hazard]
threat or to protect the [Federal] investment in
sanitation facilities[.] and the investment in the
health benefits gained through the provision of
sanitation facilities.
[(3)](c) Funding._Notwithstanding any other provision of
law--
[(A) the Secretary of Housing and Urban
Affairs is authorized to transfer funds
appropriated under the Housing and Community
Development Act of 1974 (42 U.S.C. 5301, et
seq.) to the Secretary of Health and Human
Services; and]
(1) the Secretary of Housing and Urban Development is
authorized to transfer funds appropriated under the
Native American Housing Assistance and Self-
Determination Act of 1996 (25 U.S.C. 4101 et seq.) to
the Secretary of Health and Human Services;
[(B)](2) 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 [2004a of Title 42.] 7 of the
Act of August 5, 1954 (42 U.S.C. 2004a);
[(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) Tribal capability]
(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 purpose of providing
sanitation facilities and services and place these
funds into contracts or compacts under the Indian Self-
Determination and Education Assistance 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;
(9) the Secretary of Health and Human Services shall,
by regulation, establish standards applicable to the
planning, design, and construction of sanitation
facilities funded under this Act; and
(10) the Secretary of Health and Human Services is
authorized to accept payments for goods and services
furnished by the Service from appropriate public
authorities, nonprofit organizations or agencies, or
Indian Tribes, as contributions by that authority,
organization, agency, or tribe to agreements made under
section 7 of the Act of August 5, 1954 (42 U.S.C.
2004a), and such payments shall be credited to the same
or subsequent appropriation account as funds
appropriated under the authority of section 7 of the
Act of August 5, 1954 (42 U.S.C. 2004a).
(d) Certain Capabilities Not Prerequisite.--The financial
and technical capability of an Indian [tribe or] 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) Amount of assistance]
[(1)] (e) Financial Assistance.--The Secretary is
authorized to provide financial assistance to Indian [tribes
and communities 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.] Tribes, Tribal Organizations, and Indian communities
for operation, management, and maintenance of their sanitation
facilities.
[(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) 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.
[(g) Annual]
(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.
(h) Report.--
(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 the report[;
sanitation deficiency levels]
[(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,]
Congress under section 801, a report which sets forth--
[(A) the current Indian sanitation facility
priority system of the Service;]
(A) the current Indian sanitation facility
priority system of the Service;
(B) the methodology for determining
sanitation deficiencies[;]
[(C) the level of sanitation deficiency for
each sanitation facilities project of each
Indian tribe or community;
[(D) the amount of funds necessary to raise
all Indian tribes and communities to a level I
sanitation deficiency; and
[(E) the amount of funds necessary to raise
all Indian tribes and communities to zero
sanitation deficiency.
[(2) 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.] and needs;
(C) the criteria on which the deficiencies
and needs will be evaluated;
(D) the level of initial and final sanitation
deficiency for each type of sanitation facility
for each project of each Indian Tribe or Indian
community;
(E) 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 (25 U.S.C. 4101 et seq.), and
to reduce the identified sanitation deficiency
levels of all Indian Tribes and Indian
communities to level I sanitation deficiency as
defined in paragraph (3)(A); and
(F) a 10-year plan to provide sanitation
facilities to serve existing Indian homes and
Indian communities and new and renovated Indian
homes.
[(3)] (2) 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 [tribes and] Tribes and Indian
communities.
[(4)] (3) Sanitation deficiency levels.--For purposes
of this subsection, the sanitation deficiency levels
for an [Indian tribe or community are] individual,
Indian Tribe, or Indian community sanitation facility
to serve Indian homes are determined as follows:
[(A) level I is an Indian tribe or community
with a sanitation system--]
(A) A level I deficiency exists if a
sanitation facility serving an individual,
Indian Tribe, or Indian community--
(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 [is an Indian tribe or
community with a sanitation system--]
[(i) which complies] deficiency
exists if a sanitation facility serving
an individual, Indian Tribe, or Indian
community substantially or recently
complied with all applicable water
supply [and], pollution control [laws,
and (ii) in which the], and solid waste
laws and any deficiencies relate to--
(i) small or minor capital
improvements needed to bring the
facility back into compliance;
(ii) 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 [is an Indian tribe or
community with a sanitation system which--]
deficiency exists if a sanitation facility
serving an individual, Indian Tribe or Indian
community meets 1 or more of the following
conditions--
[(i) 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) has no solid waste disposal
facility;
[(D) level IV is an Indian tribe or community
with a sanitation system which lacks either a
safe water supply system or a sewage disposal
system; and
[(E) level V is an Indian tribe or community
that lacks a safe water supply and a sewage
disposal system.
[(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.]
(i) water or sewer service in the
home is provided by a haul system with
holding tanks and interior plumbing;
(ii) major significant interruptions
to water supply or sewage disposal
occur frequently, requiring major
capital improvements to correct the
deficiencies; or
(iii) there is no access to or no
approved or permitted solid waste
facility available.
(D) A level IV deficiency exists--
(i) if a sanitation facility for 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.
(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).
[Sec. 1633. Preference to Indians and Indian firms]
SEC. 303. PREFERENCE TO INDIANS AND INDIAN FIRMS.
[(a) Discretionary authority; covered activities]
(a) Buy Indian Act.--The Secretary, acting through the
Service, may [utilize] use the negotiating authority of section
[47 of this title] 23 of the Act of June 25, 1910 (25 U.S.C.
47, commonly known as the ``Buy Indian Act''), 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 [tribes] 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 [1631 of this title and in the
construction of safe water and sanitary waste disposal] 301 and
in the construction of sanitation facilities pursuant to
section [1632 of this title.] 302. Such preference may be
accorded by the Secretary unless [he] the Secretary finds,
pursuant to [rules and] regulations [promulgated 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 [his] such a 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) Pay rates]
(b) Labor Standards.--
(1) In general.--For the [purpose] purposes of
implementing the provisions of this [subchapter, the
Secretary shall assure that the rates of pay for
personnel engaged in] title, contracts for the
construction or renovation of [facilities constructed
or renovated] health care facilities, staff quarters,
and sanitation facilities, and related support
infrastructure, funded in whole or in part [by] with
funds made available pursuant to this title [[25
U.S.C.A. Sec. Sec. 1631 et seq.] are not less than the
prevailing local wage rates for similar work as
determined in accordance with the Act of March 3, 1931
(40 U.S.C. 276a to 276a-5, known as the Davis-Bacon
Act).], 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--
(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 non-Service funds for renovation]
SEC. 304. EXPENDITURE OF NON-SERVICE FUNDS FOR RENOVATION.
[(a) Authority of Secretary]
[(1)] (a) In General.--Notwithstanding any other provision
of law, [the Secretary]if the requirements of subsection (c)
are met, the Secretary, acting through the Service, is
authorized to accept any major [renovation] expansion,
renovation, or modernization by any Indian [tribe of any
Service facility,] Tribe or Tribal Organization of any Service
facility or of any other Indian health facility operated
pursuant to a contract [entered into] or compact under the
Indian Self-Determination [Act[] and Education Assistance Act
(25 U.S.C.[A. Sec. ] [450](f) et seq.[]]), including--
[(A)] (1) any plans or designs for such expansion,
renovation, or modernization; and
[(B)] (2) 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.--
[(2)] (1) In general.--The Secretary shall maintain a
separate priority list to address the needs [of such
facilities] for increased operating expenses,
personnel, or equipment[.] for such facilities. The
methodology for establishing priorities shall be
developed through regulations. The list of priority
facilities will be revised annually in consultation
with Indian Tribes and Tribal Organizations.
[(3)](2) Report._The Secretary shall submit to the
President, for inclusion in [each] the report required
to be transmitted to [the] Congress under section [1671
of this title,] 801, the priority list maintained
pursuant to paragraph ([2]1).
([b]c) Requirements.--The requirements of this subsection
are met with respect to any expansion, renovation, or
modernization if--
(1) the [tribe or tribal organization] Indian Tribe
or Tribal Organization--
(A) provides notice to the Secretary of its
intent to expand, renovate, or modernize; and
(B) applies to the Secretary to be placed on
a separate priority list to address the needs
of such new facilities for increased operating
expenses, personnel [or equipment; and], or
equipment; and
(2) the [renovation] expansion, renovation, or
modernization--
(A) is approved by the appropriate area
director of the Service[; and] for Federal
facilities; and
(B) is administered by the [tribe] Indian
Tribe or Tribal Organization in accordance with
[the rules and] any applicable regulations
prescribed by the Secretary with respect to
construction or renovation of Service
facilities.
[(c) Recovery for non-use as Service facility]
(d) Additional Requirement for Expansion.--In addition to
the requirements under subsection (c), for any expansion, the
Indian Tribe or Tribal Organization shall provide to the
Secretary additional information pursuant to regulations,
including additional staffing, equipment, and other costs
associated with the expansion.
(e) Closure or Conversion of Facilities._If any Service
facility which has been expanded, renovated, or modernized by
an Indian [tribe] 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 [tribe] 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. 305. FUNDING FOR THE CONSTRUCTION, EXPANSION, AND MODERNIZATION OF
SMALL AMBULATORY CARE FACILITIES.
[Sec. 1636. Grant program for the construction, expansion, and
modernization of small ambulatory care facilities]
(a) Grants._
[(a) Authorization]
(1) In general._The Secretary, acting through the
Service, shall make grants to [tribes and tribal
organizations] Indian Tribes and Tribal Organizations
for the construction, expansion, or modernization of
facilities for the provision of ambulatory care
services to eligible Indians (and noneligible persons
[as provided in subsection] pursuant to subsections
(b)(2) and (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 made [to a tribe or tribal
organization] available to a Tribal Health Program
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 tribe or tribal
organization) pursuant to a contract entered into under
the Indian Self-Determination Act [25 U.S.C.A.
Sec. 450f et seq.].] an Indian Tribe or Tribal
Organization).
[(b) Use of grant
(1) 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--]
(b) Use of Grant Funds.--
(1) Allowable uses.--A grant awarded under this
section may be used 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 [1631] 301 or
section [1637 of this title] 306; and
(C) which, upon completion of such
construction[, expansion,] or modernization
will--
(i) have a total capacity appropriate
to its projected service population;
[(ii) serve no less than 500](ii)
provide annually no fewer than 150
patient visits by eligible Indians
[annually;] and other users who are
eligible for services in such facility
in accordance with section 807(c)(2);
and
(iii) provide ambulatory care in a
[service area] Service Area (specified
in the contract [entered into] or
compact under the Indian Self-
Determination and Education Assistance
Act [[](25 U.S.C.[A. Sec. ]450[f et
seq.]] et seq.)) with a population of
[not less than 2,000] no fewer than
1,500 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).
[(2)] (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). The requirements of clauses (ii) and
(iii) of paragraph (1)(C) shall not apply to [a tribe
or tribal organization] an Indian Tribe or Tribal
Organization applying for a grant under this section
[whose tribal government offices are located on an
island] for a health care facility 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 of grant]
(c) Grants.--
(1) Application._No grant may be made under this
section unless an application or proposal for [such a]
the grant has been[ submitted to and] approved by the
Secretary[. 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]
in accordance with applicable regulations and has set
forth reasonable assurance by the applicant that, at
all times after the construction, expansion, or
modernization of a facility carried out [pursuant to]
using 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 [tribes and tribal
organizations]Indian Tribes and Tribal 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 pursuant to
subsection (a)(1).
(d) [Transfer of interest to United States upon cessation
of facility]Reversion of Facilities._If any facility (or
portion thereof) with respect to which funds have been paid
under this section, ceases, at any time after completion of the
construction, expansion, or modernization carried out with such
funds, to be [utilized] used for the purposes of providing
[ambulatory] health care services to eligible Indians, all of
the right, title, and interest in and to such facility (or
portion thereof) shall transfer to the United States unless
otherwise negotiated by the Service and the Indian Tribe or
Tribal Organization.
(e) Funding 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 health care delivery demonstration project]
SEC. 306. INDIAN HEALTH CARE DELIVERY DEMONSTRATION PROJECTS.
[(a) Health care delivery demonstration projects]
(a) In General.--The Secretary, acting through the Service,
is authorized to carry out, or to enter into contracts [with,
or make grants to, Indian tribes or tribal organizations for
the purpose of carrying out]under the Indian Self-Determination
and Education Assistance Act (25 U.S.C. 450 et seq.) with
Indian Tribes or Tribal Organizations to carry out, a health
care delivery demonstration project to test alternative means
of delivering health care and services to Indians through
[health] facilities [to Indians].
(b) Use of [funds]Funds.--The Secretary, in approving
projects pursuant to this section, may authorize [funding] such
contracts 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 [non-Service Federal funds and
non-Federal]other available 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
[(c) Criteria]
(6) permit the use of Service funds to match other
funds, including Federal funds.
(c) Health Care Demonstration Projects.--
(1) General projects.--
[(1) Within 180 days after November 28, 1990, the
Secretary, after consultation with Indian tribes and
tribal organizations, shall develop and publish in the
Federal Register criteria for the review and approval
of applications submitted under this section. The
Secretary may enter into a contract or award a grant
under this section for projects which]
(A) Criteria._The Secretary may approve under
this section demonstration projects that meet
the following criteria:
[(A)] (i)There is a need for a new
facility or program, such as a program
for convenient care services, or the
reorientation of an existing facility
or program.
[(B)] (ii) A significant number of
Indians, including [those] Indians 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.]
[(D)] (iii) The project has the
potential to deliver services in an
efficient and effective manner.
[(E)] (iv) The project is
economically viable.
[(F)] (v) [The Indian tribe or tribal
organization] For projects carried out
by an Indian Tribe or Tribal
Organization, the Indian Tribe or
Tribal Organization has the
administrative and financial capability
to administer the project.
[(G)] (vi) The project is integrated
with providers of related health and
social services and is coordinated
with, and avoids duplication of,
existing services in order to expand
the availability of services.
[(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 paragraph (1).
[(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 service units which meets the criteria
specified in paragraph (1) and for which a completed
application has been received by the Secretary:]
(B) Priority.--In approving demonstration
projects under this paragraph, the Secretary
shall give priority to demonstration projects,
to the extent the projects meet the criteria
described in subparagraph (A), located in any
of the following Service Units:
(i) Cass Lake, Minnesota.
(ii[) Clinton, Oklahoma.
[(iii) Harlem, Montana.
(iv]) Mescalero, New Mexico.
([v]iii) Owyhee, Nevada.
[(vi) Parker, Arizona.]
([vii]iv) Schurz, Nevada.
[(viii) Winnebago, Nebraska.]
([ix]v) 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).]
(2) Convenient care service projects.--
(A) Definition of convenient care service.--
In this paragraph, the term ``convenient care
service'' means any primary health care
service, such as urgent care services,
nonemergent care services, prevention services
and screenings, and any service authorized by
sections 203 or 213(d), that is--
(i) provided outside the regular
hours of operation of a health care
facility; or
(ii) offered at an alternative
setting.
(B) Approval.--In addition to projects
described in paragraph (1), in any fiscal year,
the Secretary is authorized to approve not more
than 10 applications for health care delivery
demonstration projects that--
(i) include a convenient care
services program as an alternative
means of delivering health care
services to Indians; and
(ii) meet the criteria described in
subparagraph (C).
(C) Criteria.--The Secretary shall approve
under subparagraph (B) demonstration projects
that meet all of the following criteria:
(i) The criteria set forth in
paragraph (1)(A).
(ii) There is a lack of access to
health care services at existing health
care facilities, which may be due to
limited hours of operation at those
facilities or other factors.
(iii) The project--
(I) expands the availability
of services; or
(II) reduces--
(aa) the burden on
Contract Health
Services; or
(bb) the need for
emergency room visits.
(d) Peer Review Panels.--The Secretary may provide for the
establishment of peer review panels, as necessary, to review
and evaluate applications using the criteria described in
paragraphs (1)(A) and (2)(C) of subsection (c).
([d]e) Technical [assistance] 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]f) Service to [ineligible persons The]Ineligible
Persons._ Subject to section 807, 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 [service]Service facilities to non-Service health
[care] practitioners as provided in section [1680c of this
title] 807, may be included, subject to the terms of [such]
that section, in any demonstration project approved pursuant to
this section.
([f]g) Equitable [treatment] Treatment._For purposes of
subsection (c)[(1)(A) of this section,] the Secretary [shall],
in evaluating facilities operated under any contract [entered
into with the Service] or compact under the Indian Self-
Determination and Education Assistance Act[ [](25 U.S.C.[A.
Sec. ]450[f] et seq.],), shall use the same criteria that the
Secretary uses in evaluating facilities operated directly by
the Service.
([g]h Equitable [integration of facilities] Integration of
Facilities._The Secretary shall ensure that the planning,
design, construction, [and] renovation, and expansion needs of
Service and non-Service facilities [which] that are the subject
of a contract [for health services entered into with the
Service]or compact under the Indian Self-Determination and
Education Assistance Act [[](25 U.S.C.[A. Sec. ]450[f] et
seq.],) for health services are fully and equitably integrated
into the implementation of the health care delivery
demonstration projects under this section.
[(h) Reports 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. 307. LAND TRANSFER.
Notwithstanding any other provision of law, the Bureau of
Indian Affairs and all other agencies and departments of the
United States are authorized to transfer, at no cost, land and
improvements to the Service for the provision of health care
services. The Secretary is authorized to accept such land and
improvements for such purposes.
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 Organizations 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 one 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, 2009, the
Secretary shall submit to the Committee on Indian Affairs of
the Senate and the Committee on Natural 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 determined using the criteria developed
under the health care facility priority system under
section 301, unless the Secretary determines, pursuant
to regulations, that other criteria will result in a
more cost-effective and efficient method of
facilitating and completing construction of health care
facilities.
(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
in Alaska owned by any Alaska Native village, or village or
regional corporation under the Alaska Native Claims Settlement
Act (43 U.S.C. 1601 et seq.), or any land 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; and
(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 health care facility priority system under section
301(c).
(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
objectives:
(A) To base such rental rates on the
reasonable value of the quarters to the
occupants thereof.
(B) 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--
[Sec. 1638. Land transfer]
(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
[The Bureau of Indian Affairs is authorized to transfer, at
no cost, up to 5 acres of land at the Chemawa Indian School,
Salem, Oregon, to the Service for the 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.]
(B) such other date as may be mutually agreed
by the Secretary and the Tribal Health Program.
[Sec. 1638a. Authorization of appropriations]
(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.
[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. 315. APPLICABILITY OF BUY AMERICAN ACT REQUIREMENT.
[Sec. 1638b.]
(a) Applicability [of Buy American requirement (a) 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 1638a of this title.]
section 317. 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. 250 et seq.] or any
international agreement to which the United States is a party.
[(c) Fraudulent use of Made-in-America label]
(b) Effect of Violation.--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 [1638a of this title,] 317,
pursuant to the debarment, suspension, and ineligibility
procedures described in sections 9.400 through 9.409 of title
48, Code of Federal Regulations.
[(d) ``Buy American Act'' defined] (c) Definitions.--For
purposes of this section, the term [``Buy American Act''] ``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. 1638c. Contracts for provision of personal services in Indian
Health Service facilities
[In fiscal year 1995 and thereafter--]
SEC. 316. OTHER FUNDING FOR FACILITIES.
[(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.]
(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) 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.]
(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) 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.]
(c) Establishment of Standards.--The Secretary, through the
Service, shall establish standards by regulation for the
planning, design, and construction of health care facilities
serving Indians under this Act.
[(d) Liability
[Individuals providing health care services pursuant to
these contracts are covered by the Federal Tort Claims Act.]
SEC. 317. AUTHORIZATION OF APPROPRIATIONS.
[Sec. 1638d. Crediting of money collected for meals served at Indian
Health Service facilities]
There are authorized to be appropriated such sums as may be
necessary for each fiscal year through fiscal year 2017 to
carry out this title.
[Money heretofore and hereafter 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--ACCESS TO HEALTH SERVICES
[Sec. 1641. Treatment of payments under medicare program]
SEC. 401. TREATMENT OF PAYMENTS UNDER SOCIAL SECURITY ACT HEALTH
BENEFITS PROGRAMS.
[(a) Determination of appropriations
[Any payments received by 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.])]
(a) Disregard of Medicare, Medicaid, and SCHIP Payments in
Determining Appropriations.--Any payments received by an Indian
Health Program or by an Urban Indian Organization under title
XVIII, XIX, or XXI of the Social Security Act for services
provided to Indians eligible for benefits under [title XVIII of
the Social Security Act [42 U.S.C.A. Sec. 1395 et seq.]] such
respective titles shall not be considered in determining
appropriations for [health care and services to Indians.] the
provision of health care and services to Indians.
[(b) Preferences]
(b) Nonpreferential Treatment.--Nothing in this [chapter]
Act 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,] Act in preference to an Indian [beneficiary] without
such coverage.
(c) Use of Funds.--
[Sec. 1642. Treatment of payments under medicaid program]
(1) Special fund.--
[(a) Payments to special fund]
(A) 100 percent pass-through of payments due
to facilities.--Notwithstanding any other
provision of law, [payments to which any
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 section 1911 of such Act [42 U.S.C.A.
Sec. 1396j]]but subject to paragraph (2),
payments to which a facility of the Service is
entitled by reason of a provision of the Social
Security Act shall be placed in a special fund
to be held by the Secretary [and 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
facilities of such Service which may be
necessary to achieve compliance with the
applicable conditions and requirements of such
title]. In making payments from such fund, the
Secretary shall ensure that each [service unit]
Service Unit of the Service receives [at least
80] 100 percent of the [amounts] amount to
which the facilities of the Service, for which
such [service unit] Service Unit makes
collections, are entitled by reason of [section
1911 of the Social Security Act [42 U.S.C.A.
Sec. 1396j].] a provision of the Social
Security Act.
[(b) Determination of appropriation
[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 contracts with tribal organizations]
(B) Use of funds.--Amounts received by a
facility of the Service under subparagraph (A)
shall first be used (to such extent or in such
amounts as are provided in appropriation Acts)
for the purpose of making any improvements in
the programs of the Service operated by or
through such facility which may be necessary to
achieve or maintain compliance with the
applicable conditions and requirements of
titles XVIII and XIX of the Social Security
Act. Any amounts so received that are in excess
of the amount necessary to achieve or maintain
such conditions and requirements shall, subject
to consultation with the Indian Tribes being
served by the Service Unit, be used for
reducing the health resource deficiencies (as
determined under section 201(d)) of such Indian
Tribes.
[(a) Access to health services
[The Secretary, acting through the Service, shall make
grants to or enter into contracts with tribal organizations to
assist such organizations 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) enroll under section 1818 of part A and sections
1836 and 1837 of part B of title XVIII of the Social
Security Act [42 U.S.C.A. Sec. Sec. 1395i-2, 1395o, and
1395p];
[(2) pay monthly premiums for coverage 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 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 which the Secretary makes with
any tribal organization pursuant to this section. Such
conditions shall include, but are not limited to, requirements
that the organization successfully undertake to--
[(1) determine the population of Indians to be served
that are or could be recipients of benefits under
titles XVIII and XIX of the Social Security Act [42
U.S.C.A. Sec. Sec. 1395 et seq., 1396 et seq.];
[(2) assist individual Indians in becoming familiar
with and utilizing such benefits;
[(3) provide transportation to such individual
Indians to the appropriate offices for enrollment or
application for medical assistance;
[(4) 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 of the Social
Security Act [42 U.S.C.A. Sec. Sec. 1395 et
seq., 1396 et seq.].
[(c) Application for medical assistance
[The Secretary, acting through the Service, may enter into
an agreement with an Indian tribe, tribal organization, or
urban Indian organization which provides for the receipt and
processing of applications for medical assistance under title
XIX of the Social Security Act [42 U.S.C.A. Sec. Sec. 1396 et
seq.] and benefits under title XVIII of the Social Security Act
[42 U.S.C.A. Sec. 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.].
(2) Direct payment option.--Paragraph (1) shall not
apply to a Tribal Health Program upon the election of
such 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 by such
Program during the period of such election.
[Sec. 1645. Direct billing of Medicare, Medicaid, and other third party
payors]
(d) Direct Billing.--
[(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]
(1) In general.--Subject to complying with the
requirements of paragraph (2), a Tribal Health Program
may elect to directly bill for, and receive payment
for, health care items and services provided by such
[hospital or clinic] Program for which payment is made
under title XVIII or XIX 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]
(2) Direct reimbursement.--
[Each hospital or clinic participating in the program
described in subsection (a) of this section]
(A) Use of funds.--Each Tribal Health Program
making the election described in paragraph (1)
with respect to a program under a title of the
Social Security Act shall be reimbursed
directly [under the medicare and medicaid
programs for services furnished, without regard
to the provisions of section 1395qq(c) of Title
42 and sections 602(a) and 1013(b)(2)(A) of
Title 42, but all funds] by that program for
items and services furnished without regard to
subsection (c)(1), but all amounts so
reimbursed shall [first] be used by [the
hospital or clinic] Tribal Health Program for
the purpose of making any improvements in the
[hospital or clinic] facilities of the Tribal
Health Program 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--] 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.
[(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]
(B) Audits.--The amounts paid to a Tribal
Health Program making the election 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 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 1395qq(c) of Title 42 or
section 602(a) of Title 42, 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 the
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 the day before the date of
enactment of the Alaska Native and American Indian Direct
Reimbursement Act of 1999 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 program under such title, as
well as all auditing requirements applicable to
programs administered by an Indian Health Program.
Nothing in the preceding sentence shall be construed as
limiting the application of auditing requirements
applicable to amounts paid under title XVIII, XIX, or
XXI of the Social Security Act.
(C) Identification of source of payments.--
Any Tribal Health Program that receives
reimbursements or payments under title XVIII,
XIX, or XXI of the Social Security Act, shall
provide to the Service a list of each provider
enrollment number (or other identifier) under
which such Program receives such reimbursements
or payments.
(3) Examination and implementation of changes._
(A) In general.--The Secretary, acting
through the Service, and with the assistance of
the Administrator of the [Health Care Financing
Administration] Centers for Medicare & Medicaid
Services, shall examine on an ongoing basis and
implement[-- (A)] any administrative changes
that may be necessary to facilitate direct
billing and reimbursement under the program
established under this [section] subsection,
including any agreements with States that may
be necessary to provide for direct billing
under the [medicaid] a program[; and] under a
title of the Social Security Act.
[(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
the date of enactment of the Alaska Native and American Indian
Direct Reimbursement Act of 1999. The Secretary may from time
to time, after consultation with the program participants,
change the accounting information submission requirements.
[(e) Withdrawal from program]
(B) Coordination of information.--The Service
shall provide the Administrator of the Centers
for Medicare & Medicaid Services with copies of
the lists submitted to the Service under
paragraph (2)(C), enrollment data regarding
patients served by the Service (and by Tribal
Health Programs, to the extent such data is
available to the Service), and such other
information as the Administrator may require
for purposes of administering title XVIII, XIX,
or XXI of the Social Security Act.
[A participant in]
(4) Withdrawal from program.--A Tribal Health Program
that bills directly under the program established under
this [section] subsection may withdraw from
participation in the same manner and under the same
conditions that [a tribe or tribal organization] 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 [section] subsection shall be
returned to the Secretary upon the Secretary's
acceptance of the withdrawal of participation in this
program.
(5) Termination for failure to comply with
requirements.--The Secretary may terminate the
participation of a Tribal Health Program or in the
direct billing program established under this
subsection if the Secretary determines that the Program
has failed to comply with the requirements of paragraph
(2). The Secretary shall provide a Tribal Health
Program with notice of a determination that the Program
has failed to comply with any such requirement and a
reasonable opportunity to correct such noncompliance
prior to terminating the Program's participation in the
direct billing program established under this
subsection.
(e) Related Provisions Under the Social Security Act.--For
provisions related to subsections (c) and (d), see sections
1880, 1911, and 2107(e)(1)(D) of the Social Security Act.
SEC. 402. GRANTS TO AND CONTRACTS WITH THE SERVICE, INDIAN TRIBES,
TRIBAL ORGANIZATIONS, AND URBAN INDIAN
ORGANIZATIONS TO FACILITATE OUTREACH, ENROLLMENT,
AND COVERAGE OF INDIANS UNDER SOCIAL SECURITY ACT
HEALTH BENEFIT PROGRAMS AND OTHER HEALTH BENEFITS
PROGRAMS.
(a) Indian Tribes and Tribal Organizations.--From funds
appropriated to carry out this title in accordance with section
416, the Secretary, acting through the Service, shall make
grants to or enter into contracts with Indian Tribes and Tribal
Organizations to assist such Tribes and Tribal Organizations in
establishing and administering programs on or near reservations
and trust lands to assist individual Indians--
(1) to enroll for benefits under a program
established under title XVIII, XIX, or XXI of the
Social Security Act and other health benefits programs;
and
(2) with respect to such programs for which the
charging of premiums and cost sharing is not prohibited
under such programs, to pay premiums or cost sharing
for coverage for such benefits, which may be based on
financial need (as determined by the Indian Tribe or
Tribes or Tribal Organizations being served based on a
schedule of income levels developed or implemented by
such Tribe, Tribes, or Tribal Organizations).
(b) Conditions.--The Secretary, acting through the Service,
shall place conditions as deemed necessary to effect the
purpose of this section in any grant or contract which the
Secretary makes with any Indian Tribe or Tribal Organization
pursuant to this section. Such conditions shall include
requirements that the Indian Tribe or Tribal Organization
successfully undertake--
(1) to determine the population of Indians eligible
for the benefits described in subsection (a);
(2) to educate Indians with respect to the benefits
available under the respective programs;
(3) to provide transportation for such individual
Indians to the appropriate offices for enrollment or
applications for such benefits; and
(4) to develop and implement methods of improving the
participation of Indians in receiving benefits under
such programs.
(c) 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.
(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
with respect to the provision of health care items and services
to Indians under the programs established under title XVIII,
XIX, or XXI of the Social Security Act.
(e) Agreements Relating to Improving Enrollment of Indians
Under Social Security Act Health Benefits Programs.--For
provisions relating to agreements between the Secretary, acting
through the Service, and Indian Tribes, Tribal Organizations,
and Urban Indian Organizations for the collection, preparation,
and submission of applications by Indians for assistance under
the Medicaid and State children's health insurance programs
established under titles XIX and XXI of the Social Security
Act, and benefits under the Medicare program established under
title XVIII of such Act, see subsections (a) and (b) of section
1139 of the Social Security Act.
(f) Definition of Premiums and Cost Sharing.--In this
section:
(1) Premium.--The term ``premium'' includes any
enrollment fee or similar charge.
(2) Cost sharing.--The term ``cost sharing'' includes
any deduction, deductible, copayment, coinsurance, or
similar charge.
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 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.
(3) Recovery from tortfeasors.--
(A) In general.--In any case in which an
Indian Tribe or Tribal Organization that is
authorized or required under a compact or
contract issued pursuant to the Indian Self-
Determination and Education Assistance Act (25
U.S.C. 450 et seq.) to furnish or pay for
health services to a person who is injured or
suffers a disease on or after the date of
enactment of the Indian Health Care Improvement
Act Amendments of 2007 under circumstances that
establish grounds for a claim of liability
against the tortfeasor with respect to the
injury or disease, the Indian Tribe or Tribal
Organization shall have a right to recover from
the tortfeasor (or an insurer of the
tortfeasor) the reasonable value of the health
services so furnished, paid for, or to be paid
for, in accordance with the Federal Medical
Care Recovery Act (42 U.S.C. 2651 et seq.), to
the same extent and under the same
circumstances as the United States may recover
under that Act.
(B) Treatment.--The right of an Indian Tribe
or Tribal Organization to recover under
subparagraph (A) shall be independent of the
rights of the injured or diseased person served
by the Indian Tribe or Tribal Organization.
(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
such authorization 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.
SEC. 404. CREDITING OF REIMBURSEMENTS.
(a) Use of Amounts.--
(1) Retention by program.--Except as provided in
section 202(f) (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 UNDER FEDERAL HEALTH CARE PROGRAMS IN
QUALIFICATIONS FOR REIMBURSEMENT FOR SERVICES.
(a) Requirement To Satisfy Generally Applicable
Participation Requirements.--
(1) In general.--A Federal health care program must
accept an entity that is operated by the Service, an
Indian Tribe, Tribal Organization, or Urban Indian
Organization as a provider eligible to receive payment
under the program for health care services furnished to
an Indian on the same basis as any other provider
qualified to participate as a provider of health care
services under the program if the entity meets
generally applicable State or other requirements for
participation as a provider of health care services
under the program.
(2) Satisfaction of state or local licensure or
recognition requirements.--Any requirement for
participation as a provider of health care services
under a Federal health care program that an entity be
licensed or recognized under the State or local law
where the entity is located to furnish health care
services shall be deemed to have been met in the case
of an entity operated by the Service, an Indian Tribe,
Tribal Organization, or Urban Indian Organization if
the entity meets all the applicable standards for such
licensure or recognition, regardless of whether the
entity obtains a license or other documentation under
such State or local law. In accordance with section
221, the absence of the licensure of a health care
professional employed by such an entity under the State
or local law where the entity is located shall not be
taken into account for purposes of determining whether
the entity meets such standards, if the professional is
licensed in another State.
(b) Application of Exclusion From Participation in Federal
Health Care Programs.--
(1) Excluded entities.--No entity operated by the
Service, an Indian Tribe, Tribal Organization, or Urban
Indian Organization that has been excluded from
participation in any Federal health care program or for
which a license is under suspension or has been revoked
by the State where the entity is located shall be
eligible to receive payment or reimbursement under any
such program for health care services furnished to an
Indian.
(2) Excluded individuals.--No individual who has been
excluded from participation in any Federal health care
program or whose State license is under suspension
shall be eligible to receive payment or reimbursement
under any such program for health care services
furnished by that individual, directly or through an
entity that is otherwise eligible to receive payment
for health care services, to an Indian.
(3) Federal health care program defined.--In this
subsection, the term, `Federal health care program' has
the meaning given that term in section 1128B(f) of the
Social Security Act (42 U.S.C. 1320a-7b(f)), except
that, for purposes of this subsection, such term shall
include the health insurance program under chapter 89
of title 5, United States Code.
(c) Related provisions.--For provisions related to
nondiscrimination against providers operated by the
Service, an Indian Tribe, Tribal Organization, or Urban
Indian Organization, see section 1139(c) of the Social
Security Act (42 U.S.C. 1320b-9(c)).
SEC. 409. CONSULTATION.
For provisions related to consultation with representatives
of Indian Health Programs and Urban Indian Organizations with
respect to the health care programs established under titles
XVIII, XIX, and XXI of the Social Security Act, see section
1139(d) of the Social Security Act (42 U.S.C. 1320b-9(d)).
SEC. 410. STATE CHILDREN'S HEALTH INSURANCE PROGRAM (SCHIP).
For provisions relating to--
(1) outreach to families of Indian children likely to
be eligible for child health assistance under the State
children's health insurance program established under
title XXI of the Social Security Act, see sections
2105(c)(2)(C) and 1139(a) of such Act (42 U.S.C.
1397ee(c)(2), 1320b-9); and
(2) ensuring that child health assistance is provided
under such program to targeted low-income children who
are Indians and that payments are made under such
program to Indian Health Programs and Urban Indian
Organizations operating in the State that provide such
assistance, see sections 2102(b)(3)(D) and
2105(c)(6)(B) of such Act (42 U.S.C. 1397bb(b)(3)(D),
1397ee(c)(6)(B)).
SEC. 411. EXCLUSION WAIVER AUTHORITY FOR AFFECTED INDIAN HEALTH
PROGRAMS AND SAFE HARBOR TRANSACTIONS UNDER THE
SOCIAL SECURITY ACT.
For provisions relating to--
(1) exclusion waiver authority for affected Indian
Health Programs under the Social Security Act, see
section 1128(k) of the Social Security Act (42 U.S.C.
1320a-7(k)); and
(2) certain transactions involving Indian Health
Programs deemed to be in safe harbors under that Act,
see section 1128B(b)(4) of the Social Security Act (42
U.S.C. 1320a-7b(b)(4)).
SEC. 412. PREMIUM AND COST SHARING PROTECTIONS AND ELIGIBILITY
DETERMINATIONS UNDER MEDICAID AND SCHIP AND
PROTECTION OF CERTAIN INDIAN PROPERTY FROM MEDICAID
ESTATE RECOVERY.
For provisions relating to--
(1) premiums or cost sharing protections for Indians
furnished items or services directly by Indian Health
Programs or through referral under the contract health
service under the Medicaid program established under
title XIX of the Social Security Act, see sections
1916(j) and 1916A(a)(1) of the Social Security Act (42
U.S.C. 1396o(j), 1396o-1(a)(1));
(2) rules regarding the treatment of certain property
for purposes of determining eligibility under such
programs, see sections 1902(e)(13) and 2107(e)(1)(B) of
such Act (42 U.S.C. 1396a(e)(13), 1397gg(e)(1)(B)); and
(3) the protection of certain property from estate
recovery provisions under the Medicaid program, see
section 1917(b)(3)(B) of such Act (42 U.S.C.
1396p(b)(3)(B)).
SEC. 413. TREATMENT UNDER MEDICAID AND SCHIP MANAGED CARE.
For provisions relating to the treatment of Indians
enrolled in a managed care entity under the Medicaid program
under title XIX of the Social Security Act and Indian Health
Programs and Urban Indian Organizations that are providers of
items or services to such Indian enrollees, see sections
1932(h) and 2107(e)(1)(H) of the Social Security Act (42 U.S.C.
1396u-2(h), 1397gg(e)(1)(H)).
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 than 3 years after the date of
enactment of the Indian Health Care Improvement Act Amendments
of 2007, the Secretary shall submit to the Committee on Indian
Affairs and Committee on Finance of the Senate and the
Committee on Natural 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]
SEC. 415. GENERAL EXCEPTIONS.
[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 Act,
the time limitation (as a condition of payment) for notifying
the Service of such treatment or admission shall be 30 days.]
The requirements of this title shall not apply to any
excepted benefits described in paragraph (1)(A) or (3) of
section 2791(c) of the Public Health Service Act (42 U.S.C.
300gg-91).
[Sec. 1647. Authorization of appropriations]
SEC. 416. AUTHORIZATION OF APPROPRIATIONS.
There are authorized to be appropriated such sums as may be
necessary for each fiscal year through fiscal year [2000] 2017
to carry out this [subchapter] title.
TITLE V--HEALTH SERVICES FOR URBAN INDIANS
[Sec. 1651. Purpose]
SEC. 501. PURPOSE.
The purpose of this [subchapter] title is to establish and
maintain programs in [urban centers] Urban Centers to make
health services more accessible and available to [urban] Urban
Indians.
[Sec. 1652. Contracts with, and grants to, urban Indian organizations]
SEC. 502. CONTRACTS WITH, AND GRANTS TO, URBAN INDIAN ORGANIZATIONS.
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, or make grants to, [urban] Urban Indian
[organizations] Organizations to assist such organizations in
the establishment and administration, within [the urban centers
in which such organizations are situated] Urban Centers, of
programs which meet the requirements set forth in this
[subchapter. The] title. Subject to section 506, the Secretary,
acting through the Service, shall include such conditions as
the Secretary considers necessary to effect the purpose of this
[subchapter] title in any contract into which the Secretary
enters [into] with, or in any grant the Secretary makes to, any
[urban] Urban Indian [organization] Organization pursuant to
this [subchapter] title.
[Sec. 1653. Contracts and grants for the provision of health care and
referral services]
SEC. 503. CONTRACTS AND GRANTS FOR THE PROVISION OF HEALTH CARE AND
REFERRAL SERVICES.
(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, [or] and
make grants to, [urban] Urban Indian [organizations]
Organizations for the provision of health care and referral
services for [urban Indians residing in the urban centers in
which such organizations are situated] Urban Indians. Any such
contract or grant shall include requirements that the [urban]
Urban Indian [organization] Organization successfully undertake
to--
(1) estimate the population of [urban] Urban Indians
residing in the [urban center in which such] Urban
Center or centers that the organization [is situated]
proposes to serve who are or could be recipients of
health care or referral services;
(2) estimate the current health status of [urban]
Urban Indians residing in such [urban center] Urban
Center or centers;
(3) estimate the current health care needs of [urban]
Urban Indians residing in such [urban center] Urban
Center or centers;
[(4) identify all public and private health services
resources within such urban center which are or may be
available to urban Indians;
[(5) determine the use of public and private health
services resources by the urban Indians residing in
such urban center;
[(6) assist such health services resources in
providing services to urban Indians;
[(7) assist urban Indians in becoming familiar with
and utilizing such health services resources;]
[(8)] (4) provide basic health education, including
health promotion and disease prevention education, to
[urban] 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)] (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] Urban Indians; and
[(12)] (6) where necessary, provide, or enter into
contracts for the provision of, health care services
for [urban] 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 [urban] Urban Indian [organizations] 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 [urban]
Urban Indians in the [urban center] Urban Center or
centers involved;
(2) the size of the [urban] Urban Indian population
in the [urban center] Urban 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;]
[(4)] (3) the extent, if any, to which the activities
set forth in subsection (a) [of this section] would
duplicate[-- (A) any previous or] any project funded
under this title, or under any current public [or
private health services project in an urban center that
was or is] health service project funded in a manner
other than pursuant to this [subchapter; or] title;
[(B) any project funded under this subchapter;]
[(5)] (4) the capability of an [urban] Urban Indian
[organization] 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;
[(6)] (5) the satisfactory performance and successful
completion by an [urban] Urban Indian [organization]
Organization of other contracts with the Secretary
under this [subchapter;] title;
[(7)] (6) the appropriateness and likely
effectiveness of conducting the activities set forth in
subsection (a) [of this section in an urban center;
and] in an Urban Center or centers; and
[(8)] (7) 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) Grants for health promotion and disease prevention
services]
(c) Access to Health Promotion and Disease Prevention
Programs.--The Secretary, acting through the Service, shall
facilitate access to, or provide, health promotion and disease
prevention services for [urban] Urban Indians through grants
made to [urban] Urban Indian [organizations] Organizations
administering contracts entered into [pursuant to this section]
or receiving grants under subsection (a) [of this section].
[(d) Grants for immunization services]
(d) Immunization Services.--
[(1)] (1) Access or services provided.--The
Secretary, acting through the Service, shall facilitate
access to, or provide, immunization services for
[urban] Urban Indians through grants made to [urban]
Urban Indian [organizations] Organizations
administering contracts entered into [pursuant to this
section] or receiving grants under [subsection (a) of]
this section.
[(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)] (2) Definition.--For purposes of this
subsection, the term ``immunization services'' means
services to provide without charge immunizations
against vaccine-preventable diseases.
[(e) Grants for mental health services]
(e) Behavioral Health Services.--
[(1)] (1) Access or services provided.--The
Secretary, acting through the Service, shall facilitate
access to, or provide, [mental] behavioral health
services for [urban] Urban Indians through grants made
to [urban] Urban Indian [organizations] Organizations
administering contracts entered into [pursuant to this
section] or receiving grants under subsection [(a) of
this section].
[(2)A] (2) Assessment required.--Except as provided
by paragraph (3)(A), a grant may not be made under this
subsection to an [urban] Urban Indian [organization]
Organization until that organization has prepared, and
the Service has approved, an assessment of the [mental]
following:
(A) The behavioral health needs of the
[urban] Urban Indian population concerned, [the
mental].
(B) The behavioral health services and other
related resources available to that
population[, the] .
(C) The barriers to obtaining those services
and resources, [and the] .
(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) [to] To prepare assessments required
under paragraph (2)[;] .
(B) [to] To provide outreach, educational,
and referral services to [urban] Urban Indians
regarding the availability of direct [mental]
behavioral health services, to educate [urban]
Urban Indians about [mental] behavioral health
issues and services, and effect coordination
with existing [mental] behavioral health
providers in order to improve services to
[urban] Urban Indians[;] .
(C) [to] To provide outpatient [mental]
behavioral health services to [urban] Urban
Indians, including the identification and
assessment of illness, therapeutic treatments,
case management, support groups, family
treatment, and other treatment[; and] .
(D) [to] To develop innovative [mental]
behavioral health service delivery models which
incorporate Indian cultural support systems and
resources.
[(f) Grants for prevention and treatment of child abuse]
(f) Prevention of Child Abuse._
[(1)] (1) Access or services provided.--The
Secretary, acting through the Service, shall facilitate
access to[,] or provide[,] services for [urban] Urban
Indians through grants to [urban] Urban Indian
[organizations] 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 [urban] Urban Indians.
[(2) A] (2) Evaluation required.--Except as provided
by paragraph (3)(A), a grant may not be made under this
subsection to an [urban] Urban Indian [organization]
Organization until that organization has prepared, and
the Service has approved, an assessment that documents
the prevalence of child abuse in the [urban] 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) [to] To prepare assessments required
under paragraph (2)[;] .
(B) [for] For the development of prevention,
training, and education programs for [urban
Indian populations] Urban Indians, 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) [to] To provide direct outpatient
treatment services (including individual
treatment, family treatment, group therapy, and
support groups) to [urban] 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 [urban] Urban Indian perpetrators of
child abuse (including sexual abuse).
[(4)] (4) Considerations when making grants.--In
making grants to carry out this subsection, the
Secretary shall take into consideration--
(A) the support for the [urban] Urban Indian
[organization] 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 [urban] Urban Indian [organization]
Organization to address the complex problem of
child sexual abuse in the community; and
(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. 504. CONTRACTS AND GRANTS FOR THE DETERMINATION OF UNMET HEALTH
CARE NEEDS.
[(C) the assessment required under paragraph
(2).]
[Sec. 1654. Contracts and grants for determination of unmet health care
needs]
[(a) Authority] (a) Grants and Contracts Authorized.--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[, urban] Urban Indian [organizations]
Organizations situated in [urban centers] Urban Centers for
which contracts have not been entered into[,] or grants have
not been made[,] under section [1653 of this title.] 503.
(b) Purpose.--The purpose of a contract or grant made under
this section shall be the determination of the matters
described in subsection [(b)] (c)(1) in order to assist the
Secretary in assessing the health status and health care needs
of [urban] Urban Indians in the [urban center] Urban Center
involved and determining whether the Secretary should enter
into a contract or make a grant under section [1653 of this
title] 503 with respect to the [urban] Urban Indian
[organization] Organization which the Secretary has entered
into a contract with, or made a grant to, under this section.
[(b)] (c) Grant and Contract Requirements.--Any contract
entered into, or grant made, by the Secretary under this
section shall include requirements that--
(1) the [urban] Urban Indian [organization]
Organization successfully [undertake] undertakes to--
(A) document the health care status and unmet
health care needs of [urban] Urban Indians in
the [urban center] Urban Center involved; and
(B) with respect to [urban] Urban Indians in
the [urban center] Urban Center involved,
determine the matters described in [clauses]
paragraphs (2), (3), (4), and [(8)] (7) of
section [1653] 503(b) [of this title]; and
(2) the [urban] Urban Indian [organization]
Organization complete performance of the contract, or
carry out the requirements of the grant, within [one] 1
year after the date on which the Secretary and such
organization enter into such contract, or within [one]
1 year after such organization receives such grant,
whichever is applicable.
[(c) Renewal] (d) No Renewals.--The Secretary may not renew
any contract entered into[,] or grant made[,] under this
section.
SEC. 505. EVALUATIONS; RENEWALS.
[Sec. 1655.] (a) Procedures for Evaluations[; renewals]
[(a) 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 [urban] Urban Indian [organizations]
Organizations under this [subchapter] title. Such procedures
shall include provisions for carrying out the requirements of
this section.
[(b) Annual onsite evaluation]
(b) Evaluations.--The Secretary, acting through the
Service, shall [conduct an annual onsite evaluation of each
urban Indian organization] evaluate the compliance of each
Urban Indian Organization which has entered into a contract or
received a grant under section [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] 503 with the terms of such
contract or grant. For purposes of this evaluation, 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 unsatisfactory performance];
Unsatisfactory Performance.--If, as a result of the evaluations
conducted under this section, the Secretary determines that an
[urban] Urban Indian [organization] Organization has not
complied with the requirements of a grant or complied with or
satisfactorily performed a contract under section [1653 of this
title,] 503, the Secretary shall, prior to renewing such
contract or grant, attempt to resolve with [such] the
organization the areas of noncompliance or unsatisfactory
performance and modify [such] the contract or grant to prevent
future occurrences of [such] noncompliance or unsatisfactory
performance. If the Secretary determines that [such] the
noncompliance or unsatisfactory performance cannot be resolved
and prevented in the future, the Secretary shall not renew
[such] the contract or grant with [such] the organization and
is authorized to enter into a contract or make a grant under
section [1653 of this title] 503 with another [urban] Urban
Indian [organization] Organization which is situated in the
same [urban center] Urban Center as the [urban] Urban Indian
[organization] Organization whose contract or grant is not
renewed under this section.
[(d) Contract and grant renewals]
(d) Considerations for Renewals.--In determining whether to
renew a contract or grant with an [urban] Urban Indian
[organization] Organization under section [1653 of this title]
503 which has completed performance of a contract or grant
under section [1654 of this title,] 504, the Secretary shall
review the records of the [urban] Urban Indian [organization]
Organization, the reports submitted under section [1657 of this
title, and, in the case of a renewal of a contract or grant
under section 1653 of this title,] 507, and shall consider the
results of the onsite evaluations [conducted] or accreditations
under subsection (b) [of this section].
[Sec. 1656. Other contract and grant requirements]
SEC. 506. OTHER CONTRACT AND GRANT REQUIREMENTS.
[(a) Federal regulations; exceptions]
(a) Procurement.--Contracts with [urban Indian
organizations] Urban Indian Organizations entered into pursuant
to this [subchapter] title shall be in accordance with all
Federal contracting laws and regulations relating to
procurement except that, in the discretion of the Secretary,
such contracts may be negotiated without advertising and need
not conform to the provisions of [the Act of August 24, 1935
(40 U.S.C 270a, et seq.).] sections 1304 and 3131 through 3133
of title 40, United States Code.
[(b) Payment]
(b) Payments Under Contracts or Grants.--
(1) In general.--Payments under any contracts or
grants pursuant to this [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.] title, notwithstanding any term or
condition of such contract or grant--
(A) may be made in a single advance payment
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 a single advance
payment; and
(B) 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.
(2) Semiannual and quarterly payments and
reimbursements.--If the Secretary determines under
paragraph (1)(A) that an Urban Indian organization is
not capable of administering an entire single advance
payment, on request of the Urban Indian Organization,
the payments may be made--
(A) in semiannual or quarterly payments by
not later than 30 days after the date on which
the funding period with respect to which the
payments apply begins; or
(B) by way of reimbursement.
(c) Revision or [amendment] Amendment of Contracts.--
Notwithstanding any provision of law to the contrary, the
Secretary may, at the request [or] and consent of an [urban]
Urban Indian [organization] Organization, revise or amend any
contract entered into by the Secretary with such organization
under this [subchapter] title as necessary to carry out the
purposes of this [subchapter] title.
[(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.]
[(e)] (d) Fair and Uniform [provision of services and
assistance] Services and Assistance.--Contracts with, or grants
to[, urban] Urban Indian [organizations] Organizations and
regulations adopted pursuant to this [subchapter] title shall
include provisions to assure the fair and uniform provision to
[urban] 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. 507. REPORTS AND RECORDS.
[Sec. 1657.] (a) Reports [and records].--
[(a) Quarterly reports]
(1) In general.--For each fiscal year during which an
[urban] Urban Indian [organization] Organization
receives or expends funds pursuant to a contract
entered into[,] or a grant received[,] pursuant to this
[subchapter] title, such [organization] Urban Indian
Organization shall submit to the Secretary [a quarterly
report including--] not more frequently than every 6
months, a report that includes the following:
[(1)] (A) [in] In the case of a contract or
grant under section [1653 of this title,
information gathered pursuant to clauses (10)
and (11) of subsection (a) of such section;]
503, recommendations pursuant to section
503(a)(5).
[(2) information] (B) Information on
activities conducted by the organization
pursuant to the contract or grant[;].
[(3)] (C) [an] An accounting of the amounts
and [purposes] purpose for which Federal funds
were expended[; and].
[(4) such other information as the Secretary
may request.]
(D) A minimum set of data, using uniformly
defined elements, as specified by the Secretary
after consultation with Urban Indian
Organizations.
(2) Health status and services.--
(A) In general.--Not later than 18 months
after the date of enactment of the Indian
Health Care Improvement Act Amendments of 2007,
the Secretary, acting through the Service,
shall submit to Congress a report evaluating--
(i) the health status of Urban
Indians;
(ii) the services provided to Indians
pursuant to this title; and
(iii) areas of unmet needs in the
delivery of health services to Urban
Indians.
(B) Consultation and contracts.--In preparing
the report under paragraph (1), the Secretary--
(i) shall consult with Urban Indian
Organizations; and
(ii) may enter into a contract with a
national organization representing
Urban Indian Organizations to conduct
any aspect of the report.
(b) Audit [by Secretary and Comptroller General].--The
reports and records of the [urban] Urban Indian [organization]
Organization with respect to a contract or grant under this
[subchapter] title shall be subject to audit by the Secretary
and the Comptroller General of the United States.
(c) [Cost] Costs of [annual private audit] Audits.--The
Secretary shall allow as a cost of any contract or grant
entered into or awarded under section [1653 of this title] 502
or 503 the cost of an annual [private] independent financial
audit conducted by--
(1) a certified public accountant[.] ; or
[(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]
(2) a certified public accounting firm qualified to
conduct Federal compliance audits.
SEC. 508. LIMITATION ON CONTRACT AUTHORITY.
[(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 contract authority]
The authority of the Secretary to enter into contracts or
to award grants under this title shall be to the extent, and in
an amount, provided for in appropriation Acts.
[Sec. 1659. Facilities renovation]
SEC. 509. FACILITIES.
(a) Grants.--The Secretary, acting through the Service, may
make [funds available] grants to contractors or grant
recipients under this [subchapter for minor renovations to]
title for the lease, purchase, renovation, construction, or
expansion of facilities, including leased facilities, in order
to assist such contractors or grant recipients in [meeting or
maintaining the Joint Commission for Accreditation of Health
Care Organizations (JCAHO) standards] complying with applicable
licensure or certification requirements.
(b) Loan Fund Study.--The Secretary, acting through the
Service, 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, including by submitting a report in
accordance with subsection (c) of that section.
[Sec. 1660. Urban Health Programs Branch]
SEC. 510. DIVISION OF URBAN INDIAN HEALTH.
[(a) Establishment
There is [hereby] established within the Service a [Branch]
Division of Urban Indian Health[Programs], which shall be
responsible for--
(1) carrying out the provisions of this [subchapter
and for] title;
(2) providing central oversight of the programs and
services authorized under this [subchapter.] title; and
[(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.]
(3) providing technical assistance to Urban Indian
Organizations.
[Sec. 1660a. Grants for alcohol and substance abuse related services
SEC. 511. GRANTS FOR ALCOHOL AND SUBSTANCE ABUSE-RELATED SERVICES.
[(a) Grants]
[The Secretary] (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
[in] regarding, alcohol and substance abuse in [urban centers]
Urban Centers to those [urban] Urban Indian [organizations]
Organizations with [whom] which the Secretary has entered into
a contract under this [subchapter] title or under section [1621
of this title.] 201.
(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 [urban] 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;
[(4) capability of the organization to adequately
perform the activities required under the grant;]
(2) Capability of the organization to adequately
perform the activities required under the grant.
[(5) satisfactory] (3) 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].
[(6) identification of] (4) Identification of the
need for services.
(d) Allocation of Grants.--The Secretary shall develop a
methodology for allocating grants made pursuant to this section
based on [such] the criteria established pursuant to subsection
(c).
[(d) Treatment of funds received by urban Indian
organizationsAny funds]
(e) Grants Subject to Criteria.--Any grant received by an
[urban] Urban Indian [organization] Organization under this
[chapter] Act 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 certain demonstration projects]
SEC. 512. TREATMENT OF CERTAIN DEMONSTRATION PROJECTS.
[(a)] Notwithstanding any other provision of law, the Tulsa
Clinic and Oklahoma City Clinic demonstration [project and the
Tulsa Clinic demonstration project shall be treated as service
units] projects shall--
(1) be permanent programs within the Service's direct
care program;
(2) continue to be treated as Service Units and
Operating 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.[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.] 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 transferred programs]
SEC. 513. URBAN NIAAA TRANSFERRED PROGRAMS.
[(a) Duty of Secretary
[The Secretary shall, within]
(a) Grants and Contracts.--The Secretary, through the
[Branch] Division of Urban [Health Programs of the Service,]
Indian Health, shall make grants or enter into contracts with
Urban Indian Organizations, to take effect not later than
September 30, 2010, for the administration of [urban] 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 [grants] Funds.--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 [urban] 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 [organizations]
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 Urban
Health Programs of the Service.
[(e) Evaluation and report to Congress]
(d) Report.--The Secretary shall evaluate and report to
[the] Congress on the activities of programs funded under this
section [at least] not less than 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. 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. 516. 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 of services 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. 517. 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. 518. EFFECTIVE DATE.
The amendments made by the Indian Health Care Improvement
Act Amendments of 2007 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. 519. ELIGIBILITY FOR SERVICES.
Urban Indians shall be eligible for, and the ultimate
beneficiaries of, health care or referral services provided
pursuant to this title.
[Sec. 1660d. Authorization of appropriations]
SEC. 520. AUTHORIZATION OF APPROPRIATIONS.
There are authorized to be appropriated such sums as may be
necessary for each fiscal year through fiscal year [2000] 2017
to carry out this [subchapter] title.
TITLE VI--ORGANIZATIONAL IMPROVEMENTS
[Sec. 1661. Establishment of the Indian Health Service as an agency of
Public Health Service]
SEC. 601. ESTABLISHMENT OF THE INDIAN HEALTH SERVICE AS AN 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
[tribes] Tribes, as are or may be [on and after
November 23, 1988,] hereafter provided by Federal
statute or treaties, there is established within the
Public Health Service of the Department [of Health and
Human Services] the Indian Health Service.
(2) Assistant secretary for indian health._The
[Indian Health] Service shall be administered by [a
Director] an Assistant Secretary for Indian Health, who
shall be appointed by the President, by and with the
advice and consent of the Senate. The [Director of the
Indian Health Service] Assistant Secretary 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, [1993,] 2007, the term of
service of the [Director] Assistant Secretary shall be
4 years. [A Director] An Assistant Secretary may serve
more than 1 term.
(3) Incumbent.--The individual serving in the
position of Director of the Service on the day before
the date of enactment of the Indian Health Care
Improvement Act Amendments of 2007 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]--
(1) perform all functions [which] that were, on the
day before [November 23, 1988,] the date of enactment
of the Indian Health Care Improvement Act Amendments of
2007, carried out by or under the direction of the
individual serving as Director of the [Indian
Health]Service on[such] that 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[chapter] Act;
(B) the Act of November 2, 1921 (25 U.S.C.
13);
(C) the Act of August 5, 1954 (42 U.S.C.
[2001,] 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 [subchapter I of this chapter.] title
I;
(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
[Director of the Indian Health Service] Assistant
Secretary, shall have the authority--
(A) except to the extent provided for in
paragraph (2), to appoint and compensate
employees for the Service in accordance with
[Title 5] 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
provision of law, the provisions of section [472 of
this title] 12 of the Act of June 18, 1934 (48 Stat.
986; 25 U.S.C. 472), shall apply to all personnel
actions taken with respect to new positions created
within the Service as a result of its establishment
under subsection (a)[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 management information system]
SEC. 602. AUTOMATED MANAGEMENT INFORMATION 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 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 [area]
Area office of the Service;
(E) an interface mechanism for patient
billing and accounts receivable system; and
(F) a training component.
(b) Provision [to Indian tribes and organizations;
reimbursement (1) The Secretary shall provide each Indian tribe
and tribal organization that provides health services under a
contract entered into with the Service under the Indian Self-
Determination Act [25 U.S.C.A. Sec. 450f et seq.] of Systems to
Tribes and Organizations._The Secretary shall provide each
Tribal Health Program automated management information systems
which--
[(A)] (1) meet the management information needs of
such [Indian tribe or tribal organization]Tribal Health
Program with respect to the treatment by the [Indian
tribe or tribal organization] Tribal Health Program of
patients of the Service[,]; and
[(B)] (2) 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] 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. 1663. Authorization of appropriations]
SEC. 603. AUTHORIZATION OF APPROPRIATIONS.
There [are] is authorized to be appropriated such sums as
may be necessary for each fiscal year through fiscal year
[2000] 2017 to carry out this [subchapter] title.
TITLE VII--BEHAVIORAL HEALTH 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 behavioral 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
progress toward achieving the availability of
the full continuum of care described in
subsection (c).
(C) An estimate of the additional funding
needed by the Service, Indian Tribes, Tribal
Organizations, and Urban Indian Organizations
to meet their responsibilities under the plans.
(2) National clearinghouse.--The Secretary, acting
through the Service, shall coordinate with existing
national clearinghouses and information centers to
include at the clearinghouses and centers 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; and
(I) 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 approaches for risk-
related behavior;
(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 enactment of the Indian Health Care
Improvement Act Amendments of 2007, 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.
(a) Contents.--Not later than 12 months after the date of
enactment of the Indian Health Care Improvement Act Amendments
of 2007, 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 (25 U.S.C. 2401 et seq.))
with behavioral health initiatives pursuant to
this Act, particularly with respect to the
referral and treatment of dually 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).
[Sec. 1665. Indian Health Service responsibilities]
(8) Providing for an annual review of such agreement
by the Secretaries which shall be provided to Congress
and Indian Tribes and Tribal Organizations.
[The Memorandum of Agreement]
(b) Specific Provisions Required._The memoranda of
agreement updated or entered into pursuant to [section 2411 of
this title] subsection (a) shall include specific provisions
pursuant to which the Service shall assume responsibility for--
(1) the determination of the scope of the problem of
alcohol and substance abuse among [Indian people]
Indians, 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) Publication.--Each memorandum of agreement entered into
or renewed (and amendments or modifications thereto) 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. 703. COMPREHENSIVE BEHAVIORAL HEALTH PREVENTION AND TREATMENT
PROGRAM.
[Sec. 1665a. Indian Health Service program]
(a) Establishment._
[(a) Comprehensive prevention and treatment program]
(1) In general.--The Secretary, acting through the
Service, Indian Tribes, and Tribal Organizations, shall
provide a program of comprehensive [alcohol and
substance abuse prevention and treatment] behavioral
health, prevention, treatment, and aftercare, which
shall include--
(A) prevention, through educational
intervention, in Indian communities;
(B) acute detoxification [and treatment;],
psychiatric hospitalization, residential, and
intensive outpatient 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 [post partum] postpartum women and
their children; and
(F) diagnostic services.
(2) Target populations.--The target population of
such [program] programs shall be members of Indian
[tribes] 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 [health services] Health 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 [alcohol and substance abuse] behavioral health
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 [tribes] Tribes and Tribal Organizations to
develop criteria for the certification of [alcohol and
substance abuse] behavioral health 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].
[(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. 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.
SEC. 705. LICENSING REQUIREMENT FOR MENTAL HEALTH CARE WORKERS.
(a) In General.--Subject to the provisions of section 221,
and except as provided in subsection (b), any individual
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 psychologist, social worker, or
marriage and family therapist, respectively.
(b) Trainees.--An individual may be employed as a trainee
in psychology, social work, or marriage and family therapy to
provide mental health care services described in subsection (a)
if such individual--
(1) works under the direct supervision of a licensed
psychologist, social worker, or marriage and family
therapist, respectively;
(2) is enrolled in or has completed at least 2 years
of course work at a post-secondary, accredited
education program for psychology, social work, marriage
and family therapy, or counseling; and
(3) meets such other training, supervision, and
quality review requirements as the Secretary may
establish.
[Sec. 1665b. Indian women treatment programs]
SEC. 706. INDIAN WOMEN TREATMENT PROGRAMS.
[(a) Grants
[The Secretary]
(a) Grants._The Secretary, consistent with section 701, may
make grants to Indian [tribes and tribal organizations] Tribes,
Tribal Organizations, and Urban Indian Organizations to develop
and implement a comprehensive [alcohol and substance abuse]
behavioral health program of prevention, intervention,
treatment, and relapse prevention services that specifically
addresses the cultural, historical, social, and child care
needs of Indian women, regardless of age.
(b) Use of [grantsGrants] Grant 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 [alcohol and substance abuse] behavioral
health issues, including fetal alcohol [syndrome and
fetal alcohol effect] disorders;
(2) identify and provide [appropriate] psychological
services, counseling, advocacy, support, and relapse
prevention to Indian women and their families; and
(3) develop prevention and intervention models for
Indian women which incorporate traditional [healers]
health care practices, cultural values, and community
and family involvement.
(c) Criteria [for the 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
[grants] funding under this section.
[(d) Authorization of appropriations
[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)] (d) Earmark of Certain Funds._Twenty percent of the
funds appropriated pursuant to this [subsection] section shall
be used to make grants to [urban] Urban Indian [organizations
funded under subchapter IV of this chapter] Organizations.
[Sec. 1665c. Indian Health Service youth program]
SEC. 707. INDIAN YOUTH PROGRAM.
(a) Detoxification and [rehabilitation] Rehabilitation._The
Secretary, acting through the Service, consistent with section
701, shall develop and implement a program for acute
detoxification and treatment for Indian [youth who are alcohol
and substance abusers] youths, including behavioral health
services. The program shall include regional treatment centers
designed to include detoxification and rehabilitation for both
sexes on a referral basis. [These regional] 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.). Regional centers shall be integrated with the intake and
rehabilitation programs based in the referring Indian
community.
(b) Alcohol and Substance Abuse Treatment [centers or
facilities] Centers or Facilities.--
(1) Establishment.--
(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, [a] at least 1 youth regional
treatment center or treatment network in each
area under the jurisdiction of an [area office]
Area 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
area office] Area Office in California shall be
considered to be [two area offices, one] 2 Area
Offices, 1 office whose jurisdiction shall be
considered to encompass the northern area of
the State of California, and [one] 1 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 [tribes] Indian Tribes
to be served by such center.
(4) Specific provision of funds._
(4A) [(A)] In general._Notwithstanding any other
provision of this [subchapter] title, the Secretary
may, from amounts authorized to be appropriated for the
purposes of carrying out this section, make funds
available to--
(i) the Tanana Chiefs Conference,
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 [450b(l) of this
title] 4(l) of the Indian Self-Determination
and Education Assistance Act (25 U.S.C.
450b(l)).
(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.
[(B) 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 youth residing in 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 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.
[(c)] (d) Federally[owned structures]-Owned Structures.--
(1) In general._The Secretary, [acting through the
Service, shall,] in consultation with Indian [tribes]
Tribes and Tribal Organizations, shall--
(A) identify and use, where appropriate,
federally-owned structures suitable [as] for
local residential or regional [alcohol and
substance abuse] behavioral health treatment
[centers] for Indian [youth] youths; and
(B) establish guidelines for determining the
suitability of any such federally-owned
structure to be used [as a] for local
residential or regional [alcohol and substance
abuse] behavioral health treatment [center] for
Indian [youth] youths.
[(2)] (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.
[(d)] (e) Rehabilitation and [aftercare services] Aftercare
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 unit] Unit, community-based
rehabilitation and follow-up services for Indian [youth
who are alcohol or substance abusers which are designed
to integrate] youths who are having significant
behavioral health problems, and require long-term
treatment, community reintegration, and monitoring to
[monitor and] support the Indian [youth] youths after
their return to their home community.
(2) Administration._Services under paragraph (1)
shall be [administered within each service unit]
provided by trained staff within the community who can
assist the Indian [youth] youths in their continuing
development of self-image, positive problem-solving
skills, and nonalcohol or substance abusing behaviors.
Such staff [shall] may include alcohol and substance
abuse counselors, mental health professionals, and
other health professionals and paraprofessionals,
including community health representatives.
[(e)] (f) Inclusion of [family in youth treatment program]
Family in Youth Treatment Program.--In providing the treatment
and other services to Indian [youth] 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 [youth] 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 [(d) of this section] (e) shall be
used for outpatient care of adult family members related to the
treatment of an Indian youth under that subsection.
[(f) Multidrug abuse study (1) The Secretary shall conduct
a study to determine the incidence and prevalence of] (g)
Multidrug Abuse Program.--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 the abuse of
multiple forms of [drugs] substances, including alcohol, drugs,
inhalants, and tobacco, among Indian [youth] youths residing
[on Indian] in Indian communities, on or near reservations, and
in urban areas and [the interrelationship of such abuse with]
provide appropriate mental health services to address the
incidence of mental illness among such [youth] 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 for 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 costs 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 and Tribal 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 and Tribal
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 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
Indian youth are detained.
(d) Use of Funds.--
(1) In general.--An Indian Tribe or Tribal
Organization shall use a grant received under
subsection (c) for the following purposes:
(A) To provide telemental health services to
Indian youth, including the provision of--
(i) psychotherapy;
(ii) psychiatric assessments and
diagnostic interviews, therapies for
mental health conditions predisposing
to suicide, and treatment; and
(iii) alcohol and substance abuse
treatment.
(B) 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.
(C) 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.
(D) To develop and distribute culturally
appropriate community educational materials
on--
(i) suicide prevention;
(ii) suicide education;
(iii) suicide screening;
(iv) suicide intervention; and
(v) ways to mobilize communities with
respect to the identification of risk
factors for suicide.
(E) For data collection and reporting related
to Indian youth suicide prevention efforts.
(2) Traditional health care practices.--In carrying
out the purposes described in paragraph (1), an Indian
Tribe or Tribal Organization may use and promote the
traditional health care practices of the Indian Tribes
of the youth to be served.
(e) Applications.--To be eligible to receive a grant under
subsection (c), an Indian Tribe or Tribal 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 or Tribal 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) Collaboration; Reporting to National Clearinghouse--
(1) Collaboration.--The Secretary, acting through the
Service, shall encourage Indian Tribes and Tribal
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 and Tribal 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.
(g) 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.
(h) 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 Natural 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;
(2) evaluates the impact of the telemental health
services funded by the grants in reducing the number of
completed suicides among Indian youth;
(3) evaluates whether the demonstration project
should be--
(A) expanded to provide more than 5 grants;
and
(B) designated a permanent program; and
(4) evaluates the benefits of expanding the
demonstration project to include Urban Indian
Organizations.
(i) Authorization of Appropriations.--There is authorized
to be appropriated to carry out this section $1,500,000 for
each of fiscal years 2008 through 2011.
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 2007, 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 be 2 Area Offices, 1 office whose location shall be
considered to encompass the northern area of the State of
California and 1 office whose jurisdiction shall be considered
to encompass the remainder of the State of California. The
Secretary shall consider the possible conversion of existing,
underused Service hospital beds into psychiatric units to meet
such need.
[Sec. 1665d. Training and community education]
SEC. 710. TRAINING AND COMMUNITY EDUCATION.
[(a) Community education]
(a) Program.--The Secretary, in cooperation with the
Secretary of the Interior, shall develop and implement or
assist Indian Tribes and Tribal Organizations to develop and
implement, within each [service unit] Service 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 [in alcohol and substance abuse] about
behavioral health issues to political leaders, [tribal] 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. Such program may also include community-based
training to develop local capacity and tribal community
provider training for prevention, intervention, treatment, and
aftercare.
(b) [Training] Instruction.--The Secretary, acting through
the Service, shall, either directly or [by contract] through
Indian Tribes and Tribal Organizations, provide instruction in
the area of [alcohol and substance abuse] behavioral health
issues, 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 [syndrome] disorders 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 [2433 of this title] 4213 of the Indian
Alcohol and Substance Abuse Prevention and Treatment Act of
1986 (25 U.S.C. 2433).
[(c) Community-based training models] (c) Training
Models.--In carrying out the education and training programs
required by this section, the Secretary, [acting through the
Service and] in consultation with [tribes] Indian Tribes,
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 [substance
abuse] behavioral health problems faced by children of
alcoholics;
[(2) the cultural, spiritual, and multigenerational
aspects of [alcohol and substance abuse] behavioral
health problem prevention and recovery; and
[(3) community-based and multidisciplinary strategies
for preventing and treating [alcohol and substance
abuse] behavioral health problems.
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) Awards; Criteria.--The Secretary may award a grant 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.
[Sec. 1665e. Gallup alcohol and substance abuse treatment center]
(5) The project may deliver services in a manner
consistent with traditional health care practices.
[(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.]
(6) The project is coordinated with, and avoids
duplication of, existing services.
[Sec. 1665f. Reports]
(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.
[(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. 712. FETAL ALCOHOL DISORDER PROGRAMS.
[Sec. 1665g. Fetal alcohol syndrome and fetal alcohol effect grants]
(a) Programs.--
[(a) Award; use; review; criteria]
[(1) The Secretary may make grants to Indian tribes
and tribal organizations to establish fetal alcohol
syndrome and fetal alcohol effect] (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 programs as provided in this
section for the purposes of meeting the health status
objectives specified in section [1602(b) of this
title.] 3.
[(2) Grants made pursuant to this section shall be
used
to--]
(2) Use of funds.--
(A) In general.--Funding provided pursuant to
this section shall be used for the following:
[(A) develop and provide] (i) To develop and
provide for Indians community and in-school
training, education, and prevention programs
relating to [FAS and FAE;] fetal alcohol
disorders.
[(B) identify and provide alcohol and
substance abuse]
(ii) To identify and provide
behavioral health treatment to high-
risk [women;] Indian women and high-
risk women pregnant with an Indian's
child.
[(C)] (iii) To identify and provide
appropriate psychological services,
educational and vocational support,
counseling, advocacy, and information
to [FAS and FAE] fetal alcohol disorder
affected [persons] Indians and their
families or caretakers[;].
[(D)] (iv) To develop and implement
counseling and support programs in
schools for [FAS and FAE] fetal alcohol
disorder affected Indian children[;].
[(E)] (v) To develop prevention and
intervention models which incorporate
practitioners of traditional [healers]
health care practices, cultural values,
and community involvement[;].
[(F)] (vi) To develop, print, and
disseminate education and prevention
materials on [FAS and FAE; and] fetal
alcohol disorder.
[(G)] (vii) To develop and implement,
[through the tribal]in consultation
[process] with Indian Tribes, Tribal
Organizations, and Urban Indian
Organizations, culturally sensitive
assessment and diagnostic tools [for
use in tribal and urban Indian
communities]including dysmorphology
clinics and multidisciplinary fetal
alcohol disorder clinics for use in
Indian communities and Urban Centers.
(B) Additional uses.--In addition to any
purpose under subparagraph (A), funding
provided pursuant to this section may be used
for 1 or more of the following:
(i) Early childhood intervention
projects from birth on to mitigate the
effects of fetal alcohol disorder among
Indians.
(ii) Community-based support services
for Indians and women pregnant with
Indian children.
(iii) 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 [grants under this
section.]funding under this section.
[(b) Plan; study; national clearinghouse]
(b) Services.--The Secretary, acting through the Service[,
shall--] and Indian Tribes, Tribal Organizations, and Urban
Indian Organizations, shall--
[(1) develop an annual plan] (1) develop and provide
services for the prevention, intervention, treatment,
and aftercare for those affected by [FAS and FAE in
Indian communities;] fetal alcohol disorder in Indian
communities; and
[(2) 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] (2) provide supportive
services, including services to meet the special
educational, vocational, school-to-work transition, and
independent living needs of adolescent and adult
Indians [and Alaska Natives with FAS or FAE; and (3)
establish a national clearinghouse for prevention and
educational materials and other information on FAS and
FAE effect in Indian and Alaska Native communities and
ensure access to clearinghouse materials by any Indian
tribe or urban Indian organization] with fetal alcohol
disorder.
(c) Task [force]Force.--The Secretary shall establish a
task force to be known as the [FAS/FAE] Fetal Alcohol Disorder
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 [, the].
(2) The National Institute on Alcohol and
Alcoholism[, the].
(3) The Office of Substance Abuse Prevention[, the].
(4) The National Institute of Mental Health[, the].
(5) The Service[, the].
(6) The Office of Minority Health of the Department
of Health and Human Services[, the].
(7) The Administration for Native Americans[, the
Bureau of Indian Affairs, Indian tribes, tribal
organizations, urban Indian communities, and Indian
FAS/FAE].
(8) The National Institute of Child Health and Human
Development (NICHD).
(9) The Centers for Disease Control and Prevention.
(10) The Bureau of Indian Affairs.
(11) Indian Tribes.
(12) Tribal Organizations.
(13) Urban Indian Organizations.
(14) Indian fetal alcohol disorder experts.
[(d) Cooperative projects; research projects]
(d) Applied Research Projects.--The Secretary, acting
through the Substance Abuse and Mental Health Services
Administration, shall make grants to Indian [tribes, tribal
organizations, universities working with Indian tribes on
cooperative projects, and urban Indian organizations] Tribes,
Tribal Organizations, 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 [urban] Urban Indians affected by [FAS or FAE]
fetal alcohol disorder.
[(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) 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.]
[(2)] (e) Funding for Urban Indian Organizations.--
Ten percent of the funds appropriated pursuant to this
section shall be used to make grants to [urban Indian
organizations] Urban Indian Organizations funded under
[subchapter IV of this chapter] title V.
[Sec. 1665h. Pueblo substance abuse treatment project for San Juan
Pueblo, New Mexico]
SEC. 713. CHILD SEXUAL ABUSE AND PREVENTION TREATMENT PROGRAMS.
(a) Establishment.--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.]
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 values, and community involvement.
(4) To develop and implement culturally 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.
(c) Coordination.--The programs established under
subsection (a) shall be carried out in coordination with
programs and services authorized under the Indian Child
Protection and Family Violence Prevention Act (25 U.S.C. 3201
et seq.).
SEC. 714. BEHAVIORAL HEALTH RESEARCH.
The Secretary, in consultation with appropriate Federal
agencies, shall make grants to, or enter into contracts with,
Indian Tribes, Tribal Organizations, and Urban Indian
Organizations or enter into contracts with, or make grants to
appropriate institutions for, the conduct of research on the
incidence and prevalence of behavioral health problems among
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
[Sec. 1665i. Thunder Child Treatment Center]
(3) the development of models of prevention
techniques.
[(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.]
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. 1665j. Substance abuse counselor education demonstration project]
SEC. 715. DEFINITIONS.
[(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 educate
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.
[(g) Definitions]
For the [purposes] purpose of this [section] title, the
following definitions shall apply:
[(1) The term ``educational curriculum'' means one or
more of the following:
[(A) Classroom education.
[(B) Clinical work experience.
[(C) Continuing education workshops.
[(2) The term ``eligible community college'' means an
accredited community college that--
[(i) is located on or near an Indian
reservation;
[(ii) has entered into a cooperative
agreement with the governing body of such
Indian reservation to carry out a demonstration
project under this section; and
[(iii) has a student enrollment of not less
than 10 percent Indian.
[(3) The term ``tribally controlled community
college'' has the meaning given such term in section
1801(a)(4) of this title.
[(4) The term ``tribally controlled postsecondary
vocational institution'' has the meaning given such
term in section 2397h(2) of Title 20.
[(h) 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 the purposes of this section. Such sums shall remain
available until expended.]
(1) Assessment.--The term ``assessment'' means the
systematic collection, analysis, and dissemination of
information on health status, health needs, and health
problems.
(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.
(4) Dual diagnosis.--The term ``dual diagnosis''
means coexisting substance abuse and mental illness
conditions or diagnosis. Such clients are sometimes
referred to as mentally ill chemical abusers (MICAs).
(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.
[Sec. 1665k. Gila River alcohol and substance abuse treatment facility]
(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.
[(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.]
(8) Rehabilitation.--The term ``rehabilitation''
means to restore the ability or capacity to engage in
usual and customary life activities through education
and therapy.
[Sec. 1665l. Alaska Native drug and alcohol abuse demonstration
project]
(9) Substance Abuse.--The term ``substance abuse''
includes inhalant abuse.
[(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. 716. AUTHORIZATION OF APPROPRIATIONS.
[Sec. 1665m. Authorization of appropriations]
There is authorized to be appropriated such sums as may be
necessary for each fiscal year through fiscal year 2017 to
carry out the provisions of this title.
[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--MISCELLANEOUS
[Sec. 1671. Reports]
SEC. 801. REPORTS.
[The President shall, at the time the budget is submitted
under section 1105 of Title 31, United States Code, for each
fiscal year transmit to the] For each fiscal year following the
date of enactment of the Indian Health Care Improvement Act
Amendments of 2007, the Secretary shall transmit to Congress a
report containing--the following:
(1) [a] A report on the progress made in meeting the
objectives of this [chapter] Act, including a review of
programs established or assisted pursuant to this
[chapter] Act and [an assessment] 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[;].
(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 [chapter] Act and any steps that the Secretary
may have taken to consult with Indian [tribes] Tribes,
Tribal Organizations, and Urban Indian Organizations to
address such impact[; (3)] , including a report on
proposed changes in allocation of funding pursuant to
section 808.
(3) A report on the use of health services by
Indians--
(A) on a national and area or other 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).
[(4)] (7) [a] A separate statement which specifies
the amount of funds requested to carry out the
provisions of section [1621 of this title;] 201.
[(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 sections 1602(d),
1616a(n), 1621b(b), 1621h(j), 1631(c), 1632(g),
1634(a)(3), 1643, 1665g(e), 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), and 1680k(g) 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)(B)
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 non-
Service 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
as required by section 707(h).
(21) A report on the reallocation of base resources if
required by section 808.
SEC. 802. REGULATIONS.
(a) Deadlines.--
(1) Procedures.--Not later than 90 days after the date
of enactment of the Indian Health Care Improvement Act
Amendments of 2007, 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 II (except section 202) and VII, the
sections of title III for which negotiated rulemaking
is specifically required, and section 807. Unless
otherwise required, the Secretary may promulgate
regulations to carry out titles I, III, IV, and V, and
section 202, using the procedures required by chapter V
of title 5, United States Code (commonly known as the
``Administrative Procedure Act'').
(2) Proposed regulations.--Proposed regulations to
implement this Act shall be published in the Federal
Register by the Secretary no later than 2 years after
the date of enactment of the Indian Health Care
Improvement Act Amendments of 2007 and shall have no
less than a 120-day comment period.
(3) Final regulations.--The Secretary shall publish in
the Federal Register final regulations to implement
this Act by not later than 3 years after the date of
enactment of the Indian Health Care Improvement Act
Amendments of 2007.
(b) Committee.--A negotiated rulemaking committee
established pursuant to section 565 of title 5, United States
Code, to carry out this section shall have as its members only
representatives of the Federal Government and representatives
of Indian Tribes, and Tribal Organizations, a majority of whom
shall be nominated by and be representatives of Indian Tribes
and Tribal Organizations from each Service Area.
(c) Adaptation of Procedures.--The Secretary shall adapt
the negotiated rulemaking procedures to the unique context of
self-governance and the government-to-government relationship
between the United States and Indian Tribes.
[Sec. 1672.]
(d) Lack of Regulations.--The lack of promulgated
regulations shall not limit the effect 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.]
(e) Inconsistent Regulations.--The provisions of this Act
shall supersede any conflicting provisions of law in effect on
the day before the date of enactment of the Indian Health Care
Improvement Act Amendments of 2007, and the Secretary is
authorized to repeal any regulation inconsistent with the
provisions of this Act.
[Sec. 1674. Leases with Indian tribes]
SEC. 803. PLAN OF IMPLEMENTATION.
[(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.]
Not later than 9 months after the date of enactment of the
Indian Health Care Improvement Act Amendments of 2007, the
Secretary, in consultation with Indian Tribes, Tribal
Organizations, and Urban Indian Organizations, shall submit to
Congress a plan explaining the manner and schedule, by title
and section, by which the Secretary will implement the
provisions of this Act. This consultation may be conducted
jointly with the annual budget consultation pursuant to the
Indian Self-Determination and Education Assistance Act (25
U.S.C. 450 et seq.).
[Sec. 1675. Availability of funds]
SEC. 804. AVAILABILITY OF FUNDS.
The funds appropriated pursuant to this [chapter] Act shall
remain available until expended.
[Sec. 1676. Limitation on use of funds appropriated to the Indian
Health Service]
SEC. 805. LIMITATION ON USE OF FUNDS APPROPRIATED TO 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 operation. 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.
[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 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) 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. 806. ELIGIBILITY OF CALIFORNIA INDIANS.
[Sec. 1679. Eligibility of]
(a) In General.--The following California Indians shall be
eligible for health services provided by the Service:
[(a) Report to Congress
[(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
[tribe.] Tribe.
(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, (B) is] a
member of the Indian community served by a
local program of the Service[,]; and
[(C)] (B) 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.
[(c) 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, Santa Cruz,
Solano, Stanislaus, and Ventura shall be designated as a
contract health service delivery area by the Service for the
purpose of providing contract health services to Indians in
such State.
[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 services for ineligible persons
[(a) Individuals not otherwise eligible
[(1) Any individual who--]
[(A] (b) Clarification.--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. 807. HEALTH SERVICES FOR INELIGIBLE PERSONS.
(a) Children.--Any individual who--
(1) has not attained 19 years of age[,];
[(B] (2) is the natural or adopted child, [step-
child]stepchild, foster-child, legal ward, or orphan of
an eligible Indian[,]; and
[(C] (3) 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 [one] 1 year after the date [such disability has
been removed] of a determination of competency.
[(2)] (b) Spouses.--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 members of each Indian Tribe
being served are made eligible, as a class, by an appropriate
resolution of the governing body of the Indian [tribe of the
eligible Indian] Tribe or Tribal Organization providing such
services. 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.
[(b) Health facilities providing health services
[(1)(A) The Secretary is authorized to provide health
services under this subsection through health
facilities operated directly by the Service to
individuals who reside within the service area of a
service unit and who are not eligible for such health
services under any other subsection of this section or
under any other provision of law if--
[(i) the Indian tribe (or, in the case of a
multi-tribal service area, all the Indian
tribes) served by such service unit requests
such provision of health services to such
individuals, and
[(ii) the Secretary and the Indian tribe or
tribes have jointly determined that--]
(c) Provision of Services to Other Individuals._
[(I)] (1) In general.--The Secretary is authorized to
provide health services under this subsection through
health programs operated directly by the Service to
individuals who reside within the Service Unit and who
are not otherwise eligible for such health services
if--
(A) the Indian Tribes served by such Service
Unit request such provision of health services
to such individuals; and
(B) the Secretary and the served Indian
Tribes have jointly determined that--
(i) the provision of such health
services will not result in a denial or
diminution of health services to
eligible Indians[,]; and
[(II)] (ii) there is no reasonable
alternative health [facility]facilities
or services, within or without the
[service area of such service
unit]Service Unit, available to meet
the health needs of such individuals.
[(B)] (2) 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.[A. Sec. ]450[f] et seq.[]]), the governing body
of the Indian [tribe or tribal organization] Tribe or
Tribal Organization providing health services under
such contract or compact is authorized to determine
whether health services should be provided under such
contract to individuals who are not eligible for such
health services under any other subsection of this
section or under any other provision of law. In making
such determinations, the governing body of the Indian
[tribe or tribal organization] Tribe or Tribal
Organization shall take into account the considerations
described in [subparagraph (A)(ii] paragraph (1)(B).
(3) Payment for Services.--
[(2)](A) In general.--Persons receiving
health services provided by the Service [by
reason of] under 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 [1880(c) of the Social Security Act [42
U.S.C.A. Sec. 1395qq(c)], section 1642(a) of
this title,] 404 of this Act or any other
provision of law, amounts collected under this
subsection, including [medicare or medicaid]
Medicare, 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. and 1396 et seq.], shall be credited to
the account of the [facility] program providing
the service and shall be used [solely for the
provision of health services within that
facility. Amounts] for the purposes listed in
section 401(d)(2) and amounts collected under
this subsection shall be available for
expenditure within such [facility for not to
exceed one fiscal year after the fiscal year in
which collected] program.
(B) Indigent people.--Health services may be
provided by the Secretary through the Service
under this subsection to an indigent [person]
individual 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 [person]
individual.
(4) Revocation of consent for services.--
[(3)(A)] (A) Single tribe service area.--In
the case of a [service area] Service Area which
serves only [one] 1 Indian [tribe] Tribe, 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 [tribe] Tribe
revokes its concurrence to the provision of
such health services.
(B) Multitribal service area.--In the case of
a [multi-tribal service area] multitribal
Service Area, the authority of the Secretary to
provide health services under paragraph
(1)[(A)] shall terminate at the end of the
fiscal year succeeding the fiscal year in which
at least 51 percent of the number of Indian
[tribes] Tribes in the [service area] Service
Area revoke their concurrence to the
[provision] provisions of such health services.
[(c) Purposes served in providing health services to
otherwise ineligible individuals] (d) Other Services.--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,] postpartum; or
(4) provide care to immediate family members of an
eligible [person]individual if such care is directly
related to the treatment of the eligible [person]
individual.
[(d) Extension of hospital privileges to non-Service health
care practitioners] (e) Hospital Privileges for
Practitioners.--Hospital privileges in health facilities
operated and maintained by the Service or operated under a
contract [entered into under] or compact pursuant to the Indian
Self-Determination and Education Assistance Act [[](25
U.S.C.[A. Sec. ]450[f] et seq.[]]) may be extended to non-
Service health care practitioners who provide services to
[persons] individuals described in subsection (a) [or], (b) [of
this section], (c), or (d). Such non-Service health care
practitioners may [be regarded], as part of the privileging
process, be designated as employees of the Federal Government
for purposes of section 1346(b) and chapter 171 of [Title]
title 28, United States Code (relating to Federal tort claims)
only with respect to acts or omissions which occur in the
course of providing services to eligible [persons] individuals
as a part of the conditions under which such hospital
privileges are extended.
[(e)] (f) [``]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]
SEC. 808. REALLOCATION OF BASE RESOURCES.
[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 live 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) Non-impairment 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 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 base resources
[(a) Report to Congress] (a) Report required.--
Notwithstanding any other provision of law, any allocation of
Service funds for a fiscal year that reduces by 5 percent or
more from the previous fiscal year the funding for any
recurring program, project, or activity of a [service unit]
Service Unit may be implemented only after the Secretary has
submitted to [the President, for inclusion in the report
required to be transmitted to the] Congress, under section
[1671 of this title,] 801, a report on the proposed change in
allocation of funding, including the reasons for the change and
its likely effects.
(b) [Appropriated amounts] Exception.--Subsection (a) 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. 809. RESULTS OF DEMONSTRATION PROJECTS.
The Secretary shall provide for the dissemination to Indian
Tribes, Tribal Organizations, and Urban Indian Organizations of
the findings and results of demonstration projects conducted
under this Act.
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. 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 Department of Health and
Human Services, 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 the Service has submitted to the Committees on
Appropriations of the Senate and the House of Representatives a
budget request reflecting the increased costs associated with
the proposed final rule, and the request has been included in
an appropriations Act and enacted into law.
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. 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 of
the Service 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 care 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 Federal health care 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.
(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
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) 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 of the Service 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 enactment of the Indian Health
Care Improvement Act Amendments of 2007, 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 that 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 appropriation for health care for Indian persons.
(j) Nonapplicability of FACA.--The Federal Advisory
Committee Act (5 U.S.C. App.) shall not apply to the
Commission.
SEC. 815. CONFIDENTIALITY OF MEDICAL QUALITY ASSURANCE RECORDS;
QUALIFIED IMMUNITY FOR PARTICIPANTS.
(a) Confidentiality of Records.--Medical quality assurance
records created by or for any Indian Health Program or a health
program of an Urban Indian Organization as part of a medical
quality assurance program are confidential and privileged. Such
records may not be disclosed to any person or entity, except as
provided in subsection (c).
(b) Prohibition on Disclosure and Testimony.--
(1) In general.--No part of any medical quality
assurance record described in subsection (a) may be
subject to discovery or admitted into evidence in any
judicial or administrative proceeding, except as
provided in subsection (c).
(2) Testimony.--A person who reviews or creates
medical quality assurance records for any Indian Health
Program or Urban Indian Organization who participates
in any proceeding that reviews or creates such records
may not be permitted or required to testify in any
judicial or administrative proceeding with respect to
such records or with respect to any finding,
recommendation, evaluation, opinion, or action taken by
such person or body in connection with such records
except as provided in this section.
(c) Authorized Disclosure and Testimony.--
(1) In general.--Subject to paragraph (2), a medical
quality assurance record described in subsection (a)
may be disclosed, and a person referred to in
subsection (b) may give testimony in connection with
such a record, only as follows:
(A) To a Federal executive agency or private
organization, if such medical quality assurance
record or testimony is needed by such agency or
organization to perform licensing or
accreditation functions related to any Indian
Health Program or to a health program of an
Urban Indian Organization to perform
monitoring, required by law, of such program or
organization.
(B) To an administrative or judicial
proceeding commenced by a present or former
Indian Health Program or Urban Indian
Organization provider concerning the
termination, suspension, or limitation of
clinical privileges of such health care
provider.
(C) To a governmental board or agency or to a
professional health care society or
organization, if such medical quality assurance
record or testimony is needed by such board,
agency, society, or organization to perform
licensing, credentialing, or the monitoring of
professional standards with respect to any
health care provider who is or was an employee
of any Indian Health Program or Urban Indian
Organization.
(D) To a hospital, medical center, or other
institution that provides health care services,
if such medical quality assurance record or
testimony is needed by such institution to
assess the professional qualifications of any
health care provider who is or was an employee
of any Indian Health Program or Urban Indian
Organization and who has applied for or been
granted authority or employment to provide
health care services in or on behalf of such
program or organization.
(E) To an officer, employee, or contractor of
the Indian Health Program or Urban Indian
Organization that created the records or for
which the records were created. If that
officer, employee, or contractor has a need for
such record or testimony to perform official
duties.
(F) To a criminal or civil law enforcement
agency or instrumentality charged under
applicable law with the protection of the
public health or safety, if a qualified
representative of such agency or
instrumentality makes a written request that
such record or testimony be provided for a
purpose authorized by law.
(G) In an administrative or judicial
proceeding commenced by a criminal or civil law
enforcement agency or instrumentality referred
to in subparagraph (F), but only with respect
to the subject of such proceeding.
(2) Identity of participants.--With the exception of
the subject of a quality assurance action, the identity
of any person receiving health care services from any
Indian Health Program or Urban Indian Organization or
the identity of any other person associated with such
program or organization for purposes of a medical
quality assurance program that is disclosed in a
medical quality assurance record described in
subsection (a) shall be deleted from that record or
document before any disclosure of such record is made
outside such program or organization. Such requirement
does not apply to the release of information pursuant
to section 552a of title 5.
(d) Disclosure for Certain Purposes.--
(1) In general.--Nothing in this section shall be
construed as authorizing or requiring the withholding
from any person or entity aggregate statistical
information regarding the results of any Indian Health
Program or Urban Indian Organizations's medical quality
assurance programs.
(2) Withholding from congress.--Nothing in this
section shall be construed as authority to withhold any
medical quality assurance record from a committee of
either House of Congress, any joint committee of
Congress, or the Government Accountability Office if
such record pertains to any matter within their
respective jurisdictions.
(e) Prohibition on Disclosure of Record or Testimony.--A
person or entity having possession of or access to a record or
testimony described by this section may not disclose the
contents of such record or testimony in any manner or for any
purpose except as provided in this section.
(f) Exemption From Freedom of Information Act.--Medical
quality assurance records described in subsection (a) may not
be made available to any person under section 552 of title 5.
(g) Limitation on Civil Liability.--A person who
participates in or provides information to a person or body
that reviews or creates medical quality assurance records
described in subsection (a) shall not be civilly liable for
such participation or for providing such information if the
participation or provision of information was in good faith
based on prevailing professional standards at the time the
medical quality assurance program activity took place.
(h) Application to Information in Certain Other Records.--
Nothing in this section shall be construed as limiting access
to the information in a record created and maintained outside a
medical quality assurance program, including a patient's
medical records, on the grounds that the information was
presented during meetings of a review body that are part of a
medical quality assurance program.
(i) Regulations.--The Secretary, acting through the
Service, shall promulgate regulations pursuant to section 802.
(j) Definitions.--In this section:
(1) The term ``health care provider'' means any
health care professional, including community health
aides and practitioners certified under section 121,
who are granted clinical practice privileges or
employed to provide health care services in an Indian
Health Program or health program of an Urban Indian
Organization, who is licensed or certified to perform
health care services by a governmental board or agency
or professional health care society or organization.
(2) The term ``medical quality assurance program''
means any activity carried out before, on, or after the
date of enactment of this Act by or for any Indian
Health Program or Urban Indian Organization to assess
the quality of medical care, including activities
conducted by or on behalf of individuals, Indian Health
Program or Urban Indian Organization medical or dental
treatment review committees, or other review bodies
responsible for quality assurance, credentials,
infection control, patient safety, patient care
assessment (including treatment procedures, blood,
drugs, and therapeutics), medical records, health
resources management review and identification and
prevention of medical or dental incidents and risks.
(3) The term ``medical quality assurance record''
means the proceedings, records, minutes, and reports
that emanate from quality assurance program activities
described in paragraph (2) and are produced or compiled
by or for an Indian Health Program or Urban Indian
Organization as part of a medical quality assurance
program.
SEC. 816. APPROPRIATIONS; AVAILABILITY.
Any new spending authority (described in subparagraph (A)
or (B) of section 401(c)(2) of the Congressional Budget Act of
1974 (Public Law 93-344; 88 Stat. 317)) 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. 817. AUTHORIZATION OF APPROPRIATIONS.
``There are authorized to be appropriated such sums as may
be necessary for each fiscal year through fiscal year 2017 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 designation and 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. 102. SOBOBA SANITATION FACILITIES.
The Act of December 17, 1970 (84 Stat. 1465), is amended by
adding at the end the following:
``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. 103. 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) Chief operating officer.--The secretary of the
Foundation may serve, at the direction of the Board, as
the chief operating officer of the Foundation, or the
Board may appoint a chief operating officer, who shall
serve at the direction of the Board.
``(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
the percentage described in paragraph (2) 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) Percentages.--The percentages referred to in
paragraph (1) are--
``(A) for the first fiscal year described in
that paragraph, 20 percent;
``(B) for the following fiscal year, 15
percent; and
``(C) for each fiscal year thereafter, 10
percent.
``(3) Appointment and hiring.--The appointment of
officers and employees of the Foundation shall be
subject to the availability of funds.
``(4) 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 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''.
TITLE II--IMPROVEMENT OF INDIAN HEALTH CARE PROVIDED UNDER THE SOCIAL
SECURITY ACT
SEC. 201. EXPANSION OF PAYMENTS UNDER MEDICARE, MEDICAID, AND SCHIP FOR
ALL COVERED SERVICES FURNISHED BY INDIAN HEALTH
PROGRAMS.
(a) Medicaid.--
(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 Payment for Medical Assistance.--The
Indian Health Service and an Indian Tribe, Tribal Organization,
or an Urban Indian Organization shall be eligible for payment
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) Compliance with conditions and requirements.--
Subsection (b) of such section is amended to read as
follows:
``(b) Compliance With Conditions and Requirements.--A
facility of the Indian Health Service or an Indian Tribe,
Tribal Organization, or an Urban Indian Organization which is
eligible for payment under subsection (a) with respect to the
furnishing of items and services, but which does not meet all
of the conditions and requirements of this title and under a
State plan or waiver authority which are applicable generally
to such facility, shall make such improvements as are necessary
to achieve or maintain compliance with such conditions and
requirements in accordance with a plan submitted to and
accepted by the Secretary for achieving or maintaining
compliance with such conditions and requirements, and shall be
deemed to meet such conditions and requirements (and to be
eligible for payment under this title), without regard to the
extent of its actual compliance with such conditions and
requirements, during the first 12 months after the month in
which such plan is submitted.''.
(3) Revision of authority to enter into agreements.--
Subsection (c) of such section is amended to read as
follows:
``(c) 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 Organization, 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) Cross-references to special fund for improvement
of ihs facilities; direct billing option;
definitions.--Such section is further amended by
striking subsection (d) and adding at the end the
following new subsections:
``(d) Special Fund for Improvement of IHS Facilities.--For
provisions relating to the authority of the Secretary to place
payments to which a facility of the Indian Health Service is
eligible for payment under this title into a special fund
established under section 401(c)(1) of the Indian Health Care
Improvement Act, and the requirement to use amounts paid from
such fund for making improvements in accordance with subsection
(b), see subparagraphs (A) and (B) of section 401(c)(1) of such
Act.
``(e) Direct Billing.--For provisions relating to the
authority of a Tribal Health Program or an Urban Indian
Organization to elect to directly bill for, and receive payment
for, health care items and services provided by such Program or
Organization for which payment is made under this title, see
section 401(d) of the Indian Health Care Improvement Act.
``(f) Definitions.--In this section, the terms `Indian
Health Program', `Indian Tribe', `Tribal Health Program',
`Tribal Organization', and `Urban Indian Organization' have the
meanings given those terms in section 4 of the Indian Health
Care Improvement Act.''.
(b) Medicare.--
(1) Expansion to all covered services.--Section 1880
of such Act (42 U.S.C. 1395qq) is amended--
(A) by amending the heading to read as
follows:
``SEC. 1880. INDIAN HEALTH PROGRAMS.'';
and
(B) by amending subsection (a) to read as
follows:
``(a) Eligibility for Payments.--Subject to subsection (e),
the Indian Health Service and an Indian Tribe, Tribal
Organization, or an Urban Indian Organization shall be eligible
for payments under this title 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.''.
(2) Compliance with conditions and requirements.--
Subsection (b) of such section is amended to read as
follows:
``(b) Compliance With Conditions and Requirements.--Subject
to subsection (e), a facility of the Indian Health Service or
an Indian Tribe, Tribal Organization, or an Urban Indian
Organization which is eligible for payment under subsection (a)
with respect to the furnishing of items and services, but which
does not meet all of the conditions and requirements of this
title which are applicable generally to such facility, shall
make such improvements as are necessary to achieve or maintain
compliance with such conditions and requirements in accordance
with a plan submitted to and accepted by the Secretary for
achieving or maintaining compliance with such conditions and
requirements, and shall be deemed to meet such conditions and
requirements (and to be eligible for payment under this title),
without regard to the extent of its actual compliance with such
conditions and requirements, during the first 12 months after
the month in which such plan is submitted.''.
(3) Cross-references to special fund for improvement
of ihs facilities; direct billing option;
definitions.--
(A) In general.--Such section is further
amended by striking subsections (c) and (d) and
inserting the following new subsections:
``(c) Special Fund for Improvement of IHS Facilities.--For
provisions relating to the authority of the Secretary to place
payments to which a facility of the Indian Health Service is
eligible for payment under this title into a special fund
established under section 401(c)(1) of the Indian Health Care
Improvement Act, and the requirement to use amounts paid from
such fund for making improvements in accordance with subsection
(b), see subparagraphs (A) and (B) of section 401(c)(1) of such
Act.
``(d) Direct Billing.--For provisions relating to the
authority of a Tribal Health Program or an Urban Indian
Organization to elect to directly bill for, and receive payment
for, health care items and services provided by such Program or
Organization for which payment is made under this title, see
section 401(d) of the Indian Health Care Improvement Act.''.
(B) Conforming amendment.--Paragraph (3) of
section 1880(e) of such Act (42 U.S.C.
1395qq(e)) is amended by inserting ``and
section 401(c)(1) of the Indian Health Care
Improvement Act'' after ``Subsection (c)''.
(4) Definitions.--Such section is further amended by
amending subsection (f) to read as follows:
``(f) Definitions.--In this section, the terms `Indian
Health Program', `Indian Tribe', `Service Unit', `Tribal Health
Program', `Tribal Organization', and `Urban Indian
Organization' have the meanings given those terms in section 4
of the Indian Health Care Improvement Act.''.
(c) Application to SCHIP.--Section 2107(e)(1) of the Social
Security Act (42 U.S.C. 1397gg(e)(1)) is amended--
(1) by redesignating subparagraph (D) as subparagraph
(E); and
(2) by inserting after subparagraph (C), the
following new subparagraph:
``(D) Section 1911 (relating to Indian Health
Programs, other than subsection (d) of such
section).''
SEC. 202. INCREASED OUTREACH TO INDIANS UNDER MEDICAID AND SCHIP AND
IMPROVED COOPERATION IN THE PROVISION OF ITEMS AND
SERVICES TO INDIANS UNDER SOCIAL SECURITY ACT
HEALTH BENEFIT PROGRAMS.
Section 1139 of the Social Security Act (42 U.S.C. 1320b-9)
is amended to read as follows:
SEC. 1139. IMPROVED ACCESS TO, AND DELIVERY OF, HEALTH CARE FOR INDIANS
UNDER TITLES XVIII, XIX, AND XXI.
(a) Agreements With States for Medicaid and SCHIP Outreach
on or Near Reservations To Increase the Enrollment of Indians
in Those Programs.--
(1) In general.--In order to improve the access of
Indians residing on or near a reservation to obtain
benefits under the Medicaid and State children's health
insurance programs established under titles XIX and
XXI, 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 the Indian Health
Service, Indian Tribes, Tribal Organizations, and Urban
Indian Organizations to provide outreach, education
regarding eligibility and benefits, enrollment, and
translation services when such services are
appropriate.
(2) Construction.--Nothing in subparagraph (A) shall
be construed as affecting arrangements entered into
between States and the Indian Health Service, Indian
Tribes, Tribal Organizations, or Urban Indian
Organizations for such Service, Tribes, or
Organizations to conduct administrative activities
under such titles.
(b) Requirement to Facilitate 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 Indian
Health Service, Indian Tribes, Tribal Organizations, or Urban
Indian Organizations with respect to the provision of health
care items and services to Indians under the programs
established under title XVIII, XIX, or XXI.
(c) Definition of Indian; Indian Tribe; Indian Health
Program; Tribal Organization; Urban Indian Organization.--In
this section, the terms ``Indian'', ``Indian Tribe'', ``Indian
Health Program'', ``Tribal Organization'', and ``Urban Indian
Organization'' have the meanings given those terms in section 4
of the Indian Health Care Improvement Act.
SEC. 203. ADDITIONAL PROVISIONS TO INCREASE OUTREACH TO, AND ENROLLMENT
OF, INDIANS IN SCHIP AND MEDICAID.
(a) Nonapplication of 10 Percent Limit on Outreach and
Certain Other Expenditures.--Section 2105(c)(2) of the Social
Security Act (42 U.S.C. 1397ee(c)(2)) is amended by adding at
the end the following new subparagraph:
``(C) Nonapplication to expenditures for
outreach to increase the enrollment of indian
children under this title and title xix.--The
limitation under subparagraph (A) on
expenditures for items described in subsection
(a)(1)(D) shall not apply in the case of
expenditures for outreach activities to
families of Indian children likely to be
eligible for child health assistance under the
plan or medical assistance under the State plan
under title XIX (or under a waiver of such
plan), to inform such families of the
availability of, and to assist them in
enrolling their children in, such plans,
including such activities conducted under
grants, contracts, or agreements entered into
under section 1139(a).''.
(b) Assurance of Payments to Indian Health Care Providers
for Child Health Assistance.--Section 2102(b)(3)(D) of such Act
(42 U.S.C. 1397bb(b)(3)(D)) is amended by striking `(as defined
in section 4(c) of the Indian Health Care Improvement Act, 25
U.S.C. 1603(c))' and inserting `, including how the State will
ensure that payments are made to Indian Health Programs and
Urban Indian Organizations operating in the State for the
provision of such assistance'.
(c) Inclusion of Other Indian Financed Health Care Programs
in Exemption From Prohibition on Certain Payments.--Section
2105(c)(6)(B) of such Act (42 U.S.C. 1397ee(c)(6)(B)) is
amended by striking `insurance program, other than an insurance
program operated or financed by the Indian Health Service' and
inserting `program, other than a health care program operated
or financed by the Indian Health Service or by an Indian Tribe,
Tribal Organization, or Urban Indian Organization'.
(d) Satisfaction of Medicaid Documentation Requirements.--
(1) In general.--Section 1903(x)(3)(B) of the Social
Security Act (42 U.S.C. 1396b(x)(3)(B)) is amended--
(A) by redesignating clause (v) as clause
(vi); and
(B) by inserting after clause (iv), the
following new clause:
``(v)(I) Except as provided in
subclause (II), a document issued by a
federally-recognized Indian tribe
evidencing membership or enrollment in,
or affiliation with, such tribe.
``(II) With respect to those
federally-recognized Indian tribes
located within States having an
international border whose membership
includes individuals who are not
citizens of the United States, the
Secretary shall, after consulting with
such tribes, issue regulations
authorizing the presentation of such
other forms of documentation (including
tribal documentation, if appropriate)
that the Secretary determines to be
satisfactory documentary evidence of
citizenship or nationality for purposes
of satisfying the requirement of this
subsection.''.
(2) Transition rule.--During the period that begins
on July 1, 2006, and ends on the effective date of
final regulations issued under subclause (II) of
section 1903(x)(3)(B)(v) of the Social Security Act (42
U.S.C. 1396b(x)(3)(B)(v)) (as added by paragraph (1)),
an individual who is a member of a federally-recognized
Indian tribe described in subclause (II) of that
section who presents a document described in subclause
(I) of such section that is issued by such Indian
tribe, shall be deemed to have presented satisfactory
evidence of citizenship or nationality for purposes of
satisfying the requirement of subsection (x) of section
1903 of such Act.
(e) Definitions.--Section 2110(c) of such Act (42 U.S.C.
1397jj(c)) is amended by adding at the end the following new
paragraph:
``(9) Indian; indian health program; indian tribe;
etc.--The terms `Indian', `Indian Health Program',
`Indian Tribe', `Tribal Organization', and `Urban
Indian Organization' have the meanings given those
terms in section 4 of the Indian Health Care
Improvement Act.''.
SEC. 204. PREMIUMS AND COST SHARING PROTECTIONS UNDER MEDICAID,
ELIGIBILITY DETERMINATIONS UNDER MEDICAID AND
SCHIP, AND PROTECTION OF CERTAIN INDIAN PROPERTY
FROM MEDICAID ESTATE RECOVERY.
(a) Premiums and Cost Sharing Protection Under Medicaid.--
(1) In general.--Section 1916 of the Social Security
Act (42 U.S.C. 1396o) is amended--
(A) in subsection (a), in the matter
preceding paragraph (1), by striking ``and
(i)'' and inserting ``, (i), and (j)''; and
(B) by adding at the end the following new
subsection:
``(j) No Premiums or Cost Sharing for Indians Furnished
Items or Services Directly by Indian Health Programs or Through
Referral Under the Contract Health Service.--
``(1) No cost sharing for items or services furnished
to indians through indian health programs.--
``(A) In general.--No enrollment fee,
premium, or similar charge, and no deduction,
copayment, cost sharing, or similar charge
shall be imposed against an Indian who is
furnished an item or service directly by the
Indian Health Service, an Indian Tribe, Tribal
Organization, or Urban Indian Organization or
through referral under the contract health
service for which payment may be made under
this title.
``(B) No reduction in amount of payment to
indian health providers.--Payment due under
this title to the Indian Health Service, an
Indian Tribe, Tribal Organization, or Urban
Indian Organization, or a health care provider
through referral under the contract health
service for the furnishing of an item or
service to an Indian who is eligible for
assistance under such title, may not be reduced
by the amount of any enrollment fee, premium,
or similar charge, or any deduction, copayment,
cost sharing, or similar charge that would be
due from the Indian but for the operation of
subparagraph (A).
``(2) Rule of construction.--Nothing in this
subsection shall be construed as restricting the
application of any other limitations on the imposition
of premiums or cost sharing that may apply to an
individual receiving medical assistance under this
title who is an Indian.
``(3) Definitions.--In this subsection, the terms
`contract health service', `Indian', `Indian Tribe',
`Tribal Organization', and `Urban Indian Organization'
have the meanings given those terms in section 4 of the
Indian Health Care Improvement Act''.
(2) Conforming amendment.--Section 1916A (a)(1) of
such Act (42 U.S.C. 1396o-1(a)(1)) is amended by
striking ``section 1916(g)'' and inserting
``subsections (g), (i), or (j) of section 1916''.
(b) Treatment of Certain Property for Medicaid and SCHIP
Eligibility.--
(1) Medicaid.--Section 1902(e) of the Social Security
Act (42 U.S.C. 1396a) is amended by adding at the end
the following new paragraph:
``(13) Notwithstanding any other requirement of this
title or any other provision of Federal or State law, a
State shall disregard the following property for
purposes of determining the eligibility of an
individual who is an Indian (as defined in section 4 of
the Indian Health Care Improvement Act) for medical
assistance under this title:
``(A) Property, including real property and
improvements, that is held in trust, subject to
Federal restrictions, or otherwise under the
supervision of the Secretary of the Interior,
located on a 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 a reservation as designated and approved
by the Bureau of Indian Affairs of the
Department of the Interior.
``(B) For any federally recognized Tribe not
described in subparagraph (A), property located
within the most recent boundaries of a prior
Federal reservation.
``(C) Ownership interests in rents, leases,
royalties, or usage rights related to natural
resources (including extraction of natural
resources or harvesting of timber, other plants
and plant products, animals, fish, and
shellfish) resulting from the exercise of
federally protected rights.
``(D) Ownership interests in or usage rights
to items not covered by subparagraphs (A)
through (C) that have unique religious,
spiritual, traditional, or cultural
significance or rights that support subsistence
or a traditional lifestyle according to
applicable tribal law or custom.''.
(2) Application to schip.--Section 2107(e)(1) of such
Act (42 U.S.C. 1397gg(e)(1)) is amended--
(A) by redesignating subparagraphs (B)
through (E), as subparagraphs (C) through (F),
respectively; and
(B) by inserting after subparagraph (A), the
following new subparagraph:
``(B) Section 1902(e)(13) (relating to
disregard of certain property for purposes of
making eligibility determinations).''.
(c) Continuation of Current Law Protections of Certain
Indian Property From Medicaid Estate Recovery.--Section
1917(b)(3) of the Social Security Act (42 U.S.C. 1396p(b)(3))
is amended--
(1) by inserting ``(A)'' after ``(3)''; and
(2) by adding at the end the following new
subparagraph:
``(B) The standards specified by the
Secretary under subparagraph (A) shall require
that the procedures established by the State
agency under subparagraph (A) exempt income,
resources, and property that are exempt from
the application of this subsection as of April
1, 2003, under manual instructions issued to
carry out this subsection (as in effect on such
date) because of the Federal responsibility for
Indian Tribes and Alaska Native Villages.
Nothing in this subparagraph shall be construed
as preventing the Secretary from providing
additional estate recovery exemptions under
this title for Indians.''.
SEC. 205. NONDISCRIMINATION IN QUALIFICATIONS FOR PAYMENT FOR SERVICES
UNDER FEDERAL HEALTH CARE PROGRAMS.
Section 1139 of the Social Security Act (42 U.S.C. 1320b-
9), as amended by section 202, is amended by redesignating
subsection (c) as subsection (d), and inserting after
subsection (b) the following new subsection:
``(c) Nondiscrimination in Qualifications for Payment for
Services Under Federal Health Care Programs.--
``(1) Requirement to satisfy generally applicable
participation requirements.--
(A) In general.--A Federal health care
program must accept an entity that is operated
by the Indian Health Service, an Indian Tribe,
Tribal Organization, or Urban Indian
Organization as a provider eligible to receive
payment under the program for health care
services furnished to an Indian on the same
basis as any other provider qualified to
participate as a provider of health care
services under the program if the entity meets
generally applicable State or other
requirements for participation as a provider of
health care services under the program.
``(B) Satisfaction of state or local
licensure or recognition requirements.--Any
requirement for participation as a provider of
health care services under a Federal health
care program that an entity be licensed or
recognized under the State or local law where
the entity is located to furnish health care
services shall be deemed to have been met in
the case of an entity operated by the Indian
Health Service, an Indian Tribe, Tribal
Organization, or Urban Indian Organization if
the entity meets all the applicable standards
for such licensure or recognition, regardless
of whether the entity obtains a license or
other documentation under such State or local
law. In accordance with section 221 of the
Indian Health Care Improvement Act, the absence
of the licensure of a health care professional
employed by such an entity under the State or
local law where the entity is located shall not
be taken into account for purposes of
determining whether the entity meets such
standards, if the professional is licensed in
another State.
``(2) Prohibition on federal payments to entities or
individuals excluded from participation in federal
health care programs or whose state licenses are under
suspension or have been revoked.--
``(A) Excluded entities.--No entity operated
by the Indian Health Service, an Indian Tribe,
Tribal Organization, or Urban Indian
Organization that has been excluded from
participation in any Federal health care
program or for which a license is under
suspension or has been revoked by the State
where the entity is located shall be eligible
to receive payment under any such program for
health care services furnished to an Indian.
``(B) Excluded individuals.--No individual
who has been excluded from participation in any
Federal health care program or whose State
license is under suspension or has been revoked
shall be eligible to receive payment under any
such program for health care services furnished
by that individual, directly or through an
entity that is otherwise eligible to receive
payment for health care services, to an Indian.
``(C) Federal health care program defined.--
In this subsection, the term, `Federal health
care program' has the meaning given that term
in section 1128B(f), except that, for purposes
of this subsection, such term shall include the
health insurance program under chapter 89 of
title 5, United States Code.''.
SEC. 206. CONSULTATION ON MEDICAID, SCHIP, AND OTHER HEALTH CARE
PROGRAMS FUNDED UNDER THE SOCIAL SECURITY ACT
INVOLVING INDIAN HEALTH PROGRAMS AND URBAN INDIAN
ORGANIZATIONS.
(a) In General.--Section 1139 of the Social Security Act
(42 U.S.C. 1320b-9), as amended by sections 202 and 205, is
amended by redesignating subsection (d) as subsection (e), and
inserting after subsection (c) the following new subsection:
``(d) Consultation With Tribal Technical Advisory Group
(TTAG).--The Secretary shall maintain within the Centers for
Medicaid & Medicare Services (CMS) a Tribal 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 Advice Under Medicaid and SCHIP.--
(1) Medicaid state plan amendment.--Section 1902(a)
of the Social Security Act (42 U.S.C. 1396a(a)) is
amended--
(A) in paragraph (69), by striking `and' at
the end;
(B) in paragraph (70)(B)(iv), by striking the
period at the end and inserting `; and'; and
(C) by inserting after paragraph (70)(B)(iv),
the following new paragraph:
``(71) in the case of any State in which the Indian
Health Service operates or funds health care programs,
or in which 1 or more Indian Health Programs or Urban
Indian Organizations (as such terms are defined in
section 4 of the Indian Health Care Improvement Act)
provide health care in the State for which medical
assistance is available under such title, provide for 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 this title that
are likely to have a direct effect on such Indian
Health Programs and Urban Indian Organizations and
that--
``(A) shall 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; and
``(B) 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 State plan under this
title.''.
(2) Application to schip.--Section 2107(e)(1) of such
Act (42 U.S.C. 1397gg(e)(1)), as amended by section
204(b)(2), is amended--
(A) by redesignating subparagraphs (B) through
(F) as subparagraphs (C) through (G),
respectively; and
(B) by inserting after subparagraph (A), the
following new subparagraph:
``(B) Section 1902(a)(71) (relating to the
option of certain States to seek advice from
designees of Indian Health Programs and Urban
Indian Organizations).''.
(c) Rule of Construction.--Nothing in the amendments made
by this section shall be construed as superseding existing
advisory committees, working groups, guidance, or other
advisory procedures established by the Secretary of Health and
Human Services or by any State with respect to the provision of
health care to Indians.
SEC. 207. EXCLUSION WAIVER AUTHORITY FOR AFFECTED INDIAN HEALTH
PROGRAMS AND SAFE HARBOR TRANSACTIONS UNDER THE
SOCIAL SECURITY ACT.
(a) Exclusion Waiver Authority.--Section 1128 of the Social
Security Act (42 U.S.C. 1320a-7) is amended by adding at the
end the following new subsection:
``(k) Additional Exclusion Waiver Authority for Affected
Indian Health Programs.--In addition to the authority granted
the Secretary under subsections (c)(3)(B) and (d)(3)(B) to
waive an exclusion under subsection (a)(1), (a)(3), (a)(4), or
(b), the Secretary may, in the case of an Indian Health
Program, waive such an exclusion upon the request of the
administrator of an affected Indian Health Program (as defined
in section 4 of the Indian Health Care Improvement Act) who
determines that the exclusion would impose a hardship on
individuals entitled to benefits under or enrolled in a Federal
health care program.''.
(b) Certain Transactions Involving Indian Health Care
Programs Deemed to Be in Safe Harbors.--Section 1128B(b) of the
Social Security Act (42 U.S.C. 1320a-7b(b)) is amended by
adding at the end the following new paragraph:
``(4) Subject to such conditions as the Secretary may
promulgate from time to time as necessary to prevent fraud and
abuse, for purposes of paragraphs (1) and (2) and section
1128A(a), the following transfers shall not be treated as
remuneration:
``(A) Transfers between indian health
programs, indian tribes, tribal organizations,
and urban indian organizations.--Transfers of
anything of value between or among an Indian
Health Program, Indian Tribe, Tribal
Organization, or Urban Indian Organization,
that are made for the purpose of providing
necessary health care items and services to any
patient served by such Program, Tribe, or
Organization and that consist of--
``(i) services in connection with the
collection, transport, analysis, or
interpretation of diagnostic specimens
or test data;
``(ii) inventory or supplies;
``(iii) staff; or
``(iv) a waiver of all or part of
premiums or cost sharing.
``(B) Transfers between indian health
programs, indian tribes, tribal organizations,
or urban indian organizations and patients.--
Transfers of anything of value between an
Indian Health Program, Indian Tribe, Tribal
Organization, or Urban Indian Organization and
any patient served or eligible for service from
an Indian Health Program, Indian Tribe, Tribal
Organization, or Urban Indian Organization,
including any patient served or eligible for
service pursuant to section 807 of the Indian
Health Care Improvement Act, but only if such
transfers--
``(i) consist of expenditures related
to providing transportation for the
patient for the provision of necessary
health care items or services, provided
that the provision of such
transportation is not advertised, nor
an incentive of which the value is
disproportionately large in
relationship to the value of the health
care item or service (with respect to
the value of the item or service itself
or, for preventative items or services,
the future health care costs reasonably
expected to be avoided);
``(ii) consist of expenditures
related to providing housing to the
patient (including a pregnant patient)
and immediate family members or an
escort necessary to assuring the timely
provision of health care items and
services to the patient, provided that
the provision of such housing is not
advertised nor an incentive of which
the value is disproportionately large
in relationship to the value of the
health care item or service (with
respect to the value of the item or
service itself or, for preventative
items or services, the future health
care costs reasonably expected to be
avoided); or
``(iii) are for the purpose of paying
premiums or cost sharing on behalf of
such a patient, provided that the
making of such payment is not subject
to conditions other than conditions
agreed to under a contract for the
delivery of contract health services.
``(C) Contract health services.--A transfer
of anything of value negotiated as part of a
contract entered into between an Indian Health
Program, Indian Tribe, Tribal Organization,
Urban Indian Organization, or the Indian Health
Service and a contract care provider for the
delivery of contract health services authorized
by the Indian Health Service, provided that--
``(i) such a transfer is not tied to
volume or value of referrals or other
business generated by the parties; and
``(ii) any such transfer is limited
to the fair market value of the health
care items or services provided or, in
the case of a transfer of items or
services related to preventative care,
the value of the future health care
costs reasonably expected to be
avoided.
``(D) Other transfers.--Any other transfer of
anything of value involving an Indian Health
Program, Indian Tribe, Tribal Organization, or
Urban Indian Organization, or a patient served
or eligible for service from an Indian Health
Program, Indian Tribe, Tribal Organization, or
Urban Indian Organization, that the Secretary,
in consultation with the Attorney General,
determines is appropriate, taking into account
the special circumstances of such Indian Health
Programs, Indian Tribes, Tribal Organizations,
and Urban Indian Organizations, and of patients
served by such Programs, Tribes, and
Organizations.''.
SEC. 208. RULES APPLICABLE UNDER MEDICAID AND SCHIP TO MANAGED CARE
ENTITIES WITH RESPECT TO INDIAN ENROLLEES AND
INDIAN HEALTH CARE PROVIDERS AND INDIAN MANAGED
CARE ENTITIES.
(a) 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 With Respect to Indian Enrollees,
Indian Health Care Providers, and Indian Managed Care
Entities.--
``(1) Enrollee option to select an indian health care
provider 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 care provider 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 Indian health care provider and the Indian health
care provider has the capacity to provide primary care services
to such Indian, the contract with the entity under section
1903(m) or under section 1905(t)(3) shall require, as a
condition of receiving payment under such contract, that the
Indian shall be allowed to choose such Indian health care
provider as the Indian's primary care provider under the
entity.
``(2) Assurance of payment to indian health care
providers for provision of covered services.--Each
contract with a managed care entity under section
1903(m) or under section 1905(t)(3) shall require any
such entity that has a significant percentage of Indian
enrollees (as determined by the Secretary), as a
condition of receiving payment under such contract to
satisfy the following requirements:
``(A) Demonstration of participating indian
health care providers or application of
alternative payment arrangements.--Subject to
subparagraph (E), to--
``(i) demonstrate that the number of
Indian health care providers that are
participating providers with respect to
such entity are sufficient to ensure
timely access to covered Medicaid
managed care services for those
enrollees who are eligible to receive
services from such providers; or
``(ii) agree to pay Indian health
care providers who are not
participating providers with the entity
for covered Medicaid managed care
services provided to those enrollees
who are eligible to receive services
from such providers at a rate equal to
the rate negotiated between such entity
and the provider involved or, if such a
rate has not been negotiated, at 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
participating provider which is not an
Indian health care provider.
``(B) Prompt payment.--To agree to make
prompt payment (in accordance with rules
applicable to managed care entities) to Indian
health care providers that are participating
providers with respect to such entity or, in
the case of an entity to which subparagraph
(A)(ii) or (E) applies, that the entity is
required to pay in accordance with that
subparagraph.
``(C) Satisfaction of claim requirement.--To
deem any requirement for the submission of a
claim or other documentation for services
covered under subparagraph (A) by the enrollee
to be satisfied through the submission of a
claim or other documentation by an Indian
health care provider that is consistent with
section 403(h) of the Indian Health Care
Improvement Act.
``(D) Compliance with generally applicable
requirements.--
``(i) In general.--Subject to clause
(ii), as a condition of payment under
subparagraph (A), an Indian health care
provider shall comply with the
generally applicable requirements of
this title, the State plan, and such
entity with respect to covered Medicaid
managed care services provided by the
Indian health care provider to the same
extent that non-Indian providers
participating with the entity must
comply with such requirements.
``(ii) Limitations on compliance with
managed care entity generally
applicable requirements.--An Indian
health care provider--
``(I) shall not be required
to comply with a generally
applicable requirement of a
managed care entity described
in clause (i) as a condition of
payment under subparagraph (A)
if such compliance would
conflict with any other
statutory or regulatory
requirements applicable to the
Indian health care provider;
and
``(II) shall only need to
comply with those generally
applicable requirements of a
managed care entity described
in clause (i) as a condition of
payment under subparagraph (A)
that are necessary for the
entity's compliance with the
State plan, such as those
related to care management,
quality assurance, and
utilization management.
``(E) Application of special payment
requirements for federally-qualified health
centers and encounter rate for services
provided by certain indian health care
providers.--
``(i) Federally-qualified health
centers.--
``(I) Managed care entity
payment requirement.--To agree
to pay any Indian health care
provider that is a Federally-
qualified health center but not
a participating provider with
respect to the entity, for the
provision of covered Medicaid
managed care services by such
provider to an Indian enrollee
of the entity at a rate equal
to the amount of payment that
the entity would pay a
Federally-qualified health
center that is a participating
provider with respect to the
entity but is not an Indian
health care provider for such
services.
``(II) Continued application
of state requirement to make
supplemental payment.--Nothing
in subclause (I) or
subparagraph (A) or (B) shall
be construed as waiving the
application of section
1902(bb)(5) regarding the State
plan requirement to make any
supplemental payment due under
such section to a Federally-
qualified health center for
services furnished by such
center to an enrollee of a
managed care entity (regardless
of whether the Federally-
qualified health center is or
is not a participating provider
with the entity).
``(ii) Continued application of
encounter rate for services provided by
certain indian health care providers.--
If the amount paid by a managed care
entity to an Indian health care
provider that is not a Federally-
qualified health center and that has
elected to receive payment under this
title as an Indian Health Service
provider under the July 11, 1996,
Memorandum of Agreement between the
Health Care Financing Administration
(now the Centers for Medicare &
Medicaid Services) and the Indian
Health Service for services provided by
such provider to an Indian enrollee
with the managed care entity is less
than the encounter rate that applies to
the provision of such services under
such memorandum, the State plan shall
provide for payment to the Indian
health care provider of the difference
between the applicable encounter rate
under such memorandum and the amount
paid by the managed care entity to the
provider for such services.
``(F) Construction.--Nothing in this
paragraph shall be construed as waiving the
application of section 1902(a)(30)(A) (relating
to application of standards to assure that
payments are consistent with efficiency,
economy, and quality of care).
``(3) Offering of managed care through indian
medicaid managed care entities.--If--
``(A) a State elects to provide services
through Medicaid managed care entities under
its Medicaid managed care program; and
``(B) an Indian health care provider that is
funded in whole or in part by the Indian Health
Service, or a consortium composed of 1 or more
Tribes, Tribal Organizations, or Urban Indian
Organizations, and which also may include the
Indian Health Service, 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.
``(4) 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:
``(A) Enrollment.--
``(i) 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.
``(ii) 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 individuals who are not Indians.
``(iii) Default enrollment.--
``(I) In general.--If such
program of a State requires the
enrollment of Indians in a
Medicaid managed care entity in
order to receive benefits, the
State, taking into
consideration the criteria
specified in subsection
(a)(4)(D)(ii)(I), shall provide
for the enrollment of Indians
described in subclause (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
subclause, 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).
``(iv) 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.
``(B) Flexibility in application of
solvency.--In applying section 1903(m)(1) to an
Indian Medicaid managed care entity--
``(i) any reference to a `State' in
subparagraph (A)(ii) of that section
shall be deemed to be a reference to
the `Secretary'; and
``(ii) the entity shall be deemed to
be a public entity described in
subparagraph (C)(ii) of that section.
``(C) Exceptions to advance directives.--The
Secretary may modify or waive the requirements
of section 1902(w) (relating to provision of
written materials on 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.
``(D) Flexibility in information and
marketing.--
``(i) Materials.--The Secretary may
modify requirements under subsection
(a)(5) to ensure that information
described in that subsection is
provided to enrollees and potential
enrollees of Indian Medicaid managed
care entities in a culturally
appropriate and understandable manner
that clearly communicates to such
enrollees and potential enrollees their
rights, protections, and benefits.
``(ii) Distribution of marketing
materials.--The provisions of
subsection (d)(2)(B) requiring the
distribution of marketing materials to
an entire service area shall 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.
[Sec. 1680h. Demonstration projects for tribal management of health
care services]
``(5) Malpractice insurance.--Insofar as,
under a Medicaid managed care program, a health
care provider is required to have medical
malpractice insurance coverage as a condition
of contracting as a provider with a Medicaid
managed care entity, an Indian health care
provider that is--
[(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 demonstration 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.]
``(A) a Federally-qualified health center
that is covered under the Federal Tort Claims
Act (28 U.S.C. 1346(b), 2671 et seq.);
[Sec. 1680i. Child sexual abuse treatment programs]
``(B) providing health care services pursuant
to a contract or compact under the Indian Self-
Determination and Education Assistance Act (25
U.S.C. 450 et seq.) that are covered under the
Federal Tort Claims Act (28 U.S.C. 1346(b),
2671 et seq.); or
[(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).]
``(C) the Indian Health Service providing
health care services that are covered under the
Federal Tort Claims Act (28 U.S.C. 1346(b),
2671 et seq.);
[Sec. 1680j. Tribal leasing]
are deemed to satisfy such requirement.
[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.]
``(6) Definitions.--For purposes of this subsection:
[Sec. 1680k. Home- and community-based care demonstration project]
``(A) Indian health care provider.--The term
`Indian health care provider' means an Indian
Health Program or an Urban Indian Organization.
[(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 be 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.]
``(B) Indian; indian health program; service;
tribe; tribal organization; urban indian
organization.--The terms `Indian', `Indian
Health Program', `Service', `Tribe', `tribal
organization', `Urban Indian Organization' have
the meanings given such terms in section 4 of
the Indian Health Care Improvement Act.
[Sec. 1680l. Shared services demonstration project]
``(C) 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)) by the Indian Health
Service, a Tribe, Tribal Organization, or Urban
Indian Organization, 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.
[(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 of 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.]
``(D) Non-indian medicaid managed care
entity.--The term `non-Indian Medicaid managed
care entity' means a managed care entity that
is not an Indian Medicaid managed care entity.
[Sec. 1680m. Results of demonstration projects]
``(E) Covered medicaid managed care
services.--The term `covered Medicaid managed
care services' means, with respect to an
individual enrolled with a 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.
[The Secretary shall provide for the dissemination to
Indian tribes of the findings and results of demonstration
projects conducted under this chapter.]
``(F) Medicaid managed care program.--The
term `Medicaid managed care program' means a
program under sections 1903(m) and 1932 and
includes a managed care program operating under
a waiver under section 1915(b) or 1115 or
otherwise.''.
[Sec. 1680n. Priority for Indian reservations]
(b) Application to SCHIP.--Section 2107(e)(1) of such Act
(42 U.S.C. 1397gg(1)), as amended by section 206(b)(2), is
amended by adding at the end the following new subparagraph:
[(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.]
``(H) Subsections (a)(2)(C) and (h) of
section 1932.''.
[Sec. 1680o. Authorization of appropriations]
SEC. 209. ANNUAL REPORT ON INDIANS SERVED BY SOCIAL SECURITY ACT HEALTH
BENEFIT PROGRAMS.
[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.]
Section 1139 of the Social Security Act (42 U.S.C. 1320b-
9), as amended by the sections 202, 205, and 206, is amended by
redesignating subsection (e) as subsection (f), and inserting
after subsection (d) the following new subsection:
[Sec. 1681. Billing of Indians by Indian Health Service]
``(e) Annual Report on Indians Served by Health Benefit
Programs Funded Under This Act.--Beginning January 1, 2007, and
annually thereafter, the Secretary, acting through the
Administrator of the Centers for Medicare & Medicaid Services
and the Director of the Indian Health Service, shall submit a
report to Congress regarding the enrollment and health status
of Indians receiving items or services under health benefit
programs funded under this Act during the preceding year. Each
such report shall include the following:
[The Indian Health Service shall neither bill nor charge
those Indians who may have the economic means to pay unless and
until such time as Congress has agreed upon a specific policy
to do so and has directed the Indian Health Service to
implement such a policy.]
``(1) The total number of Indians enrolled in, or
receiving items or services under, such programs,
disaggregated with respect to each such program.
[Sec. 1682. Subrogation of claims by]
``(2) The number of Indians described in paragraph
(1) that also received health benefits under programs
funded by the Indian Health Service.
[Hereafter 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.]
``(3) General information regarding the health status
of the Indians described in paragraph (1),
disaggregated with respect to specific diseases or
conditions and presented in a manner that is consistent
with protections for privacy of individually
identifiable health information under section 264(c) of
the Health Insurance Portability and Accountability Act
of 1996.
[Sec. 1683. Indian Catastrophic Health Emergency Fund]
``(4) A detailed statement of the status of
facilities of the Indian Health Service or an Indian
Tribe, Tribal Organization, or an Urban Indian
Organization with respect to such facilities'
compliance with the applicable conditions and
requirements of titles XVIII, XIX, and XXI, and, in the
case of title XIX or XXI, under a State plan under such
title or under waiver authority, and of the progress
being made by such facilities (under plans submitted
under section 1880(b), 1911(b) or otherwise) toward the
achievement and maintenance of such compliance.
[$10,000,000 shall remain available until expended, for the
establishment of an Indian Catastrophic Health Emergency Fund
(hereinafter referred to as the ``Fund''). Hereafter, 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). 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.]
``(5) Such other information as the Secretary
determines is appropriate.''.