[Senate Report 108-411]
[From the U.S. Government Publishing Office]
Calendar No. 802
108th Congress Report
SENATE
2d Session 108-411
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A BILL TO AMEND THE INDIAN HEALTH CARE IMPROVEMENT ACT TO REVISE AND
EXTEND THAT ACT
_______
November 16, 2004.--Ordered to be printed
_______
Mr. Campbell, from the Committee on Indian Affairs, submitted the
following
R E P O R T
[To accompany S. 556]
The Committee on Indian Affairs, to which was referred the
bill (S. 556) to amend the Indian Health Care Improvement Act
to revise and extend that Act; having considered the same,
reports favorably thereon with an amendment in the nature of a
substitute and recommends that the bill as amended do pass.
Purpose
The purpose of the Indian Health Care Improvement Act
Amendments of 2004 (S. 556) is to reauthorize the Act and
provide a series of improvements to the Indian health care
delivery system. The reauthorization is intended to raise the
health status of American Indians and Alaska Natives to the
highest possible level in accordance with Healthy People
2010.\1\
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\1\ ``Healthy People 2010 is the prevention agenda for the Nation.
It is a statement of national health objectives designed to identify
the most significant preventable threats to health and to establish
national goals to reduce those threats.'' U.S. Department of Health and
Human Services. www.healthypeople.gov. (last reviewed July 15, 2004).
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S. 556 sets forth policies, programs and procedures
designed to address health care deficiencies in native and
urban Indian communities and streamline service delivery to
those communities. In addition, S. 556 addresses the health
problems and associated socio-economic conditions in native
communities by authorizing the Indian Health Service (IHS) and
tribes to adopt current health industry ``best practices''.
Background
First enacted in 1976, the Act established the first
comprehensive framework for the delivery of health care
services for native people and authorized funding for health
programs, projects, and facilities. The Act was last
reauthorized in 1992.
History of Federal responsibility for Indian health care
The history of the Federal responsibility for Indian health
care is quite extensive and well-documented in numerous
sources, including past Senate Reports on prior amendments to
the Act. See eg., S. Rpt. 102-392. Nevertheless, an abbreviated
history is appropriate to inform the need for reauthorizing the
Act and specific provisions in S. 556.
Based on the U.S. Constitution, treaties, statutes and the
historical, political and legal relationship with the Indian
tribes, the United States has assumed responsibility for the
provision of health care to Indian people. This jurisprudence
also serves as the backdrop for the government-to-government
relationship.
Extensive research indicates that the health of Indians\2\
deteriorated after the 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 to reservations
and, in many cases, prohibited 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.
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\2\ As the term is used in this Report, ``Indians'' includes
American Indians and Alaska natives.
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A. Agency Administration. Initially during the early 1800s,
the health care provided was little more thanvaccinations for
the Indians around the military posts 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.
According to the Task Force on Indian Health (Task Force
Six) in the Final Report to the American Indian Policy Review
Commission (Final Report), ``[t]he health care which Indians
actually received in the first 100 years was delivered in a
piecemeal, inconsistent fashion and the few appropriations made
were never large enough to meet the overwhelming need.'' Final
Report at 27.
This lack of focus and priority was compounded by an ever-
shifting administration of Indian health among the different
Federal agencies. The responsibility for Indian health first
fell to the War Department in 1803, then to the Interior
Department in 1849, before finally being transferred to the
Department of Health, Education and Welfare (DHEW), the
predecessor of the DHHS, in 1955. The Division of Indian Health
within DHEW had initial responsibility for Indian health before
eventually being renamed the Indian Health Service. Id. at 32.
B. Congressional Action. 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.
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 lack of standards in the Snyder Act and other organized
efforts led Task Force Six 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.'' Final Report at 27.
C. The Indian Health Care Improvement Act. Congress sought
to end the piecemeal approach to Indian health and to provide
meaningful direction with passage of the Act in 1976. The Act
has been revised and extended three times since then, each time
providing for additional advancements to raise the status of
Indian health.
Specific Provisions. Several important provisions were
included as part of the comprehensive framework for improving
Indian health. First, manpower training, recruitment and
retention programs were established to increase the number of
health professionals, especially Indians, in the Indian health
care system. 25 U.S.C. 1612.
Urban Indian Programs. In addition, the Act recognized the
need for urban Indian health programs, with many Indians
located in urban centers because of the Federal relocation
policy pursued in the first half of the 20th Century. Many
disparities urban Indians face can be attributed to that
Federal policy. See Final Report at 142-145.
Congress acknowledged that the Federal obligation for
Indian health care did not end at the border of the
reservation--even though relocation was initially to end
services to these urban Indians\3\ rather than to improve the
status of Indians (health, economic) in a meaningful way.\4\
See also S. Rpt. 100-508 at 25.
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\3\ Relocating Indians from reservations to urban areas is an old
Federal policy and program first begun in 1931. ``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.'' Id.
\4\ The Snyder Act, 25 U.S.C. 13, authorizes funding for health
care for ``the Indians throughout the United States''. This statute
neither confined the services to individuals who were members of
federally-recognized tribes nor to those living only on reservations.
The Snyder Act has never been repealed or otherwise limited in this
respect.
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Congress specifically included urban Indians as part of the
Indian health care system in the Act in 1976 to correct these
disparities first as pilot programs and then ``as a permanent
part'' of the Indian health care system in 1988. S. Rpt. 100-
508, at 24. Congress has expanded health services to urban
Indians since 1976. See Pub. L. 100-713, 101-630, and 102-573.
Providing for urban Indian health has been a part of
Federal policy for more than 30 years. The definition of
``urban Indian'' remains the same in S. 556 as in current law
and is well within the scope of Congressional authority to
establish such definition.
This definition does not create unlawful racial
classifications simply because ``urban Indians'' include
individuals who are members of a federally-recognized Indian
tribe and, in some cases, individuals who are not enrolled
members of any federally-recognized Indian tribe.
The view that only members of federally-recognized tribes
are eligible for such services has been thoroughly disavowed by
Congress and the courts. First, Congress has very broad powers
``to define who are Indians'' through its power to regulate
commerce with Indian tribes.\5\ Second, Congress has defined
``Indians'' in different ways under various statutes for
different purposes. See e.g., Indian Arts and Crafts Act, Pub.
L. 101-644, 25 U.S.C. 305; and No Child Left Behind Act, Pub.
L. 107-110, 20 U.S.C. 7491; and the American Indian Probate
Reform Act of 2004, Pub. L. 108-374, signed into law on October
27, 2004.
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\5\ 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).
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One such definition found in the Indian Reorganization Act
of 1934, 25 U.S.C. 477, did not include the requirement of
membership in any tribe and was upheld in U.S. v. John, 437
U.S. 634 (1978). Courts have upheld the broad Congressional
power in other contexts as well. Most recently, the court in
U.S. v. Drewry, 365 F.3d 957, 961 (10th Cir. 2004) held that
``enrollment in a tribe is not the only way an individual can
show she is an Indian'' for Federal criminal jurisdictional
purposes. The Drewry court cited a litany of cases which also
support the principle that ``Indianness'' is not limited to
membership in a federally-recognized tribe. See e.g., U.S. v.
Antelope, 430 U.S. 641 (1997).
Certainly the courts have not held that the breadth of
Congressional power in Indian affairs is expansive only when
legislating to the detriment of Indians. To the contrary,
Courts have long held with great favor that Congress has the
broad power to legislate for the benefit of Indians and to
define who is an Indian.
The history, policy and status of Indian health provide
ample support for continuing and improving programs to urban
Indians and, therefore, the Committee stands firm on not
retreating from current law; and remains committed to improving
the health care of urban Indians in this legislation.
Indian health status
A. Health Status. The health status of Native Americans has
improved significantly since the enactment of the Act in 1976,
but the statistics remain grim. The goal of the Act was to
raise the health status of Indians to achieve parity with that
of other U.S. populations. With the basic goal still
unrealized, the need for reauthorization grows even greater.
Health Indicator Rates. Indians rank at or near the bottom
of nearly every health and social indicator when compared to
the general U.S. population. Health studies indicate
disproportionately higher mortality rates for alcoholism
(between 670-770%), tuberculosis (650%), diabetes (between 318-
420%), accidental injuries (280%), suicide (190%), and homicide
(210%) than other populations. In addition to these specific
health disparities, native people suffer from high rates of
unemployment and poverty, live in substandard housing, and
receive an inadequate education\6\--all of which contribute to
poor health.
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\6\ U.S. Department of Health and Human Services, Indian Health
Service, Facts on Indian Health Disparities, 2002.
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Alcohol and Substance Abuse. Native communities are
increasingly plagued by mental health problems, including those
exacerbated by the use of alcohol and substances, at staggering
rates which destroy native families. Federal programs currently
offer several disparate and uncoordinated mental health, and
alcohol and substance abuse prevention and treatment programs.
Better coordination of these programs within a comprehensive
behavioral health program will not only bring greater benefits
to native people, but will make a more efficient and effective
use of scarce resources.
Prevention. Long-term prevention efforts would also
significantly improve the health status of Indians. Many
programs have focused on treatment due, in part, to the
progressive, degenerative or advanced nature of the diseases.
However, many of the diseases which plague native communities
are preventable, such as diabetes, and their prevention would
reduce the long-term costs to the health care system. More
attention is needed to programs focusing on health promotion
and disease control and prevention.
B. Health Care System. Since the Act was first passed, the
Indian health care system has undergone significant changes,
particularly in the tribal administration of services. Through
the Act, combined with the passage of the Indian Self-
Determination and Education Assistance Act (ISDEAA) in 1975, 25
U.S.C. 450, et seq., Indian tribes gained the means to
administer Indian health programs.\7\
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\7\ In FY 2005, the IHS projects that ``approximately $947 million
of program and tribal shares finds will be transferred to support 87
compacts.'' Department of Health and Human Services, Fiscal Year 2005,
Indian Health Service, Justification of Estimates for Appropriations
Committee (Justification) at 129.
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However, that means is sometimes thwarted by cumbersome
bureaucracy and narrow interpretations of the ISDEAA. The
ISDEAA authorizes Indian tribes or tribal organizations to
administer programs previously operated by the IHS.
Tribal Administration. As part of that administration,
Indian tribes or tribal organizations enter contracts or
compacts with the IHS through which they may also incorporate
grants or redesign programs. 25 U.S.C. 450f and 458aaa-4.
Administering such contracts allows the tribal contractors to
save significant administrative costs and increase services to
tribal members.\8\
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\8\ Tribal Perspectives on Indian Self-Determination and Self-
Governance in Health Care Management, National Indian Health Board,
Vol. II at 32.
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The Committee has received testimony regarding the need to
clarify that this funding transfer mechanism for Indian health
programs is available for grants under the Act as well.
However, the Committee does not intend to diminish the
Secretary's discretion to award grants under the Act.
The Committee also intends that those programs that were
grants in current law (i.e., the Act as passed in 1992) remain
as grants, unless the Secretary determines they are
appropriate, contractible functions. However, nothing in S. 556
is intended to modify in any way the Indian tribes authority
under ISDEAA to incorporate a grant after it has been awarded
in an ISDEAA Title I or Title V agreement.
Flexibility is a hallmark in the delivery of Indian health
care, for both the DHHS and Indian tribes. In S. 556, the
Committee included the definition of ``fund'' and ``funding
agreement'' to make clear that the funding mechanisms available
for Indian health programs include a wide range of options,
such as contracts or compacts under the ISDEAA as well as
grants.
The ISDEAA refers to ``annual funding agreements'' and
``funding agreements'' under Titles I (25 U.S.C. 450) and V (25
U.S.C. 458aaa), respectively, and those terms are both
contemplated within the Act's definition of
``fundingagreement'' to complement, not conflict with, each other. The
Committee encourages the use of contracts and compacts to enable tribal
contractors to save costs, but recognizes that certain grant
requirements or conditions may still be appropriate and incorporated
into those legal agreements. The Committee believes that these
principles will improve the administration of Indian health.
Services. According to the IHS, the Indian health programs
are administered by the IHS directly, Indian tribes, tribal
organizations and urban Indian organizations, serving over 1.6
million Indians. Justification at 15.
According to the IHS, ``there are 594 direct health care
facilities, including 51 hospitals, 231 health centers, 5
school health centers, and 309 health stations, satellite
clinics and Alaska village clinics.'' Justification at 15.
The services include inpatient and ambulatory care with an
increased focus on preventive care. More specialized care may
be provided through contract health services wherein the IHS
contracts with non-IHS providers for these services.
Community Health Aide Program. The Community Health Aides/
Practitioner Program (CHAP) was established several years ago
under the authority of the Snyder Act to address the severe
shortage of health professionals in Alaska. The program has
operated with much success and has received substantial support
from the Administration. The success of the CHAP has led the
Committee to authorize the development of a national CHAP.
Based on the success of the medical component of the CHAP,
a dental component has been developed to address the oral
health crisis in Alaska. The Committee is aware that several
practitioners are currently in a 2-year training program for
certain dental procedures. Once they complete their training,
they will be under supervision of a licensed dentist until they
have been certified to provide certain dental procedures.
However, the American Dental Association (ADA) expressed
concerns regarding the training of the CHAPs in providing so-
called ``irreversible procedures'' for Indians.
The Committee recognizes there should be a balance of
quality care and access to care in developing these programs.
Arguably, without such programs, many Alaska natives will have
no dental care whatsoever.
The Committee also recognizes that developing a dental
volunteer program as the ADA has suggested to the Committee may
provide temporary relief to the crisis, but may not be
sufficient to address the real need or have funding available
even for a ``volunteer'' program. The Committee also
understands that the IHS's dental priority in the Indian
communities located in the lower 48 states is to fill vacancies
with dentists and the national CHAPs program is not slated to
begin in the near future.
Therefore, the Committee strongly encourages the
Administration, the Indian tribes and the ADA to work together
to address the need and fill the vacancies within the Indian
health care system.
Elevation. While Indian health care has received increased
attention by the Administration by accentuating the role of the
Director of IHS among other things--institutionalizing that
role is important. Bringing a heightened role to the IHS is
needed to improve advocacy efforts for Indian health care and
coordination with other agencies in improving the health status
of Indians. Accordingly, S. 556 includes a provision to elevate
the position of Director to that of Assistant Secretary--Indian
Health.
Funding. Funding is one area where additional advocacy
could assist. Indian health has received incremental increases
in funding over time. According to the U.S. Commission on Civil
Rights, the funding has grown from $24.5 million in 1955 to
$3.5 billion in 2004. See U.S. Commission on Civil Rights, A
Quiet Crisis: Federal Funding and Unmet Needs in Indian Country
(2003) at 40. Yet, according to some estimates, the actual need
approaches $10 billion per year over the next 10 years, with
``a one-time appropriation of $8 billion for facility
construction * * *.'' Id. at 49.
Third Party Reimbursements. The ability of IHS, Indian
tribes, tribal and urban Indian organizations to access third
party reimbursements, such as Medicaid, becomes even more
important. Several Indian-specific provisions had been included
in the Medicare Prescription Drug and Modernization Act of
2003, Pub. L. 108-173, and, therefore, additional amendments
recommended by the National Steering Committee (NSC), which was
constituted to facilitate reauthorization, were not included in
the reported bill.
However, the decision not to include those provisions in
this legislation should not be viewed as a rejection of them on
the merits. The Committee expects that these Indian-specific
provisions for Medicare will be considered when future
amendments are considered to Medicare.
Payment systems have been the subject of much debate during
the development of this legislation. The study on the extent
Social Security Act payment methodologies take into account the
unique circumstances of Indian health services was not included
in the reported bill. The DHHS indicated to the Committee that
it has sufficient authority under existing law to undertake
this payment methodology review.
Thus, the Committee is confident the Secretary will perform
such a review pursuant to existing authority. The Committee
encourages the Secretary consider current payment methodologies
applicable to the Indian health system with the objective of
balancing access to care and payment at rates consistent with
those for most favored providers.
The Committee is aware that the costs of changing to a
different payment methodology could cost the IHS and Indian
tribes up to $16 million. Therefore, in the interim, the
Committee expects the Secretary to maintain the current payrate
unless another rate is determined by the Secretary to be more
beneficial to Indian health programs, given the additional costs
associated with the new system.
The Committee is aware that Indian tribes have sought to
interface with Medicaid managed care organizations (MCO) or to
develop their own tribal MCO. The primary goals for
participation are to ensure the appropriate entities achieve
the full benefit of the Medicaid funding, particularly the
capitated payments, and increase access for Indians to these
programs.
First, when an Indian--enrolled in a MCO authorized by a
State Medicaid Plan--receives covered health services from an
Indian health program, the MCO should reimburse the Indian
health program appropriately.
The rate should be no less than the rate of reimbursement
for preferred providers or at such other rate that may be
negotiated between the MCO and the Indian health program. In
the alternative, the State Medicaid Plan may make the
appropriate payments to the Indian health program, and then
make an adjustment in the capitation payment to the MCO.
The Committee is aware that Medicaid Indian patients may be
enrolled in Medicaid MCOs for which the State Medicaid Plan
makes capitation payments to the MCO. Often such an Indian
enrollee will use the Indian health program for needed health
care, especially when the MCO network providers are distant
from or unfamiliar to the patient.
Having received a capitation payment from the Medicaid
Plan, the MCO should not be permitted to escape responsibility
for reimbursing the Indian health provider when the MCO has not
included the Indian health program in its provider network, yet
has received Medicaid funding as a result of that Indian's
enrollment in the Plan.
The Committee is aware that some Indian health programs
have attempted to join the network, but have been met with some
resistance or, in the end, have found it not feasible to join.
The Committee believes the Indian health programs should not be
treated disparately in payment. Thus, S. 556 fosters
cooperative efforts in increasing access and payment equity.
Streamlined Bureaucracy. In addition to these third party
reimbursements, streamlining bureaucracy--which provides
residual increases to the aggregate health care funding--is
also needed.
Program Administration. Throughout S. 556, the Committee
has identified many priorities and programs upon which the IHS
and tribes should focus. The Committee also believes that
flexibility in program administration is needed to improve the
health status of Indian people and is best achieved by allowing
Indian tribes and the IHS to determine these matters at the
local level.
Such determinations may be made through a variety of tools
available to the IHS and Indian tribes such as consultation and
negotiated rule-making. The Committee particularly favors
negotiated rule-making, pursuant to 5 U.S.C. 561, et seq., in
developing the various program elements for several reasons.
First, the Indian tribal and urban health providers--as
first responders in the health system--should have direct
involvement in developing these programs and the regulations
that govern those programs. Second, tribal involvement leads to
a more informed rule and fosters tribal support.
Finally, negotiated rule-making saves 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 the consensus-building procedure over litigation and has
found it to be useful in other initiatives such as education,
housing and self-governance.\9\
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\9\ 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 recognizes that the Administration has
renewed efforts to involve Indian tribes in decision-making,
but the Committee remains committed to promoting tribal input
by institutionalizing such efforts.
National Steering Committee
In June, 1999, the Director of the IHS convened the NSC
comprised of tribal leaders and representatives from Indian
health organizations to consult on the reauthorization. The NSC
held a series of meetings in 1999 during which extensive
discussions were held between the NSC and DHHS officials.
In the meantime, the tribal officials of the NSC set out to
craft a comprehensive reauthorization. During the drafting of
this legislation, the tribal officials obtained technical
assistance from various DHHS officials.
The draft document produced served as the basis for
predecessor bills S. 2526 (106th Congress) and S. 212 (107th
Congress). Neither bill was enacted, but S. 212 did receive
significant attention from the Administration.
By letter dated September 27, 2001, the Administration
provided its views on S. 212 to the Committee. During 2002,
tribal officials and Committee staff reconvened to address the
Administration's concerns. The entire set of proposals was not
finalized in time to be incorporated into S. 556 upon
introduction.
But due to the size and importance of the legislation, the
Committee was compelled to begin addressing the issues
surrounding the reauthorization. The proposed revisions were
completed in May, 2003, and have been largely incorporated into
the substitute amendment to S. 556 which was favorably reported
by the Committee.
Prior legislative activity
The reauthorization of the IHCIA has been a work in
progress since the 106th Congress when Senator Campbell
introduced S. 2526, the Indian Health Care Improvement Act
Reauthorization of 2000 for himself and for Senators Inouye and
McCain. S. 2526 was favorably reported by the Committee to the
full Senate, but no further action was taken.
During the 107th Congress, Senator Campbell introduced S.
212, the Indian Health Care Improvement Act Reauthorization of
2001, on January 30, 2001 for himself and for Senators Inouye
and McCain. The bill was co-sponsored by Senators Johnson,
Dorgan, Daschle, Feinstein, and Murray.
The bill was referred to the Committee, but not reported
out.
Summary of Major Provisions
TITLE I. INDIAN HEALTH MANPOWER
The purpose of Title I is to increase, to the maximum
extent feasible, the number of American Indians and Alaska
Natives entering the health professions and to ensure an
adequate supply of health professionals to the IHS, tribal and
urban Indian health programs.
This title covers recruitment, scholarships, extern
programs, continuing education, community health
representatives, loan repayment, advanced training and
research, nursing, tribal cultural and history, inmed, health
training, incentives, residency and community health aides.
TITLE II. HEALTH SERVICES
The purpose of Title II is to establish programs that
respond to the health needs of Indians. This title has a
specific diabetes provision which complements the Special
Diabetes Program for Indians authorized pursuant to the
Balanced Budget Act of 1997.
It also governs the Indian Health Care Improvement Fund
through which Appropriation Acts supply funds to eliminate
health deficiencies and disparities in resources made available
to Indian tribes and communities.
This title also contains a catastrophic health emergency
fund; health promotion and disease prevention services; hospice
feasibility; research; mental health; managed care feasibility;
Arizona, North Dakota, South Dakota, Trenton and California
contract health services programs; mammography; patient travel;
epidemiology; school health education; Indian youth;
psychology; tuberculosis; environmental and nuclear health
hazards, and women's health.
TITLE III. FACILITIES
The purpose of Title III relates to the construction of
health facilities, including hospitals, clinics, and health
stations, necessary staff quarters, and of sanitation
facilities for Indian communities and homes. It also would
require the Government Accountability Office (GAO) to conduct a
comprehensive needs report on Indian health needs for
inpatient, outpatient and specialized care facilities. It also
would require newly-constructed/renovated facilities, whenever
practicable, to meet the construction standards of any
nationally-recognized accrediting bodies.
TITLE IV. ACCESS TO HEALTH SERVICES
The purpose of Title IV is to address payments to the IHS
and tribes for services covered by the Social Security Act
Health Care programs, and to enable Indian health programs to
access reimbursements from third party collections.
This title includes provisions to increase Indian
enrollment and participation in the third party health
services, including tribal outreach programs and advisory
groups.
TITLE V. HEALTH SERVICES FOR URBAN INDIANS
The purpose of Title V is to establish programs in urban
centers to make health services more accessible to Indians who
live in urban areas. This title authorizes the Secretary to
enter into contracts or grants to urban Indian organizations to
administer health programs and sets forth basic requirements.
This title also establishes the Office of Urban Indian
Health to provide central oversight of the programs and
services. Title V also extends Federal Tort Claims Act coverage
to urban Indian organizations and provides access to the
Federal sources of supply for pharmaceutical purchases.
TITLE VI. ORGANIZATIONAL IMPROVEMENTS
Title VI changes the ``Director--IHS'' to the ``Assistant
Secretary--Indian Health''. This title also authorizes the
Secretary through the IHS to establish an automated management
information system as well as other duties as assigned by the
Secretary for the IHS.
TITLE VII. BEHAVIORAL HEALTH PROGRAMS
Title VII is revised from current law (which only addresses
substance abuse programs) to provide a comprehensive focus on
behavioral health. It combines all substance abuse, mental
health and social service programs in one title and integrates
these programs to enhance their performance and efficiency.
The IHS is to provide comprehensive alcohol and substance
abuse prevention and treatment programs, rehabilitation and
aftercare services, an IHS youth program, and training and
community education. Demonstration projects are outlined as
well as grants focusing on Fetal Alcohol Syndrome and Fetal
Alcohol Effect. It also expands the authorization to establish
inpatient mental health facilities in each IHS Area.
The title also addresses the responsibilities of the IHS as
outlined by the Memorandum of Agreement pursuant to section 402
of the Indian Alcohol and Substance Abuse Prevention and
Treatment Act of 1986. The IHS will determine the scope and
need for substance abuse programs and estimate adequate
funding.
This title authorizes funding for development of innovative
community-based behavioral health services, including child
sexual abuse programs.
TITLE VIII. MISCELLANEOUS
The purpose of Title VIII is to address miscellaneous
topics including a compilation of the reports required under
the Act. It also applies the Negotiated Rulemaking Act to
various activities under the Act. Other provisions require the
Secretary to develop a plan of implementation to submit to
Congress. This title also describes the eligibility of
California Indians for IHS services and authorizes a Commission
to study the issue of Indian health funding as an entitlement.
Legislative History
Legislative activity
During the 108th Congress, Senator Campbell introduced S.
556, the Indian Health Care Improvement Act Reauthorization of
2003, on March 6, 2003, for himself and for Senators Inouye and
McCain. The bill was referred to the Committee on Indian
Affairs which, as noted below, immediately began holding
hearings to advance the legislation.
On July 17, 2003, Senator Johnson was added as a cosponsor.
Senator Murray was added as a cosponsor on June 3, 2004, and
Senator Daschle was added as a cosponsor on June 24, 2004.
Senator Bingaman was added as a cosponsor on September 23,
2004. On September 24, 2004, Senator Dorgan was added as a
cosponsor. Senator Murkowski was added as a cosponsor on
October 10, 2004 and Senator Cantwell was added as a cosponsor
on November 17, 2004.
On the House side, Congressman Don Young introduced a
companion bill, H.R. 2440, Indian Health Care Improvement Act
Amendments of 2003 on June 11, 2003.
Hearings held during the 108th Congress
The Committee held eight hearings overall since the 106th
Congress on the reauthorization of the Act and four hearings
during the 108th Congress.
On April 2, 2003, the Committee held its first hearing in
the 108th Congress to reauthorize the IHCIA, addressing the
``One-HHS'' initiative and the need for reauthorization. The
witnesses included DHHS and members of the NSC.
On July 16, 2003, the Committee held the second hearing--
jointly with the House Resources Committee--which addressed
health disparities, sanitation facilities and urban Indian
clinics. Witnesses included representatives from the Department
of Housing and Urban Development (DHUD), DHHS, the NSC, Alaska
Native Tribal Health Consortium, Association of American Indian
Physicians, and Urban Indian Health Clinics.
On July 23, 2003, the Committee held the third hearing to
receive testimony on Medicaid and Medicare issues from
representatives from Indian tribes, tribal health clinics and
Indian health consultants. The DHHS was invited, but provided
no witness for the hearing.
To complete the series of hearings and expedite the mark-up
of this legislation, the DHHS was informally invited to testify
on the Medicaid and Medicare issues for possible Fall, 2003 and
Spring, 2004 hearings. However, the DHHS demurred.
Finally, on July 21, 2004, Secretary Thompson testified
before the Committee regarding the Administration's views on
the proposed legislation. At this hearing, the Secretary
expressed enthusiastic support of the reauthorization and his
desire to see it enacted before the end of 2004.
Committee Recommendation and Tabulation of Vote
In an open business session on September 22, 2004, the
Committee considered a substitute amendment proposed by Senator
Campbell. By a unanimous vote, the Committee ordered the
substitute amendment favorably reported to the full Senate with
the recommendation that the bill do pass.
Section-by-Section Analysis
Section 1. Short Title. Section 1 provides the short title
of the act as the ``Indian Health Care Improvement Act
Amendments of 2004''.
Section 2. Indian Health Care Improvement Act Amended.
Section 2 sets forth the provisions of the Act beginning with
section 1 and ending with section 818. The following section
numbers of this analysis reflect the section numbers of the
Act.
Section 1. Short Title; Table of Contents. Section 1 sets
forth the short title and table of contents.
Section 2. Findings. Section 2 sets out Congressional
findings for the Act by providing a historical context for
Federal-tribal relations; a context to the framework of Indian
health; and a summary of the history, testimony, evidence,
research and other information relevant to the development of
the Indian health care system.
Section 3. Declaration of National Indian Health Policy.
This section declares the national policy to be the fulfillment
of the special trust responsibility and legal obligation to
Indians, and to continue to improve the health status of Indian
people.
Section 4. Definitions. Section 4 provides definitions for
terms used throughout the Act. New definitions for the terms
``Fund or funding'' and ``Funding Agreement'' were added to
provide clarity and reflect current practice and administration
of Indian health programs.
The term ``health profession'' includes a wide variety of
practices. The Committee provides the list as examples of the
primary types of professions employed throughout the Indian
health system. However, the Committee recognizes that the IHS,
Indian tribes or urban Indian organizations may need
flexibility in including an appropriate health profession to
meet the local needs and based on availability of funding.
TITLE I--INDIAN HEALTH, HUMAN RESOURCES, AND DEVELOPMENT
Section 101. Purpose. This section states the purpose of
this title is to increase the number of Indians entering the
health professions and to assure an optimum supply of health
professionals to provide health services to Indians.
Section 102. Health Professions Recruitment Program for
Indians. Section 102 authorizes funding for recruitment
programs to include such activities as identifying Indians with
potential for entering health professions, publicizing funding
sources, and establishing programs to facilitate enrollment in
applicable courses of study.
This section may also include appropriate intern or
temporary employment programs during any nonacademic period of
the year. However, these programs are not designed to be summer
employment programs, but rather are to increase the stability
of health professional employment. This section also addresses
funding applications and amount of funding to be provided, as
well as defining who is an Indian for purposes of sections 103
and 104.
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.
Section 103 also prohibits denial of a scholarship based
solely on scholastic achievement if the applicant has already
been admitted or maintains good standing at an accredited
institution or if the applicant is eligible for assistance
under another Federal program.
Section 104. Indian Health Professions Scholarships.
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.
Section 105. American Indians Into Psychology Program. This
section authorizes grants to at least 3 colleges and
universities for developing and maintaining Indian psychology
career recruitment programs. The Quentin N. Burdick Program
Grant at the University of North Dakota is authorized
specifically. This section directs the Secretary to issue
regulations for competitive funding, specifies conditions of
the grants and active duty service requirements.
Section 106. Funding for Tribes for Scholarship Programs.
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 conditions; specific parameters for a breach of
contract; the relationship of a scholarship under this section
to the Social Security Act; and conditions of continuance of
funding are all specified in this section.
Section 107. Indian Health Service Extern Programs. Section
107 gives preference for employment in the IHS, 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
studying.
Section 108. Continuing Education Allowances. This section
authorizes the Secretary to provide allowances to health
professionals employed in an Indian Health Program or an Urban
Indian Organization to enable them to take leave of their duty
stations for a period of time each year for professional
consultation and training courses.
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 IHS
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.
Section 110. Indian Health Service Loan Repayment Program.
This section establishes the Indian Health Service Loan
Repayment Program to ensure an adequate supply of trained
health professionals to maintain accreditation of and provide
health care services to Indians. The section specifies
eligibility for the program; application information;
priorities; recipient contracts; deadlines for decision 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; assignment of
individuals; breach of contract; waiver or suspension of
obligation; and requires an annual report to Congress under
section 801.
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. The Administration expressed
concerns with investing appropriated funds as being
inconsistent with standard Federal investment policy.
Provisions were added to expressly exclude the investment of
Federally-appropriate funds. However, other types of funds may
still be invested as needed.
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. Unpaid volunteers, potential
candidates for contracts under section 110, and their spouses
are all eligible for such reimbursement of travel. In addition,
this section requires the Secretary to assign one individual in
each Area Office to have full-time responsibility for
recruitment activities.
Section 113. Indian Recruitment and Retention Program.
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.
Section 114. Advanced Training and Research. This section
establishes a demonstration project to enable certain health
professionals to pursue advanced training or research area of
study, where a need exists, for a substantial period of time.
The section specifies a service obligation and equal
opportunity for participating in the program.
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.
Section 116. Tribal Cultural Orientation. This section
requires certain employees of the IHS who serve Indian Tribes
in each Service Area to receive instruction in the history and
culture of the tribe they serve. The section requires the
Secretary to develop such a program in consultation with the
affected Indian entity, to be implemented through tribal
colleges or universities, include instruction in American
Indian studies, and describe the use and place of Traditional
Health Care Practices.
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 (Indians Into Medicine Program). The Quentin N. Burdick
Grant is one of the authorized grants. This section also
specifies requirements for institutional applicants for these
grants.
Section 118. Health Training Programs of Community
Colleges. This section 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 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.
Finally, any program receiving assistance under this section is
required to provide advanced training for health professionals.
Funding priorities are provided to tribal colleges and
universities in Service Areas where they exist.
Section 119. Retention Bonus. Section 119 permits the
Secretary to provide retention bonuses to certain health
professionals. Rates for retention bonuses and conditions for
default of retention agreement are also specified.
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. Eligibility, program parameters and
service obligations are specified.
Section 121. Community Health Aide Program for Alaska.
Section 121 directs the Secretary to develop and operate the
CHAP in Alaska. Requirements and criteria are specified for the
Alaska program. In addition, the Secretary is authorized to
develop and operate a similar program on a national basis
without reducing funds for the Alaska program.
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.
Section 123. Health Professional Chronic Shortage
Demonstration Programs. In this section the Secretary is
authorized 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 composed of representatives from the
tribes and Indian communities which are served by the program.
The Indian tribes recommended automatic designation of
shortage areas under 42 U.S.C. 250, et seq., upon request by
the Indian tribes. The Committee has been made aware that
tribal applications receive little or no attention and,
therefore, Indian communities cannot receive the benefit of the
designation.
However, the Administration objected to the automatic
designation and instead committed to working with the Indian
tribes and the Health Resources and Services Administration to
assist them in achieving such designation. The Committee is
pleased with this commitment and will look forward to hearing
the status of tribal applications in the future.
Section 124. Treatment of Scholarships for Certain
Purposes. Scholarships provided under this section are deemed
``qualified Scholarships'' for purposes of section 11 of the
Internal Revenue Code of 1986. Such designation means the
scholarship funds are not considered taxable income of the
recipient.
Section 125. 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 withdraw funding to support such member
unless the Secretary ensures that Indians will experience no
reduction in health services. The section also exempts National
Health Service Corps scholars qualifying for the Commissioned
Corps in the United States Public Health Service from full-time
equivalent limitations when serving as a Commissioned Corps
officer in a Tribal Health Program or an Urban Indian
Organization.
Section 126. Substance Abuse Counselor Educational
Curricula Demonstration Programs. Section 126 authorizes the
Secretary to enter into contracts or make grants to accredited
colleges and universities to establish demonstration programs
developing curricula for substance abuse counseling. Duration
and renewal of the grant is specified. The section also
establishes 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''.
Section 127. 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 IHS, 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. On request of the appropriate Indian
entity, the Secretary is required to develop and implement a
program of community education on mental illness, as well as
technical assistance to tribal entities to develop community
education materials.
Within 90 days of enactment, 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 devoted to child, adolescent, and family
services.
Section 128. Authorization of Appropriations. Section 129
authorizes appropriations as are necessary to carry out this
title for each fiscal year through 2015.
TITLE II--HEALTH SERVICES
Section 201. Indian Health Care Improvement Fund. This
section 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 IHS 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 provides definitions applicable to this
section and requires that Tribal Health Programs be equally
eligible for funds as the IHS. A report is required to be
submitted to Congress 3 years after enactment which addresses
the current health status and resource deficiency for each
Service Unit. Funds appropriated under this section are to be
included in the base budget of the Indian Health Service for
determining appropriations in subsequent years.
Finally, nothing in this section is intended to diminish
the primary responsibility of the Indian Health Service to
eliminate backlogs in unmet health care nor to discourage
additional efforts of the IHS to achieve equity among tribes
and tribal organizations.
Section 202. Catastrophic Health Emergency Fund. Section
202 establishes the Catastrophic Health Emergency Fund (CHEF)
to be administered by the Secretary through the central office
of the IHS 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 are 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 through negotiated
rulemaking.
This section requires that funds appropriated to CHEF not
be used to offset or limit other appropriations made to the
IHS. It also requires that all reimbursements to which the IHS
is entitled by reason of treatment rendered to any victim of a
disaster or catastrophic illness the cost of which was paid
from CHEF be deposited back into CHEF.
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, and requires the Secretary to
provide these services and with input from the affected Tribal
Health Programs to report to Congress on the status, capacity
and resources needed to promote health and prevent disease.
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 it. 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 registries
in Area Offices; and ensure that data collected are
disseminated to other Area Offices, subject to privacy laws.
Section 205. Shared Services for Long-Term Care. This
section authorizes the Secretary to enter funding agreements
for delivering 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 is required
to encourage the use of existing underused facilities or allow
the use of swing beds for long-term or similar care.
Section 206. Health Services Research. The Secretary is
required to provide funding for both clinical and nonclinical
research to further the delivery of Indian health services and
shall 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.
Section 207. Mammography and Other Cancer Screening. This
section requires the Secretary, either through the IHS or
Indian tribes, to provide for mammography and other cancer
screening consistent with appropriate standards. This section
does not establish a standard itself, but requires an
appropriate standard be established which is consistent with
Title XVIII of the Social Security Act.
Section 208. Patient Travel Costs. Section 208 requires the
Secretary to provide funds for the travel costs of patients and
their appropriate and necessary qualified escorts, associated
with receiving health care services.
Section 209. Epidemiology Centers. This section requires
the Secretary, within 180 days of enactment, to establish and
fund epidemiology centers in each Service Area without reducing
the funding levels for centers already established.
Newly established centers may be operated by Tribal Health
Programs. The functions of these centers are delineated in this
section. The Director of the Centers for Disease Control and
Prevention is required to provide technical assistance to the
centers and the Secretary is authorized to provide funding to
tribes, tribal organizations and urban Indian organizations to
conduct epidemiological studies of Indian communities.
Section 210. Comprehensive School Health Education
Programs. Section 210 requires the Secretary to provide funding
to Indian tribes, tribal organizations and urban Indian
organizations, for the development of comprehensive school
health education programs for children from pre-school through
grade 12. The specific purposes for which funds may be used are
delineated.
Upon request, the Secretary is required to provide
technical assistance in the development and dissemination of
comprehensive health education plans, materials and
information. The Secretary, through the IHS and in consultation
with tribes, tribal organizations and urban Indian
organizations, shall establish criteria for review and approval
of applications for this funding.
Section 211. Indian Youth Program. This section authorizes
the Secretary to establish and administer programs for
innovative mental and physical disease prevention and health
promotion and treatment programs for Indian and Urban Indian
preadolescent and adolescent youths. Allowable and prohibited
uses of the funds authorized 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 provide technical assistance upon request.
The Secretary is to establish criteria for review andapproval
of applications under this section, in consultation with tribes, tribal
organizations and urban indian organizations.
Section 212. Prevention, Control, and Elimination of
Communicable and Infectious Diseases. Section 212 authorizes
the Secretary to fund projects specifically for the purpose of
preventing, controlling and eliminating communicable and
infectious diseases. Funding is also authorized for public
information and education programs, and skills improvement
activities.
Demonstration projects for the screening, treatment and
prevention of hepatitis C virus are also authorized. Funding
under this section requires an application or proposal for
funding. Entities which receive funding under this section are
encouraged to coordinate their activities with the Centers for
Disease Control and Prevention as well as State and local
health agencies.
Finally, in carrying out this section, the Secretary may
provide technical assistance upon request and shall submit a
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.
Section 213. Authority for Provision of Other Services.
This section authorizes the Secretary to fund other activities
which meet the objectives set forth in section 3 of this Act. A
partial list of such activities include: hospice care; assisted
living; long-term health care; home- and community-based
services; public health functions; and, Traditional Health Care
Practices.
Current law authorizes a feasibility study to be conducted
on these facilities. However, the IHS never completed that
study and now twelve years later, to conduct such studies would
greatly delay needed services. The Committee is concerned about
prohibiting these services from the Indian health care system
when these types of services have become an accepted part of
the national health care system and Medicare since 1983.
Discretion is provided to the IHS, Indian Tribes, or Tribal
Organizations to provide such care to persons otherwise
ineligible for the health care benefits of the IHS (subject to
reimbursement of reasonable charges). The inclusion of these
individuals is necessary to achieve the minimum patient base
needed to make the venture financially viable and to stabilize
the cost efficiencies of providing these services.
Currently, these types of services are not readily
available to Native communities. Indians must travel long
distances only to be placed in facilities which are not
familiar and not conducive to their well-being as the
facilities are not culturally-competent. Having culturally-
competent facilities close to Indian communities will promote
the patient's well-being and enable family members to visit
without extraordinary cost.
Section 214. Indian Women's Health Care. This section
requires the Secretary to provide funds to monitor and improve
health care for Indian women of all ages. The Committee
believes the health of Indian women to be vitally important and
encourages the IHS to heighten attention to addressing diseases
disproportionately affecting Indian women such as lupus.
Section 215. Environmental and Nuclear Health Hazards.
Section 215 requires the Secretary, in conjunction with other
Federal agencies, 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 of the food chain.
Upon completion of such studies the Secretary shall develop
health plans to address the health problems studied. The
Secretary is required to submit the study to Congress within 18
months of enactment and a report no later than 1 year after the
study which includes recommendations for the implementation of
the plan and evaluation activities.
This section establishes an intergovernmental task force to
identify environmental hazards and to take corrective action.
The Secretary is to chair this task force, which shall meet at
least twice yearly. If an Indian, who is employed in or around
any environmental hazard, suffers from a work-related
condition, the Indian Health Program which treats him, may be
reimbursed by the Indian's employer.
Section 216. Arizona as a Contract Health Service Delivery
Area. The State of Arizona is designated as a contract health
service delivery area for providing contract health care
services to members of Federally-recognized Indian Tribes of
Arizona. The IHS will not curtail any services as a result of
this provision.
These contract health service delivery areas under sections
216 to 218 have been authorized, but in some cases not
implemented or funded. The Committee encourages the
Administration to seek funding for these programs. The
provisions are subject to appropriations as all discretionary
programs are, and does not subject the Secretary to retroactive
liability or application.
Section 216A. North Dakota as a Contract Health Service
Delivery Area. The State of North Dakota is designated as a
contract health service delivery area for providing contract
health care services to members of Federally-recognized Indian
Tribes of Arizona. The IHS will not curtail any services as a
result of this provision.
Section 216B. South Dakota as a Contract Health Service
Delivery Area. The State of South Dakota is designated as a
contract health service delivery area for providing contract
health care services to members of Federally-recognized Indian
Tribes of Arizona. The IHS will not curtail any services as a
result of this provision.
Section 217. California Contract Health Services Program.
This section appoints the California Rural Indian Health Board
(CRIHB) to be a contract care intermediary to improve the
accessibility of health services to California Indians. The
Secretary is required to reimburse CRIHB for costs incurred
pursuant to this section.
Not more than 5 percent of the amounts provided under this
section may be for administrative expenses. No payment may be
made for treatment under this section to the extent payment may
be made under the Indian Catastrophic Health Emergency Fund or
from amounts appropriated or otherwise made available to the
California contract health service delivery area.
This section also establishes an Advisory Board, comprised
of representatives from not less than 8 Tribal Health Programs
serving California Indians covered under this section and at
least one half of whom are not affiliated with the CRIHB. The
Advisory Board will advise the CRIHB in carrying out this
section.
Section 218. California as a Contract Health Service
Delivery Area. The State of California, excluding certain
specified counties, is designated as a contract health service
delivery area for providing contract health care services to
California Indians. The excluded counties may be included only
if finding is specifically provided by the IHS for those
counties.
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 that reside in the Trenton Service Area of
Divide, McKenzie, and Williams counties in North Dakota and the
counties of Richland, Roosevelt, and Sheridan in Montana. This
section does not expand the eligibility of members of the
Turtle Mountain Band of Chippewa Indians for health services
provided by the IHS beyond the scope of eligibility for these
services that applied on May 1, 1986.
Section 220. Programs Operated by Indian Tribes and Tribal
Organizations. This section requires the IHS 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 IHS.
Section 221. Licensing or Certification. Section 221
requires that health care professionals employed by a Tribal
Health Program, if licensed or certified in any State, be
exempt from the licensing or certification requirements of the
State in which the Tribal Health Program provides the services.
This provision extends similar current authority for the IHS to
tribal health programs. However, all health professionals must
still practice within their authorized scope of practice.
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 IHS of any emergency care or health services
received from a non-IHS provider or in a non-IHS facility.
Section 223. Prompt Action on Payment of Claims. Section
223 provides a deadline for the IHS to respond to notification
of a claim by a provider of a contract care service. The
section also provides that if the IHS fails to respond within
the required time, the IHS shall accept the claim as valid. A
deadline for payment is also provided. This timeframe is
consistent with the Prompt Payment Act which requires the
Federal government to pay its claims within 30 days.
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 provider of such services and the
patient who receives them of the same, within a specified time.
Following receipt of this notice or an acceptable claim under
the previous section, a provider has no further recourse
against the patient who received the health care.
Section 225. Authorization of Appropriations. This section
authorizes appropriations as are necessary to carry out this
title for each fiscal year through 2015.
TITLE III--FACILITIES
Section 301. Consultation; Construction and Renovation of
Facilities; Reports. This section requires consultation with
Indian tribes prior to expending construction funds. In
addition, it sets forth requirements to be met prior to closing
any facility. This section also establishes and defines
criteria for the health care facilities priority system,
including reporting requirements. The responsibility for
developing the initial comprehensive needs report lies with the
GAO to ensure that it will get completed. The IHS is then
charged with the responsibility to update the list as facility
construction is completed.
Section 302. Sanitation Facilities. This section provides
the findings, certain duties for sanitation, authorized uses of
sanitation funding and facilities, reporting requirements and
establishes the deficiency levels for those facilities.
Congress has determined that sanitation is a health issue and
in 1957 placed the responsibility for sanitation in Indian
communities with the IHS.
This section prohibits IHS funding from being used for
sanitation facilities for new DHUD homes as DHUD provides
funding for such infrastructure. The IHS funds are limited and
the backlog, estimated in the billions, so great that such
funds cannot be diverted to the DHUD Native American Housing
Assistance and Self-Determination Act block grant without a
thorough examination of how to balance all the needs associated
with the sanitation facilities. The Committee believes that
appropriate flexibility is afforded to the Indian tribes for
sanitation funding, demonstrated by the fact that over 70% of
the sanitation funding is contracted by Indian tribes pursuant
to the ISDEAA.
Section 303. Preference to Indians and Indian Firms. This
section authorizes the Secretary to apply Indian preference in
hiring for certain construction activities.
Section 304. Expenditure of Nonservice Funds for
Renovation. This section authorizes the Secretary to accept any
expansion or renovation funded with non-IHS funds in accordance
with certain criteria.
Section 305. Funding for the Construction, Expansion and
Modernization of Small Ambulatory Care Facilities. This section
establishes criteria for small ambulatory care facilities,
including use of funds, priorities and peer review panels. Debt
reduction has also been included as an authorized use of funds
within to the Secretary's discretion.
Section 306. Indian Health Care Delivery Demonstration
Project. This section authorizes the Secretary to establish
demonstration projects to test alternative health care delivery
systems through such methods as hospice care and establishes
criteria for the projects. The Committee has been made aware
that the Secretary has not promulgated regulations for these
projects even though required since 1991. Incentives have been
added to encourage the Secretary to issue these regulations.
Section 307. Land Transfer. This section authorizes the
Secretary to accept any land transferred from the Bureau of
Indian Affairs for the purpose of providing health care.
Section 308. Leases, Contracts and Other Agreements. This
section authorizes the Secretary to enter leases with Indian
tribes and to consider them operating leases. Federal
appropriations law requires that all leases be considered
capital leases unless Congress otherwise designates. This
provision provides that specific authority by designating the
leases as operating leases, but gives the Secretary flexibility
to also designate them as capital leases.
Section 309. Study for Loans, Loan Guarantees and Loan
Repayment. This section authorizes a study for the feasibility
of establishing a loan or loan guarantee fund for Indian health
care facilities. Initially, this provision established a fund,
but was reduced to a study due to the objection by the
Administration. The fund was alleged to (1) disrupt the
construction priority system; (2) be inconsistent with the
Credit Reform Act; and (3) be inconsistent with standard
Federal investment policy. Consequently, the study replaced the
fund whereby those concerns could be analyzed, among other
matters. The Committee strongly encourages this study be
completed as quickly as possible so that additional financing
options can be made available to Indian tribes.
Section 310. Tribal Leasing. This section authorizes
permanent leasing of permanent structures for health services
without prior approval.
Section 311. Indian Health Service/Tribal Facilities Joint
Venture Program. This section authorizes the Secretary to enter
joint ventures with Indian tribes, provide staffing, equipment
and supplies for the operation of the facility under a no-cost
lease with the Indian tribes, in accordance with certain
criteria.
A new provision has been added to authorize those Indian
tribes that have started, but not completed construction, be
eligible to apply for joint ventures. Indian tribes should not
be penalized for attempting to address their facility needs
rather than wait interminably for the IHS to provide funding.
This new provision is not, however, authorization to
circumvent appropriate IHS planning and construction
guidelines. Balancing the criteria and priorities for those
Indian tribes that are able to start construction and those
that cannot and must continue to wait are appropriate items for
negotiated rule-making.
Section 312. Location of Facilities. This section sets
forth certain priorities in locating health care facilities to
address the economically depressed native communities.
Section 313. Maintenance and Improvement of Health Care
Facilities. This section requires reporting of backlogs in
maintenance and improvements for facilities.
Section 314. Tribal Management of Federally-Owned Quarters.
This section authorizes the Indian tribes operating a health
care facility and Federally-owned quarters pursuant to a
``638'' contract or compact to establish reasonable rental
rates for the Federally-owned quarters and directly collect the
rent payments from the employee. It allows Indian tribes to
take into account the reasonable value of the quarters and the
amount needed to sustain them. By authorizing direct
collection, cumbersome bureaucracy is eliminated.
This provision complements the quarters provisions under
the ISDEAA, section 105, which directs how rental rates are
established, but does not take into account appropriate fair
market values including location costs, nor does it allow
direct collection of rents.
Section 315. Applicability of Buy American Act Requirement.
This section requires application of the Buy American Act for
all procurement except purchases by Indian tribes or tribal
organizations under this Act.
Section 316. Other Funding for Facilities. This section
authorizes the Secretary to accept funding from other sources
for the construction of health care facilities and may transfer
such funds to Indian tribes.
Section 317. Authorization of Appropriations. This section
authorizes appropriations through fiscal year 2015.
TITLE IV--ACCESS TO HEALTH SERVICES
Section 401. Treatment of Payments Under Social Security
Act Health Care Programs. This section requires that any
Medicare, Medicaid, or State Children's Health Insurance
Program (SCHIP) payments received by an Indian Health Program
or Urban Indian Organization shall not be considered in
determining appropriations for health care services. Indians
who are covered under these programs will not be given
preferential treatment over those Indians who are not covered
by Medicare, Medicaid, or SCHIP. Specifications are made as to
how funds collected from Medicare, Medicaid, or SCHIP are to be
used. Finally, this section authorizes Tribal Health Programs
to directly bill and receive payment from Medicare, Medicaid,
SCHIP, or third party payors.
Section 402. Grants to and Funding Agreements with the
Service, Indian Tribes, Tribal Organizations, and Urban Indian
Organizations. This section requires the Secretary to make
grants or other funding agreements with tribes and tribal
organizations. In doing so, the Secretary shall place
conditions as deemed necessary to effect the purpose of such
funding. Additional agreements may be made in order to improve
the enrollment of Indians under Social Security Act programs
and to facilitate cooperation with and agreements between
States, the IHS, Indian Tribes, Tribal Organizations, or Urban
Indian Organizations. Specifications for applying this section
to Urban Indian Organizations is included in this section. This
section also codifies certain requirements contained in current
regulations for agreement with states for outreach.
Section 403. Reimbursement From Certain Third Parties of
Costs of Health Services. Section 403 continues recovery rights
established since 1988. It authorizes recovery from third
parties for health services provided to the same extent that an
individual, or any nongovernmental provider of health services,
would be eligible to receive damages, reimbursement, or
indemnification.
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,
limitations, costs and attorneys' fees are also specified.
Other items covered in this section are nonapplication of
claims filing requirements; application to urban Indian
organizations; statute of limitations; and a savings clause.
While this provision does not create a cause of action
within tribal courts, it does allow the parties more options
for their choice of law provisions in their contracts. It also
complements ERISA provisions which may apply state law. It also
does not conflict with ERISA as, under ERISA, jurisdiction is
exclusive in Federal courts for most causes of action and
concurrent for the remaining causes of action, with a right of
removal from state court to Federal court.
Section 404. Crediting of Reimbursements. This section
specifies the use of amounts collected and disallows any offset
or limit of amount obligated from the IHS because of the
receipt of reimbursements under this section.
Section 405. Purchasing Health Care Coverage. Section 405
authorizes funding to be used for purchasing health insurance
or used for a self-insurance plan providing coverage to
Indians.
The purpose of this section is to authorize the purchase of
insurance through various means instead of, or in addition to,
establishing health programs, hospitals, clinics, etc., if it
is a more cost-beneficial means of addressing Indian health
care needs.
The purchasers must be mindful of applicable Federal or
state insurance laws which may affect the purchase or coverage
for the tribal members. However, the Committee is aware that
Indian tribes may have many tribal members living in different
states and should not be prohibited from providing health care
through insurance coverage.
This provision authorizes funding to be used to support a
tribal self-insured plan. The Committee is aware that a tribal
self-insured plan may include non-eligible beneficiaries who
are tribal employees.
The Committee does not wish to discourage Indian tribes
from hiring individuals deemed to be non-eligible beneficiaries
under the Act and providing them with benefits, particularly
the health employees. In fact, the salaries and benefits for
tribal health employees is already part of the Federal funding
system, although, arguably, in their capacity as tribal health
employees, these individuals are not necessarily
``beneficiaries'' eligible or otherwise.
Section 406. Sharing Arrangements with Federal Agencies.
Within certain limitations this section authorizes the
Secretary to share medical facilities and services with the
Departments of Veterans Affairs and Defense. 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 IHS, Indian Tribe, or Tribal
Organization providing the service shall be reimbursed from the
appropriate Department.
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.
Section 408. Nondiscrimination in Qualifications for
Reimbursement for Services. Section 408 requires entities that
are operated by the IHS, an Indian Tribe, Tribal Organization,
or Urban Indian Organization to be licensed or recognized under
State or local law to furnish such services, for purposes of
receiving payment or reimbursement from any Federally-funded
health care program. This provision should not be interpreted
as establishing a payment methodology, but rather it is
criteria to apply in determining whether the provider is
eligible for payment.
Section 409. Consultation. This section establishes a
National Indian Technical Advisory Group to assist the
Secretary in identifying and addressing issues regarding health
care programs under the Social Security Act. This Group is
critical in identifying and resolving issues and barriers to
access for Indians.
Thus, it is necessary that the Urban Indian organizations
and the IHS be a part of this Group as they serve a majority of
the Indian beneficiaries. The Group would not be effective
without these two entities.
Section 410. State Children's Health Insurance Program
(SCHIP). This section authorizes the Secretary to arrange with
individual States to allow SCHIP funds for Indians to be
provided to the IHS, Indian Tribe, or Tribal Organization for
providing assistance to such individuals consistent with the
purposes of SCHIP.
The Committee is deeply concerned that Indian children are
not being served even though the Balanced Budget Act of 1997
specifically mandated that States include provisions in their
plan explaining how Indian children would be served. Briefings
before the Committee revealed that the DHHS could not determine
the number of eligible Indian children nor how many were
actually served.
The Committee believes the Administration is committed to
correcting this issue and has undertaken great efforts to find
solutions. The Committee believes that Indian tribes could
provide significant assistance in these efforts, particularly
in outreach and enrollment.
Section 411. Social Security Act Sanctions. This section
authorizes Indian Health Programs to request a waiver of a
sanction imposed against a health care provider the same way
that a State may request such a waiver. This provision is
solely a procedural mechanism for waiver, it does not otherwise
affect the Secretary's underlying authority to review and
decide upon waivers.
The Committee is aware that problems have existed in
seeking waivers as the Indian tribes may request the State seek
the waiver and those requests have not been honored. The
purpose of this provision is not to allow tribal health
programs to become havens for sanctioned providers, but to
address, in an appropriate manner, the enormous recruitment
problems they face.
The Committee also recognizes that the State, as the
Medicaid administrator, may also have an interest in commenting
on the waiver request. The Committee believes the Secretary may
provide the appropriate avenues for accommodating these
interests.
A safe harbor clause is included in this section for
transaction between and among Indian Health Care Programs. This
provision will shield the referral system existing between the
IHS, tribal and urban Indian organizations from criminal
sanctions. The referrals exist to maintain continuity of care
for Indian patients and not for monetary gain.
Section 412. Cost Sharing. This section addresses the
following areas regarding cost sharing: coinsurance,
copayments, and deductibles; exemption from Medicaid and SCHIP
premiums; limitation on medical child support recovery;
treatment of certain property for Medicaid eligibility; and,
continuation of current law protections of certain Indian
property from Medicaid estate recovery.
The medical child support recovery provisions include
Indian health programs, not just the IHS. Currently, the
Department's policy on the Medical Support Enforcement for
Tribal Members may not cover these additional programs and this
provision is designed to clarify the coverage.
The treatment of certain property for Medicaid eligibility
provision governs the various types of Indian property to be
excluded when determining eligibility. This provision should be
given the broadest possible interpretation as Congressional
policy has provided extensive protections for various types of
Indian property and taking into account that the purpose of
these provisions is to increase enrollment, not to find ways to
exclude Indians from coverage.
Section 413. Treatment under Medicaid Managed Care. Section
413 specifies actions to be taken for payment for services
furnished to Indians in Medicaid managed care programs. This
section also allows Medicaid managed care programs to be
offered and gives parameters for such.
In section 413(b), a State that operates its Medicaid
program through managed care organizations or primary care case
managers, is authorized to enter into an agreement with an
Indian health program or consortium of such programs that
intend to operate as an MCO or primary care case manager for
its Indian patients. The Indian health program must still meet
the State's quality standards, but the State and the Secretary
are authorized to waive requirements such as enrollment and
capitalization as needed to facilitate the participation of the
Indian health programs.
This provision is not intended to change the Secretary's
underlying waiver authority or any standards governing such
waivers. It merely provides the Secretary authority to waive
taking into account the special circumstances within the Indian
health system.
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 and a report of the
study are described in this section.
Section 415. Authorization of Appropriations. Section 415
authorizes appropriations of such sums as may be necessary for
each fiscal year through fiscal year 2015 to carry out this
title.
TITLE V--HEALTH SERVICES FOR URBAN INDIANS
Section 501. Purpose. This section sets forth the purpose
of the title which is to maintain urban Indian health programs
to make health services available to urban Indians.
Section 502. Contracts with, and Grants to, Urban Indian
Organizations. This section sets forth the authority of the
Secretary to enter contracts with or make grants to urban
Indian organizations.
Section 503. Contracts and Grants for the Provision of
Health Care and Referral Services. This section sets forth the
standards, criteria and uses of funds for contracts and grants
for health care services.
Section 504. Contracts and Grants for the Determination of
Unmet Health Care Needs. This section sets forth the standards,
criteria and uses of funds for contracts and grants to
determine unmet health care needs of urban Indians.
Section 505. Evaluations; renewals. This section authorizes
the Secretary to develop evaluation and renewal standards for
the various contracts and grants.
Section 506. Other contract and grant requirements. This
section sets forth other specific contract and grant
requirements such as payment methods, procurement and
amendments.
Section 507. Reports and Records. This section sets forth
certain reporting and recordkeeping requirements for urban
Indian organizations.
Section 508. Limitation on Contract Authority. This section
limits contracts to the amount of appropriations.
Section 509. Facilities. This section sets forth the
various requirements governing the funding for urban health
care facilities.
Section 510. Office of Urban Indian Health. This section
establishes an Office of Urban Indian Health within the IHS.
Section 511. Grants for Alcohol and Substance Abuse Related
Services. This section establishes criteria for alcohol and
substance abuse grants.
Section 512. Treatment of Certain Demonstration Projects.
This section makes permanent certain demonstration projects in
Oklahoma.
Section 513. Urban NIAAA Transferred Programs. This section
authorizes the Secretary to transfer to urban Indian
organizations alcohol programs that had been previously
transferred to the Secretary.
Section 514. Consultation. This section establishes
consultation requirements with Urban Indian Organizations.
Section 515. Federal Tort Claim Act Coverage. This section
authorizes the urban Indian organizations to be deemed an
executive agency for FTCA coverage.
Section 516. Urban Youth Treatment Center Demonstration.
This section authorizes the Secretary to fund at least 2 Indian
youth treatment centers in certain states where urban centers
are located.
Section 517. Use of Federal Property and Supply. This
section authorizes the Urban Indian Organizations to receive
donations of Federal excess property and access the Federal
sources of supply through 40 U.S.C. 501.
Section 518. Grants for Diabetes Prevention, Treatment and
Control. This section sets forth requirements and criteria for
diabetes grants.
Section 519. Community Health Representatives. This section
authorizes contracting for community health representatives.
Section 520. Regulations. This section authorizes the
promulgation of regulations for this title.
Section 521. Eligibility for Services. This section
establishes the beneficiaries of the services under this title.
Section 522. Authorization of Appropriations. This section
authorizes appropriations through fiscal year 2015.
TITLE VI--ORGANIZATIONAL IMPROVEMENTS
Section 601. Establishment of the Indian Health Service as
an Agency of the Public Health Service. Section 601 elevates
the position of Director of the Indian Health Service to
Assistant Secretary of Indian Health; and 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, etc., refer to the Assistant
Secretary.
Section 602. Automated Management Information System.
Section 602 requires the Secretary to establish an automated
management information system for the IHS and each Tribal
Health Program. It requires that patients have access to their
own health records. It authorizes the Secretary to enter
contracts, agreements, or joint ventures for the purpose of
enhancing information technology in Indian health programs and
facilities.
Section 603. Authorization of Appropriations. This section
authorizes appropriated funds in sums that may be necessary to
carry out this title, for each fiscal year through fiscal year
2015.
TITLE VII--BEHAVIORAL HEALTH PROGRAMS
Section 701. Behavioral Health Prevention and Treatment
Services. Section 701 states the purposes of the section;
requires the Secretary to encourage the development of plans
for delivery of Indian Behavioral Health Services; directs the
Secretary to establish a national clearinghouse of plans and
reports of outcomes; 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; and, directs the Secretary to assess the need,
availability and cost for inpatient mental health care for
Indians.
Section 702. Memoranda of Agreement with the Department of
the Interior. This section requires the Secretary to develop
and enter, or review and update, memoranda of agreement with
the Secretary of the Interior to, among other things, make a
comprehensive assessment, coordination, and annual review of
all the behavioral health care needs and services available or
unavailable to Indians. Specific provisions that are required
in this memoranda are delineated. Consultation requirements for
the Secretary are specified. Each memorandum of agreement under
this section shall be published in the Federal Register.
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. The Secretary may provide
these services through Contract Health Services.
Section 704. Mental Health Technician Program. This section
establishes a mental health technician program within the
Service, requiring high-standard paraprofessional training in
mental health care, supervision and evaluation of technicians.
This program shall involve use and promotion of Traditional
Health Care Practices of the Indian Tribes to be served.
Section 705. Licensing Requirement for Mental Health Care
Workers. This section requires that any person employed as a
psychologist, social worker, or marriage and family therapist,
be licensed to provide those services, but does not
automatically license the professionals.
Section 706. Indian Women Treatment Programs. Consistent
with section 701, this section requires that funds be made
available to develop and implement a comprehensive behavioral
health program of prevention, intervention, treatment, and
relapse prevention services, specifically addressing the
spiritual, cultural, historical, social, and child care needs
of Indian women.
Section 707. Indian Youth Program. Consistent with section
701, this section requires the development and implementation
of a program for detoxification and rehabilitation of Indian
Youth. It also establishes alcohol and substance abuse
treatment centers or facilities for Indian youth. Additional
provisions addressed in this section are: intermediate
adolescent behavioral health services; use of Federally-owned
structures; rehabilitation and aftercare services; inclusion of
family in youth treatment programs; and multi-drug abuse
programs.
Section 708. Inpatient and Community-Based Mental Health
Facilities Design, Construction, and Staffing. This section
authorizes the Secretary to provide inpatient mental health
care facilities in each Service Area.
Section 709. Training and Community Education. Section 709
requires that the Secretary, in cooperation with the Secretary
of the Interior, to provide either directly or through funding,
a program of community education in the area of behavioral
health. Specifics of instruction are delineated. This section
also requires the Secretary to develop and provide community-
based training models.
Section 710. Behavioral Health Program. This section
authorizes the development of innovative community-based
behavioral health programs; suggests criteria to be used for
funding such programs; and, requires that the same criteria as
used in evaluating other funding proposals be used for programs
under this section.
Section 711. Fetal Alcohol Disorder Funding. Section 711
establishes 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. In addition a
Fetal Alcohol Disorder Task Force is established to advise the
Secretary. Funding is to be made available for applied research
projects which propose to elevate the understanding of methods
to prevent, intervene, treat or provide rehabilitation and
aftercare for Indians affected by this disorder. Urban Indians
are to be included in these programs.
Section 712. Child Sexual Abuse and Prevention Treatment
Programs. This section establishes Child Sexual Abuse and
Prevention Treatment Programs for both the victims and
perpetrators of this abuse in Indian households or who are
Indian. The allowable uses of funds for these programs are
specified.
Section 713. Behavioral Health Research. Section 713
provides for funding for research on the incidence and
prevalence of behavioral health problems among Indians.
Research priorities are specified.
Section 714. 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.
Section 715. Authorization of Appropriations. This section
authorizes such sums as may be necessary to carry out this
section, for each fiscal year through fiscal year 2015.
TITLE VIII--MISCELLANEOUS
Section 801. Reports. This section outlines the various
reporting requirements under this Act.
Section 802. Regulations. This section sets forth the
various requirements for regulations, including negotiated
rule-making, under this Act.
Section 803. Plan of Implementation. This section requires
a plan of implementation of this Act to be submitted to
Congress.
Section 804. Availability of Funds. This section authorizes
funding to remain available until expended.
Section 805. Limitation on Use of Funds Appropriated to the
IHS. This section establishes certain limitations on the use of
funds.
Section 806. Eligibility of California Indians. This
section clarifies the eligibility for the Indians located in
California.
Section 807. Health Services for Ineligible Persons. This
section authorizes services for certain ineligible persons
under limited circumstances and outlines criteria for providing
services.
Section 808. Reallocation of Base Services. This section
limits the reallocation of base funding upon certain
requirements the Secretary must fulfill.
Section 809. Results of Demonstration Projects. This
section requires that results of demonstration projects be made
available to Indian tribes.
Section 810. Provision of Services in Montana. This section
recognizes a court decision governing services for certain
Indians in Montana whereby the IHS is responsible for making
payment for Indians' health care expenses when other funds have
been exhausted and are not available. McNabb v. Bowen, 829 F.2d
787 (9th Cir. 1987).
Section 811. Moratorium. This section authorizes the IHS to
provide certain services according to eligibility criteria in
effect on a certain date.
Section 812. Tribal Employment. This section recognizes the
governmental purposes of health care by treating Indian tribes
or tribal organizations not as an employer for certain
purposes.
Section 813. Prime Vendor. This section recognizes tribal
health programs as an executive agency for accessing the
Federal sources of supply and streamlines access. This
provision authorizes direct access for Indian tribes to the
sources of supply rather than accessing through the IHS.
Section 814. Severability Provisions. This section retains
remaining provisions if others are stricken by any court.
Section 815. Establishment of National Bipartisan
Commission on Indian Health Care Entitlement. This section
establishes a commission to study Indian health care as an
entitlement, including duties, membership and reports. This
Commission is to collect data on the extent of Indian health
care needs, including conducting hearings, studying models for
providing health care. After the study, the Commission is to
make recommendations for legislation providing for Indian
health care as an entitlement, including eligibility, benefits,
costs, and impact on the current Indian health care system. The
Commission consists of 25 members, including Members of
Congress and Indian tribes.
Section 816. Appropriations; Availability. This section
subjects new spending to the availability of funding.
Section 817. Confidentiality of Medical Quality Assurance
Records: Qualified Immunity for Participants. This section
establishes requirements for quality assurance such as
confidentiality, privacy, disclosure and liability and sets
forth the limits on such disclosure to promote the free
exchange of information and recommendations from the health
professionals and employees.
Section 818. Authorization of Appropriations. This section
authorizes appropriations through fiscal year 2015.
OTHER SECTIONS OF THE BILL
Section 2(b) and (c). Section 2(b) and (c) of the bill sets
forth provisions of the bill amending other laws such as the
references to the ``Director of Indian Health Service'' which
would be changed to ``Assistant Secretary for Indian Health'';
and amendments to the Three Affiliated Tribes and Standing Rock
Sioux Tribe Equitable Compensation Act which authorizes funding
to rebuild a health care facility.
Section 3. Section 3 of the bill retains authorization for
sanitation facilities to the Soboba Band of Mission Indians.
Section 4. Section 4 of the bill sets forth amendments to
the Medicaid and SCHIP which authorize reimbursement to Indian
health programs for medical assistance provided.
Cost and Budgetary Considerations
Due to time constraints, the cost estimate for S. 556 is
not included in this Report. When it is received by the
Committee, the cost estimate will be included in the
Congressional Record.
Regulatory Impact Statement
Paragraph 11(b) of rule XXVI of the Standing Rules of the
Senate requires each report accompanying a bill to evaluate the
regulatory and paperwork impact that would be incurred in
carrying out the bill. The Committee believes that S. 556 will
have minimal regulatory or paperwork impact.
Executive Communications
The Committee received oral and written testimony from the
U.S. Department of Health and Human Services at the hearing on
S. 556 held on April 2, 2003, July 16, 2003 and July 21, 2004.
The Committee received oral and written testimony from the U.S.
Department of Housing and Urban Development at the hearing on
S. 556 held on July 16, 2003. The written testimony is attached
as follows:
Statement of Charles W. Grim, D.D.S., M.H.S.A, Interim Director, Indian
Health Service
Mr. Chairman and Members of the Committee:
Good morning, I am Dr. Charles Grim, Interim Director of
the Indian Health Service (IHS). Today, I am accompanied by Mr.
Michel Lincoln, Deputy Director, Mr. Gary Hartz, Acting
Director of the Office of Public Health, and Dr. Craig
Vanderwagen, Director, Division of Clinical and Preventive
Services, Office of Public Health. We are pleased to have this
opportunity to testify on behalf of Secretary Thompson on S.
556, the Indian Health Care Improvement Act Reauthorization of
2003''. And, at the Committee's request, I will report on the
Secretary's One-Department Initiative as it impacts the IHS and
the president's FY 04 budget proposal to consolidate automated
information systems in the Department.
The IHS has the responsibility for the delivery of health
services to more than 1.6 million Federally-recognized American
Indians and Alaska Natives (AI/ANs) through a system of IHSA,
tribal and urban (I/T/U) operated facilities and programs based
on treaties, judicial determinations, and Acts of Congress. The
mission of the agency is to raise the physical, mental, social,
and spiritual health of AI/ANs 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 foundation is to uphold the Federal
government obligation 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 pieces of legislation are at the core of the
Federal government's responsibility for meeting the health
needs of American Indians/Alaska Natives (AI/ANs): The Snyder
Act of 1921, P.L. 67-85, and the Indian Health Care Improvement
Act (IHCIA), Public Law 94-437. The Snyder Act authorized
regular appropriations for ``the relief of distress and
conservation of health'' of American Indian/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 provided the
authority for the programs of the Federal government that
deliver health services to Indian people, but the IHCIA also
provided additional guidance in several areas. The IHCIA
contained specific language that addressed the recruitment and
retention of a number of health professionals serving Indian
communities focused on health services for urban Indian people
and addressed the construction, replacement, and repair of
health care facilities.
We are here today to discuss reauthorization of the IHCIA
and tribal recommendations for change to the existing IHCIA in
the context of the many changes that have occurred in our
country's health care environment since the law was first
enacted in 1976. S. 556 reflects the product of an extensive
tribal consultation process that took two full years and
resulted in a tribally drafted reauthorization bill. IHS staff
provided technical assistance and support to the Indian tribes
and urban Indian health programs through this lengthy
consultation.
The Department supports the purposes of S. 556 to improve
the health status of AI/AN people and to raise health status
the highest possible level. We do, however, continue to have
concerns, as expressed previously to the Committee in the
Secretary's September 27, 2001 report on S. 212, regarding a
number of provisions in that bill. As introduced, S. 556 is
identical to S. 212. There are several provisions in S. 556
that are inconsistent with current Medicare and Medicaid
provider payment practices and could inappropriately increase
costs. For example:
Title II, Section 202, which describe a new
provider type called a Qualified Indian Health Provider (QIHP)
and Sections 212 and 221 regarding extension of the 100%
Federal matching rate for Medicaid and SCHIP. These sections
are further discussed below in the statement.
In addition, Section 419 proposes to exempt
patients eligible for Medicare or Medicaid from standard cost-
sharing requirements such as deductibles, co-payments, and
premiums. We have no concern with the current exception for
Indian children exempt from premiums and co-pays in the SCHIP
program.
The Department also reported in the staff analysis of its
September 27, 2001 bill report some concerns with the managed
care provisions in Section 423 which limits appropriate cost
and utilization incentives in Medicare and Medicaid by
potentially undermining capitated payments in managed care
settings.
The Administration is seriously concerned about these
provisions, which undermine standard practices in Medicare and
Medicaid. The most pressing concerns were outlined in the
Secretary's September report which I will present to you today:
(1) the Qualified Indian Health Program (QIHP); (2) negotiated
rule making; and (3) extension of 100% Federal matching rate
for Medicaid and SCHIP.
While the Administration continues to have serious concerns
about S. 556 in its current form, we are committed to working
with the Committee on legislation to reauthorize this important
cornerstore authority for the provision of health care to
American Indians and Alaska Natives.
qualified indian health program (qihp)
The bill would amend the Medicare statute to add various
detailed provisions for a new provider type called a Qualified
Indian Health Provider (QIHP) for IHS, Tribal, and urban Indian
(I/T/U) providers participating in the Medicare and Medicaid
programs. The most problematic aspects of QIHP are the
structure and operation of the payment provisions, which are
not only burdensome but, more importantly, would not be
feasible to administer. QIHP would require the Federal
government to complete a series of complex payment computations
for each I/T/U provider, for each payment period, (including
rates and adjustments not available to any other provider) to
identify the provider type for each that yields the highest
payment amount for that period. However, such computations
could only be made after services are provided, when it is too
late for the providers to have known or complied with the
differing conditions of participation applicable to differing
provider types. In addition to the burden and feasibility
issues, on a more fundamental level, this ``full cost plus
other costs'' QIHP payment approach would be contrary to the
way that Medicare generally pays providers. Moreover, it would
impose disproportionately higher costs on a program that is
approaching insolvency. Extending such a payment approach to
Medicaid and SCHIP would raise similarly serious administrative
and budgetary concerns.
negotiated rule making; tribal consultation; administrative burdens
We are concerned that S. 556 would appear to broadly
mandate use of negotiated rule making to develop all
regulations to implement the IHCIA. Negotiated rule making is
very resource-intensive for both Federal and non-Federal
participants. It can be effective in appropriate circumstances,
but may not be the most effective way to obtain necessary
Indian provider input in the development of IHCIA rules and
regulations in a given case.
Additionally, while we appreciate the value of consultation
with Tribes, we have concerns about the consultation
requirements. The bill would require Tribal consultation prior
to the Centers for Medicare & Medicaid Services (CMS) adopting
any policy or regulation, as well as require all HHS agencies
to consult with urban Indian organizations prior to taking any
action, or approving any action of a State, that may affect
such organizations or urban Indians. Such requirements appear
to be broader than the existing Tribal consultation requirement
and would be very difficult to administer, given the hundreds
of regulations and policies potentially covered.
We have similar concerns about the considerable indirect
adverse impact of S. 556's extensive reporting requirements and
other administrative burdens on IHS and CMS that would divert
limited resources from other activities. One example is the
proposed requirement for a detailed annual report on health
care facilities construction needs and the survey of facilities
it would entail. As IHS programs and both IHS and CMS
administrative functions are funded by capped discretionary
accounts, the imposition of additional administrative duties on
IHS and CMS would have the practical effect of requiring
cutbacks in current activities.
extension of 100% federal matching rate for medicaid and schip
We also are concerned that the bill would extend the 100%
Federal matching rate to States for Medicaid and State
Children's Health Insurance Program (SCHIP) services (currently
applicable to such services provided through an IHS facility)
to other services provided to American Indians and Alaska
Natives, including those furnished by non-Indian health care
providers. This proposed change would substantially increase
Federal program and administrative costs, with no guarantee and
little likelihood of any more services for Indian beneficiaries
or better payments for Indian providers.
As we continue our thorough review of this far-reaching,
complex legislation, we may have further comments. However, we
wish to reiterate our strong commitment to reauthorization and
improvement of the Indian health care programs. We will be
happy to work with the Committee, the National Tribal Steering
Committee, and other representatives of the American Indian and
Alaska Native communities to develop a bill fully acceptable to
all stakeholders in these important programs.
one-department initiative
In addition to our expressed concerns with S. 556, I will
now present an explanation of the Secretary's One-Department
initiative and its benefit to the IHS.
The Secretary's One Department Initiative has been of great
benefit to the IHS as well as the Native American constituents
of the Department. The fundamental premise of this initiative
is that the Department of Health and Human Services must speak
with one, consistent voice. Nothing is more important to our
success as a department. With regard to our tribal constituents
the Secretary observed on his first trip to Indian Country that
tribal programs were often ``stove piped'' and that there
existed within HHS an assumption that the IHS had sole
responsibility for the health issues facing tribes. In the two
short years since the Secretary launched this initiative he has
reestablished the Intradepartmental Council for Native American
Affairs. The membership of this Council is comprised of the
heads of all the HHS Operating and Staff Division with the IHS
Director serving as the Vice-Chair. This Council serves as an
advisory body to the Secretary and has the responsibility to
assure that Indian policy is implemented across all Divisions.
The Council provides the Secretary with policy guidance and
budget formulation recommendations that span all Divisions of
HHS. A profound impact of this Council on the IHS is the
revised premise within HHS that all Agencies bear
responsibility for the government's responsibility and
obligation to the Native people of this country.
In addition to the Council the Secretary and Deputy
Secretary have traveled widely to Indian Country with their
senior staff. These trips have raised the awareness of tribal
issues and have contributed greatly to our capacity to speak
with one voice on behalf of tribes.
An example of a tangible benefit to the IHS is the FY '04
President's budget request for IHS of $20 million for
Sanitation Facilities Program. An evaluation of the program
justified an increase in the FY '04 budget for the program's
most needy homes. This increase was also a result of the
Secretary's visit to Alaska with his senior staff in 2002. They
observed the critical need for safe drinking water and
sanitation facilities in Indian Country and acted decisively to
increase the IHS budget request.
The One Department Initiative can be directly credited for
this step forward for the Native people of this nation.
fy '04 information technology consolidation
Also, I would like to address the Committee's request for
information on the FY '04 President's budget proposal to
consolidate automated information systems in the Department.
The FY '04 President's Budget for IHS includes funding to
support Departmental efforts to improve the HHS Information
Technology Enterprise Infrastructure. The request includes
funds to support an enterprise approach to investing in key
information technology infrastructure such as security and
network modernization.
These investments will enable IHS programs to carry out
their missions more securely and at a lower cost. Agency funds
will be combined with resources in the IT Security and
Innovation Fund to promote collaboration in planning and
project management and to achieve common goals such as secure
and reliable communication and lower costs for the purchase and
maintenance of hardware and software.
The IHS budget request includes savings in the IT Budget
from ongoing IT consolidation efforts and additional reduced
spending through the streamlining or elimination of lower
priority projects. As a result, the FY '04 IHS budget request
proposed a decrease in spending for information technology
below the FY '03 level of $9,282,000. This decrease is the
result of IT savings associated with the creation of ``one
HHS'' from the Department's disparate organization units and
more efficient and effective management of the base HHS
information technology system. Consolidation of IT resources
will yield savings necessary to support program requirements.
Mr. Chairman, this concludes my statement. Thank you for
this opportunity to discuss the reauthorization of the Indian
Health Care Improvement Act and other issues. We will be happy
to answer any questions that you may have.
Statement of Charles W. Grim, D.D.S., M.H.S.A., Interim Director,
Indian Health Service
Mr. Chairman and Members of the Committees:
Good morning, I am Dr. Charles Grim, Interim Director of
the Indian Health Service (IHS). Today, I am accompanied by Mr.
Gary Hartz, Acting Director of the Office of Public Health; Dr.
Richard Olson, Acting Director, Division of Clinical and
Preventive Services, Office of Public Health; and Rae Snyder,
Acting Director of the Urban Health Office. We are pleased to
have this opportunity to testify on behalf of Secretary
Thompson on S. 556, the Indian Health Care Improvement Act
Reauthorization of 2003. And, at the Committee's request, I
will discuss the health disparities, Indian health facilities
and urban Indian health concerns.
The IHS has the responsibility for the delivery of health
services to more than 1.6 million Federally-recognized American
Indians and Alaska Natives (AI/ANs) through a system of IHS,
tribal, and urban (I/T/U) operated facilities and programs
based on treaties, judicial determinations, and Acts of
Congress. The mission of the agency is to raise the physical,
mental, social, and spiritual health of AI/ANs 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 foundation is to
uphold the Federal Government's obligation 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 pieces of legislation are at the core of the
Federal Government's responsibility for meeting the health
needs of American Indians/Alaska Natives (AI/ANs): The Snyder
Act of 1921, P.L. 67-856, and the Indian Health Care
Improvement Act (IHCIA), P.L. 94-437. 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 provided the
authority for the programs of the Federal Government that
deliver health services to Indian people, but the IHCIA also
provided additional guidance in several areas. The IHCIA
contained specific language that addressed the recruitment and
retention of a number of health professionals serving Indian
communities focused on health services for urban Indian people
and addressed the construction, replacement, and repair of
health care facilities.
We are here today to discuss reauthorization of the IHCIA
and tribal recommendations for change to the existing IHCIA in
the context of the many changes that have occurred in our
country's health care environment since the law was first
enacted in 1976. S. 556 reflects the product of an extensive
tribal consultation process that took two full years and
resulted in a tribally drafted reauthorization bill. IHS staff
provided technical assistance and support to the Indian Tribes
and urban Indian health programs through this lengthy
consultation. however, we recognize that our programs overlap
and have implications for other Federal agencies and their
programs, and we are working with them to develop a
comprehensive Administration position on this legislation.
HEALTH DISPARITIES
While the mortality rates of Indian people have improved
dramatically over the past ten years, Indian people continue to
experience health disparities and death rates that are
significantly higher than the rest of the U.S. general
population:
Alcoholism--770% higher
Diabetes--420% higher
Accidents--280% higher
Suicide--190% higher
Homicide--210% higher
Those statistics are startling, yet they are so often
repeated that some view them as insurmountable facts. But every
one of them is influenced by behavior choices and lifestyle.
Making significant reductions in health disparity rates, and
even eliminating them, can be achieved by implementing best
practices, using traditional community values, and building the
local capacity to address these health issues and promote
healthy choices.
A primary area of focus that I have identified based on
these statistics is a renewed emphasis on health promotion and
disease prevention. I believe this will be our strongest front
in our ongoing battle to eliminate health disparities plaguing
our people for far too long. Although we have long been an
organization that emphasizes prevention, I am calling on the
Agency to undertake a major revitalization of its public health
efforts in health promotion and disease prevention. Both field
and tribal participation in the initial stages of planning and
implementation is critical.
Fortunately, the incidence and prevalence of many
infectious diseases, once the leading cause of death and
disability among American Indians and Alaska Natives, have
dramatically decreased due to increased medical care an public
health efforts that included massive vaccination and sanitation
facilities construction programs. Unfortunately, as the
population lives longer and adopts more of a western diet and
sedentary lifestyle, chronic diseases emerge as the dominant
factors in the health and longevity of the Indian population
with the increasing rates of cardiovascular disease, Hepatitis
C virus, and diabetes.
Cardiovascular disease is now the leading cause of
mortality among Indian people, with a rising rate that is
significantly higher than that of the U.S. General population.
This is a health disparity rate that the President, the
Secretary of Health and Human Services, and the IHS are
committed to eliminating. The IHS is working with other HHS
programs, including the Centers for Disease Control and
Prevention and the National Institutes of Health's National
Heart Lung and Blood Institute, to develop a Native American
Cardiovascular Disease Prevention Program. Also contributing to
the effort is the IHS Diabetes Program, the IHS Disease
Prevention Task Force, and the American Heart Association. The
primary focus is on the development of more effective
prevention programs for AI/AN communities. The IHS has also
begun several programs to encourage employees and our tribal
and urban Indian health program partners to lose weight and
exercise, such as ``Walk the Talk'' and ``Take Charge
Challenge'' programs.
Diabetes mortality rates have been increasing at almost
epidemic proportions. American Indians and Alaska Natives have
the highest prevalence of type 2 diabetes in the world. The
incidence of type 2 diabetes is rising faster among American
Indians and Alaska Native children and young adults than in any
other ethnic population, and is 2.6 times the national average.
As diabetes develops at younger ages, so do related
complications such as blindness, amputations, and end stage
renal disease. Today I want to report to you that we may be
seeing a change in this pattern however. In CY 2000 we have
observed for the first time ever a decline in mortality. I must
note that this is preliminary mortality data that needs to be
thoroughly examined.
What is most distressing however about these statistics is
that type 2 diabetes is largely preventable. Lifestyle changes,
such as changes in diet, exercise patterns, and weight can
significantly reduce the changes of developing type 2 diabetes.
Focusing on prevention not only reduces the disease burden for
a suffering population, but also lessens and sometimes
eliminates the need for costly treatment options. The cost-
effectiveness of a preventative approach to diabetes management
is an important consideration, since the cost of caring of
diabetes patients is staggering. Managed care estimates for
treating diabetics range from $5000-$9000 per year. Since the
Indian health system currently cares for approximately 100,000
people with diagnosed diabetes, this comes out to a
conservative estimate of $500 million just to treat this one
condition.
Another area of concern is in behavioral health,
specifically the identification and treatment of depression and
strategies for prevention of depression. A recent study from
Washington University in St. Louis has revealed that untreated
depression doubles the risk for chronic diseases like diabetes
and cardiovascular disease, not to mention the risks for
alcoholism, suicide, and other violent events. This study also
showed that of those individuals with chronic disease,
unrecognized and untreated depression doubles the risk for
complications of the chronic disease (e.g., amputations and
renal disease in diabetics). We must find the best practices
that will allow us to prevent depression primarily, or at the
least recognize and treat it early if we are to reduce the
disparities that affect Indian communities.
In summary, preventing disease and injury is a worthwhile
financial and resource investment that will result in long-term
savings by reducing the need for providing acute care and
expensive treatment processes. It also yields the even more
important humanitarian benefit of reducing pain and suffering,
and prolonging life. This is the path we must follow if we are
to reduce and eliminate the disparities in health that so
clearly affect AI/AN people.
HEALTH CARE FACILITIES
Title III authorizes the Facilities programs which
construct, renovate, maintain, and improve facilities where
Indian health services are provided. Sanitation facilities
construction is conducted in 38 States with Federal recognized
Tribes where ownership of the facilities is turned over to the
Tribes to operate and maintain them once completed. The IHS
health care facilities program including the tribal programs,
specifically, is responsible for managing and maintaining the
largest inventory of real property in the Department of Health
and Human Services, with over 9 million square feet (850 gross
square meters) of space. There are 49 hospitals, 231 health
centers, 5 school health centers, over 2000 units of staff
housing, and 309 health stations, satellite clinics, and Alaska
village clinics which support the delivery of health care to
our people. These facilities authorizations put in place the
foundation on which health care delivery is provided to
American Indians and Alaska Natives.
Health care facilities needs assessment and report
Proposed provisions in the IHCIA reauthorization bills
require IHS to report annually, after consultation with Tribes,
on the needs for health care facilities construction, including
the renovation and expansion needs. In fact, efforts are
currently underway to develop a complete description of need
similar to what would be required by the Bill. While not all
the resource issues have been resolved, the process is in
progress and the plan is to base our future facilities
construction priority system methodology application on a more
complete listing of tribal and Federal facilities needs for
delivery of health care services funded through the IHS. We
will continue to explore with the Tribes less resource
intensive means for acquiring and updating the information that
would be required in these reports.
Using sanitation facilities construction funds to serve HUD homes
Section 302(b)(3)(C) specifically proposes that IHS
sanitation facilities construction funds will not be used to
support service of sanitation facilities to Department of
Housing and Urban Development (HUD) homes. The IHS is concerned
that homes constructed using HUD funds include the necessary
infrastructure to make a home complete, including safe water
and sewer and wastewater disposal.
As you know, the Administration is actively reviewing S.
556 and will provide you with specific details of our analysis
very shortly. We are committed to working with Tribes and other
agencies to ensure that adequate facilities are planned for and
funded in conjunction with new home construction, and we
appreciate HUD's and other Federal agencies' willingness to
work with us in this regard.
Classifying long term leases as operating leases
Proposed provisions of the bills would make it possible to
classify a lease for health care space as an operating lease
and allow for long term leases for space (capital leases) to be
scored against the budget in the first year of the lease. The
intent of the proposed section is to make it possible for
Tribes to acquire a facility and enter into a long term lease
with the Government without having the full cost of the lease
scored against a single year's budget. While this may make it
possible for Tribes to more easily acquire needed space to
house health care services, there is concern that leasing
capital space in this manner will commit future Congresses and
Administrations to funding without the opportunity for review.
Retroactive funding of Joint Venture Construction Projects
Changes proposed by the bills would permit a tribe that has
``begun or substantially completed'' the process of acquisition
of a facility to participate in the Joint Venture Program,
regardless of government involvement or lack thereof in the
facility acquisition. An agreement implies that all parties
have been party to 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 and/or ineffective to
operate.
Sanitation facilities deficiency definitions
Proposed new language in the bills, which provides
definitions of sanitation deficiencies used to identify and
prioritize water and sewer projects in Indian Country, is
ambiguous. As written deficiency level III could be interpreted
to mean all methods of service delivery are adequate to level
III requirements (including methods where water and sewer
service provided by hauling rather than through piping systems
directly into the home) and only the operating condition, for
example frequent service interruptions, make that facility
deficient. This description assumes that water haul delivery
systems and piped systems provide a similar level of service.
We believe that there should be a distinction.
In addition, the definition for Deficiency Level V and
Deficiency Level IV, through phrased differently, have
essentially the same meaning. Level IV should refer to an
individual home or community lacking either water or wastewater
facilities, whereas, level V should refer to an individual home
or community lacking both water and wastewater facilities.
Tribal management of federally-owned quarters
The bills reiterate authorization already provided in the
Indian Self-Determination and Education Act (P.L. 93-638, as
amended). We are concerned that slight differences in wording
in the two bills either as written or in amendments could cause
confusion. We believe that this proposed addition of
unnecessary language should be deleted.
Threshold criteria for small ambulatory program
The Small Ambulatory Care Facility section contains
proposed language that limits participation in the Small
Ambulatory Program to facilities that provide more than 500
visits to eligible users and that provide ambulatory care in a
service area with a population of more than 1,500 eligible
Indians. These criteria are both lower limits and would apply
to many facilities including all large health centers, most of
which also qualify for priority evaluation and possible funding
under Section 301 of the two bills. We are concerned that some
facilities that meet these criteria may be of a lower priority
than those on the Priority List submitted to Congress and could
receive construction funding before higher priority
construction needs. We do, however, see a need for a Small
Ambulatory Program that addresses the needs of Tribes with
smaller facilities that do not meet the threshold to compete
for placement on the Section 301 Priority Lists. For that
reason we recommend that this section set an upper threshold
criterion of 4,400 primary care provider visits for
participation in the Small Ambulatory Program. The lower limit
should be 500 primary care provider visits. The Small
Ambulatory Program is to address the needs of small tribal
facilities that are not competitive under the Section 301
Priority System because of their size.
URBAN INDIAN HEALTH
The Title V of the IHCIA provides specific authority
focused on the provision of health services for urban Indian
people with funds appropriated to IHS. IHS currently funds 34
urban Indian programs nationally and these programs provide a
range of services in three broad categories: comprehensive
clinical programs; limited clinical programs; and outreach and
referral programs.
In addition to the 34 urban Indian health programs
currently in operation, the Congress has also authorized and
funded the Oklahoma City Clinic and Tulsa Clinic Demonstration
Programs. Both the Oklahoma City Indian Clinic and the Tulsa
Indian Clinic (now the Indian Health Care Resource Center of
Tulsa) were established in the early 1970's to serve the health
and social needs of the urban Indian populations of Oklahoma.
With the passage of the Indian Health Care Improvement Act in
September 1976, these two programs were funded by the Indian
Health Service (IHS) under Title V of that law as urban
programs.
In 1978, the entire State of Oklahoma was designated as a
Contract Health Service Delivery Area (CHSDA) by regulation (42
CFR 36.22(a)(3)). As a statewide CHSDA Indian beneficiaries
could reside anywhere in the state and maintain their
eligibility for both direct services and contract health
services. As a result of this change, the Oklahoma Indian
population count for services was inclusive of all Indians
residing in the state and counted as IHS beneficiaries in the
IHS calculation for resource requirements and allocations.
The 1992 amendments to IHCIA provided for the establishment
of two demonstration projects with the Tulsa and Oklahoma City
clinics, ``to be treated as service units in the allocation of
resources and coordination of care.'' In establishing these
demonstration projects Congress undertook a new and innovative
approach to ensuring health services were accessible to all
eligible populations in Oklahoma.
These demonstration projects have now established a
``hybrid'' system within the IHS and have a unique status. The
projects are not operated strictly as an IHS facility or tribal
contracted or compacted program or an urban program. Each
program maintains its status under the Title V as an ``urban
Indian organization.'' Contracts are signed by the projects
with the IHS, under Title V and the Buy Indian Act authority,
yet the programs function like other IHS service units and
report on the Resources and Patient Management System of the
IHS with data utilized for inclusion in the allocation of
resources. This unique status has allowed for a substantive
increase in funds to the projects from the IHS based upon
workload data and increases derived from substantial line-item
funding increases directed by Congress in fiscal year 1994
addressing facility problems at each site. Both service
population and overall utilization of services has dramatically
increased since these programs became demonstration projects
and as a result of the line item funds. They have been able to
use the best of both urban and IHS structures to build a
community controlled, high quality health system in a state
designated as a contract health service delivery area.
On the other hand this hybrid system has raised a few
concerns with some Oklahoma Tribes the operate their own health
programs under the Indian Self Determination and Education
Assistance Act, P.L. 93-638, as amended. The issue in most
basic terms is allocation of resources for tribally
administered services and urban provided services for closely
located beneficiary populations. In an environment of resources
reduced by a growing population and greater health need, the
perception of a unique or special status may cause more concern
than has been observed in the past.
While the challenges for the urban Indian health programs
are many, they are much the same as those faced by the Tribes
and the federal operations. Our work is to assure that we all
are working to fulfill our roles in the I/T/U partnership and
in collaboration to raise the health status of our Indian
people.
NEGOTIATED RULEMAKING; TRIBAL CONSULTATION; ADMINISTRATIVE BURDENS
While the Administration continues to have serious concerns
about the proposed bills in their current forms, we are
committed to working with the Committees on legislation to
reauthorize this important cornerstone authority for the
provision of health care to American Indians and Alaska
Natives.
We are concerned that both bills would appear to broadly
mandate use of negotiated rulemaking to develop all regulations
to implement the IHCIA. Negotiated rulemaking is very resource-
intensive for both Federal and non-Federal participants. It can
be effective in appropriate circumstances, but may not be the
most effective way to obtain necessary Indian provider input in
the development of IHCIA rules and regulations in a given case.
Additionally, while we appreciate the value of consultation
with Tribes, we have concerns about the consultation
requirements. The bills would require Tribal consultation prior
to the Centers for Medicare & Medicaid Services (CMS) adopting
any policy or regulation, as well as require all HHS agencies
to consult with urban Indian organizations prior to taking any
action, or approving any action of a State, that may affect
such organizations or urban Indians. Such requirements appear
to be broader than the existing Tribal consultation requirement
and would be very difficult to administer, given the hundreds
of regulations and policies potentially covered.
We have similar concerns about the considerable indirect
adverse impact of the proposed new extensive reporting
requirements and other administrative burdens on IHS and CMS
would divert limited resources from other activities. As IHS
programs and both IHS and CMS administrative functions are
funded by capped discretionary accounts, the imposition of
additional administrative duties on IHS and CMS would have the
practical effect of requiring cutbacks in current activities.
As we continue our thorough review of this far-reaching,
complex legislation, we may have further comments on other
provisions, particularly in Title IV. However, we wish to
reiterate our strong commitment to reauthorization and
improvement of the Indian health care programs. We will be
happy to work with the Committees, the National Tribal Steering
Committee, and other representatives of the American Indian and
Alaska Native communities to develop a bill fully acceptable to
all stakeholders in these important programs.
Mr. Chairman, this concludes my statement. Thank you for
this opportunity to discuss the reauthorization of the Indian
Health Care Improvement Act and other issues. We will be happy
to answer any questions that you may have.
Statement of Steven B. Nesmith, Assistant Secretary, Congressional and
Intergovernmental Relations, U.S. Department of Housing and Urban
Development
INTRODUCTION
Mr. Chairman, Mr. Vice Chairman, and Members of the
Committee, thank you for inviting me to provide comments on S.
556, the Indian Health Care Improvement Act Reauthorization of
2003.
My name is Steven B. Nesmith, and I am the Assistant
Secretary for Congressional and Intergovernmental Relations. As
you know, Public and Indian Housing (PIH) is responsible for
the management, operation and oversight of HUD's Native
American programs. These programs are available to 560
Federally-recognized and a limited number of state-recognized
Indian tribes. We serve these tribes directly, or through
tribally designated housing entities (TDHEs), by providing
grants and loan guarantees designed to support affordable
housing, community and economic development activities. Our
tribal partners are diverse; they are located on Indian
reservations, in Alaska Native Villages, and in other
traditional Indian areas.
In addition to those duties, PIH's jurisdiction encompasses
the public housing program, which aids the nation's 3,000-plus
public housing agencies in providing housing and housing-
related assistance to low-income families.
It is a pleasure to appear before you, and I would like to
express my appreciation for your continuing efforts to improve
the housing conditions of American Indian and Alaska Native
peoples. Much progress is being made and tribes are taking
advantage of new opportunities to improve the housing
conditions of the Native American families residing on Indian
reservations, on trust or restricted Indian lands, and in
Alaska Native Villages. This momentum needs to be sustained as
we continue to work together toward creating a better living
environment throughout Indian Country.
OVERVIEW
At the outset, let me reaffirm the Department of Housing
and Urban Development's support for the principle of
government-to-government relations with Indian tribes. HUD is
committed to honoring this fundamental precept in our work with
American Indians and Alaska Natives.
On behalf of Secretary Martinez, thank you for the
opportunity to provide testimony on S. 556. The Department
agrees that the Indian Health Service (IHS), a division of the
Department of Health and Human Services, is vital to the well-
being of individual Indian families and the Native American
community as a whole. Native Americans often have no other
means to receive the health care assistance and related
activities provided by IHS.
HUD's Office of Native American Programs continues its
ongoing dialog with IHS representatives to coordinate our
activities in a manner that supports tribal sovereignty, self-
determination and self-governance. The Department also
participates in a federal interagency task force on
infrastructure with the IHS, Environmental Protection Agency,
Bureau of Indian Affairs and Department of Agriculture. It is
within this perspective that the following comments are offered
on the bill.
BACKGROUND ON HUD NATIVE AMERICAN PROGRAMS
In 1996, the Native American Housing Assistance and Self-
Determination Act (25 U.S.C. 4101 et seq.) (NAHASDA) became
law. NAHASDA changed the way in which housing and housing-
related assistance is provided to Native American families.
Prior to the Act, Indian housing authorities and Indian tribes
applied for a variety of competitive, categorical grant
programs, usually with differing program eligibility and
reporting requirements. NAHASDA created the Indian Housing
Block Grant (IHBG) Program, which is a non-competitive formula
grant made to an Indian tribe or its tribally designated
housing entity (TDHE).
Under the IHBG Program an Indian tribe or the TDHE submits
to HUD a five-year and a one-year Indian Housing Plan (IHP).
The IHP contains information about how the recipient will use
its IHBG funds to engage in the six affordable housing
activities authorized by NAHASDA. Once the IHP is found to be
in compliance with statutory and regulatory requirements, the
tribe or TDHE executes a grant agreement to receive its IHBG
allocation.
The IHBG formula is based on the housing needs of each
tribe and the tribe/TDHE's ongoing operation and maintenance
needs for the dwelling units previously developed under the
Indian Housing Program authorized by the U.S. Housing Act of
1937, as amended. The IHBG formula is calculated by dividing
the total amount appropriated each fiscal year among the number
of eligible grant recipients. Formula components and variables
are weighted to ensure that the complexities and differences
among tribes are taken into consideration. Each tribe's formula
allocation reflects these factors.
The NAHASDA regulations (24 CFR 1000.306) require that the
IHBG formula be reviewed by calendar year 2003 for possible
modification or revision. At present, the Department is engaged
in negotiated rulemaking (neg-reg) with a 26-member committee
comprised of a broad cross-section of tribal stakeholders. The
first neg-reg session was held in April; additional monthly
meetings are ongoing and scheduled through this September.
SPECIFIC COMMENTS ON S. 556
Let me turn now to our specific comments on S. 556, the
Indian Health Care Improvement Act Reauthorization of 2003.
As you know, the Administration is actively reviewing S.
556 and will provide you with specific details of our analysis
very shortly. The Administration has not taken a position
regarding the transfer of NAHASDA funds between HUD and HHS. We
do, however, have concerns about transferring NAHASDA funds
between Federal agencies when NAHASDA now provides for the
direct distribution of IHBG funds to tribes and their TDHE's
based on a formula negotiated between tribes and the
Department.
An affordable housing activity under the IHBG Program is
``development,'' which includes infrastructure such as site
improvements and the development of utilities and utilities
services for housing. The provision of water and sanitation
facilities is included within this category. Tribes or TDHEs
may currently enter into agreements with IHS to provide these
services, or they may choose another service provider. We
believe this is in keeping with the policy of self-
determination that is articulated in NAHASDA.
Since 1997, nearly $28 million has been transferred to IHS
through TDHEs for offsite sanitation facilities. Tribes and
TDHEs continue to make difficult budgetary and management
decisions on how to prioritize their IHBGs, which is consistent
with tribal self-determination and self-government.
Let me assure the Committee that we will work with you, our
Federal partners in HHS and other Federal agencies, tribes and
their TDHEs to ensure that the housing infrastructure needs in
Native American communities are met in the most efficient
manner possible. We are, nevertheless, concerned about any
provisions that might erode the self-determination now provided
for in NAHASDA.
Thank you for the opportunity to express our views on S.
556.
Statement of Tommy G. Thompson, Secretary, Department of Health and
Human Services
Good afternoon, Mr. Chairman, Senator Inouye and members of
the Committee. I am honored to testify before you today on the
important issue of reauthorization of the Indian Health Care
Improvement Act (IHCIA). Accompanying me today is Dr. Charles
Grim, Director of the Indian Health Service (IHS). This
landmark legislation forms the backbone of the system through
which numerous Federal health programs serve American Indians
and Alaska Natives (AI/ANs) and encourages participation of
eligible AI/ANs in these programs. Legislation pending before
this Committee and over in the House has been given the highest
degree of consideration by the Department. My staff has worked
tirelessly to respond to this Committee's and the House
Resource Committee's request for our views on H.R. 2440. I am
pleased to share with you today the result of our efforts to
improve services provided by the Indian Health Service, Tribes,
Tribal Organizations, Alaska Native Villages and Urban Health
Programs.
As Secretary of the Department of Health and Human Services
(HHS), it has been my goal to improve coordination to the
maximum extent possible among the operating and staff divisions
at the Department and to encourage collaboration between the
Department and Tribes on the many programs impacting their
members. As you know, upon my arrival at HHS, I reactivated the
Intradepartmental Council on Native American Affairs (ICNAA) to
provide a consistent HHS policy when working with the more than
560 Federally recognized Tribes.
I am also proud of the many achievements over that past
three years in the areas of access, consultation,
collaboration, organization, education, sanitation facilities
construction and Medicare reform. And, I have traveled widely
to Indian country over the past three years and visited with
Tribes from the Chippewa Indians and Oglala Sioux Tribe, to
Alaska Native Villages including Point Hope and Kwethluk. I
just arrived back from a visit with the Navajo Nation and will
return again to Alaska later this month to meet with Native
leaders in Anchorage and representatives of Southeast Alaska
Rural Health Consortium in Juneau. Through my travels, I have
recognized the need for improvements in facilities that provide
the base from which so many health care needs are met. In this
area, I would like to work closely with Congress to continue to
address this need.
HHS ACCOMPLISHMENTS
The Department has improved Tribal access to HHS resources
in both appropriated funding as well as to non-earmarked funds
and increases in discretionary set asides. Between FY 2001 and
FY 2003, HHS resources provided to Tribes or expended for the
benefit of Tribes increased from $3.9 billion in 2001 to $4.4
billion in 2003. This reflects an 11% increase in access to HHS
funding for Tribes during just a two-year period.
In response to Tribal leader comments at the regional
Tribal consultation session, we have honored many requests
including:
Establishing a Center for Medicare and
Medicaid Services (CMS)--Technical Tribal Advisory
Group (TTAG), which held its first formal meeting at
the Department on February 10, 2004;
Revising the existing HHS Tribal
consultation policy and involving Tribal leaders in
this process;
Helping to bridge tribal/state relations for
HHS programs administered through States: HHS, the
National Congress of American Indians (NCAI) and the
American Public Human Services Association (APHSA) have
now entered into a Federal/State/Tribal collaborative
project to work together on health and human services
provided to Indian Tribes and Native organizations. HHS
is forming a workgroup to focus on key areas of
priorities identified by Tribes (TANF, Child Welfare,
Information Systems, etc.);
Improving outcomes of Indian children and
families with Diabetes by increasing education and
physical activity programs; and,
Recommending that funding be increased for
the IHS Sanitation Facilities Construction (SFC): The
President's FY 2005 Budget request for IHS includes an
increase of $10 million for SFC.
Moreover, I am pleased that the Medicare Prescription Drug,
Improvement, and Modernization Act of 2003 (MMA), passed by
Congress last year, included two provisions identified by
Indian health programs as high priorities. First, the MMA
allows Indian health programs to use Medicare's bargaining
power when purchasing care from Medicare participating
hospitals for their non-Medicare patients, thus stretching
contract health and Urban Indian health funding further.
Second, the MMA allows IHS and Tribal hospitals and clinics to
bill for additional Medicare Part B services for the period
2005-2008. Finally, we are pleased that the MMA includes
special provisions designed to help assure that pharmacies
operated by Indian health programs, as well as other
pharmacies, can participate in the temporary drug discount card
and the permanent Part D drug benefit programs.
HHS VIEWS AND COMMENTS
The Department is strongly committed to the reauthorization
of the IHCIA during this Congress in order to improve the
health status of American Indian people and to increase the
availability of health services for them. We believe that
reauthorizing legislation should provide increased flexibility
to enable the Department to work with Tribes to improve the
quality of health care for American Indian people, to better
empower the Tribes to provide quality health, to increase the
availability of health care, including new approaches to
delivering care, and to expand the scope of health services
available to eligible American Indians and Alaska Natives.
Accordingly, I commend Congress for including in H.R. 2440
various changes that respond to concerns raised in our
September 27, 2001 bill report to the Senate Committee on
Indian Affairs on S. 212, a similar IHCIA reauthorization bill
in the 107th Congress. Moreover, I would like to note our
particular interest in, and support for, certain provisions of
H.R. 2440. I an impressed with the strengthening of provisions
in all program areas including:
(1) Improving recruitment and retention of qualified
providers, which are the foundation upon which all
services are provided by the IHS, Tribes and Tribal
Organizations and Urban Health Programs (ITUs);
(2) Providing for improved health services to
eligible Indians;
(3) Exempting Indians from cost sharing in the
Medicaid and SCHIP programs, consistent with our
current treatment of eligible Indian children under
SCHIP; and,
(4) Expanding behavioral health programs to provide
for much needed prevention and treatment in the areas
of child sexual abuse, family violence, mental health,
and other problems.
In addition, we believe that H.R. 2440, by proposing to
protect eligible Indians from cost-sharing under the Medicaid
and SCHIP programs, reflects the unique government-to-
government relationship of the United States to Federally-
recognized Indian Tribes. We would support such a proposal as
consistent with current HHS policy to exempt eligible Indian
children in SCHIP from premiums and cost-sharing. The proposed
policy on cost-sharing would go far toward addressing the
continuing underenrollment of eligible Indian individuals and
families in Medicaid.
In the area of behavioral health, H.R. 2440 provides for
the needs of Indian women and youth and expands behavioral
health services to include a much needed child sexual abuse and
prevention treatment program. The Department supports this
effort, but we recommend you permit the Secretary the
flexibility to provide for these important programs in a manner
that supports the local control and priorities of Tribes to
address their specific need.
The Department does have concerns about provisions
affecting the Medicare statute. Given the magnitude of the
changes and new programs required by the recently enacted MMA
and the challenges in implementing these changes by the
statutory deadlines, we do not believe it is feasible to make
additional modifications to Medicare at this time. We also have
concerns about provisions impacting the Medicare trust funds,
which, as you know, face significant financial challenges in
the future. Finally, we have several serious concerns about the
impact of H.R. 2440 on the Medicaid and SCHIP programs.
Specifically, we do not believe that requiring access to unused
SCHIP allotments is appropriate because it would set a
precedent within SCHIP of prioritizing a population that is
already eligible for services under current law, within a fixed
amount of funds.
Additionally, the Department is concerned with several
provisions included in the bill related to consultation
requirements. H.R. 2440 proposes requirements for Federal
agencies to consult with Federally-recognized Indian Tribes and
Tribal organizations into statute. As exemplified by the
successful outcomes of the Department's consultative process
with the Tribes, the Administration remains strongly committed
to consultation with Tribes as provided in Presidential
Executive Order 13175. Furthermore, consultation with Tribes is
provided for an the Indian Self-Determination and Education
Assistance Act of 1975 (ISDEAA). We, therefore, recommend
striking all language regarding consultation requirements.
I reiterate our strong commitment to reauthorization and
improvement of Indian health care programs, and I hope to work
with this Committee and other Committees of the Congress, the
National Tribal Steering Committee, and other representatives
of Indian country to develop a bill that all stakeholders in
these important programs can support. To this end, my staff
will be communicating with your staff in the near future to
share additional comments and suggestions regarding
reauthorization.
Changes in Existing Law
In compliance with subsection 12 of rule XXVI of the
Standing Rules of the Senate, the Committee notes the following
changes in existing law made by the bill, S. 556, as ordered
reported, are shown as follows (existing law proposed to be
omitted is enclosed in black brackets, new matter is printed in
italic, existing law in which no change is proposed is shown in
roman):
UNITED STATES CODE ANNOTATED
TITLE 25. INDIANS
CHAPTER 18--INDIAN HEALTH CARE
GENERAL PROVISIONS
Sec.
1. Short title; table of contents
1601. [Congressional f]Findings.
1602. Declaration of National Indian health [objectives] policy.
1603. Definitions.
[SUBCHAPTER] TITLE I--INDIAN HEALTH, HUMAN RESOURCES, AND DEVELOPMENT
[PROFESSIONAL PERSONNEL]
1611. [Congressional statement of p]Purpose.
1612. Health [p]Professions [r]Recruitment [p]Program for Indians.
1613. Health [p]Professions [p]Preparatory [s]Scholarship [p]Program for
Indians.
1613a. Indian health professions scholarships.
105. American Indians into psychology program.
106. Funding for tribes for scholarship programs.
1614. Indian health service extern programs.
1615. Continuing education allowances.
1616. Community Health Representative Program.
1616a. Indian Health Service Loan Repayment Program.
1616a-1. Scholarship and [L]loan [R]repayment [R]recovery [F]fund.
1616b. Recruitment activities.
1616c. [Tribal] Indian recruitment and retention program.
1616d. Advanced training and research.
1616e. Quentin N. Burdick American Indians into [N]nursing program.
[1616e-1. Nursing school clinics.
[1616f. Tribal culture and history.]
1616g. I[NMED P]nmed program.
1616h. Health training programs of community colleges.
[1616i. Additional incentives for health professionals.]
1616j. Retention bonus.
1616k. Nursing residency program.
1616l. Community Health Aide Program for Alaska.
[1616m. Matching grants to tribes for scholarship programs.]
1616n. Tribal health program administration.
123. Health professional chronic shortage demonstration programs.
124. Treatment of scholarships for certain purposes.
125. National Health Service Corps.
126. Substance abuse counselor educational curricula demonstration
programs.
[1616o. University of South Dakota pilot program.]
1616p. Authorization of appropriations.
[SUBCHAPTER] TITLE II--HEALTH SERVICES
1621. Indian Health Care Improvement Fund.
1621a. Catastrophic [h]Health [e]Emergency [f]Fund.
1621b. Health promotion and disease prevention services.
1621c. Diabetes prevention, treatment, and control.
205. Shared services for long-term care.
[1621d. Hospice care feasibility study.
[1621e. Reimbursement from certain third parties of costs of health
services.
[1621f. Crediting of reimbursements.]
1621g. Health services research.
207. Mammography and other cancer screening.
[1621h. Mental health prevention and treatment services.
[1621i. Managed care feasibility study.
[1621j. California contract health services demonstration program.
[1621k. Coverage of screening mammography.]
1621l. Patient travel costs.
1621m. Epidemiology centers.
1621n. Comprehensive [school] health education programs.
1621o. Indian [y]Youth [grant] [p]Program.
[1621p. American Indians Into Psychology Program.]
1621q. Prevention, control, and elimination of [tuberculosis]
communicable and infectious diseases.
213. Authority for provision of other services.
214. Indian women's health care.
215. Environmental and nuclear health hazards.
216. Arizona as a contract health service delivery area.
216A. North Dakota as a contract health service delivery area.
216B. South Dakota as a contract health service delivery area.
217. California contract health services program.
218. California as a contract health service delivery area.
219. Contract health services for the Trenton Service Area.
220. Programs operated by Indian Tribes and Tribal Organizations.
221. Licensing or certification.
222. Notification of provision of emergency contract health services.
223. Prompt action on payment of claims.
[1621r. Contract health services payment study.
[1621s. Prompt action on payment of claims.
[1621t. Demonstration of electronic claims processing.]
1621u. Liability for payment.
[1621v. Office of Indian Women's Health Care.]
1621w. Authorization of appropriations.
[1621x. Limitation on use of funds.
[1622. Transferred.]
[SUBCHAPTER] TITLE III--[HEALTH] FACILITIES
1631. Consultation; [closure] construction and renovation of facilities;
reports.
1632. [Safe water and sanitary waste disposal] Sanitation facilities.
1633. Preference to Indians and Indian firms.
1634. Expenditure of [non-Service] nonservice funds for renovation.
[1635. Repealed.]
1636. [Grant program] Funding for the construction, expansion, and
modernization of small ambulatory care facilities.
1637. Indian [h]Health [c]Care [d]Delivery [d]Demonstration [p]Project.
1638. Land transfer.
308. Leases, contracts, and other agreements.
309. Study on loans, loan guarantees, and loan repayment.
310. Tribal leasing.
311. Indian Health Service/tribal facilities joint venture program.
312. Location of facilities.
313. Maintenance and improvement of health care facilities.
314. Tribal management of federally owned quarters.
[1638a. Authorization of appropriations.]
1638b. Applicability of Buy American requirement.
316. Other funding for facilities.
317. Authorization of appropriations.
[1638c. Contracts for personal services in Indian Health Service
facilities.
[1638d. Credit to appropriations of money collected for meals at Indian
Health Service facilities.]
[SUBCHAPTER III-A] TITLE IV--ACCESS TO HEALTH SERVICES
1641. Treatment of payments under [medicare program] Social Security Act
health care programs.
[1642. Treatment of payments under medicaid program.
[1643. Amount and use of funds reimbursed through medicare and medicaid
available to Indian Health Service.]
1644. Grants to and [contracts] funding agreements with the Service,
Indian Tribes, [t]Tribal [o]Organizations, and Urban Indian
organizations.
403. Reimbursement from certain third parties of costs of health
services.
404. Crediting of reimbursements.
405. Purchasing health care coverage.
406. Sharing arrangements with Federal agencies.
407. Payor of last resort.
408. Nondiscrimination in qualifications for reimbursement for services.
409. Consultation.
410. State children's health insurance program (SCHIP).
411. Social Security Act sanctions.
412. Cost sharing.
413. Treatment under medicaid managed care.
414. Navajo nation medicaid agency feasibility study.
[1645. Direct billing of Medicare, Medicaid, and other third party
payors.
[1646. Authorization for emergency contract health services.]
1647. Authorization of appropriations.
[SUBCHAPTER IV] TITLE V--HEALTH SERVICES FOR URBAN INDIANS
1651. Purpose.
1652. Contracts with, and grants to, [u]Urban Indian [o]Organizations.
1653. Contracts and grants for the provision of health care and referral
services.
1654. Contracts and grants for the determination of unmet health care
needs.
1655. Evaluations; renewals.
1656. Other contract and grant requirements.
1657. Reports and records.
1658. Limitation on contract authority.
1659. Facilities [renovation].
1660. Office of Urban Indian Health [Programs Branch].
1660a. Grants for alcohol and substance abuse-related services.
1660b. Treatment of certain demonstration projects.
1660c. Urban NIAAA transferred programs.
514. Consultation with Urban Indian Organizations.
515. Federal Tort Claims Act coverage.
516. Urban youth treatment center demonstration.
517. Use of Federal property and supplies.
518. Grants for diabetes prevention, treatment, and control.
519. Community health representatives.
520. Regulations.
521. Eligibility for services.
1660d. Authorization of appropriations.
[SUBCHAPTER V] TITLE VI--ORGANIZATIONAL IMPROVEMENTS
1661. Establishment of Indian Health Service as an agency of Public
Health Service.
1662. Automated management information system.
1663. Authorization of appropriations.
[SUBCHAPTER V-A--SUBSTANCE ABUSE] TITLE VII--BEHAVIORAL HEALTH PROGRAMS
[1665. Indian Health Service responsibilities.
[1665a. Indian Health Service program.]
701. Behavioral health prevention and treatment services.
702. Memoranda of agreement with the Department of the Interior.
703. Comprehensive behavioral health prevention and treatment program.
704. Mental health technician program.
705. Licensing requirement for mental health care workers.
1665b. Indian women treatment programs.
1665c. Indian [Health Service y]Youth [p]Program.
708. Inpatient and community-based mental health facilities design,
construction, and staffing.
1665d. Training and community education.
[1665e. Gallup alcohol and substance abuse treatment center.]
[1665f. Reports.]
710. Behavioral health program.
1665g. Fetal alcohol [syndrome and fetal alcohol effect grants] disorder
funding.
[1665h. Pueblo substance abuse treatment project for San Juan Pueblo,
New Mexico.
[1665i. Thunder Child Treatment Center.
[1665j. Substance abuse counselor education demonstration project.
[1665k. Gila River alcohol and substance abuse treatment facility.
[1665l. Alaska Native drug and alcohol abuse demonstration project.]
712. Child sexual abuse and prevention treatment programs.
713. Behavioral health research.
714. Definitions.
1665m. Authorization of appropriations.
[SUBCHAPTER VI] TITLE VIII--MISCELLANEOUS
1671. Reports.
1672. Regulations.
[1673. Repealed.]
[1674. Leases with Indian tribes.]
803. Plan of implementation.
1675. Availability of funds.
1676. Limitation on use of funds appropriated to the Indian Health
Service.
[1677. Nuclear resource development health hazards.
[1678. Arizona as a contract health service delivery area.]
1679. Eligibility of California Indians.
[1680. California as a contract health service delivery area.
[1680a. Contract health facilities.
[1680b. National Health Service Corps.]
1680c. Health services for ineligible persons.
[1680d. Infant and maternal mortality; fetal alcohol syndrome.
[1680e. Contract health services for the Trenton Service Area.
[1680f. Indian Health Service and Department of Veterans Affairs health
facilities and services sharing.]
1680g. Reallocation of base resources.
[1680h. Demonstration projects for tribal management of health care
services.
[1680i. Child sexual abuse treatment programs.
[1680j. Tribal leasing.
[1680k. Home- and community-based care demonstration project.
[1680l. Shared services demonstration project.]
1680m. Results of demonstration projects.
810. Provision of services in Montana.
811. Moratorium.
812. Tribal employment.
813. Prime vendor.
814. Severability provisions
815. Establishment of National Bipartisan Commission on Indian Health
Care Entitlement.
816. Appropriations; availability.
817. Confidentiality of medical quality assurance records: qualified
immunity for participants.
[1680n. Priority for Indian reservations.]
1680o. Authorization of appropriations.
[1681. Omitted.
[1682. Subrogation of claims by Indian Health Service.
[1683. Indian Catastrophic Health Emergency Fund.]
GENERAL PROVISIONS
Sec. 1601. [Congressional f]Findings
[The] Congress finds the following:
[(a)] (1) Federal delivery of health services and funding
of Indian and Urban Indian Health Programs 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 Indians, as reflected in the
Constitution, treaties, Federal statutes and the course of
dealings of the United States with Indian Tribes and the United
States' [and] resulting government-to-government relationship
with Indian Tribes and trust responsibilit[y]ies and
obligations to[, the American] Indians [people].
(2) From the time of European occupation and colonization
through the 20th century, policies and practices of the United
States caused and/or contributed to the severe health
conditions of Indians.
(3) Through the cession of over 400,000,000 acres of land
to the United States in exchange for promises, often reflected
in treaties, of health care, Indian Tribes have secured a de
facto contract which entitles Indians to health care in
perpetuity, based on the moral, legal, and historic obligation
of the United States.
(4) The population growth of Indians that began in the
later part of the 20th century increases the need for Federal
health care services.
[(b)] (5) 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 regardless of where they
live to be raised to the highest possible level that is no less
than that of the general population and to [encourage] provide
for the maximum participation of Indian[s] Tribes, Tribal
Organizations, and Urban Indian Organizations in the planning,
delivery and management of those health services.
[(c)] (6) 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)] (7) Despite such services, the unmet health needs of
[the American] Indians [people are] remain alarmingly severe
and the health status of [the] Indians is far below the health
status [that] of the general population of the United States.
(8) The disparity to be addressed is formidable. For
example, Indians suffer a death rate for diabetes mellitus that
is 318 percent higher than the all races rate for the United
States, a pneumonia and influenza death rate 52 percent
greater, a tuberculosis death rate that is 650 percent greater,
and a death rate from alcoholism that is 670 percent higher
than that of the all races United States rate.
Sec. 1602. Declaration of [health objectives] National Indian Health
Policy
[(a) The] Congress hereby declares that it is the policy of
this Nation, in fulfillment of its special trust
responsibilities and legal obligations to [the American]
Indians--[people,]
(1) to assure the highest possible health status for
Indians [and urban Indians] and to provide all
resources necessary to effect that policy[.];
[(b) It is the intent of the Congress that the Nation meet
the following health status objectives with respect to Indians
and urban Indians by the year 2000:
[(1) Reduce coronary heart disease deaths to a level
of no more than 100 per 100,000.
[(2) Reduce the prevalence of overweight individuals
to no more than 30 percent.
[(3) Reduce the prevalence of anemia to less than 10
percent among children aged 1 through 5.
[(4) Reduce the level of cancer deaths to a rate of
no more than 130 per 100,000.
[(5) Reduce the level of lung cancer deaths to a rate
of nomore than 42 per 100,000.
[(6) Reduce the level of chronic obstructive
pulmonary disease related deaths to a rate of no more
than 25 per 100,000.
[(7) Reduce deaths among men caused by alcohol-
related motor vehicle crashes to no more than 44.8 per
100,000.
[(8) Reduce cirrhosis deaths to no more than 13 per
100,000.
[(9) Reduce drug-related deaths to no more than 3 per
100,000.
[(10) Reduce pregnancies among girls aged 17 and
younger to no more than 50 per 1,000 adolescents.
[(11) Reduce suicide among men to no more than 12.8
per 100,000.
[(12) Reduce by 15 percent the incidence of injurious
suicide attempts among adolescents aged 14 through 17.
[(13) Reduce to less than 10 percent the prevalence
of mental disorders among children and adolescents.
[(14) Reduce the incidence of child abuse or neglect
to less than 25.2 per 1,000 children under age 18.
[(15) Reduce physical abuse directed at women by male
partners to no more than 27 per 1,000 couples.
[(16) Increase years of healthy life to at least 65
years.
[(17) Reduce deaths caused by unintentional injuries
to no more than 66.1 per 100,000.
[(18) Reduce deaths caused by motor vehicle crashes
to no more than 39.2 per 100,000.
[(19) Among children aged 6 months through 5 years,
reduce the prevalence of blood lead levels exceeding 15
ug/dl and reduce to zero the prevalence of blood lead
levels exceeding 25 ug/dl.
[(20) Reduce dental caries (cavities) so that the
proportion of children with one or more caries (in
permanent or primary teeth) is no more than 45 percent
among children aged 6 through 8 and no more than 60
percent among adolescents aged 15.
[(21) Reduce untreated dental caries so that the
proportion of children with untreated caries (in
permanent or primary teeth) is no more than 20 percent
among children aged 6 through 8 and no more than 40
percent among adolescents aged 15.
[(22) Reduce to no more than 20 percent the
proportion of individuals aged 65 and older who have
lost all of their natural teeth.
[(23) Increase to at least 45 percent the proportion
of individuals aged 35 to 44 who have never lost a
permanent tooth due to the dental caries or periodontal
disease.
[(24) Reduce destructive periodontal disease to a
prevalence of no more than 15 percent among individuals
aged 35 to 44.
[(25) Increase to at least 50 percent the proportion
of children who have received protective sealants on
the occlusal (chewing) surfaces of permanent molar
teeth.
[(26) Reduce the prevalence of gingivitis among
individuals aged 35 to 44 to no more than 50 percent.
[(27) Reduce the infant mortality rate to no more
than 8.5 per 1,000 live births.
[(28) Reduce the fetal death rate (20 or more weeks
of gestation) to no more than 4 per 1,000 live births
plus fetal deaths.
[(29) Reduce the maternal mortality rate to no more
than 3.3 per 100,000 live births.
[(30) Reduce the incidence of fetal alcohol syndrome
to no more than 2 per 1,000 live births.
[(31) Reduce stroke deaths to no more than 20 per
100,000.
[(32) Reverse the increase in end-stage renal disease
(requiring maintenance dialysis or transplantation) to
attain an incidence of no more than 13 per 100,000.
[(33) Reduce breast cancer deaths to no more than
20.6 per 100,000 women.
[(34) Reduce deaths from cancer of the uterine cervix
to no more than 1.3 per 100,000 women.
[(35) Reduce colorectal cancer death to no more than
13.2 per 100,000.
[(36) Reduce to no more than 11 percent the
proportion of individuals who experience a limitation
in major activity due to chronic conditions.
[(37) Reduce significant hearing impairment to a
prevalence of no more than 82 per 1,000.
[(38) Reduce significant visual impairment to a
prevalence of no more than 30 per 1,000.
[(39) Reduce diabetes-related deaths to no more than
48 per 100,000.
[(40) Reduce diabetes to an incidence of no more than
2.5 per 1,000 and a prevalence of no more than 62 per
1,000.
[(41) Reduce the most severe complications of
diabetes as follows:
[(A) End-stage renal disease, 1.9 per 1,000.
[(B) Blindness, 1.4 per 1,000.
[(C) Lower extremity amputation, 4.9 per
1,000.
[(D) Perinatal mortality, 2 percent.
[(E) Major congenital malformations, 4
percent.
[(42) Confine annual incidence of diagnosed AIDS
cases to no more than 1,000 cases.
[(43) Confine the prevalence of HIV infection to no
more than 100 per 100,000.
[(44) Reduce gonorrhea to an incidence of no more
than 225 cases per 100,000.
[(45) Reduce chlamydia trachomatis infections, as
measured by a decrease in the incidence of
nongonococcal urethritis to no more than 170 cases per
100,000.
[(46) Reduce primary and secondary syphilis to an
incidence to no more than 10 cases per 100,000.
[(47) Reduce the incidence of pelvic inflammatory
disease, as measured by a reduction in hospitalization
for pelvic inflammatory disease to no more than 250 per
100,000 women aged 15 through 44.
[(48) Reduce viral hepatitis B infection to no more
than 40 per 100,000 cases.
[(49) Reduce indigenous cases of vaccine-preventable
diseases as follows:
[(A) Diphtheria among individuals aged 25 and
younger, 0.
[(B) Tetanus among individuals aged 25 and
younger, 0.
[(C) Polio (wild-type virus), 0.
[(D) Measles, 0.
[(E) Rubella, 0.
[(F) Congenital Rubella Syndrome, 0.
[(G) Mumps, 500.
[(H) Pertussis, 1,000.
[(50) Reduce epidemic-related pneumonia and influenza
deaths among individuals aged 65 and older to no more
than 7.3 per 100,000.
[(51) Reduce the number of new carriers of viral
hepatitis B among Alaska Natives to no more than 1
case.
[(52) Reduce tuberculosis to an incidence of no more
than 5 cases per 100,000.
[(53) Reduce bacterial meningitis to no more than 8
cases per 100,000.
[(54) Reduce infectious diarrhea by at least 25
percent among children.
[(55) Reduce acute middle ear infections among
children aged 4 and younger, as measured by days of
restricted activity or school absenteeism, to no more
than 105 days per 100 children.
[(56) Reduce cigarette smoking to a prevalence of no
more than 20 percent.
[(57) Reduce smokeless tobacco use by youth to a
prevalence of no more than 10 percent.
[(58) Increase to at least 65 percent the proportion
ofparents 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.
[(c) It is the intent of the Congress that the Nation
increase the proportion of all degrees in the health
professions and allied and associated health profession fields
awarded to Indians to 0.6 percent.
[(d) The Secretary shall submit to the President, for
inclusion in each report required to be transmitted to the
Congress under section 1671 of this title, a report on the
progress made in each area of the Service toward meeting each
of the objectives described in subsection (b) of this section.]
(2) to raise the health status of Indians by the year
2010 to at least the levels set forth in the goals
contained within the Healthy People 2010 or successor
objectives;
(3) to the greatest extent possible, to allow Indians
to set their own health care priorities and establish
goals that reflect their unmet needs;
(4) to increase the proportion of all degrees in the
health professions and allied and associated health
professions awarded to Indians so that the proportion
of Indian health professionals in each Service Area is
raised to at least the level of that of the general
population;
(5) to require meaningful consultation with Indian
Tribes, Tribal Organizations, and Urban Indian
Organizations to implement this Act and the national
policy of Indian self-determination; and
(6) to provide funding for programs and facilities
operated by Indian Tribes and Tribal Organizations in
amounts that are not less than the amounts provided to
programs and facilities operated directly by the
Service.
Sec. 1603. Definitions
For purposes of this [chapter] Act[--]:
(1) The term `accredited and accessible' means on or
near a reservation and accredited by a national or
regional organization with accrediting authority.
(2) The term `Area Office' means an administrative
entity including a program office, within the Service
through which services and funds are provided to the
Service Units within a defined geographic area.
(3) The term `Assistant Secretary' means the
Assistant Secretary of Indian Health.
(4) The term `behavioral health' means the blending
of substance (alcohol, drugs, inhalants, and tobacco)
abuse and mental illness prevention and treatment, for
the purpose of providing comprehensive services. This
definition can include the joint development of
substance abuse and mental illness treatment planning
and coordinated case management using a
multidisciplinary approach.
(5) The term `California Indians' shall mean those
Indians who are eligible for health services of the
Service pursuant to section 806.
(6) The term `community college' means--
(A) a tribal college or university, or
(B) a junior or community college.
(7) The term `contract health service' means health
services provided at the expense of the Service or a
Tribal Health Program by public or private medical
providers or hospitals, other than the Service Unit or
the Tribal Health Program at whose expense the services
are provided.
(8) The term `Department' means, unless otherwise
designated, the Department of Health and Human
Services.
(9) The term `disease prevention' means the
reduction,limitation, and prevention of disease and its
complications and reduction in the consequences of disease, including--
(A) controlling--
(i) development of diabetes;
(ii) high blood pressure;
(iii) infectious agents;
(iv) injuries;
(v) occupational hazards and
disabilities;
(vi) sexually transmittable diseases;
and
(vii) toxic agents; and
(B) providing--
(i) fluoridation of water; and
(ii) immunizations.
(10) The term `fund' or `funding' means the transfer
of moneys from the Department to any eligible entity or
individual under this Act by any legal means, including
Funding Agreements, contracts, grants, memoranda of
understanding, contracts pursuant to section 23 of the
Act of April 20, 1908 (25 U.S.C. 47; commonly known as
the `Buy Indian Act'), or otherwise. Any program
administered as a grant program one day before the date
of enactment may continue to be administered as a grant
program. This definition does not otherwise modify
grant programs, except that upon request of the Indian
Tribes or Tribal Organizations, discretionary grants
and all categories of awarded nonrecurring funding
shall be included in the Funding Agreement.
Discretionary grant funds shall be governed by all the
particular terms and conditions attached to such funds,
unless waived by the Secretary. All particular terms
and conditions attached to the discretionary grant
funds must be shown in the Funding Agreement. The use
of such grant funds shall be governed by the terms and
conditions set forth in the Funding Agreement and not
the substantive provisions of the Indian Self-
Determination and Education Assistance Act (25 U.S.C.
450 et seq.).
(11) The term `Funding Agreement' means any agreement
to transfer funds for the planning, conduct, and
administration of programs, services, functions, and
activities to Indian Tribes and Tribal Organizations
from the Secretary under the Indian Self-Determination
and Education Assistance Act (25 U.S.C. 450 et seq.).
(12) The term `health profession' means allopathic
medicine, family medicine, internal medicine,
pediatrics, geriatric medicine, obstetrics and
gynecology, podiatric medicine, nursing, public health
nursing, advanced practice 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.
(13) The term `health promotion' means--
(A) fostering social, economic,
environmental, and personal factors conducive
to health, including raising public awareness
about health matters and enabling the people to
cope with health problems by increasing their
knowledge and providing them with valid
information;
(B) encouraging adequate and appropriate
diet, exercise, and sleep;
(C) promoting education and work in
conformity with physical and mental capacity;
(D) making available suitable housing, safe
water, and sanitary facilities;
(E) improving the physical, economic,
cultural, psychological, and social
environment;
(F) promoting adequate opportunity for
spiritual, religious, and Traditional Health
Care Practices; and
(G) providing adequate and appropriate
programs, including, but not limited to--
(i) abuse prevention (mental and
physical);
(ii) community health;
(iii) community safety;
(iv) consumer health education;
(v) diet and nutrition;
(vi) immunization and other
prevention of communicable diseases,
including HIV/AIDS;
(vii) environmental health;
(viii) exercise and physical fitness;
(ix) avoidance of fetal alcohol
disorders;
(x) first aid and CPR education;
(xi) human growth and development;
(xii) injury prevention and personal
safety;
(xiii) behavioral health;
(xiv) monitoring of disease
indicators between health care provider
visits, through appropriate means,
including Internet-based health care
management systems;
(xv) personal health and wellness
practices;
(xvi) personal capacity building;
(xvii) prenatal, pregnancy, and
infant care;
(xviii) psychological well-being;
(xix) reproductive health and family
planning;
(xx) safe and adequate water;
(xxi) safe housing relative to
eliminating, reducing, or preventing
contaminants which create unhealthy
housing conditions;
(xxii) safe work environments;
(xxiii) stress control;
(xxiv) substance abuse;
(xxv) sanitary facilities;
(xxvi) sudden infant death syndrome
prevention;
(xxvii) tobacco use cessation and
reduction;
(xxviii) violence prevention; and
(xxix) such other activities
identified by the Service, a Tribal
Health Program, or an Urban Indian
Organization, to promote achievement of
any of the objectives described in
section 3(2).
(14) The term `Indian' 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 `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 April 30,
1908 (25 U.S.C. 47), commonly known as the `Buy
Indian Act'.
(16) 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.).
(17) 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)).
(18) The term `reservation' means any federally
recognized Indian Tribe's reservation, Pueblo, or
colony, including former reservations in Oklahoma,
Indian allotments, and Alaska Native Regions
established pursuant to the Alaska Native Claims
Settlement Act (25 U.S.C. 1601 et seq.).
[(a)] (19) The term [``]`Secretary['']', unless
otherwise designated, means the Secretary of Health and
Human Services.
[(b)] (20) The term [``]`Service['']' means the
Indian Health Service.
[(c) ``Indians'' or ``Indian'', unless otherwise
designated, means any person who is a member of an Indian
tribe, as defined in subsection (d) of this section, except
that, for the purpose of sections 1612 and 1613 of this title,
such terms shall mean any individual who (1), irrespective of
whether he or she lives on or near a reservation, is a member
of a tribe, band, or otherorganized group of Indians, including
those tribes, bands, or groups terminated since 1940 and those
recognized now or in the future by the State in which they reside, or
who is a descendant, in the first or second degree, of any such member,
or (2) is an Eskimo or Aleut or other Alaska Native, or (3) is
considered by the Secretary of the Interior to be an Indian for any
purpose, or (4) is determined to be an Indian under regulations
promulgated by the Secretary.
[(d) ``Indian tribe'' means any Indian tribe, band, nation,
or other organized group or community, including any Alaska
Native village or group or regional or village corporation as
defined in or established pursuant to the Alaska Native Claims
Settlement Act (85 Stat. 688) [43 U.S.C.A. Sec. 1601 et seq.],
which is recognized as eligible for the special programs and
services provided by the United States to Indians because of
their status as Indians.
[(e) ``Tribal organization'' means the elected governing
body of any Indian tribe or any legally established
organization of Indians which is controlled by one or more such
bodies or by a board of directors elected or selected by one or
more such bodies (or elected by the Indian population to be
served by such organization) and which includes the maximum
participation of Indians in all phases of its activities.]
(21) The term `Service Area' means the geographical
area served by each Area Office.
(22) 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.
(23) 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)).
(24) 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.
(25) The term `Traditional Health Care Practices'
means the application by Native healing practitioners
of the Native healing sciences (as opposed or in
contradistinction to Western healing sciences) which
embody the influences or forces of innate Tribal
discovery, history, description, explanation and
knowledge of the states of wellness and illness and
which call upon these influences or forces, including
physical, mental, and spiritual forces in the
promotion, restoration, preservation, and maintenance
of health, well-being, and life's harmony.
(26) 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)).
(27) 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 Funding Agreement with the Service
under the Indian Self-Determination and Education
Assistance Act (25 U.S.C. 450 et seq.).
(28) 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.).
(29) The term `Urban Center' means any community
which has a sufficient Urban Indian population with
unmet health needs to warrant assistance under title V
of this Act, as determined by the Secretary.
[(f) ``] (30) The term `Urban Indian['']' means any
individual who resides in an [u]Urban [c]Center[, as
defined in subsection (g) of this section,] and who
meets [one] 1 or more of the [four] following criteria:
[ in subsection (c)(1) though (4) of this section.]
(A) Irrespective of whether the individual
lives on or near a reservation, the individual
is a member of a tribe, band, or other
organized group of Indians, including those
tribes, bands, or groups terminated since 1940
and those tribes, bands, or groups that are
recognized by the States in which they reside,
or who is a descendant in the first or second
degree of any such member.
(B) The individual is an Eskimo, Aleut, or
other Alaskan 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.
(31) The term `Urban Indian Organization' means a
nonprofit corporate body that (A) is situated in an
Urban Center; (B) is governed by an Urban Indian-
controlled board of directors; (C) provides for the
participation of all interested Indian groups and
individuals; and (D) is capable of legally cooperating
with other public and private entities for the purpose
of performing the activities described in section
503(a).
[(g) ``Urban center'' means any community which has a
sufficient urban Indian population with unmet health needs to
warrant assistance under subchapter IV of this chapter, as
determined by the Secretary.
[(h) ``Urban Indian organization'' means a nonprofit
corporate body situated in an urban center, governed by an
urban Indian controlled board of directors, and providing for
the maximum participation of all interested Indian groups and
individuals, which body is capable of legally cooperating with
other public and private entities for the purpose of performing
the activities described in section 1653(a) of this title.
[(i) ``Area office'' means an administrative entity
including a program office, within the Indian Health Service
through which services and funds are provided to the service
units within a defined geographic area.
[(j) ``Service unit'' means--
[(1) an administrative entity within the Indian
Health Service, or]
[(2) a tribe or tribal organization operating health
care programs or facilities with funds from the Service
under the Indian Self-Determination Act [25 U.S.C.A.
Sec. 450f et seq.],
through which services are provided, directly or by contract,
to the eligible Indian population within a defined geographic
area.
[(k) ``Health promotion'' includes--
[(1) cessation of tobacco smoking,
[(2) reduction in the misuse of alcohol and drugs,
[(3) improvement of nutrition,
[(4) improvement in physical fitness,
[(5) family planning,
[(6) control of stress, and
[(7) pregnancy and infant care (including prevention
of fetal alcohol syndrome).
[(l) ``Disease prevention'' includes--
[(1) immunizations,
[(2) control of high blood pressure,
[(3) control of sexually transmittable diseases,
[(4) prevention and control of diabetes,
[(5) control of toxic agents,
[(6) occupational safety and health,
[(7) accident prevention,
[(8) fluoridation of water, and
[(9) control of infectious agents.
[(m) ``Service area'' means the geographical area served by
each area office.
[(n) ``Health profession'' means allopathic medicine,
family medicine, internal medicine, pediatrics, geriatric
medicine, obstetrics and gynecology, podiatric medicine,
nursing, public health nursing, dentistry, psychiatry,
osteopathy, optometry, pharmacy, psychology, public health,
social work, marriage and family therapy, chiropractic
medicine, environmental health and engineering, an allied
health profession, or any other health profession.
[(o) ``Substance abuse'' includes inhalant abuse.
[(p) ``FAE'' means fetal alcohol effect.
[(q) ``FAS'' means fetal alcohol syndrome.]
[SUBCHAPTER] TITLE I--INDIAN HEALTH, HUMAN RESOURCES, AND DEVELOPMENT
[PROFESSIONAL PERSONNEL]
Sec. 1611. [Congressional statement of p]Purpose
The purpose of this [subchapter] title is to increase, to
the maximum extent feasible, the number of Indians entering the
health professions and providing health services, and to assure
an [adequate] optimum supply of health professionals to the
Indian Health Programs [Service, Indian tribes, tribal
organizations,] and [u]Urban Indian [o]Organizations involved
in the provision of health care to Indians [people].
Sec. 1612. Health P[p]rofessions R[r]ecruitment P[p]rogram for Indians
(a) [Grants for Education and Training] In General.--
The Secretary, acting through the Service, shall make
[grants] funds available to public or nonprofit private health
or educational entities, Tribal Health Programs, or Urban
Indian Organizations [or Indian tribes or tribal organizations]
to assist such entities in meeting the costs of--
(1) identifying Indians with a potential for
education or training in the health professions and
encouraging and assisting them--
(A) to enroll in courses of study in such
health professions; or
(B) if they are not qualified to enroll in
any such courses of study, to undertake such
postsecondary education or training as may be
required to qualify them for enrollment;
(2) publicizing existing sources of financial aid
available to Indians enrolled in any course of study
referred to in paragraph (1) [of this subsection] or
who are undertaking training necessary to qualify them
to enroll in any such course of study; or
(3) establishing other programs which the Secretary
determines will enhance and facilitate the enrollment
of Indians in, and the subsequent pursuit and
completion by them of, courses of study referred to in
paragraph (1) [of this subsection].
(b) [Application for grant; submittal and approval;
preference; payment] Funding._
(1) Application.--Funds under this section shall
require that [No grant may be made under this section
unless] an application [therefor] has been submitted
to, and approved by, the Secretary. Such application
shall be in such form, submitted in such manner, and
contain such information, as the Secretary shall by
regulation prescribe pursuant to this Act. The
Secretary shall give a preference to applications
submitted by Tribal Health Programs or Urban Indian
Organizations [Indian tribes or tribal organizations].
(2) Amount of funds; payment.--The amount of funds
provided to entities [any grant] under this section
shall be determined by the Secretary. Payments pursuant
to [grants under] this section may be made in advance
or by way of reimbursement, and at such intervals and
on such conditions as [the Secretary finds necessary.]
provided for in regulations issued pursuant to this
Act. To the extent not otherwise prohibited by law,
funding commitments shall be for 3 years, as provided
in regulations issued pursuant to this Act.
(c) Definition of Indian.--For purposes of this section and
sections 103 and 104, the term `Indian' shall, in addition to
the meaning given that term in section 4, also mean any
individual who is an Urban Indian.
Sec. 1613. Health P[p]rofessions P[p]reparatory S[s]cholarship
P[p]rogram for Indians
(a) [Requirements] Scholarships Authorized._
The Secretary, acting through the Service, shall provide
scholarships [make scholarship grants] to Indians who--
(1) have successfully completed their high school
education or high school equivalency; and
(2) have demonstrated the potential [capability] to
successfully complete courses of study in the health
professions.
(b) Purposes.--[and duration of grants; preprofessional and
pregraduate education]
Scholarships provided [grants made] pursuant to this
section shall be for the following purposes:
(1) Compensatory preprofessional education of any
recipient [grantee], such scholarship not to exceed
[two] 2 years on a full-time basis (or the part-time
equivalent thereof, as determined by the Secretary
pursuant to regulations issued under this Act).
(2) Pregraduate education of any recipient [grantee]
leading to a baccalaureate degree in an approved course
of study preparatory to a field of study in a health
profession, suchscholarship not to exceed 4 years [(or
the part-time equivalent thereof, as determined by the Secretary)]. An
extension of up to 2 years (or the part-time equivalent thereof, as
determined by the Secretary pursuant to regulations issued pursuant to
this Act) may be approved.
(c) [Covered expenses] Other Conditions._
Scholarships [grants made] under this section--
(1) may cover costs of tuition, books,
transportation, board, and other necessary related
expenses of a recipient [grantee] while attending
school[.];
(2) shall not be denied solely on the basis of the
applicant's scholastic achievement if such applicant
has been admitted to, or maintained good standing at,
an accredited institution; and
(3) shall not be denied solely by reason of such
applicant's eligibility for assistance or benefits
under any other Federal program.
[(d) Basis for denial of assistance
[The Secretary shall not deny scholarship assistance to an
eligible applicant under this section solely on the basis of
the applicant's scholastic achievement if such applicant has
been admitted to, or maintained good standing at, an accredited
institution.
[(e) Eligibility for assistance under other Federal
programs
[The Secretary shall not deny scholarship assistance to an
eligible applicant under this section solely by reason of such
applicant's eligibility for assistance or benefits under any
other Federal program.]
Sec. 1613a. Indian H[h]ealth P[p]rofessions S[s]cholarships
(a) In General.--[authority]
(1) Authority.--[In order to provide health
professionals to Indians, Indian tribes, tribal
organizations, and urban Indian organizations, t]The
Secretary, acting through the Service [and in
accordance with this section], shall make scholarships
[grants] to Indians who are enrolled full or part time
in [appropriately] accredited schools [and] pursuing
courses of study in the health professions. Such
scholarships shall be designated Indian Health
Scholarships and shall be made in accordance with
section 338A of the Public Health Services Act (42
U.S.C. 254l) [of Title 42], except as provided in
subsection (b) of this section.
(2) Allocation by formula.--Except as provided in
paragraph (3), the funding authorized by this section
shall be allocated by Service Area by a formula
developed in consultation with Indian Tribes, Tribal
Organizations, and Urban Indian Organizations. Such
formula shall consider the human resource development
needs in each Service Area.
(3) Continuity of prior scholarships.--Paragraph (2)
shall not apply with respect to individual recipients
of scholarships provided under this section (as in
effect 1 day prior to the date of the enactment of the
Indian Health Care Improvement Act Amendments of 2004)
until such time as the individual completes the course
of study that is supported through such scholarship.
(4) Certain delegation not allowed.--The
administration of this section shall be a
responsibility of the Assistant Secretary and shall not
be delegated in a Funding Agreement.
(b) [Recipients; a] Active D[d]uty S[s]ervice
O[o]bligation.--
[(1) The Secretary, acting through the Service, shall
determine who shall receive scholarships under
subsection (a) of this section and shall determine the
distribution of such scholarships among such health
professions on the basis of the relative needs of
Indians for additional service in such health
professions.
[(2) An individual shall be eligible for a
scholarship under subsection (a) of this section in any
year in which such individual is enrolled full or part
time in a course of study referred to in subsection (a)
of this section.]
(1)[(3)(A)] Obligation met.--The [A]active duty
service obligation under a written contract with the
Secretary under section 338A of the Public Health
Service Act (42 U.S.C. 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 on an
equivalent year-for-year obligation, by service in one
or more of the following:[--]
(A)[(i) i]In an [the] Indian Health Program.
[Service;]
[(ii) in a program conducted under a
contractentered into under the Indian
Self-Determination Act [25 U.S.C.A. Sec. 450f et seq.];]
(B)[(iii) i]In a program assisted under title
V [subchapter IV] of this Act. [chapter;]
(C)[(iv) i]In the private practice of the
applicable profession if, as determined by the
Secretary, in accordance with guidelines
promulgated by the Secretary, such practice is
situated in a physician or other health
professional shortage area and addresses the
health care needs of a substantial number of
Indians. [; or]
(2)[(B)] Obligation deferred.--At the request of any
individual who has entered into a contract referred to
in paragraph (1) [subparagraph (A)] and who receives a
degree in medicine (including osteopathic or allopathic
medicine), dentistry, optometry, podiatry, or pharmacy,
the Secretary shall defer the active duty service
obligation of that individual under that contract, in
order that such individual may complete any internship,
residency, or other advanced clinical training that is
required for the practice of that health profession,
for an appropriate period (in years, as determined by
the Secretary), subject to the following conditions:
(A)[(i)] No period of internship, residency,
or other advanced clinical training shall be
counted as satisfying any period of obligated
service [that is required] under this
subsection.
(B)[(ii)] The active duty service obligation
of that individual shall commence not later
than 90 days after the completion of that
advanced clinical training (or by a date
specified by the Secretary).
(C)[(iii)] The active duty service obligation
will be served in the health profession of that
individual[,] in a manner consistent with
paragraph (1) [clauses (i) through (v) of
subparagraph (A)].
(D)[(C)] A recipient of a[n Indian Health
S]scholarship under this section may, at the
election of the recipient, meet the active duty
service obligation described in paragraph (1)
[subparagraph (A)] by service in a program
specified under [in] that paragraph
[subparagraph] that--
(i) is located on the reservation of
the Indian T[t]ribe in which the
recipient is enrolled; or
(ii) serves the Indian T[t]ribe in
which the recipient is enrolled.
(3)[(D)] Priority when making assignments.--Subject
to paragraph (2) [subparagraph (C)], the Secretary, in
making assignments of Indian Health Scholarship
recipients required to meet the active duty service
obligation described in paragraph (1) [subparagraph
(A)], shall give priority to assigning individuals to
service in those programs specified in paragraph (1)
[subparagraph (A)] that have a need for health
professionals to provide health care services as a
result of individuals having breached contracts entered
into under this section.
(c)[(4)] Part-Time Students.--In the case of an individual
receiving a scholarship under this section who is enrolled part
time in an approved course of study--
(1)[(A) such scholarship shall be for a period of
years not to exceed the] part-time equivalent of 4
years, as determined by the Area Office [Secretary];
(2)[(B)] the period of obligated service described in
subsection (b)(1) [paragraph (3)(A)] shall be equal to
the greater of--
(A)[(i)] the part-time equivalent of 1 [one]
year for each year for which the individual was
provided a scholarship (as determined by the
Area Office [Secretary]); or
(B)[(ii) two] 2 years; and
(3)[(C)] the amount of the monthly stipend specified
in section 338A(g)(1)(B) of the Public Health Service
Act (42 U.S.C. 254l(g)(1)(B)) [of Title 42] shall be
reduced pro rata (as determined by the Secretary) based
on the number of hours such student is enrolled.
(d) Breach of Contract.--
(1) Specified breaches.--An individual shall be
liable to the United States for the amount which has
been paid to the individual, or on behalf of the
individual, under a contract entered into with the
Secretary under this section on or after the date of
the enactment of the Indian Health Care Improvement Act
Amendments of 2004 if that individual--
[(5)(A) An individual who has, on or after October
29, 1992, entered into a written contract with the
Secretary under this section and who--]
(A)[(i)] fails to maintain an acceptable
level of academic standing in the educational
institution in which he or she is enrolled
(such level determined by the educational
institution under regulations of the
Secretary)[,];
(B)[(ii)] is dismissed from such educational
institution for disciplinary reasons[,];
(C)[(iii)] voluntarily terminates the
training in such an educational institution for
which he or she is provided a scholarship under
such contract before the completion of such
training[,]; or
(D)[(iv)] fails to accept payment, or
instructs the educational institution in which
he or she is enrolled not to accept payment, in
whole or in part, of a scholarship under such
contract, in lieu of any service obligation
arising under such contract[, shall be liable
to the United States for the amount which has
been paid to him, on his behalf, under the
contract].
(2)[(B)] Other breaches.--If for any reason not
specified in paragraph (1) [subparagraph (A)] an
individual breaches a [his] written contract by failing
either to begin such individual's service obligation
required under such contract [this section] or to
complete such service obligation, the United States
shall be entitled to recover from the individual an
amount determined in accordance with the formula
specified in subsection (l) of section 110 [1616a of
this title] in the manner provided for in such
subsection.
(3)[(C)] Cancellation upon death of recipient.--Upon
the death of an individual who receives an Indian
Health Scholarship, any obligation of that individual
for service or payment that relates to that scholarship
shall be canceled.
(4)[(D)] Waivers and suspensions.--The Secretary
shall provide for the partial or total waiver or
suspension of any obligation of service or payment of a
recipient of an Indian Health Scholarship if the
Secretary, in consultation with the Area Office, Indian
Tribes, Tribal Organizations, and Urban Indian
Organizations, determines that--
(A)[(i)] it is not possible for the recipient
to meet that obligation or make that payment;
(B)[(ii)] requiring that recipient to meet
that obligation or make that payment would
result in extreme hardship to the recipient; or
(C)[(iii)] the enforcement of the requirement
to meet the obligation or make the payment
would be unconscionable.
(5)[(E)] Extreme hardship.--Notwithstanding any other
provision of law, in any case of extreme hardship or
for other good cause shown, the Secretary may waive, in
whole or in part, the right of the United States to
recover funds made available under this section.
(6)[(F)] Bankruptcy.--Notwithstanding any other
provision of law, with respect to a recipient of an
Indian Health Scholarship, no obligation for payment
may be released by a discharge in bankruptcy under
[T]title 11, United States Code, unless that discharge
is granted after the expiration of the 5-year period
beginning on the initial date on which that payment is
due, and only if the bankruptcy court finds that the
nondischarge of the obligation would be unconscionable.
[(c) Placement Office
[The Secretary shall, acting through the Service, establish
a Placement Office to develop and implement a national policy
for the placement, to available vacancies within the Service,
of Indian Health Scholarship recipients required to meet the
active duty service obligation prescribed under section 254m of
Title 42 without regard to any competitive personnel system,
agency personnel limitation, or Indian preference policy.]
Sec. 105. American Indians into Psychology Program
(a) Grants Authorized.--The Secretary, acting through the
Service, shall provide funding grants to at least 3 colleges
and universities for the purpose of developing and maintaining
Indian psychology career recruitment programs as a means of
encouraging Indians to enter the mental 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
pursuantto this Act for the competitive awarding of funds
provided under this section.
(d) Conditions of Grant.--Applicants under this section
shall agree to provide a program which, at a minimum--
(1) provides outreach and recruitment for the health
professions to Indian communities including elementary,
secondary, and accredited and accessible community
colleges that will be served by the program;
(2) incorporates a program advisory board comprised
of representatives from the tribes and communities that
will be served by the program;
(3) provides summer enrichment programs to expose
Indian students to the various fields of psychology
through research, clinical, and experimental
activities;
(4) provides stipends to undergraduate and graduate
students to pursue a career in psychology;
(5) develops affiliation agreements with tribal
colleges and universities, the Service, university
affiliated programs, and other appropriate accredited
and accessible entities to enhance the education of
Indian students;
(6) to the maximum extent feasible, uses existing
university tutoring, counseling, and student support
services; and
(7) to the maximum extent feasible, employs qualified
Indians in the program.
(e) Active Duty Service Requirement.--The active duty
service obligation prescribed under section 338C of the Public
Health Service Act (42 U.S.C. 254m) shall be met by each
graduate who receives a stipend described in subsection (d)(4)
that is funded under this section. Such obligation shall be met
by service--
(1) in an Indian Health Program;
(2) in a program assisted under title V of this Act;
or
(3) in the private practice of psychology if, as
determined by the Secretary, in accordance with
guidelines promulgated by the Secretary, such practice
is situated in a physician or other health professional
shortage area and addresses the health care needs of a
substantial number of Indians.
Sec. 106. Funding for Tribes for Scholarship Programs
(a) In General.--
(1) Funding authorized.--The Secretary, acting
through the Service, shall make funds available to
Tribal Health Programs for the purpose of providing
scholarships for Indians to serve as health
professionals in Indian communities.
(2) Amount.--Amounts available under paragraph (1)
for any fiscal year shall not exceed 5 percent of the
amounts available for each fiscal year for Indian
Health Scholarships under section 104.
(3) Application.--An application for funds 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
funds 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 one of the health professions contemplated by
this Act.
(d) Contract.--In providing scholarships under subsection
(b), the Secretary and the Tribal Health Program shall enter
into a written contract with each recipient of such
scholarship. Such contract shall--
(1) obligate such recipient to provide service in an
Indian Health Program or Urban Indian Organization, in
the same Service Area where the Tribal Health Program
providing the scholarship is located, for--
(A) a number of years for which the
scholarship is provided (or the part-time
equivalent thereof, as determined by the
Secretary), or for a period of 2 years,
whichever period is greater; or
(B) such greater period of time as the
recipient and the Tribal Health Program may
agree;
(2) provide that the amount of the scholarship--
(A) may only be expended for--
(i) tuition expenses, other
reasonable educational expenses, and
reasonable living expenses incurred in
attendance at the educational
institution; and
(ii) payment to the recipient of a
monthly stipend of not more than the
amount authorized by section
338(g)(1)(B) of the Public Health
Service Act (42 U.S.C. 254m(g)(1)(B)),
such amount to be reduced pro rata (as
determined by the Secretary) based on
the number of hours such student is
enrolled; and 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 this clause; and
(B) may not exceed, for any year of
attendance for which the scholarship is
provided, the total amount required for the
year for the purposes authorized in
subparagraph (A);
(3) require the recipient of such scholarship to
maintain an acceptable level of academic standing as
determined by the educational institution in accordance
with regulations issued pursuant to this Act; and
(4) require the recipient of such scholarship to meet
the educational and licensure requirements appropriate
to each health profession.
(e) Breach of Contract.--
(1) Specific breaches.--An individual who has entered
into a written contract with the Secretary and a Tribal
Health Program under subsection (d) shall be liable to
the United States for the Federal share of the amount
which has been paid to him or her, or on his or her
behalf, under the contract if that individual--
(A) fails to maintain an acceptable level of
academic standing in the educational
institution in which he or she is enrolled
(such level as determined by the educational
institution under regulations of the
Secretary);
(B) is dismissed from such educational
institution for disciplinary reasons;
(C) voluntarily terminates the training in
such an educational institution for which he or
she is provided a scholarship under such
contract before the completion of such
training; or
(D) fails to accept payment, or instructs the
educational institution in which he or she is
enrolled not to accept payment, in whole or in
part, of a scholarship under such contract, in
lieu of any service obligation arising under
such contract.
(2) Other breaches.--If for any reason not specified
in paragraph (1), an individual breaches a written
contract by failing to either begin such individual's
service obligation required under such contract or to
complete such service obligation, the United States
shall be entitled to recover from the individual an
amount determined in accordance with the formula
specified in subsection (l) of section 110 in the
manner provided for in such subsection.
(3) Cancellation upon death of recipient.--Upon the
death of an individual who receives an Indian Health
Scholarship, any outstanding obligation of that
individual for service or payment that relates to that
scholarship shall be canceled.
(4) Information.--The Secretary may carry out this
subsection on the basis of 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 intoan
appropriate agreement with the State agency that administers the State
plan for medical assistance under title XIX, or the State child health
plan under title XXI, of such Act to provide service to individuals
entitled to medical assistance or child health assistance,
respectively, under the plan.
(g) Continuance of Funding.--The Secretary shall make
payments under this section to a Tribal Health Program for any
fiscal year subsequent to the first fiscal year of such
payments unless the Secretary determines that, for the
immediately preceding fiscal year, the Tribal Health Program
has not complied with the requirements of this section.
Sec. 1614. Indian H[h]ealth S[s]ervice E[e]xtern P[p]rograms
(a) Employment Preference.--[of scholarship grantees during
nonacademic periods] Any individual who receives a scholarship
pursuant to section 104 or 106 shall be given preference for
employment in the Service, or may be employed by a Tribal
Health Program or an Urban Indian Organization, or other
agencies of the Department as available, during any nonacademic
period of the year.
(b) Not Counted Toward Active Duty Service Obligation.--
[Any individual who receives a scholarship grant pursuant
to section 1613a of this title shall be entitled to employment
in the Service during any nonacademic period of the year.]
Periods of employment pursuant to this subsection shall not be
counted in determining [the] fulfillment of the service
obligation incurred as a condition of the scholarship [grant].
(c) Timing; Length of Employment.--
[(b) Employment of medical and other students during
nonacademic periods]
Any individual enrolled in a program, including a high
school program, authorized under section 102(a) [course of
study in the health professions] may be employed by the Service
or by a Tribal Health Program or an Urban Indian Organization
during any nonacademic period of the year. Any such employment
shall not exceed 120 [one hundred and twenty] days during any
calendar year.
(d) Nonapplicability of Competitive Personnel System.--
[(c) Employment without regard to competitive personnel
system or agency personnel limitation; compensation]
Any employment pursuant to this section shall be made
without regard to any competitive personnel system or agency
personnel limitation and to a position which will enable the
individual so employed to receive practical experience in the
health profession in which he or she is engaged in study. Any
individual so employed shall receive payment for his or her
services comparable to the salary he or she would receive if he
or she were employed in the competitive system. Any individual
so employed shall not be counted against any employment ceiling
affecting the Service or the Department [of Health and Human
Services].
Sec. 1615. Continuing E[e]ducation A[a]llowances
[(a) Discretionary authority; scope of activities]
In order to encourage health professionals, including
community health representatives and emergency medical
technicians, [physicians, dentists, nurses, and other health
professionals] to join or continue in an Indian Health Program
or an Urban Indian Organization [the Service] and to provide
their services in the rural and remote areas where a
significant portion of [the] Indians [people] reside[s], the
Secretary, acting through the Service, may provide allowances
to health professionals employed in an Indian Health Program or
an Urban Indian Organization [the Service] to enable them for a
period of time each year prescribed by regulation of the
Secretary to take leave of their duty stations for professional
consultation and refresher training courses.
[(b) Limitation
[Of amounts appropriated under the authority of this
subchapter for each fiscal year to be used to carry out this
section, not more than $1,000,000 may be used to establish
postdoctoral training programs for health professionals.]
Sec. 1616. Community Health Representative Program
(a) In General.--Under the authority of the Act of November
2, 1921 (25 U.S.C. 13) (commonly [, popularly] known as the
Snyder Act), the Secretary, acting through the Service, shall
maintain a Community Health Representative Program under which
Indian Health Programs [the Service]--
(1) provide[s] for the training of Indians as
community health representatives; [health
paraprofessionals,] and
(2) use[s] such community health
representatives[paraprofessionals] in the provision of health care,
health promotion, and disease prevention services to Indian
communities.
(b) Duties._The [Secretary, acting through the] Community
Health Representative Program of the Service, shall--
(1) provide a high standard of training for
[paraprofessionals to C]community [H]health
[R]representatives to ensure that the [C]community
[H]health [R]representatives provide quality health
care, health promotion, and disease prevention services
to the Indian communities served by [such] the
Program[,];
(2) in order to provide such training, develop and
maintain a curriculum that--
(A) combines education in the theory of
health care with supervised practical
experience in the provision of health care[,];
and
(B) provides instruction and practical
experience in health promotion and disease
prevention activities, with appropriate
consideration given to lifestyle factors that
have an impact on Indian health status, such as
alcoholism, family dysfunction, and poverty[,];
(3) maintain a system which identifies the needs of
[C]community [H]health [R]representatives for
continuing education in health care, health promotion,
and disease prevention, and develop [maintain] programs
that meet the needs for [such] continuing education[,];
(4) maintain a system that provides close supervision
of Community Health Representatives[,];
(5) maintain a system under which the work of
Community Health Representatives is reviewed and
evaluated[,]; and
(6) promote [t]Traditional [h]Health [c]Care
[p]Practices of the Indian [t]Tribes served consistent
with the Service standards for the provision of health
care, health promotion, and disease prevention.
Sec. 1616a. Indian Health Service Loan Repayment Program
(a) Establishment
[(1)] The Secretary, acting through the Service,
shall establish and administer a program to be known as
the [Indian Health] Service Loan Repayment Program
(hereinafter referred to as the ``Loan Repayment
Program'') in order to ensure [assure] an adequate
supply of trained health professionals necessary to
maintain accreditation of, and provide health care
services to Indians through, Indian [h]Health
[p]Programs and Urban Indian Organizations.
[(2) For the purposes of this section--
[(A) the term ``Indian health program'' means
any health program or facility funded, in whole
or part, by the Service for the benefit of
Indians and administered--
[(i) directly by the Service;
[(ii) by any Indian tribe or tribal
or Indian organization pursuant to a
contract under--
[(I) the Indian Self-
Determination Act [25 U.S.C.A.
Sec. 450f et seq.], or
[(II) section 23 of the Act
of April 30, 1908 (25 U.S.C.
47), popularly known as the
``Buy-Indian'' Act; or
[(iii) by an urban Indian
organization pursuant to subchapter IV
of this chapter; and
[(B) the term ``State'' has the same meaning
given such term in section 254d(i)(4) of Title
42.]
(b) Eligible Individuals.--[Eligibility]
To be eligible to participate in the Loan Repayment
Program, an individual must--
(1)(A) be enrolled--
(i) in a course of study or program in an
accredited institution[,] (as determined by the
Secretary under section 338B(b)(1)(c)(i) of the
Public Health Service Act (42 U.S.C. 254l-
1(b)(1)(c)(i)))[, within any State] and be
scheduled to complete such course of study in
the same year such individual applies to
participate in such program; or
(ii) in an approved graduate training program
in a health profession; or
(B) have--
(i) a degree in a health profession; and
(ii) a license to practice a health
profession [in a State];
(2)(A) be eligible for, or hold, an appointment as a
commissioned officer in the Regular or Reserve Corps of
the Public Health Service;
(B) be eligible for selection for civilian service in
the Regular or Reserve Corps of the Public Health
Service;
(C) meet the professional standards for civil service
employment in the [Indian Health] Service; or
(D) be employed in an Indian [h]Health [p]Program or
Urban Indian Organization without a service obligation;
and
(3) submit to the Secretary an application for a
contract described in subsection (e) [(f) of this
section].
(c) Application [and Contract Forms].--
(1) Information to be included with forms.--In
disseminating application forms and contract forms to
individuals desiring to participate in the Loan
Repayment Program, the Secretary shall include with
such forms a fair summary of the rights and liabilities
of an individual whose application is approved (and
whose contract is accepted) by the Secretary, including
in the summary a clear explanation of the damages to
which the United States is entitled under subsection
(1) [of this section] in the case of the individual's
breach of the contract. The Secretary shall provide
such individuals with sufficient information regarding
the advantages and disadvantages of service as a
commissioned officer in the Regular or Reserve Corps of
the Public Health Service or a civilian employee of the
[Indian Health] Service to enable the individual to
make a decision on an informed basis.
(2) Clear language.--The application form, contract
form, and all other information furnished by the
Secretary under this section shall be written in a
manner calculated to be understood by the average
individual applying to participate in the Loan
Repayment Program.
(3) Timely availability of forms.--The Secretary
shall make such application forms, contract forms, and
other information available to individuals desiring to
participate in the Loan Repayment Program on a date
sufficiently early to ensure that such individuals have
adequate time to carefully review and evaluate such
forms and information.
(d) Priorities.--[Vacancies; priority]
(1) List.--Consistent with subsection (k) [paragraph
(3)], the Secretary[, acting through the Service and in
accordance with subsection (k), of this section,] shall
annually--
(A) identify the positions in each Indian
[h]Health [p]Program or Urban Indian
Organization for which there is a need or a
vacancy[,]; and
(B) rank those positions in order of
priority.
(2) Approvals.--Notwithstanding [Consistent with] the
priority determined under paragraph (1), the Secretary,
in determining which applications under the Loan
Repayment Program to approve (and which contracts to
accept), shall--
(A) give first priority to applications made
by individual Indians; and
(B) after making determinations on all
applications submitted by individual Indians as
required under subparagraph (A), give priority
to--
(i) individuals recruited through the
efforts of an Indian Health Program or
Urban Indian Organization; and [tribes
or tribal or Indian organizations.]
(ii) other individuals based on the
priority rankings under paragraph (1).
[(3)(A) Subject to subparagraph (B), of the total
amounts appropriated for each of the fiscal years 1993,
1994, and 1995 for loan repayment contracts under this
section, the Secretary shall provide that--
[(i) not less than 25 percent be provided to
applicants who are nurses, nurse practitioners,
or nurse midwives; and
[(ii) not less than 10 percent be provided to
applicants who are mental health professionals
(other than applicants described in clause
(i)).
[(B) The requirements specified in clause (i) or
clause (ii) of subparagraph (A) shall not apply if the
Secretary does not receive the number of applications
from the individuals described in clause (i) or clause
(ii), respectively, necessary to meet such
requirements.]
(e) Recipient Contracts.--[Approval]
(1) Contract required.--An individual becomes a
participant in the Loan Repayment Program only upon the
Secretary and the individual entering into a written
contract described in paragraph (2) [subsection (f) of
this section].
(2) Contents of contract.--[The Secretary shall
provide written notice to an individual promptly on--
[(A) the Secretary's approving, under
paragraph (1), of the individual's
participation in the Loan Repayment Program,
including extensions resulting in an aggregate
period of obligated service in excess of 4
years; or
[(B) the Secretary's disapproving an
individual's participation in such Program.
[(f) Contract terms]
The written contract referred to in this section
between the Secretary and an individual shall contain--
(A)[(1)] an agreement under which--
(i)[(A)] subject to subparagraph
(C)[(3)], the Secretary agrees--
(I)[(i)] to pay loans on
behalf of the individual in
accordance with the provisions
of this section[,]; and
(II)[(ii)] to accept (subject
to the availability of
appropriated funds for carrying
out this section) the
individual into the Service or
place the individual with a
Tribal Health Program or Urban
Indian Organization [tribe or
Indian organization] as
provided in clause (ii)(III);
[subparagraph (B)(iii),] and
(ii)[(B)] subject to subparagraph
(C)[(3)], the individual agrees--
(I)[(i)] to accept loan
payments on behalf of the
individual;
(II)[(ii)] in the case of an
individual described in
subsection (b)(1)--
(aa)[(I)] to maintain
enrollment in a course
of study or training
described in subsection
(b)(1)(A) [of this
section] until the
individual completes
the course of study or
training[,]; and
(bb)[(II)] while
enrolled in such course
of study or training,
to maintain an
acceptable level of
academic standing (as
determined under
regulations of the
Secretary by the
educational institution
offering such course of
study or training); and
(III)[(iii)] to serve for a
time period (hereinafter in
this section referred to as the
[``]`period of obligated
service'['']) equal to 2 years
or such longer period as the
individual may agree to serve
in the full-time clinical
practice of such individual's
profession in an Indian
[h]Health [p]Program or Urban
Indian Organization to which
the individual may be assigned
by the Secretary;
(B)[(2)] a provision permitting the Secretary
to extend for such longer additional periods,
as the individual may agree to, the period of
obligated service agreed to by the individual
under subparagraph (A)(ii)(III) [paragraph
(1)(B)(iii)];
(C)[(3)] a provision that any financial
obligation of the United States arising out of
a contract entered into under this section and
any obligation of the individual which is
conditioned thereon is contingent upon funds
being appropriated for loan repayments under
this section;
(D)[(4)] a statement of the damages to which
the United States is entitled under subsection
(1) [of this section] for the individual's
breach of the contract; and
(E)[(5)] such other statements of the rights
and liabilities of the Secretary and of the
individual, not inconsistent with this section.
(f) Deadline for Decision on Application.--The Secretary
shall provide written notice to an individual within 21 days
on--
(1) the Secretary's approving, under subsection
(e)(1), of the individual's participation in the Loan
Repayment Program, including extensions resulting in an
aggregate period of obligated service in excess of 4
years; or
(2) the Secretary's disapproving an individual's
participation in such Program.
(g) Payments.--[Loan repayment purposes; maximum amount;
tax liability reimbursement; schedule of payments]
(1) In general.--A loan repayment provided for an
individual under a written contract under the Loan
Repayment Program shall consist of payment, in
accordance with paragraph (2), on behalf of the
individual of the principal, interest, and related
expenses on government and commercial loans received by
the individual regarding the undergraduate or graduate
education of the individual (or both), which loans were
made for--
(A) tuition expenses;
(B) all other reasonable educational
expenses, including fees, books, and laboratory
expenses, incurred by the individual; and
(C) reasonable living expenses as determined
by the Secretary.
(2)[(A)] Amount.--For each year of obligated service
that an individual contracts to serve under subsection
(e),[(f) of this section] the Secretary may pay up to
$35,000 [(]or an amount equal to the amount specified
in section 338B(g)(2)(A) of the Public Health Service
Act, whichever is more, [254l-1(g)(2)(A) of Title 42)]
on behalf of the individual for loans described in
paragraph (1). In making a determination of the amount
to pay for a year of such service by an individual, the
Secretary shall consider the extent to which each such
determination--
(A)[(i)] affects the ability of the Secretary
to maximize the number of contracts that can be
provided under the Loan Repayment Program from
the amounts appropriated for such contracts;
(B)[(ii)] provides an incentive to serve in
Indian [h]Health [p]Programs and Urban Indian
Organizations with the greatest shortages of
health professionals; and
(C)[(iii)] provides an incentive with respect
to the health professional involved remaining
in an Indian [h]Health [p]Program or Urban
Indian Organization with such a health
professional shortage, and continuing to
provide primary health services, after the
completion of the period of obligated service
under the Loan Repayment Program.
(3)[(B)] Timing.--Any arrangement made by the
Secretary for the making of loan repayments in
accordance with this subsection shall provide that any
repayments for a year of obligated service shall be
made no later than the end of the fiscal year in which
the individual completes such year of service.
(4)[(3)] For the purpose of providing reimbursements
for tax liability resulting from payments 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 not
less than 20 percent and not more than 39
percent of the total amount of loan repayments
made for the taxable year involved; and
(B) may make such additional payments as the
Secretary determines to be appropriate with
respect to such purpose.
(5)[(4)] Payment Schedule.--The Secretary may enter
into an agreement with the holder of any loan for which
payments are made under the Loan Repayment Program to
establish a schedule for the making of such payments.
(h) Employment Ceiling.--[Effect on employment ceiling of
Department of Health and Human Services]
Notwithstanding any other provision of law, individuals who
have entered into written contracts with the Secretary under
this section[, while undergoing academic training,] shall not
be counted against any employment ceiling affecting the
Department [of Health and Human Services] while those
individuals are undergoing academic training.
(i) Recruitment.--[Recruiting programs]
The Secretary shall conduct recruiting programs for the
Loan Repayment Program and other [health professional programs
of the] Service manpower programs at educational institutions
training health professionals or specialists identified in
subsection (a) [of this section].
(j) Applicability of Law.--[Prohibition of assignment to
other government departments]
Section 214 of the Public Health Service Act (42 U.S.C.
215) [215 of Title 42] shall not apply to individuals during
their period of obligated service under the Loan Repayment
Program.
(k) Assignment of Individuals.--[Staff needs of health
programs administered by Indian tribes]
The Secretary, in assigning individuals to serve in Indian
[h]Health [p]Programs or Urban Indian Organizations pursuant
tocontracts entered into under this section, shall--
(1) ensure that the staffing needs of Tribal [Indian
h]Health [p]Programs and Urban Indian Organizations
[administered by an Indian tribe or tribal or health
organization] receive consideration on an equal basis
with programs that are administered directly by the
Service; and
(2) give priority to assigning individuals to Indian
[h]Health [p]Programs and Urban Indian Organizations
that have a need for health professionals to provide
health care services as a result of individuals having
breached contracts entered into under this section.
(l) Breach of Contract.--[Voluntary termination of study or
dismissal from educational institution; collection of damages]
(1) Specific breaches.--An individual who has entered
into a written contract with the Secretary under this
section and has not received a waiver under subsection
(m) shall be liable, in lieu of any service obligation
arising under such contract, to the United States for
the amount which has been paid on such individual's
behalf under the contract if that individual [who]--
(A) is enrolled in the final year of a course
of study and [who]--
(i) fails to maintain an acceptable
level of academic standing in the
educational institution in which he or
she is enrolled (such level determined
by the educational institution under
regulations of the Secretary);
(ii) voluntarily terminates such
enrollment; or
(iii) is dismissed from such
educational institution before
completion of such course of study; or
(B) is enrolled in a graduate training
program[,] and fails to complete such training
program[, and does not receive a waiver from
the Secretary under subsection (b)(1)(B)(ii) of
this section,].
[shall be liable, in lieu of any service obligation arising
under such contract, to the United States for the amount which
has been paid on such individual's behalf under the contract.]
(2) Other breaches; formula for amount owed.--If, for
any reason not specified in paragraph (1), an
individual breaches his or her written contract under
this section by failing either to begin, or complete,
such individual's period of obligated service in
accordance with subsection (e)(2) [(f) of this
section], the United States shall be entitled to
recover from such individual an amount to be determined
in accordance with the following formula: A=3Z(t-s/t)
in which--
(A) [``]`A'[''] is the amount the United
States is entitled to recover;
(B) [``]`Z'[''] is the sum of the amounts
paid under this section to, or on behalf of,
the individual and the interest on such amounts
which would be payable if, at the time the
amounts were paid, they were loans bearing
interest based on yields on appropriate
marketable Treasury securities [at the maximum
legal prevailing rate, as determined by the
Treasurer of the United States];
(C) [``]`t'[''] is the total number of months
in the individual's period of obligated service
in accordance with subsection (f) [of this
section]; and
(D) [``]`s'[''] is the number of months of
such period served by such individual in
accordance with this section.
(3) Deductions in medicare payments.--Amounts not
paid within such period shall be subject to collection
through deductions in [M]medicare payments pursuant to
section 1892 of the Social Security Act [1395ccc of
Title 42].
(4) [(3)(A)] Time period for repayment.--Any amount
of damages which the United States is entitled to
recover under this subsection shall be paid to the
United States within the 1-year period beginning on the
date of the breach or such longer period beginning on
such date as shall be specified by the Secretary.
(5) Recovery of delinquency.--
(A)[(B)] In general.--If damages described in
paragraph (4) [subparagraph (A)] are delinquent
for 3 months, the Secretary shall, for the
purpose of recovering such damages--
(i) use [utilize] collection agencies
contracted with by the Administrator of
[the] General Services
[Administration]; or
(ii) enter into contracts for the
recovery of such damages with
collection agencies selected by the
Secretary.
(B)[(C)] Report.--Each contract for
recovering damages pursuant to this subsection
shall provide that the contractor will, not
less than once each 6 months, submit to the
Secretary a status report on the success of the
contractor in collecting such damages. Section
3718 of [T]title 31, United States Code, shall
apply to any such contract to the extent not
inconsistent with this subsection.
(m) Waiver or Suspension of Obligation.--[Cancellation or
waiver of obligations; bankruptcy discharge]
[(1) Any obligation of an individual under the Loan
Repayment program for service or payment of damages
shall be canceled upon the death of the individual.]
(1) [(2)] In general.--The Secretary shall by
regulation provide for the partial or total waiver or
suspension of any obligation of service or payment by
an individual under the Loan Repayment Program whenever
compliance by the individual is impossible or would
involve extreme hardship to the individual and if
enforcement of such obligation with respect to any
individual would be unconscionable.
(2) Canceled upon death.--Any obligation of an
individual under the Loan Repayment Program for service
or payment of damages shall be canceled upon the death
of the individual.
(3) Hardship waiver.--The Secretary may waive, in
whole or in part, the rights of the United States to
recover amounts under this section in any case of
extreme hardship or other good cause shown, as
determined by the Secretary.
(4) Bankruptcy.--Any obligation of an individual
under the Loan Repayment Program for payment of damages
may be released by a discharge in bankruptcy under
[T]title 11 of the United States Code only if such
discharge is granted after the expiration of the 5-year
period beginning on the first date that payment of such
damages is required, and only if the bankruptcy court
finds that nondischarge of the obligation would be
unconscionable.
(n) [Annual r]Report.--
The Secretary shall submit to the President, for inclusion
in each report required to be submitted to [the] Congress under
section 801 [1671 of this title], a report concerning the
previous fiscal year which sets forth by Service Area the
following:[--]
(1) A list of the health professional positions
maintained by Indian Health Programs and Urban Indian
Organizations [the Service or by tribal or Indian
organizations] for which recruitment or retention is
difficult[;].
(2) [t]The number of Loan Repayment Program
applications filed with respect to each type of health
profession[;].
(3) [t]The number of contracts described in
subsection (e) [(f) of this section] that are entered
into with respect to each health profession[;].
(4) [t]The amount of loan payments made under this
section, in total and by health profession[;].
(5) [t]The number of scholarships [grants] that are
provided under sections 104 and 106 [1613a of this
title] with respect to each health profession[;].
(6) [t]The amount of scholarships [grants] provided
under section 104 and 106 [1613a of this title], in
total and by health profession[;].
(7) [t]The number of providers of health care that
will be needed by Indian [h]Health [p]Programs and
Urban Indian Organizations, by location and profession,
during the 3 [three] fiscal years beginning after the
date the report is filed[; and].
(8) [t]The measures the Secretary plans to take to
fill the health professional positions maintained by
Indian Health Programs or Urban Indian Organizations
[the Service or by tribes or tribal or Indian
organizations] for which recruitment or retention is
difficult.
Sec. 1616a-1. Scholarship and Loan Repayment Recovery Fund
(a) Establishment
There is established in the Treasury of the United States a
fund to be known as the Indian Health Scholarship and Loan
Repayment Recovery Fund (hereinafter in this section referred
to as the `LRRF' [``Fund'']). The LRRF [Fund] shall consist of
such amounts as may be collected from individuals [appropriated
to the Fund] under section 104(d), section 106(e), and section
110(l) for breach of contract, such funds as may be
appropriated to the LRRF, and interest earned on amounts in the
LRRF [subsection (b) of this section]. All [A]amounts
collected, appropriated, or earned relative to the LRRF [for
the Fund] shall remain available until expended.
[(b) Authorization of appropriations
[For each fiscal year, there is authorized to be
appropriated to the Fund an amount equal to the sum of--
[(1) the amount collected during the preceding fiscal
year by the Federal Government pursuant to--
[(A) the liability of individuals under
subparagraph (A) or (B) of section 1613a(b)(5)
of this title for the breach of contracts
entered into under section 1613a of this title;
and
[(B) the liability of individuals under
section 1616a(l) of this title for the breach
of contracts entered into under section 1616a
of this title; and
[(2) the aggregate amount of interest accruing during
the preceding fiscal year on obligations held in the
Fund pursuant to subsection (d) of this section and the
amount of proceeds from the sale or redemption of such
obligations during such fiscal year.]
(b) [(c)] Use of funds
(1) By secretary.--Amounts in the LRRF [Fund and
available pursuant to appropriation Acts] may be
expended by the Secretary, acting through the Service,
to make payments to an Indian Health Program--[tribe or
tribal organization administering a health care program
pursuant to a contract entered into under the Indian
Self-Determination Act [25 U.S.C.A. Sec. 450f et
seq.]--]
(A) to which a scholarship recipient under
section 104 and 106 [1613a of this title] or a
loan repayment program participant under
section 110 [1616a of this title] has been
assigned to meet the obligated service
requirements pursuant to such sections; and
(B) that has a need for a health professional
to provide health care services as a result of
such recipient or participant having breached
the contract entered into under section 104,
106, or 110. [1613a of this title or section
1616a of this title.]
(2) By tribal health programs.--A Tribal Health
Program, [An Indian tribe or tribal organization]
receiving payments pursuant to paragraph (1) may expend
the payments to provide scholarships or recruit and
employ, directly or by contract, health professionals
to provide health care services.
(c) [(d)] Investment of [excess f]Funds.--
[(1)] The Secretary of the Treasury shall invest such
amounts of the LRRF, except for the appropriated funds,
[Fund as such] as the Secretary determines are not
required to meet current withdrawals from the LRRF
[Fund]. Such investments may be made only in interest[-
]bearing obligations of the United States. For such
purpose, such obligations may be acquired on original
issue at the issue price, or by purchase of outstanding
obligations at the market price.
(d) Sale of Obligations.--[(2)] Any obligation acquired by
the LRRF [Fund] may be sold by the Secretary of the Treasury at
the market price.
Sec. 1616b. Recruitment A[a]ctivities
(a) Reimbursement for Travel.--The Secretary, acting
through the Service, may reimburse health professionals seeking
positions with Indian Health Programs or Urban Indian
Organizations [in the Service], including unpaid student
volunteers and individuals considering entering into a contract
under section 110 [1616a of this title], and their spouses, for
actual and reasonable expenses incurred in traveling to and
from their places of residence to an area in which they may be
assigned for the purpose of evaluating such area with respect
to such assignment.
(b) Recruitment Personnel.--The Secretary, acting through
the Service, shall assign one individual in each [a]Area
[o]Office to be responsible on a full-time basis for
recruitment activities.
Sec. 1616c. Indian [Tribal r]Recruitment and R[r]etention P[p]rogram
(a) In General.--[Projects funded on competitive basis]
The Secretary, acting through the Service, shall fund
innovative demonstration projects for a period not to exceed 3
years to enable Tribal Health Programs and Urban Indian
Organizations to recruit, place, and retain health
professionals to meet their staffing needs. [, on a competitive
basis, projects to enable Indian tribes and tribal and Indian
organizations to recruit, place, and retain health
professionals to meet the staffing needs of Indian health
programs (as defined in section 1616a(a)(2) of this title).]
(b) Eligible Entities; Application.--[Eligibility]
[(1)] Any Tribal Health Program or Urban Indian
Organization [Indian tribe or tribal or Indian
organization] may submit an application for funding of
a project pursuant to this section.
[(2) Indian tribes and tribal and Indian
organizations under the authority of the Indian Self-
Determination Act [25 U.S.C.A. Sec. 450f et seq.] shall
be given an equal opportunity with programs that are
administered directly by the Service to compete for,
and receive, grants under subsection (a) of this
section for such projects.]
Sec. 1616d. Advanced T[t]raining and R[r]esearch
(a) Demonstration [Establishment of p]Program
The Secretary, acting through the Service, shall establish
a demonstration project [program] to enable health
professionals who have worked in an Indian Health Program or
Urban Indian Organization for a substantial period of time to
pursue advanced training or research in areas of study for
which the Secretary determines a need exists. [In selecting
participants for a program established under this subsection,
the Secretary, acting through the Service, shall give priority
to applicants who are employed by the Indian Health Service,
Indian tribes, tribal organization, and urban Indian
organizations, at the time of the submission of the
applications.]
(b) Service Obligation.--[Obligated service]
An individual who participates in a program under
subsection (a) [of this section], where the educational costs
are borne by the Service, shall incur an obligation to serve in
an Indian [h]Health [p]Program or Urban Indian Organization
[(as defined in section 1616a(a)(2) of this title)] for a
period of obligated service equal to at least the period of
time during which the individual participates in such program.
In the event that the individual fails to complete such
obligated service, the individual shall be liable to the United
States for the period of service remaining. In such event, with
respect to individuals entering the program after the date of
the enactment of the Indian Health Care Improvement Act
Amendments of 2004, [October 29, 1992,] the United States shall
be entitled to recover from such individual an amount to be
determined in accordance with the formula specified in
subsection (l) of section 110 [1616a of this title] in the
manner provided for in such subsection.
(c) Equal Opportunity for Participation.--[Eligibility]
Health professionals from Tribal Health Programs and Urban
Indian Organizations [Indian tribes and tribal and Indian
organizations under the authority of the Indian Self-
Determination Act [25 U.S.C.A. Sec. 450f et seq.]] shall be
given an equal opportunity to participate in the program under
subsection (a) [of this section].
[Sec. 1616e. Nursing program
[(a) Grants
[The Secretary, acting through the Service, shall provide
grants to--
[(1) public or private schools of nursing,
[(2) tribally controlled community colleges and
tribally controlled postsecondary vocational
institutions (as defined in section 2397h(2) of Title
20), and
[(3) nurse midwife programs, and nurse practitioner
programs, that are provided by any public or private
institution,
for the purpose of increasing the number of nurses, nurse
midwives, and nurse practitioners who deliver health care
services to Indians.
[(b) Purposes
[Grants provided under subsection (a) of this section may
be used to--
[(1) recruit individuals for programs which train
individuals to be nurses, nurse midwives, or nurse
practitioners,
[(2) provide scholarships to individuals enrolled in
such programs that may pay the tuition charged for such
program and other expenses incurred in connection with
such program, including books, fees, room and board,
and stipends for living expenses,
[(3) provide a program that encourages nurses, nurse
midwives, and nurse practitioners to provide, or
continue to provide, health care services to Indians,
[(4) provide a program that increases the skills of,
and provides continuing education to, nurses, nurse
midwives, and nurse practitioners, or
[(5) provide any program that is designed to achieve
the purpose described in subsection (a) of this
section.
[(c) Application
[Each application for a grant under subsection (a) of this
section shall include such information as the Secretary may
require to establish the connection between the program of the
applicant and a health care facility that primarily serves
Indians.
[(d) Preference
[In providing grants under subsection (a) of this section,
the Secretary shall extend a preference to--
[(1) programs that provide a preference to Indians,
[(2) programs that train nurse midwives or nurse
practitioners,
[(3) programs that are interdisciplinary, and
[(4) programs that are conducted in cooperation with
a center for gifted and talented Indian students
established under section 2624(a) of this title.]
Sec. 115. [(e)] Quentin N. Burdick American Indians Into Nursing
Program
(a) Grants Authorized.--For the purpose of increasing the
number of nurses, nurse midwives, and nurse practitioners who
deliver health care services to Indians, the Secretary, acting
through the Service, shall provide grants to the following:
(1) Public or private schools of nursing.
(2) Tribal colleges or universities.
(3) Nurse midwife programs and advanced practice
nurse programs that are provided by any tribal college
or university accredited nursing program, or in the
absence of such, any other public or private
institutions.
(b) Use of Grants.--Grants provided under subsection (a)
may be used for one or more of the following:
(1) To recruit individuals for programs which train
individuals to be nurses, nurse midwives, or advanced
practice nurses.
(2) To provide scholarships to Indians enrolled in
such programs that may pay the tuition charged for such
program and other expenses incurred in connection with
such program, including books, fees, room and board,
and stipends for living expenses.
(3) To provide a program that encourages nurses,
nurse midwives, and advanced practice nurses to
provide, or continue to provide, health care services
to Indians.
(4) To provide a program that increases the skills
of, and provides continuing education to, nurses, nurse
midwives, and advanced practice nurses.
(5) To provide any program that is designed to
achieve the purpose described in subsection (a).
(c) Applications.--Each application for funding under
subsection (a) shall include such information as the Secretary
may require to establish the connection between the program of
the applicant and a health care facility that primarily serves
Indians.
(d) Preferences for Grant Recipients.--In providing grants
under subsection (a), the Secretary shall extend a preference
to the following:
(1) Programs that provide a preference to Indians.
(2) Programs that train nurse midwives or advanced
practice nurses.
(3) Programs that are interdisciplinary.
(4) Programs that are conducted in cooperation with a
program for gifted and talented Indian students.
(e) Quentin N. Burdick Program Grant.--
The Secretary shall provide one of the grants authorized
under subsection (a) [of this section] to establish and
maintain a program at the University of North Dakota to be
known as the [``] `Quentin N. Burdick American Indians Into
Nursing Program' ['']. Such program shall, to the maximum
extent feasible, coordinate with the Quentin N. Burdick Indian
Health Programs established under section 117(b) [1616g(b) of
this title] and the Quentin N. Burdick American Indians
IntoPsychology Program established under section 105(b) [1621p(b) of
this title].
(f) Active Duty Service O[o]bligation.--
The active duty service obligation prescribed under section
338C of the Public Health Service Act (42 U.S.C. 254m) [of
Title 42] shall be met by each individual who receives training
or assistance described in paragraph (1) or (2) of subsection
(b) [of this section] that is funded by a grant provided under
subsection (a) [of this section]. Such obligation shall be met
by service--
(1) [(A)] in the [Indian Health] Service;
(2) [(B)] in a program of an Indian Tribe or Tribal
Organization conducted under the Indian Self-
Determination and Education Assistance Act (including
programs under agreements with the Bureau of Indian
Affairs) [a contract entered into under the Indian
Self-Determination Act [25 U.S.C.A. Sec. 450f et
seq.]];
(3)[(C)] in a program assisted under title V
[subchapter IV] of this Act [chapter]; or
(4) [(D)]1 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.
[(g) Authorization of appropriations
[Beginning with fiscal year 1993, of the amounts
appropriated under the authority of this subchapter for each
fiscal year to be used to carry out this section, not less than
$1,000,000 shall be used to provide grants under subsection (a)
of this section for the training of nurse midwives, nurse
anesthetists, and nurse practitioners.
[Sec. 1616e-1. Nursing school clinics
[(a) Grants
[In addition to the authority of the Secretary under
section 1616e(a)(1) of this title, the Secretary, acting
through the Service, is authorized to provide grants to public
or private schools of nursing for the purpose of establishing,
developing, operating, and administering clinics to address the
health care needs of Indians, and to provide primary health
care services to Indians who reside on or within 50 miles of
Indian country, as defined in section 1151 of Title 18.
[(b) Purposes
[Grants provided under subsection (a) of this section may
be used to--
[(1) establish clinics, to be run and staffed by the
faculty and students of a grantee school, to provide
primary care services in areas in or within 50 miles of
Indian country (as defined in section 1151 of Title
18);]
[(2) provide clinical training, program development,
faculty enhancement, and student scholarships in a
manner that would benefit such clinics; and
[(3) carry out any other activities determined
appropriate by the Secretary.
[(c) Amount and conditions
[The Secretary may award grants under this section in such
amounts and subject to such conditions as the Secretary deems
appropriate.
[(d) Design
[The clinics established under this section shall be
designed to provide nursing students with a structured clinical
experience that is similar in nature to that provided by
residency training programs for physicians.
[(e) Regulations
[The Secretary shall prescribe such regulations as may be
necessary to carry out the provisions of this section.
[(f) Authorization to use amounts
[Out of amounts appropriated to carry out this subchapter
for each of the fiscal years 1993 through 2000 not more than
$5,000,000 may be used to carry out this section.]
Sec. 1616f. Tribal Cultural Orientation. [culture and history]
(a) Cultural Education of Employees.--[Program established]
The Secretary, acting through the Service, shall
requirethat [establish a program under which] appropriate employees of
the Service who serve [particular] Indian [t]Tribes in each Service
Area [shall] receive educational instruction in the history and culture
of such Indian T[t]ribes and their relationship to [in the history of]
the Service.
(b) Program.--[Tribally-Controlled Community Colleges] In
carrying out subsection (a), the Secretary shall establish a
program which shall, to the extent feasible--
[To the extent feasible, the program established under
subsection (a) of this section shall--]
(1) be developed in consultation with the affected
Indian Tribes, Tribal Organizations, and Urban Indian
Organizations; [be carried out through tribally-
controlled community colleges (within the meaning of
section 1801(4) of this title) and tribally controlled
postsecondary vocational institutions (as defined in
section 2397h(2) of Title 20),]
(2) be carried out through tribal colleges or
universities; [be developed in consultation with the
affected tribal government, and]
(3) include instruction in American Indian [Native
American] studies; and[.]
(4) describe the use and place of Traditional Health
Care Practices of the Indian Tribes in the Service
Area.
Sec. 1616g. INMED Program
(a) Grants Authorized._
The Secretary, acting through the Service, is authorized to
provide grants to [at least 3] colleges and universities for
the purpose of maintaining and expanding the Indian [Native
American] health careers recruitment program known as the [``]
`Indians into Medicine Program'[''] (hereinafter in this
section referred to as [``] `INMED'['']) as a means of
encouraging Indians to enter the health professions.
(b) Quentin N. Burdick Grant.--[University of North Dakota]
The Secretary shall provide one of the grants authorized
under subsection (a) [of this section] to maintain the INMED
program at the University of North Dakota, to be known as the
`Quentin N. Burdick Indian Health Programs', unless the
Secretary makes a determination, based upon program reviews,
that the program is not meeting the purposes of this section.
Such program shall, to the maximum extent feasible, coordinate
with the Quentin N. Burdick American Indians Into Psychology
Program established under section 105(b) [1621p(b) of this
title] and the Quentin N. Burdick American Indians Into Nursing
Program established under section 115 [1616e of this title].
(c) Regulations.--[; Contents of recruitment program]
[(1)] The Secretary, pursuant to this Act, shall
develop regulations to govern [for the competitive
awarding of the] grants pursuant to [provided under]
this section.
(d) Requirements.--[(2)] Applicants for grants provided
under this section shall agree to provide a program which--
(1)[(A)] provides outreach and recruitment for health
professions to Indian communities, including
elementary[,] and secondary schools and community
colleges located on [Indian] reservations, which will
be served by the program[,];
(2)[(B)] incorporates a program advisory board
comprised of representatives from the Indian tribes and
Indian communities which will be served by the
program[,];
(3)[(C)] provides summer preparatory programs for
Indian students who need enrichment in the subjects of
math and science in order to pursue training in the
health professions[,];
(4)[(D)] provides tutoring, counseling, and support
to students who are enrolled in a health career program
of study at the respective college or university[,];
and
(5)[(E)] to the maximum extent feasible, employs
qualified Indians in the program.
[(d) Report to Congress
[By no later than the date that is 3 years after November
23, 1988, the Secretary shall submit a report to the Congress
on the program established under this section including
recommendations for expansion or changes to the program.]
Sec. 1616h. Health [t]Training [p]Programs of [c]Community [c]Colleges
(a) Grants To Establish Programs._
(1) In general.--The Secretary, acting through the
Service,shall award grants to accredited and accessible
community colleges for the purpose of assisting such [the] community
colleges in the establishment of programs which provide education in a
health profession leading to a degree or diploma in a health profession
for individuals who desire to practice such profession on or near a [an
Indian] reservation or in an Indian Health Program [a tribal clinic].
(2) Amount of grants._T[t]he amount of any grant
awarded to a community college under paragraph (1) for
the first year in which such a grant is provided to the
community college shall not exceed $100,000.
(b) Grants for Maintenance and Recruiting.--[Eligibility]
(1) In general.--The Secretary, acting through the
Service, shall award grants to accredited and
accessible community colleges that have established a
program described in subsection (a)(1) [of this
section] for the purpose of maintaining the program and
recruiting students for the program.
(2) Requirements.--Grants may only be made under this
section to a community college which--
(A) is accredited[,];
(B) has a relationship with [access to] a
hospital facility, Service facility, or
hospital that could provide training of nurses
or health professionals[,];
(C) has entered into an agreement with an
accredited college or university medical
school, the terms of which--
(i) provide a program that enhances
the transition and recruitment of
students into advanced baccalaureate or
graduate programs which train health
professionals[,]; and
(ii) stipulate certifications
necessary to approved internship and
field placement opportunities at Indian
Health Programs; [service unit
facilities of the Service or at tribal
health facilities,];
(D) has a qualified staff which has the
appropriate certifications[, and];
(E) is capable of obtaining State or regional
accreditation of the program described in
subsection (a)(1) [of this section.]; and
(F) agrees to provide for Indian preference
for applicants for programs under this section.
(c) [Agreements and t]Technical [a]Assistance
The Secretary shall encourage community colleges described
in subsection (b)(2) [of this section] to establish and
maintain programs described in subsection (a)(1) [of this
section] by--
(1) entering into agreements with such colleges for
the provision of qualified personnel of the Service to
teach courses of study in such programs[,]; and
(2) providing technical assistance and support to
such colleges.
(d) Advanced Training
(1) Required._Any program receiving assistance under
this section that is conducted with respect to a health
profession shall also offer courses of study which
provide advanced training for any health professional
who--
(A)[(1)] has already received a degree or
diploma in such health profession[,]; and
(B)[(2)] provides clinical services on or
near a [an Indian] reservation or for an Indian
Health Program[, at a Service facility, or at a
tribal clinic].
(2) May be offered at alternate site._Such courses of
study may be offered in conjunction with the college or
university with which the community college has entered
into the agreement required under subsection (b)(2)(C)
[of this section].
(e) Funding Priority.--Where the requirements of subsection
(b) are met, funding priority shall be provided to tribal
colleges and universities in Service Areas where they exist.
[(e) Definitions
[For purposes of this section
[(1) The term ``community college'' means--
[(A) a tribally controlled community college,
or
[(B) a junior or community college.
[(2) The term ``tribally controlled community
college'' hasthe meaning given to such term by section
1801(4) of this title.
[(3) The term ``junior or community college'' has the
meaning given to such term by section 1058(e) of Title
20.
[Sec. 1616i. Additional incentives for health professionals
[(a) Incentive special pay
[The Secretary may provide the incentive special pay
authorized under section 302(b) of Title 37, to civilian
medical officers of the Indian Health Service who are assigned
to, and serving in, positions included in the list established
under subsection (b)(1) of this section for which recruitment
or retention of personnel is difficult.
[(b) List of positions; bonus pay
[(1) the Secretary shall establish and update on an
annual basis a list of positions of health care
professionals employed by, or assigned to, the Service
for which recruitment or retention is difficult.
[(2)(A) The Secretary may pay a bonus to any
commissioned officer or civil service employee, other
than a commissioned medical officer, dental officer,
optometrist, and veterinarian, who is employed in or
assigned to, and serving in, a position in the Service
included in the list established by the Secretary under
paragraph (1).
[(B) The total amount of bonus payments made by the
Secretary under this paragraph to any employee during
any 1-year period shall not exceed $2,000.
[(c) Work schedules
[The Secretary may establish programs to allow the use of
flexible work schedules, and compressed work schedules, in
accordance with the provisions of subchapter II of chapter 61
of Title 5, for health professionals employed by, or assigned
to, the Service.]
Sec. 1616j. Retention bonus
(a) Bonus Authorized.--[Eligibility]
The Secretary may pay a retention bonus to any health
professional [physician or nurse] employed by, or assigned to,
and serving in, an Indian Health Program or Urban Indian
Organization [the Service] either as a civilian employee or as
a commissioned officer in the Regular or Reserve Corps of the
Public Health Service who--
(1) is assigned to, and serving in, a position
[included in the list established under section
1616i(b)(1) of this title] for which recruitment or
retention of personnel is difficult[,];
(2) the Secretary determines is needed by Indian
Health Programs and Urban Indian Organizations; [the
Service,]
(3) has--
(A) completed 3 years of employment with an
Indian Health Program or Urban Indian
Organization; [the Service,] or
(B) completed any service obligations
incurred as a requirement of--
(i) any Federal scholarship
program[,]; or
(ii) any Federal education loan
repayment program[,]; and
(4) enters into an agreement with an Indian Health
Program or Urban Indian Organization [the Service] for
continued employment for a period of not less than 1
year.
[(b) Minimum award percentage to nurses
[Beginning with fiscal year 1993, not less than 25 percent
of the retention bonuses awarded each year under subsection (a)
of the section shall be awarded to nurses.]
(b)[(c)] Rates.--[; maximum rate]
The Secretary may establish rates for the retention bonus
which shall provide for a higher annual rate for multiyear
agreements than for single year agreements referred to in
subsection (a)(4) [of this section], but in no event shall the
annual rate be more than $25,000 per annum.
[(d) Time of payment
[The retention bonus for the entire period covered by the
agreement described in subsection (a)(4) of this section shall
be paid at the beginning of the agreed upon term of service.
[(e) Refund; interest]
(c) Default of Retention Agreement.--
Any health professional [physician or nurse] failing to
complete the agreed upon term of service, except where such
failure is through no fault of the individual, shall be
obligated to refund to the Government the full amount of the
retention bonus for the period covered by the agreement, plus
interest as determined by the Secretary in accordance with
section 110(l)(2)(B) [1616a(l)(2)(B) of this title].
(d) Other Retention Bonus.--
[(f) Physicians and nurses employed under Indian Self-
Determination Act]
The Secretary may pay a retention bonus to any health
professional [physician or nurse] employed by a Tribal Health
Program [an organization providing health care services to
Indians pursuant to a contract under the Indian Self-
Determination Act [25 U.S.C.A. Sec. 450f et. Seq.]] if such
health professional [physician or nurse] is serving in a
position which the Secretary determines is--
(1) a position for which recruitment or retention is
difficult; and
(2) necessary for providing health care services to
Indians.
Sec. 1616k. Nursing residency program
(a) Establishment of Program.--
The Secretary, acting through the Service, shall establish
a program to enable Indians who are licensed practical nurses,
licensed vocational nurses, and registered nurses who are
working in an Indian H[h]ealth P[p]rogram or Urban Indian
Organization [(as defined in section 1616a(a)(2)(A) of this
title)], and have done so for a period of not less than 1 [one]
year, to pursue advanced training.
[(b) Program components]
Such program shall include a combination of education and
work study in an Indian H[h]ealth P[p]rogram or Urban Indian
Organization [(as defined in section 1616a(a)(2)(A) of this
title)] leading to an associate or bachelor's degree (in the
case of a licensed practical nurse or licensed vocational
nurse), [or] a bachelor's degree (in the case of a registered
nurse) or advanced degrees or certification in nursing and
public health [a Master's degree].
(b)[(c)] Service O[o]bligation.--[of program participant]
An individual who participates in a program under
subsection (a) [of this section], where the educational costs
are paid by the Service, shall incur an obligation to serve in
an Indian H[h]ealth P[p]rogram or Urban Indian Organization for
a period of obligated service equal to the amount of [at least
three times the period of the] time during which the individual
participates in such program. In the event that the individual
fails to complete such obligated service, the United States
shall be entitled to recover from such individual an amount
determined in accordance with the formula specified in
subsection (l) of section 110 [1616a of this title] in the
manner provided for in such subsection.
Sec. 1616l. Community Health Aide Program for Alaska
(a) General Purposes [Maintenance] of Program.--
Under the authority of the Act of November 2, 1921 (25
U.S.C. 13)(commonly known as the `Snyder Act') [section 13 of
this title], the Secretary, acting through the Service, shall
develop and operate [maintain] a Community Health Aide Program
in Alaska under which the Service--
(1) provides for the training of Alaska Natives as
health aides or community health practitioners;
(2) uses such aides or practitioners in the provision
of health care, health promotion, and disease
prevention services to Alaska Natives living in
villages in rural Alaska; and
(3) provides for the establishment of
teleconferencing capacity in health clinics located in
or near such villages for use by community health aides
or community health practitioners.
(b) Specific Program Requirements.--[Training; curriculum;
certification board]
The Secretary, acting through the Community Health Aide
Program of the Service, shall--
(1) using trainers accredited by the Program, provide
a high standard of training to community health aides
and community health practitioners to ensure that such
aides and practitioners provide quality health care,
health promotion, and disease prevention services to
the villages served by theProgram;
(2) in order to provide such training, develop a
curriculum that--
(A) combines education in the theory of
health care with supervised practical
experience in the provision of health care;
(B) provides instruction and practical
experience in the provision of acute care,
emergency care, health promotion, disease
prevention, and the efficient and effective
management of clinic pharmacies, supplies,
equipment, and facilities; and
(C) promotes the achievement of the health
status objectives specified in section 3(2)
[1602(b) of this title];
(3) establish and maintain a Community Health Aide
Certification Board to certify as community health
aides or community health practitioners individuals who
have successfully completed the training described in
paragraph (1) or can demonstrate equivalent experience;
(4) develop and maintain a system which identifies
the needs of community health aides and community
health practitioners for continuing education in the
provision of health care, including the areas described
in paragraph (2)(B), and develop programs that meet the
needs for such continuing education;
(5) develop and maintain a system that provides close
supervision of community health aides and community
health practitioners; and
(6) develop a system under which the work of
community health aides and community health
practitioners is reviewed and evaluated to assure the
provision of quality health care, health promotion, and
disease prevention services.
(c) National Community Health Aide Program.--The Secretary,
acting through the Service, shall develop and promulgate
regulations to operate a national Community Health Aide Program
consistent with the requirements of this section without
reducing funds for the Community Health Aide Program for
Alaska.
[Sec. 1616m. Matching grants to tribes for scholarship programs
[(a) In general
[(1) The Secretary shall make grants to Indian tribes
and tribal organizations for the purpose of assisting
such tribes and tribal organizations in educating
Indians to serve as health professionals in Indian
communities.
[(2) Amounts available for grants under paragraph (1)
for any fiscal year shall not exceed 5 percent of
amounts available for such fiscal year for Indian
Health Scholarships under section 1613a of this title.
[(3) An application for a grant under paragraph (1)
shall be in such form and contain such agreements,
assurances, and information as the Secretary determines
are necessary to carry out this section.
[(b) Compliance with requirements
[(1) An Indian tribe or tribal organization receiving
a grant under subsection (a) of this section shall
agree to provide scholarships to Indians pursuing
education in the health professions in accordance with
the requirements of this section.
[(2) With respect to the costs of providing any
scholarship pursuant to paragraph (1)--
[(A) 80 percent of the costs of the
scholarship shall be paid from the grant made
under subsection (a) of this section to the
Indian tribe or tribal organization; and
[(B) 20 percent of such costs shall be paid
from non-Federal contributions by the Indian
tribe or tribal organization through which the
scholarship is provided.
[(3) In determining the amount of non-Federal
contributions that have been provided for purposes of
subparagraph (B) of paragraph (2), any amounts provided
by the Federal Government to the Indian tribe or tribal
organization involved or to any other entity shall not
be included.
[(4) Non-Federal contributions required by
subparagraph (B) of paragraph (2) may be provided
directly by the Indian tribe or tribal organization
involved or through donations from public and private
entities.
[(c) Course of study in health professions
[An Indian tribe or tribal organization shall provide
scholarships under subsection (b) of this section only to
Indians enrolled or accepted for enrollment in the course of
study (approved by the Secretary) in one of the
healthprofessions described in section 1613a(a) of this title.
[(d) Contract requirements
[In providing scholarships under subsection (b) of this
section, the Secretary and the Indian tribe or tribal
organization shall enter into a written contract with each
recipient of such scholarship. Such contract shall--
[(1) obligate such recipient to provide service in an
Indian health program (as defined in section
1616a(a)(2)(A) of this title), in the same service area
where the Indian tribe or tribal organization providing
the scholarship is located, for--
[(A) a number of years equal to the number of
years for which the scholarship is provided (or
the part-time equivalent thereof, as determined
by the Secretary), or for a period of 2 years,
whichever period is greater; or
[(B) such greater period of time as the
recipient and the Indian tribe or tribal
organization may agree;
[(2) provide that the amount of such scholarship--
[(A) may be expended only for--
[(i) tuition expenses, other
reasonable educational expenses, and
reasonable living expenses incurred in
attendance at the educational
institution; and
[(ii) payment to the recipient of a
monthly stipend of not more than the
amount authorized by section
254l(g)(1)(B) of Title 42, such amount
to be reduced pro rata (as determined
by the Secretary) based on the number
of hours such student is enrolled; and
[(B) may not exceed, for any year of
attendance for which the scholarship is
provided, the total amount required for the
year for the purposes authorized in
subparagraph (A);
[(3) require the recipient of such scholarship to
maintain an acceptable level of academic standing (as
determined by the educational institution in accordance
with regulations issued by the Secretary); and
[(4) require the recipient of such scholarship to
meet the educational and licensure requirements
necessary to be a physician, certified nurse
practitioner, certified nurse midwife, or physician
assistant.
[(e) Breach of contract
[(1) an individual who has entered into a written
contract with the Secretary and an Indian tribe or
tribal organization under subsection (d) of this
section and who--
[(A) fails to maintain an acceptable level of
academic standing in the educational
institution in which he is enrolled (such level
determined by the educational institution under
regulations of the Secretary),
[(B) is dismissed from such educational
institution for disciplinary reasons,
[(C) voluntarily terminates the training in
such an educational institution for which he is
provided a scholarship under such contract
before the completion of such training, or
[(D) fails to accept payment, or instructs
the educational institution in which he is
enrolled not to accept payment,
in whole or in part, of a scholarship under such contract, in
lieu of any service obligation arising under such contract,
shall be liable to the United States for the Federal share of
the amount which has been paid to him, or on his behalf, under
the contract.
[(2) If for any reason not specified in paragraph
(1), an individual breaches his written contract by
failing either to begin such individual's service
obligation required under such contract or to complete
such service obligation, the United States shall be
entitled to recover from the individual an amount
determined in accordance with the formula specified in
subsection (l) of section 1616a of this title in the
manner provided for in such subsection.
[(3) The Secretary may carry out this subsection on
the basis of information submitted by the tribes or
tribal organization involved, or on the basis of
information collected through such other means as the
Secretary determines to be appropriate.
[(f) Nondiscriminatory practice
[The recipient of a scholarship under subsection (b) of
this section shall agree, in providing health care pursuant to
the requirements of subsection (d)(1) of this section--
[(1) not to discriminate against an individual
seeking suchcare on the basis of the ability of the
individual to pay for such care or on the basis that payment for such
care will be made pursuant to the program established in title XVIII of
the Social Security Act [42 U.S.C.A. Sec. 1395 et. Seq.] or pursuant to
the program established in title XIX of such Act [42 U.S.C.A. Sec. 1396
et. seq.]; and
[(2) to accept assignment under section
1842(b)(3)(B)(ii) of the Social Security Act [42
U.S.C.A. Sec. 1395u(b)(3)(B)(ii)] for all services for
which payment may be made under part B of title XVIII
of such Act [42 U.S.C.A. Sec. 1395j et. seq.], and to
enter into an appropriate agreement with the State
agency that administers the State plan for medical
assistance under title XIX of such Act [42 U.S.C.A.
Sec. 1396 et. seq.] to provide service to individuals
entitled to medical assistance under the plan.
[(g) Payments for subsequent fiscal years
[The Secretary may not make any payments under subsection
(a) of this section to an Indian tribe or tribal organization
for any fiscal year subsequent to the first fiscal year of such
payments unless the Secretary determines that, for the
immediately preceding fiscal year, the Indian tribe or tribal
organization has complied with requirements of this section.]
Sec. 1616n. Tribal H[h]ealth P[p]rogram A[a]dministration
The Secretary, acting through the Service, shall, by
funding agreement [contract] or otherwise, provide training for
Indians [individuals] in the administration and planning of
T[t]ribal H[h]ealth P[p]rograms.
Sec. 123. Health Professional Chronic Shortage Demonstration Programs
(a) Demonstration Programs Authorized.--The Secretary,
acting through the Service, may fund demonstration programs for
Tribal Health Programs to address the chronic shortages of
health professionals.
(b) Purposes of Programs.--The purposes of demonstration
programs funded under subsection (a) shall be--
(1) to provide direct clinical and practical
experience at a Service Unit to health profession
students and residents from medical schools;
(2) to improve the quality of health care for Indians
by assuring access to qualified health care
professionals; and
(3) to provide academic and scholarly opportunities
for health professionals serving Indians by identifying
all academic and scholarly resources of the region.
(c) Advisory Board.--The demonstration programs established
pursuant to subsection (a) shall incorporate a program advisory
board composed of representatives from the Indian Tribes and
Indian communities in the area which will be served by the
program.
Sec. 124. Treatment of Scholarships for Certain Purposes
Scholarships provided to individuals pursuant to this title
shall be deemed `qualified Scholarships' for purposes of
section 11 of the Internal Revenue Code of 1986.
Sec. 125. National Health Service Corps
(a) No Reduction in Services.--The Secretary shall not--
(1) remove a member of the National Health Service
Corps from an Indian Health Program or Urban Indian
Organization; or
(2) withdraw funding used to support such member;
unless the Secretary, acting through the Service, Indian
Tribes, or Tribal Organizations, has ensured that the Indians
receiving services from such member will experience no
reduction in services.
(b) Exemption From Limitations.--National Health Service
Corps scholars qualifying for the Commissioned Corps in the
United States Public Health Service shall be exempt from the
full-time equivalent limitations of the National Health Service
Corps and the Service when serving as a commissioned corps
officer in a Tribal Health Program or an Urban Indian
Organization.
Sec. 126. Substance Abuse Counselor Educational Curricula Demonstration
Programs
(a) Grants and Contracts.--The Secretary, acting through
the Service, may enter into contracts with, or make grants to,
accredited tribal colleges and universities and eligible
accredited and accessible community colleges to establish
demonstration programs to develop educational curricula for
substance abuse counseling.
(b) Use of Funds.--Funds provided under this section shall
be used only for developing and providing educational
curriculumfor 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 1 year. Such contract or grant may be renewed for an
additional 1-year period upon the approval of the Secretary.
(d) Criteria for Review and Approval of Applications.--Not
later than 180 days after the date of the enactment of the
Indian Health Care Improvement Act Amendments of 2004, 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. 127. 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 funding agreement, the appropriate
Secretary shall ensure that funds to cover the costs of
such training costs are included in the funding
agreement.
(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 todevelop and implement, a program of community
education on mental illness. In carrying out this subsection, the
Service shall, upon request of an Indian Tribe, Tribal Organization, or
Urban Indian Organization, provide technical assistance to the Indian
Tribe, Tribal Organization, or Urban Indian Organization to obtain and
develop community educational materials on the identification,
prevention, referral, and treatment of mental illness and dysfunctional
and self-destructive behavior.
(e) Plan.--Not later than 90 days after the date of the
enactment of the Indian Health Care Improvement Act Amendments
of 2004, the Secretary shall develop a plan under which the
Service will increase the health care staff providing
behavioral health services by at least 500 positions within 5
years after the date of the enactment of this section, with at
least 200 of such positions devoted to child, adolescent, and
family services. The plan developed under this subsection shall
be implemented under the Act of November 2, 1921 (25 U.S.C. 13)
(commonly known as the `Snyder Act').
[Sec. 1616o. University of South Dakota pilot program
[(a) Establishment
[The Secretary may make a grant to the School of Medicine
of the University of South Dakota (hereafter in this section
referred to as ``USDSM'') to establish a pilot program on an
Indian reservation at one or more service units in South Dakota
to address the chronic manpower shortage in the Aberdeen Area
of the Service.
[(b) Purposes
[The purposes of the program established pursuant to a
grant provided under subsection (a) of this section are--
[(1) to provide direct clinical and practical
experience at the service unit to medical students and
residents from USDSM and other medical schools;
[(2) to improve the quality of health care for
Indians by assuring access to qualified health care
professionals; and
[(3) to provide academic and scholarly opportunities
for physicians, physician assistants, nurse
practitioners, nurse, and other allied health
professionals serving Indian people by identifying and
utilizing all academic and scholarly resources of the
region.
[(c) Composition; designation
[The pilot program established pursuant to a grant provided
under subsection (a) of this section shall--
[(1) incorporate a program advisory board composed of
representatives from the tribes and communities in the
area which will be served by the program; and
[(2) shall be designated as an extension of the USDSM
campus and program participants shall be under the
direct supervision and instruction of qualified medical
staff serving at the service unit who shall be members
of the USDSM faculty.
[(d) Coordination with other schools
[The USDSM shall coordinate the program established
pursuant to a grant provided under subsection (a) of this
section with other medical schools in the region, nursing
schools, tribal community colleges, and other health
professional schools.
[(e) Development of additional professional opportunities
[The USDSM, in cooperation with the Service, shall develop
additional professional opportunities for program participants
on Indian reservations in order to improve the recruitment and
retention of qualified health professionals in the Aberdeen
Area of the Service.]
Sec. 1616p. Authorization of [a]Appropriations
There are authorized to be appropriated such sums as may be
necessary for each fiscal year through fiscal year 2015 [2000]
to carry out this title [subchapter].
TITLE [SUBCHAPTER] II--HEALTH SERVICES
Sec. 1621. Indian Health Care Improvement Fund
(a) Use of Funds.--[Approved expenditures]
The Secretary, acting through the Service, is authorized to
expend funds, directly or under the authority of the Indian
Self-Determination and Education Assistance Act, which are
appropriated under the authority of this section, [through the
Service,] for the purposes of--
(1) eliminating the deficiencies in health status and
health resources of all Indian [t]Tribes[,];
(2) eliminating backlogs in the provision of health
care services to Indians[,];
(3) meeting the health needs of Indians in an
efficient and equitable manner, including the use of
telehealth and telemedicine when appropriate; [and]
(4) eliminating inequities in funding for both direct
care and contract health service programs; and
(5)[(4)] augmenting the ability of the Service to
meet the following health service responsibilities[,
either through direct or contract care or through
contracts entered into pursuant to the Indian Self-
Determination Act [25 U.S.C.A. Sec. 450f et seq.],]
with respect to those Indian [t]Tribes with the highest
levels of health status deficiencies and resource
deficiencies:
(A) [c]Clinical care, [(direct and indirect)]
including, but not limited to, inpatient care,
outpatient care (including audiology, clinical
eye and vision care), primary care, secondary
and tertiary care, and long-term care.[;]
(B) [p]Preventive health, including
[screening] mammography and other cancer
screening in accordance with section 207.
[1621k of this title;]
(C) [d]Dental care. [(direct and indirect);]
(D) [m]Mental health, including community
mental health services, inpatient mental health
services, dormitory mental health services,
therapeutic and residential treatment centers,
and training of traditional health care
[Indian] practitioners.[;]
(E) [e]Emergency medical services.[;]
(F) [t]Treatment and control of, and
rehabilitative care related to, alcoholism and
drug abuse (including fetal alcohol syndrome)
among Indians.[;]
(G) [a]Accident prevention programs.[;]
(H) [h]Home health care.[;]
(I) [c]Community health representatives.[;
and]
(J) [m]Maintenance and repair.
(K) Traditional Health Care Practices.
(b) No Offset or Limitation.--[Effect on other
appropriations; allocation to service units]
[(1)] Any funds appropriated under the authority of
this section shall not be used to offset or limit any
other appropriations made to the Service under this Act
or the Act of November 2, 1921 (25 U.S.C. 13) (commonly
known as the `Snyder Act'), [section 13 of this title,]
or any other provision of law.
(c) Allocation; Use.--[(2)(A)]
(1) In general.--Funds appropriated under the
authority of this section shall [may] be allocated to
Service Units, Indian Tribes, or Tribal Organizations
[on a service unit basis]. The funds allocated to each
Indian Tribe, Tribal Organization, or S[s]ervice
U[u]nit under this [sub]paragraph shall be used by the
Indian Tribe, Tribal Organization, or S[s]ervice
U[u]nit under this paragraph to improve [reduce] the
health status and reduce the resource deficiency of
each Indian tribe served by such S[s]ervice U[u]nit,
Indian Tribe, or Tribal Organization.
(2)[(B)] Apportionment of allocated funds.--The
apportionment of funds allocated to a S[s]ervice
U[u]nit, Indian Tribe, or Tribal Organization under
[sub]paragraph (1)[(A)] among the health service
responsibilities described in subsection (a)(5)[(4) of
this section] shall be determined by the Service in
consultation with, and with the active participation
of, the affected Indian tribes and Tribal
Organizations.
(d)[(c)] Provisions Relating to Health Status and
R[r]esource[s d]Deficienc[y]ies [levels]
For purposes of this section, the following definitions
apply:[--]
(1) Definition.--The term [``]`health status and
resource deficiency'[''] means the extent to which--
(A) the health status objectives set forth in
section 3(2)[1602(b) of this title] are not
being achieved; and
(B) the Indian [t]Tribe or Tribal
Organization does not have available to it the
health resources it needs, taking into account
the actual cost of providing health care
services given local geographic, climatic,
rural, or other circumstances.
(2) Available resources.--The health resources
available toan Indian [t]Tribe or Tribal Organization
include health resources provided by the Service as well as health
resources used by the Indian [t]Tribe or Tribal Organization, including
services and financing systems provided by any Federal programs,
private insurance, and programs of State or local governments.
(3) Process for review of determinations.--The
Secretary shall establish procedures which allow any
Indian [t]Tribe or Tribal Organization to petition the
Secretary for a review of any determination of the
extent of the health status and resource deficiency of
such Indian T[t]ribe or Tribal Organization.
(e)[(d)] Eligibility for Funds.--[Programs administered by
Indian tribe]
[(1)] Tribal Health Programs [administered by any
Indian tribe or tribal organization under the authority
of the Indian Self-Determination Act] shall be eligible
for funds appropriated under the authority of this
section on an equal basis with programs that are
administered directly by the Service.
[(2) If any funds allocated to a tribe or service
unit under the authority of this section are used for a
contract entered into under the Indian Self-
Determination Act [25 U.S.C.A. Sec. 450f et seq.], a
reasonable portion of such funds may be used for health
planning, training, technical assistance, and other
administrative support functions.]
(f)[(e)] Report [to Congress].--
By no later than the date that is 3 years after the date of
the enactment of the Indian Health Care Improvement Act
Amendments of 2004 [October 29, 1992], the Secretary shall
submit to [the] Congress the current health status and resource
deficiency report of the Service for each [Indian tribe or
s]Service [u]Unit, including newly recognized or acknowledged
Indian T[t]ribes. Such report shall set out--
(1) the methodology then in use by the Service for
determining [t]Tribal health status and resource
deficiencies, as well as the most recent application of
that methodology;
(2) the extent of the health status and resource
deficiency of each Indian tribe served by the Service
or a Tribal Health Program;
(3) the amount of funds necessary to eliminate the
health status and resource deficiencies of all Indian
tribes served by the Service or a Tribal Health
Program; and
(4) an estimate of--
(A) the amount of health service funds
appropriated under the authority of this Act
[chapter], or any other Act, including the
amount of any funds transferred to the
Service[,] for the preceding fiscal year which
is allocated to each S[s]ervice U[u]nit, Indian
[t]Tribe, or Tribal Organization [comparable
entity];
(B) the number of Indians eligible for health
services in each [s]Service [u]Unit or Indian
[t]Tribe or Tribal Organization; and
(C) the number of Indians using the Service
resources made available to each [s]Service
[u]Unit, [or] Indian [t]Tribe or Tribal
Organization, and, to the extent available,
information on the waiting lists and number of
Indians turned away for services due to lack of
resources.
(g)[(f)] Inclusion [Appropriated funds included] in [b]Base
[b]Budget [of Service].--
Funds appropriated under [authority of] this section for
any fiscal year shall be included in the base budget of the
Service for the purpose of determining appropriations under
this section in subsequent fiscal years.
(h)[(g)] Clarification.--[Continuation of Service
responsibilities for backlogs and parity]
Nothing in this section is intended to diminish the primary
responsibility of the Service to eliminate existing backlogs in
unmet health care needs, nor are the provisions of this section
intended to discourage the Service from undertaking additional
efforts to achieve equity [parity] among Indian[s t]Tribes and
Tribal Organizations.
(i)[(h)] Funding Designation.--[Authorization of
appropriations]
Any funds appropriated under the authority of this section
shall be designated as the [``]`Indian Health Care Improvement
Fund'[''].
Sec. 1621a. Catastrophic [h]Health [e]Emergency [f]Fund
(a) Establishment.--[; administration; purpose]
[(1)] There is hereby established an Indian
Catastrophic Health Emergency Fund (hereafter in this
section referred to as the `CHEF' [``Fund''])
consisting of--
(1)[(A)] the amounts deposited under subsection
(f)[(d) of this section,]; and
(2)[(B)] the amounts appropriated to CHEF [the Fund]
under this section.
(b) Administration.--[(2) The Fund] CHEF shall be
administered by the Secretary, acting through the central
office of the Service, solely for the purpose of meeting the
extraordinary medical costs associated with the treatment of
victims of disasters or catastrophic illnesses who are within
the responsibility of the Service.
[(3) The Fund shall not be allocated, apportioned, or
delegated on a service unit, area office, or any other
basis.]
(c) Conditions on Use of Fund.--[(4)] No part of CHEF [the
Fund] or its administration shall be subject to contract or
grant under any law, including the Indian Self-Determination
and Education Assistance Act,[ [25 U.S.C.A. Sec. 450f et
seq.].] nor shall CHEF funds be allocated, apportioned, or
delegated on an Area Office, Service Unit, or other similar
basis.
(d)[(b)] Regulations.--[; procedures for payment]
The Secretary shall, through the negotiated rulemaking
process under title VIII, promulgate [promulgation of]
regulations consistent with the provisions of this section to--
(1) establish a definition of disasters and
catastrophic illnesses for which the cost of the
treatment provided under contract would qualify for
payment from CHEF [the Fund];
(2) provide that a [s]Service [u]Unit shall not be
eligible for reimbursement for the cost of treatment
from CHEF [the Fund] until its cost of treating any
victim of such catastrophic illness or disaster has
reached a certain threshold cost which the Secretary
shall establish at--
(A) the 2000 level of $19,000 [for 1993, not
less than $15,000 or not more than $25,000];
and
(B) for any subsequent year, not less than
the threshold cost of the previous year
increased by the percentage increase in the
medical care expenditure category of the
consumer price index for all urban consumers
(United States city average) for the 12-month
period ending with December of the previous
year;
(3) establish a procedure for the reimbursement of
the portion of the costs that exceeds such threshold
cost incurred by--
(A) [s]Service [u]Units; [or facilities of
the Service,] or
(B) whenever otherwise authorized by the
Service, non-Service facilities or providers[,
in rendering treatment that exceeds such
threshold cost];
(4) establish a procedure for payment from CHEF [the
Fund] in cases in which the exigencies of the medical
circumstances warrant treatment prior to the
authorization of such treatment by the Service; and
(5) establish a procedure that will ensure that no
payment shall be made from CHEF [the Fund] to any
provider of treatment to the extent that such provider
is eligible to receive payment for the treatment from
any other Federal, State, local, or private source of
reimbursement for which the patient is eligible.
(e) No Offset or Limitation.--[(c) Effect on other
appropriations]
Amounts appropriated to CHEF [the Fund] under this section
shall not be used to offset or limit appropriations made to the
Service under authority of the Act of November 2, 1921 (25
U.S.C. 13) (commonly known as the `Snyder Act') [section 13 of
this title], or any other law.
(f)[(d)] Deposit of Reimbursement[s to] Funds.--
There shall be deposited into CHEF [the Fund] all
reimbursements to which the Service is entitled from any
Federal, State, local, or private source (including third party
insurance) by reason of treatment rendered to any victim of a
disaster or catastrophic illness the cost of which was paid
from CHEF [the Fund].
Sec. 1621b. Health [p]Promotion and [d]Disease [p]Prevention
[s]Services
(a) Findings.--Congress finds that health promotion and
disease prevention activities--
(1) improve the health and well-being of Indians; and
(2) reduce the expenses for health care of Indians.
[(a) Authorization]
(b) Provision of Services.--
The Secretary, acting through the Service and Tribal Health
Programs, shall provide health promotion and disease prevention
services to Indians [so as] to achieve the health status
objectives set forth in section 3(2)[1602(b) of this title].
(c)[(b)] Evaluation.--[Statement for Presidential Budget]
The Secretary, after obtaining input from the affected
Tribal Health Programs, shall submit to the President for
inclusion in each report [statement] which is required to be
submitted to [the] Congress under section 801[1671 of this
title] an evaluation of--
(1) the health promotion and disease prevention needs
of Indians[,];
(2) the health promotion and disease prevention
activities which would best meet such needs[,];
(3) the internal capacity of the Service and Tribal
Health Programs to meet such needs[,]; and
(4) the resources which would be required to enable
the Service and Tribal Health Programs to undertake the
health promotion and disease prevention activities
necessary to meet such needs.
Sec. 1621c. Diabetes [p]Prevention, [t]Treatment, and [c]Control
(a) Determinations Regarding Diabetes.--[Incidence and
complications]
The Secretary, acting through the Service, and in
consultation with [the] Indian T[t]ribes and Tribal
Organizations, shall determine--
(1) by an Indian T[t]ribe, Tribal Organization, and
by Service [u]Unit [of the Service], the incidence of,
and the types of complications resulting from, diabetes
among Indians; and
(2) based on the determinations made pursuant to
paragraph (1), the measures (including patient
education and effective ongoing monitoring of disease
indicators) each Service [u]Unit should take to reduce
the incidence of, and prevent, treat, and control the
complications resulting from, diabetes among Indian
T[t]ribes within that Service unit.
(b) Diabetes Screening.--
To the extent medically indicated and with informed
consent, t[T]he Secretary shall screen each Indian who receives
services from the Service for diabetes and for conditions which
indicate a high risk that the individual will become diabetic
and, in consultation with Indian Tribes, Urban Indian
Organizations, and appropriate health care providers, establish
a cost-effective approach to ensure ongoing monitoring of
disease indicators. Such screening and monitoring may be
conducted [done] by a Tribal Health Program and may be
conducted through appropriate Internet-based health care
management programs. [tribe or tribal organization operating
health care programs or facilities with funds from the Service
under the Indian Self-Determination Act [25 U.S.C.A. Sec. 450f
et seq.].]
(c) Funding for Diabetes.--The Secretary shall continue to
fund each model diabetes project in existence on the date of
the enactment of the Indian Health Care Improvement Amendments
Act of 2004, 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 2004 and for projects which
are added and funded thereafter.
[(c) Model diabetes projects
[(1) The Secretary shall continue to maintain through
fiscal year 2000 each model diabetes project in
existence October 29, 1992 and located--
[(A) at the Claremore Indian Hospital in
Oklahoma;
[(B) at the Fort Totten Health Center in
North Dakota;
[(C) at the Sacaton Indian Hospital in
Arizona;
[(D) at the Winnebago Indian Hospital in
Nebraska;
[(E) at the Albuquerque Indian Hospital in
New Mexico;
[(F) at the Perry, Princeton, and Old Town
Health Centers in Maine;
[(G) at the Bellingham Health Center in
Washington;
[(H) at the Fort Berthold Reservation;
[(I) at the Navajo Reservation;
[(J) at the Papago Reservation;
[(K) at the Zuni Reservation; or
[(L) in the States of Alaska, California,
Minnesota, Montana, Oregon, or Utah.
[(2) The Secretary may establish new model diabetes
projects under this section taking into consideration
applications received under this section from all
service areas, except that the Secretary may not
establish a greater number of such projects in one
service area than in any other service area until there
is an equal number of such projects established with
respect to all service areas from which the Secretary
receives qualified applications during the application
period (as determined by the Secretary).]
(d) Funding for Dialysis Programs.--The Secretary shall
provide funding through the Service, Indian Tribes, and Tribal
Organizations to establish dialysis programs, including funding
to purchase dialysis equipment and provide necessary staffing.
[(d) Control officer; registry of patients
[The Secretary shall--
[(1) employ in each area office of the Service at
least one diabetes control officer who shall coordinate
and manage on a full-time basis activities within that
area office for the prevention, treatment, and control
of diabetes;
[(2) establish in each area office of the Service a
registry of patients with diabetes to track the
incidence of diabetes and the complications from
diabetes in that area;
[(3) ensure that data collected in each area office
regarding diabetes and related complications among
Indians is disseminated to all other area offices; and
[(4) evaluate the effectiveness of services provided
through model diabetes projects established under this
section.]
(e) Other Duties of the Secretary.--The Secretary shall, to
the extent funding is available--
(1) 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 a registry of
patients with diabetes to track the incidence of
diabetes and the complications from diabetes in that
area; and
(3) ensure that data collected in each Area Office
regarding diabetes and related complications among
Indians are disseminated to all other 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.]
Sec. 205. Shared Services for Long-Term Care
(a) Funding Agreements for Long-Term Care.--Notwithstanding
any other provisions of law, the Secretary, acting through the
Service, is authorized to enter into Funding Agreements or
other arrangements with Indian Tribes or Tribal Organizations
for the delivery of long-term care and similar services to
Indians. Such funding agreements or other arrangements shall
provide for the sharing of staff or other services between the
Service or a Tribal Health Program and a long-term care or
other similar facility owned and operated (directly or through
a Funding Agreement) by such Indian Tribe or Tribal
Organization.
(b) Contents of Funding Agreements.--A Funding Agreement or
other arrangement entered into pursuant to subsection (a)--
(1) may, at the request of the Indian Tribe or Tribal
Organization, delegate to such Indian Tribe or Tribal
Organization such powers of supervision and control
over Service employees as the Secretary deems necessary
to carry out the purposes of this section;
(2) shall provide that expenses (including salaries)
relating to services that are shared between the
Service and the Tribal Health Program be allocated
proportionately between the Service and the Indian
Tribe or Tribal Organization; and
(3) may authorize such Indian Tribe or Tribal
Organization to construct, renovate, or expand a long-
term care or other similar facility (including the
construction of a facility attached to a Service
facility).
(c) Minimum Requirement.--Any nursing facility provided for
under this section shall meet the requirements for nursing
facilities under section 1919 of the Social Security Act.
(d) Other Assistance.--The Secretary shall provide such
technical and other assistance as may be necessary to enable
applicants to comply with the provisions of this section.
(e) Use of Existing or Underused Facilities.--The Secretary
shall encourage the use of existing facilities that are
underused or allow the use of swing beds for long-term or
similar care.
[Sec. 1621d. Hospice care feasibility study
[(a) Duty of Secretary
[The Secretary, acting through the Service and in
consultation with representatives of Indian tribes, tribal
organizations, Indian Health Service personnel, and hospice
providers, shall conduct a study--
[(1) to assess the feasibility and desirability of
furnishing hospice care to terminally ill Indians; and
[(2) to determine the most efficient and effective
means of furnishing such care.
[(b) Functions of study
[Such study shall--
[(1) assess the impact of Indian culture and beliefs
concerning death and dying on the provision of hospice
care to Indians;
[(2) estimate the number of Indians for whom hospice
care may be appropriate and determine the geographic
distribution of such individuals;
[(3) determine the most appropriate means to
facilitate the participation of Indian tribes and
tribal organizations in providing hospice care;
[(4) identify and evaluate various means for
providing hospice care, including--
[(A) the provision of such care by the
personnel of a Service hospital pursuant to a
hospice program established by the Secretary at
such hospital; and
[(B) the provision of such care by a
community-based hospice program under contract
to the Service; and
[(5) identify and assess any difficulties in
furnishing such care and the actions needed to resolve
such difficulties.
[(c) Report to Congress
[Not later than the date which is 12 months after October
29, 1992, the Secretary shall transmit to the Congress a report
containing--
[(1) a detailed description of the study conducted
pursuant to this section; and
[(2) a discussion of the findings and conclusions of
such study.
[(d) Definitions
[For the purposes of this section--
[(1) the term ``terminally ill'' means any Indian who
has a medical prognosis (as certified by a physician)
of a life expectancy of six months or less; and
[(2) the term ``hospice program'' means any program
which satisfies the requirements of section
1395x(dd)(2) of Title 42; and
[(3) the term ``hospice care'' means the items and
services specified in subparagraphs (A) through (H) of
section 1395x(dd)(1) of Title 42.]
Sec. 206. Health Services Research
The Secretary, acting through the Service, shall make
funding available for research to further the performance of
the health service responsibilities of Indian Health Programs
andshall coordinate the activities of other agencies within the
Department to address these research needs. Tribal Health Programs
shall be given an equal opportunity to compete for, and receive,
research funds under this section. This funding may be used for both
clinical and nonclinical research.
[Sec. 1621e. Reimbursement from certain third parties of costs of
health services
[(a) Right of recovery
[Except as provided in subsection (f) of this section, the
United States, an Indian tribe, or a tribal organization shall
have the right to recover the reasonable expenses incurred by
the Secretary, an Indian tribe, or a tribal organization in
providing health services, through the Service, an Indian
tribe, or tribal organization, to any individual to the same
extent that such individual, or any nongovernmental provider of
such services, would be eligible to receive reimbursement or
indemnification for such expenses if--
[(1) such services had been provided by a
nongovernmental provider, and
[(2) such individual had been required to pay such
expenses and did pay such expenses.
[(b) Recovery against State with workers' compensation laws
or no-fault automobile accident insurance program
[Subsection (a) of this section shall provide a right of
recovery against any State only if the injury, illness, or
disability for which health services were provided is covered
under--
[(1) workers' compensation laws, or
[(2) a no-fault automobile accident insurance plan or
program.
[(c) Prohibition of State law or contract provision
impeding right of recovery
[No law of any State, or of any political subdivision of a
State, and no provision of any contract entered into or renewed
after November 23, 1988, shall prevent or hinder the right of
recovery of the United States, an Indian tribe, or a tribal
organization under subsection (a) of this section.
[(d) Right to damages
[No action taken by the United States, an Indian tribe, or
a tribal organization to enforce the right of recovery provided
under subsection (a) of this section shall affect the right of
any person to any damages (other than damages for the cost of
health services provided by the Secretary through the Service).
[(e) Intervention or separate civil action
[The United States, an Indian tribe, or a tribal
organization may enforce the right of recovery provided under
subsection (a) of this section by--
[(1) intervening or joining in any civil action or
proceeding brought--
[(A) by the individual for whom health
services were provided by the Secretary, an
Indian tribe, or a tribal organization, or
[(B) by any representative or heirs of such
individual, or
[(2) instituting a separate civil action, after
providing to such individual, or to the representative
or heirs of such individual, notice of the intention of
the United States, an Indian tribe, or a tribal
organization to institute a separate civil action.
[(f) Right of recovery for services when self-insurance
plan provides coverage
[The United States shall not have a right of recovery under
this section if the injury, illness, or disability for which
health services were provided is covered under a self-insurance
plan funded by an Indian tribe or tribal organization.]
Sec. 207. Mammography and Other Cancer Screening
The Secretary, acting through the Service or Tribal Health
Programs, shall provide for screening as follows:
(1) Screening mammography (as defined in section
1861(jj) of the Social Security Act) for Indian women
at a frequency appropriate to such women under national
standards, such as those of the National Cancer
Institute for the National Institutes for Health, and
under such terms and conditions as are consistent with
standards established by the Secretary to ensure the
safety and accuracy of screening mammography under part
B of title XVIII of such Act.
(2) Other cancer screening meeting national
standards, such as those of the National Cancer
Institute.
[Sec. 1621f. Crediting of reimbursements
[(a) Except as provided in section 1621a(d) of this title,
subchapter III-A of this chapter, and section 1680c of this
title, all reimbursements received or recovered, under
authority of this chapter, Public Law 87-693 (42 U.S.C. 2651,
et seq.), or any other provision of law, by reason of the
provision of health services by the Service or by a tribe or
tribal organization under a contract pursuant to the Indian
Self-Determination Act [25 U.S.C.A. Sec. 450f et seq.] shall be
retained by the Service or that tribe or tribal organization
and shall be available for the facilities, and to carry out the
programs, of the Service or that tribe or tribal organization
to provide 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.]
Sec. 208. Patient Travel Costs
The Secretary, acting through the Service and Tribal Health
Programs, shall provide funds for the following patient travel
costs, including appropriate and necessary qualified escorts,
associated with receiving health care services provided (either
through direct or contract care or through Funding Agreements)
under this Act--
(1) emergency air transportation and non-emergency
air transportation where ground transportation is
infeasible;
(2) transportation by private vehicle (where no other
means of transportation is available), specially
equipped vehicle, and ambulance; and
(3) transportation by such other means as may be
available and required when air or motor vehicle
transportation is not available.
[Sec. 1621g. Health services research
[Of the amounts appropriated for the Service in any fiscal
year, other than amounts made available for the Indian Health
Care Improvement Fund, not less than $200,000 shall be
available only for research to further the performance of the
health service responsibilities of the Service. Indian tribes
and tribal organizations contracting with the Service under the
authority of the Indian Self-Determination Act [25 U.S.C.A.
Sec. 450f et seq.] shall be given an equal opportunity to
compete for, and receive, research funds under this section.]
Sec. 209. Epidemiology Centers
(a) Additional Centers.--In addition to those epidemiology
centers already established at the time of enactment of this
Act, (including those for which funding is currently being
provided in Funding Agreements), and without reducing the
funding levels for such centers, not later than 180 days after
the date of the enactment of the Indian Health Care Improvement
Act Amendments of 2004, the Secretary, acting through the
Service, shall establish and fund an epidemiology center in
each Service Area which does not yet have one to carry out the
functions described in subsection (b). Any new centers so
established may be operated by Tribal Health Programs, but such
funding shall not be divisible.
(b) Functions of Centers.--In consultation with and upon
the request of Indian Tribes, Tribal Organizations, and Urban
Indian Organizations, each Service Area epidemiology center
established under this subsection shall, with respect to such
Service Area--
(1) collect data relating to, and monitor progress
made toward meeting, each of the health status
objectives of the Service, the Indian Tribes, Tribal
Organizations, and Urban Indian Organizations in the
Service Area;
(2) evaluate existing delivery systems, data systems,
and other systems that impact the improvement of Indian
health;
(3) assist Indian Tribes, Tribal Organizations, and
Urban Indian Organizations in identifying their highest
priority health status objectives and the services
needed to achieve such objectives, based on
epidemiological data;
(4) make recommendations for the targeting of
services needed by the populations served;
(5) make recommendations to improve health care
delivery systems for Indians and Urban Indians;
(6) provide requested technical assistance to Indian
Tribes, Tribal Organizations, and Urban Indian
Organizations in the development of local health
service priorities and incidence and prevalence rates
of disease and other illness in the community; and
(7) provide disease surveillance and assist Indian
Tribes, Tribal Organizations, and Urban Indian
Organizations to promote public health.
(c) Technical Assistance.--The Director of the Centers for
Disease Control and Prevention shall provide technical
assistance to the centers in carrying out the requirements of
this subsection.
(d) Funding for Studies.--The Secretary may make funding
available to Indian Tribes, Tribal Organizations, and Urban
Indian Organizations to conduct epidemiological studies of
Indian communities.
[Sec. 1621h. Mental health prevention and treatment services
[(a) National plan for Indian Mental Health Services
[(1) Not later than 120 days after November 28, 1990,
the Secretary, acting through the Service, shall
develop and publish in the Federal Register a final
national plan for Indian Mental Health Services. The
plan shall include--
[(A) an assessment of the scope of the
problem of mental illness and dysfunctional and
self-destructive behavior, including child
abuse and family violence, among Indians,
including--
[(i) the number of Indians served by
the Service who are directly or
indirectly affected by such illness or
behavior, and
[(ii) an estimate of the financial
and human cost attributable to such
illness or behavior;
[(B) an assessment of the existing and
additional resources necessary for the
prevention and treatment of such illness and
behavior; and
[(C) an estimate of the additional funding
needed by the Service to meet its
responsibilities under the plan.
[(2) The Secretary shall submit a copy of the
national plan to the Congress.
[(b) Memorandum of agreement
[Not later than 180 days after November 28, 1990, the
Secretary and the Secretary of the Interior shall develop and
enter into a memorandum of agreement under which the
Secretaries shall, among other things--
[(1) determine and define the scope and nature of
mental illness and dysfunctional and self-destructive
behavior, including child abuse and family violence,
among Indians;
[(2) make an assessment of the existing Federal,
tribal, State, local, and private services, resources,
and programs available to provide mental health
services for Indians;
[(3) make an initial determination of the unmet need
for additional services, resources, and programs
necessary to meet the needs identified pursuant to
paragraph (1);
[(4)(A) ensure that Indians, as citizens of the
United States and of the States in which they reside,
have access to mental health services to which all
citizens have access;
[(B) determine the right of Indians to participate
in, and receive the benefit of, such services; and
[(C) take actions necessary to protect the exercise
of such right;
[(5) delineate the responsibilities of the Bureau of
Indian Affairs and the Service, including mental health
identification, prevention, education, referral, and
treatment services (including services through
multidisciplinary resource teams), at the central,
area, and agency and service unit levels to address the
problems identified in paragraph (1);
[(6) provide a strategy for the comprehensive
coordination of the mental health services provided by
the Bureau of Indian Affairs and the Service to meet
the needs identified pursuant to paragraph (1),
including--
[(A) the coordination of alcohol and
substance abuse programs of the Service, the
Bureau of Indian Affairs, and the various
tribes (developed under the Indian Alcohol and
Substance Abuse Prevention and Treatment Act of
1986) [25 U.S.C.A. Sec. 2401 et seq.] with the
mental health initiatives pursuant to this
chapter, particularly with respect to the
referral and treatment of dually-diagnosed
individuals requiring mental health and
substance abuse treatment; and
[(B) ensuring that Bureau of Indian Affairs
and Service programs and services (including
multidisciplinary resource teams) addressing
child abuse and family violence are coordinated
with such non-Federal programs and services;
[(7) direct appropriate officials of the Bureau of
Indian Affairs and the Service, particularly at the
agency and service unit levels, to cooperate fully with
tribal requests made pursuant to subsection (d) of this
section; and
[(8) provide for an annual review of such agreement
by the two Secretaries.
[(c) Community mental health plan
[(1) The governing body of any Indian tribe may, at
its discretion, adopt a resolution for the
establishment of a community mental health plan
providing for the identification and coordination of
available resources and programs to identify, prevent,
or treat mental illness or dysfunctional and self-
destructive behavior, including child abuse and family
violence, among its members.
[(2) In furtherance of a plan established pursuant to
paragraph (1) and at the request of a tribe, the
appropriate agency, service unit, or other officials of
the Bureau of Indian Affairs and the Service shall
cooperate with, and provide technical assistance to,
the tribe in the development of such plan. Upon the
establishment of such a plan and at the request of the
tribe, such officials, as directed by the memorandum of
agreement developed pursuant to subsection (c), of this
section, shall cooperate with the tribe in the
implementation of such plan.
[(3) Two or more Indian tribes may form a coalition
for the adoption of resolutions and the establishment
and development of a joint community mental health plan
under this subsection.
[(4) The Secretary, acting through the Service, may
make grants to Indian tribes adopting a resolution
pursuant to paragraph (1) to obtain technical
assistance for the development of a community mental
health plan and to provide administrative support in
the implementation of such plan.
[(d) Mental health training and community education
programs
[(1) The Secretary and the Secretary of the Interior,
in consultation with representatives of Indian tribes,
shall conduct a study and compile a list, of the types
of staff positions specified in paragraph (2) whose
qualifications include, or should include, training in
the identification, prevention, education, referral, or
treatment of mental illness or dysfunctional and self-
destructive behavior.
[(2) The positions referred to in paragraph (1) are--
[(A) staff positions within the Bureau of
Indian Affairs, including existing positions,
in the fields of--
[(i) elementary and secondary
education;
[(ii) social services and family and
child welfare;
[(iii) law enforcement and judicial
services; and
[(iv) alcohol and substance abuse;
[(B) staff positions with the Service; and
[(C) staff positions similar to those
identified in subparagraphs (A) and (B)
established and maintained by Indian tribes,
including positions established in contracts
entered into under the Indian Self-
Determination Act [25 U.S.C.A. Sec. 450f et
seq.].
[(3)(A) The appropriate Secretary shall provide
training criteria appropriate to each type of position
identified in paragraph (2)(A) and ensure that
appropriate training has been, or will be, provided to
any individual in any such position. With respect to
any such individual in a position identified pursuant
to paragraph (2)(C), the respective Secretaries shall
provide appropriate training to, or provide funds to an
Indian tribe for the training of, such individual. In
the case of positions funded under a contract entered
into under the Indian Self-Determination Act [25
U.S.C.A. Sec. 450f et seq.], the appropriate Secretary
shall ensure that such training costs are included in
the contract, if necessary.
[(B) Funds authorized to be appropriated pursuant to
this section may be used to provide training authorized
by this paragraph for community education programs
described in paragraph (5) if a plan adopted pursuant
to subsection (d) of this section identifies
individuals or employment categories, other than those
identified pursuant to paragraph (1), for which such
training or community education is deemed necessary or
desirable.
[(4) Position-specific training criteria described in
paragraph (3) shall be culturally relevant to Indians
and Indian tribes and shall ensure that appropriate
information regarding traditional Indian healing and
treatment practices is provided.
[(5) The Service shall develop and implement or, upon
the request of an Indian tribe, assist such tribe to
develop andimplement, a program of community education
on mental illness and dysfunctional and self-destructive behavior for
individuals, as determined in a plan adopted pursuant to subsection (d)
of this section. In carrying out this paragraph, the Service shall
provide, upon the request of an Indian tribe, technical assistance to
the Indian tribe to obtain or develop community education and training
materials on the identification, prevention, referral, and treatment of
mental illness and dysfunctional and self-destructive behavior.
[(e) Staffing
[(1) Within 90 days after November 28, 1990, the
Secretary shall develop a plan under which the Service
will increase the health care staff providing mental
health services by at least 500 positions within five
years after November 28, 1990, with at least 200 of
such positions devoted to child, adolescent, and family
services. Such additional staff shall be primarily
assigned to the service unit level for services which
shall include outpatient, emergency, aftercare and
follow-up, and prevention and education services.
[(2) The plan developed under paragraph (1) shall be
implemented under section 13 of this title.
[(f) Staff recruitment and retention
[(1) The Secretary shall provide for the recruitment
of the additional personnel required by subsection (f)
of this section and the retention of all Service
personnel providing mental health services. In carrying
out this subsection, the Secretary shall give priority
to practitioners providing mental health services to
children and adolescents with mental health problems.
[(2) In carrying out paragraph (1), the Secretary
shall develop a program providing for--
[(A) the payment of bonuses (which shall not
be more favorable than those provided for under
section 1616i and 1616j of this title) for
service in hardship posts;
[(B) the repayment of loans (for which the
provisions of repayment contracts shall not be
more favorable than the repayment contracts
under section 1616a of this title) for health
professions education as a recruitment
incentive; and
[(C) a system of postgraduate rotations as a
retention incentive.
[(3) This subsection shall be carried out in
coordination with the recruitment and retention
programs under subchapter I of this chapter.
[(g) Mental Health Technician program
[(1) Under the authority of section 13 of this title,
the Secretary shall establish and maintain a Mental
Health Technician program within the Service which--
[(A) provides for the training of Indians as
mental health technicians; and
[(B) employs such technicians in the
provision of community-based mental health care
that includes identification, prevention,
education, referral, and treatment services.
[(2) In carrying out paragraph (1)(A), the Secretary
shall provide high standard paraprofessional training
in mental health care necessary to provide quality care
to the Indian communities to be served. Such training
shall be based upon a curriculum developed or approved
by the Secretary which combines education in the theory
of mental health care with supervised practical
experience in the provision of such care.
[(3) The Secretary shall supervise and evaluate the
mental health technicians in the training program.
[(4) The Secretary shall ensure that the program
established pursuant to this subsection involves the
utilization and promotion of the traditional Indian
health care and treatment practices of the Indian
tribes to be served.
[(h) Mental health research
[The Secretary, acting through the Service and in
consultation with the National Institute of Mental Health,
shall enter into contracts with, or make grants to, appropriate
institutions for the conduct of research on the incidence and
prevalence of mental disorders among Indians on Indian
reservations and in urban areas. Research priorities under this
subsection shall include--
[(1) the inter-relationship and inter-dependence of
mental disorders with alcoholism, suicide, homicides,
accidents, and the incidence of family violence, and
[(2) the development of models of prevention
techniques.
[The effect of the inter-relationships and
interdependenciesreferred 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
services to Indians.
[(6) Grants made pursuant to this section may be
expended over a period of three years and no grant may
exceed $1,000,000 for the fiscal years involved.
[(l) Licensing requirement for mental health care workers
[Any person employed as a psychologist, social worker, or
marriage and family therapist for the purpose of providing
mental health care services to Indians in a clinical setting
under the authority of this chapter or through a contract
pursuant to the Indian Self-Determination Act [25 U.S.C.A.
Sec. 450f et. seq.] shall--
[(1) in the case of a person employed as a
psychologist, be licensed as a clinical psychologist or
working under the direct supervision of a licensed
clinical psychologist;
[(2) in the case of a person employed as a social
worker,be licensed as a social worker or working under
the direct supervision of a licensed social worker; or
[(3) in the case of a person employed as a marriage
and family therapist, be licensed as a marriage and
family therapist or working under the direct
supervision of a licensed marriage and family
therapist.
[(m) Intermediate adolescent mental health services
[(1) The Secretary, acting through the Service, may
make grants to Indian tribes and tribal organizations
to provide intermediate mental health services to
Indian children and adolescents, including--
[(A) inpatient and outpatient services;
[(B) emergency care;
[(C) suicide prevention and crisis
intervention; and
[(D) prevention and treatment of mental
illness, and dysfunctional and self-destructive
behavior, including child abuse and family
violence.
[(2) Funds provided under this subsection may be
used--
[(A) to construct or renovate an existing
health facility to provide intermediate mental
health services;
[(B) to hire mental health professionals;
[(C) to staff, operate, and maintain an
intermediate mental health facility, group
home, or youth shelter where intermediate
mental health services are being provided; and
[(D) to make renovations and hire appropriate
staff to convert existing hospital beds into
adolescent psychiatric units.
[(3) Funds provided under this subsection may not be
used for the purposes described in section 1621o(b)(1)
of this title.
[(4) An Indian tribe or tribal organization receiving
a grant under this subsection shall ensure that
intermediate adolescent mental health services are
coordinated with other tribal, Service, and Bureau of
Indian Affairs mental health, alcohol and substance
abuse, and social services programs on the reservation
of such tribe or tribal organization.
[(5) The Secretary shall establish criteria for the
review and approval of applications for grants made
pursuant to this subsection.
[(6) There are authorized to be appropriated to carry
out this section $10,000,000 for fiscal year 1993 and
such sums as may be necessary for each of the fiscal
year 1993 and such sums as may be necessary for each of
the fiscal years 1994, 1995, 1996, 1997, 1998, 1999,
and 2000.]
Sec. 210. Comprehensive Health Education Programs
(a) Funding for Development of Programs.--The Secretary,
acting through the Service, shall provide funding to Indian
Tribes, Tribal Organizations, and Urban Indian Organizations to
develop comprehensive school health education programs for
children from pre-school through grade 12 in schools for the
benefit of Indian and Urban Indian children.
(b) Use of Funds.--Funding provided under this section may
be used for purposes which may include, but are not limited to,
the following:
(1) Developing and implementing health education
curricula both for regular school programs and
afterschool programs.
(2) Training teachers in comprehensive school health
education curricula.
(3) Integrating school-based, community-based, and
other public and private health promotion efforts.
(4) Encouraging healthy, tobacco-free school
environments.
(5) Coordinating school-based health programs with
existing services and programs available in the
community.
(6) Developing school programs on nutrition
education, personal health, oral health, and fitness.
(7) Developing behavioral health wellness programs.
(8) Developing chronic disease prevention programs.
(9) Developing substance abuse prevention programs.
(10) Developing injury prevention and safety
education programs.
(11) Developing activities for the prevention and
control or communicable diseases.
(12) Developing community and environmental health
education programs that include traditional health care
practitioners.
(13) Violence prevention.
(14) Such other health issues as are appropriate.
(c) Technical Assistance.--Upon request, the Secretary,
acting through the Service, shall provide technical assistance
to Indian Tribes, Tribal Organizations, and Urban Indian
Organizations in the development of comprehensive health
education plans and the dissemination of comprehensive health
education materials and information on existing health programs
and resources.
(d) Criteria for Review and Approval of Applications.--The
Secretary, acting through the Service, and in consultation with
Indian Tribes, Tribal Organizations, and Urban Indian
Organizations, shall establish criteria for the review and
approval of applications for funding provided pursuant to this
section.
(e) Development of Program for BIA Funded Schools.--
(1) In general.--The Secretary of the Interior,
acting through the Bureau of Indian Affairs and in
cooperation with the Secretary, acting through the
Service, and affected Indian Tribes and Tribal
Organizations, shall develop a comprehensive school
health education program for children from preschool
through grade 12 in schools for which support is
provided by the Bureau of Indian Affairs.
(2) Requirements for programs.--Such programs shall
include--
(A) school programs on nutrition education,
personal health, oral health, and fitness;
(B) behavioral health wellness programs;
(C) chronic disease prevention programs;
(D) substance abuse prevention programs;
(E) injury prevention and safety education
programs; and
(F) activities for the prevention and control
of communicable diseases.
(3) Duties of the secretary.--The Secretary of the
Interior shall--
(A) provide training to teachers in
comprehensive school health education
curricula;
(B) ensure the integration and coordination
of school-based programs with existing services
and health programs available in the community;
and
(C) encourage healthy, tobacco-free school
environments.
[Sec. 1621i. Managed care feasibility study
[(a) The Secretary, acting through the Service, shall
conduct a study to assess the feasibility of allowing an Indian
tribe to purchase, directly or through the Service, managed
care coverage for all members of the tribe from--
[(1) a tribally owned and operated managed care plan;
or
[(2) a State licensed managed care plan.
[(b) Not later than the date which is 12 months after
October 29, 1992, the Secretary shall transmit to the Congress
a report containing--
[(1) a detailed description of the study conducted
pursuant to this section; and
[(2) a discussion of the findings and conclusions of
such study.]
Sec. 211. Indian Youth Program
(a) Program Authorized.--The Secretary, acting through the
Service, is authorized to establish and administer a program to
provide funding to Indian Tribes, Tribal Organizations, and
Urban Indian Organizations for innovative mental and physical
disease prevention and health promotion and treatment programs
for Indian and Urban Indian preadolescent and adolescent
youths.
(b) Use of Funds.--
(1) Allowable uses.--Funds made available under this
section may be used to--
(A) develop prevention and treatment programs
for Indian youth which promote mental and
physical health and incorporate cultural
values, community and family involvement, and
traditional health care practitioners; and
(B) develop and provide community training
and education.
(2) Prohibited use.--Funds made available under this
section may not be used to provide services described
in section 707(c).
(c) Duties of the Secretary.--The Secretary shall--
(1) disseminate to Indian Tribes, Tribal
Organizations, and Urban Indian Organizations
information regarding models for the delivery of
comprehensive health care services to Indian and Urban
Indian adolescents;
(2) encourage the implementation of such models; and
(3) at the request of an Indian Tribe, Tribal
Organization, or Urban Indian Organization, provide
technical assistance in the implementation of such
models.
(d) Criteria for Review and Approval of Applications.--The
Secretary, in consultation with Indian Tribes, Tribal
Organizations, and Urban Indian Organizations, shall establish
criteria for the review and approval of applications or
proposals under this section.
[Sec. 1621j. California contract health services demonstration program
[(a) Establishment
[The Secretary shall establish a demonstration program to
evaluate the use of a contract care intermediary to improve the
accessibility of health services to California Indians.
[(b) Agreement with California Rural Indian Health Board
[(1) In establishing such program, the Secretary
shall enter into an agreement with the California Rural
Indian Health Board to reimburse the Board for costs
(including reasonable administrative costs) incurred,
during the period of the demonstration program, in
providing medical treatment under contract to
California Indians described in section 1679(b) of this
title throughout the California contract health
services delivery area described in section 1680 of
this title with respect to high-cost contract care
cases.
[(2) Not more than 5 percent of the amounts provided
to the Board under this section for any fiscal year may
be for reimbursement for administrative expenses
incurred by the Board during such fiscal year.
[(3) No payment may be made for treatment provided
under the demonstration program to the extent payment
may be made for such treatment under the Catastrophic
Health Emergency Fund described in section 1621a of
this title or from amounts appropriated or otherwise
made available to the California contract health
service delivery area for a fiscal year.
[(c) Advisory board
[There is hereby established an advisory board which shall
advise the California Rural Indian Health Board in carrying out
the demonstration pursuant to this section. The advisory board
shall be composed of representatives, selected by the
California Rural Indian Health Board, from not less than 8
tribal health programs serving California Indians covered under
such demonstration, at least one half of whom are not
affiliated with the California Rural Indian Health Board.
[(d) Commencement and termination dates
[The demonstration program described in this section shall
begin on January 1, 1993, and shall terminate on September 30,
1997.
[(e) Report
[Not later than July 1, 1998, the California Rural Indian
Health Board shall submit to the Secretary a report on the
demonstration program carried out under this section, including
a statement of its findings regarding the impact of using a
contract care intermediary on--
[(1) access to needed health services;
[(2) waiting periods for receiving such services; and
[(3) the efficient management of high-cost contract
care cases.
[(f) ``High-cost contract care cases'' defined
[For the purposes of this section, the term ``high-cost
contract care cases'' means those cases in which the cost of
the medical treatment provided to an individual--
[(1) would otherwise be eligible for reimbursement
from the Catastrophic Health Emergency Fund established
under section 1621a of this title, except that the cost
of such treatment does not meet the threshold cost
requirement established pursuant to section 1621a(b)(2)
of this title; and
[(2) exceeds $1,000.
[(g) Authorization of appropriations
[There are authorized to be appropriated for each of the
fiscal years 1996 through 2000 such sums as may be necessary to
carry out the purposes of this section.]
Sec. 212. Prevention, Control, and Elimination of Communicable and
Infectious Diseases
(a) Funding Authorized.--The Secretary, acting through the
Service, and after consultation with Indian Tribes, Tribal
Organizations, Urban Indian Organizations, and the Centers for
Disease Control and Prevention, may make funding available to
Indian Tribes, Tribal Organizations, and Urban Indian
Organizations for the following:
(1) Projects for the prevention, control, and
elimination of communicable and infectious diseases
including, but not limited to, tuberculosis, hepatitis,
human immunodeficiency virus, respiratory syncytial
virus, hanta virus, sexually transmitted diseases, and
Helicobacter Pylori Infections.
(2) Public information and education programs for the
prevention, control, and elimination of communicable
and infectious diseases.
(3) Education, training, and clinical skills
improvement activities in the prevention, control, and
elimination of communicable and infectious diseases for
health professionals, including allied health
professionals.
(4) Demonstration projects for the screening,
treatment, and prevention of hepatitis C virus (HCV).
(b) Application Required.--The Secretary may provide
funding under subsection (a) only if an application or proposal
for funding is submitted to the Secretary.
(c) Coordination With Health Agencies.--Indian Tribes,
Tribal Organizations, and Urban Indian Organizations receiving
funding under this section are encouraged to coordinate their
activities with the Centers for Disease Control and Prevention
and State and local health agencies.
(d) Technical Assistance; Report.--In carrying out this
section, the Secretary--
(1) may, at the request of an Indian Tribe, Tribal
Organization, or Urban Indian Organization, provide
technical assistance; and
(2) shall prepare and submit a report to Congress
biennially on the use of funds under this section and
on the progress made toward the prevention, control,
and elimination of communicable and infectious diseases
among Indians and Urban Indians.
[Sec. 1621k. Coverage of screening mammography
[The Secretary, through the Service, shall provide for
screening mammography (as defined in section 1861(jj) of the
Social Security Act [42 U.S.C.A. Sec. 1395x9JJ0]) for Indian
and urban Indian women 35 years of age or older at a frequency,
determined by the Secretary (in consultation with the Director
of the National Cancer Institute), appropriate to such women,
and under such terms and conditions as are consistent with
standards established by the Secretary to assure the safety and
accuracy of screening mammography under part B of title XVIII
of the Social Security Act [42 U.S.C.A. Sec. 1395j et. seq.]. ]
Sec. 213. Authority for Provision of Other Services
(a) Funding Authorized.--The Secretary, acting through the
Service, Indian Tribes, and Tribal Organizations, may provide
funding under this Act to meet the objectives set forth in
section 3 through health care-related services and programs not
otherwise described in this Act, which shall include, but not
be limited to--
(1) hospice care;
(2) assisted living;
(3) long-term health care;
(4) home- and community-based services;
(5) public health functions; and
(6) Traditional Health Care Practices.
(b) Services to Otherwise Ineligible Persons.--At the
discretion of the Service, Indian Tribes, or Tribal
Organizations, services provided for hospice care, home health
care, home- and community-based care, assisted living, and
long-term care may be provided (subject to reimbursement of
reasonable charges) to persons otherwise ineligible for the
health care benefits of the Service. Any funds received under
this subsection shall not be used to offset or limit the
funding allocated to an Indian Tribe or Tribal Organization.
(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 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.
(G) Adult day care.
(H) Such other home- and community-based
services as the Secretary, an Indian Tribe, or
Tribal Organization may approve.
(2) The term `hospice care' means the items and
services specified in subparagraphs (A) through (H) of
section 1861(dd)(1) of the Social Security Act (42
U.S.C. 1395x(dd)(1)), and such other services which an
Indian Tribe or Tribal Organization determines are
necessary and appropriate to provide in furtherance of
this care.
(3) The term `public health functions' means the
provision of public health-related programs, functions,
and services including, but not limited to, assessment,
assurance, and policy development which Indian Tribes
and Tribal Organizations are authorized and encouraged,
in those circumstances where it meets their needs, to
do by forming collaborative relationships with all
levels of local, State, and Federal Government.
[Sec. 1621l. Patient travel costs
[(a) The Secretary, acting through the Service, shall
provide funds for the following patient travel costs associated
with receiving health care services provided (either through
direct or contract care or through contracts entered into
pursuant to the Indian Self-Determination Act [25 U.S.C.A.
Sec. 450f et. seq.]) under this chapter--
[(1) emergency air transportation; and
[(2) nonemergency air transportation where ground
transportation is infeasible.
[(b) There are authorized to be appropriated to carry out
this section $15,000,000 for fiscal year 1993 and such sums as
may be necessary for each of the fiscal years 1994, 1995, 1996,
1997, 1998, 1999, and 2000.]
Sec. 214. Indian Women's Health Care
The Secretary, acting through the Service and Indian
Tribes, Tribal Organizations, and Urban Indian Organizations,
shall provide funding to monitor and improve the quality of
health care for Indian women of all ages through the planning
and delivery of programs administered by the Service, in order
to improve and enhance the treatment models of care for Indian
women.
[Sec. 1621m. Epidemiology centers
[(a)(1) The Secretary shall establish an epidemiology
center in each Service area to carry out the functions
described in paragraph (3).
[(2) To assist such centers in carrying out such functions,
the Secretary shall perform the following:
[(A) In consultation with the Centers for Disease
Control and Indian tribes, develop sets of data (which
to the extent practicable, shall be consistent with the
uniform datasets 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--
[(A) collect data relating to, and monitor progress
made toward meeting, each of the health status
objectives described in section 1602(b) of this title
using the data sets and monitoring system developed by
the Secretary pursuant to paragraph (2);
[(B) evaluate existing delivery systems, data
systems, and other systems that impact the improvement
of Indian health;
[(C) assist tribes and urban Indian communities in
identifying their highest priority health status
objectives and the services needed to achieve such
objectives, based on epidemiological data;
[(D) make recommendations for the targeting of
services needed by tribal, urban, and other Indian
communities;
[(E) make recommendations to improve health care
delivery systems for Indians and urban Indians;
[(F) work cooperatively with tribal providers of
health and social services in order to avoid
duplication of existing services; and
[(G) provide technical assistance to Indian tribes
and urban Indian organizations in the development of
local health service priorities and incidence and
prevalence rates of disease and other illness in the
community.
[(4) Epidemiology centers established under this
subsection shall be subject to the provisions of the Indian
Self-Determination Act (25 U.S.C. 450f et seq.).
[(5) The director of the Centers for Disease Control
shall provide technical assistance to the centers in carrying
out the requirements of this subsection.
[(6) The Service shall assign one epidemiologist from
each of its area offices to each area epidemiology center to
provide such center with technical assistance necessary to
carry out this subsection.
[(b)(1) The Secretary may make grants to Indian tribes,
tribal organizations, and eligible intertribal consortia or
Indian organization to conduct epidemiological studies of
Indian communities.
[(2) An intertribal consortia or Indian organization is
eligible to receive a grant under this subsection if--
[(A) it is incorporated for the primary purpose of
improving Indian health; and
[(B) it is representative of the tribes or urban
Indian communities in which it is located.
[(3) An application for a grant under this subsection
shall be submitted in such manner and at such time as the
Secretary shall prescribe.
[(4) Applicants for grants under this subsection shall--
[(A) demonstrate the technical, administrative, and
financial expertise necessary to carry out the
functions described in paragraph (5);
[(B) consult and cooperate with providers of related
health and social services in order to avoid
duplication of existing services; and
[(C) demonstrate cooperation from Indian tribes or
urban Indian organizations in the area to be served.
[(5) A grant awarded under paragraph (1) may be used to--
[(A) carry out the functions described in subsection
(a)(3) of this section;
[(B) provide information to and consult with tribal
leaders, urban Indian community leaders, and related
health staff, on health care and health services
management issues; and
[(C) provide, in collaboration with tribes and urban
Indian communities, the Service with information
regarding waysto improve the health status of Indian
people.
[(6) There are authorized to be appropriated to carry out
the purposes of this subsection not more that $12,000,000 for
fiscal year 1993 and such sums as may be necessary for each of
the fiscal years 1994, 1995, 1996, 1997, 1998, 1999, and 2000.]
Sec. 215. Environmental and Nuclear Health Hazards
(a) Studies and Monitoring.--The Secretary and the Service
shall conduct, in conjunction with other appropriate Federal
agencies and in consultation with concerned Indian Tribes and
Tribal Organizations, studies and ongoing monitoring programs
to determine trends in the health hazards to Indian miners and
to Indians on or near reservations and Indian communities as a
result of environmental hazards which may result in chronic or
life threatening health problems, such as nuclear resource
development, petroleum contamination, and contamination of
water source and of the food chain. Such studies shall
include--
(1) an evaluation of the nature and extent of health
problems caused by environmental hazards currently
exhibited among Indians and the causes of such health
problems;
(2) an analysis of the potential effect of ongoing
and future environmental resource development on or
near reservations and Indian communities, including the
cumulative effect over time on health;
(3) and evaluation of the types and nature of
activities, practices, and conditions causing or
affecting such health problems including, but not
limited to, uranium mining and milling, uranium mining
tailing deposits, nuclear power plant operation and
construction, and nuclear waste disposal; oil and gas
production or transportation on or near reservations or
Indian communities; and other development that could
affect the health of Indians and their water supply and
food chain;
(4) a summary of any findings and recommendations
provided in Federal and State studies, reports,
investigations, and inspections during the 5 years
prior to the date of the enactment of the Indian Health
Care Improvement Act Amendments of 2004 that directly
or indirectly relate to the activities, practices, and
conditions affecting the health or safety of such
Indians; and
(5) the efforts that have been made by Federal and
State agencies and resource and economic development
companies to effectively carry out an education program
for such Indians regarding the health and safety
hazards of such development.
(b) Health Care Plans.--Upon completion of such studies,
the Secretary and the Service shall take into account the
results of such studies and, in consultation with Indian Tribes
and Tribal Organizations, develop health care plans to address
the health problems studied under subsection (a). The plans
shall include--
(1) methods for diagnosing and treating Indians
currently exhibiting such health problems;
(2) preventive care and testing for Indians who may
be exposed to such health hazards, including the
monitoring of the health of individuals who have or may
have been exposed to excessive amounts of radiation or
affected by other activities that have had or could
have a serious impact upon the health of such
individuals; and
(3) a program of education for Indians who, by reason
of their work or geographic proximity to such nuclear
or other development activities, may experience health
problems.
(c) Submission of Report and Plan to Congress.--The
Secretary and the Service shall submit to Congress the study
prepared under subsection (a) no later than 18 months after the
date of the enactment of the Indian Health Care Improvement Act
Amendments of 2004. 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
Safetyand Health.
(E) The Secretary of the Interior.
(F) The Secretary of Health and Human
Services.
(G) The Director of the Indian Health
Service.
(2) Duties.--The Task Force shall--
(A) identify existing and potential
operations related to nuclear resource
development or other environmental hazards that
affect or may affect the health of Indians on
or near a reservation or in an Indian
community; and
(B) enter into activities to correct existing
health hazards and ensure that current and
future health problems resulting from nuclear
resource or other development activities are
minimized or reduced.
(3) Chairman; meetings.--The Secretary of Health and
Human Services shall be the Chairman of the Task Force.
The Task Force shall meet at least twice each year.
(e) Health Services to Certain Employees.--In the case of
any Indian who--
(1) as a result of employment in or near a uranium
mine or mill or near any other environmental hazard,
suffers from a work-related illness or condition;
(2) is eligible to receive diagnosis and treatment
services from an Indian Health Program; and
(3) by reason of such Indian's employment, is
entitled to medical care at the expense of such mine or
mill operator or entity responsible for the
environmental hazard, the Indian Health Program shall,
at the request of such Indian, render appropriate
medical care to such Indian for such illness or
condition and may be reimbursed for any medical care so
rendered to which such Indian is entitled at the
expense of such operator or entity from such operator
or entity. Nothing in this subsection shall affect the
rights of such Indian to recover damages other than
such amounts paid to the Indian Health Program from the
employer for providing medical care for such illness or
condition.
[Sec. 1621n. Comprehensive school health education programs
[(a) Award of grants
[The Secretary, acting through the Service and in
consultation with the Secretary of the Interior, may award
grants to Indian tribes to develop comprehensive school health
education programs for children from preschool through grade 12
in schools located on Indian reservations.
[(b) Use of grants
[Grants awarded under this section may be used to--
[(1) develop health education curricula;
[(2) train teachers in comprehensive school health
education curricula;
[(3) integrate school-based, community-based, and
other public and private health promotion efforts;
[(4) encourage healthy, tobacco-free school
environments;
[(5) coordinate school-based health programs with
existing services and programs available in the
community;
[(6) develop school programs on nutrition education,
personal health, and fitness;
[(7) develop mental health wellness programs;
[(8) develop chronic disease prevention programs;
[(9) develop substance abuse prevention programs;
[(10) develop accident prevention and safety
education programs;
[(11) develop activities for the prevention and
control of communicable diseases; and
[(12) develop community and environmental health
education programs.
[(c) Assistance
[The Secretary shall provide technical assistance to Indian
tribes in the development of health education plans, and the
dissemination of health education materials and information on
existing health programs and resources.
[(d) Criteria for review and approval of applications
[The Secretary shall establish criteria for the review and
approval of applications for grants made pursuant to this
section.
[(e) Report of recipient
[Recipients of grants under this section shall submit to
the Secretary an annual report on activities undertaken with
funds provided under this section. Such reports shall include a
statement of--
[(1) the number of preschools, elementary schools,
and secondary schools served;
[(2) the number of students served;
[(3) any new curricula established with funds
provided under this section;
[(4) the number of teachers trained in the health
curricula; and
[(5) the involvement of parents, members of the
community, and community health workers in programs
established with funds provided under this section.
[(f) Program development
[(1) The Secretary of the Interior, acting through
the Bureau of Indian Affairs and in cooperation with
the Secretary, shall develop a comprehensive school
health education program for children from preschool
through grade 12 in schools operated by the Bureau of
Indian Affairs.
[(2) Such program shall include--
[(A) school programs on nutrition education,
personal health, and fitness;
[(B) mental health wellness programs;
[(C) chronic disease prevention programs;
[(D) substance abuse prevention programs;
[(E) accident prevention and safety education
programs; and
[(F) activities for the prevention and
control of communicable diseases.
[(3) The Secretary of the Interior shall--
[(A) provide training to teachers in
comprehensive school health education
curricula;
[(B) ensure the integration and coordination
of school-based programs with existing services
and health programs available in the community;
and
[(C) encourage healthy, tobacco-free school
environments.
[(g) Authorization of appropriations
[There are authorized to be appropriated to carry out this
section $15,000,000 for the fiscal year 1993 and such sums as
may be necessary for each of the fiscal years 1994, 1995, 1996,
1997, 1998, 1999, and 2000.]
Sec. 216. Arizona as a Contract Health Service Delivery Area
(a) In General.--For fiscal years beginning with the fiscal
year ending September 30, 1983, and ending with the fiscal year
ending September 30, 2015, the State of Arizona shall be
designated as a contract health service delivery area by the
Service for the purpose of providing contract health care
services to members of federally recognized Indian Tribes of
Arizona.
(b) Maintenance of Services.--The Service shall not curtail
any health care services provided to Indians residing on
reservations in the State of Arizona if such curtailment is due
to the provision of contract services in such State pursuant to
the designation of such State as a contract health service
delivery area pursuant to subsection (a).
Sec. 216A. North Dakota as a Contract Health Service Delivery Area
(a) In General.--For fiscal years beginning with the fiscal
year ending September 30, 2003, and ending with the fiscal year
ending September 30, 2015, the State of North 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.
(b) Limitation.--The Service shall not curtail any health
care services provided to Indians residing on reservations in
theState of North Dakota 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. 216B. South Dakota as a Contract Health Service Delivery Area
(a) In General.--For fiscal years beginning with the fiscal
year ending September 30, 2003, and ending with the fiscal year
ending on September 30, 2015, the State of 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
South Dakota.
(b) Limitation.--The Service shall not curtail any health
care services provided to Indians residing on reservations in
the State of South Dakota 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. 1621o. Indian youth grant program
[(a) Grants
[The Secretary, acting through the Service, is authorized
to make grants to Indian tribes, tribal organizations, and
urban Indian organizations for innovative mental and physical
disease prevention and health promotion and treatment programs
for Indian preadolescent and adolescent youths.
[(b) Use of funds
[(1) Funds made available under this section may be
used to--
[(A) develop prevention and treatment
programs for Indian youth which promote mental
and physical health and incorporate cultural
values, community and family involvement, and
traditional healers; and
[(B) develop and provide community training
and education.
[(2) Funds made available under this section may not
be used to provide services described in section
1621h(m) of this title.
[(c) Models for delivery of comprehensive health care
services
[The Secretary shall--
[(1) disseminate to Indian tribes information
regarding models for the delivery of comprehensive
health care services to Indian and urban Indian
adolescents;]
[(2) encourage the implementation of such models;
and]
[(3) at the request of an Indian tribe, provide
technical assistance in the implementation of such
models.
[(d) Criteria for review and approval of applications
[The Secretary shall establish criteria for the review and
approval of applications under this section.
[(e) Authorization of appropriations
[There are authorized to be appropriated to carry out this
section $5,000,000 for fiscal yar 1993 and such sums as may be
necessary for each of the fiscal years 1994, 1995, 1996, 1997,
1998, 1999, and 2000.]
Sec. 217. California Contract Health Services Program
(a) Funding Authorized.--The Secretary is authorized to
fund a program using the California Rural Indian Health Board
(hereafter in this section referred to as the 'CRIHB') as a
contract care intermediary to improve the accessibility of
health services to California Indians.
(b) Reimbursement Contract.--The Secretary shall enter into
an agreement with the CRIHB to reimburse the CRIHB for costs
(including reasonable administrative costs) incurred pursuant
to this section, in providing medical treatment under contract
to California Indians described in section 806(a) throughout
the California contract health services delivery area described
in section 218 with respect to high cost contract care cases.
(c) Administrative Expenses.--Not more than 5 percent of
the amounts provided to the CRIHB under this section for any
fiscal year may be for reimbursement for administrative
expenses incurred by the CRIHB during such fiscal year.
(d) Limitation on Payment.--No payment may be made for
treatment provided hereunder to the extent payment may be made
for such treatment under the Indian Catastrophic Health
Emergency Funddescribed 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 hereby established an
advisory board which shall advise the CRIHB in carrying out
this section. The advisory board shall be composed of
representatives, selected by the CRIHB, from not less than 8
Tribal Health Programs serving California Indians covered under
this section at least one half of whom are not affiliated with
the CRIHB.
Sec. 218. California as a Contract Health Service Delivery Area
The State of California, excluding the counties of Alameda,
Contra Costa, Los Angeles, Marin, Orange, Sacramento, San
Francisco, San Mateo, Santa Clara, Kern, Merced, Monterey,
Napa, San Benito, San Joaquin, San Luis Obispo, Santa Cruz,
Solano, Stanislaus, and Ventura, shall be designated as a
contract health service delivery area by the Service for the
purpose of providing contract health services to California
Indians. However, any of the counties listed herein may only be
included in the contract health services delivery area if
funding is specifically provided by the Service for such
services in those counties.
Sec. 219. Contract Health Services for the Trenton Service Area
(a) Authorization for Services.--The Secretary, acting
through the Service, is directed to provide contract health
services to members of the Turtle Mountain Band of Chippewa
Indians that reside in the Trenton Service Area of Divide,
McKenzie, and Williams counties in the State of North Dakota
and the adjoining counties of Richland, Roosevelt, and Sheridan
in the State of Montana.
(b) No Expansion of Eligibility.--Nothing in this section
may be construed as expanding the eligibility of members of the
Turtle Mountain Band of Chippewa Indians for health services
provided by the Service beyond the scope of eligibility for
such health services that applied on May 1, 1986.
[Sec. 1621p. American Indians Into Psychology Program
[(a) Grants
[The Secretary may provide grants to at least 3 colleges
and universities for the purpose of developing and maintaining
American Indian psychology career recruitment programs as a
means of encouraging Indians to enter the mental health field.
[(b) Quentin N. Burdick American Indians Into Psychology
Program
[The Secretary shall provide one of the grants authorized
under subsection (a) of this section to develop and maintain a
program at the University of North Dakota to be known as the
``Quentin N. Burdick American Indians Into Psychology
Program''. Such program shall, to the maximum extent feasible,
coordinate with the Quentin N. Burdick Indian Health Programs
authorized under section 1616g(b) of this title, the Quentin N.
Burdick American Indians Indians Into Nursing Program
authorized under section 1616e(e) of this title, and existing
university research and communications networks.
[(c) Issuance of regulations
[(1) The Secretary shall issue regulations for the
competitive awarding of the grants provided under this
section.
[(2) Applicants for grants under this section shall
agree to provide a program which, at a minimum--
[(A) provides outreach and recruitment for
health professions to Indian communities
including elementary, secondary and community
colleges located on Indian reservations that
will be served by the program;
[(B) incorporates a program advisory board
comprised of representatives from the tribes
and communities that will be served by the
program;
[(C) provides summer enrichment programs to
expose Indian students to the varied fields of
psychology through research, clinical, and
experiential activities;
[(D) provides stipends to undergraduate and
graduate students to pursue a career in
psychology;
[(E) develops affiliation agreements with
tribal community colleges, the Service,
university affiliated programs, and other
appropriate entities to enhance the education
of Indian students;
[(F) to the maximum extent feasible, utilizes
existing university tutoring, counseling and
student support services; and
[(G) to the maximum extent feasible, employs
qualified Indians in the program.
[(d) Active duty service obligation
[The active duty service obligation prescribed under
section 254m of Title 42 shall be met by each graduate student
who receives a stipend described in subsection (c)(2)(D) of
this section that is funded by a grant provided under this
section. Such obligation shall be met by service--
[(1) in the Indian Health Service;
[(2) in a program conducted under a contract entered
into under the Indian Self-Determination Act [25
U.S.C.A. Sec. 450f et seq.],
[(3) in a program assisted under subchapter IV of
this chapter; or
[(4) in the private practice of psychology if, as
determined by the Secretary, in accordance with
guidelines promulgated by the Secretary, such practice
is situated in a physician or other health professional
shortage area and addresses the health care needs of a
substantial number of Indians.
[Sec. 1621q. Prevention, control, and elimination of tuberculosis
[(a) Grants
[The Secretary, acting through the Service after
consultation with the Centers for Disease Control, may make
grants to Indian tribes and tribal organizations for--
[(1) projects for the prevention, control, and
elimination of tuberculosis;
[(2) public information and education programs for
the prevention, control, and elimination of
tuberculosis; and
[(3) education, training, and clinical skills
improvement activities in the prevention, control, and
elimination of tuberculosis for health professionals,
including allied health professionals.
[(b) Application for grant
[The Secretary may make a grant under subsection (a) of
this section only if an application for the grant is submitted
to the Secretary and the application is in such form, is made
in such manner, and contains the assurances required by
subsection (c) of this section and such other agreements,
assurances, and information as the Secretary may require.
[(c) Eligibility for grant
[To be eligible for a grant under subsection (a) of this
section, an applicant must provide assurances satisfactory to
the Secretary that--
[(1) the applicant will coordinate its activities for
the prevention, control, and elimination of
tuberculosis with activities of the Centers for Disease
Control, and State and local health agencies; and
[(2) the applicant will submit to the Secretary an
annual report on its activities for the prevention,
control, and elimination of tuberculosis.
[(d) Duties of Secretary
[In carrying out this section, the Secretary--
[(1) shall establish criteria for the review and
approval of applications for grants under subsection
(a) of this section, including requirement of public
health qualifications of applicants;
[(2) shall, subject to available appropriations, make
at least one grant under subsection (a) of this section
within each area office;
[(3) may, at the request of an Indian tribe or tribal
organization, provide technical assistance; and
[(4) shall prepare and submit a report to the
Committee on Energy and Commerce and the Committee on
Natural Resources of the House and the Committee on
Indian Affairs of the Senate not later than February 1,
1994, and biennially thereafter, on the use of funds
under this section and on the progress made toward the
prevention, control, and elimination of tuberculosis
among Indian tribes and tribal organizations.
[(e) Reduction of amount of grant
[The Secretary may, at the request of a recipient of a
grant under subsection (a) of this section, reduce the amount
of such grant by--
[(1) the fair market value of any supplies or
equipment furnished the grant recipient; and
[(2) the amount of the pay, allowances, and travel
expenses of any officer or employee of the Government
when detailed to the grant recipient and the amount of
any other costs incurred in connection with the detail
of such officer or employee,
when the furnishing of such supplies or equipment or the detail
of such an officer or employee is for the convenience of and at
the request of such grant recipient and for the purpose of
carrying out a program with respect to which the grant under
subsection (a) of this section is made. The amount by which any
such grant is so reduced shall be available for payment by the
Secretary of the costs incurred in furnishing the supplies or
equipment, or in detailing the personnel, on which the
reduction of such grant is based, and such amount shall be
deemed as part of the grant and shall be deemed to have been
paid to the grant recipient.
[Sec. 1621r. Contract health services payment study
[(a) Duty of Secretary
[The Secretary, acting through the Service and in
consultation with representatives of Indian tribes and tribal
organizations operating contract health care programs under the
Indian Self-Determination Act (25 U.S.C. 450f et seq.) or under
self-governance compacts, Service personnel, private contract
health services providers, the Indian Health Service Fiscal
Intermediary, and other appropriate experts, shall conduct a
study--
[(1) to assess and identify administrative barriers
that hinder the timely payment for services delivered
by private contract health services providers to
individual Indians by the Service and the Indian Health
Service Fiscal Intermediary;
[(2) to assess and identify the impact of such
delayed payments upon the personal credit histories of
individual Indians who have been treated by such
providers; and
[(3) to determine the most efficient and effective
means of improving the Service's contract health
services payment system and ensuring the development of
appropriate consumer protection policies to protect
individual Indians who receive authorized services from
private contract health services providers from billing
and collection practices, including the development of
materials and programs explaining patients' rights and
responsibilities.
[(b) Functions of study
[The study required by subsection (a) of this section
shall--
[(1) assess the impact of the existing contract
health services regulations and policies upon the
ability of the Service and the Indian Health Service
Fiscal Intermediary to process, on a timely and
efficient basis, the payment of bills submitted by
private contract health services providers;
[(2) assess the financial and any other burdens
imposed upon individual Indians and private contract
health services providers by delayed payments;
[(3) survey the policies and practices of collection
agencies used by contract health services providers to
collect payments for services rendered to individual
Indians;
[(4) identify appropriate changes in Federal
policies, administrative procedures, and regulations,
to eliminate the problems experienced by private
contract health services providers and individual
Indians as a result of delayed payments; and
[(5) compare the Service's payment processing
requirements with private insurance claims processing
requirement to evaluate the systemic differences or
similarities employed by the Service and private
insurers.
[(c) Report to congress
[Not later than 12 months after October 29, 1992, the
Secretary shall transmit to the Congress a report that
includes--
[(1) a detailed description of the study conducted
pursuant to this section; and
[(2) a discussion of the findings and conclusions of
such study.
[Sec. 1621s. Prompt action on payment of claims
[(a) Time of response
[The Service shall respond to a notification of a claim by
a provider of a contract care service with either an individual
purchase order or a denial of the claim within 5 working days
after the receipt of such notification.
[(b) Failure to timely respond
[If the Service fails to respond to a notification of a
claim in accordance with subsection (a) of this section, the
Service shall accept as valid the claim submitted by the
provider of a contract care service.
[(c) Time of payment
[The Service shall pay a completed contract care service
claim within 30 days after completion of the claim.
[Sec. 1621t. Demonstration of electronic claims processing
[(a) Not later than June 15, 1993, the Secretary shall
develop and implement, directly or by contract, 2 projects to
demonstrate in a pilot setting the use of claims processing
technology to improve the accuracy and timeliness of the
billing for, and payment of, contract health services.
[(b) The Secretary shall conduct one of the projects
authorized in subsection (a) of this section in the Service
area served by the area office located in Phoenix, Arizona.
[Sec. 1621u. Liability for payment
[(a) A patient who receives contract health care services
that are authorized by the Service shall not be liable for the
payment of any charges or costs associated with the provision
of such services.
[(b) The Secretary shall notify a contract care provider
and any patient who receives contract health care services
authorized by the Service that such patient is not liable for
the payment of any charges or costs associated with the
provision of such services.
[Sec. 1621v. Office of Indian Women's Health Care
[There is established within the Service an Office of
Indian Women's Health Care to oversee efforts of the Service to
monitor and improve the quality of health care for Indian women
of all ages through the planning and delivery of programs
administered by the Service, in order to improve and enhance
the treatment models of care for Indian women.]
Sec. 220. Programs Operated by Indian Tribes and Tribal Organizations
The Service shall provide funds for health care programs
and facilities operated by Tribal Health Programs on the same
basis as such funds are provided to programs and facilities
operated directly by the Service.
Sec. 221. Licensing or Certification
Health care professionals employed by a Tribal Health
Program shall, if licensed or certified in any State, be exempt
from the licensing or certification requirements of the State
in which the Tribal Health Program performs the services
described in its Funding Agreement.
Sec. 222. Notification of Provision of Emergency Contract Health
Services
With respect to an elderly Indian or an Indian with a
disability receiving emergency medical care or services from a
non-Service provider or in a non-Service facility under the
authority of this Act, the time limitation (as a condition of
payment) for notifying the Service of such treatment or
admission shall be 30 days.
Sec. 223. Prompt Action on Payment of Claims
(a) Deadline for Response.--The Service shall respond to a
notification of a claim by a provider of a contract care
service with either an individual purchase order or a denial of
the claim within 5 working days after the receipt of such
notification.
(b) Effect of Untimely Response.--If the Service fails to
respond to a notification of a claim in accordance with
subsection (a), the Service shall accept as valid the claim
submitted by the provider of a contract care service.
(c) Deadline for Payment of Valid Claim--The Service shall
pay a valid contract care service claim within 30 days after
the completion of the claim.
Sec. 224. Liability for Payment
(a) No Patient Liability.--A patient who receives contract
health care services that are authorized by the Service shall
not be liable for the payment of any charges or costs
associated with the provision of such services.
(b) Notification.--The Secretary shall notify a contract
care provider and any patient who receives contract health care
services authorized by the Service that such patient is
notliable for the payment of any charges or costs associated with the
provision of such services not later than 5 business days after receipt
of a notification of a claim by a provider of contract care services.
(c) No Recourse.--Following receipt of the notice provided
under subsection (b), or, if a claim has been deemed accepted
under section 233(b), the provider shall have no further
recourse against the patient who received the services.
Sec. 1621w. Authorization of appropriations
[Except as provided in sections 1621h(m), 1621j, 1621l,
1621m(b)(5), 1621n, and 1621o of this title, t] There are
authorized to be appropriated such sums as may be necessary for
each fiscal year through fiscal year 2015 [2000] to carry out
this title [subchapter].
[Sec. 1621x. Limitation on use of funds
[Amounts appropriated to carry out this subchapter may not
be used in a manner inconsistent with the Assisted Suicide
Funding Restriction Act of 1997 [42 U.S.C.A. Sec. 14401 et
seq.].
[Sec. 1622. Transferred]
TITLE [SUBCHAPTER] III--[HEALTH] FACILITIES
Sec. 1631. Consultation: Construction and Renovation of Facilities;
[closure of facilities; r]Reports
(a) Prerequisites for Expenditure of Funds.--[Consultation;
standards for accreditation]
Prior to the expenditure of, or the making of any binding
[firm] commitment to expend, any funds appropriated for the
planning, design, construction, or renovation of facilities
pursuant to the Act of November 2, 1921 (25 U.S.C. 13)
(commonly known as the `Snyder Act') [section 13 of this title,
popularly known as the Snyder Act], the Secretary, acting
through the Service, shall--
(1) consult with any Indian [t]Tribe that would be
significantly affected by such expenditure for the
purpose of determining and, whenever practicable,
honoring tribal preferences concerning size, location,
type, and other characteristics of any facility on
which such expenditure is to be made[,]; and
(2) ensure, whenever practicable and applicable, that
such facility meets the construction standards of any
accrediting body recognized by the Secretary for the
purposes of the medicare, medicaid, and SCHIP programs
under titles XVIII, XIX, and XXI of the Social Security
Act [the Joint Commission on Accreditation of Health
Care Organizations] by not later than 1 year after the
date on which the construction or renovation of such
facility is completed.
(b) Closures.--[; report on proposed closure]
(1) Evaluation required.--Notwithstanding any other
provision of law, no facility operated by the Service
[other than this subsection, no Service hospital or
outpatient health care facility of the Service, or any
portion of such a hospital or facility,] may be closed
if the Secretary has not submitted to [the] Congress at
least 1 year prior to the date of the proposed closure
[such hospital or facility (or portion thereof) is
proposed to be closed] an evaluation of the impact of
the [such] proposed closure which specifies, in
addition to other considerations--
(A) the accessibility of alternative health
care resources for the population served by
such [hospital or] facility;
(B) the cost-effectiveness of such closure;
(C) the quality of health care to be provided
to the population served by such [hospital or]
facility after such closure;
(D) the availability of contract health care
funds to maintain existing levels of service;
(E) the views of the Indian [t]Tribes served
by such [hospital or] facility concerning such
closure;
(F) the level of use of such [utilization of
such hospital or] facility by all eligible
Indians; and
(G) the distance between such [hospital or]
facility and the nearest operating Service
hospital.
(2) Exception for certain temporary closures.--
Paragraph (1) shall not apply to any temporary closure
of a facility or [of] any portion of a facility if such
closure is necessary for medical, environmental, or
construction safety reasons.
(c) Health Care Facility Priority System.--[Annual report
on health facility priority system]
(1) In general.--
(A) Establishment.--The Secretary, acting
through the Service, shall establish a health
care facility priority system, which shall--
(i) be developed with Indian Tribes
and Tribal Organizations through
negotiated rulemaking under section
802;
(ii) give Indian Tribes' needs the
highest priority; and
(iii) at a minimum, include the lists
required in paragraph (2)(B) and the
methodology required in paragraph
(2)(E).
(B) Priority of certain projects protected.--
The priority of any project established under
the construction priority system in effect on
the date of the Indian Health Care Improvement
Act Amendments of 2004 shall not be affected by
any change in the construction priority system
taking place thereafter if the project was
identified as 1 of the 10 top-priority
inpatient projects, 1 of the 10 top-priority
outpatient projects, 1 of the 10 top-priority
staff quarters developments, or 1 of the 10
top-priority Youth Regional Treatment Centers
in the fiscal year 2005 Indian Health Service
budget justification, or if the project had
completed both Phase I and Phase II of the
construction priority system in effect on the
date of the enactment of such Act.
(2)[(1)] Report; contents.--The Secretary shall
submit to the President, for inclusion in each report
required to be transmitted to [the] Congress under
section 801 [1671 of this title], a report which sets
forth the following:[--]
(A) A description of the [current] health
care facility priority system of the Service,
established under paragraph (1).
(B) Health care facilities lists, including
but not limited to--[the planning, design,
construction, and renovation needs for the 10
top-priority inpatient care facilities and the
10 top-priority ambulatory care facilities
(together with required staff quarters),]
(i) the 10 top-priority inpatient
health care facilities;
(ii) the 10 top-priority outpatient
health care facilities;
(iii) the 10 top-priority specialized
health care facilities (such as long-
term care and alcohol and drug abuse
treatment);
(iv) the 10 top-priority staff
quarters developments associated with
health care facilities; and
(v) the 10 top-priority patient
hostels associated with health care
facilities.
(C) [t]The justification for such order of
priority[,].
(D) [t]The projected cost of such projects.[,
and]
(E) [t]The methodology adopted by the Service
in establishing priorities under its health
facility priority system.
(3)[(2)] Requirements for preparation of reports.--In
preparing each report required under paragraph (2)[(1)]
(other than the initial report), the Secretary shall
annually--
(A) consult with and obtain information on
all health care facilities needs from Indian
[t]Tribes, Tribal Organizations, and Urban
Indian Organizations; [and tribal organizations
including those tribes or tribal organizations
operating health programs or facilities under
any contract entered into with the Service
under the Indian Self-Determination Act [25
U.S.C.A. Sec. 450f et seq.],] and
(B) review the total unmet needs of all
Indian [such t] Tribes, Tribal Organizations,
and Urban Indian Organizations [and tribal
organizations] for health care [inpatient and
outpatient] facilities (including hostels and
staff quarters), including [their] needs for
renovation and expansion of existing
facilities.
(4)[(3)] Criteria for evaluating needs.--For purposes
of this subsection, the Secretary shall, in evaluating
the needs of facilities operated under any Funding
Agreement [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.
(5)[(4)] Needs of facilities under isdeaa
agreements.--TheSecretary shall ensure that the
planning, design, construction, and renovation needs of Service and
non-Service facilities operated under funding agreements in accordance
with the [which are the subject of a contract for health services
entered into with the Service under the] Indian Self-Determination and
Education Assistance Act (25 U.S.C. 450 et seq.) [[25 U.S.C.A.
Sec. 450f et seq.]] are fully and equitably integrated into [the
development of] the health care facility priority system.
(d) Review of Need for Facilities
(1) Initial report.--In the year 2005, the Government
Accountability Office shall prepare and finalize a
report which sets forth the needs of the Service,
Indian Tribes, Tribal Organizations, and Urban Indian
Organizations, for the facilities listed under
subsection (c)(2)(B), including the needs for
renovation and expansion of existing facilities. The
Government Accountability Office shall submit the
report to the appropriate authorizing and
appropriations committees of Congress and to the
Secretary.
(2) Beginning in the year 2006, the Secretary shall
update the report required under paragraph (1) every 5
years.
(3) The Comptroller General and the Secretary shall
consult with Indian Tribes, Tribal Organizations, and
Urban Indian Organizations. The Secretary shall submit
the reports required by paragraphs (1) and (2), to the
President for inclusion in the report required to be
transmitted to Congress under section 801.
(4) For purposes of this subsection, the reports
shall, regarding the needs of facilities operated under
any Funding Agreement, be based on the same criteria
that the Secretary uses in evaluating the needs of
facilities operated directly by the Service.
(5) The planning, design, construction, and
renovation needs of facilities operated under Funding
Agreements shall be fully and equitably integrated into
the development of the health facility priority system.
(6) Beginning in the year 2006 and each fiscal year
thereafter, the Secretary shall provide an opportunity
for nomination of planning, design, and construction
projects by the Service, Indian Tribes, and Tribal
Organizations for consideration under the health care
facility priority system.
(e) Funding Condition.--[(d) Funds appropriated subject to
section 450f of this title]
All funds appropriated under the Act of November 2, 1921
(25 U.S.C. 13) (commonly known as the `Snyder Act'), [section
13 of this title,] for the planning, design, construction, or
renovation of health facilities for the benefit of 1 or more
[an] Indian [tribe or t]Tribes shall be subject to the
provisions of [section 102 of] the Indian Self-Determination
and Education Assistance Act (25 U.S.C. 450 et seq.) [[25
U.S.C.A. Sec. 450f]].
(f) Development of Innovative Approaches.-- The Secretary
shall consult and cooperate with Indian Tribes, Tribal
Organizations, and Urban Indian Organizations in developing
innovative approaches to address all or part of the total unmet
need for construction of health facilities, including those
provided for in other sections of this title and other
approaches.
Sec. 1632. Sanitation [Safe water and sanitary waster disposal
f]Facilities
(a) [Congressional f]Findings.--
[The] Congress [hereby] finds the following: [and declares
that--]
(1) [t]The provision of sanitation facilities [safe
water supply systems and sanitary sewage and solid
waste disposal systems] is primarily a health
consideration and function[;].
(2) Indian people suffer an inordinately high
incidence of disease, injury, and illness directly
attributable to the absence or inadequacy of sanitation
facilities. [such systems;]
(3) [t]The long-term cost to the United States of
treating and curing such disease, injury, and illness
is substantially greater than the short-term cost of
providing sanitation facilities [such systems] and
other preventive health measures[;].
(4) [m]Many Indian homes and Indian communities still
lack sanitation facilities. [safe water supply systems
and sanitary sewage and solid waste disposal systems;
and]
(5) [i]It is in the interest of the United States,
and it is the policy of the United States, that all
Indian communities and Indian homes, new and existing,
be provided with sanitation facilities. [safe and
adequate water supply systems and sanitary sewage waste
disposal systems as soon as possible.]
(b) Facilities and Services.--[Authority; assistance;
transfer offunds]
[(1)] In furtherance of the findings [and
declarations] made in subsection (a) [of this section],
Congress reaffirms the primary responsibility and
authority of the Service to provide the necessary
sanitation facilities and services as provided in
section 7 of the Act of August 5, 1954 (42 U.S.A.
2004a) [2004a of Title 42]. Under such authority, [(2)
T]the Secretary, acting through the Service, is
authorized to provide the following: [under section
2004a of Title 42.]
(1) [(A) f]Financial and technical assistance to
Indian [t]Tribes, Tribal Organizations, and Indian
communities in the establishment, training, and
equipping of utility organizations to operate and
maintain [Indian] sanitation facilities[;], including
the provision of existing plans, standard details, and
specifications available in the Department, to be used
at the option of the Indian Tribe, Tribal Organization,
or Indian community.
(2) [(B) o]Ongoing technical assistance and training
to Indian Tribes, Tribal Organizations, and Indian
communities in the management of utility organizations
which operate and maintain sanitation facilities.[;
and]
(3) [(C)] Priority funding for operation and
maintenance assistance for, and emergency repairs to,
[tribal] sanitation facilities operated by an Indian
Tribe, Tribal Organization or Indian community when
necessary to avoid an imminent [a] health hazard or to
protect the [Federal] investment in the health benefits
gained through the provision of sanitation facilities.
(c) Funding.--[(3)] Notwithstanding any other provision of
law--
(1)[(A)] the Secretary of Housing and Urban
Development [Affairs] is authorized to transfer funds
appropriated under the Native American Housing
Assistance and Self-Determination [Community
Development] Act of 1996 [1974 (42 U.S.C. 5301 et
seq.)] to the Secretary of Health and Human Services;[,
and]
(2)[(B)] the Secretary of Health and Human Services
is authorized to accept and use such funds for the
purpose of providing sanitation facilities and services
for Indians under section 7 of the Act of August 5,
1954 (42 U.S.C. 2004a); [2004a of Title 42.]
(3) unless specifically authorized when funds are
appropriated, the Secretary shall not use funds
appropriated under section 7 of the Act of August 5,
1954 (42 U.S.C. 2004a), to provide sanitation
facilities to new homes constructed using funds
provided by the Department of Housing and Urban
Development;
(4) the Secretary of Health and Human Services is
authorized to accept from any source, including Federal
and State agencies, funds for the purpose of providing
sanitation facilities and services and place these
funds into Funding Agreements;
(5) except as otherwise prohibited by this section,
the Secretary may use funds appropriated under the
authority of section 7 of the Act of August 5, 1954 (42
U.S.C. 2004a) to fund up to 100 percent of the amount
of an Indian Tribe's loan obtained under any Federal
program for new projects to construct eligible
sanitation facilities to serve Indian homes;
(6) except as otherwise prohibited by this section,
the Secretary may use funds appropriated under the
authority of section 7 of the Act of August 5, 1954 (42
U.S.C. 2004a) to meet matching or cost participation
requirements under other Federal and non-Federal
programs for new projects to construct eligible
sanitation facilities;
(7) all Federal agencies are authorized to transfer
to the Secretary funds identified, granted, loaned, or
appropriated whereby the Department's applicable
policies, rules, and regulations shall apply in the
implementation of such projects;
(8) the Secretary of Health and Human Services shall
enter into interagency agreements with Federal and
State agencies for the purpose of providing financial
assistance for sanitation facilities and services under
this Act; and
(9) the Secretary of Health and Human Services shall,
by regulation developed through rulemaking under
section 802, establish standards applicable to the
planning, design, and construction of sanitation
facilities funded under this Act.
[(c) 10-Year plan
[Beginning in fiscal year 1990, the Secretary, acting
through the Service, shall develop and begin implementation of
a 10-year plan to provide safe water supply and sanitation
sewage and solid waste disposal facilities to existing Indian
homes and communities and to new and renovated Indian homes.]
(d) Certain Capabilities Not Prerequisite.--[Tribal
capability]
The financial and technical capability of an Indian
[t]Tribe, Tribal Organization, or Indian community to safely
operate, manage, and maintain a sanitation facility shall not
be a prerequisite to the provision or construction of
sanitation facilities by the Secretary.
(e) Financial [Amount of a]Assistance.--
[(1)] The Secretary is authorized to provide financial
assistance to Indian [t]Tribes, Tribal Organizations and Indian
communities for operation, management, and maintenance of their
sanitation facilities. [in an amount equal to the Federal share
of the costs of operating, managing, and maintaining the
facilities provided under the plan described in subsection (c)
of this section.]
[(2) For the purposes of paragraph (1), the term
``Federal share'' means 80 percent of the costs
described in paragraph (1).
[(3) With respect to Indian tribes with fewer than
1,000 enrolled members, the non-Federal portion of the
costs of operating, managing, and maintaining such
facilities may be provided, in part, through cash
donations or in kind property, fairly evaluated.]
(f) Operation, Management, and Maintenance of Facilities.--
The Indian Tribe, Tribal Organization, or Indian community 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, Tribal Organization, or Indian
community is threatened with imminent failure and such operator
lacks capacity to maintain the integrity or the health benefits
of the sanitation facility, then the Secretary is authorized to
assist the Indian Tribe, Tribal Organization, or Indian
community in the resolution of the problem on a short-term
basis through cooperation with the emergency coordinator or by
providing operation, management, and maintenance service.
(g) ISDEAA Program Funded on Equal Basis.--Tribal Health
Programs shall be eligible (on an equal basis with programs
that are administered directly by the Service) for--
(1) any funds appropriated pursuant to this section;
and
(2) any funds appropriated for the purpose of
providing sanitation facilities.
[(f) Eligibility of programs administered by Indian tribes
[Programs administered by Indian tribes or tribal
organizations under the authority of the Indian Self-
Determination Act [25 U.S.C.A. Sec. 450f et seq.] shall be
eligible for--
[(1) any funds appropriated pursuant to this section,
and
[(2) any funds appropriated for the purpose of
providing water supply or sewage disposal services,
on an equal basis with programs that are administered directly
by the Service.]
(h) Report._(g) Annual report; sanitation deficiency
levels
(1) Required; Contents._The Secretary, in
consultation with the Secretary of Housing and Urban
Development, Indian Tribes, Tribal Organizations, and
tribally designated housing entities (as defined in
section 4 of the Native American Housing Assistance and
Self-Determination Act of 1996 (25 U.S.C. 4103)) shall
submit to the President, for inclusion in each report
required to be transmitted to [the] Congress under
section 801[1671 of this title], a report which sets
forth--
(A) the current Indian sanitation facility
priority system of the Service;
(B) the methodology for determining
sanitation deficiencies and needs;
(C) the level of initial and final sanitation
deficiency for each type of sanitation facility
[facilities] for each type of project of each
Indian [t]Tribe or Indian community;
(D) the amount and most effective use of
funds, derived from whatever source, necessary
to accommodate the sanitation facilities needs
of new homes assisted with funds under the
Native American Housing Assistance and Self-
Determination Act, and to reduce the identified
sanitation deficiency levels of [raise] all
Indian [t]Tribes and Indian communities to [a]
level I sanitation deficiency as defined in
paragraph (4)(A); and
(E) a 10-year plan to provide sanitation
facilities to serve existing Indian homes and
Indian communities and new and renovated Indian
homes. [the amount of funds necessary to raise
all Indian tribes and communities to zero
sanitationdeficiency.]
(2) Criteria.--The criteria on which the deficiencies
and needs will be evaluated shall be developed through
negotiated rulemaking pursuant to section 802.
[(2) In preparing each report required under
paragraph (1) (other than the initial report), the
Secretary shall consult with Indian tribes and tribal
organization (including those tribes or tribal
organizations operating health care programs or
facilities under any contract entered into with the
Service under the Indian Self-Determination Act [25
U.S.C.A. Sec. 450f et seq.]) to determine the
sanitation needs of each tribe.]
(3) Uniform methodology.--The methodology used by the
Secretary in determining, preparing cost estimates for,
and reporting sanitation deficiencies for purposes of
paragraph (1) shall be applied uniformly to all Indian
[t]Tribes and Indian communities.
(4) Sanitation deficiency levels.--For purposes of
this subsection, the sanitation deficiency levels for
an individual, Indian [t]Tribe or Indian community
sanitation facility to serve Indian homes are
determined as follows:
(A) A level I deficiency exists if a
sanitation facility serving [is] an individual,
Indian [t]Tribe or Indian community [with a
sanitation system]--
(i) [which] complies with all
applicable water supply, [and]
pollution control, and solid waste
disposal laws[,]; and
(ii) [in which the] deficiencies
relate to routine replacement, repair,
or maintenance needs[;].
(B) A level II deficiency exists if a
sanitation facility serving an individual, [is
an] Indian [t]Tribe, or Indian community
substantially or recently complied with all
applicable water supply, pollution control, and
solid waste laws and any deficiencies relate to
[with a sanitation system]--
(i) small or minor capital
improvements needed to bring the
facility back into compliance; [which
complies with all applicable water
supply and pollution control laws, and]
(ii) [in which the deficiencies
relate to] capital improvements that
are necessary to enlarge or improve the
facilities in order to meet the current
needs [of such tribe or community] for
domestic sanitation facilities; or
(iii) the lack of equipment or
training by an Indian Tribe, Tribal
Organization, or an Indian community to
properly operate and maintain the
sanitation facilities.
(C) A level III deficiency exists if a
sanitation facility serving an individual, [is
an] Indian [t]Tribe or Indian community meets
one or more of the following conditions [with a
sanitation system which]--
(i) water or sewer service in the
home is provided by a haul system with
holding tanks and interior plumbing;
[has an inadequate or partial water
supply and a sewage disposal facility
that does not comply with applicable
water supply and pollution control
laws, or]
(ii) major significant interruptions
to water supply or sewage disposal
occur frequently, requiring major
capital improvements to correct the
deficiencies; or [has no solid waste
disposal facility;]
(iii) there is no access to or no
approved or permitted solid waste
facility available.
(D) A level IV deficiency exists if--[(IV) is
an Indian tribe or community with a sanitary
system which lacks either a safe water supply
system or a sewage disposal system: and]
(i) a sanitation facility of an
individual, Indian Tribe, Tribal
Organization, or Indian community has
no piped water or sewer facilities in
the home or the facility has become
inoperable due to major component
failure; or
(ii) where only a washeteria or
central facility exists in the
community.
(E) A level V deficiency exists in the
absence of a sanitation facility, where
individual homes do not have access to safe
drinking water or adequate wastewater
(including sewage) disposal. [(V) is an Indian
tribe or community that lacks a safe water
supply and a sewage disposal system.]
(j) Definitions.--For purposes of this section, the
following terms apply:
(1) Indian community.--the term `Indian community'
means a geographic area, a significant proportion of
whose inhabitants are Indians and which is served by or
capable of being served by a facility described in this
section.
(2) Sanitation facilities.--The terms `sanitation
facility' and `sanitation facilities' mean safe and
adequate water supply systems, sanitary sewage disposal
systems, and sanitary solid waste systems (and all
related equipment and support infrastructure).
[(5) For purposes of this subsection, any Indian
tribe or community that lacks the operation and
maintenance capability to enable its sanitation system
to meet pollution control laws may not be treated as
having a level I or II sanitation deficiency.]
Sec. 1633. Preference to Indians and Indian firms
(a) Buy Indian Act.--[Discretionary authority; covered
activities.]
The Secretary, acting through the Service, may use
[utilize] the negotiating authority of section 23 [47] of the
Act of June 25, 1910 (25 U.S.C. 47, commonly known as the `Buy
Indian Act') [this title], to give preference to any Indian or
any enterprise, partnership, corporation, or other type of
business organization owned and controlled by an Indian or
Indians including former or currently federally recognized
Indian [t]Tribes in the State of New York (hereinafter referred
to as an ``Indian firm'') in the construction and renovation of
Service facilities pursuant to section 301 [1631 of this title]
and in the construction of sanitation [safe water and sanitary
waste disposal] facilities pursuant to section 302 [1632 of
this title]. Such preference may be accorded by the Secretary
unless the Secretary [he] finds, pursuant to [rules and]
regulations [promulgated] adopted pursuant to section 802 [by
him], that the project or function to be contracted for will
not be satisfactory or such project or function cannot be
properly completed or maintained under the proposed contract.
The Secretary, in arriving at such a [his] finding, shall
consider whether the Indian or Indian firm will be deficient
with respect to--
(1) ownership and control by Indians[,];
(2) equipment[,];
(3) bookkeeping and accounting procedures[,];
(4) substantive knowledge of the project or function
to be contracted for[,];
(5) adequately trained personnel[,]; or
(6) other necessary components of contract
performance.
(b) Labor Standards.--[Pay rates]
(1) In general.--For the purpose of implementing the
provisions of this title [subchapter], contracts for
the construction or renovation of health care
facilities, staff quarters, and sanitation facilities,
and related support infrastructure, funded in whole or
in part with funds made available pursuant to this
title, shall contain a provision requiring compliance
with subchapter IV of chapter 31 of title 40, United
States Code (commonly known as the `Davis-Bacon Act'),
unless such construction or renovation--[the secretary
shall assure that the rates of pay for personnel
engaged in the construction or renovation of facilities
constructed or renovated in whole or in part by funds
made available pursuant to this subchapter are not less
than the prevailing local wage rates for similar work
as determined in accordance with sections 3141 to 3144,
3146, 3147 of Title 40.]
(A) is performed by a contractor pursuant to
a contract with an Indian Tribe or Tribal
Organization with funds supplied through a
contract, compact or funding agreement
authorized by the Indian Self-Determination and
Education Assistance Act, or other statutory
authority; and
(B) is subject to prevailing wage rates for
similar construction or renovation in the
locality as determined by the Indian Tribes or
Tribal Organizations to be served by the
construction or renovation.
(2) Exception.--This subsection shall not apply to
construction or renovation carried out by an Indian
Tribe or Tribal Organization with its own employees.
Sec. 1634. Expenditure of [n]Non[-S]service [f]Funds for [r]Renovation
(a) In General.--[Authority of Secretary]
[(1)] Notwithstanding any other provision of law, if the
requirements of subsection (c) are met, the Secretary, acting
through the Service, is authorized to accept any major
expansion, renovation or modernization by any Indian [t]Tribe
or Tribal Organization of any Service facility, or of any other
Indian health facility operated pursuant to a Funding
Agreement, [contract entered into under the Indian Self-
Determination Act [25 U.S.C.A. Sec. 450f et seq.]] including--
(1)[(A)] any plans or designs for such expansion,
renovation or modernization; and
(2)[(B)] any expansion, renovation or modernization
for which funds appropriated under any Federal law were
lawfully expended. [, but only if the requirements of
subsection (b) of this section are met.]
(b) Priority List.--
(1)[(2)] In general.--The Secretary shall maintain a
separate priority list to address the needs for
increased operating expenses, [of such facilities for]
personnel, or equipment for such facilities. The
methodology for establishing priorities shall be
developed through negotiated rulemaking under section
802. The list of priority facilities will be revised
annually in consultation with Indian Tribes and Tribal
Organizations.
(2)[(3)] Report.--The Secretary shall submit to the
President, for inclusion in each report required to be
transmitted to [the] Congress under section 801 [1671
of this section], the priority list maintained pursuant
to paragraph (1)[(2)].
(c)[(b)] Requirements
The requirements of this subsection are met with respect to
any expansion, renovation or modernization if--
(1) the Indian T[t]ribe or [t]Tribal
[o]Organization--
(A) provides notice to the Secretary of its
intent to expand, renovate or modernize; and
(B) applies to the Secretary to be place on a
separate priority list to address the needs of
such new facilities for increased operating
expenses, personnel or equipment; and
(2) the expansion, renovation or modernization--
(A) is approved by the appropriate area
director of the Service for Federal facilities;
and
(B) is administered by the Indian T[t]ribe or
Tribal Organization in accordance with any
applicable [the rules and] regulations
prescribed by the Secretary with respect to
construction or renovation of Service
facilities.
(d) Additional Requirement for Expansion.--In addition to
the requirements in subsection (c), for any expansions, the
Indian Tribe or Tribal Organization shall provide to the
Secretary additional information developed through negotiated
rulemaking under section 802, including additional staffing,
equipment, and other costs associated with the expansion.
(e) Closure or Conversion of Facilities.--[(c) Recovery for
non-use as Service facility]
If any Service facility which has been expanded, renovated
or modernized by an Indian [t]Tribe or Tribal Organization
under this section ceases to be used as a Service facility
during the 20-year period beginning on the date such expansion,
renovation or modernization is completed, such Indian [t]Tribe
or Tribal Organization shall be entitled to recover from the
United States an amount which bears the same ratio to the value
of such facility at the time of such cessation as the value of
such expansion, renovation or modernization (less the total
amount of any funds provided specifically for such facility
under any Federal program that were expended for such
expansion, renovation or modernization) bore to the value of
such facility at the time of the completion of such expansion,
renovation or modernization.
[Sec. 1635. Repealed. Pub.L. 100-713, Title III, Sec. 303(b), Nov. 23,
1988, 102 Stat. 4817]
Sec. 1636. Funding [Grant program] for the [c]Construction,
[e]Expansion, and [m]Modernization of [s]Small
[a]Ambulatory [c]Care [f]Facilities
(a) Funding.--[Authorization]
(1) In general.--The Secretary, acting through the
Service, in consultation with Indian Tribes and Tribal
Organizations, shall make funding available [grants] to
Indian T[t]ribes and [t]Tribal [o]Organizations for the
construction, expansion, or modernization of facilities
for the provision of ambulatory care services to
eligible Indians (and noneligible persons pursuant to
subsections (b)(2) and (c)(1)(C) [as provided in
subsection (c)(1)(C) of this section)]. Funding [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) Funding Agreement Required.--Funding [A grant]
under paragraph (1) may only be available [made] to a
Tribal HealthProgram [tribe or tribal organization]
operating an Indian health facility (other than a facility owned or
constructed by the Service, including a facility originally owned or
constructed by the Service and transferred to a Indian T[t]ribe or
[t]Tribal [o]Organization) [pursuant to a contract entered into under
the Indian Self-Determination Act [25 U.S.C.A. Sec. 450f et seq.]].
(b) Use of Funds [grant]
(1) Allowable uses.--Funding [A grant] provided under
this section may be used [only] for the construction,
expansion, or modernization (including the planning and
design of such construction, expansion, or
modernization) of an ambulatory care facility--
(A) located apart from a hospital;
(B) not funded under section 301[1631] or
section 307[1637 of this title]; and
(C) which, upon completion of such
construction, expansion, or modernization
will--
(i) have a total capacity appropriate
to its projected service population;
(ii) provide annually no fewer than
150 eligible Indians and other users
who are eligible for services in such
facility in accordance with section
807(c)(2) [serve no less than 500
eligible Indians annually]; and
(iii) provide ambulatory care in a
[s]Service [a]Area (specified in the
Funding Agreement [contract entered
into under the Indian Self-
Determination Act [25 U.S.C.A.
Sec. 450f et seq.]]) with a population
of no fewer than 1,500 [not less than
2,000] eligible Indians and other users
who are eligible for services in such
facility in accordance with section
807(c)(2).
(2) Additional allowable use.--The Secretary may also
reserve a portion of the funding provided under this
section and use those reserved funds to reduce an
outstanding debt incurred by Indian Tribes or Tribal
Organizations for the construction, expansion, or
modernization of an ambulatory care facility that meets
the requirements under paragraph (1). The provisions of
this section shall apply, except that such applications
for funding under this paragraph shall be considered
separately from applications for funding under
paragraph (1).
(3) Use only for certain portion of costs.--Funding
provided under this section may be used only for the
cost of that portion of a construction, expansion, or
modernization project or debt reduction that benefits
the Service population identified above in subsection
(b)(1)(C)(ii) and (iii).
(4) Applicability of requirements in the case of
isolated facilities.--[(2)] The requirements of clauses
(ii) and (iii) of paragraph (1)(C) shall not apply to
an Indian Tribe [a tribe] or [t]Tribal [o]Organization
applying for funding [a grant] under this section for a
health care facility [whose tribal government offices
are] located or to be constructed on an island or when
such facility is not located on a road system providing
direct access to an inpatient hospital where care is
available to the Service population.
(c) Funding.--[Application for grant]
(1) Application.--No funding [grant] may be made
available under this section unless an application or
proposal for such funding has been [a grant has been
submitted to and] approved by the Secretary in
accordance with applicable regulations and has provided
reasonable assurance by the applicant that, at all
times after the construction, expansion, or
modernization of a facility carried out pursuant to
funding received under this section--[. An application
for a grant under this section shall be submitted in
such form and manner as the Secretary shall by
regulation prescribe and shall set forth reasonable
assurance by the applicant that, at all times after the
construction, expansion, or modernization of a facility
carried out pursuant to a grant received under this
section--]
(A) adequate financial support will be
available for the provision of services at such
facility;
(B) such facility will be available to
eligible Indians without regard to ability to
pay or source of payment; and
(C) such facility will, as feasible without
diminishing the quality or quantity of services
provided to eligible Indians, serve noneligible
persons on a cost basis.
(2) Priority.--In awarding funding [grants] under
this section, the Secretary shall give priority to
Indian T[t]ribes and [t]Tribal [o]Organizations that
demonstrate--
(A) a need for increased ambulatory care
services; and
(B) insufficient capacity to deliver such
services.
(3) Peer review panels.--The Secretary may provide
for the establishment of peer review panels, as
necessary, to review and evaluate applications and
proposals and to advise the Secretary regarding such
applications using the criteria developed during
consultations pursuant to subsection (a)(1).
(d) Reversion of Facilities.--[Transfer of interest to
united states upon cessation of facility]
If any facility (or portion thereof) with respect to which
funds have been paid under this section, ceases, within 5 years
[at any time] after completion of the construction, expansion,
or modernization carried out with such funds, to be used
[utilized] for the purposes of providing health [ambulatory]
care services to eligible Indians, all of the right, title, and
interest in and to such facility (or portion thereof) shall
transfer to the United States unless otherwise negotiated by
the Service and the Indian Tribe or Tribal Organization.
(e) Funding Nonrecurring.--Funding provided under this
section shall be nonrecurring and shall not be available for
inclusion in any individual Indian Tribe's tribal share for an
award under the Indian Self-Determination and Education
Assistance Act or for reallocation or redesign thereunder.
Sec. 1637. Indian [h]Health [c]Care [d]Delivery [d]Demonstration
[p]Project
(a) Health [c]Care [delivery d]Demonstration [p]Projects.--
The Secretary, acting through the Service, and in
consultation with Indian Tribes and Tribal Organizations, is
authorized to enter into construction project agreements and
construction contracts under the Indian Self-Determination and
Education Assistance Act (25 U.S.C. 450 et seq.) with[, or make
grants to,] Indian [t]Tribes or [t]Tribal [o]Organizations for
the purpose of carrying out a health care delivery
demonstration project to test alternative means of delivering
health care and services through [health] facilities, including
but not limited to hospice, traditional Indian health, and
child care facilities [to Indians].
(b) Use of [f]Funds
The Secretary, in approving projects pursuant to this
section, may authorize funding for the construction and
renovation of hospitals, health centers, health stations, and
other facilities to deliver health care services and is
authorized to--
(1) waive any leasing prohibition;
(2) permit carryover of funds appropriated for the
provision of health care services;
(3) permit the use of other available [non-Service
Federal funds and non-Federal] funds;
(4) permit the use of funds or property donated from
any source for project purposes; [and]
(5) provide for the reversion of donated real or
personal property to the donor[.]; and
(6) permit the use of Service funds to match other
funds, including Federal funds.
(c) Regulations.--[Criteria]
[(1) Within 180 days after November 28, 1990, t]The
Secretary[, after consultation with Indian tribes and tribal
organizations,] shall develop and promulgate regulations not
later than 1 year after the enactment of the Indian Health Care
Improvement Act Amendments of 2004. If the Secretary has not
promulgated regulations by that date, the Secretary shall
develop and publish regulations, through rulemaking under 802,
[in the Federal Register criteria] for the review and approval
of applications submitted under this section.
(d) Criteria.--The Secretary may approve [enter into a
contract or award a grant under this section for] projects that
[which] meet the following criteria:
(1)[(A)] There is a need for a new facility or
program or the reorientation of an existing facility or
program.
(2)[(B)] A significant number of Indians, including
those with low health status, will be served by the
project.
[(C) The project has the potential to address
the health needs of Indians in an innovative
manner.]
(3)[(D)] The project has the potential to deliver
services in an efficient and effective manner.
(4)[(E)] The project is economically viable.
(5)[(F)] The Indian [t]Tribe or [t]Tribal
[o]Organization has the administrative and financial
capability to administer the project.
(6)[(G)] The project is integrated with providers of
related health and social services and is coordinated
with, and avoids duplication of, existing services.
(e) Peer Review Panels.--[(2)] The Secretary may provide
for the establishment of peer review panels, as necessary, to
review and evaluate applications [and to advise the Secretary
regarding such applications] using the criteria developed
pursuant to subsection (d) [paragraph (1)].
(f) Priority.--The Secretary shall give priority to
applications for demonstration projects [(3)(A) On or before
September 30, 1995, the Secretary shall enter into contracts or
award grants under this section for a demonstration project] in
each of the following [s]Service [u]Units to the extent that
such applications are timely filed and meet the criteria
specified in subsection (d): [which meets the criteria
specified in paragraph (1) and for which a completed
application has been received by the Secretary:]
(1)[(i)] Cass Lake, Minnesota.
(2)[(ii)] Clinton, Oklahoma.
(3)[(iii)] Harlem, Montana.
(4)[(iv)] Mescalero, New Mexico
(5)[(v)] Owyhee, Nevada.
(6)[(vi)] Parker, Arizona.
(7)[(vii)] Schurz, Nevada.
(8)[(viii)] Winnebago, Nebraska.
(9)[(ix)] Ft. Yuma, California.
[(B) The Secretary may also enter into
contracts or award grants under this section
taking into consideration applications received
under this section from all service areas. The
Secretary may not award a greater number of
such contracts or grants in one service area
than in any other service area until there is
an equal number of such contracts or grants
awarded with respect to all service areas from
which the Secretary receives applications
during the application period (as determined by
the Secretary) which meet the criteria
specified in paragraph (1).]
(g)[(d)] Technical [a]Assistance.--
The Secretary shall provide such technical and other
assistance as may be necessary to enable applicants to comply
with the provisions of this section.
(h)[(e)] Service to [i]Ineligible [p]Persons.--
The authority to provide services to persons otherwise
ineligible for the health care benefits of the Service and the
authority to extend hospital privileges in [s]Service
facilities to non-Service health care practitioners as provided
in section 807[1680c of this title] may be included, subject to
the terms of such section, in any demonstration project
approved pursuant to this section.
(i)[(f)] Equitable [t]Treatment.--
For purposes of subsection (d)(1)[(c)(1)(A) of this
section], the Secretary shall, in evaluating facilities
operated under any Funding Agreement, [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 facilities operated directly by
the Service.
(j)[(g)] Equitable [i]Integration of [f]Facilities.--
The Secretary shall ensure that the planning, design,
construction, [and] renovation, and expansion needs of Service
and non-Service facilities which are the subject of a Funding
Agreement [contract] for health services [entered into with the
Service under the Indian Self-Determination Act [25 U.S.C.A.
450f et seq.],] are fully and equitably integrated into the
implementation of the health care delivery demonstration
projects under this section.
[(h) Report to Congress
[(1) The Secretary shall submit to the President, for
inclusion in the report which is required to be
submitted to the Congress under section 1671 of this
title for fiscal year 1997, an interim report on the
findings and conclusions derived from the demonstration
projects established under this section.
[(2) The Secretary shall submit to the President, for
inclusion in the report which is required to be
submitted to the Congress under section 1671 of this
title for fiscal year 1999, a final report on the
findings and conclusions derived from the demonstration
projects established under this section, together with
legislative recommendations.]
Sec. 1638. Land [t]Transfer
Notwithstanding any other provision of law, [T]the Bureau
of Indian Affairs and all other agencies and departments of the
United States are [is] authorized to transfer, at no cost, land
and improvements to the Service for the provision of health
care services. The Secretary is authorized to accept such land
and improvements for such purposes. [up to 5 acres of land at
the Chemawa Indian School, Salem, Oregon, to the Service for
the provision of health care services. The land authorized to
be transferred by this section is that land adjacent to land
under the jurisdiction of the Service and occupied by the
Chemawa Indian Health Center.]
Sec. 308. Leases, Contracts, and Other Agreements
The Secretary, acting through the Service, may enter into
leases, contracts, and other agreements with Indian Tribes and
Tribal Organization which hold (1) title to, (2) a leasehold
interest in, or (3) a beneficial interest in (when title is
held by the United States in trust for the benefit of an Indian
Tribe) facilities used or to be used for the administration and
delivery of health services by an Indian Health Program. Such
leases, contracts, or agreements may include provisions for
construction or renovation and provide for compensation to the
Indian Tribe or Tribal Organization of rental and other costs
consistent with section 105(l) of the Indian Self-Determination
and Education Assistance Act and regulations thereunder.
Notwithstanding any other provision of law, such leases,
contracts, or other agreements shall be considered as operating
leases for the purpose of scoring under the Balanced Budget and
Emergency Deficit Control Act of 1985 (2 U.S.C. 901 et seq.).
Sec. 309. Study on Loans, Loan Guarantees, and Loan Repayment
(a) In General.--The Secretary, in consultation with the
Secretary of the Treasury, Indian Tribes, and Tribal
Organizations, shall carry out a study to determine the
feasibility of establishing a loan fund to provide to Indian
Tribes and Tribal Organizations direct loans or guarantees for
loans for the construction of health care facilities,
including--
(1) inpatient facilities;
(2) outpatient facilities;
(3) staff quarters;
(4) hostels; and
(5) specialized care facilities, such as behavioral
health and elder care facilities.
(b) Determinations.--In carrying out the study under
subsection (a), the Secretary shall determine--
(1) the maximum principal amount of a loan or loan
guarantee that should be offered to a recipient from
the loan fund;
(2) the percentage of eligible costs, not to exceed
100 percent, that may be covered by a loan or loan
guarantee from the loan fund (including costs relating
to planning, design, financing, site land development,
construction, rehabilitation, renovation, conversion,
improvements, medical equipment and furnishings, and
other facility-related costs and capital purchase (but
excluding staffing));
(3) the cumulative total of the principal of direct
loans and loan guarantees, respectively, that may be
outstanding at any 1 time;
(4) the maximum term of a loan or loan guarantee that
may be made for a facility from the loan fund;
(5) the maximum percentage of funds from the loan
fund that should be allocated for payment of costs
associated with planning and applying for a loan or
loan guarantee;
(6) whether acceptance by the Secretary of an
assignment of the revenue of an Indian Tribe or Tribal
Organization as security for any direct loan or loan
guarantee from the loan fund would be appropriate;
(7) whether, in the planning and design of health
facilities under this section, users eligible under
section 807(c) may be included in any projection of
patient population;
(8) whether funds of the Service provided through
loans or loan guarantees from the loan fund should be
eligible for use in matching other Federal funds under
other programs;
(9) the appropriateness of, and best methods for,
coordinating the loan fund with the health care
priority system of the Service under section 301; and
(10) any legislative or regulatory changes required
toimplement recommendations of the Secretary based on
results of the study.
(c) Report.--Not later than September 30, 2006, the
Secretary shall submit to the Committee on Indian Affairs of
the Senate and the Committee on Resources and the Committee on
Energy and Commerce of the House of Representatives a report
that describes--
(1) the manner of consultation made as required by
subsection (a); and
(2) the results of the study, including any
recommendations of the Secretary based on results of
the study.
Sec. 310. Tribal Leasing
A Tribal Health Program may lease permanent structures for
the purpose of providing health care services without obtaining
advance approval in appropriation Acts.
Sec. 311. Indian Health Service/Tribal Facilities Joint Venture Program
(a) In General.--The Secretary, acting through the Service,
is authorized to negotiate and enter into 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 under this section if, when it submits a letter of
intent, it--
(1) has begun but not completed the process of
acquisition or construction of a health facility to be
used in the joint venture project; or
(2) has not begun the process of acquisition or
construction of a health facility for use in the joint
venture project.
(b) Requirements.--The Secretary shall make such an
arrangement with an Indian Tribe or Tribal Organization only
if--
(1) the Secretary first determines that the Indian
Tribe or Tribal Organization has the administrative and
financial capabilities necessary to complete the timely
acquisition or construction of the relevant health
facility; and
(2) the Indian Tribe or Tribal Organization meets the
need criteria which shall be developed through the
negotiated rulemaking process provided for under
section 802.
(c) Continued Operation.--The Secretary shall negotiate an
agreement with the Indian Tribe or Tribal Organization
regarding the continued operation of the facility at the end of
the initial 10 year no-cost lease period.
(d) Breach of Agreement.--An Indian Tribe or Tribal
Organization that has entered into a written agreement with the
Secretary under this section, and that breaches or terminates
without cause such agreement, shall be liable to the United
States for the amount that has been paid to the Indian Tribe or
Tribal Organization, or paid to a third party on the Indian
Tribe's or Tribal Organization's behalf, under the agreement.
The Secretary has the right to recover tangible property
(including supplies) and equipment, less depreciation, and any
funds expended for operations and maintenance under this
section. The preceding sentence does not apply to any funds
expended for the delivery of health care services, personnel,
or staffing.
(e) Recovery for Nonuse.--An Indian Tribe or Tribal
Organization that has entered into a written agreement with the
Secretary under this subsection shall be entitled to recover
from the United States an amount that is proportional to the
value of such facility if, at any time within the 10-year term
of the agreement, the Service ceases to use the facility or
otherwise breaches the agreement.
(f) Definition.--For the purposes of this section, the term
`health facility' or `health facilities' includes quarters
needed to provide housing for staff of the relevant Tribal
Health Program.
Sec. 312. Location of Facilities
(a) In General.--In all matters involving the
reorganization or development of Service facilities or in the
establishment of related employment projects to address
unemployment conditions in economically depressed areas, the
Bureau of Indian Affairs and the Service shall give priority to
locating such facilitiesand projects on Indian lands if
requested by the Indian owner and the Indian Tribe with jurisdiction
over such lands or other lands owned or leased by the Indian Tribe or
Tribal Organization. Top priority shall be given to Indian land owned
by 1 or more Indian Tribes.
(b) Definition.--For purposes of this section, the term
`Indian lands' means--
(1) all lands within the exterior boundaries of any
reservation;
(2) any lands title to which is held in trust by the
United States for the benefit of any Indian Tribe or
individual Indian or held by any Indian Tribe or
individual Indian subject to restriction by the United
States against alienation; and
(3) all 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.
Sec. 313. Maintenance and Improvement of Health Care Facilities
(a) Report.--The Secretary shall submit to the President,
for inclusion in the report required to be transmitted to
Congress under section 801, a report which identifies the
backlog of maintenance and repair work required at both Service
and tribal health care facilities, including new health care
facilities expected to be in operation in the next fiscal year.
The report shall also identify the need for renovation and
expansion of existing facilities to support the growth of
health care programs.
(b) Maintenance of Newly Constructed Space.--The Secretary,
acting through the Service, is authorized to expend maintenance
and improvement funds to support maintenance of newly
constructed space only if such space falls within the approved
supportable space allocation for the Indian Tribe or Tribal
Organization. Supportable space allocation shall be defined
through the negotiated rulemaking process provided for under
section 802.
(c) Replacement Facilities.--In addition to using
maintenance and improvement funds for renovation,
modernization, and expansion of facilities, an Indian Tribe or
Tribal Organization may use maintenance and improvement funds
for construction of a replacement facility if the costs of
renovation of such facility would exceed a maximum renovation
cost threshold. The maximum renovation cost threshold shall be
determined through the negotiated rulemaking process provided
for under section 802.
Sec. 314. Tribal Management of Federally Owned Quarters
(a) Rental Rates.--
(1) Establishment.--Notwithstanding any other
provision of law, a Tribal Health Program which
operates a hospital or other health facility and the
federally owned quarters associated therewith pursuant
to a Funding Agreement shall have the authority to
establish the rental rates charged to the occupants of
such quarters by providing notice to the Secretary of
its election to exercise such authority.
(2) Objectives.--In establishing rental rates
pursuant to authority of this subsection, a Tribal
Health Program shall endeavor to achieve the following
objections:
(A) To base such rental rates on the
reasonable value of the quarters to the
occupants thereof.
(B) To generate sufficient funds to prudently
provide for the operation and maintenance of
the quarters, and subject to the discretion of
the Tribal Health Program, to supply reserve
funds for capital repairs and replacement of
the quarters.
(3) Equitable funding.--Any quarters whose rental
rates are established by a Tribal Health Program
pursuant to this subsection shall remain eligible for
quarters improvement and repair funds to the same
extent as all federally owned quarters used to house
personnel in Services-supported programs.
(4) Notice of rate change.--A Tribal Health Program
which exercises the authority provided under this
subsection shall provide occupants with no less than 60
days notice of any change in rental rates.
(b) Direct Collection of Rent.--
(1) In general.--Notwithstanding any other provision
of law, and subject to paragraph (2), a Tribal Health
Program shall have the authority to collect rents
directly from Federal employees who occupy such
quarters in accordance with the following:
(A) The Tribal Health Program shall notify
the Secretary and the subject Federal employees
of its election toexercise its authority to
collect rents directly from such Federal employees.
(B) Upon receipt of a notice described in
subparagraph (A), the Federal employees shall
pay rents for occupancy of such quarters
directly to the Tribal Health Program and the
Secretary shall have no further authority to
collect rents from such employees through
payroll deduction or otherwise.
(C) Such rent payments shall be retained by
the Tribal Health Program and shall not be made
payable to or otherwise be deposited with the
United States.
(D) Such rent payments shall be deposited
into a separate account which shall be used by
the Tribal Health Program for the maintenance
(including capital repairs and replacement) and
operation of the quarters and facilities as the
Tribal Health Program shall determine.
(2) Retrocession of authority.--If a Tribal Health
Program which has made an election under paragraph (1)
requests retrocession of its authority to directly
collect rents from Federal employees occupying
federally owned quarters, such retrocession shall
become effective on the earlier of--
(A) the first day of the month that begins no
less than 180 days after the Tribal Health
Program notifies the Secretary of its desire to
retrocede; or
(B) such other date as may be mutually agreed
by the Secretary and the Tribal Health Program.
(c) Rates in Alaska.--To the extent that a Tribal Health
Program, pursuant to authority granted in subsection (a),
establishes rental rates for federally owned quarters provided
to a Federal employee in Alaska, such rents may be based on the
cost of comparable private rental housing in the nearest
established community with a year-round population of 1,500 or
more individuals.
[Sec. 1638a. Authorization of appropriations
[There are authorized to be appropriated such sums as may
be necessary for each fiscal year through fiscal year 2000 to
carry out this subchapter.]
Sec. 1638b. Applicability of Buy American Act R[r]equirement
(a) Applicability.--[Duty of Secretary]
The Secretary shall ensure that the requirements of the Buy
American Act [[41 U.S.C.A. Sec. 10a et seq.]] apply to all
procurements made with funds provided pursuant to [the
authorization contained in] section 317[1638a of this title].
Indian Tribes and Tribal Organizations shall be exempt from
these requirements.
[(b) Report to Congress
[The Secretary shall submit to the Congress a report on the
amount of procurements from foreign entities made in fiscal
years 1993 and 1994 with funds provided pursuant to the
authorization contained in section 1638a of this title. Such
report shall separately indicate the dollar value of items
procured with such funds for which the Buy American Act [41
U.S.C.A. Sec. 10a et seq.] was waived pursuant to the Trade
Agreement Act of 1979 [19 U.S.C.A. Sec. 2501 et seq.] or any
international agreement to which the United States is a party.]
(b) [(c)] Effect of Violation.--[Fraudulent use of Made-in-
America label]
If it has been finally determined by a court or Federal
agency that any person intentionally affixed a label bearing a
[``]`Made in America'[''] inscription[,] or any inscription
with the same meaning, to any product sold in or shipped to the
United States that is not made in the United States, such
person shall be ineligible to receive any contract or
subcontract made with funds provided pursuant to [the
authorization contained in] section 317[1638a of this title],
pursuant to the debarment, suspension, and ineligibility
procedures described in sections 9.400 through 9.409 of title
48, Code of Federal Regulations.
(c) [(d)] Definitions.--[``Buy American Act'' defined]
For purposes of this section, the term [``]`Buy American
Act'[''] means title III of the Act entitled ``An Act making
appropriations for the Treasury and Post Office Departments for
the fiscal year ending June 30, 1934, and for other purposes'',
approved March 3, 1933 (41 U.S.C. 10a et seq.).
Sec. 316. Other Funding For Facilities
(a) Authority To Accept Funds.--The Secretary is authorized
to accept from any source, including Federal and State
agencies, funds that are available for the construction of
health care facilities and use such funds to plan, design, and
construct health care facilities for Indians and to transfer
such funds to Indian Tribes or Tribal Organizations through
constructionproject agreements or construction contracts under
the Indian Self-Determination and Education Assistance Act (25 U.S.C.
450 et seq.). Receipt of such funds shall have no effect on the
priorities established pursuant to section 301.
(b) Interagency Agreements.--The Secretary is authorized to
enter into interagency agreements with other Federal agencies
or State agencies and other entities and to accept funds from
such Federal or State agencies or other sources to provide for
the planning, design, and construction of health care
facilities to be administered by Indian Health Programs in
order to carry out the purposes of this Act and the purposes
for which the funds were appropriated or for which the funds
were otherwise provided.
(c) Transferred Funds.--Any Federal agency to which funds
for the construction of health care facilities are appropriated
is authorized to transfer such funds to the Secretary for the
construction of health care facilities to carry out the
purposes of this Act as well as the purposes for which such
funds are appropriated to such other Federal agency.
(d) Establishment of Standards.--The Secretary, through the
Service, shall establish standards by regulation, developed by
rulemaking under section 802, for the planning, design, and
construction of health care facilities serving Indians under
this Act.
Sec. 317. Authorization of Appropriations
There are authorized to be appropriated such sums as may be
necessary for each fiscal year through fiscal year 2015 to
carry out this title.
[Sec. 1638c. Contracts for personal services in Indian Health Service
facilities
[In fiscal year 1995 and thereafter--
[(a) In general
[The Secretary may enter into personal services contracts
with entities, either individuals or organizations, for the
provision of services in facilities owned, operated or
constructed under the jurisdiction of the Indian Health
Service.
[(b) Exemption from competitive contracting requirements
[The Secretary may exempt such a contract from competitive
contracting requirements upon adequate notice of contracting
opportunities to individuals and organizations residing in the
geographic vicinity of the health facility.
[(c) Consideration of individuals and organizations
[Consideration of individuals and organizations shall be
based solely on the qualifications established for the contract
and the proposed contract price.
[(d) Liability
[Individuals providing health care services pursuant to
these contracts are covered by the Federal Tort Claims Act.
[Sec. 1638d. Credit to appropriations of money collected for meals at
Indian Health Service facilities
[Money before, on, and after September 30, 1994, collected
for meals served at Indian Health Service facilities will be
credited to the appropriations from which the services were
furnished and shall be credited to the appropriation when
received.]
TITLE IV [SUBCHAPTER III-A]--ACCESS TO HEALTH SERVICES
Sec. 1641. Treatment of [p]Payments [u]Under Social Security Act Health
Care [medicare] P[p]rograms
(a) Disregard of Medicare, Medicaid, and SCHIP Payments in
Determining Appropriations [Determination of appropriations]
Any payments received by an Indian Health Program or by an
Urban Indian Organization made under title XVIII, XIX, or XXI
of the Social Security Act [a hospital or skilled nursing
facility of the Service (whether operated by the Service or by
an Indian tribe or tribal organization pursuant to a contract
under the Indian Self-Determination Act [25 U.S.C.A.Sec. 450f
et seq.])] for services provided to Indians eligible for
benefits under such respective titles [Title XVIII of the
Social Security Act [42 U.S.C.A. Sec. 1395 et seq.]] shall not
be considered in determining appropriations for the provision
of health care and services to Indians.
(b) Nonpreferential Treatment.--[Preferences]
Nothing in this Act [chapter] authorizes the Secretary to
provide services to an Indian [beneficiary] with coverage
undertitle XVIII, XIX, or XXI of the Social Security Act [[42 U.S.C.A.
Sec. 1395 et seq.], as amended,] in preference to an Indian
[beneficiary] without such coverage.
[Sec. 1642. Treatment of payments under medicaid program]
(c)[(a)] Use of Funds.--[Payments to special fund]
(1) Special fund.--Notwithstanding any other
provision of law, but subject to paragraph (2),
payments to which a[ny] facility of the Service
[(including a hospital, nursing facility, intermediate
care facility for the mentally retarded, or any other
type of facility which provides services for which
payment is available under Title XIX of the Social
Security Act [42 U.S.C.A. Sec. 1396 et seq.])] is
entitled [under a State plan] by reason of a provision
of the Social Security Act [section 1911 of such Act
[42 U.S.C.A. Sec. 1396j]] shall be placed in a special
fund to be held by the Secretary and first used [by
him] (to such extent or in such amounts as are provided
in appropriation Acts) [exclusively] for the purpose of
making any improvements in the programs [facilities] of
the [such] Service which may be necessary to achieve or
maintain compliance with the applicable conditions and
requirements of [such] titles XVIII, XIX, and XXI of
the Social Security Act. Any amounts to be reimbursed
that are in excess of the amounts necessary to achieve
or maintain such conditions and requirements shall,
subject to the consultation with Indian Tribes being
served by the Service Unit, be used for reducing the
health resource deficiencies of the Indian Tribes. In
making payments from such fund, the Secretary shall
ensure that each [s]Service [u]Unit of the Service
receives 100 [at least 80] percent of the amount[s] to
which the facilities of the Service, for which such
[s]Service [u]Unit makes collections, are entitled by
reason of a provision [section 1911] of the Social
Security Act [[42 U.S.C.A. Sec. 1396j]].
(2) Direct payment option.--Paragraph (1) shall not
apply upon the election of a Tribal Health Program
under subsection (d) to receive payments directly. No
payment may be made out of the special fund described
in such paragraph with respect to reimbursement made
for services provided during the period of such
election.
(d) Direct Billing.--
(1) In general.--A Tribal Health Program may directly
bill for, and receive payment for, health care items
and services provided by such Indian Tribe or Tribal
organization for which payment is made under title
XVIII, XIX, or XXI of the Social Security Act or from
any other third party payor.
(2) Direct reimbursement.--
(A) Use of Funds.--Each Tribal Health Program
exercising the option described in paragraph
(1) with respect to a program under a title of
the Social Security Act shall be reimbursed
directly by that program for items and services
furnished without regard to section 401(c), but
all amounts so reimbursed shall be used by the
Tribal Health Program for the purpose of making
any improvements in Tribal facilities or Tribal
Health Programs that may be necessary to
achieve or maintain compliance with the
conditions and requirements applicable
generally to such items and services under the
program under such title and to provide
additional health care services, improvements
in health care facilities and Tribal Health
Programs, any health care-related purpose, or
otherwise to achieve the objectives provided in
section 3 of this Act.
(B) Audits.--The amounts paid to an Indian
Tribe or Tribal Organization exercising the
option described in paragraph (1) with respect
to a program under a title of the Social
Security Act shall be subject to all auditing
requirements applicable to programs
administered by an Indian Health Program.
(C) Identification of source of payments.--If
an Indian Tribe or Tribal Organization receives
funding from the Service under the Indian Self-
Determination and Education Assistance Act or
an Urban Indian Organization receives funding
from the Service under title V of this Act and
receives reimbursements or payments under title
XVIII, XIX, or XXI of the Social Security Act,
such Indian Tribe or Tribal Organization, or
Urban Indian Organization, shall provide to the
Service a list of each provider enrollment
number (or other identifier) under which it
receives such reimbursements or payments.
(3) Examination and implementation of changes.--The
Secretary, acting through the Service and with the
assistance of the Administrator of the Centers for
Medicare & Medicaid Services, shall examine on an
ongoing basis and implement any administrative changes
that may be necessary to facilitate direct billing and
reimbursement under the program established under this
subsection, including any agreements with States that
may be necessary to provide for direct billing under a
program under a title of the Social Security Act.
(4) Withdrawal from program.--A Tribal Health Program
that bills directly under the program established under
this subsection may withdraw from participation in the
same mannerand under the same conditions that an Indian
Tribe or Tribal Organization may retrocede a contracted program to the
Secretary under the authority of the Indian Self-Determination and
Education Assistance Act (25 U.S.C. 450 et seq.). All cost accounting
and billing authority under the program established under this
subsection shall be returned to the Secretary upon the Secretary's
acceptance of the withdrawal of participation in this program.
[(b) Determination of appropriations
[Any payments received by such facility for services
provided to Indians eligible for benefits under title XIX of
the Social Security Act [42 U.S.C.A. Sec. 1396 et seq.] shall
not be considered in determining appropriations for the
provision of health care and services to Indians.
[Sec. 1643. Amount and use of funds reimbursed through medicare and
medicaid available to Indian Health Service
[The Secretary shall submit to the President, for inclusion
in the report required to be transmitted to the Congress under
section 1671 of this title, an accounting on the amount and use
of funds made available to the Service pursuant to this
subchapter as a result of reimbursements through Titles XVIII
and XIX of the Social Security Act [42 U.S.C.A. Sec. Sec. 1395
et seq., 1396 et seq.], as amended.]
Sec. 1644. Grants to and Funding Agreements [contracts] with the
Service, Indian Tribes, T[t]ribal [o]Organizations,
and Urban Indian Organizations
(a) Indian Tribes and Tribal Organizations.--[Access to
health services]
The Secretary, acting through the Service, shall make
grants to or enter into Funding Agreements [contracts] with
Indian Tribes and T[t]ribal O[o]rganizations to assist such
Tribes and Tribal O[o]rganizations in establishing and
administering programs on or near [Federal Indian] reservations
and trust areas [and in or near Alaska Native villages] to
assist individual Indians [to]--
(1) to enroll for benefits under title XVIII, XIX, or
XXI [section 1818 of part A and sections 1836 and 1837
of part B of Title XVIII] of the Social Security Act
and other health benefits programs [[42 U.S.C.A.
Sec. Sec. 1395i-2, 1395o, 1395p]]; and
(2) to pay [monthly] premiums for coverage for such
benefits, which may be based on financial need (as
determined by the Indian Tribe or Tribes being served
based on a schedule of income levels developed or
implemented by such Tribe or Tribes). [due to financial
need of such individual; and
[(3) apply for medical assistance provided pursuant
to Title XIX of the Social Security Act [42 U.S.C.A.
Sec. 1396 et seq.].]
(b) [Terms and c]Conditions.--
The Secretary, acting through the Service, shall place
conditions as deemed necessary to effect the purpose of this
section in any [contract or] grant or Funding Agreement which
the Secretary makes with any Indian Tribe or T[t]ribal
O[o]rganization pursuant to this section. Such conditions shall
include [, by are not limited to,] requirements that the Indian
Tribe or Tribal O[o]rganization successfully undertake [to]--
(1) to determine the population of Indians eligible
for the [to be served that are or could be recipients
of] benefits described in subsection (a) [under Titles
XVIII and XIX of the Social Security Act [42 U.S.C.A.
Sec. Sec. 1395 et seq., 1396 et seq.]];
(2) to educate [assist individual] Indians with
respect to the benefits available under the respective
programs [in becoming familiar with and utilizing such
benefits];
(3) to provide transportation for [to] such
individual Indians to the appropriate offices for
enrollment or applications for such benefits [medical
assistance];
(4) to develop and implement[--]
[(A) a schedule of income levels to determine
the extent of payments of premiums by such
organizations for coverage of needy
individuals; and]
[(B)] methods of improving the participation
of Indians in receiving the benefits provided
under titles XVIII, [and] XIX, and XXI of the
Social Security Act [[42 U.S.C.A.
Sec. Sec. 1395 et seq. And 1396 et seq.]].
(c) Agreements Relating To Improving Enrollment of Indians
Under Social Security Act Programs.--[Application for medical
assistance]
(1) Agreements With Secretary To Improve Receipt
andProcessing of Applications.--
(A) Authorization.--The Secretary, acting
through the Service, may enter into an
agreement with an Indian [t]Tribe, [t]Tribal
[o]Organization, or [u]Urban Indian
[o]Organization which provides for the receipt
and processing of applications by Indians for
[medical] assistance under titles XIX and XXI
of the Social Security Act, [[42 U.S.C.A.
Sec. 1396 et seq.]] and benefits under title
XVIII of such [the Social Security] Act, by an
Indian Health Program or Urban Indian
Organization. [[42 U.S.C.A. Sec. 1395 et seq.]
at a Service facility or a health care facility
administered by such tribe or organization
pursuant to a contract under the Indian Self-
Determination Act [25 U.S.C.A Sec. 450f et
seq.].]
(B) Reimbursement of costs.--Such agreements
may provide for reimbursement of costs of
outreach, education regarding eligibility and
benefits, and translation when such services
are provided. The reimbursement may, as
appropriate, be added to the applicable rate
per encounter or be provided as a separate fee-
for-service payment to the Indian Tribe or
Tribal Organization.
(C) Processing clarified.--In this paragraph,
the term `processing' does not include a final
determination of eligibility.
(2) Agreements with states for outreach on or near
reservation.--
(A) In general.--In order to improve the
access of Indians residing on or near a
reservation to obtain benefits under title XIX
or XXI of the Social Security Act, as a
condition of continuing approval of a State
plan under such title, the State shall take
steps as to provide for enrollment on or near
the reservation. Such steps may include
outreach efforts such as the outstationing of
eligibility workers, entering into agreements
with Indian Tribes and Tribal Organizations to
provide outreach, education regarding
eligibility and benefits, enrollment, and
translation services when such services are
provided.
(B) Construction.--Nothing in subparagraph
(A) shall be construed as affecting
arrangements entered into between States and
Indian Tribes and Tribal Organizations for such
Indian Tribes and Tribal Organizations to
conduct administrative activities under such
titles.
(d) Facilitating Cooperation.--The Secretary, acting
through the Centers for Medicare & Medicaid Services, shall
take such steps as are necessary to facilitate cooperation
with, and agreements between, States and the Service, Indian
Tribes, Tribal Organizations, or Urban Indian Organizations.
(e) Application to Urban Indian Organizations.--
(1) In general.--The provisions of subsection (a)
shall apply with respect to grants and other funding to
Urban Indian Organizations with respect to populations
served by such organizations in the same manner they
apply to grants and Funding Agreements with Indian
Tribes and Tribal Organizations with respect to
programs on or near reservations.
(2) Requirements.--The Secretary shall include in the
grants or Funding Agreements made or provided under
paragraph (1) requirements that are--
(A) consistent with the requirements imposed
by the Secretary under subsection (b);
(B) appropriate to Urban Indian Organizations
and Urban Indians; and
(C) necessary to effect the purposes of this
section.
[Sec. 1645. Direct billing of Medicare, Medicaid, and other third party
payors
[(a) Establishment of direct billing program
[(1) In general
[The Secretary shall establish a program under which
Indian tribes, tribal organizations, and Alaska Native
health organizations that contract or compact for the
operation of a hospital or clinic of the Service under
the Indian Self-Determination and Education Assistance
Act may elect to directly bill for, and receive payment
for, health care services provided by such hospital or
clinic for which payment is made under title XVIII of
the Social Security Act (42 U.S.C. 1395 et seq.) (In
this section referred to as the ``medicare program''),
under a State plan for medical assistance approved
under title XIX of the Social Security Act (42 U.S.C.
1396 et seq.) (In this section referred to as the
``medicaid program''), or from any other third party
payor.
[(2) Application of 100 percent fmap
[The third sentence of section 1396d(b) of Title 42
shall apply for purposes of reimbursement under the
medicaid program for health care services directly
billed under the program established under this
section.
[(b) Direct reimbursement
[(1) Use of funds
[Each hospital or clinic participating in the program
described in subsection (a) of this section shall be
reimbursed directly under the medicare and medicaid
programs for services furnished, without regard to the
provisions of section 1880(c) of the Social Security
Act (42 U.S.C. 1395qq(c)) and sections 1642(a) and
1680c(b)(2)(A) of this title, but all funds so
reimbursed shall first be used by the hospital or
clinic for the purpose of making any improvements in
the hospital or clinic that may be necessary to achieve
or maintain compliance with the conditions and
requirements applicable generally to facilities of such
type under the medicare or medicaid programs. Any funds
so reimbursed which are in excess of the amount
necessary to achieve or maintain such conditions shall
be used--
[(A) solely for improving the health
resources deficiency level of the Indian tribe;
and
[(B) in accordance with the regulations of
the Service applicable to funds provided by the
Service under any contract entered into under
the Indian Self-Determination Act (25 U.S.C.
450f et seq.).
[(2) Audits
[The amounts paid to the hospitals and clinics
participating in the program established under this
section shall be subject to all auditing requirements
applicable to programs administered directly by the
Service and to facilities participating in the medicare
and medicaid programs.
[(3) Secretarial oversight
[The Secretary shall monitor the performance of
hospitals and clinics participating in the program
established under this section, and shall require such
hospitals and clinics to submit reports on the program
to the Secretary on an annual basis.
[(4) No payments from special funds
[Notwithstanding section 1880(c) of the Social
Security Act (42 U.S.C.A. Sec. 1395qq(c)) or section
1642(a) of this title, no payment may be made out of
the special funds described in such sections for the
benefit of any hospital or clinic during the period
that the hospital or clinic participates in the program
established under this section.
[(c) Requirements for participation
[(1) Application
[Except as provided in paragraph (2)(B), in order to
be eligible for participation in the program
established under this section, an Indian tribe, tribal
organization, or Alaska Native health organization
shall submit an application to the Secretary that
establishes to the satisfaction of the Secretary that--
[(A) the Indian tribe, tribal organization,
or Alaska Native health organization contracts
or compacts for the operation of a facility of
the Service;
[(B) the facility is eligible to participate
in the medicare or medicaid programs under
section 1395qq or 1396j of Title 42;
[(C) the facility meets the requirements that
apply to programs operated directly by the
Service; and
[(D) the facility--
[(i) is accredited by an accrediting
body as eligible for reimbursement
under the medicare or medicaid
programs; or
[(ii) has submitted a plan, which has
been approved by the Secretary, for
achieving such accreditation.
[(2) Approval
[(A) In general
[The Secretary shall review and approve a
qualified application not later than 90 days
after the date that application is submitted to
the Secretary unless the Secretary determines
that any of the criteria set forth in paragraph
(1) are not met.
[(B) Grandfather of demonstration program
participants
[Any participant in the demonstration program
authorized under this section as in effect on
November 1, 2000,shall be deemed approved for
participation in the program established under this section and shall
not be required to submit an application in order to participate in the
program.
[(C) Duration
[An approval by the Secretary of a qualified
application under subparagraph (A), or a deemed
approval of a demonstration program under
subparagraph (B), shall continue in effect as
long as the approved applicant or the deemed
approved demonstration program meets the
requirements of this section.
[(d) Examination and implementation of changes
[(1) In general
[The Secretary, acting through the Service, and with
the assistance of the Administrator of the Centers for
Medicare & Medicaid Services, shall examine on an
ongoing basis and implement--
[(A) any administrative changes that may be
necessary to facilitate direct bill and
reimbursement under the program established
under this section, including any agreements
with States that may be necessary to provide
for direct billing under the Medicaid program;
and
[(B) any changes that may be necessary to
enable participants in the program established
under this section to provide to the Service
medical records information on patients served
under the program that is consistent with the
medical records information system of the
Service.
[(2) Accounting information
[The accounting information that a participant in the
program established under this section shall be
required to report shall be the same as the information
required to be reported by participants in the
demonstration program authorized under this section as
in effect on the day before November 1.2000. The
Secretary may from time to time, after consultation
with the program participants, change the accounting
information submission requirements.
[(e) Withdrawal from program
[A participant in the program established under this
section may withdraw from participation in the same manner and
under the same conditions that a tribe or tribal organization
may retrocede a contracted program to the Secretary under
authority of the Indian Self-Determination Act [25 U.S.C.A.
Sec. 450f et seq.] . All cost accounting and billing authority
under the program established under this section shall be
returned to the Secretary upon the Secretary's acceptance of
the withdrawal of participation in this program.]
Sec. 403. Reimbursement From Certain Third Parties of Costs of Health
Services
(a) Right of Recovery.--Except as provided in subsection
(f), the United States, and 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
(or, if charges are not billed, the operational,
administrative, and other expenses incurred) 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
TribalOrganization under subsection (a).
(d) No Effect on Private Rights of Action.--No action taken
by the United States, an Indian Tribe, or Tribal Organization
to enforce the right of recovery provided under this section
shall operate to deny to the injured person the recovery for
that portion of the person's damage not covered hereunder.
(e) Enforcement.--
(1) In general.--The United States, an Indian Tribe,
or Tribal Organization may enforce the right of
recovery provided under subsection (a) by--
(A) intervening or joining in any civil
action or proceeding brought--
(i) by the individual for whom health
services were provided by the
Secretary, an Indian Tribe, or Tribal
Organization; or
(ii) by any representative or heirs
of such individual, or
(B) instituting a civil action, including a
civil action for injunctive relief and other
relief and including, with respect to a
political subdivision or local governmental
entity of a State, such an action against an
official thereof.
(2) Notice.--All reasonable efforts shall be made to
provide notice of action instituted under paragraph
(1)(B) to the individual to whom health services were
provided, either before or during the pendency of such
action.
(f) Limitation.--Absent specific written authorization by
the governing body of an Indian Tribe for the period of such
authorization (which may not be for a period of more than 1
year and which may be revoked at any time upon written notice
by the governing body to the Service), the United States shall
not have a right of recovery under this section if the injury,
illness, or disability for which health services were provided
is covered under a self-insurance plan funded by an Indian
Tribe, Tribal Organization, or Urban Indian Organization. Where
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) Right of Action Against Insurers, HMOs, Employee
Benefit Plans, Self-Insurance Plans, and Other Health Care
Plans or Programs.--Where an insurance company, health
maintenance organization, employee benefit plan, self-insurance
plan, managed care plan, or other health care plan or program
fails or refuses to pay the amount due under subsection (a) for
services provided to an individual who is a beneficiary,
participant, or insured of such company, organization, plan, or
program, the United States, Indian Tribe, or Tribal
Organization shall have a right to assert and pursue all the
claims and remedies against such company, organization, plan,
or program and against the fiduciaries of such company,
organization, plan, or program that the individual could assert
or pursue under the terms of the contract, program, or plan or
applicable Federal, State, or Tribal law.
(i) Nonapplication of Claims Filing Requirements.--An
insurance company, health maintenance organization, self-
insurance plan, manage 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.
(j) 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.
(k) 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.
(l) Savings.--Nothing in this section shall be construed to
limit any right of recovery available to the United States, an
Indian Tribe, or Tribal Organization under the provisions of
any applicable, Federal, State, or Tribal law, including
medical lien laws and the Federal Medical Care Recovery Act (42
U.S.C. 2651 et seq.).
Sec. 404. Crediting of Reimbursements
(a) Use of Amounts.--
(1) Retention by program.--Except as provided in
section 202(g) (relating to the Catastrophic Health
Emergency Fund) and section 807 (relating to health
services for ineligible persons), all reimbursements
received or recovered under any of the programs
described in paragraph (2), including under section
807, by reason of the provision of health services by
the Service, by an Indian Tribe or Tribal Organization,
or by an Urban Indian Organization, shall be credited
to the Service, such Indian Tribe or Tribal
Organization, or such Urban Indian Organization,
respectively, and may be used as provided in section
401. In the case of such a service provided by or
through a Service Unit, such amounts shall be credited
to such unit and used for such purposes.
(2) Programs covered.--The programs referred to in
paragraph (1) are the following:
(A) Titles XVIII, XIX, and XXI of the Social
Security Act.
(B) This Act, including section 807.
(C) Public Law 87-693.
(D) Any other provision of law.
(b) No Offset of Amounts.--The Service may not offset or
limit any amount obligated to any Service Unit or entity
receiving funding from the Service because of the receipt of
reimbursements under subsection (a).
Sec. 405. Purchasing Health Care Coverage
(a) In General.--Insofar as amounts are made available
under law (including a provision of the Social Security Act,
the Indian Self-Determination and Education Assistance Act, or
other law, other than under section 402) to Indian Tribes,
Tribal Organizations, and Urban Indian Organizations for health
benefits for Service beneficiaries, Indian Tribes, Tribal
Organizations, and Urban Indian Organizations may use such
amounts to purchase health benefits coverage for such
beneficiaries in any manner, including through--
(1) a tribally owned and operated health care plan;
(2) a State or locally authorized or licensed health
care plan;
(3) a health insurance provider or managed care
organization; or
(4) a self-insured plan.
The purchase of such coverage by an Indian Tribe, Tribal
Organization, or Urban Indian Organization may be based on the
financial needs of such beneficiaries (as determined by the
Indian Tribe or Tribes being served based on a schedule of
income levels developed or implemented by such Indian Tribe or
Tribes).
(b) Expenses for Self-Insured Plan.--In the case of a self-
insured plan under subsection (a)(4), the amounts may be used
for expenses of operating the plan, including administration
and insurance to limit the financial risks to the entity
offering the plan.
(c) Construction.--Nothing in this section shall be
construed as affecting the use of any amounts not referred to
in subsection (a).
Sec. 406. Sharing Arrangements with Federal Agencies
(a) Authority.--
(1) In general.--The Secretary may enter into (or
expand) arrangements for the sharing of medical
facilities and services between the Service, Indian
Tribes, and Tribal Organizations and the Department of
Veterans Affairs and the Department of Defense.
(2) Consultation by secretary required.--The
Secretary may not finalize any arrangement between the
Service and a Department described in paragraph (1)
without first consulting with the Indian Tribes which
will be significantly affected by the arrangement.
(b) Limitations.--The Secretary shall not take any action
under this section or under subchapter IV of chapter 81 of
title 38, United States Code, which would impair--
(1) the priority access of any Indian to health care
services provided through the Service and the
eligibility of any Indian to receive health services
through the Service;
(2) the quality of health care services provided to
any Indian through the Service;
(3) the priority access of any veteran to health care
services provided by the Department of Veterans
Affairs;
(4) the quality of health care services provided by
the Department of Veterans Affairs or the Department of
Defense; or
(5) the eligibility of any Indian who is a veteran to
receive health services through the Department of
Veterans Affairs.
(c) Reimbursement.--The Service, Indian Tribe, or Tribal
Organization shall be reimbursed by the Department of Veterans
Affairs or the Department of Defense (as the case may be) where
services are provided through the Service, an Indian Tribe, or
a Tribal Organization to beneficiaries eligible for services
from either such Department, notwithstanding any other
provision of law.
(d) Construction.--Nothing in this section may be construed
as creating any right of a non-Indian veteran to obtain health
services from the Service.
Sec. 407. Payor of Last Resort
Indian Health Programs and health care programs operated by
Urban Indian Organizations shall be the payor of last resort
for services provided to persons eligible for services from
Indian Health Programs and Urban Indian Organizations,
notwithstanding any Federal, State, or local law to the
contrary.
Sec. 408. Nondiscrimination in Qualifications for Reimbursement for
Services
For purposes of determining the eligibility of an entity
that is operated by the Service, an Indian Tribe, Tribal
Organization, or Urban Indian Organization to receive payment
or reimbursement from any federally funded health care program
for health care services it furnishes to an Indian, any
requirement that the entity be licensed or recognized under
State or local law to furnish such services shall be deemed to
have been met if the entity meets all the applicable standards
for such licensure, but the entity need not obtain a license.
In determining whether the entity meets such standards, the
absence of licensure of any staff member of the entity may not
be taken into account.
Sec. 409. Consultation
(a) National Indian Technical Advisory Group (TAG).--
(1) Establishment and membership.--The Secretary
shall establish within the Centers for Medicare &
Medicaid Services a National Indian Technical Advisory
Group (in this subsection referred to as the `Advisory
Group') which shall have no fewer than 14 members
including at least 1 member designated by the Indian
Tribes and Tribal Organizations in each Service Area, 1
Urban Indian Organization representative, and 1 member
representing the Service. The Secretary may appoint
additional members upon the recommendation of the
Advisory Group.
(2) Duties.--
(A) Identification of issues.--The Advisory
Group shall assist the Secretary in identifying
and addressing issues regarding the health care
programs under the Social Security Act
(including medicare, medicaid, and SCHIP) that
have implications for Indian Health Programs or
Urban Indian Organizations. The Advisory Group
shall provide advice to the Secretary with
respect to those issues and with respect to the
need for the Secretary to engage in
consultation with Indian Tribes, Tribal
Organizations, and Urban Indian Organizations.
(B) Construction.--Nothing in subparagraph
(A) shall be construed as affecting any
requirement under any applicable Executive
order for the Secretary to consult with Indian
Tribes in cases of health care policies that
have implications for Indian Health Programs or
Urban Indian Organizations.
(3) Nonapplication of federal advisory committee
act.--The Federal Advisory Committee Act (5 U.S.C.
App.) shall not apply to the Advisory Group.
(4) Meetings.--The Secretary is authorized to convene
meetings of the Advisory Group as often as needed to
fulfill the responsibilities under this section.
(b) Solicitation of Medicaid Advice.--
(1) In general.--As part of its plan for payment
under title XIX of the Social Security Act to a State
in which the Service operates or funds health care
programs or in which 1 or more Indian Health Programs
or Urban Indian Organizations provide health care in
the State for which medical assistance is available
under such title, the State may establish a process
under which the State seeks advice on a regular,
ongoing basis from designees of such Indian Health
Programs and Urban Indian Organizations on matters
relating to the application of such title to and having
a direct effect on such Indian Health Programs and
Urban Indian Organizations.
(2) Manner of advice.--The process described in
paragraph (1) should include solicitation of advice
prior to submission of any plan amendments, waiver
requests, and proposals for demonstration projects.
Such process may include appointment of an advisory
committee and of a designee of such Indian Health
Programs and Urban Indian Organizations to the medical
care advisory committee advising the State on its
medicaid plan.
(3) Payment of expenses.--Expenses in carrying out
this subsection shall be treated as reasonable
administrative expenses for which reimbursement may be
made under section 1903(a) of the Social Security Act.
(c) Construction.--Nothing in this section shall be
construed as superseding existing advisory committees, working
groups, or other advisory procedures established by the
Secretary or by any State.
Sec. 410. State Children's Health Insurance Program (SCHIP)
Notwithstanding any other provision of law, insofar as the
State health plan of a State under title XXI of the Social
Security Act may provide (whether through its medicaid plan
under title XIX of such Act or otherwise) child health
assistance to individuals who are otherwise served by the
Service or by an Indian Tribe or Tribal Organization, the
Secretary may enter into an arrangement with the State and with
the Service or 1 or more Indian Tribes and Tribal Organizations
in the State under which a portion of the funds otherwise made
available to the State under such title with respect to such
individuals is provided to the Service, Indian Tribe, or Tribal
Organization, respectively, for the purpose of providing such
assistance to such individuals consistent with the purposes of
such title.
Sec. 411. Social Security Act Sanctions
(a) Requests for Waiver of Sanctions.--For purposes of
applying any authority under a provision of title XI, XVIII,
XIX, or XXI of the Social Security Act to seek a waiver of a
sanction imposed against a health care provider insofar as that
provider provides services to individuals through an Indian
Health Program, any requirement that a State request such a
waiver shall be deemed to be met if such Indian Health Program
requests such a waiver.
(b) Safe Harbor for Transactions Between and Among Indian
Health Care Programs.--For purposes of applying section
1128B(b) of the Social Security Act, the exchange of anything
of value between or among the following shall not be treated as
remuneration if the exchange arises from or relates to any of
the following health programs:
(1) An exchange between or among the following:
(A) Any Indian Health Program.
(B) Any Urban Indian Organization.
(2) An exchange between an Indian Tribe, Tribal
Organization, or an Urban Indian Organization and any
patient served or eligible for service from an Indian
Tribe, Tribal Organization, or Urban Indian
Organization, including patients served or eligible for
service pursuant to section 807, but only if such
exchange--
(A) is for the purpose of transporting the
patient for the provision of health care items
or services;
(B) is for the purpose of providing housing
to the patient (including a pregnant patient)
and immediate family members or an escort
incidental to assuring the timely provision of
health care items and services to the patient;
(C) is for the purpose of paying premiums,
copayments, deductibles, or other cost-sharing
on behalf of patients; or
(D) consists of an item or service of small
value that is provided as a reasonable
incentive to secure timely and necessary
preventive and other items and services.
(3) Other exchanges involving an Indian Health
Program, an Urban Indian Organization, or an Indian
Tribe or Tribal Organization that meet such standards
as the Secretary of Health and Human Services, in
consultation with the Attorney General, determines is
appropriate, taking into account the special
circumstances of such Indian Health Programs, Urban
Indian Organizations, Indian Tribes, and Tribal
Organizations and of patients served by Indian Health
Programs, Urban Indian Organizations, Indian Tribes,
and Tribal Organizations.
Sec. 412. Cost Sharing
(a) Coinsurance, Copayments, and Deductibles.--
Notwithstanding any other provision of Federal or State law--
(1) Protection for eligible indians under social
security act health programs.--No Indian who is
furnished an item orservice for which payment may be
made under title XIX or XXI of the Social Security Act may be charged a
deductible, copayment, or coinsurance, if the item or service is
furnished by, or upon referral made by, the Service, an Indian Tribe,
Tribal Organization, or Urban Indian Organization.
(2) Protection for indians.--No Indian who is
furnished an item or service by the Service may be
charged a deductible, copayment, or coinsurance.
(3) No Reduction in amount of payment to indian
health providers.--The payment or reimbursement due to
the Service, Indian Tribe, Tribal Organization, or
Urban Indian Organization under title XIX or XXI of the
Social Security Act may not be reduced by the amount of
the deductible, copayment, or coinsurance that would be
due from the Indian but for the operation of this
section.
(b) Exemption From Medicaid and SCHIP Premiums.--
Notwithstanding any other provision of Federal or State law, no
Indian who is otherwise eligible for services under title XIX
of the Social Security Act (relating to the medicaid program)
or title XXI of such Act (relating to the State children's
health insurance program) may be charged a premium as a
condition of receiving benefits under the program under the
respective title.
(c) Limitation on Medical Child Support Recovery.--
Notwithstanding any other provision of law, a parent (whether
or not an Indian) of an Indian child shall not be responsible
for reimbursing a State or the Federal Government under title
XIX or XXI of the Social Security Act for the cost of medical
services relating to the child (including childbirth and
including, where such child is a minor parent, any child of
such minor parent) under circumstances in which payment would
have been made under the contract health services program of an
Indian Health Program but for the child's (or, in the case of
medical services relating to childbirth, mother's, or
grandchild's as the case may be) eligibility under title XIX or
XXI of the Social Security Act.
(d) Treatment of Certain Property for Medicaid
Eligibility.--Notwithstanding any other provision of Federal or
State law, the following property may not be included when
determining eligibility for services under title XIX of the
Social Security Act:
(1) Property, including interests in real property
currently or formerly held in trust by the Federal
Government which is protected under applicable Federal,
State, or Tribal law or custom from recourse and
including public domain allotments.
(2) Property that has unique religious or cultural
significance or that supports subsistence or
traditional lifestyle according to applicable Tribal
law or custom.
(e) Continuation of Current Law Protections of Certain
Indian Property From Medicaid Estate Recovery.--Income,
resources, and property that are exempt from medicaid estate
recovery under title XIX of the Social Security Act as of April
1, 2003, under manual instructions issued to carry out section
1917(b)(3) of such Act because of Federal responsibility for
Indian Tribes and Alaska Native Villages shall remain so
exempt. Nothing in this subsection shall be construed as
preventing the Secretary from providing additional medicaid
estate recovery exemptions for Indians.
Sec. 413. Treatment Under Medicaid Managed Care.
(a) Payment for Services Furnished to Indians.--
(1) In general.--Subject to paragraph (2), in the
case of an Indian who is enrolled with a managed care
entity under section 1932 of the Social Security Act
(or otherwise under a waiver under title XIX of such
Act) and who receives services, covered by a managed
care entity, from an Indian Health Program or an Urban
Indian Organization, either--
(A) the entity shall make payment to the
Indian Health Program or Urban Indian
Organization at a rate established by the
entity for such services that is not less than
the rate for preferred providers (or at such
other rate as may be negotiated between the
entity and such Indian Health Program or Urban
Indian Organization) and shall not require
submittal of a claim by the enrollee as a
condition of payment to the Indian Health
Program or Urban Indian Organization; or
(B) the State shall provide for payment to
the Indian Health Program or Urban Indian
Organization under its State plan under title
XIX of such Act at the rate otherwise
applicable and shall provide for an appropriate
adjustment of the capitation payment made to
the entity to take into account such payment.
(2) Payment standards.--The payment provisions shall
meet the usual medicaid standards for economy,
efficiency, and access to quality care.
(b) Offering of Managed Care.--If--
(1) a State elects under its State plan under title
XIX of the Social Security Act to provide services
through medicaid managed care organizations or through
primary care case managers under section 1932 or under
a waiver under such title; and
(2) the Indian Health Program or Urban Indian
Organization that is funded in whole or in part by the
Service, or a consortium thereof, has established a
medicaid managed care organization or a primary care
case manager that meets quality standards equivalent to
those required of such an organization or manager under
such section or waiver,
the State shall enter into an agreement under such section with
the Service, Indian Tribe, Tribal Organization, or Urban Indian
Organization, or such consortium, to serve as a medicaid
managed care organization or a primary care case manager,
respectively with respect to Indians served by such entity. In
carrying out this subsection, the Secretary and the State may
waive requirements regarding enrollment, capitalization, and
such other matters that might otherwise prevent the application
of the previous sentence.
Sec. 414. Navajo Nation Medicaid Agency Feasibility Study
(a) Study.--The Secretary shall conduct a study to
determine the feasibility of treating the Navajo Nation as a
State for the purposes of title XIX of the Social Security Act,
to provide services to Indians living within the boundaries of
the Navajo Nation through an entity established having the same
authority and performing the same functions as single-State
medicaid agencies responsible for the administration of the
State plan under title XIX of the Social Security Act.
(b) Considerations.--In conducting the study, the Secretary
shall consider the feasibility of--
(1) assigning and paying all expenditures for the
provision of services and related administration funds,
under title XIX of the Social Security Act, to Indians
living within the boundaries of the Navajo Nation that
are currently paid to or would otherwise be paid to the
State of Arizona, New Mexico, or Utah;
(2) providing assistance to the Navajo Nation in the
development and implementation of such entity for the
administration, eligibility, payment, and delivery of
medical assistance under title XIX of the Social
Security Act;
(3) providing an appropriate level of matching funds
for Federal medical assistance with respect to amounts
such entity expends for medical assistance for services
and related administrative costs; and
(4) authorizing the Secretary, at the option of the
Navajo Nation, to treat the Navajo Nation as a State
for the purposes of title XIX of the Social Security
Act (relating to the State children's health insurance
program) under terms equivalent to those described in
paragraphs (2) through (4).
(c) Report.--Not later then 3 years after the date of
enactment of the Indian Health Act Improvement Act Amendments
of 2004, the Secretary shall submit to the Committee on Indian
Affairs and Committee on Finance of the Senate and the
Committee on Resources and Committee on Ways and Means of the
House of Representatives a report that includes--
(1) the results of the study under this section;
(2) a summary of any consultation that occurred
between the Secretary and the Navajo Nation, other
Indian Tribes, the States of Arizona, New Mexico, and
Utah, counties which include Navajo Lands, and other
interested parties, in conducting this study;
(3) projected costs or savings associated with
establishment of such entity, and any estimated impact
on services provided as described in this section in
relation to probable costs or savings; and
(4) legislative actions that would be required to
authorize the establishment of such entity if such
entity is determined by the Secretary to be feasible.
[Sec. 1646. Authorization for emergency contract health services
[With respect to an elderly or disabled Indian receiving
emergency medical care or services from a non-Service provider
or in a non-Service facility under the authority of this
chapter, the time limitation (as a condition of payment) for
notifying the Service of such treatment or admission shall be
30 days.]
Sec. 1647. Authorization of [a]Appropriations
There are authorized to be appropriated such sums as may be
necessary for each fiscal year through fiscal year 2015 [2000]
to carry out this title [subchapter].
TITLE V [SUBCHAPTER IV]--HEALTH SERVICES FOR URBAN INDIANS
Sec. 1651. Purpose
The purpose of this title [subchapter] is to establish and
maintain programs in [u]Urban [c]Centers to make health
services more accessible and available to [u]Urban Indians.
Sec. 1652. Contracts [w]With, and [g]Grants to, [u]Urban Indian
[o]Organizations
Under authority of the Act of November 2, 1921 (25 U.S.C.
13), (commonly [popularly] known as the `Snyder Act'), the
Secretary, acting through the Service, shall enter into
contracts with, or make grants to, [u]Urban Indian
[o]Organizations to assist such organizations in the
establishment and administration, within [the u]Urban
[c]Centers [in which such organizations are situated], of
programs which meet the requirements set forth in this title
[subchapter]. Subject to section 506, t[T]he Secretary, acting
through the Service, shall include such conditions as the
Secretary considers necessary to effect the purpose of this
title [subchapter] in any contract into which the Secretary
enters [into] with, or in any grant the Secretary makes to, any
U[u]rban Indian O[o]rganization pursuant to this title
[subchapter].
Sec. 1653. Contracts and G[g]rants for the P[p]rovision of H[h]ealth
C[c]are and R[r]eferral S[s]ervices
(a) Requirements for Grants and Contracts._
Under authority of the Act of November 2, 1921 (25 U.S.C.
13)[, popularly] (commonly known as the `Snyder Act'), the
Secretary, acting through the Service, shall enter into
contracts with, or make grants to, [u]Urban Indian
[o]Organizations for the provision of health care and referral
services for [u]Urban Indians [residing in the urban centers in
which such organizations are situated]. Any such contract or
grant shall include requirements that the [u]Urban Indian
[o]Organization successfully undertake to--
(1) estimate the population of [u]Urban Indians
residing in the [u]Urban [c]Center or centers that the
organization proposes to serve [in which such
organization is situated] who are or could be
recipients of health care or referral services;
(2) estimate the current health status of [u]Urban
Indians residing in such [u]Urban [c]Center or centers;
(3) estimate the current health care needs of
[u]Urban Indians residing in such [u]Urban [c]Center or
centers;
(4) provide basic health education, including health
promotion and disease prevention education, to Urban
Indians [identify all public and private health
services resources within such urban center which are
or may be available to urban Indians];
(5) make recommendations to the Secretary and
Federal, State, local, and other resource agencies on
methods of improving health service programs to meet
the needs of Urban Indians [determine the use of public
and private health services resources by the urban
Indians residing in such urban center]; and
(6) where necessary, provide, or enter into contracts
for the provision of, health care services for Urban
Indians. [assist such health services resources in
providing services to urban Indians;
[(7) assist urban Indians in becoming familiar with
and utilizing such health services resources;
[(8) provide basic health education, including health
promotion and disease prevention education, to urban
Indians;
[(9) establish and implement training programs to
accomplish the referral and education tasks set forth
in paragraphs (6) through (8) of this subsection;
[(10) identify gaps between unmet health needs of
urban Indians and the resources available to meet such
needs;
[(11) make recommendations to the Secretary and
Federal, State, local, and other resource agencies on
methods of improving health service programs to meet
the needs of urban Indians; and
[(12) where necessary, provide, or enter into
contracts for the provision of, health care services
for urban Indians.]
(b) Criteria.--[for selection of organizations to enter
into contracts or receive grants]
The Secretary, acting through the Service, shall by
regulation adopted pursuant to section 520 prescribe the
criteria for selecting [u]Urban Indian [o]Organizations to
enter into contracts or receive grants under this section. Such
criteria shall, among other factors, include--
(1) the extent of unmet health care needs of [u]Urban
Indians in the [u]Urban [c]Center or centers involved;
(2) the size of the [u]Urban Indian population in the
[u]Urban [c]Center or centers involved;
[(3) the accessibility to, and utilization of, health
care services (other than services provided under this
subchapter) by urban Indians in the urban center
involved;]
(3)[(4)] the extent, if any, to which the activities
set forth in subsection (a) [of this section] would
duplicate any project funded under this title;[--]
[(A) any previous or current public or
private health services project in an urban
center that was or is funded in a manner other
than pursuant to this subchapter; or
[(B) any project funded under this
subchapter;]
(4)[(5)] the capability of an [u]Urban Indian
[o]Organization to perform the activities set forth in
subsection (a) [of this section] and to enter into a
contract with the Secretary or to meet the requirements
for receiving a grant under this section;
(5)[(6)] the satisfactory performance and successful
completion by an [u]Urban Indian [o]Organization of
other contracts with the Secretary under this title
[subchapter];
(6)[(7)] the appropriateness and likely effectiveness
of conducting the activities set forth in subsection
(a) [of this section] in an [u]Urban [c]Center or
centers; and
(7)[(8)] the extent of existing or likely future
participation in the activities set forth in subsection
(a) [of this section] by appropriate health and health-
related Federal, State, local, and other agencies.
(c) Access to Health Promotion and Disease Prevention
Programs.--[Grants for health promotion and disease prevention
services]
The Secretary, acting through the Service, shall facilitate
access to[,] or provide[,] health promotion and disease
prevention services for [u]Urban Indians through grants made to
[u]Urban Indian [o]Organizations administering contracts
entered into [pursuant to this section] or receiving grants
under subsection (a) [of this section].
(d) [Grants for i]Immunization [s]Services.--
(1) Access or services provided.--The Secretary,
acting through the Service, shall facilitate access to,
or provide, immunization services for [u]Urban Indians
through grants made to [u]Urban Indian [o]Organizations
administering contracts entered into [pursuant to this
section] or receiving grants under [subsection (a) of]
this section.
(2) Definition.--For purposes of this subsection, the
term `immunization services' means services to provide
without charge immunizations against vaccine-
preventable diseases.
[(2) In making any grant to carry out this
subsection, the Secretary shall take into
consideration--
[(A) the size of the urban Indian population
to be served;
[(B) the immunization levels of the urban
Indian population, particularly the
immunization levels of infants, children, and
the elderly;
[(C) the utilization by the urban Indians of
alternative resources from State and local
governments for no-cost or low-cost
immunization services to the general
population; and
[(D) the capability of the urban Indian
organization to carry out services pursuant to
this subsection.
[(3) For purposes of this subsection, the term
``immunization services'' means services to provide
without charge immunizations against vaccine-
preventable diseases.]
(e) Behavioral [Grants for provision of mental h]Health
[s]Services.--
(1) Access or services provided.--The Secretary,
acting through the Service, shall facilitate access to,
or provide, behavioral [mental] health services for
[u]Urban Indians through grants made to [u]Urban Indian
[o]Organizations administering contracts entered into
[pursuant to this section] or receiving grants under
subsection (a) [of this section].
(2) Assessment required.--Except as provided by
paragraph (3)(A), a [A] grant may not be made under
this subsection to an [u]Urban Indian [o]Organization
until that organization has prepared, and the Service
has approved, an assessment of the following: [mental
health needs of the urban Indian populationconcerned,
the mental health services and other related resources available to
that population, the barriers to obtaining those services and
resources, and the needs that are unmet by such services and
resources.]
(A) The behavioral health needs of the Urban
Indian population concerned.
(B) The behavioral health services and other
related resources available to that population.
(C) The barriers to obtaining those services
and resources.
(D) The needs that are unmet by such services
and resources.
(3) Purposes of grants.--Grants may be made under
this subsection[--] for the following:
(A) [t]To prepare assessments required under
paragraph (2)[;].
(B) [t]To provide outreach, educational, and
referral services to [u]Urban Indians regarding
the availability of direct behavioral [mental]
health services, to educate [u]Urban Indians
about behavioral [mental] health issues and
services, and effect coordination with existing
behavioral [mental] health providers in order
to improve services to [u]Urban Indians[;].
(C) [t]To provide outpatient behavioral
[mental] health services to [u]Urban Indians,
including the identification and assessment of
illness, therapeutic treatments, case
management, support groups, family treatment,
and other treatment.[; and]
(D) [t]To develop innovative behavioral
[mental] health service delivery models which
incorporate Indian cultural support systems and
resources.
(f) [Grants for p]Prevention [and treatment] of [c]Child
[a]Abuse
(1) Access or services provided.--The Secretary,
acting through the Service, shall facilitate access
to[,] or provide[,] services for [u]Urban Indians
through grants to [u]Urban Indian [o]Organizations
administering contracts entered into [pursuant to this
section] or receiving grants under subsection (a) [of
this section] to prevent and treat child abuse
(including sexual abuse) among [u]Urban Indians.
(2) Evaluation required.--Except as provided by
paragraph (3)(A), a [A] grant may not be made under
this subsection to an [u]Urban Indian [o]Organization
until that organization has prepared, and the Service
has approved, an assessment that documents the
prevalence of child abuse in the [u]Urban Indian
population concerned and specifies the services and
programs (which may not duplicate existing services and
programs) for which the grant is requested.
(3) Purposes of grants.--Grants may be made under
this subsection[--] for the following:
(A) [t]To prepare assessments required under
paragraph (2)[;].
(B) [f]For the development of prevention,
training, and education programs for [u]Urban
Indians [populations], including child
education, parent education, provider training
on identification and intervention, education
on reporting requirements, prevention
campaigns, and establishing service networks of
all those involved in Indian child
protection.[; and]
(C) [t]To provide direct outpatient treatment
services (including individual treatment,
family treatment, group therapy, and support
groups) to [u]Urban Indians who are child
victims of abuse (including sexual abuse) or
adult survivors of child sexual abuse, to the
families of such child victims, and to [u]Urban
Indian perpetrators of child abuse (including
sexual abuse).
(4) Considerations when making grants.--In making
grants to carry out this subsection, the Secretary
shall take into consideration--
(A) the support for the [u]Urban Indian
[o]Organization demonstrated by the child
protection authorities in the area, including
committees or other services funded under the
Indian Child Welfare Act of 1978 (25 U.S.C.
1901 et seq.), if any;
(B) the capability and expertise demonstrated
by the [u]Urban Indian [o]Organization to
address the complex problem of child sexual
abuse in the community; and
(C) the assessment required under paragraph
(2).
(g) Other Grants.--The Secretary, acting through the
Service, mayenter into a contract with or make grants to an
Urban Indian Organization that provides or arranges for the provision
of health care services (through satellite facilities, provider
networks, or otherwise) to Urban Indians in more than 1 Urban Center.
Sec. 1654. Contracts and [g]Grants for the [d]Determination of [u]Unmet
[h]Health [c]Care [n]Needs
(a) Grants and Contracts Authorized.--[Authority]
Under authority of the Act of November 2, 1921 (25 U.S.C.
13)[, popularly] (commonly known as the `Snyder Act'), the
Secretary, acting through the Service, may enter into contracts
with[,] or make grants to[, u]Urban Indian [o]Organizations
situated in [u]Urban [c]Centers for which contracts have not
been entered into[,] or grants have not been made[,] under
section 503 [1653 of this title].
(b) Purpose.--The purpose of a contract or grant made under
this section shall be the determination of the matters
described in subsection (c)[(b)](1) [of this section] in order
to assist the Secretary in assessing the health status and
health care needs of [u]Urban Indians in the [u]Urban [c]Center
involved and determining whether the Secretary should enter
into a contract or make a grant under section 503[1653 of this
title] with respect to the [u]Urban Indian [o]Organization
which the Secretary has entered into a contract with, or made a
grant to, under this section.
(c) [(b)] Grant and Contract Requirements.--
Any contract entered into, or grant made, by the Secretary
under this section shall include requirements that--
(1) the [u]Urban Indian [o]Organization successfully
undertakes to--
(A) document the health care status and unmet
health care needs of [u]Urban Indians in the
[u]Urban [c]Center involved; and
(B) with respect to [u]Urban Indians in the
[u]Urban [c]Center involved, determine the
matters described in paragraphs [clauses] (2),
(3), (4), and (7)[(8)] of section 503(b)
[1653(b) of this title]; and
(2) the [u]Urban Indian [o]Organization complete
performance of the contract, or carry out the
requirements of the grant, within 1[one] year after the
date on which the Secretary and such organization enter
into such contract, or within 1[one] year after such
organization receives such grant, whichever is
applicable.
(d) [(c)] No Renewals
The Secretary may not renew any contract entered into[,] or
grant made[,] under this section.
Sec. 1655. Evaluations; [r]Renewals
(a) Procedures for Evaluations.--[Contract compliance and
performance]
The Secretary, acting through the Service, shall develop
procedures to evaluate compliance with grant requirements
[under this subchapter] and compliance with[,] and performance
of contracts entered into by [u]Urban Indian [o]Organizations
under this title [subchapter]. Such procedures shall include
provisions for carrying out the requirements of this section.
(b) [Annual onsite e]Evaluations
The Secretary, acting through the Service, shall evaluate
the compliance [conduct an annual onsite evaluation] of each
[u]Urban Indian [o]Organization which has entered into a
contract or received a grant under section 503 with the terms
of [1653 of this title for purposes of determining the
compliance of such organization with, and evaluating the
performance of such organization under, such contract or the
terms of] such contract or grant. For purposes of this
evaluation, in determining the capacity of an Urban Indian
Organization to deliver quality patient care the Secretary
shall--
(1) acting through the Service, conduct an annual
onsite evaluation of the organization; or
(2) accept in lieu of such onsite evaluation evidence
of the organization's provisional or full accreditation
by a private independent entity recognized by the
Secretary for purposes of conducting quality reviews of
providers participating in the Medicare program under
title XVIII of the Social Security Act.
(c) Noncompliance; [or u]Unsatisfactory [p]Performance.--
If, as a result of the evaluations conducted under this
section, the Secretary determines that an [u]Urban
Indian[o]Organization has not complied with the requirements of a grant
or complied with or satisfactorily performed a contract under section
503[1653 of this title], the Secretary shall, prior to renewing such
contract or grant, attempt to resolve with the [such] organization the
areas of noncompliance or unsatisfactory performance and modify the
[such] contract or grant to prevent future occurrences of [such]
noncompliance or unsatisfactory performance. If the Secretary
determines that the [such] noncompliance or unsatisfactory performance
cannot be resolved and prevented in the future, the Secretary shall not
renew the [such] contract or grant with the [such] organization and is
authorized to enter into a contract or make a grant under section 503
[1653 of this title] with another [u]Urban Indian [o]Organization which
is situated in the same [u]Urban [c]Center as the [u]Urban Indian
[o]Organization whose contract or grant is not renewed under this
section.
(d) Considerations for [Contract and grant r]Renewals
In determining whether to renew a contract or grant with an
[u]Urban Indian [o]Organization under section 503 [1653 of this
title] which has completed performance of a contract or grant
under section 504 [1654 of this title], the Secretary shall
review the records of the [u]Urban Indian [o]Organization, the
reports submitted under section 507 [1657 of this title, and,
in the case of a renewal of a contract or grant under section
1653 of this title], and shall consider the results of the
onsite evaluations or accreditations [conducted] under
subsection (b) [of this section].
Sec. 1656. Other [c]Contract and [g]Grant [r]Requirements
(a) Procurement.--[Federal regulations; exceptions]
Contracts with [u]Urban Indian [o]Organizations entered
into pursuant to this title [subchapter] shall be in accordance
with all Federal contracting laws and regulations relating to
procurement except that[,] in the discretion of the Secretary,
such contracts may be negotiated without advertising and need
not conform to the provisions of sections 1304 and 3131 through
[3131 to] 3133 of [T]title 40, United States Code.
(b) Payment Under Contracts or Grants._
Payments under any contracts or grants pursuant to this
title shall, notwithstanding any term or condition of such
contract or grant--[subchapter may be made in advance or by way
of reimbursement and in such installments and on such
conditions as the Secretary deems necessary to carry out the
purposes of this subchapter.]
(1) be made in their entirety by the Secretary to the
Urban Indian Organization by no later than the end of
the first 30 days of the funding period with respect to
which the payments apply, unless the Secretary
determines through an evaluation under section 505 that
the organization is not capable of administering such
payments in their entirety; and
(2) if any portion thereof is unexpended by the Urban
Indian Organization during the funding period with
respect to which the payments initially apply, shall be
carried forward for expenditure with respect to
allowable or reimbursable costs incurred by the
organization during 1 or more subsequent funding
periods without additional justification or
documentation by the organization as a condition of
carrying forward the availability for expenditure of
such funds.
(c) Revision or [a]Amendment of Contracts.--
Notwithstanding any provision of law to the contrary, the
Secretary may, at the request or consent of an [u]Urban Indian
[o]Organization, revise or amend any contract entered into by
the Secretary with such organization under this title
[subchapter] as necessary to carry out the purposes of this
title [subchapter].
[(d) Existing Government facilities
[In connection with any contract or grant entered into
pursuant to this subchapter, the Secretary may permit an urban
Indian organization to utilize, in carrying out such contract
or grant, existing facilities owned by the Federal Government
within the Secretary's jurisdiction under such terms and
conditions as may be agreed upon for the use and maintenance of
such facilities.]
(d) Fair and [(e)] Uniform [provision of s]Services and
[a]Assistance.--
Contracts with[,] or grants to[, u]Urban Indian
[o]Organizations and regulations adopted pursuant to this title
[subchapter] shall include provisions to assure the fair and
uniform provision to [u]Urban Indians of services and
assistance under such contracts or grants by such
organizations.
[(f) Eligibility for health care or referral services
[Urban Indians, as defined in section 1603(f) of thistitle,
shall be eligible for health care or referral services provided
pursuant to this subchapter.]
Sec. 1657. Reports and [r]Records
(a) [Quarterly r]Reports.--
For each fiscal year during which an [u]Urban Indian
[o]Organization receives or expends funds pursuant to a
contract entered into[,] or a grant received[,] pursuant to
this title [subchapter], such Urban Indian O[o]rganization
shall submit to the Secretary not more frequently than every 6
months, a [quarterly] report that includes the following:
[including--]
(1) [i]In the case of a contract or grant under
section 503, recommendations pursuant to section
503(a)(5). [1653 of this title, information gathered
pursuant to clauses (10) and (11) of this subsection
(a) of such section;]
(2) [i]Information on activities conducted by the
organization pursuant to the contract or grant[;].
(3) [a]An accounting of the amounts and purpose[s]
for which Federal funds were expended.[; and]
(4) A minimum set of data, using uniformly defined
elements, that is specified by the Secretary in
consultation, consistent with section 514, with Urban
Indian Organizations. [such other information as the
Secretary may request.]
(b) Audit [by Secretary and Comptroller General].--
The reports and records of the [u]Urban Indian
[o]Organization with respect to a contract or grant under this
title [subchapter] shall be subject to audit by the Secretary
and the Comptroller General of the United States.
(c) Cost of [annual private a]Audits.--
The Secretary shall allow as a cost of any contract or
grant entered into or awarded under section 502 or 503 [1653 of
this title] the cost of an annual independent financial
[private] audit conducted by--
(1) a certified public accountant[.]; or
(2) a certified public accounting firm qualified to
conduct Federal compliance audits.
[(d) Health status, services, and areas of unmet needs;
child welfare
[(1) The Secretary, acting through the Service, shall
submit a report to the Congress not later than March
31, 1992, evaluating--
[(A) the health status of urban Indians;
[(B) The services provided to Indians through
this subchapter;
[(C) areas of unmet needs in urban areas
served under this subchapter; and
[(D) areas of unmet needs in urban areas not
served under this subchapter.
[(2) In preparing the report under paragraph (1), the
Secretary shall consult with urban Indian health
providers and may contract with a national organization
representing urban Indian health concerns to conduct
any aspect of the report.
[(3) The Secretary and the Secretary of the Interior
shall--
[(A) assess the status of the welfare of
urban Indian children, including the volume of
child protection cases, the prevalence of child
sexual abuse, and the extent of urban Indian
coordination with tribal authorities with
respect to child sexual abuse; and
[(B) submit a report on the assessment
required under subparagraph (A), together with
recommended legislation to improve Indian child
protection in urban Indian populations, to the
Congress no later than March 31, 1992.]
Sec. 1658. Limitation on [c]Contract [a]Authority
The authority of the Secretary to enter into contracts or
to award grants under this title [subchapter] shall be to the
extent, and in an amount, provided for in appropriation Acts.
Sec. 1659. Facilities [renovation]
(a) Grants.--The Secretary, acting through the Service, may
make grants [funds available] to contractors or grant
recipients under this title [subchapter] for the lease,
purchase, renovation, construction, or expansion of [minor
renovations to] facilities, including leased facilities, in
order to assist suchcontractors or grant recipients in
complying with applicable licensure or certification requirements
[meeting or maintaining the Joint Commission for Accreditation of
Health Care Organizations (JCAHO) standards].
(b) Loans.--The Secretary, acting through the Service or
through the Health Resources and Services Administration, may
provide to contractors or grant recipients under this title
loans from the Urban Indian Health Care Facilities Revolving
Loan Fund described in subsection (c), or guarantees for loans,
for the construction, renovation, expansion, or purchase of
health care facilities, subject to the following requirements:
(1) The principal amount of a loan or loan guarantee
may cover 100 percent of the costs (other than
staffing) relating to the facility, including planning,
design, financing, site land development, construction,
rehabilitation, renovation, conversion, medical
equipment, furnishings, and capital purchase.
(2) The total of the principal of loans and loan
guarantees, respectively, outstanding at any one time
shall not exceed such limitations as may be specified
in appropriation Acts.
(3) The loan or loan guarantee may have a term of the
shorter of the estimated useful life of the facility or
25 years.
(4) An Urban Indian Organization may assign, and the
Secretary may accept assignment of, the revenue of the
Urban Indian Organization as security for a loan or
loan guarantee under this subsection.
(5) The Secretary shall not collect application,
processing, or similar fees from Urban Indian
Organizations applying for loans or loan guarantees
under this subsection.
(c) Fund.--
(1) Establishment.--There is established in the
Treasury of the United States a fund to be known as the
Urban Indian Health Care Facilities Revolving Loan Fund
(hereafter in this section referred to as the `URLF').
The URLF shall consist of--
(A) such amounts as may be appropriated to
the URLF;
(B) amounts received from Urban Indian
Organizations in repayment of loans made to
such organizations under paragraph (2); and
(C) interest earned on amounts in the URLF
under paragraph (3).
(2) Use of amount in fund.--Amounts in the URLF may
be expended by the Secretary, acting through the
Service or the Health Resources and Services
Administration, to make loans available to Urban Indian
Organizations receiving grants or contracts under this
title for the purposes, and subject to the
requirements, described in subsection (b). Amounts
appropriated to the URLF, amounts received from Urban
Indian Organizations in repayment of loans, and
interest on amounts in the URLF shall remain available
until expended.
(3) Investment of amounts in fund.--The Secretary of
the Treasury shall invest such amounts of the URLF as
such Secretary determines are not required to meet
current withdrawals from the URLF. 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. Any obligation acquired by the URLF may be sold
by the Secretary of the Treasury at the market price.
(4) Initial funds.--There are authorized to be
appropriated such sums as may be necessary to initiate
the URLF. For each fiscal year after the initial year
in which funds are appropriated to the URLF, there is
authorized to be appropriated an amount equal to the
sum of the amount collected by the URLF during the
preceding fiscal year and all accrued interest.
Sec. 1660. Office of Urban Indian Health [Programs Branch]
[(a) Establishment]
There is hereby established within the Service an Office [a
Branch] of Urban Indian Health, [Programs] which shall be
responsible for--
(1) carrying out the provisions of this title;
[subchapter and for]
(2) providing central oversight of the programs and
services authorized under this title; and [subchapter.]
(3) providing technical assistance to Urban Indian
Organizations.
[(b) Staff, services, and equipment
[The Secretary shall appoint such employees to work in the
branch, including a program director, and shall provide such
services and equipment, as may be necessary for it to carry out
its responsibilities. The Secretary shall also analyze the need
to provide at least one urban health program analyst for each
area office of the Indian Health Service and shall submit his
findings to the Congress as a part of the Department's fiscal
year 1993 budget request.]
Sec. 1660a. Grants for [a]Alcohol and [s]Substance [a]Abuse [r]Related
[s]Services
(a) Grants Authorized.--
The Secretary, acting through the Service, may make grants
for the provision of health-related services in prevention of,
treatment of, rehabilitation of, or school and community-based
education regarding [in], alcohol and substance abuse in
[u]Urban [c]Centers to those [u]Urban Indian [o]Organizations
with which [whom] the Secretary has entered into a contract
under this title [subchapter] or under section 201 [1621 of
this title].
(b) Goals [of grant].--
Each grant made pursuant to subsection (a) [of this
section] shall set forth the goals to be accomplished pursuant
to the grant. The goals shall be specific to each grant as
agreed to between the Secretary and the grantee.
(c) Criteria.--
The Secretary shall establish criteria for the grants made
under subsection (a) [of this section], including criteria
relating to the following:[--]
(1) The size of the [u]Urban Indian population[;].
[(2) accessibility to, and utilization of, other
health resources available to such population;
[(3) duplication of existing Service or other Federal
grants or contracts;]
(2)[(4) c]Capability of the organization to
adequately perform the activities required under the
grant[;].
(3)[(5) s]Satisfactory performance standards for the
organization in meeting the goals set forth in such
grant.[, which] The standards shall be negotiated and
agreed to between the Secretary and the grantee on a
grant-by-grant basis.[; and]
(4)[(6) i]Identification of need for services.
(d) Allocation of Grants.--The Secretary shall develop a
methodology for allocating grants made pursuant to this section
based on the [such] criteria established pursuant to subsection
(c).
(e)[(d)] Grants Subject to Criteria.--[Treatment of funds
received by urban Indian organizations]
Any funds received by an [u]Urban Indian [o]Organization
under this Act [chapter] for substance abuse prevention,
treatment, and rehabilitation shall be subject to the criteria
set forth in subsection (c) [of this section].
Sec. 1660b. Treatment of [c]Certain [d]Demonstration [p]Projects.
[(a)] Notwithstanding any other provision of law, the Tulsa
Clinic and Oklahoma City Clinic demonstration projects shall--[
and the Tulsa Clinic demonstration project shall be treated as
service units in the allocation of resources and coordination
of care and shall not be subject to the provisions of the
Indian Self-Determination Act [25 U.S.C.A. Sec. 450f et seq.]
for the term of such projects. The Secretary shall provide
assistance to such projects in the development of resources and
equipment and facility needs.]
(1) be permanent programs within the Service's direct
care program;
(2) continue to be treated as Service Units in the
allocation of resources and coordination of care; and
(3) continue to meet the requirements and definitions
of an urban Indian organization in this Act, and shall
not be subject to the provisions of the Indian Self-
Determination and Education Assistance Act.
[(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
section1660d of this title to carry out this section through
fiscal year 2000, there are authorized to be appropriated such sums as
may be necessary to carry out this section for each of fiscal years
2001 and 2002.]
Sec. 1660c. Urban NIAAA [t]Transferred [p]Programs
(a) Grants and Contracts.--[Duty of Secretary]
The Secretary, through the Office [shall, within the
Branch] of Urban Indian Health, shall [Programs of the
Service,] make grants or enter into contracts with Urban Indian
Organizations for the administration of [u]Urban Indian alcohol
programs that were originally established under the National
Institute on Alcoholism and Alcohol Abuse (hereafter in this
section referred to as ``NIAAA'') and transferred to the
Service. Such grants and contracts shall become effective no
later than September 30, 2007.
(b) Use of Funds.--[grants]
Grants provided or contracts entered into under this
section shall be used to provide support for the continuation
of alcohol prevention and treatment services for [u]Urban
Indian populations and such other objectives as are agreed upon
between the Service and a recipient of a grant or contract
under this section.
(c) Eligibility.--[for grants]
Urban Indian [o]Organizations that operate Indian alcohol
programs originally funded under the NIAAA and subsequently
transferred to the Service are eligible for grants or contracts
under this section.
[(d) Combination of funds
[For the purpose of carrying out this section, the
Secretary may combine NIAAA alcohol funds with other substance
abuse funds currently administered through the Branch of Urban
Health Programs of the Service.]
(d)[(e) Evaluation and r]Report.--[to Congress]
The Secretary shall evaluate and report to [the] Congress
on the activities of programs funded under this section not
less than [at least] every 5 years.
Sec. 514. Consultation with Urban Indian Organizations
(a) In General.--The Secretary shall ensure that the
Service consults, to the greatest extent practicable, with
Urban Indian Organizations.
(b) Definition of Consultation.--For purposes of subsection
(a), consultation is the open and free exchange of information
and opinions which leads to mutual understanding and
comprehension and which emphasizes trust, respect, and shared
responsibility.
Sec. 515. Federal Tort Claim Act Coverage
(a) In General.--With respect to claims resulting from the
performance of functions during fiscal year 2004 and
thereafter, or claims asserted after September 30, 2003, but
resulting from the performance of functions prior to fiscal
year 2004, under a contract, grant agreement, or any other
agreement authorized under this title, an Urban Indian
Organization is deemed hereafter to be part of the Service in
the Department of Health and Human Services while carrying out
any such contract or agreement and its employees are deemed
employees of the Service while acting within the scope of their
employment in carrying out the contract or agreement. After
September 30, 2003, any civil action or proceeding involving
such claims brought hereafter against any Urban Indian
Organization or any employee of such Urban Indian Organization
covered by this provision shall be deemed to be an action
against the United States and will be defended by the Attorney
General and be afforded the full protection and coverage of the
Federal Tort Claims Act (28 U.S.C. 1346(b), 2671 et seq.).
(b) Claims Resulting From Performance of Contract or
Grant.--Beginning with the fiscal year ending September 30,
2003, and thereafter, the Secretary shall request through
annual appropriations funds sufficient to reimburse the
Treasury for any claims paid in the prior fiscal year pursuant
to the foregoing provisions.
Sec. 516. Urban Youth Treatment Center Demonstration
(a) Construction and Operation.--The Secretary, acting
through the Service, through grant or contract, is authorized
to fund the construction and operation of at least 2
residential treatment centers in each State described in
subsection (b) to demonstrate the provision of alcohol and
substance abuse treatment services to Urban Indian youth in a
culturally competent residential setting.
(b) Definition of State.--A State described in this
subsectionis a State in which--
(1) there resides Urban Indian youth with need for
alcohol and substance abuse treatment services in a
residential setting; and
(2) there is a significant shortage of culturally
competent residential treatment services for Urban
Indian youth.
Sec. 517. Use of Federal Property and Supplies
(a) Authorization for Use.--The Secretary, acting through
the Service, shall allow an Urban Indian Organization that has
entered into a contract or received a grant pursuant to this
title, in carrying out such contract or grant, to use existing
facilities and all equipment therein or pertaining thereto and
other real and personal property owned by the Federal
Government within the Secretary's jurisdiction under such terms
and conditions as may be agreed upon for their use and
maintenance.
(b) Donations.--Subject to subsection (d), the Secretary
may donate to an Urban Indian Organization that has entered
into a contract or received a grant pursuant to this title any
personal or real property determined to be excess to the needs
of the Service or the General Services Administration for
purposes of carrying out the contract or grant.
(c) Acquisition of Property for Donation.--The Secretary
may acquire excess or surplus government personal or real
property for donation (subject to subsection (d)), to an Urban
Indian Organization that has entered into a contract or
received a grant pursuant to this title if the Secretary
determines that the property is appropriate for use by the
Urban Indian Organization for a purpose for which a contract or
grant is authorized under this title.
(d) Priority.--In the event that the Secretary receives a
request for donation of a specific item of personal or real
property described in subsection (b) or (c) from both an Urban
Indian Organization and from an Indian Tribe or Tribal
Organization, the Secretary shall give priority to the request
for donation of the Indian Tribe or Tribal Organization if the
Secretary receives the request from the Indian Tribe or Tribal
Organization before the date the Secretary transfers title to
the property or, if earlier, the date the Secretary transfers
the property physically to the Urban Indian Organization.
(e) Urban Indian Organizations Deemed Executive Agency for
Certain Purposes.--For purposes of section 501 of title 40,
United States Code, (relating to Federal sources of supply,
including lodging providers, airlines, and other transportation
providers), an Urban Indian Organization that has entered into
a contract or received a grant pursuant to this title shall be
deemed an executive agency when carrying out such contract or
grant, and the employees of the Urban Indian Organization shall
be eligible to have access to such sources of supply on the
same basis as employees of an executive agency have such
access.
Sec. 518. Grants for Diabetes Prevention, Treatment, and Control
(a) Grants Authorized.--The Secretary may make grants to
those Urban Indian Organizations that have entered into a
contract or have received a grant under this title for the
provision 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. 519. Community Health Representatives
The Secretary, acting through the Service, may enter into
contracts with, and make grants to, Urban Indian Organizations
for the employment of Indians trained as health service
providers through the Community Health Representatives Program
under section 109 in the provision of health care, health
promotion, and disease prevention services to Urban Indians.
Sec. 520. Regulations
(a) Requirements for Regulations.--The Secretary may
promulgate regulations to implement the provisions of this
title in accordance with the following:
(1) Proposed regulations to implement this Act shall
be published in the Federal Register by the Secretary
no later than 9 months after the date of the enactment
of this Act and shall have no less than a 4-month
comment period.
(2) The authority to promulgate regulations under
this Act shall expire 18 months from the date of the
enactment of this Act.
(b) Effective Date of Title.--The amendments to this title
made by the Indian Health Care Improvement Act Amendments of
2004 shall be effective on the date of the enactment of such
amendments, regardless of whether the Secretary has promulgated
regulations implementing such amendments have been promulgated.
Sec. 521. Eligibility for Services
Urban Indians shall be eligible and the ultimate
beneficiaries for health care or referral services provided
pursuant to this title.
Sec. 1660d. Authorization of [a]Appropriations
There are authorized to be appropriated such sums as may be
necessary for each fiscal year through fiscal year 2015 [2000]
to carry out this title [subchapter].
TITLE VI [SUBCHAPTER V]--ORGANIZATIONAL IMPROVEMENTS
Sec. 1661. Establishment of the Indian Health Service as an A[a]gency
of the Public Health Service
(a) Establishment.--
(1) In general.--In order to more effectively and
efficiently carry out the responsibilities,
authorities, and functions of the United States to
provide health care services to Indians and Indian
[t]Tribes, as are or may be hereafter [on and after
November 23, 1988,] provided by Federal statute or
treaties, there is established within the Public Health
Service of the Department [of Health and Human
Services] the Indian Health Service.
(2) Assistant secretary of indian health.--The
[Indian Health] Service shall be administered by an
Assistant Secretary of Indian Health [a Director], who
shall be appointed by the President, by and with the
advice and consent of the Senate. The Assistant
Secretary [Director of the Indian Health Service] shall
report to the Secretary. [through the Assistant
Secretary for Health of the Department of Health and
Human Services.] Effective with respect to an
individual appointed by the President, by and with the
advice and consent of the Senate, after January 1,
2005[1993], the term of service of the Assistant
Secretary [Director] shall be 4 years. An Assistant
Secretary [A Director] may serve more that 1 term.
(3) Incumbent.--The individual serving in the
position of Director of the Indian Health Service on
the day before the date of enactment of the Indian
Health Care Improvement Act Amendments of 2004 shall
serve as Assistant Secretary.
(4) Advocacy and consultation.--The position of
Assistant Secretary is established to, in a manner
consistent with the government-to-government
relationship between the United States and Indian
Tribes--
(A) facilitate advocacy for the development
of appropriate Indian health policy; and
(B) promote consultation on matters relating
to Indian health.
(b) Agency.--[status]
The [Indian Health] Service shall be an agency within the
Public Health Service of the Department [of Health and Human
Services], and shall not be an office, component, or unit of
any other agency of the Department.
(c) Duties.--
The Assistant Secretary [shall carry out through the
Director] of [the] Indian Health [Service] shall--
(1) perform all functions that [which] were, on the
day before the date of enactment of the Indian Health
Care Improvement Act Amendments of 2004, [November 23,
1988,] carried out by or under the direction of the
individual serving as Director of the Indian Health
Service on that [such] day;
(2) perform all functions of the Secretary relating
to the maintenance and operation of hospital and health
facilities for Indians and the planning for, and
provision and utilization of, health services for
Indians;
(3) administer all health programs under which health
care is provided to Indians based upon their status as
Indians which are administered by the Secretary,
including [(but not limited to)] programs under--
(A) this Act [chapter];
(B) the Act of November 2, 1921 (25 U.S.C.
13);
(C) the Act of August 5, 1954 (42 U.S.C. 2001
et seq.);
(D) the Act of August 16, 1957 (42 U.S.C.
2005 et seq.); and
(E) the Indian Self-Determination and
Education Assistance Act (25 U.S.C. 450[f] et
seq.); [and]
(4) administer all scholarship and loan functions
carried out under title [subchapter] I [of this
chapter.];
(5) report directly to the Secretary concerning all
policy- and budget-related matters affecting Indian
health;
(6) collaborate with the Assistant Secretary for
Health concerning appropriate matters of Indian health
that affect the agencies of the Public Health Service;
(7) advise each Assistant Secretary of the Department
concerning matters of Indian health with respect to
which that Assistant Secretary has authority and
responsibility;
(8) advise the heads of other agencies and programs
of the Department concerning matters of Indian health
with respect to which those heads have authority and
responsibility;
(9) coordinate the activities of the Department
concerning matters of Indian health; and
(10) perform such other functions as the Secretary
may designate.
(d) Authority.--[of Secretary]
(1) In general.--The Secretary, acting through the
Assistant Secretary [Director of the Indian Health
Service], shall have the authority--
(A) except to the extent provided in
paragraph (2), to appoint and compensate
employees for the Service in accordance with
[T]title 5, United States Code;
(B) to enter into contracts for the
procurement of goods and services to carry out
the functions of the Service; and
(C) to manage, expend, and obligate all funds
appropriated for the Service.
(2) Personnel actions.--Notwithstanding any other
provisions of law, the provisions of section 12[472] of
the Act of June 18, 1934 (48 Stat. 986; 25 U.S.C. 472)
[this title], shall apply to all personnel actions
taken with respect to new positions created within the
Service as a result of its establishment under
subsection (a) [of this section].
(e) References.--Any reference to the Director of the
Indian Health Service in any Federal law, Executive order,
rule, regulation, or delegation of authority, or in any
document of or relating to the Director of the Indian Health
Service, shall be deemed to refer to the Assistant Secretary.
Sec. 1662. Automated [m]Management [i]Information [s]System
(a) Establishment.--
(1) In general.--The Secretary shall establish an
automated management information system for the
Service.
(2) Requirements of system.--The information system
established under paragraph (1) shall include--
(A) a financial management system[,];
(B) a patient care information system for
each area served by the [s]Service[,];
(C) a privacy component that protects the
privacy ofpatient information held by, or on
behalf of, the Service[, and];
(D) a services-based cost accounting
component that provides estimates of the costs
associated with the provision of specific
medical treatments or services in each [a]Area
office of the Service[.];
(E) an interface mechanism for patient
billing and accounts receivable system; and
(F) a training component.
(b) Provision of Systems to [Indian t]Tribes and
[o]Organizations.--[; reimbursement]
[(1)] The Secretary shall provide each Tribal Health
Program [Indian tribe and tribal organization that provides
health services under a contract entered into with the Service
under the Indian Self-Determination Act [25 U.S.C.A. Sec. 450f
et seq.]] automated management information systems which--
(1)[(A)] meet the management information needs of
such Tribal Health Program [Indian tribe or tribal
organization] with respect to the treatment by the
Tribal Health Program [Indian tribe or tribal
organization] of patients of the Service[,]; and
(2)[(B)] meet the management information needs of the
Service.
[(2) The Secretary shall reimburse each Indian tribe
or tribal organization for the part of the cost of the
operation of a system provided under paragraph (1)
which is attributable to the treatment by such Indian
tribe or tribal organization of patients of the
Service.
[(3) The Secretary shall provide systems under
paragraph (1) to Indian tribes and tribal organizations
providing health services in California by no later
than September 30, 1990.]
(c) Access to records.--
Notwithstanding any other provision of law, each patient
shall have reasonable access to the medical or health records
of such patient which are held by, or on behalf of, the
Service.
(d) Authority To Enhance Information Technology.--The
Secretary, acting through the Assistant Secretary, shall have
the authority to enter into contracts, agreements, or joint
ventures with other Federal agencies, States, private and
nonprofit organizations, for the purpose of enhancing
information technology in Indian health programs and
facilities.
Sec. 603. Authorization of Appropriations
There is authorized to be appropriated such sums as may be
necessary for each fiscal year through fiscal year 2015 to
carry out this title.
TITLE VII_BEHAVIORAL HEALTH [SUBCHAPTER V-A--SUBSTANCE ABUSE] PROGRAMS
Sec. 701. Behavioral Health Prevention and Treatment Services
(a) Purposes.--The purposes of this section are as follows:
(1) To authorize and direct the Secretary, acting
through the Service, Indian Tribes, Tribal
Organizations, and Urban Indian Organizations, to
develop a comprehensive behavior health prevention and
treatment program which emphasizes collaboration among
alcohol and substance abuse, social services, and
mental health programs.
(2) To provide information, direction, and guidance
relating to mental illness and dysfunction and self-
destructive behavior, including child abuse and family
violence, to those Federal, tribal, State, and local
agencies responsible for programs in Indian communities
in areas of health care, education, social services,
child and family welfare, alcohol and substance abuse,
law enforcement, and judicial services.
(3) To assist Indian Tribes to identify services and
resources available to address mental illness and
dysfunctional and self-destructive behavior.
(4) To provide authority and opportunities for Indian
Tribes and Tribal Organizations to develop, implement,
and coordinate with community-based programs which
include identification, prevention, education,
referral, and treatment services, including through
multidisciplinary resource teams.
(5) To ensure that Indians, as citizens of the United
States and of the States in which they reside, have the
same access to behavioral health services to which all
citizens have access.
(6) To modify or supplement existing programs and
authorities in the areas identified in paragraph (2).
(b) Plans.--
(1) Development.--The Secretary, acting through the
Service, Indian Tribes, Tribal Organizations, and Urban
Indian Organizations, shall encourage Indian Tribes and
Tribal Organizations to develop tribal plans, and Urban
Indian Organizations to develop local plans, and for
all such groups to participate in developing areawide
plans for Indian Behavioral Health Services. The plans
shall include, to the extent feasible, the following
components:
(A) An assessment of the scope of alcohol or
other substance abuse, mental illness, and
dysfunctional and self-destructive behavior,
including suicide, child abuse, and family
violence, among Indians, including--
(i) the number of Indians served who
are directly or indirectly affected by
such illness or behavior; or
(ii) an estimate of the financial and
human cost attributable to such illness
or behavior.
(B) An assessment of the existing and
additional resources necessary for the
prevention and treatment of such illness and
behavior, including an assessment of the
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 establish a national
clearinghouse of plans and reports on the outcomes of
such plans developed by Indian Tribes, Tribal
Organizations, Urban Indian Organizations, and Service
Areas relating to behavioral health. The Secretary
shall ensure access to these plans and outcomes by any
Indian Tribe, Tribal Organization, Urban Indian
Organization, or the Service.
(3) Technical assistance.--The Secretary shall
provide technical assistance to Indian Tribes, Tribal
Organizations, and Urban Indian Organizations in
preparation of plans under this section and in
developing standards of care that may be used and
adopted locally.
(c) Programs.--The Secretary, acting through the Service,
Indian Tribes, and Tribal Organizations, shall provide, to the
extent feasible and if funding is available, programs including
the following:
(1) Comprehensive care.--A comprehensive continuum of
behavioral health care which provides--
(A) community-based prevention, intervention,
outpatient, and behavioral health aftercare;
(B) detoxification (social and medical);
(C) acute hospitalization;
(D) intensive outpatient/day treatment;
(E) residential treatment;
(F) transitional living for those needing a
temporary, stable living environment that is
supportive of treatment and recovery goals;
(G) emergency shelter;
(H) intensive case management;
(I) Traditional Health Care Practices; and
(J) diagnostic services.
(2) Child care.--Behavioral health services for
Indians from birth through age 17, including--
(A) preschool and school age fetal alcohol
disorder services, including assessment and
behavioral intervention;
(B) mental health and substance abuse
services (emotional, organic, alcohol, drug,
inhalant, and tobacco);
(C) identification and treatment of co-
occurring disorders and comorbidity;
(D) prevention of alcohol, drug, inhalant,
and tobacco use;
(E) early intervention, treatment, and
aftercare;
(F) promotion of healthy choices and
lifestyle (related to sexually transmitted
diseases, domestic violence,sexual abuse,
suicide, teen pregnancy, obesity, and other risk/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 gender specific
services;
(C) identification and treatment of co-
occurring disorders (dual diagnosis) and
comorbidity;
(D) promotion of gender specific healthy
choices and lifestyle (related to parenting,
partners, domestic violence, sexual abuse,
suicide, obesity, and other risk-related
behavior);
(E) treatment services for women at risk of
giving birth to a child with a fetal alcohol
disorder; and
(F) gender 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 choices and
lifestyle (related to parenting, partners,
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 gender specific
services;
(C) identification and treatment of co-
occurring disorders (dual diagnosis) and
comorbidity;
(D) promotion of healthy choices and
lifestyle (managing conditions related to
aging);
(E) gender specific treatment for sexual
assault, domestic violence, neglect, physical
and mental abuse and exploitation; and
(F) identification and treatment of dementias
regardless of cause.
(d) Community Behavioral Health Plan.--
(1) Establishment.--The governing body of any Indian
Tribe, Tribal Organization, or Urban Indian
Organization may adopt a resolution for the
establishment of a community behavioral health plan
providing for the identification and coordination of
available resources and programs to identify, prevent,
or treat substance abuse, mental illness, or
dysfunctional and self-destructive behavior, including
child abuse and family violence, among its members or
its service population. This plan should include
behavioral health services, social services, intensive
outpatient services, and continuing aftercare.
(2) Technical assistance.--At the request of an
Indian Tribe, Tribal Organization, or Urban Indian
Organization, the Bureau of Indian Affairs and the
Service shall cooperate with and provide technical
assistance to the Indian Tribe, Tribal Organization, or
Urban Indian Organization in the development and
implementation of such plan.
(3) Funding.--The Secretary, acting through the
Service, may make funding available to Indian Tribes
and Tribal Organizations which adopt a resolution
pursuant to paragraph (1) to obtain technical
assistance for the development of a community
behavioral health plan and to provide administrative
support in the implementation of such plan.
(e) Coordination for Availability of Services.--The
Secretary, acting through the Service, Indian Tribes, Tribal
Organizations, and Urban Indian Organizations, shall coordinate
behavioral health planning, to the extent feasible, with other
Federal agencies and with State agencies, to encourage
comprehensive behavioral health services for Indians regardless
of their place of residence.
(f) Mental Health Care Need Assessment.--Not later than 1
year after the date of the enactment of the Indian Health Care
Improvement Act Amendments of 2004, the Secretary, acting
through the Service, shall make an assessment of the need for
inpatient mental health care among Indians and the availability
and cost of inpatient mental health facilities which can meet
such need. In making such assessment, the Secretary shall
consider the possible conversion of existing, underused Service
hospital beds into psychiatric units to meet such need.
Sec. 702. Memoranda of Agreement with the Department of the Interior
[Sec. 1665. Indian Health Service responsibilities]
(a) Contents.--Not later than 12 months after the date of
the enactment of the Indian Health Care Improvement Act
Amendments of 2004, the Secretary, acting through the Service,
and the Secretary of the Interior shall develop and enter into
a memoranda of agreement, or review and update any existing
memoranda of agreement, as required by section 4205 of the
Indian Alcohol and Substance Abuse Prevention and Treatment Act
of 1986 (25 U.S.C. 2411) under which the Secretaries address
the following:
(1) The scope and nature of mental illness and
dysfunctional and self-destructive behavior, including
child abuse and family violence, among Indians.
(2) The existing Federal, tribal, State, local, and
private services, resources, and programs available to
provide behavioral health services for Indians.
(3) The unmet need for additional services,
resources, and programs necessary to meet the needs
identified pursuant to paragraph (1).
(4)(A) The right of Indians, as citizens of the
United States and of the States in which they reside,
to have access to behavioral health services to which
all citizens have access.
(B) The right of Indians to participate in, and
receive the benefit of, such services.
(C) The actions necessary to protect the exercise of
such right.
(5) The responsibilities of the Bureau of Indian
Affairs and the Service, including mental illness
identification, prevention, education, referral, and
treatment services (including services through
multidisciplinary resource teams), at the central,
area, and agency and Service Unit, Service Area, and
headquarters levels to address the problems identified
in paragraph (1).
(6) A strategy for the comprehensive coordination of
the behavioral health services provided by the Bureau
of Indian Affairs and the Service to meet the problems
identified pursuant to paragraph (1), including--
(A) the coordination of alcohol and substance
abuse programs of the Service, the Bureau of
Indian Affairs, and Indian Tribes and Tribal
Organizations (developed under the Indian
Alcohol and Substance Abuse Prevention and
Treatment Act of 1986) with behavioral health
initiatives pursuant to this Act, particularly
with respect to the referral and treatment 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).
(8) Providing for an annual review of such agreement
by the Secretaries which shall be provided to Congress
and Indian Tribes and Tribal Organizations.
(b) Specific Provisions Required.--The [Memorandum]
memoranda of [A]agreement updated or entered into pursuant to
subsection (a) [section 2411 of this title] shall include
specific provisions pursuant to which the Service shall assume
responsibility for--
(1) the determination of the scope of the problem of
alcohol and substance abuse among Indians [people],
including the number of Indians within the jurisdiction
of the Service who are directly or indirectly affected
by alcohol and substance abuse and the financial and
human cost;
(2) an assessment of the existing and needed
resourcesnecessary for the prevention of alcohol and
substance abuse and the treatment of Indians affected by alcohol and
substance abuse; and
(3) an estimate of the funding necessary to
adequately support a program of prevention of alcohol
and substance abuse and treatment of Indians affected
by alcohol and substance abuse.
(c) Consultation.--The Secretary, acting through the
Service, and the Secretary of the Interior shall, in developing
the memoranda of agreement under subsection (a), consult with
and solicit the comments from--
(1) Indian Tribes and Tribal Organizations;
(2) Indians;
(3) Urban Indian Organizations and other Indian
organizations; and
(4) behavioral health service providers.
(d) Publication.--Each memorandum of agreement entered into
or renewed (and amendments or modifications thereof) under
subsection (a) shall be published in the Federal Register. At
the same time as publication in the Federal Register, the
Secretary shall provide a copy of such memoranda, amendment, or
modification to each Indian Tribe, Tribal Organization, and
Urban Indian Organization.
[Sec. 1665a. Indian Health Service program]
Sec. 703. [(a)] Comprehensive Behavioral Health [p]Prevention and
[t]Treatment [p]Program
(a) Establishment.--
(1) In general.--The Secretary, acting through the
Service, Indian Tribes, and Tribal Organizations, shall
provide a program of comprehensive behavioral health,
[alcohol and substance abuse] prevention, [and]
treatment, and aftercare, including Traditional Health
Care Practices, which shall include--
(A) prevention, through educational
intervention, in Indian communities;
(B) acute detoxification, psychiatric
hospitalization, residential, and intensive
outpatient [and] treatment;
(C) community-based rehabilitation and
aftercare;
(D) community education and involvement,
including extensive training of health care,
educational, and community-based personnel;
[and]
(E) specialized residential treatment
programs for high-risk populations, including
but not limited to pregnant and postpartum
[post partum] women and their children[.]; and
(F) diagnostic services.
(2) Target populations.--The target population of
such programs shall be members of Indian [t]Tribes.
Efforts to train and educate key members of the Indian
community shall also target employees of health,
education, judicial, law enforcement, legal, and social
service programs.
(b) Contract [h]Health [s]Services
(1) In general.--The Secretary, acting through the
Service, Indian Tribes, and Tribal Organizations, may
enter into contracts with public or private providers
of behavioral health [alcohol and substance abuse]
treatment services for the purpose of [assisting the
Service in] carrying out the program required under
subsection (a) [of this section].
(2) Provision of assistance.--In carrying out this
subsection, the Secretary shall provide assistance to
Indian [t]Tribes and Tribal Organizations to develop
criteria for the certification of behavioral health
[alcohol and substance abuse] service providers and
accreditation of service facilities which meet minimum
standards for such services and facilities [as may be
determined pursuant to section 2411(a)(3) of this
title].
Sec. 704. Mental Health Technician Program
(a) In General.--Under the authority of the Act of November
2, 1921 (25 U.S.C. 13) (commonly known as the `Snyder Act'),
the Secretary shall establish and maintain a mental health
technician program within the Service which--
(1) provides for the training of Indians as mental
health technicians; and
(2) employs such technicians in the provision of
community-based mental health care that includes
identification, prevention, education, referral, and
treatment services.
(b) Paraprofessional Training.--In carrying out subsection
(a), the Secretary, acting through the Service, Indian Tribes,
and Tribal Organizations, shall provide high-standard
paraprofessional training in mental health care necessary to
provide quality care to the Indian communities to be served.
Such training shall be based upon a curriculum developed or
approved by the Secretary which combines education in the
theory of mental health care with supervised practical
experience in the provision of such care.
(c) Supervision and Evaluation of Technicians.--The
Secretary, acting through the Service, Indian Tribes, and
Tribal Organizations, shall supervise and evaluate the mental
health technicians in the training program.
(d) Traditional Health Care Practices.--The Secretary,
acting through the Service, shall ensure that the program
established pursuant to this subsection involves the use and
promotion of the Traditional Health Care Practices of the
Indian Tribes to be served.
[(c) Grants for model program
[(1) The Secretary, acting through the Service shall
make a grant to the Standing Rock Sioux Tribe to
develop a community-based demonstration project to
reduce drug and alcohol abuse on the Standing Rock
Sioux Reservation and to rehabilitate Indian families
afflicted by such abuse.
[(2) Funds shall be used by the Tribe to--
[(A) develop and coordinate community-based
alcohol and substance abuse prevention and
treatment services for Indian families;
[(B) develop prevention and intervention
models for Indian families;
[(C) conduct community education on alcohol
and substance abuse; and
[(D) coordinate with existing Federal, State,
and tribal services on the reservation to
develop a comprehensive alcohol and substance
abuse program that assists in the
rehabilitation of Indian families that have
been or are afflicted by alcoholism.
[(3) The Secretary shall submit to the President for
inclusion in the report to be transmitted to the
Congress under section 1671 of this title for fiscal
year 1995 an evaluation of the demonstration project
established under paragraph (1).]
Sec. 705. Licensing Requirement for Mental Health Care Workers
Subject to the provisions of section 221, any person
employed as a psychologist, social worker, or marriage and
family therapist for the purpose of providing mental health
care services to Indians in a clinical setting under this Act
or through a Funding Agreement shall be licensed as a clinical
psychologist, social worker, or marriage and family therapist,
respectively, or working under the direct supervision of a
licensed clinical psychologist, social worker, or marriage and
family therapist, respectively.
Sec. 1665b. Indian [w]Women [t]Treatment [p]Programs
(a) Funding.--[Grants]
The Secretary, consistent with section 701, shall [may]
make grants to Indian [t]Tribes, [and t]Tribal
[o]Organizations, and Urban Indian Organizations to develop and
implement a comprehensive behavioral health [alcohol and
substance abuse] program of prevention, intervention,
treatment, and relapse prevention services that specifically
addresses the spiritual, cultural, historical, social, and
child care needs of Indian women, regardless of age.
(b) Use of Funds.--[grants]
Funds [Grants] made available pursuant to this section may
be used to--
(1) develop and provide community training,
education, and prevention programs for Indian women
relating to behavioral health [alcohol and substance
abuse] issues, including fetal alcohol disorders
[syndrome and fetal alcohol effect];
(2) identify and provide psychological services,
[appropriate] counseling, advocacy, support, and
relapse prevention to Indian women and their families;
and
(3) develop prevention and intervention models for
Indian women which incorporate [t]Traditional Health
Care Practices [healers], cultural values, and
community and family involvement.
(c) Criteria.--[for review and approval of grant
applications]
The Secretary, in consultation with Indian Tribes andTribal
Organizations, shall establish criteria for the review and approval of
applications and proposals for funding [grants] under this section.
(d) Earmark of Certain Funds.--Twenty percent of the funds
appropriated pursuant to this section shall be used to make
grants to Urban Indian Organizations.
[(d) Authorization of appropriations
[(1) There are authorized to be appropriated to carry
out this section $10,000,000 for fiscal year 1993 and
such sums as are necessary for each of the fiscal years
1994, 1995, 1996, 1997, 1998, 1999, and 2000.
[(2) Twenty percent of the funds appropriated
pursuant to this subsection shall be used to make
grants to urban Indian organizations funded under
subchapter IV of this chapter.]
Sec. 1665c. Indian [Health Service y]Youth [p]Program
(a) Detoxification and [r]Rehabilitation.--
The Secretary, acting through the Service, consistent with
section 701, shall develop and implement a program for acute
detoxification and treatment for Indian youths, including
behavioral health services [who are alcohol and substance
abusers]. The program shall include regional treatment centers
designed to include detoxification and rehabilitation for both
sexes on a referral basis and programs developed and
implemented by Indian Tribes or Tribal Organizations at the
local level under the Indian Self-Determination and Education
Assistance Act. [These r]Regional centers shall be integrated
with the intake and rehabilitation programs based in the
referring Indian community.
(b) Alcohol and Substance Abuse Treatment [c]Centers or
[f]Facilities
(1) Establishment.--
[(1)](A) In general.--The Secretary, acting
through the Service, Indian Tribes, and Tribal
Organizations, shall construct, renovate, or,
as necessary, purchase, and appropriately staff
and operate, at least 1[a] youth regional
treatment center or treatment network in each
area under the jurisdiction of an [a]Area
[o]Office.
(B) Area office in california.--For the
purposes of this subsection, the [area offices
of the Service in Tucson and Phoenix, Arizona,
shall be considered one area office and the
a]Area [o]Office in California shall be
considered to be 2 [two a]Area [o]Offices,
1[one] office whose jurisdiction shall be
considered to encompass the northern area of
the State of California, and 1[one] office
whose jurisdiction shall be considered to
encompass the remainder of the State of
California for the purpose of implementing
California treatment networks.
(2) Funding.--For the purpose of staffing and
operating such centers or facilities, funding shall be
pursuant to the Act of November 2, 1921 (25 U.S.C. 13).
(3) Location.--A youth treatment center constructed
or purchased under this subsection shall be constructed
or purchased at a location within the area described in
paragraph (1) agreed upon (by appropriate tribal
resolution) by a majority of the Indian T[t]ribes to be
served by such center.
(4) Specific provision of funds.--
(A) In general.--Notwithstanding any other
provision of this title [subchapter], the
Secretary may, from amounts authorized to be
appropriated for the purposes of carrying out
this section, make funds available to--
(i) The Tanana Chiefs Conference,
Incorporated, for the purpose of
leasing, constructing, renovating,
operating and maintaining a residential
youth treatment facility in Fairbanks,
Alaska; and
(ii) the Southeast Alaska Regional
Health Corporation to staff and operate
a residential youth treatment facility
without regard to the proviso set forth
in section 4[50b](1) of the Indian
Self-Determination and Education
Assistance Act (25 U.S.C. 450b(l))
[this title].
(B) Provision of services to eligible
youths.--Until additional residential youth
treatment facilities are established in Alaska
pursuant to this section, the facilities
specified in subparagraph (A) shall make every
effort to provide services to all eligible
Indian youths residing in Alaska [such State].
(c) Intermediate Adolescent Behavioral Health Services.--
(1) In general.--The Secretary, acting through the
Service, Indian Tribes, and Tribal Organizations, may
provide intermediate behavioral health services, which
may incorporate Traditional Health Care Practices, to
Indian children andadolescents, including--
(A) pretreatment assistance;
(B) inpatient, outpatient, and aftercare
services;
(C) emergency care;
(D) suicide prevention and crisis
intervention; and
(E) prevention and treatment of mental
illness and dysfunctional and self-destructive
behavior, including child abuse and family
violence.
(2) Use of funds.--Funds provided under this
subsection may be used--
(A) to construct or renovate an existing
health facility to provide intermediate
behavioral health services;
(B) to hire behavioral health professionals;
(C) to staff, operate, and maintain an
intermediate mental health facility, group
home, sober housing, transitional housing or
similar facilities, or youth shelter where
intermediate behavioral health services are
being provided;
(D) to make renovations and hire appropriate
staff to convert existing hospital beds into
adolescent psychiatric units; and
(E) for intensive home-and community-based
services.
(3) Criteria.--The Secretary, acting through the
Service, shall, in consultation with Indian Tribes and
Tribal Organizations, establish criteria for the review
and approval of applications or proposals for funding
made available pursuant to this subsection.
(d)[(c)] Federally [o]Owned [s]Structures.--
(1) In general.--The Secretary, [acting through the
Service, shall,] in consultation with Indian [t]Tribes
and Tribal Organizations, shall--
(A) identify and use, where appropriate,
federally owned structures suitable for [as]
local residential or regional behavioral health
[alcohol and substance abuse] treatment
[centers] for Indian youths; and
(B) establish guidelines, in consultation
with Indian Tribes and Tribal Organizations,
for determining the suitability of any such
federally owned structure to be used for [as a]
local residential or regional behavioral health
[alcohol and substance abuse] treatment
[center] for Indian youths.
(2) Terms and conditions for use of structure.--Any
structure described in paragraph (1) may be used under
such terms and conditions as may be agreed upon by the
Secretary and the agency having responsibility for the
structure and any Indian Tribe or Tribal Organization
operating the program.
(e)[(d)] Rehabilitation and [a]Aftercare [s]Services
(1) In general.--The Secretary, Indian Tribes, or
Tribal Organizations, in cooperation with the Secretary
of the Interior, shall develop and implement within
each Service [service u]Unit, community-based
rehabilitation and follow-up services for Indian youths
who are having significant behavioral health problems
and require [alcohol or substance abusers which are
designed to integrate] long-term treatment, community
reintegration, and monitoring to [monitor and] support
the Indian youths after their return to their home
community.
(2) Administration.--Services under paragraph (1)
shall be provided [administered within each service
unit] by trained staff within the community who can
assist the Indian youths in their continuing
development of self-image, positive problem-solving
skills, and nonalcohol or substance abusing behaviors.
Such staff may [shall] include alcohol and substance
abuse counselors, mental health professionals, and
other health professionals and paraprofessionals,
including community health representatives.
(f)[(e)] Inclusion of [f]Family in [y]Youth [t]Treatment
[p]Program
In providing the treatment and other services to Indian
youths authorized by this section, the Secretary, acting
through the Service, Indian Tribes, and Tribal Organizations,
shall provide for the inclusion of family members of such
youths in the treatment programs or other services as may be
appropriate. Not less that 10 percent of the funds appropriated
for the purposes of carrying out subsection (e)[(d) of this
section] shall be used for outpatient care of adult family
members related to the treatment of an Indian youth under that
subsection.
(g)[(f)] Multidrug [a]Abuse Program.--[study]
[(1)] The Secretary, acting through the Service,
Indian Tribes, Tribal Organizations, and Urban Indian
Organizations, shall provide, consistent with section
701, programs and services to prevent and treat
[conduct a study to determine the incidence and
prevalence of] the abuse of multiple forms of
substances [drugs], including, but not limited to,
alcohol, drugs, inhalants, and tobacco, among Indian
youths residing in Indian communities, on or near
[Indian] reservations, and in urban areas and provide
appropriate mental health services to address [the
interrelationship of such abuse with] the incidence of
mental illness among such youths.
[(2) The Secretary shall submit a report detailing
the findings of such study, together with
recommendations based on such findings, to the Congress
no later than two years after October 29, 1992.]
Sec. 708. Inpatient and Community-Based Mental Health Facilities
Design, Construction, and Staffing
Not later than 1 year after the date of the enactment of
the Indian Health Care Improvement Act Amendments of 2004, the
Secretary, acting through the Service, Indian Tribes, and
Tribal Organizations, may provide, in each area of the Service,
not less than 1 inpatient mental health care facility, or the
equivalent, for Indians with behavioral health problems. For
the purposes of this subsection, California shall be considered
to encompass the northern area of the State of California and 1
office whose jurisdiction shall be considered to encompass the
remainder of the State of California. The Secretary shall
consider the possible conversion of existing, underused Service
hospital beds into psychiatric units to meet such need.
Sec. 1665d. Training and [c]Community [e]Education
(a) Program.--[Community education]
The Secretary, in cooperation with the Secretary of the
Interior, shall develop and implement or provide funding for
Indian Tribes and Tribal Organizations to develop and
implement, within each [s]Service [u]Unit or tribal program, a
program of community education and involvement which shall be
designed to provide concise and timely information to the
community leadership of each tribal community. Such program
shall include education about behavioral health issues [in
alcohol and substance abuse] to political leaders, [t]Tribal
judges, law enforcement personnel, members of tribal health and
education boards, health care providers including traditional
practitioners, and other critical members of each tribal
community. Community-based training (oriented toward local
capacity development) shall also include tribal community
provider training (designed for adult learners from the
communities receiving services for prevention, intervention,
treatment, and aftercare.)
(b) Instruction.--[Training]
The Secretary, acting through the Service, shall, either
directly or through Indian Tribes and Tribal Organizations [by
contract], provide instruction in the area of behavioral health
issues [alcohol and substance abuse], including instruction in
crisis intervention and family relations in the context of
alcohol and substance abuse, child sexual abuse, youth alcohol
and substance abuse, and the causes and effects of fetal
alcohol disorders [syndrome] to appropriate employees of the
Bureau of Indian Affairs and the Service, and to personnel in
schools or programs operated under any contract with the Bureau
of Indian Affairs or the Service, including supervisors of
emergency shelters and halfway houses described in section 4213
of the Indian Alcohol and Substance Abuse Prevention and
Treatment Act of 1986 (25 U.S.C. 2433) [2433 of this title].
(c) Training [Community-based training m]Models.--
In carrying out the education and training programs
required by this section, the Secretary, [acting through the
Service and] in consultation with Indian T[t]ribes, Tribal
Organizations, Indian behavioral health experts, and Indian
alcohol and substance abuse prevention experts, shall develop
and provide community-based training models. Such models shall
address--
(1) the elevated risk of alcohol and behavioral
health problems [substance abuse] faced by children of
alcoholics;
(2) the cultural, spiritual, and multigenerational
aspects of behavioral health problem [alcohol and
substance abuse] prevention and recovery; and
(3) community-based and multidisciplinary strategies
for preventing and treating behavioral health problems
[alcohol and substance abuse].
Sec. 710. 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
outprograms to deliver innovative community-based behavioral health
services to Indians.
(b) Funding; Criteria.--The Secretary may award such
funding for a project under subsection (a) to an Indian Tribe
or Tribal Organization and may consider the following criteria:
(1) The project will address significant unmet
behavioral health needs among Indians.
(2) The project will serve a significant number of
Indians.
(3) The project has the potential to deliver services
in an efficient and effective manner.
(4) The Indian Tribe or Tribal Organization has the
administrative and financial capability to administer
the project.
(5) The project may deliver services in a manner
consistent with Traditional Health Care Practices.
(6) The project is coordinated with, and avoids
duplication of, existing services.
(c) Equitable Treatment.--For purposes of this subsection,
the Secretary shall, in evaluating applications or proposals
for funding for projects to be operated under any Funding
Agreement, use the same criteria that the Secretary uses in
evaluating any other application or proposal for such funding.
[Sec. 1665e. Gallup alcohol and substance abuse treatment center
[(a) Grants for residential treatment
[The Secretary shall make grants to the Navajo Nation for
the purpose of providing residential treatment for alcohol and
substance abuse for adult and adolescent members of the Navajo
Nation and neighboring tribes.
[(b) Purposes of grants
[Grants made pursuant to this section shall (to the extent
appropriations are made available) be used to--
[(1) provide at least 15 residential beds each year
for adult long-term treatment, including beds for
specialized services such as polydrug abusers, dual
diagnosis, and specialized services for women with
fetal alcohol syndrome children;
[(2) establish clinical assessment teams consisting
of a clinical psychologist, a part-time
addictionologist, a master's level assessment
counselor, and a certified medical records technician
which shall be responsible for conducting individual
assessments and matching Indian clients with the
appropriate available treatment;
[(3) provide at least 12 beds for an adolescent
shelterbed program in the city of Gallup, New Mexico,
which shall serve as a satellite facility to the Acoma/
Canoncito/Laguna Hospital and the adolescent center
located in Shiprock, New Mexico, for emergency crisis
services, assessment, and family intervention;
[(4) develop a relapse program for the purposes of
identifying sources of job training and job opportunity
in the Gallup area and providing vocational training,
job placement, and job retention services to recovering
substance abusers; and
[(5) provide continuing education and training of
treatment staff in the areas of intensive outpatient
services, development of family support systems, and
case management in cooperation with regional colleges,
community colleges, and universities.
[(c) Contract for residential treatment
[The Navajo Nation, in carrying out the purposes of this
section, shall enter into a contract with an institution in the
Gallup, New Mexico area which is accredited by the Joint
Commission of the Accreditation of Health Care Organizations to
provide comprehensive alcohol and drug treatment as authorized
in subsection (b) of this section.
[(d) Authorization of appropriations
[There are authorized to be appropriated, for each of
fiscal years 1996 through 2000, such sums as may be necessary
to carry out subsection (b) of this section.
[Sec. 1665f. Reports
[(a) Compilation of data
[The Secretary, with respect to the administration of any
health program by a service unit, directly or through contract,
including a contract under the Indian Self-Determination Act
[25 U.S.C.A. Sec. 450f et seq.], shall require the compilation
of data relating to the number of cases or incidents in which
any Service personnel or services were involved and which
wererelated, either directly or indirectly, to alcohol or substance
abuse. Such report shall include the type of assistance provided and
the disposition of these cases.
[(b) Referral of data
[The data compiled under subsection (a) of this section
shall be provided annually to the affected Indian tribe and
Tribal Coordinating Committee to assist them in developing or
modifying a Tribal Action Plan under section 2412 of this
title.
[(c) Comprehensive report
[Each service unit director shall be responsible for
assembling the data compiled under this section and section
2434 of this title into an annual tribal comprehensive report.
Such report shall be provided to the affected tribe and to the
Director of the Service who shall develop and publish a
biennial national report based on such tribal comprehensive
reports.]
Sec. 1665g. Fetal [a]Alcohol [d]Disorder [f]Funding.--syndrome and
fetal alcohol effect grants]
(a) Programs.--[Award; use; review criteria]
(1) Establishment.--The Secretary, consistent with
section 701, acting through the Service, Indian Tribes,
and Tribal Organizations, shall [may make grants to
Indian tribes and tribal organizations to] establish
and operate fetal alcohol disorder [syndrome and fetal
alcohol effect] programs as provided in this section
for the purposes of meeting the health status
objectives specified in section 3[1602(b) of this
title].
(2) Use of funds.--Funding provided [Grants made]
pursuant to this section shall be used for the
following:[ to--]
(A) To develop and provide for Indians
community and in[-]school training, education,
and prevention programs relating to fetal
alcohol disorders. [FAS and FAE;]
(B) To identify and provide behavioral health
[alcohol and substance abuse] treatment to
high-risk Indian women and high-risk women
pregnant with an Indian's child.[;]
(C) To identify and provide appropriate
psychological services, educational and
vocational support, counseling, advocacy, and
information to fetal alcohol disorder [FAS and
FAE] affected Indians [persons] and their
families or caretakers[;].
(D) To develop and implement counseling and
support programs in schools for fetal alcohol
disorder [FAS and FAE] affected Indian
children[;].
(E) To develop prevention and intervention
models which incorporate practitioners of
T[t]raditional Health Care Practices [healers],
cultural and spiritual values, and community
involvement[;].
(F) To develop, print, and disseminate
education and prevention materials on fetal
alcohol disorder. [FAS and FAE; and]
(G) To develop and implement, through the
tribal consultation process, culturally
sensitive assessment and diagnostic tools
including dysmorphology clinics and
multidisciplinary fetal alcohol and disorder
clinics for use in [tribal and urban] Indian
communities and Urban Centers.
(H) To develop early childhood intervention
projects from birth on to mitigate the effects
of fetal alcohol disorder among Indians.
(I) To develop and fund community-based adult
fetal alcohol disorder housing and support
services for Indians and for women pregnant
with an Indian's child.
(3) Criteria for applications.--The Secretary shall
establish criteria for the review and approval of
applications for funding [grants] under this section.
(b) Services.--[Plan; study; national clearinghouse]
The Secretary, acting through the Service and Indian
Tribes, Tribal Organizations, and Urban Indian Organizations,
shall--
(1) develop and provide services [an annual plan] for
the prevention, intervention, treatment, and aftercare
for those affected by fetal alcohol disorder [FAS and
FAE] in Indian communities; and
(2) provide supportive services, directly or through
an Indian Tribe, Tribal Organization, or Urban Indian
Organization, including services to meet [conduct a
study, directly or by contract with any organization,
entity, or institution of higher education with
significant knowledge of FAS and FAE and
Indiancommunities, of] the special educational, vocational, school-to-
work transition, and independent living needs of adolescent and adult
Indians with fetal alcohol disorder. [and Alaska Natives with FAS or
FAE; and
[(3) establish a national clearinghouse for
prevention and educational materials and other
information of FAS and FAE effect in Indian and Alaska
Native communities and ensure access to clearinghouse
materials by any Indian tribe or urban Indian
organization.]
(c) Task [f]Force.--
The Secretary shall establish a task force to be known as
the Fetal Alcohol Disorder [FAS/FAE] Task Force to advise the
Secretary in carrying out subsection (b) [of this section].
Such task force shall be composed of representatives from the
following:
(1) The National Institute on Drug Abuse.[,]
(2) T[t]he National Institute on Alcohol and
Alcoholism.[,]
(3) T[t]he Office of Substance Abuse Prevention.[,]
(4) T[t]he National Institute of Mental Health.[,]
(5) T[t]he Service.[,]
(6) T[t]he Office of Minority Health of the
Department of Health and Human Services.[,]
(7) T[t]]he Administration for Native Americans.[,]
(8) The National Institute of Child Health and Human
Development (NICHD).
(9) The Centers for Disease Control and Prevention.
(10) T[t]he Bureau of Indian Affairs.[,]
(11) Indian T[t]ribes.[,]
(12) T[t]ribal O[o]rganizations.[,]
(13) U[u]rban Indian Organizations. [communities,
and]
(14) Indian fetal alcohol disorder [FAS/FAE] experts.
(d) [Cooperative projects;] Applied R[r]esearch
P[p]rojects.--
The Secretary, acting through the Substance Abuse and
Mental Health Services Administration, shall make funding
available [grants] to Indian T[t]ribes, T[t]ribal
O[o]rganizations, and Urban Indian Organizations [universities
working with Indian tribes on cooperative projects, and urban
Indian organizations] for applied research projects which
propose to elevate the understanding of methods to prevent,
intervene, treat, or provide rehabilitation and behavioral
health aftercare for Indians and U[u]rban Indians affected by
fetal alcohol disorder [FAS or FAE].
[(e) Report
[(1) The Secretary shall submit to the President, for
inclusion in each report required to be transmitted to
the Congress under section 1671 of this title, a report
on the status of FAS and FAE in the Indian population.
Such report shall include, in addition to the
information required under section 1602(d) of this
title with respect to the health status objective
specified in section 1602(b)(27) of this title, the
following:
[(A) The progress of implementing a uniform
assessment and diagnostic methodology in
Service and tribally based service delivery
systems.
[(B) The incidence of FAS and FAE babies born
for all births by reservation and urban-based
sites.
[(C) The prevalence of FAS and FAE affected
Indian persons in Indian communities, their
primary means of support, and recommendations
to improve the support system for these
individuals and their families or caretakers.
[(D) The level of support received from the
entities specified in subsection (c) of this
section in the area of FAS and FAE.
[(E) The number of inpatient and outpatient
substance abuse treatment resources which are
specifically designed to meet the unique needs
of Indian women, and the volume of care
provided to Indian women through these means.
[(F) Recommendations regarding the
prevention, intervention, and appropriate
vocational, educational and other support
services for FAS and FAE affected individuals
in Indian communities.
[(2) The Secretary may contract the production of
this report to a national organization specifically
addressing FASand FAE in Indian communities.
[(f) Authorization of appropriations
[(1) There are authorized to be appropriated to carry
out this section $22,000,000 for fiscal year 1993 and
such sums as may be necessary for each of the fiscal
years 1994, 1995, 1996, 1997, 1998, 1999, and 2000.]
(e) Funding for Urban Indian Organizations.--[(2)] Ten
percent of the funds appropriated pursuant to this section
shall be used to make grants to U[u]rban Indian
O[o]rganizations funded under title V [subchapter IV of this
chapter].
[Sec. 1665h. Pueblo substance abuse treatment project for San Juan
Pueblo, New Mexico
[The Secretary, acting through the Service, shall continue
to make grants, through fiscal year 1995, to the 8 Northern
Indian Pueblos Council, San Juan Pueblo, New Mexico, for the
purpose of providing substance abuse treatment services to
Indians in need of such services.
[Sec. 1665i. Thunder Child Treatment Center
[(a) The Secretary, acting through the Service, shall make
a grant to the Intertribal Addictions Recovery Organization,
Inc. (commonly known as the Thunder Child Treatment Center) at
Sheridan, Wyoming, for the completion of construction of a
multiple approach substance abuse treatment center which
specializes in the treatment of alcohol and drug abuse of
Indians.
[(b) For the purposes of carrying out subsection (a) of
this section, there are authorized to be appropriated
$2,000,000 for fiscal years 1993 and 1994. No funding shall be
available for staffing or operation of this facility. None of
the funding appropriated to carry out subsection (a) of this
section shall be used for administrative purposes.
[Sec. 1665j. Substance abuse counselor education demonstration project
[(a) Contracts and grants
[The Secretary, acting through the Service, may enter into
contracts with, or make grants to, accredited tribally
controlled community colleges, tribally controlled
postsecondary vocational institutions, and eligible community
colleges to establish demonstration projects to develop
educational curricula for substance abuse counseling.
[(b) Use of funds
[Funds provided under this section shall be used only for
developing and providing educational curricula for substance
abuse counseling (including paying salaries for instructors).
Such curricula may be provided through satellite campus
programs.
[(c) Effective period of contract or grant; renewal
[A contract entered into or a grant provided under this
section shall be for a period of one year. Such contract or
grant may be renewed for an additional one year period upon the
approval of the Secretary.
[(d) Criteria for review and approval of applications
[Not later than 180 days after October 29, 1992, the
Secretary, after consultation with Indian tribes and
administrators of accredited tribally controlled community
colleges, tribally controlled postsecondary vocational
institutions, and eligible community colleges, shall develop
and issue criteria for the review and approval of applications
for funding (including applications for renewals of funding)
under this section. Such criteria shall ensure that
demonstration projects established under this section promote
the development of the capacity of such entities to education
substance abuse counselors.
[(e) Assistance to recipients
[The Secretary shall provide such technical and other
assistance as may be necessary to enable grant recipients to
comply with the provisions of this section.
[(f) Report
[The Secretary shall submit to the President, for inclusion
in the report which is required to be submitted under section
1671 of this title for fiscal year 1999, a report on the
findings and conclusions derived from the demonstration
projects conducted under this section.]
Sec. 712. Child Sexual Abuse and Prevention Treatment Programs
(a) Establishment.--The Secretary, acting through the
Service, and the Secretary of the Interior, Indian Tribes, and
Tribal Organizations shall establish, consistent with section
701, in every Service Area, programs involving treatment for--
(1) victims of sexual abuse who are Indian children
or children in an Indian household; and
(2) perpetrators of child sexual abuse who are Indian
or members of an Indian household.
(b) Use of Funds.--Funding provided pursuant to this
section shall be used for the following:
(1) To develop and provide community education and
prevention programs related to sexual abuse of Indian
children or children in an Indian household.
(2) To identify and provide behavioral health
treatment to victims of sexual abuse who are Indian
children or children in an Indian household, and to
their family members who are affected by sexual abuse.
(3) To develop prevention and intervention models
which incorporate Traditional Health Care Practices,
cultural and spiritual values, and community
involvement.
(4) To develop and implement, through the tribal
consultation process, 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.
Sec. 713. Behavioral Health Research
The Secretary, in consultation with appropriate Federal
agencies, shall provide funding to 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 interrelationship and interdependence of
behavioral health problems with alcoholism and other
substance abuse, suicide, homicides, other injuries,
and the incidence of family violence; and
(2) the development of models of prevention
techniques.
The effect of the interrelationships and interdependencies
referred to in paragraph (1) on children, and the development
of prevention techniques under paragraph (2) applicable to
children, shall be emphasized.
Sec. 714. [(g)] Definitions
For the purposes of this title [section], the following
definitions shall apply:
(1) Assessment.--The term `assessment' means the
systematic collection, analysis, and dissemination of
information on health status, health needs, and health
problems. [The term ``educational curriculum'' means
one or more of the following:
[(A) Classroom education.
[(B) Clinical work experience.
[(C) Continuing education workshops.]
(2) Alcohol-related neurodevelopmental disorders or
arnd._The term `alcohol-related neurodevelopmental
disorders' or `ARND' means a central nervous system or
behavioral disorder, following a maternal history of
alcohol consumption during pregnancy, that may
involve--
(A) physical manifestations such as
development delay, intellectual deficit,
neurologic abnormalities, or failure to thrive
as infants; or
(B) behavioral manifestations such as
irritability, or for older children,
hyperactivity, attention deficit, language
dysfunction, or perceptual or judgment
difficulties.
The term ``eligible community college'' means an accredited
community college that--
[(i) is located on or near an
Indianreservation;
[(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) Behavioral health aftercare.--The term
`behavioral health aftercare' includes those activities
and resources used to support recovery following
inpatient, residential, intensive substance abuse, or
mental health outpatient or outpatient treatment. The
purpose is to help prevent or deal with relapse by
ensuring that by the time a client or patient is
discharged from a level of care, such as outpatient
treatment, an aftercare plan has been developed with
the client. An aftercare plan may use such resources as
a community-based therapeutic group, transitional
living facilities, a 12-step sponsor, a local 12-step
or other related support group, and other community-
based providers (mental health professionals,
traditional health care practitioners, community health
aides, community health representatives, mental health
technicians, ministers, etc.)
[(3) The term ``tribally controlled community
college'' has the meaning given such term in section
1801(a)(4) of this title.]
(4) Dual diagnosis._The term `dual diagnosis' means
coexisting substance abuse and mental illness
conditions or diagnosis. Such clients are sometimes
referred to as mentally ill chemical abusers (MICAs).
[(4) The term ``tribally controlled postsecondary
vocational institution'' has the meaning given such
term in section 2397h(2) of Title 20.]
(5) Fetal alcohol disorders.--The term `fetal alcohol
disorders' means fetal alcohol syndrome, partial fetal
alcohol syndrome and alcohol related neurodevelopmental
disorder (ARND).
(6) Fetal alcohol syndrome or fas.--The term `fetal
alcohol syndrome' or `FAS' means a syndrome in which,
with a history of maternal alcohol consumption during
pregnancy, the following criteria are met:
(A) Central nervous system involvement such
as developmental delay, intellectual deficit,
microencephaly, or neurologic abnormalities.
(B) Craniofacial abnormalities with at least
2 of the following: microophthalmia, short
palpebral fissures, poorly developed philtrum,
thin upper lip, flat nasal bridge, and short
upturned nose.
(C) Prenatal or postnatal growth delay.
(7) Partial fas.--The term `partial FAS' means, with
a history of maternal alcohol consumption during
pregnancy, having most of the criteria of FAS, though
not meeting a minimum of at least 2 of the following:
microophthalmia, short palpebral fissures, poorly
developed philtrum, thin upper lip, flat nasal bridge,
and short upturned nose.
(8) Rehabilitation. The term `rehabilitation' means
to restore the ability or capacity to engage in usual
and customary life activities through education and
therapy.
(9) Substance abuse.--The term `substance abuse'
includes inhalant abuse.
Sec. 715. [(h)] Authorization of A[a]ppropriations
There is [are] authorized to be appropriated [for each of
fiscal years 1996 through 2000,] such sums as may be necessary
for each fiscal year through fiscal year 2015 to carry out the
provisions [purposes] of this title [section]. [Such sums shall
remain available until expended.]
[Sec. 1665k. Gila River alcohol and substance abuse treatment facility
[(a) Regional center
[The Secretary, acting through the Service, shall establish
a regional youth alcohol and substance abuse prevention and
treatment center in Sacaton, Arizona, on the Gila River Indian
Reservation. The center shall be established within facilities
leased, with the consent of the Gila River Indian Community, by
the Service from such Community.
[(b) Name of regional center
[The center established pursuant to this section shall be
known as the ``Regional Youth Alcohol and Substance Abuse
Prevention and Treatment Center''.
[(c) Unit of regional center
[The Secretary, acting through the Service, shall
establish, as a unit of the regional center, a youth alcohol
and substance abuse prevention and treatment facility in
Fallon, Nevada.
[Sec. 1665l. Alaska Native drug and alcohol abuse demonstration project
[(a) The Secretary, acting through the Service, shall make
grants to the Alaska Native Health Board for the conduct of a
two-part community-based demonstration project to reduce drug
and alcohol abuse in Alaska Native villages and to rehabilitate
families afflicted by such abuse. Sixty percent of such grant
funds shall be used by the Health Board to stimulate
coordinated community development programs in villages seeking
to organize to combat alcohol and drug use. Forty percent of
such grant funds shall be transferred to a qualified nonprofit
corporation providing alcohol recovery services in the village
of St. Mary's, Alaska, to enlarge and strengthen a family life
demonstration program of rehabilitation for families that have
been or are afflicted by alcoholism.
[(b) The Secretary shall submit to the President for
inclusion in the report required to be submitted to the
Congress under section 1671 of this title for fiscal year 1995
an evaluation of the demonstration project established under
subsection (a) of this section.
[Sec. 1665m. Authorization of appropriations
[Except as provided in sections 1665b, 1665e, 1665g, 1665i,
and 1665j of this title, there are authorized to be
appropriated such sums as may be necessary for each fiscal year
through fiscal year 2000 to carry out the provisions of this
subchapter.]
TITLE VIII [SUBCHAPTER VI]--MISCELLANEOUS
Sec. 1671. Reports
The President shall, at the time the budget is submitted
under section 1105 of [T]title 31, United States Code, for each
fiscal year transmit to [the] Congress a report containing the
following:[--]
(1) A[a] report on the progress made in meeting the
objectives of this Act[chapter], including a review of
programs established or assisted pursuant to this
Act[chapter] and [an] assessments and recommendations
of additional programs or additional assistance
necessary to, at a minimum, provide health services to
Indians[,] and ensure a health status for Indians,
which are at a parity with the health services
available to and the health status of[,] the general
population, including specific comparisons of
appropriations provided and those required for such
parity.[;]
(2) A[a] report on whether, and to what extent, new
national health care programs, benefits, initiatives,
or financing systems have had an impact on the purposes
of this Act[chapter] and any steps that the Secretary
may have taken to consult with Indian [t]Tribes, Tribal
Organizations, and Urban Indian Organizations to
address such impact, including a report on proposed
changes in allocation of funding pursuant to section
808.[;]
(3) A[a] report on the use of health services by
Indians--
(A) on a national and area or other relevant
geographical basis;
(B) by gender and age;
(C) by source of payment and type of service;
[and]
(D) comparing such rates of use with rates of
use among comparable non-Indian populations[.];
and
(E) provided under Funding Agreements.
(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 126(f).
(7)[(4) a]A separate statement which specifies the
amount of funds requested to carry out the provisions
of section 201. [1621 of this title;]
(8) A report of the evaluations of health promotion
and disease prevention as required in section 203(c).
(9) A biennial report to Congress on infectious
diseases asrequired by section 212.
(10) A report on environmental and nuclear health
hazards as required by section 215.
(11) An annual report on the status of all health
care facilities needs as required by section 301(c)(2)
and 301(d).
(12) Reports on safe water and sanitary waste
disposal facilities as required by section 302(h).
(13) An annual report on the expenditure of
nonservice funds for renovation as required by sections
304(b)(2).
(14) A report identifying the backlog of maintenance
and repair required at Service and tribal facilities
required by section 313(a).
(15) A report providing an accounting of
reimbursement funds made available to the Secretary
under titles XVIII, XIX, and XXI of the Social Security
Act.
(16) A report on any arrangements for the sharing of
medical facilities or services between the Service,
Indian Tribes, and Tribal Organizations, and the
Department of Veterans Affairs and the Department of
Defense, 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).
[(5) a separate statement of the total amount
obligated or expended in the most recently completed
fiscal year to achieve each of the objectives described
in section 1680d of this title, relating to infant and
maternal mortality and fetal alcohol syndrome;
[(6) the reports required by the sections 1602(d),
1616a(n), 1621b(b), 1621h(j), 1631(c), 1632(g),
1634(a)(3), 1643, 1665g(e), and 1680g(a), and 1680l(f)
of this title;
[(7) for fiscal year 1995, the report required by
sections 1665a(c)(3) and 1665l(b) of this title;
[(8) for fiscal year 1997, the interim report
required by section 1637(h)(1) of this title; and
[(9) for fiscal year 1999, the reports required by
sections 1637(h)(2), 1660b(b), 1665j(f), and 1680k(g)
of this title.]
Sec. 1672. Regulations
(a) Deadlines.--
(1) Procedures.--Not later than 90 days after the
date of the enactment of the Indian Health Care
Improvement Act Amendments of 2004, the Secretary shall
initiate procedures under subchapter III of chapter 5
of title 5, United States Code, to negotiate and
promulgate such regulations or amendments thereto that
are necessary to carry out titles I, II, III, and VII
and section 817. The Secretary may promulgate
regulations to carry out sections 105, 115, 117, and
titles IV and V, using the procedures required by
chapter V of title 5, United States Code (commonly
known as the `Administrative Procedure Act'. The
Secretary shall issue no regulations to carry out
titles VI and VIII, except as necessary to carry out
section 817.
(2) Proposed regulations.--Proposed regulations to
implement this Act shall be published in the Federal
Register by the Secretary no later than 270 days after
the date of the enactment of the Indian Health Care
Improvement Act Amendments of 2004 and shall have no
less than a 120-day comment period.
(3) Expiration of authority.--The authority to
promulgate regulations under this Act shall expire 18
months from the date of the enactment of this Act.
(b) Committee.--A negotiated rulemaking committee
established pursuant to section 565 of title 5, United 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,
Tribal Organizations, and Urban Indian 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.
(d) Lack of Regulations.--The lack of promulgated
regulations shall not limit the effect of this Act.
(e) Inconsistent Regulations.--The provisions of this Act
shall supersede any conflicting provisions of law in effect on
the day before the date of the enactment of the Indian Health
Care Improvement Act Amendments of 2004, and the Secretary is
authorized to repeal any regulation inconsistent with the
provisions of this Act.
[Prior to any revision of or amendment to rules or regulations
promulgated pursuant to this chapter, the Secretary shall
consult with Indian tribes and appropriate national or regional
Indian organizations and shall publish any proposed revision or
amendment in the Federal Register not less than sixty days
prior to the effective date of such revision or amendment in
order to provide adequate notice to, and receive comments from,
other interested parties.
[Sec. 1673. Repealed.
[Sec. 1674. Leases with Indian tribes
[(a) Notwithstanding any other provision of law, the
Secretary is authorized, in carrying out the purposes of this
chapter, to enter into leases with Indian tribes for periods
not in excess of twenty years. Property leased by the Secretary
from an Indian tribe may be reconstructed or renovated by the
Secretary pursuant to an agreement with such Indian tribe.
[(b) The Secretary may enter into leases, contracts, and
other legal agreements with Indian tribes or tribal
organizations which hold--
[(1) title to;
[(2) a leasehold interest in; or
[(3) a beneficial interest in (where title is held by
the United States in trust for the benefit of a tribe);
[facilities used for the administration and delivery of health
services by the Service or by programs operated by Indian
tribes or tribal organizations to compensate such Indian tribes
or tribal organizations for costs associated with the use of
such facilities for such purposes. Such costs include rent,
depreciation based on the useful life of the building,
principal and interest paid or accrued, operation and
maintenance expenses, and other expenses determined by
regulation to be allowable.]
Sec. 803. Plan of Implementation
Not later than 8 months after the date of the enactment of
the Indian Health Care Improvement Act Amendments of 2004, the
Secretary in consultation with Indian Tribes, Tribal
Organizations, and Urban Indian Organizations, shall submit to
Congress a plan explaining the manner and schedule (including a
schedule of appropriation requests), by title and section, by
which the Secretary will implement the provisions of this Act.
Sec. 1675. Availability of F[f]unds
The funds appropriated pursuant to this Act [chapter] shall
remain available until expended.
Sec. 1676. Limitation on U[u]se of F[f]unds A[a]ppropriated to the
Indian Health Service
Any limitation on the use of funds contained in an Act
providing appropriations for the Department [of Health and
Human Services] for a period with respect to the performance of
abortions shall apply for that period with respect to the
performance of abortions using funds contained in an Act
providing appropriations for the [Indian Health] Service.
[Sec. 1677. Nuclear resource development health hazards
[(a) Study
[The Secretary and the Service shall conduct, in
conjunction with other appropriate Federal agencies and in
consultation with concerned Indian tribes and organizations, a
study of the health hazards to Indian miners and Indians on or
near Indian reservations and in Indian communities as a result
of nuclear resource development. Such study shall include--
[(1) an evaluation of the nature and extent of
nuclear resource development related health problems
currently exhibited among Indians and the causes of
such health problems;
[(2) an analysis of the potential effect of ongoing
and future nuclear resource development on or near
Indian reservations and communities;
[(3) an evaluation of the types and nature of
activities, practices, and conditions causing or
affecting such health problems, including uranium
mining and milling, uranium mine tailing deposits,
nuclear power plant operation and construction, and
nuclear waste disposal;
[(4) a summary of any findings and recommendations
provided in Federal and State studies, reports,
investigations, andinspections during the five years
prior to December 17, 1980, that directly or indirectly relate to the
activities, practices, and conditions affecting the health or safety of
such Indians; and
[(5) the efforts that have been made by Federal and
State agencies and mining and milling companies to
effectively carry out an education program for such
Indians regarding the health and safety hazards of such
nuclear resource development.
[(b) Health care plan; development
[Upon completion of such study the Secretary and the
Service shall take into account the results of such study and
develop a health care plan to address the health problems
studied under subsection (a) of this section. The plan shall
include--
[(1) methods for diagnosing and treating Indians
currently exhibiting such health problems;
[(2) preventive care for Indians who may be exposed
to such health hazards, including the monitoring of the
health of individuals who have or may have been exposed
to excessive amounts of radiation, or affected by other
nuclear development activities that have had or could
have a serious impact upon the health of such
individuals; and
[(3) a program of education for Indians who, by
reason of their work or geographic proximity to such
nuclear development activities, may experience health
problems.
[(c) Reports to Congress
[The Secretary and the Service shall submit to Congress the
study prepared under subsection (a) of this section no later
than the date eighteen months after December 17, 1980. The
health care plan prepared under subsection (b) of this section
shall be submitted in a report no later than the date one year
after the date that the study prepared under subsection (a) of
this section is submitted to Congress. Such report shall
include recommended activities for the implementation of the
plan, as well as an evaluation of any activities previously
undertaken by the Service to address such health problems.
[(d) Intergovernmental Task Force; establishment and
functions
[(1) There is established an Intergovernmental Task
Force to be composed of the following individuals (or
their designees): the Secretary of Energy, the
Administrator of the Environmental Protection Agency,
the Director of the United States Bureau of Mines, the
Assistant Secretary for Occupational Safety and Health,
and the Secretary of the Interior.
[(2) The Task Force shall identify existing and
potential operations related to nuclear resource
development that affect or may affect the health of
Indians on or near an Indian reservation or in an
Indian community and enter into activities to correct
existing health hazards and insure that current and
future health problems resulting from nuclear resource
development activities are minimized or reduced.
[(3) The Secretary shall be Chairman of the Task
Force. The Task Force shall meet at least twice each
year. Each member of the Task Force shall furnish
necessary assistance to the Task Force.
[(e) Medical care
[In the case of any Indian who--
[(1) as a result of employment in or near a uranium
mine or mill, suffers from a work related illness or
condition;
[(2) is eligible to receive diagnosis and treatment
services from a Service facility; and
[(3) by reason of such Indian's employment, is
entitled to medical care at the expense of such mine or
mill operator;
[the Service shall, at the request of such Indian, render
appropriate medical care to such Indian for such illness or
condition and may recover the costs of any medical care so
rendered to which such Indian is entitled at the expense of
such operator from such operator. Nothing in this subsection
shall affect the rights of such Indian to recover damages other
than such costs paid to the Service from the employer for such
illness or condition.
[Sec. 1678. Arizona as a contract health service delivery area
[(a) Designation
[For the fiscal years beginning with the fiscal year ending
September 30, 1982, and ending with the fiscal year ending
September 30, 2000, the State of Arizona shall be 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. 1679. Eligibility of California Indians
(a) In General._[Report to Congress]
The following California Indians shall be eligible for
health services provided by the Service:
[(1) In order to provide the Congress with sufficient
data to determine which Indians in the State of
California should be eligible for health services
provided by the Service, the Secretary shall, by no
later than the date that is 3 years after November 23,
1988, prepare and submit to the Congress a report which
sets forth--
[(A) a determination by the Secretary of the
number of Indians described in subsection
(b)(2) of this section, and the number of
Indians described in subsection (b)(3) of this
section, who are not members of an Indian tribe
recognized by the Federal Government,
[(B) the geographic location of such Indians,
[(C) the Indian tribes of which such Indians
are members,
[(D) an assessment of the current health
status, and health care needs, of such Indians,
and
[(E) an assessment of the actual availability
and accessibility of alternative resources for
the health care of such Indians that such
Indians would have to rely on if the Service
did not provide for the health care of such
Indians.
[(2) The report required under paragraph (1) shall be
prepared by the Secretary--
[(A) in consultation with the Secretary of
the Interior, and
[(B) with the assistance of the tribal health
programs providing services to the Indians
described in paragraph (2) or (3) of subsection
(b) of this section who are not members of any
Indian tribe recognized by the Federal
Government.
[(b) Eligible Indians
[Until such time as any subsequent law may otherwise
provide, the following California Indians shall be eligible for
health services provided by the Service:]
(1) Any member of a federally recognized Indian
T[t]ribe.
(2) Any descendant of an Indian who was residing in
California on June 1, 1852, [but only] if such
descendant--
[(A) is living in California,]
(A)[(B)] is a member of the Indian community
served by a local program of the Service[,];
and
(B)[(C)] is regarded as an Indian by the
community in which such descendant lives.
(3) Any Indian who holds trust interests in public
domain, national forest, or [Indian] reservation
allotments in California.
(4) Any Indian in California who is listed on the
plans for distribution of the assets of [California]
rancherias and reservations located within the State of
California under the Act of August 18, 1958 (72 Stat.
619), and any descendant of such an Indian.
(b)[(c)] Clarification.--[Scope of eligibility]
Nothing in this section may be construed as expanding the
eligibility of California Indians for health services provided
by the Service beyond the scope of eligibility for such health
services that applied on May 1, 1986.
[Sec. 1680. California as a contract health service delivery area
[The State of California, excluding the counties of
Alameda, Contra Costa, Los Angeles, Marin, Orange, Sacramento,
San Francisco, San Mateo, Santa Clara, Kern, Merced, Monterey,
Napa, San Benito, San Joaquin, San Luis Obispo, Sant Cruz,
Solano, Stanislaus, and Ventura shall be designated as a
contract health service delivery area by the Service for the
purpose of providing contract health services to Indians in
such State.
[Sec. 1680a. Contract health facilities
[The Service shall provide funds for health care programs
and facilities operated by tribes and tribal organizations
under contracts with the Service entered into under the Indian
Self-Determination Act [25 U.S.C.A Sec. 450f et seq.]--
[(1) for the maintenance and repair of clinics owned
or leased by such tribes or tribal organizations,
[(2) for employee training,
[(3) for cost-of-living increases for employees, and
[(4) for any other expenses relating to the provision
of health services,
[on the same basis as such funds are provided to programs and
facilities operated directly by the Service.
[Sec. 1680b. National Health Service Corps
[The Secretary of Health and Human Services shall not--
[(1) remove a member of the National Health Service
Corps from a health facility operated by the Indian
Health Service or by a tribe or tribal organization
under contract with the Indian Health Service under the
Indian Self-Determination Act [25 U.S.C.A. Sec. 450f et
seq.], or
[(2) withdraw funding used to support such member,
[unless the Secretary, acting through the Service, has ensured
that the Indians receiving services from such member will
experience no reduction in services.]
Sec. 1680c. Health S[s]ervices for I[i]neligible P[p]ersons
(a) Children._Individuals not otherwise eligible
[(1)] Any individual who--
(1)[(A)] has not attained 19 years of age[,];
(2)[(B)] is the natural or adopted child, step[-
]child, foster[-]child, legal ward, or orphan of an
eligible Indian[,]; and
(3)[(C)] is not otherwise eligible for the health
services provided by the Service, shall be eligible for
all health services provided by the Service on the same
basis and subject to the same rules that apply to
eligible Indians until such individual attains 19 years
of age. The existing and potential health needs of all
such individuals shall be taken into consideration by
the Service in determining the need for, or the
allocation of, the health resources of the Service. If
such an individual has been determined to be legally
incompetent prior to attaining 19 years of age, such
individual shall remain eligible for such services
until 1[one] year after the date of a determination of
competency [such disability has been removed].
(b) Spouses.--[(2)] Any spouse of an eligible Indian who is
not an Indian, or who is of Indian descent but 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 the Indian Tribe(s) being
served are made eligible, as a class, by an appropriate
resolution of the governing body of the Indian tribe or Tribal
Organization providing such services [of the eligible Indian].
The health needs of persons made eligible under this paragraph
shall not be taken into consideration by the Service in
determining the need for, or allocation of, its health
resources.
(c)[(b)] Provision of Services to Other Individuals.--
[Health facilities providing health service]
(1)[(A)] In general.--The Secretary is authorized to
provide health services under this subsection through
health programs [facilities] operated directly by the
Service to individuals who reside within the [service
area of a s]Service [u]Unit and who are not otherwise
eligible for such health services [under any other
subsection of this section or under any other provision
of law] if--
(A)[(i)] the Indian T[t]ribes [(or, in the
case of a multi-tribal service are, all the
Indian tribes)] served by such [s]Service
[u]Unit request[s] such provision of health
services to such individuals[,]; and
(B)[(ii)] the Secretary and the served Indian
[tribe or t]Tribes have jointly determined
that--
(i)[(I)] the provision of such health
services will not result in a denial or
diminution of health services to
eligible Indians[,]; and
(ii)[(II)] there is no reasonable
alternative health facilit[y]ies or
services, within or without the
[servicearea of such [s]Service
[u]Unit, available to meet the health needs of such individuals.
(2)[(B)] ISDEAA programs.--In the case of a Tribal
Health Program [health facilities operated under a
contract entered into under the Indian Self-
Determination Act [25 U.S.C.A. Sec. 450f et seq.]], the
governing body of the Indian [t]Tribe or T[t]ribal
O[o]rganization providing health services under such
Tribal Health Program [contract] is authorized to
determine whether health services should be provided
under its Funding Agreement [such contract] to
individuals who are not otherwise eligible for such
[health] services [under any other subsection of this
section or under any other provision of law]. In making
such determination[s], the governing body [of the
Indian tribe or tribal organization] shall take into
account the considerations described in clauses (i) and
(ii) of paragraph (1)(B) [subparagraph (A)(ii)].
(3)[(2)] Payment for services.--
(A) In general.--Persons receiving health
services provided by the Service under [by
reason of] this subsection shall be liable for
payment of such health services under a
schedule of charges prescribed by the Secretary
which, in the judgment of the Secretary,
results in reimbursement in an amount not less
than the actual cost of providing the health
services. Notwithstanding section 404[1880(c)]
of this [the Social Security] Act [[42 U.S.C.A.
Sec. 1395qq(c)], section 1642(a) of this
title,] or any other provision of law, amounts
collected under this subsection, including
medicare, [or] medicaid or SCHIP reimbursements
under titles XVIII, [and] XIX, and XXI of the
Social Security Act [[42 U.S.C.A.
Sec. Sec. 1395 et seq., 1396 et seq.]], shall
be credited to the account of the program
[facility] providing the service and shall be
used [solely] for the purposes listed in
section 401(d)(2) and [provision of health
services within that facility. A]amounts
collected under this subsection shall be
available for expenditure within such program
[facility for not to exceed one fiscal year
after the fiscal year in which collected].
(B) Indigent people.--Health services may be
provided by the Secretary through the Service
under this subsection to an indigent individual
[person] who would not be otherwise eligible
for such health services but for the provisions
of paragraph (1) only if an agreement has been
entered into with a State or local government
under which the State or local government
agrees to reimburse the Service for the
expenses incurred by the Service in providing
such health services to such indigent
individual [person].
(4)[(3)] Revocation of consent for services.--
(A) Single tribe service area.--In the case
of a S[s]ervice A[a]rea which serves only
1[one] Indian T[t]ribe, the authority of the
Secretary to provide health services under
paragraph (1)[(A)] shall terminate at the end
of the fiscal year succeeding the fiscal year
in which the governing body of the Indian
T[t]ribe revokes its concurrence to the
provision of such health services.
(B) Multitribal service area.--In the case of
a multi[-]tribal S[s]ervice A[a]rea, the
authority of the Secretary to provide health
services under paragraph (1)[(A)] shall
terminate at the end of the fiscal year
succeeding the fiscal year in which at least 51
percent of the number of Indian T[t]ribes in
the S[s]ervice A[a]rea revoke their concurrence
to the provision of such health services.
(d)[(c)] Other Services.--[Purposes served in providing
health services to otherwise ineligible individuals]
The Service may provide health services under this
subsection to individuals who are not eligible for health
services provided by the Service under any other [subsection of
this section or under any other] provision of law in order to--
(1) achieve stability in a medical emergency[,];
(2) prevent the spread of a communicable disease or
otherwise deal with a public health hazard[,];
(3) provide care to non-Indian women pregnant with an
eligible Indian's child for the duration of the
pregnancy through post[ ]partum[,]; or
(4) provide care to immediate family members of an
eligible individual [person] if such care is directly
related to the treatment of the eligible individual
[person].
(e)[(d) Extension of h]Hospital [p]Privileges for [to non-
Service health care p]Practitioners
Hospital privileges in health facilities operated and
maintained by the Service or operated under a Funding Agreement
[contract entered into under the Indian Self-Determination Act
[25 U.S.C.A. Sec. 450f et seq.]] may be extended to non-Service
health care practitioners who provide services to individuals
[persons] described in subsection (a), [or] (b), (c), or (d)
[of this section]. Such non-Service health care practitioners
may, as part of the privileging process, be designated
[regarded] asemployees of the Federal Government for purposes
of section 1346(b) and chapter 171 of Title 28, United States Code
(relating to Federal tort claims) only with respect to acts or
omissions which occur in the course of providing services to eligible
individuals [persons] as a part of the conditions under which such
hospital privileges are extended.
(f)[(e) ``]Eligible Indian['' defined].--
For purposes of this section, the term [``]`eligible
Indian'[''] means any Indian who is eligible for health
services provided by the Service without regard to the
provisions of this section.
[Sec. 1680d. Infant and maternal mortality; fetal alcohol syndrome
[By no later than January 1, 1990, the Secretary shall
develop and begin implementation of a plan to achieve the
following objectives by January 1, 1994:
[(1) reduction of the rate of Indian infant mortality
in each area office of the Service to the lower of--
[(A) twelve deaths per one thousand live
births, or
[(B) the rate of infant mortality applicable
to the United States population as a whole;
[(2) reduction of the rate of maternal mortality in
each area office of the Service to the lower of--
[(A) five deaths per one hundred thousand
live births, or
[(B) the rate of maternal mortality
applicable to the United States population as a
whole; and
[(3) reduction of the rate of fetal alcohol syndrome
among Indians served by, or on behalf of, the Service
to one per one thousand births.
[Sec. 1680e. Contract health services for the Trenton Service Area
[(a) Service to Turtle Mountain Band
[The Secretary, acting through the Service, is directed to
provide contract health services to members of the Turtle
Mountain Band of Chippewa Indians that reside in the Trenton
Service Area of Divide, McKenzie, and Williams counties in the
State of North Dakota and the adjoining counties of Richland,
Roosevelt, and Sheridan in the State of Montana.
[(b) Band member eligibility not expanded
[Nothing in this section may be construed as expanding the
eligibility of members of the Turtle Mountain Band of Chippewa
Indians for health services provided by the Service beyond the
scope of eligibility for such health services that applied on
May 1, 1986.
[Sec. 1680f. Indian Health Service and Department of Veterans Affairs
health facilities and services sharing
[(a) Feasibility study and report
[The Secretary shall examine the feasibility of entering
into an arrangement for the sharing of medical facilities and
services between the Indian Health Service and the Department
of Veterans Affairs and shall, in accordance with subsection
(b) of this section, prepare a report on the feasibility of
such an arrangement and submit such report to the Congress by
no later than September 30, 1990.
[(b) Nonimpairment of service quality, eligibility, or
priority of access
[The Secretary shall not take any action under this section
or under subchapter IV of chapter 81 of Title 38 which would
impair--
[(1) the priority access of any Indian to health care
services provided through the Indian Health Service;
[(2) the quality of health care services provided to
any Indian through the Indian Health Service;
[(3) the priority access of any veteran to health
care services provided by the Department of Veterans
Affairs;
[(4) the quality of health care services provided to
any veteran by the Department of Veterans Affairs;
[(5) the eligibility of any Indian to receive health
services through the Indian Health Service; or
[(6) the eligibility of any Indian who is a veteran
to receive health services through the Department of
Veterans Affairs.
[(c) Cross utilization of services
[(1) Not later than December 23, 1988, the Director
of the Indian Health Service and the Secretary of
Veterans Affairs shall implement an agreement under
which--
[(A) individuals in the vicinity of
Roosevelt, Utah, who are eligible for health
care from the Department of Veterans Affairs
could obtain health care services at the
facilities of the Indian Health Service located
at Fort Duchesne, Utah; and
[(B) individuals eligible for health care
from the Indian Health Service at Fort
Duchesne, Utah, could obtain health care
services at the George E. Wahlen Department of
Veterans Affairs Medical Center located in Salt
Lake City, Utah.
[(2) Not later than November 23, 1990, the Secretary
and the Secretary of Veterans Affairs shall jointly
submit a report to the Congress on the health care
services provided as a result of paragraph (1).
[(d) Right to health services
[Nothing in this section may be construed as creating any
right of a veteran to obtain health services from the Indian
Health Service except as provided in an agreement under
subsection (c) of this section.]
Sec. 1680g. Reallocation of B[b]ase R[r]esources
(a) Report Required.--[to Congress]
Notwithstanding any other provision of law, any allocation
of Service funds for a fiscal year that reduces by 5 percent or
more from the previous fiscal year the funding for any
recurring program, project, or activity of a S[s]ervice U[u]nit
may be implemented only after the Secretary has submitted to
the President, for inclusion in the report required to be
transmitted to [the] Congress under section 801[1671 of this
title], a report on the proposed change in allocation of
funding, including the reasons for the change and its likely
effects.
(b) Exception.--[Appropriated amounts]
Subsection (a) [of this section] shall not apply if the
total amount appropriated to the Service for a fiscal year is
at least 5 percent less than the amount appropriated to the
Service for the previous fiscal year.
[Sec. 1680h. Demonstration projects for tribal management of health
care services
[(a) Establishment; grants
[(1) The Secretary, acting through the Service, shall
make grants to Indian tribes to establish demonstration
projects under which the Indian tribe will develop and
test a phased approach to assumption by the Indian
tribe of the health care delivery system of the Service
for members of the Indian tribe living on or near the
reservations of the Indian tribe through the use of
Service, tribal, and private sector resources.
[(2) A grant may be awarded to an Indian tribe under
paragraph (1) only if the Secretary determines that the
Indian tribe has the administrative and financial
capabilities necessary to conduct a demonstration
project described in paragraph (1).
[(b) Health care contracts
[During the period in which a demonstration project
established under subsection (a) of this section is being
conducted by an Indian tribe, the Secretary shall award all
health care contracts, including community, behavioral, and
preventive health care contracts, to the Indian tribe in the
form of a single grant to which the regulations prescribed
under part A of title XIX of the Public Health Service Act [42
U.S.C.A. Sec. 300w et seq. (as modified as necessary by any
agreement entered into between the Secretary and the Indian
tribe to achieve the purposes of the demonstration project
established under subsection (a) of this section) shall apply.
[(c) Waiver of procurement laws
[The Secretary may waive such provisions of Federal
procurement law as are necessary to enable any Indian tribe to
develop and test administrative systems under the demonstration
project established under subsection (a) of this section, but
only if such waiver does not diminish or endanger the delivery
of health care services to Indians.
[(d) Termination; evaluation and report
[(1) The demonstration project established under
subsection (a) of this section shall terminate on
September 30, 1993, or, in the case of a demonstration
project for which a grant is made after September 30,
1990, three years after the date on which such grant is
made.
[(2) By no later than September 30, 1996, the
Secretary shall evaluate the performance of each Indian
tribe that has participated in a demonstration project
established under subsection (a) of this section and
shall submit to the Congress a report on such
evaluations and demonstration projects.
[(e) Joint venture demonstration projects
[(1) The Secretary, acting through the Service, shall
make arrangements with Indian tribes to establish joint
venture demonstrative projects under which an Indian
tribe shall expend tribal, private, or other available
nontribal funds, for the acquisition or construction of
a health facility for a minimum of 20 years, under a
no-cost lease, in exchange for agreement by the Service
to provide the equipment, supplies, and staffing for
the operation and maintenance of such a health
facility. A tribe may utilize tribal funds, private
sector, or other available resources, including loan
guarantees, to fulfill its commitment under this
subsection.
[(2) The Secretary shall make such an arrangement
with an Indian tribe only if the Secretary first
determines that the Indian tribe has the administrative
and financial capabilities necessary to complete the
timely acquisition or construction of the health
facility described in paragraph (1).
[(3) An Indian tribe or tribal organization that has
entered into a written agreement with the Secretary
under this subsection, and that breaches or terminates
without cause such agreement, shall be liable to the
United States for the amount that has been paid to the
tribe, or paid to a third party on the tribe's behalf,
under the agreement. The Secretary has the right to
recover tangible property (including supplies), and
equipment, less depreciation, and any funds expended
for operations and maintenance under this section. The
preceding sentence does not apply to any funds expended
for the delivery of health care services, or for
personnel or staffing, shall be recoverable.
[Sec. 1680i. Child sexual abuse treatment programs
[(a) Continuation of existing demonstration programs
[The Secretary and the Secretary of the Interior shall, for
each fiscal year through fiscal year 1995, continue the
demonstration programs involving treatment for child sexual
abuse provided through the Hopi Tribe and the Assiniboine and
Sioux Tribes of the Fort Peck Reservation.
[(b) Establishment of new demonstration programs
[Beginning October 1, 1995, the Secretary and the Secretary
of the Interior may establish, in any service area,
demonstration programs involving treatment for child sexual
abuse, except that the Secretaries may not establish a greater
number of such programs in one service area than in any other
service area until there is an equal number of such programs
established with respect to all service areas from which the
Secretary receives qualified applications during the
application period (as determined by the Secretary).
[Sec. 1680j. Tribal leasing
[Indian tribes providing health care services pursuant to a
contract entered into under the Indian Self-Determination Act
[25 U.S.C.A. Sec. 450f et seq.] may lease permanent structures
for the purpose of providing such health care services without
obtaining advance approval in appropriation Acts.
[Sec. 1680k. Home- and community-based care demonstration project
[(a) Authority of Secretary
[The Secretary, acting through the Service, is authorized
to enter into contracts with, or make grants to, Indian tribes
or tribal organizations providing health care services pursuant
to a contract entered into under the Indian Self-Determination
Act [25 U.S.C.A. Sec. 450f et seq.], to establish demonstration
projects for the delivery of home- and community-based services
to functionally disabled Indians.
[(b) Use of funds
[(1) Funds provided for a demonstration project under
this section shall be used only for the delivery of
home- and community-based services (including
transportation services) to functionally disabled
Indians.
[(2) Such funds may not by used--
[(A) to make cash payments to functionally
disabled Indians;
[(B) to provide room and board for
functionally disabled Indians;
[(C) for the construction or renovation of
facilities or the purchase of medical
equipment; or
[(D) for the provision of nursing facility
services.
[(c) Criteria for approval of applications
[Not later than 180 days after October 29, 1992, the
Secretary, after consultation with Indian tribes and tribal
organizations, shall develop and issue criteria for the
approval of applications submitted under this section. Such
criteria shall ensure that demonstration projects established
under this section promote the development of the capacity of
tribes and tribal organizations to deliver, or arrange for the
delivery of, high quality, culturally appropriate home- and
community-based services to functionally disabled Indians;
[(d) Assistance to applicants
[The Secretary shall provide such technical and other
assistance as may be necessary to enable applicants to comply
with the provisions of this section.
[(e) Services to ineligible persons
[At the discretion of the tribe or tribal organization,
services provided under a demonstration project established
under this section may be provided (on a cost basis) to persons
otherwise ineligible for the health care benefits of the
Service.
[(f) Maximum number of demonstration projects
[The Secretary shall establish not more than 24
demonstration projects under this section. The Secretary may
not establish a greater number of demonstration projects under
this section in one service area than in any other service area
until there is an equal number of such demonstration projects
established with respect to all service areas from which the
Secretary receives applications during the application period
(as determined by the Secretary) which meet the criteria issued
pursuant to subsection (c) of this section.
[(g) Report
[The Secretary shall submit to the President, for inclusion
in the report which is required to be submitted under section
1671 of this title for fiscal year 1999, a report on the
findings and conclusions derived from the demonstration
projects conducted under this section, together with
legislative recommendations.
[(h) Definitions
[For the purposes of this section, the following
definitions shall apply:
[(1) The term ``home- and community-based services''
means one or more of the following:
[(A) Homemaker/home health aide services.
[(B) Chore services.
[(C) Personal care services.
[(D) Nursing care services provided outside
of a nursing facility by, or under the
supervision of, a registered nurse.
[(E) Respite care.
[(F) Training for family members in managing
a functionally disabled individual.
[(G) Adult day care.
[(H) Such other home- and community-based
services as the Secretary may approve.
[(2) The term ``functionally disabled'' means an
individual who is determined to require home- and
community-based services based on an assessment that
uses criteria (including, at the discretion of the
tribe or tribal organization, activities of daily
living) developed by the tribe or tribal organization.
[(i) Authorization of appropriations
[There are authorized to be appropriated for each of the
fiscal years 1996 through 2000 such sums as may be necessary to
carry out this section. Such sums shall remain available until
expended.
[Sec. 1680l. Shared services demonstration project
[(a) Authority of Secretary
[The Secretary, acting through the Service and
notwithstanding any other provision of law, is authorized to
enter into contracts with Indian tribes or tribal organizations
to establish not more than 6 shared services demonstration
projects for the delivery of long-term care to Indians. Such
projects shall provide for the sharing of staff or other
services between a Service facility and a nursing facility
owned and operated (directly or by contract) by such Indian
tribe ortribal organization.
[(b) Contract requirements
[A contract entered into pursuant to subsection (a) of this
section--
[(1) may, at the request of the Indian tribe or
tribal organization, delegate to such tribe or tribal
organization such powers of supervision and control
over Service employees as the Secretary deems necessary
to carry out the purposes of this section;
[(2) shall provide that expenses (including salaries)
relating to services that are shared between the
Service facility and the tribal facility be allocated
proportionately between the Service and the tribe or
tribal organization; and
[(3) may authorize such tribe or tribal organization
to construct, renovate, or expand a nursing facility
(including the construction of a facility attached to a
Service facility), except that no funds appropriated
for the Service shall be obligated or expended for such
purpose.
[(c) Eligibility
[To be eligible for a contract under this section, a tribe
or tribal organization, shall, as of October 29, 1992--
[(1) own and operate (directly or by contract) a
nursing facility;
[(2) have entered into an agreement with a consultant
to develop a plan for meeting the long-term needs of
the tribe or tribal organization; or
[(3) have adopted a tribal resolution providing for
the construction of a nursing facility.
[(d) Nursing facilities
[Any nursing facility for which a contract is entered into
under this section shall meet the requirements for nursing
facilities under section 1396r or Title 42.
[(e) Assistance to applicants
[The Secretary shall provide such technical and other
assistance as may be necessary to enable applicants to comply
with the provisions of this section.
[(f) Report
[The Secretary shall submit to the President, for inclusion
in each report required to be transmitted to the Congress under
section 1671 of this title, a report on the findings and
conclusions derived from the demonstration projects conducted
under this section.]
Sec. 1680m. Results of [d]Demonstration [p]Projects
The Secretary shall provide for the dissemination to Indian
T[t]ribes, Tribal Organizations, and Urban Indian Organizations
of the findings and results of demonstration projects conducted
under this Act [chapter].
[Sec. 1680n. Priority for Indian reservations
[(a) Facilities and projects
[Beginning on October 29, 1992, the Bureau of Indian
Affairs and the Service shall, in all matters involving the
reorganization or development of service facilities, or in the
establishment of related employment projects to address
unemployment conditions in economically depressed areas, give
priority to locating such facilities and projects on Indian
lands if requested by the Indian tribe with jurisdiction over
such lands.
[(b) ``Indian lands'' defined
[For purposes of this section, the term ``Indian lands''
means--
[(1) all lands within the limits of any Indian
reservation; and
[(2) any lands title which is held in trust by the
United States for the benefit of any Indian tribe or
individual Indian, or held by any Indian tribe or
individual Indian subject to restriction by the United
States against alienation and over which an Indian
tribe exercises governmental power.]
Sec. 810. Provision of Services in Montana
(a) Consistent with Court Decision.--The Secretary, acting
through the Service, shall provide services and benefits for
Indians in Montana in a manner consistent with the decision of
the United States Court of Appeals for the Ninth Circuit in
McNabb for McNabb v. Bowen, 829 F.2d 787 (9th Cir. 1987).
(b) Clarification.--The provisions of subsection (a) shall
not be construed to be an expression of the sense of Congress
on the application of the decision described in subsection (a)
with respect to the provision of services or benefits for
Indians living in any State other than Montana.
[Sec. 1680o. Authorization of appropriations
[Except as provided in section 1680k of this title, there
are authorized to be appropriated such sums as may be necessary
for each fiscal year through fiscal year 2000 to carry out this
subchapter.]
Sec. 811. Moratorium.
During the period of the moratorium imposed on
implementation of the final rule published in the Federal
Register on September 16, 1987, by the Health Resources and
Services Administration of the Public Health Service, relating
to eligibility for the health care services of the Indian
Health Service, the Indian Health Service shall provide
services pursuant to the criteria for eligibility for such
services that were in effect on September 15, 1987, subject to
the provisions of sections 806 and 807 until such time as new
criteria governing eligibility for services are developed in
accordance with section 802.
[Sec. 1681. Omitted]
Sec. 812. Tribal Employment.
For purposes of section 2(2) of the Act of July 5, 1935 (49
Stat. 450, chapter 372), an Indian Tribe or Tribal Organization
carrying out a Funding Agreement shall not be considered an
`employer'.
[Sec. 1682. Subrogation of claims by Indian Health Service
[On and after October 18, 1986, the Indian Health Service
may seek subrogation of claims including but not limited to
auto accident claims, including no-fault claims, personal
injury, disease, or disability claims, and worker's
compensation claims, the proceeds of which shall be credited to
the funds established by sections 401 and 402 of the Indian
Health Care Improvement Act.]
Sec. 813. Prime Vendor.
(a) Executive Agency Status.--For purposes of section
201(a) of the Federal Property and Administrative Services Act
(40 U.S.C. 481(a)) (relating to Federal sources of supply,
including lodging providers, airlines, and other transportation
providers), a Tribal Health Program shall be deemed an
executive agency when carrying out a contract, grant,
cooperative agreement, or Funding Agreement with the Service
and shall have access to the Federal Supply Schedule and any
other Federal source of supply to which executive agencies have
access.
(b) IHS Status.--For purposes of section 4 of Public Law
102-585 (38 U.S.C. 8126), a Tribal Health Program shall have
the status of the Indian Health Service and shall have direct
access to the Veterans Administration prime vendor provided for
in section 4 of Public Law 102-585.
(c) Employee Status.--The employees of such Tribal Health
Programs may order supplies under such respective programs on
the same basis as employees of the Service.
[Sec. 1683. Indian Catastrophic Health Emergency Fund
[$10,000,000 shall remain available until expended, for the
establishment of an Indian Catastrophic Health Emergency Fund
(hereinafter referred to as the ``Fund''). On and after October
18, 1986, the Fund is to cover the Indian Health Service
portion of the medical expenses of catastrophic illness falling
within the responsibility of the Service and shall be
administered by the Secretary of Health and Human Services,
acting through the central office of the Indian Health Service.
No part of the Fund or its administration shall be subject to
contract or grant under the Indian Self-Determination and
Education Assistance Act (Public Law 93-638) [25 U.S.C.A.
Sec. 450 et seq.]. There shall be deposited into the Fund all
amounts recovered under the authority of the Federal Medical
Care Recovery Act (42 U.S.C. 2651 et seq.), which shall become
available for obligation upon receipt and which shall remain
available for obligation until expended. The Fund shall not be
used to pay for health services provided to eligible Indians to
the extent that alternate Federal, State, local, or private
insurance resources for payment: (1) are available and
accessible to the beneficiary; or (2) would be available and
accessible if the beneficiary were to apply for them; or (3)
would be available and accessible to other citizens similarly
situated under Federal, State, or local law or regulation or
private insurance program notwithstanding Indian Health Service
eligibility or residency on or off a Federal Indian
reservation.]
Sec. 814. Severability Provisions.
If any provision of this Act, any amendment made by theAct,
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. 815. Establishment of National Bipartisan Commission on Indian
Health Care Entitlement.
(a) Establishment.--There is hereby established the
National Bipartisan Indian Health Care Entitlement Commission
(the `Commission').
(b) Duties of Commission.--The duties of the Commission are
the following:
(1) To establish a study committee composed of those
members of the Commission appointed by the Director and
at least 4 members of Congress from among the members
of the Commission, the duties of which shall be the
following:
(A) To the extent necessary to carry out its
duties, collect and compile data necessary to
understand the extent of Indian needs with
regard to the provision of health services,
regardless of the location of Indians,
including holding hearings and soliciting the
views of Indians, Indian Tribes, Tribal
Organizations, and Urban Indian Organizations,
which may include authorizing and making funds
available for feasibility studies of various
models for providing and funding health
services for all Indian beneficiaries,
including those who live outside of a
reservation, temporarily or permanently.
(B) To make recommendations to the Commission
for legislation that will provide for the
delivery of health services for Indians as an
entitlement, which will address, among other
things, issues of eligibility, benefits to be
provided, including recommendations regarding
from whom such health services are to be
provided and the cost, including mechanisms for
making funds available for the health services
to be provided.
(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 recommendations to Congress for providing
health services for Indians as an entitlement, giving
due regard to the effects of such a program on existing
health care delivery systems for Indians and the effect
of such a program on the sovereign status of Indian
Tribes.
(4) Not later than 18 months following the date of
appointment of all members of the Commission, submit a
written report to Congress containing a recommendation
of policies and legislation to implement a policy that
would establish a health care system for Indians based
on delivery of health services as an entitlement,
together with a determination of the implications of
such an entitlement system on existing health care
delivery systems for Indians on the sovereign status of
Indian Tribes.
(c) Members.--
(1) Appointment.--The Commission shall be composed of
25 members, appointed as follows:
(A) Ten members of Congress, including 3 from
the House of Representatives and 2 from the
Senate, appointed by their respective majority
leaders, and 3 from the House of
Representatives and 2 from the Senate,
appointed by their respective minority leaders,
and who shall be members of the standing
committees of Congress that consider
legislation affecting health care to Indians.
(B) Twelve persons chosen by the
congressional members of the Commission, 1 from
each Service Area as currently designated by
the Director to be chosen from among 3 nominees
from each Service Area put forward by the
Indian Tribes within the area, with due regard
being given to the experience and expertise of
the nominees in the provision of health care
toIndians 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 90
days after the date of the enactment of the Indian
Health Care Improvement Act Amendments of 2004, 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 areheld in different areas of
the United States in which large numbers of Indians are present. Such
hearings are to be held to solicit the views of Indians regarding the
delivery of health care services to them. To constitute a hearing under
this subsection, at least 5 members of the Commission, including at
least 1 member of Congress, must be present. Hearings held by the study
committee established in this section may count toward the number of
regional hearings required by this subsection.
(2) Upon request of the Commission, the Comptroller
General shall conduct such studies or investigations as
the Commission determines to be necessary to carry out
its duties.
(3)(A) The Director of the Congressional Budget
Office or the Chief Actuary of the Centers for Medicare
& Medicaid Services, or both, shall provide to the
Commission, upon the request of the Commission, such
cost estimates as the Commission determines to be
necessary to carry out its duties.
(B) The Commission shall reimburse the Director of
the Congressional Budget Office for expenses relating
to the employment in the office of the Director of such
additional staff as may be necessary for the Director
to comply with requests by the Commission under
subparagraph (A).
(4) Upon the request of the Commission, the head of
any Federal agency is authorized to detail, without
reimbursement, any of the personnel of such agency to
the Commission to assist the Commission in carrying out
its duties. Any such detail shall not interrupt or
otherwise affect the civil service status or privileges
of the Federal employee.
(5) Upon the request of the Commission, the head of a
Federal agency shall provide such technical assistance
to the Commission as the Commission determines to be
necessary to carry out its duties.
(6) The Commission may use the United States mails in
the same manner and under the same conditions as
Federal agencies and shall, for purposes of the frank,
be considered a commission of Congress as described in
section 3215 of title 39, United States Code.
(7) The Commission may secure directly from any
Federal agency information necessary to enable it to
carry out its duties, if the information may be
disclosed under section 552 of title 4, United States
Code. Upon request of the Chairman of the Commission,
the head of such agency shall furnish such information
to the Commission.
(8) Upon the request of the Commission, the
Administrator of General Services shall provide to the
Commission on a reimbursable basis such administrative
support services as the Commission may request.
(9) For purposes of costs relating to printing and
binding, including the cost of personnel detailed from
the Government Printing Office, the Commission shall be
deemed to be a committee of Congress.
(i) Authorization of Appropriations.--There is authorized
to be appropriated $4,000,000 to carry out the provisions of
this section, which sum shall not be deducted from or affect
any other appropriations for health care for Indian persons.
(j) FACA.--The Federal Advisory Committee Act (5 U.S.C.
App.) shall not apply to the Commission.
Sec. 816. Appropriations; Availability.
Any new spending authority (described in subsection
(c)(2)(A) or (B) of section 401 of the Congressional Budget Act
of 1974) which is provided under this Act shall be effective
for any fiscal year only to such extent or in such amounts as
are provided in appropriation Acts.
Sec. 817. 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) 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) 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) 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) 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) 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) 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
suchparticipation 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 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
of this title.
(j) Definitions.--In this section:
(1) 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 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.
(2) The term `medical quality assurance record' means
the proceedings, records, minutes, and reports that
emanate from quality assurance program activities
described in paragraph (1) and are produced or compiled
by or for an Indian Health Program or Urban Indian
Organization as part of a medical quality assurance
program.
(3) 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.
Sec. 818. Authorization of Appropriations.
(a) In General.--There are authorized to be appropriated
such sums as may be necessary for each fiscal year through
fiscal year 2015 to carry out this title.
(b) Rate of Pay.--
(1) Positions at level iv.--Section 5315 of title 5,
United States Code, is amended by striking ``Assistant
Secretaries of Health and Human Services (6).'' and
inserting ``Assistant Secretaries of Health and Human
Services (7)''.
(2) Positions at level v.--Section 5316 of title 5,
United States Code, is amended by striking ``Director,
Indian Health Service, Department of Health and Human
Services''.
(c) Three Affiliated Tribes Health Facility Compensation.--
(1) Findings.--Congress finds that--
(A) in 1949, the United States assumed
jurisdiction over more that 150,000 prime acres
on the Fort Berthold Indian Reservation, North
Dakota, for the construction of the Garrison
Dam and Reservoir;
(B) the reservoir flooded and destroyed vital
infrastructure on the reservation, including a
hospital of the Indian Health Service;
(C) the United States made a commitment to
the Three Affiliated Tribes of the Fort
Berthold Indian Reservation to replace the lost
infrastructure;
(D) on May 10, 1985, the Secretary of the
Interior established the Garrison Unit Joint
Tribal Advisory Committee to examine the
effects of the Garrison Dam and Reservoir on
the Fort Berthold Indian Reservation;
(E) the final report of the Committee issued
on May 23, 1986, acknowledged the obligation of
the Federal Government to replace the
infrastructure destroyed by the Federal action;
(F) the Committee on Indian Affairs of the
Senate--
(i) acknowledged the recommendations
of the final report of the Committee in
Senate Report No. 102-250; and
(ii) stated that every effort should
be made bythe Administration and
Congress to provide additional Federal funding to replace the lost
infrastructure; and
(G) on August 30, 2001, the Chairman of the
Three Affiliated Tribes testified before the
Committee on Indian Affairs of the Senate that
the promise to replace the lost infrastructure,
particularly the hospital, still had not been
kept.
(2) Rural health care facility, fort berthold indian
reservation, north dakota.--The Three Affiliated Tribes
and Standing Rock Sioux Tribe Equitable Compensation
Act is amended--
* * * * * * *
UNITED STATES PUBLIC LAWS
102D CONGRESS--SECOND SESSION
PL 102-575, OCTOBER 30, 1992
RECLAMATION PROJECTS AUTHORIZATION AND ADJUSTMENT ACT OF 1992
SEC. 3504. FUNDS.
(a) Three Affiliated Tribes Economic Recovery Fund.--
(1) There is established in the Treasury of the
United States the ``Three Affiliated Tribes Economic
Recovery Fund'' (hereinafter referred to as the
``Recovery Fund'').
(2) Commencing with fiscal year 1993, and each fiscal
year thereafter, the Secretary of the Treasury shall
deposit in the Three Affiliated Tribes Economic
Recovery Fund an amount, which shall be nonreimbursable
and nonreturnable equal to 25 percent of the receipts
from deposits to the United States Treasury for the
preceding fiscal year from the integrated programs of
the Eastern Division of the Pick-Sloan Missouri River
Basin Project administered by the Western Area Power
Administration, but in no event shall the aggregate of
the amounts deposited to the Fund established by this
subsection for compensation for the Three Affiliated
Tribes pursuant to this paragraph and paragraph (3)
exceed $149,200,000.
(3) For payment to the Three Affiliated Tribes of
amounts to which they remain entitled pursuant to the
Act entitled ``An Act to make certain provisions in
connection with the construction of the Garrison
Diversion unit, Missouri River Basin Project, by the
Secretary of the Interior,'' approved August 5, 1965
(79 Stat. 433), there is authorized to be appropriated
to the Recovery Fund established by subsection (a) for
fiscal year 1994 and each of the next following nine
fiscal years, the sum of $6,000,000.
(4) The Secretary of the Treasury shall deposit the
interest which accrues on deposits to the Three
Affiliated Tribes Economic Recovery Fund in a separate
account in the Treasury of the United States. Such
interest shall be available, without fiscal year
limitation, for use by the Secretary of the Interior,
commencing with fiscal year 1998, and each fiscal year
thereafter, in making payments to the Three Affiliated
Tribes for use for educational, social welfare,
economic development, and other programs, subject to
the approval of the Secretary. No part of the principal
of the Three Affiliated Tribes Economic Development
Fund shall be available for making such payments.
(b) Standing Rock Sioux Tribe Economic Recovery Fund.--
(1) There is established in the Treasury of the
United States the ``Standing Rock Sioux Tribe Economic
Recovery Fund.''
(2) Commencing with fiscal year 1993, and for each
fiscal year thereafter, the Secretary of the Treasury
shall deposit in the Standing Rock Sioux Tribe Economic
Recovery Fund an amount, which shall be nonreimbursable
and nonreturnable equal to 25 percent of the receipts
from deposits to the United States Treasury for the
preceding fiscal year from the integrated programs of
the Eastern Division of the Pick-Sloan Missouri River
Basin Project administered by the Western Area Power
Administration, but in no event shall the aggregate of
the amounts deposited to the Recovery Fund established
by this subsection for compensation for the Standing
Rock Sioux Tribe pursuant to this paragraph exceed
$90,600,000.
(3) The Secretary of the Treasury shall deposit the
interest which accrues on deposits to the Standing Rock
Sioux Tribe Economic Recovery Fund in a separate
account in the Treasury of the United States. Such
interest shall be available, without fiscal year
limitation, for use by the Secretary of the Interior,
commencing with fiscal year 1998, and each fiscal year
thereafter, in making payments to the Standing Rock
Sioux Tribe for use for educational, social welfare,
economic development, and other programs, subject to
the approval of the Secretary. No part of the principal
of the Standing Rock Sioux Tribe Economic Recovery Fund
shall be available for making such payments.
(c) Authorization of Appropriations.--There are authorized
to be appropriated such sums as are necessary to carry out this
section.
[SEC. 3511. AUTHORIZATION.
[There are authorized to be appropriated such sums as may
be necessary to carry out the provisions of section 3504 of
this title.]
Sec. 3511. Rural Health Care Facility, Fort Berthold Indian
Reservation, North Dakota
There are authorized to be appropriated to the Secretary of
Health and Human Services $20,000,000 for the construction of,
and such sums as are necessary for other expenses relating to,
a rural health care facility on the Fort Berthold Indian
Reservation of the Three Affiliated Tribes, North Dakota.
----------
UNITED STATES PUBLIC LAWS
106TH CONGRESS--SECOND SESSION
PL 106-310, OCTOBER 17, 2000, 114 STAT. 1101
25 U.S.C. 1671 NOTE
CHILDREN'S HEALTH ACT OF 2000
SEC. 3307. ESTABLISHMENT OF COMMISSION.
(a) In General.--There is established a commission to be
known as the Commission on Indian and Native Alaskan Health
Care that shall examine the health concerns of Indians and
Native Alaskans who reside on reservations and tribal lands
(hereafter in this section referred to as the ``Commission'').
(b) Membership.--
(1) In general.--The Commission established under
subsection (a) shall consist of--
(A) the Secretary;
(B) 15 members who are experts in the health
care field and issues that the Commission is
established to examine; and
(C) the [Director of the Indian Health
Service] Assistant Secretary for Indian Health
and the Commissioner of Indian Affairs, who
shall be nonvoting members.
UNITED STATES CODE ANNOTATED
TITLE 25--INDIANS
CHAPTER 41--INDIAN LANDS OPEN DUMP CLEANUP
Sec. 3902. Definitions
For the purposes of this chapter, the following definitions
shall apply:
(3) Assistant secretary.--The term `Assistant
Secretary' means the Assistant Secretary for Indian
Health.
(4)[(1)] Closure or close.--The term ``closure or
close'' means the termination of operations at open
dumps on Indian land or Alaska Native land and bringing
such dumps into compliance with applicable Federal
standards and regulations, or standards promulgated by
an Indian tribal government or Alaska Native entity, if
such standards are more stringent than the Federal
standards and regulations.
[(2) Director.--The term ``Director'' means the
Director of the Indian Health Service.]
(5)[(3)] Indian land.--The term ``Indian land''
means--
(A) land within the limits of any Indian
reservation under the jurisdiction of the
United States Government, notwithstanding the
issuance of any patent, and including rights-
of-way running through the reservation;
(B) dependent Indian communities within the
borders of the United States whether within the
original or subsequently acquired territory
thereof, and whether within or without the
limits of a State; and
(C) Indian allotments, the Indian titles to
which have not been extinguished, including
rights-of-way running through such allotments.
(2)[(4)] Alaska native land.--The term ``Alaska
Native land'' means (A) land conveyed or to be conveyed
pursuant to the Alaska Native Claims Settlement Act (43
U.S.C. 1600 et seq.) [43 U.S.C.A. Sec. 1601 et seq.],
including any land reconveyed under section 14(c)(3) of
that Act (43 U.S.C. 1613(c)(3)), and (B) land conveyed
pursuant to the Act of November 2, 1966 (16 U.S.C. 1151
et seq.; commonly known as the ``Fur Seal Act of
1966'').
(6)[(5)] Indian tribal government.--The term ``Indian
tribal government'' means the governing body of any
Indian tribe, band, nation, pueblo, or other organized
group or community which is recognized as eligible for
the special programs and services provided by the
United States to Indians because of their status as
Indians.
(1)[(6)] Alaska native entity.--The term ``Alaska
Native entity'' includes native corporations
established pursuant to the Alaska Native Claims
Settlement Act [43 U.S.C.A. Sec. 1601 et seq.] and any
Alaska Native village or municipal entity which owns
Alaska Native land.
(7) Open dump.--The term ``open dump'' means any
facility or site where solid waste is disposed of which
is not a sanitary landfill which meets the criteria
promulgated under section 4004 of the Solid Waste
Disposal Act (42 U.S.C. 6944) and which is not a
facility for disposal of hazardous waste.
(8) Postclosure maintenance.--The term ``postclosure
maintenance'' means any activity undertaken at a closed
solid waste management facility on Indian land or on
Alaska Native land to maintain the integrity of
containment features, monitor compliance with
applicable performance standards, or remedy any
situation or occurrence that violates regulations
promulgated pursuant to subtitle D of the Solid Waste
Disposal Act (42 U.S.C. 6941 et seq.).
(9) Service.--The term ``Service'' means the Indian
Health Service.
(10) Solid waste.--The term ``solid waste'' has the
meaning provided that term by section 1004(27) of the
Solid Waste Disposal Act (42 U.S.C. 6903) and any
regulations promulgated thereunder.
Sec. 3903. Inventory of open dumps
(a) Study and Inventory.--
Not later than 12 months after October 22, 1994, the
[Director] Assistant Secretary shall conduct a study and
inventory of open dumps on Indian lands and Alaska Native
lands. The inventory shall list the geographic location of all
open dumps, an evaluation of the contents of each dump, and an
assessment of the relative severity of the threat to public
health and the environment posed by each dump. Such assessment
shall be carried out cooperatively with the Administrator of
the Environmental Protection Agency. The Director shall obtain
the concurrence of the Administrator in the determination of
relative severity made by any such assessment.
(b) Annual Reports.--
Upon completion of the study and inventory under subsection
(a) of this section, the [Director] Assistant Secretary shall
report to the Congress, and update such report annually--
(c) 10-Year Plan.--
The [Director] Assistant Secretary shall develop and begin
implementation of a 10-year plan to address solid waste
disposal needs on Indian lands and Alaska Native lands. This
10-year plan shall identify--
Sec. 3904. Authority of [the Director of the Indian Health Service]
Assistant Secretary for Indian Health
(a) Reservation Inventory.--
(1) Upon request by an Indian tribal government or
Alaska Native entity, the [Director] Assistant
Secretary shall--
(B) determine the relative severity of the
threat to public health and the environment
posed by each dump based on information
available to the [Director] Assistant Secretary
and the Indian tribal government or Alaska
Native entity unless the [Director] Assistant
Secretary, in consultation with the Indian
tribal government or Alaska Native entity,
determines that additional actions such as soil
testing or water monitoring would be
appropriate in the circumstances; and
(2) The inventory and evaluation authorized under
paragraph (1)(A) shall be carried out cooperatively
with the Administrator of the Environmental Protection
Agency. The [Director] Assistant Secretary shall obtain
the concurrence of the Administrator in the
determination of relative severity made under paragraph
(1)(B).
(b) Assistance.--
Upon completion of the activities required to be performed
pursuant to subsection (a) of this section, the [Director]
Assistant Secretary shall, subject to subsection (c) of this
section, provide financial and technical assistance to the
Indian tribal government or Alaska Native entity to carry out
this activities necessary to--
(c) Conditions.--
All assistance provided pursuant to subsection (b) of this
section shall be made available on a site-specific basis in
accordance with priorities developed by the [Director]
Assistant Secretary. Priorities on specific Indian lands or
Alaska Native lands shall be developed in consultation with the
Indian tribal government or Alaska Native entity. The
priorities shall take into account the relative severity of the
threat to public health and the environment posed by each open
dump and the availability of funds necessary for closure and
postclosure maintenance.
Sec. 3905. Contact authority
(a) Authority of [Director] Assistant Secretary.--
To the maximum extent feasible, the [Director] Assistant
Secretary shall carry out duties under this chapter through
contracts, compacts, or memoranda of agreement with Indian
tribal governments or Alaska Native entities pursuant to the
Indian Self-Determination and Education Assistance Act (25
U.S.C. 450 et seq.), section 2004a of Title 42, or section 1632
of this title.
(b) Cooperative Agreements.--
The [Director] Assistant Secretary is authorized, for
purposes of carrying out the duties of the [Director] Assistant
Secretary under this chapter, to contract with or enter into
such cooperative agreements with such other Federal agencies as
is considered necessary to provide cost-sharing for closure and
postclosure activities, to obtain necessary technical and
financial assistance and expertise, and for such other purposes
as the [Director] Assistant Secretary considers necessary.
Sec. 3906. Tribal demonstration project
(a) In General.--
The [Director] Assistant Secretary may establish and carry
out a program providing for demonstration projects involving
open dumps on Indian land or Alaska Native land. It shall be
the purpose of such project to determine if there are unique
cost factors involved in the cleanup and maintenance of open
dumps on such land, and the extent to which advanced closure
planning is necessary. Under the program, the [Director]
Assistant Secretary is authorized to select no less than three
Indian tribal governments or Alaska Native entities to
participate in such demonstration projects.
(b) Criteria.--
Criteria established by the [Director] Assistant Secretary
for the selection and participation of an Indian tribal
government or Alaska Native entity in the demonstration project
shall provide that in order to be eligible to participate, an
Indian tribal government or Alaska Native entity must--
Sec. 3907. Authorization of appropriations
(b) Coordination.--
The activities required to be performed by the [Director]
Assistant Secretary under this chapter shall be coordinated
with activities related to solid waste and sanitation
facilities funded pursuant to other authorizations.
Sec. 3908. Disclaimers
(a) Authority of [Director] Assistant Secretary.--
Nothing in this chapter shall be construed to alter,
diminish, repeal, or supersede any authority conferred on the
[Director] Assistant Secretary pursuant to section 1632 of this
title, and section 2004a of Title 42.
----------
UNITED STATES PUBLIC LAWS
110TH CONGRESS--SECOND SESSION
PL 100-297, APRIL 28, 1988, 102 STAT. 130
25 USC 2001 NOTE
Sec. 5504. Administrative Provisions
(d) Federal Agency Cooperation and Assistance.--
(2) The Commissioner of the Administration for Native
Americans of the Department of Health and Human
Services and the [Director of the Indian Health
Service] Assistant Secretary for Indian Health of the
Department of Health and Human Services are authorized
to detail personnel to the Task Force, upon request, to
enable the Task Force to carry out its functions under
this part.
----------
UNITED STATES CODE ANNOTATED
TITLE 29--LABOR
CHAPTER 16--VOCATIONAL REHABILITATION AND OTHER REHABILITATION SERVICES
Subchapter II--Research and Training
Sec. 763. Interagency Committee
(a) Establishment; Membership; Meetings.--
(1) In order to promote coordination and cooperation
among Federal departments and agencies conducting
rehabilitation research programs, including programs
relating to assistive technology research and research
that incorporates the principles of universal design,
there is established within the Federal Government an
Interagency Committee on Disability Research
(hereinafter in this section referred to as the
``Committee''), chaired by the Director and comprised
of such members as the President may designate,
including the following (or their designees): the
Director, the Commissioner of theRehabilitation
Services Administration, the Assistant Secretary for Special Education
and Rehabilitative Services, the Secretary of Education, the Secretary
of Veterans Affairs, the Director of the National Institutes of Health,
the Director of the National Institute of Mental Health, the
Administrator of the National Aeronautics and Space Administration, the
Secretary of Transportation, the Assistant Secretary of the Interior
for Indian Affairs, the [Director of the Indian Health Service]
Assistant Secretary for Indian Health, and the Director of the National
Science Foundation.
----------
UNITED STATES CODE ANNOTATED
TITLE 33--NAVIGATION AND NAVIGABLE WATERS
CHAPTER 26--WATER POLLUTION PREVENTION AND CONTROL
Subchapter V--General Provisions
Sec. 1377. Indian Tribes
(b) Assessment of Sewage Treatment Needs; Report.--
The Administrator, in cooperation with the [Director of the
Indian Health Service] Assistant Secretary for Indian Health,
shall assess the need for sewage treatment works to serve
Indian tribes, the degree to which such needs will be met
through funds allotted to States under section 1285 of this
title and priority lists under section 1296 of this title, and
any obstacles which prevent such needs from being met. Not
later than one year after February 4, 1987, the Administrator
shall submit a report to Congress on the assessment under this
subsection, along with recommendations specifying (1) how the
Administrator intends to provide assistance to Indian tribes to
develop waste treatment management plans and to construct
treatment works under this chapter, and (2) methods by which
the participation in and administration of programs under this
chapter by Indian tribes can be maximized.
(e) Treatment as States.--
The Administrator is authorized to treat an Indian tribe as
a State for purposes of subchapter II of this chapter and
sections 1254, 1256, 1313, 1315, 1318, 1319, 1324, 1329, 1341,
1342, 1344, and 1346 of this title to the degree necessary to
carry out the objectives of this section, but only if-- . . .
Such treatment as a State may include the direct provision of
funds reserved under subsection (c) of this section to the
governing bodies of Indian tribes, and the determination of
priorities by Indian tribes, where not determined by the
Administrator in cooperation with the [Director of the Indian
Health Service] Assistant Secretary for Indian Health, is
authorized to make grants under subchapter II of this chapter
in an amount not to exceed 100 percent of the cost of a project
* * * * * * *
----------
UNITED STATES CODE ANNOTATED
TITLE 42--THE PUBLIC HEALTH AND WELFARE
CHAPTER 6A--PUBLIC HEALTH SERVICE
Subchapter II--General Powers and Duties
PART B--FEDERAL-STATE COOPERATION
Sec. 247b-14. Oral Health Promotion and Disease Prevention
(b) Community Water Fluoridation.--
(1) In general.--
The Secretary, acting through the Director of the
Centers for Disease Control and Prevention and in
collaboration with the [Director of the Indian Health
Service] Assistant Secretary for Indian Health, shall
establish a demonstration project that is designed to
assist rural water systems in successfully implementing
the water fluoridation guidelines of the Centers for
Disease Control and Prevention that are entitled
``Engineering and Administrative Recommendations for
Water Fluoridation, 1995'' (referred to in this
subsection as the ``EARWF'').
(2) Requirements.--
(A) Collaboration.--
In collaborating under paragraph (1), [the
Directors referred to in such paragraph] the
Director of the Centers for Disease Control and
Prevention and the Assistant Secretary for
Indian Health shall ensure that technical
assistance and training are provided to tribal
programs located in each of the 12 areas of the
Indian Health Service. The [Director of the
Indian Health Service] Assistant Secretary for
Indian Health shall provide coordination and
administrative support to tribes under this
section.
----------
UNITED STATES CODE ANNOTATED
TITLE 42--THE PUBLIC HEALTH AND WELFARE
CHAPTER 6A--PUBLIC HEALTH SERVICE
Subchapter III--National Research Institutes
PART C--SPECIFIC PROVISIONS RESPECTING NATIONAL RESEARCH INSTITUTES
Subpart 1--National Cancer Institute
Sec. 285a-9. Grants for Education, Prevention, and Early Detection of
Radiogenic Cancers and Diseases
(b) In General.--
The Secretary, acting through the Administrator of the
Health Resources and Services Administration in consultation
with the Director of the National Institutes of Health and the
[Director of the Indian Health Service] Assistant Secretary for
Indian Health, may make competitive grants to any entity for
the purpose of carrying out programs to--
* * * * * * *
----------
UNITED STATES CODE ANNOTATED
TITLE 42--THE PUBLIC HEALTH AND WELFARE
CHAPTER 6A--PUBLIC HEALTH SERVICE
Subchapter XII--Safety of Public Water Systems
PART E--GENERAL PROVISIONS
Sec. 300j-12. State Revolving Loan Funds
(i) Indian Tribes.--
(2) Use of funds.--
Funds reserved pursuant to paragraph (1) shall be
used to address the most significant threats to public
health associated with public water systems that serve
Indian Tribes, as determined by the Administrator in
consultation with the [Director of the Indian Health
Service] Assistant Secretary for Indian Health and
Indian Tribes.
(4) Needs assessment.--
The Administrator, in consultation with the [Director
of the Indian Health Service] Assistant Secretary for
Indian Health and Indian Tribes, shall, in accordance
with a schedule that is consistent with the needs
surveys conducted pursuant to subsection (h) of this
section, prepare surveys and assess the needs of
drinking water treatment facilities to serve Indian
Tribes, including an evaluation of the public water
systems that pose the most significant threats to
public health.
----------
UNITED STATES CODE ANNOTATED
TITLE 42--THE PUBLIC HEALTH AND WELFARE
CHAPTER 34--ECONOMY OPPORTUNITY PROGRAM
Subchapter VIII--Native American Programs
Sec. 2991b-2. Establishment of Administration for Native Americans
(d) Intra-Departmental Council on Native American
Affairs.--
(1) There is established in the Office of the
Secretary of the Intra-Departmental Council on Native
American Affairs. The Commissioner shall be the
chairperson of such Council and shall advise the
Secretary on all matters affecting Native Americans
that involve the Department. The [Director of the
Indian Health Service] Assistant Secretary for Indian
Health shall serve as vice chairperson of the Council.
----------
UNITED STATES PUBLIC LAWS
105TH CONGRESS--FIRST SESSION
PL 105-143, DECEMBER 15, 1997, 111 STAT. 2652
MICHIGAN INDIAN LAND CLAIMS SETTLEMENT ACT
Sec. 203. Limitation
(b) Consideration.--
In any case in which the Secretary, acting through the
[Director of the Indian Health Service] Assistant Secretary for
Indian Health, is required to select from more that 1
application for a contract or compact described in subsection
(a), in awarding the contract or compact, the Secretary shall
take into consideration--
* * * * * * *
----------
UNITED STATES PUBLIC LAWS
91ST CONGRESS--SECOND SESSION
PL 91-557, DECEMBER 17, 1970, 84 STAT. 1485
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).
----------
UNITED STATES CODE ANNOTATED
TITLE 42--THE PUBLIC HEALTH AND WELFARE
CHAPTER 7--SOCIAL SECURITY
Susbchapter XIX--Grants to States for Medical Assistance Programs
Sec. 1396j. Indian Health [Service facilities] Programs
(a) Eligibility for [r]Reimbursement for [m]Medical
[a]Assistance.--
[A facility of t]The Indian Health Service and an Indian
Tribe, Tribal Organization, or an urban Indian Organization
[(including a hospital, nursing facility, or any other type of
facility which provides services of a type otherwise covered
under the State plan), whether operated by such Service or by
an Indian tribe or tribal organization] (as [those] such terms
are defined in section 4 of the Indian Health Care Improvement
Act[1603 of Title 25]), shall be eligible for reimbursement for
medical assistance provided under a State plan or under waiver
authority with respect to items and services furnished by the Indian
Health Service, Indian Tribe, Tribal Organization, or Urban Indian
Organization if the furnishing of such services [and for so long as it]
meets all [of] the conditions and requirements which are applicable
generally to the furnishing of items and services [such facilities]
under this title and under such plan or waiver authority [subchapter].
[(b) Facilities deemed to meet requirements upon submission
of acceptable plan for achieving compliance
[Notwithstanding subsection (a) of this section, a facility
of the Indian Health Service (including a hospital, nursing
facility, or any other type of facility which provides services
of a type otherwise covered under the State plan) which does
not meet all the conditions and requirements of this title
which are applicable generally to such facility, but which
submits to the Secretary within six months after September 30,
1976, an acceptable plan for achieving compliance with such
conditions and requirements, shall be deemed to meet such
conditions and requirements (and to be eligible for
reimbursement under this subchapter), without regard to the
extent of its actual compliance with such conditions and
requirements, during the first twelve months in which such plan
is submitted.]
(b)[(c)] Authority to Enter Into Agreements [Agreement to
reimburse State agency for providing care and services].--
The Secretary may [is authorized to] enter into an
agreement[s] with a [the] State [agency] for the purpose of
reimbursing the State [such agency] for medical assistance
[health care and services] provided by the [in] Indian Health
Service, an Indian Tribe, Tribal Organizations, or an Urban
Indian Organization (as so defined), directly, through
referral, or under contracts or other arrangements between the
Indian Health Service, an Indian Tribe, Tribal Organization, or
an Urban Indian Organization and another health care provider
[facilities] to Indians who are eligible for medical assistance
under the State plan or under waiver authority.
(c)[(d)] Direct B[b]illing.--F[f]or Payment Under Medicare,
Medicaid, and Other Third Party Payors
For provisions relating to the authority of certain Indian
tribes, tribal organizations, and Alaska Native health
organizations to elect to directly bill for, and receive
payment for, health care services provided by a hospital or
clinic of such tribes or organizations and for which payment
may be made under this subchapter, see section 1645 of Title
25.
----------
UNITED STATES CODE ANNOTATED
TITLE 42--THE PUBLIC HEALTH AND WELFARE
CHAPTER 7--SOCIAL SECURITY
Subchapter XXI--State Children's Health Insurance Program
Sec. 1397ee. Payments to States
(c) Limitation on Certain Payments for Certain
Expenditures.--
(6) Prevention of duplicative payments.--
(B) Other Federal governmental programs.--
Except as provided in subparagraph (A) or (B)
of subsection (a)(1) or any other provision of
law, no payment shall be made to a State under
this section for expenditures for child health
assistance provided for a targeted low-income
child under its plan to the extent that payment
has been made or can reasonably be expected to
be made promptly (as determined in accordance
with regulations) under any other federally
operated or financed health care insurance
program, [other than an insurance program
operated or financed by the Indian Health
Service,] other than a health program operated
or financed by the Indian Health Service or by
an Indian Tribe, Tribal Organization, or Urban
Indian Organization (as such terms are defined
in section 4 of the Indian Health Care
Improvement Act) as identified by the
Secretary. For purposes of this paragraph,
rules similar to the rules for overpayments
under section 1396b(d)(2) of this title shall
apply.