[Congressional Bills 109th Congress]
[From the U.S. Government Publishing Office]
[S. 3524 Placed on Calendar Senate (PCS)]







                                                       Calendar No. 469
109th CONGRESS
  2d Session
                                S. 3524

   To amend titles XVIII, XIX, and XXI of the Social Security Act to 
 improve health care provided to Indians under the Medicare, Medicaid, 
and State Children's Health Insurance Programs, and for other purposes.


_______________________________________________________________________


                   IN THE SENATE OF THE UNITED STATES

                             June 15, 2006

  Mr. Grassley, from the Committee on Finance, reported the following 
     original bill; which was read twice and placed on the calendar

_______________________________________________________________________

                                 A BILL


 
   To amend titles XVIII, XIX, and XXI of the Social Security Act to 
 improve health care provided to Indians under the Medicare, Medicaid, 
and State Children's Health Insurance Programs, and for other purposes.

    Be it enacted by the Senate and House of Representatives of the 
United States of America in Congress assembled,

SECTION 1. SHORT TITLE; TABLE OF CONTENTS.

    (a) Short Title.--This Act may be cited as the ``Medicare, 
Medicaid, and SCHIP Indian Health Care Improvement Act of 2006''.
    (b) Table of Contents.--The table of contents for this Act is as 
follows:

Sec. 1. Short title; table of contents.
Sec. 2. Expansion of payments under Medicare, Medicaid, and SCHIP for 
                            all covered services furnished by Indian 
                            health programs.
Sec. 3. Increased outreach to Indians under Medicaid and SCHIP and 
                            improved cooperation in the provision of 
                            items and services to Indians under Social 
                            Security Act health benefit programs.
Sec. 4. Additional provisions to increase outreach to, and enrollment 
                            of, Indians in SCHIP and Medicaid.
Sec. 5. Premiums and cost sharing protections and eligibility 
                            determinations under Medicaid and SCHIP, 
                            and protection of certain Indian property 
                            from Medicaid estate recovery.
Sec. 6. Nondiscrimination in qualifications for payment for services 
                            under Federal health care programs.
Sec. 7. Consultation on Medicaid, SCHIP, and other health care programs 
                            funded under the Social Security Act 
                            involving Indian Health Programs and Urban 
                            Indian Organizations.
Sec. 8. Exclusion waiver authority for affected Indian Health Programs 
                            and safe harbor transactions under the 
                            Social Security Act.
Sec. 9. Rules applicable under Medicaid and SCHIP to managed care 
                            entities with respect to Indian enrollees 
                            and Indian health care providers and Indian 
                            managed care entities.
Sec. 10. Annual report on Indians served by Social Security Act health 
                            benefit programs.
Sec. 11. Effective Date.

SEC. 2. EXPANSION OF PAYMENTS UNDER MEDICARE, MEDICAID, AND SCHIP FOR 
              ALL COVERED SERVICES FURNISHED BY INDIAN HEALTH PROGRAMS.

    (a) Medicaid.--
            (1) Expansion to all covered services.--Section 1911 of the 
        Social Security Act (42 U.S.C. 1396j) is amended--
                    (A) by amending the heading to read as follows:

``SEC. 1911. INDIAN HEALTH PROGRAMS.''; AND

                    (B) by amending subsection (a) to read as follows:
    ``(a) Eligibility for Payment for Medical Assistance.--The Indian 
Health Service and an Indian Tribe, Tribal Organization, or an Urban 
Indian Organization shall be eligible for payment for medical 
assistance provided under a State plan or under waiver authority with 
respect to items and services furnished by the Indian Health Service, 
Indian Tribe, Tribal Organization, or Urban Indian Organization if the 
furnishing of such services meets all the conditions and requirements 
which are applicable generally to the furnishing of items and services 
under this title and under such plan or waiver authority.''.
            (2) Compliance with conditions and requirements.--
        Subsection (b) of such section is amended to read as follows:
    ``(b) Compliance With Conditions and Requirements.--A facility of 
the Indian Health Service or an Indian Tribe, Tribal Organization, or 
an Urban Indian Organization which is eligible for payment under 
subsection (a) with respect to the furnishing of items and services, 
but which does not meet all of the conditions and requirements of this 
title and under a State plan or waiver authority which are applicable 
generally to such facility, shall make such improvements as are 
necessary to achieve or maintain compliance with such conditions and 
requirements in accordance with a plan submitted to and accepted by the 
Secretary for achieving or maintaining compliance with such conditions 
and requirements, and shall be deemed to meet such conditions and 
requirements (and to be eligible for payment under this title), without 
regard to the extent of its actual compliance with such conditions and 
requirements, during the first 12 months after the month in which such 
plan is submitted.''.
            (3) Revision of authority to enter into agreements.--
        Subsection (c) of such section is amended to read as follows:
    ``(c) Authority To Enter Into Agreements.--The Secretary may enter 
into an agreement with a State for the purpose of reimbursing the State 
for medical assistance provided by the Indian Health Service, an Indian 
Tribe, Tribal Organization, or an Urban Indian Organization (as so 
defined), directly, through referral, or under contracts or other 
arrangements between the Indian Health Service, an Indian Tribe, Tribal 
Organization, or an Urban Indian Organization and another health care 
provider to Indians who are eligible for medical assistance under the 
State plan or under waiver authority.''.
            (4) Cross-references to special fund for improvement of ihs 
        facilities; direct billing option; definitions.--Such section 
        is further amended by striking subsection (d) and adding at the 
        end the following new subsections:
    ``(d) Special Fund for Improvement of IHS Facilities.--For 
provisions relating to the authority of the Secretary to place payments 
to which a facility of the Indian Health Service is eligible for 
payment under this title into a special fund established under section 
401(c)(1) of the Indian Health Care Improvement Act, and the 
requirement to use amounts paid from such fund for making improvements 
in accordance with subsection (b), see subparagraphs (A) and (B) of 
section 401(c)(1) of such Act.
    ``(e) Direct Billing.--For provisions relating to the authority of 
a Tribal Health Program or an Urban Indian Organization to elect to 
directly bill for, and receive payment for, health care items and 
services provided by such Program or Organization for which payment is 
made under this title, see section 401(d) of the Indian Health Care 
Improvement Act.
    ``(f) Definitions.--In this section, the terms `Indian Health 
Program', `Indian Tribe',`Tribal Health Program', `Tribal 
Organization', and `Urban Indian Organization' have the meanings given 
those terms in section 4 of the Indian Health Care Improvement Act.''.
    (b) Medicare.--
            (1) Expansion to all covered services.--Section 1880 of 
        such Act (42 U.S.C. 1395qq) is amended--
                    (A) by amending the heading to read as follows:

``SEC. 1880. INDIAN HEALTH PROGRAMS.''; AND

                    (B) by amending subsection (a) to read as follows:
    ``(a) Eligibility for Payments.--Subject to subsection (e), the 
Indian Health Service and an Indian Tribe, Tribal Organization, or an 
Urban Indian Organization shall be eligible for payments under this 
title with respect to items and services furnished by the Indian Health 
Service, Indian Tribe, Tribal Organization, or Urban Indian 
Organization if the furnishing of such services meets all the 
conditions and requirements which are applicable generally to the 
furnishing of items and services under this title.''.
            (2) Compliance with conditions and requirements.--
        Subsection (b) of such section is amended to read as follows:
    ``(b) Compliance With Conditions and Requirements.--Subject to 
subsection (e), a facility of the Indian Health Service or an Indian 
Tribe, Tribal Organization, or an Urban Indian Organization which is 
eligible for payment under subsection (a) with respect to the 
furnishing of items and services, but which does not meet all of the 
conditions and requirements of this title which are applicable 
generally to such facility, shall make such improvements as are 
necessary to achieve or maintain compliance with such conditions and 
requirements in accordance with a plan submitted to and accepted by the 
Secretary for achieving or maintaining compliance with such conditions 
and requirements, and shall be deemed to meet such conditions and 
requirements (and to be eligible for payment under this title), without 
regard to the extent of its actual compliance with such conditions and 
requirements, during the first 12 months after the month in which such 
plan is submitted.''.
            (3) Cross-references to special fund for improvement of ihs 
        facilities; direct billing option; definitions.--
                    (A) In general.--Such section is further amended by 
                striking subsections (c) and (d) and inserting the 
                following new subsections:
    ``(c) Special Fund for Improvement of IHS Facilities.--For 
provisions relating to the authority of the Secretary to place payments 
to which a facility of the Indian Health Service is eligible for 
payment under this title into a special fund established under section 
401(c)(1) of the Indian Health Care Improvement Act, and the 
requirement to use amounts paid from such fund for making improvements 
in accordance with subsection (b), see subparagraphs (A) and (B) of 
section 401(c)(1) of such Act.
    ``(d) Direct Billing.--For provisions relating to the authority of 
a Tribal Health Program or an Urban Indian Organization to elect to 
directly bill for, and receive payment for, health care items and 
services provided by such Program or Organization for which payment is 
made under this title, see section 401(d) of the Indian Health Care 
Improvement Act.''.
                    (B) Conforming amendment.--Paragraph (3) of section 
                1880(e) of such Act (42 U.S.C. 1395qq(e)) is amended by 
                inserting ``and section 401(c)(1) of the Indian Health 
                Care Improvement Act'' after ``Subsection (c)''.
            (4) Definitions.--Such section is further amended by 
        amending subsection (f) to read as follows:
    ``(f) Definitions.--In this section, the terms `Indian Health 
Program', `Indian Tribe', `Service Unit', `Tribal Health Program', 
`Tribal Organization', and `Urban Indian Organization' have the 
meanings given those terms in section 4 of the Indian Health Care 
Improvement Act.''.
    (c) Application to SCHIP.--Section 2107(e)(1) of the Social 
Security Act (42 U.S.C. 1397gg(e)(1)) is amended--
            (1) by redesignating subparagraph (D) as subparagraph (E); 
        and
            (2) by inserting after subparagraph (C), the following new 
        subparagraph:
                    ``(D) Section 1911 (relating to Indian Health 
                Programs, other than subsection (d) of such 
                section).''.

SEC. 3. INCREASED OUTREACH TO INDIANS UNDER MEDICAID AND SCHIP AND 
              IMPROVED COOPERATION IN THE PROVISION OF ITEMS AND 
              SERVICES TO INDIANS UNDER SOCIAL SECURITY ACT HEALTH 
              BENEFIT PROGRAMS.

    Section 1139 of the Social Security Act (42 U.S.C. 1320b-9) is 
amended to read as follows:

``SEC. 1139. IMPROVED ACCESS TO, AND DELIVERY OF, HEALTH CARE FOR 
              INDIANS UNDER TITLES XVIII, XIX, AND XXI.

    ``(a) Agreements With States for Medicaid and SCHIP Outreach on or 
Near Reservations To Increase the Enrollment of Indians in Those 
Programs.--
            ``(1) In general.--In order to improve the access of 
        Indians residing on or near a reservation to obtain benefits 
        under the Medicaid and State children's health insurance 
        programs established under titles XIX and XXI, the Secretary 
        shall encourage the State to take steps to provide for 
        enrollment on or near the reservation. Such steps may include 
        outreach efforts such as the outstationing of eligibility 
        workers, entering into agreements with the Indian Health 
        Service, Indian Tribes, Tribal Organizations, and Urban Indian 
        Organizations to provide outreach, education regarding 
        eligibility and benefits, enrollment, and translation services 
        when such services are appropriate.
            ``(2) Construction.--Nothing in subparagraph (A) shall be 
        construed as affecting arrangements entered into between States 
        and the Indian Health Service, Indian Tribes, Tribal 
        Organizations, or Urban Indian Organizations for such Service, 
        Tribes, or Organizations to conduct administrative activities 
        under such titles.
    ``(b) Requirement To Facilitate Cooperation.--The Secretary, acting 
through the Centers for Medicare & Medicaid Services, shall take such 
steps as are necessary to facilitate cooperation with, and agreements 
between, States and the Indian Health Service, Indian Tribes, Tribal 
Organizations, or Urban Indian Organizations with respect to the 
provision of health care items and services to Indians under the 
programs established under title XVIII, XIX, or XXI.
    ``(c) Definition of Indian Tribe; Indian Health Program; Tribal 
Organization; Urban Indian Organization.--In this section, the terms 
`Indian Tribe', `Indian Health Program', `Tribal Organization', and 
`Urban Indian Organization' have the meanings given those terms in 
section 4 of the Indian Health Care Improvement Act.''.

SEC. 4. ADDITIONAL PROVISIONS TO INCREASE OUTREACH TO, AND ENROLLMENT 
              OF, INDIANS IN SCHIP AND MEDICAID.

    (a) Nonapplication of 10 Percent Limit on Outreach and Certain 
Other Expenditures.--Section 2105(c)(2) of the Social Security Act (42 
U.S.C. 1397ee(c)(2)) is amended by adding at the end the following new 
subparagraph:
                    ``(C) Nonapplication to expenditures for outreach 
                to increase the enrollment of indian children under 
                this title and title xix.--The limitation under 
                subparagraph (A) on expenditures for items described in 
                subsection (a)(1)(D) shall not apply in the case of 
                expenditures for outreach activities to families of 
                Indian children likely to be eligible for child health 
                assistance under the plan or medical assistance under 
                the State plan under title XIX (or under a waiver of 
                such plan), to inform such families of the availability 
                of, and to assist them in enrolling their children in, 
                such plans, including such activities conducted under 
                grants, contracts, or agreements entered into under 
                section 1139(a).''.
    (b) Assurance of Payments to Indian Health Care Providers for Child 
Health Assistance.--Section 2102(b)(3)(D) of such Act (42 U.S.C. 
1397bb(b)(3)(D)) is amended by striking ``(as defined in section 4(c) 
of the Indian Health Care Improvement Act, 25 U.S.C. 1603(c))'' and 
inserting ``, including how the State will ensure that payments are 
made to Indian Health Programs and Urban Indian Organizations operating 
in the State for the provision of such assistance''.
    (c) Inclusion of Other Indian Financed Health Care Programs in 
Exemption From Prohibition on Certain Payments.--Section 2105(c)(6)(B) 
of such Act (42 U.S.C. 1397ee(c)(6)(B)) is amended by striking 
``insurance program, other than an insurance program operated or 
financed by the Indian Health Service'' and inserting ``program, other 
than a health care program operated or financed by the Indian Health 
Service or by an Indian Tribe, Tribal Organization, or Urban Indian 
Organization''.
    (d) Satisfaction of Medicaid Documentation Requirements.--
            (1) In general.--Section 1903(x)(3)(B) of the Social 
        Security Act (42 U.S.C. 1396b(x)(3)(B)) is amended--
                    (A) by redesignating clause (v) as clause (vi); and
                    (B) by inserting after clause (iv), the following 
                new clause:
            ``(v)(I) Except as provided in subclause (II), a document 
        issued by a federally-recognized Indian tribe evidencing 
        membership or enrollment in, or affiliation with, such tribe.
            ``(II) With respect to those federally-recognized Indian 
        tribes located within States having an international border 
        whose membership includes individuals who are not citizens of 
        the United States, the Secretary shall, after consulting with 
        such tribes, issue regulations authorizing the presentation of 
        such other forms of documentation (including tribal 
        documentation, if appropriate) that the Secretary determines to 
        be satisfactory documentary evidence of citizenship or 
        nationality for purposes of satisfying the requirement of this 
        subsection.''.
            (2) Transition rule.--During the period that begins on July 
        1, 2006, and ends on the effective date of final regulations 
        issued under subclause (II) of section 1903(x)(3)(B)(v) of the 
        Social Security Act (42 U.S.C. 1396b(x)(3)(B)(v)) (as added by 
        paragraph (1)), an individual who is a member of a federally-
        recognized Indian tribe described in subclause (II) of that 
        section who presents a document described in subclause (I) of 
        such section that is issued by such Indian tribe, shall be 
        deemed to have presented satisfactory evidence of citizenship 
        or nationality for purposes of satisfying the requirement of 
        subsection (x) of section 1903 of such Act.
    (e) Definitions.--Section 2110(c) of such Act (42 U.S.C. 1397jj(c)) 
is amended by adding at the end the following new paragraph:
            ``(9) Indian; indian health program; indian tribe; etc.--
        The terms `Indian', `Indian Health Program', `Indian Tribe', 
        `Tribal Organization', and `Urban Indian Organization' have the 
        meanings given those terms in section 4 of the Indian Health 
        Care Improvement Act.''.

SEC. 5. PREMIUMS AND COST SHARING PROTECTIONS UNDER MEDICAID, 
              ELIGIBILITY DETERMINATIONS UNDER MEDICAID AND SCHIP, AND 
              PROTECTION OF CERTAIN INDIAN PROPERTY FROM MEDICAID 
              ESTATE RECOVERY.

    (a) Premiums and Cost Sharing Protection Under Medicaid.--
            (1) In general.--Section 1916 of the Social Security Act 
        (42 U.S.C. 1396o) is amended--
                    (A) in subsection (a), in the matter preceding 
                paragraph (1), by striking ``and (i)'' and inserting 
                ``, (i), and (j)''; and
                    (B) by adding at the end the following new 
                subsection:
    ``(j) No Premiums or Cost Sharing for Indians Furnished Items or 
Services Directly by Indian Health Programs or Through Referral Under 
the Contract Health Service.--
            ``(1) No cost sharing for items or services furnished to 
        indians through indian health programs.--
                    ``(A) In general.--No enrollment fee, premium, or 
                similar charge, and no deduction, copayment, cost 
                sharing, or similar charge shall be imposed against an 
                Indian who is furnished an item or service directly by 
                the Indian Health Service, an Indian Tribe, Tribal 
                Organization, or Urban Indian Organization or through 
                referral under the contract health service for which 
                payment may be made under this title.
                    ``(B) No reduction in amount of payment to indian 
                health providers.--Payment due under this title to the 
                Indian Health Service, an Indian Tribe, Tribal 
                Organization, or Urban Indian Organization, or a health 
                care provider through referral under the contract 
                health service for the furnishing of an item or service 
                to an Indian who is eligible for assistance under such 
                title, may not be reduced by the amount of any 
                enrollment fee, premium, or similar charge, or any 
                deduction, copayment, cost sharing, or similar charge 
                that would be due from the Indian but for the operation 
                of subparagraph (A).
            ``(2) Rule of construction.--Nothing in this subsection 
        shall be construed as restricting the application of any other 
        limitations on the imposition of premiums or cost sharing that 
        may apply to an individual receiving medical assistance under 
        this title who is an Indian.
            ``(3) Definitions.--In this subsection, the terms `contract 
        health service', `Indian', `Indian Tribe', `Tribal 
        Organization', and `Urban Indian Organization' have the 
        meanings given those terms in section 4 of the Indian Health 
        Care Improvement Act.''.
            (2) Conforming amendment.--Section 1916A (a)(1) of such Act 
        (42 U.S.C. 1396o-1(a)(1)) is amended by striking ``section 
        1916(g)'' and inserting ``subsections (g), (i), or (j) of 
        section 1916''.
    (b) Treatment of Certain Property for Medicaid and SCHIP 
Eligibility.--
            (1) Medicaid.--Section 1902(e) of the Social Security Act 
        (42 U.S.C. 1396a) is amended by adding at the end the following 
        new paragraph:
            ``(13) Notwithstanding any other requirement of this title 
        or any other provision of Federal or State law, a State shall 
        disregard the following property for purposes of determining 
        eligibility for medical assistance under this title:
                    ``(A) Property, including real property and 
                improvements, located on a reservation, including any 
                federally recognized Indian Tribe's reservation, 
                pueblo, or colony, including former reservations in 
                Oklahoma, Alaska Native regions established by the 
                Alaska Native Claims Settlement Act, and Indian 
                allotments on or near a reservation as designated and 
                approved by the Bureau of Indian Affairs of the 
                Department of the Interior.
                    ``(B) For any federally recognized Tribe not 
                described in subparagraph (A), property located within 
                the most recent boundaries of a prior Federal 
                reservation.
                    ``(C) Ownership interests in rents, leases, 
                royalties, or usage rights related to natural resources 
                (including extraction of natural resources or 
                harvesting of timber, other plants and plant products, 
                animals, fish, and shellfish) resulting from the 
                exercise of federally protected rights.
                    ``(D) Ownership interests in or usage rights to 
                items not covered by subparagraphs (A) through (C) that 
                have unique religious, spiritual, traditional, or 
                cultural significance or rights that support 
                subsistence or a traditional lifestyle according to 
                applicable tribal law or custom.''.
            (2) Application to schip.--Section 2107(e)(1) of such Act 
        (42 U.S.C. 1397gg(e)(1)) is amended--
                    (A) by redesignating subparagraphs (B) through (E), 
                as subparagraphs (C) through (F), respectively; and
                    (B) by inserting after subparagraph (A), the 
                following new subparagraph:
                    ``(B) Section 1902(e)(13) (relating to disregard of 
                certain property for purposes of making eligibility 
                determinations).''.
    (c) Continuation of Current Law Protections of Certain Indian 
Property From Medicaid Estate Recovery.--Section 1917(b)(3) of the 
Social Security Act (42 U.S.C. 1396p(b)(3)) is amended--
            (1) by inserting ``(A)'' after ``(3)''; and
            (2) by adding at the end the following new subparagraph:
                    ``(B) The standards specified by the Secretary 
                under subparagraph (A) shall require that the 
                procedures established by the State agency under 
                subparagraph (A) exempt income, resources, and property 
                that are exempt from the application of this subsection 
                as of April 1, 2003, under manual instructions issued 
                to carry out this subsection (as in effect on such 
                date) because of the Federal responsibility for Indian 
                Tribes and Alaska Native Villages. Nothing in this 
                subparagraph shall be construed as preventing the 
                Secretary from providing additional estate recovery 
                exemptions under this title for Indians.''.

SEC. 6. NONDISCRIMINATION IN QUALIFICATIONS FOR PAYMENT FOR SERVICES 
              UNDER FEDERAL HEALTH CARE PROGRAMS.

    Section 1139 of the Social Security Act (42 U.S.C. 1320b-9), as 
amended by section 3, is amended by redesignating subsection (c) as 
subsection (d), and inserting after subsection (b) the following new 
subsection:
    ``(c) Nondiscrimination in Qualifications for Payment for Services 
Under Federal Health Care Programs.--
            ``(1) Requirement to satisfy generally applicable 
        participation requirements.--
                    ``(A) In general.--A Federal health care program 
                must accept an entity that is operated by the Indian 
                Health Service, an Indian Tribe, Tribal Organization, 
                or Urban Indian Organization as a provider eligible to 
                receive payment under the program for health care 
                services furnished to an Indian on the same basis as 
                any other provider qualified to participate as a 
                provider of health care services under the program if 
                the entity meets generally applicable State or other 
                requirements for participation as a provider of health 
                care services under the program.
                    ``(B) Satisfaction of state or local licensure or 
                recognition requirements.--Any requirement for 
                participation as a provider of health care services 
                under a Federal health care program that an entity be 
                licensed or recognized under the State or local law 
                where the entity is located to furnish health care 
                services shall be deemed to have been met in the case 
                of an entity operated by the Indian Health Service, an 
                Indian Tribe, Tribal Organization, or Urban Indian 
                Organization if the entity meets all the applicable 
                standards for such licensure or recognition, regardless 
                of whether the entity obtains a license or other 
                documentation under such State or local law. In 
                accordance with section 221 of the Indian Health Care 
                Improvement Act, the absence of the licensure of a 
                health care professional employed by such an entity 
                under the State or local law where the entity is 
                located shall not be taken into account for purposes of 
                determining whether the entity meets such standards, if 
                the professional is licensed in another State.
            ``(2) Prohibition on federal payments to entities or 
        individuals excluded from participation in federal health care 
        programs or whose state licenses are under suspension or have 
        been revoked.--
                    ``(A) Excluded entities.--No entity operated by the 
                Indian Health Service, an Indian Tribe, Tribal 
                Organization, or Urban Indian Organization that has 
                been excluded from participation in any Federal health 
                care program or for which a license is under suspension 
                or has been revoked by the State where the entity is 
                located shall be eligible to receive payment under any 
                such program for health care services furnished to an 
                Indian.
                    ``(B) Excluded individuals.--No individual who has 
                been excluded from participation in any Federal health 
                care program or whose State license is under suspension 
                or has been revoked shall be eligible to receive 
                payment under any such program for health care services 
                furnished by that individual, directly or through an 
                entity that is otherwise eligible to receive payment 
                for health care services, to an Indian.
                    ``(C) Federal health care program defined.--In this 
                subsection, the term, `Federal health care program' has 
                the meaning given that term in section 1128B(f), except 
                that, for purposes of this subsection, such term shall 
                include the health insurance program under chapter 89 
                of title 5, United States Code.''.

SEC. 7. CONSULTATION ON MEDICAID, SCHIP, AND OTHER HEALTH CARE PROGRAMS 
              FUNDED UNDER THE SOCIAL SECURITY ACT INVOLVING INDIAN 
              HEALTH PROGRAMS AND URBAN INDIAN ORGANIZATIONS.

    (a) In General.--Section 1139 of the Social Security Act (42 U.S.C. 
1320b-9), as amended by sections 3 and 6, is amended by redesignating 
subsection (d) as subsection (e), and inserting after subsection (c) 
the following new subsection:
    ``(d) Consultation With Tribal Technical Advisory Group (TTAG).--
The Secretary shall maintain within the Centers for Medicaid & Medicare 
Services (CMS) a Tribal Technical Advisory Group, established in 
accordance with requirements of the charter dated September 30, 2003, 
and in such group shall include a representative of the Urban Indian 
Organizations and the Service. The representative of the Urban Indian 
Organization shall be deemed to be an elected officer of a tribal 
government for purposes of applying section 204(b) of the Unfunded 
Mandates Reform Act of 1995 (2 U.S.C. 1534(b)).''.
    (b) Solicitation of Advice Under Medicaid and SCHIP.--
            (1) Medicaid state plan amendment.--Section 1902(a) of the 
        Social Security Act (42 U.S.C. 1396a(a)) is amended--
                    (A) in paragraph (69), by striking ``and'' at the 
                end;
                    (B) in paragraph (70)(B)(iv), by striking the 
                period at the end and inserting ``; and''; and
                    (C) by inserting after paragraph (70)(B)(iv), the 
                following new paragraph:
            ``(71) in the case of any State in which the Indian Health 
        Service operates or funds health care programs, or in which 1 
        or more Indian Health Programs or Urban Indian Organizations 
        (as such terms are defined in section 4 of the Indian Health 
        Care Improvement Act) provide health care in the State for 
        which medical assistance is available under such title, provide 
        for a process under which the State seeks advice on a regular, 
        ongoing basis from designees of such Indian Health Programs and 
        Urban Indian Organizations on matters relating to the 
        application of this title that are likely to have a direct 
        effect on such Indian Health Programs and Urban Indian 
        Organizations and that--
                    ``(A) shall include solicitation of advice prior to 
                submission of any plan amendments, waiver requests, and 
                proposals for demonstration projects likely to have a 
                direct effect on Indians, Indian Health Programs, or 
                Urban Indian Organizations; and
                    ``(B) may include appointment of an advisory 
                committee and of a designee of such Indian Health 
                Programs and Urban Indian Organizations to the medical 
                care advisory committee advising the State on its State 
                plan under this title.''.
            (2) Application to schip.--Section 2107(e)(1) of such Act 
        (42 U.S.C. 1397gg(e)(1)), as amended by section 5(b)(2), is 
        amended--
                    (A) by redesignating subparagraphs (B) through (F) 
                as subparagraphs (C) through (G), respectively; and
                    (B) by inserting after subparagraph (A), the 
                following new subparagraph:
                    ``(B) Section 1902(a)(71) (relating to the option 
                of certain States to seek advice from designees of 
                Indian Health Programs and Urban Indian 
                Organizations).''.
    (c) Rule of Construction.--Nothing in the amendments made by this 
section shall be construed as superseding existing advisory committees, 
working groups, guidance, or other advisory procedures established by 
the Secretary of Health and Human Services or by any State with respect 
to the provision of health care to Indians.

SEC. 8. EXCLUSION WAIVER AUTHORITY FOR AFFECTED INDIAN HEALTH PROGRAMS 
              AND SAFE HARBOR TRANSACTIONS UNDER THE SOCIAL SECURITY 
              ACT.

    (a) Exclusion Waiver Authority.--Section 1128 of the Social 
Security Act (42 U.S.C. 1320a-7) is amended by adding at the end the 
following new subsection:
    ``(k) Additional Exclusion Waiver Authority for Affected Indian 
Health Programs.--In addition to the authority granted the Secretary 
under subsections (c)(3)(B) and (d)(3)(B) to waive an exclusion under 
subsection (a)(1), (a)(3), (a)(4), or (b), the Secretary may, in the 
case of an Indian Health Program, waive such an exclusion upon the 
request of the administrator of an affected Indian Health Program (as 
defined in section 4 of the Indian Health Care Improvement Act) who 
determines that the exclusion would impose a hardship on individuals 
entitled to benefits under or enrolled in a Federal health care 
program.''.
    (b) Certain Transactions Involving Indian Health Care Programs 
Deemed to Be in Safe Harbors.--Section 1128B(b) of the Social Security 
Act (42 U.S.C. 1320a-7b(b)) is amended by adding at the end the 
following new paragraph:
    ``(4) Subject to such conditions as the Secretary may promulgate 
from time to time as necessary to prevent fraud and abuse, for purposes 
of paragraphs (1) and (2) and section 1128A(a), the following transfers 
shall not be treated as remuneration:
            ``(A) Transfers between indian health programs, indian 
        tribes, tribal organizations, and urban indian organizations.--
        Transfers of anything of value between or among an Indian 
        Health Program, Indian Tribe, Tribal Organization, or Urban 
        Indian Organization, that are made for the purpose of providing 
        necessary health care items and services to any patient served 
        by such Program, Tribe, or Organization and that consist of--
                    ``(i) services in connection with the collection, 
                transport, analysis, or interpretation of diagnostic 
                specimens or test data;
                    ``(ii) inventory or supplies;
                    ``(iii) staff; or
                    ``(iv) a waiver of all or part of premiums or cost 
                sharing.
            ``(B) Transfers between indian health programs, indian 
        tribes, tribal organizations, or urban indian organizations and 
        patients.--Transfers of anything of value between an Indian 
        Health Program, Indian Tribe, Tribal Organization, or Urban 
        Indian Organization and any patient served or eligible for 
        service from an Indian Health Program, Indian Tribe, Tribal 
        Organization, or Urban Indian Organization, including any 
        patient served or eligible for service pursuant to section 807 
        of the Indian Health Care Improvement Act, but only if such 
        transfers--
                    ``(i) consist of expenditures related to providing 
                transportation for the patient for the provision of 
                necessary health care items or services, provided that 
                the provision of such transportation is not advertised, 
                nor an incentive of which the value is 
                disproportionately large in relationship to the value 
                of the health care item or service (with respect to the 
                value of the item or service itself or, for 
                preventative items or services, the future health care 
                costs reasonably expected to be avoided);
                    ``(ii) consist of expenditures related to providing 
                housing to the patient (including a pregnant patient) 
                and immediate family members or an escort necessary to 
                assuring the timely provision of health care items and 
                services to the patient, provided that the provision of 
                such housing is not advertised nor an incentive of 
                which the value is disproportionately large in 
                relationship to the value of the health care item or 
                service (with respect to the value of the item or 
                service itself or, for preventative items or services, 
                the future health care costs reasonably expected to be 
                avoided); or
                    ``(iii) are for the purpose of paying premiums or 
                cost sharing on behalf of such a patient, provided that 
                the making of such payment is not subject to conditions 
                other than conditions agreed to under a contract for 
                the delivery of contract health services.
            ``(C) Contract health services.--A transfer of anything of 
        value negotiated as part of a contract entered into between an 
        Indian Health Program, Indian Tribe, Tribal Organization, Urban 
        Indian Organization, or the Indian Health Service and a 
        contract care provider for the delivery of contract health 
        services authorized by the Indian Health Service, provided 
        that--
                    ``(i) such a transfer is not tied to volume or 
                value of referrals or other business generated by the 
                parties; and
                    ``(ii) any such transfer is limited to the fair 
                market value of the health care items or services 
                provided or, in the case of a transfer of items or 
                services related to preventative care, the value of the 
                future health care costs reasonably expected to be 
                avoided.
            ``(D) Other transfers.--Any other transfer of anything of 
        value involving an Indian Health Program, Indian Tribe, Tribal 
        Organization, or Urban Indian Organization, or a patient served 
        or eligible for service from an Indian Health Program, Indian 
        Tribe, Tribal Organization, or Urban Indian Organization, that 
        the Secretary, in consultation with the Attorney General, 
        determines is appropriate, taking into account the special 
        circumstances of such Indian Health Programs, Indian Tribes, 
        Tribal Organizations, and Urban Indian Organizations, and of 
        patients served by such Programs, Tribes, and Organizations.''.

SEC. 9. RULES APPLICABLE UNDER MEDICAID AND SCHIP TO MANAGED CARE 
              ENTITIES WITH RESPECT TO INDIAN ENROLLEES AND INDIAN 
              HEALTH CARE PROVIDERS AND INDIAN MANAGED CARE ENTITIES.

    (a) In General.--Section 1932 of the Social Security Act (42 U.S.C. 
1396u-2) is amended by adding at the end the following new subsection:
    ``(h) Special Rules With Respect to Indian Enrollees, Indian Health 
Care Providers, and Indian Managed Care Entities.--
            ``(1) Enrollee option to select an indian health care 
        provider as primary care provider.--In the case of a non-Indian 
        Medicaid managed care entity that--
                    ``(A) has an Indian enrolled with the entity; and
                    ``(B) has an Indian health care provider that is 
                participating as a primary care provider within the 
                network of the entity,
        insofar as the Indian is otherwise eligible to receive services 
        from such Indian health care provider and the Indian health 
        care provider has the capacity to provide primary care services 
        to such Indian, the contract with the entity under section 
        1903(m) or under section 1905(t)(3) shall require, as a 
        condition of receiving payment under such contract, that the 
        Indian shall be allowed to choose such Indian health care 
        provider as the Indian's primary care provider under the 
        entity.
            ``(2) Assurance of payment to indian health care providers 
        for provision of covered services.--Each contract with a 
        managed care entity under section 1903(m) or under section 
        1905(t)(3) shall require any such entity that has a significant 
        percentage of Indian enrollees (as determined by the 
        Secretary), as a condition of receiving payment under such 
        contract to satisfy the following requirements:
                    ``(A) Demonstration of participating indian health 
                care providers or application of alternative payment 
                arrangements.--Subject to subparagraph (E), to--
                            ``(i) demonstrate that the number of Indian 
                        health care providers that are participating 
                        providers with respect to such entity are 
                        sufficient to ensure timely access to covered 
                        Medicaid managed care services for those 
                        enrollees who are eligible to receive services 
                        from such providers; or
                            ``(ii) agree to pay Indian health care 
                        providers who are not participating providers 
                        with the entity for covered Medicaid managed 
                        care services provided to those enrollees who 
                        are eligible to receive services from such 
                        providers at a rate equal to the rate 
                        negotiated between such entity and the provider 
                        involved or, if such a rate has not been 
                        negotiated, at a rate that is not less than the 
                        level and amount of payment which the entity 
                        would make for the services if the services 
                        were furnished by a participating provider 
                        which is not an Indian health care provider.
                    ``(B) Prompt payment.--To agree to make prompt 
                payment (in accordance with rules applicable to managed 
                care entities) to Indian health care providers that are 
                participating providers with respect to such entity or, 
                in the case of an entity to which subparagraph (A)(ii) 
                or (E) applies, that the entity is required to pay in 
                accordance with that subparagraph.
                    ``(C) Satisfaction of claim requirement.--To deem 
                any requirement for the submission of a claim or other 
                documentation for services covered under subparagraph 
                (A) by the enrollee to be satisfied through the 
                submission of a claim or other documentation by an 
                Indian health care provider that is consistent with 
                section 403(h) of the Indian Health Care Improvement 
                Act.
                    ``(D) Compliance with generally applicable 
                requirements.--
                            ``(i) In general.--Subject to clause (ii), 
                        as a condition of payment under subparagraph 
                        (A), an Indian health care provider shall 
                        comply with the generally applicable 
                        requirements of this title, the State plan, and 
                        such entity with respect to covered Medicaid 
                        managed care services provided by the Indian 
                        health care provider to the same extent that 
                        non-Indian providers participating with the 
                        entity must comply with such requirements.
                            ``(ii) Limitations on compliance with 
                        managed care entity generally applicable 
                        requirements.--An Indian health care provider--
                                    ``(I) shall not be required to 
                                comply with a generally applicable 
                                requirement of a managed care entity 
                                described in clause (i) as a condition 
                                of payment under subparagraph (A) if 
                                such compliance would conflict with any 
                                other statutory or regulatory 
                                requirements applicable to the Indian 
                                health care provider; and
                                    ``(II) shall only need to comply 
                                with those generally applicable 
                                requirements of a managed care entity 
                                described in clause (i) as a condition 
                                of payment under subparagraph (A) that 
                                are necessary for the entity's 
                                compliance with the State plan, such as 
                                those related to care management, 
                                quality assurance, and utilization 
                                management.
                    ``(E) Application of special payment requirements 
                for federally-qualified health centers and encounter 
                rate for services provided by certain indian health 
                care providers.--
                            ``(i) Federally-qualified health centers.--
                                    ``(I) Managed care entity payment 
                                requirement.--To agree to pay any 
                                Indian health care provider that is a 
                                federally-qualified health center but 
                                not a participating provider with 
                                respect to the entity, for the 
                                provision of covered Medicaid managed 
                                care services by such provider to an 
                                Indian enrollee of the entity at a rate 
                                equal to the amount of payment that the 
                                entity would pay a federally-qualified 
                                health center that is a participating 
                                provider with respect to the entity but 
                                is not an Indian health care provider 
                                for such services.
                                    ``(II) Continued application of 
                                state requirement to make supplemental 
                                payment.--Nothing in subclause (I) or 
                                subparagraph (A) or (B) shall be 
                                construed as waiving the application of 
                                section 1902(bb)(5) regarding the State 
                                plan requirement to make any 
                                supplemental payment due under such 
                                section to a federally-qualified health 
                                center for services furnished by such 
                                center to an enrollee of a managed care 
                                entity (regardless of whether the 
                                federally-qualified health center is or 
                                is not a participating provider with 
                                the entity).
                            ``(ii) Continued application of encounter 
                        rate for services provided by certain indian 
                        health care providers.--If the amount paid by a 
                        managed care entity to an Indian health care 
                        provider that is not a federally-qualified 
                        health center and that has elected to receive 
                        payment under this title as an Indian Health 
                        Service provider under the July 11, 1996, 
                        Memorandum of Agreement between the Health Care 
                        Financing Administration (now the Centers for 
                        Medicare & Medicaid Services) and the Indian 
                        Health Service for services provided by such 
                        provider to an Indian enrollee with the managed 
                        care entity is less than the encounter rate 
                        that applies to the provision of such services 
                        under such memorandum, the State plan shall 
                        provide for payment to the Indian health care 
                        provider of the difference between the 
                        applicable encounter rate under such memorandum 
                        and the amount paid by the managed care entity 
                        to the provider for such services.
                    ``(F) Construction.--Nothing in this paragraph 
                shall be construed as waiving the application of 
                section 1902(a)(30)(A) (relating to application of 
                standards to assure that payments are consistent with 
                efficiency, economy, and quality of care).
            ``(3) Offering of managed care through indian medicaid 
        managed care entities.--If--
                    ``(A) a State elects to provide services through 
                Medicaid managed care entities under its Medicaid 
                managed care program; and
                    ``(B) an Indian health care provider that is funded 
                in whole or in part by the Indian Health Service, or a 
                consortium composed of 1 or more Tribes, Tribal 
                Organizations, or Urban Indian Organizations, and which 
                also may include the Indian Health Service, has 
                established an Indian Medicaid managed care entity in 
                the State that meets generally applicable standards 
                required of such an entity under such Medicaid managed 
                care program,
        the State shall offer to enter into an agreement with the 
        entity to serve as a Medicaid managed care entity with respect 
        to eligible Indians served by such entity under such program.
            ``(4) Special rules for indian managed care entities.--The 
        following are special rules regarding the application of a 
        Medicaid managed care program to Indian Medicaid managed care 
        entities:
                    ``(A) Enrollment.--
                            ``(i) Limitation to indians.--An Indian 
                        Medicaid managed care entity may restrict 
                        enrollment under such program to Indians and to 
                        members of specific Tribes in the same manner 
                        as Indian Health Programs may restrict the 
                        delivery of services to such Indians and tribal 
                        members.
                            ``(ii) No less choice of plans.--Under such 
                        program the State may not limit the choice of 
                        an Indian among Medicaid managed care entities 
                        only to Indian Medicaid managed care entities 
                        or to be more restrictive than the choice of 
                        managed care entities offered to individuals 
                        who are not Indians.
                            ``(iii) Default enrollment.--
                                    ``(I) In general.--If such program 
                                of a State requires the enrollment of 
                                Indians in a Medicaid managed care 
                                entity in order to receive benefits, 
                                the State, taking into consideration 
                                the criteria specified in subsection 
                                (a)(4)(D)(ii)(I), shall provide for the 
                                enrollment of Indians described in 
                                subclause (II) who are not otherwise 
                                enrolled with such an entity in an 
                                Indian Medicaid managed care entity 
                                described in such clause.
                                    ``(II) Indian described.--An Indian 
                                described in this subclause, with 
                                respect to an Indian Medicaid managed 
                                care entity, is an Indian who, based 
                                upon the service area and capacity of 
                                the entity, is eligible to be enrolled 
                                with the entity consistent with 
                                subparagraph (A).
                            ``(iv) Exception to state lock-in.--A 
                        request by an Indian who is enrolled under such 
                        program with a non-Indian Medicaid managed care 
                        entity to change enrollment with that entity to 
                        enrollment with an Indian Medicaid managed care 
                        entity shall be considered cause for granting 
                        such request under procedures specified by the 
                        Secretary.
                    ``(B) Flexibility in application of solvency.--In 
                applying section 1903(m)(1) to an Indian Medicaid 
                managed care entity--
                            ``(i) any reference to a `State' in 
                        subparagraph (A)(ii) of that section shall be 
                        deemed to be a reference to the `Secretary'; 
                        and
                            ``(ii) the entity shall be deemed to be a 
                        public entity described in subparagraph (C)(ii) 
                        of that section.
                    ``(C) Exceptions to advance directives.--The 
                Secretary may modify or waive the requirements of 
                section 1902(w) (relating to provision of written 
                materials on advance directives) insofar as the 
                Secretary finds that the requirements otherwise imposed 
                are not an appropriate or effective way of 
                communicating the information to Indians.
                    ``(D) Flexibility in information and marketing.--
                            ``(i) Materials.--The Secretary may modify 
                        requirements under subsection (a)(5) to ensure 
                        that information described in that subsection 
                        is provided to enrollees and potential 
                        enrollees of Indian Medicaid managed care 
                        entities in a culturally appropriate and 
                        understandable manner that clearly communicates 
                        to such enrollees and potential enrollees their 
                        rights, protections, and benefits.
                            ``(ii) Distribution of marketing 
                        materials.--The provisions of subsection 
                        (d)(2)(B) requiring the distribution of 
                        marketing materials to an entire service area 
                        shall be deemed satisfied in the case of an 
                        Indian Medicaid managed care entity that 
                        distributes appropriate materials only to those 
                        Indians who are potentially eligible to enroll 
                        with the entity in the service area.
            ``(5) Malpractice insurance.--Insofar as, under a Medicaid 
        managed care program, a health care provider is required to 
        have medical malpractice insurance coverage as a condition of 
        contracting as a provider with a Medicaid managed care entity, 
        an Indian health care provider that is--
                    ``(A) a federally-qualified health center that is 
                covered under the Federal Tort Claims Act (28 U.S.C. 
                1346(b), 2671 et seq.);
                    ``(B) providing health care services pursuant to a 
                contract or compact under the Indian Self-Determination 
                and Education Assistance Act (25 U.S.C. 450 et seq.) 
                that are covered under the Federal Tort Claims Act (28 
                U.S.C. 1346(b), 2671 et seq.); or
                    ``(C) the Indian Health Service providing health 
                care services that are covered under the Federal Tort 
                Claims Act (28 U.S.C. 1346(b), 2671 et seq.);
        are deemed to satisfy such requirement.
            ``(6) Definitions.--For purposes of this subsection:
                    ``(A) Indian health care provider.--The term 
                `Indian health care provider' means an Indian Health 
                Program or an Urban Indian Organization.
                    ``(B) Indian; indian health program; service; 
                tribe, tribal organization; urban indian 
                organization.--The terms `Indian', `Indian Health 
                Program', `Service', `Tribe', `tribal organization', 
                `Urban Indian Organization' have the meanings given 
                such terms in section 4 of the Indian Health Care 
                Improvement Act.
                    ``(C) Indian medicaid managed care entity.--The 
                term `Indian Medicaid managed care entity' means a 
                managed care entity that is controlled (within the 
                meaning of the last sentence of section 1903(m)(1)(C)) 
                by the Indian Health Service, a Tribe, Tribal 
                Organization, or Urban Indian Organization, or a 
                consortium, which may be composed of 1 or more Tribes, 
                Tribal Organizations, or Urban Indian Organizations, 
                and which also may include the Service.
                    ``(D) Non-indian medicaid managed care entity.--The 
                term `non-Indian Medicaid managed care entity' means a 
                managed care entity that is not an Indian Medicaid 
                managed care entity.
                    ``(E) Covered medicaid managed care services.--The 
                term `covered Medicaid managed care services' means, 
                with respect to an individual enrolled with a managed 
                care entity, items and services that are within the 
                scope of items and services for which benefits are 
                available with respect to the individual under the 
                contract between the entity and the State involved.
                    ``(F) Medicaid managed care program.--The term 
                `Medicaid managed care program' means a program under 
                sections 1903(m) and 1932 and includes a managed care 
                program operating under a waiver under section 1915(b) 
                or 1115 or otherwise.''.
    (b) Application to SCHIP.--Section 2107(e)(1) of such Act (42 
U.S.C. 1397gg(1)), as amended by section 7(b)(2), is amended by adding 
at the end the following new subparagraph:
                    ``(H) Subsections (a)(2)(C) and (h) of section 
                1932.''.

SEC. 10. ANNUAL REPORT ON INDIANS SERVED BY SOCIAL SECURITY ACT HEALTH 
              BENEFIT PROGRAMS.

    Section 1139 of the Social Security Act (42 U.S.C. 1320b-9), as 
amended by the sections 3, 6, and 7, is amended by redesignating 
subsection (e) as subsection (f), and inserting after subsection (d) 
the following new subsection:
    ``(e) Annual Report on Indians Served by Health Benefit Programs 
Funded Under This Act.--Beginning January 1, 2007, and annually 
thereafter, the Secretary, acting through the Administrator of the 
Centers for Medicare & Medicaid Services and the Director of the Indian 
Health Service, shall submit a report to Congress regarding the 
enrollment and health status of Indians receiving items or services 
under health benefit programs funded under this Act during the 
preceding year. Each such report shall include the following:
            ``(1) The total number of Indians enrolled in, or receiving 
        items or services under, such programs, disaggregated with 
        respect to each such program.
            ``(2) The number of Indians described in paragraph (1) that 
        also received health benefits under programs funded by the 
        Indian Health Service.
            ``(3) General information regarding the health status of 
        the Indians described in paragraph (1), disaggregated with 
        respect to specific diseases or conditions and presented in a 
        manner that is consistent with protections for privacy of 
        individually identifiable health information under section 
        264(c) of the Health Insurance Portability and Accountability 
        Act of 1996.
            ``(4) A detailed statement of the status of facilities of 
        the Indian Health Service or an Indian Tribe, Tribal 
        Organization, or an Urban Indian Organization with respect to 
        such facilities' compliance with the applicable conditions and 
        requirements of titles XVIII, XIX, and XXI, and, in the case of 
        title XIX or XXI, under a State plan under such title or under 
        waiver authority, and of the progress being made by such 
        facilities (under plans submitted under section 1880(b), 
        1911(b) or otherwise) toward the achievement and maintenance of 
        such compliance.
            ``(5) Such other information as the Secretary determines is 
        appropriate.''.

SEC. 11. EFFECTIVE DATE.

    The amendments made by this Act take effect on the effective date 
of the amendments made by the Indian Health Care Improvement Act 
Amendments of 2006.
                                                       Calendar No. 469

109th CONGRESS

  2d Session

                                S. 3524

_______________________________________________________________________

                                 A BILL

   To amend titles XVIII, XIX, and XXI of the Social Security Act to 
 improve health care provided to Indians under the Medicare, Medicaid, 
and State Children's Health Insurance Programs, and for other purposes.

_______________________________________________________________________

                             June 15, 2006

                 Read twice and placed on the calendar