II Calendar No. 555 110th CONGRESS 2d Session S. 2532 [Report No. 110–255] IN THE SENATE OF THE UNITED STATES January 8, 2008 Mr. Baucus, from the Committee on Finance, reported under authority of the order of the Senate of December 19, 2007, 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.

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 2007. (b)

Table of contents

The table of contents of 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 under Medicaid, 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.

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:

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:

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). .

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:

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 paragraph (1) shall be construed as affecting arrangements entered into between States and the Indian Health Service, Indian Tribes, Tribal Organizations, or Urban Indian Organizations for such Service, Tribes, or Organizations to conduct administrative activities under such titles. (b)

Requirement To Facilitate Cooperation

The Secretary, acting through the Centers for Medicare & Medicaid Services, shall take such steps as are necessary to facilitate cooperation with, and agreements between, States and the Indian Health Service, Indian Tribes, Tribal Organizations, or Urban Indian Organizations with respect to the provision of health care items and services to Indians under the programs established under title XVIII, XIX, or XXI. (c)

Definition of Indian; Indian Tribe; Indian Health Program; Tribal Organization; Urban Indian Organization

In this section, the terms Indian, Indian Tribe, Indian Health Program, Tribal Organization, and Urban Indian Organization have the meanings given those terms in section 4 of the Indian Health Care Improvement Act.

.

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 (such as a tribal enrollment card or certificate of degree of Indian blood). (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. .

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 subsection (g) or (j) of section 1916. (b)

Treatment of Certain Property for Medicaid and SCHIP Eligibility

(1)

Medicaid

Section 1902(e) of the Social Security Act (42 U.S.C. 1396a) is amended by adding at the end the following new paragraph: (13)Notwithstanding any other requirement of this title or any other provision of Federal or State law, a State shall disregard the following property for purposes of determining the eligibility of an individual who is an Indian (as defined in section 4 of the Indian Health Care Improvement Act) for medical assistance under this title: (A)Property, including real property and improvements, that is held in trust, subject to Federal restrictions, or otherwise under the supervision of the Secretary of the Interior, located on a reservation, including any federally recognized Indian Tribe’s reservation, pueblo, or colony, including former reservations in Oklahoma, Alaska Native regions established by the Alaska Native Claims Settlement Act, and Indian allotments on or near a reservation as designated and approved by the Bureau of Indian Affairs of the Department of the Interior. (B)For any federally recognized Tribe not described in subparagraph (A), property located within the most recent boundaries of a prior Federal reservation. (C)Ownership interests in rents, leases, royalties, or usage rights related to natural resources (including extraction of natural resources or harvesting of timber, other plants and plant products, animals, fish, and shellfish) resulting from the exercise of federally protected rights. (D)Ownership interests in or usage rights to items not covered by subparagraphs (A) through (C) that have unique religious, spiritual, traditional, or cultural significance or rights that support subsistence or a traditional lifestyle according to applicable tribal law or custom. . (2)

Application to schip

Section 2107(e)(1) of such Act (42 U.S.C. 1397gg(e)(1)) is amended— (A)by redesignating subparagraphs (B) through (E), as subparagraphs (C) through (F), respectively; and (B)by inserting after subparagraph (A), the following new subparagraph: (B)Section 1902(e)(13) (relating to disregard of certain property for purposes of making eligibility determinations). . (c)

Continuation of Current Law Protections of Certain Indian Property From Medicaid Estate Recovery

Section 1917(b)(3) of the Social Security Act (42 U.S.C. 1396p(b)(3)) is amended— (1)by inserting (A) after (3); and (2)by adding at the end the following new subparagraph: (B)The standards specified by the Secretary under subparagraph (A) shall require that the procedures established by the State agency under subparagraph (A) exempt income, resources, and property that are exempt from the application of this subsection as of April 1, 2003, under manual instructions issued to carry out this subsection (as in effect on such date) because of the Federal responsibility for Indian Tribes and Alaska Native Villages. Nothing in this subparagraph shall be construed as preventing the Secretary from providing additional estate recovery exemptions under this title for Indians. .

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. .

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.

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. .

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. .

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, 2008, 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. .

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 2007.

January 8, 2008 Read twice and placed on the calendar